What is the best approach for a patient in their 30s with severe health anxiety and panic attacks, currently taking lorazepam (benzodiazepine) 1.5 mg/day, to taper off this medication?

Tapering Lorazepam in a Patient with Severe Health Anxiety and Panic Attacks

Direct Recommendation

Use a gradual taper over several weeks to months, reducing the dose by no more than 0.25 mg every 1-2 weeks, with the final taper being the slowest, while simultaneously initiating or intensifying cognitive-behavioral therapy or other evidence-based psychotherapy for panic disorder. 1

Rationale for Gradual Tapering

The FDA explicitly warns that abrupt discontinuation or rapid dosage reduction of lorazepam after continued use may precipitate acute withdrawal reactions, which can be life-threatening (including seizures). 1 The risk of withdrawal is particularly elevated in patients taking higher dosages or those with longer durations of use. 1

• A patient-specific gradual taper plan is mandatory to reduce the risk of withdrawal reactions, which can include rebound anxiety, insomnia, tremor, sweating, and in severe cases, seizures. 1
• The FDA boxed warning emphasizes that continued use of benzodiazepines leads to clinically significant physical dependence, making gradual discontinuation essential. 1

Specific Tapering Protocol

Starting from 1.5 mg/day, reduce by 0.25 mg every 1-2 weeks initially, then slow the taper further as you approach lower doses:

• Week 1-2: Reduce from 1.5 mg/day to 1.25 mg/day 1
• Week 3-4: Reduce to 1.0 mg/day 1
• Week 5-6: Reduce to 0.75 mg/day 1
• Week 7-9: Reduce to 0.5 mg/day (slow this step down as withdrawal symptoms typically worsen at lower doses) 1
• Week 10-12: Reduce to 0.25 mg/day 1
• Week 13-16: Discontinue completely 1

This represents a 3-4 month taper, which is appropriate for someone on 1.5 mg/day. Research shows that long-term users of lorazepam at therapeutic doses (mean 2.7 mg/day) often maintain or decrease their dose over time and do not represent abuse or addiction in the traditional sense. 2 However, this does not eliminate physical dependence requiring careful tapering.

Critical Considerations During Tapering

Monitor closely for withdrawal symptoms at each dose reduction:

• If withdrawal reactions develop (increased anxiety, insomnia, tremor, sweating, irritability), pause the taper or increase back to the previous dose level, then decrease more slowly. 3
• The final stages of tapering (below 0.5 mg/day) are typically the most difficult and may require even slower reductions (e.g., 0.125 mg decrements every 2-3 weeks). 1
• Some patients may develop protracted withdrawal syndrome with symptoms lasting weeks to more than 12 months after discontinuation. 1

Addressing the Underlying Panic Disorder

Benzodiazepine discontinuation must be accompanied by definitive treatment for panic disorder:

• While lorazepam is effective for panic disorder at therapeutic doses (research shows efficacy at mean doses of 7 mg/day), 4 it should not be used as monotherapy long-term due to dependence risks. 1
• Cognitive-behavioral therapy (CBT) should be initiated or intensified before or during the taper, as it provides durable treatment for panic disorder without the risks of benzodiazepines. 3
• Consider transitioning to an SSRI or SNRI for long-term management of panic disorder, as these medications do not carry the same dependence and withdrawal risks. 5

Common Pitfalls to Avoid

• Never abruptly discontinue lorazepam in a patient with daily use, as this can precipitate life-threatening seizures. 1
• Do not taper too quickly in patients with severe health anxiety, as withdrawal-induced anxiety will be misinterpreted as worsening disease and may derail the taper. 1
• Avoid prescribing other CNS depressants (including opioids or alcohol) during the taper, as these significantly increase respiratory depression risk and complicate withdrawal management. 1
• Do not use lorazepam as the sole treatment for panic disorder without addressing the underlying condition with psychotherapy or other pharmacotherapy. 3

Special Considerations for This Patient Population

Patients in their 30s with severe health anxiety may experience heightened somatic awareness during tapering, interpreting normal withdrawal symptoms as serious medical conditions. 2 Pre-emptive education about expected withdrawal symptoms (mild anxiety, insomnia, muscle tension) can prevent catastrophic misinterpretation and emergency department visits.

Research indicates that 47% of long-term benzodiazepine users seeking discontinuation have at least one current anxiety disorder, most commonly generalized anxiety, 2 suggesting that underlying psychiatric conditions must be actively managed during and after the taper to prevent relapse to benzodiazepine use.