Most people looking for this are asking a practical question: how serious this situation will become and how long it will last.
Here is the honest answer, step by step. First, I should mention two points because they affect how you should understand what follows.
There is a great deal of individual variation; two people who have similar drinking histories may have very different experiences when going through withdrawal, and this timeline represents a typical pattern, not a schedule against which you should measure yourself.
Alcohol withdrawal is indeed dangerous in cases of physical dependence, since, unlike most other substances, it can cause seizures and, in serious instances, can be fatal. The article is not a guide to treating the condition on your own; rather, it explains what happens so you can recognize it and get the appropriate help.

Why withdrawal happens at all

The mechanism accounts for all the other aspects, so it is worth thirty seconds.
Alcohol is a depressant of the central nervous system; it has the effect of slowing down processes. If you drink heavily every day for months or years, the brain will compensate by becoming permanently more excitable, keeping the accelerator pressed down to offset the braking action that is always in effect.
Dependence consists physically of that adaptation.
If the alcohol is stopped suddenly then the brake disappears; the accelerator remains flat against the floor and now offers no resistance at all; all that comes next – the trembling, the sweating, the rapid heartbeat, the seizures – is due to a nervous system that is over-excited and has nothing to dampen it.
That is also the reason why the severity of withdrawal tends to grow with repeated occurrences; further sensitisation of the system seems to result from each cycle of heavy drinking and then sudden stopping, which is why a previous withdrawal seizure is one of the best predictors of a subsequent one.

Hours 6–12: onset

The symptoms usually start between six and twelve hours after the individual’s last drink.
  • Tremor, most noticeably in the hands
  • Sweating, disproportionate to temperature
  • Anxiety, often free-floating and not attached to anything specific
  • Restlessness and agitation
  • Nausea, sometimes vomiting
  • Headache
  • Difficulty sleeping
  • Raised heart rate
A great many people who drink heavily every day have this situation each morning and do not realize that they are experiencing withdrawal. They say that it makes them feel rough and that it goes away after their first drink of the day. The fact that symptoms occur in the morning and are relieved by alcohol is one of the clearest signs of physical dependence, and it is the most important point to tell a doctor.

Hours 12–48: escalation and the seizure window

The symptoms get stronger. The heart rate and blood pressure rise. The tremor becomes more severe. Sweating increases greatly. Anxiety may become serious and irritability noticeable. Sleep is usually completely missing.
The period in question is the one at which withdrawal seizures are most likely to occur, this typically happening between twelve and forty-eight hours following the last drink.
A withdrawal seizure is usually generalised, involving a loss of consciousness and a full-body convulsion. It may happen suddenly in a person who had seemed to be under control. Since it is a medical emergency, immediate action is required.
Alcoholic hallucinosis is also something that some people go through at this time, consisting of seeing or hearing things that aren’t really there while at the same time remaining oriented and aware of their environment. Although it is different from delirium tremens, it too warrants an immediate medical evaluation.

Hours 48–72: the delirium tremens window

Delirium tremens represents the severe phase of alcohol withdrawal; it usually occurs between forty-eight and seventy-two hours after the last drink and is a real medical emergency since it still carries a risk of death even when hospital treatment is given.
Signs:
  • Profound confusion and disorientation — not knowing where they are or what day it is
  • Hallucinations, visual or tactile, with loss of insight that they are not real
  • Severe agitation
  • Fever
  • Heavy sweating
  • Very high heart rate and blood pressure
  • Dramatic fluctuation — periods of apparent lucidity alternating with confusion
If any of these symptoms occur, you should immediately seek emergency help—do not wait to see if they improve.
It should be noted that delirium tremens does not occur in most people who are stopping alcohol. The risk is found in individuals who have had a very heavy and continuous intake of alcohol, a previous history of DTs or withdrawal seizures, an existing illness or infection, are older, and those who are withdrawing without medical assistance.

Days 4–7: the physical turn

For the majority of people the severe physical symptoms start to fade during this stage.
The trembling lessens, the sweating diminishes, nausea gets better and the appetite often comes back, sometimes suddenly. The heart rate and blood pressure return to normal.
What does not resolve on this timetable:
To sleep is frequent, it being the last thing to come back and often being disrupted for weeks; vivid and unpleasant dreams are common when the sleep structure is reorganised following a period of suppression—since alcohol suppresses REM sleep, its return leads to a time of intense dreaming.
Mood—this is the area in which people are most surprised. Instead of experiencing relief, they end up with a sense of flatness, irritability, or unexpected tearfulness. This kind of reaction is a normal neurochemical result of the brain adjusting itself after a long period of suppression. It does not mean that something has gone wrong, and it does not indicate that drinking was the only thing keeping you going.

Days 7–14: stabilization

Most people experience a considerable improvement physically during the second week, with their energy levels rising. Their sleep starts to become more consolidated, even if it doesn’t fully do so. Concentration comes back bit by bit, and the skin and eyes often show noticeable changes, with other people usually noticing these changes before you do.
The second week is usually more difficult from a psychological point of view and this affects almost everyone unexpectedly.
The reason is clear. The thing that the alcohol was doing is no longer being done.
If it was managing anxiety, the anxiety is now unmanaged and fully audible. If it was interrupting memories, the memories are no longer interrupted. If it was filling a silence, the silence is there, every evening, at exactly the time the drinking used to start.
What is most important to realise during the fourteen days is that detox is not treatment; it only gets the substance out of the body. The reason why the substance was there is still completely there on Day 15, and in most cases an untreated detox is just a costly break.

Weeks 3–12: the part nobody warns you about

There is a recognized phase after acute withdrawal in which symptoms persist at lower intensity — commonly for weeks, sometimes for months.
Typical features:
  • Ongoing sleep disturbance
  • Mood instability and flatness
  • Irritability
  • Poor concentration and short-term memory
  • Cravings arriving in waves rather than continuously
  • Reduced capacity to feel pleasure in things that used to be pleasurable
  • Fatigue
It is for this reason that a large number of relapses take place at six weeks, eight weeks, and three months—long after both the individual and all those around them had assumed that the difficult phase was over. It is dangerous not to realise this, since the natural conclusion when one feels flat and joyless at week six is that the programme isn’t working or that this is simply what permanent sober living is going to be like.
It is not the case. It does improve, but this improvement is gradual rather than sudden, and the extent to which it has improved is more obvious when you look back over a month than from day to day.

Emergency signs — at any point

Call for emergency help immediately for:
  • Any seizure
  • Confusion about where or when they are
  • Hallucinations with loss of insight
  • Fever
  • Chest pain or severe breathing difficulty
  • Vomiting blood, or black tarry stools
  • Yellowing of the skin or eyes
  • Severe agitation that is escalating rather than fluctuating
  • Any expression of wanting to die

What determines how bad it will be

The main factors:
  • Quantity and duration. More, for longer, means more severe.
  • Earlier withdrawals; each episode is generally more severe than the one before. Having suffered a previous seizure or DT episode is the most powerful of all risk factors.
  • Other substances, especially benzodiazepines. Having both substances withdrawn is much more dangerous.
  • General health, including liver function, nutrition, cardiac condition, and infection.
  • People who are older usually find it more difficult to withdraw money.
  • If it is dealt with medically, appropriate management greatly reduces both the severity and the risk of complications.
That is why the article is structured as it is. You should not tolerate withdrawal as a test of your strength; it is a medical condition and it is safer, more comfortable, and considerably more likely to be successfully managed if it is dealt with properly.

What medical management changes

A doctor, under supervision, prescribes medication which takes the place of alcohol’s effect on the over-excited nervous system and then reduces it in a controlled manner, enabling the system to readjust gradually rather than all at once. At the same time, vitamin supplementation is carried out since a deficiency in thiamine is common among heavy drinkers and can lead to serious permanent neurological damage if not treated.
It would be unsafe to carry out any of this without first consulting a doctor; the choice of medication and the determination of the dosage are clinical decisions that depend on the individual, and making them wrong poses a danger in both directions.
If the level of withdrawal risk is judged to be moderate and the home environment is appropriate, the treatment can be carried out at home with the general practitioner providing daily supervision—Pocket Power has been running it for fourteen days on this basis at a cost of R6,000. But when the risk level is high, it should take place in a hospital, and the purpose of the assessment is to establish which of these two situations applies.

If you are reading this because you are planning to stop

You should first go and see a doctor. It’s not because you lack determination or because you’re unable to do so — it’s because, in the case of alcohol, stopping suddenly and on your own is the only way of doing it that involves a real risk to your life.
You can contact us at 069 624 3110 or by email at info@recoveryfromhome.co.za.
This article is general information and not medical advice, and must not be used to self-manage withdrawal. Alcohol withdrawal can be life-threatening. Consult a doctor before stopping or reducing alcohol intake if you are physically dependent.