THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM: TOWARDS THE DSM-V. IMPROVING THE DISCRIMINANT VALIDITY OF ALCOHOL USE DISORDER DIAGNOSIS

Alcohol & Alcoholism Vol. 40, No. 4, pp. 314 322, 2005 Advnce Access puliction 9 My 2005 doi:10.1093/lclc/gh166 THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM: TOWARDS THE DSM-V. IMPROVING THE DISCRIMINANT VALIDITY OF ALCOHOL USE DISORDER DIAGNOSIS CARLA DE BRUIJN*, WIM VAN DEN BRINK 1,2, RON DE GRAAF 3 nd WILMA A. M. VOLLEBERGH 3 Received 12 Octoer 2004; first review notified 3 Mrch 2005; in revised form 3 April 2005; ccepted 14 April 2005 Deprtment of Psychitry, University Medicl Centre Utrecht, Utrecht, The Netherlnds, 1 Deprtment of Psychitry, Acdemic Medicl Centre, Amsterdm, The Netherlnds, 2 Amsterdm Institute for Addiction Reserch, Amsterdm, The Netherlnds nd 3 Netherlnds Institute of Mentl Helth nd Addiction, Utrecht, The Netherlnds Astrct Aims: To compre the discriminnt vlidity of the DSM-IV nd the ICD-10 clssifiction of lcohol use disorders (AUD) with n lterntive clssifiction, the crving withdrwl model (CWM). CWM requires crving nd withdrwl for the dignosis of lcohol dependence nd rises the lcohol use threshold to two DSM-IV AUD criteri. Methods: Dt were derived from The Netherlnds Mentl Helth Survey nd Incidence Study, lrge representtive smple of the generl Dutch popultion. In the present study, only non-stinent sujects were included (n = 6041). Three dignostic systems (DSM-IV, ICD-10, nd CWM) were compred using the following discriminnt vriles: lcohol intke, psychitric comoridity, functionl sttus, fmilil lcohol prolems, nd tretment sought. Results: The yer prevlence of CWM lcohol dependence ws lower thn the prevlence of ICD-10 nd DSM-IV dependence (0.3% vs 1.4% nd 1.4%). The yer prevlence of use ws similr for CWM nd DSM-IV (4.7 nd 4.9%), ut lower for ICD-10 hrmful use (1.7%). DSM-IV resulted in poor distinction etween normlity nd use nd ICD-10 resulted in poor distinction etween hrmful use nd dependence. In contrst, the CWM distinctions etween normlity nd use, nd etween use, nd dependence were significnt for most of the discriminnt vriles. Conclusion: This study indictes tht CWM improves the discriminnt vlidity of AUD dignoses. The predictive vlidity of the CWM for lcohol nd other sustnce use disorders remin to e studied. INTRODUCTION Although the reliility nd vlidity of the criteri of DSM-IV lcohol dependence hve een demonstrted eyond resonle dout (Bucholz et l., 1995; Lngenucher et l., 1995; Rounsville, 2002; Schuckit et l., 2002; Hsin et l., 2003), the DSM-IV conceptuliztion of lcohol use nd dependence hs severl theoreticl nd empiricl drwcks. The min prolems concern the vlidity of the use dignosis nd the sence of crving in the criteri of DSM-IV lcohol dependence. In DSM-IV, use is heterogeneous one-symptom disorder the vlidity of which is often criticized (Vinglis, 1989; Mrtin et l., 1996; Hsin et l., 1999, 2003; Rounsville, 2002). It is sed predominntly on the occurrence of sustnce-relted dverse socil consequences in order to seprte it conceptully from dependence (Helzer, 1994). However, vrious uthors hold tht DSM-IV use reflects unwise or norm-reking ehviour rther thn psychitric disorder (Hsin, 1999; Rounsville, 2002). Another rgument ginst DSM-IV use is tht it is the only mentl disorder not widely ssocited with other psychitric disorders or functionl disilities (Merikngs et l., 1998; Rvelli et l., 1998; Bijl nd Rvelli, 2000; Grf de et l., 2003). The ICD-10 hrmful use dignosis is different from DSM-IV use. It is lso sed on only one criterion, ut this criterion is more roust nd involves medicl or psychologicl dmge insted of socil prolem (see Fig. 1). Neuroiologicl reserch of lcoholism focuses on crving nd withdrwl (Monti et l., 2000; Goldstein nd Volkow, 2002; Koo, 2003). In DSM-IV, crving is not criterion of *Author to whom correspondence should e ddressed t: Deprtment of Psychitry, University Medicl Centre Utrecht, Heidelergln 100, PO Box 85500, 3508 GA Utrecht, The Netherlnds. Tel.: +31 30 2506370; Fx: +31 30 2505443; E-mil: h.deruijn-2@psych.zu.nl the lcohol use disorders (AUD) dignoses t ll. The resons proly re lck of consensus out the definition of crving, inconclusive reserch on crving s predictor of relpse, nd inconclusive reserch on the ssocition of crving with the severity of lcoholism (Vn de Brink, 1997; McKy, 1999; Mezinskis et l., 2001). Withdrwl, when defined clerly, is ssocited with more severe forms nd lter stges of lcohol dependence (Bucholz et l., 1996; Schuckit et l., 1998, 2003; Hsin et l., 2000; O Neill nd Sher, 2000; Lejoyeux et l., 2001). In DSM-IV it is dependence criterion ut, contrry to DSM-III, the dignosis cn e mde without its presence. In this rticle we propose n lterntive AUD clssifiction, which ws designed to overcome these prolems, the crving withdrwl model (CWM). CWM ws sed on the ides of Lngenucher et l., who proposed to use withdrwl s necessry nd sufficient to dignose lcohol dependence nd to increse the threshold for dignosing use (Lngenucher et l., 2000). The two vlidtion studies of the Lngenucher model hve produced promising results (Lngenucher et l., 2000; Altermn et l., 2002). However, the Lngenucher model still leves two prolems unresolved; dependence is one-symptom dignosis nd crving is not considered in the lcoholism dignosis. In view of the concerns mentioned ove, we suggest tht the Lngenucher s model e chnged to the CWM. This ltter model requires oth crving nd withdrwl for the dignosis of lcohol dependence. Unlike mny of the other lcohol prolems, crving is not ehviourlly sed. It is often defined s n urge nd n intention of ehviour (e.g. Anton, 1999). We use the ICD-10 criterion strong desire or compulsion to drink lcohol s n pproximtion for crving, since the strong desire to drink lcohol nd the osessivecompulsive spect re usully oth considered importnt spects of crving (Anton, 1999; Verheul et l., 1999). To 314 The Author 2005. Pulished y Oxford University Press on ehlf of the Medicl Council on Alcohol. All rights reserved

THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM 315 DSM-IV Dependence: Three or more of the following seven criteri: 1. tolernce 2. withdrwl:. chrcteristic withdrwl syndrome or. drinking to relieve or void withdrwl 3. more / longer thn intended 4. persistent desire / unsuccessful efforts to cut down 5. much time spent otining, using or recovering 6. importnt ctivities re given up or reduced 7. continuing despite physicl or psychologicl hrm Ause: One or more of the following four criteri: 1. filure to fulfil mjor role oligtions 2. recurrent use in hzrdous situtions 3. recurrent legl prolems 4. continuing despite socil or interpersonl hrm ICD-10 Dependence: Three or more of the following six criteri: 1. tolernce 2. withdrwl:. chrcteristic withdrwl syndrome or. drinking to relieve or void withdrwl 3. difficulties in controlling onset, termintion or levels of use (DSM-IV 3+4) 4. neglect of lterntive interests, incresed time to otin, use or recover (DSM-IV 5+6) 5. continuing physicl or psychologicl hrm 6. crving Hrmful use: Alcohol use tht hs cused ctul dmge to the mentl or physicl helth Dependence: CWM 1. crving nd 2. withdrwl: tremor nd. chrcteristic withdrwl syndrome or. drinking to relieve or void withdrwl Ause: Two or more of the following ten criteri: 1. tolernce 2. more / longer thn intended 3. persistent desire / unsuccessful efforts to cut down 4. much time spent otining, using or recovering 5. importnt ctivities re given up or reduced 6. continuing physicl or psychologicl hrm 7. filure to fulfil mjor role oligtions 8. recurrent use in hzrdous situtions 9. recurrent legl prolems 10. continuing despite socil or interpersonl hrm Fig. 1. Alcohol use disorders ccording to DSM-IV, ICD-10, nd CWM. Dignoses in our nlyses re sed on the pst 12 months.

316 C. DE BRUIJN et l. strengthen the withdrwl concept, we required the presence of tremor, s in the DSM-III-R definition, ecuse it is the most roust clinicl nd prognostic feture of withdrwl (Sellers et l., 1991; Hsin et l., 2000). For use dignosis, we dopted the definition of Lngenucher: ny two of the other DSM IV (use nd dependence) symptoms (see Fig. 1 for comprison with DSM-IV nd ICD-10 dignoses). We hve descried our rguments for designing CWM more extensively in previous study on CWM, in which we compred the discriminnt vlidity of CWM with DSM-IV in mle popultions of tretment-seeking lcoholics, nontretment-seeking hevy drinkers, nd psychitric ptients (de Bruijn et l., 2004). CWM resulted in etter distinction etween no dignosis nd use, nd etween use nd dependence, while the totl prevlence of AUD did not differ from DSM-IV. This study ims to further vlidte CWM y compring it with DSM-IV nd ICD-10 in lrge generl Dutch popultion smple. The min discriminnt vlidtors re: lcohol intke, psychitric comoridity, functionl sttus, fmilil lcohol prolems, nd seeking tretment. METHOD Sujects The dt were derived from The Netherlnds Mentl Helth Survey nd Incidence Study (NEMESIS). NEMESIS is prospective study collecting dt in three wves (1996, 1997, nd 1999) from ntionl, multistge rndom smple (ge 18 64) in The Netherlnds. The nlyses presented here re sed on dt from the first wve. A totl of 7076 people were interviewed, the response rte ws 69.7%. The respondents dequtely reflected the Dutch popultion. For more detiled informtion on NEMESIS, see the erlier report (Bijl et l., 1998). Since the Composite Interntionl Dignostic Interview (CIDI) section on AUD ws only fully dministered in sujects who drnk 12 lcoholic units within one yer t ny time, the current study ws restricted to the 6041 sujects (85.4%) who met this criterion. Instruments Dignostic criteri. The CIDI 1.1 ws used to ssess criteri of lcohol use, mood, nd nxiety disorders in the pst 12 months. The CIDI 1.1 is relile, vlidted, fully structured dignostic interview, enling us to mke dignoses ccording to ICD-10 nd DSM-III-R criteri (Cottler et l., 1991). The interviewers hd een given four dy trining course t the WHO-CIDI trining centre of the Acdemic Medicl Centre in Amsterdm. Bsed on the CIDI 1.1, ICD-10, DSM-III-R, DSM-IV, nd CWM AUD dignoses were mde over the pst 12 months. CIDI 1.1 ws not designed to yield DSM-IV or CWM dignoses. However, since DSM-IV uses the sme AUD symptoms s DSM-III-R, we could mke DSM-IV dignoses sed on the CIDI nswers. In DSM-III-R dependence dignosis is sed on three out of nine criteri. In DSM-IV, the two withdrwl criteri re merged, nd the role oligtion criterion is considered n use criterion, leving seven dependence criteri (see Fig. 1). ICD-10 mostly uses the sme dependence criteri, ut the DSM-IV items concerning loss of control (DSM-IV dependence criteri 3 nd 4) nd the DSM-IV items regrding neglect of other interests nd much time spent (DSM-IV criteri 5 nd 6) re merged (see Fig. 1). Furthermore, in ICD-10 crving is seprte dependence criterion. CWM dependence ws dignosed if crving nd withdrwl (requiring tremor) were oth present. CWM use ws dignosed if sujects met t lest two of the other DSM-IV (use nd dependence) criteri, without meeting the criteri for CWM dependence (see Fig. 1). For ll dignostic systems, suject ws only dignosed s hving either use or dependence when the suject met the full criteri. The sujects who hd pst dignosis nd were prtilly remitted did not get dignosis. Sujects with pst dependence dignosis, who met pst yer criteri for use only, were dignosed s hving use. If sttements re mde out severl of the dignostic systems elow, ICD-10 hrmful use is considered n use ctegory nd is not lwys mentioned seprtely. Discriminnt vriles. The following vriles were selected to test the discriminnt vlidity of CWM vs DSM-IV nd ICD-10: (i) Demogrphic vriles e.g. employment sttus nd eing in reltionship. (ii) Alcohol intke ws ssessed using the CIDI questions on drinking frequency nd verge numer of drinks on drinking dy. From these nswers, men weekly lcohol drinking ws clculted using the numer of stndrd drinks or lcoholic units (AU). In The Netherlnds stndrd drink contins ~10 g of ethnol. (iii) Comoridity: The presence of mood nd nxiety disorders ccording to DSM-III-R in the pst 12 months ws sed on the CIDI. (iv) Bed rest nd sence from work: Respondents were sked how mny dys they hd to sty in ed for t lest 4 h etween 10 AM nd 4 PM owing to psychologicl or lcohol prolems nd how mny dys they were sent from work owing to psychologicl or lcohol prolems in the pst 12 months. The ltter item ws nlysed for employed sujects only. (v) Functionl sttus ws ssessed using the Short Form Helth Survey (SF-36). SF-36 is well-vlidted selfreport survey on physicl nd mentl functioning (Chern et l., 2000). It hs een trnslted nd vlidted for Dutch-speking residents of the Netherlnds (Aronson et l., 1998). (vi) Fmilil lcohol prolems nd seeking tretment were ssessed y sking respondents whether their iologicl prents or silings hd lcohol prolems. Respondents were lso sked whether they hd sought tretment for ddiction in the pst 12 months. Dt nlyses Ech respondent ws dignosed ccording to the CWM, DSM-III-R, DSM-IV, nd ICD-10 criteri. Kpp coefficients were used to mesure the greement etween the dignostic systems. For ll dignostic systems, the discriminnt vlidity ws estlished y compring the men scores of the discriminnt vlidtors for the groups with no dignosis, use, nd dependence. Continuous vriles were compred using

THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM 317 ANOVA, in which ge nd gender were included s covrites. Becuse of the group size nd vrince differences, Kruskl Wllis ws susequently performed if ANOVA showed significnt difference etween the groups. Post hoc comprisons for continuous vriles were performed using Mnn Whitney U. In situtions where mood or nxiety disorders could ct s confounders, this ssumption ws tested nd the results were corrected using ANCOVA, in which ge nd gender were lso included s covrites. Proportions were compred using Chi-squre test. If differences mong the three groups were significnt, post hoc comprisons were mde etween the no dignosis group nd the use group, nd etween the use group nd the dependence group. In cse of numers <5, Fisher s exct test ws used. Owing to the lrge numer of comprisons (k = 20), Bonferroni s correction ws pplied nd the two-sided significnce level ws set t P = 0.0025. All sttisticl nlyses were performed with Sttistics Pckge for Socil Sciences (SPSS for Windows, 12.0, 2003). RESULTS The 6041 sujects hd men ge of 41.2 (SD = 12.0), 51.3% of the sujects were mle, 64.9% were employed. The men lcohol use of the totl smple ws 9.5 AU/week (SD = 13.9), the men numer of drinking dys per week ws 2.9 (SD = 2.6). Concordnce of the CWM nd DSM-III-R, DSM-IV nd ICD-10 dignoses The greement etween DSM-IV nd DSM-III-R ws very high (kpp 0.9, Tle 1). In the reminder of the mnuscript, the results for DSM-III-R re not reported seprtely. Kpp etween DSM-IV nd CWM ws 0.6; ICD-10 hd low greement with DSM-IV nd CWM (kpp 0.3), owing to the low greement etween the hrmful use/use ctegories. Tle 1 lso shows tht CWM resulted in lower yer prevlence for dependence thn the other dignostic ctegories. The yer prevlence of use ws similr for CWM nd DSM-IV, ut lower for ICD-10 hrmful use. Of the 299 DSM-IV use sujects, 273 (91.3%) hd this dignosis sed on only one use symptom, 202 of them (74.0%) hd their dignosis sed on the item drinking in situtions in which it is hzrdous. Discriminnt vlidity Demogrphic vriles. There ws no significnt difference in employment sttus etween the dignostic ctegories. For CWM nd ICD-10 use sujects were more often single thn those with no dignosis. The difference etween dependence nd use sujects ws significnt for CWM nd DSM-IV (Tle 2). Alcohol intke. The difference in men AU per week ws significnt etween no dignosis nd use sujects, nd etween use nd dependence sujects for ll dignostic systems. The sme ws true of drinking frequency, with the exception of the difference etween ICD-10 hrmful use nd no dignosis sujects (Tle 3). Comoridity. CWM sujects with use more often hd mood disorders thn those with no dignosis. The difference in mood disorder occurrence etween dependence nd use sujects ws significnt for CWM nd DSM-IV. For nxiety disorders, the only significnt differences were etween use nd dependence sujects ccording to CWM nd DSM-IV (Tle 4). Bed rest nd sence from work. All dignostic systems showed difference etween no dignosis nd use sujects on the item dys of ed rest owing to psychologicl or lcohol prolems. Between dependence nd use sujects, this difference ws only significnt for DSM-IV. After correction Tle 1. Concordnce of DSM-III-R, DSM-IV, nd ICD-10 dignoses nd the dignoses mde y the CWM for 6041 non-stinent sujects DSM-IIIR DSM-IV ICD-10 % CWM dignoses CWM (mle) ND 2744 116 1 2752 109 2820 41 92.2 AA 37 126 63 38 139 49 155 25 46 7.3 AD 1 14 1 14 15 0.5 % DSM nd ICD dignoses 89.7 7.8 2.5 90.0 8.0 2.0 95.9 2.1 2.0 n = 3102 CWM (femle) ND 2853 24 2853 24 2848 29 97.9 AA 12 30 15 14 27 16 33 6 18 1.9 AD 1 4 1 4 5 0.2 % DSM nd ID dignoses 97.5 1.8 0.6 97.6 1.7 0.7 98.0 1.2 0.8 n = 2939 CWM (ll) ND 5597 140 1 5605 133 5668 70 95.0 AA 49 156 78 52 166 65 188 31 64 4.7 AD 2 18 2 18 20 0.3 % DSM nd ICD dignoses 93.5 4.9 1.6 93.7 4.9 1.4 96.9 1.7 1.4 n = 6041 Agreement with CWM, kpp k = 0.592 k = 0.613 k = 0.320 ND, no dignosis; AA, lcohol use; HU, hrmful use; AD, lcohol dependence. Numers displyed re numer of sujects; numers in itlics re percentges. Agreement DSM-IIIR nd DSM-IV: k = 0.913. Agreement DSM-IIIR nd ICD-10: k = 0.364. Agreement DSM-IV nd ICD-10: k = 0.335.

318 C. DE BRUIJN et l. Tle 2. Demogrphic vriles for dignostic ctegories ccording to CWM, DSM-IV, nd ICD-10 for 6041 sujects n = 5738 N = 283 n =20 n = 5659 n = 299 n =83 n = 5856 n = 101 n =84 Employed 3740 (65.2) 172 (60.8) 10 (50.0) 3675 (64.9) 205 (68.6) 42 (50.6) 3819 (65.2) 62 (61.4) 41 (48.8) ND-AA-AD P = 0.119 P = 0.010 P = 0.006 Single 1060 (18.5) 86 (30.4) 14 (70.0) 1043 (18.4) 76 (25.4) 41 (49.4) 1086 (18.5) 32 (31.7) 42 (50.0) AA-ND AD-AA P < 0.001* P < 0.001* P = 0.003 P < 0.001* P = 0.001* P = 0.011 ND, no dignosis; AA, lcohol use, HU, hrmful use; AD, lcohol dependence. Numers displyed re numer of sujects; numers within rckets re percentges. Chi-squre test for ny differences etween ll three dignostic ctegories. Chi-squre test for differences etween no dignosis nd use, or etween use nd dependence. Tle 3. Drinking ehviour for dignostic ctegories ccording CWM, DSM-IV, nd ICD-10 for 6041 sujects AU/week 8.4 (10.9) 26.5 (22.1) 93.7 (79.6) 8.4 (11.1) 20.3 (18.1) 49.3 (50.1) 8.7 (11.3) 21.7 (24.2) 51.3 (49.5) AA-ND AD-AA P < 0.001* P < 0.001* P < 0.001* P < 0.001* P < 0.001* P < 0.001* Frequency 2.8 (2.6) 4.3 (2.5) 6.3 (1.8) 2.8 (2.6) 3.6 (2.5) 5.3 (2.3) 2.8 (2.6) 3.3 (2.6) 5.5 (2.2) ND-AA-AD AA-ND P < 0.001* P < 0.001* P < 0.001* P < 0.001* P = 0.001* P < 0.001* P < 0.001* P = 0.016 P < 0.001* ND, no dignosis; AA, lcohol use; HU, hrmful use; AD; lcohol dependence; AU/week, numer of lcoholic units per week; frequency, numer of drinking dys per week. Numers displyed re mens; numers within rckets re stndrd devitions. Kruskl Wllis. Mnn Whitney U. Tle 4. Comorid mood nd nxiety disorders for dignostic ctegories ccording to CWM, DSM-IV, nd ICD-10 for 6041 sujects Mood 406 (7.1) 42 (14.8) 9 (45.0) 405 (7.2) 27 (9.0) 25 (30.1) 416 (7.1) 15 (14.9) 26 (31.0) AA-ND AD-AA P < 0.001* P < 0.001* P = 0.223 P < 0.001* P = 0.003 P = 0.009 Anxiety 674 (11.7) 43 (15.2) 14 (70.0) 667 (11.8) 38 (12.7) 26 (31.3) 683 (11.7) 20 (19.8) 28 (33.3) AA-ND AD-AA P = 0.080 P < 0.001* P = 0.630 P < 0.001* P = 0.012 P = 0.037 ND, no dignosis; AA, lcohol use; HU, hrmful use; AD, lcohol dependence. Numers displyed re numer of sujects; numers within rckets re percentges. Mood, ny mood disorder in the lst 12 months; Anxiety; ny nxiety disorder in the lst 12 months. Chi-squre test for ny differences etween ll three dignostic ctegories. Chi-squre test for differences etween no dignosis nd use, or etween use nd dependence. for the influence of nxiety nd mood disorders, the difference etween the dignostic groups remined significnt for CWM, ut not for DSM-IV nd ICD-10. The difference etween use sujects nd sujects with no dignosis on the item missed work ws significnt for CWM only. The difference etween dependence nd use sujects ws significnt for DSM-IV only. After correction for the influence of nxiety nd mood disorders, the differences etween the dignostic groups were no longer significnt (Tle 5). Functionl sttus. Tle 6 shows the outcome on five of the eight items of the SF-36. The items physicl functioning, role physicl, nd odily pin did not differ significntly etween the dignostic groups (results not shown). CWM resulted in numerous significnt differences etween no dignosis nd use sujects nd etween use nd dependence sujects. DSM-IV resulted in similrly lrge numer of significnt differences etween dependence nd use sujects, ut showed no significnt differences etween use nd no

THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM 319 Tle 5. Dys of ed rest nd dys missed t work owing to psychologicl or lcohol prolems for dignostic ctegories ccording CWM, DSM-IV, nd ICD-10 for 6041 sujects Bed rest d 0.5 (6.5) 1.8 (12.9) 7.0 (15.8) 0.5 (6.6) 0.5 (3.0) 5.3 (23.5) 0.5 (6.5) 0.6 (2.7) 5.3 (23.5) AA-ND AD-AA P < 0.001* P = 0.031 P < 0.001* P < 0.001* P < 0.001* P = 0.022 ND-AA-AD corr c P < 0.001* P = 0.455 P = 0.495 Missed work e 2.4 (19.5) 7.6 (37.3) 9.8 (17.7) 2.4 (19.7) 4.6 (30.9) 11.7 (34.6) 2.5 (20.5) 3.7 (17.1) 10.2 (32.7) ND-AA-AD P < 0.001* P < 0.001* P = 0.086 AA-ND AD-AA P < 0.001* P = 0.197 P = 0.017 P < 0.001* ND-AA-AD corr c P = 0.731 P = 0.841 ND, no dignosis; AA, lcohol use; HU, hrmful use; AD, lcohol dependence. Numers displyed re mens; numers within rckets re stndrd devitions. Bed rest, numers of dys of ed rest owing to psychologicl or lcohol prolems in the lst 12 months; Missed work, numer of dys not eing le to work owing to psychologicl or lcohol prolems in the lst 12 months; ND-AA-AD corr c, corrected for the influence of nxiety nd mood disorders. Kruskl Wllis. Mnn Whitney U. c ANCOVA. d Nine missing vlues. e Only employed sujects (n = 3917) considered. Tle 6. Functionl sttus for dignostic ctegories ccording to CWM, DSM-IV, nd ICD-10 for 6041 sujects SF d 89.8 (17.7) 87.6 (19.4) 68.3 (30.7) 89.8 (17.7) 89.9 (19.1) 78.3 (24.0) 89.9 (17.6) 84.9 (22.0) 77.7 (25.3) AA-ND AD-AA P = 0.019 P = 0.001* P = 0.683 P < 0.001* P = 0.010 P = 0.023 ND-AA-AD corr c P = 0.001* P < 0.001* P < 0.001* MH e 82.4 (14.5) 77.0 (16.8) 59.8 (24.4) 82.3 (14.6) 81.1 (14.3) 67.7 (20.4) 82.4 (14.4) 74.4 (19.2) 67.5 (21.1) AA-ND AD-AA P < 0.001* P = 0.001* P = 0.044 P < 0.001* P < 0.001* P = 0.011 ND-AA-AD corr c P < 0.001* P < 0.001* P < 0.001* RE d 92.7 (22.5) 86.8 (30.0) 63.2 (40.0) 92.6 (22.8) 92.6 (22.6) 74.0 (37.4) 92.8 (22.5) 84.2 (32.2) 72.3 (38.9) AA-ND AD-AA P <0.001* P = 0.001* P = 0.916 P < 0.001* P < 0.001* P = 0.011 ND-AA-AD corr c P < 0.001* P < 0.001* P < 0.001* VT f 72.0 (18.0) 67.5 (18.1) 50.8 (22.0) 72.0 (18.0) 70.5 (16.8) 59.6 (22.0) 72.0 (17.9) 64.5 (19.8) 59.8 (21.8) AA-ND AD-AA P < 0.001* P = 0.001* P = 0.040 P < 0.001* P < 0.001* P = 0.127 ND-AA-AD corr c P = 0.001* P = 0.001* P < 0.001* GH g 74.6 (17.6) 71.8 (17.9) 60.5 (18.0) 74.5 (17.6) 74.4 (17.2) 66.5 (18.1) 74.6 (17.6) 71.9 (19.4) 66.2 (19.6) AA-ND AD-AA P = 0.006 P = 0.006 P = 0.641 P < 0.001* P = 0.198 P = 0.031 ND-AA-AD corr c P < 0.001* P < 0.001* P = 0.002* ND, no dignosis; AA, lcohol use; HU, hrmful use; AD, lcohol dependence; SF, socil functioning; MH, mentl helth; RE, role emotionl; VT, vitlity; GH, generl helth. Numers displyed re mens; numers within rckets re stndrd devitions. ND-AA-AD corr c, corrected for the influence of nxiety nd mood disorders. Kruskl Wllis. Mnn Whitney U. c ANCOVA. d Five missing vlue. e Eight missing vlues. f Nine missing vlues. g 14 missing vlues. dignosis sujects. In contrst, ICD-10 resulted in mny significnt differences etween no dignosis nd hrmful use sujects, ut no significnt differences etween hrmful use nd dependence sujects. After correction for the influence of mood nd nxiety disorders, the differences etween the three dignostic ctegories remined significnt. For CWM nd ICD-10, ut not for DSM-IV, the differences etween no dignosis nd use lso remined significnt for most items

320 C. DE BRUIJN et l. Tle 7. Fmilil lcohol prolems nd help-seeking ehviour for dignostic ctegories ccording to CWM, DSM IIIR, DSM IV, nd ICD 10 for 6041 sujects (mle: 3102 nd femle: 2939) CWM DSM IV ICD 10 Prent d 445 (7.8) 43 (15.2) 2 (10.5) 445 (7.9) 28 (9.4) 17 (20.7) 455 (7.8) 16 (15.8) 19 (22.9) AA-ND AD-AA P < 0.001* P = 0.749 c P = 0.345 P = 0.005 P = 0.003 P = 0.225 Siling e 287 (5.3) 27 (10.0) 4 (22.2) 284 (5.3) 15 (5.3) 19 (24.4) 288 (5.2) 12 (12.4) 18 (22.2) AA-ND AD-AA P = 0.001* P = 0.113 c P = 0.974 P < 0.001* P = 0.002* P = 0.080 Tretment 9 (0.2) 4 (1.4) 5 (25.0) 10 (0.2) 2 (0.7) 6 (7.2) 7 (0.1) 5 (5.0) 6 (7.1) AA-ND AD-AA P = 0.002 c, * P < 0.001 c, * P = 0.119 c P = 0.002* P < 0.001* P = 0.530 ND, no dignosis; AA, lcohol use; HU, hrmful use; AD, lcohol dependence. Prent, t lest one prent with lcohol prolems. Siling, t lest one siling with lcohol prolems. Tretment, seeking tretment for ddiction in the lst 12 months. Numers etween rckets re percentges. Chi-squre test for ny differences etween ll three dignostic ctegories. Chi-squre test for differences etween no dignosis nd use, or etween use nd dependence. c In cse of numers <5, Fisher s exct test ws used insted of Person Chi-squre. d 33 missing vlues. e 296 missing vlues. fter correcting for differences in the presence of mood nd nxiety disorders. Most of the differences etween use nd dependence were no longer significnt fter correction for the influence of mood nd nxiety disorders for ny of the dignostic systems (results not shown). Fmilil lcohol prolems nd seeking tretment. Tle 7 shows tht the only significnt difference in prentl lcohol prolems ws etween CWM use nd no dignosis sujects. As for hving siling with n lcohol prolem, there ws significnt difference in CWM nd ICD-10 etween no dignosis nd use sujects, nd for DSM-IV etween use nd dependence sujects. For CWM nd ICD-10, sujects with use more often sought tretment for ddiction thn sujects with no dignosis. The difference etween use nd dependence sujects ws only significnt for CWM nd DSM-IV. Discordnt cses Of the sujects with dependence ccording to DSM-IV nd ICD-10, 78 nd 76%, respectively, hd use ccording to CWM (see Tle 1). These discordnt cses scored lower thn the other sujects with DSM-IV nd ICD-10 dependence nd similr to the sujects with CWM use on the vst mjority of the discriminnt vlidtors. Of the sujects with DSM-IV use, 44% hd no CWM dignosis. Their discriminnt vlidtors were similr to the whole group with no dignosis (ccording to either DSM-IV or CWM). Of the sujects with ICD-10 hrmful use, 69% hd no CWM dignosis. They were comprle with the whole group with no dignosis (ccording to either CWM or ICD-10) in their drinking ehviour nd dys of ed rest nd missed work. On the other items (demogrphic vriles, comoridity, functionl sttus, fmilil lcohol prolems nd seeking help) they were comprle to the CWM use group. All sujects with dependence ccording to CWM lso hd dependence ccording to ICD-10 nd only two of them did not get DSM-IV dignosis (see Tle 1). Of the sujects with CWM use, 18% did not get DSM-IV AUD dignosis. These cses scored similr to the rest of the CWM use group nd similr to or even worse thn the DSM-IV use group on the discriminnt vlidtors. The 66% of the sujects with CWM use nd no ICD-10 AUD dignosis lso scored similr to the rest of the CWM use group nd the group with ICD-10 hrmful use on most discriminnt vlidtors. However, on their demogrphic vriles, some SF-36 items, the fmily history nd the help-seeking ehviour, scored more similr to the group without dignosis. DISCUSSION The present study corroortes our erlier results, showing n increse in the discriminnt vlidity of CWM over DSM-IV in seprting use from sujects with no lcoholism dignosis (de Bruijn et l., 2004). ICD-10 showed cler difference etween hrmful use nd sujects with no dignosis, ut the demrction etween hrmful use nd dependence sujects ws very poor. In contrst, CWM showed good seprtion etween no dignosis nd use sujects nd etween use nd dependence sujects. The discordnt cses tht were dignosed y DSM-IV or ICD-10 nd not y CWM or vice vers, generlly corroorted the vlidity of the CWM clssifiction, especilly when compring DSM-IV nd CWM. DSM-IV use The only significnt differences etween DSM-IV use nd no dignosis were the drinking ehviour nd the dys of ed rest owing to lcohol or psychologicl prolems. Even on items regrding possile socil consequences (employment sttus, eing in reltionship, sence from work, nd the SF- 36 item socil functioning), DSM-IV use did not differ from

THE CRAVING WITHDRAWAL MODEL FOR ALCOHOLISM 321 the group with no dignosis. This is not surprising since the dignosis of most of these sujects ws solely sed on the item drinking in situtions in which it is hzrdous. These findings replicte the reserch on the poor vlidity of the DSM-IV use dignosis (Hsin et l., 1999; Mrtin et l., 1996; Rounsville, 2002). ICD-10 hrmful use We found tht ICD-10 hrmful use exhiited etter discrimintion from sujects with no dignosis thn DSM-IV use, ut the hrmful use group hrdly differed from the dependence group. A lrge proportion of the group with ICD-10 hrmful use hd no CWM dignosis (n = 70). These sujects were comprle in terms of drinking ehviour with the totl group of sujects with no dignosis ccording to CWM nd ICD-10. They scored similr to CWM use on comoridity, functionl sttus, fmilil lcohol prolems, nd seeking help. One plusile explntion for these findings is tht these sujects reduced their drinking in n effort to del with the psychologicl or physicl hrm they experienced (ICD-10 hrmful use criterion). If these sujects succeeded in reducing their drinking nd did not meet other criteri, they hd no lcoholism dignosis ccording to DSM-IV or CWM. They my still experience disilities owing to psychologicl or physicl hrm ecuse these prolems do not lwys dispper immeditely fter they reduce their lcohol intke. Risks of CWM The finding tht CWM hs theoreticl nd empiricl dvntges over DSM-IV nd ICD-10 is relevnt to the development of DSM-V. However, there re lso some possile drwcks to CWM. Contrry to our erlier findings, in this generl popultion smple, CWM resulted in lower overll prevlence of AUD compred with DSM-IV. The use group ws of pproximtely the sme size for CWM nd DSM-IV, ut the CWM dependence group ws considerly smller. The lower prevlence of CWM hs the risk of leving sujects with n lcohol prolem without dignosis, therey withholding them dequte tretment. The scores on the discordnt cses, who did hve dignosis ccording to either DSM-IV or ICD-10 ut not ccording to CWM, mostly justified the dignostic sttus ccording to CWM. The crving item deserves further ttention. Crving is multidimensionl concept tht cn e pproched from different theoreticl viewpoints. The sujective experience of crving nd the ojective signs re not strongly correlted (vn den Brink, 1997). Therefore, it is questionle whether this item is the optiml criterion for linking up with neuroiologicl reserch. Limittions to the study design There re limittions to our study design. First, it is necessry to e cutious out interpreting CIDI items s DSM nd ICD-10 criteri. Other interviews might yield different results. However, the risk seems to e firly smll since CIDI hs een well vlidted ginst other structured interviews. Although for other psychitric disorders, CIDI cn e overly inclusive, this is not the cse for AUD (Compton et l., 1996; Cottler et l., 1997; Pull et l., 1997; Ustun et l., 1997; Rounsville 2002). Second, our investigtion ws limited to those sujects meeting criteri in the lst 12 months. The performnce of CWM vs the other clssifiction systems from lifetime perspective is topic tht requires further exmintion, especilly regrding the item of fmily history nd on other items tht we did not consider in the present nlyses, like childhood trum. Furthermore, we did not consider iologicl mrkers. However, we did consider iochemicl mrkers (CDT, MCV, nd GGT) in our erlier study on CWM nd found tht the difference etween the dignostic ctegories ws often fr more significnt for CWM thn for DSM-IV (de Bruijn et l., 2004). Further reserch One of our intentions ws to reduce the gp etween neuroiologicl reserch nd clinicl ddiction dignoses. 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