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The ability of the Cognitive Status Examination (CSE), a brief neuropsychological screening instrument, to detect cognitive impairment in substance abusing patients was evaluated in 200 consecutive admissions to a drug/alcohol rehabilitation unit. While a significant proportion (25%) of patients screened were classified as impaired using the cutoff derived in the original study, agreement with an independent neurological impairment classification was much lower than that reported in the earlier work. Possible reasons for this discrepancy are discussed, including the relatively subtle nature of cognitive impairment in substance abusing patients. Implementation of regular screening did seem to heighten staff sensitivity to cognitive impairment in this sample. Alternate methods of determining the usefulness of cognitive screening tools (e.g., relationship to treatment relevant skills) are also discussed.

A contingency management system is described for enhancing participation in an inpatient chemical dependency rehabilitation program. The system employs reinforcers that are readily available in a residential milieu and makes receipt of them contingent upon appropriate patient behaviors. The behaviors include arranging aftercare treatment, involving family members in the treatment process, appropriate participation in ongoing treatment activities, and assisting with unit chores. A patient's status within the program is first regulated on a noncontingent basis, after which an accumulation of nine specified accomplishments results in the acquisition of a number of privileges. Accumulation of three demerits, given for inappropriate behaviors, results in a status reduction that can only be restored by completing ten additional behaviors. Improvement in patients' program involvement was documented in a number of areas, with a concomitant reduction in resistance to treatment. The system also resulted in an improvement in staff's charting of patients' behavior.

This paper examines definitions of alcoholism from theoretical and historical points of view. It begins with a review of definitions of alcoholism from the 19th century to the present, giving particular attention to medical approaches, psychiatric formulations, behavioral concepts, and definitions proposed by the American Psychiatric Association and the World Health Organization. It is concluded that current definitions differ widely in scope, the meanings attached to words like disease and disorder, the criteria for including signs and symptoms as essential characteristics, and the potential uses of the definitions. Based on these considerations, the practical issues of developing and applying clinically useful diagnostic procedures are discussed. The paper concludes with a discussion of diagnostic issues that should be considered in any effort to improve clinical identification, treatment planning and international communication.