Hallucinations

Patients may experience hallucinations or other perceptual disturbances (such as misperceptions) at any stage of the alcohol withdrawal phase. These must be differentiated from other causes for psychosis.

Hallucinations may be visual, tactile or auditory. Tactile perceptual changes include pins and needles, itching, burning, numbness, crawling sensations and ‘electric fleas’. Hallucinations may be accompanied by paranoid ideation or delusions, and abnormal affect (agitation, anxiety, dysphoria).

Hallucinations during withdrawal are a symptom that generally warrants admission into an appropriate facility (such as a medical, psychiatric or specialist detoxification unit) that can safely manage the patient.

Thorough psychiatric evaluation is required in order to exclude concomitant medical or psychiatric conditions. Importantly, withdrawal-related hallucinations occur as one of many features of alcohol withdrawal syndrome, and other causes should be considered if the presentation is not consistent with alcohol withdrawal (see 'Alcohol-Related Hallucinosis' below). Where withdrawal-related hallucinations can be established, the following management plan is recommended (see ‘Supportive care’ above): 

• frequent monitoring (including physical parameters, withdrawal severity) and supervision is required to ensure the safety of the patient and others 
• ensure adequate hydration 
• patient should be managed in a quiet room with minimal sensory stimulation 

Ensure adequate diazepam doses (at least 60 to 80 mg per day) until alcohol withdrawal features are alleviated.

Antipsychotic medications should be used as an adjunct to adequate benzodiazepine doses if the patient is agitated or distressed by their hallucinations, or disruptive to others. No controlled trials have demonstrated the superiority of different antipsychotic medications; practitioners should use medications with which they are most familiar. Examples of regimens include:

• haloperidol 2.5 to 10 mg oral or intramuscular, repeated as required
• olanzapine 5 to 10 mg oral or buccal dose, repeated to 30 mg daily dose as required
• risperidone 1 to 5 mg, oral or intramuscular, twice daily, repeated as required.

Antipsychotic medication should not be used in isolation (that is, without adequate benzodiazepine loading) as they do not adequately prevent the onset of alcohol withdrawal delirium and may lower seizure threshold.