Does Brain Fog From Benzodiazepine Withdrawal Go Away, and What Helps With Memory and Concentration?

What is brain fog in benzodiazepine withdrawal, and does it go away?

Brain fog is the name patients give to thinking that has slowed down. Words go missing in the middle of a sentence, a paragraph has to be read three times, and a simple decision takes real effort. It is common during a benzodiazepine taper, it is expected, and in most cases it lifts with time.

It is also a recognized symptom. Patients are not imagining it. In Chapter III of the Ashton Manual (benzo.org.uk), Professor C. Heather Ashton wrote that poor memory and concentration are features of benzodiazepine withdrawal.

Unfortunately, the people around the patient often read the fog as something else. A family member sees carelessness, an employer sees a person who has stopped trying, and a doctor may suspect misuse of the medication.

They are mistaken. Physical dependence is not addiction. In fact, in announcing its 2020 update to the benzodiazepine boxed warning, the United States Food and Drug Administration (FDA) said that physical dependence can occur when these medications are taken steadily for several days to weeks, even as prescribed. A foggy mind during a taper is part of that dependence, not a sign of anything the patient did wrong.

Can benzodiazepine withdrawal cause memory problems?

Yes, and the usual trouble is with recent events. A conversation from the morning, an appointment, or the reason for walking into a room slips away, and a person cannot say for certain whether the last dose was taken. Older memories are usually untouched.

Concentration goes with it. Attention drifts after a few minutes, a familiar name will not come, and following a film or a conversation among several people becomes work.

Part of the explanation is the medication itself. The first chapter of the Manual describes a specific deficit in episodic memory, the remembering of recent events, in people who take a benzodiazepine. In Chapter III, Professor Ashton wrote that the poor memory and concentration of withdrawal are probably due to continued effects of the drug.

So, a patient in the middle of a taper is dealing with two things at once. The benzodiazepine still in the body dulls memory, as it did before the taper began, and the nervous system is working to rebalance with less of it. Many patients were never told, when the prescription was first written, that the medication could do this.

Why does a taper cloud thinking?

A benzodiazepine strengthens the effect of gamma-aminobutyric acid (GABA), the brain’s main calming signal. With steady use, the receptors that answer to GABA become less responsive, a change often called downregulation. When the dose comes down, the calming side is weak, and glutamate, the brain’s main excitatory signal, runs comparatively unopposed. A separate article explains what happens in the brain during benzodiazepine withdrawal in more detail.

A nervous system in that state is loud. It reacts to sound, light, stress, and its own internal signals, and it sleeps badly. Attention suffers first and memory follows, because what was never attended to is not stored.

It is like trying to read in a room where a smoke alarm is sounding. The book has not changed, and neither has the reader’s ability to read. The answer is to quiet the alarm, not to try harder at the page.

That is why the fog does not yield to effort or to a better attitude. It is not a habit of thought. It is a state of the nervous system, and it eases as that system settles.

Is the fog permanent?

In most cases it is not, although on a bad week it can feel permanent. A person who has always been sharp begins to wonder whether something in the brain has been lost for good.

In Chapter III, Professor Ashton described steady, if slow, improvement in cognitive ability after withdrawal. She wrote that there is “absolutely no evidence that benzodiazepines cause permanent damage to the brain, nervous system or body.”

Yet, the honest part is the pace. Table 3 of Chapter III lists poor memory and cognition among the protracted withdrawal symptoms, and gives the usual course as gradually receding, though it may last at least a year and occasionally several years. The first chapter adds that memory and cognition come back slowly after withdrawal, and sometimes not completely.

The FDA describes something similar. Its 2020 update names cognitive impairment among the symptoms of protracted withdrawal, which persists beyond four to six weeks after the initial withdrawal and can last from weeks to more than 12 months. When symptoms continue this way, the condition is called protracted withdrawal, or benzodiazepine-induced neurological dysfunction (BIND).

Improvement is also uneven. Professor Ashton wrote in Chapter III that withdrawal symptoms “characteristically wax and wane,” from day to day and even within a single day. Patients call the clear stretches windows and the heavy ones waves. A clear afternoon is worth noticing, because it shows the ability is still there.

Fortunately, the pace of the taper is something a patient can change.

The size and timing of each reduction decide how hard the nervous system is pushed. Fog that thickens in the days after a cut, and does not ease, is information about pacing. It is not a test of willpower.

One response is a short hold at the current dose, then a smaller next step, and the patient decides when to move again, though everybody is different and some patients do better continuing at a steady pace than waiting out a long hold. Chapter II of the Ashton Manual describes reductions of up to one tenth of the dose at each step, and it says the person tapering is usually the best judge of the pace. The Maudsley Deprescribing Guidelines describe a hyperbolic pattern, in which the reductions get smaller as the dose gets lower.

The choice of medication matters too. For people who take a potent, short-acting benzodiazepine such as alprazolam (Xanax) or lorazepam (Ativan), Chapter II advises a switch to a long-acting one such as diazepam (Valium). A steadier blood level means fewer peaks and dips between doses, and for some patients a steadier head through the day.

That crossover is not a required first step. Many patients taper the medication they already take, and the reasons for switching to diazepam before a taper depend on the drug and the person.

Of course, a slow taper does not promise a clear head. What it does is keep each change small enough for the nervous system to follow.

What helps on a foggy day?

What follows is clinical experience, and it varies from person to person. There is little formal evidence for any of it, and none of it replaces a slow taper.

First, the workload gets smaller. One task at a time works better than three, and the hardest thinking goes into the clearest part of the day, in short blocks with breaks between them. A decision that can wait for a better week is allowed to wait.

Second, memory goes onto paper. A single calendar, a planner, and phone reminders do the remembering, and keys, glasses, and medication stay in the same place every day. A pill organizer or a written dose log matters most, because a missed or doubled dose is exactly the kind of swing a taper is meant to avoid.

Third, sleep is protected where it can be. The fog is heavier after a bad night, and bad nights are themselves a withdrawal symptom. Regular hours help some patients, and a separate article explains why insomnia gets worse during a taper.

A walk, regular meals, and enough water are reasonable general care. No food, vitamin, or supplement is proven to clear withdrawal fog, and questions about supplements are decided per patient, with a physician who understands the pharmacology.

Family members have a part as well. In Chapter III, Professor Ashton advised the people supporting a patient to be prepared to repeat their encouragement again and again, week after week, because the words are soon forgotten.

When should a patient call the prescribing physician?

A call is reasonable when the fog deepens after a reduction and does not ease, when doses are being missed or doubled, or when driving or work no longer feels safe. That conversation is about pacing, and it does not need to wait for the next scheduled visit.

However, a benzodiazepine should never be stopped suddenly because the fog has become unbearable. In its 2020 update, the FDA warned that stopping abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures, which can be life-threatening.

Some symptoms are not fog, and they should not be put down to withdrawal. Sudden confusion about the date or the place, trouble speaking, weakness on one side of the body, a severe headache that arrives all at once, or fainting needs immediate care. Call emergency services for a seizure or any other medical emergency.

Still, memory trouble that only gets worse, month after month, with no clear days, deserves an ordinary medical evaluation. Other conditions and other medications can cloud thinking, and being on a taper does not rule them out.

A slow, supervised taper leaves room for the foggy days.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. He is one physician who works directly with each patient, and his practice focuses on medically supervised benzodiazepine and z-drug tapering for patients in Florida.

Each taper is gradual and directed by the patient. The crossover to diazepam is used where it helps, reductions get smaller as the dose gets lower, and a hold is available whenever thinking and memory show that the pace is too fast.

With time, and a taper the nervous system can follow, thinking clears for most patients. Dr. Leeds’ practice is built around that slow process and does not hurry it. Contact the office to ask about a supervised taper.

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.