Alcohol Withdrawal

Symptom Prole and Outcome of Delirium Associated withAlcohol Withdrawal Syndrome: A Study from India

Sandeep Grover, MD, Akhilesh Sharma, MD, Natasha Kate, MD, Surendra K. Mattoo, MD,Debasish Basu, MD, Subho Chakrabarti, MD, Savita Malhotra, MD, Ajit Avasthi, MDDepartment of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India

Aim: To study the prole of delirium associated with alcoholwithdrawal syndrome (AWS) in a developing country in terms ofsymptomatology, associated risk factors/physical complications, andoutcome.Methodology: Using a prospective design, 112 patients in whomdelirium could be attributed to AWS as either the sole or a contributorycause were assessed by Delirium Rating ScaleRevised98 and theassociated etiological factors were assessed by using delirium etiologychecklist.Findings: In all patients, delirium was acute in onset and all patientshad disturbance of sleepwake cycle and inattention. Other commonsymptoms were: disorientation (99.1%), uctuation in symptoms(97.3%), motor agitation (94.6%), and shortterm memory distur-bance (92.9%). In terms of delirium etiology checklist etiologicalcategories, besides alcohol withdrawal, themost common factors weremetabolic/endocrine abnormalities (76%), followed by organ insuf-ciency and infection (37% and 35%, respectively). Most patients(67%) improved or recovered completely from delirium during theshort stay of 4 days. During the short stay of mean duration of 4 days13.4% of the patients died during the hospital stay.Conclusion: Delirium associated with alcohol withdrawal ischaracterized by an acute onset of symptoms with high prevalenceof disturbance of sleepwake cycle, inattention, disorientation,uctuation in symptoms, motor agitation, and disturbance in shortterm memory. There are certain differences in the symptom prole ofdelirium associated with alcohol withdrawal and that associated withmedicalsurgical causes. About onesixth of the patients developingdelirium due to alcohol withdrawal die during the short hospital stay of4 days. (Am J Addict 2013;22:503509)

INTRODUCTION

Alcohol withdrawal syndrome (AWS) comprises of varioussymptoms and signs which arise in alcoholdependent

individuals within 2448 hours after the last drink. AWS canoccur under abstinence from alcohol that may be initiatedby self, or under medical care. A minority with AWS maydevelop severe and even potentially fatal complications.Alcohol withdrawal delirium (AWD), commonly describedas delirium tremens (DT) is the most serious clinicalmanifestation of AWS.1 Western data suggest the rates of15% for DT and 315% for withdrawal seizures2,3 and it issuggested that genetic factors play a role in development ofthese complications.4

DT is characterized by reduced level of consciousness,disorientation, impairment in recent memory, disruption of thesleepwake cycle, transient perceptual disturbances (visual,auditory, tactile, and olfactory), evening worsening ofsymptoms, variable agitation, and maybe coarse tremors oflimbs and body. Evidence suggests that risk factors for DT are:recent heavy drinking, past history of DT or withdrawalseizures, more nonmedicinal use of sedativehypnotics,tachycardia (heart rate >120 beats/min), greater number ofwithdrawal episodes or medical problems, or current infectiousdisease.58

Even though there is a sizeable literature proling thesyndrome of DT, it suffers from two major limitations. One,almost all of this literature emanates from the West. Two, noneof the research has used any standardized scale to study the DT.Additionally, none of the research from a developing countrysetting has studied the clinical prole of DT. Further, researchaddressing the phenomenology of delirium has usually studiedgroups with heterogenous etiologies. In view of this, thepresent research aimed at proling DT in a developing countryin terms of: symptomatology as per the Delirium Rating ScaleRevised98 (DRSR98),9 associated risk factors/physicalcomplications, and outcome.

METHODOLOGY

SettingThe study was carried out at the Postgraduate Institute

of Medical Education & Research, Chandigarh (PGIMER)a

Received February 6, 2012; revised July 1, 2012; accepted July23, 2012.

Address correspondence to Dr. Grover, Assistant Professor,Department of Psychiatry, Postgraduate Institute of MedicalEducation & Research, Chandigarh 160012, India. Email:[email protected].

The American Journal on Addictions, 22: 503509, 2013Copyright American Academy of Addiction PsychiatryISSN: 1055-0496 print / 1521-0391 onlineDOI: 10.1111/j.1521-0391.2013.12063.x

503

multispecialty teaching hospital in North India. Roundtheclock psychiatric consultationliaison (CL) cover isprovided by the Department of Psychiatry for the entirehospital. Among all the referrals delirium is the most commondiagnosis.10

Ethical ConsiderationsThe study was approved by the Ethics Review Committee

of the Institute. Written consent was obtained from the primarycaregivers of the patients prior to intake. The study involvedevaluation of all the patients referred to psychiatry CL team anddiagnosed as having AWD.

DesignUsing a prospective design, all the consecutive patients

diagnosed as having delirium as per DSMIVTR criteria11 bythe CL team during the period of January 2010 toJune 2011 were eligible for the study. For inclusion into thestudy patients were to be aged 18 years or above, and had tohave developed delirium during the alcohol withdrawal phase.The demographic and clinical prole of the included cases wasrecorded. The symptom prole and severity of deliriumwas recorded on the DRSR98.9 The required informationwas obtained from the patients, caregivers, medical staff, andmedical records.

For comparison of symptoms of delirium due to AWS withdelirium due to general medical conditions, we obtained theDRSR98 data from one of our previous studies. This studyincluded 151 patients of delirium associated with multiplemedicosurgical conditions.12

InstrumentsDelirium Rating ScaleRevised98 (DRSR98)9 is a 16item

scale with 13 items constituting the severity scale and 3 itemsbeing of diagnostic signicance. Severity items are rated 03 toyield a total severity score ranging 039, a higher scoreindicating greater severity. A cutoff score of15 is considereddiagnostic of delirium. A score of1 on any item indicates thepresence of that particular symptom and forms the basis for thefrequency of symptom. The scale has good validity, sensitivity,interrater reliability (intraclass correlation coefcient .98),and specicity for distinguishing delirium from dementia,depression, and schizophrenia.9

Delirium Etiology Checklist (DEC)13 was used to record theetiologies associated with delirium. On the basis of all theavailable clinical information, etiological attributions are madeon the DEC. DEC checklist has 12 categories [drugintoxication, drug withdrawal, metabolic/endocrine distur-bance, traumatic brain injury, seizures, infection (intracranial),infection (systemic), neoplasm (intracranial), neoplasm (sys-temic), cerebrovascular, organ insufciency, other CNSdisorder, and other systemic disorder]. Role of each cause israted on a 5point scale based on the degree of attribution to thedelirium episode, and ranges from ruled out/not present/notrelevant (score0) to denite cause (score4). In additionalto the categories each etiological factor can also be recorded.

ProcedureAll the patients referred to psychiatry CL service from

January 2010 to June 2011were eligible for the study. All thosediagnosed with delirium clinically were evaluated to conrmthe diagnosis as per DSMIVTR criteria. All those with DSMIVTR diagnosis of delirium were evaluated for the possibledeliriumprecipitating etiological factors. All patients who hadalcohol dependence as per DSMIVTR criteria and hadbeen using alcohol till few days prior to admission or tillthe date of admission to the hospital were further evaluated forthe etiological role of alcohol withdrawal state. All thosepatients in whom alcohol withdrawal was considered to be adenite contributory etiological factor for precipitatingdelirium (with or without other etiological factor) were takenup for this study.

Caregivers of all the patients diagnosed as having deliriumprecipitated by alcohol withdrawal were approached andinformed about the purpose of the study and patients whosecaregivers provided the written informed consent wererecruited. After recording the clinical details and details ofalcohol use based on the information from patients, caregivers,and medical records, phenomenology was assessed on DRSR98 by a qualied psychiatrist based on the information obtainedfrom the patients, caregivers, medical staff, and medicalrecords.

AnalysisSPSS14 was used to analyze the data. Frequency,

percentage, mean, and standard deviation were calculated forthe descriptive data. Comparison between the groups was doneby using 2tailed Students t, chisquare, and Fishers exacttests. Pearson product moment or Spearman rank correlationwere also evaluated to study the relationship between variousvariables.

RESULTS

During the study period of January 2010 to June 2011, 121cases of delirium could be attributed to alcohol withdrawal aseither the sole or a contributory cause. Of the 121 cases,112 patients whose caregivers provided the written informedconsent formed the study sample.

DemographicThe study sample comprised only of men, with a mean age

of 44.25 years (SD: 13.05; range 2285 years); only 8%(N 9) of the subjects were aged 65 years. There was nosignicant difference in the sociodemographic prole of thosewho were included in the study and those who were notincluded due to lack of consent.

Alcohol Use ProfileThemean duration of alcohol dependence was about 8 years

(SD: 6.60; range: 130). All the subjects were using spirits(ofcially standard volume per volume alcohol content 42.7%)

504 Delirium Associated with Alcohol Withdrawal Syndrome SeptemberOctober 2013

in the form of Indian made foreign liquor (IMFL) or theCountry made liquor (CML). IMFL alone was used mostcommonly (50.9%), and the CML alone was used leastcommonly (12.5%), while the rest used both (36.6%). Themean quantity of alcohol consumed on a regular basis during aweek prior to the development of delirium was 563.57 ml/day.Past history of complicated withdrawal in the form of deliriumor convulsions was present in 41.1% of subjects. The meanduration of onset of delirium after the last intake of alcohol was30.11 hours (SD: 31.48; range 6120 hours); in twothirds ofcases the features of delirium were noted within 24 hours of thelast intake.

Clinical ProfileThe referrals came most commonly from surgical and

medical wards (42% each), followed by the intensive care units(16%); majority of the last group were not intubated. The meanduration of deliriumwas 3.91 days (SD: 4.52; range 12 hours to25 days). Only in a minority was the delirium associated withwithdrawal seizures (13.3%), and very few patients had severedelirium and tremors (6.2%). In 44 cases (39.28%) deliriumwas present at the time of admission.

Alcohol withdrawal was the only evident precipitatingfactor for delirium in 46.4% subjects, while in others alcoholwithdrawal was a major contributory factor for delirium, eventhough there were additional contributory factors. Theassociation of alcohol with delirium was based on the DECcategories, and accordingly only those patients in whichalcohol withdrawal was rated as a denite cause wereconsidered to alcohol withdrawal as the only precipitatingfactor. In other cases alcohol withdrawal was rated as likelycause, along with other denite/likely/possibly contributorycauses.

As shown in Table 1, in terms of DEC etiological categories,besides alcohol withdrawal, the most common factors weremetabolic/endocrine abnormalities (76%), followed by organ

insufciency and infection (37% and 35%, respectively) andhead injury and seizures (15% each).

Besides alcohol withdrawal, other individual factors whichcontributed to the development of delirium were: anemia(44.64%), hepatic impairment (37.5%), sepsis (36.6%), trauma(24.1%), renal impairment (23.2%), hypoxia (19.65%),postoperative state (18.75%), medication related (15.2%),hypokalemia (14.3%), CNS pathology (13.4%), seizures(13.4%), pancreatitis (11.6%), hyponatremia (9.82%), hypo-calcemia (8.92%), worsening of diabetes mellitus (8.03%),decompensated cardiac disease (5.35%), lung disease (4.5%),hypernatremia (2.67%), hyperkalemia (2.67%), malignancy(2.67%), hypophosphatemia (.9%), and hypercalcemia (.9%).As shown in Table 1, in terms of etiological categories, besidesalcohol withdrawal, the most common factors were metabolic/endocrine abnormalities (76%), followed by organ insufcien-cy and infection (37% and 35%, respectively) and head injuryand seizures (15% each).

Symptoms Profile of Delirium as Assessed onDRSR98

As shown in Table 2 the symptom prole of delirium wasquite diverse. Acute onset of symptoms, physical disorder,disturbance of sleepwake cycle, and inattention were presentin all the subjects. Other common symptoms were: disorienta-tion (99.1%), uctuation in symptoms (97.3%), motoragitation (94.6%), and disturbance in shortterm memory(92.9%). Motor retardation was the least common symptom,seen in only onefourth of the patients.

More severe symptoms (mean score >2) were: sleepwakecycle disturbances, motor agitation, attention disturbances, anddisturbance of concentration. Overall, the mean DRSR98severity score was 19.65 5.39 (range 1133) and meanDRSR98 total score was 25.33 5.93 (range 1540). In15 patients the DRSR98 severity score ranged 1114,suggesting a subsyndromal delirium. Those admitted to the

TABLE 1. Delirium etiology checklist

Definitecause

Likelycause

Present and possiblecontributory

Present but apparentlynot contributing

Ruled out/notpresent/not relevant

Drug intoxication 112Drug withdrawal 58 54 Metabolic/endocrine 17 21 30 1 40Traumatic brain injury 4 6 5 97Seizures 5 5 5 97Infection (intracranial) 1 2 109Infection (systemic) 4 10 21 4 73Neoplasm (intracranial) 1 111Neoplasm (systemic) 1 1 110Cerebrovascular 2 3 1 106Organ insufficiency 4 13 20 1 74Other (central nervous system) 1 2 1 108Others 10 8 12 1 81

Grover et al. SeptemberOctober 2013 505

ICUs and general wards were similar with respect to frequencyand severity of various DRSR98 symptoms.

Depending on the presence of other associated etiologies,the study sample was divided into two groups: those withdelirium due to alcohol withdrawal only and those withdelirium associated with alcohol and other etiologies too.Patients with only AWD and those with delirium due tomultiple etiologies (including alcohol withdrawal as one of theetiologies) were similar for the frequency of symptoms and theseverity of symptoms (except for signicantly higher severityof language disturbances and thought process abnormality inthose with only AWD).

Comparison of Symptom Profile of Patients withDelirium Associated with AWS and Delirium Due toGeneral Medical Conditions

Frequencies of the various DRSR98 symptoms ofdelirium associated with AWS were compared with a nonAWD cohort from one of our previous studies13 (Table 3). Thepatients with delirium associated with AWS had signicantlyhigher prevalence of delusions and thought process abnormal-ity, and a signicantly lower prevalence of motor retardation,disturbances in the longterm memory and visuospatial ability.

Correlates of SymptomsDRSR98 severity score and DRSR98 total score did not

correlate with amount of alcohol consumed prior to intake. Interms of each symptom, there was positive correlation betweenamount of alcohol consumed and severity in disturbance inlanguage (Pearsons Product moment correlation .196;

p .038) and intensity of acuteness of onset of delirium(Pearsons Product moment correlation .192; p .042).The severity of various symptoms did not correlate withduration of dependence on alcohol.

Outcome of DeliriumThe commonest outcome was for the features of delirium to

have improved signicantly by the time of discharge from thehospital (N 69; 61.6%). The next two common outcomeswere: no improvement in symptoms of delirium (N 17,15%), and death (N 15, 13.4%) over mean 3.95, SD: 4.51,and range 125 days. Only a few subjects recoveredcompletely (N 6; 5.4%) or had further worsening ofdelirium (N 4; 3.6%). Most of the cases which improvedor recovered completely (49 out of 75; 65.33%), did sowithin 3 days of starting of treatment. Most of the patients whodied (10 out of 15; 66.66%) died in the rst 2 days ofassessment. There was no difference in those who diedduring the hospital stay and those who survived with respectto the age, age group (adult versus geriatric), alcohol relatedvariables (past history of complicated withdrawal, currentcomplicated withdrawal, severity of alcohol dependence,pure alcohol withdrawal versus alcohol as a contributoryfactor, type of alcohol used, average amount of alcoholconsumed till recently, duration of alcohol dependence),presence of any of the other etiological factors, deliriumat admission/delirium starting while in hospital, severityand frequency of delirium symptoms as per DRSR98,duration of delirium prior to assessment and mean number ofetiologies.

TABLE 2. DRSR98 symptom prole (n 112)

Symptoms (items) Prevalence, N (%)Present, at leastmoderate severity

Scoremean/standarddeviation (range)

1. Sleepwake cycle disturbances 112 (100%) 102 (91.1%) 2.27 .61 (13)2. Perceptual disturbance 84 (75%) 65 (58%) 1.49 1.03 (03)3. Delusions 54 (48.2%) 28 (25%) .77 .92 (03)4. Lability of affect 93 (87%) 65 (58%) 1.49 .86 (03)5. Language 96 (85.7%) 53 (47.3%) 1.40 .82 (03)6. Thought process abnormality 93 (87%) 57 (50.9%) 1.41 .86 (03)7. Motor agitation 106 (94.6%) 100 (89.3%) 2.21 .77 (03)8. Motor retardation 28 (25%) 12 (10.7%) .39 .77 (03)9. Orientation 111 (99.1%) 92 (82.2%) 2.11 .70 (13)10. Attention 112 (100%) 98 (87.5%) 2.20 .64 (13)11. Shortterm memory 104 (92.9%) 74 (66.0%) 1.71 .77 (03)12. Longterm memory 73 (65.2%) 33 (29.5%) .96 .83 (03)13. Visuospatial ability 77 (68.8%) 45 (40.2%) 1.18 .99 (03)14. Temporal (acute) onset of symptoms 112 (100%) 97 (86.6%) 2.39 .71 (13)15. Fluctuation 109 (97.3%) 58 (51.8%) 1.49 .55 (02)16. Physical disorder 112 (100%) 85 (75.9%) 1.78 .47 (13)

DRSR98 severity score 19.65 5.39DRSR98 total score 25.33 5.93


DISCUSSION

Although DT is considered to be one of the most seriousmanifestations of delirium, no study has described thephenomenology of DT using a standardized scale. We usedDRSR98 to study the phenomenology of delirium associatedwith AWS in patients admitted to the medical surgical wards.All patients had acute onset of symptoms, presence of alcoholwithdrawal state (ie, associated etiological factor), anddisturbances of attention and sleepwake cycle. Othersymptoms reported by >90% subjects were uctuation ofsymptoms, disturbed orientation and shortterm memory andthe presence of motor agitation. Motor retardation was the leastcommon symptom. This symptom prole suggests that justlike in delirium due to any other cause, besides the behavioraldisturbances (motor agitation, perceptual abnormalities, anddelusions), cognitive symptoms are also highly prevalent inpatients with delirium associated with AWS. A comparison ofthe frequency of the various DRSR98 symptoms between ourcohort of delirium associated with AWS and a nonAWDcohort from one of our previous studies12 showed someinteresting ndings. The patients with delirium associated withAWS had signicantly higher prevalence of delusions andthought process abnormality, and a signicantly lowerprevalence of motor retardation, disturbances in the longterm memory and visuospatial ability. However, within thepresent study the pure AWD and the delirium due to multipleetiologies (including alcohol withdrawal) were no different inthe frequency of symptoms of delirium. Hence, one can safelyconclude that the core symptoms of delirium are seen in

patients with delirium due to any cause, while underlyingetiologies may contribute to subtle differences in thesymptomatology. However, this conclusion needs furtherconrmation.

The literature suggests that the clinical features of AWS startwithin hours of the last alcohol intake, while the clinicalfeatures of delirium appear 4872 or more hours later.1416 Inour study the mean duration of onset of delirium after the lastalcohol intake was 30.11 hours, with a range of 6120 hours,and with twothird of the subjects showing the features ofdelirium within 24 hours of the last intake seem discrepant.This could be due to various reasons. First, the use of astructured instrument as also a more thorough assessmentcovering a wider range of symptoms could have ensured thepicking up of early subtle signs. Second, DT symptoms couldhave overlapped with the features of alcohol intoxicationmany heavily drinking subjects would have minimal period ofnormalcy between intoxication and delirium, so that thefeatures of intoxication would have rated as features ofdelirium. In our study the recovery from delirium mostlyoccurring within the rst few days of starting of treatment isconsistent with the literature suggesting AWD to usually lastfor 4872 hours.1416

The mortality rate of 13.4% in our study appears highconsidering that the comparative rates in the Western literaturehave come down from the high of 37% for AWS17 to 15% forDT,16 to 2.4% for AWS,18 and 01% for DT.19 However, amore recent study reported AWS mortality rate of 6.6%; thepresence of DT at admission increasing the mortality rate to8.5%; and DT being a signicant predictor of mortality (odds

TABLE 3. Comparison of symptoms prole of delirium due to alcohol withdrawal with delirium due to general medical conditions

Symptoms (items)

Delirium due to generalmedical conditions (multipleetiologies)13 (N 151)

Alcohol withdrawaldelirium (N 112) Chisquare test

1. Sleepwake cycle disturbances 100% 100% 2. Perceptual disturbance 76.2% 75% .047 (p .829)3. Delusions 27.8% 48.2% 11.54 (p .001)4. Lability of affect 77.5% 87% 1.23 (p 1.23)5. Language 76.8% 85.7% 3.25 (p .07)6. Thought process abnormality 69.5% 87% 6.29 (p .012)7. Motor agitation 94% 94.6% .043 (p .835)8. Motor retardation 39.1% 25% 5.75 (p .016)9. Orientation 100% 99.1% 1.35 (p .24)10. Attention 100% 100% 11. Shortterm memory 97.4% 92.9% 2.98 (p .084)12. Longterm memory 93.4% 65.2% 33.72 (p .001)13. Visuospatial ability 96.7% 68.8% 38.92 (p .001)14. Temporal (acute) onset of symptoms 100% 100% 15. Fluctuation 95.6% 97.3% .673 (p .412)16. Physical disorder 100% 100%

p < 0.05; p < 0.001.


ratio2.5).20 Thus mortality rates in our study are in the rangereported in the existing literature for DT, although on a slightlyhigher side of the range. However, these mortality rates must beinterpreted in the light of morality rates of patients withdelirium due to any etiology at our center. In a previous study,we evaluated the mortality rates in patients of delirium due toany cause, and found that 12.1% of patients expired duringtheir hospital stay, which was higher than the mortality ratesseen in other patients referred to CL services during the sameperiod and diagnosed with other psychiatric disorders (4.43%)or who had no psychiatric diagnosis (no death). The mortalityrate in patients of delirium was also signicantly higher thanthat seen in all admissions to the hospital during the studyperiod.21 These mortality rates are consistent with reports ofhigher mortality rates in patients with delirium in general.Finding of the present study very closely resembles themortality rates in patients with delirium due to any cause andhence, should be understood as specic to DT or deliriumassociated with alcohol withdrawal.

Ten out of 15 of our patients dying in the rst 2 days ofassessment reafrms the fact that themortality being high in theinitial period, it is important to recognize DT at the earliestpossible. Our study did not nd any predictor of mortality. Thisis similar to the older studies reporting AWS deaths in theapparent absence of other problems,16,22 but not with the newerstudies showing higher mortality in AWS with: the presence ofDTat admission, existence of an underlying chronic pathologyother than liver disease and need for orotracheal intubation,20

pneumonia, gastrointestinal bleeding,2325 and cirrhosis.20,2325

A recent review of 21 studies concluded that the mostcommonly identied risk factors for DT include personalhistory of DT, seizures, presence of acute somatic comorbidityespecially infectious, presence of early withdrawal symptoms,and genetic predisposition.26 Although our study was notdesigned to look for risk factors for DT, a signicant proportionof our subjects had other medical problems which could havecontributed to development of delirium, especially sepsis,metabolic disturbances, and hepatic impairment. Hence, ourstudy supports the assertion that medical comorbiditiesincrease the risk of delirium associated with alcoholwithdrawal. Our nding of an average patient of deliriumassociated with alcohol withdrawal having 3.31 associatedmedical comorbidities, does not have a comparator in theliterature, reecting a need for the same.

The results of our study must be interpreted within itslimitations: a crosssectional assessment of phenomenology,assessment of phenomenology to a rating scale which wouldhave picked up other symptoms commonly seen in patientswith AWS. Further our study was limited to a sample referredto psychiatry CL services.

Details of the Alcohol UseTo conclude, the present study suggests that delirium

associated with alcohol withdrawal is characterized by an acuteonset of symptoms with disturbance of sleepwake cycle andinattention in all the patients. Other common symptoms

include disorientation, uctuation in symptoms, motor agita-tion, and disturbance in shortterm memory. There are certaindifferences in the symptom prole of delirium associated withalcohol withdrawal and that associated with medicalsurgicalcauses. Patients with delirium associated with AWS havesignicantly higher prevalence of delusions and thoughtprocess abnormality, and a signicantly lower prevalence ofmotor retardation, disturbances in the longterm memory andvisuospatial ability. Delirium associated with alcohol with-drawal usually improves with appropriate management,however, about 13.4% of patients died during the shorthospital stay.

Declaration of InterestThe authors report no conicts of interest. The authors alone

are responsible for the content and writing of this paper.

REFERENCES

1. MayoSmith MF, Beecher LH, Fischer TL, et al. Management of alcoholwithdrawal delirium: An evidencebased practice guideline. Arch InternMed. 2004;164:14051412.

2. Saitz R, OMalley S. Pharmacotherapies for alcohol abuse: Withdrawaland treatment. Med Clin N Am. 1997;81:881902.

3. Le Strat Y, Ramoz N, Pickering P, et al. The 3 part of the dopaminetransporter gene DAT1/SLC6A3 is associated with withdrawal seizuresin patients with alcohol dependence. Alcohol Clin Exp Res. 2008;32:2735.

4. Gorwood P, Limosin F, Batel P, et al. The A9 allele of the dopaminetransporter gene is associated with delirium tremens and alcoholwithdrawal seizure. Biol Psychiatry. 2003;53:8592.

5. Schuckit MA, Tipp JE, Reich T, et al. The histories of withdrawalconvulsions and delirium tremens in 1648 alcohol dependent subjects.Addiction. 1995;90:13351347.

6. Bayard M, Mcintyre J, Hill KR, et al. Alcohol withdrawal syndrome. AmFam Physician. 2004;69:14431450.

7. Lee JH, Jang MK, Lee JY, et al. Clinical predictors for delirium tremens inalcohol dependence. J Gastroenterol Hepatol. 2005;20:18331837.

8. Khan A, Levy P, Dehorn S, et al. Predictors of mortality in patients withdelirium tremens. Acad Emerg Med. 2008;14:788790.

9. Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium RatingScaleRevised98: Comparison with the Delirium Rating Scale and thecognitive test for delirium. J Neuropsychiatry Clin Neurosci. 2001;13:229242.

10. Grover S, Subodh BN, Avasthi A, et al. Prevalence and clinical prole ofDelirium: A study from a tertiary care hospital in north India. Gen HospPsychiatry. 2009;31:2529.

11. American Psychiatric Association. Diagnostic and Statistical Manual ofMental Disorders, 4th edn. Text Revision. Washington DC, Author; 2002.

12. Grover S, Chakrabarti S, Shah R, et al. A factor analytic study of theDelirium Rating ScaleRevised98 in untreated patients with delirium. JPsychosomatic Res. 2011;70:473478.

13. Trzepacz PT, Meagher DJ, Leonard M. Delirium. In: Levenson J, ed.American Psychiatric Publishing Textbook of Psychosomatic Medicine,2nd edn. Washington, DC: American Psychiatric Publishing; 2010.

14. StendigLindberg G, Rudy N. Stepwise regression analysis of an intensive1year study of delirium tremens.Acta Psychiatr Scand. 1980;62:273297.

15. Cutshall B. The SaundersSutton syndrome: An analysis of deliriumtremens. Q J Stud Alcohol. 1965;26:423448.

16. Victor M, Adams RD. The effect of alcohol on the nervous system. ResPubl Assoc Res Nerv Ment Dis. 1953;32:526573.


17. Boston LN. Alcohol withdrawal. Lancet. 1908;1:1819.18. Puerta Louro R, Otero Anton E, Lorenzo Zuiga V. Epidemiologa del

AWS alcohlica: Mortalidad y factores de mal pronstico. An Med Interna(Madrid). 2006;23:307309.

19. Ferguson JA, Suelzer CJ, Eckert GJ, et al. Risk factors for delirium tremensdevelopment. J Gen Intern Med. 1996;11:410414.

20. Monte R, Rabual R, Casariego E, et al. Analysis of the factorsdetermining survival of alcoholic withdrawal syndrome patients in ageneral hospital. Alcohol Alcohol. 2010;45:151158.

21. Grover S, Shah R, Aarya KR. The mortality rate among patients withdelirium 6 months after diagnosis by a consultationliaison psychiatricteam. Turkish J Psychiatry. 2012;23:189192.

22. Salum I. Delirium tremens and certain other acute sequels of alcohol abuse.Acta Psychiatr Scand. 1972;235:15144.

23. Cushman P. Delirium tremens. Update on an old disorder. Postgrad Med.1987;82:117122.

24. Foy A, Kay J, Taylor A. The course of alcohol withdrawal in a generalhospital. Q J Med. 1997;90:253261.

25. Horstmann E, Conrad E, Daweke H. Severe course of delirium tremens.Results of treatment and late prognosis.Med Klin (Munich). 1989;84:569573.

26. Thiercelin N, Rabiah Lechevallier Z, Rusch E, et al. Risk factorsfor delirium tremens: A literature review. Rev Med Interne. 2012;33:1822.


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