Variation in DSMIV Symptom Severity Depending on Type of Drug and Age: A Facets Analysis

1
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 [phone], fax (309)
  829-4661, e-Mail junsicker_at_Chestnut.Org

2
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.

3
Example Evaluating the Substance Use Disorders
(SUD) Concept

• Much of our conceptual basis of addiction comes
  from Jellnicks 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 ASAMs
  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

4
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?)
  
• 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?)

5
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?)

6
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

7
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 3past month, 2past 2-12 months, 1more
  than a year ago and 0never.
• Analyses done with a combination of Winsteps and
  Facets

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Sample Characteristics
Young Adult
Adults
Adolescents
18-25
26
(n344)
(n661)
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 9
The GAINs 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)

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Person-Item Map


PERSONS
-
MAP
-
ITEMS

(15
above)



.

2 . T

. S

.

.

.

S9PWithdrawl


.

Person Mean
1 . S

.

. S9KDespiteLegal

. S9JHazardousUse
S9UDespiteHlth

. S9TGiveUpActs

Item Mean
. M S9RCantStop


. S9NTolerance

0 . M

.

1st dimension explains 75 of variance (2nd ex
plains 1.2) Note that DSM criteria overlap and
are in a narrow range
. S9HRoleFailure
S9QLossControl

.

.

. S9MTroubleFight


.


-
1 . S

. S9STimeConsumin

.

. S

Added 3 lower severity items
.

.




-
2 . T

.

Adding items increases item spread from 2.2 to 4
.2 logits
(18
below)




EACH '' IS 44

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Item Relationships Across Substances(Ranked SUD
Sx)
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Give up act.
Time Cons
Hazardous
Withdrawal
Tolerance
Can't stop
0.80
Average Item Severity (0.00)
0.60
0.40
0.20
Rasch Severity Measure
0.00
-0.20
-0.40
-0.60
12
Symptom Severity Varied by Drug
Loss of Control
Desp.PH/MH
Despite Legal
Role Failure
Fights/troub.
Time Cons.
Give up act.
Hazardous
Withdrawal
Tolerance
Can't stop
0.80
AVG (0.00)
CAN
AMP (0.89)
0.60
OPI (0.44)
COC (-0.22)
ALC (-0.44)
0.40
CAN (-0.67)
ALC
COC
COC
OPI
Rasch Severity Measure
CAN
0.20
ALC
ALC
CAN
ALC
AMP
AMP
ALC
AMP
AMP
CAN
COC
COC
CAN
AMP
ALC
OPI
OPI
OPI
OPI
CAN
0.00
AMP
CAN
AMP
COC
OPI
OPI
COC
OPI
OPI
CAN
OPI
AMP
AMP
COC
ALC
ALC
COC
ALC
AMP
CAN
COC
OPI
COC
COC
AMP
-0.20
ALC
ALC
CAN
-0.40
CAN
-0.60
13
Symptom Severity Varied Even More By Age
Loss of Control
Desp.PH/MH
Despite Legal
Fights/troub.
Role Failure
Give up act.
Time Cons.
Withdrawal
Hazardous
Tolerance
Can't stop
1.8
26
1.6
Age
1.4
18-25
1.2
26
1
0.8
18-
25
0.6
Rasch Severity Measure
26
18-
18-
25
0.4
26
25
18-
0.2
26
18-
18-
25
25
25
18-
18-
0
26
25
25
26
18-
26
-0.2
25
18-
-0.4
18-
26
25
26
25
26
-0.6
-0.8
26
-1
Hazardous use more likely among Adol/YA
More likely to lead to fights among Adol/YA
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Comparing Substances
15
Rasch Severity by Past Month Status
2.00
1.50
1.00
0.50
0.00
-0.50
Rasch Severity Measure
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
Dependence Only
Both Abuse and Dependence
None
Diagnostic Orphan in early remission
Diagnostic Orphan
Lifetime SUD in CE 45 days
Abuse Only
Lifetime SUD in early remission

16
Severity by Past Year Symptom Count
1. Better Gradation 2. Still a lot of overlap in
range
Rasch Severity Measure
17
Severity by Number of Past Year SUD Diagnoses
1. Better Gradation 2. Less overlap in range
2.00
1.50
1.00
0.50
0.00
Rasch Severity Measure
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
0
1
2
3
4
5
18
Severity by Weighted (past month2, past year1)
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
Rasch Severity Measure
-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
19
Average Severity by Age
1. Average goes up with age 2. Complete overlap i
n range 3. Narrowing of distribution on hi
gher severity at older ages
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
Adolescent (Young Adult (18-25)
Adult (26)
20
Construct Validity (i.e., does it matter?)
Environment
Past Week
Withdrawal
Social Risk
Frequency
Emotional
Recovery
Problems
Of Use

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 Symptom Rasch \c
0.57
0.46
0.39
0.39
0.32
0.26
0.27
0.19
0.29
0.09
Weighted Drug x Symptom \c,d
\a Categorized as Past year physiology
dependence, non-physiological
dependence, abuse, other \b Raw past year sym
ptom count (0-11) \c Symptoms weighted by recency
(2past month, 12-12 months ago, 0other)
\d Symptoms by drug (alcohol, amphetamine,
cannabis, cocaine, opioids)
21
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