Elsevier

Addictive Behaviors

Volume 35, Issue 5, May 2010, Pages 373-382
Addictive Behaviors

A systematic review of the Diagnostic and Statistical Manual diagnostic criteria for nicotine dependence

https://doi.org/10.1016/j.addbeh.2009.12.013Get rights and content

Abstract

The Diagnostic and Statistical Manual diagnostic criteria for nicotine dependence (DSM-ND) are based on the proposition that dependence is a syndrome that can be diagnosed only when a minimum of 3 of the 7 proscribed features are present. The DSM-ND criteria are an accepted research measure, but the validity of these criteria has not been subjected to a systematic evaluation.

To systematically review evidence of validity and reliability for the DSM-ND criteria, a literature search was conducted of 16 national and international databases. Each article with original data was independently reviewed by two or more reviewers.

In total, 380 potentially relevant articles were examined and 169 were reviewed in depth. The DSM-ND criteria have seen wide use in research settings, but sensitivity and specificity are well below the accepted standards for clinical applications. Predictive validity is generally poor. The 7 DSM-ND criteria are regarded as having face validity, but no data support a 3-symptom ND diagnostic threshold, or a 4-symptom withdrawal syndrome threshold. The DSM incorrectly states that daily smoking is a prerequisite for withdrawal symptoms. The DSM shows poor to modest concurrence with all other measures of nicotine dependence, smoking behaviors and biological measures of tobacco use.

The data support the DSM-ND criteria as a valid measure of nicotine dependence severity for research applications. However, the data do not support the central premise of a 3-symptom diagnostic threshold, and no data establish that the DSM-ND criteria provide an accurate diagnosis of nicotine dependence.

Introduction

In 1980 the American Psychiatric Association (APA) proposed a diagnostic criteria for nicotine dependence (DSM-ND) in the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).(American Psychiatric Association, 1980b) These were developed based on the DSM criteria for alcoholism with only minor modifications, (Cottler, Helzer, Mager, Spitznagel, & Compton, 1991) reflecting a theory that all substance use disorders can be diagnosed using a single set of “generic” criteria (Benowitz, 1999, Cottler, 1993, Hughes et al., 2004, Woody et al., 1993). The DSM-ND criteria were changed in 1987, again in 1994, and are currently under review for another revision in DSM-V (American Psychiatric Association, 1987, American Psychiatric Association, 1994). The DSM is a nosology, i.e., a theoretical systematic classification of diseases, one of the many proposed for mental disorders over the years (World Health Organization, 1992). According to those involved, “DSM-III and III-R were developed by committee, without a systematic effort to collect reliability, validity and other comparative data.” (Cottler et al., 1991).

The DSM uses a “syndromal” approach to the diagnosis of nicotine dependence in which “the essential feature of this disorder is a cluster of cognitive, behavioral, and physiologic symptoms that indicate that the person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences.” (American Psychiatric Association, 1987). When the DSM-ND criteria were last revised in 1994, research had not yet identified the pathophysiology of nicotine dependence, and the generic alcoholism criteria were retained for nicotine dependence. The first published case series recently revealed that nicotine dependence is characterized by a compulsion to use tobacco that recurs with a predictable periodicity after each cigarette (DiFranza, Ursprung, & Carlson, 2010). The symptoms of this compulsion are wanting, craving or needing to smoke. Instruments that measure this compulsion predict the clinical course of nicotine dependence with 98% sensitivity and 98% specificity (DiFranza et al., 2007, DiFranza et al., 2002). It has been proposed that the recurrent compulsion to use tobacco is pathognogmonic for nicotine dependence, and on this basis it has been proposed that the identification of this symptom is all that is required to make a diagnosis (DiFranza et al., 2010). Reliance on a single diagnostic criterion conflicts with the DSM approach which requires a minimum of 3 diagnostic criteria.

Given this controversy, we undertook the first systematic review of the DSM-ND criteria to examine the evidence that they accurately diagnose nicotine dependence. Accordingly, we have applied to the DSM-ND criteria the same critical evaluation that is applicable to all measures of nicotine dependence (Colby, S., Tiffany, Shiffman, & Niarua, 2000). We examined properties relevant to clinical diagnosis, such as sensitivity, specificity, accuracy and predictive validity. As there is concern that DSM-ND criteria may under-diagnose dependence in blacks, (Strong, Kahler, Ramsey, & Brown, 2003) we also examined the evidence relevant to this concern. In relation to research applications we considered theoretical foundation, face validity, factor structure, internal reliability, test–retest reliability, concurrent validity, and concordance among the three editions of DSM (III, III-R, and IV) and between these and other measures of dependence such as the Fagerström Tolerance Questionnaire (FTQ) and the International Classification of Diseases (ICD).

Section snippets

Materials and methods

A systematic search of the literature was conducted for articles published between 1980 and October 2008 that mentioned the DSM-III, DSM-III-R, or DSM-IV ND criteria. Databases searched included: Index Medicus, Medline, the Educational Resources Information Center (ERIC), the Cochrane Library, the American Psychological Association's PsychInfo/PsychLIT Database, Indmed, Koreamed, the World Health Organization Library Information System (WHOLIS), the World Health Organization's Network of Health

Overview

A total of 2102 hits were returned on the literature search, resulting in the identification of 398 articles of initial interest. Closer examination of the content narrowed the field to 380 articles of likely interest. Twenty-one articles had no English translation. The remaining articles were reviewed by the first author, with the result that 169 articles were found to have potential relevance to our review and were assigned for data extraction by two reviewers. Additionally, the first author

Discussion

In 1980, the APA published a diagnostic criteria for nicotine dependence reflecting an assumption that criteria developed to diagnose alcoholism would be valid and reliable indicators of nicotine dependence (American Psychiatric Association, 1980b). This is the first systematic review of the DSM-ND criteria in the 3 decades since their initial publication. The DSM enjoys wide use in research and has demonstrated modest concurrent and predictive validity when used in the research setting to

Role of funding sources

This study was funded by the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Contributors

Dr. Joseph DiFranza designed the study and developed the data extraction tool for included articles. Sanouri Ursprung and Christina Bancej conducted literature searches and collected articles for pre-review. Through the Delphi process all authors participated in the analysis of the articles and the extraction of relevant data for comparison. Dr. Joseph DiFranza and Sanouri Ursprung wrote the first draft of the manuscript and all authors have contributed to and approved the final manuscript.

Conflict of interest

None of the authors have conflict of interest.

Acknowledgement

We wish to acknowledge the assistance of James Comes with the literature search.

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