View the Post on the BlogKlonopin (Clonazepam) may be the most commonly used drug in chronic fatigue syndrome (ME/CFS). Dr. Cheney hailed its use, putting the drug in the 'neuroprotector' column because its ability to reduce sensory nervous overload gave the brain, he thought, a chance to rest and rejuvenate itself. Dr. Bell agreed about its value, stating "For years I have said that Clonazepam is perhaps the most useful medication in chronic fatigue syndrome".
Indeed, studies have shown that the brains of ME/CFS patients have difficulty ignoring innocuous stimuli and some researchers believe that 'central sensitization' - a kind of central nervous system hyperactivity - is present in ME/CFS.
Klonopin's effectiveness as a sleep aid and calming agent is clear but its potential negative effects have been less well-reported. The problem is that taking Klonopin over time can, like all benzodiazepines, result in tolerance (the drug is not effective at the original dose any more), dependence (inability to stop the medication without side effects) and, in rare cases, addiction. Wikipedia reports that something called 'benzodiazepine withdrawl syndrome' 0ccurs in about a third of people treated with Klonopin (clonazepam) for longer than four weeks.
Benzodiazepine withdrawal is considered more hazardous than withdrawal from opiates and benzodiazepine withdrawal syndrome can result in anxiety, irritability, insomnia, sensory disturbances, headache, nausea, thoughts of suicide, etc. and even in very rare cases, seizures. Ironically, some the symptoms of benzodiazepine tolerance such as anxiety and thoughts of suicide can lead uninformed doctors to increase a patients dose.
Dr. Cheney and Klonopin
Dr. Cheney's 2001 view of Klonopin (http://www.prohealth.com/library/showarticle.cfm?libid=8021) , well elucidated in a report from Carol Sieverling, (not reviewed by Dr. Cheney but which he accepted for publication), has dominated the ME/CFS literature on the web. (It is the first item that comes up using a Google Search for Klonopin and chronic fatigue syndrome. The Phoenix Rising page on Klonopin, which also shows up high on search results, which is partly based on that article, has presented Klonopin in an almost wholly positive light up until now.) In fact, after reading Dr. Cheney's recommendations Gabby's doctor, who had CFS, himself, used Klonopin personally with success.
In this report Dr. Cheney was leery about calling Klonopin 'habituating' or stating that it could cause 'dependence' or withdrawal symptoms. (Dependence occurs when coming off a drug results in side effects). He felt ME/CFS patients with healthy brains could easily come off the drug but stated that if their brain was still injured coming off it could cause "all hell to break loose". He didn't feel that was a sign of 'dependence' - a relatively common occurrence with long-term use of benzodiazepenes -but instead meant the patient should still be on the drug.
"When a CFIDS patient who is still experiencing the underlying mechanisms of brain injury goes off Klonopin, there is a burst of excess neural firing and cell death. That’s the havoc we hear about that is mistakenly called withdrawal."
Dr. Cheney suggested doubling the dose during severe relapses and felt the only downside of too high of a dose of Klonopin would be to impact one's in ability to function, which would be 'inconvenient' but would actually put them into a 'healing state'. According to Carol Sieverling he stated that "You may feel like a zombie, but your brain is protected and your neurons are not getting fried. "
Gabby's Experience
Gabby (Nielk on the Phoenix Rising Forums) had a different experience. She agreed to her doctor's recommendation that she up her dose (to 3 mgs/night), only to find her old symptoms worsening over time and new ones (high blood pressure) appearing. Her withdrawl from 8 years of high-dose Klonopin use ultimately landed her in a month-long stay at a detox clinic in Florida. As Klonopin slowly washed out of her system Gabby's pain, fatigue, blood pressure, mood and sleep symptoms improved.
Not a "Do Not Use Klonopin" Blog
The intent of this blog is not to have people not use Klonopin or to get off it if they are using it. Klonopin works very well for some patients; it may, in fact, be the most prescribed drug for chronic fatigue syndrome. All of our physician commentators pointed out that different patients react differenty to drugs and Dr. Klimas pointed out that low doses can have markedly different effects from high doses.
The intent is provide some balance to what up until now has been the almost universally positive information present on Phoenix Rising (and other websites) and to make patients aware of warning signs so that they can avoid Gabby's situation.
In order to provide some perspective we asked three experienced physicians (Dr's Bateman, Lapp and Klimas) to comment on her story. A general theme emerged from their comments….all use the drug conservatively and warned about long-term use. Several noted that Gabby's higher than normal dose, and her very negative reaction were not typical.
GABBY'S STORY: KLONOPIN USE AND WITHDRAWAL
Klonopin is an anti-seizure medication that is in the Benzodiazepine family of drugs. In addition, its uses include a mood stabilizer, a tranquilizer and a sleep medication.
Patients who suffer from ME/CFS are often prescribed Klonopin to help with their insomnia and with their “neurological wired symptoms”.
Klonopin: How it works
Klonopin is a central nervous system (cns) depressant. It enhances GABA which is a neurotransmitter in the brain and tells neurons to slow down or stop firing. As a consequence, the brain’s output of excitatory neurotransmitters, including norepinephrine, serotonin, acetyl choline and dopamine, is reduced. These neurotransmitters are necessary for normal alertness, memory, muscle tone and co-ordination, emotional responses, endocrine gland secretion, heart rate and blood pressure control.
Klonopin comes with a warning to be used only as a short term treatment. Long term treatment may cause dependency and tolerance for its users. In fact, researching this drug, I found out that a third of the people taking it long term – meaning six weeks or longer, become dependent/tolerant to it. After 6 months of use this number jumps to 50% of users.
Klonopin, as well as all Benzodiazepine drugs have a very difficult and dangerous withdrawal course.
My story of Klonopin use as an ME/CFS patient:
I have been ill with ME for the past 10 years. Gradually, my symptoms worsened and I had to stop working and go on disability. I developed severe insomnia and had a sleep study taken in a hospital setting. The results of the study showed that I had many alpha wave intrusions. My doctor said that this is consistent with a CFS diagnosis which shows “neurotoxicity” of the brain. I was told that Klonopin is the most effective treatment for this and that my insomnia needed to be treated in an effectual way because sleep is the most important treatment for this illness.
I started taking Klonopin about 8 years ago. At first it was working well as far as my sleep was concerned. After a while, I became tolerant to the dose and my doctor increased it in order for it to continue working. This had to be done a number of times in order for it to remain effective.
Six years ago, I started reading about the dangers of Klonopin and Benzodiazepine drugs in general. I refused to increase my dosage which had been at the time 3 mg a night. Because I had become tolerant to the drug it was not working for me any longer. My doctor prescribed Ambien for sleep.
I was kept on my Klonopin dose of 3 mg a night because I could not reduce it in a safe way. Throughout the years I had tried at different points to slowly taper off with no success.
My problem with Klonopin Use
This past year has been my worst year yet as far as my ME/CFS is concerned. I had spent most of my year bed bound. I was in constant chronic pain. My headaches were severe and left me non-functional. I was not sleeping well and it was rare that I could get out of the house. I became depressed about my situation.
The past few months I had a new symptom of feeling edgy and my blood pressure, which has been low all the years of my illness, had increased to a high level. I started to look into these symptoms and found that one could suffer from symptoms of withdrawal from Klonopin just by remaining on a current dosage.
By then, besides feeling very edgy, I had become depressed too. I asked my doctor to help me taper off of the Klonopin. He tried by giving me Viibrid,a new medication which is an SSRI in addition to a 5HT1A receptor partial antagonist. He said that I need to build up my dosage of Viibryd in order to have a “safe” taper of the Klonopin. This didn’t work for me at all. I had a bad reaction to the Viibryd or maybe it was the combination of the Viibryd and Klonopin. I fell into a very dark, deep depression where I became suicidal. This feeling continued even though I had discontinued the Viibryd.
Another doctor tried to help me by prescribing Valium in order to help me withdraw from the Klonopin which backfired on me too. I had a paradox reaction to the Valium. In lieu of calming me, it increased my anxiety. I had to discontinue its use.
At this point, I felt totally stuck. I was suicidal. I knew that it was caused by the Klonopin but, even great doctors could not help me withdraw from Klonopin.
I now know that I was not alone in this position of no return with Klonopin. There are other patients suffering from ME/CFS who have been on long term Klonopin and found themselves in this same corner and ended their lives! This is not a subject to be taken lightly.
My recovery from Klonopin Use
I was fortunate that, with the grace of God, I was given a name of a doctor who specialized in addiction.
My family flew me down to Florida to meet him and he right away put me in a medical detox/rehab facility. I stayed there as an inpatient for 31 days. The first two weeks were sheer torture. They took away my Klonopin and Ambien the first day and substituted it with the medication Tranxene which is an older medication with a longer half life.
My health and blood pressure had to be monitored very closely. I learned there that high blood pressure is a landmark withdrawal symptom of Benzodiazapine withdrawal. I remembered that the past few months I had been suffering from high blood pressure which meant that as I thought, I had been in a state of Klonopin withdrawal all this time.
The detox/rehab facility did a great job monitoring me closely and administrating blood pressure reducing medications as needed. I needed another two weeks for rehabilitation.
Today, two weeks out of the facility, I feel like I have been given a second chance in life. I feel so much better. The only medication I am on is Trileptal which has no danger of becoming addictive. Even though I still suffer from some withdrawal symptoms which might continue for another six months to two years, I feel like a new person. I am not bed bound and my constant pain has been alleviated.
My ongoing withdrawal symptoms from KlonopinThe withdrawal symptoms still persisting include; sweating, nausea, agitation, lack of concentration, sensitivity to sound and touch, pins and needles and numbness.
These will hopefully diminish as time goes on.
Most people will not need such a “fast detox” like I went through. The slower one can taper off these Benzodiazepine medications, the safer it is. I did not have the “luxury” of time at hand. I was on a fast course to death and needed a quick fix to save my life.
I feel compelled to “tell my story” in order to help others and warn them of the very real possible dangers of starting on the road of Klonopin consumption.
I wish someone had warned me before I took my first dose of this dangerous drug.
Used or using Klonopin or other benzodiazepines? Let us know how you did. Please take the Phoenix Rising Klonopin/Benzodiazepine Survey here
Dr. Klimas' Comments
It is a compelling story. I would think it's well worth publishing, with the comments that note that her dosage was significantly higher than typical dosing and that her story demonstrates something often seen in medicine , that drugs at a low dose can have a completely different and sometimes opposite effect that the same drug binding to the same receptor at a high concentration. The biology has to do with low affinity and high affinity receptor binding - much like the low dose naltrexone vs high dose naltrexone having quite different biologic effects.
Of course at the high dosing you also run the risk of a host of other toxic side effects, and with the valium derivatives increased fatigue, less restorative sleep and slower cognition. I won't say I don't prescribe them, but I try not to, and always at the lowest possible dose.
The other take home point here is the utility of a detox unit to get a patient with a long and potentially dangerous drug list down to a simpler regimen, allows one to see how many of the symptoms are an accumulation of side effects, and what is the baseline illness. It can be life saving in the case of patients with severe depression side effects to regimens that are meant to help, but are in fact doing harm.
And finally, its important to understand that every individual metabolizes and responds to medications differently, and the clinician needs to know if unexpected things are happening, None of us want to do harm, but trying to help often involves trying a number of different approaches, one at a time to see if it is safe and has some effectiveness.
Dr. Bateman's Comments
Clonazepam is definitely a "double edged sword". It calms the central nervous system (CNS) but has habituating properties. Because people with CFS may have central sensitivity, reducing the dose (once habituated) can be very difficult, causing markedly amplified withdrawal symptoms. I also think most don't realize that the long half life of this drug causes pervasive effects on daytime fatigue, cognition and sometimes mood. For this reason I prescribe it sparingly and generally don't exceed 1 mg at bed.
Clonazepam, like any other drug, it neither Evil nor Good. One must simply learn about how the drug works and use it with expert guidance.
It's also good to remember that for every drug there is a range of response. For one it may be a great solution and for someone else a disaster.
Dr. Lapp's Comments
The story is worth printing because it points out the problems of using Klonopin (or benzodiazepines) for long periods of time.
There are a couple points to make:
1. It was an ominous sign when tolerance developed, and it would have been prudent to taper off Klonopin at that time.
2. I generally do not recommend night-time doses of Klonopin greater than 2mg, because too high a dose of Klonopin can actually interfere with sleep rather than help.
3. Please recognize that this patient was atypical in her response to medications such as Viibryd and diazepam. Most patients can be withdrawn from Klonopin without such difficulty.
4. The use of Tranxene is the accepted method of withdrawal. Please note that Tranxene is SHORT acting. Thus a short-acting drug is substituted for a long acting one, and then the Tranxene must be withdrawn.
If you decide to publish this story, please make it clear that some individuals MAY have such difficulty withdrawing from benzodiazepines, but she had unique issues.
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The Best Drug for ME/CFS? The Other Side of Klonopin: A Patient's Story and A Survey
- Thread starter Phoenix Rising Team
- Start date
There are so few drugs/therapies I've tried that have helped and Klonopin helped a LOT. Obviously, after reading this thread, I'm tapering off. And I wonder how many forum members/readers were scared into stopping cold turkey which sounds like it can be truly dangerous.
Benzos have been around a long time and we know a lot about them. My doctor has trialed me on many of the SSRIs and newer classes of drugs that are supposed to help with sleep, pain, etc. They are horrible for me. No benefits and dreadful side effects.
It's really painful to see this article and Gabby's story giving more doctors an excuse just to not prescribe drugs that are working for some of us. I read a story about one patient here who takes morphine. If I had a prescription for morphine, I'm sure I wouldn't need benzos. But I have yet to find a doctor who will prescribe any pain meds for ME/CFS, let alone morphine. If I was getting relief from ANYWHERE else, I wouldn't be taking benzos.
Here's how it goes. Over=exertion = bad sleep = pain = more bad sleep = pain + depression = more bad sleep.
Klonopin breaks the cycle. It relaxes my muscles enough so that they don't feel like they're trying to pull themselves off the bone. The way Klonopin makes me feel, it's not hard to believe there is some protective action during the really severe times.
I will be interested to hear how the survey results turn out. And shame on any doctors who use one person's response as a blanket excuse not to prescribe this drug.
jmells, it's not hostility, it's fear. Having found something that works, I'm afraid articles like this will cause doctors to be advised not to prescribe it because of one person's rather dramatic story of a health crisis that included Klonopin.
Benzos have been around a long time and we know a lot about them. My doctor has trialed me on many of the SSRIs and newer classes of drugs that are supposed to help with sleep, pain, etc. They are horrible for me. No benefits and dreadful side effects.
It's really painful to see this article and Gabby's story giving more doctors an excuse just to not prescribe drugs that are working for some of us. I read a story about one patient here who takes morphine. If I had a prescription for morphine, I'm sure I wouldn't need benzos. But I have yet to find a doctor who will prescribe any pain meds for ME/CFS, let alone morphine. If I was getting relief from ANYWHERE else, I wouldn't be taking benzos.
Here's how it goes. Over=exertion = bad sleep = pain = more bad sleep = pain + depression = more bad sleep.
Klonopin breaks the cycle. It relaxes my muscles enough so that they don't feel like they're trying to pull themselves off the bone. The way Klonopin makes me feel, it's not hard to believe there is some protective action during the really severe times.
I will be interested to hear how the survey results turn out. And shame on any doctors who use one person's response as a blanket excuse not to prescribe this drug.
jmells, it's not hostility, it's fear. Having found something that works, I'm afraid articles like this will cause doctors to be advised not to prescribe it because of one person's rather dramatic story of a health crisis that included Klonopin.
I agree with Sushi, I no longer have a problem with CFS. There are things that have helped many people. My POTS (Autonomic Neuropathy) is even improving.
That's been my experience as well -- not being personally harrassed, because I don't post on those threads to avoid it. There are a few members who have had bad experiences with Klonopin, who are loud and vocal and assume everyone will react as they did. They shout down anyone who has benefitted. I was shocked to hear Cort say that he thought the negative aspects of the drug were underrepresented on the forum.
Just a thought for those of you in the US. TALK WITH YOUR PHARMACIST about every new prescription you're taking. They are highly knowledgeable and are most happy to share what they know. They are the true experts when it comes to drugs, how to take them and interactions, side effects and signs of dependency. They are under-utilized for this purpose.
And I think it's always a bad idea to turn over responsibility for any aspect of your life to someone else. Doctors are human beings with all of the attendant weaknesses, biases and imperfections. Not questioning them and giving them authority over your health is always a bad idea. Unfortunately, many of us don't have the ability to advocate well for ourselves. I usually need someone to go to the doctor with me because the effort of getting there usually leaves me just this side of incoherent (with or without klonopin
)
Sorry, Sallysb, I don't know what Sushi said that you're agreeing with.
I hope you will start a thread telling us how you healed.
I already have a thread about that.
Sushi said treatments have helped some.
There are some of us doing very well.
Sushi said treatments have helped some.
There are some of us doing very well.
Would you mind directing us to your thread?
It is called Sally's supplements. I have it bookmarked, but I am on my IPad right now.
Thought I'd quote that as I think that advice is so important to all.
For those who are looking for Sally's thread http://forums.phoenixrising.me/index.php?threads/sallys-supplements.13919/
Mishmash is not grasping the fact that there are treatments out there that have some efficacy, but the powerful members of society have made a decision that ME/CFS patients are not deserving of these treatments because they are too expensive and the disease is "trivial".
Fewer than 1000 patients in the world have had the opportunity to try Ampligen, which was invented in the late 1970s. I am one of the lucky few.
There are at least 800,000 debilitated by ME/CFS in the United States and as many as 17,000,000 patients worldwide. What gives?
Fewer than 1000 patients in the world have had the opportunity to try Ampligen, which was invented in the late 1970s. I am one of the lucky few.
There are at least 800,000 debilitated by ME/CFS in the United States and as many as 17,000,000 patients worldwide. What gives?
Thanks to all who have contributed their stories, good or bad, on the use of benzo's and issues on withdrawals for ME/CFS patients.
Also, thanks for the How-to's, if someone were to want to detox from benzo's for whatever reason.
Also, thanks for the How-to's, if someone were to want to detox from benzo's for whatever reason.
hi Cort,
I think you should consider doing a mini-feature about the future of social security disabililty insurance. I've heard a lot of very dire talk in the news about cutting the rapid rate of increase in awarding SSDI to disabled people. I think it urgently relates to the topic of this post.
More than 15 years ago, when I used to go to the CFS support group meetings, the most common topic of advice and discussion was the best strategy to get SSDI. The newcomers to the meetings were both married, unmarried, currrently working, unemployed, former highly successful, of routine backgrounds, recently diagnosed, and long time sufferers.
The advice most often given them was go to a particular lawyer, and expect to get rejected at least twice, sometimes three times. Then you would have a good chance. They would celebrate after getting it, and it was great cause for relief.
I wish I weren't speaking the truth, but as the next President and congress come into session, SSDI is really going to be on the chopping block. I think alot of deserving PWCs are going to find themselves in panic mode. They wil be living with family or possibly living in a van down by the river. And the rate of increase in patients, I believe, is going up. Probably for the same reasons other rheumatoid illnesses are increasing, such as MS, lupus, diabetes 1, etc.
I have ranted in probably overly strong terms about the effectiveness of Klonopin for treating the symptoms of ME/CFS in most people. When a PWC shows up at a doctor's office and is paternalistically told he can't have any narcotics or opiates, the doctor should really understand what might be at stake.
That patient is dangling over a bottomless pit. In coming years there may be NO SSDI to fall back on. This country is in debt between 16 and 50 trillion, depending on the analysis. Instead of moralizing, or cowering because of rare bad reactions, the CFS doctor community really should be looking or ways to keep that patient at least partly active and employed. Uncle Sam may not be there the way he has been in the past. Use of controversial (to say the least) drugs like Klonopin, other benzos, opiates and maybe even medical marijuana, to keep people off the government dole should be considered in coming years.
I think you should consider doing a mini-feature about the future of social security disabililty insurance. I've heard a lot of very dire talk in the news about cutting the rapid rate of increase in awarding SSDI to disabled people. I think it urgently relates to the topic of this post.
More than 15 years ago, when I used to go to the CFS support group meetings, the most common topic of advice and discussion was the best strategy to get SSDI. The newcomers to the meetings were both married, unmarried, currrently working, unemployed, former highly successful, of routine backgrounds, recently diagnosed, and long time sufferers.
The advice most often given them was go to a particular lawyer, and expect to get rejected at least twice, sometimes three times. Then you would have a good chance. They would celebrate after getting it, and it was great cause for relief.
I wish I weren't speaking the truth, but as the next President and congress come into session, SSDI is really going to be on the chopping block. I think alot of deserving PWCs are going to find themselves in panic mode. They wil be living with family or possibly living in a van down by the river. And the rate of increase in patients, I believe, is going up. Probably for the same reasons other rheumatoid illnesses are increasing, such as MS, lupus, diabetes 1, etc.
I have ranted in probably overly strong terms about the effectiveness of Klonopin for treating the symptoms of ME/CFS in most people. When a PWC shows up at a doctor's office and is paternalistically told he can't have any narcotics or opiates, the doctor should really understand what might be at stake.
That patient is dangling over a bottomless pit. In coming years there may be NO SSDI to fall back on. This country is in debt between 16 and 50 trillion, depending on the analysis. Instead of moralizing, or cowering because of rare bad reactions, the CFS doctor community really should be looking or ways to keep that patient at least partly active and employed. Uncle Sam may not be there the way he has been in the past. Use of controversial (to say the least) drugs like Klonopin, other benzos, opiates and maybe even medical marijuana, to keep people off the government dole should be considered in coming years.
I think you missed what I said. ..I did not say the negative aspects of Klonopin were under-represented on the Forum - I'm sure they are very well represented on the Forum. I said the most-visited pages that show up in search engines such as the page on Phoenix Rising (I provided the link) and the Cheney article found elsewhere o did not provide both sides of the picture.....
Maybe we can work on that together...I would need some help with that.
I agree. I really don't get how someone sharing their reality/their experience is a bad thing. I don't believe in the silencing of people because it supposedly will make such a such treatment or such and such drug look bad. People are sharing what happened to them. Others can choose to take from that what they wish and do with the info as they wish or not. People can use their own minds to decide if others' experiences apply to them or not.
Neilk, I'm glad to hear you are off the Klonopin. I remember when you were posting a bit about it and the troubles you were having. Very good news to hear this resolution.
here here.
Thank you for this fantastic blog. I couldn't have wished for more when I was googling about possible side effects of Klonopin in ME/CFS. Thank you, Cort, for the balanced view of the drug and including input from my favorite ME/CFS doctors.
I like that equation. Even though I have never been diagnosed with CFS/ME, I can relate.
However, my cause in that cycle is the Klonopin/clonazepam ! And the general bad state I´m in makes discontinuing the drug much harder, if not impossible ! But at this point, the drug has become toxic.
My personal view is that people should be allowed to take the drug. But it´s really an epilepsy drug, even though it is used off label and for other indications in some countries.
That drug is much more potent than most people are aware of, there is a lot that is not known about what it actually does. I consider this drug one of the most dangerous drugs that exist.
Unfortunately, most people are not informed of the potential risks. Of course, only a small minority has to deal with the worst of the worst.
Don't know if anyone is still monitoring or responding to this old thread. I happen to chance upon Gabby's story today at the end of 2015, when looking for Klonopin for CFS pros/cons on Google.
The thing that stands out to me about her story is that, after her 8 year Klonopin buildup and hellish coming-off, she claims that she is no longer bed-bound or in constant pain, and feels better with a new chance on life. And yet she was bed-bound and experiencing terrible symptoms BEFORE she started the Klonopin; indeed that's why it was originally prescribed. But if she could experience feeling much better and un-bed-bound without Klonopin, how come she didn't do that before starting? In other words, with the Klonopin gone, what's making her so much more symptom-free now, and whatever that "remedy" is, was it available before she started the Klonopin?
And although Klonopin can make some people feel hellish in withdrawal & after-effect, but they were feeling absolutely hellish before they started taking it and nothing else but Klonopin worked, why do so many report about the hell Klonopin puts them through when removed, as if they forgot that their pre-Klonopin hell was also total hell?
The thing that stands out to me about her story is that, after her 8 year Klonopin buildup and hellish coming-off, she claims that she is no longer bed-bound or in constant pain, and feels better with a new chance on life. And yet she was bed-bound and experiencing terrible symptoms BEFORE she started the Klonopin; indeed that's why it was originally prescribed. But if she could experience feeling much better and un-bed-bound without Klonopin, how come she didn't do that before starting? In other words, with the Klonopin gone, what's making her so much more symptom-free now, and whatever that "remedy" is, was it available before she started the Klonopin?
And although Klonopin can make some people feel hellish in withdrawal & after-effect, but they were feeling absolutely hellish before they started taking it and nothing else but Klonopin worked, why do so many report about the hell Klonopin puts them through when removed, as if they forgot that their pre-Klonopin hell was also total hell?