Delirium Tremens (DT): Symptoms, timeline and treatment

Delirium Tremens is a serious, life-threatening condition caused by prolonged excessive alcohol use and occurs when a patient with a long history of alcohol misuse and alcohol dependence has stopped drinking alcohol for 2–3 days and is experiencing symptoms associated with an alcohol withdrawal syndrome. (2)

Alcohol statistics

It is estimated that alcohol that there are over three million deaths per year due to alcohol abuse. Since the global pandemic, there has been an even greater rise in the number of people drinking alcohol to excess and becoming physically dependent on alcohol.

This can result in a greater number of people suffering from physical health problems throughout the world as alcohol is known to be a significant causal factor in over 200 diseases and medical conditions. (14)

Background – How does alcohol dependence develop?

When people consistently drink over the recommended 14 units of alcohol per week they will quickly build up a tolerance to alcohol, which means they will need to increase the volume of their alcohol consumption to continuously feel its effects. In essence, they will need to drink more alcohol to become inebriated.

When drinkers who have increased their tolerance to alcohol cease to drink alcohol they will experience withdrawal symptoms such as headaches, insomnia, anxiety, irritability and even life-threatening seizures.

This is because their body and brain have slowly adapted to the presence of a depressant substance and are unable to deal with the sudden disruption to its chemical and biological functioning and the consequence of this is withdrawal symptoms.

It is when a drinker reaches this stage that he can be categorised as being alcohol dependent, and should consult with a medical professional to assess if they have an alcohol use disorder. (2,4)

Categories of alcohol use disorder

There are three categories of alcohol use disorder, mild, moderate and severe. Excessive drinkers who have been consuming high levels of alcohol for years will probably fall into the severe category and therefore be at greater risk of developing delirium tremens.

Delirium Tremens is an alcohol-induced disorder which is a severe symptom of alcohol intoxication and alcohol withdrawal and is also known as alcohol withdrawal delirium and is considered a life-threatening condition.

People who have been drinking excessively for a long time and who experience severe withdrawal symptoms when they stop drinking are highly vulnerable to developing delirium tremens. (1)

Delirium Tremens is a medical emergency

It is important for heavy drinkers who are withdrawing from alcohol to consult with medical services rather than attempt to stop drinking alcohol themselves as they are vulnerable to experiencing three symptoms which can have catastrophic outcomes for them.

These are:

• Delirium Tremens.
• Wernicke Encephalopathy
• Korsakoff syndrome

All of these three conditions represent a medical emergency. (2,9)

Delirium tremens statistics

DT will affect approximately 5–8% of people who experience alcohol withdrawal symptoms, but it does not tend to just appear suddenly without warning as people who do suffer from DT will tend to have previously experienced alcohol withdrawal symptoms several times before the condition develops.

If patients with DT are not treated swiftly and efficiently they can be in grave danger due to the resulting disruption to the functioning of the cardiovascular and respiratory systems or as a consequence of cardiac arrhythmia.

DT is probably the most complicated symptom associated with alcohol withdrawal and requires careful and immediate medical attention.  (2,4)

Delirium tremens and the alcohol withdrawal Timeline?

DT does follow a separate timeline to the standard symptoms of alcohol withdrawal experienced by the majority of people who will be diagnosed with an alcohol use disorder and is often referred to as late-stage alcohol withdrawal.

DT tends to appear 2 to 5 days after a patient last consumed alcohol and lasts for 3-5 days in total. The sequence of the four major symptoms that occur during alcohol withdrawal is:

• Symptom 1 – Tremors (6 – 10 hours after last drink).
• Symptom 2 – Hallucinations (12 – 24 hours after last drink).
• Symptom 3 – Seizure (24 hours after last drink).
• Symptom 4 – Delirium tremens (48–96 hours after last drink).

Delirium tremens occurs during the latter stages of the alcohol withdrawal timeline and several symptoms can appear before then but not everyone will necessarily reach the latter stages of withdrawal and develop DT, even many long-term drinkers do not develop the symptoms of DT. (1,4)

Diagnosing Delirium Tremens

For an accurate diagnosis of delirium tremens to be made two observations need to be apparent. Firstly, it must be apparent that the patient has delirium and secondly the patient must be experiencing severe alcohol withdrawal and therefore have other accompanying symptoms of alcohol withdrawal.

Delirium is a state of mental confusion defined by a sudden onset of disturbances to consciousness, and several aspects of cognitive functioning, for example, a patient may be;

• Unaware of what is happening around them.
• Have no idea where they are or why they are there.
• Will be unable to conduct a conversation and talk coherently.

Their confusion can become worse and be accompanied by fright, distress and agitation and tends to occur more often in the evening and at night-time. (13)

Other symptoms of delirium tremens include:

• Abnormal perceptions.
• Severe tremors.
• Irritation, agitation.
• Delusional beliefs
• Mild fever / autonomic instability.
• An increase in hallucinations, which may be auditory, or visual and be of a threatening or persecutory nature and can be terrifying.
• Susceptible to sudden mood change.
• Vivid, emotionally charged dreams
• Experiencing tactile sensations over their body, for example, they may feel like insects are crawling on their skin. (2,11)

Long term symptoms

It has been known for sub-acute symptoms to last for 4–5 weeks but the person is not in any danger once they have been treated.

Patients have reported a wide variation of many other symptoms over the long term, such as quiet confusion, agitation, and peculiar behaviour lasting several weeks at the mild end of the spectrum and at the extreme end abnormal behaviour, vivid, terrifying delusions, and perceptive disturbances. (4)

Diagnostic/treatment considerations

If a patient is displaying symptoms of DT it is necessary for medical personnel to conduct tests to rule out electrolyte deficiencies, pancreatitis and alcoholic hepatitis as many symptoms of DT may also indicate symptoms of these conditions and require specialist treatment.

Not all patients withdrawing from alcohol will experience symptoms of DT, and although symptoms usually appear 2-3 days after the person last consumed alcohol, it has been known for some patients to experience the symptoms 5-7 days after their last alcoholic drink. The symptoms of DT tend to be at their severest on days 4 and 5.

Overall DT is benign and only lasts a few days and there are established medical treatment protocols to treat the condition so that the person is not in any danger. (9,12)

Patients diagnosed with DT should be treated in a hospital

DT is classed as a medical emergency as a patient is likely to be in a hyperadrenergic state, meaning the central nervous system is highly stimulated due to the sudden decline in blood alcohol levels which is affecting GABA activity in the brain.

DT appears because heavy drinkers have not yet received any specialist pharmacological treatment to help them detox safely  A person diagnosed with DT will have severe alcohol withdrawal that requires immediate pharmacological treatment.  (9,12)

Why is DT such a dangerous condition?

Heavy drinkers diagnosed with DT will experience sudden changes in their core body temperature, their respiratory process and blood circulation.

This makes patients vulnerable to several life-threatening conditions such as:

• Irregular heartbeat and cardiac activity.
• Difficulty breathing.
• Electrolyte imbalance.
• Death can also occur from cardiac arrhythmia (irregular heartbeat).
• Because of the precarious nature of the condition patients should be treated at an intensive care unit or a ward that can regularly monitor a patient’s vital physical signs. (2,3,4)

What are the risk factors for developing Delirium Tremens

Below are some of the most common risk factors of developing DT:

• Patients who have previously experienced DT symptoms.
• Patients who have previously had seizures when withdrawing from alcohol.
• Individuals who have significantly increased the volume of their drinking in recent weeks or are long-term heavy drinkers.
• Any heavy drinker with an underlying illness.
• Going for longer than 2 days without a drink if you are a dependent drinker.
• Patients with an infection or have been diagnosed with hepatitis or pancreatitis.
• People who have damaged their liver through prolonged excessive drinking or have abnormal liver functioning due to other factors.
• Regular, heavy drinkers over 40 are more vulnerable to developing DT.
• People who experience severe withdrawal symptoms, or who have been diagnosed with a severe alcohol use disorder. (2,3,4)

Treatment for Delirium tremens

As DT requires swift medical intervention the patient must visit a hospital for treatment for the duration of the treatment, DT usually disappears after 2–5 days of the symptoms first appearing if the patient receives treatment.

Some patients may be very unwell however and may need to be treated in an intensive care unit for a longer period.

There is a strong possibility that patients with DT may exhibit symptoms of or, be at risk of developing Wernicke’s encephalopathy and doctors should make allowances for this in the treatment plan they devise.

The first task for medical professionals treating patients with alcohol withdrawal syndrome (and DT) is to assess the severity of withdrawal by using an assessment tool called the  Clinical Institute Withdrawal Assessment (CIWA) which measures the strength of withdrawal symptoms on a 0-7 scale.

There are items on the CIWA questionnaire that can help the medical staff determine the severity of a patient’s withdrawal and if they are showing symptoms of DT.

Medication / pharmacological interventions

The standard medical treatment for DT involves giving patients a benzodiazepine drug which will help to alleviate the unpleasant and life-threatening withdrawal symptoms that are at risk of occurring.

The benzodiazepines used to treat DT are usually diazepam, chlordiazepoxide and lorazepam.

Diazepam and Chlordiazepoxide are favoured because they are long-acting drugs that are very suitable for any tapering approach that might be used, and they will also help keep withdrawal symptoms at bay for at least 24 hours.

However, some patients with liver damage and/or poor liver functioning would be unable to metabolise these two benzodiazepine drugs so lorazepam would be used as this can take effect without needing to be processed (metabolised) by the liver. (10,11)

Other treatments that may be necessary for patients with DT include:

• A course of intravenous fluids, which includes key vitamins and minerals ensures the patient remains hydrated and that their electrolyte balance is at a healthy level.
• Antipsychotic drugs help relax the patient and prevent hallucinations.
• Anti-convulsant drugs prevent seizures, although the benzodiazepine drug chlordiazepoxide does possess anti-convulsant properties.
• Medication for high blood pressure.
• Pain relieving drugs. (2,4,11)

Thiamine

Also known as vitamin B, thiamine is an essential micronutrient that many heavy users of alcohol may be missing as this deficiency is strongly associated with chronic alcohol use.

Thiamine is not produced in the body but is found in healthy foods such as fish, legumes and grain, foods which people with alcohol use disorder tend not to consume due to their unhealthy diet or the lack of food they consume.

Research has indicated that thiamine supplements are an effective treatment for delirium as any deficiency in this vitamin leads to a decline in the quality of brain cells which can cause a range of problems associated with cognitive functioning including perception, awareness and memory.

Taking thiamine will also protect chronic drinkers from developing brain damage associated with alcohol use. (8)

Psychological rehabilitation for Delirium Tremens patients

It is vitally important that once patients have been treated for DT they undergo a range of psychological therapies to enable them to stop drinking, or at least reduce their intake, as their alcohol use has now reached a level where they have had to receive treatment for a life-threatening condition.

Residential treatment is advisable

Anyone who has developed DT and has not received treatment yet would be advised to join a residential alcohol rehab programme where they will receive round-the-clock support and careful monitoring of their physical and mental health.

Another benefit of residential rehab is that all the temptations from patients’ usual environment are removed meaning there will be fewer negative influences triggering their alcohol use.

This gives them the best chance of recovery because if they carry on drinking at their current rate then their health would be seriously compromised.

So if they are unable to come to terms with the psychological reasons behind their heavy drinking then it would be wise for them to engage in several psychological therapies delivered on residential rehab programmes to help them uncover the emotional and social factors behind their alcohol use. (3)

Examples of these therapies include:

• Cognitive Behavioural therapy
• One-to-one alcohol counselling
• Dialectical behavioural therapy.
• Group therapy.
• Attending an AA meeting.

If they do not change their habits then they are at risk of developing conditions such as Wernicke encephalopathy and Korsakoff syndrome which are more serious conditions that affect memory and many other aspects of cognition.

Both of these conditions will damage nerve cells in the brain and the spinal cord and require prolonged hospital treatment and the effects of these two conditions tend to be irreversible. (3,6)

References

(1) Black, D., Grant, J. (2013) DSM5 Guidebook: The Essential Companion to Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition. APP. London.

(2) Grover, S. & Ghosh, A. (2018) Delirium Tremens: Assessment and management. Journal of Clinical and Experimental Hepatology. 8(4) available@ Delirium Tremens: Assessment and Management – PMC (nih.gov)

(3) Herie, A. & Skinner, W. (ed) (2014) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada.

(4) Hoffman, R. Weinhouse, G. (2022) Management of moderate and severe alcohol withdrawal syndrome. Wolters Kluwer. Available@Management of moderate and severe alcohol withdrawal syndromes – UpToDate

(5) National Institute of Care Excellence (2022) Alcohol Use Disorder: Diagnosis and management of physical complications. available@Alcohol-use disorders: diagnosis and management of physical complications DRAFT (nice.org.uk)

(6) National Institute of Neurological Disorder and Stroke (2022) Wernicke-Korsakoff. Available@Wernicke-Korsakoff Syndrome | National Institute of Neurological Disorders and Stroke (nih.gov)

(7) NHS Digital (2020) Statistics on alcohol. Available@Statistics on Alcohol, England 2020 – NHS Digital

(8) Osiezagha, K. el al (2013) Thiamine Defiency and delirium. Innovations in Clinical Neuroscience. 10(4) p26-32 available@Thiamine Deficiency and Delirium – PMC (nih.gov)

(9) Patient.info (2022) Acute Alcohol withdrawal. Available@Acute Alcohol Withdrawal and Delirium Tremens | Patient

(10) Sachedva, A. (2015) Alcohol Withdrawal Syndrome and beyond. Journal of Clinical Diagnostical Research. Available@Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond – PMC (nih.gov)

(11) Trevisan, L. et al (1998) Complications of alcohol withdrawal: Pathophysiological Insights. Alcohol Health and Research world 22(1). available@Complications of Alcohol Withdrawal (nih.gov)

(12) University Hospital Sussex NHS Foundation Trust (2022).available@Alcohol-withdrawal-guideline-November-2021-Final.pdf (bsuh.nhs.uk)

(13) Royal College of Psychiatrists (2022 Delirium. Available@ Delirium.pdf (www.nhs.uk)

(14) World Health Organisation (2022) Alcohol. Available@ Alcohol (who.int)

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