Alcohol Use Disorders in the Dsm‐v: The Task Ahead

In this lecture, Dr Li and colleagues [1] address a central and important issue: our concepts of alcohol use disorder(s), and methods of identifying these disorders or the risk for developing them. The issue impacts on many aspects of research, e.g. inclusion criteria for randomized trials; phenotypes in genetics studies; rates fromepidemiological surveys, and conditions investigated in neuroimaging studies. Dr Li and colleagues present an excellent, complete and thoughtful review of the issues [1]. This important paper will surely stimulate further discussion as we move towards DSM-V. A few additional points may be made: In DSM-V, alcohol use disorders will need to fit within the framework for all psychiatric disorders. To improve reliability, DSM criteria are phenomenological, not etiological. The additional dimensions suggested by Li et al. (risk factors, surrogate markers) are included in DSM-IV, but only as descriptive text. Efforts expended on the text have been far less than efforts expended on the content and wording of the criteria. Elevating risk factors and surrogate markers for alcohol use disorders to the status of diagnostic criteria would require elevating them for the other disorders as well. Obtaining consensus on risk factors and surrogate markers for all disorders is desirable. Whether it can be achieved for DSM-V is uncertain. The National Longitudinal Interview Survey (NLAES) and National Epidemiologic Survey on Alcohol and Related Coditions (NESARC) unquestionably offer outstanding data on alcohol use disorders (AUDs), and as Li and colleagues suggest, these studies provide information on dynamic processes. However, thus far findings from these major surveys are based on cross-sectional data, with the usual issues of retrospective recall and selective mortality; NESARC wave 2 findings are still forthcoming. Smaller prospective studies lack the size and representativeness of the national surveys. However, to study dynamic processes, prospective studies measure phenomena as they occur during the life-span, an important advantage. Additional NLAES and NESARC perspectives on comorbidity are found in Hasin et al. 2002 [2], 2005 [3] and 2007 [4] and many other papers by B. Grant and colleagues (e.g. [5–10]). The reader is encouraged to consult them all. Li and colleagues note the potential for 5+ drinks to indicate disease risk. Support for this was shown in our prospective study of 962 community drinkers. At baseline (1991–1992), the key inclusion criterion was at least one occasion of 5+ drinks in the prior 12 months. After assessing DSM-IV AUDs at baseline, 1- and 10-year follow-up, this screening/inclusion criterion produced a sample with life-time DSM-IV alcohol dependence and abuse prevalences of 45.4% [11] and 20.0%, respectively. Thus, even at frequencies lower than weekly, 5+ drinks may be a useful indicator of life-time risk for alcohol disorders. Li and colleagues cite our review [12] as supporting the position that abuse is an early stage of dependence. The review actually shows the opposite—abuse often does not become dependence [13–16] and individuals with dependence often do not manifest abuse [17]. I agree wholeheartedly with Li et al.'s call for dimensional measures of alcohol use disorders, particularly alcohol dependence [18,19]. Further, greater public emphasis on harmful drinking patterns may help to improve the lagging treatment rates for alcohol use disorders [4]. However, analyses that I presented at the 2007 College on Problems of Drug Dependence and NIDA Genetics Consortium meetings based on methods used in Hasin et al. [19] suggest that combining dependence, abuse and consumption as criteria yields a heterogeneous measure that is not as consistently linear as the DSM-IV dependence criteria [19]. Such a heterogeneous measure may be advantageous for some public health purposes, but would not be a good phenotype in genetic association studies, where homogeneity is needed for studies to succeed. Thus, the verdict is not yet in on the advisability of combining abuse, consumption and dependence indicators for every purpose. As the DSM-V substance disorders work-group contemplates the task ahead, the usual problem confronts us: the criteria must serve many masters with different, sometimes competing needs, complicating the process of improving the diagnostic criteria. Perhaps this time, making use of databases reflecting advances in genetics, treatment outcome, epidemiology, pharmacokinetics and pharmacodynamics, real improvements can be made in the DSM-V criteria for alcohol use disorders.