Meta-analysis of DSM alcohol use disorder criteria severities: structural consistency is only 'skin deep'

How well do DSM-5 criteria measure alcohol use disorder in the general population of older Swedish adolescents? An item response theory analysis

BACKGROUND

This study assesses the psychometric properties of DSM-5 criteria of AUD in older Swedish adolescents using item response theory models, focusing specifically on the precision of the scale at the cut-offs for mild, moderate, and severe AUD.

METHODS

Data from the second wave of Futura01 was used. Futura01 is a nationally representative cohort study of Swedish people born 2001 and data for the second wave was collected when participants were 17/18 years old. This study included only participants who had consumed alcohol during the past 12 months (n = 2648). AUD was measured with 11 binary items. A 2-parameter logistic item response theory model (2PL) estimated the items' difficulty and discrimination parameters.

RESULTS

31.8% of the participants met criteria for AUD. Among these, 75.6% had mild AUD, 18.3% had moderate, and 6.1% had severe AUD. A unidimensional AUD model had a good fit and 2PL models showed that the scale measured AUD over all three cut-offs for AUD severity. Although discrimination parameters ranged from moderate (1.24) to very high (2.38), the more commonly endorsed items discriminated less well than the more difficult items, as also reflected in less precision of the estimates at lower levels of AUD severity. The diagnostic uncertainty was pronounced at the cut-off for mild AUD.

CONCLUSION

DSM-5 criteria measure AUD with better precision at higher levels of AUD severity than at lower levels. As most older adolescents who fulfil an AUD diagnosis are in the mild category, notable uncertainties are involved when an AUD diagnosis is set in this group.

Understanding alcohol use and alcohol use disorders from a developmental psychopathology perspective: Research advances, challenges, and future directions

As part of the special issue of Development and Psychopathology honoring the remarkable contributions of Dr Dante Cicchetti, the current paper attempts to describe the recent contributions that a developmental psychopathology perspective has made in understanding the development of alcohol use and alcohol-related problems over the lifespan. The paper also identifies some of the future challenges and research directions. Because the scope of this task far exceeds the confines of a journal length article this paper does not attempt a comprehensive review. Rather, it builds on an earlier review and commentary that was published in Development and Psychopathology in 2013, with a similar goal.)Building on that work and updating its conclusions and suggestions for future directions, the current paper emphasizes findings from the research areas that were identified for further study in 2013 and the findings that have been published since that time.

Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus

BACKGROUND

The prevalence and associated overdose death rates from opioid use disorder (OUD) have dramatically increased in the last decade. Despite more available treatments than 20 years ago, treatment access and high discontinuation rates are challenges, as are personalized medication dosing and making timely treatment changes when treatments fail. In other fields such as depression, brief measures to address these tasks combined with an action plan-so-called measurement-based care (MBC)-have been associated with better outcomes. This workgroup aimed to determine whether brief measures can be identified for using MBC for optimizing dosing or informing treatment decisions in OUD.

METHODS

The National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN) in 2022 convened a small workgroup to develop consensus about clinically usable measures to improve the quality of treatment delivery with MBC methods for OUD. Two clinical tasks were addressed: (1) to identify the optimal dose of medications for OUD for each patient and (2) to estimate the effectiveness of a treatment for a particular patient once implemented, in a more granular fashion than the binary categories of early or sustained remission or no remission found in The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

DISCUSSION

Five parameters were recommended to personalize medication dose adjustment: withdrawal symptoms, opioid use, magnitude (severity and duration) of the subjective effects when opioids are used, craving, and side effects. A brief rating of each OUD-specific parameter to adjust dosing and a global assessment or verbal question for side-effects was viewed as sufficient. Whether these ratings produce better outcomes (e.g., treatment engagement and retention) in practice deserves study. There was consensus that core signs and symptoms of OUD based on some of the 5 DSM-5 domains (e.g., craving, withdrawal) should be the basis for assessing treatment outcome. No existing brief measure was found to meet all the consensus recommendations. Next steps would be to select, adapt or develop de novo items/brief scales to inform clinical decision-making about dose and treatment effectiveness. Psychometric testing, assessment of acceptability and whether the use of such scales produces better symptom control, quality of life (QoL), daily function or better prognosis as compared to treatment as usual deserves investigation.

Examination of the mild, moderate, and severe alcohol use disorder severity indicators using a nationally representative sample

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition conceptualizes alcohol use disorder (AUD) as a single continuum with indicators to denote the level of severity along this spectrum with the presence of 2-3, 4-5, or 6 + symptoms indicating mild, moderate, and severe AUD, respectively. However, despite the labels of these indicators, it remains unclear how individuals compare across these indicators, both in terms of AUD severity, but also risk for other related problems (e.g., depression).

METHOD

Confirmatory factor analysis was conducted on past year AUD symptoms to obtain estimates of latent AUD severity using data from the 2020 National Survey on Drug Use and Health (unweighted n = 31,941). The range and distribution of latent trait estimates were then compared across AUD diagnostic statuses (i.e., no AUD, mild, moderate, and severe). Multinomial regressions were then used to compare diagnostic groups based on alcohol use, problems with other substances, treatment utilization, and mental/physical health.

RESULTS

Results indicated very limited overlap in latent severity estimates between individuals with different severity indicators. Multinomial regression results demonstrated that some measures increased in a roughly stepwise fashion across AUD indicators (e.g., alcohol use and drinking behavior), while many did not.

CONCLUSIONS

Results partially support the current AUD indicators as AUD severity and co-occurring problems did broadly increase across the indicators. However, the present study also explores several ways to improve these indicators in future AUD formulations. For example, having indicators that account not only for the quantitative but also the qualitative differences in AUD presentation at different severity levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predictors of symptom course in alcohol use disorder

BACKGROUND

Symptoms often play an important role in the scientific inquiry of psychological disorders and have been theorized to play a functional role in the disorders themselves. However, little is known about the course of specific symptoms and individual differences in course. Understanding the course of specific symptoms and factors influencing symptom course can inform psychological theory and future research on course and treatment.

METHODS

The current study examined alcohol use disorder (AUD) criteria to explore how etiologically relevant covariates differentially affected the course of individual criteria. The study examined 34,653 participants from Wave 1 (2001-2002) and Wave 2 (2003-2004) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), to analyze the extent to which AUD symptom course is predicted by alcohol consumption patterns, family history of alcoholism, the presence of internalizing and externalizing disorders, and race.

RESULTS

The course of all AUD criteria was significantly influenced by these predictors, with the magnitude of the influence varying across different criteria and different aspects of the course (i.e., onset, persistence, recurrence). The strength of the relationship is partially related to the theoretical proximity of a given covariate to AUD symptomatology, with heavy drinking being the strongest and family history of AUD being the weakest. The course of all criteria was strongly associated with the prevalence of the criterion in the overall sample.

CONCLUSIONS

The course of AUD criteria is heterogeneous, appearing to be influenced by conceptually proximal predictors, the prevalence of the criterion, and perhaps an underlying common factor. Diagnostic accuracy may be improved by including a criterion related to alcohol consumption. Future work should include exploring the interchangeability of criteria and alternative operationalization of them.

Diagnostic Criteria for Identifying Individuals at High Risk of Progression From Mild or Moderate to Severe Alcohol Use Disorder

Importance

Current Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) diagnoses of substance use disorders rely on criterion count-based approaches, disregarding severity grading indexed by individual criteria.

Objective

To examine correlates of alcohol use disorder (AUD) across count-based severity groups (ie, mild, moderate, mild-to-moderate, severe), identify specific diagnostic criteria indicative of greater severity, and evaluate whether specific criteria within mild-to-moderate AUD differentiate across relevant correlates and manifest in greater hazards of severe AUD development.

Design, Setting, and Participants

This cohort study involved 2 cohorts from the family-based Collaborative Study on the Genetics of Alcoholism (COGA) with 7 sites across the United States: cross-sectional (assessed 1991-2005) and longitudinal (assessed 2004-2019). Statistical analyses were conducted from December 2022 to June 2023.

Main Outcomes and Measures

Sociodemographic, alcohol-related, psychiatric comorbidity, brain electroencephalography (EEG), and AUD polygenic score measures as correlates of DSM-5 AUD levels (ie, mild, moderate, severe) and criterion severity-defined mild-to-moderate AUD diagnostic groups (ie, low-risk vs high-risk mild-to-moderate).

Results

A total of 13 110 individuals from the cross-sectional COGA cohort (mean [SD] age, 37.8 [14.2] years) and 2818 individuals from the longitudinal COGA cohort (mean baseline [SD] age, 16.1 [3.2] years) were included. Associations with alcohol-related, psychiatric, EEG, and AUD polygenic score measures reinforced the role of increasing criterion counts as indexing severity. Yet within mild-to-moderate AUD (2-5 criteria), the presence of specific high-risk criteria (eg, withdrawal) identified a group reporting heavier drinking and greater psychiatric comorbidity even after accounting for criterion count differences. In longitudinal analyses, prior mild-to-moderate AUD characterized by endorsement of at least 1 high-risk criterion was associated with more accelerated progression to severe AUD (adjusted hazard ratio [aHR], 11.62; 95% CI, 7.54-17.92) compared with prior mild-to-moderate AUD without endorsement of high-risk criteria (aHR, 5.64; 95% CI, 3.28-9.70), independent of criterion count.

Conclusions and Relevance

In this cohort study of a combined 15 928 individuals, findings suggested that simple count-based AUD diagnostic approaches to estimating severe AUD vulnerability, which ignore heterogeneity among criteria, may be improved by emphasizing specific high-risk criteria. Such emphasis may allow better focus on individuals at the greatest risk and improve understanding of the development of AUD.

Should we promote alcohol problems as a continuum? Implications for policy and practice

The highly heterogeneous nature of alcohol use and problems has presented significant challenges to those attempting to understand, treat or prevent what is commonly termed alcohol use disorder (AUD). However, any attempts to capture this complex phenomenon, including the various current criterion of AUD, come with a number of limitations. One particular limitation has been how alcohol problems are represented or understood in ways which do not capture the broad spectrum of alcohol use and harms and the many potential routes to prevention, treatment, and recovery. One possible response to this has been proposed as more explicitly framing or conceptualizing a continuum model of alcohol use and harms. In this commentary, we attempt to identify the key implications of a continuum model for policy and practice, examining the historical and current context of alcohol problem classifications and models. We argue a continuum model of alcohol use and problems holds a number of advantages for advancing public health goals, but also some potential limitations, both of which require further examination.

Temporal dynamics of emotional processing: Parsing trial-wise variance of the late positive potential using Generalizability Theory

The reliability of individual trial event-related potential (ERP) components extracted from electroencephalogram has been consistently questioned since ERP research began. This ambivalence is based on misunderstood assumptions stemming from Cronbach and Classical Test Theory. Contemporary methods allow for the reliability of individual ERP trials to be estimated and for analyses of these trial-level ERP components to be meaningfully parsed. We illustrate the use of Generalizability Theory procedures in estimating the reliability of trial-level ERPs using the late positive potential (LPP), a neural measure of motivated attention toward emotionally evocative stimuli. Individuals (N = 88) completed a passive viewing task while continuous EEG was recorded. Variability in trial-level LPP responses was decomposed into facets corresponding to individual differences, chronological trial within block, stimulus type, their two-way interactions, and specific stimuli. We estimated various reliability coefficients and found that both overall and category-specific person-level LPP estimates have good-to-excellent reliability, while the reliability of within-person differences (i.e., change) between arousal categories was fair for the early LPP. These results were generally consistent across time windows, but were highest early in the LPP time course. We argue that investigating reliability using trial-level data allows researchers to pursue hypotheses focused on neurophysiological dynamics that unfold over the course of an experiment and not risk false inferences (i.e., ecological fallacy) when using person-level aggregates to deduce such processes. Moreover, such analyses provide information that allows researchers to optimize their protocols by potentially reducing the number of individual trials, burden on participants, and cost, while retaining sufficient reliability.

The Genetically Informed Neurobiology of Addiction (GINA) model

Addictions are heritable and unfold dynamically across the lifespan. One prominent neurobiological theory proposes that substance-induced changes in neural circuitry promote the progression of addiction. Genome-wide association studies have begun to characterize the polygenic architecture undergirding addiction liability and revealed that genetic loci associated with risk can be divided into those associated with a general broad-spectrum liability to addiction and those associated with drug-specific addiction risk. In this Perspective, we integrate these genomic findings with our current understanding of the neurobiology of addiction to propose a new Genetically Informed Neurobiology of Addiction (GINA) model.

Is lower severity alcohol use disorder qualitatively different than more severe manifestations? An evaluation of multivariate symptom clusters

BACKGROUND AND AIMS

Alcohol use disorder (AUD), since the release of DSM-V, is conceptualized and studied as a unidimensional construct. However, previous research has identified clusters of AUD symptoms related to excessive consumption/tolerance, loss of control/social dysfunction and withdrawal/craving that have shown differential genetic risks, personality associations and predictive ability. Although past 'variable-centered' (e.g. factor-analytic) studies have demonstrated the importance of these clusters, the current study aimed to examine how these clusters commonly manifest using a 'person-centered' approach (e.g. latent class).

DESIGN

Cross-sectional in-person assessment.

SETTING

Indiana, USA.

PARTICIPANTS

A convenience sample of 1390 young adults (mean age = 21.43, SD = 2.47) recruited for an over-representation of alcohol problems (65% with AUD).

MEASUREMENTS

Latent class analysis (LCA) was conducted on 23 criteria from the Semi-Structured Interview on the Genetics of Alcoholism (SSAGA) that align with DSM-V AUD symptoms. Identified latent classes were characterized using multinomial regressions to examine the association of class and measures of alcohol use, other externalizing psychopathology, internalizing problems and personality.

FINDINGS

LCA results identified a 'Low Problems' class (34% of sample), a 'Heavy Consumption' class (26%) characterized by high endorsement probabilities of essentially only consumption/tolerance symptoms, a 'Consumption and Loss of Control' class (31%) characterized by endorsing consumption/tolerance and loss of control/social dysfunction symptoms, and finally a 'Consumption, Loss of Control and Withdrawal' class (9%) characterized by high endorsement probabilities of all symptom clusters. Multinomial regression results indicated an increasing spectrum of severity in terms of psychological impairment.

CONCLUSIONS

AUD appears to manifest as different clusters of symptoms at different severity levels.

Cocaine use disorder criteria in a clinical sample: an analysis using item response theory, factor and network analysis

BACKGROUND

The conceptualization of substance use disorders (SUDs) was modified in successive editions of the DSM. Dimensionality and inclusion/exclusion of several criteria was studied using various analytic approaches.

OBJECTIVE

The study aimed to deepen our knowledge of the interrelationships between the diagnostic criteria for cocaine use disorder (CUD), applying three different analytical techniques: factor analysis, Item Response Theory (IRT) models, and network analysis.

METHODS

425 (85.4% male) outpatients were evaluated for CUD using the Substance Dependence Severity Scale. Confirmatory Factor Analysis, 2-parameter logistic model (IRT) and network analysis were applied to analyze the relationships between the diagnostic criteria.

RESULTS

The results show that "legal problems" criterion is not congruent with the CUD measure on three analyses. Also, network analysis suggests the usefulness of the "craving" criterion. The criterion "quit/control" is the one that presents the best centrality indices and expected influence, showing strong relationships with the criteria of "craving," "tolerance," "neglect roles" and "activities given up."

CONCLUSIONS

Network analysis appears to be a useful and complementary technique to factor analysis and IRT for understanding CUD. The "quit/control" criterion emerges as a central criterion to understand CUD.

Endorsement of specific alcohol use disorder criterion items changes with age in individuals with persistent alcohol use disorders in 2 generations of the San Diego Prospective Study

BACKGROUND

Diagnostic and Statistical Manual (DSM) alcohol use disorder (AUD) criteria are written in broad enough terms to apply to diverse populations. The current analyses evaluate whether the endorsement of criteria changes with increasing age in individuals with persistent AUDs.

METHODS

Data regarding AUDs persisting across 3 timepoints between average ages of 31 and 43 were gathered about every 5 years from 318 interviews for 106 San Diego Prospective Study (SDPS) AUD male probands. Similar data regarding persistent AUDs across 2 timepoints were obtained from 136 interviews with 68 SDPS AUD offspring between average ages of 21 and 27. Changes in the endorsement of each AUD criterion were evaluated using Cochran's Q test.

RESULTS

For AUD probands across time, significant decreases were observed in the proportions endorsing 4 criteria (tolerance, withdrawal, failure to fulfill obligations, and using alcohol in hazardous situations). Increased rates of endorsement were documented for 3 criteria (drinking alcohol in higher amounts or for longer periods of time, spending a great deal of time regarding alcohol, and continued use despite social or interpersonal problems). Significant increases in rates of endorsements for offspring were seen for spending a great deal of time regarding alcohol and giving up or reducing important activities in order to drink.

CONCLUSIONS

These data indicate that the salience of many DSM AUD criterion items changed significantly with age in both SDPS generations among individuals with persistent AUDs. The current results support the need for additional systematic research to determine whether specific criterion items might need to be weighted differently in evaluating older and younger individuals with persistent AUDs.

Does crude measurement contribute to observed unidimensionality of psychological constructs? A demonstration with DSM-5 alcohol use disorder

Mental disorders are complex, multifaceted phenomena that are associated with profound heterogeneity and comorbidity. Despite the heterogeneity of mental disorders, most are generally considered unitary dimensions. We argue that certain measurement practices, especially using too few indicators per construct, preclude the detection of meaningful multidimensionality. We demonstrate the implications of crude measurement for detecting construct multidimensionality with alcohol use disorder (AUD). To do so, we used a large sample of college heavy drinkers (N = 909) for whom AUD symptomology was thoroughly assessed (87 items) and a blend of confirmatory factor analysis, exploratory factor analysis, and hierarchical clustering. A unidimensional AUD model with one item per symptom criterion fit the data well, whereas a unidimensional model with all items fit the data poorly. Starting with an 11-item AUD model, model fit decreased and the variability in factor loadings increased as additional items were added to the model. Additionally, multidimensional models outperformed unidimensional ones in terms of variance explained in theoretically relevant external criteria. All told, we converged on a hierarchically organized model of AUD with three broad, transcriterial dimensions that reflected tolerance, withdrawal, and loss of control. In addition to introducing a hierarchical model of AUD, we propose that thorough assessment of psychological constructs paired with serious consideration of alternative, multidimensional structures can move past the deadlock of their unidimensional representations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Subpopulations of Addictive Behaviors in Different Sample Types and Their Relationships with Gender, Personality, and Well-Being: Latent Profile vs. Latent Class Analysis

BACKGROUND

Relatively strong theoretical assumptions and previous studies concerning co-occurring addictive behaviors suggest a subpopulation representing general proclivity to behavioral addictions (BAs), and there are gender-specific subpopulations. This study aimed to compare latent profile analysis (LPA) and latent class analysis (LCA) as the methods of investigating different clusters of BAs in the general student population and among students positively screened for at least one BA. Participants and procedure: Analyses of six BAs (study, shopping, gaming, Facebook, pornography, and food) and their potential antecedents (personality) and consequences (well-being) were conducted on a full sample of Polish undergraduate students (N = 1182) and a subsample (n = 327) of students including individuals fulfilling cutoff for at least one BA.

RESULTS

LPA on the subsample mostly replicated the previous four profiles found in the full sample. However, LCA on a full sample did not replicate previous findings using LPA and showed only two classes: those with relatively high probabilities on all BAs and low probabilities. LCA on the subsample conflated profiles identified with LPA and classes found with LCA in the full sample.

CONCLUSIONS

LCA on dichotomized scores (screened positively vs. negatively) were less effective in identifying clear patterns of interrelationships between BAs based on relatively strong theoretical assumptions and found in previous research. BAs can be investigated on the whole spectrum of behavior, and person-centered analyses might be more useful when they are based on continuous scores. This paper provides more detailed analyses of the four basic clusters of BAs, prevalence, and co-occurrence of particular BAs within and between them, their gender and personality risk factors, relationships to well-being, and their interrelationships as emerging from the results of this and previous studies.

Self-reported symptoms of cannabis use disorder: Psychometric testing and validation

Cannabis use disorder (CUD) is commonly assessed using self-report items based on its symptoms as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) that are scored on a dichotomous scale (yes/no) to indicate symptom presence; however, scoring items on a dichotomy may result in relatively limited sensitivity for research. Thus, we developed a 13-item measure of CUD, the Self-Reported Symptoms of CUD (SRSCUD), based on the 11 symptoms described in the DSM-5 that is scored on a 4-point response scale indicating degree of severity. In the present study, we conduct an initial evaluation of the psychometric properties of the SRSCUD. Past-month cannabis users (N = 2,077) were recruited from nine universities in nine states throughout the U.S. Each item of the SRSCUD loaded saliently onto a single factor of CUD symptoms in both exploratory and confirmatory factor analyses. The SRSCUD was strongly correlated with measures of cannabis use, dependence severity, and cannabis-related problems. In addition, the SRSCUD was moderately positively correlated with a well-known risk factor for CUD (coping motives) and moderately negatively correlated with a well-known protective factor for CUD (protective behavioral strategies). These correlations mostly remained statistically significant while controlling for CUD symptom count and diagnosis using dichotomized SRSCUD items. Receiver operator characteristic curve analyses revealed that the SRSCUD had excellent sensitivity/specificity for predicting probable CUD. Although more research evaluating performance of the SRSCUD compared to a clinical diagnosis is needed, we found preliminary evidence for construct validity of this measure. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

On Fixed Marginal Distributions and Psychometric Network Models

This reply addresses the commentary by Epskamp et al. (in press) on our prior work, of using fixed marginals for sampling the data for testing hypothesis in psychometric network application. Mathematical results are presented for expected column (e.g., item prevalence) and row (e.g., subject severity) probabilities under three classical sampling schemes in categorical data analysis: (i) fixing the density, (ii) fixing either the row or column marginal, or (iii) fixing both the row and column marginal. It is argued that, while a unidimensional structure may not be the model we want, it is the structure we are confronted with given the binary nature of the data. Interpreting network models in the context of this artifactual structure is necessary, with preferred solutions to be expanding the item sets of disorders and moving away from the use of binary data and their associated constraints.

Reliability of Differential Item Functioning in Alcohol Use Disorder: Bayesian Meta-Analysis of Criteria Discrimination Estimates

Numerous studies leverage item response theory (IRT) methods to examine measurement characteristics of alcohol use disorder (AUD) diagnostic criteria. Less work has examined the consistency of AUD IRT parameter estimates, an essential step for establishing measurement invariance, making statements about symptom diagnosticity, and validating the theoretical construct. A Bayesian meta-analysis of IRT discrimination values for AUD criteria across 33 independent samples (Total N = 321,998) revealed that overall consistency of AUD criteria discriminations was low (generalized intraclass correlation range = .105-.249). However, specific study characteristics accounted for substantial variability, suggesting that the unreliability is partially systematic. We replicated evidence of differential item functioning (DIF) via established factors (e.g., age, gender), but the magnitudes were small compared with DIF associated with assessment instrument. These results offer practical recommendations regarding which instruments to use when specific AUD criteria are of interest and which criteria are most sensitive when comparing demographic groups.

Using Complete Enumeration to Derive "One-Size-Fits-All" Versus "Subgroup-Specific" Diagnostic Rules for Substance Use Disorder

The use of fixed diagnostic rules, whereby the same diagnostic algorithms are applied across all individuals regardless of personal attributes, has been the tradition in the Diagnostic and Statistical Manual of Mental Disorders. This practice of "averaging" across individuals inevitably introduces diagnostic error. Furthermore, these average rules are typically derived through expert consensus rather than through data-driven approaches. Utilizing National Survey on Drug Use and Health 2013 (N = 23, 889), we examined whether subgroup-specific, "customized" alcohol use disorder diagnostic rules, derived using deterministic optimization, perform better than an average, "one-size-fits-all" diagnostic rule. The average solution for the full sample included a set size of six and diagnostic threshold of three. Subgroups had widely varying set sizes (M = 6.870; range = 5-10) with less varying thresholds (M = 2.70; range = 2-4). External validation verified that the customized algorithms performed as well, and sometimes better than, the average solution in the prediction of relevant correlates. However, the average solution still performed adequately with respect to external validators.

Item Response Theory analyses of DSM-5 substance use disorder criteria in French outpatient addiction clinic participants. How much is craving special?

BACKGROUND

To evaluate the dimensionality and psychometric validity of the 11 DSM-5 criteria for 5 substance use disorders, with a focus on craving, and taking into account age, gender and psychiatric comorbidities in a French sample of subjects seeking addiction treatment.

METHODS

This cross-sectional study, included participants with DSM-5 substance use disorders that sought treatment for at least one addiction from outpatient clinics. Diagnostic criteria were evaluated with the Mini international Neuropsychiatric Interview. In Current regular user (2 times per week), factor and 2-parameter IRT analysis was used to investigate the dimensionality and psychometric properties of the 11 DSM-5 SUD criteria. Differential Item and Test functioning (DIF and DTF) analysis were performed across sociodemographic characteristics and psychiatric disorders.

RESULTS

1359 participants (alcohol n = 787, opiates n = 131, cocaine n = 141, tobacco n = 1014, cannabis n = 504), were included (68% male; mean age 38.7). One-factor dimensionality was confirmed, except for tobacco. Craving criterion had the strongest factor loadings, lower difficulty (range, -1.29 to -0.67) and higher discrimination (range, 2.11-3.05), and no DIF compared to other criteria. The tobacco criteria set functioned differently by mood and anxiety disorders.

CONCLUSIONS

We confirmed the unidimensionality of the 11 SUD DSM-5 criteria and furthermore that craving was the most selective criterion because of its psychometric properties and no DIF compared to other criteria, regardless of the substance in this adult clinical sample. Unidimensionality of tobacco criteria was not confirmed, suggesting DSM-IV abuse criteria limitations as indicators of the construct.

The Case for Cognitive Interviewing in Survey Item Validation: A Useful Approach for Improving the Measurement and Assessment of Substance Use Disorders

OBJECTIVE

To accurately identify substance use disorders, we must be confident of our ability to define and measure the construct itself. To date, research has demonstrated that the ways in which substance use disorder criteria are operationalized or assessed can significantly affect the information we obtain from these diagnoses. For example, differing operationalizations of the same construct, such as impaired control over substance use, can result in markedly different estimates of prevalence. This points to the need for approaches that aim to improve the validity of diagnostic assessments during the measure development phase.

METHOD

We performed a scoping review of the cognitive interviewing literature, a technique that aims to provide a systematic way of identifying and reducing measurement error associated with the structure and content of assessment items. Along with this, we apply cognitive interviewing to items assessing alcohol tolerance.

RESULTS

We argue that cognitive interviewing is well suited for reducing measurement error in substance use disorder assessment items.

CONCLUSIONS

Incorporating cognitive interviewing into the item generation stage of measure development for substance use disorder assessments is a worthwhile endeavor for improving validity.

Identifying an accurate self-reported screening tool for alcohol use disorder: evidence from a Swiss, male population-based assessment

BACKGROUND AND AIMS

Short screenings for alcohol use disorder (AUD) are crucial for public health purposes, but current self-reported measures have several pitfalls and may be unreliable. The main aim of our study was to provide empirical evidence on the psychometric performance of self-reports currently used. Our research questions were: compared with a gold standard clinical interview, how accurate are (1) self-reported AUD, (2) self-reported alcohol use over time and (3) biomarkers of alcohol use among Swiss men? Finally, we aimed to identify an alternative screening tool.

DESIGN

A single-center study with a cross-sectional design and a stratified sample selection.

SETTING

Lausanne University Hospital (Switzerland) from October 2017 to June 2018.

PARTICIPANTS

We selected participants from the French-speaking participants of the ongoing Cohort Study on Substance Use and Risk Factors (n = 233). The sample included young men aged on average 27.0 years.

MEASUREMENTS

We used the Diagnostic Interview for Genetic Studies as the gold standard for DSM-5 AUD. The self-reported measures included 11 criteria for AUD, nine alcohol-related consequences, and previous 12 months' alcohol use. We also assessed biomarkers of chronic excessive drinking (ethyl glucuronide and phosphatidylethanol).

FINDINGS

None of the self-reported measures/biomarkers taken alone displayed both sensitivity and specificity close to 100% with respect to the gold standard (e.g. self-reported AUD: sensitivity = 92.3%, specificity = 45.8%). The best model combined eight self-reported criteria of AUD and four alcohol-related consequences. Using a cut-off of three, this screening tool yielded acceptable sensitivity (83.3%) and specificity (78.7%).

CONCLUSIONS

Neither self-reported alcohol use disorder nor heavy alcohol use appear to be adequate to screen for alcohol use disorder among young men from the Swiss population. The best screening alternative for alcohol use disorder among young Swiss men appears to be a combination of eight symptoms of alcohol use disorder and four alcohol-related consequences.

Psychiatric Comorbidity as a Function of Severity: DSM-5 Alcohol Use Disorder and HiTOP Classification of Mental Disorders

BACKGROUND

Understanding the comorbidity of alcohol use disorder (AUD) and other psychiatric diagnoses has been a long-standing interest of researchers and mental health professionals. Comorbidity is often examined via the diagnostic co-occurrence of discrete, categorical diagnoses, which is incongruent with increasingly supported dimensional approaches of psychiatric classification and diagnosis, and for AUD more specifically. The present study examined associations between DSM-5 AUD and psychiatric symptoms of other DSM-IV and DSM-5 disorders categorically, and dimensionally organized according to the Hierarchical Taxonomy of Psychopathology (HiTOP) spectra (e.g., Internalizing, Disinhibited Externalizing).

METHODS

The comorbidity of AUD with other psychological disorders was examined in 2 independent nationally representative samples of past-year drinkers via an initial examination in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) Wave 2 and replicated in NESARC-III.

RESULTS

Analyses focusing on psychopathology symptom counts organized by spectra demonstrated that greater AUD severity was associated with a higher number of symptoms across HiTOP spectra. Traditional categorical analyses also demonstrated increasing prevalence as a monotonic function of DSM-5 AUD severity gradients.

CONCLUSIONS

This study indicates that AUD and other psychiatric disorder comorbidity implies increased presence of multiple forms of psychopathology with a corresponding increased number of symptoms across hierarchical spectra. Greater AUD severity increases the likelihood of other psychopathology and, when present, "more severe" presentations. That is, on average, a given disorder (e.g., depression) is more severe when copresenting with an AUD, and increases in severity along with the AUD.

Changes in DSM criteria following a culturally-adapted computerized CBT for Spanish-speaking individuals with substance use disorders

This study sought to replicate and extend findings regarding change in the number of endorsed Diagnostic and Statistical Manual (DSM) criteria for substance use disorders as a meaningful outcome for clinical trials with Spanish-speakers. A secondary analysis was conducted of data from 83 treatment-seeking individuals with current DSM-IV substance dependence participating in a randomized controlled trial evaluating a culturally-adapted version of a computer-based cognitive behavioral therapy program (CBT4CBT) for Spanish-speakers. Participants were randomized to either weekly standard outpatient counseling (treatment as usual - TAU), or TAU plus access to CBT4CBT (TAU+CBT4CBT). The Structured Clinical Interview for DSM-IV (SCID-IV) was administered at baseline and at the end of the 8-week treatment period to measure change in diagnostic status and total criteria count. Frequency of substance use during treatment and throughout a 6-month follow-up period was measured by self-report using a calendar-based Timeline FollowBack method, with abstinence verified through instant urine toxicology, and problem severity was measured with the Addiction Severity Index (ASI). Results of a generalized linear model with Poisson's distribution indicated significant reduction in the total count of DSM-IV dependence criteria during treatment (Wald X² = 136.20; p < .001), and a significant interaction with treatment assignment (Wald X² = 19.92, p < .001), indicating a greater reduction in endorsed criteria for those assigned to TAU+CBT4CBT compared to TAU only. Total criteria count and diagnostic status at end-of-treatment was significantly correlated with substance use outcomes during the follow-up period, such that fewer criteria endorsed were associated with greater rates of abstinence and lower problem severity. These findings paralleled the primary outcomes from the main trial, and replicated prior findings in English-speakers regarding the utility of DSM criteria count as a potential clinically meaningful outcome.

An Item Response Theory Analysis of DSM-5 Heroin Use Disorder in a Clinical Sample of Chinese Adolescents

The study examined the dimensionality and psychometric properties of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for heroin use disorder in a clinical sample of Chinese adolescents using item response theory approach. We examined 168 adolescents aged 14.8–17.9 years, who were in treatment for heroin use disorder. A two-parameter logistic item response theory model was conducted to examine the severity and discrimination of DSM-5 criteria for heroin use disorder. Differential item functioning across age and ethnicity was assessed. Results supported the hypothesis that the DSM-5 criteria for heroin use disorder were arrayed an underlying unitary dimension of severity in clinical adolescents. All the items exhibited good discriminatory power in distinguishing between clinical adolescent heroin users. Although three criteria exhibited measurement non-invariance at the item level, the overall DSM-5 heroin use disorder diagnostic criteria set appears to achieve measurement invariance at the scale level.

The influence of sample selection on the structure of psychopathology symptom networks: An example with alcohol use disorder

Increasingly, the structure of mental disorders has been studied in the form of a network, characterizing how symptoms or criteria interact with and influence each other. Many studies of psychiatric symptoms and diagnostic criteria employ community or population-based surveys using co-occurrence of the symptoms/criteria to form the networks. However, given the overall low prevalence rates of mental disorders and their symptoms in the general population, most of those surveyed may not exhibit or endorse any symptoms and yet are often included in network analyses. Consequently, because network models are built on associations between symptoms/criteria, much of the observed variability is driven by individuals who are asymptomatic. Using data from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) Wave 2 and NESARC-III, we explore the effect of these "asymptomatic" observations on the estimated relations among diagnostic criteria of alcohol use disorder to determine the effects of such observations on estimated networks. We do so using the eLasso tool, as well as with traditional measures of correlation between binary variables (the Φ coefficient and odds ratio). We find that when the proportion of asymptomatic individuals are systematically culled from the sample, the estimated pairwise relations are often significantly affected, even changing signs in some cases. Our findings indicate that researchers should carefully consider the population(s) included in their sample and the implications it has on their interpretations of pairwise similarity estimates and resulting generalizability and reproducibility of estimates of network structures. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Genome-wide association studies of alcohol dependence, DSM-IV criterion count and individual criteria

Genome-wide association studies (GWAS) of alcohol dependence (AD) have reliably identified variation within alcohol metabolizing genes (eg, ADH1B) but have inconsistently located other signals, which may be partially attributable to symptom heterogeneity underlying the disorder. We conducted GWAS of DSM-IV AD (primary analysis), DSM-IV AD criterion count (secondary analysis), and individual dependence criteria (tertiary analysis) among 7418 (1121 families) European American (EA) individuals from the Collaborative Study on the Genetics of Alcoholism (COGA). Trans-ancestral meta-analyses combined these results with data from 3175 (585 families) African-American (AA) individuals from COGA. In the EA GWAS, three loci were genome-wide significant: rs1229984 in ADH1B for AD criterion count (P = 4.16E-11) and Desire to cut drinking (P = 1.21E-11); rs188227250 (chromosome 8, Drinking more than intended, P = 6.72E-09); rs1912461 (chromosome 15, Time spent drinking, P = 1.77E-08). In the trans-ancestral meta-analysis, rs1229984 was associated with multiple phenotypes and two additional loci were genome-wide significant: rs61826952 (chromosome 1, DSM-IV AD, P = 8.42E-11); rs7597960 (chromosome 2, Time spent drinking, P = 1.22E-08). Associations with rs1229984 and rs18822750 were replicated in independent datasets. Polygenic risk scores derived from the EA GWAS of AD predicted AD in two EA datasets (P < .01; 0.61%-1.82% of variance). Identified novel variants (ie, rs1912461, rs61826952) were associated with differential central evoked theta power (loss - gain; P = .0037) and reward-related ventral striatum reactivity (P = .008), respectively. This study suggests that studying individual criteria may unveil new insights into the genetic etiology of AD liability.

Deriving alternative criteria sets for alcohol use disorders using statistical optimization: Results from the National Survey on Drug Use and Health

Much of the foundation of clinical practice, psychiatric epidemiology, and research into the etiology, course, prevention, and treatment of alcohol use disorder (AUD) rests on psychiatric diagnosis. However, existing research has failed to adequately exploit empirical techniques and existing databases to derive criteria considered optimal with respect to predicting external correlates. The current project adopts a novel approach to deriving new diagnostic criteria sets and rules for AUD. Utilizing the 2010 (N = 24,120) and 2013 (N = 23,627) National Survey on Drug Use and Health (NSDUH; Substance Abuse and Mental Health Services Administration [SAMHSA], 2011, 2014) data sets, we performed a statistical optimization procedure, using complete enumeration, on participants 21 or older who had consumed at least 1 alcoholic beverage in the past year. The goal was to maximize the distance (based on Cohen's d) between mean levels of the optimization criteria (i.e., consumption and functional impairment) in those with an AUD diagnosis versus those without. In contrast with current convention, AUD is derived transparently using a data-driven approach. The best solution included 9 criteria with a diagnostic threshold of 3, while the second-best solution comprised 5 criteria with a threshold of 2. External validation demonstrated both solutions perform similarly, suggesting it is appropriate to use either, depending on the goal of the diagnosis. Overall, statistical optimization approaches can yield highly efficient criteria sets and rules, although multiple, near equivalently performing solutions can be generated. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Severity of Substance Use Disorder: Utility as an Outcome in Clinical Settings

BACKGROUND

Some authors have pointed out the usefulness of the levels of substance use disorder (SUD) as a treatment outcome. However, in order to use this variable as an outcome measure, its impact needs to be addressed within a clinical context. The aim of this study was to analyze the sensitivity of SUD levels as a measure for detecting reliable changes and to make a comparison between the changes in SUD levels detected when using the number of criteria fulfilled and when using the reliable change index (RCI).

METHODS

The sample consisted of 206 (106 in follow-up) patients diagnosed with abuse/dependence on alcohol and cocaine, according to DSM-IV criteria. The Substance Dependence Severity Scale for DSM-5 was used to determine current alcohol use disorder (AUD) and cocaine use disorder (CUD). Number of DSM-5 criteria fulfilled and RCI were used to determine the change in SUD levels.

RESULTS

No association was found between adherence to/abandonment of treatment and AUD severity levels (χ²  = 7.029, p = 0.071) or CUD severity levels (χ²  = 2.044, p = 0.413). Statistical significant differences for levels of AUD (z = -3.870, p = 0.000) and CUD (z = -5.382, p = 0.000) were found between baseline assessment and follow-up. According to the number of DSM-5 criteria and RCI, the Kappa coefficient for the change in patient status (improved, worsened, or no change) was k = 0.61 for alcohol patients and k = 0.64 for cocaine patients. The "mild" category showed the greatest inconsistency between both procedures.

CONCLUSIONS

Levels of SUD are sensitive to the impact of treatment as measured by the difference between the baseline assessment and 3-month follow-up. However, conclusions differ according to whether the DSM-5 criteria or the RCI is applied.

Not all alcohol use disorder criteria are equally severe: Toward severity grading of individual criteria in college drinkers

Alcohol use disorder (AUD) diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) contains a severity gradient based on number of criteria endorsed, implicitly assuming criteria are interchangeable. However, criteria vary widely in endorsement rates, implying differences in the latent severity associated with a symptom (e.g., Lane, Steinley, & Sher, 2016) and demonstrating criteria are not interchangeable (Lane & Sher, 2015). We evaluated whether variation in the severity of criteria could be resolved by employing multiple indicators of each criterion varying in item-level severity. We assessed 909 undergraduate students aged 18 years or older with at least 12 drinking occasions in the past year. Participants self-administered questions on alcohol consumption and past year AUD symptoms via an online survey. For each of the 11 AUD criteria, we selected three indicators based on the difficulty values of the one-parameter logistic item response theory model ranging from low to high. We first tested a higher order AUD factor defined by 11 lower order criterion factors, χ2(551) = 2,959.35, p < .0001; root mean square error of approximation = 0.09. The 33 items were used to create severity scores: a criterion count (0-11), symptom count (0-33), and factor scores derived from a bifactor model. Though our new scores resulted in incremental validity over DSM-5 across a range of external validators, when the standardized regression estimates were compared, the new scores did not consistently outperform the DSM-5 suggesting this approach is viable for developing more sensitive diagnostic instruments but needs further refinement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol use disorder and motives for prescription opioid misuse: A latent class analysis

Introduction: Among those who misuse prescription opioids, alcohol use disorder (AUD) is associated with progression to opioid use disorder, risk of overdose, and poor treatment outcomes. However, little is known about co-occurring AUD and prescription opioid misuse. Motives, or reasons, for substance use are important factors in substance use initiation and maintenance; characterizing common motives can help inform treatment targets. The aims of the present study were to (1) identify patterns of motives for prescription opioid misuse, and (2) examine the association between AUD and motives. Methods: Data were extracted from the 2015 National Survey on Drug Use and Health. Analyses included adult respondents with past-year prescription opioid misuse (N = 2,627), of which 24.2% had a co-occurring AUD. Latent class analysis was utilized to identify patterns of motives for prescription opioid misuse. AUD was included as a predictor of class membership. Results: We identified three classes: (1) pain relief (56.1% of the sample), (2) recreational (e.g., to get high; 29.3%), and (3) mixed motives (e.g., coping, pain relief, recreational; 14.6%). AUD was associated with greater odds of membership in the recreational (OR = 2.05, 95% CI = 1.36, 3.10, p = .001) and mixed motives (OR = 2.11, 95% CI = 1.21, 3.67, p = .008) classes, as compared to the pain relief class. Results: Pain relief was the most commonly endorsed motive for opioid misuse among those with and without AUD. These results underscore the need to improve pain management among those who misuse prescription opioids. Those with co-occurring AUD might also benefit from interventions targeting negative affect and/or positive outcome expectancies.

Algorithm Analysis of the DSM-5 Alcohol Withdrawal Symptom

BACKGROUND

Alcohol withdrawal (AW) is an important clinical and diagnostic feature of alcohol dependence. AW has been found to predict a worsened course of illness in clinical samples, but in some community studies, AW endorsement rates are strikingly high, suggesting false-positive symptom assignments. Little research has examined the validity of the DSM-5 algorithm for AW, which requires either the presence of at least 2 of 8 subcriteria (i.e., autonomic hyperactivity, tremulousness, insomnia, nausea, hallucinations, psychomotor agitation, anxiety, and grand mal seizures), or, the use of alcohol to avoid or relieve these symptoms.

METHODS

We used item and algorithm analyses of data from waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (current drinkers, n = 26,946 at wave 1) to study the validity of DSM-5 AW as operationalized by the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV).

RESULTS

A substantial proportion of individuals given the AW symptom reported only modest to moderate levels of alcohol use and alcohol problems. Alternative AW algorithms were superior to DSM-5 in terms of levels of alcohol use and alcohol problem severity among those with AW, group difference effect sizes, and predictive validity at a 3-year follow-up. The superior alternative algorithms included those that excluded the nausea subcriterion; required withdrawal-related distress or impairment; increased the AW subcriteria threshold from 2 to 3 items; and required tremulousness for AW symptom assignment.

CONCLUSIONS

The results indicate that the DSM-5 definition of AW, as assessed by the AUDADIS-IV, has low specificity. This shortcoming can be addressed by making the algorithm for symptom assignment more stringent.

Impulsive dispositions and alcohol: what we know, how we know it, and where to go from here

BACKGROUND

Relations between impulsigenic traits and alcohol-related outcomes have been the focus of much research, yet precise relations remain elusive. Historically, research used broadband conceptualizations of impulsivity, which yielded inconclusive findings. Attempts to ameliorate this problem led to more work on narrowband assessments of impulsivity. Despite that several narrowband self-report measures exist, few demonstrate adequate psychometric properties. Given the limits of self-report, researchers have also utilized laboratory-based measures of impulsive dispositions; however, this seems to have contributed more uncertainty to the literature.

REVIEW

We review commonly used self-report and laboratory-based measures of narrowband impulsivity, as well as assessments of alcohol-related constructs (e.g., consumption and consequences). We discuss remaining issues in impulsivity and alcohol assessment, which limit understanding of how impulsigenic traits influence alcohol-related behaviors. Cutting-edge conceptualizations and assessment of state-level impulsivity are also discussed.

CONCLUSIONS

More work is necessary to further this area of research, including establishing consistent nomenclature and a cohesive conceptualization of impulsigenic traits as they relate to alcohol use and alcohol use disorders.

Criteria Definitions and Network Relations: The Importance of Criterion Thresholds

Across various structured diagnostic instruments, the criteria used to diagnose alcohol use disorder (AUD) are not assessed consistently. For example, different instruments often pose questions that reflect different thresholds of the underlying symptoms. We consider the criteria for craving and the inability to cut down or stop drinking to demonstrate the influence of using different thresholds for a positive symptom endorsement with respect to the estimated edges of a symptom network. Results indicate that the utilization of these differing thresholds leads to significant differences in edge weights. Generally, higher thresholds relate more strongly to lower prevalence rate criteria, and the reverse for lower thresholds. These findings have implications for reproducibility of effects in symptom networks and their generalization across studies.

Greater Prevalence of Proposed ICD-11 Alcohol and Cannabis Dependence Compared to ICD-10, DSM-IV, and DSM-5 in Treated Adolescents

BACKGROUND

Proposed International Classification of Diseases, 11th edition (ICD-11), criteria for substance use disorder (SUD) radically simplify the algorithm used to diagnose substance dependence. Major differences in case identification across DSM and ICD impact determinations of treatment need and conceptualizations of substance dependence. This study compared the draft algorithm for ICD-11 SUD against DSM-IV, DSM-5, and ICD-10, for alcohol and cannabis.

METHODS

Adolescents (n = 339, ages 14 to 18) admitted to intensive outpatient addictions treatment completed, as part of a research study, a Structured Clinical Interview for DSM SUDs adapted for use with adolescents and which has been used to assess DSM and ICD SUD diagnoses. Analyses examined prevalence across classification systems, diagnostic concordance, and sources of diagnostic disagreement.

RESULTS

Prevalence of any past-year proposed ICD-11 alcohol or cannabis use disorder was significantly lower compared to DSM-IV and DSM-5 (ps < 0.01). However, prevalence of proposed ICD-11 alcohol and cannabis dependence diagnoses was significantly higher compared to DSM-IV, DSM-5, and ICD-10 (ps < 0.01). ICD-11 and DSM-5 SUD diagnoses showed only moderate concordance. For both alcohol and cannabis, youth typically met criteria for an ICD-11 dependence diagnosis by reporting tolerance and much time spent using or recovering from the substance, rather than symptoms indicating impaired control over use.

CONCLUSIONS

The proposed ICD-11 dependence algorithm appears to "overdiagnose" dependence on alcohol and cannabis relative to DSM-IV and ICD-10 dependence, and DSM-5 moderate/severe use disorder, generating potential "false-positive" cases of dependence. Among youth who met criteria for proposed ICD-11 dependence, few reported impaired control over substance use, highlighting ongoing issues in the conceptualization and diagnosis of SUD.

Exploration of Core Symptoms for the Diagnosis of Alcohol Dependence in the ICD-10

BACKGROUND

The classification of alcohol use disorder has changed over the past century. Now, the conceptualization of alcohol dependence is still controversial. Accumulating evidence has shown the reliability and validity for the diagnosis of alcohol dependence in the ICD-10 and DSM-IV. However, the meaning and association of the respective diagnostic items, which are descriptive of representative symptoms, have hardly been examined. The core symptom of substance use disorder has been debated in various situations, but has never been elucidated logically.

METHODS

We consecutively registered 192 patients with alcohol-related problems who visited our hospital for the first time during a certain period. The relations and principal components among the checked items of the ICD-10 diagnostic criteria were examined statistically.

RESULTS

Three diagnostic items in the ICD-10 were strongly correlated with each other and were thought to form the core symptoms of alcohol dependence: "strong desire," "difficulties in controlling," and "neglect of pleasures." One major physical phenomenon, "withdrawal," seemed to complement the core symptoms in the diagnosis of alcohol dependence. Another physical phenomenon, "tolerance," was demonstrated to be a relatively independent item. The principal component analysis also demonstrated that the diagnostic item "difficulties in controlling" had the maximum component loading value, followed by 2 items, "neglect of pleasures" and "strong desire."

CONCLUSIONS

The core symptomatic elements in the diagnosis of alcohol dependence were statistically suggested in this study. Knowledge of the relations and components among the diagnostic items of alcohol dependence might also be applicable to other forms of substance use dependence and behavioral addiction.

A Cross-National Examination of Differences in Classification of Lifetime Alcohol Use Disorder Between DSM-IV and DSM-5: Findings from the World Mental Health Survey

BACKGROUND

The current study sought to examine the diagnostic overlap in DSM-IV and DSM-5 alcohol use disorder (AUD) and determine the clinical correlates of changing diagnostic status across the 2 classification systems.

METHODS

DSM-IV and DSM-5 definitions of AUD were compared using cross-national community survey data in 9 low-, middle-, and high-income countries. Participants were 31,367 respondents to surveys in the World Health Organization's World Mental Health Survey Initiative. The Composite International Diagnostic Interview, version 3.0, was used to derive DSM-IV and DSM-5 lifetime diagnoses of AUD. Clinical characteristics, also assessed in the surveys, included lifetime DSM-IV anxiety; mood and drug use disorders; lifetime suicidal ideation, plan, and attempt; general functional impairment; and psychological distress.

RESULTS

Compared with DSM-IV AUD (12.3%, SE = 0.3%), the DSM-5 definition yielded slightly lower prevalence estimates (10.8%, SE = 0.2%). Almost one-third (n = 802) of all DSM-IV abuse cases switched to subthreshold according to DSM-5 and one-quarter (n = 467) of all DSM-IV diagnostic orphans switched to mild AUD according to DSM-5. New cases of DSM-5 AUD were largely similar to those who maintained their AUD across both classifications. Similarly, new DSM-5 noncases were similar to those who were subthreshold across both classifications. The exception to this was with regard to the prevalence of any lifetime drug use disorder.

CONCLUSIONS

In this large cross-national community sample, the prevalence of DSM-5 lifetime AUD was only slightly lower than the prevalence of DSM-IV lifetime AUD. Nonetheless, there was considerable diagnostic switching, with a large number of people inconsistently identified across the 2 DSM classifications.

Assessment of Withdrawal and Hangover is Confounded in the Alcohol Use Disorder and Associated Disabilities Interview Schedule: Withdrawal Prevalence is Likely Inflated

BACKGROUND

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV) and AUDADIS-5 are diagnostic interviews used in major epidemiological and other studies of alcohol use disorder (AUD). Much of what we know regarding the prevalence of AUD in the United States is based upon this interview. However, past research and meta-analytic evidence suggest that differential operationalization of the AUD criteria across instruments can lead to differential endorsement of symptoms and resulting AUD diagnosis rates. In particular, studies employing the AUDADIS are observed to have markedly higher endorsement rates of withdrawal than other large epidemiological studies. One explanation for this is that when assessing withdrawal, the AUDADIS combines effects from the morning after drinking with those from the days following, thereby conflating hangover and withdrawal.

METHODS

This study addresses whether this operationalization confounds rates of endorsement when compared to simpler, less ambiguous hangover or withdrawal stems. To this aim, 497 college student drinkers were randomized into 1 of 3 stem conditions: (i) hangover (n = 164), (ii) withdrawal (n = 167), or (iii) combined AUDADIS-IV (n = 166).

RESULTS

Across conditions, participants were more likely to report the occurrence of each withdrawal symptom in the combined stem condition than in the explicit withdrawal stem condition, but not in the explicit hangover stem condition. Within the combined stem condition, probed symptoms were more likely to be reported as a result of a hangover.

CONCLUSIONS

The AUDADIS potentially results in false positives for withdrawal, arguably a pathognomonic symptom of alcoholism and, in turn, likely affects rates of the diagnosis of AUD.