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.