Etiology and symptoms
Protracted Withdrawal, also known as Protracted Withdrawal Syndrome (PWS) or Post-Acute Withdrawal Syndrome (PAWS), is an iatrogenic syndrome of symptoms that occur and persist long after the discontinuation of psychoactive substances, in this context, antidepressants, antipsychotics, and benzodiazepines.
The etiology of Protracted Withdrawal is not fully understood, but several hypotheses are currently being discussed, such as autonomic dysregulation1, epigenetic changes2 and receptor desensitization3.
Protracted Withdrawal can manifest as new neuropsychiatric symptoms (e.g., severe anxiety/depression, mood swings, aggression, atypical painful sensations, akathisia, muscle tics, suicidal thoughts, tinnitus and balance problems, sensory disturbances, sexual dysfunctions – to name just a few).
In contrast to what is referred to as 'withdrawal' (a term suggesting that it should quickly/linearly resolve), one hypothesis suggests that neurological damage (e.g., neurotoxicity) may have occurred due to both the drug exposure and its reduction or discontinuation. For example, similar to how permanent muscle tics can develop in some patients treated with antipsychotic medications.
What is Protracted Withdrawal?
1. Impact of antidepressant use on the autonomic nervous system: A meta-analysis and systematic review. European Neuropsychopharmacology Volume 71, June 2023, Pages 75-95
2. Epigenetic alterations in depression and antidepressant treatment. Dialogues Clin Neurosci. 2014 Sep; 16(3): 395–404.
3. Delayed Antidepressant Efficacy and the Desensitization Hypothesis. ACS Chem Neurosci. Author manuscript; available in PMC 2020 Jul 7.
4. Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum. Ther Adv Psychopharmacol. 2020 Dec
Bibliography
Recovery
Recovery can take some time and varies from person to person. Some people experience improvement within several months, while for others, it may take years, but everyone gradually improves over time. According to a study of 69 patients, the average recovery time is 37 months4. Typically, the later stages of recovery are more tolerable.
The recovery process is not linear and follows a pattern of windows and waves. This means there are alternating periods of improvement and symptom exacerbation. Over time, the periods of feeling better become more frequent, and the symptom flare-ups become less severe.
A significant aspect of the recovery stage is that symptoms are often misdiagnosed as other conditions and subsequently treated incorrectly. A misdiagnosis can lead to unnecessary medication exposure, which disrupts the healing process. Patients with PWS are particularly sensitive to medications, and reintroducing them can hinder recovery.
Written by: Tomasz Starczewski
The most important factor in the recovery process is an accurate diagnosis and assurance that gradual recovery is possible. If the medication causing neurotoxicity is still being taken, it is recommended to gradually discontinue it.
Typically, medications are tapered slowly in the hope of avoiding severe withdrawal symptoms and protracted withdrawal syndrome. However, for reasons not entirely understood, some patients—especially those who discontinued medication rapidly or suddenly, but also those who tapered off slowly—may develop long-term withdrawal syndrome.
Frequent meetings with individuals supporting the withdrawal process are helpful in managing symptoms and optimizing functioning during recovery. Psychotraumatological support also appears to be effective. It is crucial, especially during this period, to maintain a healthy lifestyle and a diet that supports the recovery process.
In some cases, certain dietary supplements may be used to potentially alleviate symptoms. Caution is essential, as the body is highly sensitive to any changes during the recovery process.
Management of Protracted Withdrawal
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