However, other aspects of the DSM-IV approach were problematic. Some issues pertained to the abuse diagnosis and others pertained to the DSM-IV-stipulated relationship of abuse to dependence. First, when diagnosed hierarchically according to DSM-IV, the reliability and validity of abuse were much lower than those for dependence (5, 10). Second, by definition, a syndrome requires more than one symptom, but nearly half of all abuse cases were diagnosed with only one criterion, most often hazardous use (11, 12). Third, although abuse is often assumed to be milder than dependence, some abuse criteria indicate clinically severe problems (e.g., substance-related failure to fulfill major responsibilities). Fourth, common assumptions about the relationship of abuse and dependence were shown to be incorrect in several studies (e.g., that abuse is simply a prodromal condition to dependence [13–17] and that all cases of dependence also met criteria for abuse, a concern particularly relevant to women and minorities [18–20]).
