Delirium Tremens

What Is Delirium Tremens?

Delirium Tremens (DTs) is the most severe form of alcohol withdrawal. It is sometimes called alcohol withdrawal delirium, though DTs is the more common term.

With symptoms that include hallucinations, high blood pressure, agitation, and withdrawal seizures, delirium tremens is a medical emergency that can become life-threatening or lead to more serious alcohol withdrawal symptoms if not treated.

In general, DTs may appear around two or three days after stopping or dramatically reducing alcohol intake, and it usually lasts between 48 and 72 hours.

What Causes Delirium Tremens?

The primary cause of Delirium Tremens is suddenly stopping or reducing heavy, long-term alcohol consumption. Since alcohol causes sedation to the nervous system, an abrupt loss of this chemical can cause over-excitability in the brain and trigger severe physical symptoms.

The risk of developing DTs during recovery from heavy alcohol use is highest for those who suffer from other medical conditions. Still, a whole host of factors can increase the chances that an individual may face DTs.

Risk factors that increase your chances of experiencing DTs include:

• Long-term, heavy drinking: Excessive and consistent alcohol consumption.
• Other symptoms of alcohol withdrawal: A history of previous episodes, including earlier experiences of DTs, increases the risk.
• High alcohol tolerance: Individuals with a high tolerance to alcohol are at greater risk during withdrawal and recovery.
• Medical issues: Related or unrelated conditions, like liver disease, seizures, diabetes, cardiac issues, and infections, may heighten the risk.
• Older age: As with most medical issues, age plays a factor in the ability to weather symptoms and recover.
• Lack of medical supervision: Stopping heavy alcohol use without a treatment plan or medical supervision can increase one’s likelihood of DTs.

Symptoms of Delirium Tremens

In short, DTs are characterized by an individual suffering from a confused, anxious state with vivid hallucinations and fluctuating levels of tremors (i.e., shaking), typically accompanied by irregular cardiac activity and fever.

For a more inclusive list, symptoms of DTs may include any or all of the below:

• Severe confusion and disorientation; inability to think clearly and understand the environment.
• Visual, auditory, or tactile hallucinations—typically vivid and disturbing
• Nausea and vomiting
• Shaking, especially in the hands (i.e., tremors)
• Profuse sweating, which can cause dehydration
• Intense restlessness
• Irritability
• Anxiety and panic
• Seizures
• Dangerously high fever (i.e., hyperthermia)
• Rapid heartbeat
• High blood pressure
• Clammy skin
• Insomnia or severe sleep disruption

Delirium Tremens VS Alcohol Withdrawal Syndrome

The Cleveland Clinic reports that about 29% of adults in the U.S. will meet the criteria for alcohol use disorder at some point in their lifetime. Of those, an estimated 1% to 1.5% will experience DTs at least once.

However, DTs is itself a severe symptom of Alcohol Withdrawal Syndrome and causes its own specific, life-threatening symptoms.

Most alcohol withdrawal symptoms can be managed with a care plan and medication under the guidance of a physician, but DTs are considered a medical emergency.

Ideally, a person receiving treatment for alcohol withdrawal will receive care designed to prevent DTs from appearing.

How Does Delirium Tremens Get Diagnosed?

Diagnosis typically involves a comprehensive evaluation by a healthcare provider to confirm DTs and confirm that it isn’t any other medical or psychiatric condition.

Delirium tremens (DTs) are diagnosed based on medical history, clinical presentation, and physical examination.

Key steps in the diagnosis include: 

1. Medical History:
   • Detailed history of alcohol consumption, including duration, quantity, and pattern of use.
   • Previous episodes of alcohol withdrawal or DTs.
   • Co-existing medical conditions and medications.
2. Clinical Presentation:
   • Assessment of symptoms such as severe confusion, agitation, hallucinations, tremors, rapid heartbeat, high blood pressure, fever, and sweating.
3. Physical Examination:
   • Evaluation of vital signs (e.g., heart rate, blood pressure, temperature).
   • Neurological examination to assess mental status, coordination, and reflexes.
4. Laboratory Tests:
   • Blood tests are performed to check for electrolyte imbalances and dehydration, and liver enzymes are assessed.
   • Blood test to check alcohol level to confirm the recent cessation of drinking.
   • A blood test to check the Complete Blood Count (CBC) is performed to note or rule out other infections or illnesses.
   • Imaging Studies: CT scans or MRI for brain imaging may be necessary to rule out other neurological conditions.
5. Use of Diagnostic Criteria:
   • Criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or other clinical guidelines outline specific symptoms and timing related to alcohol withdrawal and DTs.
6. Exclusion of Other Conditions:
   • Ruling out other potential causes of similar symptoms, such as infections, metabolic disorders, or psychiatric conditions.

Treatment for Delirium Tremens

Due to the seriousness of this condition, the treatment of alcohol withdrawal often requires medical supervision to prevent DTs from happening.

If someone is already experiencing delirium tremens, immediate medical intervention is necessary.

Hospitalization in an intensive care unit (ICU) or detoxification facility and the administration of medications to manage symptoms and prevent complications, such as benzodiazepines and antipsychotics, may be necessary.

Medical professionals will assess each case and may also administer intravenous fluids and electrolyte replacements to address dehydration and nutritional imbalances.

Key components of treatment for DTs can include:

• Inpatient care and hospitalization: Patients with DTs are typically admitted to the hospital, often to an intensive care unit (ICU), for close monitoring.
• Benzodiazepines: These medications, such as diazepam or lorazepam, are commonly used to reduce agitation, prevent seizures, and manage other withdrawal symptoms.
• Fluids and Electrolytes: Intravenous fluids and electrolytes are administered to prevent dehydration and correct imbalances, common in DTs.
• Nutritional Support: Thiamine (vitamin B1) and other vitamins are often given to prevent complications such as Wernicke’s encephalopathy, a serious neurological condition associated with alcohol withdrawal.
• Monitoring and Supportive Care: Continuous monitoring of vital signs and mental status is essential. Supportive care, including maintaining a calm environment and providing reassurance, helps reduce anxiety and agitation.
• Addressing Underlying Health Issues: Any co-occurring medical conditions or complications that arise during DTs are treated concurrently.

The goal of treatment is to ensure the safety of the patient, manage symptoms effectively, prevent complications, and support recovery from alcohol dependence.

Early recognition and intervention are crucial to improving outcomes for individuals experiencing delirium tremens.

Dangers of Untreated Delirium Tremens

Untreated delirium tremens carries a mortality rate of about 15% and is one of the most serious of the emergencies related to alcohol abuse and addiction.

The risks of untreated DTs are severe and can include:

• Death: DTs have a mortality rate ranging from 5% to 15% or higher if untreated. The risk of death primarily stems from complications such as cardiovascular collapse, respiratory failure, and other systemic issues.
• Seizures: DTs significantly increase the risk of seizures, which can be life-threatening and lead to permanent brain damage if not managed promptly. Seizures can also lead to aspiration and dangerous falls if the individual is unattended.
• Cardiovascular complications: Patients with untreated DTs are at high risk of cardiovascular instability, including rapid heartbeat (tachycardia), hypertension (high blood pressure), and potentially fatal arrhythmias or myocardial infarction (heart attack).
• Respiratory failure: Severe agitation and the hypermetabolic state associated with DTs can lead to respiratory distress and failure, made worse by potential aspiration from vomiting.
• Infections: Due to weakened immune functioning, individuals with DTs are at higher risk for infections. Even the potential for aspiration from vomiting may lead to pneumonia.
• Organ damage: DTs can cause severely high fevers as well as malnutrition (Wernicke-Korsakoff Syndrome), both of which can cause damage to the brain and other vital organs.
• Metabolic disturbances: DTs can lead to severe dehydration, electrolyte imbalances, and metabolic acidosis.
• Cognitive impairment: Long-term consequences may include long-lasting deficits in cognitive ability, increased risk of dementia, and worsening of underlying psychiatric conditions.
• Mental health issues: Untreated DTs can amplify any pre-existing mental health conditions and lead to long-term cognitive impairments.

How to Safely Stop Drinking and Avoid Delirium Tremens

By seeking medical guidance and following a structured plan, individuals can safely stop drinking and reduce the risk of experiencing severe withdrawal symptoms like delirium tremens.

Stopping drinking safely and avoiding delirium tremens (DTs) involves several extremely important steps:

1. Seek medical assessment and guidance: It is crucial to seek medical guidance before quitting alcohol consumption, particularly for those who have been drinking heavily for a long time. A primary care physician or other healthcare provider can assess overall health, evaluate any risk of severe withdrawal symptoms like DTs, and recommend an appropriate treatment plan.
2. Enroll in medical detox: For individuals at risk of severe withdrawal, a medically supervised detoxification program may be recommended. This involves monitoring by healthcare professionals who can provide medications to manage withdrawal symptoms and ensure safety throughout the process.
3. Eat nutritious, balanced meals: Alcohol dependence often leads to nutritional deficiencies. Ensuring proper nutrition, including taking supplements, can help prevent complications.
4. Find mental health support: Counseling or therapy can be beneficial in addressing psychological aspects of alcohol dependence by providing coping strategies and supporting long-term sobriety.
5. Surround yourself with people rooting for you: Supportive family members, friends, or support groups (such as Alcoholics Anonymous) can provide encouragement and assistance during recovery.
6. Avoid triggers: Identify and avoid situations that may lead to alcohol use, most especially during the early stages of recovery.
7. Stick to follow-up appointments: Check-ins with healthcare providers are important for monitoring progress, managing ongoing symptoms or complications, and adjusting treatment as needed.

Treatment Options for Alcohol Withdrawal

Treatment plans are tailored to individual needs and may involve a combination of approaches to give the best chance for long-term health.

Treatment options for alcohol withdrawal and recovery typically include:

• Detoxification: Medically supervised withdrawal to manage withdrawal symptoms safely and can take place in both inpatient and outpatient capacities.
• Medication-Assisted Treatment (MAT): Prescription medications are sometimes given in conjunction with counseling and behavioral therapies to provide a comprehensive approach.
• Counseling and Addiction Therapy: Individual or group therapy to address underlying issues and develop coping strategies.
• Rehab Programs: Both inpatient and outpatient programs exist to help you address alcohol addiction and any additional substance abuse that you might be dealing with.
• Support Groups: Participation in Alcoholics Anonymous (AA) or similar groups for peer support and guidance.
• Family Therapy: Involving family members in treatment can improve communication and support recovery.
• Dual Diagnosis Treatment: Addressing co-occurring mental health disorders alongside alcohol addiction, as well as any additional substance use disorder that you may also be dealing with.
• Lifestyle Changes: Adopting healthy habits, stress management techniques, and avoiding triggers.

Get Help for Alcohol Withdrawals

Awareness of the signs and symptoms of DTs, followed up with appropriate medical management, is essential to improve the outcome and reduce the potential for life-threatening consequences for those experiencing severe alcohol withdrawal.

Seeking medical help early can significantly improve the effectiveness of treatment and the individual’s safety.

Remember that DTs most commonly occur in individuals with a history of heavy, prolonged alcohol use, especially when they’ve abruptly stopped or reduced drinking.

To help prevent DTs, individuals should seek counseling, regular medical care, and treatment for alcohol use disorder that includes withdrawal plans and strategies to address any medical, nutritional, or mental health needs that complicate recovery.

Get started by checking out SAMHSA’s online treatment locator for a list of the different types of treatments available for managing alcohol use disorder, alcohol withdrawal, and other drinking-related issues.