Dependence symptoms but no diagnosis: diagnostic 'orphans' in a 1992 national sample

The alcohol dependence syndrome was initially presented as a condition with graded severity. However, to receive a diagnosis that is categorical, a diagnostic threshold must be determined. Much previous research on this issue has focused on setting a threshold that will produce the highest possible consistency in rates between one set of diagnostic criteria and the next. It is possible that a different threshold may be more valid. Results from a community sample supported a minimum diagnostic threshold of three or more dependence symptoms but the sample was not nationally representative. Therefore, we investigated the meaning of the 'orphan' status (one or two dependence symptoms but no DSM-IV alcohol dependence diagnosis) in a large national sample. Two sets of analyses were performed, the first using a current timeframe and the second using a lifetime timeframe. Abstainers were excluded from all analyses. In each set of analyses, three groups were compared: subjects with no symptoms of any alcohol use disorder; diagnostic 'orphans' with one or two symptoms of dependence; and subjects who met full criteria for DSM-IV alcohol dependence. Several variables significantly differentiated the three groups, including heavy drinking and family history of alcoholism. Group differences were reduced among 'orphans' and subjects with no symptoms who had at least one occasion of drinking five or more drinks in the year prior to the interview. The results provide support for the decision to require a minimum of three symptoms to make a diagnosis of alcohol dependence, for scientific as well as pragmatic reasons.