Mechanism of development and main forms
Alcohol-withdrawal psychoses develop in almost a third of patients with chronic alcohol dependence (men experience delirium 4 times more often than women). The main pathogenetic feature is reflected in the prefix «met-» — the psychosis manifests against the background of a pronounced withdrawal syndrome, when the patient has already stopped drinking alcohol.
Three main structures of psychoses are distinguished:
- Alcohol delirium (occurs in the overwhelming majority of cases).
- Alcoholic hallucinosis.
- Alcoholic paranoid psychosis.
The disease runs an acute course and most often ends in complete recovery; however, in severe cases or in the absence of care, a permanent defect—encephalopathy—may develop.
Stages of development of alcohol delirium
Alcohol delirium (delirium tremens) is an illusory-hallucinatory clouding of consciousness. The psychosis develops gradually, which allows the physician to suspect trouble before dangerous behavior occurs.
- Prodromal stage (lasts from a few hours to two days). It develops against the background of increasing withdrawal symptoms: tremor intensifies, sleep is disturbed. Affect is unstable—euphoria alternates with anxiety. The patient is fussy, distractible, and unable to maintain a coherent conversation.
- Second stage (full-blown psychosis). Pareidolic (fantastic) illusions and causeless anxiety appear. Sleep is interrupted, with a kaleidoscope of nightmares. Searching behavior is characteristic: the patient rummages through things, looking for hidden «intruders».
- Peak stage. True visual (less often auditory) hallucinations appear, often forming from real wallpaper patterns or cracks. The themes of perceptual disorders can be zoological (rats, insects), domestic, or fantastic. The patient is completely absorbed by the psychosis and actively participates in hallucinatory scenes.
Clinical features and dynamics
Delirium is characterized by a fluctuating course with a clear circadian rhythm. During the day, behavior becomes more orderly, hallucinations fade, and in the evening and at night, the psychosis sharply worsens.
- Orientation: the patient is disoriented in space and time, but maintains orientation to their own personality.
- Arousal symptom: by persistent addressing, the patient can be briefly pulled out of psychosis and prompted to give correct answers, but upon cessation of contact, they immediately return to the hallucinatory world.
- Induced hallucinations: during lucid intervals, perceptual disorders are easily suggested. Reichardt's symptom — the patient reads text from a blank sheet of paper; Aschaffenburg's symptom — talks on a disconnected telephone.
Physical condition is severe: pronounced tremor, tachycardia, profuse sweating, fever, severe dehydration. Epileptic seizures may occur.
Recovery from psychosis and amnesia
Recovery from delirium occurs critically (suddenly), usually on day 2–5. The patient falls into a deep sleep lasting 10–15 hours. After awakening, hallucinations completely disappear, but pronounced asthenia persists for several days.
Amnesia after psychosis is selective in nature. Real events (e.g., the hospitalization process, medical procedures) often drop out of memory. At the same time, the patient remembers hallucinatory scenes very vividly. Insight into the condition returns gradually: at first, the person may deliriously interpret what happened, but then spontaneously realizes the unreality of the experience.
Briefly: answers to topical questions
What atypical (severe) forms of alcohol delirium exist?
Atypical (severe) forms of alcohol delirium include muttered (mussitant), hyperkinetic, and occupational delirium.
- Mussitant delirium — accompanied by pronounced exhaustion, decreased blood pressure, unintelligible muttering, and small chaotic movements within the bed.
- Hyperkinetic delirium — manifests as extreme chaotic agitation, hyperthermia, arterial hypertension, and impaired coordination; the patient is inaccessible for contact.
- Occupational delirium — characterized by deep clouding of consciousness accompanied by the performance of habitual professional actions and communication with imaginary subordinates.
What are the main clinical differences between alcoholic hallucinosis and alcoholic delirium?
The main clinical difference lies in the state of consciousness and the predominant type of perceptual distortions.
| Sign | Alcoholic hallucinosis | Delirium tremens |
|---|---|---|
| Consciousness and orientation | Consciousness is intact, orientation is preserved | Clouding of consciousness, disorientation in place and time |
| Hallucinations | Predominantly auditory, verbal, true hallucinations; antagonistic hallucinations are possible | Predominantly visual, scenic, combined with pareidolic illusions |
| Delusions | Delusional ideas of persecution may occur | Secondary delusions |
In alcoholic hallucinosis, voices may discuss the patient among themselves in the third person, whereas in delirium, behavior is driven by the content of the hallucinatory scenes.
Which drug classes are used for intensive care and management of alcoholic delirium?
Pathogenetic and symptomatic medications are used for the intensive care and management of alcoholic delirium.
- GABAergic agents—the cornerstone of pathogenetic therapy for agitation control (benzodiazepine tranquilizers, barbiturates, sodium oxybate, zopiclone, zolpidem).
- Antipsychotics—used exclusively as symptomatic agents (e.g., haloperidol) and only in combination with GABAergic drugs; agents with pronounced anticholinergic activity are strictly contraindicated.
- Vitamins—Vitamin B (thiamine) administration is mandatory to prevent the development of encephalopathy.
Parenteral fluid administration for detoxification is also performed.
What is Lippman's sign when testing for induced hallucinations?
Lippmann's sign is a provocative test to detect susceptibility to visual hallucinations. To test for this sign, the physician applies light pressure to the patient's eyeballs over closed eyelids and then asks the patient to describe what they see. This technique is actively used to detect perceptual distortions at the onset of alcoholic delirium.
To avoid confusing induced hallucinations: Reichardt — Drawings (on a blank sheet of paper), Aschaffenburg — Allo (talking on a turned-off telephone).
Class and exam questions
Does delirium tremens occur during severe intoxication?
No. Delirium is an alcohol-induced psychosis. It starts during the recovery from severe intoxication, when ethanol intake stops and withdrawal syndrome develops.
Does the patient remember what happened to them during the psychosis?
Memory is selective. The patient remembers their "persecutors" or frightening visions down to the smallest detail, yet may completely forget real events that occurred in the hospital.
Does a patient with delirium know who they are?
Yes. Unlike some other types of altered consciousness, in alcoholic delirium, orientation to one's own personality is always preserved, even against the background of complete disorientation in place and time.
What else to study on this topic
- Clinical presentation and symptoms of withdrawal syndrome
- Differences between pseudobinges (stage II) and true binges (stage III)
- Changes in alcohol tolerance at different stages of dependence
- Somatic complications and urgent conditions in alcoholism
- Atypical forms: "delirium without delirium" and its clinical features
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