Delirium tremens (DTs) is the most severe form of alcohol withdrawal. It is a medical emergency that requires immediate clinical intervention. Understanding what it is, who is at risk, and what treatment involves can be the difference between life and death.
What are delirium tremens?
Delirium tremens is a syndrome of severe alcohol withdrawal characterised by acute confusion, extreme agitation, hallucinations, autonomic instability, and in some cases, seizures. The name comes from the Latin for 'trembling delirium', and the description is apt: patients experiencing DTs are typically profoundly confused, agitated, sweating heavily, and shaking. DTs typically develop 48–72 hours after the last drink, though they can occur up to five days into withdrawal. They affect approximately 3–5% of people experiencing alcohol withdrawal. The mortality rate with medical treatment is approximately 1–5%. Without treatment, historical mortality rates exceed 35%.
Symptoms of delirium tremens
- Severe agitation and psychomotor hyperactivity — the person cannot stay still and may become dangerous to themselves or others.
- Profound confusion and disorientation — patients may not know where they are, what year it is, or who the people around them are.
- Hallucinations — typically visual (seeing things that are not there), but also auditory and tactile. Formication — the sensation of insects crawling under the skin — is a well-described feature.
- Fever and profuse sweating.
- Very high blood pressure and rapid heart rate.
- Severe tremor.
- Seizures — which may accompany or precede DTs.
Who is at risk of delirium tremens?
Risk factors for developing DTs include:
- History of previous DTs — the single strongest predictor.
- History of previous alcohol withdrawal seizures.
- High daily alcohol consumption over an extended period.
- Older age.
- Concurrent physical illness, particularly infection or electrolyte disturbance.
- Multiple previous detox attempts.
Treatment
DTs require inpatient medical management. Treatment centres on high-dose benzodiazepine therapy to control agitation and prevent further seizures, intravenous fluids and electrolyte replacement, high-dose intravenous thiamine, and close monitoring of vital signs. In severe cases, ICU admission may be required. This is why a history of DTs is an absolute contraindication for home detox. Patients who have experienced DTs previously need inpatient supervision for any future withdrawal episode.
This article is for general clinical information. DTs are a medical emergency. If someone is experiencing symptoms consistent with delirium tremens, call 999 immediately.
