Threshold for taking benzos for generalized anxiety
March 29, 2013 11:00 AM   Subscribe

I have a prescription for lorazepam (Ativan) 1 mg that my doctor told me to take "as needed" for anxiety. Since there are downsides to using benzos, I am trying to determine how strong my anxiety needs to be before I take some. Curious what rules of thumb people have settled on. Do you take it even for slight anxiety? Or only when it gets bad?
posted by wireless to Health & Fitness (18 answers total) 9 users marked this as a favorite
Ativan is the baby of the benzo family, in all ways. So if you let your anxiety get to a 9 before you take one, there's a good chance it is not going to do shit worth noting, and you'll either have to deal with your anxiety at an 8 (still 'too high') or take more. If you take more, that's when the whole "benzos fuck you up" thing happens.

Personally, I take it when the mental and physical effects of anxiety are occupying my headspace in such a manner as to make it more difficult to do the thing I need to to make the anxiety go away, whether that is solve the problem I am anxious about, or just chill out. So if a '3' is where I need to be to fix the problem and get down to 2 or 1, then I take it when I'm at a 4 or 5.
posted by A god with hooves, a god with horns at 11:05 AM on March 29, 2013 [1 favorite]

I had a prescription for Xanax and I feel I didn't use it the best I could. I took it when I didn't really need to or when it didn't really help me. Mostly I took it because I was afraid I would be anxious, which didn't serve me well.

I would second taking it when things are bad but not too bad. I also found that if I was anxious about something that I kept obsessively thinking about, Xanax didn't do much. It was when I was generally anxious or had a lot of physical anxiety symptoms that Xanax was helpful.
posted by chainsofreedom at 11:07 AM on March 29, 2013

Not to discount chainsofreedom's advice but I would be careful in equating xanax and ativan use. They (can) have very different long and short term effects.
posted by A god with hooves, a god with horns at 11:13 AM on March 29, 2013 [1 favorite]

I've used xanax and klonopin but also caution that ativan is a different thing with different potential effects.

I've always been very careful to take it only when my anxiety is cripplingly high - for me, I have a very physical reaction to anxiety, even when it's not a strict panic attack - muscle pain, especially low back pain, tensing in my jaw etc, so I take it when things have gotten to that stage. Or if I'm in a situation I know I can't easily get out of - ie, airport checkin or something.

I was prescribed klonopin daily when I had bad anxiety/depression and got dependent. Coming off that was PURE HELL do not recommend. So I recommend being quite careful about spacing out taking benzos. They are like magic for my anxiety though.
posted by sweetkid at 11:22 AM on March 29, 2013

You know your own body and probably recognize the first signs of anxiety. IANAD, but when you feel anxiety starting would seem to be the time to take your med. Head off an incident, prevention is easier than cure, etc.
Alternately, you might ask your doctor to discuss this issue with you. I have no experience with anxiety and you should keep that in mind when reading the replies of the rest of the MeFites who are not doctors.
posted by Cranberry at 11:23 AM on March 29, 2013

I had an as-needed Rx for lorazepam for a while. I took it for a while when my anxiety was such that it was either (1) disrupting my ability to sleep or (2) disrupting my ability to concentrate on the task at hand. Sometimes I took it 'prophylactically', in anticipation of anxiety-triggering situations, and it helped a little bit there. It didn't completely defuse the feeling (since, as a god with hooves describes, it is the 'baby' in that way... I've always found clonazepam packs much more of a punch), but it made it manageable for me.

I would make sure you check in with your pdoc on your usage pattern pretty regularly, especially where "as needed" is so ambiguous. It's easy for lorazepam use to creep up. Over time I got from the point where I was taking it a couple times a week to once, sometimes twice daily. This was technically within the limits of the prescription that I had, but crossing that threshold of usage made it a lot harder to come off of it after. Because my prescription was for such a low dose, I made the terrible mistake of thinking I could just stop taking it. (Wrong, wrong, wrong. By the time I realized I was in withdrawal, it was too late to go back and taper, so I just suffered through it. It was a pretty terrible few weeks.)

And, most importantly, make sure to check in with yourself. In retrospect I kind of wish I had kept a before-and-after journal or something like that documenting how I was feeling, so I could've tracked my usage better and been mindful of it, rather than slowly watching the pills disappear from the bottle.
posted by Kosh at 11:26 AM on March 29, 2013 [1 favorite]

If you take it and then all you want to do is sleep, you took it too soon. If you take it and still feel anxious, you waited too long. That's my rule.

I wouldn't put much credence in the relative strengths of benzos. It's more about dosage and the half life of the drug. They all do the same basic thing, just over a different time period.

The shorter the half life, the more likely you are to have addictive side effects. The fast onset and clearance makes the brain crave more. A slow onset and slow clearance allows the brain to readjust and is less likely to cause rebound cravings.

As for what works for you, you have to look at what the causes and effects of your anxiety are. Like pain medication, you have to "ride the levels" and stay ahead of the anxiety. But not too far ahead: if you take it all the time, obviously, you'll quickly develop tolerance and it won't work. But if you wait until you are shaking, sweating and weeping in the corner, it will take more to bring you down. So if you know that waiting in line at the stuffy DMV makes you twitchy, try taking a half pill ahead of time and see how you react. The goal is to stem the symptoms so you can experience anxiety-causing situations without (as much) anxiety, learn that it really isn't all that bad and re-train yourself not to react in anxiety-multiplying ways when situations like that come up.
posted by gjc at 11:30 AM on March 29, 2013 [2 favorites]

Husbunny has Atavan for situational anxiety, specific things that freak him out.

I take Celexa for free-floating anxiety and it's served me well for years. Mellows me out, keeps me sharp and in the present moment.

I'm rather suspicious of Atavan unless it's for something specific like oral surgery or air travel.

If you are generally anxious, you might need something different.
posted by Ruthless Bunny at 11:37 AM on March 29, 2013 [1 favorite]

I assume from the title of your question that you've had a diagnosis of Generalized Anxiety Disorder. I don't know what your particular symptoms are (GAD can present with some weird, bad, and uncomfortable ones), but I wonder if a therapist has ever taught you any relaxation techniques such as conscious breathing or progressive muscle relaxation. My rule of thumb for taking a benzo has been to try one of those interventions first, and then if the anxiety keeps increasing, throw the benzo at it. I agree with those whose approach is to halt the anxiety train before it gets rolling. Ultimately it's up to you what your threshold for tolerable anxiety is, and whether preventing it is better for you than waiting to see what happens before you take Ativan.

If you find yourself using the Ativan daily, or building a tolerance to it, I'd go back to the prescribing doctor. I find myself wondering if he or she is is a general practitioner or a psychiatrist. First line medication these days for GAD is an SSRI like the abovementioned Celexa, though YMMV as always.

Good luck!
posted by sister nunchaku of love and mercy at 11:59 AM on March 29, 2013 [1 favorite]

Ativan is one of the milder (and less dependence causing) of the benzos, but your concerns are still very valid. I've had an Ativan rx for years and have some vague 'groundrule' I try to stick with. you don't want to develop a physical tolerance. I try to be mindful of not taking it too many days in a row or more than once in a day. on the other hand, its completely safe to take up to 3mg at once, so if you've got anxiety that you cannot relieve without meds, or that will interfere with life/work/family, then take the Ativan. its very mild and just so great for soothing those edges.
posted by supermedusa at 12:00 PM on March 29, 2013

Everyone has different experiences with benzos. I have Ativan (2mg) to take before dentist appointments and in the past have been prescribed Klonopin (1mg) for general anxiety.

Ativan, despite its short half life, gives me a 36 hour hangover and it has incredible amnesic effects on me as well. Klonopin just has a general anxiolytic effect along with some mild sedation.

How does Ativan work for you?

I'd take it when you're feeling like the anxiety is going to escalate to a point that you can't control. But I'd also see if there's maybe a better benzo out there for you. Or maybe try a beta blocker?
posted by elsietheeel at 12:01 PM on March 29, 2013

Also just to add to what I said and others are saying: Do you take it even for slight anxiety? Or only when it gets bad?

These are also questions for your doctor.
posted by sweetkid at 12:07 PM on March 29, 2013

If you don't have specified anxiety triggers, I would strongly consider going back for an SSRI. I am so grateful that my SSRI basically stops excessive anxiety before it happens, because anxiety sneaks up on me. I'm fine, I'm just a little twitchy, it's just a rough patch, no worries, BAM I'm drowning and can't function.

If it's just for shorting out occasional panic attacks, I would focus strongly on what your body is telling you, and not your head. Your head will register it as anxiety way too late, and trying to be hypervigilant about 'anxiety' is a quick way to catastrophize and bring on a panic. So keep an eye on your breathing, heart rate, etc. I'll also do this thing where I try to separate and my vision actually changes. That sort of thing.
posted by politikitty at 12:19 PM on March 29, 2013

I've had as-needed benzos (including Ativan) for many years. Most of the time I don't take them, but then I have spells of a day or a week or even months when I do. I suppose my rule of thumb is that if doing the deep breathing/relaxation type stuff is not helping, then it's time for the drugs.
posted by newrambler at 1:05 PM on March 29, 2013

I think it's clear that you're getting all sorts of different answers here and lots of good information.

You should have this conversation with the prescribing doctor. It's their job to ensure you stay healthy and non-dependent on anything unnecessary.

But I do want to add as a sidenote that years ago I began having panic attacks and was prescribed .5mg Klonopin on an as-needed basis, and because I didn't ask clarifying questions to the prescribing doctor, I ended up actually increasing my anxiety because (like you), I became anxious about the possibility of becoming addicted. At the urging of a friend who saw that I was working myself into an even worse state, I spoke with my doctor who explained everything and made me feel better. She also apologized for not being more clear and thus increasing my anxiety at the time. Once I was taking the Klonopin as needed, I was able to take on a CBT program, learn a lot of valuable techniques and my anxiety is pretty much gone.

This is why I say talk to your doctor.
posted by kinetic at 1:07 PM on March 29, 2013 [1 favorite]

Since you asked for peoples' rules of thumb:

When I had a prescription for Xanax I took it only when I had a full-blown panic attack (preventing me from acting normally) at a time when I absolutely needed to be professionally competent and interacting with others.

My doctor actually advised more liberal use than that, but I was very hesitant to use it.
posted by Cygnet at 1:51 PM on March 29, 2013

I don't have an addictive personality, so my advice is for those who don't as well. I've only taken Xanax and Klonopin at their lowest doses, so this might not apply directly to your Ativan situation.

The rule of thumb that I follow with all my benzo use has been to take the lowest dose prescribed to me, never go higher or take more than one within a 24 hour period, and rarely take them daily. I can understand the allure of taking a higher dose or taking more than one a day, but the end result is that you are raising your tolerance and only leading yourself to a bad road ahead.

Taking both has also shown me how different the benzos can be. Xanax can help ease me into sleep when I'm having bad anxiety during sleep hours. Klonopin calms me down but gets me going so I can get things done during the day during high anxiety. By following my benzo rules I still react well to the same low dose of Xanax for years now.

You don't want to ever get to the point that you feel you are dependent on benzos. I know someone who has had this happen to them and it's not pretty. They cannot sleep without 3 mg Xanax a night after slowly raising their tolerance throughout the years. The problem is that benzos can cause deep sleep disturbances and causes memory problems galore. You don't want to get to that point. If you feel that your prescription isn't working anymore, that is a sign you need to take a break and lower your tolerance again.
posted by side effect at 4:17 PM on March 29, 2013

I have a prescription for klonopin. I think of it as one tool in my tool box. Other tools include yoga, alcohol, hiding in the ladies room for a few minutes, texting friends. Sunday I started feeling anxious. I went to yoga and it helped. So maybe you should think about what's in your toolbox and how ativan fits in. I can't do yoga or text friends when I'm on a plane so that's a good time for klonopin. I can't drink or take klonopin when I'm about to do something at work so that's a good time to text a friend. What else is in your toolbox? How does ativan fit in?
posted by kat518 at 5:02 PM on March 29, 2013

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