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prolonged period of abstinence (p. 148) but the implications of this are not at all clear.
Many other disease models and psychological formulations of alcoholism were in existence at the time of Jellinek’s writing during the nineteen-forties, fifties and sixties and Jellinek provided
an extensive summary and critique of these. His own formulations were based in a reading of this international literature, of current research and in “a sample of slightly over 2,000 members of Alcoholics Anonymous” (Jellinek 1960 p. 38) and probably represent the most comprehensive description of the variety of manifestations of the condition, with hypotheses about the underlying mechanisms and etiology, but little on the natural history and outcome.
Characteristic of disease formulations was the centrality of the biological state, referred to as the neuroadapted state (Edwards et al. 1982) wherein repeated administrations of a drug result in the development of tolerance and withdrawal symptoms may follow abrupt cessation or marked reduction in the use of the drug once tolerance is established. In this framework of understanding, dependence on a specific drug constitutes a different, if similar phenomenon to dependence on another specific drug as tolerance develops in different ways and withdrawal symptoms vary with the pharmacological properties of the drug. By definition, if biological factors are understood to be components of dependence itself, then dependence must be substance specific and have different manifestations for different drugs. Dependence is seen as a categorical condition whether its source is understood to be in the characteristics of certain people or the properties of certain drugs. Although biological approaches have been criticised for their inability to explain or even describe the phenomena of repeated, compulsive use of drugs where no neuroadapted state has occurred, the term dependence is sometimes used as a simple shorthand for tolerance and withdrawal.
1.4.1 The debate about disease theories of dependence
The twentieth century has seen considerable discussion of the nature of disease, most particularly in the mental health field (Sedgwick 1982; Kendell 1975). Questions of definition revolve around whether the idea of disease denotes an objective state, whether it is a culturally specified construct, a statistical or a diagnostic phenomenon, what is the role of the individual: victim or active agent, does it imply inevitable deterioration, a predictable natural history, the requirement of treatment? It is not the purpose here to enter this debate, nor to suggest or justify one definition or another. In the addiction literature the term has been loosely applied to characterise theories of addiction and dependence which share particular features. Writing in 1994, Miller and Kurtz (1994) summarised four core assumptions of what they described as “a classic dispositional
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