Warning signs of an imminent or ongoing relapse vary depending on the individual and the substance or behavior. Signs of a relapse may include increased cravings or urges, withdrawal symptoms, changes in mood or behavior, returning to old patterns of thinking or behavior, social withdrawal or isolation, neglecting self-care or responsibilities, and denying or rationalizing substance use or behavior.
What Is a Relapse?
A relapse can be challenging to pin down as definitions differ in how best to conceptualize it. There are varying opinions on what best constitutes a relapse. It has been contextualized both as a “discrete outcome” and “a process,” with definitions ranging from a return to any use or a return to original problematic use before treatment.1 The one piece that these definitions have in common is a discontinuation of abstinence and a return to a substance or becoming reengaged with a particular behavior after having previously stopped it. Relapse rates may vary with the definition of the concept, and in relation to type of study populations and time since treatment.2
A lapse is not as severe as a relapse and is the initial transgression of problem behavior after a quit attempt.3 A lapse is simply ingesting a substance or diving into the behavior after an individual has attempted to quit. A lapse is a distinct behavior and does not indicate that a relapse will follow.
Using the Stages of a Relapse as Warning Signs
Relapse is not sudden. It is a process that plays out in stages and occurs over time rather than as one discrete event. Each stage builds upon the last and increases the likelihood of a full-blown relapse. These stages include emotional relapse, mental relapse, and physical relapse.
These stages are different from intentional relapse, where an individual intentionally chooses to use again, and from “freelapse,” where an individual unintentionally relapses after being triggered by different people, places, or events. Intervention is always a possibility and the sooner one intervenes the less likely that a relapse will occur. Increasing self-care and using coping strategies and seeking support during can be great ways to prevent relapse.
The three stages of relapse are:
The emotional stage is the first stage of the relapse process. Individuals may begin to feel anxious, stressed, or overwhelmed, which can lead to a lack of self-care and an increase in negative emotions. Emotions become overwhelming and they can be difficult to control and manage. As a result, individuals get consumed by their emotions and can even neglect their self-care and have impaired ability to function at the same high level they did previously.
Negative emotions can result from internal or external stressors that are not properly managed. It can be easy to get burdened and overwhelmed resulting in impulsive behaviors that are difficult to manage.
Characteristics of the emotional stage of relapse include:
- mood swings
- poor self-care
- internalizing feelings
- increased cravings
- loss of interest
- increased stress and anxiety
- feelings of shame or guilt
The mental stage is the second stage of the relapse process. Individuals may begin to entertain thoughts of using again and may even start to plan for a relapse. Despite their desire to remain abstinent, individuals begin to have thoughts about using drugs or alcohol. Individuals may start to reminisce about past substance use or glamorize it, which can lead to feelings of nostalgia and longing.
The mental stage can be difficult to navigate as individuals may feel ambivalent about their desire to use drugs or alcohol. They may also experience a sense of internal conflict, as part of them wants to remain sober while another part of them wants to use again. Individuals may start to make plans for using, such as visiting old friends or places where they used to use.
Characteristics of the mental stage of relapse include:
- planning to relapse
- minimizing the possible consequences
- experiencing cravings
- romanticizing the substance
- over-thinking and rumination
- loss of control
The physical stage is the third and final stage of the relapse process. During this stage, people will actually begin using and may return to their prior level of use prior to abstinence. Individuals may feel that they can get away from their traumas and issues by starting to use substances again or engaging in risky addictive behaviors. Negative thoughts and cravings will become too much for the person to manage and they will act on these thoughts even despite knowing it is against their best interest.
This stage can be accompanied by physical withdrawal symptoms, as the body readjusts to the presence of drugs or alcohol. Withdrawal symptoms can be uncomfortable and even dangerous in some cases, and can include symptoms such as tremors, sweating, nausea, and seizures.
10 Signs of a Relapse
Although it is not always apparent, signs of a relapse to be aware of include changes in behavior or mood, physical signs of substance use, increased financial issues, and issues with work or social life. It is best to approach the concern in a non-judgmental way, allowing the person to feel like you are a safe place with which they can express themselves honestly.
Identifying when a loved one has begun to relapse is not always clear. The individual may be adept at hiding their substance use or addictive behaviors after years of shame and embarrassment from others. A person may be reluctant to admit that they have started to use again because they feel like a failure and believe no one will understand or help them further. The individual may also not be displaying overt signs and symptoms indicating anything new or concerning has arisen.
Here are 10 common signs of a relapse:
1. Stealing or Asking to Borrow Money
Acute financial hardship can be a sign that someone has relapsed. The person might not have enough money to support their habit and will rely on others to help enable their behavior. It is not always the need for money but the amount, speed at which they need it, and frequency with which they ask that are additional signs that addictive behaviors might have resumed.
When someone feels attacked, they can display defensiveness. A person may be defensive simply because they do not appreciate being questioned or not trusted. However, defensiveness may also be a sign that they have something to hide and hope that their anger and aggressive outbursts will make the other person feel bad for asking or back away completely.
3. Contacting Negative Influences
When giving up an addiction it is best to distance yourself from people that can cause a trigger and pull you into using again. If a person is in contact with previous relationships related to their addiction, they may be using their substance of choice again. This person may act as a pleasant reminder of times when they were feeling good and are reaching out hoping to recapture it.
Impulsivity can act as an early sign of relapse. As cravings and urges increase, individuals may use poor judgment and act without thinking in order to stop the cravings and anxiety and find peace. They are acting impulsively because they are not taking into account how their behavior can hurt themselves or others.
5. Missing work
If someone has relapsed, responsibilities such as work can be eschewed. It is easy to miss work if someone is experiencing a hangover or oversleeps because they are actively using and high. They may continue to go to work because of the need for money, but it is likely that it’s importance and significance as a priority in their life will drop as a result.
6. Changes in physical appearance
A person in a relapse is likely to not take care of themselves. Their main goal may be using the substance or engaging in addictive behavior. Their personal hygiene can suffer and they can look sleep deprived and malnourished. These changes can serve as an overt sign that someone is using, as it can serve as a stark contrast to what they previously looked like.
7. Isolation and withdrawal
A relapse can cause a person to pull away from friends and family. There might be a fear that they will be judged or shamed for using again or feel that everyone else won’t understand. It is difficult to maintain reciprocal relationships if you are in the active stage of addiction. It might likely be best for the person to surround themselves with others who support their habit.
8. Unrealistic expectations that they can moderate their addictive behavior
Moderation can serve as a realistic goal for individuals with addiction issues. However, this is not the case for everyone and some need an abstinence goal. The issue lies when the person who needs an abstinence goal believes they can manage similarly to if they moderated their addiction. When a person starts to believe that they “got it”, it might be a sign that a relapse is happening.
9. Changes in mood
Mood swings, including increased irritability, anxiety, or depression, can be a common sign of relapse. Drugs and alcohol impair emotional brain functioning and the ability to properly regulate emotions. Individuals are more likely to be irritable or anxious if they feel that others are checking up on them and instructing them how to live.
10. Disruptions in sleep and appetite
Substances affect a person’s ability to regulate their sleep and appetite properly. Substances affect hunger cues and they can present with increased or decreased appetite or changes in eating patterns. They may skip meals or forget to eat, or may engage in binge eating or overeating. Sleep can also become a low priority or something they engage in with increased frequency. Drugs and alcohol also prevent a person from having restful sleep, even if they sleep for hours due to the effects of the substances.
Risk Factors Leading to Relapse
As motivated and engaged as an individual might be to remain abstinent, they must always remain vigilant of risk factors that can pull them back to their addiction. Risk factors can be external, such as people, places, events, or attitudes, or internal states and emotions that can overwhelm. For example, depression and situations involving negative mood have been associated with poorer prognosis and are among the most frequently cited precipitants of relapse across several substances.4
Risk factors may pop up depending where the person is in treatment or they may be in the background and in need of constant management. Acute and chronic stress may be an internal state that is always present and has major implications on the motivation to abuse addictive substances.5 Risk factors will usually become prevalent from days to months before the relapse occurs. Although it can look like it came out of nowhere, there are likely signs that a return to addiction was highly probable.
Risk factors that can trigger a relapse include:
- Negative mood states: Depression and anxiety can cause an individual to return to addiction as it can bring about hopelessness and cognitive distortions. Seeking treatment for underlying affective states can be a protective factor for addiction.
- Stress: Stress can be overwhelming and has long been known to increase vulnerability to addiction.5 Reducing stress by using coping skills will be necessary to decrease the chances of relapse.
- Interpersonal conflicts: Interpersonal conflict can drive a person away from their support system, increasing the chances they won’t have others to lean on. This conflict can be improved with communication skills, boundary setting, and making sure you have a robust system in place.
- Peer pressure: Individuals may feel peer pressure to engage in substance use or other risky behaviors in order to fit in or avoid social rejection from others. It is important to identify your values and personal goals, communicate assertively and respectfully with peers, seek out positive social support and relationships, and practice refusal skills.
- Lack of social support/isolation: Not feeling supported or having others to help you feel like you belong can increase the chances of relapse. Individuals can prioritize building and maintaining supportive relationships, participate in social activities and groups, reach out to loved ones, and engage in hobbies or activities that bring them joy and a sense of purpose.
- Physical pain: Substances can be a great way to avoid and escape pain. They can dull the senses in the brain and make living with acute or chronic pain tolerable. Pain should be managed rather than dulled and it is best to consult your doctor about potential non-narcotic ways of dealing with pain.
- Low self-efficacy/Low self-esteem: Not believing in yourself to weather the stressors without substance use can be too much. This can be addressed by practicing self-compassion and positive self-talk, setting achievable goals, and engaging in activities that promote feelings of competence and accomplishment.
- Positive moods/overconfidence: Individuals may feel a false sense of security and underestimate the power of triggers or stressors. Practicing mindfulness and self-awareness, recognizing and preparing for potential triggers or stressors, and developing coping strategies and a relapse prevention plan can all be helpful in alleviating any overconfidence.
Responding to Signs of a Relapse
Intervention is best when it is initiated at the first sign of distress. The sooner action is taken after noticing the first signs of relapse, the better chance there is to reduce the chance of physical relapse and the individual staying abstinent and healthy. It is not uncommon for individuals in and after treatment to make several lapses or relapses. Thus, there may be multiple interventions before a lasting change is achieved.
Once signs of relapse have been identified, it’s important to take action. This may involve engaging the individual in open and honest communication. Family and friends can provide a safe and supportive space for individuals to talk about their struggles and concerns, which can help them feel less isolated and more motivated to seek help. Addiction treatment providers can offer support through therapy or counseling as a first step of what to do after a relapse. Responding to signs of relapse requires a collaborative effort.
Some steps you can take to help a loved one after a relapse include:
- Find them a support group: This can provide a safe and supportive environment to share experiences, gain encouragement and accountability, and receive guidance and advice from peers. It is best to research a group that best meets your specifications.
- Provide a safe place to avoid triggers: Staying away from triggers is one of the easiest ways to avoid relapsing. An environment free from triggers and stressors can reduce risky behaviors and substance use. Identify potential triggers and stressors and create a physical or virtual space that promotes relaxation and calm.
- Help them maintain healthy boundaries: Maintaining healthy boundaries can help individuals prioritize their own needs, values, and goals. To create boundaries, people can identify their personal values and goals, communicate assertively with others, and say “no” to requests or situations that may be harmful.
- Develop a relapse prevention plan: This plan can help reduce the risk of relapse by providing a structured approach to identifying potential triggers and stressors, developing coping strategies, and taking steps to prevent relapse. A plan is created after identifying triggers and warning signs and identifying supportive people or resources.
- Suggest intensive outpatient therapy: This type of therapy can act as a structured and supportive environment to address underlying issues and develop coping strategies to manage triggers and stressors. Find a program that meets your needs and goals and where you feel comfortable spending many hours and days.
- Avoid enabling behaviors: You should avoid this type of behavior, which is characterized by giving your loved one money or covering up for them. This can prevent them from facing the consequences of their actions and hinder their recovery. Draw strict boundaries and set out expectations of how you will and won’t help.
- Be patient: Since recovery is a process, it can take time. Avoid placing undue pressure on them to recover quickly or make them feel like they are doing something wrong.
- Offer hope and encouragement: Encouragement is a big need to prevent relapse. Hope allows the person to stay positive and give them a sense of a future. Believing in them will have dramatic effects in increasing their ability to believe in themselves.
Relapse can sometimes seem unexpected but with the right knowledge of warning signs, you can help support your loved one to maintain their abstinence and support them should lapses and relapses arise. The signs of relapse are not always obvious but making sure you are educated about the risk factors and warning signs will better prepare you for the unknown. Not everyone may want or appreciate your help. One of the best acts we can provide is offering a safe, nonjudgmental space and allowing them to come to us when ready.