1 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

2 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 , , and 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 ); 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 or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) , Acknowledgement

3 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.

4 Evolution of 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 or problem scales more commonly used in evaluation

5 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?)

6 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?)

7 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? Unresolved Questions from DSM’s Substance Use Disorder Criteria

8 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

9 Differences in Symptom Severity by Drug 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 1 st dimension explains 75% of variance (2 nd explains 1.2%) Average Item Severity (0.00)

10 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

11 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

12 Lifetime Pattern of Substance Use Disorders

13 Past Month Status

14 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

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

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

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

18 Average Severity by Age Adolescent (<18)Young Adult (18-25)Adult (26+) 1. Average goes up with age 2. Complete overlap in range

19 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

20 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 impact predict validity

21 Other Progress Will work to submit a paper on this analysis this fall Also submitting papers on - 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: - 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)

22 Copies of these handouts are available… On line at or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax: (309) ,