Overcoming Benzo Withdrawal and Neurological Dysfunction

What is the neurological dysfunction that can follow benzo withdrawal?

It has a name. Benzodiazepine-induced neurological dysfunction (BIND) is the term now used for the neurological symptoms that can appear when a long-term benzodiazepine is reduced or stopped, and that can persist long after the last dose. Tremor, muscle jerks, tingling skin, dizziness, senses that overreact to light and sound, and a fog over memory and concentration are the usual complaints.

A person with these symptoms is often told that the old anxiety has returned, or that the problem is addiction. Usually, it is neither. Physical dependence is not addiction.

Addiction means compulsive use despite harm. Dependence means only that the nervous system has adapted to a medication taken every day, often exactly as a doctor prescribed it, and reacts when the dose falls.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, who supervises slow tapers of benzodiazepines and z-drugs such as zolpidem (Ambien). In his practice, these symptoms are approached as a medical condition of the nervous system. So, what is happening in the brain, and what actually helps?

A benzodiazepine presses on the brain’s brake, and the brain adjusts.

In the first chapter of the Ashton Manual, Professor C. Heather Ashton explained how these medications work. Gamma-aminobutyric acid (GABA) is the brain’s own calming messenger, the signal that tells nerve cells to slow down or stop firing. A benzodiazepine such as alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium) boosts that signal.

GABA is like the brake on a car, and the medication is a second foot on the same pedal. With daily use over time, the car is retuned around the extra pressure. As that chapter explains, the GABA receptors become less responsive, and the excitatory systems that the drug had quieted come back up to speed.

Then the second foot comes off the pedal, and if it comes off quickly, the car surges. In the words of Chapter III, after rapid removal of the drug nearly all the excitatory mechanisms in the nervous system “go into overdrive.” While this is not a perfect analogy, the point holds. The brake has to be rebuilt while the car is still on the road, and that work cannot be rushed.

Why can symptoms begin while the medication is still being taken?

Because the adjustment does not wait for a taper. In that first chapter, Professor Ashton described patients whose anxiety gradually increased over the years despite continuous use, and she wrote that withdrawal symptoms can emerge even in the continued presence of the drug. The name for this is tolerance withdrawal.

It does not take years to become dependent, either. In fact, the United States Food and Drug Administration (FDA), in its 2020 update to the benzodiazepine boxed warning, stated that physical dependence can occur when these medications are taken steadily for several days to weeks, even as prescribed.

So, a person can feel the first signs before a single dose has been cut. That is one reason the symptoms are so often mistaken for a new illness.

What do the neurological symptoms feel like?

Table 1 of Chapter III lists them in plain words, and they fall into families. The motor symptoms are tremor, muscle stiffness, weakness, poor balance, and myoclonus, the medical word for sudden twitches and jerks. The sensory symptoms include paresthesia, which is tingling, numbness, or altered sensation in the limbs, face, or trunk, along with ringing in the ears and hypersensitivity to light, sound, touch, taste, and smell.

Then there is the head itself: dizziness, light-headedness, and the poor memory and concentration that patients call brain fog. The same table lists flushing, sweating, and palpitations, and anxiety, low mood, and irritability often travel with them.

While the list is long, no one person has all of it. Patients often describe a body that seems to vibrate from the inside, a floor that sways, and words that will not come.

Of course, new symptoms should not simply be assumed to be BIND. Other conditions can cause tremor, numbness, and dizziness, and a physician should examine them.

Symptoms come in windows and waves, not in a straight line.

A common belief is that withdrawal is worst in the first week and then steadily fades. Benzodiazepine withdrawal does not keep to that timetable, least of all after an abrupt stop, which is the thing to avoid. During a gradual taper, and after it, the pattern is different.

In Chapter III, Professor Ashton wrote that symptoms “characteristically wax and wane,” varying in severity and type from day to day and week to week. She also described “windows” of normality, a few hours or days of feeling well, that become more frequent and last longer with time. Patients call the hard stretches waves.

A wave after a good week does not mean that healing has stopped. Yet, it is often the moment when a person is told to hurry the taper. A wave is not a reason to go faster.

Unfortunately, the usual answer is built for a different problem.

A person who searches for a benzodiazepine detox is usually asking how to get off the medication safely. The safe answer is not a short stay somewhere with a discharge date. It is a gradual, medically supervised taper over months, at home, at a pace the nervous system can tolerate.

In Chapter II, Professor Ashton observed that withdrawal carried out in a hospital or a special centre usually means a fairly rapid withdrawal, and often takes control away from the patient. A nervous system that adapted over months or years does not readjust on a discharge schedule. Group meetings and addiction programming are not medical care for a condition caused by a prescription.

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 benzodiazepine should never be stopped abruptly.

A seizure, chest pain, sudden confusion, or any other medical emergency is a reason to call 911. A person who is having thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour.

Fortunately, a slow taper gives the nervous system time to readjust.

The taper itself is the treatment, and the same FDA update states that no standard tapering schedule is suitable for all patients. In Chapter II, Professor Ashton wrote that the patient must be in control and proceed at a comfortable pace, and she suggested reductions of up to one tenth of the dose at each step. In fact, many people, she noted, have taken a year or more to finish.

The Maudsley Deprescribing Guidelines describe the shape of the curve. Each reduction is sized to the current dose, so the steps get smaller as the dose falls. A cut that was easy at a high dose can be far too large near the bottom, and in Dr. Leeds’ practice the plain rule is that the last step should feel like just another step.

For a person on a short-acting benzodiazepine, Chapter II describes a crossover taper to diazepam, made one dose at a time, because diazepam leaves the body slowly and its blood level falls smoothly. It is an option where it helps. It is not a requirement. Liquid formulations allow reductions smaller than any tablet can be cut, measured by volume with an oral syringe.

When a wave follows a reduction, the dose can be held until things settle, and that period of stabilization is part of the plan. In Chapter II, Professor Ashton allowed for standing still for a few weeks and advised against raising the dose again. In Dr. Leeds’ practice, a small updose after a cut that proves too large is still a legitimate correction.

What else helps while the nervous system heals?

Time, mostly. There is often nothing that moves the process along faster, and a hard stretch is answered first with a change of pace, not with another prescription.

Daily routine carries more weight than it sounds. Regular sleep with a fixed wake time, gentle movement such as walking, and regular meals built on whole foods give an overexcited nervous system fewer surprises. Foods naturally rich in B vitamins, magnesium, and omega-3 fats belong in an ordinary diet, although the evidence that any nutrient speeds healing is limited.

Alcohol acts on the same GABA receptors as a benzodiazepine, and it is best avoided during a taper. Caffeine, however, is more individual. In Chapter III, Professor Ashton found coffee or tea in moderation compatible with withdrawal, yet some patients find that a single cup worsens tremor and sleep.

Supplements and other remedies are decided one patient at a time, with a physician who understands the pharmacology. Responses vary, the evidence is thin, and none of them replaces a gradual taper. A separate article asks whether the brain can recover from benzodiazepines.

Patients ask the same three questions about BIND.

Is BIND the same as protracted withdrawal?

The two overlap. Acute withdrawal is what happens during and soon after dose reductions, and protracted withdrawal means symptoms that persist for months or longer after the last dose. BIND is the wider name for the lasting neurological symptoms, whether they began during use, during the taper, or afterward.

The term is newer than the Ashton Manual, which describes the same picture in Chapter III under protracted withdrawal symptoms. A separate page covers protracted benzodiazepine withdrawal and BIND.

Is BIND permanent?

In most cases, it is not, although after months of symptoms coming and going it can feel that way. Table 3 of Chapter III lists sensory symptoms such as tinnitus, tingling, and numbness, motor symptoms such as tremor and jerks, and poor memory and cognition as gradually receding, though they may last at least a year and occasionally several years.

Professor Ashton also wrote in Chapter III that a steady decline in symptoms almost invariably continues after withdrawal. No one can name the date.

Does a flare of symptoms mean the taper is going too fast?

Sometimes. A wave can arrive with no change in dose at all, so one bad week proves little. However, symptoms that reliably worsen in the days after each reduction are a signal to hold longer and to make the next step smaller, and that decision belongs to the patient, with the physician advising.

The nervous system heals on its own timetable.

BIND is frightening in a way that is hard to explain to anyone who has not lived through it. It is also a medical condition with a known cause. With time, and a taper that moves at the pace the nervous system can tolerate, healing is the expected course.

Dr. Leeds’ practice provides medically supervised tapering of benzodiazepines and z-drugs for patients in Florida, on a concierge basis. He works directly with each patient, the taper is gradual and patient-directed, and the plan changes when symptoms say it should. Contact Dr. Leeds to ask about a slow taper planned around these symptoms.

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.