Alcohol withdrawal and delirium tremens

What it is

Delirium tremens is an acute and sometimes fatal reaction to alcohol withdrawal. It starts within 48-96 hours after cessation of a heavy drinking pattern, so it is not the first thing to appear once drinking stops but the last stage of a course that gets worse over days.

How it presents

Alcohol withdrawal runs through stages, and each stage adds to the one before it.

• Stage 1 (mild): anxiety, tremor, insomnia, headache, palpitations, gastrointestinal disturbances
• Stage 2 (moderate): the mild symptoms and diaphoresis, increased systolic blood pressure, tachypnea, tachycardia, confusion, mild hyperthermia
• Stage 3 (delirium tremens): the moderate symptoms and disorientation, impaired attention, visual and/or auditory hallucinations, seizures

Put another way, withdrawal symptoms include tremors, anxiety, hypertension, tachycardia, sweating and insomnia; the more severe withdrawal symptoms are tonic clonic seizure, visual hallucination and delirium tremens. Visual hallucination is a sign of alcohol withdrawal.

The characteristic symptoms of delirium tremens itself are confusion, tremor, delusions, hallucinations and autonomic hyperactivity.

Two described cases show the shape of it. A man of 35 presented with severe insomnia and tremulousness, mostly in the morning, associated with paranoid delusion, confusion and visual hallucination. A male of 65 presented with tremor, difficulty sleeping, nausea, agitation and transient visual hallucinations 3 days after he stopped drinking alcohol following a 3-day heavy spell, with increasing confusion over the past several hours.