From the Guidelines
PAWS, or Post-Acute Withdrawal Syndrome, is a condition that requires a comprehensive management approach, including medication, therapy, and lifestyle changes, to alleviate its symptoms and support long-term recovery. The symptoms of PAWS can be debilitating and include mood swings, anxiety, irritability, fatigue, sleep disturbances, cognitive difficulties, and cravings 1. Management of PAWS involves a multifaceted approach, with medications such as antidepressants like SSRIs for mood symptoms, non-addictive sleep aids for insomnia, or specific medications targeting the particular substance dependence, like naltrexone for alcohol or opioid dependence.
Key Components of PAWS Management
- Cognitive-behavioral therapy is particularly effective for developing coping strategies and managing cravings
- Regular exercise, proper nutrition, adequate sleep, and stress management techniques like meditation can significantly reduce symptom severity
- Understanding that PAWS symptoms are temporary, though potentially long-lasting, can help individuals maintain sobriety through this challenging period
- A thorough history, physical examination, and eyewitness observation, if available, are crucial for diagnosing and managing PAWS, similar to the approach used for diagnosing reflex syncope, such as vasovagal syncope (VVS) 1
Neurochemical Adaptations and Recovery
PAWS occurs because prolonged substance use causes neurochemical adaptations in the brain, and when the substance is removed, the brain needs time to reestablish normal functioning. This process can take weeks, months, or even years, highlighting the importance of a long-term management plan. By prioritizing a comprehensive approach to PAWS management, individuals can better navigate the challenges of recovery and reduce the risk of relapse.
From the Research
Definition and Symptoms of PAWS
- PAWS, also known as post-acute withdrawal syndrome or protracted withdrawal syndrome, refers to a condition that occurs after stopping antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) 2.
- The symptoms of PAWS can be severe and long-lasting, with a duration ranging from 5 to 166 months, and can include affective symptoms such as anxiety, depression, and emerging suicidality, as well as somatic symptoms like headache, fatigue, and dizziness 2.
- A study found that 81% of patients reported affective symptoms, while 75% reported somatic symptoms, and 44% reported sleep problems 2.
Prevalence and Duration of PAWS
- The prevalence of PAWS is variable and can be hindered by a lack of case identification in many studies 3.
- Symptoms typically occur within a few days from drug discontinuation and can last a few weeks, but many variations are possible, including late onset and/or longer persistence of disturbances 3.
- A case report found that the withdrawal symptoms appeared a few days after stopping treatment or after a decrease of the dose, and the typical symptoms were of the gastro-intestinal type, such as loss of appetite, nausea, and vomiting 4.
Diagnosis and Detection of PAWS
- Current diagnostic methods, such as the DSM, do not take into account the phenomenon of SSRI withdrawal, and may not be adequate to identify DSM disorders when withdrawal occurs 5.
- A study found that in 77.3% of cases, the DSM-5 diagnosis of current mental disorder was not confirmed when the diagnosis of current withdrawal syndrome was established 5.
- It is recommended that treatment with SSRIs is progressively stopped over a period of several weeks to minimize the risk of withdrawal syndrome 4.
- Acknowledging that SSRI use can result in dependence and withdrawal allows patients to be better informed around decisions related to these drugs, and helps inform strategies for safe tapering as appropriate 6.