The stages of alcohol withdrawal

Alcohol addiction is a complex and challenging condition that often involves a series of stages, including withdrawal. Understanding these stages is crucial for comprehending the physical and psychological toll that addiction can take.

What is Alcohol Withdrawal?

The development of alcohol addiction can lead to physical dependence on the substance. When the body becomes accustomed to the regular presence of alcohol, it adapts by relying on it.
Consequently, when alcohol is suddenly removed from the system, individuals often endure a challenging phase known as withdrawal. Withdrawal is the body’s way of readjusting to the absence of these substances, and during this period, individuals may experience a range of uncomfortable and sometimes severe symptoms.

The British Medical Journal explains that ‘alcohol withdrawal (acute or imminent) should be suspected in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.’ Alcohol belongs to the depressant class of drugs. This means that alcohol depresses (or reduces) the functioning of the central nervous system (CNS), which acts as the body’s processing and response centre.

One literature review on the effects of alcohol explains that alcohol ‘promotes simultaneous changes in several neuronal pathways, exerting a profound neurological impact that leads to various behavioural and biological alterations.’ This means that it takes the body and brain some time to react if the amount of alcohol in the system is limited or stops altogether, leading to phenomena known as withdrawal symptoms as the body attempts to stabilise.

Alcohol Withdrawal Symptoms

Medical professionals use a tool developed by The Clinical Institute for Withdrawal Assessment (CIWA-Ar) to screen for alcohol withdrawal symptoms.

The scale includes ten common withdrawal symptoms:

• Nausea and vomiting
• Tremors
• Sweating
• Anxiety
• Agitation
• Itching, burning or numbness of the skin
• Auditory disturbances (changes in perception of sound, including hallucinations)
• Visual disturbances (changes in perception of sight, including hallucinations)
• Headaches
• Confusion or disorientation

The CIWA-ar tool scores withdrawal.

• Between 0 -8 suggests mild withdrawal
• Between 9 -15 suggests moderate withdrawal
• 15 and above suggests severe withdrawal symptoms

The Stages of Alcohol Withdrawal

Alcohol withdrawal tends to happen in stages as the body gets used to functioning without ethanol in the system. This leads to ‘the central nervous system becom[ing] overexcited as the inhibition is taken away,’ which creates withdrawal symptoms.

Alcohol withdrawal is usually experienced in three stages:

• Mild
• Moderate
• Severe

These refer to the severity of the symptoms that occur during each stage.

Symptoms experienced in the mild withdrawal stage include headaches, increased levels of anxiety and disrupted sleep patterns or insomnia.

More moderate symptoms that characterise the second withdrawal stage are disorientation, increased heart rate, and sweating as the body encounters issues with homeostasis (regulating body temperature).

The final stage is when the more severe symptoms can occur – this is typically where the onset of delirium tremens happens. Severe withdrawal also carries a risk of seizures. Whilst 50% of individuals who decrease their alcohol intake endure alcohol withdrawal symptoms, only 3-5% experience delirium tremens

What are delirium tremens?

Severe symptoms of alcohol withdrawal are known as Delirium Tremens (DTs). Delirium Tremens is sometimes also referred to as alcohol withdrawal delirium. DTs were first described by clinicians in connection with excessive alcohol consumption in 1813 by physician Thomas Sutton.

Jonathan Chick, a consultant psychiatrist at Royal Edinburgh Hospital, wrote that ‘delirium tremens proper is a dangerous state of disorientation’ and links DTs to patient fatalities.

Symptoms of Delirium Tremens…

• Disorientation, confusion or ‘altered mental status’
• Hypertension
• Hyperthermia
• Aspiration pneumonitis
• Respiratory failure
• Arrhythmias
• Death

When does delirium tremens start?…

Delirium Tremens can begin as early as two days or forty-eight hours after ‘abrupt cessation of alcohol.’

Psychological and cognitive effects of delirium tremens…

In this period, patients experience symptoms that can be very distressing, including ‘global confusion’, a reduction in cognitive function and focus and a reduction in memory.
Some people also experience hallucinations – these are commonly visual hallucinations, but auditory and tactile hallucinations have also been reported. This is known as alcohol hallucinosis. Seeing, hearing and feeling things that others may not can exacerbate the confusion that characterises DTs, meaning patients can feel agitated and overwhelmed.

Physical effects of delirium tremens…

These physiological experiences are often paired with challenging physical symptoms, such as difficulty sleeping and staying still. As delirium tremens progresses, patients often experience an increase in sweating and can develop fevers, as well as tachycardia (increased heart rate) and arrhythmia (irregular heart rate).

How long does delirium tremens last?…

These symptoms can continue for up to eight days. For most people, symptoms peak or end after 3-4 days. Delirium tremens can lead to long stretches of disturbed sleep or insomnia, followed by ‘periods of prolonged sleep.’

Treatments for Delirium Tremens

Delirium tremens and mortality risk…

The longer delirium tremens, the higher the risk of fatality, as the body and mind struggle to maintain function during such a high level of psychological and physiological disorientation. Although delirium tremens is still considered dangerous, treatment means that the mortality rate has dropped below 5%.

Treatment for delirium tremens…

Delirium tremens can be treated pharmacologically. The most common type of medicine used is benzodiazepine.

Medical professionals frequently use:

• Diazepam
• Chlordiazepoxide
• Lorazepam

These medicines are typically administered to the patient intravenously, and the frequency with which they are given is dictated by the type of regimen that is being used.

There are two types of regimen:

• A symptom-based regimen
• A fixed schedule

On a symptom-based regimen, benzodiazepines are administered as and when symptoms peak.

On a fixed schedule, they are administered at regular intervals.

Benzodiazepines are useful in the treatment of alcohol withdrawal as they ‘have been found effective in 1) preventing agitation and alcohol withdrawal seizures; 2) preventing delirium tremens; and 3) as cross-tolerant agents with ethanol.’

This means that they can ease some of the more severe symptoms of withdrawal and work well to initially replace alcohol, as both drugs affect the brain in similar ways.

Alcohol detox

Alcohol detox is a crucial first step in overcoming alcohol dependence. It involves systematically removing alcohol from the body while managing and alleviating withdrawal symptoms. Monitoring during alcohol detox is paramount to ensure the individual’s safety and well-being. This monitoring typically occurs in a medical setting like Linwood House. During detox, individuals may experience a range of withdrawal symptoms, which can vary in severity.

Medical monitoring allows our healthcare providers to assess the individual’s condition, administer medications to alleviate discomfort, prevent severe complications, and provide emotional support. The goal of alcohol detox is not only to remove alcohol from the body safely but also to prepare individuals for ongoing treatment programmes and recovery within rehab.

Get Support Today

For many people, the idea of alcohol withdrawal is a very daunting and quite intimidating process. At Linwood House, we know that it can often feel safer for many people to stay with what we know rather than take those first steps into the unknown. We function on a philosophy that understanding addiction can be one of the most valuable tools to provide yourself with the best chance of recovery.

To find out more about the stages of alcohol withdrawal and learn about the range of support options we provide for alcohol addiction, contact us today.

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