"DTs" redirects here.
For the initialism, see DTS.
For the beer, see Delirium Tremens.
For the Gold Rush town in California formerly with this name, see Omega, California.
For the album by Sulfur, see Delirium Tremens.
Delirium tremens is an acute episode of delirium that is usually caused by withdrawal from
alcohol, first described in 1813.
Benzodiazepines are the treatment of choice for delirium tremens.
Withdrawal from sedative-hypnotics other than alcohol, such as benzodiazepines, or barbiturates,
can also cause seizures, delirium tremens, and death if not properly managed.
Withdrawal from other drugs that are not sedative-hypnotics such as caffeine and cocaine do not have major
medical complications, and are not life-threatening.
Withdrawal reactions due to physical dependence on alcohol are the most dangerous and can
be fatal.
They often lead to physical effects including shivering, palpitations, sweating and in some
cases, convulsions and death if not treated.
When caused by alcohol, it occurs only in patients with a history of alcoholism.
Occurrence of a similar syndrome due to benzodiazepines does not require as long a period of consistent
intake of such drugs.
In the U.S., less than 50% to 60% of alcoholics will develop any significant withdrawal symptoms
upon cessation of alcohol intake, and of these, only 5% of cases of acute ethanol withdrawal
progress to DT.
Unlike the withdrawal syndrome associated with opiate dependence, DT can be fatal.
Mortality was as high as 35% before the advent of intensive care and advanced pharmacotherapy;
in the modern era of medicine, death rates range from 5 to 15%.
Similar hyperirritability and hallucinosis can be caused by magnesium deficiency.
Signs and symptoms The main symptoms of delirium tremens are
nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations, fever,
hypertension, diaphoresis, and other signs of autonomic hyperactivity.
These symptoms may appear suddenly but can develop 2–3 days after cessation of drinking
heavily with its highest intensity on the fourth or fifth day.
Also, these "symptoms are characteristically worse at night".
In general DT is considered as the most severe manifestation of alcohol withdrawal, which
occurs 3–10 days following the last drink.
Other common symptoms include intense perceptual disturbance such as visions of insects, snakes,
or rats.
These may be hallucinations, or illusions related to the environment, e.g., patterns
on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance
to the morphology of an insect, and are also associated with tactile hallucinations such
as sensations of something crawling on the subject — a phenomenon known as formication.
Delirium tremens usually includes extremely intense feelings of "impending doom".
Severe anxiety and feelings of imminent death are symptomatic of DT.
DT can sometimes be associated with severe, uncontrollable tremors of the extremities
and secondary symptoms such as anxiety, panic attacks and paranoia.
Confusion is often noticeable to onlookers as patients will have trouble constructing
simple sentences or making basic logical calculations.
In many cases, people who rarely speak out of turn will have an increased tendency for
gaffes even though they are sober.
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 alcoholics and carries up to 15% mortality with treatment
and up to 35% mortality without treatment.
DT is characterized by the presence of altered sensorium; that is, a complete hallucination
without any recognition of the real world.
DT has extreme autonomic hyperactivity, and 35-60% of patients have a fever.
Some patients experience seizures.
Causes Delirium tremens is mainly caused after a
long period of drinking, being stopped abruptly and experiencing withdrawal, leading to the
biochemical regulation cascade.
It may also be triggered by head injury, infection, or illness in people with a history of heavy
use of alcohol.
Yet another cause of delirium tremens is abrupt cessation of tranquilizer drugs of the barbiturate
or benzodiazepine classes in a patient with a relatively strong addiction to them.
Because these tranquilizers' primary pharmacological and physiological effects stem from their
manipulation of the GABA chemical and transmitter somatic system, the same endogenous neurotransmitter
system affected by alcohol, delirium tremens can occur upon abrupt cessation of dosage
in heavily dependent patients.
These DTs are much the same as those caused by alcohol and so is the attendant withdrawal
syndrome of which they are a manifestation.
That is the primary reason benzodiazepines are such an effective treatment for DTs, despite
also being the cause of them in many cases.
Because ethanol and tranquilizers such as barbiturates and benzodiazepines function
as positive allosteric modulators at GABAA receptors, the brain, in its desire to equalize
an unbalanced chemical system, triggers the abrupt cessation of the production of endogenous
GABA.
This cessation becomes more and more marked as the addiction becomes stronger and as higher
doses are needed to cause intoxication.
In addition to having sedative properties, GABA is an immensely important regulatory
neurotransmitter that controls the heart rate, blood pressure, and seizure threshold among
myriad other important autonomic nervous subsystems.
Delirium tremens is most common in people who have a history of alcohol withdrawal,
especially in those who drink the equivalent of 7 to 8 US pints of beer or 1 US pint of
distilled beverage daily.
Delirium tremens also commonly affects those with a history of habitual alcohol use or
alcoholism that has existed for more than 10 years.
The exact pharmacology of ethanol is not fully understood; however, it is theorized that
delirium tremens is caused by the effect of alcohol on GABA receptors.
Constant consumption of alcoholic beverages causes a counterregulatory response in the
brain in attempt to regain homeostasis.
This causes downregulation of these receptors, as well as an up-regulation in the production
of excitatory neurotransmitters, primarily glutamate, and also such as norepinephrine,
dopamine, epinephrine, and serotonin, all of which further the drinker's tolerance to
alcohol.
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"; the effects of which can include tachycardia,
hypertension, hyperthermia, hyperreflexia, diaphoresis, heart attack, cardiac arrhythmia,
stroke, anxiety, panic attacks, paranoia, and agitation.
This is all made worse by excitatory neurotransmitter up-regulation, so not only is sympathetic
nervous system over-activity unopposed by GABA, there is also more of the serotonin,
norepinephrine, dopamine, epinephrine, and particularly glutamate.
Excitory NMDA receptors are also up-regulated, contributing to the delirium and neurotoxicity
of withdrawal.
Direct measurements of central norepinephrine and its metabolites are in direct correlation
to the severity of the alcohol withdrawal syndrome.
It is possible that psychological factors also play a role, in addition to other factors
such as infections, malnutrition, or other underlying medical disorders, often related
to alcoholism.
Treatment Delirium tremens due to alcohol withdrawal
can be treated with benzodiazepines.
High doses may be necessary to prevent mortality.
Pharmacotherapy is symptomatic and supportive.
Typically the patient is kept sedated with benzodiazepines, such as diazepam, lorazepam,
chlordiazepoxide, or oxazepam and in extreme cases low-levels of antipsychotics, such as
haloperidol or even stronger benzodiazepines like temazepam or midazolam until symptoms
subside.
Older drugs such as paraldehyde and clomethiazole were the traditional treatment but these have
now largely been superseded by the benzodiazepines, although they may still be used as an alternative
in some circumstances.
Acamprosate is often used to augment treatment, and is then carried on into long term use
to reduce the risk of relapse.
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 minimize visual misinterpretations such as the visual hallucinations mentioned
above.
Alcoholic beverages can also be prescribed as a treatment for delirium tremens, but this
practice is not universally supported.
Popular culture Writer Jack Kerouac details his experiences
with delirium tremens in his book Big Sur.
In the 1945 film The Lost Weekend, an alcoholic writer named Don, played by Ray Milland, is
admitted to a hospital's alcoholic ward.
As one of the other alcoholic patients appears to go into delirium tremens, Don escapes the
hospital and heads home to drink.
Following his last consumption of liquor, he experiences DTs when an illusion of a small
rodent crawls out of a hole in the wall.
He then hallucinates a bat flying through the room as the bat proceeds to devour the
small rodent.
In the 1962 film Days of Wine and Roses, public relations man Joe Clay is committed to a sanitorium
twice.
In the first instance, he is held in a straitjacket and in a padded room while experiencing delirium
tremens.
In the second instance, Joe is committed after breaking into a liquor store and afterwards
wakes in the sanitorium, strapped down to a table and sweating profusely, whereupon
his Alcoholics Anonymous sponsor Jim Hungerford informs him that "For two days there was a
little green man chasing you around with pruning shears."
In the 2003 film The Last Samurai, Nathan Algren, a disenchanted ex-United States Army
captain and an alcoholic, who is traumatized by his experience fighting in the Civil War
and the Indian Wars, is treated by the Hirotaro family in the throes of delirium tremens after
being captured in battle with samurai troops led by Katsumoto.
In the film Leaving Las Vegas, the main character, Ben Sanderson, suffers from the DTs after
a drinking binge, and rushes to his liquor supply to prevent them from continuing.
In the novel L'Assommoir, by French author Émile Zola, the husband of the heroine Gervaise,
an alcoholic roofer named Coupeau, succumbs to delirium tremens in a Parisian hospital.
Ethan Thomas, protagonist of the video game Condemned 2, has become an alcoholic since
the events of the previous game and must regularly consume whiskey to prevent the violent shaking
of his delirium tremens from spoiling his aim.
The protagonist of Malcolm Lowry's 1947 novel Under the Volcano suffers from delirium tremens.
In the M*A*S*H episode "Bottoms Up", an alcoholic nurse gets delirium tremens.
In the film Everything Must Go, the character Nick Halsey suffers from delirium tremens
in the movie.
In the "Birthmarks" episode of season 5 of the television series House MD, a patient
who is an alcoholic suffers from delirium tremens while being treated in the hospital.
In the 1989 CBS Hallmark Hall of Fame television movie My Name Is Bill W., Bill Wilson is admitted
to the hospital where one of the doctors claims Bill is going through the early stages of
delirium tremens.
Later in the movie, he is strapped down to a bed appearing to once again have the symptoms
of DTs.
The fraternity letters Delta Tau Chi from Animal House could be a reference to delirium
tremens or possibly detox.
Irish folk singer Christy Moore wrote a song titled Delirium Tremens, humorously describing
a man going through the symptoms, which features on his 1985 album Ordinary Man.
In the 2013 Bollywood movie Matru Ki Bijlee Ka Mandola, the character Harry Mandola suffers
from DT, and has hallucinations of a grinning pink buffalo.
In the third episode of the third season of television show Perception, Dr. Daniel Pierce
interviews a suspect who is suffering from DT.
See also
Alcohol dementia Alcohol detoxification
Delusional parasitosis Excited delirium
Seeing pink elephants References
External links MedlinePlus Encyclopedia Delirium Tremens
Delirium Tremens at eMedicine