A child who appears to be oppositional or aggressive may be reacting to internal anxiety—anxiety he may, depending on his age, not be able to articulate effectively, or not even fully recognize that he’s feeling. Anxiety is based on the body’s physiological response to a threat in the environment, as a response to maximize the body’s ability to either face danger or escape danger. Some children show their anxiety by becoming quiet, shrinking away from situations that make them anxious, and having trouble separating from their parents. These symptoms of anxiety are easy to detect for most providers.

However, the above symptoms are not the only way that anxiety manifests itself. Other children react with an overwhelming need to break out of an uncomfortable situation, which can be misinterpreted as anger or opposition. What people on the outside see is intense anger that is out of proportion to the situation, property destruction, elopement and aggression. In this way, anxiety can be a great masquerader.

Anxiety can present in the school setting as disruptive behavior. A child might find the academic work hard or become frustrated if he can’t do it perfectly. A child might have a hard time taking feedback or criticism from the teacher or peers. A child might be overwhelmed with the noise level in the classroom or a crowded lunch area

When a child presents with disruptive behavior, it is important to ask screening questions in other mental health areas as well, including depression, anxiety, obsessive compulsive disorder and autism. Examples of screening questions for anxiety include: Does your child worry excessively about everyday activities? Does your child have exaggerated or irrational fears?  If any of these screening questions are positive, consider asking more detailed questions or obtaining screening questionnaires (for example the GAD7 or SCARED) to elicit more details. Referral for a more thorough diagnostic evaluation with a psychologist could be helpful as well in cases that are diagnostically confusing.

This distinction is important to make sure a child has the right diagnosis, because it impacts treatment. The therapy approach for anxiety is different than the therapy approach for disruptive behavior disorders. Psychotropic medication, if being considered, would be different as well for these diagnoses. The SSRIs would be first line medication treatment for anxiety which the stimulants or non-stimulants like the alpha agonists (guanfacine and clonidine) or atomoxetine would be first line medication treatment for ADHD and other disruptive behavior disorders. If one is considering medication treatment for behavioral dysregulation that can be seen with anxiety, the alpha agonists can be helpful specifically for that. The stimulants can actually make the anxiety worse in these clinical situations.

In summary, it is important to ask what might be underlying the externalizing behavioral problems, because you might uncover anxiety masquerading as a disruptive behavior disorder. As always, SmartCare BHCS Parent Line 858-956-5900 is available to help families find appropriate resources and SmartCare Provider Line 858-880-6405 is available to providers to help with diagnostic clarification and medication treatment questions.

References:

https://childmind.org/article/how-anxiety-leads-to-disruptive-behavior/

Beyond Behaviors by Mona Delahooke PhD: https://monadelahooke.com/beyond-behaviors/

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Co-Medical Director, Vista Hill Foundation

Health Science Clinical Professor, UCSD Department of Psychiatry

President, San Diego Academy of Child and Adolescent Psychiatry

A recent randomized control trial highlighted the role for Escitalopram in helping teenagers with generalized anxiety (Strawn et al, 2020). Interestingly, the study also found that certain genetic factors may impact effectiveness of the medication. This highlights the clear role for SSRIs in anxiety management, as well as possible future directions for tailoring psychiatric treatment. Other reviews of anxiety treatment highlight that SSRIs can be effective for multiple anxiety disorders (Generalized anxiety, social anxiety, panic disorder and others), and in general can take up to 8 weeks to take full effect (Kodish et al., 2011).

A proposed dosing strategy for adolescents with anxiety

Sertraline – start at 25 mg and increase by 25 mg every 1-4 weeks, targeting symptom remission. Typically response occurs between 100 – 150 mg, but can occur at lower doses. Sometimes doses up to 200mg may be used, provided the medication is tolerated.

Fluoxetine – start at 10 and increase by 10 mg – every 1-4 weeks, targeting symptom remission. Typically response occurs between 20 – 40 mg, but can occur at lower doses. Rarely doses up to 60 mg may be used, provided the medication is tolerated.

Escitalopram – start at 5 – 10 and increase by 5 – 10 mg – every 1-4 weeks, targeting symptom remission. Maximum dose is 20 mg, higher doses are not recommended due to QTC prolonging risks.

For referrals or psychopharm guidance

• SmartCare for Families : 858-956-5900
• SmartCare for Providers : 858-880-6405
• Psychologytoday.com
• County Sevices
  • https://www.optumsandiego.com/content/dam/san-diego/documents/socdirectory/SBC_DBH-SUDRS_Provider_Directory_English.pdfIpser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2.Strawn JR, Mills JA, Schroeder H, Mossman SA, Varney ST, Ramsey LB, Poweleit EA, Desta Z, Cecil K, DelBello MP. Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. J Clin Psychiatry. 2020 Aug 25;81(5):20m13396. doi: 10.4088/JCP.20m13396. PMID: 32857933; PMCID: PMC7504974.
  • Kodish, I., Rockhill, C., & Varley, C. (2011). Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues in clinical neuroscience, 13(4), 439–452.

When assessing inattention, it is important to consider all possible causes, including: depression, anxiety, reaction to trauma, family or psychosocial stressor, a learning disability, a sensory processing issue, mental retardation, poor educational fit, brain injury, substance abuse, and rarely psychosis. If these other causes have been considered and ruled out, the inattention symptoms are impairing in both the home and school settings and the symptoms began before age 7, then a diagnosis of ADHD is likely. A treatment course involving a stimulant medication will likely be helpful. Likewise if a diagnosis of ADHD has been made but a child does not respond to multiple medication trials including stimulants and non-stimulants, then the treating clinician should reconsider the diagnosis.

Here are two case examples to illustrate the point:

1. 14yo female presents with a chief complaint of “trouble focusing”. She previously maintained good grades and did not have concerns of inattention, hyperactivity or impulsivity in early childhood. She now has failing grades. Associated symptoms include: irritability, poor sleep, isolation including from friends and non-suicidal self-injury for the last 2 months. She has a family history of depression in her mother and maternal GM and older sister.

-This presentation is more consistent with a diagnosis of Major Depression than ADHD. Patients with depression commonly report poor concentration and trouble with attention. A diagnosis of ADHD would not be consistent with this presentation because the patient did not have symptoms begin before age 7. A good treatment plan would be to consider an SSRI and individual therapy. While a stimulant may have helped with her inattention, it would not have helped with her other depressive symptoms.

2. 6yo boy presents with a chief complaint of  “inattention and impulsivity” primarily in the school setting. This child is in protective custody after being removed from bio parents because of physical abuse and neglect. He was not in school prior to the removal and was mostly isolated at home. He also presents with delays in speech and cognitive development as well as anxiety and aggression.

-This case example is more complicated because there are factors related to trauma, as well as developmental and educational delays. It would be important to fully evaluate those delays (including a speech evaluation and cognitive evaluation) and to ensure that he is in an appropriate educational placement prior to considering a diagnosis of ADHD. Also because of the co-morbid anxiety, a stimulant may not be the best medication choice as stimulants can make anxiety worse. Other options might be atomoxetine or guanfacine. Until a more thorough assessment can be completed, a more appropriate diagnosis might be Adjustment Disorder with Disturbance of Conduct and Emotion.

Hopefully this discussion and these case examples help illustrate the importance of a thorough assessment when a child presents with a chief complaint of “trouble focusing”, prior to beginning treatment. Since most patients will first present to their primary care provider with this concern, it is important for primary care providers to be comfortable beginning that assessment process .

In the past, OCD was categorized diagnostically as an anxiety disorder, but in the DSM V it has been separated into its own category. This is largely because research has shown that the genetics of OCD is different from the genetics of other anxiety disorder. OCD is defined as obsessions (intrusive, unwanted and excessive worries) and compulsions (rituals to relieve the anxiety) that are impairing to everyday life. The impairment can be defined by the amount of time spent on the obsessions and compulsions, its effect on preventing a patient from carrying out activities of daily living and work responsibilities, and its effect on alienating important people in the patient’s life. The obsessions and compulsions can involve the following: preoccupation with contamination, cleaning, checking, symmetry and order, preoccupation with sexual, violent or religious thoughts, and hoarding.

The diagnosis of OCD is primarily a clinical one. Two good screening questions to determine if further assessment is indicated are:

1. “Are bothered by unpleasant worries that repeatedly come into your mind about contamination, ordering things, etc?
2. “Are driven to perform certain acts over and over again like checking locks or washing your hands excessively?”

The YBOCs is a good diagnostic tool for delineating specific symptoms and determining the level of severity and the patient’s level of insight. The patient is typically aware that the obsessions and compulsions are irrational and excessive but are compelled to do them anyways. This egodystonic nature of the illness is partly what leads to the suffering from OCD and can lead to an increased risk of suicide.  In rare cases, when patients are not aware that their obsessions and compulsions are irrational and excessive, they are said to have “poor insight” and their OCD is typically more treatment-resistant. These cases can often be difficult to differentiate from true psychotic delusions.

OCD is frequently co-morbid with other anxiety disorders, depressive disorders, and eating disorders in adults and ADHD and tic disorders in children. Treatment options include exposure response prevention (a CBT specifically geared for OCD) and psychotropic medications. ERP involves repeated exposure to situations that trigger the obsessive thoughts and having the patient gradually learn to tolerate the anxiety and resist the urge to perform the compulsions. Medication options include the SSRIs (Prozac, Paxil, Lexapro, Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic antidepressant, used primarily for treatment resistant cases). Medication treatment involves slow titration to avoid worsening the anxiety, and patients often need higher doses for longer periods of time for a full effect. It is important to make sure patients are aware that it can take up to 3 months to get to a full effective dose. Most patients do better with a combination of medication and ERP. There are adjunctive medication options available if full symptom relief is not achieved with an SSRI alone. These include the second-generation antipsychotic medications. Surgery and ECT vs deep brain stimulation can be used for refractory cases.

Given that OCD is more prevalent than previously thought, it is important that first line providers are comfortable with knowing when to assess for OCD and how to pursue with treatment recommendations.

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression, if that is being considered, and it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use), and duloxetine (because of limited data in children and adolescents). It is important to consider a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So for example if considering fluoxetine, a starting dose of 10mg qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.

Anxiety is a universal and highly adaptive experience, as it keeps us alert to real life dangers. Excessive and/or chronic anxiety, however, can be problematic as it reduces a person’s ability to function. Timely and effective intervention for anxiety disorders can have a dramatic positive impact on a patient’s life.

Core symptoms: The central psychological features of the anxious patient are feelings of nervousness and thinking that is constricted and dominated by worry. Other features may include ruminations, poor concentration, racing thoughts, panic and feelings of exhaustion. Physical features may include signs of over-arousal such as restlessness, muscle tension, sweating, tremor, pain, dizziness, and others. Some patients present with concern about psychological and emotional symptoms; others may present with predominantly with physical health complaints. Many suffer quietly. Acute and chronic anxiety can have significant negative impact on health conditions.

Multiple Subtypes: Anxiety disorders have many faces and it can be helpful to differentiate among the types.

Social Anxiety Disorder: shyness, embarrassment, physical distress associated with exposure

Obsessive Compulsive Disorder: thinking and action constricted, with distress and impaired functioning

Post-Traumatic Stress Disorder: past trauma exposure with ongoing distress, remembering, distress, arousal

Acute Stress Disorder: recent trauma–distress, arousal

Generalized Anxiety Disorder: pervasive and excessive worrying, typically without clear precipitant or trigger

Panic Disorder: florid episodes of intense anxiety with inter-episode apprehensiveness and anticipation

Adjustment Disorder: anxiety experienced in context of acute stressor which resolves as patient adapts or stressor abates.

Important Questions:

1) Simply asking a patient about their level of emotional distress is an important first step in reaching a diagnosis and developing a collaborative treatment relationship.

2) Is the anxiety acute or is it chronic? Most patients report lifelong challenges with their anxiety symptoms.

3) Are there current life stressors—relationships, job, financial, other? Does the patient have natural supports or others (counselors, clergy, etc.) who can help?

4) Was there prior trauma or abuse? It is best to ask this question openly and directly to see if it could be a factor in the patient’s current symptom profile.

5) Is there a family history of similar problems? If so, what helped them?

6) Is there an underlying medical problem? The list is long but endocrine and other conditions may be of note.

7) Are symptoms being triggered by a medication given for a medical or another psychiatric illness?

8) Is substance abuse a contributing factor or a risk factor?

9) Are there other psychiatric issues—depression, mood problems, personality difficulties, etc.?

Treatment: Optimal treatment often entails a combination of education, psychotherapy and/or medication intervention. Psychotherapy alone can be highly beneficial with a focus on faulty thinking patterns, self-calming strategies, social engagement and other activities. Educational resources may prove useful even without formal therapy referral.

Psychopharmacology: SSRIs and SNRIs are the first line of long term medication treatment for most of the anxiety disorders– use with a low starting dose and slow gradual up-titration, as needed and tolerated. Monitoring symptom progression and side effects is necessary early on, but if treatment is effective, routine follow ups for refills can be done more episodically.

Judicious use of anxiolytic agents such as the benzodiazepines can be an important element in psychopharm management— occasional use of low dose, short acting agents is often quite helpful, but ongoing and increased use of these medications can lead to dependence and other problems. A patient needing to take multiple daily doses of a short acting agent for a sustained period needs attention. In some cases, routine use of longer acting agents may be appropriate, with periodic trials of dose reduction planned.

NSSI can be classified as non-pathological or pathological. Non-pathological NSSI is culturally sanctioned, and includes acts like piercings and tattoos. Pathological NSSI is used by some as a method for emotional regulation to attempt to provide rapid but temporary relief from disturbing thoughts, feelings, and emotions. Pathological NSSI can be used to provide self-stimulation during times of dissociation and depersonalization. Pathological NSSI can be used to signal distress and elicit a caring response from others. Factors associated with pathological NSSI include: high levels of unpleasant thoughts or feelings; poor communication skills and problem-solving abilities; abuse or maltreatment during childhood; and under- or over-arousal responses to stress.

There are different ways to classify pathological NSSI: a functional approach and a medical approach. The functional approach focuses on the function that the behavior serves. For most people who engage in NSSI, the function it serves is as an autonomic positive reinforcement (removal or escape from an aversive affective or cognitive state). For some people, NSSI functions as an autonomic negative reinforcement (to generate feelings when one feels dissociated or numb). NSSI can serve as a social positive reinforcement (as a signal of distress to gain attention) or as a social negative reinforcement (to escape from intolerable social situations).

In the medical approach, pathological NSSI falls into 4 major categories, which are associated with specific psychiatric disorders. The 4 categories are: major, stereotypic, compulsive and impulsive. Major NSSI includes infrequent acts that destroy significant body tissue (like eye enucleation or amputation of a major body part). The majority of these occur during psychotic states and the explanation provided defies logic and displays delusional thinking. Stereotypic NSSI is repetitive and can have a rhythmic pattern, and includes acts like head banging, biting skin and face or head slapping. It is most commonly seen with intellectual disabilities and autism spectrum disorders. Compulsive NSSI, seen in certain anxiety disorders, includes excessive nail biting, hair pulling, and skin picking.

Impulsive NSSI consists of acts like skin cutting or burning, sticking pins under the skin, and interfering in wound healing. It is more common in females and typically starts during the teen years. One or two isolated incidents of minor impulsive NSSI may not be cause to worry, but it is concerning if it develops into a repetitive, addictive pattern. Many patients with borderline personality disorder engage in impulsive NSSI but not everyone with impulsive NSSI has borderline personality disorder. Impulsive NSSI can exist in patients with mood disorders, anxiety disorders and psychotic disorders, as well as other cluster B personality disorders. Other impulsive acts, like bulimia or substance abuse, may alternate or coexist with NSSI.

The first line treatment for NSSI includes psychotherapy. Dialectical behavioral therapy is an important component of treatment for impulsive NSSI. Behavioral therapy can be an important component of treatment for stereotypic NSSI. In addition, while there is no medication that treats NSSI directly, psychotropic medication to address the underlying psychiatric disorder, whether it be a psychotic disorder, anxiety disorder, or mood disorder, is also important.

Resources:

Nonsuicidal self-injury: how categorization guides treatment. Armando R. Favazza, MD. Current Psychiatry; March 2012

One such program named Preventure, based at the University of Montreal, looks at these 4 primary traits:

1. Sensation-seeking
2. Impulsiveness
3. Anxiety sensitivity
4. Hopelessness

Three of these are linked directly to mental health concerns. Impulsivity is commonly seen in people with Attention Deficit Hyperactivity Disorder (ADHD). Anxiety sensitivity refers to being overly aware and frightened of physical signs of anxiety, and is commonly seen in panic disorder and to a lesser extent other anxiety disorders. Hopelessness is a symptom of depression. One way to look at this is that most at-risk children can be spotted early, if they present with these symptoms, with early interventions to improve these risky traits.

It is also important to keep in mind that a teen who turns to drugs because of hopelessness has different expectations than a teen to turns to drugs for thrills. Distorted cognitive thinking plays a role for some adolescents who turn to drugs.

In the Preventure model, teachers are educated about these traits and students are taught ways to manage their problematic traits in a general educational workshop approach without being called out for being “at risk”. One hypothesis is that the teacher training helps make teachers more empathic to high-risk students thereby increasing their connection to their school community, which has been shown to decrease drug use.

Studies that have looked at this model have shown a decrease in binge drinking, frequent drug use, and alcohol-related problems. Other studies have shown improvement in non-addiction symptoms as well, including depression, panic attacks and impulsive behavior, which are direct sequelae of the identified 4 high-risk traits.

The idea that identifying and addressing high-risk traits for addiction can be impactful for children and adolescents is a hopeful one and can be implemented across settings, including schools, communities and medical homes. More research can be done to determine what specific types of interventions can be helpful once those at-risk youth are identified.

The success of Preventure offers providers insight into to the early signs and symptoms  of those children who are at greatest risk of addiction.  For kids with personality traits that put them at risk of addiction, learning how to manage them can potentially change the trajectory that can lead to tragedy.  Early cognitive behavioral therapy to address the underlying emotional and mental health challenges may help reduce the likelihood of addiction.

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties

The main diagnostic criteria of GAD are excessive anxiety and worry that is difficult to control, along with at least 3 from a list of 6 symptoms: restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances, and being easily fatigued and duration of the disorder for at least 6 months.  Symptoms must be distressing or impairing and not adequately explained by another related disorder.

Screening for GAD can potentially be helpful in improving detection rates in primary care, which can lead to more appropriate treatment and improved patient outcomes. GAD-7 was developed to facilitate the diagnosis. The scale has been shown to be an efficient tool that can screen for likely cases of GAD and can assess symptom severity and assist with the clinical assessment and treatment of GAD.  A link to the assessment tool is included.

The main treatment approaches for GAD include pharmacotherapy or psychotherapy or a combination of both. The often chronic and disabling nature of GAD means that some individuals may fail to respond fully to first-line treatment. Patients may therefore require a sequential trial of treatments.  Psychological therapies are an important first-line option in the management of GAD.

The treatment plan for GAD should account for (1) predominant symptoms, (2) severity of the condition, (3) presence of concomitant medical illness, (4) complications such as substance abuse or the risk of suicide, (5) outcomes of any previous treatments, (6) cost issues, (7) availability of treatment in a given area, and (8) patient preferences.

There are various options for medication management of GAD. Next week’s newsletter will focus on this topic.

GAD is frequently associated with other psychiatric conditions such as other mood or anxiety disorders, somatoform/pain disorders, medically unexplained symptoms, and substance use disorders.  It has also been linked with medical disorders such as heart disease, GI and chronic pain disorders.

Effective management of GAD has the potential to improve quality of life for patients and their families, as well as improve patient productivity and reduce the impact of the condition on health care resources.  The use of appropriate screening tools and providing information to patients with GAD on their condition and its treatment are an important starting point toward increasing recognition and appropriate treatment of GAD.

References:

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911006/

Withdrawal from benzodiazepines is similar to withdrawal from alcohol—problems may include: feeling jittery, elevated blood pressure and heart rate, anxiety, insomnia and irritability. With more severe dependence, life-threatening effects like withdrawal seizures and delirium tremens may occur.  The longer a patient has been taking daily benzodiazepines, the longer the taper process should be. If a patient is using a short-acting benzodiazepine, the taper process is smoother and more successful if the patient is first transitioned to a long-acting benzodiazepine and then tapered off the long-acting medication.

Clonazepam is a good medication to use for tapering purposes, and it is helpful to dose it twice per day to establish a more even blood level and to give the patient psychological relief by taking the medication more frequently. Clonazepam has a 1:1 ratio dose equivalence to alprazolam (i.e. 1mg clonazepam = 1mg alprazolam) and a 1:2 ratio dose equivalence to lorazepam (i.e. 1 mg clonazepam = 2 mg lorazepam).  Care should be taken when the patient is taking high doses of a benzodiazepine medication and, in certain cases, dosing clonazepam more frequently during the tapering process may be more successful.

Diazepam can also be used in a similar fashion.  It has a 10:1 ratio dose equivalence to alprazolam and a 5:1 ratio dose equivalence to lorazepam.   Some advantages of diazepam are that it has an even longer half-life than clonazapam and is available in smaller effective doses, and so often allows a smoother taper with fewer withdrawal symptoms.  Some disadvantages are that diazepam has a relatively fast onset of action, causing many patients to experience an initial “high” when they take it, much like they may experience with shorter acting medications like alprazolam.  In addition, because of the extremely long half-life (up to 100 hours including its active metabolites), the drug can often accumulate, especially in elderly and patients with liver dysfunction.

Benzodiazepine Dose Equivalents

Depending on how long the patient has been taking daily benzodiazepines, one can reduce the dose by 10% of the current dose every 4-7 days. For example if a patient has been taking 4mg of alprazolam per day in split doses for five years, one option is to change the patient over to clonazepam 2mg BID and then reduce the dose initially by 0.5 mg per week, slowing down the taper to 0.25mg at a time towards the end. This relatively slow taper would take about 2 months to complete. If a patient is having withdrawal symptoms at any point during a taper, consider slowing down the taper.

In certain circumstances, it may be appropriate for a patient to be on a long-term daily benzodiazepine. One example is a patient who has tried non-benzodiazepine medications as adjunctive to a sub-therapeutic response to an SSRI, but they do not work as well as a benzodiazepine medication and the patient is not misusing it. In this clinical situation, the provider could consider switching from a short-acting medication to a longer-acting medication like clonazepam for long-term use, with a decreased risk for dependence.

If it is determined that a patient needs a long term PRN medication for anxiety and long-term benzodiazepine use is deemed problematic, consider alternatives including propranolol or hydroxyzine.  Buspirone (Buspar) can be effective for anxiety, but must be taken daily.

We hope that this step-by-step review on tapering benzodiazepines has been helpful. The important take home point is to not rush a taper, otherwise the patient might give up if he feels uncomfortable in any way or, more seriously, there could be dangerous consequences.