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139 Sex, Sleep & Drugs – Get points on the easy stuff

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Substance-Related and Addictive Disorders

  • Chronic, relapsing brain disorders involving the dopamine reward pathway
  • Includes alcohol, opioids, stimulants, cannabis, hallucinogens, nicotine, and gambling (the only behavioral addiction formally recognized in DSM-5)
  • Marked by craving, tolerance, withdrawal, and continued use despite harm

Alcohol Use Disorder

Definition/Overview

  • Chronic and relapsing disorder with loss of control over alcohol use
  • Associated with tolerance, withdrawal, and continued use despite harm

Clinical Presentation

  • Intoxication: slurred speech, incoordination, impaired judgment
  • Withdrawal: tremor within hours, seizures (12–24 hrs), hallucinations, delirium tremens
  • Delirium tremens: severe withdrawal usually 48–96 hrs after last drink; agitation, confusion, hallucinations, fever, hypertension, tachycardia, diaphoresis; life-threatening if untreated

Labs, Studies, and Physical Exam Findings

  • Blood alcohol concentration for acute intoxication
  • CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised): scores withdrawal severity (tremor, anxiety, hallucinations, vital signs) and guides benzodiazepine dosing

Treatment

  • Acute withdrawal: benzodiazepines (diazepam, lorazepam) enhance GABA to calm nervous system and prevent seizures and DTs; dosed according to CIWA
  • Relapse prevention:
  • Naltrexone: opioid receptor antagonist, blocks rewarding effects and reduces craving; avoid in liver failure or opioid users
  • Acamprosate: modulates glutamate/GABA, reduces anxiety and insomnia; best for maintaining abstinence; safe in liver disease, avoid in renal failure
  • Disulfiram: blocks aldehyde dehydrogenase, causes flushing, nausea, palpitations if alcohol consumed; requires high motivation

Key Differentiators

  • Tremor after stopping alcohol that progresses to seizures or DTs is diagnostic of alcohol withdrawal

Test Alert

  • Patient with tremor, confusion, hallucinations, fever, and hypertension three days after stopping alcohol has delirium tremens; treat with benzodiazepines

Opioid Use Disorder

Definition/Overview

  • Chronic use of opioids such as heroin, oxycodone, or morphine with tolerance, dependence, and withdrawal

Clinical Presentation

  • Intoxication: pinpoint pupils (miosis), respiratory depression, euphoria
  • Withdrawal: rhinorrhea, tearing, yawning, sweating, anxiety, piloerection (goosebumps from autonomic overactivity)

Labs, Studies, and Physical Exam Findings

  • Urine drug screen detects opioids

Treatment

  • Overdose: naloxone (short-acting antagonist) reverses respiratory depression; repeat dosing often required
  • Maintenance:
  • Methadone: full agonist; prevents withdrawal and cravings; dispensed daily in licensed clinics; effective in severe cases but can prolong QT interval
  • Buprenorphine: partial agonist; safer due to ceiling effect on respiratory depression; often combined with naloxone (Suboxone); office-based prescribing
  • Naltrexone: long-acting antagonist; blocks euphoria if opioids used; must be opioid-free before initiation or precipitates withdrawal; best for detoxed, motivated patients

Key Differentiators

  • Pinpoint pupils with slow breathing = opioid intoxication

Test Alert

  • Patient with pinpoint pupils and shallow respirations after heroin use → give naloxone

Stimulant Use Disorder (Cocaine, Amphetamines)

Definition/Overview

  • Abuse of stimulant drugs leading to euphoria, cardiovascular complications, and withdrawal symptoms

Clinical Presentation

  • Intoxication: dilated pupils (mydriasis), euphoria, hypertension, arrhythmias, agitation
  • Withdrawal: fatigue, hypersomnia, depression

Labs, Studies, and Physical Exam Findings

  • Urine drug screen can confirm stimulant use

Treatment

  • Acute intoxication: supportive care, benzodiazepines for agitation or seizures
  • Withdrawal: no specific medication; supportive management for fatigue, hypersomnia, depression

Key Differentiators

  • Dilated pupils + hypertension + agitation = stimulant intoxication

Test Alert

  • Young man with dilated pupils, chest pain, and agitation after using cocaine → supportive care and benzodiazepines if severely agitated

Nicotine Use Disorder

Definition/Overview

  • Dependence on nicotine with tolerance, withdrawal, and strong cravings

Clinical Presentation

  • Dependence: irritability, anxiety, craving
  • Withdrawal: restlessness, increased appetite, difficulty concentrating

Labs, Studies, and Physical Exam Findings

  • Clinical diagnosis; no specific labs needed

Treatment

  • Nicotine replacement therapy: patch, gum, lozenge
  • Bupropion: norepinephrine-dopamine reuptake inhibitor; reduces cravings; useful in smokers with depression; contraindicated in seizure and eating disorders
  • Varenicline: partial agonist at nicotinic receptors; reduces cravings and blocks the reward of smoking if relapse occurs; side effects include vivid dreams and mood changes; most effective single medication for cessation

Key Differentiators

  • Nicotine withdrawal = irritability, restlessness, increased appetite, poor concentration

Test Alert

  • Patient who recently quit smoking now reports irritability, anxiety, and weight gain → nicotine withdrawal, treat with NRT, bupropion, or varenicline

Gambling Disorder

Definition/Overview

  • Persistent, recurrent gambling behavior leading to distress or impairment
  • Only behavioral addiction formally recognized in DSM-5

Clinical Presentation

  • Preoccupation with gambling, chasing losses, lying to cover behavior, jeopardizing relationships or finances

Treatment

  • Psychotherapy, especially CBT
  • Support groups (Gamblers Anonymous)

Key Differentiators

  • Only behavioral addiction in DSM-5

Test Alert

  • Patient with financial ruin, lying about losses, and repeated failed attempts to stop gambling → gambling disorder

Sleep-Wake Disorders

Insomnia Disorder

  • Persistent difficulty falling asleep, staying asleep, or waking up too early
  • Must occur at least 3 nights per week for at least 3 months, despite adequate opportunity to sleep

Clinical Presentation

  • Lying awake for hours despite being tired
  • Waking up multiple times at night or too early in the morning
  • Daytime fatigue, irritability, poor focus

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical
  • Polysomnography usually normal

Treatment

  • CBT-I: addresses unhelpful sleep thoughts, sets sleep/wake schedule, limits bed use to sleep/sex
  • Sleep hygiene: avoid screens before bed, avoid late caffeine, maintain consistent routine
  • Short-term medications if refractory:
  • Zolpidem: non-benzodiazepine hypnotic, enhances GABA to initiate sleep
  • Benzodiazepines: effective but risk dependence; not for long-term use

Key Differentiators

  • Insomnia = difficulty sleeping despite opportunity
  • Depression = early morning awakenings plus low mood, guilt, poor energy

Test Alert

  • Middle-aged patient with ≥3 months of poor sleep, daytime fatigue, and normal sleep study → insomnia disorder; best initial treatment is CBT-I

Narcolepsy

  • Neurologic disorder of sleep regulation caused by loss of orexin (hypocretin) in the hypothalamus
  • Leads to abnormal REM transitions and excessive daytime sleepiness

Clinical Presentation

  • Daytime sleep attacks despite adequate nighttime sleep
  • Cataplexy: sudden muscle weakness triggered by emotions (knees buckle, jaw drops)
  • Hypnagogic hallucinations: vivid dreamlike experiences when falling asleep
  • Sleep paralysis: transient inability to move when falling asleep or waking

Labs, Studies, and Physical Exam Findings

  • Polysomnography + multiple sleep latency test: short sleep latency, rapid REM onset

Treatment

  • Modafinil/armodafinil: wake-promoting, increase dopamine signaling, first-line for daytime sleepiness
  • Sodium oxybate: strong nighttime sedative that consolidates sleep and reduces cataplexy
  • Scheduled naps reduce daytime sleepiness

Key Differentiators

  • Narcolepsy = cataplexy, hallucinations, sleep paralysis
  • OSA = daytime sleepiness but due to apneic events, no REM features

Test Alert

  • Young adult collapses when laughing, sees vivid hallucinations when falling asleep, has daytime sleep attacks → narcolepsy treated with modafinil

Obstructive Sleep Apnea (OSA)

  • Recurrent upper airway collapse during sleep → apneas, hypoxemia, fragmented sleep

Clinical Presentation

  • Obese middle-aged man snores loudly, spouse notices pauses in breathing and gasps
  • Morning headaches, daytime fatigue, poor concentration
  • Long-term complications: hypertension, arrhythmias, pulmonary hypertension

Labs, Studies, and Physical Exam Findings

  • Polysomnography: repeated apneas with desaturation
  • STOP-BANG questionnaire: Snoring, Tiredness, Observed apneas, Pressure (HTN), BMI >35, Age >50, Neck >40 cm, Gender (male)

Treatment

  • CPAP: prevents airway collapse, improves symptoms and CV outcomes
  • Weight loss, avoid alcohol and sedatives
  • Surgery if CPAP fails or anatomy obstructive
  • Inspire device: stimulates hypoglossal nerve (CN XII) to move tongue forward and prevent collapse (for select patients)

Key Differentiators

  • OSA = obesity, loud snoring, witnessed apneas, excessive sleepiness
  • Narcolepsy = daytime sleepiness without apneas/snoring

Test Alert

  • Obese hypertensive man with loud snoring, witnessed apneas, daytime fatigue → OSA treated with CPAP

Circadian Rhythm Disorders

Definition/Overview

  • Normal sleep ability but misaligned with environment (internal clock disruption)

Clinical Presentation

  • Jet lag: insomnia and daytime fatigue after travel across time zones
  • Shift work disorder: chronic fatigue and sleep problems in night-shift workers

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical
  • Polysomnography usually normal

Treatment

  • Light therapy: bright light to reset circadian rhythm
  • Melatonin supplementation
  • Gradual adjustment of sleep schedule

Human Sexuality and Gender Dysphoria

Sexual Dysfunction Disorders

  • Disorders involving problems with desire, arousal, orgasm, or pain that cause distress or relationship difficulty
  • Must persist ≥6 months and cause significant distress

Clinical Presentation

  • Erectile disorder: persistent inability to achieve/maintain erection
  • Premature ejaculation: ejaculation within 1 minute, recurrent, distressing
  • Female sexual interest/arousal disorder: lack of thoughts, interest, or responsiveness
  • Genito-pelvic pain/penetration disorder: pain or tightening with penetration

Labs, Studies, and Physical Exam Findings

  • History distinguishes psychogenic vs organic
  • Organic ED: gradual, consistent, comorbidities
  • Psychogenic ED: sudden, situational, normal nocturnal erections

Treatment

  • Erectile disorder: PDE-5 inhibitors (sildenafil, tadalafil) increase NO/cGMP → smooth muscle relaxation, penile blood flow; avoid with nitrates
  • Premature ejaculation: SSRIs (sertraline, paroxetine) delay ejaculation by increasing serotonin; topical anesthetics decrease sensitivity; behavioral therapy (stop–start, squeeze)
  • Female sexual interest/arousal disorder: psychotherapy, couples therapy, hormonal therapy if menopausal, review meds
  • Genito-pelvic pain/penetration disorder: pelvic floor therapy, vaginal dilators, CBT for anxiety/fear

Key Differentiators

  • Erectile disorder = inability to maintain erection
  • Premature ejaculation = loss of timing control
  • Genito-pelvic pain disorder = pain/tightening, not lack of desire

Paraphilic Disorders

  • Recurrent, intense sexual urges, fantasies, or behaviors with inappropriate targets or contexts
  • Must cause distress, impairment, or risk/harm

Clinical Presentation

  • Exhibitionistic: exposing genitals to strangers
  • Voyeuristic: watching unsuspecting people undress/have sex
  • Frotteuristic: rubbing/touching non-consenting people
  • Sexual masochism: arousal from being humiliated, beaten, bound
  • Sexual sadism: arousal from causing suffering to others
  • Pedophilic: attraction to prepubescent children

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical

Treatment

  • Psychotherapy (CBT)
  • SSRIs to reduce obsessive urges
  • Anti-androgens (e.g., medroxyprogesterone) in high-risk/severe cases

Gender Dysphoria

  • Distress caused by mismatch between experienced gender identity and assigned sex at birth
  • Must cause significant distress or impairment

Clinical Presentation

  • Children: insistence on being another gender, cross-gender play/clothing, distress with birth sex roles
  • Adolescents/adults: strong desire to be treated as another gender, discomfort with anatomy, daily distress

Labs, Studies, and Physical Exam Findings

  • Diagnosis is clinical
  • Differentiate from gender nonconformity without distress

Treatment

  • Supportive psychotherapy and counseling
  • Social transition (clothing, pronouns, name)
  • Hormone therapy (blockers or cross-sex hormones) in persistent cases
  • Gender-affirming surgery for some adults after evaluation

Key Differentiators

  • Gender dysphoria = distress from mismatch
  • Gender nonconformity = no distress
  • Body dysmorphic disorder = preoccupation with physical flaw