Combining Substance Abuse and Dependence Into One Disorder

Background. The basis of the criteria for DSM-III-R and DSM-IV substance dependence (Rounsaville et al., 1986) was the Alcohol Dependence Syndrome (Edwards and Gross, 1976), a dimensional construct representing impaired control over drinking that was generalized to drugs by the World Health Organization (Edwards et al., 1981). The dependence syndrome was described as a psychobiological process leading to impaired control over persistent, heavy drinking or drug use. The causes of dependence were considered different from the causes of substance-related consequences or disabilities, giving rise to a “bi-axial” concept of alcohol and drug disorders (Edwards & Gross, 1976), with dependence on one axis and consequences on the other. The bi-axial concept led to the DSM-III-R and DSM-IV disorders, dependence and abuse. Although Edwards assumed association between the two axes (Edwards & Gross, 1986), DSM-III-R and DSM-IV made dependence take precedence hierarchically over abuse. DSM-IV required that three of seven criteria be met for dependence, and one of four for abuse. 

Problems with the abuse/dependence distinction. Early signals of problems in the DSM-IV differentiation between abuse and dependence came from studies showing that while the test-retest reliability of DSM-IV dependence was uniformly very good to excellent, the reliability of DSM-IV abuse was lower and more variable (Hasin et al., 2006; Table 3). Many assumed that abuse was often a prodromal phase of dependence, but several prospective studies showed that this was not the case (Hasin et al., 1990, 1997; Grant et al., 2001; Schuckit et al., 2001; 2008). Further, general population studies showed that the most common way for DSM-IV alcohol abuse to be diagnosed was with a single criterion, hazardous use (generally driving after drinking) (Hasin et al., 1999; Hasin & Paykin, 1999). While certainly unwise and risky behavior, whether a psychiatric diagnosis is warranted based on this symptom alone is questionable. An additional problem with the DSM-IV division between abuse and dependence explicitly mentioned by several authors was that of “diagnostic orphans” (Hasin & Paykin, 1998; 1999; Pollack and Martin, 1999; Ray et al., 2008; Degenhardt et al., 2002; Lynskey & Agrawal, 2007; Martin et al., 2008), i.e., individuals who meet two criteria for dependence but none for abuse. Such individuals could have substance problems at the same severity level as others with a diagnosis, but were left undiagnosed by DSM-IV.  

Understanding the relationship of abuse and dependence criteria. Many analyses were conducted to better understand the relationship of abuse to dependence criteria. These included factor analytic studies, latent class analyses, and item response theory analyses.  

      Factor analyses. Several studies of alcohol abuse and dependence criteria in U.S. samples found significantly better fit for a two-factor model generally corresponding to abuse and dependence criteria (Harford and Muthen, 2001; Muthen et al., 1993; Muthen, 1995; Grant et al., 2007), but with the factors very highly correlated. Other studies using data from male Virginia twins (Gillespie et al., 2007), the National Epidemiologic Survey on Alcohol and Related Conditions) (Agrawal & Lynskey, 2007), and the Australian general population (Teesson et al., 2002) showed that both 1- and 2-factor models corresponding to cannabis dependence and abuse fit the data well, but preferred the 1-factor model due to highly correlated factors in the 2-factor model, with two studies (Teesson et al., 2002; Agrawal & Lynskey, 2007; Lynskey & Agrawal, 2007) dropping some abuse items to achieve unidimensionality. Using NLAES data (Blanco et al., 2007), two factors were also found for cannabis abuse and dependence criteria, also with a high correlation (.77) between the two factors. Among adolescents, a one-factor model fit the data well for alcohol (Gelhorn et al., 2008) and cannabis (Hartman et al., 2008). The high correlations between dependence and abuse raised questions about the utility of the two-factor solutions. 

      Latent class analyses. Latent class analysis (LCA) is used to identify homogeneous classes of individuals, and assign individuals to classes. LCA of DSM-IV abuse and dependence criteria using data from a large genetics study identified four classes (Bucholz et al., 1996) largely differentiated by successively greater endorsement probabilities for all criteria across classes. In heavy-drinking twins, four classes were found for women and five for men using DSM-IV dependence and abuse criteria (Lynskey et al., 2005). LCA results generally supported the idea of a gradient of severity for alcohol use disorders defined by the number of criteria, with inconsistent results on the presence (Lynskey et al., 2005) or absence (Bucholz, 1996) of a separate abuse class. For drug disorders, in both population-based (Grant et al., 2006; Agrawal et al., 2007) and treated adolescents (Chung & Martin, 2005), LCA identified classes based largely on severity.   

      Item Response Theory analyses: U.S. alcohol studies. When factor analysis identifies a unidimensional set of criteria, then Rasch and IRT models provide information on the severity level of individual criteria. IRT analyses show that alcohol abuse and dependence criteria were intermixed on an underlying spectrum of severity (Langenbucher et al., 2004; Kahler and Strong, 2006; Martin et al., 2006; Saha et al., 2006; Saha et al., 2007; Gelhorn et al., 2008) although some analyses required removal of criteria to achieve unidimensionality (Langenbucher et al., 2004; Saha et al., 2006). IRT analyses of alcohol problem scales (as distinct from diagnostic criteria) in various samples suggested similar structure (Krueger et al., 2004; Kahler et al., 2003a; Kahler et al., 2003b). An additional analysis using the “discontinuity” approach (Hasin & Beseler, 2009) produced findings consistent with the IRT results.  

      Item Response Theory analyses: international alcohol studies.  To understand how alcohol abuse and dependence criteria perform in international settings, Borges et al. (in press) conducted IRT analyses of data from patients attending 7 emergency rooms in 4 countries: Argentina, Mexico, Poland and the U.S. DSM-IV abuse and dependence formed a unidimensional continuum in the patients regardless of the country of survey. In IRT analyses of drinkers from an Australian general population sample (Proudfoot et al., 2008) for current criteria and in an Israeli general population data (Shmulewitz et al., under review) similar results were obtained within the same sample for current and lifetime criteria. 

      Item Response Theory analyses: drug abuse and dependence. Fewer IRT analyses have been conducted for drug use disorders, but these are generally consistent with the studies on alcohol, showing that drug abuse and dependence criteria were intermixed on an underlying spectrum of severity. These include studies of the cannabis abuse and dependence criteria in the NESARC (Compton et al., 2009), other substances in NESARC (Lynskey & Agrawal, 2007), cannabis use disorder symptoms in an American Indian community sample (Gilder et al., 2009), a twin study of several different substances (Gillespie et al., 2007), two adolescent cannabis studies (Martin et al., 2006; Hartman et al., 2008), and a study of alcohol, cannabis, cocaine and heroin abuse and dependence criteria in 663 adult patients in treatment for substance and psychiatric problems (Hasin et al., in preparation).

This large body of literature on the structure of abuse and dependence criteria in clinical and general population samples suggests that the DSM-IV abuse and dependence criteria can be considered to form a unidimensional structure, with abuse and dependence criteria interspersed across the severity spectrum. 

Summary and conclusion. Problems identified with the DSM-IV division between abuse and dependence led to many studies of the structure of the abuse and dependence in a variety of general population and clinical settings. Given the empirical evidence, the DSM-V Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity, with two criteria required to make a diagnosis. 1280 

Agrawal A, Lynskey MT. 2007. Does gender contribute to heterogeneity in criteria for cannabis abuse and dependence? Results from the National Epidemiological Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 88, 300-307.

Agrawal A, Lynskey MT, Madden PA, Bucholz KK, Heath AC. 2007. A latent class analysis of illicit drug abuse/dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction 102, 94-104.

Blanco C, Harford TC, Nunes E, Grant B., Hasin D. 2007. The latent structure of arijuana and cocaine use disorders: results from the National Longitudinal Alcohol Epidemiologic Survey (NLAES). Drug Alcohol Depend. 91, 91-96.

Borges G, Ye Y, Bond J, Cherpital CJ, Cremonte M, Moskalewicz J, Swiatkiewicz G, Rubio-Stipec M. In press. The dimensionality of alcohol use disorders and alcohol consumption in a cross-national perspective Short title: The dimensionality of alcohol use disorders. Addiction.

Bucholz K, Heath AC, Reich T, Hesselbrock VM, Kramer JR, Nurnberger JI Jr, Schuckit MA, 1996. Can we subtype alcoholism? A latent class analysis of data from relatives of alcoholics in a multicenter family study of alcoholism. Alcohol Clin. Exp. Res. 20,1462-1471.

Chung T, Martin CS 2005. Classification and short-term course of DSM-IV cannabis, hallucinogen, cocaine, and opioid disorders in treated adolescents. J. Consult. Clin. Psychol. 73, 995-1004.

Compton WM, Saha TD, Conway KP, Grant BF 2009. The role of cannabis use within a dimensional approach to cannabis use disorders. Drug Alcohol Depend. 100, 221-227.

Dawson DA, Saha TD, Grant BF. 2009. A multidimensional assessment of the validity and utility of alcohol use disorder severity as determined by item response theory models. In press, Drug Alcohol Depend.

Degenhardt L, Lynskey M, Coffey C, Patton G. 2002. Diagnostic orphans' among young adult cannabis users: persons who report dependence symptoms but do not meet diagnostic criteria. Drug Alcohol Depend. 67:205-12.

Edwards G, Arif A., Hadgson R. 1981. Nomenclature and classification of drug- and alcohol-related problems: a WHO memorandum. Bull. World Health Org. 59, 225-242.

Edwards G, Gross M. 1976. Alcohol dependence: provisional description of a clinical syndrome. Br. Med. J. 1, 1058-1061.

Edwards G. 1986. The Alcohol Dependence Syndrome: a concept as stimulus to enquiry. Br. J. Addict. 81, 171-183.

Gelhorn H, Hartman C, Sakai J, Stallings M, Young S, Rhee SH, Corley R, Hewitt J, Hopfer C, Crowley T. 2008. Toward DSM-V: an Item Response Theory analysis of the diagnostic process for alcohol abuse and dependence in DSM-IV. J. Amer. Acad. Child Adol. Psychiatry 47, 1329-1339.

Gilder DA, Lau P, Ehlers CL. 2009. Item response theory analysis of lifetime cannabis use disorder symptom severity in an American Indian community sample. J. Stud. Alc Drugs 70, 839-849.

Gillespie NA, Neale MC, Prescott CA, Aggen SH, Kendler KS, 2007.  Factor and item-response analysis DSM-IV criteria for abuse of and dependence on cannabis, cocaine, hallucinogens, sedatives, stimulants and opioids.  Addiction 102, 920-930.

Grant BF, Stinson FS, Harford TC, 2001. Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: a 12-year follow-up. J. Subst. Abuse 13, 493-504.

Grant BF, Harford TC, Muthen BO, Yi H-Y., Hasin DS, Stinson FS, 2007. DSM-IV alcohol dependence and abuse: further evidence of validity in the general population. Drug Alcohol Depend. 86,154-166.

Grant JD, Scherrer JF, Neuman RJ., Todorov AA, Price RK, Bucholz KK. 2006. A comparison of the latent class structure of cannabis problems among adult men and women who have used cannabis repeatedly. Addiction 101, 1133-1142.

Harford TC, Muthen BO, 2001. The dimensionality of alcohol abuse and dependence: a multivariate analysis of DSM-IV symptom items in the National Longitudinal Survey of Youth. J. Stud. Alcohol 62, 150-157.

Hartmen CA, Gelhorn H, Crowley TJ, Sakai JT, Stallings M, Young SE, Rhee SH, Corley R, Hewitt JK, Hopfer CJ. 2008. Item Response Theory analysis of DSM-IV cannabis abuse and dependence criteria in adolescents. J. Amer. Acad. Child Adol. Psychiatry 47, 165-173.

Hasin DS, Beseler CL 2009. Dimensionality of lifetime alcohol abuse, dependence and binge drinking. Drug Alcohol Depend 101:53-61.

Hasin D, Paykin A: DSM-IV 1999. Alcohol Abuse: investigation in a sample of at-risk drinkers in the community.  J Stud Alcohol 60: 181-187.

Hasin D, Paykin A, Endicott J, Grant B: 1999. The validity of DSM-IV alcohol abuse: drunk drivers vs all others. J Stud Alcohol, 60:746-755.

Hasin DS, Grant B, Endicott J, 1990.  The natural history of alcohol abuse: implications for definitions of alcohol use disorders. Am. J. Psychiatry 147, 1537-1541.

Hasin D, Van Rossem R, McCloud S, Endicott J, 1997a. Alcohol dependence and abuse diagnoses: validity in community sample heavy drinkers. Alcohol Clin. Exp. Res. 21, 213-219.

Hasin D, Paykin A: 1999. Dependence symptoms but no diagnosis: diagnostic “orphans” in a 1992 national sample. Drug Alch Dependence, 53:215-222

Hasin D, Paykin A: 1998. Dependence symptoms but no diagnosis: diagnostic “orphans” in a community sample. Drug Alch Dependence, 50:19-26

Hasin D, Paykin A: 1999. Dependence symptoms but no diagnosis: diagnostic “orphans” in a 1992 national sample. Drug Alch Dependence, 53:215-222

Kahler CW, Strong DR, Hayaki J, Ramsey SE, Brown RA. 2003a. An item response analysis of the alcohol dependence scale in treatment-seeking alcoholics.  Journal of Studies on Alcohol 64, 127–136.

Kahler CW, Strong DR, Stuart GL, Moorek TM, Ramsey SE. 2003b. Item functioning of the alcohol dependence scale in a high risk sample. Drug Alcohol Dependence 72, 183–192.

Kahler CW, Strong DR, 2006.  A Rasch model analysis of DSM-IV alcohol abuse and dependence items in the National Epidemiologic Survey on Alcohol and Related Conditions.  Alcohol. Clin. Exp. Res. 30, 1165-1175.

Kahler CW, Lachance HR, Strong DR,  Ramsey SE. Monti PM, Brown RA. 2007. The commitment to quitting smoking scale: initial validation in a smoking cessation trial for heavy social drinkers, Addictive Behavior. 32, 2420–2424.

Krueger RF, Nicol PE, Hicks BM, Markon KE, Patrick CJ, Iacono WG, Mague M, 2004.  Using latent trait modeling to conceptualize an alcohol problems continuum.  Psychol. Assess. 16, 107-119.

Langenbucher JW, Labouvie E, Martin CS, Sanjuan PM, Bavly L, Kirisci L, 2004.  An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV.  J. Abnorm. Psychol. 113, 72-80.

Lynskey MT, Agrawal A, 2007.  Psychometric properties of DSM assessment of illicit drug abuse and dependence:  results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).  Psychol. Med. 37, 1345-1355.

Lynskey M, Nelson EC, Neuman RJ, Bucholz KK, Madden PA, Knopik VS, Slutske W, Whitfield JB, Martin NG, Heath AC, 2005. Limitations of DSM-IV operationalizations of alcohol abuse and dependence in a sample of Australian twins. Twin Res. Hum. Genet. 8, 574-584.

Martin CS, Chung T, Kirisci L, Langenbucher JW, 2006.  Item response theory analysis of diagnostic criteria for alcohol and cannabis use disorders in adolescents:  implications for DSM-V.  J. Abnorm. Psychol. 115, 807-814.

Martin CS, Chung T, Langenbucher JW, 2008. How should we revise diagnostic criteria for substance use disorders in DSM-V? J Abnormal Psychology, Vol. 117, No. 3, 561–575.

Muthen BO, Grant B, Hasin D. 1993. The dimensionality of alcohol abuse and dependence: factor analysis of DSM-III-R and proposed DSM-IV criteria in the 1988 National Health Interview Survey.  Addiction 88, 1079-1090.

Muthen BO. 1995. Factor analysis of alcohol abuse and dependence symptom items in the 1988 National Health Interview survey. Addiction 90, 637-645.

Muthén B, Asparouhov T, 2006.  Item response mixture modeling:  application to tobacco dependence criteria.  Addict. Behav. 31, 1050-1066.

Pollock NK, Martin CS. Diagnostic orphans: adolescents with alcohol symptom who do not qualify for DSM-IV abuse or dependence diagnoses. Am J Psychiatry. 1999 Jun;156(6):897-901.

Proudfoot H., Baillie, A.J., Teesson, M., 2006.  The structure of alcohol dependence in the community.  Drug Alcohol Depend. 81, 21-26.

Ray LA, Miranda R Jr, Chelminski I, Young D, Zimmerman M. 2008. Diagnostic orphans for alcohol use disorders in a treatment-seeking psychiatric sample. Drug Alcohol Depend. 96:187-91.

Rounsaville BJ, Spitzer RL, Williams JB, 1986. Proposed changes in DSM-III substance use disorders: description and rationale. Am. J. Psychiatry 143, 463-468.

Saha TD, Chou SP, Grant BF, 2006.  Toward an alcohol use disorder continuum using item response theory:  results from the National Epidemiologic Survey on Alcohol and Related Conditions.  Psychol. Med. 36, 931-941.

Saha TD, Stinson FS, Grant BF, 2007.  The role of alcohol consumption in future classifications of alcohol use disorders.  Drug Alcohol Depend. 89, 82-92.

Schuckit M, Smith TL, Danko GP, Bucholz KK, Reich T, Bierut L, 2001. Five-year clinical course associated with DSM-IV alcohol abuse or dependence in a large group of men and women. Am. J. Psychiatry 158, 1084-1090.

Schuckit MA, Danko GP, Smith TL, Bierut LJ, Bucholz KK, Edenberg HJ, Hesselbrock V, Kramer J, Nurnberger JI Jr, Trim R, Allen R, Kreikebaum S, Hinga B. 2008. The prognostic implications of DSM-IV abuse criteria in drinking adolescents. Drug Alcohol Depend 97, 94-104.

Shmulewitz D, Keyes K, Beseler C, Aharonovich E, Aivadyan C, Spivak B, Hasin D. The alcohol use disorder continuum in Israel: Item Response Theory results. Under review.