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) 827-6026, fax: (309) 829-4661, e-Mail: junsicker@Chestnut.Org

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)

Physiologicaln. 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-physiologicalq. 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: 18-25

(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 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

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) <more>|<rare> . | 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) <less>|<frequ> EACH '#' IS 44

Item Mean

Person Mean

S9E WeeklyUse

S9CHidingUse

S9DComplaints

Added 3 lower severity items

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)

Ras

ch S

ever

ity

Mea

sure

Des

p.P

H/M

H (

+0.

10)

Giv

e u

p a

ct. (

+0.

05)

Can

't s

top

(+

0.05

)

Tim

e C

on

s. (

-0.2

1)

Lo

ss o

f C

on

tro

(-0

.10)

Haz

ard

ou

s (-

0.03

)

Des

pit

e L

egal

(+

0.10

)

Ro

le F

ailu

re (

-0.1

2)

Fig

hts

/tro

ub

. (0.

17)

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80Tim

e Con

s

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

To

lera

nce

(0.

00)

Wit

hd

raw

al (

+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

Ras

ch S

ever

ity

Mea

sure

ALC

ALC

ALC

ALCALC

ALC

ALC

AMP

AMP

AMPAMP

AMP

AMP

CAN

CAN

CAN

CAN

COC COC

COC

OPI

OPIOPI

OPI

OPI

ALC

ALC ALC

ALC

AMP

AMP

AMP

AMP

AMP

CAN

CAN

CAN

CAN

CAN

CAN

CAN

COC

COCCOC

COC

COC

COCCOC

COC

OPI

OPI OPIOPI

OPI

OPI

-0.60

-0.40

-0.20

0.00

0.20

0.40

0.60

0.80Tim

e Con

s.

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

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 AgeR

asch

Sev

erit

y M

easu

re

<18 <18

<18

<18

<18

18-25

18-25

18-25

18-25

18-25

18-25

26+

26+

26+

26+

26+

26+

26+

26+

26+

26+

26+<18<18

<18

<18

<18

<18

18-25

18-25

18-25

18-25

18-25

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8Tim

e Con

s.

Role F

ailur

e

Fights/

troub

.

Loss

of C

ontro

l

Hazar

dous

Tolera

nce

Can't s

top

Give u

p ac

t.

Desp.

PH/MH

Despit

e Le

gal

With

draw

al

<18

18-25

26+

Age

Adults more likely to endorse most symptomsMore likely to lead to

fights among Adol/YAHazardous use more

likely among Adol/YA

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

Comparing Substances

Amp 0.88

Opi 0.43

Coc -0.21

Alc -0.44

Can -0.66

-1.2-1.0-0.8-0.6-0.4-0.20.00.20.40.60.81.01.21.41.6

TimeG

et

Respo

n

Troub

le

Longe

r

Unsafe

Mor

eAOD

Cutdow

n

GivupA

cs

Med

prob

s

Law With

draw

l

Avg.S

x. Sev

.

Symptoms mostly varied around whether people

used/had a problem

Rasch Severity by Past Month Status

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

None DiagnosticOrphan in early

remission

DiagnosticOrphan

Lifetime SUD

in early remission

LifetimeSUD in CE

45+ days

Abuse Only

DependenceOnly

BothAbuse

and Dependence

Ras

ch S

ever

ity

Mea

sure

Diagnostic Orphans (1-2 dependence symptoms)

are lower, but still overlap with other clinical groups

Severity by Past Year Symptom Count

-4.00-3.50-3.00-2.50-2.00-1.50-1.00-0.500.000.501.001.502.00

0 1 2 3 4 5 6 7 8 9 10 11

Ras

ch S

ever

ity

Mea

sure

1. Better Gradation2. Still a lot of overlap in range

Severity by Number of Past Year SUD Diagnoses

Ras

ch S

ever

ity

Mea

sure

-4.00

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

0 1 2 3 4 5

1. Better Gradation2. Less overlap in range

Severity by Weighted (past month=2, past year=1)

Number of Substance x SUD Symptoms

Ras

ch S

ever

ity

Mea

sure

-4.00-3.50-3.00-2.50-2.00-1.50-1.00-0.500.000.501.001.502.00

0 1-4 5-8 9-12 13-16 17-20 21-24 25-30 31-40 41+

1. Better Gradation2. Much less overlap in range

Average Severity by Age

-4.00

-3.50

-3.00

-2.50

-2.00

-1.50

-1.00

-0.50

0.00

0.50

1.00

1.50

2.00

Adolescent (<18) Young Adult (18-25) Adult (26+)

1. Average goes up with age2. Complete overlap in range3. Narrowing of distribution on higher severity at older ages

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

Fre

que

ncy

Of U

se

Pa

st W

eek

With

dra

wal

Em

otio

na

l P

robl

em

s

Re

cove

ry

En

viro

nmen

t

So

cia

l Ris

k

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 Drug x Symptom \c,d 0.26 0.27 0.19 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)

Past year Symptomcount didbetter than

DSM

Weighted Symptom Rasch \c 0.57 0.46 0.39 0.39 0.32

Rasch does

a little Betterstill

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