The Four Categories of Alcohol Withdrawal Syndrome: Minor to Fatal
- Minor withdrawal: The most common sign of alcohol withdrawal in chronic alcohol abusers is tremulousness; also referred to as the shakes or jitters (especially in the hands). These symptoms usually begin within the first 5-10 hours after the individual’s last drink, and peak between 24-48 hours. Additional symptoms of minor withdrawal may include anxiety, nausea, vomiting, rapid pulse, an increase in blood pressure, rapid breathing, irritability, nightmares or vivid dreams, insomnia, and a hypersensitivity to light, noise, and touch. In jail these symptoms are often seen the morning after arrest.
- Major Withdrawal: The hallmark of major withdrawal is alcohol hallucinations, which occurs 10-72 hours after the last drink, and may last for two days. The symptoms can appear as frank psychosis. Up to 25% of alcohol dependent individuals in withdrawal will have alcoholic hallucinations, which can be visual, tactile and/or auditory. They hear accusatory or threatening voices. They report seeing crawling insects/rats/dogs, falling coins, or other moving objects. They feel things moving on or under their skin. Alcohol hallucinations are not necessarily followed by seizures or delirium tremens.
- Withdrawal Seizures: Withdrawal seizures, were previously referred to as “rum fits”, and occur within 6-48 hours after the last drink of alcohol (the risk peaks at 24 hours). Between 23-33% of individuals in acute alcohol withdrawal syndrome will have alcohol withdrawal seizures. The seizures are usually brief, generalized, tonic-clonic (grand mal), and without any aura. They frequently occur in a cluster, but it is also common for several seizures to occur over several hours. Most seizures generally terminate spontaneously, or are easily controlled with benzodiazepines or other anti-seizure medications. About 30-50% of patients with alcohol withdrawal seizures progress to DTs.
- Delirium Tremens (DT): DT is the most severe manifestation of alcohol withdrawal; it is acute and may be fatal. Delirium tremens occurs in approximately 5% of people who experience alcohol withdrawal symptoms. Delirium tremens usually occurs 48-72 hours after the last drink, but onset may be as long as a week to 10 days. Peak intensity is usually four to five days after the last alcoholic beverage. Delirium tremens is most frequently seen in individuals who are habitual chronic drinkers; but may occur after a single heavy bout of drinking. Delirium tremens causes dangerous shifts in breathing, circulation and temperature control. Physical manifestations include hypertension, increased respirations and heart rate, fever, and severe dehydration (from excessive sweating). DT can also restrict blood flow to the brain producing symptoms of loss of consciousness, global confusion, stupor, disorientation, anxiety, agitation, aggressive behavior, sleep disturbances, delusions and hallucinations. The mortality of untreated DTs as high as 30%. However, early recognition and improved treatment has reduced this rate to less than 5%.
Delirium Tremens is Most Common in People Who:
- Have a previous history of alcohol withdrawal symptoms, especially seizures
- Drink the equivalent of 1 pint of liquor per day for several months
- Have had a history of habitual alcohol use or dependence for 10 years or more
- Other risk factors: older age, abnormal liver function, head injury, infection, other acute medical illness
The goals of treatment are to prevent death, relieve symptoms, and reduce complications of acute withdrawal syndrome. Most individuals experiencing alcohol withdrawal can be treated safely and effectively as outpatients. Intensive care hospitalization is usually indicated if there are significant changes in vital signs, vomiting, seizures, or delirium tremens. A subdued environment is ideal; with access to respiratory and cardiac emergency treatments readily available. Benzodiazepines, the medications of choice (Valium, Librium, and Ativan), are central nervous system depressants that can prevent the more severe manifestations of acute alcohol withdrawal syndrome: seizures and delirium tremens. Additional drugs that may be given include; Phenobarbital or Phenytoin (for seizures), Haldol (for hallucinations), and Clonidine or Atenolol (for arrhythmias and hypertension). Appropriate nutrition and B vitamin supplementation is also initiated. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence.