Benzodiazepine Tapering & Caffeine’s Role in Withdrawal-Induced Derealization

Can caffeine make derealization worse during a benzodiazepine taper?

It can, and for some patients it clearly does. Derealization is the feeling that the world has gone flat, foggy, or dreamlike, as if it were behind a pane of glass. Its companion, depersonalization, is the feeling of being detached from one’s own body, and at its worst even a spouse or a child can seem like a stranger.

Both are recognized symptoms of benzodiazepine withdrawal. Professor C. Heather Ashton listed them among the psychological symptoms in Table 1 of Chapter III of the Ashton Manual. Caffeine does not cause the withdrawal, but it is a stimulant, and it pushes on a nervous system that is already running too fast.

Yet, the answer is not to pour out the coffee tomorrow. Caffeine has a withdrawal of its own, and the Ashton Manual does not ask most patients to give it up. First, it helps to be clear about what the symptom is.

What do derealization and depersonalization feel like in withdrawal?

Patients often describe a familiar room that suddenly looks flat and artificial, or a drive home on a route they know by heart that feels foreign. Sounds seem far away. Their own hands or voice may feel as if they belong to someone else.

The feeling is common in withdrawal, and it is frightening. Many patients wonder whether they are losing their minds. They are not.

A person with derealization knows that the world has not actually changed. That intact awareness is what separates this symptom from psychosis.

Professor Ashton wrote that these states “probably represent a normal defensive reaction evolved as a protection against intolerable suffering.” She observed that they occur most often during over-rapid withdrawal from potent benzodiazepines. Her verdict was plain: “these feelings resolve in time and should not be interpreted as abnormal or crazy.”

A longer discussion of why benzodiazepine withdrawal makes a person feel unreal is available on this site. The question here is narrower. What does caffeine have to do with it?

Why is a nervous system in withdrawal so sensitive to stimulants?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming signal, at its receptors. With long-term use, those receptors adapt. The first chapter of the Ashton Manual explains that they “become less responsive,” so the same amount of GABA does less calming than it once did.

The problem in withdrawal is not that the brain has stopped making GABA. The problem is that the receptors are less sensitive to it, and each dose reduction removes some of the medication that was covering the gap. Until the receptors readjust, the excitatory side of the nervous system runs with less opposition, and the result is anxiety, insomnia, and a brain that startles easily.

Most coffee drinkers have felt a small version of this. A person who misses the usual morning cup has a headache, fatigue, and a short temper by afternoon. The body adapted to caffeine, and it objects when the caffeine is taken away.

Nobody treats that headache as a character flaw. It is physical dependence, and dependence is not addiction. The same holds for a patient whose brain adapted to a benzodiazepine taken exactly as prescribed.

How does caffeine feed derealization?

Caffeine blocks adenosine, the chemical signal that builds through the day and makes a person sleepy. It can also quicken the pulse and bring on jitters. In a nervous system that is already short on calming, a cup that used to be unremarkable can feel like far too much.

Professor Ashton noted in Chapter III that feelings of unreality also occur in anxiety states. Anything that raises anxiety or takes away sleep can therefore bring on a wave, and caffeine can do both.

Sleep is already fragile, since insomnia often gets worse during a benzodiazepine taper. Patients often describe the same sequence: an afternoon coffee, a racing heart, a poor night, and a next day in which nothing looks real.

The evidence on caffeine and derealization during a taper is limited. What is written here rests on the known effects of a stimulant and on clinical experience, which varies from person to person. Some patients drink coffee throughout a taper with no trouble at all.

Does a person tapering a benzodiazepine have to give up coffee?

Usually not. In fact, Professor Ashton addressed the question directly in Chapter III. She wrote that coffee or tea in moderation, “about two cups a day,” is “perfectly compatible with benzodiazepine withdrawal,” and that forbidding a cup at breakfast is “in general unduly restrictive.”

However, she made two exceptions. The first was for “the few individuals who are exquisitely sensitive to caffeine or those with very high anxiety levels.” The second was timing, since caffeine late in the evening works against sleep.

So, the question is individual. Caffeine is probably part of the problem when the unreal feeling arrives within an hour or two of a cup, when it clusters in the afternoon, or when the worst days follow the worst nights. It also helps to count all of it, because energy drinks, cola, pre-workout powders, chocolate, and some headache tablets contain caffeine too.

Why should caffeine be cut back slowly and not stopped all at once?

Caffeine has its own withdrawal. Stopping suddenly can bring several days of headache, fatigue, low mood, and foggy thinking. In a person who is already tapering a benzodiazepine, those symptoms are hard to tell apart from a withdrawal wave, and the taper may be blamed for what the missing coffee did.

A gradual step-down avoids that confusion. A smaller cup, a half-caffeinated blend, or an earlier cutoff in the day are all ways to come down gradually. Decaffeinated coffee still contains a little caffeine, so even the last step is a soft one.

It also helps to change one thing at a time. When caffeine and the benzodiazepine dose are both reduced in the same week, nobody can say which change caused a rough stretch. Of course, the benzodiazepine is never stopped abruptly either.

How should the two be sequenced? That is a decision for the taper planning conversation with the prescribing physician, alongside sleep, meals, and the timing of doses.

Is it safe to drive when the world feels unreal?

No. A person who feels detached, foggy, panicky, or sedated should not drive until the feeling has passed. If it comes on behind the wheel, the right move is to pull over somewhere safe and wait, or to call someone for a ride.

There is no separate condition called driving derealization. It is the same withdrawal symptom, arriving at a moment when distance, speed, and timing matter. The medication adds a risk of its own, and Professor Ashton wrote in the Manual’s first chapter that people taking benzodiazepines “should be warned of the risks of driving and of operating machinery.”

An episode on the road is also information. It should be reported to the physician supervising the taper, because it may mean that the last reduction was too large or came too soon.

What can family members do when a loved one says they feel like strangers?

The first thing is to believe it. The patient is describing a symptom, not passing judgment on the marriage or the family. The affection is still there, even when the feeling of connection has gone quiet for a while.

Arguing about what is real does not help. Neither does pressing for a faster taper so that it will all be over sooner, because over-rapid withdrawal is the setting in which Professor Ashton saw these states most often. Calm company, ordinary routines, and patience do more, and there is further reading on how benzodiazepine withdrawal affects family and friends.

How long does derealization last, and what helps it pass?

It passes, but not on a schedule. In Chapter III, Professor Ashton described withdrawal symptoms that “characteristically wax and wane,” with waves that become less severe and less frequent and “Windows” of normality that last longer as time goes on.

A good week followed by a bad one is the expected pattern. It does not mean that the taper has failed.

Unfortunately, for some patients the unreal feeling comes and goes for many months, and it can return in waves after the last dose, as other symptoms of protracted withdrawal do. No one can promise a date.

What helps is mostly a matter of pace. A hold at the current dose, or a smaller next step, gives the receptors time to catch up, and the patient decides when to move again.

The answer to a hard wave is rarely a new prescription. It is usually found in the pace of the taper.

Steady sleep hours, regular meals, and a daily routine help as well. Alcohol acts on the same receptors and works against the process, and adding other sedating medications without the tapering physician’s input only clouds the picture.

Some situations cannot wait. Anyone with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline. A seizure, a loss of contact with reality, or any other medical emergency is a reason to call 911.

A slow taper leaves room for questions like this one.

Fortunately, none of this calls for a list of forbidden foods and drinks. It calls for a gradual, patient-directed taper and a physician who treats caffeine, sleep, driving, and family life as parts of the same plan. Professor Ashton’s word on these feelings was that they resolve in time, and a slow taper is what gives the nervous system that time.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, and his practice provides medically supervised benzodiazepine and z-drug tapering for patients in Florida. In Dr. Leeds’ practice, reductions are gradual, the patient sets the pace, and a hold is always available when symptoms such as derealization flare. Contact the office to ask about a taper plan.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.