Why aren't benzodiazepines taken seriously in this country?

[hamstergang]

It's also recommended to try cognitive-behavioral therapy, which must work for some people or it wouldn't still exist.

Sadly, this statement as a general idea is not true -- there are many "therapies" (not psychotherapies, but therapies in general) that continue to exist despite being proven to be no better than a placebo. That said, CBT does certainly seem to work for anxiety disorders.

Above, I cited a July 2015 review of about 37,000 anxiety patients, of whom some are panic disorder patients, and for whom benzodiazepines are the second most successful line of treatment: http://journals.lww.com/intclinpsyc...f_treatments_for_anxiety_disorders___a.2.aspx

2.02 ... 1.22 ... 2.25 ... 2.15 ... 2.09 ... 1.83 ... 1.56 ... 1.36 ... 1.30 ... 1.22 ... 1.17 ... 1.11 ... 1.03 ... 0.78 ... 2.12 ... 1.23 ... 1.29

Those effects sizes are a lot larger than I'm used to seeing for anything. Are we really that good at treating anxiety, or does this make anyone else suspicious of this meta-analysis? I haven't read it at all besides what was just now posted here, but something looks fishy.

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[Psychobabbling]

Hamster you seem to have a lot of questions like this lol....yes, anxiety is usually the one thing that can be treated quite well

 

[hamstergang]

Hamster you seem to have a lot of questions like this lol....

I don't know what you mean by that.

yes, anxiety is usually the one thing that can be treated quite well

But an effect size around 2?

 

[Mahavidya2]

After further thought about the geographic issue, I now wonder if the issue to prefer, or to not prefer, benzodiazepines varies with political party or views? I wonder this because I know that psychiatrists in my area -- who are reluctant to prescribe benzodiazepines -- are strongly liberal. My entire area is highly and almost homogeneously liberal, which should be relatively evident from my earlier posts about pet therapy. In no way am I maligning liberal politics, however, since I'm pretty typically liberal myself, like so many other academics.

Is there any correlation possible here?

I can imagine that on the far-right side of things, benzodiazepines might be disliked for other reasons like believing in the Power of God, etc. I see that skew in the self-help section of my local bookstore, where there's a Venn Diagram of overlap between the far right and far left when it comes to a suspicion towards psychiatric medications as well as a desire for "purity" of some ineffable sort.

I'm trying to reason why in Southern Virginia, and apparently in other parts of the country, most of which strike me as more conservative than here, it's "common" to give out benzodiazepines when in my own life, I've never seen this and have always encountered a brisk reflex against them, with a much stronger interest in other, alternative forms of therapy, some of which are truly dubious.

 

[Mahavidya2]

Somewhere along the line I appear to have given you the impression that I am somehow implacably opposed to these medications. This is incorrect.

That was definitely not my impression.

... certain patterns seem to be consistent between these classes. Namely, someone with no prior history of chemical dependence being put on such a medication for very good reasons and finding it very difficult/functionally impossible to stop taking it.

Except why would this happen if the patient were consenting, properly educated about a discontinuation phenomenon, and then tapered off slowly? Unless of course s/he had a return of his or her original symptoms, it shouldn't be difficult or functionally impossible to stop taking benzodiazepines. I tapered off of a long-acting one while actively teaching at the university full-time plus traveling for work plus running a major academic program; I'm not someone who was teaching the occasional evening class, post-retirement. I'm very active in both my field as well as at my university.

I would have a difficult time believing some patients' self-reporting about their symptoms, especially after looking at the kinds of things stated in online patient-support forums which seemed filled with cyberchondriasis and, in real life, perhaps too much sensitivity to normal bodily processes. I had a very light withdrawal at the end, only, which do not fit whatsoever with this narrative of benzodiazepines being "functionally impossible to stop," other than that I am now wholly unmedicated and unable to leave my bed for nearly a month, which is horrific, like living only half-alive. So for me, taking some medication was 100% better than the alternative, which was to be unmedicated, which usually caused me to feel suicidal. I'm hesitant to bring that up at all, but it's part of why I find being unmedicated so unacceptable. I also understand it's not uncommon amongst untreated anxiety patients, as per the literature.

 

[smalltownpsych]

After further thought about the geographic issue, I now wonder if the issue to prefer, or to not prefer, benzodiazepines varies with political party or views? I wonder this because I know that psychiatrists in my area -- who are reluctant to prescribe benzodiazepines -- are strongly liberal. My entire area is highly and almost homogeneously liberal, which should be relatively evident from my earlier posts about pet therapy. In no way am I maligning liberal politics, however, since I'm pretty typically liberal myself, like so many other academics.

Is there any correlation possible here?

I can imagine that on the far-right side of things, benzodiazepines might be disliked for other reasons like believing in the Power of God, etc. I see that skew in the self-help section of my local bookstore, where there's a Venn Diagram of overlap between the far right and far left when it comes to a suspicion towards psychiatric medications as well as a desire for "purity" of some ineffable sort.

I'm trying to reason why in Southern Virginia, and apparently in other parts of the country, most of which strike me as more conservative than here, it's "common" to give out benzodiazepines when in my own life, I've never seen this and have always encountered a brisk reflex against them, with a much stronger interest in other, alternative forms of therapy, some of which are truly dubious.

Physcian, first do no harm. We see people becoming enslaved to addiction everyday, of course doctors are reluctant to prescribe them. I do believe that our society is a bit too paternalistic when it comes to some of these issues. I also question whether it should be up to the doctors to regulate these medications. On the other hand, I understand the dynamics of how these substances interact with the reward circuitry of the brain and how the limbic system is good at getting the frontal cortex to come up with solid justifications to get its needs met. It is a built in survival mechanism and in addiction this dynamic leads to an extremely high fatality rate. ETOH is the oldest and most widely used of the psychoactive substances. For some people, it works well, for others it is a living hell. What should society do? Great question that we are still grappling with and also raises the question of whether other available medications is a good or a bad thing in the net analysis.

 

[Mahavidya2]

Physcian, first do no harm. We see people becoming enslaved to addiction everyday, of course doctors are reluctant to prescribe them. I do believe that our society is a bit too paternalistic when it comes to some of these issues. I also question whether it should be up to the doctors to regulate these medications. On the other hand, I understand the dynamics of how these substances interact with the reward circuitry of the brain and how the limbic system is good at getting the frontal cortex to come up with solid justifications to get its needs met. It is a built in survival mechanism and in addiction this dynamic leads to an extremely high fatality rate. ETOH is the oldest and most widely used of the psychoactive substances. For some people, it works well, for others it is a living hell. What should society do? Great question that we are still grappling with and also raises the question of whether other available medications is a good or a bad thing in the net analysis.

My question was not about addiction. My question was about the liberal/conservative basis of prescriber's ideology. I appreciate your explanation of your personal ideology, which seems a bit paradoxical, that society is "paternalistic" and creating "enslaved" people and yet medication should not be so regulated by individual doctors, which would place control more in the hands of the central government or some other overseeing body. Hm. I don't entirely follow. To become not enslaved, we should put more hands into the central government. That would be more liberal.

I'm used to being pretty plain-spoken. If the president of the university asks me what the current budget is for my program, which I just had to do recently, I give an answer that is a direct response to the question and try to not get too philosophical about it. Some things are just nuts and bolts. I'm trying to understand if the reason I'm meeting with resistance is because my area doctors tend to think in very ideological terms which are somehow wed to their greater political views since this is one of the very few things that I can figure out makes where I live somewhat distinct from other parts of the United States, where I read that benzodiazepine prescription is more accepted.

Like birchswing's mention of Eugene, Oregon, this area is also "very liberal." I can't piece out any other variables that would make it an outlier, and from reading this forum, it seems more like it follows those who post here as well, assuming you are also not outliers.

 

[smalltownpsych]

My question was not about addiction. My question was about the liberal/conservative basis of prescriber's ideology. I appreciate your explanation of your personal ideology, which seems a bit paradoxical, that society is "paternalistic" and creating "enslaved" people and yet medication should not be so regulated by individual doctors, which would place control more in the hands of the central government or some other overseeing body. Hm. I don't entirely follow. To become not enslaved, we should put more hands into the central government. That would be more liberal.

I'm used to being pretty plain-spoken. If the president of the university asks me what the current budget is for my program, which I just had to present recently (fun!), I give an answer that is a direct response to the question and try to not get too philosophical about it. Some things are just nuts and bolts. I'm trying to understand if the reason I'm meeting with resistance is because my area doctors tend to think in very ideological terms which are somehow wed to their greater political views since this is one of the very few things that I can figure out makes where I live somewhat distinct from other parts of the United States, where I read that benzodiazepine prescription is more accepted.

The paternalistic view is protecting people from addiction. Father knows best. I'm not going to talk politics.

 

[whopper]

There is a view that there should be no physician whatsoever and just make all meds available to everybody. Let people medicate themselves.

The problem with this view is that the right medication for most prescribed meds takes years of training to understand. It'd be like allowing children to purchase and drive cars etc. No matter the ideology of the physician we are supposed to follow the ethics and rules of our profession. While there is wiggle room and differing opinions, following those ethics and guidelines pretty much across the board prohibits allowing us to start an addiction, enable and continue it, and to do everything within our means to treat it to end it.

 

[Mahavidya2]

There is a view that there should be no physician whatsoever and just make all meds available to everybody. Let people medicate themselves.

That's an extreme view and not one I've EVER come across. It strikes me as highly offensive, but that's probably because I fundamentally believe in expertise as well. I suppose it's the equivalent of home-schooling or even unschooling vs. a good, sound college education.

 

[Ceke2002]

Except why would this happen if the patient were consenting, properly educated about a discontinuation phenomenon, and then tapered off slowly? Unless of course s/he had a return of his or her original symptoms, it shouldn't be difficult or functionally impossible to stop taking benzodiazepines. I tapered off of a long-acting one while actively teaching at the university full-time plus traveling for work plus running a major academic program; I'm not someone who was teaching the occasional evening class, post-retirement. I'm very active in both my field as well as at my university.

I would have a difficult time believing some patients' self-reporting about their symptoms, especially after looking at the kinds of things stated in online patient-support forums which seemed filled with cyberchondriasis and, in real life, perhaps too much sensitivity to normal bodily processes. I had a very light withdrawal at the end, only, which do not fit whatsoever with this narrative of benzodiazepines being "functionally impossible to stop," other than that I am now wholly unmedicated and unable to leave my bed for nearly a month, which is horrific, like living only half-alive. So for me, taking some medication was 100% better than the alternative, which was to be unmedicated, which usually caused me to feel suicidal. I'm hesitant to bring that up at all, but it's part of why I find being unmedicated so unacceptable. I also understand it's not uncommon amongst untreated anxiety patients, as per the literature.

Because not all Doctors are as dilligent with their duty of care, and a lot of the time when it comes to the use and/or prescription of benzodiazepines you're talking about a vulnerable subset of the patient population.

I have shared my own story on here a number of times, but I'll share it again just to give you another point of view to consider. I started out using benzos in a not so legitimate manner. It's not something I'm particular proud of, but going back some years now I was pretty much the definition of the traditional addict (if I could snort it, pop it, shoot it, or doctor shop it, I was in). I was also using drugs to mask a lot of stuff, including inadequately treated mental illness as well as a fair amount of denial regarding my mental health over all owing largely to a fear of stigma ('I'm not freaking out in a complete panic for no apparent reason, I've just bunted up a bit too much speed', 'Psychotic features? Yeah as if, that's just the half tab of acid I dropped', and so on). Add on to that the fact that I have a history of abuse in childhood, and in some cases a child will develop certain people pleasing mechanisms as a protective measure which can then often be carried through to adulthood, as well as the fact that I was raised with a rather old fashioned view of most Doctors as almost these omnipotent type beings that you dare not question, and you add all that up and then plonk me in front of a Physician who shall we say is a little loose with his prescribing practices and you're almost guaranteed a recipe for disaster.

Now by the time I actually needed to use Xanax for legitimate purposes (during one of my rare drug free periods at the time, when I no longer had anything to hide behind which meant my panic/anxiety disorder, along with other diagnoses, decided to go full tilt on me), I did initially have a good Doctor on my side - there was a plan in place, the Xanax was going to be a short term prospect, enough to allow me to engage properly with therapy in the longer term, and then I would be gradually tapered off. It should have had a positive outcome, because the medication worked, everything was great, I was waiting to be placed on a waiting list to see an experienced therapist, bob's your uncle, two thumbs up. And then things took a complete nosedive when I ended up having to move, was forced to change Doctors, and unbeknownst to me at the time I ended up with a pill pusher as my GP. His idea of due dilligence was to keep me coming back for scripts as often as he could - forget therapy, forget alternate approaches to dealing with anxiety, he even gave me the whole spiel about how my brain needs Xanax like a diabetic needs to take insulin. And of course with the factors I listed above it was extremely difficult for me to say no when I was practically having scripts shoved down my throat, metaphorically speaking.

There were times during this period when I did get fed up enough with just, what felt to me like having pills thrown at my problems when I wanted to actually work towards some sort of recovery/rehabilitative framework not just symptom management (or masking). So I undertook several fairly rapid detoxes (going off 4-6 mgs of Xanax daily in around 4-6 weeks), which were unpleasant to say the least, but I got through them, and then made the mistake of returning to the same Doctor with what I thought of as this fantastic news that I was no longer on the medication and now could we please work towards a longer term solution, and invariably after 20 minutes of listening to him give every reason and argument under the sun he could come up with as to why I needed to return to my medication regime post haste I ended up leaving his office with yet another script in hand. Again, addict, addict covering up issues, abused child who developed certain skills and attitudes as a means of necessary self protection, bought up not to question the almighty Physician, all of it added up to me being in a vulnerable position that would have been very easy for the wrong sort of Doctor to milk to their advantage - which is exactly what happened seeing as I mentioned in another post in this thread, the same Doctor who so adamantly insisted I remain on Xanax was also eventually caught in a hidden camera sting operation more or less shelling out benzodiazepine scripts hand over fist to anyone who passed his way, with much of his clientele ending up as repeat customers.

And to cut a long story short, thereafter followed several years of heroin addiction, at which point I was too busy trying not to be a junkie to really give two hoots about tapering off of Xanax, and the methadone prescribing Doctor I eventually ended up seeing to get on a program and get clean decided a maximum dosage of 16mgs of Xanax a day was perfectly reasonable, again same issues as before, now coupled with a need to just concentrate all my energy into keeping off smack and so once again I just ended up accepting the (ever increasing) status quo. Obviously by this stage I had been physically dependent on benzodiazipenes for a number of years, more often that not at higher than prescribed doses, but I did eventually manage to overcome the addiction quotient of the equation, meaning I reached a point where I no longer psychologically craved the pills, or engaged in drug seeking behaviour more apt of the truly addicted patient in the classic sense of the term - but of course that didn't matter squat, because I was still physiologically dependent (basically my overall journey with Xanax went from classic addict, to classic addict with dependency, to just dependency) and couldn't exactly just flush my pills down the toilet and say I was done with it...except when I thought I could. I mentioned before that a lot of the time, even with the best advice and patient education and warning labels from here to eternity, I believe it does come down to patients just not really grasping just how bad a cold turkey withdrawal off a benzodiazepine like Xanax can be. Now maybe like me they made an ill advised decision off their own bat, maybe they lost access to a regular prescriber, maybe they were mislead by their presciber, whatever the reason when you do either decide, or are forced into a sudden withdrawal situation there can be this tendency to go into a mind mode of 'Well this is going to be a wild ride, but let's strap ourselves in nice and tight and we'll see you out the other side'. And then reality decides to just up and bitch slap you - 'that'll be two days of sheer hell, by the way you'll spend the first night having completely lost touch with reality, and I've scheduled a Grand Mal seizure for you on night two at which point you'll be rushed off to emergency having temporarily lost the ability to walk and let's add in projectile vomiting just to mix things up a bit'.

I do think a good deal of the cyberchondriasis that you talk of with Benzo patients does come from having the sorts of experiences doing a far too rapid taper can bring. I know after I made the mistake of trying to go cold turkey I became terrified for ages afterwards of even attempting to taper my dosage. It was like whenever I tried even reducing even a fraction of a dose, the slightest little niggle and I'd be in a complete state of panic thinking I was about to have another seizure. It took several more years with a good Doctor, who very patiently coaxed me towards an eventual taper from 8-12 mgs a day down to 4, at which point I was referred to a Psychiatrist (after developing a paradoxical reaction to Xanax which more or less necessitated a complete withdrawal) who set up a further and final tapering program following the Ashton Protocol. And even then, even though I knew logically that the taper was being done safely, and I had all the support in the world from an excellent GP, in the back of my mind I was still petrified of going through that same experience of sudden withdrawal like I had before. This is also where I think benzo tapering/patient support forums can be a double edged sword, because on the one hand it can be helpful to connect with people who understand, and know where you're coming from, but on the other hand if you're already in a state of heightened awareness, looking out for every little sign that something might be about to go wrong, the last thing you really need is to set yourself up with a type of group think feedback loop that keeps reiterating that you should be scared despite any quantifiable evidence to the contrary.

Irrespective of my own largely negative experience with Xanax I do still take a moderate position on their prescription and use, and that goes for all other Benzodiazipenes as well. I do think they have a place, and I don't think there should necessarily be this knee jerk reaction against prescribing them if it's for the right reasons (first do no harm). On the other hand though history has taught us that fools often rush in where angels fear to tread, so I think the benefits do need to be heavily weighed against the potential negatives before a patient and/or a physician decides to embark along the boulevard of benzos as it were.

Anyway that's just my story, my views, my opinion -- make of it what you will.

 

[birchswing]

After further thought about the geographic issue, I now wonder if the issue to prefer, or to not prefer, benzodiazepines varies with political party or views? I wonder this because I know that psychiatrists in my area -- who are reluctant to prescribe benzodiazepines -- are strongly liberal. My entire area is highly and almost homogeneously liberal, which should be relatively evident from my earlier posts about pet therapy. In no way am I maligning liberal politics, however, since I'm pretty typically liberal myself, like so many other academics.

Is there any correlation possible here?

I can imagine that on the far-right side of things, benzodiazepines might be disliked for other reasons like believing in the Power of God, etc. I see that skew in the self-help section of my local bookstore, where there's a Venn Diagram of overlap between the far right and far left when it comes to a suspicion towards psychiatric medications as well as a desire for "purity" of some ineffable sort.

I'm trying to reason why in Southern Virginia, and apparently in other parts of the country, most of which strike me as more conservative than here, it's "common" to give out benzodiazepines when in my own life, I've never seen this and have always encountered a brisk reflex against them, with a much stronger interest in other, alternative forms of therapy, some of which are truly dubious.

Well, there's a limit to the biological model and psychiatrists are running up against it and even acknowledging it, hence the interest in alternative therapies that you noted. On the average, in my opinion, doctors that don't like to prescribe benzodiazepines I would estimate as being farther along in the evolution taking place than ones that do.

Which brings us back to geography. Across the country, psychiatrists are not reimbursed as well as other professions. I have been told that in Southeastern Virginia the insurance reimbursement rates are particularly low. I would estimate that about 9/10 psychiatrists where I am are FMGs (foreign medical school graduates). That doesn't necessarily make them worse, but the thing is that these are doctors who got their degrees not only outside the US but outside the US in the 1960s and 70s. Call me xenophobic, but what was the medical education like in Pakistan in the early 1970s? The doctors here are OLD, not just a little old, but really old. They are not all caught up to speed on everything. In fact I am quite sure a couple I used to see who both still practice had some stage of dementia at the time I saw them. They didn't care about benzos because benzos weren't going to immediately kill you. When I would bring up concerns about side effects one would call me a "spaz." These are people who can only worry about things at that level and not much further.

I get the impression that Eugene (and maybe where you live) has more self-pay psychiatrists, which would also increase the number of therapies offered besides medication. They probably are more "advanced" and for you I suppose that has the unfortunate association of not being hot for benzos.

It's definitely not a liberal/conservative thing, from what I can tell. I would say it's a being brought up to speed vs not-caring/outdated-education and seeing things very, very medically (as in, given their training, a person with anxiety questioning why they're given a benzodiazepine is like a person with sepsis questioning why they're being given antibiotics--you just take the damn pill and you're done). There was a time when the biological model held a huge promise. I can remember as a child my father talking to my grandmother who was a psychiatrist in Sweden, and she talked about the anti-depressants changing everything. People who are on the cutting edge are a little bit past that, I think, even if the cutting edge is that medications aren't that great for a number of things they used to be thought of as great for (although that conversation usually involves anti-depressants—benzos seem to never be in the conversation at all).

 

[Mahavidya2]

Well, there's a limit to the biological model and psychiatrists are running up against it and even acknowledging it, hence the interest in alternative therapies that you noted. On the average, in my opinion, doctors that don't like to prescribe benzodiazepines I would estimate as being farther along in the evolution taking place than ones that do.

Which brings us back to geography. Across the country, psychiatrists are not reimbursed as well as other professions. I have been told that in Southeastern Virginia the insurance reimbursement rates are particularly low. I would estimate that about 9/10 psychiatrists where I am are FMGs (foreign medical school graduates). That doesn't necessarily make them worse, but the thing is that these are doctors who got their degrees not only outside the US but outside the US in the 1960s and 70s. Call me xenophobic, but what was the medical education like in Pakistan in the early 1970s? The doctors here are OLD, not just a little old, but really old. They are not all caught up to speed on everything. In fact I am quite sure a couple I used to see who both still practice had some stage of dementia at the time I saw them. They didn't care about benzos because benzos weren't going to immediately kill you. When I would bring up concerns about side effects one would call me a "spaz." These are people who can only worry about things at that level and not much further.

I get the impression that Eugene (and maybe where you live) has more self-pay psychiatrists, which would also increase the number of therapies offered besides medication. They probably are more "advanced" and for you I suppose that has the unfortunate association of not being hot for benzos.

It's definitely not a liberal/conservative thing, from what I can tell. I would say it's a being brought up to speed vs not-caring/outdated-education and seeing things very, very medically (as in, given their training, a person with anxiety questioning why they're given a benzodiazepine is like a person with sepsis questioning why they're being given antibiotics--you just take the damn pill and you're done). There was a time when the biological model held a huge promise. I can remember as a child my father talking to my grandmother who was a psychiatrist in Sweden, and she talked about the anti-depressants changing everything. People who are on the cutting edge are a little bit past that, I think, even if the cutting edge is that medications aren't that great for a number of things they used to be thought of as great for (although that conversation usually involves anti-depressants—benzos seem to never be in the conversation at all).

After reading further into this forum, I am certain that it's an ideological issue with its roots in a deeply paternalistic belief system about patients and not a logical one at all. It has to be, given the data that benzodiazepines are effective and some patients improve on them. Also, it's unethical to not give a consenting adult a legal medication if he or she wants that medication. Presuming that he or she starts benzodiazepines while not high on something, then that person is, in fact, able to consent, and presuming that a medication is legal and the person is able to consent, and that both of these criteria are met, it's unethical to treat a human being as though they were incapable of their own choices and self-determination, provided that these are informed and fall within no legal gray areas. Individual prescriber's morals are again, ideological, and it should ultimately be irrelevant. A good comparison might be abortion, which many doctors find objectionable, but which is presently legal and thus presently available.

Part of the issue with you, I think, is that you felt "forced" to take benzodiazepines. However, because you are no longer being forced, and from what I can tell, you've been taking these for a long time while "tapering," you are probably just some combination of both physically habituated as well as psychologically dependent. For me, it was relatively easy to discontinue them because I was not psychologically dependent on them, probably in part because I don't like the narrative of being anyone's victim: I possess some level of free will.

I've been through some intense things in my life. For one thing, I came by my anxiety disorder due to a serious illness. I don't want to detail it too much because I do need to maintain some anonymity, and it's slightly obscure and required several intensive surgeries. But it was a side effect at first of a physical disorder that was very real and which nearly killed me. I was in and out of hospitals for far too long, by no choice of my own, and I had panic attacks as a side effect of that illness. That illness was also misdiagnosed as anxiety for four years, and I was treated for anxiety with psychotherapy. That almost killed me. Since then, I have been dismissed as anxious for many illnesses that were completely real -- urinary tract infections, infected gallstones, and a relapse of the original illness. Ironically, I really do have panic disorder at this point, which I probably "learned" from the illness, which has symptoms like panic disorder at times. I assume that I also must fit into a stereotype of "anxious." I've been told that this is because I tend to be calm and literal even during serious crises, so that people doubt me (I'm a Stoic person, but that does not change a tendency towards extreme, physical attacks of panic for me accompanied by a sense of overwhelming terror; my panic attacks can also cause me to faint and have surprised people on more than one occasion since they say you cannot faint, but apparently, my blood pressure must drop since I faint at times, like when you have a phobia of something and are exposed… I think it's the degree of them and how long they can go on and on). Needless to say, it was negligent to the utmost to fail to treat the medical disorder which I had. I'm now on medication for life and would die without it. Another daily pill is literally no sweat to me because I have a deeply complex relationship with pills at this point, already. I've had to come to terms with the fact that I take a foreign substance all the time or else I will die. So, I see nothing unethical or imprudent for me about taking benzodiazepines, although I'm not currently taking any, as you know, and I'm wracked with panic today because tomorrow, I am going to see my psychiatrist and want to figure out a better treatment option or else I'm going to send in my resignation so that the university can figure out its Fall schedule a bit better since these are determined nearly a year in advance. This is just an abomination after decades of work, but there is simply no way to continue doing what I do otherwise from this vantage point. It is an insult, outright. It is paternalism at its worst. I am an educated adult who consented to taking medication, that medication continued to work for me, and that medication is still legal. It's illogical and worse, unethical.

Ironic to bring up Sweden. I've spent some time there, and it is, for all of the many good things about it, also a highly restrictive society. Trying to buy alcohol is impressively difficult, like in most Scandinavian countries, because of the government's attempts to curtail alcohol consumption. Subsequently, Swedish people are some of the most hardcore alcoholics I've ever met, other than Finns and Icelanders, who easily have the Swedes beat (and seem proud of it).

I was confused enough about the claims that psychiatry was not biological to look into it. That seems like quite the little debate. I would always side with the materialist point of view, always. Anything else is superstition.

 

[Mahavidya2]

Because not all Doctors are as dilligent with their duty of care, and a lot of the time when it comes to the use and/or prescription of benzodiazepines you're talking about a vulnerable subset of the patient population.

I have shared my own story on here a number of times, but I'll share it again just to give you another point of view to consider. I started out using benzos in a not so legitimate manner. It's not something I'm particular proud of, but going back some years now I was pretty much the definition of the traditional addict (if I could snort it, pop it, shoot it, or doctor shop it, I was in). I was also using drugs to mask a lot of stuff, including inadequately treated mental illness as well as a fair amount of denial regarding my mental health over all owing largely to a fear of stigma ('I'm not freaking out in a complete panic for no apparent reason, I've just bunted up a bit too much speed', 'Psychotic features? Yeah as if, that's just the half tab of acid I dropped', and so on). Add on to that the fact that I have a history of abuse in childhood, and in some cases a child will develop certain people pleasing mechanisms as a protective measure which can then often be carried through to adulthood, as well as the fact that I was raised with a rather old fashioned view of most Doctors as almost these omnipotent type beings that you dare not question, and you add all that up and then plonk me in front of a Physician who shall we say is a little loose with his prescribing practices and you're almost guaranteed a recipe for disaster.

Now by the time I actually needed to use Xanax for legitimate purposes (during one of my rare drug free periods at the time, when I no longer had anything to hide behind which meant my panic/anxiety disorder, along with other diagnoses, decided to go full tilt on me), I did initially have a good Doctor on my side - there was a plan in place, the Xanax was going to be a short term prospect, enough to allow me to engage properly with therapy in the longer term, and then I would be gradually tapered off. It should have had a positive outcome, because the medication worked, everything was great, I was waiting to be placed on a waiting list to see an experienced therapist, bob's your uncle, two thumbs up. And then things took a complete nosedive when I ended up having to move, was forced to change Doctors, and unbeknownst to me at the time I ended up with a pill pusher as my GP. His idea of due dilligence was to keep me coming back for scripts as often as he could - forget therapy, forget alternate approaches to dealing with anxiety, he even gave me the whole spiel about how my brain needs Xanax like a diabetic needs to take insulin. And of course with the factors I listed above it was extremely difficult for me to say no when I was practically having scripts shoved down my throat, metaphorically speaking.

There were times during this period when I did get fed up enough with just, what felt to me like having pills thrown at my problems when I wanted to actually work towards some sort of recovery/rehabilitative framework not just symptom management (or masking). So I undertook several fairly rapid detoxes (going off 4-6 mgs of Xanax daily in around 4-6 weeks), which were unpleasant to say the least, but I got through them, and then made the mistake of returning to the same Doctor with what I thought of as this fantastic news that I was no longer on the medication and now could we please work towards a longer term solution, and invariably after 20 minutes of listening to him give every reason and argument under the sun he could come up with as to why I needed to return to my medication regime post haste I ended up leaving his office with yet another script in hand. Again, addict, addict covering up issues, abused child who developed certain skills and attitudes as a means of necessary self protection, bought up not to question the almighty Physician, all of it added up to me being in a vulnerable position that would have been very easy for the wrong sort of Doctor to milk to their advantage - which is exactly what happened seeing as I mentioned in another post in this thread, the same Doctor who so adamantly insisted I remain on Xanax was also eventually caught in a hidden camera sting operation more or less shelling out benzodiazepine scripts hand over fist to anyone who passed his way, with much of his clientele ending up as repeat customers.

And to cut a long story short, thereafter followed several years of heroin addiction, at which point I was too busy trying not to be a junkie to really give two hoots about tapering off of Xanax, and the methadone prescribing Doctor I eventually ended up seeing to get on a program and get clean decided a maximum dosage of 16mgs of Xanax a day was perfectly reasonable, again same issues as before, now coupled with a need to just concentrate all my energy into keeping off smack and so once again I just ended up accepting the (ever increasing) status quo. Obviously by this stage I had been physically dependent on benzodiazipenes for a number of years, more often that not at higher than prescribed doses, but I did eventually manage to overcome the addiction quotient of the equation, meaning I reached a point where I no longer psychologically craved the pills, or engaged in drug seeking behaviour more apt of the truly addicted patient in the classic sense of the term - but of course that didn't matter squat, because I was still physiologically dependent (basically my overall journey with Xanax went from classic addict, to classic addict with dependency, to just dependency) and couldn't exactly just flush my pills down the toilet and say I was done with it...except when I thought I could. I mentioned before that a lot of the time, even with the best advice and patient education and warning labels from here to eternity, I believe it does come down to patients just not really grasping just how bad a cold turkey withdrawal off a benzodiazepine like Xanax can be. Now maybe like me they made an ill advised decision off their own bat, maybe they lost access to a regular prescriber, maybe they were mislead by their presciber, whatever the reason when you do either decide, or are forced into a sudden withdrawal situation there can be this tendency to go into a mind mode of 'Well this is going to be a wild ride, but let's strap ourselves in nice and tight and we'll see you out the other side'. And then reality decides to just up and bitch slap you - 'that'll be two days of sheer hell, by the way you'll spend the first night having completely lost touch with reality, and I've scheduled a Grand Mal seizure for you on night two at which point you'll be rushed off to emergency having temporarily lost the ability to walk and let's add in projectile vomiting just to mix things up a bit'.

I do think a good deal of the cyberchondriasis that you talk of with Benzo patients does come from having the sorts of experiences doing a far too rapid taper can bring. I know after I made the mistake of trying to go cold turkey I became terrified for ages afterwards of even attempting to taper my dosage. It was like whenever I tried even reducing even a fraction of a dose, the slightest little niggle and I'd be in a complete state of panic thinking I was about to have another seizure. It took several more years with a good Doctor, who very patiently coaxed me towards an eventual taper from 8-12 mgs a day down to 4, at which point I was referred to a Psychiatrist (after developing a paradoxical reaction to Xanax which more or less necessitated a complete withdrawal) who set up a further and final tapering program following the Ashton Protocol. And even then, even though I knew logically that the taper was being done safely, and I had all the support in the world from an excellent GP, in the back of my mind I was still petrified of going through that same experience of sudden withdrawal like I had before. This is also where I think benzo tapering/patient support forums can be a double edged sword, because on the one hand it can be helpful to connect with people who understand, and know where you're coming from, but on the other hand if you're already in a state of heightened awareness, looking out for every little sign that something might be about to go wrong, the last thing you really need is to set yourself up with a type of group think feedback loop that keeps reiterating that you should be scared despite any quantifiable evidence to the contrary.

Irrespective of my own largely negative experience with Xanax I do still take a moderate position on their prescription and use, and that goes for all other Benzodiazipenes as well. I do think they have a place, and I don't think there should necessarily be this knee jerk reaction against prescribing them if it's for the right reasons (first do no harm). On the other hand though history has taught us that fools often rush in where angels fear to tread, so I think the benefits do need to be heavily weighed against the potential negatives before a patient and/or a physician decides to embark along the boulevard of benzos as it were.

Anyway that's just my story, my views, my opinion -- make of it what you will.

It sounds like you have been through a lot. You seem like a smart person to me and like you have a complicated relationship to substances that is pretty intense. I have more to add but have to go for now.

 

[birchswing]

After reading further into this forum, I am certain that it's an ideological issue with its roots in a deeply paternalistic belief system about patients and not a logical one at all. It has to be, given the data that benzodiazepines are effective and some patients improve on them. Also, it's unethical to not give a consenting adult a legal medication if he or she wants that medication. Presuming that he or she starts benzodiazepines while not high on something, then that person is, in fact, able to consent, and presuming that a medication is legal and the person is able to consent, and that both of these criteria are met, it's unethical to treat a human being as though they were incapable of their own choices and self-determination, provided that these are informed and fall within no legal gray areas. Individual prescriber's morals are again, ideological, and it should ultimately be irrelevant. A good comparison might be abortion, which many doctors find objectionable, but which is presently legal and thus presently available.

Part of the issue with you, I think, is that you felt "forced" to take benzodiazepines. However, because you are no longer being forced, and from what I can tell, you've been taking these for a long time while "tapering," you are probably just some combination of both physically habituated as well as psychologically dependent. For me, it was relatively easy to discontinue them because I was not psychologically dependent on them, probably in part because I don't like the narrative of being anyone's victim: I possess some level of free will.

I've been through some intense things in my life. For one thing, I came by my anxiety disorder due to a serious illness. I don't want to detail it too much because I do need to maintain some anonymity, and it's slightly obscure and required several intensive surgeries. But it was a side effect at first of a physical disorder that was very real and which nearly killed me. I was in and out of hospitals for far too long, by no choice of my own, and I had panic attacks as a side effect of that illness. That illness was also misdiagnosed as anxiety for four years, and I was treated for anxiety with psychotherapy. That almost killed me. Since then, I have been dismissed as anxious for many illnesses that were completely real -- urinary tract infections, infected gallstones, and a relapse of the original illness. Ironically, I really do have panic disorder at this point, which I probably "learned" from the illness, which has symptoms like panic disorder at times. I assume that I also must fit into a stereotype of "anxious." I've been told that this is because I tend to be calm and literal even during serious crises, so that people doubt me (I'm a Stoic person, but that does not change a tendency towards extreme, physical attacks of panic for me accompanied by a sense of overwhelming terror; my panic attacks can also cause me to faint and have surprised people on more than one occasion since they say you cannot faint, but apparently, my blood pressure must drop since I faint at times, like when you have a phobia of something and are exposed… I think it's the degree of them and how long they can go on and on). Needless to say, it was negligent to the utmost to fail to treat the medical disorder which I had. I'm now on medication for life and would die without it. Another daily pill is literally no sweat to me because I have a deeply complex relationship with pills at this point, already. I've had to come to terms with the fact that I take a foreign substance all the time or else I will die. So, I see nothing unethical or imprudent for me about taking benzodiazepines, although I'm not currently taking any, as you know, and I'm wracked with panic today because tomorrow, I am going to see my psychiatrist and want to figure out a better treatment option or else I'm going to send in my resignation so that the university can figure out its Fall schedule a bit better since these are determined nearly a year in advance. This is just an abomination after decades of work, but there is simply no way to continue doing what I do otherwise from this vantage point. It is an insult, outright. It is paternalism at its worst. I am an educated adult who consented to taking medication, that medication continued to work for me, and that medication is still legal. It's illogical and worse, unethical.

Ironic to bring up Sweden. I've spent some time there, and it is, for all of the many good things about it, also a highly restrictive society. Trying to buy alcohol is impressively difficult, like in most Scandinavian countries, because of the government's attempts to curtail alcohol consumption. Subsequently, Swedish people are some of the most hardcore alcoholics I've ever met, other than Finns and Icelanders, who easily have the Swedes beat (and seem proud of it).

I was confused enough about the claims that psychiatry was not biological to look into it. That seems like quite the little debate. I would always side with the materialist point of view, always. Anything else is superstition.

My grandmother did treat quite a number of alcoholics in Sweden. Things were different. My mother said they would stop by the house as they were walking through town to say hi to her. A few of her alcoholic patients came to her funeral. Much less legalese than the US (in that you don't have a lot of lawsuits, and at least back then fraternizing with your psychiatrist wasn't a big deal). As far as paternalism, Sweden is unique in its relationship to alcohol and marijuana. I don't think that extends to all of Swedish society, though. My grandfather really liked systembolaget because it meant that they had a greater diversity of alcohol and better quality, rather than stocking based on what would sell the best. Swedes are very proud of systembolaget. You can also in an unregulated way buy beer in grocery stores at younger ages than the US. I'm not sure if their alcohol control policy contributes to alcoholism as you suggest. It is very dark in the winters and Sweden already has a higher suicide rate than other countries, which is in contrast to having such a high standard of living. It could be the darkness or genetics. I don't really see how the limit of alcohol per week contributes to alcoholism. It's not a really strict limit and many Swedes buy alcohol outside Sweden anyhow in large quantities because it's cheaper (maybe that's the part that could contribute to bingeing).

I agree with your perceptions about me (regarding my reticence to withdraw faster). A lawyer once told me that every egg cracks differently. The difference between us might be that I have not really ever felt normal or calm on the benzodiazepines, so to me, reducing them is a promise that I may eventually feel better but I'm going to feel worse first. I've for a long time not been therapeutically treated by them, and I get worse and worse waiting to take my next dose. Because of my OCD I spent a lot of time researching benzodiazepines and finding horror stories about them. I became obsessed a long time ago both with needing to get off them but it being my life's greatest fear. I'm a control freak and there was a point when I dropped out of college that I was sick of being cycled through meds and I said I don't care what you put me on but I need to hold onto something. And I did end up on a regimen that I didn't change for years. There was an OCD dutifulness to it. It was sort of irrelevant to me which medications I was on as long as it was the same and not changing. I very much went into a foxhole to recover from a lot of trauma of experiencing uncontrolled anxiety.

I haven't read as much as you have, but in your research where you see that benzodiazepines are effective, does it show that they are effective past several months for treating anxiety? I've always heard that people's general and mental health deteriorate on benzodiazepines after that period of time, which has been my experience.

I tried to read everything you wrote, but I am responding out of order because there was so much. You said you thought it was unethical to give a consenting adult a medication that he wants, but earlier it seemed like you said that you strongly believe in the concept of deferring to expertise.

I am very sorry for your position with work. It sounds like you've been through a lot. It is amazing how a medicine can flip a light switch on or off. Last year at this time I was in a really bad state. Had testing done for pheochromocytoma, various thyroid diseases, etc. I was shaking and couldn't stop the shaking. Wasn't sleeping. Lost 30 plus pounds. Extreme tachycardia. I was tested for so many things I can't even remember them all. It wasn't at all like my normal anxiety even though it was obviously distressing. My psychiatrist finally decided it was that I was in tolerance withdrawal (withdrawal symptoms without decreasing the dose as I hadn't increased my benzo dose in about 15 years) combined with having gone back to college. I barely finished my semester and was sure I was going to drop out. She then started me on my taper. The initial part of the taper was just a crossover to a bit of Valium and cutting an equivalent part of my Ativan. In reality, I think I was updosed (the equivalencies are never exact and I metabolize Valium in a way where it works more strongly in me). Everything changed. My appetite came back. I slept. My pulse was normal. As my psychiatrist put it, the Valium was "covering" me. Since then I cut down a bit of Valium then crossover a bit more then cut a bit more. It's not Ashton exactly, as my psychiatrist thinks going full Ashton would be too sedating. But I remember that moment of the Valium hitting the receptors. It was like the first time I took Ativan back in high school. You try so, so hard. Endless meditations. Sleep hypnosis. Exercise. All the right things, and then with one pill, it's like you're free of all that god awful suffering again. Of course, it doesn't stay that way for long--at least not for me, and also because I've been cutting since then. But it pulled me out of a bad place.

So, I don't have fainting and I don't have acute attacks like you do, but I know what it is like to not even be in the right ball park.

That's how I describe it to people. Sometimes people will say, well wouldn't a glass of warm milk or some relaxing music help? I tell them, yes, it will change my course about 1-2 degrees. But it won't get me in the right ballpark.

I know what you believe about your condition and I very much take you at your word, but I am curious to know what the nature of your anxiety is now being off the Xanax compared to before you took it?

The conventional wisdom would be, assuming you were on it for some length of time which I think you said you were, that you're in protracted withdrawal. But is it clear to you that what you're feeling is what the original indication was for the Xanax (meaning do you feel now the way you felt before taking Xanax and were anxious)? Or is it worse than before the Xanax?

At your appointment tomorrow, be sure to be very frank about the situation you face with work. It sounds like you are already a forceful advocate for yourself, so that probably goes without saying.

 

[Mahavidya2]

My grandmother did treat quite a number of alcoholics in Sweden. Things were different. My mother said they would stop by the house as they were walking through town to say hi to her. A few of her alcoholic patients came to her funeral. Much less legalese than the US (in that you don't have a lot of lawsuits, and at least back then fraternizing with your psychiatrist wasn't a big deal). As far as paternalism, Sweden is unique in its relationship to alcohol and marijuana. I don't think that extends to all of Swedish society, though. My grandfather really liked systembolaget because it meant that they had a greater diversity of alcohol and better quality, rather than stocking based on what would sell the best. Swedes are very proud of systembolaget. You can also in an unregulated way buy beer in grocery stores at younger ages than the US. I'm not sure if their alcohol control policy contributes to alcoholism as you suggest. It is very dark in the winters and Sweden already has a higher suicide rate than other countries, which is in contrast to having such a high standard of living. It could be the darkness or genetics. I don't really see how the limit of alcohol per week contributes to alcoholism. It's not a really strict limit and many Swedes buy alcohol outside Sweden anyhow in large quantities because it's cheaper (maybe that's the part that could contribute to bingeing).

I agree with your perceptions about me (regarding my reticence to withdraw faster). A lawyer once told me that every egg cracks differently. The difference between us might be that I have not really ever felt normal or calm on the benzodiazepines, so to me, reducing them is a promise that I may eventually feel better but I'm going to feel worse first. I've for a long time not been therapeutically treated by them, and I get worse and worse waiting to take my next dose. Because of my OCD I spent a lot of time researching benzodiazepines and finding horror stories about them. I became obsessed a long time ago both with needing to get off them but it being my life's greatest fear. I'm a control freak and there was a point when I dropped out of college that I was sick of being cycled through meds and I said I don't care what you put me on but I need to hold onto something. And I did end up on a regimen that I didn't change for years. There was an OCD dutifulness to it. It was sort of irrelevant to me which medications I was on as long as it was the same and not changing. I very much went into a foxhole to recover from a lot of trauma of experiencing uncontrolled anxiety.

I haven't read as much as you have, but in your research where you see that benzodiazepines are effective, does it show that they are effective past several months for treating anxiety? I've always heard that people's general and mental health deteriorate on benzodiazepines after that period of time, which has been my experience.

I tried to read everything you wrote, but I am responding out of order because there was so much. You said you thought it was unethical to give a consenting adult a medication that he wants, but earlier it seemed like you said that you strongly believe in the concept of deferring to expertise.

I am very sorry for your position with work. It sounds like you've been through a lot. It is amazing how a medicine can flip a light switch on or off. Last year at this time I was in a really bad state. Had testing done for pheochromocytoma, various thyroid diseases, etc. I was shaking and couldn't stop the shaking. Wasn't sleeping. Lost 30 plus pounds. Extreme tachycardia. I was tested for so many things I can't even remember them all. It wasn't at all like my normal anxiety even though it was obviously distressing. My psychiatrist finally decided it was that I was in tolerance withdrawal (withdrawal symptoms without decreasing the dose as I hadn't increased my benzo dose in about 15 years) combined with having gone back to college. I barely finished my semester and was sure I was going to drop out. She then started me on my taper. The initial part of the taper was just a crossover to a bit of Valium and cutting an equivalent part of my Ativan. In reality, I think I was updosed (the equivalencies are never exact and I metabolize Valium in a way where it works more strongly in me). Everything changed. My appetite came back. I slept. My pulse was normal. As my psychiatrist put it, the Valium was "covering" me. Since then I cut down a bit of Valium then crossover a bit more then cut a bit more. It's not Ashton exactly, as my psychiatrist thinks going full Ashton would be too sedating. But I remember that moment of the Valium hitting the receptors. It was like the first time I took Ativan back in high school. You try so, so hard. Endless meditations. Sleep hypnosis. Exercise. All the right things, and then with one pill, it's like you're free of all that god awful suffering again. Of course, it doesn't stay that way for long--at least not for me, and also because I've been cutting since then. But it pulled me out of a bad place.

So, I don't have fainting and I don't have acute attacks like you do, but I know what it is like to not even be in the right ball park.

That's how I describe it to people. Sometimes people will say, well wouldn't a glass of warm milk or some relaxing music help? I tell them, yes, it will change my course about 1-2 degrees. But it won't get me in the right ballpark.

I know what you believe about your condition and I very much take you at your word, but I am curious to know what the nature of your anxiety is now being off the Xanax compared to before you took it?

The conventional wisdom would be, assuming you were on it for some length of time which I think you said you were, that you're in protracted withdrawal. But is it clear to you that what you're feeling is what the original indication was for the Xanax (meaning do you feel now the way you felt before taking Xanax and were anxious)? Or is it worse than before the Xanax?

At your appointment tomorrow, be sure to be very frank about the situation you face with work. It sounds like you are already a forceful advocate for yourself, so that probably goes without saying.

My anxiety? How does it feel now? Terrible, but like it was before, from all that I remember. I was medicated for decades, and other than for the taper portion, which was about a year, it was always on Xanax. I was prescribed my dose, took it as prescribed, and that was that; there were no side effects or loss of strength, although a little interdose withdrawal, but nothing unmanageable. Now, I'm a shell. Let me find more universal phrasing for this. At any given time, I feel like I am going to crawl out of my own skin due to a really odd, hard-to-describe feeling, which is what I have in old journals from before medication too. It's almost painful in terms of its unremitting intensity, as though my skin were crushing me. At the same time, I feel frozen in place from the weight of this feeling. My heart does not beat rapidly but too slowly. My breathing is labored, and I know to breath carefully. My stomach gurgles and churns all the time. I am so thirsty that I could die and must drink 10-15 cups of water a day, but I'm still thirsty. My throat is tight so that I choke on my food. It doesn't seem like what I've heard anxiety described like before, exactly, because of the minimal cardiac symptoms and occasional not feeling stressed out. However, it's the same feeling that surges forth during a situational or sudden panic attack, with greater intensity, so I assume that it's adrenaline in varying degrees. I have some depersonalization with this, all of the time. The feeling is like I am out of body, observing my body instead, separately. It distorts my vision a bit though, so that it is hard to navigate through the world. Also, my voice and thoughts seem very distant and echoing. This is baseline. This is what I feel 24/7 now. Then on top of this are panic attacks, which for me strike with the rapidity of lightning. The only prodrome they have to them, which I can easily make happen by putting myself in situations that cause me to want to flee (elevators, driving in the left lane, crossing a bridge, airplanes, sitting in the center of a movie theater -- agoraphobic responses, not claustrophobic ones, and a dozen more that I could list), is a horrible and sudden tingling around the nape of my neck followed rapidly by a very serious alteration of consciousness so that I might realize I am screaming or running or trying to get out of the place. If I am in a car when this happens, and for whatever reason cannot pull over, this is when I have fainted and often convulsed, sometimes right in front of people. If I don't faint, I occasionally have tachycardia instead. I have had this thousands of times, but afterwards, if severe, I'm exhausted and need to lie down. These can never happen while teaching, so I've never taught without medication, and at most, I have a sense of being momentarily wanting to flee, and that's it. I also have associated with this agoraphobia that never lessens no matter how much I try to force myself out, and I can set my watch to feeling terribly ill at ease the moment I open the door, or in worse moments, just opening my eyes. I spent most of the day this summer lying in bed with the sheets pulled up over my face and my eyes closed, or if open, just staring at the wall. I cannot concentrate whatsoever, so I have barely read, which if you knew me, as an academic, you would find hard to believe. I do not, cannot, think when in this state. I meditate, relax, but the feeling of crawling out of my own skin doesn't leave. How do you describe what it means to want to "crawl out of your own skin?" This could mean different things to different people. It does not feel like I've drank too much coffee. It feels like I've been injected with epinephrine, tons of it, at the dentists when I've had a bad reaction to the epinephrine during a filling, but far worse. And, I am crying often, although I feel nothing other than frustrated. I'm not a person to cry, but I'm sobbing in my bed like a child due to the depths of the frustration and depression that I feel. However, my family is with me, and they find my state very troubling, so I lock the door and make excuses for why I won't come out, claiming I have a headache or whatever to them to keep them from growing upset, or in the case of my child, possibly frightened. I refuse to do that to my own child. I think constantly of suicide, not because I am depressed but because it's inconceivable, literally beyond my capacity for thought at all, to think of losing my lifes' work. It's not only teaching. It's my research that has suffered too. At first, I laughed about the return of the agoraphobia, thinking, "Oh good, now I can research and write." Also, my thoughts feel sped up when I do have them, and I go into these states where I'm flooded with one traumatic memory after another, all of which produce further anxiety and despair. Thus I am now bed-ridden. If I weren't an insomniac, I could look forward to sleeping, but unfortunately, there's also that to add to the fun. Right now, I feel filled with a feeling of sickness and disappointment that it's come to this. Part of that comes from not understanding what gives anyone the right to refuse to help me when in fact, they do not possess that right in any way.

So I think that's a rough approximation of what I feel like right now. It is not new. Years of journals that document these same feelings, pre-medication use. They never improved. One day, I was prescribed Xanax. I didn't think much of it. I believe it may have first been prescribed for vertigo, something that I have since the first surgery as a sad adverse but prolonged effect. Sorry to sound so maudlin, but you asked, and I assure you that I'm trying to be factually correct, not reeking of pathos. After a half-hour, I felt like I was a kid, before I was ill. I just felt like myself for the first time in nearly a decade, where I struggled through absurd numbers of unmedicated and then medicated panic attacks (the guinea pig years came with the Xanax, when I was tried on medication after medication after medication, until there weren't many left to try, and I tried to be a compliant patient as I did want help, and I'd never heard of benzos since this was "before the internet" -- I'd taken Valium though a few times for vertigo, and it works, but I didn't get high, and it made me heavy and drowsy and stupid, all of which I felt again on the Ashton taper; I hate Valium although it does stop panic disorder -- I'd say the side effects were similar to imipramine, but that it worked a lot more effectively since imipramine was one medication which I tried for a long time, and it was like nothing but a bag of side effects; I've noticed ZERO help from the SSRI's or SNRI's for my disorder and panic attacks, including for propanalol, which slows down a racing heart, but that's like a very small slice of my problems). The TCA's also don't seem to touch it.

I am considering ECT at this point as my most realistic option. Is it indicated for anxiety? I could have sworn it was. If I have to be medication free, I think that's the only way it would be possible. I've heard it help the hardest patients when I was in-patient. I'm petrified of it and would lose my cognitive abilities, which I'm not okay with, but the panicked, anxious, depressed state also has a severe cognitive loss right now.

Sorry to go off-topic. I'm trying to remember if you'd asked a question, and I'm weary now and will be going to sleep finally. I stay awake only to wait to go back to sleep -- if possible. That is how I've become. While on Xanax (or Valium), you would not know this person. I'm so different as for it to seem unthinkable. I'm energetic, happy, productive, easy-going, a hard worker, and very sharp, mentally. So if I missed anything in your post, sorry, but the feeling is unbearable, and I want to retreat to behind my eyelids again and just meditate or hopefully sleep.

 

[Mahavidya2]

The Ashton taper was sedating, and I switched at a lower rate, about half of the Valium that taper recommended, and had no side effects. I was supposed to taper across over a week or two, but I just switched, and it was fine after a few days. I didn't take any days off or anything. I never followed a strict schedule, but that hurt me at the end because I was trying to go too slowly, as per the taper's instructions, and I was already IN acute withdrawal, and a few mg's of valium were NOT going to stop that! So I quit it early, had a few more symptoms, mainly shakiness and fast pulse rate, and then it was over.

 

[birchswing]

My anxiety? How does it feel now? Terrible, but like it was before, from all that I remember. I was medicated for decades, and other than for the taper portion, which was about a year, it was always on Xanax. I was prescribed my dose, took it as prescribed, and that was that; there were no side effects or loss of strength, although a little interdose withdrawal, but nothing unmanageable. Now, I'm a shell. Let me find more universal phrasing for this. At any given time, I feel like I am going to crawl out of my own skin due to a really odd, hard-to-describe feeling, which is what I have in old journals from before medication too. It's almost painful in terms of its unremitting intensity, as though my skin were crushing me. At the same time, I feel frozen in place from the weight of this feeling. My heart does not beat rapidly but too slowly. My breathing is labored, and I know to breath carefully. My stomach gurgles and churns all the time. I am so thirsty that I could die and must drink 10-15 cups of water a day, but I'm still thirsty. My throat is tight so that I choke on my food. It doesn't seem like what I've heard anxiety described like before, exactly, because of the minimal cardiac symptoms and occasional not feeling stressed out. However, it's the same feeling that surges forth during a situational or sudden panic attack, with greater intensity, so I assume that it's adrenaline in varying degrees. I have some depersonalization with this, all of the time. The feeling is like I am out of body, observing my body instead, separately. It distorts my vision a bit though, so that it is hard to navigate through the world. Also, my voice and thoughts seem very distant and echoing. This is baseline. This is what I feel 24/7 now. Then on top of this are panic attacks, which for me strike with the rapidity of lightning. The only prodrome they have to them, which I can easily make happen by putting myself in situations that cause me to want to flee (elevators, driving in the left lane, crossing a bridge, airplanes, sitting in the center of a movie theater -- agoraphobic responses, not claustrophobic ones, and a dozen more that I could list), is a horrible and sudden tingling around the nape of my neck followed rapidly by a very serious alteration of consciousness so that I might realize I am screaming or running or trying to get out of the place. If I am in a car when this happens, and for whatever reason cannot pull over, this is when I have fainted and often convulsed, sometimes right in front of people. If I don't faint, I occasionally have tachycardia instead. I have had this thousands of times, but afterwards, if severe, I'm exhausted and need to lie down. These can never happen while teaching, so I've never taught without medication, and at most, I have a sense of being momentarily wanting to flee, and that's it. I also have associated with this agoraphobia that never lessens no matter how much I try to force myself out, and I can set my watch to feeling terribly ill at ease the moment I open the door, or in worse moments, just opening my eyes. I spent most of the day this summer lying in bed with the sheets pulled up over my face and my eyes closed, or if open, just staring at the wall. I cannot concentrate whatsoever, so I have barely read, which if you knew me, as an academic, you would find hard to believe. I do not, cannot, think when in this state. I meditate, relax, but the feeling of crawling out of my own skin doesn't leave. How do you describe what it means to want to "crawl out of your own skin?" This could mean different things to different people. It does not feel like I've drank too much coffee. It feels like I've been injected with epinephrine, tons of it, at the dentists when I've had a bad reaction to the epinephrine during a filling, but far worse. And, I am crying often, although I feel nothing other than frustrated. I'm not a person to cry, but I'm sobbing in my bed like a child due to the depths of the frustration and depression that I feel. However, my family is with me, and they find my state very troubling, so I lock the door and make excuses for why I won't come out, claiming I have a headache or whatever to them to keep them from growing upset, or in the case of my child, possibly frightened. I refuse to do that to my own child. I think constantly of suicide, not because I am depressed but because it's inconceivable, literally beyond my capacity for thought at all, to think of losing my lifes' work. It's not only teaching. It's my research that has suffered too. At first, I laughed about the return of the agoraphobia, thinking, "Oh good, now I can research and write." Also, my thoughts feel sped up when I do have them, and I go into these states where I'm flooded with one traumatic memory after another, all of which produce further anxiety and despair. Thus I am now bed-ridden. If I weren't an insomniac, I could look forward to sleeping, but unfortunately, there's also that to add to the fun. Right now, I feel filled with a feeling of sickness and disappointment that it's come to this. Part of that comes from not understanding what gives anyone the right to refuse to help me when in fact, they do not possess that right in any way.

So I think that's a rough approximation of what I feel like right now. It is not new. Years of journals that document these same feelings, pre-medication use. They never improved. One day, I was prescribed Xanax. I didn't think much of it. I believe it may have first been prescribed for vertigo, something that I have since the first surgery as a sad adverse but prolonged effect. Sorry to sound so maudlin, but you asked, and I assure you that I'm trying to be factually correct, not reeking of pathos. After a half-hour, I felt like I was a kid, before I was ill. I just felt like myself for the first time in nearly a decade, where I struggled through absurd numbers of unmedicated and then medicated panic attacks (the guinea pig years came with the Xanax, when I was tried on medication after medication after medication, until there weren't many left to try, and I tried to be a compliant patient as I did want help, and I'd never heard of benzos since this was "before the internet" -- I'd taken Valium though a few times for vertigo, and it works, but I didn't get high, and it made me heavy and drowsy and stupid, all of which I felt again on the Ashton taper; I hate Valium although it does stop panic disorder -- I'd say the side effects were similar to imipramine, but that it worked a lot more effectively since imipramine was one medication which I tried for a long time, and it was like nothing but a bag of side effects; I've noticed ZERO help from the SSRI's or SNRI's for my disorder and panic attacks, including for propanalol, which slows down a racing heart, but that's like a very small slice of my problems). The TCA's also don't seem to touch it.

I am considering ECT at this point as my most realistic option. Is it indicated for anxiety? I could have sworn it was. If I have to be medication free, I think that's the only way it would be possible. I've heard it help the hardest patients when I was in-patient. I'm petrified of it and would lose my cognitive abilities, which I'm not okay with, but the panicked, anxious, depressed state also has a severe cognitive loss right now.

Sorry to go off-topic. I'm trying to remember if you'd asked a question, and I'm weary now and will be going to sleep finally. I stay awake only to wait to go back to sleep -- if possible. That is how I've become. While on Xanax (or Valium), you would not know this person. I'm so different as for it to seem unthinkable. I'm energetic, happy, productive, easy-going, a hard worker, and very sharp, mentally. So if I missed anything in your post, sorry, but the feeling is unbearable, and I want to retreat to behind my eyelids again and just meditate or hopefully sleep.

I'm so sorry.

You deserve to be free of this suffering.

No matter how unfair it is that you are in this position, you have to take care of yourself. That has to be your only priority. I've been in places like yours, and you need to accept that you can't go through life without yourself. By that I mean, to continue on (teaching, etc.) ignoring your needs will be fruitless. At times like this, you have to stop and do whatever it takes. You can *always* start again at whatever you stop.

I've prayed a handful of times in my life. I asked my mother who is also not religious to pray for me last spring when I was in an awful state. I want to pray for you, if you would be OK with it.

Try this mantra: "There is nothing I have to do. Nowhere I have to go. Nothing I have to be. Nothing I have to change."

Be very gentle with yourself. When I've gotten into my worse states, I count everything I do as a success. Getting a cup of tea for myself is a success. Everything counts. Doesn't matter why or how you got to a place where you need to retreat and slowly build back up if it's where you are. You've suffered a trauma by being taken off this medication. It has upset your body and your ability to be the way that you were. The suffering is the beginning of finding the solution. You're already doing it. I'm not sure what the solution will be. Maybe you'll go back on benzos or maybe you'll get a new diagnosis or maybe you'll try another medication that will work. You've already been knocked down. I'm glad you were able to start the process here.

Keep me posted on what your psychiatrist says. I hope he or she really takes this seriously and can think of something for this anxiety/withdrawal (and I hate to offer my opinion but based on your symptoms it really does sound like your glutamate system is just really hyper-excitable right now). If not benzos, something like Neurontin or Lyrica is used sometimes among people in the benzo community for that.

 

[birchswing]

The Ashton taper was sedating, and I switched at a lower rate, about half of the Valium that taper recommended, and had no side effects. I was supposed to taper across over a week or two, but I just switched, and it was fine after a few days. I didn't take any days off or anything. I never followed a strict schedule, but that hurt me at the end because I was trying to go too slowly, as per the taper's instructions, and I was already IN acute withdrawal, and a few mg's of valium were NOT going to stop that! So I quit it early, had a few more symptoms, mainly shakiness and fast pulse rate, and then it was over.

It was over, but now . . .

I wouldn't discount the most obvious:
http://en.wikipedia.org/wiki/Post-acute-withdrawal_syndrome

 

[Ceke2002]

My anxiety? How does it feel now? Terrible, but like it was before, from all that I remember. I was medicated for decades, and other than for the taper portion, which was about a year, it was always on Xanax. I was prescribed my dose, took it as prescribed, and that was that; there were no side effects or loss of strength, although a little interdose withdrawal, but nothing unmanageable. Now, I'm a shell. Let me find more universal phrasing for this. At any given time, I feel like I am going to crawl out of my own skin due to a really odd, hard-to-describe feeling, which is what I have in old journals from before medication too. It's almost painful in terms of its unremitting intensity, as though my skin were crushing me. At the same time, I feel frozen in place from the weight of this feeling. My heart does not beat rapidly but too slowly. My breathing is labored, and I know to breath carefully. My stomach gurgles and churns all the time. I am so thirsty that I could die and must drink 10-15 cups of water a day, but I'm still thirsty. My throat is tight so that I choke on my food. It doesn't seem like what I've heard anxiety described like before, exactly, because of the minimal cardiac symptoms and occasional not feeling stressed out. However, it's the same feeling that surges forth during a situational or sudden panic attack, with greater intensity, so I assume that it's adrenaline in varying degrees. I have some depersonalization with this, all of the time. The feeling is like I am out of body, observing my body instead, separately. It distorts my vision a bit though, so that it is hard to navigate through the world. Also, my voice and thoughts seem very distant and echoing. This is baseline. This is what I feel 24/7 now. Then on top of this are panic attacks, which for me strike with the rapidity of lightning. The only prodrome they have to them, which I can easily make happen by putting myself in situations that cause me to want to flee (elevators, driving in the left lane, crossing a bridge, airplanes, sitting in the center of a movie theater -- agoraphobic responses, not claustrophobic ones, and a dozen more that I could list), is a horrible and sudden tingling around the nape of my neck followed rapidly by a very serious alteration of consciousness so that I might realize I am screaming or running or trying to get out of the place. If I am in a car when this happens, and for whatever reason cannot pull over, this is when I have fainted and often convulsed, sometimes right in front of people. If I don't faint, I occasionally have tachycardia instead. I have had this thousands of times, but afterwards, if severe, I'm exhausted and need to lie down. These can never happen while teaching, so I've never taught without medication, and at most, I have a sense of being momentarily wanting to flee, and that's it. I also have associated with this agoraphobia that never lessens no matter how much I try to force myself out, and I can set my watch to feeling terribly ill at ease the moment I open the door, or in worse moments, just opening my eyes. I spent most of the day this summer lying in bed with the sheets pulled up over my face and my eyes closed, or if open, just staring at the wall. I cannot concentrate whatsoever, so I have barely read, which if you knew me, as an academic, you would find hard to believe. I do not, cannot, think when in this state. I meditate, relax, but the feeling of crawling out of my own skin doesn't leave. How do you describe what it means to want to "crawl out of your own skin?" This could mean different things to different people. It does not feel like I've drank too much coffee. It feels like I've been injected with epinephrine, tons of it, at the dentists when I've had a bad reaction to the epinephrine during a filling, but far worse. And, I am crying often, although I feel nothing other than frustrated. I'm not a person to cry, but I'm sobbing in my bed like a child due to the depths of the frustration and depression that I feel. However, my family is with me, and they find my state very troubling, so I lock the door and make excuses for why I won't come out, claiming I have a headache or whatever to them to keep them from growing upset, or in the case of my child, possibly frightened. I refuse to do that to my own child. I think constantly of suicide, not because I am depressed but because it's inconceivable, literally beyond my capacity for thought at all, to think of losing my lifes' work. It's not only teaching. It's my research that has suffered too. At first, I laughed about the return of the agoraphobia, thinking, "Oh good, now I can research and write." Also, my thoughts feel sped up when I do have them, and I go into these states where I'm flooded with one traumatic memory after another, all of which produce further anxiety and despair. Thus I am now bed-ridden. If I weren't an insomniac, I could look forward to sleeping, but unfortunately, there's also that to add to the fun. Right now, I feel filled with a feeling of sickness and disappointment that it's come to this. Part of that comes from not understanding what gives anyone the right to refuse to help me when in fact, they do not possess that right in any way.

So I think that's a rough approximation of what I feel like right now. It is not new. Years of journals that document these same feelings, pre-medication use. They never improved. One day, I was prescribed Xanax. I didn't think much of it. I believe it may have first been prescribed for vertigo, something that I have since the first surgery as a sad adverse but prolonged effect. Sorry to sound so maudlin, but you asked, and I assure you that I'm trying to be factually correct, not reeking of pathos. After a half-hour, I felt like I was a kid, before I was ill. I just felt like myself for the first time in nearly a decade, where I struggled through absurd numbers of unmedicated and then medicated panic attacks (the guinea pig years came with the Xanax, when I was tried on medication after medication after medication, until there weren't many left to try, and I tried to be a compliant patient as I did want help, and I'd never heard of benzos since this was "before the internet" -- I'd taken Valium though a few times for vertigo, and it works, but I didn't get high, and it made me heavy and drowsy and stupid, all of which I felt again on the Ashton taper; I hate Valium although it does stop panic disorder -- I'd say the side effects were similar to imipramine, but that it worked a lot more effectively since imipramine was one medication which I tried for a long time, and it was like nothing but a bag of side effects; I've noticed ZERO help from the SSRI's or SNRI's for my disorder and panic attacks, including for propanalol, which slows down a racing heart, but that's like a very small slice of my problems). The TCA's also don't seem to touch it.

I am considering ECT at this point as my most realistic option. Is it indicated for anxiety? I could have sworn it was. If I have to be medication free, I think that's the only way it would be possible. I've heard it help the hardest patients when I was in-patient. I'm petrified of it and would lose my cognitive abilities, which I'm not okay with, but the panicked, anxious, depressed state also has a severe cognitive loss right now.

Sorry to go off-topic. I'm trying to remember if you'd asked a question, and I'm weary now and will be going to sleep finally. I stay awake only to wait to go back to sleep -- if possible. That is how I've become. While on Xanax (or Valium), you would not know this person. I'm so different as for it to seem unthinkable. I'm energetic, happy, productive, easy-going, a hard worker, and very sharp, mentally. So if I missed anything in your post, sorry, but the feeling is unbearable, and I want to retreat to behind my eyelids again and just meditate or hopefully sleep.

You said you tried Cognitive Behavioural Therapy before? Is that correct? Have you tried other forms of therapy, such as Dialetical Behavioural Therapy?

 

[splik]

Also, it's unethical to not give a consenting adult a legal medication if he or she wants that medication.

You must realize just how preposterous this is. It is unethical to withhold antibiotics from patients without bacterial infection? It is unethical to not prescribe morphine to patients who asks for it? Is it unethical to not prescribe stimulants to college students who want something to help improve their performance in exams? It is unethical to not prescribe antidepressants to patients where there is no indication? Is it unethical to not prescribe NSAIDS to a patient with peptic ulcer disease? It is unethical to not prescribe thyroxine to patient who believes they have hypothyroidism despite normal lab values? Is it unethical to not prescribe tamoxifen to a body builder who is using steroids? Is it unethical to not prescribe anticonvulsants to patient with non-epileptic attacks? Is it unethical to not prescribe IVIG to a patient with functional weakness who wants it?

Being a good psychiatrist/physician has a lot to do with being able to say "no" which a lot of people find incredibly hard.

I work with a very "challenging" patients, that most people do not want to or will not work with. However if a patient were to tell me that it was unethical for me to not prescribe them something, they would swiftly be told they need to find a new doctor.

 

[Ceke2002]

Is it unethical to not prescribe anticonvulsants to patient with non-epileptic attacks?

Assuming the non-epileptic attacks are somatoform in nature, wouldn't doing so reinforce the somatization?

 

[birchswing]

You must realize just how preposterous this is. It is unethical to withhold antibiotics from patients without bacterial infection? It is unethical to not prescribe morphine to patients who asks for it? Is it unethical to not prescribe stimulants to college students who want something to help improve their performance in exams? It is unethical to not prescribe antidepressants to patients where there is no indication? Is it unethical to not prescribe NSAIDS to a patient with peptic ulcer disease? It is unethical to not prescribe thyroxine to patient who believes they have hypothyroidism despite normal lab values? Is it unethical to not prescribe tamoxifen to a body builder who is using steroids? Is it unethical to not prescribe anticonvulsants to patient with non-epileptic attacks? Is it unethical to not prescribe IVIG to a patient with functional weakness who wants it?

Being a good psychiatrist/physician has a lot to do with being able to say "no" which a lot of people find incredibly hard.

I work with a very "challenging" patients, that most people do not want to or will not work with. However if a patient were to tell me that it was unethical for me to not prescribe them something, they would swiftly be told they need to find a new doctor.

I think that he/she misspoke, when they clearly wrote before about deferring to medical expertise. It wasn't in line with the rest of what they were writing and I think the person is in a fragile place. Brain fog can be a bitch.

Having said that, if someone were to say to you, why be reactive? I don't see how it benefits the patient for you to present as upset and go from 0 to termination. It's an expression of frustration; I wouldn't take it literally. Even if it were a philosophical debate (which I don't think it is), I don't see the big deal in saying it. It's a way of saying "I'm upset." I'm sure you've seen that many, many times.

 

[splik]

I think that he/she misspoke, when they clearly wrote before about deferring to medical expertise. It wasn't in line with the rest of what they were writing and I think the person is in a fragile place. Brain fog can be a bitch.

Having said that, if someone were to say to you, why be reactive? I don't see how it benefits the patient for you to present as upset and go from 0 to termination. It's an expression of frustration; I wouldn't take it literally. Even if it were a philosophical debate (which I don't think it is), I don't see the big deal in saying it. It's a way of saying "I'm upset." I'm sure you've seen that many, many times.

People say things they don't mean. That's fine, then they will recant. But if a patient really believes that my care is unethical I don't see how I could continue working with them as there is no alliance+, and no trust. I have been in this situation before. In which case I will say "It sounds like I'm not the right doctor for you. I really want to work with you*, but it seems like I can't provide you with the care that you want." In this situation the patient will either apologize and say "I'm sorry, I'm just really frustrated and didn't think you were taking me seriously" and we'll work it out (and will need education/confrontation about how this is not a good way of getting their needs met) or they will agree and we will part ways. It's certainly not being reactive. But it is about setting limits and realizing that sometimes when there is narrative incommensurability between doctor and patient that is not going to be resolved, it may be best to part ways. I am very flexible but it is important to have limits on what is and what isn't acceptable.

+also mindful there are some patients where there is no possibility of a therapeutic alliance anyway and this might not be relevent (e.g. manic pts, decompensated borderline pts)
*I won't say this bit if I don't, however. It sounds terrible but there are some patients I actually celebrated their departure because of how stressful it work to work with them.

 

[Shikima]

After further thought about the geographic issue, I now wonder if the issue to prefer, or to not prefer, benzodiazepines varies with political party or views? I wonder this because I know that psychiatrists in my area -- who are reluctant to prescribe benzodiazepines -- are strongly liberal. My entire area is highly and almost homogeneously liberal, which should be relatively evident from my earlier posts about pet therapy. In no way am I maligning liberal politics, however, since I'm pretty typically liberal myself, like so many other academics.

Is there any correlation possible here?

I can imagine that on the far-right side of things, benzodiazepines might be disliked for other reasons like believing in the Power of God, etc. I see that skew in the self-help section of my local bookstore, where there's a Venn Diagram of overlap between the far right and far left when it comes to a suspicion towards psychiatric medications as well as a desire for "purity" of some ineffable sort.

I'm trying to reason why in Southern Virginia, and apparently in other parts of the country, most of which strike me as more conservative than here, it's "common" to give out benzodiazepines when in my own life, I've never seen this and have always encountered a brisk reflex against them, with a much stronger interest in other, alternative forms of therapy, some of which are truly dubious.

No. You just happen to live in that part of the country where psychiatrists are typically liberal. You're likely on the one of the 2 coasts.

 

[whopper]

"Congratulations, doctor, you have created an addict" could be easily remedied by carefully explaining to all patients that they will experience a discontinuation syndrome?

I didn't read all of the very thoughtful posts above but I will simplify it as much as a I can.

Patient are very heterogeneous, doctors are too. I compare it Aristitotelean ethics. He was the first philosopher to push the idea that ethical worth is highly dependent on the set of variables going on. Killing someone in self-defense is acceptable but doing so for self-gain is horrendous. It led to the legal standard of mens rea.

From personal experience I've noticed people with lower IQs, frustration tolerance, education, and more impulsivity cannot be trusted with benzos. This often times translates to people that are outside the lower middle class to upper middle class-a demographic where people are usually working and have people to answer to if they get out of line.

I've also noticed that psychiatrists get locked into one job, spend years on it, and think what they do applies to all of psychiatry. It doesn't. I've done inpatient forensic, community, inpatient in a down-town, inpatient in a high-end private facility, emergency psych, buprenorphine provider, private practice, community inpatient, outpatient for people on the very bottom to the very top (had an Olympic athlete, a hedge fund manager, the son of a former CEO of a name-brand publicly traded corporation) and each type presents with different challenges.

In some cases I'm more open to giving a benzo, in others where there is someone with the same exact diagnosis I'm upset with other clinicians for giving them out.

The bottom line response I'm giving is this.

There are demographics where the bulks of them will not give a damn of the future consequences of the medication you offer.

One cannot simply say to themselves "if they become an addict it's their fault not mine cause I warned them." Many docs don't even give the warning despite being mandated by law to do so; many patients end up selling the stuff causing harm to others, as a physician we have a responsibility to recommend some meds and refrain from others based on the benefit/risk ratio. Assuming that someone is going to have the intellectual and emotional maturity to handle a controlled substance by simply educating the person flies in the face of common sense and known science. Everyone knows cocaine is bad for you, how many people still abuse it?

Many patients I've had that I placed on benzos back in my lesser experienced years, even if they got better with an SSRI, when I told them it was time to wean them off the benzo would start screaming at me telling me they enjoy the use of it and that this was proof it was good for them. It even got to the point in some cases where security had to be called in and some of my colleagues have received death threats.

I mentioned this before but I used to do private practice and out of a few hundred patients only about 1-2% were on chronic benzos outside of the panic disorder patients where I gave them small amounts (e.g. 4 pills of Ativan 1 mg a month) after they were maximized on an SSRI or SNRI, B-blocker, and buspirone.

 

[whopper]

IMHO here are some appropriate uses of a benzo.
One-time dosage if the person is going to go through a very phobic event. E.g. MRI scan, plane flight.
Short-term (a few days) dosing if the person experienced an extremely traumatic episode OUTSIDE THEIR CONTROL. E.g. person was hit by a drunk driver and their family was killed but they're going to survive.
Agitation in an inpatient setting but this usually should only be given with an antipsychotic. Giving out benzos only for agitation from my experience prompts some people to intentionally become violent so they could get another hit of Ativan.

Here's where it becomes more grey
1-Bridge treatment: give the person a benzo and start an SSRI. When SSRI starts working, get them off of benzo. Works good in theory, but 30% of the time SSRIs don't work (for depression, I haven't seen this gauged for anxiety). Another problem is I've seen some people freak out when you tell them you will stop the benzo. Freak out to the point where they could become violent.
2-Chronic treatment if only in limited amounts. E.g. a few pills a month. At this rate they most definitely will not become addicts of physiologically dependent. A problem, however, is this could put the patient in a comfort zone where they now don't feel a need to further reduce their problems through non-pharmacological methods. Unfortunately the majority of patients I have, when stabilized, and with a disorder where psychotherapy could get them off their meds in the future do not want to further work on it through psychotherapy or other means.
3-Patient is older and has been on a benzo for years, possibly decades. When exactly should we tell them to stop? IF the person is dying and has a few months left of life, I think all of us would agree to continue the benzo, but what about someone in their late 70s?

 

[birchswing]

People say things they don't mean. That's fine, then they will recant. But if a patient really believes that my care is unethical I don't see how I could continue working with them as there is no alliance+, and no trust. I have been in this situation before. In which case I will say "It sounds like I'm not the right doctor for you. I really want to work with you*, but it seems like I can't provide you with the care that you want." In this situation the patient will either apologize and say "I'm sorry, I'm just really frustrated and didn't think you were taking me seriously" and we'll work it out (and will need education/confrontation about how this is not a good way of getting their needs met) or they will agree and we will part ways. It's certainly not being reactive. But it is about setting limits and realizing that sometimes when there is narrative incommensurability between doctor and patient that is not going to be resolved, it may be best to part ways. I am very flexible but it is important to have limits on what is and what isn't acceptable.

+also mindful there are some patients where there is no possibility of a therapeutic alliance anyway and this might not be relevent (e.g. manic pts, decompensated borderline pts)
*I won't say this bit if I don't, however. It sounds terrible but there are some patients I actually celebrated their departure because of how stressful it work to work with them.

I felt bad after writing what I did thinking maybe I was too blunt. If so, I apologize. I am very empathetic to what it must be like to be in acute withdrawal and saying things you wouldn't otherwise. If a person legitimately thought you were unethical, I can see your point of view. It didn't really cross my mind that someone would feel that way from a rational place, when to me the desperation feels palpable, at least in my imagining of everything being discussed.

 

[Mahavidya2]

I felt bad after writing what I did thinking maybe I was too blunt. If so, I apologize. I am very empathetic to what it must be like to be in acute withdrawal and saying things you wouldn't otherwise. If a person legitimately thought you were unethical, I can see your point of view. It didn't really cross my mind that someone would feel that way from a rational place, when to me the desperation feels palpable, at least in my imagining of everything being discussed.

I never said that I thought anyone was unethical. My comment was completely decontextualized. My major premise was left out here, although it was stated in my original comment and also cited using links to support for these statements in this thread, which was that it was *conditionally* unethical, and the argument that I made was 100% based on said conditions (which the poster left out in his paraphrase of my point): It is unethical to not prescribe a legal substance to someone who is a consenting adult if they want to be treated with that substance (missing premise), and that substance has been proven to be an effective treatment option, (missing premise) and that consenting adult has a condition which can be treated by that effective treatment option.

Conclusion: It is unethical to not prescribe a legal substance to someone who is a consenting adult, which should be defined as it is legally, which includes that a person is, at the time of giving consent, of sound mind and is educated, or able to be educated, to a sufficient degree about the medication he or she is taking, and that person wants to be treated with that substance.

Major premise: Because that substance has been proven to be an effective treatment option.
And: because that person has the correct medical disorder for treatment with this substance.
And: because to not treat this person, in this context, would be a violation of that person's right to give informed consent.

Which part of this is either offensive or incorrect? I'm happy to revise my very provisional statement if there are problems with my argument; I would be remiss not to do so.

You're a nice person, from all that I can see at this point. I wanted to commend you for your compassion towards people. You're right that I've been having a hard time. It has been psychologically excruciating for me. Do I feel vulnerable? You brought that up. Yes, I do feel an unusual degree of vulnerability right now. However, I had provided every bit of that statement throughout this thread, with links, and some in the post itself, and I have no idea why what I said elicited the response that it did because it does not seem to me to be like a controversial thing to posit.

 

[Mahavidya2]

IMHO here are some appropriate uses of a benzo.
One-time dosage if the person is going to go through a very phobic event. E.g. MRI scan, plane flight.
Short-term (a few days) dosing if the person experienced an extremely traumatic episode OUTSIDE THEIR CONTROL. E.g. person was hit by a drunk driver and their family was killed but they're going to survive.
Agitation in an inpatient setting but this usually should only be given with an antipsychotic. Giving out benzos only for agitation from my experience prompts some people to intentionally become violent so they could get another hit of Ativan.

Here's where it becomes more grey
1-Bridge treatment: give the person a benzo and start an SSRI. When SSRI starts working, get them off of benzo. Works good in theory, but 30% of the time SSRIs don't work (for depression, I haven't seen this gauged for anxiety). Another problem is I've seen some people freak out when you tell them you will stop the benzo. Freak out to the point where they could become violent.
2-Chronic treatment if only in limited amounts. E.g. a few pills a month. At this rate they most definitely will not become addicts of physiologically dependent. A problem, however, is this could put the patient in a comfort zone where they now don't feel a need to further reduce their problems through non-pharmacological methods. Unfortunately the majority of patients I have, when stabilized, and with a disorder where psychotherapy could get them off their meds in the future do not want to further work on it through psychotherapy or other means.
3-Patient is older and has been on a benzo for years, possibly decades. When exactly should we tell them to stop? IF the person is dying and has a few months left of life, I think all of us would agree to continue the benzo, but what about someone in their late 70s?

Whopper, this is a very reasonable hierarchy. I think I fit into your grey-zone, items #2 and #3, although I seem to not respond to other medication despite serious attempts to do so, and I am only middle-aged and not dying.

What do you do with a middle-aged person in situation #3 who has a poor quality of life prior to benzodiazepine use followed by a highly successful quality of life after treatment followed by a poor quality of life again after discontinuation of the medication? And no, I'm not asking you for medical advice. It's what my psychiatrist had to reason through today, and I commend him because he decided that, despite being completely opposed to benzodiazepines, my situation had grown too dysfunctional, and he would like me to try a low daily dose of klonopin (.5 or 1 mg, depending on which I respond to), which I've never taken before. He said he was more comfortable with this benzodiazepine since it is often used for epilepsy as well as tapers. We discussed the "stigma" of taking benzodiazepines, and he felt that he had been prone to acting based on this, he admitted, because most of his patients seemed to be trying to discontinue medication. I'm on one of "the coasts," as someone above noted (geographic attitudes, as I suspected at first). He reflected on the many years that I've been his patient, the medications which I'd already tried, what was still available to try that could work, the voluntary in-patient diagnosis that I'd undergone, the success I've had in my life, and the state I was currently in, as well as what I stood to further lose and how realistic that was, and I watched him carefully think about all of it at length. I have not yet tried the klonopin and am intending to see if my problems don't first improve a bit more, but he did not think this was a withdrawal but a return of my original problems coupled with a reactive depression.

He said, point-blank, that he had noticed no adverse effects from taking benzodiazepines and little tolerance and no abuse potential in my case, and that this was not in line with the research, but it was definitely my situation nevertheless. He began to wonder if the literature had not accounted for cases like mine, which must not be specific only to me. It was a truly good conversation.

 

[smalltownpsych]

Whopper, this is a very reasonable hierarchy. I think I fit into your grey-zone, items #2 and #3, although I seem to not respond to other medication despite serious attempts to do so, and I am only middle-aged and not dying.

What do you do with a middle-aged person in situation #3 who has a poor quality of life prior to benzodiazepine use followed by a highly successful quality of life after treatment followed by a poor quality of life again after discontinuation of the medication? And no, I'm not asking you for medical advice. It's what my psychiatrist had to reason through today, and I commend him because he decided that, despite being completely opposed to benzodiazepines, my situation had grown too dysfunctional, and he would like me to try a low daily dose of klonopin (.5 or 1 mg, depending on which I respond to), which I've never taken before. He said he was more comfortable with this benzodiazepine since it is often used for epilepsy as well as tapers. We discussed the "stigma" of taking benzodiazepines, and he felt that he had been prone to acting based on this, he admitted, because most of his patients seemed to be trying to discontinue medication. I'm on one of "the coasts," as someone above noted (geographic attitudes, as I suspected at first). He reflected on the many years that I've been his patient, the medications which I'd already tried, what was still available to try that could work, the voluntary in-patient diagnosis that I'd undergone, the success I've had in my life, and the state I was currently in, as well as what I stood to further lose and how realistic that was, and I watched him carefully think about all of it at length. I have not yet tried the klonopin and am intending to see if my problems don't first improve a bit more, but he did not think this was a withdrawal but a return of my original problems coupled with a reactive depression.

He said, point-blank, that he had noticed no adverse effects from taking benzodiazepines and little tolerance and no abuse potential in my case, and that this was not in line with the research, but it was definitely my situation nevertheless. He began to wonder if the literature had not accounted for cases like mine, which must not be specific only to me. It was a truly good conversation.

One thing about research, especially in psychology since we are often dealing with intangible constructs like anxiety, is that we deal in probabilities and improvement compared to placebo effect. One psychiatrist during my training made a slightly tongue in cheek joke during our journal club about doubling the dose of placebo and how that would probably be even more effective than depakote or lithium for bipolar disorder. In other words, about 20% of patients responded well to placebo and 30% responded well to the treatment condition. We also see the law of thirds quite a bit in this field, 1/3 get no benefit from med, 1/3 get some benefit, and 1/3 it really works. The research is pretty solid that many people get a benefit from benzos and for many people this can lead to addiction. It also points to the fact that for many people the anxiety will get worse with benzo only therapy and their tolerance will increase so they will need more and more. These two groups of people are the focus of most in the field. It is also difficult to conduct any further research on this because of the risks involved to those two groups. Especially since we don't know how to identify these two groups although addiction history can help rule out the first if we have that info.

On another note, I really appreciate the logical argument dissection. Reminded me of one of my favorite undergrad classes, Intro to Logic, that has served me very well in my development as a psychologist. Another great class I took was Bioethics and this would have been a great discussion to have in there, as well.

 

[Mahavidya2]

smalltownpsych, putting an argument into standard form, or in this case, a really loose standard form, is extremely useful to make an argument more clear as well as to minimize bias and help everyone return to the point. Intro to Logic is always a good class, although tough for undergraduates, so hats off to you for embracing it! Usually, the pre-medical, math, bio, chem, computer science, and engineering students take this, and the Humanities students take general critical thinking (although I think both should be required for any real university education). Bioethics is of deep interest to me as well, although my focus on it has been far more generalized than the kinds of topics we're discussing. After this whole dialogue, I actually think maybe it would be a fabulous class to teach since clearly it is filled with a rich set of perspectives, and I can imagine some really strong guest-speaker potential and excellent, passionate debates. I would imagine that there are rich readings on this too in a variety of disciplines.

 

[hamstergang]

My comment was completely decontextualized. My major premise was left out here, although it was stated in my original comment and also cited using links

The problem is that your posts are, for a forum, monstrous in size. So if someone reads part of your post and thinks it's wrong, they're very unlikely to spend the time going through your previous posts to be sure they have the context correct.

The key to communicating effectively in an online forum such as this is brevity. A few short paragraphs is about all that's considered readable. Beyond that, you severely limit the number of people that will actually read all you write.

Actually, short paragraphs are the real key. You can have a good number of them before most people give up. But long paragraphs, even just one, make the eyes glaze over.

 

[Mahavidya2]

My apologies. I am far more used to writing for academics. Code-switch. Got it. I can do that.

 

[birchswing]

My apologies. I am far more used to writing for academics. Code-switch. Got it. I can do that.

As a student, code-switch to writing in simpler language in academia as well.

Some of the books I've labored through . . .

Going from a community college to a fairly prestigious university, I've noticed that the subject material isn't inherently more difficult—it's just harder to know what it is because it's seemingly obfuscated behind a lot of redundant words (particularly in my international relations courses; linguistics had by far the most accessible textbook I've ever used, which makes sense given the field).

 

[Mahavidya2]

Ahaha… I read Michel Serres in the original French and Deleuze and Guattari's A Thousand Plateaus to help my mind feel at ease for sleep. By "academic," I meant my colleagues, not my students, of course. I'm sensitive to how diverse their backgrounds are, and with that, their reading skills. Linguists are some of the weirdest people I've met, bar none. I like them though. I took some Linguistics courses as an early graduate student and found the ideas interesting, but limiting in their scope, with these totalizing views of language that were overly rigid. Thus said, I really appreciate the academic (not do-much political) writings of George Lakoff.

By "obfuscated behind a lot of redundant words," do you mean how your teachers spoke, or the texts you were asked to read? I wish two things: 1.) students read more carefully and critically, in general, and 2.) professors considered their audience a little more.

 

[whopper]

What do you do with a middle-aged person in situation #3 who has a poor quality of life prior to benzodiazepine use followed by a highly successful quality of life after treatment followed by a poor quality of life again after discontinuation of the medication?

If the dosage is anything above low and it's daily I'd recommend lowering it. If the patient is trustworthy (e.g. never called up saying they lost their meds, showed a good level of compliance and honesty), I'd be very open to slowly lowering the dosage over the course of several months, even a few years depending on how high the dosage is, and long they were on it.

If a patient is on a daily dosage of a benzo that is low (E.g. clonazepam less than 2 mg a day) I'd still recommend the patient get off the medication but I wouldn't be adamant about it in some situations, but would be in others. E.g. if the patient never even tried an SSRI for anxiety, what justifies a controlled substance that is not to be considered a first-line treatment?-I'd tell them we'll start an SSRI and if it works we'll wean them off the benzo. If they refuse the SSRI I think I would strongly consider putting a stop-gap on the benzo but how fast would depend on several factors.

A problem with the above is with impulsive patients (less education, less frustration tolerance) I've noticed many of them say the SSRI doesn't work in an amount that doesn't match the science or what I see in non-impulsive patients. Further many have a cluster B personality disorder where they will experience impulsivity and acute anxiety chronically for years that isn't improved much (usually not at all) with any pharmacotherapy other than benzos and could actually sabotage psychotherapy because the person then relies on the benzo instead of psychotherapy. ("Why should I go to a DBT therapist!?!?! This Xanax works great for me!")

 

[whopper]

From personal experience I've noticed people with lower IQs, frustration tolerance, education, and more impulsivity cannot be trusted with benzos. This often times translates to people that are (edit-outside the) lower middle class to upper middle class. It hardly ever translates to lower class or upper class. (edit-actually meant the impulsive types tend to be lower and upper class).

Major premise: Because that substance has been proven to be an effective treatment option.
And: because that person has the correct medical disorder for treatment with this substance.
And: because to not treat this person, in this context, would be a violation of that person's right to give informed consent.

This is getting back to the libertarian argument I mentioned above. If we simply codified our practice to this model, I'd be giving out benzos to about 75% of my patients, many of whom would be abusing it.

We can't simply give out guns, cars, alcohol, what have you to anyone so long as they gave informed consent. Almost of my patients I mentioned in my "impulsive model" would've had informed consent had I given to them and almost none of them would've used it appropriately. The problem also just isn't suffered by the patient-they could, for example, run over a kid because they were intoxicated while using a benzo. I have more responsibilities required than the patient's simple informed consent. An alcoholic that drinks has the capacity to drink and understand the risks but I don't have to be the guy that sells him the bottle of Jack Daniels and my professional ethical requirements are such that I shouldn't be doing so.

 

[Mahavidya2]

This is getting back to the libertarian argument I mentioned above. If we simply codified our practice to this model, I'd be giving out benzos to about 75% of my patients, many of whom would be abusing it.

We can't simply give out guns, cars, alcohol, what have you to anyone so long as they gave informed consent. Almost of my patients I mentioned in my "impulsive model" would've had informed consent had I given to them and almost none of them would've used it appropriately. The problem also just isn't suffered by the patient-they could, for example, run over a kid because they were intoxicated while using a benzo. I have more responsibilities required than the patient's simple informed consent. An alcoholic that drinks has the capacity to drink and understand the risks but I don't have to be the guy that sells him the bottle of Jack Daniels and my professional ethical requirements are such that I shouldn't be doing so.

Respectfully, I disagree with you. You're basing this on the assumption that benzodiazepines are so "intoxicating" that they can cause people to harm others because they impair motor skills. I'm unclear how this is true at therapeutic dosages in people who take them regularly and know their responses to them. If I take 2 mg xanax, no one has ever noticed any motor impairments including me. I've hiked ten miles on that dose several times. However, if I drink, I'm falling down. There's no analogy to be made here and no reason for this assumption. While I see some research showing that older people have more traffic accidents on benzos, isn't it true that older people generally have more traffic accidents? I see no literature that there are increased traffic accidents from therapeutic-range benzos used by non-elderly, non-polypharmacy, when used orally.

I'm only middle-aged. Also, my geographic location, which today, I realized really is a strange place since I got out for about two hours today and saw at least four people openly smoking pot. I haven't yet picked up the new prescription from the pharmacy and am very much debating whether or not to resume taking benzodiazepines or not, mainly because at this point, I'm terrified of how stigmatized the meds are, which I find ironic considering that marijuana is perfectly legal here.

I'm not a libertarian in the least. But to return to false analogies, guns, cars, and alcohol all are legal and really wide-spread? I don't see the connection there.

 

[smalltownpsych]

Respectfully, I disagree with you. You're basing this on the assumption that benzodiazepines are so "intoxicating" that they can cause people to harm others because they impair motor skills. I'm unclear how this is true at therapeutic dosages in people who take them regularly and know their responses to them. If I take 2 mg xanax, no one has ever noticed any motor impairments including me. I've hiked ten miles on that dose several times. However, if I drink, I'm falling down. There's no analogy to be made here and no reason for this assumption. While I see some research showing that older people have more traffic accidents on benzos, isn't it true that older people generally have more traffic accidents? I see no literature that there are increased traffic accidents from therapeutic-range benzos used by non-elderly, non-polypharmacy, when used orally.

I'm only middle-aged. Also, my geographic location, which today, I realized really is a strange place since I got out for about two hours today and saw at least four people openly smoking pot. I haven't yet picked up the new prescription from the pharmacy and am very much debating whether or not to resume taking benzodiazepines or not, mainly because at this point, I'm terrified of how stigmatized the meds are, which I find ironic considering that marijuana is perfectly legal here.

I'm not a libertarian in the least. But to return to false analogies, guns, cars, and alcohol all are legal and really wide-spread? I don't see the connection there.

I think part of the difficulty that you are having in this debate is that you are basing your argument on your own personal experience, whereas the psychiatrists are basing their thinking on the majority of patients that they treat. They are also making their treatment decisions based on a fairly straightforward risk/benefit analysis. These medications have been demonstrated by both research and our observations to cause significant problems for many people who take them. Research has also shown that they are most beneficial for short-term treatment and that exposure therapy is more effective for treating anxiety. I have given lectures explaining why this is in my intro to psych class where I use M & M's as a prop for the benzos. In brief, the treatment for anxiety is gradual exposure to the fear stimulus while avoiding the fear response. Taking a medication also prevents the fear response but this does not seem to be effective in the long term and for many people it increases the fear response. ETOH has been the front line treatment of choice for these issues for millenia and it can work for years, even decades, but when it stops working well, look out. I have seen this dynamic play out with high-functioning combat vets from Vietnam. 40 years of accomplishing things and using ETOH to manage the symptoms and it worked - until it didn't anymore.

 

[Shikima]

Benzos = ETOH. You can work on 2mg of Xanax a day because of habituation. An alcoholic on the line at GM can also do his/her job while being inebriated because they need that persistent level of ETOH in their system or else suffer significant psychological/physiological consequences.

The bottom line, You haven't learned any other coping mechanisms. You can argue any other point, we aren't treating you, and a lot of evidence has been provided. But again, you don't want to hear this and will keep arguing your point over and over using anecdotal evidence.

 

[Mahavidya2]

No, I'm not basing it on my personal experience, although I used my experience as an anecdote. As stated, I could find nothing in the research to support benzodiazepines causing more motor impairment than dozens of medications that are given out frequently, some over the counter, such as antihistamines, antipsychotics, anticonvulsants, antidepressants, mood stabilizers, cardiac medication, some cold medicines like Nyquil, motion sickness medication, ADHD medications, and narcotic pain medication. Singling out one class of medication is inappropriate when the literature doesn't reflect this as a cause for concern, especially when a recent large-scale research studies of 1,558 traffic accidents ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256838/ ) show that "for the youngest drivers, the most prevalent drugs (for injured drivers) included antidepressants/antipsychotics (14.0%), and narcotics analgesics (10.4%). For drivers aged at least 45 years and older, the highest prevalence was for cardiovascular agents (50.7%), antidepressants/antipsychotics (33.3%), and NSAIDS (26.4%)." Benzodiazepines aren't listed as a concern compared with antidepressants or antipsychotics, and when has anyone said people should not be given elavil, doxepin, remeron, or trazadone because they won't be able to drive and will kill people on the road? That seems to be of low concern. Why, considering these medications are cited as having much higher crash risks?

Antidepressant users seem to have an increased risk of traffic accidents, but they've not been singled out here: http://www.ncbi.nlm.nih.gov/pubmed/22967773

Used as a monotherapy, alprazolam did not correlate with a higher degree of traffic fatalities in this study: http://www.ncbi.nlm.nih.gov/pubmed/23257168 and monotherapy again is cited as not significant in causing traffic accidents in this 2012 study: http://www.ncbi.nlm.nih.gov/pubmed/22943663 (whereas alcohol clearly is a problem). This 2008 study says that "Drivers taking short half-life benzodiazepines did not demonstrate increased odds compared to drivers not using benzodiazepines." http://www.ncbi.nlm.nih.gov/pubmed/18836950 -- That may be an argument in favor of Xanax and Ativan over Klonopin and Valium. Either way, in all of the studies, provided that a driver isn't 1.) elderly and 2.) on multiple medications, there's little evidence that benzodiazepines cause traffic accidents. Also, other medications seem to do that.

Shikima, to return to my anecdote, I never habituated to benzodiazepines. I started at the dose that I ultimately took for many years. If you want evidence, we can look at it together. I've provided a lot in the links throughout my comments, including this one. And yes, I have learned other coping mechanisms seeing as I did CBT (not useful) and biofeedback (pretty useful), plus I meditate regularly (somewhat useful). Also, exposure therapy for agoraphobia, begun yesterday, is useful. All useful though are still of limited use. Just because you wish to indict me doesn't mean you should. If you are looking at contradictory research, by all means, provide it.

 

[Shikima]

Look at the mechanism of action. That's all that's needed.... and clearly, your skill set is much different to where you haven't experienced people presenting in an acute state of intoxication from BZD use. I'd offer that you find talk therapy of limited value because you really don't want to do it, and that's ok; Just admit it.

Ultimately, what are you wanting from continuing to argue with people, in a forum, who are *NOT* treating you? What's your end game?

 

[Mahavidya2]

The irony of course is that more panic disorder patients wind up being housebound agoraphobics and don't drive anywhere...

Look at the mechanism of action. That's all that's needed.... and clearly, your skill set is much different to where you haven't experienced people presenting in an acute state of intoxication from BZD use. I'd offer that you find talk therapy of limited value because you really don't want to do it, and that's ok; Just admit it.

Ultimately, what are you wanting from continuing to argue with people, in a forum, who are *NOT* treating you? What's your end game?

You read too much into me. I stated my "end game" in my first post: to offer a counter perspective to birchswing's from the perspective of another person who had been on long-term benzodiazepines (now off them). Also, to figure out whether my psychiatrist had good reason for discontinuing benzodiazepines in my case. Also, I'm not "arguing." I am having a dialogue, to the best of my knowledge. I've stated that I am an academic, and this is how academics discuss things: based on evidence and by using reason while not always in agreement with one another.

I did four years of weekly psychotherapy before I was diagnosed with a serious illness. Then, I resumed therapy for another nine years, weekly, sometimes with a psychologist and sometimes with a psychiatrist. That's 13 years of talk therapy, weekly. I also went back again for about a year after voluntary inpatient hospitalization since it was required for insurance. Also, group therapy. These years of talk therapy were pleasant although it failed to help with my panic attacks. I would do it again if it were free, sure, although I have no idea at all what it's supposed to do based on my experience with it. That doesn't mean it's useless. I imagine many people have difficulty. When I was a kid, it definitely helped me, although sadly, it delayed the diagnosis of a more serious medical disorder. But on its face, it was fine. It just never did anything. Not a single thing. What is it supposed to do?

To repeat, I am not arguing. I am offering a perspective counter to birchswing's perspective based on my personal experience because it is both similar to, and different from, his experience. It is alarming that the sharing of another experience, my experience, would even be construed as some kind of hostility. I'm simply sharing my real experience, as someone who can do that, who is credible, educated, and proficient at stating my experience with benzodiazepines.

 

[Mahavidya2]

Shikima, I've never seen anyone in BZD intoxication. I'm a college professor. Why would I see that sort of thing? In what context would I encounter that? If I speak anecdotally, that's because -- other than research reports -- this is the only experience that I have to draw on. I personally have trouble imagining that the medication is intoxicating, but I've also really never taken above my prescribed dose (which has been 1mg 3X per day of xanax, with 2 mg at once okay for public speaking, or airplanes, or getting stuck before crossing the bridge, etc.).

 

[smalltownpsych]

Discussion of benefits of talk therapy is a whole 'nother conversation. Most psychologists I know don't see most of their patients for years. Most improvement happens in about 20 sessions. This varies by complexity and severity of case. Some psychotherapy for more serious mental ilness that is more chronic is long term but more supportive in nature and frequency can be modulated according to need. Treatment of many anxiety disorders is going to mainly occur outside the therapy room and benzos can inhibit that process.

Edit: so can other medications to be clear especially if patient experiences a blunting or diminishing of affect.

 

[Shikima]

smalltownpsych, putting an argument into standard form, or in this case, a really loose standard form, is extremely useful to make an argument more clear as well as to minimize bias and help everyone return to the point.

Also, I'm not "arguing."

Arguing is the active voice and present tense of an argument. Which you are doing. Lawyers in court call it 'arguments'. Another synonym is debate. It's ok, you're doing this.

For you to gain insight in being taken off of them, you need to talk with your physician about it directly. We do not work in a collective or hive and know what each other is thinking.

Lastly, The only evidence you've provided was driving. Others have discussed from a clinical perspective which you've chosen not to understand, including the education provided by Whopper where he did detail why it isn't good to be continued on them from a medico-legal point of view. But you're wanting alternative research to peruse why ought not to be discontinued, here is your 'proof' should you accept it or not.

http://www.ncbi.nlm.nih.gov/pubmed/?term=benzodiazepine+dementia

http://www.ncbi.nlm.nih.gov/pubmed/?term=benzodiazepine+impulsivity

For a reasonable summary; https://en.wikipedia.org/wiki/Effects_of_long-term_benzodiazepine_use

 

[Mahavidya2]

Arguing is the active voice and present tense of an argument. Which you are doing. Lawyers in court call it 'arguments'. Another synonym is debate. It's ok, you're doing this.

For you to gain insight in being taken off of them, you need to talk with your physician about it directly. We do not work in a collective or hive and know what each other is thinking.

Lastly, The only evidence you've provided was driving. Others have discussed from a clinical perspective which you've chosen not to understand, including the education provided by Whopper where he did detail why it isn't good to be continued on them from a medico-legal point of view. But you're wanting alternative research to peruse why ought not to be discontinued, here is your 'proof' should you accept it or not.

http://www.ncbi.nlm.nih.gov/pubmed/?term=benzodiazepine dementia

http://www.ncbi.nlm.nih.gov/pubmed/?term=benzodiazepine impulsivity

For a reasonable summary; https://en.wikipedia.org/wiki/Effects_of_long-term_benzodiazepine_use

You're equivocating to argue vs. an argument, which is a logical term, which I don't expect anyone who has not studied logic and critical thinking would necessarily know. I placed the argument -- not meaning "I am arguing" but meaning making a hypothetical proposition of truth or falsity -- into that form so that it was easier to understand and follow.

The basic tenets of logic and critical thinking (like the above) are the basic building blocks of CBT, which is to restate your assumptions into clear thoughts so that you, yourself, can follow them and work through them, which is supposed to assist with anxiety and other psychiatric disorders. While I suggest this works for many people who do not already think rationally, perhaps because they are overwhelmed with emotion, it will not work for someone who is thinking critically or logically already. Likewise, neither will talk therapy since the point there seems to be to help you to think more clearly. For someone already thinking clearly, there's not much to get out of it. Comfort? Okay, it's admittedly comforting.

But I teach thinking; I study thinking and rational thought; my entire life is steeped in thought and reason: I'm just not a psychiatrist. How do psychiatrists who have panic attacks and anxiety treat it, I wonder? Interesting question. The assumption behind non-pharmacological treatments for anxiety seem to be that anxiety is a deficit in rational thought which can be corrected by the introduction of new modes of thinking, an assumption which is profoundly fraught when someone is already clear-headed and intelligent but obviously struggling with a psychiatric condition, nevertheless. Exposure therapy aside since that makes perfect sense to me.

Neither of your links apply to my situation. I'm not elderly, I do not suffer dementia, and I show no signs of impulsivity, nor have I in the several decades I've taken benzodiazepines. Some people do X ≠ All people do X ≠ Most people do X. Also, for all of these studies, I could find studies which show that benzodiazepines, for the right patients, cause more good than harm. My position on benzodiazepines as probably helpful to many more people than are prescribed these is solidified after a good review of the literature. Finally, I don't consult wikipedia for medical advice or much of anything for that matter. When I teach research methods, I ban wiki outright for good reason.

In conclusion, I've learned a lot from this exchange, although your tone is unwarrantedly abrasive. Nonetheless, thanks to all who have dialogued with me in this thread. I do not plan to comment here again though since I've shared my story and my ideas, and if you read them all and take away something, then good -- this matter deserves far more consideration than it has been given. If not, then no sweat. And if you read about a professor who fits my description but resigns from tenure this year, which is totally unlikely unless you were in my field, well, that would be me, and this story would be why.

Be good to one another. There is no end-game. There is only inquiry and the sharing of thoughts across disciplines and experiences.

 

[NickNaylor]

But I teach thinking; I study thinking and rational thought; my entire life is steeped in thought and reason: I'm just not a psychiatrist. How do psychiatrists who have panic attacks and anxiety treat it, I wonder? Interesting question. The assumption behind non-pharmacological treatments for anxiety seem to be that anxiety is a deficit in rational thought which can be corrected by the introduction of new modes of thinking, an assumption which is profoundly fraught when someone is already clear-headed and intelligent but obviously struggling with a psychiatric condition, nevertheless. Exposure therapy aside since that makes perfect sense to me.

I disagree with your assessment of therapy. Therapy's sole goal isn't to help you "think clearly," though perhaps for more unsophisticated folks that might be the primary goal. You can "think clearly" and "be logical" and still benefit from therapy. Thinking therapy is for people that don't know how to think suggests a poor understanding of what you can stand to gain from the process.