What is Post-Acute Withdrawal Syndrome? (PAWS)

Post-Acute Withdrawal Syndrome (PAWS) is Real

Glossy brochures touting the joys of sobriety fail to mention a few of the not-so-sexy, real life details. I didn’t exactly expect the first few days to be fun. Just kidding. Yes, I did.

Hello? I quit drinking! I should immediately be vibrant and well-rested, with glowing skin and the stamina of a passionate 22-year-old. Probably I’d get back to running marathons, transform my fledging coaching business into a multi-national beacon of hope and fix all the problems with all the things. If not in the first week, then in the first month (I can be reasonable). I’d listened to enough sober success stories on podcasts to know that beauty, happiness and creativity are side effects of giving up alcohol (provided you accept these gifts with humility and gratitude, of course). In my first few days sober, I dutifully attended support meetings, did some journaling, and waited for Amazon to deliver my superpowers.

Fast-forward to Day 214. This morning, I barely made it through my workout for middle-aged moms. The instructor advised me to use my knee as a kickstand in side-plank and do low-impact jumping jacks. I swear that class was easier when I was chronically hungover (and motivated to prove to myself that I was triumphant over alcohol). And now, instead of feeling energized after the workout, I’m contemplating a nap—even though I slept 8 hours last night. Also, a deep scrutiny of the mirror shows that time is still marching (or skipping) forward. I probably look better than I did eight months ago, but I’m not a fan of the “b” in subtle. I want the “A” in awesome. And adding insult to injury, I’ve gained a few pounds.

What the hell is going on? What is Post-Acute Withdrawal Syndrome? (PAWS)

Early sobriety was difficult. I suffered from anxiety, insomnia and fatigue. But as bad as the symptoms were, they reinforced that I was doing something right. Had they not been an issue, I could have too easily decided that drinking had also not been an issue. Early sobriety required a lot of self-care, and I made peace with that. I’d been beating myself up for a long time both mentally and physically. But as weeks have turned into months, the initial withdrawal phase faded into kinda-happy-but-mostly-blah phase. I feel good. But I also feel like I’m in recovery.

My symptoms qualify for what is known as PAWS (post-acute withdrawal syndrome). Various addiction websites say PAWS can last anywhere from a few weeks to two years. This is the bullshit in the fine print that the sobriety commercials fail to mention.  This felt unacceptable to my addictive personality, which is fueled by instant gratification. A month is a long time when you’re taking things day-by-day (or minute-by-minute). Who’s got years to deal with suboptimal performance?

I can only hope I do. What’s the alternative? To keep drinking? Where does that option put me in two years? Even if nothing gets worse (which it would—that’s how alcohol use disorder works), the best-case scenario is that I’d still be struggling. At this point, I’m eight months closer to the life I want. Time moves fast in a slow and grueling kind of way.

My former self would have had no tolerance for this recovery process. But the gold nugget hidden in the muck is that I’m not my former self. I had a similar realization after I had a baby (or four). There is no getting back to normal. We adjust our expectations, priorities and goals based on new needs and desires. A new normal is created one day at a time. I now liken recovery to giving birth–to me!–and my new life. For now, I’m breathing through the contractions, sleeping when the baby sleeps, and decorating my vision board with all of the wonderful things to come.

Everyone experiences sobriety differently. But if you’re new and struggling, here’s an excerpt from my journal—Maybe it will help adjust your expectations—both good and bad.

Day 30–Sober and Sad

I have not forgotten the parched brain buzz that greeted me every morning for years. I do not miss feeling intoxicated in the evening or falling asleep in a stupor. The cycle of clawing my way out of a hole each morning only to slide back each evening has been broken. Now, I begin and end each day with gratitude for this perspective. Treating my body with kindness feels like a stay of execution.

But life is not all rainbows and butterflies. It’s May 21, 2020, and we’re still under lockdown orders. A few days have been sunny and warm, but most days are dark, rainy and cold. I feel more relieved than enthusiastic about my sobriety. My energy is low, and I struggle with motivation. Thanks to my dog, I exercise every morning, but I’m not breaking any training barriers with stadium stair-laps or burpees. Consistency is my only goal. Today, after completing the bare minimum, I crawl back into bed at 1 p.m. I shouldn’t be tired. But I am tired. It feels like depression.

I realize that it probably is depression. Not likely clinical or serious, but I ponder my history with anti-depressants anyway. They have provided short-lived reprieve in the past, but the side effects quickly outweighed any benefit—especially when combined with alcohol. Now that I’m not drinking, might they help? I’m doing everything I can to feel good—eating a whole food plant-based diet, taking handfuls of supplements, exercising, meditating, and spending time in nature. What else is there? Why do I still feel flat and lethargic?

 For the first time in a month, I consider pouring a drink. I’m home alone. No one would know. I could easily slip into my old routine—grant myself a reprieve—take the night off. I allow myself to consider the possibility—play it through. Thankfully, I have run that experiment countless times and have lots of data to show the hypothesis is false. The only thing that I truly crave is the fraudulent promise—the potential in the pour. I do not actually want to feel drunk. Drinking when I feel low does not produce a high. And it’s way too soon to forget the hangover.

But I’m still depressed. And bored. I need to do something to fix that. Until. I remember Glennon Doyle’s words in Untamed. She says that all feelings are meant to be felt. We are taught to pursue happiness as though no other emotion has merit. But it’s okay–necessary–to feel all the feelings. She notes that in reality, many of our painful feelings don’t actually hurt worse than a paper cut. I check in with myself. Does this depression hurt as bad as a paper cut?

I scan my body. The melancholy feels a bit heavy, but my movements are unencumbered. I can still raise my arms above my head, so that’s good. Thoughts of loneliness bring tears to my eyes, but the sting is more like a minor itch and they don’t even fall. Sadness is a pinch of pressure around my heart, but my tennis elbow hurts worse. So, all things considered, the sensations of my depression do not, in fact, hurt worse than a paper cut.

That’s useful information. I decide that I can handle this feeling of depression. I make a mocktail, grab some dark chocolate and salty pistachios, and flip on Netflix. I turn on the fireplace, burrow under a blanket and invite the dog onto the couch. Turns out, she’s feeling depressed too and misery loves company. She extends the same grace to the two cats who join us in the covers. We all stay that way until 10 p.m. Then, I wipe the crumbs from my shirt, brush the dog and cat fur off the couch and call it a day.

It wasn’t a great day, but it sure as hell wasn’t a bad day. I could fill several pages in my gratitude journal. I learned (or remembered–I forget) that resisting difficult things is far worse than just leaning in. And feeling depressed under the influence of sobriety is far better than the alternative.

That was 185 days ago. (Yes, I’m counting)

The disappointing news for those of you on a sobriety journey is that I still have days like that. The good news is that they are fewer and farther between, with shiny bursts of productivity sprinkled among the doldrums. The lows are getting higher. My life is like a sepia-toned photograph with spots of color being added each day.

Symptoms of PAWS are cyclical (meaning they come and go in waves). What do the symptoms cycle around and what triggers the symptoms? No one seems to know. It’s not likely female hormones, as men experience post-acute withdrawal syndrome too. Maybe it’s stress? The moon? Karma? Whatever– I’m don’t particularly care. My curiosity tends to coincide with aforementioned doldrums.

Suffice it to say that when the symptoms come, as they did today, I spend a little time trying to decide which doctor/specialist to call as there must be something seriously wrong with my physical or mental health (or both). Then I realize it could also just be a rerun episode of Groundhog Day. So I try to relax, do my best and focus on my progress. PAWS is a sign that the brain is recalibrating. We can trust the process, even if we don’t understand it. This too shall pass.

Symptoms of Post-Acute Withdrawal Syndrome (PAWS)

Detoxing from an addictive substance often includes acute symptoms like muscle ache, nausea, headache, increased heart rate, the shakes, agitation, sweating and insomnia. For heavy drinkers, this usually lasts 3-10 days. Severe addicts need medical supervision as detox can trigger seizures, hallucinations and delirium tremens (DTs).

Long-term recovery begins once the withdrawal process ends (as in, you’re not done, you’re just getting started). Some impairments persist for months and even years. According to Hazelden/Betty Ford, symptoms include:

• Foggy thinking/trouble remembering/impaired focus
• Urges and cravings
• Irritability or hostility
• Sleep disturbances—insomnia or vivid dreams
• Fatigue
• Issues with fine motor coordination
• Stress sensitivity
• Anxiety or panic
• Depression
• Lack of initiative
• Mood Swings

Navigating early sobriety is analogous to paying down credit card debt. The first step towards freedom is to stop charging to the account. Then reduce expenses and pay down the balance. This requires an uncomfortable adjustment in the budget and an honest evaluation of needs versus wants. Expect to alternate between feeling deprived and feeling liberated.  The process is the same with PAWS. When we were drinking, we used alcohol to soothe our discomfort. Developing new coping skills takes time and effort. Moving away from instant gratification is a long-term strategy that requires us to learn how to manage short-term discomfort.

Instant Gratification undermines post-acute withdrawal syndrome.

Turning to sugar, caffeine and nicotine is a natural instinct when attempting to manage our mood. Unfortunately, addictive substitutes reinforce the cycle of cravings and ultimately undermine sobriety. The best offense in PAWS is to eat a nutrient-dense diet and avoid junk food. This is way easier said than done in a crisis. There is wisdom in the adage, “quit the addiction that is killing you the fastest.” When faced with a powerful craving, is it better to eat ice cream or smoke a cigarette than to take a drink? Of course.

However, it’s important to understand what’s happening on a biochemical level. Mood and cravings are a function of brain chemistry. Habitual alcohol consumption causes dysfunction of endorphins, serotonin, dopamine and other “feel good” neurotransmitters. It takes time for the brain to recalibrate. A balanced diet and a variety of supplements will accelerate the process and reduce the symptoms. Most recovery programs do not include nutritional support. Those that do have a 75 percent recovery rate, versus the 25 percent typical of A.A.

I found two books that explain this missing link, with detailed suggestions for specific symptoms. Check out Seven Weeks to Sobriety: The Proven Program to Fight Alcoholism Through Nutrition by Joan Mathews Larson, PhD., and The Mood Cure by Julia Ross.

When I quit drinking, my diet was already about as clean as it gets. I take vitamins and supplements. Regardless, I suddently had cravings for sugar and struggled to avoid foods that haven’t been a problem for me in years. After reading Mathews-Larson and Ross’s books, I paused my intermittent fasting regime and started eating a high protein breakfast. That helped. I also started taking 5-HTP, tyrosine, GABA and glutamate twice a day. This decision was based on my symptoms. You need to do your own homework. My general recommendation to anyone would be to take a multivitamin, eat as many fruits and vegetables as possible, and check out those websites and books.

Nutrition and supplements are no more an overnight cure than recovery meetings. But they are just as essential if you want to thrive in sobriety. PAWS is manageable. The most helpful thing is to remember that the lows get fewer and farther between. Accept them as part of the process and practice self-care. Rinse and repeat, one day at a time. Practice gratitude for bursts of clarity and joy. You will get through this and it is so worth it!

[I’m adding this addendum at 19 months sober. After getting certified as a professional recovery coach, I started Recovery University — check out the fabulous community of women supporting each other in this process. You don’t have to do this alone! Also, here’s a link to a video I produced about PAWS, and another that addresses the impact of SSRIs and supplements for post-acute withdrawal syndrome.