The choice of, and response to, each of these measures depends very much on the individual. The various psychological techniques have been formally tested and give the best long-term results. However, the outcome depends largely on the skill of the therapist, including his/her knowledge of benzodiazepines, and the rapport between therapist and client. Most of the people attending the clinic had been taking benzodiazepines prescribed by their doctors for many years, sometimes over 20 years. They wished to stop because they did not feel well. They realised that the drugs, though effective when first prescribed, might now be actually making them feel ill. They had many symptoms, both physical and mental. Some were depressed and/or anxious; some had "irritable bowel", cardiac or neurological complaints. Many had undergone hospital investigations with full gastrointestinal, cardiological and neurological screens (nearly always with negative results). A number had been told (wrongly) that they had multiple sclerosis. Several had lost their jobs through recurrent illnesses.

Sports – aerobics, jogging, swimming, “pilates”, walking and anything active that you find enjoyable Guided imaging (focus on pleasant, relaxing situations; relaxation tapes with music and calm words can also be used at home)Some readers may decide to go directly to the chapter on benzodiazepine withdrawal ( Chapter II). However, those who wish to understand withdrawal symptoms and techniques (and therefore to cope better with the withdrawal process) are advised to become acquainted first with what benzodiazepines do in the body, how they work, how the body adjusts to chronic use, and why withdrawal symptoms occur. These issues are discussed in this chapter. One reassuring finding from many clinical studies is that eventual success in withdrawal is not affected by duration of use, dosage or type of benzodiazepine, rate of withdrawal, severity of symptoms, psychiatric diagnosis, or previous attempts at withdrawal. Thus from almost any starting point, the motivated long-term user can proceed in good heart. PROTRACTED WITHDRAWAL SYMPTOMS Adverse effects in the elderly. Older people are more sensitive than younger people to the central nervous system depressant effects of benzodiazepines. Benzodiazepines can cause confusion, night wandering, amnesia, ataxia (loss of balance), hangover effects and "pseudodementia" (sometimes wrongly attributed to Alzheimer’s disease) in the elderly and should be avoided wherever possible. Increased sensitivity to benzodiazepines in older people is partly because they metabolise drugs less efficiently than younger people, so that drug effects last longer and drug accumulation readily occurs with regular use. However, even at the same blood concentration, the depressant effects of benzodiazepines are greater in the elderly, possibly because they have fewer brain cells and less reserve brain capacity than younger people. In the UK clobazam (Frisium) and clonazepam (Rivotril) are licensed for use as anti-epileptics only. They have taken benzodiazepines in prescribed "therapeutic" (usually low) doses for months or years.

I hardly dare to mention smoking in view of present day attitudes to this unfortunate addiction, but for those who are smokers it is probably asking too much to attempt to stop smoking and withdraw benzodiazepines at the same time. Many people have found that giving up smoking is easier when they are off benzodiazepines, when the desire for nicotine may even wane somewhat. In general, excessive worrying over your undesirable habits (or your diet) can add to the stress of withdrawal. It is better to relax a bit and be gentle with yourself. COURSE OF WITHDRAWAL A controlled study of long-term benzodiazepine users using brain function techniques would have to be carefully designed and would involve a large number of age and sex matched subjects, probably over 100 in both control and user groups. In the benzodiazepine group it would have to take into account dose, type of benzodiazepine, duration of use, psychiatric history, symptoms, use of alcohol and other drugs, and a number of other factors. Such a study would be expensive and funding would be difficult to obtain. Drug companies would be unlikely to offer support, and to date 'independent' bodies such as the Medical Research Council, the Wellcome Foundation and the Department of Health have shown little interest. Thus the question of whether benzodiazepines cause brain or other organ damage remains unanswered. There is no evidence that nutritional supplements such as vitamins, minerals, amino acids etc. are helpful in benzodiazepine withdrawal. Excessive doses of some can be toxic and others may even contain benzo-like substances that have the same adverse effects as benzodiazepines themselves. Nor is there any evidence that suggests benzodiazepine withdrawal causes vitamin, mineral or other deficiencies. No-one should take supplements without clear evidence of a specific deficiency. Those who advocate multiple supplements should first show evidence of any deficiency and then conduct proper controlled trials. In particular, taking GABA precursors does not increase GABA concentrations in the brain. Benzodiazepines do not decrease GABA concentrations; instead they alter GABA-receptor affinity. This slowly reverses without the need for supplements and there is no evidence that supplements speed the process. People taking or withdrawing from benzodiazepines should eat a normal healthy diet - which, after all, consists of "natural" substances and contains all the ingredients necessary for the body.

Discontinuing after short-term use

Flumazenil is thought to act by “resetting” GABA/benzodiazepine receptors (See Chapter I) so that they are more receptive to the inhibitory actions of GABA. The results suggest that some protracted symptoms are due to the failure of the receptors to revert to their normal state after they have become unresponsive to GABA, due to the development of tolerance (See Chapter I). The response to flumazenil also shows that benzodiazepines can cause longer-lasting pharmacological effects than previously believed. Severe depression may result from biochemical changes in the brain induced by benzodiazepines. Benzodiazepines are known to decrease the activity of serotonin and norepinephrine (noradrenaline), neurotransmitters believed to be closely involved in depression. Antidepressant drugs including the selective serotonin reuptake inhibitors (SSRIs such as Prozac) are thought to act by increasing the activity of such neurotransmitters. Therapeutic actions of benzodiazepines. Regardless of their potency, speed of elimination or duration of effects, the actions in the body are virtually the same for all benzodiazepines. This is true whether they are marketed as anxiolytics, hypnotics or anti-convulsants ( Table 1). All benzodiazepines exert five major effects which are used therapeutically: anxiolytic, hypnotic, muscle relaxant, anticonvulsant and amnesic (impairment of memory) ( Table 2). A dilemma faced by some people in the process of benzodiazepine withdrawal, or after withdrawal, is what to do if they have intolerable symptoms which do not lessen after many weeks. If they are still taking benzodiazepines, should they increase the dose? If they have already withdrawn, should they reinstate benzodiazepines and start the withdrawal process again? This is a difficult situation which, like all benzodiazepine problems, depends to some degree on the circumstances and the individual, and there are no hard and fast rules. Memory impairment. Benzodiazepines have long been known to cause amnesia, an effect which is utilised when the drugs are used as premedication before major surgery or for minor surgical procedures. Loss of memory for unpleasant events is a welcome effect in these circumstances. For this purpose, fairly large single doses are employed and a short-acting benzodiazepine (e.g. midazolam) may be given intravenously.

It is not clear whether there really is an increased incidence of infections in people undergoing benzodiazepine withdrawal, because there have been no comparisons with otherwise similar populations who have not been exposed to benzodiazepines. However, many factors affect the immune system. One of these is stress, with increased output of the stress hormone, cortisol, which inhibits immune responses. Another factor is depression, also related to stress and associated with increased cortisol secretion. Increased cortisol levels can reduce resistance to infection and also cause flare-ups of incipient infection. Benzodiazepine withdrawal can clearly be stressful but, strangely, in patients that I have tested, blood cortisol concentrations have been low. So this subject remains a mystery and probably merits further research. The message for people undergoing benzodiazepine withdrawal is to try to lead a healthy lifestyle, which includes a balanced diet, plenty of exercise and rest, and avoidance of extra stress where possible. Slow dosage tapering ( Chapter II) is the best way to reduce the stress of withdrawal. Endocrine problemsHowever, all these symptoms do settle in time. The need for sleep is so powerful that normal sleep will eventually reassert itself. Meanwhile, attention to sleep hygiene measures including avoiding tea, coffee, other stimulants or alcohol near bedtime, relaxation tapes, anxiety management techniques and physical exercise may be helpful. Taking all or most of the dose of benzodiazepine at night during the reduction period may also help. Occasionally another drug might be indicated (see section on adjuvant drugs, below). Intrusive memories They have continued to take benzodiazepines although the original indication for prescription has disappeared.