Alcohol Withdrawal Syndrome: Symptoms Day by Day and Danger Signs

What Alcohol Withdrawal Syndrome Is

In ICD-10, alcohol withdrawal syndrome is described under code F10.3 as a group of symptoms of varying severity that occur when a person completely or partially stops drinking after prolonged, heavy use. If the condition is complicated by delirium, it is coded as F10.4. In ICD-11, alcohol withdrawal is listed as a separate category, while the APA’s DSM-5 describes it as a combination of autonomic, psychological, and neurological symptoms that develop within hours to several days after stopping.

The mechanism is linked to how the brain adapts. Alcohol enhances inhibitory processes and suppresses excitatory ones. With regular drinking, the nervous system “recalibrates”: it reduces the sensitivity of inhibitory receptors and amplifies excitatory signals. When alcohol suddenly disappears, excitation is left dominant. This leads to tremor, sweating, a rapid heartbeat (tachycardia), anxiety, and insomnia, and in severe cases to seizures and psychosis.

Why There Is No Withdrawal Without Dependence

Withdrawal syndrome is one of the signs of physical dependence. In a person who drinks occasionally, the body does not have time to readjust, so after heavy drinking they get a hangover, not withdrawal. But if a person needs a drink to feel better and develops shaking and anxiety without alcohol, this points to established dependence and is a reason to see an addiction doctor (narcologist).

Alcohol Withdrawal Symptoms Day by Day

The course of withdrawal varies from person to person, but on the whole, symptoms develop in a predictable sequence. Below is a typical timeline that helps you understand what to expect and at which stage to be especially vigilant. It is important to remember that the transition to serious complications can happen quickly, so you cannot rely solely on “which day it is”: what matters is the person’s actual condition.

In many patients, withdrawal becomes more severe with each episode. If coming off a binge used to be relatively easy, that is no guarantee it will be this time. People who have been drinking for many years, have frequent binges, or have had seizures in the past should plan their withdrawal with a doctor in advance rather than waiting until things get worse, when the options for help are already narrowing.

The First 6–24 Hours

Shaking hands, sweating, nausea, sometimes vomiting, a rapid heartbeat, raised blood pressure, anxiety, irritability, and poor sleep appear. The person feels a strong craving for alcohol, since another drink quickly relieves these symptoms. At this stage, it is easy to give in and continue the binge, which is why support and calling a doctor are especially important.

Days 1–2

Symptoms intensify: the tremor becomes noticeable, sweating and palpitations increase, sleep all but disappears, and nightmares begin. During this period, brief visual or auditory misperceptions can occur while orientation remains intact. It is in the first 48 hours that seizures most often occur, sometimes without any warning signs.

Days 2–4

This is the time of the peak and the highest risk of complications. Some patients develop alcohol withdrawal delirium: orientation to time and place is lost, vivid hallucinations, fear, and agitation appear, and body temperature rises. In others, symptoms gradually begin to ease, but anxiety, insomnia, and weakness persist.

Days 5–7 and Beyond

The acute autonomic symptoms usually subside. What remains is weakness, low mood, irritability, sleep problems, and cravings for alcohol. These effects, sometimes called protracted or post-acute withdrawal, can persist for several weeks and increase the risk of relapse, so it is especially important to continue treatment during this period.

Severity Levels of Alcohol Withdrawal Syndrome

Doctors assess the severity of withdrawal using clinical rating scales such as the CIWA-Ar, which takes into account tremor, sweating, nausea, anxiety, agitation, perceptual disturbances, headache, and orientation. The total score helps decide whether observation and supportive care are enough or whether medication and inpatient care are needed. It is hard to assess severity on your own, which is why a doctor’s consultation is important.

Withdrawal is broadly classified as mild, moderate, or severe. In mild withdrawal, discomfort, anxiety, moderate shaking, and poor sleep predominate. In moderate withdrawal, these are joined by marked tremor, a rapid heartbeat, blood pressure spikes, vomiting, and severe anxiety. Severe withdrawal is accompanied by seizures, hallucinations, confusion, and fever, and requires inpatient treatment with round-the-clock monitoring.

• Mild: moderate shaking, sweating, anxiety, insomnia — treatment at home may be possible
• Moderate: severe tremor, rapid heartbeat, blood pressure spikes, vomiting — a doctor is needed
• Severe: seizures, hallucinations, confusion, fever — inpatient treatment
• Complicated by delirium: disorientation, delusions, agitation — emergency hospital admission

Which Signs of Withdrawal Are Dangerous

Some symptoms indicate that withdrawal is turning into a dangerous condition and that you cannot wait for improvement at home. First and foremost, these are seizures with loss of consciousness, even a single one. Also dangerous is confusion, when the person does not understand where they are, does not recognize family members, talks to people who are not there, or sees insects or animals. These are signs of emerging delirium.

Other warning signs include a high temperature, a very fast pulse, severe shortness of breath, chest pain, uncontrollable vomiting, vomiting blood, black stools, yellowing of the skin, and sudden severe abdominal pain. These signs may point not only to severe withdrawal but also to related complications — pancreatitis, bleeding, or a heart attack. In any of these situations, call 103 or 112.

• A seizure, even a brief, one-off one
• Disorientation: the person does not know where they are or what day it is
• Visual or auditory hallucinations, fear, or delusions of persecution
• A temperature above 38°C (100.4°F) along with marked shaking and sweating
• Chest pain, severe shortness of breath, or irregular heartbeats
• Vomiting blood, black stools, or severe abdominal pain

What Affects the Severity of Alcohol Withdrawal

The severity of withdrawal depends on several factors. The first is how long and how heavily the person has been drinking: the longer they have been drinking and the more they drink, the greater the adaptation of the nervous system. The second is the length of the current binge. The third is the number of previous withdrawal episodes: each one “kindles” the nervous system and raises the risk of seizures in the future, even if the binge itself was short.

Age, general health, coexisting liver, heart, or pancreatic disease, poor nutrition, and vitamin deficiencies also matter. The risk is higher for those who combined alcohol with sleeping pills, tranquilizers, or other substances. The most reliable predictor is a history of seizures or delirium: if they have happened before, the likelihood of them happening again is significantly higher.

How Alcohol Withdrawal Syndrome Is Treated

The goal of treatment is to get the person safely through the withdrawal period, relieve distressing symptoms, and prevent complications. The foundation is replacing fluids and electrolytes, giving B vitamins to prevent Wernicke’s encephalopathy, and monitoring blood pressure and pulse. To relieve agitation and prevent seizures, the doctor uses benzodiazepines and other medications as indicated, tailoring the dose to the individual.

Mild and moderate withdrawal can be treated at home during an addiction doctor’s visit if there are no serious illnesses and a sober adult is nearby. Severe withdrawal, delirium, and the period after seizures are treated in a hospital. At Narcology 24, a doctor makes home visits around the clock, assesses the severity of withdrawal, provides IV fluid therapy, and arranges hospital admission if needed. Once the acute symptoms have been relieved, we help the person move on to treating the addiction itself.

Why You Shouldn’t Treat Withdrawal With Alcohol

Another drink really does quickly relieve shaking and anxiety, but it only postpones withdrawal and makes it worse. This is how the vicious cycle of a binge forms. In addition, “hair of the dog” continues the toxic effects on the liver, heart, and brain. The safe path is medical care, not another drink.

What Happens After the Acute Phase

Once the acute symptoms have subsided, many people think it is all over. But for several weeks, insomnia, anxiety, low mood, irritability, difficulty concentrating, and periodic cravings may persist. This is a normal part of the nervous system’s recovery, but it is precisely during this period that relapses most often happen, especially in stressful situations.

What helps is a regular sleep schedule, regular meals, physical activity, support from loved ones, and continued treatment: consultations with an addiction doctor and a psychiatrist, addiction psychotherapy, and, with the patient’s consent, relapse-prevention therapy. If anxiety and low mood are severe, it is important to tell the doctor: sometimes they mask depression or an anxiety disorder that requires separate treatment.

When to see a doctor

• Stopping drinking brings on shaking, sweating, a racing heart, and insomnia
• The binge lasted several days, and the person is getting worse rather than better
• Previous alcohol withdrawals involved seizures, hallucinations, or delirium tremens
• There is heart, liver, or pancreatic disease, diabetes, or epilepsy
• Repeated vomiting makes it impossible to drink water or eat
• Insomnia, anxiety, or low mood persist after several weeks of sobriety
• The craving for alcohol is so strong that you are afraid of relapsing

Questions and answers

Medically reviewed by

Olga Smirnova, MDAddiction psychiatrist · experience 27 years

Alcohol dependence, alcoholism in women, dual diagnosis, coding after assessment and family consultations.