Emotional Changes During Benzodiazepine Tapering: What to Expect

Key Takeaways

• Anxiety, fear, irritability, anger, crying spells, low mood, and a strange emotional flatness are recognized effects of benzodiazepine withdrawal, and they can appear during a careful, gradual taper and not only after a sudden stop.
• These feelings are symptoms of a nervous system readapting to less medication, and they are neither a flaw in the patient’s character nor proof that the original condition has returned.
• A person who took the medication as directed and now has these symptoms is physically dependent, and physical dependence is not addiction.
• Withdrawal emotions often follow a dose reduction, arrive with physical symptoms the patient never had before, and can include feelings such as rage that were never part of the original problem.
• Symptoms come in windows and waves, so a good week followed by a bad one does not mean the taper has failed, and the waves tend to become less severe and less frequent as time passes.
• The pace of the taper is the lever. When the emotions become too much, the options are a hold at the current dose, a smaller next step, or a small step back up decided with the prescriber, and stopping the medication all at once is never one of them.
• Low mood that settles in and does not lift, hopelessness, and any thought of self-harm are information the prescriber needs to hear, and anyone with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, and call 911 for immediate danger.
• Family members help most by believing that the symptoms are real, learning about benzodiazepine withdrawal, and leaving the pace of the taper alone.

Why do emotions change so much during a benzodiazepine taper?

Emotions change because the nervous system is readapting to less medication, and mood is one of the things that system regulates. Anxiety, fear, irritability, anger, crying spells, low mood, and a strange emotional flatness are all recognized effects of benzodiazepine withdrawal. They can appear during a careful, gradual taper, and not only when a dose is stopped suddenly.

These feelings are symptoms. They are not a flaw in the patient’s character, and they are not proof that the condition the medication was prescribed for has returned.

They tend to come in waves, and they usually ease when the taper is slowed or held. So, what is happening inside the nervous system, and what can be done about it?

What is happening in the nervous system?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming signal. With steady use, the brain adjusts. In the first chapter of the Ashton Manual, Professor C. Heather Ashton explained that the GABA and benzodiazepine receptors “become less responsive,” while the activity of excitatory neurotransmitters “tends to be restored.”

The medication does not lower GABA, and the brain has not stopped making it. The receptors have become less sensitive to it. Each dose reduction removes some of the medication that was covering the gap, and until the receptors readapt, the excitatory side of the nervous system runs with less opposition.

A benzodiazepine works like a second foot resting on the brake of a car. With time, the driver’s own foot eases off. When the second foot lifts all at once, the car runs fast until the driver’s foot finds the brake again. The second foot has to come off slowly.

This adaptation is called physical dependence. In its 2020 boxed warning update, the United States Food and Drug Administration (FDA) stated that it can occur “when benzodiazepines are taken steadily for several days to weeks, even as prescribed.”

Unfortunately, a patient who cries or snaps at family during a taper is often suspected of having a drug problem. Physical dependence is not addiction. It is the body’s expected adjustment to a medication taken as directed, and the mood changes are that adjustment unwinding.

Which feelings are part of withdrawal?

Anxiety and fear lead the list. Professor Ashton wrote in Chapter III that “nearly all the acute symptoms of withdrawal are those of anxiety,” and that panic attacks “may appear for the first time during withdrawal.”

Irritability and anger are there as well. Table 1 of that chapter lists rage, aggression, and irritability beside excitability and depression. Patients often describe snapping at a spouse over something small, and then feeling ashamed for the rest of the day.

Crying spells and low mood are just as common. Professor Ashton noted that depressive symptoms “are common both during long-term benzodiazepine use and in withdrawal.” Patients often describe tears that arrive for no reason, in the car or at the kitchen sink, and are gone an hour later.

The opposite also happens. The Manual’s first chapter describes “emotional anaesthesia,” the inability to feel pleasure or pain, as a common complaint of people who have taken benzodiazepines long term. During a taper, numb days can alternate with days when everything is felt at once.

Is this the original anxiety coming back?

Patients ask this question. So do their families, and so do their prescribers. Often, the answer is no.

The confusion is understandable, because withdrawal anxiety feels like anxiety. Yet, there are clues. The feelings often follow a dose reduction, they arrive with physical symptoms the patient never had before, and they can include emotions that were never part of the original problem, such as rage in a person who was never angry.

When withdrawal is mistaken for a returning illness, the patient may be told that the medication is needed for life, or that a new one should be added. Professor Ashton observed that, for patients, a lack of explanation of the symptoms “has often added to their distress” and has introduced fears “which themselves magnify the symptoms.”

An earlier anxiety condition may still matter. However, the middle of a taper is a hard time to judge it, and the question belongs to the patient and the prescribing physician.

Why do some patients feel worse before the dose is ever reduced?

The reason is tolerance. Over time, the same dose does less, and withdrawal symptoms can break through while the medication is still being taken every day. This is known as tolerance withdrawal.

In the Manual’s first chapter, Professor Ashton wrote that many patients find that anxiety symptoms “gradually increase over the years despite continuous benzodiazepine use,” and that panic attacks “may appear for the first time after years of chronic use.” So, many patients begin a taper already anxious, low, or flat, and the taper did not cause those feelings.

Why do the feelings come in windows and waves?

A wave is a stretch of hours or days when symptoms surge. A window is a stretch when the patient feels well, sometimes fully like the person they were before.

In Chapter III, Professor Ashton wrote that withdrawal symptoms “characteristically wax and wane, varying in severity and type from day to day, week to week, and even during the course of a day.” A good week followed by a bad one does not mean that the taper has failed. Waves can arrive with no change in dose at all, so one bad day is not a reason to rewrite the plan.

The hardest part of a wave, patients often say, is the conviction that it will never end. Yet, the Manual’s answer is that “the waves become less severe and less frequent as time passes,” while the windows of normality become more frequent and last longer.

What is the medical response when the emotions become too much?

The pace of the taper is the lever. Fortunately, the pace can be changed at any time.

In Chapter II, Professor Ashton told patients, “you must be in control and must proceed at the pace that is comfortable for you.” She added that a patient who reaches a difficult point can stop there for a few weeks if necessary. A hold at the current dose gives the receptors time to catch up.

When a reduction proves too large, the next step can be smaller. Professor Ashton advised patients to try to avoid going backwards, but a small step back up is a legitimate option to discuss with the prescriber. Neither a hold nor an updose is a failure.

The Ashton Manual suggests reductions of “up to one tenth” of the dose at each step, and the Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which the steps get smaller as the dose gets lower. The specifics belong in a plan made with the prescribing physician, and a separate article explains the principles of benzodiazepine tapering.

The answer to a hard wave is never to stop the medication all at once. The FDA’s 2020 update warns that stopping abruptly, or reducing the dose too quickly, can cause withdrawal reactions, including seizures, which can be life-threatening. A seizure is a medical emergency, and the response is to call 911.

Between dose changes, a routine, steady sleep hours, and a walk can make the bad days more livable. What helps varies from person to person, the evidence for any single measure is limited, and none of it replaces a gradual taper. There is more on what helps on the bad days of a taper.

When is low mood more than a hard day?

Low mood in withdrawal is expected. Severe depression is different, and it must be taken seriously. Professor Ashton wrote in Chapter III that the depression sometimes becomes severe enough to qualify as a major depressive disorder, which “includes the risk of suicide” and may require treatment of its own.

The prescriber should hear about low mood that settles in and does not lift, about hopelessness, about days when the patient cannot eat, sleep, or get out of bed, and about any thought of self-harm. These are not confessions of weakness. They are information that changes the plan.

Some situations cannot wait for an appointment. Anyone with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour. Call 911 if a person has a plan or the means to end their life, is in immediate danger, loses touch with reality, or has any other medical emergency.

How can family members help?

The first thing is to believe it. The tears, the short temper, and the fear are symptoms of a nervous system under strain. They are not a verdict on the marriage or the family, and words said in the middle of a wave are usually regretted by the next window.

The second is to learn. Chapter II of the Manual says that support can come from a spouse, partner, family member, or close friend, ideally someone “who understands about benzodiazepine withdrawal or is prepared to read about it and learn.”

The third is to leave the pace alone. Pressing for a faster taper tends to make the emotional symptoms worse. Calm company, help with ordinary tasks on the bad days, and patience do more, and there is further reading on how benzodiazepine withdrawal affects family and friends.

What else do patients and families ask about emotions during a taper?

How long do emotional symptoms last during a benzodiazepine taper?

They can come and go for the length of the taper, and a taper is measured in months and sometimes years, not in weeks. Professor Ashton wrote, “Whether it takes 6 months, 12 months or 18 months is of little significance if you have taken benzodiazepines for a matter of years.” No timeline can be promised, because the pace is adapted to the patient.

Can emotional symptoms continue after the last dose?

Yes, for some patients. Table 3 in Chapter III of the Manual, on protracted symptoms, describes anxiety as “gradually diminishing over a year,” and the FDA’s 2020 update notes that some patients have had withdrawal symptoms lasting many months. The pattern is usually the same, with weaker waves and longer windows.

A slow taper gives the emotions time to settle.

The feelings that surface during a taper are real, and they can be severe. Yet, they are signs of a nervous system finding its balance again, and they are not the person. With a gradual pace, holds when they are needed, and a family that understands what it is seeing, the waves become easier to bear.

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 available whenever emotional symptoms 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.