Anxiolytics

 BZD are used for GAD, Panic disorder, stress related insomnia, alcohol withdrawal, night
terrors. The BZDs have found use as adjunctive agents in the treatment of mania and
acute psychosis, usually combined with mood stabilizers and antipsychotics,
respectively.
 Benzodiazepines work by enhancing the effects of gamma-aminobutyric acid (GABA). GABA is an
inhibitory neurotransmitter: it suppresses the activity of neurons. Excessive activity of neurons in the
amygdale circuits may be the behind anxiety and benzodiazepines reduce the activity of neurons by
enhancing the effects of GABA. GABA agonists
 The BZDs may be divided into three main groups—long- (60 hrs) , intermediate-, and
short-acting (2 hrs)—based on their elimination half-lives. Intermediate-acting BZDs:
lorazepam, clonazepam, alprazolam.
 The side effects of BZDs are primarily extensions of their sedative properties. Though
generally well tolerated, BZDs can produce drowsiness, fatigue, weakness,
lightheadedness, ataxia (lack of voluntary coordination of muscle movements that can
include gait abnormality, speech changes, trouble performing fine motor tasks, and
abnormalities in eye movements), respiratory suppression (hypoventilation, ineffective
breathing), and falls. Confusion, psychomotor retardation, amnesia, depression, and
paradoxical excitation are also seen. Some predisposed individuals can become
psychologically and/or physically dependent on BZDs. Withdrawal effects if suddenly
discontinued. Rebound insomnia.
 BZD use in first trimester associated with cleft lip or palate and impaired intrauterine
growth (growth of the fetus in the uterus). BZD use in third trimester associated with:
floppy baby syndrome (hypotonia: low muscle tone).
 In elderly and chronically ill patients, use BZD on short term basis. Risk of cognitive
impairment, confusion (especially in those with dementia), falls (hip fractures), drug
interactions.
 There are only a few studies of BZDs for the treatment of GAD and panic disorder in
children and adolescents. Most recent research has focused on the use of serotonergic
agents in treating childhood anxiety, and BZDs are now recommended only for short-
term use in younger populations.

(Only short term use of BZD is recommended in elderly and children.)

 For GAD: BZD and SSRIs

 For Panic Disorder: SSRIs used as first-line agents (as well as cognitive-behavioral
therapy). BZDs are used as second-line treatments for panic disorder
 Social Anxiety: SSRIs are treatment of choice.
 PTSD: SSRIs first choice. BZDs should be avoided as substance abuse is common in
patients with PTSD.
 Insomnia: BZD effective for short term stress related insomnia, but not for long term.
 REM sleep behavioral disorder: BZD might be effective
 Night terrors: BZD are useful.
 Substance withdrawal: BZDs are the treatment of choice for alcohol withdrawal.
 Paroxetine (SSRI): FDA approved for OCD, GAD, PD, PTSD, Social anxiety.
 Management of side effects: dose reduction, administration at night time.
 For all drugs: Use minimum effective drug, and avoid sudden dosage increase.
 With the exception of alprazolam (xanax), BZDs generally lack antidepressant properties
and may cause or exacerbate depression in some patients.
 Avoid BZDs if possible in patients with sleep-related breathing problems
 BZD discontinuation may lead to withdrawal symptoms. Key management strategy is
very slow taper of BZDs