Post-Acute Withdrawal Symptom

By Brian Shrawder, MSMFT

Post-Acute Withdrawal Syndrome

Is your loved one suffering from Post-Acute Withdrawal Syndrome or PAWS? The idea of withdrawal generally brings about thoughts of physical symptomatology. However, PAWS is common among substance abusers. In fact, 60 days to several years following the end of an individual’s active addiction these symptoms can present themselves. The time period depends on the substance used, the length of time and severity of abuse.

Symptoms of PAWS

PAWS is very common in substance abusers. Symptoms can present in several ways including but not limited to: stress sensitivity, sleep disturbances, memory problems, impaired concentration, emotional overreaction or numbness and cravings.

Stress sensitivity

Substance abusers in early recovery often struggle with situations which bring about stress. It is important to remember that addicts while in active addiction participated in addictive behaviors as a means to cope or get away from the stressful events. Many times addicts describe themselves as “raw.” Treatment needs to include coping skills to replace the abusive behaviors.

Sleep disturbances

This symptom should subside as time passes. Non-addictive medications may be prescribed by a medical provider. Non-medication interventions such as creating a regular routine and sleep schedule can be helpful. In addition, exercise is a great way to burn energy and assist in reducing other PAWS symptoms.

Memory Problems

Forgetfulness is common and can be stress provoking. It can be useful to write down a daily schedule or list of activities each day

Impaired Concentration

Attention-Deficit disorder (ADD) is not uncommon with substance abusers. These individuals struggle with focusing and may be easily distracted.

Emotional Overreaction or Numbness

Addicts commonly describe feeling either no emotions or flooded. In time this can pass. Those in recovery are encouraged to verbalize either their lack of emotions or being flooded by them.

Utilizing mood journals can be beneficial. A mood journal is sometimes used by a therapist in working with a client to help track thoughts and break thoughts down as rational versus irrational.


They derive from a trigger (physical, emotional, or sensory). Often time’s addicts refer to triggers as people, places, and things. The cravings often bring about anxiety and depression symptoms.

Some people in treatment think they won’t experience any cravings due to being in treatment. Of course, this is not the case. However, talking about triggers in and out of treatment can be helpful. While in a treatment program, it is important to communicate triggers to family members. This is important as family members can be helpful in noticing body cues in the substance abuser when they are experiencing a craving. Utilizing thought stopping techniques such as “rubber band therapy” which is placing a rubber band around your wrist and snapping yourself when experiencing a craving can be a helpful technique.

Interestingly, PAWS does not show it’s self constantly. However, the symptoms do seem to come about at times of increased stress. It is important to remember that emotional sobriety is equally as important as physical. If the emotional aspect of addiction is
ignored relapse is a highly probable reality.

What is the cause of PAWS?

Due to prolonged substance abuse the brain has been negatively affected. Once the abuser is no longer in active addiction the brain begins to repair by creating more neurons. Neurons are nerve cells and similar to other cells except for one difference. The difference being neurons transmit information throughout our bodies.

Neurons transmit information in two different ways, chemically and electrically. There are different types of neurons which have varying tasks. The sensory neurons transmit information from sensory receptors throughout the body to the brain. Motor neurons carry information from the brain to our muscles. Interneurons carry information from one neuron to another.

Neurons are made-up of dendrites, cell body and axons. Interestingly, neurons come in different shapes and sizes. Some neurons are made-up of more dendrites and can take in more information. Other neurons have larger or shorter axons.

Information is transmitted from dendrites to neurons and from one to another using chemicals called neurotransmitters. There are several types of neurotransmitters such as dopamine, glutamate, and gamma-aminbutyric acid (GABA). Overtime an individual’s
substance abuse increases the level of dopamine which brings the addiction. The substance abuse behavior increases the glutamine which speeds up communication between neurons to the point that an excitement occurs in the brain. The GABA levels would normally keep the glutamine in check and not allow for the speedup in communication. However, in the increase of substance abuse behavior the GABA levels are decreased and the glutamine is not held in check. This excitement in the brain brings about cravings in the individual. If these cravings are not met PAWS then begins.

How to Manage Symptoms of PAWS

There are several ways to manage symptoms of PAWS. Relaxation techniques such as deep breathing and meditation are an option. Meeting with your primary care physician is always a good idea for medication options if warranted. Make sure to keep a list of symptoms and be open and honest about the substance abuse behaviors so that the physician can have adequate information to provide appropriate treatment.

Therapy with a certified drug and alcohol and or marriage and family therapist is another option. The drug and alcohol counselor has been trained in substance abuse and issues which come along with addictive behaviors. The marriage and family therapist is a skilled clinician in working with families and couples. Substance abuse is a family disease and marriage and family therapists can help construct interventions in assisting family members with problems that come up when dealing with this disease.

Exercise is a great way to get physically fit and work off extra energy. Jogging, hiking, walking, lifting weights, and swimming are but a few great ways to stay active. These are also beneficial coping skills which can assist in reducing a number of symptoms such as stress, anxiety, and depression.

Attending meetings such as AA, NA, and CA can be a great way to reduce stress by surrounding yourself in the recovery community.

Have you spoken to your sponsor lately? Do you have a sponsor?

If you have not spoken to your sponsor, get on the phone. This is why sponsors exist, to help others struggling with addiction. If you do not have a sponsor it is important you work on getting one as soon as possible.

Brian Shrawder is a primary therapist for Seabrook West in North Central Pennsylvania. Seabrook West is an extended trauma informed treatment facility for men struggling with substance abuse where Brian facilitates relapse prevention and anger management groups.
Brian is a 2013 graduate of Capella University with a degree in Marriage and Family therapy. He is currently working towards his PhD specializing in Couple’s Therapy at North Central University.