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What Are Symptoms of Alcohol Withdrawal?

I'm Sam and have strong interest in substance use and abuse and the psychology of behavioral problems.

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Most of us are aware of how alcohol can be a dangerous substance. Even if we don't know firsthand, many of us have been indirectly exposed to alcohol through the actions of our friends and families who drink. Despite the blatant toxic nature of alcohol’s effects on our minds and bodies, a lot of people still don’t know just how dangerous alcohol can be.

One of the most dangerous things about alcohol is the withdrawal that it can cause. Serious alcohol dependency can create an addiction that is more difficult to quit than even heroin or crystal meth. Contrary to popular belief, heroin withdrawal cannot kill you, but alcohol withdrawal can.

Add that on top of the fact that alcohol-related deaths form one of the most significant statistic pools in the western world, and one might wonder why people choose to drink this substance. Unfortunately, one of the reasons is because that once alcohol dependency strikes, it’s often easier to keep drinking than it is to suffer through withdrawal.

What Causes Alcohol Withdrawal?

Excitotoxicity.

Excitotoxicity is a very dangerous symptom that occurs when certain neurons (brain cells) become overstimulated. In the case of alcohol withdrawal, this happens because of a process known as downregulation and a different process known as glutamate rebound.

Downregulation

Is the neurochemical process that induces tolerance. Tolerance is when you begin to need more of a substance, in this case, alcohol, to get the same effects that you once did. This occurs because alcohol stimulates your brain’s GABA receptors.

  • Your brain doesn’t differentiate between the external source of GABA stimulation (alcohol) and your normal neurotransmitters. Since your brain works very hard to modulate all of its receptor and neurotransmitter systems, it assumes that you are producing too much GABA yourself. To compensate, it downregulates the receptors by making them less sensitive. This means that they need more stimulation to cause the same effects.
  • Downregulation contributes to withdrawal because once you stop drinking, your receptors are still desensitized to GABA. You won’t be able to produce enough to satisfy the receptors, and it can take weeks for them to upregulate. Since GABA is a neurotransmitter responsible for getting rid of anxiety, helping you sleep, and keeping you calm, relaxed, and able to manage stress, this is not a pleasant situation.

Glutamine Rebound

The sudden production of large amounts of glutamine, or spontaneous upregulation of glutamine receptors. Alcohol suppresses the production of glutamine, which is a neurotransmitter heavily involved in learning, forming memories, and putting thoughts together. This is why it’s so easy to black out when you’re drinking alcohol, or why you can’t seem to remember people’s names at parties when you’re drunk.

While you drink, the opposite thing happens to the glutamine system compared to your GABA system. Since alcohol suppresses glutamine, these receptors upregulate. When you stop drinking, your body’s production of glutamine spikes and your glutamine receptors, which are already upregulated, are bombarded with the compound.

Excitotoxicity is caused by the glutamine rebound. Glutamine is a highly excitable neurotransmitter that functions by sending electrical charges as a form of communication. Usually, glutamine is modulated by GABA, which helps to nullify excess glutamine and prevent it from getting too excited, or to calm you if you're glutamine system is in overdrive.

Since your brain isn’t going to be able to feel GABA for a while after you stop drinking, you have no natural mechanism to fight off this glutamine rebound. Excitotoxicity can leave permanent damage in your brain and can even cause fatal seizures.

what-are-the-symptoms-of-alcohol-withdrawal

What Are The Symptoms of Alcohol Withdrawal?

You don’t need to understand the science behind withdrawal to know the pain and discomfort it can bring. Full-blown alcohol withdrawal is one of the most debilitating and unpleasant things that a person can go through, and it’s highly ill-advised to attempt to go through serious withdrawal without medical supervision. Seizures caused by excitotoxicity can kill you, so it’s worth it to seek out medical help or a professional detox.

Even if your withdrawal isn’t serious enough to kill you, the rest of the symptoms may make you want to die. This, combined with the emotional instability that can surface during alcohol addiction and withdrawal, can be a dangerous combination. If you are having suicidal thoughts during withdrawal or at any point during your alcohol addiction, consider contacting a suicide helpline.


Alcohol withdrawal symptoms can begin to appear in as little as two hours after your last drink, though this isn’t a very common occurrence. In this case, it’s probably best for you to arrange a medically supervised detox before attempting to go clean.

More likely, though, it will take you around 12- 24 hours to start feeling withdrawal symptoms, unless you’re a very heavy drinker. This would give you enough time to plan and schedule getting to or setting up an environment for you to begin your detox.

The symptoms of alcohol vary in intensity depending on the severity of your alcohol problem. Any or all of the following can affect someone going through alcohol withdrawal. The times listed are an estimation as to when you will first feel the symptoms. There is no way to be certain how long they will last.

8-12 hours after your last drink

  • Excessive shaking, particularly in the hands, sometimes to the point of being unable to hold anything or eat food
  • Extreme nausea and vomiting, unable to hold food down
  • Anxiety and panic attacks
  • Severe dehydration
  • Headaches
  • Diarrhea
  • Constant sweating
  • Hot flashes and chills
  • Insomnia

24-48 hours after your last drink

  • Delirium, fragmented or confusing thoughts
  • Sensations of ‘primal terror’
  • Hallucinations, most often auditory
  • High blood pressure
  • Fever
  • Delirium tremens, which can include: hyperadrenergic stage caused by adrenaline rebound, disorientation and confusion, tremors and an impaired attention span and consciousness.
  • Seizures (in the most intense cases)

The peak intensity of these symptoms has usually been reached by the 72-hour mark. This is also the time that the alcoholic is most susceptible to having seizures, so it’s important to keep them under close watch and provide them with anti-seizure medication.

The symptoms will continue at maximum intensity for another 24-96 hours, depending on the length and intensity of your alcohol addiction. The first set of symptoms should begin to dwindle on the fifth day, but if you were seriously afflicted by the more serious symptoms that strike after 24 hours, you should prepare for a longer withdrawal. These symptoms can last for anywhere between 4-12 days.

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Protracted or post-acute withdrawal syndrome (PAWS)

There aren’t a ton of medical journals that have done research on protracted withdrawal, or PAWS, so it’s not listed in the Diagnostic and Statistical Manual of Mental Disorders. PAWS is generally understood to be a condition in which the symptoms of withdrawal remain for much longer than the typical withdrawal timeline would suggest.

Usually, after the acute phase of withdrawal is finished - around day 5 or 6 - symptoms will rapidly decline until the user hits baseline. In the case of PAWS, some symptoms can persist for months or years.

While the symptom present in PAWS differ from person to person, the condition is most associated with psychological symptoms. Many people report that the anxiety, depression, cravings, anhedonia (an inability to enjoy pleasurable things), sensory distortion, insomnia and confusion.

1. This suggests that, in the vulnerable state caused by alcohol withdrawal, the brain becomes more susceptible for adopting negative thought patterns or habits that can contribute to mental illnesses.


2. Anhedonia is an addiction-related condition that actually has an understood biochemical cause:

  • The brain is naturally wired to release dopamine at predefined ‘pleasurable’ moments - while there is some variability that determines our personal tastes for certain foods and activities, the average brain releases dopamine after accomplishing things, having sex, exercising, making friends, etc.
  • Any addiction brings the user pleasure, whether the addiction is based on drugs, food, sex, or anything else.
  • Every time you experience something pleasurable, the dopamine travels through the mesolimbic reward pathway and you create a mild association between that activity and the reward, a pleasant feeling.
  • Most addictions cause sufficient release of dopamine, which provides us with that ‘rewarding’ sensation of contentedness. Habitually engaging in these activities will rewire the mesolimbic pathway so that it releases more dopamine after you accomplish that particular activity (scoring drugs, having sex) and less dopamine during natural activities.
  • This makes you physically and biochemically less capable of enjoying things. This is one of the reasons it is so hard for recovering addicts to return to a stable life.

How can I ease the withdrawal symptoms?

A lot of people will tell you that you can’t ease the symptoms of withdrawal, or that anything you do to ease the symptoms will end up replacing one addiction with another. Even hospitals will usually just load you up with highly addictive benzodiazepines to ease the symptoms. Benzodiazepines are great at reducing symptoms, but they are dangerous, and despite what many uninformed doctors say, they are simply not true when people say you cannot ease your withdrawal symptoms.

The reason many people suggest that withdrawal cannot be mitigated is because they are ignorant. The average individual - even the average physician of a medical facility - does not understand or does not care about the underlying mechanisms responsible for causing withdrawal. Many people think it’s the same mechanism that causes a hangover.

When you start to look at the underlying mechanisms of alcohol withdrawal - receptor downregulation, excitotoxicity, and glutamine rebound - you open up new avenues for helping the situation. On that note, it’s vital to remember that serious alcohol withdrawal should always be done under medical supervision. These things may ease withdrawal symptoms, but that won’t be much benefit if a seizure kills you.

GABAergics. There is a lot of inconsistency in the medical community regarding GABAergics and withdrawal. Particularly the fact that the strong GABAergics,benzodiazepines, are often prescribed for alcohol withdrawal, and yet people kicking benzodiazepines are relentlessly warned to avoid alcohol during the withdrawals.

  • GABAergics are the most effective method to eliminate many of the worst symptoms of alcohol withdrawal. Benzodiazepines, in particular, are potent anticonvulsants and can save you from a deadly seizure. However, benzodiazepines pose a huge risk of addiction themselves. Other GABAergics, like baclofen and gabapentin, can reduce symptoms of alcohol withdrawal or PAWS with much less risk of addiction. These two medications also work as calcium-channel blockers, compounds that slow glutaminergic activity. This makes them a more effective solution for raising the seizure threshold (making them less likely) in serious alcoholics who are cross-tolerant to benzodiazepines.
  • If you absolutely must use benzodiazepines, use long-lasting ones for as short a time period as possible
  • Taurine, a simple amino acid, can help ease withdrawal symptoms and reduce liver damage and alcohol-induced oxidation. Taurine is best taken for several weeks prior to trying to go sober, so it can build up and exert its protective effects on the liver.
  • Mirtazapine, typically prescribed for insomnia or depression, has been proven to speed up the alcohol recovery process. It primarily helps users recover from anxiety and depression much quicker, and it also severely reduces cravings for alcohol. Mirtazapine is also a potent anti-emetic and will help get rid of nausea.
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Seeking professional help for alcohol withdrawal

Many rehabilitation facilities offer in-house detoxes. You will be provided with some medication - probably benzodiazepines. They will also probably tell you not to bring any other vitamins or medication to assist your recovery because, despite studies proving their efficacy, treatment with things like Mirtazapine, taurine, and even Gabapentin haven’t made it into mainstream medical education yet.

Usually a detox will be administered prior to you attending a formal rehab. If your addiction is so serious that you are experiencing harsh withdrawal, an inpatient rehab is probably best for you.

Inpatient rehabs are more comprehensive than outpatient rehabs. For the duration of the treatment, you’re not allowed to leave the rehab facility. This allows the patients to focus more on their own recovery, while also eliminating many of the stressors and triggers that can lead to relapse in the outside world.

If you are hoping to help somebody else with their alcohol problem, remember to approach the situation very carefully. It’s important to be compassionate so they don’t think you are attacking them. Once they understand the harm they are doing to you and themselves, they should be easier to commit to rehab.

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2021 Sam Shepards

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