Everything you need to know about alcohol withdrawal

Alcohol withdrawal symptoms can be extremely unpleasant and, in some cases, even life-threatening. Withdrawing from any substance is difficult, but alcohol is one of a handful of substances that can cause death if the withdrawal symptoms are severe and not managed appropriately.

We’re going to explore everything you need to know about alcohol withdrawal – symptoms, timelines, what to expect after withdrawal and how to get help.

What is alcohol withdrawal?

Alcohol withdrawal syndrome is the cluster of signs and symptoms that appear in alcohol-dependent people 6-24 hours after they have their last drink. Mild alcohol withdrawal is quite common – an Australian survey of problem drinkers found that 14% of those surveyed reported sweating the day after drinking, and 9% reported tremors. However, symptoms can be far more severe than this and may require professional support and monitoring depending on how dependent on alcohol you are.

Causes of alcohol withdrawal

Heavy and prolonged drinking has profound effects on the brain and its balance of neurotransmitters. The two that are most responsible for alcohol withdrawal are gamma-aminobutyric acid (GABA) and glutamate. GABA is the brain’s main inhibitory neurotransmitter – it calms down the brain. This is why drinking alcohol makes people feel calmer, or sometimes even sleepy. Alcohol also suppresses glutamate – the brain’s main excitatory neurotransmitter.

If you drink for a long time, the brain adjusts to high levels of alcohol and compensates for the enhanced levels of GABA and suppressed glutamate in the brain in a process called downregulation. This means your brain becomes less sensitive to GABA and more sensitive to glutamate. When alcohol is taken away, this imbalance of neurotransmitters causes the brain to enter into an overexcited state – and this can be dangerous. This imbalance is the cause of many of the more unpleasant and dangerous withdrawal symptoms like seizures. It’s also why, in the case of severe alcohol addiction, it’s much safer to taper off alcohol or treat it with medication, as suddenly stopping can launch the brain into this dangerous, excited state without giving it time to readjust.

Symptoms of alcohol withdrawal

Alcohol withdrawal symptoms can have different levels of severity. A popular model of alcohol withdrawal divides symptoms into three sets with specific causes.

Symptoms caused by autonomic hyperactivity appear quickly and peak within 24-48 hours. The autonomic nervous system controls many of the body’s involuntary functions, and these symptoms are caused by this system going into overdrive. Common symptoms include sweating, shaking, anxiety and agitation.

Neuronal excitation symptoms occur in 12-48 hours and can include seizures similar to those found in epilepsy.

The third set of symptoms is delirium tremens. This set of symptoms is rare and causes psychological disturbances like hallucinations.

Mild, medium and severe withdrawal symptoms cannot be broken down neatly into these three categories. The seizures found in a state of neuronal excitation, for instance, can be life-threatening. For about ten per cent of people going through alcohol withdrawal, some autonomic withdrawal symptoms can be more severe if the autonomic nervous system goes into a state of very elevated activity. These people will experience big increases in blood pressure, pulse, breathing rate and body temperature.

Milder alcohol withdrawal symptoms include:

• Sweating
• Shaking
• Anxiety
• Low mood
• Irritability
• Fatigue
• Nausea and vomiting
• Sleep disturbances
• Headaches.

More severe symptoms include:

• Agitation
• Confusion
• Disorientation
• Seizures
• Fever
• Hallucinations
• Increased heart and breathing rate.

Timeline

Acute withdrawal symptoms should subside relatively quickly, and the most severe symptoms are usually over in a week – although some can linger afterwards.

In the first 12 hours

Symptoms will begin will to appear. These will generally be milder symptoms like headaches, anxiety and insomnia.

Within 24 hours of the last drink

More severe symptoms will start to present. If hallucinations are going to be part of the withdrawal process, they can begin to occur within 24 hours.

From 24-72 hours from the last drink

Withdrawal symptoms peak at this time. You are at the highest risk of seizures in this window, and delirium tremens may start to kick in. Mild to moderate withdrawal symptoms will reach their most severe at this point and begin to resolve themselves.

After the peak, withdrawal symptoms will start to subside, although lingering withdrawal symptoms like insomnia or mood disturbances can persist for weeks to months.

Post-acute withdrawal syndrome

After acute alcohol withdrawal, a secondary set of symptoms related to mood and cognitive difficulties can present themselves. This is called post-acute withdrawal syndrome or PAWS.

PAWS increases the risk of relapse due to the difficulties it presents for people experiencing it. PAWS symptoms can be very dispiriting and demotivating. They can include depression, anxiety, irritability, impaired concentration and memory issues. Neurobiological changes from prolonged drinking are the likely culprit for developing PAWS. Imbalances in serotonin, cortisol and the dopamine reward system are all caused by long-term alcohol consumption.

Changes to the dopamine reward system, in particular, might explain why PAWS is so difficult. Much like the brain’s GABA and glutamate receptors, dopamine receptors are downregulated when alcohol is consumed heavily over a long time. This is because drinking causes a large increase in dopamine, so the brain desensitises its dopamine receptors to compensate. Downregulated dopamine receptors are less able to register rewards from normal activities, which can lead to anhedonia – a persistent state of a lack of pleasurable feelings. Dopamine receptors can return to normal – but this takes time and patience.

PAWS can last a while after alcohol is discontinued. While total recovery from PAWS may take several years, recovery from symptoms is most rapid at the beginning. Most of the recovery is done in the first six months.

Kindling

Withdrawal symptoms can worsen with repeated episodes of withdrawal. Kindling happens when weaker stimuli that don’t cause severe effects initially progressively lead to worse responses when repeated. Someone may withdraw from alcohol with no ill effects but experience seizures, cognitive impairment and brain damage after withdrawing repeatedly.

Because of this, withdrawal shouldn’t be treated as a singular event, and previous withdrawals should be taken into account when a person is being treated to ensure they can withdraw safely.

The importance of medical supervision and ongoing support

Because alcohol withdrawal can be dangerous, and symptoms can linger afterwards, professional support gives you the best chance of stopping drinking safely and remaining sober.

You may need medical supervision or support with medication to undergo withdrawal. Supervision allows professionals to monitor your vital signs and help you to withdraw safely, and you might be prescribed drugs like benzodiazepines to counter withdrawal symptoms and prevent seizures.

However, once acute withdrawal is completed, the battle isn’t over. Getting professional help will give you access to therapy, treatments and support groups that can bolster your ongoing sobriety. If you’re struggling with the symptoms of post-acute withdrawal syndrome, you may feel low, anxious and demotivated – and these can all increase the risk of relapse. Emotional and psychological interventions and long-term recovery planning are all crucial, especially in the early stages of recovery when PAWS symptoms are the most pronounced.

We can help you quit alcohol – safely and permanently

If you want to quit drinking but you’re scared of the withdrawal process, UKAT can help. We can get you through the alcohol detox process safely and comfortably and give you the ongoing support you need to stay sober and build a healthier, happier life.

Reach out today to start your journey.