"A continuum of symptoms and signs of central nervous system (including autonomic) hyperactivity may accompany cessation of alcohol intake.

"A mild alcohol withdrawal syndrome includes tremor, weakness, headache, sweating, hyperreflexia, and gastrointestinal symptoms. Tachycardia may be present and blood pressure can be slightly elevated. Symptoms usually begin within about 6 hours of cessation. Some patients have generalized tonic-clonic seizures (called alcohol-related seizure, or rum fits) but usually not > 2 in short succession. Seizures generally occur 6 to 48 hours after cessation of alcohol.

"Alcoholic hallucinosis (hallucinations without other impairment of consciousness) follows abrupt cessation from prolonged, excessive alcohol use, usually within 12 to 24 hours. Hallucinations are typically visual. Symptoms may also include auditory illusions and hallucinations that frequently are accusatory and threatening; patients are usually apprehensive and may be terrified by the hallucinations and by vivid, frightening dreams.

"Alcoholic hallucinosis may resemble schizophrenia, although thought is usually not disordered and the history is not typical of schizophrenia. Symptoms do not resemble the delirious state of an acute organic brain syndrome as much as does delirium tremens (DT) or other pathologic reactions associated with withdrawal. Consciousness remains clear, and the signs of autonomic lability that occur in DT are usually absent. When hallucinosis occurs, it usually precedes DT and is transient.

"Delirium tremens usually begins 48 to 72 hours after alcohol withdrawal; anxiety attacks, increasing confusion, poor sleep (with frightening dreams or nocturnal illusions), profuse sweating, and severe depression also occur. Fleeting hallucinations that arouse restlessness, fear, and even terror are common. Typical of the initial delirious, confused, and disoriented state is a return to a habitual activity; eg, patients frequently imagine that they are back at work and attempt to do some related activity.

"Autonomic lability, evidenced by diaphoresis and increased pulse rate and temperature, accompanies the delirium and progresses with it. Mild delirium is usually accompanied by marked diaphoresis, a pulse rate of 100 to 120 beats/minute, and a temperature of 37.2 to 37.8° C. Marked delirium, with gross disorientation and cognitive disruption, is accompanied by significant restlessness, a pulse of > 120 beats/minute, and a temperature of > 37.8° C; risk of death is high.

"During delirium tremens, patients are suggestible to many sensory stimuli, particularly to objects seen in dim light. Vestibular disturbances may cause them to believe that the floor is moving, the walls are falling, or the room is rotating. As the delirium progresses, resting tremor of the hand develops, sometimes extending to the head and trunk. Ataxia is marked; care must be taken to prevent self-injury. Symptoms vary among patients but are usually the same for a particular patient with each recurrence."


Gerald F. O’Malley, DO, and Rika O’Malley , MD. Alcohol Toxicity and Withdrawal. Merck Manual - Professional Version. Reviewed/Revised Dec. 2022. Last accessed July 22, 2023.