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 Orla McBride ⁎ ,1 , Gary Adamson School of Psychology, University of Ulster at Magee Campus, Northland Road, Co. Londonderry, BT48 7JL, Northern Ireland, United Kingdom abstract article info Keywords: Epidemiology Dependence Abuse NESARC Psychiatric classification Aims: Research suggests that diagnostic orphans (i.e., individuals experiencing only 1–2 criteria for DSM-IV alcohol dependence) may be at increased risk for developing more severe alcohol problems. This study aimed to: (i) investigate the course of diagnostic orphans in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and (ii) explore whether a specific symptom endorsement pattern(s) could identify diagnostic orphans at Wave 1 who remitted or progressed to alcohol dependence at Wave 2. Methods: Current drinkers (n = 15,751) were divided into diagnostic groups at Waves 1 and 2: no-alcohol use disorder (AUD); one-criterion orphans, two-criterion orphans, alcohol abuse, or alcohol dependence. Multinomial logistic regression analysis explored the association between diagnostic status at Wave 1 and Wave 2. Chi-square tests investigated differences in the criteria endorsement patterns of diagnostic orphans. Results: Compared to the no-AUD group, one-criterion orphans at Wave 1 were twice as likely to be in the abuse group and four times more likely to be dependent at Wave 2. Two-criterion orphans were three times more likely to be in the abuse group and eight times more likely to have progressed to dependence. Criterion endorsement patterns of diagnostic orphans at baseline did not significantly differentiate between those who remitted and those who progressed to dependence at follow-up. Conclusions: Like previous research, diagnostic orphans are at increased for developing to more severe alcohol problems. Relying solely on the DSM-IV AUD diagnostic criteria, however, may not be sufficient to identify those diagnostic orphans who are at risk for progressing to dependence. © 2010 Elsevier Ltd. All rights reserved. 1. 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, Lewinsohn, Kahler, Seeley, & Brown, 2001; Chung, Martin, Armstrong, & Labouvie, 2002; Eng, Schuckit & Smith, 2003; Wells, Horwood, & Fergusson, 2006; Schuckit et al., 2008), in genetic, clinical and community studies (Olfson et al., 1996; Hasin & Paykin, 1999; Ray, Miranda, Chelminski, Young, & Zimmer- man, 2008); Sarr, Bucholz, & Phelps, 2000; Shankman, Klein, Lewinsohn, Seeley, & Small, 2008), and in the general population (Hasin & Paykin, 1999; Harford, Grant, Yi, & Chen, 2005; Harford & Yi, 2008; McBride, Adamson, Bunting & McCann, 2009a,b). 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, Rae, Robins, & Regier, 2002; Hoffmann & Hoffmann, 2003). Findings from a growing body of cross-sectional studies, however, have revealed that com- pared 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, Adamson, Bunting, & McCann, 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,c). 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 Addictive Behaviors 35 (2010) 586–592 ⁎ Corresponding author. Tel.: + 44 28 71375367; fax: + 44 28 71375315. E-mail address: o.mcbride@ulster.ac.uk (O. McBride). 1 Present address of author: Department of Epidemiology, Michigan State University, B601 West Fee Hall, East Lansing, MI 48824, USA. 0306-4603/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2010.01.014 Contents lists available at ScienceDirect Addictive Behaviors