This video goes over everything you would ever possibly want to know about benzodiazepine protracted withdrawal. It actually comes from an educational video that we use exclusively with our patients at the taper clinic to orient our patients as to what they can expect with their care.

For those of you who don't know me, my name is Dr. Josef with during. I'm a board-certified psychiatrist and I'm an expert in psychiatric drug injuries. So let's begin.

The purpose of this video is to provide a comprehensive overview of benzodiazepine protracted withdrawal injuries. This will allow you and anyone caring for you to best understand what the condition is, what causes it, what the symptoms, the clinical course and the prognosis are, what the treatment strategy is, and what the most commonly asked questions are that we hear at the clinic. This video is essential to ensure consistent understanding between you, your family, and your clinical team. And I would recommend grabbing a pen and paper to take any notes so you can bring them to your clinicians for any clarification. And just so you know, we're going to be supporting a lot of these claims with research pulled from the Maudsley deep prescribing guidelines by professors Taylor and Horowitz. The Maudsley series is an authoritative textbook series from the UK and I would say it's the leading academic resource that we have right now on protracted withdrawal injuries. I would highly recommend buying this book as it aligns closely with how we practice at the taper clinic.

So to start with, what is benzodiazepine protracted withdrawal? So benzodiazepine protracted withdrawal or a benzodiazepine protracted withdrawal injury is a serious long-lasting adverse reaction to stopping or lowering a benzodiazepine medication or a closely related Z-drug medication. Up on the screen now you can see some of the names of the common benzodiazepines and on this screen you can see the names of the common Z-drugs.

It's important to understand that a protracted withdrawal injury is a neurological injury induced by a severe reaction. When I say neurological injury, think minor traumatic brain injury, concussion, or a drug reaction that injures neurons like someone might experience on a chemotherapy. It's important to understand this because a common misconception is that this is withdrawal, meaning that the symptoms are only due to the brain lacking the drug that it had adapted to over many months or years. And that because it is only withdrawal, going back on the drug should make the symptoms go away. Now, this is incorrect. In protracted withdrawal injuries, going back on the drug does not make the symptoms go away because once the injury has taken place, the symptoms are not coming from withdrawal. They are coming from damaged neurons, and going back on the drug will not fix the damaged neurons. To emphasize this point, the use of the word withdrawal in protracted withdrawal or protracted withdrawal injury means that the injury was induced by the uncontrolled withdrawal symptoms, not that the person is still in withdrawal. A helpful analogy to understand this is to think about abrupt discontinuation withdrawal triggering an electrical storm of withdrawal in the brain that fries the circuits out, or metaphorically, the neurons. Following the storm, the brain is now suffering from fried out circuits that need to be fixed.

Many people also wonder how common this is, and it's actually more common than many people may think. In fact, this is what Professors Taylor and Horowitz found when they looked into this. Here's what they say, "Although there are some uncertainty, people experienced in the treatment of withdrawal estimate that a sizable minority, perhaps 10 to 25% of people who stop long-term benzodiazepines will experience a protracted course of withdrawal consisting of mental and physical symptoms that fluctuate unpredictably known in a pattern of waves and windows."

Now, it is not known why only some people seem to be vulnerable to protracted withdrawal reactions and others are not, but it is believed that the duration of use and older age increased the risk of having a protracted withdrawal injury. Some people also wonder why they only experienced a protracted withdrawal injury now, given that they've gone off and come off medications rapidly before without any problems. Again, it's not clear. However, it is believed that these injuries may only manifest in some people after multiple uncontrolled withdrawals. Much like a football player who may only develop dementia after multiple consecutive concussions.

Many people also wonder why they've never heard of protracted withdrawal injuries, and they wonder whether there's recognition of this within the medical literature. Well, what I can say is that protracted withdrawal injuries from benzodiazepines were definitively acknowledged by the FDA in 2020 when they updated the labeling of all benzodiazepines in the US to warn people about this risk. And that's what you're seeing right now on the screen. This is the current warning for all benzodiazepines in the United States. In addition, this adverse reaction now turns up frequently in the peer-reviewed medical literature.

Now, despite the clear recognition by the FDA and in the medical literature, many doctors are still not aware of this condition as they are still relying on what they were taught about these medications during their training, and they have not been reading the up-to-date labels. Furthermore, when the FDA updated the labels, they did not send out a dear doctor letter to all the physicians to inform them of this new change. So, unless someone is routinely reviewing the drug labels for new information, it would be missed. As a result of this, as Dr. Taylor and Horowitz note, due to the lack of awareness about this condition, it is frequently misdiagnosed as other medical or psychiatric conditions.

Now, what are the symptoms of a benzodiazepine protracted withdrawal injury? Well, they cause widespread neurological and psychiatric symptoms. Doctors Horowitz and Taylor have conducted analysis on these symptoms, and they've put together this list right here. As you can see, there are global symptoms across multiple organ systems here, you know, ranging from the neurological, the cognitive, the gastrointestinal, and the sensory.

However, I want to bring this to life in a different way because this is what we typically see in our clinic. Patients with these injuries are typically stuck in a severely anxious and negative mood. In severe cases, the anxiety may even border on paranoia. They also frequently describe concentration problems and feel like they're losing their mind. Insomnia is also very, very common. In addition to the psychiatric symptoms, many patients complain of tingling in their face, neck, hands, or feet. They can also describe a tight, anxious feeling in the chest or gut, a feeling of needing to pace, or inner feelings of tension and agitation, often referred to as inner akathisia. It's a state where you can never truly relax. They may also experience tremors or a heart that seems to beat rapidly for no reason, bouts of severe nausea, and other gastrointestinal symptoms. These symptoms signify that the adverse reaction has caused global neurological problems throughout the body.

There are also a number of other unique symptoms which patients describe, such as waking up with adrenaline or cortisol surges in the morning. Toxic naps are also a common experience. When someone is about to fall asleep, they get jolted awake with a surge of adrenaline. Our conceptual understanding about why some people with this injury react so strongly to falling asleep, waking up, and napping is that the nervous system has become so sensitized that just the normal fluctuations of hormones in our physiology that wake us up and put us to sleep can bristle up against those fried circuits and can generate unpleasant symptoms. In addition, many patients report that they react very poorly to medications or even foods, things that they used to tolerate just fine before. Now, our understanding here is that this occurs because once the nervous system has changed, it is much more sensitive to drugs and food entering the body. And finally, it is also quite common for the symptoms to wax and wane throughout the day. We have several patients that report that the mornings and afternoon are difficult, but then they have gaps where they feel a little bit better in the evening. And I've also seen the reverse pattern happen as well.

Let's move on now and talk about how protracted benzodiazepine withdrawal injuries occur. Well, typically, what we see is that this condition emerges after someone lowers a medication too quickly or comes off the medication too quickly. And this was recently acknowledged by the American Society of Addiction Medicine, who put together a best practices guideline on how to safely get people off benzodiazepine medications. This was endorsed by numerous authoritative medical groups. And here's what they say. They say, "Current guidelines suggest that gradual dose reduction and slow tapers may reduce the risk of protracted withdrawal injuries." And that is what I found in my own practice. I've never seen someone who tapered off the medications gradually, listening to their body and pacing the reductions in that way, go on to develop a protracted withdrawal injury. It essentially only happens when people come off too quickly.

Now, let's talk about what happens when someone comes off these medications too quickly. Generally, I see two things happen. The first is that someone comes off and they experience a bad withdrawal. However, they try and just white-knuckle it through the worst of the withdrawal, expecting that the symptoms will go away in a month or two. However, after a few months, they'll start to notice that they are in fact getting worse, not better. At that point, they try to reinstate the medication, but find that it does not resolve the symptoms or that the drug actually makes them feel worse. The second common presentation that I see is where someone comes off the medication and they experience mild withdrawal symptoms or they may actually feel better off the drug. And then, out of the blue, a few months later, they feel like a bomb goes off in their nervous system and they develop the whole constellation of symptoms. Doctors Taylor and Horowitz describe this well in their analysis of patients with benzodiazepine protracted withdrawal. This is what they write. "There are also reports of withdrawal symptoms being delayed for weeks after cessation for reasons that are not well understood, but often with quite distinctive characteristics of benzodiazepine withdrawal symptoms." This is something that I see a lot. And I have to bring this up because the second presentation is particularly challenging for patients and doctors as they usually do not expect this honeymoon period before this delayed withdrawal. And when it happens like that, they often are unable to link the symptoms that are occurring to actually coming off the medication.

Next, I want to talk to you about a hallmark feature of benzodiazepine protracted withdrawal injuries. It is that the symptoms come and go. Colloquially, experts in the field often refer to this as waves and windows, where a wave is described as a period of worse symptoms and a window is a period of lesser symptoms. In my experience, this is present in around 80% of protracted withdrawal injuries, and doctors Taylor and Horowitz summarize this well here. Here's what they say. "Some patients have symptoms that fluctuate in severity in cycles that last from hours to weeks in duration, overlaying a syndrome that generally improves over time. This pattern of non-linear symptoms, often described as waves and windows, can be perplexing to patients and clinicians, especially as the periodicity of symptoms can vary, as well as the constellation of symptoms over time, with specific groups of symptoms predominating at different time points."

Now, waves and windows, if I want to break down this to the core idea, in its simplest explanation, it is the understanding that neurological injuries from psychiatric drug withdrawal does not improve in a linear way. Because you see, most people expect that after an injury, day-by-day, symptoms will gradually get better over time, with each day being a little bit better than the day before. This is not the typical pattern in recovery from psychiatric drug withdrawal injury. It is actually much more like a feather floating to the ground, where it will gradually, over time, the symptoms will get less, but as it gets less, you get these little upswings, which are the waves, and then you get the windows as it goes back down. And over time, in totality, the symptoms will lessen. This is extremely important to recognize, as many patients and families will panic when they enter a wave period, feeling like something quickly needs to change in their recovery plan, and this can often make things worse, when in fact, it is just par for the course that you have these upswings in symptoms, and just waiting it out for the next window is almost always the best course of action.

Now, let's discuss the prognosis of benzodiazepine protracted withdrawal injuries. I'm really glad to say that they have a good prognosis. Firstly, this is what doctors Taylor and Ashton would say. They said protracted withdrawal recovery may take 12 to 18 months and sometimes longer. And next, let's look at what Professor Heather Ashton found. For those of you who are not aware of her, she was a physician in the UK that looked after patients with benzodiazepine injuries for several years. She also wrote the Ashton manual, which for many years has been used as a guide to come off these medications. So, she really knows what she's talking about. Here's what she says, "All of the evidence shows that a steady decline in symptoms almost invariably continues after withdrawal. Though it can take a long time, even several years in some cases. Most people experience a definite improvement over time, so that symptoms gradually decrease to the level nowhere near as intense as in the early days of withdrawal. And eventually, almost entirely disappear. All the studies show steady, if slow, improvement in cognitive and physical symptoms. And although most studies have not extended beyond a year after withdrawal, the results suggest that improvement continues beyond this time. There is absolutely no evidence that benzodiazepines cause permanent damage to the brain, nervous system, or body." And I find that very reassuring. But this also fits in with what I see in my clinical practice. So, in my practice, and I have to say I see mostly more complicated and sicker patients, people are generally substantially better within 18 to 24 months. What I see is that the first 6 to 9 months are the hardest, and then people gradually get better over time. With most people having a full or near-full recovery around the 18 to 24-month mark. As long as they don't make any mistakes that irritate system or cause a setback. And don't worry because we have a comprehensive section on how to avoid all of those mistakes coming up next.

This next section deals with the treatment of protracted withdrawal injuries. And we're going to first start with reinstatement. So, this is what professors Taylor and Ashton would say about this. "One method employed to trial reinstatement whilst mitigating the possibility of a negative outcome is to reinstate a very small test dose of the original medication. Generally simpler than using a novel benzodiazepine. For example, 1/2 mg to 1 mg of diazepam or equivalent. If this test dose has a positive effect, an increase in dose may be cautiously attempted. Recognizing that some patients may need titration to approximately the same dose on which they were previously stable. If this test reinstatement produces a negative effect, then reinstatement can be abandoned."

Now, at the Tape Clinic, generally, we feel pretty good attempting a reinstatement within about 3 months of someone coming off the medication. That is because within those 3 months, there's a really good chance that they're still an actual real withdrawal that their brain has not adapted to the absence of the drug, and it's generating that electrical storm still. And so, if you reintroduce the drug within that period of time, you can actually shut down that electrical storm. And you one, you can make someone feel a lot better, but two, you can protect them from the damaging effects of being in that electrical storm. However, if you've been off the medication for longer than that, maybe it's been 6, 7, 8 months. At that time point, it is much less likely that you're in acute withdrawal anymore, and that the symptoms you're experiencing are much more due to the fried circuits that have been damaged. And at that time point, reintroducing the drug is going to be much less effective, as it's not going to be ceasing any ongoing withdrawal. And so, if you're in this situation now, and you're thinking about a possible reinstatement, bring this up with your clinician, and they'll discuss whether it makes sense for you on a case-by-case basis.

The next thing to keep in mind is managing interdose withdrawal treatment. At the Tape Clinic, everyone is assessed for interdose withdrawal, and if we pick up on it, we may recommend a change to the spacing of the medication that you're on, or switching to a longer-acting drug like Valium. That's because you can develop withdrawal symptoms in between the doses of your medication. This is commonly observed in long-term benzodiazepine users, as Doctors Taylor and Horowitz show here. Here's what they say. "Withdrawal symptoms, perhaps counterintuitively, can occur during maintenance treatment, and if not recognized, can lead to the erroneous diagnosis of a new condition or the impression that the original condition has worsened, leading to escalation of doses or the introduction of new treatments. The situation is most clearly seen with interdose withdrawal between doses of short-acting benzos. For example, patients taking triazolam as a hypnotic can develop daytime anxiety and even hallucinations or psychotic symptoms that are relieved by redosing the drug. Patients taking alprazolam, which is Xanax, or Ativan, which is lorazepam, can develop increasing anxiety and panic in between doses that are relieved by taking the medication."

Now, it is really important to understand what the telltale sign is of interdose withdrawal, and that sign is that you have worse symptoms in the hour before your next dose. And so, if you're simply feeling awful throughout the entire day or at times other than immediately before your next dose, you're probably not having interdose withdrawal, but you're simply suffering from the general neurological irritation from the protracted withdrawal injury. And I will say this, if someone is already taking their medication two or three times a day and it's a longer-acting medication like Klonopin, the chance that someone's symptoms are due to interdose withdrawal becomes much lower. Because remember, patients with protracted withdrawal injuries often simply just have bouts of more severe fluctuating symptoms throughout the day, which is just par for the course. And if that's happening to you, pursuing additional dose splitting or potentially converting to a longer-acting drug will likely not be helpful. Your clinician will assess you to let you know whether dose splitting or choosing a longer-acting drug may be helpful for you.

The next thing that patients often wonder is whether they should transition to Valium and then taper with that medication. This comes from the very famous Ashton method that was put together by Professor Heather Ashton. And it looks a lot like this. These are tables directly from the Ashton manual that essentially show how to transition from Xanax right now onto an equivalent dose of Valium for tapering.

Now, what I want to say is that this is not essential, and I've learned this from experience because during the first 3 years of my practice, I mostly tapered patients using the Ashton method. However, I don't routinely do that now, and here is why. Patients with protracted withdrawal can often respond poorly to a Valium transition. Many patients will report feelings of depression or sedation, which is a common side effect of Valium that most patients don't tolerate well. And because of these problems, what I found during my first 3 years was that I was attempting a lot of these crossovers, and I would simply have to transition people back, and then at that time point, we had wasted 3 months or so trying to do this when we could have just been tapering on the medication that they were already on. Now, because of this, I have come to believe for the most part that it is better to dance with the devil you know, the drug that your brain has gotten used to over time, than to try and transition to a drug like Valium. There is, however, some exceptions to this. If someone is on a Z-drug, which is a very short-acting drug like Ambien or Sonata, or they're taking a very short-acting drug like Halcion, which is a benzodiazepine, anecdotally, what I found is that with those super short-acting drugs, people often do better with a Valium transition. However, for drugs like Xanax, Ativan, and Klonopin, I usually feel like it's safer to just remain on that drug and taper it from them. And I have to say that it's not just me that's noticed this because Doctors Taylor and Horowitz also report something very similar in the Maudsley Deprescribing Guideline. Here's what they say. "There are mixed views on switching to a longer-acting benzodiazepine to facilitate tapering. A Cochrane review on this topic was equivocal about switching, not finding strong evidence one way or another. Theoretically, a longer-acting drug should cause a more gradual change in plasma levels following reductions that should minimize withdrawal. This may be particularly helpful for patients who are experiencing interdose withdrawal from short-acting benzos and Z-drugs during maintenance treatment, although more frequent dosing could also solve this issue. Other patients may find switching difficult or prefer to taper from the original familiar drug." And that's very much the way I look at this now. Now, your clinician is going to discuss whether a Valium transition is appropriate for you, but for the most part it's not going to be unless you're on a short-acting Z-drug or an ultra-short benzodiazepine like Halcion.

I now want to talk about something that I believe to be the cornerstone of recovery from protracted withdrawal injuries. And that is removing medications that may be irritating your nervous system. Because often many patients with protracted withdrawal injuries, they return to the very drug that caused the injury or to a similar drug in the same class. And usually this happens in one of two ways. First, it is a very logical assumption that because they deteriorated when the drug was removed, putting the drug back should make the symptoms go away. However, as we've previously discussed, this often does not work because once the injury has occurred, it is no longer simply a physiological withdrawal problem. It has become a neurological injury problem. Now, the second reason is that a doctor desperate to help the patient feel better has prescribed the same medication or a similar medication in an attempt to treat the symptoms, often with limited or no success.

Now, patients in this situation are often left asking two important questions. Should I stay on the medication and wait for my symptoms to improve or should I taper off because it's not helping me? Now, while there are certainly reports online of people staying on these medications and recovering, there is also a lot of people that say, "Hey, you know, you shouldn't touch anything until you stabilize." At the Taper Clinic, we believe that once a protracted withdrawal injury has occurred, it is much, much more preferable to gradually remove the medication. And here is why. Having worked with hundreds of patients with this condition over the last 7 years, I frequently see patients who have remained on these medications for years with only limited or incomplete improvement. When a patient is in this situation, both them and I, we naturally start to wonder why they're not gradually recovering, which is what you would typically expect in a protracted withdrawal injury. And one question we almost always consider is whether the continued presence of the medication is preventing the nervous system from healing. And this concern is not just hypothetical speculation. It is supported by the medical literature in two important ways.

And the first way is that benzodiazepines are already well known to directly cause psychiatric and adverse effects. Let's have a look at the evidence here that was summarized by doctors Taylor and Horowitz. And I know this is a lot here, but I want to go through this because it's really important. So, they talk about the psychiatric adverse effects. They say benzos may worsen a number of psychiatric symptoms. Studies have reported increased levels of depression in chronic benzodiazepine users, with one study finding that non-depressed patients who were administered benzodiazepines had a fourfold increased chance in developing clinically significant depressive symptoms. In addition, benzos have been observed to cause worsening anxiety in long-term users, sometimes called benzodiazepine-induced hyper-anxiogenesis. Indeed, in one case series, 20% of patients on benzodiazepines developed agoraphobia only after taking benzodiazepines, which resolved on cessation. I have seen that happen a lot. Furthermore, these effects have been compared to the long-term seemingly paradoxical effects, that means worsening, of opioids such as opioid-induced hyperalgesia, where the pain feels even worse, and nicotine, with worsening anxiety, which resolves after cessation. And in support of these observations, studies have observed improved anxiety and depression scores in those patients who discontinued benzodiazepines. A case series of 50 patients, this was done by Professor Heather Ashton, noted that patients' mental states seemed to improve after tapering off long-term benzodiazepines after the period of withdrawal effects. Cases of agoraphobia and suicidality, as well as gastrointestinal and neurological complaints which developed only after the benzos were started and had been unamenable to treatment during benzodiazepine use, largely resolved after cessation. This is essentially summarizing that long-term use of these medications can neurologically and psychiatrically make people stay in a place of sickness.

Now, the second issue that I want to bring up and perhaps this is even more concerning, is that these medications appear capable of directly injuring the nervous system through what is now being referred to as bind. And this is a phenomenon that has been observed in animal models. Let's see what Doctors Taylor and Horowitz say about this here. "Some researchers suggest that long-lasting neurological, cognitive, affective, and somatic problems which persist for years after stopping benzos in some people are best conceptualized as benzodiazepine-induced neurological dysfunction bind, which generally shows gradual improvement over time. There is a lack of understanding of the underlying mechanism of this condition, but it has been postulated to be related to persistent neuroadaptations or cumulative direct neurotoxic effects as seen in animal models."

Now, I want to add my take here about whether I think it's direct toxic effects or whether it's persistent neuroadaptations that are causing the symptoms and protracted withdrawal and bind. And what I think is actually happening more so than persistent neuroadaptations is that it's direct toxicity. Because if this was just a neuroadaptation problem where the brain hasn't fully adjusted to the drug disappearing, what we would find is that when we reintroduce the drug, the symptoms would go away. Or when we fixed interdose withdrawal by dosing the drug more frequently, or when we raised the dose, the symptoms would go away. In the majority of cases, so many of my patients have tried that and I've tried that with many of my patients and it often does not make the symptoms go away or it only partially helps, there are always a lot of residual symptoms outside of that. Now, that tells me that we are actually dealing more with a toxicity problem, rather than a adaptation problem. And this direct toxicity problem actually happens with many people. Many people think that you can only get these benzo problems by coming off the drug quickly. That's not true. Some people will get on these medications, and they'll take it for a few months or a few years, and then they'll get sicker and sicker over time, and they'll develop bind. And this famously occurred with Dr. Jordan Peterson, who gradually worsened on Klonopin over about 5 years of use, until he was disabled by the drug. And I've covered this story in depth on my YouTube channel, if you want to check that out.

Now, because there is mounting evidence from animal models and patients and my own clinical experience that these medications can be directly toxic and harmful to people, what we do at the Taper Clinic is that we recommend initiating a taper shortly after someone has become toxic on benzos, or they've developed a protracted withdrawal injury. However, many patients are very afraid of lowering the medication, cuz they're worried that the tapering will make them worse. They'll say things like, "Hey, I just want to wait it out until I'm more stable. I can't afford to taper now, because I can't get any worse." However, I have to tell you that I have seen people say this for years, and not make any progress or even get worse. And ultimately, I now believe that the safest path to actually stability, it's not waiting. It's not waiting around indefinitely for years, crossing your fingers. It's actually removing the drug, so that you know for sure that it isn't causing any unpleasant psychiatric and neurological problems, or even worse, potentially direct toxicity that's preventing your recovery. Furthermore, what I find is that reducing the medication in a highly controlled manner, which is typically around 5 to 10% per month, often using liquid formulations, is so gradual that it's unlikely to trigger significant withdrawal symptoms. We have been using this approach for years with hundreds of our patients, and we continue to see gradual improvement over time, contrary to the concern that many patients have that the tapering itself will prolong recovery or make them worse. In addition, what I find is that most people who have experienced a severe drug-induced nervous system injury, they prefer tapering as they desperately want to be medication-free long-term to minimize any future risk of drug-induced harm. And rationally, many of them decide that they would rather taper the medication while their nervous system is healing, so that by the time they have recovered substantially, the medication is already gone, and they can move on with their life without having to face a taper at that time. Now, because of this, at the taper clinic, given that there is very limited downside to doing a gradual taper, and there's actually a lot of upside in removing the drug, we encourage all of our patients with persistent protracted withdrawal symptoms who remain on these medications to gradually taper off them.

The next important part of treatment is to avoid making abrupt medication changes. This includes rapidly lowering or increasing a medication, as well as starting new medications and supplements one after another. These changes can often trigger abrupt deteriorations, often referred to as kindling reactions. Now, doctors Taylor and Horowitz describe this phenomenon well. Let's have a look at what they say here. "It has been thought that several cycles on and off benzodiazepines, and perhaps other psychiatric medications, can make subsequent withdrawal attempts more difficult due to increased sensitization, often called kindling. This was also described by Adele Framer, who is an expert in protracted withdrawal, who published on her experience helping 10,000 people taper off psychotropic medications in the peer-reviewed medical journal Therapeutic Advances in Psychopharmacology. She says this, As withdrawal symptoms indicate neurological instability, we have found that dosage increases, reinstatement, or other drug treatments should be approached very cautiously. Many site members seem to react badly to what I considered minimal doses of any psychoactive substances, usually responding with activation or paradoxical reactions. The hyper reactivity can be triggered by small amounts of alcohol, neurologically active antibiotics, herbs, even foods and supplements such as caffeine, B vitamins, St. John's Wort, or fish oils, as well as sound, light, and other stimuli. This hyper reactivity closely resembles neurological sensitization observed in alcohol, amphetamines, benzodiazepines, cocaine, and antipsychotic use. A consequence of repeated episodes of psychotropic withdrawal and reintroduction that predisposes to kindling reactions."

So, let me break this down and explain this. To understand what kindling is, it helps to know where the term comes from. It originated in the alcohol withdrawal literature, where researchers observed that repeated episodes of abrupt withdrawal from alcohol led to progressively worse withdrawal seizures. If If you're not aware, if you suddenly stop drinking alcohol, you have a seizure. And that actual uncontrolled seizure, that's damaging to the brain. So, what these researchers were noticing was that, you know, someone would have a seizure after their first abrupt alcohol withdrawal, and maybe it would last a short period of time. But, as they had more of those seizures over time, those seizures damaged the brain, and they would actually have longer and longer and more severe seizures over time as the nervous system became more and more destabilized. Now, this is similar to what's happening in protracted withdrawal, except instead of it just being withdrawal from the medications, it is just insults in general. And so, what are the insults in protracted withdrawal injury? Well, it could be starting a supplement, it could be starting a new medication, it could be going too high on a dose, it could be dropping down the medication too quickly. Once you're really sensitized, if you make a lot of these changes, that can irritate the nervous system, and it can ramp up your symptoms, and it can push you into a place where you have even worse symptoms over time, being further destabilized. This is often frightening to hear for a lot of people, because many people who are currently suffering often feel that strong desire of I need to change something, I need need fix something, I need to try a new medication. And this is extremely normal because let's think about it, especially in the first 6 to 9 months where symptoms are severe, who wouldn't want to make these changes? Who wouldn't want to try anything that they could possibly do to make the symptoms better? On top of that, many of these patients are going through waves and windows where all of a sudden they feel a little bit better and then they feel a little bit worse and they interpret that as something being wrong with their plan or with a medication that they're taking. They're simply not aware that the symptoms ebb and flow like that in a protracted withdrawal injury. And that And that pushes them to feel like they need to make changes. On top of that, these patients are often extremely anxious and they have brain fog and their families are watching them and they're panicking. And all of this creates this sense of urgency that we have to do something right now. And so what I want you to hear is that if this is how you feel right now, there's absolutely no judgment about this. Nearly everyone with a protracted withdrawal injury, especially in the first 6 to 9 months, feels this way. However, what I need to be really clear about is that rapid medication changes often makes things worse, exactly as described by doctors Taylor and Horowitz and Dell Fava. And I have also seen this repeatedly in my own practice working with hundreds of these patients over the last 7 years. Because after someone has a significant neurological injury from a medication, the brain needs stability. We need to let the dust settle. We need to establish the new baseline. We need to understand your symptom pattern. And if multiple medication changes are made in quick successions, it becomes almost impossible to determine whether a worsening of symptoms represents just a wave that you're going into or perhaps maybe your taper is going too quickly or whether you're having a reaction to a new medication or supplement. And so during these early months, your tapering clinician is really going to function much like a financial advisor during a market crash. Now, a good financial advisor doesn't tell their clients to panic and sell everything after a temporary decline in the market because emotional reactions will often lead to worse long-term outcomes. And the same principle applies here with protracted withdrawal. Early in a protracted withdrawal injury, severe waves are often followed by another window, whether it's days or weeks later. And over time, patients will begin to recognize that these fluctuations are just part of the recovery and that despite these temporary setbacks, the overall trajectory is good and there's gradual improvement. And so if you're suffering acutely right now and you're thinking there must be some change I can make or some medication I can try and you're noticing that your clinician seems reluctant to change a medication, please do not mistake that hesitation for a lack of compassion. Nothing could be further from the truth. If there were a clear clinical reason to make a medication change, we would do it immediately. When we recommend staying the course, it's because we believe that maintaining stability, even during severe symptoms, is usually the fastest, safest, and most rational path back to recovery. And just to tack on another piece of support for this, this is from the American Society of Addiction Medicine. This is their guidelines on benzodiazepine de-prescribing that was published in 2025 and endorsed by numerous professional organizations. Here's what they say here. They noted that when clinicians do not recognize patient symptoms as protracted withdrawal, they may recommend medications for symptom management that have direct or indirect effects on GABAergic signaling. Those medications can exacerbate or lengthen the duration of those symptoms. So again, there is further authoritative support to simply let things settle and not throw a million things at the wall cuz that will often make things worse.

Now, the next thing I need to talk about is that it's very important to avoid exposure to non-psychiatric medications that are known to cause severe neurological adverse reactions. Given that you've already sustained a serious adverse reaction, you do not want another one. Furthermore, patients with protracted withdrawal injuries are already more sensitive to adverse reactions in general, and they are much more likely to have an adverse reaction to another drug, even if they're rare. Now, while many medications can do this, here's a short list of the worst drugs to try and avoid if you can. So, the first one are the fluoroquinolone antibiotics, such as ciprofloxacin or Cipro, or levofloxacin or Levaquin. Now, this medication can cause a whole range of neurological side effects, such as convulsions or toxic psychosis. These antibiotics, they're often used for bowel infections or also severe UTIs. And if anyone ever prescribes that to you, you want to ask the doctor if it's possible to take a different medication. The next drug that I want to talk about are steroids. Now, steroids are well-known to cause a whole host of psychiatric side effects, like insomnia, mania, and anxiety. These are drugs like prednisone or methylprednisone or prednisolone. They're often used in autoimmune conditions. The next drugs to talk about are nausea drugs like Reglan or Compazine. Now, many people think these are benign because they're used for nausea, but they can cause a whole host of neurological side effects, and so you want to avoid Reglan and Compazine, and perhaps take something like ondansetron instead if you need to take something for nausea. Now, in general, if you are given any new medication by an outside doctor, please tell your clinician first so they can look up the drug label and confirm that the drug is not known for causing any severe neurological adverse reactions, as they may be able to suggest alternative medications. And finally, at the end of the day, this is all risk reduction. Even though these medications can irritate the nervous system, if you have a severe infection that requires a fluoroquinolone, then you should take that medication, as the risk of the infection harming you is probably much higher than the risk of having another adverse reaction to it. In addition, if you have a severe autoimmune problem or you have a cancer and you need to take some steroids, then the risk of that cancer or autoimmune condition may outweigh the risk of irritating your nervous system with the drug. And so, you always just want to consider those two risks when deciding whether you're going to take the medication or not.

Next, I want to talk about optimizing your physical health. I believe this section is one of the most important in this entire video. Here's why. Protracted withdrawal injuries gradually improve over time as the brain heals. But, this raises the question, is there anything that I can do to accelerate this healing? Now, sadly, there are no studies evaluating interventions that improve healing rates in protracted withdrawal injuries. But, there are, however, studies in both humans and animals with traumatic brain injuries, and here's what they find. This first study published in neurorehabilitation did a comprehensive review on dietary interventions for veterans with traumatic brain injuries. And here's what they found. "Preclinical studies and early human trials suggest that specific nutrients and diets may offer neuroprotection or benefit during mild traumatic brain injury rehabilitation. Omega-3 fatty acids, creatine, vitamin D are generally safe when taken within the guidelines. The DoD's warfighter nutrition guide recommends a whole food diet rich in antioxidants, phytonutrients, omega-3s, micronutrients, probiotics, and fiber to optimize long-term health and performance." Now, this should make sense to everyone here. Your brain is part of your body, and if we can get your body nutritionally sound and give it all of the nutrients it needs, it will accelerate the healing of your brain. And so, to address this, in-house at the Tait Clinic, our dietary specialist will assess your diet, your macronutrient intake, and they will help you identify foods that provide your body with the nutrients needed to support healing. Our nutrition specialist may also order micronutrient and vitamin testing to guide any additional supplementation, if appropriate.

Now, the second thing to keep in mind is the effect of movement and exercise on healing. And here's what the study by Archer found. They found that the influence of exercise on TBI is multiple, ranging from anti-apoptotic effects, that means uh keeping neurons alive, to the augmentation of neuroplasticity. That means accelerating the growth of neurons in the brain. Physical exercise diminishes cerebral inflammation by elevating factors and agents involved in immunomodulatory functions, but your glial cells, cerebrovascular, and blood-brain barrier intactness. On top of that, Gordon also found this in his study of actual patients. They looked at 240 individuals with TBIs, and they compared exercises to non-exercises. And here's what they found. It was found that the TBI exercises were less depressed than the non-exercising individuals with TBIs. And that the TBI exercises reported fewer symptoms, and their self-reported health status was better than the non-exercising individuals with TBI. So, as you can see, studies consistently show that gentle exercise reports recovery after a TBI. But, there's one caveat that I want you to keep in mind. Many patients with protracted withdrawal injuries, especially during the first 6 to 9 months, find that exercise actually makes them worse. It can flare up their symptoms. And so, if that is you, don't worry about it. You don't need to exercise at the beginning. You may need to simply just wait for the symptoms to die down a little bit before you can start to introduce exercise. And when you do that, you want to do it slowly. Start with a little bit of walking, then extend that, then you, you know, walk longer, and then eventually you can say, you know, can I do a bit of maybe hill walking, or maybe even some jogging. You want to gently expand what you can tolerate, but don't throw yourself in the deep end right from the start. And so, right now, if you're someone and you can't exercise cuz you're really symptomatic, just continue to rest. That's totally okay. Very soon, you'll be able to introduce a little bit of that.

And the last thing to keep in mind is that we want to treat any medical conditions that you have. So, if you have any medical problems right now, like sleep apnea or thyroid dysfunction, we need to make sure that they are appropriately treated. Because if you have medical conditions that are taxing your body, that is also going to hold back your recovery. And so, at the Taip of clinic, your clinician will do a complete review of your medical history with extensive testing. And if we identify any medical problems that need treatment, we're going to send out the appropriate referrals and make sure that that's taken care of.

Now, next I want to talk about the role of therapy in protracted withdrawal injuries because many patients and families often wonder whether seeing a therapist is helpful during recovery from protracted withdrawal. And the answer is yes. However, the type of therapy that is helpful depends entirely on the challenges that someone is facing at this stage of recovery. You see, protracted withdrawal presents several very different psychological challenges. The first is managing the neuro emotions. Now, these are not psychological problems in the traditional sense. These are intense psychological symptoms being generated by an injured nervous system. Now, Adele described this really well in her article. Here's what she wrote. "Emotional spirals and neuro emotions. People experiencing withdrawal may adapt every possible variation of depression or anxiety. Like other adverse drug reactions, withdrawal might generate psychological symptoms including suicidality that are unprecedented or more severe than ever before experienced. Often bewildered by their symptoms having no other vocabulary to describe their unusual psychological states, patients might claim not feeling myself, I feel OCD, I feel psychotic, I'm having a breakdown, or this doesn't feel like my depression. Like physiologic withdrawal symptoms, emotions generated by the neurological chaos of withdrawal often come in intense sporadic waves with exaggerated amplitude. We call them neuro emotions. Among them may be extreme anxiety, despair, or anger, as well as mania or hypomania."

Now, I want to bring this to life in a different way because here is what I see in my practice. I see patients stuck in a persistent negative mood state. They catastrophize. They often describe cognitive impairment and the defining feature of this neuro emotion state is that they become stuck in constant loops of fear and dread that seem impervious to any type of reassurance. In addition, because of this, they constantly second-guess their plan and desperately want to change things because internally, something always feels bad, wrong, or doomed to fail. Some patients, when they get in this state, they're also terrified of being alone, and they need to be with someone all the time. Now, during the stage of protracted withdrawal, what people need the most is consistent, repetitive reassurance, validation that what they're experiencing is real and normal, and ongoing support and community. At this stage of severe symptoms, there should be no pressure to engage in emotionally taxing therapy that dredges up the past or requires them to challenge these thoughts, as these thoughts are often not logical at all. Think of them as steam coming off damaged neurons. They're not really rational thoughts. They're just a consequence of a damaged nervous system generating frightened emotions. Now, often what I see is that around 6 to 9 months into the injury, these neural emotions die down on their own. Therefore, most patients should be reassured to

Just wait this period out with just gentle and compassionate supports from their friends, family, and therapists.

Now, the second therapeutic area which people should focus on is navigating the practical consequences of this injury. Now, Professor A.J. Finlayson from Vanderbilt conducted a survey on patients with benzodiazepine protracted withdrawal injuries, where he asked them about the impact this condition had on their life. And this is what he found. Look at this column here for enormous problems. Work life, 49% had enormous problems. Fun recreation, 48%. Social interaction, friendship, 41%. Ability to take care of home and others, nearly 40%. Relationship with spouse, family, 37%. Ability to drive or work. As you can see, protracted withdrawal injuries frequently disrupt major aspects with your life, such as your relationship with your spouse, or your kids, or your work.

Many people may be dealing with going on disability for the first time or taking a leave from work. Other patients may be dealing with how to look after their kids now that one of the parents is injured. It may be very taxing on the relationships. And so working with a therapist on troubleshooting practical solutions to these problems can be extremely valuable. Having a clear understanding of how you will handle work or child care during this injury will allow you to put those stresses away and then focus on your recovery.

Also very important can be having a therapist simply help the patient grieve the temporary loss of their health and their ability to do all the things that they wanted to do. And those inevitable feelings of guilt about feeling like a burden to those who are now caring for them.

Now, the last area that I think can be helpful in the therapy of protracted withdrawal is teaching distress tolerance skills and acceptance and emotional regulation. Now, as the nervous system begins to settle and the intensity of those neuro emotions decreases, the brain becomes much more capable of learning new coping strategies. This is where interventions such as meditation or breath work or cognitive behavioral therapy or acceptance-based therapies can become more helpful. However, timing matters. If someone is still experiencing overwhelming neuro emotions from the protracted withdrawal injury, asking them to simply challenge their thoughts or reason their way out of their symptoms is often ineffective and it's going to frustrate them. Those therapies tend to work much better once the nervous system has regained some stability.

And finally, there's always some people out there who wonder whether their symptoms are actually the result of unresolved trauma. While previous trauma absolutely influences how people experience and respond to difficult life events, I generally find it's far too difficult to meaningfully engage in any trauma therapy when someone is actively recovering from a neurological injury. For that reason, I usually recommend focusing on what we've discussed here. That is support and reassurance, practical problem-solving, meditation and distress tolerance skills until the nervous system has substantially recovered. Once recovery is well on the way, trauma work can always be revisited if it appears clinically appropriate.

Okay, so who do we recommend that you work with here? Well, at The Tapei Clinic, we are fortunate to have some of the most experienced therapists in the world working specifically with people recovering from protracted withdrawal. They have personally experienced these withdrawal injuries themselves, and they have advanced training in therapy. And so, if therapy is needed, your clinician will discuss this with you and provide a referral to our in-house specialists. And in addition to the individual therapy, we also offer three support groups led by our protracted withdrawal specialists a week. These groups provide reassurance, education, practical guidance, distress tolerance skills, and perhaps most importantly, a sense of community with other people going through protracted withdrawal injuries who are recovering from them right now alongside you.

We're now going to move on to answer some of the most commonly asked questions about benzodiazepine protracted withdrawal. One of the most common concerns early in protracted withdrawal injury is whether the symptoms could be due to another medical condition. In fact, because many doctors have never heard of this condition before, they often misdiagnose it as other medical conditions. This is such a common occurrence that it's clearly described by Doctors Taylor and Horowitz, who write this in their section on misdiagnosis of withdrawal as a new onset mental or physical condition. They say, "Withdrawal symptoms can be misdiagnosed as another physical diagnosis such as medically unexplained symptoms, chronic fatigue syndrome, or functional neurological disorder, somatoform disorder, multiple sclerosis, because the myriad of symptoms of benzodiazepine withdrawal such as psychiatric symptoms, fatigue, muscle fasciculations, cramps, tremors, and other neurological symptoms overlap with the diagnostic criteria of these syndromes."

And they are right, because a lot of the symptoms of protracted withdrawal do seem like they could be potentially medical. I mean, look over here. These are a list of the most commonly reported symptoms from Professor Finlayson's article from Vanderbilt. And have a look at this. Muscle weakness, cardiac irregularities, hypertension, headaches, nausea, diarrhea, balance problems, stabbing pains, tingling in the skin, burning sensations, concentration difficulties, trembling. So, as you can see, these symptoms affect multiple organ systems. Like, if if we look at the central nervous system, they're causing vision and hearing changes, tingling in the hands, feet, face, neck, and balance problems. In the motor nervous system, we have tremors or muscle tightness. In the higher order cognitive and emotional systems in the brain, we've got concentration problems, brain fog, dissociation, high anxiety. Our autonomic nervous system, which is our unconscious nervous system that controls our heart and our digestive tracts, we've got, you know, palpitations, we have sweating, we have nausea and diarrhea.

Now, because protracted withdrawal injuries also cause intense anxiety, when people have these symptoms in these different organ systems, they develop a health anxiety. And patients will frequently feel like they've contracted a serious medical condition or they're dying. For instance, someone who now has strong racing heart palpitations that come out of nowhere will all of a sudden start to wonder whether they've developed a cardiac condition, and they'll think that they need to see a cardiologist. Someone who's having ongoing nausea or diarrhea or bloating will believe they have a gastrointestinal problem and they need to see a gastroenterologist. Someone who's having serious emotional and cognitive problems alongside tremors may believe that they have Parkinson's, multiple sclerosis, or ALS, and they want to see a neurologist. These are all completely normal and natural concerns when you have new onset severe symptoms and high anxiety.

However, these concerns should be managed strategically because there are pros and cons to going down these rabbit holes and beginning to investigate all of these concerns. Well, let's start with some potential benefits. What are the pros? Well, potentially, you find a real problem that has a solution and improves your quality of life. But, there's also another really important pro, even if you don't find a real problem. The other pro is simply the peace of mind that comes with a doctor telling you that they did not find any signs of the condition you're worried about. For instance, a doctor saying that your brain scan does not show Parkinson's. Or a cardiologist saying that they're not finding any concerning arrhythmias that would put you at risk of cardiac arrest.

However, there's also a lot of downsides and cons to going down these rabbit holes. It can be expensive to see these specialists. It can be time-consuming. They may order multiple tests, some of which are uncomfortable and could expose you to medications or procedures. Think endoscopies for GI concerns. The doctor might misdiagnose you and present you with a treatment plan of something just to be safe and prescribe some medications that don't work or potentially make you worse. And so, each patient and family will need to decide how many of these investigations and specialists they want to engage with. Also, your clinician at the taper clinic will help you reason through what they believe are the ones that make the most sense. Generally, however, we do not recommend patients follow up with multiple specialists routinely when the symptoms are clearly suggestive of a protracted withdrawal injury. For example, if you come off a benzodiazepine that you've been on for 5 years and within a couple of months you're hit with a constellation of psychiatric, neurologic, cardiac, and gastrointestinal symptoms that are classic for a protracted withdrawal injury. And on top of that, you've got medication sensitivity, morning cortisol surges, and a wave and window pattern of symptoms. In a case like this, it is much more likely that your symptoms are fully accounted for by a protracted withdrawal injury, rather than you spontaneously developing multiple new medical conditions. And because of this, further investigations and meetings with specialists are unlikely to yield actionable and helpful interventions.

And I want to say this, this is a good thing because the prognosis of protracted withdrawal is good. The heart palpitations get better. The cognitive problems and tremors get better. This is not like a cardiac arrhythmia issue, which puts you at risk or something like Parkinson's. You almost want it to be protracted withdrawal because the prognosis is much more likely to be positive. But, all that being said, if you feel that the peace of mind of seeing a cardiologist, neurologist, or another specialist would greatly reduce your anxiety, we are essentially supportive of you doing that because that allows you to turn over the stone, make sure that there's nothing scary hiding underneath there, and then after that, you have that peace of mind and you can just focus on your recovery without having that concern in the back of your mind. Additionally, you may actually have a family history of cardiac problems, gastrointestinal, or neurological problems. And then, we actually may encourage you to undergo additional testing as you could potentially be at higher risk of one of these conditions developing spontaneously.

Another concern that a lot of people have is whether this could be due to another psychiatric condition, such as major depressive disorder. This is really common. Again, Doctors Taylor and Horowitz note this, that sometimes symptoms that emerge on dose cessation are misdiagnosed as a new-onset mental health condition, such as anxiety, insomnia, or bipolar disorder. Now, typically, this concern arises because of the abrupt worsening of severe anxiety, obsessive negative thoughts, occasional paranoia, and cognitive impairment. Understandably, with such serious symptoms, one would wonder whether they have spontaneously developed a serious psychiatric condition. Usually, part of the question is logical, and it's important to go through the diagnostic criteria of these psychiatric conditions and compare them to the diagnostic criteria for protracted withdrawal injuries.

Let's consider major depressive disorder. This is a very loosely defined psychiatric condition in which you receive the diagnosis if you've had five out of nine symptoms for more than 2 weeks, as you can see up here on the screen. Now, if you do not respond to two antidepressant medications, you are often considered to have treatment-resistant depression at that time. Now, briefly, something I really want you to understand that this is not a condition defined by objective measures such as a laboratory test, genetic findings, or brain imaging. It is a symptom-based diagnosis. And statistically, because major depressive disorder can be diagnosed by any combination of these five out of nine symptoms, there's over 10,000 different ways that someone can meet the diagnostic criteria. This is one of the major criticisms of psychiatry in general. Our diagnoses sound like discrete disease entities, but they're often just labels applied to broad clusters of symptoms.

Furthermore, researchers have searched extensively for biological abnormalities that reliably distinguish people with depression from healthy controls, including differences in brain imaging, genetics, neurotransmitters, hormones, and other biomarkers. And despite decades of research, academic psychiatrists have not found a single biological abnormality that has been consistently shown to define or explain depression. In fact, what they find as Professor Joanna Moncrieff from the University College London says here in her correspondence in Nature, is that social adversity, childhood maltreatment, and a lack of social support, and stressful life events show some of the largest and most consistent associations with depression, rather than any of these other biological underpinnings.

Furthermore, psychiatric conditions like major depressive disorder do not typically involve global neurological symptoms, such as sound sensitivity, light sensitivity, heart palpitations, tremors, nausea, tingling in the hands, adrenaline surges in the morning or during naps, medication sensitivity, or a loss of medication response, and the characteristic wave and windows of patterns during symptoms. Again, if I draw you over to this list of symptoms of protracted withdrawal injury from Finlayson, you'll see that many of these symptoms are not part of the diagnostic criteria for depression. So, consequently, if you're experiencing psychiatric symptoms that are severe and appear out of proportion to the stresses going on in your life right now, and you're having that together with a range of neurological symptoms that are classic from protracted withdrawal like marked medication sensitivity and symptoms that emerged within a few months of an abrupt medication change, the most likely explanation is that you've developed protracted withdrawal, not that you've developed treatment resistant depression.

And one important aside is this, and I want to acknowledge this. It is entirely possible to have a psychiatric condition start at the same time as protracted withdrawal, because it is natural that the disability and suffering associated with the protracted withdrawal injury could make anyone feel depressed or anxious. However, this is very different from concluding that the totality of the symptoms is due solely to a primary psychiatric condition that has just emerged. And ultimately, what I want to say is this, a co-occurring diagnosis of depression or anxiety does not change the treatment plan in protracted withdrawal, as we would not recommend this condition be treated with any psychiatric medications. Given that once you develop a protracted withdrawal injury, often taking psychiatric medications will make it worse. And we're going to discuss this more really shortly.

Now, I know a lot of this may seem really clear on a logical level, but there's an emotional component to this, because having worked with many patients experiencing protracted withdrawal, there's powerful psychological reasons why people will want to believe that their symptoms are due to a psychiatric condition such as depression. First, many patients have spent years believing in the traditional psychiatric model and the effectiveness of psychiatric medications. Consequently, when a severe adverse reaction like a protracted withdrawal injury occurs, they may psychologically prefer to remain within a familiar framework of understanding rather than face the possibility that they've been harmed by a side effect that the traditional psychiatric system has largely failed to recognize. Second, there's often an element of grief processing that occurs early in the diagnosis of protracted withdrawal injury, particularly the stages of denial and bargaining, because despite the evidence pointing most strongly towards someone having a protracted withdrawal injury, some patients may continue to hope that they actually have a traditional psychiatric diagnosis because it preserves the belief that perhaps the next medication or intervention, whether that's an antidepressant like ketamine or TMS, will ultimately fix what's happening to them. And so if you have questions about whether your symptoms could be due in whole or in part to a primary psychiatric condition, please discuss this with your clinician and they will apply the relevant diagnostic criteria to your specific symptoms and then explain why they believe one diagnosis is more likely than the other.

The next question a lot of people have is, is there a cure for this? Now, following a protracted withdrawal injury, it is natural to frantically search for a cure. Often times the idea of waiting for recovery seems much too passive for a condition that has not only disabled someone, but it is causing daily severe symptoms and having a huge impact on their family life. Understandably, many people end up searching the ends of the internet for cures. I've had patients try stem cells, IVIG, a new drug or intervention with supposedly healing properties like ketamine, microdosing psychedelics, or TMS. Some people have considered going to clinics where they can be sedated with anesthetics and have the drug removed in a quote-unquote comfortable way, or they're put on flumazenil, which will apparently reset the benzodiazepine receptors.

What I want you to hear right now is that there is no clinical trial research on any interventions for protracted withdrawal injuries. What this means is that everything here is experimental and there's no clear data on efficacy or safety. And having worked with hundreds of patients with protracted withdrawal injuries over the last 7 years, I have not found any clear-cut cures that work with any consistency, even anecdotally. And on top of that, I have professional relationships with leading figures in this space, from Adele Framer to Mark Horowitz, and even in-house here with Nicole Lamberson, who's been doing this for 15 years. And so collectively, we have been in this space for nearly 50 years together, and we have helped thousands of people, and we have spent years trawling online forums and reading experiences from patients and interviewing them. And if there was something out there that one of these professionals had found that consistently worked, they would have told me about it, and we would be screaming it from the rooftops, but we have not found anything yet.

That said, I do want to acknowledge that the desire to want to try and experiment with anything is natural. And so if you do so, the clinical team will try and steer you towards interventions that are less likely to cause worsening symptoms or be unreasonably expensive. For instance, stem cells, especially in Mexico, carry contamination and quality control risks. There's also substantial uncertainty about their effectiveness despite the hype. Ketamine, psychedelics, and TMS have worsened many patients that I've worked with before. And any facility promising abrupt discontinuation under sedation ultimately risks worsening the underlying injury by inducing a withdrawal. And finally, using flumazenil, which essentially disengages benzodiazepines from the receptors, that can also precipitate an uncontrolled withdrawal. And there really isn't any evidence that it {quote} "resets the receptors." And so I'd recommend avoiding those treatments.

That said, there are other things out there, things like hyperbaric oxygen therapy, cold plunge, red light therapy, dietary strategies, certain supplements, and other interventions as well that are generally targeted towards improving general health, lowering inflammation, or improving mitochondrial function. All of these things may hypothetically improve recovery, and they tend to be lower risk and less financially burdensome. And so therefore, we're are likely to support them. And so if you're interested in trying any experimental treatments, please contact your clinician who's going to vet the opportunity with you and ensure you do it in the safest possible way.

Can I take medications for symptom relief? Many patients often wonder if there are any drugs they can take for symptom relief. Additionally, family members are often highly distressed by watching their loved ones suffer and also wonder if there's any drugs that can help them. Sadly, there is no clinical trial research on whether medications work with protracted withdrawal injury symptoms. And in addition, the existing published surveys paint a very bleak picture on how effective medications are in this condition. For instance, let's look at what Adele wrote. Remember, this is the professional who had worked with 10,000 people coming off psychiatric medications. Here's what she says. As withdrawal symptoms indicate neurological instability, we have found dose increase reinstatement and other drug treatments should be approached very cautiously. Many site members seem to react badly to what I considered minimal doses of any psychoactive substances, usually responding with activation or paradoxical reactions. This is a theme that you've seen throughout this video. The injured nervous system responds unpredictably to drugs. She says this, "Some arrive already racked by failed withdrawal attempts or adverse reactions to aggressive drug treatments because their prescribers thought they were suffering a relapse or another psychiatric disorder and they wanted to help."

Outside of Adele, another researcher, Michael Hengartner, did a survey of individuals with any depressant protracted withdrawal, which is really very similar to benzodiazepine protracted withdrawal. And here is what he found in the individuals who had tried other medications to help with the symptoms. He says this, "Treatment with drugs other than the one implicated in the protracted withdrawal syndrome was attempted by 33 subjects. Four reported some benefit and two substantial benefit. Gosh, those are really bad odds. That's like less than 25%."

Now, I I say that my own experience really lines up with what these other experts are saying. Because personally, I've worked closely one-on-one with hundreds of patients with this condition over the last 7 years, and I found very similar results. Initially, when I first started working with these patients, I frequently attempted to use multiple medications because patients and their families would beg me to do anything to relieve their symptoms. I have personally tried nearly every psychiatric, neurological, and cardiac medication on patients with protracted withdrawal injuries. I've even put patients on morphine, oxycontin, and fentanyl to try and help them find relief. And in nearly all of the cases, interventions did not work, and in many cases, I made patients worse or complicated their course. And even in the instances where the medications worked at the start, the beneficial effects typically wore off quickly, leaving the patient on a medication that really wasn't helping them anymore. So consequently, for the last 4 years that I've been doing this, I've consistently recommended that patients try to avoid taking any medications to mask or suppress the symptoms of protracted withdrawal injuries, as they often worsen or prolong the recovery course.

That said, sometimes patients feel like they must try something, and they are willing to take the risk of some worsening or the need to later remove that drug more slowly. Generally, in these instances, I've had some minor success with propranolol, clonidine, hydroxyzine, or even sometimes low doses of Benadryl. These are generally mild drugs, which may only improve symptoms in a minor way. However, many patients find psychological relief simply having something on hand to take when they're having severe symptoms. And so if you're interested in trying a medication for symptom management, despite our general preference that patients avoid these medications cuz they can irritate you and make you worse, you can discuss how to try and do this safely with your clinician. Generally, we will recommend starting the medication at a quarter to half of the normal therapeutic dose, and then slowly increasing it to carefully test response before exposing you to the full dose.

Can I take supplements to lessen symptoms? Many patients with protracted withdrawal injuries understandably want to do everything that they can to accelerate their healing. This often means they consider supplements or they are offered supplements by well-meaning doctors during their healing journey. The taper clinic has some clear guidelines on how we recommend people use supplements if they choose to. The first thing to be aware of is that just because something is called a supplement and it's available over-the-counter or it's labeled natural does not mean it's safe. There are multiple supplements that have potent effects and for the most part they can be considered neurologically active drugs and they should therefore be treated like drugs meaning they can irritate the nervous system. They can cause dependence and they can cause withdrawal reactions when you come off. Some supplements such as ashwagandha and lion's mane can even cause serious neurological problems and I've covered this in depth on my YouTube channel. And even naturally occurring compounds like the amino acid L-theanine which is used for anxiety when taken at 200 mg which is a common dose for this supplement which is much higher than what naturally occurs in the body, it can lead to dependence and withdrawal reaction if you go and look in forums. And so because many of these supplements are clearly neurologically active, they should be used cautiously as they can irritate the nervous system and cause dependence and eventually withdrawal issues. Again, this was noted by Adele Framer who commented this. She said the hyper reactivity can also be triggered by small amounts of alcohol and neurologically active antibiotics, herbs, foods, supplements, caffeine, B vitamins, St. John's Wort, and fish oil. And honestly, this has been my experience as well.

And because of these concerns at the taper clinic, we generally separate supplements into two categories. The first category is something called a nutraceutical. So what is a nutraceutical? Well, it is a concentrated source of a nutrient taken at a dose that far exceeds what a human would naturally make or access in a natural food source. These can be things like vitamins, minerals, amino acids, herbal extracts, which are taken in pill, capsule, or liquid form. And because of their potent strength and their pharmaceutical properties, these doses can actually create a drug effect beyond their nutritional value. Think about L-theanine or ashwagandha or lion's mane, which all clearly have psychological properties. So, that's the first category, the nutraceuticals. These are the supplements that really act like drugs. The second category are supplements that correct deficiencies as they are not inducing new drug-like states through their pharmacology or unnaturally high doses, but are merely correcting clearly identified deficiencies. In addition, we will recommend ongoing testing to know when to cease the use of them so that you do not have to take them indefinitely, and we ensure that we do not overshoot the natural levels in the body. And as you might have guessed, we recommend against using any nutraceuticals due to concerns for kindling, lack of efficacy, paradoxical reactions, and dependence and withdrawal eventually. And so, our team is going to review all of your supplements and let you know which ones we recommend keeping, starting, and stopping to best support your recovery and minimize the risk of any of them causing problems.

What do I do if I need a surgery or procedure during my recovery? Many people with protracted withdrawal injuries, given their history of multiple bad reactions to medications, are worried when they need to get a surgery or procedure. This is because it involves anesthesia, anti-nausea medications, and sometimes antibiotics. Here is how I would recommend approach these decisions. First, you should ask yourself, do I really need this procedure now? If it's a routine colonoscopy, you may decide to put it off for 1 to 2 years while you recover. Yes, there's a risk you may miss something, but unless you're high risk and you're having a bleed, the risk is likely small. You can simply wait until your nervous system fully recovers before going in for the procedure. However, if it's something you cannot avoid, here's what I would recommend. Clearly tell the anesthesiologist which medications you do not tolerate well and which medications you have tolerated well in the past. Some patients with protracted withdrawal injuries may have had poor experiences with benzodiazepines and they may prefer to avoid them completely. Others can tolerate them just fine. In general, what I've seen over the last 7 years helping these patients is that the vast majority of my patients seem to tolerate short one-off treatments with benzodiazepines, ketamine, and propofol without major issues and these are the most common prescribed anesthetics for procedures and surgeries. Some patients with protracted withdrawal injuries may have had very bad experiences with benzodiazepines before and they may prefer to completely avoid them. Others can tolerate them just fine even though they were the drugs that triggered the withdrawal injury. But in general, what I find in the vast majority of my patients with protracted withdrawal injuries is that they seem to tolerate short one-off treatments with benzodiazepines, ketamine, and propofol without any major issues and these are the most common anesthetics used for procedures and surgeries.

Next, you want to tell the surgeon and the anesthesiologist to avoid Compazine and Reglan for nausea. If significant nausea develops, ondansetron has a much safer side effect profile for nausea control. And finally, if antibiotics are needed, see if they can avoid fluoroquinolone antibiotics such as ciprofloxacin and levofloxacin. However, these are rarely used outside of kidney and bowel surgeries. Overall, if a surgery or procedure is truly needed, you may need to proceed despite the small risk that you could destabilize your protracted withdrawal injury and your clinician is going to help you make that decision. Thankfully, having helped hundreds of these patients, I've not seen a single case where a surgery or procedure has caused a significant setback in a patient.

How can family and friends best support someone with a protracted withdrawal injury? This role is very important and it can be very demanding. Many patients with protracted withdrawal have severe anxiety. They may constantly believe things are worsening or that they are physically dying even if nothing is materially changing. Consequently, they may constantly be asking their supports for reassurance. On top of this, many of them may struggle with being left alone, and who can blame them? If you're suffering a lot, being left alone can be terrifying. And finally, given the degree of cognitive impairment many patients have at the beginning, they often struggle to remember the reassurances of their clinical team and may need things repeated to them frequently. These factors can make friends and family feel like they are constantly providing the same reassurance again and again and again, and that it's not making any difference to their loved one, and it can feel exhausting. This is natural and normal for protracted withdrawal recovery, and this is simply what providing support for these individuals looks like, especially during the first year. And it can be very intense and excessive. But as the nervous system heals, the demands for reassurance will go down, and you will eventually see that all your efforts were absolutely life-saving in helping your loved one through an extraordinarily difficult health crisis.

But here is some practical advice for you, the caregiver, to best endure this challenging time. The first thing that I would recommend is that you look after your own mental health. You cannot be expected to be on call 24/7 for them. You need to be able to recharge. If you don't, you will burn out. If it is hard for you to get away and find the space, our therapists will work with you and your loved one to help find ways for you to recharge. Second, you should consider bringing in additional family support. This is a serious medical crisis. If you need siblings, cousins, or other trusted people to provide some respite care, now is the time to consider calling them. Also, paid support can be arranged through certified nursing assistants who can come to the house and provide supervision. Speak to your insurance company to see if you have any coverage for this. Next, come to our monthly support groups for families and friends of people with protracted withdrawal. Bring questions. Connect with other family members. These are private groups for families to speak freely about their experiences and learn from one another. On top of that, I also have some psychological advice. But first, I would recommend you learn about what this condition is. Review this entire video, so you have a deep understanding of this condition and its treatment. Attend clinical meetings with the patient, so you know what the clinician is saying and you can learn how to repeat the reassurance that the clinician gives. Third, do not judge yourself if you get frustrated or overwhelmed. This is completely normal when you are dealing with your regular life stresses and a medical crisis occurs. This is temporary and this will pass. Next, remember your loved one is likely not themselves right now. The level of instability in their nervous system is hijacking their thoughts and putting them into a very negative state of mind. Things are often not as hopeless as they may express, as their thoughts are clouded by the injury. Try to not get sucked into their doom spiraling. Try to create some emotional distance from it and continue to provide support and reassurance. Now, if you don't know what to say to reassure them, what I would simply say are things like this. Firstly, you should direct it back to the clinician. What you're going through right now is really important and I can see you're suffering a lot. I don't have the answer to this question, but let's talk to your clinician as soon as we can, so we can figure this out. If your loved one is just generally suffering and they don't know how they're going to get through this, sometimes simply saying something like, "All I can tell you right now is that I love you and I'm not going anywhere and I promise you that I will be there with you while you get through this." You may need to say things like this multiple times a day. And finally, what I also want to tell you, because many family members are worried about this. They feel like they have lost their spouse, their parent, or their child. They worried that they will never be able to do all the things that they wanted to do with them, whether it was retiring and visiting that favorite European city or going on that mother-daughter trip that they always wanted to do. What I want to remind you is that this condition has a great prognosis and it will get better over time. Your loved one will return to you, so please stay hopeful.

What happens if I become intensely suicidal? Protracted withdrawal injuries have a great prognosis and they are not progressive. All patients I've seen over the last 7 years have gradually improved over time with the vast majority seeing full or near full improvement by 18 to 24 months, but sometimes sooner. That said, the major risk to recovery is the risk of suicide, particularly within the first 6 to 9 months of the injury where symptoms tend to be at their most intense. If intense suicidal thoughts occur, immediately tell your family and clinician. We will set up a meeting to discuss how we can better support you. This may involve more frequent clinical check-ins and therapy support. We may also discuss risk mitigation such as temporarily removing access to means such as firearms during this acute period of severe symptoms. Sometimes symptoms may be so acute that we will recommend seeking inpatient or residential treatment, mostly for enhanced safety monitoring during a particularly bad wave. This is because outpatient monitoring with family support does not provide the level of supervision needed to ensure safety if someone's having intense suicidal thoughts during a wave. If this happens, our team will collaborate with the inpatient team to educate them on your condition. Please do not view temporary hospitalization or residential care as a failure. Many patients need short-term safety monitoring during the first year while symptoms are at their most intense. These hospitalizations keep you safe and also allow the clinical team time to work with your family to strengthen our outpatient supports and monitoring to keep you safe. Remember, how you feel is temporary and the longer you're able to hang on, the more your nervous system will cool off and the symptoms will abate. If you are feeling intensely suicidal and unable to immediately discuss your concerns with your clinician, please ask your family member to bring you to the local ER for safety monitoring. If you are alone, call 988 or 911 and report that you're suicidal. The ER will monitor you until our clinical team can contact you and help advise you and your family on the next steps.

Can I use common drugs like caffeine, nicotine, alcohol, and cannabis during protracted withdrawal injury recovery? We strongly recommend avoiding caffeine, nicotine, alcohol, and cannabis, and other drugs during recovery from protracted withdrawal. Stimulating drugs like caffeine and nicotine, and for that matter ADHD drugs, shift the body into a more sympathetic or activated state. This is the opposite of what we want. We want the body shifted towards a parasympathetic or recovery state. States of chronic sympathetic activation suppress neurogenesis, essentially the healing of the nervous system. So, we do not want to be putting any additional pressure on a system that is already ramped up. Likewise, alcohol use can reduce sleep quality, which can slow down the healing process and lead to worsening anxiety. Cannabis use is also associated with worse psychiatric symptoms, suicidality, and mood instability. Please contact your clinician about strategies to remove these drugs if you're taking any of them.

Now, finally, how do you stay well after you recover? Well, congratulations. If you get here, you have survived a struggle that most people will never comprehend. Going through a serious health crisis often provides patients with a deep appreciation for life and family. Many find that the inner strength that they've had to muster during this ordeal provides them with immense strength that can help them throughout their life. However, sadly, you are not completely out of the woods yet. And the next phase of your life needs to center around maintaining your recovery. Once symptoms have largely abated, a common mistake people make is to throw themselves back into life at full force. And who can blame them? They have been suffering, sometimes for years, and they feel like they've been missing out. We have had patients who begin to drink alcohol, resume caffeinated beverages, and use nicotine products. Others begin experimenting with drugs like psychedelics or cocaine. Some throw themselves headlong into work, trying to make up for lost time. Some begin taking medications without thoroughly assessing their drug labels to ensure they're not associated with neurological harm. Please do not do any of this, as this can trigger a setback.

Now, a setback is a regression back into a state of severe symptoms. It's essentially a kindling injury induced by overwhelming your fragile nervous system with too many insults. And these can last for several months or longer. A setback is essentially a second injury induced by not caring for your nervous system. This is absolutely devastating when it occurs, because you have already fought so hard to survive, and you now need to do it again. And so, why does this happen? Well, once you start to feel better, it is important to recognize that this means that your nervous system has only recovered to the point where it's no longer experiencing severe symptoms, but that the nervous system is still fragile and is still going through a process of healing. On the shorter side, I would recommend resuming life cautiously for at least 2 years following recovery to allow your nervous system additional time to fortify. This means avoiding stimulants and recreational drugs, avoiding alcohol, intense workouts, and avoiding returning to stressful work too quickly. Think about your recovery like a precious small fire that has been lit. It needs to be carefully nurtured over the next few years to ensure it can become robust. After a few years, you can increase the intensity of your physical workouts and stress. You can also introduce some caffeinated beverage and some alcohol within reason. However, there are a few things that I would recommend avoiding indefinitely. First, avoid psychiatric medications. No matter how tempting it is to reach out for a daily medication, the toll of a daily neurological medication is a clear way to re-injure yourself. And from experience, we already know that you have a tendency towards bad reactions with neurological medications. And so, after you've had a protracted withdrawal injury, you are firmly in a category of individuals who need to learn to find non-drug approaches to manage their mental health. Given the high severity of what you experienced, it's hard to imagine that the risk-benefit of any ongoing psychiatric medication would be worth it. Next, you want to avoid stimulating drugs like cocaine, methamphetamine, psychedelics, LSD, and psilocybin. These drugs are potent and induce strong excitatory reactions in the brain, and they have been linked to setbacks even years after recovery. Third, avoid fluoroquinolone antibiotics. And fourth, in general, avoid all non-essential medications and even vaccinations. On top of this, review all medications for neurological side effects, and if they are present, only take them if absolutely necessary. Remember, you have a prior history of severe adverse reactions to drugs, and you will be at a higher risk for future adverse reactions.

Get Our Mobile App

Everything You Want to Know About Benzo Withdrawal

Transcription