Will I Get Delirium Tremens Symptoms During Alcohol Withdrawal?

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According to the 2019 National Survey on Drug Use and Health, nearly 15 million Americans met the diagnostic criteria for alcohol use disorder (AUD), a medical condition characterized by an inability to stop or control drinking despite negative consequences.¹ Every year approximately 95,000 people die from alcohol-related causes.² One potential alcohol-related cause of death is delirium tremens symptoms that aren’t properly managed and treated.³

What Is Delirium Tremens?

Delirium tremens (DT) is the most severe form of alcohol withdrawal and is sometimes referred to as alcohol withdrawal delirium.⁴ DT involves sudden and severe nervous system changes. DT can occur any time after a prolonged period of heavy alcohol abuse, especially if you haven’t eaten any food.⁵

Delirium tremens was first recognized as a condition attributed to excessive alcohol misuse in 1813. The anticipated mortality of DT is 37% if an individual does not receive medical attention and treatment.⁵

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However, while DT is highly dangerous, it is also rare. Research indicates that DT occurs in less than 1% of the general population and approximately 2% of people who are dependent on alcohol.³

To be diagnosed with delirium tremens, you must have delirium and be in severe alcohol withdrawal. Delirium is characterized by rapid onset of symptoms, which include disturbances in consciousness, motor activity, cognition and thinking, and sleep-wake cycles.

Delirium tremens is usually a short-lasting condition with a typical duration of 3-4 days but can last up to 10 days.⁴ It usually starts with cognitive disturbances and confusion and ends with prolonged sleep.

What Are Delirium Tremens Symptoms?

Delirium tremens occurs when you experience signs of delirium and severe alcohol withdrawal symptoms after a sudden cessation of heavy and prolonged alcohol use. Delirium tremens symptoms usually occur about 48-72 hours after your last drink.³

Alcohol Withdrawal

The first symptom of alcohol withdrawal is typically tremors—or uncontrollable shaking—which can show up as soon as 6 hours after cessation of heavy alcohol use.

Severe Alcohol Withdrawal

While rare, hallucinations can occur and usually show up in the first 12-24 hours. The third symptom of severe alcohol withdrawal is seizure, which may happen anytime after the first 24 hours.³

Delirium Tremens

Delirium tremens symptoms are considered the fourth and final major symptom of severe alcohol withdrawal. Because DT symptoms do not show up suddenly, early intervention in the first 48 hours of alcohol withdrawal can prevent delirium tremens.³

Common delirium tremens symptoms include:^{3, 4, 5}

Changes in mental function
Brain fog
Severe confusion
Hallucinations (i.e., seeing, hearing, or feeling sensations that do not match reality)
Body tremors
Fear or excitement
Irritability or agitation
Deep sleep that lasts for a day or longer
Fatigue or drowsiness
Sudden changes in mood
Bursts of energy
Stupor (i.e., unresponsiveness that requires vigorous physical stimulation to be broken)
Sensitivity to sound, light, and touch
Restlessness
Seizures

While seizures are a common symptom of DT, they are also a manifestation of less severe alcohol withdrawal. Alcohol-related seizures are usually generalized tonic-clonic (aka grand mal) seizures and occur within 12-48 hours of the last drink. Tonic-clonic seizures involve loss of consciousness and muscle convulsions. Alcohol-related seizure activity is most likely in people with past complications from alcohol withdrawal.³

What Are Delirium Tremens Risks?

Delirium tremens risks can be serious. Some possible complications include:^{4, 5}

Seizures
Injuries from falls that occur during seizures
Injuries to self or others caused by delirium, confusion, or hallucinations
Irregular heartbeat that may become life-threatening
High blood pressure
Altered mental status
Profound confusion
Aspiration pneumonitis (i.e., lung injury caused by inhalation of vomit or gastric contents)
Respiratory failure

The mortality rate for delirium tremens is around 1-4%. DT-related death most often occurs due to:³

Cardiac arrhythmia (i.e., an abnormal heartbeat, including too fast, too slow, or irregular)
Hyperthermia (i.e., abnormally high body temperature)
Seizure complications
Medical conditions related to chronic alcohol abuse, such as progression of alcohol-related liver disease

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Who Is at Risk for Delirium Tremens?

Delirium tremens symptoms are rare, even in people with alcohol dependence. Only about half of people diagnosed with alcohol use disorder experience alcohol withdrawal symptoms. Of all people with alcohol dependence only an approximate 2% experience DT.³

Few studies have been done on the prevalence of DT symptoms. However, one study showed a 1.8% prevalence rate of DT in those with alcohol dependence. The prevalence of DT increases with the severity of alcohol dependence. Those with severe cases of alcohol use disorder and longer histories of chronic heavy alcohol abuse are at highest risk of developing delirium tremens symptoms.³

While the cause is not well understood based on current research, adult men are the demographic most likely to develop DT. The DT prevalence is highest in young, Caucasian men who have never married. The lifetime risk of developing delirium tremens in this population is 5-10%.⁵

Liver disease is a common comorbidity with delirium tremens. Researchers believe that this comorbidity may suggest that those with liver conditions are at higher risk of DT. However, the liver disease may not cause DT because liver disease is often caused by long-term alcohol abuse, which is a known risk factor for delirium tremens.³

Older age is also a risk factor, with elderly persons with AUD more at risk of experiencing delirium tremens symptoms during withdrawal.³

Research indicates that the following are also delirium tremens risk factors: ^{3, 4, 5}

History of delirium tremens
Prior history of seizures
Prior history of alcohol detox or withdrawal
More than 10 years of heavy alcohol use
Concurrent illness
Electrolyte imbalance
Head injury
Infection
Low platelet count
High blood levels of the amino acid homocysteine, which must be broken down by vitamins B6 and B12 to support normal brain function
Low levels of Vitamin B6
Low magnesium levels
Low potassium levels

These risk factors can also increase the mortality of delirium tremens. According to research, those with head injuries have an 11% mortality rate from DT compared to the average 1-4% mortality rate.³

How Is Delirium Tremens Treated?

Delirium tremens is a medical emergency that requires immediate treatment. Treatment is provided to relieve symptoms, prevent complications, and reduce the risk of permanent side effects or death.⁴

Physical Exams and Testing

When you seek medical care for DT, your health care provider performs a physical exam, monitoring you for the following delirium tremens symptoms:^{4, 5}

Irregular or rapid heartbeat
Rapid muscle tremors
Increased startle reflex
Heavy sweating
Problems with eye muscle movement
Dehydration

Your provider may also perform the following tests:^4,5

Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar)
Comprehensive metabolic panel
Electrocardiogram (ECG)
Electroencephalogram (EEG)
Blood phosphate and magnesium levels
Renal and liver function tests
Toxicology screen
Urinalysis/drug screening

To diagnose and treat delirium tremens, your doctor may also ask questions about your medical history, including: ⁵

How much alcohol you drink, how often, and how long you have abused alcohol in that amount
How long it has been since your last alcoholic drink
If you have gone into alcohol withdrawal before and what your symptoms were, as well if you received any treatment
If you use any other substances, including legal, over-the-counter, or recreational substances like anxiety medication (e.g., Xanax), Tylenol, or marijuana
If you have any complicating medical problems such as:
- Coronary heart disease
- Diabetes
- Chronic liver disease

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Hospital Stay

Delirium tremens treatment requires a hospital stay. During this time, your healthcare provider routinely checks your electrolytes, blood serum levels, body fluids, and vital signs (e.g., pulse, blood pressure, breathing rate, and body temperature).⁴

While in the hospital, you may be prescribed medication to treat your symptoms, relieve any tremors or seizures, keep you calm and treat any co-occurring medical conditions.⁴

Medications

Benzodiazepines such as diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the typical course of treatment. Benzodiazepine treatment has drastically reduced mortality rates from delirium tremens.³

Treatment can be administered on a fixed schedule (i.e., at the same time every day) or a symptom-triggered regimen (i.e., when you experience a specific symptom), and it is typically given intravenously. Symptom-triggered regimens usually require the least amount of medication and the shortest duration of treatment. There is no standard dosage requirement as it can vary from person to person.

Some patients with severe delirium tremens symptoms may not respond to benzodiazepines. In these cases, barbiturates, such as phenobarbital, may also be prescribed. Propofol is also sometimes used with benzodiazepines, but only during mechanical ventilation.⁵

Aftercare and Long-Term Treatment

Long-term treatment is recommended after you recover from delirium tremens and are released from the hospital. Some post-withdrawal symptoms such as mood swings, drowsiness, and insomnia, can last for a year or longer. You may benefit from counseling or medications to help ease these symptoms if they occur.⁴

Addiction treatment can help you maintain abstinence from alcohol and prevent relapse. Some treatment options you may consider include:⁴

Inpatient rehabilitation
Outpatient programs
Individual counseling and psychotherapy
Family therapy
Peer support groups, such as Alcoholics Anonymous, HAMS, SOS, and SMART Recovery

If you are struggling with alcohol misuse or dependence, call 800-948-8417 Who Answers? to speak to a specialist about alcohol addiction treatment options.

Resources

National Institute on Alcohol Abuse and Alcoholism. (2021). Alcohol Facts and Statistics.
Centers for Disease Control and Prevention. (2021, October 29). Alcohol and Public Health.
Grover, S. & Ghosh, A. (2018). Delirium Tremens: Assessment and Management. Journal of Clinical and Experimental Hepatology, 8(4), 460-470.
U.S. National Library of Medicine. (2022, February 18). Delirium tremens. MedlinePlus.
Rahman, A. & Paul, M. (2021, August 27). Delirium Tremens. Treasure Island (FL): StatPearls Publishing.