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Withdrawal Reactions from
Benzodiazepines

Excerpt from a Report
by Peter R. Breggin M.D.
2002

Clinical experience and the scientific literature confirm that chronic benzodiazepine use impairs mental function in general (reviewed in Breggin, 1998; Lader and Petursson, 1984; Lucki, Rickels, and Geller, 1986 et al., 1994).

The existence of chronic or persistent adverse effects after withdrawal from the benzodiazepines is confirmed by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (both the 1987 and 1994 editions) which contain the relevant diagnoses: Sedative, Hypnotic, or Anxiolytic-Induced Persisting Dementia (292.82). The existence of these diagnoses in this manual confirms that experts in the field consider that the effects are clinically and scientifically demonstrable (see discussion below).

Chronic brain dysfunction can also lead to increased difficulties with disinhibition and loss of impulse control, starting with irritability and mild mood swings, and progressing to more dangerous behavior.

Menkes and Laverty (1996) point out that alprazolam, a short-acting benzodiazepine similar to lorazepam, is especially prone to cause withdrawal reactions that may be long-lasting: "Symptoms usually last 1-6 weeks but may persist for many months, leaving the patient in a vulnerable state." They note that anxiety, depression, "paranoid psychoses" and "delirium" may occur.

Similarly, the American Psychiatric Association (1990) Task Force on Benzodiazepine Dependence, Toxicity, and Abuse observed that short half-life benzodiazepines are prone to produce "intense discontinuation syndromes."

The American Psychiatric Association Task Force (1990) produced a table listing discontinuation symptoms from benzodiazepines in three separate categories: "very frequent, common but less frequent, and uncommon." Very frequent withdrawal symptoms included "anxiety", "agitation", and "irritability", common but less frequent withdrawal reactions included "depression" and uncommon withdrawal reactions included "psychosis", "confusion", "paranoid delusions", and "hallucinations." Noteworthy are the large numbers of citations used to confirm the findings listed in the table. The task force also confirmed that these withdrawal symptoms "may persist up to several weeks (occasionally for months)" (p. 17).

The following two tables from standard sources used in psychiatry summarize many of the withdrawal effects of this class of drugs:

From American Psychiatric Association, Benzodiazepine Dependency, Toxicity and Abuse (1990), Table 3, p. 18

Very Frequent:

  • Anxiety
  • Insomnia
  • Restlessness
  • Agitation
  • Irritability
  • Muscle Tension

Uncommon:

  • Psychoses
  • Seizures
  • Persistent Tinnitus
  • Confusion
  • Paranoid Delusion
  • Hallucinations

From Rapport and Covington Hospital and Community Psychiatry (December 1989), Table I, p. 1278

Emotional / Cognitive:

  • Anxiety
  • Apprehension
  • Fear
  • Irritability
  • Emotional Lability
  • Depression
  • Paranoia
  • Delusions
  • Decreased Memory
  • Decreased Concentration

*Perceptual:

  • Disorientation
  • Depersonalization
  • Hallucinations
  • Clouded Consciousness
  • Metallic Taste
  • Paresthesias
  • Sensitivity to light, sound, touch, pain
  • Feeling of Motion

    • *order rearranged

Official Scientific Recognition of Benzodiazepine Toxicity and Withdrawal

Benzodiazepine toxicity and withdrawal is so well-established that it has received official recognition in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (1994) in the form of fifteen categories. Each of these diagnoses encompasses the benzodiazepines which are in fact "sedative", "hypnotic", and "anxiolytic." The fifteen diagnostic categories are:

  1. Sedative, Hypnotic, or Anxiolytic Withdrawal (292.89)

  2. Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium (292.81)
  3. Sedative, Hypnotic, or Anxiolytic Dependence (304.10)
  4. Sedative, Hypnotic, or Anxiolytic Abuse (305.40)
  5. Sedative, Hypnotic, or Anxiolytic Intoxication (292.89)
  6. Sedative, Hypnotic, or Anxiolytic Intoxication Delirium (292.81)
  7. Sedative, Hypnotic, or Anxiolytic-Induced Anxiety Disorder (292.89)
  8. Sedative, Hypnotic, or Anxiolytic-Induced Mood Disorder (292.84)
  9. Sedative, Hypnotic, or Anxiolytic-Induced Persisting Amnestic Disorder (292.83)
  10. Sedative, Hypnotic, or Anxiolytic-Induced Persisting Dementia (292.82)
  11. Sedative, Hypnotic, or Anxiolytic-Induced Psychotic Disorder with Delusions (292.11)
  12. Sedative, Hypnotic, or Anxiolytic-Induced Psychotic Disorder with Hallucinations (292.12)
  13. Sedative, Hypnotic, or Anxiolytic-Induced Sleep Disorder (292.89)
  14. Sedative, Hypnotic, or Anxiolytic Sexual Dysfunction (292.89)
  15. Sedative, Hypnotic, or Anxiolytic-Related Disorder NOS (Not Otherwise Specified)

A similar set of diagnoses can be found in the earlier edition, the DSM-III-R published in 1987. Only five diagnoses are in the 1987 publication under the following rubrics: Sedative, Hypnotic or Anxiolytic abuse, amnestic disorder, dependence, intoxication and withdrawal delirium. However, these categories can subsume all of the ones found in the DSM-VI and indeed the descriptions in the 1987 edition are sometimes more vivid and detailed.

These DSM categories are produced by a committee of experts in the specific field and therefore represent an attempt to reach a consensus among those most familiar with the subject, in this case benzodiazepine adverse effects. The inclusion of these multiple benzodiazepine-related disorders in the DSM III-R (1987) and DSM-VI (1994) indicates a consensus that benzodiazepine use can cause all of these problems from amnesia and dementia to withdrawal. There can be no doubt, therefore, that the capacity of benzodiazepines to cause a variety of adverse drug reactions and emotional disturbances is well established as a scientific fact within the scientific community and the psychiatric profession. In forensic or medical-legal terms, there should be no Daubert issue concerning the fact that benzodiazepines can cause all of the adverse reactions subsumed under fifteen categories in the DSM-IV.

Patients on long-term benzodiazepines are likely to suffer from many or even all of these disorders. However, patients vary widely in the degree of toxicity and withdrawal reactions that they experience. They will also vary widely in their capacity to understand or describe the adverse drug reactions that they are suffering from.




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