Delirium tremens
- For the beer, see Delirium Tremens (beer).
Delirium tremens (colloquially, the DTs, "the horrors", "the shakes" or "rum fits") is an acute episode of delirium that is usually caused by withdrawal or abstinence from alcohol following habitual excessive drinking. Delirium tremens can also appear after a rapid reduction in the amount of alcohol being consumed by heavy drinkers, or as a complication of withdrawal from benzodiazepines or barbiturates. It only occurs in individuals with a history of constant, long-term alcohol consumption. Delirium tremens typically manifests about 18 to 24 hours after discontinuation of alcohol consumption, but can appear on the second or third day of abstinence.
Five percent of acute ethanol withdrawal cases progress to delirium tremens[1]. Unlike the withdrawal syndrome associated with opiate or stimulant addiction, delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated, though if treated early, death rates may be as low as 5%.
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Symptoms
The main symptoms are confusion and agitation. Other common symptoms include intense hallucinations such as visions of insects, snakes or rats. These may be related to the environment, e.g., drawings on wallpaper that the patient would perceive as giant spiders attacking her or him. Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, but associated with tactile hallucinations such as sensations of something crawling on the subject - a phenomenon known as formication. Delirium tremens can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia.
Delirium tremens (DT) should be distinguished from alcoholic hallucinosis, the latter occurring in approximately 20% of hospitalized alcoholics and not carrying a significant mortality. In contrast, DT occurs in 5-10% of alcohol-dependent people and carries up to 5% mortality with treatment and up to 35% mortality without treatment. DT is characterized by the presence of altered sensorium--i.e. complete hallucination without any recognition of the real world. DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever.
Causes
The exact pharmacology of ethanol is not fully understood: however, it is theorized that delirium tremens is caused by the effect of alcohol on the benzodiazepine-GABAA-chloride receptor complex for the inhibitory neurotransmitter GABA. Constant consumption of alcoholic beverages (and the consequent chronic sedation) causes a counterregulatory response in the brain in attempt to re-achieve homeostasis.
This causes downregulation of these receptors, as well as an up-regulation in the production of excitatory neurotransmitters such as norepinephrine, dopamine, epinephrine, and serotonin - all of which further the drinker's tolerance to alcohol and may intensify tonic-clonic seizures. When alcohol is no longer consumed, these down-regulated GABAA receptor complexes are so insensitive to GABA that the typical amount of GABA produced has little effect; compounded with the fact that GABA normally inhibits action potential formation, there are not as many receptors for GABA to bind to - meaning that sympathetic activation is unopposed. This is also known as an "adrenergic storm". Effects of this "adrenergic storm" can include (but are not limited to) tachycardia, hypertension, hyperthermia, hyperreflexia, diaphoresis, heart attack, cardiac arrhythmia, stroke, anxiety, panic attacks, paranoia, and agitation.
This is all made worse by excitatory neurotransmitter upregulation, so not only is sympathetic nervous system over-activity unopposed by GABA, there is also more of the serotonin, norepinephrine, dopamine, and epinephrine. Direct measurements of central norepinephrine and its metabolites is in direct correlation to the severity of the alcohol withdrawal syndrome.
It is possible that psychological (i.e., non-physical) factors also play a role, especially those of infections, malnutrition, or other underlying medical disorders - often related to alcoholism.
Treatment
Pharmacotherapy is symptomatic and supportive. Typically the patient is kept sedated with benzodiazepines, such as diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) and in extreme cases low-levels of antipsychotics, such as haloperidol until symptoms subside. If status epilepticus is present, seizures are treated accordingly.Controlling environmental stimuli can also be helpful, such as a well-lit but relaxing environment to minimise visual misinterpretations such as the visual hallucinations mentioned above.
Cultural References
Irish folk singer, Christy Moore, sang a song titled "Delirium Tremens," which appears on his Ordinary Man album. It is a comedic trawl through a protagonist's visions, with such lines as "I dreamt Ian Paisley was sayin' the Rosary, and Mother Teresa was takin' the pill." He finds the visions so scary (culminating in being in a jacuzzi with Margaret Thatcher "that oul whore in Number 10"), that he vows never to drink again. A live version of the song can be found on the album Live At The Point.
Delirium Tremens is also referenced in Eugene O'Neill's play The Hairy Ape. Yank, the principal character in the play, cites the condition as the cause of his mother's death when referring to his troubled childhood.
In the 1945 Billy Wilder film The Lost Weekend, the main character, played by Ray Milland, suffers delirium tremens after fleeing a detoxification ward following a weekend of binge drinking. In the movie, Milland's delirium comes in the form of a bat that perches on an apartment wall and devours a mouse tucked into a crack in the plaster.
Another cultural reference is in Smokey and the Bandit II.
In the 1995 film Leaving Las Vegas, Nicolas Cage portrays a character who experiences this symptom following binge drinking and withdrawal.
In the television show Strangers with Candy, the main character suffers from delirium tremens due to decades of drinking.
In Mark Twain's "The Adventures of Huckleberry Finn" Huck's father suffers from delirium tremens.
Jack Kerouac's "Big Sur" discusses his experiences with Delirium tremens.
See also
External links
Categories
Alcohol abuse | Psychiatry | Neurology | Latin medical phrases