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Toward an alcohol use disorder continuum using item response theory: results from the National Epidemiologic Survey on Alcohol and Related Conditions


Background. Item response theory (IRT) was used to determine whether the DSM-IV diagnostic criteria for alcohol abuse and dependence are arrayed along a continuum of severity.

Method. Data came from a large nationally representative sample of the US population, 18 years and older. A two-parameter logistic IRT model was used to determine the severity and discrimination of each DSM-IV criterion. Differential criterion functioning (DCF) was also assessed across subgroups of the population defined by sex, age and race-ethnicity.

Results. All DSM-IV alcohol abuse and dependence criteria, except alcohol-related legal problems, formed a continuum of alcohol use disorder severity. Abuse and dependence criteria did not consistently tap the mildest or more severe end of the continuum respectively, and several criteria were identified as potentially redundant. The drinking in larger amounts or for longer than intended dependence criterion had the greatest discrimination and lowest severity than any other criterion. Although several criteria were found to function differentially between subgroups defined in terms of sex and age, there was evidence that the generalizability and validity of the criterion forming the continuum remained intact at the test score level.

Conclusions. DSM-IV diagnostic criteria for alcohol abuse and dependence form a continuum of severity, calling into question the abuse–dependence distinction in the DSM-IV and the interpretation of abuse as a milder disorder than dependence. The criteria tapped the more severe end of the alcohol use disorder continuum, highlighting the need to identify other criteria capturing the mild to intermediate range of the severity. The drinking larger amounts or longer than intended dependence criterion may be a bridging criterion between drinking patterns that incur risk of alcohol use disorder at the milder end of the continuum, with tolerance, withdrawal, impaired control and serious social and occupational dysfunction at the more severe end of the alcohol use disorder continuum. Future IRT and other dimensional analyses hold great promise in informing revisions to categorical classifications and constructing new dimensional classifications of alcohol use disorders based on the DSM and the ICD.

Corresponding author
Laboratory of Epidemiology and Biometry, Room 3077, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fishers Lane, MS 9304, Bethesda, MD 20892-9304, USA. (Email:
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Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
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