Delirium Tremens: Symptoms, Timeline & Treatment

What is Delirium Tremens (DTs)?

Delirium tremens (DTs) is one of the most severe manifestations of alcohol withdrawal. It occurs after a period of heavy drinking, typically in those with a history of chronic alcohol use and those who have previously experienced severe alcohol withdrawal symptoms. It is a rare, life-threatening condition, and it doesn’t occur in everyone who withdraws from alcohol.^2,3,4 It’s estimated that about half of the people who abuse alcohol will experience withdrawal symptoms, but only a handful (at most 5%) of those people will exhibit symptoms of delirium tremens.⁵ Symptoms of delirium tremens are different from typical alcohol withdrawal symptoms and occur on a different timeline.^4,6 Symptoms range in severity from irritability and confusion to tremors, nausea, vomiting, and seizures.

Delirium Tremens Symptoms

Symptoms of delirium tremens don’t just suddenly appear, but rather progress from earlier withdrawal symptoms. Symptoms may change over the course of the day and can include:^2,3,4,5,7,8

• Agitation, aggression, or irritability.
• Confusion.
• Severe autonomic hyperactivity such as trembling, sweating, tachycardia, nausea, and vomiting.
• Impaired consciousness.
• Visual, tactile, or auditory hallucinations.
• Tremors or seizures.

Risk Factors for and Causes of Delirium Tremens

Alcohol use changes excitatory and inhibitory mechanisms of activity within the nervous system resulting in a slowdown of brain functioning that a person typically experiences as sedation and decreased anxiety.^3,5 With continued alcohol use, the brain compensates for the ongoing presence of alcohol by altering the interplay of these two mechanisms and, as a result, the person will have to drink increasing amounts of alcohol .^3,5 This adaptation is referred to as tolerance. Over time, the brain continues to adapt as a person continues drinking. Eventually a person develops a dependence to alcohol, which means that when alcohol use is stopped or significantly reduced, the brain is still producing excitatory signals to compensate for alcohol’s inhibitory effects. This overcompensation results in greater weight on excitatory signals and causes a state of hyper-arousal that a person experiences as withdrawal symptoms.^3,5

Some risk factors related to the severity of alcohol withdrawal, including the development of delirium tremens, include:⁶

• Higher amounts of alcohol consumed in the weeks prior to withdrawal.
• The number of previous episodes of alcohol withdrawal.
• Previous experience with severe alcohol withdrawal symptoms, which includes DTs or withdrawal seizures.
• Underlying health issues, which can include major injuries, liver or heart disease, or traumatic brain injury.
• Being of older age.
• Other medications or supplements.
• Having a psychiatric disorder.
• Being in poor general health, particularly lacking a well-balanced diet.

Delirium Tremens Medication

It is strongly recommended that if you are at risk of severe alcohol withdrawal symptoms that you get medical attention before starting to detox from alcohol. Delirium tremens is a medical emergency, and you will likely require inpatient care so that medical professionals can offer medication and monitoring around the clock.^3,8 In severe cases, you may need to be treated in an intensive care unit (ICU).⁶ Delirium tremens can be fatal, and symptoms can worsen rapidly.^3,8 Medications used to treat delirium tremens include:^3,5,7,8,9

• Benzodiazepines, such as lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide (Librium), which can effectively manage the majority of alcohol withdrawal symptoms, including delirium tremens, and reduce the risk of seizures. These are the most commonly used medications, and large doses may be required.
• Barbiturates, such a phenobarbital, although these tend to be added on when benzodiazepines alone haven’t been sufficient in managing symptoms.
• Antipsychotics, such as haloperidol (Haldol), may be used in low doses to help reduce problematic behaviors such as agitation, manage psychotic symptoms such as hallucinations, and help you think more clearly, although this type of medication has been associated with negative side effects.

Is Delirium Tremens Reversible?

Delirium tremens isn’t a permanent condition, but it can potentially be fatal. Prompt medical attention to alcohol withdrawal symptoms can help ensure withdrawal does not progress to the severity of DTs.^3,7 This condition typically lasts 3-4 days but can last as long as 8 days.³ However, the severity and duration of DTs will vary between individuals. Although medical treatment is important to receive while experiencing symptoms, symptoms may still progress and become increasingly severe once manifested.⁸ It is important to note that if you continue to drink after you finish detoxing from alcohol, you are more likely to experience DTs in the future.^3,8

How to Prevent Delirium Tremens

The easiest way to prevent delirium tremens is to avoid drinking alcohol, or if you do choose to drink alcohol, consume amounts according to U.S. dietary guidelines.^4,11 Current dietary guidelines state that if you do drink alcohol, men should not have more than 2 drinks in a day, and women should not have more than 1 drink in a day.¹⁰

If you consume greater quantities of alcohol and are at risk for experiencing alcohol withdrawal symptoms, especially if you have one or more of the risk factors for developing severe withdrawal (which includes seizures and DTs), you should contact a medical professional and/or a treatment center prior to stopping or significantly reducing alcohol use. Proper and prompt treatment of alcohol withdrawal can potentially lower the risk of symptoms developing into DTs.^3,4

How Long Does Delirium Tremens Last? The DTs Timeline

Although the course of DTs tends to follow a general timeline, symptoms can fluctuate and some may persist longer than others.^4,9A typical timeline of delirium tremens symptoms may resemble the following:^3,4,5,8

• Symptoms of alcohol withdrawal appear between 6 to 24 hours after heavy, prolonged drinking is stopped.
• More severe symptoms, such as hallucinations or seizures, appear around 12 to 48 hours after the last drink and may evolve during this time into delirium tremens.
• Delirium tremens symptoms continue for 3-4 days and typically resolve after 5 days, although it may last up to 8-10 days.

Delirium Tremens Treatment

If delirium tremens develops, the condition should be treated as an emergency and managed in an ICU or inpatient environment. Within these settings as well as emergency room environments, the aforementioned medications can be used to treat DTs and prevent symptom progression. Delirium tremens treatment is also centered around:³

• Lessening symptoms such as agitation, which is likely to decrease the risk of injury, seizures, and death.
• Identifying and treating underlying medical co-morbidities.
• Providing prompt, adequate, and protocol-driven treatment for alcohol withdrawal.

Once a person has been stabilized and the medical emergency subsides with successful delirium tremens treatment, the person may eventually resume with ongoing alcohol use disorder treatment.³ This treatment, then, can include various levels of care, such as further detox, inpatient/residential care, intensive outpatient programs (IOPs), partial hospitalization programs (PHPs), outpatient care, aftercare, and sober living solutions.

How Much Alcohol Do I Have to Drink to Get Delirium Tremens?

Delirium tremens results from prolonged periods of heavy drinking.⁴ Unlike an episode of binge drinking, which involves drinking large amounts of alcohol (5 or more drinks for men, or 4 or more drinks for women) in a 2-hour period, DTs results from heavy drinking that occurs for many days over long periods of time.^4,11 People who drink very large amounts of alcohol daily for at least several months are more likely to develop delirium tremens.⁴ The longer you drink regularly, the higher your risk for developing DTs.⁴

Delirium Tremens Statistics: Is it Common?

Delirium tremens is not a common condition, especially considering how widespread issues are with alcohol misuse and alcohol use disorders. Some facts relevant to delirium tremens include:^3,5,12

• In 2019, 14.5 million Americans aged 12 or older were diagnosed with an alcohol use disorder.
• At least half of these people experience some symptoms of withdrawal when they stop or dramatically reduce their alcohol intake.
• Of the people who go through alcohol withdrawal, only 3-5% develop severe withdrawal symptoms, such as seizures and delirium tremens.
• Without proper treatment, DTs can have a mortality rate of up to 37%.

Is Delirium Tremens a Medical Emergency?

Delirium tremens should always be treated as a medical emergency, as it can be fatal if left untreated.^3,8 Death commonly results from an inability to effectively regulate body temperature, abnormal heart rhythms, worsening of seizures due to alcohol withdrawal, and/or exacerbation of existing medical issues.^3,5 Since people who are older or those who have additional physical health conditions are at significantly higher risk for the development of delirium tremens, it is important to seek medical care if you have these risk factors and want to stop heavy, prolonged use of alcohol.^4,8 These issues can also make symptoms of delirium tremens worse, more unpredictable, harder to manage, and more dangerous to your health and safety; thus, severe alcohol withdrawal may require treatment in an intensive care unit as opposed to typical inpatient hospitalization.^3,5,8

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