Can Benzodiazepine Withdrawal Cause Psychosis or Hallucinations?

Can stopping a benzodiazepine cause psychosis?

Yes, it can. Hallucinations, false beliefs, and severe confusion have all occurred in benzodiazepine withdrawal. Yet, they occur almost entirely when the drug is stopped suddenly or reduced far too fast, especially from a high dose.

With a slow taper, they hardly ever happen. That is the wording of Professor C. Heather Ashton in Chapter III of the Ashton Manual, where she writes that psychotic symptoms and severe confusion are seen in rapid withdrawal and “hardly ever occur with slow dosage tapering.”

She says the same about hallucinations. Terrifying ones have occurred in people who came off high doses rapidly or abruptly, and she calls them “exceedingly rare” with slow tapering. So, what do these symptoms look like, when are they an emergency, and how does a slow taper prevent them?

What do psychotic symptoms in withdrawal look like?

Psychosis means losing contact with reality. A person may see or hear things that are not there, hold beliefs that are plainly false, or become convinced that family members mean them harm. Severe confusion can come with it, so that the person does not know the date, the place, or the people in the room.

In Chapter III, Professor Ashton describes withdrawal hallucinations as usually visual, although they can also involve hearing, smell, and touch. Some people see small creatures, usually insects, and feel them crawling on the skin. At the time, the hallucinations seem real.

These symptoms follow a sudden stop or a steep cut in dose. They are not a stage that every taper passes through.

How is this different from ordinary withdrawal anxiety?

Many people in a careful taper are afraid that they are losing their minds. Withdrawal can bring surges of anxiety and panic, racing thoughts, heightened sensitivity to light and sound, and a feeling of unreality known as depersonalization or derealization.

Professor Ashton describes perceptual distortions too. A coat hanging on a door may look, for a moment, like a person, and walls may seem to slope inward. She writes that feelings of unreality resolve in time and “should not be interpreted as abnormal or crazy.”

While these experiences are frightening, they are not psychosis. The difference is insight. A person with withdrawal anxiety or derealization knows that something is wrong with how the world looks and feels, and can say so.

In psychosis, that knowledge is gone, and the vision or the belief is taken as fact. When insight is lost, or when nobody can tell, it is an emergency.

When is it an emergency?

Psychotic symptoms after stopping a benzodiazepine are a medical emergency. They are not something to wait out at home. Call 911 or go to the nearest emergency department if a person who has stopped or sharply reduced a benzodiazepine:

• has a seizure or convulsion
• sees, hears, or feels things that are not there and believes they are real
• is severely confused about where they are, what day it is, or who is with them
• holds false or frightening beliefs and may act on them
• has a fever, heavy sweating, or shaking along with confusion
• talks about suicide or about harming someone else

Anyone with thoughts of suicide can also call or text 988, the Suicide and Crisis Lifeline, at any hour.

In the emergency department, the treatment is medical. The staff need to know which benzodiazepine was taken, the dose, for how long, and when the last dose was, because severe withdrawal is often steadied by giving a benzodiazepine again. A family member should stay with the person and bring the pill bottles.

Emergency care is for the emergency. Once the person is stable, coming off the medication belongs in a slow, planned taper, and never in another fast one.

Why does stopping suddenly do this?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the brain’s main calming messenger. With steady use, over weeks and months, the brain adapts. Its own receptors become less responsive, and the systems that excite the nervous system push harder to keep things in balance.

It is like driving for years with one foot resting on the brake. The engine learns to work harder to keep the car moving. Lift the foot all at once, and the car lurches forward.

That lurch is acute withdrawal. Professor Ashton writes in Chapter III that abrupt withdrawal may come with an uncontrolled release of the brain chemicals involved in hallucinations. In Chapter II, she warns that “abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states).”

The United States Food and Drug Administration (FDA) agrees. Its 2020 boxed-warning update warns that stopping abruptly or reducing the dose too quickly can cause withdrawal reactions, including seizures, that can be life-threatening, and it lists hallucinations and psychosis among the more severe reactions. Professor Ashton adds that rapid withdrawal can bring on seizures, especially with high-potency benzodiazepines such as alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin).

Unfortunately, a fast withdrawal is often not the patient’s choice.

Few people stop a benzodiazepine suddenly because they want to. A prescriber retires or declines to refill. A hospital stay interrupts the home medication. Or, a facility takes the dose to zero in days, on a fixed schedule.

Others stop on their own, frightened by what they have read about long-term use. It is an understandable reaction, and it is the wrong way off. Physical dependence can form after only a few weeks of daily use, and the FDA update says it can occur when the drug is taken steadily for several days to weeks, even as prescribed.

When psychotic symptoms follow, the person is often misread. The episode may be taken for a new mental illness, or the person may be treated as someone who misused the drug. In fact, it is the nervous system reacting to the loss of a medication it had adapted to. Physical dependence is an expected effect of the drug, and dependence is not addiction.

In Chapter II, Professor Ashton told readers that they might need to resist attempts by clinics and doctors to persuade them into a rapid withdrawal. That advice still holds.

Fortunately, a slow taper is the prevention.

The protection is in the pace. A gradual taper gives the brain time to readjust after each reduction. It takes months, sometimes longer, and it is fitted to the person.

Reductions are small, and each one is sized to the current dose, so the steps get smaller as the dose gets lower. This is the hyperbolic pattern set out in the Maudsley Deprescribing Guidelines. Where it helps, the Ashton Manual’s crossover taper to diazepam, a long-acting benzodiazepine, evens out the swings between doses.

Holds are part of the method. If a reduction brings hard symptoms, the patient stays at that dose for a short stretch while things settle, a small updose is legitimate after a cut that proves too large, and a hold that does not settle within a few weeks is a reason to talk with the physician about the next step rather than to wait indefinitely. The patient sets the pace, and the physician must keep each step small enough to tolerate.

Professor Ashton’s verdict was that hallucinations “should not worry anyone undergoing slow withdrawal.” So, nobody who takes a benzodiazepine regularly should stop it abruptly, even when the drug seems to be doing harm. The first step is a conversation with the prescriber about a gradual plan.

Do psychotic symptoms become part of protracted withdrawal?

Some people have symptoms that continue for months, sometimes longer, after the last dose. This is protracted withdrawal, also called benzodiazepine-induced neurological dysfunction (BIND).

Table 3 of Chapter III lists the symptoms Professor Ashton found most likely to be long-lasting: anxiety, depression, insomnia, tinnitus, tingling and numbness, muscle pain and tremor, poor memory, and stomach and bowel symptoms. Hallucinations and psychotic symptoms are not on that list. They belong to the acute picture of a fast withdrawal.

She also writes that protracted symptoms are almost certainly much less common after a slow taper under the patient’s own control, and that symptoms almost invariably keep declining with time. So, a hallucination or a loss of touch with reality that appears long after the taper is over should not be assumed to be withdrawal. It needs prompt medical evaluation.

Does a psychotic episode in withdrawal mean a lasting mental illness?

Not by itself. Professor Ashton writes of withdrawal hallucinations that “they do not herald the onset of madness,” and that the brain “will right itself in time.”

What matters is that every doctor involved knows the full benzodiazepine history: the drug, the dose, the years of use, and how fast it was stopped. Without that history, a withdrawal reaction can be mistaken for something else.

A slow taper is not the thing to fear.

Psychosis in benzodiazepine withdrawal is real, and it is frightening to read about. However, it is a consequence of speed. A person who comes down slowly, in small steps, with holds when they are needed, is very unlikely ever to face it.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale. His practice provides medically supervised benzodiazepine and z-drug tapering for patients in Florida, with gradual reductions, a pace set by the patient, and a hold whenever symptoms flare. His practice is not emergency care, and the symptoms described above call for 911. Contact the office to ask about a taper plan.

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.