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Delirium Tremens in Alcohol Withdrawal

When you struggle with addiction, both making the commitment to stop using and admitting that you might need help to do so are two of the more important decisions you can make.

However, you need to make an informed decision when you do so, taking into account the risks involved. Some substances are not associated with any severe withdrawal symptoms, but quitting others, such as alcohol, may result in serious and, in some cases, life-threatening complications when left unmanaged. One of the more significant complications of alcohol withdrawal is a condition called delirium tremens, or DTs. Even though it is potentially very serious, it can be managed well in professional medical detox settings with trained staff.

No matter your situation, recovery is achievable.

What Is Delirium Tremens?

Not being in a good mental state due to addiction.Delirium tremens is one of the most severe consequences of alcohol withdrawal.1 Delirium tremens (DTs) represents a collection of many possible symptoms affecting the person’s mental health and mental state.1

For a person to receive a diagnosis for DTs, they must be experiencing both alcohol withdrawal and delirium, which is an acute, fluctuating change in normal attention and cognition.2 Separately, either one of these conditions may introduce setbacks to early recovery, but when combined, their potential negative impact increases.

Other issues like head injury, infection, and illness might additionally increase the likelihood of DTs in individuals with a history of significant alcohol abuse.Typically, the term "delirium tremens" refers specifically to alcohol withdrawal delirium, though withdrawal from other drugs (e.g., benzodiazepines and other sedatives) may also be associated with delirium.

Why Does it Happen?

Understanding delirium tremens requires understanding the effect of alcohol on the brain. With steady drinking over time, the brain adapts to the presence of alcohol in the system by adjusting the activity of certain brain chemicals.3

In this manner, when the brain balances itself to the point that the person is no longer well without alcohol, such an individual is said to have developed physical dependence. After significant levels of alcohol dependence develop, a person must drink simply for their body to maintain "normal" operations, or homeostasis. When they stop drinking, the brain’s new chemical balance set point is disrupted, which triggers the emergence of withdrawal symptoms.3

What are the Signs and Symptoms?

What withdrawal from alcohol feels likeAs mentioned, DTs are marked by both a delirium and other symptoms common to the acute alcohol withdrawal syndrome.

The most common symptoms of someone suffering from delirium tremens are:1

  • Delirium – rapid onset of severe confusion
  • Cognitive problems
  • Tremors
  • Agitation
  • Increased sensitivity to sounds, touch, and light
  • Rapid mood shifts
  • Unexpected bursts of energy, restlessness, and excitement
  • Extreme fatigue and sleepiness
  • Sleeping for extended periods, e.g., more than a day
  • Hallucinations

In the case of alcohol withdrawal, symptoms come about very quickly and represent a significant shift from a person’s normal level of functioning.4 It will be important to be sure there is no evidence of another neurological condition, such as an underlying dementia, capable of producing these symptoms.4

In some instances, isolated seizures may occur without the presence of the other symptoms above. Seizures are more common in people with previous complications experienced during alcohol withdrawal.1 The type of seizures most commonly associated with alcohol withdrawal are described as generalized tonic-clonic seizures (i.e., grand mal seizures).4

Addiction professionals may recognize the phenomenon of delirium tremens based on medical history and clinical observation alone; however, there are some tests and labs which support the diagnosis, such as:1

  • Blood chemistries (e.g., complete metabolic panel, serum magnesium, serum phosphorus)
  • Toxicology screening
  • Electrocardiogram (ECG)
  • Electroencephalogram (EEG)

What Are Other Alcohol Withdrawal Symptoms?

Delirium tremens, while a risk in alcohol withdrawal, is rare, affecting approximately 3-5 percent of those hospitalized for alcohol withdrawal.2 Other, more common symptoms of alcohol withdrawal include:1,4

  • Headache
  • Fever
  • Increased sweating
  • Quickened heart rate
  • Heart palpitations
  • Nausea and vomiting
  • Insomnia
  • Anxiety
  • Shakiness and feeling “jumpy”
  • Mood swings
  • Depression

Possible Dangerous Outcomes

What makes delirium tremens so serious? As many as 4 percent of people with the condition will die.2

This statistic is alarming, especially when you consider that it only takes into account those patients who received inpatient treatment for withdrawal delirium.2 It is possible that many more who do not receive proper treatment will suffer the ill effects of DTs as well.

During DTs, people may endure:2

  • Hyperthermia – overheating of the body
  • Irregular heart rhythms
  • Problems related to seizure activity
  • Worsening of preexisting medical conditions

Because the confusion and irritability associated with delirium can be so great, someone experiencing DTs may be aggressive toward others during this time or may hurt themselves. This is another reason it's important to detox from alcohol in a safe environment under medical supervision.

How Common Is It?

Alcohol use problems are quite prevalent throughout the world, with an estimated 20 percent of men and 10 percent of women in Western societies meeting the criteria for an alcohol use disorder at some point in their lives.2 About half of these people will experience some withdrawal symptoms when they try to stop or cut down their drinking.2

The majority of these people won't experience life-threatening symptoms and only about 5 percent of these people will experience seizures, delirium, or both.2 Estimates show that between 3 percent and 5 percent of people receiving inpatient care for alcohol withdrawal progress to a state of withdrawal delirium.2

However, because very severe symptoms can arise unexpectedly, inpatient detox is the safest route for alcohol dependent individuals who want to quit. Your safety or the safety of your loved one is too important to leave to chance.

What Other Drugs Cause Delirium?

Alcohol is not the only drug associated with severe withdrawal or withdrawal delirium.5 Other substances with potentially serious withdrawal syndromes include opioids like heroin and prescription painkillers and certain sedatives such as prescription sleep aids and benzodiazepines (Klonopin, Ativan, Xanax, etc.).4,6

Currently, research regarding delirium tremens triggered during withdrawal from substances other than alcohol is lacking. The American Psychiatric Association does recognize opioid withdrawal delirium and sedative withdrawal delirium, though.4 In some of the literature, the withdrawal delirium associated with benzodiazepines is called "delirium tremens," though the term is usually reserved for alcohol.

Inhalant withdrawal may also cause delirium in rare cases, and detoxing individuals who have been abusing inhalants chronically may show symptoms similar to DTs.6,7

How Long Do Symptoms Last?

How long is the process of detoxification?Alcohol withdrawal follows a fairly predictable schedule, with symptoms beginning about eight hours after the blood alcohol content decreases in the body. Symptoms peak during day three and then gradually resolve after about a week of sobriety.2

However, the specific DTs timeline is a bit different. DTs often start approximately three days after last alcohol use.2 Delirium tremens can last anywhere from 1 to 8 days, but the average duration is 2-3 days.2

Other Drug Timelines

Sedative withdrawal delirium may begin within a day of last use.8 With specific sedatives like Gamma­hydroxybutyrate (GHB), a withdrawal delirium may develop in as little as one hour following the last dose.6

The timeline for onset of opioid withdrawal can vary significantly among patients. Case reports of opioid withdrawal delirium show some individuals experiencing delirium within less than 48 hours, with another report showing a rare case of a patient experiencing it after seven days.9,10

What Increases the Risk?

It might be impossible to forecast exactly who will experience DTs, but there are some risk factors, the biggest of which is heavy consumption of alcohol for extended periods of time.1

People who have been heavily drinking for more than 10 years are at greater risk of DTs, but symptoms may even occur after a few months of regular binge drinking.1

Other factors linked to higher rates of alcohol-related DTs are:2

  • Recent withdrawal seizures.
  • Previous symptoms of delirium during withdrawal.
  • Advanced age.
  • Recent use of other depressant drugs, including sedatives and opioids.
  • Electrolyte issues, including low levels of magnesium and potassium.
  • Low platelet counts.
  • Respiratory conditions.
  • Preexisting or worsening cardiac problems, especially high blood pressure and higher pulse during withdrawal.
  • Gastrointestinal disease.

Is Treatment Effective?

Seeking treatment in an inpatient setting.Those at risk of delirium tremens should seek withdrawal treatment in a medical setting, such as a hospital or inpatient medical detox center.6 Only these settings afford the acuity of care—including round-the-clock monitoring and interventions—needed to ensure safety and stability during the withdrawal process.

Professionals in these settings will work to accomplish three clear goals:1

  • Reduce symptoms
  • Minimize complications
  • Prevent serious harm or death

These goals can be accomplished by:2

  • Frequently monitoring vital signs to track symptoms and progress through withdrawal
  • Conducting lab work to identify possible risk factors including:
    • Electrolyte levels
    • Pancreatic enzymes
    • Platelet counts
    • Liver functioning
  • Administering other medications orally and intravenously to:
    • Reduce symptoms
    • Improve sleep
    • Raise the seizure threshold to limit seizure risk
  • When appropriate, administering antipsychotic medications, like haloperidol, to mitigate agitation, aggression, and hallucinations.
  • Offering supportive care in a quiet, non-stimulating environment.

Those at risk of delirium tremens should seek withdrawal treatment in a medical setting.

The primary treatment at this stage of recovery will be the administration of benzodiazepines, usually intravenously, to reduce the severity of delirium-associated agitation and insomnia and to lower seizure risk.2,6 Using medications like diazepam or lorazepam, physicians will usually begin with a high dose before gradually lowering over time.6

This period of detoxification is hugely valuable for someone withdrawing from alcohol or other drugs, but continued substance abuse treatment (e.g., inpatient rehab, residential programs, or outpatient treatment settings) is often needed to best maintain sobriety and begin an extended period of recovery.11

By participating in therapy, medication management, and support groups, recovering alcoholics can:11

  • Begin to return their brain to previous levels of functioning.
  • Lower ongoing withdrawal symptoms and cravings for more of the substance.
  • Identify and understand the reasons for previous substance use.
  • Increase motivation for recovery.
  • Build coping skills to avoid relapse.
  • Create a supportive network of sober individuals. 

Longer periods of treatment are linked to longer periods of recovery.11 Addiction may not be cured, but it can be managed.

If you or someone you know is at risk of withdrawal delirium from any substance, seek emergency medical treatment. It truly is a matter of life or death.

References

  1. U.S. National Library of Medicine: MedlinePlus. (2017). Delirium Tremens.
  2. Schuckit, M.A. (2014). Recognition and Management of Withdrawal Delirium (Delirium Tremens). New England Journal of Medicine, 371, 2109-2113.
  3. Medscape. (2017). Withdrawal Syndromes.
  4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  5. Medscape. (2017). Withdrawal Syndromes.
  6. Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
  7. Medscape. (2017). Inhalants Clinical Presentation.
  8. Bosshart, H. (2011). Withdrawal-induced delirium associated with a benzodiazepine switch: a case reportJournal of Medical Case Reports5, 207.
  9. Sharma, R. C., Kumar, R., Sharma, D. D., & Kanwar, P. (2017). Opium Withdrawal Delirium: Two Case ReportsPsychopharmacology Bulletin47(1), 48–51.
  10. Raj, B. N., Manamohan, N., Hegde, D., Huded, C. B., & Pradeep, J. (2017). A Rare Case of Complicated Opioid Withdrawal in Delirium Without ConvulsionsIndian Journal of Psychological Medicine39(2), 191–193.
  11. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide.