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 The opinions are those of the author and do not reflect official positions of the consortium or government. Available on line at or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,

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  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” (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 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  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)  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  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.  Analyses done with a combination of Winsteps and Facets

Sample Characteristics Adolescents: <18 (n=2474) Young Adult: (n=344) Adults: 26+ (n=661) Male 74%58%47% Caucasian 48%54%29% African American 18%27%63% Hispanic 12%7%2% Average Age 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

The GAIN’s Substance Problem Scale (SPS)  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)  Dimensional Symptom counts for lifetime, past year and/or past month with internal consistencies of.8 to.9 (test retest of.7 to.9)  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 PERSONS- MAP- ITEMS (15% above) |. | 2. +T. S|.########### |. | ########## | S9PWithdrawl. | 1.######### +S. |. | S9KDespiteLegal.######### | S9JHazardousUse S9UDespiteHlth. | S9TGiveUpActs.######### M| S9RCantStop. | S9NTolerance 0.######### +M. |.######### | S9HRoleFailure S9QLossControl. |.######### |. | S9MTroubleFight. | -1.######## +S. | S9STimeConsumin.######## |. S|. |.######## | | -2. +T. | (18% below) | EACH '#' IS 44 Item Mean Person Mean S9E WeeklyUse S9CHidingUse S9DComplaints Added 3 lower severity items S9FMentHlth S9GPhysHlth Adding items increases item spread from 2.2 to 4.2 logits 1st dimension explains 75% of variance (2nd explains 1.2%) Note that DSM criteria overlap and are in a narrow range

Item Relationships Across Substances (Ranked SUD Sx) Rasch Severity Measure Desp.PH/MH (+0.10) Give up act. (+0.05) Can't stop (+0.05) Time Cons. (-0.21) Loss of Contro (-0.10) Hazardous (-0.03) Despite Legal (+0.10) Role Failure (-0.12) Fights/troub. (0.17) Time Cons Role Failure Fights/troub. Loss of Control Hazardous Tolerance Can't stop Give up act. Desp.PH/MH Despite Legal Withdrawal Tolerance (0.00) Withdrawal (+0.34) 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 Average Item Severity (0.00)

Symptom Severity Varied by Drug Easier to endorse hazardous use for ALC/CAN Rasch Severity Measure ALC AMP CAN COC OPI ALC AMP CAN COC OPI Time Cons. Role Failure Fights/troub. Loss of Control Hazardous Tolerance Can't stop Give up act. Desp.PH/MHDespite Legal Withdrawal AVG (0.00) ALC (-0.44) AMP (+0.89) CAN (-0.67) COC (-0.22) OPI (+0.44) Easier to endorse fighting/ trouble for ALC/CAN Easier to endorse time consuming for CAN Easier to endorse moderate Sx for COC/OPI Easier to endorse despite legal problem for ALC/CAN Easier to endorse Withdrawal for AMP/OPI Withdrawal much less likely for CAN

Symptom Severity Varied Even More By Age Rasch Severity Measure < < Time Cons. Role Failure Fights/troub. Loss of Control Hazardous Tolerance Can't stop Give up act. Desp.PH/MH Despite Legal Withdrawal < Age Adults more likely to endorse most symptoms More likely to lead to fights among Adol/YA Hazardous use more likely among Adol/YA Continued use in spite of legal problems more likely among Adol/YA

Comparing Substances Symptoms mostly varied around whether people used/had a problem

Rasch Severity by Past Month Status NoneDiagnostic Orphan in early remission Diagnostic Orphan Lifetime SUD in early remission Lifetime SUD in CE 45+ days Abuse Only Dependence Only Both Abuse and Dependence Rasch Severity Measure Diagnostic Orphans (1-2 dependence symptoms) are lower, but still overlap with other clinical groups

Severity by Past Year Symptom Count Rasch Severity Measure 1. Better Gradation 2. Still a lot of overlap in range

Severity by Number of Past Year SUD Diagnoses Rasch Severity Measure Better Gradation 2. Less overlap in range

Severity by Weighted (past month=2, past year=1) Number of Substance x SUD Symptoms Rasch Severity Measure Better Gradation 2. Much less overlap in range

Average Severity by Age Adolescent (<18)Young Adult (18-25)Adult (26+) 1. Average goes up with age 2. Complete overlap in range 3. Narrowing of distribution on higher severity at older ages

Construct Validity (i.e., does it matter?) FrequencyOf Use Past Week WithdrawalEmotionalProblemsRecovery Environment Social Risk DSM diagnosis \a Symptom Count Continuous \b 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) Past year Symptom count did better than DSM Weighted Symptom Rasch \c Rasch does a little Better still Weighted symptom by drug count severity did WORSE

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 improve construct validity