Why Does Benzodiazepine Withdrawal Cause Panic Attacks and Overwhelming Fear?

Are panic attacks a normal part of benzodiazepine withdrawal?

Yes. A panic attack is a sudden surge of fear that peaks within minutes, with a pounding heart, shortness of breath, shaking, and a conviction that something terrible is about to happen. Professor C. Heather Ashton listed panic attacks among the withdrawal symptoms in Table 1 of Chapter III of the Ashton Manual, and wrote that they “may appear for the first time during withdrawal.”

Many people who have a first panic attack during a taper took the medication exactly as prescribed and were never warned. In its 2020 boxed warning update, the United States Food and Drug Administration (FDA) stated 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, panic after a dose reduction says nothing about willpower or character. It is a nervous system reacting to a change. So, why would a medication taken to quiet fear produce the worst fear of a person’s life on the way out?

Why does fear surge when the dose comes down?

Benzodiazepines enhance gamma-aminobutyric acid (GABA), the brain’s main calming chemical, as Chapter I of the Manual explains. Over weeks and months of daily use, the nervous system adapts. The same chapter describes the receptors becoming less responsive to GABA, a change often called down-regulation, which leaves the body’s own calming system weaker.

Professor Ashton described withdrawal reactions in Chapter III as tending to mirror the drug’s original effects, with tranquility giving way to anxiety and panic. When the drug is removed rapidly, she wrote, nearly all the excitatory mechanisms in the nervous system “go into overdrive.” Until new adaptations develop, the brain is left hyperexcitable and vulnerable to stress.

The alarm response that prepares a person to fight or run is one of those mechanisms. A panic attack in withdrawal is likely that alarm firing with nothing to fight. The fear is real, even when there is no danger in the room.

Does a pounding heart during a panic attack mean heart disease?

Usually, it does not. Palpitations, a rapid pulse, flushing, sweating, and breathlessness often come with panic attacks, and Professor Ashton wrote in Chapter III that they “do not signify heart or lung disease but are simply the expression of an overactive autonomic nervous system.” That system runs heart rate, breathing, and sweating without conscious effort.

She compared these sensations to what anyone feels when running for a bus. While an attack feels dangerous, she wrote that panic attacks are “never fatal,” and that they usually pass in about half an hour.

Yet, withdrawal does not protect anyone from ordinary illness. A first episode of chest pain, or one that feels different from the others, deserves an examination by the person’s own physician or an emergency room, and nobody should feel foolish for asking. Palpitations can also come without a panic attack, and the same overactive nervous system explains why benzodiazepine withdrawal makes the heart race at other times.

What about terror, dread, and the feeling that nothing is real?

Not every surge of fear arrives as a panic attack. Patients often describe a dread with no object, terror on waking, a fear of being left alone, or a sudden inability to leave the house, which Table 1 of Chapter III lists as agoraphobia.

The same table lists depersonalization and derealization, the feelings of unreality in which a person seems detached from the body or the world looks strange. Professor Ashton wrote that these feelings “resolve in time and should not be interpreted as abnormal or crazy.” Like the panic, these feelings belong to the withdrawal, and they are part of why benzodiazepine withdrawal can make a person feel unreal for a time.

Fear this far out of proportion to anything in the room is hard to imagine for people who have not lived through it. Many patients fear that they are losing their minds. This is not a change of personality. It is the chemistry of withdrawal, and in most cases it eases as the nervous system readjusts.

Panic after a dose reduction usually means the cut was too large.

Withdrawal panic tends to keep a schedule. Patients often describe a first attack within days of a reduction, and the attacks settle when the dose is held steady. That timing says the step was too large, or that it came too soon.

Unfortunately, panic in the middle of a taper is often read as the original anxiety coming back. Some of these patients were prescribed the drug for sleep or a muscle spasm. It is hard for an anxiety disorder to return to a person who never had one.

Why is an extra dose or a second drug not the answer?

The advice that follows is often an extra tablet when panic strikes, or another sedating drug. Chapter II of the Manual advises against taking extra tablets in times of stress, and Chapter III calls the discovery that a panic attack can be controlled without a tablet “a great boost to self-confidence.”

A small, planned step back up after a cut that has proved too large is a different matter. The Manual’s advice is to try not to raise the dose again once it has come down. Even so, a small step back up is a legitimate choice, made with the prescriber and followed by smaller steps.

And, a sedating drug added to cover a cut that was too large is one more medication that may later need a taper of its own. Whether anything is added is a decision for the patient and a physician who understands benzodiazepine withdrawal, with the risks weighed first.

Fortunately, the first answer is a short hold and a slower taper.

In the practice of Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, a run of panic attacks after a reduction is a reason to hold at the current dose for a short stretch while things settle, then continue with smaller steps, and a hold that does not settle within a few weeks is a decision to make with him rather than an open-ended wait. This follows Chapter II of the Ashton Manual, which suggests reductions of up to one tenth of the dose at each step, says the person tapering must be in control of the pace, and allows standing still for a few weeks.

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. With a short-acting drug, panic can also arrive between doses as each one wears off. Where it helps, Dr. Leeds uses the crossover taper to diazepam (Valium) described in the Manual, because a long-acting drug evens out those swings.

What helps while a panic attack is happening?

Professor Ashton called controlling a panic attack a skill that improves with practice, and slow breathing comes first. Chapter III lists diaphragmatic breathing among its techniques for anxiety and notes that many anxious people hyperventilate. Fast, shallow breathing can cause dizziness and tingling, and slower, deeper breaths interrupt that loop.

Grounding, a second tool, means pulling attention back to the present by naming objects in the room, pressing the feet into the floor, or holding something cold. Exercise, which Chapter III also mentions, helps some people. The evidence for either in benzodiazepine withdrawal is limited, and what steadies one person may do nothing for another.

The Manual also lists a structured talking therapy that teaches a person to react differently to the thoughts that drive panic. Dr. Leeds does not offer talk therapy as a separate service, although counseling is part of his medical care during visits. Whether talk therapy helps during a benzodiazepine taper is a separate question, and the choice to try it belongs to the patient.

Of course, none of these tools replaces a taper that moves at the right pace.

Some symptoms need emergency care, not a breathing exercise.

A panic attack in withdrawal is usually frightening without being dangerous. However, it can resemble conditions that are. Any of the following needs emergency care right away:

• Chest pain or pressure that does not settle as the panic passes, or that spreads to the arm, jaw, or back.
• Fainting.
• Signs of a seizure, such as jerking movements, lost awareness, or sudden confusion.
• Trouble breathing that does not ease with rest.

Call 911 for a seizure, chest pain that does not settle, fainting, or any other medical emergency. The FDA’s 2020 update warns that stopping a benzodiazepine abruptly, or reducing the dose too quickly, can bring on withdrawal reactions, including seizures, that can be life-threatening. A person in crisis or thinking about suicide can call or text the 988 Suicide & Crisis Lifeline.

Does the panic stop?

In the middle of an attack, with the heart pounding and the walls closing in, it is hard to believe that this will end. In most cases, it does. The Manual says in Chapter III that withdrawal symptoms characteristically wax and wane, and that the waves become less severe and less frequent with time.

Nobody can promise a date. While some people stop having panic attacks soon after the pace is corrected, others have hard days scattered across many months. What the nervous system needs is small steps and time.

Dr. Leeds’ practice in Fort Lauderdale has one primary service, the medically supervised tapering of benzodiazepines and z-drugs for patients in Florida. It is a concierge practice, and every patient sees Dr. Leeds at every visit, so the doctor who plans each reduction is the one who hears how the last one went. The taper is gradual and patient directed, it takes months and sometimes longer, and a panic attack along the way is a reason to slow down and to be heard. Contact the office to ask about a gradual 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.