Substance-Related and Addictive Disorders

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socw 6090

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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.

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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). 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(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. 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. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The alcohol use disorders identification test: Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization. DEVELOPMENT OF A BRIEF DSM–5 AUD ASSESSMENT Babor, T. F., & Del Boca, F. K. (1992). Just the facts: Enhancing the measurement of alcohol consumption using self-report methods. In R. Z. Litton & J. P. Allen (Eds.), Techniques for measuring alcohol consumption (pp. 3–19). Clifton, NJ: Humana Press. http://dx.doi.org/10.1007/ 978-1-4612-0357-5_1 Beck, K. H., Arria, A. M., Caldeira, K. M., Vincent, K. B., O’Grady, K. E., & Wish, E. D. (2008). Social context of drinking and alcohol problems among college students. American Journal of Health Behavior, 32, 420 – 430. http://dx.doi.org/10.5993/AJHB.32.4.9 Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315–336. http://dx.doi.org/ 10.1111/j.1360-0443.1993.tb00820.x Campbell, C. M., & Demb, A. (2008). College high risk drinkers: Who matures out? And who persists as adults? Journal of Alcohol and Drug Education, 52, 19 – 46. Casey, M., Adamson, G., Shevlin, M., & McKinney, A. (2012). The role of craving in AUDs: Dimensionality and differential functioning in the DSM–5. Drug and Alcohol Dependence, 125, 75– 80. http://dx.doi.org/ 10.1016/j.drugalcdep.2012.03.019 Dawson, D. A., Grant, B. F., Stinson, F. S., & Chou, P. S. (2004). Another look at heavy episodic drinking and alcohol use disorders among college and noncollege youth. Journal of Studies on Alcohol, 65, 477– 488. http://dx.doi.org/10.15288/jsa.2004.65.477 Hagman, B. T., & Cohn, A. M. (2011). Toward DSM-V: Mapping the alcohol use disorder continuum in college students. Drug and Alcohol Dependence, 118, 202–208. http://dx.doi.org/10.1016/j.drugalcdep.2011 .03.021 Hagman, B. T., Cohn, A. M., Schonfeld, L., Moore, K., & Barrett, B. (2014). College students who endorse a sub-threshold number of DSM–5 alcohol use disorder criteria: Alcohol, tobacco, and illicit drug use in DSM–5 diagnostic orphans. The American Journal on Addictions, 23, 378 –385. http://dx.doi.org/10.1111/j.1521-0391.2014.12120.x Hasin, D. (2003). Classification of alcohol use disorders. Alcohol Research & Health, 27, 5–17. Hasin, D. S., Fenton, M. C., Beseler, C., Park, J. Y., & Wall, M. M. (2012). Analyses related to the development of DSM–5 criteria for substance use related disorders: 2. Proposed DSM–5 criteria for alcohol, cannabis, cocaine and heroin disorders in 663 substance abuse patients. Drug and Alcohol Dependence, 122, 28 –37. http://dx.doi.org/10.1016/j.drugalcdep.2011.09 .005 Hasin, D. S., & Grant, B. F. (2004). The co-occurrence of DSM–IV alcohol abuse in DSM–IV alcohol dependence: Results of the National Epidemiologic Survey on Alcohol and Related Conditions on heterogeneity 805 that differ by population subgroup. Archives of General Psychiatry, 61, 891– 896. http://dx.doi.org/10.1001/archpsyc.61.9.891 Hasin, D., Hatzenbuehler, M. L., Keyes, K., & Ogburn, E. (2006). Substance use disorders: Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM–IV) and International Classification of Diseases, tenth ed. (ICD-10). Addiction, 101(Suppl. 1), 59 –75. http://dx.doi .org/10.1111/j.1360-0443.2006.01584.x Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indices in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55. http://dx.doi.org/10.1080/10705 519909540118 Kahler, C. W., Strong, D. R., Read, J. P., Palfai, T. P., & Wood, M. D. (2004). Mapping the continuum of alcohol problems in college students: A Rasch model analysis. Psychology of Addictive Behaviors, 18, 322– 333. http://dx.doi.org/10.1037/0893-164X.18.4.322 Knight, J. R., Wechsler, H., Kuo, M., Seibring, M., Weitzman, E. R., & Schuckit, M. A. (2002). Alcohol abuse and dependence among U.S. college students. Journal of Studies on Alcohol, 63, 263–270. http://dx .doi.org/10.15288/jsa.2002.63.263 Martin, C. S., Chung, T., & Langenbucher, J. W. (2008). How should we revise diagnostic criteria for substance use disorders in the DSM–V? Journal of Abnormal Psychology, 117, 561–575. http://dx.doi.org/10 .1037/0021-843X.117.3.561 Monti, P. M., Tevyaw, O., & Borsari, B. (2005). Drinking among young adults: Screening, brief intervention, and outcome. Alcohol Research & Health, 28, 236 –244. (Original work Published 2004) Presley, C. A., Meilman, P. W., & Lyerla, R. (1994). Development of the Core Alcohol and Drug Survey: Initial findings and future directions. Journal of American College Health, 42, 248 –255. http://dx.doi.org/10 .1080/07448481.1994.9936356 Raistrick, D., Dunbar, G., & Davidson, R. (1983). Development of a questionnaire to measure alcohol dependence. British Journal of Addiction, 78, 89 –95. http://dx.doi.org/10.1111/j.1360-0443.1983.tb02484.x Scientific Software International. (2003). Parscale (Version 4.1) [Computer software]. Lincolnwood, IL: Author. Skinner, H. A., & Allen, B. A. (1982). Alcohol dependence syndrome: Measurement and validation. Journal of Abnormal Psychology, 91, 199 –209. http://dx.doi.org/10.1037/0021-843X.91.3.199 Stockwell, T., Murphy, D., & Hodgson, R. (1983). The Severity of Alcohol Dependence Questionnaire: Its use, reliability and validity. British Journal of Addiction, 78, 145–155. http://dx.doi.org/10.1111/j.1360-0443 .1983.tb05502.x Windle, M. (2003). Alcohol use among adolescents and young adults. Alcohol Research & Health, 27, 79 – 85. (Appendix follows) 806 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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Name
Institution
Date

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DIAGNOSTIC SUMMARY OF L’S CASE

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Diagnostic Summary of L’s Case
Patient L is presenting a case of mental and behavioral disorder, classified as an
Unspecified Mental Disorder under the ICD-10-CM coding system of mental complications. Its
ICD-10-CM code is F99-F99. In this regard, the Z code applicable to the patient’s case is Z03.2,
which relates to observation for suspected mental and behavioral disorders. The severity levels of
the patient in this case are very high, especially noted by the high numbers of suicide attempts
that she has done by cutting her wrists (Best et al., 2016). Judging from her unpredictable
behavioral disorders, it is appropriate to assert that the specifiers to her case could be bi-polar
disorders, as she finds herself doing things she does not like, or not remembering some of the
things she has just done.
However, the clinical diagnosis of her psychological complication affirmed that the main
cause of her problem is the male presence in her life that instructs and controls some of her
behaviors, actions, decisions, and movements. As such, there is possibility that she is being
haunted or communing with ghosts, as her statements affirm that the death of her best friend
Michael when she was 6 years old is what triggered the visions of the male presence in her life,
who communicates to her through her mind (Gowin et al., 2017). In most cases, the male
presence drives her to commit acts that harm her life so that she can die and join her deceased
best friend, Michael, whom she misses so much. Therefore, it is notable that her weakness which
the male presence exploits in order to control her life and behaviors is the grief that she has for
her deceased friend. In this regard, the best approach to treating her case is to help her grieve for
her friend and get over his untimely death.
Noting that Michael died when she was still very young and did not know much about
grieving, it is possible that the loss had a major psychological impact on her subconscious, which

DIAGNOSTIC SUMMARY OF L’S CASE

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in turn led to the male presence taking control of her life. In conducting this clinical diagnosis, it
is imperative to understand the possibility of having a differential diagnosis, and therefore,
necessary to identify any wrongful alternatives ...


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