Alcoholism, or alcohol use disorder (AUD), is the inability to control alcohol use despite negative consequences. Individuals with AUD have a physical and mental dependence on alcohol.
When people who regularly use alcohol suddenly stop drinking, they usually develop uncomfortable and dangerous withdrawal symptoms. Alcohol detoxification (alcohol detox) is how the body rids itself of alcohol and its metabolites.
Alcohol withdrawal syndrome (AWS) refers to the collection of alcohol withdrawal symptoms that typically occur when people who drink alcohol regularly suddenly stop or reduce their alcohol intake.
What Causes Alcohol Withdrawal?
Alcohol causes drastic changes in many brain chemicals (neurotransmitters), especially two important ones: GABA and glutamate. Both neurotransmitters help regulate the excitability of the brain. Because alcohol suppresses excitability, drinking alcohol causes slowing of thinking, reaction time, speech and body movements.
- Suppressed Neurotransmitter System
With prolonged alcohol use, this neurotransmitter system grows increasingly suppressed as tolerance develops and alcohol use increases. The brain tries to compensate for the alcohol-induced brain slowing by increasing its efforts at exciting the brain.
- Hyper-Excitability in the Brain
When the alcohol consumption is suddenly removed or reduced, the result is a huge spike in GABA and glutamate, resulting in a “hyper-excitable” brain. This excitement causes rapid metabolism effects (increased heart rate, blood pressure and breathing rates), shaking, unstable movements and an over-active brain as is seen in delirium tremens (DTs). In severe cases, this hyper-excitability can cause seizures.
- Low Levels of Dopamine
Another important neurotransmitter that is affected by alcohol use is dopamine, which is a key part of the brain’s reward (feel-good) system. When people are intoxicated with alcohol, the alcohol causes abnormally high levels of dopamine to be released, which is why people feel good for a period of time when they are drunk. This over-activation of the brain’s reward system is part of what makes people addicted to alcohol.
The brain responds to the abnormally high levels of dopamine from the alcohol use by down-regulating dopamine production and the brain’s dopamine receptors. When the alcohol use is stopped, the brain is left with very low levels of dopamine, resulting in feeling depressed, tired and lethargic. It may take some time for the brain chemistry to return to normal, so these effects may persist for some time.
What Are the Symptoms of Withdrawal?
The symptoms of withdrawal are the effects that are felt by the brain and body as the body endures the toxic effects of alcohol and its metabolites, and rebounds to functioning without alcohol intake after regular exposure to alcohol.
Some common alcohol withdrawal symptoms include:
- Muscle spasms
- Increased irritability
- Feelings of anxiety and depression
- Diaphoresis (profuse sweating, cold sweats)
- Difficulty sleeping, or insomnia
- Nausea and vomiting
- Hallucinations, confusion, jitteriness and agitation (common among people who drink heavily)
Types of Alcohol Withdrawal
There are different types of withdrawal syndromes that can occur:
- Initial withdrawal symptoms, or a hangover
- Alcohol withdrawal seizures
- Delirium tremens (DTs)
- Post-acute withdrawal syndrome (PAWS)
People can experience some or all of these types of withdrawal symptoms after stopping or reducing their alcohol intake, or even following a binge-drinking episode.
Alcohol withdrawal syndrome usually starts with general hangover symptoms and starts within six to 12 hours after the last drink. Symptoms may include nausea, vomiting, headaches, muscle spasms and sweating. Some people may experience hallucinations, too.
The hallucinations in early withdrawal are different from the ones seen in the DTs, and are referred to as alcoholic hallucinosis. These are usually predominantly auditory hallucinations (hearing things that aren’t there).
About 24 to 48 hours after the last drink, the possibility of alcohol withdrawal seizures arises, and seizures may occur within two hours and up to 20 days after the last drink. People who experience these grand mal seizures may lose consciousness and fall. Their body stiffens, and the person may grunt, drool and froth at the mouth. They may also begin shaking violently. Alcohol withdrawal seizures are a medical emergency, so bystanders should call 911 immediately.
A dangerous complication of AWS is delirium tremens (DTs), the most severe complication of alcohol withdrawal, which can be fatal.
The DTs are characterized by:
- Hallucinations (usually visual)
- Diaphoresis (drenching sweats)
- Severe confusion
- Severe shaking
- High blood pressure, rapid heart rate and elevated body temperature
The DTs usually begin between 48 and 72 hours after the last drink, peak at five days, and last from four to 12 days.
Risk factors for DTs include:
- Previous episodes of withdrawal seizures
- Previous episodes of DTs
- Poor physical health
- Abnormal liver function
- Old age
The severity of symptoms is dictated by a number of factors, the most important of which is the degree of alcohol intake, length of time the individual has been using alcohol and previous episodes of detoxing from alcohol (this additive effect of episodes of detoxing is known as kindling).
As with seizures, the DTs are always a medical emergency, and bystanders should call 911 immediately.
Post-acute withdrawal syndrome (PAWS) is a term that is also referred to as protracted withdrawal syndrome. This syndrome is a collection of symptoms that develops in some people and follows acute withdrawal and may persist for a year or more.
Many of the symptoms of PAWS are simply acute withdrawal symptoms that last longer than the usual duration, especially:
- Low energy, fatigue or apathy
- Sleep disturbances
- Depressive symptoms
- High blood pressure, body temperature, heart rate or breathing rate
There is some debate within the research community about the validity of PAWS as a diagnosis, as many experts feel that the symptoms are simply symptoms of mental health disorders, such as depression. However, it is widely agreed that protracted abstinence from alcohol after heavy and prolonged use can cause lasting symptoms due to brain effects from the alcohol use.
It has been theorized that PAWS may play a role in relapse among people in recovery from AUD, although this has yet to be properly assessed by research.
How Is Withdrawal Diagnosed?
People with AUD are often secretive and even deny their alcohol use, so if they are having a seizure or DTs and are brought to the hospital, the cause may not be readily apparent. However, the cause is usually found after some simple investigations.
Withdrawal is anticipated in people who are stopping their alcohol intake, so diagnosis is generally not an issue in those who are forthcoming about their alcohol use.
Alcohol Withdrawal Timeline
The symptoms of AWS usually follow a timeline:
- Onset is anywhere from two hours to a few days after the last drink (average time of onset is about six hours after the last drink)
- Peak at 24-72 hours
- Symptoms usually improve and taper off by seven days, although they can last for weeks
- The risk of DTs usually begins 48 to 72 hours after the last drink
- If DTs occur, they usually peak at five days after the last drink, and last from four to 12 days
- The danger of withdrawal seizures starts about 24 to 48 hours after the last drink
- Seizures can occur within two hours and up to 20 days after the last drink
The time of onset, duration and severity of withdrawal symptoms depends on several different factors, including:
- Whether or not the withdrawal is being medically assisted
- The health of the liver (which is responsible for metabolizing alcohol and detoxing the body)
- The age and gender of the individual
- The general health of the individual
- The number of previous episodes of AWS (due to the kindling effect)
- The genetic and biological make-up of the individual
Treatment for Alcohol Withdrawal
The main goals of treatment of alcohol withdrawal are:
- Relapse prevention during detox
- Seizure prevention
- Proper hydration and nutrition
- Medical management of complications, such as DTs or seizures
- Symptom relief (especially nausea, insomnia, hallucinations, anxiety, etc.)
Treatment for alcohol withdrawal also includes administration of vitamin B1, also known as thiamine, either through an intravenous or oral route. This therapy is to treat any undetected Wernicke encephalopathy (sometimes referred to as “wet brain”) effects that may have developed in the individuals.
Medical detox is the safest and most comfortable way to withdraw and detoxify from alcohol use. Detox usually happens in a rehab setting that provides a safe place to get through the detox process without any distractions or temptations from the outside world, and with constant supervision from medical professionals in case of any complications.
Medical detox allows for the provision of the medications and support needed to prevent seizures and other potential complications and to treat uncomfortable symptoms. For people who are vomiting, intravenous fluids and medications can be provided, which can result in a remarkable improvement in symptoms and complications.
Medical detox also allows for recovery planning, as simply detoxing from alcohol use does not constitute treatment for AUD.
Medication-assisted treatment consists of medications used to help people through detox, or to improve their chances of successful recovery after detox by reducing cravings and helping to prevent relapse.
Several medications are useful in helping some people to detox from alcohol use:
- Benzodiazepines: for seizure prevention, sedation and reducing agitation and anxiety
- Heart and blood pressure medications (such as beta blockers or clonidine)
- Anti-seizure medications
- Muscle relaxants
- Thiamine and magnesium: to treat nutritional deficiencies associated with alcohol use that can have serious medical consequences
Other medications are sometimes used, starting during or shortly after detox, but are meant to help with relapse prevention and not with withdrawal or detox specifically:
Detoxing at Home
However, if people are considering self-detoxing, they should consider doing so only if certain conditions are in place:
- They consult their physician first
- Their alcohol use was not heavy or prolonged
- They do not live alone, and there are people there who know that they are detoxing
- They have a safe and alcohol-free home
- There is help available if they develop serious complications, such as DTs or seizures, and can’t help themselves
One of the hallmark psychological characteristics of alcohol use disorder is that people maintain a persistent need for control and remain convinced that they can handle their addiction on their own, even after multiple failures to do so. As such, people with AUD may be wise to consult their physician and loved ones when they decide that they want to self-detox.
When people develop seizures or DTs, they can’t help themselves, so having capable and informed help nearby is essential.
Finding a Detox Center
It is important to find a detox center that has the expertise and experience to assess and treat withdrawal from alcohol use as well as addressing any co-occurring substance use or mental health disorders. It is also wise to consider a facility that has treatment facilities so that individuals can transition smoothly into treatment for their AUD following successful medical detox.
To find a detox center, you can:
- Use the Substance Abuse and Mental Health Services Administration’s treatment locator tool
- Call The Recovery Village Palm Beach at Baptist Health, which offers comprehensive medical detox and rehab programs
- Search for recovery resources in the state of Florida
If you have concerns about alcohol use in yourself or a loved one, please feel free to contact us for a confidential discussion with one of our staff.
Bhat, Pookala, et al. “Alcoholic hallucinosis.” Industrial Psychiatry Journal. July-December 2012. Accessed July 3, 2019.
Jesse, S., et al. “Alcohol withdrawal syndrome: Mechanisms, manifestations, and management.” Acta Neurologica Scandinavica, September 1, 2016. Accessed July 3, 2019.
Heilig, M.; Egli, M.; Crabbe, J.; et al. “Acute withdrawal, protracted abstinence and negative affect in alcoholism: Are they linked?” Addiction Biology, April 2010. Accessed July 3, 2019.
Heinz, Andreas, et al. “Reward craving and withdrawal relief craving: Assessment of different motivational pathways to alcohol intake.” Alcohol and Alcoholism, January 2003. Accessed July 3, 2019.
Latt, N.; Dore, G. “Thiamine in Wernicke’s encephalopathy.” Internal Medicine Journal, September 8, 2014. Accessed July 3, 2019.
Maldonado, José, et al. “The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome.” Alcohol, January 2014. Accessed July 3, 2019.
Rogawski, Michael. “Update on the neurobiology of alcohol withdrawal seizures.” Epilepsy Currents, November 2005. Accessed July 3, 2019.
Sachdeva, Ankur; Choudhary, Mona; Chandra, Mina. “Alcohol withdrawal syndrome: Benzodiazepines and beyond.” Journal of Clinical & Diagnostic Research, September 2015. Accessed July 3, 2019.
Schuckit, Marc. “Recognition and management of withdrawal delirium (delirium tremens).” The New England Journal of Medicine, November 27, 2014. Accessed July 3, 2019.
Substance Abuse and Mental Health Services Administration (SAMHSA). “Medication for the treatment of alcohol use disorder: A brief guide.” 2015. Accessed July 3, 2019.
Trevisan, Louis; Boutros, Nashaat; Petrakis, Ismene; Krystal, John H. “Complications of alcohol withdrawal.” Pathophysiological Insights, 1998. Accessed July 3, 2019.
Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.