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 imcocnIhiw
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AkpJ§Ä
 ]n³amä AkzkvYXIÄ
Withdrawal Symptoms
Nne BfpIfn cà¯nse aZy¯nsâ Afhv Ipdbpt¼mÄ Nne ]n³amä
AkzkvYXIÄ DWvSmImw
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HmÀ½bnÃmbva,
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(]m¼v, tXfv, F«pImen)
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 Three stages of withdrawals

1st stage 2nd stage 3rd stage

Characte- Tremulousness, Intensification of symptoms of Known as Delirium (DT)

rized by restlessness, appetite loss, 1st stage, tremors become more All symptoms of previous
insomnia, anxiety and severe; patient may ‘shake stages.
intense feeling of inside’. Psychomotor agitation
apprehensiveness Grand mal seizure may occur become more intense
(not epilepsy)
Other Pulse and respiration are Pulse, respiration and BP Pulse, respiration and BP
symptoms rapid elevate elevate,
Fever may develop
Behaviour Extremely Audio visual hallucinations may (Audio visual) + Tactile
Uncomfortable, occur, but oriented to time, hallucination with insects
Ready to jump out of the place and person and in reality. and creatures. Orientation
skin Need and respond well to lost, confusion and
reassurance and pacification paranoia. No reality
Awfulness Not dangerous situation. Grand mal seizure may be self Mortality is associated with
May drink to relieve the injurious DT
pain
Requirement Hallucination express emotional Dangerous situation.
and intrapsychic conflict. Should be handled by an
Clinician should analyse the experienced Medical
meaning of hallucinations Therapist
 1st stage
Characte- Tremulousness, restlessness, appetite
rized by loss, insomnia, anxiety and intense
feeling of apprehensiveness

Other Pulse and respiration are rapid

symptoms
Behaviour Extremely Uncomfortable,
Ready to jump out of the skin

Awfulness Not dangerous situation. May drink to

relieve the pain
Requirement
 2nd stage
Characterized Intensification of symptoms of 1st stage, tremors
by become more severe; patient may ‘shake inside’.
Grand mal seizure may occur (not epilepsy)

Other Pulse, respiration and BP elevate

symptoms
Behaviour Audio visual hallucinations may occur, but
oriented to time, place and person and in reality.
Need and respond well to reassurance and
pacification

Awfulness Grand mal seizure may be self injurious

Requirement Hallucination express emotional and intrapsychic
conflict. Clinician should analyse the meaning of
 3rd stage

Characte-rized Known as Delirium (DT)

by All symptoms of previous stages.
Psychomotor agitation become more
intense
Other Pulse, respiration and BP elevate,
symptoms Fever may develop
Behaviour (Audio visual) + Tactile hallucination
with insects and creatures. Orientation
lost, confusion and paranoia. No reality
Awfulness Mortality is associated with DT
Require-ment Dangerous situation.
Should be handled by an experienced
Medical Therapist
 Alcohol Withdrawal Syndrome

Stage I: Tremulousness
Stage II: Hallucinations
Stage III: Seizures
Stage IV: Delirium tremens
Not necessarily sequential*
 Timing of Alcohol Withdrawal
Syndrome Onset after last drink
I. Tremulousness 6-36 hours
II. Hallucinations 12-48 hours
III. Seizures 6-48 hours
IV. Delirium Tremens 3-5 days
 Stage I: Tremulousness

• Symptoms appear within 6 to 36 hours of last drink

• 13-71% of alcohol dependent patients develop
withdrawal symptoms
• Caused by autonomic hyperactivity

Saitz et al. Pharmacotherapies for alcohol abuse. Med Clin of North America. 1997;81:881-907.
 Stage I: Tremulousness

Symptoms Signs
– Tremor – Tachycardia
– Anxiety – Hypertension
– Agitation – Hyper-reflexia
– Insomnia
– Hyperthermia
– Diaphoresis
– Anorexia
– Nausea
– Palpitations
Hall, et al. The Alcohol Withdrawal Syndrome. Lancet, 1997;349:1897-1900.
 Stage II: Alcohol Hallucinations

• Occur within 12-48 hours of last drink

• 3-10 % of withdrawal develop hallucinations
• Duration is variable
• Usually visual (pink elephants)
• Occasionally auditory, tactile (formication), olfactory

Hall, et al. The Alcohol Withdrawal Syndrome. Lancet, 1997;349:1897-1900.

Erwin, et al. Delirium Tremens. Southern Medical Journal, 1998: 91: 425-32.
 Stage III: Seizures “Rum Fits”

• Occur within 6 to 48 hours of last drink

• 3 to 15% of untreated patients develop seizures
• Grand mal
• Risk is increased by duration of alcohol abuse
• 40% are single episodes
• 30% of untreated patients go on to delirium tremens

Saitz et al. Pharmacotherapies for alcohol abuse. Med Clin of North America. 1997;81:881-907.
Erwin, et al. Deliriums. Southern Medical Journal, 1998: 91: 425-32.
 Stage III: Seizures “Rum Fits”
• Alcohol is an independent risk factor for seizures
• Retrospective of 308 pts in a city hospital with new
seizures
• 51-100 gm/day intake= 3 fold increase
• 101-200 gm/day intake= 8 fold increase
• 201-300 gm/day intake= 20 fold increase
– Note 10 gm= 1 beer

Stephen KC, et al. Alcohol Consumption and Withdrawal in New-Onset Seizures. NEJM, 1988: 319: 666--73.
 Stage IV: Delirium Tremens

“In this condition the danger of death is great, and the

mortality is high because delirium tremens
constitutes a major ordeal for the patient’s entire
system, accompanied or preceded as it may be by
intoxication, disturbed nutrition, exhaustion and
exposure of various types.”

Moore, et al. Delirium Tremens: A study of the cases at the Boston City Hospital, 1915-36.
NEJM, 1939: 220: 953-6.
 Stage IV: Delirium Tremens

• Begins 3 to 5 days after last drink

• Occurs in less than 5% of withdrawal patients
• Marked by disorientation and global confusion
• Mortality: 2-10%
• Death: cardiovascular, metabolic, and infections

Holbrook A, et al. Diagnosis and management of acute alcohol withdrawal. CMAJ, 1999: 160: 675-80.