Mood disturbance

This is an important feature of the withdrawal syndrome. Mildly dependent individuals may feel 'a bit edgy'. Severely dependent individuals may present with clinically significant symptoms of anxiety and depression.

Relief or avoidance of withdrawal symptoms by further drinking

In the early stages of dependence individuals may find that they need a lunchtime drink to alleviate discomfort. As dependence progresses there emerges the need for an early morning drink to relieve the symptoms of alcohol withdrawal coming on after a night's abstinence. Later, individuals may wake in the middle of the night for a drink, and alcohol is often kept by the bed. If they have to go for 3 or 4 h without a drink during the day, they value the next drink for its relief effect.

Clues to the degree of dependence can be obtained by taking a detailed history of the first drink of the day. The person drinking from a bottle kept by the side of the bed before they get up is more dependent than the person who has breakfast and reads the paper first. The woman who pours whisky into her first cup of tea is more dependent than the librarian who slips out to the lavatory at midday to drink from a quarter bottle of vodka hidden in her handbag.

Subjective awareness of compulsion to drink

This describes an altered subjective experience of an inability to limit drinking to an acceptable level. Although the familiar term 'loss of control' has been used to denote this element, it is more likely that control has been 'impaired' rather than lost.

Another complex experience is that of 'craving', the subjective experience of which is greatly influenced by environment. Individuals can experience craving of very different intensities on different occasions. Cues for craving include the experience of intoxication, the withdrawal syndrome, mood (anger, depression, elation), or situational cues (being in a pub (bar), passing an off-licence (liquor store)).

Here the key experience may best be described as a compulsion to drink. The desire for a further drink is seen as irrational, and is resisted, but despite this a further drink is taken.

Reinstatement after abstinence

Alcohol dependent individuals who begin to drink again after a period of abstinence invariably relapse back into the previous stage of the dependence syndrome. This process occurs over a variable time course, with moderately dependent individuals perhaps taking weeks or months and severely dependent individuals taking a couple of days.

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