Chronic gamma-hydroxybutyric-acid use followed by gamma-hydroxybutyric-acid withdrawal mimic schizophrenia: a case report

INTRODUCTION: Gamma-hydroxybutyric-acid is a potentially addictive drug known for its use in “rave” parties. Users have described heightened sexual drive, sensuality and emotional warmth. Its euphoric, sedative and anxiolytic-like properties are also sought by frequent users. Abrupt gamma-hydroxybutyric-acid withdrawal can rapidly cause tremor, autonomic dysfunction and anxiety, and may later culminate in severe confusion, delirium, auditory, visual or tactile hallucinations, or even death. CASE PRESENTATION: A 23-year-old woman presented to the emergency room with paranoid delusions and auditory hallucinations. Her psychiatric history included two brief psychotic episodes induced by amphetamines and marijuana. In the last six months, she had demonstrated bizarre behaviour, had been more isolated and apathetic, and unable to take care of daily chores. The patient reported occasional use of gamma-hydroxybutyric-acid, but her initial accounts of drug use were contradictory. Since the toxicology urine screen was negative, a schizophrenic disorder was initially suspected and an antipsychotic medication was prescribed. A few hours after her admission, signs of autonomic dysfunction (tachycardia and hypertension) appeared, lasting 24 hours. Severe agitation and confusion were also present. Restraints and a cumulative dose of 7 mg lorazepam were used to stabilize her. The confusion resolved in less than 72 hours. The patient then revealed that she had been using gamma-hydroxybutyric-acid daily for the last six months as self-medication to treat insomnia and anxiety, before stopping it abruptly 24 hours prior to her visit. CONCLUSIONS: In our opinion, this original case illustrates the importance of considering gamma-hydroxybutyric-acid withdrawal delirium in the differential diagnosis of a first-break psychosis. In this case, the effects of chronic GHB use were incorrectly identified as the negative symptoms of schizophrenia prodrome. Likewise, severe gamma-hydroxybutyric-acid withdrawal syndrome was initially mistaken for acute positive symptoms of schizophrenia, until autonomic dysfunction manifested itself more clearly.