alcohol withdrawal

Last edited 10/2020

Alcohol withdrawal syndrome (AWS) represents a clinical condition characterized by symptoms of autonomic hyperactivity such as agitation, tremors, irritability, anxiety, hyperreflexia, confusion, hypertension, tachycardia, fever and diaphoresis:

  • usually develops in alcohol-dependent patients within 6–24 hours after the abrupt discontinuation or decrease of alcohol consumption

  • potentially life-threatening condition whose severity ranges from mild/moderate forms characterized by tremors, nausea, anxiety, and depression, to severe forms characterized by hallucinations, seizures, delirium tremens (DT) and coma

  • Diagnostic and Statistical Manual of mental disorders (DSM-5) criteria (2)
    • diagnosis of AWS is based on the observation of signs and symptoms of withdrawal in those patients who experienced an abrupt reduction or cessation of alcohol consumption
    • DSM-5 requires the observation of at least two of the following symptoms: autonomic hyperactivity (sweating or tachycardia); increased hand tremor; insomnia; nausea or vomiting; transient visual, tactile or auditory hallucinations or illusions; psychomotor agitation; anxiety; and tonic–clonic seizures

  • mild-moderate form of AWS is often self-managed by patients or disappears within 2–7 days from the last drink (1)

  • severe AWS requires medical treatment

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scale is a useful tool to assess severity of AWS (1)

  • the scale is not a diagnostic tool as it has not been found to be useful in differentiating between DT and delirium due to medical illnesses (3)
  • scale includes 10 common signs and symptoms of alcohol withdrawal with the notable exceptions of pulse rate and blood pressure, which must be a part of the assessment of alcohol withdrawal states

Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants (3)

  • evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity

Alcohol withdrawal may produce features similar to those seen with phaeochromocytoma.


  • DT is a specific type of delirium occurring in patients who are in alcohol withdrawal states
    • alcohol withdrawal delirium is typically associated with psychomotor agitation (hyperactive delirium) and in cases of hypoactive delirium comorbid hepatic encephalopathy, hyponatraemia or other medical illnesses such as pneumonia ((3)
    • alcohol withdrawal delirium has a high mortality of about 8% (3)


  • Mirijello A et al. Identification and Management of Alcohol Withdrawal Syndrome Drugs. 2015 Mar; 75(4): 353–365.
  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th. Arlington: American Psychiatric Association; 2013
  • Kattimani S, Bharadwaj B.Clinical management of alcohol withdrawal: A systematic review. Ind Psychiatry J. 2013 Jul-Dec; 22(2): 100–108.