AM. J. DRUG ALCOHOL ABUSE, 9(4), pp. 431-434 (1982-83)

Prodromal Syndromes in Delirium Tremens

FRANK MILLER, MD

Department of Psychiatry Payne- Whitney Clinic Cornell University Medical Center New York, New York 10021

ABSTRACT

Three cases of hallucinatory delirium preceded by prodromal symptoms of several months duration are described. The prodromes were reoccurring visual and tactile hallucinations which were misdiagnosed and ascribed to nonalcohol-related illness such as schizophrenia and disorders of mood.

The classical syndrome of delirium tremens when fulminant and complete is unambiguous. Closely related to typical delirium tremens and about as common are the “atypical delirious hallucinatory states” or “incomplete” syndromes [ 11 . Also related but less clearly delineated in the literature are the so-called prodromal (premonitory) syndromes [2]. In this report prodromal syndromes are described and clinical case material presented, for, in the author’s view, these syndromes though common are frequently overlooked and generally are absent from differential diagnostic consideration.

CASE REPORTS

Cizse 1. Kaye was a 49-year-old White woman at the time of her first psychiatric hospitalization. She had been a steady drinker of 15 to 30 oz of

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432 MILLER

ethanol per week for over 10 years. Six months prior to admission she ex- perienced the following symptom. She awoke during the night and saw at her bedroom window “peanut-shaped men huddling together and gesturing to one another.” This experience was recurrent; at first several times per week, then every night without fail. The patient sought psychiatric consultation and was started on diazepam. Fearing she would be hospitalized as a result of the interview, she minimized her alcohol use and denied hallucinations. Three months prior to admission the patient experienced the associated symptom that something or someone was “grabbing” her from behind. Five weeks prior to admission the patient had a serious automobile accident and her alcohol con- sumption decreased dramatically. During treatment in an emergency room for lacerations sustained in the accident, the surgical resident diagnosed the patient as suffering from schizophrenia. One week later she experienced an episode of delirium. Psychiatric hospitalization was being arranged for her when the episode ceased abruptly. She refused admission and returned home. Four weeks later she was hospitalized with the chief complaint that dozens of little men were swarming over her body. She was terrified, disoriented, restless, nauseated, and vomiting.

Case 2. Bea was a 51-year-old White single woman at the time of her first psychiatric hospitalization. She had been a steady drinker of at least 20 oz of ethanol per week all of her adult life. She had been hospitalized on medical units for alcohol detoxification and on one occasion had been given the diagnosis of delirium tremens. One month prior to admission she sought treatment for a dermatologic condition which proved to be self-induced excoriation of her fore- arms and shins. She hinted that “parasites” might be the cause of the problem. On the day of admission she arrived for a scheduled dermatology clinic visit and complained of disturbing sensations in her arms and legs. She was noted to be restless and manifested a fine tremor of her hands and tongue. She was suspicious and argumentative. Psychiatric consultation was sought and hospitalization was arranged. That evening she became restless, agitated, and disoriented. She believed that parasites were under her skin and were driving her insane. By morning she was asymptomatic and had no memory for the preceding night.

Case 3. Carl was a 40-year-old White man at the time of his eighth psychiatric hospitalization. He had been a steady drinker of 30 to 50 oz of ethanol per week throughout his adult life. Three months prior to admission he attempted to reduce his alcohol intake. He had had a recurrence of gastritis and believed that decreasing his consumption of alcohol would speed his recovery. Shortly there- after his sleep was disturbed by the following symptom. He would awake

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PRODROMAL SYNDROMES IN DELIRIUM TREMENS 433

abruptly and see coming toward his head “six to eight large black rocks.” He would “duck” and the rocks would “crash together throwing off sparks and chips.” The patient stated that this would occur three to five times per week, then dis- appear for a week only to reoccur. The patient noted that during these episodes he would sweat profusely. On the day he sought hospital admission, he was ex- hibiting tremor, agitation, restlessness, diaphoresis, nausea, and vomiting. During the first night in the hospital the patient experienced the sudden onset of a terrify- ing hallucinatory delirium involving black rocks, sparks, and smoke lasting three days and ending as abruptly as it started. The patient claimed total amnesia for the epidode.

DISCUSSION

Contemporary textbooks of psychiatry and medicine do not discuss prodromal syndromes [3, 41. Nevertheless prodromal syndromes appear to be common and either are not recognized as such or are considered signs of other illnesses. For ex- ample, during Kaye’s psychiatric hospitalization, records were obtained from the emergency room where she received treatment for lacerations sustained in her auto- mobile accident. These records revealed that the treating resident diagnosed the patient as suffering from schizophrenia based upon her report of recurrent visual hallucinations. This diagnosis was made even though the triage nurse’s notes described the patient as intoxicated. The record of Bea’s visits to the dermatology clinic, though mentioning her chronic alcoholism, did not document that any con- sideration had been given to the possibility that alcoholism was at the basis of her delusional parasitosis.

Prodromes may take the form of visual or tactile hallucinations. Kaye believed that something was “grabbing her from behind.” Bea complained that her arms and legs felt abnormal and that “parasites” were under her skin. Carl saw black rocks crashing together, throwing off sparks and chips.

as distinct from incomplete or atypical delirious hallucinatory states remains to be determined. The contributions of Gross and his associates suggest that a continuum exists which connects the delirious alcoholic psychoses with the hallucinatory alcoholic psychoses [S, 61. Gross postulates the presence of a factor which produces a generalized hallucinogenic effect. This generalized hallucinogenic effect comes into play only after alcohol has produced a metabolic disturbance of neurophysiological activity.

Whether or not the prodromal syndromes described above should be considered

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4 34 MILLER

For the clinician the concept of a distinct prodromal syndrome has value in that it describes a category of alcohol-related illness in which the sensorium is still unclouded and the patient still approachable. In time, prodromes are likely to merge either imperceptibly or abruptly into delirious hallucinatory states. For this reason the recognition of prodromes is imperative. In the final analysis the presence of a prodromal syndrome should be considered when the patient admits to the history of a recurrent visual or tactile hallucination occurring in the context of drinking and in the absence of other indications of functional psychosis.

REFERENCES

Thorn, G., Adams, R., Baunwald, E., Isselbacher, K., and Petersdorf, R. (eds.), Harrison's Principles of Internal Medicine, 8th ed., McGraw-Hill, New York, 1977. Bleuler, E., Textbook of Psychiatry (Translated by A. A. Brill), Dover Publications, New York, 1951. Freedman, A., Kaplan, H., and Sadock, B. (cds.), Comprehensive Textbook of Psychiatry-11, 2nd ed., Williams and Wilkins, Baltimore, 1975. Beeson, P., McDermott, W., and Wyngaarden, J. (eds.), Cecil Textbook of Medicine, 15th ed., Saunders, Philadelphia, 1979. Gross, M., Halpert, E., and Sabot, L., Toward a revised classification of the acute alcoholic psychoses, J. Nerv. Men?. Dis. 145500-508 (1968). Gross, M., Lewis, E., Best, S., Young, N., and Feuer, L., Quantitative changes of signs and symptoms associated with acute alcohol withdrawal: Incidence, severity, circadian effects in experimental studies of alcoholics, Adv. Exp. Med. Biol. 54:615- 631 (1975).

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