Does Keeping a Journal Help During Benzodiazepine Withdrawal, and What Should Go in a Taper Diary?

Does journaling help during benzodiazepine withdrawal?

It does, and the most useful kind is also the plainest. A dated diary of dose, sleep, and the main symptoms gives a tapering patient and the prescriber something that memory cannot supply, which is a record. It does not treat withdrawal, but it does show what each dose reduction actually did.

That may sound like homework for someone who is being watched, but it is not. A person who takes a benzodiazepine as prescribed, and whose nervous system has adapted to it, has physical dependence, and dependence is not addiction.

So, the diary is not a behavior chart, and nobody grades it. It is a clinical record, and it belongs to the patient. Why write it down, though, when a person could simply remember?

Why does a written record beat memory during a taper?

Withdrawal symptoms do not hold still. In Chapter III of the Ashton Manual, Professor C. Heather Ashton wrote that 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.”

Memory does poorly with a moving target. On a bad day, it seems as if every day has been bad, and on a good day, the last reduction seems as if it was nothing.

Withdrawal also affects the instrument itself. Poor memory and concentration are on Professor Ashton’s list of withdrawal symptoms in Table 1 of that chapter, and many patients describe brain fog during a taper. So, when a doctor asks how the last three weeks have been, the answer is usually how this morning went.

To a person standing in the surf, every wave feels like the whole ocean. A tide chart is what shows whether the water is coming in or going out. The diary is the tide chart.

What should go in a taper diary each day?

Four things, written down at about the same time each day, in about five minutes. A paper notebook, a notes app, and a spreadsheet all work. The best format is the one that still gets filled in during a bad week.

First, each dose and the time it was taken, along with the date of every change. The time matters, because symptoms that build before the next dose is due point toward interdose withdrawal, meaning withdrawal that arrives between doses. That is a different problem from a reduction that was too large.

Second, last night’s sleep, in a few estimates. The sleep log gets its own section below.

Third, the two or three symptoms that matter most to that person, each rated on the same simple scale every day, such as 0 to 10. Not every symptom, because a long checklist turns into a daily hunt for sensations, and it rarely survives a bad week.

Fourth, anything notable, in a single line. An illness, a hard day at work, travel, a change in caffeine, a new medication or supplement, and the point in the menstrual cycle all count. These lines explain the spikes that would otherwise be blamed on the taper.

How does a diary show windows and waves?

Patients call the good stretches windows and the bad stretches waves. Professor Ashton described the same thing in Chapter III. She wrote that “Windows” of normality, when a person feels well for a few hours or days, typically appear after some weeks, and that they gradually become more frequent and last longer.

She also wrote of “wave-like recurrences” that “become less severe and less frequent as time passes.” Unfortunately, nobody can feel that trend from inside a wave. A wave feels like a return to the first week.

On paper, it looks different, because a person can count the good days in this month and in the month before, or compare how high the ratings climbed after the last two reductions. Often, the diary shows a trend that could not be felt.

Sometimes, it does not, and if the waves are not getting shorter or milder over time, that is information as well. The prescriber should hear it.

A taper is not paced by a calendar. The diary shows when to hold and when to reduce.

In Chapter II, Professor Ashton wrote that the precise rate of withdrawal is an individual matter, and she told patients to be in control of their own schedule. The United States Food and Drug Administration (FDA) made a similar point in its 2020 boxed warning update, which states that no standard tapering schedule is suitable for all patients.

A plan built for one person needs information about that person, and the diary is where that information comes from. After a reduction, the ratings often rise for a while and then settle. When they have come back to about where they were, and stayed there, the next reduction can be discussed.

When they have not, the usual answer is a hold, which means staying at the same dose for longer. Professor Ashton wrote that a patient who reaches a difficult point can stay at that dose for a few weeks if necessary.

The record also shows when the steps themselves need to change. If reductions of the same size land harder as the dose gets lower, the next ones can be made smaller. The Maudsley Deprescribing Guidelines call this hyperbolic tapering, and it is why reductions get smaller as the dose gets lower.

Professor Ashton preferred not to go backwards. Still, when the diary shows that one reduction was too large, a small step back up, agreed with the prescriber, is legitimate.

Of course, the diary does not make these decisions. The patient and the prescriber make them together, with the patient setting the pace, and the record keeps the conversation honest.

It guards against pushing on because a date was circled on a calendar. It also guards against blaming a reduction for a week that was really the flu.

What does a sleep log add?

Poor sleep is a common part of a taper, and a bad night colors the whole next day. The log needs only a few estimates: when the person went to bed, about how long it took to fall asleep, how many times they woke, and when they got up.

It should be filled in the next morning, as a rough estimate. Watching the clock at night to get the numbers right tends to make the night worse.

Over several weeks, the log shows whether insomnia during the taper follows the dose changes, and whether it eases between them. That is hard to believe at 3 am. Professor Ashton’s reassurance, in Chapter III, was that “normal sleep will eventually reassert itself.”

What about expressive writing and gratitude journals?

These are optional, and they are separate from the log. Expressive writing means putting a hard day on the page without editing it. A gratitude journal means noting one or two things that went right.

Many patients find that the first takes some weight off a difficult week, and that the second helps them notice progress that the symptoms hide. Some find that writing tomorrow’s worries down before bed makes them easier to set aside.

Yet, the evidence that writing of this kind changes withdrawal itself is limited, and it should not be oversold. It is a way of coping, and individual response varies. It is never a substitute for a gradual taper.

It can also backfire, because for some people, writing at length about symptoms keeps attention fixed on them. If the pages make the day worse, the pages can go and the four-line log can stay. Gratitude is not owed, either, and nobody in withdrawal owes anyone a cheerful page.

The diary, or one page drawn from it, goes to the visit.

A single page can list the date of each reduction, the main symptom ratings before and after, a few lines on sleep, and the questions that came up between visits. A prescriber can read a month that way in two minutes.

A dated record also changes the conversation. Unfortunately, many patients have described withdrawal symptoms to a doctor and been told that the original anxiety was coming back. Symptoms that rise after each reduction and then settle are harder to wave away when the dates are on the page.

A diary is for patterns, not emergencies. A seizure, or any other medical emergency, is a reason to call emergency services right away, not an entry to save for the next appointment.

With time, and at a pace the nervous system can keep up with, the entries usually get shorter and duller. A boring diary is good news.

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, the pace of each taper is set together with the patient, and a dated record of how the last reduction went is the kind of information that helps with that decision. Contact Dr. Leeds to ask about a gradual, medically supervised 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.