Alcohol withdrawal and seizures

Alcohol Withdrawal Syndrome (AWS)

Alcohol Withdrawal Syndrome (AWS) is the collection of symptoms that occur when an habitual drinker stops or drastically reduces alcohol intake. The symptoms start anywhere from two hours to a few days after the last drink. They usually begin around six hours following the last drink, are worst at 24 to 72 hours, and improve by seven days. They can last weeks.

The "hangover" that we get the day after drinking is actually part of AWS. So, even someone who is not an habitual drinker will experience some AWS after a night of binge-drinking.

Alcohol Withdrawal Syndrome encompasses a variety of disorders: a simple "hangover", Delirium Tremens (DTs), alcoholic hallucinosis, and alcohol withdrawal seizures. Unfortunately, some of these can be fatal, making alcohol withdrawal dangerous in habitual drinkers. We will discuss each of these in turn.

Although they are not included in AWS, I like to think of the ongoing symptoms of alcohol withdrawal in the people who are "alcoholic." This includes prolonged insomnia, cravings, and disordered psychology. Prominent among the disordered psychology is the "pink cloud effect" (Click Here), and the "insanity of alcoholism" (Click Here).

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Other prolonged effects that can be seen in alcohol withdrawal can be the consequences of alcohol liver disease (Click Here), "wet brain" (Click Here), and "relapse dreams" (Click Here).

As well, the suppressed dopamine and other brain chemicals that persist after stopping alcohol intake can result in depression and anxiety, and sometimes other mental health illnesses (Click Here). The brain is usually able to bring these neurotransmitters back to healthy levels, although it may take months (Click Here).

Symptoms of alcohol withdrawal

In general, the severity of alcohol withdrawal symptoms depends on how much and for how long a person has been drinking. However, many other factors come into play, so it is impossible to predict what kind of a withdrawal anyone will have. Because of this, people who are considering stopping or reducing their alcohol intake should do so in consultation with their doctor, or at a medically supervised 7-day detox facility.

As soon as 2 hours - but usually 6 to 12 hours - after the last drink, withdrawal symptoms such as shaking, headache, sweating, anxiety, insomnia, and nausea or vomiting occur. For chronic, heavy drinkers, by 12 to 24 hours it may progress to confusion, hallucinations, hand tremor, agitation, diaphoresis (drenching sweats), psychomotor agitation (jittery movements), and insomnia.

The hallucinations are frightening to experience. They involve seeing, feeling, or hearing things that aren't there. This condition is called alcoholic hallucinosis. When it occurs it usually ends within 48 hours. Unlike the hallucinations that come with DTs, people with alcoholic hallucinosis are aware that the things they see, hear, or feel aren't real.

Seizures

By 24 to 48 hours the possibility of seizures arises. Alcohol-withdrawal seizures carry the risk of death. Withdrawal seizures usually first strike between 24 and 48 hours after someone stops drinking, although they can appear as early as 2 hours after drinking stops. The risk of seizures is especially high in people who previously have undergone multiple detoxifications. This effect of increased seizure risk in people who have detoxed many times is known as kindling.

Seizures occur in a little more than 5% of untreated people in acute alcohol withdrawal. More than 90 percent of alcohol withdrawal seizures occur within 48 hours of the last drink, but rarely (about 3% of seizures) occur up to 20 days after the last drink.

Withdrawal seizures usually consist of generalized tonic-clonic (GTC) seizures. These are the ones you may know of as "grand mal" seizures. The person loses consciousness and falls to the floor. Their body stiffens with the legs extended and the arms fully bent at the elbows so that the fists are on the chest. There may will be grunting, drooling and frothing at the mouth. This lasts about a minute and then the person starts shaking rapidly, which lasts a few minutes. After the seizure the person may be difficult to rouse, and remain in a deep sleep for hours. I have seen many of these seizures in my time as an ER doctor, and they are scary to watch, especially if you haven't seen one before and it's a loved one.

An alcohol withdrawal seizure is always a medical emergency and a 911 call should be made for immediate medical help.

Why the seizures occur

Alcohol causes drastic changes in the brain chemicals (neurotransmitters) GABA and glutamate. These neurotransmitters are involved in regulating the excitability of the brain. Alcohol suppresses excitability, which is why our thinking slows, our reaction time slows, our speech slows and slurs, and even our movements slow.

With prolonged alcohol use this neurotransmitter system gets more and more suppressed as tolerance develops and our alcohol intake increases. Our brain tries to compensate for the alcohol-induced brain slowing by increasing its efforts at exciting the brain. When you suddenly remove or reduce the alcohol, the result is a "hyper-excitable" brain, which can cause seizures.

Delirium Tremens (DTs)

A dangerous complication of AWS is delirium tremens (DTs). Delirium tremens is the most severe form of withdrawal. It occurs in 5 to 20% of patients experiencing detoxification and 1/3 of patients experiencing withdrawal seizures. The DT's are fatal in 5 to 25% of cases.

In most cases, by 48 hours the withdrawal symptoms begin to improve, and the person begins to feel better daily. However, it can sometimes continue to increase in severity to DTs, characterized by hallucinations that are indistinguishable from reality, severe confusion, anxiety, seizures, severe shaking, high blood pressure, diaphoresis (drenching sweats), rapid heart rate, and fever.

DTs usually begin between 48 and 72 hours after drinking has stopped, peak at 5 days, and can last anywhere from 4 to 12 days.

Risk factors for DTs include previous withdrawal seizures or DTs, poor health, abnormal liver function, and older age. The severity of symptoms is dictated by a number of factors, the most important of which is degree of alcohol intake, length of time the individual has been using alcohol, and previous episodes of detoxing from alcohol (kindling).

The alcoholic with DTs is a sorry sight. They are drenched in sweat, disheveled, usually unaware of who or where they are, terrified by hallucinations, shaking badly, and may fall to the ground and have a seizure.

As with seizures, the DTs are a medical emergency, and a 911 call should be made for immediate medical assistance.

Who gets AWS?

In the Western world about 15% of people who drink become alcoholics. About half of people with alcoholism will develop withdrawal symptoms upon reducing their use, with four percent developing severe symptoms. Among those with severe symptoms up to 15% die.

People who have had repeated bouts of heavy alcohol use followed by withdrawal (the so-called "chronic relapsers") are at particularly high risk for severe AWS, including DTs and seizure. The accumulated effects on the brain of the ups and downs of drinking, then a sober period cycling over and over again cause severe symptoms. This is the "kindling" effect I referred to previously.

Treatment

Because of the unpredictability of AWS, any person planning to reduce or stop their alcohol intake should consult a doctor first.

If you have mild to moderate withdrawal symptoms, your doctor may prefer to treat you in an outpatient setting, especially if you have supportive family and friends. Outpatient detoxification in consultation with your doctor is usually safe, effective, and less costly than inpatient detoxification at a hospital or other facility. However, people who are pregnant, lack a support system, are detoxing alone, or have other risk factors may require inpatient detoxification. Be honest with your doctor about your drinking and your medical history so that you can make safe decisions together

The typical treatment of alcohol withdrawal is with benzodiazepines such as chlordiazepoxide or diazepam, especially for the first five days. These medications help prevent seizures and DTs and provide sedation to make the withdrawal process more comfortable. Thiamine should be given for three days in case of "wet brain." Dehydration, low blood sugar, and unhealthy salt levels in the blood are common and should be addressed.

The doctor may wish to treat any rapid heart rate or blood pressure spikes. As well, medications can be used to help with agitation and hallucinations. In cases of severe malnutrition, magnesium may be given to prevent serious heart complications.

At some point in early recovery a complete physical exam and lab work and imaging should be done to assess overall health and to identify any health issues specifically from the drinking. Liver health, in particular, should be checked. Co-existing mental health issues should be screened for as well, but this is often over-looked.

Insomnia is a common symptom, and can persist weeks or months. Insomnia has also been found to be a risk factor for relapse, so it really should be addressed. Studies have found that magnesium or Trazodone can help treat insomnia in recovering alcoholics. Insomnia can be difficult to treat in alcoholics because many of the traditional sleep aids (especially benzodiazepines) work via the same neurotransmitter receptor system as alcohol and are cross-tolerant with alcohol, rendering them ineffective (for sleep) in early recovery. Trazodone is not cross-tolerant with alcohol and has low abuse potential, making it a good option.

Because successful treatment of alcohol withdrawal syndrome doesn't address the underlying disease of addiction, it should be followed by putting together a viable plan for recovery.

Final Thoughts

It has been my experience that alcoholics have a compelling obsession with being in control, as well as a fear of being exposed. Because of this, many try to medically manage their own alcohol withdrawal by obtaining medications on the street or from relatives. I strongly discourage this practice.  Committing to recovery involves letting go of this need for control, because doing things our own way has always failed us.

It's an awesome thing to be happy and healthy and in recovery. But you have to get there safely.

Thanks for reading! Please feel free to leave comments, or to email us with your stories, comments, questions, or words of wisdom at recovery.folio@gmail.com. Please register for free as a member of our recovery community to get notifications of new articles as they come out (click here).