From Psychic And Physical Dependence To Dependence Syndrome

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The changing perspectives on the general concept of drug dependence, given momentum by the 1977 WHO report on alcohol and by other research, were ultimately reflected in changes in the definitions and other positions of the World Health Organization and in its 1980 International Classification of Diseases, 9th edition (ICD-9). With its publication, the concept of an alcohol dependence syndrome formally emerged at an international level. The ICD-9 concept of dependence was based on a 1976 proposal by researchers Griffith Edwards and Milton Gross, who defined seven characteristics of the alcohol dependence syndrome and proposed that there are certain implicit assumptions to the syndrome: First, it is a symptom complex involving both biological processes and learning. Second, it should be defined along a continuum of severity, rather than as a discrete category. Third, dependence should be differentiated from alcohol-related disabilities. Both dependence and disabilities exist in degrees, rather than on an all-or-none basis. There is some evidence that people with more severe degrees of alcohol dependence who seek treatment have a different clinical course from those with less severe dependence.

By the late 1970s, the American Psychiatric Association's Diagnostic and Statistical Manual, 3rd edition (DSM-III), moved away from more descriptive and psychodynamic orientation toward a nomenclature in which specific diagnostic criteria were laid out for specific syndromes. In the case of alcohol and drug dependence, the original drafts of DSM-III considered inclusion of a dependence syndrome that varied in degree of severity and in which tolerance and physical dependence were important, but not essential, criteria for diagnosis. At the last moment, however, it was decided that tolerance and physical dependence were both necessary and sufficient for a diagnosis of drug dependence; the presence of other criteria listed were by themselves insufficient without tolerance and physical dependence. Nevertheless, by distinguishing drug (or alcohol) dependence from drug (or alcohol) abuse, DSM-III recognized the two-dimensional conceptualization previously put forth in the WHO report of 1977 and in ICD-9.

In 1980, during the short interval between the publication of DSM-III and the beginning of work on DSM-III-R, a WHO working group met to further refine terminology. One result of the meeting was the publication of a WHO memorandum on nomenclature and classification of drug- and alcohol-related problems that endorsed the concept that drug dependence is a syndrome that exists in degrees and that can be inferred from the way in which drug use takes priority over a drug user's once-held VALUES. The criteria for making this inference included many of those mentioned by Edwards and Gross in their 1976 paper and some that had been developed for DSM-III. The WHO memorandum, while recognizing the importance of tolerance and physical dependence, did not view these phenomena as always essential and required. It endorsed again the two-dimensional perspective— not all drug or alcohol problems are manifestations of dependence; and harmful or hazardous use can occur independently of the decreased flexibility and constricted choice that are the hallmarks of the dependence syndrome. This perspective was underscored by pointing out that the presence of physical dependence per se (as in the case of patients taking drugs for pain) was not in itself sufficient for the diagnosis of dependence. The memorandum also presented a model of dependence emphasizing that the dependence phenomenon is not a property of the individual but resides in the relationships among the elements in the model— social, psychological, and biological. This view has been called the biopsychosocial model.

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