Assessment of alcohol tolerance in adolescents.

OBJECTIVE: To improve assessment of the DSM-IV alcohol tolerance criterion in adolescents, this study tested the performance of a minimum percentage increase in drinking quantity, and a proxy measure of tolerance (i.e., average heavy-drinking quantity per occasion) in identifying adolescents with alcohol dependence. METHOD: Two adolescent samples were examined. In one sample (N = 415, 58% male, 79% white, 57% clinical), a modified version of the SCID was used to determine DSM-IV alcohol diagnoses, and lifetime drinking history data were collected by interview. In the second sample (N = 470, 60% male, 76% white, 100% clinical), the Adolescent Diagnostic Interview was used to determine DSM-IV alcohol diagnoses and to collect data on initial- and current-drinking quantities needed to become intoxicated. The performance of a percentage increase and average heavy-drinking quantity in identifying those with dependence was evaluated using receiver operating characteristic analysis. RESULTS: The utility of a percentage increase definition was limited by the high degree of variability in initial-drinking quantities. Percentage increase may underassign the tolerance symptom when initial-drinking quantities are high and overassign the symptom when initial-drinking quantities are low. Average heavy-drinking quantity per occasion, combined with a minimum frequency of drinking, demonstrated better performance than any percentage increase definition. CONCLUSIONS: Alternatives to a change-based (e.g., percentage increase) definition of tolerance warrant study due to limits of change-based definitions when initial-drinking quantity shows a high degree of variability. The variability in initial-drinking quantity may reflect individual differences in initial sensitivity that need to be considered in tolerance assessment.

State-level treatment outcome studies using administrative databases.

State substance dependence administrative databases contain both administrative and clinical information on large numbers of patients collected over extended time periods. Access to other state databases--employment, criminal behavior, and Medicaid--has also been achieved in some instances. Such data could prove an important source for the evaluation of long-term treatment outcomes and their determinants. This selected review describes and evaluates the treatment outcome and cost-related findings of the most advanced studies using these databases. A number of these studies have shown that completion of substance dependence treatment is associated with reduced societal costs. Some of these studies have focused on significant subpopulations of patients, including pregnant women and adolescents. A shortcoming of the findings of most of these studies concerns their use of noncompleter or non-randomly collected comparison groups. The utility of these databases can be enhanced by coupling them with clinical research treatment outcome evaluation approaches.

The validity of self-reported cost events by substance abusers. Limits, liabilities, and future directions.

The following review considers data on the validity of self-reports in addict populations, and then it discusses (a) the types of cost-related questions and the assumptions underlying them that are useful to the evaluation of addictions treatment, (b) both internal and external sources of invalidity, (c) the limits on cost-related information that is gathered from administrative databases, (d) methods for assessing measure validity, and (e) the means for improving the validity of self-reports of cost events. With some important exceptions, addicts provide valid data about both medical and criminal cost events. Skilled socioeconomic researchers able to monetarize these events should be able to produce significant cost of illness, cost offset, cost-benefit, and cost-effectiveness research using self-report data.

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.

Clinical features of pathological gambling in an addictions treatment cohort.

This study examined the prevalence and descriptive psychopathology of pathological gambling in a heterogeneous treatment sample of 372 substance users. About 14% of male participants and 10% of female participants were identified as presumptive pathological gamblers (PGs) on the South Oaks Gambling Screen (SOGS). The authors contrasted 49 PGs with 323 participants who were not pathological gamblers (NPGs) on a host of variables measuring premorbid risk, pathological patterns of substance use, consequences of use, and psychiatric comorbidity. PGs showed more disturbance than NPGs on some measures of premorbid risk, pathological substance use, social consequences of use, and psychiatric comorbidity. Gambling status may be an important comorbid condition in addictions treatment settings and a significant covariate in research.

Toward the DSM-V: the Withdrawal-Gate Model versus the DSM-IV in the diagnosis of alcohol abuse and dependence.

The Diagtnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) classifies as dependent many cases of mild alcohol problems. DSM-IV diagnoses have modest relationships with predictive and some concurrent validators and often improperly sequence the onset of abuse versus dependence, perhaps due to insufficient emphasis on physiological features. Testing reliability, syndrome prevalence, syndrome sequencing, and concurrent and predictive validity, this study contrasted the DSM-IV with the Withdrawal-Gate Model (WGM), in which alcohol withdrawal is necessary and sufficient for the dependence diagnosis. Clinical samples of adults (baseline n = 318) and adolescents (baseline n = 214) meeting abuse or dependence were assessed for DSM-IV alcohol symptoms and external measures of problem severity and reinterviewed at 6 (adults) and 12 months (adults and adolescents). Among DSM-IV dependent cases, the WGM shifted 32% of adults and 80% of adolescents to the abuse category, making both categories more symptomatically severe, but had a negligible effect on the prevalence of total alcohol diagnoses. The WGM was more reliable than the DSM-IV and temporally sequenced abuse before dependence in a greater number of cases. The WGM was superior to the DSM-IV in concurrent and predictive validity on most measures. Future diagnostic systems may be more reliable and valid if they require evidence of withdrawal for substance dependence.

Diagnostic concordance of DSM-III, DSM-III-R, DSM-IV and ICD-10 alcohol diagnoses in adolescents.

OBJECTIVE: Little is known about the validity of diagnostic criteria for alcohol use disorders (AUDs) when applied to adolescents. This study examined the diagnostic concordance of DSM-III, DSM-III-R, DSM-IV and ICD-10 AUDs in a sample of adolescents with a broad range of alcohol problem severity. METHOD: Participants were 413 adolescents (250 male), ages 13 to 19, drawn from clinical and community sources. AUDs were assessed using the Structured Clinical Interview for the DSM (SCID), modified to make diagnoses in the four nosological systems. Diagnostic agreement for lifetime diagnoses was quantified with the kappa statistic. RESULTS: Agreement was fair to high across the three categories of alcohol dependence, alcohol abuse and no alcohol diagnosis (kappa = 0.51 to 0.76); for alcohol dependence (kappa = 0.51 to 0.83); and for the categories of any AUD versus no AUD (kappa = 0.55 to 0.96). Concordance was very low for alcohol abuse diagnoses (kappa = 0.10 to 0.23), with the exception of DSM-III-R and DSM-IV (kappa = 0.62). Dependence was superior to abuse in the degree of temporal overlap in diagnostic agreements. CONCLUSIONS: Similar to findings with adults, diagnostic concordance among adolescents tended to be fair to high for alcohol dependence and very low for alcohol abuse. The data highlight the inconsistency across nosological systems in the conceptual framework and definition of the alcohol abuse category.

Adolescents are not adults: developmental considerations in alcohol users.

Much of the work in adolescent substance abuse assessment and treatment has been a direct transport from tools and modalities used in adult substance use populations. There was a consensus among symposium participants that developmental issues are important in assessment, evaluation, and treatment of adolescents with substance use disorders. These issues directly impact outcome at all levels. Presentations from the symposium may be helpful for conceptualizing the problems of adolescent substance use as well as formulating strategies for future research. Information from the symposium may be viewed as a springboard for future research and clinical intervention in adolescent substance abuse.

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.

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

OBJECTIVE: This study tested the ability of DSM-IV physiological alcohol dependence to predict multiple indices of medical problems and relapse behavior. It also tested the ability of three additional variables--DSM-IV nonphysiological dependence, an alternative dichotomous criterion for coding physiological dependence and a dimensional measure of physiological dependence--to predict medical problems and relapse behavior in alcoholism. METHOD: A heterogeneous group of 365 patients was recruited from eight addictions treatment programs in the northeastern United States. A multidimensional assessment battery able to diagnose the presence of physiological dependence according to each of three systems--the criteria of DSM-IV, alternative dichotomous criteria and a dimensional scale-- was administered about 2 weeks after admission, and 241 subjects were reinterviewed 6 months later. The three systems were compared for their ability to predict a variety of external measures of medical complications and relapse liability. RESULTS: Physiological alcohol dependence as diagnosed by DSM-IV bore no relationship to either risk for medical problems or relapse behavior. Further analyses showed that this failure was due to operational problems of physiological dependence in DSM-IV, rather than to a lack of conceptual merit for physiological dependence per se as a course specifier. Use of alternative criteria for coding physiological dependence which are difficult and less internally consistent, and use of a dimensional measure, found improved relationships with the external validators. CONCLUSIONS: Contrary to early reports, physiological dependence can serve as a course specifier for alcohol problems, but must be more sensitively scaled than it was in DSM-IV. Tests of alternative options suggest that a multistage criterion to replace DSM-IV's dichotomous criterion is the best remedy.

The comorbidity of alcoholism and personality disorders in a clinical population: prevalence rates and relation to alcohol typology variables.

This study assessed prevalence rates and overlap among Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; DSM-III-R; American Psychiatric Association, 1987) personality disorders in a multisite sample of 366 substance abusers in treatment. In addition, the relation of antisocial personality disorder (APD), borderline personality disorder (BPD), and paranoid personality disorder (PPD) to alcohol typology variables was examined. Structured diagnostic interviews and other measures were administered to participants at least 14 days after entry into treatment. Results indicated high prevalence rates for APD and non-APD disorders. There was extensive overlap between Axis I disorders and personality disorders, and among personality disorders themselves. APD, BPD, and PPD were linked to more severe symptomatology of alcoholism and other clinical problems. However, only APD and BPD satisfied subtyping criteria, after controlling for other comorbidity. Implications for classifying alcoholics by comorbid disorders are discussed.

Measuring diagnostic agreement.

Diagnostic agreement tests the reliability and concordance of diagnostic systems. The introduction of measures of agreement with reputations for baserate independence (e.g., Yule's Y and Q), and new studies occasioned by the publication of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) and the International Classification of Diseases--10 (ICD-10; World Health Organization, 1992) make it necessary to study the relationship of illness baserates to measures of agreement. Testing diagnostic concordance for diagnoses of drug dependence from the third edition of the DSM (American Psychiatric Association, 1980) versus DSM-IV diagnoses of drug dependence under 3 baserate conditions, it was found that Yule's Y and Q proved as vulnerable to differences in baserates as kappa or percent agreement and that specificity covaried with baserate rather than being fixed, as most theoretical discussions assume. The uncritical use of Y and Q, therefore, is likely to lead to optimistic interpretations of agreement. Kappa should be preferred for most purposes, although an adjustment to the computational formulas for Y and Q is presented that can diminish their positive bias.

Staging in the onset of DSM-IV alcohol symptoms in adolescents: survival/ hazard analyses.

OBJECTIVE: This research examined staging in the time to onset of DSM-IV alcohol symptoms in adolescents. Consistent staging in the onset of symptoms provides important tests of the construct validity of diagnostic systems, and aids the development of early case identification strategies. METHOD: The Structured Clinical Interview for the DSM (SCID), adapted to assess DSM-IV alcohol abuse and dependence symptoms, was used to determine time to symptom onset in 102 male and 97 female adolescent drinkers with and without alcohol use disorders. The sample provided a broad range of drinking practices and alcohol-related problems. Symptom onset patterns were examined using survival-hazard analyses. RESULTS: Survival and hazard data suggested three stages of alcohol problems distinguished by time to onset: heavy and heedless drinking with associated social and role obligation problems, psychological dependence, and withdrawal. This three-stage model fit both the male and female data, and described staging patterns in 70% of the subjects. CONCLUSIONS: The symptom onset model suggested a first stage of adolescent alcohol symptoms characterized by heavy and heedless drinking with associated interpersonal and role obligation problems. The data did not support the construct validity of DSM-IV alcohol abuse when applied to adolescents, and suggested staging among DSM-IV alcohol dependence symptoms. Implications for the diagnosis and early identification of adolescent alcohol problems are discussed.

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.

Alcohol treatment and health care system reform.

After reviewing the empirical literature, we suggest that advances in the assessment and treatment of alcohol problems have the following important implications for health care system reform: (1) alcohol use disorders and problems associated with alcohol use are prevalent and are complicated by various comorbid conditions, and they result in large costs to the health care system and to society; (2) alcohol treatment generally results in reduced drinking and more efficient use of health care resources; (3) specific treatments have demonstrated effectiveness; (4) screening and assessment instruments with excellent sensitivity to the heterogeneity of alcohol problems have been developed; (5) evidence that specific treatments have differential effectiveness with different patients groups is accumulating; and (6) good evidence exists for the effectiveness of brief interventions, particularly with less severe and chronic alcohol problems. These findings suggest that alcohol treatment services in a reformed health care system should include (1) universal coverage for alcohol treatment, including full benefits for outpatient care; (2) a rational system of assessment and triage for treatment, including an increased emphasis on screening and brief interventions in primary medical care settings; (3) a full range of treatment services that vary in intensity; and (4) addictions treatment provider incentives and contingencies to provide treatments of proven effectiveness. When fully implemented, an efficient approach to the treatment of alcohol-related problems will result in one of the largest pools of cost savings in a reformed American health care system.

On criterion weighting in the DSM-IV.

Differential weighting of illness signs and symptoms has surfaced recurrently in psychiatric nosology. Six alternately weighted algorithms for diagnosing alcohol dependence in accordance with the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), based on statistical, unit, rational and random criterion weighting systems, were used to predict an array of concurrent validators and 6-month drinking outcomes in a regional clinical sample of 365 participants. Comparable predictive efficiency across all algorithms, including the randomly weighted versus statistical best-fit model, was observed. Further analyses and geometric modeling suggested that this was due to the extremely high internal consistency of the DSM-IV criteria. An alternative strategy that favors factorially complex, less homogeneous criteria was used to develop an experimental DSM-IV algorithm from an array of 39 candidate criteria. This algorithm had extremely low internal consistency, high difficulty, and complex factor loadings. Differential weighting of its criteria produced a good range of efficiencies, predictive power for rational models exceeding the random weight model, and a best-fit algorithm with substantial surplus predictive power. These results illustrate an emerging conflict in nosology between 2 opposing trends: a press for the promulgation of criterion arrays with high internal consistency and a clear desire to assign some criteria extra weight for prognosis or decision making. Both cannot be had in the same algorithm. An alternative approach emphasizing diagnostic criteria with complex structures can satisfy the multiple demands of brevity, validity, and weighting performance.

DSM-III, DSM-IV and ICD-10 as severity scales for drug dependence.

The construct of illness severity serves many scientific and clinical functions. This study tested the performance as severity scales of three systems for diagnosing drug dependence--DSM-III, DSM-IV and ICD-10--in a multisite regional sample of 370 clinical subjects. Both lifetime and current severity of four drug problems--alcohol, cannabis, cocaine and opiate dependence--was studied in three stages: (a) item difficulty and internal consistency analysis; (b) probabilistic modeling of distribution behavior; and (c) concurrent validation against a set of independent measures. All three systems, for most drugs correlated with most test variables, had good to excellent concurrent validity. Unexpectedly, DSM-III showed in some instances better item behavior, composite score behavior and concurrent validity than the other systems, though DSM-IV and ICD-10 are based on slimmer generic algorithms, and may represent a good balance between simplicity and concurrent validity. Results suggest that the design of future diagnostic algorithms start at the item level and strive for moderate levels of both internal consistency and difficulty. Composite score distributions can then be modeled in field research, and necessary item corrections can be made before the algorithm is widely promulgated.

Onset and staging of DSM-IV alcohol dependence using mean age and survival-hazard methods.

Orderly onset of psychiatric symptoms has implications for both case detection and the construct validity of the underlying illness. Mean age and survival-hazard techniques were used to study the onset of alcohol abuse and dependence (as defined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association, 1994) in 369 clinical cases drawn from a heterogeneous regional sample. The methods provided a similar general pattern of symptom sequencing, though only survival-hazard analysis described a punctuated onset of alcoholism in 3 discrete stages: alcohol abuse, dependence, and accommodation to the illness. This model survived a rigorous program of tests for goodness of fit and described the majority of the sample, supporting the construct validity of both alcohol abuse as a discrete first illness phase and of dependence as a set of core constructs distinct from and succeeding abuse. The specific strengths of survival-hazard analysis as a research tool in illness staging research are discussed.

Diagnostic concordance of substance use disorders in DSM-III, DSM-IV and ICD-10.

Diagnostic concordance of DSM-III, DSM-IV and ICD-10 was tested in a heterogeneous unrestricted sample of 370 clinical cases drawn from a regional consortium. Agreement for abuse/harmful use, dependence, and the collapsed category of 'any diagnosis' was studied across eight drug classes. A probabilistic approach to the cross-classifications based on configural frequency analysis was applied, permitting the computation of four indices of agreement. In contrast to earlier studies, ICD-10 appeared to be the most inclusive system, and often diagnosed cases that were undiagnosed by both DSMs. Generally satisfactory coherence between the ICD-10 harmful use category and the DSM category of abuse was found, but this agreement was often due to a preponderance of negative or undiagnosed cases; disagreement was common on which cases in particular warrant a mild diagnosis. In general, the greatest diagnostic concordance was observed for sedative/hypnotics, opiates and alcohol, the poorest for amphetamines, cocaine and PCP. The analytic approach produced an array of cross-system relationships that are more complex and conditional than those previously reported, and scientists and clinicians are cautioned to study particular drugs, diagnostic levels and measures of concordance before applying cross-system results to their own data or design needs.