An alcohol-dependence history should establish what the person drinks, how the pattern has changed, what happens when intake falls and how alcohol affects their life. Counting units is useful, but it does not replace asking about loss of control, withdrawal, immediate illness or the person's own reasons for seeking help.
This is an original MRCPsych CASC teaching exercise, not a recalled station. The clinical framing uses NICE alcohol-dependence guidance, NICE guidance on acute alcohol complications and the NHS explanation of alcohol units, checked on 27 September 2026. It does not provide a withdrawal prescription.
Agree the focus without confrontation
Start by asking what brought the person to the consultation and how they understand the concern. "Could you take me through a usual day of drinking, starting with yesterday?" is often easier to answer than "How much do you drink?" The latter may produce an estimate shaped by different glass sizes, irregular weeks or uncertainty about what counts.
Do not label the person as unreliable because their first account is incomplete. Ask neutral, concrete questions and explain why the detail matters. "I ask about the time of the last drink because stopping or reducing suddenly can sometimes cause important symptoms" connects the question to care rather than judgement.
When the person says a relative is exaggerating, explore the discrepancy without taking sides. Ask what the relative has noticed and what the person thinks has changed. An assessment can recognise the person's wish to keep working or improve sleep while still examining harmful effects.
Quantify consumption using actual drinks
Record the drink, container or serving size, alcohol by volume and frequency. "Four cans" is not a reproducible quantity without their size and strength. Ask about drinks at home and elsewhere, stronger products, refills and variation between weekdays and weekends.
The NHS calculation, checked on 27 September 2026, is:
UK alcohol units = volume in millilitres x ABV percentage / 1,000
One UK unit represents 10 ml of pure alcohol. This is a UK convention, not an interchangeable international "standard drink". The NHS units page is the source; using an American or Australian drink count without stating its definition can change the apparent consumption.
In this fictional example, a person reports four 500 ml cans at 5% ABV each evening. Each can contains 500 x 5 / 1,000 = 2.5 UK units, so the evening total is 10 units. If that exact pattern occurs on seven days, it totals 70 units for that week. Those are calculations from invented consumption data, not a recommended intake or a clinical severity score.
Now add uncertainty: the person reports an unmeasured spirit poured at home. Do not assign it an assumed quantity merely to finish the arithmetic. Establish the bottle strength and approximate serving volume, or record that this part remains uncertain. A transparent minimum estimate is more useful than a falsely precise total.
| Reported drink in the fictional history | Calculation | Interpretation |
|---|---|---|
| One 500 ml can at 5% ABV | 500 x 5 / 1,000 | 2.5 UK units |
| Four identical cans | 4 x 2.5 | 10 UK units |
| Same pattern on seven days | 7 x 10 | 70 UK units, if the pattern is accurate |
| Unmeasured additional spirit | Insufficient volume information | Clarify rather than invent a number |
Explore pattern and dependence features
Ask about the timing of drinking, the first drink of the day, alcohol-free periods, efforts to cut down and what happened during those efforts. Establish whether drinking occupies more time, whether the person drinks more than intended and whether other activities have been displaced. Explore craving and continued drinking despite recognised harm without assuming that a high weekly total alone establishes every dependence feature.
The history should distinguish a usual pattern from the recent pattern. Illness, loss of income, admission, travel or family pressure may cause an abrupt reduction. The amount consumed last week does not tell you what has happened during the last day.
Ask about tolerance in concrete terms: whether the person now needs more alcohol to obtain the effect previously experienced, or whether the pattern has changed for another reason. Do not turn one positive answer into a complete diagnostic conclusion. The NICE assessment framework supports considering dependence, associated problems and the wider clinical context together.
Ask about withdrawal and immediate concerns
Establish the time of the last drink and any recent reduction, then ask about symptoms during periods of reduced intake. Important history includes previous withdrawal seizures, severe confusion or delirium, and previous medically supported withdrawal. Ask about current physical symptoms and observations rather than presuming that the person is well because they are attending an interview.
NICE's acute-complications guidance, checked on 27 September 2026, supports hospital admission for acute withdrawal when there is a high risk of withdrawal seizures or delirium tremens, with additional consideration of vulnerability and support. A teaching conversation that reveals severe symptoms must recognise the need for urgent clinical assessment rather than continue solely to complete a checklist.
Do not advise a dependent person to stop suddenly as an unqualified closing instruction. NICE specifically warns about sudden reduction where appropriate support has not been arranged. The safe educational conclusion is to assess withdrawal risk and arrange the appropriate clinical pathway, not to prescribe an unsupervised alcohol schedule or a drug regimen in the article.
Understand physical, psychological and social consequences
Ask about injuries, falls, gastrointestinal symptoms, nutrition, sleep, memory and other medical concerns. Review mental health, self-harm or suicidal thoughts where relevant, and other substances or medicines that may change immediate risk. The history should connect problems to timing without assuming that alcohol explains every symptom.
Explore work, relationships, housing, finances, caring responsibilities and driving or other safety-sensitive activity. Use open questions before focused clarification. "What has become harder to manage?" may identify the person's priorities more effectively than a rapid list of consequences.
Avoid treating social stability as proof of low clinical concern. Someone can remain employed while experiencing dependence and dangerous withdrawal. Conversely, social adversity should not be used as a shortcut to a diagnosis. Document the specific impact and the support available.
Use an original branching interview
The fictional patient is an adult attending because their partner is worried. They describe evening drinking as a way to sleep, report the four-can pattern used above and initially say that work is unaffected. Their private role card includes two recent absences, morning shakiness after missed drinks and a previous episode of severe withdrawal requiring hospital care. These details are disclosed when asked respectfully, not all volunteered at the start.
Branch one: confrontational wording. The candidate says, "You must know that is far too much, so why have you not stopped?" The patient becomes defensive and says the partner is the real problem. The observer should not conclude that the patient is inherently difficult. The question contains judgement, assumes readiness and fails to assess the consequences of stopping.
Branch two: focused curiosity. The candidate says, "You have described drinking to help you sleep. What happens on a day when you drink less or cannot get alcohol?" The patient describes shakiness and the previous admission. The conversation now has information that changes clinical priorities.
A further branch introduces a recent reduction because of vomiting. The candidate must establish current symptoms and seek appropriate assessment rather than merely record a lower recent unit total as improvement. Reduced consumption can be clinically important for more than one reason.
Explore readiness and summarise the assessment
Ask what the person would like to change and what makes change difficult. They may prioritise getting to work, avoiding arguments or sleeping better rather than identifying abstinence as an immediate goal. Reflect the concern, explain the health issues identified and agree the next assessment or support step without turning a history task into an unsolicited lecture.
A concise fictional summary might be: "You have described regular evening drinking with an additional amount that we have not yet quantified. You report symptoms when intake falls and a previous severe withdrawal episode. Your recent vomiting and reduced intake need clinical assessment, and we should plan any change in drinking with appropriate support. You would also like help with sleep and maintaining work."
This summary separates reported facts, unresolved quantities, urgent concerns and personal goals. It does not claim that a particular unit total predicts a seizure, or that one conversation determines a complete treatment plan.
Debrief what the candidate actually established
Use a worksheet with the following fields: drink and strength, typical and recent pattern, last drink, dependence features, previous and current withdrawal concerns, physical and mental health, consequences, support, goals and next action. Record "not established" where necessary. Do not reward a complete-looking record built from assumptions.
The observer should identify one missed branch rather than say "take a fuller history". Examples include failing to distinguish usual from recent intake, not clarifying an unmeasured serving, or giving abrupt cessation advice before assessing withdrawal risk. Repeat the encounter with a changed pattern to test whether the correction transfers.
Per iatroX product information, September 2026, question-linked Socratic tutoring and conversational simulations can support rehearsal and explanation. They do not replace assessment of an unwell person, supervised psychiatric practice or the current local alcohol-treatment pathway.
Frequently asked questions
Does a weekly alcohol-unit total diagnose dependence?
No. The total is one part of assessment; pattern, control, withdrawal, associated harm and the wider clinical picture must also be explored.
Should every person who drinks heavily be told to stop immediately?
Not as an unqualified instruction. Possible dependence and withdrawal risk require assessment and an appropriately supported plan, particularly after previous severe withdrawal.
Can I assume the size of a drink to complete the calculation?
No. Clarify the serving and strength, or record the uncertainty rather than presenting an invented precise total.