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Interactions of Alcohol Addiction on the Brain and Behavior

Permission graciously given by the author to reproduce this paper:   

Interactions of Alcohol Addiction on the Brain and Behavior:
A Review of the Literature

Pam Pare’
2004

Abstract:  This paper focuses on the interaction of alcohol addiction on the brain and on behavior. A review of the literature centers on the biology and etiology of alcohol addiction, genetic factors, psychomotor behavior, and neuropsychological impairment.  Addictive behaviors and alcohol abuse are presented as interactive, specifically, violence and aggression, impulsivity and other personality traits.  Other behaviors shown to be correlated with addiction include gambling, drinking to cope, absenteeism at work, and family/spousal functioning and communication.  Various treatment options researched in the literature are presented. 

     The role of biological factors in alcohol addiction has been more and more investigated in recent literature.  The biological role is particularly relevant when the focus is on the etiology of alcohol addiction.  Alcohol addiction has been defined in the literature as an inability to stop daily drinking for long periods of time, along with repeated efforts to control the drinking.  This behavior is accompanied by impaired social and/or occupational functioning (Schuckit, 1987). 

     There is now evidence that alcohol addiction is genetically influenced through specific gene markers for alcoholism  found that men at high risk for alcoholism showed a different pattern on their cortical electroencephalograms, and a decreased strength of reaction to low doses of ethanol  Schuckit (1987) found from twin studies, that 50% of alcoholic vulnerability has a genetic base. According to Schuckit , locating the genes responsible for alcohol addiction is an important goal for alcohol research.

     Thus, there is evidence from twin and animal studies, that genetics plays an important role in the etiology of alcohol addiction. Gordis (2000) reports that there is evidence in the research of certain chromosomal hot spots (chromosomes 1 and 2), and Schuckit (1987) reports that genetic factors may play a role in the absorption and elimination rates of alcohol in the system. He states that these genetic influences interact with environmental factors, such as social and economic stressors, to produce a vulnerability to alcohol abuse. Animal studies have shown how alcohol acts on the central nervous system (CNS) in people who are genetically prone to alcohol sensitivity, and the amount of alcohol consumed to cause intoxication (Schuckit, 1987). 

     Scientists are studying genetic technology using what they call “knockout” technology.  They alter the genes of an animal in the laboratory, by knocking out a specific gene. Isolating these genes, such as PKCy and Serotonin 1B, they can deduce the importance that gene has in whatever system they are studying (Gordis, 2000). One avenue of study by researchers (Gordis, 2000) is how alcohol affects the y-aminobutryc acid (GABA) receptor, the major inhibitory neurotransmitter in the brain. In this way, researchers can determine why people develop a tolerance for alcohol.

     Genetic markers can be observed before onset of alcoholism and after it develops. Scientists have determined that these markers trigger biological, emotional and cognitive changes in some people that makes them predisposed to alcoholism (Schuckit, 1987).  Schuckit (1987)and his colleagues quote studies of men with a predisposition to alcoholism.  In these studies, an attempt was made to identify the genetic trait markers responsible for the future development of alcoholism.  By studying children and families of alcoholics, this genetic trait could be observed.  A more time/economically efficient way would be to study homologous groups at high risk for alcoholism. 

     Schukit’s study (1987) documented alcohol reactions in the sons of alcoholic men.  They found two types of brain waves that acted as markers for alcoholism.  Alcoholics were shown to have abnormal alpha and P300 brain waves on electroencephalograms prior to drinking.  Other forms of predisposition to alcoholism were found in this study.  Unique patterns of blood proteins were found in alcoholics even after sustained abstinence (Schukit, 1987).  In Orientals, there appears to be a genetic marker enzyme, ALDH, in the liver that causes higher levels of acetaldehyde in the blood after drinking. Schukit (1987) states that sons of alcoholics tend to have lower levels of the enzyme, monoamine oxidase (MAO), which controls the release of brain neurotransmitters.

     Gordis (2000) reports that two factors – alcohol reinforcement and cellular adaptation – may explain the biological processes involved in the development of alcoholism in the brain. Alcohol appears to interact with the brain’s reward system.  Upon continued drinking, alcohol in the brain produced adaptable changes in certain neurons that lead to tolerance and dependence (Gordis, 2000).  There has been evidence through genetic mapping techniques, showing that alcohol triggers changes in cellular communication by altering the behavior of certain genes, and that these changes can affect the degree of reinforcement towards drinking (Gordis, 2000). 

     Further research on genetic influences, personality and alcohol abuse has come more recently from Mustanski and his colleagues (2003). They assessed the connection between two types of personality and alcohol abuse through twin studies.  The authors state that growing evidence in the research points to indications of genetic affects on alcohol abuse.  In their study, they used questionnaires to measure zygosity, personality and alcohol consumption and related problems.

     The personality traits of social deviance and excitement seeking were robust in predicting both consumption and alcohol-related problems.  The authors reported genetic correlations between personality and alcohol outcomes.  In fact, the authors stated that genetic factors were the main contributors in the tendency toward alcohol abuse.  The author and his colleagues explained this connection through a biological process, whereby both frontal lobe and executive cognitive deficits interact with social deviance and alcohol-related problems.  They noted that these same genetic factors also influenced the mesolimbic dopamine system, thereby reinforcing increased sensitivity to alcohol (Mustanski et al, 2003). 

     Errico and his colleagues (Errico et al, 1990) meanwhile, had already developed an instrument for detecting neuropsychological impairment in alcoholics.  This was a self-report instrument involving a 50-item checklist of symptoms administered to 73 male alcoholics from a veterans hospital.  They called this instrument the Neuropsychological Impairment Scale (NIS).  It measured three main areas of cognitive functioning:  learning and memory, problem solving skills, and perceptual/motor skills.  They concluded that the NIS was a reliable and valid measure, as some of the scales correlated with measures of drinking behavior (Errico et al, 1990).

     Alcohol and its link with psychomotor activation was investigated by Wise and Bozarth (1987). They theorized that a large array of addictive substances could cause psychomotor activation, and that these substances, including alcohol, shared a biological mechanism, whereby this mechanism would be homologous with positive reinforcement for substances (Wise & Bozarth, 1987).  They built their case from previous studies showing a common derivation of different organs from embryonic tissue.  They are homologous because they are under the same genetic control.  Likewise for behaviors.  In this vein, the authors saw a homologous relationship among addiction, positive reinforcement, and psychomotor activation       The authors defined addiction as “compulsive drug-seeking behavior,” and dependence as “a condition that develops with habitual drug intake and that is revealed by a distress syndrome when habitual intake is discontinued or pharmacologically blocked (Wise & Bozarth, 1987, p. 471).  These authors advocated a physiological source for psychological dependence, and offered the premise that if the distress from withdrawal can cause one to continue to self-medicate, then physical dependence could partially explain addiction.

     Furthermore, these researchers pointed out that research has shown opiates to be reinforcing when locally injected into the area of the brain where there are opiate receptors imbedded in nerve cell membranes.  These receptors are located in the ventral tegmental area (VTA).  This work has shown that opiates could be habit forming even when there is no full withdrawal syndrome (Wise & Bozarth, 1987).  This kind of Pavlovian action has played an important role in learning about drug and alcohol addiction. The behavior of self-administration is the common denominator for both alcohol reinforcement and alcohol addiction (Wise & Bozarth, 1987).

     Wise and Bozarth (1987) stated that an event would be reinforcing if it increases the behaviors that it followed.  This was the negative reinforcement model of behavior, because alcohol would take away the negative stimulus of withdrawal, thereby reinforcing the desire to drink. Therefore, the object of the Wise article identified addiction in terms of operant reinforcement, with psychomotor stimulant drug acting as the reinforcer.  The following condition was that the reinforcing affects of drugs and alcohol would induce psychomotor activation, thus the liability for addiction. 

     Looking at alcohol addiction in terms of approach/withdrawal behavior was based on evolutionary history, where approach behavior and positive reinforcement were activated by electrical stimulation of the forebrain bundle.   (Wise & Bozarth, 1987).  This history evolved into a biological theory of reinforcement, where electrical stimulation of the medial forebrain bundle fibers produced approach behaviors and positive reinforcement.  According to the view of psychobiologists, any drug, including alcohol, that acts as a positive rein forcer, should stimulate forward locomotion.  This would be done by activating the dopamine system located in the medial forebrain bundle.  This system is also involved in brain stimulation reward (Wise & Bozarth, 1987). 

     Wise and his colleague (Wise & Bozwarth, 1987) hypothesized that both loco motor (movement triggered by psychic or mental action) effects and positive reinforcing effects of alcohol were homologous, and that both of these operations were derived from a common mechanism, responsible for approach/reinforcement rewards.  Thus, the mechanism by which psychomotor stimulation is initiated was mediated by central dopaminergic neurons located at two subdivisions of the same anatomical system:  the mesolimbic and nigrostriatal fibers (Wise & Bozwarth, 1987).

     Wise and Bozwarth (1987) projected that drugs of abuse, including alcohol, generally were looked at as central nervous system (CNS) depressants.  But they also had psychomotor stimulant properties as well, mediated by brain mechanisms similar to those that activate the stimulant properties of cocaine.  Alcohol, as with barbiturates and opiates, showed effects on locomoter activity, and was found to activate ventral tegmental dopaminergic neurons.  The authors theorized from this, that there was a common mechanism that fostered both psychomotor stimulation and positive reinforcement (Wise & Bozwarth, 1987).

     Researchers hoped that finding such a common denominator between the domaminergic system and alcohol’s stimulant actions on the brain, would lead to enlightenment on drinking behavior and addiction, and that this link would lead to greater understanding both for future research and treatment of alcohol addiction.

     Research has frequently focused on the effects of alcohol addiction on behavior. Whiteside did a study on the role of impulsivity and alcohol abuse by testing an instrument that measured this phenomenon (Whiteside & Lynam, 2003).  These researchers investigated the relation among four personality traits connected to impulsive behavior and alcohol abuse.  The authors defined impulsive behavior as “a tendency to engage in behaviors without proper regard for consequences or inherent risks (p. 210). 

     Based on this definition, the authors developed a scale to measure impulsive behaviors, called the Impulsive Behavior Scale, UPPS, which intended to measure four traits of impulsive behavior:  urgency, lack of premeditation, lack of perseverance, and sensation seeking.  Urgency referred to the need to act on impulse in order to reduce the intensity of negative emotions.  Lack of premeditation corresponded to an failure to think or reflect on consequences of an action before engaging in that action.  Lack of perseverance was linked to one’s failure to stick with a task until completion, and sensation seeking, which involved an urge to try new experiences that could be dangerous (Whiteside & Lynam, 2003).

     Thus, the UPPS was designed to assess the relationship between impulsivity and alcohol abuse, since alcohol abuse was defined as an inability to refrain from drinking in the face of negative consequences (Whiteside & Lynam, 2003).  In developing this instrument, the authors focused on two categories of alcoholics based on their antisocial characteristics:  Type I and Type II, Type II having more association with antisocial personality traits. The researchers used a personality assessment inventory designed to measure psychopathology (the PAI), the South Oaks Gambling Screen (SOGS), and the Alcohol Use Disorders Identification Test (AUDIT) (Whiteside & Lynam, 2003). They found that the UPPS made a distinction between the two types based on antisocial traits.  Type II alcoholics showed more antisocial personality traits and showed higher levels of pathological gambling, but the test failed to show a distinction between the two groups on impulsive behavior based on the UPPS (Whiteside & Lynam, 2003).

     The authors proposed that sense of urgency might be the trait most associated with alcoholics., because it coincided with a need to self-medicate, or need to cope. 
Along this line, Todd and his colleagues used data from two studies to develop a validity measure of drinking to cope by using daily records kept by community-residing drinkers.  The studies evolved around stress, negative affect and drinking.  The authors made reference to other research on drinking to cope (DTC), and how DTC was used to intercept the negative effects of stress, and foster avoidant coping.  Research used this model of alcohol consumption to explain how the coping mechanisms of drinking was linked to both alcohol use and drinking problems (Todd et al, 2003).

     In their research, the authors looked at the information recorded by people to examine their DTC habits to see what kind of information these people used to characterize their DTC levels.  They used a 4-item alcohol use subscale from a coping measure, a neuroticism measure called the NEO Personality Inventory, daily diary assessments (daily events, mood, perceived stress, desire to drink, and alcohol consumption), and an assessment of events involving a daily check list.  The variables assessed were perceived stress, negative affect, the desire to drink, and alcohol consumption (Todd et al, 2003).

     Based on their findings, the authors concluded that the stress of high DTC people appeared to be unrelated to drinking and negative affect, and that drinking after a negative or stressful event and drinking to enhance social interactions and positive affect were correlated. They found an association between a high DTC and response to both positive and negative experiences, and that people were likely to drink following a variety of situations.  They also concluded that people who drank more, and experienced more drinking-related problems, more often sought explanations for their problem drinking (Todd et al, 2003). 

     From their results, the authors hypothesized that people who drink in times of stress as well as celebration, might be more at risk for problems with their mates, and other social situations, as well as problems with the law.  In this vein, problem drinkers would most likely be associated with coping-related drinking.   Bored and lonely moods were most likely to occur, reflecting DTC behavior for distinct kinds of negative behaviors.  Thus, their results showed a positive link between self-reports of DTC and levels of alcohol consumption.  Continuing on the theme of a link between drinking and associated behavior, many studies focused on alcohol consumption and levels of aggression.

     Fals-Steward (2003) investigated the likelihood of partner physical aggression on days of alcohol consumption.  First, the author reported on three models of drinking and violence purported in the literature to explain the relationship between alcohol abuse and interpartner violence.  One model, the spurious model, was designed to show that this relationship was influenced by other factors outside the relationship.  In the indirect effects model, long-term alcohol abuse was the cause of a lower satisfaction in the marriage, and family conflict.  The third model, the proximal effects model, people who drink are more likely to commit violence in their relationships, because of the effects of alcohol intoxication on cognitive functioning, and the acute effects of alcohol on increased partner violence.

     Fals-Steward (2003) also cited research showing a significant relationship between alcohol consumption and partner violence, and lab studies finding a link between drinking and increased aggression as measured by levels of electric shock.  Apparently, drinking and marital conflict appeared to increase levels of negative interaction, and reports from victims of physical aggression indicated acute alcohol intoxication immediately preceded episodes of physical aggression.  Fals-Steward’s (2003) intent was to show a day-to-day relationship between drinking and partner physical aggression. 

     The 135 married couples who participated in his study kept a daily physical aggression log where they each recorded the frequency and times of physical aggression, and were interviewed with two structured interviews:  the Timeline Followback Spousal Violence Interview, and the Timeline Followback Interview, to assess episodes of male-to-female physical aggression.  The extent of the husband’s alcohol problems was evaluated with the Michigan Alcoholism Screening Test (MAST) and the Structured Clinical Interview for DSM-IV.

     His results showed that heavy drinking of the husbands was strongly correlated with the likelihood of male-to-female physical aggression, and that on days when heavy drinking occurred, the likelihood of male-to-female physical aggression increased by 17 times.  Results also revealed a tendency for male-to-female violence to occur during or shortly after a drinking episode, rather than after a lapse of time from a drinking episode (Fals-Stewart, 2003).  Surprisingly, results indicated that those drinkers seeking treatment for domestic violence, who also have severe problems with alcohol use, were just as likely to engage in violent acts against their female partners on days of sobriety (Fals-Stewart, 2003). 

     Other researchers also studied the role of treatment in alcohol-related partner violence.  O’Farrell et al (2004) investigated partner violence before and after treatment with behavioral couples therapy (BCT).  Specifically, the study sought answers to three research predictions:  Verbal abuse would be greater in male alcoholics before BCT than the normal sample, increased drinking after BCT would be linked to greater partner aggression, and more involvement in BCT would result in less violence (mediated by the extent of drinking and quality of relationship function). This study, like the Fals-Stewart study (2003) showed a link between lower violence, and reduced problem drinking.  O’Farrell attempted to show a causal link between these two factors, mediated by enhanced relationship functioning.

     O’Farrell et al (2004) cited a recent study, where both male-to-female violence and verbal aggression were reduced after BCT, although couples with a history of comorbid drug problems were excluded from the study.  He cited another study, in which Alcoholics Anonymous (AA) was shown to be effective in promoting abstinence and nonviolent behavior. 

     Patients in the study had a prior DSM-IV diagnosis of alcohol dependence. The BCT included  a daily sobriety contract and an agreement to take antabuse. To assess violence, the authors used the verbal aggression and violence subscales of the Conflict Tactics Scale (CTS). This subscale had items in graduating aspects of violent behavior (e.g. threw something at the partner, or beat up and threatened with a gun). Couples behavior was measured by the Couples Behaviors Questionnaire (CBQ). 

     The sample of alcoholic and non-alcoholic men and their partners was obtained from those who participated in the National Family Violence Re-Survey (NFVS, 1985).  The sobriety contract included  12-step meetings and urine screenings at each session.  Results supported predictions that violence and male-to-female aggression would lessen after BCT, and that for those who abstained from drinking after BCT, significant reductions in violence would occur. In the context of treatment, alcoholism recovery was closely linked with reductions in violent behavior to a level similar to the non-alcoholic population. Results also reflected that the relationship between BCT involvement and partner violence after BCT was mediated by both problem drinking and relationship adjustments, indicating that BCT involvement positively affected alcohol abuse and partner violence (O’ Farrell et al, 2004). 

     Other results of the study showed that male-female partner violence had the strongest  negative impact on children’s functioning, and BCT produced an improvement in the psychosicoal lives of these children. 

     Other research has been done on couples, communication and problem drinking.  Research has shown, for example, that couples that have problems with alcohol and relationships have often reported poor communication skills (Kelly et al, 2002).  Self reports of communication problems between couples were shown to coexist with alcohol abuse in women.  Kelly and his colleagues assessed couples to study this problem, and found that a connection existed in relationships where the woman drank, between the drinking behavior and male demands in the form of criticism on the female, who tended to withdraw.  Meanwhile, the woman had high rates of negative listening in male-female confrontations (Kelly et al, 2002). 

     Another facet of familial problem drinking examined in the research was parental problem drinking.  Research has shown that parental problem drinking behavior has been linked with behavioral problems and problematic situations in children (El-Sheikh & Buckhalt, 2003).  El-Sheikh and Buckhalt (2003) studied children and their perceived attachments with parents in terms of parental drinking and outcomes for children.  They looked for a mediator that linked parental problem drinking with child outcomes.  The Michigan Alcoholism Screening Test (MAST) was used to classify parents as alcoholics. Children were given the Inventory of Parent and Peer Attachment (IPPA). 

     Their results showed higher rates of parental problem drinking together with lower family cohesion and adaptability, along with more behavioral and social problems in the children.  One could deduce from this, that children of problem-drinking parents have a higher risk of running into social-emotional problems when there is little or no parental support (Kelly & Buckhalt, 2003).

     Alcoholic behavioral traits in families was further investigated through other studies on children of alcoholics.  Assaad and his associates (Assaad et al, 2003) studied relationships among aggressiveness and heart rate response to intoxication of sons of male alcoholics (SOMAs), and a family history of alcoholism. Because of the difficulty in establishing a cause-effect link between characteristics of alcoholics and alcohol abuse, the authors thought it better to focus on those who were not alcoholics, but were at increased risk of developing alcoholism.  Other studies had shown that SOMA’s were four to nine times more likely to develop alcoholism (Assaad et al, 2003).

     SOMA’s characteristics typically were associated with family adversity, low socioeconomic status, cognitive impairment, increased heart rate (HR) to alcohol intoxication, and aggression.  The positive heart rate response suggested to these authors that an increased susceptibility existed to psychomotor stimulation, or reward, of alcohol.  Involved were interactive systems in the brain, including the behavioral activation system, behavioral inhibition system, and arousal system (Assaad et al, 2003).

     Based on this research, the authors predicted that HR responses to alcohol could be used as markers of the system response to the reward of alcohol. Specifically, they hypothesized that SOMA’s at high risk of alcoholism who were aggressive, would show a larger HR response to alcohol. 

     Eleven-year-old boys identified as SOMAs were given the Michigan Alcoholism Screening Test (MAST).  These scores were used to assess the problems, behaviors and consequences associated with alcohol abuse, and were therefore, used to determine the alcoholic status of the biological fathers.  They were also given the Physical Aggression subscale of he Self-Reported Delinquency Questionnaire (SRDQ), measured longitudinally.  All participants were at least 18 years old at the time of testing. There was also a non-SOMA control group, so that both groups were divided further into four subgroups:  low-aggressive non-SOMAs, high-aggressive non-SOMAs,  low-aggressive SOMAs, and high aggressive SOMAs (Assaad et al, 2003).

     In the lab, the subjects were given doses of alcohol according to their weight, until they were intoxicated.  Blood alcohol concentrations (BACs) were taken with an Alco-Sensor Intoximeter.  The researchers next collected information of alcohol ingestion patterns through use of a structured interview.  A polygraph collected psychophysiological data before and after alcohol consumption. 

     Results showed that high-aggressive subjects obtained higher intoxicated HR responses, with a significant relationship between Physical Aggression and Family History.  Intoxicated HR response was positively linked with the interraction between physical aggression and family history.  From this, the authors concluded that only SOMAs with high scores on aggression, would show an increased HR response to alcohol.  High aggression SOMAs were shown to have increased alcohol consumption.  Assaad and his colleagues cautiously observed that in men with a positive family history of alcoholism, increased HR response patterns could be driven by physical aggression in SOMAs (Assaad et al, 2003).

     This study, like other aforementioned studies, implicated cognitive, biochemical, psychophysiological, and genetic factors in the development of alcoholism.  Heart rate was a factor studied in other research. Research has shown a link, for example, between alcohol  dependence and a risk for gambling behavior, and that this risk could have at its basis, genetic factors (Brunelle et al, 2003).

     Brunelle and  her colleagues (2003) studied alcohol-induced heart rate (HR) activity and the increased risk of pathological gambling in a sample of men who had been followed in a longitudinal study since they were five years old. They were given the South Oaks Gambling Screen (SOGS) and HR was measured with the Contact Precision Instrument. The literature had pointed to an exaggerated baseline HR as a shared factor in people at increased risk for alcohol dependence and pathological gambling. Alcohol was viewed as a positive rein forcer, activating the behavioral activation system, dopaminergical etiologically, and a sensitivity to an alcohol-induced reward was shown by an increased HR response.  The Brunelle study showed that this alcohol-induced heart rate was connected with pathological gambling behavior (Brunelle at al, 2003). 

     The research has shown a link between substance abuse and problem gambling, with data also suggested that those gamblers with alcohol dependence histories showed more persistent and severe gambling addiction and co-morbid psychiatric problems. Preoccupation, loss of control, tolerance, withdrawal symptoms, and cyclical abstinence and relapse were shown to be symptomatic in both alcohol dependence and pathological gambling  (Ladd & Petry, 2003). 

     Ladd and Petry (2003) evaluated a group of people admitted to treatment programs for pathological gambling.  They were given the Gambling, Alcohol, Drug, Psychiatric and Employment scales of the Addiction Severity Index and the SOGS.  The authors examined the severity of gambling problems in those with substance abuse treatment histories, and found that pathological gambling and substance abuse were co-linked with severe gambling and psychiatric problems, as well as increased employment problems. 

    Difficulties in maintaining employment appears to be another major factor influenced by heavy drinking.  In the literature, alcohol abuse and absenteeism were shown to be associated (McFarlin & Stewart, 2002).  Other researchers had already found that increased alcohol use was associated with increased absenteeism at work, and that those who met criteria for alcohol abuse lost three times as many days from work as those who did not meet such criteria.  Building on research done on the causes and consequences of workplace absenteeism, McFarlin and Stewart (2002) investigated the day-to-day relationship between alcohol abuse and absenteeism in the workplace, and found such a relationship. 

     Alcoholism appears to be associated with other co morbid behavior as well.  Patten et al (2001) found a relationship between nicotine dependence, a history of alcoholism  and poorer smoking cessation outcomes.  The authors noted that a longer period of alcohol abstinence and participation in 12-step group treatment may contribute to successful long-term smoking cessation.

     Treatment appears to be successful in increasing the rate of abstinence from alcohol.  Contingency management (CM) treatment interventions appear to be especially effective in successfully treating target goals, such as job training attendance, medication compliance, and group therapy attendance (Helmus et al, 2003).  Helmus and his colleages (2003), for example, evaluated the effectiveness of a community-based CM model for reinforcing group counseling attendance and negative breath alcohol levels of 20 dual-diagnosis patients (patients that have an alcohol abuse diagnosis plus one other psychiatric disorder.)  This appeared to be a real problem in the inpatient populations of treatment centers, as resources and staffing are limited. 

     Helmus et al (2003) demonstrated that a motivation interview, as part of a CM intervention treatment program, could modify group counseling attendance along with a positive rein forcer, such as a small gift certificate.  Thus, with stringent, successive approximation behavior shaping mechanisms, and daily, consistent breath tests, daily on-time group attendance would be reinforced, and alcohol abstinence would be maintained.  Motivation, therefore, has been shown in the research to be a strong contingency management technique for maintaining treatment attendance and fewer drinking days during and after treatment ended (Helmus et al, 2003).

     Problem drinkers appear to be more dependent on avoidance techniques for coping with stress, than non-problem drinkers, and conversely, reductions in a problem drinker’s use of avoidance ways of coping as a response to stress, may predict better treatment outcomes  .  An increase in approach coping skills, such as making a plan and taking appropriate action, was shown to improve long-term (12-month) alcohol remission.  Along with this, a reduction in avoidance ways of coping with stress, such as use of wishful thinking and venting negative feelings, predicted fewer incidents of relapse, and lower severity of long-term alcohol problems (Helmus et al, 2003). 

     Finally, a growing amount of research has shown exercise to be a positive factor in successful alcohol treatment outcome and recovery and in dealing with stress (Read & Brown, 2003).  Global lifestyle changes were predicted to be important aspects of recovery, including the health benefits of exercise, and exercise, according to behavioral scientists, could be a positive treatment approach to prevent relapse.  For example, exercise was looked at as a way to achieve a pleasurable state in lieu of alcohol, thus improving mood and increasing self-efficacy, as well as providing a substitute behavior for drinking (Read & Brown, 2003).  With a viable exercise program involving others, a recovering alcoholic could gain the social support of a group, and increase adherence to the exercise program.  Stress reduction, also, would be an added benefit from exercise, as it has been proven in research to be an effective stress buffer (Read & Brown, 2003).

     In summary, the role of biological factors in alcohol addiction has been more and more investigated in recent literature. Much of the research centered on genetic influences, personality and alcohol abuse, including that done with twin studies, with results showing growing evidence  pointing to indications of genetic affects on alcohol abuse. There is now evidence that alcohol addiction is genetically influenced through specific gene markers for alcoholism. Scientists have determined that these markers trigger biological, emotional and cognitive changes in some people that makes them predisposed to alcoholism. 

.   Research has frequently focused on the effects of alcohol addiction on behavior, such as the twin studies showing behavior to be the common denominator for both alcohol reinforcement and alcohol addiction   Motivation, therefore, has been shown in the research to be a strong contingency management technique for maintaining treatment attendance and fewer drinking days during and after treatment ended.

    Research revealed a significant relationship between alcohol consumption and partner violence, and lab studies finding a link between drinking and increased aggression.  For instance, a significant relationship was found between Physical Aggression and Family History of alcoholics.  Alcoholic behavioral traits in families was further investigated through other studies on children of alcoholics, implicating cognitive, biochemical, psychophysiological, and genetic factors in the development of alcoholism. 

     Other behaviors alcoholic-related behaviors studies in the research include a link between substance abuse and problem gambling, with data also suggested that those gamblers with alcohol dependence histories showed more persistent and severe gambling addiction and co-morbid psychiatric problems.

     Finally, treatment appears to be successful in increasing the rate of abstinence from alcohol.  Contingency management (CM) treatment interventions and 12-step programs, such as AA, appear to be especially effective in successfully treating target goals.  A growing amount of research has shown exercise to be a positive factor in successful alcohol treatment outcome and recovery and in dealing with stress

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