title: The harmful dysfunction model of alcohol use disorder: revised criteria to improve the validity of diagnosis and prevalence estimates.
abstract: OBJECTIVE
  To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity.
  
  
  METHODS
  DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data.
  
  
  METHODS
  United States.
  
  
  METHODS
  National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54 years (wave 1, n = 29 673; wave 2, n = 24 244).
  
  
  METHODS
  NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group.
  
  
  RESULTS
  Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group.
  
  
  CONCLUSIONS
  Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.
authors.affiliation: School of Social Work and Department of Psychiatry, New York University, New York, NY,, USA.
authors.forename: Jerome C
authors.initials: JC
authors.lastname: Wakefield
authors.affiliation: School of Social Work, Temple University, Philadelphia, PA,, USA.
authors.forename: Mark F
authors.initials: MF
authors.lastname: Schmitz
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000428:Alcohol Drinking / Q000453:epidemiology; D019973:Alcohol-Related Disorders / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D000437:Alcoholism / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology; D066249:Craving; D003951:Diagnostic Errors / Q000517:prevention & control; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008960:Models, Psychological; D015995:Prevalence; D011569:Psychiatric Status Rating Scales; D015203:Reproducibility of Results; D012309:Risk-Taking; D009626:Terminology as Topic; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Addiction; DSM; DSM-5; DSM-IV; NESARC; alcohol dependence; alcohol use disorder; concept of mental disorder; diagnosis; diagnostic criteria; harmful dysfunction; psychiatric epidemiology; validity