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Alcohol use disorder and withdrawal
Alcohol withdrawal runs by the clock — tremor, hallucinations, seizures and finally delirium tremens after 2–4 days; benzodiazepines treat it and prevent seizures, and thiamine is given before glucose to prevent Wernicke encephalopathy.
Why it matters in the exam
Exam questions present an inpatient who starts sweating, shaking and becoming confused a day or two after admission, and ask for the diagnosis and treatment. Know the timetable: tremor and anxiety after 6–24 hours, hallucinations (mainly visual) with a clear sensorium after 12–48 hours, seizures after 6–48 hours, and delirium tremens — confusion, fever, tachycardia and hypertension — after 48–96 hours. Delirium tremens is life-threatening. Treatment is symptom-triggered benzodiazepines (CIWA-Ar scale); with severe liver disease or old age a short-acting benzodiazepine not dependent on the liver is chosen (lorazepam, oxazepam).
The second part of the questions deals with complications and staying sober. Wernicke encephalopathy — confusion, ataxia and an eye movement disorder — is treated with high-dose IV thiamine, and some patients progress to Korsakoff syndrome with memory loss and confabulation. For staying sober: naltrexone (forbidden with opioids and in acute liver failure), acamprosate (suitable in liver disease, adjusted to kidney function) and disulfiram (only under supervision and with high motivation). Tests that point to chronic drinking: GGT, a raised MCV and an AST to ALT ratio above 2. The screening tools CAGE and AUDIT also appear in the exam.
Key points
- Tremor 6–24 hours, hallucinations 12–48, seizures 6–48, delirium tremens 48–96.
- Benzodiazepines by CIWA-Ar; lorazepam or oxazepam in liver disease.
- Thiamine before glucose.
- Wernicke: confusion, ataxia, eye movements.
- Sobriety: naltrexone, acamprosate, disulfiram.
Summary table
| Stage or topic | Time or finding | Treatment | Exam notes |
|---|---|---|---|
| Mild withdrawal | 6–24 hours: tremor, sweating, anxiety, tachycardia | Benzodiazepines by CIWA-Ar | Monitor vital signs and electrolytes |
| Alcoholic hallucinosis | 12–48 hours; mainly visual hallucinations, clear sensorium | Benzodiazepines | Not delirium — orientation is preserved |
| Withdrawal seizures | 6–48 hours; generalised tonic-clonic | Benzodiazepines; not phenytoin | Antipsychotics alone lower the seizure threshold |
| Delirium tremens | 48–96 hours: confusion, fever, tachycardia, hypertension | High-dose benzodiazepines, intensive care; phenobarbital if refractory | Significant mortality without treatment |
| Wernicke and Korsakoff | Confusion, ataxia, eye movement disorder; later amnesia and confabulation | High-dose IV thiamine before glucose | Korsakoff is usually irreversible |
| Staying sober | After withdrawal | Naltrexone, acamprosate, disulfiram; support groups | Acamprosate suits liver disease; naltrexone not with opioids |
Free exam questions
בן 54 , אושפז בבית חולים כללי בשל בלבול ואפתיה. לדברי אשתו, שנים רבות הוא שותה אלכוהול בכמות מופרזת. מה מהבאים הכי סביר למצוא בבדיקתו? (the question as examined, in Hebrew)
- א. Gait Apraxia
- ב. Paraparesis
- ג. שיתוק מבט
- ד. אי שליטה על סוגרים
בבית יתומים בשל מצב סוציאלי, הושאר על ידי אמו. במשך שישה חודשים נראתה נסיגה בהתנהגותו, חלה במחלות עונתיות רבות. שבה לקחת אותו חל שיפור במצב כאשר אמו. המצב המתואר מה שם? (the question as examined, in Hebrew)
- א. Sensory Deprivation
- ב. Learned Helplessness
- ג. Insecure-Avoidant Attachment
- ד. Anaclitic Depression
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Sources
- ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, 2020 — Assessment and management of alcohol withdrawal
- APA Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder, 2018 — Medications for alcohol use disorder
- NICE guideline CG100, 2010, updated 2017 — Alcohol-use disorders: diagnosis and management of physical complications
- Kaplan and Sadock's Synopsis of Psychiatry, 12th edition (2021) — Alcohol-Related Disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.