Predicting cognitive performance in alcoholics and nonalcoholics: specification of affective, childhood behavior disorders, and antisocial variables.

Glenn, Errico, Parsons, King, and Nixon (1993) reported that composite indexes of childhood behavior disorders, current affective distress, and lifetime antisocial behaviors predicted different aspects of neurocognitive functioning in abstinent male and female alcoholics and in peer nonalcoholics. To make the results more pertinent to clinical assessment, we have: (a) identified the components of the composite indexes that were the best predictors, (b) added new data predicting overall impairment, and (c) conducted within-group male and female comparisons. In alcoholics, the depressive symptoms component of the affective distress composite index predicted set-shifting and overall impairment scores; the childhood attention deficit disorder behaviors component of the childhood behavior disorders composite predicted lower verbal performance. For nonalcoholics, childhood attention disorder behaviors predicted verbal, visuospatial, set-shifting, and overall impairment scores. Results for men and women were generally consistent with overall group analyses. The results have implications for cognitive assessment in alcoholic and nonalcoholic persons.

Neuropsychological deficits in sober alcoholics: influences of chronicity and recent alcohol consumption.

BACKGROUND: The relationships between severity of neuropsychological (NP) deficits and quantity and duration of alcoholic drinking remain controversial. Eckardt et al. (1998) proposed that NP deficits can be observed only if chronicity of alcohol abuse equals or exceeds 10 years. In this study we tested the hypothesis of Eckardt et al. and reexamined the relationship of NP performance and alcohol consumption. METHODS: One hundred sixty-two alcoholics and 165 controls completed a NP test battery at least 3 weeks after the alcoholics attained sobriety. Chronicity varied from 4 to 9 years for 55 alcoholics and from 10 to 33 years for the remaining 107. RESULTS: Compared to controls, both groups of alcoholics were impaired on the Shipley Vocabulary and Abstraction tests and on two versions of the Digit Symbol test, but there was no difference between the two alcoholic groups on any measure. Regression analyses that controlled for age and education showed that chronicity predicted less than 0.5% of the variance on NP measures. By contrast, a measure of recent alcohol consumption, the Quantity-Frequency Index, contributed significantly (approximately 5% of the variance) to the prediction of alcoholics' NP performance. CONCLUSIONS: These data provide weak support for a dose effect relationship between degree of NP impairment and level of alcoholic drinking in the past 6 months but no evidence for an influence of chronicity.

Effects of cues on memory in alcoholics and controls.

This study was conducted to determine whether alcoholics' memory difficulties are due, in part, to access (retrieval) or to availability (retention) deficits. Forty-four alcoholics (n = 20 females) and 44 controls (n = 22 females) learned a paired associate list consisting of 12 adjective-CCC trigram pairs. Half of the subjects in each group learned the list to a low degree of learning (DOL; 4/12 pairs); the remainder to a high DOL (8/12 pairs). Two distinct environmental contexts (providing implicit cues) were used during acquisition. Subjects then completed a cued recall (an explicit cue) test in either the same or a different room. Alcoholics were significantly inferior in the acquisition phase on trials required to reach criterion, regardless of DOL required [F(1,68) = 10.92, p = 0.002]. The main effect for implicit cuing was not significant; similarly, there were no significant interactions. In contrast, the explicit cue manipulation produced a significant group x DOL interaction on the number of trigrams correctly recalled [F = (1,77) = 6.38, p = 0.01]; alcoholics' recall did not benefit from the higher DOL in contrast to a significant improvement in recall by controls. The failure of alcoholics to demonstrate improvement with higher levels of learning is consistent with a deficit in the availability of information. The results confirm previous reports of recovering alcoholics' verbal learning and memory dysfunction, and suggest that these deficits may be attributed, in part, to a deficit in the availability of information (retention).

Anger in an inpatient treatment sample of chronic alcoholics.

Four measures of anger were investigated in sober male and female alcoholics and nonalcoholic peers. The relationships among anger variables, past drinking behavior, and substance abuse consequences in alcoholics were explored. Additionally, the interrelationships among anger, depression, and anxiety in the groups were examined, and the relationships between an overall dysphoria index and drinking behavior and substance abuse consequences were determined. 104 alcoholics (sober 21 to 45 days) and 70 community controls, aged 21 to 56, were given the Spielberger Anger Expression Inventory, the Beck Depression Inventory, and the Spielberger State Anxiety Inventory. Alcoholics scored higher than controls on Trait Anger, Anger-In, and Anger-Out, but not on State Anger. There were no main effects of sex. Anger-In was significantly negatively correlated with the Quantity-Frequency Index in alcoholic males. Anger-In was significantly positively correlated with depression in male and female alcoholics and with substance abuse consequences in the latter group. The depression measure was significantly correlated with consequences in female, but not in male alcoholics. These data have treatment implications, especially for female alcoholics.

Neurocognitive deficits in alcoholics and social drinkers: a continuum?

Our research program has investigated neurocognitive deficits in sober alcoholics for several decades. We have shown that both male and female adult alcoholics--compared with peer nonalcoholic controls--have deficits on tests of learning, memory, abstracting, problem-solving, perceptual analysis and synthesis, speed of information processing, and efficiency. The deficits are equivalent to those found in patients with known brain dysfunction of a mild to moderate nature. Attempts to identify factors other than alcoholism to account for these differences have been unsuccessful. The deficits appear to remit slowly over 4 to 5 years. Relapse of recovering alcoholics is predicted by behavioral (e.g., depressive symptoms and neurocognitive performance) and biological measures (e.g., event-related potentials) obtained at the end of treatment. Results of recent studies support the hypothesis of a continuum of neurocognitive deficits ranging from the severe deficits found in Korsakoff patients to moderate deficits found in alcoholics and moderate to mild deficits in heavy social drinkers (more than 21 drinks/week). Individual differences in the presence and magnitude of neurocognitive deficits in social drinkers and alcoholics are hypothesized to be due, in part, to individual differences in vulnerability of the brain to alcohol or its metabolites' toxic effects.

Cognitive functioning in sober social drinkers: a review of the research since 1986.

Several studies published in the late 1970s and early 1980s reported that quantity of beverage alcohol typically ingested was inversely related to cognitive performance in sober social drinkers. After reviewing the widespread attempts to confirm these findings, Parsons concluded in 1986 that (1) there was no consistent evidence for residual impaired cognitive functions as a result of alcohol ingestion in sober social drinkers and (2) the importance of the problem called for continued research with improved methodology. In this article we evaluate the literature since 1986. Out of 19 pertinent studies, 17 investigated the relationships between cognitive tests and sober social drinking, one investigated event-related potentials (ERPs) and one investigated both cognitive performance and ERPs. Seven studies found that heavy social drinkers had significantly worse performance on one or more cognitive tests than the light drinkers. Ten studies reported negative results. Samples in negative studies had significantly lower averages of weekly drinks (mean = 16.4) than the samples in the positive studies (mean = 41.9). Both ERP studies found differences between heavy and light social drinkers. Our conclusions support an alcohol-causal-threshold hypothesis and suggest the following testable hypotheses: persons drinking five or six U.S. standard drinks per day over extended time periods manifest some cognitive inefficiencies; at seven to nine drinks per day, mild cognitive deficits are present; and at 10 or more drinks per day, moderate cognitive deficits equivalent to those found in diagnosed alcoholics are present.

Assessment of prose recall performance in chronic alcoholics: recall of essential versus detail propositions.

Evidence for impaired psychological functions mediated by the left hemisphere in sober alcoholics is inconsistent. We predicted that sober alcoholics have deficits in immediate and delayed memory similar to deficits found in left hemisphere damaged patients. Four prose stories were administered to 24 alcoholics and 24 nonalcoholic peers and were scored according to Webster et al's criteria for essential and detail propositions. These investigators found that right hemisphere stroke patients performed significantly worse than controls on recall of detail propositions, but left hemisphere damaged stroke patients performed worse on recall of both detail and essential propositions. Similar to their left hemisphere group, our alcoholics were impaired on both proposition types supporting the hypothesis of a residual mild generalized brain dysfunction state in sober alcoholics.

Organization of psychological functions in alcoholics and nonalcoholics: a test of the compensatory hypothesis.

OBJECTIVE: We investigated the compensatory hypothesis that cognitive deficits in sober alcoholics would reveal differences in the organization of their cognitive structures or functions relative to nonalcoholic peers with no deficits. METHOD: Following the method of Tracy and Bates, who tested a similar hypothesis in light versus heavy social drinkers, we used structural equation modeling (SEM: LISREL) to test the compensatory hypothesis. Alcoholics (n = 131, 83 male) and peer nonalcoholics (n = 83, 47 male) were given tests of verbal, visual-spatial and abstracting/problem-solving skills. RESULTS: LISREL analyses indicated that the three factors (latent variables) representing the three skills and the loading of the tasks on these factors were invariant (i.e., similar) across groups. However, factor variances and covariances were noninvariant. Analyses identifying the sources of these differences revealed similarities between the heavy social drinkers of Tracy and Bates' study and our alcoholic sample. CONCLUSIONS: Results from the present study on cognitive organization in alcoholics, as well as our interpretation of Tracy and Bates' findings on the same in heavy social drinkers, support the notion of compensation and reorganization of cognitive function; however, other explanations cannot be ruled out.

Altered cortisol response in sober alcoholics: an examination of contributing factors.

We have previously reported an attenuated plasma cortisol stress response in alcoholics abstinent from alcohol up to 4 weeks. The present study replicates and extends these findings by examining urinary cortisol levels in detoxified alcoholics (n = 40) and controls (n = 14) at rest and following mental arithmetic and isometric handgrip stress. Although the groups had similar baseline cortisol levels, the alcoholics showed an attenuated cortisol response to the combined stressors. This cortisol response reduction was unrelated to potential confounds such as smoking, liver function, age, depression, or anxiety. A multivariate model showed a trend for an association between severity of withdrawal and alcoholics' poststress cortisol levels. Although these results indicate decreased adrenocortical response to biobehavioral stress in alcoholics abstinent up to four weeks, higher stress cortisol values were seen in the patients with the most severe withdrawal symptoms.

Hemodynamic alterations in alcohol-related transitory hypertension.

Alcoholic patients are often transiently hypertensive (tHT) during days 1-3 of withdrawal but become normotensive thereafter. However, at 3-4 weeks postwithdrawal these tHT patients may still show exaggerated blood pressure rises to isometric handgrip exercise. We examined the hemodynamic mechanisms associated with persistent altered pressure response. Forty-two alcoholic inpatients were equally divided into three subgroups based on admission BPs: transitory hypertensive (tHT;BP > or = 160/95 mmHg), transitory borderline hypertensive (tBH; 140/ 90 < or = BP < 160/95), and normotensive (NT; BP < 140/90). After 3-4 weeks of sobriety, the alcoholics and a normotensive nonalcoholic group (CONTs; n = 14) were tested during rest and an isometric handgrip task. Impedance cardiographic evaluation at both times showed elevated peripheral resistance, elevated heart rate, and reduced stroke volume in tHTs. Liquor consumption was found to be highly predictive of the altered hemodynamic and BP activity. Alcoholic patients with acute withdrawal hypertension (1-3 days) may show a persistent alteration of BP regulation even when resting pressures are normal.

ERP responses to target and nontarget visual stimuli in alcoholics from VA and community treatment programs.

This study had three aims: 1) to cross-validate previously reported findings that sober alcoholics compared to nonalcoholic peers have reduced ERP P300 amplitudes to visual target stimuli at the Pz electrode; 2) to test the hypothesis that alcoholics from VA Hospital treatment programs will manifest more ERP indications of brain dysfunction than peer alcoholics from community treatment programs (paralleling our neuropsychological findings in these samples); and 3) to explore differences among the groups in ERP responses to the little-studied nontarget stimuli. Nineteen VA alcoholics, 32 community alcoholics, and 24 peer community controls were given a visual "oddball" stimulus task. The total group of alcoholics had significantly lower P300 amplitudes than controls for target stimuli at the Pz electrode but VA and community alcoholic subgroups did not differ. There were no latency differences between or among the groups. On the nontarget stimuli, alcoholics had significantly higher P100 and lower N100 amplitudes than the controls at all three scored electrodes (Fz, Cz, and Pz). We conclude that cross-validation of reduced P300 amplitudes at Pz in sober alcoholics was obtained but that differences in severity of brain dysfunction, at least as measured by neuropsychological test performance, cannot account for alcoholics' ERP changes relative to controls. Finally, our data suggest that ERP changes to nontarget visual stimuli should be investigated in addition to the more traditional ERP measures to target stimuli.

Behavioral dysfunction and cognitive efficiency in male and female alcoholics.

This study was conducted to examine the role of childhood behavioral disorders (CBDs) and residual attention deficit disorder (ADDRT) in alcohol-related cognitive dysfunction in male and female subjects. Alcoholic (n = 44 females, 56 males) and control (n = 40 females, 40 males) subjects completed assessments that included measures of CBDs, ADDRT, and cognitive and psychosocial functioning. Cognitive tests were specifically designed to assess efficiency in function. As expected, alcoholics were inferior to controls in their cognitive efficiency [F(1,171) = 10.43, p = 0.0015]. Alcoholics reported more CBDs [F(1,161) = 12.02, p = 0.0007], regardless of sex. They also reported more ADDRT [F(1,173) = 44.12, p = 0.0001] than did controls. There were also sex [F(1,173) = 13.31, p = 0.0004] and group by sex effects [F(1,173) = 3.93, p = 0.05]. Female alcoholics reported more ADDRT symptoms than any other group. Regression equations conducted to clarify the relation between group, sex, CBDs, ADDRT, and cognitive efficiency indicated that the best predictor of cognitive efficiency was group classification (alcoholic versus control). That is, although symptoms of behavioral disorders were reported significantly more frequently by both male and female alcoholic subjects, these symptoms could not account for the cognitive impairment observed in either sex.

Patterns of cognitive impairment among alcoholics: are there subtypes?

The mild generalized dysfunction hypothesis of alcohol abuse's deleterious effects on cognitive processes has gained support from a number of studies in which detoxified alcoholics have a lower mean performance level than peer controls on a variety of neuropsychological tests. This approach might obscure consistent but different patterns of preserved and impaired cognitive performance among subgroups of alcoholics, suggestive of alternative hypotheses. To test this possibility, neuropsychological test data from two large, independent samples of alcoholics (sample 1, n = 143; sample 2, n = 130) and controls (sample 1, n = 97; sample 2, n = 83) were subjected to separate centroid hierarchical cluster analyses. For both samples, the majority of alcoholics (94% and 94%) exhibited a pattern of impaired verbal and nonverbal performance and deficits in memory and perceptual motor skill, with normal motor skill. The alcoholics who did not fit this pattern showed more severe or wide-ranging impairments. These findings indicate that empirical support for the mild generalized dysfunction hypothesis of alcoholics' cognitive deficits is not an artifact of averaging.

Eysenck's personality dimensions and sex steroids in male abstinent alcoholics and nonalcoholics: an exploratory study.

This study investigated the relationship between alcoholics' personality characteristics [as indexed by the Eysenck Personality Questionnaire (EPQ)] and sex steroid levels. Three serum samples were drawn over a 90-min period in 58 inpatient male alcoholics (mean 33 days sober) and 33 non-alcoholic controls. The EPQ was administered at approximately the same point in the treatment process. Replicating previous work, we found alcoholics scored significantly higher on the Neuroticism and Psychoticism scales of the EPQ than controls. Alcoholics also had higher levels of estradiol and total testosterone than controls, which may be reflective of a biological rebound or characteristic premorbid levels. A significant positive correlation was found between testosterone and extroversion in controls, but not in alcoholics. Alcoholics showed a positive correlation between estradiol and neuroticism and a negative relationship between estradiol and extroversion. The results suggest that (a) 'normal' hormone-personality relationships are disrupted in male alcoholics, and b) personality and psychological changes consistent with the physical feminization syndrome may occur in male alcoholics.

A methodological study of the Shipley Institute of Living Scale in alcoholics and non-alcoholics: reliability, discriminating items and alternate forms.

In Study 1, 430 sober male alcoholics and 98 nonalcoholics completed the Shipley Institute of Living-Vocabulary (SILS-V) and Abstraction (SILS-A) under the standard instructions. Alcoholics performed significantly more poorly than the nonalcoholics on SILS-A. High test-retest reliability of the SILS with a 2-week interval between testings was obtained. Item analysis of the 20-item SILS-A revealed that only items 4-14 discriminated alcoholics and controls, six items required reversal of a cognitive set (reversal) and five did not (nonreversal items). Exploratory factor analyses confirmed essentially the same division of items. In Study 2, two 10-item forms of SILS-A equated for difficulty level and reversal-nonreversal cognitive demands were administered to 186 male and female college students. Results indicate the two forms are equivalent in difficulty, demonstrate no gender differences and correlate significantly with cumulative college grade point averages.

Simple reaction time event-related potentials: effects of alcohol and diazepam.

Acute effects of alcohol and diazepam on reaction time (RT) and event-related potential (ERP) measures were examined in 108 healthy male volunteers. The subjects engaged in a simple RT task at two levels of stimulus intensity during baseline and treatment sessions. Lower stimulus intensity produced increased RT's, increased ERP peak latencies, and suppression of peak amplitudes. Moderate and high doses of alcohol, and high doses of diazepam produced increased RT's. Alcohol suppressed P100 and N100 amplitudes, while diazepam suppressed P100 amplitudes only. P100 amplitudes were correlated to RT's under baseline and treatment conditions. These results were taken as evidence for impaired stimulus detection during alcohol and diazepam intoxication, with both drugs influencing sensory-perceptual processes and alcohol alone influencing the degree of attentiveness.

Performance by normal subjects on the Shipley Institute of Living Scale.

The usefulness of the Shipley Institute for Living Scale is limited by the lack of norms on middle-aged and older adults. This study reports data from 254 normal subjects aged 20 to 29 to 50 and older.

Assessment of recovery of electrophysiological and neuropsychological functions in chronic alcoholics.

Potential recovery of electrophysiological and neuropsychological functions was investigated in alcoholics completing treatment and controls. Event-related potentials (ERPs) and neuropsychological tests were administered initially and repeated 14 months later. Alcoholics were classified as resumers or abstainers based on consumption patterns before retest. Resumers (n = 28), abstainers (n = 44), and controls (n = 44) differed significantly on ERP measures. No test-retest or group x test-retest interactions were found, indicating little recovery or change in ERPs over time. Differences between groups could not be attributed to family history factors. For neuropsychological efficiency (Accuracy/Time) measures, significant group differences were found. All groups improved from test to retest, with resumers showing the greatest improvement. Analysis of the separate efficiency components indicated resumers' improvement was due to a decrease in performance time, whereas accuracy scores remained significantly impaired. Whether the continued deficits in ERPs and neuropsychological performance at retest is a permanent effect of alcohol abuse, or would remit over longer periods of time, or reflects premorbid deficits, remains to be investigated.

Drinking history is related to persistent blood pressure dysregulation in postwithdrawal alcoholics.

We have previously demonstrated that alcoholics with transitory (< 72 hr) elevations in blood pressure (BP) during withdrawal continue to show residual cardiovascular dysregulation up to 4 weeks of abstinence. The present study replicates and extends these findings. Alcoholic inpatients were divided into three subgroups (ns = 14) based on BP during the first 72 hr of withdrawal: transitory hypertensives (tHTs; BP > 160/95 mm Hg), transitory borderline hypertensives (tBHs; 140/90 < or = BP < 160/95), and normotensives (NTs; all BPs < 140/90). All patients had normal resting pressures after 72 hr of withdrawal. At 3-4 weeks postadmission, the alcoholics and 14 nonalcoholic controls (CONTs) were tested at rest and during a 5-min handgrip task. The tHTs showed an exaggerated systolic and diastolic BP response to handgrip compared with NTs and CONTs, with tBHs intermediate (ps < 0.05). Drinking history showed the tHTs had the highest reported level of alcohol consumption and severity of withdrawal symptoms (ps < 0.05). Regression analyses indicated that consumption of hard liquor was the variable most predictive of admission BPs; further, parental history of hypertension potentiated this relationship for systolic BP. Age and consumption of nicotine and caffeine were not significant predictors of admission BP. The results suggest a persistent cardiovascular dysregulation in alcoholics showing transient hypertensive withdrawal BPs. These alcoholics may be at increased risk for future alcohol-related cardiovascular disorder.