Alcohol Withdrawal – What, Why, When, Etc.

person in hospitalAcute alcohol withdrawal symptoms can occur in any habitual drinker. Of all the mood altering substances people can detoxify from, alcohol is the most life-threatening. In rare cases (like during Delirium Tremens) the symptoms can lead to death. Acute alcohol withdrawal is made more troubling due to the fact that estimates show that barely 10-20 % of sufferers experiencing acute alcohol withdrawal are treated in a medical facility, therefore it’s possible that as many as 2 million Americans may undergo symptoms of acute alcohol withdrawal at home every year. This means that alcohol is not merely the most typically abused chemical; it’s also the drug that most Americans detoxify from at home. Unfortunately, countless people that try this outside of a clinic/hospital will probably be so overwhelmed by the discomforts of Acute Withdrawal Syndrome (AWS) that they will go back to consuming alcohol in order to relieve the pain and discomfort caused by the detox symptoms. Anytime someone detoxes from alcohol without medical supervision they expose themselves to significant risk.
Indicators of Acute Alcohol Withdrawal Syndrome will appear roughly 8 to 12 hours after the final drink and might continue for as long as 2 weeks. During this time, symptoms can include nausea or vomiting, diarrhea, insomnia, tremors, hallucinations, grand mal seizures, delirium tremens, and precariously high blood pressure levels. We will be exploring the main categories of symptoms below.

Hyperarousal

Alcohol withdrawal hyperarousal is the earliest showing and most common withdrawal symptom. It includes irritability, anxiety, insomnia, inability to eat or loss of appetite, increased heart rate, and the shakes. Alcoholics attempt to avoid this condition usually consist of a morning drink or two.
Probably anyone who has been really drunk has experienced the mild form of some of these symptoms. The most common way for regular people to experience really mild forms of hyperarousal is by “sweating out” the toxins of the weekend on Monday. Or they may have hands with the “alcohol shakes” the next day. But these are very mild symptoms compared to what the alcoholic experiences.
Alcohol withdrawal hyperarousal will get worse as abstinence continues. The alcoholic will startle easily, shake more violently, sleep very lightly if they can sleep at all, and generally be “amped” up in a very unpleasant way. This alcohol withdrawal duration can be 2 to 3 days and then should be almost gone.
Acute alcohol withdrawal hyperarousal doesn’t start until all the alcohol has left the body. They may wake up after a long bender and be semi functional but, that is because all the alcohol isn’t out of their system yet. It can be 12 hours after they wake up before things get really nasty. That is probably when all the alcohol has been processed out of their bodies.
Remember, alcoholics have a high tolerance to alcohol which allows them to consume much more than a normal person would or could. Their liver, however, will only process alcohol out at the same rate as everyone else’s, if their liver isn’t damaged. If it is damaged then it will be slower. So when a normal person wakes up the alcohol is probably gone or almost gone. The drunk may still have quite a bit to process out.
I have experienced alcohol withdrawal hyperarousal. Think of anxiety about two notches down from a panic attack that goes on and on for hours and hours. You can stay pretty “amped” up for 2 or so days, it is impossible to sleep, you are covered in sweat, it can be hard to walk because you feel unsteady, and once you have the energy to take a shower the water will feel weird touching your clammy skin . My alcohol withdrawal hyperarousal usually lasted for three days. With the symptoms of withdrawal diminishing each day, so the first day was the worse and each day after being a little better.

Hallucinations

Hallucinations

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Alcohol withdrawal hallucinations occur in about 25% of alcoholics. They are usually auditory and visual but, can be tactile. So the person suffering from this may see or hear things. They may also feel like bugs are crawling all over them. Additionally, they may misinterpret or misperceive their environment. For them, these things are real and they will react accordingly.
These hallucinations are almost always negative. They are threatening or demeaning. They generally create a lot of guilt in the person. These aren’t the pleasant trips of the 1960’s flower children. People having these hallucinations need to be watched to insure they don’t hurt themselves or anyone else.
People in this condition will likely experience very vivid dreams. Again, they will most likely be negative. Most people report having terrible nightmares. The increased dreaming is due to the fact that alcohol suppresses REM sleep (that’s of the sleep stage we can remember our dreams from), when it is removed we swing the other way and have more dreams. It’s the body’s way of regaining equilibrium. (how withdrawal symptoms effect REM sleep are now being reconsidered)
All of these symptoms should decrease after 3 or 4 days but, may take up to a week to completely stop.
I have never experienced alcohol withdrawal hallucinations, only alcohol withdrawal seizures. So I can’t speak from personal experience.

Seizures

Alcohol withdrawal seizures are usually generalized, meaning your whole body will convulse. Your eyes will roll back in your head, your body will begin to shake violently and you will lose consciousness. The attack will usually last a minute or two and may leave you groggy for 6 to 8 hours. They are quite frightening to watch but, aren’t usually dangerous as long as the person can breathe and doesn’t hurt themselves while they are thrashing around on the floor, but seizures can kill you.  However, since most alcoholics detox at home, this can be a serious problem if they live alone.
The convulsions usually occur with 12 to 48 hours after a person has stopped drinking. About 1/3 of the people who exhibit this go on to develop the delirium tremens (DTs).
This is considered rebound activity because alcohol has an anticonvulsant effect which makes the seizure threshold higher. When it is removed the threshold decreases, and seizures become more likely, until the body has regained equilibrium.
I have had alcohol withdrawal seizures. It is quite disconcerting to not be in control of your body. I remembered everything about my seizure and was groggy for at least 6 hours after.  Don’t attempt an alcohol withdrawal seizure at home, it is horrible.

The DTs or Delirium Tremens

Delirium Tremens is alcohol withdrawal syndrome with a few new symptoms. It is rare.
From Patient.co.uk

Delirium tremens (DTs)
is a more severe reaction after stopping alcohol. It occurs in about 1 in 20 people who have alcohol withdrawal symptoms about 2-3 days after their last drink. Symptoms include: marked tremor (the shakes) and delirium (agitation, confusion and seeing and hearing things that are not there). Some people have convulsions. Complications can develop, such as dehydration and other serious physical problems. It is fatal in some cases.

From Medline Plus:

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes.
Causes Delirium Tremens
Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food.
Delirium tremens may also be caused by head injury, infection, or illness in people with a history of heavy alcohol use.
It is most common in people who have a history of alcohol withdrawal. It is especially common in those who drink 4 – 5 pints of wine or 7 – 8 pints of beer (or 1 pint of “hard” alcohol) every day for several months. Delirium tremens also commonly affects people who have had an alcohol habit or alcoholism for more than 10 years.
Symptoms Delirium Tremens
Symptoms most often occur within 48-96 hours after the last drink. However, they may occur up to 7 – 10 days after the last drink.
Symptoms may get worse quickly, and can include:
• Body tremors
• Changes in mental function
• Agitation, irritability
• Confusion, disorientation
• Decreased attention span
• Deep sleep that lasts for a day or longer
• Delirium
• Excitement
• Fear
• Hallucinations (seeing or feeling things that are not really there)
• Increased activity
• Quick mood changes
• Restlessness, excitement
• Sensitivity to light, sound, touch
• Stupor, sleepiness, fatigue
Seizures (may occur without other symptoms of DTs)
• Most common in first 12 – 48 hours after last drink
• Most common in people with past complications from alcohol withdrawal
• Usually generalized tonic-clonic seizures

From Medline Plus

Alcohol Withdrawal Timeline

You don’t have to be completely sober for alcohol withdrawal symptoms to set in. When your body is accustomed to acting with a certain amount of alcohol in it and it doesn’t have that amount the person may show symptoms of withdrawal.
With regular use of alcohol the Central Nervous System is constantly depressed. When alcohol is removed, the CNS reacts to the absence of alcohol depression by becoming overactive. This is rebound hyperactivity.
Withdrawal will usually last however long it takes for the CNS to reach an equilibrium. It’s normal operating level. It is during this rebound or equalizing phase that withdrawal symptoms show themselves.
The alcohol withdrawal timeline is just a matter of how long it takes your CNS to reach its normal operating level.
Not everyone experience withdrawal the same. Three things seem to be most important to the duration.
• For how long and how much has the person been drinking.
• What is the person’s physical state. Are they generally healthy or are they in bad shape.
• And, the person’s basic physiological makeup.
So accurately predicting how a person will progress through the withdrawal timeline can only be done in general terms.
Side note: For binge drinkers, folks who drink for several days and then stop, withdrawal will be much easier to predict. They have been through it several times and have a good idea what’s going to happen.

 

Syndrome Clinical manifestation Onset after last drink
Minor withdrawal symptoms:
These usually resolve within 24 to 48 hours
Tremulousness, anxiety, headache, diaphoresis, palpitations, GI symptoms including diarrhea and anorexia6 to 36 hours
Alcohol related seizures,
Occur in approximately 3 % of chronic alcoholics
Generalized, tonic-clonic, rarely status epilepticus (3% of those with seizures)6 to 48 hours
Alcoholic hallucinosis
Alcoholic hallucinosis refers to hallucinations that develop within 12 to 24 hours of abstinence and resolve within 24 to 48 hours (which is the earliest point at which delirium tremens typically develops)
Hallucinations are usually visual, although auditory and tactile phenomena may also occur. In contrast to delirium tremens, alcoholic hallucinosis is not associated with global clouding of the sensorium, but with specific hallucinations.12 to 48 hours
Delirium Tremens (DT), seen in approximately 5% of those in alcohol withdrawal. Has a mortality rate of 5%. Death is usually due to arrhythmias or complicating illnesses such as pneumonia.DTs generally produce hallucinations, disorientation, tachycardia, hypertension, low-grade fever, agitation, and diaphoresis. Withdrawal may also have an important impact on fluid and electrolyte status. Almost all patients in acute withdrawal are dehydrated as a result of diaphoresis, hyperthermia, vomiting, and tachypnea. Hypokalemia is common due to renal and extra-renal losses, alterations in aldosterone levels, and changes in potassium distribution across the cell membrane. Hypomagnesemia occurs frequently with DTs and may predispose to withdrawal seizures. (7) Hypophosphatemia may occur due to malnutrition, may be symptomatic, and if severe, may contribute to cardiac failure and rhabdomyolysis.48 to 96 hours

Chart taken almost entirely from Signavitae.

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