Rationale for Changes to Substance-Related Disorders
Tentative new title of new combined section: Addiction and related disorders
Combining Substance Abuse and Dependence Into One Disorder
Background. The basis of the criteria for DSM-III-R and DSM-IV substance dependence (Rounsaville et al., 1986) was the Alcohol Dependence Syndrome (Edwards and Gross, 1976), a dimensional construct representing impaired control over drinking that was generalized to drugs by the World Health Organization (Edwards et al., 1981). The dependence syndrome was described as a psychobiological process leading to impaired control over persistent, heavy drinking or drug use. The causes of dependence were considered different from the causes of substance-related consequences or disabilities, giving rise to a “bi-axial” concept of alcohol and drug disorders (Edwards & Gross, 1976), with dependence on one axis and consequences on the other. The bi-axial concept led to the DSM-III-R and DSM-IV disorders, dependence and abuse. Although Edwards assumed association between the two axes (Edwards & Gross, 1986), DSM-III-R and DSM-IV made dependence take precedence hierarchically over abuse. DSM-IV required that three of seven criteria be met for dependence, and one of four for abuse.
Problems with the abuse/dependence distinction. Early signals of problems in the DSM-IV differentiation between abuse and dependence came from studies showing that while the test-retest reliability of DSM-IV dependence was uniformly very good to excellent, the reliability of DSM-IV abuse was lower and more variable (Hasin et al., 2006; Table 3). Many assumed that abuse was often a prodromal phase of dependence, but several prospective studies showed that this was not the case (Hasin et al., 1990, 1997; Grant et al., 2001; Schuckit et al., 2001; 2008). Further, general population studies showed that the most common way for DSM-IV alcohol abuse to be diagnosed was with a single criterion, hazardous use (generally driving after drinking) (Hasin et al., 1999; Hasin & Paykin, 1999). While certainly unwise and risky behavior, whether a psychiatric diagnosis is warranted based on this symptom alone is questionable. An additional problem with the DSM-IV division between abuse and dependence explicitly mentioned by several authors was that of “diagnostic orphans” (Hasin & Paykin, 1998; 1999; Pollack and Martin, 1999; Ray et al., 2008; Degenhardt et al., 2002; Lynskey & Agrawal, 2007; Martin et al., 2008), i.e., individuals who meet two criteria for dependence but none for abuse. Such individuals could have substance problems at the same severity level as others with a diagnosis, but were left undiagnosed by DSM-IV.
Understanding the relationship of abuse and dependence criteria. Many analyses were conducted to better understand the relationship of abuse to dependence criteria. These included factor analytic studies, latent class analyses, and item response theory analyses.
Factor analyses. Several studies of alcohol abuse and dependence criteria in U.S. samples found significantly better fit for a two-factor model generally corresponding to abuse and dependence criteria (Harford and Muthen, 2001; Muthen et al., 1993; Muthen, 1995; Grant et al., 2007), but with the factors very highly correlated. Other studies using data from male Virginia twins (Gillespie et al., 2007), the National Epidemiologic Survey on Alcohol and Related Conditions) (Agrawal & Lynskey, 2007), and the Australian general population (Teesson et al., 2002) showed that both 1- and 2-factor models corresponding to cannabis dependence and abuse fit the data well, but preferred the 1-factor model due to highly correlated factors in the 2-factor model, with two studies (Teesson et al., 2002; Agrawal & Lynskey, 2007; Lynskey & Agrawal, 2007) dropping some abuse items to achieve unidimensionality. Using NLAES data (Blanco et al., 2007), two factors were also found for cannabis abuse and dependence criteria, also with a high correlation (.77) between the two factors. Among adolescents, a one-factor model fit the data well for alcohol (Gelhorn et al., 2008) and cannabis (Hartman et al., 2008). The high correlations between dependence and abuse raised questions about the utility of the two-factor solutions.
Latent class analyses. Latent class analysis (LCA) is used to identify homogeneous classes of individuals, and assign individuals to classes. LCA of DSM-IV abuse and dependence criteria using data from a large genetics study identified four classes (Bucholz et al., 1996) largely differentiated by successively greater endorsement probabilities for all criteria across classes. In heavy-drinking twins, four classes were found for women and five for men using DSM-IV dependence and abuse criteria (Lynskey et al., 2005). LCA results generally supported the idea of a gradient of severity for alcohol use disorders defined by the number of criteria, with inconsistent results on the presence (Lynskey et al., 2005) or absence (Bucholz, 1996) of a separate abuse class. For drug disorders, in both population-based (Grant et al., 2006; Agrawal et al., 2007) and treated adolescents (Chung & Martin, 2005), LCA identified classes based largely on severity.
Item Response Theory analyses: U.S. alcohol studies. When factor analysis identifies a unidimensional set of criteria, then Rasch and IRT models provide information on the severity level of individual criteria. IRT analyses show that alcohol abuse and dependence criteria were intermixed on an underlying spectrum of severity (Langenbucher et al., 2004; Kahler and Strong, 2006; Martin et al., 2006; Saha et al., 2006; Saha et al., 2007; Gelhorn et al., 2008) although some analyses required removal of criteria to achieve unidimensionality (Langenbucher et al., 2004; Saha et al., 2006). IRT analyses of alcohol problem scales (as distinct from diagnostic criteria) in various samples suggested similar structure (Krueger et al., 2004; Kahler et al., 2003a; Kahler et al., 2003b). An additional analysis using the “discontinuity” approach (Hasin & Beseler, 2009) produced findings consistent with the IRT results.
Item Response Theory analyses: international alcohol studies. To understand how alcohol abuse and dependence criteria perform in international settings, Borges et al. (in press) conducted IRT analyses of data from patients attending 7 emergency rooms in 4 countries: Argentina, Mexico, Poland and the U.S. DSM-IV abuse and dependence formed a unidimensional continuum in the patients regardless of the country of survey. In IRT analyses of drinkers from an Australian general population sample (Proudfoot et al., 2008) for current criteria and in an Israeli general population data (Shmulewitz et al., under review) similar results were obtained within the same sample for current and lifetime criteria.
Item Response Theory analyses: drug abuse and dependence. Fewer IRT analyses have been conducted for drug use disorders, but these are generally consistent with the studies on alcohol, showing that drug abuse and dependence criteria were intermixed on an underlying spectrum of severity. These include studies of the cannabis abuse and dependence criteria in the NESARC (Compton et al., 2009), other substances in NESARC (Lynskey & Agrawal, 2007), cannabis use disorder symptoms in an American Indian community sample (Gilder et al., 2009), a twin study of several different substances (Gillespie et al., 2007), two adolescent cannabis studies (Martin et al., 2006; Hartman et al., 2008), and a study of alcohol, cannabis, cocaine and heroin abuse and dependence criteria in 663 adult patients in treatment for substance and psychiatric problems (Hasin et al., in preparation).
This large body of literature on the structure of abuse and dependence criteria in clinical and general population samples suggests that the DSM-IV abuse and dependence criteria can be considered to form a unidimensional structure, with abuse and dependence criteria interspersed across the severity spectrum.
Summary and conclusion. Problems identified with the DSM-IV division between abuse and dependence led to many studies of the structure of the abuse and dependence in a variety of general population and clinical settings. Given the empirical evidence, the DSM-V Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity, with two criteria required to make a diagnosis. 1280
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Elimination of Legal Problems Criterion for Substance Use Disorder Diagnosis
Statistical analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), National Longitudinal Alcohol epidemiologic Survey (NLAES), adults and youth from the high risk family study Collaborative Study on the Genetics of Alcoholism (COGA) international data from patients treated in the Emergency Departments, and a clinical sample of 663 patients treated for substance and psychiatric disorders all indicate that the legal problems criterion has an extremely low prevalence relative to other criteria, and its removal from the diagnosis has very little effect on the prevalence of substance use disorders while adding little information to the diagnoses in the aggregate.
Addition of New Diagnostic Criterion Representing Craving
Craving is defined as a strong desire for a substance, usually a specific substance. It is a common clinical symptom, tending to be present on the severe end of the severity spectrum. It has been variously defined as a trait with a time component (present or recent past) or as a lifetime component (ever experienced in your life). As a time limited state, craving has been frequently used in published clinical trials as an outcome measure. Brain imaging studies have demonstrated subjective craving precipitated by drug-related cues and correlated with increased activity (blood flow) and dopamine release (PET study) in specific parts of the brain reward system. In large population studies (e.g., NESARC, COGA) craving has been defined by a question about strong urges for the drug in the past.
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