Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Mrs. M," 58-year-old school administrator, presenting to ED with seizure 30 hours after abruptly discontinuing alprazolam she has taken daily for 6 years.

Chief Concern: "My doctor retired and the new doctor refused to refill my Xanax. I've been taking it every day for 6 years. Yesterday I ran out. This morning I had a seizure. I'm shaking, I can't sleep, everything sounds too loud."

History of Present Illness: Mrs. M has been prescribed alprazolam (Xanax) 2mg three times daily (total 6mg/day) for 6 years, originally for generalized anxiety. Her prescribing physician retired. The replacement physician, concerned about long-term high-dose benzodiazepine use, declined to refill the prescription and advised her to 'stop taking them.' She took her last dose approximately 30 hours ago. She experienced a witnessed generalized tonic-clonic seizure at home this morning (approximately 28 hours post-last dose). Current symptoms: visible tremor, diaphoresis, tachycardia, perceptual disturbances (sounds are painfully loud, lights are too bright), severe anxiety ('worse than anything I've ever felt'), insomnia, nausea. She denies alcohol use. She has been taking her alprazolam exactly as prescribed and has never taken more than the prescribed dose.

Medical History: Generalized anxiety disorder (treated with alprazolam for 6 years). Hypertension (controlled). No epilepsy. No prior seizures.

Mental Status Exam: Tremulous, diaphoretic. Pulse 112, BP 168/96. Appearing distressed. Oriented x3. Speech slightly pressured (anxiety-driven). Perceptual: reports hyperacusis (sounds painfully loud) and photophobia (lights too bright). No hallucinations currently. Severe anxiety. No confusion (delirium not yet present but risk is high).

Step 1: Sedative Withdrawal DSM-5-TR Criteria

Criterion A: Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been prolonged.

Abrupt cessation of alprazolam 6mg/day after 6 years of daily use. Prolonged, high-dose exposure. MET.

Criterion B: ≥2 of the following developing within hours to days after Criterion A: autonomic hyperactivity, hand tremor, insomnia, nausea/vomiting, transient hallucinations, psychomotor agitation, anxiety, grand mal seizures.

Autonomic hyperactivity (tachycardia 112, BP 168/96, diaphoresis). Tremor. Insomnia. Nausea. Anxiety (severe). Seizure (witnessed tonic-clonic). Perceptual disturbances (hyperacusis, photophobia). 7 of 8 criteria present. MET — 7/8 including SEIZURE.

Criterion C: Symptoms cause significant distress or impairment.

Seizure (medical emergency). Severe distress. Unable to function. MET.

Criterion D: Not attributable to another condition.

No alcohol use (excludes alcohol withdrawal). No epilepsy. No other medical cause for seizure. Temporal relationship is definitive: symptoms began after abrupt alprazolam cessation. MET.

Step 2: Benzodiazepine Withdrawal Risk Assessment

Risk Factor Assessment This Patient
Dose Higher dose = higher risk 6mg/day alprazolam — HIGH dose
Duration Longer use = higher risk 6 years — PROLONGED
Half-life Short-acting (alprazolam) = MORE seizure risk than long-acting (diazepam) Short-acting (alprazolam t½ ~11h) — HIGHEST RISK
Abruptness Abrupt cessation vs. gradual taper ABRUPT cessation — MAXIMUM RISK
Seizure history Prior withdrawal seizures increase risk First seizure — but conditions are highest risk

Medical Emergency

This case represents a MEDICAL EMERGENCY caused by iatrogenic harm. The replacement physician's instruction to abruptly discontinue high-dose, long-term alprazolam was medically inappropriate. Benzodiazepine withdrawal, like alcohol withdrawal, can be FATAL. Treatment: immediate benzodiazepine reinstatement followed by a gradual, supervised taper over weeks to months.

Diagnostic Formulation

Diagnostic Conclusion

Sedative, Hypnotic, or Anxiolytic Withdrawal, with Perceptual Disturbances (F13.232): All DSM-5-TR criteria met. Withdrawal seizure 28 hours after abrupt cessation of alprazolam 6mg/day (6 years). Seven of 8 withdrawal criteria present including seizure. Treatment: (1) Immediate: IV lorazepam loading, transition to long-acting benzodiazepine (diazepam or chlordiazepoxide) for taper. (2) Taper: convert total daily alprazolam dose to diazepam equivalent and reduce 10-25% every 1-2 weeks. (3) Adjuncts: gabapentin or carbamazepine for seizure prophylaxis during taper. (4) Long-term: address underlying GAD with SSRI/SNRI and CBT before and during taper.

Teaching Points

  • Benzodiazepine withdrawal can be LIFE-THREATENING. Like alcohol (which acts on the same GABA-A receptor), abrupt cessation after prolonged use can cause seizures, delirium, and death. NEVER abruptly discontinue high-dose, long-term benzodiazepines. Always use a gradual, supervised taper.
  • Short-acting benzodiazepines (alprazolam, lorazepam) produce MORE intense withdrawal than long-acting agents (diazepam, clonazepam) because their rapid elimination creates a steeper decline in GABA-A receptor stimulation. The standard taper strategy is to cross-taper to a long-acting agent (diazepam) and then reduce gradually.
  • The Ashton Manual protocol for benzodiazepine taper recommends: convert to equivalent dose of diazepam, stabilize for 1-2 weeks, then reduce by approximately 10% every 1-2 weeks. Total taper duration for long-term, high-dose use may be 3-12 months. Faster tapers increase seizure and rebound anxiety risk.
  • Iatrogenic benzodiazepine dependence (dependence caused by appropriate medical use) is a significant clinical problem. Mrs. M took her medication exactly as prescribed for 6 years. She is not a drug abuser. Her dependence is a predictable consequence of chronic GABA-A receptor agonism, and the withdrawal is a medical emergency caused by inappropriate prescriber management.
  • During benzodiazepine taper, the underlying condition (GAD in Mrs. M's case) must be addressed with alternative treatments (SSRI/SNRI, CBT) BEFORE or DURING the taper. Simply removing the benzodiazepine without treating the underlying disorder will result in relapse to benzodiazepine use.