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identifiable by evidence of the withdrawal syndrome itself or by use of the same or a similar substance to relieve or avoid withdrawal symptoms.
The guidelines also state that the subjective awareness of compulsion to use drugs, the ‘strong desire or sense of compulsion’ is most commonly seen during attempts to stop or control substance use. However, this becomes an essential feature for the diagnosis of dependence during times of abstinence, according to the guidelines.
The remaining three of the seven features described are ‘difficulties in controlling use’, ‘continued use in the face of harmful consequences’ and ‘progressive neglect of other activities in favour of the substance use’. The guidelines go on to say that ‘narrowing of the repertoire of patterns of use’ has also been described as a characteristic feature but it is unclear what is its status alongside the seven characteristic features of which at least three must be present for a diagnosis. Thus while tolerance and withdrawal are seen as diagnostic criteria, they are neither necessary (as they constitute two out of the seven features) nor sufficient for a diagnosis of the dependence syndrome. What distinguishes this from the psychological theories of dependence is that these phenomena do represent central features of the syndrome and are given greater importance than behavioural features like the narrowing of the repertoire or the planning of daily activities around the use of the substance.
Withdrawal is separately defined as “A group of symptoms of variable clustering and severity occurring after repeated and usually prolonged and/or high dose use of that substance” and no mention of dependence is made at all in this section.
The disaggregated approach wherein substance abuse is distinguished from substance dependence has an interesting history in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the second version (DSM-II), the term dependence included both psychological and physiological dependence. In DSM-III, dependence is used only in the physiological sense and “requires evidence of either tolerance or withdrawal” (American Psychiatric Association 1980 p. 381). In this version, the behavioural components of loss of control and salience of drug seeking behaviour fell under the heading of substance abuse. Moreover, this heading combined both the psychological descriptors of the condition with physical (with the exception of tolerance and withdrawal), psychological and social consequences. In the revised version of DSM-III, DSM-III-R, substance dependence was re-defined along the lines of the dependence syndrome (Edwards et al. 1982) and included impaired control, repeated attempts to cut down or stop, salience of drug seeking and using behaviours, frequent intoxication, withdrawal and continued use despite consequences, evidence of tolerance, withdrawal symptoms and relief use. It included the
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