The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines alcohol use disorder (AUD), a condition that was once called alcoholism, by 11 criteria. These include the inability to stop drinking once you start, continuing to drink even when relationships suffer, putting yourself in danger because of drinking, experiencing intense cravings for alcohol, and experiencing withdrawal symptoms when you quit drinking or can’t drink.
Withdrawal symptoms associated with AUD include the following:
- Anxiety, nervousness, and restlessness
- Depression and fatigue
- Shakiness or jumpiness
- Nightmares, insomnia, and other sleep disturbances
- Mood swings
- Sweating or clammy skin
- Enlarged or dilated pupils
- Appetite changes, especially loss of appetite
- Nausea and vomiting
- Pale skin
- Rapid heart rate
- Shaking or tremors in the hands, feet, or other parts of the body
These symptoms are uncomfortable. Without supervision in a medically managed detox program, withdrawal from alcohol may lead to relapse, which can lead to worsening AUD or alcohol poisoning.
While none of the above symptoms are physically harmful, there is a serious form of alcohol withdrawal called delirium tremens (DTs) that can be fatal. If you struggle with AUD, developing DTs is rare if you quit drinking; however, between 3 percent and 5 percent of people who try to quit drinking will develop this condition, especially if they attempt to quit drinking on their own.
The Symptoms of Delirium Tremens Are Physically Harmful
Delirium tremens was first recognized as a medical condition with severe outcomes in 1813. Now, medical professionals know to watch for the development of DTs within two days (48 hours) after someone in their care has quit drinking alcohol.
Although DTs is most likely to develop in people who have struggled with heavy drinking or alcohol abuse for 10 years or more, or people who drink more than 5 pints to 8 pints of soft alcohol or 1 pint of hard liquor a day for several months, the condition may arise in others who struggle with compulsive behaviors involving alcohol. This is a rare condition, but avoiding DTs is one of the major reasons to get medical supervision during the alcohol detox process.
Symptoms of DT include the following:
- Sudden, severe confusion (delirium)
- Full body tremors
- Changes in mental function, such as forgetfulness
- Agitation, irritability, or aggressiveness
- Intense excitement or fear
- Deep sleep, lasting a full day or more
- Bursts of energy followed by periods of exhaustion
- Rapid mood changes
- Sensitivity to stimuli like sound, touch, and light
- Stupor, or appearing awake but being unresponsive
- Chest pain
- Stomach pain
- High fever
Hallucinations, high fever, heart problems, and seizures can all be deadly effects from developing DTs. While about half of the people who try to quit drinking develop withdrawal symptoms – depression, anxiety, insomnia, and cravings are the most common – very few people will experience DTs. Still, the risk from the acute symptoms of DTs means that it is important to get medical supervision to manage withdrawal from alcohol.
The reason such a severe syndrome develops among some people who have struggled with alcohol abuse involves alcohol’s relationship to the gamma-Aminobutyric acid (GABA) receptors. Alcohol changes how the GABA neurotransmitter is managed, leading to the neurons firing less often and producing less of that neurotransmitter.
Over months or years of exposure to a lot of alcohol, the GABA system will decrease in activity and alter its functionality. Suddenly quitting alcohol after this system in the brain has come to rely on it means there will suddenly be less regulation of anxiety-like symptoms – the excitatory action of the brain. This can lead to intense stress, fast heartbeat, high blood pressure, nausea, and other symptoms. In extreme circumstances, DTs can develop.
An addiction specialist will understand if you are at risk of developing DTs and then help you manage the withdrawal process in a safe, clinical setting. The specialist may use an assessment chart like the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). The person may ask you about any history of:
- Early morning vomiting or nausea
- Physical tremors
- Anxiety and irritability
- Drinking alcohol before noon
- Amnesia or blackouts from drinking
These symptoms, especially when they are consistent, can indicate whether you may potentially develop delirium tremens. The condition can last up to five days, so it is extremely important to receive treatment to reduce or prevent seizures, hallucinations, heart problems, and fever during that time.
How a Clinician May Diagnose and Treat Delirium Tremens
Once you decide to stop abusing alcohol, seek help from a physician, therapist, or addiction specialist to begin the detox process. They can refer you to an appropriate detox treatment, which may be inpatient if you are at risk of developing DTs.
There are specific criteria clinicians use to determine their patients’ risk of developing DTs. They include:
- How much the individual drank and for how long
- If there have been attempts to quit before, followed by relapse
- Two or more of the following symptoms developed within six hours to two days after quitting:
- Autonomic hyperactivity, indicated with symptoms like sweating or a heart rate over 100 beats per minute
- Increasing hand tremors
- Tactile, visual, auditory, or other hallucinations
- Nausea or vomiting
- Psychomotor agitation or purposeless physical activity
- Grand mal seizures
- Symptoms that lead to distress or impairment of social, occupational, or other important functioning
- Symptoms that are not part of a different medical or mental condition
After these criteria are understood, your clinician will conduct a physical examination to understand your current health. This will include understanding your family history and personal history with heart disease, liver disease, stomach problems, and any additional drug use.
If your clinician uses the CIWA-Ar, the highest possible score is 67. The higher the score on this scale, the greater the risk you will develop DTs. The points as listed on the scale are:
- Less than 8 points: There is a mild risk of withdrawal symptoms. Those who score between 8 and 10 typically do not need medications like benzodiazepines or anticonvulsants to manage withdrawal.
- 8 to 15 points: There is a moderate risk of withdrawal symptoms that may be uncomfortable, but a lower risk of delirium tremens specifically.
- 15 or more: There is an elevated risk of severe withdrawal syndrome, leading up to DTs.
You are likely to need inpatient treatment if you are at risk of developing delirium tremens, you are in the process of developing DTs, or you had developed DTs before when you tried to stop drinking. The goals of treatment are to minimize the discomfort of the withdrawal process, preserve your dignity during the process, and prevent severe complications. DTs is a severe, life-threatening complication, and hospitalization or inpatient treatment during detox may be the best way to keep you safe and healthy.
Medications and Rehabilitation After Detoxing From Alcohol
Because benzodiazepines like Valium and Klonopin work on the same region of the brain as alcohol, they are often used to manage symptoms associated with serious alcohol withdrawal, including DTs. In some instances, your doctor may prescribe anticonvulsants instead, especially if your main risk from DTs is seizures rather than high fever or heart palpitations.
While there are few differences between benzodiazepines when applied for DTs, the distress and anxiety in people who develop DTs may require a shorter-acting benzodiazepine. Often, Valium is prescribed for the tapering process, but lorazepam (Ativan) may be prescribed immediately to reduce anxiety associated with the discomfort of withdrawal and DTs.
Once you have completed detox, which likely includes a benzodiazepine taper or administration of anticonvulsant medication, you should enter rehabilitation. If you have a history of relapsing back into alcohol abuse, you may want more intensive rehabilitation, like inpatient residential treatment, partial hospitalization, or intensive outpatient treatment. Ensuring you have an aftercare plan, support groups, and potentially maintenance medications like naltrexone are also beneficial.