Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options

Carissa E. Mancuso, PharmD; Maria G. Tanzi, PharmD; Michael Gabay, PharmD


Pharmacotherapy. 2004;24(9) 

Lorazepam and Diazepam


Paradoxical reactions to lorazepam were described in a 22-year-old, healthy woman with a fear of elevators and escalators.[8] To help overcome this phobia, the patient was prescribed oral lorazepam 3 mg/day for 1 week followed by dosage titrations until the fear was resolved. After receiving the first dose, the woman's anxiety ceased and she experienced no fear of the elevator. However, hours later, she reported feelings of distress and uncontrollable anger. She was unable to perform her functions at work and responded to a situation with a coworker by yelling and screaming, acts which were out of character. The paradoxical reactions subsided within 24 hours. Subsequently, her fear of elevators was treated successfully with chlordiazepoxide with no adverse effects. This case report illustrates that paradoxical reactions may occur with lorazepam and may be precipitated by a frustrating stimulus, such as the situation with a coworker.


Dose-dependent, paradoxical reactions to diazepam have been reported.[9] A 28-year-old woman with a medical history significant for depression sought medical attention for frequent crying spells, diminished libido, and irritability, which had persisted for several months. She was prescribed an antidepressant and had minimal response. Six weeks after starting therapy, she requested an anxiolytic. Oral diazepam 5 mg was started with directions to take every 6 hours as needed. As the dose of diazepam was titrated over the next month, the patient began to experience sexual and aggressive fantasies. The woman was physically abusive to her daughter, hostile to her therapist, and became self-destructive and reported repeatedly banging her head against the wall. Her behavior improved within 2-3 days of discontinuing diazepam.