Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. Physical effects may include shaking, shivering,

irregular heart rate Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

, and sweating. People may also hallucinate. Occasionally, a very high body temperature or

seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...

s (colloquially known as "rum fits") may result in death. Alcohol is one of the most dangerous drugs to withdraw from. Delirium tremens typically only occurs in people with a high intake of alcohol for more than a month. A similar syndrome may occur with

benzodiazepine Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, ...

and barbiturate withdrawal. Withdrawal from stimulants such as

cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...

do not have major medical complications. In a person with delirium tremens it is important to rule out other associated problems such as electrolyte abnormalities,

pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic p ...

, and alcoholic hepatitis. Prevention is by treating withdrawal symptoms. If delirium tremens occurs, aggressive treatment improves outcomes. Treatment in a quiet

intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...

with sufficient light is often recommended.

Benzodiazepine Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, ...

s are the medication of choice with

diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...

lorazepam Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, insomnia, trouble sleeping, Psychomotor agitation, severe agitation, active Epileptic seizure, seizures including ...

, chlordiazepoxide, and oxazepam all commonly used. They should be given until a person is lightly sleeping. The

antipsychotic Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range o ...

haloperidol may also be used. The vitamin

thiamine Thiamine, also known as thiamin and vitamin B1, is a vitamin, an essential micronutrient, that cannot be made in the body. It is found in food and commercially synthesized to be a dietary supplement or medication. Phosphorylated forms of t ...

is recommended. Mortality without treatment is between 15% and 40%. Currently death occurs in about 1% to 4% of cases. About half of people with

alcoholism Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomina ...

will develop withdrawal symptoms upon reducing their use. Of these, 3% to 5% develop DTs or have seizures. The name delirium tremens was first used in 1813; however, the symptoms were well described since the 1700s. The word "delirium" is

Latin Latin (, or , ) is a classical language belonging to the Italic branch of the Indo-European languages. Latin was originally a dialect spoken in the lower Tiber area (then known as Latium) around present-day Rome, but through the power ...

for "going off the furrow," a plowing metaphor. It is also called the shaking frenzy and Saunders-Sutton syndrome. There are numerous nicknames for the condition, including "the DTs" and " seeing pink elephants" (see

below Below may refer to: *Earth * Ground (disambiguation) * Soil * Floor * Bottom (disambiguation) * Less than *Temperatures below freezing * Hell or underworld People with the surname * Ernst von Below (1863–1955), German World War I general * Fr ...

Signs and symptoms

The main symptoms of delirium tremens are nightmares, agitation, global confusion, disorientation, visual and auditory hallucinations, tactile hallucinations, fever,

high blood pressure Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high b ...

, heavy sweating, and other signs of autonomic hyperactivity ( fast heart rate and high blood pressure). These symptoms may appear suddenly but typically develop two to three days after the stopping of heavy drinking, being worst on the fourth or fifth day. These symptoms are characteristically worse at night. In general, DT is considered the most severe manifestation of alcohol withdrawal and 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 common DT symptoms. DT can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks, and

paranoia Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy conce ...

. Confusion is often noticeable to onlookers as those with DT will have trouble forming simple sentences or making basic logical calculations. DT should be distinguished from alcoholic hallucinosis, the latter of which occurs in approximately 20% of hospitalized alcoholics and does not carry a risk of 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.

Causes

Delirium tremens is mainly caused by a long period of drinking being stopped abruptly. Withdrawal leads to a biochemical regulation cascade. Delirium tremens is most common in people who are in alcohol withdrawal, especially in those who drink the equivalent of of beer or of

distilled beverage Liquor (or a spirit) is an alcoholic drink produced by distillation of grains, fruits, vegetables, or sugar, that have already gone through alcoholic fermentation. Other terms for liquor include: spirit drink, distilled beverage or hard ...

daily. Delirium tremens commonly affects those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years.

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 receptor The ''N''-methyl-D-aspartate receptor (also known as the NMDA receptor or NMDAR), is a glutamate receptor and ion channel found in neurons. The NMDA receptor is one of three types of ionotropic glutamate receptors, the other two being AMPA rece ...

s. This combined with desensitization of

alpha-2 adrenergic receptor The alpha-2 (α2) adrenergic receptor (or adrenoceptor) is a G protein-coupled receptor (GPCR) associated with the Gi heterotrimeric G-protein. It consists of three highly homologous subtypes, including α2A-, α2B-, and α2C-adrenergic. Som ...

s, results in a homeostatic upregulation of these systems in chronic alcohol use. When alcohol use ceases, the unregulated mechanisms result in hyperexcitability of neurons as natural

GABAergic In molecular biology and physiology, something is GABAergic or GABAnergic if it pertains to or affects the neurotransmitter GABA. For example, a synapse is GABAergic if it uses GABA as its neurotransmitter, and a GABAergic neuron produces GABA. A ...

systems are down-regulated and excitatory glutamatergic systems are unregulated. This combined with increased noradrenergic activity results in the symptoms of delirium tremens.

Diagnosis

Diagnosis is mainly based on symptoms. In a person with delirium tremens it is important to rule out other associated problems such as electrolyte abnormalities,

, and alcoholic hepatitis.

Treatment

Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent death. Amounts given are based on the symptoms. Typically the person is kept sedated with

s, such as

, chlordiazepoxide, or oxazepam. In some cases antipsychotics, such as haloperidol may also be used. Older drugs such as

paraldehyde Paraldehyde is the cyclic trimer of acetaldehyde molecules. Formally, it is a derivative of 1,3,5-trioxane, with a methyl group substituted for a hydrogen atom at each carbon. The corresponding tetramer is metaldehyde. A colourless liquid, it ...

and clomethiazole were formerly the traditional treatment but have now largely been superseded by the benzodiazepines. 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 Status epilepticus (SE), or status seizure, is a single seizure lasting more than 5 minutes or 2 or more seizures within a 5-minute period without the person returning to normal between them. Previous definitions used a 30-minute time limit. The s ...

occurs it is treated in the usual way. It can also be helpful to provide a well lit room as people often have hallucinations.

Alcoholic beverage An alcoholic beverage (also called an alcoholic drink, adult beverage, or a drink) is a drink that contains ethanol, a type of alcohol that acts as a drug and is produced by fermentation of grains, fruits, or other sources of sugar. The c ...

s can also be prescribed as a treatment for delirium tremens, but this practice is not universally supported. High doses of

often by the intravenous route is also recommended.

Society and culture

Nicknames for delirium tremens include "the DTs", "the shakes", "the oopizootics", "barrel-fever", "the blue horrors", "bottleache", "bats", "the drunken horrors", " seeing pink elephants", "gallon distemper", "quart mania", "heebie jeebies", "pink spiders", and "riding the ghost train", as well as "ork orks", "the zoots", "the 750 itch", and "pint paralysis". Another nickname is "the

Brooklyn Brooklyn () is a borough of New York City, coextensive with Kings County, in the U.S. state of New York (state), New York. Kings County is the most populous Administrative divisions of New York (state)#County, county in the State of New York, ...

Boys", found in

Eugene O'Neill Eugene Gladstone O'Neill (October 16, 1888 – November 27, 1953) was an American playwright and Nobel laureate in Nobel Prize in Literature, literature. His poetically titled plays were among the first to introduce into the U.S. the drama tech ...

's one-act play ''

Hughie ''Hughie'' is a short two-character play by Eugene O'Neill set in the lobby of a small hotel on a West Side street in Midtown Manhattan, New York, during the summer of 1928. The play is essentially a long monologue delivered by a small-time hus ...

'' set in

Times Square Times Square is a major commercial intersection, tourist destination, entertainment hub, and neighborhood in Midtown Manhattan, New York City. It is formed by the junction of Broadway, Seventh Avenue, and 42nd Street. Together with adjacent ...

in the 1920s. 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'. English author

George Eliot Mary Ann Evans (22 November 1819 – 22 December 1880; alternatively Mary Anne or Marian), known by her pen name George Eliot, was an English novelist, poet, journalist, translator, and one of the leading writers of the Victorian era. She wrot ...

provides a case involving delirium tremens in her novel ''

Middlemarch ''Middlemarch, A Study of Provincial Life'' is a novel by the English author Mary Anne Evans, who wrote as George Eliot. It first appeared in eight installments (volumes) in 1871 and 1872. Set in Middlemarch, a fictional English Midland town, i ...

'' (187172). 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 Dr. Tertius Lydgate's orders. French writer

Émile Zola Émile Édouard Charles Antoine Zola (, also , ; 2 April 184029 September 1902) was a French novelist, journalist, playwright, the best-known practitioner of the literary school of naturalism, and an important contributor to the development of ...

'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 Samuel Langhorne Clemens (November 30, 1835 – April 21, 1910), known by his pen name Mark Twain, was an American writer, humorist, entrepreneur, publisher, and lecturer. He was praised as the "greatest humorist the United States has p ...

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

Joseph Conrad Joseph Conrad (born Józef Teodor Konrad Korzeniowski, ; 3 December 1857 – 3 August 1924) was a Polish-British novelist and short story writer. He is regarded as one of the greatest writers in the English language; though he did not sp ...

's novel ''

Lord Jim ''Lord Jim'' is a novel by Joseph Conrad originally published as a serial in ''Blackwood's Magazine'' from October 1899 to November 1900. An early and primary event in the story is the abandonment of a passenger ship in distress by its crew, i ...

'' experiences "DTs of the worst kind" with symptoms that include seeing millions of pink frogs. English author M. R. James mentions delirium tremens in his 1904 ghost story

'Oh, Whistle, and I'll Come to You, My Lad' "Oh, Whistle, and I'll Come to You, My Lad" is a ghost story by British writer M. R. James, included in his collection ''Ghost Stories of an Antiquary'' (1904). The story is named after a 1793 poem of the same name penned by Robert Burns. Plo ...

. 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". In the 1945 film ''

The Lost Weekend ''The Lost Weekend'' is a 1945 American drama film noir directed by Billy Wilder, and starring Ray Milland and Jane Wyman. It was based on Charles R. Jackson's The Lost Weekend (novel), 1944 novel about an Alcoholism, alcoholic writer. The film ...

'',

Ray Milland Ray Milland (born Alfred Reginald Jones; 3 January 1907 – 10 March 1986) was a Welsh-American actor and film director. His screen career ran from 1929 to 1985. He is remembered for his Academy Award and Cannes Film Festival Award-winning ...

won the

Academy Award for Best Actor The Academy Award for Best Actor is an award presented annually by the Academy of Motion Picture Arts and Sciences (AMPAS). It is given to an actor who has delivered an outstanding performance in a leading role in a film released that year. The a ...

for his depiction of a character who experiences delirium tremens after being hospitalized, hallucinating that he saw a bat fly in and eat a mouse poking through a wall. Writer

Jack Kerouac Jean-Louis Lebris de Kérouac (; March 12, 1922 – October 21, 1969), known as Jack Kerouac, was an American novelist and poet who, alongside William S. Burroughs and Allen Ginsberg, was a pioneer of the Beat Generation. Of French-Canadian anc ...

details his experiences with delirium tremens in his book ''

Big Sur Big Sur () is a rugged and mountainous section of the Central Coast of California between Carmel and San Simeon, where the Santa Lucia Mountains rise abruptly from the Pacific Ocean. It is frequently praised for its dramatic scenery. Big S ...

''. The ''

M*A*S*H ''M*A*S*H'' (Mobile Army Surgical Hospital) is an American media franchise consisting of a series of novels, a film, several television series, plays, and other properties, and based on the semi-autobiographical fiction of Richard Hooker (auth ...

'' TV series episode "Bottoms Up" (season 9, episode 15) featured a side story about a nurse (Cpt. 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

from a witnessing nurse. During the filming of the 1975 film '' Monty Python and the Holy Grail'',

Graham Chapman Graham Chapman (8 January 1941 – 4 October 1989) was a British actor, comedian and writer. He was one of the six members of the Surreal humour, surreal comedy group Monty Python. He portrayed authority figures such as The Colonel (Monty Pyth ...

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. Irish singer-songwriter

Christy Moore Christopher Andrew "Christy" Moore (born 7 May 1945) is an Ireland, Irish folk singer, songwriter and guitarist. In addition to his significant success as an individual, he is one of the founding members of Planxty and Moving Hearts. His first ...

has a song on his 1985 album, '' Ordinary Man'', called "Delirium Tremens" which is a satirical song, directed towards the leaders in Irish politics and culture. Some of the people mentioned in the song include former Fianna Fáil leader

Charles Haughey Charles James Haughey (; 16 September 1925 – 13 June 2006) was an Irish Fianna Fáil politician who served as Taoiseach on three occasions – 1979 to 1981, March to December 1982 and 1987 to 1992. He was also Minister for the Gaeltacht from ...

, at the time a Labour TD, later the party leader Ruairi Quinn, former Labour Party leader Dick Spring and

Roger Casement Roger David Casement ( ga, Ruairí Dáithí Mac Easmainn; 1 September 1864 – 3 August 1916), known as Sir Roger Casement, Companion of the Order of St Michael and St George, CMG, between 1911 and 1916, was a diplomat and Irish people, Irish I ...

, who was captured bringing German guns to Ireland for the 1916 Easter Rising. 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. In the 1995 film '' Leaving Las Vegas'',

Nicolas Cage Nicolas Kim Coppola (born January 7, 1964), known professionally as Nicolas Cage, is an American actor and film producer. Born into the Coppola family, he is the recipient of List of awards and nominations received by Nicolas Cage, various ac ...

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 Vodka ( pl, wódka , russian: водка , sv, vodka ) is a clear distilled alcoholic beverage. Different varieties originated in Poland, Russia, and Sweden. Vodka is composed mainly of water and ethanol but sometimes with traces of impuriti ...

. Cage's performance as Ben Sanderson in the film won the

in 1996. Russian composer

Modest Mussorgsky Modest Petrovich Mussorgsky ( rus, link=no, Модест Петрович Мусоргский, Modest Petrovich Musorgsky , mɐˈdɛst pʲɪˈtrovʲɪtɕ ˈmusərkskʲɪj, Ru-Modest Petrovich Mussorgsky version.ogg; – ) was a Russian compo ...

(1839-1881) died of delirium tremens.

References

External links

Why Does Alcohol Cause the Shakes?
, Alcohol Withdrawal Syndrome Tremors , Dr Peter MCcann MCC, MBBS , Castle Craig Hospital {{DEFAULTSORT:Delirium Tremens Health effects of alcohol Addiction psychiatry Intensive care medicine Neurological disorders Latin medical words and phrases Medical emergencies Alcohol abuse Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate