Benzodiazepines: Hindering CBT since 1960 (& how to help your anxious client quit)

by Joye C. Anestis

I agonized over the title of this post.  I wanted something catchy, but found that was hard to do without being a little snarky.  So, I want to state up front that benzodiazepines are a useful medication for a number of serious conditions.  That being said, there are a number problems associated with anxiety disordered clients taking these medications.  In this article, I write briefly about benzodiazepines, why anxious clients might want/need to quit taking them, and how to use CBT to help clients discontinue their use (with the consultation of a physician, of course).

First a little about benzodiazepines.  Benzodiazepines are a class of sedatives commonly prescribed to anxious clients.  Valium, Librium, Ativan, Klonopin, and Xanax are just a few of the many benzodiazepines commonly prescribed for a number of conditions, both mental and physical, and they are quite effective at knocking out feelings of anxiety.  Thus, benzodiazepines are commonly prescribed in the treatment of anxiety disorders (Boizet et al., 1996; Bruce et al., 2003).  One recent survey estimated that almost 20% patients with a current anxiety disorder take benzodiazepines (Beck et al., 2005), and half of patients presenting with anxiety disorders are already taking benzodiazepines (Romach et al., 1995).

In a recent article, Ahmed, Westra, & Stewart (2008) delineate multiple reasons why clients with anxiety disorders might want to discontinue the use of benzodiazepines and then offer suggestions for assisting clients in tapering off the medication, from a cognitive-behavioral standpoint.  Reasons clients wish to discontinue benzodiazepine use include:

• Addiction: Individuals have quite a hard time discontinuing benzodiazepines (Ashton, 1994), and the withdrawal profile of these drugs can be quite severe.  Ahmed et al. (2008) note that some well-documented withdrawal effects include rebound panic attacks in panic disorder patients (Fyer et al., 1987) and rebound physiological symptoms of anxiety, such as shakiness and agitation (Roy-Byrne & Hommer, 1988).  Ironically (and awfully for the person experiencing the withdrawal), the severity of the withdrawal symptoms are equal to or worse than the anxiety symptoms experienced prior to benzodiazepine treatment (Noyes et al., 1991; Rickels et al., 1990).  In fact, it has been proposed that benzodiazepine use exacerbates anxiety disorders (Otto et al., 1992).  Take panic disorder as an example.  If you have panic disorder and take a benzodiazepine, your physiological symptoms of anxiety decrease (i.e., no more panic attacks), but the benzodiazepine does nothing to treat the fear of anxiety symptoms inherent in panic disorder.  Furthermore, these fears may escalate when you discontinue benzodiazepines because discontinuing causes a return, or even increase, of the symptoms you feared.  Several studies have demonstrated the utility of CBT for benzodiazepine discontinuation (e.g., Bruce, Spiegel, & Hegel, 1999; Hegel et al., 1994).
• Interference with CBT:  We have written multiple PBB articles on CBT as the front-line treatment for anxiety disorders (e.g., obsessive-compulsive disorder, PTSD, generalized anxiety disorder, social anxiety disorder; also see National Institute for Health & Clinical Excellence).  And several studies have noted that benzodiazepine use hampers the utility CBT.  Studies comparing CBT with and without accompanying benzodiazepine use suggest a superiority of CBT alone (e.g., Marks et al., 1993; see Otto, Smits, & Reese, 2005, for a review).  Many reasons have been proposed for this.  For example, benzodiazepines are known to negatively effect learning and memory, thus they may prevent clients from remembering & integrating the therapy.  Additionally, CBT for anxiety disorders almost always involve exposure exercises.  One purpose of exposure is for clients to experience anxiety, learn that it is bearable, and learn that it goes away on its own.  If clients are taking a drug that prevents them from feeling anxiety, then the usefulness of exposure is decreased.
• Cognitive problems: I just mentioned the memory and learning impairments associated with benzodiazepines, but they deserve to be mentioned by themselves.  Benzodiazepines have reliably been shown to cause specific memory impairments (anterograde amnesia, effects on both explicit and implicit memory; see Buffett-Jerrott & Stewart, 2002, for a review).  This can be quite scary and impairing.
• Patient preference: A number of studies have shown that anxiety patients, patients with any mental health problems, and non-patients (who hypothetically chose a preferred treatment) strongly prefer psychotherapy over pharmacotherapy (Banken & Wilson, 1992; Deaon & Abramowitz, 2005; Dwight-Johnson et al., 2000; Walker, et al., 2000).

Ahmed et al. (2008) created a self-help handout to assist client in discontinuing benzodiazepines.  Of course, no medication should be terminated without consultation with the physician/prescriber.  The handout is a very detailed and well-written guideline for clients, and it uses basic cognitive-behavioral strategies to aid clients in tapering off their medication use.  Their recommendations include:

• Before tapering off of the medication, discontinue using on as needed basis and instead take a more regulated dose to help begin breaking the connection between benzodiazepine use and fear reduction.
• Use the Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1992) to assess your clients.  Ahmed et al. (2008) recommend that the client have an ASI score in the nonclinical range before tapering benzodiazepines.  Interoceptive exposure is recommended to decrease anxiety sensitivity in clients who have elevated scores on this scale.  For more information on the ASI, see our Assessment Tools page.
• Discuss benzodiazepine discontinuation in depth with your client.  The handout includes questions for clients to assess their readiness for discontinuation, and these questions can be part of a therapist-client dialogue.  Again, encourage clients to discuss any changes in medications with their physician/prescriber prior to discontinuation.
• Ahmed et al. (2008) delineate common worries that individuals have about discontinuing benzodiazepine use and offer assistance in challenging these cognitions.

Although the specific handout published by Ahmed et al. (2008) has not yet been examined experimentally, the use of CBT in assisting benzodiazepine discontinuation is supported by a number of studies.  They have provided ample psychoeducation and cognitive assistance to make the process easier and less scary for clients.  There are a number of reasons why clients might not want to take benzodiazepine once they seek out psychotherapy.  Cognitive & behavioral strategies can help them achieve that goal.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.