Posted by: thealienist | February 26, 2010

Treatment with Benzodiazepines for Anxiety

Benzodiazepines are medications that are related to Valium.  They are very effective anxiolytics (medications that reduce anxiety) and hypnotics (sleep medications) and are generally very safe to use.  However, there are few medications in the psychiatrist’s medicine bag that are more misunderstood and less artfully used.  This post will address important issues in the therapeutic use of benzodiazepines.

What are the Benzodiazepines?

First, let’s discuss what benzodiazepines are.  Benzodiazepines are medications that fight anxiety and promote sleep.  They do this by strengthening the effect of a chemical in the brain that reduced brain activity.  This neurotransmitter is called gamma-amino butyric acid (GABA) and is the most common inhibitory neurotransmitter in the brain.  Because of the way that the benzodiazepines work, they are safer to use than their close relatives, the barbiturates, but are dangerous when mixed with alcohol.  When taken together, benzodiazepines and alcohol over-inhibit the brain and can cause death.

Benzodiazepines are often prescribed (along with other medications) for patients who have troublesome anxiety or difficulty sleeping.  Some of the more common benzodiazepines are Valium (diazepam), Ativan (lorazepam), Xanax (alprazolam), Klonopin (clonazepam), Librium (chlordiazepoxide), Tranxene (clorazepate), Dalmane (flurazepam), Restoril (temazepam), and Serax (oxazepam).  They all work the same way in the brain.  The only major difference between these medications is their potency (strength) and their half-life (duration of action).

At low doses, benzodiazepines treat anxiety.  As the doses increase, however, the sedating side effects of the medications become stronger.  If you are taking a benzodiazepine for anxiety but find it too sedating, you may be taking too high of a dose.  Talk to you doctor about reducing your dose or changing to a less potent benzodiazepine.

Benzodiazepines and the Behavioral Science of Anxiety

Anxiety is a distressing emotion that occurs when there is a sense of danger with no obvious cause.  This is different from fear, in which the danger is directly perceived.  For example, if you are crossing the street and step off the curb, the car horn of the automobile that is about to run over you causes fear.  On the other hand, if you are leaving home for vacation and begin to worry about whether you turned the stove off, you are experiencing anxiety.

Behavioral responses to anxiety include freezing, avoidance, and escape.  On another level, we can see two broad classes of response — passive and active.  The passive responses include freezing and passive avoidance.  Freezing is a very common response and is illustrated by putting a rat into a cage that has been scented with cat urine.  The rat will freeze and scan the environment for signs of danger.  Passive avoidance is also common and can be illustrated by putting a rat into a cage, one side of which has an electrical grid that can deliver a mild shock to the feet.  After experiencing the shock, the rat will simply remain on the side of the cage that does not have the electrical grid.  Although the previous examples focused on rats, these behaviors are also very common in anxious people.  Anxiety-induced freezing interrupts ongoing behavior as anyone who has gotten anxious while giving a speech can attest to.  Passive avoidance is often expressed in anxious people becoming housebound, thus avoiding the stressful world outside their homes.

Active responses to anxiety include active avoidance and escape.  In active avoidance, we may choose a different route to work to avoid travelling past the location of a previous automobile accident, or we may plan our schedule so that we are not in the same room with a supervisor we fear is angry with us.  In this way, we avoid coming in contact with a feared situation.  In escape, however, we find ourselves in a feared situation and we take action to get away from it.  For example, if I have a fear of spiders, I may have actively avoided them by taking care not to exit my house through the garage.  But if I suddenly found a spider in my bedroom, I might very actively and energetically run screaming from the room.

Mild anxiety can often be coped with using active responses.  If we don’t fear situations too strongly, we may trust ourselves with the risk of actually encountering our feared situations.  If we are comfortable with our ability to avoid the situation while engaging in other activities, or if we are convinced of our ability to appropriately escape (or even endure) a direct encounter with the situation, then our anxieties will not be too disruptive to our lives.  Moderate to severe anxiety, however, is often coped with using passive responses.  The most disruptive of the passive responses is passive avoidance.  If our anxiety is too strong, we will not trust ourselves to cope with even the risk of encountering our feared situation.  We will begin giving up more and more of our lives in order to be “safe” from our feared circumstances, and as passivity takes over our lives, we become more and more depressed and dissatisfied with our lives.  When anxiety becomes very severe, active responses may periodically occur in the form of escape.  This is one explanation for the high rate of suicide in people with anxiety disorder.

With the exception of escape by suicide, in general the healthiest responses to anxiety are active responses.  Being able to freely choose between active responses to feared situations is a sign of excellent mental health.  For example, choosing to constructively engage a supervisor at work with whom you have a conflict is more healthy than actively avoiding him or walking out of the room when he arrives.  These active responses, however, are healthier than staying home from work to avoid being around him.

Benzodiazepines are tools that clinicians and patients can use to improve coping with anxiety.  The goal of treatment with benzodiazepines is to allow patients to move from more problematic passive responses to anxiety to more adaptive active responses.  However, like any tool, the benzodiazepines can be misused.

The Proper Use of Benzodiazepines

When benzodiazepines are used properly, they are among the safest psychiatric medications available.  The hallmark of proper benzodiazepine use is the patient’s increased active engagement with the environment.  Where the patient was passively avoidant, now the patient is actively pursuing his goals in life (though he may still actively avoid particular feared situations).  Where the patient would formerly freeze in the face of anxiety, now he engages his environment and takes some measure of control in anxiety-causing situations.  For those patients who were actively avoiding situations, now they can endure them and participate in them.  Thus, with the use of benzodiazepines, patients can reclaim parts of their lives that they had given over to anxiety and can reconstruct a meaningful and satisfying life.

It should be noted, however, that benzodiazepines may not be enough to enable patients to reclaim important parts of their lives.  Sometimes, they have been passive for so long that their skills for dealing with an active life have been forgotten or they lack confidence in their ability to use them.  In these cases, patients need to relearn and practice these skills with their clinicians so that they can make full use of their benzodiazepines.

Improper Use of Benzodiazepines

When benzodiazepines are used improperly, they are among the worst, most useless, and problematic of psychiatric medications.  The hallmark of improper benzodiazepine use is the patient’s decreased engagement with the environment.  Benzodiazepines can be used to numb one’s emotions and dull the mind.  They can be used to retreat into sleep instead of engaging in life.  Misused, benzodiazepines are the ultimate in passive avoidance as misguided patients retreat into the fantasies of their own minds instead of reclaiming their lives.  Thus, the anxiety and depression continue to worsen, and medications become less and less effective.

Improperly used, benzodiazepines are addictive.  The body develops tolerance to the medications so that higher and higher doses are required to get the desired numbing of the emotions and mind.  Withdrawal symptoms occur when the benzodiazepine is not available, and these withdrawal symptoms can be fatal.  Withdrawal from benzodiazepines is almost identical to alcohol withdrawal and can even include delirium tremens (the D.T.’s).  As patients become tolerant to benzodiazepines, they may mix it with alcohol to get the additional numbing effect.  This puts the patient at risk for respiratory arrest and death.


Benzodiazepines are marvelously effective medications when used properly.  Their proper use depends on the clinician and the patient having an understanding of healthy behavioral responses to anxiety and stress.  The benzodiazepines are not to be used to eliminate anxiety since anxiety is a normal part of life.  They are most effective when they are used to decrease anxiety to the point that patients can actively confront and engage the situations they  must encounter in their lives.  This will allow patients to freely search for a life full of meaning and satisfaction.


  1. Thank you, I found this post extremely helpful in furthering my understanding of not only benzo’s but the different types of responses in regards to anxiety.


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