All About Alcohol Withdrawal

Alcohol withdrawal syndrome (AWS) describes a broad range of symptoms a person with AUD may experience when reducing or stopping alcohol misuse.

It’s considered a substance-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). More specifically, it falls under “alcohol-related disorders.”

You may experience AWS between a few hours to a few days after your last drink or suddenly after reducing heavy alcohol use.

AWS is often accompanied by intense cravings to drink and may affect your emotional, cognitive, and physical well-being.

Still, while it’s essential to have your symptoms evaluated by a medical professional, it may be reassuring to know that people with mild-moderate AWS can often manage symptoms by themselves or with the support of family and friends based on their doctor’s recommendations.

In some cases, AWS can be a medical emergency and — if complications arise — potentially life threatening.

Alcohol withdrawal symptoms can range from mild to severe. The symptoms most commonly begin between 6 to 24 hours after your last drink. Still, some symptoms — often more severe — can set in after 2 to 3 days.

Some symptoms of alcohol withdrawal primarily affect your automatic body functions and body movement. These early symptoms typically include:

• tremors
• hyperactivity
• insomnia
• headaches
• stomach pain or nausea
• anxiety
• palpitations
• overactive or over responsive reflexes

These symptoms can range in severity. For example, some people may experience mild nausea with no vomiting, while others may have severe nausea and frequent vomiting or dry heaving.

Still, people experiencing these withdrawal symptoms are generally fully conscious and can think clearly.

Some people also experience psychiatric symptoms, including:

• hallucinations of voices, sounds, or physical objects
• illusions while awake

Delirium tremens and seizures

Delirium tremens (DT) is the most severe form of AWS and occurs in 5% of people with AWS.

These symptoms usually begin 48 to 72 hours after you stop drinking and most commonly last 5 to 7 days. In some cases, symptoms of DT could show up to 10 days later.

During DT, you could experience rapid changes in consciousness and cognition. This may be accompanied by:

• severe sweating
• nausea
• unstable heart rate (palpitations)
• tremor
• anxiety
• agitation or irritability
• hallucinations
• disorientation
• delirium
• psychosis
• hyperthermia
• extremely high blood pressure (malignant hypertension)
• seizures
• coma

Seizures often occur in the early stages of withdrawal, and they may happen in the absence of other AWS. More than 90% of acute seizures occur in the first 48 hours after your last drink.

DT can also cause medical complications, including:

• aspiration pneumonia
• irregularities in your heartbeat (arrhythmia)
• heart attack

These complications may be fatal in 1% to 5% of people.

Minor alcohol withdrawal symptoms typically set in about 6 hours after your last drink and may last 4 to 48 hours.

These symptoms usually peak in intensity on the second or third day of being sober and tend to improve significantly between 2 to 7 days without alcohol use unless more severe symptoms develop.

Moderate symptoms of alcohol withdrawal may last up to 6 days, whereas severe symptoms may last for 5 to 7 days.

Moreover, some symptoms may persist for up to 3 to 6 months but at a lower intensity. These may include:

• anxiety
• insomnia
• tremors
• high blood pressure
• nausea

This is sometimes referred to as protracted or post-acute alcohol withdrawal (PAW), though it’s not recognized in DSM-5. It’s estimated that about 75% of people following acute alcohol withdrawal experience prolonged symptoms.

Some researchers note that these prolonged but lower-intensity symptoms can even persist for 2 or more years — especially symptoms that affect your sleep.

Ultimately, the way your withdrawal presents, the length of time it’ll last, and the range of symptoms you experience vary based on many factors, including

• your medical history
• the duration of your AUD
• the amount of alcohol you typically ingested

When you engage in chronic heavy drinking, your brain adapts to the presence of alcohol in your blood to maintain homeostasis (a balanced state). As your brain grows accustomed to higher blood alcohol concentration levels, it starts to rely on alcohol to function properly.

Once you stop drinking, though, the sudden change may come as a shock to your brain, which altered some of its chemistry to make up for the alcohol’s presence.

Ethanol is the primary alcohol that’s ingested by people with alcohol use disorder. It produces euphoria and other effects at low blood concentrations. It’s also a central nervous system depressant, and your body may become more reliant on ethanol the longer it’s exposed to it. This is the process of developing an alcohol tolerance.

When you stop drinking, after doing so heavily for a long time, the depressant on your central nervous system stops, causing your nervous system to become overexcited. Your body may get overloaded because it has no alcohol to counteract your now perpetually excited nervous system.

This results in the symptoms of withdrawal.

The DSM-5 outlines four diagnostic criteria for alcohol withdrawal.

1. You recently stopped drinking alcohol after heavy and prolonged alcohol use.
2. After stopping or significantly reducing your intake, two or more of the following symptoms occur:
   • autonomic hyperactivity (e.g., sweating or a pulse greater than 100 bpm)
   • increased hand tremors
   • insomnia
   • nausea or vomiting
   • fleeting visual, auditory, or tactile hallucinations or illusions
   • mental restlessness (psychomotor agitation)
   • anxiety
   • seizures
3. Your symptoms cause distress or make it more difficult for you to function normally at work, with friends, and in other important areas of life.
4. Your symptoms aren’t due to another medical condition, mental disorder, or substance.

AWS can evolve in a few hours or a few days but often develops between 6 to 24 hours after your last drink.

The likelihood of developing alcohol withdrawal increases with the amount and frequency of your alcohol intake.

If you seek medical help, the healthcare professional will likely ask you about your:

• drinking habits
• when your symptoms started
• any past experience with AWS

Your doctor may also use a questionnaire like the Clinical Institute for Withdrawal Assessment for alcohol revised scale (CIWA-Ar) to determine the severity of your withdrawal symptoms.

Research shows that only a small portion of people with AWS require medical treatment.

Still, if you’re experiencing alcohol withdrawal, it’s essential to have your symptoms evaluated by a medical professional.

If your symptoms are mild (or perhaps even moderate), your doctor may suggest that you reach out to a friend or family member to help you monitor your symptoms at home.

It’s best to be in a calm and controlled environment to reduce the risk of symptoms progressing toward hallucinations.

If your symptoms become more severe, it’s essential to reach out to your treatment team and seek professional help right away.

The medical professional who evaluated your AWS symptoms may suggest daily follow-ups via telephone or video chat to check on your symptoms and progress. They may also prescribe medications to take at home.

If you have severe symptoms, you may require inpatient or even intensive care level monitoring. In these cases, you’re likely to receive one of the various medications, such as benzodiazepines, the most successful in these cases.

Alcohol withdrawal may cause extreme discomfort. This is why some people may be hesitant or afraid to quit drinking. Still, try to keep in mind that these symptoms — though uncomfortable — are temporary.

The main goal of treatment is to minimize your symptoms and prevent more severe ones like seizures or delirium, which could be fatal in some cases.

After treatment for AWS, treatment of the AUD is recommended. This may include medications, therapy, or both and can be offered in a variety of settings, both inpatient, outpatient, or a hybrid model. It’s also often recommended to join a sobriety support group.

If you’re experiencing alcohol withdrawal, your body might be going through an array of uncomfortable physical and mental changes.

This isn’t the time to be alone. It’s important first to get evaluated by a medical professional and to reach out to a support system if you’re able. This could be family members, friends, members of your community, or people in sobriety support groups.

Try to keep in mind that symptoms are temporary. The most severe symptoms tend to disappear within days, whereas less intense ones may last longer.

The outcomes for most people with alcohol withdrawal are good.

Withdrawal is a natural part of recovering from alcohol use disorder. As you embark on this journey, it’s important to take care and not shame yourself for addiction.

If you want to learn more about substance or alcohol use disorder, alcohol withdrawal, and available support, consider reaching out to one of these resources:

• SAMHSA. You can call the Substance Abuse and Mental Health Services Administration (SAMHSA) helpline at 800-662-4357. This is a free, confidential, 24/7 treatment referral and information service available in English and Spanish.
• National Harm Reduction Coalition. If you’re looking for advocacy, the National Harm Reduction Coalition is an action-oriented group for people with substance use disorder. They also offer a resource center.
• NIAAA. The National Institute on Alcohol Abuse and Alcoholism has a page that details treatment for alcohol problems, specifically finding and getting help.

Alcohol withdrawal is widespread among people with alcohol use disorders who decide to stop drinking or reduce their intake.

Symptoms can range in severity, and it’s essential to have your symptoms evaluated by a medical professional.

While you may be able to manage mild symptoms on your own or with the support of family and friends based on your doctor’s recommendations, more severe symptoms usually require medical treatment.

You’ve taken an important first step toward recovery by deciding to stop drinking. Now, try to keep in mind that even though withdrawal symptoms may be unpleasant, they’re temporary, and treatment is available during this time.