Validation of DSM-IV Substance Use Disorder by Substance and Age Using Rasch

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 24-30.

2. Acknowledgement 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 207-98-7047, 277-00-6500, and 270-2003-00006 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 018183); 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 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

3. Goals • Examine the origins, definitions and current debates surrounding the Diagnostic and Statistical Manual IV TR (DSM-IV-TR) substance use disorder (SUD) construct • Use Rasch analysis of the GAIN’s Substance Problem Scale (SPS) data to inform current debates related to SUD • 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. Unresolved Questions from DSM’s Substance Use Disorder Criteria • 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?

8. Sample Characteristics Young Adult: Adults: Adolescents: 18-25 26+ <18 (n=2474) (n=344) (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

9. Withdrawal (+0.34) Despite Legal (+0.10) Desp.PH/MH (+0.10) Give up act. (+0.05) Can't stop (+0.05) Tolerance (0.00) Hazardous (-0.03) Loss of Contro (-0.10) Fights/troub. (0.17) Role Failure (-0.12) Time Cons. (-0.21) 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 Differences in Symptom Severity by Drug Loss of Control Desp.PH/MH Despite Legal Fights/troub. Role Failure Give up act. Time Cons Withdrawal Hazardous Tolerance Can't stop 0.80 1st dimension explains 75% of variance (2nd explains 1.2%) Average Item Severity (0.00) 0.60 0.40 0.20 Rasch Severity Measure 0.00 -0.20 -0.40 -0.60

10. Withdrawal much less likely for CAN Easier to endorse despite legal problem for ALC/CAN Easier to endorse moderate Sx for COC/OPI Easier to endorse hazardous use for ALC/CAN Easier to endorse Withdrawal for AMP/OPI Easier to endorse fighting/ trouble for ALC/CAN Easier to endorse time consuming for CAN Symptom Severity Varied by Drug Loss of Control Desp.PH/MH Despite Legal Fights/troub. Role Failure Give up act. Time Cons. Withdrawal Hazardous 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) COC ALC COC OPI Rasch Severity Measure CAN 0.20 ALC ALC CAN ALC AMP AMP ALC AMP AMP COC CAN COC CAN AMP ALC OPI OPI OPI OPI CAN 0.00 AMP CAN AMP OPI COC OPI COC OPI OPI CAN OPI AMP COC AMP ALC ALC COC ALC AMP CAN COC OPI COC COC AMP -0.20 ALC ALC CAN -0.40 CAN -0.60

11. Continued use in spite of legal problems more likely among Adol/YA Adults more likely to endorse most symptoms 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 18-25 1.2 26+ 1 0.8 18- <18 25 0.6 Rasch Severity Measure 26+ 18- 18- <18 0.4 25 26+ 25 <18 <18 <18 <18 18- 0.2 18- 26+ 18- <18 25 25 25 18- 18- 0 26+ 25 <18 25 <18 26+ 18- 26+ -0.2 25 18- -0.4 18- 26+ 25 26+ 25 26+ -0.6 <18 <18 -0.8 26+ -1 Hazardous use more likely among Adol/YA More likely to lead to fights among Adol/YA

12. Lifetime Pattern of Substance Use Disorders

13. Past Month Status

14. Diagnostic Orphans (1-2 dependence symptoms) are lower, but still overlap with other clinical groups 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

15. 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 0 1 2 3 4 5 6 7 8 9 10 11 Severity by Past Year Symptom Count 1. Better Gradation 2. Still a lot of overlap in range Rasch Severity Measure

16. 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

17. Severity by Weight (past month=2, past year=1) 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+

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

19. Past year Symptom count did better than DSM Rasch does a little Better still Weighted symptom by drug count severity did WORSE Construct Validity (i.e., does it matter?) Environment Past Week Social Risk Withdrawal Frequency Emotional Recovery Problems Of Use 0.47 0.40 0.32 0.30 0.30 DSM diagnosis \a 0.48 0.43 0.39 0.32 0.31 Symptom Count Continuous \b 0.57 0.46 0.39 0.39 0.32 Weighted Symptom Rasch \c 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 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)

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 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