Alvaro Vergés

Age and ethnic differences in the onset, persistence and recurrence of alcohol use disorder

AIMS To estimate ethnic differences in three components of alcohol use disorder and alcohol dependence course (onset, persistence and recurrence) in a developmental framework. DESIGN Longitudinal data from The National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), collected using face-to-face interviews. SETTING Civilian non-institutionalized US population aged 18 years and older, with oversampling of Hispanics, blacks and those aged 18-24 years. PARTICIPANTS Individuals who completed both NESARC assessments, were not life-long abstainers and were either white (n = 17,458), black (n = 4995), US-born Hispanic (n = 2810) or Hispanic-born outside the United States (n = 2389). MEASUREMENTS Alcohol dependence (AD) and alcohol use disorder (AUD; abuse or dependence) onset, persistence and recurrence were examined using the Alcohol Use Disorders and Associated Disabilities Interview Schedule, DSM-IV version. FINDINGS Among men: relative to whites aged 18-29, AUD onset and persistence were elevated only in US-born Hispanics aged 40 years and older; odds were reduced for all non-US-born Hispanics, older whites, most blacks and US-born Hispanics aged 30-39. For AD, onset risk was elevated for all younger minority men and only reduced among non-US-born aged Hispanics 40 or older. For women: compared to young whites, non-US-born Hispanics were at decreased AUD and AD onset risk; AUD and AD onset and persistence were increased for older blacks and US-born Hispanics. CONCLUSIONS In the United States, ethnic differences in alcohol disorder transitions (onset, persistence, and recurrence) vary across age, gender and whether a broad (alcohol use disorder) or narrow (alcohol dependence) alcohol definition is used. Evidence of increased risk for some transitions in minority groups suggests that attention should be paid to the course of alcohol use disorders, and that differences in prevalence should not be assumed to reflect differences in specific transitions.

The structure of Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision) personality disorder symptoms in a large national sample.

We examined the latent structure underlying the criteria for DSM-IV-TR (American Psychiatric Association, 2000, Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.) personality disorders in a large nationally representative sample of U.S. adults. Personality disorder symptom data were collected using a structured diagnostic interview from approximately 35,000 adults assessed over two waves of data collection in the National Epidemiologic Survey on Alcohol and Related Conditions. Our analyses suggested that a seven-factor solution provided the best fit for the data, and these factors were marked primarily by one or at most two personality disorder criteria sets. A series of regression analyses that used external validators tapping Axis I psychopathology, treatment for mental health problems, functioning scores, interpersonal conflict, and suicidal ideation and behavior provided support for the seven-factor solution. We discuss these findings in the context of previous studies that have examined the structure underlying the personality disorder criteria as well as the current proposals for DSM-5 personality disorders.

Transactional models between personality and alcohol involvement: a further examination.

Although correlated changes between personality and alcohol involvement have been shown, the functional relation between these constructs is also of theoretical and clinical interest. Using bivariate latent difference score models, we examined transactional relations (i.e., personality predicting changes in alcohol involvement, which in turn predicts changes in personality) across two distinct but overlapping developmental time frames (i.e., across college and during young adulthood) using two large, prospective samples. Across college, there was some evidence that alcohol involvement predicted changes in personality; however, these findings were limited to models that included more proximal measures of alcohol use. When examined across a longer timeframe, we found no evidence that alcohol involvement significantly predicted changes in personality but found some evidence that personality predicted changes in alcohol use. We did find reliable evidence of correlated changes between personality and alcohol use, especially during emerging adulthood. The findings from our datasets highlight that the impact of alcohol involvement on personality change may be limited to shorter intervals during specific developmental time-frames and that the relation between changes in personality and alcohol involvement may be best viewed from a noncausal perspective.

Letter to the Editor: The proposed 2/11 symptom algorithm for DSM-5 substance-use disorders is too lenient

Substance-use disorder (SUD) diagnoses are critically important for research and clinical practice. Unlike the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), the draft diagnostic criteria for SUDs in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) define a single SUD for various substance classes - such as ‘alcohol-use disorder’ (AUD)- based upon 11 symptoms. This criterion set is composed of all seven DSMIV substance dependence symptoms, three of the four DSM-IV substance-abuse symptoms (all but legal problems) and a craving symptom. AUD and other SUDs would be diagnosed if a person has at least 2/11 cooccurring symptoms. The 2/11 threshold was chosen, in large part, to emulate rates of any DSM-IV SUD (abuse plus dependence) (http://www.DSM5.org). We believe that the 2/11 algorithm is too lenient and creates serious multiple problems. The proposed algorithm would diagnose many whose substance involvement has questionable clinical significance, leading SUD diagnosis away from mainstream neuro-behavioral theory regarding what constitutes a mental ‘disorder’ and ‘addiction’. Further, the algorithm allows so much heterogeneity that the clinical and research utility of the diagnostic category would be greatly compromised. We illustrate these points with past-year AUD symptom data from 29993 lifetime drinkers aged 21 years and above, from wave 2 of the National Epidemiological Survey of Alcohol Use and Related Conditions (NESARC; Grant et al. 2003) (analytic details available upon request). Unlike wave 1, wave 2 had a craving item allowing us to study proposed DSM-5 diagnoses with respect to AUD prevalence, severity and heterogeneity.

Did Lifetime Rates of Alcohol Use Disorders Increase by 67% in 10 Years? A Comparison of NLAES and NESARC

Two nationally representative epidemiological samples (the National Longitudinal Alcohol Epidemiological Survey and the National Epidemiological Survey of Alcohol and Related Conditions) have been used to track changes in the prevalence of alcohol use disorders (AUDs) between 1992 and 2002 in the United States. Strikingly, estimates from these two data sets suggest that the lifetime prevalence of AUD increased by approximately 67% (from 18.2% to 30.3%) during this time frame. This article explores potential reasons for these discrepant estimates. Analyses indicated that a vast majority of change in lifetime AUD occurred with respect to alcohol abuse and not alcohol dependence. Most of this increase in abuse was attributable to self-reported changes in hazardous use that did not track with other archival measures of outcomes related to hazardous use in the population. Key methodological differences regarding the frequency requirements for prior-to-past-year alcohol abuse appeared to explain most of the discrepancy in lifetime AUD estimates. These findings, in conjunction with the relative lack of differences in the 12-month prevalence of AUDs, suggest that the discrepant lifetime estimates are likely due to methodological differences between the two surveys. These findings have important implications for substance use and other psychiatric surveillance and epidemiology where meaningful cross-temporal comparisons are desired.

It’s the Algorithm! Why Differential Rates of Chronicity and Comorbidity are Not Evidence for the Validity of the Abuse-Dependence Distinction

The validity of the abuse-dependence distinction within alcohol use disorders (AUDs) has been increasingly questioned on psychometric and conceptual grounds. Two types of findings are often cited as support for the validity of this distinction: (a) Dependence is more persistent than abuse, and (b) dependence is more highly comorbid with other Axis I and Axis II disorders than is abuse. Using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), we examined the extent to which the current diagnostic algorithm (3 of 7 dependence criteria for a diagnosis of dependence; 1 of 4 abuse criteria for a diagnosis of abuse if dependence criteria are not met) produces this pattern of findings independent of item set. Analyses in which all 330 permutations of the 11 AUD criteria were partitioned into a 4-item abuse set and a 7-item dependence set were conducted to examine the relevance of the criteria sets to estimates of persistence and comorbidity independent of criteria. Regardless of the criteria used, the dependence set (i.e., 3/7 criteria) always and substantially outperformed the abuse set (1/4) with respect to both persistence and comorbidity. These data indicate that chronicity and comorbidity are flawed indicators for the abuse-dependence distinction (and likely other conditions in which hierarchical decision rules are used). In addition, our analyses show that the current set of criteria defining alcohol dependence and abuse are not optimal.

Integrating Contextual Issues in Ethical Decision Making

Many issues in ethics arise in relation to the contexts in which psychologists work. However, most ethical decision-making models reproduce the way in which psychologists tend to approach ethics by focusing on ethical dilemmas and proposing a step-by-step response to deal with them. Although these models might be useful, their emphasis on reactive approaches and their lack of contextualization constitute significant limitations on their applicability. In this article, an approach to ethical decision making that highlights the importance of the context in developing proactive strategies to solve ethical issues is proposed. This approach is further explained through its application to medical and rural settings. The implications of these suggestions to the training in ethics are finally discussed.

Working memory as a moderator of impulsivity and alcohol involvement: Testing the cognitive-motivational theory of alcohol use with prospective and working memory updating data

Research consistently shows that individuals high in impulsivity are at increased risk for excessive alcohol use and alcohol-related problems including alcohol use disorders (AUDs). Recent theorizing posits that working memory (WM) ability might moderate this association, but extant studies have suffered from methodological shortcomings, particularly mischaracterizing WM as a single, unitary construct and using only cross-sectional designs. This paper reports two studies that attempted to replicate and extend previous investigations of the relationship between WM, impulsivity, and alcohol involvement using two independent samples. Study 1 used a large (N=489 at baseline), prospective cohort of college students at high and low risk for AUD to investigate interactions between WM capacity and impulsivity on cross-sectional and prospective alcohol involvement. Study 2 used a large (N=420), cross-sectional sample of participants in an alcohol challenge study to investigate similar interactions between WM updating and impulsivity on recent alcohol involvement. Whereas Study 1 found that WM capacity moderates the relationship between some measures of impulsivity and alcohol involvement, with effects prospectively predicting alcohol involvement for up to three years, Study 2 did not find similar moderation effects when using measures of WM updating. These findings highlight the multifaceted nature of WM, which is often overlooked in the alcohol and impulsivity literature.

Refining the Notion of Maturing Out: Results From the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES Our aim was to determine if the decrease in drug use disorders with age is attributable to changes in persistence, as implied by the notion of maturing out. Also, we examined the association between role transitions and persistence, recurrence, and new onset of drug use disorders. METHODS We performed secondary analysis of the 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions data (baseline assessment 2001-2002, follow-up conducted 2004-2005). We conducted logistic regressions and multinomial logistic regression to determine the effect of age on wave 2 diagnosis status, as well as the interaction between age and role transitions. RESULTS Rates of persistence were stable over the life span, whereas rates of new onset and recurrence decreased with age. Changes in parenthood, marital, and employment status were associated with persistence, new onset, and recurrence. We found an interaction between marital status and age. CONCLUSIONS Our findings challenge commonly held notions that the age-related decrease in drug use disorders is attributable to an increase in persistence, and that the effects of role transitions are stronger during young, compared with middle and older, adulthood.

Motivational typologies of drinkers: do enhancement and coping drinkers form two distinct groups?

AIMS This study used a person-centered approach to test whether drinking motive typologies could be identified. DESIGN Longitudinal study of college students within the intensive multivariate prospective alcohol college-transitions (IMPACTS) data set. SETTING University campus in the United States. PARTICIPANTS University students (baseline n reporting alcohol motives = 2158; baseline age = 18.60 years old). MEASUREMENTS The drinking motives questionnaire-revised (DMQ-R). FINDINGS Using Steinley & Bruscos cluster analysis approach [based on the theoretical ratio expected between the within sum of squares and the total sum of squares when the data are divided into two clusters when no cluster structure is present; the cut-off for the ratio is 0.25 for uniform (multivariate uniform) distributions and 0.36 for normal (multivariate normal) distributions], we examined whether there was evidence for distinct clusters of individuals that differed on their overall level of motives to drink. We tested the fit of a one-group (cluster) solution compared to multi-cluster solutions. Both cross-sectionally and prospectively, the data could not be partitioned into two or more clusters [regardless of whether the cut-off assuming a multivariate uniform distribution (i.e. 0.25) or the more liberal multivariate normal distribution (i.e., 0.36) was used]. These findings showed that enhancement and coping drinkers do not form two distinct groups but, rather, these motives exist on a continuum such that individuals who are high in one internal motive tend to be high in the other motive. CONCLUSIONS Coping and enhancement drinkers do not form two distinct groups. Variable-centered approaches to drinking motives may be a better alternative to classifying all drinkers as either enhancement or coping drinkers for both clinical and research endeavors.