norman g. hoffmann, ph.d. western carolina university [email protected] 828-454-9960
TRANSCRIPT
DSM-5 & TAAD-5: Implications for
First Time OffendersNorman G. Hoffmann, Ph.D.Western Carolina [email protected]
828-454-9960
Overriding PrinciplesClinicians determine diagnoses – assessment instruments don’tClinicians make decisions – tools don’tInstruments are tools to be used by clinicians to systematically gather informationClinicians should utilize all available information in making determinations including assessment results, legal records, and other corroborating information
Screening vs. Triage vs. Diagnostic Assessment
Screening: short, fast, cheap estimate of probability that a person has a conditionTriage: brief coverage of all diagnostic criteria to make initial decisionsDiagnostic assessment: comprehensive coverage of all diagnostic criteria that when combined with all other sources of information allow clinicians to make a definitive diagnosis
WHEN TO SCREEN?Screen for what is NOT the presenting complaint or problem area.
Screen for common problems other than the presenting complaint
Addiction programs screen for MH
MH clinics screen for addictions
Follow with an assessment for the presenting complaint or problem areas identified by positive screen results.
The UNCOPEU – Have you spent more time drinking/using
than intended? (Unintended Use)N – Have you ever neglected usual
responsibilities because of using?C – Have you ever wanted to cut down on
drinking/using?O – Has anyone objected to your drinking/use?P – Have you found yourself thinking a lot
about drinking/use? (Preoccupied)E – Have you ever used to relieve emotional
distress, such as sadness, anger, or boredom?
UNCOPE: A Brief Free Screen for Substance Use Disorders
Six items used in screening adults and adolescents for any substance use disorder
Free – from Evince Clinical Assessments[research tab at www.evinceassessment.com]
Two or more positive responses indicate risk for a severe substance use disorder
Sensitivity for severe = 90% to 95%
Specificity for severe = 90% to 95%
UNCOPE and the DSM-5The first five UNCOPE items conform to five DSM-5 criteria:
Criterion 1: U = unplanned useCriterion 5: N = role fulfillment failureCriterion 2: C = desire to cut downCriterion 6: O = interpersonal conflictCriterion 4: P = craving
Item E = possible self-medication – not a DSM-5 criterion
WHEN/WHERE TO TRIAGE?Need more than a screening probability estimate
Results: negative finding; severe diagnosis; mild to moderate or unclear
When limited time, circumstance, or task precludes a comprehensive assessment
Emergency room settingsDUI/DWI evaluationsInitial inmate evaluation (e.g., jails)
Follow with a comprehensive assessment if indicated/required
WHAT IS REQUIRED FOR TRIAGECover all of the diagnostic criteriaEnable clinicians to exclude a diagnosis based on sufficient negative findings of key markersConfirm obvious diagnoses (especially severe) based on positive criteria findingsProvide a concrete summary of positive findings that can be externally reviewed and confirmed by the appropriately trained clinician
WHEN IS A COMPREHENSIVE ASSESSMENT REQUIRED?Treatment intake
screens are totally inappropriate and triages may be inconclusive for treatment planning purposes
For court dispositions that might require treatment recomendations
When litigation may be involved
Any situation that requires a potentially life-altering decision
WHAT IS REQUIRED FOR A COMPREHENSIVE ASSESSMENT
Thorough coverage of all diagnostic criteria with multiple questionsCurrent and collateral findings regarding problem areas – family, past records, etc.Mechanism for providing a checklist or narrative summary of DSM-5 criteria – a numeric “score” on a “scale” is insufficient – must be based on the specific DSM-5 criteria that are positive
Substance Use Disorder Criteria1.Use in larger amounts or longer than intended2. Desire or unsuccessful effort to cut down3. Great deal of time using or recovering4. Craving or strong urge to use5. Role obligation failure6. Continued use despite social/interpersonal
problems7. Sacrificing activities to use or because of use8. Use in situations where it is hazardous
DSM-5 SUD Criteria continued9. Continued use despite knowledge of having a
physical or psychological problem caused or exacerbated by use
10.Tolerance11. Withdrawal
Criteria 1-4 relate to use; Criteria 5-8 relate to behavioral issues
associated with use; Criteria 9-11 relate to physical/emotional issues
DSM-5 Initial VS. DSM-5 FinalInitially the proposed DSM-5 had two diagnostic categories: moderate and severe defined by 2-3 and 4+ positive criteria
Final formulation has three categories: mild (2-3), moderate (4-5), and severe (6+ positive criteria)
Original “moderate” becomes “mild”
No compelling empirical basis for cut points
Pros vs. Cons of theDSM-5Pros
The severe diagnosis identifies people who in all probability need to set abstinence as a goalThe mild diagnosis will in most cases be those who do NOT need to have abstinence as a goalProvides a framework for making better treatment decisions based on collection of outcome findings
ConsMay give the impression that the severe diagnosis is simply a versions of the moderate and mild diagnosesThe distinctions between diagnoses are not empirically derived and may not be the optimal points of discrimination
GENDER COMPARISON of DSM-5 ALCOHOL DIAGNOSES
Males N = 6,871 Females N = 801
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
Kopak, Metz, & Hoffmann (in press)
GENERAL COMPARISON of DSM-5 CANNABIS DIAGNOSES
Males N = 6,871 Females N = 801
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
Kopak, Proctor, & Hoffmann, 2012
GENERAL COMPARISON of DSM-5 COCAINE DIAGNOSES
Males N = 6,871 Females N = 801
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
Proctor, Kopak, & Hoffmann, 2012, in press
COMPARISON of DSM-5 DIAGNOSES FOR ADOLESCENTS
Males N = 571 Females N = 333
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
No
Dx
Abuse
Depen
denc
e0%
20%
40%
60%
80%
100%
SevereMod.MildNo Dx
Malone & Hoffmann, 2012
DSM-5 vs. DSM-IV SummaryAlmost all who did not get a DSM-IV-TR diagnosis will still not have a DSM-5 diagnosis
The vast majority of those with a dependence diagnosis will fall into the severe designation of the DSM-5
Substantial changes will be seen for those now diagnosed with abuse
Most will receive a diagnosis of mild substance use disorder
A significant minority will no longer get a diagnosis
A smaller minority will get a moderate diagnosis
Comparison of TAAD vs. SUDDS-IV DSM-IV Alcohol Diagnoses
Males N = 6,871 Females N = 801
No
Dx
Abuse
Dep.
0%
20%
40%
60%
80%
100%
De-pen-denceAbuse
No Dx
TAAD Dx
Model
No
Dx
Abuse
Dep.
0%
20%
40%
60%
80%
100%
De-pen-denceAbuse
No Dx
SUDDS-IV Diagnosis SUDDS-IV Diagnosis
TAAD Dx
Comparison of TAAD VS. SUDDS-IV DSM-IV ResultsSUDDS-IV is a longer and more comprehensive assessment (30-45 min.)
TAAD is brief (10-15 min.) and is more specific for alcohol
All TAAD classifications of dependence are confirmed by SUDDS-IV
TAAD may underestimate dependence among abusers
TAAD VS. SUDDS-IV with Initial Alcohol DSM-5 Diagnosis
Males N = 6,871 Females N = 801
No
DxM
ild
Mod
-Sev
0%
20%
40%
60%
80%
100%
Mod-SevMildNo Dx
TAAD Dx
Model
No
DxM
ild
Mod
-Sev
0%
20%
40%
60%
80%
100%
Mod-SevMildNo Dx
SUDDS-IV Diagnosis SUDDS-IV Diagnosis
TAAD Dx
Comparison of TAAD VS. SUDDS-IV DSM-5 ResultsAll TAAD moderate to severe confirmed by the longer SUDDS-IV
Compared to the DSM-IV results, the TAAD appears to miss more mild diagnoses
This may be due to lack of craving and compulsion items on the original TAAD
These are added to the TAAD-5 and may resolve this issue
DSM-5 Diagnostic Distribution for First-time DUI/DWI Offenders
54.1
27.4
9.7
8.8
N = 658
No DxMildModerateSevere
Comparison of Diagnostic Results for First-time DUI Offenders
Abuse Dependence0%
20%
40%
60%
80%
100%
SevereMod-erateMildNo Dx
DSM-5 Di-agnoses
DSM-IV-TR Diagnoses
N = 658
Distribution of Positive DSM-5 Criteria
0 1 2 3 4 5 6 7 8 9 +0
5
10
15
20
25
30 26.927.2
16.2
11.2
6.53.2 2.9 1.5 1.1 3.3
N = 658 First-time DWI/DUI Offenders
54.1% No diagnosis
45.9% at least mild diagnosis
18.5% at least moderate diagnosis
Other Drug Use Given Alcohol DSM-5 Diagnosis
No Dx Mild Moderate Severe0
5
10
15
20
25
30
35
40
45
CannabisOther DrugAny Drug
General DSM-5 FindingsMost first-time DUI/DWI offenders will not receive a DSM-5 diagnosis due to:
Elimination of legal problemsRequirement for two positive criteria
The moderate and severe diagnoses conform almost exactly to dependence for almost one in five first-time offenders
Positive diagnostic findings for alcohol related to higher probability of drug use
DSM-5 CRITERIA Differentials on Inmate Populations
All criteria are not equal in implications
Some criteria are found almost exclusively among those in the severe alcohol or other substance use disorder diagnoses
Other criteria are more common among the mild to moderate alcohol use disorder group
Tolerance and dangerous use are actually common among those with no diagnosis
Distribution of Positive Alcohol Criteria for 6,871 Males
DSM-IV Criteria Based on SUDDS-IV Results
DSM-5 Designations Pop. Prev.No
DxMild Mod. Sev.
1. Unplanned use 2% 8% 11% 79% 27%2. Unable to cut down <1% 4% 7% 88% 21%3. Time spent using 2% 6% 11% 81% 28%4. Craving/compulsion 1% 3% 7% 89% 21%5. Role failure <1% 3% 9% 88% 25%6. Social Conflicts 3% 13% 14% 70% 34%
Distribution of Positive Alcohol Criteria for 6,871 Males
DSM-IV Criteria Based on SUDDS-IV Results
DSM-5 Designations Pop. Prev.No
DxMild Mod. Sev.
7. Sacrifice activities <1% 2% 9% 89% 23%8. Dangerous use 8% 15% 15% 62% 36%9. Contraindications 3% 10% 11% 76% 30%10. Tolerance 12% 11% 11% 66% 33%11. Withdrawal <1% 3% 7% 90% 19%Self-medication 5% 9% 11% 75% 27%
Distribution of Positive Alcohol Criteria for 801 Females
DSM-IV Criteria Based on SUDDS-IV Results
DSM-5 Designations Pop. Prev.No
DxMild Mod. Sev.
1. Unplanned use 3% 8% 9% 80% 31%2. Unable to cut down 0% 2% 6% 92% 24%3. Time spent using 0% 1% 7% 92% 26%4. Craving/compulsion <1% <1% 3% 96% 23%5. Role failure <1% 5% 5% 90% 26%6. Social Conflicts 3% 10% 10% 77% 33%
Distribution of Positive Alcohol Criteria for Females
DSM-IV Criteria Based on SUDDS-IV Results
DSM-5 Designations Pop. Prev.No
DxMild Mod. Sev.
7. Sacrifice activities <1% 3% 4% 93% 25%8. Dangerous use 6% 8% 9% 77% 29%9. Contraindications 3% 9% 10% 78% 32%10. Tolerance 10% 5% 10% 75% 32%11. Withdrawal 0% 2% 3% 95% 20%Self-medication % % % % %
Positive Alcohol Criterion within DSM-5 Diagnostic Designations
DSM-5 Criteria Based on TAAD Results
DSM-5 Designations
No Dx Mild Mod. Severe
1. Unplanned use 19% 72% 80% 98%2.Unable to cut down 2% 14% 38% 69%3. Time spent using 0 4% 25% 62%4. Craving/compulsion <1% 3% 12% 43%5. Role failure <1% 6% 12% 74%6. Conflicts (interpersonal) 3% 28% 74% 90%
Positive Alcohol Criterion within DSM-5 Diagnostic Designations
DSM-5 Criteria Based on TAAD Results
DSM-5 Designations
No Dx Mild Mod. Severe
7. Sacrifice activities 0 8% 22% 81%8. Dangerous use 11% 43% 59% 83%9. Contraindications 8% 5% 17% 60%10. Tolerance 13% 52% 81% 86%11. Withdrawal 0% 5% 12% 48%Self-medication 3% 14% 25% 61%
SUD Criteria Prevalent in Mod. to Severe – Rare if no Diagnosis
The “Big Five”
Wanting to cut down/unable to do so
Craving with compulsion to use
Sacrifice activities to use
Failure at role fulfillment due to use
Withdrawal symptoms
Clinical Implications of the Differential Criteria PatternsDifferent populations are consistent in the finding that the “Big Five” are predominately found among the more severely involved
Some differences noted for time spent:Female inmatesDUI/DWI offenders
Population specific interpretations might be required for best clinical results
DSM-5 Criteria Differentials – Is it the Number or the Pattern?
All criteria are not equal in implications
The pattern of positive criteria findings can suggest differential needs and prognoses
Could the diagnostic discriminations based on the number of findings be less important than the pattern of positive results?
Sample of AlcoholDiagnostic Documentation
Alcohol Diagnosis Diagnostic Criteria1 2 3 4 5 6 7 8 9 10 11
Case 1 X X X X X X X XCase 2 X X XCase 3 X X X X XCase 4 X X X X X
Severe
Mild
Moderate
Moderate
Cases 3 & 4 with the same diagnosis may have different prognoses if the Big Five are related to outcomes
CASE 3: Positive DSM-5 Criteria3. Great deal of time using10. Tolerance1. Unplanned use: more or longer use8. Use in hazardous situation (impaired driving)6. Recurrent interpersonal conflicts
Conclusions No loss of control indicated Misuse and possible irresponsible behavior Moderation may be a reasonable initial goal
CASE 4: Positive DSM-5 Criteria4. Craving/compulsion to use1. Unplanned use: more or longer use5. Role obligation failures2. Desire/efforts to cut down7. Sacrificing activities to use
Conclusions Loss of control indicated Positive on 4 of the “Big Five” Abstinence likely required for recovery
Implications for DispositionEducation and brief counseling may be appropriate for majority of 1st time offendersFor those with a diagnosis, the pattern may be as important as the number of positive criteriaThose positive on any of the Big Five criteria should be carefully evaluated regarding the current and projected trajectory of their condition
Final Criticism of the DSM-IV Loss of control not required for a dependence diagnosis – e.g., tolerance, spending time using, and occasionally drinking more/longer than intended – got the chronic diagnosisSome abuse criteria are stronger indications of a serious condition than some dependence criteria
Role obligation failure is a Big Five criterionTolerance is often seen in mild cases or even among those with no diagnosis
Summary for DSM-5The TAAD and SUDDS-IV produced similar results for the DSM-IV
The TAAD did not approximate the DSM-5 as well necessitating development of the TAAD-5
We expect that the TAAD-5 will better match the results of the SUDDS-5
However, since the TAAD-5 is shorter, it may still underestimate severity in some cases severely affected
Indications of Drug UseAlcohol may not be the only substance of concern with 1st time offendersMarijuana use most common drug used – about 10% not dependent vs. 25-40% of dependent (moderate to severe alcohol Dx)Cocaine use unusual for those not dependent on alcohol (severe alcohol use disorder)Use of multiple drugs provides even stronger evidence of probable diagnosis indicating need for abstinence as a treatment goal
General Issues of ValidityValidity scales are of limited utilityValidity scales themselves may be inaccurateAssessment challenge is to document indications of a substance use disorderEven if some responses are inaccurate, the overall indications might still be accurateInvalidity based on a validity scale does not provide grounds for legal or administrative dispositions
Issues of TAAD-5 ValidityConcurrent validity of TAAD with the SUDDS-IVFindings of no diagnosis very likely to be accurate compared to extensive assessmentTAAD findings of moderate to severe substance use disorder consistently confirmed by more extensive assessmentSome underestimate of severity is likely to persist with the TAAD-5 due to its brevity
TAAD-5 Interpretation StrategyAccept a determination of no diagnosis or severe alcohol use disorderFor mild or moderate alcohol use disorder, a relatively small proportion will have a more severe condition – consider further inquiry if there is a questions of severityMultiple positive findings on “Big Five” items with a moderate diagnosis suggests a guarded prognosis with possible emergence of a more serious problem
Referral/Disposition ModelBased on empirical evidence
Assumes policies and regulations are flexible
Uses the diagnostic and assessment findings to drive referral/disposition options
Incorporates existing monitoring technologiesMotor vehicle interlocks SCRAM (Secure Continuous Remote Alcohol Monitoring) monitors alcohol secretion via an ankle bracelet and reports results via modemTelemetry breathalyzer
Technology OptionsVehicle Interlock
Verifies that person starting vehicle is not intoxicatedMight be defeated with participation of confederates
SCRAMAnkle unit monitors level of consumption 24/7Additional sensors to detect tampering
Telemetry breathalyzerLinked to mobile phone for random testing
Ideal World ConceptsSome options involve monitoringClinical findings inform the disposition chosenMonitoring of results can refine the decision processesDisposition decisions utilize all available information – assessment, treatment history (if any), BAC, prior offenses (if any), etc.All options will involve comparable financial costs and time requirements for the offender
Option 1: Moderate-Severe CaseSCRAM or breathalyzer monitoring to ensure abstinence during period of supervisionAddiction treatment based on ASAM Criteria required for reinstatementFine (if any) is balance between the treatment recommended and cost of intensive treatmentSanctions for noncompliance or failure to remain abstinent
Option 2: Moderate (no Big Five) Monitoring with SCRAM or breath – no intoxication – OR InterlockEducation program regarding drinking & driving plus low intensity treatment if recommendedBased on the assumption that some individuals may drink so long as they do not become intoxicated or drive under the influenceFine is equivalent to the cost of addiction treatment minus treatment recommendedSanctions for failure to adhere to protocol
Option 3: Mild or No Clinical DxPossible monitoring with interlock if desired – assumes moderated use possibleEducation and brief counseling regarding drinking and drivingBased on the assumption that these individuals may drink so long as they do not drive if intoxicatedFine is equivalent to cost of intensive treatment minus the cost of education and counselingSanctions for failure to adhere to protocol
Assessment Ground Rules for Clinical Practice
Rule 1: NO assessment instrument “makes a diagnosis” or a disposition recommendationRule 2: Assessment instruments provide relevant information to professionals – nothing moreRule 3: Only professionals with the requisite expertise make diagnoses, referrals, or other disposition decisionsRule 4: See Rule 1
Norman G. Hoffmann, Ph.D.Adjunct Professor of Psychology
Western Carolina [email protected]
828-454-9960www.evinceassessment.com