Alcohol withdrawal and delirium tremens !
Symptoms that appear when someone who drinks heavily every day stops or cuts down. Most cases are mild, but seizures and delirium tremens can be fatal.
Updated 2026-11-01
Structures involved
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Why it happens
- Alcohol: how it injures the liver, brain, heart and fetus
- The main neurotransmitters
- Synaptic transmission
What it is
A syndrome of nervous-system overactivity that starts hours to days after a person with long, heavy alcohol use stops or sharply reduces drinking. It ranges from tremor and anxiety to withdrawal seizures and delirium tremens, a medical emergency.
Who gets it
Harmful alcohol use is one of the leading substance problems in Colombia and Latin America, and withdrawal is a frequent reason for emergency visits and a common complication in hospitalised patients who stop drinking on admission (trauma, surgery, pancreatitis, liver disease). Only a minority of people in withdrawal progress to delirium tremens.
Causes
- Abrupt stop or reduction of drinking after weeks to years of heavy daily use
- Unplanned abstinence on hospital admission (surgery, trauma, acute illness)
- Lack of food and intercurrent illness, which lower the threshold for severe forms
Risk factors
- Previous withdrawal seizures or delirium tremens (kindling: each episode tends to be worse)
- Long duration and high amount of daily drinking
- Older age and concurrent medical illness (infection, liver disease, head injury)
- Electrolyte disturbances such as low potassium or magnesium
- Concurrent use of benzodiazepines or other sedatives
Pathophysiology
Chronic alcohol enhances inhibitory GABA-A signalling and blocks excitatory NMDA glutamate receptors; the brain adapts by down-regulating GABA-A and up-regulating NMDA receptors. When alcohol is withdrawn, the brain is left with too little inhibition and too much excitation, plus a surge of noradrenaline. The result is autonomic hyperactivity, tremor, seizures and, in the most severe cases, delirium.
Classification
- Minor withdrawal (about 6–24 hours): tremor, anxiety, sweating, palpitations, nausea, insomnia
- Alcoholic hallucinosis (about 12–48 hours): mostly visual hallucinations with a clear sensorium and stable vital signs
- Withdrawal seizures (about 6–48 hours): generalised tonic-clonic, often single or in a short cluster
- Delirium tremens (about 48–96 hours): delirium with marked autonomic instability; can last several days
Symptoms and signs
- Hand tremor, sweating, anxiety and irritability
- Tachycardia, raised blood pressure and mild fever
- Nausea, vomiting and insomnia with vivid dreams
- Visual, tactile (insects crawling) or auditory hallucinations
- Generalised seizures
- In delirium tremens: disorientation, fluctuating attention, agitation, severe tremor, drenching sweats and fever
Diagnosis
- Clinical
- History of heavy, prolonged drinking and the time of the last drink, with the typical signs. Severity is scored with the CIWA-Ar scale, which guides symptom-triggered treatment; a full examination looks for head injury, infection, liver disease and signs of Wernicke encephalopathy.
- Tests
- Blood glucose, electrolytes including magnesium and phosphate, kidney and liver function, complete blood count, lipase when pancreatitis is suspected, blood alcohol level and a toxicology screen. ECG for arrhythmia.
- Imaging
- Not needed for typical withdrawal. Head CT after a first seizure, a focal seizure, head trauma or an atypical course of confusion.
Differential diagnosis
- Other causes of delirium: sepsis, hypoglycaemia, hepatic encephalopathy, head injury
- Wernicke encephalopathy
- Withdrawal from benzodiazepines or other sedatives
- Stimulant (cocaine, amphetamine) intoxication or anticholinergic toxicity
- Thyroid storm
Goal of treatment
Control symptoms safely, prevent seizures and delirium tremens, correct thiamine, fluid and electrolyte deficits, treat associated illness, and link the person to treatment of alcohol use disorder.
Treatment
- Acute
- Delirium tremens and repeated seizures need hospital care, often in intensive care, with airway protection, intravenous fluids and close monitoring.
- Medical
- Benzodiazepines are first-line: given on a fixed schedule or triggered by the CIWA-Ar score; shorter-acting agents such as lorazepam are preferred in advanced liver disease or old age. Phenobarbital or other agents are used for cases refractory to benzodiazepines.
- Medical
- Thiamine is given before glucose-containing fluids to prevent Wernicke encephalopathy, with correction of magnesium, potassium and phosphate and attention to refeeding risk in malnourished patients. Antipsychotics are not used alone because they lower the seizure threshold.
- Follow-up
- Nursing care: regular CIWA-Ar scoring and vital signs, seizure and fall precautions, a quiet well-lit room, reorientation, fluid balance and close watch for aspiration.
- Conservative
- After detoxification, treatment of alcohol use disorder (psychosocial therapy and, when indicated, medicines that reduce relapse) to prevent future episodes.
Drugs for this condition
Complications
- Delirium tremens with death from arrhythmia, hyperthermia or cardiovascular collapse
- Status epilepticus
- Aspiration pneumonia
- Wernicke encephalopathy and Korsakoff syndrome
- Injuries from falls or agitation
- Electrolyte disorders and refeeding syndrome
Prognosis
Most withdrawal resolves within about a week. Untreated delirium tremens carries a high mortality, which falls sharply with early recognition and intensive care. Each episode raises the risk that the next one will be more severe, and relapse into drinking is common without ongoing treatment.
Prevention
- Screening hospitalised patients for heavy drinking and scoring withdrawal early
- Planned, medically supervised detoxification instead of abrupt stopping
- Routine thiamine for people with heavy alcohol use
Test yourself
Think of the answer, then tap the question to see it.
Which scale is used to score the severity of alcohol withdrawal and guide treatment?
The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised).
Within what time window after the last drink does delirium tremens typically begin?
About 48 to 96 hours after the last drink.
Which drug class is first-line for alcohol withdrawal?
Benzodiazepines, given on a fixed schedule or triggered by symptoms.
Why is thiamine given before glucose in a patient with heavy alcohol use?
Glucose can use up the remaining thiamine and precipitate Wernicke encephalopathy.
How does alcoholic hallucinosis differ from delirium tremens?
In hallucinosis the sensorium is clear and vital signs are stable; delirium tremens has confusion and marked autonomic instability.
Related conditions
- Delirium
- Wernicke encephalopathy (thiamine deficiency)
- Cirrhosis
- Acute pancreatitis
- Upper gastrointestinal bleeding
- Epilepsy and seizures
- Community-acquired pneumonia
- Refeeding syndrome
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Alcohol withdrawal (MedlinePlus (U.S. National Library of Medicine), 2025); Delirium tremens (MedlinePlus (U.S. National Library of Medicine), 2025).
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