{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T14:28:28Z","timestamp":1787927308038,"version":"build-2784847793"},"reference-count":11,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Substance Use &amp; Addiction Journal"],"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>\n                      Benzodiazepines are central nervous system depressants that act on GABA-A receptors and enhance the activity of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). Prolonged use of benzodiazepines carries a high risk of physiological dependence and abrupt discontinuation following high-dose or long-term benzodiazepine use may precipitate withdrawal. Benzodiazepine withdrawal symptoms include autonomic hyperarousal (e.g., tachycardia, hypertension, sweating and tremors), anxiety, insomnia, confusion and rarely psychotic features including delusions and hallucinations. Clonidine is an \u03b1\n                      <jats:sub>2<\/jats:sub>\n                      -adrenergic agonist that has sympatholytic activity and thereby attenuates the features of autonomic hyperarousal. In a person who is on regular clonidine, benzodiazepine withdrawal symptoms may be masked by clonidine, resulting in a diagnostic dilemma.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case:<\/jats:title>\n                    <jats:p>A 35-year-old man with no significant past psychiatric history presented to the Emergency Department with confusion, persecutory delusions, auditory and visual hallucinations, and bradycardia (40-45\u2009bpm) for 3\u2009days. He underwent a below-knee amputation a few months ago following complications of a crush injury. He had been on multiple medications for post-amputation pain and had abruptly ceased long-term diazepam a week before his current presentation. Organic screening for delirium, metabolic and infective causes were unremarkable. The presentation was suggestive of benzodiazepine withdrawal psychosis; however, persistent bradycardia was inconsistent with the typical autonomic hyperarousal seen in benzodiazepine withdrawal.<\/jats:p>\n                    <jats:p>A thorough medication review revealed concomitant administration of clonidine, and a diagnosis of benzodiazepine withdrawal masked by clonidine\u2019s sympatholytic effect was made. With recommencement and titration of benzodiazepines, psychosis and confusion resolved within 24\u2009hours.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion:<\/jats:title>\n                    <jats:p>This case highlights the need for awareness of drug interactions that may mask typical withdrawal symptoms of benzodiazepines. Furthermore, it emphasises the need for thorough collateral history particularly when the patient is incapacitated and highlights the importance of addressing complex pain needs to prevent self-medication.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/29767342261479888","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T11:26:26Z","timestamp":1787657186000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Benzodiazepine Withdrawal Masked by Clonidine: An Emergency Presentation With a Diagnostic Challenge"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2287-8880","authenticated-orcid":false,"given":"Isuri","family":"Wimalasiri","sequence":"first","affiliation":[{"name":"Western Health Mental Health and Wellbeing Services, St Albans, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2025-9591","authenticated-orcid":false,"given":"Simon","family":"Boyd","sequence":"additional","affiliation":[{"name":"Western Health Mental Health and Wellbeing Services, St Albans, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7329-8264","authenticated-orcid":false,"given":"Soumitra","family":"Das","sequence":"additional","affiliation":[{"name":"Western Health Mental Health and Wellbeing Services, St Albans, VIC, Australia"},{"name":"Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naveen","family":"Thomas","sequence":"additional","affiliation":[{"name":"Western Health Mental Health and Wellbeing Services, St Albans, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"issue":"5","key":"e_1_3_2_2_2","first-page":"414","article-title":"Psychosis during benzodiazepine withdrawal: a case report and literature review","volume":"9","author":"Stallvik M","year":"2015","unstructured":"Stallvik M, Nordahl HM, Skogvoll E. Psychosis during benzodiazepine withdrawal: a case report and literature review. J Addict Med. 2015;9(5):414-416.","journal-title":"J Addict Med"},{"issue":"5","key":"e_1_3_2_3_2","first-page":"382","article-title":"Clonidine poisoning mimicking opioid intoxication","volume":"51","author":"Victorri-Vigneau C","year":"2013","unstructured":"Victorri-Vigneau C, Tournier M, Chevallier C, et al. Clonidine poisoning mimicking opioid intoxication. Clin Toxicol (Phila). 2013;51(5):382-385.","journal-title":"Clin Toxicol (Phila)"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.2169\/internalmedicine.8234-16"},{"key":"e_1_3_2_5_2","first-page":"68","article-title":"Bradycardia associated with concomitant amiodarone and clonazepam in a dialysis patient","volume":"33","author":"Hasegawa C","year":"2012","unstructured":"Hasegawa C, Narumiya H, Yamada H, Deguchi M. Bradycardia associated with concomitant amiodarone and clonazepam in a dialysis patient. 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