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The Betel Nut Withdrawal: an Often Overlooked Psychiatric Condition?

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The Betel Nut Withdrawal: an Often Overlooked Psychiatric Condition? • 54 • Taiwanese Journal of Psychiatry (Taipei) Vol. 25 No. 1 2011 Case Report The Betel Nut Withdrawal: An Often Overlooked Psychiatric Condition? Yung-Lung Chen, M.D.1, Winston W. Shen, M.D.1,2, Mong-Liang Lu, M.D., M.S.1,2 Objective: The use of betel nut has been widespread in Southeast Asia and the south Pacifi c islands. Betel nut-chewing leads to habituation, addiction, and with- drawal. We report a case of a patient with betel nut withdrawal which had been an often overlooked psychiatric problem. Case Report: A 51-year-old male patient with habitual chewing of betel nuts developed withdrawal symptoms after stop- ping his betel nut use. Those symptoms included mood swings, anxiety, sleep dis- turbances, and fl u-like symptoms. His symptoms were resolved after receiving supportive pharmacological treatments with a low dose of antidepressant/anxio- lytic and hypnotics. Conclusion: Our patient in this case report supported the con- cept of clinically identifi able betel nut withdrawal and its dependence, which can be diagnosed using criteria similar to those currently used for other substances of abuse. Based on the report in this case and those in the literature, we are calling at- tention to this psychiatric problem of betel use. Key words: betel nut, withdrawal, dependence (Taiwanese Journal of Psychiatry [Taipei] 2011; 25: 54-7) the south Pacifi c islands [1-3]. In Taiwan, the be- Introduction tel nut is also called “Taiwanese chewing gum.” People who habitually chew betel nuts, are esti- The betel nut is the fourth most commonly mated about 2.4 million, or 11.4% of the total used addictive substance worldwide after tobacco, population in Taiwan [4]. alcohol, and caffeine [1]. The use of betel nut has The betel nut is traditionally masticated as a been known since the fourth century A.D. for its quid along with various ingredients, such as betel both medical and psychosomatic purposes, e.g. as leaf, slaked lime, catechu, different types of to- a breath refresher, digestive agent, worm expel- bacco, other additives, perfumes, and stimulants lent, and maintaining energy [2]. The use of betel [2]. Complex reactions and interactions may oc- nuts has been widespread in Southeast Asia and cur while chewing the betel quid. The betel nut 1 Department of Psychiatry, Taipei Medical University-Wan Fang Medical Center, Taipei, Taiwan 2 Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan Received: July 23, 2010; revised: September 27, 2010; accepted: October 12, 2010 Address correspondence to: Dr. Mong-Liang Lu, Department of Psychiatry, Taipei Medical University-Wan Fang Medical Center, No. 111, Section 3, Hsin-Long Road, Taipei 116, Taiwan Chen YL, Shen WW, Lu ML • 55 • has four major alkaloids: arecoline, arecaidine, ance, craving, and loss of control of the amount of guvacoline, and guvacine. Arecoline, the major chewing betel. He continued to chew betel nuts alkaloid of betel nut, has been extensively studied, despite knowing the physical problems such as and has been thought to be responsible for most oral cancer that betel nut-chewing might cause. claimed effects. Arecoline is a parasympathomi- He chewed nearly 600 pieces of betel quid every metic tertiary amine that has action on both nico- day to maintain his alertness during work in the tinic and muscarinic receptors [2, 3, 5]. In the recent one year. He had ever attempted to cut presence of lime, arecoline and guvacoline are hy- down the habit of betel nut-chewing but he failed drolyzed into arecaidine and guvacine, respective- repeatedly. ly, which are strong inhibitors of GABA uptake In the past two years, he spent most of the [2, 5]. In addition, piper leaf contains aromatic time in China and did not have any adjustment or phenolic compounds which can stimulate the re- mood problems over there. He continued to smoke lease of cateholamines, causing sympathetic acti- and drink alcohol as he did previously in Taiwan. vation [5]. Thus, betel nut-chewing may affect the But he was involuntary to stop chewing betel nuts, central and autonomic nervous systems through which were not available in the city he worked, its cholinergic (parasympathetic), adrenergic while he went to China for work. Then, he suf- (sympathetic), and GABAnergic, functions. fered from anxiety, dysphoric mood, and insom- The claimed effects of betel nut-chewing are nia after he stopped chewing betel nuts. Those to produce a sense of well-being, euphoria, height- symptoms were associated with poor appetite, ened alertness, sweating, salivation, warm sensa- nausea, diarrhea, and symptoms of upper respira- tion of the body, and feeling of having increased tory tract infection such as generalized malaise capacity to work [2, 5]. Many labor workers chew and running nose. This clinical picture had lasted large amount of betel nuts in the working hours to for about one and half month, making him to come enhance their physical activity. Previous reports back to Taiwan for seeking medical attention. The have suggested that betel nut-chewing leads to ha- symptoms were more severe initially for 3-4 days, bituation, withdrawal, and addiction, although the and attenuated during the following one week. underlying mechanisms remain poorly understood The periods of having mild and severe symptoms [6, 7]. In comparison with the well-known role of alternated with each other. The patient thought chewing betel nuts in causing oral cancers, the that those symptoms were related to the cessation psychiatric consequences produced by betel nut- of betel use because he had experienced the simi- chewing remain underestimated. lar symptoms while he reduced the amount of be- Here, we report the case of a patient whose tel use previously but those were not severe as in psychiatric symptoms could be traced to with- the past. drawal from the betel nut use. As the patient’s report, his symptoms got gradually improved after he came back to Taiwan Case Report and he did not chew betel nut after he came back to Taiwan. He thought those symptoms were A 51-year-old male patient had the history of caused by the fact that he stopped chewing betel habit of having chewed betel nuts for over 10 nuts but he was not sure. He visited our psychiat- years. The patient had developed features of toler- ric clinic for consultation of those symptoms and • 56 • Betel Nut Withdrawal also wished to quit from betel nuts. We prescribed developing more severe dependence [1]. Previous him melitracen 10 mg /fl upentixol 0.5 mg studies also showed that women and younger peo- (Deanxit®) 1 tablet t.i.d. and estazolam 2 mg h.s., ple especially those from rural and/or lower socio- p.r.n. for his sleep disturbances and anxiety of be- economic backgrounds with poorer educational tel nuts withdrawal. attainment are more likely to use betel nut prod- ucts [1, 3]. Discussion In Taiwan, the betel nut-chewers are grow- ing. The distribution of the betel nut-chewing Our patient developed dysphoric mood, anx- population is concentrated on blue-collar workers iety, insomnia, and symptoms that resembled up- or less-educated people in urban areas [9]. But per respiratory tract infection after his stopping this situation is changing and the habit has gradu- betel nut-chewing. A clear temporal relation exist- ally been spreading to those of younger genera- ed between the onset of those symptoms and the tions and more highly educated people, and be- cessation of betel nut use. Arecoline, the principal coming generally widespread in all areas of alkaloid in betel nut, acts as an agonist primarily Taiwan [10]. In the study of Wang et al., more at muscarinic acetylcholine receptors, and causes than 10% of senior high school students admitted increases in the levels of monoamines such as nor- that they themselves chew betel nuts [10]. The adrenaline. This leads to subjective effects of in- prevalence of chewing betel nuts among students creased well-being, alertness and stamina. is increased when urbanization of the related areas Arecaidine, another active ingredient, may have is decreased [10]. anxiolytic properties throught inhibition of GABA The psychiatric aspects of betel use have reuptake [1] . Previous reports describe mild with- been less addressed in previous studies. We pre- drawal syndrome of betel nut, including poor con- sented this case of a patient with betel nut with- centration, mood swings, feeling uneasy, anxiety, drawal, to call clinicians’ attention to be aware of fi dgeting, despondence, general lassitude, sleep the psychiatric consequences caused by betel nut- disturbances, and even episodes of paranoia [2, 5, chewing, and its potential of dependence. 7]. Those withdrawal symptoms have been report- ed even among mild habituated abusers, suggest- References ing rapid infl uences of active components on the neurochemical system within the body [5, 7]. 1. Benegal V, Rajkumar RP, Muralidharan K: Does are- This patient had also met the criteria of de- ca nut use lead to dependence? Drug Alcohol Depend pendence despite that betel nut use was not men- 2008; 97: 114-21. tioned specifi cally in DSM-IV-TR [8]. In the study 2. Burton-Bradley BG: Arecaidinism: betel chewing in of Benegal et al., about 38.8% current users of be- transcultural perspective. Can J Psychiatry 1979; 24: 481-8. tel nuts develop a clearly recognizable clinical 3. Chandra PS, Carey MP, Carey KB, Jairam KR: picture of dependence, fulfi lling DSM-IV-TR cri- Prevalence and correlates of areca nut use among teria of dependence [1]. In that study, investiga- psychiatric patients in India. Drug Alcohol Depend tors identifi ed that increased frequency of use, 2003; 69: 311-6. larger quantities used on typical use occasions, 4.
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