Posted by: thealienist | March 4, 2010

Treatment with Benzodiazepines for Anxiety (Part II)

After publishing my first post on benzodiazepine use in anxiety, I realized that there was an important piece of information that I have left out.  This post addresses the decision to use scheduled vs. as needed benzodiazepines in the treatment of anxiety.

For many of my patients, the decision on how to take their medication depends on the pattern of anxiety they have.   Some patients have chronic anxiety  or very frequent intermittent anxiety.  For example, they may have a generalized anxiety disorder in which they worry much of the day every day, or they may have a panic disorder in which they have significant panic attacks every day or almost every day.  Others may have relatively rare episodes of anxiety, such as a panic disorder with panic attacks many days or weeks apart, or a specific social phobia that only rarely becomes problematic.  These two classes of anxiety can benefit from different patterns of benzodiazepine use.

I recommend to my patients with the first pattern of anxiety to take their benzodiazepines on a schedule.  I urge them not to wait until they are miserable to take their medications.  We certainly would not tell a diabetic, ” Whenever your blood sugar gets to 400, be sure to take your insulin.”  We would try to prevent the manifestations of illness before it started.  I often tell my patients, “It’s better to prevent misery than to chase it around with a pill.”  The dose and frequency of use of a benzodiazepine differs with each medication.  Each medication has a different potency, rate of onset of effects, and duration of action.  Physicians and patients will have to discuss which medications are most appropriate, how much of the patient’s day needs to be covered (i.e. just the mornings, just the afternoons, just the evenings, or all day), potential side effects of each medication, and anticipated duration of treatment.

To patients with the second pattern of symptoms (widely spaced and intermittent), I often suggest that patients can take their benzodiazepines as needed.  This is especially true if their anxiety disorder results in predictable patterns of distress such as anxiety in social situations.  In such a case, I urge my patients to take their medications approximately 30 minutes before the expected anxiety-provoking event (to allow time for absorption of the medication).  In patients who have rare and intermittent anxiety that is unpredictable in its onset, I often encourage them try to tolerate the anxiety and learn coping strategies to manage it until it subsides, but I also sometimes provide them with short-acting and rapid onset benzodiazepines (such as alprazolam (Xanax)) to use as an escape from their anxiety, if they absolutely need it.  There is some behavioral risk with this strategy, since each time a patient uses the benzodiazepine to escape their anxiety, they are likely to attribute their ability to endure to the medication.  Increasing a patient’s reliance on medication as the source of their ability to cope rather than as one of many tools they can use to cope may be counterproductive.

For those clinicians who wish to use benzodiazepines skillfully and for those patients who seek relief from their anxiety by learning to use these effective medications, I hope that you have found these posts helpful.  I look forward to comments from clinicians and patients that will improve our ability to use benzodiazepines wisely.

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Responses

  1. IMANY MEDICATIONS CAUSE DEPENDENCE AGREE WITH YOU EXCELLENT ARTICLE ON BENZODIAZEPINES.I AM CURRENTLY TAKING KLONOPIN PRN .25 TO .5 MG DAILY IF NEEDED.IT IS EXCELLENT,SUBTLE AND WELL TOLERATED BEING VERY SAFE.MANY MEDICATIONS CAUSE DEPENDENCE WHICH IS NOT THE SAME AS ADDICTIVE. ANY PERSON WHO WILL ABUSE KLONOPIN WILL ABUSE ANYTHING GIVING KLONOPIN A BAD NAME.I WOULD APPRECIATE A REPLY. THANK YOU.

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