Could my worsening anxiety and insomnia be a paradoxical reaction to benzodiazepines?
Probably not. Yet, the reason is worth understanding, because it decides what to do. A true paradoxical reaction to benzodiazepines is uncommon, and when it happens, it happens early, in the first doses or right after a dose increase. It does not show up in the third year of a prescription.
Of course, the question is a fair one. You were given Xanax, Klonopin, or Ativan for anxiety, or for sleep, and it worked. Now the anxiety is back, or worse than it ever was, and the nights are worse still.
Can Xanax cause anxiety? Can a sleeping pill cause insomnia? How does a drug do the exact opposite of its job? It turns out that a benzodiazepine can do the opposite of its job in two very different ways.
One is rare, comes on fast, and looks like agitation. The other is common, creeps in over months, and looks exactly like the condition the drug was prescribed for. So, which one you have decides what to do next.
Dr. Leeds is an osteopathic physician and deprescribing specialist who helps patients taper off of benzodiazepines through a concierge telemedicine practice, and he serves on the medical advisory board of the Benzodiazepine Information Coalition (BIC). Patients bring him this question often, usually after a prescriber has told them that their anxiety is simply “coming back.” Which one is it?
What is a true paradoxical reaction to benzodiazepines?
A paradoxical reaction is a stimulant response to a sedative drug. Instead of calming down, the person becomes excited, talkative, restless, irritable, or aggressive, sometimes within an hour of the dose.
The Ashton Manual describes it as paradoxical excitement, with increased anxiety, insomnia, nightmares, hallucinations as sleep begins, irritability, and in some cases hostile or violent behavior. The word that best captures it is disinhibition.
The benzodiazepine turns down the brain’s brakes, and in a small number of people, what comes out from under the brakes is not calm but anger, impulsivity, or panic. In fact, the people around you usually notice before you do.
Notice what the list does not include: a slow, steady rise in ordinary anxiety over months, or waking at four in the morning, month after month, with your heart pounding. While those symptoms are real, and the benzodiazepine can cause them, they are not paradoxical. They are something else.
Who is at risk for paradoxical reactions?
Unfortunately, no one fully understands why one person out of many reacts this way, and what we do know comes from patterns. Paradoxical reactions are seen more often in children and in older adults, in people with a history of heavy drinking, and at high doses, especially when a benzodiazepine is given by injection before a medical procedure.
Some psychiatric histories seem to raise the risk as well, and the Ashton Manual notes that these reactions are most frequent in anxious and aggressive people, which is worth knowing when the drug was prescribed for anxiety in the first place. Interestingly, the same drug at the same dose can calm one sibling and enrage another, so genetics probably plays a part. Beyond that, the honest answer is that we cannot predict it in advance.
Can Xanax cause anxiety after months or years? Yes, and it is usually not paradoxical.
Nearly every article on paradoxical anxiety skips this part. Why would a calming drug stop calming? Because the brain adapts to benzodiazepines, and it adapts quickly.
Within weeks of daily use, it is thought to turn down the gamma-aminobutyric acid type A (GABA-A) receptors the drug acts on, in number or in sensitivity, so the same dose produces less and less calm. This adaptation is called tolerance, and it is the root of everything that follows.
An analogy that might help is a pair of dark sunglasses. Imagine wearing them indoors, all day, every day. At first the room is dim, and then, after a few weeks, your pupils open wider to let in more light, and the room looks normal again, through the lenses.
Now take the sunglasses off, and the same lamp that was ordinary a month ago is blinding, because your eyes adapted to the dark. Put the glasses back on, and the room is merely normal, not dim.
The calm is gone, and only the absence of glare remains. That is tolerance.
While this is not a perfect analogy, it explains what patients feel. The drug that once dimmed the anxiety now only holds it at baseline. And, as the adaptation deepens, it cannot even do that.
The anxiety you feel on the pill is not the drug misfiring. It is your nervous system, adjusted to the drug, on edge whenever the drug’s effect falls short.
What is interdose withdrawal, and why does it feel like a panic attack on a schedule?
Interdose withdrawal is withdrawal that happens between doses. While Xanax, or alprazolam, works quickly, it also leaves quickly, and its prescribing information gives a half-life of roughly eleven hours, so the blood level falls well before the next dose is due. And, a tolerant brain notices every time.
The pattern is easy to spot once you know to look for it. If you take Xanax at 8 am, 4 pm, and midnight, you may feel your worst around noon, 8 pm, and 4 am, and feel better within an hour of each dose. Patients often describe the hour before a dose as the worst hour of the day, and the relief after a dose as proof that they “need” it.
Klonopin, or clonazepam, lasts longer, and Valium, or diazepam, longer still. Yet, interdose symptoms can occur with Klonopin too, especially at once-daily dosing, and especially at night.
Waking at four in the morning deserves its own mention, because it is where anxiety and insomnia meet. A short-acting benzodiazepine taken at bedtime has largely worn off by the early hours, and the rebound is a sudden, wide-awake alertness, often with a racing heart. The Xanax label itself lists early morning anxiety and anxiety emerging between doses.
Patients have described setting an alarm for the next dose because the panic at half past three was worse than the broken sleep. Many of them had been told this was depression, or a new anxiety disorder. It was the pill wearing off.
What is tolerance withdrawal, and why does raising the dose only work for a while?
Tolerance withdrawal is the next stage, where symptoms are no longer tied to the clock but present most of the day, on a dose that has not changed, because the brain’s adaptation has outrun the drug. In fact, you are in mild withdrawal while taking your medication exactly as prescribed.
The usual remedy for a medication that has stopped working is more of it. With a benzodiazepine, that remedy works, for a while, which is exactly the problem. While the higher dose dims the room again, the pupils open a little wider, and a few months later you are back where you started, on more of the drug.
Unfortunately, the other usual remedy is a second drug. When a benzodiazepine seems to cause anxiety, the answer offered is often an antidepressant, an antipsychotic, or a gabapentinoid layered on top, which adds a second dependence to the first and does nothing about tolerance. This article will not suggest one.
Tolerance withdrawal also explains a symptom list that keeps growing. Alongside the anxiety and insomnia, patients describe symptoms they never had before the prescription: internal vibrations, sensitivity to light and sound, burning skin, a stomach that no longer works properly.
Those are not signs of a new illness. They are one nervous system, adapted to a drug, with many branches, a pattern now called benzodiazepine-induced neurological dysfunction (BIND).
How can you tell a paradoxical reaction from tolerance or interdose withdrawal?
Timing is the first clue, and usually the decisive one. A paradoxical reaction shows up within hours or days of starting the drug, or of a dose increase. Tolerance and interdose withdrawal show up after weeks, months, or years of steady use, in a person who did well on the drug at first.
The second clue is pattern: interdose withdrawal keeps time with your doses and improves for an hour or two after each one. A paradoxical reaction does the opposite, worsening after a dose, and tolerance withdrawal ignores the clock altogether and simply stays.
The third clue is character, and paradoxical reactions look like disinhibition: agitation, restlessness, talkativeness, anger out of proportion, a person who does not seem like themselves to the people around them. Tolerance and interdose withdrawal look like the original anxiety and insomnia, now with company: the physical symptoms listed above, which anxiety alone does not usually cause.
So, ask yourself three questions. Did this start within days of a new prescription or a higher dose? Does it get worse right after a dose? Have I been taking this drug, and doing well on it, for a long time?
If the first two answers are no and the third is yes, you are almost certainly looking at tolerance, and not at a paradoxical reaction.
What should you write down before you call your prescriber?
The three questions above are easier to answer on paper than from memory, and a doctor can only sort this out with the timing in front of them. So, for a week before the appointment, write down the time of every dose and the time each symptom peaks, in a notebook or on your phone.
Note when the medication started and every dose change since then. A reaction that began within days of a new prescription or a higher dose tells a different story from one that crept in during a year on the same dose, and the date is the first thing an experienced doctor will ask for.
Then ask the people who live with you what they have noticed. The Ashton Manual observes that the milder form of paradoxical excitement, irritability and argumentativeness, is much more common than the dramatic attacks and is often noticed first by the family. So, a spouse who says you have not seemed like yourself since the new prescription is handing your doctor a clue that you cannot see from the inside.
While a diary is not a diagnosis, it turns “my medication is making me worse” into a pattern a doctor can read in a minute. Patients often say that the notebook, more than anything they said out loud, was what moved the conversation from “your anxiety is coming back” to “let’s look at the timing.” Bring the notebook.
What should you not do when a benzodiazepine seems to be making you worse?
Do not stop taking it on your own. This is the one instruction in this article that applies to both explanations. A brain that has adapted to a benzodiazepine, even over a few weeks, will react to its sudden absence, and the reaction can include seizures, which can be life-threatening.
Do not accept a second psychiatric medication as the answer to the first one without asking a plain question: what is the second drug supposed to fix? If the mechanism is tolerance, another drug does not reverse tolerance. It adds another adaptation for your brain to make, and another taper for later.
Do not let anyone talk you into a detox center or a rehab. You may have been asked whether you are “addicted” to your medication, or told that your fear of taking the pill is a problem with you.
Fear of a pill that makes you feel worse is not disobedience. It is information, and it belongs in a conversation with your doctor.
Of course, rehabs do good work for people with addictions. They are simply the wrong place for a nervous system that needs months, not thirty days, on a timeline set by insurance rather than by receptors. In fact, a fast detox is the one thing most likely to turn a manageable problem into a protracted one.
What should you do instead?
If the timing points to a true paradoxical reaction, contact the prescriber today, not next month. The FDA-approved label for Valium, or diazepam, says that when a paradoxical reaction occurs the drug should be discontinued. While that decision belongs to the prescriber, it should be made with you, and it should be made soon.
Stopping may be simple if you have taken the drug for only a few days. If you have taken it long enough for dependence to develop, that stop is itself a taper, and it must be planned.
How long is long enough? The United States Food and Drug Administration (FDA), in its 2020 benzodiazepine label update, put that window at days to weeks of steady use.
If the timing points to tolerance or interdose withdrawal, which is far more likely, the first step is a distinction. Physical dependence is not addiction. It is the brain adapting to a drug it is given every day, and it happens to people who never took one pill more than they were told.
What it calls for is a gradual, patient-directed medical taper, not a recovery program. The pace belongs to you. If a reduction is too fast, your doctor must slow it down, and if it is going well, the two of you may agree to go a bit faster, as tolerated.
And, three things are emergencies. If any step of this ever brings thoughts of harming yourself, call or text 988, the Suicide and Crisis Lifeline. If a benzodiazepine has been stopped suddenly and a seizure, confusion, or hallucinations follow, call 911. The same is true of a paradoxical reaction that brings rage or violence toward yourself or the people around you: that is a 911 call or an emergency room visit, not a message to leave with the prescriber’s office.
Why does a slow taper fix what a higher dose cannot?
Fortunately, the same mechanism that causes the problem points to the solution. Because tolerance is an adaptation of receptors, and because the relationship between dose and receptor occupancy is not a straight line, a taper works best when the cuts become smaller as the dose gets lower. This is hyperbolic tapering, the principle behind the Maudsley Deprescribing Guidelines: the last milligrams matter more than the first, so the taper slows as it goes.
Going back to the sunglasses, the answer is not a darker pair. It is to lighten the lenses one shade at a time, slowly enough that your eyes keep up, and more slowly still as the room gets bright. While a higher dose buys a few months, a slower taper buys the only thing that lasts, a nervous system that has adapted back.
For interdose symptoms, your doctor may suggest smaller doses spread more evenly across the day, or a crossover taper to a longer-acting benzodiazepine, so that the blood level stops rising and falling between doses. Neither step is a cure by itself, but each one makes the taper that follows steadier.
Your anxiety did not come back on its own. Your nervous system adapted to a drug, and, given time and a taper slow enough to let it, it can adapt its way back.
A doctor who tapers benzodiazepines asks about timing first.
When a patient comes to Dr. Leeds convinced that Xanax or Klonopin has turned against them, the first questions are the ones in this article: when it started, how it moves with the clock, and what a dose does to it. Nearly always, the answer is tolerance, and the plan is a slow taper built around the patient’s own response, with weekly appointments and direct access to the physician between visits.
While the plan differs by medication, the principle does not. A Xanax tapering plan usually begins by steadying the dosing or crossing over to a longer-acting medication, and a Klonopin tapering plan can often proceed on the same medication.
Dr. Leeds provides prescribing and medical management for patients located in Florida through his telehealth benzodiazepine tapering program. An initial consultation is available as a standalone appointment.
It is not a medical visit, and it does not establish a physician-patient relationship. To begin, contact Dr. Leeds through the contact form at drleeds.com.
Frequently asked questions about paradoxical reactions to benzodiazepines
What is paradoxical anxiety, and is it the same as a paradoxical reaction to benzodiazepines?
Paradoxical anxiety is the patient’s name for it, and yes, it is the same thing: a stimulant response to a sedative drug, with agitation, irritability, anger out of proportion, or worsened anxiety and insomnia, usually within hours of a dose. It is uncommon, it appears with the first doses or after a dose increase rather than after months of steady use, and, outside of a person who already has epilepsy, seizures are not part of it.
Who is at risk for paradoxical reactions?
Children and older adults, people with a history of heavy drinking, people taking high doses, people with certain psychiatric histories, and, according to the Ashton Manual, anxious and aggressive people. Most adults taking a moderate prescribed dose who did well at first do not fit this pattern, and their worsening symptoms are far more likely to be tolerance.
Can Xanax cause anxiety?
Yes, and so can Ativan, or lorazepam, and so can Klonopin and Valium. Benzos cause anxiety as a class, because the mechanism belongs to the class and not to one brand. In long-term use the usual route is tolerance and interdose withdrawal rather than a paradoxical reaction. The Ashton Manual describes anxiety symptoms that gradually increase over years of continuous use, and panic attacks that appear for the first time after years on the drug, and explains both as tolerance to the calming effect letting withdrawal symptoms emerge while the drug is still being taken. Xanax is the clearest case because it is short-acting, so a tolerant brain feels the drug wearing off between doses, and the result looks like the original anxiety, on a schedule.
What should I do if I think I am having a paradoxical reaction?
Contact your prescriber promptly, describe when the symptoms started and how they relate to your doses, and do not stop the medication on your own. If you have taken it for more than a few weeks, any decision to stop needs a planned, gradual taper with your doctor.
Does a paradoxical reaction mean I am allergic to benzodiazepines?
No. An allergy is the immune system reacting to a drug, and the Valium label lists a known hypersensitivity, which is the label’s word for an allergic reaction, as a reason never to take the drug at all. A paradoxical reaction sits in a different part of the same label, as something that can happen to a person who is not allergic: the drug acting on the same receptors it always acts on, in a nervous system that answers with excitement instead of calm. Both belong in a call to your prescriber, but they are not the same problem, and one does not imply the other.
How long does a paradoxical reaction to benzodiazepines last?
About as long as the dose does. Because it is an effect of the drug itself rather than an adaptation to it, it is expected to fade as the drug wears off, within hours for a short-acting benzodiazepine such as Xanax and over a longer stretch for a long-acting one such as Valium. Whether the drug is stopped or tapered after that is the prescriber’s call, made with you, as the section above explains. What a paradoxical reaction does not do is build for months on a dose that has not changed. Symptoms that behave that way are tolerance, and the sections above explain them.
I had a paradoxical reaction to Xanax. Will Ativan or Valium do the same thing?
Possibly, and no one can promise otherwise. The paradoxical effects of benzodiazepines belong to the class rather than to one brand. The Ashton Manual describes paradoxical excitement as an occasional effect of benzodiazepines in general, and the Valium label says that psychiatric and paradoxical reactions are known to occur when using benzodiazepines. So, an Ativan paradoxical reaction is possible in a person who reacted to Xanax, and a Valium one is too. Xanax, Ativan, Klonopin, and Valium all work by enhancing the same brain chemical, GABA, at the same receptor. Unfortunately, no test predicts who will react, so a switch to a different benzodiazepine after a true paradoxical reaction is a decision for the prescriber who saw the first one, never an experiment to run on your own.
Can a paradoxical reaction happen during a taper?
Rarely, and in principle at one point only. A taper lowers the dose, and a paradoxical reaction is a response to the drug rather than to its absence, so symptoms that arrive as the dose comes down are withdrawal, and the answer to withdrawal is a slower taper, not a new diagnosis. The exception, in principle, is a crossover taper, when a long-acting benzodiazepine such as Valium is introduced for the first time: the first days on a drug you have never taken are the one moment in a taper when a true paradoxical reaction can occur, and it looks like the agitation described above, not like withdrawal. Tell the doctor running the taper the same day.
Can Klonopin cause insomnia?
Yes, and in most cases the route is tolerance rather than a paradoxical reaction. The Ashton Manual notes that tolerance to the sleep-inducing effect of benzodiazepines develops rapidly, with sleep recordings showing sleep patterns back at their pre-treatment level after a few weeks of regular use, so a bedtime dose of Klonopin, or clonazepam, may be holding sleep at baseline within a month and losing ground after that. Because Klonopin is long-acting, the clock pattern that gives Xanax away is muted, and the more common Klonopin story is a bedtime dose that gradually stops delivering and a morning that starts earlier every month. A slow taper, not a higher bedtime dose, is what gives sleep the chance to come back.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
About the physician
Mark Leeds, D.O. is an osteopathic physician providing concierge telemedicine care focused on benzodiazepine and z-drug tapering and psychiatric medication deprescribing. He serves on the medical advisory board of the Benzodiazepine Information Coalition and hosts The Rehab Podcast on the Mental Health News Radio Network. Medical management and prescribing are available for patients located in Florida.
