An Application of Item Response Theory Analysis to Alcohol, Cannabis, and Cocaine Criteria in DSM-IV.

Item response theory (IRT) is supplanting classical test theory as the basis for measures development. This study demonstrated the utility of IRT for evaluating DSM-IV diagnostic criteria. Data on alcohol, cannabis, and cocaine symptoms from 372 adult clinical participants interviewed with the Composite International Diagnostic Interview--Expanded Substance Abuse Module (CIDI-SAM) were analyzed with Mplus (B. Muthen & L. Muthen, 1998) and MULTILOG (D. Thissen, 1991) software. Tolerance and legal problems criteria were dropped because of poor fit with a unidimensional model. Item response curves, test information curves, and testing of variously constrained models suggested that DSM-IV criteria in the CIDI-SAM discriminate between only impaired and less impaired cases and may not be useful to scale case severity. IRT can be used to study the construct validity of DSM-IV diagnoses and to identify diagnostic criteria with poor performance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward the DSM-V: The Withdrawal-Gate Model versus the DSM-IV in the diagnosis of alcohol abuse and dependence.

The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) classifies as dependent many cases of mild alcohol problems. DSM-IV diagnoses have modest relationships with predictive and some concurrent validators and often improperly sequence the onset of abuse vs dependence, perhaps due to insufficient emphasis on physiological features. Testing reliability, syndrome prevalence, syndrome sequencing, and concurrent and predictive validity, this study contrasted the DSM-IV with the Withdrawal-Gate Model (WGM), in which alcohol withdrawal is necessary and sufficient for the dependence diagnosis. Clinical samples of adults (baseline n?=?318) and adolescents (baselinen?=?214) meeting abuse or dependence were assessed for DSM-IV alcohol symptoms and external measures of problem severity and reinterviewed at 6 (adults) and 12 mo (adults and adolescents). Among DSM-IV dependent cases, the WGM shifted 32% of adults and 80% of adolescents to the abuse category, making both categories more symptomatically severe, but had a negligible effect on prevalence of total alcohol diagnoses. The WGM was more reliable than the DSM-IV and temporally sequenced abuse before dependence in a greater number of cases. The WGM was superior to the DSM-IV in concurrent and predictive validity on most measures. Future diagnostic systems may be more reliable and valid if they require evidence of withdrawal for substance dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Classification and short-term course of DSM-IV cannabis, hallucinogen, cocaine, and opioid disorders in treated adolescents.

This study examined the latent class structure of Diagnostic and Statistical Manual of Mental Disorders (text rev.; DSM-IV; American Psychiatric Association, 2000) symptoms used to diagnose cannabis, hallucinogen, cocaine, and opiate disorders among 501 adolescents recruited from addictions treatment. Latent class results were compared with the DSM-IV categories of abuse and dependence, and latent transition analysis (LTA) was used to examine changes in symptom severity over a 1-year follow-up. Although 2- and 3-class solutions provided the best fit to the data (2-class: hallucinogens, cocaine, opioids; 3-class: cannabis), 3-class solutions provided more substantive results and were emphasized in analyses. There was good agreement between latent classes and DSM-IV diagnosis. LTA suggested greater likelihood of transitioning to a less severe class at 1 year for all 4 drugs; in- and outpatients differed in pattern of change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Construct validity of the dependence syndrome as measured by DSM-IV for different psychoactive substances

The Diagnosis of Drug Dependence in the Official Psychiatric Nomenclatures (DSM-III-R, DSM-IV, and ICD 10) are based on the Drug Dependence Syndrome construct. Although the validity and utility of the dependence syndrome has been widely documented for alcohol, the generalizability of the dependence syndrome to other psychoactive substances is still not clear. Thus, this article examines the construct validity of the drug dependence syndrome, as measured by diagnostic criteria for DSM-IV, using both internal consistency analyses and confirmatory factor analyses. Data were obtained from non-mutually exclusive groups of abusers for five drugs (alcohol, cocaine, marijuana, opioids, sedatives, stimulants) drawn from a pool of 521 subjects obtained from drug treatment, general psychiatric and community samples. As predicted by the theory, drug dependence items were found to be unidimensional and factorially distinct from measures of the consequences of substance abuse (e.g. legal problems) for all drug groups. Moreover, the drug dependence items yielded internally consistent scales that produced a distribution of scores reflecting a continuum from low to high severity of abuse for all drugs.     

Motives for cannabis use in high-risk adolescent users.

The present investigation examined the relationships between motives for cannabis use and negative consequences associated with cannabis use following a brief intervention. The sample consisted of 205 adolescent cannabis users (66.3% male), who were recruited in high schools and randomly assigned to a brief two-session motivational enhancement therapy (MET) or an educational feedback control (EFC). Results supported the hypothesis that using cannabis to cope with negative affect would predict the number of problems and dependence symptoms related to cannabis use, after controlling for age, gender, years and frequency of cannabis use, and internalizing and externalizing behavior problems. Significant interactions between internalizing behavior problems and the coping motive showed that using to cope was associated with a higher number of cannabis dependence symptoms among adolescents reporting lower levels internalizing behavior problems. Findings support the potential utility of conducting further research to explore the coping motive as an important indicator of problematic cannabis use. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Alcohol Consumption Moderates the Link Between Cannabis Use and Cannabis Dependence in an Internet Survey.

The link between cannabis use and cannabis dependence remains poorly understood. Some people use cannabis regularly without signs of dependence; others show dependence despite using less. This study examined alcohol consumption as a moderator of this association. A sample of 476 people (primarily Caucasian men) who used cannabis at least once per week reported their alcohol consumption, cannabis use, and cannabis dependence symptoms in an Internet survey. Regressions revealed significant interactions between measures of cannabis use and alcohol consumption when predicting cannabis dependence. Cannabis use covaried with cannabis dependence, particularly in people who consumed alcohol frequently or in large amounts per week. Despite limitations, these data suggest that alcohol may decrease the safety of cannabis consumption. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nosological comparisons of DSM-III-R and DSM-IV alcohol abuse and dependence in a clinical facility: comparison with the 1988 National Health Interview Survey results

The purpose of this study was to compare DSM-III-R and proposed formulations of DSM-IV diagnoses of alcohol use disorders in a clinical sample with the same assessment methods used in a large national survey previously reported. Issues included the number of symptoms required for abuse and dependence diagnoses, the effects of requiring evidence of physiological dependence to make the dependence diagnosis (Option 1 vs. Option 2), whether to require a duration criterion, and the concept of alcohol abuse. The diagnostic criteria proposed in the 1991 DSM-IV options book were the criteria investigated in this study. Concordance between DSM-III-R and DSM-IV was closest when the form of DSM-IV used was most similar to DSM-III-R. The duration criterion had much less effect on a dependence diagnosis in this clinical sample than in the general population. DSM-IV Option 2 for alcohol dependence excluded a number of cases from the dependence diagnosis who received such a diagnosis under DSM-III-R and DSM-IV Option 1. Abuse continued to function as a residual category, especially noticeable under increasingly restrictive definitions of dependence, and was rare in both the clinical and general population sample. Implications of the findings for research and other purposes are discussed.     

Limitations in the Assessment of DSM-IV Cannabis Tolerance as an Indicator of Dependence in Adolescents.

The usefulness of the Diagnostic and Statistical Manual's (4th ed.; DSM-IV; American Psychiatric Association, 1994) tolerance criterion as an indicator of dependence has been debated. The authors of this study evaluated the performance of DSM's cannabis tolerance criterion, operationally defined as a percentage increase in quantity needed to get high, in distinguishing adolescents with and without cannabis dependence. Two samples of adolescent cannabis users (ages 12-19) provided data (ns = 417 and 380). Tolerance, defined as a percentage increase (median increase = 300% and 175%, respectively, in the samples), had only moderate overall sensitivity and specificity in distinguishing those with and without cannabis dependence. Results suggest limitations of the DSM-IV and change-based operational definition of tolerance in adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How should we revise diagnostic criteria for substance use disorders in the DSM-V?

This article reviews literature on the validity and performance characteristics of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for substance use disorders (SUDs) and recommends changes in these criteria that should be considered for the next edition of the DSM (DSM-V). Substantial data indicate that DSM-IV substance abuse and substance dependence are not distinct categories and that SUD criteria are best modeled as reflecting a unidimensional continuum of substance-problem severity. The conceptually and empirically problematic substance abuse diagnosis should be abandoned in the DSM-V, with substance dependence defined by a single set of criteria. Data also indicate that various individual SUD criteria should be revised, dropped, or considered for inclusion in the DSM-V. The DSM-V should provide a framework that allows the integration of categorical and dimensional approaches to diagnosis. Important areas for further research are noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Stability and Impact of Environmental Factors on Substance Use and Problems After Adolescent Outpatient Treatment for Cannabis Abuse or Dependence.

Because alcohol or other drug use following adolescent substance abuse treatment is common, understanding mediators of posttreatment outcome could help improve treatment interventions. The authors conducted path analyses based on data from 552 adolescents (aged 12-18; 82% male) with cannabis abuse or dependence who participated in outpatient treatment. The analysis used the Family Conflict and Cohesion subscales, from the Family Environment Scale, and several scales and indices from the Global Appraisal of Individual Needs. Family conflict, family cohesion, and social support indirectly predicted substance use and substance-related problems as mediated by recovery environment and social risk. This model replicated across 4 follow-up waves (3, 6, 9, and 12 months postintake). These results support the idea of targeting environmental factors during continuing care as a way to improve treatment outcomes for adolescents with cannabis disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationships between frequency and quantity of marijuana use and last year proxy dependence among adolescents and adults in the United States

The association between levels of marijuana use and last year dependence is investigated in a nationally representative sample of adolescents and adults, who used marijuana within the last year (n = 9284). Data are aggregated from three surveys (1991-1993) of the National Household Survey on Drug Abuse. A proxy measure of DSM-IV dependence criteria was developed from self-reported symptoms of dependence and drug-related problems. Both frequency and quantity of marijuana use within the last year are linearly associated with the logit of the probability of being dependent on marijuana. The associations vary significantly by age but not gender. Adolescents are dependent at a lower frequency and quantity of use than adults: the differences diverge as level of use increases. Twice as many adolescents as adults who used marijuana near-daily or daily within the last year were identified as being dependent (35% versus 18%). Frequency and quantity of use each retained a unique effect on dependence, but frequency appeared to be more important than quantity in predicting last year dependence. These results provide insight into the processes underlying the age and sex differentials observed in the prevalence of marijuana dependence. The implications of the findings for the epidemiology of marijuana use and dependence are discussed.     

Patterns of use and their relationship to DSM-IV abuse and dependence of alcohol among adolescents and young adults

First use and initiation of regular alcohol use has been frequently found to start in adolescence. However, only few studies have also investigated how many adolescents proceed during ages 14-24 to harmful drinking or even develop alcohol use disorders. This paper - using the EDSP baseline sample of 3,021 community respondents from the Munich area - examines the prevalence of use, abuse and dependence and investigates the dose/disorder relationship. Alcohol abuse was reported by 9.7% of respondents and alcohol dependence by 6.2%. Men were more likely to report an alcohol disorder than women, prevalence also increased in the older age cohorts. However, even among 14- to 17-year-olds a substantial proportion of respondents report high and regular consumption rates, the occurrence of abuse and dependence criteria and even a full dependence syndrome. There is however only a moderate association between average number of standard drinks consumed with the risk of developing abuse and dependence. In light of the substantial rates among adolescents and young adults the validity of DSM-IV alcohol disorder criteria is discussed.     

Psychosocial Variables Associated With Adolescent Gambling.

The authors empirically examined the relations between several psychosocial variables associated with adolescent problem gambling. Participants were 2,336 students in Grades 7-13, and all completed a questionnaire regarding gambling activities, gambling severity, perceived social support, drug and alcohol dependence, and various social, emotional, and behavioral problems. With respect to gambling severity, 4.9% of adolescents met the criteria for pathological gambling, and 8.0% were found to be at risk. Psychosocial difficulties associated with problem gambling include poor perceived familial and peer social support, substance use problems, conduct problems, family problems, and parental involvement in gambling and substance use. A set of predictor variables that may lead to problem gambling includes having family problems, having conduct problems, being addicted to drugs or alcohol, and being male. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The DSM-IV construct of cocaine dependence in a treatment sample of Black, Mexican American, and White men.

The unidimensionality of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-lV) construct of cocaine dependence was examined among 263 Black, 212 Mexican American, and 256 White men admitted consecutively to 5 substance abuse treatment programs in the Bay Area of northern California. Interviews of about 1 hr were conducted in the programs' facilities by trained interviewers who used a standardized questionnaire. Results of the confirmatory factor analysis (CFA) generally supported a unidimensional model of the 7 indicators of DSM-IV cocaine dependence across the men in all 3 ethnic groups. The results of the CFA, latent trait analysis, and latent class analysis suggested that the indicator representing health problems from cocaine use may not be as useful as the other criteria for identifying cocaine dependence. Limitations and suggestions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recent thinking about the concept of alcohol dependence

This paper reviews past definitions of alcohol dependence as well as that presently adopted in the 4th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. The role of alcohol consumption in diagnostic criteria and the measurement of various dimensions of drinking (frequency, usual quantity per occasion, overall volume) are also discussed. Reliable criteria for identifying both alcohol abuse and dependence are available. Methodology for assessment of different dimensions of drinking behavior also exists. Epidemiologists examining the role of alcohol in health problems should consider the diagnostic category and the dimensions of drinking behavior that are important to their study. Measurements should be adopted in accordance with this assessment.     

DSM-IV alcohol disorders in a general population sample of adolescents and young adults

AIMS/DESIGNS: As part of the Early Developmental Stages of Psychopathology (EDSP) study, results from the baseline cross-sectional assessment of DSM-IV alcohol disorders are presented for a sample of 14-24-year-olds residents in Munich, Germany (N = 3021; 71% response rate). FINDINGS: Life-time prevalence of DSM-IV alcohol abuse (men: 15.1%; women; 4.5%) was found to be considerably more prevalent than dependence (men: 10.0%; women 2.5%) with few cases among respondents younger than 16 years of age; 12-month prevalence of abuse was 8.4% among men and 2.7% among women and of dependence was 7.3% among men and 2.2% among women. Results show that peak incidence of alcohol disorders occurs at 16-17 years of age and that early initiation into alcohol use is associated with an increasing odds of disorder onset, especially for dependence among women. Exploratory analysis of retrospectively assessed diagnostic stability show: a temporal progression to abuse and then dependence, that nearly half of past abuse diagnoses are in remission, abuse remission is more common than progression to dependence, and dependence is highly persistent, especially among women. CONCLUSIONS: Alcohol disorders are frequent in adolescent and young adults being characterized by transient abuse and less prevalent but persistent dependence syndromes. The relatively high prevalence of dependence diagnoses in this young population wit few years of alcohol use is discussed with regard to the clinical validity of DSM-IV criteria in adolescents and young adults.     

Cannabis use, abuse, and dependence in a population-based sample of female twins

OBJECTIVE: The rate of cannabis use by women has been increasing in recent decades. This study examined the etiology of cannabis use and abuse among women and the possible role of genetic risk factors. METHOD: Unselected individual twins (N=1,934) from female-female pairs ascertained through a population-based registry, including both members of 485 monozygotic pairs and of 335 dizygotic pairs, were interviewed by telephone to assess lifetime cannabis use, heavy use, abuse, and dependence as defined by DSM-IV criteria. Biometric model fitting was performed with the Mx computer package. RESULTS: The prevalences of lifetime cannabis use, heavy use, abuse, and dependence were 47.9%, 6.7%, 7.2%, and 2.2%, respectively. Model fitting suggested that twins' resemblance for liability to cannabis use was due to both genetic and familial-environmental factors, while twins' resemblance for heavy cannabis use and abuse and symptoms of dependence resulted solely from genetic factors, with heritabilities ranging from 62% to 79%. The frequency of adolescent social contact between co-twins, which was greater among monozygotic than among dizygotic twins, predicted the twins' resemblance in cannabis use. However, further analyses suggested that the heritability of cannabis use was at most modestly inflated by such social factors. CONCLUSIONS: In women, genetic risk factors have a moderate impact on the probability of ever using cannabis and a strong impact on the liability to heavy use, abuse, and, probably, dependence. By contrast, the family and social environment substantially influences risk of ever using cannabis but plays little role in the probability of developing heavy cannabis use or abuse.     

Reasons for drinking alcohol: Relationships with DSM-IV alcohol diagnoses and alcohol consumption in a community sample.

The relationship between self-reported reasons for drinking and the DSM-IV alcohol use disorders and alcohol consumption was examined. Participants were 777 heavy drinking community residents who completed the Alcohol Use Disorders and Associated Disabilities Interview Schedule (B. F. Grant and D. Hasin, 1992) and a self-report assessment battery. Drinking to reduce negative affect was greater among drinkers with a current DSM-IV alcohol dependence diagnosis compared with drinkers with no DSM-IV alcohol use disorder. The DSM-IV alcohol abuse and the no-diagnosis groups did not differ in reasons for drinking. A positive association was demonstrated between drinking to reduce negative affect and frequency of intoxication. Drinking for enjoyment was positively associated with the frequency of binge drinking, frequency of intoxication, and average daily ethanol consumption. However, the relationship between drinking for enjoyment and average daily ethanol consumption was stronger among those with no alcohol disorder compared to those with DSM-IV alcohol dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences and similarities in the personality correlates of adolescent alcohol problems.

The personality traits of behavioral undercontrol (BU) and negative emotionality (NE) are associated with alcohol problems. The authors examined gender differences in the associations of BU and NE with alcohol problems in 710 adolescents (aged 11.9–19.7 yrs) recruited from community and treatment sources. Multiple measures were used to characterize each construct, and the specified 2-factor model provided a reasonably good fit to the data. ANCOVAs were used to examine each construct by gender across four groups: never-regular drinkers, regular drinkers, and those with DSM-IV alcohol abuse and alcohol dependence. Males had significantly higher BU and lower NE than did females. BU and NE both increased with degree of alcohol problems. However, there was not a significant Gender * Alcohol Group interaction for BU or NE. Although there are gender differences in levels of BU and NE, mechanisms of alcohol involvement related to these 2 personality traits may operate similarly in adolescent males and females. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Traumas and other adverse life events in adolescents with alcohol abuse and dependence

OBJECTIVE: Clinical observation suggests that adolescents with alcohol use disorders often have complex histories that include childhood maltreatment and other traumas. The aim of this study was to determine the relationships among adolescent alcohol use disorders and a broad range of traumas and adverse life events. METHOD: The subjects were 132 adolescents with alcohol dependence, 51 adolescents with alcohol abuse, and 73 adolescents recruited from the community as a control group. Trauma history was assessed by a semistructured interview and other adverse life events by questionnaire. RESULTS: Traumatic events reflecting interpersonal violence had occurred in many of the adolescents with alcohol dependence and abuse and few of the control adolescents. Adolescents with alcohol abuse or dependence, compared with control subjects, were 6 to 12 times more likely to have a physical abuse history and 18 to 21 times more likely to have a sexual abuse history. Sexual abuse was more common in females, and victimization by other violent acts was more common in males. Many other adverse life events were also significantly more common in the alcohol use disorder groups than in the control group, including having a close friend die, arguments within the family, and legal difficulties. CONCLUSIONS: These results demonstrate that trauma and other adverse life events are strongly associated with alcohol use disorders in adolescents. Clinical screening of adolescents with alcohol use disorders for a range of traumatic events is recommended.