Anxiety rebound

Likelihood and severity of withdrawal are a function of dose and duration of exposure. Gradual tapering of dosage is necessary to minimize withdrawal and rebound anxiety. 

Because GAD is a chronic illness, benzodiazepines are often used in long-term maintenance therapy, leading to physical dependence over the course of several weeks. Consequently, abrupt discontinuation of a benzodiazepine can result not only in rebound anxiety and a rapid relapse but an acute benzodiazepine withdrawal... 

Triazolam (ti/2 of elimination -1.5-5.5 h) is especially likely to impair memory (anterograde amnesia) and to cause rebound anxiety or insomnia and daytime confusion. The severity of these and other adverse reactions (e.g., rage, violent hostility, hallucinations), and their increased frequency in the elderly, has led to curtailed or suspended use of triazolam in some countries (UK). 

Discontinuation Problems Further controversy has surrounded misleading claims in the lay media that SSRls have addictive properties. These centre around reports of patients suffering symptoms when trying to discontinue medication. As with the benzodiazepines, these symptoms may be a recurrence of the premorbid anxiety, although rebound anxiety has not been clearly demonstrated. Self-limiting symptoms associated with SSRl withdrawal have been widely reported (Haddad 1998), and are generally described as the SSRl discontinuation syndrome (Table 4). The most frequently occurring symptoms are dizziness, nausea and headache. 

Ondansetron. The S-HTj antagonist ondansetron has been reported to be effective in the treatment of generalized anxiety disorder, with efficacy comparable to that of diazepam [Lader 1991). Sedation and rebound anxiety during withdrawal from ondansetron were not observed [Lader 1991). Ondansetron has been considered for phase 111 clinical trials for the treatment of social phobia and panic disorder. 

Forming a therapeutic alliance, giving positive support that medication will be decreased slowly to avoid rebound anxiety and relapse of the underlying anxiety disorder and withdrawal symptoms... 

Rickels K, Fox IL, Greenblatt DJ. Clorazepate and lorazepam clinical improvement and rebound anxiety. Am J Psychiatry 1988 145 312-317. 

Power KG, Jerrom DWA, Simpson RJ, et al. Controlled study of withdrawal symptoms and rebound anxiety after six-week course of diazepam for generalized anxiety. BrMedJ 1985 290 1246-1248. 

Fontaine R, Chouinard G, Annable L. Rebound anxiety in anxious patients after abrupt withdrawal of benzodiazepine treatment. Am J Psychiatry 1984 141 848-852. 

Kales A, Soldatos CR, Bixler EO, et al. Rebound insomnia and rebound anxiety a review. Pharmacology 1983 26 121-137. 

Several open trials have reported significant improvement or remission of panic attacks in patients given clonazepam ( 60, 61, 62, 63, 64, 65 and 66). One double-blind, placebo-controlled study comparing the efficacy of alprazolam, clonazepam, and placebo found both drugs superior to placebo and comparable with each other (67). Because favorable response to clonazepam usually occurs early in treatment, lack of initial improvement may predict treatment failure ( 42, 61, 68). Interdose and morning rebound anxiety have not been reported. Clonazepam is not approved by the FDA for panic attacks, and because there are only a few controlled studies, there is only limited knowledge about its efficacy for this indication. 

Within a short time of starting Halcion, rebound begins to dominate the clinical picture, and insomnia worsens. Nishino et al. (1995) observed that short-acting BZs were initially preferred for elderly patients. They remarked, However, it has since been found that short-acting BZs induce rebound insomnia (a worsening of sleep beyond baseline levels on discontinuation of a hypnotic), rebound anxiety, anterograde amnesia, and even paradoxical rage. ... 

BZs can produce a wide variety of abnormal mental responses and very hazardous behavioral abnormalities rebound anxiety, insomnia, psychosis, paranoia, violence, antisocial acts, depression, and suicide. They impair cognition, especially memory, and can cause confusion. There is strong evidence that they produce persisting memory dysfunction, dementia, and shrinkage of brain tissue reflected in ventricular dilation. 

Kales, A., Soldatos, C., Bixler, E., 8c Kales, J. (1983). Rebound insomnia and rebound anxiety A review. Pharmacology, 26, 121-137. 

Q10 A major problem associated with benzodiazepines is the development of tolerance, a gradual increase in the dose needed to elicit the therapeutic effect and dependence in chronic use. Following the cessation of treatment, the patient may suffer from rebound anxiety and insomnia. Withdrawal from benzodiazepines also occasionally causes bizarre visual disturbances. 

The authors suggested that the duration of action of alprazolam is too brief to prevent rebound anxiety with administration four times a day, but this explanation is highly speculative. This case illustrates the potential severity of alprazolam rebound and how its long-term use can exacerbate the symptoms for which it was originally administered. 

Sedation, anterograde amnesia in severe OD (or IV use), reverse with flumazenil Rebound insomnia, rebound anxiety... 

One of the problems associated with benzodiazepine anxiolytics is rebound anxiety and/or insomnia, which may occur between dose intervals or after withdrawal of the drug [83, 84], In three experiments performed with squirrel monkeys, (92) (up to 20 mg/kg p.o.) did not cause any apparent physical or behavioural signs of withdrawal after abrupt discontinuation of treatment or even after attempted precipitation of withdrawal by administration of flumazenil. 

Patients may develop a tolerance to drug effects with chronic use, and a rebound anxiety is also seen in waking hours. Impaired cognitive and motor functions also may occur, particularly in the elderly. 

Adequate sleep improves the quality of daytime wakefulness, and hypnotics should be used judiciously to avoid its impairment. A number of pharmacological agents are available for the treatment of insomnia. The perfect hypnotic would allow sleep to occur with normal sleep architecture rather than produce a pharmacologically altered sleep pattern. It would not cause next-day effects, either of rebound anxiety or of continued sedation. It would not interact with other medications. It could be used chronically without causing dependence or rebound insomnia on discontinuation. Regular moderate exercise meets these criteria but often is not effective by itself, and many patients may not be able to exercise. However, even small amounts of exercise often are effective in promoting sleep. 

---