• Socio- demographic details

• Presenting problems and reasons for seeking treatment

• Details of alcohol use including alcohol use history timeline (including age started drinking, first problems, drinking pattern, type of drink, quantity, frequency)

• Any behaviours associated with alcohol use that may risk the person’s health and the health of others (where, when and with whom alcohol consumption typically occurs, what triggers alcohol consumption, activities when intoxicated, financial implications, capacity to care for children, and violence towards others)

• Commencement and development of alcohol use in relation to other life events, for example, by taking a chronological history

• Features of harmful use/ dependence

• Social networks and the person’s alcohol consumption patterns

• Current situation (accommodation, living arrangements, relationships, children, social support, work/study, legal issues, other agencies involved in care)

• Risk assessment for self-harm/ suicide, aggression and violence

• Adverse consequences due to alcohol use

• Details of use of other psychoactive substances

• Details of past abstinent attempts

• Details of past treatment sought

• Past medical and surgical history

• Conditions that may contraindicate use of certain medications

• Family history

• Personal history

• Premorbid personality

• Signs of intoxication

• Signs of withdrawals

• Physical complications (Liver disease: jaundiced (yellow) skin and eyes, palpable and tender liver edge (in early liver disease), ascites (distended abdomen filled with fluid), spider naevi (spider-like blood vessels visible on the surface of the skin), and altered mental status (hepatic encephalopathy); Cerebellar damage: Look for problems with balance, walking, coordinating movements, and nystagmus.)

• Physical/ psychiatric comorbidity

• Conditions that may contraindicate use of certain medications

• Guided by the clinical assessment

• Common investigations include-

  • complete haemogram

  • blood sugar levels

  • serum electrolytes

  • liver function test

  • renal function test

  • ultra-sonogram of abdomen

  • fibroscan

• Investigations for other possible causes of clinical presentation and co-occurring medical conditions

A transient condition following the administration of alcohol, resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.

This should be a main diagnosis only in cases where intoxication occurs without more persistent alcohol- related problems being concomitantly present.

Some of the clinical features of acute alcohol intoxication include-

• Dysfunctional behavior, as evidenced by:

  • disinhibition

  • argumentativeness

  • aggression

  • lability of mood

  • impaired attention

  • impaired judgement

  • interference with personal functioning

• Other signs:

  • unsteady gait

  • difficulty standing

  • slurred speech

  • nystagmus

  • decreased level of consciousness (e.g. stupor, coma)

  • flushed face

  • conjunctival injection

A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of alcohol after repeated, and usually prolonged and/or high-dose, use of alcohol. The withdrawal state may be complicated by convulsions.

Some clinical features of alcohol withdrawal state include-

• tremor of the outstretched hands, tongue or eyelids

• sweating

• nausea, retching or vomiting

• tachycardia or hypertension

• psychomotor agitation

• headache

• insomnia

• malaise or weakness

• transient visual, tactile or auditory hallucinations or illusions

• grand mal convulsions

A pattern of alcohol use that is causing damage to health. The damage may be physical (e.g. alcoholic liver disease) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol). The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.

A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

• a strong desire or sense of compulsion to take alcohol

• difficulties in controlling alcohol-taking behaviour in terms of its onset, termination, or levels of use

• a physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by the characteristic withdrawal syndrome for alcohol, or use of alcohol or a closely related substance with the intention of relieving or avoiding withdrawal symptoms

• evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses

• progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects

• persisting with alcohol use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy alcohol use, or alcohol-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm