When Alcoholics or Drug Addicts Suffer a Mental Breakdown - Oscar Bamwebaze

According to the Red Pepper newspaper, Tom Nkurungira (Tonku), a drug addict facing murder charges in Uganda, run mad shortly after he was imprisoned. Many Ugandans, and the Red Pepper newspaper, think that he is being haunted by the spirit of his victim. In reality however, Tonku is simply experiencing the withdrawal symptoms of his alcoholism and drug addiction.

When an alcoholic willingly or unwillingly stops drinking, he will experience withdrawal symptoms within 6 to 48 hours and these will peak about 24 to 35 hours after his drink. During this period the inhibition of brain activity caused by alcohol is abruptly reversed. Stress hormones are overproduced and the central nervous system becomes overexcited. Some of the common symptoms of these withdrawals include: Anxiety, Irritability, Agitation, and Insomnia. Some of the more serious symptoms include: extremely aggressive behaviour, fever, rapid heartbeat, changes in blood pressure (either higher or lower), and mental disturbances. Seizures occur in about 10% of adults who are experiencing withdrawal symptoms, and in about 60% of these patients, the seizures are multiple. The time between the first and last seizure is usually 6 hours or less.

In extreme cases, the alcoholic experiences what we call Delirium tremens (DTs). These are withdrawal symptoms that become progressively severe and include altered mental states (hallucinations, confusion, severe agitation) or generalized seizures. DTs are potentially fatal and they are considered to be a medical emergency. They develop in up to 5% of alcoholic patients, usually 2 to 4 days after the last drink, although it may take 2 or more days to peak. It appears that Tonku is experiencing DT’s, and if he doesn’t get the appropriate medical treatment, he may die in prison.

We are also aware of the fact that Tonku was a drug addict, but what we do not know is whether he was taking other drugs apart from marijuana. Depending on what types of drugs he was taking, his condition may be critical. Withdrawal from sedative-hypnotics other than alcohol, such as benzodiazepines or barbiturates can also result in seizures, delirium tremens and death in the absence of proper medical treatment. Withdrawal from other drugs which are not sedative-hypnotics such as opiods, marijuana, cocaine etc. do not have major medical complications and they are therefore not life threatening.

When DT’s are caused by alcohol, they occur only in individuals with a history of chronic alcohol consumption. But occurrence of DT’s due to benzodiazepine does not require as long a period of consistent intake of such drugs. The most dangerous situation is prior use of both benzodiazepines and alcohol which compounds the symptoms. According to a recent study, delirium tremens (and alcohol withdrawal in general) can be fatal. Mortality was found to be as high as 35% before the advent of intensive care and medical treatment. In most cases, the death rates from such DT’s range from 5-15%.

The main symptoms of DT’s are confusion, diarrhoea, disorientation and agitation and other signs of severe autonomic instability (fever, tachycardia, and hypertension). Other common symptoms include intense perceptual disturbance such as visions of insects, snakes, rats, or other scary creatures. These are often hallucinations, or illusions related to the environment. Though similar to the hallucinations associated with schizophrenia, delirium tremens hallucinations are primarily visual, but are also associated with tactile hallucinations such as sensations of something crawling on the subject - a phenomenon known as formication.

Delirium tremens are frequently associated with severe, uncontrollable tremors of the extremities and secondary symptoms such as anxiety, panic attacks and paranoia. The alcoholic will also tend to be in a state of visible confusion because they will have trouble constructing simple sentences or making basic logical calculations.

Delirium tremens (DT) are not the same as alcoholic hallucinations, which occur in approximately 20% of hospitalized alcoholics and which do not carry a significant mortality. In contrast, DT’s occur in 5-10% of alcohol-dependent people and they carry up to 5% mortality with treatment and up to 35% mortality without treatment. The major difference between the two is that DT’s are characterized by the presence of altered sensorium; that is, a complete hallucination without any recognition of the real world.

The treatment of DT’s requires a skilled psychiatrist who is conversant with the illness. Delirium tremens due to alcohol withdrawal are usually treated with benzodiazepines. High doses may be necessary to prevent mortality.  In most cases the patient is kept sedated with benzodiazepines such as diazepam (Valium),lorazepam (Ativan), chlordiazepoxide (Librium), or oxazepam (Serax). In extreme cases the patient may be given low-levels of antipsychotics such as haloperidol, or even stronger benzodiazepines like temazepam (Restoril) or midazolam (Versed) until his symptoms subside.

Older drugs such as paraldehyde and clomethiazole were the traditional treatment but they have now largely been replaced with the benzodiazepines, although they may still be used as an alternative in some circumstances. The seizures have to be treated accordingly and the environment controlled so as to enhance recovery. It is advisable to create a well-lit but relaxing environment to minimise visual misinterpretations such as the visual hallucinations. Strangely, in some cases, an alcohol drip may be prescribed to sedate severe patients, who will then have to be "weaned" off of the alcohol.

 

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