Benzodiazepine Withdrawal Syndrome

As shown in the Dependence page, longer-term (>4 weeks) use of benzodiazepines often leads to physiologic dependence. Benzodiazepines also frequently generate adverse effects and/or they are no longer an effective treatment. Due to their effects on receptors, stopping the use of benzodiazepines can be challenging. In most cases, however, it is very important to taper off of these agents.

While in the process of discontinuing benzodiazepines, a wide and variable range of symptoms can develop. Collected together this is called a withdrawal syndrome. An excellent description can be found in “Benzodiazepines: How They Work and How to Withdraw” – also known as the “Ashton Manual”, authored by Heather Ashton, MD, more than 25 years ago, which is readable by patients and practitioners alike.  It is augmented by a follow-up publication by Dr. Ashton, the Ashton Manual Supplement.

In clinical practice it can be difficult to determine whether or not a patient’s symptoms are due to benzodiazepine withdrawal, or to something else. Symptoms can be interpreted as rebound or relapse of the condition (e.g., anxiety) for which these drugs are being prescribed or perhaps the development of a new condition (e.g., insomnia).  Withdrawal from most addiction-prone substances – like alcohol – results in a gradual decline in withdrawal-related symptoms followed by complete resolution.  For benzodiazepines this is not necessarily the case and can be very confusing to clinicians.  Patient responses to tapering and discontinuation are highly variable, though there appears to be specific overarching patterns:

4) A mix of patterns 2 and 3 above with with spikes in withdrawal symptom severity that overlies these patterns – likely the most common case for BZWS sufferers.

Note that with patterns 2 through 4, resolution can range from full (no symptoms) to partial (highly variable ongoing symptoms).