Post–acute withdrawal syndrome

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. Infants born to mothers who used substances of dependence during pregnancy may also experience a post acute withdrawal syndrome. 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.

Background
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.

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

The protracted withdrawal syndrome from benzodiazepines can produce symptoms identical to generalised anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine withdrawal, abrupt withdrawal is not advised.

Common symptoms of post acute withdrawal syndrome are:
 * Psychosocial dysfunction
 * Anhedonia
 * Depression
 * Impaired interpersonal skills
 * Obsessive-compulsive behaviour
 * Feelings of guilt
 * Autonomic disturbances
 * Pessimistic thoughts
 * Impaired concentration
 * Lack of initiative
 * Craving
 * Inability to think clearly
 * Memory problems
 * Emotional overreactions or numbness
 * Sleep disturbances
 * Physical coordination problems
 * Stress sensitivity
 * Increased sensitivity to pain
 * Panic disorder
 * Generalised anxiety disorder

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
 * Too much on your to-do list

Post-acute benzodiazepine withdrawal
Disturbances in mental function can persist for several months or years after withdrawal from benzodiazepines. Psychotic depression persisting for more than a year following benzodiazepine withdrawal has been documented in the medical literature. The patient had no prior psychiatric history. The symptoms reported in the patient included, major depressive disorder with psychotic features, including persistent depressed mood, poor concentration, decreased appetite, insomnia, anhedonia, anergia and psychomotor retardation. The patient also had paranoid ideation believing she was being poisoned and persecuted by co-employees, and sensory hallucinations. Symptoms developed after abrupt withdrawal of chlordiazepoxide and persisted for 14 months. Various psychiatric medications were trialed which were unsuccessful in alleviating the symptomatology. Symptoms were completely relieved by recommencing chlordiazepoxide for irritable bowel syndrome 14 months later. Another case report, reported similar phenomenomin a female patient who abruptly reduced her diazepam dosage from 30 mg to 5 mg per day. She developed electric shock sensations, depersonalisation, anxiety, dizziness, left temporal lobe EEG spiking activity, hallucinations, visual perceptual and sensory distortions which persisted for years.

A clinical trial of patients taking the benzodiazepine alprazolam (Xanax) for as little as 8 weeks triggered protracted symptoms of memory deficits which were still present after up to 8 weeks post cessation of alprazolam.

Treatment
The condition gradually improves over a period of months or in severe cases years after. Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome. Cognitive behavioural therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.