Can Mindful Breathing Help With Benzodiazepine Withdrawal During a Slow Taper?

Why does anxiety surge during a benzodiazepine taper?

Benzodiazepines such as Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), and Valium (diazepam) strengthen the calming signal of gamma-aminobutyric acid (GABA) in the brain. With steady use, the brain adapts to that borrowed calm and turns its own down to compensate. The drug then does less, which is tolerance, and the nervous system runs hot whenever the drug level falls.

That happens between doses, especially with short-acting drugs, where the Ashton Manual in Chapter II describes a mini-withdrawal that many people feel before the next tablet is due. It happens once tolerance has set in, when withdrawal symptoms appear even though the dose has not changed. And, it happens after each dose reduction during a taper, until the brain catches up with the new level.

None of this is addiction. A person who took a prescribed medication as directed and now depends on it has a medical condition, and dependence is not addiction. The United States Food and Drug Administration (FDA) drew the same line in its 2020 boxed-warning update, which treats physical dependence as its own risk and says it can occur after steady use for several days to weeks, even as prescribed.

The same update warns that stopping abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures. A seizure is a medical emergency, and the right response is to call 911. So, the question for a patient in a gradual taper is not whether to keep going, but what to do in the hours when the surge arrives.

Slow breathing supports the taper. It never replaces it.

Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, treats breathing as a support for the taper and never as a substitute for it. Nothing in this article shortens a taper or justifies cutting a dose sooner.

The stress response in withdrawal is a bit like a smoke alarm that keeps ringing after the toast is out of the toaster. While this is not a perfect analogy, it shows what slow breathing can and cannot do. It does not switch the alarm off, but it turns the volume down enough to think.

Professor C. Heather Ashton wrote in Chapter II of the Ashton Manual that techniques such as acupuncture and yoga probably act only as an aid to relaxation. That modest claim fits breathing too. An aid to relaxation is worth a great deal at three in the morning.

Yet, breathing must never become a test of whether a person can handle a faster taper. If a dose cut brings symptoms that no amount of slow breathing settles, the doctor must advise a hold or a smaller step. Returning to the previous dose for a while is stabilizing, not failing.

How do you breathe from the diaphragm?

People who are anxious tend to breathe fast and high in the chest, and the Ashton Manual notes in Chapter III that many people with anxiety hyperventilate. Panic in withdrawal often starts there, and the Manual’s advice for a panic attack is slower, deeper breaths that reach the bottom of the lungs instead of just the top of the chest.

Sit or lie down and put one hand on the chest and the other on the belly. Breathe in slowly through the nose so that the lower hand rises while the upper hand stays nearly still. Then let the breath out slowly, longer than the breath in, and let the belly fall on its own.

While it feels awkward at first, a few minutes at a time is enough. Two mistakes undo it: chest breathing, where the shoulders climb and the belly never moves, and holding the breath, which adds tension instead of releasing it. Keep the air moving.

What about 4-7-8 breathing and a paced count?

Counting steadies the mind for some people. The 4-7-8 pattern is one version: breathe in through the nose for a count of four, hold for a count of seven, and breathe out slowly through the mouth for a count of eight. In fact, the long exhale is the point, and four rounds is plenty to start.

A paced count with equal parts is another: in for four, hold for four, out for four, and rest for four before the next breath, lengthening the counts as they become comfortable. It is silent, and nobody in a waiting room will notice. Of course, anyone who feels light-headed with either pattern should drop the holds and go back to slow belly breathing.

When during a taper do these techniques help most?

Three moments come up again and again. The first is before bed, when insomnia and a racing mind are at their worst and a few minutes of slow breathing in the dark can tip the balance toward sleep. Fortunately, the Manual is reassuring on this in Chapter III: the need for sleep is so powerful that normal sleep eventually reasserts itself.

The second is the interdose peak. A person on a short-acting benzodiazepine can often name the hour when symptoms climb. Slow breathing in that window does not replace the next dose or move it earlier, but it makes the wait more bearable.

The third is the day of a dose reduction and the days after it, when patients often describe a wave of anxiety that peaks and then eases as the brain catches up. Breathing through the wave is the skill. Deciding that the wave means the taper is wrong is a conversation for the doctor.

Progressive muscle relaxation adds a second tool.

Benzodiazepines relax muscles, and the Ashton Manual notes in Chapter III that stopping them after long-term use brings a rebound increase in muscle tension. Progressive muscle relaxation works on that tension directly, one muscle group at a time, and pairs naturally with slow breathing.

Lying down, tense the hands into fists for a few seconds, then let them go and notice the difference. Move on to the arms, shoulders, face, belly, thighs, calves, and feet, tensing each group gently and then releasing it, breathing slowly the whole time. Never strain, and skip anything that hurts, because the tension is a cue and not a workout.

Faith, meditation, and company matter too.

A months-long taper is easier when a person is not carrying it alone. For patients whose faith matters to them, prayer is a calming practice in its own right, and a faith community offers practical help: a ride to an appointment, a meal on a bad week, someone to sit with. Meditation does the same quiet work for those who do not pray.

The Ashton Manual, in Chapter II, puts support from a spouse, partner, family, or close friend near the center of a successful withdrawal, and adds that it is encouraging to find that you are not alone. Support-group programs are not medical care, and no one needs a program to have the company of people who understand.

Withdrawal can also bring despair, and some people have thoughts of suicide during the hardest waves. Those thoughts are serious, and they deserve an immediate response, not silence. The 988 Suicide and Crisis Lifeline answers calls and texts at any hour, and 911 is the number for any medical emergency.

Making, writing, and moving give the months a shape.

A taper is measured in months, and a person needs something to point to besides a dose. Drawing, playing music, writing, gardening, or walking a little farther each week gives the time a structure and a record of progress that a symptom diary never will.

Dr. Leeds coaches patients, many of them intelligent and creative people, to reconnect with the activities that once meant something to them, as part of care rather than as a distraction from it. Getting a hand back on the guitar is not a treatment. It is evidence of healing that a person can hold.

How does Dr. Leeds’ practice fit these tools into a taper?

Dr. Leeds’ practice offers one service: medically supervised benzodiazepine and z-drug tapering, for patients in Florida, on a concierge basis. He also helps patients taper other psychiatric medications.

The taper is gradual, patient-directed, and adjusted to the person, over months and sometimes longer. Where it helps, Dr. Leeds uses the Ashton Manual’s crossover taper to diazepam, so that a short-acting drug with sharp interdose peaks gives way to a long-acting one with smoother levels. The reductions follow the hyperbolic shape in the Maudsley Deprescribing Guidelines: smaller steps as the dose falls, and a hold after each one until the person feels steady.

Abrupt stopping is never recommended. While the Ashton Manual allows one exception to slow reduction, for the very short-acting sleeping drug triazolam (Halcion), Dr. Leeds prefers a gradual taper there too, in line with the FDA’s 2020 warning against stopping abruptly. Informed consent comes first: the risks laid out plainly, the alternatives including not tapering yet, an exit plan from the start, and the patient’s right to decline or pause at any point.

The pace belongs to the patient. If the taper is too fast, the doctor must advise a slower one, and if it is too slow, doctor and patient may agree to go a bit faster, as tolerated.

Slow breathing will not carry anyone off a benzodiazepine. A careful, supervised taper can, and that is what Dr. Leeds’ practice is for. Patients in Florida who want one physician to plan and supervise a gradual taper can Contact Dr. Leeds.

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.