High-potency BZD

Alprazolam. In a review of high-potency BZDs for psychotic disorders. Bodkin recommended avoidance of alprazolam for psychotic agitation because it may be activating and may induce belligerence or mania (178, 179, 180,181, 182,183, 184,185 and 186). 

Another high-potency BZD, clonazepam, also has been shown to be effective. In addition, there is evidence that higher than usual doses of diazepam, lorazepam, bromazepam, or clobazam may also block panic attacks (17). 

Patients with panic disorder have usually been treated with TCAs [93], monoamine oxidase inhibitors (MAOIs) [94], and high-potency BZDs (i.e., alprazolam, clonazepam) [95, 96], Although the MAOIs had demonstrated effectiveness for panic disorder in several studies, they left the sleep complaint relatively unaffected [97],... 

Whereas iithium has been the standard approach, increased complications in elderly patients, especially when there is compromise of the CNS, endocrine, or renal systems, makes this agent a less attractive choice. Lower doses (e.g., 150 to 300 mg) should be initiated, with many elderly patients achieving adequate response on total daily doses of lithium in the 450- to 600-mg range. If a more rapid response is necessary, low-dose high-potency antipsychotics can also be used in the early phases. Alternatively, a BZD, such as clonazepam or lorazepam, may be indicated (297). 

Similarly, BZDs are used for insomnia but are best reserved for short-term use. They are also used to assist withdrawal from alcohol, where a long elimination half-life drug is best. In acute psychotic states short-term use of a high-potency drug, such as lorazepam, can be helpful in managing acute agitation or aggression. 

Withdrawal seizures originally were thought to occur only when high BZD doses were abruptly stopped, but now there is evidence that seizures may follow abrupt discontinuance of therapeutic doses of a BZD, especially short half-life BZDs. One report ( 239) discusses five cases of seizures after withdrawal of flunitrazepam, lorazepam, or triazolam. Both abrupt cessation of BZD intake and use of high doses seemed to be critical for the appearance of seizures. Shorter elimination half-life and higher potency might also contribute to the seizures observed in these patients. Seizures are virtually unknown when a BZD is gradually discontinued. 

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