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Post–acute withdrawal syndrome (PAWS) (also sometimes referred to as post withdrawal syndrome or protracted withdrawal syndrome) is a set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines and other substances.[1][2][3][4] Infants born to mothers who used substances of dependence during pregnancy may also experience a post acute withdrawal syndrome.[5][6] Post acute withdrawal syndrome affects many aspects of recovery and everyday life, including the ability to keep a job and interact with family and friends. Symptoms occur in three-quarters of persons recovering from long-term use of alcohol, methamphetamine, or benzodiazepines and to a lesser degree other psychotropic drugs. Symptoms can include mood swings, cognitive impairment, and difficulty forming new memories.


Drug abuse, including alcohol and prescription drugs can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also 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.[7]


The syndrome may be in part due to persisting physiological adaptions in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyperexcitability of neuronal pathways.[8][9][10][11] The symptoms of post acute withdrawal syndrome occur because the brain's ability to react to stress has been weakened by long-term substance use. 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.


Symptoms can sometimes come and go with wave like reoccurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, anxiety which may reach severe levels which can lead to relapse.[12][13]

Common symptoms of post acute withdrawal syndrome are:[14][15][16][17]

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
  • Multitasking
  • Feelings of anxiety, fearfulness or anger
  • Social Conflicts
  • Unrealistic expectations of oneself


The condition gradually improves over a period of months or in severe cases years.[19][20] Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal.[21][22] Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome.[23][24][25] Cognitive behavioural therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.[26]

See alsoEdit


  1. (2003) "4" Oxford Handbook of Clinical Specialties, 6, Oxford University Press.
  2. Miller FT (Mar-Apr 1994). Protracted alcohol withdrawal delirium. J Subst Abuse Treat 11 (2): 127–30.
  3. Ashton H (1991). Protracted withdrawal syndromes from benzodiazepines. J Subst Abuse Treat 8 (1-2): 19–28.
  4. 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.
  5. 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.
  6. Gaillard MC, Borruat FX (April 2002). [New finding: transitory horizontal pendular nystagmus secondary to neonatal abstinence syndrome]. Klin Monatsbl Augenheilkd 219 (4): 317–9.
  7. (1 March 2001) Dual Diagnosis: Counseling the Mentally Ill Substance Abuser, 2nd, 75–76, Guilford Press.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. Vik PW, Cellucci T, Jarchow A, Hedt J (March 2004). Cognitive impairment in substance abuse. Psychiatr Clin North Am 27 (1): 97–109.
  18. 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 2 (1): 37–44.
  19. Roberts AJ, Heyser CJ, Cole M, Griffin P, Koob GF (June 2000). Excessive ethanol drinking following a history of dependence: animal model of allostasis. Neuropsychopharmacology 22 (6): 581–94.
  20. De Soto CB, O'Donnell WE, De Soto JL (October 1989). Long-term recovery in alcoholics. Alcohol Clin Exp Res 13 (5): 693–7.
  21. Beleslin D (1991). [Modern drug therapy in alcoholism]. Med Pregl 44 (7-8): 279–84.
  22. 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.
  23. Malcolm R, Myrick H, Brady KT, Ballenger JC (2001). Update on anticonvulsants for the treatment of alcohol withdrawal. Am J Addict 10 Suppl: 16–23.
  24. 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.
  25. 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.
  26. 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.
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