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Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis

Christine Pace, MD, MSc
Section Editor
Richard Saitz, MD, MPH, FACP, DFASAM
Deputy Editor
Richard Hermann, MD


Minor manifestations of alcohol withdrawal include anxiety, agitation, restlessness, insomnia, tremor, diaphoresis, palpitations, headache, and alcohol craving, and often loss of appetite, nausea, and vomiting. Moderate and severe withdrawal syndromes can include hallucinations, seizures, or delirium tremens; the latter two can be life-threatening.

Most people with alcohol use disorder do not experience significant withdrawal when they stop or reduce drinking, but withdrawal is common among medical and surgical inpatients and in emergency departments.

This topic reviews the clinical manifestations, course, assessment and diagnosis of alcohol withdrawal. Ambulatory and inpatient management of alcohol withdrawal syndromes are reviewed separately. (See "Ambulatory management of alcohol withdrawal" and "Management of moderate and severe alcohol withdrawal syndromes".)

The epidemiology, pathogenesis, clinical manifestations, course, screening, assessment, diagnosis, and treatment of risky drinking and alcohol use disorder are also reviewed separately. (See "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Psychosocial treatment of alcohol use disorder" and "Pharmacotherapy for alcohol use disorder".)


The prevalence of alcohol use disorder (alcohol abuse and dependence in DSM-IV) is estimated to be 14 percent in community based samples in the United States [1] and as high as 40 percent among hospitalized patients [2]. Approximately half of patients with alcohol use disorder experience alcohol withdrawal when they reduce or stop drinking [3,4].

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Literature review current through: Nov 2017. | This topic last updated: Jul 20, 2017.
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  1. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 2015; 72:757.
  2. Maldonado JR, Sher Y, Ashouri JF, et al. The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol 2014; 48:375.
  3. Schuckit MA, Danko GP, Smith TL, et al. A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component. Alcohol Clin Exp Res 2003; 27:818.
  4. Goodson CM, Clark BJ, Douglas IS. Predictors of severe alcohol withdrawal syndrome: a systematic review and meta-analysis. Alcohol Clin Exp Res 2014; 38:2664.
  5. Pecoraro A, Ewen E, Horton T, et al. Using the AUDIT-PC to predict alcohol withdrawal in hospitalized patients. J Gen Intern Med 2014; 29:34.
  6. Reoux JP, Malte CA, Kivlahan DR, Saxon AJ. The Alcohol Use Disorders Identification Test (AUDIT) predicts alcohol withdrawal symptoms during inpatient detoxification. J Addict Dis 2002; 21:81.
  7. Saitz R, O'Malley SS. Pharmacotherapies for alcohol abuse. Withdrawal and treatment. Med Clin North Am 1997; 81:881.
  8. Marik P, Mohedin B. Alcohol-related admissions to an inner city hospital intensive care unit. Alcohol Alcohol 1996; 31:393.
  9. de Wit M, Best AM, Gennings C, et al. Alcohol use disorders increase the risk for mechanical ventilation in medical patients. Alcohol Clin Exp Res 2007; 31:1224.
  10. Bard MR, Goettler CE, Toschlog EA, et al. Alcohol withdrawal syndrome: Turning minor injuries into a major problem. J Trauma 2006; 61:1441.
  11. Most D, Ferguson L, Harris RA. Molecular basis of alcoholism. Handb Clin Neurol 2014; 125:89.
  12. Turner RC, Lichstein PR, Peden JG Jr, et al. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med 1989; 4:432.
  13. Limosin F, Loze JY, Boni C, et al. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Neurosci Lett 2004; 362:91.
  14. Holzbach E. Thiamine absorption in alcoholic delirium patients. J Stud Alcohol 1996; 57:581.
  15. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA 1997; 278:144.
  16. ISBELL H, FRASER HF, WIKLER A, et al. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 1955; 16:1.
  17. VICTOR M, ADAMS RD. The effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis 1953; 32:526.
  18. Gorwood P, Limosin F, Batel P, et al. The A9 allele of the dopamine transporter gene is associated with delirium tremens and alcohol-withdrawal seizure. Biol Psychiatry 2003; 53:85.
  19. Victor M, Brausch C. The role of abstinence in the genesis of alcoholic epilepsy. Epilepsia 1967; 8:1.
  20. Saitz R. Introduction to alcohol withdrawal. Alcohol Health Res World 1998; 22:5.
  21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  22. Schuckit MA. Recognition and management of withdrawal delirium (delirium tremens). N Engl J Med 2014; 371:2109.
  23. van Munster BC, Korevaar JC, de Rooij SE, et al. Genetic polymorphisms related to delirium tremens: a systematic review. Alcohol Clin Exp Res 2007; 31:177.
  24. Palmstierna T. A model for predicting alcohol withdrawal delirium. Psychiatr Serv 2001; 52:820.
  25. Eyer F, Schuster T, Felgenhauer N, et al. Risk assessment of moderate to severe alcohol withdrawal--predictors for seizures and delirium tremens in the course of withdrawal. Alcohol Alcohol 2011; 46:427.
  26. Berggren U, Fahlke C, Berglund KJ, et al. Thrombocytopenia in early alcohol withdrawal is associated with development of delirium tremens or seizures. Alcohol Alcohol 2009; 44:382.
  27. Wright T, Myrick H, Henderson S, et al. Risk factors for delirium tremens: a retrospective chart review. Am J Addict 2006; 15:213.
  28. Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002; 162:1117.
  29. Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994; 272:519.
  30. Hecksel KA, Bostwick JM, Jaeger TM, Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 2008; 83:274.