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by further drinking, a subjective awareness of a compulsion to drink and rapid reinstatement after a period of abstinence (Edwards and Gross 1976). In the subsequent WHO formulation, dependence was described as consisting of the following:-
• an altered behavioural state, referring primarily to diminished variability in the individual’s
drinking behaviour, to continued drinking in the face of negative consequences such as illness or social sanction and to the salience of drink seeking behaviour over other important activities;
• an altered subjective state, referring primarily to impaired control or its subjective concomitant, to the experience of craving and the drink centredness of thoughts;
• an altered psycho-biological state, referring primarily to the development of tolerance and withdrawal with relief drinking to avoid or ameliorate the symptoms of withdrawal. (Edwards et al. 1977a).
The dependence syndrome formulation departed in significant ways from the condition described as alcoholism which preceded it. The previously held components of loss of control and craving were reformulated into subjective experiences rather than inevitable, biologically based and universally observed phenomena. As the term syndrome suggests, there is a clustering of certain elements not all of which need be present or present in the same degree, but with greater severity of the condition more of the symptoms are likely to be manifest in growing intensity. An attempt to show whether specific symptoms were associated with lower and with higher degrees of dependence revealed that the symptom of ‘loss of control’ tended to appear early in the development of the syndrome but this was not the case for all subjects (Chick and Duffy 1979).
Stockwell and colleagues (1994) collected data on the Severity of Alcohol Dependence Questionnaire in a general population sample in Western Australia and showed that dependence could be detected on a continuum in the whole population. A qualification of the finding of Stockwell and colleagues stems from the fact that they used primarily symptoms of physical and affective withdrawal to measure dependence. When subjects were asked whether they drank in order to relieve these symptoms, a far smaller proportion of the general population sample than the clinical samples said that they did. Critiques of the syndrome idea have suggested that retaining tolerance and withdrawal as part of dependence rather than a closely related phenomenon results in confusion between the effects of consumption and the nature of dependence.
Using a modified concept of dependence Raistrick and his colleagues showed a different distribution of dependence in the general population to that of a clinical population during the
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