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Barbarannamated

Ashton Manual recommendation of antidepressants

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Barbarannamated

Someone recently posted that their physician advised DCing a benzo prior to SS/NRI with the thinking that the AD would ameliorate WD symptoms of benzo.

 

Ashton Manual, 2002

http://www.benzo.org.uk/manual/bzcha03.htm

 

*I am posting this as a cautionary FYI about info in the Ashton Manual and NOT as tapering advice. I realize that it was written many years ago (2002) and Dr. Ashton was ahead of her time. However, I think that we need to be aware that this manual is advising 'antidepressants' to treat benzo-induced depression (protracted). This was last published well into the SSRI era when SSRI withdrawal/discontinuation syndrome known.

There was a Supplement published in 2011 stating that little progress has been made. I see no retraction or modification of her recommendation to use 'antidepressants' for protracted depression. This is disturbing.

2011 Supplement

http://www.benzo.org.uk/ashsupp11.htm

 

I find a striking similarity between the withdrawal symptoms (acute and protracted) of benzos and SS/NRIs. I would feel comfortable taking this list to any physician to describe my experience.

 

Exerpt is out of order from publication.

 

 

Depression.

Depression may be caused or aggravated by chronic benzodiazepine use, but is also a feature of the withdrawal syndrome. Depressive symptoms may appear for the first time after withdrawal, sometimes after a delay of a few weeks, and it can be severe and protracted for some months. It is not clear whether people who have had depression before, or have a family history of depression, are more prone to this complication, and its causes are not understood. As discussed in Chapters I and II, benzodiazepines disrupt the function of many neurotransmitters and hormones and depression could be the result, for example, of low serotonin activity combined with the stress of withdrawal. If severe enough to require definitive treatment, the depression in withdrawal responds to antidepressant drugs and/or cognitive therapy and usually diminishes gradually over 6-12 months.

 

TABLE 3. SOME PROTRACTED BENZODIAZEPINE WITHDRAWAL SYMPTOMS

 

Symptoms - Usual Course

Anxiety - Gradually diminishing over a year

Depression - May last a few months; responds to antidepressant drugs

Insomnia - Gradually diminishing over 6-12 months

Sensory symptoms: tinnitus, tingling, numbness, deep or burning pain in limbs, feeling of inner trembling or vibration, strange skin sensations - Gradually receding but may last at least a year and occasionally several years

Motor symptoms: muscle pain, weakness, painful cramps, tremor, jerks, spasms, shaking attacks - Gradually receding but may last at least a year and occasionally several years

Poor memory and cognition - Gradually receding but may last at least a year and occasionally several years

Gastrointestinal symptoms - Gradually improving but may last a year and occasionally several years

 

 

TABLE 4. SOME POSSIBLE CAUSES OF PROTRACTED BENZODIAZEPINE WITHDRAWAL SYMPTOMS

 

Possible mechanisms Effects

1. Learning of stress-coping strategies blocked by benzodiazepine use exposed on withdrawal Anxiety, vulnerability to stress

2. Impairment of memory caused by benzodiazepines prevents normal resolution of distressing life events which are exposed on withdrawal Anxiety, depression

3. Traumatic experiences during previous withdrawal Post-traumatic stress symptoms

4. (?) Biochemical alterations caused by benzodiazepines (serotonin, norepinephrine [noradrenaline], stress hormones) Depression

5. Nervous system hyperexcitability due to persisting changes in GABA/benzodiazepine receptors Sensory and motor symptoms, anxiety, insomnia

6. (?) Structural or functional damage to brain tissue Poor memory and cognition

7. (?) Changes in gut and immune systems Gastrointestinal symptoms

8. (?) Long-term retention of benzodiazepines in tissues of the body Prolongs nervous system hyperexcitability

 

(?) indicates possible mechanisms for which at present there is no scientific evidence

 

Anxiety

Anxiety persisting after the acute phase of withdrawal may be partly due to the uncovering of a learning defect caused by the benzodiazepines. These drugs specifically impair the learning of new skills, including stress-coping strategies. Such skills are normally acquired continuously from childhood to middle age or later as experience of life accumulates. Their development may be blocked for a period of years during which benzodiazepines are taken. After withdrawal the ex-user is left in a vulnerable state with a decreased ability to deal with stressful situations. Full recovery may require many months of learning new stress-coping strategies to replace the years when this facility was blanketed by pills.

 

Secondly, benzodiazepine withdrawal may uncover life problems that have never been fully addressed. For example, the impairment of memory caused by benzodiazepines may prevent the normal resolution of personal stresses such as bereavement or a car crash. Such buried or half-forgotten experiences may have to be faced after withdrawal and may prolong both anxiety and depression. It is not uncommon for a widow or widower, first prescribed benzodiazepines on the death of the spouse, to go through the grieving process for the first time after withdrawal, even though the bereavement had occurred many years previously.

 

A third factor may operate in people who have had frightening experiences during withdrawal. This is not uncommon in those who have undergone rapid withdrawal without adequate explanation, often in hospital or detoxification centres but sometimes at home when their doctor has withdrawn prescriptions. Such people may develop symptoms of post-traumatic stress disorder (PTSD) in which their experiences are constantly repeated as flashbacks or nightmares and so prolong the anxiety.

 

In addition, many (though by no means all) long-term benzodiazepine users are constitutionally highly strung, sensitive people with relatively low self-esteem, whose anxiety problems have led to the prescription of benzodiazepines in the first place and whose continuing anxiety (possibly heightened by the benzodiazepines) has prompted the doctor to go on prescribing the drugs. It may take a long time for these people to regain, or attain, full confidence in themselves.

 

Despite these factors, protracted anxiety symptoms, including agoraphobia and panics, do tend to subside gradually and rarely last more than a year. The process may be hastened by good psychological support and by the measures described under acute anxiety symptoms. Believe it or not, people often feel more self-confident after withdrawal than they did before starting to take benzodiazepines.

 

Insomnia Poor sleep is a common accompaniment of both anxiety and depression. In anxiety there is typically a difficulty in falling asleep, while depression is associated with early morning waking as well as frequent wakings during the night. Insomnia is also common as an acute withdrawal symptom along with nightmares and other sleep disturbances. Occasionally, however, insomnia (sometimes with "restless legs" and muscle jerks) persists as an isolated symptom after other symptoms have disappeared, and may last for many months. However, poor sleepers can be reassured that an adequate sleep pattern does return at last. There are powerful natural mechanisms in the body which ensure that the brain does not become severely sleep-deprived.

 

Sensory and motor disturbances There is no doubt that benzodiazepine withdrawal leaves in its wake a nervous system that is exquisitely sensitive to all sensory and motor stimuli. Usually this state settles in a few weeks but occasionally disturbing sensations persist.

 

One of the most distressing sensory symptoms is tinnitus, a constant ringing or hissing in the ears which has been noted in several studies of benzodiazepine withdrawal. One lady described her tinnitus as a "needle of sound" piercing deep inside her head. Tinnitus is often associated with a degree of hearing loss and is not uncommon in people with partial nerve deafness who have never taken benzodiazepines. Nevertheless, it often makes its first appearance during benzodiazepine withdrawal in people who have had hearing loss for years. Also, it may be unilateral or precisely localised, even in those with symmetrical bilateral hearing loss. Whether people who have taken long-term benzodiazepines are particularly prone to tinnitus and if so why, is not known. It can persist for years and does not always respond to the usual treatments for tinnitus (maskers, etc); nor is it always relieved by restarting benzodiazepines. However, people with persisting tinnitus after withdrawal should seek the advice of a hearing specialist and may be lucky enough to find a clinic which specialises in this symptom.

 

A number of unpleasant bodily sensations may persist after withdrawal including tingling, "pins and needles" or patches of numbness in the trunk, face, limbs and fingers. These may be accompanied by burning pain or aches that sometimes seem to originate deep in the muscles or bones. Some people complain of an "inner trembling" or a sense of vibration, and some have described bizarre sensations as of water or slime running over the body or a serpent-like writhing on the scalp. Motor symptoms that may persist include muscle tension, weakness, cramps, jerks, spasms and shaking attacks.

 

Possible mechanisms of persisting sensory and motor symptoms. Although the above symptoms are often made worse by stress, they are clearly not simply due to anxiety. They suggest a dysfunction in motor and sensory pathways in the spinal cord and/or brain. A possible clue to their mechanism is provided by a trial with flumazenil (Anexate, Romazicon) a benzodiazepine receptor antagonist, published by Lader and Morton (Journal of Psychopharmacology 1992, 6, 357-63). This drug, when infused intravenously brought rapid relief of protracted symptoms (muscle tension, "pins and needles", weakness, muscle cramps or jerks, burning, tremor or shaking) that had been present for 5-42 months post-withdrawal in 11 patients. The symptoms were improved by 27-82 percent and the greatest response occurred in patients with the lowest anxiety ratings. There was no response to infusions of saline solution.

 

Such symptoms may be partially alleviated by relaxation techniques; some motor and sensory systems may respond to carbamazepine (Tegretol) and motor symptoms may respond to propranolol (Inderal).

 

Poor memory and cognition Although it is well known that benzodiazepines impair memory and some cognitive functions, particularly the ability to sustain attention, some long-term users complain of continued loss of intellectual abilities persisting after withdrawal. There have been several studies on this question which indicate that improvement may be very slow. The longest studies in therapeutic dose long-term users extend for only 10 months after withdrawal. Cognitive impairment, though slowly improving, persisted for at least this time and was not related to anxiety levels (Tata et al. Psychological Medicine 1994, 24, 203-213). Some Swedish studies have found that intellectual impairment, although improved, was still present 4-6 years after cessation of benzodiazepine use, but it was not clear whether high dosage and/or alcohol use were added factors.

 

Do benzodiazepines cause structural brain damage? These results have raised the question of whether benzodiazepines can cause structural brain damage. Like alcohol, benzodiazepines are fat soluble and are taken up by the fat-containing (lipid) membranes of brain cells. It has been suggested that their use over many years could cause physical changes such as shrinkage of the cerebral cortex, as has been shown in chronic alcoholics, and that such changes may be only partially reversible after withdrawal. However, despite several computed tomography (CT) scan studies, no signs of brain atrophy have been conclusively demonstrated in therapeutic dose users, and even the results in high dose abusers are inconclusive. It is possible that benzodiazepines can cause subtle changes which are not detected by present methods, but on the available evidence there is no reason to think that any such changes would be permanent.

 

Gastrointestinal symptoms Gastrointestinal symptoms may be prolonged after withdrawal, usually in people who have a previous history of digestive troubles. Such people may develop apparent intolerance to certain foods, although reliable tests for true food allergy (e.g. antibodies against specific food constituents) are nearly always negative. Nevertheless many sufferers feel that they have damage to the immune system or have developed intestinal candidiasis. There is at present no clear scientific evidence on these topics, though as mentioned before, benzodiazepine receptors are present in the gut and benzodiazepine use or withdrawal may affect immune responses. There is some evidence that chronic hyperventilation provokes the release of histamine (a substance released in allergic reactions) and that the incidence of food-intolerance and "pseudo-allergic" reactions is high in chronic hyperventilators. Advice on diet, breathing and candida infections is given in books by Shirley Trickett quoted at the end of this chapter. It is usually inadvisable to stick to a strict exclusion diet; with a normal balanced diet and sensible general health measures, including regular exercise, gastrointestinal symptoms due to withdrawal gradually abate.

 

Coping with protracted symptoms A number of people are expressing fears that some benzodiazepine withdrawal symptoms last for ever, and that they can never completely recover. Particular concerns have been raised about impairment of cognitive functions (such as memory and reasoning) and other lingering problems such as muscle pains and gastrointestinal disturbances.

 

People with such worries can be reassured. All the evidence shows that a steady decline in symptoms almost invariably continues after withdrawal, though it can take a long time - even several years in some cases. Most people experience a definite improvement over time so that symptoms gradually decrease to levels nowhere near as intense as in the early days of withdrawal, and eventually almost entirely disappear. All the studies show steady, if slow, improvement in cognitive ability and physical symptoms. Although most studies have not extended beyond a year after withdrawal, the results suggest that improvement continues beyond this time. There is absolutely no evidence that benzodiazepines cause permanent damage to the brain, nervous system or body.

 

People bothered by long-term symptoms can do a lot to help themselves. For example:

 

Exercise your body. Physical exercise improves the circulation and function of both brain and body. Find an exercise that you enjoy: start at low level, work up gradually and keep it up regularly. Exercise also helps depression, decreases fatigue and increases general fitness.

 

Exercise your brain. Use your brain to devise methods to improve its efficiency: make lists, do crossword puzzles, find out what bothers you most - there is always a way round it. Cognitive retraining helps people to find ways around their temporary impairment.

 

Increase your interests. Finding an outside interest which you have to work at employs the brain, increases motivation, diverts attention away from your own symptoms and may even help others.

 

SIDEBARB: Soooo easy to do all of these when feeling like s**t !

 

Calm your emotions. Above all, stop worrying. Worry, fear and anxiety increase all withdrawal symptoms. Many of these symptoms are actually due to anxiety and not signs of brain or nervous system damage. People who fear withdrawal have more intense symptoms than those who just take it as it comes and think positively and confidently about recovery.

 

How long do benzodiazepines stay in the body after withdrawal? This question is often asked by people with long-term symptoms. Is it possible that one cause of protracted symptoms is that benzodiazepines remain in the body even after months, lurking perhaps deep in such tissues as brain and bones? Could slow elimination from these sites keep the withdrawal symptoms going?Like many other issues concerning benzodiazepines, the answers to these questions are still unclear. Benzodiazepine concentrations in the blood have been measured and shown to reach undetectable levels in 3-4 weeks after cessation of use in people withdrawn from clinical doses. Information on benzodiazepine concentrations in the brain and other tissues is difficult to obtain, especially in humans. Benzodiazepines certainly enter the brain and also dissolve in all fatty (lipid-containing) tissues including fat deposits all over the body. It is possible that they linger in such tissues for some time after blood levels have become undetectable. However, most body tissues are in equilibrium with the blood that constantly perfuses them, and there is no known mechanism whereby benzodiazepines could be "locked up" in tissues such as the brain. There is no data on how long benzodiazepines remain in bones, which have a lower fat content but also a slower rate of cell turnover.

 

Nevertheless, the concentration of benzodiazepines remaining in body tissues after withdrawal must be very low, otherwise the drugs would leak back into the blood in discernible amounts. It is difficult to imagine that such concentrations would be sufficient to produce clinical effects or that any direct effects could last for months or years. However, it is not inconceivable that even low concentrations might be enough to prevent the return of GABA/benzodiazepine receptors in the brain to their pre-benzodiazepine state. If so, the receptors would continue to be resistant to the natural calming actions of GABA (See Chapter I), and the effect could be to prolong the state of nervous system hyperexcitability. Possible factors contributing to protracted symptoms are outlined in Table 4.

 

 

 

 

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Altostrata

From Ashton, above:

As discussed in Chapters I and II, benzodiazepines disrupt the function of many neurotransmitters and hormones and depression could be the result, for example, of low serotonin activity combined with the stress of withdrawal. If severe enough to require definitive treatment, the depression in withdrawal responds to antidepressant drugs and/or cognitive therapy and usually diminishes gradually over 6-12 months.

As I read this, it sounds like Prof. Ashton is speculating that the symptom of depression in benzo withdrawal is due to low serotonin, therefore serotonin-boosting drugs will reduce this symptom.

 

Her reasoning is faulty, it is based on the "chemical imbalance" theory then in vogue. In no case is depression of any sort caused by low serotonin.

 

Therefore, adding an antidepressant to a benzo withdrawal regimen is not indicated.

 

I don't blame Prof. Ashton, many very insightful doctors at the time endorsed the "chemical imbalance" theory and, focused on a different area of practice, she didn't question the common knowledge that you dump an antidepressant on any sign of depression.

 

I'm not a doctor, but under no circumstances would I add an antidepressant during benzo withdrawal. It only complicates the neurological situation. For unclear reasons, you are adding the risk of antidepressant withdrawal syndrome on top of a nervous system already weakened by benzo withdrawal.

 

The combination of antidepressant withdrawal symptoms with benzo withdrawal symptoms is often worse than either type of withdrawal by itself.

 

If you are already taking the combination of antidepressant and benzo, personally I feel more confident in the advice I got recently from a knowledgeable doctor who deals with both antidepressant and benzo withdrawal: You withdraw the most "activating" drugs first: in most cases that would be the antidepressant. "Activating" means stimulative, causing agitation, hypomania, mania, wakefulness, or anxiety.

 

Antidepressants, being "activating," would aggravate anxiety produced by benzo withdrawal.

 

Benzos are "regulating" drugs, which may dampen the anxiety symptoms caused by antidepressant withdrawal.

 

In fact, often clinicians who are sort of aware of antidepressant withdrawal syndrome think a benzo is a good way to alleviate withdrawal symptoms. (I beg to differ, but it's in the literature, and they believe it.)

 

Everyone is different, you have to make these decisions for yourself.

 

If you correspond with Dr. Ashton to get her current views on this, including her assumptions about the "chemical imbalance" theory of mood disorders, please let us know what she says.

 

PS Feel free to repost my post on the benzo forums, with a link and attribution to me, thank you.

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Rhiannon

Dr. Ashton knows a lot about benzo withdrawal, but otherwise I have not found her to have much insight or knowledge about other psych meds, and even some of her ideas about benzos are, in my opinion, outdated.

 

She doesn't seem to have much awareness about neuroplasticity and the chemical and genetic changes induced by psychiatric medications. She also apparently doesn't realize that there's no actual evidence that serotonin is involved in depression.

 

Overall, on the "benzo boards," most of us advise people not to take ADs or any other psych medication to cope with benzo withdrawal, because there's no real evidence that other meds will help, and there's a lot of evidence that they can lead to further problems down the road.

 

Pretty much what you find is doctors advising benzos to help people get off ADs and ADs to help people get off benzos, and in either case it's out of the frying pan into the fire, IMO.

 

So when it comes to anything but the actual nuts and bolts of getting off benzos, when reading Ashton I would grab hold of the same salt shaker I use when I read anything by any psychiatrist or doctor, although you might be able to take her with smaller grains of salt.

 

Still, she's probably saved tens of thousands of people. So I'm not complaining.

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alexjuice

I've tried to contact her. An underling responded that she doesn't respond to email. I forget his reason.

 

I assume, based on the dates she was at Oxford, that she is 80 at a minimum. In light of her age, I suspect that Dr. Ashton isn't aggressively monitoring current research and that her major contributions are behind her.

 

She did a lot of good though. And she seems very caring based on some video I've seen.

 

It's very bizarre to me that I've never met a professional in medicine, psychiatry or psychology (academic or clinical) who has heard of her.

 

Alex

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alexjuice

Rhi-

What are the main benzoboards, just for my information?

 

Alex

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Barbarannamated

 

It's very bizarre to me that I've never met a professional in medicine, psychiatry or psychology (academic or clinical) who has heard of her.

 

 

Yep. Even ones involved in Addiction Medicine.

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compsports

Hi Barb,

 

I loved this part of your post in which you made this comment, "SIDEBARB: Soooo easy to do all of these when feeling like s**t !" in reference to the suggestions for improving brain function. I was thinking the exact same thing and you beat me to it:)

 

Regarding improving cognitive abilities, when I read the part about there was a possibility that there were studies showing brain structure damage from chemotherapy in the short term, initially, I felt I was too tired to even find the link. But forcing myself to hunt for it is helpful to my brain in my opinion. Anyway, here it is:

 

http://www.medscape.com/viewarticle/548279

 

Long term, this seems to have disappeared. I can't remember if this jives with what breast cancer survivors are saying it seems this complaint is only recent.

 

Anyway, even though my memory and concentration are poor, forcing myself to find the article and then look for the relevant points was helpful in stimulating my cognitive areas.

 

I do admit when I read the article in which it it mentioned the possibility of decrease intellectual functioning even after being off of Benzos for years, I worry about whether I will experience the same effect due to my long term use of antidepressants. Of course, I can't worry about it but I would be less than honest if I didn't admit it was in the back of my mind.

 

Thank you for sharing this.

 

CS

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Barbarannamated

We need a BIG salt shaker.

How 'bout a salt shaker emoticon?!

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Altostrata

I would love a salt shaker emoticon! If you find one, send it me and I'll figure out how to load it.

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Barbarannamated

I would love a salt shaker emoticon! If you find one, send it me and I'll figure out how to load it.

 

I wouldn't even know where to look!

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Altostrata

In Dr. Stuart Shipko's e-book Xanax Withdrawal (2012), he addresses the Ashton Manual's apparent recommendation of antidepressants to counter benzo-withdrawal depression:

 

I agree with Ashton on most issues, however, there are a few areas where my experience and approach to withdrawal has been different.... Ashton avoids “updosing,” which refers to increasing the dosage of the drug during tapering. In my tapering strategy, sometimes patients do take a backward step, updosing at times or episodically taking small extra doses of Xanax outside of the tapering schedule -- but only in the interest of taking two more steps forward. Ashton feels comfortable prescribing antidepressants for depression which sometimes emerges as a withdrawal symptom. I do not prescribe antidepressants during withdrawal. It is my opinion that the neurotoxic and dependency forming aspects of the antidepressants, in particular the SSRIs, are not worth the potential benefits, and often have withdrawal syndromes which are as bad, or worse, than withdrawing from Xanax. If withdrawal related depression is too severe, instead of using antidepressants, tapering is stopped entirely with return to the original dosage. This will alleviate the depression. Tapering can be tried later, after the depression has resolved.

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superheather

Barbarannamated:

 

I know this is a very old post but can you please tell me where the information in grey that you posted is from?  Is it from the Ashton Manual?  

Thank you kindly,

Heather

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Altostrata

The long selection in post #1 is from the most recent supplement to the Ashton Manual.

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Shashal

I’m from BB and successfully tapered from the benzos few days ago, unfortunately I was wrongly put on the AD meds by my doctor who denied my benzo withdrawal symptoms. Now I’m on this situation, more and more clues showed that some of my symptoms were not related to the benzo but AD meds, although the symptoms are very similar, I can’t imagine that if I haven’t found the Ashton Manual and SA, the doctor just ruined my life with lack of the knowledge about benzo and WD withdrawal. Thank you SA🤗 

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