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Excerpts from Toxic Psychiatry

Chapter 11 by Peter R. Breggin, M.D. http://www.breggin.com/

Suppressing the Passion of Anxiety: Overwhelm with Drugs: The Minor
Tranquilizers, Including Xanax, Valium, BuSpar, Ativan, and Halcion,
and the Antidepressant Anafranil

Just as the 1980s was the decade in which those suffering from various
forms of depression were identified and treated, so, [NIMH director
Lewis] Judd and other specialists hope, the 1990s will be the era
when the recognition and treatment of anxiety disorders predominate.
Judd recently announced that NIMH will launch a national education
and prevention campaign, which, he says, "will be pointed toward early
identification and diagnosis." - Washington Post Health, May 22,
1990.

From the U.S. Congress to the American public, psychiatry's marketing
strategy for the
1990s aims at people who feel anxious. It has become an axiom within
modern economics that advertising actually creates consumer needs. By
targeting people suffering from anxiety, psychiatry should be able to
generate an unlimited demand for its drugs. Prescriptions for one
class of these drugs, the benzodiazepines, already are estimated at
nearly one hundred million a year in the United States, for a cost of
about $500 million. Some estimates place the total cost at $800
million or more.

This chapter will give special attention to two minor tranquilizers
that have drawn considerable publicity. One is BuSpar (buspirone),
whose potentially damaging effects have been largely ignored, even in
the psychiatric literature. The other is Xanax
(alprazolam), one of the most intensively marketed and yet dangerous
drugs in psychiatry. Then chapter 15 will focus on the political
campaign that made Xanax so successful. [Note: this information can
be found in Toxic Psychiatry by Dr. Breggin]

Unlike most of the drugs discussed in this book, the minor
tranquilizers are highly sought after. Even without doctors pushing
them, people would want them. Indeed, they are actively sold
illegally on the street. This is not surprising, since people often
resort to taking anything that promises even temporary relief from
anxiety. Millions drink alcohol, smoke cigarettes, and use marijuana,
opiates, and other street drugs. Others eat excessively, exercise
compulsively, work to exhaustion, watch TV endlessly, escape into
books, relentlessly pursue ***, and overindulge any number of
otherwise harmless habits in an attempt to escape their tensions and
apprehensions. In chapter 10 we saw that obsessions, compulsions,and
phobias also can be seen as efforts to control anxiety. Overall,
psychiatric interventions play a relatively minor role in humanity's
never-ending struggle to deal with anxiety.

The Minor Tranquilizers and Other Sedative-Hypnotics

Among psychiatric medications for the treatment of anxiety, the most
commonly used are the minor tranquilizers, starting in 1957 with the
introduction of Librium
(chlordiazepoxide). In the 1970s the minor tranquilizer Valium
(diazepam) topped the charts as the most widely prescribed drug in
America, to be replaced by Xanax in
1986. Most of the minor tranquilizers belong to the group called
benzodiazepines and are closely related chemically to Librium,
Valium, and Xanax. They differ mostly in their duration of action and
in the dosage required to achieve the same effect. They have nearly
identical clinical effects.

The benzodiazepine minor tranquilizers include Xanax, Valium, Librium,
Tranxene
(clorazepate), Paxipam (halazepam), Centrax or Verstran (prazepam),
Klonopin
(formerly Clonopin) (clonazepam), Dalmane (flurazepam), Serax
(oxazepam), Ativan
(lorazepam), Restoril (temazepam), and Halcion (triazolam)*.

(*The drugs are called "minor" tranquilizers to distinguish them from
"major" tranquilizers, but nowadays the latter are called
neuroleptics or antipsychotics. While the minor tranquilizers might
now simply be called tranquilizers, that term itself is somewhat
misleading. Basically they are sedatives. )

An older minor tranquilizer is Miltown or Equanil (meprobamate).

Other minor tranquilizers are chemically antihistamines, such as
Atarax or Vistaril
(hydroxyzine).

Sleeping medications also have tranquilizing effects. These include
Doriden
(glutethimide), Noludar (methyprylon), Placidyl (ethchlorvynol), and
Noctec, Somnos, or Beta-Chlor (chloral hydrate), and the various
barbiturates, including Seconal
(secobarbital), Luminal (phenobarbital), Butibel (butabarbital),
Amytal (amobarbital), Nembutal (pentobarbital), and Tuinal
(amobarbital and secobarbital).

All of these drugs have the potential for abuse and addiction. Since
all have a calming or sedative effect, people addicted to these
"downers" use many of them interchangeably, depending on what is
available, often mixing them with alcohol. The minor tranquilizers
and alcohol make a very dangerous, frequently lethal, combination.

BuSpar, the most recent addition to the minor tranquilizers, is being
promoted as nonsedative, nonaddictive, and relatively safe.

The Most Widely Used Psychiatric Drugs

According to FDA data reported by Carlene Baum and her associates in
the February
1988 Medical Care, there was a dramatic decline in the use of minor
tranquilizers and other antianxiety drugs, from a peak of 103 million
prescriptions in 1975 to 67 million in
1981 in the United States. There are no complete totals available for
recent years, but the APA's task force report, Benzodiazepine
Dependence, Toxicity and Abuse (1990), estimates that annual
prescriptions for benzodiazepines have leveled off since the
mid-1980s at about 61 million.

The minor tranquilizers, now led by Xanax, remain by far the most
commonly prescribed psychiatric medications. In some countries, such
as France, the use of these agents continues to escalate.

Most minor tranquilizer prescriptions - 65 percent - were for women in
1984. However, women predominate in all psychiatric drug categories.
Thirty-five percent of all patients were sixty years of age or older.

Are the Minor Tranquilizers Something New?

Because of the popularity surrounding the minor tranquilizers, we tend
to think that they represent something very new and radically
different among drugs; but I recall my medical school professor of
psychopharmacology reminding us in 1960 that the sedative attributes
of minor tranquilizers differ little from those of the barbiturates,
such as phenobarbital...

Sedative-Hypnotics and Central Nervous System Depression

All of the commonly used minor tranquilizers - with the possible
exception of BuSpar - are central nervous system depressants very
similar to alcohol and barbiturates in their clinical effects. Along
with alcohol and barbiturates, they are classified as
sedative-hypnotics, meaning that they produce relaxation (sedation) at
lower doses and sleep (hypnosis) and eventually coma at higher ones.
It is important to grasp the principle that minor tranquilizers are
central nervous system depressants - and, in particular,
sedative-hypnotics - because this classification removes the mystery
surrounding these "tranquilizers." The so-called antianxiety effect is
merely an early stage of central nervous system depression -
sedation. The basic clinical effect on the mind cannot be
distinguished from alcohol or barbiturates.

It should be emphasized again that all minor tranquilizers combine
with each other or with other central nervous system depressants -
such as barbiturates, antidepressants, neuroleptics, lithium, and
alcohol - with a potentially fatal result. While they can be lethal
when taken alone, they are especially dangerous in combination with
these other drugs. A large percentage of drug-related emergency room
visits involve minors tranquilizers.

All of the minor tranquilizers impair mental alertness and physical
coordination and can dangerously compromise mechanical performance,
such as automobile driving.

At low doses the minor tranquilizers are sufficiently potent to impact
noticeably on the brain waves on routine EEGs, especially in the
frontal lobe region. However, they do not typically have the
lobotomizing impact epitomized by the neuroleptics.

Addiction, Tolerance, and Withdrawal Symptoms

All hypnotic-sedatives, including the minor tranquilizers, are habit
forming and addictive and can produce withdrawal symptoms or an
abstinence syndrome when they are stopped. In the extreme, the
abstinence syndrome can cause life-threatening neurological
reactions, including fever, psychosis, and seizures. Less severe
withdrawal symptoms include increased heart rate and lowered blood
pressure; shakiness; loss of appetite; muscle cramps; impairment of
memory, concentration, and orientation; abnormal sounds in the ears
and blurred vision; and insomnia, agitation, anxiety, panic, and
derealization. Obvious withdrawal symptoms typically last two to four
weeks. Subtle ones can last months.

Consistent with the principle that the minor tranquilizers differ
little in their clinical effect from other sedatives, the Xanax
write-up in the 1991 PDR acknowledges that withdrawal symptoms are
"similar in character to those noted with barbiturates and alcohol."

Studies of Xanax (see ahead) show that most patients develop
withdrawal symptoms during routine treatment lasting only eight
weeks. Tolerance, or the need for increasing doses to achieve the
same psychoactive effect, is the underlying physical mechanism of
addiction. Within two to four weeks, tolerance can develop to the
sedative effect of minor tranquilizers taken at night for sleep. This
again warns against the use of these drugs for more than a few days
at a time.

The short-acting benzodiazepines can produce especially severe
withdrawal symptoms, because the drug is cleared from the body at a
relatively rapid rate. These include Xanax, Halcion, Ativan,
Restoril, and Serax. However, according to expert Louis Fabre in a
February 1991 interview with me, tightness of binding to receptors is
probably more indicative of addictive potential, and the most tightly
binding are Xanax, Halcion, Ativan, and Klonopin.

Individuals who take only one pill daily for sleep or anxiety are not
exempt from withdrawal problems. In my private practice during the
last few years I have worked with several people who were unable to
stop taking a once-a-day standard dose of Xanax, Ativan, Klonopin, or
other minor tranquilizers. In each case, the attempt to stop the
medication led to a disturbing degree of anxiety or insomnia within
twenty-four hours. The problem seemed to be caused by rebound anxiety
or rebound insomnia (see ahead). In a personal communication in late
December 1990, internist John Steinberg confirmed that patients
taking one Xanax tablet each day for several weeks can become
addicted. Steinberg is medical director of the Chemical Dependency
Program at the Greater Baltimore Medical Center and president of the
Maryland Society of Addiction Medicine. He points to research that
Xanax and other short-acting benzodiazepines can cause a reactive
hyperactivity of the receptors that they block. The hyperactive
receptors then require one or more doses of Xanax each day or they
produce anxiety and emotional discomfort. Steinberg calls the impact
of Xanax "a fundamental change in the homeostasis of the brain."
After the patient stops taking the Xanax, according to Steinberg, it
takes the brain six to eigh**** months to recover. Xanax patients
should be warned, he says, that it can take a long time to get over
painful withdrawal symptoms. Since doctors frequently don't realize
this, they, too, are likely to be confused and to continue the drug
in the hope of "treating" the patient's drug-induced anxiety and
tension.

Many detoxification beds are occupied by patients addicted to minor
tranquilizers and even more by those who are cross-addicted with
alcohol and other drugs. Steinberg says that Xanax is "by far and
away" the worst offender and that it definitely causes addiction
without being mixed with other sedatives. Steinberg estimates that one
in ten patients receiving Xanax will become addicted.* (Based on an
estimated fif**** million people receiving Xanax each year in the
United States, Steinberg concludes that 1.5 million Xanax addicts are
produced each year.

(*Steinberg does not use the term addiction loosely. By addiction he
means that the patient periodically loses control of his or her drug
intake and has a pattern of compulsive use, despite adverse
consequences. If Steinberg were merely speaking of habituation, or
difficulty stopping the use of the drug, his estimates would be much
higher. He considers Xanax "very easily habituating" and observes that
people are especially susceptible to the initial "euphoria or
disinhibiting effect" that it has in common with alcohol.)

Rebound Anxiety and Insomnia

Rebound anxiety is one of the common reactions to withdrawal or to
dose reduction of a minor tranquilizer. As with most psychiatric
drugs, the use of the medication eventually causes an increase of the
very symptoms that the drug is supposed to ameliorate, and thus
rebound anxiety can lead to a false diagnosis of chronic anxiety
disorder. As noted in the American Psychiatric Press Textbook of
Psychiatry, long-term treatment can be erroneously maintained or
reinstated when drug-induced rebound anxiety occurs. Addiction is the
ultimate outcome.

Some experts, such as John Steinberg, disagree with my assertion that
there is no difference between a tranquilizing and a sedative effect.
They suspect that in addition to the obvious sedation, minor
tranquilizers probably also produce a specific inhibition of anxiety.
If true, this means that they also cause a specific rebound anxiety as
the blocked receptors become hyperactive.

Rebound insomnia also results from taking most sleeping medications,
because the brain reacts against the central nervous system (CNS)
depressant effects by becoming more aroused or alert. Medications for
sleep generally should not be taken for more than a day or two at a
time.

Addiction Can Go Unnoticed

Seriously addicted patients may show no outward signs to their family
or physicians until accidentally removed from the medication - for
example, following surgery or during a medical emergency. Their
withdrawal symptoms may then be wholly misinterpreted as an aspect of
some other disorder or as a psychological problem. Marked withdrawal
symptoms, including persistent rebound anxiety, can begin as much as
five to seven days after stopping the medication and can last up to a
month.

Paradoxical Reactions

The minor tranquilizers can produce paradoxical reactions - acute
agitation, confusion, disorientation, anxiety, and aggression -
especially in children, adults with brain disease, and the elderly.
The Xanax report in the 1991 PDR states, "As with all
benzodiazepines, paradoxical reactions such as stimulation, agitation,
rage, increased muscle spasticity, sleep disturbances, hallucinations
and other adverse behavioral effects may occur in rare instances and
in a random fashion."

In nursing homes the medications may seem to help the insomnia of an
elderly patient for a night or two, only to produce generalized brain
dysfunction as the medication ac***ulates in the system. The agitated
patient may then be mistakenly overdosed with further medication,
perhaps a neuroleptic. According to Robert Hales and Stuart
Yudofsky's Textbook of Neuropsychiatry (1987), the "routine"
prescription of these medications in nursing homes and hospitals
"should be avoided," especially for anything but brief periods of
insomnia related to a particularly difficult or stressful situation.

As in response to alcohol, some people more readily lose their self
control and become violent when taking minor tranquilizers. There are
frequent references to this in the literature, including cases of
murder under the influence of minor tranquilizers. Partly because of
this disinhibiting effect, the drugs cannot be used effectively for
purposes of controlling behavior within institutions.

Halcion has been especially implicated in causing aggressive and
suicidal behavior, as well as delirium, hallucinations, and seizures.

Memory Dysfunction from Minor Tranquilizers

Recently there has been much-publicized concern about Halcion
producing amnesia for events prior to the taking of the drug.
However, this has long been an unheralded problem with minor
tranquilizers in general. Years ago I recall noticing that patients
who mixed alcohol with Valium the night before a psychotherapy
session sometimes would have severe black-out spells and could not
recall much of the prior evening. It is well known that the
intravenous infusion of benzodiazepines, such as Valium or Ativan,
typically produces a similar amnesia for the several hours surrounding
the infusion. While this may be a benefit in forgetting the painful
effects of surgery, it becomes a potentially serious problem in the
routine use of the minor tranquilizers for anxiety or sleep disorders
and can interfere with psychotherapy, studying, learning anything new,
or recalling previously retained memories.

Long-Term Effects on Mental Function from the Minor Tranquilizers

Despite the obvious need for concern, few studies have attempted to
measure the impact of long-term minor tranquilizer usage on overall
mental function. Susan Golombok and her colleagues from the Institute
of Psychiatry in London published "Cognitive Impairment in Long-Term
Benzodiazepine Users" in the 1988 Psychological Medicine. Using a
variety of neuropsychological tests to evaluate the impact of minor
tranquilizers on cognitive function in patients who were administered
the medication for at least one year, they found chronic impairment
in measures of visual-spatial ability and attention span.

Golombok and her coworkers were unable to follow up with tests after
drug termination. However, these findings of chronic brain
dysfunction raise a serious concern about possible permanency. The
investigators comment: "It is impossible to determine how long it is
safe for a patient to continue to take benzodiazepines, or at what
dose, before cognitive ability will begin to deteriorate.
Nevertheless, it is clear from the inspection of our data that taking
a low dose for a short time has little effect, while a high intake is
almost always certainly harmful." (P. 371)

The test results indicate that "these patients are not functioning
well in everyday life," while they remain unaware of their
impairment: "This is in line with clinical evidence that patients who
withdraw from their medication often report improved concentration and
increased sensory appreciation and that only after withdrawal do they
realize that they have been functioning below par... It appears,
therefore, that not only are long-term benzodiazepine users at risk
of dependence, but that cognitive impairment also represents a very
real hazard." (P. 373)

It cannot be overemphasized that brain-disabling treatments render
patients less able to evaluate their own dysfunction. The Golombok
study is exceedingly important from the viewpoint of the patient who
wishes to avoid brain dysfunction and from the viewpoint of the
ethical physician who wishes to avoid causing it in his or her
patients.

If doctors wish to prescribe minor tranquilizers or if patients want
to take them, it would be prudent to follow the advice of The New
Harvard Guide to Psychiatry (1988): "The main usefulness of the
antianxiety agents is in general medicine in the short-term treatment
of relatively transient forms of anxiety, fear, and tension" (p. 524).

Brain Shrinkage from Long-Term Minor Tranquilizer Use

An even more terrifying specter haunts the long-term use of minor
tranquilizers - the possibility of brain atrophy. Although rarely
mentioned in establishment books or reviews, in their letter to the
editor in the July 1989 Archives of General Psychiatry, Isaac Marks
and his ten colleagues summarize the as yet brief literature: "The
cerebral ventricular enlargement reported in patients with
anxiety/panic disorders who were long-term benzodiazepine users could
be due to the disorder or to other factors rather than to the drugs,
but wisdom advises caution" (p. 669). In fact, the cerebral
ventricular enlargement - the equivalent of atrophy of the brain - is
most likely due to the drugs. C. Schmauss and J-C. Kreig in
"Enlargement of Cerebrospinal Fluid Spaces in Long-Term
Benzodiazepine Abusers" in the 1987 Biological Medicine found that
"our data suggest that the increase in the VBRs [ventricular
enlargement] is dose-dependent on long-term BDZ [benzodiazepine]
medication" (p. 873).

I mentioned the studies on brain atrophy to one expert who replied
that although he had not heard of them, he was not surprised. "The
minor tranquilizers are like alcohol," he observed, "and alcohol when
used long-term causes brain shrinkage." He asked to remain anonymous
for fear of offending other drug experts.

See also:
#

Peter R. Breggin M.D. & The International Center for the Study of
Psychiatry &
Psychology
#

Withdrawal Reactions from Benzodiazepines
#

Xanax - Approved for Panic Disorder from Toxic Psychiatry, Chapter 11
#

Brain-Disabling Effects of Benzodiazepines

http://www.benzo.org.uk/breggin2.htm