Alcohol withdrawal syndrome

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Alcohol Withdrawal Syndrome
Classification and external resources
ICD-10F10.23, F10.23(0-9)



Signs and symptoms


Withdrawal usually begins 6 to 24 hours after the last drink.[3] It can last for up to one week.[4] To be classified as alcohol withdrawal syndrome, patients must exhibit at least two of the following symptoms: increased hand tremor, insomnia, nausea or vomiting, transient hallucinations (auditory, visual or tactile), psychomotor agitation, anxiety, tonic-clonic seizures, and autonomic instability.[5]

The severity of symptoms is dictated by a number of factors, the most important of which is degree of alcohol intake, length of time the individual has been using alcohol, and previous history of alcohol withdrawal.[5] Symptoms are also grouped together and classified:

  • Delirium tremens: hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness, and visual and auditory hallucinations.[5] This usually occurs 24 to 72 hours after alcohol cessation. Delirium tremens is the most severe form of withdrawal and occurs in 5 to 20% of patients experiencing detoxification and 1/3 of patients experiencing withdrawal seizures.[6]


Typically the severity of the symptoms experienced will depend on the amount and duration of prior alcohol consumption, as well as the number and severity of previous withdrawals. Even the most severe of these symptoms can occur in as little as 2 hours after cessation; therefore, the overall unpredictability necessitates either pre-planned hospitalization, treatment coordinated with a doctor, or at the very least fast access to medical care and a supporting system of friends or family should be introduced prior to addressing detoxification. In many cases, however, symptoms follow a reasonably predictable time frame as exampled below:[citation needed]

Six to 12 hours after the ingestion of the last drink, withdrawal symptoms such as shaking, headache, sweating, anxiety, nausea or vomiting occur. Other comparable symptoms may also exist in this period. Twelve to 24 hours after cessation, the condition may progress to such major symptoms as confusion, hallucinations (with awareness of reality), tremor, agitation, and similar ailments. It's between the 24 and 48 hour period that seizures typically may begin to emerge among the previous symptoms in the period, and this is where the serious risk of mortality begins. Although most often, the condition begins to improve past the 48 hour mark, it can sometimes continue to increase in severity to delirium tremens, characterized by hallucinations that are indistinguishable from reality, severe confusion, more seizures, high blood pressure and fever which can persist anywhere from 4 to 12 days.

Protracted withdrawal






Kindling can cause complications and may increase the risk of relapse, alcohol-related brain damage and cognitive deficits. Chronic alcohol misuse and kindling via multiple alcohol withdrawals may lead to permanent alterations in the GABAA receptors.[16] The mechanism behind kindling is sensitization of some neuronal systems and desensitization of other neuronal systems which leads to increasingly gross neurochemical imbalances. This in turn leads to more profound withdrawal symptoms including anxiety, convulsions and neurotoxicity.[17]




Many hospitals use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol in order to assess the level of withdrawal present and therefore the amount medication needed.[5] When overuse of alcohol is suspected but drinking history is unclear, testing for elevated values of carbohydrate-deficient transferrin and/or gammaglutamyl transferase can help make the diagnosis of alcohol overuse and dependence more clear.


Benzodiazepines are effective for the management of symptoms as well as the prevention of seizures.[20] Certain vitamins are also an important part of the management of alcohol withdrawal syndrome. In those with severe symptoms inpatient care is often required.[3] In those with lesser symptoms treatment at home may be possible with daily visits with a health care provider.[3]








Some evidence indicates that topiramate[14] carbamazepine and other anticonvulsants are effective in the treatment of alcohol withdrawal however, research is limited.[14][26] A Cochrane review similarly reported that the evidence to support the role of anticonvulsants over benzodiazepines in the treatment of alcohol withdrawal is not significant and noted weaknesses in the studies available. The Cochrane review did note however, that paraldehyde combined with chloral hydrate showed superiority over chlordiazepoxide with regard to life threatening side effects and also noted that carbamazapine may have advantages for certain symptoms.[27]


Clonidine may be used in combination with benzodiazepines to help some of the symptoms.[5] There is insufficient evidence to support the use of baclofen for AWS.[28]

Antipsychotics, such as haloperidol, are sometimes in addition to benzodiazepines to control agitation or psychosis.[5] Antipsychotics may potentially worsen alcohol withdrawal as they lower the seizure threshold. Clozapine, olanzapine or low potency phenothiazines(e.g. chlorpromazine) are particularly risky; if used, extreme caution is required.[29]



Failure to manage the alcohol withdrawal syndrome appropriately can lead to permanent brain damage or death.[31] It has been proposed that brain damage due to alcohol withdrawal may be prevented by the administration of NMDA antagonists, calcium antagonists, and glucocorticoid antagonists.[32] The NMDA antagonist acamprosate reduces excessive glutamate rebound thereby suppressing excitotoxicity and potential withdrawal related neurotoxicity.[33]

Substances impairing recovery

Continued use of benzodiazepines may impair recovery from psychomotor and cognitive impairments from alcohol.[34] Cigarette smoking may slow down or interfere with recovery of brain pathways in recovering alcoholics.[35]


  1. Cite error: Invalid <ref> tag; no text was provided for refs named Alcohol withdrawal seizures
  2. Cite error: Invalid <ref> tag; no text was provided for refs named Medical Toxicology
  3. 3.0 3.1 3.2 Muncie HL, Jr; Yasinian, Y; Oge', L (2013 Nov 1). "Outpatient management of alcohol withdrawal syndrome". American family physician. 88 (9): 589–95. PMID 24364635. Check date values in: |date= (help)
  4. 4.0 4.1 4.2 McKeon, A; Frye, MA; Delanty, N (August 2008). "The alcohol withdrawal syndrome". Journal of neurology, neurosurgery, and psychiatry. 79 (8): 854–62. PMID 17986499.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Cite error: Invalid <ref> tag; no text was provided for refs named aws
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  12. Cite error: Invalid <ref> tag; no text was provided for refs named Changes in GABA(A) receptor gene expression associated with selective alterations in receptor function and pharmacology after ethanol withdrawal
  13. Cite error: Invalid <ref> tag; no text was provided for refs named The pentylenetetrazol-like interoceptive stimulus produced by ethanol withdrawal is potentiated by bicuculline and picrotoxinin
  14. 14.0 14.1 14.2 Cite error: Invalid <ref> tag; no text was provided for refs named Hughes-2009
  15. Heilig M, Egli M, Crabbe JC, Becker HC (April 2010). "Acute withdrawal, protracted abstinence and negative affect in alcoholism: are they linked?". Addict Biol. 15 (2): 169–84. doi:10.1111/j.1369-1600.2009.00194.x. PMC 3268458. PMID 20148778.CS1 maint: multiple names: authors list (link)
  16. Cite error: Invalid <ref> tag; no text was provided for refs named GABA systems, benzodiazepines, and substance dependence
  18. Cite error: Invalid <ref> tag; no text was provided for refs named Stephens-2008
  19. Cite error: Invalid <ref> tag; no text was provided for refs named Courtney-2009
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  21. Bird, RD (January 1994). "Alcohol withdrawal: what is the benzodiazepine of choice?". The Annals of pharmacotherapy. 28 (1): 67–71. PMID 8123967. Unknown parameter |coauthors= ignored (|author= suggested) (help)
  22. Cite error: Invalid <ref> tag; no text was provided for refs named Changes in GABAA receptor function and cross-tolerance to ethanol in diazepam-dependent rats
  23. Cite error: Invalid <ref> tag; no text was provided for refs named Chronic ethanol produces a decreased sensitivity to the response-disruptive effects of GABA receptor complex antagonists
  24. Cite error: Invalid <ref> tag; no text was provided for refs named Alcohol use and anxiety
  25. Cite error: Invalid <ref> tag; no text was provided for refs named Treatment of Alcohol Withdrawal
  26. Cite error: Invalid <ref> tag; no text was provided for refs named Treatment of alcohol withdrawal syndrome with carbamazepine, gabapentin, and nitrous oxide
  27. Cite error: Invalid <ref> tag; no text was provided for refs named Minozzi-2010
  28. Liu, J (Feb 28, 2013). "Baclofen for alcohol withdrawal". The Cochrane database of systematic reviews. 2: CD008502. PMID 23450582. Unknown parameter |coauthors= ignored (|author= suggested) (help)
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  30. Hodges, B (November 2004). "Intravenous ethanol for the treatment of alcohol withdrawal syndrome in critically ill patients". Pharmacotherapy. 24 (11): 1578–85. PMID 15537562. Unknown parameter |coauthors= ignored (|author= suggested) (help)
  31. Hanwella R, de Silva V (June 2009). "Treatment of alcohol dependence". Ceylon Med J. 54 (2): 63–5. PMID 19670554.
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  33. De Witte P, Littleton J, Parot P, Koob G (2005). "Neuroprotective and abstinence-promoting effects of acamprosate: elucidating the mechanism of action". CNS Drugs. 19 (6): 517–37. PMID 15963001.CS1 maint: multiple names: authors list (link)
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