OURN L OF THE ROYAL SOCIETY OF MEDICINE Volume 88 February 99 Alcohol an d benzodiazepines generate anxiety panic and phobias Samuel Cohen MD FRCPsych J R S o c Med 1996;88:73-77 Keywords: alcohol; benzodiazepines; anxiety; panic; phobias SUMMA RY I n almost half t h e patients seeking advice foranxiety, panic a n d phobias t he cause w as alcohol or benzodiazepines. I n t h e remainder i t w as psychological usually a state of conflict o r a traumatic event. When symptoms ar e persistent following a distressing event i t is often the case that alcohol o r benzodiazepines a r e keeping them going. There i s a large variation i n individual vulnerability a n d t he mechanism responsible f o r these symptoms i s rebound arousal. Many ca n accept t h e need t o stop thesesubstances when the above i s explained, a n d when i t i s pointed o u t that they have a choice between the symptoms a n d t h e drink o r tablets. These patients a r e often extremely i l l a n d c an be restored t o complete Illustrative case-histories a r e given. INTRODUCTION Many people have anxious temperaments a n d minor phobias ar e very common. Doctors a r e consulted a s a rule only if anxiety o r a phobia begins t o interfere with daily living. When consulted about problems of this kind o n e very important question t o a s k i s What has caused the person s level o f anxiety o r arousal to rise above i t s basal level s o a s t o make intolerable features that were previously contained? T h e common psychological causes o f severe anxiety a re t h e presence o f persisting major conflicts i n t h e person s life o r the occurrence o f a major distressing event. I n the former case, t he anxiety willsubside when the conflict i s resolved i n o n e w a y o r another and, i n t h e latter, i t will subside with th e passage o f time. I f i t does not, then o n e must ask What i s keeping i t going? T he answer t o both these questions m a y frequently b e t he taking o f alcohol, n o t necessarily i n amounts that would b e regarded a s alcohol abuse , o r the taking o f benzodiazepine drugs a n d t h e mechanism responsible f or t h e generation o f the anxiety i s rebound arousal. A COMMON PROBLEM A l l patients referred foranxiety orphobias seen f o r t h e first time i n o n e unselected general teaching-hospital psychiatric clinic over a period o f 2 years, 1988/1990 were reviewed. A n assessment w a s made o f t h e frequency with which alcohol o r benzodiazepines were the cause o f these symptoms. T h e only criterion for causation wa s that t h e patients lost their symptoms when they stopped taking these substances. There were 5 9 such patients i n whom there w a s n o reference t o alcohol or benzodiazepine u s e i n t h e referral letter except f o r Case 4 (below) where i t h a d n o t been appreciated b y the referrer that there w a s any connection between the drug a n d t h e symptoms. I n 2 2 o f t h e 5 9 patients alcohol w a s t h e cause o f t h e symptoms a n d i n four benzodiazepines. Four more refused t o stop their benzodiazepine drugs a n d although i t was probable that these were t h e cause of t h e symptoms o n e could n o t b e a s certain a s i n t h e cases ofthose w h o were relieved when they stopped. I n t h e remaining 3 3 patients, th e cause w a s o n o f t h e usual psychological causes o f these symptoms such a s a major persisting conflict. From t h e patients reviewed t h e following group o f seven, w h o illustrate different points i n diagnosis a n d management were selected. They were a l l severely i l l a n d became completely well when they stopped taldng these substances s o that each example allows a before/after comparison t o b e made. ILLUSTRATIVE EXAMPLES Case I A 55-year-old senior civil servant h a d A severe phobia o f being with people for several weeks. His work involved contact with t h e public a n d he had h a d to run o u t o f t h e office when someone entered. H e h a d attended a self-help phobias group without a n y improvement. There had been no recent major disturbing events i n h i s life b u t h e was a very heavy drinker, suffered from morning shakes, w a s extremely anxious a n d w a s trembling. S i x weeks after stopping drinldng h e wa s free o f symptoms. Professor Emeritus o f Psychiatry, T h e London Hospital Medical Colege London Cormspondence t o : Professor S Cohen 8 Unnell Drive, London N W I 1 7LT, U K 7 3
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7/25/2019 Alcohol and Benzodiazepines Generate Anxiety, Panic and Phobias
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OURN L OF THE ROYAL SOCIETY OF MEDICINE Volume 88 February 99
A l c o h o l an d benzodiazepines generate anxietypanic an d phobiasSamuel Cohen MD F R C P s y c h
J R S o cMed 1 9 9 6 ; 8 8 : 7 3 - 7 7
K e y w o r d s :a l c o h o l ;b e n z o d i a z e p i n e s ;a n x i e t y ;p a n i c ;p h o b i a s
SUMMARY
I na l m o s th a l ft h e p a t i e n t s s e e k i n ga d v i c ef o r a n x i e t y ,p a n i ca n d p h o b i a st h e c a u s e w as a l c o h o l o r b e n z o d i a z e p i n e s .
I nt h e r e m a i n d e ri t w as p s y c h o l o g i c a l u s u a l l y a s ta t e o f c o n f l i c to r a t r a u m a t i ce v e n t . When symptoms a r e p e r s i s t e n t
f o l l o w i n ga d i s t r e s s i n ge v e n t i t i s o f te n t hec a s e t h at a l c o h ol o r b e n z o d i a z e p i n e sa r e k e e p i n gthem g o i n g .T h e r ei s a
l a r g ev a r i a t i o ni n i n d i v i d u a l v u l n e r a b i l i t ya n d t h e mechanism r e s p o n s i b l ef o rt h e s e symptoms i s r e b o u n da r o u s a l .
M a n yc a na c c e p tt h en e e dt os t o pt h e s e s u b s t a n c e sw h e nt h ea b o v ei se x p l a i n e d ,a n dw h e ni t i sp o i n t e do u tt h a tt h e yh a v ea c h o i c eb e t w e e nt h es y m p t o m sa n d t h ed r i n ko r t a b l e t s .T h e s ep a t i e n t sa r eo f t e ne x t r e m e l yi l la n dc a nb er e s t o r e dt oc o m p l e t eh e a l t h .I l l u s t r a t i v ec a s e - h i s t o r i e sa r eg i v e n .
INTRODUCTION
M a n yp e o p l eh a v ea n x i o u st e m p e r a m e n t sa n dm i n o rp h o b i a sa r ev e r yc o m m o n .D o c t o r sa r ec o n s u l t e da s a r u l eo n l yi fa n x i e t yo r a p h o b i ab e g i n st o i n t e r f e r ew i t hd a i l yl i v i n g .W h e nc o n s u l t e da b o u tp r o b l e m so f t h i sk i n do n e v e r yi m p o r t a n tq u e s t i o nt o a s ki s W h a th a sc a u s e dt h e p e r s o n s
l e v e lo fa n x i e t yo ra r o u s a lt or i s ea b o v ei t sb a s a ll e v e ls oa st om a k ei n t o l e r a b l ef e a t u r e st h a tw e r ep r e v i o u s l yc o n t a i n e d ?T h e c o m m o np s y c h o l o g i c a lc a u s e so fs e v e r ea n x i e t ya r et h ep r e s e n c eo fp e r s i s t i n gm a j o rc o n f l i c t si n t h ep e r s o n sl i f eo rt h eo c c u r r e n c eo fa m a j o rd i s t r e s s i n ge v e n t .I n t h ef o r m e rc a s e ,t h ea n x i e t yw il l s u b s i d ew h e nt h ec o n f l i c ti sr e s o l v e di no n ew a yo ra n o t h e ra n d ,i nt h el a t t e r ,i t w i l ls u b s i d ew i t ht h ep a s s a g eo ft i m e .I fi t d o e sn o t ,t h e no n e m u s t a s k W h a ti sk e e p i n gi t g o i n g ?T h e a n s w e rt o b o t ht h e s eq u e s t i o n sm a yf r e q u e n t l yb e t h e t a k i n go f a l c o h o l ,n o t n e c e s s a r i l yi na m o u n t st h a tw o u l db er e g a r d e da s a l c o h o la b u s e ,o r t h et a k i n go f b e n z o d i a z e p i n e d r u gsa n d t h e m e c h a n i s m
r e s p o n s i b l ef o r t h eg e n e r a t i o no f t h ea n x i e t yi s r e b o u n da r o u s a l .
A COMMON PROBLEM
A l lp a t i e n t sr e f e r r e df o r a n x i e t yo r p h o b i a ss e e nf o rt h ef i r s tt i m ei n o n e u n s e l e c t e dg e n e r a lt e a c h i n g - h o s p i t a lp s y c h i a t r i c
c l i n i co v e ra p e r i o do f2 y e a r s ,1 9 8 8 / 1 9 9 0w e r er e v i e w e d .A n a s s e s s m e n tw a s m a d e o f t h e f r e q u e n c yw i t hw h i c ha l c o h o lo r b e n z o d i a z e p i n e sw e r e t h e c a u s eo f t h e s es y m p t o m s .T h e o n l yc r i t e r i o n f o rc a u s a t i o nw a s t h a tt h ep a t i e n t sl o s tt h e i rs y m p t o m sw h e nt h e ys t o p p e dt a k i n gt h e s es u b s t a n c e s .T h e r ew e r e5 9 s u c hp a t i e n t si nw h o mt h e r ew a sn o r e f e r e n c et oa l c o h o l o rb e n z o d i a z e p i n eu s ei nt h er e f e r r a ll e t t e re x c e p tf o rC a s e 4 ( b e l o w )w h e r ei t h a d n o t b e e na p p r e c i a t e db yt h er e f e r r e rt h a tt h e r ew a s a n y c o n n e c t i o nb e t w e e nt h ed r u ga n dt h es y m p t o m s .I n2 2 o ft h e5 9 p a t i e n t sa l c o h o lw a s t h e c a u s eo f t h e s y m p t o m sa n d i n f o u rb e n z o d i a z e p i n e s .F o u r m o r e r e f u s e dt o s t o p t h e i rb e n z o d i a z e p i n ed r u g sa n da l t h o u g hi t w a s p r o b a b l et h a tt h e s ew e r e t h ec a u s eo ft h es y m p t o m so n e c o u l dn o t b e a sc e r t a i na si n t h ec a s e so f t h o s ew h ow e r er e l i e v e dw h e nt h e ys t o p p e d .I nt h er e m a i n i n g3 3 p a t i e n t s ,t h ec a u s ew a s o n e o ft h eu s u a lp s y c h o l o g i c a lc a u s e so ft h e s es y m p t o m ss u c ha s am a j o r p e r s i s t i n gc o n f l i c t .F r o mt h ep a t i e n t sr e v i e w e dt h ef o l l o w i n gg r o u po fs e v e n ,w h oi l l u s t r a t ed i f f e r e n tp o i n t si nd i a g n o s i sa n dm a n a g e m e n tw e r e s e l e c t e d .T h e y w e r e a l ls e v e r e l yi l la n db e c a m ec o m p l e t e l yw e l lw h e nt h e ys t o p p e dt a l d n gt h e s es u b s t a n c e ss o t h a te a c he x a m p l ea l l o w sab e f o r e / a f t e rc o m p a r i s o nt o b em a d e .
ILLUSTRATIVE EXAMPLES
Case I
A 5 5 - y e a r - o l ds e n i o rc i v i ls e r v a n th a d As e v e r ep h o b i ao fb e i n gw i t hp e o p l ef o r s e v e r a lw e e k s .H i sw o r ki n v o l v e dc o n t a c tw i t ht h ep u b l i ca n dh e h a dh a dt o r u n o u t o ft h eo f f i c ew h e ns o m e o n ee n t e r e d .H e h a da t t e n d e da s e l f - h e l pp h o b i a sg r o u pw i t h o u ta n yi m p r o v e m e n t .T h e r eh ad b ee nn or e c e n tm a j o rd i s t u r b i n ge v e n t si n h i sl i f eb u th e w a s a v e r yh e a v yd r i n k e r ,s u f f e r e df r o mm o r n i n gs h a k e s ,w a se x t r e m e l ya n x i o u sa n d w a s t r e m b l i n g .S i x w e e k s a f t e rs t o p p i n gd r i n l d n gh ew a s f r e eo fs y m p t o m s .
P r o f e s s o rE m e r i t u so f P s y c h i a t r y ,T h e L o n d o nH o s p i t a lM e d i c a lC o l e g eL o n d o nUKC o r m s p o n d e n c et o :P r o f e s s o rS C o h e n 8 U n n e l lD r i v e ,L o n d o nN W I1 7 LT,UK 7
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JOU RNAL OF THE ROYAL S O C I E T Y OF MEDICINE Vo l u m e 88 February 1995
F o l l o wup
A y e a rl a t e rh e a t t e n d e dw i t ha r e c u r r e n c eo f t h es a m es y m p t o m sh ew a s a g a i nd r i n l d n ga n d t h es y m p t o m sw e r ea g a i nr e l i e v e dw h e nh es t o p p e d .A r r a n g e m e n t sw e r em a d ef o rh i m t o a t t e n do n e o f t h ea g e n c i e sf o rh e l p i n gh e a v yd r i n k e r s .
C o m m e n t
T h i sp a t i e n tw a s p r o b a b l ys u f f e r i n gf r o mr e p e a t e da l c o h o lw i t h d r a w a ls y m p t o m sp r o d u c e db y t h er e b o u n da r o u s a lf o l l o w i n gt h eh e a v yd r i n l d n g o ft h ep r e v i o u sn i g h t .I t i se s s e n t i a lt o m a k et h ec o r r e c td i a g n o s i sb e f o r et r e a t m e n t ;s e l f - h e l pg r o u p sw i l ld o n o d t i n gf o ra p o i s o n e db r a i n .
Case 2
T h i s 2 7 - y e a r - o l dwoman h a d b e e n a n x i o u s ,t e n s e ,d e p r e s s e d ,i r r i t a b l ew i t hp o o r s l e e pa n d a p p e t i t ef o r
s e v e r a ly e a r s .M o r er e c e n t l y ,s h eh a dd e v e l o p e da n x i o u sh y p e r v e n t i l a t i o nw i t hp i n sa n dn e e d l e s .A t t i m e st h es y m p t o m sa m o u n t e dt o s e v e r ep a n i c .T h e r ew e r e m a j o rp r o b l e m si nh e rl i f ew h i c hh a d i n c r e a s e dd u r i n gt h e t i m et h a ts h eh a d h a dh e rs y m p t o m sa n df o r2 y e a r ss h eh a db e e nt r e a t e db y a p s y c h o l o g i s ta t t a c h e dt oa g e n e r a lp r a c t i c e .S h ew a s d r m i d n gh a l fa b o t t l eo r m o r e o f w h i s k yp e rd a y b e c a u s eo f t h ep r o b l e m sa n da n x i e t y .F i v ew e e k sa f t e rs t o p p i n gd r i n l d n gs h eh a dn o s y m p t o m s .
C o m m e n t
T h eq u e s t i o nh e r ew a sw h i c hw a st h ec a r ta n dw h i c hw a st h eh o r s e ?W a ss h e d r i n k i n gb e c a u s e o fh e rp r o b l e m so r d i d s h eh a v es y m p t o m sb e c a u s eo ft h ea l c o h o l ? :i . e .w h a tw a s t h ed i a g n o s i s ?T h e o n l yw a yt o r e s o l v et h i sq u e s t i o ni s t o s t o pd r i n l i n ga n d t o r e v i e wa f t e rs e v e r a lw e e k s .
P r o b l e m sl i k et h ea b o v ea r ec o m m o nb u tf r o mt i m e t ot i m e o n e s e e sp a t i e n t sw i t hs i m i l a rs y m p t o m sw h o s ec o n s u m p t i o no fa l c o h o li s a p p a r e n t l ym u c hm o r e m o d e s t ,a s i n t h ef o l l o w i n ge x a m p l e .
Case 3
A 3 5 - y e a r - o l dm an h a d b e c o m et o of r i g h t e n e dt o d r i v eh i s
l o r r y .He w a s d r i n l d n ga b o u tn i n ew h i s k i e sa n d t w o g l a s s e so fl a g e ro n c e o r o c c a s i o n a l l yt w i c e e a c hw e e k e n da n dw a s
t o t a l l yr e l i e v e do fh i ss y m p t o m sa f e ww e e k sa f t e rs t o p p i n gd r i n l d n g .H i sw i f ew a s c o n f i d e n tt h a th ew a s n o t d r i n l d n gm o r et h a nh e s t a t e da s s h ew a s a l w a y sp r e s e n ti n t h ep u bw i t hh i ma n dh ed i dn o t d r i n ka t h o m e .
C o m m e n t
W h i l s to n e c a n n e v e r b e c e r t a i na b o u tt h ea m o u n tt h a ts o m e o n ei s d r i n l d n gi t i s i m p o r t a n tt o c o n s i d e rt h a ts o m ep e o p l ea r e m u c h m o r e v u l n e r a b l et h a no t h e r si n t h e i rr e s p o n s et o d r u g sa n do t h e rs u b s t a n c e s .
Case 4
A 3 2 - y e a r - o l dm a r r i e dw o m a nw h ow a sa s e n i o r s e c re ti n a f i n a n c i a li n s t i t u t i o nw a s r e f e r r e df o r h e l pw i t hb e n z o d i a z e p i n ew i t h d r a w a la n d p h o b i ca n x i e t y .S h e h a db e e na n e r v o u s c h i l dw i t ha f e a ro fh e i g h t sa n ds h eh a d t w i c ep r e v i o u s l ye x p e r i e n c e de p i s o d e so fp a n i c ,b o t h i nt h es e t t i n go fu p s e t t i n ge v e n t si nh e rl i f e1 0y e a r sa n d4 y e a r s p r e v i oa n db o t hh a ds u b s i d e d .S h eh ad b ee nh a p p i l ym a r r i e df o r1 0y e a r sb u ts h ea n d h e rh u s b a n d w e r e d i s t r e s s e da t h e ri n f e r t i l i t y ,w h i c hw a s f u l l yd i s c u s s e dw i t ht h e m . Tw o y e a r sp r e v i o u s l ys h eh a dh a da n i n v i t r of e r t i l i z a t i o nw h i c hh a df a i l e d .S h eb e c a m ed i s t r e s s e da n dw a sg i v e nL o r a z e p a mI m ga n dD i a z e p a m1 O m gd a i l yw h i c hs h ew a s s t i l lt a k i n g .S h eh a d b e e na n x i o u sa n d p a n i c k ye v e r s i n c e .I t w a su n d e r s t a n d a b l et h a ts h es h o u l dh a v eb e c o m ed i s t r e s s eb u ti t s e e m e du n u s u a lt h a th e rs y m p t o m sh a dp e r s i s t e ds i n c ep r e v i o u s l yi nh e rl i f ea n x i e t yf o l l o w i n gd i s t r e s s i n ge v e n t sh a ds u b s i d e d .I t w a s r e a s o n a b l et o s u p p o s et h a t t h eb e n z o d i a z e p i n ed r u g sw e r e p r o l o n g i n gi t . T h e r e w a s n ow a y o fa s c e r t a n i n a g t h ec a u s eu n t i la f t e rt h ed r u g sw e r es t o p p e d .S h ew a s a d v i s e da c c o r d i n g l ya n d8 w e e k sl a t e rs h es a i d I am v e r yw e l l - p e o p l eh a v eb e e nt e l l i n gm e h o ww e l lI l o o k .T h e o n l ys y m p t o m ss h eh a da f t e r8 w e e k sw e r es o m em y o c l o n i cj e r k sw h i c hh a db e e n p r e s e n ta t t h es t a r ta n dw e r eg r a d u a l l yd e c l i n i n gi n f r e q u e n c y .
F o l l o wup
A y e a rl a t e rs h et e l e p h o n e da ss h eh a db e c o m ep a n i c k ya n di tt u r n e do u tt h a tt h i sh a dh a p p e n e dw h e n a f r i e n di n a
n e i g h b o u r i n go f f i c eg a v eb i r t ht o a b a b y .T h e s y m p t o m ss u b s i d e di n a b o u ta w e e kw i t hn o s p e c i a lt r e a t m e n t : I dn e v e rt a k ea n o t h e rt a b l e t .
C o m m e n t
T h e p e r s i s t i n gm y o c l o n i cj e r k s ,a r e b o u n dp h e n o m e ni n d i c a t et h a tt h e b ra i nh a ss t i l ln o t r e t u r n e dt o i t sn o r m a ls t a t e .
Case 5
A m a r r i e d51- y e a r - o l dwoman w a sr e f e r r e df r o mt h ed e n t a ld e p a r t m e n ta s s h en e e d e dd e n t u r e sb u t c o u l dn o t t o l e r a tt h i n g sp u ti nh e rm o u t ha n db e h a v i o u r a lm e t h o d so fh e l p i nh e rh a df a i l e d .S h es a i d ,h o w e v e r ,t h a th e rm a i np r o b l ew a sn o t t h i sb u t a n x i e t y ,p a n i ca n dd e p r e s s i o nf o r3 0 y e a r s S h eh a d n e v e rb e e n a n a n x i o u sp e r s o nb e f o r et h ea g eo f2 1a n da t t h a tt i m e h a da p a n i ca t t a c kf o l l o w i n ga n a b o r t i o nS h eh a db e e no n s e d a t i v e so fv a r i o u sk i n d se v e r s i n c e ,m o r e
r e c e n t l yt a k i n gO x a z e p a m1 Sm g d a i l y .S h eh a dh a ds y m p t o m se v e rs i n c e .S i xw e e k sa f t e rs t o p p i n gt h et a b l e t s I c o u l d n tb r e a t h e - Ih a dt e n s i o ni nm y a r m sa n dl e g s - i t g o n e .A f t e r1 2w e e k s , I mv e r yw e l lt h a n kyou a g r e a ti m p r o v e m e n t .A t t h a tp o i n tI a s k e dh e rw h e t h e rs h ew i s h e4
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JOU RNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 88 February 99
t o d ea lw i t h t h ep r o b l e mw i t hh e rt e e t ht ow h i c hs h er e p l i e d I m i g h tb e t o o t h l e s sb u tI mc a l m e r .
C o m m e n t
A f t e rs t o p p i n ga s o - c a l l e ds e d a t i v es u b s t a n c et h i sp a t i e n ti sc a l m e r .
Case 6
T h i s7 5 - y e a r - o l dw o m a nh a d a l w a y sb e e n r a t h e rp h o b i co fl i f t sa n dt r a i n s .F o r2 y e a r ss h eh a dh a ds e v e r ea n x i e t y ,p a n i c ,t e r r o r ,m i s e r y ,f o l l o w i n ga no p e r a t i o no n h e rk n e es i n c ew h e ns h eh a dt a k e nL o r a z e p a m2m g d a i l y .S h ew a ss of r i g h t e n e dt h a ts h ec o u l d n o ts t a y i nt h ec a rw h i l s th e rh u s b a n dw e n ti n t oa s h o pt o b u y a n e w s p a p e r .H e r t a b l e t sw e r e s t o p p e do v e ra p e r i o do f4 w e e k s .At t h ee n do f5w e e k ss h es a i di t h a db e e n t h ew o r s t5 w e e k so fm y l i f e .A t8 w e e k st h e r eh ad b ee na f e ws p e l l so ff e e l i n gn o r m a ll a s t i n g
f o ru p t o ad a y .A t 1 2w e e k ss h ew a s o n l yo c c a s i o n a l l yt e a r f u lo r a n x i o u s ;s e v e r ei n s o m n i ap e r s i s t e db u ts h eh a db e e n i n al i f t A t 1 6w e e k ss h ew a s c o m p l e t e l yw e l la n dh a p p y .S h ec o u l ds i ti n t h ec a rl o n ge n o u g hf o rh e rh u s b a n dt oh a v eh i sh a i rc u t .
Case 7
A s e v e r ea g o r a p h o b i cs i n c e1 7t h i s5 5 - y e a r - o l dwoman h a dh a da l e u c o t o m y ,a f t e rw h i c hs h ew a s a b l e t oc o p er a t h e rb e t t e ra n de v e n t u a l l yt o m a r r y .S h ea l w a y sn e e d e do n e
p e r s o nw i t hh e rw h e ns h ew e n to u tb u t1 0y e a r sp r e v i o u s l yb e g a nt on e e dt w op e o p l ea n ds o o na f t e r w a r d ss t o p p e dg o i n go u ta l t o g e t h e r .S h ew a sa t t e n d i n ga s u p p o r t i v ec l i n i cr u n b ya c o l l e a g u ew h of o u n dt h a th e c o u l dn o l o n g e rs u p p o r th e ra sa n o u t p a t i e n t .H e rh u s b a n dw a sa t t h ee n do fh i st e t h e ra n dh er e q u e s t e da d m i s s i o n .T h er e w e r em a n yp r o b l e m si nh e rl i f e a n d u p b r i n g i n gt h a t w e r e r e s p o n s i b l ef o r t h ed e v e l o p m e n to f s y m p t o m si n h e rt e e n sb u tw e a d d r e s s e dt h eq u e s t i o no fw h yt h e yb e c a m ep r o g r e s s i v e l ym o r es e v e r e1 0 y e a r se a r l i e r .T h e r ew a s f u l ld o c u m e n t a t i o no f h e rt r e a t m e n tf o ro v e r3 0 y e a r sa n dwe w e r ea b l et os e et h a ts h eh a ds t a r t e dt r e a t m e n tw i t hC h l o r d i a z e p o x i d ei n 1 9 6 9w h i c hw a s l a t e rc h a n g e dt oD i a z e p a m .T h e r eh ad b ee na n i n c r e a s e
i n t h ed o s e a b o u t1 5 y e a r sb e f o r ea n ds h eh a dt a k e nD i a z e p a m4 0 m g a t l e a s td a i l ys i n c et h e n ,o c c a s i o n a l l ym o r e .I t s e e m e dr e a s o n a b l e t h e r e f o r et o b e g i nb ya t t e m p t n gt os t o pt h i sd r u ga n dw h e ns h ew a sg i v e na n e x p l a n a t i o no fw h yt h i sc o u l db e h e l p f u lh e rr e s p o n s ew a s i fy o us a yt h a t sw h a tt h e yd o I d o n tw a n tt ot a k et h e m .F o u rw e e k sa f t e rt h el a s td o s e s h eb e g a nt ow a l ka sf a ra st h eh o s p i t a ls h o p .A t t h ee n do f1 0w e e k ss h ew e n th o m eb u ts t i l lh a d m a n ys y m p t o m s .A f t e r2 0 w e e k st h ec o l l e a g u ev i s i t e dh e ra th o m ea n dw r o t e
m u c ht om y s u r p r i s et h es i t u a t i o nh a dt o t a l l yc h a n g e d .S h ea p p e a r e dc a l ma n dc h e e r f l . . g o i n go u t e v e r yd a y. . . v i s i t i n ga f r i e n d .S h eh a dn o t b e e na b l et o g o t i sf a rf r o mh o m ef o r2 0 y e a r s .S h eh a sb e e n
t a k i n gh e rd o gf o ra w a l ka n ds i t t i n go n a b e n c hw a t c i n gt h ew o r l dg o b y .S h eg o e so u tt o b u y t o b a c c oa n d p a p e r sf o rh e rh u s b a n dw i t h o u tp a n i d k n g .
A y e a rl a t e rs h ew a sd o i n ge v e nm o r e .
DISCUSSION
Rebound
W h e na n ys e l f - r e g u l a t i n gp h y s i o l o g i c a ls y s t e mi s s u b j e c tt oi n t e r f e r e n c ei t s c o n t r o lm e c a n i s mr e s p o n d ss o a s t om i n i m i z et h ee f f e c to ft h ei n t e r f e r e n c e .I f t h ei n t e r f e r e n c ec e a s e st h e nr e b o u n dp h e n o m e n aw i l la p p e a ra n dw i l lb em o r e s e v e r ei f t h e i n t e r f e r e n c es t o p ss u d d e n l y .T h u s ,r e b o u n de f f e c t sf o l l o w i n gt h eu s eo f d r u g sa r eg e n e r a l l ym o r es e v e r ew i t ht h o s ed r u g st h a th a v ea s h o r th a l f - l i f ea si s
v e r yw e l lk n o w ni n t h ec a s eo ft h eb e n z o d i a z e p i n e sw h e na f t e ra n e v e n i n gd o s e ,e a r l ym o r n i n gi n s o m n i ai sf o l l o w e db yi n c r e a s e da n x i e t yt h ef o l l o w i n gd a y .R e b o u n dp h e n o m e n aw i t ht h e u s eo fb e n z o d i a z e p i n e sh a v eb e e nk n o w nf o ra l o n gt i m e l A 3 .S i m i l a r l yw i t ha l c o h o la n da s l o n g a g oa s 1 9 7 3O s w a l d st e a m( O g u n r e m ie t a l . 4c o m m e n t i n go n r e b o u n dw a k e f u l n e s sa n da n x i e t ya s a c o n s e q u e n c eo f s t o p p i n gb a r b i t u r a t e so r a l c o h o ls t a t e dt h a tt h ep a t i e n t s m a yt h e nt u r nf o rr e l i e ft o t h ev e r ya g e n t st h a th a v ec o n t r i b u t e dt ot h e i ra n x i e t y .T h i sp r o b l e mi s n o ta t a l lu n u s u a lf o l l o w i n gb e r e a v e m e n to r a m a j o rt r a u m aw h e nb e n z o d i a z e p i n e sa r eg i v e ni n a p p r o p r i a t e l y ,o r p e o p l eb e g i nt o d r i n k ;t h es y m p t o m sw h i c hw o u l dt h e nb e e x p e c t e dt o s u b s i d ed on o td o s o .A l c o h o la b u s ea m o n gp a t i e n t sw i t hs o c a l l e d
p o s t - t r a u m a t i cs t r e s sd i s o r d e ri s c o m m o n 5 .
B o t ha l c o h o la n db e n z o d i a z e p i n e sp o t e n t i a t et h ea c t i o no fG A B A 6t h em a j o ri n h i b i t o r yn e u r o t r a n s m i t t e ra n dw h e nt h e ya r es t o p p e dr e b o u n da r o u s a lf o l l o w s ,w i t ha n x i e t ya n ds e i z u r ed i s o r d e r sr a n g i n gf r o mm y o c l o n i cj e r k st og r a n dm a l .W h i l s tt h i se f f e c to f a l c o h o la p p e a r st o s u b s i d er e l a t i v e l yq u i d d yt h ee f f e c to fb e n z o d i a z e p i n e ss e e m st o p e r s i s tf o rv e r ym u c hl o n g e ra st h ea b o v ec a s e si l l u s t r a t e .I ft h ep a t i e n ti s t ob er el i ev ed t h e ni t i sd e s i r a b l et h a tt h ec h a n g e ss h o u l db er e v e r s e da sq u i c l d ya sp o s s i b l ea s a p r o l o n g e dp e r i o do fw i t h d r a w a lw i l lp r o l o n gt h ew i t h d r a w a ls y m p t o m sa n dw i l li n c r e a s et h et e m p t a t i o nt o r e s u m et a k i n gt h ed r u g .G i v i n g
s m a l la m o u n t ss y m p t o m a t i c a l l ya f t e rs t o p p i n gt h ed r u g sm e r e l yp r o l o n g st h ea g o n yo fw i t h d r a w a ls y m p t o m s .
V u l n e r a b i l i t y
T h e r ei s a ne n o r m o u sr a n g eo fv a r i a b i l i t yi n t h er e s p o n s et od r u g sa n do t h e rs u b s t a n c e sn o t l e a s tt o a l c o h o la n db e n z o d i a z e p i n e sa n d s o m e p e o p l e d e v e l o ps y m p t o m so n
d o s e st h a td o n o ta p p e a rt o h a r m o t h e r s .I n t h ec a s eo fa l c o h o lL i s h m a n 7h a ss h o w nt h a to v e ro n e - h a l fo ft h eb r a i n so fh e a v yd r i n k e rc a nb es h o w nt o h a v es h r u n k( a n da b o u th a l fh a d n o t ) .A t m u c hl o w e rl e v e l so fc o n s u m p t i o nt h e r em u s t a l s ob ea v a r i a t i o ni n t h ev u l n e r a b i l i t yo ft h eb r a i ns o 7
7/25/2019 Alcohol and Benzodiazepines Generate Anxiety, Panic and Phobias
http://slidepdf.com/reader/full/alcohol-and-benzodiazepines-generate-anxiety-panic-and-phobias 4/5
JOU RNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 88 February 99
t h a ts o m ep e o p l e d e v e l o pa n x i e t ys ym p to m s o na na m o u n to f a l c o h o lt h a td o e sn o tp r o d u c es y m p t o m si n o t h e r s .P a t i e n t sn o t i n f r e q u e n t l ys a yt h a tt h e yk n o wo fo t h e rp e o p l et a k i n ge v e nl a r g e rq u a n t i t i e so fa l c o h o lo r d r u g sw h oa r en o ti l la n d i t i s t h e r e f o r ei m p o r t a n tt o e x p l a i nt h a tv u l n e r a b i l i t yv a r i e s ,a n d t h a ti t i s n o to n l yt h e a b s o l u t eq u a n t i t yo f
s u b s t a n c et h a t i s i m p o r t a n tb u t t h e q u a n t i t y f o rt h a ti n d i v i d u a l .
H o w t o s t o p b e n z o d i a z e p i n e s
T h e p a t i e n t w i l la s kw h yh e / s h es h o u l ds t o p t a l d n gt h et a b l e t se s p e c i a l l ya sm o s tu s u a l l yf e e ls o m er e l i e ff r o mt h e m .T h ea n s w e rt ot h eq u e s t i o nm u s tc o n s i s to f a ne x p l a n a t i o no fh o wt h e s ed r u g sc a u s e t h es y m p t o m so fa n x i e t y ,s o m e t i m e su s i n ga d i a g r a mt o e x p l a i nt h en a t u r eo fr e b o u n da r o u s a l .I ts h o u l db e p o i n t e do u tt h a th e o rs h ei s s t i l la n x i o u sd e s p i t et a i d n gt h e d r u gs ,t h a tt h eo n l ya n x i e t yt h a ti sb e i n gr e l i e v e d
i s t h a tc a u s e db y t h ed r u ga n dt h a ti f t h e ys t o pt h e yw i l le v e n t u a l l yf e e lm u c hb e t t e rt h a nt h e yh a v ef e l tf o ra l o n gt i m e .I s o m e t i m e sa d dt h a tt h e ym a y n o tb e a b l et or e m e m b e rw h a t i t f e e l sl i k et o h a v ea n o r m a lb r a i n ,o rw o r d st o t h a te f f e c t ,a n dt h a ts l e e pi s l i k e l yt o b e c o m ef a rs o u n d e rt h a ni t h a sb e e nf o ra l o n gt i m e .M o s tp a t i e n t sw i l la s ka b o u tw i t h d r a w a ls y m p t o m ss i n c et h e s eh a v eh a da g r e a td e a lo fp u b l i c i t y .A f u l le x p l a n a t i o ns h o u l db eg i v e no fw h a ti s l i k e l yt oh a p p e n :t h e yw i l lf e e lm o r ea n x i o u s ,t h e ym a yb eu n a b l et o d o t h e i rj o bp r o p e r l y ,t h e i rs l e e pw i l lb e m o r ed i s t u r b e d ,t h e ym a y h a v en i g h t m a r e sa n dt h a t t h e s es y m p t o m sm a y l a s tf o r a n y t h i n gf r o m 3 w e e k s t o 3
m o n t h so rs o ,b u tt h a tt h e ym a yb e o n eo ft h ef o r t u n a t eo n e si n w h i c ht h e ya r eo v e rq u i d d y .I t i s m a d ec l e a r ,h o w e v e r ,t h a tt h e r ei s n o w a y t o o b t a i nt h eb e n e f i t so f s t o p p i n gw i t h o u tg o i n gt h r o u g ht h i sw i t h d r a w a lp e r i o d .I u s u a l l ys a yt h a tm a n yo t h e r sh a v ed o n e s o a n da r ea m o n g s tt h em o s tg r a t e f u lp a t i e n t sI h a v eh a d .I ft h es y m p t o m sa r ei n t o l e r a b l et h e ya r ef r e et o c o m et o s e em e o r s h o u l dg o t o s e et h e i rf a m i l yd o c t o rt ow h o mI a l w a y sg i v ea f u l le x p l a n a t i o no ft h et r e a t m e n tp l a ns o m e t i m e sr e i n f o r c e db ya t e l e p h o n ec a l l .F o r r e a s o n sg i v e na b o v e ,i t i s e s s e n t i a lt o s h o r t e nt h ew i t h d r a w a lp e r i o da s f a ra s p o s s i b l ea n dw h i l s tt h e r ea r ed a n g e r si n r a p i dc e s s a t i o no fv e r y l a r g ed o s e s t h ea v e r a g ep a t i e n tc a nr e a c ha z e r od o s ei n a b o u t2 - 3 w e e k s .Wi t h d r a w a ls y m p t o m sl a s ta v a r y i n gt i m e ,u s u a l l y6 - 8w e e k sb u ts o m e t i m e sl o n g e r .I t i s e s s e n t i a lw h e ng i v i n gt h i sa d v i c et oa v o i dm a k i n gp e o p l ef e e lg u i l t yt h a tt h e ya r et a l d n gt h e s es u b s t a n c e s ,a n d i t s h o u l db e e x p l a i n e dt h a tt h e yh a v eac h o i c eb e t w e e nt h e i rs y m p t o m sa n dt h e i rt a b l e t s ,d i f f i c u l tt h o u g hi t m a yb et om a k et h i sc h o i c e .F i n a l l y ,s o m ej u d g ei tu s e f u lt o r e p l a c ea s h o r ta c t i n gd r u gw i t ha l o n g e ra c t i n gd r u gs u c ha sD i a z e p a mb e f o r eb e g i n n i n gw i t h d r a w a l 8a n di to c c a s i o n a l l yc a n b e h e l p f u ld u r i n gt h ew i t h d r a w a lp h a s et og i v ea s m a l ld o s eo fa p h e n o t h i a z i n eb yd a yo r C h l o r a la tn i g h tt h o u g ht h i si s n o t u s u a l l yn e c e s s a r y .
S i m i l a r l y ,i n t h ec a s eo fp a t i e n t sw h o s es y m p t o m sr e s u l tf r o ma l c o h o l .I t i s i m p o r t a n tt o a v o i dt h eu s e o ft e r m sl i k e a l c o h o l i co r h e a v yd r i n k e ro r a b u s e .T o t a l kd o w nt ot h ep a t i e n ti s l i k e l yt om a k eh i mf e e lt h a th e i sb e i n gt r e a t e dl i k ea n a u g h t yc h i l da n d t o p r o v o k ea n e g a t i v e r e s p ow h e r e a st o g i v eh i m a na d u l tc h o i c eb e t w e e nh i ss u b s t a n ca n dh i ss y m p t o m si sm o r el i k e l yt os u c c e e d .T h i sa p p r o a c hi sp a r t i c u l a r l yu s e f u li n d e a l i n gw i t h a n x i e t ys y m p t o m si nr e l a t i v e l ym o d e s t d r i n k e r sw h e r e t h e r em a y n o tb e ap r o b l e mo fa d d i c t i o n .
A l t h o u g ha n x i e t y ,p a n i ca n dd e p r e s s i o na r ew e l lk n o w nt oo c c u ri nh e a v yd r i n k e r s ,m a n yt e x t b o o k ss t r a n g e l yd o n o tm e n t i o n t h e s es y m p t o m sa n d c o n f i n et h e m s e l v e st op r o b l e m so f a d d i c t i o no n t h eo n e h a n d a n d t o s e r i o u sc o m p l i c a t i o n sl i k e d e m e n t i a ,W e r n i c k e - K o rs y n d r o m e ,p a r a n o i dd i s o r d e ro r m o r b i dj e a l o u s yo n t h eo t h e r .H o w e v e rT h eR o y a lC o l l e g eo fP s y c h i a t r i s t sr e p o r t 9A l c o h o l :O u rF a v o u r i t eD r u gw r i t e st h a t a n y o n ew h ot h i n k sh ei s d r i n k i n gb e c a u s eo fh i s / h e r n e r v e sm u s t a s kw h e t h et h e n e r v e sa r et r o u b l e db e c a u s e o f d r i nl d n g .I t s t a t e st h a ti n a b o u t9 5 o f 1 0 0p a t i e n t sw h e r et h i sq u e s t i o na r i s e st h ea n s w e ri s t h a tt h e d r i n ki s t h ec a u s eo ft h es y m p t o m st h a ta n yt r e a t m e n tw i t hp s y c h o t r o p i cd r u g sw h e r ed e p r e s s i o no r
p h o b i aa r ec a u s e db y a l c o h o lm a ym a k em a t t e r sw o r s ea n dt h a tu s u a l l yt h es y m p t o m sa r er e l i e v e di n 2 w e e k si f t h ep a t i e n t s t o p sd r i n l i d n g .T o o m a n yp a t i e n t sw i t hs i m i l a rs y m p t o m sa r e r e f e r r e dt o v a r i o u sa n c i l l a r i e si n g e n e r ap r a c t i c ea n dr e c e i v es y m p t o m a t i ct r e a t m e n t ,i n s t e a do ft o ap s y c h i a t r i cc l i n i cw h e r ea p r o p e rd i a g n o s i sc o u l db em a d e
( C a s e s1
a n d2 .I t i se r r o n e o u st ot h i n kt h a tt h e s es y m p t o m sc a nb ec a l l e d m i n o r .W h e t h e ra p r o b l e mi sm a j o ro rm i n o rc a nb ed e c i d e do n l ya f t e rt h ed i a g n o s i sh a sb e e n m a d ea n dn o t o n t h en a t u r eo ft h es y m p t o m s .I t h a sb e e nr e p o r t e d l 0I
t h a to v e r h a l fo f 6 0 a l c o h o l i c sh a da g o r a p h o b i ao r s o c i a lp h o b i aa n dt h a ta b s t i n e n c ew a s a s s o c i a t e dw i t hs u b s t a n t ii m p r o v e m e n t .P r o f e s s o rM a r k so fT h e M a u d s l e yH o s p i t a( S a m a r a s i n g h ee t a l .1 2 i n s i s t st h a ts u c hp a t i e n t ss h o u l dw i t h d r a wf r o m t h e s e s u b s t a n c e sb e f o r es t a r t i n gb e h a v i ot h e r a p y .A s h t o n 1 3d e s c r i b e dt h i sp r o b l e mi n t h ec a s eo fb e n z o d i a z e p i n e sv e r yd e a r l yi n 1 9 8 4 ,b u tt h e s ea n do t h e ro b s e r v a t i o n sh a v en o tb e e n t a k e nu p s u f f i c i e n t l yf i r m l yb y
d o c t o r sa n d , a c c o r d i n g l y ,m a n ya r e s u f f e r i n gf r o m v e r yu n p l e a s a n ts y m p t o m so fa n x i e t yo r p h o b i aw h i c hc o u l db er e l i e v e d .I s u s p e c tt h a tm a n ya t t e n d e r sa t s e l f - h e l pg r o u p sa n dc l i n i c sf o r s t r e s s ,t e n s i o no r p h o b i a sa n dm a n yo ft h o s ed i a g n o s e da s p o s tt r a u m a t i cs t r e s sd i s o r d e ra r ep r o b a b ld r i n l d n ga n dw o u l dg e tw e l li ft h e ys t o p p e dc o m p l e t e l yf o ras h o r tt i m e a n ds i m i l a r l yb u t i n s m a l l e rn u m b e r sf o rb e n z o d i a z e p i n e s .
I n t h ec a s eo f a l c o h o li t t a k e st i m e a n dp r o g r e s s id a m a g et o t h eb r a i nt o g e tf r o m a s t a t eo fn o r m a l i t yt op a r a n o i dp s y c h o s i sa n de v e n m o r e d a m a g et o a r r i v ea td e m e n t i a .W h a twe a r ec o n s i d e r i n gh e r ei s t h ed a m a g e6
7/25/2019 Alcohol and Benzodiazepines Generate Anxiety, Panic and Phobias
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OURN L OF THE ROY L SOCIETY OF MEDICINE Volume 88 February 99
r e v e r s i b l ea s a r u l e ,t h a tm a y b e d o n e b e f o r et h i s .T h ep o s s i b i l i t yo f t h e u s eo f s e d a t i v es u b s t a n c e ss h o u l db ec o n s i d e r e di n a l lp a t i e n t sp r e s e n t i n gw i t ha n x i e t y ,p a n i ca n dp h o b i a s .
B e n z o d i a z e p i n ed r u g sh a v en o p l a c ei n t h et r e a t m e n to fa n x i e t yt h o u g ht h e yh a v et h e i ri n d i c a t i o n si n a n a e s t h e s i a ,e p i l e p s y,o r t h o p a e d i cs u r g e r ya n ds o m e t i m e sf o rt h ec o n t r o lo fe x t r e m e l yd i s t u r b e db e h a v i o u ri na p a t i e n ts u f f e r i n gf r o ma n a c u t ep s y c h o s i s .T h e t r e a t m e n to fa n x i e t yw i l ld e p e n du p o nt h ec a u s ea n ds o m e t i m e sp a t i e n t sn e e dt ob eh e l p e dt of a c et h ef a c tt h a t t h e i rp r o b l e m sa n dc o n f l i c t sm a yn o t h a v ea n e a s ys o l u t i o n .T h e c a s e sd e s c r i b e dd oh a v ea s i m p l es o l u t i o na n dt h ed o c t o r sr o l ei s t o h e l pt h ep a t i e n tc a r r yt h r o u g hw h a t m a y b e a p a i n f u lt a s kt o a s u c c e s s f u lc o n c l u s i o n .
REFERENCES
I M o r g a nK , O s w a l dI A n x d e t yc a u s e db ya s h o r t - l i f eh y p n o t i c .B M J1 9 8 2 ; 2 8 4 : 9 4 2
2 P e t u r r s o nH L a d e rM . D e p e n d e n c eo nT r a n q u i l l i z e r s .O x f o r d :O x f o r dU n i v e r s i t yP r e s s ,1 9 8 4
3 L a d e rM L a w s o n C . S l e e ps t u d i e sa n d r e b o u n di n s o m n i a :m e t h o d o l o g i c a lp r o b l e m ,l a b o r a t o r yf i n d i n g sa n dd i n i c a li m p l i c a t i o n s .C l i nN e u r o p h a r m a c o l1 9 8 7 ; 1 0 : 2 9 1 - 3 1 2
4 O g u n r e m i0 0 A d a m s o nL , B r e z i n o v aV , e t a l .Tw o a n t i - a n x i e t yd r u g s :a p s y c h o n e u r o e n d o c n n es t u d y .B M J1 9 7 3 ; 2 : 2 0 2 - S
5 W i l s o nG T . A l c o h o la n da n x i e t y .B e h a vR e sT h e r1 9 8 8 ; 2 6 : 3 6 9 - 8 16 C o w e nP J , N u t t D . A b s t i n e n c es y m p t o m sa f t e rw i t h d r a w a l o f
t r a n q u i l i z i n gd r u g s :i s t h e r ea c o m m o nn e u r o c h e m i c a lm e c h a n i s m ?L a n c e t1 9 8 2 ; i i : 3 6 0 - 2
7 L i s h m a nW A . A l c o h o la n d t h eb r a i n .B r J P s y c h1 9 9 0 ; 1 5 6 : 6 3 5 - 4 4
8 T y r e rP , R u t h e r f o r dD H u g g e t T . B e n z o d i a z e p i n ew i t h d r a w a ls y m p t o m sa n dP r o p r a n o l o l .L a n c e t1 9 8 1; i l : 5 2 0 - 2
9 R o y a lC o l l e g e o fP s y c h i a t r i s t s .A l c o h o lO u rF a v o u r i t eD r u g .L o n d o n ;NewY o r k : T a v i s t o c kP u b l i c a t i o n s ,1 9 8 6 : 8 7 - 8
1 0 S m a i lP , S t o c k w e l lT , C a n t e rS , H o d g s o nR .A l c o h o ld e p e n d e n c ea n dp h o b i ca n x i e t ys t a t e s :I A p r e v a l e n c es t u d y .B r JP s y c h1 9 8 4 ; 1 4 4 : 5 3 -
1 1 S t o c k w e l lT , S m a i lP , H o d g s o n C a n t e rS . A l c o h o ld e p e n d e n c ea n dp h o b i ca n x i e t ys t a t e s :I I A r e t r o s p e c t i v es t u d y .B r jP s y c h1 9 8 4 ; 1 4 4 : 5 8 -6 3
1 2 S a m a r a s i n g h eD S T i l l e yS , M a r k sI M .A l c o h o la n ds e d a t i v eu s ei nn e u r o t i co u t p a t i e n t s .B r JP s y c h1 9 8 4 ; 1 4 5 : 4 5 - 8
1 3 A s h t o nH . B e n z o d i a z e p i n ew i t h d r a w a l :a n u n f i n i s h e ds t o r y .B M J1 9 8 4 ; 2 8 8 :1 1 3 5 - 4 0
( A c c e p t e d2 7 A u g u s t1 9 9 3 )
7
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