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Benzodiazepines and Anxiety: The Rebound Effect


Are They Really Useful?

Benzodiazepines, commonly known as tranquilizers, are a type of medication used to treat anxiety and various other medical disorders. Benzodiazepines are the most widely prescribed anti-anxiety medication in the U.S.

Most people know benzodiazepines by these commercial names:

  • Valium
  • Xanax
  • Halcion
  • Ativan
  • Klonopin
  • Alprazolam
  • Diazepam
  • Lorazepam
  • Clonazepam

Physicians prescribe benzodiazepines for:

A report published in 2020 by the U.S. National Center for Health Statistics showed that between 2014 and 2016, physicians prescribed benzodiazepines at around 27 out of every 100 office visits, which adds up to roughly 66 million benzodiazepine prescriptions per year. The study, which included data from over 70,000 office visits, is large enough to make population level generalizations, and reasonably assume those numbers – 27% of office visits, 66 million prescriptions per year – are reliable national averages.
Physicians prescribe benzodiazepines for anxiety because they’re effective. Short acting forms relieve acute anxiety and extended-release forms control chronic anxiety. People who use benzodiazepines report they enable them to carry out daily activities which would previously have been impossible, due to high levels of agitation, nervousness, fear, and other psychological and emotional states associated with clinical anxiety.

Our first answer to the question in the subheading of this article – Are They Really Useful? – is yes, they are. However, a growing body of evidence shows that the dangers of benzodiazepines may outweigh the benefits.

We’ll discuss those dangers in detail below.

First, a quick history of benzodiazepines.

Benzodiazepines: How We Got Here

Benzodiazepines are the third generation of a class of anti-anxiety medication that first appeared around the beginning of the 20th century. Originally called barbiturates, they were first developed by German pharmaceutical companies and became popular among people in the U.S. in the 1930s. Prescribed by physicians to help patients relax, take the edge off, and relieve day-to-day stress, the use of barbiturates such as Seconal, Luminal, and Nambutol peaked around 1941, when records show that people in the U.S. consumed over one billion barbiturates every year.

Over the next ten years, patients and doctors began to understand the dangers of this class of medication. While barbiturates worked as intended – to help ease nerves and prevent insomnia – they also led to tolerance, dependence, addiction, and carried a risk of overdose when combined with alcohol.

In the 50s, lawmakers passed legislation requiring a prescription for barbiturates. Also during the 50s, the next generation of barbiturates appeared: first Librium, and next a drug almost everyone knows about, Valium. These medications quickly became as popular as the barbiturates they were meant to replace. But physicians and the public also quickly realized that, just like the first wave of barbiturates, benzodiazepines also led to tolerance, dependence, addiction, and carried the same risk of overdose. This second wave also presented a new problem: a difficult and dangerous withdrawal.

This brought us to the 1970s and the third wave of this type of medication, which includes the medications listed at the beginning of this article. They’re the ones most of us know about today. Publicized as safe alternatives to Valium, medications like Xanax became common go-to answers for anxiety of all sorts: short-term, long-term, and everything in between.

By the 90s, though, we knew these medications were every bit as dangerous as those that preceded them.

The Dangers of Benzodiazepines

We want to be clear that benzodiazepines are effective medications for specific disorders and conditions. When used properly, they do exactly what they’re supposed to do: relieve the uncomfortable symptoms of anxiety. What physicians and researchers have learned over the past fifty years, though, is important to understand:

  1. They’re safe for short-term use, meaning anywhere from one to two weeks.
  2. After around two weeks, risk of tolerance, dependence and addiction develops.
  3. Higher dosage – over 2mg for a drug like Xanax – increases risk of tolerance, dependence, and addiction.
  4. Abrupt cessation – i.e. stopping use all of a sudden or going cold turkey ­– leads to extremely uncomfortable and potentially fatal withdrawal.
  5. Discontinuing long-term benzodiazepine use can lead to what’s called PAWS, or Post-Acute Withdrawal Syndrome. People who experience PAWS report withdrawal symptoms can persist for six months to a year.

Let’s stop on that last point: PAWS.

A simple way to think about withdrawal is that what a person experiences during withdrawal is the opposite of what they experience while the drug is in their system. Therefore, with an anti-anxiety medication, a major symptom of withdrawal is anxiety. That’s the exact thing they took the drug to avoid in the first place. The problem with benzodiazepines is that with long-term use, they change brain chemistry. When an individual stops using them, they may experience the rebound effect. The changes in the brain result, in many cases, in a higher default level of anxiety than before the individual began taking the drug.

There’s another problem. For most people with anxiety disorders who take benzodiazepines, their symptoms appear in response to environmental triggers. Triggers can be anything: people, places, work deadlines, or social events. During withdrawal, though, debilitating anxiety may appear without any trigger at all.

But why?

The Rebound Effect Explained

In an article called “I Have a Physical Dependency on Xanax. The Drug’s Dark Side Isn’t Discussed Enough” published recently in Salon, clinical counselor Angela Robinson describes how benzodiazepines work in the body:

“The drug works by slowing down activity from your nervous system to your brain. It diffuses the physiological and emotional side effects of stress. Because the drug tranquilizes the activity within the nervous system, your body will start to feel restless. Clients develop uncontrollable shakes, psychosis and/or feel panicky. Other common withdrawal symptoms include sweating profusely, chills, insomnia and/or trouble sleeping, suicidal ideation, and increased depression.”

In the same article, Dr. Aaron Weiner explains how the characteristics of the medication lead to what’s known as the rebound effect:

“Generally speaking, anxiety is caused by something in the environment, seeing a threat, or sometimes it’s being on edge. If you’ve been on edge for so long, because you feel like something bad is going to happen, that can become a habit, but what’s going on with the withdrawal is that it’s purely driven by a biological change and imbalance of chemicals in the brain that is in the process of being corrected slowly.”

What this means is that a person who begins taking a benzodiazepine for anxiety may, when they stop, experience anxiety of a different type than before. Rather than panic attacks or anxiety triggered by environmental cues, they may experience a persistent, default state of anxiety. And because of the changes that long-term use creates in the brain, it may take a long time – six months to a year – for withdrawal-related anxiety and symptoms to fade.

That’s why mental health professionals recommend counseling and psychological support alongside medication. According to Robinson:

“The drug does not solve the root cause of the stress.”

Benzodiazepine Withdrawal: What It’s Like

Ask someone who’s experienced withdrawal from benzodiazepines, and they’ll tell you it’s miserable, and they never want to feel that way ever again. That’s true for mild, moderate, and severe withdrawal. We understand, though, that miserable may not drive home exactly how extreme benzodiazepine withdrawal can be.

We’ll outline the physical and psychological symptoms of benzodiazepine withdrawal below, starting with the symptoms associated with severe withdrawal.

Benzodiazepine Withdrawal: Severe

Severe symptoms appear when an individual on long-term high dosage stops using suddenly. They appear within two to ten days, may last two weeks, and are typically followed by mild to moderate symptoms of withdrawal.

Physical symptoms include:

  • Seizures
  • Insomnia
  • Headaches
  • Body pains
  • Sensitivity to noise, light, smell, taste, touch
  • Chest pain
  • Rapid breathing
  • Rapid heart rate
  • Stomach pains
  • Diarrhea
  • Shaking and tremors in hands and body
  • Flushing
  • Excess sweating

Psychological symptoms include:

  • Extreme anxiety
  • Extreme paranoia
  • Loss of touch with reality
  • Hallucinations
  • Rage
  • Aggression
  • Irritability

Benzodiazepine Withdrawal: Mild to Moderate

Mild to moderate symptoms appear when an individual uses benzodiazepines for two weeks or more. They appear within 12 to 36 hours and typically last two weeks, but in some cases – see PAWS above – may last up to a year.

Physical symptoms include:

  • Insomnia
  • Stomach problems
  • Abdominal pai
  • Diarrhea
  • Chest pain
  • Hyperventilation
  • Flushing
  • Excessive sweating
  • Rapid heart rate
  • Fatigue,
  • Sensitivity to noise, light, smell, taste, touch
  • Vision problems
  • Hearing problems
  • Headache
  • Dizziness
  • Muscle spasms
  • Muscle pain, weakness, and stiffness
  • Nasal congestion
  • Dry mouth
  • Difficulty swallowing
  • Itching
  • Numbness
  • Tingling or burning (feeling) skin
  • Changes in weight and appetite
  • Low sexual desire
  • Female hormone problems

Psychological symptoms include:

  • Depression
  • Memory problems
  • Difficulty concentrating
  • Drowsiness
  • Rage
  • Aggression
  • Irritability
  • Paranoia
  • Depersonalization (loss of sense of reality)

This list of symptoms is enough to raise a simple question: why would anyone take benzodiazepines in the first place?

A Short-Term Answer, Not a Long-Term Solution

The answer is that when used short-term, as directed, benzodiazepines work well for anxiety, insomnia, and various non-psychological physical disorders. In fact, when used as directed for acute anxiety, they’re exactly what’s needed. However, the overwhelming preponderance of data indicates they’re not a long-term cure or remedy.

Dr. Weiner, in the Salon article linked to above, points out:

“The tools do have a place in time…like if someone has just lost a family member or there’s something urgent that has just gone on, but not so much for the chronic stuff. I think they are over-prescribed because it can be alluring, both from the provider perspective who wants to provide a solution, and then also for the patient.”

In addition, the symptoms we describe above happen when someone stops taking benzodiazepines abruptly. In the 1990s, physicians realized that a safe and relatively problem-free way to discontinue benzodiazepine use was to taper off the medication gradually.

Taper off means that, under medical guidance, a person who uses high-dose benzodiazepines or uses them for a long time needs to gradually reduce the dosage in order to avoid the worst of the withdrawal symptoms. When a taper is performed slowly, with continuous monitoring, the body has time to adjust to the absence of the medication. The changes in the brain the medications causes – that are responsible for the most uncomfortable withdrawal symptoms – will return to a normal, functional baseline, over time.

In addition, experts recommend therapy and support during the tapering period. Approaches that help include:

What’s interesting here is that those four things – CBT, meditation, mindfulness, and exercise – are effective treatments for anxiety independent of anti-anxiety medications like benzodiazepines. And they’re also the first-line treatments for adolescents with anxiety.

Teens, Anxiety, and Medication: Use Only If Needed

Studies indicate that clinical anxiety disorders that go untreated typically do not resolve on their own, and get worse over time. That’s why treatment is essential. The most effective way to treat anxiety disorders in teens is with a combination of therapy and medication, but benzodiazepines should not be used as a first-choice medication. And when they are, they should only be prescribed for short periods of time.

Parents of teens with an anxiety disorder should find an adolescent treatment center that uses the following therapies and methods:

Evidence-Based Therapies for Anxiety In Teens

Medications For Anxiety In Teens

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  • Tricyclic Antidepressants (TCAs)
  • Benzodiazepines (if needed)

With regards to the use of benzodiazepines for treating anxiety in teens, doctors may prescribe them to manage symptoms until the prescribed anti-depressants (SSRIs, SNRIs, TCAs) reach a steady state in the body and achieve their full, desired effect.

To support therapy and medication, clinicians at treatment centers for adolescent or teen anxiety regularly use lifestyle modifications and complementary therapeutic support. These supports include, but are not limited to:

  • Mindfulness-Based Stress Reduction (MBSR)
  • Meditation
  • Exercise
  • Mindfulness-based physical practices, such as:
    • Yoga
    • Tai Chi
    • Chi Kung

For parents of teens who receive a clinical diagnosis for an anxiety disorder, it’s important to understand the facts about benzodiazepines. We can summarize those facts here:

  1. Benzodiazepines are effective for the short-term management of anxiety symptoms
  2. Long-term – over two weeks – use of benzodiazepines presents a real risk of addiction
  3. Discontinuing benzodiazepines after long-term use is dangerous and extremely uncomfortable.
  4. Discontinuing benzodiazepines after long-term use requires a tapering regimen monitored by a medical professional.
  5. The anxiety that appears during withdrawal may be different – and worse – than the anxiety that preceded the medical use of benzodiazepines.

Given these facts, it’s critical for parents to meet with their teen’s psychiatrist or counselor to discuss the benefits and risks of including benzodiazepines in any course of treatment for anxiety.

Finding Help: Resources

If you’re seeking treatment for a teen with an anxiety disorder, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.

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