Describe each substance separately
Establish what is used, the route, approximate amount, frequency, duration and most recent use. Ask about more than one substance, including tobacco and medicines used outside the prescribed plan. Record the units and preparation described rather than converting an uncertain account into a falsely precise quantity.
Compare the current pattern with earlier periods. Ask about the circumstances of starting, escalation, periods without use and what accompanied a return to use. The reason for seeking help now may differ from the reason use began.
Separate related phenomena
Intoxication, withdrawal, tolerance and the longer-term pattern of impaired control describe different aspects of substance use. They should not be used interchangeably. A physiological response to a substance is not, on its own, a complete account of dependence or addiction.
The supplied history-taking handout uses an older ICD-10 dependence framework. Use it for interview organization, not as a current classification checklist. Record the actual features and consult the classification system in use when a clinician assigns a diagnosis.
Explore effects and goals
Ask about physical health, mood, cognition, relationships, responsibilities and financial consequences. Establish whether psychiatric symptoms appeared before use, during use, during withdrawal or in sustained periods without use. These temporal details help a clinician examine co-occurrence and alternative explanations.
Include previous efforts to change, helpful supports and the person’s present goals. Describe barriers without moral labels. This article is an interview framework; acute intoxication and withdrawal require assessment under the appropriate clinical service and local protocol.
For your next supervision discussion
Compare a reported quantity with the pattern over time. What additional information would help distinguish acute effects, physiological adaptation and the longer-term effect on daily responsibilities?
References · 3
Page numbers distinguish PDF position from the numbering visible within the supplied document.
- Psychiatric history takingNitin Sethi · Edition and year not established.Substance use disorders. PDF pages 67, 68, 69; printed pages: 63–65.Supports: Exposure, course, consequences and goals.
- Introduction to Addiction PsychiatryR. Andrew Chambers and Kevin G. Masterson · 2025.Addiction: clinical phenomenology. PDF pages 48, 49; printed pages: 37–38.Supports: Distinguishing intoxication, withdrawal, tolerance and addiction.
- Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disordersWorld Health Organization · 2024.Substance dependence. PDF pages 481, 482; printed pages: 463–464.Supports: Current classification differs from the older handout.