By Alycia (ADAVIC Volunteer)


What you should know, and what to ask your doctor!

Have you ever found yourself feeling restless, excessively tired and irritable, or suffered from difficulties in concentration? Maybe you have been concerned about a trip to the dentist, or nervous for a job interview. These occurrences, unbeknown    to most, are symptoms of anxiety and are not uncommon. Many individuals are likely to experience one or more of these symptoms several times a year and abundantly throughout their life span. Incidents of worry and tension are a conventional aspect of human behaviour, however, frequent episodes of cumulative symptoms can be extremely debilitating to sufferers. This in turn can cause problems with occupational and social functioning, resulting in the development of an anxiety disorder. If this is the case, and like many others, you or a loved one find themselves overwhelmed by feelings of panic and despair, what do you do?

The answer is quite positive; there are a great number of things you can do! Treatment options for anxiety are vast and several have had great success. As time passes, we are learning more and more about anxiety conditions and with knowledge comes great power. However, when you are considering treatments for anxiety, or an anxiety spectrum illness, it is important to note that some treatments to be called upon more so than others. While these treatments can be effective, they can also be detrimental if not employed correctly. For many sufferers, the first treatment they are likely to come across is medication. Pharmacological treatments tend to be the most commonly used for anxiety disorders, particularly a collection of psychiatric drugs known as benzodiazepines. Most individuals are prescribed benzodiazepines by their general practitioner (GP) under more common names such as Xanax or Karma. While these drugs are helpful to some, and GPs can favour them at times, it is important to be well informed. Before taking medication, it pays to understand the medication in its entirety, and to become aware of its benefits and pitfalls.

To help navigate through the treatment process and decide if this medication is the right choice for you or your loved one, I have provided a brief explanation of how benzodiazepines work to reduce anxiety, as well as possible side effects.  Also I have listed five key points that are important to discuss with your doctor prior to taking the medication. Remember, knowledge is power!!!!

How benzodiazepines affect your body

Benzodiazepines, although many are not aware, target a very delicate chemical system in our brain. The human body naturally produces different brain chemicals, which either have a quietening or excitatory effect. These natural brain chemicals are known as neurotransmitters and aid in the sending of messages from one brain cell to another. GABA is the brain’s naturally occurring quietening or tranquillising neurotransmitter. Benzodiazepines and related drugs work to enhance the effect of GABA, however, this is not always helpful.

Something that many people don’t realise is just how clever and well-adapted the mind and body is. Our body’s natural make- up equips us with the ability to cope with almost any situation without the need for outside assistance. For example, when one suffers from anxiety or a panic attack, the brain becomes over-active and needs the transmitters associated with quietening chemicals to come into action. At this point, messages are sent to the brain cells to slow down or to stop. Until now, this process would have occurred naturally. All the systems in the body would have quietened down, allowing for a feeling of     relaxation without the need for medication. When you add benzodiazepines to the mix, this process is amplified. There are a greater number of transmitters sending out messages to brain cells, resulting in an excessive slowing down or shutting down of these cells. As a consequence of this increase in the numbers of cells being slowed, the brains output of excitatory transmitters is reduced. These excitatory transmitters are vital for normal alertness, memory, co-ordination, emotional responses, heart rate, and blood pressure. Failure to produce enough excitatory transmitters therefore affects the functioning of these systems and the body’s normal process. It seems that by interfering with a process that occurs naturally, we could possibly be causing a greater number of problems than we were originally set out to treat.

Possible side effects to consider

Having given you a rundown of what the medication does, it is also important for you to be aware of how the process can   affect the body, in both the short and long- terms. Current investigations into the use of this medication show that the manner in which it interferes with a naturally occurring chemical balance has the potential to be quite destructive.  At the onset, this medication may seem like it’s a miracle worker, given that it is a fast acting drug that will take effect within half an hour of  being consumed. It has the capacity to mellow a person’s emotional and physical state and perhaps even make them feel serene. This feeling is often a welcome relief, but sadly it will not last for long and can cause a series of complications. The side effects of this medication often mirror the condition that it is prescribed to treat.  It can help with symptoms for a short while; however, after a period of time, it does more to urge symptoms than to hinder them. Some of the most well documented short term side effects of this medication are:

• Impaired motor coordination
• Drowsiness, lethargy, fatigue
• Impaired thinking and memory
• Confusion
• Altered vision
• Slurred speech, stuttering
• Vertigo- a subtype of dizziness, where there is a feeling of motion when one is stationary, can cause difficulty standing or walking
• Tremors
• Respiratory depression
• Slowed reflexes
• Mood swings
• Hostile and erratic behaviour
• Euphoria
• Nausea, constipation, dry mouth, abdominal discomfort, loss of appetite, vomiting, diarrhea

Note: The above side effects occur mostly when under the influence of the drug or shortly after its use.

In addition to these possible outcomes, there may also be long-term side effect that could be experienced if you take the  medication for longer than the recommended period. Generally, it is felt by professionals that the medication should not be taking for longer than around three to four weeks, however, in some situations this may vary and it is advisable to always    consult your GP. The long-term side effects of this medication are quite confronting and many of them occur even when the medication is absent or the implementation of the drug has ceased. Persistent cognitive and memory impairments are often observed in the long-term user, as well as a number of other effects that appear to be an exacerbation of the original symptoms. All users should be well aware that extended use of this medication is not always advisable, and with prolonged use individuals may encounter illnesses more troublesome and enduring than the original diagnosis.

In long- term users, the following effects may be present even when the drug is no longer present within the body’s system, possibly extending for several months after use is terminated:

• Memory impairment
• Personality changes  
• Aggression
• Depression
• Agoraphobia
• Anxiety, and panic attacks
• Emotional numbing
• Cognitive impairment (inability to follow a line of reasoning or think logically)
• Social deterioration
• Tolerance
• Dependence
• Self-harm
• Suicidal ideation – suicide
• You may have noticed that tolerance and dependence appear in bold. This is very deliberate. These issues are among the most serious of the side effects that occur from long term use. Below is an explanation of these two side effects.

Tolerance: prolonged use of benzodiazepines forces the brain to make physical changes to overcome the effects of the drug. This process is known as tolerance. Tolerance can develop within weeks and causes GABA, the natural calming chemical produced by the brain, to become less effective. As a result of this, when one tries to discontinue the drug after long term use, the brain’s natural chemical balance is no longer a sufficient calming tool. Anxiety, memory problems, panic attacks, paranoia, and other such symptoms often result. Tolerance also means that the dosage of medication taken will eventually become   ineffective, and higher dosages will be needed to achieve the same result.


Dependence: dependence occurs when a person becomes tolerant to a drug and, as a result of both physiological tolerance and withdrawal symptoms, they develop a psychological and physiological need for the medication. This need or dependence can manifest itself upon dosage reduction or cessation in what is known as benzodiazepine withdrawal syndrome. This syndrome can be extremely problematic, with violent symptoms that may result in the need for hospitalisation.


Five crucial points to discuss with your doctor

After discussing the side effects, it’s good to know that many of them can be avoided if the medication is used appropriately. Taking the recommended dose and not being on the medication for any longer than the advised period can drastically reduce the amount of side effects you experience, while also reducing the likelihood of tolerance, dependence and withdrawal syndrome occurring. It’s important to note that benzodiazepines have their place, and if you are faced with severe symptoms, they can be very useful in providing fast acting relief. It is okay to take this medication; just be well educated and don’t be afraid to ask questions. In fact there are certain questions that you should definitely ask your GP if this medication is on the cards for you. Listed below are five key points for you to discuss with your GP. Remember it is your right to know. Even if you need to book a slightly longer consultation, it’s worth it. After all, it’s your health!!!


1. Information request: what does this medication actually do?

Before taking the medication, get your GP to explain what it does. It’s important that both you and your doctor   understand what systems in your body are affected. Having this knowledge will give you both a greater appreciation and respect for the medication; perhaps encouraging adherence to the prescription recommendations. Obtain a print out of information from your doctor and consider one thing, if your doctor can’t properly explain what the medication does, should they be prescribing it? And perhaps more importantly, should you be accepting it from them?


2. Dosage and duration: how much is safe to take and how long do I take it for?

It is extremely important with this medication to have the right dose and not be on it for longer than necessary, as to avoid side effects, particularly tolerance and dependence. Query your doctor about the dose they wish to give you, be sure it is appropriate for your weight and age. Elderly people take longer to metabolise these medications, so a lower dosage is normally preferable. Furthermore, after reading this article you are somewhat aware of the amount of time you can take it for. Let your doctor know what you know. Have your GP outline to you how long they believe you will be on the medication for. Furthermore, have them explain why they have chosen this duration and if it is safe. If you have any doubts, get a second opinion.


3. Side effects: what side effects should I look out for? Please explain the minor side effects as well as the most severe?

It’s important with this medication to understand the effects of what it can do to your body. As explained above, there are short-term and long-term side effects. Have your doctor discuss them with you, in particular those that are more complex, such as tolerance and cognitive/psychomotor impairments. As a consumer you should be aware of symptoms to look out for and your doctor should be concerned about this. Often, GPs do not explain the severity of the side effects of this medication due to time constraints. In some cases, doctors do not provide information about the avid risk of tolerance and dependence because it can take extra time to work through. For this reason, it may  pay to book a longer consultation. You and your doctor shouldn’t feel rushed when having this conversation. It is important to keep in mind that the side effects have the potential to be detrimental, and everything possible should be done to avoid them.


4. History and possible interactions: is the medication safe to take with my current medications? Does it matter if I am a smoker or have/had issues with addiction?

Find out from your doctor if there are any harmful interactions that may occur between your current medications and the use of benzodiazepines. Have your doctor explain how alcohol consumption can affect this medication and discuss if any previous or continuing addictions make you ill fitted to this medication due to its highly addictive  properties.


5. Alternatives and the Mental Health Care Plan: are there any other treatments or therapies I can use? What is the Mental Health Care Plan and a Mental Health Assessment?

As a consumer, it is important to be aware of your options, and there are many for the treatment of anxiety and anxiety spectrum illnesses. Seeing a psychologist has had great success in many cases, particularly psychologists that work with an approach known as cognitive behavioural therapy (CBT). CBT is a therapy that is quite widely used and renowned for its effectiveness in treating many mental illnesses, particularly anxiety. Ask your GP about seeing a psychologist, and if they can help you find one close to you. Furthermore, Medicare offers a service known as the Mental Health Care Plan, which can assist with the cost for those who are eligible. In order to find out if you are eligible, your GP can carry out a mental health assessment. This is a short questionnaire that asks how you have been feeling in the past two weeks. It’s very simple and can provide you with a Medicare rebate of $83.25 if you see a general psychologist or $122.16 if you see a clinical psychologist. This rebate is valid for up to ten of your visits. Alternative methods of treatment should always be explored and it is a good idea to have a mental health assessment, regardless of which treatment path you choose to take.


References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.

Barker, M. J., Greenwood, K. M., Jackson, M., Crowe, S. F. (2004).  Cognitive effects of long term benzodiazepine use a  Meta- analysis. CNS drugs, (18, 1) 37-48.

Emery, R. E., Oltmanns, T. F. (2010). Abnormal psychology (6th ed). Pearson Education Inc.     

Joughin, N., Tata, P., Collins, M., Hopper, C., Falkowski, J. (1991). In patient withdrawal from long-term benzodiazepine use. British Journal of addiction, (86) 449-455.

Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, F., Thibodeau, N. (2000). Efficacy of a cognitive- behavioural treatment for genralised anxiety disorder: evaluation in a controlled clinical trial. Journal of consulting and clinical  psychology, (85,6) 957-954.

Martinez-Cano, H., De Iceta Iganez De Gauna, M., Vela-Bueno, A., Wittchen, H. U. (1999). DSM-III- R co morbidity in  benzodiazepine dependence. Addiction, (94,1) 97-107.

Nystrom, C. (2005). Effects of long term benzodiazepine medication. A prospective cohort study: methodological and clinical aspects. Nord J psychiatry, (59,6) 492-497.

Saric, R. H. (1998). Generalized anxiety disorder guidelines of diagnosis and treatment. CNS drugs, (9,2) 85-98.