Delirium Tremens

What is delirium tremens?

Delirium tremens (DTs) is the most severe form of alcohol withdrawal. This condition can sometimes be life-threatening. DTs is possible when someone with alcohol use disorder, especially moderate or severe alcohol use disorder, suddenly stops drinking entirely.

Long-term heavy alcohol use sets up a tug-of-war-like effect in your body. Alcohol is on one side, slowing down central nervous system (CNS) activity. Your CNS controls your body’s automatic processes like breathing and heart rate. Alcohol is a depressant, so it slows down this activity. Your CNS is on the other side of the rope pulling back by increasing its own activity to keep things running. Over time, your CNS adjusts and sees that increased activity level as its new normal.

If you suddenly stop drinking, it’s like the alcohol side letting go of the rope. Suddenly, your CNS doesn’t have to pull back against alcohol to keep activity at a proper level. But your CNS can’t bring its activity level down quickly. That means your CNS is much more active than needed, to the point that it negatively affects automatic body processes. This causes DTs.

How common is this condition?

Alcohol use disorder is common. About 29% of adults in the U.S. will meet the criteria for it at some point in their lifetime. Of those people, approximately 1% to 1.5% will have DTs.

What are the symptoms?

There are many possible symptoms of DTs, and some are more well-known than others. The symptoms can include:

• Tremors or shakes. These are among the most common (and most stereotypical) of DTs symptoms. They’re most apparent in your hands.
• Confusion. This is a form of delirium specific to alcohol withdrawal (healthcare providers sometimes call this altered mental status). This, along with tremors, is where DTs gets its name.
• Agitation or anxiety. This can often lead to combative or aggressive behavior.
• Psychosis symptoms. People with DTs may have hallucinations — seeing, feeling or hearing things that aren’t really there. Other psychosis symptoms are also possible, like paranoia.
• Sensory disruptions and disorientation. People with DTs often have reduced awareness of the environment around them because their senses aren’t working properly.
• Bouts of heavy sweating (diaphoresis). People with DTs will have periods where they sweat noticeably and heavily. These come and go.
• Seizures. These often start before withdrawal turns into DTs. Seizures can be dangerous or even deadly if they turn into status epilepticus.
• High body temperature (hyperthermia).
• Headaches.
• Nausea and vomiting.
• Fast heart rate (tachycardia).

What causes delirium tremens?

The only cause of DTs is withdrawal that happens when someone with alcohol use disorder stops drinking alcohol suddenly. They usually appear between one and three days after your last drink and are usually most intense four to five days after your last drink.

What are the risk factors for delirium tremens?

Several risk factors can make DTs more likely to happen. They include:

• A personal history of alcohol withdrawal symptoms, including seizures and DTs.
• Multiple instances of stopping heavy alcohol use.
• Heavy alcohol intake (the heavier the intake, the greater the risk).
• Any other kind of substance use disorder happening at the same time, especially sedatives or hypnotics (sleep-inducing medications). These substances also slow down your CNS.
• Increasing age. It becomes easier to develop DTs as you get older. Alcohol withdrawal and DTs are rare in people under age 30.
• Other medical problems. These include nutrition deficiencies or other medical conditions like cardiovascular disease and liver disease.

What are the complications of delirium tremens?

Alcohol use disorder and DTs can both contribute to a number of complications, many of them serious. They include:

• Nutritional deficiencies, especially Wernicke-Korsakoff syndrome (alcohol-related B1 deficiency).
• Seizures.
• Anxiety and depression.
• Sleep disruptions.
• Heart and circulatory problems.

How is delirium tremens diagnosed?

A healthcare provider, typically an emergency room physician or other clinician, can diagnose DTs based on a combination of methods and tools. These include:

• Physical examination.
• Neurological examination.
• Specialized checklists with scoring tools that indicate how likely DTs is based on symptoms. One example of this is the Clinical Institute for Withdrawal Assessment for Alcohol Revised Scale (CIWA-Ar).
• Lab testing.

What tests will be done to diagnose delirium tremens?

Most of the tests that help diagnose DTs happen in the laboratory and involve blood or urine samples. The tests look for issues with the following:

• Organ function, especially your liver, kidneys and heart.
• Blood alcohol level.
• Urine drug test.
• Electrolyte levels.

Other tests may be possible, depending on your symptoms or if you have any other health problems. Your healthcare provider can tell you more about the tests they recommend or used for you (or your loved one) and why.

How is delirium tremens treated, and is there a cure?

DTs isn’t curable, but it’s very treatable. Because confusion is a key symptom of DTs, people with this condition can’t make informed choices about their care. It may be necessary for family or loved ones to make decisions if you can’t make choices for yourself.

One of the priorities in treating this condition is to lower nervous system activity. A healthcare provider will treat this using drugs that reduce how active your CNS is. Multiple types of medication can help with this.

Treating DTs generally starts with sedatives. They help lower activity in your CNS, which is the source of most of the dangerous problems with DTs. The most common sedatives are benzodiazepines, but other drug types are possible, too. In rare situations, people with very high CNS activity may need general anesthesia to fully sedate them and avoid the most dangerous symptoms of DTs.

Many people with DTs also have dehydration, electrolyte imbalances or mineral deficiencies. Your healthcare provider can treat these by infusing you (through an IV in your vein) with the necessary vitamins and minerals. Some infusions come specially prepared for this type of situation. An example of this is an infusion that healthcare providers often refer to by the nickname “banana bag” (because the solution in them is yellow). It contains vitamin B1 (thiamine), B9 (folate), a multivitamin, electrolyte solution and more.

Alcohol use disorder treatment

The main underlying issue that causes DTs is alcohol use disorder. The long-term goal after treating DTs is to treat alcohol use disorder. There are many treatment approaches for alcohol use disorder. Receiving treatment for it can help reduce the odds of developing DTs in the future.

Complications or side effects of the treatment

Complications of DTs treatments largely depend on the treatments you receive. Because there are many different medications and treatment approaches, the side effects can vary widely. Your healthcare provider is the best person to tell you more about the possible complications you might experience after your symptoms improve and confusion resolves. Your provider may also tell loved ones authorized to know and make choices about your care.

How soon after treatment will I feel better?

The main symptoms of DTs often take between three to seven days to go away. You should start to feel better gradually during that time. In severe cases, you may experience some symptoms for weeks to months.

Can delirium tremens be prevented?

The only definitive way to prevent DTs is to avoid alcohol entirely.

If you have alcohol use disorder and want to stop drinking, talk to a healthcare provider. They can help you find resources, care and support that’ll help you reduce alcohol intake safely, and also give you the best chance at a positive outcome. They can recommend alcohol rehabilitation programs, specialist providers, support groups and more.

The best way to avoid or reduce your risk of developing alcohol use disorder (and DTs) is to drink in moderation. That means drinking according to the following guidelines:

• For men and people assigned male at birth (AMAB), the recommended number of alcoholic drinks is no more than two per day, and no more than 14 per week.
• For women and people assigned female at birth (AFAB), the recommended number of alcoholic drinks is no more than 1 per day and no more than seven per week.

Alcohol use disorder isn’t a condition that happens for just one reason. Family history, mental health conditions and many other factors can play a role. If you’re concerned about your risks for developing alcohol use disorder, it’s a good idea to talk to a healthcare provider. They can help you understand your risks and guide you on what to do about them.

What’s in a drink?

One drink is equal to 14 grams (g.) of pure alcohol, which can take many different forms because some forms have a higher concentration of alcohol than others.

Each of the following examples of those forms is equal to one drink.

What can I expect if I have delirium tremens?

If you have delirium tremens, confusion is one of the key symptoms you’ll experience. You’ll have trouble understanding what’s happening to or around you. It’s also possible that you’ll experience hallucinations, meaning you’ll see or hear things that seem real to you, but that aren’t really there.

Because of these symptoms, you won’t be able to make decisions about your medical care. Healthcare providers will treat you to stabilize you (unless you have some kind of advance medical directive on file with them). They may also talk to family, friends or loved ones you previously approved to know and make decisions about your medical care.

How long does delirium tremens last?

DTs generally lasts up to seven days. Some people may experience some symptoms for up to two weeks.

What’s the outlook for delirium tremens?

The outlook for delirium tremens depends on multiple factors. Those include:

• How severe the symptoms are.
• The severity of your alcohol use disorder.
• Other medical conditions you have.
• How soon you received medical care.

Even with treatment, one of the possible complications of DTs is death. Without treatment, about 15% of people with DTs don’t survive. The risk of death is also higher if you have other severe medical conditions. With treatment, the survival rate of DTs is about 95%. The earlier a person gets treatment for DTs, the better the odds of survival and a positive outcome.

How much do you have to drink to develop delirium tremens?

DTs can develop in anyone who meets the criteria for heavy alcohol use. For people AMAB, that means drinking three or more drinks per day and 15 or more drinks per week. For people AFAB, that means drinking two or more drinks per day and eight or more drinks per week. However, DTs becomes more and more likely the more you drink and the longer this continues.

It’s hard to pinpoint an exact number for each person because everyone’s different. Some people have higher alcohol tolerances. Some have genetic conditions that mean it’s very easy for them to experience intoxication from alcohol. Others may be more susceptible to intoxication and DTs because of medications they take, health conditions and other factors.

Because DTs can happen to people at various drinking levels, the best way to avoid DTs is to drink in moderation or not at all.

A note from Cleveland Clinic

Delirium tremens is a severe, life-threatening form of withdrawal that can happen when a person with alcohol use disorder suddenly stops drinking. Reducing alcohol intake or quitting alcohol entirely is an important step toward improving your health if you have alcohol use disorder. But this is a goal you should also approach safely, and you don’t have to do it alone.

If you have alcohol use disorder and want to reduce how much you drink or quit entirely, a primary care provider can guide you to resources and rehabilitation programs that can help. Many people feel shame or embarrassment asking for this kind of help, but your provider’s job is to help, not to judge. That way, you can reduce your drinking safely and improve your health, well-being and overall quality of life.