Etiology of alcoholism reconsidered. The case for a biopsychosocial process.

The etiology of alcoholism is best understood within the context of a longitudinal-developmental framework that includes physiological behavioral and sociocultural variables. The recently reported Vaillant fol- low-up study, although ostensibly set within such a frame- work, in fact understates the role of personality influences and dismisses childhood effects out of hand. We review these data and offer a different set of conclusions about the roles of childhood influences, personality, and cultural factors in the etiologic process. An alternative integrative review of the existing longitudinal literature is presented that sets these findings in the context of a biopsychosocial process. Alcoholism is a profoundly damaging disorder whose im- pact spreads far beyond the one who suffers from it. The problem of understanding its causes is also an especially interesting one. Recent evidence suggests that the char- acteristics that lead an individual to begin drinking may only be tied loosely to influences on later stage drinking and problem drinking phenomena. The factors connected with beginning a pattern of problem use are not neces- sarily the same as those pharmacological and behavioral characteristics that contribute to the maintenance of the alcohol use pattern or to the later build-up of a habitual problem involving alcohol abuse or dependency. Given this state of affairs, it is also likely that different orderings of the importance of etiologic factors will be needed to adequately describe cause and effect at different stages in the process. Thus, Korsakoff's syndrome, one end-state phenomenon of chronic alcohol abuse, is a pathology best described in neuropathological terms; the direction of ef- fect is best understood as going from brain dysfunction to behavior (Wilkinson & Carlen, 1981). In contrast, the onset of alcohol use is best understood as a phenomenon predicted by individual difference variables and social in- fluences (Jessor & Jessor, 1975; Margulies, Kessler, & Kandel, 1977). The theoretical models and data language used to describe these multiple phenomena of onset, maintenance, and dependency involve radically different levels of explanation and different orderings of physio- logical, behavioral, and socioenvironmental variables at different points in the life cycle. It is not surprising, there- fore, that such a complex multidisciplinary problem has in earlier times generated simplistic and reductionistic explanations in an effort to describe its process. In the past decade, several etiologically focused lon- gitudinal studies have been carried out with a broad enough data set and a multivariate analytic strategy that begins to allow for the partitioning of variance contri- butions. However, all of those that have moved far enough along to warrant publication have been concerned with the early stages of drinking and problem drinking ac- quisition (Huba & Bentler, 1984; Jessor & Jessor, 1977; Kandel & Logan, 1984), or have dealt with a group of subjects who have had largely normal or at worst episod- ically disturbed drinking patterns (Fillmore, 1975; Fill- more, Bacon, & Hyman, 1979). None have dealt with frankly alcoholic respondents, and none have been suf- ficiently comprehensive to allow for the evaluation of the extent of effect contributed by biological (including ge- netic), psychological, social, and cultural factors. It is, therefore, a significant event for the field when a data set is presented that promises to address the etiological ques- tion of how alcoholism evolves, with a prospective method and a sufficiently broad array of variables such that the potential biopsychosocial nature of the disorder can be examined. This is the importance of a recent report by Vaillant and Milofsky (1982). Since its publication, this study has received sub- stantial attention in the literature. Given the significant disagreement we have with the authors' interpretation of their own data as well as their interpretation of earlier longitudinal work in the area, we felt that an alternative interpretation of their findings and of the earlier studies was in order. In the present article, we examine very closely the details of Vaillant and Milofsky's study with particular attention to the role of personality and of childhood influences on alcoholic behavior, reach a dif- ferent set of conclusions, and find significant support for an alternative position based on our own integrative re- view of the prospective literature on alcoholic etiology that substantially differs from Vaillant and Milofsky's ac- count. Vaillant's Follow-up Study