The harmful dysfunction model of alcohol use disorder: Revised criteria to improve the validity of diagnosis and prevalence estimates

Jerome C. Wakefield, Mark F. Schmitz

    Research output: Contribution to journalArticle

    Abstract

    Aims: To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity. Design: DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data. Setting: United States. Participants: National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54years (wave 1, n=29673; wave 2, n=24244). Measures: NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group. Findings: Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95% confidence intervals): HD life-time 6.7% (6.2, 7.2%), 1-year 2.3% (2.0, 2.5%); and DSM-5 life-time 38.2% (36.5, 39.9%), 1-year 12.4% (11.7, 13.1%). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0% (38.1, 43.9%), DSM-5 11.5% (10.7, 12.3%); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1% (47.3, 52.9), DSM-5 32.8% (31.6, 34.0). HD criteria eliminated 83% of a DSM-5 teen transient drinker false-positives criterion group. Conclusions: Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.

    Original languageEnglish (US)
    Pages (from-to)931-942
    Number of pages12
    JournalAddiction
    Volume110
    Issue number6
    DOIs
    StatePublished - Jun 1 2015

    Fingerprint

    Alcohols
    Diagnostic and Statistical Manual of Mental Disorders
    Alcoholism
    School Health Services
    Diagnostic Errors
    Drinking
    Confidence Intervals
    Pathology
    Psychology
    Surveys and Questionnaires

    Keywords

    • Addiction
    • Alcohol dependence
    • Alcohol use disorder
    • Concept of mental disorder
    • Diagnosis
    • Diagnostic criteria
    • DSM
    • DSM-5
    • DSM-IV
    • Harmful dysfunction
    • NESARC
    • Psychiatric epidemiology
    • Validity

    ASJC Scopus subject areas

    • Medicine (miscellaneous)
    • Psychiatry and Mental health

    Cite this

    The harmful dysfunction model of alcohol use disorder : Revised criteria to improve the validity of diagnosis and prevalence estimates. / Wakefield, Jerome C.; Schmitz, Mark F.

    In: Addiction, Vol. 110, No. 6, 01.06.2015, p. 931-942.

    Research output: Contribution to journalArticle

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    abstract = "Aims: To formulate harmful dysfunction (HD) diagnostic criteria for alcohol use disorder (AUD) and test whether they increase validity relative to standard DSM criteria, as evidenced by lowered prevalence, increased validator levels including service use, severity and family history and enhanced specificity. Design: DSM-IV AUD, DSM-IV dependence, DSM-5 AUD and HD AUD definitions were compared on eight validity related tests using nationally representative community data. Setting: United States. Participants: National Epidemiologic Survey of Alcoholism and Related Conditions (NESARC) respondents, aged 18-54years (wave 1, n=29673; wave 2, n=24244). Measures: NESARC DSM-IV and DSM-5 criteria were taken from published studies. Whereas DSM-5 diagnosis requires any two AUD symptoms, HD criteria were constructed from NESARC items to require symptoms of both impaired-control dysfunction [withdrawal, drink to prevent/stop withdrawal, cannot stop/reduce drinking, or craving (wave 2 only)] and harm (sacrificed important activities, problems caring for home/family, job/school problems, health problems, psychological problems or problems with family/friends). Validators included service use, severity and family history, among others. Specificity was tested using a teen transient drinker criterion group. Findings: Compared with DSM-5 AUD (DSM-IV results were similar), HD criteria yielded lower prevalence (95{\%} confidence intervals): HD life-time 6.7{\%} (6.2, 7.2{\%}), 1-year 2.3{\%} (2.0, 2.5{\%}); and DSM-5 life-time 38.2{\%} (36.5, 39.9{\%}), 1-year 12.4{\%} (11.7, 13.1{\%}). HD AUD was higher than DSM-5 on pathology validators, including: life-time alcohol-related service use: HD 41.0{\%} (38.1, 43.9{\%}), DSM-5 11.5{\%} (10.7, 12.3{\%}); severity (number of life-time alcohol symptoms): HD 20.8 (20.4, 21.2), DSM-5 10.6 (10.4, 10.8); and family history of alcohol problems: HD 50.1{\%} (47.3, 52.9), DSM-5 32.8{\%} (31.6, 34.0). HD criteria eliminated 83{\%} of a DSM-5 teen transient drinker false-positives criterion group. Conclusions: Prevalence estimates of alcohol use disorder are lowered and diagnostic validity improved when using 'harmful dysfunction' diagnostic criteria compared with standard DSM criteria, partly by reducing misdiagnosis of teenage transient drinkers.",
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    KW - Harmful dysfunction

    KW - NESARC

    KW - Psychiatric epidemiology

    KW - Validity

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