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Tinnitus treatment benzodiazepines, seasonal depression disorder test - Review

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BENZODIAZEPINES are the most widely prescribed psychotropic drugs.(1-3) A mild abstinence syndrome may appear after discontinuation of long-term therapeutic doses of benzodiazepine4 and is characterized, among other symptoms, by poor appetite, gastrointestinal disturbances, insomnia, and tremor.
The long-term consequences of withdrawal of benzodiazepines from therapeutic doses are not well characterized.
A 57-year-old retired salesman was seen at the Addiction Research Foundation Clinical Institute for treatment of diazepam dependence. He participated in the outpatient treatment of benzodiazepine dependence offered at our hospital.
The patient was offered to continue on low doses of benzodiazepines to diminish the tinnitus but he chose to remain abstinent. Four days after discontinuation of diazepam, he complained of tinnitus ("ears buzzing"), neck stiffness, headache, and insomnia.
A 49-year-old male computer programmer using 5 to 20 mg of diazepam daily for 12 years presented to the Clinical Institute of the Addiction Research Foundation with memory impairment, difficulty in concentration, and severe tinnitus upon diazepam discontinuation.
His use of benzodiazepines had started 12 years before admission to decrease his anxiety over work stress and had been almost constant.
The three cases described here provide evidence for an uncommon consequence of long-term therapeutic benzodiazepine use after drug discontinuation. The long-term management of these cases is difficult but may include the use of very low doses of benzodiazepines, particularly if the tinnitus is impairing the quality of life. In one of these patients, the association of the tinnitus appearance with the drug discontinuation was documented in a double-blind, randomized, crossover single case study.

We report three cases of protracted tinnitus associated with benzodiazepine withdrawal in patients without tinnitus prior to the time the patients began to use benzodiazepines. Blood and urine concentrations were low at the end of the treatment and negative at the 3-month follow-up. An inverse correlation between the total plasma diazepam concentration and the severity of the tinnitus as measured by the scale was observed. These symptoms were attributed to diazepam withdrawal and had resolved at the 1-month follow-up with the exception of neck stiffness and tinnitus, which were still present 3 months later. In one of the cases, a strong association between diazepam withdrawal and tinnitus was established. More appropriately, gradual tapering of benzodiazepines in long-term users may help to minimize short-term symptomatology.(4) Because the indications for long-term therapeutic use of benzodiazepines are few, careful assessment, in each individual case of the reasons for long-term use of benzodiazepines seems indicated in all patients. Objective confirmation of drug use or of abstinence was performed by obtaining plasma benzodiazepine concentrations. In one of these patients, we were able to perform a single case, double-blind, randomized experiment comparing the effect of diazepam and placebo on the occurrence and severity of the tinnitus. At the 6-month follow-up, the gastrointestinal symptoms had resolved, but the tinnitus persisted. No obvious cause for the tinnitus was found on neurological examination and the patient had no history of previous tinnitus. For example, four cases of hyperacusis during the first 2 weeks of withdrawal among 22 patients withdrawing from benzodiazepines have been reported.(17) Two to 4 weeks after drug discontinuation, only two patients continued to complain of the same symptoms.

The probability that the tinnitus was related to the diazepam withdrawal was assessed using the Adverse Drug Reaction Probability Scale, which gave a score of 11.(9) This score means that the tinnitus was definitely related to benzodiazepine withdrawal.
The findings provide further documentation that sensory disturbances of short-and long-term duration are among the most distinctive clinical features of the benzodiazepine withdrawal syndrome. He reported that this was the first time he had experienced tinnitus in his life, and he described it as a high-pitched ringing in the ear (both sides) being the worst in silence and in bed. At a 6-month follow-up appointment, the tinnitus was only occasional and of short duration. He maintained that the main reason for not being able to achieve abstinence from benzodiazepines was a high-pitched, very intense ringing in both ears that began each time the diazepam dose was reduced. The tinnitus disappeared 15 minutes after a dose of diazepam was ingested, but reappeared approximately 4 hours after every dose.
He also participated in the outpatient treatment of benzodiazepine dependence.4 He was successfully detoxified and blood and urine screens were negative 6 weeks after starting on the program. He objectively remained abstinent from benzodiazepines and other drugs for the full 1-year follow-up period, documented by plasma benzodiazepine concentrations.

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