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1.5 Dependence as a bio-psycho-social phenomenon
In spite of the exhortation by Edwards et al.(1982) to separate what was previously referred to as physical dependence from psychological dependence by giving it the name neuroadaptation and seeing it as a consequence of the repeated use of a substance rather than part of the phenomenon of dependence itself, nonetheless this neuroadapted state was retained as an element of the dependence syndrome. Probably the most prevalent view currently in the scientific literature is that dependence is a ‘bio-psycho-social’ condition with, as the name suggests, biological, social and psychological features coexisting as essential components. In this formulation, the dependence syndrome concept was first described with reference to alcohol (Edwards and Gross 1976). The authors of this provisional description were keen to emphasise the need to progress the debate on the nature of the condition from the circular theorising which characterised the previously held disease concept (Jellinek 1960). The central tenets of the disease formulations of alcohol dependence, namely loss of control and craving, the categorical nature of the condition and the inevitability of deterioration in the event of continued drinking were being called into question by a growing body of empirical evidence. There was, however, some question of whether the syndrome idea was not yet another disease based formulation of dependence as in many of its descriptions the centrality of tolerance and withdrawal is retained, the pathological nature of the state is referred to and the question of whether or not there is a decline in dependence once established is implicit in the ‘reinstatement’ marker. Rapid reinstatement of the syndrome following a period of abstinence was one of the markers of dependence listed in the World Health Organisation (WHO) formulation (Edwards et al. 1982).
While the disease concept could be said to be holding sway up to the middle of the twentieth century, a landmark study which caused heated debate in the field was reported by Davies (1962). He and a colleague at the Maudsley Hospital followed up 93 patients who had been suffering from alcohol addiction and found that seven of them reported “having been able to drink normally for periods of seven to eleven years after discharge from hospital”. Addiction was defined according to the WHO (1955) criteria as a categorical condition with the characteristics noted above. Normal drinking was defined as “their use of alcohol has never gone beyond the limits regarded as permissible in the cultural groups from which they are drawn” (Davies 1962). The criteria used in the assessment of these patients for alcohol addiction included pattern of use, withdrawal symptoms and maximum recent recorded intake. It is not clear how consistently this diagnosis was applied. Certainly they all experienced serious alcohol related problems, but on the question of symptoms of
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