Long-term outcome after discontinuation of benzodiazepines for insomnia: a survival analysis of relapse

Discontinuation of benzodiazepine (BZD) treatment for insomnia can be a difficult task. Cognitive-behavior therapy (CBT) for insomnia, combined with a supervised medication taper, can facilitate withdrawal but there is limited evidence on long-term outcome after discontinuation. The objective of this study was to examine medication-free survival time and predictors of relapse (i.e., resumed BZD hypnotics) over a 2-year period in 47 older adults (mean age 62.1 years) with persistent insomnia and prolonged BZD use (average duration of 18.9 years), who had successfully discontinued BZD following CBT for insomnia, a supervised medication taper program, or a combined approach. The Kaplan-Meier product-limit method was used to estimate survival time, defined as time between end-of-treatment and relapse or end of follow-up. By the end of the 24-month follow-up, 42.6% of the samples had resumed BZD use. Participants in the Combined (33.3%) and Taper (30.8%) groups relapsed significantly less than their counterparts from the CBT group (69.2%). Survival rates at 3 months were 61.5% (CBT), 100% (Taper), and 80.9% (Combined). At 12 months, they were 38.5%, 83.3%, and 70.8%, respectively; and, at 24 months, they were 28.9%, 64.8% and 64.9%, respectively. Mean survival time was significantly longer for both the Taper (18.6 months, SE = 2.1) and Combined groups (12.6 months, SE = 1.4), relative to the CBT group (8.5 months, SE = 1.8). Significant predictors of relapse included treatment condition, end of treatment insomnia severity, and psychological distress. In conclusion, there is a substantial relapse rate following BZD discontinuation among prolonged users. CBT booster sessions might enhance compliance with CBT and prove useful in preventing relapse.     

Who Fights,Who Flees? An Integration of the LC4MP and Psychological Reactance Theory

ABSTRACT

This study tests the hypothesis that defensive message processing, like defensive behaviors in the real world, has two directions, fight-and-flight. The Limited Capacity Model of Motivated Mediated Message Processing (LC4MP) characterizes defensive message processing by increases in unpleasantness and arousal reports, and accelerated heart rate indicating either a focus on internal processing (internal thoughts) or the active withdrawal of cognitive resources from processing highly arousing and unpleasant media messages. However, the LC4MP has not included direct measures that allow discrimination between fight-and-flight responses. Psychological reactance theory (PRT) predicts defensive responses including anger and counterarguments (reactance) when media messages threaten viewers’ freedom and autonomy. We hypothesized that PRT provides the LC4MP with the appropriate measures (anger and counterarguments) needed to discriminate fight-or-flight responses. Results supported this prediction. Participants (N = 49 adult-smokers) high in defensive and low in appetitive reactivity (risk-avoiders) withdrew from the message (fled: characterized by low anger and counterarguments) while those high in appetitive and low in defensive reactivity (risk-takers) experienced reactance (fought: characterized by high anger and counterarguments) in response to freedom threatening antitobacco messages that are highly arousing and unpleasant. Moreover, both reactance and message withdrawal yielded the same cognitive, emotional, and physiological responses predicted by the LC4MP as indicators of defensive message processing. Theoretical and message design recommendations are discussed.     

A Psychoanalytic Reader’s Commentary: On Erasure and Negation as a Barrier to the Future

This paper is a psychoanalytically informed critical race theoretical commentary on Daniel Gaztambide’s paper, “A Preferential Option for the Repressed: Psychoanalysis Through the Eyes of Liberation Theology,” which received the 2014 Multiculturalism and Psychoanalysis Award by the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis’ Committee on Ethnicity, Race, Culture, Class & Language. This discussion is an attempt to utilize psychoanalytic and literary techniques to explore some of the ways psychoanalysis continues to inscribe cultural practices and normative thinking that foreclose opportunities to expand its margins to be more inclusive. I selected one sentence and used it to suggest how it affected this Black American reader who is also a psychoanalyst.