Motivations for Alcohol Use


Evan Goulding, MD, PhD

Department of Psychiatry and Behavioral Sciences

Feinberg School of Medicine, Northwestern University

© Alcohol Medical Scholars Program


I. Introduction

      A. Why motivations matter

            1. Alcohol use causes substantial problems (SLIDE 2)

                  a. Costly: USA- $185 billion/yr1

                  b. Lethal: USA- 3rd leading modifiable cause of death (after smoking, obesity)2

            2. Lifetime prevalence of alcohol use and problems but only some develop problems3-5 (SLIDE 3)

                  a. Alcohol exposure common: use = 90%

                  b. Alcohol use disorders (AUDs, I’ll define below)   = 15%

            3. Identifying risk factors can help prevention and treatment

                  a. Problems related to alcohol use take time to develop

                  b. So gives clinician time for intervention

            4. Reasons person drinks important11-21 (SLIDE 4)

                  a. Certain motivations → ↑ risk

                  b. Knowing motivations identifies risk

                  c. Knowing motivations can guide intervention, assist use and harm

            5. Examples: how knowing reasons matters (SLIDE 5)

                  a. Across 3 cases

                        1’. 18 yo males, starting college

                        2’. All say drinking makes going out more fun

                  b. Unique differences

                        1’. Tom: likes getting high, it's exciting, pleasant, less bored

                        2’. Rich:  helps enjoy a party, celebrate, fit in with friends, to be liked, sociable

                        3’. Harry: likes the feeling, more self-confident, helps when upset, cheers up

      B. This lecture covers (SLIDE 6)

            1. Alcohol use and problems:

                  a. Why motivations matter

                  b. Definitions, prevalence, time course

            2. Risk factors for developing problems

            3. Different types of motivations for alcohol use

            4. How motivations to drink relate to:

                  a. Use and problems

                  b. Personality traits                

            5. How motivations can guide prevention and treatment

      C. Key points include: (SLIDE 7)

            1. Different motivations for alcohol use exist

            2. Different motivations predict different levels of risk for alcohol use/problems

            3. Asking about motivations can guide clinical care

      D. This lecture covers - alcohol use and problems: definitions, prevalence, time course (SLIDE 8)

II. Alcohol Use and Problems: Definitions, Prevalence, Time course

       A. Definition of Alcohol Use Disorders (AUDs) DSM5 (SLIDE 9)

            1. Pattern of use → significant impairment

            2. ≥ 2 of following,  within a 12-mo period

            3. Left column (DSM 4 alcohol abuse)

                  a. Failure to fulfill major role obligations

                  b. Use in physically hazardous situations

                  c. Social or interpersonal problems

                  d. Craving (new in DSM5, legal problems in DSM4 dropped in DSM5)           

4. Right column (DSM 4 alcohol dependence, AD)

                        a. Tolerance

                        b. Withdrawal

                        c. Use larger amounts/longer than intended

                        d. Persistent desire/unsuccessful efforts cut down/control use

                        e. ↑ time spent obtaining/using/recovering from use

                        f. Important activities given up/↓ due to use

                        g. Continued use despite problems

B. Definition of at-risk drinking (SLIDE 10)

            1.Recommended safe drinking limits22  

                        a. For women 

                              1’. Drinks per week           ≤ 7

                              2’. Drinks per occasion     ≤ 3

                        b. For men

                              1’. Drinks per week           ≤ 14

                              2’. Drinks per occasion     ≤ 4

            2. Above these limits = at-risk drinking, ↑ probability of 8, 22-25 (SLIDE 11)

                        a. Liver disease

                        b. Financial and marital problems

                        c. Serious injuries 

                        d. Problematic use, including AUDs as defined next

      C. Alcohol use patterns, one year prevalence:22, 26, 27 (SLIDE 12)

            1. Abstain (0 drink last mo, <12/yr):   ~49%

            2. Use:                                                 ~51%

                  a. Low-risk drinking:                    ~22%

                  b. At-risk drinking w/out AUD:   ~21%

                  c. AUD:                                        ~  8%

      D. Progression of use & problems over time4, 14, 28-33 (SLIDE 13)

            1. By age 18:

                  a. 75% tried alcohol

                  b. 60% intoxicated 1+ times

            2. Quantities peak early twenties

            3. Then ↓, as shown by comparing heavy use (≥ 5 drinks on ≥ 5 days in last 30 days)

                  a. 21-25 yo = 18%

                  b. 50-54 yo =   8%

            4. ↓ perhaps related to34, 35

                  a. Entering workforce

                  b. Marriage, parenthood

                  c. Brain matures

                  d. Self-regulation of behavior ↑s

            5. Ongoing ↑ quantities → problems

            6. Progression from use to problems takes time36, 37

                  a. Onset of use to dependence:     ~15 yrs

                  b. Most start drinking by:             ~15 yo

                  c. Most develop AD by:               ~30 yo

            7. Basic pattern: Initiate use → at-risk use → problems → AUDs

      E. Identifying risk factors for developing problems important because (SLIDE 14)

            1. Only some people develop problems

            2. Ample time to intervene earlier in process of progression

            3. Need to know who is at risk

      F. This lecture covers - risk factors for developing problems (SLIDE 15)

III. Risk factors for developing ↑ drinking and problems

      A. Genes contribute alcohol use/problems (SLIDE 16)

            1. Explain ~50% for at-risk drinking and problems38

            2. Operate through four prominent intermediate characteristics

                  a. Impaired breakdown of alcohol → ↓ risk

                        1’. First alcohol metabolite, acetaldehyde ↑

                        2’. Causes flushing, ↑ reaction to alcohol

                  b. Low level sensitivity to alcohol - ↑ risk

                        1’. If get less effect per drink

                        2’. Tend to drink more/occasion

                        3’. → select heavy drinking peers

                        4’. → belief at-risk drinking OK (“all my friends do it”)

                  c. Some psychiatric disorders - ↑ risk

                        1’. Bipolar (manic-depressive)/schizophrenia (long term psychosis)             

                        2’. Some serious anxiety disorders (e.g.,panic, posttraumatic stress, social phobia)

                  d. Personality traits - focus on in this lecture

       B. Personality traits relate to alcohol quantities and problems39-45

            1. Personality = stable patterns of thinking, feeling, behaving in relation to oneself/others (SLIDE 17)

            2. Many are genetically influenced                      

           3. Traits that ↑ risk include: (SLIDE 18)

                  a. ↑ sensation seeking - pursue exciting/novel experiences, even if dangerous/risky

                  b. ↑ impulsivity - act without planning/considering outcomes, fast response to urges

                  c. ↓ conscientiousness - not very: deliberative, dutiful, or self-disciplined

                  d. ↑ negative mood - self-doubt, anxious, sensitive, guilty, angry                                                                                   e. ↑ mood lability - rapid frequency, speed, and range of change in mood state

      C. Environment also contributes34, 35, 46-48 (SLIDE 19)

            1. Family

                  a. Modeling:  parental drinking (even after account ↑ genetic risk) - ↑ risk

                  b. Management: permissive environment - ↑ risk                               

                  c. Bonding/cohesion: lower levels - ↑ risk

                  d. Parental support: lower levels - ↑ risk

                  e. Neglect - ↑ risk

            2. Peers

                  a. Heavy drinking - ↑ risk

                  b. Deviance (theft/property damage) - ↑ risk

                  c. Academic competence - ↓ risk

            3. Social and Cultural

                  a. Belief that most people drink heavily - ↑ risk

                  b. Belief that role models drink heavily - ↑ risk

            4. Current status

                  a. Absence of positive incentives (lack access/engagement in pleasurable activities) - ↑ risk

                  b. Presence of negative incentives (exposure to stressors) - ↑ risk           

            5. Current situation

                  a. Availability - easy to get alcohol (eg cost, location, legal access) - ↑ risk

                  b. Suitability    - ↑ time places where drink (eg at parties) - ↑ drink

      D. Motives link genetic/environmental factors to drinking patterns and problems (SLIDE 20)

            1. Genetic/environmental factors affect motives to drink

            2. Motives affect drinking patterns and problems

      E. Understanding motivations may

            1. ↑ understand how personality traits → use/problems

            2. Identify risk pathways: different traits → different motivations → different outcomes (+/- problems)

            3. Assist clinicians identify those at risk

            4. Improve intervention and treatment

      F. This lecture covers - different types of motivations for alcohol use (SLIDE 21)

IV. Motivations for Alcohol Use That Can ↑ Problems (central theme of this lecture)

      A. Model of how motivation relates to alcohol use 49-56 (SLIDE 22)

            1. Propose: alcohol use

a. Is a goal directed behavior

                  b. Goal - desire to achieve some outcome (e.g., a change in mood state)

                  c. We make decisions to drink & how much based on goal want to achieve

            2. Hypothesis: drinking motivated by different goals will have different

                  a. Preceding risk factors (e.g. personality traits)

                  b. Subsequent outcomes (e.g. abstain, low-risk use, at-risk use, AUDs)

                  c. Different traits→ different motivations → different outcomes

      B. Motives have 2 dimensions based on desired outcome (SLIDE 23)

            1. Valence: direction of mood change

                  a. ↑ positive mood

                  b. ↓ negative mood

            2. Source: change mood by altering an

                  a. Internal state

                  b. External situation

      C. 2 dimensions result in 4 types of motivations (SLIDE 24)

            1. Social (↑ positive valence; external source)

                  a. Have a good time w/ friends

                  b. Be sociable

            2. Conformity (↓ negative valence; external source)

                  a. Be liked/fit in with group

                  b. Friends pressure to drink

            3. Enhancement (↑ positive valence; internal source)

                  a. Get high

                  b. Fun/exciting

            4. Coping (↓ negative valence; internal source)

                  a. Forget problems/worries

                  b. Help when feel depressed/nervous

                  c. Cheer up when in a bad mood

                  d. Feel more self-confident and sure of yourself

      D. Most common responses to motives questionnaires overall (SLIDE 25)

            1. Have a good time w/ friends    = 72% (social)      

            2. Get high                                          = 48%  (enhancement)

            3. Relax                                         = 41%  (coping)

            4. Due to boredom                              = 23%  (coping)

            5. Get away from problems          = 21%  (coping)

            6. Due to frustration/anger            = 17%  (coping)

            7. Fit in                                          = 10%  (conformity)

      E. Average strength endorsement strongest to weakest:  social > enhancement > coping > conformity

      F. Many people endorse more than one motive28

      G. Motives specific to groups of young drinkers57-59 (SLIDE 26)

            1. Social

                  a. Endorse social motives

                  b. ~50% of teens

            2. Enhancement/Social

                  a. Endorse enhancement/social motives

                  b. ~30%

            3. Coping/Enhancement/Social

                  a. Strongly endorse coping motives

                  b. Also enhancement/social motives

                  c. ~10%

      I. This lecture covers - how motivations to drink relate to: (SLIDE 27)

                  a. Use and problems

                  b. Personality traits          

V. Pathways to Use and Problems

      A. Motives relate to drinking outcomes

            1. Explain 20-40% variance alcohol use49, 60

            2. Explain ~25% variance at-risk drinking/alcohol problems49

            3. Endorse more motives/stronger endorsement = ↑ levels use28, 53, 54

      B. Types of motives relate to types of outcomes28, 49, 50, 52-56, 60, 61 (SLIDE 28)

            1. Social motives (e.g. be sociable, enjoy a party) related to:

      `           a. Low-risk drinking

                  b. Drink at mixed sex parties & bars, or with families

            2. Enhancement motives (e.g. get high, fun, exciting) related to:

                  a. At-risk drinking

                  b. Drink bars w/same-sex friends

            3. Coping motives (e.g. forget problems, cheer up) related to:

                  a. At-risk drinking

                  b. Alcohol problems

                  c. Drink at home alone

      C.  Prospective studies show11-13, 15, 62-64

            1. Coping motives ↑ risk AD:             ~ 1.5 fold                               

            2. Enhancement motives ↑ risk AD:   ~ 1.3 fold

            3. Generally, enhancement weaker relation w/ AD than coping

      D. With alcohol dependence (AD), more likely endorse coping motives

      E. Different personality traits also relate to different motives65-74 (SLIDE 29)

            1. Enhancement motives related to:

                  a. ↑ sensation seeking

                  b. ↓ conscientiousness

                  c. ↑ impulsivity

            2. Coping motives related to:

                  a. ↑ negative mood

                  b. ↑ mood lability

                  c. ↑ impulsivity

      F. Motives link traits with outcomes (SLIDE 30)

G. Changes with age (from 18 to 35 yo)14, 63 (SLIDE 31)

      1. Personality

            a. Impulisivity

            b. Negative mood/mood lability

      2. Motivations

            a. Enhancement motives ↓ (eg get high ↓ 47% → 32%)

                  b. Coping motives ↓ (eg  due to boredom ↓ 23% →   6%, forget problems ↓ 20% → 10%)

                  c. Only ↑ relax - ↑ 41% → 69%

            3. Drinking patterns

                  a. Use peaks ~22 yo

                  b. Use ↓ after about ~22 yo (especially heavy drinking episodes = ≥ 4/occasion)

                  c. Alcohol related problems ↓

            4. Individual variation personality and at-risk use/problems correlated over time (SLIDE 32)

                  a. Alcohol problems ↓ as personality moves toward more mood stability/self-control

                  b. ↑ Mood stability associated with ↓ coping motives

                  c. ↓ Coping motives associated ↓ use and problems

                  d. Process of "maturing out" from at-risk use/problems

            5. Coping motives link change personality and at-risk use/problems

            6. Continued drinking to cope → ongoing at-risk use/problems

      H. Clinical implications14, 63, 75 (SLIDE 33)

            1. Personality factors might help match to different treatment approaches

            2. Treatments targeting improved coping skills may be effective

            3. Recognize coping motives to: identify risk and provide feedback to patients

      I. This lecture covers - how motivations can guide prevention and treatment (SLIDE 34)

VI. Knowing Personality Traits and Motivations Can Guide Prevention/Intervention

      A. Prevention in high school16-19, 21 (SLIDE 35)

            1. Are limited effects of current generic programs to ↓ heavy drinking

            2. Might improve if target students with risky personality traits (eg ↑ negative mood, ↑impulsivity)

            3. Educate target students about

                  a. Relationship risky personality traits and coping/enhancement motives

                  b. Increase in at-risk drinking, problems with coping/enhancement motives

                  c. Disadvantages of using alcohol to cope

                  d. Alternative coping skills

            4. These steps ↓

                  a. Drinking and heavy drinking episodes

                  b. Problem drinking symptoms

                  c. Endorsement of coping motives

      B. Prevention in college

            1. Same approach as in high school might help (SLIDE 36)

            2. Even more important as college age = age onset AUD in some

            3. Brief intervention (BI) by student health staff → alcohol use if problems ID’d76 (SLIDE 37)

                  a. Ask - if drink, frequency, quantity

                  b. Advise - state concern, recommend change

                  c. Assess - determine willingness change

                  d. Assist - if ready help make change

                  e. Arrange - reinforce change with follow-up

             4. Effective intervention involves discussing motives for

                  a. Drinking

                  b. Engaging in alternative activities (eg life goals)

             5. Helps to address avoiding alcohol to cope with stress and give alternative coping strategies 75

      C. Asking why people drink helps (SLIDE 38)

            1. Identify individuals at risk

                  a. Coping → ↑ risk heavy alcohol use and ↑ risk problems (directly)

                  b. Enhancement → ↑ risk heavy alcohol use (directly) → ↑ risk problems (indirectly)

            2. Can guide intervention, assist in ↓ use and harm

                  a. Provide feedback about risk of different motives

                  b. Coping - provide alternatives to ↓ negative mood

                  c. Enhancement - provide alternatives to ↑ positive mood

      D. Three cases (all 18 yo males, starting college, drinking makes going out more fun):

            1. Tom says - like feeling, like getting high, it's exciting, pleasant, less bored (SLIDE 39)

                  a. Type:           social/enhancement

                  b. Risk:            intermediate

                  c. Traits:          ↑ sensation seeking, ↓conscientiousness, ↑ impulsivity may play a role

                  d. Discuss:       risks associated enhancement motives, impact alcohol use on life goals

                  e. Suggest:       alternatives to ↑ positive affect

            2. Rich say - helps enjoy a party, celebrate, fit in with friends, to be liked, sociable (SLIDE 40)

                  a. Type      :           social/conformity

                  b. Risk:            lower

                  c. Discuss:       support use within recommended drinking limits

            3. Harry says - likes the feeling, more self-confident, helps when upset, cheers up (SLIDE 41)

                  a. Type      :           social/enhancement/coping

                  b. Risk:            higher

                  c. Traits:          ↑ negative mood, ↑ mood lability, ↑ impulsivity may play a role

                  d. Discuss:       risks associated coping motives, impact alcohol use on life goals

                  e. Suggest:       alternatives to ↓ negative affect (eg stress reduction, coping skills)

                  f. Consider:     Rx for alcohol &/or mood problems depending on

                        1’ Degree alcohol involvement

                        2’ Degree psychological distress

                        3’ Assessment co-moribid psychiatric disorders

V. Summary (SLIDE 42)

      A. Different personality traits→ different motivations → different outcomes

            1. Coping

                  a. ↑ risk heavy alcohol use and ↑ risk problems

                  b. Associated traits: ↑ negative mood, ↑ mood lability, ↑ impulsivity

                  c. Provide alternatives to ↓ negative mood

            2. Enhancement

                  a. ↑ risk heavy alcohol use → ↑ risk problems

                  b. Associated traits: ↑ sensation seeking, ↓ conscientiousness, ↑ impulsivity

                  c. Provide alternatives to ↑ positive mood

      B. Asking about motivations may:

                  a. Improve clinical care

                  b. Prevent escalating to AUD




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