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Delirium Tremens: Symptoms, Timeline Treatment

Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS).

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Delirium tremens, or DTs, and seizures are the most severe form of alcohol withdrawal.

This page will help you understand more about delirium tremens, what causes this condition, what factors increase its risk, what its symptoms are, how it is treated, whether it is reversible, and whether the condition can be prevented.

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Delirium tremens (DTs) is one of the most severe manifestations ofalcohol 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 doesnt occur in everyone who withdraws from alcohol.2,3,4Its estimated that about half of the people who abuse alcohol will experience withdrawal symptoms, only a handful (at most 5%) of those people will exhibit symptoms of delirium tremens.5Symptoms of delirium tremens are different from typical alcohol withdrawal symptoms and occur on a different timeline.4,6Symptoms range in severity from irritability and confusion to tremors, nausea, vomiting, and seizures.

Symptoms of delirium tremens dont just suddenly appear, but rather progress from earlier withdrawal symptoms. Symptoms may change over the course of the day.2Symptoms can include:3,4,5,7,8

Agitation, aggression, or irritability.

Severe autonomic hyperactivity such as trembling, sweating, tachycardia, nausea, and vomiting.

Visual, tactile, or auditory hallucinations.

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Alcohol usechanges 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.3,5With continued alcohol use, the brain compensates for the ongoing presence of alcohol by altering the interplay of these two mechanismsand, as a result, person will have to drink increasing amount of alcohol .3,5This 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 alcohols 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 in poor general health, particularly lacking a well-balanced diet.

What Medications Are Used to Treat Delirium Tremens?

It is strongly recommended that if you are at risk of severe alcohol withdrawal symptoms that you get medical attention before starting todetoxfrom alcohol. Delirium tremens is a medical emergency, and you will likely require inpatient care so that medical professionals can offermedicationand monitoring around the clock.3,8In severe cases, you may need to be treated in an intensive care unit (ICU).6Delirium tremens can be fatal and  symptoms can worsen rapidly.3,8Medications 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, like phenobarbital, although these tend to be added on when benzodiazepines alone havent 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 like hallucinations, and help you think more clearly, although this type of medication has been associated with negative side effects.

Delirium tremens isnt 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.3,7This condition typically lasts 3-4 days but can last as long as 8 days.3However, 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.8It is important to note that if you continue to drink after you finish detoxing, you are more likely to experience DTs in the future.3,8

Delirium Tremens typically lasts 3-4 days but can last as long as 8 days.3

The easiest way to prevent delirium tremens is to avoid drinking alcohol, or if you do choose to drink alcohol, consume amounts according to American dietary guidelines.4,11Current 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

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 resolved after 5 days, although it may last up to 8-10 days.

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Delirium tremens results from prolonged periods of heavy drinking.4Unlike an episode ofbinge 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.4,11People who drink very large amounts of alcohol daily for at least several months are more likely to develop delirium tremens.4The longer you drink regularly, the higher your risk for developing DTs.4

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Delirium tremens is not a common condition, especially considering how widespread issues are with alcohol abuse 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% of people 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.3,8Death commonly results from an inability to effectively regulate body temperature, abnormal heart rhythms, worsening of seizures due to alcohol withdrawal, or due to exacerbation of existing medical issues.3,5Since 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.4,8These issues can also make symptoms of delirium tremens worse and more unpredictable, harder to manage, and more dangerous to your health and safety; severe alcohol withdrawal may require treatment in an intensive care unit as opposed to typical inpatient hospitalization.3,5,8

Hersh, D., Kranzler, H.R., & Meyer, R.E. (1997).Persistent delirium following cessation of heavy alcohol consumption: Diagnostic and treatment implications.

American Journal of Psychiatry, 154(6), 846-851

Delirium tremens: Assessment and management

Journal of Clinical and Experimental Hepatology, 8(4), 460-470

U.S. National Library of Medicine. (2019).

. Treasure Island, FL: StatPearls Publishing.

Center for Substance Abuse Treatment. (2006).

Detoxification and substance abuse treatment

. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Hersh, D., Kranzler, H.R., & Meyer, R.E. (1997).Persistent delirium following cessation of heavy alcohol consumption: Diagnostic and treatment implications.

Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings

. Geneva, Switzerland: World Health Organization.

Centers for Disease Control and Prevention. (2020).

Centers for Disease Control and Prevention. (2019).

Substance Abuse and Mental Health Services Administration. (2020).

Key substance abuse and mental health indicators in the United States: Results from the 2019 national survey on drug use and health.

Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.

Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS).

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