Drug and Alcohol Dependence,
Elsevier Scientific Publishers
Agreement
Linda B. Cottlera,
29 (1991) 17-25 Ireland Ltd.
between
17
DSM-III and disorders
III-R
John E. Helzerb, Douglas Mager”, Edward Wilson M. Compton”
substance
L. Spitznagel”
use
and
uDepartment of Psychiatry, Washington University School of Medicine 4940 Audubon Avenue, St. Louis, MO 63110. “Department of Psychiatry, University of Vermont College of Medicine Burlington, VT 04501 and ‘Depurtment of Mathematics. Washington University, One Brookings Drive, St. Louis, MO 63130 (U.S.A.)
(Received October lOth, 1990)
With proposed criteria for DSM-IV substance dependence imminent, an evaluation of the impact of changes from DSM-III to DSM-III-R would be informative. Recent admissions to St. Louis drug treatment centers were interviewed with the DIS-IIIR, which covers criteria from both systems. Kappa values for system agreement, diagnostic overlap and percent positive agreement are reported by substance. The DSM-III-R system cast a wider net for dependence than DSM-III for alcohol, tobacco and amphetamines. Neither system predominated for cannabis, opioids and barbiturates/sedatives/hypnotics. Reasons for differences and implications of findings are discussed. Key words: substance use disorders;
DSM-III-R; nosology; reliability
Introduction
The history of psychiatric diagnostic systems is one of change. (Robins, et al., 1986) Over the years scientists have tried to agree on one set of diagnostic criteria with little success. Instead, ‘old’ systems have been replaced with newer ones. Replacement was suggested if a system did not adequately cover all of the phenomenon to be classified, or if there were a gain in the predictive accuracy of the new classification. For example, Diagnostic and Statistical ManualRevised (American Psychiatric Association, 1987) (DSM-III-R) criteria have supplanted the formerly prevailing diagnostic systems of Feighner, (Feighner, et al., 1972) the Research Diagnostic Criteria (Spiker, et al.; 1975) and the DSM-III. Comespondence to: Linda B. Cottler, Ph.D., Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Avenue, St. Louis, MO 63110, U.S.A. 0376~8716/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
In DSM-III, a diagnosis of alcohol abuse requires a pattern of pathological use lasting for at least 1 month and impairment in social or occupational functioning due to alcohol. A l-month duration criterion was added to DSM-III in order to exclude persons whose only use was exEvidence of 1984). perimental (Robins, tolerance or withdrawal and at least one of the above symptoms are required for alcohol dependence. DSM-III abuse of and dependence on drugs and tobacco follow patterns similar to alcohol (See Table I), although supplemental criteria are described for each substance. The substance abuse and dependence criteria were among the disorders most changed by the newer DSM-III-R system, which conceptualizes a ‘dependence syndrome’ originally formulated by Edwards and Gross. (Edwards and Gross, 1976) As shown in Table I, DSM-III-R requires at least 3 out of 9 criteria to be positive for a diagnosis of dependence; but does not necessarily Ireland Ltd.
18 Table I. Diagnostic criteria for psychoactive substance dependence. DSM-IZZ (in general) A. Either pathological use or impairment occupational functioning B. Either tolerance or withdrawal
in social or
DSM-III-R A. 3 out of 9 symptoms*; symptoms have equal weight B. Duration of some symptoms for at least 1 month or symptoms occurred repeatedly over a longer period of time
*cl) Taking substance in larger amount or over longer period than intended. desire or unsuccessful efforts to cut down or control use. (3) Spending a great deal of time to get or use the substance, or recover from its after effects. (4) Frequent intoxication or withdrawal when expected to fulfill major obligations. (5) Giving up activities for substance use. (6) Continuing to use despite problems. (7) Tolerance. (3) Withdrawal. (9) Using substance to relieve or avoid withdrawal symptoms.
(2) Persistent
require evidence of tolerance or withdrawal. In an attempt to standardize criteria, symptom requirements for abuse and dependence are identical across substance categories; although one of the symptoms, withdrawal, does not apply to cannabis, hallucinogens or PCP. Because criteria are identical across substances, this newer format is hoped to yield better communication among researchers while also allowing for meaningful comparisons to be made across substance use categories. The elimination of tolerance and withdrawal as necessary symptoms in the DSM-III-R system reflects a recognition that dependence is a disorder centered around compulsive use and loss of control often leading to physical, psychological and social consequences. The substance abuse disorder category, reserved for persons who never met criteria for dependence, is a residual category unlike DSM-III in which users can be labeled with both abuse and dependence. In DSM-III-R, the duration criterion is vaguely
defined as ‘persistence for at least 1 month, or the symptom occurs repeatedly over a longer period of time’. This construct is difficult to operationalize which may lead to’ unreliable ascertainment (Cottler and Keating, 1990). Despite the considerable change in definition, DSM-III-R was not expected to drastically change the overall rates of substance use disorders, although it was expected that fewer persons would be labeled ‘abusers’ with more meeting dependence criteria. ADAMHA has been funding several studies which examine agreement between the DSM systems and differential reliability and validity. Results consistently indicate that DSM-III-R labels more persons dependent than does DSM-III. (Rounsaville, et al., 1987; Caetano, 1987; Segal, 1987; Blackwell, 1987; Prado, 1987; Rounsaville, 1987a; Rounsaville, 1987b). The reasons for discrepancies between diagnostic systems are related to the changes in the criteria themselves; for example, the vague duration criterion might have an effect on rates. Additionally, removing the required criterion of tolerance and withdrawal might label persons who were abusers in DSM-III as dependent in III-R: Perhaps requiring only three out of nine possibly overlapping symptoms also widens the net to include more substance users than DSM-III. With the changes in dependence criteria in DSM-III-R, the American view of substance dependence has begun to reflect more closely the ICD-10 (World Health Organization (WHO)) concept of dependence. (Edwards et al., 1981; Kosten, 1987) Even so, comparisons between ICD-10 and DSM-III-R find that DSM-III-R makes the dependence diagnosis more often than ICD-10 (Cottler, et al., in press). As Kendler recently noted, American investigators are finally taking notice of both the problems and process of psychiatric nosology. (Kendler, 1990) This includes how classification changes should be made and evaluated. DSM-III and III-R were developed by committee, without a systematic effort to collect reliability, validity and other comparative data. DSM-IV is now in its early stages, but before the criteria are
published, the developers are analyzing existing data and conducting extensive field trials to examine the acceptability of any changes. These are being done under the direction of the DSMIV Task Force, chaired by Dr. Allen Frances. Comparing substance dependence in DSM-III and III-R will help inform the field of the potential for rate differences if the proposed DSM-IV criteria, which require tolerance or withdrawal, are adopted. Although field studies are necessary to test the diagnostic overlap between the DSM-III and III-R psychoactive substance dependence disorders and eventually ICD-10, data presented here from an ongoing longitudinal study of drug abusers in treatment provides an early opportunity to examine overlap and reasons for discordance. Especially noteworthy is the inclusion of African Americans, females, and a population with a range of diagnoses to allow for the fairest test of reliability and validity. Methods
The data for these comparisons come from a NIDA-funded longitudinal study of HIV seroprevalence and psychiatric comorbidity among St. Louis substance abusers and their sexual partners. Index subjects for this study, called the Substance Abuse and Risk for AIDS study (SARA), are 18-44-year-olds who have been admitted to treatment for a substance abuse problem in the prior 6 months and their sexual partners. Potential subjects were recruited for the study from treatment admission logs through a random number table. A sample of treatment centers was selected for the study; however intravenous drug use was not a requirement for eligibility into the study. Sampling was conducted at two methadone maintenance clinics, two residential drug-free programs, two outpatient drug-free programs, an outpatient program for reforming prostitutes and a residential ‘recovery shelter’ for women. All subjects were asked to provide the names of their most steady partner in the past 12 months. The names of partners were pooled and potential subjects were selected randomly.
Baseline interviews were conducted on 605 persons, 514 index and 91 partners.* Over half (59%) of the sample is male, 63% is African American. On average, the subjects have had 11 years of education; 15% are presently married and 38% presently employed. Almost half (47%) report a lifetime history of intravenous substance use. Data were elicited by personal interviews conducted by trained non-clinicians using the substance use disorders sections from the NIMH-Diagnostic Interview Schedule (DIS) Version III-R (Robins et al., 1989). These sections include questions necessary to simultaneously assess criteria for DSM-III and III-R abuse and dependence for ten classes of psychoactive substances: tobacco, alcohol, cannabinoids, cocaine, amphetamines, barbiturates/sedatives/hypnotics, hallucinogens, PCP, inhalants and opioids. The criteria are assessed for those substances that have been used 6 times or more on a lifetime basis. This minimum threshold was arbitrarily chosen in 1980 as the screen for the NIMH Epidemiological Catchment Area study. Diagnoses are scored by computer algorithms. The DIS and the relevant computer programs are available from the authors upon request. Since our intention is to evaluate diagnostic agreement between lifetime DSM-III and III-R substance use disorders, trichotomous mutuallyexclusive variables were used, forming 3 x 3 tables. Thus, in the DSM-III system, the classifications included dependence with or without abuse (since DSM-III allows for a person to have both dependence and abuse), abuse only and neither. For III-R, users were classified as having dependence, abuse only and neither (see Table II). Denominators include only per‘A total of 818 persons Among the 524 potential
were approached for the study. index subjects approached, 514
participated - representing a 98% completion rate. Of the 10 who did not participate, only 2 were refusals; the remaining 8 did not return to the treatment facility and could not be further followed without signed informed consent. Of the pool of 294 sexual partners, 91 participated, 49 refused (17%) two were too ill to be interviewed and 152 could not be located or were ineligible.
20 Table II. Diagnostic comparisons. DSM-III-R
Dependence Abuse only Neither
DSM-III Dependence wlwo abuse
Abuse only
Neither
A D G
B E H
C F I
However, significantly more drinkers qualified for a DSM-III-R diagnosis of alcohol dependence than DSM-III dependence (59% vs. 53%). This discrepancy is largely due in large part to the many individuals who met criteria for DSM-III abuse but were labeled DSM-III-R dependent. Tobacco
sons at risk for the disorder - i.e., those who reported ever using the particular substance six or more times. Results Table III shows the rate of DSM-III and III-R diagnoses for each substance. Categories are mutually exclusive; the diagonals show the agreements between diagnostic labels. Overall percent agreement between individual DSM-III and DSM-III-R psychoactive substance dependence disorders is the sum of the diagonals divided by the total number of users. A modification of the McNemar test was used to evaluate the statistical significance of diagnostic differences. Agreement
assessment
for the agreement Chance-corrected trichotomous comparisons were made using the Kappa statistic. (Cohen, 1960) Kappa values greater than 0.75 are generally considered to represent high agreement; values between 0.40 and 0.75 are considered to indicate fair to good agreement, and values between 0 and 0.40 are considered to show poor agreement. Values near zero indicate that agreement is due to chance. Alcohol
Of the 605 persons interviewed, 15 reported lifetime abstinence from alcohol and thus were removed from the analysis of alcohol disorders. The overall percent agreement (83%) and Kappa value (0.79) indicate high concordance overall.
Comparisons are made for the 524 persons who used a tobacco product daily for a month or more. Only nicotine dependence was assessed, since abuse is not described in either system. Tobacco dependence had the lowest diagnostic concordance. A statistically significantly greater proportion of persons met criteria for DSMIII-R tobacco dependence (77% vs. 65%) than for DSM-III. In fact, 85 of the 406 persons labeled DSM-III-R nicotine dependent were negative in DSM-III. DSM-III requires unsuccessful attempts to quit or cut down, withdrawal symptoms, or continuing to smoke despite a physical disorder exacerbated by smoking, whereas DSM-III-R accepts any three out of nine symptoms. Cannabis
Overall percent agreement for cannabis abuse and/or dependence was fair (79%) and there was no significant difference between overall rates of disorder. However, the Kappa was only moderate (0.56) due to the fact that although overall rates were similar, concordance for specific diagnoses of abuse or dependence was not as high. For example, only 10 persons met criteria for abuse in DSM-III-R compared to 50 persons in DSM-III and 24 of these were labeled dependent in DSM-III-R. Cocaine
Because cocaine dependence was not included in DSM-III, agreement statistics are not available. However, the impact of establishing new criteria to diagnose cocaine dependence in the DSM-III-R system is shown in Table III. Almost all (N = 229) of the 233 persons labeled abusers in DSM-III met criteria for DSM-III-R cocaine dependence.
21 Table III.
Agreement
Comparisons* DSM-III-R
Alcohol (N = 590) Tobacco (N = 524) Cannabis (N = 501) Cocaine* * (N = 439) Heroin and other opiates (N = 314) Sedatives, TQ, barbiturates (N = 264) Amphetamines (N = 246) Hallucinogens* * (N = 187) PCP” (N = 152)
between DSM-III and DSM-III-R substance use disorders (N = 605). Dep Dep Ab None
293
2 16 321 0 18 90 0 25 0 0 0 218 1 7 60 0 11 54 0 8 0 0 0 0
DSM-III zt Ab A D G
Ab B E H
None C F I
38 17 21 0 0 0 24 5 21 229 1 3 6 1 4 6 1 5 13 2 3 12 2 2 28
19 2 182 85 0 100 29 5 302 72 6 128 3 0 74 10 4 167 14 2 150 17 5 149 14 0 107 -
83%
0.79
(311)
82%
0.53
79%
0 Inhalants* * * (N = 56)
-
Dependence criteria met
Overall percent agreement kappa
1 -
DSM-III
DSM-III-R
(N) %
(N) %
53%
(350)
59% +
(339)
65%
(406)
77% +
0.56
(115)
23%
(143)
28%
-
-
(0)
0%
(301)
69%
93%
0.84
(226)
71%
(227)
72%
86%
0.70
(71)
27%
(76)
29%
84%
0.66
(62)
25%
(81)
33Yo’
(0)
0%
(29)
16Yo
-
(0)
0%
(42)
27w
-
-
-
(8)
15%
A + B + C = DSM-III-R dependence. A + D + G = DSM-III dependence +I- abuse. D + E + F = DSM-III-R abuse only. C + F + I = DSM-III negative. C + H + I = DSM-III-R negative. B + E + H = DSM-III abuse only. *See Table II for complete description of comparisons. **Dependence criteria were not specified in DSM-III. ***Disorder did not exist in DSM-III. +McNemar’s x2 one-tailed test (1 degree of freedom) is significant at P < 0.05; meaning DSM-III-R diagnosed more persons than DSM-III.
Heroin and other opioids Sedativeslbarbituratesitranquilizers.
Rate differences for these two groups of drugs did not reach statistical significance. Overall percent agreements were high. The Kappa value for opioids (0.84) indicates excellent concordance
for abuse and dependence. The Kappa value for sedatives was 0.70, still in the good range. Amphetamines
The Kappa value indicated good overall agreement between the diagnostic systems (0.66).
22
Significantly more dependence on amphetamines was diagnosed with the DSM-III-R criteria than with the DSM-III criteria (33% vs. 25%). Hallucinogens, PCP As with cocaine, dependence criteria for these substances were not specified in the DSM-III system so comparisons which include dependence cannot be made. However, DSM-III-R dependence on hallucinogens was not as common as other substance use disorders in this population (16%). Among this sample, PCP dependence was as common as cannabis and sedative dependence. Inhalants
Because neither inhalant abuse nor dependence diagnoses were part of the DSM-III system, no comparison can be made. Among the 56 users, 15% were labeled DSM-III-R dependent. Differing withdrawal
requirements
for
tolerance
and
The main difference between dependence in the two DSM systems is the requirement in DSM-III for evidence of tolerance or withdrawal. These indicators of ‘physiological dependence’ are two of the nine criteria listed for dependence in the DSM-III-R system, but neither is required. To evaluate the impact of these variables on the labelling of dependence, we assessed what proportion of persons labeled DSM-III-R dependent reported tolerance or withdrawal. Shown in Table IV are the number of users of each substance (Column A) and the proportion of users meeting III-R dependence (Column B). From 1% to 60% of those meeting criteria for DSM-III-R dependence disorder did not report tolerance or withdrawal (Column C). One interpretation of these findings is that little change in diagnostic status would result for tobacco or opioids if tolerance or withdrawal were required for dependence. However, substantial reassignment of diagnostic labels would occur for
hallucinogens, PCP and inhalants if physiologic measures of dependence (tolerance/withdrawal) were required - these users would be labeled as abusers. The impact of requiring tolerance or withdrawal is more difficult to assess for alcohol, cannabis, cocaine, sedatives and amphetamines - substances most commonly used and abused. Many of these users would be reclassified from DSM-III-R dependence to abuse if a history of tolerance or withdrawal were required for dependence. For example, 17% of the persons who met criteria for alcohol dependence did not report a history of tolerance or withdrawal. Thus, the percent positive for dependence would fall from 59% to 49%, a 10% reduction in prevalence. About one-third of those labeled either cannabis or amphetamine dependent did not report tolerance or withdrawal symptoms. Thus, the rate of a dependence diagnosis would fall by one-third. Moreover, if either tolerance or withdrawal symptoms were required for DSMIV cocaine dependence, a 26% reduction would occur, which would change the prevalence of dependence from 69% to 51%. To further evaluate this proposed revision, we stratified those with DSM-III-R dependence into those having 3 or 4 symptoms, 5 or 6, or 7 to 9 symptoms (Table IV, Column D). This was an effort to determine whether persons with mild, moderate or severe dependence were equally likely to report tolerance and withdrawal. As expected, persons with severe dependence (7-9 symptoms) almost always reported tolerance and/or withdrawal. Thus, requiring tolerance or withdrawal would have resulted in no change in diagnosis (except for cocaine) among the most severely impaired. That is not the case with the moderate or milder cases (Table IV). Effect of the DSM-III-R pendence diagnosis
‘B’ criterion
on de-
The ‘B’ criterion required in DSM-III-R for dependence requires that ‘some of the symptoms persist for at least 1 month or occur repeatedly over a longer period of time’. We have argued previously that the concepts.measuring time are
23 Table IV.
Tolerance/withdrawal
and duration criteria.
COL A Users
COL B % of Co1 A
COL c % of Co1 B
COL D % w/o tolerance
COL E % of Users
N
w/III-R dependence
w/o tolerance or withdrawal
or withdrawal
w/ 3+ criteria who do not ‘B’ criterion
61 1
9
0
0
0
5 4
3-4 crit.
5-6 Crit.
7-9 crit.
Alcohol Tobacco
590 524
59 77
17
Cannabis Cocaine Heroin/other Opiates
501 439
28 69
34 26
53 53
24 39
0 1
2 0
314
72
4
19
0
0
I
SedativeslTQ Barbiturates Amphetamines Hallucinogens
264 246 187
29 33 16
11 33 52
47 56 70
12 13 0
0 0 0
0
PCP Inhalants
152 56
27 15
60 50
82 100
44 0
0 0
0 0
vague, and that the definition of ‘some’ and ‘persisted’ are hard to operationalize. (Cottler and Keating, 1990) This criterion requires that each time a symptom is positively endorsed, a followup question must be asked which confirms whether the duration of the symptom is sufficient for the criterion requirement. In practice, this questioning has added substantially to the length of diagnostic interviews and has repeatedly confused respondents. Because the criteria in both systems are written to include persons with a ‘pattern of symptomology’ and not just isolated occurrences, we suggest that the ‘B’ criterion be deleted since most criterion items contain the words ‘often’ and ‘several times’. The data in Table IV, Column E, confirm that this criterion could be omitted without reservation. Rarely are persons with three or more criterion symptoms not positive for the ‘B’ criterion. It is our feeling that the respondents who did not meet criteria for ‘B’ misunderstood the question that assessed this item. Discussion
Our detailed comparisons of DSM-III and IIIR substance use diagnoses indicate that DSMIII-R dependence on alcohol, tobacco and am-
1 0
phetamines is more common than DSM-III dependence; dependence on cannabis, sedatives/tranquilizers/barbiturates and opioids was as likely to be diagnosed in DSM-III as in III-R. Because criteria for dependence on cocaine, hallucinogens and PCP were not specified in DSM-III such a comparison is not possible. All trichotomous comparisons found persons classified as ‘abusers’ in DSM-III who were labeled III-R dependent. Leading the list of reasons for this discrepancy is the exclusion of the tolerance/withdrawal criteria. This finding is important as we head toward finalizing DSM-IV. We were especially surprised to find more tobacco dependence with the DSM-III-R system since that system requires more symptoms than DSM-III. Among the 85 persons who were DSMIII-R positive but DSM-III negative, the difference was found to be related to the withdrawal criterion. Fifty-seven of 85 persons met III-R criteria for withdrawal. Although withdrawal is listed as one of the 3 symptoms for a DSM-III disorder, and by itself would qualify for a nicotine dependence disorder, this criterion was negative in the DSM-III system among these persons. This indicates a sizeable difference, due to the composition of withdrawal criteria from
24
one system to the other. For example in DSMIII-R, decreased heart rate, increased appetite or weight gain are included in the list of symptoms but not included in DSM-III. Two recent studies have shown that appetite change is a common symptom of nicotine withdrawal. (Hughes, 1991; Williamson, et al., 1991) DSMIII includes headaches, drowsiness and GI disturbances which are not included in DSM-IIIR. A focused evaluation of these differences will need to be explored further. In general, the implications of our findings for prevalence studies using DSM-III-R definitions are that a significantly greater proportion of persons will be classified alcoholic, tobacco and amphetamine dependent than in previous studies using DSM-III criteria. In addition, cocaine, hallucinogen and PCP dependence will now be evident. These changes in prevalence rates will be reported among epidemiologic studies, studies on the familial aspects of disorders, genetic linkage studies and clinical studies where randomization is based on diagnostic screening. Insurance companies may be asked to pay more claims, or alternatively if DSM-IV adds subtyping which includes tolerance or withdrawal, insurance companies may not pay for persons who do not meet the more severe subtype. In addition, individual substance abuse treatment plans may be revised to consider the new diagnoses among clients. The concern that DSM-III-R dependence criteria are too easily met needs to be addressed in future publications. What are the implications of our findings for DSM-IV? A critical issue is: are tolerance and withdrawal key concepts of dependence? For some substances it seems they are, and for others it seems they are not. Our data suggest tolerance and withdrawal are key concepts of dependence for tobacco and opioids, and also when the drug dependence is severe (when 7, 8 or 9 criteria are reported). However, tolerance and withdrawal do not seem to be key concepts among the mildly dependent (when only 3 or 4 criteria are involved). If evidence of tolerance or withdrawal was required many of these persons would not meet criteria for dependence. In fact,
if these symptoms were necessary, many of the moderately dependent - those reporting 5 or 6 criteria - would be labeled abuse, not dependence, for cocaine, cannabis, sedatives and amphetamines. These findings might suggest that DSM-IV criteria need to be written separately for certain classes of substances. Regarding our analyses of the duration criterion, our conjecture that it has little utility is strengthened. This criterion does not expedite a diagnostic decision, since almost all persons with the required 3 or more criteria are positive for the duration criteria. Thus, it is our recommendation that for practical reasons which include operationalization, this requirement should be removed in future proposals. A further point of discussion includes the ascertainment of information for use in nosological studies. Structured interviews which assess multiple diagnostic systems, like the DIS used in this study and other instruments like the CID1 (Robins et al., 1988) and the CIDI-SAM (Robins, et al., 1987; Cottler, et al., 1989) which include ICD-10 criteria, are valuable tools for diagnostic comparison studies. Additionally, these studies should be made in both treated and untreated populations, both in the U.S. and abroad. Studies which assess reliability and validity of criteria should also be encouraged. As Shrout et al. report, a good reliability study of criteria is the starting point, though reliability is not sufficient for validity. (Shrout, et al., 1987) Many years ago Robins and Guze described a method for achieving diagnostic validity in psychiatric diagnoses. (Robins, et al., 1970) Even today, these five phases remain our best resources: clinical descriptions, laboratory studies, delimitation from other disorders, follow-up and family studies. Findings such as those presented here suggest the implications of changing, loosening and broadening diagnostic criteria or going from older to newer concepts. When comparisons are made they suggest areas of improvement. Before DSM-IV criteria are adopted, investigators should study data from all three existing systems (ICD-10, DSM-III and III-R) and
25
weigh the differences and similarities. In this of dependence can be way, our concept empirically-based and communication between scientists, planners and treatment providers improved. Acknowledgements Dr. Cottler acknowledges the support of DA05585, DA05619, DA06163, a MacArthur Foundation DSM-IV Analysis Award and the technical assistance of Jeanette Haynes. References American Psychiatric Association. (1987) Diagnostic and statistical manual of mental disorders, third edn., revised. APA, Washington DC. Blackwell, J. (1987) Proposed changes in DSM-III substance dependence criteria. Letter to the Editor. Am. J. Psychiatry 144, 258. Caetano, R. (1987) A commentary on the proposed changes in the DSM III concepts of alcohol dependence. Drug Alcohol Depend. 19, 345-355. Cohen, J. (1960) A coefficient of agreement of nominal scales. Educ. Psychol. Meas. 20, 37-46. Cottler, L.B., Robins, L.N. and Helzer, J.E. (1989) The reliability of the CIDI-SAM: a comprehensive substance abuse interview. Br. J. Addict. 84, 801-814. Cottler, L.B. and Keating, SK. (1990) Operationalization of alcohol and drug dependence criteria by means of a structured interview. In: 1988 Recent Developments in Alcoholism (Gallanter, M., eds.) pp. 59-83. Plenum Publishing Co., New York. Cottler, L.B., Robins, L.N., Grant, B.F., Blaine, J., Wittthen, H-U. and Sartorius, N. The CID1 core substance abuse and dependence questions: cross-cultural and nosological issues. Br. J. Psychiatry (in press). Edwards, G. and Gross, M.M. (1976) Alcohol dependence: provisional description of a clinical syndrome. Br. Med. J 1, 1058- 1061. Edwards, G., Arif, A. and Hodgson, R. (1981) Nomenclature and classification of drug and alcohol-related problems: a WHO memorandum. Bull. W. H. 0. 59, 225-242. Feighner, J., Robins, E., Guze, S., Woodruff, R., Winokur, G. and Munoz, R. (1972) Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26, 57-63. Hughes, J.R.. Gust, S.W., Skoog, K., Keenan, R. and Fenwick, J.W. (1991) Symptoms of tobacco withdrawal. A replication and extension. Arch. Gen. Psychiatry 48, 52-59. Kendler, K. (1990) Toward a scientific psychiatric nosology: strengths and limitations. Arch. Gen. Psychiatry 47, 969 - 973.
Kosten, T.R., Rounsaville, B.J., Babor, T.F., Spitzer, R.L. and Williams, J.B. (1987) Substance-use disorders in DSM-III-R: evidence for the dependence syndrome across different psychoactive substances. Br. J. Psychiatry 151, 834-843. Prado, A. (1987) Proposed changes in DSM-III substance dependence disorders. Letter to the Editor. Am. J. Psychiatry 144, 258. Robins, E. and Guze, S. (1970) Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am. J. Psychiatry 126, 983-987. Robins, L.N. (1984) The diagnosis of alcoholism after DSMIII Revised for Psychiatric Update Vol. III, (Grinspoon, L., ed.) pp. 301-310. American Psychiatric Press, Inc., Washington DC. Robins, L.N., Cottler, L.B. and Babor, T. (1983) WHO/ADAMHA Composite International Diagnostic Interview (CID1 Substance abuse module) Washington University: St. Louis, revised 1990. Robins, L.N., Wing, J., Wittchen, H., HeIzer, J.E., Babor, T.F., Burke, J., Farmer, A., Jablenski, A., Pickens R. and Regier, D.A. (1988) The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch. Gen. Psychiatry 45, 1069 - 1077. Robins, L.N. and Helzer, J.E. (1986) Diagnosis and clinical assessment: the current state of psychiatry. Ann. Rev. Psychol. 37, 409 - 432. Robins, L., Helzer, J., Cottler, L. and Goldring, E. (1989) The Diagnostic Interview Schedule. Version III-R St. Louis. Rounsavihe, B.J., Spitzer, R.L. and Williams, J.B.W. (1987a) Proposed changes in DSM-III substance use disorders: description and rationale. Am. J. Psychiatry 143, 463 - 468. Rounsaville, B.J., Spitzer, R.L. and Williams, J.B.W. (1987b) Proposed changes in DSM-III substance use disorders: Dr. Rounsaville and colleagues reply. Letter to the Editor. Am. J. Psychiatry 144, 259. Rounsaville, B.J. and Kranzler, H.R. (1989) DSM-III-R diagnosis of alcoholism. Review of Psychiatry, Vol. 8 (Allan, T., Hales, R.E. and Frances, A.J., eds.) pp. 323- 340. American Psychiatric Press, Inc., Washington, DC. Segal, B.M (1987) Proposed changes in DSM-III substance dependence criteria. Letter to the Editor. Am. J. Psychiatry 144, 257. Shrout, P.E., Spitzer, R.L. and Fleiss, JL (1987) Quantification of agreement in psychiatric diagnosis revisited. Arch. Gen. Psychiatry 44, 172 - 177. Spitzer R., Endicott, J. and Robins, E. (1975) Clinical criteria for psychiatric diagnosis and DSM-III. Am. J. Psychiatry 132, 1187 - 1192. Williamson, D.F., Madans J., Anda, R.F., Kleinman, J.C., Giovino, G.A. and Byers, T. (1991) Smoking cessation and severity of weight gain in a national cohort. New Engl. J. Med. 324, 739-745.
Elsevier Scientific Publishers
Agreement
Linda B. Cottlera,
29 (1991) 17-25 Ireland Ltd.
between
17
DSM-III and disorders
III-R
John E. Helzerb, Douglas Mager”, Edward Wilson M. Compton”
substance
L. Spitznagel”
use
and
uDepartment of Psychiatry, Washington University School of Medicine 4940 Audubon Avenue, St. Louis, MO 63110. “Department of Psychiatry, University of Vermont College of Medicine Burlington, VT 04501 and ‘Depurtment of Mathematics. Washington University, One Brookings Drive, St. Louis, MO 63130 (U.S.A.)
(Received October lOth, 1990)
With proposed criteria for DSM-IV substance dependence imminent, an evaluation of the impact of changes from DSM-III to DSM-III-R would be informative. Recent admissions to St. Louis drug treatment centers were interviewed with the DIS-IIIR, which covers criteria from both systems. Kappa values for system agreement, diagnostic overlap and percent positive agreement are reported by substance. The DSM-III-R system cast a wider net for dependence than DSM-III for alcohol, tobacco and amphetamines. Neither system predominated for cannabis, opioids and barbiturates/sedatives/hypnotics. Reasons for differences and implications of findings are discussed. Key words: substance use disorders;
DSM-III-R; nosology; reliability
Introduction
The history of psychiatric diagnostic systems is one of change. (Robins, et al., 1986) Over the years scientists have tried to agree on one set of diagnostic criteria with little success. Instead, ‘old’ systems have been replaced with newer ones. Replacement was suggested if a system did not adequately cover all of the phenomenon to be classified, or if there were a gain in the predictive accuracy of the new classification. For example, Diagnostic and Statistical ManualRevised (American Psychiatric Association, 1987) (DSM-III-R) criteria have supplanted the formerly prevailing diagnostic systems of Feighner, (Feighner, et al., 1972) the Research Diagnostic Criteria (Spiker, et al.; 1975) and the DSM-III. Comespondence to: Linda B. Cottler, Ph.D., Department of Psychiatry, Washington University School of Medicine, 4940 Audubon Avenue, St. Louis, MO 63110, U.S.A. 0376~8716/91/$03.50 0 1991 Elsevier Scientific Publishers Printed and Published in Ireland
In DSM-III, a diagnosis of alcohol abuse requires a pattern of pathological use lasting for at least 1 month and impairment in social or occupational functioning due to alcohol. A l-month duration criterion was added to DSM-III in order to exclude persons whose only use was exEvidence of 1984). perimental (Robins, tolerance or withdrawal and at least one of the above symptoms are required for alcohol dependence. DSM-III abuse of and dependence on drugs and tobacco follow patterns similar to alcohol (See Table I), although supplemental criteria are described for each substance. The substance abuse and dependence criteria were among the disorders most changed by the newer DSM-III-R system, which conceptualizes a ‘dependence syndrome’ originally formulated by Edwards and Gross. (Edwards and Gross, 1976) As shown in Table I, DSM-III-R requires at least 3 out of 9 criteria to be positive for a diagnosis of dependence; but does not necessarily Ireland Ltd.
18 Table I. Diagnostic criteria for psychoactive substance dependence. DSM-IZZ (in general) A. Either pathological use or impairment occupational functioning B. Either tolerance or withdrawal
in social or
DSM-III-R A. 3 out of 9 symptoms*; symptoms have equal weight B. Duration of some symptoms for at least 1 month or symptoms occurred repeatedly over a longer period of time
*cl) Taking substance in larger amount or over longer period than intended. desire or unsuccessful efforts to cut down or control use. (3) Spending a great deal of time to get or use the substance, or recover from its after effects. (4) Frequent intoxication or withdrawal when expected to fulfill major obligations. (5) Giving up activities for substance use. (6) Continuing to use despite problems. (7) Tolerance. (3) Withdrawal. (9) Using substance to relieve or avoid withdrawal symptoms.
(2) Persistent
require evidence of tolerance or withdrawal. In an attempt to standardize criteria, symptom requirements for abuse and dependence are identical across substance categories; although one of the symptoms, withdrawal, does not apply to cannabis, hallucinogens or PCP. Because criteria are identical across substances, this newer format is hoped to yield better communication among researchers while also allowing for meaningful comparisons to be made across substance use categories. The elimination of tolerance and withdrawal as necessary symptoms in the DSM-III-R system reflects a recognition that dependence is a disorder centered around compulsive use and loss of control often leading to physical, psychological and social consequences. The substance abuse disorder category, reserved for persons who never met criteria for dependence, is a residual category unlike DSM-III in which users can be labeled with both abuse and dependence. In DSM-III-R, the duration criterion is vaguely
defined as ‘persistence for at least 1 month, or the symptom occurs repeatedly over a longer period of time’. This construct is difficult to operationalize which may lead to’ unreliable ascertainment (Cottler and Keating, 1990). Despite the considerable change in definition, DSM-III-R was not expected to drastically change the overall rates of substance use disorders, although it was expected that fewer persons would be labeled ‘abusers’ with more meeting dependence criteria. ADAMHA has been funding several studies which examine agreement between the DSM systems and differential reliability and validity. Results consistently indicate that DSM-III-R labels more persons dependent than does DSM-III. (Rounsaville, et al., 1987; Caetano, 1987; Segal, 1987; Blackwell, 1987; Prado, 1987; Rounsaville, 1987a; Rounsaville, 1987b). The reasons for discrepancies between diagnostic systems are related to the changes in the criteria themselves; for example, the vague duration criterion might have an effect on rates. Additionally, removing the required criterion of tolerance and withdrawal might label persons who were abusers in DSM-III as dependent in III-R: Perhaps requiring only three out of nine possibly overlapping symptoms also widens the net to include more substance users than DSM-III. With the changes in dependence criteria in DSM-III-R, the American view of substance dependence has begun to reflect more closely the ICD-10 (World Health Organization (WHO)) concept of dependence. (Edwards et al., 1981; Kosten, 1987) Even so, comparisons between ICD-10 and DSM-III-R find that DSM-III-R makes the dependence diagnosis more often than ICD-10 (Cottler, et al., in press). As Kendler recently noted, American investigators are finally taking notice of both the problems and process of psychiatric nosology. (Kendler, 1990) This includes how classification changes should be made and evaluated. DSM-III and III-R were developed by committee, without a systematic effort to collect reliability, validity and other comparative data. DSM-IV is now in its early stages, but before the criteria are
published, the developers are analyzing existing data and conducting extensive field trials to examine the acceptability of any changes. These are being done under the direction of the DSMIV Task Force, chaired by Dr. Allen Frances. Comparing substance dependence in DSM-III and III-R will help inform the field of the potential for rate differences if the proposed DSM-IV criteria, which require tolerance or withdrawal, are adopted. Although field studies are necessary to test the diagnostic overlap between the DSM-III and III-R psychoactive substance dependence disorders and eventually ICD-10, data presented here from an ongoing longitudinal study of drug abusers in treatment provides an early opportunity to examine overlap and reasons for discordance. Especially noteworthy is the inclusion of African Americans, females, and a population with a range of diagnoses to allow for the fairest test of reliability and validity. Methods
The data for these comparisons come from a NIDA-funded longitudinal study of HIV seroprevalence and psychiatric comorbidity among St. Louis substance abusers and their sexual partners. Index subjects for this study, called the Substance Abuse and Risk for AIDS study (SARA), are 18-44-year-olds who have been admitted to treatment for a substance abuse problem in the prior 6 months and their sexual partners. Potential subjects were recruited for the study from treatment admission logs through a random number table. A sample of treatment centers was selected for the study; however intravenous drug use was not a requirement for eligibility into the study. Sampling was conducted at two methadone maintenance clinics, two residential drug-free programs, two outpatient drug-free programs, an outpatient program for reforming prostitutes and a residential ‘recovery shelter’ for women. All subjects were asked to provide the names of their most steady partner in the past 12 months. The names of partners were pooled and potential subjects were selected randomly.
Baseline interviews were conducted on 605 persons, 514 index and 91 partners.* Over half (59%) of the sample is male, 63% is African American. On average, the subjects have had 11 years of education; 15% are presently married and 38% presently employed. Almost half (47%) report a lifetime history of intravenous substance use. Data were elicited by personal interviews conducted by trained non-clinicians using the substance use disorders sections from the NIMH-Diagnostic Interview Schedule (DIS) Version III-R (Robins et al., 1989). These sections include questions necessary to simultaneously assess criteria for DSM-III and III-R abuse and dependence for ten classes of psychoactive substances: tobacco, alcohol, cannabinoids, cocaine, amphetamines, barbiturates/sedatives/hypnotics, hallucinogens, PCP, inhalants and opioids. The criteria are assessed for those substances that have been used 6 times or more on a lifetime basis. This minimum threshold was arbitrarily chosen in 1980 as the screen for the NIMH Epidemiological Catchment Area study. Diagnoses are scored by computer algorithms. The DIS and the relevant computer programs are available from the authors upon request. Since our intention is to evaluate diagnostic agreement between lifetime DSM-III and III-R substance use disorders, trichotomous mutuallyexclusive variables were used, forming 3 x 3 tables. Thus, in the DSM-III system, the classifications included dependence with or without abuse (since DSM-III allows for a person to have both dependence and abuse), abuse only and neither. For III-R, users were classified as having dependence, abuse only and neither (see Table II). Denominators include only per‘A total of 818 persons Among the 524 potential
were approached for the study. index subjects approached, 514
participated - representing a 98% completion rate. Of the 10 who did not participate, only 2 were refusals; the remaining 8 did not return to the treatment facility and could not be further followed without signed informed consent. Of the pool of 294 sexual partners, 91 participated, 49 refused (17%) two were too ill to be interviewed and 152 could not be located or were ineligible.
20 Table II. Diagnostic comparisons. DSM-III-R
Dependence Abuse only Neither
DSM-III Dependence wlwo abuse
Abuse only
Neither
A D G
B E H
C F I
However, significantly more drinkers qualified for a DSM-III-R diagnosis of alcohol dependence than DSM-III dependence (59% vs. 53%). This discrepancy is largely due in large part to the many individuals who met criteria for DSM-III abuse but were labeled DSM-III-R dependent. Tobacco
sons at risk for the disorder - i.e., those who reported ever using the particular substance six or more times. Results Table III shows the rate of DSM-III and III-R diagnoses for each substance. Categories are mutually exclusive; the diagonals show the agreements between diagnostic labels. Overall percent agreement between individual DSM-III and DSM-III-R psychoactive substance dependence disorders is the sum of the diagonals divided by the total number of users. A modification of the McNemar test was used to evaluate the statistical significance of diagnostic differences. Agreement
assessment
for the agreement Chance-corrected trichotomous comparisons were made using the Kappa statistic. (Cohen, 1960) Kappa values greater than 0.75 are generally considered to represent high agreement; values between 0.40 and 0.75 are considered to indicate fair to good agreement, and values between 0 and 0.40 are considered to show poor agreement. Values near zero indicate that agreement is due to chance. Alcohol
Of the 605 persons interviewed, 15 reported lifetime abstinence from alcohol and thus were removed from the analysis of alcohol disorders. The overall percent agreement (83%) and Kappa value (0.79) indicate high concordance overall.
Comparisons are made for the 524 persons who used a tobacco product daily for a month or more. Only nicotine dependence was assessed, since abuse is not described in either system. Tobacco dependence had the lowest diagnostic concordance. A statistically significantly greater proportion of persons met criteria for DSMIII-R tobacco dependence (77% vs. 65%) than for DSM-III. In fact, 85 of the 406 persons labeled DSM-III-R nicotine dependent were negative in DSM-III. DSM-III requires unsuccessful attempts to quit or cut down, withdrawal symptoms, or continuing to smoke despite a physical disorder exacerbated by smoking, whereas DSM-III-R accepts any three out of nine symptoms. Cannabis
Overall percent agreement for cannabis abuse and/or dependence was fair (79%) and there was no significant difference between overall rates of disorder. However, the Kappa was only moderate (0.56) due to the fact that although overall rates were similar, concordance for specific diagnoses of abuse or dependence was not as high. For example, only 10 persons met criteria for abuse in DSM-III-R compared to 50 persons in DSM-III and 24 of these were labeled dependent in DSM-III-R. Cocaine
Because cocaine dependence was not included in DSM-III, agreement statistics are not available. However, the impact of establishing new criteria to diagnose cocaine dependence in the DSM-III-R system is shown in Table III. Almost all (N = 229) of the 233 persons labeled abusers in DSM-III met criteria for DSM-III-R cocaine dependence.
21 Table III.
Agreement
Comparisons* DSM-III-R
Alcohol (N = 590) Tobacco (N = 524) Cannabis (N = 501) Cocaine* * (N = 439) Heroin and other opiates (N = 314) Sedatives, TQ, barbiturates (N = 264) Amphetamines (N = 246) Hallucinogens* * (N = 187) PCP” (N = 152)
between DSM-III and DSM-III-R substance use disorders (N = 605). Dep Dep Ab None
293
2 16 321 0 18 90 0 25 0 0 0 218 1 7 60 0 11 54 0 8 0 0 0 0
DSM-III zt Ab A D G
Ab B E H
None C F I
38 17 21 0 0 0 24 5 21 229 1 3 6 1 4 6 1 5 13 2 3 12 2 2 28
19 2 182 85 0 100 29 5 302 72 6 128 3 0 74 10 4 167 14 2 150 17 5 149 14 0 107 -
83%
0.79
(311)
82%
0.53
79%
0 Inhalants* * * (N = 56)
-
Dependence criteria met
Overall percent agreement kappa
1 -
DSM-III
DSM-III-R
(N) %
(N) %
53%
(350)
59% +
(339)
65%
(406)
77% +
0.56
(115)
23%
(143)
28%
-
-
(0)
0%
(301)
69%
93%
0.84
(226)
71%
(227)
72%
86%
0.70
(71)
27%
(76)
29%
84%
0.66
(62)
25%
(81)
33Yo’
(0)
0%
(29)
16Yo
-
(0)
0%
(42)
27w
-
-
-
(8)
15%
A + B + C = DSM-III-R dependence. A + D + G = DSM-III dependence +I- abuse. D + E + F = DSM-III-R abuse only. C + F + I = DSM-III negative. C + H + I = DSM-III-R negative. B + E + H = DSM-III abuse only. *See Table II for complete description of comparisons. **Dependence criteria were not specified in DSM-III. ***Disorder did not exist in DSM-III. +McNemar’s x2 one-tailed test (1 degree of freedom) is significant at P < 0.05; meaning DSM-III-R diagnosed more persons than DSM-III.
Heroin and other opioids Sedativeslbarbituratesitranquilizers.
Rate differences for these two groups of drugs did not reach statistical significance. Overall percent agreements were high. The Kappa value for opioids (0.84) indicates excellent concordance
for abuse and dependence. The Kappa value for sedatives was 0.70, still in the good range. Amphetamines
The Kappa value indicated good overall agreement between the diagnostic systems (0.66).
22
Significantly more dependence on amphetamines was diagnosed with the DSM-III-R criteria than with the DSM-III criteria (33% vs. 25%). Hallucinogens, PCP As with cocaine, dependence criteria for these substances were not specified in the DSM-III system so comparisons which include dependence cannot be made. However, DSM-III-R dependence on hallucinogens was not as common as other substance use disorders in this population (16%). Among this sample, PCP dependence was as common as cannabis and sedative dependence. Inhalants
Because neither inhalant abuse nor dependence diagnoses were part of the DSM-III system, no comparison can be made. Among the 56 users, 15% were labeled DSM-III-R dependent. Differing withdrawal
requirements
for
tolerance
and
The main difference between dependence in the two DSM systems is the requirement in DSM-III for evidence of tolerance or withdrawal. These indicators of ‘physiological dependence’ are two of the nine criteria listed for dependence in the DSM-III-R system, but neither is required. To evaluate the impact of these variables on the labelling of dependence, we assessed what proportion of persons labeled DSM-III-R dependent reported tolerance or withdrawal. Shown in Table IV are the number of users of each substance (Column A) and the proportion of users meeting III-R dependence (Column B). From 1% to 60% of those meeting criteria for DSM-III-R dependence disorder did not report tolerance or withdrawal (Column C). One interpretation of these findings is that little change in diagnostic status would result for tobacco or opioids if tolerance or withdrawal were required for dependence. However, substantial reassignment of diagnostic labels would occur for
hallucinogens, PCP and inhalants if physiologic measures of dependence (tolerance/withdrawal) were required - these users would be labeled as abusers. The impact of requiring tolerance or withdrawal is more difficult to assess for alcohol, cannabis, cocaine, sedatives and amphetamines - substances most commonly used and abused. Many of these users would be reclassified from DSM-III-R dependence to abuse if a history of tolerance or withdrawal were required for dependence. For example, 17% of the persons who met criteria for alcohol dependence did not report a history of tolerance or withdrawal. Thus, the percent positive for dependence would fall from 59% to 49%, a 10% reduction in prevalence. About one-third of those labeled either cannabis or amphetamine dependent did not report tolerance or withdrawal symptoms. Thus, the rate of a dependence diagnosis would fall by one-third. Moreover, if either tolerance or withdrawal symptoms were required for DSMIV cocaine dependence, a 26% reduction would occur, which would change the prevalence of dependence from 69% to 51%. To further evaluate this proposed revision, we stratified those with DSM-III-R dependence into those having 3 or 4 symptoms, 5 or 6, or 7 to 9 symptoms (Table IV, Column D). This was an effort to determine whether persons with mild, moderate or severe dependence were equally likely to report tolerance and withdrawal. As expected, persons with severe dependence (7-9 symptoms) almost always reported tolerance and/or withdrawal. Thus, requiring tolerance or withdrawal would have resulted in no change in diagnosis (except for cocaine) among the most severely impaired. That is not the case with the moderate or milder cases (Table IV). Effect of the DSM-III-R pendence diagnosis
‘B’ criterion
on de-
The ‘B’ criterion required in DSM-III-R for dependence requires that ‘some of the symptoms persist for at least 1 month or occur repeatedly over a longer period of time’. We have argued previously that the concepts.measuring time are
23 Table IV.
Tolerance/withdrawal
and duration criteria.
COL A Users
COL B % of Co1 A
COL c % of Co1 B
COL D % w/o tolerance
COL E % of Users
N
w/III-R dependence
w/o tolerance or withdrawal
or withdrawal
w/ 3+ criteria who do not ‘B’ criterion
61 1
9
0
0
0
5 4
3-4 crit.
5-6 Crit.
7-9 crit.
Alcohol Tobacco
590 524
59 77
17
Cannabis Cocaine Heroin/other Opiates
501 439
28 69
34 26
53 53
24 39
0 1
2 0
314
72
4
19
0
0
I
SedativeslTQ Barbiturates Amphetamines Hallucinogens
264 246 187
29 33 16
11 33 52
47 56 70
12 13 0
0 0 0
0
PCP Inhalants
152 56
27 15
60 50
82 100
44 0
0 0
0 0
vague, and that the definition of ‘some’ and ‘persisted’ are hard to operationalize. (Cottler and Keating, 1990) This criterion requires that each time a symptom is positively endorsed, a followup question must be asked which confirms whether the duration of the symptom is sufficient for the criterion requirement. In practice, this questioning has added substantially to the length of diagnostic interviews and has repeatedly confused respondents. Because the criteria in both systems are written to include persons with a ‘pattern of symptomology’ and not just isolated occurrences, we suggest that the ‘B’ criterion be deleted since most criterion items contain the words ‘often’ and ‘several times’. The data in Table IV, Column E, confirm that this criterion could be omitted without reservation. Rarely are persons with three or more criterion symptoms not positive for the ‘B’ criterion. It is our feeling that the respondents who did not meet criteria for ‘B’ misunderstood the question that assessed this item. Discussion
Our detailed comparisons of DSM-III and IIIR substance use diagnoses indicate that DSMIII-R dependence on alcohol, tobacco and am-
1 0
phetamines is more common than DSM-III dependence; dependence on cannabis, sedatives/tranquilizers/barbiturates and opioids was as likely to be diagnosed in DSM-III as in III-R. Because criteria for dependence on cocaine, hallucinogens and PCP were not specified in DSM-III such a comparison is not possible. All trichotomous comparisons found persons classified as ‘abusers’ in DSM-III who were labeled III-R dependent. Leading the list of reasons for this discrepancy is the exclusion of the tolerance/withdrawal criteria. This finding is important as we head toward finalizing DSM-IV. We were especially surprised to find more tobacco dependence with the DSM-III-R system since that system requires more symptoms than DSM-III. Among the 85 persons who were DSMIII-R positive but DSM-III negative, the difference was found to be related to the withdrawal criterion. Fifty-seven of 85 persons met III-R criteria for withdrawal. Although withdrawal is listed as one of the 3 symptoms for a DSM-III disorder, and by itself would qualify for a nicotine dependence disorder, this criterion was negative in the DSM-III system among these persons. This indicates a sizeable difference, due to the composition of withdrawal criteria from
24
one system to the other. For example in DSMIII-R, decreased heart rate, increased appetite or weight gain are included in the list of symptoms but not included in DSM-III. Two recent studies have shown that appetite change is a common symptom of nicotine withdrawal. (Hughes, 1991; Williamson, et al., 1991) DSMIII includes headaches, drowsiness and GI disturbances which are not included in DSM-IIIR. A focused evaluation of these differences will need to be explored further. In general, the implications of our findings for prevalence studies using DSM-III-R definitions are that a significantly greater proportion of persons will be classified alcoholic, tobacco and amphetamine dependent than in previous studies using DSM-III criteria. In addition, cocaine, hallucinogen and PCP dependence will now be evident. These changes in prevalence rates will be reported among epidemiologic studies, studies on the familial aspects of disorders, genetic linkage studies and clinical studies where randomization is based on diagnostic screening. Insurance companies may be asked to pay more claims, or alternatively if DSM-IV adds subtyping which includes tolerance or withdrawal, insurance companies may not pay for persons who do not meet the more severe subtype. In addition, individual substance abuse treatment plans may be revised to consider the new diagnoses among clients. The concern that DSM-III-R dependence criteria are too easily met needs to be addressed in future publications. What are the implications of our findings for DSM-IV? A critical issue is: are tolerance and withdrawal key concepts of dependence? For some substances it seems they are, and for others it seems they are not. Our data suggest tolerance and withdrawal are key concepts of dependence for tobacco and opioids, and also when the drug dependence is severe (when 7, 8 or 9 criteria are reported). However, tolerance and withdrawal do not seem to be key concepts among the mildly dependent (when only 3 or 4 criteria are involved). If evidence of tolerance or withdrawal was required many of these persons would not meet criteria for dependence. In fact,
if these symptoms were necessary, many of the moderately dependent - those reporting 5 or 6 criteria - would be labeled abuse, not dependence, for cocaine, cannabis, sedatives and amphetamines. These findings might suggest that DSM-IV criteria need to be written separately for certain classes of substances. Regarding our analyses of the duration criterion, our conjecture that it has little utility is strengthened. This criterion does not expedite a diagnostic decision, since almost all persons with the required 3 or more criteria are positive for the duration criteria. Thus, it is our recommendation that for practical reasons which include operationalization, this requirement should be removed in future proposals. A further point of discussion includes the ascertainment of information for use in nosological studies. Structured interviews which assess multiple diagnostic systems, like the DIS used in this study and other instruments like the CID1 (Robins et al., 1988) and the CIDI-SAM (Robins, et al., 1987; Cottler, et al., 1989) which include ICD-10 criteria, are valuable tools for diagnostic comparison studies. Additionally, these studies should be made in both treated and untreated populations, both in the U.S. and abroad. Studies which assess reliability and validity of criteria should also be encouraged. As Shrout et al. report, a good reliability study of criteria is the starting point, though reliability is not sufficient for validity. (Shrout, et al., 1987) Many years ago Robins and Guze described a method for achieving diagnostic validity in psychiatric diagnoses. (Robins, et al., 1970) Even today, these five phases remain our best resources: clinical descriptions, laboratory studies, delimitation from other disorders, follow-up and family studies. Findings such as those presented here suggest the implications of changing, loosening and broadening diagnostic criteria or going from older to newer concepts. When comparisons are made they suggest areas of improvement. Before DSM-IV criteria are adopted, investigators should study data from all three existing systems (ICD-10, DSM-III and III-R) and
25
weigh the differences and similarities. In this of dependence can be way, our concept empirically-based and communication between scientists, planners and treatment providers improved. Acknowledgements Dr. Cottler acknowledges the support of DA05585, DA05619, DA06163, a MacArthur Foundation DSM-IV Analysis Award and the technical assistance of Jeanette Haynes. References American Psychiatric Association. (1987) Diagnostic and statistical manual of mental disorders, third edn., revised. APA, Washington DC. Blackwell, J. (1987) Proposed changes in DSM-III substance dependence criteria. Letter to the Editor. Am. J. Psychiatry 144, 258. Caetano, R. (1987) A commentary on the proposed changes in the DSM III concepts of alcohol dependence. Drug Alcohol Depend. 19, 345-355. Cohen, J. (1960) A coefficient of agreement of nominal scales. Educ. Psychol. Meas. 20, 37-46. Cottler, L.B., Robins, L.N. and Helzer, J.E. (1989) The reliability of the CIDI-SAM: a comprehensive substance abuse interview. Br. J. Addict. 84, 801-814. Cottler, L.B. and Keating, SK. (1990) Operationalization of alcohol and drug dependence criteria by means of a structured interview. In: 1988 Recent Developments in Alcoholism (Gallanter, M., eds.) pp. 59-83. Plenum Publishing Co., New York. Cottler, L.B., Robins, L.N., Grant, B.F., Blaine, J., Wittthen, H-U. and Sartorius, N. The CID1 core substance abuse and dependence questions: cross-cultural and nosological issues. Br. J. Psychiatry (in press). Edwards, G. and Gross, M.M. (1976) Alcohol dependence: provisional description of a clinical syndrome. Br. Med. J 1, 1058- 1061. Edwards, G., Arif, A. and Hodgson, R. (1981) Nomenclature and classification of drug and alcohol-related problems: a WHO memorandum. Bull. W. H. 0. 59, 225-242. Feighner, J., Robins, E., Guze, S., Woodruff, R., Winokur, G. and Munoz, R. (1972) Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26, 57-63. Hughes, J.R.. Gust, S.W., Skoog, K., Keenan, R. and Fenwick, J.W. (1991) Symptoms of tobacco withdrawal. A replication and extension. Arch. Gen. Psychiatry 48, 52-59. Kendler, K. (1990) Toward a scientific psychiatric nosology: strengths and limitations. Arch. Gen. Psychiatry 47, 969 - 973.
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