CLINICAL HANDBOOK OF SCHIZOPHRENIA

190 III. SOMATIC TREATMENTdemonstrated specific effects of benzodiazepines on psychotic symptoms; the other halffared no better than placebo.Although monotherapy with benzodiazepines in schizophrenia cannot be recommendedon the basis of the available literature, benzodiazepines are commonly usedalong with antipsychotics in the management of acutely agitated patients with psychosis.In a review of randomized, double-blind studies using benzodiazepines as adjunctive therapy,Wolkowitz and Pickar (1991) concluded that benzodiazepines may have some positiveeffects in improving the response to antipsychotic medications; however, other literaturesuggests that this response may not be maintained beyond the acute phase of theillness. Nevertheless, it is our opinion that short-term use of oral or intramuscularbenzodiazepines is often a safer alternative for treatment of agitation in acute schizophreniathan increasing the dose of antipsychotic.One area in which the data appear to be more consistent concerns the use ofbenzodiazepines in catatonia. A review of the international literature by Pommepuy andJanuel (2002) concluded that lorazepam is safe and 80% effective in the treatment ofcatatonia. The APA Guidelines for the Treatment of Schizophrenia (www.psych.org) reportthat most studies use lorazepam at doses of 1–2 mg intravenously or 2–4 mg bymouth, repeated as needed over 48–72 hours, after which treatment can progressively bereduced. Clonazepam, oxazepam, and diazepam have also been used successfully in thetreatment of catatonia.Finally, although benzodiazepines are frequently used in the treatment of anxiety disordersthat co-occur with schizophrenia, there are only case reports and case series reportingthe use of benzodiazepines (e.g., alprazolam and diazepam) in panic disorder andother anxiety states in schizophrenia. There are no randomized, placebo-controlled studies;thus, no evidence-based rationale supports or refutes their use in anxiety disordersand schizophrenia.Although benzodiazepines may produce some beneficial effects in the acute phase ofschizophrenia, both in helping to control agitation and in treating catatonia, they may notbe ideal drugs in the long-term treatment of this illness because of their significant side effectprofile. Benzodiazepines contribute to sedation and to the development of tolerance aftereven a brief period of treatment. Ataxia, sedation, dysarthria, nausea, vomiting, confusion,excitation, disinhibition, and/or assaultiveness have all been reported. Furthermore, withdrawalfrom benzodiazepines may include psychosis and seizures. Thus, although benzodiazepinesmay benefit some patients, they may be counterproductive in others.SummaryIn summarizing these results, there appears to be no evidence-based rationale for the useof benzodiazepine monotherapy in the treatment of schizophrenia. The adjunctive use ofbenzodiazepines with antipsychotics is often helpful for the short-term treatment of agitationand anxiety during the acute phase of the illness. Benzodiazepine augmentation maybe particularly useful when patients are receiving antipsychotics that do not have intrinsicsedating properties, such as risperidone, ziprasidone, or aripiprazole. Moreover, theseagents should be withdrawn as agitation diminishes. Although no data compare the differentbenzodiazepines to one another, we recommend use of the high-potency benzodiazepines,such as lorazepam and clonazepam. Benzodiazepines such as lorazepam dohave a role in the treatment of catatonia, in which they may produce rapid, dramatic, andsustained improvement. However, the adverse effects of benzodiazepines, such as sedation,tolerance, and potential withdrawal effects, limit their utility in the long-term treatmentof schizophrenia.