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.
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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
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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
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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
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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
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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:
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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).
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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:
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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
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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
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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
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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
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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.
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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
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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
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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. Given the high rates of AUD diagnosis in this
at-risk population of drinkers, a brief assessment measure for
detecting DSM–5 AUDs in college students offers several unique
advantages such as providing a cost-efficient method for obtaining
an AUD diagnosis, cutting down on the time and intensive nature
of “gold standard” clinical interviews, and it can be easily incorporated into screening and brief intervention protocols. In sum, the
development of the Brief DSM–5 AUD Assessment is a necessary
step toward efficient assessment of DSM–5 AUDs in college
students.
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(Appendix follows)
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HAGMAN
Appendix
Brief DSM–5 AUD Assessment Items and Instructions
Below are questions related to your experiences from alcohol
use within the past year. 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, despi...
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