Not all alcohol use disorder criteria are equally severe: Toward severity grading of individual criteria in college drinkers

Abstract

Alcohol use disorder (AUD) diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) contains a severity gradient based on number of criteria endorsed, implicitly assuming criteria are interchangeable. However, criteria vary widely in endorsement rates, implying differences in the latent severity associated with a symptom (e.g., Lane, Steinley, & Sher, 2016) and demonstrating criteria are not interchangeable (Lane & Sher, 2015). We evaluated whether variation in the severity of criteria could be resolved by employing multiple indicators of each criterion varying in item-level severity. We assessed 909 undergraduate students aged 18 years or older with at least 12 drinking occasions in the past year. Participants self-administered questions on alcohol consumption and past year AUD symptoms via an online survey. For each of the 11 AUD criteria, we selected three indicators based on the difficulty values of the one-parameter logistic item response theory model ranging from low to high. We first tested a higher order AUD factor defined by 11 lower order criterion factors, χ2(551) = 2,959.35, p < .0001; root mean square error of approximation = 0.09. The 33 items were used to create severity scores: a criterion count (0-11), symptom count (0-33), and factor scores derived from a bifactor model. Though our new scores resulted in incremental validity over DSM-5 across a range of external validators, when the standardized regression estimates were compared, the new scores did not consistently outperform the DSM-5 suggesting this approach is viable for developing more sensitive diagnostic instruments but needs further refinement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Figure 1.

Higher-Order Confirmatory Factor Analysis of the 33 Alcohol Use Disorder Symptom Indicators. This figure demonstrates the higher-order model specified to demonstrate the unidimensionality of the 33 alcohol use disorder symptom indicators chosen from the IRT-models to indicate low, medium, and high severity. Table 2 lists full descriptions of the 33 items ranging from low to high severity. All estimates are standardized. Estimator = WLSMV. χ² [551] = 2959.35,p < .0001; RMSEA = 0.09. **p < .001, *p < .01. LL = “Alcohol is taken in larger amounts or over longer periods than was intended;” TS = “A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects;” CD = “There is a persistent desire or unsuccessful efforts to cut down or control alcohol use;” CR = “Craving, or a strong desire or urge to use alcohol;” FF = “Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home;” GU = “Important social, occupational, or recreational activities given up or reduced because of alcohol use;” HAZ = “Recurrent alcohol use in situations in which it is physically hazardous.” PP = “Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.” TOL = “Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect (b) A markedly diminished effect with continued use of the same amount of alcohol.” WD = “Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for alcohol, (b) Alcohol (or a closely related substance, such as benzodiazepine) is taken to relieve or avoid withdrawal symptoms.” SI = “Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.”