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Intravenous diazepam for facilitating relaxation for desensitization
J. Behav. Thee. & Exp. Psychtat. Voi. 3, pp. 39--41.Pergamon Press, 1972. Printed in Great Britain.
INTRAVENOUS DIAZEPAM FOR FACILITATING RELAXATION FOR DESENSITIZATION J. C. PECKNOLD, J. RAEBURN a n d E. G . POSER*
Behavior Therapy Unit, Douglas Hospital, Montreal Summary--Intravenous diazepam was found to be a safe, convenient agent for producing relaxation in two subjects unable to relax themselves. It was used for desensitization in two subjects and made it possible for self-relaxation to be induced subsequently. INDICATIONS for the use of drugs in behavior
therapy have been well reviewed by Silverstone (1970) who concludes that intravenous preparations can be of considerable value in the treatment of phobias and other situational anxieties. The theoretical rationale for the use of depressant drugs in conjunction with desensitization is to produce a central lowering of arousal to enhance performance (Malmo, 1966). Traditionally methohexital has been used in relaxation (Friedman and Silverstone, 1967) and more recently propanidid. The general procedure with methohexital has been to give increasing doses intravenously during the desensitization session; and while good results have been reported by several authors (Friedman and Silverstone, 1967, 1968; Skoblo, 1968) others (Yorkston et aL, 1968) have obtained indifferent results as well as complications with larger doses--impaired memory, distorted time sense, exercise intolerance, drowsiness, euphoria, inappropriate behavior and barbiturate dependence (Sergeant and Yorkston, 1968). Furthermore, Wise et aL (1969) state that in conservative dentistry, with a mean dosage of 460 mg of methohexital for a mean duration of 74 min, there has been a clinically undetectable respiratory obstruction, depression of the laryngeal reflex, and arterial hypoxemia. A further study (Allen et aL, 1970) notes that in general anaesthesia by means of methohexital
there was a depression of peripheral resistance with a fall in the mean arterial pressure. Another study (Lader and Mathews, 1970) notes a dose-dependent tachycardia when methohexital was used. Young (1968) obtained good results in the treatment of a subway phobia and of snake phobias with a single large intravenous dose of diazepam. Its most readily observable pharmacological property is the production of muscle relaxation. According to pharmacological experiments (Parkes, 1968) it seems that the drug reduces the hippocampal response to stimulation of the amygdala and thereby breaks the patterns of neuronal activity which cause anxiety. Stovner and Endoresen (1965) compared the intravenous effects of diazepam with those of shorter acting barbiturates, and found that less respiratory and circulatory depression was produced by the former. This was confirmed by Hellewell (1968). Intravenous diazepam has also been found, in electrical cardio-version, to be safer and less productive of cardiac arrthythmia than barbiturate anaesthetics (Totem 1970). We shall describe the use of intravenous diazepam as a desensitizing agent in two cases. Our decision to use intravenous diazepam in small dosages was determined by the above findings as well as by the fact that both patients came into hospital because of barbiturate drug
*Requests for reprints should be addressed to Ernest G. Poser, Director, Behavior Therapy Unit, Douglas Hospital, 6875LaSalle Blvd., Montreal 204, Quebec. 39
40
J . C . PECKNOLD, J. RAEBURN and E. G. POSER
dependence, one (Case 1) having had severe reactions on withdrawal from barbiturates, the other (Case 2) a seizure when barbiturates were withdrawn too quickly. Neither patient had been able to relax sufficiently through relaxation training according to the Jacobson method. Case I
A 25-year-old single man gave a history of panic attacks and barbiturate dependence of 4 years" standing. When he was admitted, he was anxious, unable to move outside the unit, crying and constantly voicing fears of losing control. A few months earlier he had re~ived behavior therapy at another hospital with poor response. He was discharged on a massive dose of medication (including barbiturates). Once rehospitalized, his medication was withdrawn and a toxic psychosis due to barbiturate withdrawal occurred. Subsequently, he was transferred to the Behavior Therapy Unit, and maintained on Nozinan 50 mg/day.* We started relaxation training by the usual modified Jacobson method (Wolpe, 1969). After 15 sessions the response was inadequate; the patient became further demoralized and we decided to use intravenous diazepam to assist relaxation. At the first session, we administered a 5 mg dose. Verbal relaxation instructions were also given, and a profound degree of relaxation was obtained in about 15 min. This permitted the presentation of items from a desensitization hierarchy which concerned "loss of control". (Sample item: "Not being able to follow my treatment programme.") Four similar intravenous diazepam relaxation and desensitization sessions followed, the diazepam being reduced by approximately 1 rag/day. The same degree of profound relaxation was maintained during the sixth session, when no intravenous diazepam was given. Another 2 mg of diazepam were given in the seventh session. Thereafter, for the 14 sessions required to complete the desensitization hierarchy, no further diazepam was used, relaxation remained good, and the patient's
fears of loss of control were eliminated. The diazepam series was the turning point in the patient's treatment, and he is now in the process of rehabilitation. Case 2
A 36-year-old single woman gave a 10-year history of barbiturate addiction and multiple phobias. Before admission, she had been immobilized in her home for several months. Her heavy intake of barbiturates required a withdrawal period of 4 weeks after her entry into the Unit. During this period verbal relaxation training was started to provide a substitute for the drugs, but as she was too anxious for the relaxation to take effect, we introduced diazepam-assisted relaxation training, Six consecutive sessions of intravenous diazepam plus verbal relaxation instructions were given, with doses of diazepam decreasing to zero. No desensitization hierarchy was presented at this time. Total barbiturate withdrawal coincided with the fourth session. After the diazepam series, two further sessions of verbally induced relaxation were given with excellent results. Desensitization was begun in the ninth session, and proceeded to a successful conclusion. Aversion therapy to barbiturates is still continuing with this patient. With both Case 1 and Case 2, no undue side-effects of diazepam were noted beyond a burning sensation at the time and site of injection. There was no drowsiness following the sessions and the patients were fully mobile after treatment.
DISCUSSION The significant aspect of this approach is the use of intravenous diazepam as an adjunct to, rather than as a substitute for, the wellestablished procedure of systematic desensitization. In view of the findings by Sergeant and Yorkston (1968) that barbiturate dependence
*Most patients in the Behavior Therapy Unit have no medication. However, there was a suspicion of late schizophrenia in this case.
INTRAVENOUS DIAZEPAM FOR FACILITATING RELAXATION FOR DESENSITIZATION
follows on prolonged methohexital desensitization, there may be objections to the use of diazepam. We found no evident craving in our two barbiturate dependent patients, partly because of the discomfort of receiving the intravenous needle; however, the satisfactory degree of relaxation obtained after this series rendered further diazepam unnecessary. As for the safety and convenience of intravenous diazepam in a dose range of 5-7 mg or less, there was no evidence of drug toxicity during or after these interventions. After the treatment sessions, the patients were fully mobile. Furthermore, there was no evidence of drug accumulation during daily intravenous diazepam administrations. For extremely anxious patients intravenous diazepam gives some indication of what relaxation is like. With our first patient, the initial attempts at relaxation by verbal means often brought complaints of "loss of control"; but with diazepam these feelings ceased. The patient acquired greater confidence in himself regarding relaxation.
REFERENCES ALLEN G. D., EVERETTG. B. and KENNEDYW. J., Jr. (1970) Cardio respiratory effect of general anaesthesia on out-patients, J. oral Surg. 28, 814-817.
41
DAVIDSONG. C. and VALINSS. (1968) On self-produced and drug produced relaxation, Behav. Res. & Therapy 6, 401--402. FRIEDMAN D. and SILVERSTONEJ. F. (1968) Methohexitone relaxation, Lancet 2, 833. FRIEDMAN D. and SILVERSTONEJ. F. (1967) Treatment of phobic patients by systematic desensitization, Lancet 1, 470-472. HELLEWELL J. (1968) Diazepam in Anaesthesia, Proceedings, Royal Society of Medicine (Edited by KNIGHT S. and BURGESS C. G.), pp. 47-51, John Wright & Sons, Bristol, LADER M. H. and MATHEWSA. M. (.1970) Comparison of methods of relaxation using psychological measures, Behav. Res. & Therapy 8, 331-337. MALMO R. B. (1966) Studies of Anxiety: Some clinical origins of the activation concept, Anxiety and Behavior (Edited by SPIELBERGERC. D.), Academic Press, New York. PARKES i . W. (1968) Diazepara in Anaesthesia, Proceedings, Royal Society of Medicine. (Edited by KNIGHT S. and BURGESS C. G.), pp. 1-7, John Wright and Sons, Bristol. SERGEANTH. G. S. and YORKSa~ONN. J. (1968) Some complications of using Methohexitone to relax anxious patients, Lancet 2, 653---656. SILVERSTONET. F. (1970) The use of drugs in behavior therapy, Behav. Therapy 1, 485-497. SKOBLO M. (1968) Methohexitone relaxation, Lancet 2, 877. STOVNER J. and ENDORESEN R. (1965) Diazepam in intravenous anaesthesia, Lancet 2, 1298. TOTEM C. E. (1970) Diazepam injectable as premedication for electrical cardioversion, Can. Ned. Ass. J. 103, 1381-1382. WISE C. C., ROBINSON J. S., HEALTH M. J. and TOMLIN P. J. (1969) Physiological responses to intermittent Methohexitone for conservative dentistry, Br. Med, Z 2, 540-543. WOLPE J. (1969) The Practice of Behavior Therapy, Pergamon Press, New York. YEUNG D. P. H. (1968) Diazepam for treatment of phobias, Lancet 1, 475-476. YORKSTONN. J., SERGEANTH. G. S. and RACHMANS. (1968) Methohexitone relaxation for desensitizing agoraphobic patients, Lancet 2, 651-653.
(First received 23 August 1971 ; in revised form 30 October 1971)
INTRAVENOUS DIAZEPAM FOR FACILITATING RELAXATION FOR DESENSITIZATION J. C. PECKNOLD, J. RAEBURN a n d E. G . POSER*
Behavior Therapy Unit, Douglas Hospital, Montreal Summary--Intravenous diazepam was found to be a safe, convenient agent for producing relaxation in two subjects unable to relax themselves. It was used for desensitization in two subjects and made it possible for self-relaxation to be induced subsequently. INDICATIONS for the use of drugs in behavior
therapy have been well reviewed by Silverstone (1970) who concludes that intravenous preparations can be of considerable value in the treatment of phobias and other situational anxieties. The theoretical rationale for the use of depressant drugs in conjunction with desensitization is to produce a central lowering of arousal to enhance performance (Malmo, 1966). Traditionally methohexital has been used in relaxation (Friedman and Silverstone, 1967) and more recently propanidid. The general procedure with methohexital has been to give increasing doses intravenously during the desensitization session; and while good results have been reported by several authors (Friedman and Silverstone, 1967, 1968; Skoblo, 1968) others (Yorkston et aL, 1968) have obtained indifferent results as well as complications with larger doses--impaired memory, distorted time sense, exercise intolerance, drowsiness, euphoria, inappropriate behavior and barbiturate dependence (Sergeant and Yorkston, 1968). Furthermore, Wise et aL (1969) state that in conservative dentistry, with a mean dosage of 460 mg of methohexital for a mean duration of 74 min, there has been a clinically undetectable respiratory obstruction, depression of the laryngeal reflex, and arterial hypoxemia. A further study (Allen et aL, 1970) notes that in general anaesthesia by means of methohexital
there was a depression of peripheral resistance with a fall in the mean arterial pressure. Another study (Lader and Mathews, 1970) notes a dose-dependent tachycardia when methohexital was used. Young (1968) obtained good results in the treatment of a subway phobia and of snake phobias with a single large intravenous dose of diazepam. Its most readily observable pharmacological property is the production of muscle relaxation. According to pharmacological experiments (Parkes, 1968) it seems that the drug reduces the hippocampal response to stimulation of the amygdala and thereby breaks the patterns of neuronal activity which cause anxiety. Stovner and Endoresen (1965) compared the intravenous effects of diazepam with those of shorter acting barbiturates, and found that less respiratory and circulatory depression was produced by the former. This was confirmed by Hellewell (1968). Intravenous diazepam has also been found, in electrical cardio-version, to be safer and less productive of cardiac arrthythmia than barbiturate anaesthetics (Totem 1970). We shall describe the use of intravenous diazepam as a desensitizing agent in two cases. Our decision to use intravenous diazepam in small dosages was determined by the above findings as well as by the fact that both patients came into hospital because of barbiturate drug
*Requests for reprints should be addressed to Ernest G. Poser, Director, Behavior Therapy Unit, Douglas Hospital, 6875LaSalle Blvd., Montreal 204, Quebec. 39
40
J . C . PECKNOLD, J. RAEBURN and E. G. POSER
dependence, one (Case 1) having had severe reactions on withdrawal from barbiturates, the other (Case 2) a seizure when barbiturates were withdrawn too quickly. Neither patient had been able to relax sufficiently through relaxation training according to the Jacobson method. Case I
A 25-year-old single man gave a history of panic attacks and barbiturate dependence of 4 years" standing. When he was admitted, he was anxious, unable to move outside the unit, crying and constantly voicing fears of losing control. A few months earlier he had re~ived behavior therapy at another hospital with poor response. He was discharged on a massive dose of medication (including barbiturates). Once rehospitalized, his medication was withdrawn and a toxic psychosis due to barbiturate withdrawal occurred. Subsequently, he was transferred to the Behavior Therapy Unit, and maintained on Nozinan 50 mg/day.* We started relaxation training by the usual modified Jacobson method (Wolpe, 1969). After 15 sessions the response was inadequate; the patient became further demoralized and we decided to use intravenous diazepam to assist relaxation. At the first session, we administered a 5 mg dose. Verbal relaxation instructions were also given, and a profound degree of relaxation was obtained in about 15 min. This permitted the presentation of items from a desensitization hierarchy which concerned "loss of control". (Sample item: "Not being able to follow my treatment programme.") Four similar intravenous diazepam relaxation and desensitization sessions followed, the diazepam being reduced by approximately 1 rag/day. The same degree of profound relaxation was maintained during the sixth session, when no intravenous diazepam was given. Another 2 mg of diazepam were given in the seventh session. Thereafter, for the 14 sessions required to complete the desensitization hierarchy, no further diazepam was used, relaxation remained good, and the patient's
fears of loss of control were eliminated. The diazepam series was the turning point in the patient's treatment, and he is now in the process of rehabilitation. Case 2
A 36-year-old single woman gave a 10-year history of barbiturate addiction and multiple phobias. Before admission, she had been immobilized in her home for several months. Her heavy intake of barbiturates required a withdrawal period of 4 weeks after her entry into the Unit. During this period verbal relaxation training was started to provide a substitute for the drugs, but as she was too anxious for the relaxation to take effect, we introduced diazepam-assisted relaxation training, Six consecutive sessions of intravenous diazepam plus verbal relaxation instructions were given, with doses of diazepam decreasing to zero. No desensitization hierarchy was presented at this time. Total barbiturate withdrawal coincided with the fourth session. After the diazepam series, two further sessions of verbally induced relaxation were given with excellent results. Desensitization was begun in the ninth session, and proceeded to a successful conclusion. Aversion therapy to barbiturates is still continuing with this patient. With both Case 1 and Case 2, no undue side-effects of diazepam were noted beyond a burning sensation at the time and site of injection. There was no drowsiness following the sessions and the patients were fully mobile after treatment.
DISCUSSION The significant aspect of this approach is the use of intravenous diazepam as an adjunct to, rather than as a substitute for, the wellestablished procedure of systematic desensitization. In view of the findings by Sergeant and Yorkston (1968) that barbiturate dependence
*Most patients in the Behavior Therapy Unit have no medication. However, there was a suspicion of late schizophrenia in this case.
INTRAVENOUS DIAZEPAM FOR FACILITATING RELAXATION FOR DESENSITIZATION
follows on prolonged methohexital desensitization, there may be objections to the use of diazepam. We found no evident craving in our two barbiturate dependent patients, partly because of the discomfort of receiving the intravenous needle; however, the satisfactory degree of relaxation obtained after this series rendered further diazepam unnecessary. As for the safety and convenience of intravenous diazepam in a dose range of 5-7 mg or less, there was no evidence of drug toxicity during or after these interventions. After the treatment sessions, the patients were fully mobile. Furthermore, there was no evidence of drug accumulation during daily intravenous diazepam administrations. For extremely anxious patients intravenous diazepam gives some indication of what relaxation is like. With our first patient, the initial attempts at relaxation by verbal means often brought complaints of "loss of control"; but with diazepam these feelings ceased. The patient acquired greater confidence in himself regarding relaxation.
REFERENCES ALLEN G. D., EVERETTG. B. and KENNEDYW. J., Jr. (1970) Cardio respiratory effect of general anaesthesia on out-patients, J. oral Surg. 28, 814-817.
41
DAVIDSONG. C. and VALINSS. (1968) On self-produced and drug produced relaxation, Behav. Res. & Therapy 6, 401--402. FRIEDMAN D. and SILVERSTONEJ. F. (1968) Methohexitone relaxation, Lancet 2, 833. FRIEDMAN D. and SILVERSTONEJ. F. (1967) Treatment of phobic patients by systematic desensitization, Lancet 1, 470-472. HELLEWELL J. (1968) Diazepam in Anaesthesia, Proceedings, Royal Society of Medicine (Edited by KNIGHT S. and BURGESS C. G.), pp. 47-51, John Wright & Sons, Bristol, LADER M. H. and MATHEWSA. M. (.1970) Comparison of methods of relaxation using psychological measures, Behav. Res. & Therapy 8, 331-337. MALMO R. B. (1966) Studies of Anxiety: Some clinical origins of the activation concept, Anxiety and Behavior (Edited by SPIELBERGERC. D.), Academic Press, New York. PARKES i . W. (1968) Diazepara in Anaesthesia, Proceedings, Royal Society of Medicine. (Edited by KNIGHT S. and BURGESS C. G.), pp. 1-7, John Wright and Sons, Bristol. SERGEANTH. G. S. and YORKSa~ONN. J. (1968) Some complications of using Methohexitone to relax anxious patients, Lancet 2, 653---656. SILVERSTONET. F. (1970) The use of drugs in behavior therapy, Behav. Therapy 1, 485-497. SKOBLO M. (1968) Methohexitone relaxation, Lancet 2, 877. STOVNER J. and ENDORESEN R. (1965) Diazepam in intravenous anaesthesia, Lancet 2, 1298. TOTEM C. E. (1970) Diazepam injectable as premedication for electrical cardioversion, Can. Ned. Ass. J. 103, 1381-1382. WISE C. C., ROBINSON J. S., HEALTH M. J. and TOMLIN P. J. (1969) Physiological responses to intermittent Methohexitone for conservative dentistry, Br. Med, Z 2, 540-543. WOLPE J. (1969) The Practice of Behavior Therapy, Pergamon Press, New York. YEUNG D. P. H. (1968) Diazepam for treatment of phobias, Lancet 1, 475-476. YORKSTONN. J., SERGEANTH. G. S. and RACHMANS. (1968) Methohexitone relaxation for desensitizing agoraphobic patients, Lancet 2, 651-653.
(First received 23 August 1971 ; in revised form 30 October 1971)