Physiological alcohol dependence as a "specifier" of risk for medical problems and relapse liability in DSM-IV

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.

DSM-5 criteria for substance use disorders: recommendations and rationale

Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, adding cannabis and caffeine withdrawal syndromes, aligning tobacco use disorder criteria with other substance use disorders, and moving gambling disorders to the chapter formerly reserved for substance-related disorders. The proposed changes overcome many problems, while further studies will be needed to address issues for which less data were available.

Limitations of DSM-IV Operationalizations of Alcohol Abuse and Dependence in a Sample of Australian Twins

Alcohol abuse and dependence are among the most common psychiatric conditions identified in epidemiological surveys of the general population. The aim of this article is to examine the psychometric properties of Diagnostic and Statistical Manual of Mental Disorders, (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for alcohol abuse and dependence using latent class analysis (LCA). Six thousand two hundred and sixty-five young Australian twins (median age 30 years) were interviewed by telephone between 1996 and 2000 using a modified version of the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA). DSM-IV symptoms of alcohol abuse and dependence were collected by structured diagnostic interview and analyzed using methods of LCA. LCA revealed a 4-class solution for women that classified individuals according to the severity of their alcohol- related problems: no/few problems (66.5%), heavy drinking (23.9%), moderate dependence (7.6%) and severe dependence (2.0%). Among men the preferred solution included 5 classes corresponding to no/few problems (46.4%), heavy drinking (34.3%), moderate dependence (12.2%), severe dependence (3.0%) and abuse (4.0%). Evidence of a male-specific class of alcohol-related problems corresponding to abuse partially supports the DSM conceptualization of alcohol use disorders but suggests that this conceptualization — and measurement — may need to be refined for women. Identification of a male- specific abuse class also has important implications for interventions and treatment as these individuals experienced significant alcohol-related problems and comprised approximately 21% of all men classified with an alcohol use disorder.

Patient predictors of alcohol treatment outcome: a systematic review

Patient characteristics as predictors of alcohol use disorder treatment outcome were examined on three levels, identifying whether or not variables were significant predictors of drinking-related outcome in univariate analysis, in multivariate analysis, and in multivariate analyses limited to studies including several "key predictors." Also, a model was developed to predict total percentage of variance in treatment outcome accounted for in each study using each of the key predictors and a range of methodological factors. The most consistent univariate predictors were baseline alcohol consumption, dependence severity, employment, gender, psychopathology rating, treatment history, neuropsychological functioning, alcohol-related self-efficacy, motivation, socioeconomic status/income, treatment goal, and religion. When these key predictors were combined into multivariate analyses, baseline alcohol consumption and gender showed substantial reductions in predictive consistency whereas the remaining variables were not greatly affected. The most consistent predictors overall were dependence severity, psychopathology ratings, alcohol-related self-efficacy, motivation, and treatment goal. The two predictor variables most associated with greater variance accounted for in predictive models, when controlling for broader methodological variables, were baseline alcohol consumption and dependence severity. Few predictor variables were examined in more than a third of studies reviewed, and few variables were found to be significant predictors in a clear majority of studies. However, a subset of variables was identified, which collectively could be considered to represent a consistent set of predictors. Too few studies controlled for other important predictor variables. Attempts to synthesize findings were often hampered by lack of agreement of the best measure for predictor variables.

Reliability of use, abuse, and dependence of four types of inhalants in adolescents and young adults

Inhalants, as a class of drugs, consists of heterogeneous substances that increase the probability of many serious illnesses and death. Research on inhalant abuse has lagged behind other drugs partly because of the need for a diagnostic instrument of different types of inhalants. This study was conducted to obtain reliability estimates for the new Substance Abuse Module DSM-IV inhalants diagnoses for four types of inhalants: aerosols, gases, nitrites, and solvents as well as different diagnostic configurations of inhalant-related criteria. Participants were 162 community sample adolescents or young adults (mean age=20.3 years, S.D.=2.4). Two-thirds of the sample was male and 83.3% was Caucasian. Kappas and intraclass correlation coefficients were computed to estimate test-retest reliabilities. Results suggested (a) abuse was more common than dependence (34.6% versus 12.3%), (b) reliabilities of abuse criteria and diagnosis were good to excellent across subtypes, and (c) reliabilities of dependence criteria and diagnoses were poor to good across subtypes. Alternative configurations of DSM-IV criteria that were consistent with previous research on adolescents provided excellent reliabilities across subtypes of inhalants. Moreover, 11.1% of participants experienced inhalants withdrawal.

Reliability of DSM-IV diagnostic criteria using the semi-structured assessment for drug dependence and alcoholism (SSADDA)

The semi-structured assessment for drug dependence and alcoholism (SSADDA) yields reliable DSM-IV diagnoses for a variety of psychiatric disorders, including alcohol and drug dependence. This study examines the reliability of individual DSM-IV criteria for lifetime substance dependence diagnoses and the impact of those criteria on diagnostic reliability.

METHODS

Two hundred ninety-three subjects (52.2% women; 38.2% African American, 46.8% European American, 7.5% Hispanic) were interviewed twice over a 2-week period to examine the inter-rater reliability (n=173) or test-retest reliability (n=120) of the SSADDA. Cohen's kappa-statistic and its confidence interval were used to assess the reliability of individual diagnostic criteria.

RESULTS

Overall, the inter-rater reliability estimates were excellent for individual DSM-IV criteria for nicotine and opioid dependence; good for alcohol and cocaine dependence, and fair for dependence on cannabis, sedatives and stimulants. The impact of any individual criterion on diagnostic reliability was minimal, consistent with the notion that the DSM-IV diagnosis of substance dependence measures an underlying construct that is relatively consistent across specific groups of substances.

CONCLUSIONS

These results, combined with results from a study of the SSADDA's diagnostic reliability [Pierucci-Lagha, A., Gelernter, J., Feinn, R., Cubells, J.F., Pearson, D., Pollastri, A., Farrer, L., Kranzler, H.R., 2005. Diagnostic reliability of the semi-structured assessment for drug dependence and alcoholism (SSADDA). Drug Alcohol Depend. 80, 303-312], show that the instrument can be used reliably to assess substance dependence.

Behavioral effects of aminoadamantane class NMDA receptor antagonists on schedule-induced alcohol and self-administration of water in mice

RATIONALE

Aminoadamantanes represent a class of NMDA glutamate receptor antagonists that reduce alcohol consumption and may prevent alcohol-induced neuronal adaptations and side effects.

OBJECTIVE

Behavioral specificity of memantine and amantadine on alcohol drinking in a schedule-induced polydipsia (SIP) task was investigated in mice.

METHODS

Male C57BL/6J mice were food-deprived and divided into four groups: 5% alcohol SIP, water SIP, 1 h limited access regulatory water drinking, and a control group to determine if either drug altered ethanol drinking. Behavioral specificity of memantine (5, 10, and 25 mg/kg, ip) and amantadine (20, 40, and 60 mg/kg, ip) was determined by comparing alterations in alcohol or water consumption in SIP and regulatory water drinking. Drug effects on SIP drinking-specific measures (grams per kilogram consumption) were also compared to nondrinking measures (locomotion, head-entries for food, and lick efficiency).

RESULTS

Compared to saline, memantine reduced alcohol SIP drinking (10 and 25 mg/kg). Memantine increased locomotion during alcohol SIP (25 mg/kg) and during water SIP (5 and 25 mg/kg). In contrast, amantadine reduced both alcohol SIP (40 mg/kg) and water SIP (40 and 60 mg/kg). Both drugs reduced regulatory water consumption over the entire dose range tested. Blood alcohol concentrations indicated consumption of physiologically meaningful amounts of alcohol during SIP, and that changes in alcohol metabolism did not account for drug-induced reductions in alcohol drinking.

CONCLUSIONS

In addition to reducing alcohol drinking, both drugs had other behavioral effects that included reductions in regulatory drinking. These results suggest that the therapeutic utility of these drugs for ameliorating human alcohol addiction remains questionable.

Progress in Using Mouse Inbred Strains, Consomics, and Mutants to Identify Genes Related to Stress, Anxiety, and Alcohol Phenotypes

This article summarizes the proceedings of a symposium that took place at the 2005 meeting of the Research Society on Alcoholism. The organizers/chairs were Daniel Goldowitz and Katheen A. Grant. The presentations were as follows: (1) High-Throughput Screening for Ethanol Phenotypes, by Douglas B. Matthews and Kristin M. Hamre; (2) Genetic Basis of Schedule-Induced Polydipsia in Mice, by Guy Mittleman and Elissa J. Chesler; (3) Effects of Stress and Ethanol Dependence on Ethanol Self-administration in Inbred and Mutant Mice, by Howard C. Becker and Marcelo F. Lopez; (4) Changes in Dopaminergic Mechanisms Associated With Ethanol Dependence, by Sara R. Jones and Tiffany A. Mathews; and (5) Defining Brain Region-Specific Gene Networks Relevant to Ethanol Behaviors, by Michael F. Miles and Robnet Kerns.

Alcohol abuse and dependence criteria as predictors of a chronic course of alcohol use disorders in the general population

AIMS

To investigate whether DSM-IV abuse and dependence criteria and the ICD-10 criterion for craving differentially predict a chronic course of alcohol use disorders (AUD) in the general population.

METHODS

Data were derived from the Netherlands Mental Health Survey and Incidence Study, a large representative sample of the general Dutch population with a baseline and a 1- and 3-year follow-up assessment. In the present study, a cohort of subjects with a DSM-IV AUD diagnosis at baseline was followed (n = 382). Diagnostic criteria of AUD according to DSM-IV and ICD-10 were assessed using the Composite International Diagnostic Interview (CIDI).

RESULTS

In our cohort of subjects with an AUD diagnosis at baseline, the presence of all dependence criteria, except tolerance, significantly increased the risk for dependence at 1 and 3 years follow-up. Abuse criteria displayed much lower and often non-significant risks for dependence at follow-up, with the exception of the criterion 'legal problems'. The ICD-10 criterion 'craving' had the highest relative risk (RR) of all criteria for dependence at 1 year (RR = 12.4, 95% CI = 5.5-27.8) and 3 years follow-up (RR = 12.9, 95% CI = 4.4-37.7).

CONCLUSION

With the exception of tolerance, all DSM-IV dependence criteria are useful in predicting the course of AUD in the general population.

Craving and withdrawal as core symptoms of alcohol dependence

There is ongoing debate regarding the validity of the distinction of alcohol abuse and dependence, the distinction between normality and alcohol abuse, and the absence of craving in the DSM-IV classification of alcohol use disorders. In this study, we examine the discriminant validity of the DSM-IV alcohol use disorder diagnoses in three different populations (98 patients from an alcohol treatment service, 68 nontreatment-seeking heavy drinkers, and 75 psychiatric outpatients). We compare the results of the DSM-IV classification with an alternative classification that requires craving and withdrawal for the diagnosis of dependence and at least two DSM-IV abuse-dependence symptoms for the diagnosis of abuse: the Craving Withdrawal Model (CWM). Although the total prevalence of any alcohol use disorder did not differ between DSM-IV and CWM, the distinction between normality and abuse and between abuse and dependence was better for the CWM categories.

A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component

BACKGROUND

The DSM-III-R removed tolerance and withdrawal as required elements for a diagnosis of alcohol dependence. Although this practice was continued in DSM-IV, the more recent manual asked clinicians to note whether physiological aspects of withdrawal (tolerance and withdrawal) had ever been experienced. Few studies have determined the prognostic meaning of a history of a physiological component to DSM-IV alcohol dependence.

METHODS

Face-to-face structured interviews were used to evaluate the course of alcohol, drug, and psychiatric problems during the subsequent 5 years for 1094 alcohol-dependent men and women. These subjects had been classified into subgroups at the time of initial interview regarding evidence of tolerance or withdrawal, and all evaluations were based on DSM-IV criteria. At baseline, the application of DSM-IV diagnostic guidelines resulted in 649 (59.3%) individuals having a history of an alcohol withdrawal syndrome, with or without tolerance (group 1); 391 (35.7%) with histories of tolerance but not withdrawal (group 2); and 54 (4.9%) with no lifetime histories of tolerance or withdrawal (group 3).

RESULTS

During the 5-year follow-up, both the broad (group 1 plus 2 versus group 3) and narrow (group 1 versus group 2 plus group 3) definitions of physiological dependence were associated with more alcohol and drug problems. However, for most items, this differential primarily reflected differences between groups 1 and 3, with a less impressive effect by group 2. Although no group differences were noted for the rate of independent major depressive episodes, substance-induced depressions did differentiate among groups, a finding also most closely related to the distinction between groups 1 and 3.

CONCLUSIONS

These data support the prognostic importance of noting the presence of a physiological component in alcohol dependence and indicate the potential relevance of limiting the definition of a physiological component to withdrawal.

Prevalence of DSM-IV alcohol diagnoses and symptoms in adolescent community and clinical samples

OBJECTIVE

Summary prevalence data are critical to determining the utility of DSM-IV criteria for alcohol use disorders among adolescents. This study examined cross-study consistency in the relative prevalence of DSM-IV alcohol symptoms, the ratio of alcohol abuse to dependence diagnoses, the prevalence of the physiological dependence subtype, and the proportion of subthreshold cases of dependence.

METHOD

DSM-IV alcohol diagnosis and symptom prevalence data were obtained from five community and four clinical adolescent samples.

RESULTS

There was a moderate level of cross-study agreement on the relative prevalence of alcohol symptoms (mean Spearman p = 0.47). The most common symptoms were dependence criteria: tolerance and drinking more or longer than intended. A relatively high degree of variability in the ratio of abuse to dependence diagnoses and the proportion with physiological dependence was observed. All samples included a significant proportion of subthreshold cases of dependence: up to 12% in community and up to 34% in clinical samples.

CONCLUSIONS

Alcohol dependence symptoms of tolerance and drinking more or longer than intended have relatively high prevalence among adolescents. These high prevalence symptoms affect the ratio of abuse to dependence diagnoses in some studies, the prevalence of the physiological dependence subtype, and the proportion of subthreshold cases of dependence.

Changes in alcoholic patients' coping responses predict 12-month treatment outcomes

Patient subtypes (Types A and B alcoholism), determinants, and outcomes associated with changes in coping responses of 133 alcoholic patients in the year following admission to treatment were examined. In general, patients' use of avoidance coping declined and use of approach coping increased. Type B patients used more avoidance coping than did Type A patients, but the subtypes did not differ in rate of change in coping. As a determinant of coping, cognitive appraisal of threat showed a trend toward predicting avoidance coping at 6- and 12-month follow-ups. Decreased cognitive avoidance coping (e.g., daydreaming) predicted fewer alcohol, psychological, and interpersonal problems. Increased behavioral approach coping (e.g.. taking action) predicted lower severity of alcohol problems. Further study of changes in the cognitive aspects of coping (i.e., appraisals and cognitive avoidance coping) is needed to determine mechanisms underlying cognitive processes associated with treatment outcomes.

Psychopathology: description and classification

DSM-IV's strong empirical base has yielded an instrument with good to excellent reliability and improved validity. Diagnostic reliability depends on both the clarity and validity of diagnostic criteria and the changeability of disorders over time: The reliability of schizophrenic spectrum disorders, personality disorders, and some childhood and adolescent disorders remains problematic. Findings on diagnostic validity appear paradoxical: Attempts to validate schizophrenic spectrum disorders with neurobiological and genetic-familial validators have been only modestly successful, whereas the tripartite personality trait model has differentiated a range of depressive and anxiety disorders. Research on comorbidity has identified several highly comorbid disorders (substance-related disorders, personality disorders, depression, and anxiety) as well as some adverse consequences of comorbidity. The advantages of dimensional approaches to diagnosis have largely been demonstrated conceptually; ultimate conclusions about the strengths and weaknesses of dimensional and syndromal methods await substantial additional empirical research.

Symptoms and characteristics of individuals with different types of recovery from DSM-IV alcohol dependence

Symptoms and criteria for DSM-IV alcohol dependence and demographic and drinking characteristics are compared for three groups. Group I (N = 1,044) consists of persons who formerly met the criteria for dependence but were abstinent in the past year, Group II (N = 2,325) consists of persons who were formerly dependent but did not meet the criteria for abuse or dependence in the past year despite drinking, and Group III (N = 22,204) consists of persons who never met the criteria for dependence. Members of Group II lay between members of Groups I and III in terms of the numbers of prior dependence symptoms and criteria, past level of intake, degree of familial alcoholism and history of alcohol treatment. Both groups of former alcoholics were equally likely to have experienced withdrawal, drinking more/longer than intended and tolerance. The criteria that most strongly distinguished the groups were continued use despite physical or psychological consequences, time spent drinking and activities given up, all of which were far more common in Group I than in Group II. Members of Group II had earlier onsets of heavy drinking and dependence than members of Group I, supporting the existence of a developmentally limited subtype of alcoholism that is subject to spontaneous remission in early adulthood without treatment. The paper compares three options for tightening the criteria for dependence, all of which remove more members from Group II (28% to 41% depending on option) than from Group I (12% to 19%).

Predictors of relapse to heavy drinking in alcohol dependent subjects following alcohol detoxification-the role of quality of life measures, ethnicity, social class, cigarette and drug use

Sixty DSM-IV alcohol dependent adults (39 males, 21 females) admitted to a voluntary sector alcohol detoxification unit in South London were studied. Socio-demographic data and information on level of alcohol dependence, quality of life, family history, cigarette smoking and the use of prescription/illicit drugs were collected. The subjects were followed-up at 12 weeks and subdivided into two groups, relapse and non-relapse. A relapse was defined as drinking 21 units or more per week for males and 14 units or more per week for females. Data were analysed for baseline and 12-week follow-up comparisons. At 12 weeks, 58 (97%) subjects (38 males, 20 females) were successfully followed-up and 36/58 (62%) had relapsed. After controlling for a Type I error there were significant differences between the relapse and non-relapse subgroups at 12-week followup on the following outcome measures; depression, life situation, withdrawal symptoms, energy, emotional reactions and social isolation. There were no significant differences at baseline between the relapse and nonrelapse subgroups for most of the socio-demographic variables, but Irish nationality and membership of lower social classes (IV and V) were associated with relapse. Major predictors of relapse at baseline after a forward stepwise logistic regression were (in order of increasing statistical significance) Irish nationality, lower social class, greater number of cigarettes smoked and disturbed sleep. The findings are discussed with reference to their consistency with existing research and potential clinical implications.

Illness severity and self-efficacy as course predictors of DSM-IV alcohol dependence in a multisite clinical sample

Illness severity and self-efficacy are two constructs of growing interest as predictors of clinical response in alcoholism. Using alternative measures of illness severity (DSM-IV symptom count, Alcohol Dependence Scale, and Addiction Severity Index) and self-efficacy (brief version of the Situational Confidence Questionnaire) rigorously controlled for theoretically important background variables, we studied their unique contribution to multiple indices of relapse, relapse latency, and use of alternative coping behaviors in a large, heterogeneous clinical sample. The Alcohol Dependence Scale contributed to the prediction of 4 of 5 relapse indicators. The SCQ failed to predict relapse behavior or its precursor, coping response. The findings emphasize the predictive validity of severity of dependence as a course specifier and underline the need for more sensitive and externally valid measures of cognitive processes such as self-efficacy for application in future studies of posttreatment behavior.