From basic concepts to clinical reality. Unresolved issues in the diagnosis of dependence

This chapter discusses clinical and conceptual issues pertaining to the diagnosis of alcohol and drug dependence. Emphasis is given to the difficulties involved in moving from diagnostic concepts, such as those contained in the major psychiatric classification systems, to the clinical situation where diagnostic decisions are made. To illustrate how diagnostic concepts approximate clinical reality, a set of case histories is used to organize a discussion of unresolved issues in the diagnosis of dependence. These issues include the putative syndrome nature of dependence, the problem of diagnosing polysubstance use, the primary-secondary distinction, the presence of other psychopathology, and the use of multiaxial evaluation.