Based on Positron Emission Tomography (PET) findings, Soyka, et al .[3] suggested a hypo function of thalamus in alcoholic psychosis. Carl Sherman[4] had described a follow-up study undertaken by Dr. JM Anderson in East Glasgow, where alcohol dependence syndrome (ADS) is known to be particularly severe in the population. Initially 16 of 124 (13%) patients with a diagnosis of ADS had alcoholic hallucinosis of which five had continuous hallucinations. Hallucinations were auditory, distinct and usually in second person. At follow-up after eight years three had deceased, five were abstinent and without psychosis and two were abstinent but had features of schizophrenia. Five were consuming alcohol and had features of alcoholic hallucinosis.

When the neurotransmitters are no longer suppressed, but are used to working harder to overcome the suppression, they go into a state of overexcitement. If you suddenly stop drinking or significantly reduce the amount of alcohol you drink, it can cause alcohol withdrawal.

However, in my opinion, CIWA-Ar is a flawed instrument. CIWA-Ar has at least two major problems and several minor ones. The first major problem with CIWA-Ar is that it does not incorporate the single best objective measure of the severity of alcohol withdrawal -- the heart rate. In my experience, the heart rate corresponds very well to the progression of alcohol withdrawal. Patients with minor withdrawal tend to have normal heart rates -- less than 100. As the severity of withdrawal symptoms worsen, so does the heart rate -- predictably. DT patients have markedly elevated heart rates -- usually well over 150. I would be very concerned by a patient whose heart rate went up from, say, 80 to 110 even if her other subjective symptoms did not change. Heart rate is also an objective measure -- as opposed to the CIWA-Ar scoring measures, which are all subjective.

A 43-year-old DSC soldier with few months of service was referred for psychiatric evaluation in January 2010 by unit authorities in view of his behavioral abnormalities noted since joining the unit. He was found to be gloomy, reclusive, not sleeping and talking to oneself. Evaluation revealed that he was apparently asymptomatic when he retired after 18 year of service in Army (Para Unit) in 2004. He had been consuming alcohol since 1984 and gradually the frequency and quantity increased to 360 ml of rum daily by 1996. He used to have sleep disturbances irritability and tremors on temporarily stopping alcohol consumption.

After leaving the service in 2004, he started consuming about 600 ml of country liquor daily. By 2005, family members noted him to be talking to himself, not taking adequate self care and becoming irritable easily. He complained of hearing voices of family members, even when he was alone, abusing him and threatening him. Initially he used to reply to these voices but gradually started neglecting them. Sometimes he used to see the faces of pervious acquaintances, which used to change in shape and size. He also used to feel as if someone touching and fondling with his genitals. All these things used to disturb him, he was not doing any job and to over come these problems used to drink country liquor regularly. Though his family members got him treated from local doctor, there was no significant improvement.

Alcoholic hallucinosis has been rare in my patients . As taught in the textbooks, alcoholic hallucinosis is a syndrome that begins around 12-24 hours after the last drink and can last for 1 or 2 days. These patients typically see bugs or animals in the room ("pink elephants"). Patients with alcoholic hallucinosis are reportedly not disoriented and have normal vital signs.

You're Wrong About Alcohol Withdrawal.

Onset of delirium tremens doesn't always fit textbook timelines . Emergency Medicine: A Comprehensive Study Guide , for example, says that DTs occur 3-5 days after the last drink. While this may be true in the majority of cases, it is not at all uncommon for my patients to manifest severe alcohol withdrawal much sooner than this and also much later.