Alcohol withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of alcohol in individuals who have developed dependence on alcohol or have used alcohol for a prolonged period or in large amounts.
• Presenting features of Alcohol Withdrawal may include autonomic hyperactivity (e.g., tachycardia, hypertension, perspiration), increased hand tremor, nausea, retching or vomiting, insomnia, anxiety, psychomotor agitation, depressed or dysphoric mood, transient visual, tactile or auditory illusions or hallucinations, and distractibility. Less commonly, Alcohol Withdrawal is complicated by seizures.
• Onset of Alcohol Withdrawal typically occurs within 6 to 12 hours after last use, as blood alcohol concentrations decline. Symptoms vary in type, severity, onset and duration according to the duration and intensity of alcohol use prior to cessation or reduction of use.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Specifiers for clinical presentation:

Because of clinically important variation in their withdrawal syndromes, the following specifiers can be applied to Alcohol Withdrawal (6C40.4).

6C40.40 Alcohol Withdrawal, uncomplicated

All diagnostic requirements for Alcohol Withdrawal are met and the withdrawal state is not accompanied by perceptual disturbances or seizures.

6C40.41 Alcohol Withdrawal, with perceptual disturbances

All diagnostic requirements for Alcohol Withdrawal are met and the withdrawal state is accompanied by perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. There is no evidence of confusion and other diagnostic requirements for Delirium are not met. The withdrawal state is not accompanied by seizures.

6C40.42 Alcohol Withdrawal, with seizures

All diagnostic requirements for Alcohol Withdrawal are met and the withdrawal state is accompanied by seizures (i.e., generalized tonic-clonic seizures) but not by perceptual disturbances.

6C40.43 Alcohol Withdrawal, with perceptual disturbances and seizures

All diagnostic requirements for Alcohol Withdrawal are met and the withdrawal state is accompanied by both seizures (i.e., generalized tonic-clonic seizures) and perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. Diagnostic requirements for Delirium are not met.

6C40.4Z Alcohol Withdrawal, unspecified

Additional Clinical Features:

• Features of mild or moderate withdrawal typically last for 3 to 7 days after cessation of alcohol use and include autonomic hyperactivity, increased hand tremor, anxiety, insomnia, nausea, vomiting, and headache. Features of moderate withdrawal may also include transient visual, tactile or auditory illusions or hallucinations, distractibility and psychomotor agitation.
• Characteristic features of Alcohol Withdrawal are opposite to the acute pharmacological effects of alcohol.
• In 1-3% of cases, Alcohol Withdrawal is complicated by seizures of a tonic-clonic type. When seizures occur, they are usually single seizures with onset within 6 to 48 hours after last use. Evidence of a premorbid seizure disorder, other intracranial pathology, or co-occurring use of other substances does not preclude a presumptive Alcohol Withdrawal diagnosis.
• Approximately 2% of cases of Alcohol Withdrawal progress to a very severe syndrome sometimes referred to as delirium tremens (DTs) characterized by confusion and disorientation, delusions, and prolonged visual, tactile or auditory hallucinations. When delirium is present, a separate diagnosis of Alcohol-Induced Delirium should also be assigned. Presence of seizures during withdrawal represents a risk factor for development of Delirium. If unrecognized or untreated, Delirium during Alcohol Withdrawal is associated with substantially increased mortality as compared to Alcohol Withdrawal without co-occurring Delirium.
• Some symptoms associated with Alcohol Withdrawal such as autonomic hyperactivity, anxiety, and insomnia can recur or persist for several months after abstinence, particularly when the person is exposed to alcohol-associated cues (a conditioned withdrawal state). The presence of such persisting symptoms is not sufficient to meet diagnostic requirements for Alcohol Withdrawal
• Alcohol Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Alcohol Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of alcohol. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Alcohol Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’). For example, if low mood and reduction in energy are reported following use of alcohol, and other characteristic features of Substance Withdrawal are not present, a diagnosis of Substance Withdrawal should not be assigned.
• Some individuals who have previously had Alcohol Dependence may experience symptoms similar to those of Alcohol Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past alcohol use. These symptoms are more transient than those observed during Alcohol Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Alcohol Withdrawal should not be assigned under these circumstances.

Course Features:

• Alcohol Withdrawal is time-limited. Factors that influence the features and time course of Alcohol Withdrawal include: (1) the severity of Alcohol Dependence, if present, (2) the dose, frequency of use, and duration of alcohol use prior to cessation or reduction of that use, (3) the half-life and duration of action of alcohol, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of alcohol. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Alcohol Dependence: Many individuals with Alcohol Dependence develop Alcohol Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Alcohol Dependence and Alcohol Withdrawal should be diagnosed. However, Alcohol Withdrawal can be diagnosed in the absence of a diagnosis of Alcohol Dependence.
• Boundary with Alcohol Intoxication: The onset of Alcohol Intoxication occurs immediately or shortly after the consumption of alcohol. In contrast, Alcohol Withdrawal occurs upon cessation or reduction in the amount of alcohol in the context of Alcohol Dependence or when alcohol has been taken for a prolonged period or in large amounts. For alcohol, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with Alcohol-Induced Delirium: Delirium is characterized by disturbances in attention, orientation, and awareness that develop within a short period of time with symptoms that are transient and may fluctuate depending on the underlying etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium may occur as an aspect of Alcohol Withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both Substance Withdrawal and Alcohol-Induced Delirium should be assigned.
• Boundary with other Alcohol-Induced Mental Disorders: Mental or behavioural symptoms that arise during Alcohol Withdrawal should only be used as a basis for diagnosing an Alcohol-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Alcohol Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Alcohol Withdrawal and an Alcohol-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Alcohol Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Alcohol Withdrawal occur in specific temporal relationship to the cessation of use of alcohol and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of alcohol use, the symptoms persisting for a substantial period of time after cessation of alcohol or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with alcohol use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Alcohol Withdrawal (e.g., tachycardia, hypertension, perspiration, nausea, insomnia, seizures) and those that are characteristic of other medical conditions. Symptoms of Alcohol Withdrawal occur in specific temporal relationship to the cessation of use of alcohol and diminish with the passage of time.
• Boundary with Foetus or Newborn Affected by Maternal Use of Tobacco, Alcohol, or Other Drugs of Addiction: The ICD-11 chapter on Certain Conditions Arising During the Perinatal Period contains categories for ‘Foetus or newborn affected by maternal use of tobacco, alcohol, and other drugs.’ A neonate exhibiting signs of Alcohol Withdrawal may also be Alcohol Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.