Hallucinogen-related disorders — bad trip, HPPD, and PAT interface (MEQ)

(i) Acute assessment and management. ABC and medical exclusion first (vitals, glucose already done; watch for adulterant toxicity, hyperthermia, trauma, MDMA co-toxidrome if history expands). Secure environment to prevent road injury. Low-stimulus setting, calm talk-down, continuous observation through expected peak; time-limited benzodiazepine (here lorazepam 1 mg orally) for severe panic/agitation when support alone is insufficient. Antipsychotic not automatic for every perceptual change. Do not start "hallucinogen detox" seizure protocols. Document substance timeline, capacity and risk.^[1][2]

(ii) Psychosis risk and dual formulation. Acute persecutory content temporally linked to claimed LSD with relatively clear orientation favours substance-related intoxication/psychotic symptoms rather than proven lifelong primary schizophrenia on day one. Maternal uncle with schizophrenia elevates vulnerability and mandates honest risk counselling and longitudinal follow-up — dual formulation remains open if symptoms persist after washout. Family pressure for immediate lifelong depot is a trap; use timeline, collateral and planned review.^[5]

(iii) HPPD definition and management. Re-experiencing of perceptual phenomena (trailing, geometric patterns) after cessation, with distress and occupational impairment, fits HPPD rather than ongoing intoxication. Validate; exclude alternative visual/neurological causes as indicated; advise ongoing abstinence from hallucinogens and ideally cannabis; treat secondary anxiety; evidence for specific anti-HPPD drugs is limited/case-level — avoid inventing a mandatory complex polypharmacy algorithm.^[3][4]

(iv) PAT evidence interface. Protocolised trials (e.g. Goodwin: single 25 mg oral psilocybin superior to 1 mg control at 3 weeks on primary depression outcome in TRD under research conditions with support) are not equivalent to unsupervised microdosing. Explain screening, preparation, session support and integration; legal and safety limits in ANZ standard care; offer evidence-based depression pathways instead of colluding with illicit supply.^[1][6]

(v) Disposition and harm reduction. Discharge only when MSE safe and supports available; written advice on set/setting, dose uncertainty/adulterants, no driving while residual effects, avoid use given family psychosis risk and HPPD, AOD brief intervention, dual-diagnosis or early-intervention follow-up, crisis contacts, ophthalmology/neurology thresholds if visual differential unclear.^[1][3][5]