Strategies for Managing Anxiety During Benzodiazepine Withdrawal

Why does anxiety get worse when the dose comes down?

Benzodiazepines calm the brain by enhancing gamma-aminobutyric acid (GABA), the brain’s own calming chemical, which tells nerve cells to slow down or stop firing. The Ashton Manual, written by Professor C. Heather Ashton, describes tolerance as compensatory changes in the GABA and benzodiazepine receptors, which become less responsive, so that the calming action of both GABA and the drug is reduced (Chapter I).

So, the nervous system’s own calming signal now lands on receptors that answer it less, and the drug has been making up the difference. When the dose comes down, the Manual explains, withdrawal produces a mirror image of the drug’s original effects: tranquility gives way to anxiety and panic, dreamless sleep to insomnia, and muscle relaxation to tension and spasm (Chapter III).

The anxiety of a taper is usually a withdrawal effect, not proof that the original condition has come back. How can a person tell the difference?

Is the old anxiety back, or is this withdrawal?

Patients often describe a fear that feels bigger and stranger than anything they had before the prescription: a racing heart at rest and a dread with no object. While the old anxiety may still be there underneath, a symptom that appears within days of a dose reduction and eases as the weeks pass is the reduction talking.

Think of a person who has worn noise-canceling headphones in a loud workshop for years. Take the headphones off suddenly and the room is deafening, though the machines are no louder than they were. The ears adjust, in fits and starts.

Withdrawal anxiety is the volume, not new noise. The nervous system is hearing its own signals without the drug’s dampening, and the way to spare the ears is to bring the volume down slowly. That is what a taper is.

How bad the anxiety gets depends on four things.

Severity tracks the drug, the dose, how long it was taken, and above all how fast it is reduced. The Manual says that with a sufficiently gradual schedule adapted to the person, withdrawal can be quite tolerable, even easy (Chapter II).

The United States Food and Drug Administration (FDA) said as much in its 2020 boxed-warning update: physical dependence can occur when benzodiazepines are taken steadily for several days to weeks, even as prescribed, and stopping abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures, that can be life-threatening. Call 911 for a seizure or any medical emergency.

Physical dependence is not addiction. A patient who became dependent on a prescribed medication has a medical condition caused by that medication, and the remedy is a gradual taper, not a treatment built for compulsive drug use.

Slowing the taper is the first remedy, not the last.

When anxiety climbs after a reduction, the first question is whether the taper has run ahead of the nervous system. In Dr. Mark Leeds’ practice the remedy is a hold at the current dose until the symptoms settle, then a smaller reduction, and the patient decides when. The Manual allows the same: a person can stand still at a stage in the schedule for a few weeks, though it is best to avoid ever increasing the dose again (Chapter II).

The Manual puts the patient in control of the pace and suggests reductions of up to one tenth of the dose at each step, while the Maudsley Deprescribing Guidelines describe a hyperbolic pattern, each cut a fraction of the current dose rather than the original, so the steps shrink as the dose falls. The shape is a slow curve flattening toward zero over months, sometimes longer, and the pace belongs to the patient, set with the prescriber.

With a short-acting drug, anxiety that arrives at the same hours each day is often interdose withdrawal. A crossover taper to diazepam can smooth that out, and Dr. Leeds’ page on tapering with the Ashton Manual explains how. Stopping abruptly is never the answer.

Progress comes in windows and waves.

Unfortunately, withdrawal does not improve in a straight line. The Manual is plain that symptoms characteristically wax and wane, varying in severity and type from day to day, week to week, and even within a day (Chapter III).

Patients call the good stretches windows and the bad ones waves, and the Manual describes the same thing: windows of normality, a few hours or days of feeling well, appear after some weeks and gradually become more frequent and last longer. A wave does not undo the reductions already made.

Fortunately, the trend over months is toward fewer and shorter waves. A minority of people have symptoms that last much longer, and the Manual says even those decline steadily with time. Time is the treatment nobody can hurry.

Know your own triggers, and write them down.

The triggers that matter during a taper are dose reductions, interdose withdrawal on a short-acting drug, caffeine, alcohol, poor sleep, and a calendar with no slack in it. Alcohol and other sedatives act on the same GABA system as the benzodiazepine and should be avoided during a taper.

On caffeine, the Manual is moderate: coffee or tea in moderation, about two cups a day, is compatible with withdrawal, but the very anxious and the caffeine-sensitive are the exceptions and do better without it, and nobody with insomnia should take it late in the evening (Chapter III). It also hides in decaf, tea, chocolate, and some pain relievers. Cut back gradually, because the headache and fatigue of caffeine withdrawal are easily mistaken for a benzodiazepine wave.

A simple diary does the sorting. Note each dose, each reduction, the night’s sleep, what was drunk, and the anxiety at a few fixed times, and after a month the pattern usually shows which symptoms follow the schedule and which follow the coffee. It is the best evidence for a smaller step or a hold.

Some plain things help day to day.

None of what follows treats withdrawal or stands in for slowing the taper. It is what patients commonly report helps, and experience varies.

Sleep comes first. Keep the same wake time seven days a week and keep tea and coffee away from bedtime, as the Manual advises (Chapter III). Some adults find a weighted blanket calming at night, though it is never for infants or small children, and the guide to benzodiazepine insomnia during tapering covers the nights.

Movement is next. The Manual recommends regular moderate exercise during withdrawal for fitness, circulation, and mood, and the operative word is enjoyable: a daily walk that happens beats a training plan that does not (Chapter III).

Breathing needs a caution. Many anxious people over-breathe, and forcing big, deep breaths during a panic can make it worse. The useful version is a slow exhale: breathe in through the nose without effort, let the breath out through the mouth for longer than it came in, and repeat until the heart rate comes down. Watching the anxiety as a physical sensation, rather than arguing with it, is a skill many patients learn.

Eat at regular times and drink water, since skipped meals and dehydration make a wave feel worse. No one in the middle of a wave has ever been rescued by a list of hobbies, yet an absorbing task, something done with the hands, gives the alarm somewhere to go. Family and friends help most when they know what a wave is.

Know when anxiety has become an emergency.

Low mood is common in withdrawal, and it sometimes brings thoughts of suicide the person has never had before. These thoughts are a symptom, and they are also an emergency. Call or text the 988 Suicide and Crisis Lifeline at any hour, and tell the prescriber the same day.

Call 911 or go to the nearest emergency room for a seizure, for chest pain or trouble breathing, for confusion or hallucinations, or for any thought of self-harm that cannot be kept at bay. Emergency care is never the wrong choice. Short of that, rising anxiety is a reason to call the taper doctor and slow down, never a reason to stop the drug.

The anxiety of withdrawal does pass.

A patient whose doctor once promised the drug was safe has every reason to be wary of a doctor now asking for patience. Yet, Professor Ashton puts it on the page: a steady decline in symptoms almost invariably continues, and most people find that symptoms fall to levels nowhere near the early days and eventually almost disappear (Chapter III). The anxiety that seemed to prove the old illness was back turns out to have been the taper, and it fades with the dose.

None of this asks a person to be brave. It asks for a pace the nervous system can follow, a doctor who will slow down when asked, and a few plain skills for the hours in between.

Dr. Leeds’ practice in Fort Lauderdale provides medically supervised benzodiazepine and z-drug tapering by telemedicine for patients throughout Florida: one physician, a pace set with each patient, and informed consent that starts with the risks, covers the alternatives and the right to decline, and includes an exit plan from the first visit. Contact Dr. Leeds to talk about a taper that respects your nervous system.

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.