Transcript Primer on GAIN Scales and Indices

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.
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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: [email protected]
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Goals
1. Examine the origins, definitions and current
debates surrounding the Diagnostic and Statistical
Manual IV TR (DSM-IV-TR) substance use
disorder (SUD) construct
2. Use Rasch analysis of the GAIN’s Substance
Problem Scale (SPS) data to inform current
debates related to SUD
3. 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
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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 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
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emotional problems you were having?)
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 DSM’s
Substance Use Disorder Criteria
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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:
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%
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Differences in Symptom Severity by Drug
Withdrawal (+0.34)
Desp.PH/MH (+0.10)
Give up act. (+0.05)
Can't stop (+0.05)
Tolerance (0.00)
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
Hazardous (-0.03)
Average Item Severity (0.00)
0.60
1st dimension explains
75% of variance (2nd explains 1.2%)
Despite Legal (+0.10)
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
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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
for10
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
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Lifetime Pattern of Substance Use Disorders
Substance Use Disorders, Lifetime
8%
4%
Both
Dependence
Only
Abuse
20%
Diagnostic
Orphan
Neither
2%
66%
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Past Month Status
Substance Use Disorders, Past Month
8%
3%
Both
26%
Dependence Only
Abuse Only
25%
Diagnostic Orphan
3%
Lifetime SUD in CE
45+ days
Lifetime SUD in
early remission
21%
12%
Diagnostic Orphan
in early remission
Lifetime use only
2%
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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
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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
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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
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Rasch Severity Measure
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
-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
2.00
1. Average goes up with age
2. Complete overlap in range
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+)
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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
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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 impact predict validity
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Other Progress
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Will work to submit a paper on this analysis this fall
Also submitting papers on
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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:
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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: (309) 829-4661, e-Mail:
[email protected]
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