Response to Granoff

Abstract

Back to table of contents Previous article Next article Communications and UpdatesFull AccessResponse to GranoffBarbara Olasov Rothbaum, Ph.D., A.B.P.P. Kerry Ressler, M.D., Ph.D.Barbara Olasov RothbaumSearch for more papers by this author, Ph.D., A.B.P.P. Kerry ResslerSearch for more papers by this author, M.D., Ph.D.Published Online:1 Nov 2014https://doi.org/10.1176/appi.ajp.2014.14070821rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Dr. Granoff comments on the benzodiazepine arm of our study in which Afghanistan and Iraq veterans with posttraumatic stress disorder (PTSD) received six sessions total, with five sessions of virtual reality exposure therapy combined with 0.25 mg of alprazolam or 50 mg of d-cycloserine or pill placebo administered 30 minutes prior to the virtual reality sessions. We agree with Dr. Granoff’s first comment that the dose of alprazolam at 0.25 mg is generally subtherapeutic. However, we would point out that this can be an effective dose for some people with anxiety, so it is not entirely a subclinical dose. With that said, we did purposefully choose a low dose of alprazolam in an attempt to not break the blind. d-Cycloserine is virtually undetectable when administered as used in our study (i.e., 50 mg once/week), and it was felt that even 0.50 mg of alprazolam may be noticeable by the subject and thus break the blind. Dr. Granoff’s second point, that “having participants discontinue their short-acting benzodiazepines 2 weeks before screening and discontinue their long-acting benzodiazepines 1 month before screening followed by a subtherapeutic dose of alprazolam is likely to have contributed to the lack of treatment effects in the alprazolam group,” likely had less of an impact. This is because very few subjects in the study discontinued chronic benzodiazepine use, so we do not believe that this possibility explains our data. This also addresses Dr. Granoff’s third point, that the number of patients who discontinued benzodiazepines was not reported. The fact that such a low dose of alprazolam was associated with lower efficacy of virtual reality exposure therapy we feel makes an even stronger case that benzodiazepines should be used with caution in general with patients with PTSD and certainly when patients are receiving exposure therapy. In conclusion, we agree that benzodiazepines in general can be quite useful for treatment of anxiety disorders. However, there is also the possibility, specifically with regard to extinction-based prolonged exposure therapy, that benzodiazepines may in some cases interfere with the consolidation of emotional memory during this process, as suggested in our study, and that this possibility warrants further investigation.From the Trauma and Anxiety Recovery Program, Emory University School of Medicine, Atlanta; and the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine.The authors’ disclosures accompany the original article. FiguresReferencesCited byDetailsCited byNone Volume 171Issue 11 November 01, 2014Pages 1222-1222 Metrics PDF download History Accepted 1 August 2014 Published online 1 November 2014 Published in print 1 November 2014