Acute GBL Withdrawal Delirium in an Adolescent – Letter Response

We have read Dr. Fink's comments on our case report on a 16-year-old boy with severe gamma-butyrolactone (GBL) withdrawal delirium [4] with great interest and appreciate the comments he has made. However, the clinical observations which we made and presented in our case report did not allow us to diagnose a delirious mania (DM) which we find inappropriate in this case. The patient was delirious but not manic.

The patient only fulfilled the criteria for delirium, i. e., the sudden onset of complete disorientation in time and place, delusions and disorganized behaviour. However, these symptoms are not specific to DM: they are also characteristic features of a withdrawal delirium. Other than this symptom complex, no manic symptoms were observed (i. e., no feelings of grandiosity or elation). This ruled out the diagnosis of DM. In addition, the delirium was not toxic in terms of an over-ingestion as stated by Dr. Fink, but was related to the acute withdrawal of GBL.

Dr. Fink suggested ECT might have been an appropriate intervention for our patient. The use of ECT with children and adolescents is controversial in many countries, including Germany for ethical reasons. According to the treatment guidelines of the German Society for Child and Adolescent Psychiatry and Psychotherapy (DGKJP) the evidence supporting the safety and efficiency of ECT with children and adolescents with mania or bipolar affective disorders is currently insufficient. The uncritical use of ECT with these patients should be avoided before other therapeutic options have been implemented [1]. In accordance with this ECT was not appropriate in the above-mentioned case. However, we are aware of the fact that ECT is used more frequently in other countries and may be an option of treatment in certain cases, particularly if the patient suffers from DM. This was definitely not the case with the patient we described.

The dosage of benzodiazepines to which Dr. Fink refers also deserves comment as there are virtually no evidence-guided recommendations on how to treat acute GBL-withdrawal delirium in adolescents. Thus the authors had to refer to the adult literature [2] [3], keeping their eyes on ethical issues and alternative treatment strategies, such as the dosage of drugs. Consequently moderate dosages of benzodiazepines were used and side-effects related to treatment with benzodiazepines were monitored cautiously.

We appreciate the suggestions made but must stress that the diagnostic criteria for DM were not met in the case presented.

References

• 1 Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (DGKJP) . u. a. (Eds) Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kindes- und Jugendalter.  Deutscher Ärzte Verlag, 3. überarbeitete Auflage. 2007;  45-56
• 2 Kasper S. In: Möller, Laux, Kapfhammer (Eds). Psychiatrie und Psychotherapie, Band 1. 2008: 669-675
• 3 Zepf FD, Holtmann M, Duketis E. et al . Withdrawal syndrome after abuse of GHB (gamma-hydroxybutyrate) and its physiological precursors − its relevance for child and adolescent psychiatrists.  Z Kinder Jugendpsychiatr Psychother. 2009;  37 413-420
• 4 Zepf FD, Holtmann M, Duketis E. et al . A 16-year-old boy with severe gamma butyrolactone (GBL) withdrawal delirium.  Pharmacopsychiatry. 2009;  42 202-203

Correspondence