Delirium Tremens: Symptoms, Timeline & Treatment

Last updated on November 1, 2023

Delirium tremens (DTs) is the most severe alcohol withdrawal symptom that needs to be adequately managed to prevent fatal outcomes.1 This alcohol dependence-related condition happens more frequently to individuals with a long history of heavy alcohol use when they abruptly stop drinking or attempt to significantly cut down the amount or frequency of their alcohol use.2 The US statistics of alcohol-related DTs highlight the importance of recognizing and addressing alcohol use disorder (AUD) as a significant public health concern. Early intervention and appropriate treatment can help prevent severe complications and save lives.1

According to the National Survey on Drug Use and Health (NSDUH), an estimated 15.2 million adults over the age of 18 had an alcohol use disorder in 2020. Of these, about 6% (912,000) experienced severe AUD, which included symptoms like DTs. When it comes to demographics, men are more likely than women to develop DTs, and the risk also increases with age. According to a study published in the Journal of Addiction Medicine, the incidence of DTs was highest among men aged 45-54, and women aged 55-64.3

What Is Delirium Tremens?

Delirium tremens is a severe, potentially life-threatening complication of alcohol withdrawal that typically develops within 2-3 days after a person stops drinking. It’s characterized by a combination of physical and mental health symptoms, like tremors, hallucinations, confusion, agitation, and fever. DTs can happen to anyone who has been drinking heavily for a long time and suddenly stops, but it is more common in people with a history of alcohol dependence. The risk is also higher in individuals who have previously experienced withdrawal symptoms, like seizures or hallucinations.1

DT treatment generally requires hospitalization and close monitoring of vital signs, hydration, and nutrition. In addition, medications such as benzodiazepines are often used to alleviate symptoms; in most severe cases, antipsychotic drugs may also be prescribed. Immediately seeking medical attention is crucial if you or someone you know experiences symptoms of DTs. If left untreated, this condition can lead to seizures, cardiac arrest, or even death.4

What Are the Symptoms of Delirium Tremens

The symptoms of DTs can include agitation, confusion, tremors, hallucinations, and seizures. The most severe, life-threatening cases have a mortality rate of up to 5%. delirium tremens symptoms typically begin 48-72 hours after the last drink and can last several days. Some of the most common symptoms of DTs include:1

Agitation: Restlessness, irritability, and anxiousness. The individual may have difficulty sitting still or staying calm.
Confusion: The individual could be confused or disoriented, have difficulty concentrating or paying attention, and have trouble remembering recent events.
Hallucinations: DTs can cause visual, auditory, or tactile hallucinations. These hallucinations can be frightening or disturbing, aggravating agitation and confusion even further.
Tremors: Shaking or tremors, particularly in the hands, can also be one of the symptoms. They can be quite severe and interfere with daily activities.
Seizures: DTs can cause seizures, ranging from mild to severe, even life-threatening.
Elevated heart rate and blood pressure: DTs can cause an increase in heart rate and blood pressure, which can further worsen other symptoms.
Sweating: Excessive sweating is a common symptom of DTs and can contribute to dehydration and electrolyte imbalance.
Fever: Some individuals may develop a fever which could be a sign of infection or another underlying medical condition.
Dehydration: DTs can cause considerable fluid loss, leading to dehydration and electrolyte imbalances. This can cause further complications if not addressed promptly.

It’s important to note that not all individuals with alcohol withdrawal will experience DTs, and symptoms can vary in severity. If you or someone you know is experiencing symptoms of alcohol withdrawal or delirium tremens, seek immediate medical attention.3

How to Diagnose Delirium Tremens?

The diagnosis of delirium tremens is usually made based on the individual’s symptoms and clinical history. A healthcare provider typically performs a physical examination and orders diagnostic tests to rule out other medical conditions that could be causing the same symptoms. DT is diagnosed when a patient demonstrates changes or fluctuations in mental status, lack of attention, using auditory and visual tests, and disorganized thinking or otherwise altered level of consciousness.1

Some of the diagnostic methods that may be used to diagnose DTs include:1, 5

Physical examination: A healthcare provider performs a physical exam to assess the individual’s vital signs, blood pressure, heart rate, and temperature. They may also examine the individual for signs of dehydration, malnutrition, or other medical conditions.
Laboratory tests: Blood and urine tests are requested to evaluate liver function, electrolyte levels, blood glucose levels, and other health indicators. Low potassium and low magnesium levels are also an indicator of delirium tremens.
Imaging tests: In some cases, imaging tests such as a CT scan or MRI might be ordered to rule out other medical conditions that could be causing similar symptoms.
Clinical history: The healthcare provider asks questions about the individual’s alcohol use history, including the amount and duration of alcohol use, previous episodes of alcohol withdrawal, and other factors contributing to the development of DTs.
Diagnostic criteria: The healthcare provider may use diagnostic criteria like the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) to help diagnose DTs.

What Are the Causes of Delirium Tremens?

The main cause of delirium tremens is alcohol withdrawal in individuals with a long history of heavy alcohol use. Alcohol use can cause changes in the brain structure and functioning that result in physical dependence. When an individual with alcohol dependence suddenly stops or significantly decreases alcohol consumption, their body and brain experience a shock that can trigger a range of withdrawal symptoms, including DTs.1

Potential root causes of DT can include:3

Alcohol dependence: Heavy, long-term alcohol use is the primary risk factor for developing delirium tremens.
Sudden alcohol cessation: Suddenly stopping or reducing alcohol consumption after prolonged heavy drinking.
Previous alcohol withdrawal: Individuals who have previously experienced withdrawal symptoms, like seizures or hallucinations, are at a higher risk of developing delirium tremens.
Pre-existing medical conditions: Certain medical conditions, like liver disease or some infections, can increase the risk of delirium tremens during alcohol withdrawal.
Malnutrition: Chronic alcohol use can lead to malnutrition, which can exacerbate the risk of DTs.
Electrolyte imbalances: Alcohol use can disrupt electrolyte balances in the body, leading to various physical and mental health symptoms.
Genetics: Some individuals could be genetically predisposed to developing delirium tremens during alcohol withdrawal.

It’s important to note that not all individuals who experience alcohol withdrawal develop delirium tremens and that the condition’s root causes can vary from person to person. Seeking medical attention and monitoring during withdrawal can help reduce the risk of DTs and other complications. The exact mechanisms that cause delirium tremens are not fully understood. Still, it is believed to involve a complex interplay of factors, including neurotransmitter changes, hormonal and metabolic imbalances, and genetic and environmental factors.3, 6

How Much Do You Have to Drink to Get Delirium Tremens?

The amount and duration of alcohol consumption needed to trigger DTs can vary from person to person, and there’s no fixed threshold that applies to everyone. However, long-term alcohol use is the primary risk factor for developing DTs. Individuals who have been drinking heavily for years are more likely to experience DTs when they stop drinking suddenly.7

Those with a history of multiple instances of withdrawal symptoms that include seizures and hallucinations are at a higher risk, as mentioned. It’s difficult to give an exact amount of alcohol or duration of use that would lead to DT since it can depend on many factors, like overall health, genetics, and alcohol consumption patterns.7

How Long Does Delirium Tremens Last?

With immediate treatment and medical care, most people with DTs recover within a few days to a week. Delirium tremens treatment typically involves hospitalization, medication to manage symptoms (usually benzodiazepines), and supportive care to prevent complications such as dehydration and electrolyte imbalances. Individuals may sometimes require long-term treatment for alcohol use disorder to prevent future DTs episodes.1

The duration of delirium tremens can vary from person to person, but the symptoms typically peak within 2-3 days after they begin and usually last up to a week, sometimes longer. A general delirium tremens timeline would look like this:1

Day 1-2: Symptoms of alcohol withdrawal, such as anxiety, restlessness, and tremors, begin to develop. They can escalate quickly, and the person might experience hallucinations and confusion.
Day 2-4: Signs of DT typically peak during this time. The person may experience intense hallucinations, confusion, agitation, and fever. They may also have difficulty sleeping and experience rapid heart rate and blood pressure changes. In most severe cases, patients will have muscle contractions, lose consciousness, and may fall into a coma.
Day 5-7: DT symptoms begin to subside, but the patient would still experience lingering physical and psychological effects. Medical monitoring and support are still necessary, to prevent complications and ensure the person’s safety.

What Medications Are Used to Treat Delirium Tremens?

Some of the standard medications used in the treatment of delirium tremens include:1, 3, 8, 9

Benzodiazepines. Benzodiazepines are a class of drugs that help to reduce anxiety and seizures. They help manage symptoms like tremors, hallucinations, and agitation.
Antipsychotics. Antipsychotic medications, such as haloperidol or olanzapine, may help manage severe agitation or hallucinations.
Beta-blockers help with blood pressure and reduce heart rate. They’re used to help manage the physical symptoms of withdrawal, like rapid heartbeat and high blood pressure.
Anticonvulsants: Anticonvulsant medications, like valproic acid, help manage seizures or tremors,
Thiamine. This is vitamin B1 and is often given to individuals with alcohol withdrawal to help manage symptoms and prevent complications like Wernicke-Korsakoff syndrome.

A medical professional should carefully monitor any medication used during DT treatment. The specific drugs used vary depending on the patient’s symptoms and medical history.1

Delirium Tremens Treatment Programs

Treatment for DTs and the subsequent alcohol addiction recovery can be complex, and the chosen approach will be determined according to the severity of the symptoms and the individual’s medical history. Most treatment programs involve a combination of medication and supportive care. Some of the commonly used treatment elements and therapy approaches for DTs include:10

Medications: The primary medications used to treat delirium tremens are benzodiazepines, a class of drugs that help calm the brain activity and reduce withdrawal symptoms. Benzodiazepines such as lorazepam or diazepam can be given orally or intravenously. In some cases, antipsychotic medications may also help control hallucinations and delusions.
Supportive care: This involves providing care and support to help manage the physical and emotional signs of DT. It may include hospitalization in an intensive care unit or a specialized medical facility like a licensed SUD treatment provider facility. Such facilities can offer close monitoring of vital signs like blood pressure, heart rate, and temperature. Fluids and electrolytes can also be replenished as needed.
Behavioral therapies: Cognitive-behavioral therapy (CBT) and Motivational Interviewing (MI) can help address underlying psychological and emotional issues that might have contributed to alcohol abuse and dependence. This typically involves working with a therapist and adopting coping strategies and skills to manage cravings and prevent relapse.
Holistic approaches can be used as part of the AUD treatment after experiencing delirium tremens. A holistic approach considers the person’s physical, emotional, and spiritual well-being and aims to treat the whole person rather than just the symptoms. It may include mindfulness-based approaches, exercise and physical activity, nutrition, and healthy eating, art therapy, or other creative therapies.
Aftercare. This is a vital part of recovery and usually includes ongoing medical care if necessary, continuing with psychotherapy, taking part in mutual support groups, sober living, and other available resources to help maintain sobriety and prevent relapse.

If you’re struggling with alcohol dependence and need accurate information about treatment options, you can always call one of the free and confidential alcohol addiction hotlines. They’re available 24/7 and can refer you to reliable substance abuse treatment providers, like American Addiction Centers (AAC), one of the largest networks of rehab facilities across the U.S. AAC’s hotline representatives can present your treatment options, explain costs of various types of treatment, and refer you to the nearest or most suitable rehab center according to your needs.