Harmen Beurmanjer

45 Illness Perception in Patients with GUD 3 and night every few hours in order to supress withdrawal symptoms and negative affect. Participants often turned to combination use with benzodiazepines in reaction to withdrawal symptoms. The initial positive associations with GHB use remained present in this phase. Although users did become aware that something is wrong, consecutive GHB use made them forget this. This lead to a situation where they were either awake and intoxicated, or sleeping due to a GHB induced coma by intentional overdosing. During this phase GHB use was perceived as both the source and the solution to their problems. The described changes in affect and subsequent changes in behaviour could be caused by changes in the neurocircuitry, which are also described in the development of other substance use disorders (Koob, 2006; Koob & Simon, 2009; Koob & Volkow, 2016). In our study participants showed a mainly positive view towards the use of GHB, “it made them a better person”. One explanation for the positive view towards GHB was explained by the absence of negative feedback loops. The substance has strong rewarding effects and participants feel no negative effects such as a hangover after alcohol or stimulants use (Snead 3rd & Gibson, 2005). This and the almost instant intoxicating effects of the substance could explain why the participants remain to have positive associations with GHB. Another explanation is that some studies suggest that GHB has antidepressant properties (Bosch & Seifritz, 2016; Ha et al., 2009) The realisation that GHB has downsides usually came during the negative reinforcement phase, when participants enrolled into treatment. After detoxification they realized that the years of active GUD led to limited education, unemployment, social isolation, and or loss of a sense of purpose. This and the remaining positive association towards GHB can lead to a vicious cycle when there is no reasonable alternative for the substance use (McKay, 2017). For GUD patients their experienced psychological problems (mainly anxiety and depression) increased after detoxification, this is then followed by renewed GHB use, relapse and another detoxification, at which point the burden of psychological problems increased again. This process is seen often in patients with SUD, for instance in alcohol (Schellekens, de Jong, Buitelaar, & Verkes, 2015). Patients with alcohol use disorder who suffered from co morbid anxiety disorders were more prone to show early relapse after detoxification. The expressed treatment needs by participants were mainly aimed towards dealing with depression and anxiety, and not towards GHB or abstinence. Participants in the current study mentioned that their “real” problems started only after detoxification. According to the participants, treatment for GUD should focus on psychological problems, helping patients get proper housing, a supportive social network andmeaningful daytime activities and/or work. Abstinence was initially not rewarding to the participants, but made them feel worse. This is not uncommon in substance dependent patients, as after long term substance use they sometimes have few positive reinforcements left in their life, outside the drug itself (McKay, 2017; McLellan, Lewis, O’Brien, & Kleber, 2000). Besides psychological problems, treatment for GUD should, according to the participants, be focused on helping patients get proper housing, a supportive social