Symptoms and signs of alcohol withdrawal
Symptoms and signs of acute alcohol withdrawal usually appear within 6 to 24 hours of the last drink, peak by about 48 to 72 hours, and wane over up to 5 daysSchuckit, 2009. Symptoms that persist beyond 7 days after the last drink are not likely to be caused by acute alcohol withdrawal; they are likely to reflect comorbidities, such as anxiety disorders, which may be precipitating factors for drinking. For an illustration of the progression of alcohol withdrawal over time, see the Guidelines for the Treatment of Alcohol Problems.
Most people have only mild to moderate symptoms and signs of alcohol withdrawal such as anxiety, insomnia, tremor, mild sweating, headache, nausea and vomiting.
More severe symptoms and signs of alcohol withdrawal include agitation, marked sweating, seizures, perceptual disturbances, and delirium. Delirium tremens is rareSchuckit, 2009; a patient may use the term ‘DTs’ incorrectly to describe withdrawal tremors experienced on waking (without delirium). Recognising that these are different entities is important to avoid undue alarm when assessing the risk of severe withdrawal. Predictors of severe alcohol withdrawal are listed in Predictors of severe or complicated alcohol withdrawal. A history of severe alcohol withdrawal is typically a good clinical predictor of risk during a new episode of alcohol withdrawal.
Rarely, withdrawal can be life threatening if severe features go untreated.
Wernicke encephalopathy is an important comorbidity and differential diagnosis to consider in alcohol withdrawal; see Thiamine supplementation and Wernicke-Korsakoff syndrome in alcohol dependence for discussion of diagnosis, management and prevention.
a history of moderate to severe alcohol withdrawal, especially multiple bouts
current acute medical or surgical illness
current acute mental illness, such as anxiety [NB1]
severe comorbidity that might be destabilised (eg chronic liver disease, chronic obstructive pulmonary disease), seizure disorder or suspected lowered seizure threshold
history of memory blackouts (acute memory loss during alcohol intoxication)Maldonado, 2014
cognitive impairment
early-morning drinking to alleviate withdrawal symptoms (anxiety, nausea, tremor)
use of more than one substance (polysubstance use), particularly benzodiazepines, but also opioids, stimulants
in older patients or those with polysubstance use, an intake of more than 8 standard drinks of alcohol per day [NB2]
NB1: Alcohol withdrawal in a person with an anxiety disorder causes escalation in anxiety levels. Many of the signs monitored on an alcohol withdrawal scale are also exacerbated by anxiety (tremor, tachycardia, sweating). The usual duration of the acute alcohol withdrawal phase is 2 to 3 days. Anxiety that persists longer is often misinterpreted as persisting acute withdrawal, leading to prolonged use of the alcohol withdrawal scale and excessive administration of diazepam.
NB2: In other patients, the feature of early-morning drinking to alleviate withdrawal is more relevant than the number of drinks per day.