Many sources continue to maintain the notion of a separation between physical withdrawal symptoms and psychological withdrawal symptoms.
This separation is artificial and ignores the current understanding of behavior. All behavior is a result of physical, cognitive, and emotional forces that are all interrelated to one another. There is no such thing as a purely “psychological” or “emotional” type of behavior that is not related to some physiological process. Likewise, any major process that can be defined as “physical” or “physiological” most likely has associated emotional and cognitive ramifications. All of these notions are interrelated and not mutually exclusive.
Psychological or Physical Addiction?
An even more radical and invalid notion sometimes still encountered in addiction literature is the notion of the distinction between physical addiction and psychological addiction to a drug or class of drugs. These distinctions are meaningless and do little to enhance the understanding of addiction and physical dependence.
For a moment, consider an individual who experiences severe nausea and vomiting as a result of withdrawing from a drug. The nausea and vomiting would be considered physical symptoms of withdrawal; however, experiencing nausea and vomiting is also associated with a number of other psychological/emotional and cognitive effects that can include things like anxiety, depression, despair, a loss of motivation to continue in recovery, and increased cravings or desire to use one’s drug of choice in order to stop the physical feelings of being ill. Likewise, individuals who are emotionally distraught and experiencing severe anxiety and depression will experience physical symptoms, such as nausea, in a much different way than individuals who are not emotionally distraught. Typically, someone experiencing moderate to severe emotional stress results in a magnified perception of their physical distress. Individuals who are depressed are often severely anxious, and what might normally be perceived as mild stomach discomfort can be magnified into a major issue with nausea, which can result in severe vomiting, a feeling of being severely ill, and a feeling of being helpless.
Thus, the symptoms that occur in any withdrawal syndrome are all interrelated and have significant effects on one another. These symptoms do not occur in isolation and cannot be considered purely physical or psychological. In addition, classifying withdrawal syndromes as either “physical” or “psychological” can potentially result in different approaches to the treatment of the individual expressing these syndromes. Individuals who are expressing primarily “purely psychological symptoms” may not be given as serious consideration as those individuals believed to be expressing “purely physical symptoms.” Not only is this type of approach to practice unethical, it also undermines serious attempts to help certain individuals who are in need of consideration.
This article will discuss some features of withdrawal from drugs that are highly emotional or psychological in their presentation. It should be remembered that any form of behavior represents interplay of the three aforementioned processes that are mutually dependent on one another.
The Notion of Psychological Withdrawal Symptoms
Psychological withdrawal symptoms (sometimes still referred to as psychological dependence) represent a form of symptomatology that primarily involves emotional and motivational features. These symptoms include depression, anxiety, reduced motivation, difficulties experiencing pleasure, apathy, and even more serious symptoms, such as the development of hallucinations and delusions. The process that is believed to contribute to the presentation of withdrawal symptoms that are primarily emotional or psychological in nature is believed to be related to a form of learning known as operant conditioning.
Operant conditioning represents the notion of learning via reinforcement (or in some cases punishment) that affects the probability of an individual repeating certain behaviors. In the process of developing a substance use disorder, individuals experience a number of reinforcing effects associated with drug use that increases the probability that they will continue to repeat using the drug. Essentially, reinforcement is broken down into two major processes:
- Positive reinforcement in drug abuse occurs when an individual experiences pleasurable associations related to drug use, and these pleasurable associations increase the probability that they will repeat their drug usage.
- Negative reinforcement in drug abuse occurs when the individual experiences a cessation or reduction of unpleasant experiences (e.g., withdrawal symptoms or negative effects associated with stress) as a result of using their drug of choice. The cessation of these unpleasant experiences as a result of using the drug increases the probability that the individual will continue to use the drug.
Both positive and negative reinforcement are psychological concepts that also have a physiological basis. According to scholarly works, such as the books Drugs and Society and Molecular Neuropharmacology: A Foundation for Clinical Neuroscience, psychological dependence or the manifestation of psychological withdrawal symptoms is primarily mediated through the process of negative reinforcement; however, a lack of positive reinforcement may also be associated with certain psychological or behavioral symptoms. When an individual stops using the drug and no longer experiences the reinforcement for it, they develop a number of emotionally based symptoms, such as depression, anxiety, etc., that are also associated with the presence of physical withdrawal symptoms or with psychological reactions to stress. However, it is also well known that many of the emotionally based symptoms associated with the withdrawal process are also associated with decreased levels of neurotransmitters, such as dopamine in the brain. Many biological-based researchers consider even these emotional symptoms to be manifestations of a physical process. But as mentioned above, all these processes are interrelated and interconnected.
Psychological Symptoms during the Withdrawal Process from Major Classes of Drugs
Withdrawal from any type of drug will result in the expression of a number of symptoms with psychological and emotional presentations. A brief explanation of the major psychological symptoms associated with certain classes of drugs of abuse follows.
Although alcohol is a central nervous system depressant, the withdrawal process is so complicated that it discussed separate from other drugs in this class.
- Depression, especially in individuals who may have been clinically depressed and used alcohol to dampen the symptoms of depression
- Issues with anxiety, which often have a physiological basis
- Irritability, agitation, and mood swings
- Increased sensitivity to environmental stimulation, such as light, sound, and touch
- Insomnia or increased somnolence
- Confusion, especially in individuals with severe alcohol use disorders who develop delirium tremens
- Hallucinations, which also have a physiological basis and are primarily visual in nature but may include auditory, somatic, and olfactory hallucinations
- Severe cravings for alcohol
In severe alcohol use disorders, individuals may experience a syndrome known as delirium tremens, which includes severe confusion, hallucinations, and seizures. The syndrome results when there is a rapid decrease in the blood alcohol level of an individual with a severe alcohol use disorder and requires immediate medical attention.
Treatment for many of these other symptoms will most often include a combination of medication and psychosocial approaches, such as therapy, relaxation training, and stress reduction techniques. When an individual has completed the detox process, and their system is relatively alcohol-free, many of these symptoms may still be present, such as depression, anxiety, and mood swings. These symptoms require continued attention and treatment in order to avoid potential relapse.
Other central nervous system depressants include drugs like benzodiazepines (e.g., Xanax, Valium, etc.), barbiturates (e.g., Seconal, Amytol, etc.), narcotic medications for pain (e.g., morphine, OxyContin, Vicodin, and even heroin), and sedative medications (e.g., Lunesta, Sonata, Ambien, etc.). The withdrawal process from these medications includes a number of symptoms that primarily present as psychological or emotional issues, including:
- Irritability and mood swings
- Anhedonia (difficulty experiencing pleasure)
- Insomnia or somnolence
- Social withdrawal
Withdrawal from some central nervous system depressants, such as benzodiazepines, may also produce potentially dangerous seizures, and these should be given immediate medical attention. In addition, withdrawal from central nervous system depressants may often produce rebound effects, which represent an exacerbation of the symptoms that the medication was initially designed to control. For example, benzodiazepines are very effective for controlling anxiety, and individuals withdrawing from benzodiazepine use disorders will often experience severe anxiety. Narcotic medications are primarily designed for pain control, and individuals withdrawing from narcotic medications may experience increased sensitivity to pain.
Stimulant medications speed up the central nervous system and other body processes. Stimulants include illicit drugs, such as cocaine in all of its forms, methamphetamine (crystal meth), MDMA (ecstasy), and drugs used for medicinal purposes, such as Ritalin, Adderall, Concerta, and other amphetamines. Much of the literature regarding the withdrawal process from these drugs emphasizes that many of the symptoms are primarily psychological in nature.
- Lethargy and somnolence
- Increased appetite
- Anhedonia, depression, mild anxiety, and a loss of motivation
- Severe cravings
- The potential to develop hallucinations and/or delusions
Withdrawal associated with amphetamines, especially from drugs such as cocaine, is also often associated with a severe “crash” that includes severe feelings of depression, apathy, and cravings that result in drug-seeking behavior. Initially thought to be primarily “psychological,” it has been determined that stimulant medications increase levels of certain neurotransmitters, such as dopamine and norepinephrine, and discontinuation of these drugs results in a severe depletion of these neurotransmitters in the brain that contribute to the psychological experience of the “crash” associated with discontinuation of these drugs. Thus, again, the notion of purely psychological or purely physical symptoms appears to have little validity.
Readers should consider several important conclusions that should be taken from the above information.
First, it is important to note that any potential psychological or physical symptom may be associated with withdrawal processes from any class of drugs. The lists presented above represent the more common psychologically based symptoms associated with withdrawal from a particular class of drugs.
Second, as mentioned throughout this article, it is important to note that the separation of symptoms that occur during the withdrawal process into “psychological” and “physical” symptoms represents a false dichotomy. All of the symptoms associated with withdrawal represent an interaction of physical and psychological/emotional forces.
Third, treatment for any withdrawal symptom should include a combination of both medical (e.g. medicines) and psychosocial (e.g., therapy) approaches in order to address the symptoms efficiently. The treatment of withdrawal should include the most comprehensive yet least restrictive approach that clinicians can use to effectively address the individual’s unique presentation.
Finally, it is important to remember that withdrawal symptoms from any drug are never primarily physical in nature and that many of the psychological presentations associated with withdrawal may also occur long after the physical withdrawal process from drugs is complete. Symptoms like reactions to stress, anxiety, and depression may continue to occur in individuals who are recovering from substance use disorders long after the physical withdrawal process is over. This means that individuals attempting to maintain successful recovery should continue to engage in a long-term program of treatment and recovery support in order to avoid relapse.