Fighting Fear

Confronting phobias and other fears

The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium

One day I was sitting in the hospital cafeteria when a surgeon was called to answer the telephone. I knew he was a surgeon because he was wearing surgical scrubs. I found myself listening to his conversation. Read More

Flying

What does would I be recommended to take before flying ( I'm literally petrified) and have severe anxiety/panc attacks now and then.. Is it recommended to take a few days before up until I actually fly? Thanks

I think it is bad practice to

I think it is bad practice to recommend medications for people I haven't seen. Sometimes there are other drugs the patient is on, or other illnesses, that affect the dose of the drug I might suggest. Also, there is a variability of dose of the tranquilizers that depends on just how "petrified" the patient may be. One man once told me that he had traveled coast to coast by airplane and tried to calm himself down by having a drink every time the stewardess passed him (It was first class.)When I asked, he told me he had had 18 drinks without calming down! I didn't believe him. 18 drinks is enough to put most people in the hospital, and it is a potentially fatal dose of alcohol. But I spoke to his wife who was on the trip with him and who counted the drinks. She confirmed that he had 18 drinks.The fact that you start off petrified does not mean you will stay that frightened. The longer the flight the more likely it is that you will calm down. Most of the time you are likely to feel comfortable (The man above was an extraordinary exception. It is just as likely, or more likely, that you will have little or no anxiety.) Most people fall in-between.
For a typical patient, I usually recommend that they take .5 mgm of Xanax on evenings before the flight so there will be a chance the patient will sleep comfortably. Usually, on the day of the flight I recommend a similar dose before leaving for the airport. Another dose can be taken 45 minutes later and still another dose an hour later if necessary. In such a way, the patient will either calm down or go to sleep. The only price most people pay is to be very sleepy upon disembarking. But I cannot recommend this sort of thing to you. You may have special reasons for requiring more or less. Most time I think the patient is really responding to the thought that he/she has something to fall back on, rather than the actual pharmacological effect of the drug.

Thanks for that advie it was

Thanks for that advie it was very helpfull, I think I'll try the dose you said before and after and during the flight. Thanks again

My ex was prescribed Xanax

My ex was prescribed Xanax for depression by a gp. He became addicted ( resulted in a rehab stint) and it was PURE HELL for him, me and our family. This drug is a class 3 narcotic and most doctors seem uneducated on how dangerous and addictive it is. It is not a minoe tranq. by any means, shape or form. Beware!

It is not a doctor's

It is not a doctor's responsibility to make sure their patients aren't mis-using/abusing drugs -- that is the responsibility of the patient! Come on people, we are adults who have to take responsibility for our actions, it is insulting and paternalistic to be policed and babysat (by doctors, or anyone else). Of course addiction is a terrible thing and support is needed to help people recover from it, but these people are NOT the standard from which prescribing guidelines should be shaped. Prescribing guidelines that are obsessed/overly focused on "addiction" results in throwing a whole group of people who are truly suffering under the bus, those who NEED benzos for relief and quality of life. The drug hysteria and ignorance and mis-information needs to stop, because people who NEED this class of drugs are being under-prescribed or not prescribed it at all, and their suffering is inhumane and criminal.

Hmmm

The person above in which you commented on never said that her boyfriend actually abused his medication. This class of medications is highly addictive and he likely was a victim of circumstance.

.5mg of xanax is not a "low

.5mg of xanax is not a "low dose", regardless of what your books tell you. Plenty of people have developed a horrible dependency on .5mg of xanax, ativan, or klonopin that caused then to endure debilitating withdrawals.

I know because I am one of them. 2.5 years after my last dose I have recovered from most of the dozens of symptoms I have had to endure for the past 30 months, but I am still left with severe cognitive problems. The other day I had to ask my senior citizen father to help me decipher a soup recipe so I could finish cooking dinner. Yes, it's that bad, and it only started upon discontinuation of clonazepam, and it is actually a little better now than it has been for the past couple of years.

I applaud you for taking a conservative stance with these drugs, but you and every other doctor need to learn the facts about these dangerous drugs before writing any more scripts.

Xanax

5 mgm of Xanax is a huge dose. I think you are referring, as I did in the blog, to .5mgm, which is one tenth that dose. Even this smaller dose is enough to put someone to sleep if they take it at night. The drug is commonly prescribed in higher doses, but also lower doses too. There is a .25mgm pill

I am referring to 1/2

I am referring to 1/2 milligram. Lots of doctors claim that this is a small dose. I don't know who decides what is "small" or what criteria they use but there are plenty of people who will attest to the fact that you can most definitely develop a serious physiological dependency from .5 xanax or klonopin.

The books are wrong. If you want the truth about these drugs you can read the Ashton Manual, or better yet read the stories of all the patients who have had their lives destroyed by these drugs (there are over 11,000 member on the benzobuddies.org forum alone).

The truth started to come out years ago with valium but it got swept under the rug when they introduced the newer, "safer", and much more potent alprazolam, clonazepam and lorazepam which are 10-20 times more potent than diazepam. The same doctor who would cringe at the idea of prescribing a patient 40 milligrams of valium has no problem giving them 2 milligrams of klonopin.

Xanax Withdrawal Risks

Interesting article, Dr. Neuman. I have been self-medicating with Xanax for about three years now. I take it 3 or 4 times a week, at 1.5 mgm per episode, for insomnia. I do not take any during the day. I wish to stop, but after reading articles on the internet, gradual tapering seems to be recommended for cessation, apparently because it is a short-lived drug in the human body. If I were to follow the tapering schedules I have seen on-line, I would actually be increasing my doses (i.e. taking it throughout the day as well as before bedtime). This has me confused and a bit frightened to quit using it for insomnia. Can I abruptly quit taking the 1.5 mgm. per night every other night, or do I run the seemingly serious risks associated with abrupt withdrawal? I do not drink any alcohol or take any other drugs. I would appreciate your thoughts. Sleepless in Pittsburgh. TIA.

withdrawal from Xanax

As a matter of principle, I cannot make drug recommendations for patients I have not seen. I will say this, though: In general when I give Xanax for purposes of sleep, it is usually .25mgm or .5 mgm. I tell patients to skip the medication every third or fourth night since the body adjusts to the medicine even in that brief period of time. Waiting to a fourth or fifth night, and then skipping, will lead to delayed onset of sleep and interrupted sleep. The minimum addicting dose is said to be 3 to 4 mgm a day over a period of at least three months. Someone who is not addicted to these drugs can usually taper them outside of the hospital safely.
Some patients become psychologically dependent on any sleep medicine--even in very small doses. It is always a problem for them to stop, but not because of any dire consequences to stopping.
Sleeping medicines are not, in my opinion, useful for the treatment of insomnia except on a very temporary basis. To read about my suggestions for the CBT treatment of insomnia, read my blog post on first aid for insomnia.

A little misinformed...

This is exactly why it is extremely hard for people who have mental illnesses, such as I, with OCD or actually to be specific, body dysmorphic disorder, to find medical professionals who actually fully understand this class of drugs. This doctor says they are bad, another they are fine, another maybe they are okay in small doses. Also, the problem doctors have is that they themselves have never taken these drugs to know the side effects. For you to say that this person in your above article was likely to feel better not because the medication actually worked, but because he had a psychological belief that it worked is just not fair to include in your article without delving into people like me where the medication actually works, not because I believe it does. Look at all the studies of patients with BDD. If given a placebo they still feel the same way as before, therefore no psychological thinking/ belief. You give a BDD patient Klonopin like a take, and in most cases there is a noticeable difference. Unlike people who suffer from different types of mental illnesses, people with BDD in studies don't suffer from the "i'm taking medication so I automatically feel better syndrome". We know. We have a different pattern of thinking. I was on klonopin for 10 years. It worked pretty well for a long while. I was on 4 mg, and started to go through a really bad period in my life and felt like I needed to change meds. I tried just about every anxiolytic on the market and nothing made me feel better. I felt worse every day. I started becoming agoraphobic, it was hell. Now, it was also hell going off of klonopin. I never had a psychological urge to take it. I just got every possible horrible withdrawal symptom you could imagine. I felt insane at times, getting no sleep, deer in the headlights, just awful. I didn't get back on Klonopin much after I went through the withdrawal symptoms, and after going through dozens of medication changes. For me, as much as it hurts to say, I will probably be on it for life because it has been the only medication that can get me to act like a semi-normal human being. I now can go out, I have a job, a boyfriend, and live a decent life. Is this drug a miracle, by no means. I still go through issues and have ups and downs. I just have to manage myself, be involved in cognitive behavioral therapy, and be aware of how I am feeling at all times. I do understand where people have so many complaints about benzos. I have been through the hell of withdrawal. Thank god I never was psychologically addicted, just physiologically. I do think people need to look at both sides of the stories of these meds. Weigh the pros and the cons and make a well informed decision with your doctor. Just because Jane Doe had this and that happen to her when she was on it, doesn't mean you will. Always be vigilant and be an advocate for yourself, because frankly, no medical professional can do this for you. In all honestly, and I am a humble person, I know more about this stuff than any doctor who hasn't experienced the same things as I have, and taken the same medications. I'd make a great psychiatrist because I could tell you the possible symptoms of most medications used to treat various mental illnesses. I chose not to go into the field when I realized how crooked, misinformed that most psychiatrists are. Some do give pills out like candy. Some just collect a check and send you on your way. Some call you a guinea pig (which I was actually called when I was seeing a neurologist) and decide to does you up with 5 extremely powerful medications at one time and then yell at you when you say you feel out of it, or your tongue is swelling up and you don't think you want to take that medication anymore. Yes, this happened to me when I was 15. My parents believed in this doctor, so I was forced to take these medicines that effected me so badly I almost killed myself. But that is my story. I am glad I feel better and know that benzos aren't right for everyone, but do work for others.

Panic attacks. I am a concert

Panic attacks. I am a concert level pianist. For many years I was unable to play for a large group because of panic attacks/anxiety. I froze up mentally, and my hands shook and sweated.

Klonopin didn't help because one can't play when "drunk." The precision of mind and body has to be 100%.

One day a doctor prescribed what's called a beta blocker. It is something that I believe is used for heart patients? It left me completely calm, but completely alert and co-ordinated. For the first time in years I was completely relaxed at the piano despite the audience.

This experience caused me to want to play for people, and before long I didn't need the beta blocker. I had regained my confidence. I just needed help to stop anticipating the panic, and to again learn to enjoy the experience.

I'm not a doctor and I don't know why more don't prescribe this for situational panic such as flying. It really worked for me without the side effect of being "tranquilized" with lost coordination mentally or physically.

Cheers

Beta blockers and performance anxiety

The physiological effects of beta-blockers (drugs used primarily as anti-hypertensive agents)include slowing the heart rate and diminishing trembling in the voice and hands. They have been studied in musicians, and they are given, also, to social phobics who are overly concerned about other people noticing their hands shaking. The effect is primarily on the outward manifestations of anxiety. A number of patients have told me they continue to feel anxious inwardly, but that their pulse is slow and their hands do not shake.
If a patient comes to me already on these drugs, I will continue them; otherwise I do not recommend them. As Anonymous indicates, playing his instrument publicly is a matter of self-confidence. The symptoms he complained about are what are usually referred to as "stage fright." If a pianist can be persuaded to play publicly, these feelings usually go away in the first few moments, only to return the next time around, usually. I think there is a psychological advantage to coping naturally with these feelings (which are a natural consequence of confronting danger.)Usually, the patient can be taught not to feel he/she is in danger.
Sometimes I see patients who are taking sub-clinical doses of beta-blockers in order to address business meetings. They are then largely a placebo; but patients hang on to them for years,nevertheless. Having said all that, I am willing to try anything that works, even if the effect is minor and transitory.

Beta blockers and performance anxiety

I understand your points, and well taken. It is good to learn to overcome fear naturally, but then again one can't "fall apart" and ruin a concert for an orchestra and a conductor in front of 3,000 people either, can he? (Well yes, I suppose he can because I have.)

When I first took the beta blocker, I walked out and sat at the piano and immediately knew that my hands and body were still, that they weren't sweating, and I had immediate complete control just as if I were home alone.

The benefit for me was that I had fun playing for an audience for the first time in years. If a pianist can't control the shaking and sweating of his hands, he will fail. He will fail himself and everyone else in the room. But after just 3 or 4 experiences without those problems, and enjoying myself, I never needed the med again.

Being certain that I would fail became self-fulfilling, just as being sure I wouldn't fail put the confidence back. Turning a nightmare into fun was all it took. I just needed a little boost.

I'm not a doctor. I don't know what's right for anyone else. I had stage fright so bad that I don't think I would have gotten over it without help. After all, it is all about what we think, isn't it? At least it was for me.

I'm just happy that the drug usage was so temporary, and that the change occurred so fast for me.

Benzos Get a Bad Rap

I have been on Ativan, (lorazepam), for almost 30 years. I have no brain damage, no liver or kidney damage and this anti-anxiety medication has allowed me to lead a fairly normal life. When a person has chronic depression doctors have no problem putting them on anti-depressants for the rest of their lives and many anti-depressants are much more toxic that benzos.

I have chronic anxiety, PTSD, social phobia and agoraphobia that made me home bound for many years until my psycho-pharmacologist prescribed lorazepam. I was then able to go to school, get a job and support myself instead of relying on social security.

Why is chronic anxiety medication used under a doctor's care any different or worse than any anti-depressant medication? Some people need it their whole lives. It's a fact and it saved my life.

I do no believe if you only need it for short term it is the right choice. Long term it is. I believe the opposite of what is written in medical manuals and I am living proof that for some it is the right choice. Every person is different. Let's get back to idiosyncratic diagnoses and medication distribution instead of consistently trying to group individuals into categories.

Lorazepam saves me

I have many issues including PTSD, OCD, and acute anxiety. I have been on lorazepam for 10 years. It has literally saved my life. It helps to calm me down and I feel if I didn't have it I may have turned into an alcoholic like the rest of my family. Mental disorders are not fun and if you have never had to deal with it you can't pass judgment. Over the years the dosage has had to double for me at times. I try to monitor my dosage and cut back on days that are not so difficult. I am glad my doctor understood my condition. I hope that people reading the post don't get scared off of taking it if needed. Like everything in life you need to make wise choices. I have a job, and have been successful. I've never missed a day of work. I exercise, eat well and I am healthy . Before I was prescribed lorazepam I had high blood pressure, migraines, constant worry, nightmares. It isn't always perfect and there are still very bad days, but just knowing that I have relief, I get by. There are benefits to benzos, it just seems to me all you hear is the negative.

Need More Caution

.5mg of xanax is equivalent to 10mg of valium and certainly can create dependence if used daily for more than a couple weeks. I also strongly urge you and all prescribing doctors read the Ashton Manual as well as the research papers she and other reputable researchers who have spent careers focused on this medication have submitted.

Benzodiazepines curb and sometimes completely block slow wave and REM sleep. I was on them for 6 years and slept long hours. Only after stopping them did I truly experience real, healthy sleep. I see no benefit to using them as a sleep aid ever.

It's very easy for doctors to claim to know the difference between a psychological dependence and a physical dependence because the science of neurology is rudimentary when understanding the complexity of the organ it studies. This gives doctors like yourself far too much power to judge behavior. I'm glad you're conservative in prescribing these medications but I honestly believe you don't fully realize how much you don't know about the brain, psychology, neurology and psychiatric medications you prescribe.

I certainly didn't until I got off benzodiazepines.

I'm sorry, I was given Xanax

I'm sorry, I was given Xanax .5 broken in half for chilling me enough to sleep. I took it fir 3 months and thought I was doing much better in therapy until I tried to get off it because I was experiencing difficulty with memory and analysis, interfered with my work. The withdrawal from .5 of Xanax taken once a day were severe and completely unexpected to me. I ended up having to do .25 for a while then every other day and so on. I had extreme head pain and other effects. It took me two months to get off. Now when exhausted I will take .25 once for no more than 3 days to avoid the most serious withdrawal effects. You should do your homework on benzos like Xanax, they are immediately addictive due to the way they interact with GABA receptors, these withdrawal symptoms are not our imagination. They are very real.

I have never taken Xanax. I

I have never taken Xanax. I have been using Klonopin for about 20 years? and I can take it or leave it as needed. About a year ago I had a couple of terrible things happen in my life and I lived on it for 2 or 3 months until I got a grip. Then I didn't use it at all for at least a month and no problems for me.

When I'm on it I become tired and unmotivated so I don't take it unless I really need it.

I do believe that a drug can affect different people differently. For instance Percocet which is a sched. II narcotic (Opioid) given to me by a dentist for tooth pain didn't help the pain and wired me up all night instead of making me drowsy. I switched to Advil which killed the pain and allowed me to sleep. Go figure.

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Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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