Categorical and Continuous Models of Liability to Externalizing Disorders

CONTEXT: Patterns of genetic, environmental, and phenotypic relationships among antisocial behavior and substance use disorders indicate the presence of a common externalizing liability. However, whether this liability is relatively continuous and graded, or categorical and class-like, has not been well established. OBJECTIVES: To compare the fit of categorical and continuous models of externalizing liability in a large, nationally representative sample. DESIGN: Categorical and continuous models of externalizing liability were compared using interview data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). SETTING: Face-to-face interviews conducted in the United States. PARTICIPANTS: Random sample of 43 093 noninstitutionalized adult civilians living in the United States. MAIN OUTCOME MEASURES: Lifetime and current (past 12 months) diagnoses of antisocial personality disorder, nicotine dependence, alcohol dependence, marijuana dependence, cocaine dependence, and other substance dependence. RESULTS: In the entire sample, as well as for males and females separately, using either lifetime or current diagnoses, the best-fitting model of externalizing liability was a continuous normal model. Moreover, there was a general trend toward latent trait models fitting better than latent class models, indicating that externalizing liability was continuous and graded, rather than categorical and class-like. CONCLUSIONS: Liability to externalizing spectrum disorders is graded and continuous normal in distribution. Research regarding etiology, assessment, and treatment of externalizing disorders should target externalizing liability over a range of severity. Current diagnoses represent extremes of this continuous liability distribution, indicating that conditions currently classified as subthreshold are likely to provide important information regarding liability to externalizing phenomena.