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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: [email protected]
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