Protracted Withdrawal Syndrome (PWS)

For a number of patients tapering off psychiatric medication, the nervous system does not immediately settle once a reduction has been made - this is especially true in cases of rapid tapering and cold turkeying medication.¹ 

Instead, the patient may enter a phase known as Protracted Withdrawal Syndrome (PWS), or long-term withdrawal. 

Protracted withdrawal refers to withdrawal symptoms that persist for many weeks, months, or, in some cases, years after reduction or cessation of medication.² 

It is characterised by persistent, fluctuating waves of physical and psychological symptoms. [See also: Windows and Waves]. Importantly, withdrawal symptoms can sometimes be mistaken for a continuation or recurrence of the original condition. Distinguishing withdrawal from psychiatric relapse can therefore be clinically challenging.³ 

The Honeymoon Phase 

One of the most confusing and emotionally jarring aspects of the PWS period is the honeymoon phase. After reduction or cessation of medication, some patients experience a surprising window of clarity, feeling completely fine, clear-headed or even euphoric for the first few weeks or month. They believe they have beaten the odds and escaped withdrawal entirely. 

The biological reasons for this fluctuating pattern are not fully understood. Withdrawal symptoms do not necessarily appear immediately or progress in a predictable linear fashion, and the timing varies substantially according to the medication, its pharmacology, the tapering process and individual factors.⁴ Horowitz & Taylor discuss the complex relationship between antidepressant dose, pharmacological effect and withdrawal, while Prof. Heather Ashton describes considerable variation in the timing and persistence of benzodiazepine withdrawal symptoms. For some people, a period of relative stability can therefore be followed by a later emergence or intensification of withdrawal symptoms. This can be frightening, particularly when the person had initially believed that withdrawal was over.⁵ 

Anticipating the honeymoon phase is vital so patients are not blindsided when a deceptive period of early calm suddenly gives way to the true recovery timeline.

Signs and Symptoms of Protracted Withdrawal Syndrome

While symptoms vary greatly from person to person, protracted withdrawal may involve a mix of physical and neurological challenges that can wax and wane in intensity. Many of the symptoms listed on the home page  of this site, for example, are present in varying degrees across cases of PWS, depending on the offending medication.

Why Does Protracted Withdrawal Happen?

The duration and severity of withdrawal are heavily influenced by several factors unique to each individual's physical makeup and medical history:

The Method of Cessation: Previous cold turkeys, rapid linear reductions, or multiple failed stop-start cycles can increase the likelihood or severity of withdrawal symptoms. [See also: Kindling]

Duration of Use and Dosage: Longer exposure and higher cumulative doses require extensive cellular and receptor remodeling by the brain. This process of neuroadaptation can lead to pharmacodynamic tolerance in benzodiazepines.⁶ 

Biological Vulnerability and Genetics: Factors such as medication pharmacology, metabolism, duration of exposure and individual biological characteristics may contribute to differences in withdrawal experiences, although reliable predictors of prolonged withdrawal remain limited.⁷  

Coping and Finding Hope in Protracted Withdrawal Recovery 

Living with protracted withdrawal requires a radical shift in perspective and immense self-compassion. Healing on a protracted timeline does not happen in weeks; it happens in months and seasons. Tracking recovery week-by-week can be discouraging, but looking back across six-month or yearly intervals often reveals slow, undeniable progress.

Fighting the symptoms or constantly searching for a quick fix can add layers of mental stress to an already overburdened nervous system. Learning to float through the waves and accept them as a physiological healing process helps reduce suffering. 

References

1. Royal College of Psychiatrists. (2023). RCPsych comments on new NICE guidance regarding patients withdrawing from antidepressants. www.rcpsych.ac.uk/news-and-features/latest-news/detail/2023/01/17/rcpsych-comments-on-new-nice-guidance-regarding-patients-withdrawing-from-antidepressants

2. Ashton, C. H. (1995). Protracted withdrawal from benzodiazepines: The post-withdrawal syndrome. Psychiatric Annals, 25(3), 174–179 https://www.benzo.org.uk/pha-1

3. Horowitz, M. A., & Taylor, D. (2022). Distinguishing relapse from antidepressant withdrawal: Clinical practice and antidepressant discontinuation studies. BJPsych Advances, 28(5), 297–311. https://doi.org/10.1192/bja.2021.62

4. Ashton, C. H. (1995/2004). Descriptions of windows of normality and fluctuating/protracted withdrawal symptoms. www.benzo.org.uk/pha-1

5. Ashton, C. H. (2004). Protracted withdrawal symptoms from benzodiazepines. www.benzo.org.uk/pha-1

6. Horowitz, M. A., & Taylor, D. (2019), and Ashton (1991/2004), regarding physiological adaptation and withdrawal.

7. Ashton, C. H. (1991), regarding the absence of reliable predictive factors for vulnerability to protracted benzodiazepine withdrawal. www.benzo.org.uk/pha-1