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What are the Signs and Symptoms of Alcohol Withdrawal?

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 09/25/2020

Number of References: 5 Sources

The signs and symptoms of alcohol withdrawal manifest both external and internal, some of which can become obvious within hours of the last drink. These can manifest in a variety of ways, and their intensity can vary depending on someone's drinking habits. Here we will examine the unique symptoms of alcohol withdrawal, their differences between drinkers, and the underlying causes of these symptoms. Finally, we will run through some of the preferred treatment options for managing these symptoms.

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Alcohol Withdrawal Symptoms

Acute alcohol withdrawal is the highest risk phase and the first one encountered when ceasing alcohol use. The symptoms can begin anywhere from 6 to 48 hours after the last drink and escalate over the course of the next few days. This phase can be fatal if someone is heavily addicted to alcohol or if they have underlying health conditions such as diabetes or heart issues. The symptoms will vary in intensity but often include:

  • Shakes or Tremors
  • Insomnia
  • Constant and Excessive Sweating
  • Elevated or Irregular Heart Rate
  • Wild Changes in Blood Pressure
  • Anxiety and Panic Attacks
  • Disorganized or Scattered Thinking

Some of the more dangerous symptoms will begin to appear around 1 or 3 days after the last drink and include:

  • Hallucinations and Confusion
  • Seizures
  • Delirium Tremens

These are the most dangerous symptoms of acute withdrawal and indicate an extreme and possibly fatal, although temporary, neurotransmitter imbalance. In particular, the condition of delirium tremens is often fatal if not treated by medical professionals. The imbalances that cause this condition can also frequently cause heart failure, brain-damaging seizures, and stroke.

Repeated cases of acute withdrawal will increase the severity of the symptoms the next time withdrawal is experienced. The way this works is not fully understood but is referred to as the “kindling process” by medical professionals.

Signs of Alcohol Withdrawal

The first outward signs of alcohol withdrawal will appear as if someone is very nervous. Sweating, shaking, and an increase in anxiety may manifest in less than 12 hours from the last time someone took a drink. Depending on their drinking habits these may increase slightly in severity and then plateau if they were a fairly light, but still daily, drinker. On the other hand, if they drank heavily every single day, then this is just the beginning of withdrawal symptoms.

The factor which most significantly affects the severity of withdrawal is the amount of alcohol someone drank and the length of time they drank, although there are several other, more minor contributors. Depending on differences in these habits they may be perfectly fine with only minor symptoms, or they could soon be in a potentially life-threatening situation. Let’s break down these different levels of alcohol withdrawal to better explore their risks and qualities.

Signs of Minor Withdrawal

Minor alcohol withdrawal symptoms can manifest even if someone does not necessarily “get drunk” every day. For example, a healthy middle-aged man drinking a six-pack of beer daily for several months or years can lead to minor alcohol withdrawal symptoms. These will usually begin to appear around 8 to 10 hours after the last time someone took a drink and typically resolve within 48 hours.

Some early signs of minor alcohol withdrawal include:

  • Minor Shakes or Tremors
  • Increased Anxiety
  • Constant Sweating (regardless of ambient temperature)
  • Insomnia

These symptoms are usually very minor and may fully resolve within a day or two of the last drink. While not normally dangerous, this can be a fairly uncomfortable experience. The symptoms will usually peak around 12 to 16 hours after the last time someone had a drink, and begin a rapid improvement from this point forward.

Signs of Moderate Withdrawal

Moderate alcohol withdrawal symptoms can be much more problematic, as there are more intense and varied symptoms. Someone may experience moderate withdrawal if they had been drinking a little more than a pint of liquor a day for several months or years. These symptoms may begin a little sooner than during mild withdrawal, typically around 12 to 24 hours after the last time someone had a drink. The symptoms will escalate much more quickly as well, usually reaching their peak intensity within a few hours of their appearance.

Some of the early signs of moderate alcohol withdrawal include:

  • Visible Shaking and Tremors
  • Heavy, Constant Sweating (regardless of ambient temperature)
  • Intense Anxiety
  • Heart Rate and Blood Pressure Increases
  • Minor Hallucinations
  • Mild Confusion

These symptoms may become quite unpleasant and usually last for several days. Someone may appear at first to only have minor withdrawal symptoms, but these will escalate to a greater level of severity. Due to this, there is a greatly increased risk of cardiovascular issues and complications due to the rapid changes in heart function. Additionally, someone experiencing moderate withdrawal is at an increased risk of seizure, so medical attention is always recommended if someone is expecting moderate withdrawal symptoms.

Signs of Severe Withdrawal

Severe alcohol withdrawal is an extremely dangerous and possibly fatal set of symptoms that absolutely require medical attention if someone is to complete withdrawal safely. The symptoms will begin mildly and only escalate from there. Not only is someone’s own well being at stake, but it is not uncommon for people experiencing severe withdrawal symptoms to become violent and confused, possibly injuring those around them. These symptoms will begin around 6 hours from the last time someone had a drink.

Some of the early signs of severe alcohol withdrawal include:

  • Severe Shaking and Tremors
  • Tonic-Clonic (Grand Mal) Seizures
  • Hallucinations (audio, visual, tactile, but usually a combination)
  • Wild Changes in Heart Rate and Blood Pressure
  • Hyper- or Hypothermia
  • Severe Sweating (regardless of ambient temperature)
  • Severe Anxiety
  • Confusion and Delirium
  • Increased Irritability or Aggression

These symptoms will appear and increase very rapidly, reaching extremely intense levels in a short time. Symptoms may last for around a week in some cases and the greatest risk of seizure is between 36 to 72 hours since the last time someone drank. Someone in this position is in great danger, and medical help must be summoned if they are to make it through this safely.

These symptoms pose a great danger in and of themselves, but an additional risk posed by severe alcohol withdrawal is the emergence of delirium tremens. This is an extremely intense and amplified version of these symptoms which includes very vivid hallucinations, profound disorientation with regard to time and place, and paranoid delusions which may result in violent outbursts. Delirium tremens poses an even greater risk of withdrawal seizure, stroke, cardiac arrest, and brain damage and is considered a medical emergency by healthcare professionals.

Post-Acute Withdrawal Symptoms

Post-acute withdrawal syndrome can last anywhere from weeks to months depending on someone’s use habits and is a more minor, and strictly psychological set of symptoms. Additionally, there are few symptoms which are added to this roster such as depression, and cravings, in particular, may increase during post-acute alcohol withdrawal. Some of the most common symptoms during the post-acute phase include:

  • Depression and Lethargy
  • Irritability and Fatigue
  • Insomnia
  • Increased Anxiety
  • Very Vivid Dreams or Nightmares
  • Extreme Mood Swings
  • Increased Cravings for Alcohol

This phase of alcohol withdrawal can last for many weeks, or even many months. The severity of the symptoms will decrease with time, but again, someone’s use habits will determine the length of time this lasts.

What Causes Alcohol Withdrawal Symptoms?

The short answer: physical dependence. The symptoms of alcohol withdrawal are actually due to the neuroplasticity and neuroadaptive abilities of the brain. When someone drinks for an extended time, the brain will adapt so that it can better function in the presence of alcohol. The way alcohol affects the brain is to slow everything down by turning up the effectiveness of some neurotransmitters, and simultaneously turning down the effectiveness of others.

After prolonged use, the brain attempts to balance these levels by undergoing regulation processes. For the neurotransmitters that were amplified, it undergoes “downregulation” to bring their impact back down to normal levels. For the neurotransmitters whose effect was turned down, it undergoes “upregulation” to make the lower levels have more of an effect.

Downregulated Neurotransmitters

The neurotransmitters GABA, dopamine, and serotonin are released at high levels through alcohol use. The levels released are different between these three, but in the case of alcohol use and withdrawal, GABA is the number one offender. It is an inhibitory neurotransmitter that plays a role in relaxation, response time, and pain relief. Once downregulation occurs, the brain lowers the number of receptors for GABA so that it doesn’t continuously moderate brain functions. After alcohol is removed the downregulated GABA system has much less of a calming effect on the brain, and this reduces the brain’s ability to manage the hyperactive symptoms of alcohol withdrawal such as tremors, hallucinations, anxiety, and elevated vital functions. Downregulation of dopamine and serotonin during alcohol withdrawal is a factor as well but typically does not manifest physically and only produces mental effects such as depression, anxiety, and fatigue.

Upregulated Neurotransmitters

Glutamate and norepinephrine are the two main neurotransmitters responsible for alcohol withdrawal. These are both stimulating neurotransmitters which help promote activity in the brain and body. Glutamate is a general excitatory neurotransmitter that acts as an amplifier, helping signals move between neurons. Norepinephrine is a stress-related neurotransmitter in the brain and a stress hormone in the body. It is responsible for a variety of vital functions such as muscle contraction, heart function, blood circulation, and signaling the production of adrenaline from the adrenal glands. Since both of these neurotransmitters have reduced effect in the presence of alcohol, the body turns up the number and sensitivity of receptors to compensate. Once alcohol is removed, this upregulated response to glutamate and norepinephrine is responsible for the majority of alcohol withdrawal symptoms. The nervous system hyperactivity, hallucinations, and symptoms of delirium tremens (DT) are a direct result of the increased effect that these chemicals have.

During alcohol withdrawal, not only is there a decrease in neurotransmitters that relax and slow brain functions (GABA), there is also an increase in neurotransmitters that produce hyperactivity and excitation (glutamate and norepinephrine). The effects of selective up and down-regulation processes produce a perfect storm of risk and discomfort for anyone going through acute alcohol withdrawal.

Alcohol Withdrawal Treatment Medications

Alcohol use and withdrawal have both been common for a very long time. Due to this, medical science has had substantial time to develop medications for alcohol withdrawal treatment. There are many effective medications that are extremely well tested and many which are investigational or currently undergoing clinical trials. Also, the difference in symptoms between the acute and post-acute phases of alcohol withdrawal requires distinct medications for treatment.

Some of the more commonly used medications for acute alcohol withdrawal include:

  • Benzodiazepines
  • Barbiturates
  • Antipsychotics
  • Certain Blood Pressure Medications
  • Certain Muscle Relaxers

The treatment of post-acute alcohol withdrawal requires more fine-tuning due to the variety and different severity of the symptoms between individuals. The most commonly reported symptoms include depression, cravings, insomnia, and anxiety. Some of the medications frequently prescribed during this phase include:

  • Antidepressants
  • Anti-Anxiety Medications (typically non-narcotic)
  • Sleep Aids (non-narcotic)
  • Opioid Antagonists (to reduce cravings)
Alcohol Withdrawal Medications

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