Alcohol Withdrawal
Psychiatry
Illness script · Psychiatry
Alcohol Withdrawal
CNS hyperexcitability syndrome following abrupt cessation or reduction of chronic heavy alcohol use, ranging from tremor to life-threatening seizures and delirium.
This illness script for Alcohol Withdrawal covers predisposing factors, classic presentation, mechanism, workup, management, and the clinical pivots that separate it from look-alikes—written for USMLE Step 1 and clerkship reasoning.
01
Predisposing factors
- Chronic heavy alcohol use (typically >8 drinks/day for weeks)
- Prior withdrawal episodes (kindling effect increases severity)
- Older age and poor nutritional status increase risk
- Concurrent benzodiazepine or sedative dependence amplifies risk
- Liver disease impairs alcohol metabolism, prolonging exposure
02
Presentation
- Timeline: tremor 6–24 h → seizures 12–48 h → delirium tremens 48–72 h after last drink
- Tremulousness, diaphoresis, tachycardia, hypertension, anxiety (early)
- Withdrawal seizures: generalized tonic-clonic, often multiple, self-limited
- Delirium tremens (DTs): confusion, agitation, hallucinations (visual > tactile), fever, severe autonomic instability
- Alcoholic hallucinosis: vivid hallucinations with clear sensorium, occurs ~12–24 h
- CIWA-Ar score quantifies severity and guides treatment intensity
03
Pathophysiology
- Chronic alcohol → upregulates NMDA (glutamate) receptors, downregulates GABA-A receptors
- Abrupt cessation → unopposed glutamate excitation + GABA deficit → CNS hyperexcitability
- Autonomic surge: catecholamine excess drives tachycardia, hypertension, diaphoresis
- Kindling: repeated withdrawal episodes lower seizure threshold over time
04
Diagnostics
- Clinical diagnosis; CIWA-Ar score ≥10 indicates pharmacotherapy needed
- BMP: check electrolytes (hypokalemia, hypomagnesemia), glucose (hypoglycemia risk)
- LFTs, CBC, coagulation studies to assess liver disease severity
- Serum alcohol level; urine tox screen to rule out co-ingestion
- Head CT if first-time seizure or focal neurologic findings to exclude structural cause
05
Management
- First-line: benzodiazepines (diazepam or lorazepam) — symptom-triggered or fixed-schedule dosing
- Lorazepam preferred in hepatic failure (no active metabolites)
- Thiamine 100 mg IV BEFORE glucose to prevent Wernicke encephalopathy
- Replete magnesium and potassium; maintain hydration
- DTs require ICU admission; refractory cases add phenobarbital or propofol
- Avoid antipsychotics alone — lower seizure threshold; not a substitute for benzos
06
Clinical pivots
How to separate this script from the look-alikes that show up on exams and on the wards.
Sympathomimetic toxidrome (cocaine, amphetamines)
Toxidrome has mydriasis and no prior alcohol use history; urine tox screen positive
Wernicke encephalopathy
Triad of confusion + ataxia + ophthalmoplegia; give thiamine empirically — can coexist with withdrawal
Benzodiazepine withdrawal
Clinically identical syndrome but longer timeline (days–weeks); elicit full drug history
Serotonin syndrome
Features clonus, hyperreflexia, and serotonergic drug exposure — not alcohol cessation history
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Educational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.