1483

THE AMERICAN JOURNAL OF PSYCHIATRY

The Bad Trip-The Etiology of the Adverse LSD Reaction

BY J. THOMAS UNGERLEIDER, M.D., DUKE D. FISHER, M.D.,

MARIELLE FULLER, AND ALEX CALDWELL, PH.D.

In an attempt to identify the factors respon- at that time the incidence increased gradu-
sible for adverse reactions to LSD and to ally from five to 20 cases a month, with
elucidate the rising incidence of hospital three to five telephone calls being received,
admissions associated with use of the drug, for every person seen, from other persons in
the authors compared 25 psychiatric inpa- trouble from LSD who were not subsequent-
tients hospitalized following LSD inges- ly seen. Other hospitals throughout the
tion with 25 members of a group who took country have reported a similar increase.
LSD together regularly without reported The demographic characteristics of the first
difficulty. Although some differences were 70 such patients seen at UCLA have pre-
found between the groups, there were no viously been reported(9). These patients
outstanding historical or current clinical fea- came most often with hallucinations, fol-
tures which could be used to predict an lowed by anxiety to the point of panic, by
individuals response to LSD with accuracy. depression, often with suicidal thoughts or
These findings support the hypothesis that attempts, and by confusion.
LSD interacts with schizoid trends, unsteady The question has thus been raised why
reality testing, and related factors in a com- these persons should have experienced dif-
plex way that makes accurate prediction of ficulty from LSD when others claim to take
response virtually impossible. the drug regularly and apparently have no
adverse effects. A number of pertinent ad-
ditional questions are then raised. First of
S INCE APPROXIMATELY the fall of 1965 the all, how do we know
trouble from alleged
the persons
use of LSD
who get in
are really
incidence of adverse LSD reactions
throughout the country has mushroomed. taking LSD? Since Sandoz Pharmaceuticals,
At the UCLA Neuropsychiatric Institute the one legitimate manufacturer, discontin-
prior to September 1965 one problem case ued production, all LSD that is available is
associated with LSD ingestion was seen ap- black market, with all the impurities and
proximately every two months. Beginning dosage confusion that is attendant upon such
illegal supply. Secondly, how do we know
that those persons who have difficulty from
Read at the 123rd annual meeting of the LSD were not already emotionally dis-
American Psychiatric Association, Detroit, Mich., turbed? (In our original study 37 percent
May 8-12, 1967.
had had psychiatric care previously and 33
The authors are with the department of psy-
chiatry, UCLA Center for the Health Sciences, percent were unemployed, which were per-
Los Angeles, Calif. 90024, where Dr. Ungerleider
haps gross indices of mental illness.)
is assistant professor, Dr. Fisher is a resident in
psychiatry, Miss Fuller is research associate, and There is no applicable chemical test for
Dr. Caidwell is assistant professor of medical LSD once it is inside the body and no
psychology.
The authors would like to express their ap- pathognomonic signs or symptoms on which
preciation to Nancy West, R.N., for her assistance to make the diagnosis. Although most typ-
in obtaining the questionnaire data from the com-
parison group. ically passive, the LSD user may present
Thie One
Amer. I. Psychiat. 124: II, May 1968 [41]

IlID
lIl1INIU
UII IIIIIIIUIIIIII
1484 THE BAD TRIP

with almost any kind of behavior. However, member had initially tried to read a state-
beyond the history of LSD ingestion, there ment advocating unlimited use of LSD dur-
are no unique features although dilated ing a question and answer session follow-
pupils along with the peculiar I feel sorry ing the lecture. Afterwards, he approached
for you nonusers smile are characteristic. us and insisted that there were many per-
LSD users describe the perceptual sons who were taking the drug without dif-
changes following drug ingestion in intense ficulty. They had formed a group, to be re-
and often characteristic ways. When one ferred to as the Disciples, which consisted
hears about visual and auditory unfolding of 100 regulars with as many as 500 total
of nature it is typical of LSD and other members who met regularly and took LSD.
psychedelics alone. In addition, the most This was before possession of LSD was
common side effects reported by these sub- made illegal in California. After we agreed
jects were consistent with those described to observe the group, we were screened
elsewhere following experimental adminis- by five members at the Los Angeles Airport.
tration of LSD(3, 4). We had several drug They were satisfied that we were not law
samples spot-checked for LSD content. Al- enforcement officials and we were invited to
though the user always overestimated the observe some of their LSD happenings.
amount of LSD in his sample, all did con- Numerous subsequent visits were made to
tain LSD(8). the headquarters of the Disciples. This
The entire issue of predictability for the was located in a suburb of Los Angeles
adverse LSD reaction is unsettled. This is where about a dozen of the group were liv-
particularly cogent in view of the fact that ing in a large house on spacious grounds.
some researchers have advocated the use of They were literally tilling the soil and had
LSD not only experimentally but in clinics decorated the house in psychedelic fashion.
where creative and normal persons could There were pictures of Buddha and Jesus
receive the drug in order to create a psyche- on the walls. Every Wednesday night the
delic experience for them. This study is a group gathered to have a non-LSD religious
preliminary attempt to try to assess some of experience consisting of prayer and medi-
the factors in the etiology of the bad trip, tation. The drug-taking sessions were sched-
the adverse LSD reaction. uled for the weekends.
The group did not go along with the
Methodology drop out part of the turn on, tune in and
drop out that Dr. Timothy Leary advo-
Of the previous 70 patients reported up- cates. They claimed to be working, making
on, 25 were hospitalized and the rest were money, and to have rehabilitated them-
treated as outpatients. This group of 25 in- selves. Most of the members of the group
patients, hospitalized following adverse LSD said that they were ex-criminals and drug
reactions, are compared in this study with addicts who were now finding a new and
25 other frequent LSD users who reported useful life through LSD.
no difficulties from the drug. This latter After we observed a number of their love
comparison group claimed to have ingested sessions and all-day LSD experiences, the
the drug in doses of from 250 to 1200 g. group agreed to psychiatric interviews, in-
from once to three times a week for up to cluding mental status examinations and the
18 months. It should be emphasized that Minnesota Multiphasic Personality Inventory
these 25 subjects were part of an existing (MMPI). We examined the first 25 who
were available on one weekend. We then
religious group who took their LSD to-
compared these data to corresponding data
gether.
from the 25 hospitalized patients.
We initially made contact with this group
when one of their members sought us out
Results
following a lecture which two of the authors
(J.T.U. and D.D.F.) were giving on the Background. There were no significant
LSD situation to a community service or- differences in race, sex, or age between the
ganization in a suburb of Los Angeles. The two groups. Both groups had comparable

[42] Amer. J. Psychiat. 124: 11, May 1968

UNGERLEIDER, FISHER, FULLER, AND CALDWELL 1485

amounts of early parental deprivation. Religion. We could not obtain religious

Both groups resided predominantly in the information for the comparison group. They
Los Angeles area. had formed a new religion, and they all
Marital status. There was a highly sig- denied having any previous religion or that
nificant difference (p less than .001) in their families even had any religion. In fact
marital status between the two groups. No they had repudiated orthodox religions to-
inpatients were married at the time of ad- tally until they found God under LSD.
mission to the hospital (84 percent of the Thirty-two percent of the inpatient group
inpatients had never been married) versus said they had no religion.
60 percent married (with 19 children) in Police records. Table 3 shows the his-
the comparison group at the time they were tories of criminal behavior-64 percent of
examined (see table 1). the comparison group had police histories.
Employment. Only 20 percent of the in- The major crimes that the comparison
patients were earning a living at the time group had been involved in were forgery,
of admission, while over 70 percent of the stealing, carrying concealed weapons, man-
controls were working; this was a highly sig- slaughter, grand theft auto, and aiding a
nificant difference (p less than .01). The fugitive. Disturbances of the peace, delin-
comparison subjects were mainly blue-collar quency, minor fights, and petty thefts were
workers and their jobs included those of classified as minor crimes. Only eight per-
plumber, longshoreman, gas station atten- cent of the inpatient group gave histories of
dant, grocery and drug store clerk, janitor, police records, which was a significantly
construction worker, truck loader, tractor smaller proportion (p less than .001).
mechanic, aircraft plant worker, stockboy, Education. Fifty-six percent of the com-
gardener, and surfboard renter. The average parison group finished high school and an
length of time working was three years for additional 16 percent had had some col-
this comparison group (see table 2). lege education, for a total of 72 percent who
were at least high school graduates. The
remaining twenty-eight percent were high
1 Separation from one or both parents for over
six months before the age of 16(2). school dropouts. For the inpatient group 64
percent had finished high school, 32 percent
TABLE 1 were dropouts, and one patient was a high
Marital Status school student. This difference was not sig-
COMPARISON nificant.
INPATIENTS SUBJECTS
Previous psychiatric history. Seventy-six
STATUS NUMBER PERCENT NUMBER PERCENT
percent of the comparison group had no
Single 21 84 10 40
Married 0 15 60
TABLE 3
Divorced 2 8
Police Record
Other (widow) 1 4
Nodata 1 4 COMPARISON
Total 25 100 25 100 INPATIENTS SUBJECTS
CONVICTION FOR NUMBER PERCENT NUMBER PERCENT

Major crime only 3 12

TABLE 2
Alcohol only 2 8
Occupation
Drugs only 1 4 2 8
COMPARISON Minor crime only
INPATIENTS SUBJECTS
(including
STATUS NUMBER PERCENT NUMBER PERCENT
delinquency) 1 4 0
Unemployed 13 52 5 20 Major crime plus
Housewives 2 8 2 8 drugs, alcohol
Students 5 20 0 or minor crime 5 20
White-collar jobs 2 8 0 Minor crime plus
Artists 3 12 0 drugs or alcohol 4 16
Blue-collar jobs 0 18 72 None 23 92 9 36
Total 25 100 25 100 Total 25 100 25 100

Amer. I. Psychiat. 124: 11, May 1968 [431

1486 THE BAD TRIP

previous psychiatric history (see table 4). eluding heroin, while 20 percent had used
Sixteen percent had been in outpatient treat- multiple drugs including heroin. Thus 40
ment and eight percent had been inpatients. percent were chronic multiple drug users.
This is not significantly different from the Twenty percent had never used any drugs
44 percent of the inpatient group who had in the remote past. In the comparison group
had previous psychiatric care. in the remote past (before joining the Dis-
ciples) 32 percent had taken only psyche-
TABLE 4 delics, 44 percent were multiple drug users
Past Psychiatric Histo ry excluding heroin, and 24 percent were mul-
tiple drug users including heroin. Thus 68
COMPARISON
INPATIENTS SUBJECTS
percent were chronic multiple drug users. It
TREATMENT NUMBER PERCENT NUMBER PERCENT should be noted that none of these differ-
ences was statistically significant.
Outpatient 8 32 4 16
Diagnosis. As recorded in the hospital
Inpatient 3 12 2 8
None 13 52 19 76 charts, the resident psychiatrists diagnosed
Nodata 1 4 0 40 percent of the inpatients as psychotic
Total 25 100 25 100 and 28 percent as neurotic; diagnoses of
character disorder, borderline psychotic, and
multiple diagnoses accounted for eight per-
Drug history. Half of the inpatient group cent each (see table 6). Four percent each
were taking only LSD at the time of ad- were diagnosed as addict and adolescent
mission and the other half were taking both adjustment reactions. We compared these
LSD and marihuana or LSD and other diagnostic frequencies with a random sam-
drugs, in approximately equal numbers (see ple of 95 other inpatients in the same hos-
table 5). The comparison group was taking pital. The differences in frequency were
either LSD alone (44 percent) or LSD small and appeared to be random; greater
and marihuana (56 percent). It was part of differences would occur by chance seven
the Disciples religion not to take other times in ten.
drugs. No attempt was made o classify the com-
As for past drug history prior to six weeks parison group diagnostically since so many
before being seen in the emergency room, were functioning without symptoms, were
40 percent of the inpatient group had taken not in psychiatric treatment, and were work-
only psychedelics. Twenty percent of the in- ing at the time they were seen. Their indices
patient group had taken multiple drugs ex- of psychosocial disturbance were: previous

TABLE 5
Drug History

INP ATIENTS COMPAR lION SUBJECTS

DRUG USED NUMBER PERCENT NUMBER PERCENT

Current history
Marihuana + LSD 7 28 14 56
ISO only 12 48 11 44
Other 6 24 0
Total 25 100 25 100

(Over 6 weeks before (Before joining Disci-

Past drug history seen) pies)
Only psychedelics (marihuana, LSD, mesca-
line, psilocybin) 10 40 8 32
Multiple * (excluding heroin) 5 20 11 44
Multiple * (including heroin) 5 20 6 24
None 5 20
Total 25 100 25 100
* More than one of amphetamines,
barbiturates, alcohol, psychedelics, and tranquilizers.

[44] Amer. J. Psychiat. 124: 11, May 1968

UNGERLEIDER, FISHER, FULLER, AND CALDWELL 1487
TABLE 6
Diagnosis

COMPARISON
INPAT IENTS * INPAT IENTS ** SUBJECTS **
DIAGNOSIS NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT

Psychotic 3 12 1 4
Toxic (organic) 2 8
Functional 8 32
Neurotic 7 28 1 4 0
Character disorder 2 8 6 24 12 48
Borderline psychotic 2 8 6 24 4 16
Addict 1 4 0
Adolescent adjustment
reaction 1 4 0
Multiple diagnoses 2 8 6 24 3 12
Invalid (extreme F) 3 12
Undiagnosabie 5 20
Total 25 100 25 100 25 100
* Diagnosis via hospital chart.
* * Diagnosis by MMPI testing.

school trouble (28 percent dropped out of sonality disorder associated with passive-
high school), police trouble (64 percent), aggressive, antisocial, paranoid, and sexually
past psychiatric history (24 percent had had deviant trends.
previous outpatient or inpatient care), and The other comparison subject who was
past history of symptoms (one person ad- unable to abstract proverbs was a 24-year-
mitted to hallucinations while on LSD and old married father of two who had no pre-
another person had had anxiety symptoms vious psychiatric history. He had been on
prior to but not after taking LSD). Eighty marihuana, barbiturates, and dextroam-
percent of the group claimed to have extra- phetamine sulfate before joining the reli-
sensory perception when under LSD, but gious group two months prior to the initial
this was considered to be a part of their interviewing. He had a drug and theft po-
religious beliefs and not truly delusional. lice record and claimed to have had trouble
We did, however, assess psychopathology talking (stammering) which was cured by
on the mental status examination (for the LSD. He had used LSD approximately 40
comparison group) and by the MMPI (for times in reported doses of up to 900 jig.
both groups). On mental status examination Before he joined the group, LSD had caused
two comparison subjects showed a clinical the past to come rushing forth, and oc-
concreteness in their interpretations of prov- casionally suspicious thoughts, but this
erbs and one subject could not subtract was never true after joining the group.
sevens or threes serially. The latter subject About ten months after the initial inter-
subsequently volunteered that he had been view one of us (J.T.U.) received a call from
out of my head with pot at the time of the this mans wife. She stated that he had been
examination and then did the subtractions using LSD almost every day for several
correctly. months, and that she had just signed papers
One of the subjects who was unable to to have him committed to the hospital.
abstract stated that he often could not think However, he was refusing to talk to anyone
straight since he had begun to take LSD, but the senior author, and the judge had
but he had held his job as mechanic for 18 acquiesced. His wife stated that he had quit
months without difficulty. He had never seen his job and often stayed away from home,
a psychiatrist, but had been addicted to wandering about in the woods for days at a
barbiturates and dextroamphetamine sul- time. He refused to eat anything colored
fate in the remote past and had been ar- red and threw out everything red in their
rested several years previously for drunk house, and he frequently told her to shut up
driving. His MMPI revealed a definite per- while he conversed with Jesus and the saints.

Amer. I. Psychiat. 124: 11, May 1968 [45]

1488 THE BAD TRIP

The final straw for her was when he re- FIGURE 1

fused to pick up the unemployment checks. Frequency of Highest Elevations Among the Two Groups
When interviewed, he detailed his plans on the Eight Basic Clinical Scales of the MMP1 (Hypo-
chondriasis, Depression, Hysteria, Psychopathic Deviate,
for beginning a new church. He spoke about
Paranoia, Psychasthenia, Schizophrenia, and Hypomania)
green vapors interchanging from his body
lepat,ents (20 *al,d p*f,les) Cocpacsoe subjects
into the atmosphere through the umbilicus
and leaned forward to whisper, You
wouldnt eat anything red, would you? He
denied having any problems, however, and
claimed total happiness.
Another MMPI was obtained and com-
pared with that from the previous years
comparison group testing. His initial MMPI
(presymptomatic) showed a paranoid per-
sonality pattern. The second testing yielded
a very similar profile with even more guard-
edness, denial, and evasiveness.
A comparison of the MMPIs on both
groups revealed:
1. Most of the comparison subjects were Scales Hs 0 Hy Pd Pa Pt Sc Ma

Fequeecy 0 1 3 3 0 3 8 2 C S 14 1 0 0 4
quite defensive toward the MMPI (two-
thirds at least moderately so), and they did
ic patterns.
not exaggerate or fake sick. The inpatients
To summarize our results, the inpatient
did overstate; three profiles were clearly in-
and comparison groups did not show signifi-
valid, and several others were borderline.
cant differences in race, sex, age, educa-
Only one inpatient was notably defensive. tion, or early parental deprivation. Signifi-
2. PD (psychopathic deviate) was the
cant differences were found in marital status,
predominant peak in the comparison group
occupational history, and police records. Se-
and Sc (schizophrenia) was the most fre- vere psychopathology was seen clinically in
quent peak of the hospitalized group (see
the inpatient group while hospitalized. No
figure 1). All 25 inpatients had one or more
comparable clinical psychopathology was
deviant scores (elevations at or over a T evident in the comparison sample. The
score of 70). In contrast, only 11 of the 25
MMPI profiles clearly corresponded to these
comparison subjects had one or more path-
results, although the comparison group was
ological scores. Eight men among the com-
much more defensive toward the testing.
parison cases and none of the inpatients
(MMPI profiles are shown in figure 1.)
had the specific sexual deviation pattern
(Code 45 or Code 54). Discussion
3. A majority of the inpatients obtained
mixed, borderline, and overtly psychotic pat- It can be asked whether all those who had
terns; only five of the 25 comparison sub- chronic adverse LSD reactions were emo-
jects appeared borderline psychotic on the tionally predisposed or were to some degree
testing, although a few others were am- emotionally ill prior to LSD ingestion. This
biguously defensive. However, none of these is very difficult to answer. Well known at
five were openly schizoid patterns; rather, all many hospitals are the anecdotal reports
were of a controlled and potentially para- of local interns and residents who were
noid type. carefully screened before taking LSD (or
4. The comparison subjects obtained had even been psychoanalyzed) but who
character disorder types of patterns quite subsequently had severe adverse reactions
consistently, but niany of these were well from LSD. In addition there are now a num-
within the normal range. Although character ber of reports of nonprofessional persons
disorder elements occurred consistently in screened by psychiatric history and/or psy-
the profiles of the inpatients, they were chological testing who have had adverse
complex, niixed, and predominantly psychot- LSD reactions. Although 44 percent of our

[46] Amer. J. Psydmiat. 124: 11. May 1968

UNGERLEIDER, FISHER, FULLER, AND CALDWELL 1489

inpatients with a history of previous psy- after LSD( 1). There is an ever-growing
chiatric care is a high figure, it is certainly LSD mythology, too, much of it having to
less than 100 percent. None of the 24 per- do with set and setting( 6, 7). For exam-
cent of the comparison group who had ple, one commonly hears that a bad LSD
previous psychiatric treatment had difficulty experience will not result if:
from their ingestion of LSD. -One is in a calm frame of mind (no
Among psychiatric patients with LSD his- fights that day with spouse or employer);
tories, we are now seeing at the hospital -One takes the LSD with one or two
fewer chronic, multiple drug users who are good friends or with an experienced sitter or
obviously emotionally disturbed. Instead we guide present;
are seeing more teenagers who tried LSD -The room has soft lighting and a thick
once, for example at a party, got over its ef- carpet or mattress to sit on;
fects in 12 to 16 hours, but then presented -One is listening to the Indian music of
at a hospital some months later with recur- Ravi Shankar and reading reassuring phrases
rent symptomatology without ever having from the Tibetan Book of the Dead; and
taken the drug again. A decreasing propor- perhaps if one has a downer or chior-
tion of our patients are chronic drug users. promazine pill at hand.
However, it is not clearly demonstrable But we have hospitalized many persons
whether this is due to a change in incidence who had taken these precautions and who
or to a shift in selective referrals to our also had had up to 100 previous good LSD
hospital. experiences. Our inpatient group took their
This brings us to a consideration of set LSD in many varied settings, from kick-
or, specifically, the attitude with which one type, acid-test parties (56 percent) to iso-
approaches the LSD experience and the lated ingestions in their rooms (16 percent).
setting or environment in which one takes However, some (8 percent) were most care-
the LSD. Everyone recognizes the impor- ful and serious about the preparations for
tance of these factors in the LSD experi- taking LSD. (There were no data for set-
ence. In fact people now have psychedelic ting in 20 percent of the inpatient group.)
experiences in groups in the proper setting Despite their hospitalizations a large pro-
where they hallucinate, etc., but never take portion of the inpatients persisted in claim-
drugs at all(S). ing benefit from the drug and many re-
The parallels between the LSD subject turned to it after discharge.
and the good hypnotic subject are striking, How reliable were the data from our com-
particularly in the realm of passivity and parison group? Obviously they were prosely-
suggestibility. Our comparison group dressed tizers of LSD. This could explain why they
alike and even used identical phrases in all claimed no previous religion and even no
answering questions. One of their favorites religion for their parents. It also could ex-
was for sure, chanted over and over. plain why they claimed to have developed
They obviously received a tremendous ESP as well as to have found love from
amount of support, both during and be- LSD and also why they identified themselves
tween trips, from the group itself. The as a bunch of ex-criminals and drug ad-
average length of stay with the group was dicts before using the drug.
eight months, and 24 of the 25 controls
claimed that LSD (taken with the group)
Summary
had led them to God, love, or peace of
mind. They may thus have been successful
Twenty-five hospitalized psychiatric pa-
LSD users because the group support out-
weighed or overcame the adverse potentials tients with adverse LSD reactions were com-
of the drug. pared to a sample of 25 subjects who had
We should not conclude, however, that not had adverse reactions from the repeated
set and settings are the only determinants of use of LSD.
the type of trip one has. There is one study In all of our comparisons there were no
reported where all subjects expected psy- historical elements or current clinical aspects
chosis, but all felt only relaxed and friendly that were unique to either group. Clearly

A mner. I. Psychiai. 124: 11, May 1968 [47]

1490 THE BAD TRIP

there is no single factor that guarantees im- of LSD-25. New York: Atherton Press, 1964.

munity from an adverse LSD reaction. The 2. Brill, N. Q., and Liston, E. H., Jr.: Parental
Loss in Adults with Emotional Disorders,
prediction of successful versus unsuccessful
Arch. Gen. Psychiat. 14:307-314, 1966.
users is further complicated by the occur-
3. Cohen, S.: LSD: Side Effects and Complica-
rence of cases in which subjects used LSD tions, J. Nerv. Ment. Dis. 130:30-40, 1960.
100 times or more with no adverse reactions 4. Cole, J. 0., and Katz, M. K.: The Psychot-
and then subsequently developed psychiatric omimetic Drugs: An Overview, in Solomon,
symptomatology. Set and setting appear to D., ed.: LSD: The Consciousness Expanding
help but not to guarantee against adverse Drug. New York: G. P. Putnams Sons, 1964.

complications. 5. Hoffman, R.: The Psychedelic Game, Made-

moiselle, March 1966, p. 179.
One hypothesis, strongly supported by our
6. Ungerleider, J. T., and Fisher, D. D.: LSD:
test data, is that the LSD interacts with
Research and Joyride, The Nation 202:574-
schizoid trends, unsteady reality testing,
576, May 16, 1966.
and related psychological factors. Such a
7. Ungerleider, T., and Fisher,
J. D. D.: LSD:
complex interaction-which is difficult to
Factand Fantasy, Arts and Architecture 83:
anticipate even with the best of clinical and 18-20, December 1966.
test data-would predict that adverse LSD 8. Ungerleider, J. T., and Fisher, D. D.: The
reactions will be with us for some time to Problems of LSD and Emotional Disorders,
come. Calif. Med. 106:49-55, 1967.
9. Ungerleider, J. T., Fisher, D. D., and Fuller,
REFERENCES
M.: The Dangers of LSD, J.A.M.A. 197:
1. Blum, R., ed.: Utopiates: The Use and Users 389-392. 1966.

I am resolved to grow fat, and look young till forty.

-JOHN DRYDEN

[48] Amer. J. Psychiat. 124: 11, May 1968