History

Fact Explanation
History of recent ingestion of alcohol and disturbances in level of consciousness, behavioural disinhibition, agitation or hyperactivity, sometimes socially withdrawn introverted behaviour, sudden onset of aggression and often violent behaviour that is not typical of the individual when sober etc These are features of acute intoxication. Sedation is seen at very high levels of alcohol ingestion[1]
Continued consumption of alcohol even when there is damage to physical and or mental health(i.e. presence of liver disease, hypertension, myocardial disorders, immune dysfunction, neurological and psychiatric disorders etc. ) This indicates of harmful use[1]
Strong desire or sense of compulsion to take alcohol The patients with alcohol dependence has a very strong desire to take alcohol. This is recognized when patient attempts to stop or control alcohol use. He finds it difficult because of his craving for alcohol[1]
Having difficulties in controlling alcohol taking behaviour This is a symptom of alcohol dependence. The patient finds it difficult to control the onset, termination or the level of alcohol consumption[1]
Presence of physiological withdrawal state This is also a symptom that suggests alcohol dependence. When alcohol consumption has ceased or is reduced, the patient experiences alcohol withdrawal syndrome described below. He consumes alcohol in order to relieve or avoid withdrawal syndrome[1]
Evidence of tolerance to alcohol This also suggests alcohol dependence. When there is tolerance, increased amounts of alcohol is needed to achieve effects originally produced by lower amounts. Asking the patient what is the amount that was taken at the early days when he first started alcohol intake and comparing it with what he takes now, will indicate whether there is tolerance. Tolerant alcohol users may take daily doses sufficient to incapacitate or kill non-tolerant users[1]
Progressive neglect of alternative pleasures or interests because of alcohol consumption The patient increasingly neglects activities that he previously enjoyed and spends most of his day trying to obtain or consume alcohol or to recover from its effects. This symptom is also seen in patients with alcohol dependence[1]
Continuing alcohol use despite clear evidence of overtly harmful consequences Patient may continue to consume alcohol even though he knows that alcohol consumption has caused damage to his health. (e.g. liver damage through excessive drinking, hematemesis, depression etc). This is also a symptom of alcohol dependence. If three or more of the above symptoms of dependence have been present together some time during the previous year, the patient is considered to have dependence syndrome[1]
Presence of symptoms such as anxiety, depression, disorientation and clouding of the sensorium, insomnia, loss of appetite, nausea, vomiting, tremor, sweating, tactile, auditory, and visual disturbances, headache etc and symptoms are relieved by further alcohol use If these symptoms are present the patient is in withdrawal state. If left untreated, alcohol withdrawal can lead to delirium, seizures, and even death[1][2][3]
Clouding of consciousness and confusion, vivid hallucinations and illusions affecting any sensory modality, marked tremor, delusions, agitation, insomnia or sleep-cycle reversal, autonomic overactivity These are features of alcohol-induced delirium tremens. Onset may be preceded by withdrawal convulsions[1][6]
Ophthalmoplegia, nystagmus, ataxia, and delirium with significant spatial and temporal disorientation, confusion, apathy, impaired awareness of the immediate situation, inability to concentrate a agitation, hallucinations, and behavioral disturbances Indicates of Wernicke's encephalopathy (WE) which results from thiamine deficiency. If left untreated may develop Krosakoff's syndrome, coma, death[1][5]
Anterograde and retrograde amnesia, poor recall, impairment of recent memory, confabulation Indicates of Krosakoff's syndrome which is a chronic neurological condition that usually occurs as a consequence of WE[1][5]
Patient presenting with predominant auditory hallucinations, delusions and mood disturbances that occur either during or after a period of heavy alcohol consumption These are the characteristic features of Alcohol induced Psychotic Disorder/Alcoholic hallucinosis which is a rare complication of chronic alcohol abuse[1][7]
History of significant alcohol consumption by the mother during the pregnancy and baby having craniofacial abnormalities such as smooth philtrum, thin vermilion border, short palpebral fissures etc, impaired prenatal and/or postnatal growth, learning or behavioural difficulties These features suggest of fetal alcohol spectrum disorder[1][4]
References
  1. The ICD-10 Classification of Mental and Behavioural Disorders; Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 2 June 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf
  2. MELSON J, KANE M, MOONEY R, MCWILLIAMS J, HORTON T. Improving Alcohol Withdrawal Outcomes in Acute Care Perm J [online] 2014, 18(2):e141-e145 [viewed 21 June 2014] Available from: doi:10.7812/TPP/13-099
  3. BAYARD M, MCINTYRE J, HILL KR, WOODSIDE J (JR), JAMES H. Alcohol Withdrawal Syndrome.Am Fam Physician [online] 2004 Mar 15;69(6):1443-1450[viewed 21 June 2014] Available from; http://www.aafp.org/afp/2004/0315/p1443.html#afp20040315p1443-t3
  4. CHUDLEY AE, CONRY J, COOK JL, LOOCK C, ROSALES T, LEBLANC N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis CMAJ [online] 2005 Mar 1, 172(5 Suppl):S1-S21 [viewed 17 June 2014] Available from: doi:10.1503/cmaj.1040302
  5. OSIEZAGHA K, ALI S, FREEMAN C, BARKER NC, JABEEN S, MAITRA S, OLAGBEMIRO Y, RICHIE W, BAILEY RK. Thiamine Deficiency and Delirium Innov Clin Neurosci [online] , 10(4):26-32 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659035
  6. MAINEROVA B, PRASKO J, LATALOVA K, AXMANN K, CERNA M, HORACEK R, BRADACOVA R. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub [online] 2013 Dec 11 [viewed 22 June 2014] Available from: doi:10.5507/bp.2013.089
  7. BHAT PS, RYALI V, SRIVASTAVA K, KUMAR SR, PRAKASH J, SINGAL A. Alcoholic hallucinosis Ind Psychiatry J [online] 2012, 21(2):155-157 [viewed 22 June 2014] Available from: doi:10.4103/0972-6748.119646

Examination

Fact Explanation
Signs such as icterus, enlarged and sometimes tender liver, hepatic bruit, spider angiomata, varicosities, palmar erythema, ascites These indicates presence of chronic alcoholic liver disease[1][4]
Signs such as tremor, ataxia or neuropathies (causing pain, altered sensation, weakness etc. in the extremities that can advance centrally) Indicate alcohol induced neurological disease[1][3]
Hypertension, arrhythmia, features of heart failure etc These signs suggest presence of alcoholic cardiovascular disease[5][6]
Presence of signs such as short palpebral fissures, a thin upper lip, long, smooth philtrum, flat midface, ptosis of the eyelids, epicanthal folds, an upturned nose with a flat nasal bridge, underdeveloped ears, clinodactyly of the fifth fingers ,camptodactyly, “hockey stick” palmar creases, hirsutism, and cardiac defects; height or weight below the 10th percentile for age and race; microcephaly Suggests Fetal alcohol spectrum disorder[2]
References
  1. BURGE SK, SCHNEIDER FD. Alcohol-Related Problems: Recognition and Intervention Am Fam Physician[online] 1999 Jan 15;59(2):361-370[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/1999/0115/p361.html
  2. WATTENDORF DJ, MUENKE M. Fetal Alcohol Spectrum Disorders. Am Fam Physician[online] 2005 Jul 15;72(2):279-285[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/2005/0715/p279.html#afp20050715p279-f5
  3. CHOPRA K, TIWARI V. Alcoholic neuropathy: possible mechanisms and future treatment possibilities Br J Clin Pharmacol [online] 2012 Mar, 73(3):348-362 [viewed 22 June 2014] Available from: doi:10.1111/j.1365-2125.2011.04111.x
  4. CHAYANUPATKUL M, LIANGPUNSAKUL S. Alcoholic hepatitis: A comprehensive review of pathogenesis and treatment World J Gastroenterol [online] 2014 May 28, 20(20):6279-6286 [viewed 22 June 2014] Available from: doi:10.3748/wjg.v20.i20.6279
  5. KLATSKY AL. Alcohol and cardiovascular health. Integr Comp Biol [online] 2004 Aug, 44(4):324-8 [viewed 22 June 2014] Available from: doi:10.1093/icb/44.4.324
  6. DAVIDSON DM. Cardiovascular effects of alcohol. West J Med [online] 1989 Oct, 151(4):430-439 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1026830

Differential Diagnoses

Fact Explanation
Hypoglycaemia Can present with autonomic hyperactivity, behavior change, seizures and coma. Consider even in patients with a history of alcohol abuse, presenting with similar features[1][3]
Intoxication due to mixed substance use Should be considered in a patient presenting with acute alcohol intoxication[1]
Dementia Induced by chronic alcohol abuse should be differentiated from other causes of dementia, particularly due to other treatable causes[1][4][5]
Delirium Delirium tremens should be differentiated from other causes of delirium such as central nervous system infection, liver failure etc.[1]
Schizophrenia Presents with hallucinations, delusions and is a differential diagnosis for alcohol induced psychosis. Also alcohol and other substance abuse is an increasingly recognized problem in patients with schizophrenia[1][7]
Depression Studies have shown that co-occurrence of depression and alcohol abuse is common. These patients tend to be more severely depressed than others[6]
Thyrotoxicosis Can result in increased sympathetic activity and altered mental state mimicking alcohol withdrawal syndrome[2]
Anticholinergic drug poisoning Can result in increased sympathetic activity and altered mental state mimicking alcohol withdrawal syndrome[2]
Amphetamine or cocaine abuse Can result in increased sympathetic activity and altered mental state mimicking alcohol withdrawal syndrome[2]
Central nervous system infection Can cause seizures and mental status changes, similar to alcohol withdrawal syndrome[2]
Intracranial hemorrhage/acute head injury Can cause seizures and mental status changes, similar to alcohol withdrawal syndrome[2]
References
  1. The ICD-10 Classification of Mental and Behavioural Disorders; Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 2 June 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf
  2. BAYARD M, MCINTYRE J, HILL KR, WOODSIDE J (JR), JAMES H. Alcohol Withdrawal Syndrome.Am Fam Physician [online] 2004 Mar 15;69(6):1443-1450[viewed 21 June 2014] Available from; http://www.aafp.org/afp/2004/0315/p1443.html#afp20040315p1443-t3
  3. HAMMERSTEDT H, CHAMBERLAIN SL, NELSON SW, BISANZO MC. Alcohol-related hypoglycemia in rural Uganda: socioeconomic and physiologic contrasts Int J Emerg Med [online] :5 [viewed 22 June 2014] Available from: doi:10.1186/1865-1380-4-5
  4. RIDLEY NJ, DRAPER B, WITHALL A. Alcohol-related dementia: an update of the evidence Alzheimers Res Ther [online] , 5(1):3 [viewed 22 June 2014] Available from: doi:10.1186/alzrt157
  5. VIEIRA RT, CAIXETA L, MACHADO S, SILVA AC, NARDI AE, ARIAS-CARRIóN O, CARTA MG. Epidemiology of early-onset dementia: a review of the literature Clin Pract Epidemiol Ment Health [online] :88-95 [viewed 22 June 2014] Available from: doi:10.2174/1745017901309010088
  6. SKULE C, ULLEBERG P, DALLAVARA LENDING H, BERGE T, EGELAND J, BRENNEN T, LANDRø NI. Depressive Symptoms in People with and without Alcohol Abuse: Factor Structure and Measurement Invariance of the Beck Depression Inventory (BDI-II) Across Groups PLoS One [online] , 9(2):e88321 [viewed 22 June 2014] Available from: doi:10.1371/journal.pone.0088321
  7. CHAKRABORTY R, CHATTERJEE A, CHAUDHURY S. Impact of Substance Use Disorder on Presentation and Short-Term Course of Schizophrenia Psychiatry J [online] 2014:280243 [viewed 22 June 2014] Available from: doi:10.1155/2014/280243

Investigations - for Diagnosis

Fact Explanation
Blood alcohol level Detection of alcohol related disorders is largely based on the history using a screening methods such as Alcohol Use Disorders Identification Test (AUDIT) or Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire etc. Testing blood alcohol level is useful to detect recent alcohol consumption[1][2][3]
Breathalyzer/ Breath analysis This is used to detect the small amounts of ethyl alcohol excreted in breath of recent alcohol users. Alcohol in alveolar air is in equilibrium with that in pulmonary capillary blood. Therefore the results of breath analysis can be used as an indicator of blood-alcohol levels[1][4]
References
  1. ENOCH MA. Problem Drinking and Alcoholism: Diagnosis and Treatment. Am Fam Physician[online] 2002 Feb 1;65(3):441-449[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/2002/0201/p441.html
  2. JONAS DE, GARBUTT JC, BROWN JM, et al. Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Comparative Effectiveness Reviews, No. 64.) Results. Available from: http://www.ncbi.nlm.nih.gov/books/NBK99204/
  3. CALAFAT A, FERNáNDEZ-HERMIDA JR, BECOñA E, JUAN M, DUCH M, FERNáNDEZ DEL RIO E, SALVá J, MONZóN S, GARCIA-TORO M. Blood alcohol level tests in nightlife recreational settings as a preventive tool. Actas Esp Psiquiatr [online] 2013 Jan-Feb, 41(1):10-6 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23440531
  4. BEGG TB, HILL ID, NICKOLLS LC. BREATHALYZER AND KITAGAWA-WRIGHT METHODS OF MEASURING BREATH ALCOHOL. Br Med J [online] 1964 Jan 4, 1(5374):9-15 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14071643

Investigations - Fitness for Management

Fact Explanation
Complete blood count In early disease mean corpuscular volume (MCV) may be slightly elevated. This may result from folate deficiency and the direct effects of alcohol on red blood cells. Later with advanced disease, blood loss from the gastrointestinal tract may cause iron deficiency anemia leading to production of smaller red blood cells, resulting in a low MCV and low hemoglobin (Hb) level. If both of these present, the MCV will be normal, but the red cell distribution width will be elevated. In end-stage disease, all cell lines will be reduced as a result of the direct toxic effect of alcohol on the bone marrow[1]
Liver enzyme levels γ-glutamyl transferase is usually the first to become elevated. This will be followed by elevatio of aspartate aminotransferase (AST) level, which is often elevated to twice the level of alanine aminotransferase (ALT), which will also be elevated[1][2]
Prothrombin time This is elevated because of decreased production of clotting factors by the liver with development of liver disease[1][2]
References
  1. BURGE SK, SCHNEIDER FD. Alcohol-Related Problems: Recognition and Intervention Am Fam Physician[online] 1999 Jan 15;59(2):361-370[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/1999/0115/p361.html
  2. CHAYANUPATKUL M, LIANGPUNSAKUL S. Alcoholic hepatitis: A comprehensive review of pathogenesis and treatment World J Gastroenterol [online] 2014 May 28, 20(20):6279-6286 [viewed 22 June 2014] Available from: doi:10.3748/wjg.v20.i20.6279

Management - General Measures

Fact Explanation
Haloperidol Can be used to treat agitation and hallucinations but it can lower seizure threshold[1]
Atenolol When used in conjunction with oxazepam has been shown to improve vital signs more quickly and to reduce alcohol craving more effectively. Can also be considered in patients with coronary artery disease, who may not tolerate the strain placed by alcohol withdrawal syndrome, on the cardiovascular system [1]
Clonidine Has shown to improve the autonomic symptoms of alcohol withdrawal syndrome[1]
Supportive care Supportive care such as correction of dehydration and electrolyte imbalance, vitamin and nutritional support is needed to aid the patients recovery[2][3]
References
  1. BAYARD M, MCINTYRE J, HILL KR, WOODSIDE J (JR), JAMES H. Alcohol Withdrawal Syndrome.Am Fam Physician [online] 2004 Mar 15;69(6):1443-1450[viewed 21 June 2014] Available from; http://www.aafp.org/afp/2004/0315/p1443.html#afp20040315p1443-t3
  2. KIM JW, LEE BC, KANG TC, CHOI IG. The Current Situation of Treatment Systems for Alcoholism in Korea J Korean Med Sci [online] 2013 Feb, 28(2):181-189 [viewed 22 June 2014] Available from: doi:10.3346/jkms.2013.28.2.181
  3. MAINEROVA B, PRASKO J, LATALOVA K, AXMANN K, CERNA M, HORACEK R, BRADACOVA R. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub [online] 2013 Dec 11 [viewed 22 June 2014] Available from: doi:10.5507/bp.2013.089

Management - Specific Treatments

Fact Explanation
Management of Alcohol Withdrawal Syndrome(AWS) The AWS severity can be determined using CIWA-Ar, which is based on 10 symptoms of withdrawal. Patients with mild AWS (CIWA-Ar score<8-10) can be monitored on an outpatient basis and may not require medication. Patients with moderate AWS (CIWA-Ar score 8-15) may require medication to alleviate withdrawal symptoms but can be monitored on an outpatient basis. Patients with a CIWA-Ar score of 15 or higher or a history of alcoholic withdrawal seizure, suicidal ideation, or other comorbid conditions or if they develop seizures, delirium, or worsening of symptoms, require inpatient treatment. Long-acting benzodiazepines (e.g. Chlordiazepoxide) are given for patients receiving inpatient treatment, because of a decreased risk of delirium and seizure. Short-acting benzodiazepines (e.g. Lorazepam, Oxazepammay) are given to patients with comorbidities, such as liver disease. These can be given as fixed-schedule or symptom-triggered regimens. If patient develops seizures, acute management seizures should be initiated. Benzodiazepines or carbamazepine is useful in seizure prophylaxis. Long term anti-epileptic treatment is unnecessary[1][2][3][4][11][13]
Managing alcohol dependence and relapse prevention Psychosocial interventions such as cognitive-behavioral therapy, contingency management, motivational enhancement/motivational interviewing and brief intervention are effective methods of treatment. Psychological therapy not only leads to either a reduction or abstinence from alcohol but also makes improvements in a broad range of areas of functioning, which include physical health, psychological health,interpersonal relationships etc. In order to change their alcohol taking behavior, each patient passes through the motivational cycle consist of stages of change, namely, pre-contemplation, contemplation, abstinence, maintenance and relapse. Patient is said to be in pre-contemplation when he has not thought of change. When the patient is aware that he needs to change but ambiguous towards change, he is in contemplation. When the patient is committed he enters the next change. When this behavior is maintained for more than several months, he is in the maintenance.There can be returning to alcohol consumption. i.e. relapse. The patient should restart going through the motivational cycle. Patients should be provided with guidance and encouragement to pass through each stage. Psychosoicial interventions can be done alone or can be combined with the following medication[1][8][9][11] Topiramate is an anticonvulsant which is an effective adjunctive medication to decrease alcohol consumption and increase abstinence in alcohol-dependent patients[3] Naltrexone is an opioidreceptor antagonist which blocks endogenous endorphin release. It is approved for use in the treatment of alcohol dependence. Disulfiram inhibits acetaldehyde dehydrogenase which leads unpleasant symptoms such as palpitations, flushing, nausea, vomiting, and headache etc. and acts as a deterrent. There is potential for severe alcohol–disulfiram interactions, leading to myocardial infarction, congestive heart failure, respiratory depression, and even death. Therefore disulfiram is contraindicated in patients who are receiving or have recently received metronidazole or ingested alcohol, have psychosis, cardiovascular disease, severe pulmonary disease, chronic renal failure, diabetes, or those older than 60 years, patients with peripheral neuropathy, seizures, or cirrhosis with portal hypertension. Acamprosate blocks glutaminergicN-methyl-Daspartate receptors, activate 3-aminobutyric acid type A receptors and is shown to be effective in maintaining abstinence[1][6][11]
Management of fetal alcohol spectrum disorder This requires referral to a multidisciplinary team consist of dysmorphologist/clinical geneticist, developmental pediatrician, mental health professional, social worker, and educational specialist[5] Pregnant women should be screened for alcohol related disorders and treated appropriately. Education regarding effects of alcohol on the fetus in the prenatal and antenatal period will help to reduce alcohol consumption during pregnancy[7]
Mnagement of Wernicke’s encephalopathy (WE) WE is a medical emergency. When this disorder is suspected, thiamine should be initiated immediately, either intravenously or intramuscularly and continued daily for 3 to 5 days, or until clinical improvement ceases, followed by oral doses[1][10][11]
Management of delirium tremens Through monitoring and prompt treatment of withdrawal syndrome helps prevent severe complications such as delirium tremens. Benzodiazepines are used in the treatment. Patient should be treated in a quiet, calm, safe environment with minimal disturbances. Other aspects of treatment include patient monitoring, proper nutrition and hydration, vital function support, prevention of urine and fecal retention, early mobilizatio etc.[12][13]
References
  1. Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications; NATIONAL CLINICAL GUIDELINE CENTER (UK). [online] 2010 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22876380
  2. MELSON J, KANE M, MOONEY R, MCWILLIAMS J, HORTON T. Improving Alcohol Withdrawal Outcomes in Acute Care Perm J [online] 2014, 18(2):e141-e145 [viewed 21 June 2014] Available from: doi:10.7812/TPP/13-099
  3. RICKS J, REPLOGLE WH, COOK NJ, Management of Alcohol Withdrawal Syndrome. Am Fam Physician[online] 2010 Aug 15;82(4):344-347[viewed on 21 June 2014]Available from; http://www.aafp.org/afp/2010/0815/p344.html#afp20100815p344-t1
  4. BAYARD M, MCINTYRE J, HILL KR, WOODSIDE J (JR), JAMES H. Alcohol Withdrawal Syndrome.Am Fam Physician [online] 2004 Mar 15;69(6):1443-1450[viewed 21 June 2014] Available from; http://www.aafp.org/afp/2004/0315/p1443.html#afp20040315p1443-t3
  5. WATTENDORF DJ, MUENKE M. Fetal Alcohol Spectrum Disorders. Am Fam Physician[online] 2005 Jul 15;72(2):279-285[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/2005/0715/p279.html#afp20050715p279-f5
  6. WILLIAMS SH, Medications for Treating Alcohol Dependence. Am Fam Physician[online] 2005 Nov 1;72(9):1775-1780 [viewed on 21 June 2014] Available from; http://www.aafp.org/afp/2005/1101/p1775.html
  7. Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. Geneva: World Health Organization; 2014. RECOMMENDATIONS. Available from: http://www.ncbi.nlm.nih.gov/books/NBK200683/
  8. JHANJEE S. Evidence Based Psychosocial Interventions in Substance Use Indian J Psychol Med [online] 2014, 36(2):112-118 [viewed 22 June 2014] Available from: doi:10.4103/0253-7176.130960
  9. JAFARI M, SHAHIDI S, ABEDIN A. Comparing the effectiveness of Cognitive Behavioral Therapy and Stages of Change Model on Improving Abstinence Self-Efficacy in Iranian Substance Dependent Adolescents Iran J Psychiatry Behav Sci [online] 2012, 6(2):7-15 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940013
  10. OSIEZAGHA K, ALI S, FREEMAN C, BARKER NC, JABEEN S, MAITRA S, OLAGBEMIRO Y, RICHIE W, BAILEY RK. Thiamine Deficiency and Delirium Innov Clin Neurosci [online] , 10(4):26-32 [viewed 22 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659035
  11. WILLENBRING ML, MASSEY SH, GARDNER MB. Helping Patients Who Drink Too Much: An Evidence-Based Guide for Primary Care Physicians.Am Fam Physician[online] 2009 Jul 1;80(1):44-50.[viewed on 21 June 2014] Available from; http://www.aafp.org/afp/2009/0701/p44.html
  12. MAINEROVA B, PRASKO J, LATALOVA K, AXMANN K, CERNA M, HORACEK R, BRADACOVA R. Alcohol withdrawal delirium - diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub [online] 2013 Dec 11 [viewed 22 June 2014] Available from: doi:10.5507/bp.2013.089
  13. NARAYANASWAMY JC, VISWANATH B, NAGPAL K, GOPINATH S, MATH SB, CHANDRASEKHAR CR. Successful Use of Oxazepam in the Treatment of Delirium Tremens Prim Care Companion CNS Disord [online] 2012, 14(6):PCC.12l01404 [viewed 22 June 2014] Available from: doi:10.4088/PCC.12l01404