Alcohol withdrawal syndrome; A Review.


A review on alcohol withdrawal syndrome

Table of content:

  • What is alcohol withdrawal syndrome
  • Alcohol use epidemiology
  • Causes of alcohol withdrawal syndrome
  • Signs and symptoms of alcohol withdrawal syndrome
  • Factors that affect alcohol withdrawal syndrome
  • Alcohol detoxification
  • Kindling
  • Alcohol withdrawal syndrome diagnosis
  • Treatment of alcohol withdrawal syndrome
  • Preventing further drinking
  • References

What is alcohol withdrawal syndrome

Alcohol withdrawal syndrome (AWS) is the name for the symptoms that occur when a heavy drinker that has been drinking for weeks, months or years suddenly stops or significantly reduces their alcohol intake.

Alcohol exerts a pervasively negative physical influence throughout the body, and sustained heavy use can cause significant damage to the brain, liver, and heart. If you or someone you know abuses alcohol, it’s essential to seek help. There are many treatment options available, many of which start with formal detoxification.

With alcohol withdrawal syndrome, you may experience both physical and emotional symptoms, ranging from mild anxiety and fatigue to nausea. Some symptoms of AWS are as severe as hallucinations and seizures. It could cause severe complications like delirium tremens (also called DTs). Delirium tremens are characterized by confusion, rapid heartbeat, Disorientation, Tremors, Sweating, Hallucinations, Agitation, Increased blood pressure, fever, etc. The death rate from DTs is estimated to range from 1% to 5%. Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can occur days later. Symptoms usually peak by 24 to 72 hours, but may go on for weeks.


Alcohol use epidemiology

Alcohol is the most widely consumed psychoactive substance in the world. While alcohol can be consumed safely and responsibly, excessive alcohol use can quickly lead to abuse and dependence.

A recent survey from the Substance Abuse and Mental Health Services Administration (SAMHSA) found that 140 million Americans, 12 or older, use alcohol. Of these people, 23% are considered binge drinkers. Roughly 6% were considered heavy drinkers, and another 6% met the criteria for an alcohol use disorder. Unfortunately, only a very small percentage of those with an alcohol use disorder seek treatment, according to these recent findings.


Causes of alcohol withdrawal syndrome

WebMD explained the cause of alcohol withdrawal thus: Heavy, prolonged drinking — especially excessive daily drinking — disrupts the brain’s neurotransmitters, the brain chemicals that transmit messages.

For example, alcohol initially enhances the effect of GABA, the neurotransmitter which produces feelings of relaxation and calm. But chronic alcohol consumption eventually suppresses GABA activity so that more and more alcohol is required to produce the desired effects, a phenomenon known as tolerance.

Chronic alcohol consumption also suppresses the activity of glutamate, the neurotransmitter which produces feelings of excitability. To maintain equilibrium, the glutamate system responds by functioning at a far higher level than it does in moderate drinkers and nondrinkers.

When heavy drinkers suddenly stop or significantly reduce their alcohol consumption, the neurotransmitters previously suppressed by alcohol are no longer suppressed. They rebound, resulting in a phenomenon known as brain hyperexcitability. So, the effects associated with alcohol withdrawal — anxiety, irritability, agitation, tremors, seizures, and DTs — are the opposite of those associated with alcohol consumption.


Signs and symptoms of alcohol withdrawal syndrome

The central nervous system is the most affected by the AWS. The severity of withdrawal can vary from mild symptoms such as sleep disturbances and anxiety to severe and life-threatening symptoms such as delirium, hallucinations, and autonomic instability.

Withdrawal usually begins 8 to 24 hours after the last drink. It can last for up to one week. To be classified as alcohol withdrawal syndrome, patients must exhibit at least two of the following symptoms: increased hand tremor, insomnia, nausea or vomiting, transient hallucinations (auditory, visual or tactile), psychomotor agitation, anxiety, tonic-clonic seizures, and autonomic instability.

The severity of symptoms is dictated by a number of factors, the most important of which is degree of alcohol intake, length of time the individual has been using alcohol, and previous history of alcohol withdrawal. Symptoms are also grouped together and classified:

Alcohol hallucinosis: Patients have transient visual, auditory, or tactile hallucinations, but are otherwise clear.

Withdrawal seizures: Seizures occur within 48 hours of alcohol cessations and occur either as a single generalized tonic-clonic seizure or as a brief episode of multiple seizures.

Delirium tremens: Hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness, and visual and auditory hallucinations. This usually occurs 24 to 72 hours after alcohol cessation. Delirium tremens is the most severe form of withdrawal and occurs in 5 to 20% of patients experiencing detoxification and 1/3 of patients experiencing withdrawal seizures.


Factors that affect alcohol withdrawal syndrome

The severity of AWS depends on a number of factors, including:

  • Alcohol use (level of consumption, frequency, length of use).
  • Use of additional substances.
  • Past withdrawal history.
  • Peak blood alcohol levels.
  • Past withdrawal history is another important factor in alcohol withdrawal. Three or more past withdrawal periods – especially if any one period was severe – can serve as a potential risk for severe withdrawal episodes in the future.
  • Any longstanding abuse of alcohol places you at risk of experiencing the significant adverse effects of alcohol withdrawal.

An assessment from a physician or alcohol addiction specialist will help determine what method of detoxification is right for you, whether you need to attend an inpatient program, and what additional treatment options might be appropriate.


Alcohol Detoxification

Alcohol detoxification is a management method adopted to treat patient with alcohol withdrawal syndrome. There has been a problem of kindling from repeated alcohol detoxification.



Wikipedia explain Kindling thus:

Kindling is a phenomenon where repeated alcohol detoxifications leads to an increased severity of the withdrawal syndrome. For example, binge drinkers may initially experience no withdrawal symptoms, but with each period of alcohol use followed by cessation, their withdrawal symptoms intensify in severity and may eventually result in full-blown delirium tremens with convulsive seizures. Alcoholics who experience seizures during detoxification are more likely to have had previous episodes of alcohol detoxification than patients who did not have seizures during withdrawal. In addition, patients with previous withdrawal syndromes are more likely to have more medically complicated alcohol withdrawal symptoms.

Kindling can cause complications and may increase the risk of relapse, alcohol-related brain damage and cognitive deficits. Chronic alcohol misuse and kindling via multiple alcohol withdrawals may lead to permanent alterations in the GABAA receptors. The mechanism behind kindling is sensitization of some neuronal systems and desensitization of other neuronal systems which leads to increasingly gross neurochemical imbalances. This in turn leads to more profound withdrawal symptoms including anxiety, convulsions and neurotoxicity.

Binge drinking is associated with increased impulsivity, impairments in spatial working memory and impaired emotional learning. These adverse effects are believed to be due to the neurotoxic effects of repeated withdrawal from alcohol on aberrant neuronal plasticity and cortical damage. Repeated periods of acute intoxication followed by acute detoxification has profound effects on the brain and is associated with an increased risk of seizures as well as cognitive deficits. The effects on the brain are similar to those seen in alcoholics who have been detoxified multiple times but not as severe as in alcoholics who have no history of prior detox. Thus the acute withdrawal syndrome appears to be the most important factor in causing damage or impairment to brain function. The brain regions most sensitive to harm from binge drinking are the amygdala and prefrontal cortex.

People in adolescence who experience multiple withdrawals from binge drinking show impairments of long-term nonverbal memory. Alcoholics who have had two or more alcohol withdrawals show more frontal lobe cognitive dysfunction than alcoholics who have experienced one or no prior withdrawals. Kindling of neurons is the proposed cause of withdrawal-related cognitive damage. Kindling from multiple withdrawals leads to accumulating neuroadaptational changes. Kindling may also be the reason for cognitive damage seen in binge drinkers.


Alcohol withdrawal syndrome diagnosis

The patient medical history is very important during the process of diagnosing AWS, and it will also be needful in the mode of detoxification program to be adopted. The doctor will ask about your symptoms, and conduct a physical exam. Some signs your doctor will look for include:

  • Hand tremors
  • Irregular heart rate
  • Dehydration
  • Fever

Your doctor may also perform a toxicology screen. This tests how much alcohol is in your body.

The Clinical Institute withdrawal assessment of alcohol (CIWA-Ar) is a series of questions used to measure AWS. Your doctor may use this test to diagnose AWS. It can also be used to determine the severity of your symptoms. The scale measures the following 10 symptoms:

  • Agitation
  • Anxiety
  • Auditory disturbances
  • Clouding of sensorium, or the inability to think clearly.
  • Headache
  • Nausea/vomiting
  • Paroxysmal sweats, or sudden, uncontrollable sweating
  • Tactile disturbances
  • Tremor
  • Visual disturbances


Questions your doctor may ask include:

  • Who am I?
  • What day is this?
  • Does it feel like there is a band around your head?
  • Do you feel sick to your stomach?
  • Do you feel bugs crawling under your skin?


Treatment of Alcohol Withdrawal Syndrome

Failure to manage the alcohol withdrawal syndrome appropriately can lead to permanent brain damage or death.  It has been proposed that brain damage due to alcohol withdrawal may be prevented by the administration of NMDA antagonists, calcium antagonists, and glucocorticoid antagonists.

If you have mild to moderate withdrawal symptoms, your doctor may prefer to treat you in an outpatient setting, especially if you have supportive family and friends. Outpatient detoxification is safe, effective, and less costly than inpatient detoxification at a hospital or other facility.

However, you may require inpatient treatment if you don’t have a reliable social network, are pregnant, or have a history of any of the following:

  • Severe withdrawal symptoms
  • Withdrawal seizures or DTs
  • Multiple previous detoxifications
  • Certain medical or psychiatric illnesses

The goals of treatment are threefold:

  • Reducing immediate withdrawal symptoms
  • Preventing complications and
  • Beginning long-term therapy to promote alcohol abstinence.

Prescription drugs of choice include benzodiazepines, such as diazepam (Valium), chlordiazepoxide (Librium), lorazepam (Ativan), and oxazepam (Serax). Such medications can help control the shakiness, anxiety, and confusion associated with alcohol withdrawal and reduce the risk of withdrawal seizures and DTs. In patients with mild to moderate symptoms, the anticonvulsant drug carbamazepine (Tegretol) may be an effective alternative to benzodiazepines, because it is not sedating and has low potential for abuse.

To help manage withdrawal complications, your doctor may consider adding other drugs to a benzodiazepine regimen. These may include:

  • An antipsychotic drug, which can help relieve agitation and hallucinations
  • A beta-blocker, which may help curb a fast heart rateand elevated blood pressure related to withdrawal and reduce the strain of alcohol withdrawal in people with coronary artery disease.
  • Clonidine(Catapres), another blood pressure drug
  • Phenytoin (Dilantin), an anticonvulsant which doesn’t treat withdrawal seizures but may be useful in people with an underlying seizure disorder.


Prevention of further drinking

There are three medications used to help prevent a return to drinking: disulfiram, naltrexone, and acamprosate. They are used after withdrawal has occurred.

Getting support from alcoholism



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