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PSYCHIATRIC EMERGENCIES

ALCOHOL
WITHDRAWAL
 DSM-V, ALCOHOL WITHDRAWAL PG 499-503

Alcohol Withdrawal
Diagnostic Criteria
 A = Cessation/reduction in alcohol use which has been heavy &
prolonged.
 B = ≥ 2 of the following, developed within hours to a few days after
Criteria A:
 Autonomic hyperactivity (sweating, tachycardia)
 Increased hand tremor
 Insomnia
 Nausea or vomiting
 Transient visual, tactile, or auditory hallucination or illusions
 Psychomotor agitation
 Anxiety
 Generalized tonic-clonic seizures

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 DSM-V, ALCOHOL WITHDRAWAL PG 499-503

Alcohol Withdrawal
Diagnostic Criteria
 C = The sign & symptoms in Criteria B causes
clinically significant impairment in social,
occupational, or other important areas of functioning.
 D = The sign & symptoms are not attributable to
another medical condition and mental disorder
including intoxication or withdrawal from another
substance.

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CLINICAL FEATURES
Tremulous

Psychotic & perceptual symptoms

Seizures

Delirium Tremens

General Irritability

Gastrointestinal problems (nausea, vomiting)

Autonomic hyperactivity (anxiety, arousal, sweating, facial flushing, tachycardia

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Withdrawal Progression

- Within 6-8 hours - 8-12 hours -12-24 hours - Within the first 72
- Tremulous - Visual, auditory or - Generalized tonic- hours
- GI symptoms tactile clonic. - Global confusion
- Palpitations - Usually singular - Agitation
- Anxiety - Hallucination
- Diaphoresis - Autonomic
hyperactivity

DELIRIUM
MINOR SYMPTOMS PSYCHOSIS SEIZURE
TREMENS

The withdrawal symptoms sometimes skips the usual progression & for example, goes
directly to DT 5
6
 ALCOHOL WITHDRAWAL
DIAGNOSTIC TOOL

 Scores of less than 8 to 10 = minimal to

mild withdrawal.
 Scores of 8 to 15 = moderate withdrawal
(marked autonomic arousal).
 Scores of 15 or more = severe withdrawal
(impending delirium tremens)

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 ALCOHOL WITHDRAWAL

Prevalence
 It is estimated that approximately 50% of middle- class,
highly functional individuals with alcohol use disorder
have ever experienced a full alcohol withdrawal syndrome.
 Among individuals with alcohol use disorder who are
hospitalized, the rate of alcohol withdrawal may be greater
than 80%.
 Less than 10% of individuals in withdrawal ever
demonstrate alcohol withdrawal delirium or withdrawal
seizures.

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TREATMENT
Clinical Problem Drug Route Dosage Comments

Tremulous & mild to Chlordiazepoxide Oral 25-100mg, 4- Initial dose can be

repeated every 2 hours
moderate agitation 6 hours until patient is calm;
subsequent doses must
Diazepam Oral 5-20 mg, 4-6 be individualized and
hours titrated

Hallucinosis Lorazepam Oral 2-10mg, 4-6

hours
Give until patient is
Extreme agitation Chlordiazepoxide Intravenous 0.5mg/kg, calm, subsequent doses
must be individualized
2.5mg/min and titrated
Withdrawal seizures Diazepam Intravenous 0.15mg/kg,
2.5mg/min
Delirium tremens Lorazepam Intravenous 0.1mg/kg,
2.0mg/min

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12/4/2023 10

PSYCHIATRIC EMERGENCIES

SUBSTANCE
INDUCED
INTOXICATION
 SUBSTANCE INDUCED INTOXICATION

Substance Induced
Intoxication
 A general description of substance intoxication includes
the following points:
 The development of a reversible substance-specific
syndrome due to recent ingestion of (or exposure to ) a
substance.
 Clinically significant maladaptive behavioural or
psychological changes that are due to effects of the
substance on the central nervous system and develop
during or shortly after use of the substance.
 The symptoms are not due to a general medical condition
and are not better accounted for by another mental disorder
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Substance commonly misused:
CNS depressants (sedatives, hypnotics, anxiolytics e.g barbiturates, benzodiazepine)

CNS stimulants (amphetamine, methylphenidate, cocaine, caffeine)

Opiates (heroin, morphine)

Hallucinogens (Phencyclidine (PCP), Lysergic acid diethylamide (LSD))

General Irritability

Cannabinoids (Cannabis/Marijuana, Hashish)

Inhalants (Glues, Paints, Toluent, Acetone)

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 BENZODIAZEPINES

CNS depressants
 The intoxication syndromes induced by all these drugs
are similar and include incoordination, dysarthria,
nystagmus, impaired memory, gait disturbance and in
severe cases stupor, coma or death.
 Benzodiazepine intoxication:
 Associated with less euphoria

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 BENZODIAZEPINES

CNS depressants
 Barbiturates and like-substances
• The sluggishness ( resolved after a few hours & impaired
judgement, remain for 12 to 24 hours)

 The diagnosis of intoxication by one of this class of

substances is best confirmed by obtaining a blood sample
from the substance screening.

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