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Clinical Atlas Prestige · Evidence-first

Psych VivasAddiction psychiatry — hallucinogen-related disorders

Psych Vivas · Addiction psychiatry — hallucinogen-related disorders

Hallucinogen-related disorders — structured clinical viva

Fellowship viva on classic psychedelic intoxication, 5-HT2A mechanism, talk-down care, HPPD, dual formulation of psychosis, and accurate PAT trial framing.

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Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. A 26-year-old woman ingested mushrooms 4 hours ago, is panicking with geometric visual changes, BP 132/80, temperature 36.9°C, clear consciousness. Partner asks whether she has schizophrenia and whether she needs lifelong antipsychotic. She later asks for a microdosing prescription because she read that psilocybin beats antidepressants. Discuss acute management, class pharmacology, HPPD risk, dual formulation, and the research evidence interface.

Interpretation

Reveal interpretation

This is an acute intoxication and dual-diagnosis viva, not a pure research seminar. Clear consciousness with geometric visual change and panic after mushrooms fits classic serotonergic psychedelic intoxication. First-line care is medical exclusion of toxicity, then low-stimulus talk-down and observation; benzodiazepines if severe agitation; antipsychotics only if dangerous persistent psychosis.[1][2]

Mechanism answer expected: 5-HT2A agonism (Nichols). Contrast with NMDA dissociatives if the examiner probes street "hallucinogen" mislabelling.[2]

Partner's schizophrenia fear: use timeline and dual formulation — do not diagnose lifelong primary psychosis from a single intoxication episode, but do not dismiss vulnerability or need for follow-up if symptoms persist after washout.[1]

HPPD: uncommon but real post-cessation perceptual re-experiencing with distress/impairment (Halpern); counsel risk without catastrophising every use.[3]

Microdosing demand: cite research precisely — Goodwin 25 mg vs 1 mg TRD signal under protocol; Carhart-Harris primary endpoint nuance versus escitalopram; Bogenschutz AUD heavy-drinking reduction with assisted psychotherapy — none authorise unsupervised recreational prescribing in standard ANZ care.[4][5][6]

No classic life-threatening withdrawal detox; no methadone-equivalent substitution for classic psychedelics.[2]

Key points

Talk-down first

Low-stimulus support is first-line for classic psychedelic distress; sedatives second-line; antipsychotics not automatic.

5-HT2A vs NMDA

Classic psychedelics are serotonergic; dissociatives are NMDA antagonists — class matters for toxidrome.

Trial ≠ DIY

PAT efficacy signals require protocolised support; they do not create home microdosing scripts.
[1] [2] [4]

References

  1. [1]Johnson MW, Richards WA, Griffiths RR Human hallucinogen research: guidelines for safety J Psychopharmacol, 2008.PMID 18593734
  2. [2]Nichols DE Psychedelics Pharmacol Rev, 2016.PMID 26841800
  3. [3]Halpern JH, Pope HG Jr Hallucinogen persisting perception disorder: what do we know after 50 years? Drug Alcohol Depend, 2003.PMID 12609692
  4. [4]Goodwin GM, Aaronson ST, Alvarez O, et al. Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression N Engl J Med, 2022.PMID 36322843
  5. [5]Carhart-Harris R, Giribaldi B, Watts R, et al. Trial of Psilocybin versus Escitalopram for Depression N Engl J Med, 2021.PMID 33852780
  6. [6]Bogenschutz MP, Ross S, Bhatt S, et al. Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder JAMA Psychiatry, 2022.PMID 36001306