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Alcohol withdrawal syndromes

A review of pathophysiology, clinical presentation, and treatment

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References

  1. Butynski W, Record N, Bruhn P, Canova D. State resources and services related to alcohol and drug abuse problems. Washington, DC: National Association State Alcohol and Drug Abuse Directors, Inc, 1987.

    Google Scholar 

  2. Victor M, Adams RD. Effect of alcohol on the nervous system. Res Publ Assoc Res Nerv Ment Dis. 1953;32:526–3.

    PubMed  CAS  Google Scholar 

  3. Tavel ME, Davidson W, Batterton TD. A critical analysis of mortality associated with delirium tremens: review of 39 fatalities in a nine-year period. Am J Med Sci. 1961;242:18–29.

    PubMed  CAS  Google Scholar 

  4. Wolfe SM, Victor M. The relationship of hypomagnesemia and alkalosis to alcohol withdrawal. Ann NY Acad Sci. 1969;162:973–84.

    Article  PubMed  CAS  Google Scholar 

  5. Hemmingsen R, Kramp P, Rafaelsen OJ. Delirium tremens and related clinical states. Aetiology, pathophysiology and treatment. Acta Psychiatr Scand. 1979;59:337–69.

    PubMed  CAS  Google Scholar 

  6. Kramp P, Hemmingsen R, Rafaelsen OJ. Magnesium concentrations in blood and cerebrospinal fluid during delirium tremens. Psychiatry Res. 1979;1:161–71.

    Article  PubMed  CAS  Google Scholar 

  7. Kalant H. Comparative aspects of tolerance to, and dependence on, alcohol, barbiturates and opiates. Adv Exp Med Biol. 1977;858:169–86.

    Google Scholar 

  8. Goldstein DB. Pharmacological aspects of physical dependence upon ethanol. Life Sci. 1976;18:533–61.

    Google Scholar 

  9. Mendelson JH, Mello NK. Basic mechanisms underlying physical dependence upon alcohol. Ann NY Acad Sci. 1978;311;69–79.

    Article  PubMed  CAS  Google Scholar 

  10. Linnoila M, Mattila MJ, Mitchell BS. Drug interactions with alcohol. Drugs. 1979;18:299–311.

    PubMed  CAS  Google Scholar 

  11. Hawley RJ, Major LF, Schulman EA, Linnoila M. Cerebrospinal fluid 3-methoxy-4-hydroxyphenylglycol and norepinephrine levels in alcohol withdrawa. Correlations with clinical signs. Arch Gen Psychiatry. 1984;42:1052–62.

    Google Scholar 

  12. Borg S, Czarnecka A, Kvande H, Mossberg D, Sedvall G. Clinical conditions and concentrations of MOPEG in the cerebrospinal fluid and urine of male alcoholic patients during withdrawal. Alcoholism (NY). 1983;7:411–5.

    CAS  Google Scholar 

  13. Mefford I. Ethanol and brain epinephrine. In: Linoila M, moderator. Alcohol withdrawal and noradrenergic function. Ann Intern Med. 1987;107;875–89.

    PubMed  Google Scholar 

  14. Myers RD. Neurotransmitters, alcohol and alcoholism. In: In: Advances in alcoholism. Raleigh Hills Foundation, 17861 Cartwright Road, Irvine, CA, January 1982;II:3.

    Google Scholar 

  15. Airaksinen MM, Peura P. Mechanisms of alcohol withdrawal syndrome. Med Biol. 1987;65:105–12.

    PubMed  CAS  Google Scholar 

  16. Liljequist S, Engel J. The effect of chronic ethanol administration on central neurotransmitter mechanisms. Med Biol. 1979;57:199–210.

    PubMed  CAS  Google Scholar 

  17. Myers RD. Alkaloid metabolites and addictive drinking of alcohol. In: Chang NC, Chao HM, eds. Early identification of alcohol abuse. National Institute on Alcohol Abuse and Alcoholism, 1985; Research Monograph 17.

  18. Whitfield CL, Davis JE, Barker LR. Alcoholism. In: Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2nd ed. Baltimore: Williams and Wilkins, 1986;245–77.

    Google Scholar 

  19. Sellers EM, Kalant H. Alcohol intoxication and withdrawal. N Engl J Med. 1976;294:757–62.

    Article  PubMed  Google Scholar 

  20. Gross MM, Lewis E, Best S, et al. Quantitative changes of signs and symptoms associated with acute alcohol withdrawal: incidence, severity and circadian effects in experimental study of alcoholics. In: Gross MM, ed. Alcohol intoxication and withdrawal: experimental studies II. New York, Plenum Press, 1975;615–31.

    Google Scholar 

  21. Diagnostic and statistical manual of mental disorders. 3rd ed. (revised) (DSM-III-r). Washington, DC: American Psychiatric Association. 1987;127–34.

  22. Brown CG. The alcohol withdrawal syndrome. Ann Emerg Med. 1982;11:276–80.

    Article  PubMed  CAS  Google Scholar 

  23. Holloway HC, Hales PE, Watanabe HK. Recognition and treatment of acute alcohol withdrawal syndromes. Psychiatr Clin North Am. 1984;7:729–43.

    PubMed  CAS  Google Scholar 

  24. Elton M. Alcohol withdrawal: clinical symptoms and management of the syndrome. Acta Psychiatr Scand. 1986;327 (suppl):80–90.

    CAS  Google Scholar 

  25. Naranjo CA, Sellers EM. Clinical assessment and pharmacotherapy of the alcohol withdrawal syndrome. Recent Dev Alcohol. 1986;4:265–81.

    PubMed  CAS  Google Scholar 

  26. Gross MM, Lewis E, Nagarajan M. An improved quantitative system for assessing the acute alcohol psychoses and related states (TSA and SSA). In: Gross MM, ed. Alcohol intoxication and withdrawal: experimental studies. Adv Exp Med Biol. 1973:35;365–76.

    Google Scholar 

  27. Shaw JM, Kolesar GS, Sellers EM, et al. Development of optimal treatment tactics for alcohol withdrawal: I. assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981;1:382–3.

    Article  PubMed  CAS  Google Scholar 

  28. Marjot DH. Delirium tremens in the Royal Navy and British Army in the 19th century. J Stud Alcohol. 1977;38:1614.

    Google Scholar 

  29. Isbell H, Fraser HF, Wikler A, Belleville MA, Eisenman AJ. An experimental study of the etiology of “rum fits” and delirium tremens. Q J Stud Alcohol. 1955;16:1–33.

    PubMed  CAS  Google Scholar 

  30. Mendelson JH, LaDou J. Experimentally induced chronic intoxication and withdrawal in alcoholics. Part I. Background and experimental design. Q J Stud Alcohol. 1964;2(suppl):1–13.

    Google Scholar 

  31. Lefebvre-D’Amour M, Shaham BT, Young RR. Tremor in alcoholic patients. In: Desmedt J, ed. Physiological tremor, pathologic tremor and clonus. Prog Clin Neurophysiol. 1978;5:160–4.

    Google Scholar 

  32. Kelley JT, Reilly EL. EEG, alcohol and alcoholism. In: Hughes JR, Wilson WP, eds. EEG and evoked potentials in psychiatry and behavioral neurology. Boston: Butterworths, 1983;59–60.

    Google Scholar 

  33. Williams HL, Rundell OH. Altered sleep physiology in chronic alcoholics: reversal with abstinence. Alcoholims: (NY). 1981;5:318–25.

    CAS  Google Scholar 

  34. Victor M. Treatment of alcoholic intoxication and the withdrawal syndrome. Psychosom Med. 1966;28:636–50.

    Google Scholar 

  35. Thomas PK. Alcohol and disease: central nervous system. Acta Med Scand (suppl). 1985;703:251–64.

    CAS  Google Scholar 

  36. Lishman WA. Organic psychiatry. The Psychological consequences of cerebral disorder. Oxford, England: Blackwell Scientific Publications, 1978.

    Google Scholar 

  37. Victor M, Brausch C. The role of abstinence in the genesis of alcoholic epilepsy. Epilepsai. 1967;8:1–20.

    Article  CAS  Google Scholar 

  38. Johnson R. Alcohol and fits. Br J Addict. 1985;80:227–32.

    Article  PubMed  CAS  Google Scholar 

  39. Aminoff MJ, Simon RP. Status epilepticus: causes, clinical features and consequences in 98 patients. Am J Med. 1980;69:657–66.

    Article  PubMed  CAS  Google Scholar 

  40. Pristach CA, Smith CM, Whitney RB. Alcohol withdrawal syndromes—prediction from detailed medical and drinking histoires. Drug Alcohol Depend. 1983;11:177–99.

    Article  PubMed  CAS  Google Scholar 

  41. Victor M. The alcohol withdrawal syndrome. Postgrad Med. 1970;47:68–72.

    PubMed  CAS  Google Scholar 

  42. Potter JF, Beevers DG. Pseudo-pheochromocytoma due to alcohol withdrawal. Postgrad Med J. 1985;61:721–3.

    PubMed  CAS  Google Scholar 

  43. Abraham E, Shoemaker WC, McCartney SF. Cardiorespiratory patterns in severe delirium tremens. Arch Intern Med. 1985;145:1057–9.

    Article  PubMed  CAS  Google Scholar 

  44. Harper C. Wernicke’s encephalopathy. A more common disease than realized. A neuropathological study of 51 cases. J Neurol Neurosurg Psychiatry. 1979;42:226–31.

    PubMed  CAS  Google Scholar 

  45. Victor M, Adams R, Collins GH. The Wernicke-Korsakoff syndrome. A clinical and pathological study of 245 patients, 92 with postmortem examinations. Oxford, England: Blackwell Scientific Publications, 1971.

    Google Scholar 

  46. Knochel JP. The pathophysiology and clinical characteristics of severe hypophosphatemia. Arch Intern Med. 1977;137:203–20.

    Article  PubMed  CAS  Google Scholar 

  47. Knochel JP, Barcenas C, Cotton JR, et al. Hypophosphatemia and rhabdomyolysis. J Clin Invest. 1978;62:1240–6.

    Article  PubMed  CAS  Google Scholar 

  48. Levy LJ, Duga J, Girgis M, Gordon EE. Ketoacidosis associated with alcoholism in nondiabetic subjects. Ann Intern Med. 1973;78;213–9.

    PubMed  CAS  Google Scholar 

  49. Lowenstein SR, Gabow PA, Cramer J, Oliva PB, Ratner K. The role of alcohol in new-onset atrial fibrillation. Arch Intern Med. 1983;143:1882–5.

    Article  PubMed  CAS  Google Scholar 

  50. Leroy JB. Recognition and treatment of the alcohol withdrawal syndrome. Primary Care. 1979;6(3):529–39.

    PubMed  CAS  Google Scholar 

  51. Abrams A. Outpatient treatment of withdrawal In: Barnes HN, Aronson MD, Delbanco TL, eds. Alcoholism: a guide for the primary care physician. New York: Springer-Verlag, 1987;78–82.

    Google Scholar 

  52. Whitfield CL, Thompson G, Lamb, et al. Detoxification of 1,024 alcoholic patients without psychoactive drugs. JAMA. 1978;239(14):1409–12.

    Article  PubMed  CAS  Google Scholar 

  53. McGovern MP. Comparative evaluation of medical vs. social treatment of alcohol withdrawal syndrome. J Clin Psychiatry. 1983;39:791–803.

    CAS  Google Scholar 

  54. Flygenring J, Hansen J, Holst B, Petersen E, Sorensen A. Treatment of alcohol withdrawal symptoms in hospitalized patients: a randomized double-blind comparison of carbamazepine “Tegretol” and barbital “Diemal.” Acta Psychiatr Scand. 1984;69:398–408.

    PubMed  CAS  Google Scholar 

  55. Borg V, Weinholdt T. Bromocriptine in the treatment of the alcohol-withdrawal syndrome. Acta Psychiatr Scand. 1982;65:101–11.

    PubMed  CAS  Google Scholar 

  56. Ritson B, Chick J. Comparison of two benzodiazepines in the treatment of alcohol withdrawal: effects on symptoms and cognitive recovery. Drug Alcohol Depend. 1986;18:329–34.

    Article  PubMed  CAS  Google Scholar 

  57. Muller DJ. A comparison of three approaches to alcohol-withdrawal states. South Med J. 1969;62:495–6.

    PubMed  CAS  Google Scholar 

  58. Chambers JF, Schultz JD. Double-blind study of three drugs in the treatment of acute alcoholic states. Q J Stud Alcohol. 1965;26:10–18.

    PubMed  CAS  Google Scholar 

  59. Kaim SC, Klett CJ, Rothfeld B. Treatment of the acute alcohol withdrawal state: a comparison of four drugs. Am J Psychiatry. 1969;125:1640–6.

    PubMed  CAS  Google Scholar 

  60. Golbert TM, Sanz CJ, Rose HD, Leithshuh TH. Comparitive treatments of alcohol withdrawal syndromes. JAMA. 1967;201:113–6.

    Article  Google Scholar 

  61. Kramp P, Rafaelsen OJ. Delirium tremens: a double-blind comparison of diazepam and barbital treatment. Acta Psychiatr Scand. 1978;58:174–90.

    PubMed  CAS  Google Scholar 

  62. Wilson A, Vulcano BA. Double-blind trial of alprazolam and chlordiazepoxide in the management of the acute ethanol withdrawal syndrome. Alcoholism: (NY). 1985;9:23–7.

    CAS  Google Scholar 

  63. Daghestani AN. Alcohol withdrawal: a comprehensive approach to treatment. Postgrad Med. 1987;81:111–8.

    PubMed  CAS  Google Scholar 

  64. Moskowitz G, Chalmers TC, Sacks HS, Fagerstrom RM, Smith H. Deficiencies of clinical trials of alcohol withdrawal. Alcholism (NY). 1983;7(1):42–6.

    CAS  Google Scholar 

  65. Thompson WL, Johnson AD, Maddrey WL, et al. Diazepam and paraldehyde for treatment of severe dilirium tremens. Ann Intern Med. 1975;82:175–80.

    PubMed  CAS  Google Scholar 

  66. Browne JL, Hauge KJ. A review of alprazolam withdrawal. Drug Intell Clin Pharmacol. 1986;20:837–41.

    CAS  Google Scholar 

  67. Goodman LS, Gilman A. The pharmacologic basis of therapeutics. New York: MacMillan, 1985;340–51, 433–8.

    Google Scholar 

  68. Rosenbloom AJ. Optimizing drug treatment of alcohol withdrawal. Am J Med. 1986:81:901–4.

    Article  PubMed  CAS  Google Scholar 

  69. Sellers EM, Naranjo CA, Harrison M, Devenyi P, Roach C, Sykora K. Diazepam loading: simplified treatment of alcohol withdrawal. Clin Pharmacol Ther. 1983;34(6):822–6.

    Article  PubMed  CAS  Google Scholar 

  70. Nolop KB, Natow A. Unprecedented sedative requirements during delirium tremens. Crit Care Med. 1985;13:246–7.

    Article  PubMed  CAS  Google Scholar 

  71. Physicians’ desk reference. Oradell, NJ: Medical Economics, 1989;1765–6.

  72. Spencer J. Use of injectable lorazepam in alcohol withdrawal. Med J Aust. 1980;2:211–2.

    PubMed  CAS  Google Scholar 

  73. Kantz RB, Horst HM. Management of alcohol withdrawal in the critically ill patient: a selected review. Henry Ford Hosp Med J. 1986;34(2):87–9.

    PubMed  CAS  Google Scholar 

  74. Palestine ML. Drug treatment of the alcohol withdrawal syndrome and delirium tremens: a comparison of haloperidol with mesoridazine and hydroxyzine. Q J Stud Alcohol. 1973;34:185–93.

    PubMed  CAS  Google Scholar 

  75. Seiverwright N, Tyrer PJ. Use of beta-blocking drugs in withdrawal states. Postgrad Med J. 1984;60:47–50.

    Google Scholar 

  76. Sellers EM, Zilm DH, Degani NC. Comparative efficacy of propranolol and chlordiazepoxide in alcohol withdrawal. J Stud Alcohol (suppl). 1977;38(11):2096–108.

    CAS  Google Scholar 

  77. Kraus ML, Gottlieb LD, Horwitz RI, Anscher M. Randomized clinical trial of atenolol in patients with alcohol withdrawal. N Engl J Med. 1985;313:905–9.

    Article  PubMed  CAS  Google Scholar 

  78. Liskow B, Reed J. Atenolol for alcohol withdrawal. N Engl J Med. 1986;314:782–3.

    Article  Google Scholar 

  79. Carmichael D, Unwin R, Wadsworth J. Atenolol for alcohol withdrawal. N Engl J Med. 1986;314:782–3.

    Article  Google Scholar 

  80. Schnoll SH. Atenolol for alcohol withdrawal. N Engl J Med. 1986;314:782–3.

    Article  Google Scholar 

  81. Walinder J, Balldin K, Bokstrom K, Karlsson I, Lundstrom B. Clonidine suppression of the alcohol withdrawal syndrome. Drug Alcohol Depend. 1981;8:345–8.

    Article  PubMed  CAS  Google Scholar 

  82. Manhem P, Nilsson LH, Moberg AL, Wadstein J, Hokfelt B. Alcohol withdrawal: effects of clonidine treatment on sympathetic activity, the renin — aldosterone system, and clinical symptoms. Alcholism (NY). 1985;9:238–43.

    CAS  Google Scholar 

  83. Bumgartner GR, Rowan RC. Clonidine vs. chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Arch Intern Med. 1987;147:1223–6.

    Article  Google Scholar 

  84. Lichtigfeld FJ, Gillman MA. The treatment of alcoholic withdrawal states with oxygen and nitrous oxide. S. Afr Med J. 1982;61:349–51.

    PubMed  CAS  Google Scholar 

  85. Huffman G, Becker T. The treatment of delirium tremens and of incomplete alcoholic delirium — a brief history. Acta Psychiatr Scand (suppl). 1986;329:124–8.

    Google Scholar 

  86. Rothstein E. Prevention of alcohol withdrawal seizures: the roles of dephenylhydantoin and chlordiazepoxide. Am J Psychiatry. 1973;130:1381–2.

    PubMed  CAS  Google Scholar 

  87. Sampliner R, Iber FL. Diphenylhydantoin control of alcohol withdrawal seizures: results of a controlled study. JAMA. 1974;230(10):1430–2.

    Article  PubMed  CAS  Google Scholar 

  88. Hillbom ME, Hjelm-Jager M. Schould alcohol withdrawal seizures be treated with anti-epileptic drugs? Acta Neurol Scand. 1984;69:39–42.

    Article  PubMed  CAS  Google Scholar 

  89. Alpert MA, Alcohol withdrawal syndromes. Part II: Management. Mo Med. 1985;82(3):140–4.

    PubMed  CAS  Google Scholar 

  90. McMicken D. Seizures in the alcohol-dependent patient: a diagnostic and therapeutic dilemma. J Emerg Med. 1984;1:311–6.

    Article  PubMed  CAS  Google Scholar 

  91. Wilson A, Vulcano B. A double-blind, placebo-controlled trial of magnesium sulfate in the ethanol withdrawal syndrome. Alcoholism (NY). 1984;8:542–5.

    CAS  Google Scholar 

  92. Shils ME. Experimental human magnesium depletion. J Med. 1969;48:61–82.

    Article  CAS  Google Scholar 

  93. Iseri LT, Freed J, Bures AR. Magnesium deficiency and cardiac disorders. Am J Med. 1975;58:837–46.

    Article  PubMed  CAS  Google Scholar 

  94. Embry CK, Lippman S. Use of magnesium sulfate in alcohol withdrawal. Am Fam Phsycian. 1987;35:167–70.

    CAS  Google Scholar 

  95. Evans RA, Carter JN, George CRP, et al. The congenital magnesium-losing kidney: report of two patients. Q J Med. 1981;50:39–52.

    PubMed  CAS  Google Scholar 

  96. Beard JD, Knott DH. Fluid and electrolyte balance during acute withdrawal in chronic alcoholic patients. JAMA. 1968;204:133–7.

    Article  Google Scholar 

  97. Watson WS, Lawson PMcN, Beattie AD. The effect of acute alcohol withdrawal on the serum potassium and total body potassium in heavey drinkers. Scott Med J. 1984;29:222–6.

    PubMed  CAS  Google Scholar 

  98. Wadstein J, Skude G. Does hypokalemia precede delirium tremens? Lancet. 1978;2:549–50.

    Article  PubMed  CAS  Google Scholar 

  99. Scientific American medicine. New York: Scientific American, Inc, 1987.

  100. Kessler RK, Channick BJ, Kessler WB, Metzger MD. Beer drinkers hyponatremia: a hypoosmolality syndrome. Del Med J. 1984;56:625–8.

    PubMed  CAS  Google Scholar 

  101. Ayus JC, Krothpalli RK, Arieff AI. Changing concepts in treatment of severe symptomatic hyponatremia: rapid correction and possible relation to central pontine myelinolysis. Am J Med. 1985;78:897–902.

    Article  PubMed  CAS  Google Scholar 

  102. Thompson WL. Management of alcohol withdrawal syndromes. Arch Intern Med. 1978;138:278–83.

    Article  PubMed  CAS  Google Scholar 

  103. Barnes NH, Aronson MD, Delbano TL, eds. Alcoholism: a guide for the primary care physician. New York: Springer-Verlag, 1987.

    Google Scholar 

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Received from the Department of Medicine, Section of General Internal Medicine, East Carolina University School of Medicine, Greenville, North Carolina.

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Turner, R.C., Lichstein, P.R., Peden, J.G. et al. Alcohol withdrawal syndromes. J Gen Intern Med 4, 432–444 (1989). https://doi.org/10.1007/BF02599697

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