Mr. C does not return for his follow-up appointment; however, in a telephone follow-up 6 months later, he denies experiencing withdrawal symptoms after discharge. Mr. C is now undergoing drug rehabilitation.
The authors’ observations
Benzodiazepine withdrawal symptoms occur 7 to 10 days after abrupt cessation (Table 3).10 Symptoms are similar to those of alcohol withdrawal and include tachycardia, hypertension, clouding of consciousness, and auditory and visual hallucinations.11 Serious reactions to benzodiazepine withdrawal include seizures and death.12
Because of the high prevalence of poly-substance misuse, obtain a detailed substance use history in patients undergoing benzodiazepine withdrawal to determine the likelihood of polysubstance withdrawal.13 A cross-tolerant sedative such as clonazepam could prevent withdrawal symptoms as the dose is gradually decreased. Long-acting benzodiazepines such as clonazepam or diazepam are recommended.14
In Mr. C’s case, minor withdrawal symptoms, such as disturbed sleep and irritability, began 3 to 4 days after discontinuing benzodiazepines15 and preceded development of psychosis. Withdrawal symptoms usually resolve after 2 weeks.16 Mr. C responded only partially to IV lorazepam because he did not receive the total replacement dose. Had we known he was experiencing benzodiazepine withdrawal, Mr. C could have been managed with detoxi"cation of the primary drug, alprazolam, with diazepam substitution and tapering over 3 weeks.17
Table 3
Criteria for sedative, hypnotic, or anxiolytic withdrawal
| A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been heavy and prolonged |
B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
|
| C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning |
| D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder |
| Source: Reference 10 |
Related Resource
- Vikander B, Koechling UM, Borg S, et al. Benzodiazepine tapering: a prospective study. Nord J Psychiatry. 2010; 64(4):273-282.
Drug Brand Names
- Alprazolam • Xanax
- Aripiprazole • Abilify
- Chlordiazepoxide • Librium
- Diazepam • Valium
- Diphenhydramine • Diphenhydramine injection
- Divalproex • Depakote
- Haloperidol • Haldol
- Lorazepam • Ativan
- Ziprasidone • Geodon
Acknowledgements
The authors wish to thank Reena Kumar, MD, and Sonja Gennuso, fourth-year medical student at Louisiana State University Health Sciences Center, Shreveport, for their help in preparing this manuscript.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Table 1
Mr. C’s hospital course in the emergency department
| Time after presentation | Description |
|---|---|
| 2 hours | Mr. C is alert and oriented to his name and place. He rests comfortably but asks questions about his girlfriend and uncle, falsely believing they are in the emergency department |
| 4 hours | Hand lacerations are repaired, but Mr. C continues to dig in his wounds with the opposite hand and place it over his mouth despite constant redirection. He reports hearing his uncle’s voice behind the curtain. He then uses the pulse oximeter as a telephone and holds a conversation with his uncle on the other side of the curtain. On redirection, Mr. C replies that the pulse oximeter looks like a telephone and begins mumbling to himself |
| 5 hours | Mr. C continues to mumble but responds when directly questioned. He keeps insisting that the pulse oximeter is a telephone and that he can tell his uncle to come over from the other side of the curtain. He continues to act inappropriately despite the presence of family members but he is aware of their identities |
| 6 hours | Mr. C becomes disoriented and agitated and pulls out his IV line. Because of the high WBC count, we order blood cultures and a urine culture and give him IV antibiotics |
| WBC: white blood cell count | |
Table 2
Mr. C’s hospital course on the medical unit
| Time after presentation | Description |
|---|---|
| 54 hours | He is oriented to person and place. Staff notices he is talking to someone in the room but no one is present. Mr. C appears to be responding to visual hallucinations, but upon questioning he denies any symptoms. Restraints are discontinued. Divalproex is increased to 2,000 mg/d |
| 62 hours | Mr. C remains calm for several hours but later begins hallucinating and calls to his mother and others when no one is in the room. He receives IV lorazepam, 2 mg, without much response. Again he is placed in restraints and receives another dose of IV lorazepam, 3 mg, and IM ziprasidone, 20 mg. He becomes calmer. Restraints are continued as a precautionary measure. Mr. C calms down after several hours but cannot sleep |
| 78 hours | The next morning, Mr. C remains agitated and aggressive with loud speech. He denies any further hallucinations but talks to an invisible person. He remains in restraints and receives his routine medications. His blood pressure is 141/99 mm Hg and pulse is 110. Pulse rate normalizes during the day and he becomes calmer but seclusive |