Transcript Slide 1

Variation in DSM-IV
Symptom Severity Depending
on Type of Drug and Age:
A Facets Analysis
Michael L. Dennis, Ph.D.
Chestnut Health Systems, Bloomington, IL
Presentation at the International Conference on Outcome Measurement,
September 11, 2008, Bethesda, MD. This presentation supported by National
Institute on Drug Abuse (NIDA) grant no R37 DA11323 and Center for
Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA) contract 270-07-019. 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) 8276026, fax: (309) 829-4661, e-Mail: [email protected]
Objectives are to...


Use Rasch to evaluate the distribution of DSM IV
criteria substance use disorders (abuse &
dependence)
Use Rasch to inform some of the key question that
have been raised about the current approach to
categorizing severity and variation by substance and
age.
Example: Evaluating the
Substance Use Disorders (SUD) Concept
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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 biopsycho-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” (e.g., ASI, SFS) or “problem” scales (e.g.,
MAST, DAST, CAGE) more commonly used in treatment
research
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
(No dependence and 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?)
On-Going Debates About SUD Concept
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•
•
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Formal assumption that symptoms of “physiological
dependence” (either tolerance or withdrawal) are
markers of high severity
Debate about whether “abuse” symptoms should be
dropped, thought of as early dependence, or thought
of as moderate/high severity markers that warrant
treatment even in the absence of a full syndrome
Debate about whether to treat diagnostic orphans (1-2
symptoms of dependence) as abuse or continue to
ignore them
Concern about whether the current symptoms (which
were based primarily on adult data) are appropriate
for use with adolescents
Concern about the sensitivity to change
Conrad et al 2007
Data Source and Methods
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Data from 2474 Adolescents, 344 Young Adults and 661
Adults interviewed between 1998 and 2005 with the
Global Appraisal of Individual Needs (GAIN; Dennis et al
2003)
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Participants recruited at intake to Early Intervention,
Outpatient, Intensive Outpatient, Short, Moderate & Long
term Residential, Corrections Based and Post Residential
Outpatient Continuing Care as part of 72 local evaluations
around the U.S. and pooled into a common data set
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Analysis here focuses on the GAIN Substance Use
Disorder Scale (SUDS) with symptoms of dependence and
abuse overall and by substance. The rating scale is 3=past
month, 2=past 2-12 months, 1=more than a year ago and
0=never.
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Analyses done with a combination of Winsteps and Facets
Sample Characteristics
Young Adult:
Adolescents:
18-25
<18 (n=2474)
(n=344)
Male
74%
Caucasian
48%
African American
18%
Hispanic
12%
Average Age
15.6
Substance Disorder
85%
Internal Disorder
53%
External Disorder
63%
Crime/Violence
64%
Residential Tx
31%
Current CJ/JJ invol.
69%
Note: all significant, p < .01
Adults:
26+
(n=661)
58%
47%
54%
29%
27%
63%
7%
2%
20.2
37.3
82%
90%
62%
67%
45%
37%
51%
34%
56%
74%
74%
45%
The GAIN’s
Substance Problem Scale (SPS)
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DSM-IV Clinical Diagnosis categories and courser
specifiers (Kappa of .5 to .7)

Epidemiological Lifetime, Past Year and/or Past Month
Diagnosis categories (Kappa of .5 to .7)
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Dimensional Symptom counts for lifetime, past year and/or
past month with internal consistencies of .8 to .9 (test retest
of .7 to .9)
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16 items:
- 7 symptoms for dependence (including physiological
symptoms),
- 4 for abuse,
- 2 lower severity items (complaints about use, hiding
use, weekly use), and
- 2 higher severity items (substance induced health and
mental health Sx)
Person-Item
Map
Added 3 lower
severity items
Person
Mean
Item
Mean
1st dimension explains
75% of variance
(2nd explains 1.2%)
Note that DSM criteria overlap
and are in a narrow range
Added 3 lower
severity items
Adding items increases item
spread from 2.2 to 4.2 logits
PERSONS - MAP - ITEMS
(15% above)
<more>|<rare>
. | S9GPhysHlth
2
. +T
. S|
.########### |
. |
. |
########## | S9PWithdrawl
. |
1
.######### +S
. |
. | S9KDespiteLegal
.######### | S9JHazardousUse
. | S9TGiveUpActs
.######### M| S9RCantStop
. | S9NTolerance
0
.######### +M
. |
.######### | S9HRoleFailure
. |
.######### |
. | S9MTroubleFight
. |
-1
.######## +S
. | S9STimeConsumin
.######## | S9DComplaints
. S|
. |
.######## |
|
-2
. +T
. | S9E WeeklyUse
(18% below)
<less>|<frequ>
EACH '#' IS 44
S9UDespiteHlth
S9FMentHlth
S9QLossControl
S9CHidingUse
Item Relationships Across Substances
(Ranked SUD Sx)
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)
0.00
Role Failure (-0.12)
0.20
Time Cons. (-0.21)
Rasch Severity Measure
0.40
Despite Legal (+0.10)
Average Item Severity (0.00)
0.60
Withdrawal (+0.34)
0.80
-0.20
-0.40
-0.60
Abuse Sx:
Abuse Symptoms are also
spread over continuum
Physiological Sx:
While Withdrawal is
High severity, Tolerance
Dependence Sx:
is only Moderate
Other dependence Symptoms
spread over continuum
Symptom Severity Varied by Drug
0.80
Withdrawal much less likely for CAN
AVG (0.00)
0.60
CAN
AMP (+0.89)
Rasch Severity Measure
OPI (+0.44)
COC (-0.22)
0.40
ALC (-0.44)
CAN (-0.67)
0.20
ALC
CAN
0.00
AMP
OPI
ALC
COC
-0.20
OPI
AMP
ALC
CAN
COC
COC
OPI
AMP
COC
OPI
OPI
CAN
ALC
AMP
COC
ALC
AMP
CAN
CAN
OPI
AMP
COC
OPI
COC
-0.60
Easier to endorse
Easier to endorse time fighting/ trouble
for ALC/CAN
consuming for CAN
OPI
COC
ALC
CAN
AMP
OPI
ALC
CAN
ALC
AMP
AMP
OPI
COC
AMP
ALC
CAN
-0.40
ALC
AMP
CAN
OPI
COC
CAN
ALC
COC
Easier to
endorse
hazardous
use for
ALC/CAN
Easier to
endorse
moderate
Sx for
COC/OPI
Easier to
endorse
Easier to
despite legal endorse
problem for Withdrawal
ALC/CAN
for
AMP/OPI
Symptom Severity Varied Even More By Age
1.8
Rasch Severity Measure
1.6
26+
Age
1.4
<18
1.2
18-25
Continued use in spite
of legal problems more
likely among Adol/YA
26+
1
0.8
1825
0.6
26+
0.4
26+
0.2
1825
0
<18
1825
-0.2
-0.4
-0.6
-0.8
<18
1825
<18
26+
<18
1825
<18
1825
<18
1825
26+
<18
1825
1825
<18
1825
<18
26+
26+
26+
26+
26+
26+
-1
More likely to lead to
fights among Adol/YA
1825
<18
<18
Hazardous use more
likely among Adol/YA
Adults more
likely to endorse
most symptoms
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
-0.2
-0.4
-0.6
-0.8
-1.0
-1.2
l
vg
.S
x.
Se
v.
w
A
dr
a
W
ith
iv
up
A
cs
M
ed
pr
ob
s
La
w
G
n
Symptoms mostly varied
around whether people
used/had a problem
td
ow
Cu
O
D
eA
or
M
U
ns
a
fe
r
Lo
ng
e
ub
le
Tr
o
Ti
m
eG
et
Re
sp
on
Comparing Substances
Amp 0.88
Opi 0.43
Coc -0.21
Alc -0.44
Can -0.66
Rasch Severity by Past Month Status
2.00
Rasch Severity Measure
1.50
1.00
0.50
Diagnostic Orphans (1-2
dependence symptoms)
are lower, but still overlap
with other clinical groups
0.00
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
None
Diagnostic Diagnostic Lifetime
Lifetime
SUD
Orphan Orphan
SUD
in early
in early
in CE
remission 45+ days
remission
Abuse
Only
Dependence Both
Only
Abuse
and
Dependence
Rasch Severity Measure
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
1. Better Gradation
2. Still a lot of overlap in range
0
1
2
3
4
5
6
7
8
9
10
11
Severity by Number of
Past Year SUD Diagnoses
1. Better Gradation
2. Less overlap in range
2.00
Rasch Severity Measure
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
Rasch Severity Measure
Severity by Weighted (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
-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
2.00
1. Average goes up with age
2. Complete overlap in range
3. Narrowing of distribution on
higher severity at older ages
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?)
Recovery
Environment
DSM diagnosis \a
Symptom Count Continuous \b
0.47
0.48
0.40
0.43
0.32
0.39
0.30 0.30
0.32 0.31
Weighted Symptom Rasch \c
Weighted Drug x Symptom \c,d
0.57
0.26
0.46
0.27
0.39
0.19
0.39 0.32
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)
Social Risk
Emotional
Problems
Weighted
symptom by
drug count
severity did
WORSE
Past Week
Withdrawal
Rasch
does
a little
Better
still
Frequency
Of Use
Past year
Symptom
count did
better than
DSM
Implications for SUD Concept
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“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 improve construct validity