Substance-Related and Addictive Disorders

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timer Asked: Oct 29th, 2018
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Question description

The sign of an effective clinician is the ability to identify the criteria that distinguish the diagnosis from any other possibility (otherwise known as a differential diagnosis). An ambiguous clinical diagnosis can lead to a faulty course of treatment and hurt the client more than it helps. In this Assignment, using the DSM-5 and all of the skills you have acquired to date, you assess an actual case client named L who is presenting certain psychosocial problems (which would be diagnosed using Z codes).

This is a culmination of learning from all the weeks covered so far.

Submit the following 2-part Assignment:

Part A: A 5- to 7-minute PowerPoint (PPT) presentation in which you:

  • Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention).
  • Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used.
  • Identify 2–3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated.
  • Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis.
  • Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations.
  • Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions.
  • Identify client strengths, and explain how you would utilize strengths throughout treatment.
  • Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so.

Part B:

Provide a written diagnostic summary which:

  • Includes the essential diagnostic information presented in your Power Point.
  • Is written in the form of case notes to be placed in a client’s file.

The Case of L Presenting Problem Client presented in the emergency room (ER) having been brought in the previous night by her parents. Following an argument with her parents, L cut her right wrist. L's mother reported that L started screaming rapidly and became physically violent toward her prior to cutting her own wrist. Psychological Data L is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father, and older sister. She is in 11th grade at the local public school. L appeared to be of average to above-average intelligence, as she was able to respond to numerous questions in an articulate and intelligent manner. She was well versed about world history and current affairs. Her mother confirmed that she has done well in school, maintaining a B+ average and participating in various school activities (e.g., chorus, school paper) until last year. L slowly dropped out of many activities she liked in the past. Her mother noticed about 8 months ago that L had also begun having difficulty doing schoolwork. Erratic behavior arose during episodes when L also became irritable and explosive. During these repeated episodes, she became quite defiant, cut classes, had to be placed in school detention, and had even assaulted the principal. L has numerous friends and believed she can relate to all types of people. She has a boyfriend who adores her, but she said she doesn't feel the same about him. The school counselor confirmed that L is outgoing, popular, and smart; but during these episodes she became another person, one who is very violent and difficult. Medical History A physical examination by a staff doctor revealed superficial cuts on L’s left and right wrist. The cuts appeared to be a few weeks old. There were cigarette burns on her right wrist that looked to be approximately one week old. In questioning L about the cigarette burns, L responded, "I just wanted to see how it felt—now I know." When questioned about old cuts on her left wrist, she responded, "I don't want to talk about it." L weighs 103 pounds and is 5’ 6” tall. L denied any dieting or fasting, but her mother noticed over this past year that her weight has dropped. Substance Abuse History L denied any drug or alcohol use. When she was questioned regarding such, her response was "I could do drugs if I wanted to. I don't want to, because it’s dumb." Family History L’s mother is 42 years old and works as a secretary for a large telephone company. Her father is 49 years old and operates a small landscaping business. Both are U.S. citizens, with a cultural background from Guatemala of which they are proud. Both have 1 a high school education. L’s sister is considerably younger, aged 8. Their relationship is described as unremarkable, although L’s mother noted that the younger sister stays away when L is upset. Marital circumstances are uncertain, although the parents admitted that they are trying to keep the family together for their children, and they are of the Catholic faith. Treatment costs for L have been an additional difficulty for the family, but they said they are very worried about L’s lack of self-control and discipline. Extended family are far away and mostly still in Guatemala. L’s parents were not aware of any other family members with psychiatric problems. Psychiatric History L was evaluated three times at the community hospital ER during the past 4 years. Hospital evaluations were usually done after suicide attempts or threatening violent behavior toward others. L thought that the clinicians trying to diagnose her only had book skills and no people skills. She assumed that no one will ever know what is wrong with her; she did not plan to tell them because she doesn't like them. L said she knows she “is not crazy,” but she was convinced that the therapist thought she is crazy or a “bad” kid. "They're just experimenting with me," L said. L indicated that she had been prescribed medications to alter her mood, but she couldn't recall what it was, as she stated, "I don't need those; nothing is wrong with me." L's mother reported that L was involved in outpatient counseling on at least four occasions as well as being placed in a shelter once after school truancy, running away from home, and threatening to assault her. A social worker was even sent for home visits for a 3-month period. Each time, L would abruptly end therapy by becoming verbally abusive or totally noncommunicative toward the therapist and would adamantly refuse to continue therapy. She even admitted to shoving a desk toward a therapist and threatening her with a pencil. When questioned about this behavior, L responded, "Well she told me to express myself and let my true feelings out, so I did." (L also laughed and glanced at her mother during this exchange.) L’s mother was particularly perplexed and overwhelmed by these behaviors. She stated that her husband is completely frustrated and angry. Both admitted that L’s behavior is part of the considerable strain on their marriage. L denied being under any continued psychiatric care even though it was recommended numerous times. She refused to go, stating, "The therapists are the ones who are crazy." L was first seen in outpatient counseling 9 years ago after she began to have nightmares and experienced tremendous anxiety after her godmother threatened to kidnap her. Her godmother became obsessed with L when L was 6 years old, first threatening to kidnap her then. Her godmother had to be institutionalized after exhibiting bizarre behavior. Recently, the godmother started threatening to kidnap L again. Three years ago, L was sent for counseling after she ran away from home after getting a bad report card and also discovering that her parents were considering a divorce. L requested therapy, as she reported that at 8 years of age she was sexually molested by an older man in the community (who is now deceased). She expressed having mixed emotions, because she viewed her perpetrator as her friend. By pretending that nothing 2 happened, she could think of him as a nice old man, and she didn't have to deal with the thought of something this bad happening to her. L’s mother reported that she herself was raped at 8 years old and that L had knowledge of this. Two years ago, L and the entire family again became involved in outpatient counseling after L's godmother accused L's mother of child abuse. L's mother thought this was largely done out of spite. An investigation by Child Protective Services revealed no abuse. Mental Status (1 day after she had been evaluated at the ER) L presented casually, disheveled, in shorts and a tee shirt, and with minimal makeup. L admitted to being in a nasty mood. There was little eye contact, and conversation was difficult. Thought and speech patterns were clear. Affect was flat. She was oriented to time, place, and person. L denied feeling depressed. When questioned about her suicide attempt the previous day, she suddenly became quiet and teary eyed. She lowered her head and responded, "You don’t understand, he made me do it. I don't want to hurt myself." L denied even remembering cutting her wrist, saying, "He must have done it or made me do it.” L was questioned about the person she was talking about. She related that there has been a male presence in her life since she was 6 years old and that he makes her do things that she doesn't want to do or things she can't even remember. This presence showed up after the funeral of her best friend, Michael. L said he communicates with her through her mind. She seemed distressed when speaking about him. Her mother appeared distressed and fearful as well. L’s mother confirmed that L had trouble sleeping and concentrating at school after the funeral. She did not want to attend Girl Scouts anymore, because the uniform had gotten tight and the male presence was laughing at her. L’s mother remembered how scared she had become on a few occasions when L attempted to run out into traffic. Every time L’s mother yelled at L for doing that, L stated that the male presence explained that this was how she could join her friend Michael. L’s mother took L to a therapist. When L entered the third grade, L’s mother took her out of therapy. L reported that during her awake hours she can't see this presence, but she can sense him. She said she does see him in her dreams, and his appearances in them have intensified within the past year. In her dreams, he torments children, and he controls people through a haunted mirror and a magic book. He reads and controls thoughts. L described him this way: “He looks in his 40s, but is really ageless. Always dressed in dark colors, but I can’t tell the exact colors he wears. I know his eyes are powerful, but I never really look at his eyes.” L was asked why she never shared this information before. She stated, "Because I would be put in the hospital and medicated—and I told you, I'm not crazy. I know you don't understand, but I am him and he is me, and he eventually wants to totally control me." She admitted to acting out impulsively at times, such as throwing things for no reason. L reported that the presence was in the room during this interview. When questioned about why he doesn't influence her now or make her do something, she replied, "He's too smart, he wouldn't do that." L also mentioned that during the past 3 couple of months another male presence has been with her. This new presence seems to be controlled by and intimidated by the primary presence. The two males communicate with one another about how to hurt the children in her dreams. L ended the session by saying, "I know this sounds weird, but this is what is happening to me. If you tell any other therapist, I'll deny it, because I don't want to be put away." 4
Alcoholism Treatment Quarterly ISSN: 0734-7324 (Print) 1544-4538 (Online) Journal homepage: http://www.tandfonline.com/loi/watq20 Addictions as Emotional Illness: The Testimonies of Anonymous Recovery Groups Paula Helm To cite this article: Paula Helm (2016) Addictions as Emotional Illness: The Testimonies of Anonymous Recovery Groups, Alcoholism Treatment Quarterly, 34:1, 79-91, DOI: 10.1080/07347324.2016.1114314 To link to this article: https://doi.org/10.1080/07347324.2016.1114314 Published online: 08 Jan 2016. Submit your article to this journal Article views: 398 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=watq20 ALCOHOLISM TREATMENT QUARTERLY 2016, VOL. 34, NO. 1, 79–91 http://dx.doi.org/10.1080/07347324.2016.1114314 Addictions as Emotional Illness: The Testimonies of Anonymous Recovery Groups Paula Helm, PhD Department of Political Theory, Goethe Universität, Frankfurt, Germany ABSTRACT Participants in recovery groups from a variety of addictions, following the Alcoholics Anonymous model, identify with each other as suffering from a common “illness of the emotions.” This study analyzes metaphors used to describe the patterns and dynamics of this emotional illness and recovery, derived from the personal writings and testimonials of group participants. Ways in which the participants discover alternate ways to deal with their emotional illness other than manipulating it to an active addiction are also explored. KEYWORDS Addictions; emotion illness; alcoholics anonymous; recovery groups; personal writings and testimonials; anonymity Introduction Mutual support-groups are one of the most striking phenomena in the field of addictions therapy. Mutual support groups are nonprofessional, self-organized groups that follow the approach of Alcoholics Anonymous (AA). In those groups people who suffer from various kinds of addictions meet to address not only their symptoms of their illness but also the deeper emotional roots of their condition. In doing so, they understand addiction not only mentally and physically but experientially. This level of understanding is germane to the process of recovery as it addresses a disease induced and selfimposed emotional isolation that is born out of a fear of facing the pain and suffering associated with one’s disease. In the recovery groups, participants develop the ability to face themselves and the reality of their destructive behavior seen through the eyes of another with the same condition. Yet, before the group experience, participants fear this pivotal moment. This fear of seeing the reality of their disease in the eyes of another dooms these individuals. Based on this insight, participants of early AA groups developed a new category to describe their alcoholism as an “illness of the emotions” (Alcoholics Anonymous [AA], 1957, p. 239) they called it. Using this category they could identify with each other on a deeper CONTACT Paula Helm, PhD helm@em.uni-frankfurt.de Department of Political Theory, Goethe Universität Frankfurt, Room 3. G 039, Theodor-W-Adorno-Platz 6, 60323 Frankfurt am Main, Germany. The author approved the manuscript and this submission. The author reports no conflicts of interest. © 2016 Taylor & Francis Group, LLC 80 P. HELM level other than just a behavioral level, finding solace in the commonality of their suffering and breaking through their isolation. Analyzing groups that understand addiction as an illness of the emotions adds to our understanding of the multidimensional character of addiction. The focus of this article is on emotional illness as an essential component of substance use disorders. Using an ethnographic approach the aim of this study is to capture patterns of emotional illness, identified by studying the groups themselves as well as personal stories, which participants’ author as part of their therapeutic process. In their personal writings they reflect not only on their disease but also on their recovery. An analysis of group rituals and personal stories of the participants identifies not only patterns of emotional illness but also of emotional recovery as recounted in group settings. Method A 2-year imperial study was undertaken to identify and collate patterns of emotional illness and recovery as recounted in recovery groups. Two primary sources were identified: (1) Personal testimony archived by recovery groups such as AA, Narcotics Anonymous (NA), Sex Addicts Anonymous, Overeaters Anonymous, and various autobiographic writings that have been published by the groups. (2) Personal participatory observation by the author in the recovery groups in New York and in Germany. Sample The sample comprises a heterogeneous mixture of 50 narratives, between 1930 and 2013, including members of different groups, of varying ages, genders, and cultural backgrounds. The sample consists of unpublished narratives, written for the purpose of creating a moral inventory and taken from trademarked texts of 12-Step networks; the source texts were on loan from each group’s World Service Office (WSO). Metaphors used to express and define emotional illness and recovery were collected from members’ autobiographic writings and personal testimonies. The narratives over the years were studied to determine which elements of the narrative structure remained consistent despite cultural and historical changes. Because all the stories of the sample conform to one specific narrative structure that addresses the taking of a moral inventory of one‘s internal experience, examples from single stories can be quoted to represent an archetype. The authors themselves call the way they structure their narratives ALCOHOLISM TREATMENT QUARTERLY 81 a “formula” (AA, 2003). This formula was developed in the 1930s when the founders of AA collected participant narratives designed to tease out the typical patterns of emotional reactions to varied stimuli. The following quote from a letter from Bill W. to Bob S. captures this trend and the origins of a narrative “formula”: It might be a good idea to ask people to write their own stories in their own language and at all the length they want to cover those experiences from childhood up which illustrate the salient points of their character. Probably emphasis should be placed on those qualities and actions which caused them to come into collision with their fellows. The queer state of mind and emotion, the first medical attention required, the various institutions visited; these ought to be brought in. (. . .) There ought to be descriptions of the feelings when he met our crowd, his feeling of hopelessness and the victory over it, his application of principles to his everyday life, including domestic, business and relations the problems which still face him, and his progress with them; these are other possible points. (AA, 1935–1939, Bill W. letter to Bob S., 1938) The formula extracted from the stories collected during the following months serves as an emotional compass, a compass helping to “make sense of otherwise confusing sequences of experience” (AA, 1935–1939, Bill W. letter to Bob S., 1938). In this article, quotes taken from an overall sample of 20 unpublished documents and 30 published documents, all following the original formula, are used to exemplify the patterns of emotional illness and recovery. The author also used data for analysis and reference based on ethnographic insights gathered during one year of participant observation of mutual support groups in New York and Germany. The author identified herself as a researcher in open meetings conducted by Overeaters Anonymous, Underearners Anonymous, Sex Addicts Anonymous, AA, NA, and Al-Anon Family Groups. Analysis To get insight into the dynamics of emotional illness and recovery process an empirical investigation was conducted, that combined two different approaches: (1) For analyzing the concepts of emotional illness indicating the different areas of addiction and recovery within the autobiographic writings, a method was applied that works through coding and decoding metaphors. The method was developed by Lakoff and Johnson (2003). It focuses on how people express subtle emotional processes by projecting commonly used metaphors on to psychological and emotional 82 P. HELM platforms. As a first step in developing an initial system of categorization, an open-coding pass was applied on all the text materials of the sample. As a second step, new codes were added whenever a new metaphor arose that did not fit into any of the previously created categories. After classification, all codes were clustered thematically using affinity diagramming. (2) Turner’s ritual-theory (Turner, 1969, 2000) helps us understand the manner in which mutual support interacts with patterns of emotional illness. The common rituals practiced in the groups were studied following this model. The model concentrates on those ritualized sequences that, despite the different locations, sizes, and topics of the groups, were repeated each and every time. This focus enables us to identify the substantial factors in a group setting that empower people to communicate their emotions and thereby allows mutual identification at the emotional level. By combining both approaches, the textual analysis and the ritual study, six major themes of emotional illness and four major themes of emotional recovery were be identified. Theoretical basis The study embraced a subject-centered perspective (Reckwitz, 2003, p. 284). This perspective implies that the participants themselves are understood to be the “experts of their own life” (Thiersch, 2002, p. 124). Another analytical foundation of this study was one that identified the groups as rites of transition (Van Gennep, 1960/2010). In analyzing the ritualized process of change taking place within the group participants, the Turner model of liminality was used. This model understands liminality as a performativity created space where people (inter)act “beyond the norms and ideals of the social structure” (Turner, 1969, p. 94). Defining the groups as such a space, where people can experience themselves through a paradigm other than that to which they are accustomed, allows nonparticipants to understand how participation in anonymous group rituals positively affects the process of transition from emotional illness to emotional health. Barthes’ (1982) methodology provides the framework for the critical approach concerning the social factors of the disease of addiction. He advises analyzing pre- and late-modern narrative structures as myths. His approach to history is performative, meaning he understands the subjective perception of reality as determined through a specific representation of the past, which gives meaning and creates cultural currency. This approach serves the purpose of determining how the exchange of ALCOHOLISM TREATMENT QUARTERLY 83 unconscious, tacit norms influences participants, and how it correlates to broader mythological concepts. Results The result section is divided into two parts. The first part is devoted to the five patterns of emotional illness as found in the textual analysis: initial crisis, rationalizing contradictions, metaphors of fight and war, a public and private self, and cycles of selfishness. The second part deals with the narrative of emotional recovery as practiced in the groups and as exemplified in the autobiographic writings of participants. Four patterns are identified: hitting bottom, anonymity, the emotional bottom, capitulation. Patterns of emotional illness Initial crisis An initial crisis is a common theme in all of the samples that were analyzed. These crises are described as either personal losses, or collective events such as war, financial crisis. Bill W.’s narrative, in 1939, serves as a constant point of reference for such a crisis: War fever ran high in the New England town to which we knew, young officers from Plattburg were assigned. [. . .) I was part of life at least and in the midst of excitement I discovered liquor. (. . .) In time we sailed “Over There.” I was very lonely and again I turned to Alcohol. Much moved, I wandered outside. My attention was caught by doggerel on an old tombstone: “Here lies a Hamshire Grenadier who caught his death drinking cold small beer. A good soldier is ne’er forgot hether he dieth by musket or by pot.” Ominous warning—which I failed to heed. (AA, 1939, p. 1) Bill W. describes how he uses alcohol as a comforter to avoid experiencing the emotional loneliness of his wartime experience and the distress of his subsequent postwar disorientations. Bill uses alcohol to numb his emotional pain and in doing so enters a downward spiral of obsession, compulsion, and addiction. Alcoholics like Bill W. are unable to confront their emotional illness and continue to pursue a pattern of life, seeking temporary relief in alcohol-induced forgetfulness. Rationalizing contradictions Another theme of contradiction and rationalization emerges from an analysis of the samples. This emotional conflict is again captured in the writings of Bill W. Upon his return from the war he was conflicted by the demands of leadership and of obedience. He uses the myth of the drunken genius to excuse his spirit of rebelliousness. Bill W., writing in 1939, describes his emotional confusion as follows: 84 P. HELM Twenty-two, and already a veteran of foreign wars, I went home at last. (. . .) I took a night law course, and obtained employment (. . .) Potential alcoholic that I was, I nearly failed my law course. Though my drinking was not yet continuous, it already disturbed my wife. I would still her forebodings by telling her that the men of genius always conceived their most majestic construction of philosophical thought when drunk. (AA, 1939, p. 2) He rationalizes his drinking by using the myth of the drunken genius who can be extremely creative when drunk. His fanciful thinking is again captured in the following quote: Twenty-two, and already a veteran of foreign wars, I went home at last. I fancied myself a leader, for had not the men of my battery given me a special token of appreciation? My talent for leadership, I imagined, would place me at the head of vast enterprises. The drive for success was on and took me to Wall Street. Many lost money but some became rich—why not I? (AA, 1939, p. 2) Like Bill W., Susan, a young member of NA finds the roots of her illness in her first life crisis. Her crisis is of a personal nature. It is constructed around the death of her father. However different the natures of Susan and Bills’ crises, the reader finds in both stories the common thread of disorientation: After my father died, I did not know where to go. I felt lost. Since my father always told me that he was going to meet friends when going to the pub, I started going there too, searching for consolation. (. . .) What I found there was alcohol. The bottle soon became my best and only friend. (Narcotics Anonymous, 1986, p. 7) Susan didn’t know how to handle becoming an orphan at age 18. Because she had no social network, like NA or AA to direct her in her grief work, she felt helplessly stuck. The resulting reaction was a desperate search for a friend, giving her orientation. She sought solace from her emotional pain in her new friend; that friend was the Friend in the Bottle. Metaphors of fight and war An analysis of the samples reveals that metaphors of fight and war were used to capture the emotional illness of persons with various addictions. The following quotes, taken from autobiographies of participants with different addictions, genders, and social status, capture one more piece of fight and war. Jane writes in Overeaters Anonymous (2001), “I had built an armor of fat, protecting me from my subtle anger against all men. This armor was my prison” (p. 10). Bill writes in AA (1939), “Out of an alloy of drink and speculation I commenced to forge the weapon that one day would turn its flight like a boomerang and all but cut me to ribbons” (p. 2). Bob writes in AA (1939), “At the end I had no more power left to fight.” Susan writes in her personal testimonies, “I realized I treated my addiction like an inner enemy. Today I know I have to welcome this enemy as friend, if I wish to stay abstinent” (Susan N., personal testimonies, collected 2014). ALCOHOLISM TREATMENT QUARTERLY 85 In these examples, one can see different approaches that capture the interior struggle of persons dealing with the emotional illness of their condition. The following questions emerge: Who is fighting against whom here and how to help the struggling individuals deal with the conflict? A public and a private self The narratives reveal that persons with addictions deal with two competing notions of self: a public self and a private self. The emotional illness of the addiction finds full expression in the private self. Various substances and behaviors are used to numb the sense of pain that is experienced by the private self. At the same time, the person seeks to maintain an idealized public self. To maintain some sense of balance between the competing selves, the person who is drug dependent uses destructive rationalizations, denial, and isolation to deal with a bipolar self. The private and public images drift further and further apart as the addiction progresses, producing feelings of constant emotional isolation and alienation. Helen, an Overeaters Anonymous member, describes this feeling of the two separate selves as follows: Taking a look at my resume, my life looks just as perfection claims. But secretly I always thought to myself: If they knew what price I pay (. . .) if they knew the secret – that I can only manage to keep my perfect appearance because I puke as soon as I get home (. . .) nobody would trust me anymore. (. . .) I was haunted by the fear that if anybody would discover my secret, nobody would trust me anymore. Everybody would hate me. I honestly thought that way. And I believed what I thought. (. . .) When I started attending Meetings I made the experience of sharing my worst fears and secrets and being acknowledged with them. Today I’m so grateful because I feel that my private and my public self slowly melt together to be one again. (Helen S., personal testimonies, collected 2014) This narrative illustrates the struggle between the two selves: the public and the private selves. Helen received social acknowledgment for the perfect self she displayed in public. Helen’s hidden self, the suffering self, remains a source of deep emotional distress that she treats with her addictive behavior. In recovery she discovers an ability to bring her two selves together in a context of healing that is promoted through her group participation. Cycles of selfishness The participants also recount patterns and cycles of selfishness. These behaviors are closely related expressions of an emotional illness, such as selfisolation and inner conflicts of self, which characterize various forms of addiction. This inward focus is described as “self-centeredness and selfpity” and again “as the root of all problems” (AA, 1939, p. 62). This internal obsession is offset by an outward, exaggerated expression of competitiveness and of self-importance. Mel T., as a woman member of Underearners Anonymous, captures this emotional turmoil as she writes: 86 P. HELM I used to be a know-it-all. I was arrogant because I’m insecure. I feel superior to my family and to all black people (. . .) and I hate white people. So I act like I’m better than I believe myself to be. There is a lot of compulsive need to prove (. . .) as the only smart black kid at grammar school. I used to walk into a room and feel like the entirety of the black people were depending on me to get it right. I think people are out there to get me, that people are patronizing me because I’m black and poor and uncultured. I created an attitude of opportunity and enjoyment that manifest in the appearance of my clothes, my office, my teeth, my hair. (. . .) But when I ran into situations that showed my ignorance and small living to the world, I hide. I get scared and intimidated. I hide and bite. (. . .) I create an attitude of poverty and paucity. (. . .) I even have run from opportunities in the past. I ignore my inner gifts and strength. (. . .) A lot of that is dissipating now due to writing in the Steps teaching me to take an honest look at myself. (Mel T., personal testimonies, collected 2014) Mel T. in this narrative captures another expression of the two competing selves that are encountered in addictive states. Neither self is an authentic one, and the conflict between the two produce profound alienation and isolation, expression of her interior emotional illness, her ability to take “an honest look at myself” at the beginning of her recovery. Narratives of emotional recovery An analysis of the narratives also reveals metaphors and rituals that illustrate the dynamics associated with recovery. These experiences called “emotional recovery” are closely related to the pattern of emotional illness described in the previous section. Hitting bottom Many emotional crises characterize the narratives of the group participants in this study (AA, 2003). “Hitting bottom” differs from the previous crisis that, though in themselves are painful and devastating, do not confront the denial of the addictive condition or open the pathway to recovery. Rainer, a German addicted to alcohol, captures the essence of truly “hitting bottom” in distinguishing the various “bottoms” he has experienced in the course of his illness: My name is Rainer and I’m an alcoholic. I pray to my higher power that the crisis I recently went through will be my bottom. I’ve often believed I’d hit it, but, so far, I was doomed to be proved wrong each time. Today I write down my life-story, a story that I was always afraid to face. I sit down to write, carrying the hope that writing about my last bottom will help to make it be my last one. (Anonyme Alkoholiker, 2009, p. 256) There are many narratives, which replicate Rainer’s experience, when analyzing these studies. They recount the desperate struggles of persons with addictions to break the destructive patterns of their addictive behaviors ALCOHOLISM TREATMENT QUARTERLY 87 and to escape from their profound emotional illness, characterized by powerlessness, hopelessness, self-hatred, and desperation. The narrative of Eileen, across American woman with addictions captures her desperate struggle to escapes from the horrors of her addictions to alcohol and medications: I knew nothing about Delirium Tremens but I’d scream at the telephone that I’d split wide open. I knew that alcohol and I had to part. I knew I couldn’t live with it anymore. And yet, how was I to live without it? I didn’t know. After pills and alcohol I became work addicted.(. . .) I sat for a week, a body in a chair, a mind of in the air. I thought the two would never get together. I went to my doctor again. I said: “I can’t find a middle way in life. Its either all work or I drink.” He said: “Why don’t you try the groups?” (AA, 2003, p. 298) Finding “the groups,” an AA group, proves to be the turning point in Eileen’s recovery. She finds an alternative to her destructive behaviors and emotional suffering by “hitting bottom” and by finding a recovery group where she can share her suffering in the context of understanding and acceptance. Eddy T., one of the earliest members of AA, recalls his desperate cries of struggling with alcoholism prior to the foundation of AA, when incarceration or closed psychiatric wards were the only options available (Lobdell, 2007, p. 10). Eddie T., like Helen at a much later date would find his salvation in AA groups after he, too, had experienced “hitting bottom.” Anonymity Anonymity, since the inception of AA in 1935, has been one of the most cherished and effective elements of the recovery process from addictions and, in the context of this study, from the emotional agony of the illness. The founders of AA and its earliest members embodied the “attitude of anonymity” (Desmond T as quoted in AA, 2010) by creating a space where group participants can freely share their most overwhelmingly emotional and physical agony (AA, 1939, p. 9) The group setting creates a liminal space, a space where Turner (1969) describes as a “space beyond the everyday life social structures.” Within this safe space, group participants are empowered by a revered ritual that enables them to reveal their hidden wounded selves with others who are experiencing like suffering. A performative potential is created where the group members can share their stories, by identifying themselves by their first names only unencumbered by the pretense surrounding their inflated egos and their public selves that they have created as part of their addictive behavior. The group settings if free of social stigmatization (Goffman, 1963) and isolation and alienation are breached in a setting where anonymity equates with equality and 88 P. HELM acceptance. The power of anonymity is captured in the testimonies of an early group member in Akron, Ohio. Everybody who knew me said I was a hopeless drunk. But when I ended up in hospital I believe every member of the Akron Group did come to see me. They impressed me terrifically, not so much because of the stories they told me, but because they would take the time to come and talk to me without knowing who I was. They didn’t need to know me, they simply believed in my potential to change. (AAA, 2003, p. 244) Emotional bottom Another emotional bottom emerges as group participants reveal more freely by the safe liminal space afforded by the group leadings. Discarded and empowered by anonymity, persons who are recovering see themselves reflected in the stories of others. One narrator recounts she discovered an understanding of her illness through the story of another: “Yes, that’s me, I’m like that too, and if he says he is ill, then I am ill, too” (AA, 1957, p. 69). Helen, a member of Overeaters Anonymous, identifies the two bottoms that she encounters in the course of her recovery. I was raised to be no ghetto child, to hold my head up and not act like or be mistaken as an American black, but my story has all the classical embarrassments of being an American black. Ghetto parents, theft, denial, neglect, violence, ignorance, sexual abuse. (. . .) The process I’m going through right now in this program is the act of rooting out the distress, the clearing and cleaning of my system. However, right now, as I get to the bottom of my distress, I believe I have gotten to the bottom of the bottom within myself. I’ve allowed myself to see and feel it. (. . .) I’m embarrassed by my upbringing and the only way to cleanse and purge it is to write about it. The laxatives didn’t do it. I got nice and thin, but it never erased what happened. Nothing will erase what happened. I just have to live with it all now. (Helen S., personal testimonies, collected 2014) Capitulation The narratives analyzed in this study constantly report that capitulation (surrender) is a metaphor used to describe the ability to choose another path resulting from “hitting bottom.” As a polar opposite of the fight/war metaphors identified by participants as a component of their emotional illness, capitulation implies surrender, or radical deconstructions of one’s former attitudes and self-image. The process of capitulation (surrender) is debilitated by group rituals especially those that describe “hitting bottom” in the dynamics of the death and rebirth experience (Turner, 2000; Van Gennep, 1960/2010). Anniversaries of sobriety in AA and other mutual help groups are celebrated as birthdays. ALCOHOLISM TREATMENT QUARTERLY 89 Discussion This study identifies “emotional illness” as an expression of various forms of addiction. Patterns of emotional suffering have been identified from an analysis through the writings and personal testimonies of participants in mutual help groups, representing the earliest experiences of the AA groups and subsequent groups modeled after the AA experience. Six integrated expressions of emotional illness are described in the Results section together with four corresponding patterns of recovery. In this Discussion section, important elements of emotional illness and of early recovery are identified. Ongoing crises of an emotional nature emerge as a constant feature in the narratives, between 1935 and 2013, and is embraced by this study. Persons experiencing addictions are enabled to deal with such crises without a supportive network or principles that restore some sense of inner peace. Unable to address an ongoing state of emotional turmoil, persons with addictions become dependent on addictive substances or like behaviors in an effort to medicate their emotional suffering. This condition is further aggravated by isolation and alienation and by desperate efforts to rationalize the conflict between the contradictory sources of self-destructive behavior and the desire to address the cause of this profound inner conflict. Two selves develop as a result of this conflict, the public self that would maintain some semblance of normalcy and the inner self that is racked by guilt, remorse, and a host of other negative emotions. A cycle of self-centeredness and selfishness designed to conceal the inner self from the addictive person and others emerges. These factors allied with the other negative forces create a downward spiral of self-destruction. The crises multiply and culminate in a major crisis that is described by the studies participants as “hitting bottom.” This experience becomes an indispensable product of recovery, when it is shared in the context of a recovery group. Otherwise it is yet another devastating loss and emotional crisis in the continuing downward spiral of self-destruction that characterizes an addiction. The textual and self-testimony analysis embodied in this study confirms that group participants clearly identify “emotional illness” as an essential component of their addiction. This finding is not a novel one, but it does emphasize the need to maintain a consistent focus on the emotional dimensions of addiction and in the concomitant process of recovery that addresses the emotional illness. The other contribution of this study is found in its identification of some essential qualities of the processes of change and early recovery as captured from the narratives of the participants. “Hitting bottom” has a decisive emotional element that serves as an agent of ongoing change and 90 P. HELM transformation when shared in a group setting. A group ritual, influenced by the disarming power of anonymity, creates a safe liminal space for the group members. The context of trust and honesty, facilitating capitulation (surrender), by telling ones stories in a symbolic and real way has the power of “performative magic” as described by Audehm (2001). A dramaturgy is at work in the group dynamics as illness and recovery are described in one’s life story in terms of spiraling down, hitting bottom, which results in confirmative change experienced at the emotional and spiritual levels. As the process of rebirth is a constant feature of the narratives study in which the old self, with its selfish, self-centered ego is abandoned, and a renewed, caring and connected self is embraced. “Self-sacrifice,” in AA terminology, is at work in this process (AA, 1957, p. 91). Conclusion Metaphors and rituals are used in this study to further amplify our understanding of the dynamics of change experienced by participants in mutual self-help groups. Emotional illness is identified as an essential element of addiction, and corresponding elements of recovery are also explored. Concentrating on and inspecting the narratives of the participants allows the participants to tell their stories in their own voices as they share the emotional devastation of their illness and the day-to-day hope embodied in their recoveries. This tradition of story-telling is central to the healing process embodied in AA and other like self-help groups (Kurtz, 1991). This tradition, now 80 years old, has been respectfully employed in this study. Acknowledgment The author specifically acknowledges the editorial report of Marsha Elizabeth Thompson in preparing this article. References Alcoholics Anonymous. (1935–1939). Correspondences 1935-1939 [Unpublished archive material]. New York, NY: Alcoholics Anonymous, Central Archives, New York, NY. Alcoholics Anonymous. (1939). Alcoholics Anonymous (1st ed.). New York, NY: Alcoholics Anonymous World Service, Inc. Alcoholics Anonymous. (1952). Twelve Steps and twelve traditions. New York, NY: Alcoholics Anonymous World Service, Inc. Alcoholics Anonymous. (1957). Alcoholics Anonymous coming of age. New York, NY: Alcoholics Anonymous World Service, Inc. ALCOHOLISM TREATMENT QUARTERLY 91 Alcoholics Anonymous. (1992). The AA message in a changing world. In Alcoholics Anonymous (Ed.), The 42nd Annual Meeting of the General Service Conference (pp. 8–13). New York, NY: The Grapevine, Inc. and Alcoholics Anonymous Publishing. Alcoholics Anonymous. (2003). Experience, strength, hope. stories. New York, NY: Alcoholics Anonymous World Service, Inc. Alcoholics Anonymous. (2010). Our spiritual responsibility in a digital world. In Alcoholics Anonymous (Ed.), The 62nd Annual Meeting of the General Service Conference (p. 12). New York, NY: The A.A. Grapevine, Inc. and Alcoholics Anonymous Publishing. Alcoholics Anonymous. (2012). A. A. around the world. New York, NY: Alcoholics Anonymous World Service, Inc. Anonyme Alkoholiker. (2009). Anonyme Alkoholiker [Alcoholics Anonymous]. Marktoberdorf, Germany: Schnitzerdruck. Audehm, K. (2001). Die macht der sprache. Performative magie bei Pierre Bourdieu [The power of language. Pierre Bourdieu’s performative magic]. In J. Wulf (Ed.), Grundlagen des Performativen. Eine Einführung in die Zusammenhänge von Sprache, Macht und Handeln (pp. 101–128). Weinheim, Germany: Weinheim. Barthes, R. (1982). Mythen des Alltags [Mythologies]. Frankfurt am Main, Germany: Suhrkamp. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York, NY: Prentice Hall. Kurtz, E. (1991). Not-God. A short history of Alcoholics Anonymous. San Francisco, CA: Hazelden. Lakoff, G., & Johnson, M. (2003). Metaphors we live by. Chicago, IL: University of Chicago Press. Lobdell, J. (2007). The messengers to Ebby. Culture Alcohol & Society Quarterly, 3, 5–10. Narcotics Anonymous. (2008). Narcotics Anonymous (6th ed.). Van Nuys, CA: Author. Overeaters Anonymous. (2008). Overeaters Anonymous. New York, NY: Overeaters Anonymous World Service Offices, Inc. Reckwitz, A. (2003). Grundelemente einer Theorie sozialer Praktiken Eine sozialtheoretische Perspektive [Thinking about social practices from a social-theory perspective. Elements of a theoretical approach]. Zeitschrift für Soziologie, 32, 282–301. Thiersch, H. (2002). Lebensweltorientierte soziale arbeit. Weinheim, Germany: Bentz. Turner, V. (1969). The ritual process. Structure and anti-structure. New York, NY: Aldine. Turner, V. (2000). Dramas, fields, and metaphors: Symbolic action in human society. Ithaca, NY: Cornell University Press. Van Gennep, A. (2010). The rites of passage (reprint ed.). Chicago, IL: Routledge. (Original work published 1960)
Psychology of Addictive Behaviors 2017, Vol. 31, No. 7, 797– 806 In the public domain http://dx.doi.org/10.1037/adb0000320 Development and Psychometric Analysis of the Brief DSM–5 Alcohol Use Disorder Diagnostic Assessment: Towards Effective Diagnosis in College Students Brett T. Hagman National Institute of Alcohol Abuse and Alcoholism, Bethesda, Maryland The Diagnostic and Statistical Manual of Mental Disorders (5th edition) Alcohol Use Disorder (DSM–5 AUD) criteria have been modified to reflect a single, continuous disorder. It is critical that we develop brief assessment measures that can accurately assess for DSM–5 AUD criteria in college students to assist in screening, referral, and brief intervention services implemented on college campuses. The present study sought to develop and assess for the psychometric properties of a brief 13-item measure designed to capture the full spectrum of the DSM–5 AUD criteria in a sample of college students. Participants were past-year drinkers (N ⫽ 923) between the ages of 18 to 30 enrolled at 3 universities. Respondents completed a 30-min anonymous battery of questionnaires online. The Brief DSM–5 AUD Assessment consisted of 13 items designed to reflect the DSM–5 AUD criteria. Results indicated a high degree of internal consistency reliability with high item-to-scale correlations. Confirmatory factor analyses indicated that a dominant single factor emerged with good model fit. The Item Response Theory (IRT) analyses indicated that the difficulty parameters for each criterion were intermixed along the upper portion of the underlying AUD severity continuum, and the discrimination parameters were all high. Additional analysis indicated that those with a DSM–5 AUD had greater levels of alcohol and other drug use and problem severity in comparison to those without a DSM–5 AUD. Study findings provide empirical support for the reliability and validity of the Brief 13-item DSM–5 Assessment. It should be routinely included into research and clinical practice efforts. Keywords: college students, AUD, alcohol use, screening, assessment dence has shown that prevalence estimates of AUDs for college students range up to approximately 30% under the Diagnostic and Statistical Manual (4th edition; DSM–IV) and DSM–5 diagnostic systems (Dawson et al., 2004; Hagman et al., 2014; Hasin & Grant, 2004; Knight et al., 2002). These high rates of AUDs are particularly disconcerting because if an AUD in college is left undiagnosed, then it has the potential to lead to a more hazardous form of AUD severity (Campbell & Demb, 2008). Thus, it is critical that college treatment providers and administrators develop brief assessment tools that provide reliable and accurate diagnostic information to identify individuals who may be “at risk” or in need of treatment/referral to deter risky levels of alcohol use and/or prevent a more severe course of problematic alcohol use from developing in later adulthood. The DSM–IV has been the primary taxonomic system used to diagnose someone with an AUD (DSM–IV–TR; American Psychiatric Association [APA], 2000). Under the former DSM–IV AUD diagnostic system, alcohol abuse and dependence were represented as separate diagnoses with a hierarchical structure posited between them (i.e., alcohol dependence criteria set were considered more severe than abuse criteria; Hasin, Hatzenbuehler, Keyes, & Ogburn, 2006; Hasin, 2003; Martin, Chung, & Lagenbucher, 2008). While the DSM–IV AUD criteria have been used extensively in research and clinical practice, several limitations have consistently been identified: (a) factor analytic and Item Response Theory (IRT) analyses have indicated a dominant single factor with the abuse and dependence criteria intermixed at the upper portion of The college years constitute as a critical developmental period wherein alcohol use and risky drinking practices significantly increase (Windle, 2003). As such, people in this critical period experience the highest rates of heavy alcohol use compared to any other at-risk groups of drinkers (Campbell & Demb, 2008; Dawson, Grant, Stinson, & Chou, 2004). This high-risk level of alcohol involvement is associated with a plethora of alcohol-related consequences that are specific (i.e., poor academic functioning) to this important life transition (Beck et al., 2008; Kahler, Strong, Read, Palfai, & Wood, 2004). More importantly, research has consistently indicated that rates of alcohol use disorders (AUDs) also peak during the college years (Dawson et al., 2004; Hagman, Cohn, Schonfeld, Moore, & Barrett, 2014). Epidemiological evi- Parts of the manuscript have been presented at the annual Research Society on Alcoholism’s annual research conference in Denver, Colorado. This study was funded by contract LD966 from the Florida Department of Children and Families. The contents of this article only reflect the views of the authors and not those of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) or National Institutes of Health. I thank Lawrence Schonfeld, from the Department of Mental Health Law and Policy at the University of South Florida for his consultation to this project from which these data were derived. Correspondence concerning this article should be addressed to Brett T. Hagman, Division of Treatment and Recovery Research, National Institute of Alcohol Abuse and Alcoholism, 5635 Fishers Lane, Room 2044, Bethesda, MD 20892. E-mail: brett.hagman@nih.gov 797 798 HAGMAN the underlying AUD severity continuum, suggesting no hierarchy among the DSM–IV criteria; (b) the legal problem criterion demonstrates poor item fit in factor analytic analyses, and (c) a craving criterion should be incorporated into the DSM–5 AUD criteria given that it is a pertinent indicator of the AUD severity diagnostic syndrome (APA, 2013; Hagman & Cohn, 2011; Hasin, Fenton, Beseler, Park, & Wall, 2012). As a result of these limitations, the DSM–5 Substance Use Task Force made the following changes to the AUD diagnostic criteria in the DSM–5 manual: (a) eliminate the alcohol abuse and dependence distinction by combining the DSM–IV criteria into a single disorder; (b) add a new diagnostic threshold whereas endorsement of two or more of any AUD criteria reflect an AUD; (c) create a severity qualifier that reflect a minimal AUD (2 to 3 criteria), moderate AUD (4 to 5 criteria), or severe AUD (ⱖ6 criteria); and (d) exclude the legal problems criterion and incorporate a new craving criterion into the DSM–5 criteria set (APA, 2013). The process of reliable and valid screening and assessment for detecting AUD symptoms has become a routine procedure within screening, referral, and brief intervention protocols implemented across college campuses and universities (Bien, Miller, & Tonigan, 1993; Monti, Tevyaw, & Borsari, 2004/2005). Several brief assessment and alcohol screening measures (i.e., Alcohol Dependence Scale [ADS]; Short Alcohol Dependence Data questionnaire [SADD]; Severity of Alcohol Dependence Questionnaire [SADQ]; Alcohol Use Disorders Identification Test [AUDIT]) have been developed to detect at-risk problem drinking, identify individuals at-risk for an AUD or to determine the presence and severity of AUD symptomatology within these protocols (Babor, Higgins-Biddle, Saunders, & Monterio, 2001; Raistrick, Dunbar & Davidson, 1983; Skinner & Allen, 1982; Stockwell, Murphy, & Hodgson, 1983). A primary limitation associated with these assessment-based measures is that each was designed for a specific purpose and do not fully capture the range of AUD criteria conceptualized in the DSM–5. For example, while the Short Alcohol Dependence Data questionnaire (SADD) was designed to measure the severity of alcohol dependence, it only includes items that reflect behavioral and subjective changes associated with problem drinking, and therefore it has greater sensitivity in identifying drinkers who are not experiencing withdrawal symptoms (Raistrick et al., 1983). Along these lines, the SADQ is focused on assessing withdrawal symptoms and does not include items that reflect the development of tolerance and the subjective awareness of the compulsion to drink, thereby providing greater sensitivity to individuals experiencing withdrawal symptoms (Stockwell et al., 1983). With respect to the AUDIT, while the items are used to screen for being at-risk for an AUD, three of the 10 items only reflect alcohol consumption and do not capture the full range of diagnostic criteria, thereby requiring additional follow-up assessment to make a clinical diagnosis. More importantly, under the new DSM–5 diagnostic guidelines, a craving criterion has been added to the diagnosis, but none of these measures include item(s) that assess for craving. A final limitation is that each of these measures focuses on assessing the nature and severity of symptoms of alcohol dependence and has not been validated for obtaining a DSM–5 AUD diagnosis. In light of these shortcomings, it is critical to develop brief assessment measures that accurately capture the full spectrum of the AUD continuum as well as more validly reflect the criteria outlined in the newly implemented DSM–5 AUD criteria. In sum, college students represent a distinct group of drinkers at elevated risk for developing an AUD in comparison to other populations of drinkers. The DSM–5 AUD criteria have been modified to reflect a single, continuous disorder with the removal of the legal problems criterion and the addition of a craving criterion. As such, it is critical that we develop brief assessment measures that can accurately assess for and directly capture the DSM–5 AUD criteria in college students as well in other populations of drinkers. The development of such a measure will assist in detecting an AUD diagnosis more quickly compared to most alcohol screening measures within our alcohol screening, referral, and brief intervention protocols via directly assessing the DSM–5 AUD criteria, thereby permitting more expedient patient referrals to an appropriate level of intervention. A brief assessment measure of DSM–5 AUD criteria can also cut down on the time and costs of undergoing a thorough, rigorous, standardized clinical assessment that requires a trained clinician to conduct, and can easily be self-administered to clients and research participants without undergoing the stigma that can result from undergoing a face-to-face clinical assessment. In addition, a brief assessment of DSM–5 AUD criteria has the potential to enhance epidemiological, needs assessment, and program planning efforts across college and university settings by providing a cost-effective method to conduct mass screenings across a college campus in order to obtain campus-specific prevalence rates of DSM–5 AUDs. Lastly, such a measure could be routinely included into university health settings as part of their formal intake and assessment procedures. Based on this background, the present study focused on the development and measurement of the Brief DSM–5 AUD Assessment, which is designed to capture the full spectrum of the DSM–5 AUD criteria in a sample of college students. The present study utilizes methods from Classical Test Theory (e.g., Cronbach’s alpha) and IRT to evaluate the psychometric properties of the Brief DSM–5 AUD Assessment. Method Participants and Procedure This study is a secondary data analysis of the Core Alcohol and Drug Use survey, which was implemented at several universities (Presley, Meilman, & Lyerla, 1994). The data for this study sample (N ⫽ 923) were collected at three public universities located in the southeastern United States, with enrollment occurring during the Spring and Fall, 2014 semesters. Participants were invited to participate via e-mail in an online anonymous assessment of their drug and alcohol use as part of a larger effort to understand more about the etiology and prevalence of alcohol use and problems among college students. Participants were included in this study if they were between the ages of 18 to 30 years of age, an undergraduate attending college either full- or part-time, and consumed alcohol in the prior year. For all participants, after providing informed consent to the study, respondents completed a 30-min anonymous battery of questionnaires online. Due to anonymity of responses, all procedures were considered exempt for review by the current Institutional Review Board (IRB). There was no compensation given to participants for their participation. DEVELOPMENT OF A BRIEF DSM–5 AUD ASSESSMENT Measures Development of the Brief DSM–5 AUD assessment. As shown in the Appendix, a total of 13 questions were developed to reflect the DSM–5 AUD criteria and included as part of the administration of the Core survey. These diagnostic questions were developed by the author and not routinely included in the Core survey. For this measure, two separate questions (4 total) were used to obtain diagnostic information for the tolerance criterion (i.e., diminished effect with continued use and need to drink more to get desired effect) and withdrawal criterion (i.e., experience withdrawal symptoms from not drinking and drink to avoid withdrawal symptoms). Endorsement of either question or both for each criterion reflected presence of that criterion. The questions paralleled wording from the Diagnostic and Statistical Manual’s DSM–5 AUD criteria (APA, 2013; see the Appendix for specific wording of each diagnostic criterion). The DSM–5 craving question was included by asking participants the following: “During the past year, as a result of your alcohol use, did you have a strong desire or craving to drink?” This item has been used in prior research (Casey, Adamson, Shevlin, & McKinney, 2012), which has indicated it to be a reliable and valid indicator of craving. Participants were asked to report if the occurrence (yes) or absence (no) of each criterion occurred more than once within the past year. Alcohol, other drug use, and negative consequences. A series of questions from the Core survey were developed to collect alcohol and other drug use data from each participant. With respect to the alcohol use module, participants were asked to report their frequency of alcohol use (1 ⫽ did not use to 9 ⫽ every day) in the prior year and during the prior 30-days (1 ⫽ 0 days to 7 ⫽ all 30 days) on Likert-type scales. With respect to binge drinking, participants were asked to report on a 6-point Likert-type scale the number of times (1 ⫽ none to 6 ⫽ 10 or more times) they consumed five or more drinks in a sitting in the prior 2 weeks. Quantity of alcohol use was assessed by asking participants to report the average number of standard drinks consumed per week. Lastly, participants reported their age of first alcohol use (1 ⫽ did not use to 9 ⫽ 26 or older) on a 9-point Likert-type scale. Pearson correlations between each of the alcohol use measures were high and ranged from .595 to .803 providing evidence of their validity. In regard to the illicit drug use module, three sets of questions were of interest. Participants were asked to report their frequency of drug use in the prior year (1 ⫽ did not use to 9 ⫽ every day) by reporting whether they had used each of 11 specific types of drugs (marijuana, cocaine, amphetamines, sedatives, hallucinogens, opiates, inhalants, designer drugs, steroids, and other types not listed) on a 9-point Likert-type scale. Similarly, participants reported their frequency of using (1 ⫽ none to 6 ⫽ 10 or more times) 11 specific types of drugs in the prior 30 days using a 6-point Likert-type scale. Lastly, participants indicated how often (1 ⫽ never to 6 ⫽ 10 or more times) they experienced 19 different types of consequences (e.g., “performed poorly on a test or important project”; “been hurt or injured”) as a result of their drug or alcohol use in the last year based on a 6-point Likert-type scale. Construction of drug use indices. Three indices of illicit drug use were constructed based on self-reports from the illicit drug use module. First, a drug use in the prior year frequency index was created by summing items specific to the frequency of illicit drug use in the prior year. Second, a drug use in the prior 30 799 days frequency index was created by summing the response items specific to the frequency of illicit drug use in the prior 30 days. Lastly, an alcohol and drug use consequences frequency index was constructed by summing the items specific to the types of alcohol and drug use consequences that occurred in the prior year. To ensure that each index is approximately unidimensional, principal components analyses were performed. Results indicated that each index had an approximately unidimensional structure associated with it and accounted for approximately 63.42%, 50.43%, and 31.28% of the common variance for the drug use in the prior 30 days index, drug use in the prior year index, and alcohol and drug use consequences index, respectively. Cronbach’s coefficient alphas for each index was high and ranged from .732 for the frequency of drug use in prior year index to .871 for the alcohol and other drug use consequences index. Classification of AUD status. For the classification of the DSM–5 AUD diagnostic system, we used the guidelines set forth by DSM–5 Substance Use Task Force (APA, 2013). Participants who did not endorse any criteria were classified as no AUD; those who endorsed one of any criteria were classified as DSM–5 diagnostic orphans/DO; and those who endorsed two or more of any criteria were classified as DSM–5 AUD⫹. Data Analytic Plan Classical test theory analyses: Reliability and validity analyses. Classical test theory (CTT) analyses were conducted to evaluate the overall reliability and validity of the Brief DSM–5 AUD Assessment. To evaluate the reliability of the DSM–5 AUD criteria, internal consistency reliability was assessed by calculating Cronbach’s coefficient alpha with each item removed, and additional reliability analyses examined the item-to-total scale correlations for each criterion. To assess the validity of the Brief DSM–5 AUD Assessment, several analyses were conducted. Convergent validity analyses were conducted by performing Pearson correlations between total number of DSM–5 AUD symptoms endorsed with several external validators of alcohol and other drug use (average drinks per week, binge drinking in prior 2 weeks, age of onset of drinking, frequency of alcohol use in prior year, frequency of alcohol use in prior 30 days, drug use in the prior 30 days index, drug use in the prior year index, and the alcohol and drug use consequences index). To evaluate differences between those with and without a DSM–5 AUD, a Hoetellings T2 test was performed. For the Hoetellings T2 analysis, we evaluated differences across several external validators of alcohol and illicit drug use using the DSM–5 AUD system (i.e., two groups: No DSM–5 vs. DSM–5 AUD) as a primary independent variable in the analysis. The following eight alcohol use and illicit drug use external validators were included as dependent variables: average drinks per week, binge drinking in prior 2 weeks, age of onset of drinking, frequency of alcohol use in prior year, frequency of alcohol use in prior 30 days, drug use in the prior 30 days index, drug use in the prior year index, and the alcohol and drug use consequences index. Post hoc t tests were conducted if multivariate significance was achieved. To control for Type I error inflation, we set alpha at p ⬍ .01 to achieve statistical significance. Item Response Theory analysis. Item Response Theory analyses were also conducted on the DSM–5 AUD criteria to derive HAGMAN 800 that the probability of endorsing a specific item increases monotonically as the latent-trait continuum increases. Lastly, a total information curve was plotted for the 11 DSM–5 criteria. This curve provides information about the point along the continuum where the DSM–5 AUD criteria are most reliable. All IRT models were analyzed using Parscale IRT software (Scientific Software International, 2003), which estimates criterion parameters via a Bayesian expectation-maximization (EM) equation. The convergence criterion for the EM equation was set to .005 for all IRT analyses. item difficulty and discrimination parameters for each criterion. Prior to conducting the IRT analyses, a confirmatory factor analysis (CFA) on the 11 DSM–5 AUD criteria was conducted to ensure that assumptions (i.e., items reflect a single factor solution) were met. A single factor solution and tetrachoric correlation matrix was specified for the CFA. The following guidelines proposed were used to assess for model fit in the CFA. Comparative Fit Index (CFI) ⬎ 0.95, Tucker-Lewis Index (TLI) ⬎ 0.95, and a root mean square error of approximation (RMSEA) ⬍ 0.06 (Hu & Bentler, 1999). A robust unweighted least squares estimation was specified to derive parameter estimates. Next, an IRT analysis was conducted on the 11 DSM–5 AUD criteria. Two-parameter logistic models were specified estimating item difficulty (location) and discrimination (slope) parameters for each criterion. A high difficulty parameter indicates that a greater level of alcohol problem severity is necessary to endorse that criterion. The discrimination parameter provides a numerical value (typically ranges from 0 to 3) of the magnitude of the relationship between each AUD criterion and the underlying latent-trait continuum. A high discrimination value indicates that a specific AUD criterion is able to accurately classify individuals with various levels of the latent-trait of AUD severity. Item characteristic curves (ICCs) were then plotted for all criteria. ICCs provide a graphical depiction of the probability that a specific criterion is endorsed as a function of the value of the purported underlying latent-trait. The typical ICC indicates Results Demographic Characteristics of Current Sample As shown in Table 1, participants were between the ages of 18 to 30 (M ⫽ 19.64; SD ⫽ 1.19). The sample was fairly representative of college students with respect to race and ethnicity with 70.7% (n ⫽ 653) Caucasian, 16.1% (n ⫽ 149) Hispanic, 4.9% (n ⫽ 45) African American, 3.1% (n ⫽ 29) Asian/Pacific Islander, and 4.8% (n ⫽ 44) representing other racial/ethnic groups. With respect to class rank, 28.9% (n ⫽ 267) were freshman, 28.4% (n ⫽ 262) sophomores, 28.2% (n ⫽ 260) juniors, and 14% (n ⫽ 129) seniors. The majority of the sample were female (68.7%; n ⫽ 634), Table 1 Demographics of Current Study Sample Across DSM–5 AUD Status Demographic classification variable Class rank Freshman Sophomore Junior Senior Age 18 to 20 21 to 22 23 or older Ethnicity Hispanic Asian/Pacific Islander White Black Other Gender Male Female Residence On campus Off campus GPA A average B average C or below average Student status Full time Part time Overall N NO AUD DO DSM–5 AUD % N % N % N % 267 262 260 129 28.9 28.4 28.2 14.0 111 121 132 64 25.8 28.1 30.6 14.8 50 53 50 28 27.6 29.3 27.6 15.5 93 75 65 32 34.8 28.1 24.3 12.0 733 175 13 79.6 19 1.4 335 89 6 77.7 20.6 1.4 140 39 2 77.4 21.6 1.1 230 33 4 86.2 12.4 1.5 149 29 653 45 4.8 16.1 3.1 70.7 4.9 44 69 14 301 19 26 16.1 3.2 69.8 4.4 6.0 30 4 124 15 8 16.6 2.2 68.5 8.3 4.4 44 10 196 9 8 16.5 3.7 73.4 3.4 2.9 289 634 31.3 68.7 113 318 26.2 73.8 64 117 35.4 64.6 92 175 34.5 65.5 358 634 31.3 68.7 157 274 36.4 63.6 64 117 35.4 64.6 124 143 46.4 53.6 383 431 108 41.5 46.7 11.8 205 176 50 47.6 40.8 11.6 59 98 24 32.6 54.1 13.3 99 137 30 37.1 51.3 11.6 890 32 96.4 3.5 419 12 97.2 2.8 173 8 95.6 4.4 257 9 96.6 3.4 Note. No AUD ⫽ no DSM–5 AUD diagnosis; DO ⫽ DSM–5 diagnostic orphans; AUD ⫽ DSM–5 AUD diagnosis; DSM–5 AUD ⫽ Diagnostic and Statistical Manual of Mental Disorders, fifth edition Alcohol Use Disorder; GPA ⫽ grade-point average. DEVELOPMENT OF A BRIEF DSM–5 AUD ASSESSMENT lived off campus (61.2%; n ⫽ 565), and reported having at least a B or higher grade-point average (GPA; n ⫽ 814; 88.2%). Alcohol and Other Drug Use Characteristics The overall sample reported drinking, on average, 4.24 (SD ⫽ 7.61) standard drinks per week. Approximately 52.4% (n ⫽ 483), 47% (n ⫽ 435), and 42.6% (n ⫽ 393) of the sample reported drinking at least 5 or more days per month, binge drinking on at least one occasion during the prior 2 weeks, and consumed alcohol more than once a week, respectively. The most commonly occurring alcohol- and drug-related consequences among the overall sample in the past year were as follows: “had a hangover” (66.9%; n ⫽ 622), “vomited” (64.5%; n ⫽ 602), “had memory loss” (42.9%; n ⫽ 406), and “latter regretted action under the influence” (36.3%, n ⫽ 349). With respect to illicit drug use, the most commonly used in the prior year were as follows: marijuana (47.4%; n ⫽ 442), tobacco (39.4%: n ⫽ 366), designer drugs (e.g., ecstasy; 10.4%; n ⫽ 97), and hallucinogens (8.7%; n ⫽ 84). Classification of DSM–5 AUDs Based on this classification scheme, the percentages of those with no DSM–5 AUD diagnosis, DSM–5 diagnostic orphans, and DSM–5 AUD⫹ diagnosis were 46.7% (n ⫽ 431), 19.6% (n ⫽ 181), and 28.9% (n ⫽ 267), respectively. In addition, approximately 17.8% (n ⫽ 164), 6.6% (n ⫽ 61), and 4.8% (n ⫽ 42) were classified as mild DSM–5 AUD, moderate DSM–5 AUD, and severe DSM–5 AUD, respectively. Reliability Analyses As shown in Table 2, Cronbach’s alpha with each item removed were conducted for each of the DSM–5 AUD criteria, which all were in the high range with relatively little variation (Cronbach’s alphas ranging from .754 to .778). Along these lines, item-to-total scale correlations were conducted with correlations ranging from .321 to .517. The overall Cronbach’s alpha for the DSM–5 AUD 801 criteria was .781, which indicates a high degree of internal consistency reliability. Validity Analyses To demonstrate the validity of the DSM–5 AUD criteria, Pearson correlations between total sum of DSM–5 criteria endorsed and other meaningful variables were conducted. Results indicated that total sum DSM–5 criteria scores were significantly related to average binge drinking in the prior 2 weeks (r ⫽ .45, p ⬍ .001), average drinks per week (r ⫽ .44, p ⬍ .001), age of alcohol use onset (r ⫽ ⫺.16, p ⬍ .001), alcohol use in prior year (r ⫽ .46, p ⬍ .001), alcohol use in prior 30 days (r ⫽ 46, p ⬍ .001), have a perceived problem with alcohol and other drugs (r ⫽ .441, p ⬍ .001), drug- and alcohol-related negative consequences (r ⫽ .69, p ⬍ .001), frequency of drug use in the prior 30 days (r ⫽ .31, p ⬍ .001), and frequency of drug use in the prior year (r ⫽ .36, p ⬍ .001). Evaluating Differences Between Those With and Without a DSM–5 AUD Table 3 displays results of the Hotellings T2 that examined mean differences between the DSM–5 diagnostic groups (i.e., No diagnosis vs. DSM–5⫹ diagnosis) across the external validator variables of alcohol consumption, illicit drug use, and alcohol/drugrelated negative consequences. With respect to the Hotellings T2 analysis, the overall omnibus tests was significant for the DSM–5 AUD criteria [Hotelling’s Trace ⫽ .469, F(8, 850) ⫽ 49.80, p ⫽ .001]. All follow-up univariate t tests across each external validator were significant (all ps ⬍ .01). Compared to those who did not meet criteria for a DSM–5 AUD (i.e., No AUD diagnosis), those with a DSM–5 AUD diagnosis reported greater levels of alcohol use, illicit drug use, and drug/alcohol-related negative consequences providing support for the utility of the DSM–5 diagnostic threshold. Table 2 Reliability Analyses (Item-to-Scale Correlations; Cronbach’s Coefficient Alpha With Each Item Missing) for the DSM–IV and DSM–5 AUD Criteria DSM–5 AUD diagnostic criteria 1) Unable to fulfill role obligations (abuse) 2) Physically hazardous situations (abuse) 3) Legal problems (abuse) 4) Social/Interpersonal problems (abuse) 5) Larger/Longer amounts (dependence) 6) Unsuccessful efforts (dependence) 7) Great deal of time (dependence) 8) Important activities given up (dependence) 9) Recurrent physical/psychological problems (dependence) 10) Craving (DSM–5) 11) Tolerance (dependence) 12) Withdrawal (dependence) Overall Cronbach’s alpha % endorsed DSM–5: Item to-scale DSM–5: Alpha 8.2 19.8 3.1 9.2 24.1 4.9 7.3 4.7 7.3 16.7 26.9 3.9 .351 .362 .774 .778 .509 .517 .442 .493 .475 .480 .483 .480 .431 .755 .754 .765 .758 .763 .760 .757 .760 .767 .781 ⴱ ⴱ Note. DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders, fifth edition Alcohol Use Disorder. ⴱ p ⬍ .001. HAGMAN 802 Table 3 DSM–5 AUD Hoetelling’s T2 Analysis Across External Validators of Alcohol and Illicit Drug Use Overall No DSM–5 AUD DSM–5 AUD Alcohol and illicit drug use variable Mean SD Mean SD Mean SD Drug- and alcohol-related consequences Frequency of drug use in past year Frequency of drug use in prior 30-days Binge drinking in prior 2 weeks Average drinks per week Age of alcohol use onset Alcohol use in prior year Alcohol use in prior 30 days 28.36 12.69 11.31 1.98 3.99 5.87 4.89 2.79 10.44 5.73 4.03 1.32 7.05 1.31 1.74 1.40 24.64 11.82 10.85 1.65 2.42 5.95 4.41 2.41 6.86 4.33 2.98 1.12 4.61 1.42 1.68 1.27 36.83 14.61 12.28 2.73 7.69 5.68 5.99 3.64 12.12 7.69 11.29 1.42 10.15 1.11 1.31 1.32 MANOVA results Univariate F-tests F(1, F(1, F(1, F(1, F(1, F(1, F(1, F(1, 850) 850) 850) 850) 850) 850) 850) 850) ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ ⫽ 349.24ⴱ 45.55ⴱ 23.51ⴱ 142.12ⴱ 109.45ⴱ 7.258ⴱ 182.78ⴱ 163.61ⴱ Note. DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders, fifth edition Alcohol Use Disorder; MANOVA ⫽ multivariate analysis of variance. ⴱ p ⬍ .001. Item Response Theory Analyses As shown in Table 5, results from the CFA indicated that a dominant single factor emerged with good model fit for the DSM–5 AUD criteria: Tucker-Lewis Index (TLI) ⫽ 0.991, Comparative Fit Index (CFI) ⫽ 0.982, and Root Mean Square Error of Approximation (RMSEA) ⫽ 0.028. As shown in Table 2, the standardized factor loadings were high and ranged from .542 “physically hazardous (abuse)” to .836 “important activities given up (dependence).” In addition, the “alcohol craving” criterion factor loading was adequate (.737) and indicated good fit within the CFA model. Overall, findings indicated IRT assumptions were met and that the DSM–5 AUD criteria model reflects a strong, dominant single factor. Final IRT Model Analyses As shown in Table 4, the frequency of endorsement for each of the 11 DSM–5 AUD criteria ranged from 3.9% “withdrawal (abuse)” to 26.9% “tolerance (dependence).” The DSM–5 AUD criteria with the highest level of endorsement were “tolerance (dependence),” “drinking in larger/longer amounts (dependence),” “physically hazardous situations (abuse),” “craving (DSM–5),” whereas the items with the lowest frequency of endorsement were “withdrawal (dependence)” and “important activities given up (dependence).” Table 5 presents IRT difficulty and discrimination parameter estimates across the DSM–5 AUD IRT model. The difficulty parameters for the IRT model that includes the DSM–5 AUD criteria indicated that the abuse and dependence criteria were intermixed along the latent-trait AUD severity continuum. The IRT difficulty parameters for the DSM–5 AUD criteria ranged from 0.81 “tolerance (dependence)” to 2.44 “unable to fulfill role obligations (abuse).” Overall, the following difficulty parameters for the DSM–5 AUD criteria were ranked the lowest and were plotted toward the middle of the latent-trait AUD severity continuum (values ranging from 0 to 1.5): “tolerance (dependence),” “larger/longer amounts (dependence),” “alcohol craving (DSM– 5),” and “physically hazardous (abuse).” In addition, the difficulty parameters for the DSM–5 criteria “social/interpersonal problems (abuse),” “great deal of time (dependence),” “recurrent physical and psychological problems (dependence),” and “important activ- Table 4 Results of Factor Analyses and Item Response Theory Analyses for the DSM–5 AUD Criteria DSM–5 AUD diagnostic criteria % endorsed 1) Unable to fulfill role obligations (abuse) 2) Physically hazardous situations (abuse) 3) Social/Interpersonal problems (abuse) 4) Larger/Longer amounts (dependence) 5) Unsuccessful efforts (dependence) 6) Great deal of time (dependence) 7) Important activities given up (dependence) 8) Recurrent physical/psychological problems (dependence) 9) Craving (DSM–5) 10) Tolerance (dependence) 11) Withdrawal (dependence) CFI TLI RMSEA 8.2 19.8 9.2 24.1 4.9 7.3 4.7 7.3 16.7 26.9 3.9 DSM–5: Loadings .596 .542 .796 .777 .792 .817 .836 .783 .737 .735 .797 .982 .991 .028 DSM–5 DSM–5 Difficulty SE Discrimination SE 2.44 1.46 1.66 .88 2.04 1.75 2.01 1.83 1.26 .81 2.19 .32 .16 .12 .07 .16 .12 .14 .14 .09 .07 .19 1.21 1.22 2.29 2.24 2.24 2.55 2.66 2.24 2.04 2.02 2.38 .19 .16 .31 .24 .41 .38 .38 .14 .24 .21 .41 Note. SE ⫽ standard error; DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders, fifth edition Alcohol Use Disorder; CFI ⫽ comparative fit index; TLI ⫽ Tucker-Lewis Index; RMSEA ⫽ root-mean-square error of approximation. DEVELOPMENT OF A BRIEF DSM–5 AUD ASSESSMENT ICCs and Total Information Curves 1.00 Role obligaons Physically hazardous situaons Probability of Endorsement 0.80 Social/Interpersonal Problems 0.70 Larger/Longer Amounts 0.60 Unsuccessful efforts 0.50 Great deal of me 0.40 Important acvies given up 0.30 Recurrent physical/psychological problems Craving 0.20 0.10 Tolerance 0.00 Withdrawal -3 -2 -1 0 1 2 12 10 8 6 4 2 0 -3 -2 -1 0 1 2 3 Latent-Trait AUD Connuum Figure 2. Plot of total information curve for Diagnostic and Statistical Manual (5th edition) Alcohol Use Disorder (DSM–5 AUD) criteria (craving). The x-axis of the total information curve reflects the latent-trait AUD severity continuum, whereas the y-axis reflects the point along the continuum where the 13-item Brief DSM–5 AUD assessment is most reliable. Discussion Item characteristic curves (ICCs) for the DSM–5 AUD criteria were generated and plotted in Figure 1. The X-axis represents the latent-trait AUD severity continuum in standardized z-scores (axis ranges from ⫺3 to 3), and the Y-axis represents the probability of endorsement (axis ranges from 0 to 100%). Overall, the ICCs indicate that the DSM–5 AUD criteria cover the middle to more severe end of the continuum, and increases monotonically as the latent-trait AUD severity continuum increases. These findings were also confirmed by the total information curve for the DSM–5 AUD criteria (see Figure 2). The DSM–5 AUD total information curve had a higher peak and provided greater information (i.e., reliability) toward the more severe end of the continuum. 0.90 Total Informaon Curve With Craving Criterion Included 14 Total Informaon ities given up (dependence)” were plotted in the moderate range (values between 1.5 to 2) of the latent-trait AUD severity continuum. Lastly, the difficulty parameters for “unable to fulfill role obligations (abuse),” “withdrawal (dependence),” and “unsuccessful efforts (dependence)” were plotted toward the most severe end of the latent-trait AUD severity continuum (values ⱖ2). The IRT discrimination parameters for the DSM–5 AUD criteria ranged from 1.21 “unable to fulfill role obligations (abuse)” to 2.66 “important activities given up (dependence)” (see Table 5). All parameters were high indicating good discrimination for each criterion across the latent-trait AUD severity continuum. The lowest discrimination parameters found for the criteria were “unable to fulfill role obligations (abuse),” “physically hazardous situations (abuse),” and “tolerance (dependence),” which indicated that these criteria provided a lower degree of discrimination across the latenttrait AUD severity continuum. The highest discrimination parameters found for the criteria were “important activities given up (dependence),” “great deal of time (dependence),” “withdrawal (dependence),” and “social/interpersonal problems (abuse),” which indicated that these criteria provided a greater degree of precision in classifying individuals with an AUD across the latenttrait AUD severity continuum. 803 3 Latent-Trait AUD Severity Connuum Figure 1. Item Characteristic Curves (ICCs) for the 11 Diagnostic and Statistical Manual (5th edition) Alcohol Use Disorder (DSM–5) alcohol use disorder criteria (craving criterion included). The x-axis on the ICCs figure reflects the latent-trait AUD severity continuum with values typically ranging from ⫺3 to 3, whereas the y-axis reflects the probability of endorsing each specific AUD criterion. The present study sought to develop and evaluate the psychometric properties of the Brief DSM–5 AUD Assessment in a sample of college students. The first aim was to evaluate the reliability and validity of the Brief DSM–5 AUD Assessment using CTT techniques. Overall, CTT psychometric analyses on the Brief DSM–5 AUD Assessment exhibited a high degree of reliability and validity. Cronbach’s coefficient alpha indicated an adequate degree of internal consistency associated with the Brief DSM–5 AUD Assessment. Each of the item-to-total scale correlations exceeded conventional standards (i.e., ⬎ .30) with the majority of the correlations ranging from .44 to .51, indicating that none of the items require consideration of deletion from the measure. With respect to the validity analyses, a confirmatory factor analysis indicated that a single latent AUD severity factor provided the best fit to the 11 DSM–5 AUD criteria, which is consistent with prior research supporting a dominant, single factor associated with the DSM–IV and DSM–5 AUD criteria (Casey et al., 2012; Hagman & Cohn, 2011; Hasin et al., 2012). In addition, correlation coefficients between total DSM–5 AUD sum scores and other relevant clinical variables (e.g., alcohol use; negative consequences from drinking) provided support for the concurrent validity of the Brief DSM–5 AUD Assessment. Lastly, findings also found significant differences across the DSM–5 AUD diagnostic threshold (ⱖ2 criteria endorsed) providing support for its utility, as those with and without a DSM–5 AUD can be distinguished from each other across pertinent measures of alcohol and illicit drug use and problem severity. Specifically, multivariate analyses indicated that those who met criteria for a DSM–5 AUD had elevated levels of alcohol and illicit drug use and negative consequences from drinking and drug use in comparison to those who did not meet criteria for a DSM–5 AUD. Overall, these findings provide empirical support for the 804 HAGMAN reliability and validity of the Brief DSM–5 AUD Assessment in college students. Continued research is needed to replicate our findings across diverse samples of college students and other at-risk groups of drinkers (e.g., noncollege peers) to validate findings derived from the current study. An additional aim of this study was to evaluate the psychometric properties of the Brief DSM–5 AUD Assessment using methods from Item Response Theory (IRT). Item Response Theory techniques can improve upon CTT methods by providing statistical parameters for each item that provide information about the reliability and validity of each item across the latenttrait continuum that is being assessed by a specific measure (e.g., AUD criteria reflect the latent-AUD severity continuum). As expected, the difficulty parameters for the DSM–5 AUD criteria indicated that the DSM–5 AUD criteria were more valid toward the more severe end of the AUD latent-trait severity continuum. This is consistent with prior IRT analyses of DSM–IV and DSM–5 AUD criteria in samples involving college students and other at-risk populations of drinkers (Casey et al., 2012; Hagman & Cohn, 2011; Hasin et al., 2012). With regards to the discrimination parameters, all were in the good-toexcellent range indicating that each of the DSM–5 AUD criterion can reliably distinguish across individuals with various levels of AUD severity. More research is needed across diverse samples of drinkers and college students to ensure stability of the IRT parameters derived from the current sample. Findings from this study highlight important information about the developmental trajectories of DSM–5 AUDs in college students. First, findings indicate that the most commonly endorsed DSM–5 AUD criteria were “tolerance” and “drinking in larger and longer amounts than intended.” This suggests that each criterion may constitute as early markers for the development of alcohol problems in college students and should be routinely included in screening and assessment efforts. Second, no studies to date have evaluated the utility of the DSM–5 AUD “craving” criterion among college students. The IRT findings from this study indicate that that the craving criterion exhibited a high degree of discrimination with the corresponding difficulty estimate located in the middle of the difficulty ranges in comparison to the other 10 AUD criteria. With respect to the CTT analyses, results from the CFA indicate that the craving criterion fits a single dimension factor structure, and the Cronbach’s coefficient alpha analysis with each item removed was one of the lowest values when the craving criterion was removed in comparison to the other DSM–5 AUD criteria. Collectively, these findings provide empirical support for the reliability and validity of the inclusion of a craving criterion within a sample of college students. Lastly, under the new DSM–5 AUD system, there remains a residual set of college students who endorsed a subthreshold number of AUD criteria (i.e., endorse only one criterion), but do not receive a formal diagnosis. It is critical that clinical and research efforts seek to understand more about this new set of “diagnostic orphans” with to respect to their risk for developing a DSM–5 AUD. There were some limitations associated with the current study. First, the veracity of the data obtained in the current study was reliant on self-report recall of information, which is subject to potential recall biases. Prior research has indicated that the inclusion of methodological procedures such as assur- ances of anonymity and the use of psychometrically validated instruments enhances response accuracy (Babor & Del Boca, 1992), all of which were a part of this study, thereby reducing this concern. Another limitation of the current study is that a convenience sample was used, which has the potential to impact the generalizability of the current study findings. That said, the rates of DSM–5 AUDS and binge drinking as well as heavy alcohol consumption found in this sample are similar to those found in other convenience and national probability-based samples of college students (Dawson et al., 2004; Hagman & Cohn, 2011; Knight et al., 2002). Lastly, while our Hoetelling’s T test results do provide support for the potential utility of the DSM–5 AUD diagnostic threshold (i.e., significant differences across DSM–5 AUD diagnostic status), a taxometric analysis is necessary to provide a more formal evaluation of the validity of the DSM–5 AUD diagnostic threshold. Collectively, the strengths and innovation of the current study outweigh these potential study limitations. The present study provides several avenues for future evaluations of the Brief DSM–5 AUD Assessment. The “gold standard” for obtaining a DSM–5 AUD diagnosis is to undergo a formal clinical interview. It would be important to evaluate the degree of correspondence between the Brief DSM–5 AUD Assessment in relation to more standard diagnostic assessments to provide further validation of findings derived from the current study. While several psychometric analyses were performed on the Brief DSM–5 AUD Assessment, the test–retest reliability was not examined, and it is recommended that future evaluations evaluate the stability of diagnoses obtained from the Brief DSM–5 AUD Assessment across time. It also remains unknown how the psychometric properties derived from the current study hold in other at-risk samples of drinkers (e.g., outpatient treatment seekers). Continued research is warranted to evaluate the current findings across diverse samples of drinkers. The addictions field currently lacks standardized brief assessment tools that directly assess for DSM–5 AUD criteria. The Brief DSM–5 AUD Assessment was developed for this specific purpose, and this is one of the first studies to develop such a measure in college students. 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Please circle your best answer to each question as to whether each experience occurred more than once in the prior year in response to your own alcohol use. If you have questions about these examples, please feel free to ask the research assistant. REMEMBER TO CIRCLE YOUR BEST ANSWER During the past year, were you unable to or failed to fulfill major role obligations at work, school or home? YES NO During the past year, did you consume alcohol in situations in which it was physically hazardous (e.g., driving while intoxicated)? YES NO During the past year, did you continue to drink alcohol despite persistent or recurrent social or interpersonal problems caused by the effects of the alcohol (e.g., arguments with a significant other or family member, physical fight)? YES NO During the past year, as a result of your drinking, did you have a need to drink more to become intoxicated or get the desired effect? YES NO During the past year, as a result of your drinking, did you notice a diminished effect with continued use of the same amount of alcohol? YES NO During the past year, as a result of your drinking, did you experience any withdrawal symptoms from not drinking (e.g., shakes, tremors, sleeplessness, anxiety, sweating, flushing)? YES NO During the past year, as a result of your drinking, did you drink to relieve or avoid withdrawal symptoms? YES NO During the past year, did you drink alcohol in larger amounts or over a longer period than intended? YES NO During the past year, as a result of alcohol use, did you have a persistent desire or have unsuccessful efforts to cut down or control alcohol use? YES NO During the past year, as a result of alcohol use, did you spend a great deal of time in activities necessary to obtain alcohol or recover from its effects? YES NO During the past year, as a result of alcohol use, were important social, occupational, or recreational activities given up or reduced because of alcohol use? YES NO During the past year, as a result of alcohol use, did you continue to drink alcohol, despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by drinking? YES NO During the past year, as a result of alcohol use, did you have a strong desire or craving to drink? YES NO Received March 30, 2017 Revision received August 30, 2017 Accepted September 5, 2017 䡲
ADDICTION RESEARCH & THEORY, 2016 VOL. 24, NO. 2, 111–123 http://dx.doi.org/10.3109/16066359.2015.1075980 Overcoming alcohol and other drug addiction as a process of social identity transition: the social identity model of recovery (SIMOR) David Best1, Melinda Beckwith2, Catherine Haslam3, S. Alexander Haslam3, Jolanda Jetten3, Emily Mawson2, and Dan I. Lubman2 1 Department of Law and Criminology, Sheffield Hallam University, Heart of the Campus Building, Collegiate Crescent, Sheffield, UK, Eastern Health Clinical School, Monash University/Turning Point, Fitzroy, Melbourne, Australia, and 3School of Psychology, University of Queensland, St. Lucia, Australia 2 ABSTRACT KEYWORDS In recent years, there has been an increasing focus on a recovery model within alcohol and drug policy and practice. This has occurred concurrently with the emergence of community- and strengths-based approaches in positive psychology, mental health recovery and desistance and rehabilitation from offending. Recovery is predicated on the idea of substance user empowerment and self-determination, using the metaphor of a ‘‘journey’’. Previous research describing recovery journeys has pointed to the importance of identity change processes, through which the internalised stigma and status of an ‘‘addict identity’’ is supplanted with a new identity. This theoretical paper argues that recovery is best understood as a personal journey of socially negotiated identity transition that occurs through changes in social networks and related meaningful activities. Alcoholics Anonymous (AA) is used as a case study to illustrate this process of social identity transition. In line with recent social identity theorising, it is proposed that (a) identity change in recovery is socially negotiated, (b) recovery emerges through socially mediated processes of social learning and social control and (c) recovery can be transmitted in social networks through a process of social influence. connectedness, social networks, social support, social influence, mutual aid, peer support, Alcoholics Anonymous, communities Defining recovery As a concept that is still relatively new to alcohol and other drug policy and practice, there is as yet no established definition of recovery from addiction. The Betty Ford Institute Consensus Panel defines recovery from substance dependence as a ‘‘voluntarily maintained lifestyle characterised by sobriety, personal health and citizenship’’ (2007, p. 222). This position is consistent with the UK Drug Policy Commission statement on recovery as ‘‘voluntarily sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society’’ (2008, p. 6). These definitions emphasise a process of ‘‘personal’’ transformation that is evident in observable outcomes across multiple domains of functioning and supported by abstinence or increased control over substance use. In contrast, client-led perspectives on recovery, such as Valentine’s (2011) statement ‘‘you are in recovery if you say you are’’ (p. 264), emphasise the importance of the subjective experience of change. This definition is consistent with the mental health recovery model HISTORY Received 3 December 2014 Revised 20 July 2015 Accepted 21 July 2015 Published online 17 August 2015 advanced by Deegan (1988). She argues that recovery constitutes the lived experience of people as they accept and overcome the challenge of disability, ‘‘recovering a new sense of self and of purpose within and beyond the limits of the disability’’ (Deegan, 1988, p. 54). These two types of definitions differ, with the former based on external and observable behaviours and the latter on subjective states and experiences. What they have in common is their failure to identify the mechanisms of change, or the social context in which change occurs. Instead, both focus on the characteristics of those ‘‘in recovery’’ or who regard themselves as ‘‘recovered’’. Yet, when it comes to matters of policy and practice, knowing how to identify a person who is ‘‘in recovery’’ tells us very little about how to assist them in their recovery journey. The purpose of this article is to describe a conceptual framework that explains how the transition to recovery can occur, together with the social and psychological dynamics that underpin it. The paper introduces a new and key aspect of recovery, involving social identity change and outlines how this is implicated in both the initiation and the maintenance of recovery pathways. Correspondence: Professor David Best, Department of Law and Criminology, Sheffield Hallam University, Heart of the Campus Building, Collegiate Crescent, d.best@shu.ac.uk Sheffield S10 2BQ, UK. ß 2015 Taylor & Francis 112 D. BEST ET AL. While there has been considerable literature on the role of individual identity change in recovery, the role of social identity has been largely neglected until recent work by Buckingham, Frings, and Albery (2013) attempted to reconcile the literature on recovery and social identity. To address this lacuna, in this article, we examine the contribution of social identity processes to recovery using the example of Alcoholics Anonymous (AA). This program provides the basis for a strong social identity that supplants a salient addict identity to support recovery. In this context, we consider the role of social connections in the recovery journey (e.g. changes in friendship networks and group memberships), and the resulting impact on identity and self-definition. A key argument here is that identity change is bound up with AA group membership and its capacity to furnish active members with a new sense of social identity. Recovery as a process of social group change Existing evidence from the alcohol and other drugs (AOD) field highlights the important role of social groups in recovery. More specifically, a review of evidence supports claims that simply belonging to one or more social groups or networks is supportive for recovery (Best et al., 2010). This emphasis is consistent with related observations that groups and their associated norms influence a range of substance-related outcomes including the initiation and maintenance of substance use (Hawkins, Catalano, & Miller, 1992), attrition from treatment (Dobkin, Civita, Paraherakis, & Gill, 2002), as well as risk of relapse following AOD treatment (Hser, Grella, Hsieh, Anglin, & Brown, 1999). Additional support for this argument comes from a study of 141 cocaine-dependent individuals by Zywiak et al. (2009). This found that patients who had better treatment outcomes typically had larger social networks, more frequent contact with their social network and an increase over time in the proportion of people in their social network who did not use any substances, including alcohol. In other words, amongst people with problems relating to cocaine use, those with the best outcomes were more socially connected, particularly with social groups whose norms were not supportive of continued substance use. Further evidence for the centrality of social processes in recovery is provided by Litt, Kadden, Kabela-Cormier, and Petry (2007, 2009). In this randomized controlled trial, people who completed residential detoxification from alcohol were randomly allocated to either standard aftercare or to a ‘‘network support’’ intervention that involved developing a relationship with at least one non-drinking peer. Compared to standard aftercare, those who added at least one non-drinking member to their social network showed a 27% increase at 12 months post-treatment in the likelihood of treatment success (defined as being without alcohol 90% of the time). Furthermore, this increase in the likelihood of treatment success emerged despite no pre- to post-treatment change in the number of people who drank alcohol in their social network. This suggests that it was the addition of non-drinking peers that accounted for improved outcomes. Increasing the availability and appropriateness of recovery-oriented social networks may also be crucial to long-term recovery from addiction. Beattie and Longabaugh (1999) reported that whilst both general social support and abstinence-specific support predicted abstinence at three months post-treatment amongst formerly alcohol-dependent people, only social support for abstinence predicted longer-term abstinence (at 15 months post-treatment). Similarly, Longabaugh, Wirtz, Zywiak, and O’Malley (2010) found that greater opposition to a person’s drinking from within their social network predicted more days without alcohol use both during and after treatment, and fewer heavy drinking days post-treatment. In addition, less frequent drinking within the person’s social network predicted more days without alcohol use during and after treatment. Based on this, the authors concluded that transition to sustained recovery was underpinned by a move from a social network supportive of problematic drinking to one supportive of recovery. In addition, Zywiak, Longabaugh, and Wirtz (2002) found that, while alcohol-dependent patients with larger networks and a higher proportion of non-drinking network members showed better longterm treatment outcomes, these effects were moderated by the patient’s frequency of contact with the social network (this being taken as an index of their investment in that network). Frequency of contact with a recovery-oriented social network is important because it determines exposure to both recovery values and processes (Longabaugh et al., 2010; Moos, 2007), and the creation of a social environment in which an emerging sense of self as ‘‘nonusing’’ or ‘‘in recovery’’ can be nurtured and shaped by the norms, values and expectations of the group (Best, Ghufran, Day, Ray, & Loaring, 2008; Best et al., 2012). Furthermore, the benefits of social support for recovery (which may take the form of information or practical assistance, emotional support and a sense of belonging) appear to be dependent on the degree to which those providing support are perceived to be relevant, similar and connected to the self. Thus, support is likely to be most effective (i.e. most likely to be welcomed and taken SOCIAL IDENTITY AND RECOVERY on board) when those who provide it are seen to embody a shared sense of identity (i.e. as ‘‘one of us’’; Jetten, Haslam, Haslam, Dingle, & Jones, 2014; Haslam, O’Brien, Jetten, Vormedal, & Penna, 2005). In line with this reasoning, research with adolescents has found that the negative effects of support for continued substance use coming from substance-using social networks are reduced when adolescents do not see members of these networks as similar to themselves. Conversely, the positive effects of recovery support from non-substance using social network members are enhanced when adolescents rate these network members as similar to themselves (Vik, Grizzle, & Brown, 1992). Based on this, researchers have concluded that the degree to which adolescents perceive members of their social network as similar to themselves moderates the impact of social network support on their recovery, as well as their risk of relapse post-treatment. Recovery as a process of identity change The idea that identity change is central to recovery was first advanced by Biernacki (1986) who argued that, in order to achieve recovery, ‘‘addicts must fashion new identities, perspectives and social world involvements wherein the addict identity is excluded or dramatically depreciated’’ (p. 141). Building on this theme, McIntosh and McKeganey (2000, 2002) collected the recovery narratives of 70 former addicts in Glasgow, Scotland and concluded that, through substance misuse, the addicts’ ‘‘identities have been seriously damaged by their addiction’’ (McIntosh & McKeganey, 2002, p. 152). Based on this, they argued that recovery required the restoration of a currently ‘‘spoiled’’ identity. In a critique of this conclusion, Neale, Nettleton, and Pickering (2011) contend that the notion of a spoiled identity is pejorative and that it neglects the range of alternative identities available to individuals across different social contexts (e.g. as father, daughter, neighbour, etc.) and overemphasises the salience and primacy of the identity associated with substance misuse. More recently, Radcliffe (2011) extended the argument around multi-faceted identity in a paper on recovery from substance abuse among pregnant women and new mothers. This argued that participants’ motivation for recovery occurred in the context of an emerging ‘‘maternal’’ identity, which is often perceived to be ‘‘spoiled’’ in the eyes of health and welfare professionals as a consequence of the mothers’ substance abuse. Yet, for women who currently or formerly abused a substance, their pregnancy provided a turning point, or ‘‘second chance’’, allowing them to construct a ‘‘normal, unremarkable and un-stigmatised motherhood’’ identity 113 that supported their transition to recovery (Radcliffe, 2011, p. 984). Based on this, Radcliffe argued that shared narratives of recovery, and recognition of the legitimacy of alternate identities by others, were crucial for the stability of the mothers’ recovery. Through such work it can be seen that both Biernacki, and McIntosh and McKeganey, hold to a conceptualisation of identity that emphasises a particular identity related to substance use. This ignores other identities that the person may hold, the wider social context of groups they may belong to and the impact of their social network on substance-related behaviour. In this regard, the value of taking a social identity perspective – as we do in the social identity model of recovery (SIMOR) outlined below – is that it avoids framing addiction and recovery in moralistic terms, as the ‘‘un-spoiling’’ of a spoiled identity. Instead, it frames recovery as involving changes in a person’s social world that coincide with changes in a socially derived sense of self, thus broadening appreciation of the ways in which recovery can occur. The social identity model of recovery The SIMOR applies the Social Identity Approach to the process of recovery from addiction. This model frames the mechanism of recovery as a process of social identity change in which a person’s most salient identity shifts from being defined by membership of a group whose norms and values revolve around substance abuse to being defined by membership of a group whose norms and values encourage recovery. This emerging sense of self is shared with others in recovery, thus strengthening the individual’s sense of belongingness within recoveryoriented groups. This emerging social identity is gradually internalised, so that the individual comes to embody the norms, values, beliefs and language of recovery-oriented groups. This, in turn, helps the individual shape and makes sense of changes in substance-related behaviour, and reinforces the new social identity. Social identity model of recovery (SIMOR) builds on two complementary theories – Social Identity Theory (SIT) and Self-Categorisation Theory (SCT). SIT proposes that, in a range of social contexts, people’s sense of self is derived from their membership of various social groups. The resulting social identities serve to structure (and restructure) a person’s perception and behaviour – their values, norms and goals; their orientations, relationships and interactions; what they think, what they do, and what they want to achieve (Tajfel & Turner, 1979; see also Haslam, 2014). SCT explains not only when and why groups come to define the self, but also 114 D. BEST ET AL. how particular individuals achieve standing within the group. The theory argues that increased status within a group is achieved as individuals become increasingly representative of a group, and that representativeness is achieved by embodying perceptions and expectations of what in-group members have in common, and of what distinguishes them from relevant out-groups (Turner, Hogg, Oakes, Reicher, & Wetherell, 1987). In this way, groups not only provide a sense of belonging, purpose and support (Cruwys, Dingle, et al. 2014; Dingle, Brander, Ballantyne, & Baker, 2012; Haslam & Reicher, 2006; Jetten, Haslam, & Haslam, 2012a, 2012b), but also provide a basis for social influence (Turner, 1991). As noted earlier in discussing the influence of social networks on adolescent substance use, individuals are more willing to be guided by others when those others are seen as ‘‘one of us’’ rather than ‘‘one of them’’. As Hogg and Reid observe, in these terms, social influence can be understood as ‘‘the internalisation of a contextually salient in-group norm, which serves as the basis for self-definition, and thus attitude and behaviour regulation’’ (2006, p. 14). The extent to which one’s sense of self is derived from membership of a group will have a range of consequences for both perception and action. According to SCT, the extent to which a given social identity comes to define the self in a particular environment arises from an interaction of two factors: accessibility and fit (Bruner, 1957; Turner, Oakes, Haslam, & McGarty, 1994). The accessibility of a given social identity will tend to be higher if it has been a basis for self-definition and behaviour in the past, particularly in a similar social environment (Millward & Haslam, 2013; Peteraf & Shanley, 1997). The fit of a given social identity arises from meaningful patterns of perceived intra-group similarity and inter-group difference in the situation at hand, such that the relative differences between those defined as ‘‘us’’ (the in-group) are perceived to be smaller than the differences between ‘‘us’’ and ‘‘them’’ (the comparison out-groups). In a recovery context, this means that a recovery-based social identity is more likely to become salient to the extent that individuals consider themselves to be relatively similar to other recovery group members and to be relatively different from the members of groups engaged in substance abuse. One previous study that provides evidence of these processes at work involved the observation of British students transitioning from home to university life (Iyer, Jetten, Tsivrikos, Postmes, & Haslam, 2009; Jetten, Iyer, Tsivrikos, & Young, 2008). In this, students were found to be more comfortable in assuming a ‘‘university student’’ identity, and thus adjusted more successfully to university life, if this identity was compatible with their other social identities, both in the present (because the new identity fitted with values and beliefs derived from the other groups of which they were members) and in the past (because the new identity was more accessible due to a similar social identity having previously been enacted in a similar environment). This meant that the transition to a new ‘‘university student’’ identity proved particularly challenging for those students for whom this identity was incompatible with previous and existing group memberships, something that tended to be more true for students from working-class families where education was less valued. This analysis suggests that challenges in recovery from addiction are likely to be experienced when a recoverybased identity is fundamentally inconsistent with social identities that have previously been enacted, or where the person starting their recovery journey maintains involvement with, or commitment to, any group (including family) whose values and beliefs incorporate active substance abuse. In this way, the social identity approach offers an explanation for the beneficial effects of group membership found in previous research (Best et al., 2012; Zywiak et al., 2009). However, it can neither be assumed that all the groups to which individuals belong have a positive impact on physical and psychological wellbeing (Haslam, Reicher, & Levine, 2012; Jetten et al., 2014), nor that they all promote healthy behaviours (Oyserman, Fryberg, & Yoder, 2007). As groups are strong determinants of self-definition (Turner, 1991), strong affiliation with a group that is discriminated against and socially excluded due to involvement in deviant norms and activities (e.g. groups of injecting drug users) may also increase group members’ health vulnerability and reduce subjective wellbeing and selfesteem (Schofield, Pattison, Hill, & Borland, 2001). Social exclusion and stigma around addictive behaviours may also lead using group members to identify more strongly with one another, seeing themselves as different from any other social group and thereby reinforcing membership. However, as SIMOR highlights, this need not prevent recovery, provided there is a basis from which to develop or strengthen other group memberships that support recovery. In particular, if a person self-categorizes as a member of a recovery-oriented group comprising former users, they will internalise the shared characteristics of the group as part of the self, and this new selfcategorisation will typically involve distancing themselves from, and diminishing identification with, using groups due to their inconsistency with the characteristics of the recovery group. This means that when (and to the extent that) people come to define themselves in terms of a recovery-based SOCIAL IDENTITY AND RECOVERY social identity (i.e. as ‘‘us in recovery’’), their behaviour will be informed by the normative expectations associated with that identity (e.g. avoiding environments and people associated with substance abuse). Their identification with a recovery group will shape their understanding of substance-related events (e.g. an offer to go to the pub with friends) and their response to it (rejection on the grounds that it would put their recovery at risk). In sum, group memberships exert influence on individuals through the transmission of social norms, which are internalised and thus shape subsequent attitudes and behaviour. Identification with the group increases exposure to its norms and values, as well as receptivity to them. This increases the likelihood the group’s norms will be integrated into one’s own sense of self (who I am). Once salient, such positive social identities act as resources that support psychological health and adjustment (Jetten, Haslam, Iyer, & Haslam, 2009; Jetten et al., 2014). Along these lines, there is evidence that internalised group memberships become personal resources that support positive adaptation to change in times of life transition (Jetten et al., 2009, 2014). For example, Haslam et al. (2008) found that life satisfaction among patients recovering from stroke was greater for those who belonged to more social groups before their stroke, and who retained more of those group memberships following their stroke. In addition, the formation of new group memberships following a traumatic event has been found to predict fewer symptoms of traumatic stress over time, after controlling for individual differences in post-traumatic symptoms at baseline (Jones et al., 2012). This is because, to the extent that people identify with them, groups provide a basis for a sense of belonging, meaning, support and efficacy (Cruwys, Haslam, Dingle, Haslam, & Jetten, 2014; Haslam, Jetten, Postmes, & Haslam, 2009), and social identities provide a reservoir of social resources that the individual can draw on in their recovery journey. An emerging recovery-based social identity can also help to make sense of new decisions around situations and groups associated with the previous using lifestyle and may also contribute to a sense of self-efficacy that reinforces the utility of the recovery-based identity and increases the perceived desirability of recovery group membership. By applying a social identity approach, recovery can be conceptualised as involving the emergence of a new sense of self, encompassing a history of substance abuse, yet embedded within new, health-promoting social groups. Here, recovery is seen not as a personal attribute that can be observed and measured (Best & Lubman, 2012), but rather as a socially mediated process, facilitated and structured by changes in group 115 membership and resulting in the internalisation of a new social identity. This social identity exerts influence on individual values, beliefs and action and is reinforced and made more salient by successful use in challenging situations. Factors that maintain recovery are primarily social; recovery involves moving away from the using social network and actively engaging with an alternative social network that includes other people in recovery. However, it is important to note that the factors that initiate recovery often relate to becoming tired with one’s lifestyle, and these can often be brought to a head by a crisis event (Best et al., 2008). Indeed, although not highlighted in the literature, there is also the possibility that changes in social identity may in turn accelerate the process of becoming ‘‘tired of the lifestyle’’. Clearly, there are challenges in initiating this transition. In part, these can arise from a lack of awareness of, or wariness of, pro-social or recovery groups, something that can be exacerbated by the social exclusion that results from a heavy substance-using lifestyle. Nevertheless, there is evidence that even a single positive group experience, in the face of multiple negative ones, can provide the necessary scaffolding to help vulnerable and excluded individuals seek out meaningful groups and supportive networks (Cruwys, Dingle, et al. 2014; Cruwys, Haslam, et al. 2014). This suggests that even deep-seated experiences of isolation can be challenged in the process of initiating the recovery transition. Setting the scene for initial contact with recoveryoriented groups is one of the primary motives of an ‘‘assertive linkage’’ approach that supports individuals to engage with various groups. Testing this approach, both Timko, DeBenedetti, and Billow (2006) and Manning et al. (2012) have demonstrated the benefits of using peers to support active engagement in groups. In each of these trials, peers linked to specialist treatment providers acted as ‘‘connectors’’ between socially isolated clients and pro-social groups, resulting in both increased engagement in group activity and better substance use outcomes. Similarly, Litt et al. (2009) reported a 27% reduction in the likelihood of alcohol relapse in the year following residential detoxification amongst members of a trial group assigned to a ‘‘network support’’ condition that involved adding one person to their social network who neither drank alcohol nor used other substances. The effectiveness of assertive linkage approaches points both to ways in which the initiation of group engagement can occur for excluded individuals and to the role of the group in building resilience by promoting engagement and a sense of belonging (Jones & Jetten, 2011). SIMOR argues that motivation to change can be initiated through two processes. The first involves 116 D. BEST ET AL. SOCIAL IDENTITY CHANGE USING GROUP NON-USING GROUP NON-USING GROUP NON-USING GROUP USING GROUP acve use NON-USING GROUP early recovery RECOVERY INITIATION Inial exposure to recovery groups; aracon to and gradual engagement with new recovery group RECOVERY GROUP NON-USING GROUP USING GROUP NON-USING GROUP RECOVERY GROUP stable recovery RECOVERY MAINTENANCE acve parcipaon in recovery group; salience of recovery-focused identy increases Figure 1. A schematic representation of social identity transition in the course of recovery from addiction. increasing exposure to recovery-oriented groups that are perceived to be attractive to the individual. Second, motivation to change may also be precipitated by a crisis event (e.g. loss of a relationship or of a job), which may enhance the desire to change through increasing tiredness with a substance-using lifestyle. This may also occur through engagement with a recovery-oriented group as part of specialist treatment programmes (e.g. participation in 12-step meetings), or through encouragement and enthusiasm from friends. Thus, the initial drive may be to escape the adverse and stigmatised consequences of a substance-using lifestyle, but the catalyst and mechanism for change lies in the changing social dynamics that an individual experiences as they transition between using and recovery-oriented groups. This causes the person to move away from the using groups and to engage more actively with recovery-oriented groups. In SIMOR, we argue that there are at least two key phases in the recovery transition (Figure 1) although, in reality, this process is likely to be experienced as a gradual transition in social identity and related behaviours. The journey towards recovery proceeds alongside initial exposure to recovery groups in the context of ambivalence towards an existing social identity linked to active substance use. This transitioning occurs as a recovery-based social identity becomes more accessible and increasingly salient and as the using identity, while still salient and accessible, starts to diminish. As the sense of identity associated with recovery-oriented groups stabilises, becoming highly accessible and salient, the using identity diminishes in salience and relevance. The new recovery-oriented social identity may take time to develop as this requires a fundamental shift in group memberships, values and goals that occurs alongside growing recognition of the incompatibility of this identity with the values of the using group. Indeed, this may explain why rates of relapse are so high early in recovery. Nevertheless, if factors prompting initial attraction to a recovery group can overcome its perceived incompatibility, participation in the recovery group may offer new values and norms that ‘‘fit’’ with the individual’s recovery aims. The transition to a maintained state of stable recovery (represented on the right of Figure 1) involves ongoing involvement with recovery-oriented groups whose mechanisms of impact include social learning and social control thereby shaping social identity. Here, the salience and stability of a recovery-focused identity will grow as the individual becomes actively engaged in recovery groups. Moreover, as this identity becomes internalised the influence of using group values and norms significantly diminishes. In response, the recovery-focused identity becomes the more accessible and meaningful social identity, thus supporting recovery maintenance. The result of this entire process is a transition in social identity – from one that is predominantly using based to one that is recovery-focused. The latter is then sustained and maintained through active participation in recoveryoriented group activities. While the identity associated with substance use is not altogether lost or discarded, its salience diminishes as the ‘‘fit’’ of the new recoverybased identity increases and that of the substance usebased identity diminishes. Over time, this reduces the likelihood of the using-based identity providing a basis for behaviour. A similar process of social transition has been highlighted by Longabaugh et al. (2010) in predicting increased abstinent days from alcohol. SIMOR is also consistent with evidence reported by Buckingham et al. (2013) that both substance users and smokers are more SOCIAL IDENTITY AND RECOVERY likely to remain abstinent if they identify strongly with a recovery group. In other words, as former users come to identify more strongly with recovery-oriented groups, and less strongly with using groups, their likelihood of sustained recovery increases. More recently, Frings and Albery (2015) have developed a Social Identity Model of Cessation Maintenance (SIMCM), which draws on previous research showing that therapeutic group interventions that create a sense of shared identification are the basis for cure or, in the present context, recovery (Haslam et al., 2010, 2014; Jetten et al., 2012a). Like SIMOR, this model highlights the importance of social identity processes in recovery maintenance, but approaches this from a social cognitive perspective, positing that attending group therapy generates a recovery identity for each individual within the group and, through this group identification process, that an individual increases their self-efficacy to maintain recovery. The model assesses this in the context of group therapy for addiction, seeing this as a vehicle through which to promote a positive recovery-based identity that individual members can draw on in negotiating their current lifestyle. This is a significant contribution to the field, and is complementary to the SIMOR model we are proposing, but with a difference in emphasis. While both models emphasise the importance of group membership and identity to recovery, SIMOR focuses on social identity transition within a changing social context, drawing on social identity theorising from a systemic, rather than an individual, perspective to explain how this transition occurs. Second, SIMOR highlights the point that structured recovery groups, such as AA, are not the only source from which a person can develop a recoverybased identity. The role of structured groups, compared with informal groups such as friendship groups or social groups, is an area that will need further exploration in both the SIMCM and SIMOR models. For SIMOR, we argue that engaging with informal non-using groups can result in similar positive recovery outcomes to structured groups and, as informal groups can be formed based on any shared experience, preference, goal, activity and so on, there are more of them, offering a greater variety in experiences, and allowing for multiple sources of support in the recovery transition. Third, SIMOR highlights multiple phases within the recovery process, recognising that group memberships are continually being negotiated and proposing that shifts in social identity may well be initiated prior to a conscious investment in recovery. Consequently, SIMOR suggests a transition in social identity is being negotiated throughout the recovery process and is consolidated 117 during recovery maintenance. The strength of our model may therefore lie in its contribution to framing how the change process may work. Social identity model of recovery (SIMOR) draws on social identity approaches to understand how recovery is initiated, produced and maintained whilst also recognising, and accounting for, the possibility of relapse. Thus, while SIMCM makes an important contribution by recognising the central role that social identity and group process play in addiction treatment outcomes, SIMOR builds on this analysis by characterising recovery transition in terms of an interplay between memberships of various groups, some of which promote non-using or at least non-harmful using, norms over addictive using norms and examining how these dynamics play out in the process of social identity change. The evolution of both SIMCM and SIMOR are key to emphasising the central role that social identity plays in recovery and each suggests key areas for further empirical research. Alcoholics anonymous: a model of effective social intervention for alcohol abuse If this model accurately represents the social identity transition in recovery, then the social processes identified as critical in recovery from addiction should be evident in successful recovery group-based, peer-driven programs. In this regard, AA offers an appropriate test case as it provides the most widely available community support programme for problem drinkers (Kelly & Yeterian, 2008). AA is a mutual aid organisation for peers to support each other to overcome an addiction to alcohol, based on 12 steps and 12 traditions that members work through over time (e.g. Step 1 requires members to admit that they are powerless over alcohol). AA is used as a case study for the current paper because, with more than 2.1 million members and 100,766 groups in 150 countries, it is the mutual aid recovery group with the largest membership and the strongest empirical evidence base. Nevertheless, we would draw obvious parallels to other mutual aid groups (such as Narcotics Anonymous and SMART Recovery) as well as other peer-based recovery groups and services. Meta-analytic reviews report a positive association between AA participation and abstinence, as well as reductions in substance-related health care costs (Tonigan, Toscova, & Miller, 1996). The efficacy of AA involvement in supporting recovery is also evident across a diverse range of populations (Emrick, Tonigan, Montgomery, & Little, 1993; Moos & Moos, 2006). In addition, and in line with SIMOR’s theoretical analysis, higher rates of attendance at AA meetings have been associated both with greater rates of abstinence from 118 D. BEST ET AL. alcohol and an increase in the number of non-drinking friends (Humphreys, Mankowski, Moos, & Finney, 1999). Such evidence suggests that the process of categorising oneself as a member of a group that values abstinence provides a plausible explanation for the efficacy of the recovery model promoted and utilised by AA. Put simply, AA offers a positive recovery-based social identity that is accessible for members to use as a basis for self-definition. This identity is largely defined by the norms and values of AA’s prescribed social behaviours and traditions, which are laid out in the AA ‘‘Big Book’’ (Alcoholics Anonymous, 1939) and that are discussed in many AA meetings. This is reinforced by a shared lexis (‘‘fake it till you make it’’, ‘‘one day at a time’’, ‘‘rock bottom’’ etc.), the deployment of which denotes association with AA and fosters identification with the group. The frequent deployment of the AA lexicon may be indicative not only of internalisation of a recovery identity but also may imply some level of implicit identity (Frings & Albery, 2015). Indeed, 12-step fellowships may be unique in containing a range of rituals and practices that serve as warrants of membership and that, when enacted, clearly convey engagement with and adherence to, the ideology outlined in the Big Book. In serving to embed the recovery identity, such rituals and practices are likely to have significant implications for perceptions and recognition of group membership and hence for the sustainability of a recovery-based social identity. Furthermore, AA promotes meaningful and pro-social behaviour by emphasising the need to make amends and to help others as central to the recovery journey (Humphreys, 2004). In this regard, it is noteworthy that many of AA’s prescribed practices are inherently social. New members are encouraged to seek out ‘‘sponsors’’ (people in recovery themselves who act as personal guides for the recovery journey) and to speak to as many ‘‘experienced’’ members as possible. Accepting that one is powerless over one’s use of alcohol and therefore in need of support, the sharing of one’s own story and the structure of the sponsor system all serve to generate active engagement and membership, thus binding individuals to AA on an ongoing basis. Furthermore, the principle of ‘‘keeping it by giving it away’’ speaks to a process whereby individuals protect their own ongoing recovery by helping others around them achieve this as well. A substantial proportion of the efficacy of AA in supporting recovery is therefore achieved not merely through attendance itself but rather through active participation at meetings (Kelly, 2013), thus embedding members within the group in ways that encourage them to embody and live out the group’s norms and values. In addition, higher levels of engagement in AA-related helping activity (e.g. helping to organise meetings, taking on administrative roles and so on) have been associated with greater abstinence, and lower levels of depression, at 1 and 3 years follow-up (Pagano, Friend, Tonigan, & Stout, 2004; Zemore, 2007). Expanding on this, Pagano, White, Kelly, Stout, and Tonigan (2013) found that active helping in AA meetings was associated with greater abstinence at 10 years follow-up compared to standard professionally delivered alcohol treatment interventions. In other words, the more members are immersed in the activities and roles of the recovery group, the more they benefit from their membership of that group. SIMOR as a basis for understanding AA efficacy The impact and effectiveness of AA can readily be explained from a social identity perspective. To recap, the principal tenet of the social identity approach is that individuals internalise group characteristics as elements of the self (Turner et al., 1987) and that social identities become increasingly salient as a function of their meaningfulness and successful application in everyday situations and activities. In these terms, it is the perception of the self as belonging to a group that provides the foundations for self-definition in social terms (Turner et al., 1994). In AA, new members’ initial attendance is said to be precipitated by ‘‘hitting rock bottom’’ (Alcoholics Anonymous, 1939). As Best et al. (2008) note, this is typically understood as a culmination of the adverse effects of their drinking reaching a crisis point, and it is this understanding that provokes early engagement with recovery groups. When first attending AA, new members are greeted by existing members, who encourage them to commit time and energy to active engagement in the group. New members actively engage by attending 90 meetings in 90 days, by finding a sponsor to guide them through the 12-step program, by ‘‘working’’ the 12 steps, and by speaking to established members (recovery elders) both during and after meetings. In this way, the efficacy of AA for new members can be seen to result partly from the availability and support of recovery role models who are established members and who provide identity-based leadership by seeking to exemplify the norms and values of AA (Haslam, Reicher, & Platow, 2011). Established members are encouraged to ‘‘keep it [their sobriety] by giving it away’’ and do so by engaging with and encouraging new members through formal and informal mentoring, assisting them to actively engage in SOCIAL IDENTITY AND RECOVERY AA meetings and support. By having a sponsor and identifying a ‘‘home group’’, new members are incorporated into the social world of AA. This facilitates the internalisation of the norms and values of the 12-step fellowship and the adoption of an AA-based social identity. The foregoing analysis is consistent with the work of Moos (2007), who has argued that one of the effective elements of mutual aid groups like AA is the availability of opportunities for social learning provided by the observation of group members who are further into their recovery journeys. Moos goes further to argue that it is not just role models that AA offers but also an implicit expectation that new members will learn and conform to the group’s norms to achieve and maintain membership, a process he refers to as ‘‘social control’’. In addition, opportunities for social learning by observing and imitating the recovery behaviours of more experienced peers in recovery promotes the development of coping skills, and positive attitudes, beliefs and expectations, that support sustained recovery. In line with SIMOR’s emphasis on the changing structure of identity-based networks, Kelly, Hoeppner, Stout, and Pagano (2012) also found that it was the influence of AA engagement on social network change, together with increases in abstinence self-efficacy, that were crucial to recovery from alcohol addiction. This is reflected in the literature around social networks and recovery. As discussed earlier, individuals who form new social networks with non-substance using peers are more likely to sustain abstinence (Best et al., 2011; Kelly et al., 2012), and those who report larger social networks and greater frequency of contact with their social network show more positive outcomes post-treatment (Zywiak et al., 2002). As the individual cultivates their recoverybased social identity through immersion in AA activities and internalisation of AA values, so the social identity associated with their using group is diminished (Buckingham et al., 2013). The established importance of social network support for long-term recovery (Best et al., 2012; Dobkin et al., 2002; Litt et al., 2009; Longabaugh et al., 2010; Pagano et al., 2004) speaks to the underlying effect of social influence and social control on the transmission of recovery behaviours (Best & Lubman, 2012). More specifically, individuals are only likely to take on board the values, goals, messages and support from networks of people with whom they can already identify. Without a basis for shared identification, there is little motivation to engage with well-intentioned others, a point that underscores the central role of social identification in achieving such influence. As outlined in our model, there is an established role for assertive 119 linkage to recovery and other pro-social groups (Litt et al., 2009; Manning et al., 2012) led by either peers or professionals. Nevertheless, more work is clearly needed to assess the impact of such interventions on perceptions of support and the growth of recovery capital (Cloud & Granfield, 2008). There are also critical practice implications for professional and peer services relating to the importance of assertive linkage to community groups. For many alcohol and drug users who have lost or broken their ties with recovery-supportive networks and who do not have access to recovery groups, assertive linkage in the form of practical support (e.g. providing transport) and emotional support (e.g. encouraging and accompanying people to recovery meetings) is essential. This has important implications for treatment services engaged in recovery planning as it highlights the need to initiate active engagement with recoveryoriented groups, and to provide concrete advice and support around the process of transitioning from using based to recovery-based groups. Social identity model of recovery (SIMOR) also offers an approach that is complementary to specialist alcohol treatment in targeting social and contextual factors that are inadequately addressed by pharmacotherapies and many psychological interventions. For policy makers, the implications of the SIMOR approach relate to the need to enhance acute therapies and promote social engagement strategies that can help initiate and sustain recovery-supportive lifestyles in the community, both during and after formal treatment. And, while the example we have used to illustrate the current model focuses on alcohol recovery, similar issues of social identity change and assertive linkage to supportive community groups apply not only to addictions to other substances, but also to other forms of social exclusion and stigma, such as those associated with obesity, homelessness and mental health problems such as anxiety and depression (Crabtree, Haslam, Postmes, & Haslam, 2010; Cruwys, Dingle, et al., 2014; Cruwys, Haslam, et al., 2014). There are also research implications related to the generalisability of the model in terms of individual differences and addiction-related factors. For example, one emergent research hypothesis might be that those who are not actively engaged in social groups, who are introverted or who avoid group situations may be less receptive to, or find less relevance in, interventions promoting social identity change. A second empirical question that arises from such an assumption is whether the model is less applicable to the experiences of those who are not involved in using in groups, and instead use in isolation (as with people who drink heavily at 120 D. BEST ET AL. home alone), or to those who have little engagement with recovery supports in group-based social situations (e.g. those who manage their recovery through individual psychotherapy or medication only). The limited evidence from assertive linkage studies would suggest the SIMOR model is similarly applicable to a range of experiences. Cruwys et al. (Cruwys, Dingle, et al., 2014; Cruwys, Haslam, et al., 2014) have found little evidence that individual differences (e.g. in extroversion) explain substantial variation in responsiveness to group-based interventions. It is possible that people whose addictive behaviours do not lead to social exclusion or stigmatisation (as may be the case with some less problematic or entrenched drinkers) may have limited motivation to consider a social identity transition as suggested in the SIMOR model. At the same time, the model presented in Figure 1 provides an important basis for empirically testing the effects of identity salience and fit at varying phases of recovery. Those still actively using would be hypothesised to identify more strongly with using groups, while those in an early phase of recovery would be more likely to report a diminishing using identity in tandem with a growing recovery-based social identity. The transition to a recovery-based social identity should then be considerably more salient by the time the individual achieves stability in their recovery. These various issues also raise wider questions about the testability of the model. Our sense is that these are best addressed through empirical work, and indeed some of this is already underway with this population. In two existing papers based in drug and alcohol therapeutic communities (Beckwith, Best, Dingle, Perryman, & Lubman, 2015; Dingle, Stark, Cruwys, & Best, 2014), the authors have demonstrated that new entrants whose identification with the therapeutic community increased in the first 2 weeks of treatment (which related to a decrease in using group-based identity) had significantly better retention and completion rates. Similarly, better post-treatment outcomes were observed among participants who reported stronger recovery-based social identities following discharge from treatment. Both these studies demonstrate the predictive importance of a social identity shift in the recovery transition. Another longitudinal study is currently underway across four therapeutic communities in Australia that will further assess the impact of group belonging and social identity change on recovery pathways whilst controlling for other possible explanations (e.g. individual differences, addiction severity, demographic factors and context). Importantly, this research will also assess the relationship between social identity change, treatment outcomes, quality of life and recovery capital. Conclusion: recovery as a socially embedded process Rather than locating recovery solely in individual processes, we argue that recovery is more usefully framed as a social process, underpinned by transitions in social network composition that includes the addition of new recovery-oriented groups, where such groups are perceived as attractive, beneficial and relevant (Jetten et al., 2014), and involves the concurrent emergence of a new recovery-based social identity. These changes are sustained and supported through group processes of social influence, through the transmission of recoveryoriented norms and values, and through the social control that comes from internalising these norms and values (Moos, 2007). The social processes embedded in Alcoholics Anonymous, an enduring and successful peer-based mutual aid group, provide an effective and tangible case study through which to examine the role of group-based social influence on social identity change in recovery. To better understand recovery, we need to move away from the view that it is simply an individualised personal journey and see it instead as a socially embedded process of successful social identity transition. Acknowledgements The authors would like to thank John Kelly and William White for their helpful comments on an early draft of this paper. Declaration of interest The research is supported by funding from the Australian Research Council (DP140103579; FL110100199). 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ARTICLES Vulnerability for Alcohol Use Disorder and Rate of Alcohol Consumption Joshua L. Gowin, Ph.D., Matthew E. Sloan, M.D., M.Sc., Bethany L. Stangl, Ph.D., Vatsalya Vatsalya, M.D., M.Sc., Vijay A. Ramchandani, Ph.D. Objective: Although several risk factors have been identified for alcohol use disorder, many individuals with these factors do not go on to develop the disorder. Identifying early phenotypic differences between vulnerable individuals and healthy control subjects could help identify those at higher risk. Binge drinking, defined as reaching a blood alcohol level of 80 mg%, carries a risk of negative legal and health outcomes and may be an early marker of vulnerability. Using a carefully controlled experimental paradigm, the authors tested the hypothesis that risk factors for alcohol use disorder, including family history of alcoholism, male sex, impulsivity, and low level of response to alcohol, would predict rate of binging during an individual alcohol consumption session. Method: This cross-sectional study included 159 young social drinkers who completed a laboratory session in which they self-administered alcohol intravenously. Cox proportional Alcohol use disorder has a lifetime prevalence of nearly one in three individuals in the United States (1). An important goal is to identify at-risk individuals prior to the development of this disorder so that they can be targeted for early intervention. One way to determine early phenotypic differences in those at risk is to examine behavior at the level of an individual drinking session. For example, the rate of drinking and total alcohol exposure may differ between those at high and low risk. These parameters, however, are difficult to quantify in the field because of the lack of instruments that can continuously and accurately monitor blood alcohol concentration. Furthermore, asking individuals to report details about their rate of consumption does not account for variability in absorption and metabolism (2) and would likely be inaccurate because intoxication impairs recall (3). Despite these measurement difficulties, there is evidence that the rapid consumption of large quantities of alcohol leading to a blood alcohol concentration of 80 mg%, defined as binge drinking (4), affects psychological and physical well-being. Binge drinking is associated with greater risk of negative health consequences hazards models were used to determine whether risk factors for alcohol use disorder were associated with the rate of achieving a binge-level exposure. Results: A greater percentage of relatives with alcoholism (hazard ratio: 1.04, 95% CI=1.02–1.07), male sex (hazard ratio: 1.74, 95% CI=1.03–2.93), and higher impulsivity (hazard ratio: 1.17, 95% CI=1.00 to 1.37) were associated with a higher rate of binging throughout the session. Participants with all three risk factors had the highest rate of binging throughout the session compared with the lowest risk group (hazard ratio: 5.27, 95% CI=1.81–15.30). Conclusions: Binge drinking may be an early indicator of vulnerability to alcohol use disorder and should be carefully assessed as part of a thorough clinical evaluation. Am J Psychiatry 2017; 174:1094–1101; doi: 10.1176/appi.ajp.2017.16101180 (e.g., myocardial infarction) and legal trouble (5, 6). Binge drinking may signify an innate preference for higher brain alcohol exposure and may begin before an individual meets criteria for an alcohol use disorder, but this hypothesis has never been empirically tested. One method to assess alcohol consumption that overcomes many of these measurement difficulties is intravenous alcohol self-administration (7). This method has shown good testretest reliability and external validity (8, 9) and has been employed in pharmacological (10) and genetic studies (11). Intravenous alcohol self-administration has several advantages over oral self-administration. Whereas oral administration at fixed doses can result in up to threefold variability in alcohol exposure between individuals as a result of pharmacokinetic differences (12, 13), intravenous administration standardizes alcohol exposure by bypassing gastrointestinal absorption and first-pass metabolism. Interindividual differences in alcohol distribution and elimination are accounted for by using an infusion algorithm that adjusts for age, sex, height, and weight (2). Accordingly, each infusion increases See related features: Editorial by Dr. Petrakis (p. 1034), Clinical Guidance (Table of Contents), CME course (p. 1127), AJP Audio (online), and Video by Dr. Pine (online) 1094 ajp.psychiatryonline.org Am J Psychiatry 174:11, November 2017 GOWIN ET AL. alcohol levels by a fixed quantity, allowing the TABLE 1. Characteristics of the Sample by Sex infusion software to provide continuous estiCharacteristic Male (N=86) Female (N=73) mates of blood alcohol levels that closely track Mean SD Mean SD brain alcohol exposure (14) and breathalyzer 26.4 5.2 25.8 5.0 readouts (15). These estimates can then be used to Age (years) 3.6 8.5 2.6 6.9 Family history densitya,b measure an individual’s total alcohol exposure, as Delay discountinga,c –4.7 1.8 –4.5 1.7 well as howquickly the individual reaches a binge Level of alcohol responsed,e 4.8 2.1 3.7 1.7 level of exposure. This paradigm also eliminates Alcohol Use Disorder Identification Test score 5.8 2.5 5.1 2.8 specific cues associated with oral alcoholic bevN % N % erages, including taste, smell, and appearance. As Family history positive 17 19.8 11 15.1 a result, intravenous self-administration should Current alcohol abusea 2 2.4 2 2.7 be driven primarily by alcohol’s pharmacody- a Data were missing for some participants (family history, N=158; delay discounting, N=134; current namic effects, such as dopamine release in the alcohol abuse, N=158). nucleus accumbens (16). This method is there- b Family history density was obtained by dividing the number of first- and second-degree relatives with an alcohol use disorder by the total number of first- and second-degree relatives; it is reported fore ideal to determine whether preference for as a percentage. The value displayed represents the mean and SD for the whole sample (see Table higher alcohol exposure is evident prior to the S1 in the online data supplement for family history density in the family history positive group). development of alcohol use disorder among in- c Delay discounting is a behavioral measure of impulsivity in which participants choose between smaller immediate or larger delayed rewards; values are reported as the natural logarithm of the discounting dividuals with biological risk factors. constant, k; lower values of ln(k) indicate lower degrees of delay discounting and less impulsivity. The DSM-5 lists the following genetic and d Level of alcohol response is derived from the Self-Rating of the Effects of Alcohol form, assessing physiological risk factors for alcohol use disresponse during the first five drinking occasions; the final score represents the mean of the number of drinks needed to achieve four possible intoxication-related outcomes, with a higher order (17): family history of alcoholism (18), number indicating a lower level of response to alcohol. male sex (1), impulsivity (19), absence of acute e Male and female participants showed statistically different distributions for level of alcohol realcohol-related skin flush (20), pre-existing sponse using the Mann-Whitney test (Zu=3.7, p,0.01). schizophrenia or bipolar disorder (21), and low level of response to alcohol (22). Although these factors markedly of mood, anxiety, or psychotic disorder; 3) current or lifetime increase the risk of developing alcohol use disorder, it remains history of substance dependence (including alcohol and unclear how they affect the likelihood of risky drinking patterns nicotine); 4) recent illicit use of psychoactive substances; prior to disorder onset. In the present study, we examined the 5) history of acute alcohol-related skin flush; 6) regular tolargest community sample to date of young adult social drinkers bacco use (.20 uses/week); 7) history of clinically significant using intravenous alcohol self-administration. We investigated alcohol withdrawal; 8) lifetime history of suicide attempts; 9) whether the genetic and physiological risk factors listed in DSM-5 current or chronic medical conditions, including cardiovascular (except for skin flush and comorbid psychiatric disorders, which conditions, requiring inpatient treatment or frequent medical were exclusion criteria) were associated with the rate of bingevisits; or 10) use of medications that may interact with alcohol level exposure during an individual drinking session. We hywithin 2 weeks prior to the study. Females were excluded if they pothesized that individuals at higher risk for developing an alwere breastfeeding or pregnant or if they intended to become cohol use disorder would exhibit a preference for higher brain pregnant. alcohol exposure as demonstrated by higher rates of binging All participants were assessed for psychiatric diagnoses, throughout the session and higher levels of total alcohol exposure. history of acute alcohol-related skin flush, drinking history, and other risk factors for alcohol use disorder. Diagnoses were assessed by the Structured Clinical Interview for DSM-IV Axis I METHOD disorders (23). History of acute alcohol-related skin flush was Participant Characteristics assessed using the Alcohol Flushing Questionnaire (24). Drinking A total of 162 social drinkers between the ages of 21 and history was assessed using the Alcohol Use Disorder Identifi45 were recruited through newspaper advertisements and cation Test (25). Two participants were excluded from this the National Institutes of Health (NIH) Normal Volunteer analysis because they were heavy drinkers based on the Timeline Office (for detailed demographic information, see Table 1 and Followback Interview (.20 drinks/week for males, .15 drinks/ Tables S1–S3 in the data supplement accompanying the online week for females). One participant was excluded because version of this article). To be included, participants must have software failure caused the session to be terminated prior consumed at least five drinks on one occasion at one point in to minute 20 of the alcohol self-administration session, their life. Participants completed a telephone screen and subresulting in a final sample size of 159 participants. sequently completed an in-person assessment at the NIH Clinical Center in Bethesda, Md. The study protocol was approved by Alcohol Use Disorder Risk Factor Measures the NIH Addictions Institutional Review Board, and participants Family history. Participants completed the Family Tree were enrolled after providing written, informed consent. Questionnaire (26) to identify first- and second-degree relParticipants were excluded if they met any of the folatives who may have had alcohol-related problems. They lowing 10 exclusion criteria: 1) nondrinker; 2) lifetime history subsequently completed the family history assessment plus Am J Psychiatry 174:11, November 2017 ajp.psychiatryonline.org 1095 VULNERABILITY FOR ALCOHOL USE DISORDER AND RATE OF CONSUMPTION individual assessment modules of the Semi-Structured Assessment for Genetics of Alcoholism for all identified relatives (27). This assessment is widely used in family history-based studies, including large genetic studies, such as the Collaboration on the Genetics of Alcoholism (28). If no information was available about a relative, then that relative was scored as a 0. Relatives with a known history of alcohol-related problems were scored as a 1. A family history density score was calculated by dividing the number of relatives with alcohol problems by the total number of first- and second-degree relatives. One participant did not complete this measure, and his value was imputed with the sample median of 0 given that family history density was not normally distributed (Shapiro-Wilk test: p,0.001). We conducted all models with and without this participant and found that his exclusion did not alter our findings, and thus we report the results with this participant included. Behavioral impulsivity. Participants completed a delay discounting task (29), which is a well-validated measure of behavioral impulsivity that has a robust association with alcohol use disorder (30, 31). During this task, participants chose between smaller immediate rewards or $100 received after a delay (e.g., $90 now or $100 in 7 days). Immediate rewards ranged in value from $0 to $100, and delay periods ranged from 7 to 30 days. The degree of discounting delayed rewards, k, can be calculated using the equation developed by Mazur et al. (32). Since k values were not normally distributed, they were normalized using a logarithmic transformation and reported as ln(k). Lower values of ln(k) suggest less impulsivity and lower degrees of discounting. A portion of the sample did not complete this task (N=25), and missing values of ln(k) were imputed with the sample mean. Level of response to alcohol. Participants also completed the Self-Rating of the Effects of Alcohol form (33). This instrument assesses response to alcohol during the first five drinking occasions of a person’s life, their heaviest drinking period, and their most recent drinking period. For each period, it asks how many drinks it took for them to feel different, to feel dizzy, to begin stumbling, and to pass out. The final score represents the mean of the number of drinks needed to achieve each outcome, with a higher number of drinks indicating a lower level of response to alcohol. We focused on the first five drinking occasions in the present analyses to reduce the potentially confounding impact of tolerance. Intravenous Alcohol Self-Administration Participants were instructed not to drink alcohol in the 48 hours prior to study procedures. Upon arrival, they provided a breathalyzer reading to confirm abstinence. Participants also provided a urine sample that was tested for illicit drugs and, for females, pregnancy; both had to be negative to proceed with the study session. After the participant ate a 1096 ajp.psychiatryonline.org standardized (350 kcal) meal, an intravenous catheter was inserted into a vein in the forearm. Self-administration was conducted using the computer-assisted alcohol infusion system software, which controlled the rate of infusion of 6.0% v/v alcohol in saline for each individual using a physiologically based pharmacokinetic model for alcohol distribution and metabolism that accounts for sex, age, height, and weight (2). The alcohol self-administration session consisted of a 25-minute priming phase and a 125-minute free-access phase. During the first 10 minutes of the priming phase, participants were required to push a button four times at 2.5-minute intervals. Each button press resulted in an alcohol infusion that raised blood alcohol concentration by 7.5 mg% in 2.5 minutes, such that participants achieved a peak concentration of approximately 30 mg% at minute 10. During the next 15 minutes, the button remained inactive while participants experienced the effects of the alcohol. At minute 25, the free-access phase began, and participants were instructed to “try to recreate a typical drinking session out with friends.” Participants could self-administer ad libitum, but they had to wait until one infusion was completed before initiating another. Blood alcohol concentration was estimated continuously by the software based on infusion rate and modelestimated metabolism, and a readout was provided at 30-second intervals. Breath alcohol concentration was also obtained via breathalyzer at 15-minute intervals to confirm the software-calculated estimates; these readings were entered into the software to provide the model feedback, and the infusion rate was automatically adjusted accordingly (2). Software estimates of blood alcohol concentration were used to determine whether a participant reached bingelevel exposure, defined as achieving an estimated blood alcohol concentration greater than 80 mg% (4). A limit was imposed such that estimated blood alcohol concentration could not exceed 100 mg% to prevent adverse events due to intoxication. Statistical Analysis To examine whether risk factors for alcohol use disorder were predictors of rate of binging throughout the freeaccess phase of the intravenous alcohol self-administration session, we plotted Kaplan-Meier survival curves and conducted Cox proportional hazards models. We generated the following four Kaplan-Meier survival curves using binary variables (Figure 1): 1) male compared with female; 2) family-history positive compared with negative; 3) high compared with low impulsivity (median split); and 4) high compared with low level of response to alcohol (median split). For the Cox proportional hazards analyses, the outcome variable was time to binge (estimated blood alcohol concentration of 80 mg%), and participants were censored when they reached a binge or ended the session early (one participant). For the initial Cox proportional hazards model, five independent variables were included: sex was coded as a binary variable (0 for females, 1 for Am J Psychiatry 174:11, November 2017 GOWIN ET AL. FIGURE 1. Cumulative Probability of Achieving Binge-Level Exposure by Each Alcohol Use Disorder Risk Factora Delay Discounting Family History 100 100 Negative (N=130) Low (N=67) Positive (N=28) High (N=67) Censored Censored 80 Percent Reaching Binge Percent Reaching Binge 80 60 40 20 60 40 20 0 0 0 20 40 60 80 100 120 0 20 Time (minutes) 40 Level of Response to Alcohol 120 80 100 120 Sex High (N=86) F (N=73) Low (N=73) M (N=86) Censored Censored 80 Percent Reaching Binge Percent Reaching Binge 100 100 80 60 40 60 40 20 20 0 20 40 60 80 100 120 Time (minutes) a 80 Time (minutes) 100 0 60 0 0 20 40 60 Time (minutes) Cumulative probability of achieving a binge-level exposure (estimated breath alcohol concentration of 80 mg%) was higher in males compared with females, in family-history positive compared with family-history negative individuals, in high compared with low delay discounters, and in low compared with high responders to alcohol. males), and delay discounting, family history density, level of response to alcohol, and age were entered as continuous variables. To determine whether faster rate of consumption translated into greater overall exposure to alcohol, we calculated the area under the curve for the estimated breath alcohol concentration by time plot during the free-access phase of the session. Three individuals ended the session early due to software malfunction or adverse events (at minutes 59, 88.5, and 99.5); thus, in order to generate the area under the curve for these participants, we imputed values for Am J Psychiatry 174:11, November 2017 the remainder of the session by carrying their last observed alcohol concentration forward. To confirm the validity of this approach, we applied the same imputation procedure for 20 random participants starting at minute 59 and found that the imputed values correlated highly with the actual values (Spearman’s rho .0.9). We conducted Mann-Whitney tests to compare area under the curve distributions for each risk factor, as area under the curve values were not normally distributed (Shapiro-Wilk test: p,0.05). For these analyses, we used the binary categorical risk factors described above. ajp.psychiatryonline.org 1097 VULNERABILITY FOR ALCOHOL USE DISORDER AND RATE OF CONSUMPTION To assess the additive effects of significant variables from the aforementioned analyses, we coded individuals according to their number of risk factors for alcohol use disorder. For this analysis, we only used the binary risk factors described above, excluding level of response to alcohol, which did not contribute to the aforementioned models. We thus created four groups: zero-, one-, two-, and three-risk factor groups. The zero-risk factor group served as the reference group. We plotted Kaplan-Meier survival curves to examine differences between groups and also to fit a Cox proportional hazards model additionally adjusted for age. We also tested whether there was evidence of additive effects of risk factors on overall alcohol exposure during the session by comparing the area under the curve values for different risk groups using a Jonckheere-Terpstra test (34, 35). Effects of Individual Risk Factors on Total Alcohol Exposure We also tested whether each individual risk factor was associated with total alcohol exposure as measured by the area under the estimated blood alcohol concentration versus time curve during the free-access phase. Median alcohol exposure was higher in family-history positive individuals, males, and participants with delay-discounting scores above the median (see Figure S1 in the online data supplement), with significantly different distributions across sex and delaydiscounting groups and marginal significance across family history groups (family history: U[28, 130]=2247, p=0.052; sex: U[86, 73]=3763, p=0.031; delay discounting: U[67, 67]=2839, p=0.008). There was no significant difference between those with high and low levels of alcohol response (U[73, 86]=2619, p=0.072). RESULTS Additive Effects of Risk Factors on Rate of Binging To investigate whether the significant risk factors from the prior analysis had additive effects, we divided participants based on their number of risk factors into four groups: zero risk factors (N=26), one risk factor (N=65), two risk factors (N=36), and three risk factors (N=8), where zero risk factors indicates a family-history negative female with a delay-discounting score below the median (Figure 2) (see Table S5 in the online data supplement for characteristics of the sample by risk factor group). Cox proportional hazards regression controlling for age demonstrated that compared with the zero-risk factors group, individuals in the two-risk factors group (hazard ratio=2.54, 95% CI=1.05–6.12, p=0.038) and three-risk factors group (hazard ratio=5.27, CI=1.81–15.30, p=0.002) binged at higher rates throughout the session. The zerorisk factors group and the one-risk factor group did not differ (hazard ratio=1.29, 95% CI=0.55–3.04, p=0.562). These effects remained significant when controlling for the level of alcohol response as a continuous variable and the Alcohol Use Disorder Identification Test score (see Table S6 in the online data supplement). Effect of Risk Factors on Rate of Binging Overall, 60 participants achieved a binge-level exposure, and 99 participants had estimated blood alcohol concentrations beneath 80 mg% across the entire session. A higher percentage of bingers was found in family-history positive compared with negative individuals (57.1% and 33.1%, respectively), males compared with females (43.0% and 31.5%, respectively), high compared with low delay-discounting individuals (49.3% and 29.9%, respectively), and those with a low compared with high level of response to alcohol (43.8% and 32.6%, respectively) (Figure 1). We tested whether risk factors for alcohol use disorder predicted the rate of binging throughout the session using a Cox proportional hazards model with all four risk factors and age as independent variables (model 1). Family history density was a significant predictor (hazard ratio=1.04, 95% confidence interval [CI]=1.02–1.07, p=0.001), whereas male sex (hazard ratio=1.71, 95% CI=1.00–2.94, p=0.052) and delay discounting (hazard ratio=1.17, 95% CI=1.00–1.37, p=0.056) were marginally significant. Level of response to alcohol was not a significant predictor of the rate of binging throughout the session (hazard ratio=1.01, 95% CI=0.89–1.15, p=0.840) (Table 2). Because the level of response was not contributing to the model and was significantly correlated with sex (Spearman’s rho=0.29, see Table S4 in the online data supplement), we dropped it from the model. In this second analysis (model 2), male sex (hazard ratio=1.74, 95% CI=1.03–2.93, p=0.038), delay discounting (hazard ratio=1.17, 95% CI=1.00–1.37, p=0.048), and family history density (hazard ratio=1.04, 95% CI=1.02–1.07, p=0.002) all significantly predicted binge rate throughout the session. The effects of these risk factors remained consistent when controlling for the Alcohol Use Disorder Identification Test score (model 3). As would be expected, participants with a higher Alcohol Use Disorder Identification Test score were more likely to binge (hazard ratio=1.14, 95% CI=1.04–1.24, p=0.004). 1098 ajp.psychiatryonline.org Additive Effects of Risk Factors on Total Alcohol Exposure Individuals with a greater number of risk factors achieved higher levels of alcohol exposure, with median area under the curve values of 2132.5 mg%*min, 3814.8 mg%*min, 4565.7 mg%*min, and 7208.5 mg%*min for individuals with the lowest to highest number of risk factors, respectively. The results of a Jonckheere-Terpstra test for ordered alternatives indicated that there was a significant effect of number of risk factors on the distribution of area under the curve values with a small-to-medium effect size (TJT=3746.0, p=0.001, Kendall’s t=0.22) (Figure 3). Bonferroni-corrected pairwise comparisons indicated that the distribution of the areas under the curve for the two- and three-risk factors groups were significantly different than that of the zero-risk factors group, and the three-risk factors group distribution of area under the curve values also Am J Psychiatry 174:11, November 2017 GOWIN ET AL. TABLE 2. Hazard Ratios From Cox Proportional Hazards Models Examining the Effect of Alcohol Use Disorder Risk Factors on Rate of Binginga Model 1 Variable Family history density (%) Male sex Delay discounting Level of alcohol response Age (years) Alcohol Use Disorder Identification Test score a Model 2 Model 3 Hazard Ratio 95% CI Hazard Ratio 95% CI Hazard Ratio 95% CI 1.04 1.71 1.17 1.01 0.90 — 1.02–1.07 1.00–2.94 1.00–1.37 0.89–1.15 0.83–0.97 — 1.04 1.74 1.17 — 0.90 — 1.02–1.07 1.03–2.93 1.00–1.37 — 0.83–0.96 — 1.04 1.67 1.17 — 0.91 1.14 1.02–1.07 0.99–2.82 1.00–1.37 — 0.85–0.98 1.04–1.24 Model 1 examined alcohol use disorder risk factors and age; model 2 excluded level of alcohol response because it was significantly correlated with sex and did not contribute to model 1; model 3 also accounted for the Alcohol Use Disorder Identification Test score to control for the effect of alcohol consumption; for all three models, female sex is the reference group. differed from that of the one-risk factor group (all p values ,0.05). FIGURE 2. Cumulative Probability of Achieving Binge-Level Exposure by Alcohol Use Disorder Risk Factor Groupa 100 Risk Factors DISCUSSION Am J Psychiatry 174:11, November 2017 0 (N=26) 1 (N=65) 80 Percent Reaching Binge Young social drinkers at risk for an alcohol use disorder had consumption patterns that were markedly different from low-risk drinkers during a free-access intravenous alcohol self-administration session. Vulnerable drinkers had higher rates of binging throughout the session and greater overall exposure to alcohol. The effects of these risk factors were additive. This finding is especially remarkable given the similarity of Alcohol Use Disorder Identification Test scores between the higher- and lower-risk groups and given that these effects remained largely unchanged when controlling for test scores. To our knowledge, this is the first large pharmacokinetically controlled study to show that the presence of risk factors for alcohol use disorder leads to different patterns of drinking at the level of an individual drinking session in young social drinkers who have not yet developed the disorder. These findings suggest an innate neurobiological preference for higher alcohol exposure that may contribute to alcohol use disorder risk. Of the factors we examined, family history of alcoholism was most strongly associated with the rate of binging during the session, with a small-to-medium effect size. This finding is in accordance with epidemiologic studies showing that up to one-half of the risk of alcoholism is genetic and corroborates the results of a small intravenous alcohol selfadministration study demonstrating that family-history positive individuals achieved higher alcohol exposures (36). Our study extends these intravenous alcohol selfadministration results by showing that participants with a greater percentage of biological relatives with alcohol problems were at greater risk. Our study also found higher rates of alcohol consumption in males compared with females, which is consistent with a recent study of intravenous alcohol self-administration in adolescents (9). Delay discounting has previously been observed as a predictor of laboratory alcohol consumption (8), and we confirmed that here. The level of response to alcohol was not related to the rate of binging or total alcohol exposure in our study. This may be 2 (N=36) 3 (N=8) Censored 60 40 20 0 0 20 40 60 80 100 120 Time (minutes) a Each participant was categorized as having zero, one, two, or three risk factors (0=female, family-history negative, low impulsivity; 3=male, family-history positive, high impulsivity). The cumulative probability of binging increased in participants with a greater number of risk factors. partially due to the surprising fact that participants with a low level of response to alcohol in our study actually had lower family history densities for alcoholism than participants with a high level of response (see Table S3 in the online data supplement), which is the opposite of what has been found in most studies (37), although controlling for family history density did not change our results. Level of response to alcohol may have been influenced by recall bias and may have shown more predictive power if it had been assessed experimentally, as in the original studies by Schuckit (22). Despite some evidence that level of response may vary as a function of rate of change in blood alcohol concentration and drinking history (37, 38), we chose to use a simpler static measure of level of response here. More complex assessments of level of response may yield different results. There were several limitations to this study, most notably the cross-sectional design. Longitudinal studies will be ajp.psychiatryonline.org 1099 VULNERABILITY FOR ALCOHOL USE DISORDER AND RATE OF CONSUMPTION FIGURE 3. Total Alcohol Exposure by Alcohol Use Disorder Risk Factor Groupa A Area Under the Curve (mg% * min) 10,000 8,000 6,000 4,000 2,000 0 0 (N=26) 1 (N=65) 2 (N=36) 3 (N=8) Number of Risk Factors Estimated Blood Alcohol Concentration (mg%) B 100 0-Risk Factors Group 1-Risk Factor Group 80 2-Risk Factors Group 3-Risk Factors Group 60 40 20 AUTHOR AND ARTICLE INFORMATION Drs. Gowin and Sloan contributed equally to this study. 0 0 20 40 60 80 100 120 Time (minutes) a 30. When we controlled for age in our analyses, the effects we observed remained significant. The additive risk factor analysis requires replication, especially given the low number of individuals in the three-risk factors group. Finally, we could not assess how acute alcohol-related skin flush, smoking, and preexisting psychiatric disorders contributed to the rate of binging in this sample because these were exclusion factors for our study. This limits the generalizability of our findings, especially because smoking and psychopathology are highly comorbid with alcoholism. Future studies should determine whether these factors affect rates of alcohol consumption in young adults. Prior to the development of an alcohol use disorder, those at higher risk demonstrated differing patterns of alcohol consumption, including higher rates of binging and greater total alcohol exposure. Although most screening tools for alcoholism focus on quantity of consumption across many sessions, focusing on binging and total alcohol exposure during individual drinking sessions may be clinically relevant and may allow for earlier detection of high-risk individuals. Assessing binging and total alcohol exposure in the laboratory, and eventually in the field when appropriate technology is available, may be a helpful way of selecting individuals who require early intervention. Clinical questions regarding the time course of typical drinking sessions, in addition to standard questions about quantity of alcohol consumed, may help better characterize total alcohol exposure and stratify risk. There are likely neurobiological factors that contribute to the way each person drinks, and this may dispose some individuals to achieve blood alcohol concentrations that endanger them. Graph A shows the area under the curve for the estimated breath alcohol concentration by time plot (total alcohol exposure) examined in each alcohol use disorder risk factor group. Having a higher number of risk factors was significantly associated with total alcohol exposure during the session. The horizontal line in the middle of each box indicates the median, while the bottom and top borders of the box represent the 25th and 75th percentile values, respectively. In graph B, the lines represent the mean blood alcohol concentration for each group. needed to confirm that differing patterns of consumption early on are predictive of the development of an alcohol use disorder. Intravenous alcohol self-administration also differs in many ways from real-world alcohol consumption. However, recent results suggest that intravenous selfadministration is reflective of external consumption patterns when comparing across drinkers of varying severity (9, 39). A few individuals in our sample were in their forties, and an even younger sample would have been ideal to assess the effects of these risk factors, although the vast majority of the individuals in our sample (86.1%) were at or below the age of 1100 ajp.psychiatryonline.org From the Section on Human Psychopharmacology, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and the University of Louisville and Robley Rex Veterans Affairs Medical Center, Louisville, Ky. Address correspondence to Dr. Ramchandani (vijayr@mail.nih.gov). Supported by the NIAAA Division of Intramural Clinical and Biological Research (Z1A AA000466). Development of the software used for the intravenous alcohol self-administration session was supported by Sean O’Connor, M.D., at the Indiana Alcohol Research Center (NIH P60 AA007611). The authors thank the late Dr. Daniel Hommer for his mentorship and clinical oversight, Dr. Mary Lee, Dr. David T. George, and Nurse Practitioner LaToya Sewell for medical support and monitoring safety of the participants, as well as Markus Heilig, Reza Momenan, and Melanie Schwandt for their programmatic and operational support. The authors also thank Tasha Cornish and Monique Ernst for comments on earlier drafts of this study; Joel Stoddard and Ruth Pfeiffer for analytic suggestions; the staff of the 5-SW day hospital and 1-HALC alcohol clinic at the NIH Clinical Center; and, for their help with data collection, Julnar Issa, Megan Cooke, Marion Coe, Molly Zametkin, Kristin Corey, Jonathan Westman, Lauren Blau, and Courtney Vaughan. ClinicalTrials.gov identifier: NCT00713492 The authors report no financial relationships with commercial interests. Received Oct. 26, 2016; revision received March 28, 2017; accepted May 4, 2017; published online Aug. 4, 2017. Am J Psychiatry 174:11, November 2017 GOWIN ET AL. REFERENCES 1. 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