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1
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.
2
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: [email protected]
Acknowledgement
3
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.
4
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
5
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?)
6
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?)
7
• 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
8
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
9
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)
10
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
11
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
12
Lifetime Pattern of Substance Use Disorders
66%2%
20%
4%8%
Both
DependenceOnly
Abuse
DiagnosticOrphan
Neither
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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
21
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)
22
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: [email protected]