Sedative- Hypnotic- or Anxiolytic-Related Disorders
According to the American Psychiatric Association (2013), the diagnostic criteria for sedative-, hypnotic- or anxiolytic-related disorders include problematic use of these agents which in turn result in significant distress or impairment that is manifested by the presence of two or more symptoms within 12 months. These symptoms include:
- Continued use despite persistent adverse side-effects, tolerance, and withdrawal
- Excessive time spent obtaining these substances
- The inability to reduce usage
- Taking larger amounts of these substances than before
- Impaired performance at school, work, or home due to substance abuse
- Continued use of these agents despite social and interpersonal problems related to usage
- Using agents in dangerous and inappropriate situations
- A lot time spent on trying to recover from these agents (APA, 2013)
This disorder can further be categorized as mild, moderate or severe. This categorization depends on the number of symptoms displayed by the patient. Mild disease is defined by the presence of 2-3 symptoms. 4-5 symptoms indicate moderate disease and severe disease is defined by the presence of 6 or more symptoms.
The disease can further be specified by the presence of early remission or sustained remission. Early remission is when no criteria has been met for a period of at least 3 months and not more than 12 months. Sustained remission is the presence of no criteria for a period of 12 months or more.
The principles of treatment and rehabilitation aim to achieve complete abstinence and a return to normal living. For better effectiveness, an individualized plan is necessary, one designed with specific patient needs in mind. The options available for treatment include psychotherapy and psychopharmacology and the intervening practitioner should discuss the same with the patient (McKnight et al., 2019).
A full psychiatric assessment is necessary to identify any comorbidities and the reasons behind the abuse of these substances. Psychoeducation of the patient and the family by providing information on the harms and consequences of substance abuse is the first step in enhancing motivation to change.
The basics of psychological and pharmacological dependence should be covered to help the patient understand why they are addicted. Cognitive-behavioral Therapy (CBT) is an effective intervention for patients with psychiatric comorbidities (Morin, Harris & Conrod, 2017). For patients with a complete breakdown of social structure, support groups based on the 12-step mantra can provide support (McKnight et al., 2019).
Pharmacological treatments aim to reduce acute withdrawal symptoms and preserve long-term remission. Antidepressant agents can be prescribed to treat depression and sleep disorders that arise from the use of these substances.
Substance use disorder related to benzodiazepines, should be managed by gradually reducing the dose over a period of four to six weeks to and avoid severe withdrawal symptoms and prevent seizures (Soyka, 2017). Patients abusing short-acting benzodiazepines may need to switch to long-acting agents like diazepam.
Patients who abuse Opioids should be approached using the principles of airway, breathing and circulation. The antidote to opioids is naloxone which may be given IM of IV preferably. The usual dose is 400 μg IV (McKnight et al., 2019). Withdrawal is undertaken by giving methadone which is a long-acting synthetic opioid agonist. The dose is usually 60-120 mg PO daily (McKnight et al., 2019).
The DSM-V states that patients with sedative-, hypnotic- or anxiolytic-related disorders usually display significant cravings, tolerance, and continued use despite the social or interpersonal problems related to use (APA, 2013). These usually result in such patients seeking prescriptions from several different providers including pharmacies (Soyka, 2017).
Other clinical features may include dependence which leads to the patients needing the substances to carry out regular daily activities (Soyka, 2017). Clinical features of withdrawal from sedative, hypnotic, or anxiolytic agents include anxiety, autonomic hyperactivity, hand tremors, insomnia, auditory hallucinations, and grand mal seizures (APA, 2013). The prognosis for this disorder is good (Soyka, 2017). Understanding the diagnostic criteria and knowing the interventions and treatment can help providers and patients create effective treatment plans
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). Washington, D.C.
McKnight, R., Price, J., & Geddes, J. (2019). Psychiatry (5th ed.). Oxford University Press.
Soyka, M. (2017). Treatment of benzodiazepine dependence. New England Journal of Medicine, 367(12), 1147-1157. DOI:10.1056/NEJMra1611832.
Morin, J-F. G., Harris, M. & Conrod, P. J. (2017). A review for CBT treatments for substance abuse disorders. Oxford Handbook Online, (). https://www.semanticscholar.org/paper/A-Review-of-CBT-Treatments-for-Substance-Use-Morin-Harris/999434f7bebb4ae11405b316fc6a9bbc8e3f1d8a