What are the symptoms of Benzodiazepine (BZD) withdrawal?

From the Guidelines

Benzodiazepine withdrawal symptoms can be severe and potentially life-threatening, and therefore, a gradual tapering schedule is recommended to minimize these symptoms, including rebound anxiety, hallucinations, seizures, delirium tremens, and death 1. When managing benzodiazepine withdrawal, it is essential to consider the potential symptoms that may arise, such as:

• Rebound anxiety
• Hallucinations
• Seizures
• Delirium tremens
• Death A commonly used tapering schedule that has been used safely and with moderate success is a reduction of the benzodiazepine dose by 25% every 1–2 weeks 1. It is crucial to monitor patients for withdrawal symptoms during the tapering process and consider adjunctive medications to manage these symptoms, such as:
• Propranolol for physical symptoms of anxiety
• Trazodone or melatonin for insomnia
• Anticonvulsants like gabapentin if needed Additionally, psychological support and cognitive behavioral therapy (CBT) can significantly improve success rates of benzodiazepine tapering 1. The withdrawal process may take weeks to months depending on the duration of use and dosage, and a gradual approach is necessary to avoid dangerous rebound excitatory activity in the central nervous system. A gradual tapering schedule, rather than abrupt discontinuation, is the recommended approach to minimize benzodiazepine withdrawal symptoms and ensure a safer withdrawal process 1.

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 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 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 symptoms of Benzodiazepine (BZD) withdrawal include:

• Acute withdrawal signs and symptoms:
  • 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
  • Tremor
• More severe acute withdrawal signs and symptoms:
  • Catatonia
  • Convulsions
  • Delirium tremens
  • Depression
  • Hallucinations
  • Mania
  • Psychosis
  • Seizures
  • Suicidality
• Protracted withdrawal syndrome:
  • Anxiety
  • Cognitive impairment
  • Depression
  • Insomnia
  • Formication
  • Motor symptoms (e.g., weakness, tremor, muscle twitches)
  • Paresthesia
  • Tinnitus 2

From the Research

Symptoms of Benzodiazepine Withdrawal

• Anxiety 3, 4
• Mood alterations 3, 4
• Perception disturbances 3, 5
• Neurological symptoms 3
• Vegetative signs 3
• Sleep disturbances 3
• Seizures, including grand mal seizures 6, 4
• Autonomic hyperactivity 7
• Agitation 7
• Combativeness 7
• Hallucinations 7
• Delirium 7
• Rebound insomnia, particularly with short-acting agents 4
• Hypersensitivity to sensory stimuli 5
• Abnormal perception of movement 5
• Depersonalisation 5
• Derealisation 5

Factors Influencing Withdrawal Symptoms

• Dose and duration of benzodiazepine use: higher doses and longer use increase the risk of withdrawal symptoms 3, 6, 4
• Type of benzodiazepine: long-acting benzodiazepines with psychoactive metabolites may have a higher risk of withdrawal symptoms, while short-acting agents may have a higher risk of rebound insomnia 4
• Method of withdrawal: abrupt discontinuation may lead to more severe symptoms, while gradual tapering may reduce the risk of withdrawal symptoms 3, 6, 5