eMedicine Specialties > Psychiatry > Addiction

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

Author: Joji Suzuki, MD, Fellow in Addiction Psychiatry, Department of Psychiatry, Boston University School of Medicine
Coauthor(s): Christopher L Sola, DO, Clinical Assistant Professor, University of Vermont, College of Medicine; Director of Consultation-Liaison Psychiatry, Department of Psychiatry, Maine Medical Center; Olakunle PA Akinsoto, MD, Consulting Staff, Family Health Center, Jacksonville Medical Center
Contributor Information and Disclosures

Updated: Jun 8, 2006

Differential Diagnoses

Alcohol-Related Psychosis
Hyperthyroidism
Amphetamine-Related Psychiatric Disorders
Pheochromocytoma
Anxiety Disorders
Cocaine-Related Psychiatric Disorders
Head Trauma

Other Problems to Be Considered

Withdrawal syndromes

Delirium tremens and other alcohol-related syndromes
Pheochromocytoma
Thyrotoxicosis
Anxiety disorders
Psychotic illnesses
Anticholinergic or sympathomimetic drug overdoses
Schizophrenia
Seizure disorders
Mood disorders

Toxicity syndromes

Electrolyte, metabolic, or endocrine derangements
CNS structural or degenerative disorders
Cerebellar disease
Vasculitic or infectious disorders
Posttraumatic stress disorder

Workup

Laboratory Studies

  • Careful review of the patient's history and examination will typically suffice; however, further studies may be performed to rule out an underlying pathology with a similar presentation. This is particularly true if the patient presents with severe symptoms or when a reliable history cannot be obtained. Workup depends on the type of presenting disorder, especially if no prior knowledge of ingestion of sedatives is known. If a laboratory workup is necessary, it should include the following:
    • 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.
    • Thyroid panel, as thyrotoxicosis and hypothyroidism can mimic sedative withdrawal and overdose disorders, respectively
    • Toxicity screen, including CNS depressants, cannabis, PCP, and stimulants such as amphetamines and cocaine
    • Serum drug levels if patient is known to take lithium, carbamazepine, valproic acid, or TCAs
    • Blood alcohol level
    • Arterial blood gasses
    • Urinalysis

Imaging Studies

  • CT scan of head to rule out space-occupying lesions, intracranial bleeding, and certain CNS infections (eg, toxoplasmosis, Cryptococcus)
  • MRI of the head if the CT scan is unremarkable and a space-limiting lesion is suspected, or if intravenous (IV) contrast is contraindicated

Other Tests

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

Procedures

  • Consider a lumbar puncture, depending on the symptoms. If seizures are suspected, complete an EEG.

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

  1. Allgulander C, Borg S, Vikander B. A 4-6-year follow-up of 50 patients with primary dependence on sedative and hypnotic drugs. American Journal of Psychiatry. 1984;141(12):1580-2.

  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington, DC: American Psychiatric Press, Inc. 2000.

  3. Bernstein J. Handbook of Drug Treatment in Psychiatry. 3rd ed. 1995.

  4. Freidman L, Flemming N F. Source book of Substance Abuse and Addiction. 1996.

  5. Galanter M, Kleber HD, eds. Textbook of Substance Abuse Treatment. 3rd ed. American Psychiatric Publishing;. 2004.

  6. Gilman, Ruddon, Limgird. Goodman & Gilman: Pharmacological Basis Therapeutics. 9th ed. 1996.

  7. Kaplan, Sadock. Comprehensive Textbook of Psychiatry VI. 6th ed. 1995.

  8. Karch Steven B, ed. Drug Abuse Handbook. CRC Press:1997.

  9. Katzung. Basic & Clinical Pharmacology. 7th ed. 1996.

  10. Rabe-Jablonska J, Bienkiewicz W. [Anxiety disorders in the fourth edition of the classification of mental disorders prepared by the American Psychiatric Association: diagnostic and statistical manual of mental disorders (DMS-IV -- options book]. Psychiatr Pol. Mar-Apr 1994;28(2):255-68. [Medline].

  11. Simon R. Psychiatry and Law for Clinicians. 2nd ed. 1998.

  12. Teifion Davies, TKJ Craig. ABC of Mental HealthBritish Medical Journal. BMJ Books. 1998:39-42.

  13. Weaver MF, Jarvis MA, Schnoll SH. Role of the primary care physician in problems of substance abuse. Arch Intern Med. May 10 1999;159(9):913-24. [Medline].

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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

Joji Suzuki, MD, Fellow in Addiction Psychiatry, Department of Psychiatry, Boston University School of Medicine
Joji Suzuki, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher L Sola, DO, Clinical Assistant Professor, University of Vermont, College of Medicine; Director of Consultation-Liaison Psychiatry, Department of Psychiatry, Maine Medical Center
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.

Olakunle PA Akinsoto, MD, Consulting Staff, Family Health Center, Jacksonville Medical Center
Olakunle PA Akinsoto, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jennifer S Berg, MD, Program Director, Department of Psychiatry, Naval Medical Center San Diego; Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego
Jennifer S Berg, MD is a member of the following medical societies: Aerospace Medical Association and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

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; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other

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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