Post-Acute Withdrawal Syndrome (PAWS)

It's widely understood that withdrawal from alcohol or other drugs can involve everything from physical discomfort to life-threatening conditions. What are less known but very common are the lingering effects of withdrawal, called "post-acute withdrawal syndrome" (PAWS), which can seriously challenge sobriety. These symptoms are a result of brain dysfunction caused by the brain readjusting to being without alcohol and drugs. Recovery from PAWS usually takes somewhere between six and 24 months.

If you understand what the symptoms are, you are in a position 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.

PAWS symptoms can include:

• Inability to think clearly
• Memory problems
• Emotional overreactions or numbness
• Sleep disturbances
• Physical coordination problems
• Stress sensitivity

The following are suggestions that can help you manage or respond to any or all of the typical PAWS symptoms.

• Talk about what you are experiencing with your Twelve Step peers, sponsor, counselor, therapist, or family—anyone who will not criticize or minimize your experiences.
• Express your feelings with your Twelve Step peers, sponsor, counselor, therapist, or family—anyone who will not criticize you.
• Take a reality check. Ask a trusted friend if you are making sense, if you are "on target."
• Become a "Monday morning quarterback"—carefully reviewing the events that preceded the flare-up of your PAWS symptoms, and your reaction to them.
• Consider starting a journal to document your experiences and identifying alternative ways of responding next time.

Difficulty thinking clearly

Symptoms

• Concentration problems
• Abstract thinking problems
• Circular thinking

Suggestions

• Limit the amount of time you spend on any one task to no more than 15 minutes.
• Increase the time only when you are consistently successful.
• Give yourself permission to be a concrete thinker for this period.
• Interrupt the circular thinking cycle by doing something very different (e.g. talk to a friend, listen to music, workout).

Memory problems

Symptom

• Short-term memory—most common

Suggestions

• Give yourself permission to sometimes not be able to remember things for even 15 minutes.
• Tell your trusted friends about your memory problem, letting them know it is a PAWS symptom.

Emotional overreaction or numbness

Symptoms

• Reaction disproportionate to event
• Emotional numbness if emotionally overloaded
• Unpredictable mood swings

Suggestions

• Discuss your possible overreaction with as many of those with whom you live and work, explaining that it is a symptom of post-acute withdrawal syndrome.
• Negotiate with those friends to be able to talk with you about your reaction when it seems to be disproportionate.
• Recognize that frequent mood swings are a symptom of PAWS.
• Negotiate with trusted friends, giving them permission to talk with you about your mood swings and provide reality checks.

Sleep disturbances

Symptoms

• Nightmares/terrors
• Difficulty falling asleep, staying asleep
• Changes in sleep patterns

Suggestions

• Acknowledge sleep problems as a symptom of PAWS.
• Trust that "this too shall pass."

Physical coordination problems

Symptoms

• Dizziness
• Balance problems
• Sluggish reflexes
• Impaired eye-hand coordination

Suggestions

• Identify, as best you can, under what circumstances these symptoms occur and what has triggered them.
• Avoid high risk situations when you are experiencing these symptoms (e.g. operating a motor vehicle).
• Tell your family and co-workers about your symptoms so that they don't think you have relapsed.

Stress sensitivity

Symptoms

• Difficulty managing stress
• All other PAWS symptoms can increase during times of high stress, making managing stress more difficult

Suggestions

• Get to know your stress triggers and your stress threshold.
• Do all you can to minimize your stress triggers.
• Let trusted friends, family members, counselors, and your sponsor know about your stress triggers.
• Be prepared to experience an increase in other PAWS symptoms if you are under high stress.

Bob Carty, LCSW, CADC, CCJP, is the director of clinical services at Hazelden in Chicago, a part of the the Hazelden Betty Ford Foundation. He has served in the addiction treatment profession for more than 35 years as a counselor, supervisor, trainer, author, mentor, board member and administrator.