Is the continuity of externalizing psychopathology the same in adolescents and middle-aged adults? A test of the externalizing spectrum's developmental coherence

Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain

OBJECTIVE

The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.

METHODS

Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.

RESULTS

The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.

CONCLUSIONS

Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie☆

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

Implications of Medical and Recreational Marijuana Laws for Neuroscience Research: a Review

Purpose of Review

Review of US medical and recreational marijuana laws (MML and RML), their effects on cannabis potency, prevalence of non-medical cannabis use and cannabis use disorder (CUD) in adolescents and adults, and implications for neuroscience research, given what is known about the relationship of cannabis to neurocognitive impairments and underlying brain functioning.

Recent Findings

Cannabis potency may be increasing faster in states with MML or RML than in other states. MML and RML have not impacted prevalence in adolescents but have consistently been shown to increase rates of adult non-medical use and CUD.

Summary

Recent neurocognitive or neuroimaging studies may be more impacted by cannabis than studies conducted when MML and RML were less common. Neurocognitive or neuroimaging studies conducted in MML or RML states should carefully test potential participants for recent cannabis use. More research is needed on cannabis and cognition in medical marijuana patients.

Meta-analysis of aberrant post-error slowing in substance use disorder: implications for behavioral adaptation and self-control

Individual with substance use disorders have well-recognized impairments in cognitive control, including in behavioral adaptation after mistakes. One way in which this impairment manifests is via diminished post-error slowing, the increase in reaction time following a task-related error that is posited to reflect cautionary or corrective behavior. Yet, in the substance use disorder literature, findings with regard to post-error slowing have been inconsistent, and thus could benefit from quantitative integration. Here, we conducted a meta-analysis of case-control studies examining post-error slowing in addiction. Twelve studies with 15 unique comparisons were identified, comprising 567 substance users and 384 healthy controls across three broad types of inhibitory control paradigms (go-no/go, conflict resolution, and stop signal tasks, respectively). Results of the random-effects meta-analysis revealed a moderate group difference across all studies (Cohen's d = 0.31), such that the individuals with substance use disorder had diminished post-error slowing compared with controls. Despite this omnibus effect, there was also large variability in the magnitude of the effects, explained in part by differences between studies in task complexity. These findings suggest that post-error slowing may serve as a promising and easy-to-implement measure of cognitive control impairment in substance use disorder, with potential links to aberrant brain function in cognitive control areas such as the anterior cingulate cortex.

The role of effortful control in the development of ADHD, ODD, and CD symptoms

Many adolescents have difficulty regulating their impulses and become prone to externalizing problems (e.g., attention-deficit/hyperactivity disorder [ADHD], oppositional defiant disorder [ODD], and conduct disorder [CD]) and other adverse consequences. Using multimethod data from a longitudinal study of Mexican-origin youth (N = 674), assessed annually from age 10 to 16, we examined the relations between effortful control and ADHD, ODD, and CD symptoms over time. Bivariate latent growth curve models showed negative correlations between the trajectories of effortful control and ADHD, ODD, and CD, indicating that steeper decreases in effortful control were related to steeper increases in ADHD, ODD, and CD symptoms. Using a novel statistical technique, the factor of curves model (FOCUS), we found that ADHD, ODD, and CD share a common "externalizing" trajectory during adolescence. Although effortful control was strongly associated with this common trajectory, it had few unique associations with the individual disorder trajectories, above and beyond their shared trajectory. When we extended the FOCUS model to include the effortful control trajectory as an indicator, we found that ADHD and ODD had strong loadings, whereas effortful control and CD had comparatively weak loadings on the shared developmental trajectory. Follow-up analyses showed that a two-factor solution, with externalizing symptom trajectories on one factor and the effortful control facet trajectories on a separate factor, was a better fit to the data than a one-factor solution. Finally, parent ASPD symptoms were related to increases in CD, but had no significant influence on effortful control, ADHD, or ODD. We discuss the implications for personality and externalizing problem development. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Progress in achieving quantitative classification of psychopathology

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

The cross-national structure of mental disorders: results from the World Mental Health Surveys

BACKGROUND

The patterns of comorbidity among mental disorders have led researchers to model the underlying structure of psychopathology. While studies have suggested a structure including internalizing and externalizing disorders, less is known with regard to the cross-national stability of this model. Moreover, little data are available on the placement of eating disorders, bipolar disorder and psychotic experiences (PEs) in this structure.

METHODS

We evaluated the structure of mental disorders with data from the World Health Organization Composite International Diagnostic Interview, including 15 lifetime mental disorders and six PEs. Respondents (n = 5478-15 499) were included from 10 high-, middle- and lower middle-income countries across the world aged 18 years or older. Confirmatory factor analyses (CFAs) were used to evaluate and compare the fit of different factor structures to the lifetime disorder data. Measurement invariance was evaluated with multigroup CFA (MG-CFA).

RESULTS

A second-order model with internalizing and externalizing factors and fear and distress subfactors best described the structure of common mental disorders. MG-CFA showed that this model was stable across countries. Of the uncommon disorders, bipolar disorder and eating disorder were best grouped with the internalizing factor, and PEs with a separate factor.

CONCLUSIONS

These results indicate that cross-national patterns of lifetime common mental-disorder comorbidity can be explained with a second-order underlying structure that is stable across countries and can be extended to also cover less common mental disorders.

Mental disorder comorbidity and treatment utilization

OBJECTIVE

Effective interventions have been developed for myriad common psychological and substance use disorders, though they remain highly underutilized. Previous research has shown that the likelihood of treatment utilization varies across disorder diagnosis. However, studies that focus on individual disorders have resulted in a large, piecemeal literature that neglects the high rates of multivariate comorbidity. The current study investigated the association between treatment utilization and transdiagnostic comorbidity factors.

METHODS

In a nationally representative sample of the United States adult population (N=34,653), we applied the internalizing-externalizing latent comorbidity model to examine its association with lifetime utilization of various treatments for mood, anxiety, and substance use disorders.

RESULTS

Both internalizing and externalizing transdiagnostic factors were positively associated with all forms of treatment utilization. Stronger within-domain domain (e.g., internalizing's association with mood or anxiety treatment) than between-domain (e.g., internalizing's association with substance use disorder treatment) associations were found. Significant antagonistic internalizing-by-externalizing interactions were also observed.

CONCLUSIONS

These results underscore the importance of applying a nuanced approach to modeling comorbidity when predicting treatment utilization. Clinical implications are discussed.

Genetic and environmental sources of covariation between early drinking and adult functioning

The vast majority of individuals initiate alcohol consumption for the first time in adolescence. Given the widespread nature of its use and evidence that adolescents may be especially vulnerable to its effects, there is concern about the long-term detrimental impact of adolescent drinking on adult functioning. While some researchers have suggested that genetic processes may confound the relationship, the mechanisms linking drinking and later adjustment remain unclear. The current study utilized a genetically informed sample and biometric modeling to examine the nature of the familial influences on this association and identify the potential for genetic confounding. The sample was drawn from the Minnesota Twin Family Study (MTFS), a longitudinal study consisting of 2,764 twins assessed in 2 cohorts at regular follow-ups from age 17 to age 29 (older cohort) or age 11 to age 29 (younger cohort). A broad range of adult measures was included assessing substance use, antisocial behavior, personality, socioeconomic status, and social functioning. A bivariate Cholesky decomposition was used to examine the common genetic and environmental influences on adolescent drinking and each of the measures of adult adjustment. The results revealed that genetic factors and nonshared environmental influences were generally most important in explaining the relationship between adolescent drinking and later functioning. While the presence of nonshared environmental influences on the association are not inconsistent with a causal impact of adolescent drinking, the findings suggest that many of the adjustment issues associated with adolescent alcohol consumption are best understood as genetically influenced vulnerabilities. (PsycINFO Database Record

The interaction between temperament and the family environment in adolescent substance use and externalizing behaviors: Support for diathesis-stress or differential susceptibility?

Both individual and environmental factors predict externalizing behaviors and substance use (EB-SU); however, different patterns of interaction among these factors may have different implications. This review first examines how temperament and the family environment interact in the prediction of adolescent EB-SU. Second, studies are reviewed according to two theoretical models: (1) diathesis-stress, i.e., certain individual characteristics are linked to vulnerability and later problems in adverse environments; (2) differential susceptibility, i.e., these characteristics are linked to susceptibility, predicting problems in adverse environments, but also better than average outcomes in good environments. Fourteen studies focusing on the prediction of EB-SU at ages 12-18 were selected through a literature search. Results showed that certain temperament traits (high levels of impulsivity and disinhibition; low levels of effortful control, negative affect, fearfulness and shyness), hereby designated as "adventurous" disposition, were associated with higher levels of EB-SU in adverse family environments. Some studies also showed that children with "adventurous" temperament traits in positive environments had the lowest levels of EB-SU. This suggests that prevention of EB-SU might target family factors such as parenting and focus on children with "adventurous" temperament traits. Further, studies that supported the differential susceptibility model were those assessing temperament and the family environment in childhood and studies that supported the diathesis-stress model assessed these variables in adolescence. It is thus possible that some of these "adventurous" temperament traits, with regard to EB-SU, would be indicators of susceptibility to both enriched and adverse environments in childhood but no longer in adolescence, when they would only be indicators of vulnerability to adverse environments.

Personality Traits Predict the Developmental Course of Externalizing: A Four-Wave Longitudinal Study Spanning Age 17 to Age 29

The objective of the present study was to determine whether and how personality predicts the developmental course of externalizing problems, including antisocial behavior and substance dependence. In a large, population-based longitudinal study (N = 1,252), the 11 personality traits assessed by the Multidimensional Personality Questionnaire were measured at age 17, and DSM diagnoses of adult antisocial behavior, alcohol dependence, and drug dependence were obtained at ages 17, 20, 24, and 29. We fit a quadratic multiple indicator latent growth model where the three diagnoses loaded onto an externalizing factor. This model fit the data well, and externalizing increased until it started to decline at age 24. High aggression and low control were the most significant predictors of the development of externalizing, with aggression playing a significant role in the development of externalizing across the 12-year time span, and control predicting the development from age 17 to 24. The findings highlight the importance of considering the developmental course of externalizing in the context of personality and suggest that the specific personality traits of aggression and control might be targeted in externalizing prevention and intervention programs.

Transdiagnostic factors of psychopathology and substance use disorders: a review

PURPOSE

Research on the structure of mental disorders and comorbidity indicates that many forms of psychopathology and substance use disorders are manifestations of relatively few transdiagnostic latent factors. These factors have important consequences for mental disorder research and applied practice.

METHODS

We provide an overview of the transdiagnostic factor literature, with particular focus on recent advances.

RESULTS

Internalizing and externalizing transdiagnostic factors have been well characterized in terms of their structures, links with disorders, stability, and statistical properties (e.g., invariance and distributions). Research on additional transdiagnostic factors, such as thought disorder, is quickly advancing latent structural models, as are integrations of transdiagnostic constructs with personality traits. Genetically informed analyses continue to clarify the origins of transdiagnostic factor levels, and links between these factors and important environmental exposures provide promising new avenues of inquiry.

CONCLUSIONS

Transdiagnostic factors account for the development and continuity of disorders and comorbidity over time, function as the primary links between disorders and important outcomes such as suicide, mediate associations between environmental exposures and disorders, provide an empirically supported classification system, and serve as foci for efficient, broadband intervention approaches. Overall, transdiagnostic factor research indicates the paramount importance of understanding these constructs and, thereby, broadening our understanding of mental disorder in general.

Genetic relationship between the addiction diagnosis in adults and their childhood measure of addiction liability

Transmissible liability index (TLI), developed employing a high-risk design and item response theory, enables quantification of the latent trait of liability to drug use disorders (DUD) in children. TLI has been shown to have high heritability and predict DUD in young adulthood. This study extends prior research and determines the genetic contribution of DUD liability measured by TLI to adult liability as indexed by DUD diagnosis. The study utilizes data from a twin sample tracked from age 11 to age 25. In addition to confirming TLI's high heritability and predictive validity, it shows that the genetic component of variance in TLI assessed in childhood accounts for over half of the genetic variance in DUD diagnosis and the entire phenotypic relationship between the two liability measures. This validates TLI as an early measure of DUD liability and supports its utility in early-age genetic and other mechanistic studies of DUD.

Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample

BACKGROUND

Alcohol, tobacco and marijuana are the most commonly used drugs by adolescents in the U.S. However, little is known about the patterning of early adolescent substance use, and its implications for problematic involvement with substances in young adulthood. We examined patterns of substance use prior to age 16, and their associations with young adult substance use behaviors and substance use disorders in a nationally representative sample of U.S. adolescents.

METHOD

Using data from Wave 4 of the Add Health Survey (n=4245), we estimated the prevalence of various patterns of early adolescent use of alcohol, cigarettes, and marijuana use individually and in combination. Then we examined the effects of patterns of early use of these substances on subsequent young adult substance use behaviors and DSM-IV substance use disorders.

RESULTS

While 34.4% of individuals reported no substance use prior to age 16, 34.1% reported either early use of both alcohol and marijuana or alcohol, marijuana and cigarettes, indicating the relatively high prevalence of this type of polysubstance use behavior among U.S. adolescents. Early adolescent use of all three substances was most strongly associated with a spectrum of young adult substance use problems, as well as DSM-IV substance use disorder diagnoses.

CONCLUSIONS

This research confirms the elevated prevalence and importance of polysubstance use behavior among adolescents prior to age 16, and puts early onset of alcohol, marijuana and cigarette use into the context of use patterns rather than single drug exposures.

Alcohol and drug abuse among U.S. veterans: comparing associations with intimate partner substance abuse and veteran psychopathology

This study examined the relative influences of posttraumatic stress disorder (PTSD), other psychopathology, and intimate partner alcohol and drug use on substance-related problems in U.S. veterans (242 couples, N = 484). Hierarchical regression analyses revealed that partner alcohol and drug use severity explained more variance in veteran alcohol use and drug use (20% and 13%, respectively) than did veteran PTSD, adult antisocial behavior, or depression symptoms combined (6% for veteran alcohol use; 7% for veteran drug use). Findings shed new light on the influence of relationship factors on veteran alcohol and drug use and underscore the importance of couples-oriented approaches to treating veterans with comorbid PTSD and substance abuse.

Confluence of genes, environment, development, and behavior in a post Genome-Wide Association Study world

This article serves to outline a research paradigm to investigate main effects and interactions of genes, environment, and development on behavior and psychiatric illness. We provide a historical context for candidate gene studies and genome-wide association studies, including benefits, limitations, and expected payoffs. Using substance use and abuse as our driving example, we then turn to the importance of etiological psychological theory in guiding genetic, environmental, and developmental research, as well as the utility of refined phenotypic measures, such as endophenotypes, in the pursuit of etiological understanding and focused tests of genetic and environmental associations. Phenotypic measurement has received considerable attention in the history of psychology and is informed by psychometrics, whereas the environment remains relatively poorly measured and is often confounded with genetic effects (i.e., gene-environment correlation). Genetically informed designs, which are no longer limited to twin and adoption studies thanks to ever-cheaper genotyping, are required to understand environmental influences. Finally, we outline the vast amount of individual difference in structural genomic variation, most of which remains to be leveraged in genetic association tests. Although the genetic data can be massive and burdensome (tens of millions of variants per person), we argue that improved understanding of genomic structure and function will provide investigators with new tools to test specific a priori hypotheses derived from etiological psychological theory, much like current candidate gene research but with less confusion and more payoff than candidate gene research has to date.