Alcohol withdrawal syndrome

Alcohol withdrawal syndromeAlcohol withdrawal syndrome (also known as discontinuation syndrome) is a condition that occurs after the cessation of drinking in persons with alcohol addiction.


Description

Alcohol withdrawal is a condition that follows a reduction in alcohol use in addicted individuals. Signs and symptoms of withdrawal include fast heart rate, increased blood pressure, fever, headache, tremor, nausea, vomiting, increased sweating, dilated pupils, shaking, tremor, insomnia, depression and anxiety or nervousness.

Chronic alcohol abuse and withdrawal are more common in men than women.


Causes

Alcohol withdrawal occurs after a reduction in alcohol consumption or an abrupt cessation of drinking in addicted persons.

Alcohol withdrawal syndrome is more likely to develop in persons who have other medical conditions.

Alcohol consumption leads to repetitive alteration of the dopamine levels in the brain and therefore the body expects the presence of alcohol. When the level of alcohol in the blood decreases the brain fails to produce dopamine causing withdrawal symptoms.

 

Risk factors

People who are addicted to alcohol or who drink heavily and regularly  are at high risk of experiencing alcohol withdrawal. It is more common in adults, but children and teenagers who drink excessively may be affected as well.
When a person has past history of severe withdrawal, thrombocytopenia and hypokalemia he/she is more likely to experience severe withdrawal.

 

Kindling

Kindling is a phenomenon of substantive withdrawal from sedative-hypnotic drugs, including alcohol and benzodiazepines. With every next withdrawal the symptoms are more severe than previously. In this case the risk of developing seizures is higher and therefore life-threatening conditions are more likely to occur.


Symptoms

Alcohol withdrawal syndrome leads to activation of autonomic nervous system hyperactivity and the following signs develop fast heart rate, increased blood pressure, hyperthermia, headache, tremor, nausea, vomiting, increased sweating, dilated pupils, insomnia and anxiety or nervousness.Other symptoms of alcohol withdrawal include: depression, fatigue, irritability, shakiness, mood swings, nightmares, loss of appetite, pallor and tremor of the hands or other body parts.

The symptoms are the most severe the next day after the last drink, they usually subside until the 4th or 5th day. However, some of the symptoms (anxiety, insomnia and autonomic symptoms) in a less severe form may persist for a few weeks up to 5 or 6 months.

Alcohol withdrawal syndrome (delirium tremens) occurs between 36 and 72 hours following  alcohol withdrawal syndrome cessation. This condition is characterized by illusions, hallucinations (auditory, visual, or tactile – having a sense of itching, burning, or numbness that isn’t actually occurring ), psychomotor agitation, fluctuating cloudiness of consciousness and disorientation.

In some cases, seizures (grand mal seizures) occur within the first 48 hours after the cessation.

 

Withdrawal severity(stages of withdrawal)

Mild withdrawal, which occurs within 24 hours of the last drink is characterized by:

  • Tremulousness (shaking);
  • Insomnia;
  • Anxiety;
  • Hyperreflexia;
  • Abdominal pain;
  • Nausea;
  • Mild autonomic hyperactivity (increased sweating, fast heart rate etc.)

Usually the symptoms begin 8 hours following the last drink.

Moderate withdrawal occurs 24-36 hours after the alcohol withdrawal syndrome cessation, it includes:

  • Intense anxiety;
  • Tremors;
  • Insomnia;
  • High blood pressure;
  • Fever;
  • Confusion;
  • Excessive symptoms of autonomic hyperactivity;

Severe withdrawal develops more than 48 hours after a cessation of alcohol consumption. The following symptoms are characteristic:

  • Profound alteration of perception, including such signs as confusion, disorientation, agitation, and hallucinations;
  • Seizures;
  • Severe autonomic hyperactivity that causes tremulousness, tachycardia, tachypnea, fever, and excessive sweating.

 

Post-Acute Withdrawal Syndrome (PAWS)

Some people may experience prolonged side effects of acute withdrawal. This syndrome is called post-acute withdrawal symptoms and is also known as protracted withdrawal syndrome or prolonged withdrawal syndrome. PAWS is characterized by withdrawal symptoms that occur after an acute withdrawal. Depending on the severity of the Alcohol withdrawal syndrome abuse, PAWS lasts  from a few weeks to a year.

The symptoms of PAWS include:

  • Irritability and emotional outbursts, anxiety;
  • Low energy, weakness, fatigue;
  • Trouble sleeping, insomnia;
  • Memory loss;
  • Dizziness;
  • Delayed reflexes;


Diagnosis

Serum glucose, arterial blood gas analysis, CBC, comprehensive metabolic panel, urinalysis and toxicology  testing are usually indicated in case of withdrawal .Alterations in ECG, in particular an increase in QT interval, and EEG abnormalities are seen during early withdrawal.

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Treatment


Typically the treatment of alcohol withdrawal includes benzodiazepines such as chlordiazepoxide or diazepam.

Diazepam can be administered intravenously, orally, or per rectum. The initial intravenous dose is 5 mg.

If massive doses of benzodiazepines are not effective, intravenous infusion of propofol or intravenous boluses of barbiturates (phenobarbital and pentobarbital) should be added.

Thiamine is also recommended.