Is It Relapse or Post Acute Withdrawal Syndrome (PAWS)?

I was recently providing individual counseling to a patient who had just completed both inpatient and outpatient treatment for alcohol dependence. During our session she was giddy, energetic, demonstrated mood liability, cognitive problems, memory problems, and some physical coordination problems. My first thought was -I wonder if she has relapsed. Then I caught myself and reminded myself about PAWS. This syndrome is a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines and other psychotropic drugs.

Common PAWS symptoms include:

• Mood swings, depression, anxiety, panic attacks

• Psychosocial dysfunction/Impaired interpersonal skills

• Anhedonia (the inability to feel pleasure from anything besides drug use)

• Insomnia/Sleep disturbances

• Suicidal ideation, pessimistic thoughts, feelings of guilt and shame

• Excessive fatigue, excessive thirst, light-headedness, fainting

• Impaired concentration/Lack of initiative, Intense drug cravings

• Memory problems/general cognitive impairment/inability to think clearly

• Emotional overreactions or numbness

• Physical coordination problems

• Stress sensitivity/Increased sensitivity to pain

It is estimated that PAWS occurs in over 90% of people withdrawing from a long-term opioid abuse (such as heroin addiction), and about 75 % of persons recovering from long-term abuse of alcohol, methamphetamine, or benzodiazepines. It occurs less frequently with abuse of other psychotropic drugs.

The length of time PAWS symptoms linger varies from person to person. Symptoms of PAWS can last from a year to several decades, and some symptoms remain can indefinitely. The presence of symptoms vacillates between periods of relative remission, intermittent presence of symptoms and highly symptomatic periods. However, by the end of one year, most 'clean & sober' persons have returned to their baseline levels of functioning and the symptoms of PAWS dissipate.

Some believe the symptoms of PAWS occur because the brain's ability to react to stress has been weakened by long-term substance abuse. PAWS may be a result of the adaptations in the central nervous system and changes in the brain's communication system. Drug-related disruptions in the 'normal' communication between neurotransmitters and hyperexcitability of neuronal pathways may be an underlying cause. Research has demonstrated that when a person's drug abuse becomes an addiction, there are structural changes that occur in the brain.

It is important for treatment providers, 12-step sponsors, and the friends and family of the recovering person to keep PAWS in mind when interacting with the recovering person. The symptoms of PAWS sometimes mimic mental health symptoms, behaviors/symptoms that occurred during the person's active use, and mimic acute withdrawal symptoms from recent use.

This situation with my patient reminded me how important it is to balance knowing the high likelihood and incidence of relapse for recovering persons, knowing the relapse 'red flags' to watch for, and knowing that PAWS sometimes mimics the signs of relapse.