Concept of Affective Dependence and Validation of an Affective Dependence Scale

Background

There is a degree of affective interdependence that is considered normal and only becomes pathological if it causes excessive suffering, both for the subject and for those close to them. Our objective was to introduce and psychometrically validate a short and effective affective dependency scale, the Affective Dependence Scale (ADS-9).

Methods

We used a sample of 762 participants (clinical: emotional dependent subjects n = 212, comparison: non-emotionally-dependent addicted subjects n = 272, and general population n = 278) to assess the factor structure, the psychological construct validity and the measurement invariance for the ADS-9 by means of independent exploratory factor analyses for each sample group and subsequent multigroup confirmatory factor analyses.

Results

Our results confirm that ADS-9 is a psychometrically consistent instrument, with construct and clinical validity, as well as configural, metric and scalar invariance across different sample groups (clinical, comparison and general population). A hypothesized two-dimensional structure was confirmed by means of factor analyses. Both sub-scales of this abbreviated form, Submission and Craving, showed a good agreement with the previously validated Relationships and Sentimental Dependencies Inventory (IRIDS-100).

Conclusion

The ADS-9 is a brief instrument that appears to reliably detect the dependent and pathological components of affective dependence. It consists of two sub-scales, describing Submission (adaptation, accommodation, and subjugation) and Craving (imperative need for the other with the presence of disturbing states). We suggest that it is a versatile scale that may be useful for clinicians and researchers.

Craving and opioid use disorder: A scoping review

INTRODUCTION

The subjective experience of drug craving is a prominent and common clinical phenomenon for many individuals diagnosed with opioid use disorder (OUD), and could be a valuable clinical endpoint in medication development studies. The purpose of this scoping review is to provide an overview and critical analysis of opioid craving assessments located in the published literature examining OUD.

METHOD

Studies were identified through a search of PubMed, Embase, and PsychInfo databases and included for review if opioid craving was the focus and participants were diagnosed with or in treatment for OUD.

RESULTS

Fifteen opioid craving assessment instruments were identified across the 87 studies included for review. The most common were the Visual Analog Scale (VAS, 41 studies), Desires for Drug Questionnaire (DDQ, 12 studies), Heroin Craving Questionnaire (HCQ, 10 studies), and Obsessive-Compulsive Drug Use Scale (OCDUS, 10 studies). Craving assessments varied considerably in their format, content, time frame, and underlying subscales, and only 6 of 15 had been psychometrically evaluated.

DISCUSSION

This review identified a variety of opioid craving assessments, but few had been evaluated for their psychometric properties making it difficult to ascertain whether craving is being assessed optimally in studies of OUD. Thus, the development of a reliable and valid opioid craving assessment would be worthwhile and could be guided by recently published Food and Drug Administration Clinical Outcome Assessment (COA) guidelines. Importantly, a COA focused on opioid craving could be a valuable addition to research studies designed to evaluate novel treatments for OUD.

Craving as a DSM-5 Symptom of Alcohol Use Disorder in Non-Treatment Seekers

Aims

DSM-5 has added craving as a new criterion and changed the diagnostic structure of alcohol use disorder (AUD). Though craving has long been a target of intervention, less is known about the impact this addition will have on prevalence and factor structure of AUD, particularly in non-treatment seeker with alcohol problems.

Methods

Non-treatment seeking individuals reporting alcohol-related problems (N = 296) completed a structured clinical interview and the Penn Alcohol Craving Scale (PACS). PACS scores greater than 20 were considered to meet diagnostic criteria for the alcohol craving symptom. This study examined DSM-IV to DSM-5 diagnostic conversion and conducted an exploratory factor analysis to test the factor structure of the DSM-5 symptoms, including craving.

Results

The mean PACS score was 13.1 and alcohol craving was strongly correlated with other measures of alcohol use. Using the proposed cut-off score of PACS > 20, 46 participants (16.2%) met criteria for alcohol craving. Craving loaded moderately (0.47) onto the retained DSM symptoms and produced a unidimensional factor structure. The majority of participants who met for a DSM-IV AUD also met for a DSM-5 AUD (98.8%).

Conclusions

Craving prevalence using the PACS was relatively low compared to the remaining 10 DSM-5 symptoms, possibly due to the non-treatment seeking nature of the sample. Conversion of DSM-IV to DSM-5 in this sample led to a small increase in overall AUD prevalence. Craving loaded well onto a single factor structure for AUD.

The role of craving in AUDs: dimensionality and Differential Functioning in the DSM-5

BACKGROUND

The dimensionality and the contribution of the proposed diagnostic criteria for the DSM-5 model of alcohol-use disorders (AUDs) which will provide guidelines for future diagnoses have not been examined in depth.

METHOD

Data from past year drinkers in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Wave 2 (n=22 177) were analysed. Severity and discrimination of DSM-5 diagnostic criteria was determined using a two-parameter logistic Item Response Theory model. Comparative analyses were conducted on the DSM-IV criteria. Differential functioning of the criteria across a number of socio-demographic variables was assessed.

RESULTS

The proposed criteria supported a unidimensional AUD model, with a factor loading range of 0.625-0.914 (craving=0.818). The model measured intermediate severity of AUDs with 'reduced time on important/pleasurable activities' and 'failure to meet major role obligations' criteria having the highest severity and discrimination. Craving, endorsed by 4.2% of the general population, was in the mid-range for both severity (sixth) and discrimination (seventh). Significant measurement bias was found on four criteria across socio-demographic subgroups.

CONCLUSIONS

Application of the proposed DSM-5 changes yields an improved one-factor model of AUD over the existing DSM-IV model. Inclusion of a craving criterion improves the application of the diagnostic criteria in a general population sample, covering a previously unrepresented problem area. Additionally, criteria measuring the milder end of the AUD continuum remain absent and some criteria exhibit measurement non-invariance. The AUD classification may require further refinement to enhance validity and reliability.

The clinical significance of drug craving

Although drug craving has received considerable research attention over the past several decades, to date there has been no systematic review of the general clinical significance of craving. This paper presents an overview of measurement issues of particular relevance to a consideration of use of craving in clinical settings. The paper then considers the relevance of craving across a broad array of clinical domains, including diagnosis, prognostic utility, craving as an outcome measure, and the potential value of craving as a direct target of intervention. The paper is both descriptive and prescriptive, informed by the current state of the science on craving with recommendations for the definition of craving, assessment practices, future research, and clinical applications. We conclude that craving has considerable utility for diagnosis and as a clinical outcome, and that findings from future research will likely expand the clinical potential of the craving construct in the domains of prognosis and craving as a treatment target.

Measuring alcohol craving: development of the Alcohol Craving Experience questionnaire

AIMS

To develop a measure of craving based on the Elaborated Intrusion (EI) theory of desire and to examine the construct, concurrent and discriminant validity of the instrument.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

Patients from a hospital alcohol and drug out-patient service (n = 230), participants in a randomized controlled trial (n = 219) and students in a university-based study of alcohol craving (n = 202) were recruited.

MEASUREMENTS

The Alcohol Craving Experience questionnaire (ACE) was developed to measure sensory aspects of craving (imagining taste, smell or sensations of drinking and intrusive cognitions associated with craving) when craving was maximal during the previous week (ACE-S: strength), and to assess frequency of desire-related thoughts in the past week (ACE-F: frequency). All participants completed the ACE and the Alcohol Use Disorders Identification Test (AUDIT). The Obsessive Compulsive Drinking Scale (OCDS) and the Depression Anxiety and Stress Scale (DASS) were completed by hospital patients and randomized control trial participants.

FINDINGS

Exploratory factor analysis on the ACE-S and ACE-F resulted in a three-factor structure representing imagery, intensity and intrusion. An attempt to confirm this factor structure required a reduction in items (two from ACE-S, five from ACE-F) before a good fit to the three-factor model was obtained. Concurrent validity with the OCDS, with severity of alcohol dependence and with depression, anxiety and stress, was demonstrated. The ACE discriminated between clinical and non-clinical populations and between those at higher risk of alcohol dependence and those at lower risk.

CONCLUSIONS

A new scale, the Alcohol Craving Experience questionnaire, based on the Elaborated Intrusion theory of desire appears to capture key constructs of the theory and correlate with indices of alcohol dependence.

Clinical and laboratory assessment of the subjective experience of drug craving

Measures of subjective drug craving - often defined as the experience of an intense or compelling urge or desire - may be used to predict relapse, evaluate psychological and pharmacological treatments, and test theories of addiction and craving. This review summarizes both direct self-report questionnaires and indirect behavioral, physiological and reaction time measures designed to assess craving for alcohol, amphetamines, cocaine, heroin, marijuana, and tobacco. Multi-item questionnaires have typically been based on one of four underlying conceptualizations of addiction or craving (obsessive-compulsive, approach-avoidance, multi-dimensional, intensity-frequency-duration). Most multi-item self-report questionnaires have high internal consistency, correlate significantly with single-item craving ratings, and demonstrate several aspects of construct validity. Proposed indirect or proxy measures of craving include drug dreams, speed of drug consumption, willingness to work for drug access, selection of monetary rewards over drug access, psychophysiological reactivity, and attentional bias to drug cues. These proxy measures of craving are presumed to obviate self-report biases, to be less subject to conscious self-control, and to reflect craving which the person may not be able to articulate; however, there have been too few demonstrations of their validity and they have too many practical limitations to supplant self-report measures of craving at this time.

Craving e dependência química: conceito, avaliação e tratamento

O craving ou fissura, cuja definição mais comum é o desejo intenso por uma substância, é um conceito controverso entre os pesquisadores da área da dependência química. OBJETIVO: Realizar revisão teórica a respeito do craving nos bancos de dados PsycInfo, Medline, ProQuest e Science Direct. MÉTODO: As palavras-chave utilizadas foram craving, dependence e drug e o período pesquisado foi entre 1995 e 2007. RESULTADOS: Os resultados demonstraram que são encontrados diversos significados para o craving, alguns se restringindo a desejo, e outros, considerando-o não só como desejo, mas como antecipação do resultado positivo do uso da substância, alívio dos sintomas de abstinência ou afeto negativo e intenção de fumar, o que reflete uma visão multidimensional deste construto. A etiologia do craving pode ser explicada por intermédio dos modelos: comportamental, cognitivo ou psicossocial e neurobiológico, porquanto a opção por um destes influencia a avaliação e o manejo. CONCLUSÃO: Conclui-se quanto à multidimensionalidade do craving e quanto à necessidade de que seja utilizado um modelo biopsicossocial que integre os diversos modelos no tratamento de dependentes químicos. Destaca-se a importância da realização de mais estudos para a compreensão do craving em função deste ser um dos principais riscos de recaída.

The validity and reliability of a brief measure of cocaine craving

INTRODUCTION

Although craving plays an important role in relapse, there are few brief, valid and reliable instruments to measure the desire to use cocaine in routine clinical practice. The 45-item Cocaine Craving Questionnaire-Now (CCQ-Now) is widely used in research, but its length makes its use in everyday clinical work relatively impractical. This study sought to determine the psychometric properties of the CCQ-Brief, a measure composed of 10 items from the CCQ-Now, in treatment-seeking cocaine abusers.

METHOD

Subjects with cocaine abuse or dependence (n=247) completed the CCQ-Brief, the CCQ-Now, the Voris Cocaine Craving Scale, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and the Addiction Severity Index.

RESULTS

The CCQ-Brief was significantly correlated with the CCQ-Now (r=.85, p<.01), the CCQ-Now with the items in common with the CCQ-Brief removed (r=.78, p<.01), all four subscales of the VCCS (craving intensity: r=.47, p<.01; mood: r=.27, p<.01; energy: r=.30, p<.01; sick feelings: r=.28, p<.01), the BDI-II (r=.39, p<.01), the BAI (r=.35, p<.01) and recent drug use (r=.26, p<.01). The internal consistency of the CCQ-Brief was strong (alpha=.90).

DISCUSSION

The CCQ-Brief is a valid and reliable instrument that can be easily administered as a measure of current cocaine craving.

Effects of Forgiveness Therapy on Anger, Mood, and Vulnerability to Substance Use Among Inpatient Substance-Dependent Clients

Anger and related emotions have been identified as triggers in substance use. Forgiveness therapy (FT) targets anger, anxiety, and depression as foci of treatment. Fourteen patients with substance dependence from a local residential treatment facility were randomly assigned to and completed either 12 approximately twice-weekly sessions of individual FT or 12 approximately twice-weekly sessions of an alternative individual treatment based on routine drug and alcohol therapy topics. Participants who completed FT had significantly more improvement in total and trait anger, depression, total and trait anxiety, self-esteem, forgiveness, and vulnerability to drug use than did the alternative treatment group. Most benefits of FT remained significant at 4-month follow-up. These results support FT as an efficacious newly developed model for residential drug rehabilitation.

Differential brain activity in alcoholics and social drinkers to alcohol cues: relationship to craving

Using fMRI, our group previously found that after a sip of alcohol and exposure to alcohol beverage pictures, alcoholics compared to social drinkers had increased differential brain activity in the prefrontal cortex and anterior thalamus. This study extends this earlier work with several improvements including imaging the entire brain (rather than the anterior half previously) and recording craving, while the subjects viewed images within the scanner. In a Philips 1.5 T MRI scanner, 10 nontreatment-seeking alcoholics and 10 age-matched healthy social drinkers were given a sip of alcohol before viewing a 12 min randomized presentation of pictures of alcoholic beverages, nonalcoholic beverages, and two different visual control tasks. During picture presentation, changes in regional brain activity were measured in 15 transverse T2(*)-weighted blood oxygen level dependent slices. Subjects rated their urge to drink after each picture sequence. After a sip of alcohol, while viewing alcohol cues compared to viewing other beverage cues, the alcoholics, but not social drinkers, reported higher craving ratings and had increased activity in the prefrontal cortex and anterior limbic regions. Brain activity in the left nucleus accumbens, anterior cingulate, and left orbitofrontal cortex significantly correlated with subjective craving ratings in alcohol subjects but not in control subjects. This study suggests, as did our earlier study, that alcoholics and not social drinkers, when exposed to alcohol cues, have increased brain activity in areas that reportedly subserve craving for other addictive substances.

fMRI BOLD response to alcohol stimuli in alcohol dependent young women

BACKGROUND

Cue reactivity in alcohol dependent adults has revealed autonomic, cognitive, and neural responses to alcohol-related stimuli that differ from those of nonabusers. Cue reactivity and craving responses have not been studied in youth.

METHOD

Alcohol-dependent young women (n=8) and female light social drinkers (n=9) ages 18-24 were administered an alcohol cue reactivity task during functional magnetic resonance imaging (fMRI) to examine brain response to alcohol-related words.

RESULTS

Alcohol dependent young women demonstrated significantly more blood oxygen level dependent (BOLD) response than nonabusers during alcohol word presentation trials relative to neutral word trials in subcallosal, anterior cingulate, left prefrontal, and bilateral insular regions (P<.025). However, controls showed greater response to alcohol words in some right hemisphere cortical regions. Increased craving after cue exposure correlated with increased subcallosal cortex BOLD response to alcohol cues (r=.87) among alcohol dependent subjects.

CONCLUSIONS

This pilot study corroborates previous reports of increased limbic and frontal response to substance cues and extends these findings to young alcohol dependent women. This limbic reaction may underlie the elevated physiological response and altered cognitive reactions to alcohol stimuli that are observed in alcohol dependent individuals.

Current Pharmacotherapies of Alcoholism: A U.S. Perspective

Advances in the neurobiology of addiction and improved clinical trial methodology have accelerated the evaluation of medication for alcoholism. While psychosocial interventions have been useful to reduce consumption and support abstinence, considerable improvement in treatment is needed. Medication can play a crucial role in the reduction of craving and drinking and the maintenance of abstinence. This article reviews pharmacotherapy for alcoholism with an emphasis on the perspective of the United States. The opiate antagonist naltrexone, the glutamate modulator acamprosate, and serotonergic agents will be highlighted in this review. In general, both naltrexone and acamprosate have been found in a number of studies to be efficacious agents for the treatment of alcohol dependence. Serotonin reuptake inhibitors have not consistently shown to be efficacious but may be useful in certain subgroups of alcoholics. The serotonin type-3 antagonist, ondansetron, has shown promise in early-onset alcoholics but needs more extensive study.

Initial validation of two opiate craving questionnaires the obsessive compulsive drug use scale and the desires for drug questionnaire

In the present study, the factor structure, internal consistency, and the concurrent validity of two heroin craving questionnaires are examined. The Desires for Drug Questionnaire (DDQ) measures three factors: desire and intention, negative reinforcement, and control. The Obsessive Compulsive Drug Use Scale (OCDUS) also measures three factors: thoughts about heroin and interference, desire and control, and resistance to thoughts and intention. Subjects were 102 Dutch patients who were currently in treatment for drug dependency. All proposed scales have good reliability and concurrent validity. Implementation of these instruments in both clinical and research field is advocated.

The measurement of craving

This article presents an overview of the definition and measurement of "craving" as it is applied to drug and alcohol abuse research. Examples of craving measures are described and organized in terms of whether they structure craving as a single factor or as a multifactorial construct. The application of craving scales in cue-conditioning studies, in medication treatment trials, and as outcome measures in other treatment studies is considered. It is concluded that no single craving scale, or type of scale, has unequivocal support, because few studies have administered more than one scale to the same population. It is suggested that our understanding of craving will be advanced by designing studies that compare and contrast several craving scales within the same study. Likewise, craving is only one possible cause of relapse. Future studies should compare several alternate relapse mechanisms within the same study.

An etiologic model of alcoholism from a developmental ecological perspective

To reflect the complexity of alcoholism and the heterogeneity of the alcoholic population, an etiologic model should integrate biological, psychological, and environmental factors. The model proposed here does so, postulating that "risk" for alcoholism fluctuates throughout the lifespan of an individual. In addition, this developmental ecological model takes into account both the imputed risk and the protective factors, makes possible a more detailed analysis for each life stage of an individual, and remains flexible enough to accommodate forthcoming empirical data.