Characteristics of nosologically informative data sets that address key diagnostic issues facing the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) and International Classification of Diseases, eleventh edition (ICD-11) substance use disorders workgroups

Towards ICD-11 for alcohol dependence: Diagnostic agreement with ICD-10, DSM-5, DSM-IV, DSM-III-R and DSM-III diagnoses in a Swedish general population of women

BACKGROUND

The proposed ICD-11 classification includes major revisions of alcohol dependence. We aimed to evaluate the presence of, and concordance between the proposed ICD-11 dependence and ICD-10, DSM-5, DSM-IV, DSM-III-R and DSM-III in a general population. We also examine as aspects of validity, including longitudinal stability and how meaningful clinical correlates associated across the systems.

METHODS

Longitudinal population-based study of women in Gothenburg, Sweden. Participants (n = 1,614) were sampled during 1989-2015 through double-phase stratified random sampling. Alcohol use disorders were assessed through structured diagnostic interviews (CIDI-SAM), at baseline and follow-up 5-10 years later (n = 930). Concordance was examined using contingency tables and Cohen's kappa coefficient.

RESULTS

At baseline, the prevalence of lifetime alcohol dependence was 10.6 % according to ICD-11. Corresponding figures were ICD-10, 4.0 %; DSM-IV, 4.3 %; DSM-III-R, 7.5 %; and DSM-III, 12.3 %.DSM-5 Alcohol Use Disorder was 14.3 %. Concordance between ICD-11 and other diagnoses ranged from almost perfect agreement (with DSM-5 AUD) to substantial (with DSM-III and DSM-III-R) and moderate (with ICD-10 and DSM-IV). The broadening of the "persistent use despite problems" criteria in ICD-11 had little effect on the prevalence. ICD-11 captured a lower proportion of family history of alcohol problems and treatment-seeking compared to ICD-10 and DSM-IV and showed lower stability.

CONCLUSIONS

The proposed ICD-11 algorithm yields a higher prevalence than either ICD-10 or DSM-III-R /-IV dependence, as well as lower agreement with previous diagnostic systems, lower longitudinal stability and weaker associations with clinical correlates. This is important for knowing how changes in diagnostic criteria impact prevalence estimates and related research.

The association between quantity, frequency and duration of cocaine use during the heaviest use period and DSM-5 cocaine use disorder

BACKGROUND

Quantity (Q), frequency (F), and duration (D) of cocaine use during a person's heaviest use period are important aspects of cocaine use patterns that associated with cocaine use disorder (CocUD).

METHODS

A total 2988 lifetime cocaine users who met CocUD after the onset of cocaine heaviest use were identified from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). QFD were each categorized into four levels. Hierarchical regressions were used to examine the association between QFD of cocaine use and CocUD. Two-way interactions between QFD were also examined.

RESULTS

As the level of cocaine use increased from low to very high, the prevalence of CocUD increased. Compared to people with low F, cocaine users with very high F were 12.09 times (95 %CI 6.33, 23.07) as likely to meet criteria for CocUD. Similarly, Q was associated with 4.84 (95 %CI 2.55, 9.18) times the risk of CocUD. D was not significantly associated with the risk of CocUD. Significant additive interaction was identified between Q*F on CocUD prevalence. Approximately one-third of the excess risk associated with having high Q & high F was due to the interactive effect.

CONCLUSION

Of these three cocaine use patterns, F had the strongest association with CocUD, followed by the Q. High Q and high F was a very dangerous pattern of cocaine use as the combination had as a synergistic effect on the risk of CocUD. It is important for intervention programs to focus on the reduction of both Q and F.

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).

Psychoanalytic treatment of psychological addiction to alcohol (alcohol abuse)

The DSM-V Committee plans to abolish the distinction between Alcohol Abuse and Alcohol Dependence (dsm5.org). The author presents a case report as a proof of concept that this distinction should be retained. The author has asserted that Alcohol Abuse is a purely psychological addiction, while Alcohol Dependence involves capture of the ventral tegmental dopaminergic SEEKING system (Johnson, 2003). In psychological addiction the brain can be assumed to function normally, and ordinary psychoanalytic technique can be followed. For the patient described, transference interpretation was the fundamental key to recovery. Alcoholic drinking functioned to prevent this man from remembering overwhelming childhood events; events that were also lived out in his current relationships. Murders that occurred when he was a child were hidden in a screen memory. The patient had an obsessional style of relating where almost all feeling was left out of his associations. After he stopped drinking compulsively, he continued to work compulsively. The maternal transference had to be enacted and then interpreted in order for overwhelming memories to be allowed into conscious thought. After psychoanalysis, the patient resumed drinking and worked a normal schedule that allowed more fulfilling relationships. He had no further symptoms of distress from drinking over a 9-year followup. This case illustrates that Alcohol Abuse is a purely psychological illness, that it does not have the brain changes typical of Alcohol Dependence. Combining epidemiological, neurobiological, longitudinal, and psychoanalytic observations would allow multiple sources of information to be used in creating diagnostic categories. Losing details of human behavior by relying only on epidemiological studies is likely to cause errors in categorization of disorders. In turn, having faulty categories as the basis of further research is likely to impair identification of specific effective treatments.

Assessing the dimensionality of lifetime DSM-IV alcohol use disorders and a quantity-frequency alcohol use criterion in the Australian population: a factor mixture modelling approach

AIMS

With the revision of the DSM-IV underway, two important research issues currently dominate the addiction literature: (a) how can the dimensionality of DSM-IV alcohol use disorders (AUD) diagnostic criteria best be described? and (ii) should a quantity-frequency alcohol use (QF) criterion be added to the existing diagnostic criteria set in the DSM-V? The current study addressed these aims by analysing lifetime data from a recent Australian population survey.

METHODS

Data from adults screened for lifetime DSM-IV AUD in the 2007 National Survey on Mental Health and Wellbeing (NSMHWB) were analysed (n = 5409). A series of alternative factor analytic, latent class and factor mixture or 'hybrid' models were used to assess the dimensionality of lifetime DSM-IV AUD diagnostic criteria and a lifetime QF criterion.

RESULTS

Examination of the goodness-of-fit indices revealed that a one-factor or a two-factor model, a three-class latent class model or a two-factor zero-class hybrid model, were all acceptable models for the data. A simple structure one-factor model was considered to be the most parsimonious and theoretically meaningful model, given the high correlation between the abuse and dependence factors (0.874) in the two-factor model. The inclusion of the QF criterion did not enhance the fit of the one-factor model.

CONCLUSIONS

Incorporating both dimensional and categorical conceptions of lifetime AUD did not provide substantial gains over a simple structure unidimensional model of AUD severity. The utility of a QF use criterion in helping to diagnose AUD is questionable. These findings should be of relevance to the DSM-5 substance use disorder workgroup.

Are subthreshold alcohol dependence symptoms a risk factor for developing DSM-IV alcohol use disorders? A three-year prospective study of 'diagnostic orphans' in a national sample

AIMS

Research suggests that diagnostic orphans (i.e., individuals experiencing only 1-2 criteria for DSM-IV alcohol dependence) may be at increased risk for developing more severe alcohol problems. This study aimed to: (i) investigate the course of diagnostic orphans in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and (ii) explore whether a specific symptom endorsement pattern(s) could identify diagnostic orphans at Wave 1 who remitted or progressed to alcohol dependence at Wave 2.

METHODS

Current drinkers (n = 15,751) were divided into diagnostic groups at Waves 1 and 2: no-alcohol use disorder (AUD); one-criterion orphans, two-criterion orphans, alcohol abuse, or alcohol dependence. Multinomial logistic regression analysis explored the association between diagnostic status at Wave 1 and Wave 2. Chi-square tests investigated differences in the criteria endorsement patterns of diagnostic orphans.

RESULTS

Compared to the no-AUD group, one-criterion orphans at Wave 1 were twice as likely to be in the abuse group and four times more likely to be dependent at Wave 2. Two-criterion orphans were three times more likely to be in the abuse group and eight times more likely to have progressed to dependence. Criterion endorsement patterns of diagnostic orphans at baseline did not significantly differentiate between those who remitted and those who progressed to dependence at follow-up.

CONCLUSIONS

Like previous research, diagnostic orphans are at increased for developing to more severe alcohol problems. Relying solely on the DSM-IV AUD diagnostic criteria, however, may not be sufficient to identify those diagnostic orphans who are at risk for progressing to dependence.

Test-re-test reliability of DSM-IV adopted criteria for 3,4-methylenedioxymethamphetamine (MDMA) abuse and dependence: a cross-national study

AIMS

This study evaluated the prevalence and reliability of DSM-IV adopted criteria for 3,4-methylenedioxymethamphetamine (MDMA) abuse and dependence with a purpose to determine whether it is best conceptualized within the category of hallucinogens, amphetamines or its own category.

DESIGN

Test-re-test study.

PARTICIPANTS

MDMA users (life-time use >5 times) were recruited in St Louis, Miami and Sydney (n=593). The median life-time MDMA consumption was 50 pills at the baseline.

MEASUREMENTS

The computerized Substance Abuse Module for Club Drug (CD-SAM) was used to assess MDMA abuse and dependence. The Discrepancy Interview Protocol (DIP) was used to determine the reasons for the discrepant responses between the two interviews. Reliability of diagnoses, individual diagnostic criteria and withdrawal symptoms was examined using the kappa coefficient (κ). findings for baseline data, 15% and 59% met MDMA abuse and dependence, respectively. Substantial test-re-test reliability of the diagnoses was observed consistently across cities (κ=0.69). 'Continued use despite knowledge of physical/psychological problems' (87%) and 'withdrawal' (68%) were the two most prevalent dependence criteria. 'Physically hazardous use' was the most prevalent abuse criterion. Six dependence criteria and all abuse criteria were reported reliably across cities (κ: 0.53-0.77). Seventeen of 19 withdrawal symptoms showed consistency in the reliability across cities. The most commonly reported reason for discrepant responses was 'interpretation of question changed'. Only a small proportion of the total discrepancies were attributed to lying or social desirability.

CONCLUSION

The adopted DSM-IV diagnostic classification for MDMA abuse and dependence was moderately reliable across cities. findings on MDMA withdrawal support the argument that MDMA should be separated from other hallucinogens in DSM.

Reflections on 40 Years of Drug Abuse Prevention Research

Over the past twenty-five years, tremendous progress has been made in the area of drug abuse prevention research. The accumulated findings from longitudinal studies of adolescents regarding the factors associated with vulnerability to the substance use and abuse and trends from national surveys of substance use showing their association to societal perceptions of the harmfulness resulting from the use of these substances have informed the development of effective innovative prevention strategies. The 1990s saw a reversal in the perception of the value and importance of drug abuse prevention research with recognition of the field's approach to intervention development and implementation and its scientific rigor in demonstrating intervention impact. This paper reflects on this history anticipating both the positive and negative aspects of the future for the field.

Current status of Kampo (Japanese herbal) medicines in Japanese clinical practice guidelines

BACKGROUND AND AIMS

Kampo (Japanese herbal) medicines are often used in clinical practice in Japan. However, it is unclear how Kampo medicines are quoted and evaluated in current clinical practice guidelines (CPGs). Here, we systematically reviewed Japanese CPGs, and aimed to reveal how Kampo medicines are described in the CPGs.

MATERIALS AND METHODS

We reviewed the quasi-comprehensive list of Japanese CPGs available from the Toho University Medical Media Center (TUMMC) having the largest data base on Japanese CPGs, and also used a hand search. CPGs containing Kampo products were classified into three types based on how Kampo was handled. CPGs that provided recommendations based on evidence were classified as "type A". Those which cited references but did not provide any recommendations were classified as "type B". Those which described the Kampo practice or Kampo-related terms without providing any relevant references were classified as "type C".

RESULTS

By the end of March of 2007, 35 (10.1%) of 346 CPGs listed by TUMMC contained descriptions of Kampo products. We discovered one Kampo-related CPGs in a hand search process. Of these 36 CPGs, 6 were "type A", 13 were "type B", and 17 were "type C". Although results from pertinent randomized controlled trials (RCTs) were available, we noticed that some well-known RCTs studying Kampo medicines are missing in corresponding CPGs.

CONCLUSIONS

We revealed that the citation rate of Kampo medicines in CPGs was approximately 10% and that some pivotal trials for Kampo medicines were not quoted in CPGs. Kampo medicines in CPGs should be assessed more comprehensively and scientifically.

How should we revise diagnostic criteria for substance use disorders in the DSM-V?

This article reviews literature on the validity and performance characteristics of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria for substance use disorders (SUDs) and recommends changes in these criteria that should be considered for the next edition of the DSM (DSM-V). Substantial data indicate that DSM-IV substance abuse and substance dependence are not distinct categories and that SUD criteria are best modeled as reflecting a unidimensional continuum of substance-problem severity. The conceptually and empirically problematic substance abuse diagnosis should be abandoned in the DSM-V, with substance dependence defined by a single set of criteria. Data also indicate that various individual SUD criteria should be revised, dropped, or considered for inclusion in the DSM-V. The DSM-V should provide a framework that allows the integration of categorical and dimensional approaches to diagnosis. Important areas for further research are noted.

Alcohol measurement methodology in epidemiology: recent advances and opportunities

AIM

To review and discuss measurement issues in survey assessment of alcohol consumption for epidemiological studies.

METHODS

The following areas are considered: implications of cognitive studies of question answering such as self-referenced schemata of drinking, reference period and retrospective recall, as well as the assets and liabilities of types of current (e.g. food frequency, quantity-frequency, graduated frequencies and heavy drinking indicators) and life-time drinking measures. Finally we consider units of measurement and improving measurement by detailing the ethanol content of drinks in natural settings.

RESULTS AND CONCLUSIONS

Cognitive studies suggest inherent limitations in the measurement enterprise, yet diary studies show promise of broadly validating methods that assess a range of drinking amounts per occasion; improvements in survey measures of drinking in the life course are indicated; attending in detail to on- and off-premise drink pour sizes and ethanol concentrations of various beverages shows promise of narrowing the coverage gap plaguing survey alcohol measurement.

DSM-V research agenda: substance abuse/psychosis comorbidity

For diagnosis of patients with comorbid psychotic symptoms and substance use disorders (SUDs), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, makes clear distinctions between independent psychotic disorders (eg, bipolar disorder, schizophrenia) and substance-induced syndromes (eg, delirium, dementias). Most substance-induced psychotic symptoms are considered to be short lived and to resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal. These guidelines are challenged by practical difficulties in distinguishing between substance-induced and independent psychoses and by mounting evidence that marijuana use may be a contributing cause of schizophrenia. To inform the diagnostic distinction between substance-induced vs independent psychotic symptoms, 2 kinds of information could be sought from longitudinal research: (a) identification of early markers that clearly differentiate the 2 conditions and (b) more precise information about duration of psychotic symptoms induced by different substances. Evidence of this type could emerge from reanalysis of existing data from large-scale longitudinal studies of community samples. To inform possible nosological changes related to the possible schizophrenia-inducing role of marijuana (eg, designating a "cannabis-induced" subtype), a wide range of research evidence will be needed to clarify the relationship between effects of cannabis and schizophrenia symptoms. Ultimately, the ideal psychiatric nomenclature will define syndromes on the basis of established etiology and/or pathophysiology. Given the strong association between SUDs and psychotic disorders, research on the neurobiology of psychotic disorders could fruitfully include subjects with comorbid SUDs to shed light on shared etiology and pathophysiology.