Key Takeaways
- Protracted withdrawal means symptoms that continue for months, and sometimes years, after a benzodiazepine has been stopped, while for most people who taper slowly the symptoms fade within a few months of the last dose.
- Benzodiazepine-Induced Neurological Dysfunction, or BIND, names the same condition by its cause and includes symptoms that appear during long-term use and during a taper, not only after the last dose.
- The Ashton Manual estimates that perhaps 10 to 15 percent of long-term users develop a post-withdrawal syndrome, and that the rate after a slow taper under the person’s own control is very much lower.
- Symptoms come in windows and waves, and a wave is not evidence that healing has stopped, because the direction over months is upward even when the last week was not.
- Persistent symptoms are not the original anxiety returning, since the Manual lists depersonalization, tingling, perceptual distortions, and muscle twitching as common in withdrawal but unusual in anxiety states, and they are not a sign of addiction either.
- Recovery is the rule: Professor Ashton’s 2011 supplement says that by far the greatest majority of long-term users recover, given time, and that even protracted symptoms decrease gradually.
- A slow taper under the person’s own control is the best protection against protracted symptoms, and stopping abruptly can cause withdrawal reactions including seizures.
- Time is the main treatment, and steady routines and moderate activity help, while restarting the benzodiazepine after a long gap is an individual decision made with a prescriber.
What is protracted benzodiazepine withdrawal?
Protracted withdrawal is the name for symptoms that continue for months, and sometimes years, after a benzodiazepine has been stopped. Most people who taper slowly are through the worst of it within weeks. Yet, a minority are not, and for them the acute phase settles into a long, uneven tail.
The Ashton Manual, in Chapter III, estimates that perhaps 10 to 15 percent of long-term benzodiazepine users develop what the Manual calls a post-withdrawal syndrome. The Manual adds that the incidence after a slow taper under the person’s own control is almost certainly very much lower.
The 2020 United States Food and Drug Administration (FDA) benzodiazepine label update says that physical dependence can develop within days to weeks of steady use, even as prescribed. It also records that some patients have had withdrawal symptoms lasting many months.
This is a condition of physical dependence, not addiction. The people it affects took their medication as directed, did not escalate the dose, and did not crave it. Their nervous systems adapted to the drug, and the adaptation is taking a long time to undo.
What is BIND, and is it the same thing as protracted withdrawal?
Benzodiazepine-Induced Neurological Dysfunction, or BIND, is the current term for the persistent neurological symptoms that benzodiazepines can cause. It covers symptoms that surface during long-term use, during a taper, and after the last dose. The term does not require that the drug has been stopped, and that is the point of it.
So, how do the two terms fit together? Protracted withdrawal names the condition by its timing, since it is what persists after stopping. BIND names the same condition by its cause, the drug’s effect on the nervous system, and it includes the person who is still tapering and already unwell.
Readers will also meet the older phrase post-acute withdrawal syndrome, or PAWS, which says nothing about the cause, so this site uses it sparingly. Ashton Manual Guide uses BIND for the condition and protracted withdrawal for its timing, and the rest of this article holds to that.
What do the symptoms feel like?
People in protracted withdrawal describe a nervous system that reacts to everything. Ordinary light and sound feel like too much, the skin tingles or burns, and the ears ring or hiss, a symptom the Manual singles out as one of the most distressing. Anxiety arrives without a subject, and sleep is shallow and broken.
The cognitive fog is often what people mind most. Words go missing and a page of text takes three readings. Muscles twitch or stay tense, the gut is unsettled, and a symptom that dominates one month may fade and hand over to another.
Chapter III of the Manual lays this out in Table 3, “Some protracted benzodiazepine withdrawal symptoms,” with the usual course of each. Anxiety gradually diminishes over a year, insomnia over six to twelve months, and the sensory, motor, memory and gastrointestinal symptoms recede more slowly, over a year and occasionally several. Those are patterns across many people, not a schedule for any one of them.
Why do symptoms come in waves and windows?
The Manual describes symptoms that wax and wane, varying in severity and type from day to day and week to week. Windows are stretches of feeling normal, or nearly normal. Waves are the return of symptoms, often after a window long enough to raise hopes.
Fortunately, a wave is not evidence that healing has stopped. The Manual describes the course of withdrawal that way, with the windows growing more frequent and longer while the discomfort between them ebbs away, and people in protracted withdrawal report the same pattern stretched over a longer time. The direction is upward even when the last week was not.
It helps to picture a tide going out. Every wave still runs up the sand, and some run higher than the one before, yet the waterline moves steadily down the beach. Judging recovery by a single wave is how a person concludes, wrongly, that nothing is changing.
It is not addiction, and it is not the original anxiety coming back.
Unfortunately, when symptoms persist for months, two wrong explanations tend to be offered. The first is that the original condition has returned, so the medication should be resumed. The second is that the person has an addiction, so the answer is an addiction program.
Neither fits. Chapter III of the Manual notes that depersonalization, feelings of unreality, tingling and numbness, perceptual distortions and muscle twitching are common in benzodiazepine withdrawal but unusual in anxiety states. A person whose trouble began as poor sleep does not, years later, develop ringing ears and a fear of bright light because the poor sleep came back.
Nor is a person who took a prescribed dose for years, and now cannot stop without months of symptoms, a person with an addiction. Dependence is a physiological adaptation, and addiction is compulsive use despite harm.
In fact, the Manual’s own account in Chapter I is that most long-term benzodiazepine use is prescribed therapeutic-dose use, and recreational use is a small fraction of it. The treatment for one is time and patience. The treatment offered for the other tends to be fast, structured and wrong for this condition.
Does it get better, and does it get better completely?
Is protracted withdrawal permanent? In nearly all cases, it is not, though after a year of symptoms that come and go it can feel as if it is. Professor C. Heather Ashton’s 2011 supplement to the Manual says that by far the greatest majority of long-term benzodiazepine users do recover from withdrawal, given time, and that even protracted symptoms tend to decrease gradually, sometimes over years.
The supplement frames the period after withdrawal as a convalescence, a prolonged period in which the body repairs the damage as far as it can. That is a slower promise than most people want. Yet, it is a promise of recovery rather than of lifelong management, and the difference matters when the second year begins.
No article can tell a reader how long their own recovery will take, because length of use, taper speed, age and plain variation all bear on it. Improvement is the rule, it is gradual, and a bad month does not cancel it.
A slow taper is the best protection against protracted symptoms.
Chapter III’s finding on incidence is the practical one: a slow taper under the person’s own control makes protracted symptoms far less likely. Abrupt stopping is worse still. The 2020 FDA label update warns that stopping abruptly, or reducing too quickly, can cause withdrawal reactions including seizures, which can be life-threatening, and a seizure or any medical emergency is a reason to call 911 or local emergency services at once.
The Manual’s method is a gradual reduction, often after a crossover taper to diazepam, with the pace set by the person tapering. The Maudsley Deprescribing Guidelines, consistent with those principles, describe reductions proportionate to the current dose, so the steps shrink as the dose falls. The benzodiazepine taper calculator on this site shows what a schedule of that kind looks like, as a planning tool to take to a prescriber, never as a plan to follow alone.
What helps, and what does not.
Time is the main treatment, and there is no way to hurry it. What a person can do is avoid loading a nervous system that is already over-excitable: steady sleep and waking times even when sleep is poor, modest daily activity, and fewer commitments for a while. The Manual recommends regular moderate exercise during withdrawal for fitness, circulation and mood, and people in protracted withdrawal usually learn that moderate is the operative word.
The Manual is direct about supplements. Chapter III says there is no general need for dietary supplements or extra vitamins or minerals, or for “detoxifying” measures, and that all of these can be harmful in excess. The 2011 supplement adds that there is no evidence vitamins, minerals or amino acids help in benzodiazepine withdrawal, and magnesium falls under the same rule.
Alcohol acts on the same gamma-aminobutyric acid (GABA) receptors the benzodiazepine did, and caffeine stimulates a system that is already over-stimulated. The Manual permits moderate amounts of both during withdrawal itself, but in protracted withdrawal many people find that even a little brings on a wave, and leaving both alone until the nervous system has settled is the simpler course.
Should the benzodiazepine be restarted if symptoms become severe?
That is a decision for the reader and their prescriber together. Someone who stopped too fast and is days or a few weeks out is in a different position from someone a year out. The Maudsley Deprescribing Guidelines treat a return to the last comfortable dose, followed by a hold, as an ordinary move during a taper that has gone too fast.
Further out, the Manual is cautious. The 2011 supplement says that anyone who has remained benzodiazepine-free for weeks or months would be ill-advised to start again, and that the original dose often does not work the second time round. Chapter III also reassures readers that a single dose given for an operation does not bring the dependence back, though the stress of an operation may re-awaken the anxiety felt during withdrawal for a time.
Still, none of that is a directive, and this site does not issue one. Reinstatement after a long gap is an individual judgment about one person’s history, symptoms and options, made with a prescriber who knows that history. Anyone in the United States who is having thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour, and a seizure or any medical emergency means calling 911.
Questions readers ask about protracted withdrawal and BIND.
How long does protracted benzodiazepine withdrawal last?
The Manual’s Table 3 gives anxiety a usual course of gradually diminishing over a year, insomnia six to twelve months, and the sensory, motor, memory and gastrointestinal symptoms at least a year and occasionally several. The 2020 FDA label update describes a protracted withdrawal syndrome lasting weeks to as long as twelve months. Individual courses vary widely.
Can protracted withdrawal be permanent?
The Manual’s 2011 supplement states that by far the greatest majority of long-term users recover, given time, and that even protracted symptoms decrease gradually, sometimes over years. Recovery, not permanence, is the rule. What the condition can be is long, and the length is what frightens people.
Can BIND start before a benzodiazepine is stopped?
Yes. Symptoms that appear while the daily dose has not changed are called tolerance withdrawal, and they count as BIND, which is why the term does not require that the drug has been stopped. A person can be unwell on a steady prescribed dose, during the taper, and after it, and those are one condition at three points in time.
BIND can also mimic a variety of neurological conditions without the person having them, so it is sometimes mistaken for one of them at first. That is a reason the term exists: it ties the symptoms to their cause, whatever the stage.
What can be shown to a doctor who says the symptoms are just anxiety?
The 2020 FDA benzodiazepine label update is the plainest document to bring. It formally recognizes physical dependence, withdrawal reactions including protracted withdrawal, and the need for gradual dose reduction, and sections 5 and 9 of the updated labeling, available on DailyMed, set this out in the label itself.
Chapter III of the Manual helps with the second half of the conversation. Depersonalization, feelings of unreality, tingling and numbness, perceptual distortions, and muscle twitching are common in benzodiazepine withdrawal and unusual in anxiety states, and a symptom list that reads like that points away from the original condition and toward the drug.
Two other articles on this site sit beside this one.
The windows and waves post looks more closely at why symptoms fluctuate, and the family and BIND post is written for the people living alongside someone who is going through this.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
