Much remains to be clarified about the associations of internalizing and externalizing psychopathology with the likelihood, expression and course of alcohol dependence and how they vary by gender. The few studies that have directly addressed gender differences did not adjust for potential confounders, e.g., other comorbid conditions, which could increase the risk of spurious associations (Grant et al., 2009). Moreover, gender differences in the association of alcohol dependence with other specific disorders cannot be presumed to extend to the broader categories of internalizing and externalizing psychopathology. The mediating roles of drinking per se and consumption level have received little if any attention, despite the literature linking externalizing behavior with early onset and heavy drinking. Studies of the expression and course of alcoholism based on treatment samples cannot be extrapolated to the general population. Treatment samples are over-representative of individuals with multiple disorders (Carroll et al., 2006), and any gender differences in treatment utilization could affect interactions between gender and psychopathology. Given that only about one quarter of alcoholics access any type of alcohol treatment (Dawson et al., 2006), data from alcohol treatment samples cannot be assumed to reflect the experience of the majority of alcohol-dependent individuals.
