Delirium tremens

Delirium tremens (colloquially, the DTs or, "the shakes") is a condition nearly invariably associated with complete alcohol withdrawal, although it also occurs as a complication of benzodiazepine and barbiturate withdrawal. It only occurs in individuals with a history of constant, long-term alcohol consumption. Delirium tremens typically manifests about 18 to 24 hours after discontinuation of alcohol consumption.

Five percent of acute ethanol withdrawal cases progress to delirium tremens. Unlike the withdrawal syndrome associated with opiate or stimulant addiction, delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35% if untreated, though if treated early, death rates may be as low as 5%.

Symptoms
The symptoms include severe, uncontrollable tremors of the extremities and intense hallucinations (eg, drawings on wallpaper that the patient would perceive as giant spiders ready to attack her or him). Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual.

Causes
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-GABAa-chloride receptor complex for the inhibitory neurotransmitter GABA. Constant consumption of alcoholic beverages down-regulates these receptors; when alcohol is no longer consumed, there are not as many receptors for GABA to bind to.

As GABA normally inhibits action potential formation, fewer receptors mean that sympathetic activation is unopposed.

It is possible that psychological (i.e., non-physical) factors also play a role.

Treatment
Treatment is symptomatic and supportive. Typically the patient is kept sedated with benzodiazepines, such as diazepam (Valium) or oxazepam (Serax) until symptoms subside. If status epilepticus is present, seizures are treated accordingly.