Overview
Sedative-, Hypnotic-, or Anxiolytic Use Disorder is a type of substance-related disorder characterized by the problematic use of sedative, hypnotic, or anxiolytic substances.
These substances typically include benzodiazepines and benzodiazepine-like substances, carbamates, barbiturates, and barbiturate-like hypnotics.
Simply put, this category of substances involves medication prescribed for sleep-related problems as well as anti-anxiety medication. Sedative-, Hypnotic-, or Anxiolytic Use Disorder may be a result of misusing prescription drugs, or using substances in the absence of a prescription.
A female preponderance is identified, and the typical age of onset is considered to be between adolescence and early adulthood.
A multiplicity of factors including genetic, neurobiological, temperamental, and environmental factors, is implicated in the aetiology of Sedative-, Hypnotic-, or Anxiolytic Use Disorder.
Treatment modalities may differ from person to person, and the key focus is to reinforce abstinence with the use of various behavioral strategies.
Signs and Symptoms:
- Using sedative, hypnotic, or anxiolytic substances for longer duration than intended
- Unsuccessful attempts at cessation of sedative, hypnotic, or anxiolytic use
- Continuous efforts to stop using sedatives, hypnotics, or anxiolytics
- Spending significant amounts of time trying to procure and use sedative, hypnotic, or anxiolytic substances, as well as recover from their use
- Being unable to keep up with obligations at school, work, or at home due to use of sedative, hypnotic, or anxiolytic substances
- Disruptions in social, occupational, and recreational aspects of life due to use of sedative, hypnotic, or anxiolytic substances
- Use of sedative, hypnotic, or anxiolytic substances in dangerous or hazardous situations
- Use of sedative, hypnotic, or anxiolytic substances in spite of awareness of their harmful effects
- Needing increased amounts of sedative, hypnotic, or anxiolytic substances in order to feel their effects
- Experiencing withdrawal symptoms upon cessation of the use of sedative, hypnotic, or anxiolytic substances
Risk Factors
Sedative, hypnotic, and anxiolytic substances include benzodiazepines, which are commonly used as anti-anxiety medication, as well as carbamates, barbiturates, and barbiturate-like hypnotics.
Sleeping medications and anti-anxiety medications that are prescribed for use fall under this category of substances. A female preponderance has been suggested in the prevalence of Sedative-, Hypnotic-, or Anxiolytic Use Disorder.
The aetiology of Sedative-, Hypnotic-, or Anxiolytic Use Disorder has been associated with multiple factors. Individual differences are explained through biological correlates, with a significant influence of genetic factors implicated both directly and indirectly.
The role of GABA varied expressions receptor subunits has also been speculated in changed levels of addiction risk.
Temperamental factors are also considered to play an important part, with impulsive and novelty-seeking temperaments associated more highly with a tendency to develop substance use disorders.
Several environmental factors are also implicated in the development of Sedative-, Hypnotic-, or Anxiolytic Use Disorder. Family history of alcohol dependence or drug use and limited social support are considered to be contributing factors.
Development of the disorder is typically seen among adolescents or those in early adulthood as a result of increasing social use of the substances, leading to high tolerance and subsequent difficulties such as withdrawal symptoms during attempted cessation.
On the other hand, the disorder may also develop as a result of individuals increasing their dosage of prescribed medication for disorders such anxiety, insomnia, or somatic problems.
Higher rates of Sedative-, Hypnotic-, or Anxiolytic Use Disorder are found among those who have also been diagnosed with alcohol use disorder.
Other substance use disorders, tobacco use disorders, antisocial personality disorder, as well as depressive and bipolar disorders have been associated with the disorder as comorbidities.
Diagnosis
It is important to take into consideration the first signs that point towards development of the disorder. Warning signs such as asking for an increase in prescribed dosage or asking for refills on medicine, as well as reporting lost or stolen prescriptions.
The assessment of Sedative-, Hypnotic-, or Anxiolytic Use Disorder includes a thorough clinical evaluation, along with a comprehensive patient history and laboratory tests if necessary.
The determination of co-occurring mental disorders is of importance, and can be done through additional screening measures after the initial case history and interview procedure.
The DSM-5 provides the following criteria for the diagnosis of Sedative-, Hypnotic-, or Anxiolytic Use Disorder:
A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
- Sedatives, hypnotics, or anxiolytics are often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.
- A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.
- Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
- Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household).
- Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).
- Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.
- Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).
- Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of the sedative, hypnotic, or anxiolytic.
Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics.
- Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are taken to relieve or avoid withdrawal symptoms.
Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.
Treatment
Treatment modalities may initially focus on immediate management of intoxication or withdrawal symptoms. Further, the focus should be on discontinuation of substance use.
Providing adequate education with regards to withdrawal during management is vital, as individuals may mistake the onset of withdrawal symptoms as a relapse of initial psychopathology.
Gradually reducing the use of sedative, hypnotic, or anxiolytic substances is considered to be more beneficial than sudden cessation.
Reinforcing abstinence is the most important part of the management of any substance use disorder.
Behavioral therapy may help with this, by focusing on anxiety and stress relief, meditation techniques, coping, relaxation, and other strategies that help the individual abstain from use of substances.
The individual may also partake in 12-step programmes or support groups that can decrease the risk of relapse.
Differential Diagnosis
1. Other mental disorders or medical conditions: Individuals with sedative-, hypnotic-, or anxiolytic-induced disorders may present with symptoms similar to other mental disorders. Symptoms like slurred speech, incoordination, and other features of sedative, hypnotic, or anxiolytic intoxication could be the result of another medical condition such as multiple sclerosis or of a prior head trauma.
2. Alcohol use disorder: Sedative, hypnotic, or anxiolytic use disorder must be differentiated from alcohol use disorder.
3. Clinically appropriate use of sedative, hypnotic, or anxiolytic medications: Individualsmay take benzodiazepine medication according to a physician’s direction for a medical condition. These individuals do not develop symptoms that meet the criteria for sedative, hypnotic, or anxiolytic use disorder because its use does not interfere with their performance of usual social or occupational roles.
Comorbidity
Nonmedical use of sedative, hypnotic, or anxiolytic agents is associated with alcohol use disorder, tobacco use disorder, and, generally, illicit drug use.
There may also be an overlap between sedative, hypnotic, or anxiolytic use disorder and antisocial personality disorder; depressive, bipolar, and anxiety disorders; and other substance use disorders, such as alcohol use disorder and illicit drug use disorders
Specialist
Primary healthcare providers may be able to recognize the symptoms of Sedative-, Hypnotic-, or Anxiolytic Use Disorder and provide adequate referrals for treatment.
In case the disorder is due to a misuse of prescription medication, the psychiatrist responsible for the patient may be involved in management.
