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Post-Traumatic Stress Disorder (PTSD) was first recognized by the American Psychiatric Association in 1980. Before that, it went by various unofficial names, including “combat neurosis” and “shell shock.” One of the most commonly prescribed treatments when PTSD became an official medical diagnosis were benzodiazepines.
Benzos – for short – included Xanax (alprazolam), Klonopin (clonazepam), and Valium (diazepam). However, today, the U.S. Department of Veterans Affairs recommends against using them for PTSD treatment. “The evidence is mounting on the harms associated with chronic benzodiazepine use in patients with PTSD.”
So what changed? And how is it that, per the V.A., 30% of its PTSD patients had a prescription for benzos in 2012?
Trauma is everywhere
“Trauma—with or without the diagnosis of PTSD—is ubiquitous in mental healthcare,” says Dr. Jeffrey Guina, MD, Clinical Assistant Professor of Psychiatry at the Wright State University Boonshoft School of Medicine. “Trauma is a risk factor for virtually all mental disorders, including psychotic, mood, anxiety, and addictive disorders.”
In the 1960s there were a string of high-profile celebrity deaths at the hands of barbiturates. The passing of Elvis Presley, Marilyn Monroe, and Judy Garland highlights the danger of those drugs. That’s why benzos were developed with the hope that they’d be a less harmful alternative to these and other sedatives.
“They quickly became one of the most prescribed medications in the world,” Guina says. “Since trauma often resulted in anxiety and insomnia, well-meaning clinicians attempted to calm anxiety and induce sleep using these new drugs.”
New views on benzos
However, in the 1980s and 1990s, the conversation around them changed. Research began to show that they were capable of the same harmful side effects as what they replaced—addiction, coma, and death among them. “[This period] also saw the advent of antidepressants (SSRIs) and trauma-focused therapies, both safer and more effective treatments for PTSD,” he says.
Guina says he saw first-hand the effects of benzos on patients with PTSD when he first saw new patients who had prescriptions from other providers.
“Most of these patients started the appointment by asking for refills… Some were surprised—and frequently resistant—when I asked them to talk about their lives and their traumas before discussing a treatment plan,” Guina remembers. “Despite describing numerous functional impairments (such as unemployment, depending on government assistance, multiple divorces, estrangement from family, and difficulty leaving the home), most claimed that their benzos were ‘the only thing that works.’”
He says the contrast perplexed him at first. It was odd that people could say a medication was working despite continuing to suffer significant occupational, interpersonal, and general life dysfunction. Fairly quickly, he realized these patients were “defining success as a measure of sedation.” As long as their anxiety—and to a certain extent, emotion altogether—was absent, they were happy. With benzodiazepines, they didn’t want to explore other options for PTSD.
“By discussing, thinking about, and processing trauma and its effects, individuals often experience a short-term worsening of anxiety, but through repeated exposure and cognitive processing, the brain literally changes and anxiety improves in the long-term,” Guina says. He explained this to some of his patients who depended on benzodiazepines for treatment. He added that sedatives inherently fostered avoidance. As a result, they had the exact opposite effect, reducing anxiety in the short-term but, in the long-term, worsening it. A long term prescription for benzodiazepines lets the ability to manage anxiety go unpracticed. Over time, the capacity to cope with unavoidable stressors gets reduced.
This eventually led Guina to pursue the subject in a scientific context. He and a number of colleagues published a paper in 2015 in the Journal of Psychiatric Practice based on a systematic review and meta-analysis of benzodiazepine use for PTSD patients. They found that “benzodiazepines are associated with specific problems in patients with PTSD. There’s worse overall severity, significantly increased risk of developing PTSD with use after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use.”
He says the V.A.’s decision to change its views on treatment via benzodiazepines is based primarily on a sudden abundance of convincing scientific research. However, just because one organization has announced a policy change doesn’t mean there isn’t work for clinicians to do.
Alternatives to benzos
“The gold standard treatment for PTSD is trauma-focused psychotherapies,” Guina says. These include Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing Therapy (EMDR).
Additionally, medications can be an important reinforcing treatment. “Serotonergic agents (antidepressants) increase the activity of serotonin. That’s a chemical in the brain related to one’s sense of well-being and emotional and behavioral regulation,” Guina says. “Unlike sedatives, which globally inhibit the entire brain, serotonin selectively inhibits the amygdala. That’s the stress center of the brain which tends to be over active in PTSD. It enhancing the prefrontal cortex and hippocampus. Those are the cognitive and memory centers of the brain which tend to be less active in PTSD. By normalizing stress-induced changes in these areas, serotonergic agents can reduce distress, improve cognitive processing and improve learning of new coping skills.”