The switch from unaffected to affected was largely attributable to the reassignment of prior “diagnostic orphans” (no abuse and one or two DSM-IV dependence criteria)(46;47) to the moderately affected DSM-5 category. Not surprisingly, over 90% of these switches were due to the more commonly endorsed criteria of larger/longer or quit/cut-back, either together or with another criterion, such as tolerance. In terms of their drinking behavior, those switching from unaffected to affected reflected intermediate levels of drinking, quite similar to those switching from affected to unaffected. Consistent with their assignment to the moderately affected category of DSM-5 AUDs, they appear to be less severely affected than those who remained stably affected. The inclusion of these subjects as affected is important as several studies have indicated that diagnostic orphans are at high risk for developing AUDs (48–52). It is noteworthy here that Martin argues that the 2+ cut-point for DSM-5 may be too lenient and produce heterogeneity in the pool of affecteds (53).
