What is Post-Acute-Withdrawal Syndrome?

Post-acute-withdrawal syndrome (PAWS) is something that’s rarely discussed in the early stages of recovery and it really should be.  The physical, emotional, and psychological changes that happen in the first few months of quitting drinking can be really scary and if you don’t know the science behind them the chances of relapse and increased anxiety are so much higher. 

PAWS is the “second detox” after the first detox and can feel incredibly draining and never-ending

When you stop drinking your body is suddenly deprived of its usual supply of alcohol and the effects it has on your body and mind and so it needs time to adjust to a new way of functioning and that will cause uncomfortable side effects.  Alcohol withdrawal can trigger life-threatening health complications so it’s very important to receive professional care during this time if your level of alcohol dependency is high.  My advice would be to see your regular doctor or go to a walk-in clinic and tell them your plans on quitting and give them a rundown on your use and symptoms.  Let the doctor decide if you’re safe to quit drinking on your own or if you should go to a detox facility.  Currently, in Nova Scotia, if you want to go through a formal alcohol detox and rehab program you have two options- free (through Nova Scotia Health Authority) or paid (private facilities).  For the free one, you must call the intake team to discuss a plan at 902-424-8866 or toll-free at 1-866-340-6700. 

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The Stages of Detox/Withdrawal

There are 2 stages of detox/withdrawal- acute and post-acute-withdrawal syndrome.  Post-acute-withdrawal syndrome refers to the emotional and psychological symptoms you experience after the acute withdrawal has resolved.  Acute withdrawal is where you’ll experience the physical symptoms that happen immediately after quitting drinking and they can last from a few days up to two weeks.  Mild acute withdrawal symptoms would be anxiety, digestion issues, heart palpitations (where you suddenly feel and hear your heart loudly speed up or flutter and feel the sensation that it skipped a beat or added an extra beat), tremors, headaches, sleep disturbances.  Moderate acute withdrawal symptoms are elevated body temperature, sweating, mild confusion, rapid shallow breathing, increased systolic blood pressure, and rapid heartbeat.  It would be a good idea to seek medical help if you’re experiencing these moderate symptoms and you should definitely seek help for the more severe symptoms of withdrawal as they can be life-threatening.  They include delirium tremens, disorientation, seizures, psychosis, and visual and/or auditory hallucinations.

For some people who quit drinking they may experience some of the acute symptoms then go on with their life without alcohol or with a more relaxed/part-time approach to drinking.  For others, PAWS is the “second detox” after the first detox and can feel incredibly draining and never-ending.  Thankfully it’s only temporary and once you push through it you’re so much better equipped to deal with life.

What is Post-Acute-Withdrawal Syndrome?

Post-Acute-Withdrawal Syndrome (PAWS) is what some people can experience after the initial physical withdrawal effects fade away and it varies in severity and duration, depending on your alcohol use history.  It can feel like a rollercoaster of emotions and symptoms and can change minute-to-minute or day-to-day.  Why?  PAWS is basically your brain managing and fixing the chemical imbalances suffered during active addiction.  Alcohol messes with your brain chemistry in a lot of ways so when alcohol is removed your brain has to almost “rewire” itself.  Everyone is different and will feel these symptoms to varying degrees and lengths of time.

Symptoms of Post-Acute-Withdrawal Syndrome

• Mood swings
• Emotional overreactions/outbursts
• Lack of emotion/numbness
• Anxiety and/or panic
• Memory problems
• Irritability and/or hostility
• Tiredness
• Variable energy
• Physical coordination problems
• Stress sensitivity
• Low enthusiasm
• Lack of initiative
• Variable concentration
• Inability to think clearly and/or focus
• Disturbed sleeping patterns
• Depression

My Experience with Post-Acute-Withdrawal Syndrome

I’ve experienced all the aforementioned symptoms in the first few weeks of sobriety and weeks 1-2 were the worst.  I kept a journal for my first few years of sobriety and here are some excerpts regarding my PAWS experiences:

“Heading into my second week of sobriety was still numbing.  I was starting school and meeting new people and learning new things which probably helped but it also aided in stress, albeit good stress.  I was noticing that sometimes I’d feel very foggy headed.  You know that feeling when you barely slept the night before then you have a 20 minute nap after work then as soon as you wake up from that nap you feel slightly disorientated and to hold a conversation would be virtually impossible?  Well that’s how I’d feel sometimes.  Like once a day or once every second day.  My roommate would be talking to me and I’d feel all her words and all my thoughts slip through my mind like my brain was a wicker basket.  I couldn’t hold a conversation and it was very difficult to appear as if I was.  That feeling would last 15-20 minutes then I’d be fine.  Then my class went bowling and I excited all day for it.  So we get to the bowling alley and I pretty much instantly started to feel very blah.  It was a huge effort for me to even feel at a normal level.  I was super low enthusiasm and had to force myself to talk or to have fun.  It was quite difficult to try and feel something.  Anything!  A spark of enthusiasm, I jolt of excitement, anything.  But it didn’t come.  I was still social and friendly, I may have just appeared tired.  I was thinking maybe because in the past I’d equate bowling with beer.  I’m not sure.

After bowling I went to my Mum’s house.  Then that thing started happening again where I get super foggy headed and my mind starts doing the ol’ wicker basket thing.  I explained it all to Mum and she said it could be anxiety.  But I said I’ve never experienced anxiety like that before.  It was like my brain wasn’t working or it was short circuiting.  And I know anxiety since I’ve battled it for 16 years and have experienced numerous peaks in the disorder.  But this was different.”

Memory problems were an issue for me too.  Here’s another excerpt from my journal when I was 3 weeks sober:

“I’ve been with the same company for 6 years and never had any issues in the past with the alarm code.  I remember numbers pretty quickly and I retain them for decades.  But the second I walked through the shop door I panicked- I forgot the alarm code!  That’s never happened to me before and I swear, the blaring alarm was heard within a 1km radius of the store.  I called in the false alarm but the cops still showed up.  I was embarrassed and shocked that I actually forgot my simple 4 digit code that I’ve been using for the better part of 6 years.  It turned out that I sort of knew one of the police officers that arrived and I explained that I just quit drinking and explained that memory lapses was one of the symptoms of post-acute-withdrawal syndrome.  Neither of them knew that was a thing so I felt pretty awesome teaching a cop something new haha At least they were more sympathetic to my embarrassing situation.”

Emotional outbursts and overreactions also plagued me in my first month of recovery as explained in this journal excerpt:

“The post-acute-withdrawal syndrome symptom of emotional outbursts/overreactions?  Yup, definitely a thing.  I hate it.  I’m trying so hard to change that part of me.  Hours pass after an episode and I’m still in a very negative head space.  In those moments I want to be normal again so so bad but it was like my brain is against me.  It’s like I can almost feel my brain being blocked.  I found out later by my social worker that what I was experiencing after a particular fight with my boyfriend was called amygdala hijacking.  That part of my brain that experiences emotions and the “fight or flight” response was fully activated and that part of my brain that sees logic and the calm and rational approach to situations (neocortex) was quiet to non existent.  I started saying things like “I’m a horrible person” (and actually truly mean it), “I hate myself and who I am, I’m nothing, I’m worthless, I’ll never get better”.  I was incredibly depressed and felt trapped and like a piece of shit who didn’t deserve to be here.  I knew logically that I shouldn’t be saying those things to myself.  I could hear my Mum (not literally) saying “Tell yourself positive things, don’t hate talk, love yourself” but it wasn’t working.  Something in my brain wasn’t letting me be a logical human.  I eventually started to calm down (hours later) and envisioned him alone in his room having a bad day and that it was me who could have made him so much more happier.  And I started to “click” into that logic.  That extreme emotional outburst was pretty much a direct result of my PAWS.  Plus a combination of my own flaws (self seeking, dependence, expectations, lack of empathy defects) that was just magnified by my brain healing/rewiring.”

Tips on Managing PAWS

1.  Connect with mental health professionals – Because PAWS symptoms are psychological, ongoing support from counselors, psychologists, and therapists is incredibly helpful in reducing the severity of the experience.  Talk therapy will help you make sense of what’s in your mind, help you understand triggers to avoid relapse, and give you clearer direction on steps to healing.  An addictions counsellor or therapist can educate you on withdrawal and relapse prevention, give encouragement, help manage impulse control, provide healthy coping mechanisms, and assess and help with co-occurring disorders.  I highly recommend going the route I took when I first got sober- contact Mental Health and Addictions Services at 902-424-8866 or toll-free at 1-866-340-6700 where they’ll set you up with FREE counselling and/or group therapy.

2.  Improve your diet and nutrition – Alcohol can deplete your body of essential nutrients and can mess with your gut microbiome and hormone health so fixing your body through diet and nutrition is imperative for physical and mental health.  My advice would be to work with a naturopathic doctor for a thorough investigation into your specific needs.  Listen to podcasts, read books (here’s one that helped me – Practical Paleo by Diane Sanfilippo), read blogs on nutrition and healing the gut.

3.  Talk about it – Discuss how you’re feeling and thinking with your spouse, family, friends, or AA peers.  You could also join the private Sober City Chat group on Facebook to talk to people who get it who also live in Nova Scotia.  I also run monthly hangouts where we all get together and talk about whatever is on our minds around recovery, addiction, and managing an alcohol-free life.

4.  Be good to yourself – Self-care is huge!  Eat well, exercise, reach out to supportive friends, take bubble baths, allow yourself to cry when you want, tell yourself it’s perfectly okay to leave a social gathering 15 minutes in because you feel too overwhelmed, tell yourself you’re doing great even when it’s really hard, forgive yourself, give yourself a day off for a movie marathon and pizza, do anything it takes to feel loved by the one person you have to spend the rest of your life with – you.

5.  Utilize a calendar and notepad – I use apps on my phone but you can to it the old-fashioned way too.  Writing down important information and events will take some of the pressure off your glitchy memory.

6.  Read up on good sleep hygiene – If insomnia is a problem for you limit the amount of caffeine you consume in the hours before bedtime, maybe try blue-blocking glasses, switch out your regular lightbulbs for red ones in your bedroom, go to bed and wake up at the same time every day, adjust the temperature in your room to be cooler, etc.  There are so many ways you can regulate your circadian rhythm, sleep better, and sleep longer. 

7.  Journal – Get all your thoughts, fears, and accomplishments out on paper (or digital paper) like I did!  If you’re not sure what to write I highly recommend buying a guided journal like this one called Look at Me Getting Sober and Shit.  Write about the events that lead to your quitting, write about your PAWS symptoms, think about ways you could deal with them when they come up again in the future.

If you’re currently experiencing post-acute-withdrawal syndrome know that it’s only temporary and with time you’ll begin to feel better and stronger with each passing week.  It’s hard to get through but you can and you will get through it.  I believe in you!