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

 

 

References

1.   Harwood, H.J., Fountain, D. & Fountain, G. Economic cost of alcohol and drug abuse in the United States, 1992: a report. Addiction (Abingdon, England) 94, 631-635 (1999).

2.   Mokdad, A.H., Marks, J.S., Stroup, D.F. & Gerberding, J.L. Actual causes of death in the United States, 2000. JAMA 291, 1238-1245 (2004).

3.   Hasin, D.S., Stinson, F.S., Ogburn, E. & Grant, B.F. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 64, 830-842 (2007).

4.   SAMHSA. Results from the 2007 National Survey on Drug Use and Health: National Findings. (ed. D.o.H.a.H. Services) (SAMHSA, Office of Applied Studies, http://oas.samhsa.gov/, 2007).

5.   Chen, K. & Kandel, D.B. The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of Public Health 85, 41-47 (1995).

6.   Bertholet, N., Daeppen, J.B., Wietlisbach, V., Fleming, M. & Burnand, B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine 165, 986-995 (2005).

7.   Cuijpers, P., Riper, H. & Lemmers, L. The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction (Abingdon, England) 99, 839-845 (2004).

8.   Dinh-Zarr, T., Goss, C., Heitman, E., Roberts, I. & DiGuiseppi, C. Interventions for preventing injuries in problem drinkers. Cochrane database of systematic reviews (Online), CD001857 (2004).

9.   Miller, W.R. & Wilbourne, P.L. Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction (Abingdon, England) 97, 265-277 (2002).

10. Wilk, A.I., Jensen, N.M. & Havighurst, T.C. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. Journal of General Internal Medicine 12, 274-283 (1997).

11. Beseler, C.L., Aharonovich, E., Keyes, K.M. & Hasin, D.S. Adult transition from at-risk drinking to alcohol dependence: the relationship of family history and drinking motives. Alcoholism: Clinical and Experimental Research 32, 607-616 (2008).

12. Carpenter, K., Hasin, DS. Reasons for Drinking Alcohol: Relationships with DSM-IV Alcohol Diagnoses and Alcohol Consumption in a Community Sample. Psychology of Addictive Behaviors 12, 168-184 (1998).

13. Carpenter, K.M. & Hasin, D. A prospective evaluation of the relationship between reasons for drinking and DSM-IV alcohol-use disorders. Addictive Behaviors 23, 41-46 (1998).

14. Patrick, M.E. & Schulenberg, J.E. How trajectories of reasons for alcohol use relate to trajectories of binge drinking: National panel data spanning late adolescence to early adulthood. Developmental Psychology 47, 311-317 (2011).

15. Patrick, M.E., Schulenberg, J.E., O'Malley, P.M., Johnston, L.D. & Bachman, J.G. Adolescents' reported reasons for alcohol and marijuana use as predictors of substance use and problems in adulthood. Journal of Studies on Alcohol and Drugs 72, 106-116 (2011).

16. Conrod, P.J., Castellanos, N. & Mackie, C. Personality-targeted interventions delay the growth of adolescent drinking and binge drinking. Journal of Child Psychology and Psychiatry, and Allied Disciplines 49, 181-190 (2008).

17. Conrod, P.J., Castellanos-Ryan, N. & Mackie, C. Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents. Journal of Consulting and Clinical Psychology 79, 296-306 (2011).

18. Conrod, P.J., Castellanos-Ryan, N. & Strang, J. Brief, personality-targeted coping skills interventions and survival as a non-drug user over a 2-year period during adolescence. Archives of General Psychiatry 67, 85-93 (2010).

19. Conrod, P.J., Stewart, S.H., Comeau, N. & Maclean, A.M. Efficacy of cognitive-behavioral interventions targeting personality risk factors for youth alcohol misuse. J Clin Child Adolesc Psychol 35, 550-563 (2006).

20. Conrod, P.J., et al. Efficacy of brief coping skills interventions that match different personality profiles of female substance abusers. Psychol Addict Behav 14, 231-242 (2000).

21. O'Leary-Barrett, M., Mackie, C.J., Castellanos-Ryan, N., Al-Khudhairy, N. & Conrod, P.J. Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers. Journal of the American Academy of Child and Adolescent Psychiatry 49, 954-963 e951 (2010).

22. U.S. Department of Health and Human Services, N.I.o.H., National Institue on Alcohol Abuse and Alcoholism,. Helping patients who drink too much: a clinician’s guide. NIH publication no. 07-3769 (http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf) (2007).

23. Batty, G.D., Lewars, H., Emslie, C., Gale, C.R. & Hunt, K. Internationally recognized guidelines for 'sensible' alcohol consumption: is exceeding them actually detrimental to health and social circumstances? Evidence from a population-based cohort study. Journal of Public Health (Oxford, England) 31, 360-365 (2009).

24. Bradley, K.A., Donovan, D.M. & Larson, E.B. How much is too much? Advising patients about safe levels of alcohol consumption. Archives of Internal Medicine 153, 2734-2740 (1993).

25. Dawson, D.A., Li, T.K. & Grant, B.F. A prospective study of risk drinking: at risk for what? Drug and Alcohol Dependence 95, 62-72 (2008).

26. Babor, T.F.H.-B., J.C. Brief Intervention for Hazardous and Harmful Drinking: A Manual for use in Primary Care. World Health Organisation, Document No. WHO/MSD/MSB/01.6b http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf (2001).

27. Willenbring, M.L., Massey, S.H. & Gardner, M.B. Helping patients who drink too much: an evidence-based guide for primary care clinicians. American Family Physician 80, 44-50 (2009).

28. Terry-McElrath, Y.M., O'Malley, P.M. & Johnston, L.D. Reasons for Drug Use among American Youth by Consumption Level, Gender, and Race/Ethnicity: 1976-2005. Journal of Drug Issues 39, 677-714 (2009).

29. Heiman, G.A., Ogburn, E., Gorroochurn, P., Keyes, K.M. & Hasin, D. Evidence for a two-stage model of dependence using the NESARC and its implications for genetic association studies. Drug and Alcohol Dependence 92, 258-266 (2008).

30. Nelson, C.B., Heath, A.C. & Kessler, R.C. Temporal progression of alcohol dependence symptoms in the U.S. household population: results from the National Comorbidity Survey. Journal of Consulting and Clinical Psychology 66, 474-483 (1998).

31. Nelson, C.B., Little, R.J., Heath, A.C. & Kessler, R.C. Patterns of DSM-III-R alcohol dependence symptom progression in a general population survey. Psychol Med 26, 449-460 (1996).

32. Schuckit, M.A., Anthenelli, R.M., Bucholz, K.K., Hesselbrock, V.M. & Tipp, J. The time course of development of alcohol-related problems in men and women. Journal of Studies on Alcohol 56, 218-225 (1995).

33. Wagner, F.A. & Anthony, J.C. From first drug use to drug dependence; developmental periods of risk for dependence upon marijuana, cocaine, and alcohol. Neuropsychopharmacology 26, 479-488 (2002).

34. Brown, S.A., et al. A developmental perspective on alcohol and youths 16 to 20 years of age. Pediatrics 121 Suppl 4, S290-310 (2008).

35. Stone, A.L., Becker, L.G., Huber, A.M. & Catalano, R.F. Review of risk and protective factors of substance use and problem use in emerging adulthood. Addictive Behaviors 37, 747-775 (2012).

36. Moss, H.B., Chen, C.M. & Yi, H.Y. Subtypes of alcohol dependence in a nationally representative sample. Drug and Alcohol Dependence 91, 149-158 (2007).

37. Moss, H.B., Chen, C.M. & Yi, H.Y. Prospective follow-up of empirically derived Alcohol Dependence subtypes in wave 2 of the National Epidemiologic Survey on Alcohol And Related Conditions (NESARC): recovery status, alcohol use disorders and diagnostic criteria, alcohol consumption behavior, health status, and treatment seeking. Alcoholism: Clinical and Experimental Research 34, 1073-1083 (2010).

38. Schuckit, M.A. An overview of genetic influences in alcoholism. Journal of Substance Abuse Treatment 36, S5-14 (2009).

39. Malouff, J.M., Thorsteinsson, E.B., Rooke, S.E. & Schutte, N.S. Alcohol involvement and the Five-Factor model of personality: a meta-analysis. Journal of Drug Education 37, 277-294 (2007).

40. Ruiz, M.A., Pincus, A.L. & Dickinson, K.A. NEO PI-R predictors of alcohol use and alcohol-related problems. Journal of Personality Assessment 81, 226-236 (2003).

41. Ruiz, M.A., Pincus, A.L. & Schinka, J.A. Externalizing pathology and the five-factor model: a meta-analysis of personality traits associated with antisocial personality disorder, substance use disorder, and their co-occurrence. Journal of Personality Disorders 22, 365-388 (2008).

42. Sher, K.J., Bartholow, B.D. & Wood, M.D. Personality and substance use disorders: a prospective study. Journal of Consulting and Clinical Psychology 68, 818-829 (2000).

43. Slutske, W.S., et al. Personality and the genetic risk for alcohol dependence. Journal of Abnormal Psychology 111, 124-133 (2002).

44. Slutske, W.S., et al. The heritability of alcoholism symptoms: "indicators of genetic and environmental influence in alcohol-dependent individuals" revisited. Alcoholism: Clinical and Experimental Research 23, 759-769 (1999).

45. Littlefield, A.K., et al. Does variance in drinking motives explain the genetic overlap between personality and alcohol use disorder symptoms? A twin study of young women. Alcoholism: Clinical and Experimental Research 35, 2242-2250 (2011).

46. Merline, A., Jager, J. & Schulenberg, J.E. Adolescent risk factors for adult alcohol use and abuse: stability and change of predictive value across early and middle adulthood. Addiction (Abingdon, England) 103 Suppl 1, 84-99 (2008).

47. Moos, R.H. Theory-based active ingredients of effective treatments for substance use disorders. Drug and Alcohol Dependence 88, 109-121 (2007).

48. Zucker, R.A. Anticipating problem alcohol use developmentally from childhood into middle adulthood: what have we learned? Addiction (Abingdon, England) 103 Suppl 1, 100-108 (2008).

49. Cooper, M. Motivations for Alcohol Use Among Adolescents: Development and Validation of a Four-Factor Model. Psychological Assessment 6, 117-128 (1994).

50. Cox, W.M. & Klinger, E. A motivational model of alcohol use. Journal of Abnormal Psychology 97, 168-180 (1988).

51. Doyle, S.R., Donovan, D.M. & Simpson, T.L. Validation of a nine-dimensional measure of drinking motives for use in clinical applications: the desired effects of drinking scale. Addictive Behaviors 36, 1052-1060 (2011).

52. Gmel, G., Labhart, F., Fallu, J.S. & Kuntsche, E. The association between drinking motives and alcohol-related consequences - room for biases and measurement issues? Addiction (Abingdon, England) 107, 1580-1589 (2012).

53. Kuntsche, E., Knibbe, R., Gmel, G. & Engels, R. Why do young people drink? A review of drinking motives. Clinical Psychology Review 25, 841-861 (2005).

54. Kuntsche, E., Knibbe, R., Gmel, G. & Engels, R. Who drinks and why? A review of socio-demographic, personality, and contextual issues behind the drinking motives in young people. Addictive Behaviors 31, 1844-1857 (2006).

55. Kuntsche, E., Stewart, S.H. & Cooper, M.L. How stable is the motive-alcohol use link? A cross-national validation of the Drinking Motives Questionnaire Revised among adolescents from Switzerland, Canada, and the United States. Journal of Studies on Alcohol and Drugs 69, 388-396 (2008).

56. Cutter, H.S. & O'Farrell, T.J. Relationship between reasons for drinking and customary drinking behavior. Journal of Studies on Alcohol 45, 321-325 (1984).

57. Coffman, D.L., Patrick, M.E., Palen, L.A., Rhoades, B.L. & Ventura, A.K. Why do high school seniors drink? Implications for a targeted approach to intervention. Prev Sci 8, 241-248 (2007).

58. Littlefield, A.K., Verges, A., Rosinski, J.M., Steinley, D. & Sher, K.J. Motivational typologies of drinkers: do enhancement and coping drinkers form two distinct groups? Addiction (Abingdon, England)  (2012).

59. Mackie, C.J., Conrod, P.J., Rijsdijk, F. & Eley, T.C. A systematic evaluation and validation of subtypes of adolescent alcohol use motives: genetic and environmental contributions. Alcoholism: Clinical and ExperimentalRresearch 35, 420-430 (2011).

60. Kuntsche, E., Knibbe, R., Engels, R. & Gmel, G. Drinking motives as mediators of the link between alcohol expectancies and alcohol use among adolescents. Journal of Studies on Alcohol and Drugs 68, 76-85 (2007).

61. Kuntsche, E. & Cooper, M.L. Drinking to have fun and to get drunk: motives as predictors of weekend drinking over and above usual drinking habits. Drug and Alcohol Dependence 110, 259-262 (2010).

62. Carpenter, K.M. & Hasin, D.S. Drinking to cope with negative affect and DSM-IV alcohol use disorders: a test of three alternative explanations. Journal of Studies on Alcohol 60, 694-704 (1999).

63. Littlefield, A.K., Sher, K.J. & Wood, P.K. Do changes in drinking motives mediate the relation between personality change and "maturing out" of problem drinking? Journal of Abnormal Psychology 119, 93-105 (2010).

64. Tragesser, S.L., Sher, K.J., Trull, T.J. & Park, A. Personality disorder symptoms, drinking motives, and alcohol use and consequences: cross-sectional and prospective mediation. Experimental and Clinical Psychopharmacology 15, 282-292 (2007).

65. Adams, Z.W., Kaiser, A.J., Lynam, D.R., Charnigo, R.J. & Milich, R. Drinking motives as mediators of the impulsivity-substance use relation: pathways for negative urgency, lack of premeditation, and sensation seeking. Addictive Behaviors 37, 848-855 (2012).

66. Comeau, N., Stewart, S.H. & Loba, P. The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents' motivations for alcohol, cigarette, and marijuana use. Addictive Behaviors 26, 803-825 (2001).

67. Cooper, M.L., Frone, M.R., Russell, M. & Mudar, P. Drinking to regulate positive and negative emotions: a motivational model of alcohol use. Journal of Personality and Social Psychology 69, 990-1005 (1995).

68. Kaiser, A.J., Milich, R., Lynam, D.R. & Charnigo, R.J. Negative urgency, distress tolerance, and substance abuse among college students. Addictive behaviors 37, 1075-1083 (2012).

69. Mezquita, L., Stewart, SH, Ruperez, A. Big-five personality domains predict internal drinking motives in young adults. Personality and Individual Differences 49, 240-245 (2010).

70. Read, J.P., Wood, M.D., Kahler, C.W., Maddock, J.E. & Palfai, T.P. Examining the role of drinking motives in college student alcohol use and problems. Psychol Addict Behav 17, 13-23 (2003).

71. Schuckit, M.A. & Smith, T.L. The relationship of behavioural undercontrol to alcoholism in higher-functioning adults. Drug and Alcohol Review 25, 393-402 (2006).

72. Simons, J.S., Gaher, R.M., Correia, C.J., Hansen, C.L. & Christopher, M.S. An affective-motivational model of marijuana and alcohol problems among college students. Psychol Addict Behav 19, 326-334 (2005).

73. Stewart, S., Devine H. Relations between personality and drinking motives in young adults. Personality and Individual Differences 29, 495-511 (2000).

74. Theakston, J., Stewart, SH, Dawson, MY, Knowlden-Loewn, SAB, Lehman, DR. Big-Five personality domains predict drinking motives. Personality and Individual Differences 37, 971-984 (2004).

75. Schuckit, M.A., Kalmijn, J.A., Smith, T.L., Saunders, G. & Fromme, K. Structuring a college alcohol prevention program on the low level of response to alcohol model: a pilot study. Alcoholism: Clinical and Experimental Research 36, 1244-1252 (2012).

76. Fleming, M.F., et al. Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics. Journal of Studies on Alcohol and Drugs 71, 23-31 (2010).