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Benzodiazepines and Therapies
by Pam Armstrong
Council For Involuntary Tranquilliser Addiction (CITA)
Cavendish House, Brighton Road, Waterloo, Liverpool,
England, UK L22 5NG Helpline: 0151 932 0102
(lines open Monday to Friday, 10am-1 pm).
Seven years working as Director of the Council For Involuntary Tranquilliser Addiction (CITA) has convinced me that withdrawal from long term use of these drugs should be a very practical and directive process. I firmly believe that the cognitive and behavioural aspects cannot normally be separated and much of my work with anxiety favours the use of Ellis's Rational Emotive Therapy in order to facilitate less rigid thinking in the anxious client. However, with those addicted to benzodiazepines, I see withdrawal as almost totally behavioural: cognition is enormously impaired by the drugs. Therapy which involves anything beyond the most superficial cognition is thus rendered virtually ineffective. Only when withdrawal is complete can work on thought processes begin.
Benzodiazepines work by impairing the ability of receptors in the brain to receive stress stimulating messages from the outside world. In the anxious client this quickly has the effect of improving his or her sense of well being as it means that natural pain and stress coping chemicals - called endorphins - have less to contend with and the client's perception is that he/she feels calmer. This situation, however, does not continue indefinitely. Endorphins are controlled by a use-it or lose-it type mechanism, so that gradually the quality of available endorphins is drastically reduced, resulting in a renewed and greater perception of anxiety. At this point the client is likely to return to the GP and ask for a higher dose of benzodiazepines in the belief that this will relieve symptoms.
In addition to the effect on receptors and endorphins, benzodiazepines also alter the precisely balanced adrenaline reflex, which normally responds to danger signals resulting in blood being pumped into the right place at the right time to produce the flight-or-fight response. The effect of benzodiazepines is to throw this delicate mechanism into confusion producing inappropriate bursts of adrenaline resulting in panic attacks and fear of what this perceived sensation of panic means.
Benzodiazepines are also fat soluble which means that they are extremely slow to leave the body: months after the last tablet has been taken the drugs are still present in fat cells.
So what do all these properties of benzodiazepines mean to the client and what are the implications for the therapist? They mean that the former is often inexplicably full of panic and fear which interferes with concentration and consequently with the ability to attend for meetings and consultations. Benzodiazepines affect memory which is one of the reasons they are popular as pre medications before surgery. This factor, coupled with lack of concentration, are the main reasons why thought processes are so greatly impaired. Simple behaviour remembering by rote learning is not damaged and since this level of function may appear normal, long term users of benzodiazepines may not be so easily detected. However, thinking at a higher level is, in the opinion of our organisation, often precluded to a great extent.
We have found it cruel and wasteful of resources to attempt to use psychotherapy or counselling for those who are still taking benzodiazepines and who have been long term. Clients will almost certainly vote with their feet and not attend for appointments if they are required to use skills which they - at least temporarily - cannot call upon. We believe very directive measures are called for - such as help in planning ways to carry out decisions - with a great deal of support from family, friends and primary health care teams: particularly GP self help groups of knowledge counsellors. While reducing the drugs, many people also find anxiety management and relaxation of little use. Commonly any efforts to use these skills frustrate the individual and exacerbate the condition. An understanding of the way the drugs affect the client makes it clear why this happens, revealing that a lack of endorphins combined with indiscriminate rushes of adrenaline make relaxation almost impossible. In such cases gentle exercise may help to use up adrenaline in a natural way. However, some clients have reported that exercise must not be overdone, as this may result in extreme fatigue. Another property of benzodiazepines is that they act as a muscle relaxant, which after long term use may produce some levels of dysfunction in muscles; in withdrawal this may even produce pain and muscle spasm.
All symptoms created by long term benzodiazepine use appear to be reversible, but if recovery is to occur, full withdrawal from the drugs must take place. In order to facilitate this, clients are asked to transfer to a long acting benzodiazepines. These produce a gentler effect so that the user is not continually aware of when the next dose is due. Diazepam is the drug of choice here: it is conveniently shaped and can be broken up accurately to vary the dose as required. There is also a liquid dilution method, comprising concentrated liquid and a buffer agent, used to gradually bring about reduction. Transferring patients to diazepam also makes them more aware how much benzodiazepines they are actually taking, in a way that drugs in small doses may not.
As a rough guide, a rate of reduction of about 1mg every two to three weeks should be considered. When the overall dose is below 5mg, this increment may need to be smaller. If the client is on a dose of over 30mg, then the reduction may be in larger amounts at any one time as the proportion reduced is a smaller percentage of the overall dose.
The supporter working with the clients needs to provide information, reassurance and a place of safety for the person to be themselves and pour out their fears. Very often, those around them at work and home do not know what is going on, and the client does not what to tell them. Withdrawal may take over twelve months, depending on the dose from which reduction occurs steadily. The client should not proceed too slowly however, as he/she may lose concentration, and such slow reduction could interfere with the outcome. It is important that the client takes control of recovery now, since for so long control has been taken away.
Some people benefit from self help groups, others prefer to work one-to-one with the therapist, as fear may prevent them from joining a group. Some patients may also feel embarrassed to admit to a group that they are addicted to benzodiazepines, and may think it amounts to washing dirty linen in public.
When total withdrawal has finished the story does not necessarily end. It is at this time that healing and rehabilitation must take place - for here is a human being who has lost many life skills - an important point to consider.
While stress is lessened by benzodiazepines, the skill of adapting behaviour to cope with stress can be forgotten, and the ability to grow and learn consequently much diminished due to lack of concentration and poor memory. At this stage, clients are often extremely immature emotionally, especially those who have been prescribed benzodiazepines from an early age. There may be an enormous amount of time to make up, and a terrific amount of stimuli impinging on the central nervous system and on a mind which has been impenetrable for so long. Clients often report colours seeming excessively bright, sounds extremely loud and smells unexpectedly pungent: the responses of a central nervous system returning to life.
Another common response to benzodiazepine withdrawal is anger. With returning awareness comes the sudden realisation of what has gone on, of the many years that have been lost and the memories which will never return. This anger needs to be worked through, and some clients do get stuck at this point.
For many, this emergence form benzodiazepines is a process of rebirth, and certainly a time for refinding themselves and re-establishing their personality. Now is the time for anxiety management to be taught: psychotherapy, acupuncture, counselling, aromatherapy and any number of therapies may be of use to clients as their needs emerge. I am particularly excited about work being carried out using acupuncture, for the reduction of adrenaline and improvement of available endorphins, to facilitate recovery.
Whatever the therapy, I believe the therapist needs to fully understand what has gone on, and what benzodiazepines do to human beings, before embarking on a course of recovery with a client.
The Council for Involuntary Tranquilliser Addiction (CITA) was founded in 1987 to respond to concerns about addiction to tranquillisers. The most recent figures put the number of prescriptions written annually by doctors in Britain for these drugs at 20 million, which translates as 3 million people taking tranquillisers every day.
CITA's aims are:
to raise awareness about addiction to benzodiazepines, tranquillisers and sleeping pills.
to support withdrawal and rehabilitation of those addicted to tranquillisers.
to train doctors and health workers concerning benzodiazepine withdrawal.
to help doctors in their efforts to support patients in withdrawal.
Since its inception the organization has dealt with 61,000 calls and advised over 8,000 people towards withdrawal from tranquillisers. It offers the only national help line for those dependent on the drugs.
All staff are specially trained by CITA.
CITA is open five days a week with limited service at weekends (all calls are returned within 24 hours).
National and local training is available through CITA. Several training days are held each year for those working with benzodiazepines and anxiety management, both in Liverpool and throughout the country, many commissioned by FHSAs and Health Authorities. Post Graduate Accreditation has been acquired through Liverpool University.
CITA's information service can supply a letter of introduction and guidelines for patients to take to their doctors, books and self-help tapes on addiction and anxiety.
For more information contact:
Council For Involuntary Tranquilliser Addiction (CITA)
Cavendish House, Brighton Road,
Waterloo, Liverpool, England, L22 5NG
Helpline: 051 932 0102
(lines open Monday to Friday, 10am-1 pm)
CITA, The Council for Involuntary Tranquilliser Addiction Web Site.
Back to Life (CITA) Web Site. Pam Armstrong (UK).
See also: The relevance of mind altering drugs to the counselling process by Pam Armstrong.
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