Medications for Anxiety (Ch 17, Edmund Bourne)

The use of medication is a critical issue among those who struggle with anxiety on a daily basis, as well as for professionals treating anxiety disorders. For many people, medication is a positive turning point along the path to recovery. For others, medication can confuse and complicate the recovery process, when freedom from anxiety is purchased at the cost of long-term addiction to tranquilizers. For still other people—those who are either phobic of or philosophically opposed to all types of drugs—medication may seem not to be an option, even when it’s needed. 
One thing is clear: the pros and cons of relying on medication are unique and variable in each individual case.

As you will have gathered, this workbook offers a range of nonmedical strategies to help you overcome anxiety, panic, and phobias. My personal view is that natural methods should always be thoroughly explored before you develop a reliance on prescription drugs. Medications can induce unnatural changes in your body’s physiology, with attendant short-and long-term side effects.

Quite a few people find that they can avoid drugs—or eliminate those they have been taking— by implementing a comprehensive personal health program that includes: 

• Positive changes in nutrition and the use of appropriate supplements 

• A program of daily, vigorous exercise 

• A daily practice of deep relaxation or meditation 

• Changes in self-talk and basic beliefs encouraging a less driven, more relaxed approach to life 

• Human support from family and/or friends 

• Simplifying your life and environment to reduce stress Such approaches may be all you need if your anxiety symptoms are relatively mild. By “mild,”

I mean that your problem does not significantly interfere with your ability to work or interfere with important personal relationships. Also, the problem does not cause you serious and/or constant distress.

If, on the other hand, you have a more severe problem with anxiety, appropriate use of medication may be an important part of your treatment. This is particularly true if you’re dealing with panic disorder, agoraphobia, or obsessive-compulsive disorder. It’s also true for social phobia and generalized anxiety disorder when these problems interfere with the quality of your life in a major way. Approximately 50 to 60 percent of my clients take medication. My impression is that for them, a combination of natural methods and medication provides the most helpful, effective, and compassionate approach to recovery.
Be aware that it’s often unnecessary to take medications indefinitely. However, the use of the right medication for the right period of time can help you to turn a corner toward improving your condition. This chapter presents some information about the various types of medication used to treat anxiety problems. Beyond this, you’ll find a number of guidelines to help you decide whether medication is something you should consider.

When to Consider Medication

In my experience, there are certain types of individuals, in certain types of situations, for whom medications are appropriate. What follows is a list of these types of situations, along with the types of medication that might appropriately be used.

1. You have panic attacks that are so frequent (for example, one or more per day) and severe that they impede your ability to work and earn a living, your primary personal relationships, and/or your sense of basic security and control over your life. It is particularly important to consider medication if you have severe symptoms of panic or anxiety that have not improved over a period of two or three weeks. “Severe” means that you have difficulty functioning and/or are suffering considerable distress. Enduring severe levels of anxiety for long periods of time can, unfortunately, predispose your nervous system to stay anxious much longer than it would if the anxiety were reduced by medication early on. Two types of medication are most frequently used to treat panic attacks. The first type is antidepressants. Though they’re labeled “antidepressants,” such medications also have a potent effect in reducing anxiety. The most commonly used antidepressants are SSRIs, or selective serotonin reuptake inhibitors, such as: 

#1 Paxil (paroxetine), 
#2 Zoloft (sertraline),
#3 Luvox (fluvoxamine), 
#4 Celexa (citalopram), and 
#5 Lexapro (escitalopram). 

Another class of antidepressant medications sometimes used is the tricyclics, such as: 
#1 Tofranil (imipramine) or 
#2 Pamelor (nortriptyline); these days, however, they are a second choice after SSRIs have been tried. 

The other type of medication used to treat panic (and other anxiety disorders) is the benzodiazepine tranquilizers. Among these, 

#1 Xanax (alprazolam), 
#2 Klonopin (clonazepam), or 
#3 Ativan (lorazepam) are typically used. (Descriptions of the major types of drugs used to treat anxiety disorders follow this section.) 

Usually, tranquilizers are prescribed for a period of six months to two years at a high enough dose to significantly reduce the frequency and severity of panic, as well as anxiety about panic.

2. You are agoraphobic and have a difficult time undertaking real-life exposure to phobic situations (see chapter 7). That is, you’ve tried for some time without medication and not gotten very far. Low doses of a benzodiazepine tranquilizer, such as Klonopin (in the range of 0.25 to 0.5 mg per day), may enable you to negotiate the first stages of graded exposure to your phobias. The benefits of exposure are likely to be retained even after the medication is discontinued, if the dose has been sufficiently low. This is less likely, however, for higher doses of tranquilizers (that is, more than 2 mg per day). You need to feel at least mild anxiety while undertaking exposure for the technique to be effective. 
After exposure hierarchies have been completed with tranquilizers, it’s important to rework them without medication, to ensure a full and permanent recovery from your phobias. The SSRI antidepressants (see the section of the same name later in the chapter) can also be highly effective in helping people undertake exposure. In fact, many psychiatrists consider SSRI medications to be an essential part of the treatment of agoraphobia.

3. You’re dealing with acute anxiety in response to a crisis situation. You may benefit from relying on a benzodiazepine tranquilizer on a short-term basis to get you through a particularly stressful time (such as interviewing for a new job, dealing with a significant health crisis, the death of a close relative, or other such major life events). 
Alternatively, a sedative (Restoril or Ambien, for example) might be prescribed to help you sleep during such a time.

4. If you have chronic or severe depression accompanying panic disorder, agoraphobia, or any other anxiety disorder, you will usually benefit from a prescription antidepressant medication. Milder cases of depression (that is, you do not lose your appetite, your ability to sleep, or your interest in simple pleasures, and/or you do not have suicidal thoughts) may respond to the herb Saint-John’s- wort, the supplement S-adenosylmethionine (SAM-e), or amino acids such as tryptophan (tryptophan itself or the popular supplement 5-HT), tyrosine, or DL-phenylalanine (see the section “The Use of Natural Supplements” at the end of this chapter). Moderate to severe cases of depression are best treated with SSRIs, tricyclics, or another type of antidepressant medications. Such medications will help relieve depression, panic, and anxiety at the same time.

5. If you suffer from performance anxiety in public speaking or other performance situations—especially if the anxiety involves heart palpitations—you may be helped by short-term doses of beta-blocking drugs, such as Inderal (propranolol). A benzodiazepine tranquilizer, such as Xanax or Klonopin, may also be used on occasion (not regularly) to help you negotiate high-performance situations.

6. Difficult cases of social phobia or social anxiety (for example, you avoid a wide range of social situations or you are unable to attend important meetings at work) may be helped by SSRI antidepressant medications or sometimes by SNRI medications. Medications should be taken in conjunction with individual or, preferably, group cognitive behavioral therapy (see chapter 1, the section on social phobia).

7. Those with obsessive-compulsive disorder often benefit from the use of antidepressant medication, usually in combination with cognitive therapy, exposure, and response prevention.
Medications such as Anafranil (clomipramine), Prozac (fluoxetine), Paxil (paroxetine), or Luvox (fluvoxamine) are frequently used in the treatment of this disorder.
Between 60 and 70 percent of persons with obsessive-compulsive disorder experience an improvement in their symptoms while taking one of these drugs. All of these medications appear to be helpful in treating obsessive-compulsive disorder itself, whether or not it is accompanied by depression. Anafranil, however, does have some potentially undesirable side effects.
For further information on various factors that can affect your decision to rely on medication, see the section “The Choice to Use Medication: What to Consider” later in this chapter.

Types of Medication Used to Treat Anxiety Disorders

What follows is a description of the major classes of prescription medications used in the treatment of anxiety disorders. Potential advantages and drawbacks of each type of medication are considered.

SSRI Antidepressant Medications

The SSRI (selective serotonin reuptake inhibitor) antidepressant medications include: 
#1 Prozac (fluoxetine), 
#2 Zoloft (sertraline), 
#3 Paxil (paroxetine), 
#4 Luvox (fluvoxamine), 
#5 Celexa (citalopram), and 
#6 Lexapro (escitalopram). 

In the past twenty years, they have become the first-line medications used by most psychiatrists to treat anxiety disorders. The SSRIs all increase levels of the neurotransmitter serotonin in the brain by preventing the reabsorption of serotonin at synapses (spaces between nerve cells). With increased serotonin, the number of serotonin receptors on nerve cells in the brain can decrease (not as many are needed). The reduction in serotonin receptors takes place over the first month or two of taking an SSRI and is technically called downregulation.

Downregulation allows the millions of nerve cells in the serotonin receptor system (particularly those in parts of the brain responsible for anxiety) to become less sensitive to changes in the neurochemical environment of the brain created by stress. That means less dramatic shifts in mood and less vulnerability to anxiety.
The SSRIs tend to be as effective—sometimes more effective—than the older tricyclic antidepressants that have been used to treat panic (for example:

#1 imipramine, 
#2 desipramine, 
#3 nortriptyline).

They also have the distinct advantage of causing fewer side effects for most people than the older antidepressants. SSRIs are used most often to treat panic, panic with agoraphobia, or obsessive-compulsive disorder. They have also found use with social phobia, particularly generalized social phobia, in which a person is phobic of most types of social situations and encounters. Sometimes they are used to treat post-traumatic stress disorder or generalized anxiety disorder, especially when these difficulties are accompanied by depression. People differ quite a lot in their response to the SSRIs. If you try one and experience no benefit, be willing to try another. To gain full benefit from an SSRI, you may need to take it for one to two years. Relapse with SSRI medications appears to be low when the medication is taken for at least eighteen months; however, reliable data on the exact percentage of relapse is not available at the time of this writing. Typical effective daily doses for SSRIs are Prozac, 20 to 40 mg; Paxil, 20 to 40 mg; Zoloft, 50 to 100 mg; Luvox, 50 to 100 mg; Celexa, 20 to 40 mg; and Lexapro, 10 to 20 mg. Effective doses of these medications for OCD tend to be somewhat higher. However, some OCD clients find that they obtain good results from lower doses.

Advantages

1. The SSRIs can be helpful for any of the anxiety disorders or depression. 

2. They have been particularly helpful for people with panic disorder, agoraphobia, or obsessive-compulsive disorder.

3. SSRIs are easily tolerated and safe for medically ill or elderly persons. 

4. They are not addictive.

5. They do not cause problems when taken long term. 

6. In most cases, they do not lead to weight gain.

Drawbacks

Although SSRIs have fewer side effects than the older tricyclic antidepressants, they can cause side effects in some people including: 
#1 jitteriness, 
#2 agitation, 
#3 restlessness, 
#4 dizziness, 
#5 drowsiness, 
#6 headaches, 
#7 nausea, 
#8 gastrointestinal distress, and 
#9 sexual dysfunction. 

These side effects tend to go away after two weeks, so it’s important to try to ride them out during the early phase of treatment. All of these side effects can be minimized by starting off with a very low dose of the medication and increasing it, over time, to therapeutic levels. For example, doses might start at 5 mg per day for Prozac or Paxil and 10 mg for Zoloft or Luvox. To achieve such doses, you need to start with a quarter of a tablet per day in most cases, then gradually increase up to a tablet per day over a period of several weeks. Be willing to take plenty of time in increasing the dose gradually. (You may notice side effects increase for a day or two after each dose increase.) The one side effect that can be problematic over time is reduced sexual motivation and/or sexual dysfunction (for example, absent or delayed orgasm). This can be upsetting to many people and, in some cases, can lead them to discontinue the medication. For a certain percentage of people who take SSRIs, normal sexual functioning will resume after two or three months on the medication, so it’s a good idea to stay with an SSRI even if at first you experience diminished sex drive.
If the problem doesn’t get better, it can be mitigated in one of four ways, under the supervision of your doctor: 

1) reducing the dose of the SSRI by half on days you choose to be sexually active,

2) augmenting the use of the SSRI with 5 to 10 mg per day of Buspar, 

3) supplementing the SSRI with the medications amantadine or cyproheptadine, or 

4) trying the supplement DHEA, available at most health food stores, at 25 to 50 mg per day. Many people find that one or two of these interventions can help them restore more normal sexual activity while continuing to take an SSRI.

A third disadvantage is that SSRIs, while often effective, take four to five weeks to produce any significant therapeutic benefit. Sometimes the full therapeutic potential is not achieved until the medication has been taken for twelve weeks or longer. (There is some evidence that even further benefits occur over the course of one year.) If you’re suffering from severe and disabling panic, your doctor may recommend you take a tranquilizer (most likely a high-potency benzodiazepine—see below) while waiting for the SSRI to take effect.
In the past few years, many people have found the medication Paxil to be especially difficult to discontinue. Approximately 5 to 10 percent of persons withdrawing from Paxil may experience severe symptoms such as panic attacks, mood swings, profuse sweating, depersonalization, and “electric shock”-like sensations. Before deciding to use Paxil, be sure to discuss this potential problem with your physician.
A final drawback of SSRIs is their expense. Without insurance, you can pay upward of $200 per month for some SSRIs. The optimal duration for taking an SSRI medication is one to two years. You increase your risk of a return of symptoms if you take the medication for a shorter time period.
Note: People with bipolar disorder (manic depression) should take SSRIs only under the supervision of a knowledgeable physician, as SSRIs can aggravate manic states.

High-Potency Benzodiazepines

The high-potency benzodiazepine tranquilizers (BZs): 
#1 Xanax (alprazolam), 
#2 Ativan (lorazepam), and 
#3 Klonopin (clonazepam) are commonly used to treat anxiety disorders. 

Older benzodiazepine drugs, such as: 
#1 Valium, 
#2 Librium, or 
#3 Tranxene, are occasionally tried when someone is sensitive to the side effects of the newer BZs. 

The benzodiazepines are often used in conjunction with SSRI antidepressants (or older tricyclic antidepressants) to treat severe cases of panic disorder.

Frequently, it’s possible to gradually withdraw from use of the BZ after the antidepressant medication has achieved its full antianxiety benefit (that is, from four to six weeks after starting the drug).

Benzodiazepine drugs generally depress the activity of the entire central nervous system and thus directly and efficiently decrease anxiety. They do so by binding with receptors in the brain that function to tone down or suppress activity in those parts of the brain responsible for anxiety:
#1 the amygdala, 
#2 locus coeruleus, and 
#3 limbic system, in general. 

In higher doses, BZ tranquilizers act like sedatives and may promote sleep. 
Lower doses tend to simply reduce anxiety without sedation. 
The main difference between various benzodiazepines is each medication’s “half-life,” or the length of time their chemical metabolites stay in your body. 
For example: 

1. Xanax has a half-life of eight hours;
2. Klonopin (clonazepam), eighteen to twenty-four hours; and 
3. Valium, forty-eight to seventy-two hours.

At present, the most common tranquilizer used to treat anxiety disorders is Xanax (alprazolam).
Alprazolam differs from other BZs in that it has an antidepressant effect, as well as the ability to relieve anxiety. It also tends to have a less sedating effect than other tranquilizers. Because Xanax has a short half-life, two or three doses per day are usually prescribed. If you take only one dose per day, you may experience “rebound anxiety”—the tendency to experience heightened levels of anxiety as the medication wears off. BZs with longer half-lives, such as Klonopin, tend to cause less rebound anxiety and can often be taken in a single dose per day. Research indicates that high doses of Xanax, 2 to 6 mg per day, are necessary to fully suppress panic attacks. In clinical practice, however, it’s common to administer low doses, in the range of 0.25 to 1 mg two or three times per day. (Daily doses of Xanax tend to be higher than for Klonopin.) Such doses can significantly reduce the symptoms of panic attacks with less sedating side effects.

Advantages 

BZs work very quickly, reducing symptoms of anxiety within fifteen to twenty minutes. Unlike antidepressants, which need to be taken regularly, BZs can be taken on an as-needed basis. That is, you can take a small dose of Xanax, Ativan, or Klonopin only when you have to confront a challenging situation, such as a graded exposure task, going to a job interview, or taking a flight.
The BZs tend to have less bothersome side effects for many people than the antidepressant medications (especially the tricyclic antidepressants). Sometimes they are the only medication that can provide relief when a person is unable to take any of the antidepressant medications.
Generic forms of BZs are available, reducing their cost.

Drawbacks

BZs, unlike antidepressant medications, tend to be addictive. The higher the dose (that is, more than 1 mg per day for high-potency BZs) and the longer you take them (that is, more than one month), the more likely you are to become physically dependent. Physical dependency means that if you stop taking the medication abruptly, severe anxiety symptoms are likely to occur.

Many people who have taken Xanax (or other BZs) in high doses for a month or low doses for several months report that it’s very difficult getting off the medication. (There is some evidence that withdrawal from Klonopin, because of its longer half-life, may be slightly easier and less protracted than withdrawal from Xanax.) Abrupt withdrawal from these medications is dangerous and may produce panic attacks, severe anxiety, confusion, muscle tension, irritability, insomnia, and even seizures. A more gradual tapering off of the dose, stretched out over many weeks or even months, is what makes discontinuation possible. The ease with which people can withdraw from Xanax varies, but as a general rule, it’s best to taper off very gradually over a period of one to four months, under medical supervision. During this withdrawal period, you may suffer a recurrence of panic attacks or other anxiety symptoms for which the drug was originally prescribed.

If a BZ medication is tapered off too quickly, you can experience rebound anxiety. 

Rebound anxiety is the occurrence of anxiety symptoms greater than those you experienced prior to taking the drug in the first place. Rebound may lead to relapse, a return of your anxiety disorder at equal or greater severity than what you experienced before taking the medication. To minimize the risk of rebound, it is critical to withdraw from your dose of a BZ very gradually, preferably over several months. (For example, if you have been taking 1.5 mg of Xanax per day for six months, reduce your dose by 0.25 mg every two to three weeks.) Another drawback of BZs is that they are effective only as long as you take them. When you stop taking them, your anxiety disorder has virtually a 100 percent chance of returning, unless you have learned coping skills (that is, abdominal breathing, relaxation, exercise, stress management, working with self-talk, assertiveness, and so on) and made lifestyle changes that will result in long-term anxiety relief. Taking a BZ only, without doing anything else, amounts to merely suppressing your symptoms without getting at the cause of your difficulty.

A final problem with benzodiazepines is that they tend to have a blunting effect, not only on anxiety but on feelings in general. Many people report that their emotional responses are muted while they are taking these drugs (for example, they may have trouble crying or getting angry, even at times when these reactions are appropriate). To the extent that anxiety is related to suppressed and unresolved feelings, taking these drugs will tend only to alleviate symptoms rather than relieve the cause of the problem. (Some people have a paradoxical reaction to benzodiazepines, during which they actually become more emotional or impulsive, although this tends to happen infrequently.) Emotional blunting is somewhat less likely with antidepressant medications, although it may occur.
Long-term use of BZs (more than two years) is sometimes necessary in those cases of severe panic and anxiety that do not respond to any other type of medication. While it enables many people to function, long-term BZ use has several problems. Many long-term BZ users report that they feel depressed and/or less vital and energetic than they would like. It is as though the medication tends to sap them of a certain degree of energy. Often, if they are able to switch to an antidepressant medication to help manage their anxiety, they regain a sense of vitality and enthusiasm for life. Many doctors currently regard the BZs as most appropriate for treating short-term, acute anxiety and stress rather than longer-lasting conditions such as agoraphobia, post-traumatic stress disorder, or obsessive-compulsive disorder. Wherever possible, chronic, long-term anxiety disorders are most appropriately treated with SSRI antidepressants. There are, however, certain individuals who seem to need to take a low dose of a BZ over the long term in order to function.
They accept the addiction and other side effects in exchange for protection from the anxiety that they have been unable to manage using solely natural techniques or other types of medication.
If you are over fifty years old and have been taking a BZ medication for more than two years, you should periodically receive medical checkups, including an evaluation of your liver function.

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Antidepressants

SNRI antidepressants work by blocking the reuptake of two major neurotransmitters: serotonin and norepinephrine. 

At present, the three most commonly used SNRIs are: 
#1 Cymbalta (duloxetine),
#2 Effexor (venlafaxine), and 
#3 Pristiq (desvenlafaxine). 

Desvenlafaxine is the mirror-image isomer of venlafaxine, and is claimed by some to have fewer side effects than venlafaxine, though there is no systematic research on this. The SNRIs are potent medications and may be tried when response to SSRIs is insufficient. They are most commonly used to treat depression and/or generalized anxiety disorder but may be used to treat other anxiety disorders such as panic disorder or OCD.
The main advantage of SNRIs over the SSRIs is that they can stabilize both the norepinephrine and serotonin receptor systems, instead of just the serotonin system alone. So for certain people, they are more powerful anxiolytics than the SSRIs. They have the same disadvantages as the SSRIs, with side effects including dizziness, nausea, weakness, dry mouth, insomnia, and sexual dysfunction. Like the SSRIs, the dose needs to be tapered off gradually when SNRIs are discontinued. Abrupt discontinuation is associated with withdrawal symptoms.

Serotonin Modulator and Stimulator (SMS) Antidepressants 

SMS antidepressants are a relatively new class of medications that, in addition to promoting serotonin reuptake inhibition like SSRIs, also stimulate transmission at one or more serotonin receptor sites.
Viibryd (vilazodonehydrochloride), with a normal dose range of 10 to 40 mg per day, facilitates the serotonin receptor 5-HT1A, a mechanism of action it shares with the anxiolytic medication Buspar (buspirone) as well as the atypical antipsychotic medication Abilify (aripiprazole).

Viibryd was approved in early 2011 for use in the United States. In September 2011, the FDA raised questions about whether Viibryd showed any advantage over previously and commonly available SSRIs. Some users have reported good results with Viibryd, both with respect to anxiety and depression, while others have reported side effects such as nausea, diarrhea, sleeplessness, and weight gain, leading them to discontinue the drug. Viibryd was marketed as having fewer sexual side effects than other SSRIs, though results so far have shown that this benefit is not invariably reported.

Brintellix (vortioxetine), with a normal dose range of 5 to 20 mg per day, was introduced in the United States in late 2013. It is described as a multimodal antidepressant because it has a differential action on different types of serotonin receptors. Specifically, it has an antagonistic (inhibitory) reaction toward serotonin receptors 5-HT3A and 5-HT7, while it tends to facilitate neurotransmission at 5-HT1A and 5-HT1B receptors. It’s also a potent serotonin reuptake inhibitor like typical SSRIs.

Preliminary research indicates that these multiple effects on several different serotonin receptors may result in increased noradrenaline (as in SNRIs) and dopamine (as in mood stabilizers) as well as increased glutamine transmission. So the drug appears to have a variety of effects beyond that of simple serotonin reuptake inhibition.
Brintellix is currently being studied for potentially beneficial cognitive effects, apart from its antidepressant effects, in elderly persons.

Tricyclic Antidepressants

Tricyclic antidepressants include: 
1. Tofranil (imipramine), 
2. Pamelor (nortriptyline), 
3. Norpramin (desipramine), 
4. Anafranil (clomipramine), 
5. Elavil (amitriptyline), and 
6. Sinequan (doxepin), among others. 

These medications (especially imipramine) are sometimes used to treat panic attacks, whether such attacks occur by themselves or in conjunction with agoraphobia. Tricyclic antidepressants seem to reduce both the frequency and intensity of panic reactions for many people. They are also effective in reducing the depression that often accompanies panic disorder and agoraphobia.
While it used to be believed that Tofranil was the most effective antidepressant for treating panic, more recent evidence indicates that any of the tricyclic antidepressant medications can be helpful, depending on the individual. Anafranil tends to be specifically helpful in treating OCD.
The tricyclic antidepressants are used less these days than SSRI antidepressants because they tend to have more troublesome side effects. For example, in studies of imipramine, usually about one-third of the subjects drop out because they cannot tolerate side effects (only about 10 percent do in studies using SSRIs). On the other hand, tricyclic antidepressants are sometimes a better choice than SSRIs for certain people because most of them (other than Anafranil) modify a different receptor system in the brain (the noradrenergic system instead of the serotonin system).
As with SSRIs, tricyclic antidepressants are best tolerated by starting with a very low dose (for example, 5 mg per day of imipramine) and gradually working up to a therapeutic dose level (approximately 100 to 200 mg per day).

Advantages 

Tricyclic antidepressants, like the SSRIs, do not lead to physical dependence. They have a beneficial effect on depression as well as on panic and anxiety. They block panic attacks, even if you are not depressed. Because generic forms are available, they are inexpensive.
Drawbacks Tricyclic antidepressants (unlike SSRIs) tend to produce anticholinergic side effects, including dry mouth, blurred vision, dizziness or disorientation, and postural hypotension (causing dizziness).
Weight gain and sexual dysfunction can also occur. With imipramine, in particular, anxiety may increase during the first few days of administration. With clomipramine (effective for OCD), side effects can be particularly bothersome.

Although these side effects tend to diminish after one or two weeks, they persist for 25 to 30 percent of people who take tricyclic antidepressants after the initial adjustment period.
Like the SSRIs, tricyclic antidepressants take about three to four weeks to offer therapeutic benefits. While able to block panic attacks, these medications may not be as effective as SSRIs and benzodiazepine tranquilizers in reducing anticipatory anxiety about the possibility of having a panic attack or having to face a phobic situation.
Finally, about 30 to 50 percent of people will relapse (experience a return of panic or anxiety symptoms) after discontinuing tricyclic antidepressant medications. This is, however, a much lower relapse rate than occurs when benzodiazepines are discontinued.
MAO-Inhibitor Antidepressants If you have given SSRIs and tricyclic antidepressants a fair trial and still have obtained no benefit, your doctor may try the oldest class of antidepressant medications—the MAO-inhibitors (MAOIs). Nardil (phenelzine) is the MAOI most commonly used to treat panic, although Parnate (tranylcypromine) is sometimes used. While MAOIs are potent medications, they are frequently last in line to be tried because they can cause serious or even fatal rises in blood pressure when combined with 1) foods that contain the amino acid tyramine, such as wine, aged cheeses, and certain meats, and 2) certain medications, including some over-the- counter analgesics. If you are taking an MAOI, you should be under close supervision by your doctor.
Advantages MAOIs have a potent panic-blocking effect and are sometimes effective when other types of antidepressants have failed. There is also some research indicating that they are helpful in treating social phobia, especially generalized social phobia (a tendency to be phobic toward a wide range of interpersonal situations or encounters). They may also help severe depression that has been unresponsive to other classes of antidepressants.

Drawbacks

Side effects include weight gain, hypotension (low blood pressure), sexual dysfunction, headache, fatigue, and insomnia. These side effects may be most pronounced during the third and fourth weeks of treatment and then are likely to diminish.
Dietary restrictions are critical. When taking an MAOI, you need to avoid foods containing tyramine, including most cheeses, homemade yogurt, most alcoholic beverages, aged meats and fish, liver, ripe bananas, and certain vegetables. Over-the- counter cold medicines, diet pills, and certain antihistamines also need to be avoided. Prescription amphetamines and SSRI or tricyclic antidepressants should be avoided as well.

Other Antidepressants

Other antidepressant medications occasionally used with anxiety disorders include Remeron (mirtazapine), Wellbutrin (bupropion), and Desyrel (trazodone). Remeron is classified as a noradrenergic/specific serotonergic antidepressant (NaSSA), and, like Effexor, it has a dual action, increasing the levels of both norepinephrine and serotonin at the synapse. Remeron is very sedating at lower doses and may be used to promote sleep. At higher doses, it is an effective antidepressant, and may be used when Effexor is not well tolerated. Psychiatrists sometimes use it in combination with an SSRI, like Paxil or Celexa, to enhance the antianxiety and/or antidepressant effects of the SSRI, a strategy called augmentation.
Wellbutrin is often helpful for depression but can be difficult for people with anxiety disorders to tolerate, since its side effects can include anxiety and insomnia. 
On the positive side, Wellbutrin is one of the newer antidepressants that does not have sexual side effects.
Trazodone (brand name Desyrel) is an older antidepressant medication that has been around since the early 1980s. While not frequently prescribed for anxiety, it can be a highly effective sedative for many people. It has the advantage of not being addictive (unlike Restoril, Ambien, or Lunesta), and may be more potent for some people than natural sedatives like melatonin and tryptophan. Its side effects are similar to those listed for the tricylic antidepressants.
Beta Blockers Although there are several different beta-adrenergic blocking drugs (popularly called beta blockers), the two most commonly used with anxiety disorders are Inderal (propranolol) and Tenormin (atenolol). These medications can be helpful for anxiety conditions with marked body symptoms, especially heart palpitations (rapid or irregular heartbeat) and sweating. Beta blockers are quite effective in blocking these peripheral manifestations of anxiety, but are less effective in reducing the internal experience of anxiety mediated by the central nervous system. Inderal or Tenormin may be used in conjunction with a benzodiazepine tranquilizer, such as Xanax, in treating panic disorder when heart palpitations are prominent. By themselves, beta blockers are often given in a single dose (for example, 20 to 40 mg Inderal) to relieve body symptoms of anxiety (rapid heartbeat, shaking, or blushing) prior to a high-performance situation, such as public speaking, a job interview, final examinations, or a musical recital. Beta blockers are also often used to treat mitral valve prolapse, a benign heart arrhythmia that sometimes accompanies panic disorder.
Although these medications are relatively safe, they can produce side effects, such as the excessive lowering of blood pressure (causing dizziness or light-headedness), fatigue, and drowsiness.
In some people, they can also cause depression. Unlike tranquilizers, these medications do not tend to be physically addictive. Still, if you’ve been taking them for a while, it’s preferable to taper your dose gradually to avoid rebound elevations of blood pressure. Beta blockers are not recommended for people with asthma or other respiratory illnesses that cause wheezing, or for diabetics.
Buspar Buspar (buspirone) has been available for about twenty years. To date, it has been found useful in diminishing generalized anxiety but is less effective in reducing the frequency or intensity of panic attacks. Some research indicates that Buspar can be helpful in treating social phobia or in augmenting the effects of SSRI medications used to treat OCD. Some practitioners prefer it over Xanax (and other benzodiazepines) for treating generalized anxiety because it is less prone to cause drowsiness and is nonaddictive. There is little risk of your becoming physically dependent on Buspar or requiring a protracted period of time to withdraw from it. Research in recent years, however, has not found Buspar to be any more effective than SSRIs in treating generalized anxiety.
An ordinary starting dose for Buspar is 5 mg two or three times per day. It takes from two to three weeks before the full antianxiety effect of this medication is achieved. Some people with generalized anxiety respond well to Buspar, while others report side effects (lethargy, nausea, dizziness, or paradoxical anxiety).

Other Medications Used to Treat Anxiety

When antidepressant medications and/or BZ tranquilizers are ineffective or not fully effective in treating panic disorder, psychiatrists may try other medications such as: 
1. Depakote (valproic acid), 
2. Neurontin (gabapentin), 
3. Gabitril (tiagabine), or 
4. Lyrica (pregabalin). 

Although such medications are often used to treat seizure disorders or bipolar disorder, they also have an antianxiety effect. 

It’s thought that they work by increasing levels or activity of the neurotransmitter GABA in the brain. (Tiagabine is actually a selective GABA reuptake inhibitor.) 

Certain clients, most often those with generalized anxiety disorder, seem to benefit from one or another of these medications, taken either alone or with an SSRI antidepressant. Effective dose ranges for Depakote are 700 to 1500 mg per day; Neurontin, 300 to 1800 mg per day; Gabitril, 4 to 10 mg per day; and Lyrica, 150 to 300 mg per day.
The advantage of these medications is that they work rapidly, are nonaddictive, and are not associated with sexual side effects. Numerous people receive genuine help from these drugs. On the downside, some people report that Neurontin or Gabitril makes them feel tired, lethargic, or occasionally nauseated. Depakote is generally well tolerated but has been associated with liver problems in certain people (so it needs monitoring). If you have not had a good response to antidepressants and want to avoid the addictive problems associated with benzodiazepines, these medications are worth trying.

The Choice to Use Medication: What to Consider

The decision to include medication in your effort to recover from anxiety involves many considerations.
First and foremost, it’s always a decision to be made in consultation with your physician.
Your doctor, preferably a psychiatrist, should be knowledgeable and experienced in treating anxiety disorders and should work with you in a collaborative (not authoritarian) way. Second, your decision depends on a number of personal factors, including: 

1) the severity of your problem with anxiety, 

2) your personal outlook and values regarding medication, and 

3) your patience, which may be tested in those situations where several medications need to be tried before the right one for you can be found.

Be wary of pat answers and simple generalizations when you consider undertaking a course of medication. The following twelve vignettes illustrate the complex range of situations that might lead a person to decide for or against taking medication.

1. A busy physician has numerous duties at work, at home, and in his community. He takes time to meditate, jog, express feelings, and work with self-talk, but still has debilitating panic attacks. He finds that an SSRI antidepressant helps him to sleep better and carry out his round of daily responsibilities with less anxiety.

2. A mother who has been housebound with agoraphobia for a long time has a difficult time beginning exposure therapy. She finds that taking an SSRI medication helps her to get started. After one year of exposure, she is confident enough to continue without medication.

3. A secretary who has been taking medication for mixed anxiety and depression for a year discovers she is pregnant. She stops her medication and puts up with intensified symptoms for nine months in order to have a healthy baby.

4. A husband going through a divorce has a heart attack followed by mixed anxiety and depression. Although he has been opposed to taking medication up to this time, he decides to rely on a benzodiazepine medication to help him negotiate this severe crisis.

5. A woman who has just been promoted to a more demanding job learns her mother has died. She elects to take medication for a period of several months to handle her stressful life circumstances.

6. A chiropractor who teaches classes in nutrition and is heavily involved in alternative health practices has obsessive-compulsive disorder. He finds that he needs to take an SSRI antidepressant in order to handle his work.

7. A student who decides to enroll in a certificate program to be an acupuncturist has a strong desire, despite her panic attacks, to embrace only natural methods (such as herbs, nutrition, tai chi, and meditation) to handle her anxiety. She decides not to use medication.

8. A man who has been taking various SSRI antidepressants for panic disorder over five years wants to evaluate how he might do without medication. He discontinues it over a period of two months and does well.

9. A long-term user of benzodiazepines feels they are causing her to be depressed and decides she would rather have some anxiety and emotional intensity in her life than feel numbed or de-energized by a tranquilizer. She discontinues her use of BZs.

10. A minister with panic disorder is unable to tolerate any antidepressant medication. He finds he is best able to function taking a low dose of a tranquilizer every day over the long term.

11. A woman who belongs to a religious group that espouses that prayer and right living are the answer to life’s difficulties has a strong philosophical belief that medications are unnecessary for her recovery. She elects not to use medication for her panic attacks.

12. A recovering alcoholic with two years’ sobriety begins taking Xanax to manage his anxiety. Within two months, he starts escalating the dose. Both his doctor and his 12-step program friends advise him to discontinue the medication. In the interest of maintaining a commitment to a substance-free lifestyle, he does so.

Whether you’re considering starting medication or thinking about stopping medication you’ve been taking for a while, the two most important factors to look at in making a decision for yourself are your own personal values and the severity of your condition. Each of these is considered below.
Personal Values What are your personal values about medication? Are you open to including medication as a part of your recovery program, or do you feel strongly about adhering to natural methods alone? While your symptoms may warrant trying medication and while your doctor might encourage you to do so, the decision is ultimately your own. If you happen to be committed to the ideal of natural healing without the aid of medication, that is a perfectly legitimate option. Many people can recover from anxiety disorders by natural methods alone if they have sufficient motivation, persistence, and diligence in practicing natural methods, such as those outlined in this book. At the opposite extreme, there are people who lack sufficient interest or motivation to put in the time and effort involved in practicing relaxation, exercise, exposure, and cognitive skills on a daily basis. They seek immediate relief of symptoms through taking a drug. In many cases, this is also a viable choice. It is not for anyone to judge a person’s decision to seek relief from anxiety disorders through medication. Medications certainly do provide a great deal of relief for many people.
In making a choice about whether to rely on medication, it’s important to have all the information that you need to make the most informed and enlightened decision possible. Such a decision should not be based solely on impulse—for example, a desire to take a high dose of medication to eliminate all symptoms of anxiety as soon as possible. Nor should it be based upon fear or avoidance of medication because you have a phobia of it. The purpose of this chapter is to give you as much information as possible so that you can make the optimal decision for yourself.

Severity of Your Condition

Apart from your personal values, the next thing to look at in considering medication is the severity of your symptoms. As a general rule, the more severe your problem, the more likely you will benefit from a trial of medication. Severity can be defined in two ways: your ability to function and your level of distress. Use the following questions to evaluate the severity of your own condition.

First, does your problem with anxiety significantly interfere with your ability to function in your everyday life? Are you having a hard time working, or are you unable to work at all? Is your ability to raise your children or be responsive to your spouse impaired by your anxiety? Do you have a hard time organizing your thoughts to complete basic tasks, such as cooking or paying bills? 

Second, does your problem with anxiety cause you considerable distress, to the point that you have two or more hours every day during which you feel very uncomfortable? Is it hard for you just to make it through each day? Do you wake up each morning in a state of dread? If your answer to any of these questions is yes, you may want to consider medication.

Another factor in considering medication is depression. Significant depression accompanies anxiety disorders in up to about 50 percent of cases. The highest association is with generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD), while the lowest association is with specific phobias. There is also a syndrome—mixed anxiety and depression—that has received attention in recent years. Criteria for depression include lack of energy, continuous low mood or apathy, loss of appetite, disturbed sleep, frequent self-criticism, difficulty concentrating, and possibly suicidal thoughts. If you are depressed, antidepressant medication can be especially helpful because it tends to restore the motivation and energy you need to practice the skills promoted in this book, such as abdominal breathing, relaxation, exercise, cognitive restructuring, and graded exposure. If you have had suicidal thoughts, your doctor will most certainly recommend medication.
In addition to severity of symptoms, chronicity—how long you’ve had your problem—is another important factor to consider. If your anxiety is of recent origin and a response to stressful circumstances, it may pass when you learn stress-management techniques and work through whatever problem instigated the stress. On the other hand, if you’ve been suffering for more than a year—and especially if you’ve tried cognitive behavioral therapy and have not yet received the benefit you wanted—a trial of medication may be helpful. To conclude, the more severe and/or the more chronic (long-standing) your condition, the more likely you may be to respond favorably to medication.

How Long to Continue Medication

For anyone who is considering trying or is presently taking a prescription medication, how long to take it is a very important issue. Unfortunately, there is no simple answer. The length of time you need to take medication depends on at least three different factors: 

• What type of medication (for example, tranquilizer or antidepressant) 

• What type of anxiety disorder (for example, panic, social phobia, or obsessive-compulsive disorder) 

• Your motivation and commitment to utilize natural approaches (as a committed program of nonmedication approaches may help you to stop relying on medication or else reduce your dose) What Type of Medication Some types of medication, such as tranquilizers or beta blockers, can be used on an as-needed basis only. That is, you only use the medication when dealing with an acute, anxiety-provoking situation, such as confronting a phobia. Tranquilizers can also be used over a period of a few weeks to help you get through a particularly difficult situation, such as the death of a loved one or taking the bar exam. For a period of one to two years, tranquilizers may be useful if you are unable to take any type of antidepressant medication for anxiety. Long-term use of tranquilizers (more than two years), while having certain problems, may even be justified in some cases (see the previous section on benzodiazepine tranquilizers).

Antidepressant medications are usually taken on a daily basis for a minimum of six months.
In my experience, they are most effective in treating anxiety disorders when taken for a period of one to two years. Risk of relapse once you discontinue the antidepressants is lower if you’ve taken them for this length of time. For some people, long-term use of antidepressant medication (that is, more than two years), at a maintenance dose level, offers an optimal quality of life.
What Type of Anxiety Disorder If you have a fairly mild case of agoraphobia, you may need to take medication (a tranquilizer or an antidepressant) only up to and during the early stages of graded exposure to your phobic situation. Then, during later stages, you may wean yourself off the medication and work through your exposure hierarchies on your own. Being able to do so without the use of medication will enhance your sense of mastery over your phobia. On the other hand, if you are having frequent panic attacks and/or are practically housebound, you may benefit from taking medication for a longer time. For SSRI antidepressant medications, the one-to two-year period mentioned above is optimal. Long-term maintenance on a low dose of antidepressant medication may be necessary in some cases.
For social phobia, you may take an antidepressant (SSRI or SNRI antidepressant) or a benzodiazepine, especially if you suffer from generalized social phobia (anxiety in a wide variety of social situations). One to two years on the medication will likely optimize your treatment. Long-term maintenance at a low dose, as with agoraphobia, may be necessary in some cases.
With obsessive-compulsive disorder, long-term use of an SSRI medication at a higher dose is often the best strategy. After two years, you can try lowering the dose to see what is the minimum you need to correct the neurobiological problem associated with OCD. On the other hand, some people with OCD are able to manage their problem with cognitive behavioral strategies alone—sometimes from the outset and sometimes after a year or two on medication. (See the book Brain Lock by Jeffrey Schwartz, listed at the end of this chapter.) Generalized anxiety disorder will require medication only in moderate to severe cases or in situations where you are unmotivated or unwilling to make the behavioral and lifestyle modifications that can help.
Finally, post-traumatic stress disorder may frequently be helped by antidepressant medication in conjunction with cognitive behavioral therapy; severe cases may need a long-term maintenance dose.
Your Motivation and Commitment to Utilize Natural Approaches In many cases, it’s possible to eliminate or at least reduce your need for medication over the long term, if you maintain a committed program of natural approaches. The brain has an inherent ability to heal from the stress-induced imbalances that may have led to your original need for medication.
While it may take your brain somewhat longer to recover than would be the case for a broken bone or a torn ligament, the brain can regain, with proper cognitive, behavioral, and lifestyle modifications, much or all of its natural integrity over time. Your very belief that you can recover from anxiety and eventually wean yourself off medication will help make it more likely that you do. The popular idea of “mind over matter” is not an idle notion. Any of the approaches suggested in this book will help you to heal yourself naturally. The more of these approaches you are able to implement on a regular basis, the sooner and more powerfully you will be able to foster a state of natural health in body and mind.

Discontinuing Medication

If you’ve decided that you want to stop relying on prescription medications, observe the following guidelines: 1. Be sure you’ve gained some level of mastery of the basic strategies for overcoming anxiety and panic presented in this book. In particular, it would be a good idea to have established a daily practice of deep relaxation and exercise, along with skills in using abdominal breathing and countering fearful self-talk to overcome anxiety symptoms. If you plan to withdraw from Xanax or a BZ tranquilizer, these skills will serve you well in dealing with possible recurrences of anxiety during the withdrawal period, as well as over the long run.
Be assured that any resurgence of high anxiety during withdrawal from a tranquilizer is temporary and should not persist if you proceed through your withdrawal in a sufficiently gradual manner.

2. Consult with your doctor to set up a program for gradually tapering off the dosage of your medication.
This is especially important if you’ve been taking a BZ tranquilizer (the tapering-off period is dose-dependent but may need to be as long as six months or even longer). A tapering-off period (usually a month or two) also needs to be observed if you’re curtailing your use of an antidepressant medication like Paxil or a beta blocker such as Inderal.

Generally, the longer you’ve taken a medication, the longer and more gradual the tapering period should be.

3. For many people, benzodiazepine tapering can be difficult. The nervous system adapts to these drugs, and it may take you quite some time to readapt to living without them. Often psychiatrists prescribe an SSRI antidepressant, or other nonaddictive antianxiety medication such as Neurontin, during and after the BZ tapering-off process in order to ease withdrawal symptoms. For people unable to tolerate these prescription medications, sometimes high doses of the amino acids tryptophan, theanine, GABA, taurine, and glycine—administered either intravenously or orally—can be helpful both during and for some time after the tapering-off period. There are two approaches to withdrawing from the benzodiazepines. One is to reduce the dose very slowly over a period of several months—preferably with the aid of a nonaddictive antianxiety medication, as previously described. Alternatively, drug rehabilitation programs do a more rapid tapering off over a period of two to three weeks and use an alternative (long half-life) benzodiazepine, such as Valium, or else phenobarbital, in lieu of the high-potency benzodiazepine (such as Xanax or Klonopin) that is being withdrawn. After withdrawal from the secondary drug, an antidepressant or other nonaddictive antianxiety medication may be used to assist adjustment for several months after the tapering off is finished. For more detailed information on benzodiazepine tapering, see the resources by C. Heather Ashton listed at the end of this chapter.

4. Be prepared to increase your reliance on the strategies described in this workbook during your tapering-off period. Especially important are abdominal breathing, relaxation, exercise, coping strategies for anxiety, and countering negative self-talk.
Your withdrawal from medication is an opportunity to practice and improve your skills at using these strategies.
You’ll gain increased self-confidence by learning to use self-activated strategies to master anxiety and panic without having to rely on medication.

5. Don’t be disappointed if you need to rely on medication during future periods of acute anxiety or stress. Stopping regular use of a medication doesn’t necessarily mean that you might not benefit from the short-term use of that medication in the future. For example, using a tranquilizer or sleep medication for two weeks during a time of acute stress due to a traumatic experience is appropriate and unlikely to lead to dependence. If you’re subject to seasonal affective disorder, you may stand to benefit from taking an antidepressant medication during the winter months. Don’t consider it a sign of weakness or a lack of self-control if you occasionally need to rely on prescription medications for a limited period of time.

Given the stress and pressures of modern life, there are quite a few people who occasionally use prescription medications to help them cope.
Working with Your Doctor The purpose of this chapter has been to provide a balanced view of the role of medications in treating anxiety. There are certainly a variety of situations where the benefits of prescription drugs outweigh their associated risks and drawbacks. It’s important, however, that before taking any medication you become fully aware of all of its potential side effects and limitations. It is your doctor’s responsibility to: 

1) obtain a complete history of your symptoms, 

2) inform you of the possible side effects and limitations of any particular drug, and 

3) obtain your informed consent to try out a medication. 

It’s your responsibility not to withhold information your doctor requests in taking your medical history, as well as to let him or her know, should he or she fail to ask, whether: 

1) you have allergic reactions to any drugs, 

2) you are pregnant, 

3) you are taking any other prescription or over-the- counter medications, or 

4) you are taking any natural supplements.

Once this exchange of information has taken place between you and your physician, both of you will be in a position to make a fully informed and mutual decision about whether taking a particular prescription medication is in your best interest. If your doctor is unwilling to take a collaborative rather than authoritarian stance, or to allow for your informed consent, seek out another doctor who will. Medications may enable you to turn the corner in recovering from your particular problem, but it is essential that they be used with the utmost care and responsibility.

Note: The Internet offers websites that distribute various antianxiety medications, especially tranquilizers, without a prescription. It’s best to avoid these sites, as they may take your money without sending you anything, send you the wrong medication, or send you an inferior or toxic version of the medication you ordered. It is worth your time and money to consult with an experienced physician or psychiatrist when you are in need of medication, and to utilize reputable pharmacies that require a prescription.

In Conclusion

Appropriate use of medication does not conflict with holistic values or a natural lifestyle. There is a time and place for the use of medication in treating anxiety disorders, and not to use them at those times is equivalent to not taking good care of yourself. The real question to ask, in my opinion, is this: What is the most compassionate thing you can do for yourself? In some cases, the answer may be to wean yourself off medication—especially if you have become overly dependent on or addicted to a drug for several years without having evaluated how you might fare without it. In some cases, the answer may be to use medication for a period of several months (up to a year) to get through a difficult time or to jump-start your motivation to utilize cognitive behavioral and other natural approaches. In other cases, long-term use of medication (particularly the SSRIs), in conjunction with the full spectrum of cognitive, natural, and lifestyle changes suggested in this book, may be the most compassionate response you can have for yourself.
There are few set answers when it comes to the subject of medication. Getting all the information you can, working with a competent physician whom you can trust, and then listening to your own intuition is the best you can do.
The Use of Natural Supplements Since this chapter is about prescription medications, it doesn’t include detailed information on natural substances that can be useful in the treatment of anxiety problems. Full descriptions of all of the natural supplements used to treat anxiety and depression may be found in the section “Supplements for Anxiety” in chapter 15.
There are two classes of such substances. Natural tranquilizers include herbs such as kava, valerian, passionflower, and chamomile, as well as amino acids such as theanine and GABA.
Natural antidepressants, which can have an anxiety-reducing effect as well, include the herb Saint-John’s- wort,
S-adenosylmethionine (abbreviated as SAM-e), and the amino acids tryptophan and tyrosine. You may find any of these supplements at your local health food store or online. Any one or a combination of them may be quite helpful as an alternative to prescription drugs in treating your problem with anxiety or depression. The key consideration in deciding to try natural supplements is whether you consider your anxiety problem to be in the mild to moderate range of severity. If anxiety is more of a nuisance—a discomfort or inconvenience in your life—and not a debilitating or highly distressing condition, you might want to consider natural supplements first before consulting with a psychiatrist about prescription drugs. If you are already taking an SSRI antidepressant or BZ tranquilizer, do not try natural supplements without first consulting with a doctor well versed in combining prescription medications with supplements.

Summary of Things to Do

1. Review this chapter to provide yourself with an overview of the various types of medications used to treat anxiety disorders. Be familiar with the benefits and limitations of those medications that may have relevance for your particular issue.
If you are not currently taking medication but wonder if you could benefit from doing so, contact a psychiatrist who is knowledgeable about anxiety disorders to discuss your options. The Anxiety and Depression Association of America offers a “Find a Therapist” link on their website, adaa.org, that may assist you in finding a specialist in your local area (see appendix 1).
If you are currently taking a medication and would like to stop, consult your prescribing physician to discuss the appropriateness of doing so. If you and your physician jointly decide that you are ready to discontinue the medication, follow the guidelines in the section “Discontinuing Medication.” Remember, it’s preferable to stop medication only after you’ve gained some mastery of the skills discussed in chapters 4 through 15 of this book. If you wish to withdraw from a benzodiazepine medication that you have been taking for more than a month, prepare to take some time tapering off the dose gradually, possibly over a period of several months. Consult the website benzo.org.uk and The Ashton Manual for assistance.

2. If you feel your problem with anxiety is relatively mild (if it’s more of an inconvenience or nuisance than a debilitating or highly distressing condition), consider trying natural supplements, as described in chapter 15, before resorting to drugs. You may also want to take a look at the books Healing Anxiety Naturally by Harold Bloomfield or my book Natural Relief for Anxiety.

Further Reading 

1. Ashton, C. Heather. Benzodiazepines: How They Work and How to Withdraw. Boston: Benzodiazepine Awareness Network, 2002. (See the website benzo.org.uk, where you can download The Ashton Manual.) Bloomfield, Harold. Healing Anxiety Naturally. New York: HarperPerennial, 1999.

2. Bourne, Edmund, Arlen Brownstein, and Lorna Garano. Natural Relief for Anxiety. Oakland, CA: New Harbinger Publications, 2004.

3. Norden, Michael. Beyond Prozac. Revised and updated edition. New York: HarperPerennial, 1996.

4. Preston, John, John H. O’Neal, and Mary C. Talaga. Handbook of Clinical Psychopharmacology for Therapists. Sixth edition. Oakland, CA: New Harbinger Publications, 2010.

5. Schwartz, Jeffrey. Brain Lock: Free Yourself from Obsessive-Compulsive Behavior. New York: Regan Books / HarperPerennial, 1997.

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