Benzodiazepines: How They Work and How to Withdraw (aka The Ashton Manual)

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These results have raised the question of whether benzodiazepines can cause structural brain damage. Like alcohol, benzodiazepines are fat soluble and are taken up by the fat-containing (lipid) membranes of brain cells. It has been suggested that their use over many years could cause physical changes such as shrinkage of the cerebral cortex, as has been shown in chronic alcoholics, and that such changes may be only partially reversible after withdrawal. However, despite several computed tomography (CT) scan studies, no signs of brain atrophy have been conclusively demonstrated in therapeutic dose users, and even the results in high dose abusers are inconclusive. It is possible that benzodiazepines can cause subtle changes which are not detected by present methods, but on the available evidence there is no reason to think that any such changes would be permanent. Gastrointestinal symptoms Dependence. Benzodiazepines are potentially addictive drugs: psychological and physical dependence can develop within a few weeks or months of regular or repeated use. There are several overlapping types of benzodiazepine dependence. Regular moderate exercise is recommended during withdrawal as it maintains general fitness, builds up stamina, increases the circulation to brain, muscle and skin and improves mood, but there is no point in slavishly doing exercises that you hate. The aim is to lead a healthy lifestyle which by definition includes some exercise in a form that is enjoyable for you. Smoking Teaches patients to understand their thinking patterns so that they can react differently to anxiety-provoking situations During benzodiazepine withdrawal, symptoms characteristically wax and wane, varying in severity and type from day to day, week to week, and even during the course of a day. Some symptoms come and go; others may take their place. There is no need to be discouraged by these wave-like recurrences; the waves become less severe and less frequent as time passes. Typically “Windows” of normality, when you feel positively well for a few hours or days, appear after some weeks; gradually the “Windows” become more frequent and last longer, while any intervening discomfort ebbs away.

Mechanisms of action. Anyone struggling to get off their benzodiazepines will be aware that the drugs have profound effects on the mind and body apart from the therapeutic actions. Directly or indirectly, benzodiazepines in fact influence almost every aspect of brain function. For those interested to know how and why, a short explanation follows of the mechanisms through which benzodiazepines are able to exert such widespread effects. At the same time, the nerves to the muscles are hyperexcitable, leading to tremor, tics, jerks, spasm and twitching, and jumping at the smallest stimulus. All this constant activity contributes to a feeling of fatigue and weakness (“jelly-legs”). In addition, the muscles, especially the small muscles of the eye, are not well co-ordinated, which may lead to blurred or double vision or even eyelid spasms (blepharospasm). T he benzodiazepine withdrawal symptom that raises most fear of going mad is hallucination. Terrifying hallucinations have occurred in people undergoing rapid or abrupt withdrawal from high doses, but the reader can be reassured that they are exceedingly rare with slow dosage tapering as outlined in Chapter II. If hallucinations occur, they are usually visual – patients have described hallucinations of a large bat sitting on the shoulder, or the appearance of horns sprouting from a human head – but auditory, olfactory and tactile hallucinations can also occur. Somewhat less frightening are hallucinations of small creatures, usually insects, which may be associated with the sensations of insects crawling on the skin (similar hallucinations occur in cocaine and amphetamine withdrawal). Sometimes hallucinations merge with illusions and misperceptions. For example, a coat hanging on the door may give the illusion of being a person. Floors apparently tilting and walls that seem to slope inwards are perceptual distortions. The advice given to prescribed benzodiazepine users (and their doctors) in the 'Ashton Manual' remains relevant today and requires little updating. This supplement adds further information in response to questions that have frequently been asked by benzodiazepine users during and after withdrawal. Such questions are difficult to answer because, like most benzodiazepine problems, they depend on many individual factors. Such factors include personality and genetic make-up, reasons for benzodiazepine prescription, dose, duration and type of benzodiazepine use, present symptoms, environmental stresses and others. Individuals seeking answers from the general information provided in this supplement need to work out which factors apply to them personally.

Discontinuing after short-term use

Drug withdrawal reactions in general tend to consist of a mirror image of the drugs’ initial effects. In the case of benzodiazepines, sudden cessation after chronic use may result in dreamless sleep being replaced by insomnia and nightmares; muscle relaxation by increased tension and muscle spasms; tranquillity by anxiety and panic; anticonvulsant effects by epileptic seizures. These reactions are caused by the abrupt exposure of adaptations that have occurred in the nervous system in response to the chronic presence of the drug. Rapid removal of the drug opens the floodgates, resulting in rebound overactivity of all the systems which have been damped down by the benzodiazepine and are now no longer opposed. Nearly all the excitatory mechanisms in the nervous system go into overdrive and, until new adaptations to the drug-free state develop, the brain and peripheral nervous system are in a hyperexcitable state, and extremely vulnerable to stress. Acute withdrawal symptoms

These sensations return towards normal as withdrawal progresses, and some people are pleased with the new, seemingly extraordinary, clarity of their perceptions. Only in withdrawal do they realise how much their senses have been obscured by benzodiazepines. One lady described how thrilled she was when she could suddenly see individual blades of grass in her newly bright green lawn; it was like the lifting of a veil. Thus, these sensations need not give rise to fear; they can be viewed as signs of recovery. Depersonalisation, derealisation Once started on an antidepressant for depression, the treatment should be continued for some months (usually about 6 months) to avoid recurrence of the depression. Benzodiazepine tapering can continue during this time, and the antidepressant will sometimes act as a welcome umbrella during the last stages of withdrawal. It is important to finish the benzodiazepine withdrawal before starting to withdraw the antidepressant. Quite often, people taking long-term benzodiazepines are already taking an antidepressant as well. In this case they should stay on the antidepressant until the benzodiazepine withdrawal is complete.However, there are some drugs which may help to control particular symptoms in withdrawal and which deserve consideration in certain situations though not recommended for routine use. Usually they will only be required temporarily, but they can sometimes ease a difficult situation and enable the user to proceed with the withdrawal program. Antidepressants In the UK clobazam (Frisium) and clonazepam (Rivotril) are licensed for use as anti-epileptics only. Table 3 shows the symptoms most likely to be long-lasting. These include anxiety, insomnia, depression, various sensory and motor symptoms, gastrointestinal disturbances, and poor memory and cognition. The reasons why these symptoms persist in some people are not clear. Probably many factors are involved, some directly due to the drug and some to indirect or secondary effects (See Table 4). TABLE 3. SOME PROTRACTED BENZODIAZEPINE WITHDRAWAL SYMPTOMS Symptoms