Coding note: The |CD-9-CM code is 291.81. The |CD-10-CM code for alcohol withdrawal without perceptual disturbances is F10.239, and the |CD-10-CM code for alcohol withdrawal with perceptual disturbances is F10.232. Note that the |CD-10-CM code indicates the comor- bid presence of a moderate or severe alcohol use disorder, reflecting the fact that alcohol with- drawal can only occur in the presence of a moderate or severe alcohol use disorder. It is not permissible to code a comorbid mild alcohol use disorder with alcohol withdrawal.
When hallucinations occur in the absence of delirium (i.e., in a clear sensorium), a diagno- sis of substance/medication-induced psychotic disorder should be considered.
The essential feature of alcohol withdrawal is the presence of a characteristic withdrawal syndrome that develops within several hours to a few days after the cessation of (or re- duction in) heavy and prolonged alcohol use (Criteria A and B). The withdrawal syn- drome includes two or more of the symptoms reflecting autonomic hyperactivity and anxiety listed in Criterion B, along with gastrointestinal symptoms.
Withdrawal symptoms cause clinically significant distress or impairment in social, oc- cupational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another men- tal disorder (e.g., generalized anxiety disorder), including intoxication or withdrawal from another substance (e.g., sedative, hypnotic, or anxiolytic withdrawal) (Criterion D).
Symptoms can be relieved by administering alcohol or benzodiazepines (e.g., diazepam).
The withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4—12 hours) after alcohol use has been stopped or reduced. Reﬂecting the relatively fast metabolism of alcohol, symptoms of alcohol withdrawal usually peak in inten- sity during the second day of abstinence and are likely to improve markedly by the fourth or fifth day. Following acute withdrawal, however, symptoms of anxiety, insomnia, and auto- nomic dysfunction may persist for up to 3—6 months at lower levels of intensity.
Fewer than 10% of individuals who develop alcohol withdrawal will ever develop dra- matic symptoms (e.g., severe autonomic hyperactivity, tremors, alcohol withdrawal delir- ium). Tonic-clonic seizures occur in fewer than 3% of individuals.
Although confusion and changes in consciousness are not core criteria for alcohol with- drawal, alcohol withdrawal delirium (see ”Delirium” in the chapter "Neurocognitive Dis- orders”) may occur in the context of withdrawal. As is true for any agitated, confused state, regardless of the cause, in addition to a disturbance of consciousness and cognition, with- drawal delirium can include visual, tactile, or (rarely) auditory hallucinations (delirium tre- mens). When alcohol withdrawal delirium develops, it is likely that a clinically relevant medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, an electrolyte imbalance, postoperative status).
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 or homeless, the rate of al- cohol withdrawal may be greater than 80%. Less than 10% of individuals in withdrawal ever demonstrate alcohol withdrawal delirium or withdrawal seizures.
Acute alcohol withdrawal occurs as an episode usually lasting 4—5 days and only after extended periods of heavy drinking. Withdrawal is relatively rare in individuals younger than 30 years, and the risk and severity increase with increasing age.