tremens

Delirium tremens, sometimes referred to simply as tremens, is a life-threatening form of alcohol withdrawal that can occur in people with a history of heavy, prolonged alcohol use when intake is abruptly reduced or stopped. The condition is part of a spectrum of alcohol withdrawal syndromes and usually develops within 48 to 72 hours after the last drink, though onset can be earlier or later depending on individual factors.

Clinical features include severe confusion or disorientation, tremor, agitation, rapid heart rate, high blood pressure, fever, sweating, and pronounced autonomic instability. Visual, tactile, or auditory hallucinations may accompany delirium, and patients can experience severe insomnia, dehydration, electrolyte disturbances, and seizures. Without timely treatment, delirium tremens carries a substantial risk of complications and death.

Pathophysiology is linked to neuroadaptations from chronic alcohol exposure, including downregulation of GABAergic activity and upregulation of excitatory NMDA receptor function. This creates a hyperadrenergic and hyperexcitable state when alcohol is removed, contributing to delirium and autonomic dysfunction. Risk factors include a long history of heavy drinking, previous withdrawal episodes, coexisting medical or psychiatric illnesses, poor nutrition, and electrolyte abnormalities.

Diagnosis is clinical, based on history and the characteristic symptom cluster. Management requires medical supervision, usually in a hospital setting. Core treatments include thiamine administration to prevent Wernicke’s encephalopathy, intravenous fluids with electrolyte correction, and benzodiazepines as first-line therapy to control agitation and prevent seizures. Additional agents or critical care support may be needed for severe cases.

With appropriate treatment, symptoms typically improve over several days. Preventive strategies focus on medically supervised withdrawal and ongoing support for abstinence to reduce the risk of recurrence.