Is Fear of Being Alone (Monophobia) a Benzodiazepine Withdrawal Symptom?

Can benzodiazepine withdrawal make a person afraid to be alone?

Yes. A person who has lived alone comfortably for years may find, partway through a benzodiazepine taper, that an empty house feels unsafe. The dread starts when a spouse picks up the car keys, and it lifts when the car pulls back into the driveway.

The fear of being alone is sometimes called monophobia. Table 1 in Chapter III of the Ashton Manual, the tapering guide written by Professor C. Heather Ashton, lists increased anxiety, panic attacks, agoraphobia, and social phobia among the psychological symptoms of withdrawal.

Fear of being alone is a close relative of agoraphobia, the fear of being somewhere that help feels out of reach. It is not in the table by name. It is a pattern that patients in withdrawal often describe, so it rests on clinical experience.

What patients describe is rarely a fear of solitude itself. It is a fear of what might happen with no one there: a panic attack, a surge of symptoms, a medical event with nobody to call for help. So, why would a taper produce that?

Why does a nervous system in withdrawal treat an empty room as a threat?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming chemical. With regular use, the nervous system adapts to the extra help. When the dose comes down, it is left for a time with less calming than it needs.

Professor Ashton described withdrawal reactions in Chapter III as a mirror image of the drug’s effects, with calm replaced by anxiety and panic. When the drug is removed rapidly, she wrote, the brain and nerves are left in a hyperexcitable state, extremely vulnerable to stress, until new adaptations develop.

In that state, ordinary quiet can register as danger. Another person in the house becomes the one dependable sign that help is close. The fear comes from a nervous system that is set too high. It says nothing about how safe the house is.

This is a withdrawal symptom, not a new phobia.

The fear arrived with the dose reductions, and it tends to ease as the nervous system adapts to each lower dose. The Manual describes a steady decline in symptoms that continues after the taper is over, although it can take a long time. Yet, no one can promise a date.

Think of a person crossing an icy sidewalk who reaches for an arm to hold. Nobody concludes that the person has forgotten how to walk. The ground has changed, and when the ice melts, the arm is no longer needed.

It is not a character flaw either. Unfortunately, family members sometimes read the fear as clinginess, or as evidence of a drug problem. A person who took a benzodiazepine as prescribed and now has withdrawal symptoms does not have a drug problem. That person has physical dependence, which is the nervous system’s adaptation to a medication.

Physical dependence is not addiction. In fact, the United States Food and Drug Administration (FDA) stated in its 2020 boxed warning update that physical dependence can occur after several days to weeks of steady use, even as prescribed.

Fortunately, the first response is a slower taper.

When fear of being alone appears or sharpens after a reduction, the taper is the first place to look. The ordinary answer is a hold, which means staying at the current dose until the nervous system settles, and then making the next reduction smaller. Where a cut proved too large, a small increase is a legitimate adjustment, not a failure.

Chapter II of the Ashton Manual suggests reductions of up to one tenth of the dose at each step, and it is plain about who sets the pace of a taper. Professor Ashton told patients to be in control of their own schedule, and to stop for a few weeks at a difficult point if necessary.

The Maudsley Deprescribing Guidelines add hyperbolic tapering, in which each step is sized to the dose that remains, so the steps get smaller as the dose gets lower. The actual numbers are worked out between the patient and the prescriber.

What helps during the hours alone?

A person to call comes first. One relative or friend who has agreed to pick up the phone is often enough, because knowing that the call can be made takes much of the threat out of the room. In Chapter II, Professor Ashton advised finding someone reliable, such as a partner, relative, or close friend, who will give support regularly and who is willing to learn what withdrawal is.

It helps to tell family and friends plainly what is needed. A phone call at noon, or someone in the next room for the afternoon, is a request that people can meet.

A structured day helps as well. Fixed times for meals, a walk, an errand, and a call give the hours edges. Short, chosen periods alone, lengthened as the taper allows, keep solitude familiar without forcing it. The aim is company that is available, not company that is required.

It also helps to know that a panic attack passes. Professor Ashton wrote in Chapter III that panic attacks, distressing as they are, usually last little more than 30 minutes.

Some people also choose to work with a therapist on anxiety that was present before the prescription. That is optional, and another article covers talk therapy during a taper.

Two things do not help. The first is isolation, because weeks at home with the phone off tend to make the fear larger. The second is stopping the benzodiazepine abruptly to end the fear. The FDA’s 2020 update warns that stopping abruptly, or reducing the dose too quickly, can cause withdrawal reactions that include seizures.

Call 911 for a seizure or any other medical emergency, and call or text 988, the Suicide and Crisis Lifeline, if the fear turns into thoughts of suicide.

Where does a physician fit in?

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. His practice is concierge, not insurance based, and it provides medically supervised tapering of benzodiazepines and z-drugs, the related sleep medications, for patients in Florida. He works directly with each patient, and the taper is gradual, patient directed, and measured in months, sometimes longer, with a crossover to diazepam per the Ashton Manual where that helps.

The fear of being alone during a taper has a cause, and it tends to ease as the nervous system is given time and a pace that it can tolerate. Dr. Leeds’ practice is built around that kind of taper. Contact Dr. Leeds to ask about a gradual, medically supervised benzodiazepine 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.