What is Alcohol Withdrawal?

Alcohol withdrawal refers to a collection of symptoms that arise when a person who is physically dependent on alcohol abruptly stops drinking or significantly reduces their alcohol consumption.

Symptoms of alcohol withdrawal include tremors, profuse sweating, anxiety, irritability, restlessness, increased heart rate, blood pressure, sleep disturbances, delirium tremens, hallucinations, and seizures.

The timeline of the alcohol withdrawal unfolds over several days in different stages. The stages progress, starting from mild symptoms such as tremors and anxiety within 6 hours after the last drink. More severe symptoms, such as hallucinations and seizures, appear between 12 to 48 hours. The most critical phase occurs between 48 to 72 hours, leading to delirium tremens (DTs), a potentially life-threatening condition. The timeline and severity vary based on the individual’s drinking history and health.

What is alcohol withdrawal?

Alcohol withdrawal refers to the clinical syndrome characterized by physical and psychological symptoms that occur when individuals who have been consuming alcohol heavily or for a prolonged period suddenly reduce or cease their intake. When alcohol is abruptly discontinued, the central nervous system (CNS), having adjusted to its sedative effects, becomes overactive. This heightened activity results in a range of withdrawal symptoms.

According to the research article “Introduction to Alcohol Withdrawal” by Richard Saitz published in the journal Alcohol Health and Research World in 1998, sudden cessation of alcohol leads to disruption in the neurotransmitter balance of the brain. Chronic alcohol use enhances inhibitory effects via gamma-aminobutyric acid (GABA) and increases excitatory activity through glutamate. When alcohol is removed, this imbalance causes brain hyperactivity, resulting in withdrawal symptoms such as tremors, seizures, and delirium tremens (DTs), with severity depending on the level of alcohol addiction.

What is delirium tremens?

Delirium tremens is a serious form of alcohol withdrawal that leads to sudden and intense disruptions in mental and nervous system functions. First recognized in 1813 as related to heavy alcohol use, it generally affects individuals who have been drinking heavily for a prolonged period and then abruptly stop or drastically cut back. While not as common as other withdrawal symptoms, delirium tremens is a medical emergency because of the severity of its manifestations, which include severe anxiety, confusion, shaking, paranoia, hallucinations, profuse sweating, elevated body temperature, heart palpitations, and high blood pressure.

Delirium tremens has a mortality rate ranging from 5 to 25 percent, as disclosed in the article “Complications of Alcohol Withdrawal” authored by Louis A. Trevisan et al. and published by the Alcohol Health and Research World Journal in 1998.

What percentage of people with alcoholism experience alcohol withdrawal?

59.3% of people with alcoholism experience alcohol withdrawal symptoms, according to an article titled “A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component” authored by M. A. Schuckit et al. published in the journal Alcoholism, Clinical and Experimental Research in 2003. This study assessed alcohol dependence using the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM -IV) criteria and found that a significant proportion of individuals with alcohol dependence reported experiencing withdrawal symptoms. These findings underscore the prevalence of withdrawal as a critical component in the clinical profile of alcohol dependence, highlighting the importance of monitoring and treating alcohol withdrawal to mitigate its impact on health outcomes.

In another review article “Recognition and Management of Withdrawal Delirium (Delirium Tremens)” by Marc A. Schuckit published in The New England Journal of Medicine in 2014, it is noted that approximately 50% of individuals with alcohol-use disorders (AUDs) experience withdrawal symptoms after cessation or reduction in consumption of alcohol.

Who is most commonly affected by alcohol withdrawal?

Individuals most commonly affected by alcohol withdrawal are those who have been consuming substantial amounts of alcohol daily, often exceeding eight drinks per day, over a prolonged period. According to the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), published by the American Psychiatric Association in 2013, individuals with a prior history of alcohol withdrawal, or those with conduct disorder and antisocial personality disorder are particularly at high risk.

Additionally, individuals who concurrently use sedative-hypnotic drugs, suffer from underlying medical conditions or have genetic predispositions experience more severe symptoms of withdrawal. Besides these, other factors that predict severe withdrawal include past episodes of alcohol withdrawal delirium, low potassium levels in the blood, reduced platelet counts, and elevated blood pressure.

What are the symptoms of alcohol withdrawal?

The symptoms of alcohol withdrawal are listed below.

• Tremors: Tremors observed in hands or other body parts are a common sign of alcohol withdrawal. The tremors occur as the body struggles to adapt to the absence of alcohol. According to Roger L. Weir’s research article titled “Extrapyramidal Dysfunction in Alcoholism” published in the Journal of The National Medical Association in 1980, these tremors are similar to normal tremors but are more pronounced due to anxiety. Tremors are one of the most frequent neurological problems during withdrawal, often starting 10 to 20 hours after stopping drinking.
• Profuse sweating: Profuse sweating, particularly on the palms and face, is a common early symptom of alcohol withdrawal. Alcohol consumption stimulates both the circulatory and central nervous systems, which results in an elevated heart rate. This elevation in heart rate causes the blood vessels to dilate, resulting in increased sweating. During withdrawal, the body’s intensified response to the absence of alcohol further amplifies this sweating, making it more noticeable than under normal circumstances.
• Anxiety, irritability, and restlessness: People in withdrawal frequently experience anxiety, restlessness, and irritability. This is attributed to the brain’s dependency on alcohol to regulate mood and stress hormones like cortisol.
• Increased heart rate and blood pressure: During alcohol withdrawal, individuals commonly experience tachycardia (a rapid heartbeat) and hypertension (elevated blood pressure). Normally, alcohol functions as a central nervous system depressant, however, during withdrawal, the absence of alcohol causes the nervous system to become overstimulated. This leads to an increase in heart rate and blood pressure, as the body tries to regain balance.
• Sleep disturbances: Difficulty falling or staying asleep is a hallmark of alcohol withdrawal. Alcohol initially has a sedative effect, but its absence causes rebound insomnia, as the brain struggles to return to normal sleep patterns. A 2010 report “Substance Abuse Treatment Advisory: News for the Treatment Field Protracted Withdrawal” published by the Substance Abuse and Mental Health Services Administration (SAMHSA), shows that sleep difficulties last for 1 to 3 years after stopping alcohol consumption.
• Delirium tremens: Delirium tremens is a severe and life-threatening form of alcohol withdrawal, which usually develops 48-72 hours after cessation of alcohol consumption, as outlined in the research article “Delirium Tremens: Assessment and Management” by Sandeep Grover and Abhishek Ghosh published in the Journal of Clinical and Experimental Hepatology in 2018.
• Hallucinations: Alcohol withdrawal leads to visual, auditory, or tactile (itching or numbness) hallucinations, usually emerging within 12-24 hours after stopping alcohol consumption. According to Richard Saitz in his 1998 research article, “Introduction to Alcohol Withdrawal” published in the journal Alcohol Health and Research World, individuals who consumed the largest quantities of alcohol were more likely to experience hallucinations.
• Seizures: Seizures are a serious manifestation of alcohol withdrawal, and typically arise from the dysregulation of the brain’s electrical activity when alcohol is no longer present. According to the 2017 study, “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management,” by S. Jesse et al. published in the journal Acta Neurologica Scandinavica, over 90% of acute symptomatic seizures develop within 48 hours of stopping prolonged alcohol use. These are usually generalized tonic-clonic types of seizures.

What are the causes of alcohol withdrawal

The causes of alcohol withdrawal are listed below.

• Sudden alcohol cessation and reduction: Alcohol withdrawal is primarily caused by the sudden cessation or significant reduction of alcohol consumption in individuals who have been drinking heavily over a long period. According to the research article “Introduction to Alcohol Withdrawal” authored by Richard Saitz published in the journal Alcohol Health and Research World in 1998, the brain, accustomed to alcohol’s depressant effects, becomes overly excitable when alcohol is abruptly withdrawn. This imbalance occurs due to the reduced inhibitory action of gamma-aminobutyric acid (GABA) and heightened glutamate stimulation, leading to central nervous system hyperactivity. The resulting withdrawal symptoms range from mild anxiety and tremors to severe seizures and delirium tremens.
• Chronic drinking habit: Individuals who have alcoholism for a long period are at a higher risk of developing alcohol withdrawal. The article “Alcohol withdrawal in past-year drinkers with unhealthy alcohol use: Prevalence, characteristics, and correlates in a national epidemiologic survey” by Ofir Livne et al. published in the journal Alcoholism, Clinical and Experimental Research in 2022, found that 14.3% of respondents with unhealthy alcohol use met the criteria for alcohol withdrawal syndrome (AWS). The study showed that individuals with prolonged and heavy alcohol consumption are at higher risk of developing AWS when they stop drinking.
• Tolerance and physical dependence: With prolonged alcohol use, the body develops tolerance requiring increasingly larger amounts to achieve the same effects as before. This tolerance results in physical dependence, where the body becomes reliant on alcohol to function properly, causing a severe shock to the system when alcohol intake is reduced or stopped.
• Previous withdrawal episodes: According to the research article “Kindling in Alcohol Withdrawal” by Howard C. Becker published in the journal Alcohol Health and Research World in 1998, individuals who have experienced withdrawal before are more likely to suffer from more severe withdrawal symptoms. This phenomenon is known as “kindling,” where repeated withdrawals sensitize the brain, increasing the severity of symptoms.

What is the timeline of alcohol withdrawal?

The timeline of alcohol withdrawal typically progresses through several stages with symptoms appearing within hours after the last drink and potentially lasting for several days. These alcohol withdrawal stages are clearly defined in the research study, “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management,” by S. Jesse et al. published in the journal Acta Neurologica Scandinavica in 2017.

In the early stages of alcohol withdrawal, typically around 6 hours after the last drink, mild symptoms appear that include tremors, hyperactivity, insomnia, and headaches. Despite these symptoms, patients typically remain fully conscious and oriented. This stage, often called “minor withdrawal,” lasts between 4 to 48 hours and marks the initial phase of alcohol withdrawal.

As alcohol withdrawal progresses into the moderate phase, lasting between 12 and 24 hours, symptoms become more severe. Individuals while remaining conscious experience visual, tactile, or auditory hallucinations. These hallucinations and illusions persist for up to 6 days.

Between 24 to 48 hours after the last drink, the risk of acute symptomatic seizures significantly increases. Hallucinations become more intense, and illusions become more pronounced. The individual experiences increased disorientation, agitation, and confusion. Symptoms from earlier stages, such as tremors, nausea, and anxiety, either persist, worsen, or resolve. However, the added risk of seizures during this period poses a serious medical concern, marking a critical window where medical intervention is often necessary to prevent further complications.

The most severe phase of alcohol withdrawal, known as delirium tremens (DT), typically begins 48 to 72 hours after the cessation of drinking. This stage is characterized by severe psychiatric symptoms, such as paranoia, disinhibition, and awareness disturbances, often accompanied by confusion, fever, and a rapid heart rate. Delirium tremens is life-threatening, and without treatment, it lasts up to two weeks, marking the final and last stage of withdrawal.

As alcohol withdrawal progresses, the risk of unprovoked seizures persists even after the initial acute phase. These seizures occur between 6 and 48 days after the last drink, indicating the potential for prolonged withdrawal symptoms and complications.

Withdrawal symptoms typically start to improve after 72 hours and are likely to resolve completely within 4 to 7 days. However, certain individuals continue to experience lingering symptoms such as difficulty sleeping and changes in mood for several weeks or even months.

When does alcohol withdrawal start?

Alcohol withdrawal starts within 6 to 12 hours after a person’s last drink. The exact timing varies based on factors such as the duration and intensity of alcohol use, individual physiology, and previous withdrawal experiences. According to the study “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management,” by S. Jesse et al. published in the journal Acta Neurologica Scandinavica in 2017, withdrawal symptoms start as early as six hours after the cessation of prolonged heavy drinking and typically peak within 24 to 72 hours. This timeframe is consistent with clinical observations and helps guide medical supervision and intervention to manage withdrawal safely.

How long does alcohol withdrawal last?

Alcohol withdrawal typically lasts between 2 to 10 days, as supported by the World Health Organization’s (WHO) 2009 guidelines, detailed in the chapter “Withdrawal Management” of the book Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. After the initial two-week period, the symptoms typically shift to being primarily psychological and continue for several months in certain individuals.

What are the side effects (complications) of alcohol withdrawal?

The side effects (complications) of alcohol withdrawal are listed below.

• Withdrawal seizures: Alcohol withdrawal seizures are potentially life-threatening complications in individuals dependent on alcohol. These seizures are typically generalized tonic-clonic, characterized by sudden loss of consciousness and intense muscle contractions, making them particularly dangerous during alcohol withdrawal.
• Wernicke-Korsakoff syndrome (WKS): WKS is associated with a deficiency of thiamine (vitamin B1) during alcohol withdrawal and is marked by cognitive impairment, delirium, and memory disorders. According to a research article “Complications of Alcohol Withdrawal” by Louis A. Trevisan et al. published in the journal Alcohol Health and Research World in 1998, approximately 80% of alcoholic patients recovering from Wernicke’s syndrome later develop Korsakoff’s syndrome, which is characterized by a selective memory disturbance.
• Alcoholic hallucinosis: Alcoholic hallucinosis is a rare but significant complication of alcohol withdrawal, characterized by vivid and distressing hallucinations—sensory experiences of things that are not present. It typically occurs in chronic alcohol users who abruptly stop drinking. Unlike delirium tremens (DTs), alcoholic hallucinosis primarily involves hallucinations without delirium (i.e., without confusion or disorientation).
• Cardiovascular complications: Alcohol withdrawal triggers arrhythmias (irregular heartbeat) and sudden cardiac events, especially after binge drinking, as outlined in the article “Effects of alcohol withdrawal on the cardiovascular system” by Seppo Kähkönen et al. published in the journal Progress in Neuro-Psychopharmacology and Biological Psychiatry in 2011.
• Delirium tremens (DTs): DTs are a severe complication of alcohol withdrawal. Consuming large amounts of alcohol daily for several months—such as more than four pints of wine, seven to eight pints of beer, or half a liter of hard liquor—greatly increases the risk of developing DTs, which primarily affect individuals with prolonged excessive alcohol use.
• Disturbances of thought, mood, and perception: Alcohol withdrawal leads to psychiatric disturbances including anxiety, depression, and sleep issues. Palpitations and hyperventilation accompany anxiety symptoms. Depression presents with a heightened risk of suicidal ideation (SI), especially during the early stages of withdrawal. Sleep disturbances such as difficulty falling and staying asleep, persist for weeks, thereby affecting daytime functioning.

Can alcohol withdrawal be fatal?

Yes, alcohol withdrawal can be fatal, especially if it progresses to severe forms such as delirium tremens (DTs), seizures, or Wernicke encephalopathy. According to the article “Alcohol Withdrawal Syndrome” by Bethany R. Canver et al. published in the book StatPearls updated in 2024, alcohol withdrawal presents a significant clinical challenge, with severe cases potentially resulting in life-threatening complications. The article highlights that a lack of thiamine deficiency leads to Wernicke encephalopathy, which is a serious neurological condition that, in its most severe form, is fatal. This condition is marked by ocular disturbances, confusion, and ataxia, underscoring the significant need for early intervention and proper management during alcohol withdrawal.

Alcohol withdrawal delirium, previously known by the name delirium tremens (DTs) is the most dangerous manifestation of alcohol withdrawal, characterized by symptoms such as agitation, tachycardia, fever, disorientation, hypertension, and hallucinations. It typically occurs 3 to 8 days after alcohol cessation and affects approximately 3% to 5% of patients experiencing alcohol withdrawal. If left untreated, this condition proves fatal. Historically, the mortality rate of delirium tremens has been as high as 20%, though modern medical intervention has reduced this risk to around 1%.

What are the treatments for alcohol withdrawal?

The treatments for alcohol withdrawal are listed below.

• Medically-assisted detoxification (MAD): MAD is a supervised process that helps individuals safely withdraw from alcohol, using medications to manage withdrawal symptoms. Healthcare professionals monitor vital signs and adjust medications to ensure safety. While it provides a supportive environment for successful detox, it’s only the initial phase of inpatient addiction treatment. Medications used in MAD include benzodiazepines such as chlordiazepoxide and diazepam. However, in cases of co-morbidities, shorter-acting medications such as lorazepam and oxazepam are utilized. A key component of MAD is medication tapering, which involves gradually reducing the dose of medications to minimize alcohol dependence and reduce withdrawal symptoms like anxiety, tremors, or seizures. As outlined in the research article “Clinical management of alcohol withdrawal: A systematic review” by Shivanand Kattimani and Balaji Bharadwaj, published in the Industrial Psychiatry Journal in 2013, benzodiazepines, such as diazepam is commonly preferred due to its calming effects while lorazepam is noted for its ability to prevent severe symptoms such as seizures.
• Outpatient treatment: Before the 1980s, alcohol withdrawal syndrome was typically treated in inpatient settings. However, by the mid-1990s, people were able to get treatment in outpatient settings. According to the article “Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond” by Ankur Sachdeva et al. published in the Journal of Clinical & Diagnostic Research in 2015, it is found that no serious medical complications were observed in outpatient treatment. Individuals with mild to moderate alcohol withdrawal syndrome are safely treated in an outpatient setting, provided there are no contraindications such as a high risk of delirium tremens, or a history of seizure.
• Emergency care: According to the article “Alcohol Withdrawal Syndrome” by Bethany R. Canver et al. published in the book StatPearls updated in 2024, patients experiencing worsening symptoms during alcohol withdrawal need to seek immediate medical attention at an emergency department. Symptoms such as severe agitation, confusion, seizures, or hallucinations signal that the withdrawal process is becoming more serious and requires urgent intervention. Early evaluation and treatment are important in preventing life-threatening complications like delirium tremens or seizures. In a hospital setting, healthcare professionals provide the necessary interventions to stabilize the patient and manage the withdrawal process safely.
• Nutritional and electrolyte management: Individuals undergoing alcohol withdrawal are often deficient in essential nutrients. Administering thiamine and folate supplements, along with electrolytes such as magnesium and phosphorus, is therefore important. During a blood test, if an acid-base imbalance, specifically anion-gap metabolic acidosis, is detected, it is indicated that the individual has ketoacidosis. In response, treatment is administered using glucose-containing fluids, such as dextrose 5% in normal saline.
• Behavioral therapy: Behavioral therapies constitute psychological interventions designed to modify behavior patterns related to substance abuse. They play a vital role in alcoholism treatment by addressing the psychological aspects of withdrawal and promoting long-term behavioral changes. The effectiveness of cognitive-behavioral therapy (CBT) is supported by a study titled “Cognitive-Behavioral Therapy for Substance Use Disorders,” conducted by R. Kathryn McHugh et al. and published in the journal Psychiatric Clinics of North America in 2010. The research indicates that CBT is effective both as a primary treatment and in combination with other interventions such as motivational interventions, contingency management, and relapse prevention.

How do you overcome alcohol withdrawal symptoms?

Overcoming alcohol withdrawal symptoms requires a comprehensive approach to manage both physical and psychological aspects. Start by seeking professional medical guidance from experienced healthcare providers. Establish a support system that includes friends, or family for emotional support. Incorporate healthy habits, such as eating nutritious foods, exercising, and getting adequate sleep, to help alleviate withdrawal symptoms like mood swings. If appetite is low, consider taking a multivitamin or drinking electrolyte-rich beverages, such as sports drinks. Continue taking any prescribed medications as directed by your doctor.

Utilize relaxation methods like deep breathing, meditation, or mindfulness to help with stress and anxiety. Stay hydrated, maintain a balanced diet, and communicate openly with your healthcare team to ensure your treatment plan is effective and adjusted as necessary.

How do you support someone going through alcohol withdrawal?

To support someone going through alcohol withdrawal, assistance is needed on both emotional and practical levels. Ensure they have professional medical care, as withdrawal is difficult. Offer a non-judgmental space for them to express their struggles and encourage participation in support groups like Alcoholics Anonymous (AA) or therapy. Promote healthy coping mechanisms, recognize their progress, and help reduce exposure to stressors or triggers. Be patient, and provide them reassurance and encouragement throughout their recovery journey.

 

 

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