![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 23 of 23. This is the beginning of the thread.
Posted by JohnKeats on December 8, 2005, at 5:08:54
The benzos - clonazepam, lorazepam, Xanax, are definitely the first line treatment for severe social anxiety, but I've come to believe that they really shouldn't be used medium or long-term at all for anxiety and atypical depression. The require higher and higher doses as tolerance builds up, and, more importantly they can screw up the effacy of other meds you might take.
I took clonazepam 2-4mg for the anxiety symptom of Avoidant Personality Disorder for more than 6 years. I started at 2mg, but as my use lengthened, I had to titrate up to maintain the effects. For main line AvPD treatment I went through Stablon, Elavil, Prozac, Effexor, Dogmatil (sulpiride) and others, but no dice. AvPD still bad as ever. Effexor (@375mg) I was particularly hopeful about, but for me it was as good as placebo.
But lo one night,I took a big dose of Elavil to sleep, having forgotten to take the clononazepam during the day, and when I woke up next morning, my brain felt clear. Like there wasn't this constant 100 mph conversation going on back there outside my control. When I went out the phobia was better - like I didn't have this inner voice criticizng me all the time. After that incident I decided to make the effort to come off the clonazepam. It took a while for me to completely come off and I still have residual anxiety from withdrawal, but I'm not going back. I have a long long way to go, but I feel better now with the Elavil, and I have hope that I can retry the previous meds with better success
If you're taking a benzo with other meds for OCD, phobia, depression and/or anxiety you might want to consider scaling back (see my next post) the benzo to see if it is adversely affecting the other meds. It doesn't have to be a long-term trial, try devoting 2 days (like a weekend) when you can safely take a break from the benzo and see how it goes with the other meds. It was a real eye-opener for me. I only wish I had discovered this sooner. I'll try to post any research I can find about benzos negatively interacting with other meds.
Posted by gardenergirl on December 8, 2005, at 7:19:11
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
Posted by jamestheyonger on December 8, 2005, at 10:48:59
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
> The benzos - clonazepam, lorazepam, Xanax, are definitely the first line treatment for severe social anxiety, but I've come to believe that they really shouldn't be used medium or long-term at all for anxiety and atypical depression.
I have used Atavin for 20 years without ever raising the dose, for GAD.
Posted by RobertDavid on December 8, 2005, at 10:54:52
In reply to Re: Be wary of benzos affecting effacy of other meds, posted by jamestheyonger on December 8, 2005, at 10:48:59
I have used klonopin for 12 years for SAD and GAD and have actually dropped down from 3mgs to 2mgs with the same benefit. I guess everyone is different.
Posted by JohnKeats on December 8, 2005, at 18:22:02
In reply to Welcome to Babble (nm) » JohnKeats, posted by gardenergirl on December 8, 2005, at 7:19:11
Good to be here. Been lurking for quite a while actually. PB's helped quite a lot with med research, and more importantly, just reading other people posts who are going through the same stuff you are is a huge amount of support in itself. I guess the fact that I'm delurked and ready to try to support others indicates a bit of improvement.
Posted by Phillipa on December 8, 2005, at 21:50:10
In reply to Thanks » gardenergirl, posted by JohnKeats on December 8, 2005, at 18:22:02
Well if you have been lurking for a while you know who I am. And I have never had to up my dose of benzos. The only time I've had to was for a short time when I could not sleep. And even then taking more did not help. My mind is so powerful it was stronger than the meds. Fondly, Phillipa
Posted by ace on December 9, 2005, at 12:03:53
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
> The benzos - clonazepam, lorazepam, Xanax, are definitely the first line treatment for severe social anxiety, but I've come to believe that they really shouldn't be used medium or long-term at all for anxiety and atypical depression. The require higher and higher doses as tolerance builds up, and, more importantly they can screw up the effacy of other meds you might take.
Not true. They do NOT require higher and higher doses.....initially the liver enzymes work overtime, but everything steadies out in a month and the same dose is retained with the same efficacy. Go to PubMed and look up the clinical trials demonstrating this.
> I took clonazepam 2-4mg for the anxiety symptom of Avoidant Personality Disorder for more than 6 years. I started at 2mg, but as my use lengthened, I had to titrate up to maintain the effects.
Benzo's are generally contraindicated in all Personality Disorders....
For main line AvPD treatment I went through Stablon, Elavil, Prozac, Effexor, Dogmatil (sulpiride) and others, but no dice. AvPD still bad as ever. Effexor (@375mg) I was particularly hopeful about, but for me it was as good as placebo.
>
> But lo one night,I took a big dose of Elavil to sleep, having forgotten to take the clononazepam during the day, and when I woke up next morning, my brain felt clear. Like there wasn't this constant 100 mph conversation going on back there outside my control. When I went out the phobia was better - like I didn't have this inner voice criticizng me all the time. After that incident I decided to make the effort to come off the clonazepam. It took a while for me to completely come off and I still have residual anxiety from withdrawal, but I'm not going back. I have a long long way to go, but I feel better now with the Elavil, and I have hope that I can retry the previous meds with better success
>
> If you're taking a benzo with other meds for OCD, phobia, depression and/or anxiety you might want to consider scaling back (see my next post) the benzo to see if it is adversely affecting the other meds.If anything the opposite is true...they more than like HELP the other meds....
It doesn't have to be a long-term trial, try devoting 2 days (like a weekend) when you can safely take a break from the benzo and see how it goes with the other meds. It was a real eye-opener for me. I only wish I had discovered this sooner. I'll try to post any research I can find about benzos negatively interacting with other meds.You won't find much to post.
Benzos rule and save lifes. Period.
Ace.
Posted by ace on December 9, 2005, at 12:05:14
In reply to Re: Be wary of benzos affecting effacy of other meds, posted by jamestheyonger on December 8, 2005, at 10:48:59
> > The benzos - clonazepam, lorazepam, Xanax, are definitely the first line treatment for severe social anxiety, but I've come to believe that they really shouldn't be used medium or long-term at all for anxiety and atypical depression.
>
> I have used Atavin for 20 years without ever raising the dose, for GAD.
There you go. GAD is not a personality disorder and responds excellant to Benzos. I have heard stories like this again and again.Ace
Posted by ace on December 9, 2005, at 12:06:23
In reply to Re: Be wary of benzos affecting effacy of other meds, posted by RobertDavid on December 8, 2005, at 10:54:52
> I have used klonopin for 12 years for SAD and GAD and have actually dropped down from 3mgs to 2mgs with the same benefit. I guess everyone is different.
As i stated in another post THIS is the usual trend when benzos are used responsibly.I'm outraged they are not prescribed more.
Ace
Posted by ace on December 9, 2005, at 12:07:39
In reply to Re: Thanks » JohnKeats, posted by Phillipa on December 8, 2005, at 21:50:10
Same story again....benzos rule and you do not have to raise dose...only in very initial period....
Ace
Posted by ace on December 9, 2005, at 12:09:02
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
Posted by Emme on December 9, 2005, at 12:40:35
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
I'm sorry, but your post does not seem to indicate that the clonazepam was negatively interacting with your other drugs. All it says is that you felt better with Elavil than with clonazepam, and that you had little success with Effexor, Prozac, and some others. It doesn't follow that clonazepam was actually preventing the other drugs from working. The clonazepam may just not agree with you. (You also do not say what other drugs you were taking when you decided to d/c the clonazepam.)
A couple of references about successful benzo augmentation:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12128237&query_hl=3In this case, a benzodiazepene *reduced* clearance of an AD.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1424422&query_hl=3
> They require higher and higher doses as tolerance builds up.Prescribed and used correctly, these drugs can be taken by many people for extended periods without the need for dose escalation. I use xanax prn and my need floats both up *and* down depending on my circumstances.
Good luck with elavil. It sounds as if that may be a good drug for you.
emme
Posted by JohnKeats on December 10, 2005, at 0:27:54
In reply to Re: Be wary of benzos affecting effacy of other meds » RobertDavid, posted by ace on December 9, 2005, at 12:06:23
> > I have used klonopin for 12 years for SAD and GAD and have actually dropped down from 3mgs to 2mgs with the same benefit. I guess everyone is different.
>
>
> As i stated in another post THIS is the usual trend when benzos are used responsibly.
>
> I'm outraged they are not prescribed more.
>
> Ace
>
>Umm I'm not against prescibing benzos to anyone; if you read my post I started off by saying that they should be the first-line attack for social phobia.
You can extend this to people experiencing panic attacks and acute anxiety disorders. The point I was making that it may not be the best medium-term, long-term treatment for anxiety comorbid with depression.
The physical dependency on benzos is pretty substantial, if you search through PB archives you'll find a lot of people having a heck of a time stopping it. That alone would be reason enough to look for another long-term treatment. I never knew what drug dependence and withdrawal until I tried stopping clonazepam. Try searching for ("klonopin withdrawal" or "klonopin tolerance" in the archives.For GAD and panic attacks, klonopin works differently, see this post: http://www.dr-bob.org/babble/20030718/msgs/244239.html
Again I was not talking about these types of anxiety disorders.Apparently prescribing/not prescribing benzos stirs up a lot of emotion with you ace, but that wasn't really what I was talking about.
Posted by Phillipa on December 10, 2005, at 0:47:06
In reply to Re: Be wary of benzos affecting effacy of other me » ace, posted by JohnKeats on December 10, 2005, at 0:27:54
I've never had trouble with stopping or switching a benzo and this is after 35years. They are safe and you will not increase your dose if they are the right med for you. Of course there are always people's unique reactions to any medication. Remember this is a board for treatment resistant depression and meds in general. Not to say that some do have problems stopping a med. Fondly, Phillipa
Posted by JohnKeats on December 10, 2005, at 1:30:01
In reply to Re: Be wary of benzos affecting effacy of other me » JohnKeats, posted by Emme on December 9, 2005, at 12:40:35
> I'm sorry, but your post does not seem to indicate that the clonazepam was negatively interacting with your other drugs. All it says is that you felt better with Elavil than with clonazepam, and that you had little success with Effexor, Prozac, and some others. It doesn't follow that clonazepam was actually preventing the other drugs from working. The clonazepam may just not agree with you. (You also do not say what other drugs you were taking when you decided to d/c the clonazepam.)
>
> A couple of references about successful benzo augmentation:
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12128237&query_hl=3
>
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7961537&query_hl=3
>
> In this case, a benzodiazepene *reduced* clearance of an AD.
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1424422&query_hl=3
>
>
> > They require higher and higher doses as tolerance builds up.
>
> Prescribed and used correctly, these drugs can be taken by many people for extended periods without the need for dose escalation. I use xanax prn and my need floats both up *and* down depending on my circumstances.
>
> Good luck with elavil. It sounds as if that may be a good drug for you.
>
> emmeEmme, maybe you should read the post again: I said that I took clonazepam for a long time with a lot of different AD drugs including Elavil, but not one of the AD drugs seemed to have any effect on my AvPD. Clonazepam agreed with me fine, and helped me tremendously to manage the acute anxiety I was experiencing as a result of AvPD. But when I missed my clonazepam for one day and took a dose of Elavil I saw improvement in the depression. So my reasoning was that the clonazepam was impairing the effacy of Elavil, and possibly the other AD drugs I had tried. This has nothing to do with the effects of clonazepam on anxious symptoms.
I'm not advocating the banishment of benzos. The point I was making (sorry if I wasn't clear) was that based on the negative effects of long term use on on a lot of people (which should be self evident) as well as my experience with them on the effacy of another drug, I didn't think they were a medium-long term treatment for atypical depression w/ anxiety. That's my own experience and reaction with drugs, like with everything else on PB I thought the YMMV was evident.
As I said in my post to Ace, people with GAD and panic attacks seem to react differently to long-term benzo use. I wasn't talking about this group in my post, I was talking about people suffering from depression and anxiety from personality disorders like AvPD or OCD. I was trying to support the people who have a benzo in their med cocktail (like me) and are not seeing any improvement in their illness. The post didn't say throw out the benzo, it said try stopping it briefly for one or two days and see if there's any change in the effects of the other drugs you are taking.
Posted by JohnKeats on December 10, 2005, at 1:55:19
In reply to Re: Be wary of benzos affecting effacy of other me » JohnKeats, posted by Phillipa on December 10, 2005, at 0:47:06
> I've never had trouble with stopping or switching a benzo and this is after 35years. They are safe and you will not increase your dose if they are the right med for you. Of course there are always people's unique reactions to any medication. Remember this is a board for treatment resistant depression and meds in general. Not to say that some do have problems stopping a med. Fondly, Phillipa
Phillipa, as you point out different people have different reactions to drugs. I have been reading PB for a long time and a lot of people do develop tolerance to benzos and require dosage increases as the treatment goes along. A lot of people become physically dependent on benzos and it is very hard for them to stop without experiencing acute withdrawal symptoms. You don't have to take my word for it; do a search for it in the archives. People with acute anxiety syndromes seem to be the exception but this isn't true in the general case. The point I was making in the post is that I don't believe they are a viable medium-long term treatment for people with depression and anxiety. I wasn't really commenting on their efficacy on acute anxiety disorders.
Posted by cecilia on December 10, 2005, at 2:34:49
In reply to Re: Be wary of benzos affecting effacy of other meds » JohnKeats, posted by ace on December 9, 2005, at 12:03:53
Re: benzos being contraindicated in personality disorders-personally, I've never figured out the difference between avoidant personality disorder and severe social anxiety disorder. The same patient could go to 2 different doctors and get totally different treatments on the whim of a label. Cecilia
Posted by JohnKeats on December 10, 2005, at 3:42:54
In reply to benzos and personality disorders, posted by cecilia on December 10, 2005, at 2:34:49
> Re: benzos being contraindicated in personality disorders-personally, I've never figured out the difference between avoidant personality disorder and severe social anxiety disorder. The same patient could go to 2 different doctors and get totally different treatments on the whim of a label. Cecilia
I never heard the term AvPD until a few years ago. I don't know if practically you can distinguish AvPD from severe social anxiety. AvPD is even defined as severe persistent social anxiety. My best guess would be that with phobias, the fear only grips you when you are in the particular circumstances. In personality disorders your whole life becomes oriented around the fear. In AvPD, avoiding social contact becomes a way of life. The fear doesn't manifest itself in a acute attack, it's just there constantly under the surface. In my case my fear has gotten so morbid I now desperately fear showing my fear to others. I think that people see me as weak and awkward. I could go on and on, but yeah I think there is a difference. AvPD kicks in when the fear becomes very morbid and neurotic. But its true that most doctors would probably have a hard time diagnosing it.
Check this Wikipedia article:
http://en.wikipedia.org/wiki/Avoidant_personality_disorder
Posted by ShellyM on December 10, 2005, at 9:23:11
In reply to Be wary of benzos affecting effacy of other meds, posted by JohnKeats on December 8, 2005, at 5:08:54
Hi John,
Thanks for your post. I too made the decision to go off benzos (long history of severe panic attacks, anxiety, avoidance phobias) - they definitely helped but I had taken them for many, many years and had constantly had to go up in doses and found they only helped for a few hours versus long term. And I developed a huge dependency on them.
I tried many AD's (Paxil, Lexapro, Imimpramine) and now after being off the benzos for 3 months, am hopeful that Cymbalta may be the medicinal side of the answer to my life long struggle with panic and anxiety. I've been on 30mg for a couple of weeks and so far, so good. The constant chatter and fear seems to be lessening.
I would love to hear more of what you are taking for your panic / anxiety / phobias, along with any other methods you are using to overcome this painful affliction.
Kind Regards and much thanks for your post.
Shelly
> The benzos - clonazepam, lorazepam, Xanax, are definitely the first line treatment for severe social anxiety, but I've come to believe that they really shouldn't be used medium or long-term at all for anxiety and atypical depression. The require higher and higher doses as tolerance builds up, and, more importantly they can screw up the effacy of other meds you might take.
>
> I took clonazepam 2-4mg for the anxiety symptom of Avoidant Personality Disorder for more than 6 years. I started at 2mg, but as my use lengthened, I had to titrate up to maintain the effects. For main line AvPD treatment I went through Stablon, Elavil, Prozac, Effexor, Dogmatil (sulpiride) and others, but no dice. AvPD still bad as ever. Effexor (@375mg) I was particularly hopeful about, but for me it was as good as placebo.
>
> But lo one night,I took a big dose of Elavil to sleep, having forgotten to take the clononazepam during the day, and when I woke up next morning, my brain felt clear. Like there wasn't this constant 100 mph conversation going on back there outside my control. When I went out the phobia was better - like I didn't have this inner voice criticizng me all the time. After that incident I decided to make the effort to come off the clonazepam. It took a while for me to completely come off and I still have residual anxiety from withdrawal, but I'm not going back. I have a long long way to go, but I feel better now with the Elavil, and I have hope that I can retry the previous meds with better success
>
> If you're taking a benzo with other meds for OCD, phobia, depression and/or anxiety you might want to consider scaling back (see my next post) the benzo to see if it is adversely affecting the other meds. It doesn't have to be a long-term trial, try devoting 2 days (like a weekend) when you can safely take a break from the benzo and see how it goes with the other meds. It was a real eye-opener for me. I only wish I had discovered this sooner. I'll try to post any research I can find about benzos negatively interacting with other meds.
Posted by gardenergirl on December 10, 2005, at 11:17:43
In reply to Re: benzos and personality disorders » cecilia, posted by JohnKeats on December 10, 2005, at 3:42:54
>
> I never heard the term AvPD until a few years ago. I don't know if practically you can distinguish AvPD from severe social anxiety.Personality disorders in general are conditions which are pervasive in the person's life, usually began late in adolescence, and involve quite rigid ways of coping.
You all are right, this is quite difficult to diagnose, and a thorough history, at the minimum, is necessary. And a severe Axis I disorder may have started in childhood or early adulthood, may be pervasive, and may have resulted in the person using sort of "tried and true" ways of coping, even if the methods are not so adaptive.
I think a key difference would be the inflexibility of use of defense mechanisms and coping strategies you seen in a personality disorder. A person with an Axis I disorder, such as Severe GAD, might have tried more strategies, or may use different ones, (perhaps none too sucessful) in different situations.
Just a bit of tangential information.
gg
Posted by zero on December 11, 2005, at 1:44:52
In reply to Re: benzos and personality disorders » cecilia, posted by JohnKeats on December 10, 2005, at 3:42:54
Avoidant Personality Disorder = severe generalized Social Phobia.
No difference.
(IMHO)
z.
Posted by Emme on December 11, 2005, at 11:21:50
In reply to Re: Be wary of benzos affecting effacy of other me, posted by JohnKeats on December 10, 2005, at 1:30:01
>….. So my reasoning was that the clonazepam was impairing the effacy of Elavil, and possibly the other AD drugs I had tried. This has nothing to do with the effects of clonazepam on anxious symptoms.
When you said that you thought it was impairing the efficacy of other meds, I read this to mean that you believed that there is a pharmacologic interaction between the meds whereby the benzodiazepine was altering the metabolism of the other drugs (perhaps that’s not what you meant). My point was that that doesn’t necessarily follow from your experience. It may simply be that the effects of the clonazepam were offsetting the benefits of the other drugs for you, but not necessarily increasing or decreasing their clearance per se. I’d have to look a little further to learn about any pharmacologic interactions. And someone here probably already knows that. But as I said, perhaps you were not thinking in terms of actual interactions.
> I'm not advocating the banishment of benzos.
That’s good.
> The post didn't say throw out the benzo, it said try stopping it briefly for one or two days
I would agree that it may not hurt to see how what happens if you drop it down temporarily. I think that would apply in many situations where you aren’t sure if one of the meds is helping or needed; lower it and see how it goes.
>. That's my own experience and reaction with drugs, like with everything else on PB I thought the YMMV was evident.
The YMMV was not evident to me. Your statements came across to me as generalizations that for many people don’t apply. Benzos do work well long term and at stable dosages for lots of people (myself included).
emme
Posted by RobertDavid on December 11, 2005, at 13:03:05
In reply to Re: Be wary of benzos affecting effacy of other me » JohnKeats, posted by Emme on December 11, 2005, at 11:21:50
I tried lots of meds to treat generalized social anxiety. None worked till I tried klonopin. For the first time I could actually feel relief, it happened in days.
I started taking klonopin 12 years ago. The most I ever took was 3 mgs. I did great, but wondered a few years ago if I could get by with less so I started dropping .25mgs every two weeks.
I found 2mgs worked just as good, but when I got below that some of the old symptoms returned so I have stayed at 2mgs since.
A few months ago I wanted to see what I would be like if I got off it all together and gave it a try dropping .25 at a time, while adding lyrica.
That was a flop. All my old symptoms returned. I forgot how bad I used to be. So I'm now back up to 2 mgs, feel great and have learned that for me, klonopin is a wonder drug.
I'm looking for something to blend with klonopin to treat a mild depression (I have always had), but as far as the anxiety goes, nothing, not even other benzos have worked like klonopin.
I think benzos are fabulous drugs for many. It's my opinion you've got to find the right one and the right dose which will be different for everyone. It's trial and error with this stuff. If I were a doctor (which I'm not) my first try would be with klonopin.
Lastly, the doctor I see is one of the top psychs/researchers in the nation. He advised me not to take generic with klonopin and to pay the extra cost if I could as the generics are made in other countries, that the FDA allows up to a 20% variance in the drug. That could mean from refil to refil you could get a 30 to 40 percent variance in dose. Appearantly thats significant because of the long half life of klonopin.
Just my thoughts, good luck to all!
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.