Delirium Tremens: Early Signs, When It Starts, and What Family Members Should Do

What Delirium Tremens Is

In medicine, delirium tremens (known in Russian as “belaya goryachka,” or “white fever”) is called alcohol withdrawal delirium. In ICD-10, it is coded as F10.4 — withdrawal state with delirium. It is an acute disturbance of consciousness in which the person loses their orientation, perceives things that are not there, and acts under the influence of fear and hallucinations. Delirium develops not while the person is intoxicated but during alcohol withdrawal in someone with long-standing dependence.

At its core is severe overexcitation of the nervous system, which occurs when alcohol, which has long suppressed its activity, suddenly stops coming in. Added to this are dehydration, electrolyte imbalances, B vitamin deficiency, coexisting liver disease, and infections. Together, these lead to serious brain dysfunction. Without treatment, delirium is life-threatening because of heart problems, dehydration, overheating, injuries, and accidents.

Why It Is Called “White Fever” in Russian

The popular Russian name comes from the fact that delirium is often accompanied by a rise in temperature and feverish agitation. It is called “white” because it arises from “white wine,” as vodka used to be called. The name itself is not a medical term, but it captures the essence well: this is an acute, feverish state, not ordinary drunkenness. The English medical term “delirium tremens” (“trembling delirium”) highlights another key feature — severe shaking.

The First Signs of Delirium Tremens

Delirium rarely starts suddenly. It is usually preceded by a period of escalating withdrawal symptoms that lasts from several hours to a day. The person becomes restless and anxious and cannot fall asleep — and if they do, they have nightmares and wake up in fear. Shaking and sweating intensify, and the pulse quickens. Mood changes rapidly: from irritability to dejection or unnatural excitement.

Gradually, episodes of bewilderment appear: the person confuses the time of day, keeps asking where they are, may see flickering shadows, or hear someone calling them. At first these episodes are brief, and in between the person behaves normally. If you notice such changes in a loved one who is coming off a binge, this is a signal to call a doctor urgently: at this point, full-blown delirium can still be prevented.

• Insomnia, especially if the person has not slept for more than 24 hours
• Increasing anxiety, restlessness, and fidgeting
• Severe shaking of the hands, tongue, or whole body that others can see
• Heavy sweating, a fast pulse, and raised blood pressure
• Nightmares, crying out in sleep, and waking up in fear
• Brief visual or auditory misperceptions
• Confusion about the time of day and where they are

When Delirium Tremens Starts After a Binge

The typical timing is the second to fourth day after the last drink, and less often later, up to a week. That is why it is dangerous to assume that if the first day went relatively smoothly, the worst is over. Delirium often begins in the evening or at night, when the light is low and there are fewer external cues. Sometimes it is triggered by an injury, infection, surgery, or hospital admission for another reason that forced the person to stop drinking abruptly.

The risk is higher in people who have been drinking for many years, have frequent and long binges, have previously had delirium or seizures during withdrawal, have coexisting liver disease, infections, or head injuries, or are elderly. If these risk factors are present, it is better to plan coming off the binge with a doctor in advance, and in some cases to do it in a hospital, where delirium can be prevented or treated at the very earliest stage.

What Full-Blown Delirium Looks Like

In the full-blown stage, the person is disoriented to time and place, and sometimes even to their own identity. They see vivid, moving hallucinations: insects, small animals, snakes, threads or cobwebs, or people who have supposedly come for them. Auditory misperceptions are possible — threats or someone calling out — as well as tactile sensations, as if something is crawling on the skin. The person reacts to these images as if they were real: trying to brush them off, running away, hiding, or defending themselves.

Typical features include fear, agitation, fidgety movements, incoherent speech, marked shaking, sweating, a high temperature, and a fast pulse. The condition may fluctuate: during the day the person is relatively calm, while in the evening and at night the symptoms intensify. Because of fear and misperception of their surroundings, the risks of injuries, falls, and aggression increase. Without treatment, delirium can lead to serious heart problems and death.

Can a Person in Delirium Understand What Is Happening?

As a rule, no. The person is convinced that the images they see are real, and arguing with them is pointless. Unlike the misperceptions of mild withdrawal, when the person may doubt what they have seen, in delirium all insight into the hallucinations is lost. That is why persuasion does not help — emergency medical care is needed.

What Family Members Should Do Before the Ambulance Arrives

The first and most important step is to call 103 or 112 and describe the situation: the person is coming off a binge, is disoriented, is seeing things that are not there, and is agitated. Do not try to treat delirium yourself or give sleeping pills, sedatives, or alcohol — this will not help and may make things worse. Delirium tremens does not go away on its own, and the time until treatment begins matters for the outcome.

Until the crew arrives, try to keep the person safe. Remove sharp objects, close the windows and the balcony door, and do not leave the person alone. Turn on the lights, speak calmly and briefly, and tell them who you are and where they are. Don’t argue with them about the hallucinations, and don’t try to restrain them by force unless they are a danger to themselves. If they become aggressive, move to a safe distance and tell the dispatcher.

1. Call 103 or 112 and describe the person’s condition
2. Remove sharp objects; close the windows and balcony
3. Turn on the lights, switch off the TV, and reduce noise in the room
4. Speak calmly and briefly; tell them who you are and where they are
5. Don’t argue about the hallucinations or mock their fears
6. Don’t give alcohol, sleeping pills, or sedatives
7. Don’t leave the person alone, but don’t put yourself at risk

How Delirium Tremens Is Treated

Alcohol withdrawal delirium is treated only in a hospital — in an addiction, psychiatric, or intensive care unit. Treatment includes medications to relieve agitation and restore sleep, usually benzodiazepines; intensive IV fluid therapy to replace fluids and electrolytes; high doses of thiamine to prevent and treat brain damage; and monitoring of temperature, heart function, and breathing. At the same time, coexisting conditions are identified and treated: infections, injuries, and pancreatitis.

With timely treatment, delirium usually resolves within a few days, after which the person often has little memory of what happened. This is followed by a recovery period with weakness and sleep problems. It is important to understand that having had delirium tremens is a serious warning sign. The risk of it recurring during the next binge is high, so after discharge it is essential to continue addiction treatment.

Can Someone Be Hospitalized Without Their Consent?

The Code of the Republic of Kazakhstan “On Public Health and the Healthcare System” allows medical care to be provided without consent in life-threatening conditions, as well as in mental disorders when a person is a danger to themselves or others or is helpless. Alcohol withdrawal delirium is one such condition, so an emergency crew can admit the person to the hospital in accordance with the procedure established by law.

How to Prevent Delirium Tremens

The most reliable way is not to stop a long binge abruptly and without medical supervision if the person is at high risk. During planned medical detox, the doctor assesses the severity of withdrawal and the risk factors, prescribes medications to prevent seizures and delirium and B vitamins, and replaces fluids. If the risk is high, inpatient treatment is recommended, where the first signs can be spotted in time and treatment started promptly.

At Narcology 24, an addiction doctor (narcologist) makes home visits around the clock, assesses the risk of complications, and, if needed, arranges hospital admission right away. After the acute phase, we help the person move on to addiction treatment: consultations with an addiction doctor and a psychiatrist, psychotherapy, and — with the patient’s consent — relapse-prevention therapy and rehab. Care is anonymous, with no registration on the state addiction registry.

When to see a doctor

• The person is coming off a long binge, and insomnia, shaking, and anxiety are getting worse
• Previous alcohol withdrawals have already involved delirium tremens or seizures
• Brief episodes of confusion or “seeing things” have appeared while coming off the binge
• There is liver or heart disease, a head injury, or an infection during the binge
• The person is elderly and has been misusing alcohol for a long time
• After an episode of delirium, addiction treatment needs to be planned

Questions and answers

Medically reviewed by

Olga Smirnova, MDAddiction psychiatrist · experience 27 years

Alcohol dependence, alcoholism in women, dual diagnosis, coding after assessment and family consultations.