" Modern" Alcohol and Drug Outpatient Treatment
Post Acute Withdrawl (PAW)
Exerpted From "Staying Sober" By: Terence T. Gorski
with additions by: Lee Jamison
When most people think about alcoholism or drug addiction they think only of the alcohol/drug-based symptoms and forget about the sobriety-based symptoms. Yet it is the sobriety-based symptoms, especially post acute withdrawal, that make sobriety so difficult. The presence of brain dysfunction has been documented in 75-95% of the recovering alcoholics/addicts tested. Recent research indicates that the symptoms of post-acute withdrawal associated with alcohol/drug-related damage to the brain may contribute to many cases of relapse.
Post-acute withdrawal means symptoms that occur after acute withdrawal. Post means after. And syndrome means a group of symptoms.
Syndrome: A group of symptoms
Post Acute Withdrawal: Symptoms that occur after acute withdrawal.
Post-acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals. In the alcoholic/addict these symptoms appear seven to fourteen days into abstinence, after stabilization from the acute withdrawal.
Post-acute withdrawal is a bio-psycho-social syndrome. It results from the combination of damage to the nervous system caused by alcohol or drugs and the psychosocial stress of coping with life without drugs or alcohol.
Recovery causes a great deal of stress. Many chemically dependent people never learn to manage stress without alcohol and drug use. The stress aggravates the brain dysfunction and makes the symptoms worse. The severity of PAW depends upon two things: the severity of the brain dysfunction caused by the addiction and the amount of psychosocial stress experienced in recovery.
The symptoms of PAW typically grow to peak intensity over three to six months after abstinence begins. The damage is usually reversible, meaning the major symptoms go away in time if proper treatment is received. So there is no need to fear. With proper treatment and effective sober living, it is possible to learn to live normally in spite of the impairments. But the adjustment does not occur rapidly. Recovery from the nervous system damage usually required from six to 24 months with the assistance of a healthy recovery program. Recent research is showing that for some recovering people the symptoms of PAW often occur at regular "moon cycle" intervals and without apparent outside stressors. Often those 30, 60, 90, 120, 180, and 1 & 2-year sobriety dates seem to be "triggering" times for PAW symptoms to increase. People recovering from long term opiate and stimulant use often have PAW symptoms for no apparent reason for up to 10 years after they have stopped using their drug of choice. Often PAW symptoms appear to come and go without apparent reason and without any specific pattern. Individuals who intend to have consistent long-term recovery must learn to recognize these symptoms and learn how to manage them.
SYMPTOMS OF POST ACUTE WITHDRAWAL
How do you know if you have PAW? The most identifiable characteristic is the inability to solve usually simple problems. There are six major types of PAW symptoms that contribute to this They are the inability to think clearly, memory problems, emotional overreactions and numbness, sleep disturbances, physical coordination problems, and general problems in managing stress. The inability to solve usually simple problems because of any or all of these symptoms leads to diminished self-esteem. A person often feels incompetent, embarrassed, and not okay about themselves. Diminished self-esteem and the fear of failure interfere with productive and challenging living. Lets take a look at some of the PAW symptoms that contribute to the inability to solve usually simple problems.
TYPES OF PAW SYMPTOMS
1. Inability to think clearly
2. Memory problems
3. Emotional overreactions or numbness
4. Sleep disturbances
5. Physical coordination problems
6. Stress sensitivity
Inability to Think Clearly
There are several thought disorders experienced by a recovering person when PAW is activated. Intelligence is not affected. It is as if the brain is malfunctioning sometimes. Sometimes it works all right. Sometimes is does not.
One of the most common symptoms is the inability to concentrate for more than a few minutes. Impairment of abstract reasoning is another common symptom of post acute withdrawal. An abstraction is a nonconcrete idea or concept, something that you cannot hold in your hand, take a picture of, or put in a box. Concentration is more of a problem when abstract concepts are involved.
Another common symptom is rigid and repetitive thinking. The same thoughts may go around and around in your head and you are unable to break through this circular thinking in order to put thoughts together in an orderly way.
Short-term memory problems are very common in the recovering person. You may hear something and understand it, but within 20 minutes you forget it. Someone will give an instruction and you know exactly what to do. But you may walk away, and that memory becomes clouded or may disappear completely.
Sometimes during stressful periods it may also be difficult to remember significant events from the past. These memories are not gone; the person may be able to remember them easily at other times. The person realizes that he or she knows but just cannot recall it while experiencing the stress.
For an alcoholic named Jan this created a problem in AA. I have trouble presenting my story at AA, she said. I have trouble remembering events that happened before my drinking days, let alone things that happened while I was drinking. So to put my life in story form is hard for me. I dont remember all of my story. I do remember that some things occurred, but I get confused about when they happened. Many times I can remember things when I am alone with no pressure that I cant remember under the stress I feel when I talk at meetings.
Because of memory problems in recovery, it may be difficult to learn new skills and information. You learn skills by acquiring knowledge and building upon what you have already learned. Memory problems make it difficult to build upon what you have already learned.
Emotional Overreaction or Numbness
Persons with emotional problems in sobriety tend to overreact. When things happen that require two units of emotional reaction, they react with ten. It is like holding the times key down on a calculator. You may find yourself becoming angry over what may later seem a trivial matter. You may feel more anxious or excited than you have reason to be. When this overreaction puts more stress on the nervous systems than it can handle, there is an emotional shutdown. If this happens to you, you become emotionally numb, unable to feel anything. And even when you know you should feel something, you do not. You may swing from one mood to another without knowing why.
Most recovering people experience sleep problems. Some of them are temporary; some are lifelong. The most common in early recovery is unusual or disturbing dreams. These dreams may interfere with your ability to get the sleep you need. But they become less frequent and less severe as the length of abstinence increases.
Mike was a periodic drinker. Periods of sobriety usually lasted for several months. During the time he was not drinking, he had dreams that severely disrupted his sleep. His wife said, I never realized the nightmares Mike was having had anything to do with drinking or not drinking. He would frequently jump out of bed, screaming in terror. When I was able to awaken him and calm him, he couldnt remember what he dreamed, but he remembered being afraid. After a year of sobriety, he seldom had the dreams. Only then did I realize that they were related to his drinking.
Even if you do not experience unusual dreams, you may have difficulty falling asleep or staying asleep. You may experience changes in your sleep patterns; sleeping for long periods at a time or sleeping at different times of the day. Some of these patterns may never return to normal, but most people are able to adjust to them without severe difficulty.
Physical Coordination Problems
A very serious PAW problem though perhaps not as common as the others is difficulty with physical coordination. Common symptoms are dizziness, trouble with balance, problems with coordination between hand and eye, and slow reflexes. These result in clumsiness and accident proneness. This is how the term dry drunk came into being. When alcoholics appeared drunk because of stumbling and clumsiness, but had not been drinking, they were said to be dry drunk. They had the appearance of being intoxicated without drinking.
Difficulty in managing stress is the most confusing and aggravating part of post acute withdrawal. Recovering people are often unable to distinguish between low-stress situations and high-stress situations. They may not recognize low levels of stress, and then overreact when they become aware of the stress they are experiencing. They may feel stressful in situations that ordinarily would not bother them, and in addition, when they react they overreact. They may do things that are completely inappropriate for the situation. So much so that later on they may wonder why they reacted so strongly.
To complicate things further, all of the other symptoms of post acute withdrawal become worse during times of high stress. There is a direct relationship between elevated stress and the severity of PAW. Each intensifies the other. The intensity of PAW creates stress, and stress aggravates PAW and makes it more severe. At times of low stress, the symptoms get better and may even go away. When you are well rested and relaxed, eating properly, and getting along well with people, you will probably appear to be fine. Your thoughts will be clear, your emotions appropriate, and your memory all right. At times of high stress, however, your brain may suddenly shut down. You may begin experiencing thinking problems, inappropriate emotions, and memory problems.
If your thoughts become confused and chaotic or you are unable to concentrate, if you have trouble remembering or solving problems, you may feel you are going crazy. You are not. These symptoms are a normal part of your recovery and are reversible with abstinence and a recovery program. If you do not understand this you may develop shame and guilt which leads to diminished self-esteem and isolation which creates stress and increased PAW. It is a painful cycle that is unnecessary if you understand what is happening. As your body and your mind begin to heal and as you learn ways to reduce the risk of post acute withdrawal symptoms, productive and meaningful living is possible in spite of the very real possibility of recurring symptoms.
Recovery from the damage caused by the addiction requires abstinence. The damage itself interferes with the ability to abstain. This is the paradox of recovery. Use of alcohol or other drugs can temporarily reverse the symptoms of the damage. If alcoholics drink, or drug addicts use, they will think clearly for a little while, be able to have normal feelings and emotions for a little while, feel healthy for a little while. Unfortunately, the disease will eventually trigger a loss of control that will again destroy these functions.
For this reason it is necessary to do everything possible to reduce the symptoms of PAW. It is necessary to understand PAW and to recognize that you are not incompetent and you are not going crazy. Because post acute withdrawal symptoms are stress sensitive, you need to learn about PAW and methods of control when stress levels are low in order to be able to prevent the symptoms or to manage them when they occur.
Here are some stories about some people who experienced post acute withdrawal and how it affected their lives without their being aware of what was happening to them.
Ray is a young, single, recovering alcoholic. He stopped drinking when he was 22 and was very excited about the possibilities that lay ahead of him in his sobriety. After his initial treatment he began restructuring his life around recovery. He was eager to make up for the time he had wasted during his years of drinking. He got a full-time job, enrolled in college, and committed himself to doing some volunteer work.
After a while he began to notice that he was having trouble with his schoolwork. He found himself confused about things that had at one time been easy for him to follow and figure out. He was having trouble taking care of his financial responsibilities, and when people that cared about him tried to help him figure things out, he felt panicky and overwhelmed. Thoughts rushed through his head, and he was unable to put them in order. He says, When someone in the financial aid office at the college started talking to me about grant money, loan money, interest, and forms that needed to be filled out, I was so confused and overwhelmed that I couldnt hear what she was saying. Everything was going around in my head at once and I had to get away. I got up and left without filling out the financial aid form.
In desperation, and out of fear that he would drink, Ray ran. Instead of evaluating what things in his life he needed to change and what he needed to hold onto, he gave up everything. He quit his job, dropped out of school, and stopped doing volunteer work. He gave up his apartment and moved in with a relative until he could get himself together. These actions created additional problems with which he found it increasingly difficult to cope. Until he went to a counselor and learned some ways to manage his symptoms, Ray thought he was having a nervous breakdown, when in fact what he was experiencing was PAW.
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