Executive Functioning Early in Abstinence FromAlcohol

Sandra Zinn, Roy Stein, and H. Scott Swartzwelder

Background: Executive dysfunction is among the cognitive impairments that may persist after abstinencein alcohol-dependent persons. The type(s) and extent of executive dysfunction early in abstinence have notbeen well characterized, but they may have important implications for the evolution of behavioral treatmentstrategies.

Methods: To determine which aspects of executive functioning were impaired in early abstinence, weadministered memory and executive function tests to veterans who successively presented for treatment atan outpatient substance abuse clinic. We then compared the neuropsychological performance of theserecovering alcoholics (n � 27) with that of age-matched primary care outpatients (n � 18). We alsoexamined group differences in self-evaluation of cognitive decline and evaluated associations betweendrinking history and cognitive impairment in the index group.

Results: We found that the normal and alcohol-dependent groups differed on abstract reasoning,memory discrimination, and effectiveness on timed tasks. Patients in the alcohol-dependent sample werealso more likely to perceive themselves as cognitively impaired. It is interesting to note that the duration ofalcohol use did not relate to neuropsychological test performance, but recent quantity consumed and daysof sobriety were associated with nonverbal abstract reasoning ability.

Conclusions: Executive functions are impaired early in abstinence and should, therefore, be taken intoaccount when early behavioral treatments are being developed.

Key Words: Alcoholism, Cognition Disorders, Memory Disorders, Abstinence, Alcohol-Induced Dis-orders.

THERE IS CONSIDERABLE evidence that prolonged,excessive alcohol use is associated with an increased

likelihood of cognitive impairment that can persist afterdrinking cessation (Eckardt et al., 1995; Grant, 1987; Yo-hman et al., 1985). It has been estimated that 45% ofalcohol-dependent individuals have residual deficits onneuropsychological testing after 3 weeks of abstinence, andas many as 15% retain deficits after 1 year of abstinence(Rourke and Loberg, 1996). In particular, abstract think-ing, cognitive flexibility and persistence, and inhibition ofcompeting responses seem to be frequently impaired afteryears of heavy alcohol consumption (Noel et al., 2001; Ratti

et al., 2002). These functions are among those known as theexecutive functions—cognitive operations linked to thefrontal cortex that guide complex behavior over timethrough planning, decision-making, and response control.Structural and physiological changes in relevant brain areasadd to the evidence that executive dysfunction is a charac-teristic sequela of chronic heavy drinking. For example,chronic alcohol use causes atrophy of the frontal lobes (Krilet al., 1997; Kubota et al., 2001) and hypometabolism in thefrontal cortex (Adams et al., 1993; Dao-Castellana et al.,1998; Demir et al., 2002), which is associated with specificneuropsychological deficits (Dao-Castellana et al., 1998).For a detailed review of frontal lobe and executive functionchanges associated with chronic alcoholism, see Moselhy etal. (2001).

In general, alcohol-related cognitive impairment seemsto attenuate over time after cessation of drinking (De Sotoet al., 1985; Grant et al., 1987; Munro et al., 2000; Reed etal., 1992), although factors such as age (Munro et al., 2000;Rourke and Grant, 1999), poor nutrition (Lotfi and Meyer,1989; Skinner et al., 1989), and medical comorbidity (Ad-ams and Grant, 1986; Edwin et al., 1999; Solomon andMalloy, 1992) seem to diminish the extent and prolong thetime course of recovery. There is gathering evidence thatexecutive functioning may also recover with the cessation ofdrinking, though systematic studies have been lacking. For

From Research and Development (SZ, HSS), Health Services Researchand Development (SZ), and Mental Health Services (RS), Durham VeteransAffairs Medical Center; and Department of Psychiatry and Behavioral Sci-ences (SZ, RS, HSS), Duke University Medical Center, Durham, NorthCarolina.

Received for publication October 9, 2003; accepted May 11, 2004.Supported by the US Department of Veterans Affairs, Veterans Health

Administration, Health Services (Program 824) Funds, a Rehabilitation R&DCareer Development Award (Program 124) (SZ), a VA Merit Review Grant(HSS), a VA Senior Research Career Scientist Award, and NIAAA GrantR01 (HSS).

Reprint requests: H. Scott Swartzwelder, PhD, VA Medical Center, 508Fulton St., Bldg. 16, Room 24, Durham, NC 27705; Fax: 919-286-4662;E-mail: hss@duke.edu.

Copyright © 2004 by the Research Society on Alcoholism.

DOI: 10.1097/01.ALC.0000139814.81811.62

0145-6008/04/2809-1338$03.00/0ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

Vol. 28, No. 9September 2004

1338 Alcohol Clin Exp Res, Vol 28, No 9, 2004: pp 1338–1346

example, abstracting abilities (Mann et al., 1999; Rourkeand Grant, 1999), perceptual motor speed (Mann et al.,1999), and spatial abilities (Kish et al., 1980) show somerecovery within several months of abstinence, but short-term, or working, memory has proved more resistant torecovery (Mann et al., 1999). This raises the question ofwhether some executive functions are related to the quan-tity or chronicity of intake, whereas others may be aninvariant sequela of abuse or may exist premorbidly (Gian-cola and Moss, 1998).

The time course of cognitive recovery after cessation ofdrinking is also unclear, especially during the first fewweeks. Some studies have shown partial recovery with 14 to20 days of abstinence (Carlen et al., 1984), whereas othershave concluded that cognition is relatively stable throughearly abstinence (Eckardt et al., 1979; Mann et al., 1999;Unkenstein and Bowden, 1991; Volkow et al., 1994). Thiscould be important for treatment. If residual cognitiveimpairment after detoxification typically includes executivefunctions, learning, and memory (as well as visuospatialprocessing and perceptual/motor integration; Noel et al.,2001; Parsons, 1986; Rourke and Loberg, 1996; Sullivan etal., 2000), a patient’s ability to use rehabilitative informa-tion is likely to be compromised during this period (Ihara etal., 2000; McCrady and Smith, 1986). It is clear that cogni-tive impairment affects the prognosis for treatment success(Parsons, 1983) and that moderate cognitive impairmentcompromises the learning of treatment content (Beckerand Jaffe, 1984; Godding et al., 1992; Smith and McCrady,1991).

Executive function deficits are among the alcohol-relatedcognitive impairments that are most likely to affect reha-bilitation success (Ihara et al., 2000). Impairment of exec-utive functions in alcoholics has been associated with attri-tion from rehabilitation and higher rates of relapse (Miller,1991), as well as with social difficulties such as increasedmarital disruption (Tuck and Jackson, 1991) and employ-ment failure (Moriyama et al., 2002), all of which conspiretoward poor treatment outcomes. Thus, this study wasdesigned to assess the pattern of executive function deficitsearly in abstinence. To accomplish this, we examined cog-nitive operations (memory and executive functions) in vet-erans who successively presented for treatment at an out-patient substance abuse clinic. To determine which aspectsof executive functioning were impaired in this cohort, wecompared cognitive performance in these recovering alco-holics with cognitively normal age-matched outpatientcontrols.

METHODS

Participants

All participants were male veterans receiving treatment at the DurhamVeterans Affairs Medical Center. (Due to the low frequency of womenentering substance abuse treatment at our facility, only men were en-rolled.) Alcohol-dependent participants were recruited by clinicians in theSubstance Abuse Clinic during their initial treatment sessions. Twenty-

seven veterans with alcohol dependence were recruited, and they partic-ipated in at least the initial testing session. Eligibility criteria for indexparticipants included a clinical diagnosis of alcohol dependence withDSM-IV criteria, abstinence of 6 weeks or less, and no history of frequentinhalant or opiate use, schizophrenia, or active psychosis.

Given the high rates of head injury among abusers of alcohol (Solomonand Malloy, 1992), we included participants with this history (if not severe)and recorded its presence and severity to evaluate any effect on ouroutcome analyses. Head injury was reported in 33% of the controls and in52% of the substance abuse patients. The pooled samples were grouped bythe presence or absence of mild to moderate head injury, and thencomparison of group means for neuropsychological test scores was per-formed with a t test. To ensure that there was no synergistic effect betweenalcohol consumption and the residual effects of head injury, score meansfor the substance abuse patients were examined separately. There were nosignificant differences in scores attributable to head injury in either case.

Control participants were recruited from the Primary Care Clinic at theDurham Veterans Affairs Medical Center. Primary care patients of par-ticipating physicians were contacted before their appointments, screenedby a brief interview for substance abuse and exclusionary medical condi-tions, and invited to participate if they qualified. Patients with majordepression, untreated sleep apnea, polypharmacy, severe head injury,stroke, any chronic neurological condition affecting cognition (such asAlzheimer’s or Parkinson’s disease), chronic psychosis, or schizophreniawere excluded from both the alcohol-dependent and control groups.Medical charts were examined to corroborate participants’ self-reports.Nineteen control participants were recruited. (One control participant wasexcluded from the analyses due to a borderline estimated IQ.) Participantsreceived $10 for each test session attended. The study was approved by thelocal Division of Veterans Affairs Institutional Review Board.

Demographic characteristics for the two groups, including an estimateof participants’ premorbid IQ based on the Barona index (Barona andChastain, 1986), are shown in Table 1. The groups were not significantlydifferent in age or education. The substance abuse group had a higherproportion of African Americans. The mean estimated Full Scale IQdiffered significantly between groups, as shown in Table 1. Two WAIS-IIIsubtests (Similarities and Matrix Reasoning) were administered as part ofthe neuropsychological battery, and we examined the mean observedscores on these tests to validate the estimated group IQ differences byusing a Wilcoxon summed ranks statistic. The controls had higher meanscores on these tests, but the group disparities for actual performance onthese subtests from the IQ measure were far less significant (Similarities,p � 0.04; Matrix Reasoning, p � 0.02) than those of the Barona formulaestimate. The estimate may exaggerate IQ differences in our samples dueto its dependence on race and occupational achievement.

Because various medications may affect cognition, we examined themedical records of both index and control participants to determinewhether any of these medications was being taken at or near the time oftesting. Selective serotonin reuptake inhibitor–type antidepressants werethe most frequent psychotropic medications taken. None of the substanceabuse patients was taking benzodiazepines, although one control patientwas. The number of cognition-affecting medications was tabulated foreach subject, and the frequency of such medication use for substanceabuse patients and controls was evaluated with a �2 test. There was nosignificant difference in medication use between the substance abuse andcontrol groups that would be expected to account for any neuropsycho-logical test score differences found. Eleven of the substance abusers were

Table 1. Participant Characteristics by Group

Demographic variable

Substanceabuse patients

(n � 27)Controls(n � 18)

Mean age, years (SD) 50.8 (5.6) 52.4 (8.5)Race (% Caucasian)* 22.2% 77.8%Mean years of education (SD) 12.6 (2.1) 13.4 (2.5)Estimated Full Scale IQ (SD)* 99.0 (8.1) 106.5 (7.8)

* Significantly different, p � 0.005.

EXECUTIVE FUNCTIONING EARLY IN ABSTINENCE FROM ALCOHOL 1339

taking no cognition-impairing medications, whereas 16 were taking 1 ormore of these. For the control participants, 7 were not taking any of thesemedications, and 11 were taking one or more.

Test Administration

Testing was conducted within 1 week of treatment intake for thesubstance abuse patients. All participants were first interviewed abouttheir background and daily functioning. As part of this interview, partic-ipants were asked self-evaluative questions about their cognition, such as“Do you believe your thinking is as good as it’s always been?” and “Whenyou are trying to solve a problem, are you more easily frustrated than youused to be?” A history of head injury was taken. Participants with analcohol abuse history were also interviewed to obtain a detailed drinkinghistory. The participants were then administered a fixed-order neuropsy-chological battery of seven tests. All instruments were administered by theprincipal investigator or a trained research assistant. Standardized admin-istration of the instruments was ensured through training and rote use ofprinted administration instructions.

Instruments

To pursue our examination of which aspects of executive functioningmight reflect the exigencies of early abstinence, we selected measures offluency, abstract reasoning, cognitive flexibility, and psychomotor speed.Both reasoning and fluency have been associated with impaired function-ing of the frontal cortex in alcoholic patients, as noted previously. Becauseit has been hypothesized that right-hemisphere (or nonverbal) functionsare more frequently affected than left-hemisphere functions (Clifford,1986), we assessed both verbal and nonverbal aspects of abstract reason-ing, fluency, and memory. Fluency tests require rapid production ofvariations on a theme (words beginning with the same letter or linepatterns connecting dots) while avoiding repetition. We used the Con-trolled Oral Word Association Test (Borkowski et al., 1967) to assessverbal fluency and the Ruff Figural Fluency Test (RFFT) (Ruff et al. 1987,1994) to assess nonverbal fluency.

Several measures of abstract reasoning have shown performance defi-cits in patients with alcoholism, as noted previously. Lezak (1995) notesthat concrete thinking and reduced cognitive flexibility are common withgeneralized brain damage. Two subtests from the WAIS-III (Wechsler,1997) were used to assess abstract reasoning. Similarities is a well knownmeasure of verbal concept formation that requires the respondent to drawincreasingly abstract relationships between concepts. Matrix Reasoning issimilar to Raven’s Progressive Matrices and assesses increasingly complexvisual analogies by having the respondent fill in the missing part of apattern from five choices. To assess psychomotor speed and cognitiveflexibility, we administered the Trail Making Test (Armitage, 1945). TrailsPart A is a more direct measure of psychomotor speed, whereas TrailsPart B, with its set-switching demands, also reflects cognitive flexibility.The RFFT perseveration score provided another index of cognitiveflexibility.

We also examined whether verbal and nonverbal memory were differ-entially affected by chronic alcohol abuse. Verbal memory was assessedwith the Hopkins Verbal Learning Test (HVLT) (Benedict et al., 1998;Brandt, 1991). The HVLT is a verbal list learning task that uses threesemantically related categories, three learning trials, and both a free recalland a recognition memory trial after a 30-min delay. The number of wordsrecalled on HVLT trial 4 were used to index delayed memory function.Indices of memory discrimination, typically considered to be dependent onexecutive functions, were provided by recognition accuracy and the num-ber of intrusion words on recall for the HVLT.

Nonverbal memory was assessed with the Rey Osterrieth ComplexFigure (ROCF) test (Rey and Osterrieth, 1993). The ROCF is a complexfigure construction task with an unwarned delayed recall. (We did notadminister an immediate recall trial.) Delayed spatial memory was mea-sured by the ROCF delayed recall accuracy score. An organization scorefor the ROCF (Zinn and Swartzwelder, 2002) was used to assess organi-

zational strategy, an executive function–based component of visual mem-ory (Gaffan et al., 2002; Lange et al., 2000).

Because the samples were age matched, we used raw test scores forbetween-group comparisons of neuropsychological variables. Comparisonof neuropsychological test scores for those older than 50 years with thoseaged 50 years or less (by using a t test) revealed no differences. Tominimize any potential confounding of age in examining drinking historyand addiction severity relationships, however, we used age-corrected testscores, standardized with commonly accepted normative samples for eachtest, in these analyses.

The Addiction Severity Index (ASI; McLellan et al., 1985) is a wellvalidated instrument assessing substance abuse patient functioning inmultiple life domains (Alterman et al., 1994; Hodgins and El-Guebaly,1992; Stoeffelmayr et al., 1994). For this assessment, substance-abusingpatients are administered a structured interview to determine the severityof their addiction problem by assessing its effect on seven areas of poten-tial difficulty: medical, psychiatric, legal, family, employment, alcohol, andother drug use. The ASI was administered at treatment intake by thetrained clinicians of the Substance Abuse Clinic. We examined both theaddiction severity score and the composite score, a weighted sum reflect-ing current status and functioning in the seven dimensions assessed by theASI.

Drink History

Participants recruited from the Substance Abuse Clinic were inter-viewed regarding their drinking history. We asked them at what age theybegan using alcohol, how many years they had been dependent drinkers,and their weekly average intake over the past 6 months. We also askedthese participants the date of their last drink, which we validated by usingthe medical chart reports of their clinic intake. We used self-report ofyears of dependency as the measure of chronicity. The average number ofyears of dependency for our sample was 29.9 (range, 17–50). Average ageof drinking onset was 14 years (SD, 3.7 years). Our measure of recentquantity consumed, the weekly average intake for each participant, wasconverted into standard drinks. Mean weekly intake was 12.9 (SD, 11.0)drinks. The minimum reported recent intake was 1.52, and the maximumwas 46.3. We defined abstinence duration as the number of days from thelast drink to the date of testing. Participants were sober for 21.7 days onaverage at the time of testing; however, one had been abstinent for only 1day, and one had been abstinent for 58 days. (We examined the test scoresof the individual who had been abstinent only 1 day, but these weretypically within 1 SD for the mean of the group, so the data were includedin the analyses.) The addiction severity composite score from the ASI wasalso used as a measure of drink history. This index reflects the conse-quences of substance abuse, as well as quantity and use history.

Statistical Tests

Comparisons of demographic characteristics between controls and al-cohol abusers were conducted with t tests or �2 tests, as appropriate.Between-group differences for cognitive functioning were examined witht tests for normally distributed raw test scores, whereas cognitive functionindices from which the data were not normally distributed were assessedwith the nonparametric Wilcoxon summed ranks test by using the prob-ability value for a one-sided t distribution (predicting worse scores for thealcohol abuse sample). To examine the relationship between cognitivefunctioning and both drinking history and addiction severity, Spearmancorrelations were established between age-corrected test scores and thevariables described previously. To reduce type II error, we conductedcorrelations only on test score variables that were different betweencontrols and substance abusers.

RESULTS

Significant differences in cognitive performance werefound between recovering patients and controls for several

1340 ZINN ET AL.

indices of executive functioning (Table 2). These are pre-sented by the cognitive function assessed. Given the possi-bility that IQ differences might account for the disparitybetween groups, we also performed analyses of covariance(ANCOVAs) with estimated verbal or performance IQ (asappropriate) as a covariate predicting each test score thatshowed a significant difference between controls and pa-tients with alcoholism. These ANCOVA results are re-ported as each test result is described. For direct contrast ofthe scores, graphs showing both samples’ scores standard-ized as z scores, using the manual norms for each test(Heaton norms for Trail Making), presented in Figs. 1 and 2.

Fluency

Only nonverbal fluency showed group differences; verbalfluency was similar in the two groups. Figural fluency (as-sessed by number of unique designs produced) was im-paired in the substance abuse group relative to the controlgroup. When estimated performance IQ was used as acovariate in an ANCOVA model, it was a significant pre-dictor of the figural fluency score (p � 0.003), but the effectof group status remained (p � 0.001).

Abstract Reasoning

Both verbal and nonverbal reasoning differed betweengroups. The sample of alcohol-dependent patients scoredsignificantly worse on verbal abstraction, as measured bythe Similarities subtest, than did the controls. Abstractreasoning for visual material, assessed by Matrix Reason-ing, was worse in the substance abuse patients. Our checkfor the potential confound of premorbid IQ suggested thatpremorbid IQ was a more potent predictor of reasoningperformance in both modalities than group status, althoughgroup status remained a significant predictor. For predic-tion of both verbal and nonverbal reasoning, estimated IQ(verbal for Similarities; performance for Matrix Reasoning)was significant at p � 0.001, whereas group status in eachcase had a p value of 0.02.

Memory

Although learning and verbal memory were equivalentbetween groups, patients with alcohol dependence hadmore difficulty discriminating list words from other seman-tically related words during retrieval; this resulted in moreintrusions during recall but adequate recognition of listwords. Nonverbal memory, as reflected in ROCF delayedrecall accuracy, was also poorer in the alcohol group. Esti-

Fig. 1. Performance by group on memory tests.

Fig. 2. Performance by group on executive function tests.

Table 2. Means and Standard Deviations of Neuropsychological Test Scoresby Group

Neuropsychological test score

Substanceabuse patients

(n � 27)Controls(n � 18) p Value

COWA (total words) 39.2 (9.3) 43.8 (10.5) 0.13Ruff Figural Fluency—uniques 58.3 (23.1) 81.3 (24.1) 0.002Similarities 18.6 (4.5) 21.5 (5.0) 0.05Matrix Reasoning 10.8 (5.5) 14.4 (5.5) 0.04HVLT Learning (additional words) 2.9 (1.8) 2.8 (1.1) 0.44HVLT Delayed Recall (No. words) 7.4 (2.5) 8.6 (1.9) 0.09HVLT Intrusions 2.2 (2.5) 0.9 (1.2) 0.02HVLT Recognition—true positives 10.9 (1.3) 11.4 (1.3) 0.24HVLT Recognition—false positives 1.2 (1.4) 1.1 (0.8) 0.30Rey Osterrieth—copy accuracy 27.6 (5.9) 29.9 (4.1) 0.15Rey Osterrieth—delayed recall 13.9 (5.3) 17.3 (4.8) 0.03Rey Osterrieth—organization 48.7 (24.6) 49.8 (29.0) 0.88Ruff Figural Fluency—perseverations 18.5 (22.1) 16.7 (22.6) 0.48Trails A (time in seconds) 43.6 (16.3) 33.8 (8.5) 0.01Trails B (time in seconds) 151.3 (98.9) 84.1 (40.0) 0.003

COWA, Controlled Oral Word Association Test.

EXECUTIVE FUNCTIONING EARLY IN ABSTINENCE FROM ALCOHOL 1341

mated IQ was not predictive of the memory indices, al-though for figural recall, estimated performance IQ showeda trend toward significance at p � 0.07. Group status wassignificantly related to figural recall at p � 0.03.

Psychomotor Speed and Cognitive Flexibility

Finally, patients with a history of alcohol abuse also tooklonger to complete each trial of the Trail Making Test thandid controls. Trails Part A, an assessment of psychomotorspeed, showed differences between controls and alcoholabuse patients. Part B, which indexes cognitive flexibility,demonstrated a highly significant difference betweengroups. It is interesting to note that estimated performanceIQ accounted for a significant portion of the variance inTrail Making scores. For part A, both group status andPerformance IQ (PIQ) were significant at p � 0.02; for partB, group status was significant at p � 0.007, whereas PIQcontributed to prediction at p � 0.04.

Participants’ perceptions of their cognitive status andproblem-solving ability were consistent with these findings(Table 3). Patients who were chronic alcohol abusers morefrequently reported that their thinking was worse than itused to be. These patients distinguished their general cog-nitive ability from their memory functioning, as predicted:fewer reported worse memory, and their rates of endorse-ment did not significantly differ from those of controls,although there was a trend nearing significance (p � 0.07).The participants recovering from alcohol dependence alsonoted increased frustration at higher rates than the controlparticipants.

Our prediction that recent drink quantity would be re-lated to executive function tests with a psychomotor speedcomponent was not supported. The only executive functionmeasure to correlate with drink history was nonverbal ab-stract reasoning (Matrix Reasoning; Table 4). This scorecovaried with both recent quantity and days since the lastdrink. It is interesting to note that both correlations werepositive—both higher quantities of recent drinking and alonger duration of sobriety were associated with a betterMatrix Reasoning score (Figs. 3 and 4).

Examination of the association between the days of so-briety and recent drink quantity variables revealed a signif-icant correlation (r � 0.52; p � 0.005). Thus, heavier drink-

ers were likely to have been sober longer at the time oftesting.

Substance-abusing patients’ cognitive functioning didnot, in general, show significant relationships to daily lifedifficulties rated in the ASI. Nonverbal reasoning was,however, related to employment difficulties: poorer reason-ing was associated with greater difficulty in staying em-ployed (r � �0.56; p � 0.008). More intrusions (autodis-traction) on word recall were related to family difficulties (r� 0.42; p � 0.05). The Legal, Medical, and Psychiatricsubscales of the ASI showed no significant relationships toneuropsychological performance.

DISCUSSION

Executive Function

We found several deficits in executive functioning amongtreatment-seeking, recently abstinent alcohol-abusing pa-tients relative to same-age control patients. Reasoning,nonverbal fluency, performance of timed complex tasks,and difficulty with discriminative memory were impaired inpatients with alcohol dependency. However, executivefunctions were not consistently impaired across the board,nor were nonverbal functions uniformly depressed. Forexample, nonverbal fluency was impaired, whereas verbalfluency was not. Although this alcohol-abusing sample hadgreater difficulty in general with nonverbal, right hemi-sphere–related executive tasks (consistent with our hypoth-eses and other reports; Grant, 1987), they manifested mildverbally related performance deficits as well. Furthermore,although perseveration and strategy are thought to be de-pendent on the frontal cortex, the substance abuse grouphad few perseverations on the RFFT and did not differ intheir organizational ability (on the ROCF) from the con-trols. It is not clear whether some of the variability in ourresults may be due to the inclusion of less-alcohol-dependent patients in our sample.

The neuropsychological variables showing the greatestdiscrepancy between alcohol-abusing patients and controls(RFFT unique designs and Trails Part B) are both timedtasks with a motor component, visual perception elements,and considerable working memory demands. This raises thepossibility that some deficits found after chronic alcoholabuse may be due to a superimposition of mild perfor-mance decrements in different cognitive operations. Im-pairment on these tasks did not seem to be related to recentdrinking patterns and may represent gradually acquireddeficits that do not remit early in abstinence. The contri-bution of premorbid ability, represented by estimated per-formance IQ, to these cognitive efficiency tasks was mini-mal. Nonverbal or novel tasks may be more susceptible tothe effects of chronic alcohol because of their reliance onglobal or generic processes that become less effective withchronic alcohol abuse and eventually erode to the point ofdeficit on a high-demand task.

Impairments in our sample were also observed on both

Table 3. Self-Perceptions of Everyday Performance: Frequency DifferencesBetween Groups

QuestionSubstance abuse

(% endorsing)Controls (%endorsing)

Is your thinking worse than it usedto be?

85.2* 44.4

Is your memory worse than it usedto be?

48.2 22.2

Are you more easily frustrated thanyou used to be?

73.1** 44.4

Are you typically less patient thanothers?

55.6 44.4

* p � 0.01.** p � 0.05.

1342 ZINN ET AL.

verbal and nonverbal memory tests. Learning rates, de-layed recall, and recognition were not impaired for ver-bal material. The verbal memory difficulty involved in-trusions on free recall, with improvement on recognition.This pattern suggests that retrieval, but not learning orretention, is affected and thus implicates frontal ratherthan temporal cortical involvement, as predicted. Severalstudies have suggested that patients with impaired exec-utive functioning have faulty retrieval strategies (Man-gels et al., 1996; Moscovitch and Melo, 1997) and, hence,faulty discrimination between target words and distract-ers. The source of the impairment in figure recall for oursample was less clear. It seems likely that impaired en-coding or retrieval strategies would account for some ofthe nonverbal memory deficit. Inadequate organizationon construction, typically associated with executive dys-function, can affect figure recall (Dawson and Grant,2000), but there was no clear impairment of organiza-tional quality in our sample. It may be that our measureof organization was less sensitive or reliable than thoseused in the Dawson and Grant study. Further research isneeded to determine whether figural memory deficits inchronic abusers of alcohol may involve frontal, parietal,and temporal lobe– based processes.

Self-Perception of Cognitive Deficits

The picture of reduced cognitive power drawn by ourfindings is also supported by the personal experience of thealcohol abusers in our sample. These patients perceivedtheir thinking as deteriorating over time and their frustra-tion level as increasing, in comparison to the control sam-ple. There was a trend toward perception of increasedmemory difficulties as well. These acknowledgments ofimpaired cognition suggest that patients have observedcognitive lapses on multiple occasions in their daily lives.

Although denial of consequences has been documentedin persons with alcoholism, at least while intoxicated, ourparticipants’ responses show that they are aware of somedeleterious effects. It is not clear, however, that theseperceptions of impairment are any more effective thanother health concerns in motivating a reduction in drinking.Maintenance of sobriety does not seem directly related toneuropsychological variables, despite the compelling intui-tive appeal of this idea. The treatment-adherence literaturesupports the ineffectiveness of knowledge as a sufficientprerequisite for healthy behavior in many persons withvarious medical problems; the multiple approaches to un-derstanding lack of behavior change in that literature maybe fruitful for the substance abuse population.

Fig. 3. Correlations of Matrix Reasoning with duration of sobriety. Fig. 4. Correlations of Matrix Reasoning with average daily intake quantity.

Table 4. Correlations With Drink Indices (n � 27)

Executive function measure Years drinkingRecent quantity (in

standard drink units) Days sober

Verbal memory (HVLT Intrusions raw score) �0.02 (0.92) 0.07 (0.74) 0.07 (0.73)Verbal memory (HVLT true positives on recognition z score) 0.07 (0.74) �0.19 (0.35) 0.01 (0.95)Figural memory (RO figure delayed recall accuracy) 0.21 (0.30) �0.17 (0.40) �0.10 (0.62)Figural fluency (RFFT Unique Designs z score) 0.04 (0.85) 0.06 (0.78) 0.26 (0.18)Verbal abstract reasoning (Similarities scaled score) 0.11 (0.58) �0.12 (0.58) �0.12 (0.57)Nonverbal abstract reasoning (Matrix Reasoning scaled score) 0.29 (0.16) 0.51 (0.008) 0.41 (0.04)Trails A (t score) 0.00 (0.99) 0.01 (0.94) 0.01 (0.95)Trails B (t score) 0.29 (0.15) 0.00 (0.99) 0.12 (0.54)

RO � Rey Osterrieth.Data are r value (p value).

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It is reasonable to infer that these observed cognitivelapses would have affected real-world functioning in per-sons with chronic alcohol abuse. Cognitive impairment hasbeen related to posttreatment employment success (Don-ovan et al., 1984; Moriyama et al., 2002); we found acorrelation with an indicator of past employment success(on the ASI). Consistency in this finding may reflect thegreater cognitive demnds of work environments. However,we found little other evidence that measured cognitiveimpairment related to the effect of alcohol in domains ofdaily living. Studies attempting to link neuropsychologicaltest performance with clinically relevant outcomes in thispopulation have also been largely unsuccessful (Jin et al.,1998; Macciocchi et al., 1989). Executive dysfunction, inparticular, is likely to be the result of complex processes,because significant associations with indices of drinkingchronicity are rarely found [see Adams and Grant (1986) orBeatty et al. (2000) for discussions of these factors]. Thedevelopment of models that propose more complex medi-ated relationships between consumption history and cogni-tive functioning is merited. The use of more ecologicallyvalid neuropsychological instruments to measure executivedysfunction may also facilitate this line of investigation(Moriyama et al., 2002). It may be that other psychologicalconstructs, such as depression or increased frustration,moderate the effect of cognitive impairment on real-worldfunctioning.

Because alcoholism treatment approaches rely heavily onpsychosocial components, their efficacy depends, in part,on the cognitive and psychological functioning of the pa-tient. Deficits in executive functioning would thus seem tobe a significant impediment to positive treatment out-comes. Indeed, executive function has been associated withemployment outcomes in patients who were not in treat-ment (Moriyama et al., 2002). Thus, our findings of exec-utive dysfunction early in abstinence suggest that cliniciansmight consider tailoring treatment approaches for recentlydetoxified alcoholics in ways that demand less of thesefunctions—particularly in the domains of learning, reason-ing, and cognitive flexibility—as has been suggested forcognitive dysfunction in general (McCrady and Smith,1986). Clearly, these data cannot be interpreted directly tosuggest particular alterations in treatment strategy, but theydo imply that executive dysfunction early in abstinence maybe a factor to consider. Our results suggest that alcohol-dependent individuals are aware of their impairment; it islikely that such individuals will accept a rationale for treat-ment approaches that help them compensate for theirdeficits.

Possible Influences of IQ

The relation of estimated premorbid ability to the cog-nitive impairments found is intriguing. Group differencesin reasoning ability seemed largely due to estimated IQ forboth verbal and nonverbal domains. It is unclear whether

this stronger association for these functions in our data isassociated with the use of subtests from the WAIS-III thathave a high correlation with g (the general intelligencefactor). Both of these subtests are among the four testsused in Wechsler’s brief battery to estimate IQ (WechslerAbbreviated Scale of Intelligence; The Psychological Cor-poration © 1999). Thus it would seem that these scoresrepresent intellectual potential, a purportedly stable aspectof cognition. A recent study by Donders et al. (2001) foundthat Matrix Reasoning did not seem to be sensitive totraumatic brain injury. However, our findings in toto sug-gest that the picture may be more complex.

Although, in general, drinking history was not associatedwith neuropsychological variables, nonverbal reasoning wasassociated with recent patterns of use. Our data showedthat longer abstinence was associated with higher MatrixReasoning scores. Other studies have found improvementin scores on different measures of nonverbal reasoningwithin weeks of abstinence (Cocchi and Chiavarini, 1995;Kish et al., 1980). This raises the question: how stable is IQin chronic alcohol abusers? Because reasoning seems to beconsistently affected by chronic drinking (Cocchi and Chia-varini, 1995; Kish et al., 1980), then measures of IQ duringearly treatment may not reflect true premorbid ability. Kishet al. (1980) found improvements in performance on threeWAIS subtests with abstinence. WAIS-R performancesubtests have also been affected early in detoxification(Blennerhassett et al., 1993). It is possible that althoughraw intellectual ability may remain fairly constant, demon-stration of that ability on testing may be affected by gen-eralized impairment or reduced cognitive efficiency fromchronic alcohol abuse.

CONCLUSION

Our findings provide further documentation for an im-pairment of executive functions in persons who chronicallyabuse alcohol. Both psychomotor components and gener-alized inefficiencies may contribute to the deficits found.Premorbid ability and recent alcohol intake each seem tohave a role in executive functioning early in abstinence, buttheir relations are not simple or universal. Although thesize and demographic makeup of our sample may haveaffected the findings, it is clear that multiple factors need tobe evaluated to map out the relationship between alcoholdependence and executive functioning. There may be dif-ferent paths to cognitive impairment that involve familyhistory, psychosocial environment, drink history, and indi-vidual differences in resilience. The external effect of ex-ecutive functions on the daily lives of alcohol-dependentpersons is likely to require similar complex modeling. Thesometimes-subtle effects of executive dysfunction may beapparent only in large-scale longitudinal studies, as hasbeen the case in mild traumatic brain injury (Kolitz et al.,2003). We believe that executive dysfunction early in absti-nence is a challenge to treatment, and we encourage fur-

1344 ZINN ET AL.

ther research on the factors that may moderate its devel-opment, effect, and recovery.

ACKNOWLEDGMENTS

Special thanks to Nan Birchall, Pat Murphy, Bert Loro,Heather Klein, Ashlee Carter, and Linda Leimone for their in-valuable assistance in conducting this study.

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