Alcohol Withdrawal Delirium

What is alcohol withdrawal delirium?

Key points

  1. Alcohol withdrawal delirium is the most severe form of alcohol withdrawal.
  2. All heavy, long-term drinkers are at risk for alcohol withdrawal delirium.
  3. Alcohol withdrawal delirium can be fatal. It’s important to address issues with heavy drinking in a safe, medical environment rather than trying it on your own.

Alcohol withdrawal delirium (AWD) is the most serious form of alcohol withdrawal. It causes sudden and severe problems in your brain and nervous system.

An estimated 50 percent of people who have an alcohol addiction will experience withdrawal symptoms if they stop drinking. Of those people, 3 to 5 percent will experience AWD symptoms like grand mal seizures and severe confusion.



What causes alcohol withdrawal delirium?

AWD only affects people with a history of heavy alcohol use. Heavy drinkers may develop this condition if they:

  • suddenly stop drinking
  • reduce their alcohol use too quickly
  • don’t eat enough when reducing alcohol use
  • have a head injury
  • are sick or have an infection

Excessive drinking excites and irritates the nervous system. If you drink daily, your body becomes dependent on alcohol over time. When this happens, your central nervous system can no longer adapt easily to the lack of alcohol.

Alcohol can impact your brain’s neurotransmitters. These are chemicals that act as your brain’s messengers to other parts of your brain and nervous system. When you drink, the alcohol suppresses certain neurotransmitters in the brain. This is what can cause you to feel relaxed when drinking. When the neurotransmitters are no longer suppressed, but are used to working harder to overcome the suppression, they go into a state of over-excitement. If you suddenly stop drinking or significantly reduce the amount of alcohol you drink, it can cause alcohol withdrawal.

At-risk groups

Who is at risk of alcohol withdrawal delirium?

You’re at risk of AWD if you have:

  • been drinking heavily for a long time
  • a history of alcohol withdrawal
  • a history of AWD
  • other health problems in addition to alcoholism
  • a history of seizure disorder or other brain damage

All heavy, long-term drinkers are at risk of AWD. The Centers for Disease Control and Prevention defines heavy drinking as 15 drinks a week for men and eight drinks a week for women.

The following are the equivalent of one drink:

  • 1.5 ounces of distilled spirits or liquor, including gin, rum, vodka, and whiskey
  • 5 ounces of wine
  • 8 ounces of malt liquor
  • 12 ounces of beer

Binge drinking is the most common form of heavy drinking. For women, it is defined as four or more drinks in one sitting. For men, it is defined as five or more drinks in one sitting.

Talk to your doctor if you’re concerned about your drinking habits. They can recommend programs that will help you stop drinking. They can also help you manage any symptoms of alcohol withdrawal you experience when you stop drinking.



What are the symptoms of alcohol withdrawal delirium?

Symptoms of AWD usually occur within three days of changing alcohol use. However, sometimes they may take a week or more to appear. Symptoms of AWD may include:

  • anxiety
  • agitation or irritability
  • confusion
  • excitement
  • fear
  • sudden mood changes
  • delirium (an extremely disturbed state of mind)
  • sensitivity to light, sound, or touch
  • delusions (irrationally believing things that are untrue)
  • hallucinations (seeing or hearing things that are not there)
  • nightmares
  • fever
  • fatigue
  • nausea
  • restlessness
  • chest pain
  • stomach pain
  • increased heart rate or breathing rate
  • excessive sweating
  • increased startle reflex (an exaggerated reaction to unexpected stimuli)
  • involuntary muscle contractions
  • seizures
  • eye and muscle movement problems

Withdrawal timeline

Alcohol withdrawal timeline

Alcohol withdrawal symptoms can start as early as two hours after your last drink, but it’s most likely to start between six hours to a day after your last drink, according to guidelines from American Family Physician.

Withdrawal can be broken down into four stages with distinct symptoms.

Stage 1: 6-12 hours after last drink

The first stage of alcohol withdrawal usually sets in six to 12 hours after the last drink. These minor withdrawal symptoms can include:

  • anxiety
  • insomnia
  • nausea
  • loss of appetite
  • sweating
  • headache
  • increased or irregular heartrate

Stage 2: 12-24 hours after last drink

Alcoholic hallucinosis may be experienced 12 to 24 hours after the last drink, and may continue up to 48 hours after the last drink. It can involve the following different types of hallucinations:

  • tactile hallucinations, such as having a sense of itching, burning, or numbness that isn’t actually occurring
  • auditory hallucinations, or hearing sounds that don’t exist
  • visual hallucinations, or seeing images that don’t exist

It’s rare for people going through alcohol withdrawal to experience hallucinations more than 48 hours after their last drink.

Stage 3: 24 to 48 hours

Withdrawal seizures are most typically experienced 24 to 48 hours after the last drink.

Stage 4: 48 to 72 hours

Alcohol withdrawal delirium sets in 48 to 72 hours after the last drink. Most symptoms will typically peak five days after they begin and will begin to decrease about five to seven days after they begin.



How is alcohol withdrawal delirium diagnosed?

Contact your doctor right away if you’re concerned about the symptoms you’re experiencing during alcohol withdrawal.

Your doctor will review your medical history, 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. Toxicology screening is typically done with a blood or urine sample, and can also indicate if any other substances are in the body. If you’re receiving in-patient treatment, your doctor may perform toxicology screens more than once to monitor your alcohol levels.

Other tests that may be ordered to evaluate your dependency on alcohol or the severity of withdrawal include:

Blood magnesium level: A blood magnesium level, or serum magnesium level, can be done with a simple blood test. Low magnesium levels can indicate alcoholism or severe alcohol withdrawal. Normal magnesium levels are necessary to keep the heart functioning properly.

Blood phosphate level: This can also be evaluated with a blood test. Low phosphate levels may also indicate alcoholism.

Comprehensive metabolic panel: This is a blood test that requires fasting. Abnormal results can indicate alcoholism. It can also tell doctors about your overall health, including liver and kidney functioning.

ECG: An ECG, or an electrocardiograph, checks for abnormalities in the electrical activity in your heart. Since some withdrawal patients experience heart palpitations or arrhythmias, this can evaluate heart health and the severity of withdrawal.

EEG: An EEG, or electroencephalogram, can detect electrical abnormalities in the brain. This may be used to evaluate patients with severe alcohol withdrawal, especially in those who are prone to or are experiencing seizures.

The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) is a series of questions used to measure alcohol withdrawal. Your doctor may use this test to diagnose alcohol withdrawal. 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?


How is alcohol withdrawal delirium treated?

Treatments for AWD may include:

  • intravenous fluids
  • anticonvulsants to prevent or stop seizures
  • sedatives to calm agitation and treat anxiety
  • antipsychotic medications to prevent hallucinations
  • medication to reduce fever and body aches (if they occur)
  • treatment for other alcohol-related conditions
  • rehabilitation to help you stop drinking

AWD can be fatal. Your doctor may suggest that you receive treatment in a hospital so your healthcare team can monitor your condition and manage any complications. It may take up to a week for you to feel better.

Rehabilitation is a long-term treatment plan intended to help treat alcohol addiction.



Complications of alcohol withdrawal delirium

In cases of severe alcoholism or severe alcohol withdrawal, complications may arise that will need to be treated. These are typically associated with frequent heavy consumption of alcohol. Other conditions related to heavy drinking that may need to be treated include:

Alcohol-related liver disease: This occurs after years of heavy drinking and results in scarring and cirrhosis on the liver. Treatment may include antibiotics, “water pills” to remove fluid build-up, and removal of fluid from the abdomen. Left untreated, alcoholic liver disease can cause liver cancer and kidney failure.

Alcoholic cardiomyopathy: In alcoholic cardiomyopathy, the long term use of alcohol leads to hear failure. Treatment may include reducing sodium intake, and prescribing beta blockers and ACE inhibitors. A heart transplant may be needed if cardiomyopathy is not reversible.

Alcoholic neuropathy: Alcoholic neuropathy is damage to the nerves from excessive drinking. Symptoms can include numbness, tingling, painful sensations, and muscle problems. Treatment may rely on physical therapy and controlling symptoms. The nerve damage is normally permanent.

Wernicke-Korsakoff syndrome: Wernicke-Korsakoff syndrome is a brain disorder tied to alcoholism. It often results in brain damage in the thalamus and hypothalamus, and permanent damage to the parts of the brain involved with memory. Vitamin B1 can improve symptoms that include muscle problems, but memory loss is often permanent.

People with AWD are also at increased risk of:

  • injuries from falling during a seizure
  • injuring themselves or someone else while confused
  • developing an irregular heartbeat


Outlook for alcohol withdrawal delirium

Early treatment for AWD is important. Treatment significantly lowers your risks of complications and death.

With timely medical treatment, AWD has very low death rate. However, some symptoms of alcohol withdrawal may last for more than a year. These include:

  • mood swings
  • fatigue
  • sleeplessness


Preventing alcohol withdrawal delirium

The best way to prevent AWD is to drink moderately or not at all. Talk to your doctor if you think you drink heavily. They can help you quit drinking in a safe environment and prevent serious symptoms of alcohol withdrawal. It’s important to address issues with heavy drinking in a safe, medical environment rather than trying it on your own.

Get emergency medical help if you think you’re experiencing symptoms of AWD. You have a better chance of making a full recovery if you receive prompt medical attention.


Support groups for alcohol withdrawal

If you’re planning on decreasing your dependence on alcohol, consult your doctor. They can recommend in-patient or out-patient care, depending on your current health status.

You can also find support groups and resources in a number of places, both online and near you. These include:

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