Validation of DSMIV Substance Use Disorder by Substance and Age Using Rasch

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
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 Foundations Drug Outcome Monitoring
Study (DOMS), Robert Woods Johnson Foundations
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 [phone],
fax [phone], e-Mail junsicker_at_chestnut.
org
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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 GAINs 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.

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Evolution of the Substance Use Disorders (SUD)
Concept

• Much of our conceptual basis of addiction comes
  from Jellnicks 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 ASAMs
  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)

• 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?)

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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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Unresolved Questions from DSMs 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?

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Sample Characteristics
Young Adult
Adults
Adolescents
18-25
26
(n344)
(n661)
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 9
Differences in Symptom Severity by Drug
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Give up act.
Time Cons
Hazardous
Withdrawal
Tolerance
Can't stop
0.80
1st dimension explains 75 of variance (2nd expl
ains 1.2)
Average Item Severity (0.00)
0.60
0.40
0.20
Rasch Severity Measure
0.00
-0.20
-0.40
-0.60
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Symptom Severity Varied by Drug
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Time Cons.
Give up act.
Hazardous
Withdrawal
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)
ALC
COC
COC
OPI
Rasch Severity Measure
CAN
0.20
ALC
ALC
CAN
ALC
AMP
AMP
ALC
AMP
AMP
CAN
COC
COC
CAN
AMP
ALC
OPI
OPI
OPI
OPI
CAN
0.00
AMP
CAN
AMP
COC
OPI
OPI
COC
OPI
OPI
CAN
OPI
AMP
AMP
COC
ALC
ALC
COC
ALC
AMP
CAN
COC
OPI
COC
COC
AMP
-0.20
ALC
ALC
CAN
-0.40
CAN
-0.60
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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
18-25
1.2
26
1
0.8
18-
25
0.6
Rasch Severity Measure
26
18-
18-
25
0.4
26
25
18-
0.2
26
18-
18-
25
25
25
18-
18-
0
26
25
25
26
18-
26
-0.2
25
18-
-0.4
18-
26
25
26
25
26
-0.6
-0.8
26
-1
Hazardous use more likely among Adol/YA
More likely to lead to fights among Adol/YA
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Lifetime Pattern of Substance Use Disorders
13
Past Month Status
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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

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Severity by Past Year Symptom Count
1. Better Gradation 2. Still a lot of overlap in
range
Rasch Severity Measure
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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
17
Severity by Weight (past month2, past year1)
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
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Average Severity by Age
1. Average goes up with age 2. Complete overlap i
n 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 (Young Adult (18-25)
Adult (26)
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Construct Validity (i.e., does it matter?)
Environment
Past Week
Withdrawal
Social Risk
Frequency
Emotional
Recovery
Problems
Of Use

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 Symptom Rasch \c
0.57
0.46
0.39
0.39
0.32
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 sym
ptom count (0-11) \c Symptoms weighted by recency
(2past month, 12-12 months ago, 0other)
\d Symptoms by drug (alcohol, amphetamine,
cannabis, cocaine, opioids)
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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 [phone], e-Mail
  junsicker_at_chestnut.org