History Taking · Intermediate · Psychiatry

Alcohol Misuse and Dependency Concerns

Practise this PLAB 2 history taking station on Alcohol Dependence. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr John Mason, a 52-year-old man, has come to see you for a routine blood test follow-up. The results show deranged liver function, and you suspect alcohol-related liver disease. Please take a focused history of alcohol use and discuss screening tools and management options.

Background notes: PMH: Hypertension, no diabetes, no depression diagnosed

What this station tests

  • CAGE questionnaire as a screening tool for alcohol dependence
  • ICD-11 dependence features: compulsion, impaired control, withdrawal, tolerance, neglect, persistent use despite harm
  • Graduated alcohol history: patients minimise, require gentle but persistent questioning
  • Do not advise sudden cessation if dependent: withdrawal can cause seizures and death
  • Brief intervention: express concern, provide information, offer support without coercion

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Alcohol dependence identified through abnormal bloods requires the candidate to take an accurate alcohol history from a patient who will minimise, assess for dependence features, and offer support without judgment. Mr Mason is 52, attending for blood results showing raised GGT and MCV. He expects to be told everything is fine. Open with: 'Mr Mason, I have your blood results. There are some changes I want to discuss with you. Tell me about your drinking habits.'

Core approach

Take a graduated alcohol history. He will minimise initially ('a few pints after work'). Use the CAGE questionnaire: Cut down (has he tried?), Annoyed (irritated by comments about drinking?), Guilty (about drinking?), Eye-opener (morning drink to steady nerves?). Quantify: units per week, pattern (daily, binge), type of drink, where (home alone is more concerning than social drinking).

Assess for dependence features (ICD-11). Compulsion to drink. Difficulty controlling intake. Withdrawal symptoms (morning shakes, anxiety, sweating). Tolerance (needing more to achieve the same effect). Neglecting other activities. Continuing despite harm. Three or more indicates dependence.

Screen for complications. Liver disease (elevated GGT, MCV suggesting macrocytosis). Mental health: depression, anxiety (alcohol is both a cause and a consequence). Relationships: his wife has been concerned, children are distancing. Work: any impact? Any legal issues (drink-driving)?

Closing and safety netting

Communicate the blood results honestly. 'Your liver enzymes and blood count are showing the effects of alcohol. This tells me your body is being affected even if you feel well.' If dependence features present: do not advise sudden cessation (withdrawal can be dangerous). Refer to alcohol services for supervised detoxification if needed. Brief intervention: express concern, provide information, offer support.

If he is in pre-contemplation (not ready to change): do not force. 'I am not here to judge. But I want you to know that support is available when you are ready.' Give written information. Follow-up bloods in 3 months. Safety net: 'If you develop jaundice, abdominal swelling, vomiting blood, or confusion, come in urgently.' Drinkline and local alcohol services contact details.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for alcohol dependence. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: CAGE applied. Dependence features assessed. Alcohol quantified accurately. Complications screened. Psychosocial impact explored.

Costs marks: Accepting minimised history. Not assessing dependence. Not screening complications.

Domain 2 (Primary focus)

Scores well: Blood results explained. Brief intervention delivered. Alcohol services referral offered. Not advising sudden cessation if dependent. Follow-up bloods. Complications safety netting.

Costs marks: Advising sudden cessation. No referral. No follow-up.

Domain 3 (Primary focus)

Scores well: Non-judgmental throughout. Exploring ambivalence. Not forcing change. Leaving the door open. Acknowledging family impact.

Costs marks: Being judgmental. Being coercive. Lecturing. Closing the door if he is not ready.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Accepting the initial minimised history: 'a few pints' often means much more, and candidates must probe further
  2. Advising sudden cessation without assessing dependence: alcohol withdrawal in dependent drinkers can be fatal
  3. Being judgmental: judgment shuts down communication and prevents the patient from returning

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this alcohol dependence station?

Alcohol dependence identified through abnormal bloods requires the candidate to take an accurate alcohol history from a patient who will minimise, assess for dependence features, and offer support without judgment. Mr Mason is 52, attending for blood results showing raised GGT and MCV. He expects to be told everything is fine.

What does a strong performance look like to the examiner in this station?

Strong performances show: CAGE applied. Dependence features assessed. Alcohol quantified accurately. Complications screened. Psychosocial impact explored. Weak performances: Accepting minimised history. Not assessing dependence. Not screening complications.

What is the biggest pitfall in this alcohol dependence station?

Accepting the initial minimised history: 'a few pints' often means much more, and candidates must probe further.

How should I prepare for alcohol dependence if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: ICD-11 dependence features: compulsion, impaired control, withdrawal, tolerance, neglect, persistent use despite harm. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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