What is the best course of action for a patient with a history of anxiety, who experienced worsening anxiety symptoms after being prescribed medication, and now presents with tingling sensations in their legs and arms, as well as memory issues, 3 months after discontinuing the medication?

Medication Discontinuation Syndrome with Persistent Neurological Symptoms

This patient is experiencing a protracted benzodiazepine or SSRI/SNRI discontinuation syndrome, and requires immediate neurological evaluation to rule out alternative causes, followed by symptom-targeted treatment and consideration of medication reinstitution at a lower dose with proper tapering. 1

Immediate Assessment Required

Rule out medical causes first before attributing symptoms to medication withdrawal:

• Evaluate for thyroid dysfunction (hypothyroidism can cause memory issues, paresthesias, and anxiety) 1
• Check for electrolyte imbalances, particularly calcium and B12 deficiency (can cause tingling and cognitive impairment) 1
• Assess for cardiac dysfunction (palpitations and anxiety overlap) 1
• Screen for substance use, particularly alcohol or stimulants 1, 2
• Consider neurological consultation if symptoms persist beyond 3 months, as this exceeds typical discontinuation syndrome duration 1

Understanding the Clinical Picture

The timeline and symptom constellation strongly suggest protracted withdrawal syndrome:

• Benzodiazepines carry the highest risk for severe and prolonged withdrawal symptoms, including paresthesias, memory impairment, and rebound anxiety that can persist for months 1
• Abrupt discontinuation of benzodiazepines can cause hallucinations, seizures, and in rare cases death—symptoms at 3 months post-discontinuation indicate inadequate tapering 1
• SSRIs/SNRIs can cause discontinuation syndrome with paresthesias ("brain zaps"), cognitive difficulties, and anxiety, though typically resolving within 2-8 weeks 1, 3

Treatment Algorithm

Step 1: Symptom Management (Weeks 1-4)

For tingling/paresthesias:

• Ensure adequate B12, calcium, and vitamin D supplementation 1
• Consider gabapentin 100-300mg three times daily if symptoms are severe and interfering with function 4

For memory issues and cognitive symptoms:

• Cognitive rehabilitation exercises and structured daily routines 1
• Rule out delirium from any toxic state or medication interactions 1
• Consider sertraline 25-50mg daily if depression is contributing to cognitive symptoms, as it has favorable efficacy for cognitive symptoms 5, 3

For anxiety:

• Initiate cognitive behavioral therapy immediately—this has the strongest evidence base (Hedges g = 1.01 for generalized anxiety disorder) and addresses both neurobiological and psychological components 3, 6
• Avoid restarting benzodiazepines due to abuse/dependence risk 1

Step 2: If No Improvement After 4 Weeks

Consider medication reinstitution with proper tapering:

• If the original medication was a benzodiazepine, do NOT restart it; instead, initiate an SSRI (sertraline 25-50mg daily or escitalopram 5-10mg daily) 3, 6
• If the original medication was an SSRI/SNRI, consider restarting at 50% of the previous dose, then taper by 25% every 1-2 weeks over 2-3 months 1
• The CDC explicitly recommends tapering benzodiazepines gradually because abrupt withdrawal causes rebound anxiety, and when patients receive both benzodiazepines and other medications requiring tapering, it is safer to taper the non-benzodiazepine medication first 1

Step 3: Ongoing Management (Months 2-6)

Monitor response every 2-4 weeks using standardized scales:

• Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms 6
• Patient Health Questionnaire-9 (PHQ-9) for depression 1
• Subjective cognitive complaints and functional status 1

Optimize psychotherapy engagement:

• CBT demonstrates superior efficacy compared to medication alone for anxiety disorders (small to medium effect sizes: SMD -0.55 for GAD, -0.67 for social anxiety) 6
• Address any barriers to therapy adherence 1

Critical Pitfalls to Avoid

Do not dismiss symptoms as "just anxiety"—the 3-month duration with neurological symptoms (tingling, memory issues) warrants medical workup: 1

Do not restart benzodiazepines even if they were the original medication—the risk of dependence and the severity of withdrawal symptoms make them inappropriate for long-term anxiety management: 1

Do not prescribe SSRIs without concurrent psychotherapy—combination therapy achieves superior outcomes (approximately 50% remission) compared to medication alone (30% remission): 3, 6

Do not wait longer than 6-8 weeks to modify treatment if there is inadequate response—delayed intervention worsens outcomes: 3, 7

Medication Selection if Pharmacotherapy is Indicated

First-line options (choose one):

• Sertraline 25-50mg daily (titrate to 50-200mg) - extensive evidence base, lower QT prolongation risk than escitalopram 5, 3, 6
• Escitalopram 5-10mg daily (titrate to 10-20mg maximum) - favorable drug interaction profile, but monitor for QT prolongation 3, 6
• Venlafaxine XR 37.5-75mg daily (titrate to 75-225mg) - SNRI with slightly better efficacy than SSRIs for treatment-resistant cases, though higher adverse effect rates 3, 6

Continue medication for 6-12 months after symptom remission, then taper gradually over 2-3 months to prevent recurrence: 1, 4, 7