Risks of Benzodiazepine Use

Wouldn’t it be wonderful if you could just swallow a pill and have all of your anxiety just magically disappear? There is such a pill, it’s called a benzodiazepine, actually an entire class of drugs. Popular benzos include Xanax (Alprazolam), Ativan (Lorazepam), and Klonopin (Clonazepam), and they’re incredibly effective.

The reason they’re effective is that benzodiazepines are GABA agonists. All psychoactive drugs work by influencing the chemical messengers between neurons, called neurotransmitters. GABA is the principal inhibitory neurotransmitter in the brain, meaning that it slows things down in the body, eliminating the arousal. Dosage is usually started at the lowest effective dose and increased as needed.

Many clients consider benzodiazepines to be a “magic pill” that takes away the symptoms. Elimination of symptoms is what clients are looking for in the medical model. In fact, benzodiazepines are so effective at eliminating anxiety that they are considered highly addictive. Elsewhere on this site, we discussed negative reinforcement as removal of an aversive symptom. That’s exactly what Benzodiazepines do. They remove the symptoms, and they do it completely, given an adequate dosage. So of course they’re highly addictive.

As with almost everything magical, there’s also a downside. The downside is an apparently permanent lifetime predisposition to the development of dementia later in life, and it’s a dose-dependent effect. The more benzodiazepines you use, the greater the possibility of developing dementia in your older years. That’s what the research shows, and this finding is now solid, well replicated, and validated with meta analytic studies, which combine the effect of many smaller studies. A predisposition is not destiny, of course, but it is what it is. If you reach 75 and find yourself having memory problems, it would be sad to connect this to benzodiazepine use in your 40s.

Does this mean you should avoid benzodiazepines altogether? Some of my clients interpret it this way. If you have a family history of early onset dementia, for example, then you may already have a genetic predisposition, and it doesn’t make sense to add another risk factor. Some of my clients also say they have longevity in their family, with family members living into their 90s. These clients feel it would be unwise to increase the chances of dementia, which are already large going into the 80s.

Many clients receive a prescription through their primary care physician, and unfortunately, many primary care physicians are not yet aware of the association between benzodiazepines and dementia. Sometimes I see older clients who have longstanding benzodiazepine prescriptions and memory problems, and I always wonder about the extent to which these memory issues were caused by benzodiazepine use. So consider your brain, it’s the only one you’ll ever have. You can buy new clothes, but you can’t buy a new brain.

Having said that, some clients ask, “Do the benefits justify the risks?” Sometimes the answer is yes. If you feel that your very emotional stability is at risk, then absolutely emotional stability becomes a life priority. The first rule of medicine is to stabilize the patient. Then you can think about treatment strategies. Without a stable patient, there is only crisis management. For whatever reason, psychiatric facilities have the reputation of being highly aversive, not a place you’d want to spend any amount of time.

Fortunately, many patients receive prescriptions calling for up to a certain number of pills per day. The words “up to” are key, because it means that the dosage is somewhat controlled by the client. The client can somewhat mitigate the risks associated with benzodiazepine use by taking less than the prescribed amount, and taking it only when anxiety becomes intolerable. These clients use benzodiazepine only when they feel they really really need them. They refuse to take a benzodiazepine every single day. Whenever possible, they tough out their anxiety and save their pills. Particularly judicious clients will take half a pill in order to reduce their anxiety and make it cope-able. Some clients will take a pill as a sleep aid if they wake up in the middle of the night knowing that they have a stressful day ahead. All such use make sense to me as a means of obtaining some relief while minimizing risks. My older clients with anxiety diagnoses often proudly report the number of days since they last took their benzodiazepine.

When clients do opt to use benzodiazepines, I let them know that it’s not really possible to work on their anxiety unless they allow themselves to feel some anxiety. Unless you feel some anxiety, anxiety cannot undergo extinction. You cannot learn that you’re actually safe in situations that evoke anxiety, because the absence of anxiety is always attributed to the benzodiazepine, not to your own mastery of the situation. I once had a young man show up with a prescription for Klonopin, at a dosage level that completely eliminated his anxiety. He was absolutely tranquil. He was also detached from any concerns about his own life.

Note that I am not advocating that you decrease or drop your benzodiazepine if that’s what you’ve been prescribed. I don’t think you should make changes in your medical regimen based on what you read in a self-help book or a website. Nevertheless, it’s important that you understand some of the issues involved. Please consult with your doctor before making any changes to your medications.