Alcohol Withdrawal DSM-5 291.81 (F10.329, F10.232)
DSM-5 Category: Alcohol-Related Disorders
Introduction
Alcohol Withdrawal is a diagnosis in DSM-5 which may be a potentially life-threatening state that is found in people who engage in heavy drinking for a period of time, then either stop or dramatically decrease their alcohol intake. The period of heavy drinking can be variable, for weeks, months, or years. The more the person drinks during this time, the more likely it is for alcohol withdrawal symptoms to occur (Dugdale, 2013). Most of the time, these symptoms are found in adults, but may develop in adolescents or even children. The occurrence of these symptoms is one significant sign of serious alcohol addiction (Caetano, Clark, & Greenfield, 1998). Symptoms can vary greatly from relatively mild tremors to very significant convulsions (Myrick & Anton, 1998).
Symptoms of Alcohol Withdrawal
Alcohol Withdrawal symptoms can start as soon as two hours past the last drink (Karriem-Norwood, 2013). Typically, the onset of symptoms is within eight hours of the last drink. They may continue for a period of time ranging from days to weeks, depending on severity. Most of the time, these symptoms reach their peak in 24 to 72 hours.
Symptoms listed in the DSM-5 include sweating and increased heart rate (over 100 beats per minute), hand tremors, insomnia, nausea and vomiting, agitation, anxiety,
and in more severe cases hallucinations and seizures (American Psychiatric Association, 2013). Other sources (Dugdale, 2013; Medina, 2014) list other symptoms as being common. These include depression, fatigue, irritability, mood swings, nightmares, confused thinking.
Other symptoms included are clammy skin, dilated pupils, headache, loss of appetite, paleness, and tremors of the body. Fever and severe confusion may be seen in
more severe cases.
Symptoms of alcohol withdrawal may significantly worsen quickly (Karriem-Norwood, 2013). Because of this possibility, medical attention should be sought even if initial symptoms appear to be mild. If the symptoms worsen and become severe, this constitutes a medical emergency. Seizures, fever, severe confusion, hallucinations and irregular heartbeat are causes for calling 911 or taking the person to the nearest emergency room.
Risk Factors
Factors that may affect the length of time withdrawal symptoms last and how severe they may become have been discussed in Asplund, Aaronson, & Aaronson (2004). Some of these factors were how long a person has consumed alcohol, how many times in their lives they have been through detoxification, if there were seizures or
episodes of DTs (delirium tremens), and intense craving for alcohol. These conditions will determine the course of treatment for the current episode, including the detoxification course.
Diagnosis
Criteria for diagnosing Alcohol Withdrawal according to DSM-5 (American Psychiatric Association, 2013) are specific. Either stopping completely or severely
curtailing consumption of alcohol that has been heavy and has lasted for a long time. Two or more of these symptoms beginning a few hours or days after stopping or reducing alcohol intake: sweating or pulse rate over 100 beats per minute, hand tremors, difficulty sleeping, nausea or vomiting, illusions or hallucinations that come and go, physical agitation, anxiety, seizures. The symptoms listed must cause significant distress or impairment in areas of functioning. They are not due to a general medical condition or another mental disorder including withdrawal or intoxication from another substance.
Differential Diagnosis
There are a number of other conditions that may have similar or some of the same symptoms as alcohol withdrawal. It is very important to differentiate these conditions
in order to proceed with the appropriate course of treatment.
Intoxication with several other drugs may lead to enough similarities in symptom picture to require taking a close look at what may be going on. There are a number of
other drugs that bring on symptoms like increased blood pressure, fast heartbeat, fever, and sweating. Screening for these drugs can rule them out as a possible reason for these symptoms.
People with encephalitis can exhibit symptoms like those of alcohol withdrawal, also. Some of these symptoms include sensorimotor issues and altered mental states.
Specific medical evaluation must be completed to rule this condition out.
Meningitis can bring on fever and change in mental status, also. Once again, specific medical tests must be conducted to determine the possibility of this condition
being present.
Hypoglycemia may show symptoms like tremor, anxiety, fatigue, and even loss of consciousness. Medical evaluation to rule this condition out is necessary.
Other mental disorders also have symptom pictures similar to that of alcohol withdrawal. Schizophrenia involves bizarre thoughts, no motivation, and poor hygiene.
Somatization disorders can involve seizure-like behavior, anxiety, and depression. Careful evaluation including specific questioning regarding behavior, onset, and duration, along with information gained from significant others of the patient can help in differentiating these conditions from alcohol withdrawal.
Treatment of Alcohol Withdrawal
As with any psychological or physical disorder, careful evaluation of the patient is a necessity in order to plan and conduct the appropriate course of treatment.
With alcohol withdrawal being one of those disorders which may include significant physical issues, this type of evaluation must include a thorough physical examination.
The possibility of serious medical conditions being present with the psychological issues involved in this disorder suggests the first step in appropriate treatment to be caring for any of these being present. Alcohol withdrawal should never be considered a routine event.
The goals of treatment for alcohol withdrawal are the same whether inpatient or outpatient treatment is used. These goals include keeping withdrawal symptoms to as low a level as possible, treating and possibly preventing any complications resulting from the use of alcohol, and social and psychotherapies to bring on abstinence and to deal with any psychological issues that may arise.
Mild to moderate symptoms may allow a patient to be treated in an outpatient setting (Karriem-Norwood, 2013). This is appropriate if the patient has sufficient
family and social support. Of course, outpatient treatment is less expensive than inpatient treatment in a hospital or institution that works with alcohol-related problems. It also is safe and effective for many patients. Daily contact with a health-care provider may be necessary.
Treatment in outpatient settings may include medications to ease the withdrawal symptoms. These medications may include benzodiazepines, chlordiazepoxide, lorazepam, or oxazepam. In some cases, carbamazepine (an anticonvulsant medication) may be used in the place of benzodiazepines because of the lower potential for abuse and less sedative properties. These medications take the edge off some of the symptoms and may reduce the possibility of developing more serious medical problems.
In cases where the withdrawal symptoms are more severe, other medications may be added. Antipsychotic drugs may be used to control hallucinations and reduce agitation. Beta-blockers can reduce heart rate and blood pressure. Clonidine also can reduce blood pressure. Phenytion may be prescribed to deal with underlying
seizure disorders, even though it won’t affect withdrawal seizures.
If the alcohol withdrawal seizures are severe, patients may be admitted to the hospital for more intensive treatment. This treatment is chosen in cases where delirium tremens develops and if hallucinations are prevalent. Patients who have had previous detoxification episodes and those with some comorbid medical or psychiatric conditions will be treated on an inpatient basis.
Treatment goals are the same as those for outpatient treatment. On the inpatient unit, patients are monitored for blood pressure, temperature heart rate, and blood
levels of body chemicals. Some medications or fluid replacement can be administered by intravenous route. At times, sedation may be used to assist the patient who is going through very severe withdrawal symptoms.
Whether treated in an outpatient or inpatient setting, it is important for the person experiencing alcohol withdrawal to return to a supportive environment where others will help him or her in maintaining abstinence. The best treatment for alcohol withdrawal is continuing abstinence. It may be necessary for the patient to undergo long-term therapy to deal with psychological issues that may underlie or contribute to the alcohol consumption that leads to withdrawal.
Living With Alcohol Withdrawal
Prolonged changes may occur with alcohol withdrawal. Changes in sleep patterns is often seen and may be an influence on rates of relapse. Mood changes and physical
tiredness may last for months after the initial withdrawal period. If the patient continues to drink heavily, physical problems like liver and heart disease may develop.
The lasting changes due to alcohol withdrawal depends on how much damage to bodily organs may have already taken place. Whether the patient can maintain sobriety also determines the lasting effects of alcohol withdrawal.
It is easy to see the necessity of strong support from family and friends to make lasting recovery possible. Continuing to utilize support groups may be necessary to
help the patient continue the behaviors necessary for recovery.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Arlington, VA: American Psychiatric Publishing.
Asplund, C.A., Aaronson, J.W., & Aaronson, H.E. (2004, July). 3 regimens for alcohol withdrawal and detoxification. The Journal of Family Practice. Retrieved from
http://www.jfponline.com/Pages.asp?AID=1730.
Caetano, R., Clark, C.L., & Greenfield, T.K. (1998). Prevalence, trends, and incidence of alcohol withdrawal symptoms. National Institute on Alcohol Abuse and
Alcoholism Epidemiologic Bulletin Number 38. 22(1), 73-79.
Dugdale, D.C. (2013). Alcohol withdrawal. Retrieved from http://www.nim.nih.gov/medlineplus/ency/article/000764.htm
Karriem-Norwood, V. (2013). Alcohol withdrawal. Retrieved from http://www.webmd.com/mental-health/addiction/alcohol-withdrawal-symptoms-treatment.
Medina, J. (2014). DSM-5 alcohol withdrawal symptoms. Retrieved from http://wwwpsychcentral.com/disorders/alcohol-withdrawal/
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