Substance-Induced Withdrawal Delirium

Sometimes referred to as the "DTs," "the shakes," or "the horrors," substance-induced withdrawal delirium, or delirium tremens (DTs), are an acute episodic delirium that can prove fatal without proper medical management. DTs can occur during withdrawal from tranquilizers, such as barbiturates and benzodi-azepines, but more commonly occur during alcohol withdrawal induced by a period of abstinence following excessive and habitual alcohol use. DTs are the most severe of the alcohol withdrawal syndromes. The [Page 880]most common symptoms of DTs are confusion, dis-orientation, and agitation. However, symptoms can also include tremors, anxiety and restlessness, irritability, emotional liability, depression, fatigue, clouded thinking, hyperreflexia (overexaggeration of reflexes), heart palpitations and tachycardia (excessively rapid heartbeat), high blood pressure, diaphoresis (excessive perspiration), nausea and vomiting, insomnia, paranoia, visual hallucinations (often insects, snakes, rats, stereotypical "pink elephants"), auditory hallucinations, tactile hallucinations (sensation of something crawling on the skin, called formication), sensitivity to light, sensitivity to sound, sensitivity to touch, fever, and seizures.

The symptoms of DTs result from the chronic effects of alcohol on the brain. Chronic heavy alcohol use sedates the brain by causing a downregulation of the inhibitory neurotransmitter GABA, as well as the upregulation of excitatory neurotransmitters, such as glutamate. Cessation of alcohol use removes its sedating effects and causes the brain to become overly excitable, which, in turn, results in autonomie nervous system arousal and neurotoxicity. Following cessation of alcohol use, withdrawal symptoms may be initially mild but can rapidly worsen. Within 3 to 6 hours following cessation of alcohol use, minor alcohol withdrawal can begin, with symptoms including insomnia, anxiety, tremor, hyperreflexia, hypertension, tachycardia, diaphoresis, nausea, vomiting, and alcohol cravings. Within 24 hours after cessation, major alcohol withdrawal may begin, which can last from 1 to 3 days and include auditory hallucinations, visual hallucinations, anxiety, and hyperactivity. When DTs occur, they occur most often between 3 and 5 hours after cessation of alcohol use. With regard to duration, 62% of episodes last no longer than 5 days, although in some cases they can last much longer.

DTs occur in approximately 5% to 10% of individuals with alcohol dependency and in roughly 5% to 20% of those hospitalized for alcohol withdrawal. It most commonly occurs in people with a history of chronic and excessive alcohol use over many years, for example, consumption of 16 ounces of 80-proof alcohol each day for a period of 10 or more years. However, DTs can occur after heavy use of only a few months duration. It may be triggered by infection, head injury, or another medical illness. Those with a history of alcohol withdrawal may be particularly prone to DTs, as might those with a history of seizure or those who are malnourished.

For an accurate diagnosis of DTs to be made, other similarly presenting conditions should be carefully ruled out. A number of brain disorders have symptoms similar to DTs, including brain tumors (neoplasms), brain infections, and seizure disorders. Endocrine and metabolic disorders can also cause symptoms similar to those of DTs, as can more generalized infection, nutritional deficiency, cardiopulmonary disease, and exposure to toxic agents other than alcohol.

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