Mental disorders involving antisocial behavior and substance use are genetically linked and vary continuously. The authors present a review and integrative conceptualization of these observations in terms of a dimensional and hierarchically organized externalizing spectrum. As a foundation for this conceptualization, the authors introduce a quantitative, model-based approach to comparing categorical and continuous conceptions of psychopathology and apply this approach in an empirical study of patterns of comorbidity among externalizing disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders. The authors present evidence that comorbidity among externalizing disorders is best modeled by an underlying normally distributed continuum of risk for multiple disorders within the externalizing spectrum. The authors conclude by discussing implications of the externalizing spectrum conceptualization for classification of disorders in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.
Keywordssubstance abuse/dependence; antisocial behavior; impulsivity; aggression; classification Problems with antisocial behavior and substance use and personality traits such as aggression and impulsivity commonly co-occur. In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), these problems constitute the symptoms of a variety of specific mental disorders, and these mental disorders are described in a variety of distinct sections of the manual. In this article, we argue that in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), these problems should be classified together under the rubric of externalizing disorders. We argue that etiologic commonalities should be a major consideration in efforts to classify psychopathological entities (cf. Gottesman, 2002;Skinner, 1981;Tsuang, Stone, & Faraone, 2000;Westen, Heim, Morrison, Patterson, & Campbell, 2002). Moreover, classification of entities in science in general tends to proceed from being more initially descriptive to being based more on underlying principles as these underlying principles become more clearly articulated (Hempel, 1965). Current evidence, reviewed herein, indicates that various externalizing syndromes are linked to the same underlying etiologic factors.We also consider the issue of whether externalizing problems are better conceived of in terms of dimensions or categories. We evaluate this issue both within specific syndromes and in terms of the co-occurrence of syndromes within the externalizing spectrum, and we conclude by endorsing a dimensional conceptualization on the basis of the existing evidence. However, even if externalizing syndromes and their patterns of co-occurrence are dimensional in nature, this does not preclude categorical decision making for clinical purposes. The key is to make clear the distinction between the empirical structure of these syndromes and the ways in which knowledge...