11.5 Alcohol Use Disorder & Withdrawal

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

11.5 Alcohol Use Disorder & Withdrawal

Key Takeaways Explain This Topic AI

Substance use disorder is a named Psychiatry blueprint subsection and substance abuse is also a cross-content area embedded across categories.

Withdrawal tremor and anxiety begin within hours, seizures cluster at 12 to 48 hours, and delirium tremens typically appears at 48 to 96 hours.

Symptom-triggered benzodiazepine dosing using a validated scale reduces total dose and duration compared with fixed schedules.

Lorazepam and oxazepam are preferred in significant liver disease because they lack active metabolites.

Thiamine must be given before glucose to avoid precipitating Wernicke encephalopathy.

Last updated: August 2026

Substance use disorders and psychiatric toxic emergencies constitute high-acuity medical scenarios encountered across inpatient wards, emergency departments, and intensive care units. Mastery of withdrawal timelines, targeted pharmacotherapies, antidote administration, and comprehensive suicide risk stratification is paramount for the ABIM Internal Medicine examination.

• 1. Alcohol Use Disorder (AUD): Screening & Withdrawal Syndrome
• Clinical Screening & Risk Assessment

AUDIT-C (Alcohol Use Disorders Identification Test-Consumption): Highly sensitive 3-question screen evaluating drinking frequency, typical quantity, and binge drinking (scored 0-12). A score of >=4 in men or >=3 in women indicates hazardous drinking / active AUD.

CAGE Questionnaire: 4-item screen (Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener). A score of >=2 is clinically positive (sensitivity 93%, specificity 76% for alcohol dependence).

Alcohol Withdrawal Syndrome: Pathophysiology & Timeline

Pathophysiology: Chronic ethanol consumption enhances inhibitory GABA-A receptor activity and downregulates excitatory NMDA glutamate receptors . Sudden cessation or reduction of alcohol removes GABAergic inhibition and unmasks profound NMDA glutamate upregulation and central noradrenergic excess, precipitating severe neuroexcitation, autonomic storm, and delirium. Chronological Spectrum of Alcohol Withdrawal Syndrome

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1. Mild Withdrawal (6 to 12 Hours post-cessation):

- Autonomic: Fine postural hand tremor, tachycardia (HR >100), hypertension, diaphoresis.

- Systemic: Anorexia, nausea, vomiting, insomnia, headache, mild anxiety.

- Sensorium: Completely CLEAR; intact orientation to person, place, and time.

2. Alcoholic Hallucinosis (12 to 24 Hours post-cessation):

- Perceptual Disturbances: Visual (seeing insects/animals), auditory, or tactile (formication).

- CRITICAL BOARD PEARL: Hallucinations occur with a CLEAR SENSORIUM and INTACT ORIENTATION.

- Vital signs are frequently normal or only mildly elevated; does NOT equal Delirium Tremens.

3. Withdrawal Seizures / "Rum Fits" (12 to 48 Hours post-cessation):

- Seizure Type: Generalized tonic-clonic, brief, singular or in a cluster of 2 to 3.

- Non-status; normal interictal EEG. If untreated, ~30% progress to Delirium Tremens.

4. Delirium Tremens / DTs (48 to 96 Hours [up to 7-10 days] post-cessation):

- MEDICAL EMERGENCY: 5% to 15% mortality if untreated (circulatory collapse, arrhythmias).

- Clinical Tetrad: Severe Delirium + Profound Global Disorientation + Visual/Tactile Hallucinations

+ Severe Autonomic Instability (malignant hypertension, HR >120, temp >38.5°C, drenching diaphoresis).

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• Clinical Management Protocol & Benzodiazepine Selection

Objective Monitoring with CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol):

Quantifies 10 withdrawal parameters (nausea, tremor, sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation; max score 67).

Score < 8: Mild withdrawal (supportive care, no pharmacotherapy needed).

Score 8 to 14: Moderate withdrawal (initiate symptom-triggered benzodiazepines).

Score >= 15: Severe withdrawal (aggressive IV benzodiazepine therapy; high risk of seizures/DTs).

Symptom-Triggered Benzodiazepine Protocol:

Administering benzodiazepines only when CIWA-Ar >=8-10 is superior to fixed-schedule dosing (results in significantly shorter treatment duration, lower total sedative dose, and reduced risk of over-sedation).

First-Line Agents: IV/oral Diazepam (5-10 mg) or Lorazepam (2-4 mg) titrated every 1-2 hours until patient is calm and vital signs normalize.

Severe Hepatic Cirrhosis, Alcoholic Hepatitis, or Geriatric Patients (LOT Mnemonic):

Use Lorazepam , Oxazepam , or Temazepam .

Pharmacologic Rationale: These agents undergo direct Phase II hepatic glucuronidation without Phase I CYP450 microsomal oxidation and generate no active metabolites . Long-acting agents (diazepam, chlordiazepoxide) undergo hepatic oxidation and produce long-lived active metabolites (nordiazepam, desmethyldiazepam) that accumulate in liver failure, precipitating hepatic encephalopathy or prolonged respiratory depression.

Refractory Delirium Tremens: Defined as persistent severe agitation requiring >50 mg of diazepam or >10 mg of lorazepam in the first hour. Transfer to ICU and initiate continuous IV Phenobarbital or continuous IV Propofol / Dexmedetomidine with mechanical ventilation.

Wernicke Encephalopathy & Korsakoff Syndrome

Pathophysiology: Thiamine (Vitamin B1) deficiency leading to impaired cerebral glucose utilization, accumulation of lactate, and microvascular hemorrhages in the mamillary bodies , periventricular thalamus , and periaqueductal gray .

Classic Clinical Triad (present in only ~30% of cases):

Encephalopathy / Acute Confusion: Lethargy, profound inattention, spatial disorientation.

Cerebellar Ataxia: Wide-based, staggering gait, truncal ataxia, dysmetria.

Oculomotor Dysfunction: Bilateral horizontal nystagmus, bilateral lateral rectus palsy (CN VI / abducens nerve), conjugate gaze palsies.

EMERGENCY BOARD RULE: Thiamine Administration Timing High-dose IV Thiamine (500 mg IV TID for 3 to 5 days) must be administered BEFORE or SIMULTANEOUSLY WITH any intravenous dextrose or glucose-containing fluids . Mechanism: Thiamine pyrophosphate (TPP) is an indispensable cofactor for Pyruvate Dehydrogenase and Alpha-Ketoglutarate Dehydrogenase in the Krebs cycle. Administering IV glucose to a thiamine-deficient patient accelerates aerobic glycolysis, rapidly consumes all residual thiamine reserves, and triggers acute lactic acidosis, leading to permanent irreversible Korsakoff Syndrome (dense anterograde/retrograde amnesia, confabulation, apathy) or fatal brainstem herniation.

Loading diagram... Clinical Differentiation and Toxidrome Matrix: Serotonin Syndrome vs. Neuroleptic Malignant Syndrome vs. Anticholinergic Toxicity

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