Medical students from the universities of Liverpool and Lancaster, under the guidance of Dr Jane Wilcock and Mr Nick Mullin, provide an A-Z of unusual psychiatric conditions that GPs might encounter. Illustrations by Grace Mutton
12. Delirium tremens
Delirium tremens (DT) is an uncommon but severe complication of acute alcohol withdrawal occurring in approximately 5% of cases.1,2 ICD-10 defines the syndrome of alcohol withdrawal as any three of the following: tremor, sweating, nausea/vomiting, tachycardia, psychomotor retardation, headache, insomnia, malaise/weakness, transient hallucinations, grand mal seizures.3 DT is a medical emergency that can occur anywhere between 1-8 days after the patient’s last ingestion of alcohol, but there is usually a peak around 48hrs.4 Alongside the symptoms of an uncomplicated withdrawal syndrome, DT presents with an acute, global confusional state (hence ‘delirium’) with many psychological symptoms (clouded consciousness, fluctuating disorientation, delusions, illusions, hallucinations – often auditory, tactile or ‘liliputian’).5 Loss of insight and amnesia are common and differentiates DT from alcoholic hallucinosis.1,5 There are also somatic symptoms of DT, such as marked tachycardia, hyperthermia and cardiac arrhythmias which may prove fatal.
The first descriptions of DT hail back to Hippocrates, in which he described a man by the name of Chaerion, who was grasped by fever, rigors and incomprehensible speech on day four of abstinence after a ‘drinking-bout’.6 It took Chaerion 20 days to become completely symptom free.
The pathophysiology of DT is thought to be due to the chronic effects of ethanol on the CNS, i.e. increased inhibitory effect (via GABA-receptor stimulation), decreased stimulatory effect (via glutamate-receptor inhibition). As a tolerance develops, the patient requires more alcohol to achieve the same euphoric effects that a non-alcohol dependent person would otherwise experience. An abrupt abstinence from this ‘tolerance state’ reveals that the previously ‘inhibited’ glutamate-receptors have been upregulated and GABA-receptors downregulated, therefore the excitatory tone of the patient is now increased.5,4 It’s somewhat unsurprising that risk factors for DT relate to a prolonged history of drinking, age, previous history of DT.4 The rationale behind treatment is to allow the discordance between the regulation of GABA and glutamate receptors to resolve themselves slowly over time. Benzodiazepines such as oral lorazepam or parenteral lorazepam/haloperidol (which act on GABA-receptors) play a role by allowing a slow alcohol detoxification without any acute side effects.7,5 Other forms of treatment are thiamine (vitamin B1), glucose and propranolol for nutritional and somatic symptomatic relief respectively.5
1. Semple D, Smyth R. Oxford Handbook of Psychiatry. 3RD ed. Oxford: Oxford University Press; 2013
2. Schuckit M. N Engl J Med. 2014;371(22):2109–13
3. World Health Organisation. ICD-10 classification of Mental and Behavioural Disorders. Edingburgh: Churchill Livingstone; 1994
4. Hoffman RS, Weinhouse GL. https://www-uptodate-com.liverpool.idm.oclc.org/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=search_result&search=delirium tremens&selectedTitle=1~89 (accessed 03/06/2017)
5. Mainerova B, Prasko J, Latalova K, Axmann K, Cerna M, Horacek R, et al. Biomed Pap. 2015;159(1):44–52
6. Rodriguez Porcel FJ, Schutta HS. J Hist Neurosci. 2015;24(4):378–95.
13. Dhat syndromeGeorge Reid
Dhat syndrome describes the preoccupation and anxiety associated with perceived excess semen loss. It is a culture-bound syndrome, almost exclusively described by young males who are often single and come from a rural, uneducated upbringing.1 It is largely found in the Indian subcontinent, with cases commonly found in India and Sri Lanka.2
The cause of the semen loss has been attributed to a variety of different causes, some biological, such as loss through urination, urinary tract infections and masturbation. Other causes are more psychosocial in nature, including monetary concerns, poor company and disturbed sleep.1 In cultures where Dhat syndrome is prevalent, semen, alongside blood and bone marrow, is described as ‘Dhatus’, which approximately translates to ‘a fluid which is of fundamental importance to body’.
Imbalance in the ‘Dhatus’ is believed to be detrimental to the person’s health, leading to vague generalised symptoms associated with Dhat syndrome.1,2 Tiredness, anxiety, depression, weakness and sexual dysfunction are regularly reported and some sufferers even believe Dhat syndrome will lead to a reduced life expectancy and cause teratogenic effects in their unborn children.2
1. Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting. Indian Journal of Psychiatry. 2016;58(2):129-41.
2. Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R. Dhat Syndrome: A Systematic Review. Psychosomatics. 2013;54(3):212-8.
14. Diogenes syndromeShanju Rai
Diogenes, 4th century Greek philosopher, whose beliefs were: ‘life according to nature’, ‘self-sufficiency’, ‘freedom from emotion’, ‘lack of shame’, ‘outspokenness’, and ‘contempt for social organisation’ is the reference for the nomenclature of Diogenes syndrome.1,2 Diogenes syndrome is a reference to the isolation and rejection of the outside world and its material possessions practised by the philosopher, Diogenes. However, the syndrome differs from the philosophy as it incorporates refusal or rejection of help from the world as its foundation, rather than rejecting the world and its material possessions like the philosopher.1
This syndrome creates irrational relationships with:
- Society – refusal or rejection of help
- Body – extreme self-neglect
- Objects – hoarding (syllogamania).
These unreasoned relationships eventually lead to social isolation, physical illness and hoarding an excessive amount of possessions that are valueless to others.1,2,3
The main ‘symptom’ is the refusal or rejection of help. This makes it distinct from hoarding, which is often used interchangeably with Diogenes.
It is associated with social isolation, not wanting/seeking help or refusing help, psychiatric illnesses like chronic psychotic illness, OCD, alcohol abuse, dementia with frontotemporal and frontal lobe dysfunction. There may be varied pre-morbid personality traits; being unfriendly, aloof, stubborn, aggressive, compulsivity, paranoia etc.1,3 Over the years, Diogenes syndrome has been referred to as ‘senile breakdown’, ‘social breakdown’, or ‘senile squalor syndrome’.1,2 However, the much-debated terminology Diogenes is still used more frequently over others.
1. Browne, D., Hegde, R. Diogenes syndrome: Patients living with hoarding and squalor. Progress in Neurology and Psychiatry 2015; 19(5)
2. Lavigne B, Hamdan M, Faure B, Merveille H, Pareaud M, Tallon E, Bouthier A, Clément JP, Calvet B. Diogenes syndrome and Hoarding disorder: Same or different?. L’Encéphale 2016; 42(5)
3. Catherine Oppenheimer. Oxford Textbook of Old Age Psychiatry, 2nd ed. : Oxford University Press; 2013.
15. Ekbom syndromeShanju Rai
Ekbom Syndrome, named after the Swedish neurologist Karl-Axel Ekbom,1 is also known as delusional parasitosis or delusional infestation.2 It commonly affects middle aged females and people who have cognitive, psychiatric disorders.1 Some neuroimaging studies have identified that the putamen maybe involved.3
It is a psychiatric disorder where the person has a fixed false belief that he/she is infested with small living organisms in the skin, such as bugs, parasites or insects.1-4 The person has tactile hallucinations and can also have visual hallucinations of the organisms.2,4 Differentials might be:
- Actual parasitosis, where the person is infested with an organism, e.g. scabies or demodex mites etc., and can be proven with lab tests
- Insect phobias, where the patient has an irrational fear of insect bites or infestation occurring; the patient with Ekbom’s believes that they are already infested.1
It is a delusion as the belief that they are infested with these organisms is unshakeable and cannot be altered, even with evidence.2 Due to this, patients often seek help from various specialists such as physicians, entomologists, dermatologists, psychiatrists etc.2 The delusional nature of this syndrome requires neuroleptic medications, such as those used in schizophrenia.2
1. Ekbom’s syndrome II, available at: http://www.whonamedit.com/synd.cfm/2338.html (Last accessed 21/02/2017)
2. Hinkle NC. Ekbom Syndrome: The Challenge of “Invisible Bug” Infestation. Annual Review of Entomology 2010. 55
3. Bhatia MS, Gautam P, Kaur J. Ekbom syndrome occurring with multi infarct dementia. Journal of Clinical and Diagnostic Research 2015. 9(4)
4. Kimsey LS. Delusional infestation and chronic pruritus: A review. Acta Dermato-Venereologica 2016: 96(3): 298-320.