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Drug & Alcohol Treatment & Rehabilitation For those whose lives have been touched by addiction to drugs, alcohol or otherwise. For addicts and those who care about them.

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Old 03-21-2006, 10:26 AM
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Shelby Shelby is offline
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Default PAWS~ Post Acute Withdrawl Syndrome

This is really long, but worth reading. Gives a good insight into relapse .

Excerpted From "Staying Sober" By: Terence T. Gorski

Post Acute Withdrawl (PAW)

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:
Syndrome: A group of symptoms
Post: After
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. Let’s 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.

Memory Problems
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. 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.

Sleep Problems
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. 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.

Stress Sensitivity
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.

PATTERNS OF POST ACUTE WITHDRAWAL
Post-acute withdrawal symptoms are not the same in everyone. They vary in how severe they are, how often they occur, and how long they last. Some people experience certain symptoms; some people have other symptoms; some people have none at all.
Over a period of time PAW may get better, it may get worse it may stay the same, or it may come and go. If it gets better with time we call it regenerative . If it gets worse we call it degenerative . If it stays the same we call it stable . And if it comes and goes we call it intermittent .
Regenerative PAW gradually improves over time. The longer a person is sober the less severe the symptoms become. It is easier for people with regenerative PAW to recover because the brain rapidly returns to normal.

Degenerative PAW is the opposite. The symptoms get worse the longer a person is sober. This may happen even when a person is going to AA/NA and/or following some type of recovery program. People with degenerative PAW tend to become relapse prone. Sobriety becomes so painful that they feel they must self-medicate the pain with alcohol or drugs, collapse physically or emotionally, or commit suicide to end the pain.

A person with stable PAW experiences the same level of symptoms for a long period of time into recovery. There may be days when the symptoms are a little better or a little worse, but essentially the symptoms remain unchanged. Most recovering people find this very frustrating because they believe that they should be feeling better the longer they are sober. With sufficient sober time many people learn to manage these symptoms.

With intermittent PAW the symptoms come and go. Initially people with intermittent symptoms will appear to experience a regenerative pattern. In other words, their symptoms rapidly get better. But them they begin to experience periodic PAW episodes that can be quite severe. For some people the episodes get shorter, less severe, and farther apart until they stop altogether. In others they occur periodically throughout life.

These patterns describe people who have not had treatment for PAW and who do not know how to manage or prevent the symptoms. Traditional treatment does not address these symptoms because until recently they were unrecognized. If you know what to do and you are willing to do it, degenerative PAW can be changed into stable, stable into regenerative, and regenerative into intermittent PAW.

The most common pattern of PAW is regenerative and over time it becomes intermittent. It gradually gets better until the symptoms disappear and then it comes and goes. The first step is to bring PAW symptoms into remission. This means bringing them under control so that you are not experiencing them at the present time. Then the goal is to reduce how often they occur, how long the episode lasts, and how bad the symptoms are. You must remember that even when you are not experiencing them there is always the tendency for them to recur. It is necessary to build a resistance against them – an insurance policy that lowers your risk.

MANAGING PAW SYMPTOMS
The less you do to strengthen yourself against an episode of post-acute withdrawal, the weaker your resistance becomes. It is like a tetanus shot. The longer it has been since you have had one, the more risk there is that you will become seriously ill if you cut yourself on a piece of rusty metal. Conditions that put you in high risk of experiencing post acute withdrawal symptoms are usually lack of care of yourself and lack of attention to your recovery program. If you are going to recover without relapse you need to be aware of stressful situations in your life that can increase your risk of experiencing PAW.

Since you cannot remove yourself from all stressful situations you need to prepare yourself to handle them when they occur. It is not the situation that makes you go to pieces; it is your reaction to the situation.
Because stress triggers and intensifies the symptoms of post acute withdrawal, learning to manage stress can control PAW. You can learn to identify sources of stress and develop skills in decision making and problem solving to help reduce stress. Proper diet, exercise, regular habits, and positive attitudes all play important parts in controlling PAW. Relaxation can be used as a tool to retrain the brain to function properly and to reduce stress.

Stabilization
If you are experiencing post acute withdrawal symptoms, it is important to bring them under control as soon as possible. Here are some suggestions that may help you be aware of what is going on and help you to interrupt the symptoms before they get out of control.

Verbalization: Start talking to people who are not going to accuse, criticize, or minimize. You need to talk about what you are experiencing. It will help you look at your situation more realistically. It will help you bring internal symptoms to your conscious awareness. And it will give you support when you need others to rely upon.

Ventilation: Express as much as you can about what you are thinking and feeling even if it seems irrational and unfounded.

Reality Testing: Ask someone if you are making sense. Not just what you are saying but your behavior. Your perception of what is going on may be very different from reality.

Problem Solving and Goal Setting: What are you going to do right now about what is going on? You can choose to take action that can change things.

Backtracking: Think back over what has been happening. Can you identify how the episode started? What could have turned it off sooner? Think of other times that you were experiencing symptoms of PAW. What turned it on? What turned it off? Were there other options that might have worked better or sooner?

Education and Retraining
Learning about addictive disease, recovery, and post acute withdrawal symptoms helps to relieve the anxiety, guilt, and confusion that tend to create the stress that intensify PAW symptoms. As a recovering person, you need information in order to realize what symptoms are normal during recovery.
You also need to learn management skills so that you will know what to do to interrupt and control the stress and the symptoms when they occur. Through retraining you can improve your ability to remember, to concentrate, and to think clearly. Retraining involves practicing certain skills in a safe environment as you build confidence. It includes learning to take things step by step and to handle one thing at a time so you do not feel overwhelmed. It includes writing down what you want to remember and asking questions when you think that need to have something clarified.
Learning about the symptoms of post acute withdrawal, knowing what to expect, and not overreacting to the symptoms increase the ability to function appropriately and effectively.

Self-Protective Behavior
When all is said and done, you are responsible for protecting yourself from anything that threatens your sobriety or anything that triggers post acute withdrawal symptoms. Reducing the stress resulting from and contributing to the symptoms of post acute withdrawal must be of prime consideration for you. You must learn behavior that will protect you from the stress that might put your sobriety in jeopardy. This self-protective behavior is behavior that will enable you to be firm in accepting your own needs and not allowing other people or situations to push you into reactions that are not in the best interest of your sobriety.
In order to protect yourself from unnecessary stress, you must first identify your own stress triggers, those situations that might bring about an overreaction from you. Then learn to change those situations, avoid them, change your reactions, or learn to interrupt them before they get out of control.

Nutrition
The way you eat has a lot to do with the level of stress you experience and your ability to manage the symptoms of post-acute withdrawal. Poor health itself contributes to stress, and malnutrition contributes to poor health. You may be malnourished because of poor eating habits or because your body, damaged by alcohol or drugs, was unable to use the nutrients that you consumed.
Abstinence from alcohol and drugs will bring about some improvement but abstinence alone is not sufficient to rebuild damaged body tissue and maintain good health. New eating habits must be established and practiced regularly and permanently. Your daily diet should contain a balance of vegetables, fruit, carbohydrates, proteins, fats, and dairy products. Ask a nutritionist to help you figure out how many calories you need each day and what quantities of each type of food.

DIET FOR A RECOVERING PERSON -
Three Well-Balanced Meals Daily –
- Three Nutritious Snacks Daily –
- No Sugar and Caffeine –

Hunger produces stress. Try to plan your eating schedule so that you do not skip meals and so that you can have periodic nutritious snacks. Do not eat candy, donuts, soft drinks, potato chips, or other high calorie, low nutrient foods. You should specifically avoid foods that produce stress such as concentrated sweets and caffeine. Both of these produce the same kind of chemical reaction in your body as being frightened or overly excited. Concentrated sweets such as candy, jelly, syrup, and sugar-sweetened soft drinks will give you a quick “pick-up,” but you will experience a let-down about an hour later accompanied by nervousness and irritability. Remember that your reason for eating a snack is to combat fatigue and nervousness. Have a nutritious snack before you feel hungry to prevent a craving for sweets.
Caffeine also causes nervousness and restlessness. It may also interfere with concentration and your ability to sleep. Loss of sleep or irregular sleep causes irritability, depression, and anxiety.

Exercise
Exercise helps rebuild the body and keep it functioning properly while also reducing stress. Exercise produces chemicals in your brain that make you feel good. These chemicals are nature’s own tranquilizers to relieve pain, anxiety, and tension.

Different types of exercise are helpful for different reasons. Stretching and aerobic exercise will probably be most helpful for your recovery. Stretching exercises help to keep your body limber and to relieve muscle tension. Aerobics are rhythmical and vigorous exercises for the large muscles. Aerobics are intended to raise your heart rate to 75% of its maximum rate and maintain that rate for at least 20-30 minutes.

We recommend regular use of aerobic exercise. Jogging, swimming, jumping rope, and bicycling are common aerobic exercises, or you might want to join an aerobics class. Dancing can also be aerobic, but remember that it must be done vigorously.

Many recovering people will testify to the value of exercise in reducing the intensity of PAW symptoms. After they exercise they feel much better, find it easier to concentrate and remember, and are able to be more productive.
Choose a form of exercise that is fun for you so that you will stick with it. Most doctors and health books will tell you to exercise three or four times a week, but we recommend that recovering people make time for it every day because of its value in reducing stress. Any day that you do not exercise is a day that you are cheating yourself of a way to feel more relaxed, be more productive, and have more energy. Whatever exercise you choose, remember, do not over-do it! If it hurts don't do it. The old adage "no pain, no gain" is not true for recovering people. Consistency and regularity are the key words for the recovering person.

Relaxation
There are things you can do to readily reduce or escape the stress you feel when you are unable to change a situation or to better cope with the stress of everyday living. Laughing, playing, listening to music, story telling, fantasizing, reading, and massage are some methods of natural stress reduction.
Playing is a necessary form of relaxation that is often neglected. It is difficult to define play because it is not so much what you do as how you do it. We all need time for having fun, laughing, being childlike and free. There are other “diversions” you can use as natural stress reducers. Try a body massage, a bubble bath, a walk by yourself or with a friend.

Deep relaxation is a way of relaxing the body and mind to reduce stress and produce a sense of well-being. Deep relaxation rebalances the body and reduces the production of stress hormones. What happens when you relax is the opposite of the “fight or flight” reaction. When you relax, your muscles become heavy, your body temperature rises, and your breathing and heart rate slow down. A muscle cannot relax and tense at the same time. It is impossible to maintain tension while physically relaxing. You can learn techniques to allow your body to relax. The distress resulting from thought process impairments, emotional process impairments, memory impairments, and stress sensitivity can be reduced or relieved through proper use of relaxation.

There are a variety of relaxation exercises that you can use. You can get a book that will offer you a selection of exercises or you can purchase tape-recorded exercises. You can close your eyes in a comfortable position and repeat a pleasant word over and over to yourself. Or you can imagine yourself in a soothing environment such as by a quiet lake or in a green meadow. Pick a method that is relaxing to you and use it often. You will find it a helpful aid for reducing stress and creating peace of mind and serenity.

Spirituality
Spirituality can be defined as "an active relationship with a power greater than yourself that gives your life meaning and purpose." When you work a spiritual program, you consciously, actively attempt to become a part of something bigger, greater, and more powerful than yourself.

Belief in a Higher Power takes you out of the center of your universe and offers peace of mind and serenity by an awareness that there is a power that is not restricted by your weaknesses and limitations. Through spiritual development you can develop new confidence in your own abilities and develop a new sense of hope. It is through a spiritual program that you can reach with hope and a positive attitude toward the future.

In working on your spirituality it is important for you to use the principles of the AA/NA program. AA/NA provides guidelines for “increasing your conscious contact with your higher power.” You do not have to have any one image of your higher power to increase your conscious contact. You do have to be open to the possibility of a Higher Power and be willing to experiment with communicating with that Power. It is important to structure your life in such a way as to spend time alone each day to interact with your Higher Power. It is important to examine your values and look within yourself to determine whether your life is in harmony with those values.

Spiritual discipline is a consciously chosen course of action. Discipline is uncomfortable for many recovering addicts. They have lived lives of immediate gratification, and discipline is the reverse of that. The purpose of spiritual discipline is freedom from the slavery of self-indulgence. Spiritual discipline includes prayer and meditation, spiritual fellowship, and regular inventory of your spiritual growth.

Balanced Living
Balanced living means that there is bio-psycho-social-spiritual harmony in your life. It means that you are healthy physically and psychologically and that you have healthy relationships. It means that you are spiritually whole. It means that you are no longer focused on one aspect of your life. It means you are living responsibly, giving yourself time for your job, your family, your friends as well as time for your own growth and recovery. It means allowing a Higher Power to work in your life. It means wholesome living.

It means having a balance between work and play, between fulfilling your responsibilities to other people and your need for self-fulfillment. It means functioning as nearly as possible at your optimum stress level, maintaining enough stress to keep you functioning in a healthy way and not overloading yourself with stress so that it becomes counterproductive. With balanced living, immediate gratification as a lifestyle is given up in order to attain fulfilling and meaningful living.

Balanced living requires proper health care so that the body is functioning well. Nutrition, rest, and exercise all receive the proper focus in your life to provide energy, manage stress, allow freedom from illness and pain, combat fatigue, and rebuild a damaged body.

Freedom from physical distress allows psychological growth. When you feel good it is easier to think about your attitudes and values and to work on eliminating denial, guilt, and anger. Balanced living requires doing things to develop self-confidence and self-esteem and learning to feel good about yourself.
Balanced living needs a strong social network that nurtures you and encourages a healthy, recovery-oriented lifestyle. A healthy network provides a sense of belonging. It includes relationships in which you feel you are a valuable part. It includes immediate family members, friends, relatives, co-workers, counselors, employers, self-help group members, and sponsors.

This article is copyrighted by Terence T. Gorski. Permission is given to reproduce this article if the following conditions are met: (1) The authorship of the article is properly referenced and the internet address is given; (2) All references to the following three websites are retained when the article is reproduced - www.tgorski.com, www.cenaps.com, www.relapse.org, www.relapse.net; (3) If the article is published on a website a reciprocal link to the four websites listed under point two is provided on the website publishing the article.
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Old 01-25-2008, 02:25 PM
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Default Thank you Shelby

I may have never experienced state lock up, but I know another prison that you released me from with your information of PAWS! I hope I don't offend anybody on this forum. I still had to thank you and all the others out there who know how hard it is to change or deal with mistakes. I just hope that no matter what, everyone who has dealt with the state can get help to be okay and happy and free. Regardless of what some may say - we are all brothers and sisters here to help each other. So, Thank You, Thank You! Sincerely, a past county bound.
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Old 02-03-2008, 11:09 PM
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thanks for sharing.
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Love,
Patty

"Love Is Stronger than any Addiction"

My Loved one is Now Home
June 02, 2008
Thank God!
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Old 04-14-2008, 10:58 PM
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I am going to write this word for word and send it to my hubby. He will be home in 3 weeks, and I just feel like we are not prepared!!!
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Old 05-05-2008, 06:16 AM
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Shelby,
I thank you for this valuable information. As a person who has never done drugs at all, but wants to learn how to understand and help others i find this article a eye opener.
You made my day. I will print this out to help others.
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Old 05-30-2008, 12:37 PM
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Thanks for posting this. I learned a whole bunch from reading it once, and I know I'll problably read it again and again.
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