Toward DSM-V: An Item Response Theory Analysis of the Diagnostic Process for DSM-IV Alcohol Abuse and Dependence in Adolescents

Objective: Item response theory analyses were used to examine alcohol abuse and dependence symptoms and diagnoses in adolescents. Previous research suggests that the DSM-IV alcohol use disorder (AUD) symptoms in adolescents may be characterized by a single dimension. The present study extends prior research with a larger and more comprehensive sample and an examination of an alternative diagnostic algorithm for AUDs. Method: Approximately 5,587 adolescents between the ages of 12 and 18 years from adjudicated, clinical, and community samples were administered structured clinical interviews. Analyses were conducted to examine the severity of alcohol abuse and dependence symptoms and the severity of alcohol use problems (AUDs) within the diagnostic categories created by the DSM-IV. Results: Although the DSM-IV diagnostic categories differ in severity of AUDs, there is substantial overlap and inconsistency in AUD severity of persons across these categories. Item Response Theory-based AUD severity estimates suggest that many persons diagnosed with abuse have AUD severity greater than persons with dependence. Similarly, many persons who endorse some symptoms but do not qualify for a diagnosis (i.e., diagnostic orphans) have more severe AUDs than persons with an abuse diagnosis. Additionally, two dependence items, "tolerance" and "larger/longer," show differences in severity between samples. Conclusions: The distinction between DSM-IV abuse and dependence based on severity can be improved using an alternative diagnostic algorithm that considers all of the alcohol abuse and dependence symptoms conjointly. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47(11):1329-1339.