Decision Making, Risky Behavior, and Alcoholism Making Risky Behav… · Camchong, Endres, Fein 2 Decision making, risky behavior and alcoholism A hallmark symptom of alcoholism is

Camchong, Endres, Fein 1

Decision Making, Risky Behavior, and Alcoholism

Chapter 13 - Section 5

To appear in: HANDBOOK OF CLINICAL NEUROLOGY, 3rd Series

Authors: Jazmin Camchong, PhD Michael J. Endres, PhD George Fein, PhD 3rd Series Co-Editors: Edith V. Sullivan, Ph.D. Adolf Pfefferbaum, M.D.

Series Editors: Michael Aminoff, M.D, D.Sc., FRCP Francois Boller, M.D., Ph.D. Dick Swaab Publisher: Elsevier (in press 2013)


Decision making, risky behavior and alcoholism

A hallmark symptom of alcoholism is the continual engagement in dangerous or risky

drinking behavior despite recurring social or personal difficulties such as alienation from friends

and family, trouble with the law and at work, or problems with physical and emotional well-

being. It has been suggested that the alcoholic’s propensity for such risky behavior is

manifested by impulsive decision-making processes, wherein potential short-term appetitive

outcomes of drinking (e.g. intoxication) are deemed more important than potential long-term

aversive consequences of drinking (e.g., drunk driving arrests). Dual process models of

alcoholism hold that separate but interrelated neurocognitive pathways to impulsive decision

making exist. One reflected by weak “top-down” executive control over impulsive and

compulsive urges to consume alcohol. The other reflected by a strong “bottom-up” appetitive

drive in impulsive and compulsive urges to consume alcohol. The current chapter surveys

evidence that functional and organizational patterns in brain executive control and appetitive

drive networks characterize impulsive decision making and risky behavior in alcoholics, and

that these patterns differ at different stages of alcoholism dependence and recovery.

POOR EXECUTIVE CONTROL leads to poor decision making

Impairments in executive cognitive ability have been consistently noted in alcoholics at

various stages of alcohol dependence and recovery. Actively drinking alcoholics typically

perform more poorly than non-substance abusing controls in a variety of neurocognitive

domains related to attention, memory, and contingency learning (Finn and Hall, 2004, Finn et

al., 2009, Bechara and Martin, 2004, Bogg and Finn, 2010). Finn et al. (2009) showed that

severity of alcoholism and other related externalizing problems predicted poor short-term and

working memory capacity, with the greatest impairments exhibited by those with other co-

occurring externalizing behavior problems. Alcoholics’ poor cognitive capacity also has been

linked with a broad constellation of personality traits related to impulsiveness, poor-harm

avoidance, and antisocial behavior tendencies (Bogg and Finn, 2010). In the same vein,

laboratory evidence has suggested that poor executive cognitive capacity is partially

responsible for impulsive decision making in alcoholics and related externalizing syndromes


(Finn, 2002, Endres et al., 2011, Bogg et al., 2012). Recent evidence also shows that, when

combined with highly impulsive trait dispositions, poor executive cognitive capacity predicts

more heavy and dangerous drinking behavior in active alcoholics (Gunn and Finn, 2013). In

summary, the evidence suggests that impaired or weak executive cognitive control processes

are at least partially responsible for the impulsive decision-making tendencies and risky

behaviors of actively drinking alcoholics.

Alcoholics who stop drinking, and remain sober, experience recovery in some, but not

all, domains of neuropsychological functioning. Studies have shown that while

neuropsychological impairments in executive cognitive ability are present in recently detoxified

and short-term abstinent alcoholics, such impairments may resolve with extended abstinence;

nonetheless, the major recovery is observed in the first year of abstinence (Fein et al., 2006,

Mann et al., 1999, Sullivan et al., 2000, Nixon and Glenn, 1995, Stavro et al., 2012). A recent

meta-analysis by Stavro et al. (2012) found widespread deficits in executive cognitive ability

characterized recently detoxified and short-term abstinent alcoholics; but, such impairments

were dramatically attenuated in long-term abstinent alcoholics. However, Stavro et al. (2012)

also noted a dearth of research on the persistence of inhibitory control/impulsive decision-

making deficits in those with multi-year abstinence. A longitudinal study by Sullivan et al. (2000)

found similar evidence of recovery, demonstrating alcoholics with sustained abstinence

improved in short-term memory, visuospatial processing, attention, and gait and balance

abilities. Likewise, Fein et al. (2006) showed that long-term abstinent (LTA) alcoholics with an

average of 6.7 years abstinence did not differ from non-substance abusing controls in

numerous executive cognitive domains, including cognitive abstraction/flexibility, attention,

short-term/working memory, psychomotor function/reaction time, and verbal skills. For

example, Fein et al. (2006) showed spatial processing deficits were present in LTAs. Thus,

evidence suggests that executive cognitive impairments in attention, memory, and motor

control to a large extent normalize with extended abstinence. However, as reviewed below,

evidence also suggests that cognitive impairments related to the processing of appetitive

and/or emotional information remain present in multi-year abstinent alcoholics.


STRONG APPETITIVE DRIVE leads to poor decision making

Psychometric evidence has suggested that impulsive decision-making in alcoholism and related

externalizing syndromes comprises three independent domains: myopia to the future,

unwillingness to delay gratification, and difficulties with passive avoidance (Dom et al., 2007).

Myopic decision-making reflects insensitivity to the long-term aversive consequences of

appetitive goal-directed behavior and has been assessed with simulated gambling tasks such as

the Iowa Gambling Task ) (Bechara et al., 1994). Preference for immediate gratification reflects

a tendency to choose smaller immediate appetitive outcomes over larger delayed appetitive

outcomes and has been assessed with intertemporal choice paradigms such as the delay

discounting task (DDT)(Rachlin et al., 1991). Poor passive avoidance refers to difficulty stopping

or withholding proponent or appetitive behavior so as to avoid sub-optimal or aversive

outcomes and has been assessed with measures of inhibitory control, such as the stop-signal

(SST)(Logan et al., 1997), go/no-go (GNG) (Newman et al., 1985), or balloon analog risk task

(BART) (Lejuez et al., 2002).

Acute alcohol use has disinhibiting effects on behavior control, impairing rational

decision making and fueling such risky behavior as gambling, getting a tattoo, or having

unprotected sex (Lin et al., 2005, Purdie et al., 2011, Tzambazis and Stough, 2000). Separate

studies have shown active alcoholics typically make more impulsive or disinhibited decisions

than non-substance abusing controls, with those presenting other co-occurring externalizing

symptoms exhibiting the poorest performances on the Iowa Gambling Task, DDT, and GNG

(Cantrell et al., 2008, Finn et al., 2002, Mazas et al., 2000, Endres et al., 2011, Bobova et al.,

2009). Evidence also suggests that impaired processing of aversive feedback leads to impulsive

decision-making in alcoholism and related externalizing syndromes, and this information

processing impairment is associated with factors that predate the onset of clinical problems,

such as a family history of alcoholism (Finn et al., 1994, Fein and Chang, 2008).

Impulsive decision-making tendencies also have been observed in abstinent alcoholics,

and unlike impairments in executive cognitive ability, evidence has suggested that impulsive

decision-making tendencies persist for weeks, months, and even years of abstinence. Research


has shown abstinent alcoholics to be less willing to delay gratification in the DDT relative to

non-substance abusing controls, and this effect was still present after controlling for impulsive

personality traits (Mitchell et al., 2005). Evidence also has suggested recently detoxified

alcoholics make more myopic decisions in the Iowa Gambling Task than controls with little to

no improvement in this capacity at 1 month follow (Dom et al., 2007). Similar myopic decision-

making tendencies have also been found in short-term and long-term abstinent alcoholics (Fein

et al., 2010b), with short-term and long-term abstainers showing comparable impulsive

decision-making during the Iowa Gambling Task relative to non-substance abusing controls

(Ando et al., 2012). Long-term abstinent alcoholics also are known to have persistent difficulties

with emotion perception and affective decision-making (Fein et al., 2010b, Foisy et al., 2007,

Philippot et al., 1999, Kornreich et al., 2001, Endres and Fein, 2012). Endres and Fein (2012)

recently showed that LTA’s persistent difficulties with passive avoidance in an affective GNG

task were largely due to a history of externalizing problems and independent of more general

difficulties in lexical decision-making. However, research has suggested a disassociation

between antisocial symptoms and traits in LTA, suggesting that antisocial behaviors return to

normal levels in the face of elevated antisocial and reward-seeking trait dispositions (Fein and

Fein, 2012). In light of the fact that alcoholics can remain sober in spite of elevated levels of

impulsive traits and decision-making tendencies, researchers have suggested that other

compensatory mechanisms come into play, such as heighted executive control and

conscientiousness aid in abstinence maintenance (Ando et al., 2012, Camchong et al., 2013a).

When together, research has shown impulsive decision-making tendencies are present in

alcoholics throughout the recovery process, but such impulsive personality and decision-making

tendencies do not appear to militate against the ability to maintain abstinence.

It is still not completely clear whether poor decision making and risky behavior

contribute to the vulnerability of becoming an alcoholic or whether they are a consequence of

chronic alcohol use. There is evidence supporting the idea that poor decision making exists

before alcohol dependence. A longitudinal study on young adults in college found that poor

decision making (as assessed with the Iowa Gambling Task) at second year of college is

associated with heavy drinking two years later (Goudriaan et al., 2009). Poor decision making


(assessed with the Iowa Gambling and Stroop tasks) has also been identified in individuals at

risk for alcoholism (with family history of alcoholism) when compared to healthy controls

(Lovallo et al., 2006). Heavy drinking adolescents have shown poor decision making and higher

impulsivity than light drinking adolescents (Field et al., 2007).

There is also evidence suggesting that chronic alcohol consumption during adolescence,

a period in which decision making brain regions are still developing, has a long-term effect on

adult decision making. A longitudinal study using a rodent model of chronic alcohol use found

that rats that were exposed to chronic alcohol use during adolescence had poor decision

making (did not properly weigh benefits and costs) and preferred more risky options (chose

large but uncertain rewards over small but certain rewards) when performing a probability-

discounting instrumental response task in adulthood versus rats that were exposed to a

placebo (Nasrallah et al., 2009). Further research needs to be conducted to better determine

whether poor decision making is present before or is a consequence of alcoholism.

Other aspects of behavior related to poor decision making in alcoholics

Even though poor decision making has been identified in alcoholics and individuals at

risk of becoming alcoholics, this behavioral deficit is not specific to alcoholism. Poor decision

making in alcoholism has been associated with other aspects of behavior such as antisocial

tendencies, stress, number of detoxifications, and onset of alcohol dependence.

An individual with antisocial personality disorder does not adhere to accepted societal

norms and often engages in criminal and other impulsive behavior (APA, 1994). Antisocial

Personality Disorder is more prevalent in alcoholics than in healthy controls (Compton et al.,

2005, Goldstein et al., 2007). Previous research has proposed that poor decision making in

alcohol dependent individuals is increased in those with a comorbid Antisocial Personality

Disorder. A study by Miranda et al (2009) compared risky decision making (Iowa Gambling Task

performance) between men with alcohol dependence (abstinent >30 days) with and without

ASPD comorbidity compared with non-substance abusing control men. Both alcoholic groups

made significantly more risky decisions (manifested as poorer Iowa Gambling Task

performance) than the control group. However, while alcoholics without ASPD comorbidity


showed a slow and steady improvement in advantageous decision making during the task,

alcoholics with ASPD comorbidity showed an initial improvement but were unable to sustain it.

Moreover, authors reported evidence that impulsive behavioral traits (e.g., propensity for rash

impulsive behavior) mediated disadvantageous decision making in alcoholics with ASPD

comorbidity. These findings suggest that poor decision making in alcoholics is closely related to

impulsive antisocial tendencies. Because there is evidence that alcoholics’ antisocial behavior

resolves with extended periods of abstinence, while antisocial disposition does not (Fein and

Fein, 2012), findings of poor decision making in long-term abstinent alcoholics might be related

to a persistent disposition to appetitive drive tendencies.

There is evidence that decision making improves when stress is induced in actively

heavy drinkers. A study that compared decision making in heavy and light drinkers reported

that heavy drinkers made significantly more disadvantageous decisions than light drinkers (with

more attention to gains and less attention to losses). When anticipatory stress was induced (by

asking them to give a speech), decision making was improved in both heavy and light drinkers

(by increasing attention to losses) (Gullo and Stieger, 2011). Evidence from this study suggests

that stress is needed to better focus attention on negative consequences and hence better

decision making. It should be noted, however, that the effect of stress on decision making may

be different in individuals that have been diagnosed with alcohol dependence or substance

dependence (Zhang et al., 2011). In addition, the level of stress induced by requesting

participants to give a speech may not be severe, chronic, or realistic enough to negatively affect

drinkers’ decision making.

Another aspect that has been found to affect decision making in individuals with alcohol

dependence is the number of detoxifications an individual has been through. A study that

compared a group with fewer than 2 detoxifications (low-detox group) versus a group with >2

detoxifications (high-detox group) reported that the low-detox group had a significantly greater

rate of improvement in choices throughout the Iowa Gambling Task than the high-detox group

(Loeber et al., 2009). This evidence suggests that individuals with repeated withdrawal

episodes lack the ability to make proper decisions and to adapt behavior to newly learned rules.


More research needs to be conducted to find out whether poor decision making leads to

repeated relapse episodes or whether the negative effects of repeated withdrawals affect

decision making.

Higher levels of impulsive decision making have been associated with early-onset

alcoholism (Dom et al., 2006). Early-onset alcoholics have shown higher levels of impulsive

decision making during a delayed discounting task than late-onset alcoholics and controls (Dom

et al., 2006). This claim, however, needs to be further examined considering other factors

related to poor decision making in early-onset alcoholism such as fewer years of education,

potentially higher genetic load, or longer lifetime alcohol use.

Neural correlates of decision making and risky behavior in alcoholism

Behavioral aspects of alcoholism such as poor decision making and risky behavior have

been associated with corresponding brain functional differences from non-substance abusing

individuals. The executive control (principally mediated by cortical regions particularly in

frontal cortex) and appetitive drive (principally mediated by striatal regions) brain networks

have prominent roles in decision making and risky behavior in alcoholism. During its early

stages, alcohol consumption is a goal-directed behavior, initiated and executed by regions

within the executive control network (such as dorsolateral prefrontal cortex and anterior

cingulate cortex) with its rewarding effects processed by appetitive drive regions (such as

nucleus accumbens). After alcohol is repeatedly consumed, evidence for or consistent with

poor decision making, consumption becomes more automatic (with more involvement of

appetitive drive regions such as caudate and putamen) and less voluntary (with less

involvement of executive control regions) (Everitt and Robbins, 2005). Alcohol consumption

shifts to a more habitual mode, particularly as a response to avoid withdrawal symptoms. An

individual with alcohol dependence seeks alcohol compulsively, a behavior that has been

associated with increased activity of appetitive drive regions when presented with an alcohol

cue, and a lack of engagement of prefrontal regions when required to stop a prepotent,

maladaptive behavior such as alcohol consumption. The quality of interaction between and

within these functional networks (frontal executive and striatal appetitive networks) is


becoming an increasingly relevant topic in alcoholism and addiction in general. Both the

attenuation of the executive control and the enhancement of the appetitive drive networks are

closely related to behavioral aspects of alcoholism such as poor decision making and

subsequently risky behavior.

To examine functional brain activity and synchrony associated with poor decision

making in alcoholics, participants are required to perform tasks while functional magnetic

resonance imaging (fMRI) data are collected. Numerous neuroimaging studies have used

specific tasks to tap into functional brain differences associated with poor decision making and

risky behavior during alcohol use, abuse and dependence.

Brain function associated with decision making in binge-drinking

A study by Xiao et al (2012) compared brain functional activity of 14 binge-drinking

adolescents while they made decisions during the Iowa Gambling Task compared with 14

adolescents who had never consumed alcohol. Binge drinkers had both behavioral and brain

functional differences manifested as inflexible poor decision making (kept making

disadvantageous decision) together with higher activity than non-drinkers in limbic brain

regions known to play a role in the emotional aspects of decision making (amygdala and insula).

Because they also found that adolescents that had higher limbic activity while performing the

decision making task had more self-reported drinking problems, Xiao et al. (2012) proposed

that a hyperactive bottom-up affective network may be a good candidate for a biological

marker that can be used to identify individuals at risk of alcohol dependence. A previous

behavioral study used the original Iowa Gambling Task and a variant of the Iowa Gambling Task

to dissect whether poor decision- making found in binge-drinkers is attributable to insensitivity

to long-term consequences (lack of executive control, planning) or to hypersensitivity to reward

(enhanced appetitive drive) (Johnson et al., 2008). After comparing Iowa Gambling Task

performance between adolescent binge-drinkers to adolescent never-drinkers, Johnson et al

(2008) found that poor decision making in binge-drinkers is associated to hypersensitivity to

reward. Results from these studies provide evidence that at early stages of alcohol abuse there

is enhanced behavior ruled by appetitive drive together with a hyperactive bottom-up network.


Brain function associated with decision making in active drinkers with alcohol dependence

The neural correlates of decision making have been examined in active drinkers with a

diagnosis of alcohol dependence (Amlung et al., 2012). Amlung et al (2012) compared brain

activity during delayed reward discounting between active drinkers with an alcohol dependence

diagnosis (AUD+; n = 13) versus active drinkers without an alcohol dependence diagnosis (AUD-;

n = 12). AUD+ showed more impulsive decision making and higher activity in executive control

(dorsolateral prefrontal cortex) and attention (precuneus) regions than AUD- during delayed

reward decisions. Although the study has a small sample size, was limited to men, but did

compare drinkers with a control (non-drinking) group, this study provides important evidence

of greater brain activity in executive control regions when alcoholics are required to delay

gratifications, a finding that may reflect alcoholics’ increased demand of executive control

when required to make decisions on behavior ruled by appetitive drive. These neural

differences need to be explored further in larger samples that include a comparison to control

groups.

Brain function associated with decision making in short-term abstinent alcoholics

Although it is important to understand the neural network differences in active drinkers,

findings from these studies may be affected by the acute effects of alcohol and caution needs

to be taken when comparing such results with those in abstinent treated samples. Active

drinking samples may comprise a different population from treated samples - they may not

have an alcohol use disorder (AUD) or have less severe AUDs than treatment samples (Fein and

Landman, 2005, Di Sclafani et al., 2008, Fein et al., 2010a). The neural substrates of decision

making have been extensively investigated in short-term abstinent alcoholics (STAA).

Park et al (2010) compared brain activity during reward-guided decision making

between 20 STAA with at least 7 days of abstinence (mean = 16.9 days of abstinence) and 16

healthy controls. Subjects performed a task that required them to make a choice between two

abstract stimuli to be allocated a probabilistically pre-determined reward. This task measured

learning rates and outcome because subjects needed to update the reward values associated

with the stimuli to guide their future responses. While STAA did not differ from controls in


striatal activity associated with predicting errors during task performance, they did show

significantly lower fronto-striatal synchrony (i.e., ventral striatum and right dorsolateral

prefrontal cortex) when presented with feedback of wins versus losses. Park et al (2010)

suggest that while STAA do not have impaired brain activity associated with the representation

of prediction error in the ventral striatum (nucleus accumbens), they do not seem to relay this

information to brain regions that mediate higher executive control processes (dorsolateral

prefrontal cortex - DLPFC) and are not able to integrate reward-related information for proper

control of behavior following a reward (Park et al., 2010). While this study was limited to only

men and to the examination of functional synchrony of the ventral striatum, it provides

valuable evidence pointing to differences in functional synchrony between brain regions that

mediate appetitive drive and regions that guide decision making in STAA versus healthy

controls. The lack of interaction between these executive control and appetitive drive regions

may underlie alcoholics’ difficulty in guiding future reward-related choices and goal-directed

behavior. Furthermore, results from this study suggest that these neural network differences

are evident after short periods of abstinence.

A study by Li et al (2009) investigated differences in brain activity specifically related to

impulsive control and risk-taking between 24 STAA and 24 healthy controls using the stop-

signal task (SST). By dissecting the component processes of SST performance (response

inhibition, error processing, post-error slowing, risk taking) they could examine neural

differences specific to discrete aspects of impulse control and risky behavior. Authors reported

that while groups did not differ in overall SST performance, STAA compared to healthy controls

showed significantly (1) lower left DLPFC activity when inhibiting a response, (2) lower right

DLPFC activity during post-error slowing (behavioral adjustment after an error), (3) lower

amygdala, striatal, and posterior cingulate cortex activity during post-trial speeding

(representing a risk-taking decision), and (4) higher activity in visual cortex and anterior

cingulate cortex (ACC) when failing to stop a response. Results from this study showed that

even though overall performance did not differ between groups, STAA showed differences in

brain activity during individual trials that reflect specific instances of poor decision making such

as post-trial speeding and failure to stop a response.


Evidence from studies mentioned above suggest that poor decision making and risky

behavior in STAA are associated with brain functional differences in regions within the

executive control (lower activity) and appetitive drive (higher activity) networks known to be

involved in cognitive and emotional control. Whether these brain functional differences

predispose to alcohol problems or are a consequence of unhealthy alcohol use is not clear.

Brain function associated with decision making in individuals at risk for alcoholism

Neuroimaging studies on adolescents at risk for alcoholism have identified brain

functional differences associated with poor decision making in such samples. A study by

Acheson et al (2009) compared brain function between 15 adolescents with a family history of

alcoholism (FHP) and 19 with a negative family history of alcoholism (FHN) when performing

the Iowa Gambling Task. While groups did not differ in behavioral performance, the FHP group

showed more activity in left dorsal anterior cingulate cortex (ACC) and left caudate nucleus

than the FHN group. Because activity in dorsal ACC has been associated with risk prediction

and activity in caudate nucleus with risky responses, Acheson et al (2009) suggest that FHP

need to recruit additional brain regions for proper decision making involving risk-taking when

compared to FHN. A study by Cservenka et al (2012) provided a different perspective on

predisposing biological markers of alcoholism. They investigated whether there were

differences in functional activity associated with risk-taking when FHP versus FHN adolescents

performed the “Wheel of Fortune” decision making task (WOF). While there were no

behavioral differences in risk-taking, FHP showed significantly lower activity in right dorsolateral

prefrontal cortex (DLPFC) and right cerebellar tonsil than FHN in the risky versus safe decision

making contrast. Authors suggest that attenuated DLPFC response to risk-taking in FHP may be

associated with poorer cognitive control and hence poorer behavioral regulation in FHP, making

them vulnerable to failure in the decision to avoid risk-taking and ultimately contributing to out

of control alcohol consumption.

A study by Norman et al (2011) investigated the neural correlates of another aspect that

contributes to risky behavior in adolescents, the lack of response inhibition. They examined

brain function in adolescents while they performed a go/no-go task that measured response


inhibition and response selection. Based on follow-up interviews assessing alcohol use

information (after a mean of 4.2 years), the sample was classified as either heavy alcohol users

(n=21) or healthy controls (n=17). While there were no behavioral differences in impulse

control during the go/no-go task at baseline, adolescents that later became heavy alcohol users

showed significantly lower activity during no-go trials than healthy controls in prefrontal

regions (inferior frontal gyrus, dorsolateral and medial frontal gyri), striatum (putamen) and

inferior parietal lobules. The authors suggest that when required to exert control over a

prepotent response, individuals that are at risk of becoming alcoholics show less responsive

frontal regions even before the onset of drinking problems. Although these findings are

important, they still do not provide decisive evidence for a predetermined predisposition

because these may indicate that future problem drinkers have either (1) a pre-existing

disadvantage (maybe genetic) due to poor engagement of frontal regions needed to properly

exert executive control on impulsive and risky behaviors or (2) a delayed cortical maturity, in

which activation in the executive control network is still not fully specialized yet, but never

reaches its full potential because its development is later stunted by alcohol use. More studies

need to be conducted to fully address these issues.

Brain function associated with decision making in long-term abstinent alcoholics

To investigate whether brain functional differences identified in actively drinking or

recently abstinent alcoholics are permanent or can be overcome with long periods of

abstinence, it is essential to examine long-term abstinent alcoholics. The examination of

executive and appetitive drive networks during rest in long-term abstinent alcoholics (LTAA) has

yielded results consistent with an ongoing compensatory mechanism in LTAA. A study by

Camchong et al (2013a) that compared resting state synchrony of executive and appetitive

drive networks between 23 LTAA (with more than 18 months of abstinence from alcohol use)

and 23 healthy controls found that LTAA have (1) lower synchrony of appetitive drive regions

and (2) greater synchrony of executive control regions than healthy controls. Moreover, these

resting state synchrony differences were positively correlated with performance in a task that

measured cognitive flexibility in decision making (e.g., higher resting state synchrony of


executive control regions significantly correlated with better performance). Results from this

study reflect adaptive mechanisms in brain ongoing functional organization that may support

proper executive control of behavior in long-term abstinent alcoholics and successfully stop

behavior that may lead to relapse. A follow-up study by Camchong et al (2013b) that studied

this effect in STAA (6-15 weeks of abstinence) found ordered effects from STAA to LTAA within

both the executive control and appetitive drive networks: higher resting state synchrony of the

executive control network (Figure 1) and lower resting state synchrony of the reward

processing network (Figure 2) than healthy controls. These results provided further evidence

that this compensatory mechanism follows an adaptive progression from short- to long-term

abstinence. Longitudinal studies of brain functional organization need to be conducted to

explore the hypothesis suggesting that synchrony within the executive control network

progressively increases and synchrony within the appetitive drive network progressively

decreases with length of abstinence.

Differences in brain function and organization in prefrontal executive control regions are

not specific to decision making and risky behavior in alcoholics. Alcoholics have shown similar

differences as described above in neural activity in executive control regions (dorsolateral

prefrontal cortex and anterior cingulate cortex) during tasks that hone in on other aspects of

executive function such as spatial working memory (Pfefferbaum et al., 2001) or verbal working

memory (Desmond et al., 2003, Cservenka and Nagel, 2012). Moreover, brain activity and

functional organization differences associated with executive control differences have been

identified in other samples with addiction to other substances such as cocaine and nicotine

(Camchong et al., 2011, Gu et al., 2010, Janes et al., 2010).

Although neuroimaging studies have identified brain function and organization

differences in executive and appetitive drive networks in alcoholics, these differences vary

depending on whether the alcoholic is actively drinking or has been abstinent for short or

extended periods of time. A number of studies reviewed in the sections above do not show

performance differences between alcoholic and comparison groups, but instead find

differences between groups in brain activation patterns associated with comparable


performance. Such findings are often interpreted as indicating lack of efficiency in alcoholics vs.

controls of specific brain regions in performing some function. However, it is important to

remember that such a statement is a hypothesis, not a finding. If an impairment in some

function is present (less efficient processing by a brain region is an impairment), there should

be experimental challenges that will result in impaired performance on some task. A recent

paper by Chanraud et al (2013) found that while controls and recovering alcoholics had similar

performance levels during a spatial working memory task, they recruited different brain

networks. While controls recruited prefrontal-cerebellar regions known to mediate working

memory, recovering alcoholics recruited two additional fronto-cerebellar networks, presumably

to compensate and achieve normal working memory performance (Chanraud et al., 2013). It is

also important to emphasize that the phenomena discussed above are not necessarily reflected

in all aspects of behavior. For example, Fein et al. (2004) found impaired performance on the

Iowa Gambling Task in long-term abstinent alcoholics – they were able to achieve multi-year

abstinence despite the persistent decision making impairments on the Iowa Gambling Task. In

contrast, Fein et. al. (2006) found normal Iowa Gambling Task performance in actively drinking

treatment naïve alcoholics. These individuals drank harmfully (a poor decision) despite having

normal Iowa Gambling Task performance. These examples point out that propensities and

inherited vulnerabilities do not fully control behavior. The research reviewed above suggests

some of the adaptive changes that may take place in the development of alcoholism and in the

struggle to achieve long-term abstinence.


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