ࡱ> #` ibjbj .a@ @ @ @ $d < ^      $$h>P  PP>  SP  P  0b@ Ti0qqhq,(,hJ<6,,,>> ,,,PPPP| |  Alcohol and memory: General In order to evaluate the effects of alcohol, or any other drug, on memory, one must first identify a model of memory formation and storage to use as a reference. One classic, oft cited model, initially proposed by Atkinson and Shiffrin (1968), posits that memory formation and storage takes place in several stages, proceeding from sensory memory (which lasts up to a few seconds) to short-term memory (which lasts from seconds to minutes depending upon whether the information is rehearsed) to long-term storage. This model is often referred to as the modal model of memory, as it captures key elements of several other major models. Indeed, elements of this model can still be seen in virtually all models of memory formation. In the model, when one attends to sensory information, it is transferred from a sensory memory store to short-term memory. The likelihood that information will be transferred from short-term to long-term storage, or be encoded into long-term memory, was thought to depend primarily on how long the individual keeps the information active in short-term memory via rehearsal. While rehearsal clearly influences the transfer of information into long-term storage, it is important to note that other factors, such as the depth of processing (i.e., the level of true understanding and manipulation of the information), motivation, and arousal also play important roles (Craik and Lockhart 1972; Otten et al. 2001; Eichenbaum, 2002) .1  INCLUDEPICTURE "http://www.duke.edu/~amwhite/Images/alcohol_and_memory.jpg" \* MERGEFORMATINET  General model of memory showing the primary effects of alcohol The figure displays a general model of memory formation, storage, and retrieval based on the modal model of memory originally proposed by Atkinson and Shiffrin (1968). Alcohol seems to influence most stages of the process to some degree. However, its primary effect appears to be on the transfer of information from short-term to long-term storage. Intoxicated subjects are typically able to recall information immediately after its presentation and even keep it active in short-term memory for one minute or more if they are not distracted. Subjects are also normally able to recall long-term memories formed prior to becoming intoxicated. However, beginning with just one or two drinks, subjects begin to show impairments in the ability to transfer information into long-term storage. Under some circumstances, alcohol can impact this process so severely that, once sober again, subjects are unable to recall critical elements of events, or even entire events, that occurred while intoxicated. Such impairments are known as blackouts. Variability in the use of terms, particularly in operational definitions of short-term memory, makes it difficult to formulate a simple synopsis of the literature on alcohol-induced memory impairments. As Mello (1973) stated three decades ago with regard to the memory literature in general, "The inconsistent use of descriptive terms has been a recurrent source of confusion in the short-term memory literature and short-term memory has been variously defined as 5 seconds, 5 minutes, and 30 minutes" (p. 333). In spite of this inconsistency, several conclusions can be drawn from research on alcohol-induced memory impairments. One conclusion is that the impact of alcohol on the formation of new long-term "explicit" memories-that is, memories of facts (e.g., names and phone numbers) and events-is far greater than the drug's impact on the ability to recall previously established memories or to hold new information in short-term memory (Lister et al. 1991). (See figure 1 for a diagram depicting the stages of memory and where alcohol interferes with memory.) Intoxicated subjects are typically able to repeat new information immediately after its presentation and can often keep it active in short-term storage for up to a few minutes if they are not distracted (for an early review, see Ryback 1971), though this is not always the case (Nordby et al. 1999). Similarly, subjects normally are capable of retrieving information placed in long-term storage prior to acute intoxication. In contrast, alcohol impairs the ability to store information across delays longer than a few seconds if subjects are distracted between the time that they are given the new information and the time that they are tested, thus preventing rehearsal. In a classic study, Parker and colleagues (1976) reported that when intoxicated subjects were presented with "paired associates"-for example, the letter "B" paired with the month "January", they were impaired when asked to recall the items after delays of a minute or more. However, subjects could recall paired associates that they had learned before becoming intoxicated. More recently, Acheson and colleagues (1998) observed that intoxicated subjects could recall items on words lists immediately after the lists were presented but were impaired when asked to recall the items 20 minutes later. Ryback (1971) characterized the impact of alcohol on memory formation as a dose-related continuum with minor impairments at one end and large impairments at the other, and with all impairments representing the same fundamental deficit in the ability to transfer new information from short-term to long-term storage. When doses of alcohol are small to moderate (producing blood alcohol concentrations (BACs) below 0.15%), memory impairments tend to be small to moderate as well. At these levels, alcohol produces what Ryback (1971) referred to as cocktail party memory deficits, lapses in memory that people might experience after having a few drinks at a cocktail party, often manifested as problems remembering what another person said or where they were in conversation. Several studies have revealed that alcohol at such levels causes difficulty forming memories for items on word lists or learning to recognize new faces (Westrick et al. 1988; Mintzer et al. 2002). As the dose increases, the resulting memory impairments can become much more profound, sometimes culminating in blackouts-periods for which a person is unable to remember critical elements of events, or even entire events, that transpired while he or she was intoxicated. 1 It is well beyond the scope of this review to assess the impact of alcohol on memory utilizing multiple perspectives on information processing and storage. For simplicity, this review will characterize the effects of alcohol on memory using a three-stage process of memory formation akin to the modal model. However, the interpretation of the effects of alcohol on memory likely would vary somewhat depending on the memory model that one uses.  INCLUDEPICTURE "http://www.duke.edu/~amwhite/Blackouts/spacer.gif" \* MERGEFORMATINET  Blacking out vs. passing out Blacking out is commonly confused with passing out . It cannot be overemphasized that these two conditions are mutually exclusive. That is, by definition, at any given time, you cannot have one if you have the other. A blackout is a period of amnesia during which the person is actively engaged in behaviors (e.g., walking, talking) but the brain is unable to form new memories for the events, leaving the person unable to recall the events once they are no longer intoxicated. Consistent with the definitionsused by other researchers, Goodwinet al. (1969a) defined a blackoutas "amnesia for the events of any part of a drinking episode, without loss of consciousness" (p. 194). Indeed, far from losing consciousness, the literature suggests that it is possible for individuals to experience blackouts whileappearing only moderately intoxicated to the outside world. Jennison and Johnson (1994) state, "Blackouts usually happen in a drinking setting during which the person may or may not appear to be intoxicated" (p. 24). Further, Sweeney (1989) indicates that "...a person may drive a car and carry on a conversation in a nearly 'normal' fashion" (p. 161). The term passing out is less clearly defined, but is invariably used to mean either falling asleep from excessive drinking or literally drinking oneself unconscious. Even in its most general, colloquial usage, passing out indicates the occurrence of a state that is incompatible with active behavior. Given that blackouts tend to occur at relatively high BAC levels, particularly after rapid consumption of alcohol, it is certainly possible that an individual could experience a blackout prior to passing out. However, the two states cannot occur simultaneously, as a person cannot be both conscious and unconscious at the same time. Blood Alcohol Concentrations (BAC) and blackouts Drinking large quantities of alcohol often precedes blackouts, but several other factors also appear to play important roles in causing such episodes of memory loss. As Goodwin and colleagues (1969a) stated with regard to subjects in one of their studies, "Although blackouts almost always were associated with heavy drinking, this alone seemed insufficient to produce one. On many other occasions, subjects said they had drunk as much or more without memory loss" (p. 195). Among the factors that preceded blackouts were gulping drinks and drinking on an empty stomach, both of which lead to rapid rises in BAC. In other words, drinking in this wayresults in a lot of alcohol getting into the body very fast. As we will discuss in the section on brain function and blackouts, flooding the system with alcohol quickly mightcatch critical brain regions unprepared, thus essentially knocking them offline for a while. Subsequent research provided additional evidence suggesting a link between blackouts and rapidly rising BACs. Goodwin and colleagues (1970) examined the impact of acute alcohol exposure on memory formation in a laboratory setting. The author recruited 10 male subjects for the project, all but one through the unemployment office in St. Louis, Missouri. Most subjects met diagnostic criteria for alcoholism and half had a history of frequent blackouts. The men were asked to consume roughly 16 to18 ounces of 86-proof bourbon in approximately 4 hours. Beginning 1 hour after subjects began drinking, memory was tested by presenting subjects with several different stimuli, including a series of children's toys and scenes from erotic films. Subjects were asked to recall details regarding these stimuli 2 minutes, 30 minutes, and 24 hours after the stimuli were shown. Half of the subjects reported no recall for the stimuli or their presentation 30 minutes and 24 hours after the events, though most seemed to recall the stimuli 2 minutes after presentation. Lack of recall for the events 24 hours later, while sober, represents clear experimental evidence for the occurrence of blackouts. The fact that subjects could remember aspects of the events 2 minutes after they occurred but not 30 minutes or 24 hours afterward provides compelling evidence that the blackouts stemmed from an inability to transfer information from short-term to long-term storage. For all but one subject in the blackout group, memory impairments began during the first few hours of drinking, when BAC levels were still rising. The average peak BAC in this group occurred approximately 2.5 hours after the onset of drinking and was roughly 0.28%. In a similar study, Ryback (1970) examined the impact of alcohol on memory in seven hospitalized alcoholics given access to alcohol over the course of several days. All subjects were white males between the ages of 31 and 44. Blackouts occurred in five of the seven subjects, as evidenced by an inability to recall salient events that occurred while drinking the day before (e.g., one subject could not recall preparing to hit another over the head with a chair). Estimates of BAC levels during blackout periods suggested that they often began at levels around 0.20% and as low as 0.14%. The duration of blackouts ranged from 9 hours to 3 days. Based on his observations, Ryback concluded that a key predictor of blackouts was the rate at which subjects consumed their drinks. He states, "It is important to note that all the blackout periods occurred after a rapid rise in blood alcohol level" (p. 622). The two subjects who did not black out, despite becoming extremely intoxicated, experienced slow increases in blood alcohol levels.  INCLUDEPICTURE "http://www.duke.edu/~amwhite/Blackouts/spacer.gif" \* MERGEFORMATINET  Do blackouts always suggest alcoholism? Blackouts occur quite often among alcoholics. This fact led Jellinek (1946) to conclude that blackouts are one of the most powerful indicators of alcoholism. However, the simple fact that alcoholics frequently report blackouts is not sufficient evidence to draw the conclusion that blackouts are key indicators of alcoholism. Closer examination of this logic reveals a common error known as affirming the consequent. Jellinek essentially stated, "Alcoholics have blackouts. Therefore, if you have blackouts, you're an alcoholic." This would be like stating, "Dogs have eyes. Therefore, if you have eyes, you're a dog". Without question, blackouts are a warning sign that a person is drinking in a hazardous manner and might, in fact, have a serious problem with alcohol. Blackouts should not be ignored. However, the occurrence of a blackout alone does not indicate that a person is addicted to alcohol anymore than a sneeze alone indicates that a person has a cold. Here is a brief review of two studies that bare relevance to this issue. Blackouts among college students  INCLUDEPICTURE "http://www.duke.edu/~amwhite/Blackouts/cancunblackout2.gif" \* MERGEFORMATINET  For many people, the environment plays a key role in determining current drinking habits. One environment in which excessive drinking is often tolerated, if not supported, is the college campus (Keeling, 2002). As might be expected given the drinking habits of some college students. blackouts are not uncommon in this population. In 1993, 1997, 1999, and 2001, the Harvard School of Public Health surveyed roughly 15,000 students from over 100 colleges in the U.S. about their drinking habits and experiences (2002). An item in the survey asked students if, during the previous year, they had forgotten what they did or where they went as a result of drinking. In 1993, almost 25% of the students who consumed alcohol in the year before the survey indicated having had such an experience during this time period. The percentage of students reporting blackouts in the previous year increased slightly, but significantly, to roughly 27% in 1997, 1999, and 2001. The significant increase in the prevalence of blackouts paralleled, or more likely followed, a significant increase in rates of heavy episodic drinking and an increase in self-reported rates of drinking with the intent to get drunk. White et al. (2002) recently surveyed 772 undergraduates regarding their experiences with blackouts. The occurrence of a blackout was operationally defined as a positive response to the question, "Have you ever awoken after a night of drinking not able to remember things that you did or places that you went?" Approximately (51%) of those who had ever consumed alcohol reported experiencing at least one blackout at some point in their lives, and 40% experienced one in the year before the survey. Among those who drank in the two weeks before the survey, nearly 1/10 (9.4%) experienced a blackout during this time period. Students later learned that they participated in a wide range of salient events for which they had no recollection. Such activities included vandalism, unprotected intercourse, driving an automobile, spending money, and others. The slide below lists the percentages of students indicating that they participated in these and other activities at least once during a blackout. The percentages are based on the number ofstudents who have had at least one blackout (355), not the entire sample of772 subjects.  INCLUDEPICTURE "http://www.duke.edu/~amwhite/Images/what_happens.gif" \* MERGEFORMATINET  During the two weeks preceding the survey, equivalent percentages of males and females experienced blackouts, despite the fact that males drank significantly more often and more heavily than females. This outcome suggests that females, a group infrequently studied in the blackout literature, are at greater risk than males for experiencing blackouts, likely due to well-known differences in body weight, proportion of body fat, etc. There is also some evidence that females are more susceptible than males to milder forms of alcohol-induced memory impairments even when given comparable doses of alcohol (Mumenthaler et al., 1999). Ryback (1971) suggested that mild memory impairments and blackouts represent two points on a continuum separated primarily by level of intoxication, rather than being qualitatively different types of memory impairments. Thus, the greater susceptibility of females to mild memory impairments might be predictive of greater susceptibility to blackouts. While the available evidence clearly indicates that blackouts occur among college students, very little is known regarding the exact nature of these impairments among younger drinkers. As discussed above, our understanding of blackouts has been crafted largely from observations and interviews with middle-aged male alcoholics, many of whom were hospitalized. This group clearly does not represent the typical drinker in the US, raising questions regarding the generalizability of their experiences to the experiences of those in other groups. For instance, based on his interviews with male alcoholics, Goodwin concluded that blackouts can be divided into fragmentary and en bloc forms, and that memory loss of the fragmentary type can often be recovered with cueing or the simple passage of time. The duration of blackouts observed by Goodwin et al ranged from nine hours to three days in alcoholics drinking in a laboratory setting. It is largely unknown whether blackouts that occur among college students tend to fall into the en bloc or fragmentary categories, or how long the impairments tend to last. The literature is replete with wild accounts of events that transpire during blackouts among alcoholics, included traveling long distances of several days or even selling real estate (Goodwin, 1995). Little is known about the events that transpire during blackouts in college students. Further, it remains unknown how students find out about the events that transpired, how they felt about it, whether the experiences altered their drinking, etc. A recent study White and colleagues (2004 in press) sheds light on some of the gaps in information regarding blackouts among young drinkers. The researchers interviewed 50 undergraduate students, all of whom had experienced at least one blackout, to gather more information about the factors related to blackouts. As in the previous study, students reported engaging in a range of risky behaviors during blackouts, including sexual activity with both acquaintances and strangers, vandalism, getting into arguments and fights, and others. During the night of their most recent blackout, most students drank either liquor alone or in combination with beer. Only 1 student out of 50 reported that their most recent blackout occurred after drinking beer alone. On average, students estimated that they consumed roughly 11.5 drinks before the onset of the blackout. Males reported drinking significantly more than females, but they did so over a significantly longer period of time. As a result, estimated peak BACs during the night of the last blackout were similar for males (0.30%) and females (0.35%). Fragmentary blackouts occurred far more often than en bloc blackouts, with four out of five students indicating that they eventually recalled bits and pieces of the events. Roughly half of all students (52%) indicated that their first full memory after the onset of the blackout was of waking up in the morning, often in an unfamiliar location. Many students, more females (59%) than males (25%), were frightened by their last blackout and changed their drinking habits as a result. A very interesting study by Hartzler and Fromme (2003) also provides valuable and much needed information about blackouts among young drinkers. The authors interviewed 136 volunteers (mean age roughly 23 years) to gain insight into their experiences with alcohol-induced memory deficits. As in the study by White and colleagues, fragmentary blackouts were far more common than those of the en bloc variety. Blackouts tend to occur after rapid consumption of large amounts of alcohol. At these levels of intoxication, it is quite likely that a variety of other cognitive functions, beyond memory, are severely impaired. At doses far lower than those necessary to produce blackouts, alcohol impairs judgment, decision-making, impulse control and host of other functions. Colloquially, people often refer to this constellation of effects as reduced inhibitions. In other words, while drinking, people often do things that they might not normally do, and take risks that they might notnormallytake. There are certainly multiple mechanisms underlying these effects. Fromme et al. (1997) observed that intoxicated subjects underestimate the true likelihood that negative consequences will follow risky behaviors. Because fear of consequences typically serves to reducerisky behavior, this effect could essentially take the brakes off, leading an individual to believe that they will not be impacted negatively by their actions while intoxicated. During a blackout, it is entirely possible for individuals to engage in a wide array of risky behaviors and awaken the next day with no memory of these actions. As Jennison and Johnson (1994) state, "...blackout experiences, especially those of the en bloc variety, are impressive, ranging from driving cars long distances, engaging in conversation at parties in an outwardly normal state, to criminal acts such as robbery, assault, and even murder" (p. 26). Individuals whoexperience blackouts oftenwake upunaware of where they are, how they arrived there, or what they did the night before. For this reason, it is perhaps not surprising that individuals are often frightened by the occurrence of blackouts.Based upon his interviewswith alcoholics, Goodwin (1977) stated, "Realization of having had such a blackout is often accompanied by a feeling of dread or apprehension. Younger drinkers seem to react to blackouts with similar apprehension. White and colleagues (in press) reportedthat half (25/50) of the college studentsthey interviewed, more females than males, were frightened by their most recent blackout experience. As discussed above, it is not uncommon for younger drinkers to learnthat, during a blackout, they were in arguments or fights, vandalized property,had intercourse,or engaged in other activities that might be uncharacteristic of them. Understandably, such realizations can compound the feelings of fear or disbelief that often followblackouts. Below is an excerpt from a recent report on college drinking from the NIAAA. The statementprovides an unfortunate example of the complexity of alcohol-induced blackouts and the uncertainty that can follow. Alcohol interacts with several other drugs, many of which are capable of producing amnesia on their own. For instance, diazepam (Valium) and flunitrazepam (Rohypnol) are benzodiazepine sedatives that can produce severe memory impairments at high doses (White et al. 1997; Saum and Inciardia 1997). Similarly, gamma-hyrdoxybutyrate (GHB) is capable of producing amnesia when used alone (Miotto et al., 2001). Alcohol enhances the effects ofbenzodiazepines and GHB (White et al., 1997). Thus, combining these compounds with alcohol could dramatically increase the likelihood of experiencing memory impairments. Similarly, the combination of alcohol and THC, the primary psychoactive compound in marijuana, produces greater memory impairments than when either drug is given alone (Ciccocioppo et al. 2002). Given that many college students use other drugs in combination with alcohol (O'Malley and Johnston 2002), some of the blackouts reported by students may arise from polysubstance use rather than from alcohol alone. Indeed, based on interviews with 136 heavy-drinking young adults (mean age 22), Hartzler and Fromme (2003b) concluded that en bloc blackouts often arise from the combined use of alcohol and other drugs. 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