Can Benzodiazepine Withdrawal Cause Dysautonomia, and Do the Autonomic Symptoms Go Away?

Is this dysautonomia, or is it benzodiazepine withdrawal?

Dysautonomia is a general term for an autonomic nervous system that is not regulating the body’s automatic functions smoothly. A heart that races on standing, sweats that come from nowhere, a churning gut, and lightheadedness in a hot shower all fit under it. So, can tapering a benzodiazepine cause it? In the everyday sense of the word, yes.

The Ashton Manual, written by Professor C. Heather Ashton, describes the pounding heart, rapid pulse, flushing, and sweating of withdrawal in Chapter III as “simply the expression of an overactive autonomic nervous system.” They are a recognized part of benzodiazepine withdrawal. In most cases, they are a state the nervous system passes through, not a new disease that has come to stay.

Many people who search this question took their medication exactly as prescribed and were never told this could happen. The United States Food and Drug Administration (FDA) acknowledged in its 2020 boxed warning update that physical dependence can occur when a benzodiazepine is taken steadily for several days to weeks, even as prescribed.

Physical dependence is not addiction. In fact, a pounding heart after a dose reduction says nothing about a person’s character. It says that a nervous system adapted to a medication.

What does the autonomic nervous system do?

The autonomic nervous system runs the functions nobody has to think about. It sets the heart rate, adjusts blood pressure when a person stands up, opens the sweat glands, holds body temperature steady, and moves food through the gut.

Benzodiazepines reach this system indirectly. They enhance gamma-aminobutyric acid (GABA), the brain’s main calming chemical, which Professor Ashton explains in Chapter I tells the neurons it reaches to slow down or stop firing. As a consequence, she writes, the brain puts out less of its excitatory chemicals, including norepinephrine, and those chemicals are needed for heart rate and blood pressure control.

Why does a nervous system that has adapted to a benzodiazepine overshoot?

Taken daily for months, the drug becomes part of the nervous system’s settings. The Manual’s account of tolerance, in Chapter I, is that the body answers the continued presence of a drug with a series of adjustments that tend to overcome its effects.

Picture a person bracing against a steady push, leaning into it to stay upright. The benzodiazepine is the push, and the nervous system is the person leaning. If the push disappears all at once, the person lurches forward. If it eases off a little at a time, the person straightens up along with it.

Chapter III of the Manual describes the lurch. Rapid removal of the drug brings rebound overactivity in the systems the benzodiazepine had damped down, and nearly all of the excitatory mechanisms in the nervous system go into overdrive until new adaptations develop. The autonomic nervous system is one of those systems.

A smaller version can follow each step of a taper. With a short-acting drug, it can also appear between doses, before any taper has begun.

Which symptoms come from an overactive autonomic nervous system?

The heart is usually what people notice first. Chapter III names palpitations, a pounding heartbeat, and a rapid pulse, and a separate article explains why benzodiazepine withdrawal makes the heart race.

Blood pressure can run high or jump from one reading to the next. The class labeling that followed the FDA’s 2020 update lists hypertension (high blood pressure) and tachycardia (fast heart rate) among the signs of acute withdrawal. Another article asks whether a benzodiazepine taper can raise blood pressure.

Dizziness and lightheadedness appear in Table 1 of the Manual’s Chapter III, and patients often describe them as worst on standing up, which is a reason to rise slowly. Flushing and sweating share a line with palpitations in the same table. Many people describe night sweats and swings between feeling overheated and chilled, though a measured fever is a different matter and should be checked.

Professor Ashton wrote in Chapter III that digestive symptoms may be partly due to overactivity in the autonomic nervous system, which controls the motility and secretions of the gut and is very reactive to stress. Nausea, diarrhea, constipation, and the bloating that patients call benzo belly can trace back to it.

Does a pounding heart during withdrawal mean heart disease?

Usually, it does not. Palpitations, pounding heart, rapid pulse, flushing, sweating, and breathlessness, Professor Ashton wrote in Chapter III of the Ashton Manual, “do not signify heart or lung disease.” In an otherwise healthy person, the heart and blood vessels are sound. They are taking orders from an overexcited control system.

Yet, withdrawal does not protect anyone from ordinary illness, and a new symptom deserves an ordinary examination. That examination belongs to the patient’s own physician. It may include pulse and blood pressure taken lying down and standing, a review of every other medication, and an electrocardiogram (ECG) when the history calls for one.

Symptoms that rise within days of a dose reduction and settle during a hold point to withdrawal. A normal examination is good news, and it is not proof that the symptoms are imagined.

Unfortunately, a person who describes a racing heart, sweats, and dizziness in a short appointment may be told that the anxiety is back, and may leave with a prescription for another sedating drug. A sedative added in the middle of a taper is one more medication that may later need a taper of its own. Whether anything is added should be decided by the patient and a physician who understands benzodiazepine withdrawal, with the risks weighed first.

How does a slower taper calm these symptoms?

Fortunately, the most useful tool is the taper itself. In the practice of Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, autonomic symptoms that flare after a reduction are treated as information about the pace. One response is a short hold at the current dose and then smaller steps, though everybody is different, and some patients do better continuing at a steady pace than waiting out a long hold, with the change planned together and the medication never stopped suddenly.

This follows Chapter II of the Ashton Manual, which suggests reductions of up to one tenth of the dose at each step, tells the person tapering to be in control of the schedule, and allows standing still for a few weeks when needed. The Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each step is sized to the current dose, which is why dose reductions get smaller as the dose gets lower.

Where it helps, Dr. Leeds uses the crossover taper to diazepam (Valium) that the Manual describes. Diazepam leaves the body slowly, which the Manual says allows a smooth, gradual fall in blood level, and that evens out the between-dose swings that set off the heart and the sweat glands. For a person who already carries a diagnosis of dysautonomia, such as postural orthostatic tachycardia syndrome (POTS), that history is a reason to plan the pace even more conservatively from the start.

Some symptoms need emergency care, not a slower taper.

Most autonomic symptoms during a taper are miserable without being dangerous. Any of the following needs emergency care right away:

• Fainting or passing out.
• Chest pain or pressure, especially with exertion or spreading to the arm, jaw, or back.
• A seizure, or any spell of lost awareness or sudden confusion.
• Shortness of breath at rest, sudden weakness on one side, or trouble speaking.

Call 911 for a seizure, chest pain, fainting, or any other medical emergency. The FDA’s 2020 update states that stopping a benzodiazepine abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, that can be life-threatening. Anyone in crisis or thinking about suicide can call or text 988, the Suicide & Crisis Lifeline, at any hour.

Do the autonomic symptoms go away?

On a bad day, with the heart pounding at rest and the room tilting on the walk to the kitchen, it is hard to believe that this will pass. People who have not lived through it rarely understand how frightening it is.

In most cases, it does pass. The Manual says in Chapter III that withdrawal symptoms characteristically wax and wane, and that the waves become less severe and less frequent as time passes. There is no honest timeline for it.

Some people feel steadier within weeks of a hold. However, others describe waves of pounding, sweating, and dizziness that come and go for many months. The system that overshoots is the same system that settles, and what it needs is small changes and time.

The pace should answer to the body.

Dr. Leeds’ practice focuses on medically supervised tapering off of benzodiazepines and z-drug sleeping pills for patients in Florida. It is a concierge practice with a single physician, so the doctor who plans each reduction is the one who hears how the body answered it. The taper is gradual, patient directed, and adapted to the person, and it takes months, sometimes longer.

A racing heart or a dizzy spell during a taper is a reason to slow down and to be heard. It is not a reason to stop abruptly, and it does not mean the body is broken. Dr. Leeds’ practice in Fort Lauderdale is a place to start. Contact the office to ask about a gradual, medically 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.