When Ativan Backfires:
Understanding Disinhibition in Teens and Older Adults
DISCLAIMER
The content in this Substack post is for informational and entertainment purposes only and is not intended to serve as medical advice. The views expressed are those of the author and should not be considered definitive or authoritative. Do not rely solely on the information in this post to guide patient care. Always consult a licensed healthcare professional before making decisions about diagnosis, treatment, or medication.
Ativan (lorazepam) is a go-to benzo in inpatient psych. It’s fast, reliable, and generally well-tolerated. Until it isn’t. Sometimes, instead of calming a patient down, it ramps them up. They become louder, more impulsive, even aggressive. It looks like they’re escalating, but the real culprit might be the medication itself.
This is disinhibition, a paradoxical response to Ativan that shows up more often than you’d think, especially in adolescents and the elderly.
What is disinhibition?
Disinhibition is when a sedative like Ativan removes too much of a patient’s natural behavioral restraint. Instead of calming them, it lowers the threshold for impulsivity, aggression, or agitation. You might see:
Verbal outbursts or inappropriate language
Increased motor activity (pacing, restlessness)
Risk-taking or unsafe behaviors
Emotional lability or irritability
In some cases, worsening aggression
Rather than knocking someone out, it unmasks or intensifies the behaviors you were trying to reduce.
Think of it like alcohol. Most people relax with a drink or two, but others get loud, impulsive, or aggressive. Same substance, different response. Ativan can have that same effect. Instead of sedation, you get behavioral unmasking. It’s not that the patient is resisting the med, it’s that the med is lowering their guard!
Who is most vulnerable?
Two groups tend to be more sensitive:
1. Older adults:
Age-related changes in the brain, especially in the frontal cortex, reduce a person’s ability to regulate behavior. Add in slower hepatic metabolism and decreased GABA receptor sensitivity, and even small doses of Ativan can cause confusion, agitation, or aggression.
2. Adolescents:
Teens with underdeveloped frontal lobes are also prone to poor impulse control. Add Ativan, and they may lose what little filter they have left. This is particularly true in teens with trauma histories, DMDD, borderline traits, or mania-spectrum disorders.
What it looks like in practice
In older adults:
You give 0.5 or 1 mg for anxiety, sleep, or restlessness. Thirty minutes later they’re pulling at their gown, yelling at staff, or trying to leave AMA. It’s often mistaken for worsening dementia or sundowning.
In teens:
You give a dose during a behavioral episode, hoping to settle them. Instead, they escalate. They’re louder, more oppositional, more unpredictable. The Ativan didn’t fail, it flipped the switch the wrong way.
Clinical pearls
Start low. Titrate slowly. Especially in vulnerable populations
Reassess behavior 30 to 90 minutes post-dose. If they’re worse, do not redose
Do not assume it’s nonresponse. If symptoms escalate after Ativan, consider disinhibition
Swap the agent. Hydroxyzine, propranolol, low-dose antipsychotics, or clonidine may be better tolerated depending on the clinical picture
Educate staff. Disinhibition is easy to miss. It’s often interpreted as med failure or worsening illness, which leads to more meds and more chaos
Final Thoughts
Disinhibition is one of those subtle clinical landmines that can derail care if you are not watching for it. Ativan is not always calming. In some patients, especially the elderly and adolescents, it can be the spark that escalates a situation instead of defusing it.
When you recognize this reaction for what it is and adjust your approach accordingly, it sets you apart as a thoughtful and clinically sound provider.