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Validation of DSM-IV Substance Use Disorder by Substance and Age Using Rasch

Michael L. Dennis, Ph.D.,* Kendon Conrad** and Rodney Funk**Chestnut Health Systems, Bloomington, IL

** University of Illinois, Chicago, IL

Presentation at the “Joint Conference of the Canadian Evaluation Society (CES) and the American Evaluation Association (AEA)”, Toronto, Ontario,

Canada, October 24-30.

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This presentation was supported by analytic runs provided Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT) under Contracts 207-98-7047, 277-00-6500, and 270-2003-00006 using data provided by the following grantees: CSAT (TI11320, TI11324, TI11317, TI11321, TI11323, TI11874, TI11424, TI11894, TI11871, TI11433, TI11423, TI11432, TI11422, TI11892, TI11888, TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671, TI11320, TI12541, TI00567); NIAAA (R01 AA 10368); NIDA (R37 DA11323; R01 DA 018183); Illinois Criminal Justice Information Authority (95-DB-VX-0017); Illinois Office of Alcoholism and Substance Abuse (PI 00567); Intervention Foundation’s Drug Outcome Monitoring Study (DOMS), Robert Woods Johnson Foundation’s Reclaiming Futures. Any opinions about this data are those of the authors and do not reflect official positions of the government or individual grantees. The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@chestnut.org

Acknowledgement

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Goals

1. Examine the origins, definitions and current debates surrounding the Diagnostic and Statistical Manual IV TR (DSM-IV-TR) substance use disorder (SUD) construct

2. Use Rasch analysis of the GAIN’s Substance Problem Scale (SPS) data to inform current debates related to SUD

3. Discuss the implications of the findings for further refinement of the SUD concept.

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Evolution of the Substance Use Disorders (SUD) Concept

• Much of our conceptual basis of addiction comes from Jellnick’s 1960 “disease” model of adult alcoholism

• Edwards & Gross (1976) codified this into a set of bio-psycho-social symptoms related to a “dependence” syndrome

• In practice, they are typically complemented by a set of separate “abuse” symptoms that represent other key reasons why people enter treatment

• DSM 3, 3R, 4, 4TR, ICD 8, 9, & 10, and ASAM’s PPC1 and PPC2 all focus on this syndrome

• Note that these symptoms are only correlated about .4 to .6 with use or problem scales more commonly used in evaluation

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DSM (GAIN) Symptoms of Dependence (3+ Symptoms)

Physiologicaln. Tolerance (you needed more alcohol or drugs to get high or found that the

same amount did not get you as high as it used to?)p. Withdrawal (you had withdrawal problems from alcohol or drugs like

shaking hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or drugs to stop being sick or avoid withdrawal problems?)

Non-physiologicalq. Loss of Control (you used alcohol or drugs in larger amounts, more often or

for a longer time than you meant to?) r. Unable to Stop (you were unable to cut down or stop using alcohol or drugs?) s. Time Consuming (you spent a lot of your time either getting alcohol or drugs,

using alcohol or drugs, or feeling the effects of alcohol or drugs?)t. Reduced Activities (your use of alcohol or drugs caused you to give up,

reduce or have problems at important activities at work, school, home or social events?)

u. Continued Use Despite Personal Problems (you kept using alcohol or drugs even after you knew it was causing or adding to medical, psychological or emotional problems you were having?)

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DSM (GAIN) Symptoms of Abuse (1+ symptoms)

h. Role Failure (you kept using alcohol or drugs even though you knew it was keeping you from meeting your responsibilities at work, school, or home?)

j. Hazardous Use (you used alcohol or drugs where it made the situation unsafe or dangerous for you, such as when you were driving a car, using a machine, or where you might have been forced into sex or hurt?)

k. Legal problems (your alcohol or drug use caused you to have repeated problems with the law?)

m. Continued Use after Legal/Social Problems (you kept using alcohol or drugs even after you knew it could get you into fights or other kinds of legal trouble?)

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• Do abuse and dependence symptoms vary along the same or different dimensions?

• Are physiological symptoms (tolerance and withdrawal) good markers of high severity?

• Are abuse symptoms good markers of low severity?

• Does the average and pattern of symptom severity vary by substance?

• Are there differential item function by age? (Note: there was no adolescent data considered at the time DSM-IV was created).

• Are diagnostic orphans (1-2 symptoms of dependence without abuse) similar to abuse or lower?

Unresolved Questions from DSM’s Substance Use Disorder Criteria

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Sample Characteristics

Adolescents: <18 (n=2474)

Young Adult: 18-25

(n=344)

Adults: 26+

(n=661)

Male 74% 58% 47%

Caucasian 48% 54% 29%

African American 18% 27% 63%

Hispanic 12% 7% 2%

Average Age 15.6 20.2 37.3

Substance Disorder 85% 82% 90%

Internal Disorder 53% 62% 67%

External Disorder 63% 45% 37%

Crime/Violence 64% 51% 34%

Residential Tx 31% 56% 74%

Current CJ/JJ invol. 69% 74% 45%

Note: all significant, p < .01

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Differences in Symptom Severity by DrugR

asch

Sev

erit

y M

easu

re

Des

p.P

H/M

H (

+0.

10)

Giv

e u

p a

ct. (

+0.

05)

Can

't s

top

(+

0.05

)

Tim

e C

on

s. (

-0.2

1)

Lo

ss o

f C

on

tro

(-0

.10)

Haz

ard

ou

s (-

0.03

)

Des

pit

e L

egal

(+

0.10

)

Ro

le F

ailu

re (

-0.1

2)

Fig

hts

/tro

ub

. (0.

17)

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80Tim

e Con

s

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

To

lera

nce

(0.

00)

Wit

hd

raw

al (

+0.

34)

Physiological Sx:While Withdrawal is

High severity, Tolerance is only

Moderate

Dependence Sx: Other dependence Symptoms

spread over continuum

Abuse Sx: Abuse Symptoms are also

spread over continuum

1st dimension explains 75% of variance (2nd explains 1.2%)Average Item Severity (0.00)

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Symptom Severity Varied by Drug

Easier to endorse

hazardous use for

ALC/CAN

Ras

ch S

ever

ity

Mea

sure

ALC

ALC

ALC

ALCALC

ALC

ALC

AMP

AMP

AMPAMP

AMP

AMP

CAN

CAN

CAN

CAN

COC COC

COC

OPI

OPIOPI

OPI

OPI

ALC

ALC ALC

ALC

AMP

AMP

AMP

AMP

AMP

CAN

CAN

CAN

CAN

CAN

CAN

CAN

COC

COCCOC

COC

COC

COCCOC

COC

OPI

OPI OPIOPI

OPI

OPI

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80Tim

e Con

s.

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

AVG (0.00)

ALC (-0.44)

AMP (+0.89)

CAN (-0.67)

COC (-0.22)

OPI (+0.44)

Easier to endorse fighting/ trouble for ALC/CAN

Easier to endorse time consuming for CAN

Easier to endorse

moderate Sx for

COC/OPI

Easier to endorse

despite legal problem for ALC/CAN

Easier to endorse

Withdrawal for

AMP/OPI

Withdrawal much less likely for CAN

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Symptom Severity Varied Even More By AgeR

asch

Sev

erit

y M

easu

re

<18 <18

<18

<18

<18

18-25

18-25

18-25

18-25

18-25

18-25

26+

26+

26+

26+

26+

26+

26+

26+

26+

26+

26+<18<18

<18

<18

<18

<18

18-25

18-25

18-25

18-25

18-25

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8Tim

e Con

s.

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

<18

18-25

26+

Age

Adults more likely to endorse most symptomsMore likely to lead to

fights among Adol/YAHazardous use more

likely among Adol/YA

Continued use in spite of legal problems more likely among Adol/YA

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Lifetime Pattern of Substance Use Disorders

66%2%

20%

4%8%

Both

DependenceOnly

Abuse

DiagnosticOrphan

Neither

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Past Month Status

26%

3%

21%

2%12%

25%

3%8%

Both

Dependence Only

Abuse Only

Diagnostic Orphan

Lifetime SUD in CE45+ days

Lifetime SUD inearly remission

Diagnostic Orphanin early remission

Lifetime use only

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Severity by Past Month Status

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

None DiagnosticOrphan in early

remission

DiagnosticOrphan

Lifetime SUD

in early remission

LifetimeSUD in CE

45+ days

Abuse Only

DependenceOnly

BothAbuse

and Dependence

Ras

ch S

ever

ity

Mea

sure

Diagnostic Orphans (1-2 dependence symptoms)

are lower, but still overlap with other clinical groups

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Severity by Past Year Symptom Count

-4.00-3.50-3.00-2.50-2.00-1.50-1.00-0.500.000.501.001.502.00

0 1 2 3 4 5 6 7 8 9 10 11

Ras

ch S

ever

ity

Mea

sure

1. Better Gradation2. Still a lot of overlap in range

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Severity by Number of Past Year SUD DiagnosesR

asch

Sev

erit

y M

easu

re

-4.00

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

0 1 2 3 4 5

1. Better Gradation2. Less overlap in range

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Severity by Weight (past month=2, past year=1) Number of Substance x SUD Symptoms

Ras

ch S

ever

ity

Mea

sure

-4.00-3.50-3.00-2.50-2.00-1.50-1.00-0.500.000.501.001.502.00

0 1-4 5-8 9-12 13-16 17-20 21-24 25-30 31-40 41+

1. Better Gradation2. Much less overlap in range

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Average Severity by Age

-4.00

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

Adolescent (<18) Young Adult (18-25) Adult (26+)

1. Average goes up with age2. Complete overlap in range

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Construct Validity (i.e., does it matter?)

Fre

que

ncy

Of U

se

Pa

st W

eek

With

dra

wal

Em

otio

na

l P

robl

em

s

Re

cove

ry

En

viro

nmen

t

So

cia

l Ris

k

DSM diagnosis \a 0.47 0.40 0.32 0.30 0.30

Symptom Count Continuous \b 0.48 0.43 0.39 0.32 0.31

Weighted Drug x Symptom \c,d 0.26 0.27 0.19 0.29 0.09

\a Categorized as Past year physiology dependence, non-physiological dependence, abuse, other\b Raw past year symptom count (0-11)\c Symptoms weighted by recency (2=past month, 1=2-12 months ago, 0=other)\d Symptoms by drug (alcohol, amphetamine, cannabis, cocaine, opioids)

Past year Symptomcount didbetter than

DSM

Weighted Symptom Rasch \c 0.57 0.46 0.39 0.39 0.32

Rasch does

a little Betterstill

Weighted symptom by drug count severity did

WORSE

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Implications for SUD Concept

• “Tolerance” is not a good marker of high severity; withdrawal (and substance induced health problems are)

• “Abuse” symptoms are consistent with the overall syndrome and represent moderate severity or “other reasons to treat in the absence of the full blown syndrome”

• Diagnostic orphans are lower severity, but relevant• Pattern of symptoms varies by substance and age, but all symptoms are

relevant• “Adolescents” experienced the same range of symptoms, though they (and

young adults) were particularly more likely to be involved with the law, use in hazardous situations, and to get into fights at lower severity

• Symptom Counts appear to be more useful than the current DSM approach to categorizing severity

• While weighting by recency & drug delineated severity, it did not impact predict validity

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Other Progress

• Will work to submit a paper on this analysis this fall• Also submitting papers on

- Differential item functioning by age, gender, & race- Differential item functioning over time- Computer adaptive testing to shorten the GAIN

• Started doing Rasch analyses of other scales: - Internal Mental Distress Scale (somatic, depression, suicide,

anxiety, trauma)- Behavior Complexity Scale (ADHD, CD, and other impulse control

disorders)- Crime/Violence Scale (violence, property, interpersonal, and drug

related crime)- General Individual Severity Scale (total symptom count for above

and substance problems scale)

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Copies of these handouts are available…

• On line at www.chestnut.org/LI/Posters

• or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@chestnut.org