Addiction Psychiatry: Neurobiology, Withdrawal, and Treatment
Questions test the neurobiology of reward and the clinical management of intoxication, withdrawal, and maintenance. The mesolimbic dopamine system mediates reinforcement, and chronic use produces tolerance, dependence, and sensitization. Know withdrawal syndromes: alcohol (tremor, seizures, delirium tremens), benzodiazepines (seizures), opioids (autonomic hyperactivity without seizures), and stimulants (dysphoria, fatigue). Treatment includes motivational interviewing, CBT, contingency management, and pharmacotherapy: naltrexone and acamprosate for alcohol, buprenorphine and methadone for opioid use disorder, and nicotine replacement or varenicline for tobacco.
Traps
- Missing alcohol withdrawal as a cause of seizures or delirium.
- Assuming opioid withdrawal is life-threatening-it is intensely uncomfortable but rarely fatal, unlike alcohol or benzodiazepine withdrawal.
- Overlooking co-occurring psychiatric disorders.
- Ignoring harm reduction and medication-assisted treatment.
Rule of thumb
For any substance-related vignette, define the substance, the syndrome (intoxication, withdrawal, dependence), and the stage of change. Worked example: a patient with alcohol use disorder and withdrawal tremor should receive benzodiazepines, thiamine before glucose, and long-term relapse-prevention planning with naltrexone or acamprosate.