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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

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validation of dsm iv substance use disorder by substance and age using rasch

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.

acknowledgement
Acknowledgement

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

goals
Goals
  • Examine the origins, definitions and current debates surrounding the Diagnostic and Statistical Manual IV TR (DSM-IV-TR) substance use disorder (SUD) construct
  • Use Rasch analysis of the GAIN’s Substance Problem Scale (SPS) data to inform current debates related to SUD
  • Discuss the implications of the findings for further refinement of the SUD concept.
evolution of the substance use disorders sud concept
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
dsm gain symptoms of dependence 3 symptoms
DSM (GAIN) Symptoms of Dependence(3+ Symptoms)

Physiological

n. 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-physiological

q. 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?)

dsm gain symptoms of abuse 1 symptoms
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?)

unresolved questions from dsm s substance use disorder criteria
Unresolved Questions from DSM’s Substance Use Disorder Criteria
  • 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?
sample characteristics
Sample Characteristics

Young Adult:

Adults:

Adolescents:

18-25

26+

<18 (n=2474)

(n=344)

(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

differences in symptom severity by drug

Withdrawal (+0.34)

Despite Legal (+0.10)

Desp.PH/MH (+0.10)

Give up act. (+0.05)

Can't stop (+0.05)

Tolerance (0.00)

Hazardous (-0.03)

Loss of Contro (-0.10)

Fights/troub. (0.17)

Role Failure (-0.12)

Time Cons. (-0.21)

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

Differences in Symptom Severity by Drug

Loss of Control

Desp.PH/MH

Despite Legal

Fights/troub.

Role Failure

Give up act.

Time Cons

Withdrawal

Hazardous

Tolerance

Can't stop

0.80

1st dimension explains

75% of variance (2nd explains 1.2%)

Average Item Severity (0.00)

0.60

0.40

0.20

Rasch Severity Measure

0.00

-0.20

-0.40

-0.60

symptom severity varied by drug

Withdrawal much less likely for CAN

Easier to endorse despite legal problem for ALC/CAN

Easier to endorse moderate Sx for COC/OPI

Easier to endorse hazardous use for ALC/CAN

Easier to endorse Withdrawal for AMP/OPI

Easier to endorse fighting/ trouble for ALC/CAN

Easier to endorse time consuming for CAN

Symptom Severity Varied by Drug

Loss of Control

Desp.PH/MH

Despite Legal

Fights/troub.

Role Failure

Give up act.

Time Cons.

Withdrawal

Hazardous

Tolerance

Can't stop

0.80

AVG (0.00)

CAN

AMP (+0.89)

0.60

OPI (+0.44)

COC (-0.22)

ALC (-0.44)

0.40

CAN (-0.67)

COC

ALC

COC

OPI

Rasch Severity Measure

CAN

0.20

ALC

ALC

CAN

ALC

AMP

AMP

ALC

AMP

AMP

COC

CAN

COC

CAN

AMP

ALC

OPI

OPI

OPI

OPI

CAN

0.00

AMP

CAN

AMP

OPI

COC

OPI

COC

OPI

OPI

CAN

OPI

AMP

COC

AMP

ALC

ALC

COC

ALC

AMP

CAN

COC

OPI

COC

COC

AMP

-0.20

ALC

ALC

CAN

-0.40

CAN

-0.60

symptom severity varied even more by age

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

Adults more likely to endorse most symptoms

Symptom Severity Varied Even More By Age

Loss of Control

Desp.PH/MH

Despite Legal

Fights/troub.

Role Failure

Give up act.

Time Cons.

Withdrawal

Hazardous

Tolerance

Can't stop

1.8

26+

1.6

Age

1.4

<18

18-25

1.2

26+

1

0.8

18-

<18

25

0.6

Rasch Severity Measure

26+

18-

18-

<18

0.4

25

26+

25

<18

<18

<18

<18

18-

0.2

18-

26+

18-

<18

25

25

25

18-

18-

0

26+

25

<18

25

<18

26+

18-

26+

-0.2

25

18-

-0.4

18-

26+

25

26+

25

26+

-0.6

<18

<18

-0.8

26+

-1

Hazardous use more likely among Adol/YA

More likely to lead to fights among Adol/YA

severity by past month status

Diagnostic Orphans (1-2 dependence symptoms) are lower, but still overlap with other clinical groups

Severity by Past Month Status

2.00

1.50

1.00

0.50

0.00

-0.50

Rasch Severity Measure

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

Dependence

Only

Both

Abuse

and

Dependence

None

Diagnostic

Orphan

in early

remission

Diagnostic

Orphan

Lifetime

SUD

in CE

45+ days

Abuse

Only

Lifetime

SUD

in early

remission

severity by past year symptom count

2.00

1.50

1.00

0.50

0.00

-0.50

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

-4.00

0

1

2

3

4

5

6

7

8

9

10

11

Severity by Past Year Symptom Count

1. Better Gradation

2. Still a lot of overlap in range

Rasch Severity Measure

severity by number of past year sud diagnoses
Severity by Number of Past Year SUD Diagnoses

1. Better Gradation

2. Less overlap in range

2.00

1.50

1.00

0.50

0.00

Rasch Severity Measure

-0.50

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

-4.00

0

1

2

3

4

5

severity by weight past month 2 past year 1 number of substance x sud symptoms
Severity by Weight (past month=2, past year=1) Number of Substance x SUD Symptoms

1. Better Gradation

2. Much less overlap in range

2.00

1.50

1.00

0.50

0.00

Rasch Severity Measure

-0.50

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

-4.00

0

1-4

5-8

9-12

13-16

17-20

21-24

25-30

31-40

41+

average severity by age
Average Severity by Age

1. Average goes up with age

2. Complete overlap in range

2.00

1.50

1.00

0.50

0.00

-0.50

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

-4.00

Adolescent (<18)

Young Adult (18-25)

Adult (26+)

construct validity i e does it matter

Past year

Symptom

count did

better than

DSM

Rasch

does

a little

Better

still

Weighted symptom by drug count severity did WORSE

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

Environment

Past Week

Social Risk

Withdrawal

Frequency

Emotional

Recovery

Problems

Of Use

0.47

0.40

0.32

0.30

0.30

DSM diagnosis \a

0.48

0.43

0.39

0.32

0.31

Symptom Count Continuous \b

0.57

0.46

0.39

0.39

0.32

Weighted Symptom Rasch \c

0.26

0.27

0.19

0.29

0.09

Weighted Drug x Symptom \c,d

\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)

implications for sud concept
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
other progress
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)
copies of these handouts are available
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