Delirium Tremens — MRCPsych Paper B MCQ

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EasySubstance MisuseDelirium TremensMRCPsych Paper B

A 50-year-old man with alcohol dependence presents 48 hours after his last drink. He is disoriented and has severe tremor, tachycardia, sweating, a temperature of 38.5°C, and vivid visual hallucinations of insects crawling on the walls. Which is the most likely diagnosis?

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Correct answer: B — Delirium tremens

The diagnosis is **delirium tremens**, a severe alcohol-withdrawal syndrome. The decisive features are onset 48 hours after alcohol cessation, acute disorientation, vivid visual hallucinations, severe tremor, fever and autonomic hyperactivity manifested by tachycardia and sweating. It is a medical emergency requiring hospital treatment. Wernicke's encephalopathy may cause confusion but is more strongly suggested by ocular abnormalities and gait or cerebellar dysfunction. Korsakoff syndrome causes a predominantly chronic amnestic syndrome with confabulation. Alcohol-related dementia produces persistent cognitive decline rather than an acute autonomically activated delirium. Hepatic encephalopathy requires evidence of significant hepatic dysfunction and is not specifically linked to the characteristic timing and features of alcohol withdrawal. NICE recommends oral lorazepam first line for delirium tremens, rather than routine intravenous benzodiazepine treatment.

Reference: Royal College of Psychiatrists. Alcohol, mental health and the brain, section 'Delirium tremens'. Current webpage, accessed 19 August 2026. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/alcohol-mental-health-and-the-brain