Case 30: A man who sees squirrels in his room on his third day in hospital

Case 30: A man who sees squirrels in his room on his third day in hospital

A 56-year-old man admitted to a psychiatric ward to stop drinking who, on his third day there, becomes confused, frightened and tremulous and says there are squirrels in his room.

  • 2 min read
  • Checked 01 Nov 2026

The case

A 56-year-old man is admitted to a psychiatric clinic for a long-standing drinking problem. He has drunk every day for more than 30 years, lately about a litre of spirits a day. He is keen to give up alcohol and begin treatment, and had his last drink on the evening before he came in. On his third day on the ward he becomes confused, perplexed and uneasy, with slurred speech and a worse tremor. He looks around in fear, does not sleep, and says there are squirrels in his room.

Summary

Diagnosis

Delirium in alcohol withdrawal (delirium tremens).

What points to it

  • Long and heavy drinking with dependence: a litre of spirits a day for years.
  • Onset on the third day after his last drink, the usual timing.
  • Disorientation and clouding of consciousness, perplexity, fear and sleeplessness.
  • Coarse tremor and vivid visual hallucinations of animals.

What else it could be

Wernicke's encephalopathy (confusion, eye signs, unsteady gait), which can come with it; hepatic encephalopathy; a head injury; infection such as pneumonia; low glucose or sodium; withdrawal from other sedatives taken alongside alcohol.

Management

  • Delirium tremens is a medical emergency: transfer to medical care if the psychiatric ward cannot monitor him closely, and look for infection, injury and electrolyte disturbance.
  • Parenteral thiamine (for example Pabrinex) straight away, before any glucose, then continued for several days.
  • A benzodiazepine, usually diazepam (lorazepam if the liver is badly damaged), given against his symptoms on a scale such as CIWA-Ar or in front-loaded doses until he is calm but rousable. The dose is set by his response.
  • Fluids and electrolytes, potassium and magnesium especially; a calm, lit, safe room and close observation to prevent falls and harm.
  • Once he is well, continue his treatment for alcohol dependence.

Outlook

Delirium tremens fluctuates and usually clears within days to two weeks, but it has a reported mortality of 5 to 10%, less with prompt treatment. Wernicke–Korsakoff syndrome or an alcohol-related dementia can follow.