Selected Topics: Psychiatric Emergencies PSYCHIATRIC EMERGENCIES FOR CLINICIANS: EMERGENCY DEPARTMENT MANAGEMENT OF BENZODIAZEPINE WITHDRAWAL Sara E. Puening, MD,* Michael P. Wilson, MD, PHD,†‡ and Kimberly Nordstrom, MD, JD*‡§ *University of Colorado Denver, School of Medicine, Aurora, Colorado, †University of California at San Diego Medical Center, San Diego, California, ‡Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Laboratory, University of California San Diego, San Diego, California, and §Denver Health Medical Center, Department of Behavioral Health, Psychiatric Emergency Service, Denver, Colorado Reprint Address: Kimberly Nordstrom, MD, JD, Psychiatric Emergency Services, Denver Health Medical Center, 777 Bannock Street, Mail Code 0116, Denver, CO 80204 CLINICAL SCENARIO A 67-year-old female presented to the emergency depart- ment (ED) after calling police about ‘‘suspicious neigh- bors.’’ In the ED, she initially complained of extreme anxiety and the belief that people wanted to hurt her. On re- view of systems, she also complained of insomnia, ‘‘heart flutters,’’ and general body aches. The review was negative for alcohol or recreational substance use, fever, other symp- toms of infection, and new medications. She had recently watched a news program about the dangers of addiction to prescription drugs and decided to stop taking some of her medications, which she had been on ‘‘for years.’’ The dis- continued medications were unknown. The symptoms had been worsening over 12 days. On observing the patient, she was diaphoretic, had a noticeable tremor, appeared anxious, and was looking suspiciously around the examina- tion room. Her vital signs included a temperature of 98.3  F (36.5  C), heart rate of 120 beats/min, blood pressure of 145/ 102 mm Hg, respiratory rate of 20 breaths/min, and oxygen saturation of 98%. On examination, she was not oriented to time, being off by day and month. She had brisk deep tendon reflexes and a gross tremor. Otherwise, her examination ap- peared normal. A complete metabolic panel, complete blood count, and urinalysis were within normal limits. WHAT DO YOU THINK IS GOING ON WITH THIS PATIENT? The clinical presentation strongly suggests benzodiaze- pine withdrawal. In the early 1960s, when benzodiaze- pines were first introduced, they were believed to be an effective and safe treatment for anxiety when compared with previous treatment options, such as bar- biturates (1). However, benzodiazepine use is not without its risks; tolerance, withdrawal, dependence, drug diversion, dangers in overdose when combined with other substances, and memory impairment associ- ated with long-term use are all concerns (2,3).A recent study showed that 5.2% of adults aged 1880 years filled a benzodiazepine prescription in 2008 and that women aged 6580 years are the group with the highest rate of use (4). In addition, ED visits involving benzodiazepines approximately doubled be- tween 2005 and 2011 (2). What Key Findings Lead to the Diagnosis? In the case presented here, clues to benzodiazepine with- drawal include recent discontinuation of benzodiazepine in the setting of long-term use because the patient 1 The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter