Signs and Symptoms of Delirium Tremens

Alcohol withdrawal can have fatal consequences. (Antonio Guillem/Shutterstock)

When substance abusers first enter addiction treatment, their entry survey or interview almost always contains one specific question. This question pertains to whether the addict or alcoholic in question has ever suffered from “DTs.” Many patients falsely assume this to be an abbreviation for “detox.” And while the two are most certainly related, this is not quite the case. In reality, “DTs” stands for “delirium tremens.” Some may also know delirium tremens by its alternate name—alcohol withdrawal delirium, or AWD.

As the name implies, AWD occurs during alcohol withdrawal. In some cases, it also occurs as a result of withdrawal from prescription drugs, particularly benzos or barbiturates. These drugs act on the same neurotransmitters as alcohol, resulting in similar withdrawal symptoms. Those suffering from alcoholism or prescription drug addiction should bear this in mind, as delirium tremens sometimes proves fatal in severe cases. And even in less severe cases, those who suffer delirium tremens will find themselves greatly impaired. This is why alcoholics often receive Librium or other withdrawal medications during detox. Attempting to detox without such medications can prove incredibly uncomfortable, if not altogether deadly.

Below, we’ll discuss in further detail the potential causes of delirium tremens. We’ll also discuss the primary symptoms of AWD and how medical professionals go about making a diagnosis. Finally, we’ll discuss the manner in which delirium tremens is treated and prevented. Those who suffer from alcoholism or addiction should bear this in mind when deciding to quit. Those who do not suffer from substance use disorders should keep this information in mind before deciding to use in the first place. Given the deadly nature of addiction itself, no one should subject themselves to further danger when finally deciding to recover.

What Is Delirium Tremens?

Delirium tremens is related to the stereotype of “seeing pink elephants.” (kristy ART/Shutterstock)

When heavy drinkers try to quit cold turkey without taking effective withdrawal medications, they put themselves at risk of delirium tremens. The same thing happens when abruptly quitting tranquilizers such as barbiturates or benzodiazepines. This usually only results from particularly heavy use, especially when using frequently for a period of thirty days or more. Even a sharp decrease in dosage may result in AWD. Both alcohol and tranquilizers affect the GABA chemical in the brain, as well as the transmitter somatic system, thereby leading to their similar withdrawal effects. This chemical similarity also accounts for the use of benzos such as Librium in withdrawal management.

The brain’s GABA receptors generally act as a sedative. But over long periods of alcohol or benzo abuse, the brain slows production. Upon quitting, the brain finds itself without these important receptors, which also regulate blood pressure, heart rate and other nervous subsystems. At the same time, the brain increases production of excitatory neurotransmitters such as dopamine, serotonin, epinephrine and glutamate. In short, the central nervous system becomes overstimulated in what medical professionals refer to as an adrenergic storm. This leads to the primary symptoms associated with delirium tremens.

Alcohol withdrawal delirium may also occur as a result of illness, infection or head trauma. Again, these only trigger delirium tremens in patients with a severe history of alcohol or tranquilizer abuse. The risk becomes even worse when said patients also have a history of going into withdrawal. Some believe that other factors, such as malnutrition or certain psychological disorders, may also raise the risk of suffering AWD. One should not confuse delirium tremens with alcohol hallucinosis, nor with alcohol-related dementia (also known as “wet brain”). The former is far less fatal than AWD, while the latter occurs from excessive consumption rather than withdrawal.

Delirium tremens goes by many names. Aside from AWD, one might hear the DTs referred to as pint paralysis, quart mania, the horrors, the shakes or barrel fever. Other less common names include the 750 itch, gallon distemper, bottleache, ork orks and the zoots. Due to its hallucinogenic side effects, delirium tremens is also commonly associated with the stereotype of seeing pink elephants. However, while many invoke this euphemism as a source for humor, make no mistake that the DTs often prove fatal. So while you may laugh at that one scene in Dumbo, you’ll want to remember the following side effects if you ever face alcohol withdrawal in the real world.

Side Effects of Withdrawal

AWD can result in frightening hallucinations. (Cyrsiam/Shutterstock)

Alcohol withdrawal can cause a wide variety of symptoms, but most associate delirium tremens with altered sensorium. In this particular form of hallucination, the sufferer fails to harbor any ability to differentiate fiction from reality. Their hallucinations overtake their senses entirely, causing them to leave the real world far behind. This means that the DTs result in visual, auditory and tactile hallucinations. Since symptoms of AWD grow worse at night, delirium tremens also results in nightmares, in addition to general confusion and disorientation. Many experience feelings of imminent doom, and will specifically experience visions of less-than-cuddly creatures such as snakes, rats and insects.

The DTs also affect the way a person speaks. They may be prone to speaking in incomplete sentences, stuttering, or generally saying things that are inappropriate or simply nonsensical. Sufferers of AWD, as a result of their disorientation, experience numerous gaps and inconsistencies in logic. This sometimes stems from anxiety and paranoia, which also result in panic attacks. Some also experience formication, the feeling of something crawling underneath their skin. Fear of death also appears as a common side effect of DTs.

Delirium tremens results in numerous physical symptoms as well. As many as 60% of patients suffer from fever, and some will also experience seizures. Autonomic hyperactivity is also common, resulting in rapid pulse, high blood pressure and an abnormal breath rate. Heavy sweating also commonly occurs and, due to formication, the patient may experience an unusual scratch reflex as a result of itchiness. Alcohol withdrawal delirium only occurs in about 5-10% of alcoholics, but mortality rates remain high. Those who receive treatment may still experience fatal symptoms at rates of 15%, while this number rises to 35% for those who go untreated.

It can take up to 10 days following the most recent drink for these symptoms to occur, although they often manifest within 2-3 days. The earliest they may start is between six hours and one day. Withdrawal itself tends to start within 12 hours, with alcoholic hallucinosis starting within 24 hours. Seizures may occur between 24-48 hours after the last drink. Proper delirium tremens begins after these three stages. After 4-5 days, the symptoms tend to reach their peak. Between 5-7 days after the onset of symptoms, they should begin to markedly decrease. Some symptoms—such as mood swings, fatigue and insomnia—may persist to some degree for more than a year.

Treating Delirium Tremens

The DTs are generally treated with medications such as Librium. (Zadorozhnyi Viktor/Shutterstock)

Delirium tremens requires immediate treatment in order to minimize the risk of fatality. As noted above, most treatment for alcohol withdrawal takes the form of benzodiazepines such as Librium. In severe cases, high doses may be required. The specific pills, as well as the dosage, will often depend on the specific symptoms present. Technically, one may use alcohol as a treatment (for much the same reason they might use benzos), although this practice is rare and will not generally be encountered in hospitals or treatment centers.

In the case of severe hallucinations, patients suffering from delirium tremens may benefit from antipsychotic medications. One of the more common antipsychotics used in the treatment of alcohol withdrawal is haloperidol. Other uses for haloperidol include the treatment of schizophrenia, bipolar disorder, Tourette syndrome and acute psychosis. In the past, doctors also used medications such as clomethiazole and paraldehyde. Not only did these drugs facilitate recovery from withdrawal, but also helped to alleviate seizures. Today, however, these medications are rarely used in the treatment of delirium tremens. Acamprosate, a medication used to treat alcohol addiction, may be used alongside benzodiazepines.

Despite the outdated use of paraldehyde and clomethiazole, doctors may still require medications to treat ongoing seizures, known as status epilepticus. Other conditions that might require extra treatment include ongoing mood swings or sleeplessness, which may persist long after the primary effects of delirium tremens have worn off. Additionally, professionals may prescribe acamprosate long-term in order to combat relapse. Other forms of treatment, such as therapeutic counseling, may also help prevent heavy drinkers from relapsing. At the very least, those who relapse will be less likely to experience another bout of delirium tremens if they have had sufficient time to recover and if their relapse is short-lived.

While treatment centers are often capable of treating delirium tremens, many medical professionals recommend seeking treatment at a hospital. This stems from the risk of fatality and the need to ensure that the patient can remain under constant supervision. In the event of complications, the availability of doctors and other medical staff will increase the patient’s chances of survival. After recovering from the DTs, however, heavy drinkers should consider rehabilitation at an addiction treatment facility. Those who suffer from alcohol addiction will find long-term treatment quite helpful. And with enough effort, such individuals may never suffer the discomfort of AWD again.