Additional information on sedative-, hypnotic-, or anxiolytic-related disorders
Additional Information on Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
Associated Features and Disorders
Associated descriptive features and mental disorders.
Sedative, Hypnotic, or Anxiolytic Dependence and Abuse may often be associated with Dependence on, or Abuse of, other substances (e.g., alcohol, cannabis, cocaine, heroin, methadone, amphetamines). Sedatives are often used to alleviate the unwanted effects of these other substances. Acute Intoxication can result in accidental injury through falls and automobile accidents. For elderly individuals, even short-term use of these sedating medications at prescribed doses can be associated with an increased risk for cognitive problems and falls. Some data indicate that the disinhibiting effects of these agents can, like alcohol, actually contribute to overly aggressive behavior, with subsequent interpersonal and legal problems. Intense or repeated Sedative, Hypnotic, or Anxiolytic Intoxication may be associated with severe depressions that, although temporary, can be intense enough to lead to suicide attempts and completed suicides. Accidental or deliberate overdoses, similar to those observed for Alcohol Abuse or Dependence or repeated Alcohol Intoxication, can occur. In contrast to their wide margin of safety when used alone, benzodiazepines taken in combination with alcohol appear to be particularly dangerous, and accidental overdoses have been reported. Accidental overdoses have also been reported in individuals who deliberately misuse barbiturates and other nonbenzodiazepine sedatives (e.g., methaqualone). With repeated use in search of euphoria, tolerance develops to the sedative effects, and a progressively higher dose is used. However, tolerance to brain stem depressant effects develops much more slowly, and as the person takes more substance to achieve euphoria, there may be a sudden onset of respiratory depression and hypotension, which may result in death. Antisocial behavior and Antisocial Personality Disorder are associated with Sedative, Hypnotic, or Anxiolytic Dependence and Abuse, especially when the substances are obtained illegally.
Associated laboratory findings.
Almost all of these substances can be identified through laboratory evaluations of urine or blood (the latter of which can quantify the amounts of these agents in the body). Urine tests are likely to remain positive for up to a week or so after the use of long-acting substances (e.g., flurazepam).
Associated physical examination findings and general medical conditions.
Physical examination is likely to reveal evidence of a mild decrease in most aspects of autonomic nervous system functioning, including a slower pulse, a slightly decreased respiratory rate, and a slight drop in blood pressure (most likely to occur with postural changes). Overdoses of sedatives, hypnotics, and anxiolytics may be associated with a deterioration in vital signs that may signal an impending medical emergency (e.g., respiratory arrest from barbiturates). There may be consequences of trauma (e.g., internal bleeding or a subdural hematoma) from accidents that occur while intoxicated. Intravenous use of these substances can result in medical complications related to the use of contaminated needles (e.g., hepatitis and human immunodeficiency virus [HIV] infection).
Specific Culture, Age, and Gender Features
There are marked variations in prescription patterns (and availability) of this class of substances in different countries, which may lead to variations in prevalence of Sedative-, Hypnotic-, or Anxiolytic-Related Disorders. Deliberate Intoxication to achieve a "high" is most likely to be observed in teenagers and individuals in their 20s. Withdrawal, Dependence, and Abuse are also seen in individuals in their 40s and older who escalate the dose of prescribed medications. Both acute and chronic toxic effects of these substances, especially effects on cognition, memory, and motor coordination, are likely to increase with age as a consequence of pharmacodynamic and pharmacokinetic age-related changes. Individuals with dementia are more likely to develop Intoxication and impaired physiological functioning at lower doses. Women may be at higher risk for prescription drug abuse of substances of this class.
Prevalence
In the United States, up to 90% of individuals hospitalized for medical care or surgery receive orders for sedative, hypnotic, or anxiolytic medications during their hospital stay, and more than 15% of American adults use these medications (usually by prescription) during any 1 year. Most of these individuals take the medication as directed, without evidence of misuse. Among the medications in this class, the benzodiazepines are the most widely used, with perhaps 10% of adults having taken a benzodiazepine for at least 1 month during the prior year. In both the United States and elsewhere, these drugs are usually prescribed by a primary care provider, and prescribed use of these medications is higher in women and increases with age.
A 1996 national survey of drug use indicated that around 6% of individuals acknowledged using either sedatives or "tranquilizers" illicitly, including 0.3% who reported illicit use of sedatives in the prior year and 0.1% who reported use of sedatives in the prior month. The age group with the highest lifetime prevalence of sedatives (3%) or "tranquilizers" (6%) was 26- to 34-year-olds, while those aged 18-25 were most likely to have used in the prior year.
Because most surveys assessed patterns of use rather than disorders, it is not known how many of those who used substances from this class had symptoms that met criteria for Dependence or Abuse. A 1992 U.S. national survey reported a lifetime prevalence for Abuse or Dependence of less than 1%, including less than 0.1% for 12-month prevalence.
Course
The more usual course involves young people in their teens or 20s who may escalate their occasional use of sedatives, hypnotics, and anxiolytics to the point at which they develop problems that might qualify for a diagnosis of Dependence or Abuse. This pattern may be especially likely among individuals who have other Substance Use Disorders (e.g., related to alcohol, opioids, cocaine, amphetamine). An initial pattern of intermittent use at parties can lead to daily use and high levels of tolerance. Once this occurs, an increasing level of interpersonal, work, and legal difficulties, as well as increasingly severe episodes of memory impairment and physiological withdrawal, can be expected to ensue.
The second and less frequently observed clinical course begins with an individual who originally obtained the medication by prescription from a physician, usually for the treatment of anxiety, insomnia, or somatic complaints. Although the great majority of those who are prescribed a medication from this class do not develop problems, a small proportion do. In these individuals, as either tolerance or a need for higher doses of the medication develops, there is a gradual increase in the dose and frequency of self-administration. The person is likely to continue to justify use on the basis of the original symptoms of anxiety or insomnia, but substance-seeking behavior becomes more prominent and the person may seek out multiple physicians to obtain sufficient supplies of the medication. Tolerance can reach high levels, and Withdrawal (including seizures and Withdrawal Delirium) may occur. Other individuals at heightened risk might include those with Alcohol Dependence who may receive repeated prescriptions in response to their complaints of alcohol-related anxiety or insomnia.
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders may present with symptoms (e.g., anxiety) that resemble primary mental disorders (e.g., Generalized Anxiety Disorder versus Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder, With Onset During Withdrawal). See p. 210 for a discussion of this differential diagnosis.
Sedative, Hypnotic, or Anxiolytic Intoxication closely resembles Alcohol Intoxication, except for the smell of alcohol on the breath. In older persons, the clinical picture of intoxication can resemble a progressive dementia. In addition, the slurred speech, incoordination, and other associated features characteristic of Sedative, Hypnotic, or Anxiolytic Intoxication could be the result of a general medical condition (e.g., multiple sclerosis) or of a prior head trauma (e.g., a subdural hematoma).
Alcohol Withdrawal produces a syndrome very similar to that of Sedative, Hypnotic, or Anxiolytic Withdrawal. The anxiety, insomnia, and autonomic nervous system hyperactivity that is a consequence of intoxication with other drugs (e.g., stimulants such as amphetamines or cocaine), that are consequences of physiological conditions (e.g., hyperthyroidism), or that are related to primary Anxiety Disorders (e.g., Panic Disorder or Generalized Anxiety Disorder) can resemble some aspects of Sedative, Hypnotic, or Anxiolytic Withdrawal.
Sedative, Hypnotic, or Anxiolytic Intoxication and Withdrawal are distinguished from the other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders (e.g., Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder, With Onset During Withdrawal) because the symptoms in these latter disorders are in excess of those usually associated with Sedative, Hypnotic, or Anxiolytic Intoxication and Withdrawal and are severe enough to warrant independent clinical attention.
It should be noted that there are individuals who continue to take benzodiazepine medication according to a physician's direction for a legitimate medical indication over extended periods of time. Even if physiologically dependent on the medication, many of these individuals do not develop symptoms that meet the criteria for Dependence because they are not preoccupied with obtaining the substance and its use does not interfere with their performance of usual social or occupational roles.