delirium tremens

   Also known as shaking delirium and Saunders-Sutton syndrome. The term delirium comes from the Latin verb delirare, which means to go off the furrow, to derail. The adjective tremens is Latin for trembling or shaking. The expression delirium tremens is used to denote a subtype of " delirium that may occur following the cessation of a prolonged and excessive intake of alcohol, benzodiazepines, barbiturates or other tranquillizers. The term was introduced in 1813 by the British physician Thomas Sutton (1767-1835), who used it to demarcate the concomitant cluster of symptoms from other types of delirium, as well as from other alcohol withdrawal syndromes. The eponym Saunders-Sutton syndrome refers to Sutton and to his Scottish colleague Willam Saunders (1743-1817), who had lectured on the subject, and gave Sutton advice while he was preparing his original paper on the subject. According to the historians of psychiatry Gregory Zilboorg (1890-1960) and George W. Henry (1890-1964), the symptoms characteristic of delirium tremens have been known since prehistoric times, as has their association with alcohol withdrawal. The clinical symptoms of delirium tremens include tremor, tachycardia, tachypnea, either hypertension or hypotension, increased perspiration, an alteration ofbody temperature, gastritis, vomiting, disorientation, hyperkinesis, anxiety, panic attacks, agitation, insomnia, food aversion, confabulations, paranoia, hallucinations, "illusions, "paraesthesias, epileptic seizures, and coma. The hallucinations occurring in the context of delirium tremens are primarily of a "complex visual or "compound nature. They tend to consist of vivid, terrifying images of people, animals (i.e. "zoopsia) or insects that can be felt crawling upon or beneath the skin (i.e. "formication). A special type of visual hallucination described in the context of delirium tremens that can be evoked by the covering of one eye is the "monocular hallucination. As pointed out by the Swiss psychiatrist Ferdinand Morel (1888-1957), many of the " visual illusions (and perhaps also hallucinations) in delirium tremens are associated with the presence of a positive "scotoma, which can be described adequately by the affected individual during sober phases, but which may act as a "point de repère for their development when consciousness is clouded. The symptoms of delirium tremens typically arise several days to a week after the cessation of a prolonged episode of excessive alcohol intake. Without adequate treatment these symptoms may last for several weeks. As noted by 19th-century authors, untreated delirium tremens is always self-limiting, in the sense that it ends either in spontaneous recovery or death. The mortality rate of untreated delirium tremens is estimated to lie between 15 and 40%. Even with adequate treatment, the mortality rate is between 1 and 15%. The pathophysiology of delirium tremens is largely unknown, but it is attributed mainly to the central effects of alcohol on the benzodiazepine-GABAA-chloride receptor complex for the neurotransmitter gamma amino butyric acid (GABA). The high mortality rate is associated primarily with comorbid conditions such as hyperthermia, dehydration, vitamin depletion, electrolyte disturbances, cardiac arrhythmia, cardiac failure, and hepatic coma.

   References

   Cutshall, B.J. (1965). The Saunders-Sutton syndrome: An analysis of delirium tremens. Quarterly Journal of Studies on Alcohol, 25, 423-448.

   David, N.F. (1976). Hallucinations during delirium tremens. Journal ofthe American Medical Association, 235, 1688.

   Madden, J.S. (1995). Substance use disorders. Clinical section.In: A history of clinical psychiatry. The origin and history ofpsychiatric disorders. Edited by Berrios, G.E., Porter, R. London: Athlone.

   Morel, F. (1937). Hallucination et champ visuel. De la texture, de la forme, de la multiplicité, des mouvements que présentent les hallucinations visuelles du delirium tremens. Annales Médico-psychologiques, 95, 742-757.

   Zilboorg, G., Henry, G.W. (1941). A history of medical psychology. New York, NY: W.W. Norton & Company.