Clinical Vignette
Patient: "Mr. S," 54-year-old construction foreman, presenting to the ED with tremor, diaphoresis, and anxiety 18 hours after his last drink.
Chief Concern: "I ran out of vodka yesterday and couldn't get more. I woke up this morning shaking so bad I couldn't hold a cup. My heart is racing. I need a drink to feel normal."
History of Present Illness: Mr. S has been drinking daily for 12 years, with progressive escalation. His current consumption is 750mL of vodka daily (approximately 17 standard drinks). He drinks from morning to night, starting with 'eye-opener' drinks to stop morning tremor. He has tried to reduce his drinking multiple times but develops withdrawal symptoms within 12-18 hours: tremor, diaphoresis, tachycardia, anxiety, insomnia, and nausea. He reports tolerance: 'I used to get drunk on 6 drinks; now I need at least 12 to feel anything.' He has lost his marriage (wife left due to drinking), received 2 DUI convictions, was demoted at work (from general contractor to foreman), and his physician has told him his liver enzymes are 'dangerously high.' Despite these consequences, he continues drinking. He has had 2 prior inpatient detoxifications (3 and 5 years ago), both followed by relapse within 1 month. He has no history of withdrawal seizures or delirium tremens, but his current withdrawal presentation is concerning given the volume and chronicity.
Medical History: Elevated liver enzymes (AST 180, ALT 95, GGT 450). Macrocytic anemia (MCV 102). Fatty liver on ultrasound. 2 prior inpatient detox admissions.
Mental Status Exam: Tremulous, diaphoretic. Pulse 108. BP 162/94. Temperature 37.8°C. Alert, oriented. Speech slightly pressured. Mood 'terrible.' Affect anxious, restless. Mild psychomotor agitation. No hallucinations. No confusion. No seizure activity. CIWA-Ar score: 18 (moderate withdrawal).
Step 1: Alcohol Use Disorder DSM-5-TR Criteria
Criterion 1: Alcohol taken in larger amounts or over a longer period than intended.
Intended to have 'a few drinks' but consistently consumed 750mL vodka daily. MET.
Criterion 2: Persistent desire or unsuccessful efforts to cut down.
Multiple failed attempts to reduce. Two prior detoxifications with relapse. MET.
Criterion 3: Great deal of time spent obtaining, using, or recovering from alcohol.
Drinks from morning to night. Recovery from daily intoxication occupies remaining hours. MET.
Criterion 4: Craving.
'I need a drink to feel normal.' Immediate craving upon cessation. MET.
Criterion 5: Failure to fulfill major role obligations.
Demoted at work. Marriage dissolution. MET.
Criterion 6: Continued use despite social/interpersonal problems.
Wife left. DUI convictions. Continued despite all losses. MET.
Criterion 7: Important activities given up or reduced.
Social activities, hobbies, and family events abandoned. MET.
Criterion 8: Recurrent use in physically hazardous situations.
2 DUI convictions. Drinking while operating heavy construction equipment. MET.
Criterion 9: Continued use despite knowledge of physical/psychological problems.
Continues despite elevated liver enzymes, physician warnings, fatty liver. MET.
Criterion 10: Tolerance.
'Used to get drunk on 6 drinks, now need 12.' Classic tolerance escalation. MET.
Criterion 11: Withdrawal.
Tremor, diaphoresis, tachycardia, anxiety within 12-18 hours of last drink. Drinks to relieve withdrawal ('eye-opener'). MET.
TOTAL: 11/11 criteria. Severity: SEVERE (≥6 criteria).
All 11 DSM-5-TR criteria met. SEVERITY: SEVERE.
Step 2: Withdrawal Risk Assessment
| Feature | Mild Withdrawal | Moderate Withdrawal | Severe Withdrawal (DT risk) | This Patient |
|---|---|---|---|---|
| Onset | 6-12 hours | 12-24 hours | 48-72 hours | 18 hours — moderate window |
| Symptoms | Anxiety, insomnia, tremor, GI distress | Hallucinations (visual/tactile), elevated vitals | Delirium, seizures, autonomic instability | Moderate: tremor, tachycardia, diaphoresis, anxiety |
| CIWA-Ar | <10 | 10-18 | >20 | 18 — moderate |
| Risk factors for DT | Low volume, short duration | Moderate volume, years of use | Prior DT/seizures, heavy use, medical comorbidity | High risk: heavy use (17 drinks/day), 12 years, liver disease |
Medically Managed Withdrawal
CIWA-Ar 18 with vital sign abnormalities warrants inpatient medical detoxification. Despite no prior seizures or DT, his consumption level (17 drinks daily for 12 years) and liver disease place him at elevated risk for complicated withdrawal.
Diagnostic Formulation
Diagnostic Conclusion
Alcohol Use Disorder, Severe, with Physiological Dependence (F10.20): All 11 DSM-5-TR criteria met. Severe. Physiological dependence (tolerance + withdrawal). Currently in moderate withdrawal (CIWA-Ar 18). Treatment: (1) Inpatient medical detoxification with symptom-triggered benzodiazepine protocol (CIWA-guided). (2) Thiamine 500mg IV for 3 days (Wernicke prevention). (3) Folate and magnesium supplementation. (4) Post-detox: naltrexone or acamprosate for relapse prevention. (5) Psychosocial: motivational enhancement therapy (MET) + CBT relapse prevention + mutual support (AA or SMART Recovery).
Teaching Points
- DSM-5-TR uses a single diagnosis (Alcohol Use Disorder) on a severity continuum: Mild (2-3 criteria), Moderate (4-5), Severe (6+). This replaced DSM-IV's separate 'alcohol abuse' and 'alcohol dependence' categories. Mr. S meets all 11 criteria, representing the extreme end.
- CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) is the standard tool for monitoring withdrawal severity. Scores guide treatment: <10 (mild, may not require medication), 10-18 (moderate, symptom-triggered benzodiazepines), >20 (severe, fixed-dose + rescue benzodiazepines, consider ICU monitoring).
- Thiamine must be given BEFORE glucose in all alcohol withdrawal patients. Glucose administration without thiamine can precipitate Wernicke encephalopathy by depleting the remaining thiamine stores. The protocol is: thiamine IV first, then glucose-containing fluids.
- Three FDA-approved medications for AUD relapse prevention: (1) Naltrexone (opioid antagonist — reduces craving and heavy drinking days), (2) Acamprosate (glutamate modulator — reduces protracted withdrawal symptoms and craving), (3) Disulfiram (aldehyde dehydrogenase inhibitor — produces aversive reaction with alcohol; limited by adherence).
- Alcohol withdrawal delirium (delirium tremens) is a medical emergency with a mortality rate that can be significant without treatment. It typically occurs 48-72 hours after the last drink and presents with confusion, hallucinations, severe autonomic instability, and seizures. Prior history of DT is the strongest predictor of future DT.