Specific symptoms can vary based on the severity of withdrawal, but the most common alcohol withdrawal symptoms usually begin between 6 to 12 hours after the last time someone took a drink. Symptoms will often increase in severity quite rapidly over the next 12 to 18 hours before plateauing. Around 24 hours after the last drink, someone may notice a slight decrease in symptom intensity, and this will mark the beginning of a gradual decline and weakening of symptoms which typically takes several days to fully resolve.
For a good withdrawal timeline example, we can look at one particular study which involved 217 subjects who underwent alcohol detox. In 24% of these subjects withdrawal symptoms either did not appear at all or had fully resolved within the first day, while 33% of subjects had their withdrawal symptoms resolved by the end of the second day. Another 13.8% of subjects had their symptoms resolved on the third day, with another 10.6% resolving on the fourth day. On the fifth day another 7.8% had their symptoms resolve, while only 10.8% of subjects had withdrawal symptoms that persisted longer than 5 days. To illustrate, the alcohol withdrawal timeline for most people may look like this:
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:
At this point, the shakes can become full-on alcohol withdrawal seizures and can be quite severe. Anxiety will continue to increase, sometimes to the point of full-blown panic attacks. Hallucinations may emerge around this time as well, usually auditory or tactile in nature which may sound like whispers or feel like bugs crawling on the skin.
Some of the more dangerous symptoms will begin to appear around 2 to 3 days after the last drink and include:
If someone is going to experience delirium tremens, this will usually begin around the 48-hour mark. Delirium tremens (DTs) is an intense form of alcohol withdrawal that includes violent seizures, rapid heart rate, elevated blood pressure, intense hallucinations and delusions, and severe confusion and irritability. Without medical care, delirium tremens has a mortality rate of between 35–37%, so this should illustrate the severity of this condition. If someone does develop delirium tremens, these symptoms may persist for around 14 days since the last drink. While it is rare, there have been documented cases in which DTs lasted for 28 days and 35 days, respectively.
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.
By the beginning of the third day, most if not all symptoms will still be present but the severity will be greatly decreased. Seizures and tremors will usually resolve first, followed by elevated cardiovascular function. The last symptoms to resolve are usually shaking, insomnia, sweating, and confusion. In particular, anxiety and depression may persist for several more weeks to some degree, although they will decrease over time. This usually marks the end of the acute phase, and post-acute withdrawal symptoms may persist for several more months.
Post-acute withdrawal syndrome is a more mild form of the withdrawal symptoms which are strictly psychological in nature. This phase may begin after the acute, physical symptoms have subsided and may last for very long periods of time. While the symptoms may appear during the acute phase, it is not until the physical symptoms have resolved that someone is considered to be in post-acute withdrawal from alcohol.
Post-acute alcohol withdrawal 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 that 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:
These symptoms are much milder than the acute detox symptoms, but they last much longer. Insomnia is often the first symptom to resolve, usually after about a month or so. Cravings may slowly reduce over time but may be present for several weeks. Anxiety and depression may persist for several months, although they will usually lessen in intensity over this time. Entering an alcohol detox center will be able to provide medical relief from both the acute and post-acute symptoms of alcohol withdrawal, and possibly even shorten the duration of symptoms.
There is quite a lot of variability between alcohol withdrawal timeline and the intensity of symptoms between individuals. This is due to a variety of factors, some of which are within someone’s control while others were set in stone the moment someone was conceived.
Some of the factors which contribute greatly to the duration of withdrawal and detox include:
By far the greatest contributing factor for the duration of withdrawal symptoms is the amount of alcohol that someone regularly drank. This will directly impact both the severity of symptoms as well as the length of time these symptoms will persist. Withdrawal is a direct result of changes that the brain makes in the continued presence of alcohol. The more someone drinks, the greater these changes become, and thus the withdrawal symptoms become more intense. Likewise, the greater the changes, the longer they will take to reverse and correct. Once these changes have been made and then alcohol is removed, brain function becomes very unstable and chaotic with the result being alcohol withdrawal.
The length of time that someone drinks is also a major contributor to the duration of withdrawal. Similar to the way that the amount of alcohol used can affect withdrawal, the length of time someone drinks can lead to a more complete and “permanent” type of change in the brain. These changes are reversible, but the longer the brain remains in an altered state in the chronic presence of alcohol, the longer it will take to undo the adaptive changes the brain made in the first place.
The number of times that someone has previously undergone withdrawal is also a large contributor to the duration and the intensity of detox. This is known as the “kindling process” and there is a large, and currently growing, body of evidence to suggest that episodes of withdrawal will substantially increase the likelihood of subsequently worsening withdrawal symptoms and durations. This can result in someone experiencing withdrawal which only exhibits mild tremors initially, but through repeated episodes can progress to full blown convulsive seizures. This seems to be the case even if they had drank the same amounts of alcohol for the same duration prior to each withdrawal period.
Mental health issues such as bipolar disorders and schizophrenia may also contribute to the duration and intensity of withdrawal symptoms. These issues may contribute in a more indirect manner, but they certainly affect the experience of withdrawal. During withdrawal, the delirious and possibly psychotic symptoms may be more likely to occur, manifest in a more severe manner, and be more likely to persist longer if someone were to have a preexisting mental health issue. This may be more an issue of withdrawal worsening the underlying mental health issues, but the end result is that withdrawal can last longer, and be more intense if someone is suffering from a preexisting condition.
A genetic predisposition towards alcoholism or addiction can also contribute to the experience of alcohol withdrawal, although the exact relationship is unclear at present. This may either be behavioral or metabolic in nature, but either way a genetic predisposition is an indicator of both withdrawal severity, and withdrawal severity is a fairly reliable predictor and indicator of withdrawal duration.
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.
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.
Glutamate and norepinephrine are the two main neurotransmitters responsible for alcohol withdrawal. These are both stimulating neurotransmitters that 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.
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). This upregulated response to glutamate and norepinephrine is responsible for the majority of dangerous alcohol withdrawal symptoms. The nervous system hyperactivity, hallucinations, and symptoms of delirium tremens (DT) are a direct result of the increased effect that these neurotransmitters have. 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 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 of 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:
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:
Even though alcohol withdrawal can be dangerous, continued alcohol use has its own set of potentially fatal consequences. These include physical, neurological, and psychological consequences that can be devastating and the risks rise the longer someone continues to drink. No matter the risks of alcohol detox, it is almost always safer than continuing to drink alcohol.
Due to the variability in symptoms intensity and duration, unmonitored withdrawal can be a truly horrible experience and can even be potentially fatal in severe cases. When someone is expecting to undergo withdrawal, it is critical that they reach out to medical professionals for help. Alcohol detox centers have trained medical staff, specialized medications, and the latest therapies to provide the most effective treatments for a safe and comfortable alcohol withdrawal and detox experience. Asking for help may be the deciding factor in someone surviving withdrawal. More than surviving, these centers may help someone obtain further treatment care so that they can build a new life free from alcohol.
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