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  • Alcohol & Post-Acute Withdrawal Syndrome (PAWS) | Symptoms, Causes, Risk Factors, & Treatment

    Alcohol & Post-Acute Withdrawal Syndrome (PAWS)

    Depending on a person’s level of dependence, alcohol withdrawal symptoms can begin as soon as six hours after their last drink, peaking between days two and four and then tapering off by the end of a week or two.

    However, for some, the experience of alcohol withdrawal is far more drawn out, with some symptoms persisting much longer than normal. This is commonly known as post-acute withdrawal syndrome.

    Post-Acute Withdrawal Syndrome (PAWS)

    While not an officially recognized medical diagnosis, post-acute withdrawal syndrome (PAWS), also known as protracted withdrawal syndrome, has been defined and studied in regards to alcohol use disorder (AUD) since the 1990s. 

    It describes a condition where certain psychological (rather than physical) symptoms of alcohol withdrawal continue for a period of months or potentially years, well after the symptoms of acute withdrawal have resolved.

    While PAWS is often associated with alcohol use disorder it can also develop following detox from a variety of other substances, ranging from benzodiazepines and methamphetamine to opiates/opioids.

    Symptoms Of Post-Acute Withdrawal Syndrome

    Symptoms of PAWS can vary from individual to individual, but may include:

    • cravings for alcohol
    • difficulty focusing
    • mood swings
    • irritability or anger
    • sleep disturbances
    • fatigue
    • poor coordination and clumsiness
    • difficulty coping with stressful situations
    • depression, anxiety, or panic
    • obsessive-compulsive behaviors
    • lack of motivation or apathy
    • anhedonia, or an inability to feel pleasure

    These common symptoms may begin during detox and continue afterwards, or develop unexpectedly weeks or months into the future. 

    And once the effects are felt, there may be rollercoaster-like cycles in which symptoms fade away only to return with increased intensity before fading again.

    Physical symptoms, including muscle aches, nausea, headaches, heart palpitations, or fast heart rate, may occur in PAWS as well but are much less common.

    PAWS Causes

    PAWS and the long-term complications that can develop amid alcohol addiction recovery are not fully understood. However, PAWS is believed to be caused by central nervous system imbalance and stress from breaking patterns of heavy alcohol use.

    Central Nervous System Imbalance

    It’s known that the chronic overconsumption of alcohol has a profoundly damaging impact on neurotransmitter activity in the brain, throwing gamma aminobutyric acid (GABA), dopamine, endorphins, and the central nervous system as a whole out of balance.

    While some of this imbalance is corrected during acute withdrawal, it can take a long time for the brain to fully restore itself.

    The psychological symptoms of PAWS, including mood swings, difficulty sleeping, and exhaustion, are thought to be side-effects of this lengthy process. 


    PAWS is also believed to be aggravated by stress and the difficulty of breaking ingrained patterns of behavior related to past substance use.

    PAWS Risk Factors

    Risk factors for developing post-acute withdrawal symptoms are believed to include:

    Treating PAWS

    Because most symptoms of PAWS are mental or emotional rather than physical, treatment generally consists of therapy, counseling, and peer support. 

    However, certain medications may also be of benefit, including:

    • acamprosate (Campral), which helps normalize brain chemistry after long-term alcohol abuse
    • naltrexone (Vivitrol, Revia), a medication that helps reduce cravings for alcoholic drinks
    • disulfiram (Antabuse), a medication that discourages relapse by causing uncomfortable physical reactions when alcohol is consumed
    • antidepressants, which may help to stabilize the mood and mental state of those experiencing protracted withdrawal symptoms

    PAWS Controversy

    Because PAWS is excluded from diagnostic manuals and largely consists of subjective symptoms, some in the medical community have expressed doubt that it is a real phenomenon.

    However, many others who study substance use disorders have determined that it is indeed a real complication of recovery, albeit an unpredictable and demoralizing one for those who experience it. 

    PAWS & Relapse Prevention

    Unfortunately, even if an individual is committed to their recovery, long-term struggles with PAWS symptoms greatly increases the risk of relapse. Accordingly, therapists and counselors help prepare those in addiction recovery to face this potential complication productively.

    Strategies for self-treatment include:

    • being aware of PAWS and its symptoms
    • celebrating each small accomplishment during the recovery process
    • cultivating good sleeping habits
    • proper exercise and nutrition
    • participating with 12-step support groups
    • developing effective coping strategies
    • practicing beneficial self-care
    • being open and honest with loved ones and healthcare providers

    Alcohol Addiction Treatment

    Recovering from alcohol use disorder can be a difficult process, regardless of whether you develop PAWS symptoms or not. 

    That’s why addiction treatment centers offer professional services designed and tested to give participants every advantage as they work out their own recovery. 

    Available treatment options for alcohol use disorder may include:

    To learn more or inquire about program availability, please contact an Ark Behavioral Health representative today. 

    Written by Ark Behavioral Health Editorial Team
    ©2023 Ark National Holdings, LLC. | All Rights Reserved.
    This page does not provide medical advice.

    Alcohol Health and Research World - Complications of Alcohol Withdrawal
    Semel Institute for Neuroscience and Human Behavior - Post-Acute Withdrawal Syndrome (PAWS)
    Substance Abuse and Mental Health Services Administration (SAMHSA) - Protracted Withdrawal

    Medically Reviewed by
    Manish Mishra, MBBS
    on June 28, 2021
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