@skywalker45 5511 wrote:

I’ve been taking Klonopin (clonazepam) for several years for anxiety and panic disorder. When I started I was taking 0.5mg a day. Now I’m taking 1 to 1.5 mg a day. I cannot stop taking it! I can’t sleep, I feel like I’m losing my cognitive abilities and I’m extremely worried and don’t even know how to approach my doctor with this! What can I do? Not to mention the anxiety is really only getting worse…

Every medication will have an action which will be counteracted to a certain extent by the body. This is called the development of tolerance to a medication. This leads to dependence on a treatment. Dependence is defined as the development of tolerance such that a person will develop withdrawal symptoms when the medication is abruptly stopped. Dependence is not abuse. Abuse is taking a medication not for its prescribed purpose such that dysfunction rather than improvement in function occurs.

Anxiety is a condition where the fight-flight component of the nervous system (the sympathetic nervous system ) is overactive, producing excessive norepinephrine – the primary signal for stress – triggering the emotion of either fear or anger or both depending on a person’s biological personality or temperment and other factors.

Medications called Benzodiazepines such as Clonazepam work by increasing GABA signaling by increasing one’s sensitivity to GABA – the primary calming signal in the nervous system. This then tones down and counteracts the effects of norepinephrine.

For many people who suffer from anxiety, this is a sufficient treatment, particularly when they are healthy enough physically and psychologically to have other means to counteract excessive norepinephrine signaling.

And there are many other alternative medications which help control norepinephrine signaling. Off the top of my head, these include:
1. Psychotherapy, meditation, yoga, and other treatments to improve brain function through neuroplastic change.
2. Serotonin-increasing medications – such as Lexapro, Prozac, Zoloft, Celexa, Paxil, Effexor (at least partially), Trazodone, Nefazodone, MAOI inhibitors (such as Selegiline, Parnate – which have other complex effects)
3. Anti-seizure medications – such as Lamictal, Neurontin, Tegretol, Depakote, Topamax
4. Atypical Antipsychotic medications – such as Seroquel, Abilify
5. Anti-histamines – such as Atarax
6. Serotonin-like medications – such as Buspar
7. Norepinephrine-receptor blockers – such as the beta-blockers Propranolol, Coreg, etc.
8. Norepinephrine production reduces – such as the alpha-2 agonist Clonidine and Tenex
9. Lithium
10. Calcium Channel Blockers – including Verapamil, Lyrica, Keppra
11. Hormonal – including Progesterone, Testosterone
12. Nutritional/Herbal – including 5HTP, GABA, Tryptophan

Generally, other medications which are less prone to result in tolerance and reduced effectiveness over time are used as the base treatment for anxiety. The most common example used are the serotonin increasing medications such as the serotonin-reuptake inhibitors Lexapro, Zoloft, Paxil, etc. The benzodiazepines are then used to augment treatment either through regular dosing or as needed dosing.

When a single medication, such as Clonazepam, is insufficient to reduce anxiety because of the development of tolerance, then combining it with alternatives may result in a more effective treatment.

Note that controlling excessive norepinephrine signaling helps reduce anxiety but it does not often directly address the physiologic cause(s) of anxiety.

This requires a deeper level of understanding of the illness and much more work. Doing this work more fully answers the question: why and how is this person anxious?

In order to cause a mental illness, generally, there are multiple simultaneous underlying causes of the illness such that the person’s becomes unable to address them all well enough to maintain function.

Generally, there may be problems with the nervous system, the endocrine system, the immune system, and/or metabolism and nutrition contributing to anxiety – in addition to a person’s genetics, biological personality/temperament, environment/parent-family relationships, psychological framework and experience.

For example, immune system issues such as infections (including dental infections) can lead to an activation of the sympathetic nervous system, causing anxiety or even panic. Nutritional deficiencies may lead to an increase in sympathetic nervous system activity, leading to anxiety. Using nervous system treatments will not generally address problems like these.

Over time, some of the underlying causes of anxiety may worsen, thus increasing the need to use higher doses of medications such as Clonazepam. Directly addressing the problem (e.g. treating the infection or the nutritional deficiency) will then reduce the need to use higher and higher doses of Clonazepam. And if all of the underlying causes can be addressed (some cannot be fully addressed), then perhaps Clonazepam wouldn’t be needed at all or would be relegated to as needed use.