Q. I am a second year student at Harvard Med and we are studying a case about a woman with depression and problems sleeping. She took some of a friend's Alprazolam (Xanax) to help her sleep, and when she presented to the doctor, she specifically requested more benzodiazepines.
As we are currently studying Neuroanatomy and the Sleep Cycle, we know that the Benzodiazepines potentiate the GABA receptors, which then increase Cl- channel conductance and hence, work on the VOPL to potentiate sleep, and therefore help people to sleep.
However, in understanding this, we have learned that benzos decrease the amount of non-REM (deep, slow wave) sleep. I was hoping that you could clarify then why doctors would give a benzo for treating a sleeping disorder, or to help with sleep.
Also, the patient's depression continued, and her mood fluctuated -- though she comments that her mood improved after a deep sleep. Can you please explain the details of this feeling also? Especially since we learned that the benzos don't allow for the true deep sleep. Why then is she feeling better if benzos increase REM sleep and reduce the deep, non-REM sleep?
Really, what is the mechanism by which these benzodiazepines inhibit deep sleep?
Eventually, in our "case", the patient re-presents begging for more benzos, and had gone through an entire month's supply of Halcyon (triazolam) at 0.25 mg in eleven days. We have concluded that she develops a benzo addiction, and may also possibly have a drinking problem. What are the effects of benzos with alcohol?
Later, the patient presents with tonic clonic seizure. Is this due to her developed addiction to the benzos, and their consumption with alcohol>?
The patient also develops extreme anxiety. What is this from? She also presents being diaphoretic, and agitated, and dilated pupils. Can you please explain the effects of the Autonomic Nervous System due to benzos and alcohol?
Many students would really appreciate it if you could answer these questions
as they would be extremely useful to know!
A. The patient presented is hard to decipher because of lack of data. If I were to guess, however, this would be my guess. First, if you can imagine the worst you ever felt after not sleeping for a night, and then imagine what it would be like to not sleep for weeks at a time, you can imagine how poorly the patient feels. Second, benzodiazepines are basically freeze-dried alcohol. That is why you used benzos to detoxify an alcoholic or prevent delirium tremens (DTs). Third, the vast majority of patients with depression also have comorbid anxiety, which all benzodiazepines treat. Fourth, benzos have a side effect of sedation and are cheap, which make them good sleepers for short term use. Thus, your patient was tired, anxious, depressed, and probably had been using alcohol to self medicate. By giving Xanax (alprazolam) you sedated her and temporarily treated the anxiety. By the way, 1 mg of alprazolam is equal to 20 mg of diazepam (Valium), so it is quite potent. Further the half life of alprazolam is 3-4 hours and diazepam is 20-40 hours.
In medicine, you should operate by the idea of parsimony of diagnosis. A patient has one disease with many symptoms. Treat the underlying disease, and the patient will get better. That is why you use antibiotics for strep, and not cold baths. You treat the underlying cause of the disease, the strep, and not the symptom (fever). Chances are the anxiety is part of the depression, just like the drinking, sleep problem, and any somatic complaints (headaches, IBS, PMS, etc.) the patient may have. The seizures could be a host of things. More drinking than you thought, benzos from other providers, abuse of other drugs.
Treat the depression, and all should get better in time. Sleep is too deep a topic to cover here. There are many ways to "knock someone out," but this does not make for good sleep. Treat the disease and the sleep will improve.
