Psychosis associated with ayahuasca: A narrative review of traditional use, vulnerability, and case evidence

ABSTRACT

Ayahuasca, a traditional Amazonian brew containing N,N-dimethyltryptamine (DMT) and β-carboline monoamine oxidase inhibitors, has expanded globally beyond Indigenous ceremonial systems. While acute visionary and psychotomimetic effects are expected and culturally integrated in ritual contexts, concerns have emerged about persistent psychotic symptoms in vulnerable individuals. This narrative review examines anthropological and clinical distinctions between culturally normative visionary experiences and pathological psychosis, and evaluates vulnerability, pharmacological mechanisms, and case-based outcomes. A narrative search was conducted in PubMed, Scopus, Web of Science, SciELO, and Google Scholar (2007–2025), including anthropological, pharmacological, clinical, and forensic evidence. Eligible sources comprised clinical studies, case reports, case series, systematic reviews, and documented ritual practices. Non-documented anecdotal reports were excluded. Psychotic reactions associated with ayahuasca are uncommon in screened participants within supervised ceremonial or research settings. Reported cases involve individuals with personal or familial vulnerability to psychosis or bipolar disorder, concomitant serotonergic drug use, schizotypal traits, or early trauma. Both transient and persistent courses have been described, including forensic cases. Culturally embedded visionary experiences are more prone to being pathologized when ayahuasca use takes place in nontraditional, hybrid, or inadequately supervised environments that lack shared interpretive frameworks. Ayahuasca is not a robust inducer of persistent psychosis in culturally embedded or clinically supervised use. Nevertheless, psychotic or manic episodes may occur in vulnerable individuals, particularly in globalized, unsupervised, or pharmacologically adulterated settings. Safety requires psychiatric screening, regulation of hybrid practices and protection of Indigenous frameworks to balance clinical risk reduction with cultural integrity.