As a rule, individuals drink to gain a sense of ease, reduce stress, or escape modern-day life problems. Turning to alcohol to soothe oneself might serve to help one cope, but this is only a temporary fix and repeated use can lead to other issues. With time, continued alcohol use leads to tolerance and dependence. Once individuals are physically and emotionally dependent on alcohol, they may find it difficult to abstain. In addition to giving up the perceived emotional benefits of alcohol, a long-time alcohol user may find themselves agitated, irritated, and anxious as they physically withdraw from alcohol.

Alcohol withdrawal causes various physical and emotional effects that may begin as early as 4-6 hours following the last drink but can last for hours, days, and even months. The acute phase of Alcohol Withdrawal Syndrome (AWS) typically resolves within seven days but may require management by a physician depending on its severity. The intensity of the AWS symptoms is dependent on the individual’s history of alcohol use, mainly the frequency and amount taken in.

Healthcare providers rate AWS symptoms using the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) or a similar tool. A copy of this form is available online and might help evaluate the need to be seen by a physician. The CIWA-Ar enables the clinician to assess the individual’s symptoms in the following areas:

• Nausea and vomiting
• Tactile disturbances
• Tremor
• Auditory disturbances
• Paroxysmal sweats
• Visual disturbances
• Anxiety
• Agitation, and
• Orientation and clouding of sensorium.

It is important to note that alcohol withdrawal can be fatal, and this risk increases each time an individual goes through alcohol withdrawal. When in doubt, the individual should seek medical attention to ensure a safer withdrawal. Healthcare providers can prescribe and administer appropriate medication to assist with the withdrawal process while monitoring the individual’s health.

Anxiety, agitation, and irritability may be seen relatively early on in the withdrawal process and likely increase as the time since the last drink increases. The physical symptoms and possible social consequences of longtime alcohol use would be enough to make a person edgy, but there’s more to the story. Long-term alcohol use alters the activity and disrupts the pathways within our brains. It is these changes within the brain that increase the difficulty of stopping.

Alcohol specifically affects the pathways and actions of several neurotransmitters. Neurotransmitters are basically chemical messengers that help transmit messages in our brains. These messengers can promote, prevent, or moderate activity. Long-term alcohol use specifically affects:

• Dopamine
• Serotonin
• GABA
• Glutamate

Each neurotransmitter has specific areas of expertise or focus. Dopamine’s functions include reward and pleasure, while serotonin focuses on mood, memory processing, and sleep cognition. Alcohol has the adverse effect of overloading the brain with dopamine and serotonin while also reducing the brain’s receptors for these neurotransmitters. GABA and glutamate are meant to balance each other out in their roles in our central nervous system, but chronic alcohol use causes an imbalance between the two. These changes lead to the symptoms experienced during AWS, including agitation, irritation, and anxiety.

With the removal of alcohol, these changed pathways are unable to function in the way they did before long-term alcohol use, but also cannot work in their current state because the alcohol intake has stopped. Other neurotransmitters further complicate matters by stepping in and trying to help.

Agitation and irritability during withdrawal can also be complicated by the existence of a mental health disorder. According to the National Alliance on Mental Illness, about one-third of those with disordered drinking also suffer from mental illness. Such a dual diagnosis can result in increased anxiety, agitation, or irritability during alcohol withdrawal. The presence or absence of any prescribed psychiatric medications may also contribute to a more complicated withdrawal process and  presumably a greater need for the involvement of a medical professional.

The CIWA rates anxiety on a scale from 0 to 7 with the following descriptions: 

• 0 “no anxiety, the patient at ease.”
• 1 “mildly anxious.”
• 4 “moderately anxious or guarded, so anxiety is inferred.”
• 7 “equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions.” 

Likewise, agitation is rated in the same way with the following descriptions:

• 0 “normal activity.”
• 1 “somewhat normal activity.”
• 4 “moderately fidgety and restless.”
• 7 “paces back and forth, or constantly thrashes about.” 

These ratings and descriptions demonstrate the range of symptoms that may be experienced during alcohol withdrawal. As the anxiety and agitation increase, the individual may try to push through the withdrawal by staying busy with activities such as walking, exercising, and showering. Connecting with others who are already alcohol-free in groups such as Alcoholics Anonymous, SMART Recovery, and other recovery programs can also help. However, if the individual’s symptoms worsen, medical attention should be considered either through the nearest ER or detox facility. Withdrawal from alcohol can produce feelings of sadness and depression because of the changes caused to the dopamine and serotonin pathways. These feelings, along with the physical symptoms of AWS, highlight the importance of a support system during withdrawal.

Whether withdrawal is managed at home or a facility, the work does not end when the acute withdrawal phase is complete. Those who have come to rely on alcohol to self-medicate or as coping assistance will need to address their needs in these areas to remain alcohol-free. Often, individuals must change several aspects of their lives to adopt this new way of life. Patience and persistence are critical during the initial months as the brain learns to work without alcohol and re-balance itself. Working with a healthcare provider during this time may be helpful as there are medications available that can target neurotransmitters in the brain and assist with abstinence. Additionally, any residual anxiety or depression can be treated as the individual moves forward without alcohol. Leaving these untreated could increase the difficulty experienced in remaining alcohol-free.