Category: Withdrawal

Few experiences in benzodiazepine withdrawal are as confusing as feeling almost normal one day and being knocked flat the next. Patients often wonder what they did wrong to lose their progress. The answer is usually nothing.

This up-and-down pattern has a name. It is called windows and waves, and it is one of the most important concepts for anyone going through benzodiazepine withdrawal to understand.

What Windows and Waves Mean

A window is a period of relief. Symptoms ease, energy returns, and the patient may feel like their old self for hours, days, or even weeks. These moments can feel like proof that recovery is real.

A wave is the opposite. Symptoms come back or intensify, sometimes suddenly and without any clear cause. The patient may feel as though all their progress has vanished.

Windows and waves alternate throughout recovery. The pattern is irregular and hard to predict, which is part of what makes it so unsettling. A good week can be followed by a difficult one for no obvious reason.

This pattern is a normal part of healing from benzodiazepine withdrawal. It is not a sign that something has gone wrong or that the taper has failed.

Why the Pattern Happens

Benzodiazepine withdrawal involves a nervous system that is trying to recalibrate. Long-term use reduced the brain’s calming receptors, and now those systems are slowly relearning how to regulate themselves without the drug. This adaptation is physical dependence, and physical dependence is not addiction: a nervous system that adjusted to a prescribed medication is showing a predictable medical response, not a behavioral problem.

This relearning does not happen in a straight line. The nervous system makes adjustments, overshoots, corrects, and adjusts again. Windows reflect moments when regulation is working better, while waves reflect moments of temporary destabilization.

Because so many systems are involved, including sleep, mood, digestion, and the stress response, a wave can affect different symptoms at different times. One wave might bring insomnia and another might bring physical pain or anxiety.

The important point is that waves are part of the process, not a step backward. The nervous system is responding to change, not breaking down.

What Can Trigger a Wave

Sometimes waves arrive without any identifiable cause, which is genuinely the case for many patients. Other times, certain factors seem to set them off.

Stress is a common trigger. Because withdrawal involves an overactive stress response, emotional or physical stress can tip the nervous system into a wave. A demanding event, poor sleep, or illness can all play a role.

Changes in routine can also contribute. Travel, schedule disruptions, or even ordinary life events can intensify symptoms temporarily. Hormonal fluctuations across the menstrual cycle can also influence the timing of waves.

Identifying triggers can help patients prepare, but it is not always possible. Accepting that some waves simply happen can reduce the frustration of searching for an explanation that may not exist.

How the Pattern Changes Over Time

The most hopeful feature of windows and waves is that the pattern tends to shift in a favorable direction over time. Early in recovery, waves may feel long and windows may feel rare and brief.

As healing continues, windows generally become longer and more frequent. Waves tend to grow shorter and less intense. The overall trend moves toward more good time and less suffering, even though the day-to-day picture remains uneven.

This gradual shift is easy to miss in the moment. A patient deep in a wave may feel as bad as they did months earlier, even though their windows have clearly improved.

Tracking symptoms over weeks and months, rather than hours and days, helps reveal the larger trend. Looking back over a long stretch often shows progress that is invisible in the present moment.

Why Waves Are Not Failures

One of the most harmful beliefs a patient can hold is that a wave means the taper failed. This belief can lead to panic, rushed decisions, or the temptation to make sudden changes.

A wave does not by itself mean the medication needs to be increased or that the taper was a mistake. Most waves mean the nervous system is going through a difficult stretch of an ongoing process, and the healing is still happening underneath the symptoms. The exception is a cut that was too large or too fast. That is a reason to talk with your prescriber about holding the current dose or stepping back, and the section below on true setbacks describes how to tell the difference.

Reacting to every wave with a major change can make healing harder. Stability and patience usually serve the patient better than abrupt responses to temporary worsening.

Understanding this protects patients from despair during the hardest moments. A wave is weather, not climate. It will pass.

Living Through the Waves

Knowing that waves are temporary makes them more bearable, even when they are severe. Patients who understand the pattern can remind themselves that a window will return.

During a wave, the goal is to get through it with as little added stress as possible. Reducing demands, resting, and using calming routines can help. This is a time for self-compassion, not self-criticism.

During a window, patients can gently rebuild. Reconnecting with activities and relationships supports healing, as long as the patient does not overextend and trigger another wave by doing too much too soon.

Pacing across both windows and waves is a skill that develops with experience. Over time, patients learn to ride the pattern rather than fight it.

Telling a Wave Apart From a True Setback

One of the hardest skills in recovery is learning to tell an ordinary wave from a genuine problem. Most difficult stretches are simply waves, but patients understandably worry that something has gone wrong.

A wave typically arrives as a return or intensification of familiar symptoms, then eases again over time. It moves and shifts, and it does not usually signal that the taper itself is flawed.

A true setback is different and less common. It might follow a reduction that was too large or too fast, leaving the patient persistently destabilized rather than moving through a temporary dip.

When symptoms remain severe and unrelenting after a dose change, it is worth discussing with a physician. Holding at the current dose until things settle is a common first step, and a taper where the cuts have stopped working is its own situation with its own options. The distinction between riding out a wave and adjusting the plan is best made with experienced guidance rather than alone.

Some symptoms are not a wave at all and should be checked rather than waited out. Chest pain, fainting, a seizure, a sudden loss of vision or hearing, a high fever, or a symptom that is entirely new and unlike anything from earlier in withdrawal all deserve a prompt medical evaluation. Call emergency services (911 in the United States) for a seizure, chest pain, or any symptom that feels like an emergency, and call or text 988 if you are having thoughts of harming yourself.

Supporting Someone Through the Pattern

Windows and waves do not only affect the patient. Family members and friends often struggle to understand why a loved one seems fine one week and overwhelmed the next.

This unpredictability can lead to misunderstandings. A supporter may assume the patient is better for good during a window, then feel confused or frustrated when a wave arrives.

Educating loved ones about the pattern helps prevent this. When supporters understand that waves are expected and temporary, they can offer steady reassurance instead of alarm.

The most helpful support is patient and consistent across both windows and waves. Believing the patient, reducing pressure, and remembering that the trend improves over time all make a real difference.

How Long the Pattern Lasts

A common question is how long windows and waves continue. The honest answer is that the timeline varies widely from person to person, and there is no fixed end date.

For some patients, the pattern softens within months of finishing a taper. For others, especially those recovering from protracted withdrawal, it can persist much longer before fading.

What tends to hold true across patients is the direction of change. Even when the pattern lasts a long time, windows generally lengthen and waves generally shorten as the months pass.

Focusing on this direction, rather than on a specific finish line, helps patients stay grounded. Recovery is measured in a gradual shift over time, not in the disappearance of every difficult day at once.

The Bigger Picture of Recovery

Windows and waves describe the texture of recovery from benzodiazepines, but they do not define its destination. The pattern is the path the nervous system takes as it heals.

A nervous system in this state is responding to the loss of a prescribed drug it was made to depend on, and these regulatory systems can recalibrate with time, safety, and proper medical supervision.

Working with a physician who understands this pattern helps patients interpret their experience accurately and avoid harmful overreactions. Knowing that windows and waves are normal turns a frightening mystery into an understandable process. On the worst day of a wave, that knowledge is what lets you remember that the weather is changing while the climate slowly improves.

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.

Insomnia is one of the most common and most exhausting symptoms of benzodiazepine withdrawal. Patients who tolerated their original anxiety or sleep complaint relatively well now find themselves staring at the ceiling for entire nights, awake at three in the morning with their nervous system on full alert, or sleeping in two-hour increments that produce no real rest. The fatigue compounds across days. Cognitive function deteriorates. Patience erodes. Other withdrawal symptoms intensify because the nervous system never gets the overnight reset that healthy sleep would have provided.

Sleep is one of the hardest parts of coming off a benzodiazepine, and it is one of the most poorly addressed by conventional approaches. Understanding what is happening in the sleeping brain during withdrawal, and what can and cannot be done about it, is part of getting through this phase without making the situation worse. If you are in the middle of it now, the sections below are written for you.

Why the Brain Forgets How to Sleep

Sleep is regulated by an interaction between several neurotransmitter systems, and gamma-aminobutyric acid (GABA), the brain’s main inhibitory messenger, is one of the central players. The transition from wakefulness to sleep depends in part on rising GABA-mediated inhibition that quiets the cortex, lets the body relax, and permits the cascade of neurochemical changes that produce sleep architecture. Benzodiazepines, which act on the GABA-A receptor, support this transition pharmacologically. Long-term use, however, leads to receptor adaptation. The working model is that the body comes to rely on the medication to produce the inhibitory tone that initiates sleep, and the system’s own capacity to do this work weakens.

When the medication is reduced or removed, the brain’s own sleep-initiating machinery has to come back online. This return is slow. The receptor adaptation that took months or years to develop does not seem to reverse on a timescale that is comfortable for the patient. In the meantime, you are left with a nervous system that no longer remembers how to descend into sleep on its own.

This is likely what patients mean when they describe forgetting how to sleep. On the working model, the neurological process of falling asleep has itself been impaired, and it takes time to rebuild.

The Different Patterns of Withdrawal Insomnia

Withdrawal insomnia does not present uniformly. Several patterns are common, sometimes appearing in the same patient at different points in the taper.

In sleep onset insomnia, you lie in bed for hours, often into the early morning, unable to make the transition into sleep. The body is exhausted but the nervous system will not allow the descent. This pattern is most common early in the taper or after a recent dose reduction.

In sleep maintenance insomnia, you fall asleep without major difficulty but wake after one or two hours and cannot return to sleep. The early-morning awakening, often around three or four, becomes a recurring pattern. This is one of the most common features of benzodiazepine withdrawal and one of the most frustrating, because you do not even get the partial rest that a slow sleep onset at least leaves intact.

Fragmented sleep looks like several hours of sleep from the outside, but you wake repeatedly, sometimes a dozen times a night, often without clearly remembering each awakening. The morning experience is one of having slept without resting.

Disturbed sleep architecture is the fourth pattern. Even when the total sleep time looks reasonable on paper, the proportions of light sleep, deep sleep, and rapid eye movement (REM) sleep can be thrown off. Patients describe waking from what should have been enough sleep feeling unrefreshed, with vivid dreams or nightmares, or with a sense that the sleep was somehow not real.

Each pattern is probably driven by the same underlying receptor adaptation but reflects which part of the sleep cascade is most disrupted at a given moment. The patterns can shift over the course of a taper.

A few sleep problems are not withdrawal and deserve their own evaluation. Loud snoring with pauses in breathing, or waking up gasping, points toward sleep apnea. An irresistible urge to move the legs at night points toward restless legs. Several nights of little or no sleep with racing thoughts, unusual energy, and no sense of needing sleep can be an emerging mania, which needs medical attention in its own right. Sleep loss that comes with thoughts of self-harm needs help the same day: call or text 988 in the United States, and call emergency services if you are in immediate danger.

The Sleep Medication Trap

The natural impulse, when sleep collapses, is to reach for a sleep medication. For benzodiazepine patients in active taper, this is usually the wrong move, and several traps are worth recognizing.

Z-drugs such as zolpidem, eszopiclone, and zaleplon act on the same receptor system as benzodiazepines. Substituting a Z-drug for a benzodiazepine during a taper is, from the receptor’s perspective, not really substituting at all. You may feel briefly better, but you are continuing to load the same system you are trying to unload. Many patients have ended up with a Z-drug dependence stacked on top of the benzodiazepine dependence they were trying to leave behind.

It helps to be clear about what that word means. Physical dependence is not addiction. It is the nervous system’s adaptation to a drug it has been given on schedule, and it happens to people who never took a pill they were not prescribed. A second dependence is a second medical problem, not a character flaw, but it is still one more thing that will eventually need its own taper.

Trazodone, mirtazapine, and similar medications are sometimes used. These can produce sedation, but each has its own complexities, and the response in benzodiazepine-injured patients is unpredictable. What helps one patient may worsen another. None of them addresses the underlying adaptation.

Antipsychotics such as quetiapine are frequently prescribed off-label for sleep. The risks of producing or worsening akathisia, of adding cognitive effects, and of creating a new dependence pattern make this a particularly difficult class for benzodiazepine patients. A patient who picks up a quetiapine prescription for sleep during a taper has often added a future tapering problem to the current one.

Antihistamines such as diphenhydramine, doxylamine, and hydroxyzine are sometimes used. These can be modestly helpful but rarely produce reliable sleep through the most difficult phases of withdrawal, and tolerance to their sedating effect tends to develop quickly with regular use. There is a separate piece on why even a potent antihistamine can do nothing at all for withdrawal symptoms.

The pattern across all of these is that no medication that leaves the underlying receptor adaptation untouched reliably restores sleep during active benzodiazepine withdrawal. The goal during this phase is usually to support you through the difficulty without creating new dependencies. None of this is an argument for stopping anything on your own. Whatever you are taking for sleep now, any change to it belongs in a conversation with your prescriber.

What Can Help

The measures that consistently make a small but real difference are not the ones that produce sleep on demand. They are the ones that support the sleep system as it heals over time.

Maintaining a consistent wake time, even after a night with little or no sleep, gives the body’s circadian system a stable anchor. The temptation to sleep in after a poor night usually backfires because it shifts the circadian phase later. Getting up at the same time every morning is one of the most underrated supports for the return of sleep.

Morning light exposure, ideally outdoor light within the first hour of waking, sends a strong circadian signal that supports the evening drop into sleep. Even fifteen minutes outside in the morning can help over time.

Limiting evening light and screen exposure gives the system the dim signal it needs to begin shifting toward sleep. Bright bathroom lights, screens close to the face, and stimulating content all push against the natural drift toward rest.

Reducing or eliminating caffeine, particularly in the afternoon, can matter more than you would expect. Caffeine lasts long enough in the body that an afternoon coffee can still be working on a sensitive nervous system at midnight.

Building a wind-down routine that the body can recognize as a sleep cue gives the healing system something to respond to. The specifics are less important than the consistency. A predictable sequence of low-stimulation activities in the same order each night can, over time, reestablish the body’s pre-sleep state.

Cognitive behavioral therapy for insomnia, often abbreviated CBT-I, is the best-supported non-medication approach available. It works by addressing the thoughts and behaviors that perpetuate insomnia, and it is increasingly available through telehealth and self-guided programs. For benzodiazepine patients with persistent insomnia, CBT-I is worth considering as a structured approach.

The Role of Patience

The hardest part of withdrawal insomnia is the timeline. The receptor adaptation that produced the dependence took months or years to develop. The return of natural sleep often takes months, sometimes longer. There is no intervention that compresses this timeline reliably. What helps is the willingness to support the system without forcing it, and to avoid measures that may produce short-term sleep at long-term cost.

Patients who have come through severe withdrawal insomnia and out the other side describe the return as gradual. Sleep comes back in pieces. A patient who has been getting two or three fragmented hours a night begins to get four. Then five. Then occasionally a night of seven hours that feels like a revelation. The improvement is not linear, and there are setbacks. But the trajectory over months is real, and most patients eventually reach a stable sleep that approaches what they had before the medication years.

Reframing Insomnia as a Wave

One useful piece of cognitive work during withdrawal insomnia is to reframe it as a wave rather than a permanent state. A patient in the middle of a difficult sleep stretch can feel as though sleep is gone forever, that they will never sleep normally again. The lived experience of any single bad night supports that interpretation. The longer arc of healing does not.

Holding the wave framing during the worst nights, even when you cannot believe it in the moment, helps you endure. The night will end, the wave will pass, and the next phase of healing will continue whether or not it feels that way at three in the morning.

The Clinical View

Dr. Leeds approaches insomnia in benzodiazepine patients as a symptom of the underlying receptor adaptation rather than a separate problem to medicate around. The most reliable path through is the one that supports the sleep system as it heals without re-engaging the receptors the patient is trying to unload. This is harder than reaching for a sleep medication and gives slower relief, but it preserves the trajectory of healing and avoids creating new tapering problems for later. One thing a bad night never justifies is stopping the benzodiazepine abruptly to force the issue, because a sudden stop can cause seizures. If a seizure or any other severe reaction occurs, call 911.

Sleep does come back. Your job during the worst stretches is to get through the nights, support the circadian system as best you can, and trust that the receptor work happening in the background is real, even when the night feels otherwise.

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.

Akathisia is one of the most distressing experiences a person can have, and one of the least understood by clinicians who have not seen it in benzodiazepine patients. The word itself comes from a Greek root meaning “unable to sit,” but that translation does not capture what the experience actually feels like. Patients describe a relentless internal restlessness, a sense of needing to move that cannot be relieved by movement, a feeling of being driven from inside their own skin. It can produce pacing for hours, an inability to lie still, a sense that the body is being electrified, and a level of suffering that breaks down even patients who have weathered everything else withdrawal has thrown at them.

Physical dependence on a prescribed benzodiazepine is not addiction. It is the expected result of regular use, and a slow taper exists to unwind it.

Akathisia is not a fringe symptom of benzodiazepine withdrawal. It is one of the symptoms patients fear most, and one of the symptoms that most often goes unrecognized when patients show up in emergency rooms or psychiatric offices looking for help. Understanding what akathisia is, why it happens during benzodiazepine withdrawal, and what does and does not help matters for patients living with it and for the clinicians trying to support them.

What Akathisia Actually Is

Akathisia is a movement disorder, but the movement is the visible part of a deeper neurological state. The patient’s nervous system has shifted into a pattern of dysregulation that produces a continuous feeling of needing to move, combined with a continuous failure of movement to provide any relief. A person with simple anxiety paces because they are anxious. A person with akathisia paces because they cannot stop, and the pacing does not help.

The internal experience is what makes akathisia so difficult to convey. Patients describe it as restlessness multiplied many times over, as agitation that has no emotional cause, as a feeling of wanting to crawl out of their own body. Sleep becomes nearly impossible because lying still is intolerable. Sitting through a meal can feel like sitting on hot coals. Even the smallest tasks become exhausting because the body is constantly in motion or constantly demanding motion.

This experience is often mistaken for severe anxiety, and the two can coexist, but they are not the same. Anxiety responds to calming inputs. Akathisia does not. A patient with akathisia will tell you that nothing they have tried touches it, and they are usually correct.

Why Benzodiazepine Withdrawal Produces Akathisia

Benzodiazepines work primarily through gamma-aminobutyric acid type A (GABA-A) receptors, the main inhibitory system in the central nervous system. Long-term benzodiazepine use leads to receptor adaptation: the system becomes less responsive to the medication and to the body’s own GABA. When the medication is reduced or removed, the inhibitory tone that was being maintained pharmacologically is no longer available. The nervous system is left in a state of relative excitation that the body has not yet reorganized to handle.

That excitation does not show up uniformly. It manifests through whichever pathways are most vulnerable in the individual patient. In some patients it is sleep that breaks down. In others it is autonomic regulation. In others it is sensory processing. And in some, the pattern of dysregulation produces akathisia. The mechanism is not settled. One theory is that the dopamine and adrenaline signaling systems are pulled off balance along with the GABA system, and that the result is a motor and sensory state resembling the akathisia produced by certain antipsychotics, even though the trigger is entirely different.

The Misdiagnosis Problem

Patients with benzodiazepine-induced akathisia are routinely misdiagnosed. Emergency room clinicians, primary care physicians, and even psychiatrists who have not specifically encountered withdrawal-related akathisia often interpret the presentation as severe anxiety, agitated depression, or a panic state. The patient describes inability to sit still, racing internal feelings, and overwhelming distress. The diagnostic conclusion is usually that the patient needs more medication for their anxiety, not less.

This misreading drives some of the worst clinical decisions made for benzodiazepine patients. A patient with akathisia from benzodiazepine withdrawal who is given a higher dose of benzodiazepine may feel briefly better and then feel worse. A patient given an antipsychotic for what is interpreted as agitation may have their akathisia made dramatically worse, because antipsychotics can produce akathisia of their own through a different mechanism. The original problem is not addressed, and the medication response often adds new layers of suffering.

Part of the misreading is a mislabel. A person who became physically dependent on a benzodiazepine that was prescribed to them has a medical condition caused by the medication, not an addiction, and akathisia in that person is a withdrawal injury, not drug-seeking or a personality change. Recognizing akathisia for what it is, in the context of a benzodiazepine taper or a recent reduction, changes the entire treatment approach. The problem is not anxiety but a nervous system that has been pushed past what it can compensate for.

Not every restlessness is withdrawal, though, and some of it needs checking on its own terms. If the restlessness began soon after starting or increasing another medication, particularly an antipsychotic, an anti-nausea drug such as metoclopramide or prochlorperazine, or an antidepressant, that medication is the first suspect. Restlessness that arrives with fever, muscle stiffness, confusion, or a racing or irregular heartbeat needs urgent medical evaluation, in an emergency room if it comes on quickly, rather than a withdrawal label. Restlessness confined to the legs that comes only at night is a different condition and also worth a visit of its own.

What Standard Responses Get Wrong

Several common clinical responses to akathisia during benzodiazepine withdrawal tend to make the situation worse rather than better.

Adding antipsychotics is one of the most damaging. Quetiapine, risperidone, olanzapine, and similar medications carry their own risk of producing akathisia. For a patient already in a withdrawal-related akathisia state, adding an antipsychotic can compound the problem. The patient ends up with two overlapping akathisias driven by different mechanisms, and the second one will not resolve until the antipsychotic is removed.

Increasing or reinstating benzodiazepines often produces partial relief that does not last. The dose needed to suppress the akathisia tends to climb. Reinstatement may be the right move for some patients in some contexts, but it is not a long-term solution for akathisia.

Pushing the taper forward through severe akathisia is rarely the answer. Many patients have been told to “stay the course” when their nervous system is signaling that the rate of reduction is more than it can manage. Continuing to cut while in active akathisia tends to deepen the problem.

What Can Help

No medication reliably eliminates withdrawal-related akathisia. There are interventions that sometimes reduce the intensity, and there are strategies that help the patient survive the experience until time and a stabilized nervous system bring the akathisia down.

Slowing or pausing the taper is usually the first step. Akathisia often signals that the current rate of reduction is exceeding what the nervous system can absorb. Holding at the current dose, or even returning to a slightly higher prior dose, can give the system time to settle.

Physical strategies that some patients find partial relief in include cold water on the face or hands, weighted blankets, slow rhythmic movement that the patient chooses rather than being driven into, and time outdoors with the kind of low-stimulation environment that does not amplify the sensory load. None of these is a treatment. They are tools that may help a patient endure the hours and days while the underlying state slowly improves.

Beta blockers such as propranolol are sometimes used to reduce the adrenaline-driven component, with mixed results; there is a separate article on propranolol and clonidine. Hydroxyzine is sometimes useful at the margins. Patients respond differently, and no single approach works for everyone.

Severe akathisia can bring thoughts of not wanting to go on. If you cannot stay safe, or you have thoughts of harming yourself, call 911 or go to the nearest emergency room. In the United States you can also call or text 988, the Suicide and Crisis Lifeline, at any hour.

The Role of Time

Akathisia driven by benzodiazepine withdrawal eventually subsides, but the time course is highly variable. Some patients see improvement within days of stabilizing the taper. Others live with significant akathisia for months. A subset of patients with protracted symptoms or benzodiazepine-induced neurological dysfunction (BIND) experience akathisia as a long-term feature that gradually softens over many months or years rather than weeks.

This is why the work of recognizing akathisia early and adjusting the taper accordingly matters so much. The longer a patient remains in active akathisia, the longer healing tends to take. Dr. Leeds approaches akathisia as a signal that something is wrong with the rate of reduction, not as a symptom to medicate around. The most effective response is usually the one that addresses the underlying destabilization, supports the patient through the difficult window, and avoids interventions that risk making the akathisia worse.

Patients who live through severe akathisia and come out the other side describe it as one of the most difficult experiences of their lives. The fact that it improves, and that patients do get better, is a piece of information worth holding on to during the worst of it.

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.

Why am I having hot flashes in the middle of a benzodiazepine taper?

Hot flashes, drenching night sweats, and swings from chilled to sweating are a recognized physical symptom of benzodiazepine withdrawal. The Ashton Manual lists flushing, sweating, and palpitations in Table 1 of Chapter 3, and the same chapter, under bodily sensations, says that sensations of hot and cold are not uncommon during withdrawal. Professor C. Heather Ashton described the flushing, sweating, and pounding heart of withdrawal as the expression of an overactive autonomic nervous system, not heart or lung disease.

Yet, when you describe these symptoms at an appointment, they usually get filed elsewhere. A woman in her late forties hears menopause. Everyone else hears thyroid or anxiety, and anxiety is often the reason the benzodiazepine was prescribed in the first place, so the circle closes neatly.

The reduction you made two weeks ago is rarely on the list. Withdrawal is expected to look like anxiety and insomnia, and a body temperature problem does not fit. So, how do you tell whether your hot flashes are hormonal, glandular, nervous, or the taper?

Menopause, the thyroid, and anxiety are the three usual explanations.

Each of the three is a reasonable guess, and each can be checked. Menopause is the default for women in the perimenopausal years, which are also the years when many people have taken a benzo for a decade or more. While an overactive thyroid produces sweating, palpitations, and heat intolerance too, it is a simple blood test to rule out.

Anxiety is the trickiest of the three, because it is incomplete rather than wrong. Withdrawal does raise anxiety, and anxiety does raise heart rate and sweating. Yet, a nervous system reacting to a lower drug level is a different thing from a person who is worried about something.

Dr. Leeds’ view is that the three explanations deserve their turn. The problem is that the fourth one, the taper itself, so often never gets one.

What do withdrawal-related temperature swings feel like?

Patients describe episodes that arrive without a trigger, in a cool room, sitting still, at any hour. The heat comes with flushing of the face and chest, sweating, sometimes a pounding heart, tremor, and an inner agitation that can be louder than the heat itself. Then it passes, and what follows is sometimes the opposite.

The opposite is a chill that no blanket reaches. Some people describe hours of shivering followed by an hour of sweating, with abrupt transitions. This alternation is one of the more distinctive features, because menopause and an overactive thyroid tend to run in one direction.

There is also a mismatch between what you feel and what your body is doing. You may feel as if you are burning while a partner’s hand on your forehead finds cool skin, or frozen in a warm room. The fault is in the control system rather than the room.

Why should a drug for anxiety do this? The brain’s temperature control is thought to run partly through the same GABA, or gamma-aminobutyric acid, signaling that the benzodiazepine acted on for years, and that system does not reset the moment a dose comes down. That is about as far as the evidence takes us.

The time-locking test is the tell.

Symptoms that begin or worsen in the days after a dose reduction, and settle when the dose is held, are pointing at the taper. Menopause does not read your taper calendar. Neither does a thyroid.

So, keep one. Write down the date of each reduction and, separately, the days the hot flashes or night sweats were worst, then look at the two side by side. If the worst days cluster in the week or two after each reduction, you have your answer, in a form your doctor can read in thirty seconds.

An old shower is a fair picture of the problem, with limits.

Think of an old shower with a slow mixer valve. You turn the handle toward cold, nothing changes, so you turn it further, and a few seconds later the water goes icy. You swing back toward hot, overshoot again, and the swings only settle when you learn to make small turns and wait.

A nervous system coming off a benzodiazepine behaves something like that valve. The drug held it at one setting for years, and with each reduction the system overshoots hot and cold before finding its level. While this is not a perfect analogy, since a shower has one valve and you have a great many receptors, it fits what patients describe.

It also fits the remedy. Small turns, and wait.

Both can be true at once.

A woman in the perimenopausal years who is tapering a benzodiazepine can have hormonal hot flashes and withdrawal hot flashes at the same time. The two follow different calendars. The hormonal ones track her cycle and the years, and the withdrawal ones track her reductions.

Your doctor may check a follicle-stimulating hormone, or FSH, level and thyroid function, and look for other causes if the picture is unusual. What the tests cannot do is tell you how much of the heat is the taper, since there is no blood test for withdrawal.

Response is the better guide. A common pattern is a woman who starts hormone therapy for hot flashes that began, to the day, after her second reduction, gets partial relief, and finds the rest when the taper is held. Both things were true.

Withdrawal flushing also tends to keep company. Tingling, sensitivity to light and sound, muscle twitches, and gastrointestinal, or GI, upset sit on the same Ashton table, and a hot flash that arrives with several of them is more likely to be withdrawal than one that arrives alone.

Slowing or holding the taper is the first relief.

Fortunately, the calendar that finds the symptom also points at the relief. If reductions bring on the heat, fewer and smaller reductions bring on less of it. Chapter 2 of the Ashton Manual says to design the schedule around your own symptoms and to stand still for a few weeks and have a vacation from further withdrawal if circumstances call for it, and the Maudsley Deprescribing Guidelines describe hyperbolic tapering, with reductions that shrink as the dose falls, because the low doses are where each step is felt most.

Unfortunately, a patient who asks to slow down is sometimes treated as though they were clinging to the drug. Physical dependence is not addiction. Dependence is the nervous system’s adaptation to a medication taken as prescribed, and the pace at which it can un-adapt belongs to the nervous system, not to willpower.

What a hold does not mean is stopping. The 2020 United States Food and Drug Administration (FDA) benzodiazepine label update warns that abrupt discontinuation or rapid dose reduction can bring on severe withdrawal, including seizures. A hold keeps the dose steady until your temperature control catches up, and the pace after that is a conversation between you and your doctor.

What do patients try for the episodes themselves?

None of this is a cure, and the evidence for any of it is thin, so what follows is what patients report, which varies. Layers that come off in seconds, a fan by the bed, a cool bedroom, and separate covers so a night sweat does not wake two people are the common ones. Some keep a cold drink or a damp cloth within reach, and some find slow, paced breathing takes the edge off the agitation that comes with a flush.

Every medication added for the heat brings its own dependence or discontinuation profile into a taper that already has one, and the drugs offered for menopausal hot flashes are no exception. The comfort medications that come up most often are compared, with their trade-offs, in clonidine versus propranolol for symptom relief. Hormone therapy for a hormonal piece is a decision for you and your doctor, and it will not reach the withdrawal piece.

Sometimes the heat is not withdrawal, and it needs to be checked.

Withdrawal is a diagnosis you settle on after other things have been looked at. A fever with the sweats, unexplained weight loss, night sweats with swollen glands, a cough that will not clear, or a fast or irregular heartbeat that does not settle between episodes are reasons to be examined rather than reassured, and so are hot flashes with no relationship to your reductions.

Chest pain, fainting, a seizure, or a sudden loss of vision or hearing is a reason for emergency care that day. It is not a note for the next appointment. A taper never makes any of those safe to wait on.

For most patients, the swings settle.

The heat is temporary for most patients, even when it has gone on long enough to feel permanent. The nervous system recalibrates at its own pace, and for many people the thermal symptoms ease over the months after the taper ends, along with the broader picture known as benzodiazepine-induced neurological dysfunction, or BIND. No one can give you a date, and an honest doctor will say so.

What you can do is hand your doctor the calendar. If the reductions are too big for your temperature control, your doctor can help you make them smaller, and if the holds are working, the two of you can agree on when to move again. The calendar that proved the heat was the taper will, in time, show you the day it stopped coming.

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.