The 7 Types of Symptoms of Protracted Withdrawal

Alternative to Meds Editorial Team
Medically Reviewed by Dr John Motl MD

What is protracted withdrawal?

Protracted withdrawal is a set of withdrawal symptoms that lingers, or comes back, after the first (acute) withdrawal period is over. It is also called post-acute withdrawal syndrome (PAWS) or protracted withdrawal syndrome (PWS). Acute withdrawal is what happens when you first stop a drug, alcohol, or medication. Protracted withdrawal can show up later and keep surfacing throughout recovery, which makes it feel unpredictable.

It is very common. Ninety percent or more of people who have had acute withdrawal symptoms go on to experience PAWS.¹ For a smaller group, around 5% to 10%, symptoms fully settle after the initial detox period. Others have lingering symptoms for weeks, months, or even years.

Why it matters: left unaddressed, PAWS is a major predictor of relapse, and at the very least it causes real distress.¹ If you are living with it, you are not imagining it, and you are not failing. Withdrawal is a signal that your body needs help, and there are many ways to manage it.

Acute vs. protracted withdrawal

What is acute withdrawal? Acute withdrawal is what a person experiences when they first detox from drugs, alcohol, or a medication. It is usually the most medically severe phase, and it can be especially severe for people quitting alcohol or benzodiazepines.

Acute withdrawal from barbiturates can include:²

• Nausea and vomiting
• Headaches and migraines
• Intense cravings
• Anxiety, insomnia, and trouble sleeping
• Depression and joint pain
• Hallucinations, delirium tremens, and seizures

With alcohol, loss of physical coordination, a high pulse rate, and grand mal seizures are also possible.³

How protracted withdrawal is different:

• Timing. Acute withdrawal happens during the initial detox. Protracted symptoms may begin within days or weeks after acute symptoms fade.¹³
• Severity. Acute withdrawal is usually more severe medically. Protracted withdrawal is often harder to cope with because it is long and unpredictable.
• Pattern. Acute withdrawal tends to run one course. Protracted withdrawal can recur in waves.¹³
• Range of symptoms. Protracted withdrawal reaches beyond the body, into thinking, emotions, relationships, and sense of meaning.

Do withdrawal symptoms come in waves?

Yes, they can. Withdrawal can seem to end, for example after a two-week detox, and then return as PAWS symptoms.⁵ These symptoms may come and go, which is why people often describe them as “waves.”

Not everyone experiences this. But if you feel better for a while and then symptoms return, it does not mean you have gone backward. A lull followed by a new wave is a recognized part of protracted withdrawal.

Withdrawal is not the same as cravings or triggers. People often joke about being “in withdrawal” from sugar or a nightly glass of wine. That use of the word blurs the meaning. Cravings happen throughout recovery, though withdrawal cravings are intense. Triggers are events, places, sounds, emotions, or people that tempt a person to use again at any stage. Cognitive behavioral therapy (CBT) has been shown to be highly effective for learning to recognize and handle intense cravings and triggers after detox.⁶

The 7 types of protracted withdrawal symptoms

These seven groups are categories of symptoms, not a complete list. The actual symptoms are extensive and unique to each person, with some common threads.

1) Cognitive symptoms

Cognitive symptoms affect how memories are organized and kept. They go beyond simple forgetfulness.⁸

• Memory loss and trouble remembering
• General brain fog
• Difficulty remembering certain events or periods of time
• Foggy or false memories, or trouble telling confusing memories from reality
• Vivid dreams that feel real

2) Intellectual symptoms

Intellectual symptoms are related to cognitive ones but not the same. You may feel slowed down or even “dumbed down.” This does not mean you have lost intelligence; that is not common.⁹ It is typically the brain responding and relearning after a long period of chemical dependency.

• Trouble organizing your thoughts
• Difficulty multitasking
• Trouble paying attention for long
• Difficulty putting thoughts and feelings into words

Some substances, such as the stimulant Adderall, can make a person feel sharper while using, so stopping can feel like a step down for a while. Medications used in medication-assisted treatment (MAT), such as Suboxone, may also cause cognitive sluggishness, separate from withdrawal itself.¹⁰

3) Emotional symptoms

The brain is doing “mental gymnastics” to cope with the loss of a substance it depended on. That can make it hard to respond in proportion.

• Tears over a minor inconvenience
• Rage over a small slight from a friend or partner
• Emotional instability that feels jarring

This is considered normal in early recovery. Learning strategies for coping with intense emotional flare-ups is highly recommended.

4) Sex-related symptoms

Some withdrawal symptoms are specific to sexual health.

• Trouble becoming aroused, linked to dysphoria (the absence of the euphoria felt while using). This is common early on.
• Loss of interest in sex, or trouble finding it satisfying.
• Different causes. Sometimes it is the brain’s chemistry during withdrawal; sometimes a medication causes sexual dysfunction; sometimes it is psychological, such as believing sex won’t be gratifying without the substance.

5) Spiritual difficulties

Some people struggle spiritually during withdrawal, for reasons unique to them.

• A spiritual person may find it hard to feel connected to God or a higher power through the fog and emotional turmoil.
• Someone new to spirituality may find that connection feels foreign at such a hard time.

It can still be worth the effort. In an extensive addiction recovery study by Laudet et al., 78% of successfully recovered participants reported a daily or almost daily spiritual connection through prayer or meditation, whatever their personal beliefs.¹¹

6) Physical symptoms

Physical symptoms are the most obvious group. They range from mildly annoying, like nausea and headache, to life-threatening, like seizures.¹²

Physical symptoms of acute or protracted withdrawal include:

• Digestive: nausea, vomiting, loss of appetite
• Energy: lethargy, extreme fatigue, weakness
• Nervous system: tremors, seizures, dizziness, loss of balance, tinnitus (ringing in the ears)
• Sensory and pain: tingling in the hands, feet, and limbs, burning sensations, muscle spasms, chronic pain
• Sexual and bladder: decreased libido, sexual dysfunction (including erectile dysfunction), incontinence

7) Social symptoms

Social well-being can suffer greatly during PAWS. Many people withdraw or isolate from others. This may be linked to a co-occurring condition such as social anxiety or bipolar disorder, or simply to the experience of quitting.

• Pulling away from friends and family
• Avoiding social situations
• Feeling cut off or alone

Is dizziness a withdrawal symptom?

It can be. Dizziness can happen in both acute and protracted withdrawal, and it often shows up alongside other symptoms. But dizziness has many possible causes, so it is not always withdrawal.

It is also a common side effect of many medications, whether used as prescribed or misused, including some used in medication-assisted treatment.⁴ If dizziness is new or severe, let your prescriber or care team know.

Protracted benzodiazepine withdrawal

Withdrawal from benzodiazepines is one of the most intense and dangerous forms of withdrawal, both during detox and during protracted withdrawal. It is most comparable to alcohol withdrawal, and both can be life-threatening because of seizures.⁷

Who it affects: benzo dependence disproportionately affects women, and it can begin with a legitimate prescription for a diagnosed condition. That makes it complicated to treat.⁷

Protracted benzodiazepine withdrawal syndrome: the term protracted withdrawal syndrome (PWS) is often used interchangeably with PAWS but is strongly associated with benzodiazepines. Recovery timelines are often longer after benzos. Some people report mild PWS for up to seven years after their last dose, although this is not common.

Typical timelines for benzo protracted withdrawal symptoms to ease:¹⁴

• Anxiety: diminishes markedly over one year
• Insomnia: typically improves between six months and one year
• Depression: typically lasts a few months
• Sensory symptoms (pain, tingling, burning, numbness): one to three years or more
• Muscular symptoms (weakness, tremors): one year or more, gradually decreasing
• Cognitive symptoms: one year or more, gradually decreasing
• Gastrointestinal symptoms: one year or more, gradually decreasing

Learn more about benzodiazepine withdrawal and our benzodiazepine withdrawal program.

Protracted withdrawal after psychiatric medications

Protracted withdrawal isn’t limited to alcohol and street drugs. As the benzodiazepine example shows, it can follow medications that were legitimately prescribed.⁷ The seven symptom groups above can appear after stopping many kinds of psychiatric medication.

What applies across medications:

• Don’t quit cold turkey. Stopping a medication alone and abruptly is hazardous.
• Taper with professionals. Coming off safely takes a thoughtful combination of therapy and medication tapering under the care of medical and mental health professionals.
• Medications can blur the picture. Medicating a person in recovery can obscure where symptoms come from and delay full recovery.

For medication-specific guides, see antidepressant withdrawal, antipsychotic withdrawal treatment, and how we treat medication withdrawal.

How long does protracted withdrawal last?

It varies a lot from person to person, but there is reason for hope.

• When it starts: often within days or weeks after acute symptoms fade.¹³
• How it behaves: it may recur in waves rather than fading in a straight line.¹³
• When it ends: many people who stay consistent with their recovery therapy no longer have symptoms after 18 months, and some have complete relief by six months.¹³
• After benzodiazepines: timelines are often longer, as described above.¹⁴

Are withdrawal symptoms permanent? For most people, no. Even when symptoms last for years, you don’t have to despair. Symptoms tend to ease with time and consistent support.

What helps with protracted withdrawal

Knowing what is happening is a real help in itself. Beyond that, these approaches are supported by the research cited here:

• Counseling, especially CBT. CBT has been shown highly effective for recognizing and managing intense cravings and triggers after detox.⁶
• Non-medicated (psychosocial) treatment. A meta-analysis in the journal Addictive Behaviors found psychosocial treatment superior to prescription medication.¹⁵
• Coping skills for emotional flare-ups. Learning specific strategies helps when emotions swing out of proportion.
• Spiritual connection. Daily or near-daily prayer or meditation was common among people who recovered successfully.¹¹
• Consistency. People who stay consistent with their recovery therapy are the ones most often symptom-free by 6 to 18 months.¹³
• A tailored plan. Holistic care lets you and your providers build a plan around your individual needs.

What to avoid: stopping or changing medication on your own. Any medication change should be supervised and paced to how you respond.

Supporting a loved one through protracted withdrawal

Watching someone you love struggle for months can be exhausting and frightening. A few things help:

• Believe them. Protracted withdrawal is real and common, even when it isn’t visible.¹
• Expect waves. A good week followed by a hard one is part of the pattern, not a failure.
• Be patient with emotions. Outsized tears or anger are a recognized symptom in early recovery.
• Gently counter isolation. Low-pressure contact helps when they pull away.
• Discourage going it alone. Encourage supervised care instead of stopping medication abruptly, and take seizures, severe symptoms, or talk of relapse seriously.

Coping alone vs. supported care

When to get help

Consider reaching out if:

• Symptoms are severe, such as seizures, or are getting worse
• You have tried to come off a medication before and couldn’t
• Waves keep returning and are wearing you down
• You are isolating, or worried about relapse

How Alternative to Meds Center helps. We have specialized in medication withdrawal for nearly 20 years, and our outcomes are documented in published evidence. Our residential program in Sedona averages about 60 days, with our clinical team on site.

• Individualized tapering. Never one-size-fits-all; the pace is adjusted as you respond.
• Precise dosing. Each dose step is planned by our medical team, using half tablets or liquid preparations as needed.
• Brain chemistry support. Nutrient therapy and neurotransmitter support.
• Root causes. Nutrition, toxins, and counseling are addressed, not just symptoms.

Learn more about medication withdrawal treatment, benzodiazepine withdrawal, antipsychotic withdrawal, and our Sedona facility. Don’t let fear of withdrawal or PAWS keep you from improving your life.

Protracted withdrawal FAQs

Sources:

1. https://americanaddictioncenters.org/withdrawal-timelines-treatments/post-acute-withdrawal-syndrome

2. https://pubmed.ncbi.nlm.nih.gov/10349206/

3. https://www.benzoinfo.com/protracted-withdrawal-syndrome/

4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853661/

5. https://www.benzoinfo.com/protracted-withdrawal-syndrome/

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844157/

7. https://bmcwomenshealth.biomedcentral.com/articles/10.1186/1472-6874-4-S1-S8

8. https://www.sciencedirect.com/science/article/pii/S0887617703000969

9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5087336/

10. https://americanaddictioncenters.org/suboxone/side-effects

11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1526775/

12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312739/

13. https://www.ncbi.nlm.nih.gov/books/NBK310652/

14. https://americanaddictioncenters.org/withdrawal-timelines-treatments/post-acute-withdrawal-syndrome

15. https://pubmed.ncbi.nlm.nih.gov/15236814/

Additional sources:
https://doi.org/10.1186/1472-6874-4-S1-S8
https://www.alternativetomeds.com/blog/benzodiazepine-withdrawal/
https://en.wikipedia.org/wiki/Drug_withdrawal
https://meshb.nlm.nih.gov/record/ui?ui=D013375
https://recoveryfirst.org/blog/the-7-types-of-symptoms-of-protracted-withdrawal/

Originally Published July 16, 2021 by Lyle Murphy

This content has been reviewed and approved by a licensed physician.

Dr. John Motl, M.D.

Dr. Motl is currently certified by the American Board of Psychiatry and Neurology in Psychiatry, and Board eligible in Neurology and licensed in the state of Arizona.  He holds a Bachelor of Science degree with a major in biology and minors in chemistry and philosophy. He graduated from Creighton University School of Medicine with a Doctor of Medicine.  Dr. Motl has studied Medical Acupuncture at the Colorado School of Traditional Chinese Medicine and at U.C.L.A.

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Lyle Murphy

Lyle Murphy is the founder of the Alternative to Meds Center, a licensed residential program that helps people overcome dependence on psychiatric medication and addiction issues using holistic and psychotherapeutic methods.