Post-acute-withdrawal syndrome (PAWS), or the terms post-withdrawal syndrome, protracted withdrawal syndrome, prolonged withdrawal syndromes describe a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants and other substances. Infants born to mothers who used substances of dependence during pregnancy may also experience a post-acute withdrawal syndrome. While post-acute withdrawal syndrome has been reported by those in the recovery community, there have been few scientific studies supporting its existence. Because of this, the disorder is not recognized by the Diagnostic and Statistical Manual of Mental Disorders or major medical associations.
Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and during the withdrawal state. In some cases these substance-induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate alcohol sustained use may increase anxiety and depression levels in some individuals. In most cases these drug-induced psychiatric disorders fade away with prolonged abstinence.
Signs and symptoms
Symptoms can sometimes come and go with wave-like reoccurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse.
The protracted withdrawal syndrome from benzodiazepines can produce symptoms identical to generalized anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine withdrawal, abrupt withdrawal is not advised.
- Psychosocial dysfunction
- Impaired interpersonal skills
- Obsessive-compulsive behaviour
- Feelings of guilt
- Autonomic disturbances
- Pessimistic thoughts
- Impaired concentration
- Lack of initiative
- Inability to think clearly
- Memory problems
- Emotional overreactions or numbness
- Sleep disturbances
- Physical coordination problems
- Stress sensitivity
- Increased sensitivity to pain
- Panic disorder
- Generalized anxiety disorder
- Sleep disturbance (dreams of using, behaviors associated with the life style)
Symptoms occur intermittently, but are not always present. They are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short while or longer. Any of the following may trigger a temporary return or worsening of the symptoms of post-acute withdrawal syndrome:
- Stressful and/or frustrating situations
- Feelings of anxiety, fearfulness or anger
- Social conflicts
- Unrealistic expectations of oneself
Post-acute benzodiazepine withdrawal
Disturbances in mental function can persist for several months or years after withdrawal from benzodiazepines. Psychotic depression persisting for more than a year following benzodiazepine withdrawal has been documented in the medical literature. The patient had no prior psychiatric history. The symptoms reported in the patient included, major depressive disorder with psychotic features, including persistent depressed mood, poor concentration, decreased appetite, insomnia, anhedonia, anergia and psychomotor retardation. The patient also experienced paranoid ideation (believing she was being poisoned and persecuted by co-employees), accompanied by sensory hallucinations. Symptoms developed after abrupt withdrawal of chlordiazepoxide and persisted for 14 months. Various psychiatric medications were trialed which were unsuccessful in alleviating the symptomatology. Symptoms were completely relieved by recommending chlordiazepoxide for irritable bowel syndrome 14 months later. Another case report, reported similar phenomenon in a female patient who abruptly reduced her diazepam dosage from 30 mg to 5 mg per day. She developed electric shock sensations, depersonalisation, anxiety, dizziness, left temporal lobe EEG spiking activity, hallucinations, visual perceptual and sensory distortions which persisted for years.
A clinical trial of patients taking the benzodiazepine alprazolam (Xanax) for as little as 8 weeks triggered protracted symptoms of memory deficits which were still present after up to 8 weeks post cessation of alprazolam.
The syndrome may be in part due to persisting physiological adaptations in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyperexcitability of neuronal pathways in regards to alcohol. However, data supports neuronal and overwhelming cognitive normalization in regards to chronic amphetamine use and PAWS. Stressful situations arise in early recovery, and the symptoms of post acute withdrawal syndrome produce further distress. It is important to avoid or to deal with the triggers that make post acute withdrawal syndrome worse. The types of symptomatology and impairments in severity, frequency, and duration associated with the condition vary depending on the drug of use.
Flumazenil was found to be more effective than placebo in reducing feelings of hostility and aggression in patients who had been free of benzodiazepines for 4–266 weeks. This may suggest a role for flumazenil in treating protracted benzodiazepine withdrawal symptoms.
Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome in regards to alcohol use. Cognitive behavioral therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.
- Collier, Judith; Longmore, Murray (2003). "4". In Scally, Peter. Oxford Handbook of Clinical Specialties (6 ed.). Oxford University Press. p. 366. ISBN 978-0-19-852518-9.
- Miller FT (Mar–Apr 1994). "Protracted alcohol withdrawal delirium". J Subst Abuse Treat 11 (2): 127–30. doi:10.1016/0740-5472(94)90029-9. PMID 8040915.
- Ashton H (1991). "Protracted withdrawal syndromes from benzodiazepines". J Subst Abuse Treat (benzo.org.uk) 8 (1-2): 19–28. doi:10.1016/0740-5472(91)90023-4. PMID 1675688.
- Wu JM; Wei DY; Luo YF; Xiang XY (November 2003). "[Clinic research on heroin de-addiction effects of acupuncture and its potentiality of preventing relapse]". Zhong Xi Yi Jie He Xue Bao 1 (4): 268–72. doi:10.3736/jcim20030412. PMID 15339529.
- Lejeune C; Floch-Tudal C; Montamat S; Crenn-Hebert C; Simonpoli AM (March 1997). "[Management of drug addict pregnant women and their children]". Arch Pediatr 4 (3): 263–70. doi:10.1016/S0929-693X(97)87247-8. PMID 9181022.
- Gaillard MC; Borruat FX (April 2002). "[New finding: transitory horizontal pendular nystagmus secondary to neonatal abstinence syndrome]". Klin Monatsbl Augenheilkd 219 (4): 317–9. doi:10.1055/s-2002-30650. PMID 12022028.
- Satel SL (May 1993). "Should protracted withdrawal from drugs be included in DSM-IV?". American Journal of Psychiatry 150 (5): 695–704. doi:10.1176/ajp.150.5.695. PMID 8097618.
- "Symptoms & Treatments of Mental Disorders". psychcentral.com. Retrieved 2014-10-01.
- Evans, Katie; Sullivan, Michael J. (1 March 2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). Guilford Press. pp. 75–76. ISBN 978-1-57230-446-8.
- Stojek A; Madejski J; Dedelis E; Janicki K (May–Jun 1990). "[Correction of the symptoms of late substance withdrawal syndrome by intra-conjunctival administration of 5% homatropine solution (preliminary report)]". Psychiatr Pol 24 (3): 195–201. PMID 2084727.
- Bokhan NA; Abolonin AF; Krylov EN; Vetlugina TP; Ivanova SA (2003). "Comparative Efficiency of Proproten-100 during the Therapy of Patients with Alcoholism in the Stage of Therapeutic Remission". Bull Exp Biol Med 135 (Suppl 1): 171–5. doi:10.1023/A:1024709014483. PMID 12949690.
- Riba, Michelle B.; Ravindranath, Divy (12 April 2010). Clinical manual of emergency psychiatry. Washington, DC: American Psychiatric Publishing Inc. p. 197. ISBN 978-1-58562-295-5.
- De Soto CB; O'Donnell WE; Allred LJ; Lopes CE (December 1985). "Symptomatology in alcoholics at various stages of abstinence". Alcohol Clin Exp Res 9 (6): 505–12. doi:10.1111/j.1530-0277.1985.tb05592.x. PMID 3911810.
- Voltaire-Carlsson A; Hiltunen AJ; Koechling UM; Borg S (Sep–Oct 1996). "Effects of long-term abstinence on psychological functioning: a prospective longitudinal analysis comparing alcohol-dependent patients and healthy volunteers". Alcohol 13 (5): 415–21. doi:10.1016/0741-8329(96)81678-8. PMID 8888936.
- Watanabe KI; Ogihara-Hashizume A; Kobayashi Y; Mitsushio H; Komiyama T (April 2001). "Impaired sleep during the post-alcohol withdrawal period in alcoholic patients". Addict Biol 6 (2): 163–169. doi:10.1080/13556210020040244. PMID 11341856.
- Vik PW; Cellucci T; Jarchow A; Hedt J (March 2004). "Cognitive impairment in substance abuse". Psychiatr Clin North Am 27 (1): 97–109. doi:10.1016/S0193-953X(03)00110-2. PMID 15062633.
- Janiri L; Martinotti G; Dario T; Reina D; Paparello F; Pozzi G; Addolorato G; Di Giannantonio M; De Risio S (June 3, 2005). "Anhedonia and substance-related symptoms in detoxified substance-dependent subjects: a correlation study". Neuropsychobiology 52 (1): 37–44. doi:10.1159/000086176. PMID 15942262.
- Modell JG (Mar–Apr 1997). "Protracted benzodiazepine withdrawal syndrome mimicking psychotic depression" (PDF). Psychosomatics (Psychiatry Online) 38 (2): 160–1. doi:10.1016/S0033-3182(97)71493-2. PMID 9063050.
- Shader RI; Greenblatt DJ (1981). "The use of benzodiazepines in clinical practice". Br J Clin Pharmacol 11 (Suppl 1): 5S–9S. doi:10.1111/j.1365-2125.1981.tb01832.x. PMC 1401641. PMID 6133535.
- Curran, Hv; Bond, A; O'Sullivan, G; Bruce, M; Marks, I; Lelliot, P; Shine, P; Lader, M (November 1994). "Memory functions, alprazolam and exposure therapy: a controlled longitudinal study of agoraphobia with panic disorder.". Psychological Medicine 24 (4): 969–76. doi:10.1017/S0033291700029056. ISSN 0033-2917. PMID 7892364.
- Rimondini R; Sommer WH; Dall'Olio R; Heilig M (March 2008). "Long-lasting tolerance to alcohol following a history of dependence". Addict Biol 13 (1): 26–30. doi:10.1111/j.1369-1600.2007.00079.x. PMID 17850416.
- Ahveninen J; Jääskeläinen IP; Pekkonen E; Hallberg A; Hietanen M; Näätänen R; Sillanaukee P (June 8, 1999). "Post-withdrawal changes in middle-latency auditory evoked potentials in abstinent human alcoholics". Neurosci Lett 268 (2): 57–60. doi:10.1016/S0304-3940(99)00378-X. PMID 10400077.
- Kiefer F; Andersohn F; Jahn H; Wolf K; Raedler TJ; Wiedemann K (January 2002). "Involvement of plasma atrial natriuretic peptide in protracted alcohol withdrawal". Acta Psychiatr Scand 105 (1): 65–70. doi:10.1034/j.1600-0447.2002.0_011.x. PMID 12086228.
- Bruijnzeel AW; Gold MS (November 2005). "The role of corticotropin-releasing factor-like peptides in cannabis, nicotine, and alcohol dependence". Brain Res Brain Res Rev 49 (3): 505–28. doi:10.1016/j.brainresrev.2005.01.007. PMID 16269317.
- Hart, CL; Marvin, CB; Silver, R; Smith, EE (Feb 2012). "Is cognitive functioning impaired in methamphetamine users? A critical review.". Neuropsychopharmacology 37 (3): 586–608. doi:10.1038/npp.2011.276. PMC 3260986. PMID 22089317.
- Salo, Ruth; Buonocore, Michael; Laemon, Martin (2011-01-15). "Extended findings of brain metabolite normalization in MA-dependent subjects across sustained abstinence: A proton MRS study". Drug and Alcohol Dependence 113 (2–3): 133–138. doi:10.1016/j.drugalcdep.2010.07.015. Retrieved 2014-10-22.
- Roberts AJ; Heyser CJ; Cole M; Griffin P; Koob GF (June 2000). "Excessive ethanol drinking following a history of dependence: animal model of allostasis" (PDF). Neuropsychopharmacology 22 (6): 581–94. doi:10.1016/S0893-133X(99)00167-0. PMID 10788758.
- De Soto CB, O'Donnell WE, De Soto JL (October 1989). "Long-term recovery in alcoholics". Alcohol Clin Exp Res 13 (5): 693–7. doi:10.1111/j.1530-0277.1989.tb00406.x. PMID 2688470.
- L. Saxon, S. Borg & A. J. Hiltunen (August 2010). "Reduction of aggression during benzodiazepine withdrawal: effects of flumazenil". Pharmacology, biochemistry, and behavior 96 (2): 148–151. doi:10.1016/j.pbb.2010.04.023. PMID 20451546.
- Beleslin D (1991). "[Modern drug therapy in alcoholism]". Med Pregl 44 (7-8): 279–84. PMID 1806768.
- Wilde MI; Wagstaff AJ (June 1997). "Acamprosate. A review of its pharmacology and clinical potential in the management of alcohol dependence after detoxification". Drugs 53 (6): 1038–53. doi:10.2165/00003495-199753060-00008. PMID 9179530.
- Malcolm R; Myrick H; Brady KT; Ballenger JC (2001). "Update on anticonvulsants for the treatment of alcohol withdrawal". Am J Addict. 10 Suppl (1): 16–23. doi:10.1080/10550490150504100. PMID 11268817.
- Le Bon O; Murphy JR; Staner L; Hoffmann G; Kormoss N; Kentos M; Dupont P; Lion K; Pelc I; Verbanck P (August 2003). "Double-blind, placebo-controlled study of the efficacy of trazodone in alcohol post-withdrawal syndrome: polysomnographic and clinical evaluations". J Clin Psychopharmacol 23 (4): 377–83. doi:10.1097/01.jcp.0000085411.08426.d3. PMID 12920414.
- Mueller TI; Stout RL; Rudden S; Brown RA; Gordon A; Solomon DA; Recupero PR (February 1997). "A double-blind, placebo-controlled pilot study of carbamazepine for the treatment of alcohol dependence". Alcohol Clin Exp Res 21 (1): 86–92. doi:10.1111/j.1530-0277.1997.tb03733.x. PMID 9046378.
- Hori T; Komiyama T; Harada S; Matsumoto T (2005). "[Treatment of substance dependence by a bio-cognitive model based on behavioral pharmacology]". Seishin Shinkeigaku Zasshi 107 (11): 1147–58. PMID 16408423.