Again. At least I think so. Or hope so ? Because if it’s not …. .

I’d never really heard of PAWS before I became a non drinker; when after the initial difficulties and emotional roller coaster of withdrawal, I didn’t exactly enter the happy calm space I was anticipating … No, I found myself still subject to mood swings, unexpected bouts of depression, sudden onset of anxiety symptoms, insomnia, and emotional uncertainty …

Then kind members of the sober community enlightened me, and I started reading about PAWS.

After acute withdrawal, the next stage of sobriety includes symptoms known as the Post Acute Withdrawal Syndrome (PAWS). This stage has fewer physical symptoms, the manifestations are more emotional and psychological.

As I understand it,  Post-acute withdrawal occurs because your brain chemistry is gradually returning to normal. As your brain recovers from being regularly poisoned,  the levels of your brain chemicals fluctuate as they approach the new normal equilibrium, and this fluctuation causes PAWS.

Over the past decades, much has come to be known about the long-term effects of drugs of addiction, especially on the neurobiology of the brain. Most substances of addiction, like alcohol, benzodiazepines, opiates, and stimulants lead to lasting changes in the brains handling of learning, motivation, and pleasure. Primarily, these drugs hijack the brain’s “reward” circuits, a critical part of which is dopamine. In the case of alcohol (and drug) abuse and dopamine, the brain not only becomes tolerant, but it also gets used to, and “expects” an excess of dopamine, meaning the newly sober user  experiences a simultaneous lack of dopamine (which is unpleasant) AND increased brain craving for the trigger that provides dopamine. In other words, not only does an addict feel bad without the drug, his focus turns solely to it to make him feel good again. Great ! Cravings explained in one easy sentence ….

There are several other key neurotransmitters involved, as well as dopamine, including serotonin ( mentioned here )

While different drugs of abuse seem to lead to different sub-sets of PAWS symptoms, PAWS that occur from alcohol and benzodiazepines are generally more similar because they’re pharmacologically more similar in mode of action – key things are irritability, anxiety, and sleep difficulties. I have read that how long people experience these paws symptoms is typically a reflection of how long they were using  the drugs as opposed to how much.  great . So my 30 odd years of alcohol excess is definitely going to come back and haunt me here ….

The most common post-acute withdrawal symptoms are:

Mood swings  (triple tick)
Anxiety. tick
Irritability. Tick
Tiredness. Double tick
Variable energy, double tick
Low enthusiasm. Triple tick
Variable concentration double tick
Disturbed sleep tick

Im utterly fed up right now. I’m stressed , fighting with Mr Lily over problems that are insoluble, anxious about the responsibility I’m taking on in our upcoming holiday, worried about no 1 son – and totally alone with no support in this one, I feel fat, sluggish, lazy and unmotivated. So unmotivated I even missed my favourite yoga class this evening.
This feels like a total rollercoaster of symptoms. At the beginning; the first two weeks were really tough – my symptoms would change minute to minute and hour to hour. Then I had a period of pink cloud – when I felt AWESOME …. I enjoyed that 🙂 But in the last 3 months of so, I don’t feel I’ve made any significant progress . I get these awful low moods, then they will disappear for a few days / a week , only to return again. I hoped that  the good stretches would get longer and longer, I’m not sure that’s happening and the bad periods of post-acute withdrawal are just as intense and last just as long.

Thank goodness I’m not craving alcohol right now, as I’m feeling so very vulnerable ….



I’ve been really struck in the last few days at the number of blog posts I have read from people struggling with guilt and shame at having to take, or being recommended to take, antidepressants / medication for anxiety.

I work as a General/ Family practitioner and I see this so often. People struggling with crippling anxiety and debilitating anhedonia, who somehow believe this is a sign of ‘weakness’ or  a character flaw. That if they could just “pull themselves together’ it would all go away.

This is just NOT the case. Low mood / anxiety are two sides of the same coin and they are both due, in part at least, to low levels of the neurotransmitter serotonin. This is FACT. An individual can no more control their levels of serotonin than their levels of insulin. Ergo, will power alone will NOT , CANNOT manage anxiety and depression.

Anxiety / Low mood is very,very, very common. Probably about one in three people will visit their doctor at some time with this complaint. Sometimes its presented as fatigue, sometimes as somatic symptoms. But the underlying low serotonin, if treated, will improve all these symptoms

(and before any one jumps on me, not everyone with fatigue is depressed, obviously, but its very common)

This is a somewhat simplified version of the role of neurotransmitters, as my aim with this blog post is not to discuss the finer points of neurophysiology, but offer evidence that might make someone who is low, feel less stigmatised about being offerred / taking antidepressants.

NEUROTRANSMITTERS are the brain chemicals that communicate information throughout our brain and body.  They relay signals between nerve cells, called “neurons”  The brain uses neurotransmitters to tell your heart to beat, your lungs to breathe, and your stomach to digest.  Serotonin is a neurotransmitter which affects mood, sleep, concentration, weight, anxiety, appetite, memory and learning, temperature, and behaviour. Norepinephrine, dopamine, endorphines and oxytocin are also involved in various aspects of mood.

Lots of things, obviously affect mood. Social circumstances, relationships and thousands of other things. But low serotonin levels- are definitely one of the factors that affect mood and one of the factors that we can modify. The diagram below shows the overlapping relationships between some of the neuro chemicals involved


We can ‘help ourselves’ with exercise and a variety of other techniques, we can try to manage stress levels, and we can avoid substances that deplete serotonin – eg alcohol… BUT, for many people, medication is a very useful tool to improve mood and reduce anxiety. I will often explain to my patients that lifting your mood allows one to create a ‘virtuous circle’ – when you feel a but more motivated, you are likely to exercise more, get more done – this makes you feel better – and so on…

so please, if you are low, depressed, anxious, unmotivated, exhausted, struggling with mood disorder, please recognise that this is an illness; Its not under your ‘control’ and there is treatment that can help.

DOI. I take a serotonin reuptake inhibitor, and I believe it has, if not saved my life, helped me beyond measure.