Performance of a craving criterion in DSM alcohol use disorders

Validity of the DSM-5 craving criterion for alcohol, tobacco, cannabis, cocaine, heroin, and non-prescription use of prescription painkillers (opioids)

BACKGROUND

Although the DSM-5 was adopted in 2013, the validity of the new substance use disorder (SUD) diagnosis and craving criterion has not been investigated systematically across substances.

METHODS

Adults (N = 588) who engaged in binge drinking or illicit drug use and endorsed at least one DSM-5 SUD criterion were included. DSM-5 SUD criteria were assessed for alcohol, tobacco, cannabis, cocaine, heroin, and opioids. Craving was considered positive if "wanted to use so badly that could not think of anything else" (severe craving) or "felt a very strong desire or urge to use" (moderate craving) was endorsed. Baseline information on substance-related variables and psychopathology was collected, and electronic daily assessment queried substance use for the following 90 days. For each substance, logistic regression estimated the association between craving and validators, i.e. variables expected to be related to craving/SUD, and whether association with the validators differed for DSM-5 SUD diagnosed with craving as a criterion v. without.

RESULTS

Across substances, craving was associated with most baseline validators (p values<0.05); neither moderate nor severe craving consistently showed greater associations. Baseline craving predicted subsequent use [odds ratios (OR): 4.2 (alcohol) - 234.3 (heroin); p's ⩽ 0.0001], with stronger associations for moderate than severe craving (p's < 0.05). Baseline DSM-5 SUD showed stronger associations with subsequent use when diagnosed with craving than without (p's < 0.05).

CONCLUSION

The DSM-5 craving criterion as operationalized in this study is valid. Including craving improves the validity of DSM-5 SUD diagnoses, and clinical relevance, since craving may cause impaired control over use and development and maintenance of SUD.

The relationships between social media exposure, food craving, cognitive impulsivity and cognitive restraint

BACKGROUND

Young adults are increasingly exposed to social media and their image/video-based activities. They use these platforms to share images, videos and advice in different fields like food and nutrition with: recipe ideas, nutritional opinions or specific diets. Along with the rise of digital technologies, the prevalence of eating disorders in young adults continues to grow. The present study analyzes the psychological and eating processes through which exposure to social media may lead to the development of food craving and problematic eating behaviors.

METHODS

A total of 103 young adult men (n = 15) and women (n = 88) answered questionnaires measuring their impulsivity (Barratt Impulsiveness Scale), eating habits (Three-Factor Eating Questionnaire), food craving (Food Cravings Questionnaire-Trait-reduced), and time exposure to social media.

RESULTS

The results showed two significant serial mediations. We found a correlational link between time exposure to social media and food craving scores. This positive relation is indirectly mediated by cognitive impulsivity. We also found a positive correlation between cognitive impulsivity and food craving scores that was mediated by cognitive restraint.

CONCLUSION

A better understanding of the existing links between social media, food craving and eating behaviors such as cognitive restraint could help researchers and clinicians to better guide young adults in their use and appropriation of social media food contents.

Cocaine use disorder criteria in a clinical sample: an analysis using item response theory, factor and network analysis

BACKGROUND

The conceptualization of substance use disorders (SUDs) was modified in successive editions of the DSM. Dimensionality and inclusion/exclusion of several criteria was studied using various analytic approaches.

OBJECTIVE

The study aimed to deepen our knowledge of the interrelationships between the diagnostic criteria for cocaine use disorder (CUD), applying three different analytical techniques: factor analysis, Item Response Theory (IRT) models, and network analysis.

METHODS

425 (85.4% male) outpatients were evaluated for CUD using the Substance Dependence Severity Scale. Confirmatory Factor Analysis, 2-parameter logistic model (IRT) and network analysis were applied to analyze the relationships between the diagnostic criteria.

RESULTS

The results show that "legal problems" criterion is not congruent with the CUD measure on three analyses. Also, network analysis suggests the usefulness of the "craving" criterion. The criterion "quit/control" is the one that presents the best centrality indices and expected influence, showing strong relationships with the criteria of "craving," "tolerance," "neglect roles" and "activities given up."

CONCLUSIONS

Network analysis appears to be a useful and complementary technique to factor analysis and IRT for understanding CUD. The "quit/control" criterion emerges as a central criterion to understand CUD.

Reliability of Differential Item Functioning in Alcohol Use Disorder: Bayesian Meta-Analysis of Criteria Discrimination Estimates

Numerous studies leverage item response theory (IRT) methods to examine measurement characteristics of alcohol use disorder (AUD) diagnostic criteria. Less work has examined the consistency of AUD IRT parameter estimates, an essential step for establishing measurement invariance, making statements about symptom diagnosticity, and validating the theoretical construct. A Bayesian meta-analysis of IRT discrimination values for AUD criteria across 33 independent samples (Total N = 321,998) revealed that overall consistency of AUD criteria discriminations was low (generalized intraclass correlation range = .105-.249). However, specific study characteristics accounted for substantial variability, suggesting that the unreliability is partially systematic. We replicated evidence of differential item functioning (DIF) via established factors (e.g., age, gender), but the magnitudes were small compared with DIF associated with assessment instrument. These results offer practical recommendations regarding which instruments to use when specific AUD criteria are of interest and which criteria are most sensitive when comparing demographic groups.

Psychometric validation of an adaptation of the Penn Alcohol Craving Scale to assess aggregated drug craving

PURPOSE

Clinicians need a broad spectrum measurement of psychoactive substance craving (i.e., alcohol and/or drug) to assess collective treatment effects, especially in the context of polysubstance use. In three separate studies, we investigated the psychometric properties of an adapted version of the Penn Alcohol Craving Scale (PACS), designed to measure broad range substance craving.

DESIGN

In Study One, we examined the latent factor structure for craving, as well as concurrent validity with measures of frequency and severity of substance use. In Study Two, we examined the short-term test-retest reliability. In Study Three, we examined the long-term sensitivity to treatment effects at 12 month postdischarge.

SETTING

An inpatient SUD program in Guelph, Ontario, Canada.

PARTICIPANTS

Adult patients receiving treatment for SUD: Study One, n = 971; Study Two, n = 35; Study Three, n = 191.

MEASUREMENTS

We used an adapted version of the PACS, termed the Aggregated Drug Craving Scale (ADCS), and measures of substance use frequency, severity, and abstinence.

FINDINGS

In Study One, confirmatory factor analysis supported the unidimensional structure of the craving scale (CFI: 0.994, RMSEA: 0.071, SRMR: 0.010). In addition, statistically significant, medium effect size associations provided evidence of concurrent validity with measures of substance use frequency and severity (CFI = 0.992; RMSEA = 0.054; SRMR = 0.015). In Study Two, the ADCS demonstrated good agreement over two time points (ICC = 0.82), exhibiting acceptable short-term retest reliability. In Study 3, the mean craving score decreased significantly from 19.6 at baseline to 7.5 at 12-month follow-up (t = -18.48, p < 0.001), demonstrating an ability to detect long-term sensitivity to treatment effects (Cohen's d = -1.54).

CONCLUSIONS

Together, these findings provide initial support for a concise, broad-spectrum measure of aggregated drug cravings among an SUD treatment population.

The performance of DSM-5 alcohol use disorder and quantity-frequency of alcohol consumption criteria: An item response theory analysis

BACKGROUND

Maladaptive patterns of drinking are central to the development of AUD. However, no DSM-5 criteria ask about patterns of alcohol use, such as 5+/4+ binge drinking. It is important to examine whether such an item would improve the diagnostic utility of the DSM-5 instrument.

METHOD

Using a large representative sample of the US population, we used item response theory (IRT) methodology to examine the threshold, discrimination, and information value and differential criterion functioning of DSM-5 AUD criteria, along with a 5+/4+ drinking pattern criterion assessed at various levels of frequency.

RESULTS

The best fit drinking pattern criterion (defined at 5+/4+ drinking at least once a week in the past year) tapped the milder end of that continuum, which was similar to the criterion of drinking in larger amounts or for longer than intended. The new DSM-5 craving criterion was associated with mid-level values of threshold and discrimination. The AUD criteria with the addition of the 5+/4+ drinking pattern criterion demonstrated invariance across important subgroups of the population.

CONCLUSIONS

Among the criteria with the lowest level of threshold, the drinking pattern criterion has demonstrated its utility of the DSM-5 classification by identifying clinically significant but milder AUD cases. Along with its relationship to AUD relapse, the new craving criterion tapped the moderate levels of threshold and discrimination and thus, argues for its continued inclusion in the DSM-5 AUD formulation. Study results showed that DSM-5 AUD criteria and the 5+/4+ drinking pattern criterion formed a unidimensional continuum of AUD severity.

Item Response Theory analyses of DSM-5 substance use disorder criteria in French outpatient addiction clinic participants. How much is craving special?

BACKGROUND

To evaluate the dimensionality and psychometric validity of the 11 DSM-5 criteria for 5 substance use disorders, with a focus on craving, and taking into account age, gender and psychiatric comorbidities in a French sample of subjects seeking addiction treatment.

METHODS

This cross-sectional study, included participants with DSM-5 substance use disorders that sought treatment for at least one addiction from outpatient clinics. Diagnostic criteria were evaluated with the Mini international Neuropsychiatric Interview. In Current regular user (2 times per week), factor and 2-parameter IRT analysis was used to investigate the dimensionality and psychometric properties of the 11 DSM-5 SUD criteria. Differential Item and Test functioning (DIF and DTF) analysis were performed across sociodemographic characteristics and psychiatric disorders.

RESULTS

1359 participants (alcohol n = 787, opiates n = 131, cocaine n = 141, tobacco n = 1014, cannabis n = 504), were included (68% male; mean age 38.7). One-factor dimensionality was confirmed, except for tobacco. Craving criterion had the strongest factor loadings, lower difficulty (range, -1.29 to -0.67) and higher discrimination (range, 2.11-3.05), and no DIF compared to other criteria. The tobacco criteria set functioned differently by mood and anxiety disorders.

CONCLUSIONS

We confirmed the unidimensionality of the 11 SUD DSM-5 criteria and furthermore that craving was the most selective criterion because of its psychometric properties and no DIF compared to other criteria, regardless of the substance in this adult clinical sample. Unidimensionality of tobacco criteria was not confirmed, suggesting DSM-IV abuse criteria limitations as indicators of the construct.

Childhood Trauma and Two Stages of Alcohol Use in African American and European American Women: Findings from a Female Twin Sample

The current investigation assessed for moderating effects of childhood trauma on genetic and environmental contributions to timing of alcohol use initiation and alcohol use disorder in African American (AA) and European American (EA) women. Data were drawn from diagnostic telephone interviews conducted with 3786 participants (14.6% AA) in a longitudinal female twin study. Childhood trauma was defined alternately as child maltreatment and more broadly to include other events (e.g., witnessing violence). Phenotypic associations between childhood trauma and alcohol outcomes were estimated using logistic regression analyses. Twin modeling was conducted to test for moderating effects of childhood trauma on the contributions of genetic and environmental factors to timing of initiation and alcohol use disorder. Under both definitions, childhood trauma was associated with early initiation (relative risk ratios: 1.90, 1.72) and alcohol use disorder (odds ratios: 1.92, 1.76). Yet gene by environment effects were observed only for child maltreatment and timing of initiation in EA women, with heritable influences less prominent in those who had experienced child maltreatment (0.35, 95% CI: 0.05-0.66 vs. 0.52, 95% CI: 0.30-0.73). We found more similarities than differences in the association of childhood trauma with alcohol outcomes across racial/ethnic groups, trauma type, and stages of alcohol use. However, findings suggest that the relative contribution of genetic factors to alcohol outcomes differs by childhood maltreatment history in EA women specifically in the earliest stage of alcohol use.

Eating Behaviours and Food Cravings; Influence of Age, Sex, BMI and FTO Genotype

Previous studies indicate that eating behaviours and food cravings are associated with increased BMI and obesity. However, the interaction between these behaviours and other variables such as age, sex, BMI and genetics is complex. This study aimed to investigate the relationships between eating behaviours and food cravings, and to examine the influence of age, sex, body mass index (BMI) and fat mass and obesity-associated (FTO) genotype on these relationships. A total of 475 participants (252 female, 223 male, BMI: 25.82 ± 6.14 kg/m², age: 30.65 ± 14.20 years) completed the revised 18-question version of the Three Factor Eating Questionnaire (TFEQ-R18) to assess cognitive restraint, uncontrolled eating and emotional eating, and the Food Cravings Inventory (FCI) to assess cravings for fatty food, sweet food, carbohydrates and fast food. DNA samples were genotyped for the rs9939609 polymorphism in the obesity-linked gene FTO. Questionnaire data was analysed for associations between the TFEQ-R18 and FCI subscales for the whole study group, and the group divided by sex, genotype and age (≤25 years versus >25 years). Finally, mediation analysis was used to explore the relationships between BMI, cognitive restraint and food cravings. FTO AA + AT genotype was associated with increased BMI, but not with differences in eating behavior scores or food craving scores; age was associated with increased BMI and decreases in food craving scores in which this effect was stronger in women compared to men. Increased cognitive restraint was associated with decreased food craving scores in the ≤25 years group. Mediation analysis demonstrated that in this group the association between BMI and reduced food cravings was mediated by cognitive restraint indicating that in this age group individuals use cognitive restraint to control their food cravings. The positive correlation between age and BMI confirms previous results but the findings of this study show that age, sex, FTO genotype and BMI have an influence on the relationships between eating behaviours and food cravings and that these variables interact.

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 generalizability of the structure of substance abuse and antisocial behavioral syndromes: A systematic review

BACKGROUND

Although several authors have suggested that a single externalizing spectrum encompassing both antisocial behavioral syndromes and substance use disorder is to be preferred, this assumption has not been evaluated systematically throughout studies.

PURPOSE

The objective was to establish the generalizability of transdiagnostic models of externalizing disorders across different types of disorders and populations, in regard to the strength of the evidence.

METHOD

We conducted a systematic literature review using combinations of two sets of keywords: 1) "antisocial", "externalizing", "conduct disorder", "disruptive behavior disorder", "substance abuse", "substance-related disorder", "cannabis", "cocaine", "hallucinogen", "alcoholism", "opioid"; 2) "latent structure", "factor analysis", "multivariate analysis".

RESULTS

Models supporting a superordinate factor appeared dominant in a limited set of different populations, on which the majority of the research sample was focused.

CONCLUSIONS

Although the externalizing spectrum model is a promising angle for future research and treatment, extending research on this model in a higher diversity of populations is recommended to enhance the understanding and applicability of the externalizing spectrum model.

Alcohol Use Disorders in Argentinian Girls and Women 12 Months Before Delivery: Comparison of DSM-IV, DSM-5, and ICD-10 Diagnostic Criteria

BACKGROUND

The evidence of important problems related to prenatal alcohol exposure has faced researchers with the problem of understanding and screening alcohol use in this population. Although any alcohol use should be considered risky during pregnancy, identifying alcohol-drinking problems (ADPs) could be especially important because women with ADPs could not benefit from a simple advice of abstinence and because their offsprings are subjected to a higher risk of problems related with prenatal alcohol exposure. In this context, we aim to study the prevalence and characteristics of ADPs in pregnant women, evaluating the performance of different diagnostic systems in this population.

OBJECTIVES

The aims of the study were to describe the prevalence of ADPs obtained with the criteria of the Diagnostic and Statistical Manual of Mental Disorders in its fourth (DSM-IV) and fifth edition (DSM-5), and the International Classification of Diseases (ICD)-10, in Argentinean females aged 13 to 44 years, 12 months before delivery; to evaluate the level of agreement between these classification systems; and to analyze the performance of each diagnosis criterion in this population.

METHODS

Data were collected through personal interviews of a probability sample of puerperal women (N = 641) in the city of Santa Fe (Argentina), between October 2010 and February 2011. Diagnoses compatible with DSM-IV, DSM-5, and ICD-10 were obtained through the Composite International Diagnostic Interview. Agreement among diagnostic systems was measured through Cohen kappa. Diagnosis criteria performance were analyzed considering their prevalence and discriminating ability (D value).

RESULTS

Total ADP prevalence was 6.4% for DSM-IV (4.2% abuse and 2.2% dependence), 8.1% for DSM-5 (6.4% mild, 0.8% moderate, and 0.9% severe alcohol use disorder), and 14.1% for the ICD-10 (11.9% harmful use and 2.2% dependence). DSM-5 modifications improved agreement between DSM and ICD. The least prevalent and worst discriminating ability diagnostic criterion was "legal problems." The most prevalent and 1 of the best discriminating ability diagnostic criterion was '"health issues."

CONCLUSIONS

DSM-IV and ICD-10 dependence prevalence was similar to that of previous studies in pregnant women, whereas abuse prevalence was surprisingly higher. Our results indicate a better performance of the DSM-5 alcohol use disorder category relative to the DSM-IV dual categorization. Nevertheless, the poor diagnostic performance of some DSM-5 criteria in this population could evidence their intercultural variability.

Differences in childhood physical abuse reporting and the association between CPA and alcohol use disorder in European American and African American women

The goal of the current study was to examine whether the magnitude of the association between childhood physical abuse (CPA) and alcohol use disorder (AUD) varies by type of CPA assessment and race of the respondents. Data are from the Missouri adolescent female twins study and the Missouri family study (N = 4508) where 21.2% identified as African American (AA) and 78.8% as European American (EA); mean age = 23.8. Data were collected using a structured comprehensive interview which assessed CPA experiences using behavioral questions about specific abusive behaviors and trauma checklist items. Cox proportional hazards regression analyses were conducted, adjusting for additional risk factors associated with AUD, including co-occurring psychiatric disorders (defined as time-varying) and parental alcohol misuse. Overall, CPA reporting patterns were highly correlated (tetrachoric ρ = 0.73); although, only 25.8% of women who endorsed behaviorally defined CPA also endorsed checklist items whereas 72.2% of women who endorsed checklist items also endorsed behavioral questions. Racial disparities were evident, with behaviorally defined CPA increasing the hazard for AUD in EA but not AA women. Additional racial disparities in the risk for AUD were observed: increased hazard for AUD were associated with major depressive disorder in AA, and cannabis dependence and paternal alcohol problems in EA, women. Results demonstrate the relevance of the type of CPA measure in assessing CPA in studies of alcohol-related problems-behavioral items may be more inclusive of CPA exposure and more predictive of AUD- and highlight racial distinctions of AUD etiology in women. (PsycINFO Database Record

Prevalence of 'Food Addiction' as Measured with the Yale Food Addiction Scale 2.0 in a Representative German Sample and Its Association with Sex, Age and Weight Categories

BACKGROUND/AIMS

To assess the prevalence and correlates of addictive-like eating behavior in Germany.

METHODS

The German version of the Yale Food Addiction Scale (YFAS) 2.0 was used to investigate, for the first time, the prevalence of 'food addiction' in a representative sample aged 18-65 years (N = 1,034).

RESULTS

The prevalence of 'food addiction' measured by the YFAS 2.0 was 7.9%. Individuals meeting criteria for 'food addiction' had higher BMI and were younger than individuals not meeting the threshold. Underweight (15.0%) and obese (17.2%) individuals exhibited the highest prevalence rate of 'food addiction'. Addictive-like eating was not associated with sex, education level, or place of residence.

CONCLUSION

YFAS 2.0 'food addiction' was met by nearly 8% of the population. There is a non-linear relationship between addictive-like eating and BMI, with the highest prevalence among underweight and obese persons. These findings suggest that 'food addiction' may be a contributor to overeating but may also reflect a distinct phenotype of problematic eating behavior not synonymous with obesity. Further, the elevated prevalence of YFAS 2.0 'food addiction' among underweight individuals may reflect an overlap with eating disorders and warrants attention in future research.

The dimensionality of DSM5 alcohol use disorder in Puerto Rico

AIMS TO

Test the dimensionality and measurement properties of lifetime DSM-5 AUD criteria in a sample of adults from the metropolitan area of San Juan, Puerto Rico.

DESIGN

Cross-sectional study with survey data collected in 2013-2014.

SETTING

General population.

PARTICIPANTS

Random household sample of the adult population 18 to 64years of age in San Juan, Puerto Rico (N=1510; lifetime drinker N=1107).

MEASUREMENT

DSM-5 alcohol use disorder (2 or more criteria present in 12months).

RESULTS

Lifetime reports of AUD criteria were consistent with a one-dimensional model. Scalar measurement invariance was observed across gender, but measurement parameters for tolerance varied across age, with younger ages showing a lower threshold and steeper loading.

CONCLUSIONS

Results provide support for a unidimensional DSM-5 AUD construct in a sample from a Latin American country.

Gender and Alcohol Use Disorders Diagnostic Criteria in Emergency Department Patients of Argentina

BACKGROUND

Alcohol consumption and its related consequences are not equal for women and men, although related studies do not frequently include gender analysis.

OBJECTIVE

Our aim was to characterize differences in endorsement of ICD-10 and DSM 5 alcohol use disorder (AUD) criteria by gender in an Argentinean emergency department population.

METHODS

A probability sample of patients (N = 923) from the largest emergency department in the city of Mar del Plata, Argentina (44% were females, aged 16 to 86, M (SD) = 37.31(15.20) was collected. Using a structured questionnaire, diagnostic criteria for alcohol use disorders, alcohol consumption, and socio-demographic variables were obtained. Bivariate and multivariate analyses were used to assess differences in the endorsement of each diagnostic criterion by gender.

RESULTS

Women were less likely to endorse each of the criteria for each of the diagnostic schemes. Even after controlling alcohol consumption, socio-demographic variables, severity of alcohol use disorders and adjusting for multiple comparisons females had a lower probability than males of endorsing withdrawal and impaired control.

CONCLUSIONS

gender differences in the endorsement of diagnostic criteria for both the DSM 5 and ICD-10 were found. Some differences in endorsement but not all, might be partially explained by alcohol consumption patterns and socio-demographic factors, and same remained after controlling severity of the AUD. Results also suggest a differential functioning of DSM 5 and ICD-10 AUD criteria for women and men.

Association of Specific Traumatic Experiences With Alcohol Initiation and Transitions to Problem Use in European American and African American Women

BACKGROUND

The aims of this study were to (i) characterize racial differences in alcohol involvement and (ii) examine the risk conferred by specific trauma exposures and posttraumatic stress disorder (PTSD) for different stages of alcohol involvement in European American (EA) and African American (AA) women.

METHODS

Data are from the Missouri Adolescent Female Twins Study (N = 3,787, 14.6% AA; mean age at most recent interview = 24.5 [SD 2.8]). Trauma exposures (e.g., sexual abuse [SA], physical abuse [PA], witnessing another person being killed or injured, experiencing an accident, and experiencing a disaster) were modeled as time-varying predictors of alcohol initiation, transition to first alcohol use disorder (AUD) symptom, and transition to AUD diagnosis using Cox proportional hazards regression while taking into account other substance involvement, parental characteristics, and commonly co-occurring psychiatric disorders.

RESULTS

In EA women only, SA was associated with alcohol initiation prior to the age of 14, PA predicted transition from initiation to first AUD symptom, and PA, witnessing injury or death, and SA predicted transition to AUD diagnosis. No association was discovered between trauma exposures or PTSD for any stage of alcohol involvement in AA women.

CONCLUSIONS

Results reveal trauma experiences as important contributors to all stages of alcohol involvement in EA women only, with different trauma types conferring risk for each stage of alcohol involvement. PTSD was not revealed as a significant predictor of AUD in EA or AA women, suggesting trauma, independent of PTSD, directly contributes to alcohol involvement. Findings highlight the importance of considering racial differences when developing etiologic models of the association of traumatic experiences with alcohol involvement.

Largely overlapping neuronal substrates of reactivity to drug, gambling, food and sexual cues: A comprehensive meta-analysis

Cue reactivity to natural and social rewards is essential for motivational behavior. However, cue reactivity to drug rewards can also elicit craving in addicted subjects. The degree to which drug and natural rewards share neural substrates is not known. The objective of this study is to conduct a comprehensive meta-analysis of neuroimaging studies on drug, gambling and natural stimuli (food and sex) to identify the common and distinct neural substrates of cue reactivity to drug and natural rewards. Neural cue reactivity studies were selected for the meta-analysis by means of activation likelihood estimations, followed by sensitivity and clustering analyses of averaged neuronal response patterns. Data from 176 studies (5573 individuals) suggests largely overlapping neural response patterns towards all tested reward modalities. Common cue reactivity to natural and drug rewards was expressed by bilateral neural responses within anterior cingulate gyrus, insula, caudate head, inferior frontal gyrus, middle frontal gyrus and cerebellum. However, drug cues also generated distinct activation patterns in medial frontal gyrus, middle temporal gyrus, posterior cingulate gyrus, caudate body and putamen. Natural (sexual) reward cues induced unique activation of the pulvinar in thalamus. Neural substrates of cue reactivity to alcohol, drugs of abuse, food, sex and gambling are largely overlapping and comprise a network that processes reward, emotional responses and habit formation. This suggests that cue-mediated craving involves mechanisms that are not exclusive for addictive disorders but rather resemble the intersection of information pathways for processing reward, emotional responses, non-declarative memory and obsessive-compulsive behavior.

Gender-related Differences in Food Craving and Obesity

Food craving is often defined as a strong desire to eat. Much work has shown that it consistently and prospectively predicts eating and weight-related outcomes, contributing to the growing obesity epidemic. Although there are clear gender differences in the prevalence and health consequences of obesity, relatively little recent work has investigated gender differences in craving, or any sex-hormone-based differences as they relate to phases of the menstrual cycle. Here, we propose that gender-related differences in food craving contribute to gender-related differences in obesity. Drawing on findings in the addiction literature, we highlight ways to incorporate gender-based differences in food craving into treatment approaches, potentially improving the efficacy of obesity and weight loss treatment. Overall, this review aims to emphasize the importance of investigating gender differences in food craving, with a view towards informing the development of more effective treatments for obesity and weight loss.

Meta-analysis of DSM alcohol use disorder criteria severities: structural consistency is only 'skin deep'

BACKGROUND

Item response theory (IRT) analyses of alcohol use disorder (AUD) and other psychological disorders are a predominant method for assessing overall and individual criterion severity for psychiatric diagnosis. However, no investigation has established the consistency of the relative criteria severities across different samples.

METHOD

PubMed/Medline, PsycINFO, Web of Science and ProQuest databases were queried for entries relating to alcohol use and IRT. Study data were extracted using a standardized data entry sheet. Consistency of reported criteria severities across studies was analysed using generalizability theory to estimate generalized intraclass correlations (ICCs).

RESULTS

A total of 451 citations were screened and 34 papers (30 unique samples) included in the research synthesis. The AUD criteria set exhibited low consistency in the ordering of criteria using both traditional [ICC = 0.16, 95% confidence interval (CI) 0.06-0.56] and generalized (ICC = 0.18, 95% CI 0.15-0.21) approaches. These results were partially accounted for by previously studied factors such as age and type of sample (e.g. clinical v. community), but the largest source of unreliability was the diagnostic instrument employed.

CONCLUSIONS

Despite the robust finding of unidimensional structure of AUDs, inconsistency in the relative severities across studies suggests low replicability, challenging the generalizability of findings from any given study. Explicit modeling of well-studied factors like age and sample type is essential and increases the generalizability of findings. Moreover, while the development of structured diagnostic interviews is considered a landmark contribution toward improving psychiatric research, variability across instruments has not been fully appreciated and is substantial.

Nosologic Comparisons of DSM-IV and DSM-5 Alcohol and Drug Use Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III

OBJECTIVE

The purpose of this study was to examine prevalences and concordances between Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and Fifth Edition (DSM-5) substance use disorders (SUDs) in a newly completed U.S. epidemiologic survey.

METHOD

The National Epidemiologic Survey on Alcohol and Related Conditions-III surveyed 36,309 civilian, noninstitutionalized adults. SUDs were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Concordances between DSM-IV and DSM-5 disorders were assessed using kappa statistics.

RESULTS

Prevalences of past-year substance-specific DSM-5 disorders (2+ criteria) were modestly higher than those of DSM-IV dependence and abuse combined for alcohol, sedatives/tranquilizers, opioids, and heroin, but lower for cannabis, cocaine, and stimulants. Lifetime prevalences were lower under DSM-5. Prevalences were similar between moderate to severe (4+ criteria) DSM-5 disorders and dependence, whereas prevalences of DSM-5 disorders at 3+ criteria (DSM-5 [3+]) were higher, particularly for cannabis. Past-year concordances were excellent for DSM-IV dependence and abuse combined versus any DSM-5 and DSM-IV dependence versus DSM-5 moderate to severe disorders; lifetime concordances were fair to excellent. Past-year concordances between DSM-IV and DSM-5 (3+) were generally similar to or modestly higher than those with any DSM-5 disorder; lifetime concordances were mostly lower.

CONCLUSIONS

Findings are consistent with those informing the development of DSM-5. Future research should examine differences in patterns between past-year and lifetime disorders, particularly for cannabis. Other questions warranting investigation include whether different combinations of the same numbers of criteria carry different clinical or nosologic implications, whether changes innosology yield changes in treatment demand, and whether changes in characteristics of individuals with DSM-5 SUDs dictate modifications to screening and intervention.

Alcohol Effects on Stress Pathways: Impact on Craving and Relapse Risk

A significant amount of neurobiological research regarding the development of alcohol use disorders (AUDs) has focused on alcohol-related activation and long-term alterations in the mesocortical dopaminergic reward pathways. However, alcohol does not only interact with brain reward systems. Many of its acute and chronic effects may be related to allostatic adaptations in hypothalamic and extrahypothalamic stress regulation pathways. For example, acute binge intoxication is associated with hypothalamically driven increases in blood cortisol, norepinephrine, and sex steroid metabolite levels. This may contribute to the development of mesocortical sensitization to alcohol. Furthermore, chronic alcohol exposure is associated with systemic dysregulation of the hypothalamic pituitary adrenal axis, sympathetic adrenal medullary system, and sex steroid systems. This dysregulation appears to manifest as neuroendocrine tolerance. In this review, we first summarize the literature suggesting that alcohol-induced alterations in these hypothalamic systems influence craving and contribute to the development of AUDs. We note that for women, the effects of alcohol on these neuroendocrine stress regulation systems may be influenced by the rhythmic variations of hormones and steroids across the menstrual cycle. Second, we discuss how changes in these systems may indicate progression of AUDs and increased risk of relapse in both sexes. Specifically, neuroendocrine tolerance may contribute to mesocortical sensitization, which in turn may lead to decreased prefrontal inhibitory control of the dopaminergic reward and hypothalamic stress systems. Thus, pharmacological strategies that counteract alcohol-associated changes in hypothalamic and extrahypothalamic stress regulation pathways may slow the development and progression of AUDs.

Commonalities and Differences Across Substance Use Disorders: Phenomenological and Epidemiological Aspects

BACKGROUND

Although psychoactive substances vary in many ways, they have important commonalties, particularly in their ability to lead to an addiction syndrome. The field lacks an updated review of the commonalities and differences in the phenomenology of alcohol, cannabis, tobacco, stimulants, opioids, hallucinogens, sedatives/tranquilizers, and inhalants and their related substance use disorders (SUDs).

METHODS

DSM-IV and DSM-5 SUD diagnostic criteria were reviewed, as was evidence from recent epidemiological and clinical research: psychometric studies (test-retest reliability, latent trait analysis); physiological indicators (tolerance, withdrawal); prevalence and age of onset. Information was incorporated from previous reviews, PubMed and Scopus literature searches, and data from large U.S. national surveys.

RESULTS

Empirical evidence in the form of test-retest reliability and unidimensionality supports use of the same DSM-IV dependence or DSM-5 SUD diagnostic criteria across substances. For most substances, the criteria sets were generally most informative in general population samples at moderate-to-severe levels of SUD. Across substances, 2 criteria (tolerance and use in hazardous situations) were identified as functioning differently in population subgroups. Since substances have different pharmacological effects, withdrawal is assessed using substance-specific symptoms, while tolerance is not; issues remain with the assessment of tolerance. Alcohol, tobacco, and cannabis were consistently identified as the substances with earliest onset of use, highest prevalence of lifetime use, and highest prevalence of lifetime disorder.

CONCLUSIONS

Despite differences between psychoactive substances, the generic DSM criteria set appears equally applicable across substances. Additional studies of tolerance and hazardous use will be useful for future nosologies. Alcohol, cannabis, and tobacco are the substances with the greatest public health impact due to the high prevalence and early onset of their use, and the potential all 3 substances have to lead to addiction.

Limits of Current Approaches to Diagnosis Severity Based on Criterion Counts: An Example with DSM-5 Alcohol Use Disorder

Within DSM-5, some diagnoses are now associated with a severity gradient based on the number of diagnostic criteria satisfied. Reasons for questioning the validity of this approach include the implicit assumptions of equal criterion severity and strict additivity of criteria combinations. To assess the implications of heterogeneity of criterion configurations on severity grading, we examined the association between all observed combinations of DSM-5 alcohol use disorder criteria endorsement, at each level of number of criteria endorsed, and multiple validity measures among 22,177 past-year drinkers from Wave 2 of the NESARC. Substantial variability of implied severity across criteria combinations was observed at each level of endorsement, with nontrivial overlap in implied severity across criterion counts. Findings suggest severity indices are at best imprecise and, potentially, misleading. These problems are likely inherent in traditional polythetic approaches to diagnosis and almost certainly applicable to other disorders. Approaches for improving severity grading are proposed.

Dimensionality and stages of severity of DSM-5 criteria in an international sample of alcohol-consuming individuals

INTRODUCTION

The DSM-5 alcohol use disorder (AUD) criteria proposal contains 11 criteria that include most of the DSM-IV abuse and dependence criteria plus craving. The aims of the current study in a large and international alcohol-consuming sample were to confirm the dimensionality of the DSM-5 AUD criteria and to differentiate grades of severity of DSM-5 AUD in subjects who pass the proposed DSM-5 diagnostic threshold of two criteria.

METHOD

We used the World Health Organization (WHO)/International Society on Biomedical Research on Alcoholism (ISBRA) Study on State and Trait Markers of Alcohol Use and Dependence dataset. Subjects included in the analyses were aged ≥ 18 years and were recruited in five countries: Australia, Brazil, Canada, Finland and Japan. Assessment of AUD and additional characteristics was conducted using an adapted version of the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS). Dimensionality of the DSM-5 criteria was evaluated using factor analysis and item response theory (IRT) models. The IRT results led to the classification of AUD patients into three severity groups. External validators were used to differentiate statistically across subgroups.

RESULTS

A total of 1424 currently drinking individuals were included in the analyses. Factor and IRT analyses confirmed the dimensional structure of DSM-5 AUD criteria. More than 99% of the subjects could be allocated to one of the suggested severity subgroups. The magnitude of the external validators differed significantly across the severity groups.

CONCLUSIONS

The results confirm the dimensional structure of the proposed DSM-5 AUD criteria. The suggested stages of severity (mild, moderate and severe) may be useful to clinicians by grouping individuals not only in the mild but also in the moderate to severe spectrum of DSM-5 AUD.

Pharmacological approaches to reducing craving in patients with alcohol use disorders

Research on the concept of craving may lead to better understanding of the biobehavioural circuitries that contribute to the complexity of alcohol use disorders (AUDs). The experiences described as craving or desire to drink are often associated with physical responses such as increased salivation and heart rate, and alteration of stress hormones, as well as psychological responses such as anxiety and depression. Greater craving has been associated with an increased probability of alcohol relapse. Reversal of craving, which is understood as a symptom of protracted abstinence, offers the possibility of preventing relapses and treating alcoholism. Various medications have been studied to establish whether they are able to reduce craving; however, the results obtained from clinical studies have been inconsistent. Here, we review the interdisciplinary models developed to evaluate craving, then the different approaches used to assess and measure craving and, finally, the medications utilized and tested to lessen craving in patients suffering from AUDs.

Comparing factor, class, and mixture models of cannabis initiation and DSM cannabis use disorder criteria, including craving, in the Brisbane longitudinal twin study

Accumulating evidence suggests that the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for cannabis abuse and dependence are best represented by a single underlying factor. However, it remains possible that models with additional factors, or latent class models or hybrid models, may better explain the data. Using structured interviews, 626 adult male and female twins provided complete data on symptoms of cannabis abuse and dependence, plus a craving criterion. We compared latent factor analysis, latent class analysis, and factor mixture modeling using normal theory marginal maximum likelihood for ordinal data. Our aim was to derive a parsimonious, best-fitting cannabis use disorder (CUD) phenotype based on DSM-IV criteria and determine whether DSM-5 craving loads onto a general factor. When compared with latent class and mixture models, factor models provided a better fit to the data. When conditioned on initiation and cannabis use, the association between criteria for abuse, dependence, withdrawal, and craving were best explained by two correlated latent factors for males and females: a general risk factor to CUD and a factor capturing the symptoms of social and occupational impairment as a consequence of frequent use. Secondary analyses revealed a modest increase in the prevalence of DSM-5 CUD compared with DSM-IV cannabis abuse or dependence. It is concluded that, in addition to a general factor with loadings on cannabis use and symptoms of abuse, dependence, withdrawal, and craving, a second clinically relevant factor defined by features of social and occupational impairment was also found for frequent cannabis use.

DSM-5 latent classes of alcohol users in a population-based sample: results from the São Paulo Megacity Mental Health Survey, Brazil

BACKGROUND

We aimed to identify different categorical phenotypes based upon the DSM-V criteria of alcohol use disorders (AUD) among alcohol users who had at least one drink per week in the past year (n=948).

METHODS

Data are from the São Paulo Megacity Mental Health Survey collected in 2005-2007, as part of the World Mental Health Survey Initiative. A latent class analysis of the 11 DSM-5-AUD criteria was performed using Mplus, taking into account complex survey design features. Weighted logistic regression models were used to examine demographic correlates of the DSM-5-AUD latent classes.

RESULTS

The best latent-class model was a three-class model. We found a "non-symptomatic class" (69.7%), a "use in larger amounts class" (23.2%), defined by high probability (>70%) of the "use in larger amounts" criterion only, and a "high-moderate symptomatic class" (7.1%), defined by high-moderate probability of all the 11 AUD criteria. Compared to those in the non-symptomatic class, individuals in the "high-moderate symptomatic class" were more likely to have been married, have lower educational attainment and to be unemployed or in non-regular/informal employment. Those on the "use in larger amounts class" were more likely to have been married or never married.

CONCLUSION

The two symptomatic classes clearly represented the dimensionality of the new proposed AUD criteria, and could be more specifically targeted by different prevention or treatment strategies. DSM-5-AUD has the advantage of shedding light on risky drinkers included in the "use in larger amounts class", allowing for preventive interventions, which will reach a large number of individuals.

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.

Genetic influences on craving for alcohol

INTRODUCTION

Craving is being considered for inclusion in the Diagnostic and Statistical Manual (DSM) DSM-5. However, little is known of its genetic underpinnings - specifically, whether genetic influences on craving are distinct from those influencing DSM-IV alcohol dependence.

METHOD

Analyses were conducted in a sample of unrelated adults ascertained for alcohol dependence (N=3976). Factor analysis was performed to examine how alcohol craving loaded with the existing DSM-IV alcohol dependence criteria. For genetic analyses, we first examined whether genes in the dopamine pathway, including dopamine receptor genes (DRD1, DRD2, DRD3, DRD4) and the dopamine transporter gene (SLC6A3), which have been implicated in neurobiological studies of craving, as well as alpha-synuclein (SNCA), which has been previously found to be associated with craving, were associated with alcohol craving in this sample. Second, in an effort to identify novel genetic variants associated with craving, we conducted a genomewide association study (GWAS). For variants that were implicated in the primary analysis of craving, we conducted additional comparisons - to determine if these variants were uniquely associated with alcohol craving as compared with alcohol dependence. We contrasted our results to those obtained for DSM-IV alcohol dependence, and also compared alcohol dependent individuals without craving to non-dependent individuals who also did not crave alcohol.

RESULTS

Twenty-one percent of the full sample reported craving alcohol. Of those reporting craving, 97.3% met criteria for DSM-IV alcohol dependence with 48% endorsing all 7 dependence criteria. Factor analysis found a high factor loading (0.89) for alcohol craving. When examining genes in the dopamine pathway, single nucleotide polymorphisms (SNPs) in DRD3 and SNCA were associated with craving (p<0.05). There was evidence for association of these SNPs with DSM-IV alcohol dependence (p<0.05) but less evidence for dependence without craving (p>0.05), suggesting that the association was due in part to craving. In the GWAS, the greatest evidence of association with craving was for a SNP in the integrin alpha D (ITGAD) gene on chromosome 7 (rs2454908; p=1.8×10(-6)). The corresponding p-value for this SNP with DSM-IV alcohol dependence was similar (p=4.0×10(-5)) but was far less with dependence without craving (p=0.02), again suggesting the association was due to alcohol craving. Adjusting for dependence severity (number of endorsed criteria) attenuated p-values but did not eliminate association.

CONCLUSIONS

Craving is frequently reported by those who report multiple other alcohol dependence symptoms. We found that genes providing evidence of association with craving were also associated with alcohol dependence; however, these same SNPs were not associated with alcohol dependence in the absence of alcohol craving. These results suggest that there may be unique genetic factors affecting craving among those with alcohol dependence.

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.

Scaling properties of the combined ICD-10 dependence and harms criteria and comparisons with DSM-5 alcohol use disorder criteria among patients in the emergency department

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), alcohol use disorders (AUDs) classifications offer competing and somewhat overlapping diagnostic tools for assessing alcohol dependence and harms/abuse. Both systems are in active stages of development in anticipation of their next respective iterations. Although much psychometric work has been done studying DSM-IV criteria, efforts toward the ICD-11 have been less prevalent.

METHOD

Data from 3,191 drinkers in seven emergency department sites in four countries (United States, Mexico, Argentina, and Poland) were used to study the psychometric properties of the combined ICD-10 dependence and harms criteria. Comparisons with the proposed set of DSM-5 criteria and diagnostic thresholds are also included.

RESULTS

Item response theory analyses of the combined ICD-10 dependence and harms criteria suggested a single underlying factor, both overall and for each site separately, with only moderate differential item functioning across sites. Overall agreement between the summative combined ICD-10 dependence and harms criteria and the proposed 11-criteria DSM-5 scale was very high (r = .97), as was agreement between proposed diagnostic threshold levels of 0-1 (negative AUD), 2-3 (moderate AUD), and 4 or more (severe AUD) criteria endorsed (κ = .84). Although disagreement between the two three-level diagnoses was only 5.5% of the sample, a majority of these were because of differences between endorsement rates of abuse versus harms criteria.

CONCLUSIONS

Although there is support for efforts to align the two schemes, results are consistent with other studies finding the largest differences between the two systems emanating from differences between the abuse and harms domains. More research is needed before differences between the two systems can be reconciled.

Analyses related to the development of DSM-5 criteria for substance use related disorders: 2. Proposed DSM-5 criteria for alcohol, cannabis, cocaine and heroin disorders in 663 substance abuse patients

BACKGROUND

A number of changes have been proposed and investigated in the criteria for substance use disorders in DSM-5. However, although clinical utility of DSM-5 is a high priority, relatively little of the empirical evidence supporting the changes was obtained from samples of substance abuse patients.

METHODS

Proposed changes were examined in 663 patients in treatment for substance use disorders, evaluated by experienced clinicians using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM). Factor and item response theory analysis was used to investigate the dimensionality and psychometric properties of alcohol, cannabis, cocaine and heroin abuse and dependence criteria, and craving.

RESULTS

The seven dependence criteria, three of the abuse criteria (hazardous use; social/interpersonal problems related to use; neglect of roles to use), and craving form a unidimensional latent trait for alcohol, cannabis, cocaine and heroin. Craving did not add significantly to the total information offered by the dependence criteria, but adding the three abuse criteria and craving together did significantly increase total information for the criteria sets associated with alcohol, cannabis and heroin.

CONCLUSION

Among adult patients in treatment for substance disorders, the alcohol, cannabis, cocaine and heroin criteria for dependence, abuse (with the exception of legal problems), and craving measure a single underlying dimension. Results support the proposal to combine abuse and dependence into a single diagnosis in the DSM-5, omitting legal problems. Mixed support was provided for the addition of craving as a new criterion, warranting future studies of this important construct in substance use disorders.

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.

DSM-IV to DSM-5: the impact of proposed revisions on diagnosis of alcohol use disorders

AIMS

To determine the prevalence of past 12-month DSM-5 alcohol use disorders (AUDs), to quantify and characterize individuals who remain stably unaffected or affected and those who 'switch' diagnostically between DSM-IV and DSM-5 classifications.

DESIGN

Data from the nationally representative wave 2 of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) collected in 2004-05.

SETTING

General population survey.

PARTICIPANTS

All surveyed participants (n=34,653, aged 21 years and older) and 29,993 individuals reporting life-time alcohol use across both waves of NESARC.

MEASUREMENTS

DSM-IV and DSM-5 criteria were coded using proposed guidelines.

FINDINGS

The prevalence of DSM-5 AUDs was 10.8% with the corresponding prevalence of DSM-IV abuse/dependence being 9.7%, implying a modest 11.3% increase. Those who switched diagnostically from affected to unaffected (19.6% of DSM-IV affected) were most likely to have endorsed hazardous use, due particularly to drinking and driving, while those who transitioned from unaffected to affected (3.3% of DSM-IV unaffected) were primarily DSM-IV diagnostic orphans reporting larger/longer and quit/cut-back. Dropping the legal criterion did not affect the prevalence significantly, while the addition of craving also had a relatively modest impact on prevalence.

CONCLUSION

The proposed DSM-5 revisions eliminate successfully individuals diagnosed previously with DSM-IV alcohol abuse due primarily to hazardous use alone and incorporate diagnostic orphans into the diagnostic realm. Definitions of craving and importantly, hazardous use require considerable attention as it is likely that they will contribute to variations in reports of increased prevalence of alcohol use disorders between DSM-IV to DSM-5.

Nicotine dependence, abuse and craving: dimensionality in an Israeli sample

AIMS

Evidence-based changes planned for Diagnostic and Statistical Manual 5th edition (DSM-5) substance use disorders (SUDs) include combining dependence and three of the abuse criteria into one disorder and adding a criterion indicating craving. Because DSM-IV did not include a category for nicotine abuse, little empirical support is available for aligning the nicotine use disorder criteria with the DSM-5 criteria for other SUDs.

DESIGN

Latent variable analyses, bootstrap tests and likelihood ratio tests were used to explore the unidimensionality, psychometric properties and information of the nicotine criteria.

SETTING AND PARTICIPANTS

A sample of household residents selected from the Israeli population register yielded 727 life-time cigarette smokers.

MEASUREMENTS

DSM-IV nicotine dependence criteria and proposed abuse and craving criteria, assessed with a structured interview.

FINDINGS

Three abuse criteria (hazardous use, social/interpersonal problems and neglect roles) were prevalent among smokers, formed a unidimensional latent trait with nicotine dependence criteria, were intermixed with dependence criteria across the severity spectrum and significantly increased the diagnostic information over the dependence-only model. A craving criterion was shown to fit well with the other criteria.

CONCLUSION

Similar to findings from research on other substances, nicotine dependence, abuse and craving criteria appear to derive from a common underlying dimension. The results support alignment of nicotine criteria with those for alcohol and drug use disorders in Diagnostic and Statistical Manual 5th edition.

Threshold and optimal cut-points for alcohol use disorders among patients in the emergency department

BACKGROUND

Current research suggests that Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV alcohol abuse and dependence form a unidimensional continuum in emergency department (ED) patients in 4 countries: Argentina, Mexico, Poland, and the United States. In this continuum of alcohol use disorder (AUD), there are no clear-cut distinctions between the criteria for dependence and abuse in the severity dimension based on prior results from item response theory (IRT) analysis. Nevertheless, it is desirable to find a threshold for identifying cases for clinical practice and cut-points of clinical utility in this continuum to distinguish between patients more or less affected by an AUD, using a scale of symptoms count.

METHODS

Data from 5,193 patients in 7 ED sites in the same 4 countries (3,191 current drinkers) were used to study the structure, threshold, and possible cut-points for the diagnoses of AUD.

RESULTS

The proposed changes in the DSM-V, dropping the abuse item "legal problems" and adding an item on "craving," did not impact the IRT performance and unidimensionality of AUD in this sample. With a total set of 11 items (deleting "legal problems" and adding "craving" to the current set of DSM criteria), an endorsement of 2 or more criteria can be used as the threshold to define those with an AUD in clinical practice. Furthermore, we can distinguish at least 2 levels of clinical severity, 2 to 3 criteria (moderate), and 4 or more criteria (severe).

CONCLUSIONS

A dimensional approach to AUD using the proposed new set of criteria for the DSM-V can be used to propose a threshold and levels of severity. More research in different populations and countries is needed to further substantiate a threshold and cut-points that could be used in new formulations of substance use disorders.

Predictive value of obsessive-compulsive drinking scale (OCDS) for outcome in alcohol-dependent inpatients: results of a 24-month follow-up study

BACKGROUND

The present study examined whether craving as measured by the obsessive-compulsive drinking scale (OCDS) predict long-term outcome in alcohol-dependent inpatients.

METHODS

This was a 24-month prospective, observational study in 198 alcohol-dependent inpatients treated under standardized conditions. The primary outcome criterion was abstinence, defined as no subjective report or objective indication of alcohol consumption since discharge from treatment. The patients self-rated their craving for alcohol at the 6- and 12-month follow-ups by using the German version of the OCDS, which measures obsessive and compulsive aspects of craving. Univariate and logistic regression analyses with covariates were performed.

RESULTS

Of the 104 patients interviewed at the 24-month follow-up, 60% (n = 62) were abstinent. We found significant associations between total OCDS scores at 6 months and outcome at 12 months and between total OCDS scores at 12 months and outcome at 24 months: the higher the OCDS total score at one follow-up evaluation, the less likely patients were to be abstinent at the subsequent one. The same association was found for each of the two OCDS subscales, control and consequences and drinking obsessions.

CONCLUSIONS

These results support earlier findings that OCDS scores can predict outcome in alcohol-dependent patients. This information can be used for the timely development of protective resources. Hence, decisions over the use of resources can be made on the basis of objectified parameters to develop a personalized treatment concept. Consequently, economic considerations can induce a reduction of high medical costs.