Norman G. Hoffmann, Ph.D. Evince Clinical Assessments Western Carolina University

Historical Background Lack of serenity or active discomfort in recovery viewed as relapse risk Was lack of serenity tied to past experience – concept of co-dependency? Empirical verification – based on assessment was required to assess relationships G-OM (Gerwe Orchestration Method) past experiences, emotional memory, and behavioral implications as a possible treatment or treatment component

Codependence Theories Various concepts and formulations Lack of compelling empirical validation of any theory Controversies – Disease, syndrome, or assortment of traits Whether addictions need to be involved Blaming women a criticism of some theories Need for objective exploration of constructs

Observations by Persons in Recovery Some in remission (sober) were abstinent but had not achieved serenity Unresolved issues perceived to be inducing current distress Medicating unresolved issues with antianxiety and depression prescriptions not a solution Current distress seemed to pose a relapse risk Current distress reduced quality of life

Empirical Approach Operationalize codependence constructs Family of origin issues Dysfunctional relationships – compulsive helper Addictions to substances Current distress indications Enmeshment and other relationship issues Gather sample of general population, treatment cases, and family members – then clinical sample Build initial instrument & refine

Empirical Results Robust Factor Scales Dysfunctional family of origin Helper oriented relationships (enabling?) Current distress Personal addiction indications PTSD scale – added after initial results No disease taxon and no syndrome identified for “co-dependence” Relatively independent factors each with potential clinical implications

Family of Origin Scale 10 Items Content concepts Being unwanted Inconsistent parenting Suppression of feelings Victimization Parental substance use NOT included Internal consistency reliability =.721

Victimization: A Three Item Subset of the Origin Scale Types of victimization Physical abuse Sexual abuse Emotional abuse Correlation with overall Origin Scale =.700 Victimization related to other family dysfunction

Relationship Scale 11 Items Content concepts Helping others at one’s own determent Overly sensitive to other’s needs Difficulty saying “no” Guilt about doing something for self Internal consistency reliability =.814

Jolt Scale 7 Items Content concepts Clearly remember first use Get a memorable “jolt” from use Nothing else gives a feeling like use Feel different after use Nothing else is like feeling with use Internal consistency reliability =.665

Avoidance Coping Scale 6 Items Content concepts Use to forget troubles Use to alleviate depression or anxiety Use to improve mood Use to feel more confident Use to forget worries Internal consistency reliability =.665

PTSD Scale – Based on DSM-5 Criterion A: Type of traumatic event: 4 items Criterion B: Intrusion symptoms : 5 items Criterion C: Avoidance of stimuli/reminders: 2 items Criterion D: Negative cognitions/mood : 7 items Criterion E: Arousal and reactivity : 6 items Total number of items 24 Produces a scale based on the total number of positive criteria; Internal Consistency =.892 Algorithm produces a diagnosis based on Criteria B through E all being positive on one or more items

Distress Scale - DARNU 18 Items Content concepts: DARNU Dissatisfied Anxious Restless Nervous Uncomfortable Internal consistency reliability =.915

Sample DARNU Items I often feel discontented. I often think I should be feeling better about myself. I tend to be a nervous person. I am an anxious person. I usually have less fun than most people. I (don’t) feel very positive about myself. I (don’t) have a strong sense of self-worth. I am (not) confortable with who I am most of the time.

Comments about Distress Scale More complex and distinct from depression or anxiety Distinct from the MMPI Demoralization Scale, which has more hopelessness with depressive content The Distress Scale seems to reflect an active disquiet and discomfort

The UNCOPE as SUD Scale U – Have you spent more time drinking/using than intended? (Unintended Use) N – Have you ever neglected usual responsibilities because of using? C – Have you ever wanted to cut down on drinking/using? O – Has anyone objected to your drinking/use? P – Have you found yourself thinking a lot about drinking/use? (Preoccupied) E – Have you ever used to relieve emotional distress, such as sadness, anger, or boredom?

UNCOPE: A Brief Free Screen for Substance Use Disorders Six items used in screening adults and adolescents for any substance use disorder Free – from Evince Clinical Assessments [research tab at Two or more positive responses indicate risk for a severe substance use disorder Sensitivity for severe = 90% to 95% Specificity for severe = 90% to 95%

UNCOPE and the DSM-5 The first five UNCOPE items conform to five different DSM-5 criteria: Criterion 1: U = unplanned use Criterion 5: N = role fulfillment failure Criterion 2: C = desire to cut down Criterion 6: O = interpersonal conflict Criterion 4: P = craving Item E = possible self-medication – not a DSM-5 criterion – but related to SUD

Co-dependence Summary Current distress (DARNU) is modestly related to negative family of origin issues, indications of substance dependence, and dysfunctional relationships Family of Origin problems and dysfunctional relationships are not significantly related No syndrome, BUT family of origin and dysfunctional relationships may be related to current problems without manifesting a “syndrome”

Pavillon Study of Trauma, Distress, and Craving Evaluation of potential problems and relapse risks for those entering treatment Distress measure, PTSD symptom count, and validated craving measures for alcohol and drugs Explore the possibility of identifying level of distress and trauma relative to craving

Initial Correlations Among Scales OriginHelperAvoidJoltDARNUUNCOPE Helper Avoid Jolt DARNU UNCOPE PTSD *.128 Crave

Correlation Summary Origin and Helper modestly related to DARNU DARNU and PTSD close to identical scales – DARNU highly predictive of PTSD JOLT has the highest average correlations with all the other scales – suggests that “reactivity” to substances is important construct – also a risk factor on Dimension 5 of the ASAM Criteria

Correlations of Interest AvoidJoltDARNUUNCOPEPTSD Avoid-- Jolt DARNU UNCOPE PTSD * Crave

Scales of Interest JOLT, PTSD, and DARNU correlate highest with craving Multivariate regression yields a moderate association (R =.519) – because the scales correlate with each other they don’t tend to add unique contribution to prediction Multivariate regression for PTSD: R =.796 not much more than DARNU alone

Trauma, Distress, and Craving DARNU: D – DissatisfiedA – Anxious R – Restless N – Nervous U – Uncomfortable 18- item self-report scale DARNU correlates highly with PTSD and craving PTSD correlates highly with craving (r =.41) Implications: 1.DARNU can identify probable PTSD 2.PTSD “severity” related to greater craving

DARNU Scale and PTSD DARNU elevation quartiles N = 124

Questions to be Addressed Can a written instrument with either the DARNU and/or PTSD scales identify PTSD in routine clinical practice with questions scored from 1 (strongly disagree) to 4 (strongly agree)? What do those with high DARNU but no PTSD look like? Does the level of DARNU have a relationship to the severity or prognosis for those with PTSD diagnosis? Is prognosis predictable from these scales?

Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology Western Carolina University