Alcohol Withdrawal: Symptoms, Causes, Timeline, Complications, And Treatment

Alcohol withdrawal describes a range of symptoms that develop when someone who is physically dependent on alcohol suddenly stops or sharply reduces their drinking.

Symptoms of alcohol withdrawal can include shaking, heavy sweating, nervousness, irritability, agitation, rapid heartbeat, elevated blood pressure, difficulty sleeping, delirium tremens, hallucinations, and seizures.

The progression of alcohol withdrawal symptoms typically spans several days and occurs in various stages. The process begins with milder symptoms like tremors and anxiety, which can start as early as six hours after the last drink. More intense symptoms, including hallucinations and seizures, may develop between 12 and 48 hours. The most dangerous stage usually happens between 48 and 72 hours, where delirium tremens (DTs)-a serious and potentially fatal condition-may occur. The duration and intensity of symptoms differ depending on the person’s drinking patterns and overall health.

Approaches to managing alcohol withdrawal include medically supervised detox (MAD), outpatient care, emergency interventions, management of nutrition and electrolytes, as well as behavioral therapies.

What is alcohol withdrawal?

Alcohol withdrawal is a clinical condition marked by both physical and psychological symptoms that arise when individuals who have consumed large amounts of alcohol over an extended period abruptly stop or sharply reduce their intake. This occurs because the central nervous system, which adapts to alcohol’s depressant effects over time, becomes overstimulated once alcohol is removed. The resulting brain hyperexcitability, due to imbalances in neurotransmitters like GABA and glutamate, leads to symptoms such as tremors, sweating, nausea, irritability, anxiety, seizures, and in severe cases, delirium tremens (DTs), as outlined by Richard Saitz and supported by studies published in Alcohol Health and Research World and Alcohol and Alcoholism. Alcohol Withdrawal Syndrome (AWS) can be life-threatening if not properly managed, with complications including cognitive decline, gait disturbances, and coma in severe chronic cases.

However, alcohol withdrawal does not typically occur after just one night of drinking. The condition primarily affects individuals with chronic, heavy alcohol use, as it requires sustained alcohol exposure for the brain to develop a physical dependence. While someone may experience temporary aftereffects such as anxiety or poor sleep after a night of heavy drinking, these are not true withdrawal symptoms but rather short-term alcohol-related effects. Withdrawal becomes a concern only when the body has adapted to the constant presence of alcohol and then suddenly loses that input.

What is delirium tremens?

Delirium tremens represents a severe type of alcohol withdrawal that causes abrupt and intense disturbances in both mental status and nervous system activity. First identified in 1813 in connection with chronic heavy alcohol use, it typically occurs in individuals who suddenly stop or significantly reduce prolonged, excessive drinking. Although less frequent than other withdrawal symptoms, delirium tremens constitutes a medical emergency due to the intensity of its effects, which can include extreme anxiety, disorientation, tremors, paranoia, vivid hallucinations, heavy sweating, increased body temperature, irregular heartbeats, and heightened blood pressure.

‍

As reported in the article “Complications of Alcohol Withdrawal” by Louis A. Trevisan and colleagues, published in Alcohol Health and Research World in 1998, delirium tremens carries a mortality rate between 5 and 25 percent.

What percentage of people with alcoholism experience alcohol withdrawal?

According to the article “A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component” by M. A. Schuckit et al., published in Alcoholism, Clinical and Experimental Research in 2003, 59.3% of individuals with alcoholism experience symptoms of alcohol withdrawal. This study, which utilized the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) criteria to evaluate alcohol dependence, determined that a substantial portion of those with alcohol dependence reported withdrawal symptoms. These results highlight withdrawal’s prevalence as a key aspect of alcohol dependence and emphasize the necessity of monitoring and treating withdrawal to lessen its effects on health outcomes.

Additionally, in the review article “Recognition and Management of Withdrawal Delirium (Delirium Tremens)” by Marc A. Schuckit, published in The New England Journal of Medicine in 2014, it is reported that about 50% of individuals with alcohol-use disorders (AUDs) develop withdrawal symptoms after stopping or decreasing alcohol intake.

Who Is Most Likely to Experience Alcohol Withdrawal?

Individuals most likely to experience alcohol withdrawal are those who have engaged in heavy, prolonged daily drinking, typically consuming eight or more alcoholic drinks per day over an extended period. These individuals are at higher risk because their bodies and brains have become physically dependent on alcohol to maintain chemical balance. When alcohol intake is suddenly reduced or stopped, the central nervous system becomes hyperactive, triggering withdrawal symptoms.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), those with a prior history of alcohol withdrawal or co-occurring conditions like conduct disorder or antisocial personality disorder face a significantly increased risk. Additionally, people who are taking sedative-hypnotic medications, have underlying medical conditions, or possess genetic vulnerabilities may experience more severe or complicated withdrawal symptoms.

Clinical indicators such as a past episode of delirium tremens (DTs), low potassium levels, low platelet counts, and elevated blood pressure can also signal a higher likelihood of severe withdrawal. Research confirms that these factors are associated with greater withdrawal severity and increased medical risk during detoxification.

What are the symptoms of alcohol withdrawal?

The following are the symptoms associated with alcohol withdrawal.

• Tremors: Shaking in the hands or other parts of the body is a frequent indicator of alcohol withdrawal. These tremors arise as the body attempts to adjust to the lack of alcohol. In the study “Extrapyramidal Dysfunction in Alcoholism” by Roger L. Weir, published in the Journal of the National Medical Association in 1980, it is highlighted that such tremors resemble regular tremors but are intensified by anxiety. Tremors commonly appear as one of the earliest neurological symptoms during withdrawal, typically beginning 10 to 20 hours after alcohol cessation.
• Profuse sweating: Notable sweating, particularly on the palms and face, occurs in the early stages of alcohol withdrawal. Alcohol intake stimulates both the circulatory and central nervous systems, leading to an increased heart rate, which then dilates blood vessels and produces more sweat. During withdrawal, the body’s heightened adjustment to the absence of alcohol magnifies this sweating, making it more prominent than usual.
• Anxiety, irritability, and restlessness: Individuals undergoing withdrawal often report feelings of anxiety, irritability, and agitation. This is due to the brain’s dependence on alcohol to help modulate mood and hormones related to stress, like cortisol.
• Increased heart rate and blood pressure: Tachycardia (rapid heartbeat) and hypertension (high blood pressure) are frequent during alcohol withdrawal. Alcohol generally acts as a depressant on the central nervous system, but without it, overstimulation of the nervous system occurs. This triggers elevated heart rate and blood pressure as the body works to restore equilibrium.
• Sleep disturbances: Trouble falling asleep or staying asleep is a signature sign of alcohol withdrawal. While alcohol initially provides a sedative effect, its absence brings about rebound insomnia as the brain tries to normalize its sleep patterns. The report “Substance Abuse Treatment Advisory: News for the Treatment Field Protracted Withdrawal,” published by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2010, indicates that sleep challenges can persist for 1 to 3 years after alcohol is discontinued.
• Delirium tremens: Delirium tremens represents a critical and potentially fatal complication of alcohol withdrawal, usually appearing 48 to 72 hours following the last drink, as described in the article “Delirium Tremens: Assessment and Management” by Sandeep Grover and Abhishek Ghosh in the Journal of Clinical and Experimental Hepatology, 2018.
• Hallucinations: Withdrawal from alcohol can cause visual, auditory, or tactile hallucinations-such as sensations of itching or numbness-typically arising 12 to 24 hours after stopping drinking. Richard Saitz’s 1998 article “Introduction to Alcohol Withdrawal” in Alcohol Health and Research World notes that those with heavier alcohol consumption are at greater risk for hallucinations.
• Seizures: Seizures are a serious complication of alcohol withdrawal, resulting from disrupted electrical signaling in the brain once alcohol is no longer present. The 2017 publication “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management” by S. Jesse et al. in Acta Neurologica Scandinavica explains that over 90% of acute symptomatic seizures develop within 48 hours of stopping long-term alcohol use, most often as generalized tonic-clonic seizures.

How long do alcohol withdrawal symptoms last?

Alcohol withdrawal symptoms typically begin within 6 to 12 hours after the last drink, peak around 24 to 72 hours, and gradually improve over 5 to 7 days. Mild symptoms such as anxiety, nausea, sweating, and insomnia often appear early, while more severe complications like seizures or delirium tremens (DTs) may arise between 48 and 72 hours after stopping alcohol. In some cases, individuals may experience prolonged withdrawal symptoms, including sleep disturbances, fatigue, and mood swings, that can persist for several weeks or even months, a condition known as post-acute withdrawal syndrome (PAWS). The exact duration and intensity of withdrawal depend on factors such as the severity of alcohol dependence, individual health status, and history of previous withdrawals. According to findings referenced on Consensus, the timeline of withdrawal is highly individualized but generally follows this acute phase pattern.

What are the causes of alcohol withdrawal?

The underlying reasons for alcohol withdrawal are outlined below.

• Abrupt stoppage or significant decrease in alcohol intake: The main driver behind alcohol withdrawal is the sudden halt or major reduction in alcohol consumption among individuals with a history of heavy, long-term drinking. In the research article “Introduction to Alcohol Withdrawal” by Richard Saitz, published in Alcohol Health and Research World in 1998, it is explained that the brain, having adapted to alcohol’s sedative influence, becomes excessively excitable when alcohol is quickly removed. This shift results from lessened inhibitory effects of gamma-aminobutyric acid (GABA) and heightened stimulation by glutamate, leading to excessive central nervous system activity. This can cause symptoms ranging from mild anxiety and tremors to severe seizures and delirium tremens.
• Longstanding patterns of alcohol use: Those with extended periods of alcohol misuse face an increased risk for experiencing alcohol withdrawal. The article “Alcohol withdrawal in past-year drinkers with unhealthy alcohol use: Prevalence, characteristics, and correlates in a national epidemiologic survey” by Ofir Livne et al., published in Alcoholism, Clinical and Experimental Research in 2022, reported that 14.3% of individuals with unhealthy drinking habits met the criteria for alcohol withdrawal syndrome (AWS). The findings show that prolonged, heavy drinking greatly raises the risk of AWS when consumption is stopped.
• Development of tolerance and physical reliance: Continued alcohol use results in tolerance, meaning higher amounts are needed to achieve the same effects. This leads to physical dependence, where the body relies on alcohol to function normally, so its absence causes a significant shock to the system.
• History of past withdrawal episodes: As detailed in the article “Kindling in Alcohol Withdrawal” by Howard C. Becker in Alcohol Health and Research World in 1998, individuals with earlier episodes of withdrawal are at greater risk of experiencing more intense symptoms in subsequent withdrawals. This process, called “kindling,” means that repeated withdrawal episodes make the brain more sensitive, leading to progressively severe symptoms.

What is the timeline of alcohol withdrawal?

The progression of alcohol withdrawal usually unfolds through several stages, with symptoms emerging within hours of the last drink and potentially lasting for several days. These stages of alcohol withdrawal are thoroughly described in the study “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management” by S. Jesse et al., published in Acta Neurologica Scandinavica in 2017.

During the initial phase, commonly beginning about 6 hours after the last drink, mild symptoms such as tremors, increased nervous system activity, sleeplessness, and headaches may develop. Despite these symptoms, individuals typically stay alert and aware of their surroundings. This phase, referred to as “minor withdrawal,” generally spans from 4 to 48 hours, representing the earliest stage of withdrawal.

As the process advances to the moderate stage-between 12 and 24 hours-symptoms intensify. While individuals remain conscious, they may experience hallucinations affecting sight, touch, or hearing. These false perceptions and illusions can persist for up to six days.

From 24 to 48 hours after stopping alcohol use, the likelihood of acute symptomatic seizures rises sharply. Hallucinations and illusions can intensify, and symptoms such as confusion, agitation, and disorientation become more pronounced. Manifestations from earlier phases, like shaking, nausea, and anxiety, may persist, become more severe, or begin to resolve. The increased risk of seizures in this time frame represents a significant medical concern, often requiring intervention to avoid serious complications.

The most critical stage, known as delirium tremens (DT), generally sets in 48 to 72 hours after alcohol cessation. Symptoms include severe psychiatric disturbances such as paranoia, loss of inhibition, disrupted awareness, as well as confusion, elevated body temperature, and a rapid heart rate. Delirium tremens is potentially fatal and, without appropriate treatment, can last as long as two weeks, making this phase the most dangerous.

Even after the initial acute withdrawal has passed, there is still a risk for unprovoked seizures, which may occur between 6 and 48 days following the last drink. This pattern demonstrates the potential for extended withdrawal symptoms and complications.

Most withdrawal symptoms begin to subside after 72 hours and typically resolve completely within 4 to 7 days. However, some individuals may continue to experience persistent issues, such as sleep problems and mood changes, for several weeks or months.

When Does Alcohol Withdrawal Begin?

Alcohol withdrawal typically begins within 6 to 12 hours after the last drink. The onset can differ depending on factors such as the length and severity of alcohol use, individual biological characteristics, and any history of prior withdrawal episodes. The study “Alcohol Withdrawal Syndrome: Mechanisms, Manifestations, and Management” by S. Jesse et al., published in Acta Neurologica Scandinavica in 2017, notes that symptoms may appear as early as six hours following the end of extended heavy drinking, with the most severe symptoms usually occurring between 24 and 72 hours. This timeline aligns with clinical practice and is used to direct appropriate medical monitoring and intervention for safe management of withdrawal.

How Long Does Alcohol Withdrawal Continue?

Alcohol withdrawal generally persists for 2 to 10 days, according to the World Health Organization’s (WHO) 2009 guidelines found in the “Withdrawal Management” chapter of Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Following the first two weeks, most symptoms become mainly psychological and can persist for several months in some individuals.

What are the side effects (complications) of alcohol withdrawal?

The complications (side effects) of alcohol withdrawal are outlined below.

• Withdrawal seizures: Seizures related to alcohol withdrawal pose a significant threat to individuals dependent on alcohol. These are typically generalized tonic-clonic seizures, involving sudden unconsciousness and powerful muscle contractions, which makes them particularly hazardous during withdrawal.
• Wernicke-Korsakoff syndrome (WKS): This condition is linked to a deficiency of thiamine (vitamin B1) during withdrawal and presents with cognitive impairment, delirium, and memory problems. The research article “Complications of Alcohol Withdrawal” by Louis A. Trevisan et al., published in Alcohol Health and Research World in 1998, indicates that about 80% of alcoholic patients recovering from Wernicke’s syndrome may subsequently develop Korsakoff’s syndrome, which results in prominent memory disturbances.
• Alcoholic hallucinosis: This rare but notable complication features vivid, distressing hallucinations-sensory perceptions of things that are not actually present. It is most often seen in chronic drinkers who suddenly stop drinking. In alcoholic hallucinosis, unlike delirium tremens, there is a lack of confusion or disorientation; the primary symptoms are hallucinations.
• Cardiovascular complications: Alcohol withdrawal can provoke arrhythmias (irregular heartbeats) and sudden cardiac incidents, particularly after episodes of binge drinking. This is described in the article “Effects of alcohol withdrawal on the cardiovascular system” by Seppo Kähkönen et al., published in Progress in Neuro-Psychopharmacology and Biological Psychiatry in 2011.
• Delirium tremens (DTs): DTs represent a major and dangerous complication of alcohol withdrawal. Consuming large amounts of alcohol regularly over an extended period-such as more than four pints of wine, seven to eight pints of beer, or half a liter of spirits-increases the risk for DTs, which mainly affect those with long-term, excessive alcohol use.
• Disturbances of thought, mood, and perception: Psychiatric issues such as anxiety, depression, and sleep disturbances frequently occur during alcohol withdrawal. Anxiety is often accompanied by palpitations and rapid breathing, while depression increases the risk of suicidal thoughts, especially early in withdrawal. Sleep problems, including trouble falling or staying asleep, can persist for weeks and negatively impact daytime functioning.

Can Alcohol Withdrawal Lead to Fatalities?

Yes, alcohol withdrawal can be fatal, especially in cases where it progresses to severe medical conditions like delirium tremens (DTs), seizures, or Wernicke encephalopathy. These life-threatening complications typically occur in individuals with a long history of heavy alcohol use who suddenly stop drinking without medical supervision.

According to a 2024 review in StatPearls by Bethany R. Canver et al., alcohol withdrawal poses serious clinical risks. One critical condition, Wernicke encephalopathy, results from thiamine deficiency during withdrawal and is marked by confusion, abnormal eye movements, and loss of coordination. If left untreated, it can lead to permanent brain damage or death.

The most dangerous manifestation, alcohol withdrawal delirium (DTs), affects about 3% to 5% of individuals undergoing withdrawal. DTs typically develop 3 to 8 days after the last drink and are characterized by severe agitation, hallucinations, fever, high blood pressure, and confusion. Historically, this condition carried a mortality rate of up to 20%, though with proper medical care, the risk has decreased to about 1%.

Supporting this, studies referenced in the Consensus confirm that alcohol withdrawal syndrome can result in significant morbidity and mortality, especially when unmanaged. These findings emphasize the importance of early detection, medical monitoring, and nutritional support, including thiamine supplementation, during withdrawal to reduce the risk of fatal outcomes.

What are the treatments for alcohol withdrawal?

Treating alcohol withdrawal involves a combination of medical supervision, medication, nutritional support, and behavioral therapy to manage symptoms safely and reduce the risk of complications. The severity of symptoms and the individual’s health history determine whether treatment occurs in an inpatient, outpatient, or emergency setting.

• Medically-assisted detoxification (MAD): This involves supervised withdrawal in a clinical setting where medications are used to manage symptoms and monitor vital signs. Commonly used drugs include benzodiazepines like diazepam, chlordiazepoxide, lorazepam, and oxazepam. Medication tapering is applied to gradually reduce dependence and relieve symptoms such as anxiety, tremors, and seizures. This is typically used for moderate to severe cases.
  
• Outpatient treatment: Appropriate for individuals with mild to moderate withdrawal symptoms who are at low risk for seizures or delirium tremens. Patients are managed outside of a hospital setting while still receiving professional support. This option provides more flexibility and is cost-effective when medically appropriate.
  
• Emergency care: Critical for managing severe withdrawal symptoms such as hallucinations, seizures, severe agitation, or delirium tremens. Emergency departments provide rapid stabilization, medical interventions, and close monitoring to prevent life-threatening complications.
  
• Nutritional and electrolyte management: Many individuals in withdrawal have deficiencies in essential nutrients like thiamine, folate, magnesium, and phosphorus. Supplementing these nutrients helps prevent complications such as Wernicke encephalopathy. In cases involving metabolic disturbances like ketoacidosis, glucose-containing fluids such as dextrose in saline are administered to restore balance.
  
• Behavioral therapy: Psychological support is crucial in managing alcohol addiction and preventing relapse. Cognitive-behavioral therapy (CBT) is commonly used to help individuals identify triggers, challenge harmful thinking, and build healthy coping mechanisms. CBT may be combined with motivational interviewing, relapse prevention strategies, and other supportive interventions for long-term recovery.

What is the best medicine to treat alcohol withdrawal?  

The best medication to treat alcohol withdrawal is diazepam, a long-acting benzodiazepine. Diazepam is favored due to its effectiveness in alleviating withdrawal symptoms, preventing seizures, and reducing the risk of delirium tremens. Its long half-life allows for smoother symptom control and less frequent dosing, which can enhance patient comfort and adherence to the treatment regimen.

In patients with liver impairment, lorazepam is often preferred. Unlike diazepam, lorazepam is metabolized through conjugation rather than oxidation, making it safer for individuals with compromised liver function. This metabolic pathway reduces the risk of drug accumulation and associated side effects in these patients.

Another commonly used benzodiazepine is chlordiazepoxide, which is effective for managing alcohol withdrawal symptoms. However, due to its active metabolites and longer half-life, it may not be suitable for patients with liver dysfunction.

The choice among these medications depends on individual patient factors, including liver health, severity of withdrawal symptoms, and risk of complications. Healthcare providers assess these factors to determine the most appropriate and safe treatment option for each patient.

How can alcohol withdrawal symptoms be managed effectively?

Effectively managing alcohol withdrawal symptoms involves addressing both the physical and psychological elements. Begin by consulting medical professionals who can provide expert care and monitor your progress. Build a strong support network with friends or family members to offer emotional encouragement. Adopt healthy routines, including balanced nutrition, regular exercise, and sufficient rest, to help ease symptoms like mood changes. If your appetite is reduced, use a multivitamin or consume electrolyte-rich fluids like sports drinks.

Engage in relaxation techniques such as deep breathing exercises, meditation, or mindfulness practices to manage stress and anxiety. Ensure you stay well-hydrated, maintain a nutritious diet, and keep open communication with your healthcare providers to make sure your treatment plan remains effective and is adjusted as needed. Continue all prescribed medications as instructed by your doctor.

How to deal with alcohol withdrawal at home?  

Dealing with alcohol withdrawal at home can be challenging and potentially dangerous, especially without medical supervision. However, for individuals experiencing mild withdrawal symptoms and who have no history of seizures or delirium tremens, there are steps that can help reduce discomfort and support stabilization. First, stay hydrated by drinking plenty of water and fluids containing electrolytes, as dehydration is common during withdrawal. Eat small, balanced meals with foods rich in vitamins, particularly thiamine (vitamin B1), to support brain function and reduce the risk of complications like Wernicke encephalopathy.

Get plenty of rest, but try to stay gently active during the day to help regulate your sleep-wake cycle. Minimize stress by creating a quiet, calm environment and avoiding triggers like alcohol-related media or social pressures. If anxiety, restlessness, or cravings become intense, use relaxation techniques such as deep breathing, mindfulness meditation, or light exercise like stretching or walking. It's also crucial to inform a trusted friend or family member who can check in regularly and help monitor your condition. While these strategies may help manage minor symptoms, any sign of severe withdrawal, including confusion, hallucinations, high fever, or seizures, requires immediate emergency medical attention.

What steps can you take to help someone who is experiencing alcohol withdrawal?

Assisting someone during alcohol withdrawal involves providing both emotional support and practical help. Make sure they receive appropriate medical attention, as professional care is essential during withdrawal. Create a judgment-free environment where they feel comfortable sharing their feelings and challenges. Encourage involvement in support groups such as Alcoholics Anonymous (AA) or therapy sessions. Suggest healthy coping strategies, acknowledge their achievements, and help minimize exposure to triggers or stressful situations. Remain patient and offer consistent reassurance and encouragement as they move through their recovery process.

How many days without alcohol to detox can you survive? 

Most individuals can physically survive alcohol detox if symptoms remain mild, and the process typically lasts about 5 to 7 days. Withdrawal symptoms usually begin within 6 to 24 hours after the last drink, peak around 24 to 72 hours, and gradually lessen within a week. However, survival during detox depends on the severity of alcohol dependence. In severe cases, especially when complications like seizures or delirium tremens (DTs) occur, withdrawal can be life-threatening without medical help, potentially becoming critical within 3 to 5 days of stopping alcohol.

Several factors influence how long you can safely detox without medical support:

• Severity and duration of alcohol use: The more prolonged and intense the alcohol use, the greater the risk of severe withdrawal.
  
• Past withdrawal history: Those who have experienced seizures or DTs before are at higher risk of fatal outcomes.
  
• Overall health status: Conditions like heart disease, liver damage, or malnutrition can make detox more dangerous.
  
• Age and metabolism: Older adults or individuals with slower metabolism may detox more slowly and be at greater risk.
  
• Use of other substances: Concurrent use of sedatives or drugs can worsen withdrawal outcomes.

While some individuals can detox without professional help, medical supervision is strongly recommended for anyone with a history of heavy or prolonged alcohol use to reduce the risk of complications or death.