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, benzodiazepines or other substances. [cite journal |author=Miller FT |journal=J Subst Abuse Treat |title=Protracted alcohol withdrawal delirium |year=1994 |month=Mar-Apr |volume=11 |issue=2 |pages=127–30 |pmid=8040915 |doi=10.1016/0740-5472(94)90029-9 ] [cite journal | journal=J Subst Abuse Treat | year =1991 | volume=8 | issue=1-2 | pages=19–28 | title=Protracted withdrawal syndromes from benzodiazepines | author=Ashton H |pmid=1675688 |url=http://www.benzo.org.uk/ashpws.htm |publisher=benzo.org.uk | doi=10.1016/0740-5472(91)90023-4 ] [cite journal | author=Wu JM | coauthors=Wei DY, Luo YF, Xiang XY | year=2003 | month=Nov | title= [Clinic research on heroin de-addiction effects of acupuncture and its potentiality of preventing relapse] | journal=Zhong Xi Yi Jie He Xue Bao | volume =1 | issue =4 | pages=268–72 | pmid=15339529 | doi=10.3736/jcim20030412 ] Infants born to mothers who used substances of dependence during pregnancy may also experience a post acute withdrawal syndrome. [cite journal | author =Lejeune C | coauthors= Floch-Tudal C, Montamat S, Crenn-Hebert C, Simonpoli AM | year =1997 | month=Mar | title = [Management of drug addict pregnant women and their children] | journal =Arch Pediatr | volume =4 | issue =3 | pages =263–70 | pmid =9181022 | doi =10.1016/S0929-693X(97)87247-8 ] [cite journal | author =Gaillard MC | coauthors=Borruat FX | year =2002 | month=Apr | title = [New finding: transitory horizontal pendular nystagmus secondary to neonatal abstinence syndrome] | journal =Klin Monatsbl Augenheilkd | volume =219 | issue =4 | pages =317–9 | pmid =12022028 | doi =10.1055/s-2002-30650 ] 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 in recovery from long-term use of alcohol or benzodiazepines and to a lesser degree other psychotropic drugs. Symptoms can include mood swings, cognitive impairment, and difficulty forming new memories.

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. [cite journal | author =Rimondini R | coauthors=Sommer WH, Dall'Olio R, Heilig M | year =2008 | month=Mar | title =Long-lasting tolerance to alcohol following a history of dependence | journal =Addict Biol | volume =13 | issue =1 | pages =26–30 | pmid =17850416 | doi =10.1111/j.1369-1600.2007.00079.x ] [cite journal | author =Ahveninen J |coauthors=Jääskeläinen IP, Pekkonen E, Hallberg A, Hietanen M, Näätänen R, Sillanaukee P | year =1999 | month=Jun | date =8 | title =Post-withdrawal changes in middle-latency auditory evoked potentials in abstinent human alcoholics | journal =Neurosci Lett | volume =268 | issue =2 | pages =57–60 | pmid =10400077 | doi =10.1016/S0304-3940(99)00378-X ] [cite journal | author=Kiefer F |coauthors=Andersohn F, Jahn H, Wolf K, Raedler TJ, Wiedemann K | year=2002 | month=Jan | title=Involvement of plasma atrial natriuretic peptide in protracted alcohol withdrawal | journal =Acta Psychiatr Scand | volume=105 | issue=1 | pages=65–70 | pmid=12086228 | doi=10.1034/j.1600-0447.2002.0_011.x ] [cite journal | author=Bruijnzeel AW |coauthors=Gold MS | year=2005 | month=Nov | title=The role of corticotropin-releasing factor-like peptides in cannabis, nicotine, and alcohol dependence | journal=Brain Res Brain Res Rev | volume=49 | issue=3 | pages=505–28 | pmid=16269317 | doi=10.1016/j.brainresrev.2005.01.007 ] The symptoms of post acute withdrawal syndrome occur because the brain's ability to react to stress has been weakened by long-term substance misuse. 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.

ymptoms

Symptoms can sometimes come and go with wave like reoccurances 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. [cite journal | author = Stojek A | coauthors = Madejski J, Dedelis E, Janicki K | year = 1990 | month = May-Jun | title = [Correction of the symptoms of late substance withdrawal syndrome by intra-conjunctival administration of 5% homatropine solution (preliminary report)] | journal = Psychiatr Pol | volume = 24 | issue = 3 | pages = 195–201 | pmid = 2084727 ] [cite journal | author =Bokhan NA | coauthors =Abolonin AF, Krylov EN, Vetlugina TP, Ivanova SA | year =2003 | month = | title =Comparative Efficiency of Proproten-100 during the Therapy of Patients with Alcoholism in the Stage of Therapeutic Remission | journal =Bull Exp Biol Med | volume =135 | issue =Suppl 1 | pages =171–5 | pmid =12949690 | doi =10.1023/A:1024709014483 ]

Common symptoms of post acute withdrawal syndrome are: [cite journal | author =De Soto CB |coauthors=O'Donnell WE, Allred LJ, Lopes CE | year =1985 | month=Dec | title =Symptomatology in alcoholics at various stages of abstinence | journal =Alcohol Clin Exp Res | volume =9 | issue =6 | pages =505–12 | pmid =3911810 | doi =10.1111/j.1530-0277.1985.tb05592.x ] [cite journal | author=Voltaire-Carlsson A |coauthors=Hiltunen AJ, Koechling UM, Borg S | year =1996 | month=Sep-Oct | title =Effects of long-term abstinence on psychological functioning: a prospective longitudinal analysis comparing alcohol-dependent patients and healthy volunteers | journal =Alcohol | volume =13 | issue =5 | pages =415–21 | pmid=8888936 | doi=10.1016/0741-8329(96)81678-8 ] [cite journal | author=Watanabe KI |coauthors=Ogihara-Hashizume A, Kobayashi Y, Mitsushio H, Komiyama T | year=2001 | month=Apr | title=Impaired sleep during the post-alcohol withdrawal period in alcoholic patients | journal=Addict Biol | volume=6 | issue=2 | pages=163–169 | pmid=11341856 | doi=10.1080/13556210020040244 ] [cite journal | author=Vik PW |coauthors=Cellucci T, Jarchow A, Hedt J | year=2004 | month=Mar | title=Cognitive impairment in substance abuse | journal=Psychiatr Clin North Am | volume=27 | issue=1 | pages=97–109 | pmid=15062633 | doi=10.1016/S0193-953X(03)00110-2 ]
* Psychosocial dysfunction
* Anhedonia [cite journal | author=Janiri L |coauthors=Martinotti G, Dario T, Reina D, Paparello F, Pozzi G, Addolorato G, Di Giannantonio M, De Risio S | year=2005 | month=Jun |date=3 | title=Anhedonia and substance-related symptoms in detoxified substance-dependent subjects: a correlation study | journal=Neuropsychobiology | volume=2 | issue=1 | pages=37–44 | pmid=15942262 | doi=10.1159/000086176 ]
* 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

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
* Trying to do more than one thing at once
* Feelings of anxiety, fearfulness or anger
* Conflict with others
* Unrealistic expectations of yourself

Treatment

The condition gradually improves over a period of months or in severe cases years. [cite journal | author=Roberts AJ |coauthors=Heyser CJ, Cole M, Griffin P, Koob GF | year=2000 | month=Jun | title=Excessive ethanol drinking following a history of dependence: animal model of allostasis | journal =Neuropsychopharmacology | volume=22 | issue=6 | pages=581–94 | pmid=10788758 |url=http://www.nature.com/npp/journal/v22/n6/pdf/1395491a.pdf |format=PDF | doi=10.1016/S0893-133X(99)00167-0] [cite journal | author =De Soto CB |coauthors=O'Donnell WE, De Soto JL | year =1989 | month =Oct | title =Long-term recovery in alcoholics | journal =Alcohol Clin Exp Res | volume =13 | issue =5 | pages =693–7 | pmid =2688470 | doi =10.1111/j.1530-0277.1989.tb00406.x ] Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. [cite journal | author = Beleslin D | year = 1991 | title = [Modern drug therapy in alcoholism] | journal = Med Pregl | volume = 44 | issue = 7-8 | pages = 279–84 | pmid = 1806768 ] [cite journal | author =Wilde MI | coauthors=Wagstaff AJ | year =1997 | month=Jun | title =Acamprosate. A review of its pharmacology and clinical potential in the management of alcohol dependence after detoxification | journal =Drugs | volume =53 | issue =6 | pages =1038–53 | pmid =9179530 ] Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome. [cite journal | author =Malcolm R | coauthors=Myrick H, Brady KT, Ballenger JC | year =2001 | title =Update on anticonvulsants for the treatment of alcohol withdrawal | journal =Am J Addict | volume =10 Suppl | pages =16–23 | pmid =11268817 ] [cite journal | author =Le Bon O | coauthors=Murphy JR, Staner L, Hoffmann G, Kormoss N, Kentos M, Dupont P, Lion K, Pelc I, Verbanck P | year =2003 |month=Aug | title =Double-blind, placebo-controlled study of the efficacy of trazodone in alcohol post-withdrawal syndrome: polysomnographic and clinical evaluations | journal =J Clin Psychopharmacol | volume =23 |issue=4 | pages =377–83 | pmid =12920414 | doi =10.1097/01.jcp.0000085411.08426.d3 ] [cite journal | author=Mueller TI | coauthors=Stout RL, Rudden S, Brown RA, Gordon A, Solomon DA, Recupero PR | year=1997 |month=Feb | title=A double-blind, placebo-controlled pilot study of carbamazepine for the treatment of alcohol dependence | journal=Alcohol Clin Exp Res | volume=21 |issue=1 | pages=86–92 | pmid=9046378 ] Cognitive behavioural therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature. [cite journal | author=Hori T | coauthors=Komiyama T, Harada S, Matsumoto T | year=2005 |month= | title= [Treatment of substance dependence by a bio-cognitive model based on behavioral pharmacology] | journal=Seishin Shinkeigaku Zasshi | volume=107 |issue=11 | pages=1147–58 | pmid=16408423 ]

ee also

*Alcohol withdrawal syndrome
*Benzodiazepine withdrawal syndrome

References