Benzodiazepines

At a glance

Compared with waiting

Large difference compared with waiting, in a combined analysis of 101 trials. Few of those trials tested benzodiazepines.

Compared with other treatments

Better than placebo in a few trials. In a US trial of 75 people, 78 in 100 responded to clonazepam, compared with 20 in 100 on placebo.

Does it last

In a US study, people who slowly came off clonazepam after 6 months were more likely to relapse than people who stayed on it.

What it takes

Prescribed by a doctor, usually for a limited time, with regular reviews.

What they are

Benzodiazepines (“benzos”) are calming medicines. Examples are clonazepam, alprazolam, lorazepam and diazepam. They act quickly and reduce anxiety while they are in your system. A doctor decides if they are suitable and for how long.

What people report

On Reddit, people describe benzodiazepines in two very different ways. Some say a benzo was the only thing that ever calmed them enough to function socially. Others say they ended up worse than when they started, because of tolerance, dependence or withdrawal. These are reports from people, not trial results.

What the trials show

• They help, in a few trials. In a US trial of 75 people, 78.3% responded to clonazepam over up to 10 weeks, compared with 20.0% on placebo. Unsteadiness and dizziness were worse and lasted longer on clonazepam.
• Large effects, thin evidence. A Cochrane review found a large benefit for benzodiazepines, but it rested on only 2 trials. A study that combined 101 trials also found a large effect compared with waiting. That is similar to SSRIs and smaller than individual CBT.
• Symptoms come back when they are stopped. In a US study of people who had improved on clonazepam for 6 months, none relapsed if they continued. Of those who slowly came off it, 21.1% relapsed. Withdrawal symptoms were also more common in the group that came off it (27.7% compared with 12.5%).

Why guidelines are cautious

• Canada’s guideline lists benzodiazepines as a second choice, not a first choice.
• The UK guideline (NICE) advises against routinely offering them for social anxiety disorder.
• In the US, the FDA added its strongest warning to all benzodiazepines in 2020. It says that misuse, addiction and physical dependence can happen even at prescribed doses. Physical dependence can start after several days to weeks of steady use.

There are two more reasons people with social anxiety need care:

• Alcohol. Social anxiety disorder is linked to alcohol problems. Some people say they drink to get through social events. Alcohol makes the side effects of benzodiazepines worse. See alcohol and social anxiety.
• Learning. Facing a situation while sedated may teach you “I only coped because of the pill”. This can work like a safety behaviour. It is a common concern among clinicians, but it has not been well tested.

Side effects and risks

• Drowsiness, unsteadiness, dizziness and slower reactions. Do not drive until you know how it affects you.
• Dependence and withdrawal. Stopping suddenly, or cutting down too fast, can cause withdrawal reactions, which can include seizures.
• Dangerous combinations. Taken with opioid painkillers or certain other medicines, they can cause serious breathing problems. Alcohol makes the side effects worse.

Never stop a benzodiazepine suddenly or change the dose without your doctor. A doctor can plan a slow reduction.

If you are using alcohol or pills to get through the day and feel low, see depression and social anxiety. If you are thinking of harming yourself, contact a crisis line now.