Post Acute Withdrawal Syndrome (PAWS) is not a new concept in the chemical dependency field but is not always understood by addicts or their loved ones. It was taught to me when I went to rehab in 1996 and was around before that. I had been there a couple weeks and my moods were all over the place. Each day was a roller coaster of emotions yet there was an absence of any clear emotional triggers. I thought I was going crazy so I went to my counselor “Big Mike” and told him I needed medication. He looked at me and simply said “relax, you got PAWS.” After explaining PAWS to me I realized that’s exactly what was going on.
I work with a lot of addicts and the road to recovery is bumpy to say the least. Often once a person achieves sobriety all the loved ones are so relieved and excited to get their loved one back they want to stop and finally breathe and let the balloons drop. Then they quickly realize their loved one is still struggling and it can be challenging for all. For addicts, early recovery can be a very confusing and triggering time. For the families and loved ones, early recovery can be baffling and difficult to navigate. This article is intended to help all parties better understand PAWS and early recovery; not just from its traditional biological perspective but expanding and deconstructing it from a psychological and social perspective as well. Before we go further however, I must define early recovery.
According to a study published by the National Institute of Health (Dennis & Scott, 2007) the highest possibility of relapse comes in the first three years. Their study found over a 7 year period 64% of their participants relapsed in the first year. Even after one year sober 34% relapsed. Other studies actually put the relapse rates higher. The best rates they found were once they reached 3-5 years sober, only 14% relapsed. Based on this research, and the research of others, I consider the first 3-5 years of sobriety early recovery. By having a better understanding of early recovery we can increase awareness on what the addict can do to achieve lifelong sobriety and how their loved ones can support their recovery and work on the underpinnings to their addiction; after all, sober doesn’t mean we’re all better. For the addicts, my hope is this article will help you understand your Self and your experiences at a deeper level and bring insight and compassion into your battles and areas for growth. For families and loved ones my hope is this article will help you understand “who they are” and their struggle at a deep level so you can have compassion and understanding at such a trying time for all and strengthen the bond between you.
As I mentioned earlier PAWS is typically explained from a brain deficiency perspective. Meaning within our brains are chemicals that stabilize our moods, help us focus, handle stressful situations, communicate, etc…These chemicals are called neurotransmitters. We have many different types of neurotransmitters and each one has its own function and also influences other neurotransmitters. Like gears in a clock, each one has its own function but also helps turn the other gears. If one gear is malfunctioning, the whole clock will malfunction. All throughout the day we draw from our supply to help us deal with our day to day obstacles, lowering our natural supply. Through good food, good sleep, and good exercise these reserves are replenished. Alcohol and drugs affect this system by flooding us with these neurotransmitters and depleting our reserves; that’s why the reward feels so good yet leaves us empty afterward. Let’s take marijuana for example.
When someone smokes pot it releases a large amount of Serotonin (along with Dopamine, Oxytocin, Opiate Endorphines, and depending on the strain some other chemicals) this feels good but depletes the person of Serotonin, a chemical that helps balance our mood, motivation, sleep, and appetite. So then the individual smokes more to help balance their mood, sleep, and appetite. If the person starts using regularly (3-5x a week) the brain starts to depend on them to provide it with Serotonin and stops replenishing it internally. Thus, when the person stops they are deficient in Serotonin and feel like weed helps them eat, sleep, and feel good when in reality it is creating the problems. This happens with all substance abusers, regardless of the name of the drug. If the person stops suddenly after years of using the brain doesn’t just start producing it again, it has come to depend on the individual providing it with the chemical/s. It often does not start “kicking in” again until 6-8 weeks sober.
The initial withdrawal stage is the physical withdrawals the individual goes through. PAWS is the emotional roller coaster that comes from the brain chemistry being out of balance, which can often resemble mental illness. Depression, anxiety, obsessive thinking, anger, accident prone; all can be symptoms of PAWS. If these symptoms were not there prior to the drug use and they are there in early recovery there is a good chance they are going through PAWS. How long PAWS lasts varies depending on the individual. The first 6 months are the most difficult but it can last 18 months or longer. For instance benzodiazepines withdrawal can last years. Luckily, there are certain things that can be done to help repair the neurological damage that has been done.
Healthy relationships, good food, adequate sleep, regular exercise, spirituality, consistent meditation, and even medication all have scientific backing when it comes to helping repair the brain. These are what I call restorative interventions; they help restore the brain functioning. Unfortunately most addicts get sober and are drawn to depleting behaviors; behaviors that continue to deplete the brain. Not exercising regularly, poor sleep patterns, binging on sugar, carbs, caffeine, and nicotine as well as chasing porn, sex, and co-dependent relationships, to name a few. Restorative behaviors don’t come with instant gratification but help repair in the long run. Depleting behaviors come with instant gratification but continue to keep reserves low and stunt emotional growth and brain repair.
This is normally where the discussion on PAWS ends but I want to expand on it more. The full understanding of PAWS is multilayered, as is addiction and mental health. In addition to the biological damage that comes from addiction there is also psychological and social damage. Our society is all too caught up in trying to find fast tracked simplistic “cures” for complex multifaceted problems. PAWS are an example of this. PAWS have biological, psychological, and social components to it. Simply addressing one of these leaves treatment incomplete.
Psychologically we all have a “window of tolerance” for our emotional experience (see image). When in our window we can tolerate our emotions, listen and communicate effectively, make eye contact, and socially engage. Once pushed to the edge or beyond our threshold we are flooded and overwhelmed and have difficulty coping. When we can utilize healthy ways of coping then our tolerance for emotions expands. We learn we can walk through it, know we will be okay, and learn how to navigate it next time; this in turn expands our window. However, if we turn to unhealthy ways of coping by instead numbing, avoiding, or enhancing those emotions then our ability to adapt to stress, good or bad, decreases in turn decreasing our window.
For most boredom is not a terribly overwhelming emotion; but is one of the most common triggers for addicts. This is due in large part because their window has shrunk over the years so boredom or happiness pushes them outside what they can tolerate. (See image) How early one started, how long they used, genetics, epigentics, temperament, life experiences, and in utero experiences, all influence each person’s individual’s window. Often even before their chemical use many addicts window was already more sensitive; resulting in a fragile stress tolerance. So, in addition to being chemically depleted addicts are emotionally stunted. Rebuilding, or building what wasn’t there in the first place, can be quite difficult. Addicts already sensitive to stress AND they are chemically depleted; mood swings are to be expected. As you can see above if someone’s window is significantly depleted then even a “normal” range of emotions can be overwhelming. This is part of the deeper work that addicts need to work on once they get sober, and this takes time.
Another component to understanding PAWS and the addict in early recovery has to do with their overall sense of Self. Our sense of Self is nurtured and constructed i n our relationships with our caregivers and experiences with others. I like to use Maslow’s Hierarchy of Needs to help illustrate how core Needs influence our sense of Self. Maslow believed there is a set of motivation systems that drive us to achieve certain needs. Once one Need is achieved we are then motivated to go on to achieve the next Need with the last need, and ultimate goal, being Self-Actualization. Self-Actualized people are fulfilled, doing what they are capable of, have a Higher Purpose, and strive to help others achieve self actualization. Self-Actualization is the ultimate goal; in order to reach our full potential though the other needs must be met. I’ll go over each one but keep in mind this is a snapshot. Whole chapters and books are written on these subjects.
Our basic primitive Needs come first. Physiologically
we Need to breathe, eat, sleep, and excrete. If we don’t survival is nearly impossible because our body will shut down. Here we are learning to regulate our bodily functions. Our next Need is Safety; which consists of physical safety, economic safety, health and overall well being. Here we are learning to regulate our nervous system. If we feel safe our nervous system rests; if not then we fight, flee, and/ or freeze. When our basic needs are met then we move on to our psychological needs.
Family, friends, bonding and intimacy nurture our Need for Love & Belonging. This is where we strengthen our attachments with people and learn to turn to others for help. If this Need is met then we are motivated to move towards Esteem. This is where our self worth, confidence, self acceptance, and sense of Self really start blooming. Socializing, trusting others, and building close relationships helps to regulate our emotional experiences, called co-regulation. These early foundational Needs are crucial for developing a whole and complete Self. For almost all addicts there is usually a disruption in their need for Safety (shock trauma) and/or Love & Belonging (developmental trauma).
Our Need for Safety is disrupted when we experience sexual, physical, and emotional abuse; as well as near death experiences and witnessing violence. This “shock” trauma is especially disruptive in early childhood years but can also lead to regression in later years. This can also be disrupted if our health, financial security, or the neighborhood we grow up in is not stable. Because this type of trauma literally “shocks” our body it leaves our nervous system dysregulated leading to anxiety, anger, and depression. We become mistrusting of people and don’t feel safe in certain situations leading to social isolation, awkwardness, and/ or strained relationships. A shocked nervous system is exhausting and leads to a depleted immune system so aside from the emotional effects this also comes with long term damage of gastrointestinal problems, weakened immune systems, and shorter life spans. Shock trauma is an easy experience for people to help understand addiction. “It makes sense they’re an addict given what they went through.” However there are a great number of addicts who have not experienced this. Instead they have experienced Relational/ Developmental trauma; which presents more subtly but can be just as harmful. This happens when our Need for Love & Belonging gets disrupted.
Feeling felt and understood, or a sense of belonging, is crucial for humans. We are pack animals at our core. We are not born wanting to be isolated and alone, in fact we will die if that happens as babies. It makes sense to us when a dog gets depressed if it is isolated and alone yet we forget sometimes we experience that too. Sometimes we can even be surrounded by people yet still feel alone. Even if showered with love by their family, if they don’t feel like they belong they won’t absorb the love. This is called “Relational trauma.” If you go to 12 step meetings you will hear countless stories of people who have experienced one or both types of trauma. This keeps them emotionally stunted and disrupts the following needs from getting met. These individuals often have a difficult time socializing, letting people know how they are feeling, if they’re struggling, and asking for help. Their defenses keep them guarded making it difficult to have deep meaningful relationships. Once they get sober these deficits are clearly displayed, in many ways, and need to be repaired not just so they can integrate into a community of recovery but also to Self-Actualize. This work is a slow process and takes hard work, time, patience, and compassion. We don’t expect children to develop into adults over night so we need to keep in mind that addicts are stunted and it takes time to either repair an injury or develop skills, experiences, and a sense of Self that wasn’t there in the first place.
I have crammed a lot of information into this article and I still didn’t touch on all the information. The reality is that for every topic brought up there are whole chapters and books written on them. Let’s just focus on the big picture; addicts are wounded. They are wounded and their ability to tolerate and adapt to stress is weakened. There is a reason they are shoving insane amounts of alcohol and drugs into their body and it’s more than just a psychological craving; otherwise detox would cure everyone. In his later years Bill Wilson, Co-Founder of Alcoholics Anonymous, spoke about “Emotional Sobriety as the next frontier for those who have already been relieved of the obsession to use.” These underpinnings to addiction often keep people stuck, depressed, anxious, or relapsing.
If you are an addict, or know of an addict, it is important to understand the nuances of early recovery. PAWS is not just about a chemical imbalance that will correct itself with time. As I have explained PAWS effects people biologically, psychologically, and socially. The fields of interpersonal neurobiology, neuropsychiatry, epigenetics, etc…are uncovering a wealth of information that helps us understand people at a deep bio-psycho-social-spiritual level. Addicts are deficient in these critical areas that help us adapt to stress and live a fulfilling life. Physical sobriety comes first but emotional sobriety must follow.
Curtis Buzanski, LMFT, LAADC