What Is Alcohol Withdrawal Syndrome?

Abstinence syndrome occurs when long-term (more than 2 to 3 weeks) heavy drinking and suddenly stop drinking or significantly reduce the amount of alcohol. The patient then develops a series of symptoms and signs, which is called abstinence syndrome or withdrawal syndrome. The pathogenesis is due to the central nervous system's loss of alcohol inhibition and the brain cortex or -adrenergic nerve over-excitation. Occurs mostly in alcoholics who already have physical dependence. Present tremors, delirium, convulsions, confusion, psychomotor and autonomic overexcitation. Each of the major symptoms of withdrawal syndrome can occur more or less in its simple form, but often in different combinations.

Basic Information

nickname

Withdrawal syndrome

English name

Alcohol withdrawal syndrome

Visiting department

Clinical Psychology

Multiple groups

Alcoholics who already have physical dependence

Common causes

The central nervous system loses the inhibitory effect of alcohol, resulting in overexcitation of the cerebral cortex and / or -adrenergic nerves

Common symptoms

Tremor, delirium, convulsions, confusion, psychomotor and autonomic overexcitation

Contagious

no

Causes of alcohol withdrawal syndrome

Physically dependent alcoholics, during the process of abstinence, the central nervous system loses the inhibitory effect of alcohol, resulting in overexcitation of the cerebral cortex and / or -adrenergic nerves.

Clinical manifestations of alcohol withdrawal syndrome

Alcoholic tremor

Or called quitting tremor, is the most common and mild quitting syndrome, often showing the following symptoms:

(1) Common symptoms: accompanied by irritability and gastrointestinal symptoms, especially nausea and vomiting. These symptoms usually begin in the morning after drinking for several days and suddenly abstain from drinking. Resumption of drinking can quickly relieve the symptoms, and the symptoms recur and worsen after stopping drinking again. Symptom duration can vary widely, usually for 2 weeks. The illness peaked 24 to 36 hours after stopping drinking completely. Generalized tremor is the most obvious feature of the disease. It is a tremor that is rapid (6 to 8 Hz), varies in severity, and is relieved in a quiet environment but aggravated during exercise and emotional stress. The tremor can be so severe that the patient cannot stand on his own, can't pronounce clearly, and can't even eat by himself. Sometimes there is no obvious objective manifestation of tremor, only the patient complains of "internal tremor". Flushing anorexia, tachycardia, and tremor in the back can be alleviated after a few days, but excessive alertness, frightening, and exercise tremor can last for a week or more. The feeling of restlessness lasted for 10 to 14 days.

(2) Characteristic clinical manifestations: dark red face, conjunctival hyperemia, tachycardia, anorexia, nausea, and retching. Patients are completely awake, vulnerable to frightening, insomnia, lack of concentration, unwillingness to answer questions, and may respond to rough or threatening ways. The patient may also have a mild temporal disorientation disorder, and cannot fully recall the events a few days after the drinking period, but there is no obvious disturbance of consciousness, and he has a certain understanding of the surrounding environment and his own condition.

2. Alcoholic hallucinations

Refers to the state of hallucinations caused by long-term heavy drinking, which is a rare abstinence syndrome. Patients often have a large number of bright hallucinations within 24 hours after abruptly stopping drinking or reducing doses, and the clinical vision and hearing hallucinations are the main.

(1) Alcoholic hallucinations: often accompanied by various hallucinations. Patients reported having nightmares accompanied by sleep disturbances. Sometimes patients could not distinguish between dreaming and real situations, and hallucinations and reality were confused. Familiar objects are distorted or considered unreal (illusions). According to the frequency of occurrence, it is simple visual hallucination type, audiovisual mixed type, touch hallucination or auditory hallucination. There is no evidence to support that certain visual hallucinations (such as bugs, red elephants) are specific to alcoholism. In fact, the hallucinations of alcoholism are extensive. There are more living than inanimate people. People or animals can be single or group; they can be reduced or enlarged; they can be natural and pleasant; they can also be deformed and scary. And horrible.

(2) Alcoholic mental disorder composed of more or less simple auditory hallucinations: is a special type. Kraepelin calls it alcoholic hallucinations or alcoholic mania. The core manifestation is that although the patient feels normal, for example, the patient has normal directional reactivity and memory, but he has auditory hallucinations. The nature of hallucinations can be unstructured sounds, such as bee buzzing, ringing, gunshots, or tapping, or music-like, low-key humming or chatting. But the most common voice is human voice. Voice can directly talk to patients, but it is more common to talk about patients with third parties. In most cases, voices are malicious, accusatory or intimidating, which seriously interfere with patients' normal lives. To the patient, the sound is extremely real. Another hallmark of auditory hallucinations (and visual hallucinations) is that patients respond to the hallucinations accordingly. Patients may call the police or defend themselves against invasion in order to protect themselves, or they may even attempt suicide to avoid the threat of sound. Its duration varies and can be temporary or retransmit intermittently over several days, and in individual cases can last for weeks or months.

(3) In hallucinations, most people are unaware of the untrueness of hallucinations: As the condition improves, patients begin to doubt the truthfulness of their hallucinations, are willing to tell others about the hallucinations and doubt whether they are conscious. Being able to recognize that the sound you hear is imaginary. If you can recall the abnormal content of thoughts during the onset of mental disorders, it is a sign of complete recovery.

3. Withdrawal seizures

Also known as "rum attack" is a more common symptom during alcohol withdrawal (relative or absolute abstinence after chronic chronic alcoholism). More than 90% of withdrawal seizures occur 7 to 48 hours after stopping drinking, and the peak time is 13 to 14 hours. During the convulsive activity period, the EEG is usually abnormal, but it can be recovered after a few days. It can manifest as a one-time outbreak but most cases are sudden 2 to 6 outbreaks, sometimes more. 2% of patients develop a state of sustained epilepsy, mostly with major seizures. Local seizures suggest the presence of local lesions (mostly trauma) in addition to alcohol. About 30% of patients with systemic seizures develop a state of tremor and delirium, and seizures are a precursor to delirium.

4. Tremor delirium

Tremor delirium is the most severe state of alcoholic disease that can lead to death. It is an acute encephalopathy syndrome that appears on the basis of chronic alcoholism. It occurs mostly in alcohol-dependent patients who continue to drink a lot. It can be caused by trauma, infection and other factors that weaken the body's resistance. Sudden onset usually occurs 3 to 5 days after abstaining from alcohol or weight loss. It is mainly manifested by severe confusion, loss of orientation, vivid delusions and hallucinations, accompanied by tremor, anxiety, insomnia and hyperactive sympathetic nerves, such as dilated pupil , Fever, rapid breathing and heartbeat, increased or decreased blood pressure, and sweating. Most patients have a self-limiting course of delirium. After a few days of restlessness and insomnia, they often stop by going to sleep and then wake up. After waking up, they are conscious, quiet and tired, and have no memory of the events in the delirium stage. In rare cases, delirium gradually subsides. If delirium tremor is a single episode, most patients last no more than 72 hours. Rare cases can have one or more relapses, several delirium attacks of varying degrees, separated by a relatively awake interval, the entire process lasts several days, and occasionally can last 4 to 5 weeks. In some cases, tremor and delirium did not fully recover, and the course progressed to Wernicke encephalopathy or Korsakov syndrome. A small number of cases without complications have a lower case fatality rate in a timely manner. Once complications occur, the mortality rate will increase significantly, often due to high fever, pneumonia or heart failure, etc., or they may die suddenly and the cause cannot be determined. Atypical delirium-hallucinations or states of confusion are closely related to the typical tremor delirium (DT) and have the same incidence. Patients may show only transient, quiet confusion, anxiety, or abnormal behavior that lasts for days or months. Unlike the typical tremor delirium, the atypical state often appears as a single localized event and will not be repeated. Occasional seizures do not cause death. It can also be said that this atypical state is partial mild tremor and delirium.

Abstinence Syndrome Test

Blood test

Occasionally, blood glucose is significantly reduced under the condition of alcohol withdrawal, and normal glycemic ketoacidosis can also occur. The incidence and extent of electrolyte disturbances vary, and changes in blood sodium are uncommon. If changed, it is more common to increase than decrease. The same changes were found in blood chlorine and blood phosphorus, and about a quarter of patients had lower serum calcium and potassium. Most patients have some degree of hypomagnesemia, low partial pressure of carbon dioxide, and elevated arterial pH.

2. Routine lumbar puncture examination

The identification of acute alcohol withdrawal syndrome, especially tremor and delirium, is very meaningful.

3. EEG examination

During the period of chronic alcoholism, the brain wave frequency decreases, and the EEG can return to normal quickly after stopping drinking. The transient arrhythmia (spike wave and paroxysmal discharge) consistent with convulsive activity also returns to normal soon. Except for short-term irregularities during the withdrawal period, the abnormal rate of EEG in patients with rum attacks is not higher than that in normal people, and the abnormal rate of electroencephalogram (EEG) is much higher in patients with non-alcoholic recurrent seizures.

Abstinence Syndrome Diagnosis

Abstinence syndrome occurs when long-term (more than 2-3 weeks) heavy drinking suddenly stops drinking, or when the amount is significantly reduced. The main manifestations are tremor, delirium, convulsions, confusion, psychomotor and autonomic overexcitation. Based on medical history and typical clinical manifestations, diagnosis is generally not difficult. EEG, craniocerebral, chest X-rays, and CT scans are helpful in differential diagnosis.

1. There must be clear evidence of recent discontinuation or reduction in alcohol consumption after repeated, long-term, or heavy drinking.

2. Symptoms and signs cannot be explained by other physical conditions or other mental disorders.

3. At least two of the following symptoms must be present: hyperactive autonomic nervous function; tremor of tongue, eyeball or hands; insomnia; nausea or vomiting; transient hallucinations or illusions; psychomotor agitation; anxiety; Seizures.

Differential diagnosis of alcohol withdrawal syndrome

1. Pay attention to the identification with other toxic encephalopathy.

2. Special attention should be paid to certain primary epilepsy or traumatic epilepsy, etc. may also be induced by drinking, and should be carefully ruled out before making a diagnosis. Large generalized seizures with local manifestations, or epileptic seizures with local manifestations, such as psychomotor or complex partial epilepsy, local motor epilepsy, etc., are not likely to be abstinence epilepsy. Electroencephalography is helpful for identification.

Abstinence Syndrome Treatment

Treatment measures

It is important to distinguish between mild withdrawal symptoms and tremor delirium because mild withdrawal symptoms are benign in nature and respond well to sedative drugs, while tremor delirium has a high mortality rate and relatively poor response to drugs. The principle for the treatment of mild withdrawal symptoms is to ensure rest and sleep, and for patients with delirium and tremor, the treatment is to reduce mental stress.

2. Drug treatment

Phenytoin (phenytoin sodium) does prevent and treat alcoholic epilepsy. If patients are allergic to phenytoin, carbamazepine can be used instead, but barbiturates should be used with caution, as they may increase the risk of respiratory depression. Benzodiazepines are commonly used clinically to control alcohol withdrawal syndrome and to perform detoxification (addiction) treatments because they have cross-tolerance with alcohol. Generally, benzodiazepines with a long half-life are selected for replacement, and the decrease is ended in a short period (about 2 weeks). The decrease principle is fast first and then slow.

3.Treatment of tremor and delirium

(1) Patients should be carefully checked for trauma (especially brain lacerations and subdural hematomas), infections (pneumonia or meningitis), pancreatitis and liver lesions. These complications are very common and serious, and should be performed Craniocerebral and chest X-rays and CT scans were routinely performed with lumbar puncture. For patients with severe tremor and delirium, body temperature, pulse and blood pressure should be recorded every 30 minutes in order to detect peripheral circulation failure and high fever in time. These factors coupled with trauma and infection are often the causes of death. Patients in shock should be given whole blood, body fluids and booster drugs in a timely manner. High fever states require the use of ice caps or blankets in addition to treatment for infections. Correcting water and electrolyte disorders is crucial in the treatment. Due to extreme anxiety and heavy sweating, fluids are needed every day. If serum sodium is very low, special care should be taken to prevent it from causing myelin lysis in the central pontine. For rare hypoglycemia, glucose should be replenished quickly. People with ketoacidosis but normal or mildly elevated blood sugar usually recover quickly without insulin.

(2) It should be noted that the use of glucose solution by alcoholics is particularly dangerous. Intravenous glucose depletion of the final reserve of vitamin B ₁ can induce Wernicke encephalopathy. Tremor delirium is not caused by vitamin deficiency, but alcoholics generally have an eating disorder, high sugar intake (alcohol breakdown into sugars), low vitamin B ₁ content, and B vitamins reserves in the body can also be caused by gastroenteritis and pancreatitis And diarrhea was further reduced. Therefore, in any case, it is best to administer glucose together with B vitamins.