Greater prevalence of proposed DSM-5 nicotine use disorder compared to DSM-IV nicotine dependence in treated adolescents and young adults.

Proposed Diagnostic and Statistical Manual (DSM) of Mental Disorders, fifth edition (DSM-5), substance use disorder (SUD) criteria (www.dsm5.org) would involve more change for nicotine, compared to other drug classes in DSM-IV (1–3). Specifically, proposed DSM-5 nicotine use disorder (NUD) criteria would increase the number of criteria used for diagnosis from 7 to 11, with the addition of three DSM-IV abuse criteria (used for most other substances in DSM-IV with the exception of nicotine), and a new Craving criterion. In addition, the threshold for nicotine diagnosis would be lowered from 3 to 2 symptoms. The implications of proposed changes to NUD criteria with regard to the prevalence and validity of nicotine diagnoses, and diagnostic concordance across iterations of DSM warrant study prior to the publication of DSM-5 in 2013. DSM-IV recognizes two SUDs: substance abuse and dependence. A diagnosis of substance abuse requires 1 of 4 criteria representing certain negative consequences resulting from substance use: recurrent failure to meet Role Obligations, Hazardous Use, Interpersonal Problems, and Legal Problems. DSM-IV substance dependence requires the co-occurrence of 3 of 7 criteria within 1-year: Tolerance, Withdrawal, use more or longer than intended (Larger/Longer), failed attempts or strong desire to limit use (Quit/Cut), Much Time spent using, Reduce Activities in order to use, and psychological or physical problems exacerbated or caused by use (Psych/Phys). Importantly, DSM-IV acknowledges that some of the generic dependence criteria used to determine a nicotine diagnosis do not appear to directly apply to nicotine or require some explanation as to how they might apply to nicotine (2: page 243; 3: page 264). Proposed DSM-5 NUD criteria include 11 symptoms (1): 3 DSM-IV abuse criteria (i.e., Role Obligations, Hazardous Use, Interpersonal Problems), all 7 DSM-IV dependence criteria, and a new Craving symptom (i.e., strong desire to engage in use). Proposed DSM-5 NUD requires the co-occurrence of two or more of 11 symptoms within 1-year. Presence of 2–3 symptoms represents “moderate” NUD, and 4 or more symptoms represents “severe” NUD. The use of a criterion set that combines abuse and dependence symptoms in DSM-5 is based on the idea that the proposed criteria represent a single dimension, which has been supported for alcohol and some other drugs (e.g., 4, 5, 6). To date, only 1 study has examined the dimensionality of proposed DSM-5 NUD criteria (7), and like other studies of nicotine-related symptoms (e.g., 8, 9), found support for a single dimension. Because few existing datasets include data relevant to examining proposed DSM-5 NUD criteria, we attempted to replicate (cf. 7) the dimensionality and performance characteristics of 10 of the 11 (Role Obligation not assessed) proposed DSM-5 NUD criteria. Decisions to include new diagnostic criteria, such as Craving, need to consider whether the criteria improve diagnosis in terms of reliability, validity, and case identification (10). This study examined concordance of DSM-IV dependence and proposed DSM-5 NUD, and evidence for concurrent validity of the two algorithms in adolescents and young adults, who were initially recruited from substance use treatment. This study addresses the DSM-5 workgroup’s call for field trials in patient samples because patient samples tend to have more, and more severe symptoms, compared to the general population (1). We focus on adolescents and young adults because nicotine addiction often has origins in adolescence, and peak rates of tobacco use emerge in young adulthood (11). For analyses comparing the prevalence of DSM-IV dependence and proposed DSM-5 NUD, we predicted greater prevalence of proposed DSM-5 NUD compared to DSM-IV, due to proposed DSM-5’s lower threshold and expanded array of symptoms. We also predicted that lowering the threshold to 2 symptoms would result in limited concurrent validity for proposed DSM-5 NUD, relative to DSM-IV nicotine dependence. We tested the unidimensionality of proposed DSM-5 NUD criteria, and used Item Response Theory (IRT) to examine symptom performance characteristics. We predicted that the 3 DSM-IV abuse items would show poor psychometric performance (e.g., low rates of endorsement) when included in the proposed DSM-5 algorithm.