Addiction Alcohol Use Withdrawal and Relapse Is PAWS Real or Just Another Relapse Excuse? Post Acute Withdrawal Syndrome Blamed for Many Relapses By Buddy T Buddy T Facebook Twitter Buddy T is an anonymous writer and founding member of the Online Al-Anon Outreach Committee with decades of experience writing about alcoholism. Learn about our editorial process Updated on December 17, 2020 Medically reviewed Verywell Mind articles are reviewed by board-certified physicians and mental healthcare professionals. Medical Reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. Content is reviewed before publication and upon substantial updates. Learn more. by John C. Umhau, MD, MPH, CPE Medically reviewed by John C. Umhau, MD, MPH, CPE John C. Umhau, MD, MPH, CPE is board-certified in addiction medicine and preventative medicine. He is the medical director at Alcohol Recovery Medicine. For over 20 years Dr. Umhau was a senior clinical investigator at the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH). Learn about our Medical Review Board Print valentinrussanov / Getty Images Post-acute withdrawal syndrome (PAWS) has been cited for many years by members of the recovery community as a major cause of relapse for those who are trying to remain clean and sober. After recovering alcoholics and addicts get past the stress and severity of the initial acute withdrawal symptoms of early abstinence, some experts say, another group of symptoms comes along that are uncomfortable or aggravating enough to prompt some to relapse merely to relieve those nagging symptoms. But, the phenomenon also known as protracted withdrawal syndrome or simply prolonged withdrawal is not without some controversy. PAWS is not an official medical diagnosis and it's not found in the Diagnostic and Statistical Manual of Mental Disorders. There are very few published scientific research studies that even confirm the existence of PAWS and there is a particular lack of any recent research about post-acute withdrawal. Controversy The shortage of scientific evidence and the exclusion from the diagnostic manuals of the syndrome has caused some confusion in the mainstream medical community as to whether PAWS is a real phenomenon, or simply a popular excuse for a relapse. Others have questioned if the so-called syndrome actually exists or is an invention of the professional alcohol and drug treatment industry to try to justify a need for their long-term services. For those who have experienced the unexpected symptoms of PAWS, however, post-acute withdrawal syndrome is indeed very real. Warning Signs of Drug or Alcohol Relapse Parameters One study was specifically conducted to determine if PAWS should be included in the DSM-IV. After a review of the existing literature at the time, Satel and colleagues at Yale University School of Medicine concluded that the diagnosis should not be included. But, the Yale scientists came to that conclusion, not because the syndrome does not exist, but because of "methodologic limitations of the studies and lack of consensus definition of the term itself." Studies that did consistently describe symptoms extending beyond acute withdrawal failed to conclusively demonstrate protracted withdrawal from alcohol and opiates because they did not: Do multiple time-point samplingUse standardize instrumentsUse control groupsRe-administer the substance to suppress the symptoms While methodological issues may have excluded PAWS from the DSM, there is research suggesting that the syndrome exists and can contribute to relapse. Research Although few studies over the years have agreed on the exact definition and parameters of protracted withdrawal, some investigators have documented some of the symptoms associated with the syndrome. One German study found that long-term alcohol use tends to inhibit the effects of certain chemicals in the brain (atrial natriuretic peptide) and those effects remain diminished weeks after abstinence. This resulted in an increased craving for alcohol and increased feelings of anxiety during protracted withdrawal. A long-term study at Johns Hopkins University of 312 abstinent alcoholics found that some of the more "demoralizing" symptoms of withdrawal—guilt, depression, interpersonal sensitivity—decreased progressively with prolonged abstinence, but in some cases could take 10 years to return to "normal levels." Authors of the Johns Hopkins study concluded that their findings were "consistent with the concept of a protracted withdrawal syndrome." Post-Acute Withdrawal Syndrome After Detoxing Causes As the symptoms of acute withdrawal in early abstinence begin to diminish and stabilize, the symptoms of post acute withdrawal begin to appear, usually between seven and 14 days into sobriety. Long-term alcohol and drug use can cause chemical changes in the brain. When someone suddenly stops using, the brain must re-adjust to being without those substances. How long this adjustment lasts can depend on how much damage prolonged substance abuse did to the body's nervous system. The process of the brain adjusting to being without drugs or alcohol can be aggravated by the stress of trying to maintain abstinence after years of drinking or doing drugs. Because many people in recovery used alcohol and drugs to deal with stress in the past, any stress they experience while trying to remain sober can make their protracted withdrawal symptoms worse. Recovery experts believe the severity of post-acute withdrawal symptoms depend on upon two factors: the amount of damage alcohol and drug use did to the nervous system over the years and the amount of stress the person experiences during recovery. Symptoms People who experience post-acute withdrawal syndrome describe the symptoms as coming in "waves" or being on an emotional roller coaster of ups and downs. Recovering alcoholics and addicts, weeks into abstinence, report having these kinds of symptoms: Unstable and Unpredictable Moods One of the most common symptoms reported by people suffering from PAWS are mood swings or unpredictable changes in their mood. They report sudden feelings of overwhelming depression without any reason or provocation, while later experiencing excited bouts of anxiety or agitation. Anhedonia Anhedonia is losing interest in things that you previously enjoyed doing, sometimes described as having your ability to feel pleasure turned off. In extreme cases, anhedonia can extend to losing interest is pursuing basic needs, like eating. Intensified Emotions or Feelings of Numbness This symptom can vary widely in recovering individuals. Many tend to overreact. Sometimes they can become overly excited and excessively angry over small matters, then go into a stage of not feeling any emotions at all. Some describe it as being empty or numb inside. Inability to Concentrate or Think Clearly People experiencing protracted withdrawal will many times not have the ability to solve even simple problems due to their inability to think clearly. They report difficulty concentrating and sometimes it's because they find it hard to think about anything but the fact that they are not drinking or using drugs. Rigid or repetitive thinking is also common. Poor Coordination and Clumsiness This symptom is not as common as some symptoms of PAWS, but it is a serious one. Some people in protracted withdrawal experience dizziness, slow reflexes, coordination problems and trouble with balance. People who experience stumbling and clumsiness during prolonged withdrawal can appear to be intoxicated when they are in fact abstinent. Sleep Disturbances Probably the PAWS symptoms most responsible for relapses are those related to sleep disturbances. Not only do they find it difficult to fall asleep, but they will also find their sleep is interrupted. Many report having their sleep disturbed when they wake up after having a "using dream" in which they used alcohol or drugs. Strong Cravings This, of course, is another reason that many trying to quit decide to relapse. Even after weeks—and sometimes years—of abstinence, people in recovery can suddenly experience strong cravings for their drug of choice. Increased Sensitivity to Stress One unexpected protracted withdrawal symptoms for many recovering addicts is an increased sensitivity to stress and stressful events. Some report that they not only more easily stressed, but can become overwhelmed by even slightly stressful situations. Treatment experts believe that this hypersensitivity to stress can exacerbate all the other post-acute withdrawal symptoms. Signals of a Mood Disorder It is important to note that several of the symptoms of PAWS described above—such as unstable moods, anhedonia, impaired concentration, and sleep disturbances—may also reflect a mood disorder like major depression. Mood disorders can often co-occur with substance use. If these symptoms persist, are severe, and particularly if they are accompanied by suicidal thoughts, a psychiatric evaluation should be sought. Coping Although information about post acute withdrawal is somewhat sparse in the scientific literature, it is well documented in the recovery community. Those who treat withdrawal symptoms and try to prevent relapse are very familiar with prolonged withdrawal. If you have gone through a professional treatment program or have been a member of a support group such as Alcoholics Anonymous in the past 20 years, you have probably heard a lot about post acute withdrawal syndrome. Best-selling author and internationally recognized substance abuse expert Terrence T. "Terry" Gorski literally wrote the book on post-acute withdrawal. His book, "Staying Sober: A Guide for Relapse Prevention" (buy it on Amazon) not only describes the syndrome in detail but outlines ways recovering people can cope with PAWS. Education According to Gorski, the key to not letting protracted withdrawal symptoms result in a relapse is to educate yourself about the symptoms so that you know what to expect, prepare yourself to deal with each symptom as it arises, and develop a plan for handling stress without drugs and alcohol. "Conditions that put you at high risk of experiencing post-acute withdrawal symptoms are usually lack of care of yourself and lack of attention to your recovery program," Gorski wrote. "If you are going to recover without relapse you need to be aware of stressful situations in your life that can increase your risk of experiencing PAWS." Stress Management "Since you cannot remove yourself from all stressful situations you need to prepare yourself to handle them when they occur. It is not the situation that makes you go to pieces; it is your reaction to the situation," Gorski said. Bob Carty, director of clinical services at Hazelden in Chicago, agrees that knowing what the protracted withdrawal symptoms are is important to learn how to manage them. "Successful management of your alcohol or drug withdrawal symptoms will help you feel better physically and emotionally, improve your self-esteem, and reduce your risk of relapse," Carty says on the Hazelden Betty Ford website. Symptoms Management Because stress can make PAWS symptom more intense, learning to manage stress can help you control your post-acute withdrawal symptoms, Gorski said. Tips for Managing PAWS Symptoms According to "Staying Sober" these are tools that you can use to control withdrawal symptoms:Identify your sources of stressDevelop decision-making and problem-solving skillsMaintain a proper dietExercise regularlyDevelop regular habitsKeep a positive attitudeLearn relaxation skills Both Gorski and Carty agree that talking about your symptoms and stress triggers with someone you trust, such as a counselor or an A.A. sponsor, can help you cope with prolonged withdrawal. Telling others about what you are experiencing can help you see the situation more realistically. If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area. For more mental health resources, see our National Helpline Database. Duration Some people who quit alcohol and drugs never experience post-acute withdrawal symptoms at all, while others can still face some symptoms years into abstinence. The amount of time the symptoms can last can also depend on the type of drug from which you are withdrawing. Recovery experts say that patients abstaining from alcohol and opiate-based painkillers will typically experience post-acute withdrawal from six to 24 months. "The symptoms of PAWS typically grow to peak intensity over three to six months after abstinence begins," Gorski said. "The damage is usually reversible, meaning the major symptoms go away in time if proper treatment is received. So there is no need to fear." Help for Post-Acute Withdrawal Syndrome 3 Sources Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Satel SL, Kosten TR, Schuckit MA, Fischman MW. Should protracted withdrawal from drugs be included in DSM-IV? Am J Psychiatry. 1993;150(5):695-704. doi:10.1176/ajp.150.5.695 Kiefer F, Andersohn F, Jahn H, Wolf K, Raedler TJ, Wiedemann K. Involvement of plasma atrial natriuretic peptide in protracted alcohol withdrawal: ANP and alcohol. Acta Psychiatrica Scandinavica. 2002;105(1):65-70. doi:10.1034/j.1600-0447.2002.0_011.x Soto CBD, O’Donnell WE, Allred LJ, Lopes CE. Symptomatology in alcoholics at various stages of abstinence. Alcoholism Clin Exp Res. 1985;9(6):505-512. doi:10.1111/j.1530-0277.1985.tb05592.x Additional Reading Lerner A, Klein M. Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development. Brain Communications. 2019;1(1):fcz025. doi:10.1111/j.1530-0277.1985.tb05592.x By Buddy T Buddy T is an anonymous writer and founding member of the Online Al-Anon Outreach Committee with decades of experience writing about alcoholism. See Our Editorial Process Meet Our Review Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error Submit Get Treatment for Addiction Advertiser Disclosure × The offers that appear in this table are from partnerships from which Verywell Mind receives compensation.