Delirium tremens

What is delirium tremens?

Delirium tremens (alcoholic delirium) is the most common type of alcoholic psychosis. The ratio of the frequency of delirium tremens and acute alcoholic hallucinosis can be used to judge the massiveness of alcohol abuse by the population. The more often delirium tremens occurs, the higher the per capita alcohol consumption by the population, including alcoholics.
In the overwhelming majority of cases, delirium tremens occurs in the first 3 days after stopping alcohol abuse, less often - on the 6th day. All delirium develops in the second and third stages of alcoholism, the duration of the hangover syndrome by the time the first delirium in life occurs usually exceeds 5 years, the age of patients is about 40 years. The duration of daily alcohol consumption most often exceeds a week, with more than 500 ml of vodka consumed per day. Before the onset of the first delirium in life, a prolongation of the binge, a transition to stronger alcoholic beverages, or an increase in daily alcohol doses are very often observed. In 10% of cases, delirium tremens occurs not at the height of the hangover syndrome, but at the stage of its reverse development. In some cases, delirium tremens develops in a state of so-called "relative abstinence", when during a binge, after another intake of alcohol, the concentration of alcohol in the blood drops and manifestations of the abstinence syndrome are detected. Alcohol intake temporarily eliminates the deceptions of perception, then full-blown psychosis occurs. In about 30% of cases, delirium tremens is preceded by various somatic diseases that force an abrupt cessation of alcohol consumption. This leads to an aggravation of the hangover syndrome and the occurrence of delirium tremens. Typical delirium, or classic delirium tremens, is characterized by stages of development.

Symptoms of delirium tremens:

The prodromal stage should be considered alcohol withdrawal syndrome, which, before the onset of delirium tremens, in most cases develops after a longer binge than is typical for the patient. Before the end of the binge, a deterioration in physical condition is often noted. Appetite decreases, sometimes an aversion to food appears. Nausea in the morning often ends in vomiting. Drinkers complain of a feeling of heaviness, colic, pain in the epigastric region. Dizziness increases, blood pressure rises, unpleasant sensations and headaches arise. Chilliness gives way to a feeling of heat with pronounced sweating. Sleep becomes restless, intermittent, shallow. At night, there are attacks of suffocation, pain in the heart, numbness in the arms and legs, convulsive contractions of the calf muscles, sometimes the muscles of the arms. Those suffering from delirium tremens try to alleviate the condition by taking small doses of alcohol, which they prepare for the night. Quite often, the single and daily dosage of alcohol is reduced, physical weakness increases, and work capacity drops sharply.
After stopping drinking, the withdrawal syndrome in most cases is particularly severe. Multiple vomiting occurs, suffocation and pain in the heart area increase, fear of death appears, and sweating increases sharply. Those suffering from delirium tremens hardly sleep. Physical weakness and ataxia make it impossible to confidently move around the apartment, sometimes this is possible only with outside help. Movements become imprecise, uncertain, awkward, poorly coordinated. The face looks puffy, the skin of the face is often red, yellowness of the sclera is often detected. Increased pulse rate is combined with arterial hypertension, breathing becomes more frequent. The tongue is covered with a coating, with a sufficiently long duration of binge drinking the coating becomes dark brown. Poor health is reflected in suffering facial expressions.
Neurological disorders are expressed in the appearance of large-scale tremors in the hands, head, unsteady gait, muscle weakness. The pupils are somewhat dilated, photoreactions can be sluggish, there aretwitching of the eyeballs. Tendon and periosteal reflexes are activated.
Against the background of an anxious and melancholy state, irritability increases, anger, impatience, and aggressiveness appear. Those who have suffered traumatic brain damage may experience sudden weakness, dizziness, and headaches.
Much less often, moderate withdrawal symptoms are noted that are not accompanied by the appearance of pronounced neurological symptoms, severe sleep disturbances, or severe weakness. This happens in cases where, during a binge, those suffering from delirium tremens continue to eat normally, there is no vomiting, and there is no aversion to food.
A change in mental state indicates the approach of delirium tremens. A severe subjective state, accompanied by motor retardation, is replaced by animation, hyperexpressiveness of facial expressions and motor skills, motor activity with hurried efficiency, fussiness, and restlessness. A gloomy depressive affect with gloomy hypochondria, touchiness, suspiciousness, wariness, anger is replaced by an elevated mood with a tendency to humorous statements. Sometimes fleeting states of fear, confusion, transient confusion arise. Unstable ideas of attitude, jealousy, persecution, witchcraft may appear. Vivid memories and figurative representations arise, the smallest details and particulars of old events are reproduced. Unusual talkativeness is combined with inconsistency of statements, their contradiction. By evening, this pathology intensifies. Dreams become disturbing, sometimes fantastic. Upon awakening, those suffering from delirium tremens cannot always distinguish between dreams and real events.
Pathological bodily and organ sensations intensify and become more varied. They acquire ever greater intensity and affective saturation. With closed eyes, visual hallucinations appear, often scenic deceptions of perception. Those suffering from delirium tremens seem to find themselves in a familiar environment or at work, take part in various events, quarrels, adventurous adventures. This is accompanied by a vivid affect, adequate to the content of the deceptions of perception. Those suffering from delirium tremens jump up, mumble something, turn on the light, suspiciously examine the room. Abundant illusions appear. The intensity of illusory disorders increases when concentrating attention on them and decreases when distracted. The condition fluctuates all the time. At times, people suffering from delirium tremens understand that something is happening to them, they talk about the painful nature of deceptions of perception and unpleasant physical sensations. The periods of clarity of consciousness are shortened, motor restlessness increases, attention becomes unstable, the affective state easily changes.
All neurological symptoms, like psychopathological ones, are characterized by instability. Usually, the severity of neurological symptoms precedes the appearance of hallucinatory clouding of consciousness.

Debuts of delirium tremens.

In about a third of all observations, delirium tremens debuts with the appearance of verbal hallucinations that determine the mental state for several hours. Verbal deceptions sometimes very quickly acquire features characteristic of extensive verbal hallucinosis. At the same time, a tendency to systematize ideas of persecution, instrumental observation, physical impact is noted. The subject of delirium is closely related to the content of verbal hallucinations. People suffering from delirium tremens may not say anything about the content of the voices because of their offensive and unpleasant content, which often touches on the most intimate aspects of life. Intense hallucinations are accompanied by a change in consciousness, as evidenced by amnesia of experiences. Everything that is heard seems so real that people suffering from delirium tremens use the word "saw" rather than "heard" to describe scenes of executions or shootings of people. The content and nature of auditory deceptions are distinguished by a number of features rarely encountered in alcoholic hallucinosis. The content of the voices is often divorced from reality, bears the imprint of fantasy. Behavior is characterized by insufficient motivation for actions, the desire to carry out hallucinatory "orders". This is primarily where the delirious coloring of verbal hallucinosis is manifested. The depth of clouding of consciousness can be such that people suffering from delirium tremens amnesia for quite long periods of time when they were talking to someone,listened, threw out remarks, made comments, gesticulated, tried to arm themselves, protested.

Delirium tremens can debut with the appearance of visual hallucinations against the background of intact orientation in time and a specific-objective environment. In these cases, already at the end of the binge, frightening dreams with scenes of pursuit, attacks by animals appear. Visual hypnagogic hallucinations can appear on the first night after the end of the binge. They are combined with fear or anxiety. During the daytime, distractibility and forgetfulness increase, and those suffering from delirium tremens attract attention with their stupidity and fussiness. The emotional state becomes unstable: a good-natured, elevated mood easily gives way to an anxious, fearful one. By the evening, deceptions of perception occur with the eyes open. They can be projected onto smooth surfaces. People with delirium tremens see a “movie on the wall” or on the ceiling, watch a concert taking place in the yard. The appearance of scene-like or even panoramic hallucinations is not accompanied by a disturbance of orientation in a specific, objective environment for some time. People with delirium tremens know where they are, name the date and time of day. At the same time, they see crowds of people at stores, dogs, dwarfs who have entered their apartment, threads, ribbons, and wires hanging from the ceiling. Hallucinations of the oral cavity may occur at the same time. Under delirium tremens, people feel films, wire, fish scales, hair, threads, and seeds stuck in their throats. Deceptions of perception are assessed as reality. There is no surprise about strangers penetrating through a wall, or about a large number of small animals or strange creatures appearing in a room. Under delirium tremens, people catch animals, drive out dwarfs, crush and throw out worms and insects, pull things out of their mouths, and spit them out. True visual hallucinations can be combined with ideas of persecution and staging. People with delirium tremens feel as if a movie is being filmed in their apartment and that they are actively participating in it. The “events” unfolding in the apartment may not be threatening, but the hallucinations are accompanied by alertness and anxiety. What is happening is assessed by drinkers as someone’s tricks, mischief, or hooliganism. People with delirium tremens see a train wreck on the roof of a neighboring house, inflatable rubber dummies next to them, and photographs and portraits are “slipped” into their windows. This is regarded as a hint of an impending massacre, mockery. The stage of oriented delirium can last several hours.

The onset of delirium tremens with the appearance of delusional ideas of persecution is most often observed during the development of alcoholic psychosis during a train journey, at a train station, at an airport. In connection with the appeal for help and the wrong behavior of drinkers, they are hospitalized. Then there is a clouding of consciousness with an influx of auditory and visual hallucinations.
About 12% of drinkers, the onset of delirium tremens is preceded by one or a series of seizures with loss of consciousness.

Consequences of delirium tremens