Delirium tremens
Delirium tremens | |
---|---|
barbiturate withdrawal[3] | |
Treatment | Intensive care unit, benzodiazepines, thiamine[2] |
Prognosis | Risk of death ~2% (treatment), 25% (no treatment)[4] |
Frequency | ~4% of those withdrawing from alcohol[2] |
Delirium tremens (DTs; lit. 'shaking frenzy') is a
Delirium tremens typically occurs only in people with a high intake of alcohol for more than a month.
Prevention is by treating withdrawal symptoms using similarly acting compounds to taper off the use of the precipitating substance in a controlled fashion.
Mortality without treatment is between 15% and 40%.[4] Currently death occurs in about 1% to 4% of cases.[2]
About half of people with alcoholism will develop withdrawal symptoms upon reducing their use.[2] Of these, 3% to 5% develop DTs or have seizures.[2]
The name delirium tremens was first used in 1813; however, the symptoms were well described since the 1700s.
Signs and symptoms
The main symptoms of delirium tremens are nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations,
These symptoms are characteristically worse at night.[12] For example, in Finnish, this nightlike condition is called liskojen yö, lit. 'the night of the lizards', for its sweatiness, general unease, and hallucinations tending towards the unseemly and frightening.
In general, DT is considered the most severe manifestation of alcohol, or other GABA-receptor active drug, withdrawal, and occurs 2–10 days following the last drink.[10] It often overcomes the patient by surprise, because a brief period of uneventful sobriety of 1–2 days tends to precede it, it can fully manifest itself within a single hour, and unlike usual withdrawal symptoms experienced by an alcoholic, the condition will not easily go away using the typical intake amount or schedule of the drug.
Other common symptoms include intense perceptual disturbance such as visions or feelings 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 feelings of "impending doom". Anxiety and feelings of imminent death are common DT symptoms.[13]
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 those with DT will have trouble forming simple sentences or making basic logical calculations.[citation needed]
DT should be distinguished from
Causes
Delirium tremens is mainly caused by a long period of drinking being stopped abruptly. Withdrawal leads to a biochemical regulation cascade.[citation needed]
Delirium tremens is most common in people who are in
Pathophysiology
Delirium tremens is a component of alcohol withdrawal hypothesized to be the result of compensatory changes in response to chronic heavy alcohol use. Alcohol positively allosterically modulates the binding of GABA, enhancing its effect and resulting in inhibition of neurons projecting into the nucleus accumbens, as well as inhibiting NMDA receptors. This combined with desensitization of alpha-2 adrenergic receptors, results in a homeostatic upregulation of these systems in chronic alcohol use.[16]
When alcohol use ceases, the unregulated mechanisms result in hyperexcitability of neurons as natural GABAergic systems are down-regulated and excitatory glutamatergic systems are upregulated. This combined with increased noradrenergic activity results in the symptoms of delirium tremens.[16]
Diagnosis
Diagnosis is mainly based on symptoms. In a person with delirium tremens, it is important to rule out other associated problems, such as
Treatment
Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent death.[17] Amounts given are based on the symptoms. Typically the person is kept sedated with benzodiazepines, such as diazepam, lorazepam, chlordiazepoxide, or oxazepam.
In some cases
Acamprosate is occasionally used in addition to other treatments, and is then carried on into long-term use to reduce the risk of relapse. If status epilepticus occurs it is treated in the usual way.[citation needed]
It can also be helpful to provide a well lit room as people often have hallucinations.[19]
Alcoholic beverages can also be prescribed as a treatment for delirium tremens,[20] but this practice is not universally supported.[21]
High doses of thiamine often by the intravenous route is also recommended.[2]
Delirium tremens in literature
French writer Émile Zola's novel The Drinking Den (L'Assommoir) includes a character – Coupeau, the main character Gervaise's husband – who has delirium tremens by the end of the book.
American writer Mark Twain describes an episode of delirium tremens in his book The Adventures of Huckleberry Finn (1884). In chapter 6, Huck states about his father, "After supper pap took the jug, and said he had enough whisky there for two drunks and one delirium tremens. That was always his word." Subsequently, Pap Finn runs around with hallucinations of snakes and chases Huck around their cabin with a knife in an attempt to kill him, thinking Huck is the "Angel of Death".
One of the characters in
English author M. R. James mentions delirium tremens in his 1904 ghost story "'Oh, Whistle, and I'll Come to You, My Lad'". Professor Parkins while staying at the Globe Inn when in coastal Burnstow to "improve his game" of golf, despite being "a convinced disbeliever in what is called the 'supernatural'", when face to face with an entity in his "double-bed room" during the story's climax, is heard "uttering cry upon cry at the utmost pitch of his voice" though later "was somehow cleared of the ready suspicion of delirium tremens".
American writer Jack Kerouac details his experiences with delirium tremens in his book Big Sur.[22]
English author George Eliot provides a case involving delirium tremens in her novel Middlemarch (1871–72). Alcoholic scoundrel John Raffles, both an abusive stepfather of Joshua Riggs and blackmailing nemesis of financier Nicholas Bulstrode, dies, whose "death was due to delirium tremens" while at Peter Featherstone's Stone Court property. Housekeeper Mrs. Abel provides Raffles' final night of care per Bulstrode's instruction whose directions given to Abel stand adverse to Tertius Lydgate's orders.
Delirium tremens in film and TV
In the 1945 film
The M*A*S*H TV series episode "Bottoms Up" (season 9, episode 15, aired on March 2, 1981) featured a side story about a nurse (Capt. Helen Whitfield) who was found to be drinking heavily off-duty. By the culmination of the episode, after a confrontation by Maj. Margaret Houlihan, the character swears off alcohol and presumably quits immediately. At mealtime, roughly 48 hours later, Whitfield becomes hysterical upon being served food in the Mess tent, claiming that things are crawling onto her from it. Margaret and Col. Sherman Potter subdue her. Potter, having recognized the symptoms of delirium tremens orders 5 ml of paraldehyde from a witnessing nurse.
During the filming of the 1975 film Monty Python and the Holy Grail, Graham Chapman developed delirium tremens due to the lack of alcohol on the set. It was particularly bad during the filming of the bridge of death scene where Chapman was visibly shaking, sweating and could not cross the bridge. His fellow Pythons were astonished as Chapman was an accomplished mountaineer.[26]
In the 1995 film Leaving Las Vegas, Nicolas Cage plays a suicidal alcoholic who rids himself of all his possessions and travels to Las Vegas to drink himself to death. During his travels, he experiences delirium tremens on a couch after waking up from a binge and crawls in pain to the refrigerator for more vodka. Cage's performance as Ben Sanderson in the film won the Academy Award for Best Actor in 1996.
Delirium tremens in music
Irish singer-songwriter
Russian composer Modest Mussorgsky (1839-1881) died of delirium tremens.[27]
Delirium tremens in popular culture
Nicknames for delirium tremens include "the DTs", "the shakes", "the oopizootics", "barrel-fever", "the blue horrors", "the rat's", "bottleache", "bats", "the drunken horrors", "seeing pink elephants", "gallon distemper", "quart mania", "heebie jeebies", "pink spiders", and "riding the ghost train",[28] as well as "ork orks", "the zoots", "the 750 itch", and "pint paralysis". Another nickname is "the Brooklyn Boys", found in Eugene O'Neill's one-act play Hughie set in Times Square in the 1920s.[29] Delirium tremens was also given an alternate medical definition since at least the 1840s, being known as mania a potu, which translates to 'mania from drink'.[30]
The Belgian beer "Delirium Tremens," introduced in 1988, is a direct reference and also uses a pink elephant as its logo to highlight one of the symptoms of delirium tremens.[31][32]
See also
- Alcohol dementia
- Alcohol detoxification
- Delusional parasitosis
- Excited delirium
- On the wagon
References
- ^ ISBN 978-0-7020-2997-4. Archivedfrom the original on 8 September 2017.
- ^ S2CID 205116954.
- ^ ISBN 9780198043362. Archivedfrom the original on 2016-03-04.
- ^ ISBN 9781441912237. Archivedfrom the original on 2016-03-04.
- ^ "rum fits". Medical dictionary. Farlex, Inc. Retrieved 22 November 2022.
- PMID 13741146. Retrieved 1 February 2023.
- ISBN 9781452266015. Archivedfrom the original on 2015-12-22.
- ^ PMID 20944765.
- ISBN 978-1-58562-276-4. Archivedfrom the original on 4 March 2016.
- ^ a b Delirium Tremens (DTs)~clinical at eMedicine
- ^ Hales, R.; Yudofsky, S.; Talbott, J. (1999). Textbook of Psychiatry (3rd ed.). London: The American Psychiatric Press.[page needed]
- ^ Gelder et al, 2005 p188 Psychiatry 3rd Ed. Oxford: New York.[page needed]
- ^ "Delirium tremens: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2023-11-08.
- ^ Delirium Tremens (DTs): Prognosis at eMedicine
- ^ MedlinePlus Encyclopedia: Delirium Tremens
- ^ PMID 20944765.
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- ^ "Big Sur Introduction | Shmoop". Shmoop.com. Archived from the original on 28 June 2011. Retrieved 17 November 2022.
- ^ Bailey, Blake. "Weekend in the Sun; Hollywood went wild over Charles Jackson and his 1944 best-seller, The Lost Weekend. Jackson reciprocated, thrilled that the celebrated Billy Wilder wanted to direct his dark, autobiographical novel of addiction. But would the result—a cinematic classic—destroy his literary achievement?" Archived 2016-04-13 at the Wayback Machine, Vanity Fair (magazine), February 28, 2013. Accessed February 15, 2017. "That summer, Hollywood columns had buzzed with rumors about who would play Don Birnam, the genteel alcoholic who ends up howling with delirium tremens. The role had been turned down by everyone from Cary Grant to Gary Cooper before the Welshman Ray Milland took it, refusing to heed an all but universal warning that he was committing 'career suicide.'"
- ^ Cameron, Kate. ‘The Lost Weekend’ effectively portrays the damage caused by alcoholism on screen. Archived 2017-02-16 at the Wayback Machine, New York Daily News, January 2, 1945, reprinted February 17, 2015. Accessed February 15, 2017. "If you read the book, which was a best-seller last year, you know that Jackson did a remarkable job of recording the actions of Birnam, during a weekend binge of monumental proportions, and in setting down in graphic prose the effects produced on him by liquor. In adapting the book to the screen, Brackett and Wilder have accomplished an equally remarkable feat of projecting a case of delirium tremens on screen."
- ISBN 9780786421190. Accessed February 15, 2017. "Finally, Don's hallucination in which a wheeling bat devours a mouse places The Lost Weekend in a direct line of descent from the Gothicism of the '30s Universal horror cycle."
- ^ Chapman, Graham (April 20, 1982). "Late Show with David Letterman, episode #1.46" (video). youtube.com. NBC.
- ^ "Алкогольная трагедия легендарного композитора Мусоргского". Sobesednik.ru. Retrieved 17 November 2022.
- ISBN 9781611028706. Archivedfrom the original on 2016-03-04.
- ^ Paulson, Michael, "Gambling on O'Neill: Forest Whitaker Makes His Broadway Debut in 'Hughie'" Archived 2016-02-29 at the Wayback Machine, New York Times, February 3, 2016. Retrieved 2016-02-03.
- ISBN 9781275311367.
- ^ Belgian, Beers (2020-05-29). "The Pink Elephant beer: Delirium Tremens". Belgian Beers. Retrieved 2020-05-29.
- ^ "11 Things You Should Know About Delirium Tremens". Vinepair.com. 8 December 2017.
External links
- Why Does Alcohol Cause the Shakes? | Alcohol Withdrawal Syndrome Tremors | Dr Peter MCcann MCC, MBBS | Castle Craig Hospital