Alcohol and Mental Illness
Alcohol related withdrawal psychoses
Delirium tremens
Delirium tremens (DT) is a potentially fatal form of alcohol withdrawal. Delirium tremens is more common in people with a long history of ethanol use and a prior history of significant withdrawal. Manifestations of alcohol withdrawal may start several hours to days after cessation or diminution of alcohol intake. Alcohol withdrawal seizures typically occur 6-48 hours after the last drink. DT usually begins 24-72 hours after cessation or reduction of alcohol use. DT occurs in 5-10% of alcohol-dependent people and carries up to 5% mortality with treatment and up to 35% mortality without treatment.[5]
Delirium tremens (colloquially, the DTs, “the horrors”, “the fear”,”the shakes”, “jazz hands”,”the rats” or “rum fits”; afflicted individuals referred to as “jitterbugs” in 1930s Harlem slang; literally, “shaking delirium” or “trembling madness” in Latin) is an acute episode of delirium that is usually caused by withdrawal or abstinence from alcohol following habitual excessive drinking. Risk factors for developing DTs include coexisting acute illness, long duration of alcohol intake, a large volume of alcohol intake, severe withdrawal symptoms at presentation, prior DTs, prior seizures, prior detoxification, and intense craving for alcohol.
In delirium tremens, the person is initially anxious and later develops increasing confusion, sleeplessness, nightmares, excessive sweating, and profound depression. The pulse rate tends to speed up. Fever typically develops. Other common symptoms include intense fleeting hallucinations such as visions of insects, snakes or rats (or stereotypically, pink elephants or tiny figures). These may be related to the environment, e.g., patterns on wallpaper that the person would perceive as giant spiders attacking him or her. Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, but also are associated with tactile hallucinations such as sensations of something crawling on the subject – a phenomenon known as formication. Objects seen in dim light may be particularly terrifying, and the person becomes extremely confused. The floor may seem to move, the walls fall, or the room rotates. Delirium tremens can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia. As the delirium progresses, the hands develop a persistent tremor that sometimes extends to the head and body, and most people become severely uncoordinated. Delirium tremens can be fatal, particularly when untreated.
Causes
Delirium tremens can occur after a period of heavy alcohol drinking, especially when the person does not eat enough food. It may also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol. It is most common in people who have a history of alcohol withdrawal, especially in those who drink the equivalent of 7 – 8 pints of beer (or 1 pint of “hard” alcohol) every day for several months. Delirium tremens also commonly affects those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years.
Alcoholic Hallucinosis
Alcoholic hallucinosis is a rare complication of alcohol withdrawal in alcoholics. This develops about 12 to 24 hours after drinking stops. This condition is distinct from delirium tremens since it develops and resolves rapidly, involves a limited set of hallucinations and has no other physical symptoms. Symptoms consist of auditory hallucinations, of persecutory or threatening voices), or (most commonly) visual and tactile hallucinations. The person’s conscious awareness is otherwise clear in the early stage, and the person recognises hallucinations. However, in the advanced stage, these hallucinations are perceived as real and may provoke extreme fear and anxiety. The person can be seen pulling at imaginary objects, clothing, and sheets, for example. The risk of developing alcoholic hallucinosis is increased by long-term heavy alcohol abuse and the use of other illicit drugs. As many as 25% of patients with a prolonged history of alcohol abuse have alcoholic hallucinosis. Hallucinosis is not necessarily followed by delirium tremens.
Alcohol-related psychosis
Alcohol-related psychosis is a secondary psychosis with predominant hallucinations occurring in many alcohol-related conditions, including acute intoxication, withdrawal, after a major decrease in alcohol consumption, and alcohol idiosyncratic intoxication. Alcohol-related psychosis is often an indication of chronic alcoholism; thus, it is associated with medical, neurological, and psychosocial complications. Alcohol-related psychosis spontaneously clears with discontinuation of alcohol use and may resume during repeated alcohol exposure. Although distinguishing alcohol-related psychosis from schizophrenia through clinical presentation often is difficult, it is generally accepted that alcohol-related psychosis remits with abstinence, unlike schizophrenia. If persistent psychosis develops, diagnostic confusion can result. Comorbid psychotic disorders, e.g., schizophrenia and bipolar affective disorder, may exist, resulting in the psychosis being attributed to the wrong aetiology. The appearance of alcohol-related psychosis occurs with long-term alcohol abuse; therefore, it is associated with the same morbidity and mortality of long-term alcoholism. Prognosis with treatment is considered good, with only 10-20% of psychosis cases becoming chronic.
Alcohol-related psychosis may indicate undiagnosed schizophrenia or other psychotic disorders. The use of alcohol may potentiate or initiate psychosis through “kindling,” a process where repetitive neurological insult results in greater expression of the disease.
Alcohol idiosyncratic intoxication
Alcohol idiosyncratic intoxication is an unusual condition that occurs when a small amount of alcohol produces intoxication that results in aggression, impaired consciousness, prolonged sleep, transient hallucinations, illusions, and delusions. These episodes occur rapidly, can last from only a few minutes to hours, and are followed by amnesia. Alcohol idiosyncratic intoxication often occurs in elderly persons and those with impaired impulse control.
Wernicke’s encephalopathy
Wernicke’s encephalopathy is a brain disorder caused by a lack of thiamine (vitamin BI). Lack of thiamine is a common condition amongst heavy drinkers due to poor diet and/or frequent vomiting, both of which deplete vitamin stores. The onset of Wernicke’s can be quite sudden, in some cases within hours, and needs emergency hospital treatment. The condition can be treated by large doses of thiamine by intravenous or intramuscular injection.
The symptoms can be easy to miss and in some cases are mistaken for simple drunkenness. They include:
- Confusion about the time or place
- Drowsiness
- Poor balance
- Double vision (this is a key indicator)
- Abnormal eye movement or paralysis of eye muscles
It has been reported that 20% of people who develop Wernicke’s encephalopathy die as a result of the condition and that 80% of survivors go on to develop Korsakoffs psychosis. Autopsies often reveal undiagnosed cases of the condition (19 – Thompson, 1997).
Korsakoff’s psychosis
If Wernicke’s encephalopathy is left untreated, Korsakoff’s psychosis can develop. It is signified by profound memory loss, affecting both the ability to recall events and to form new memories. Korsakoff patients often fill out their memory gaps with elaborate fantasies, a process known as confabulation. This state may be treatable by prolonged thiamine treatment and abstention from alcohol, but improvement is seen in only about a third of cases. Korsakoff’s psychosis can develop without Wernicke’s encephalopathy.
Wernicke’s encephalopathy and Korsakoff’s psychosis are related but separate disorders. Post-mortem studies suggest that Wernicke-Korsakoff syndrome occurs in about 2% of the general population and 12.5% of dependent drinkers (20 – Cook, 1997).
Alcoholic dementia
Patients clinically defined as alcohol dependent may also suffer more generalised brain damage. Even when general intelligence appears intact, brain scans can show loss of brain tissue and mental tests may reveal specific abnormalities in abstract reasoning, learning new skills and coping with complex visuo-spatial problems. These changes often improve with abstinence. Although known as alcoholic dementia this condition has no link to progressive diseases such as Alzheimer’s disease.
