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Basics of BIND

Updated: 1 day ago

Introduction


Benzodiazepine Induced Neurological Dysfunction (BIND) is a chronic health condition that some individuals experience after long-term use of the benzodiazepine class (Xanax, Ativan, Klonopin, Valium, etc.) of sedative medications. This article provides a solid introduction to BIND including


Contents


Important Disclaimers


Stopping benzodiazepines abruptly can be very dangerous!


For those who wish to reduce or discontinue their medication, PLEASE work with a licensed physician to do so. Most medical literature, including the ASAM Guideline on Deprescribing, recommends a slow taper under doctor supervision. See the "Caution: Taper Slowly" section below for more info.


FOR THE NEW PATIENT: Fear is common for individuals who believe they may be dependent on benzodiazepines. Please note, thousands have tapered from long-term benzodiazepine use successfully and are living happy, healthy lives. Sites like A Calm Voice (Uneven), Benzodiazepine Information Coalition, and the Alliance for Benzodiazepine Best Practices are loaded with helpful information should you have any concerns.


ABOUT THE AUTHOR: The following information is developed and maintained by D E Foster, host of the Benzo Free and Uneven podcasts, author of the book Benzo Free, co-author of the published study that identified BIND, and panelist on the ASAM Joint Clinical Practice Guidelines on Benzodiazepine Tapering.


DISCLAIMER: This post is for informational purposes only and should never be considered medical or professional health advice of any kind. D E Foster is NOT a medical professional; he provides peer support only. Any decisions about changes in your medication should be made in consultation with your own qualified healthcare provider. View our disclaimer page for more information.


Benzodiazepines & Z-Drugs


The term “benzos” is short for benzodiazepines, a class of anti-anxiety medication also known as minor tranquilizers, sedatives, BZDs, BZRAs, and others. These drugs are typically prescribed for anxiety disorders, panic attacks, insomnia, muscle spasms, and seizures.


Nonbenzodiazepines (Z-drugs) is another class of sedatives. While this class has a different chemical structure separate from benzodiazepines, their effects can be similar including withdrawal complications and/or long-term neurological complications. That being said, the research referenced in this article was specific only to the benzodiazepine class.


To learn more about these drugs, please visit our Basics of Benzos page. To learn more about BIND, please read on.


BIND Terminology


The standard terms used to define the long-lasting neurological complications associated with benzodiazepine use and/or discontinuation vary greatly depending on the source.


Previous Terms for BIND

  1. Benzo Dependence / Withdrawal

  2. Benzodiazepine Withdrawal Syndrome (BWS)

  3. Post-Acute Withdrawal Syndrome (PAWS)

  4. Protracted / Persistent / Prolonged Withdrawal Syndrome (PWS)

  5. Benzodiazepine Protracted Withdrawal (BPS)

  6. Benzodiazepine Injury Syndrome

  7. Benzo Brain Injury

…and many others.


Many of the above terms still exist within benzo literature, including this site. Symptoms that we now relate to BIND, have been considered part of withdrawal, dependence, and even addiction in the past. As we gain knowledge about this condition, terminology changes.


BIND Definition


BIND (Benzodiazepine-Induced Neurological Dysfunction) defines the lingering neurological effects of sustained benzodiazepine exposure.


This term was proposed by our research team in 2022 and was formerly presented in a 2023 research article in the open access journal PLOS ONE titled, "Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey" (Ritvo 2023). BIND is now becoming widely adopted by organizations such as The Alliance for Benzodiazepine Best Practices, Benzodiazepine Information Coalition (BIC), the Benzodiazepine Action Work Group (BAWG), and here at A Calm Voice (uneven).


Here is the formal definition of BIND:

Benzodiazepine-Induced Neurological Dysfunction (BIND) is a constellation of functionally limiting neurologic symptoms (both physical and psychological) that are the consequence of neuroadaptation and/or neurotoxicity to benzodiazepine exposure. These symptoms may begin while taking or tapering benzodiazepines, and can persist for weeks, months, or even years after discontinuation. — Benzodiazepine Nosology Workgroup

BIND Origin


A team of 23 experts with mostly academic, clinical, and/or lived experience formed the Benzodiazepine Nosology Workgroup. This Workgroup defined the rationale for the selection of BIND as the most appropriate terminology for the enduring effects of benzodiazepine exposure. The scientific paper listed above above explains this process and illustrates the need for consensus in nomenclature and convergence on BIND as the single descriptive term (Ritvo 2023).


DISCLOSURE: The author of this article, D E Foster, is a member of the Benzodiazepine Nosology Workgroup and the Benzodiazepine Survey Research Team, and a co-author on their published papers.


Withdrawal vs. BIND


In the past, withdrawal and terms associated with BIND have been somewhat interchangeable. This is no longer the case. Based on recent research, we now understand that these are two distinct effects of benzodiazepine use.


Benzodiazepine withdrawal is specific to the removal of the drugs from the body, which typically lasts 7 to 28 days after discontinuation. Symptoms which are common and related to this process can include tremors, hallucinations, and seizures, which can be severe and even life-threatening. Thankfully, these symptoms are usually of short-duration. These are the symptoms that most physicians have been trained to look for when someone is discontinuing benzos. This is one of the key reasons why BIND has been so rarely recognized by the medical community.


BIND symptoms are typically longer lasting. There are dozens of neurological symptoms — some claim more than a hundred — that can be attributed to BIND. The most frequently reported of these based on the benzodiazepine survey (2018-2019) are severe anxiety, difficulty focusing and distraction, low energy, and insomnia (Huff 2023). Others like memory loss, sensitivity to light, sound and smell, digestion difficulties, pain, akathisia, trembling, tinnitus, uncontrollable emotions, muscle weakness, pulls, and strains, were also common. These are thought to be attributed to neuroadaptation and/or neurotoxicity, and recovery from these symptoms can take months, even years in some people.


The Truth About BIND


Some people claim that BIND (formerly known as BWS, PAWS, or withdrawal) is not a real illness, that the patients are making it up or have succumbed to online hysteria and hypochondria. It’s an understandable argument considering the laundry list of seemingly unrelated symptoms which some patients may attribute to this illness. But BIND is real. and the evidence supports it repeatedly.


Here are a few quotes regarding the legitimacy of protracted withdrawal (BIND):

Physical dependence can occur when benzodiazepines are taken steadily for several days to weeks, even as prescribed. Stopping them abruptly or reducing the dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening. — U.S. FDA Black Bow Warning on Benzodiazepines (FDA 2020)
Withdrawal from benzos can be more dangerous than withdrawal from heroin. —Dr. Stuart Gitlow, Addiction Psychiatrist and President of the American Society of Addiction Medicine
Facts: Benzodiazepine use can result in physical dependence at any dose with prolonged use. —New York City Department of Health and Mental Hygiene (New York City 2016)
Benzodiazepines are potentially addictive drugs; physical and psychological dependence can develop within weeks of regular use…Dependence upon prescribed benzodiazepines is now recognized as a major clinical problem. —U.K. National Health Service / NHS Grampian (NHS 2006)
I’ve met people who’ve been addicted to benzodiazepines for 20 or 30 years — wrecked their lives, wrecked their jobs, wrecked their families. It’s a silent addiction. We all know about illegal drugs, we all know about alcohol, we don’t know about this group. — Anne Milton, U.K. Public Health Minister

Most governments and medical associations agree that benzo dependence is real, it can develop as quickly as two to four weeks, and the neurological effects can be debilitating, drawn out over a long period of time, and even fatal in extreme cases.


The Science Behind BIND


While somewhat effective treating some conditions, benzos can cause physical dependence when taken continuously for longer than 2-4 weeks. One of the processes that is thought to be affected by benzo use, is that of homeostasis.


Homeostasis is the human body’s tendency toward physiological stability. When a new drug is introduced into the body, the body’s physiology changes according to the effects of the drug. Eventually, the body tends to re-balance itself — to find new stability. This process can often reduce the effects of the drug, which leads to the need for stronger doses. This is called tolerance.


As one’s body adapts to a benzodiazepine, it down-regulates the gamma-Aminobutyric acid (GABA) receptors, decreasing their sensitivity. So, GABA has less of an effect. And since GABA is an inhibitory neurotransmitter, the calming effect of GABA is less effective. The sensitivity of the glutamate receptors is also affected, but they become more susceptible to stimulation increasing the excitatory effect. The result is a decrease in calming influence and an increase in excitability.


When a person discontinues taking benzodiazepines, all the physiological changes are exposed, which results in a rebound effect. The effect is generally the opposite of the initial effects of the drug. The homeostasis process kicks in again, but as before, this process takes time. Sometimes weeks, months, or even years. Eventually, stability is reached again, and the withdrawal symptoms subside. The body returns to normal.


The effects of benzo use are not limited to the central nervous system (CNS). There is evidence that the peripheral nervous system and mitochondria are also affected by these drugs. Dopamine, CRF concentrations, and even hyperventilation syndrome might also play a part. The long-lasting neurological effects are thought to be part of neuroadaptation and/or neurotoxicity, causing structural changes in the brain.


After discontinuation, there also may exist what Ashton calls a learning deficit. While on benzos, the drug aided in the patient’s psychological and physiological response to stress. The patient didn’t have to develop — or learn — coping mechanisms to handle the anxiety. When the drug is removed, this learning deficit is exposed, and the patient has to create new synaptic pathways to manage the worries and complications of ordinary life.


BIND Symptoms


If someone had to use just one word to convey the general experience of symptoms during benzo discontinuation and BIND, it would have to be hypersensitivity. People in benzo withdrawal feel more — more pain, more agitation, more restlessness, more emotion, more aches, more spasms, more anxiety, more depression, more hopelessness.

Benzodiazepine dependence has caused the central nervous system to become hypersensitive and over-reactive to everyday stimuli.


Imagine drinking one cup of coffee but reacting like you drank five. Or even ten. A work party might induce mild anxiety in the average person. Imagine if that same event felt like you were speaking in front of a thousand people. Naked. Imagine being dog tired but inside your body energy is on a rampage and your muscles are spasming as if you just drank a six-pack of Red Bull.


Not fun, right? And sensitivity is just the tip of the iceberg. Some individuals also experience depersonalization, memory and cognitive dysfunction, muscle tightness and spasms, heart palpitations, phantom nerve sensations, and chronic gastrointestinal distress, just to name a few. And even though most evidence points to these symptoms being temporary, recovery can be drawn out over a long time.


That being said, please remember that these examples are the extremes. Approximately 70% of long-term benzo users will not experience a drawn out, complicated withdrawal. And as for the other 30%, the withdrawal experience can be significantly improved with proper planning, a healthy lifestyle, and a healing-focused mindset.


To see a more complete list of possible symptoms, visit our BIND Symptoms page.


Methods of Tapering


Tapering is the process of reducing one’s dosage of a benzo over a period of time, usually several months. Abrupt cessation of benzos can be dangerous and often leads to a more difficult experience. A slow taper under doctor supervision is recommended by most experts. 


There are three primary options for tapering from benzos:

  1. Direct Taper – The first and most straightforward method of tapering is a direct taper. This means that the patient reduces the dosage of the benzodiazepine they are currently on and they don’t substitute another benzo.

  2. Substitution Taper – This method of tapering includes switching, over time, from the patient’s current benzo to another benzo that is better for tapering. The choice for substitution is usually diazepam.

  3. Titration Taper – Titration means mixing benzos with milk or water to create a liquid form of the drug, allowing the user to better control her dosage. This allows for very small and accurate doses.


The Ashton Manual covers tapering methodology in more detail.


Caution: Taper Slowly


For those who chose to stop taking their benzos, we understand the urgent desire to become free from this medication. But the most important thing to remember is that quitting cold turkey will most likely make it worse. It can even be fatal in extreme cases. If one decides to stop taking benzos, a slow taper under doctor supervision is the recommended course of action.


Abrupt cessation of benzodiazepines may be very dangerous. — Prof. C. Heather Ashton, The Ashton Manual

For those who have already stopped taking benzos cold turkey (CT), don’t panic. Thousands of people have CT’d and recovered fully — many under doctor’s orders. While all evidence points to a better outcome for those who taper slowly, it also points to success even for those who stop more rapidly.


For more information about discontinuing (tapering) from benzodiazepines, please check out the Deprescribing Guidelines from the Benzodiazepine Action Work Group.


No one should reduce their dosage of benzos or any other prescription medication unless under the direct supervision of a licensed physician. 


BIND in Scientific Literature


Our research article formally introducing the term BIND was published on June 29, 2023 in the open access journal PLOS ONE, titled "Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey."


This story has been picked up by dozens of publications including Psychology Today, the New York Post, and WebMD among others.


BIND Research Roundtable Video


Join the Benzodiazepine Survey Research Team for a lively roundtable discussion about their research, the findings from the survey, and their latest paper which formally introduces the term benzodiazepine-induced neurological dysfunction, or BIND.


This video was recorded on June 9th, 2023 and is available on the Uneven Life YouTube Channel, among many other videos and podcast episodes.



Benzodiazepine Effects on the Brain and Body


This 8-minute animated video was created by the Benzodiazepine Action Work Group for the "Recovering from Benzodiazepines for Peer Support" training course. It demonstrates the effects that benzodiazepines have on the nervous system, the role glutamate, GABA, and GABA receptors play, how homeostasis affects healing, and why this process may take months or years.


References

For Informational Purposes Only – Not Medical Advice


All information presented here is for informational purposes only, and should never be considered medical or health advice. Withdrawal, tapering, or any change in dosage of benzodiazepines or any other prescription drugs should only be done under the direct supervision of a licensed physician.


Please read our site disclaimer for more information.


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