From the Guidelines
Benzodiazepine withdrawal symptoms that are concerning and require immediate medical attention include seizures, psychosis, hallucinations, severe confusion, and delirium, as well as less severe symptoms such as anxiety, insomnia, irritability, tremors, sweating, nausea, vomiting, headaches, muscle pain, and sensory hypersensitivity. These symptoms can occur when stopping or reducing the dosage of benzodiazepines, and their severity depends on factors such as the dosage, duration of use, and whether cessation was abrupt or tapered 1. The timeline for the onset of these symptoms varies, typically beginning within 1-4 days after stopping short-acting benzodiazepines or within 5-10 days for long-acting ones.
Some key points to consider when managing benzodiazepine withdrawal include:
- The importance of gradual tapering to minimize the risk of severe withdrawal symptoms, with a commonly used schedule involving a reduction of the benzodiazepine dose by 25% every 1–2 weeks 1.
- The potential benefits of cognitive behavioral therapy (CBT) in increasing tapering success rates, particularly for patients struggling with benzodiazepine taper 1.
- The need for medical supervision and sometimes the substitution of a longer-acting benzodiazepine to ease the withdrawal process.
- The risks associated with concurrent use of benzodiazepines and opioids, including a near quadrupling of the risk for overdose death compared with opioid prescription alone 1, highlighting the importance of careful management and monitoring in patients taking both medications.
Given the potential dangers of benzodiazepine withdrawal, including the risk of seizures, psychosis, and even death, it is crucial for individuals taking benzodiazepines to work closely with a healthcare provider to develop a safe tapering plan, rather than attempting to stop abruptly or without medical guidance.
From the FDA Drug Label
Abuse and misuse of benzodiazepines often (but not always) involve the use of doses greater than the maximum recommended dosage and commonly involve concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes, including respiratory depression, overdose, or death The following adverse reactions have occurred with benzodiazepine abuse and/or misuse: abdominal pain, amnesia, anorexia, anxiety, aggression, ataxia, blurred vision, confusion, depression, disinhibition, disorientation, dizziness, euphoria, impaired concentration and memory, indigestion, irritability, muscle pain, slurred speech, tremors, and vertigo The following severe adverse reactions have occurred with benzodiazepine abuse and/or misuse: delirium, paranoia, suicidal ideation and behavior, seizures, coma, breathing difficulty, and death Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor More severe acute withdrawal signs and symptoms, including life-threatening reactions, have included catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures, and suicidality Protracted withdrawal syndrome associated with benzodiazepines is characterized by anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms (e.g., weakness, tremor, muscle twitches), paresthesia, and tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal
The concerning symptoms when withdrawing from benzodiazepines include:
- Mild to moderate symptoms: anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions, headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor
- Severe symptoms: catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures, and suicidality
- Protracted withdrawal symptoms: anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms, paresthesia, and tinnitus that can last weeks to more than 12 months 2
From the Research
Concerning Symptoms of Benzodiazepine Withdrawal
The symptoms associated with benzodiazepine withdrawal can be concerning and varied. Some of the common symptoms include:
- Sleep disturbance
- Irritability
- Increased tension and anxiety
- Panic attacks
- Hand tremor
- Sweating
- Difficulty in concentration
- Dry retching and nausea
- Some weight loss
- Palpitations
- Headache
- Muscular pain and stiffness
- Perceptual changes 3
Severe Withdrawal Symptoms
In some cases, more severe symptoms can occur, such as:
- Seizures
- Psychotic reactions
- Life-threatening symptoms similar to those experienced during alcohol withdrawal 4
Patterns of Withdrawal
Withdrawal from benzodiazepines can result in different patterns of symptoms, including:
- A short-lived "rebound" anxiety and insomnia
- A full-blown withdrawal syndrome, usually lasting 10-14 days
- The return of anxiety symptoms that persist until treatment is instituted 3
Factors Influencing Withdrawal Severity
The severity of withdrawal symptoms can be influenced by factors such as:
- The dose and duration of benzodiazepine use
- The type of benzodiazepine used (e.g., short-acting vs. long-acting)
- The presence of other substance use disorders (e.g., alcohol or other sedatives) 3, 5
Management of Withdrawal
The management of benzodiazepine withdrawal typically involves a gradual tapering of the medication, accompanied by psychological interventions and occasional prescription of concomitant medication 6, 5