Delirium tremens (Latin for "shaking frenzy", also referred to as The DTs, "the horrors" or "the shakes.") is an acute episode of delirium that is usually caused by withdrawal from alcohol, first described in 1813.^[1][2] Benzodiazepines are the treatment of choice for delirium tremens (DT).^[3]

Withdrawal from sedative-hypnotics other than alcohol, such as benzodiazepines, or barbiturates, can also result in seizures, delirium tremens, and death if not properly managed. Withdrawal from other drugs which are not sedative-hypnotics such as caffeine, cocaine, etc. do not have major medical complications, and are not life-threatening.^[4] Withdrawal reactions as a result of physical dependence on alcohol is the most dangerous and can be fatal. It often creates a full blown effect which is physically evident through shivering, palpitations, sweating and in some cases, convulsions and death if not treated.^[5]

When caused by alcohol, it occurs only in patients with a history of alcoholism. Occurrence of a similar syndrome due to benzodiazepines does not require as long a period of consistent intake of such drugs.

In the U.S., fewer than about 50% to 60% of alcoholics will develop any significant withdrawal symptoms upon cessation of alcohol intake, and of these, only 5% of cases of acute ethanol withdrawal progress to DT.^[1] Unlike the withdrawal syndrome associated with opiate dependence, DT (and alcohol withdrawal in general) can be fatal. Mortality was as high as 35% before the advent of intensive care and advanced pharmacotherapy; in the modern era of medicine, death rates range from 5-15%.^[1]

Similar hyperirritability and hallucinosis can be caused by magnesium deficiency.^[6]

Symptoms[link]

The main symptoms of Delirium Tremens are confusion, diarrhea, insomnia, nightmares, disorientation and agitation and other signs of severe autonomic instability (fever, tachycardia, hypertension).^[7] These symptoms may appear suddenly but can develop 2–3 days after cessation of drinking heavily with its highest peak/ intensity on the fourth or fifth day.^[8] Also, these "symptoms are characteristically worse at night".^[9] Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, or rats. These may be hallucinations, or illusions related to the environment, e.g., patterns on the wallpaper or in the peripheral vision that the patient falsely perceives as a resemblance to the morphology of an insect. Unlike hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, in the peripheral field of vision, but are also associated with tactile hallucinations such as sensations of something crawling on the subject — a phenomenon known as formication. Delirium Tremens usually includes extremely intense feelings of "impending doom". Severe anxiety and feelings of imminent death are symptomatic of DT.

DT can sometimes be associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia. Confusion is often noticeable to onlookers as patients will have trouble constructing simple sentences or making basic logical calculations. In many cases, people who rarely speak out of turn will have an increased tendency for gaffes even though they are sober.

DT should be distinguished from alcoholic hallucinosis, the latter occurring in approximately 20% of hospitalized alcoholics and not carrying a significant mortality. In contrast, DT occurs in 5–10% of alcoholics and carries up to 15% mortality with treatment and up to 35% mortality without treatment.^[2] DT is characterized by the presence of altered sensorium; that is, a complete hallucination without any recognition of the real world. DT has extreme autonomic hyperactivity (high pulse, blood pressure, and rate of breathing), and 35-60% of patients have a fever. Some patients experience seizures.

Causes[link]

Delirium tremens is mainly caused after a long period of drinking, being stopped abruptly and experiencing withdrawal, leading to the biochemical regulation cascade. It may also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol. Yet another cause of delirium tremens is abrupt cessation of tranquilizer drugs of the barbiturate or benzodiazepine classes in a patient with a relatively strong addiction to them.

Because these tranquilizers' primary pharmacological and physiological effects stem from their manipulation of the GABA chemical and transmitter somatic system, the same endogenous neurotransmitter system affected by alcohol, delirium tremens can occur upon abrupt cessation of dosage in heavily dependent patients. These DTs are much the same as those caused by alcohol and so is the attendant withdrawal syndrome of which they are a manifestation. That is the primary reason benzodiazepines are such an effective treatment for DTs, despite also being the cause of them in many cases. Because ethanol and tranquilizers such as barbiturates and benzodiazepines function as positive allosteric modulators at GABAA receptors, the brain, in its desire to equalize an unbalanced chemical system, triggers the abrupt cessation of the production of endogenous GABA. This cessation becomes more and more marked as the addiction becomes stronger and as higher doses are needed to cause intoxication. In addition to having sedative properties, GABA is an immensely important regulatory neurotransmitter that controls the heart rate, blood pressure, and seizure threshold among myriad other important autonomic nervous subsystems.

Delirium tremens is most common in people who have a history of alcohol withdrawal, especially in those who drink the equivalent of 7 to 8 US pints (3310–3790 ml or 5.83–6.66 imp pt) of beer or 1 US pint (473 ml or 16.65 imp fl oz) of distilled beverage daily. Delirium tremens also commonly affects those with a history of habitual alcohol use or alcoholism that has existed for more than 10 years.^[10]

The exact pharmacology of ethanol is not fully understood; however, it is theorized that delirium tremens is caused by the effect of alcohol on GABA receptors. Constant consumption of alcoholic beverages (and the consequent chronic sedation) causes a counterregulatory response in the brain in attempt to regain homeostasis.

This causes downregulation of these receptors, as well as an up-regulation in the production of excitatory neurotransmitters, primarily glutamate, and also such as norepinephrine, dopamine, epinephrine, and serotonin, all of which further the drinker's tolerance to alcohol. When alcohol is no longer consumed, these down-regulated GABA_A receptor complexes are so insensitive to GABA that the typical amount of GABA produced has little effect; compounded with the fact that GABA normally inhibits action potential formation, there are not as many receptors for GABA to bind to — meaning that sympathetic activation is unopposed. This is also known as an "adrenergic storm"; the effects of which can include (but are not limited to) tachycardia, hypertension, hyperthermia, hyperreflexia, diaphoresis, heart attack, cardiac arrhythmia, stroke, anxiety, panic attacks, paranoia, and agitation.

This is all made worse by excitatory neurotransmitter up-regulation, so not only is sympathetic nervous system over-activity unopposed by GABA, there is also more of the serotonin, norepinephrine, dopamine, epinephrine, and particularly glutamate. Excitory NMDA receptors are also up-regulated, contributing to the delirium and neurotoxicity (by excitotoxicity) of withdrawal. Direct measurements of central norepinephrine and its metabolites are in direct correlation to the severity of the alcohol withdrawal syndrome.^[11] It is possible that psychological (i.e., non-physical) factors also play a role, especially those of infections, malnutrition, or other underlying medical disorders, often related to alcoholism.

Treatment[link]

Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines. High doses may be necessary to prevent mortality.^[12] Pharmacotherapy is symptomatic and supportive. Typically the patient is kept sedated with benzodiazepines, such as diazepam (Valium), lorazepam (Ativan), chlordiazepoxide (Librium), or oxazepam (Serax) and in extreme cases low-levels of antipsychotics, such as haloperidol or even stronger benzodiazepines like temazepam (Restoril) or midazolam (Versed) until symptoms subside. Older drugs such as paraldehyde and clomethiazole were the traditional treatment but these have now largely been superseded by the benzodiazepines, although they may still be used as an alternative in some circumstances. Acamprosate is often used to augment treatment, and is then carried on into long term use to reduce the risk of relapse. If status epilepticus is present, seizures are treated accordingly. Controlling environmental stimuli can also be helpful, such as a well-lit but relaxing environment to minimize visual misinterpretations such as the visual hallucinations mentioned above.

In the media[link]

• Writer Jack Kerouac details his experiences with delirium tremens in his book Big Sur.^[13]
• In the 1945 film The Lost Weekend, an alcoholic writer, played by Ray Milland, is admitted to a hospital's alcoholic ward in the throes of delirium tremens.
• In the 1962 film Days of Wine and Roses, public relations man Joe Clay (played by Jack Lemmon) is committed to a sanitorium twice. In the first instance, he is held in a straitjacket and in a padded room while experiencing delirium tremens. In the second instance, Joe is committed after breaking into a liquor store and afterwards wakes in the sanitorium, strapped down to a table and sweating profusely, whereupon his Alcoholics Anonymous sponsor Jim Hungerford (played by Jack Klugman) informs him that "For two days there was a little green man chasing you around with pruning shears."
• In the 2003 film The Last Samurai, Nathan Algren (Tom Cruise), a disenchanted ex-United States Army captain and an alcoholic, who is traumatized by his experience fighting in the Civil War and the Indian Wars, is treated by the Hirotaro family in the throes of delirium tremens after being captured in battle with samurai troops led by Katsumoto.
• In the film Leaving Las Vegas, the main character, Ben Sanderson (Nicolas Cage), suffers from the DTs after a drinking binge, and rushes to his liquor supply to prevent them from continuing.
• In the novel L'Assommoir (1876), by French author Emile Zola, the husband of the heroine Gervaise, an alcoholic roofer named Coupeau, succumbs to delirium tremens in a Parisian hospital.
• Ethan Thomas, protagonist of the video game Condemned 2, has become an alcoholic since the events of the previous game and must regularly consume whiskey to prevent the violent shaking of his delirium tremens from spoiling his aim.
• The protagonist of Malcolm Lowry's 1947 novel Under the Volcano suffers from delirium tremens.
• In M*A*S*H episode Bottoms Up, an alcoholic nurse gets delirium tremens.
• In Everything Must Go (film), the character Nick Halsey (played by Will Ferrell) suffers from delirium tremens in the movie.

See also[link]

• Alcohol dementia
• Alcohol detoxification
• Delusional parasitosis
• Excited delirium

References[link]

External links[link]

Psychiatry portal

• MedlinePlus Encyclopedia Delirium Tremens
• Delirium Tremens (DTs) at eMedicine

v t e Alcohol and health Dependency prevention Sobriety Teetotalism Alcoholics Anonymous Temperance movement Alcohol detoxification Alcohol rehabilitation Alcohol limitation Recommended maximum intake of alcoholic beverages Alcohol anti-addictive entheogens Cannabidiol (CBD) (neuroprotection) Cannabis sativa (speculative) Ibogaine Salvia divinorum Alcohol and religion Christianity and alcohol (alcohol in the Bible) Islam and alcohol Prohibition Social issues Driving under the influence Binge drinking (0.08 BAC) Domestic violence French paradox Neurotoxin American Indian alcoholism Conditions digestive system Alcoholic liver cirrhosis Fatty liver Alcoholic hepatitis Alcoholic liver disease Gastritis Pancreatitis nervous system Delirium tremens Alcohol dementia Alcoholic hallucinosis Blackout (alcohol-related amnesia) Wernicke-Korsakoff syndrome cardiovascular system Alcohol and cardiovascular disease Alcoholic cardiomyopathy Alcoholic lung disease Disorders Physical dependence (Alcohol dependence, alcohol withdrawal syndrome / post-acute-withdrawal syndrome (PAWS), delirium tremens) Alcoholism (alcohol addiction) Alcohol abuse Alcohol flush reaction Alcohol induced mood disorders Alcohol intoxication Alcoholic psychoses Fetal alcohol syndrome (FAS) / Fetal alcohol spectrum disorder (FASD) Ataxia Diseases Diabetes mellitus type 2 Macrocytosis Interactions Alcohol tolerance Alcohol myopia Aging Breast cancer Cancer Family systems Sex Sleep Weight Short-term effects of alcohol/Long-term effects of alcohol Neonatal abstinence syndrome (NAS) Politics Alcohol law Alcohol prohibition Political parties Prohibition Party Prohibition party (Canada) Scottish Prohibition Party

Christy Moore
Christy Moore in Liverpool Philharmonic , October 2008.
Background information
Birth name	Christopher Andrew Moore
Born	(1945-05-07) 7 May 1945 (age 67)
Origin	Newbridge, County Kildare, Ireland
Genres	Folk, traditional Irish, Pop
Occupations	Musician, songwriter
Instruments	Vocals, guitar, Bodhrán
Years active	1969–present
Associated acts	Planxty, Moving Hearts
Website	http://www.christymoore.com/

Christopher Andrew "Christy" Moore (born 7 May 1945) is an Irish folk singer, songwriter, and guitarist. He is well known as one of the founding members of Planxty and Moving Hearts. His first album, Paddy on the Road (a minor release of 500, although made available again on CD through his website and at gigs in 2010) was recorded with Dominic Behan (brother of Brendan) in 1969. In 2007, he was named as Ireland's greatest living musician in RTÉ's People of the Year Awards.^[1]

Early life[link]

Moore was born in Newbridge, County Kildare, Ireland. He was originally a bank employee who wanted to express himself using traditional music. A bank strike in 1966, which lasted six months (and effectively paralysed Irish commercial life for the duration), resulted in Moore spending considerable time practising music. When the strike ended, Moore had already decided where his passion in life arose, and left the bank for good.^[2]

Musical career[link]

1972 brought his first major release, Prosperous (named after the village of Prosperous, County Kildare, where the album was recorded), which brought together the four musicians who shortly thereafter formed Planxty: Liam O'Flynn, Andy Irvine, and Dónal Lunny. For a time they called themselves "CLAD", an acronym of their names, but soon decided on Planxty.^[2]

After leaving Planxty in 1975, Moore continued on his solo career, reforming his old band on occasion (which he has been doing ever since). He also formed the band Moving Hearts with Lunny and five other musicians in 1980. In 2000 he published his autobiography, One Voice.^[2]

Moore's earlier years of heavy drinking, sleeping dysfunctional hours, continual travelling, and often eating takeaway foods resulted in a decline in health, and several operations. Moore's battle with alcohol, and subsequent heart operations have taken their toll. At the end of the 1990s, Moore was requested to reduce his workload for medical reasons.^[2]

Some of Moore's songs are heavily influenced by drink and the effects of drink. His song "Delirium Tremens" being a good example. Listening to Johnny Mulhern's song "Hard Cases" causes Moore, in his website chat, to recall the Galway drinking scene with local musicians  Mickey Finn, Pete Galligan, Corky and Terry Smith.

On 17 April 2009, Moore released his first new studio album in four years, titled 'Listen' and it was promoted through a series of live gigs.^[3]

In December 2011, Moore released his latest album Folk Tale and made it available on Irish music website IrishCountry.ie

Political and social commentary[link]

Moore is best known for his political and social commentary, which reflects a leftwing Irish Republican perspective, this despite the fact that his mother was a Fine Gael county councillor and parliamentary candidate in Kildare.^[4] He supported the republican H-Block protestors in the 1970s and 1980s with the album H-Block in 1978, the launch of which was raided by the police, and The Spirit of Freedom.^[5] He has also recorded songs by the hunger striker Bobby Sands. However, in 1987 he ceased supporting the military activities of the IRA as a result of the Enniskillen bombing.^[6]

Individual political songs he has performed throughout his career include Mick Hanly's 'On the Blanket' about the protests of republican prisoners, his own 'Viva la Quinta Brigada' about Irish volunteers in the Spanish Civil War and his own 'Minds Locked Shut' about Bloody Sunday in Derry.

Moore has endorsed a long list of left wing support causes, ranging from El Salvador to Mary Robinson in the 1990 Presidential Election.^[2] At Glastonbury Festival in 2005 he sang about the Palestinian solidarity activist Rachel Corrie.

With typical Moore social consciousness, he opened the festival marking Ballymun's inception as Dublin's first Fairtrade Town on 23 November 2006. Ballymun, once synonymous with social deprivation and drug problems, is currently the largest urban regeneration project in northern Europe.

Allusions in his songs[link]

• The former Bishop of Galway, Eamon Casey, is the subject of Martin Egan's song 'Casey' often performed by Moore.
• In 2005, his popular release "Don't Forget Your Shovel" (written by Christie Hennessey) was referenced in a number 1 UK single "The JCB Song" by Nizlopi: "And the engine rattles my bum like berserk. While we're singin, 'Don't forget your shovel if you want to go to work!'" It was further referenced in the video for the same song; as the line is sung, the characters in the JCB pass a shop called "Christie's Shovels".
• In his song "If I Get an Encore" he compares Tulsk to hell,"Mountbellew was like purgatory but Tulsk was just like being in hell". Its a reference to a row that broke during one of his gigs in a Tulsk venue.

Musical style[link]

His solo style includes driving rhythms on guitar and bodhrán as well as slower ballads.

Family[link]

Moore's brother Barry, whose stage name is Luka Bloom, is also a successful singer-songwriter.^[7] His nephew, Conor Byrne, is also an accomplished traditional flautist and tin whistle player, with Christy appearing on his Wind Dancer album.^[8]

Memorable events[link]

An Góilín Surprise[link]

On 6 October 2006 Moore paid a surprise visit to the An Góilín traditional singers' club in Dublin. There, before fifty or so people, Moore took out his guitar (instruments are rarely used in An Góilín, it being a singers' refuge) and sang songs reflective of the Irish language and socially radical culture of the club such as Na Conghailigh, about the deaths of Tomás and Seán Ó Conghaile off Conamara, and Viva la Quinta Brigada, about the role of the Irish fighting with the socialists in the Spanish Civil War.

[edit] Desert Island Discs

In June 2007, Moore was guest on Desert Island Discs, a BBC programme that is often considered an accolade. He selected mainly Irish folk music that had inspired him and spoke of personal and political issues that had shaped his life.

Detention incident, 2004[link]

In October 2004, a story in several news agencies revealed how Moore had been stopped and detained by customs officers at the Welsh port of Holyhead.^[9][10] The article claimed the singer was stopped in his van with his driver, taken into an office and questioned over the lyrics of his songs. The following day in response to The Irish Times article, Moore released a statement saying: "My driver and I were stopped and held for two hours at Holyhead last Monday, under the Prevention of Terrorism Act 2002. My driver and I were held separately in two interrogation rooms. I found the whole experience threatening. I was questioned about the contents of my briefcase." Despite initial reports to the contrary, the singer's van, which was full of musical equipment, was not searched. "I was questioned about lyrics of songs and I was asked a lot of personal questions about members of my family and my children and about my home. At no time was I given any explanation as to why I was being held and interrogated in this manner", he added. He said the fact that Irish people are still being treated this way on their way to Britain is very "saddening". "I had hoped to deal with this matter out of the public domain. But seeing as it has become a news item, I feel the need to offer my side of the story. I found the whole affair quite frightening."^{[citation needed]}

Oxegen[link]

On Sunday 10 July 2011 Moore joined Chris Martin from Coldplay on stage at 2011 Oxegen Festival performing the song "Ride On".

Discography[link]

Solo[link]

• Paddy on the Road (1969)
• Prosperous (1972)
• Whatever Tickles Your Fancy (1975)
• Christy Moore (1976)
• The Iron Behind the Velvet (1978)
• Live in Dublin (1978)
• H Block (1980)
• Christy Moore and Friends (1981)
• The Time Has Come (1983)
• Ride On (1984)
• Ordinary Man (1985)
• The Spirit of Freedom (1986)
• Unfinished Revolution (1987)
• Voyage (1989)
• Smoke and Strong Whiskey (1991)
• King Puck (1993)
• Live at the Point (1994)
• Graffiti Tongue (1996)
• Traveller (1999)
• This is the Day (2001)
• Live at Vicar Street (2002)
• Burning Times (2005)
• Live at The Point 2006 (2006)
• Listen (2009)
• Folk Tale (2011)

With Planxty[link]

• Planxty (1972)
• The Well Below the Valley (1973)
• Cold Blow And The Rainy Night (1974)
• After The Break (1979)
• The Woman I Loved So Well (1980)
• Words and Music (1983)
• Planxty Live 2004 (2004)

With Moving Hearts[link]

• Moving Hearts (1981)
• Dark End Of The Street (1982)

Compilation albums[link]

• High Kings of Tara (Christy Moore, Planxty,..) (1980)
• Nice 'n Easy (1984)
• Aris (Planxty) (1984)
• Christy Moore (Compilation USA) (1988)
• The Christy Moore Collection 1981–1991 (1991)
• Christy Moore Collection Part 2 (1997)
• The Box Set 1964 2004 (2004)

Video[link]

• Christy (1995) 54 mins - Christy reflects on life and career.

DVDS[link]

• Christy Moore Uncovered (2001) 104 mins - features collaborations with Jimmy MacCarthy, Wally Page, Shane McGowan, Sinéad O'Connor and John Spillane.
• Planxty Live 2004 The reunion of the hugely popular and influential group after a 20 year hiatus.
• Christy Moore Live In Dublin 2006 (2006) 143 mins - First time a live solo concert has been recorded and released outside CD format. Filmed over 4 nights in December 2005 and January 2006.
• Christy Moore's Come All You Dreamers - Live At Barrowland (2009) - Filmed in Barrowland in Glasgow featuring Declan Sinnott.

References[link]

External links[link]

• Christy Moore's home page
• Review of a Christy Moore concert in Nottingham November 2007
• Review of a Christy Moore concert in Dublin in 2001
• Christy Moore The Early Years
• 4711ers.org '4711' is a term Christy coined which refers to his online fanbase.