A 20-year-old female presents to student health at her university for excessive daytime sleepiness. She states that her sleepiness has caused her to fall asleep in all of her classes for the last semester, and that her grades are suffering as a result. She states that she normally gets 7 hours of sleep per night, and notes that when she falls asleep during the day, she immediately starts having dreams. She denies any cataplexy. A polysomnogram and a multiple sleep latency test rule out obstructive sleep apnea and confirm her diagnosis. She is started on a daytime medication that acts both by direct neurotransmitter release and reuptake inhibition. What other condition can this medication be used to treat?

Attention-deficit hyperactivity disorder

A 30-year-old man is brought to the emergency department by the police after starting a fight at a local bar. He has several minor bruises and he appears agitated. He talks incessantly about his future plans. He reports that he has no history of disease and that he is "super healthy" and "never felt better". His temperature is 38.0°C (100.4°F), pulse is 110/min, respirations are 16/min, and blood pressure is 155/80 mm Hg. On physical examination reveals a euphoric and diaphoretic man with slightly dilated pupils. An electrocardiogram is obtained and shows tachycardia with normal sinus rhythm. A urine toxicology screen is positive for cocaine. The patient is held in the ED for observation. Which of the following symptoms can the patient expect to experience as he begins to withdraw from cocaine?

Increased sympathetic stimulation

A mother presents to the family physician with her 16-year-old son. She explains, "There's something wrong with him doc. His grades are getting worse, he's cutting class, he's gaining weight, and his eyes are often bloodshot." Upon interviewing the patient apart from his mother, he seems withdrawn and angry at times when probed about his social history. The patient denies abuse and sexual history. What initial test should be sent to rule out the most likely culprit of this patient's behavior?

Sexually transmitted infection (STI) testing

A 30-year-old man presents to his family physician admitting to using heroin. He says he started using about 6-months ago when his back pain medication ran out. At first, he says he would borrow his wife’s Percocet but, eventually, that ran out and he had to find a different source. Since then, he has been having more and more issues related to his heroin use, and it has started to affect his work and home life. He is concerned that, if he continues like this, he might end up in real trouble. He denies sharing needles and is sincerely interested in quitting. He recalls trying to quit last month but recounts how horrible the withdrawal symptoms were. Because of this and the strong cravings, he relapsed shortly after his initial attempt. Methadone maintenance therapy is prescribed. Which of the following would most likely be the most important benefit of this new treatment plan in this patient?

Prevention of withdrawal symptoms and reduced cravings

Euphoria without the side effects

Reduced risk of hepatitis B and C transmission

Improved interpersonal relationships

Withdrawal management for USMLE Step 1: High-Yield Psychiatry Lessons

Alcohol Withdrawal - Shakes, Seizures, & DTs

Clinical Timeline: Symptom onset after last drink.

Assessment: Use CIWA-Ar scale to guide therapy.
- Score > 15 indicates severe withdrawal requiring medication.
Management Protocol:
- Benzodiazepines: First-line treatment (e.g., Chlordiazepoxide, Diazepam, Lorazepam). Titrate dose to CIWA-Ar score.
- Thiamine (Vitamin B1): Administer 100mg IV/IM before glucose to prevent Wernicke-Korsakoff syndrome.

⭐ In patients with liver failure/cirrhosis, use Lorazepam, Oxazepam, or Temazepam (LOT) as they undergo glucuronidation without forming active metabolites.

CIWA-Ar Scale for Alcohol Withdrawal Assessment

Opioid Withdrawal - The Unbearable Flu

Presentation: Resembles a severe flu. Onset varies by opioid half-life (e.g., heroin: 6-12h; methadone: 24-48h).
Symptoms: Dysphoria, myalgia, nausea/vomiting/diarrhea.
- Autonomic signs: Lacrimation, rhinorrhea, yawning, piloerection ("cold turkey").
Assessment: Clinical Opioid Withdrawal Scale (COWS). Treatment indicated for moderate-to-severe withdrawal (COWS > 12).

Clinical Opioid Withdrawal Scale (COWS)

Management:
- Agonist replacement: Methadone (long-acting) or Buprenorphine (partial agonist).
- Symptomatic control: Clonidine (α2-agonist) for autonomic hyperactivity; loperamide for diarrhea, ondansetron for nausea.

⭐ High-Yield: Buprenorphine can precipitate withdrawal if given to a patient not yet in withdrawal, due to its high receptor affinity but lower intrinsic activity, displacing other opioids.

Sedative-Hypnotic Withdrawal - The Taper Imperative

Causative Agents: Primarily Benzodiazepines (e.g., alprazolam, lorazepam) and Barbiturates.
Clinical Features: A life-threatening emergency. Presents with anxiety, insomnia, perceptual disturbances, and autonomic hyperactivity (↑tachycardia, ↑hypertension). Severe cases can progress to generalized seizures and psychosis.
Management: The core principle is a gradual taper to prevent seizures.

⭐ Abrupt cessation, especially of short-acting benzodiazepines, poses the highest risk for severe withdrawal, including refractory seizures.

Stimulant Withdrawal - The Depressive Crash

Substances: Cocaine, amphetamines.
Clinical Picture (The "Crash"): A distinct dysphoric period following cessation of use.
- Symptoms: Severe depression, anhedonia, fatigue, hypersomnia, increased appetite (hyperphagia), and intense craving.
- Patients may also experience vivid and unpleasant dreams.
Management: Primarily supportive care.
- There are no FDA-approved medications for stimulant withdrawal.
- ⚠️ Crucial: Monitor for suicidality risk, which can be significant during the crash phase.

⭐ While not typically medically dangerous, the primary risk in stimulant withdrawal is suicide due to the severe depressive symptoms.

High‑Yield Points - ⚡ Biggest Takeaways

Alcohol withdrawal: Manage with benzodiazepines (e.g., lorazepam, chlordiazepoxide) to prevent life-threatening seizures and delirium tremens.

Opioid withdrawal: Treat flu-like symptoms and autonomic hyperactivity with supportive care, clonidine, or opioid agonists like buprenorphine.

Benzodiazepine withdrawal: Requires a slow taper of a long-acting agent to prevent potentially fatal seizures.

Stimulant withdrawal: Characterized by a dysphoric "crash" with severe depression and fatigue; management is supportive.

Delirium tremens: A medical emergency 48-96 hours post-alcohol; treat aggressively with IV benzodiazepines.

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Withdrawal management