Drug Use Disorders Identification Test Extended – DUDIT-E

Abstract

The Drug Use Disorders Identification Test Extended (DUDIT-E) is an advanced, clinically oriented psychometric instrument designed to assess non-alcohol illicit and prescription drug use patterns, motivational readiness, and the cognitive decisional balance underlying substance use disorders (SUD). Developed in 2007 by Anne H. Berman, Hans Bergman, Tom Palmstierna, and Frans Schlyter at the Karolinska Institutet in Stockholm, Sweden, the DUDIT-E builds directly upon the standard 11-item screening questionnaire, the Drug Use Disorders Identification Test (DUDIT). While the primary DUDIT instrument identifies consumption frequency, dependence indicators, and drug-related harms, the extended DUDIT-E serves a complementary diagnostic and therapeutic function. Specifically, it operationalizes key constructs from Prochaska and DiClemente's Transtheoretical Model (TTM) and Motivational Interviewing (MI), enabling clinicians to map an individual’s subjective evaluation of their substance use.

The DUDIT-E comprises an initial 10-class substance frequency checklist followed by three core psychometric modules: (1) Positive Aspects of Drug Use (17 items, assessing perceived functional, affective, and social benefits), (2) Negative Aspects of Drug Use (17 items, assessing psychological distress, interpersonal conflict, physical morbidity, and legal consequences), and (3) Treatment Readiness and Thoughts About Drugs (10 items, capturing problem recognition, ambivalence, external/internal motivation, and perceived self-efficacy for change). Across extensive validation studies in outpatient addiction clinics, custodial settings, and community cohorts, the DUDIT-E has demonstrated exceptional internal consistency, with Cronbach's alpha coefficients typically ranging between α = .88 and α = .94 for the Positive and Negative subscales, and α = .78 to α = .85 for the Treatment Readiness dimension. Exploratory and confirmatory factor analyses confirm distinct, stable latent structures reflecting multidimensional reinforcers and adverse sequelae. By providing a quantified “decisional balance” score alongside motivation readiness indices, the DUDIT-E bridges standard psychometric screening with tailored, client-centered intervention planning.

Keywords

Drug Use Disorders Identification Test Extended, DUDIT-E, Substance Use Disorders, Psychometrics, Decisional Balance, Transtheoretical Model, Motivational Interviewing, Treatment Readiness, Reinforcement Expectancies, Addiction Assessment, Karolinska Institutet

Authors

The Drug Use Disorders Identification Test Extended was developed by a multidisciplinary team of clinical psychologists, psychiatrists, and criminologists under the leadership of the Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden:

• Anne H. Berman, PhD — Professor of Clinical Psychology, Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden. Primary investigator in the conceptualization and psychometric validation of the DUDIT and DUDIT-E instruments. Contact: [email protected].
• Hans Bergman, PhD — Associate Professor of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. Renowned psychometrician and co-developer of Swedish adaptations of the Alcohol Use Disorders Identification Test (AUDIT) and the original DUDIT.
• Tom Palmstierna, MD, PhD — Professor of Forensic Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden, and St. Olavs University Hospital, Trondheim, Norway. Expert in forensic risk assessment, substance-related violence, and dual diagnosis.
• Frans Schlyter — Clinical specialist and researcher affiliated with the Swedish Prison and Probation Service (Kriminalvården) and Karolinska Institutet, focusing on evidence-based substance abuse rehabilitation within institutional and community correctional contexts.

Purpose

The primary clinical and psychometric objective of the DUDIT-E is to provide a structured, standardized mapping of the client's subjective relationship with illicit drugs and non-prescribed pharmaceuticals. While traditional diagnostic screening instruments — such as the DUDIT, the Addiction Severity Index (ASI), or the Drug Abuse Screening Test (DAST-10) — focus primarily on pathological symptoms, consumption frequency, physiological tolerance, and adverse psychosocial consequences, they generally omit the functional utility or perceived positive reinforcement that drives compulsive drug-taking behavior.

In clinical addiction psychiatry and counseling psychology, ignoring the perceived benefits of substance use introduces a significant blind spot. Clients do not consume psychoactive substances in a psychological vacuum; rather, substance use serves as a powerful compensatory mechanism for mood regulation, trauma mitigation, stress relief, social integration, and cognitive stimulation. The DUDIT-E was intentionally developed to resolve this asymmetry. By measuring both the self-perceived positive reinforcers (the "pros") and the negative consequences (the "cons") of drug use alongside specific cognitive markers of treatment readiness, the instrument operationalizes the core tenets of decisional balance in addiction treatment.

Clinically, the DUDIT-E serves four essential purposes:

• Facilitating Motivational Interviewing: Clinicians utilize the item responses to explore ambivalence non-judgmentally. Reviewing an individual’s endorsed positive items (e.g., "Lose tension and become relaxed," "I can control feelings like anxiety, anger and depression") validates their lived internal experience, dismantling defensive resistance and laying the groundwork for collaborative therapeutic rapport.
• Establishing Motivational Profiling: Through the calculation of an empirical Motivational Index (contrasting total negative scores against positive scores, weighted by treatment readiness), clinicians can determine whether a patient is situated within the precontemplation, contemplation, preparation, or action stages of change.
• Targeted Relapse Prevention Planning: The 17 positive items pinpoint specific high-risk cues and internal coping deficits (such as chronic somatic pain, social alienation, or existential boredom) that require non-pharmacological substitution during cognitive-behavioral therapy (CBT).
• Longitudinal Treatment Evaluation: Administered serially across an episode of care, the DUDIT-E tracks cognitive shifts: successful interventions typically show a significant decline in perceived positive attributes of drug use, a realistic recognition of past negative consequences, and marked gains in treatment readiness and self-efficacy.

Psychological Construct

The DUDIT-E operationalizes a triadic psychometric construct comprising Positive Expectancies / Functional Reinforcement, Experienced Negative Consequences, and Treatment Readiness / Ambivalence. Each dimension reflects distinct psychological and cognitive processes that govern behavioral maintenance and behavioral change.

1. Perceived Positive Aspects of Drug Use (17 Items)

This subscale captures the individual’s cognitive expectancies and experienced positive and negative reinforcement, which serve as the primary maintenance factors in the addiction cycle. Consistent with operant conditioning models, psychoactive substances deliver both positive reinforcement (e.g., euphoria, heightened sensory pleasure, social bonding) and negative reinforcement (e.g., alleviation of dysphoria, physical pain reduction, tension relief). The 17 items span several distinct functional domains:

• Affect and Tension Regulation: Items such as "Sleep better" (Item 1), "Lose tension and become relaxed" (Item 2), and "Feel 'normal'" (Item 5) measure the use of chemical coping strategies to manage baseline autonomic hyperactivity, emotional dysregulation, and psychological distress.
• Mood and Self-Concept Elevation: Items like "Become happy" (Item 3), "Become strong" (Item 4), and "More self-confidence" (Item 9) capture chemical augmentation of self-esteem, self-efficacy, and positive affectivity.
• Social Affiliation and Interpersonal Functioning: Items such as "Love everybody and the whole world" (Item 8), "With drugs I can function socially" (Item 14), and "With drugs I feel that I am part of the group" (Item 15) quantify the drug's utility as a social lubricant and a buffer against social phobia, isolation, or loneliness.
• Cognitive and Behavioral Activation: Items including "Become creative" (Item 6), "Become active (clean home, do dishes, wash the car, etc.)" (Item 7), and "Life without drugs is boring" (Item 12) address dopamine-driven stimulation, anhedonia mitigation, and functional productivity.
• Somatic Relief: Item 10 ("Feel less pain in my back, neck, head etc.") isolates self-medication for chronic physical pain.

2. Experienced Negative Consequences of Drug Use (17 Items)

The negative subscale evaluates the biopsychosocial harms directly attributed by the respondent to their substance use over the preceding 12 months. This dimension evaluates whether the client cognitively connects their drug consumption to objective impairment across multiple life spheres:

• Severe Functional and Systemic Impairments: The first four items evaluate acute disruptions requiring institutional or external intervention using a 5-point frequency metric (from "Never" to "Daily or almost every day"): work/school/home role failure (Item 1), medical/hospital care or organic pathology such as hepatitis or memory deficits (Item 2), interpersonal violence and altercations (Item 3), and criminal-justice contact or police intervention (Item 4).
• Psychological and Internal Sequelae: Items 5 through 7 and 10 assess subjective psychiatric distress, including anxiety induction (Item 5), suicidal ideation (Item 6), profound social withdrawal (Item 7), and cognitive fragmentation or concentration failure (Item 10).
• Somatic and Biological Deterioration: Items 8, 11, and 14 capture nausea, cephalalgia, loss of libido/sexual dysfunction, and systemic health degradation.
• Relational, Financial, and Existential Breakdown: Items 9, 12, 13, 15, 16, and 17 measure the dissolution of friendships, financial ruin, behavioral passivity, interpersonal callousness, domestic destruction, and generalized existential cognitive chaos ("See everything as a big chaos").

3. Treatment Readiness and Thoughts About Drugs (10 Items)

This subscale measures the client’s current motivational orientation, cognitive appraisal of need, and therapeutic self-efficacy. Rather than classifying individuals into static diagnostic categories, this dimension captures dynamic cognitive stages:

• Hedonic Attachment vs. Satiation/Fatigue: Assessed via Item 1 ("Do you enjoy taking drugs?") and Item 2 ("Do you feel tired of using drugs?"), isolating the transition from hedonic drive to motivational burnout.
• Problem Recognition and Risk Appraisal: Items 3 ("Have you been worried about your drug use over the past year?") and 8 ("Do you think it is important to change your drug use?") evaluate cognitive dissonance regarding consumption.
• Change Commitment and Help-Seeking Intent: Items 4 ("Are you ready to work to change your drug use?") and 5 ("Do you think you need professional help to change your drug use?") differentiate self-managed cessation readiness from willingness to engage formal treatment structures.
• Treatment Expectancies and Perceived Self-Efficacy: Items 6 and 7 evaluate optimistic versus pessimistic treatment expectancies, while Items 9 and 10 evaluate anticipated task difficulty and active relapse-prevention orientation.

Theoretical Framework

The architectural foundation of the DUDIT-E is grounded in three prominent psychological paradigms: the Transtheoretical Model of Behavior Change, Motivational Interviewing Theory, and Social Cognitive Expectancy Theory.

Foremost among these is the Transtheoretical Model (TTM) formulated by James O. Prochaska and Carlo DiClemente. Central to TTM is the construct of Decisional Balance, derived from Janis and Mann’s classic conflict-decision model. Decisional balance posits that an individual’s decision to alter an addictive behavior involves a cognitive appraisal weighing the perceived "Pros" against the "Cons" of the behavior. In early stages (Precontemplation), the Pros of drug use markedly outweigh the Cons. As individuals progress into Contemplation, the perceived Cons increase until they reach parity with the Pros, generating profound ambivalence. Successful transition into Preparation and Action is universally characterized by the Cons surpassing the Pros, accompanied by an escalation in self-efficacy and active intention to change. The DUDIT-E provides a direct, metric-driven operationalization of this balance sheet, enabling researchers and clinicians to calculate whether the client's balance is positive, neutral, or negative.

Concurrently, the DUDIT-E operationalizes the clinical principles of Motivational Interviewing (MI), developed by William R. Miller and Stephen Rollnick. MI conceptualizes addiction not as an immutable characterological defect or denial-based pathology, but as a state of ambivalence where an individual is caught between competing internal motivations. By providing an explicit inventory of the drug's perceived functions (positive items), the DUDIT-E allows the therapist to validate the client's internal reasons for using substances without condoning the behavior itself. This structural validation reduces psychological reactance, diminishes defensiveness, and creates an empirical basis for eliciting client-generated "change talk" (arguments for change) in contrast to "sustain talk" (arguments for maintaining drug use).

Finally, the scale integrates concepts from Albert Bandura's Social Cognitive Theory and outcome expectancy frameworks developed by Alan Marlatt. These models demonstrate that substance use is heavily influenced by learned cognitive expectancies regarding the drug's capacity to produce physiological, affective, or social rewards. The 17 positive items of the DUDIT-E serve as an expectancy assessment, identifying the cognitive scenarios in which the individual anticipates that substance administration will restore homeostatic balance or amplify reward signaling.

Validity

Psychometric evaluations of the DUDIT-E demonstrate solid construct, convergent, discriminant, and criterion-related validity across varied clinical, correctional, and community settings.

Construct and Structural Validity

The structural validity of the DUDIT-E was rigorously examined in the foundational validation study by Berman et al. (2007), which evaluated a sample of 220 drug-using individuals recruited from Swedish prisons, probation offices, and specialized addiction clinics. Confirmatory and exploratory analyses confirmed that the Positive and Negative subscales represent distinct latent dimensions rather than opposite ends of a single continuum. The correlation between the Positive subscale and the Negative subscale is typically low to moderate (ranging from r = .15 to r = .32), confirming that an individual can simultaneously perceive high functional benefits and experience high adverse consequences — the exact theoretical definition of addiction-related ambivalence.

Convergent and Concurrent Validity

The convergent validity of the DUDIT-E is corroborated by strong correlations with established legacy instruments:

• Correlation with DUDIT and ASI: Total scores on the DUDIT-E Negative subscale correlate strongly with the original 11-item DUDIT screening score (r = .68 to .76, p < .001) and with the composite medical, psychiatric, and legal domains of the Addiction Severity Index (ASI) (r = .52 to .64).
• Correlation with Stages of Change Measures: The Treatment Readiness items correlate significantly with standardized readiness instruments, including the University of Rhode Island Change Assessment (URICA) and the Stages of Change and Treatment Eagerness Scale (SOCRATES). Endorsement of Readiness items 4, 5, and 8 correlates positively with the SOCRATES "Recognition" and "Taking Steps" factors (r > .60, p < .001).

Discriminant and Criterion Validity

Discriminant validity is demonstrated by the instrument's capacity to differentiate between voluntary community-based treatment seekers, mandated forensic clients, and non-dependent experimental users. Berman et al. (2007) established that clients entering voluntary outpatient clinics score significantly higher on the DUDIT-E Negative scale and Treatment Readiness index, and significantly lower on the Positive scale, than non-treatment-seeking incarcerated populations who exhibit higher Positive-to-Negative expectancy ratios. Furthermore, prospective studies have demonstrated criterion validity: individuals with higher Treatment Readiness and a negative decisional balance (Negative score > Positive score) show significantly higher rates of subsequent treatment session attendance, lower treatment drop-out rates, and fewer urinalysis-verified drug relapses over 3- and 6-month follow-up intervals.

Reliability

The DUDIT-E exhibits high internal consistency and measurement precision across international studies and clinical populations.

Internal Consistency

In the initial psychometric validation by Berman et al. (2007), the scale demonstrated high internal consistency across all sub-dimensions:

• DUDIT-E Positive Aspects (17 items): Cronbach's alpha reached α = .93 in clinical populations and α = .91 in prison samples, reflecting strong internal item homogeneity. Corrected item-total correlations ranged from .48 to .74.
• DUDIT-E Negative Aspects (17 items): Cronbach's alpha was α = .88 in clinical samples and α = .89 in correctional samples. All items contributed positively to overall variance, with corrected item-total correlations exceeding .40 across items 5 through 17.
• DUDIT-E Treatment Readiness (10 items): Cronbach's alpha yielded α = .78 to .83. Given the multidimensional nature of readiness (which encompasses pleasure, fatigue, ambivalence, and professional help-seeking), an alpha around .80 demonstrates adequate structural integrity without excessive item redundancy.

Test-Retest Stability

Test-retest stability was evaluated across clinical subsamples retested over a 2- to 3-week interval prior to major clinical interventions. Intraclass correlation coefficients (ICC) confirmed strong stability for the Positive subscale (ICC = .86) and Negative subscale (ICC = .84). The Treatment Readiness subscale exhibited slightly more variability (ICC = .74), which is theoretically expected given that motivational readiness is a dynamic psychological state sensitive to immediate contextual events and clinical encounters.

Factor Analysis

Both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) have been conducted on the DUDIT-E across diverse samples to evaluate its underlying dimensionality.

Factor Structure of DUDIT-E Positive Aspects

Principal axis factoring with oblimin and varimax rotations has identified four distinct first-order factors within the 17-item Positive scale, which load onto an overarching higher-order positive reinforcement construct:

• Factor 1: Tension Relief and Affect Regulation: Encompasses items 1, 2, 5, 10, and 13 (e.g., "Sleep better," "Lose tension and become relaxed," "I can control feelings like anxiety, anger and depression"). Factor loadings range from .58 to .82.
• Factor 2: Social Facilitation and Affiliation: Encompasses items 8, 14, 15, and 16 (e.g., "Love everybody and the whole world," "With drugs I feel that I am part of the group," "I get better contact with others"). Loadings range from .62 to .85.
• Factor 3: Activation and Creativity: Encompasses items 4, 6, 7, and 12 (e.g., "Become strong," "Become creative," "Become active," "Life without drugs is boring"). Loadings range from .51 to .76.
• Factor 4: Euphoria and Optimism: Encompasses items 3, 9, 11, and 17 (e.g., "Become happy," "More self-confidence," "Get a feeling that everything will work out," "I get more out of my life"). Loadings range from .54 to .79.

Factor Structure of DUDIT-E Negative Aspects

Factor analysis of the 17 negative items demonstrates a clear two-factor or three-factor structure depending on sample severity:

• Factor 1: Psychosocial, Relational, and Institutional Chaos: Highly influenced by items 1, 3, 4, 9, 12, 15, 16, and 17 (police trouble, violence, destruction of finances and family life, and seeing everything as chaos). Loadings range from .55 to .83.
• Factor 2: Physical and Psychological Morbidity: Defined by items 2, 5, 6, 7, 8, 10, 11, 13, and 14 (suicidal ideation, anxiety, medical problems/hepatitis, passivity, concentration loss, nausea, and health deterioration). Loadings range from .48 to .78.

Model Fit Indices

Confirmatory factor analytic models testing the multidimensional structure yield acceptable to excellent goodness-of-fit indices across published validations:

• Comparative Fit Index (CFI) > .92
• Tucker-Lewis Index (TLI) > .90
• Root Mean Square Error of Approximation (RMSEA) = .052 to .068 (90% CI [.044, .076])
• Standardized Root Mean Square Residual (SRMR) < .06

Instrument / Measurement Tool

• Instrument Name: Drug Use Disorders Identification Test Extended (DUDIT-E)
• Authors: Anne H. Berman, Hans Bergman, Tom Palmstierna, & Frans Schlyter (2007)
• Primary Administration Modality: Standardized self-report paper-and-pencil questionnaire, clinician-administered structured interview, or interactive computer-based assessment.
• Target Population: Adolescents and adults (ages 15+) in clinical addiction treatment, forensic settings, criminal justice facilities, psychiatric services, and specialized research settings.
• Completion Time: Approximately 15 to 25 minutes.
• Overall Structure (4 Sections, 44 Test Items plus Substance Checklist):
  • Substance Frequency Checklist: Maps 10 primary substance categories (Cannabis, Amphetamines, Cocaine, Opiates, Hallucinogens, Solvents/Thinner, GHB, Sedatives/Hypnotics, Prescription Analgesics, and Tobacco) across a 6-point frequency scale (Never [0], Tried it one or more times [1], Once a month or less often [2], 2-4 times a month [3], 2-3 times a week [4], 4 times a week or more [5]) with an optional checkbox for relapse/binge use patterns.
  • Section 1: Positive Aspects of Drug Use (17 Items): Explores perceived functional and psychological reinforcers. Response scale: 5-point Likert scale (0 = Not at all, 1 = A little, 2 = Somewhat, 3 = A lot, 4 = Totally). Score range: 0 to 68.
  • Section 2: Negative Aspects of Drug Use (17 Items): Explores biopsychosocial harms and clinical consequences.
    • Items 1–4 (Institutional/Behavioral Harms): 5-point frequency scale (0 = Never, 1 = Less often than once a month, 2 = Every month, 3 = Every week, 4 = Daily or almost every day).
    • Items 5–17 (Internal/Somatic Harms): 5-point severity scale (0 = Not at all, 1 = A little, 2 = Somewhat, 3 = A lot, 4 = Totally).
    • Total Score Range: 0 to 68.
  • Section 3: Treatment Readiness and Thoughts About Drugs (10 Items): Assesses ambivalence, problem recognition, and change commitment. Response scale: 3-point categorical scale (0 = Not at all, 1 = Partly, 2 = Totally). Score range: 0 to 20.
• Scoring and Clinical Interpretation:
  • DUDIT-E Positive Score (0–68): Higher scores denote heavy psychological and functional reliance on substances for coping, mood alteration, and social functioning, signaling high relapse vulnerability under stress.
  • DUDIT-E Negative Score (0–68): Higher scores denote severe personal disruption, medical impairment, and negative psychosocial consequences.
  • Decisional Balance Differential (Negative Score minus Positive Score): Negative resulting scores denote precontemplative status (pros outweigh cons); scores around zero reflect active ambivalence (contemplation); positive resulting scores denote readiness for behavioral intervention (cons outweigh pros).
  • DUDIT-E Motivational Index: Derived algorithm combining readiness scores with the decisional balance differential to guide stage-matched interventions (e.g., motivational interviewing vs. active relapse prevention skills training).

Permissions & Fee and Test Year

The Drug Use Disorders Identification Test Extended (DUDIT-E) was published in 2007 by Anne H. Berman and colleagues. As an instrument developed with public academic funding from the Karolinska Institutet and the Swedish Prison and Probation Service, the DUDIT-E is placed in the public domain for non-commercial clinical, educational, and scientific research purposes. No royalty fees are charged for its clinical adoption or academic deployment.

The scale, scoring keys, and documentation are made accessible internationally through the European Union Drugs Agency (EUDA, formerly EMCDDA). Clinicians, health networks, and independent researchers who wish to translate, adapt, digitize, or utilize the DUDIT-E for commercial software platforms or formal cross-cultural translation projects are requested to contact the lead author, Prof. Anne H. Berman (Department of Clinical Neuroscience, Karolinska Institutet, Email: [email protected]), to register their project, preserve psychometric consistency, and obtain the official translation manual.

References

Berman, A. H., Bergman, H., Palmstierna, T., & Schlyter, F. (2005). Evaluation of the Drug Use Disorders Identification Test (DUDIT) in criminal justice and addiction treatment settings. Karolinska Institutet, Department of Clinical Neuroscience. Stockholm.

Berman, A. H., Palmstierna, T., Källmén, H., & Bergman, H. (2007). The self-report Drug Use Disorders Identification Test-Extended (DUDIT-E): Reliability, validity, and motivational Index. Journal of Substance Abuse Treatment, 32(4), 357–369. https://doi.org/10.1016/j.jsat.2006.10.001

DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and processes of change for change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (2nd ed., pp. 3–24). Plenum Press. https://doi.org/10.1007/978-1-4899-1934-2_1

European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (2007). Drug Use Disorders Identification Test Extended (DUDIT-E) Instrument Repository. Lisbon: EMCDDA. http://www.emcdda.europa.eu/html.cfm/index61869EN.html

Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press.

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.

Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L., Silva, C. A., & Redding, C. A. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39–46. https://doi.org/10.1037/0278-6133.13.1.39

Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7(4), 363–371. https://doi.org/10.1016/0306-4603(82)90005-3

13. Items of the Scale (Questionnaire)