# 05 - Alcohol withdrawal

# Alcohol withdrawal

480
The Maudsley® Prescribing Guidelines in Psychiatry
CHAPTER 4
The following structured assessment tools are recommended:2
■
■The Alcohol Use Disorders Identification Test (AUDIT)4 questionnaire is a ­10-­item 
questionnaire which is useful as a screening tool in those identified as being at 
increasing risk. Questions 1–3 address the quantity of alcohol consumed, 4–6 the 
signs and symptoms of dependence and 7–10 the behaviours and symptoms associated with harmful alcohol use. Each question is scored 0–4, giving a ­maximum 
total score of 40. A score of 8 or more is suggestive of hazardous or harmful alcohol use. Hazardous drinking = consumption of alcohol likely to cause harm. 
Harmful drinking = ­consumption already causing mental or physical health 
problems.
■
■The Severity of Alcohol Dependence Questionnaire (SADQ)5 is a more detailed 20-­item 
questionnaire with the score on each item ranging from 0 to 3, giving a ­maximum total 
score of 60.
Severity of alcohol dependence
Mild
=
SADQ score of 15 or less
Moderate
=
SADQ score 15–30
Severe
=
SADQ score >30
Alcohol withdrawal
In alcohol-­dependent drinkers, the central nervous system (CNS) has adjusted to the 
constant presence of alcohol in the body (neuroadaptation). When the blood alcohol 
concentration (BAC) is suddenly lowered, the brain remains in a hyper-­excited state, 
resulting in the withdrawal syndrome (Tables 4.1 and 4.2). There is no evidence to support prophylactic use of additional anticonvulsant medication to prevent seizures in 
high-­risk individuals.
Table 4.1  Mild alcohol withdrawal.
Mild alcohol withdrawal 
manifestations
Usual timing of onset after 
last drink
Other information
Agitation/anxiety/irritability
Tremor of hands, tongue, eyelids
Sweating
Nausea/vomiting/diarrhoea
Fever
Tachycardia
Systolic hypertension
General malaise
Onset at 3–12 hours
Peak at 24–48 hours
Duration up to 14 days
Symptoms are non-­specific
Absence does not exclude withdrawal
May commence before blood alcohol 
levels reach zero
Management
■
■May be self-­limiting but mitigated with adequate benzodiazepine cover and supportive treatment.
■
■Monitor vital signs. Use a withdrawal assessment scale.
■
■See Table 4.2 for the various benzodiazepine regimens recommended.

Addictions and substance misuse
CHAPTER 4
Table 4.2  Severe alcohol withdrawal.
Severe alcohol withdrawal complications
Usual timing 
of onset after 
last drink
Other information
Generalised seizures
12–18 hours
May commence 
before blood alcohol 
levels reach zero
Management
■
■The occurrence of a first seizure during medically assisted withdrawal requires investigation to rule out organic 
disease or idiopathic epilepsy.
■
■A meta-­analysis of trials assessing the efficacy of drugs preventing alcohol withdrawal seizures demonstrated 
that benzodiazepines, particularly long-­acting preparations such as diazepam, significantly reduced seizures de 
novo.6,7
■
■Long-­acting benzodiazepine is recommended as prophylaxis in those with a previous history of seizures.8
■
■Some anticonvulsants are as effective as benzodiazepines, with some units recommending carbamazepine 
loading in patients with untreated epilepsy, or where seizures have occurred despite adequate benzodiazepine 
loading.6
■
■Phenytoin does not prevent alcohol withdrawal-­related seizures when used on its own or in combination with 
benzodiazepines.9 There is no need to continue anticonvulsants long term when used to prevent seizures in 
alcohol withdrawal.9
Delirium tremens
Clouding of consciousness/confusion
Vivid hallucinations, particularly in visual and tactile modalities
Marked tremor
Other clinical features also include: autonomic hyperactivity 
(tachycardia, hypertension, sweating and fever), paranoid delusions, 
agitation and insomnia
Prodromal symptoms include: night-­time insomnia, restlessness, fear 
and confusion
Risk factors: severe alcohol dependence, self-­detoxification without 
medical input, multiple previous admissions for alcohol withdrawal, 
concurrent medical illness, previous history of delirium tremens and 
alcohol withdrawal seizures, low potassium, low magnesium, thiamine 
deficiency, inadequately treated withdrawal
Recognition is important because treatment is different from delirium 
arising from other causes; delirium tremens needs larger doses of 
benzodiazepines and more caution with antipsychotics
3–4 days
(72–96 hours)
Develops in 3–5% of 
those admitted to 
hospital for alcohol 
withdrawal
A medical emergency
Mortality 10–20% if 
untreated
Management
■
■Delirium tremens is a medical emergency and requires prompt transfer to a general hospital,9 preferably to a 
high-­dependency setting.10,11