The criteria for dependence also include those that indicate physiological dependence (tolerance and withdrawal), as well as a loss of control as evidenced by repeated unsuccessful attempts to quit or cut down.

The term “addiction” closely resembles the definition of “dependence” as found in the DSM-IV. This is because the definition of dependence implies that there has been some change in the way the brain is functioning, as evidenced by the development of tolerance and withdrawal symptoms and by loss of control, which indicates the development of cravings.

But in an individual case, the distinction between abuse and dependence is not always clear, because behavioral or descriptive criteria are imprecise. For practical purposes, we can say that people who meet the criteria for the abuse of a substance are at high risk for developing addiction or for already having the brain dysfunction that constitutes dependence or addiction.

For the clinician, distinguishing abuse from dependence is difficult but has important implications for predicting the course and prognosis of an individual’s case.

Dependence implies that biologically based addiction has occurred with the associated changes in brain functioning. If it were possible to measure this brain dysfunction with a scan or a test, the determination would be easy. But we can’t do that, so we infer the diagnosis from behavior and history.

The philosophy of successful addiction treatment is based on the idea of complete abstinence from all mood-altering chemicals. This approach is the result of years of experience on the part of clinicians and of those with long-term recovery in programs such as Alcoholics Anonymous.

But now and then a study is done revealing that a number of people who have gone through treatment for “alcoholism” have returned, apparently successfully, to social drinking. It may be that what was felt to be alcoholism was actually alcohol abuse and was not yet associated with the brain changes that occur in alcohol dependence. Until the distinction between alcohol abuse and dependence can be made with certainty, it would seem prudent to recommend total abstinence.

The criteria for diagnosing abuse or dependence are based on a look at the consequences that have occurred. But since the nature and degree of the consequences caused by the use of the substance depend to a large extent on what individuals are doing while intoxicated, it is also important to consider the entire context of their lives. For example, it can be difficult to identify any negative consequences of drinking (such as DUI arrests or loss of jobs) in a housewife who does all of her drinking at home alone. This is one of the reasons why alcoholism in women has been underrecognized. But a close look at the quality of such a person’s relationships and achievements in the context of her social setting can often clarify the picture.

The stage of life someone is in is also important to consider.