eMedicine Specialties > Psychiatry > Addiction

Sedative, Hypnotic, Anxiolytic Use Disorders: Differential Diagnoses & Workup

Author: Christopher L Sola, DO, Assistant Professor in Psychiatry, Mayo Clinic School of Medicine; Medical Director of Inpatient Medical Psychiatry Program, Department of Psychiatry and Psychology, Mayo Clinic
Coauthor(s): Amit Chopra, MD, Resident Physician, Department of Psychiatry, Mayo Clinic, Rochester; Abhinav Rastogi, MBBS, MRCPsych, Resident Psychiatrist, Stratford Road Day Centre, Birmingham, UK
Contributor Information and Disclosures

Updated: Jan 29, 2010

Differential Diagnoses

Alcohol-Related Syndromes
Mood Disorders
Amphetamine-Related Psychiatric Disorders
Pheochromocytoma
Anxiety Disorders
Schizophrenia
Cerebellar Disease
Seizure Disorders
CNS Structural or Degenerative Disorders
Thyrotoxicosis
Cocaine-Related Psychiatric Disorders
Toxicity, Anticholinergic
Delirium Tremens
Toxicity, Sympathomimetic
Electrolyte Disorders
Vasculitic or Infectious Disorders
Endocrine Disorders
Hyperthyroidism
Metabolic Disorders

Other Problems to Be Considered

Sedative/hypnotic/anxiolytic withdrawal syndromes

Delirium tremens and other alcohol-related syndromes
Substance withdrawal (amphetamines, cocaine)
Anticholinergic or sympathomimetic drug overdoses
Anxiety disorders
Mood disorders
Schizophrenia
Seizure disorders
Pheochromocytoma
Thyrotoxicosis

Sedative/hypnotic/anxiolytic toxicity syndromes

Substance intoxication (ethanol intoxication, gamma hydroxybutyrate [GHB])
Electrolyte, metabolic, or endocrine derangements
Stroke
Encephalitis/meningitis
CNS structural or degenerative disorders
Cerebellar disease
CNS vasculitic disorders
Carbon monoxide poisoning

Workup

Laboratory Studies

  • Careful review of the patient's history and examination should typically suffice; however, further studies may be performed to rule out an underlying pathology with a similar presentation. This is particularly relevant if the patient presents with severe symptoms or when a reliable history cannot be obtained. Workup depends on presenting symptoms (intoxication/withdrawal), especially if no prior knowledge of ingestion of sedatives is known. If a laboratory workup is necessary, it should include the following:
    • Appropriate laboratory investigations are performed in patients with fever or other signs of infection. CBC, urinalysis, and chest radiography (CXR) should be performed, particularly in elderly patients.
    • Comprehensive metabolic panel to assess for metabolic encephalopathy seen in hepatic and renal failure and other electrolyte derangements that can mimic sedative and anxiolytic intoxication.
    • Fingerstick glucose, to rule out hypoglycemia as the cause of any alteration in mental status
    • Arterial blood gasses to rule out blood gas abnormalities secondary to respiratory depression. Carbon monoxide poisoning should be ruled out, if suspected, by obtaining carboxyhemoglobin level measured by cooximetry of a blood gas sample.
    • Urine drug screen including CNS depressants, cannabis, PCP, and stimulants such as amphetamines and cocaine
    • Ethanol and phenobarbital intoxication can be ruled out by obtaining serum concentrations.
    • Serum drug levels if the patient is known to take lithium, carbamazepine, valproic acid, or TCAs, to rule out concomitant psychotropic drug toxicity
    • Acetaminophen and salicylate levels, to rule out these common coingestions
    • Thyroid panel, as thyrotoxicosis and hypothyroidism can mimic sedative-hypnotic withdrawal and overdose states, respectively

Imaging Studies

  • CT/MRI of the head, to rule out space-occupying lesions and intracranial bleeding

Other Tests

  • ECG may be helpful to rule out arrhythmias, which can increase the probability of emboli to the brain and cause altered mental status.
  • Consider an EEG, as it may show paroxysmal bursts of high-voltage, slow-frequency activities that precede the development of seizures in the setting of sedative-hypnotic withdrawal. In the context of hallucinations, EEG may rule out neurologic conditions such as temporal lobe epilepsy.

Procedures

  • Consider a lumbar puncture, if meningitis/encephalitis suspected.

More on Sedative, Hypnotic, Anxiolytic Use Disorders

Overview: Sedative, Hypnotic, Anxiolytic Use Disorders
Differential Diagnoses & Workup: Sedative, Hypnotic, Anxiolytic Use Disorders
Treatment & Medication: Sedative, Hypnotic, Anxiolytic Use Disorders
Follow-up: Sedative, Hypnotic, Anxiolytic Use Disorders
References
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References

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Further Reading

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Keywords

sedatives, hypnotics, anxiolytics, benzodiazepine abuse, barbiturate abuse, drug abuse, addiction

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Contributor Information and Disclosures

Author

Christopher L Sola, DO, Assistant Professor in Psychiatry, Mayo Clinic School of Medicine; Medical Director of Inpatient Medical Psychiatry Program, Department of Psychiatry and Psychology, Mayo Clinic
Christopher L Sola, DO is a member of the following medical societies: Academy of Psychosomatic Medicine, American Medical Association, American Osteopathic Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Amit Chopra, MD, Resident Physician, Department of Psychiatry, Mayo Clinic, Rochester
Disclosure: Nothing to disclose.

Abhinav Rastogi, MBBS, MRCPsych, Resident Psychiatrist, Stratford Road Day Centre, Birmingham, UK
Disclosure: Nothing to disclose.

Medical Editor

Jennifer S Morse, MD, Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego
Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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