Sedative, hypnotic or anxiolytic withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of sedatives, hypnotics or anxiolytics in individuals who have developed dependence on sedatives, hypnotics or anxiolytics or have used sedatives, hypnotics or anxiolytics for a prolonged period or in large amounts. Note: Sedative, Hypnotic or Anxiolytic Withdrawal can occur when prescribed sedatives, hypnotics or anxiolytics (e.g., benzodiazepines) have been used in standard therapeutic doses.
• Presenting features of Sedative, Hypnotic or Anxiolytic Withdrawal may include anxiety, psychomotor agitation, insomnia, increased hand tremor, nausea or vomiting, and transient visual, tactile or auditory illusions or hallucinations. There may be signs of autonomic hyperactivity (e.g., tachycardia, hypertension, perspiration), or postural hypotension. The withdrawal state may be complicated by seizures.
• The severity and time course of Sedative, Hypnotic or Anxiolytic Withdrawal is related to the particular substance taken, its half-life and duration of action, and the amount, frequency and duration of use before cessation or reduction of use.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Specifiers for clinical presentation:

Because of clinically important variation in their withdrawal syndromes, the following specifiers can be applied to Sedative, Hypnotic or Anxiolytic Withdrawal (6C44.4).

6C44.40 Sedative, Hypnotic or Anxiolytic Withdrawal, uncomplicated

All diagnostic requirements for Sedative, Hypnotic or Anxiolytic Withdrawal are met and the withdrawal state is not accompanied by perceptual disturbances or seizures.

6C44.41 Sedative, Hypnotic or Anxiolytic Withdrawal, with perceptual disturbances

All diagnostic requirements for Sedative, Hypnotic or Anxiolytic Withdrawal are met and the withdrawal state is accompanied by perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. There is no evidence of confusion and other diagnostic requirements for Delirium are not met. The withdrawal state is not accompanied by seizures.

6C44.42 Sedative, Hypnotic or Anxiolytic Withdrawal, with seizures

All diagnostic requirements for Sedative, Hypnotic or Anxiolytic Withdrawal are met and the withdrawal state is accompanied by seizures (i.e., generalized tonic-clonic seizures) but not by perceptual disturbances.

6C44.43 Sedative, Hypnotic or Anxiolytic Withdrawal, with perceptual disturbances and seizures

All diagnostic requirements for Sedative, Hypnotic or Anxiolytic Withdrawal are met and the withdrawal state is accompanied by both seizures (i.e., generalized tonic-clonic seizures) and perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. Diagnostic requirements for Delirium are not met.

6C44.4Z Sedative, Hypnotic or Anxiolytic Withdrawal, unspecified

Additional Clinical Features:

• The withdrawal state associated with short-acting drugs typically has its onset within 12 to 24 hours after cessation of use and has a course of up to 14 days. Withdrawal onset may be delayed by 3 to 5 days with longer-acting drugs and may persist for several weeks.
• Sedative, Hypnotic or Anxiolytic Withdrawal may be complicated by seizures, which are of a tonic-clonic type and may be single or multiple.
• Sedative, Hypnotic or Anxiolytic Withdrawal, especially when untreated, may progress to a very severe form of Delirium, characterized by confusion and disorientation, delusions, and more prolonged visual, tactile or auditory hallucinations. In such cases, a separate diagnosis of Sedative, Hypnotic or Anxiolytic-induced Delirium should also be assigned.
• Medical sequelae of complicated withdrawal include status epilepticus, respiratory compromise, and renal failure.
• Some features of Sedative, Hypnotic or Anxiolytic Withdrawal such as anxiety, transient illusions or hallucinations, and derealisation may persist for several months after cessation of use.
• Characteristic features of Sedative, Hypnotic or Anxiolytic Withdrawal are opposite to the acute pharmacological effects of sedatives, hypnotics or anxiolytics.
• Sedative, Hypnotic or Anxiolytic Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Sedative, Hypnotic or Anxiolytic Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of sedatives, hypnotics or anxiolytics. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Sedative, Hypnotic or Anxiolytic Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’). For example, if low mood and reduction in energy are reported following use of alcohol; sedatives, hypnotics or anxiolytics and other characteristic features of Substance Withdrawal are not present, a diagnosis of Substance Withdrawal should not be assigned.
• Some individuals who have previously had Sedative, Hypnotic or Anxiolytic Dependence may experience symptoms similar to those of Sedative, Hypnotic or Anxiolytic Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past sedative, hypnotic or anxiolytic use. These symptoms are more transient than those observed during Sedative, Hypnotic or Anxiolytic Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Sedative, Hypnotic or Anxiolytic Withdrawal should not be assigned under these circumstances.

Course Features:

• Sedative, Hypnotic or Anxiolytic Withdrawal is time-limited. Factors that influence the features and time course of Sedative, Hypnotic or Anxiolytic Withdrawal include: (1) the severity of Sedative, Hypnotic or Anxiolytic Dependence, if present, (2) the dose, frequency of use, and duration of sedative, hypnotic or anxiolytic use prior to cessation or reduction of that use, (3) the half-life and duration of action of sedatives, hypnotics or anxiolytics, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of sedatives, hypnotics or anxiolytics. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Sedative, Hypnotic or Anxiolytic Dependence: Many individuals with Sedative, Hypnotic or Anxiolytic Dependence develop Sedative, Hypnotic or Anxiolytic Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Sedative, Hypnotic or Anxiolytic Dependence and Sedative, Hypnotic or Anxiolytic Withdrawal should be diagnosed. However, Sedative, Hypnotic or Anxiolytic Withdrawal can be diagnosed in the absence of a diagnosis of Sedative, Hypnotic or Anxiolytic Dependence, for example in response to cessation of medically appropriate treatment with sedatives, hypnotics or anxiolytics (e.g., benzodiazepines), when the other Essential Features of Substance Dependence are not present.
• Boundary with Sedative, Hypnotic or Anxiolytic Intoxication: The onset of Sedative, Hypnotic or Anxiolytic Intoxication occurs immediately or shortly after the consumption of sedatives, hypnotics or anxiolytics. In contrast, Sedative, Hypnotic or Anxiolytic Withdrawal occurs upon cessation or reduction in the amount of sedatives, hypnotics or anxiolytics in the context of Sedative, Hypnotic or Anxiolytic Dependence or when sedatives, hypnotics or anxiolytics have been taken for a prolonged period or in large amounts. For sedatives, hypnotics or anxiolytics, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with Sedative, Hypnotic or Anxiolytic-Induced Delirium: Delirium is characterized by disturbances in attention, orientation, and awareness that develop within a short period of time with symptoms that are transient and may fluctuate depending on the underlying etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium may occur as an aspect of Sedative, Hypnotic or Anxiolytic Withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both Substance Withdrawal and Sedative, Hypnotic or Anxiolytic-Induced Delirium should be assigned.
• Boundary with other Sedative, Hypnotic or Anxiolytic-Induced Mental Disorders: Mental or behavioural symptoms that arise during Sedative, Hypnotic or Anxiolytic Withdrawal should only be used as a basis for diagnosing a Sedative, Hypnotic or Anxiolytic-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Sedative, Hypnotic or Anxiolytic Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Sedative, Hypnotic or Anxiolytic Withdrawal and a Sedative, Hypnotic or Anxiolytic-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Sedative, Hypnotic or Anxiolytic Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Sedative, Hypnotic or Anxiolytic Withdrawal occur in specific temporal relationship to the cessation of use of sedatives, hypnotics or anxiolytics and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of sedative, hypnotic or anxiolytic use, the symptoms persisting for a substantial period of time after cessation of sedatives, hypnotics or anxiolytics or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with sedative, hypnotic or anxiolytic use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Sedative, Hypnotic or Anxiolytic Withdrawal (e.g., nausea or vomiting, seizures, perspiration, postural hypotension, decreased or increased heart rate, insomnia) and those that are characteristic of other medical conditions. Symptoms of Sedative, Hypnotic or Anxiolytic Withdrawal occur in specific temporal relationship to the cessation of use of sedatives, hypnotics or anxiolytics and diminish with the passage of time.
• Boundary with Foetus or Newborn Affected by Maternal Use of Tobacco, Alcohol, or Other Drugs of Addiction: The ICD-11 chapter on Certain Conditions Arising During the Perinatal Period contains categories for ‘Foetus or newborn affected by maternal use of tobacco, alcohol, and other drugs.’ A neonate exhibiting signs of Sedative, Hypnotic or Anxiolytic Withdrawal may also be Sedative, Hypnotic or Anxiolytic Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.