DSM-IV Diagnosis Of Alcohol Dependence Research Articles

Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder

Although classic psychedelic medications have shown promise in the treatment of alcohol use disorder (AUD), the efficacy of psilocybin remains unknown. To evaluate whether 2 administrations of high-dose psilocybin improve the percentage of heavy drinking days in patients with AUD undergoing psychotherapy relative to outcomes observed with active placebo medication and psychotherapy. In this double-blind randomized clinical trial, participants were offered 12 weeks of manualized psychotherapy and were randomly assigned to receive psilocybin vs diphenhydramine during 2 day-long medication sessions at weeks 4 and 8. Outcomes were assessed over the 32-week double-blind period following the first dose of study medication. The study was conducted at 2 academic centers in the US. Participants were recruited from the community between March 12, 2014, and March 19, 2020. Adults aged 25 to 65 years with a DSM-IV diagnosis of alcohol dependence and at least 4 heavy drinking days during the 30 days prior to screening were included. Exclusion criteria included major psychiatric and drug use disorders, hallucinogen use, medical conditions that contraindicated the study medications, use of exclusionary medications, and current treatment for AUD. Study medications were psilocybin, 25 mg/70 kg, vs diphenhydramine, 50 mg (first session), and psilocybin, 25-40 mg/70 kg, vs diphenhydramine, 50-100 mg (second session). Psychotherapy included motivational enhancement therapy and cognitive behavioral therapy. The primary outcome was percentage of heavy drinking days, assessed using a timeline followback interview, contrasted between groups over the 32-week period following the first administration of study medication using multivariate repeated-measures analysis of variance. A total of 95 participants (mean [SD] age, 46 [12] years; 42 [44.2%] female) were randomized (49 to psilocybin and 46 to diphenhydramine). One participant (1.1%) was American Indian/Alaska Native, 3 (3.2%) were Asian, 4 (4.2%) were Black, 14 (14.7%) were Hispanic, and 75 (78.9%) were non-Hispanic White. Of the 95 randomized participants, 93 received at least 1 dose of study medication and were included in the primary outcome analysis. Percentage of heavy drinking days during the 32-week double-blind period was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group, a mean difference of 13.9%; (95% CI, 3.0-24.7; F1,86 = 6.43; P = .01). Mean daily alcohol consumption (number of standard drinks per day) was also lower in the psilocybin group. There were no serious adverse events among participants who received psilocybin. Psilocybin administered in combination with psychotherapy produced robust decreases in percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These results provide support for further study of psilocybin-assisted treatment for AUD. ClinicalTrials.gov Identifier: NCT02061293.

Alcohol Craving Predicts Relapse After Residential Addiction Treatment.

Replicate the previously reported association of elevated alcohol craving, measured by Penn Alcohol Craving Scale (PACS) during residential treatment, with post-treatment relapse and explore whether elevated craving scores 3 months post-treatment are also associated with subsequent relapse. Alcohol craving was assessed with the PACS on admission and at several time points post-treatment in 190 subjects with DSM-IV diagnosis of alcohol dependence admitted to residential treatment. Data about relapse to any drinking (primary outcome measure) was collected at 3, 6, 9 and 12 months after treatment. Cox regression models were used to determine whether PACS scores were associated with relapse. Statistical models were adjusted for meaningful demographic and clinical covariates. Follow-up data was available for 149/190 (78%) of subjects. Elevated PACS scores at discharge were associated with increased relapse risk within the first 3 and 12 months after discharge (P = 0.032 and P = 0.045, respectively). Elevated PACS scores at 3 months were associated with increased risk of subsequent relapse within 12 months after treatment in contacted subjects (P = 0.034) and in the intent-to-treat analysis (P = 0.0001). Our findings indicate strong association of post-treatment relapse with elevated alcohol craving measured at treatment completion and at 3 months after treatment and justify the use of this measure to guide relapse-prevention efforts.

Spiritual awakening predicts improved drinking outcomes in a Polish treatment sample.

This study examined concurrent and longitudinal associations between two dimensions of affiliation in Alcoholics Anonymous (AA)-attendance and spiritual awakening-and drinking outcomes among adult patients who were in treatment for alcohol dependence in Warsaw, Poland. In a study conducted at four addiction treatment centers, male and female patients (n = 118) with a DSM-IV diagnosis of alcohol dependence were assessed at baseline (Time 1 or T1), 1 month (T2), and 6-12 months postbaseline (T3) for AA meeting attendance, various aspects of AA affiliation, and alcohol use. Alcoholics Anonymous meeting attendance and alcohol consumption were measured using the Timeline Followback interview. Self-report of having had a spiritual awakening was measured using a modified version of the Alcoholics Anonymous Involvement Scale. There were no cross-sectional or longitudinal associations between AA meeting attendance and improved drinking outcomes. In contrast, self-report of a spiritual awakening between T2 and T3 was significantly associated with abstinence (OR = 2.4, p < .05) and the absence of any heavy drinking (OR = 3.0, p < .05) at T3, even when demographic and clinical characteristics were statistically controlled. Self-reports of spiritual awakening predicted improved drinking outcomes in a Polish treatment sample.

The microstructural integrity of the corpus callosum and associated impulsivity in alcohol dependence: A tractography-based segmentation study using diffusion spectrum imaging

Previous post-mortem and structural magnetic resonance imaging (MRI) studies in patients with alcohol dependence have demonstrated abnormalities of brain white matter. The present study investigated the microstructural integrity in the corpus callosum and the associations of this integrity with neurobehavioral assessments. Twenty-five male cases fulfilling the DSM-IV diagnosis of alcohol dependence and 15 male control subjects were scanned using a 3T MRI system. Callosal fiber tracts were reconstructed by diffusion spectrum imaging tractography and were subdivided into seven functionally distinct segments. The microstructural integrity was quantified in terms of generalized fractional anisotropy (GFA). Compared with normal subjects, men with alcohol dependence showed lower GFA values on all segments of the corpus callosum. The segment interconnecting the bilateral orbitofrontal cortices was the most affected. The score on the Barratt Impulsivity Scale showed an inverse relationship with GFA on the callosal fiber tracts connecting the bilateral orbitofrontal cortices. Furthermore, the duration of regular use was negatively associated with GFA on the callosal fiber tracts connecting the bilateral temporal and parietal cortices. Our findings suggest that a high self-rated impulsivity level was associated with low anisotropy in white matter of corpus callosum sectors extending to the orbitofrontal cortex.

Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients

A new training to decrease attentional bias (attentional bias modification training, ABM) was tested in a randomized controlled experimental study with alcohol-dependent patients as an addition to cognitive behavioral therapy. In alcohol dependence, attentional bias has been associated with severity of alcoholism, craving, treatment outcome, and relapse. Forty-three patients with DSM-IV diagnosis of alcohol dependence were randomly assigned to an ABM intervention or control training. The procedure consisted of five sessions in which patients were trained to disengage attention from alcohol-related stimuli (ABM condition) or in which they were trained on an irrelevant reaction-time test (control condition). We measured the effects of ABM on the visual-probe task, with stimuli that were presented in the ABM and with new stimuli. Craving was measured with the Desires for Alcohol Questionnaire. Follow-up data were gathered for overall treatment success, and relapse up to 3 months after the intervention. ABM was effective in increasing the ability to disengage from alcohol-related cues. This effect generalized to untrained, new stimuli. There were no significant effects on subjective craving. For other outcome measures there were indications of clinically relevant effects. Results indicate that ABM among alcohol-dependent patients was effective and that it may affect treatment progression. Large-scale trials are warranted to further investigate this new field.

Gene Study Helps Unravel Biology of Alcoholism

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessGene Study Helps Unravel Biology of AlcoholismJun YanJun YanSearch for more papers by this authorPublished Online:21 Aug 2009https://doi.org/10.1176/pn.44.16.0025A new genomewide association study (GWAS) has found several mutations linked to increased susceptibility for developing alcohol dependence, bringing scientists a step closer to understanding the complex biological mechanisms of alcohol use disorders.Two single nucleotide polymorphisms (SNPs), both located on the chromosomal region 2p35, had the highest degree of association with alcohol dependence in a relatively homogenous patient population. These SNPs are located near the PECR gene, which encodes an enzyme (peroxisomal trans-2-enoyl-coA reductase) involved in fatty-acid metabolism, particularly when the body's energy supply is switched from glucose to fat.A third SNP with a slightly lower association with alcohol dependence is located within the PECR gene. These three variants are “in strong linkage disequilibrium, or LD, meaning that the same variants at different loci almost always appear together,” Marcella Rietschel, M.D., the senior author of the study, told Psychiatric News. “So it is very likely—but still not certain—that the PECR gene is involved [in alcohol dependence].”Rietschel is a professor of genetic epidemiology in psychiatry at the Central Institute of Mental Health Mannheim at the University of Heidelberg, Germany.This chromosomal region has been implicated in alcohol dependence in previous research. The PECR gene is expressed most heavily in the liver, but very little in the brain. “As alcohol does not act only on the brain, alcohol dependence can be modulated by many factors whose primary target is not the brain,” Rietschel said. “The best known genetic variants modulating alcohol addiction are variants in the genes metabolizing alcohol, like variants in the alcohol dehydrogenase gene clusters.”Indeed, this study confirmed several other SNPs associated with alcohol dependence, including those located in the ADH1C gene coding for one of the alcohol-metabolizing alcohol dehydrogenases, as well as the CDH13 gene coding for a cell-adhesion protein known as T-cadherin. Both genes have been implicated in alcohol dependence in previous studies.Despite the strong evidence, these variants and their impact on alcohol dependence need to be replicated by additional studies. “The uncertainty is a problem encountered in many GWA studies: A SNP is found to be associated but is not functional itself, so one cannot be sure if this SNP is itself involved in the regulation of genes or if it is only in LD with other causal SNPs, which can be quite far away or even in other genes,” said Rietschel. Since the three top SNPs discovered in this study are close to and in the PECR gene, “this gene definitely merits further investigation.”The researchers first performed a genomic scan for more than 500,000 SNPs, using a sample of 487 alcohol-dependent patients and 1,358 controls. The GWAS identified 121 SNPs that were likely candidates for genetic association.The patients selected for the GWAS were German men with a DSM-IV diagnosis of alcohol dependence, whose condition was severe enough to require hospitalization for treatment or prevention of alcohol withdrawal. In addition, the subjects all had an onset of alcohol dependence before age 28; early-onset alcohol dependence has been shown to have a stronger hereditary component. Because alcohol dependence is a multifactorial disorder with multiple phenotypes and genotypes, the researchers narrowed their sampling to clinically similar patients to reduce the heterogeneity.Because of the vast number of mutations existing in every person and the large number scanned in a GWAS, scientists face the challenge of weeding out too many potential false-positive “hits,” or variants that appear to be significantly associated with a disease when they are, in fact, random coincidences. To minimize false hits and maximize true disease-associated mutations, strategies such as stringent statistical criteria and replication studies are often used in genetic association studies.Here, the researchers used a method called convergent functional genomics. This approach combines gene-expression data from animal models, evidence from human genetic association studies, and findings from human tissues such as brain tissue in autopsies to help prioritize investigation on the most promising candidate genes or the most likely biological pathways. In this study, 19 SNPs were identified after the human GWAS findings were compared with homologous, over-expressed genes in rats that were“ alcoholic” strains.Armed with 121 candidate SNPs from the GWAS and 19 SNPs derived from convergent functional genomics analysis, the researchers performed a replication study of 1,024 male patients with alcohol dependence and 996 age-matched controls. The replication study confirmed that 15 SNPs have a significant association with alcohol dependence.This study was funded by grants from the German government and the European Commission.An abstract of “Genome-Wide Association Study of Alcohol Dependence” is posted at<archpsyc.ama-assn.org/cgi/content/abstract/66/7/773>.▪ ISSUES NewArchived

The latent structure of alcohol dependence in female federal prisoners

Results obtained from a structured interview of substance abuse diagnoses were subjected to taxometric analysis in a group of 459 low and minimum security female federal prisoners applying for admission to a comprehensive drug treatment program. Drawing indicators from a DSM-IV diagnosis of alcohol dependence (tolerance/withdrawal, loss of control, negative social/psychological consequences) the authors conducted a taxometric analysis using the following procedures: mean above minus below a cut (MAMBAC), maximum eigenvalue (MAXEIG), and latent mode factor analysis (L-Mode). Results were generally consistent with taxonic (categorical) latent structure for a DSM-IV diagnosis of alcohol dependence. The implications and limitations of this study are examined and recommendations for future research are offered.

Generalizability of clinical trials for alcohol dependence to community samples

There is a growing concern that results of tightly controlled clinical trials of individuals with alcohol use disorders may not generalize to broader community samples. To assess the proportion of community-dwelling adults with alcohol dependence who would have been eligible for a typical alcohol dependence treatment study, we developed a new, simple method: we applied a standard set of eligibility criteria commonly used in alcohol outcome studies to a large ( n = 43,093) representative US adult sample interviewed face-to-face, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We found that approximately one-half (50.5%) of all individuals with a DSM-IV diagnosis of alcohol dependence ( n = 1484) and 79.4% of those who sought treatment ( n = 185) were excluded by one or more study criteria. Individual study criteria excluded from 0.9% to 48.2% of the overall sample and 0.8% to 43.7% of the treatment-seeking sample. For the overall sample, the lack of motivation/compliance and financial situation criteria excluded the largest percentage of individuals. In the treatment-seeking subsample, comorbid medical conditions and legal problems excluded the largest proportions of individuals. Our study provides a new method to assess the generalizability of clinical trials, and gives further evidence that typical clinical trials for alcohol dependence likely exclude most adults with the disorder in the community and under care, and support the notion that clinical trials recruit “pure” rather than “typical” patients. Clinical trials should carefully evaluate the effects of the selected eligibility criteria on the generalizability of their results.

Reliability and Validity of the German Version of the 49-item – Addiction Research Center Inventory in a sample of detoxified alcoholic patients

The Addiction Research Center Inventory, originally developed by Haertzen et al. (1963) and shortened by Martin et al. (1971), permits the assessment of subjective effects of specific substances. It was developed to evaluate reinforcing effects of drugs or abuse liability of drugs. It is considered as the standard to assess the human equivalent of drug discrimination. Validated translations have been established for Spain and France. The present study has two aims. First we want to introduce a translation into the German language of the short form of the ARCI (Martin et al., 1971) and present an assessment of reliability and concurrent validity in a sample of detoxified alcohol-dependent patients. The second aim is the assessment of subjective effects experienced under alcohol. A total of 124 patients with DSM-IV Diagnosis of alcohol dependence completed the ARCI and other self-ratings, while recalling being in a specific drinking situation. The procedure was repeated a week later to permit the assessment of retest-reliability. Estimates of the internal consistency revealed that the ARCI-scales represent the focused effects of drugs with adequate reliability. Correlations with other questionnaires assessing the emotional state and subjective physiological effects were calculated and confirmed in general the expectations regarding the direction of the associations.

Differential Effects of Maternal and Paternal Alcoholism and Gender on Drinking, Alcohol-Related Self-Cognition, and Psychopathology

Familial alcoholism is associated with various types of psychopathology in offspring, yet most studies do not differentiate maternal from paternal alcoholism. The purpose of this study was to examine the influence of maternal and paternal alcoholism and gender on alcohol consumption, an alcohol-related self-cognition, and four types of psychopathologic symptoms in young adults. Data were drawn from a study designed to examine the role of the self-concept in alcoholism and recovery. The sample included young adults with a current DSM-IV diagnosis of alcohol dependence (n = 25), those with a history of DSM-IV alcohol dependence who were abstinent for at least 12 months (n = 18), and nonalcoholic controls (n = 23). Regression analyses showed that 1) alcoholism on the paternal side of the family independently predicted drinking behavior and symptoms of social phobia over and above the effects of current alcohol dependence, 2) neither alcoholism on the maternal nor paternal side of the family predicted the alc...

Reduced Frontal Lobe Activity in Subjects With High Impulsivity and Alcoholism

Impulsivity is an important characteristic of many psychiatric disorders, including substance-related disorders. These disinhibitory disorders have a similar underlying genetic diathesis, with each disorder representing a different expression of the same underlying genetic liability. This study assessed whether there is a relationship between impulsivity and alcohol dependence, and their correlations with P3 (P300) amplitude, a proposed endophenotype of alcoholism. Healthy control subjects (n=58) and subjects with DSM-IV diagnosis of alcohol dependence (n=57) were assessed with a visual oddball task. Event-Related Potentials (ERPs) were recorded from 61 scalp electrodes and P3 amplitudes measured. Barratt Impulsiveness Scale (BIS), version 11, was used to evaluate impulsivity. Source localization of P3 was computed using low-resolution brain electromagnetic tomography (LORETA). Alcoholic subjects manifested reductions in target P3 amplitudes (p<0.0001). Using LORETA, significantly reduced activation was mapped in the cingulate, medial, and superior frontal regions in alcoholic subjects and highly impulsive subjects. Alcoholic subjects had significantly higher scores on the BIS (p<0.0001) than nonalcoholic individuals. There were significant negative correlations between total scores on BIS and P3 amplitude (r=-0.274, p=0.003, on Pz; r=-0.250, p=0.007, on Cz). Our results demonstrate a strong frontal focus of reduced activation during processing of visual targets in alcoholic subjects and individuals with higher impulsivity. The findings suggest that impulsivity may be an important factor that underlies the pathogenesis of alcohol dependence. Studies are underway to examine the relationship between impulsivity and ERPs in offspring of alcoholic subjects, and to identify genes associated with the underlying predisposition involved in disinhibitory disorders.

Determining a cut-off on the Severity of Dependence Scale (SDS) for alcohol dependence

Optimal cut-off points on the Severity of Dependence Scale (SDS) indicative of clinically significant dependence have been determined for a range of substance types. This study aims to determine a cut-off point on SDS that discriminates between the presence and absence of a DSM-IV diagnosis of alcohol dependence. A structured interview was administered to 90 alcohol users in Sydney, Australia. Receiver Operating Characteristic curve analysis confirmed the utility of the SDS-alcohol for characterising and diagnosing persons with respect to their alcohol-dependent status to an accuracy of 85%. A SDS score of 3 or above was determined as optimal for characterising alcohol dependence. Evidence is also provided confirming that the SDS-alcohol is a valid, reliable uni-dimensional scale for measuring alcohol dependence. It has been demonstrated that the SDS-alcohol can be used to characterise an individual's alcohol-dependent status. A cut-off value for SDS-alcohol provides additional meaning and value to the scale for clients and clinicians and will enable researchers to characterise the prevalence of alcohol dependence in their target populations.

Five-Year Clinical Course Associated With DSM-IV Alcohol Abuse or Dependence in a Large Group of Men and Women

Objective: The prognostic validity of the DSM-IV diagnoses of alcohol abuse and alcohol dependence was evaluated by examining the 5-year clinical course associated with those diagnoses in a large group of predominantly blue-collar men and women. Method: Personal semistructured interviews were carried out 5 years after an initial evaluation with 1,346 (75%) of the approximately 1,800 men and women participating in the Collaborative Study on the Genetics of Alcoholism who were eligible for follow-up. Results: About two-thirds of the 298 subjects with DSM-IV alcohol dependence at baseline maintained that diagnosis during the 5-year study period. Fifty-five percent of the 288 subjects with DSM-IV alcohol abuse at baseline continued to meet one or more of the 11 DSM-IV abuse/dependence criteria, and 3.5% went on to meet the criteria for dependence at follow-up. Among the 760 subjects with no alcohol diagnosis at baseline, 2.5% met the criteria for alcohol dependence and 12.8% for alcohol abuse at follow-up. Baseline characteristics that predicted the occurrence of any of the 11 DSM-IV abuse/dependence criteria during the 5-year interval included male gender, lack of marital stability, presence of several of the criteria for dependence, and history of illicit drug use. Conclusions: The data suggest that over 5 years the DSM-IV diagnosis of alcohol dependence predicts a chronic disorder with a relatively severe course, while DSM-IV alcohol abuse predicts a less persistent, milder disorder that does not usually progress to dependence.

The Five‐Year Predictive Validity of Each of the Seven DSM‐IV Items for Alcohol Dependence Among Alcoholics

Background Information about the prognostic implications of a DSM‐IV diagnosis of alcohol dependence is important to both clinicians and researchers. In this regard, only limited data are available on the performance of specific diagnostic items.Methods This study reports data gathered with a structured, validated interview with 642 alcohol‐dependent men and women from the Collaborative Study of the Genetics of Alcoholism (COGA). The goals were to evaluate the ability of each of the DSM‐IV dependence items to predict the occurrence over the next 5 years of a broad pattern of 27 alcohol‐related problems. For comparison, similar data are reported regarding the performance of abuse criteria for 516 additional subjects.Results The results revealed that dependence item 3 (use of alcohol in larger amounts) was the only criterion that did not relate significantly to outcome, and indicated that the dependence criteria related relatively similarly to different types of outcomes among alcoholics. No specific combination of diagnostic items stood out in predicting outcome but, rather, the span of items generally performed well.Conclusions These data support the potential usefulness of the DSM‐IV dependence criteria.

Evidence in an International Sample of Alcohol‐Dependent Subjects of Subgroups With Specific Symptom Patterns of Antisocial Personality Disorder

An earlier latent class analysis (LCA) of the symptoms of antisocial personality disorder in alcohol-dependent subjects enrolled in the Montreal sample of the WHO/ISBRA Study on State and Trait Markers of Alcohol Use and Dependence suggested a three-class qualitative solution. The present analysis of a larger, international WHO/ISBRA sample provides evidence of a four-class solution with expanded symptomatic differentiation. An unrestricted LCA of 15 antisocial behaviors expressed after 15 years of age was performed in 465 males with DSM-IV diagnosis of alcohol dependence, from the Montreal center (n = 120, overlapping the previous LCA), Helsinki (n = 80), São Paolo (n = 145), Sapporo (n = 22), and Sydney (n = 98); subjects were of various races, were ascertained from various sources, and showed a wide range of social adjustment. Four latent classes that appeared to differ qualitatively were identified. For descriptive purposes, the classes are termed socially adjusted adults (SAA, n = 197), antisocial work-adjusted adults (AWAA, n = 126), antisocial work-maladjusted adults (AWMA, n = 120), and antisocial aggressive adults (AAA, n = 23). The AAA class had the earliest age of onset for alcohol dependence, which decreased across classes. Proportion of alcohol-dependent first-degree relatives was low in the SAA class (13.6%), moderate in the AWAA and the AWMA classes (20.8% and 18.7% respectively), and high in the AAA class (33.3%). It is unknown if and to what extent racial, cultural, and ascertainment heterogeneity between collaborating centers might have influenced these analyses. The results presented here show qualitative differences among antisocial alcohol-dependent individuals in job adjustment and aggressive behavior, but only the latter distinction was relevant to familial alcohol dependence. Moreover, both the aggressive class and socially adjusted class differed in familial loading for alcohol dependence from the remaining two antisocial classes. These data provide improved empirical support for qualitative differentiation of aggressive from nonaggressive antisocial alcohol-dependent individuals and might also have nosological implications for antisocial personality disorder.

Five-year clinical course associated with DSM-IV alcohol abuse or dependence in a large group of men and women.

The prognostic validity of the DSM-IV diagnoses of alcohol abuse and alcohol dependence was evaluated by examining the 5-year clinical course associated with those diagnoses in a large group of predominantly blue-collar men and women. Personal semistructured interviews were carried out 5 years after an initial evaluation with 1,346 (75%) of the approximately 1,800 men and women participating in the Collaborative Study on the Genetics of Alcoholism who were eligible for follow-up. About two-thirds of the 298 subjects with DSM-IV alcohol dependence at baseline maintained that diagnosis during the 5-year study period. Fifty-five percent of the 288 subjects with DSM-IV alcohol abuse at baseline continued to meet one or more of the 11 DSM-IV abuse/dependence criteria, and 3.5% went on to meet the criteria for dependence at follow-up. Among the 760 subjects with no alcohol diagnosis at baseline, 2.5% met the criteria for alcohol dependence and 12.8% for alcohol abuse at follow-up. Baseline characteristics that predicted the occurrence of any of the 11 DSM-IV abuse/dependence criteria during the 5-year interval included male gender, lack of marital stability, presence of several of the criteria for dependence, and history of illicit drug use. The data suggest that over 5 years the DSM-IV diagnosis of alcohol dependence predicts a chronic disorder with a relatively severe course, while DSM-IV alcohol abuse predicts a less persistent, milder disorder that does not usually progress to dependence.

Dependence symptoms but no diagnosis: diagnostic `orphans' in a community sample

To receive a DSM-IV diagnosis of alcohol dependence, an individual must manifest at least three out of seven possible dependence criteria. Thus, individuals may manifest one or two dependence criteria yet not receive the dependence diagnosis. In a sense, these latter individuals may be seen as diagnostic `orphans', since they have individual symptoms of dependence but no diagnoses. A study of these individuals sheds light on the validity of the three-symptom severity threshold for a diagnosis of DSM-IV alcohol dependence. Thus, we investigated the meaning of the `orphan' status through cross-sectional and longitudinal research in a general population sample. Three groups were compared at baseline, subjects with no symptoms of any alcohol use disorder (148), diagnostic `orphans' with one or two symptoms of dependence (136) and subjects who met full criteria for DSM-IV alcohol dependence (140). Several variables significantly differentiated the three groups, including binge drinking and family history of alcoholism. At a 1-year follow-up point, very few of the `orphans' met criteria for DSM-IV alcohol dependence. The proportion of new onsets from the `orphan' group and the group with no symptoms did not differ significantly. Binge drinking predicted chronicity of `orphan' status, but family history of alcoholism did not. The results support the decision to require a minimum of three symptoms to make a diagnosis of alcohol dependence.