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PS3.1 | Addiction Psychiatry — Assignment
CLINICAL SCENARIO
You are a final-year MBBS student posted in a general medicine ward in a district hospital. A 44-year-old male labourer, Mr Ramesh K., has been admitted for road traffic accident injuries. During the admission history, he discloses that he drinks 60–80 mL of country liquor (approximately 8–10 standard units) daily for the past 12 years. He scores 3/4 on CAGE (Cut down, Annoyed, Guilty) and has mild hepatomegaly on examination. He last drank 14 hours ago. Nursing staff note that he is tremulous and diaphoretic. His vitals: BP 155/92, HR 108, Temperature 37.4°C. His serum magnesium is 0.6 mg/dL. He says, 'I can stop anytime I want, but I need a drink right now.' His wife is present and is distressed about his drinking.
Instructions
Using the clinical scenario above, write a structured response addressing each section below. Your answer should reflect integration of ICD-11 diagnostic criteria, the alcohol withdrawal management protocol (including the correct thiamine-before-glucose sequence), evidence-based brief intervention techniques (FRAMES), and relapse-prevention pharmacotherapy options. Write in clinical note style where appropriate. Total length: 600–900 words across all sections.
Length: 600-900 words
What to Submit
1. Diagnosis and ICD-11 Classification
Apply ICD-11 criteria to classify Mr Ramesh K.'s alcohol use. Is this harmful use or dependence? Justify your answer by citing the three required features of ICD-11 dependence syndrome. What does his CAGE score indicate, and what are its limitations as a diagnostic tool?
2. Immediate Medical Assessment and Withdrawal Risk
Based on his vitals, tremor, diaphoresis, and the 14-hour post-cessation timeline, which stage of alcohol withdrawal is he in? What is the life-threatening complication you must anticipate over the next 48–72 hours? Why must thiamine be administered BEFORE intravenous dextrose if hypoglycaemia is detected? Identify the electrolyte abnormality present and explain its significance for his withdrawal seizure risk.
3. Withdrawal Management Plan
Outline a structured withdrawal management plan for the next 72 hours. Include: (a) first-line pharmacological agent (benzodiazepine choice and rationale), (b) thiamine supplementation regimen and timing, (c) correction of the identified electrolyte deficit, and (d) monitoring parameters (CIWA-Ar or clinical equivalent). Specify when you would escalate to ICU-level care.
4. Brief Intervention (FRAMES)
Mr Ramesh says 'I can stop anytime I want.' Apply the FRAMES brief intervention framework to this consultation. What motivational technique would you use to address his ambivalence? How would you involve his wife in a supportive (not enabling) role? Keep this section to 100–150 words in a practical, patient-centred tone.
5. Relapse-Prevention Pharmacotherapy
After successful detoxification, which pharmacological agent would you consider for relapse prevention, and why? Compare disulfiram, naltrexone, and acamprosate on mechanism of action and suitability given his hepatomegaly. Identify which agent(s) require caution or are contraindicated in the presence of liver disease.
Grading Rubric — Addiction Psychiatry Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| ICD-11 Diagnosis: Correctly applies the three dependence criteria (impaired control, increasing priority, physiological features) and distinguishes dependence from harmful use; accurately interprets CAGE ≥2 as positive screen while acknowledging it is not a diagnostic instrument | 10 pts | All three ICD-11 dependence features correctly identified and applied to the case; CAGE score accurately interpreted with clear statement of its screening (not diagnostic) role |
| Withdrawal Timeline and Risk Identification: Correctly identifies current withdrawal stage (uncomplicated, 14 hours post-cessation); anticipates delirium tremens at 48–72 hours; recognises hypomagnesaemia as seizure-risk amplifier; correctly states thiamine-before-glucose rule with rationale (Wernicke prevention) | 10 pts | All four elements present: correct stage, DTs anticipated at 48–72 h, thiamine-before-glucose with Wernicke rationale, hypomagnesaemia and seizure risk clearly linked |
| Withdrawal Management Plan: Identifies benzodiazepine as first-line agent (with rationale: GABA-A agonism, cross-tolerance); includes thiamine 100 mg IV before dextrose; corrects hypomagnesaemia; specifies monitoring (CIWA-Ar or clinical equivalent) and escalation criteria for ICU | 10 pts | All four components: correct BZD with rationale, thiamine timing, Mg correction, CIWA-Ar monitoring, and explicit ICU escalation criteria (e.g., DTs, refractory seizures) |
| Brief Intervention (FRAMES): Applies Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy framework in a non-confrontational, patient-centred manner; addresses ambivalence appropriately; roles wife supportively without enabling | 10 pts | FRAMES clearly applied; motivational technique (e.g., reflective listening, decisional balance) used for 'I can stop anytime'; wife's role described supportively and appropriately |
| Relapse-Prevention Pharmacotherapy: Compares disulfiram, naltrexone, and acamprosate on mechanism and hepatic safety; correctly identifies disulfiram and naltrexone as requiring caution in liver disease; recommends acamprosate with rationale | 10 pts | All three agents compared by mechanism (aversion/reward/GABA-glutamate); hepatic safety correctly addressed; acamprosate recommended with rationale (renally cleared, safe in liver disease) |
PEER REVIEW
Review your peer's submission using the 5-criterion rubric above. For each criterion, assign a score (2, 4, 6, 8, or 10) and write 2–3 sentences explaining your rating. Focus on: (1) accuracy of ICD-11 diagnostic criteria application, (2) completeness and clinical safety of the withdrawal management plan (especially thiamine timing and DTs anticipation), (3) evidence-based pharmacotherapy reasoning. Offer one specific suggestion for improvement under each criterion. Your peer review should be constructive, specific, and written as you would a clinical supervisor's feedback.