Medications For Combat PTSD

cont. from

Confusion of pleasant side-effects with main effect: The pleasant, couple-of-drinks, or drowsy feeling that you get when you first take a benzo (especially the ones that are rapidly absorbed into the blood) is a side-effect that most (not all) people get tolerant to. Because it comes on at the same time as the anti-anxiety effect, it is natural for patients to think that this pleasant feeling is the anti-anxiety effect. One of the strengths of the benzos is that people do not get tolerant to the therapeutic anti-anxiety effect. A very common problem is that people feel the drug is quitting on them when they become tolerant to the pleasant side-effect, and become very afraid that their anxiety symptoms will return. Often out of fear of fear, they double up on their meds and pressure their doctors to increase their dose. This natural confusion of a gradually weakening, pleasant side-effect with the main effect is responsible for some addictive properties of the benzos.

Mini-withdrawal syndrome between doses: Benzos differ from each other mainly in their pharmacokinetics, that is, how fast they go into the body and how fast they leave. Mini-withdrawal reactions are particularly likely to happen with the benzos that leave the body quickly, such as Halcyon (generic name: triazolam). This is why people who take this drug for sleep often wake up in the middle of the night because they are in the withdrawal phase. Though Xanax does not leave the body quite as fast as Halcyon, it is particularly prone to giving mini-withdrawals between doses. My observation has been that many combat vets on Xanax have periods of anxiety and irritability during each day that do them great harm, and which, in my view are mostly mini-withdrawal reactions between doses.

Possible dangerous peculiarities of Xanax in PTSD during withdrawal: The staff of the in-patient PTSD unit at the American Lake VA in Washington State have published a paper reporting extreme violence by combat vets treated for long periods with Xanax and then taken off of it. This was apparently more frequent and more severe than what they found taking their patients off of other benzos, such as Valium. Several Vietnam combat veteran peer counselors whom I respect very highly, feel that Xanax has done a lot of harm. Xanax has some unique properties among its cousins in the benzodiazepine family. In lab tests Xanax acts the opposite at low blood levels of how it acts in the larger amounts actually used in medical practice. When you think about it, everybody passes through a low blood level twice when they take a pill -- once when the pill is just being absorbed in the body and once when the body is almost done getting rid of it (unless, of course, the person takes the same pill again, before the first one is completely gone). Whether this is what causes the problems with Xanax is not clear right now.

2. Caffeine

   The pharmacology of caffeine is horribly complicated: it's not just one drug, it's really three, each of which can have a different effect on different people. The way it's three drugs is that it's the original caffeine, then the body converts it into theobromin, which the body then converts into theophyllin. The peak effects of these three successive drugs are roughly two hours for caffeine, four hours for theobromin and six hours for theophyllin. The good effects that any of these three drugs can have is feeling more awake, energetic, and optimistic. The bad psychological effects that any of these three drugs can have are anxiety and depression. A given person does not necessarily react to all three the same way. (I'm not talking here about the well-known effects of caffeine on sleep -- this is another important topic in itself. What many people are unaware of is that at very high doses -- like 15+ cups of coffee a day -- caffeine can reverse on you and it can be impossible to stay awake, unless the caffeine is stopped.)

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Someone who reacts badly to caffeine itself has usually found that out long ago, because the anxiety and/or depression hits them soon after the big mug of coffee. These people know it's not for them. But there are literally millions of people who feel good after caffeine itself but have bad reactions to either theobromin or theophyllin (four or six hours after that big mug of coffee) and just think it's their life that's out of whack, not their brain chemistry. THERE IS NO WAY TO TELL WHETHER CAFFEINE AND ITS METABOLITES ARE RESPONSIBLE FOR YOUR ANXIETY AND/OR DEPRESSION UNLESS YOU TAKE YOURSELF OFF IT COMPLETELY FOR SEVERAL WEEKS. This means coffee, tea, Coke, Pepsi, Mountain Dew, Jolt, headache pills with caffeine. Some people are so sensitive to it that even the small amount of caffeine in decaffeinated coffee and in chocolate causes psychiatric symptoms. If you decide to take yourself off caffeine to see what your life is like, don't go cold turkey. Taper yourself off over a week or so, or you are likely to get severe withdrawal headaches.

3. Yohimbine

   Yohimbine (brand names: Actibine, Aphrodyne, Yocon, Yohimex) is absolutely contraindicated in combat PTSD. It causes flashbacks and panic attacks. This drug is sometimes used to treat impotence.

4. Any illegal drug

   The problems and appeals of specific illegal drugs in combat PTSD is a very big subject that can't be covered here, but all illegal drugs cause the following problems for combat vets with PTSD.Expense is the first problem -- I know there are Vietnam vets who have been very successful financially, but the men I know who have severe, chronic PTSD have a heroic struggle to make ends meet. I know it's stating the obvious, but the first problems of illegal drugs is the expense.

The second problem is much more subtle -- Getting illegal drugs involves you in relationships with and obligations to people you normally wouldn't let within a mile. Most of the combat vets I know have a very sharp eye for quality in human beings, and feel constantly tainted by the people they get involved with to support their habits.

The third problem is that situations of real danger and the presence of weapons gets in the way of healing from PTSD. In this country and time it's not possible to sustain a drug habit over a period of years without running into situations that rekindle PTSD because of their real combat elements.

The fourth problem is the worst -- using illegal drugs often puts veterans in situations where they bring down other vets. Calling for rescue is a very common way of bringing down other vets, even if the rescue is "successful." Users need to be rescued from the medical complications of their habits, from the pressure of debts to dealers, and so on. Vets who have been on rescue missions are put back into combat-mode and are wired for weeks after a rescue. Sometimes users bring down other vets by asking them for dangerous favors (e.g., "hold this for me till I come for it" where "this" is a parcel of drugs or drug-related weapons or money). And finally -- this is really obvious but it needs to be said -- if a fellow vet is trying to stay clean and you're using, this amounts to a standing invitation to break out.

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Reviewed: 04/2006