Delirium Tremens: A Dangerous Alcohol Withdrawal State

July 3, 2025

Delirium tremens (DTs), also referred to as alcohol withdrawal delirium (AWD), represents the most severe and potentially life-threatening complication of ethanol withdrawal. It is characterized by a rapid onset of mental confusion, agitation, hallucinations, and tremors. It could potentially lead to death unless managed adequately and immediately.
About half of the patients with alcohol use disorders develop withdrawal symptoms, but only a small percentage progress to DT. Therefore, it’s not very common even among individuals with alcohol dependence. In the general population, the prevalence of DT ranges from 1% to 2%, and this can increase with the severity of alcohol use disorder.¹

Causes & Risk Factors of DT

The sole cause of DTs is withdrawal, which occurs when someone stops drinking alcohol suddenly. The condition typically appears between 48 and 72 hours after the last drink and usually peaks in intensity around day 4 to 5. Several risk factors increase the likelihood of developing DTs, including:

Heavy alcohol intake
A history of alcohol withdrawal symptoms
Increasing age
Multiple episodes of withdrawal or repeated attempts to quit drinking
Medical problems such as nutritional deficiencies, liver disorders, and cardiovascular diseases.
Low platelet count, low potassium, low pyridoxine, and high blood homocysteine.²

Symptoms of Delirium Tremens

There are several possible symptoms of DTs. These include:

Tremors & Confusion:

These are among the hallmark symptoms of DTs. Tremors (shaking, often in the hands) and confusion (altered mental status) frequently appear together and help characterize the condition.

Anxiety & Agitation

People with DTs often experience intense anxiety, restlessness, or agitation. This can sometimes escalate to aggressive or combative behavior.

Psychiatric and Perceptual Disturbances

Hallucinations are common—people may hear, see, or feel things that are not actually present. Some may also develop paranoia, an exaggerated sense of fear or belief that others are threatening them.³

Disorientation or Sensory Disruptions

People with DTs often have reduced awareness of what is happening around them. This is often due to sensory misprocessing.

Seizures

Withdrawal seizures can occur and may be dangerous, especially if they develop into status epilepticus—a prolonged or repeated seizure state that requires emergency care.⁴

Autonomic Symptoms

Diaphoresis (Excessive sweating)
Hyperthermia (they often have a high body temperature)
Nausea and Vomiting
Headche
Tachycardia (Rapid Heart Rate)
Hypertension
Insomnia, malaise, weakness
Psychomotor hyperactivity
Disturbance of cognition
Dilated pupils (mydriasis)
Increased reflexes (hyperreflexia)⁵

Patient with anxiety issues — Patient with severe agitation and anxiety presenting the symptoms of delirium tremens.

Pathophysiology

It is not clear why some people suffer from more severe symptoms than others. Some evidence suggests that genetic predisposition can also play a role. Alcohol acts as a central nervous system (CNS) depressant. It enhances the action of gamma-aminobutyric acid (GABA)—an inhibitory neurotransmitter—and suppresses the action of excitatory neurotransmitters, particularly by inhibiting NMDA (N-methyl-D-aspartate) receptors, which respond to glutamate. With prolonged alcohol use, the brain compensates by:

Downregulating GABAergic activity
Upregulating NMDA/glutamate activity

When alcohol is suddenly stopped, this balance is disrupted:

Decreased GABA action leads to reduced CNS inhibition
Increased glutamate action leads to excessive CNS excitation

This hyperexcitability is responsible for the classic signs of DT: tremors, agitation, hallucinations, hypertension, and seizures.⁶

Diagnosis of Delirium Tremens

The healthcare provider diagnoses DT based on a combination of methods and tools. These include:

History & Physical Examination:

The patient’s history and physical examination are crucial for establishing the diagnosis. The pertinent information in the medical history includes:

The quantity of alcohol use
Duration of alcohol use
Duration since last drink
Any prior history of severe alcohol withdrawal
Co-use of other substances

Findings of physical examination include:

Autonomic instability, such as hypertension, tachycardia, and hyperthermia.
Hydration status (reduced skin turgor and dry mucous membrane).
Neurological signs include mydriasis, hyperflexia, and coarse tremors.

Additional evaluation is necessary to identify comorbidities, including chronic liver disease, coronary artery disease, and heart failure, which may complicate the clinical picture. Some signs may not be evident through self-reporting alone, so close clinical observation is crucial.

Assessment Tools and Scoring Systems

CIWA-Ar

The best validated tool to evaluate the severity of alcohol withdrawal is CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Revised). CIWA-Ar is a 10-item questionnaire tool. It assesses, monitors, and treats alcohol withdrawal.⁷

A score of 8 points or lower corresponds to a mild withdrawal.
A score of 9 to 15 shows a moderate withdrawal.
A score of 15 or more depicts severe withdrawal symptoms.⁸

CAM

The Confusion Assessment Method (CAM) is among the most commonly used screening tools. It helps in diagnosing the condition as well as assessing the severity of the delirium. CAM assesses features such as inattention, acute onset, altered levels of consciousness, and disorganised thinking. The sensitivity and specificity vary widely, ranging from 50% to 100%.⁹ It is designed to help healthcare providers, including non-psychiatric physicians, identify delirium quickly and accurately at the bedside.¹⁰ A patient must have the first two features (acute onset and inattention), plus either disorganized thinking or altered consciousness, for a positive diagnosis of delirium.

For non-verbal or critically ill patients—such as those who are intubated—the CAM-ICU version is used. This modified tool retains the core features of CAM but is adapted for use without spoken responses. It can be administered by trained healthcare staff in just 1–2 minutes, making it especially useful in ICU settings.¹¹

DRS-R98

The DRS-R98 is a structured clinical tool designed to assess both the presence and severity of delirium. It is intended for use only by trained clinicians, typically in psychiatric or hospital settings.

This scale includes:

13 severity items that assess cognitive, behavioral, and physical symptoms over the past 24 hours
3 diagnostic items that help confirm the presence of delirium

The DRS-R98 is useful for both diagnosing delirium and tracking changes in symptom severity over time, making it valuable in both clinical and research settings.¹²

RASS

The Richmond Agitation Sedation Scale (RASS) assesses agitation. It is a ten-point scale. Physicians and nurses can easily administer RASS. This instrument is highly useful for patients who are uncooperative and those in the ICU.

Laboratory Workup:

Laboratory tests can include:

Liver function tests are used to assess the liver damage caused by alcohol.
Complete blood counts to detect infections.
Electrolyte imbalance identifies the exacerbating symptoms.
Toxicology screening to rule out other intoxications.

Treatment & Management of Delirium Tremens

Delirium Tremens (DT) requires immediate intervention. The main goals of treatment are to control symptoms (such as seizures and agitation), prevent complications, and address the underlying causes of alcohol dependence.

Pharmacological Management:

Benzodiazepines (BDZs) are the first-line treatment for DTs. Long-acting BDZs are preferred over short-acting ones. The efficacy of long-acting BDZs is more pronounced due to their potential for self-tapering and maintaining constant serum levels, which provide continuous relief from symptoms. The three treatment regimens for the management of DT include:

Front-Loading Regimen

Front loading is performed with diazepam to achieve light sedation or to bring down the CIWA-Ar <8. It involves administering intravenous 5 to 20mg diazepam after every ten minutes until the achievement of light sedation.¹³

Symptom-Triggered Therapy

In this approach, medication is given based on the severity of symptoms. It includes the administration of intravenous diazepam (10 to 20 mg IV every 1 to 2 hours until CIWA-Ar <8) and lorazepam (2 to 4mg after every 15 to 20 minutes until the achievement of front-loading regimen aims).¹⁴

Fixed-Dose Regimen

This regimen involves giving scheduled doses of benzodiazepines regardless of symptoms. It is usually reserved for the outpatient management of alcohol withdrawal and is not typically used in severe cases like DT..

Supportive Care:

Several individuals with DTs suffer from electrolyte imbalances, mineral deficiencies, and dehydration. The healthcare provider treats this by infusing you with the necessary minerals or vitamins. An example of this infusion is ‘Banana Bag’. It contains thiamine (B1), Folic acid (B9), electrolytes, and multivitamins. These help correct deficiencies and prevent complications like Wernicke’s encephalopathy.

Thiamine

Thiamine is specifically used to treat Wernicke-encephalopathy (brain disorder), a potential comorbidity with DT. The doctors administer 500 mg infused over 30 minutes, almost twice a day, for approximately three days.¹⁵

Rehabilitation:

To prevent disorientation, the patient should be referred to the support groups.
Referral to a psychiatrist for anxiety and depression can help patients overcome alcoholism.
Cognitive behavior therapy can also help patients prevent relapse.

Prevention

The sole definitive way to prevent the DTs is to avoid alcohol consumption entirely.
If you are addicted to alcohol and want to stop drinking it, first talk to your healthcare provider. He will help you find the sources, support, and care that will help you reduce the intake of alcohol safely.
The best way to reduce the risk of developing DTs is to drink alcohol only in moderation.
If you want to quit drinking alcohol, then you can join support groups and rehabilitation programs.

Prognosis

Early recognition and treatment can substantially decrease the mortality from DTs. It has been observed that early interventions have reduced mortality rates to less than 5%.¹⁶ Without treatment, however, DTs can be fatal, with mortality rates historically exceeding 20%.

Differential Diagnosis

DT shares features with several other medical and neurological conditions. The differential diagnosis includes:

Stroke
Uremia
Sepsis
Meningitis
Wernicke encephalopathy
Pheochromocytoma
Neuroleptic malignant syndrome
Electrolyte abnormalities (e.g., hyponatremia, hypokalemia)
Drug toxicity
Cerebral hemorrhage
Thyrotoxicosis
Diabetic ketoacidosis
Acute liver failure
Cerebral embolism
Hypoglycemia
Brain abscess

These conditions can mimic the altered mental status, autonomic instability, or neurological findings seen in DT and must be ruled out through appropriate clinical and laboratory evaluation.¹⁷

Complications of Delirium Tremens

DTs can contribute to several complications. Many of them can also be severe. The possible complications can include:¹⁸

Global confusion or persistent cognitive impairment
Sleep disorders
Respiratory failure
Aspiration pneumonitis
Arrhythmias
Heart and circulatory disorders
Death, especially in severe or untreated cases

Alcoholic Hallucinosis Versus DT

Alcoholic hallucinosis and DTs both result from alcohol withdrawal. However, they differ significantly in terms of onset, symptoms, severity, and prognosis. The key differences are highlighted in the table:

Features	DTs	Alcoholic Hallucinosis
Onset and Duration	They appear 48 to 72 hours after ceasing heavy alcohol intake.¹⁹ They can occur from seven to ten days after the last drink.	Typically develops within 12 to 24 hours after the last drink. It may persist for several days to a few weeks.
Symptoms and Clinical Features	DT involves severe mental and physical symptoms. These include: tremors progressing from hands to the whole body, fever, disorientation, profound confusion, rapid heart rate, seizures, and hallucinations. Consciousness is markedly impaired, unlike alcoholic hallucinations.	This condition is mainly characterized by auditory and sometimes visual hallucinations. The patient maintains clear consciousness. Some other symptoms individuals can experience before hallucinations are: Insomnia, irritability, dizziness, and headache.
Severity and Prognosis	DT is a medical emergency with a high mortality rate if it goes untreated. It requires immediate medical intervention.	Alcoholic hallucinosis is a less severe condition. It has a better prognosis and complete recovery. Some cases may have persistent symptoms.

Final Remarks

DT is recognized as the most severe complication of alcohol withdrawal. Mortality is usually the result of DT-associated comorbidities. Benzodiazepines are the mainstay treatment of DT. Supportive therapy for vitamin deficiencies and other symptoms is of paramount importance. It can also mediate the outcome. Reducing alcohol intake or quitting alcohol entirely is an important Step towards better health, but you need to do it under the supervision of your healthcare provider.

Refrences

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Perälä, J., et al., Alcohol-induced psychotic disorder and delirium in the general population. The British Journal of Psychiatry, 2010. 197(3): p. 200-206.
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Muncie Jr, H.L. and Y. Yasinian, Outpatient management of alcohol withdrawal syndrome. American family physician, 2013. 88(9): p. 589-595.
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Grover, S. and A. Ghosh, Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 2018. 8(4): p. 460-470.
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Grover, S. and A. Ghosh, Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 2018. 8(4): p. 460-470.
13
Grover, S. and A. Ghosh, Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 2018. 8(4): p. 460-470.
14
Grover, S. and A. Ghosh, Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 2018. 8(4): p. 460-470.
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Grover, S. and A. Ghosh, Delirium tremens: assessment and management. Journal of clinical and experimental hepatology, 2018. 8(4): p. 460-470.
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Mayo-Smith, M. F. (1997). Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. JAMA, 278(2), 144–151. https://doi.org/10.1001/jama.1997.03550020076041
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UpToDate. (2024). Clinical features and diagnosis of delirium. In S. K. Inouye & T. Neufeld (Eds.), UpToDate. Retrieved from https://www.uptodate.com
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Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal, 22(2), 100–108. https://doi.org/10.4103/0972-6748.132914
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