Drug and Alcohol Elsevier Scientific
Dependence, 31 (1992) 51- 55 Publishers Ireland Ltd.
Unidimensionality
51
of Alcohol Dependence
Syndrome?
D. Mohan, R. Ray and H. Sethi Department
of Psychiatry
and Drug Dependence
Treatment
Centre, All India (India)
(Accepted
April
Institute
of Medical
Sciences,
New Delhi - 110029
6, 1992)
To evaluate the coherence of Alcohol Dependence Syndrome (ADS), as per DSM-III-R criteria, 72 and 223 subjects with alcohol dependence disorder from Hospital and Community settings, respectively, were interviewed. Nine DSM-III-R criteria assessing the dependence syndrome were factor-analysed. A single factor model provides an adequate description of the interrelationship among the nine criteria and supports the coherence of the dependence syndrome for the hospital sample but not for the community. A two factor model, namely ‘withdrawal’ and ‘social’, fits the community data. When the criteria were combined into cumulative scales, they formed good approximations of unidimensional Guttman scales for both the hospital and community settings. For hospital data, preoccupation was the highly central criterion (A = 0.95) in defining the dependence syndrome while ‘can’t stop’ (V = 0.11) measured the most severe level of dependence. In the community the ‘socially dysfunctional use’ identified as a separate secondary factor measured the most severe level of dependence.
Key words: alcohol dependence;
coherence setting
Introduction
Alcohol Dependence Syndrome (ADS), was conceptualised as a provisional description (Edwards, 1976). In the conceptualisation, no assumptions were made about aetiology. The syndrome implied co-occurance of phenomena, with some coherence. It attempted to bridge medical and social science approaches. These have been incorporated in various diagnostic systems (WHO 1976, Am. Psychiat. Assoc., 1989a,b) including the proposed ICD 10 draft and the revised DSM III criteria (Rounsaville et al., 1986). The concept was essentially formulated from the cultures where alcohol consumption was a normative pattern and was a compromise between the traditional AngloSaxon and French views on alcoholism. Even though in other settings a diagnosis based on Correspondence to: D. Mohan, Department of Psychiatry and Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi - 110029, India.
0376~8716/92/$05.00 0 1992 Elsevier Printed and Published in Ireland
Scientific
Publishers
ICD 9 and DSM III or DSM-III-R criteria have been applied, these were in the absence of information on existing normative patterns of alcohol consumption. The present communication presents information from India on the coherence of the ADS. Our study aimed (1) to assess the coherence of the Alcohol Dependence Syndrome and (2) to compare a range of dependence severity criteria. Materials
and Methods
The data was collected from 72 patients attending the Drug Dependence Treatment Centre at the All India Institute of Medical Sciences and 273 individuals diagnosed as alcohol dependent from the general population sample selected consecutively after a random start. In both cases, DSM-III-R criteria were applied to arrive at the diagnosis and only males above the age of 15 years were included. The exclusion criteria were presence or diagnosis of concurrent psychiatric and organic brain Ireland
Ltd.
52 Table I. Relationship Dependence Syndrome. DSM-III-R Tolerance
of DSM-III-R
criteria
to Alcohol
Alcohol Dependence Syndrome Marked tolerance need for markedly
in-
creased amounts (at least 50% increase), in order to achieve desired effect or markedly diminished effect with continued use of the same amount. Withdrawal Withdrawal avoidance Can’t stop
Can’t limit use Preoccupation
Use despite problems
Salience
Socially dysfunctional use
Characteristic withdrawal symptoms under alcohol induced disorder. Use of alcohol to relieve or avoid withdrawal symptoms. Persistent desire or one or more unsuccessful efforts to cut down or control alcohol use. Alcohol taken often in larger amounts or longer period than the person intended. A great deal of time is spent in activities necessary to procure alcohol, or recovering from its effects. Continued use despite knowledge of having problems. Problems: persistent, physical, social or psychological, that are caused by or increased due to alcohol use (health, legal). Important social, occupational or recreational activities being given up or reduced due to alcohol use. Frequent intoxication or withdrawal symptoms, dysfunctional use when expected to fulfill major role obligations, at work or at home.
disorders. In the treatment setting the information was collected by trainee residents in psychiatry and the community data was collected by trained research staff having Masters level degrees in social sciences, using DSM-III-R criteria. The DSM-III-R criteria are given in Table I. Two related methods, Guttman’s scaling and factor analysis were applied on nine ADS criteria to test the coherence of the syndrome. The frequency distribution on the endorsement of the above criteria was tabulated and subjected to Guttman’s scaling (Gardner Lindzey) in order to determine common syndrome elements. Reproducibility coefficients (CR) were calculated to assess for unidimensional attributes. Factor analysis was used in
testing the coherence by means of co-relations and by extracting as much variance as possible among the criterion. The centrality of a criteria was measured by its loading. The loading of each criterion in relation to the dependence syndrome was examined. The severity of each criterion was measured by means of 2 scores. Results Criterion endorsem$ frequencies (Table II) The results showed different frequencies of the criterion endorsements among the hospital and community data sets and CR values were around 0.9 for both, suggesting that unidimensionality of ADS was present in both with the Guttman scaling. In the hospital setting, 7 of the 9 criteria had endorsement rates ranging between 54% and 92%. In the community setting, only 4 of the 9 criteria had endorsement rates between 54% and 90%. In the hospital data almost all the criterion endorsement rates were higher than that in the community. ‘preoccupation’ among the hospital and ‘salience’ in the community were the least reported criterion. ‘Tolerance’, ‘use despite problems’ and ‘can’t limit use’ were most commonly endorsed in the community. No distinct clustering of physiologically based criteria (tolerance, withdrawal and withdrawal avoidance) was observed in either sample. Table
II.
Criterion
% endorsement
Community sample
Hospital sample Preoccupation Withdrawal avoidance Can’t stop use Salience Socially dysfunctional use Use despite problems Withdrawal Can’t limit use Tolerance Coefficient of reproducibility
and Guttman’s scaling.
34.7 34.7 54.2 56.9 65.3 80.6 83.6 88.9 91.7 0.90
Salience Withdrawal avoidance Withdrawal Can’t stop use Socially dysfunctional use Pre-occupation Tolerance Can’t limit use Use despite problems
23.3 25.1 28.7 41.7 45.7 54.3 75.3 84.8 90.0 0.86
53 Table III.
Factor structures and severity scores (v).
Criterion
Hospital sample Severity score (v)
Preoccupation Withdrawal avoidance Can’t stop Salience Socially dysfunctional use Use despite problems Withdrawal Can’t limit use Tolerance
0.39 0.39 -0.11 -0.18 -0.39 0.88 0.96 - 1.23 - 1.41
Criterion
Community sample Severity score (v)
Factor structure 0.95
0.11 0.36 0.43 0.36 0.30 0.18 0.01 -0.20
Salience Withdrawal avoidance Withdrawal Can’t stop Socially dysfuncttional use Preoccupation Tolerance Can’t limit use Use despite problems
Factor structure Withdrawal Social
0.74 0.68
0.82
0.47 -
0.56 0.21 0.11
0.99 0.43 -
0.75
-
0.40 -
-0.11 -0.68 1.0 1.29
-
Loadings below 0.3 are not reported.
There were 41 criterion response profiles for the hospital data and 76 response profiles in the community data. In the community, excluding tolerance, clustering was suggestive of cognitive and social dimensions. Around 5% of individuals reported 9 criteria profiles, another 9% each reported 8 criteria profiles excluding ‘preoccupation’ and ‘withdrawal avoidance’ from the hospital data. In the community, 2.7% reported all nine criteria profiles, (2.7%) reported eight criteria profiles, excluding ‘withdrawal avoidance’ and 7% reported 7 criteria profiles excluding ‘withdrawal’ and ‘withdrawal avoidance’. Factors profiles (cewtrality)fseverity (Table III) (a) Centrality. The factor analysis for
dichotomous responses was carried out with SPSS (Microsoft-Inc., 1984) using a generalised least square estimation procedure. Factor structures were created separately for hospital and community data sets. Chi-square goodness-of-fit was provided for each model. Each of the nine criteria was described in terms of common factors. A single factor (accounting for 21% of the variance) more than the total starting communality, fitted the hospital data (X = 32.3, P = 0.022). In the community sample, the first
two eigen values accounted for more than the total communality, suggesting a two factor model (accounting for 45% of the variance). The two factors were labelled as ‘withdrawal/withdrawal avoidance’ and ‘social’. (b) Severity. In the hospital data, 5 out of 9 criteria obtained moderate to high severity scores (0.11 to 0.39). In the community, 7 out of 9 criteria received moderate to high severity scores (0.11 to 0.74). In the hospital data ‘can’t stop’, ‘salience’, ‘socially dysfunctional use’, ‘withdrawal’ and ‘preoccupation’ received higher severity ratings. In the community, ‘preoccupation’, ‘socially dysfunctional use’ and ‘can’t stop use’ received higher severity ratings. ‘Can’t limit use’ received low severity in both settings. ‘Tolerance’ in hospital and ‘can’t limit use’ in the community received very low severity. In hospital data ‘pre-occupation’ was the most central (A = 0.95) but had moderate severity. In the community, on the other hand ‘social dysfunctional use’ was the only criteria with high severity and emerged as a second separate factor with high loading (A = 0.8). Loadings were weak in determining the centrality of the dependence syndrome in hospital data. ‘Socially dysfunctional use’ was the only
54
criterion in the community which was most central with high severity. None of the criteria in the hospital sample had both high centrality and severity. Discussion
Studies on coherence or unidimensionality have consisted mainly of two groups. The first group attempted to operationalise the ADS provisional model (Stockwell et al. 1979a, 1983b, Chick, 1980, Meehan, 1985, Ray et al., 1989). Most of them have tended to favour the notion that Alcohol Dependence Syndrome had coherence and unidimensionality, even though the scales and items differed. Other studies have utilised existing diagnostic criteria, with standardised interview schedules to validate the dependence syndrome (Kosten et al., 1987). Part of the reason for fewer studies in the latter group could be related to measurement of the severity and centrality in the ADS and the flexibility in that not all elements of the dependence syndrome may always be present at the same time, nor should they be present with same degree of severity. Edwards (1986a,b) cogently reviewed the studies that have been reported and with caution concluded that the evidence seemed to support the unitary concept of ADS. He further suggested that arbitrary classification systems cannot have the same heuristic significance. The present study was undertaken utilising existing DSM-III-R criteria, on the rationale that if a formulation is incorporated in the diagnostic systems, however imperfectly, it needs to be validated. The endorsement frequencies in the hospital led to an understandable clustering reflecting the physiological and cognitive components (tolerance; withdrawal; use despite problems; and can’t limit use) in the ADS. The clustering in the community sample was more behaviourally related (can’t limit use; pre-occupation; and use despite problems). Two methodological elements need to be used in order to test construct validity, i.e., measurable covariation of cognitive, behavioural and
physiological criteria used to define coherence of dependence syndrome. Secondly, the means of relating these to an underlying dimension of dependence severity. Both of the above requirements demonstrated construct validity of the ADS. On severity scores, in the hospital sample, the clustering was more on cognitive and social than physiological criteria (socially dysfunctional use; salience; can’t stop; and relief drinking). The inter-correlation between these items was significant. The median severity score was in high range (0.39). Even though bio-medical criteria of ADS received higher endorsement values, the self environmental perception of alcohol dependence was being influenced by the social dimension. The median severity score in the community was in the moderate severity range (0.68). This also was in keeping with the hospital data, emphasising cognitive, social rather than bio-medical criteria (preoccupation; salience; socially dysfunctional use; and can’t stop). The distribution of criteria on severity indicates that range was adequate and there was no need for additional criteria in the ADS. On factor analysis, the hospital data supported of the “coherence” and “unidimensionality” ADS. The only drawback was the low level of variance and poor inter-correlation between the criteria (r < 0.5), supporting the view that perhaps in Indian settings ‘alcoholism,’ if it was a unitary attribute, was an attribute made of poorly associated components (Horn, 1969). Ray et al. (1989) in a hospital study from India, identified four significant factors, ‘withdrawal’; ‘pathological drinking’; ‘legal difficulties’; and ‘family problems’. If re-interpreted for this study, these factors would come under ‘withdrawal’; ‘can’t limit use’; and ‘socially dysfunctional use’. The factor structure in the community showed two factors, the first reflected the biological elements of the ADS, while the second factor reflected on the social dimension. The second factor could also be very near the general factor of dependence, best given the name ‘problem drinking’ conceived of an outcome of the interaction of the individual and the environment.
55
What then can be made of the low severity of ‘can’t limit use’ in both settings? In the absence of normative data on drinking patterns in the community, it could perhaps reflect a concern of modest increase in quantities or alternatively reflect a very rapid escalation in quantities being consumed, among alcohol users and thus be related to extrusion of ‘cases’ from problem drinkers in the community to treatment setting. The limitations of the study were the weakness in collection of data. The diagnosis was arrived at by two separate groups: in the hospital sample, by trained physicians, while in the community by Masters in social sciences. This perhaps affected the rigorousness in data collection, which needs further examination. Acknowledgement The data on general population was collected with a grant-in-aid of the Indian Council of Medical Research, New Delhi, India. References Am. Psychiatr. Assoc. (1989) Diagnostic and Statistical Manual, III edn., Washington DC. Am. Psychiatr. Assoc. (1989) Diagnostic and Statistical Manual, III revised edn., Washington D.C. Chick, J. (1980) Is there a unidimensional Alcohol Dependence Syndrome? Br. J. Addict. 75, 265-280. Edwards, G. (1986a) The Alcohol Dependence Syndrome: a concept as stimulus to enquiry. Br. J. Addict. 81, 171- 183.
Edwards, G. (1986b) The Alcohol Dependence Syndrome: a concept as stimulus to enquiry. Br. J. Addict. 81, 621- 630. Edwards, G. and Gross, M.M. (1976) Alcohol dependence: provisional description of a clinical syndrome. Br. Med. J. 1, 1058- 1061. Gardner Lindzey and Elliot Arpmson (1975) The Handbook of Social Psychology, 2nd edn., University of Texas. Horn, J.L. and Wanberg, K.W. (1969) Symptom patterns related to excessive use of alcohol. Quart. J. Stud. Alcohol 30, 35-58. Kosten, T.R., Rounsaville, B.J., Babor, T.F., Spitzer, R.L. and Williams, J.B.W. (1987) Substance abuse disorders in DSM-III-R. Evidence for dependence syndrome across different psychoactive substances. Br. J. Psychiatry 151, 834 - 843. Meehan, J.P., Webb, M.G.I. and Unwin, A.R. (1985) The severity of alcohol dependency questionnaire (SADQ) in sample of Irish problem drinkers. Br. J. Addict. 80, 57-63. Microsoft Inc. (1984) Statistical Package for Social Sciences. Ray, R., Subbakrishna, D.K., Gentiana, M., Neeliyara, T. and Desai, N.G. (1989) Alcohol assessment and diagnosis. Drug Alcohol Depend. 23, 79 - 81. Rounsaville, B.J., Spitzer, R.L. and Williams, J.B.W. (1986) Proposed changes in DSM-III substance use disorders. Am. J. Psychiatry 143, 463-468. Stockwell, T., Hodgson, R., Edwards, G., Taylor, C. and Ankin, H. (1979) The development of a questionnaire to measure severity of alcohol dependence. Br. J. Addict. 74, 79-87. Stockwell, T., Murphy, D. and Hodgson, R. (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. Br. J. Addict. 78, 145-155. Stripp, A.M. and Burgass, P.M. (1990) An evaluation of psychoactive substance dependence syndrome in its application to opiate users. Br. J. Addict. 85, 621-627. WHO (1976) International Classification of Diseases, 9th revision, WHO, Geneva.
Dependence, 31 (1992) 51- 55 Publishers Ireland Ltd.
Unidimensionality
51
of Alcohol Dependence
Syndrome?
D. Mohan, R. Ray and H. Sethi Department
of Psychiatry
and Drug Dependence
Treatment
Centre, All India (India)
(Accepted
April
Institute
of Medical
Sciences,
New Delhi - 110029
6, 1992)
To evaluate the coherence of Alcohol Dependence Syndrome (ADS), as per DSM-III-R criteria, 72 and 223 subjects with alcohol dependence disorder from Hospital and Community settings, respectively, were interviewed. Nine DSM-III-R criteria assessing the dependence syndrome were factor-analysed. A single factor model provides an adequate description of the interrelationship among the nine criteria and supports the coherence of the dependence syndrome for the hospital sample but not for the community. A two factor model, namely ‘withdrawal’ and ‘social’, fits the community data. When the criteria were combined into cumulative scales, they formed good approximations of unidimensional Guttman scales for both the hospital and community settings. For hospital data, preoccupation was the highly central criterion (A = 0.95) in defining the dependence syndrome while ‘can’t stop’ (V = 0.11) measured the most severe level of dependence. In the community the ‘socially dysfunctional use’ identified as a separate secondary factor measured the most severe level of dependence.
Key words: alcohol dependence;
coherence setting
Introduction
Alcohol Dependence Syndrome (ADS), was conceptualised as a provisional description (Edwards, 1976). In the conceptualisation, no assumptions were made about aetiology. The syndrome implied co-occurance of phenomena, with some coherence. It attempted to bridge medical and social science approaches. These have been incorporated in various diagnostic systems (WHO 1976, Am. Psychiat. Assoc., 1989a,b) including the proposed ICD 10 draft and the revised DSM III criteria (Rounsaville et al., 1986). The concept was essentially formulated from the cultures where alcohol consumption was a normative pattern and was a compromise between the traditional AngloSaxon and French views on alcoholism. Even though in other settings a diagnosis based on Correspondence to: D. Mohan, Department of Psychiatry and Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi - 110029, India.
0376~8716/92/$05.00 0 1992 Elsevier Printed and Published in Ireland
Scientific
Publishers
ICD 9 and DSM III or DSM-III-R criteria have been applied, these were in the absence of information on existing normative patterns of alcohol consumption. The present communication presents information from India on the coherence of the ADS. Our study aimed (1) to assess the coherence of the Alcohol Dependence Syndrome and (2) to compare a range of dependence severity criteria. Materials
and Methods
The data was collected from 72 patients attending the Drug Dependence Treatment Centre at the All India Institute of Medical Sciences and 273 individuals diagnosed as alcohol dependent from the general population sample selected consecutively after a random start. In both cases, DSM-III-R criteria were applied to arrive at the diagnosis and only males above the age of 15 years were included. The exclusion criteria were presence or diagnosis of concurrent psychiatric and organic brain Ireland
Ltd.
52 Table I. Relationship Dependence Syndrome. DSM-III-R Tolerance
of DSM-III-R
criteria
to Alcohol
Alcohol Dependence Syndrome Marked tolerance need for markedly
in-
creased amounts (at least 50% increase), in order to achieve desired effect or markedly diminished effect with continued use of the same amount. Withdrawal Withdrawal avoidance Can’t stop
Can’t limit use Preoccupation
Use despite problems
Salience
Socially dysfunctional use
Characteristic withdrawal symptoms under alcohol induced disorder. Use of alcohol to relieve or avoid withdrawal symptoms. Persistent desire or one or more unsuccessful efforts to cut down or control alcohol use. Alcohol taken often in larger amounts or longer period than the person intended. A great deal of time is spent in activities necessary to procure alcohol, or recovering from its effects. Continued use despite knowledge of having problems. Problems: persistent, physical, social or psychological, that are caused by or increased due to alcohol use (health, legal). Important social, occupational or recreational activities being given up or reduced due to alcohol use. Frequent intoxication or withdrawal symptoms, dysfunctional use when expected to fulfill major role obligations, at work or at home.
disorders. In the treatment setting the information was collected by trainee residents in psychiatry and the community data was collected by trained research staff having Masters level degrees in social sciences, using DSM-III-R criteria. The DSM-III-R criteria are given in Table I. Two related methods, Guttman’s scaling and factor analysis were applied on nine ADS criteria to test the coherence of the syndrome. The frequency distribution on the endorsement of the above criteria was tabulated and subjected to Guttman’s scaling (Gardner Lindzey) in order to determine common syndrome elements. Reproducibility coefficients (CR) were calculated to assess for unidimensional attributes. Factor analysis was used in
testing the coherence by means of co-relations and by extracting as much variance as possible among the criterion. The centrality of a criteria was measured by its loading. The loading of each criterion in relation to the dependence syndrome was examined. The severity of each criterion was measured by means of 2 scores. Results Criterion endorsem$ frequencies (Table II) The results showed different frequencies of the criterion endorsements among the hospital and community data sets and CR values were around 0.9 for both, suggesting that unidimensionality of ADS was present in both with the Guttman scaling. In the hospital setting, 7 of the 9 criteria had endorsement rates ranging between 54% and 92%. In the community setting, only 4 of the 9 criteria had endorsement rates between 54% and 90%. In the hospital data almost all the criterion endorsement rates were higher than that in the community. ‘preoccupation’ among the hospital and ‘salience’ in the community were the least reported criterion. ‘Tolerance’, ‘use despite problems’ and ‘can’t limit use’ were most commonly endorsed in the community. No distinct clustering of physiologically based criteria (tolerance, withdrawal and withdrawal avoidance) was observed in either sample. Table
II.
Criterion
% endorsement
Community sample
Hospital sample Preoccupation Withdrawal avoidance Can’t stop use Salience Socially dysfunctional use Use despite problems Withdrawal Can’t limit use Tolerance Coefficient of reproducibility
and Guttman’s scaling.
34.7 34.7 54.2 56.9 65.3 80.6 83.6 88.9 91.7 0.90
Salience Withdrawal avoidance Withdrawal Can’t stop use Socially dysfunctional use Pre-occupation Tolerance Can’t limit use Use despite problems
23.3 25.1 28.7 41.7 45.7 54.3 75.3 84.8 90.0 0.86
53 Table III.
Factor structures and severity scores (v).
Criterion
Hospital sample Severity score (v)
Preoccupation Withdrawal avoidance Can’t stop Salience Socially dysfunctional use Use despite problems Withdrawal Can’t limit use Tolerance
0.39 0.39 -0.11 -0.18 -0.39 0.88 0.96 - 1.23 - 1.41
Criterion
Community sample Severity score (v)
Factor structure 0.95
0.11 0.36 0.43 0.36 0.30 0.18 0.01 -0.20
Salience Withdrawal avoidance Withdrawal Can’t stop Socially dysfuncttional use Preoccupation Tolerance Can’t limit use Use despite problems
Factor structure Withdrawal Social
0.74 0.68
0.82
0.47 -
0.56 0.21 0.11
0.99 0.43 -
0.75
-
0.40 -
-0.11 -0.68 1.0 1.29
-
Loadings below 0.3 are not reported.
There were 41 criterion response profiles for the hospital data and 76 response profiles in the community data. In the community, excluding tolerance, clustering was suggestive of cognitive and social dimensions. Around 5% of individuals reported 9 criteria profiles, another 9% each reported 8 criteria profiles excluding ‘preoccupation’ and ‘withdrawal avoidance’ from the hospital data. In the community, 2.7% reported all nine criteria profiles, (2.7%) reported eight criteria profiles, excluding ‘withdrawal avoidance’ and 7% reported 7 criteria profiles excluding ‘withdrawal’ and ‘withdrawal avoidance’. Factors profiles (cewtrality)fseverity (Table III) (a) Centrality. The factor analysis for
dichotomous responses was carried out with SPSS (Microsoft-Inc., 1984) using a generalised least square estimation procedure. Factor structures were created separately for hospital and community data sets. Chi-square goodness-of-fit was provided for each model. Each of the nine criteria was described in terms of common factors. A single factor (accounting for 21% of the variance) more than the total starting communality, fitted the hospital data (X = 32.3, P = 0.022). In the community sample, the first
two eigen values accounted for more than the total communality, suggesting a two factor model (accounting for 45% of the variance). The two factors were labelled as ‘withdrawal/withdrawal avoidance’ and ‘social’. (b) Severity. In the hospital data, 5 out of 9 criteria obtained moderate to high severity scores (0.11 to 0.39). In the community, 7 out of 9 criteria received moderate to high severity scores (0.11 to 0.74). In the hospital data ‘can’t stop’, ‘salience’, ‘socially dysfunctional use’, ‘withdrawal’ and ‘preoccupation’ received higher severity ratings. In the community, ‘preoccupation’, ‘socially dysfunctional use’ and ‘can’t stop use’ received higher severity ratings. ‘Can’t limit use’ received low severity in both settings. ‘Tolerance’ in hospital and ‘can’t limit use’ in the community received very low severity. In hospital data ‘pre-occupation’ was the most central (A = 0.95) but had moderate severity. In the community, on the other hand ‘social dysfunctional use’ was the only criteria with high severity and emerged as a second separate factor with high loading (A = 0.8). Loadings were weak in determining the centrality of the dependence syndrome in hospital data. ‘Socially dysfunctional use’ was the only
54
criterion in the community which was most central with high severity. None of the criteria in the hospital sample had both high centrality and severity. Discussion
Studies on coherence or unidimensionality have consisted mainly of two groups. The first group attempted to operationalise the ADS provisional model (Stockwell et al. 1979a, 1983b, Chick, 1980, Meehan, 1985, Ray et al., 1989). Most of them have tended to favour the notion that Alcohol Dependence Syndrome had coherence and unidimensionality, even though the scales and items differed. Other studies have utilised existing diagnostic criteria, with standardised interview schedules to validate the dependence syndrome (Kosten et al., 1987). Part of the reason for fewer studies in the latter group could be related to measurement of the severity and centrality in the ADS and the flexibility in that not all elements of the dependence syndrome may always be present at the same time, nor should they be present with same degree of severity. Edwards (1986a,b) cogently reviewed the studies that have been reported and with caution concluded that the evidence seemed to support the unitary concept of ADS. He further suggested that arbitrary classification systems cannot have the same heuristic significance. The present study was undertaken utilising existing DSM-III-R criteria, on the rationale that if a formulation is incorporated in the diagnostic systems, however imperfectly, it needs to be validated. The endorsement frequencies in the hospital led to an understandable clustering reflecting the physiological and cognitive components (tolerance; withdrawal; use despite problems; and can’t limit use) in the ADS. The clustering in the community sample was more behaviourally related (can’t limit use; pre-occupation; and use despite problems). Two methodological elements need to be used in order to test construct validity, i.e., measurable covariation of cognitive, behavioural and
physiological criteria used to define coherence of dependence syndrome. Secondly, the means of relating these to an underlying dimension of dependence severity. Both of the above requirements demonstrated construct validity of the ADS. On severity scores, in the hospital sample, the clustering was more on cognitive and social than physiological criteria (socially dysfunctional use; salience; can’t stop; and relief drinking). The inter-correlation between these items was significant. The median severity score was in high range (0.39). Even though bio-medical criteria of ADS received higher endorsement values, the self environmental perception of alcohol dependence was being influenced by the social dimension. The median severity score in the community was in the moderate severity range (0.68). This also was in keeping with the hospital data, emphasising cognitive, social rather than bio-medical criteria (preoccupation; salience; socially dysfunctional use; and can’t stop). The distribution of criteria on severity indicates that range was adequate and there was no need for additional criteria in the ADS. On factor analysis, the hospital data supported of the “coherence” and “unidimensionality” ADS. The only drawback was the low level of variance and poor inter-correlation between the criteria (r < 0.5), supporting the view that perhaps in Indian settings ‘alcoholism,’ if it was a unitary attribute, was an attribute made of poorly associated components (Horn, 1969). Ray et al. (1989) in a hospital study from India, identified four significant factors, ‘withdrawal’; ‘pathological drinking’; ‘legal difficulties’; and ‘family problems’. If re-interpreted for this study, these factors would come under ‘withdrawal’; ‘can’t limit use’; and ‘socially dysfunctional use’. The factor structure in the community showed two factors, the first reflected the biological elements of the ADS, while the second factor reflected on the social dimension. The second factor could also be very near the general factor of dependence, best given the name ‘problem drinking’ conceived of an outcome of the interaction of the individual and the environment.
55
What then can be made of the low severity of ‘can’t limit use’ in both settings? In the absence of normative data on drinking patterns in the community, it could perhaps reflect a concern of modest increase in quantities or alternatively reflect a very rapid escalation in quantities being consumed, among alcohol users and thus be related to extrusion of ‘cases’ from problem drinkers in the community to treatment setting. The limitations of the study were the weakness in collection of data. The diagnosis was arrived at by two separate groups: in the hospital sample, by trained physicians, while in the community by Masters in social sciences. This perhaps affected the rigorousness in data collection, which needs further examination. Acknowledgement The data on general population was collected with a grant-in-aid of the Indian Council of Medical Research, New Delhi, India. References Am. Psychiatr. Assoc. (1989) Diagnostic and Statistical Manual, III edn., Washington DC. Am. Psychiatr. Assoc. (1989) Diagnostic and Statistical Manual, III revised edn., Washington D.C. Chick, J. (1980) Is there a unidimensional Alcohol Dependence Syndrome? Br. J. Addict. 75, 265-280. Edwards, G. (1986a) The Alcohol Dependence Syndrome: a concept as stimulus to enquiry. Br. J. Addict. 81, 171- 183.
Edwards, G. (1986b) The Alcohol Dependence Syndrome: a concept as stimulus to enquiry. Br. J. Addict. 81, 621- 630. Edwards, G. and Gross, M.M. (1976) Alcohol dependence: provisional description of a clinical syndrome. Br. Med. J. 1, 1058- 1061. Gardner Lindzey and Elliot Arpmson (1975) The Handbook of Social Psychology, 2nd edn., University of Texas. Horn, J.L. and Wanberg, K.W. (1969) Symptom patterns related to excessive use of alcohol. Quart. J. Stud. Alcohol 30, 35-58. Kosten, T.R., Rounsaville, B.J., Babor, T.F., Spitzer, R.L. and Williams, J.B.W. (1987) Substance abuse disorders in DSM-III-R. Evidence for dependence syndrome across different psychoactive substances. Br. J. Psychiatry 151, 834 - 843. Meehan, J.P., Webb, M.G.I. and Unwin, A.R. (1985) The severity of alcohol dependency questionnaire (SADQ) in sample of Irish problem drinkers. Br. J. Addict. 80, 57-63. Microsoft Inc. (1984) Statistical Package for Social Sciences. Ray, R., Subbakrishna, D.K., Gentiana, M., Neeliyara, T. and Desai, N.G. (1989) Alcohol assessment and diagnosis. Drug Alcohol Depend. 23, 79 - 81. Rounsaville, B.J., Spitzer, R.L. and Williams, J.B.W. (1986) Proposed changes in DSM-III substance use disorders. Am. J. Psychiatry 143, 463-468. Stockwell, T., Hodgson, R., Edwards, G., Taylor, C. and Ankin, H. (1979) The development of a questionnaire to measure severity of alcohol dependence. Br. J. Addict. 74, 79-87. Stockwell, T., Murphy, D. and Hodgson, R. (1983) The severity of alcohol dependence questionnaire: its use, reliability and validity. Br. J. Addict. 78, 145-155. Stripp, A.M. and Burgass, P.M. (1990) An evaluation of psychoactive substance dependence syndrome in its application to opiate users. Br. J. Addict. 85, 621-627. WHO (1976) International Classification of Diseases, 9th revision, WHO, Geneva.
