Cracking the Doors of Perception
Population research suggests that psychedelics, for most people, may not meaningfully increase the average risk of psychosis.
Epidemiological research has its problems, though, which we needn’t explore here.
And this broad reassurance can obscure a smaller and significant subset of cases – where individuals experience a lasting ensemble of disturbances known as ‘persisting psychosis’. Clinical reports and user testimonies describe not just visual distortions (as in hallucinogen persisting perception disorder, HPPD), but episodes sometimes indistinguishable from schizophrenia and lasting months or more.
Psychedelic-induced psychosis (PIP) probably differs from classical schizophrenia. Many PIP cases may lack the hallmark emotional blunting and acoustic hallucinations. Instead, they may present as acute affective or paranoid states – sometimes with spiritual or mystical themes – rich in visual hallucinations, or rather as a delusional response to troublesome feelings of irreality. They may resolve within days and weeks or last much longer. This makes PIP resemble both brief psychotic disorder and early-stage schizophrenia, without fitting neatly into either category.
Research on Psychedelic-Induced Psychosis
Within popular culture and the psychiatric literature, there are many case reports of such so-called ‘LSD psychosis’, ‘autonomous psychosis’ and ‘schizophrenia-like’ syndromes, and stories of ‘acid casualties’. Rick Strassman, in a 1984 review of adverse reactions, proposed that whether a psychedelic experience turns into a lasting psychosis depends on multiple factors: the person’s family history of psychosis, premorbid personality, the intensity of use, and other drugs like cannabis can all contribute. In essence, psychedelics “add fuel” to a predisposition, catalysing a breakdown that might not otherwise have occurred at that time, which may be risked further through things like lack of sleep and a traumatic event within the trip.
In PIP cases, what begins as a transient disruption can harden into a longer-term disorder, for reasons we don’t entirely understand. Are these cases simply latent schizophrenia triggered by psychedelics? Or can PIP become chronic via mechanisms distinct from schizophrenia’s usual pathways?
A recent Ontario cohort study (2008–2021) of 9.2 million people found that individuals who had a serious hallucinogen-related incident (an emergency room visit due to LSD/psilocybin/MDMA, etc.) later had markedly higher rates of schizophrenia diagnosis. Within three years of such an ER visit, 4% were diagnosed with schizophrenia vs. 0.15% of the general population, a 21-fold relative risk (about 3.5-fold even after adjusting for other substance use and history). A large-scale study by Starser et al. (2017) of 6,788 Danish individuals found that hallucinogen-induced psychosis had a conversion rate of 27.8% to a chronic mental disorder. A figure cited in a recent 2025 meta-analysis suggested a rate of 13%.
However, a purely clinical framing often fails to capture the phenomenology of these states – the lived, first-person experience. Drug-induced psychoses can be existential events, charged with metaphor, terror, and at times religious awe. If clinicians fail to recognise the subtle phenomenological shifts that precede full-blown psychosis – shifts that may be triggered or intensified by psychedelic experience – then their efforts at integration or support may misfire, or even do harm. A phenomenological analysis also helps us move beyond the biomechanical shorthand of “triggering schizophrenia,” which makes such experiences seem more remote and ‘othered’. DSM-5 data and the 2006 ‘Swedish study’ showed that the majority of people diagnosed with schizophrenia – around 96% – have no family history of the condition. We also live in a society still marked by worsening stigma toward psychosis and schizophrenia – this stigma worsened by a biomechanical view – with sufferers facing extreme rates of unemployment, imprisonment, and poverty.
Personal Accounts of Psychedelic-Induced Psychosis
Many accounts of PIP centre on solipsism, death, and derealisation, which is an increasingly noted complication of psychedelic trips: a feeling that the world is alien and dream-like. One Reddit user, for instance, vapourised 5-MeO-DMT (toad venom) in search of an earth-shattering mystical experience – “I felt I was ready to meet God” – but instead was plunged into debilitating derealisation and depersonalisation (DP/DR) unlike anything he had ever known. “The outside world made absolutely no sense – what was once familiar became unfamiliar and alien.” His cognitive abilities were impaired: memory gaps (forgetting street names, not recognising his own home), difficulty speaking and forming thoughts, and a general sense that the drug had “wiped” part of his mind.
“It feels like I will never get out of it… it feels like I died,” he confessed, describing the episode as “the scariest experience of my life.”
Phenomenologist Klaus Conrad described the early phase of psychosis as “Trema”, a “delusional mood” where the world seems strangely charged with significance, or where the usual reality sense is altered: a commonly desired effect of the psychedelic drug. Patients may feel heightened meaning in trivial details, as if “something big” is happening. At this stage, there may be no clear false beliefs, only a pervasive sense that reality is “off.” As this state intensifies, the mind seeks explanations, leading to an “apophany” or revelatory moment in which the strangeness is rationalised into a delusion – such as believing one is dead (Cotard delusion) or targeted by a conspiracy. Insight may initially remain, but it often fades as these interpretations solidify.
In one remarkable Reddit report, a user recounted being utterly convinced that he was dead or “that nothing else truly exists”. He simultaneously experienced other delusions (at times believing he was God or immortal) and a variety of hallucinations. The “walking corpse” belief proved impervious to family and friends’ reassurances – he thought others were figments of his imagination while he roamed in a sort of afterlife simulation. Tragically, this led him to a suicide attempt (to “escape from this reality/simulation”), after which he was hospitalised. With treatment, his Cotard’s delusion eventually remitted: after receiving antipsychotic therapy in the hospital, he reported being “hallucination-free and I believe that I exist and that I am alive”. (He wryly noted that the godlike delusion was harder to shake entirely, though greatly diminished.)
Another case, of a 16-year-old who developed long-term LSD psychosis, died by suicide while in a delusional state “because he didn’t think it would kill him”. LSD may pose a higher risk than psilocybin due to its longer duration, but the impact can be as severe. As one veteran put it, “It’s always a gamble… especially if you’ve already had psychosis once”.
Rather than merely feeling unreal, the psychotic may be so impressed by their affective state that they become convinced of their death/nihility. “My friend took mushrooms half a year ago”, one said. “He is convinced that he is not alive and is still in a trip. He still acts fairly normal in person but he keeps telling me that he believes he's dead.”
Another anecdote comes from a Reddit user who had a bad LSD trip that planted a different unsettling idea: the notion that reality is a simulation, akin to The Matrix or The Truman Show, and people around him are “made up robots”. (It is worth noting that no less than Timothy Leary adopted a similar belief after his first LSD trip, after noticing the ways in which his speech and actions seemed to occur in a scripted behaviourist fashion in line with social mores. Equally, the popularity of ‘simulation’ must represent a quasi-intelligible response to broader existential or technological anxieties.)
After the trip, part of him truly believed his simulation theory and couldn’t shake it off. “It’s like 2 parts of my brain are fighting… One second I think it’s stupid to think this way, and the next I think it may be true because of what I saw during my drug experience,” he wrote, describing a tormenting back-and-forth between rationality and the bizarre conviction. The form of derealisation “I felt like I wasn’t real and everything was a simulation” one cannabis user said of a recurring episode.
Blogger Aella documented taking LSD weekly for 10 months (around 40 trips, often 150–400 µg each, with some up to 600 µg). As the experiment went on, she experienced a progressive detachment from reality and selfhood. She fell into a nihilistic, death-like mental state, whispering “I am dead” to herself and losing all desire and affect.
Rather than believing one is dead, the derealised subject may instead begin to believe that they are the only living person: solipsism. In a correspondence, a 35-year-old surgeon recounted a months-long descent into solipsism following heavy LSD use amidst a personal crisis. Initially prompted by an affair with a woman suffering from MDMA psychosis and BPD, his drug use spiralled into self-punishment and metaphysical unravelling. What began as emotional vulnerability metastasised into full psychosis, where he believed he was God in a solipsistic universe and attempted suicide to prove the reality of his beliefs. As he explained, “The altered state bled into sober life… I experienced the multiverse every waking moment.”
In responding to such cases, Adam Knowles, a psychedelic integration therapist and ayahuasca researcher, advocates ‘epistemological pluralism’ – opening interpretive space to the poetical meaning of their feelings, without categorising them simply as ‘delusions’. If a man believes he is Jesus, Knowles might ask, “Maybe Jesus is all of us?” Indeed, after the acute phase, many fall into a depression, feeling “lost” or fearing permanent brain damage due to self-stigma. “I feel like I gave myself brain damage and I’m never going to be the same”, one user wrote the day after his 5-hour psychosis (weed/LSD/DMT mix), perhaps reflecting the need to move away from a more passive brain-based understanding. Further, if the trip was terrifying, the person may develop symptoms akin to PTSD – nightmares, anxiety triggers (for instance, hearing a certain song that played during the trip might induce panic), intrusive delusional thoughts and memories of the trip’s most fearsome moments. Such a person may not be delusional per se, but extremely distressed and fearful that they could go crazy again, which paradoxically can feed into anxious paranoia. There are innumerable flavours to the break from reality. One cannabis user literally begged his friend to crash the car they were in, “so we could crash and I could end my suffering”, because he believed he was irreversibly “mentally ruined” – demonstrating how the catastrophism of depressive thought may blur towards delusion. The commenter noted that subsequent use of a 70% THC cannabis strain led to panic and chronic depersonalisation. Another user, in a stimulant (crack) induced psychosis, said, “I almost committed suicide because I didn’t think it would end”.
A Reddit user shared a harrowing story after participating in an ayahuasca ceremony in Costa Rica. Like many others, her psychosis was not gradual but suddenly began with an extreme snap of anxiety and panic while intoxicated. Over the next 8 months, she said:
Intense energy sizzled through my body… My thoughts made me believe I was… trapped in hell for all eternity… I was… disconnected from life, my heart, and spirit… I ended up in the hospital from going manic and from constantly screaming that I was doomed for eternity… I was constantly planning my own suicide.
Similar somatic symptoms may occur without cognitive or affective changes. On psychedelic forums, long-time users acknowledge that unexplained shaking, seizure, and tremor episodes can occur with high doses of mushrooms or LSD. One experienced user called it “one of the mushroom world’s dirty little secrets… this happens all the time and there is no credible explanation for it”. The speculation in that community ranges from physiological causes like dehydration to psychological causes like conversion disorder (a stress-induced somatic reaction), but no consensus exists.Even after recovering, some users report residual symptoms or an increased risk of relapse. In an online psychosis support forum, one commenter described how every subsequent drug use could thrust them back into psychosis after an initial LSD-triggered break. “Mine started with LSD, and eventually I couldn’t do anything [psychoactive] without going back into an episode… I’ve [been left with] lasting delusions that I can ignore or laugh off”, they wrote.Yet it is worth distinguishing PIP from flashbacks, known clinically as Hallucinogen Persisting Perception Disorder (HPPD), in which a person experiences ongoing perceptual disturbances (tracers, afterimages, visual snow, etc.) for months or years after hallucinogen use. Yet Dr. Henry Abraham’s work documents patients whose visuals include grotesque or “devilish” figures otherwise found in more psychotic states. Here, the ‘meaning’ of the visuals is critical. A conventional psychiatric framing may risk estranging patients from their own percepts. When framed as evidence of “brain damage,” such a distance can become existentially corrosive. Faced with this dissonance, some reinterpret their visuals, folding them into mystical or occult worldviews. Psychedelic-induced psychosis can be particularly insidious because the user may not realise anything is wrong. Psychedelics often engender mystical or spiritual sensations. “I didn’t know that I was psychotic – I thought I was having a spiritual awakening,” one individual admitted in retrospect. Indeed, psychedelics amplify the mind’s natural pattern-seeking tendencies, fostering the rapid formation of false or grandiose beliefs that may linger well beyond the acute experience. In a cultural landscape already saturated with unfounded conspiracy theories and loose spiritual syncretism – the “cultic milieu” described by Colin Campbell – such ideas can find ready-made interpretive frameworks that validate and reinforce them. In the digital age, the search to understand a strange experience almost inevitably leads online. Algorithms on YouTube, TikTok, and Reddit can steer a vulnerable person deeper into fringe ideas. The looping quality of the psychedelic state may lend itself to later issues with tangential thinking. A recovering user noted his speech and thoughts were disorganised for a while. A mother described conversations with her psychotic son as “very weird” and full of non-sequiturs (like delusions about Elon Musk and Moses). “It’s been 4 months… my attention and memory are to the ground,” wrote one individual after a psychosis, worrying “I don’t know if I can have a job and family.” A Redditor recounts a harrowing weekend where a friend binged LSD and MDMA over three days, then eight years before. “He’s not even a shell of his former self… talking to him is like talking to a crazy person.”
A user on a psychonaut forum described a dramatic change in his longtime friend’s mentality after psychedelics. Over a year, the friend became “very interested and invested in a variety of conspiracy theories” to the point that “I’m convinced that he believes in [them].” He became convinced that the world would end in a couple of years, propagated the 432 Hz vs 440 Hz music tuning conspiracy, and subscribed to the flat-Earth theory. These were not ideas he held prior to using psychedelics. Additionally, this individual started exhibiting paranoid apocalyptic thinking (e.g. that an Armageddon is imminent) and identification with grandiose roles (he felt it was his mission to “preach” these revelations, and he almost considered himself a god). Family and friends grew alarmed as his behaviour became more radical. In this case, the duration has been over one year and is ongoing.
Making Sense of Distressing Changes to Reality
While “delusion” is often treated as a fixed, categorical label, there is in fact a continuum between frank psychosis and more everyday forms of ungrounded insight. Psychedelics regularly induce false beliefs in so-called “healthy normal” subjects: it is not unheard of for people to believe that they are the second coming of Jesus Christ while tripping, for instance. Some people may continue to hold to such ideas to lesser or greater extents, likely due to differences in temperament and the mode of drug use outlined above, but not in ways that guarantee complete safety. Perhaps more perniciously, the drugs may simply invest banal ideas that aren’t obviously batty with a self-authenticating revelatory sense. This may make bad, unhelpful, vague, or basically uninteresting ideas far harder to surmount than a frank delusion.
What is considered pathological is not always clear, though. For instance, high doses of psilocybin (“heroic doses”) often lead people to feel they “encountered otherworldly beings” or transcended reality, and some come away convinced of the reality of those experiences. One user recounts that after a 5-gram mushroom trip, he was imbued with the sense that “life is a complex game” or simulation arranged before birth. In the weeks following, he was “still trying to process and rationalise” what this revelation meant, without coming to a definitive conclusion. Viewing reality through a metaphysical lens (e.g. life as a game, or a “simulation theory” outlook) needn’t be pathological, but it may risk a slide into psychosis.
The belief systems that surround a drug can shape the PIP. More than drugs like LSD and psilocybin, ayahuasca culture is embedded within animistic worldviews populated by invisible beings. One case involved a 26-year-old man who took part in a single ceremony, during which he experienced terrifying visions wherein “it was revealed to him” that an evil spirit, sent by a neighbour, had infiltrated his body. After the ceremony, he continued to believe he was “tormented by unclean spirits” and became increasingly erratic and aggressive, eventually needing hospitalisation. Psychiatrists in Spain reported the case of a 43-year-old ayahuasca user with no psychiatric history who felt “an increased sensitivity to electromagnetic fields around her” and became convinced these invisible forces were draining her “vital energy.” She also experienced thought blocking, speech lagging, and depressed mood – all of which she attributed to these imagined energy fields attacking her.
One hallmark of psychosis is a disruption in the very experience of the self. Louis Sass identified two defining abnormalities: hyperreflexivity and diminished self-affection. Hyperreflexivity means an exaggerated self-consciousness – things that are normally automatic or tacit (like one’s thoughts, inner speech, or even bodily sensations) become objects of intense focus. For example, a patient might become acutely aware of the act of thinking, to the point they experience their thoughts as voices coming from outside or as inserted by an external force. Early-phase schizophrenia patients sometimes report feeling disembodied, watching themselves act, or that their thoughts are no longer truly “owned” by them: a “cognitive distancing” often enabled by psychedelic states and encouraged by therapeutic practices. This erosion of the tacit embodied grip on reality means normal reality-testing fails – when a thought arises (“what if the TV is sending me signals?”), it isn’t automatically dismissed as imagination. Instead, the hyperreflective gaze examines it from all angles, and with the self weakened, the thought can take on a life of its own as a perceived external reality. Insight may be lost at this point. The “internal commentary” and bizarre perceptions feel as real as any external event.For instance, one Reddit user recounted how psychedelics “opened doors in my mind that I could no longer shut”. At first, voices appeared “within a psychedelic journey” but then began infiltrating dreams and manifesting as external, alien impulses that “wanted me to live my life according to the Bible”, likely shaped by the Christian syncretic culture around ayahuasca. Over time, these directives morphed into full-blown haunting commands: “They were telling me that I was a sinner, and I would go to hell. That I was going to die, and I might as well take my own life.” These were not “Godly voices,” they emphasised, but punitive, intent on breaking them.
From a therapeutic standpoint, the overlap between psychedelics and psychosis has mixed qualities. Informed by numerous anecdotal success stories, some researchers even ask whether psychedelics, paradoxically, might have a place in treating certain aspects of psychosis – for example, using carefully controlled psychedelic sessions to alleviate negative symptoms or introspective deficits in schizophrenia, or better relate to and challenge hallucinations and fixed beliefs.
All in all, the complex aftershocks of a psychedelic encounter cannot be reduced to diagnostic categories, or soothed away with big data. They are shaped as much by the “cultic milieu” of our time as by any latent vulnerability, and the intrinsic potential for the psychedelic state to flood and utterly overwhelm the subject. The phenomenology reminds us that the border between insight and delusion is porous. To understand why some emerge with renewed perspective while others spiral and unravel, we must hold these different tendencies together, and place equal focus on listening to people’s experiences in their own terms.