Post-Acute Withdrawal (PAW): What It Is And Why You Should Care

By Terence T. Gorski

post-acute withdrawal (PAW)

When most people think about alcoholism or drug addiction they think only of the alcohol/drug-based symptoms and forget about the sobriety-based symptoms. Yet it is the sobriety-based symptoms, especially post- acute withdrawal, that make sobriety so difficult. The presence of brain dysfunction has been documented in 75- 95% of the recovering alcoholics/addicts tested. Recent research indicates that the symptoms of post-acute withdrawal (PAW) are associated with alcohol/drug-related damage to the brain which may contribute to many cases of relapse.

Post-Acute Withdrawal (PAW)

Post-Acute Withdrawal (PAW) is a group of addiction symptoms that occur as a result of abstinence from addictive chemicals. In the alcoholic/addict these symptoms appear within seven to fourteen days into abstinence, after the person has stabilized from the acute withdrawal.

• Post means- after.
• Acute means- immediate or severe; short-term
• Post-Acute Withdrawal: Symptoms that occur after acute

Post-acute withdrawal is a bio-psycho-social syndrome. This means that the symptoms are caused by the combination of damage to the brain and nervous system (Bio), difficulty thinking clearly and managing feelings and emotions (Psycho), and problems with relationships (Social). The PAW symptoms get worse when you are under stress. During periods of low stress they are very mild or not present at all.

Recovery causes a great deal of stress. Many chemically dependent people never learn to manage stress without using alcohol and drugs. The stress aggravates the brain dysfunction and makes the symptoms worse. The severity of PAW depends upon two things:

1. The severity of the brains dysfunction caused by the addiction.
2. The amount of psychosocial stress experienced in recovery.

The symptoms of PAW typically grow to peak intensity over three to six months after abstinence begins. The damage is usually reversible which means the major symptoms go away in time if proper treatment is received. So there is no need to fear. With proper treatment and effective sober living, it is possible to learn to live normally in spite of the periodic episodes of PAW. The brain does heal, but it doesn’t happen quickly. Recovery from damage to the nervous system usually requires from six to 24 months with the assistance of a healthy recovery program. Recent research is showing that for some recovering people the symptoms of PAW often occur at regular intervals and without apparent outside stressors. People report experiencing intense PAW symptoms 30, 60, 90, 120, 180 days, and at 1 and 2-year sobriety dates.

PAW symptoms can appear to come and go without apparent reason and without any specific problems or stressors. Long-term recovery means learning how to recognize managing PAW. If you don’t, the PAW can make you feel so miserable and dysfunctional in recovery that you can be tempted to medicate the symptoms by drinking or using drugs.


How do you know if you have PAW? There are six major symptoms to look for:

1. Difficulty Thinking Clearly: You have difficulty organizing your thoughts and you can’t solve usually simple problems. You feel confused and don’t understand what is going on.
2. Difficulty Managing Feelings and Emotions: This includes both emotional overreaction, where little things set off a big stress reaction, and emotional numbness, where it seems like you can’t feel anything. You can also swing from overreacting to feeling numb for what seems like no reason at all.
3. Difficulty Remembering Things: Something happens and you feel like you won’t forget it. But in a few moments you can’t remember exactly what happened. This is because your brain
recognizes what is happening in the moment but has problems storing these immediate memories into your long-term memory.
4. Sleep Disturbances: You have difficulty sleeping restfully. You can’t fall asleep. When you do sleep you’re fitful and often have bizarre dreams. When you wake up you don’t feel rested. You tend to sleep during the day and are agitated and awake most of the night.
5. Physical Coordination Problems: You feel clumsy and have problems with hand-eye coordination. This can cause you to become accident-prone.
6. Stress Sensitivity: During periods of high stress the symptoms get worse. When you are having a stressful day or wake up after a restless night of sleep the symptoms get worse.

These PAW symptoms can make you start feeling crazy, incompetent and embarrassed. You can swing in and out of depression as you move in and out of the stressful situations that activate PAW. Low self-esteem and the fear of failure interfere with your ability to live a productive and challenging life. The problems are more severe if you were raised in a dysfunctional family, because as a child you never learned how to effectively manage stress.


PAW is not the same in everyone. Some people experience certain symptoms; some people have other symptoms; some people have none at all. Over a period of time, PAW may get better or it may get worse, it may stay the same or it may come and go. If it gets better with time we call it regenerative. If it gets worse we call it degenerative. If it stays the same we call it stable. And if it comes and goes we call it intermittent.

Just knowing about PAW makes most people feel better. Fortunately, there are ways to manage PAW symptoms when they occur. This will be the subject of next month’s article.

Terence T. Gorski is the Founder and President of The CENAPS Corporation. He is an internationally recognized expert on substance abuse, mental health, violence, and crime. He is best known for his contributions to relapse prevention, managing chemically dependent offenders and developing community-based teams for managing the problems of alcohol, drugs, violence, and crime. He is a prolific author and has published numerous books and articles. Terence is the Director of The National Certification School for Relapse Prevention Specialists.
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