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| __NOTOC__ | | __NOTOC__ |
| | {{Template:Delirium tremens}} |
| '''For patient information, click [[Delirium tremens (patient information)|here]]''' | | '''For patient information, click [[Delirium tremens (patient information)|here]]''' |
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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 3543 |
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| ICD10 = F10.4 |
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| ICD9 = {{ICD9|291.0}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000766 |
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| MeshID = D000430 |
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| }}
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| {{SI}}
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| {{CMG}} | | {{CMG}} |
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| {{SK}} the horrors; rum fits; the shakes; shaking delirium; trembling madness; DT's | | {{SK}} Rum fits; DT's; shaking delirium; trembling madness; delerium tremens |
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| ==Overview== | | ==[[Delirium tremens overview|Overview]]== |
| '''Delirium tremens''' is an acute episode of [[delirium]] that is usually caused by [[withdrawal]] or [[abstinence]], from [[alcohol]] following [[alcoholism|habitual excessive drinking]], or [[benzodiazepines]] or [[barbiturates]] (and other major tranquilizers).
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| ==Pathophysiology== | | ==[[Delirium tremens historical perspective|Historical Perspective]]== |
| Delirium tremens can also appear after a rapid reduction in the amount of [[alcohol]] being consumed by heavy drinkers, or a [[benzodiazepine withdrawal syndrome|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 withdrawal syndrome|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. | |
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| 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<sub>A</sub>-chloride receptor complex for the inhibitory neurotransmitter [[Gamma-aminobutyric acid|GABA]]. Constant consumption of [[alcoholic beverage]]s (and the consequent chronic sedation) causes a counterregulatory response in the brain in attempt to re-achieve [[homeostasis]]. This causes [[downregulation]] of these [[Receptor (biochemistry)|receptor]]s, 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<sub>A</sub> 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 nervous system|sympathetic]] activation is unopposed. This is also known as an "[[adrenergic]] storm".
| | ==[[Delirium tremens classification|Classification]]== |
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| 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 receptor]]s 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.
| | ==[[Delirium tremens pathophysiology|Pathophysiology]]== |
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| ==Causes== | | ==[[Delirium tremens causes|Causes]]== |
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| * [[Alcohol withdrawal]]
| | ==[[Delirium tremens differential diagnosis|Differentiating Delirium Tremens from other Diseases]]== |
| * [[Benzodiazepine withdrawal ]]
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| * [[Barbiturate withdrawal]]
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| ==Differentiating Delirium Tremens from other Disease== | | ==[[Delirium tremens epidemiology and demographics|Epidemiology and Demographics]]== |
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| 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]]; that is, a complete hallucination without any recognition of the real world. DT has extreme [[Autonomic nervous system|autonomic]] hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some individuals experience [[seizure]]s as well.. | | ==[[Delirium tremens risk factors|Risk Factors]]== |
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| ==Epidemiology and Demographics== | | ==[[Delirium tremens screening|Screening]]== |
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| Five percent of acute ethanol withdrawal cases progress to delirium tremens. 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%.
| | ==[[Delirium tremens natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Risk Factors==
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| * [[Head injury]]
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| * [[CNS infection ]]
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| * [[Sepsis]]
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| * [[Drug abuse]]
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| * [[Malnutrition]]
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| * [[Alcoholism]] that has existed for more than 10 years
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| ==Natural History, Complications and Prognosis==
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| ===Complications===
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| [[Adrenergic]] storm causes a few complications which include (but are not limited to)
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| * [[Hypertension]]
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| * [[Hyperthermia]]
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| * [[Myocardial infarction|Heart attack]]
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| * [[Cardiac arrhythmia]]
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| * [[Stroke]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
| | [[Delirium tremens history and symptoms|History and Symptoms]] | [[Delirium tremens physical examination|Physical Examination]] | [[Delirium tremens laboratory findings|Laboratory Findings]] | [[Delirium tremens electrocardiogram|Electrocardiogram]] | [[Delirium tremens chest x ray|Chest X Ray]] | [[Delirium tremens CT|CT]] | [[Delirium tremens MRI|MRI]] | [[Delirium tremens other imaging findings|Other Imaging Findings]] | [[Delirium tremens other diagnostic studies|Other Diagnostic Studies]] |
| The main symptoms are
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| * [[Confusion]]
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| * [[Disorientation]]
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| * [[Agitation]]
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| Other common symptoms include
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| * Intense [[hallucination]]s - [[formication]]
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| * [[Tremor]]s
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| * [[Anxiety]]
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| * [[Panic attacks]]
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| * [[Paranoia]]
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| ==Treatment== | | ==Treatment== |
| Pharmacotherapy is symptomatic and supportive. Typically the patient is kept sedated with [[benzodiazepine]]s, 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, [[seizure]]s are treated accordingly.
| | [[Delirium tremens medical therapy|Medical Therapy]] | [[Delirium tremens primary prevention|Primary Prevention]] | [[Delirium tremens secondary prevention|Secondary Prevention]] | [[Delirium tremens cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Delirium tremens future or investigational therapies|Future or Investigational Therapies]] |
| 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.
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| ==Cultural references== | | ==Case Studies== |
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| * Literature
| | [[Delirium tremens case study one|Case #1]] |
| ** In [[Fyodor Dostoyevsky]]'s ''[[The Brothers Karamazov]]'', Ivan Karamazov suffers from delirium tremens.
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| ** In [[George Eliot]]'s ''[[Middlemarch]]'', John Raffles suffers and eventually dies from delirium tremens.
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| ** In [[Mark Twain]]'s ''[[The Adventures of Huckleberry Finn]]'', Huck's father suffers from delirium tremens.
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| ** [[Jack Kerouac]]'s ''[[Big Sur (novel)|Big Sur]]'' discusses his experiences with delirium tremens.
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| ** In [[Joseph Conrad]]'s [[Lord Jim]], the chief engineer of the Patna is described as having the condition which results in his being hospitalized.
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| ** Australian writer, [[Henry Lawson]], who was himself an alcoholic, refers in numerous short stories to the "jim-jams", a colloquialism for the "DTs".
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| ** 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.
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| ** In [[Charlotte Perkins Gilman]]'s "[[The Yellow Wallpaper]]" the term is referenced.
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| ** The [[George Orwell]] book, [[Burmese Days]] features an alcoholic character known as Mr Lackersteen who suffers from delirium tremens.
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| **Ignacio Solares’ [http://www.amazon.com/dp/1568385188 ''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.
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| * Theater/film/television
| | ==Related Chapters== |
| ** 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?"
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| ** 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.
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| ** 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.
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| ** 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]].
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| ** Another cultural reference is in ''[[Smokey and the Bandit II]]''.
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| ** In the 1995 film ''[[Leaving Las Vegas]]'', Nicolas Cage portrays a character who experiences this symptom following binge drinking and withdrawal.
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| ** In the television show ''[[Strangers with Candy]]'', the main character suffers from delirium tremens due to decades of drinking.
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| ** In the television show "[[M*A*S*H (TV series)|M*A*S*H]]", one of "Hot Lips" Hoolihan's nurses and best friend, Helen Whitfield, suffers from delirium tremens.
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| ** 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.
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| ** 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]]
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| ** In [[Jean-Pierre Melville]]'s ''[[Le Cercle Rouge]]'', [[Yves Montand]]'s character Jensen experiences delirium tremens.
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| * Music
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| ** 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."
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| ** 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 [[Contraception|pill]]." He finds the visions so scary (culminating in being in a jacuzzi with [[Margaret Thatcher]] "that oul [[Prostitute|whore]] in [[10 Downing Street|Number 10]]"), that he vows never to drink again.
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| ** "Delirium Tremens" is the title of a song contained in the disk "Enemigos Intimos" published on 1998 by [[BMG España]] featuring [[Fito Paez]] and [[Joaquin Sabina]]
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| * Comics
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| ** In the comic series, [[Preacher (comics)|Preacher]], the Irish vampire [[Cassidy (comics)|Cassidy]] swears off drinking, and suffers from delirium tremens.
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| ** Two [[Recurring characters in Asterix#Others|Asterix]] albums feature a perpetually drunk [[Roman legionnaire]] named '''Tremensdelirius'''.
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| ==References== | |
| {{reflist|2}}
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| ==See also==
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| * [[Alcoholism]] | | * [[Alcoholism]] |
| * [[Withdrawal]] | | * [[Withdrawal]] |
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| {{Mental and behavioural disorders}} | | {{Mental and behavioural disorders}} |
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| [[da:Delirium tremens]] | | [[Category:Substance abuse]] |
| [[de:Delirium tremens]] | | [[Category:Alcohol abuse]] |
| [[et:Delirium tremens]]
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| [[es:Delirium tremens]]
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| [[fr:Delirium tremens]]
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| [[hu:Delirium tremens]]
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| [[nl:Delirium tremens (ontwenningsverschijnsel)]]
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| [[nn:Delirium tremens]]
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| [[pl:Majaczenie alkoholowe]]
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| [[pt:Delirium tremens]]
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| [[ru:Белая горячка]]
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| [[sl:Alkoholni delirij]]
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| [[sr:Делиријум тременс]]
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| [[fi:Delirium tremens]]
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| [[sv:Delirium tremens]]
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| [[tr:Deliriyum tremens]]
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| [[Category:Abuse]] | | [[Category:Abuse]] |
| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Neurology]] | | [[Category:Neurology]] |
| | [[Category:Disease]] |
| | [[Category:Intensive care medicine]] |
| | [[Category:Emergency medicine]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |