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This column is a continuation of the last Doctor Debug column. That column discussed non-medication methods for reducing anxiety. This column will address common medications. To fully understand this column, I recommend reading the earlier column. It can be found at Debugging Anxiety with the Relaxation Response.
It should be noted that there is a large amount of misunderstanding and stigma related to the use of anti-anxiety medications, such as the benzodiazepines. Although such anti-anxiety medications can be very helpful, unlike most antidepressants, they do not appear to provide our brains or bodies with a biological fix that lasts, so they are vulnerable to being classified as "habituating."
"Addiction" and "habituation" are complex and value-laden terms. In a society that values willpower, independence, and discipline, people with chronic anxiety often find themselves wondering why they "just can't get it together." Addiction is possible, but does not occur very often with appropriate use of anti-anxiety medications. The primary sign of addiction is the development of tolerance -- having to use larger amounts of the same medication to get the same positive results. What does take place more often with certain anti-anxiety medications is a "discontinuation syndrome" that mimics some of the well-known addiction withdrawal symptoms. A discontinuation syndrome does not necessarily indicate addiction.
Providing a long-term medication solution for a biological deficit, such as diabetes, is not viewed as producing "habituation," although a person with diabetes will likely always need to take an appropriate medication. "Withdrawing" from such a necessary diabetic medication could not only be difficult and ill-advised, but also life-threatening. It seems that only in matters of the brain do we have difficulty accepting that a brain deficit may require long-term use of a medication.
Many medications, including antidepressants, can have positive effects on anxiety. Anxiety can be part of clinical depression, attention deficit disorder, schizophrenia, bipolar disorder, and other, primarily brain-based mental illnesses. By treating the underlying disorder, the medication may clear up many of the anxiety symptoms.
In this column, I am only going to address the more specific anxiety of phobias, and disorders such as obsessive-compulsive, general anxiety, social anxiety, panic, posttraumatic stress, and performance anxiety. I classify anti-anxiety medications into two categories: (1) those that assist more with anticipatory anxiety, and (2) those that assist more with the peripheral symptoms of an anxiety episode (reduce shakiness, sweating, blood pressure, flashbacks, etc.).
Those that assist more with anticipatory reactions are primarily the benzodiazepines -- alprazolam (Xanax® -- short-acting), clonazepam (Klonopin® -- medium-acting), diazepam (Valium® -- long-acting). Benzodiazepines offer a more rapid onset of benefit without the frequent sexual dysfunction side-effects associated with many antidepressants. However, medication for anxiety disorders is shifting away from the use of benzodiazepines toward antidepressants that increase serotonin. Research shows that such SSRI antidepressants are significantly effective and may give a longer-lasting result even after they are discontinued.
When utilizing antidepressants to treat anxiety symptoms, it may be useful to start at low doses and increase dosages very gradually over an extended period of time to minimize side-effects. One class of antidepressants that has been shown to be very helpful for social phobia, but which are not often used are the monoamine oxidase inhibitors (MAOIs) phenelzine (Nardil®) and tranylcypromine (Parnate®).
Medications that assist more with the actual signs and symptoms of an anxiety episode are primarily beta blockers and one alpha-blocker, which are more often used to treat heart conditions and high blood pressure. These include the alpha blocker, prazosin (Minipress®), and the beta blockers, propranolol (Inderal®) and atenolol (Tenormin®).
Prazosin has been shown to be effective in reducing the night terrors, nightmares and flashbacks of posttraumatice stress disorder, and the beta blockers have been shown to prevent the shakiness, numbness, disorientation, and increased blood pressure associated with performance and social anxiety. The beta blockers are used on demand, just prior to a potentially challenging social or performance situation. Many symphony musicians and other performers utilize beta blockers to reduce the peripheral effects of anxiety so that their performances are improved.
I hope this is helpful. -- Best wishes, Dr. Debug.
Ron Sterling, M.D. (Dr. Debug) is an award-winning psychiatrist in Seattle, Washington. He has been writing for newspapers and magazines since 1998 on subjects ranging from good manners to senior mental health. He hosts and maintains the well-known Internet mental health center, DearShrink.com. The Doctor Debug column is dedicated to assisting with the "debugging of malfunctioning elements in our own personal programming."
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