DSM-III

For more information, see Withdrawal

Diagnostic Criteria

A. Cessation of or reduction in heavy prolonged (several days or longer) ingestion of alcohol, followed within several hours by coarse tremor of hands, tongue, and eyelids and at least one of the following:

  1. nausea and vomiting
  2. malaise or weakness
  3. autonomic hyperactivity, e.g., tachycardia, sweating, elevated blood pressure
  4. anxiety
  5. depressed mood or irritability
  6. orthostatic hypotension

B. Not due to any other physical or mental disorder such as Alcohol Withdrawal Delirium.

Differential Diagnosis

Alcohol Withdrawal Delirium

In Alcohol Withdrawal Delirium there are a clouded state of consciousness and other symptoms characteristic of Delirium.

Alcohol Hallucinosis

In Alcohol Hallucinosis the hallucinations are prominent and persistent whereas if they occur in Alcohol Withdrawal, they are brief and poorly formed.

Barbiturate or Similarly Acting Sedative or Hypnotic Withdrawal

Barbiturate or Similarly Acting Sedative or Hypnotic Withdrawal produces a syndrome essentially identical with that of Alcohol Withdrawal.

Hypoglycemia and diabetic ketoacidosis

Hypoglycemia, whether or not related to alcohol, and diabetic ketoacidosis result in symptoms similar to those of Alcohol Withdrawal.

Essential tremor

Essential tremor may suggest the tremulousness of Alcohol Withdrawal.

DSM-IV

For more information, see Substance Withdrawal

The essential feature of Alcohol Withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of (or reduction in) heavy and prolonged alcohol use (Criteria A and B). The withdrawal syndrome includes two or more of the following symptoms: autonomic hyperactivity (e.g., sweating or pulse rate greater than 100); increased hand tremor; insomnia; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures. When hallucinations or illusions are observed, the clinician can specify With Perceptual Disturbances (see below). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (e.g., Sedative, Hypnotic, or Anxiolytic Withdrawal or Generalized Anxiety Disorder) (Criterion D).

Symptoms are usually relieved by administering alcohol or any other brain depressant. The withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been stopped or reduced. However, withdrawal symptoms can develop after longer periods of time (i.e., for up to a few days). Because of the short half-life of alcohol, symptoms of Alcohol Withdrawal usually peak in intensity during the second day of abstinence and are likely to improve markedly by the fourth or fifth day. Following acute Withdrawal, however, symptoms of anxiety, insomnia, and autonomic dysfunction may persist for up to 3-6 months at lower levels of intensity.

Fewer than 5% of individuals who develop Alcohol Withdrawal develop dramatic symptoms (e.g., severe autonomic hyperactivity, tremors, and Alcohol Withdrawal Delirium). Grand mal seizures occur in fewer than 3% of individuals. Alcohol Withdrawal Delirium includes disturbances in consciousness and cognition and visual, tactile, or auditory hallucinations ("delirium tremens," or "DTs"). When Alcohol Withdrawal Delirium develops, it is likely that a clinically relevant general medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, an electrolyte imbalance, or postoperative status).

Diagnostic Criteria

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after Criterion A:

  1. autonomnic hyperactivity (e.g., sweating or pulse rate greater than 100)
  2. increased hand tremor
  3. insomnia
  4. nausea or vomiting
  5. transient visual, tactile, or auditory hallucinations or illusions
  6. psychomotor agitation
  7. anxiety
  8. grand mal seizures

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Specify if:

  • With Perceptual Disturbances

Specifier

The following specifier may be applied to a diagnosis of Alcohol Withdrawal:

With Perceptual Disturbances

This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations, should be considered.

DSM-5

Diagnostic Criteria

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:

  1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bmp).
  2. Increased hand tremor.
  3. Insomnia.
  4. Nausea or vomiting.
  5. Transient visual, tactile, or auditory hallucinations or illusions.
  6. Psychomotor agitation.
  7. Anxiety.
  8. Generalized tonic-clonic seizures.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specify if:

  • With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.

Note: Alcohol withdrawal can only occur in the presence of a moderate or severe alcohol use disorder. It is not permissible to record a comorbid mild alcohol use disorder with alcohol withdrawal.

Specifiers

When hallucinations occur in the absence of delirium (i.e., in a clear sensorium), a diagnosis of substance/medication-induced psychotic disorder should be considered.

Differential Diagnosis

Other medical conditions

The symptoms of alcohol withdrawal can also be mimicked by some medical conditions (e.g., hypoglycemia and diabetic ketoacidosis). Essential tremor, a disorder that frequently runs in families, may erroneously suggest the tremulousness associated with alcohol withdrawal.

Sedative, hypnotic, or anxiolytic withdrawal

Sedative, hypnotic, or anxiolytic withdrawal produces a syndrome very similar to that of alcohol withdrawal.

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