Case Report: Prolonged DAWS in an RLS patient under severe relational stress

TL;DR

A 51-year-old man with restless legs syndrome developed severe withdrawal symptoms after stopping dopamine agonists, with symptoms worsening during periods of personal stress.

Contribution

This case report highlights DAWS in RLS patients at low dopamine agonist doses and suggests relational stress may exacerbate symptoms.

Findings

DAWS occurred in an RLS patient on low-dose pramipexole, with severe withdrawal symptoms.

Relational stress episodes correlated with DAWS symptom relapses and increased severity.

The patient partially recovered after 13 months but still experiences RLS and fatigue.

Abstract

Dopamine agonist withdrawal syndrome (DAWS) is a severe condition reported primarily in Parkinson's disease (PD) but increasingly recognized in restless legs syndrome (RLS). While DAWS is classically associated with high-dose dopamine agonists (DAs) in Parkinson's disease, it has also been reported in RLS patients treated with low-dose therapy (≤ 0.75 mg pramipexole equivalent), although such cases remain rare. While direct evidence is lacking, psychological and relational stressors, in conjunction with prior medication adjustments, could plausibly modulate DAWS severity through a mechanism akin to kindling.

We describe the case of a 51-year-old male who developed severe DAWS after withdrawing from low-dose pramipexole (0.26 mg) prescribed for RLS. A 6-month venlafaxine taper, completed 2 weeks before DA tapering, may have increased neurochemical vulnerability. Initial dose reduction caused akathisia, tremors, panic attacks, RLS worsening, and depressive symptoms. After brief reinstatement, abrupt cessation triggered painful electric-like sensations in the lower back and emotional collapse. The patient was transitioned to rotigotine (2 mg/day), together with other psychotropic medications, which provided partial and temporary relief. Symptoms relapsed during tapering, with marked worsening occurring in parallel with episodes of severe relational stress within a close personal connection. Clinical assessments explored these interactions as potential psychological stressors, as reported by the patient. Given the temporal association between these stressors and symptom relapses, relational factors may have contributed to the severity and recurrence of DAWS episodes. At 13 months after complete DA discontinuation, the patient has regained nearly full functionality, although episodes of marked fatigue and significant bedtime RLS persists.

This case illustrates that DAWS can occur in RLS patients even at low DA doses, with atypical symptoms possibly involving autonomic and central sensitization. Relational stress may significantly exacerbate symptom severity, potentially leading to profound neurological destabilization through mechanisms such as cross-system hypersensitivity or a kindling-like process, as suggested by existing literature. This factor may need to be systematically assessed in DAWS management. As a rare patient-authored account, this report contributes to the understanding of DAWS in non-PD populations and highlights the need for longitudinal research to guide safer withdrawal protocols and integrated care.

Figures

Timeline of the patient's medication (orange) and of DAWS-related events (green).

Schematic representation of the kindling model in DAWS. This model illustrates how repeated dopamine agonist exposure, abrupt withdrawals, drug reinstatements, and cumulative stress can lead to progressive hypersensitization of neural circuits. The final outcome is DAWS severity escalation, characterized by long-lasting neurological dysfunction.

Tables

Table 1. Systematic chronological record of medication changes, clinical events, and observed outcomes in the management of DAWS.

Date	Medication / event	Notes / observations / diagnostic
Feb 1, 2023	Sifrol 0.38 mg (RLS), Bisoprolol 1.25 mg (POTS), Venlafaxine ER 112.5 mg (fibromyalgia/PTSD)	Initial treatment
Mar–Jul, 2023	Progressive Venlafaxine tapering (112.5–75–37.5–0 mg)	Transient withdrawal symptoms at dose reductions : hot flashes, excessive sweating, fatigue, muscle pain, mental blankness, brain zaps
Mar 13, 2023	Sifrol 0.38 mg replaced by Mirapexin ER 0.26 mg + Sifrol 0.19 mg
May 2023	Cessation of Sifrol 0.19 mg	RLS improved
Aug 2, 2023	Skipped one dose of Mirapexin ER 0.26 mg/day	Electric-like sensations, tremors, panic; resolved after reinstatement
Aug 15, 2023	Mirapexin ER tapered to 0.13 mg	Increased anxiety
Sep 2, 2023	First acute DAWS crisis
Sep 3, 2023	ED visit	Suspicion of DA withdrawal syndrome
Sep 4, 2023	Reinstatement of Mirapexin ER 0.26 mg	Partial relief
Oct 6, 2023	Cholecystectomy. Iron infusion (Ferinject 1,000 mg)	No relief of nausea and other DAWS symptoms
Oct 12, 2023	Gastroscopy	Stress-related antral gastritis
Oct 14–27, 2023	Hospitalization (psychiatry). Rivotril 0.5 mg, Arcoxia 80 mg; abrupt withdrawal of Mirapexin ER. Rivotril and Arcoxia stopped at discharge	DAWS symptoms markedly worsened after cold-turkey DA withdrawal, with strong suicidal ideation
Nov 6–20, 2023	Hospitalization (neurology). Neupro 2 mg, pregabalin 150 mg, alprazolam 1.5 mg, dipyridamole 75 mg, Tradonal ER 100 mg, Rivotril 0.5 mg; L4-L5 hernia
Dec 12, 2023	Neurology consultation. Neupro 1.8 mg, alprazolam 1.25 mg	Diagnosis: DAWS with hypersensitization to dopamine, serotonin, and noradrenaline, similar to opioid withdrawal
Jan 2024	Neupro 1.6 mg, dipyrimadole stopped, alprazolam 1 mg
Feb 8, 2024	Neupro 1.4 mg, alprazolam 0.75 mg, dipyridamole 0 mg
Feb 20–27, 2024	Hospitalization (neurology). Tradonal ER increased to 200 mg	DAWS exacerbation
Mar 2024	Neupro 1.2 mg, alprazolam quickly tapered by patient to 0 mg	Impulsive abrupt benzodiazepine discontinuation in context of ongoing DAWS
Mar 29–Apr 11, 2024	Hospitalization (neurology). Tradonal ER 2 x 100 mg. Transtec 35μg trial, stopped (sleep paralysis)	Decision to slow rotigotine tapering. Psychological assessment: suspicion of a maladaptive relational dynamic
May 8, 2024	Neurology consult. Neupro 1.15 mg, pregabalin 300 mg
May 23-Jun 7, 2024	Hospitalization (neurology)	Self-decreased Neupro to 1 mg; Wellbutrin XR 150 mg introduced (stopped soon after)
End Jun–end Aug, 2024	Phase of acute relational stress in long-term close personal connection → rupture
End Jun, 2024	Neupro self-tapered from 1 mg to 0.6 mg over 10 days
Jul 4, 2024	Neupro stopped completely by patient
Jul 17, 2024	Suicide attempt, ~60 drops clonazepam → ED visit	ED evaluation: normal; psychiatric assessment: distress in DAWS and complex relational context; discharge with follow-up
Jul 21–26, 2024	Hospitalization (neurology). Pregabalin 300 mg; Neupro reinstated at 1 mg
Jul 31–Aug 5, 2024	Hospitalization (neurology)	Neupro increased to 2 mg (refused); referred to other neurologist
Aug 27, 2024	Neurology consult (other hospital). Mirtazapine 15 mg trial failed; pregabalin 600 mg; venlafaxine 37.5 mg	DAWS confirmed
Sep 18–23, 2024	Hospitalization (nephrology). Acute prostatitis. Ciprofloxacin 1,000 mg until Oct 7
Sep 30–Oct 4, 2024	Hospitalization (neurology). Clonidine 0.15 mg trial failed; rotigotine 0 mg; iron infusion (Ferinject 1,000 mg)
Dec 2024	Baclofen (3 × 10 mg/day; no appreciable effect, discontinued after a few weeks)
Jan 2025	Significant stressor	Strong condition degradation
		Attestation of trauma bonding by therapist
Mar 2025	Suicide attempt. Rivotril 25 mg + 1 g Tradonal → ED visit	No psychological consultation; discharged
Feb–Jun 2025	Tapering of Rivotril from 0.5 mg to 0 mg
Sep 2024–Jun 2025	Gradual improvement with episodic acute collapses
From Jun 2025	Full functionality regained

Full text

Introduction

1

RLS is a chronic neurological disorder marked by an uncontrollable urge to move the legs, typically accompanied by uncomfortable sensations that worsen during rest and disrupt sleep (Allen et al., 2014). Although its pathophysiology remains incompletely understood, evidence points to dopaminergic dysfunction, impaired iron metabolism, and central nervous system hyperexcitability as key mechanisms (Xu et al., 2025). Sleep disorders are also highly prevalent in Parkinson's disease (PD) and encompass insomnia, RLS, REM sleep behaviour disorder and other disturbances that significantly impair quality of life (Taximaimaiti and Luo, 2021; Zhang et al., 2020). Large cohort data further show that RLS itself is associated with substantial mental and physical health burden and may be linked to increased cardiovascular risk (Wang et al., 2021).

Dopamine agonists (DAs), including pramipexole and rotigotine, are widely prescribed first-line treatments for RLS due to their effectiveness in reducing sensory discomfort (Trenkwalder et al., 2016). However, long-term DA therapy carries notable risks: augmentation (a paradoxical worsening of RLS), impulse control disorders, and other neuropsychiatric effects (Winkelman et al., 2016; Trenkwalder et al., 2018). Discontinuation attempts often result in withdrawal phenomena, among which dopamine agonist withdrawal syndrome (DAWS) is particularly severe.

DAWS is well recognized in patients with PD especially after discontinuing high-dose DAs (Rabinak and Nirenberg, 2010). It encompasses physical and psychiatric symptoms—including anxiety, depression, akathisia, autonomic dysregulation—that can persist for months and severely affect quality of life (Nirenberg, 2013). In contrast, DAWS remains underreported in non-PD populations, particularly RLS patients on low-dose therapy (Dorfman and Nirenberg, 2013; Shimo et al., 2015).

The pathophysiology of DAWS probably involves persistent dopaminergic dysregulation, serotonergic-noradrenergic imbalance, and limbic circuit dysfunction (Yu and Fernandez, 2017). While pharmacological risk factors dominate the literature, psychosocial stressors (including relational stressors) could plausibly exacerbate DAWS symptoms by activating the hypothalamic-pituitary-adrenal (HPA) axis and downstream alterations in dopaminergic signaling (Pruessner et al., 2004; Hollon et al., 2015; Koob and Volkow, 2016). However, this inference currently relies solely on the neurobiology of stress and addiction, rather than on DAWS-specific data.

We present a rare case of prolonged DAWS in a patient with RLS after withdrawal from low-dose pramipexole (0.26 mg), shortly after venlafaxine withdrawal. This case is notable for: (1) DAWS emerging at a dose rarely linked to the syndrome; (2) recent withdrawal of a serotonin and noradrenaline reuptake inhibitor (SNRI) drug that could increase vulnerability; and (3) marked exacerbation of symptoms coinciding with intense relational stress within a close personal connection. Unusual symptoms, such as persistent electric-like sensations in the lower back, were also observed.

This patient-authored report contributes to understanding DAWS beyond PD and highlights the potential impact of relational stress on its severity and chronicity.

Case description

2

Medical background

2.1

The patient is a 51-year-old male research scientist with no history of substance abuse or psychiatric hospitalization. In 1994, following a military peacekeeping mission, he developed symptoms consistent with postural orthostatic tachycardia syndrome (POTS), anxiety, and widespread pain, initially diagnosed as fibromyalgia and later reinterpreted as post-traumatic stress disorder (PTSD). Treatment with venlafaxine (225 mg) and bisoprolol (10 mg) led to long-term stabilization. Over time, he was able to reduce venlafaxine to a dose ranging between 37.5 mg and 112.5 mg, and bisoprolol to 1.25 mg.

In 2005, mild RLS symptoms appeared and progressively worsened. By 2020, the condition was clinically categorized as severe. A sleep study that year confirmed both severe RLS and moderate sleep apnea. Trials of CPAP, gabapentin, and pregabalin were largely ineffective or poorly tolerated. Pregabalin provided partial symptom relief but caused mild memory impairment and daytime sleepiness. In 2021, pramipexole (0.19 mg) was initiated as a potentially more effective alternative, and later replaced by extended-release pramipexole (0.26 mg) due to augmentation, with intermittent re-addition of 0.19 mg Sifrol. The sleep apnea was eventually well controlled using a nighttime mandibular advancement device.

DA withdrawal and early symptoms

2.2

In mid-2023, venlafaxine (112.5 mg) was tapered and discontinued over 6 months, with only mild withdrawal effects. During this period, RLS symptoms improved, allowing discontinuation of the add-on Sifrol. At the end of July 2023, the patient skipped one dose of pramipexole and experienced acute symptoms: electric-like sensations in the lower back, pelvic tremors, and panic. Symptoms resolved with reinstatement.

In August, the DA dose was halved. Initially tolerated, a full-blown DAWS episode emerged on September 2, marked by akathisia, crying, worsened RLS, nausea, and depression. A brief reinstatement offered partial relief. In early October 2023, during a period of diagnostic uncertainty, biliary dysfunction was suspected and a cholecystectomy was performed. When symptoms persisted and intensified, the patient was hospitalized, and pramipexole was abruptly discontinued during the inpatient stay. This led to a dramatic worsening, with severe neuropathic pain and suicidal ideation. The patient was rehospitalized in another service, where the clinical team recognized the presentation as DAWS and formally established the diagnosis.

Initial treatment and clinical evolution

2.3

Rotigotine (2 mg), clonazepam (0.5 mg), alprazolam (1.5 mg), extended-release (ER) tramadol (100 mg), and pregabalin (150 mg) were prescribed. A rotigotine taper (10%/month) was initiated. By end 2023, the patient regained significant functionality, except for recurrent anxiety episodes. However, from March 2024 onward, the patient's condition worsened in a stepwise manner, with each major deterioration coinciding with episodes of intense relational stress.

Increasing relational stress and symptom exacerbation

2.4

The patient reported that DAWS made a long-term close personal connection increasingly unstable from early 2024 onward. A hospital psychologist briefly considered the possibility of a maladaptive relational dynamic, although this interpretation was later withdrawn after individual discussions. The patient described a progressive reduction in the emotional support he perceived, with interactions he interpreted as invalidating or distressing.

During acute DAWS episodes, he acknowledged reacting with confusion, impulsivity, or abrupt communication, which appeared to heighten relational tension. Once stabilized, he reported apologizing, but felt that the other person remained affected and occasionally responded in ways he experienced as psychologically harmful.

While recognizing that the situation may have been psychologically challenging for both parties, the patient described a persistent sense of emotional unsafety and isolation that he perceived as exacerbating his symptoms. These relational tensions appeared, from the patient's perspective, to be temporally associated with worsening DAWS manifestations, including increased suicidal ideation. Several peaks of relational stress were followed by marked symptom deterioration requiring neurological hospitalization.

Acute collapse

2.5

By late June 2024, the patient's condition had markedly worsened, leaving him with near-complete functional incapacity. During this period, an emotionally destabilizing relational situation—characterized by a request for distance and a prolonged phase of uncertainty regarding the long-standing close personal connection—added psychological strain to an already critical clinical state. The patient experienced this evolving and unresolved situation as highly distressing, reporting intense psychological and affective destabilization.

Facing escalating symptoms and persistent functional decline, the patient progressively reduced his rotigotine dose from late June, motivated by severe adverse effects and a withdrawal-influenced belief that discontinuation was necessary, a belief he later recognized as shaped by cognitive and emotional dysregulation. He fully discontinued the medication in early July. Symptom severity further intensified, contributing to marked functional impairment. Approximately 2 weeks later, amid escalating symptoms and emotional dysregulation, the patient attempted suicide by clonazepam overdose.

By late August 2024, the relational disconnection appeared more definitive to the patient, although the extended period of uncertainty and intermittent contact had already contributed to significant psychological destabilization and symptom exacerbation.

In January 2025, the patient's psychotherapist documented features consistent with trauma bonding, in relation to a relational dynamic that the patient experienced as psychologically harmful.

Dopamine agonists cessation

2.6

The patient was rehospitalized at the end of July 2024. Rotigotine was briefly reinstated (1 mg/day) but rapidly lost effectiveness. Refusing dose escalation, he consulted an expert neurologist, recommended on an online forum. A structured withdrawal plan was implemented, increasing pregabalin to 600 mg and reintroducing venlafaxine (37.5 mg, then 75 mg).

DA cessation was achieved by late September 2024.

Behavioral dysregulation and gradual stabilization

2.7

Following the acute degradation of the long-standing close personal connection, the patient entered a period of marked emotional dysregulation. During the whole summer 2024, the patient experienced episodes of intense anxiety, intrusive ruminations, and an overwhelming need for reassurance, leading to impulsive repeated attempts to re-establish contact with the other person involved in the relationship. He retrospectively understood these behaviors as manifestations of DAWS-related distress and impaired impulse control rather than deliberate intention.

During this period, the patient reported alternating phases of confusion, desperation, and heightened sensitivity to perceived rejection. These symptoms gradually lessened after the acute phase of DAWS stabilization. By late 2024, although residual emotional reactivity persisted, the frequency and intensity of these behaviors had markedly diminished.

From early 2025 onward, the patient described a progressive return to baseline self-regulation. By May 2025, episodes of impulsive communication had ceased, and he reported a stable mood, coherent thought processes, and restored behavioral control. This timeline was consistent with the extended recovery trajectory described in severe or protracted DAWS cases.

Diagnostic assessment, therapeutic intervention, and follow-up

3

Diagnostic assessment

3.1

Following the abrupt discontinuation of pramipexole, the patient developed a constellation of symptoms—including akathisia, electric shock-like sensations in the lower back, tremors, panic attacks, and depressive episodes—that led to a neurological hospitalization in November 2023. A diagnosis of dopamine agonist withdrawal syndrome (DAWS) was established by the attending neurologist, based on clinical presentation, history of dopamine agonist exposure and withdrawal, and the exclusion of alternative diagnoses.

Comprehensive neurological investigations were conducted over the following months. These included magnetic resonance imaging (MRI) of the spinal cord, brain, and pelvis; computed tomography (CT) scans of the brain, pelvis, and lungs; and visual evoked potential testing. All results were unremarkable, ruling out structural, vascular, demyelinating, or oncological causes.

Given the persistent and fluctuating nature of the symptoms, particularly the electric-like spinal sensations and RLS exacerbation, a central sensitization process was considered likely. The absence of radiological or electrophysiological abnormalities supported a functional origin, potentially related to dopaminergic dysregulation and autonomic imbalance.

In parallel, the patient engaged in multiple psychotherapeutic interventions aimed at managing anxiety, neuropathic pain, depressive symptoms, and the persistent relational stress. These therapies included trauma-informed psychotherapy and supportive care; however, the treating clinicians were not familiar with complex psychotropic withdrawal syndromes such as DAWS.

No pharmacological or structural etiology beyond DAWS was identified. The temporal proximity of the 6-month venlafaxine taper raises the possibility that residual SNRI withdrawal could have contributed to some of the early anxiety and dysphoria. However, several features supported DAWS as the primary syndrome: (i) the close temporal association between pramipexole dose reductions or discontinuations and symptom exacerbations, (ii) the partial but consistent relief of symptoms after DA reinstatement, (iii) the persistence and fluctuating course of symptoms far beyond the usual time frame described for venlafaxine withdrawal, and (iv) the marked worsening of RLS during DA withdrawal contrasted with the transient improvement observed during the venlafaxine taper, which is consistent with reports that venlafaxine and other SNRIs tend to induce or exacerbate RLS rather than alleviate it (Kolla et al., 2018). In this context, we interpreted the preceding venlafaxine taper mainly as a factor increasing neurochemical vulnerability to DAWS rather than as an alternative primary diagnosis.

Therapeutic intervention

3.2

A detailed chronological record of all medication changes, hospitalizations, and related clinical events is provided in Table 1.

As explained in Section 2.3, initial pharmacological management included rotigotine (2 mg/day), pregabalin (150 mg/day), ER tramadol (100 mg/day, increased to 200 mg/day from February 2024, and benzodiazepines (clonazepam 0.5 mg/day); and alprazolam 1.5 mg/day, tapered and discontinued after 2 months). In addition to ER tramadol, the patient was prescribed 50 mg immediate-release tramadol tablets for breakthrough pain, with a maximum daily dosage of tramadol not exceeding 400 mg. These treatments provided partial relief but did not prevent recurrent symptom relapses, which often coincided with periods of relational stress.

A gradual rotigotine taper (approximately 10% per month) was initiated in late 2023. However, due to recurrent destabilizations, tapering was temporarily suspended. In an effort to accelerate symptom resolution—driven by increasing physical and emotional suffering—the patient occasionally deviated from medical advice by cutting larger portions of the rotigotine patch (up to 5%), against the neurologist's recommendation to pause tapering and allow neurophysiological recovery. Buprenorphine (Transtec patch) was trialed but discontinued due to the onset of sleep paralysis. The patient declined methadone, favoring non-opioid strategies, and also declined lamotrigine (an antiepileptic) to avoid further central nervous system–active medications.

Following a significant physical and psychological deterioration, and a medication-related suicide attempt in July 2024, his primary neurologist advised halting the taper and reinstating rotigotine at 2 mg/day or more. The patient refused. Instead, a neurologist with extensive experience in DA tapering proposed a structured and accelerated taper, combined with pregabalin up-titration and the reintroduction of venlafaxine (initially 37.5 mg/day, later 75 mg/day). Baclofen (3 × 10 mg/day) was introduced in December 2024 but had no appreciable effect.

Follow-up and outcomes

3.3

Following the DA cessation by late September 2024, the patient experienced a temporary stabilization after structured neurological guidance, increased pregabalin dosing, and the reintroduction of venlafaxine. Although an overall functional improvement was observed by October 2024, daily symptoms persisted and continued to fluctuate, particularly in response to emotional triggers associated with the recent rupture of the long-standing close personal connection.

The patient remained off dopamine agonists. His treatment included pregabalin (600 mg/day), venlafaxine (75 mg/day), ER tramadol (200 mg/day), and clonazepam, gradually tapered from 0.5 mg to 0 from Feb to Jun 2025. Immediate-release tramadol (50 mg) was used for breakthrough symptoms, with a daily maximum of 400 mg for tramadol.

Despite progress, the patient experienced several major relapses marked by intense physical pain, depressive symptoms, and the resurgence of trauma-related distress. On March 16, 2025, he attempted suicide by ingesting 25 mg of clonazepam and 1,000 mg of tramadol, requiring emergency intervention. This episode reflected the cumulative psychological burden of protracted withdrawal symptoms and unresolved trauma.

From Mar to Jun 2025, the patient continued to experience characteristic electric-like spinal sensations—initially pain-responsive to tramadol, later more neuropathic and treatment-resistant—pelvic tremors, muscular weakness, and chronic fatigue. He also reported increased sensitivity in previously injured areas and generalized musculoskeletal discomfort, raising the possibility of cross-system sensitization. Although emotional stability had improved and the trauma bond had weakened, pain crises still provoked transient depressive episodes. Neurological follow-up emphasized non-pharmacological strategies, including rest, light physical activity, stress minimization, and meditation.

From June 2025 onward, these neurological symptoms progressively resolved, with disappearance of spinal sensations and tremors, marked improvement in muscle strength, and gradual resumption of physical activity to near full functional capacity. As of December 2025, the patient still shows a significant vulnerability to stress, and remains prone to episodes of chronic fatigue, brief crises (hours) of exhaustion accompanied by urge-like contractions, and severe bedtime RLS attacks, which can be alleviated by tramadol. Psychologically, he reports residual post-traumatic stress symptoms, with mood fluctuations that have been progressively subsiding as recovery stabilizes.

Figure 1 shows the timeline of the DA withdrawal of the patient, including the global evolution of his medication and DAWS-related events.

Timeline of the patient's medication (orange) and of DAWS-related events (green).

Discussion

4

Recognition and management of DAWS in RLS patients

4.1

This case underscores the severity of DAWS in a patient treated for RLS, highlighting a gap in current clinical awareness. Although DAWS is well characterized in PD, its occurrence in non-PD populations remains under-recognized. Here, DAWS developed following the withdrawal of a relatively low dose of pramipexole (0.26 mg), indicating that even modest dopamine agonist exposures can trigger severe syndromes. Numerous patient reports on a RLS online forum (HealthUnlocked Community, 2025) describe similarly severe withdrawal symptoms following dopamine agonist tapering, suggesting that such cases may be more frequent than currently acknowledged in the scientific literature. Nevertheless, the present case appears unusually extreme in both intensity and duration compared to most of those patient testimonies.

The fluctuating and debilitating symptoms observed—including electric-like spinal sensations, akathisia, mood swings, and depressive episodes—were resistant to standard tapering protocols and required prolonged neurological and psychological support. Repeated hospitalizations and persistent impairment illustrate the syndrome's potential to cause long-term dysfunction even in patients without neurodegenerative disease.

In this case, the combination of low-dose DA withdrawal, erratic early medical management, and intense relational stress was associated with a progressive deterioration, culminating in a complete loss of functionality in an otherwise physically and intellectually active patient. The disruption not only resulted in the destruction of a long-term relationship but also left persistent physical and psychological sequelae, including chronic pain, trauma-related symptoms, and the need to taper four additional psychotropic medications. This illustrates the potential for DAWS to produce life-altering consequences even in non-neurodegenerative contexts, especially when compounded by psychosocial stressors and complex early treatment adjustments.

Given these complexities, we advocate for a multidisciplinary management approach combining neurology, psychiatry, and trauma-informed psychotherapy. Individualized tapering, psychological screening, and awareness of DAWS presentations in RLS populations are essential. Current treatment guidelines, largely extrapolated from PD care, may not be adequate for this distinct group of patients.

In similar cases, we recommend a structured treatment plan combining gradual DA tapering (≤ 10 % per month when possible) instead of abrupt changes, minimization of concurrent psychotropic changes, regular monitoring for psychosocial stressors, and a strong coordination between neurology, psychiatry, and psychotherapy services.

Psychological stress, trauma bonding, and neurochemical sensitization

4.2

This case also illustrates how relational dynamics perceived as psychologically destabilizing may interact with and worsen dopaminergic withdrawal. Between March and July 2024, each major episode of intense relational stress involving a long-standing close personal connection coincided with marked symptom exacerbation, sometimes requiring neurological hospitalization. The deterioration of the personal relationship of July 2024 was followed by a suicide attempt, and a second attempt occurred in March 2025 during a depressive relapse that the patient associated with persistent trauma-related attachment.

The concept of trauma bonding, often discussed in contexts involving perceived emotional inconsistency, invalidation, or chronic psychological strain, provides a framework for understanding the patient's heightened vulnerability. The observed cyclical pattern—emotional distress followed by neurological destabilization—aligns with evidence that sustained psychological stress can disrupt dopaminergic signaling, amplify HPA-axis activity, and increase neurochemical reactivity (Pruessner et al., 2004; McEwen, 2006; Pizzagalli, 2014; Hollon et al., 2015; Koob and Volkow, 2016).

This interaction may also relate to the concept of kindling—originally developed in epilepsy research (Goddard et al., 1969)—which describes how repeated subthreshold stressors or withdrawals can sensitize neural circuits to increasingly severe responses (Becker, 1998; Rothwell et al., 2010). In this case, multiple modifications of psychotropic drugs (venlafaxine withdrawal, DA discontinuation, abrupt reinstatements) and episodes of psychological trauma may have contributed to a progressive sensitization, as suggested by previous research (Post, 2007; Kostrzewa, 1995), culminating in severe episodes of DAWS.

Beyond a possible kindling-like sensitization of dopaminergic circuits, this case may also be consistent with the hypothesis of a broader neurochemical hypersensitization affecting multiple neurotransmitter systems—including serotonergic, noradrenergic, glutamatergic, and GABAergic pathways. The succession of psychotropic withdrawals (e.g., venlafaxine), abrupt reinstatements, and chronic stress may have contributed to a state of heightened excitability across several neurotransmitter networks, as described in prior studies (McEwen, 2006; Kalivas and Volkow, 2005; Nestler, 2013; Hollon et al., 2015). Such generalized sensitization, if present, could help explain the persistent vulnerability to stress, the recurrence of atypical sensory symptoms, and the difficulty in achieving long-term stabilization even after cautious pharmacological management by a specialist.

Figure 2 illustrates this hypothesis, showing how repeated psychotropic drug withdrawals, reinstatements, and chronic stress may have led to progressive sensitization, ultimately exacerbating DAWS severity.

Schematic representation of the kindling model in DAWS. This model illustrates how repeated dopamine agonist exposure, abrupt withdrawals, drug reinstatements, and cumulative stress can lead to progressive hypersensitization of neural circuits. The final outcome is DAWS severity escalation, characterized by long-lasting neurological dysfunction.

The patient perspective (see Section 5) provides additional insight into how psychosocial factors may influence DAWS symptom severity and recovery trajectories.

Misinterpreted symptoms and therapeutic pitfalls

4.3

The patient's fluctuating electric-like spinal sensations, triggered by stress and exacerbated upon waking, were among the most distressing and persistent symptoms. These sensations evolved from acute pain responsive to tramadol into neuropathic discomfort resistant to pharmacological intervention. Although neuropathic pain and akathisia are recognized features of DAWS, spinal sensory phenomena are rarely reported and may be underdiagnosed.

Such symptoms may reflect dopaminergic withdrawal-induced dysfunction in descending pain modulatory pathways or altered autonomic feedback loops. Their overlap with symptoms seen in dysautonomia or fibromyalgia suggests a broader role for autonomic dysregulation in DAWS pathophysiology (Novak, 2019; Clauw, 2014; Goldstein, 2014).

These complexities can lead to misinterpretation of post-withdrawal symptoms as a worsening of primary RLS, rather than as part of a transient hypersensitivity phase. In response, opioids such as methadone and buprenorphine are often introduced. However, initiating opioids during acute neurochemical instability may hinder intrinsic recovery, increasing the risk of long-term dependence (Garcia-Borreguero et al., 2013; Trenkwalder et al., 2018; Osório de Oliveira et al., 2016; Winkelman et al., 2023).

This case illustrates the importance of distinguishing DAWS-related symptom exacerbation from permanent RLS progression. When possible, delaying opioid initiation and supporting the nervous system through non-opioid, non-dopaminergic strategies may yield better long-term outcomes.

Implications for future research

4.4

This case highlights several avenues for future investigation.

First, systematic studies are needed to determine the prevalence and risk factors for DAWS in patients with RLS treated with low-dose dopamine agonists, a population in which the syndrome remains under-recognized.

Second, the course of this case suggests a possible interaction between psychosocial stressors and DAWS symptom trajectories, which warrants prospective evaluation using validated stress and symptom monitoring tools.

Third, given the protracted and severe course observed here, there is a need to evaluate personalized tapering strategies that integrate both pharmacological and psychosocial interventions, aiming to minimize withdrawal severity and functional impairment.

Finally, the clinical evolution suggests a potential kindling—like process, whereby frequent medication changes— including abrupt dose reductions and switches—possibly compounded by recurrent psychosocial stressors, may progressively exacerbate DAWS severity and prolong recovery. While such a phenomenon has been documented in other neurological and psychiatric contexts, its occurrence in DAWS remains hypothetical, with no direct neurophysiological evidence to date, and should be further investigated as a possible target for prevention.

Validity of the findings

4.5

While this single-case report cannot establish causality, several elements strengthen the validity of the interpretation presented. The diagnostic classification of DAWS was based on established clinical criteria and was confirmed independently by neurologists familiar with dopamine agonist withdrawal phenomena. The case further demonstrates a temporally coherent relationship between DA tapering and symptom trajectories, with deterioration following dose reductions and partial remissions after stabilization, suggesting a pharmacodynamically meaningful pattern.

The sequential withdrawal of multiple psychotropic agents, including venlafaxine, represents an important contextual factor that may have shaped vulnerability and early symptom expression. This report does not attempt to mechanistically disentangle overlapping withdrawal syndromes; instead, it highlights how cumulative neurochemical adaptations and stress exposure may interact to influence recovery trajectories in complex withdrawal presentations. Definitive differentiation would require longitudinal neurochemical or autonomic markers, standardized tapering frameworks, and systematic monitoring tools that are not yet established in current clinical practice.

The proposed sensitization and cross-system hypotheses should therefore be regarded as exploratory and hypothesis-generating. They are grounded in convergent frameworks from addiction neuroscience, stress physiology, and affective disorders, rather than DAWS-specific experimental evidence. Accordingly, the interpretations offered here aim to contribute to a broader understanding of DAWS in non-PD populations and to motivate future research into the potential role of relational stress and repeated psychotropic adjustments in shaping the severity and chronicity of DA withdrawal.

Strengths and limitations

4.6

This case report offers several strengths. It provides a rare, detailed longitudinal account of DAWS in a non-Parkinsonian patient, documenting both pharmacological and psychosocial factors over an extended follow-up. The dual perspective of a patient–author and clinician input allows for rich temporal resolution and contextual depth, which may help generate hypotheses for future research.

However, it also has important limitations. First, it describes a single patient, which limits the generalizability of the observations. Second, the clinical history is based primarily on patient self-report, making it susceptible to recall bias, particularly regarding the timing and severity of symptoms. Third, the proposed mechanisms—including psychosocial stress interactions, a possible kindling-like process, and cross-system hypersensitivity—are inferred from broader neurobiological evidence (e.g., addiction and withdrawal models) rather than DAWS-specific experimental data, and remain hypothetical in this context. Fourth, no objective neurobiological or neuroimaging measures were obtained to confirm the hypothesized pathways. Finally, the temporal association between medication changes, stressors, and symptom fluctuations does not establish causality. In addition, the temporal proximity of venlafaxine discontinuation represents an important confounder. Although several clinical features pointed toward DAWS as the primary syndrome, we cannot fully exclude a contributory role of SNRI withdrawal in the early phase of symptom development. Despite these limitations, the detailed account may provide useful insights into potential risk factors and pathophysiological processes in non-Parkinsonian DAWS.

Patient perspective

5

As both the patient and the author of this case report, I have experienced firsthand the complexity, severity, and clinical blind spots surrounding DAWS in non-Parkinsonian populations. Although DAs are often prescribed early in the management of RLS, my experience suggests they should be considered only as a last resort—after exhausting non-dopaminergic alternatives and thoroughly assessing the long-term risks.

One of the most difficult aspects of this journey was the lack of clear clinical guidance and the scarcity of physicians experienced in DA withdrawal management. I strongly encourage any patient planning to discontinue dopamine agonists to seek out a specialist familiar with DAWS. My condition worsened significantly during tapering attempts, underscoring the challenges of adapting available protocols to my clinical situation.

In retrospect, the relational environment also proved to be a critical, yet often overlooked, factor in my clinical trajectory. Emotional instability and perceived invalidation within a close relationship coincided with several relapses and complicated my recovery. In cases as fragile as DAWS, psychosocial stressors can act as powerful modulators of symptom intensity and duration. I believe the patient's relational context should be routinely assessed and taken seriously in treatment planning.

Despite the hardships, this experience has deepened my understanding of how biological and emotional factors intertwine in withdrawal syndromes—and the importance of addressing both with equal care. Looking ahead, my treatment plan is to gradually discontinue pregabalin, venlafaxine, and tramadol, aiming to achieve the lowest possible level of psychotropic medication.

Author's note

Descriptions of relational interactions in this case report reflect exclusively the patient's subjective perception at the time of the events. These accounts are included only to document psychological stressors potentially relevant to the clinical course. They do not imply factual assessment of another individual's behavior, and temporal details have been minimized to preserve privacy.