Are subthreshold alcohol dependence symptoms a risk factor for developing DSM-IV alcohol use disorders? A three-year prospective study of ‘diagnostic orphans’ in a national sample
Introduction
The DSM-IV (American Psychiatric Association, 1994) diagnostic criteria for alcohol abuse and dependence isolate a group of individuals who do not meet the diagnostic criteria for either disorder but who experience one or two diagnostic criteria for alcohol dependence – the so-called ‘diagnostic orphans’ (Hasin & Paykin, 1998). Diagnostic orphans have been identified in adolescent and young adult samples (Pollock & Martin, 1999, Rohde et al., 2001, Chung et al., 2002, Eng et al., 2003, Wells et al., 2006, Schuckit et al., 2008), in genetic, clinical and community studies (Olfson et al., 1996, Hasin & Paykin, 1999, Ray et al., 2008); Sarr et al., 2000, Shankman et al., 2008), and in the general population (Hasin & Paykin, 1999, Harford et al., 2005, Harford & Yi, 2008, McBride et al., 2009a, McBride et al., 2009b). It is estimated that between 10.9% and 14.3% of all alcohol users in the general population meet the requirements for diagnostic orphan status (Hasin & Paykin, 1999, Harford & Yi, 2008, McBride et al., 2009b).
The identification of diagnostic orphans has been met with a degree of scepticism in the literature. It has been suggested that the symptoms experienced by this group of alcohol users are too mild to warrant clinical attention or diagnosis (cf. Narrow et al., 2002, Hoffmann & Hoffmann, 2003). Findings from a growing body of cross-sectional studies, however, have revealed that compared to individuals without an alcohol use disorder (AUD), diagnostic orphans are more likely to frequently engage in hazardous drinking patterns (Hasin & Paykin, 1998, McBride et al., 2009b), are at increased risk for experiencing other mental disorders including drug use disorders (Ray et al., 2008, McBride et al., 2009a) and report moderate levels of functional impairment (Olfson et al., 1996, McBride et al., 2009c). Recent research has also demonstrated that diagnostic orphans are at greater risk for experiencing more adverse life events and poorer physical health compared to those with alcohol abuse (McBride et al., 2009b, McBride et al., 2009c).
Although it has been proposed that diagnostic orphan status is a transient phenomenon (Hasin & Paykin, 1998), findings from longitudinal studies suggest that this sub-threshold condition has the potential to be persistent and increases the likelihood for the transition to AUD. For example, Schuckit et al. (2008) explored the five-year course of DSM-IV AUD in a sample of 12–19 years olds (n = 616), who were offspring of individuals involved in the Collaborative Study on the Genetics of Alcoholism (COGA; Begleiter et al., 1995). Alcohol and drug use intake and problems were highest for the alcohol abuse and dependence groups at the follow-up; however, diagnostic orphans were significantly more likely to experience higher rates of conduct disorder and alcohol or drug use compared to the no-AUD group. Regression analysis revealed that diagnostic orphans at baseline were almost twice as likely to meet the criteria for an AUD at the follow-up, compared to those with no-AUD. No clear outcome pattern for diagnostic orphans emerged at the follow-up, with equal percentages (23.5%) remaining in the same category or returning to no-AUD, respectively. Approximately 38.2% of diagnostic orphans progressed to alcohol abuse and 14.8% developed alcohol dependence. In another five-year study of participants involved in the San Diego Prospective Study (Schuckit & Smith, 1996), Eng et al. (2003) demonstrated that 17% of diagnostic orphans at the baseline assessment progressed to either alcohol abuse or dependence at the follow-up, compared to only 3.1% of the baseline no-AUD group. Recent analysis of data from the National Longitudinal Survey of Youth (NLYS) also revealed that although 61.7% of diagnostic orphans experiencing one dependence criterion at baseline returned to no-AUD at the follow-up, 14.8% had developed an AUD (Harford & Yi, 2008). Only half of the diagnostic orphans experiencing two dependence criteria were categorized as no-AUD five years later (48.7%) whereas 27.4% had progressed to an AUD.
The weight of evidence from the aforementioned studies suggests that this substantial group of alcohol users may not be experiencing temporary symptoms of alcohol dependence and may be at increased risk for progressing to more serious alcohol problems. Analysis of longitudinal data from the general population would strengthen this existing body of research and would be particularly useful for determining how diagnostic orphans might best be handled in the future (cf. Cottler & Grant, 2006, Schuckit & Saunders, 2006). The current study, which analyses data from the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant & Kaplan, 2005), was devised to address two main aims: (i) explore the three-year course of diagnostic orphans in the general population, and (ii) investigate whether a specific alcohol-related symptom, or patterns of symptoms, can help predict which diagnostic orphans may be at increased risk for progressing to DSM-IV alcohol dependence.
Section snippets
Survey
The NESARC is a longitudinal, nationally representative sample of the civilian, non-institutionalised adult population residing in all 50 states of the USA, including the District of Columbia (Grant, Kaplan, et al., 2003, Grant & Kaplan, 2005). The survey included individuals who were living in households, military personnel living off base, and people residing in group quarters (e.g. shelters, college quarters, boarding rooms, non-transient hotels and motels, etc.). The first wave of the
Descriptive statistics
The mean age of the participants at Wave 1 was 46.3 years (SD = 18.06 years; range 18–90 years) and the majority of the sample were male (52.80%), White (56.44%), married or cohabiting (51.56%), and had a high school education but had not completed college (76.51%). Approximately 33.51% of individuals had used illegal drugs, 21.96% had encountered a mood disorder, 18.65% had experienced an anxiety disorder, 21.7% were dependent on nicotine, and 14.81% had experienced drug use disorder, in their
Discussion
The current study differentiated between diagnostic orphans experiencing one or two criteria of alcohol dependence to explore the three-year course of these alcohol users using data from the longitudinal NESARC. Consistent with previous research (Eng et al., 2003, Harford & Yi, 2008, Schuckit et al., 2008), higher percentages of individuals in the Orphan1 and Orphan2 groups at baseline progressed to alcohol dependence at the follow-up, compared to the no-AUD group (11.5% and 20.7% versus 3.7%,
Role of Funding Sources
The NESARC was conducted and funded by the National Institute on Alcohol Abuse and Alcoholism with supplemental support from the National Institute on Drug Abuse. No funding source had any involvement or role in this paper such as study design, analysis and interpretation of the data, the writing of the report, or the decision to submit the paper for publication.
Contributors
Orla McBride devised the concept and design of the paper, conducted the statistical analysis, and drafted the manuscript. Gary Adamson provided critical revisions of the manuscript. Both authors have contributed to and approved the final manuscript.
Conflict of Interest
None.
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Present address of author: Department of Epidemiology, Michigan State University, B601 West Fee Hall, East Lansing, MI 48824, USA.