Older people in benzos

[SpinDktr]

Yes, elderly people without psychotic disorders should not be prescribed antipsychotics. Schlogging elderly people with Seroquel to keep them from making annoying demands of care staff is a travesty.

If you're talking about someone who needs the antipsychotic to control a chronic psychotic disorder, this is not comparable to benzodiazepines because antipsychotics are effective (to greater or lesser degrees) for psychosis, while chronic use of benzodiazepines is generally not effective for anything other than prevention of benzodiazepine withdrawal, so it's a totally different risk/benefit ratio.

I see this attitude so much from other psychiatrists, but in practice this attitude doesn't work, even in MDD.

I am the director for a geriatric psychiatry unit, and I will always try antidepressants first for depression. But antipsychotics have their role and are important. Not that you want to sedate people to pacify them, but antipsychotics have an indication in severe or treatment refractory depression as well, let's not forget that. If I took the attitude that I would never prescribe antipsychotics I would never be able to discharge people from this unit. And I am talking about depression, not dementia here.

I have also seen many cases of catatonia in this role, not from schizophrenia but also severe MDD. Benzodiazepines are absolutely essential where I practice because there is such a dearth of ECT resources. When someone goes from declining and looking like they will need hospice in the near future to improving to the point they can eat/drink or at least have some quality of life....well if I was in their shoes, I would want to have a doctor that would empathize enough to do that as well.

Antipsychotics also have a very useful role in dementia with behavioral disturbances, but this is more controversial, and needs to be taken on a case by case basis. I don't really want to go down that rabbit hole here, but others may chime in.

---

Members don't see this ad.

 

[clausewitz2]

Not sure if 'defining' is the issue here.
We define hypertension based on whatever measurement we get (or other criteria..etc), but we aren't treating people for hypertension because they deviate from that measurement. We're treating them because we do not want them to have strokes and suffer. Ultimately, the experience of suffering (i.e illness) is the arbiter of medicine, and it's the patient's subjective experience, not ours.

If I am sad because my partner left me, it is very hard to argue that this is not suffering. Similarly, if my parent or child dies, I will very likely suffer, often intensely, possibly for a good long while. Being homeless because you lost your job and are broke will cause you to suffer. Belonging to an oppressed ethnic or racial group in a given society will cause you to suffer.

We do not regard these things as psychiatric disorders. I tend to agree with that assessment but note that it cannot be based simply on the fact or even amount of suffering.

It's the critical difference between disease and illness. Disease is a practical, scientific way of looking at biological function but its ultimate goal is to treat illness. It's the same concept in psychiatry. I do not treat psychiatric illness because I think something needs fixing and it deviates from normal. I treat it because the patient is coming with an experience of suffering and they need and request help with this.

Oh, boy. I have given entire lectures on the disease concept in psychiatry and I will gloss it by saying that the distinction you are drawing is not actually hugely well founded in our field (and, to be fair, in some other branches of medicine) and is going to bear less weight than you would like it to.

Say that I genuinely believe that I am too anxious to ever go back to work again. I come to you asking for help, making it clear that I cannot go back to the job I am due back at tomorrow. Or even better, you treat me for a while, and I decide I can never go back to any work ever again because I am simply too fearful of the discomfort I think I will experience if I do so. I am not interested in psychotherapy and don't want that form of help. Is your response to say, "well, sure, then I will support your disability until we can get the meds right?"

I should hope the answer is no, and I would agree with you 100%, but I am not going to be able to explain why on the basis of the patient in question not suffering or not asking for help.

Now it's true, you bring a good point with personality disorders, but just because we do things one way (whoever sat on those DSM meetings really), it doesn't mean it's the right way. I mentioned classical psychoanalysis and it was the mainstream of psychiatry for a few decades, and its history is terrible, basically because they tried to pathologize everything that deviates from social norms.
We run the risk of doing the same thing whenever "a flourishing person" is the standard. This means so many different things in many different settings.

And yet the "functional impairment" criteria of most DSM disorders requires a notion of human flourishing in order to have any content whatsoever. Without some kind of standard in mind, "functional impairment" becomes "whatever I the diagnoser think is a real problem at this moment."

Since then, we moved into concepts of distress which are most certainly more patient-centered, and personality disorders themselves don't have a shortage of critics.

And yet, if we apply the disease concept from medicine, BPD is one of the best candidates we have for a specifically defined syndrome with (putative) specific etiology, characteristic clinical course and symptoms, and specific treatment. It is also a description of distress that many patients who qualify for the diagnosis find extremely descriptive of their experience.

At the end of the day, if what we are treating is distress or, even worse, suffering , why exactly do we have any special license or training as physicians to be the ones doing it? Just to be the one prescribing pharmaceuticals or administering ECT? Why should we engage in any non-somatic aspect of treatment instead of being replaced by non-medical psychotherapists, or priests, or shamans, or life coaches?

 

[G Sheb]

If I am sad because my partner left me, it is very hard to argue that this is not suffering. Similarly, if my parent or child dies, I will very likely suffer, often intensely, possibly for a good long while. Being homeless because you lost your job and are broke will cause you to suffer. Belonging to an oppressed ethnic or racial group in a given society will cause you to suffer.

We do not regard these things as psychiatric disorders. I tend to agree with that assessment but note that it cannot be based simply on the fact or even amount of suffering.




Oh, boy. I have given entire lectures on the disease concept in psychiatry and I will gloss it by saying that the distinction you are drawing is not actually hugely well founded in our field (and, to be fair, in some other branches of medicine) and is going to bear less weight than you would like it to.

Say that I genuinely believe that I am too anxious to ever go back to work again. I come to you asking for help, making it clear that I cannot go back to the job I am due back at tomorrow. Or even better, you treat me for a while, and I decide I can never go back to any work ever again because I am simply too fearful of the discomfort I think I will experience if I do so. I am not interested in psychotherapy and don't want that form of help. Is your response to say, "well, sure, then I will support your disability until we can get the meds right?"

I should hope the answer is no, and I would agree with you 100%, but I am not going to be able to explain why on the basis of the patient in question not suffering or not asking for help.



And yet the "functional impairment" criteria of most DSM disorders requires a notion of human flourishing in order to have any content whatsoever. Without some kind of standard in mind, "functional impairment" becomes "whatever I the diagnoser think is a real problem at this moment."



And yet, if we apply the disease concept from medicine, BPD is one of the best candidates we have for a specifically defined syndrome with (putative) specific etiology, characteristic clinical course and symptoms, and specific treatment. It is also a description of distress that many patients who qualify for the diagnosis find extremely descriptive of their experience.

At the end of the day, if what we are treating is distress or, even worse, suffering , why exactly do we have any special license or training as physicians to be the ones doing it? Just to be the one prescribing pharmaceuticals or administering ECT? Why should we engage in any non-somatic aspect of treatment instead of being replaced by non-medical psychotherapists, or priests, or shamans, or life coaches?

Your job is certainly not to do what the patient says. I think that's besides the point. If you think this will not help them or that it contravenes your own values, you don't have to proceed.
Anyone can get out with a DSM diagnosis if they visit a mental health practitioner and there's distress, but to your point, I agree we're not carte blanche suffering-healers. We're supposed to use our scientific and technical knowledge about the brain/mind to ameliorate suffering, when we can. But the centrality of patient suffering to medical practice is still the same, regardless of specialty. If we put the cart before the horse ("fix the abnormal"), I think we're on the wrong side of history and ethics as well.

 

[samac]

This is a great question that I think got lost a bit in the discussion. Wondering what your context is (PCP office, psych, etc)?

For the Benzos + opioids question, especially for full agonists like hydrocodone or if people are using street fentanyl, I try to be kind but firm that this regimen is associated with a higher risk of mortality, especially through accidental overdose. Not because I think they're misusing either medication, but as an elderly person with crappy drug clearance it wouldn't take a lot to get a little sick, add another unrelated med, or do something else that changes drug clearance to increase OD risk even if their dose of opioids/benzos is unchanged. The doses you describe are pretty eye popping (12mg TDD of clonazepam is a lot!!), especially in someone who's elderly.

For a younger person requesting to go up on their benzo, I guess it would depend a little bit on their dose (ex. is this someone on 0.25mg BID or 1 TID already), but in general I would ask what would make this dose change different, and what would stop us from having the same conversation again in 6 months? This gives space to talk about habituation/tolerance, other interventions to improve anxiety, etc. This would also be a good time to assess trauma if you haven't already, because although it happens all the time benzos are well known to interfere with effective PTSD treatment. Sometimes you can get buy in from someone about not sabotaging their trauma recovery if this is important to them.

At the end of the day though, I feel like the answer is just that sometimes you have to say no. It's not particularly fun, but I find that if it's truly done with the patient's best interests in mind and explained as such (rather than hiding behind the DEA or medical board), it often doesn't go as bad as you would expect.

I’m a 3rd year resident, we have attendings who pretty much let residents do whatever they want and I’ve got some seriously interesting benzo regimens I’m uncomfortable with.

As far as being kind but firm are there any specific resources you share with them?

I like the thought of talking with patients about having the exact same conversation in 6 months. Xanax was rarely used, but I got a lot of folks ok Klonopin 1-2 TID that fail SSRIs and are on nothing else and I hate it so much.

 

[Crayola227]

Yes, but, isn't one of the literally most annoying things all physicians deal with on a near constant basis, the bias that "pills are bad" etc? So I think it has great potential to backfire to appeal to that in order to get compliance for discontinuing a med, and so I find it somewhat disingenuous to use that as a rationale. Because certainly there are many people who need to be or will need to be on say, 10 different medications to live. So arguably even for us as docs it's not truly about the number, but the appropriateness. So when you have physicians at one time giving credence to the idea that "more is bad" then later it can seem like a real contradiction when you're putting them on like 10 meds for combo heart and kidney failure.

Obviously whether it's appropriate to be on 10 meds or not is more complicated than number. But I don't expect patients to understand the nuances of that the way a doc does, and to understand when it's appropriate for us to push another med or to d/c one.

But I prefer to focus on how appropriate the medication and the combinations are, over simplistic arguments that boil down to how it's better to be on a lower number of pills.

I have a friend who is currently dying of cancer, cancer that she is now aggressively treating. Before she opted not to do chemo and radiation (when it could have made more of a difference) because she thought these were "bad" and she wanted to do something more "natural." So needless to say I hate these sorts of arguments and I think it doesn't help at all when we push narratives that patients might mistake as reaffirming of certain laypeople notions, like "more pills are bad."

 

[Crayola227]

yup, very much this. I have found that when I have a longer "med management" visit, the psychotherapy although brief is a tremendous help in history gathering and improving patient insight and involvement in their treatment planning. I tell people, often they are pleasantly surprised to see how simple their regimen can be. And what can be more empowering than that?! Versus not taking ownership or a more active role, you are allowing yourself to be a prisoner and putting yourself at the mercy of what little medications can do in many circumstances. Although, I think some people get a need met maladaptively by staying in the patient role (and sometimes the caregiver from the attention and/or want to quiet down the patient) and we start to broach that delicate topic of, why they want to stay in that position and how to have healthier, more fulfilling life experiences. Because the truth is, they can say what they want and try to believe what they want, but their actions show they still feel miserable. They are free to try to force medications on a non-medication issue, much like trying to force a square peg into a round hole, but the outcome will not be any more favorable just because they force it harder. That's where the therapeutic alliance is such a must. Patients do seem to get a better grasp when you explain the pharmacology in ways they can digest and that the medications are designed to treat disease processes, not wipe away symptoms. When there is a symptom, like any good healthcare provider, one must try to identify the underlying cause and treat said cause.

Well and that's what I agree with and what we're sort of dancing around, talking about the patient perspective vs the physician's. The reality is that it is all about the therapeutic alliance, and essentially the degree or overlap to which the patient and physician understand one another's perspective and formulation of the problem, the goal of care, and what each is willing to do to try to address it. In that sense, every visit can be seen as a sort of negotiation of sorts.

 

[Crayola227]

At the end of the day though, I feel like the answer is just that sometimes you have to say no. It's not particularly fun, but I find that if it's truly done with the patient's best interests in mind and explained as such (rather than hiding behind the DEA or medical board), it often doesn't go as bad as you would expect.

👏

 

[Evidence Based]

I’m a 3rd year resident, we have attendings who pretty much let residents do whatever they want and I’ve got some seriously interesting benzo regimens I’m uncomfortable with.

As far as being kind but firm are there any specific resources you share with them?

I like the thought of talking with patients about having the exact same conversation in 6 months. Xanax was rarely used, but I got a lot of folks ok Klonopin 1-2 TID that fail SSRIs and are on nothing else and I hate it so much.

Got it! In terms of resources for the patient, the VA has some interesting patient facing brochures on the risk/benefit ratio of benzos that I like, but have not yet used with a patient:
Benzo risks and shared decision making: https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Benzodiazepine_Provider_AD_ Risk_Discussion_Guide.pdf
Benzos and PTSD: https://www.ptsd.va.gov/professional/treat/docs/Benzodiazepines_PTSD_Booklet.pdf
This one is providing facing but really good as a reference "Re-evaluating the Use of Benzodiazepines": https://www.pbm.va.gov/PBM/Academic...zodiazepine_Provider_AD_Educational_Guide.pdf

From our side, it's a lot of DBT effective communication skills tbh. Expressing clear concern, being consistent in your messaging, explaining your reasoning, being willing to negotiate when it's appropriate (ex. schedule for a taper, taper from an unsafe to a safer dose and then reassessing), and being firm when negotiation is not appropriate (no, staying on 2mg clonazepam QID or 40 of Adderall QID is not a possibility for you).

And of course it's always a chance to plug good therapy for anxiety (CBT, ACT) which most of our patients have unfortunately not tried before ending up on clonazepam (often due to access issues)

 

[Crayola227]

Not sure if 'defining' is the issue here.
We define hypertension based on whatever measurement we get (or other criteria..etc), but we aren't treating people for hypertension because they deviate from that measurement. We're treating them because we do not want them to have strokes and suffer. Ultimately, the experience of suffering (i.e illness) is the arbiter of medicine, and it's the patient's subjective experience, not ours. It's the critical difference between disease and illness. Disease is a practical, scientific way of looking at biological function but its ultimate goal is to treat illness (which is inherently subjective). It's the same concept in psychiatry. I do not treat psychiatric illness because I think something needs fixing and it deviates from normal. I treat it because the patient is coming with an experience of suffering and they need and request help with this.

Now it's true, you bring a good point with personality disorders, but just because we do things one way (whoever sat on those DSM meetings really), it doesn't mean it's the right way. I mentioned classical psychoanalysis and it was the mainstream of psychiatry for a few decades, and its history is terrible, basically because they tried to pathologize everything that deviates from social norms.
We run the risk of doing the same thing whenever "a flourishing person" is the standard. This means so many different things in many different settings.

Since then, we moved into concepts of distress which are most certainly more patient-centered, and personality disorders themselves don't have a shortage of critics.

Yes well and even if someone doesn't accept they have a PD, I think you would be hard pressed to find the person who meets criteria, that has lost jobs, friends, etc impairment in societal functioning, that wouldn't describe subjectively that they have suffered. They may not seek treatment or acknowledge their issues as the cause. However, what this means is that we can have the flawed DSM AND apply your standard about illness, and the vast majority of the time it will work out. Because the odds that someone meets criteria for PD and doesn't have clinically significant subjective suffering is quite low. The two follow together.

So someone presents with suffering, and then we seek to apply these standards. But I think you are quite correct that given the principle of autonomy, that in most cases it makes sense that the formulation of the problem is effectively initiated by the patient and driven by them.

 

[G Sheb]

Yes well and even if someone doesn't accept they have a PD, I think you would be hard pressed to find the person who meets criteria, that has lost jobs, friends, etc impairment in societal functioning, that wouldn't describe subjectively that they have suffered. They may not seek treatment or acknowledge their issues as the cause. However, what this means is that we can have the flawed DSM AND apply your standard about illness, and the vast majority of the time it will work out. Because the odds that someone meets criteria for PD and doesn't have clinically significant subjective suffering is quite low. The two follow together.

So someone presents with suffering, and then we seek to apply these standards. But I think you are quite correct that given the principle of autonomy, that in most cases it makes sense that the formulation of the problem is effectively initiated by the patient and driven by them.

Exactly, which is why the issue of diagnostic definition is a bit superfluous. At the end of the day, diagnostic categories (as flawed as they are, especially in psychiatry) are tools at our disposal to help us manage why the patient presented in the first place and how we can best address their subjective experience. Even PDs.

 

[Candidate2017]

Not really. Who makes us the arbiter of 'restoring function, meaningful change and growth'?
It's the patient who decides what is function, what is meaningful change and growth.

Patients get to decide restoration of function? Ok. Sounds like an ad for one of those nationwide online NP psych clinics.

Or one of the many clinics in the community, where almost all patients are on chronic benzos. The chief complaint of "My anxiety" will get you benzos from a psychiatrist who finds it easier to maintain their $500k+ income by hitting the refill button for 3-4 patients an hour, 5 days a week for the past 10-20 years, rather than actually treat anxiety or even stop to ponder whether there is actual anxiety disorder vs. anxiety. BTW where is that med student that keeps posting 50 different questions on how to make bank in psychiatry?

But, no. I decide. The buck stops at my (controlled sub) script pad. My job is to offer opinions. There is nothing paternalistic. The patient is the arbiter of whether they accept my opinion. If they do, great, we will work together. If not, they are free to seek someone else's opinion.

The fact is most patients are indifferent to medications and would rather not take any meds. Except of course, controlled substances to which they have developed dependence. If I were to tell patients to stop their insulin, blood thinners, or just about any other medication that literally keeps them alive, I dare say 95% would immediately and happily comply. But the moment the topic of tapering benzos is brought up? Begging, crying, and threats from almost all patients. If that isn't dysfunction, I don't know what is.

chronic use of benzodiazepines is generally not effective for anything other than prevention of benzodiazepine withdrawal, so it's a totally different risk/benefit ratio.

Yes. And chronic use of benzos for anxiety means treatment failure.

 

[Candidate2017]

I really appreciate this thread. It helps my perspective. I know there’s patients I’ll never get off benzos,

Not true. You can, but it likely won't be pleasant for you. Expose yourself to that unpleasantness while in residency, everyday. And work through it with a good supervisor.

My biggest problems are I inherited so many geriatric patients that get benzos from us and chronic opioids from a pain doctor. I’m talking Klonopin 2-3mg QID to Hydrocodone 10mg TID. Anyone have a good way on how to be firm about coming down on the dose? Of course I want to do it slowly, but continuing that is not something I’m willing to do.

It's just the inverse of prescribing a medication. You present the facts, the negatives, your opinion on treatment and alternatives, why you're doing what you're going to do, the side effects to expect, what to do in case of emergency. Emphasize that you care about their wellbeing but you'd be happy to send them down the street to the NP clinic if they don't agree. In my experience, about 2/3 will stay. And they will complain and whine. Every time they do, I say, "Yes, see what chronic benzos do?" and move on.

And what do you all do when you inherit someone who’s 30 begging to go up on the benzos they’ve been taking for a year? This has also been a common problem I’m running into and I in good conscious will not go up on them, they’ve got to try other avenues (therapy, SSRIs, Buspar).

Do the same thing. Also, weekly scripts that taper weekly can help those who are highly resistant. It's a pain to calculate in the EMR, but patients will argue and whine less. A 7 day supply requires a patient to comply with the taper. And a patient who has to stick to a 7 day ration and has to show up weekly to pick up their next 7 day supply, well it really hits home that it is all about the benzos and how dependent they are on it, rather than actual anxiety.

 

[clausewitz2]

Yes well and even if someone doesn't accept they have a PD, I think you would be hard pressed to find the person who meets criteria, that has lost jobs, friends, etc impairment in societal functioning, that wouldn't describe subjectively that they have suffered. They may not seek treatment or acknowledge their issues as the cause. However, what this means is that we can have the flawed DSM AND apply your standard about illness, and the vast majority of the time it will work out. Because the odds that someone meets criteria for PD and doesn't have clinically significant subjective suffering is quite low. The two follow together.

So someone presents with suffering, and then we seek to apply these standards. But I think you are quite correct that given the principle of autonomy, that in most cases it makes sense that the formulation of the problem is effectively initiated by the patient and driven by them.

That 'clinically significant' qualifier is doing some incredibly heavy lifting. I am at a loss to define this without a value statement or recourse to professional intuition, but am open to hearing about alternatives.

 

[Stagg737]

Not really. Who makes us the arbiter of 'restoring function, meaningful change and growth'?
It's the patient who decides what is function, what is meaningful change and growth.
You don't have to go along if you disagree with what the patient wants, but I really take issue with this sort of normative approach to something inherently subjective. Our obligation is to provide ethical care, keeping the patient's interests front and center, not to decide what is good for them.

On this topic, I fully agree that if an elderly person has been on long term benzos you weigh the pros and the cons of a taper and whether they are on board or not. I am not sure closing shop and telling them to find someone else is the right thing to do.

I don't disagree, but there are so many gray zones within these thoughts that it's easy to become a member of a service industry instead of a physician acting to maintain a patient's health. Boundaries and standards should be somewhat flexible but are necessary and have to have a hard line somewhere. How would you treat a patient with BIID requesting a limb amputation to create "meaningful change and growth" who is severely distressed by being able-bodied? Where do you draw the line for ethical care when the patient's interests are in direct conflict with their health and even functioning? Obviously an extreme example, but there are plenty of far more common situations where this applies like various capacity evals.

Maybe you already addressed this, but simply put I believe we should work with our patients, not for our patients (when they actually have the ability to work with us).

We define hypertension based on whatever measurement we get (or other criteria..etc), but we aren't treating people for hypertension because they deviate from that measurement. We're treating them because we do not want them to have strokes and suffer.

But we actually are treating based on a deviation from a set measurement because we've determined that at that measurement the increased risk of events like a stroke is high enough to warrant treatment. As above, we allow for some flexibility but at some point we have to acknowledge the data is strong enough that our recommendations should override patient preference. I don't see another way to look at this unless you argue that patients should have full autonomy of choice regarding their treatment which overrides any opinions or recommendations we make.

Also, regarding the criticism of paternalism - I do reserve the right to insist my patients get thier psyches in good order rather than confront problems in living with sedatives. Not claiming the moral high ground here, but that's the service I offer.

I think this emphasizes the other side of the coin of what we are obligated to do from a personal perspective. Should a physician capable of prescribing a med or performing a procedure be forced to do so regardless of their personal beliefs or views? I can see an argument for being forced in emergency situations, but what about elective treatments? At what point does that violate the autonomy of the physician?

 

[Stagg737]

I really appreciate this thread. It helps my perspective. I know there’s patients I’ll never get off benzos, and I accept that as long as they continue to listen to me discuss the risks. My biggest problems are I inherited so many geriatric patients that get benzos from us and chronic opioids from a pain doctor. I’m talking Klonopin 2-3mg QID to Hydrocodone 10mg TID. Anyone have a good way on how to be firm about coming down on the dose? Of course I want to do it slowly, but continuing that is not something I’m willing to do.

And what do you all do when you inherit someone who’s 30 begging to go up on the benzos they’ve been taking for a year? This has also been a common problem I’m running into and I in good conscious will not go up on them, they’ve got to try other avenues (therapy, SSRIs, Buspar).

You've already gotten some good answers, but some other thoughts...

Emphasize how dangerous the above doses are in the elderly. EB made an excellent point that for those patients relatively small events (infections, accidental misdosing, etc) can have catastrophic results. One of my attendings in residency who ran our pain clinic would give patients the choice, benzos or opiates. She'd tell them she'd work with them to optimize whichever one they chose and provide safer alternatives to the once tapered, but she'd tell them straight up she wasn't willing to endanger their lives in that way. I was surprised how effective this was and also gave a lot more clarity regarding what the patient's priorities were and where their major distress was really coming from.

For the younger crowd, arguments will vary. I had one attending whose opinion was that he didn't have problems increasing (within reason) as once patients reached an effective dose they wouldn't need further adjustments. Apparently worked pretty well for him, though not something I do.

Something else to keep in mind regarding anxiety in general is the importance of diagnostic clarity. Anxiety is so subjective and variable in it's description and sources that it's important to really understand what the patient is experiencing. There are many patients who describe being "anxious", but when you really dive into it what they describe is not anxiety at all. The etiology is also essential IMO. I treat patients experiencing anxiety from PTSD vs. PD vs. ADHD vs. GAD very differently, and the meds and treatments you utilize should reflect that. I've had more than a few patients who did pretty great and came off benzos fairly uneventfully when their actual underlying issue was addressed and they were generally very grateful for it.

I do think benzos have their place for anxiety, and I'll disagree with a few above posters and say that (very rarely) chronic benzos may be necessary for someone to be able to function adequately. However, the few patients I encountered where I felt that way were individuals that I spent a lot of time with and who had already put the work in with many other treatments (including multiple forms of therapy) but were still significantly distressed without benzos. I'll also add that all of those individuals were on relatively low doses (think <1mg of Klonopin equivalents in a day) and wanted to stay on the lowest dose they could.

 

[Crayola227]

That 'clinically significant' qualifier is doing some incredibly heavy lifting. I am at a loss to define this without a value statement or recourse to professional intuition, but am open to hearing about alternatives.

I'm defining "clinically significant subjective suffering" as suffering that prompts a person to seek professional help for it by voluntarily presenting to a clinician for it. This might not meet criteria *we* have, but we can say that if the patient is bothered enough to show up to a clinic, then it means just that, they are bothered enough to show up to a clinic.

Naturally this leaves out people who may have PDs by some standard but yet never seek professional help for what they suffer.

I was taught that this is the broadest definition for clinically significant subjective suffering. Example, patient has chest pain and think they're going to die and present to the ED. It is determined they lifted something a little heavy and are actually experiencing a twinge of rib pain that gave them panic. This may not be a big deal to the clinician, but it would be fair to say that in the patient's view they had subjective suffering that reached the limit of clinically significant. Essentially it's this view that anything that brings a patient in, is clinically significant because of the importance to the patient (important enough to seek care in their view).

The patient in my example may not even have any impairment. But it isn't fair to say the subjective suffering wasn't clinically significant.

It's a view that just about any patient complaint can be seen as actionable in some way by the physician. Certainly such a visit generates a note, lol. But like sometimes the only thing the physician need do is reassurance.

 

[painballer27]

It's fine.

 

[Crayola227]

Patients get to decide restoration of function? Ok. Sounds like an ad for one of those nationwide online NP psych clinics.

Or one of the many clinics in the community, where almost all patients are on chronic benzos. The chief complaint of "My anxiety" will get you benzos from a psychiatrist who finds it easier to maintain their $500k+ income by hitting the refill button for 3-4 patients an hour, 5 days a week for the past 10-20 years, rather than actually treat anxiety or even stop to ponder whether there is actual anxiety disorder vs. anxiety. BTW where is that med student that keeps posting 50 different questions on how to make bank in psychiatry?

But, no. I decide. The buck stops at my (controlled sub) script pad. My job is to offer opinions. There is nothing paternalistic. The patient is the arbiter of whether they accept my opinion. If they do, great, we will work together. If not, they are free to seek someone else's opinion.

The fact is most patients are indifferent to medications and would rather not take any meds. Except of course, controlled substances to which they have developed dependence. If I were to tell patients to stop their insulin, blood thinners, or just about any other medication that literally keeps them alive, I dare say 95% would immediately and happily comply. But the moment the topic of tapering benzos is brought up? Begging, crying, and threats from almost all patients. If that isn't dysfunction, I don't know what is.



Yes. And chronic use of benzos for anxiety means treatment failure.

Wow I didn't know GAD was one of those conditions you could just cure and get people off the medication, like an infection or something

 

[Crayola227]

Not true. You can, but it likely won't be pleasant for you. Expose yourself to that unpleasantness while in residency, everyday. And work through it with a good supervisor.



It's just the inverse of prescribing a medication. You present the facts, the negatives, your opinion on treatment and alternatives, why you're doing what you're going to do, the side effects to expect, what to do in case of emergency. Emphasize that you care about their wellbeing but you'd be happy to send them down the street to the NP clinic if they don't agree. In my experience, about 2/3 will stay. And they will complain and whine. Every time they do, I say, "Yes, see what chronic benzos do?" and move on.



Do the same thing. Also, weekly scripts that taper weekly can help those who are highly resistant. It's a pain to calculate in the EMR, but patients will argue and whine less. A 7 day supply requires a patient to comply with the taper. And a patient who has to stick to a 7 day ration and has to show up weekly to pick up their next 7 day supply, well it really hits home that it is all about the benzos and how dependent they are on it, rather than actual anxiety.

My main issue with some of the posts, is they read more like steps the physician is taking to deal with the ins and outs of their workday than it does, like, how does the patient do with all this? That's what I want to know.

 

[tr]

Wow I didn't know GAD was one of those conditions you could just cure and get people off the medication, like an infection or something

Is this sarcasm?? Of course GAD is curable. Exposure therapy is often quite effective. Maybe not every patient but certainly it's possible to have people start with both medication and psychotherapy and become able to wean off medication once they've mastered the skills from therapy.

 

[G Sheb]

Patients get to decide restoration of function? Ok. Sounds like an ad for one of those nationwide online NP psych clinics.

Or one of the many clinics in the community, where almost all patients are on chronic benzos. The chief complaint of "My anxiety" will get you benzos from a psychiatrist who finds it easier to maintain their $500k+ income by hitting the refill button for 3-4 patients an hour, 5 days a week for the past 10-20 years, rather than actually treat anxiety or even stop to ponder whether there is actual anxiety disorder vs. anxiety. BTW where is that med student that keeps posting 50 different questions on how to make bank in psychiatry?

But, no. I decide. The buck stops at my (controlled sub) script pad. My job is to offer opinions. There is nothing paternalistic. The patient is the arbiter of whether they accept my opinion. If they do, great, we will work together. If not, they are free to seek someone else's opinion.

The fact is most patients are indifferent to medications and would rather not take any meds. Except of course, controlled substances to which they have developed dependence. If I were to tell patients to stop their insulin, blood thinners, or just about any other medication that literally keeps them alive, I dare say 95% would immediately and happily comply. But the moment the topic of tapering benzos is brought up? Begging, crying, and threats from almost all patients. If that isn't dysfunction, I don't know what is.



Yes. And chronic use of benzos for anxiety means treatment failure.

I really disagree with your approach and your projections are completely false.
I’m very hesitant with chronic benzos, but it’s not because I think it’s better for them to suffer and then grow and change the way I want them to. But because chronic benzos are not the best treatments for anxiety (their distress) and the risks overweigh the benefits most of the time. Addiction, tolerance, falls.. especially someone with a substance use problem.
If an older patient who’s on benzos is seeking care I do weigh the risks of taking them off to the benefit.
Also just because you’re operating in a patient centered model it doesn’t mean you do what they say. I don’t know where you get that impression. You’re still the expert and you don’t need to do anything that contravenes your values.
Your post certainly reads like you’re very disgruntled with your patients and that’s understandable.

 

[tr]

Not true. You can, but it likely won't be pleasant for you. Expose yourself to that unpleasantness while in residency, everyday. And work through it with a good supervisor.



It's just the inverse of prescribing a medication. You present the facts, the negatives, your opinion on treatment and alternatives, why you're doing what you're going to do, the side effects to expect, what to do in case of emergency. Emphasize that you care about their wellbeing but you'd be happy to send them down the street to the NP clinic if they don't agree. In my experience, about 2/3 will stay. And they will complain and whine. Every time they do, I say, "Yes, see what chronic benzos do?" and move on.



Do the same thing. Also, weekly scripts that taper weekly can help those who are highly resistant. It's a pain to calculate in the EMR, but patients will argue and whine less. A 7 day supply requires a patient to comply with the taper. And a patient who has to stick to a 7 day ration and has to show up weekly to pick up their next 7 day supply, well it really hits home that it is all about the benzos and how dependent they are on it, rather than actual anxiety.

You are reducing people's benzo doses q 7 days?? How do you manage withdrawal?

Some patients who are eager to get off have maybe gone this fast on their own initiative but I would never try to impose it. More like q month if tolerating. I have definitely seen people who need to stay at the same dose for a few months to equilibrate before reducing further.

 

[G Sheb]

I don't disagree, but there are so many gray zones within these thoughts that it's easy to become a member of a service industry instead of a physician acting to maintain a patient's health. Boundaries and standards should be somewhat flexible but are necessary and have to have a hard line somewhere. How would you treat a patient with BIID requesting a limb amputation to create "meaningful change and growth" who is severely distressed by being able-bodied? Where do you draw the line for ethical care when the patient's interests are in direct conflict with their health and even functioning? Obviously an extreme example, but there are plenty of far more common situations where this applies like various capacity evals.

Maybe you already addressed this, but simply put I believe we should work with our patients, not for our patients (when they actually have the ability to work with us).



But we actually are treating based on a deviation from a set measurement because we've determined that at that measurement the increased risk of events like a stroke is high enough to warrant treatment. As above, we allow for some flexibility but at some point we have to acknowledge the data is strong enough that our recommendations should override patient preference. I don't see another way to look at this unless you argue that patients should have full autonomy of choice regarding their treatment which overrides any opinions or recommendations we make.



I think this emphasizes the other side of the coin of what we are obligated to do from a personal perspective. Should a physician capable of prescribing a med or performing a procedure be forced to do so regardless of their personal beliefs or views? I can see an argument for being forced in emergency situations, but what about elective treatments? At what point does that violate the autonomy of the physician?

Biid is a great example to delineate some of these nuances.
I think it would be the wrong stance to refuse the amputation because YOU think suffering from a limb that you don’t want is better than not being able to use it. That’s when you impose your values on others.
But there are other issues with amputations with biid. For one thing, it’s not clear that these patients have capacity. Biid appears to be a neurological condition and you lose insight for the very thing you’re trying to get rid of. It’s also not clear that an amputation actually treats the condition. There will be other things to amputate. It’s rare so we don’t know much and so weighing the risks and the benefits, it’s probably not wise to proceed. There’s a nice paper about the ethics with biid. It’s certainly not straightforward but I would not operate from the stance that I know better how they should be using their limbs because I’m the doctor.
I’m not sure what’s your point about blood pressure. You seem to be saying the same thing as I am. Those numbers mean absolutely nothing if they aren’t related to a real but subjective experience of suffering, the suffering from having a stroke.

 

[Crayola227]

Is this sarcasm?? Of course GAD is curable. Exposure therapy is often quite effective. Maybe not every patient but certainly it's possible to have people start with both medication and psychotherapy and become able to wean off medication once they've mastered the skills from therapy.

There's a touch of sarcasm, because I never thought of it like that, but then again, I'm not an expert, it occurred to me as I said this that maybe it is? I hoped someone might explain.

What is the cure rate for GAD vs how many patients will just continue to struggle? Because I've never seen that. But I think physicians outside psychiatry tend to be more struck by the more chronic issues.

I would have guessed it was the exception rather than the rule.

 

[Crayola227]

I really disagree with your approach and your projections are completely false.
I’m very hesitant with chronic benzos, but it’s not because I think it’s better for them to suffer and then grow and change the way I want them to. But because chronic benzos are not the best treatments for anxiety (their distress) and the risks overweigh the benefits most of the time. Addiction, tolerance, falls.. especially someone with a substance use problem.
If an older patient who’s on benzos is seeking care I do weigh the risks of taking them off to the benefit.
Also just because you’re operating in a patient centered model it doesn’t mean you do what they say. I don’t know where you get that impression. You’re still the expert and you don’t need to do anything that contravenes your values.
Your post certainly reads like you’re very disgruntled with your patients and that’s understandable.

Precisely, for me, it's more if there's a knee-jerk "but this is a controlled substance and those are bad" kind of thinking that bugs me. I want to know that someone actually considered and weighed what, if any benefit, there is to continuance.

 

[smalltownpsych]

There's a touch of sarcasm, because I never thought of it like that, but then again, I'm not an expert, it occurred to me as I said this that maybe it is? I hoped someone might explain.

What is the cure rate for GAD vs how many patients will just continue to struggle? Because I've never seen that. But I think physicians outside psychiatry tend to be more struck by the more chronic issues.

I would have guessed it was the exception rather than the rule.

My experience is that people with most of our disorders, including anxiety, don’t get cured as much as they learn to mitigate the effects of their neurological tendencies and hopefully avoid serious exacerbations of those tendencies. There are always patients who are very difficult to treat and don’t respond as well to psychotherapy just as some patients don’t respond well to SSRIs or other medications. I am very against using benzos to treat anxiety as a general rule and especially in the mood to moderate case, and initially in my career was very much against it. At this point though, I have seen patients for whom it was an effective component of their treatment and also realize that we have no absolute answers either.

 

[WisNeuro]

There's a touch of sarcasm, because I never thought of it like that, but then again, I'm not an expert, it occurred to me as I said this that maybe it is? I hoped someone might explain.

What is the cure rate for GAD vs how many patients will just continue to struggle? Because I've never seen that. But I think physicians outside psychiatry tend to be more struck by the more chronic issues.

I would have guessed it was the exception rather than the rule.

Meta-analyses with 6month and 1 year follow-up have shown 55-77% rates of people no longer meeting diagnostic criteria. CBT and CBT+PE showing rates on the higher end. Other metas that only report ES show weighted ES of a little over 2.0. I've treated a few over the years with good results. This generally responds fairly well to therapy. Not as good as something like Panic Disorder, but still pretty high compared to other psychiatric diagnoses.

 

[clausewitz2]

You are reducing people's benzo doses q 7 days?? How do you manage withdrawal?

Some patients who are eager to get off have maybe gone this fast on their own initiative but I would never try to impose it. More like q month if tolerating. I have definitely seen people who need to stay at the same dose for a few months to equilibrate before reducing further.

I like to do q7 day decreases because it helps maintain the sense of momentum, but we are talking about a week-to-week decrease like 20 mg of Valium total daily being reduced to 19 mg daily. Week by week is fine if it's super small. Still do have to stop for a while sometimes.

 

[clausewitz2]

I'm defining "clinically significant subjective suffering" as suffering that prompts a person to seek professional help for it by voluntarily presenting to a clinician for it. This might not meet criteria *we* have, but we can say that if the patient is bothered enough to show up to a clinic, then it means just that, they are bothered enough to show up to a clinic.

Naturally this leaves out people who may have PDs by some standard but yet never seek professional help for what they suffer.

We are going to make the definition of what counts as something doctors ought to treat depend on availability of services and, say, how flexible someone's schedule might be?

I was taught that this is the broadest definition for clinically significant subjective suffering. Example, patient has chest pain and think they're going to die and present to the ED. It is determined they lifted something a little heavy and are actually experiencing a twinge of rib pain that gave them panic. This may not be a big deal to the clinician, but it would be fair to say that in the patient's view they had subjective suffering that reached the limit of clinically significant. Essentially it's this view that anything that brings a patient in, is clinically significant because of the importance to the patient (important enough to seek care in their view).

The patient in my example may not even have any impairment. But it isn't fair to say the subjective suffering wasn't clinically significant.

It's a view that just about any patient complaint can be seen as actionable in some way by the physician. Certainly such a visit generates a note, lol. But like sometimes the only thing the physician need do is reassurance.

The problem is for anxiety, reassurance is often absolutely the wrong move. To move (partially) beyond the traditional psychiatric domain, think about folks with chronic LBP. Assuming no obvious surgical abnormality, part of best practice for addressing it is having the conversation about how we're not going to try and make the pain go away completely. Rather, the idea is to help figure out how they can live their life and at the same time accept that they are going to experience pain.

In the chest pain example you gave, the fact that you even can reassure the patient about their MSK rib pain is that it is not clinically significant, aka, "don't worry about it, it's nothing." Alternately, Typhoid Mary was fine and clearly saw no problems in continuing to work as a cook in multiple households but still had a very clinically significant problem, as evidenced by the multiple families she infected.

Ultimately, though, if we accept your view of clinical significance, patients simply cannot be wrong by definition about whether what they are experiencing is clinically significant. If they bother showing up, it matters, and if they don't, it doesn't. This has the virtue of simplicity for sure, but at the risk of being accused of being paternalistic, this surrenders too much of our discriminatory (in the sense of deciding between alternatives) role.

 

[smalltownpsych]

We are going to make the definition of what counts as something doctors ought to treat depend on availability of services and, say, how flexible someone's schedule might be?



The problem is for anxiety, reassurance is often absolutely the wrong move. To move (partially) beyond the traditional psychiatric domain, think about folks with chronic LBP. Assuming no obvious surgical abnormality, part of best practice for addressing it is having the conversation about how we're not going to try and make the pain go away completely. Rather, the idea is to help figure out how they can live their life and at the same time accept that they are going to experience pain.

In the chest pain example you gave, the fact that you even can reassure the patient about their MSK rib pain is that it is not clinically significant, aka, "don't worry about it, it's nothing." Alternately, Typhoid Mary was fine and clearly saw no problems in continuing to work as a cook in multiple households but still had a very clinically significant problem, as evidenced by the multiple families she infected.

Ultimately, though, if we accept your view of clinical significance, patients simply cannot be wrong by definition about whether what they are experiencing is clinically significant. If they bother showing up, it matters, and if they don't, it doesn't. This has the virtue of simplicity for sure, but at the risk of being accused of being paternalistic, this surrenders too much of our discriminatory (in the sense of deciding between alternatives) role.

I think you’re equating the operational definition of clinically significant subjective suffering with what we should diagnose or treat as opposed to what I taken crayola227 as saying is that it is part of what we consider. I always taught that psychological disorders are non-normative, and have a degree functional impairment and/or subjective distress. That distress is often determined by the individual but not alway because some of our disorders have a degree of lack of awareness. It seems that the argument is more how much relevance to the patients subjective sense of suffering verses our subjective option about their suffering.

 

[clausewitz2]

I think you’re equating the operational definition of clinically significant subjective suffering with what we should diagnose or treat as opposed to what I taken crayola227 as saying is that it is part of what we consider. I always taught that psychological disorders are non-normative, and have a degree functional impairment and/or subjective distress. That distress is often determined by the individual but not alway because some of our disorders have a degree of lack of awareness. It seems that the argument is more how much relevance to the patients subjective sense of suffering verses our subjective option about their suffering.

I see the issue you're pointing out. I was pursuing "clinically significant" in context of "what counts as part of the domain of healthcare of some kind". If we are back to assessing functional impairment, you are explicitly comparing the patient to some idea of what functioning ought to look like for a similarly situated person in their demographic in your society. This obviously entails values and an idea of how people should act/think/feel.

The solution isn't to try and purge values from practice, since you can't, but I think it is imperative to be clear-eyed about the values you are basing those judgments on. Sadler's Values and Psychiatric Diagnosis is a book-length treatment of this issue.

EDIT:

And an open-access paper covering the same area:

Looking with both eyes open: fact and value in psychiatric diagnosis?

In this article we argue the case for a proposal: that psychiatry should recognise, embrace and take seriously the role of values, alongside facts, in diagnosis. We present a three-step argument in support of our proposal; we raise a number of key questions ...

www.ncbi.nlm.nih.gov

 

[Candidate2017]

You are reducing people's benzo doses q 7 days?? How do you manage withdrawal?

Some patients who are eager to get off have maybe gone this fast on their own initiative but I would never try to impose it. More like q month if tolerating. I have definitely seen people who need to stay at the same dose for a few months to equilibrate before reducing further.

Yes, generally weekly. I convert to a long acting benzo. I educate them on what to expect, and what to watch out for. Everyone withdraws a little, but there's withdrawal vs. dangerous withdrawal. If someone calls complaining of what could be borderline problematic withdrawal, I give the option of coming in for vitals or going to ER. However, that is rare.

I suspect withdrawal is worse and life threatening when a 30 day supply is given with a slow taper. Patients will come back in 30 days (or call) and complain how terrible the taper is going, but won't tell you it's because they used more than prescribed and ran out days earlier. The severity of withdrawal and complaints increase with each successive month because you are tapering but the patient is still taking the same dose and running out earlier and earlier.

A 7 day supply ensures compliance. Interestingly, subjective reports of "withdrawal" seem less severe (and less anger, threats, and crying) with weekly tapers. When patients can see a physically small quantity of pills, they can see they need to ration them over 7 days. When someone has to ration their pills before they can make the next weekly trip to the pharmacy, it really hits home that they are dependent on the benzo.

My inherited panel has gone down from 50%+ on benzos (some on Xanax 2 mg qid), to just 5% on tiny amounts. I admit I forget to continue to taper on these 5% and reflexively refill their monthly 4 tablets of some tiny, non-therapeutic dose of benzo. God knows what they use them for. Maybe keep their tiny dogs calm during storms.

 

[Candidate2017]

My main issue with some of the posts, is they read more like steps the physician is taking to deal with the ins and outs of their workday than it does, like, how does the patient do with all this? That's what I want to know.

Sure, it's just another work day. It's what I do. I am in the people managing business, managing people and helping people manage themselves.

 

[Stagg737]

Biid is a great example to delineate some of these nuances.
I think it would be the wrong stance to refuse the amputation because YOU think suffering from a limb that you don’t want is better than not being able to use it. That’s when you impose your values on others.
But there are other issues with amputations with biid. For one thing, it’s not clear that these patients have capacity. Biid appears to be a neurological condition and you lose insight for the very thing you’re trying to get rid of. It’s also not clear that an amputation actually treats the condition. There will be other things to amputate. It’s rare so we don’t know much and so weighing the risks and the benefits, it’s probably not wise to proceed. There’s a nice paper about the ethics with biid. It’s certainly not straightforward but I would not operate from the stance that I know better how they should be using their limbs because I’m the doctor.
I’m not sure what’s your point about blood pressure. You seem to be saying the same thing as I am. Those numbers mean absolutely nothing if they aren’t related to a real but subjective experience of suffering, the suffering from having a stroke.

I've seen videos/documentaries on a couple of BIID cases. Most interesting one to me was someone who felt that they were meant to be a blind person, blinded themselves with bleach or acid or something, and then experienced near total resolution of distress. Which is nice from the suffering standpoint you mentioned. However, that individual was unable to continue working, received disability, and required extensive support d/t the adjustment. Let's say this patient became blind via a treatment administered by a physician. That doc would have been very successful in terms of alleviating suffering but would have failed miserably in terms of helping them function.

To the bolded, my point is that we're not just trying to prevent suffering but also preserve functioning. You're conflating suffering and functioning which are two related but completely separate experiences with grossly variable metrics, with suffering being nearly completely subjective and functioning easily being measured objectively. I think preoccupation with suffering is neglecting numerous other responsibilities we have to our patients and on a larger level society as a whole. Clause's example of rib pain and Typhoid Mary is a good example of a situation where aspects other than suffering need to take priority and be addressed.

My experience is that people with most of our disorders, including anxiety, don’t get cured as much as they learn to mitigate the effects of their neurological tendencies and hopefully avoid serious exacerbations of those tendencies. There are always patients who are very difficult to treat and don’t respond as well to psychotherapy just as some patients don’t respond well to SSRIs or other medications. I am very against using benzos to treat anxiety as a general rule and especially in the mood to moderate case, and initially in my career was very much against it. At this point though, I have seen patients for whom it was an effective component of their treatment and also realize that we have no absolute answers either.

I think we have to keep in mind that the individuals on this forum are often not seeing the more mild/acute cases of anxiety that are more amenable to being "cured". This comes back to what I was saying about etiology of the condition earlier. The patients that we see are either struggling with a more severe or chronic form of anxiety that's less likely to have mostly situational component and more likely to be rooted in deeper psychological processes ingrained in them over years or decades or have a major biological component which prevents complete resolution of symptoms.

 

[Crayola227]

Sure, it's just another work day. It's what I do. I am in the people managing business, managing people and helping people manage themselves.

My point is that our jobs are to work to where the patient's average day is better than it was before treatment, not to make our own workday easier.

 

[painballer27]

My point is that our jobs are to work to where the patient's average day is better than it was before treatment, not to make our own workday easier.

Why not both?

 

[Crayola227]

I've seen videos/documentaries on a couple of BIID cases. Most interesting one to me was someone who felt that they were meant to be a blind person, blinded themselves with bleach or acid or something, and then experienced near total resolution of distress. Which is nice from the suffering standpoint you mentioned. However, that individual was unable to continue working, received disability, and required extensive support d/t the adjustment. Let's say this patient became blind via a treatment administered by a physician. That doc would have been very successful in terms of alleviating suffering but would have failed miserably in terms of helping them function.

To the bolded, my point is that we're not just trying to prevent suffering but also preserve functioning. You're conflating suffering and functioning which are two related but completely separate experiences with grossly variable metrics, with suffering being nearly completely subjective and functioning easily being measured objectively. I think preoccupation with suffering is neglecting numerous other responsibilities we have to our patients and on a larger level society as a whole. Clause's example of rib pain and Typhoid Mary is a good example of a situation where aspects other than suffering need to take priority and be addressed.



I think we have to keep in mind that the individuals on this forum are often not seeing the more mild/acute cases of anxiety that are more amenable to being "cured". This comes back to what I was saying about etiology of the condition earlier. The patients that we see are either struggling with a more severe or chronic form of anxiety that's less likely to have mostly situational component and more likely to be rooted in deeper psychological processes ingrained in them over years or decades or have a major biological component which prevents complete resolution of symptoms.

When I read this about BIID and the blindness, I do think it's sort of a sad thing about modern society, compared to some more traditional societies or like hunter gatherers, how disabled individuals are cared for and part of the society. That essentially we're saying, no matter how much more this individual would have suffered with sight, that is preferable as long as they can continue to be independent and make money. If you really think about it, it's an extremely capitalist, independent, ableist POV. It's acting like the most important thing was for this individual to function in a way that society deems is good for society, and the suffering was irrelevant, and how much more we are collectively inconvenienced by this individual monetarily is what really matters.

I certainly can understand that we do need to consider effects on society (I don't find Typhoid Mary to be a very good comparison because the harm bystanders might experience from getting a contagious and potentially deadly disease is not the same thing as my neighbor becoming blind by choice), but I don't want to just dismiss this person's suffering because golly, they ended up on social security disability and happy instead of miserable and employed. And that's not even how the government structures disability, meaning not even Uncle Sam requires someone be employed and in pain to the level of disability, it is acceptable for people to not work to diminish the level to which their disability causes pain and suffering.

If even Uncle Sam can say, it is cruel to make this individual suffer to be self-supporting in some cases, I would just say, you know, function doesn't actually come ahead of suffering. Sometimes we exactly sacrifice function for comfort in medicine.

What if this individual would have committed suicide instead? Is that better? Perhaps on disability, this person, despite not working, will develop a romantic relationship and have kids and be a great parent? That is of enormous value to society right now if you read anything about the birth rate.

Disabled individuals unable to work can have enormous value to society and can have rich full lives outside of just having a job. Having a job and living independently is not actually the greatest value of a human being, it merely seems that way in our current system sometimes.

Now, I know you aren't saying what I'm saying here, and I know it's more complicated than this when a previously physically healthy person voluntarily impairs one of their major physical functions, but I couldn't help but point out, that again, there sort of slips in this attitude like the most important thing is to get this person to "function" (and much of that is frankly measured in $$$ and how good they are for other people), and it can be to the point where we effectively might not even care that someone feels literally tortured.

Now I am not necessarily arguing that physicians to treat such a condition must be willing to maim people how they wish.

My point is that once we consider suffering, and not just function, this algebra is much more complicated.

I have effectively seen ob/gyns take out uteruses women wanted out believing it was the cause of their distress, when the surgeon did not believe this. "The patient is convinced, but the data suggests her specific pain will not be treated by hysterectomy. But I'll do it, because if I don't, she will just eventually find a surgeon who will." And this patient will not be able to consider other treatment options until she does. Now, I hope we see how even for a woman who says she is done childbearing, removing a uterus is a not for nothing sort of thing.

So to act like no form of this already happens, well, it does. And we can debate the ethics. But there can be something gained by the physician that does effectively "indulge" the patient in some cases.

So all I personally can conclude, is that it is more complicated. I can see why we see some physicians making choices others would not.

And the whole function thing is a bit annoying. It has utility, certainly. But it simply is not the end all be all to these decisions. But I can see why we would like it to be.

 

[Crayola227]

Why not both?

Well then you better be sure that you are acheiving the former, and not sacrificing it for the latter. One need acknowledge the potential for conflict of interest.

 

[painballer27]

Well then you better be sure that you are acheiving the former, and not sacrificing it for the latter. One need acknowledge the potential for conflict of interest.

True that

 

[TheRightMedication]

I have a strong reaction to the idea that it's okay for an able bodied person to willfully disable themselves and force others to support them. Such and individual has committed a great act of coercion against every single member of society.

Humans are sacred and we will value and care for all of them no matter what. We can still condemn and rebuke those who exploit this fact, and their enablers.

This is well chosen by the above posters as an example of why treating subjective suffering as the primary therapeutic target is wrong. We help restore normal function as far as possible first and foremost, providing relief of suffering only when this does not conflict with the first directive.

I firmly believe this is why benzodiazepines so often are the wrong choice.

This may seem harsh on the face of it, but it is respectful of the human person and can be done with patience and kindness. Alleviating suffering at the cost of the patient's human potential is cruel, at best.

 

[Crayola227]

I have a strong reaction to the idea that it's okay for an able bodied person to willfully disable themselves and force others to support them. Such and individual has committed a great act of coercion against every single member of society.

Humans are sacred and we will value and care for all of them no matter what. We can still condemn and rebuke those who exploit this fact, and their enablers.

This is well chosen by the above posters as an example of why treating subjective suffering as the primary therapeutic target is wrong. We help restore normal function as far as possible first and foremost, providing relief of suffering only when this does not conflict with the first directive.

I firmly believe this is why benzodiazepines so often are the wrong choice.

This may seem harsh on the face of it, but it is respectful of the human person and can be done with patience and kindness. Alleviating suffering at the cost of the patient's human potential is cruel, at best.

Omg, the idea that the secondary gain of "being supported by others" could ever explain someone *blinding* themselves? You think they did that because of how much easier it made their life?

You think the average person on social security disability is just having a huge party rolling around in all that money?

It is nearly always better to have your body function to the point you can work a full time job, just about any job, in this country.

I guess someone could think they're taking the easy way out to like, shoot themselves in both legs to get them amputated so they can auto-qualify, but I can guarantee you that person will be missing those feet and find ss disability payments a very poor compensation for them after the fact. Someone might go into it thinking it is a good idea maybe, but most do not or will not like it.

I reject this. The average person on disability actually feels awful, wishes they weren't the way they are, and wishes they could work. There are exceptions I'm sure.

So when I hear about this guy, I'm not saying "Oh woe is me my taxes are supporting them" (when in truth a fair amount of taxes pay for golf and killing people and other bull**** as well), I'm thinking to myself, how much does a person have to be suffering to give up sight and an independent life earning money to decide to pour ****ing acid on their corneas and live off the wealth of SS?

Seriously, how much money could I give you to have your eyes destroyed with acid? Say there is some amount. Are you sure that's equal to $840-3345 a month cash to live on? Say you get $440 in HUD, $169 foodstamps, $60 energy assistance, $15 phone, and free medical. Do you truly think anyone WELL makes that kind of choice??

This individual is clearly unwell. As such, I don't begrudge them. Consider that if they had been born in hunter-gatherer times, had the same illness, managed the same thing blinding themselves, (let's say no one knows they did it on purpose, I can't to speak to those values, but blindness before the modern era was exceptionally common as was old age, and evidence and examples from today suggest it's NO BIG DEAL for blind people to be supported in these societies), the rest of us would just spend an extra 5 min collecting that many more foodstuffs and it's no big deal.

It's a big deal now for us to care for our disabled members. I mean, I can't play as much golf if I have to pay more taxes or work. It's fine, it might even be legit that it's a burden for society, but before we get righteous about that, let's just rememeber that that too, is just as much of our making as a society of humans, as it was for the dude to blind himself. We have changed things enormously that now disability of many kinds is this huge burden on society.

No, I don't think he did it for secondary gain. He was suffering more as a sighted person than he is an impoverished blind one. That's profound, to me. This person didn't ask for the BIID. And it's only by the way we've structured modern existence that such a person is such a "burden." If we lived as we once did, it wouldn't matter very much in many socieities. Or maybe he would have had to wander off into the woods to die in some, I don't know. My point is that if we are not going to hold ourselves responsible for a world that can no longer support illness, then I fail to see why we would hold this person any more responsible for their illness. The taxpayer does not "suffer." Society does not "suffer." We care for the people who suffer.

I don't know why these peope feel this way. They cannot expect others to take action to remove otherwise healthy body parts. But I have zero judgement for the people suffering if removing them relieves their suffering. I wish there was another way. Understandably many of us can't be part of what they feel they need to do. But if they do it, as you say, we will all collectively care for these people. I can only hope that the whatever they do to relieve their suffering, does so

There is no "exploitation" when someone is suffering in these ways. Are you going to tell me autistic people who are nonverbal and cannot live on their own or have jobs are "exploiting" the rest of us?

You are seriously defining this person as "well"? That's the issue where you see them differently than the severely autistic person. They weren't "well" before they took their own eyes.

As far as "enablers," see my example of women seeking hysterectomy for pelvic pain of otherwise unexplainable origin. The only difference is we can understand why such a person believes the surgery will help them.

People with chronic pain, and some forms of the suffering from mental illness probably has a lot in common, many people would literally cut off their right foot if it made what ailed them go away, cut off their balls or their uterus. Nevermind if that was the "cause," if someone had a magic wand and that was the price, many would. So I'm baffled how we would blame someone with BIID for doing what they do. I'm not saying this means I'm jumping up to cut on them or I think that should be the treatment, but damn if I don't feel for those folks and think they sound some kind of sick and suffering.

I can't imagine this person was well, but hey, maybe they just did it for the sweet sweet ss money.

 

[G Sheb]

I've seen videos/documentaries on a couple of BIID cases. Most interesting one to me was someone who felt that they were meant to be a blind person, blinded themselves with bleach or acid or something, and then experienced near total resolution of distress. Which is nice from the suffering standpoint you mentioned. However, that individual was unable to continue working, received disability, and required extensive support d/t the adjustment. Let's say this patient became blind via a treatment administered by a physician. That doc would have been very successful in terms of alleviating suffering but would have failed miserably in terms of helping them function.

To the bolded, my point is that we're not just trying to prevent suffering but also preserve functioning. You're conflating suffering and functioning which are two related but completely separate experiences with grossly variable metrics, with suffering being nearly completely subjective and functioning easily being measured objectively. I think preoccupation with suffering is neglecting numerous other responsibilities we have to our patients and on a larger level society as a whole. Clause's example of rib pain and Typhoid Mary is a good example of a situation where aspects other than suffering need to take priority and be addressed.



I think we have to keep in mind that the individuals on this forum are often not seeing the more mild/acute cases of anxiety that are more amenable to being "cured". This comes back to what I was saying about etiology of the condition earlier. The patients that we see are either struggling with a more severe or chronic form of anxiety that's less likely to have mostly situational component and more likely to be rooted in deeper psychological processes ingrained in them over years or decades or have a major biological component which prevents complete resolution of symptoms.

If they are free from distress, you don't think it will help them function? How exactly are they functioning when they are in so much distress that they want to get rid of the limb they have? Why do you think this person wouldn't 'function' better when he's blind if he's not being tortured every waking hour?
Obviously "do no harm" means if we have better treatments where you don't have to get rid of your eyes or the limb, we should definitely pursue that. But many ethicists and physicians believe the reason why perhaps we should opt to intervene is precisely because otherwise patients will end up hurting themselves... cutting their own limbs or blinding themselves in the vain attempt to get rid of what is torturing them.
In any case, even if your end goal is distress, it does not mean you just go along with the amputation. A careful risk/benefit analysis may very well yield that you're actually not helping them with the suffering if you do that. And the ethics of non-intervention vs intervention (by acting on your own value system) are inherently different.
As for functioning being 'objective' and 'easily measured', lol, really? There's a reason why DSM doesn't even try with a definition, and leave it as vague as they could ('occupational, social and other important areas of functioning'). The definition is so broad, it's almost meaningless.


Anyways, I'm glad we're having this conversation. Overall I'm not terribly surprised with these responses (wanting patients to function according to your own values and what this means to you), though I certainly think it's bad practice. I am though shocked by one or two posts.

 

[Crayola227]

If they are free from distress, you don't think it will help them function? How exactly are they functioning when they are in so much distress that they want to get rid of the limb they have? Why do you think this person wouldn't 'function' better when he's blind if he's not being tortured every waking hour?
Obviously "do no harm" means if we have better treatments where you don't have to get rid of your eyes or the limb, we should definitely pursue that. But many ethicists and physicians believe the reason why perhaps we should opt to intervene is precisely because otherwise patients will end up hurting themselves... cutting their own limbs or blinding themselves in the vain attempt to get rid of what is torturing them.
In any case, even if your end goal is distress, it does not mean you just go along with the amputation. A careful risk/benefit analysis may very well yield that you're actually not helping them with the suffering if you do that. And the ethics of non-intervention vs intervention (by acting on your own value system) are inherently different.
As for functioning being 'objective' and 'easily measured', lol, really? There's a reason why DSM doesn't even try with a definition, and leave it as vague as they could ('occupational, social and other important areas of functioning'). The definition is so broad, it's almost meaningless.


Anyways, I'm glad we're having this conversation. Overall I'm not terribly surprised with these responses (wanting patients to function according to your own values and what this means to you), though I certainly think it's bad practice. I am though shocked by one or two posts.

Said much more concisely and eloquently than I could.

 

[smalltownpsych]

Just to add to the it’s complicated part, people tend to feel better when they function well. Of course, if they are comparing that functioning to the doctors level of functioning, they might feel that they are coming up a bit short. I kind of go with a change is inevitable and you’re either getting better or you’re getting worse and most people want to improve their lives and I try to help them choose what metrics they want to use for that. Typically, they are trying to live up to many other’s expectations other than ours: parents, siblings, social media, etc. If I can get them to identify what they want to do, then we can come up with strategies to work toward that. If a goal is unrealistic, “I want to not have anxiety”, then I help them identify a more attainable goal, “I want anxiety to be lower so that I can _________“. Typically the blank is filled with some type of functioning. If they don’t identify a reason why they want the emotional distress relieved, I push them to identify it because when they accomplish it, it’s a bit more concrete for them than the vagaries of subjective distress. I also challenge them when goals seem to be just what is socially acceptable or what they think I might want them to say.

 

[tr]

I think we have to keep in mind that the individuals on this forum are often not seeing the more mild/acute cases of anxiety that are more amenable to being "cured". This comes back to what I was saying about etiology of the condition earlier. The patients that we see are either struggling with a more severe or chronic form of anxiety that's less likely to have mostly situational component and more likely to be rooted in deeper psychological processes ingrained in them over years or decades or have a major biological component which prevents complete resolution of symptoms.

I don't really think the people who end up on chronic benzos are mostly in that situation because of severe anxiety unresponsive to other treatments. It's usually because they happened to run into a practitioner who thought that chronic benzos were a good idea and that there was no reason to try to do things differently.

I would say the majority of the new patients I see have never been exposed to results-oriented, evidence-based psychotherapies.

I have tapered a lot of people off their benzos (often taking up to a year or longer to complete discontinuation, often with adjunctive evidence-based psychotherapy for anxiety by me or someone else) and I have never, ever had someone come all the way off and then say they really felt like their anxiety was uncontrolled and they wanted to go back on. Never. They usually say they feel great and their cognition is noticeably clearer.

 

[Stagg737]

When I read this about BIID and the blindness, I do think it's sort of a sad thing about modern society, compared to some more traditional societies or like hunter gatherers, how disabled individuals are cared for and part of the society. That essentially we're saying, no matter how much more this individual would have suffered with sight, that is preferable as long as they can continue to be independent and make money. If you really think about it, it's an extremely capitalist, independent, ableist POV. It's acting like the most important thing was for this individual to function in a way that society deems is good for society, and the suffering was irrelevant, and how much more we are collectively inconvenienced by this individual monetarily is what really matters.

I certainly can understand that we do need to consider effects on society (I don't find Typhoid Mary to be a very good comparison because the harm bystanders might experience from getting a contagious and potentially deadly disease is not the same thing as my neighbor becoming blind by choice), but I don't want to just dismiss this person's suffering because golly, they ended up on social security disability and happy instead of miserable and employed. And that's not even how the government structures disability, meaning not even Uncle Sam requires someone be employed and in pain to the level of disability, it is acceptable for people to not work to diminish the level to which their disability causes pain and suffering.

If even Uncle Sam can say, it is cruel to make this individual suffer to be self-supporting in some cases, I would just say, you know, function doesn't actually come ahead of suffering. Sometimes we exactly sacrifice function for comfort in medicine.

What if this individual would have committed suicide instead? Is that better? Perhaps on disability, this person, despite not working, will develop a romantic relationship and have kids and be a great parent? That is of enormous value to society right now if you read anything about the birth rate.

Disabled individuals unable to work can have enormous value to society and can have rich full lives outside of just having a job. Having a job and living independently is not actually the greatest value of a human being, it merely seems that way in our current system sometimes.

Now, I know you aren't saying what I'm saying here, and I know it's more complicated than this when a previously physically healthy person voluntarily impairs one of their major physical functions, but I couldn't help but point out, that again, there sort of slips in this attitude like the most important thing is to get this person to "function" (and much of that is frankly measured in $$$ and how good they are for other people), and it can be to the point where we effectively might not even care that someone feels literally tortured.

Now I am not necessarily arguing that physicians to treat such a condition must be willing to maim people how they wish.

My point is that once we consider suffering, and not just function, this algebra is much more complicated.

I have effectively seen ob/gyns take out uteruses women wanted out believing it was the cause of their distress, when the surgeon did not believe this. "The patient is convinced, but the data suggests her specific pain will not be treated by hysterectomy. But I'll do it, because if I don't, she will just eventually find a surgeon who will." And this patient will not be able to consider other treatment options until she does. Now, I hope we see how even for a woman who says she is done childbearing, removing a uterus is a not for nothing sort of thing.

So to act like no form of this already happens, well, it does. And we can debate the ethics. But there can be something gained by the physician that does effectively "indulge" the patient in some cases.

So all I personally can conclude, is that it is more complicated. I can see why we see some physicians making choices others would not.

And the whole function thing is a bit annoying. It has utility, certainly. But it simply is not the end all be all to these decisions. But I can see why we would like it to be.

You're looking at things on a societal level and I think your arguments are valid, but at the same time you're ignoring the non-monetary needs this patient now has which require already limited resources to be further stretched to care for her. The home-health aids/nurses who she now requires are being taken away from other people who may need their care. Medical specialists who may have limited availability are now seeing her which may prolong the suffering of other individuals' who did not choose to maim themselves d/t decreased appointment availability.

We live in a society with limited man-power and physical resources, whether it should be or not it is a zero-sum game in many situations and increases the societal burden and leads to others not receiving those resources. Whether we like it or not, part of our jobs as physicians is resource allocation and choosing who gets what. I'm not saying there are any absolutes or that suffering should be disregarded or minimized, but if we were to simply make recommendations and treat based on the prioritization of alleviating suffering it would be disastrous for many patients. This is actually one of the biggest aspects of my current job and I'm happy to provide more specifics for this example in DM if you'd like as this was recently a huge issue at our hospital. Or you can just look at everything that happened 2 years ago when the COVID epidemic was at its peak to realize alleviation of suffering cannot be our primary driving ideology.

Omg, the idea that the secondary gain of "being supported by others" could ever explain someone *blinding* themselves? You think they did that because of how much easier it made their life?

Not to be contrarian, but in this situation, it seemed like secondary gain certainly did play a role in her choice to blind herself. I'll try and find the actual video, but if I remember correctly there actually seemed to be a component of factitious disorder as well.

Actually, her name is Jewel Shuping and she's part of the transableism movement. There's tons of media on her, and as you can imagine there's been a lot of controversies surrounding this. You can find YouTube videos which are fairly objective but paint it in a fairly positive light, but there's also been a lot of outrage from the blind community for obvious reasons. If you watch the video, there was one comment that I think is particularly relevant and comparative to the subject and sums up many of my thoughts well:

"Someone with BIID being told that they can cut off their limbs if it will make them happier is like telling someone with anorexia that they should starve themselves to make them feel better."

Aka, when we're providing certain treatments, what are we actually treating? It's important to stop and ask ourselves this sometimes, especially when we are recommending treatments with permanent effects or prescribing potentially dangerous meds (like benzos) long-term.

No, I don't think he did it for secondary gain. He was suffering more as a sighted person than he is an impoverished blind one. That's profound, to me. This person didn't ask for the BIID. And it's only by the way we've structured modern existence that such a person is such a "burden." If we lived as we once did, it wouldn't matter very much in many socieities. Or maybe he would have had to wander off into the woods to die in some, I don't know. My point is that if we are not going to hold ourselves responsible for a world that can no longer support illness, then I fail to see why we would hold this person any more responsible for their illness. The taxpayer does not "suffer." Society does not "suffer." We care for the people who suffer.

That's nice, but we don't live in a hunter/gatherer society where simply keeping someone alive and helping them survive is adequate. It's far more complicated than that. You're completely ignoring the extent of the increased burden on everyone close to the individual. Not only are they no longer working and sitting at home receiving gov benefits because of a choice they made (let's totally ignore those issues), someone now has to assist them with everything in their day-to-day life, at least initially.

They need assistance with ADLs which requires someone to constantly be available, sometimes assisting with tasks that can be distressing to the caregiver (ie bodily fluids). The patient can't drive anymore, so someone has to take them to all their appointments, shopping, any form of entertainment, etc. They're now blind, so they can't read or use most websites, so now someone has to help them with bills or any form of paperwork that's necessary. If they were responsible to others like caring for parents or children of their own, they will now require others to assist those individuals in addition to themselves.

Individuals may suffer more psychologically without certain treatments, but let's not pretend that those treatments are immune from causing significant suffering to individuals close to that patient. This is especially relevant for individuals close to elderly individuals who experience significant events secondary to high-risk medication administration.

There is no "exploitation" when someone is suffering in these ways. Are you going to tell me autistic people who are nonverbal and cannot live on their own or have jobs are "exploiting" the rest of us?

A person born with a condition (or develops one regardless of their choices, like ALS) that is chronic and unchangeable is very, very different from people choosing to do something which impairs themselves to alleviate their distress. I think it's pretty reprehensible when someone makes a choice to have their WANTS fulfilled when it interferes or prevents another individual from having their NEEDS addressed. That is absolutely exploitation. You can argue that alleviation of suffering is a need, but everyone suffers. Choosing unhealthy or detrimental forms of coping instead of using more reasonable means of MANAGEMENT does not actually benefit anyone.

To bring this back to OP's situation, knowingly continuing benzos (or any med), especially at moderate to high doses, in the elderly in many situations serves as a means to just make things easier for either the patient or someone else at the expense of addressing what the patient actually needs. Ie, take this med/dosage that will increase risks and impair your cognition to mask your problems and sit in the corner so we don't have to put in the effort to actually address the issue.

 

[Stagg737]

If they are free from distress, you don't think it will help them function? How exactly are they functioning when they are in so much distress that they want to get rid of the limb they have? Why do you think this person wouldn't 'function' better when he's blind if he's not being tortured every waking hour?
Obviously "do no harm" means if we have better treatments where you don't have to get rid of your eyes or the limb, we should definitely pursue that. But many ethicists and physicians believe the reason why perhaps we should opt to intervene is precisely because otherwise patients will end up hurting themselves... cutting their own limbs or blinding themselves in the vain attempt to get rid of what is torturing them.
In any case, even if your end goal is distress, it does not mean you just go along with the amputation. A careful risk/benefit analysis may very well yield that you're actually not helping them with the suffering if you do that. And the ethics of non-intervention vs intervention (by acting on your own value system) are inherently different.
As for functioning being 'objective' and 'easily measured', lol, really? There's a reason why DSM doesn't even try with a definition, and leave it as vague as they could ('occupational, social and other important areas of functioning'). The definition is so broad, it's almost meaningless.


Anyways, I'm glad we're having this conversation. Overall I'm not terribly surprised with these responses (wanting patients to function according to your own values and what this means to you), though I certainly think it's bad practice. I am though shocked by one or two posts.

Many forms of functioning are very easy to objectively measure and many fields have excellent methods of measuring this. If you're not familiar, I'd suggest speaking with some physiatrists and looking into their measures. Most common that we see would be something like a KELS. Are these measures perfect? No. Do they have problems? Of course. However, there are numerous aspects of "functioning" that can be measured objectively across a wide variety of domains. Additionally, saying we can't objectively measure mental or cognitive processes is taking a pretty huge shot at the fields of neuropsychology/psychiatry and psychometry. Again, they have their problems but minimize or diminish the aspect of objectivity is either ignorant or willfully obtuse. Let's not even go into the DSM, as I think we all recognize the depth and breadth of problems when considering it at face value.

Again, I'm not sure if you're just conflating distress/suffering and function, but being free of distress and suffering is not causative of higher functioning. You're also using hyperbole when comparing suffering and functioning. Plenty of people suffer and are able to maintain high levels of functioning, and using people who are "tortured every waking hour" as your metric just seems disingenuous.

To be clear, I'm not arguing that we disregard suffering and only address functioning. I agree that's just poor practice. Like you said, this is a risk/benefit analysis. However, suffering should not be our primary foundational concern and numerous domains including both distress/suffering and functioning (along with resource management, impacts on other individuals directly affected by the patient's care, and general patient safety) should be considered as they are often directly inter-related and affect each other. I realize this is not always possible, but should be considered whenever it can be.

I don't really think the people who end up on chronic benzos are mostly in that situation because of severe anxiety unresponsive to other treatments. It's usually because they happened to run into a practitioner who thought that chronic benzos were a good idea and that there was no reason to try to do things differently.

I would say the majority of the new patients I see have never been exposed to results-oriented, evidence-based psychotherapies.

I have tapered a lot of people off their benzos (often taking up to a year or longer to complete discontinuation, often with adjunctive evidence-based psychotherapy for anxiety by me or someone else) and I have never, ever had someone come all the way off and then say they really felt like their anxiety was uncontrolled and they wanted to go back on. Never. They usually say they feel great and their cognition is noticeably clearer.

Oh, of course. I'd say the individuals chronically requiring some benzos to maintain a reasonable baseline is a small sliver of the pie. I would just argue that there are likely those rare individuals where it is unfortunately necessary. I've also had a similar experience with those who I have been able to taper, where most are thrilled and feel much better in many ways.

However, I have had a few people (notably 2 come to mind) who even after 3-6 months of being benzo free could not handle being completely off of them. I'll add these people did not want to take them and particularly want to restart them, but in the end just did well with low doses and were able to minimize polypharmacy when they had them.