It's the algorithm! why differential rates of chronicity and comorbidity are not evidence for the validity of the abuse-dependence distinction

The validity of the abuse-dependence distinction within alcohol use disorders (AUDs) has been increasingly questioned on psychometric and conceptual grounds. Two types of findings are often cited as support for the validity of this distinction: (a) Dependence is more persistent than abuse, and (b) dependence is more highly comorbid with other Axis I and Axis II disorders than is abuse. Using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), we examined the extent to which the current diagnostic algorithm (3 of 7 dependence criteria for a diagnosis of dependence; 1 of 4 abuse criteria for a diagnosis of abuse if dependence criteria are not met) produces this pattern of findings independent of item set. Analyses in which all 330 permutations of the 11 AUD criteria were partitioned into a 4-item abuse set and a 7-item dependence set were conducted to examine the relevance of the criteria sets to estimates of persistence and comorbidity independent of criteria. Regardless of the criteria used, the dependence set (i.e., 3/7 criteria) always and substantially outperformed the abuse set (1/4) with respect to both persistence and comorbidity. These data indicate that chronicity and comorbidity are flawed indicators for the abuse-dependence distinction (and likely other conditions in which hierarchical decision rules are used). In addition, our analyses show that the current set of criteria defining alcohol dependence and abuse are not optimal.