Delirium Tremens (DTs):
The Alcohol Withdrawal Syndrome
from Hell

Gary E Cordingley, MD, PhD
Most people have heard of DTs, but how many really know what they are? This
is definitely a condition you'd rather read about than discover the hard way.
Imagine that you're walking along a city sidewalk. You round a corner and suddenly—there in front of you—is a
giant grizzly bear.  What happens next?  You get an adrenaline rush, your heart races, your blood pressure
shoots up, you shake like a leaf, your pupils get large as saucers, your hairs stand on end, you break into a
sweat, and you run like heck. Do you have a strong mental picture of this? Good. Hold that thought; we'll come
back to it.

Delirium tremens, also known as the DTs, is the most serious of several syndromes that can occur when
someone who is physically dependent on alcohol stops drinking. By serious, I mean that people with this condition
can die. Even with hospital treatment the death rate can be 1-5%, but without treatment it could be 20%. Even
convulsive seizures—another alcohol withdrawal syndrome—are less likely to be lethal than the DTs.

Symptoms of DTs typically start 2-4 days after the last drink in someone with prior heavy and prolonged
consumption of alcohol. Earliest signs of DTs can be the three T's—temperature elevation, tremor and
tachycardia (rapid heartbeat). The affected individual can experience anxiety, restlessness, nausea, and
impaired sleep. By the time delirium tremens becomes fully developed, it includes the entire battery of "grizzly
bear" symptoms mentioned above. These occur because a portion of the nervous system responsible for
regulating basic bodily processes, the sympathetic system, jumps into overdrive.

But DTs involve much, much more. The parts of the brain responsible for perception and thought go haywire.
Ordinary lights and sounds seem excessively harsh. The afflicted individual becomes confused, agitated, and
even psychotic. He or she might even fail to identify family members. There is constant and sometimes incoherent
talk. Ordinary components of the environment, like patterns on wallpaper, can be perceived as frightful threats,
like spiders or snakes.

Moreover, hallucinations can occur. These can include terrifying sights, sounds or smells that others in the room
can't detect. In addition, there can be distressing sensations as if the skin is being touched by insects or other
unseen intruders.

At first, the person in DTs might have lucid intervals in which he or she makes appropriate conversation, but then
becomes more continuously inaccessible to questions. Subsequently, the symptoms subside usually in a matter
of days and recovery can even be sudden.

What makes these terrible things occur? The evidence to date suggests that in people with heavy and prolonged
drinking, the brain gets used to alcohol's constant presence, and the normal chatter among brain cells no longer
gets toned down by alcohol like it does in the brains of occasional drinkers. The brains of heavy drinkers
probably accomplish this by reducing the number of locations on brain cells where the natural inhibitory chemical,
GABA (gamma-amino-butyric acid), can act to slow things down.

So what if alcohol is suddenly removed from the picture? In that case, the brain's GABA has fewer locations on
which it can act to put on the brakes. As a consequence, the brain's cells become unmanageably over-active,
and the symptoms of delirium tremens ensue.

DTs are a medical emergency requiring hospitalization, generally in an intensive care unit. The patient needs
intravenous fluids, vitamins, nutrition, and correction of salt-and-water imbalances in the bloodstream. Drugs
known as benzodiazepines are usually administered to relieve the over-excitation of brain cells. The medical team
searches for complications, like infections or irregular heartbeats, that require other treatments. Medical
personnel monitor the patient frequently. Family and friends provide valuable assistance by keeping the patient
calm.

But in delirium tremens the old adage applies—an ounce of prevention is worth a pound of cure. The best case is
the one that doesn't happen. Of course, this doesn't mean that a patient with alcohol dependence should
continue drinking. Rather, it means that professional help should be enlisted in order to withdraw from alcohol
safely.

This begs the question of who has alcohol dependence in the first place. More than one set of yardsticks exist,
but the "CAGE" questionnaire provides a simple and effective screen in which the letters of the word correspond
to each of four questions:

C – Have you ever felt you should CUT down on your drinking?
A – Have people ANNOYED you by criticizing your drinking?
G – Have you ever felt bad or GUILTY about your drinking?
E – Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover (EYE-opener)?

A "yes" answer to one of the four questions raises the possibility of alcohol dependence. A "yes" answer to two of
the questions makes alcohol dependence likely, and help should be requested.


(C) 2005 by Gary Cordingley