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Definition

Delirium tremens is a severe form of alcohol withdrawal. It involves sudden and severe mental or nervous system changes.

Causes

Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food.

Delirium tremens may also be caused by head injury, infection, or illness in people with a history of heavy alcohol use.

It occurs most often in people who have a history of alcohol withdrawal. It is especially common in those who drink 4 to 5 pints (1.8 to 2.4 liters) of wine, 7 to 8 pints (3.3 to 3.8 liters) of beer, or 1 pint (1/2 liter) of "hard" alcohol every day for several months. Delirium tremens also commonly affects people who have used alcohol for more than 10 years.

Symptoms

Symptoms most often occur within 48 to 96 hours after the last drink. But, they may occur 7 to 10 days after the last drink.

Symptoms may get worse quickly and can include:

• Agitation, irritability
• Body tremors
• Changes in mental function
• Deep sleep that lasts for a day or longer
• Sudden, severe confusion (delirium)
• Excitement or fear
• Fever
• Seeing or feeling things that are not really there (hallucinations)
• Bursts of energy
• Quick mood changes
• Restlessness
• Sensitivity to light, sound, touch
• Stupor, sleepiness, fatigue

Seizures (may occur without other symptoms of DTs):

• Most common in the first 12 to 48 hours after the last drink
• Most common in people with past complications from alcohol withdrawal
• Usually generalized whole body seizures

Symptoms of alcohol withdrawal, including:

• Anxiety, depression
• Fatigue
• Headache
• Insomnia (difficulty falling and staying asleep)
• Irritability or excitability
• Loss of appetite
• Nausea, vomiting
• Nervousness, jumpiness, shakiness, palpitations (sensation of feeling the heart beat)
• Pale skin
• Rapid emotional changes
• Sweating, especially on the palms of the hands or the face

Other symptoms that may occur:

• Chest pain
• Stomach pain

Exams and Tests

Delirium tremens is a medical emergency.

The health care provider will perform a physical exam. Signs may include:

• Heavy sweating
• Increased startle reflex
• Irregular heartbeat
• Problems with eye muscle movement
• Rapid breathing
• Rapid heart rate
• Rapid muscle tremors

The following tests may be done:

• Blood magnesium level
• Blood phosphate level
• Comprehensive metabolic panel
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)
• Toxicology screen (drug test)

Treatment

The goals of treatment are to:

• Save the person's life
• Relieve symptoms
• Prevent complications

A hospital stay is needed. The health care team will regularly check:

• Blood test results, such as electrolyte levels
• Body fluid levels
• Vital signs (temperature, pulse, breathing rate, blood pressure)

While in the hospital, the person will receive medicines to:

• Stay calm and relaxed (sedated) until the DTs are finished
• Treat seizures, anxiety, or tremors
• Treat mental disorders, if any

Long-term preventive treatment should begin after the person recovers from DT symptoms. This may involve:

• A "drying out" period, in which no alcohol is allowed
• Total and lifelong avoidance of alcohol (abstinence)
• Counseling
• Going to support groups (such as Alcoholics Anonymous)

Treatment may be needed for other medical problems that can occur with alcohol use, including:

• Alcoholic cardiomyopathy (heart muscle disease)
• Alcoholic liver disease
• Alcoholic neuropathy (brain and nerve disease)
• Wernicke-Korsakoff syndrome (serious brain disease that results from vitamin B1 deficiency, which can be caused by heavy alcohol use)

Support Groups

Attending a support group regularly is a key to recovering from alcohol use. More information and support for people with alcohol use disorder and their families can be found at:

• Alcoholics Anonymous -- www.aa.org
• Al-Anon Family Groups/Al-Anon/Alateen -- al-anon.org
• National Institute on Alcohol Abuse and Alcoholism -- www.niaaa.nih.gov
• SMART Recovery - www.smartrecovery.org/
• Substance Abuse and Mental Health Services Administration -- www.samhsa.gov/atod/alcohol

Outlook (Prognosis)

Delirium tremens is serious and may be life-threatening. Some symptoms related to alcohol withdrawal may last for a year or more, including:

• Emotional mood swings
• Feeling tired
• Sleeplessness

Possible Complications

Complications can include:

• Injury from falls during seizures
• Injury to self or others caused by altered mental state (confusion/delirium)
• Irregular heartbeat, which may be life-threatening
• Seizures

When to Contact a Medical Professional

Go to the emergency room or call 911 or the local emergency number if you have symptoms. Delirium tremens is an emergency condition.

If you go to the hospital for another reason, tell the providers if you've been drinking heavily so they can monitor you for symptoms of alcohol withdrawal.

Prevention

Avoid or reduce the use of alcohol. Get prompt medical treatment for symptoms of alcohol withdrawal.

If you have a drinking problem, it is best to stop drinking alcohol completely. Total and lifelong avoidance of alcohol (abstinence) is the safest approach.

References

Kelly JF, Renner JA. Alcohol-related disorders. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 2nd ed. Philadelphia, PA: Elsevier; 2016:chap 26.

O'Connor PG. Alcohol use disorders. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 30.

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