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Letter to the Editor   |    
?-Hydroxybutyrate Dependence With Social Phobia
GEORGE TRENDELENBURG, M.D.; ANDREAS HEINZ, M.D.; ANDREAS STRÖHLE, M.D.
Am J Psychiatry 2004;161:375-376. doi:10.1176/appi.ajp.161.2.375

To the Editor: γ-Hydroxybutyrate (GHB), an endogenous γ-aminobutyric acid (GABA) metabolite with a short half-life, is a neurotransmitter and an emerging drug of abuse. First isolated in 1960, GHB was found to be a CNS depressant with similarities to classical sedatives/hypnotics, such as barbiturates and benzodiazepines. GHB binds reversibly to specific GHB receptors, although its mechanism of action is poorly understood (1). Clinically, it has been used as an anesthetic and to treat alcohol and opioid dependence (2), and it has been recently approved by the Food and Drug Administration for the treatment of narcolepsy. In the last decade, the use of GHB as a club drug (sold as "liquid X," "liquid ecstasy," "soap," "salty water," etc.) dramatically increased in the United States because of its mild euphoric and sedative effects. Case reports of physical dependence and of a severe withdrawal syndrome have been reported (1). We report on a patient who "successfully" self-treated his social phobia with GHB and became dependent.

Mr. A was a 24-year-old highly educated European man who became psychiatrically ill with symptoms of social phobia at age 15 without having any other psychiatric disorder, according to DSM-IV. Because of his symptoms, he feared and avoided a variety of social and performance duties required during his university studies. During a practical course in China 4 years before, he followed the advice of a French physician and self-administered GHB, finally in a dose of 20 g/day.

GHB was obtained by means of the Internet and applied every 90–120 minutes. According to Mr. A, his symptoms of social phobia completely vanished under GHB treatment. However, sleep disturbances appeared, and finally, a single sleep period did not exceed 4 hours. Two hours after each drug administration, he experienced withdrawal symptoms, such as agitation, insomnia, sweating, trembling, tachycardia, and overheating. Six attempts at self-managed abstinence were unsuccessful. Finally, he applied to our institute and was admitted to the ward. GHB withdrawal with transient administration of diazepam (up to 40 mg/day) was successfully accomplished without complications. We started treatment with paroxetine and cognitive behavior therapy. We applied the Liebowitz Social Anxiety Scale before and after withdrawal and observed 70% less total social anxiety than during GHB intake. This is well above the 39.1% mean reduction in score after paroxetine treatment, as reported by Stein et al. (3).

To our knowledge, this is the first report of a patient who self-treated his social phobia—the third most common psychiatric disorder—with GHB and who subsequently developed GHB dependency. GHB has been shown to possess anxiolytic effects in some animal models (1). However, anxiolytic properties in humans apparently have never been studied explicitly. Because of the potential anxiolytic properties of GHB, patients with anxiety disorders may be at a higher risk of abusing GHB and becoming dependent on this sedative drug. In addition, its anxiolytic properties, the therapeutic potential of GHB, and the exact mode of action deserve further research.

Nicholson KL, Balster RL: GHB: a new and novel drug of abuse. Drug Alcohol Depend  2001; 63:1–22
[PubMed]
 
Gallimberti L, Canton G, Gentile N, Ferri M, Cibin M, Ferrara SD, Fadda F, Gessa GL: Gamma-hydroxybutyric acid for treatment of alcohol withdrawal syndrome. Lancet  1989; 2:787–789
[PubMed]
 
Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I: Paroxetine treatment of generalized social phobia (social anxiety disorder). JAMA  1998; 280:708–713
[PubMed]
[CrossRef]
 
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References

Nicholson KL, Balster RL: GHB: a new and novel drug of abuse. Drug Alcohol Depend  2001; 63:1–22
[PubMed]
 
Gallimberti L, Canton G, Gentile N, Ferri M, Cibin M, Ferrara SD, Fadda F, Gessa GL: Gamma-hydroxybutyric acid for treatment of alcohol withdrawal syndrome. Lancet  1989; 2:787–789
[PubMed]
 
Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I: Paroxetine treatment of generalized social phobia (social anxiety disorder). JAMA  1998; 280:708–713
[PubMed]
[CrossRef]
 
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Gamma-hydroxybutyrate dependence with social phobia. Am J Psychiatry 2004;161(2):375-6.