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Delirium tremens (colloquially, the DTs, "the horrors", "the shakes" or "rum fits;" literally, "shaking delirium" or "trembling madness" in Latin) is an acute episode of delirium that is usually caused by withdrawal or abstinence, from alcohol following habitual excessive drinking, or benzodiazepines or barbiturates (and other minor tranquilizers). Delirium tremens can also appear after a rapid reduction in the amount of alcohol being consumed by heavy drinkers, or a rapid reduction of intake of benzodiazepines or barbiturates. Caused by alcohol, it only occurs in individuals with a history of constant, long-term alcohol consumption. Occurrence due to benzodiazepine or barbiturate withdrawal does not require as long a period of consistent intake of such drugs. Prior use of both tranquilizers and alcohol can compound the symptoms, and while extremely rare, is the most dangerous especially if untreated. Barbiturates are generally accepted as being extremely dangerous, both due to overdose potential and addiction potential including the extreme withdrawal syndrome that usually is marked by delirium tremens upon discontinuation. Due to this, barbiturates are rarely used ambulatory anymore, being replaced by the generally accepted less dangerous benzodiazepines, which however still cause a similar withdrawal syndrome. Image File history File links Broom_icon. ... Delirium Tremens is a brand of Belgian blond beer produced by Huyghe Brewery in Melle. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Medical Subject Headings (MeSH) is a huge controlled vocabulary (or metadata system) for the purpose of indexing journal articles and books in the life sciences. ... For other uses, see Latin (disambiguation). ... This article is about the mental state and medical condition. ... Withdrawal, also known as withdrawal syndrome, refers to the characteristic signs and symptoms that appear when a drug that causes physical dependence is regularly used for a long time and then suddenly discontinued or decreased in dosage. ... Abstinence is a voluntary restraint from indulging a desire or appetite for certain bodily activities that are widely experienced as giving pleasure. ... This article does not cite any references or sources. ... Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to the extent that this behavior interferes with the drinkers normal personal, family, social, or work life, and may lead to physical or mental harm. ... Benzodiazepine tablets The benzodiazepines are a class of drugs with hypnotic, anxiolytic, anticonvulsant, amnestic and muscle relaxant properties. ... Barbiturates are drugs that acts as central nervous system (CNS) depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. ... Benzodiazepine withdrawal syndrome, caused by withdrawal or dosage reduction of benzodiazepines, is the symptoms which appear when a patient who has taken the drug for a period of time stops taking the drug. ... Barbiturates are drugs that acts as central nervous system (CNS) depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. ... Benzodiazepine withdrawal syndrome, caused by withdrawal or dosage reduction of benzodiazepines, is the symptoms which appear when a patient who has taken the drug for a period of time stops taking the drug. ...

Five percent of acute ethanol withdrawal cases progress to delirium tremens^[1]. Unlike the withdrawal syndrome associated with opiate addiction (generally), delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated; if treated early, death rates range from 5-15%.^[2] For other uses see Opiate (disambiguation), or for the class of drugs see Opioid. ...

Symptoms

The main symptoms are confusion, disorientation and agitation. Other common symptoms include intense hallucinations such as visions of insects, snakes or rats (or stereotypically, pink elephants). These may be related to the environment, e.g., drawings on wallpaper that the patient would perceive as giant spiders attacking him or her. 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. A hallucination is a sensory perception experienced in the absence of an external stimulus, as distinct from an illusion, which is a misperception of an external stimulus. ... Image of a real elephant retouched to paint it pink. ... Formication is a tactile hallucination that insects or snakes are crawling over or under the skin. ... For the film see Tremors (film). ... For other senses of this word, see paranoia (disambiguation). ...

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. ^[3] 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 (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some individuals experience seizures as well. The term sensorium (plural: sensoria) refers to the sum of an organisms perception, the seat of sensation where it experiences and interprets the environments within which it lives. ... This article or section is in need of attention from an expert on the subject. ... This article is about epileptic seizures. ...

Causes

Delirium tremens can occur after a period of heavy alcohol drinking, especially when the person does not eat enough food. It may also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol.

It is most common in people who have a history of alcohol withdrawal, especially in those who drink the equivalent of 7 - 8 pints of beer (or 1 pint of "hard" alcohol) every day for several months. 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 the benzodiazepine-GABA_A-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 regain homeostasis. Gamma-aminobutyric acid (usually abbreviated to GABA) is an inhibitory neurotransmitter found in the nervous systems of widely divergent species. ... Alcoholic beverages An alcoholic beverage is a drink containing ethanol, commonly known as alcohol, although in chemistry the definition of alcohol includes many other compounds. ... Homeostasis is the property of either an open system or a closed system, especially a living organism, which regulates its internal environment so as to maintain a stable, constant condition. ...

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 GABA_A 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. Down regulation is the process by which a cell decreases the number of receptors to a given hormone or neurotransmitter to reduce its sensitivity to this molecule. ... In biochemistry, a receptor is a protein on the cell membrane or within the cytoplasm or cell nucleus that binds to a specific molecule (a ligand), such as a neurotransmitter, hormone, or other substance, and initiates the cellular response to the ligand. ... Neurotransmitters are chemicals that are used to relay, amplify and modulate electrical signals between a presynaptic and a postsynaptic neuron. ... A. A schematic view of an idealized action potential illustrates its various phases as the action potential passes a point on a cell membrane. ... The Sympathetic Nervous System (SNS) is a branch of the autonomic nervous system. ... An adrenergic is a drug, or other substance, which has effects similar to, or the same as, epinephrine (adrenaline). ... An adrenergic is a drug, or other substance, which has effects similar to, or the same as, epinephrine (adrenaline). ... This article or section does not cite any references or sources. ... For other forms of hypertension, see Hypertension (disambiguation). ... Hyperthermia in its advanced state referred to as heat stroke or sunstroke, is an acute condition which occurs when the body produces or absorbs more heat than it can dissipate. ... Hyperreflexia is defined as overactive or overresponsive reflexes. ... Diaphoresis is excessive sweating commonly associated with shock and other medical emergency conditions. ... Heart attack redirects here. ... Cardiac arrhythmia is any of a group of conditions in which the electrical activity of the heart is irregular or is faster or slower than normal. ... For other uses, see Stroke (disambiguation). ... Anxiety is a physiological state characterized by cognitive, somatic, emotional, and behavioral components (Seligman, Walker & Rosenhan, 2001). ... A panic attack is a period of intense fear or discomfort, typically with an abrupt onset and usually lasting no more than 30 minutes. ... For other senses of this word, see paranoia (disambiguation). ... Agitation may have the following special meanings Agitation, an emotional state Agitation, putting into motion (by shaking or stirring) Agitation, a term from the lexicon of Communists: political activities aimed at urging people to do something This is a disambiguation page — a navigational aid which lists other pages that...

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, epinephrine, and particularly glutamate. Excitory NMDA receptors are also upregulated, contributing to the delirium and neurotoxicity (by excitotoxicity) of withdrawal. Direct measurements of central norepinephrine and its metabolites is in direct correlation to the severity of the alcohol withdrawal syndrome. Serotonin (pronounced ) (5-hydroxytryptamine, or 5-HT) is a monoamine neurotransmitter synthesized in serotonergic neurons in the central nervous system (CNS) and enterochromaffin cells in the gastrointestinal tract of animals including humans. ... Norepinephrine (INN)(abbr. ... For other uses, see Dopamine (disambiguation). ... Adrenaline redirects here. ... Glutamate is the anion of glutamic acid. ... The NMDA receptor (NMDAR) is an ionotropic receptor for glutamate (NMDA (N-methyl d-aspartate) is a name of its selective specific agonist). ... Excitotoxicity is the pathological process by which nerve cells are damaged and killed by glutamate and similar substances. ...

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. Psychological science redirects here. ... An infection is the detrimental colonization of a host organism by a foreign species. ... Percentage of population affected by malnutrition by country, according to United Nations statistics. ... Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to the extent that this behavior interferes with the drinkers normal personal, family, social, or work life, and may lead to physical or mental harm. ...

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. 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 minimise visual misinterpretations such as the visual hallucinations mentioned above. Alprazolam 2 mg tablets The benzodiazepines (pronounced , or benzos for short) are a class of psychoactive drugs considered minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties, which are mediated by slowing down the central nervous system. ... Diazepam (IPA: ), first marketed as Valium by Hoffmann-La Roche) is a benzodiazepine derivative drug. ... Lorazepam is a benzodiazepine tranquilizer with short to medium duration of action. ... Oxazepam (marketed under brand names Alepam, Murelax, Oxascand, Serax, Serepax, Seresta, Sobril) is a drug which is a benzodiazepine derivative. ... Haloperidol (sold under the tradenames Aloperidin, Bioperidolo, Brotopon, Dozic, Duraperidol (Germany), Einalon S, Eukystol, Haldol, Halosten, Keselan, Linton, Peluces, Serenace, Serenase, Sigaperidol) is a conventional, or typical, butyrophenone antipsychotic drug. ... acamprosate ... This article is about epileptic seizures. ...

Cultural references

• Literature
  • In George Eliot's Middlemarch, John Raffles suffers and eventually dies from delirium tremens.
  • 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.
  • In Joseph Conrad's Lord Jim, the chief engineer of the Patna is described as having the condition which results in his being hospitalized.
  • Australian writer, Henry Lawson, who was himself an alcoholic, refers in numerous short stories to the "jim-jams", a colloquialism for the "DTs".
  • In Aleksis Kivi's novel Seven Brothers, Simeoni has delirium tremens and hallucinates that the devil takes him on a huge tower made of boot leather and shows him the future of the world.
  • In Charlotte Perkins Gilman's "The Yellow Wallpaper" the term is referenced.
  • The George Orwell book, Burmese Days features an alcoholic character known as Mr Lackersteen who suffers from delirium tremens.
  • Ignacio Solares’ Delirium tremens (1979) is a work of non-fiction that collects stories of nightmarish visions experienced by alcoholics when undergoing delirium tremens. Solares’ father had experienced delirium tremens when Solares was a boy.
  • The Brothers Karamazov, Book XI, Chapter 9: The Devil, Ivan Fyodorovich’s Nightmare, describes a delirium tremens induced hallucination.

• Theater/film/television
  • In a line from the stage and movie version of West Side Story, Lieutenant Shrank asks, "How's your old man's DT's Arab?"
  • 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.
  • In Blake Edwards's 1965 film "Days of Wine and Roses", Jack Lemmon's character, Joe Clay, experiences delirium tremens before detoxing and discovering Alcoholics Anonymous.
  • 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 the television show "M*A*S*H", one of "Hot Lips" Hoolihan's nurses and best friend, Helen Whitfield, suffers from delirium tremens.
  • In the movie Fried Green Tomatoes Smokey suffers from alcoholic tremor while attempting to eat corn with a fork. He is then given a bottle of whiskey by Idgy Threadgood in order to prevent the development of delirium tremens.
  • In an episode of Coronation Street Jamie's mother, an alcoholic is seen shaking on the sofa with DT after promising to go cold turkey
  • In Jean-Pierre Melville's Le Cercle Rouge, Yves Montand's character Jensen experiences delirium tremens.

• Music
  • Hard Rock band Aerosmith mentions it in their song "Falling in Love (Is Hard on the Knees)." "I'm Jonesin' on love / Yeah I got the DTs."
  • 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.
  • "Delirium Tremens" is the title of a song contained on the disc "Enemigos Intimos," published in 1998 by BMG España featuring Fito Paez and Joaquin Sabina

• Comics
  • In the comic series Preacher, the Irish vampire Cassidy swears off drinking and suffers from delirium tremens.
  • Two Asterix albums feature a perpetually drunk Roman legionnaire named Tremensdelirius.

Mary Ann (Marian) Evans (22 November 1819 – 22 December 1880), better known by her pen name George Eliot, was an English novelist. ... See also Middlemarch, New Zealand. ... Samuel Langhorne Clemens (November 30, 1835 – April 21, 1910),[1] better known by the pen name Mark Twain, was an American humorist, satirist, lecturer and writer. ... Huckleberry Finn and Jim Adventures of Huckleberry Finn (1885) by Mark Twain (Samuel Clemens) is commonly accounted as the first Great American Novel. ... Jack Kerouac (pronounced ) (March 12, 1922 – October 21, 1969) was an American novelist, writer, poet, and artist. ... Big Sur, a 1962 novel by Jack Kerouac. ... // Joseph Conrad (born Teodor Józef Konrad Nałęcz-Korzeniowski, 3 December 1857 – 3 August 1924) was a Polish-born novelist who spent most of his adult life in Britain. ... Lord Jim is a novel by Joseph Conrad, originally published in Blackwoods Magazine from October 1899 to November 1900. ... Henry Lawson, circa 1902 Henry Lawson[1] (17 June 1867 - 2 September 1922) was an Australian writer and poet. ... Aleksis Kivi (October 10, 1834 - December 31, 1872), born Alexis Stenvall, was a Finnish author who wrote the first significant novel in the Finnish language, Seven Brothers (Finnish title: Seitsemän veljestä). Aleksis Kivi was born at Nurmijärvi, Finland, in a tailors family. ... Seven Brothers (originally Seitsemän veljestä) is the only novel of the Finnish author Aleksis Kivi and the first significant novel in the Finnish language. ... Charlotte Perkins Gilman (July 3, 1860 – August 17, 1935) was a prominent American poet, non-fiction writer, short story writer, novelist, lecturer, and social reformer. ... The Yellow Wallpaper is a short story by author Charlotte Perkins Gilman. ... Eric Arthur Blair (25 June 1903 [1] [2] – 21 January 1950), better known by the pen name George Orwell, was an English author and journalist. ... Burmese Days is a novel by British writer George Orwell. ... For other uses, see The Brothers Karamazov (disambiguation). ... This article is about the musical. ... Eugene Gladstone ONeill (October 16, 1888 – November 27, 1953) was a Nobel- and four-time Pulitzer Prize-winning American playwright. ... The Hairy Ape is an expressionist play by Eugene ONeill (1922). ... Billy Wilder (June 22, 1906 – March 27, 2002) was an Austrian-born, Jewish-American journalist, screenwriter, film director, and producer whose career spanned more than 50 years and 60 films. ... For The Cosby Show episode, see The Lost Weekend (The Cosby Show). ... This article or section does not cite any references or sources. ... Days of Wine and Roses is the title of: A 1962 film directed by Blake Edwards and starring Jack Lemmon A popular song composed for the film by Henry Mancini and Johnny Mercer This is a disambiguation page — a list of pages that otherwise might share the same title. ... John Uhler Lemmon III (February 8, 1925 – June 27, 2001), better known as Jack Lemmon, was a two-time Academy Award-winning American actor and comedian. ... AA meeting sign // Alcoholics Anonymous (AA) is an informal meeting society for recovering alcoholics whose primary purpose is to stay sober and help other alcoholics achieve sobriety. ... Smokey and the Bandit II is a film released on August 15, 1980 in the United States, January 1, 1981 in Australia, January 22, 1981 in West Germany, January 30, 1981 in Sweden, February 7, 1981 in Norway, and March 27, 1981 in Finland. ... For other uses, see Leaving Las Vegas (disambiguation). ... Strangers with Candy is a television series produced by Comedy Central. ... M*A*S*H is an American television series developed by Larry Gelbart, inspired by the 1968 novel M*A*S*H: A Novel About Three Army Doctors by Richard Hooker (penname for H. Richard Hornberger) and its sequels, but primarily by the 1970 film MASH, and influenced by the... Fried Green Tomatoes at the Whistle Stop Cafe is the name of a novel by Fannie Flagg. ... Coronation Street is an award-winning British soap opera. ... Cold turkey is a slang expression describing the actions of a person who gives up a habit or addiction all at once. ... Jean-Pierre Melville (born Jean-Pierre Grumbach) (October 20, 1917 – August 2, 1973) was a noted French director. ... Le Cercle rouge (The Red Circle, 1970) is a crime film set in Paris, France. ... Yves Montand Yves Montand (October 13, 1921 – November 9, 1991) was a French/Italian actor, born Ivo Livi in Monsummano Alto, Italy. ... This article is about the band Aerosmith. ... Christopher Andrew Christy Moore (born on May 7, 1945, in Newbridge, County Kildare) is a very popular Irish folk singer, songwriter, and guitarist. ... Ian Richard Kyle Paisley (born 6 April 1926), styled The Revd and Rt Hon. ... Our Lady of Lourdes - Mary appearing at Lourdes with Rosary beads. ... Mother Teresa (born Agnes Gonxha Bojaxhiu IPA: ) (August 26, 1910 – September 5, 1997) was a Roman Catholic nun who founded the Missionaries of Charity and won the Nobel Peace Prize in 1979 for her humanitarian work. ... Birth control is the practice of preventing or reducing the probability of pregnancy without abstaining from sexual intercourse; the term is also sometimes used to include abortion, the ending of an unwanted pregnancy, or abstinence. ... Margaret Hilda Thatcher, Baroness Thatcher, LG, OM, PC, FRS (née Roberts; born 13 October 1925) served as British Prime Minister from 1979 to 1990 and leader of the Conservative Party from 1975 until 1990, being the first and to date only woman to hold either post. ... Prostitution is the sale of sexual services (typically manual stimulation, oral sex, sexual intercourse, or anal sex) for cash or other kind of return, generally indiscriminately with many persons. ... Prime Minister Tony Blair and U.S. Vice President Dick Cheney stand in front of the famous main door to Number 10. ... Fito Paez is a popular rock and roll pianist, lyricist, and Spanish language singer from Rosario, Argentina. ... Joaquín Sabina is a talented singer and songwriter. ... Preacher was a comic book series created by writer Garth Ennis and artist Steve Dillon, published by the American comic book label Vertigo imprint of DC Comics, with painted covers by Glenn Fabry. ... Cassidy is a fictional character, an Irish vampire from the comic book Preacher. ... This is a list of recurring characters in the Asterix comics. ... The Roman Legion (from Latin , from lego, legere, legi, lectus — to collect) is a term that can apply both as a transliteration of legio (conscription or army) to the entire Roman army and also, more narrowly (and more commonly), to the heavy infantry that was the basic military unit of...

References

1. ^ http://www.emedicine.com
2. ^ http://www.emedicine.com/med/topic524.htm
3. ^ http://www.emedicine.com/EMERG/topic123.htm

See also

• Alcoholism
• Withdrawal
• Cold turkey
• Delusional parasitosis

Alcoholism is the consumption of, or preoccupation with, alcoholic beverages to the extent that this behavior interferes with the drinkers normal personal, family, social, or work life, and may lead to physical or mental harm. ... Withdrawal, also known as withdrawal syndrome, refers to the characteristic signs and symptoms that appear when a drug that causes physical dependence is regularly used for a long time and then suddenly discontinued or decreased in dosage. ... Cold turkey is a slang expression describing the actions of a person who gives up a habit or addiction all at once. ... Delusional parasitosis is a form of psychosis in which sufferers hold a delusional belief they are infested with parasites [1]. Delusional parasitosis is also referred to as Ekboms Syndrome, named after a Swedish neurologist, Karl Axel Ekbom,[2] who published seminal accounts of the disease in 1937 and 1938. ...

External links

• Medline Encyclopedia: Delirium Tremens
• eMedicine Delirium Tremens