Anxiety

Managing

More than one third of people taking benzodiazepines--such as alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium)--for more than one month become dependent on them. Because of this high risk, the prescribing physician should monitor patients closely, and patients considering these drugs should both understand the possible side effects and know the precautions to take to avoid developing dependence.

Because of the risk of dependence, two classes of antidepressant drugs--selective serotonin reuptake inhibitors and tricyclics--have become the first line of treatment for anxiety disorders in many people. Serotonin and norepinephrine reuptake inhibitors and tetracyclics are also used to treat these conditions. These drugs are not habit forming and are indicated when a person with anxiety is also depressed. In addition, a newer drug called buspirone (BuSpar) has fewer adverse effects than benzodiazepines, but it may be less effective, in particular for panic disorder. As a result, benzodiazepines are still used in many people with anxiety.

Dependence vs. addiction. The words "addiction" and "dependence" are often used interchangeably, but they are not synonymous. Dependence and tolerance refer to physiologic responses to a drug, while addiction is a behavioral and psychological phenomenon. Tolerance is defined as a reduction in response to a drug over time, and physical dependence means that withdrawal symptoms would occur if a substance is abruptly stopped or dramatically decreased. Tolerance and physical dependence do not necessarily lead to addiction, which involves the compulsive, uncontrolled use of a drug with no regard for any harm it may cause. Tolerance, physical dependence, and addiction are all possible with benzodiazepines.

Who is at risk? The risk of becoming dependent on a benzodiazepine is influenced by personal characteristics and increases with long-term use and high doses. Patients most at risk include those whose anxiety is combined with depression or obsessive-compulsive disorder and those with a history of drug abuse. Older patients and women are also more likely to develop a dependency, which may be because they are also prescribed benzodiazepines more often.

Prevention. The short-acting benzodiazepines, such as lorazepam (Ativan) and alprazolam, are the most potent and therefore should be taken with the most care. Moreover, doses should be as low as possible because excessive doses increase the risk of adverse effects, dependence, and problems in withdrawal. In addition, duration of treatment should be as short as possible--ideally, no longer than four weeks. If patients need treatment for a longer period, it is preferable to use intermittent therapy--for example, two to four weeks of taking the drug regularly interspersed with tapering off it for one to two weeks--rather than continuous long-term therapy.

Coping effectively with withdrawal. Patients who become addicted to these drugs usually experience both physical and psychological withdrawal symptoms when the medication is discontinued. Physical symptoms include increased anxiety, irritability, agitation, restlessness, loss of appetite, and muscle aches. Psychological dependency is characterized by a persistent desire for the drug after it has been discontinued.

Patients should not stop taking any medication without consulting their physician: Abrupt discontinuation of benzodiazepines can cause dangerous complications such as insomnia, loss of appetite, tremor, muscle aches, and--in some people --confusion or seizures. But if you feel you are developing a dependency or need increasingly higher doses to feel the same effects, inform your physician immediately. The drug will need to be discontinued very carefully. To avoid withdrawal symptoms, your doctor will prescribe a discontinuation program in which the dose of the benzodiazepine is gradually decreased over a period of three months to a year. You may also require extra psychological support, such as psychotherapy, to help you learn alternate methods of managing anxiety and confronting the sources of your anxiety.

Warning Signs of Addiction

• obtaining repeat prescriptions
• development of tolerance--the need for increasing doses to gain the desired effect
• maintaining a desire for the drug after treatment has been discontinued
• experiencing withdrawal symptoms

This section has more on alternatives to medication.

Alternatives to medication

Other treatment methods used in conjunction with psychotherapy may help and may be even more effective than medications for certain patients. For example, relaxation techniques--exercises involving slow, deep breathing and positive visualization--may relieve the physical effects of anxiety. Such techniques can help to achieve and maintain a feeling of calm and confidence in anxiety-provoking situations or during a panic attack. Some experts have found that people with panic disorder, for example, tend to have slightly higher-than-average breathing rates; learning to breathe slowly can help them both deal with an attack and prevent future ones.

Psychological relaxation techniques, such as meditation and self-hypnosis, may also be useful tools. These methods involve learning to remove yourself mentally from a distressing situation by concentrating on a word or phrase or by imagining a calming place or event. Joining a support group for people with anxiety may also prove helpful.