A unique feature of this alcoholic psychosis is its evolution, in a small proportion of the patients, to a state of chronic auditory hallucinosis. The chronic disorder begins like the acute one, but after a short period, perhaps a week or two, the symptomatology begins to change. The patient becomes quiet and resigned, even though the hallucinations remain threatening and derogatory. Ideas of reference and influence and other poorly systematized paranoid delusions become prominent. At this stage the illness may be mistaken for paranoid schizophrenia and indeed was so identified by Bleuler. There are, however, important differences between the two disorders: the alcoholic illness develops in close relation to a drinking bout and the past history rarely reveals schizoid personality traits. Moreover, alcoholic patients with hallucinosis are not distinguished by a high incidence of schizophrenia within their families (Schuckit and Winokur; Scott), and a large number of such patients, whom our colleagues Victor and Adams evaluated long after their acute attacks, did not show signs of schizophrenia. There is some evidence that repeated attacks of acute auditory hallucinosis render the patient more susceptible to the chronic state.
In the setting of alcohol withdrawal either as relative or absolute abstinence following a period of chronic inebriation, convulsive seizures are common. More than 90 percent of withdrawal seizures occur during the 7to 48-h period following the cessation of drinking, with a peak incidence between 13 and 24 h. During the period of seizure activity, the EEG is usually abnormal, but it reverts to normal in a matter of days, even though the patient may go on to develop delirium tremens. During the period of seizure activity and for days afterward, the patient is unusually sensitive to stroboscopic stimulation; almost half the patients respond with generalized myoclonus or a convulsive seizure (photoparoxysmal response).
Seizures occurring in the abstinence period have a number of other distinctive features. There may be only a single seizure, but in the majority of cases the seizures occur in bursts of 2 to 6 over a day, occasionally even more; only 2 percent of patients studied by Victor (1968) developed status epilepticus. The seizures are generalized and convulsive. Focal seizures should always suggest the presence of a focal brain lesion (most often traumatic) in addition to the effects of alcohol. Twenty-eight percent of Victor’s patients with generalized withdrawal seizures went on to develop delirium tremens (see Victor, Adams and Collins, the percentage has been less in other series); almost invariably, the seizures preceded the delirium. The postictal confusional state may blend imperceptibly with the onset of the delirium, or the postictal state may have cleared over several hours or even a day or longer before the delirium sets in. Seizures of this type typically occur in a patient whose drinking history has extended over a period of many years and must be distinguished from other forms of seizures that have their onset in adult life. The term rum fits, or whiskey fits—the names sometimes used by alcoholics—is reserved for seizures with the attributes described here. This serves to distinguish them from seizures that occur in the interdrinking period, long after withdrawal has been accomplished.
It is important to note that the common idiopathic or posttraumatic forms of epilepsy are also influenced by alcohol. In these types of epilepsy, a seizure or seizures may be precipitated by only a short period of drinking (e.g., a weekend, or even one evening of heavy social drinking); perhaps unsurprisingly in these circumstances, the seizures occur not when the patient is intoxicated but usually the morning after, in the “sobering-up” period. Except for the transient dysrhythmia in the withdrawal period, the incidence of EEG abnormalities in patients who have had rum fits is no greater than in normal persons, in sharp contrast to the EEGs of nonalcoholic patients with recurrent seizures.
Treatment and Prevention of Withdrawal Seizures