Contributor: Travis Barlock MD

Educational Pearls:

• Alcohol binds the GABA receptor, which produces an inhibitory response, hence the "depressive" effects of ethanol beverages.

• Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures.

• Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake.

• The awake dream-like state of delirium tremens (DT) differs from alcohol hallucinosis

• Alcohol hallucinosis presents with visual hallucinations in a wakeful state

• DT presents with a generalized clouding of the sensorium and a dream-like state

• Treatment for DT is better achieved with phenobarbital due to predictable pharmacology

• Phenobarbital acts on GABA and NMDA receptors

References

1. Davies M. The role of GABAA receptors in mediating the effects of alcohol in the central nervous system. J Psychiatry Neurosci. 2003;28(4):263-274.

2. Fujimoto J, Lou JJ, Pessegueiro AM. Use of Phenobarbital in Delirium Tremens. J Investig Med High Impact Case Reports. 2017;5(4):4-6. doi:10.1177/2324709617742166

3. Walker, M. Chapter 13: iPads, Factory Whistles, and Nightcaps In: Walker, M, Why We Sleep. Scribner; 2017, pg. 272.

4. Zarcone V. Alcoholism and sleep. Adv Biosci. 1978;21:29-38.

Summarized & Edited by Jorge Chalit, OMSII