As the disease progresses to the middle stage, drinking continues to increase and dependency develops. Strong cravings for alcohol are typical at this stage, and drinking isn’t just for enjoyment anymore. Because the body has adapted to deal with an alcohol-rich environment, the alcoholic physically needs it to avoid the painful symptoms of withdrawal.

When alcohol is not present, individuals may experience uncomfortable symptoms such as restlessness, tremors, headache, nausea, vomiting and insomnia. These symptoms can occur six to 24 hours after their last drink.

Alcoholics in this stage have a hard time controlling their drinking. They may begin drinking early in the day and plan their day around their drinking. In social situations, they may be unable to stop drinking when others do and find that they can’t handle as much as they previously could without becoming drunk. Blackout episodes, where the individual does not remember what they’ve said or done while drinking, may occur. They may also drink in secret and lie about their drinking.

Despite efforts to hide their addiction, their drinking problem is quite obvious to others. Work performance usually suffers at this stage, and impairment in the workplace is common. Personal relationships are unraveling as well. Middle-stage alcoholics may become irritable or angry if confronted about their drinking. Mood swings, depression and feelings of guilt and shame are common.

By this stage, their drinking is taking an obvious physical toll as well. They may appear red in the face or look bloated and generally unwell. The alcoholic probably isn’t sleeping or eating well at this point and may not be keeping up with personal hygiene.