What are the symptoms of alcohol withdrawal?

Alcohol Withdrawal Symptoms: Comprehensive Overview

Alcohol withdrawal syndrome produces a spectrum of symptoms beginning 6-24 hours after cessation of alcohol in chronic heavy drinkers, ranging from mild autonomic hyperactivity to life-threatening delirium tremens that can cause death if untreated. 1

Timeline and Progression

Early symptoms (6-24 hours):

• Tremors - particularly hand tremor, one of the earliest and most common manifestations 1
• Autonomic hyperactivity - tachycardia, hypertension, sweating, and fever 1
• Gastrointestinal symptoms - nausea and vomiting 1
• Anxiety and agitation - due to central nervous system rebound excitation 2
• Insomnia - disrupted sleep patterns are common 3

Intermediate symptoms (12-48 hours):

• Alcohol withdrawal seizures - generalized tonic-clonic seizures occurring as a rebound phenomenon due to lowered seizure threshold 1, 4
• These seizures typically occur singly or in brief clusters, though status epilepticus can occur 4
• Hallucinations - visual, auditory, or tactile hallucinations may develop 1, 2

Severe symptoms (48-120 hours, peak at 3-5 days):

• Delirium tremens (DTs) - the most serious complication with potential mortality if untreated 1, 5
  • Altered mental status and marked inattentiveness 4
  • Disorientation to person, place, or time 1
  • Fluctuating level of alertness 4
  • Marked tremulousness 4
  • Severe autonomic instability: high fever, severe tachycardia, severe hypertension 1
  • Profound agitation 4
  • Intra- and inter-daily variation of symptoms 1

Critical Distinguishing Features

Alcohol withdrawal seizures are distinct from epileptic seizures:

• They are a rebound phenomenon, not true epilepsy 1
• Anticonvulsants alone are not needed; benzodiazepines are the appropriate treatment 1, 6
• This distinction is clinically important to avoid inappropriate long-term anticonvulsant therapy 1

Associated Complications Requiring Monitoring

Metabolic and systemic complications that commonly accompany withdrawal:

• Dehydration and electrolyte imbalances - require careful fluid management 1
• Hypoglycemia - frequent comorbidity requiring monitoring 4
• Thiamine deficiency - can lead to Wernicke-Korsakoff syndrome if not addressed 1, 7
• Renal failure - may develop in severe cases 1
• Liver failure - particularly in patients with underlying alcoholic liver disease 1
• Infection and sepsis - increased susceptibility during withdrawal 1, 4
• Gastrointestinal bleeding - risk is elevated 1
• Pancreatitis - common comorbid condition 1, 4
• Head trauma - from falls during intoxication or withdrawal 1

Severity Assessment

The CIWA-Ar scale is useful for severity assessment but not for diagnosis:

• Score >8 indicates moderate AWS requiring intervention 5
• Score ≥15 indicates severe AWS requiring immediate aggressive treatment 5
• However, high scores can occur in conditions mimicking AWS (anxiolytic withdrawal, anxiety disorders, sepsis, hepatic encephalopathy, severe pain), so clinical judgment is essential 1

Risk Factors for Severe Withdrawal

Patients at highest risk for progression to severe symptoms:

• Chronic heavy drinking history 7
• Previous history of withdrawal seizures 7
• Previous history of delirium tremens 7
• Concurrent liver disease 5
• Multiple prior detoxification attempts 7

Common Pitfalls

Failure to recognize early signs leads to rapid progression to life-threatening complications - close monitoring of vital signs is mandatory, particularly in the first 3-5 days when symptoms peak 1, 5. The progression from mild tremor to delirium tremens can occur within hours, making early intervention critical for preventing mortality 5.