Adolescents with alcohol problems: redefining the basics

December 16, 2001

For some nosologists - people interested in the classification of diseases - the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) lies somewhere between serving as a valuable diagnostic tool and one in need of revision. Of special concern is the validity of DSM-IV alcohol-use disorder (AUD) diagnoses when applied to adolescents. A study in the December issue of Alcoholism: Clinical & Experimental Research uses an advanced quantitative technique called latent class analysis (LCA) to examine the utility of new ways of classifying adolescent alcohol problems.

"There is controversy regarding the use of DSM-IV criteria with adolescents," said Tammy Chung, assistant professor of psychiatry at the University of Pittsburgh Medical Center and lead author of the study. "For example, existing criteria include symptoms that are not commonly experienced by adolescent problem drinkers, which limits their utility when applied to this age group. Symptoms such as alcohol withdrawal and alcohol-related legal problems typically occur only after years of heavy drinking. Conversely, other DSM-IV-defined symptoms, such as alcohol tolerance, generally tend to have a high prevalence in adolescent drinkers, and do not clearly distinguish between adolescents with and without drinking problems. In certain cases, individuals may have alcohol-related symptoms, but fail to meet DSM-IV AUD criteria for a diagnosis. We need to remember that these criteria were developed for use with adults, and little is known about their validity when applied to adolescents. Although a few papers have addressed this topic cross-sectionally, this study is among the first to address this issue in adolescents using longitudinal data."

"There are all kinds of problems with DSM-IV when applied to adolescents," agreed James Langenbucher, associate professor at the Center of Alcohol Studies at Rutgers University. "One of these is that the way in which we diagnose alcohol and drug problems, and even gambling problems and eating disorders, is based on the prototype of a middle-aged white man, probably a patient in a Veterans Affairs hospital during the 1960s to 1970s. This prototype gave us all the ideas that have filtered down and been codified. No one had in mind a 17-year old Latino kid in Philadelphia when deciding what were the essential characteristics of alcohol and drug abuse disorders."

The first DSM was published by the American Psychiatric Association in 1952. Diagnostic criteria for alcohol and other drug problems were added in 1980 (DSM-III). In general, there are three DSM-IV categories of substance-use disorders: no diagnosis, abuse, and dependence. Alcohol abuse and dependence are defined by mutually exclusive criterion sets. Alcohol abuse is diagnosed by meeting at least one of four symptoms representing recurrent hazardous use and negative psychosocial consequences resulting from drinking. Alcohol dependence requires meeting three of seven symptoms within a 12-month period, precludes a diagnosis of abuse, and includes symptoms related to physical dependence, impaired control over drinking behavior, and increased salience of alcohol consumption.

For the Chung study, researchers used LCA to identify subgroups of adolescents who share a common pattern, profile of symptoms, or other characteristics. They then used the subgroups' symptom profiles to refine the DSM-IV criteria used to diagnose AUDs.

"We were able to develop severity-based categories of adolescents with milder and more severe alcohol-related problems," said Chung. "The milder and more severe categories derived in this study provided better coverage of symptomatic individuals than DSM-IV alcohol abuse and dependence categories, suggesting that some re-organization of DSM-IV AUD criteria may improve the identification of individuals who may benefit from treatment. In addition, longitudinal data indicated an overall decrease in the severity of adolescents' alcohol-related problems one year after substance-abuse treatment."

"Another important finding," said Langenbucher, "is that case severity in these data seems to be carried by the number, not the type, of symptom. It's the overall number of symptoms that best accounts for the severity of the case. This argues for a dimensional system that relates abuse to dependence, perhaps not different categories, but different ranges on the severity continuum."

"Furthermore," said Chung, 'these results suggest that a small proportion of symptomatic adolescents who may benefit from intervention, may not meet criteria for a DSM-IV AUD diagnosis, and thus may not be eligible for third-party reimbursement for substance-abuse treatment. As our own findings confirmed, treated adolescents tended to show reductions in alcohol-related problems one year after substance-abuse treatment, a finding that does not support the notion of an inevitable progression to more severe problems."

Chung added that she and her colleagues are currently trying to identify and test developmentally appropriate AUD criteria for use with adolescents that would better capture the types of alcohol symptoms most commonly reported by youth. Youth-specific criteria, she noted, that would improve the identification of adolescents who may benefit from early intervention or substance abuse treatment.

"What we want to eventually do," said Langenbucher, "is aid in the development of DSM-V. That version should be out toward the close of this decade. We want improved diagnostic rules for all kinds of psychiatric diagnoses, including major depression, schizophrenia, and also substance-use disorders."
The co-author of the Alcoholism: Clinical & Experimental Research paper was Christopher S. Martin of the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Alcoholism: Clinical & Experimental Research

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