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Diagnosis & Assessment of Alcohol Dependence 2006 RSA Lecture Series. Deborah Hasin, Ph.D. Columbia University New York State Psychiatric Institute. Importance to different types of research.

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Diagnosis & Assessment of Alcohol Dependence2006 RSA Lecture Series

Deborah Hasin, Ph.D.

Columbia University

New York State Psychiatric Institute

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Importance to different types of research

  • Treatment: inclusion and exclusion criteria for studies of behavioral & pharmacological interventions

  • Etiologic: phenotypes in genetic studies, defines case and control groups in other studies

  • Epidemiology: defines conditions to determine rates in populations and subgroups

  • Policy: determines & documents services needs

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Importance of diagnosis and assessment in treatment

  • Formulation of treatment plans

  • Facilitates communication between clinicians

  • Teaching tool

  • Justifies third-party payment

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DSM-IV/V importance in treatment

  • Formulation of treatment plans

  • Communication between clinicians with different training or experience

  • Justifying 3rd party payment

  • Teaching and training

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Before “Alcohol Dependence…”

  • Ongoing debate over “alcoholism” vs. “alcohol problems”

  • 12-step(AA) philosophy vs. social science vs. psychoanalysis

  • Little conceptual agreement

  • Assessments not standardized

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Isn’t “alcoholism” obvious? Don’t you “know one when you see one?”

Not necessarily…

  • Concepts of what constitutes an alcohol disorder vary by culture, training, and personal experience

  • Non-standardized assessments yield inconsistent coverage

  • Variation in concepts and coverage lead to poor reliability (agreement) and validity

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What is reliability?

  • Reliability: between-rater agreement on presence, absence, or level of a diagnosis

    • Joint rating design sometimes used

    • Test-retest more common, informative design

  • Reliability coefficients

    • Kappa (K) most common for binary diagnoses

    • Intraclass correlation coefficient (ICC) most common for continuous

    • Interpretation: > .75 excellent, .60 - .74 good, .40 - .59 fair, <.40 poor

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What is validity?

  • This indicates that the condition (diagnosis) being measured is the condition of interest and not something else

    • No single “validity coefficient” or “gold standard”

    • Validity of diagnosis often indicated by comparison to more authoritative evaluation

    • Single biological indicators for alcohol dependence or abuse do not exist

    • Usual design compares diagnosis to expert judgment based on longitudinal course, family history, multiple informants, etc.

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The need for good reliability and validityled (in steps) to DSM-IV

  • Concern over inconsistent concepts of psychiatric disorders led to specific diagnostic criteria

  • Concern over inconsistent and incomplete assessment led to standardized diagnostic interviews

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Alcohol Dependence Syndrome(Edwards and Gross, 1976)

  • Dependence concept based on close observation of patients

  • The concept: a combination of physiological and psychological processes

  • Dimensional rather than yes or no

  • Bi-axial distinction of core alcohol dependence syndrome from its consequences the basis for dependence/abuse

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DSM-IV Alcohol Dependence

Maladaptive drinking leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period:

  • Drinking more or longer than intended

  • Persistent desire or unsuccessful efforts to cut down or stop

  • A great deal of time spent on drinking or getting over its effects

  • Important activities given up or reduced because of drinking

  • Continued drinking despite knowledge of a serious physical or psychological problem

  • Tolerance

  • Withdrawal, or drinking to avoid or relieve drinking

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DSM-IV Alcohol Dependence – Physiological subtype

  • Includes tolerance and/or withdrawal

  • DSM-IV withdrawal criteria: cessation/reduction in heavy, prolonged use & within several hours to a few days

  • 2 or more withdrawal symptoms, including:

    • Autonomic hyperactivity (sweating or rapid pulse)

    • Hand tremor

    • Insomnia

    • Nausea or vomiting

    • Transient hallucinations or illusions

    • Psychomotor agitation

    • Anxiety

    • Seizures

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DSM-IV Alcohol Abuse

Not dependent, and maladaptive drinking leading to clinically significant impairment or distress, shown by 1 + of the following:

  • Continued use despite social/interpersonal problems

  • Hazardous use (e.g., driving when impaired by alcohol)

  • Frequent drinking leading to failure to function in major roles

  • Legal problems

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Dependence: 3 out of 9 Criteria

Abuse: 1 out of 2 Criteria, no dependence


Dependence: 3 out of 6 Criteria

Harmful use: Mental, physical, social harm to user, no dependence


Dependence: 3 out of 7 Criteria

Abuse: 1 out of 4 Criteria, no dependence

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Reliability and validity evidence

Although developed in patient samples:

  • DSM-III-R, DSM-IV and ICD-10 alcohol dependence highly reliable in general population, medical and other populations in the U.S. and elsewhere

  • Dependence valid in many designs

  • Reliability and validity less consistent for abuse

  • Abuse criteria themselves fairly reliable

  • When diagnosed “hierarchically” as required in

    DSM-IV, reliability is lower

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How diagnostic criteria ascertained in different types of assessments

  • Fully structured: close-ended questions read to participants exactly as worded. Usually more than one question (“item”) per diagnostic criterion.

  • Semi-structured: initial questions provided, but interviewer expected to ask additional questions to clarify responses

  • Unstructured: interviewers ask their own questions to determine diagnostic criteria

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Structured Clinical Interview for DSM-IV (SCID) assessmentsWilliams et al., Arch Gen Psychiatry 1992

  • Designed for clinicians, often administered by research assistants

  • Reliance on clinical judgment for many ratings

  • Reliability of alcohol abuse/dependence: excellent, validity good (Kranzler et al., 1996)

  • Used mainly in clinical studies to determine inclusion,

  • exclusion criteria

  • Semi-structured: initial questions included, interviewer then

  • adds own probes if more information needed

  • Major Axis I disorders, SCID-II for Axis II disorders

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Psychiatric Research Interview for assessmentsSubstance & Mental Disorder (PRISM)Hasin et al., Am J Psychiatry 1996; 2006

  • Mainly clinical studies where differentiating primary and substance-induced psychiatric disorders important

  • Semi-structured

  • Major Axis I disorders, Antisocial and Borderline PD

  • Designed for clinicians or research assistants

  • Specified guidelines provided for most ratings

  • Test-retest reliability of DSM-IV alcohol dependence excellent, alcohol abuse fair (non-hierarchical, excellent)

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National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2001-2002

  • National sample

  • N= 43,093

  • NIAAA & NIDA sponsored

  • Household, group residents

  • Oversampled Blacks, Hispanics, adults 18-24 yrs

  • DSM-IV diagnoses

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Alcohol Use Disorders and Associated Disabilities Interview Schedule(AUDADIS)Grant et al., Drug Alcohol Depend 1995; 2003

  • Used mainly in large-scale epidemiologic studies

  • Fully structured

  • Designed for lay interviewers

  • Major Axis I disorders, Axis II disorders

  • Test-retest reliability of DSM-IV alcohol abuse/dependence excellent

  • Validity excellent via psychiatrist re-appraisal and other designs

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Semi-Structured Assessment for the Genetics of Alcoholism Schedule(SSAGA) Bucholz et al., J Stud Alcohol 1994; 2006

  • Mainly used in genetics studies

  • Semi-structured

  • Major Axis I disorders, Antisocial PD

  • Designed for non-clinicians with supervision from an editor

  • Test-retest reliability of DSM-IV alcohol dependence excellent, alcohol abuse fair to very good

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National Comorbidity Study – Replication Schedule(NCS-R) 2001-2002

  • National sample

  • N= 9,282

  • NIMH sponsored

  • Household participants 18+yrs

  • DSM-IV diagnoses


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The Composite International Diagnostic Interview (CIDI) Schedule

  • Used mainly in epidemiologic and clinical studies

  • Fully structured, designed for lay interviewers

  • Early versions such as CIDI-SAM (substance abuse module) similar to other interviews

  • Recent versions (NCS-R, WMH Survey) skipped dependence questions in respondents with no abuse symptoms

  • Agreement with SCID for alcohol dependence fair

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NESARC findings, Schedulecurrent dependence with and without abuse – alcoholHasin et al., Arch Gen Psychiatry, 2004

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NESARC findings, Schedulelifetime dependence with and without abuse – alcoholHasin et al., Arch Gen Psychiatry, 2005

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Designs for Validity Research Schedule

  • Longitudinal – course stays “true” over time, and/or is consistent with theoretical prediction

  • Multi-method comparison – methods agree because they measure a consistent underlying construct

  • Construct – Conditions associated (or not) with external variables in theoretically predicted patterns

  • Factor/latent class analysis – criteria cluster in theoretically predicted patterns

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Longitudinal Schedule course:Dependence and Abuse distinctly different

  • Hasin et al.NationalAm J Psychiatry 1990

  • Hasin et al.Community heavy J Subst Abuse 1997


  • Grant et al.National J Subst Abuse 2001

  • Schuckit et al.UCSD male Am J Psychiatry 2000


  • Schuckit et al.COGA Am J Psychiatry 2001

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Multi-Method Comparison ScheduleDependence: ExcellentAbuse hierarchical: LowAbuse non-hierarchical: Better*

  • Rounsaville et al. Clinical Addiction 1993

  • Schuckit et al. COGA Addiction 1994

  • Hasin et al. Community * Addiction 1996

  • Grant National Alch Clin Exp Res 1996

  • Hasin et al.WHO Int’l Drug Alch Depend 1997

  • Pull et al. WHO Int’l * Drug Alch Depend 1997

  • Cottler et al. WHO Int’l * Drug Alch Depend 1997

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Construct Validation: Dependence ScheduleDrinkers from a community and national sample

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Construct Validation: Abuse ScheduleCommunity Heavy Drinkers and NLAES drinkers

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Factor analyses Schedule:Dependence and Abuse

  • Harford, MuthenU.S. national, NLSY 2 factors

  • Muthen et al.U.S. national, NHIS 2 factors

  • Proudfoot et al.Australian, National 1 factor

  • Saha et al.U.S. NESARC 1 factor

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DSM-V issues concerning dependence Schedule

  • Alcohol dependence is a highly reliable, valid alcohol diagnosis, however:

    • Should a severity indicator of dependence be added, as has been used in small-sample/low-frequency genetics studies (Hasin et al., 2002; Heath et al., 2001)?

    • Should drinking level be added as a criterion or as an extra requirement, e.g., Project COMBINE? (Anton et al., 2006)

    • Can biological endophenotypes be identified that would aid in the diagnosis, e.g., the COGA study? (Hesselbrock et al., 2001; Edenberg et al., 2004)

    • Can the relationship of substance and psychiatric disorders be specified better than the current primary/substance-induced differentiation?

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DSM-V issues concerning abuse Schedule

  • Alcohol abuse is less clear

    • Keep abuse as it is now?

    • Diagnose it independently from dependence?

    • Add a severity indicator?

    • Combine abuse and dependence criteria?

    • Rename?

    • Drop category entirely?

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Clinical assessment and diagnosis Schedule

  • NIAAA Clinician’s Guide

  • http://pubs.niaaa.nih.gov/publications/ Practitioner/CliniciansGuide2005/guide.pdf

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Acknowledgements Schedule

  • K05 AA014223, R01 AA008159, AA008910, DA008409DA010919 DA018652

  • New York State Psychiatric Institute

  • Presentation: Valerie Richmond, M.A.

  • Contact: [email protected]