For some, it was Lewis Baxter's PET (positron emission tomography) scans that revealed the vanishing line between biology and behavior. Baxter's 1992 study of obsessive-compulsive disorder for the first time demonstrated that brain changes in glucose utilization were similar in patients who responded to behavioral treatment and patients who responded to pharmacological treatment.
Others, including the Israeli cognitive-behavioral scientist Y. Dudai, may have seen it all along. About a decade earlier, Dudai admonished, "Behavioral scientists must remember that beyond behavior, there is a brain, and molecular biologists must remember that the animal behaved prior to homogenization."
No matter when or where we first encounter the vanishing line, alcohol researchers and clinicians almost always see it as the most far-reaching change in the modern progress of our field. For researchers, it means that many bear credentials that do not necessarily reflect the work that they do: Psychologists study genetics and neuroscientists study behavior. For clinicians, it marks an end to the era of brain-free behavioral approaches and the beginning of an era in which insights from genetics and neuroscience play an increasing role in prevention, diagnosis and treatment.
An eye on research
Two major trends point the way for behavioral science in alcohol research. The recognition that genes are a risk for future addiction, not destiny, places new emphasis on the cognitive processes involved in alcohol abuse and alcoholism. The National Institute on Alcohol Abuse and Alcoholism looks to behavioral science to understand:
Affect (the mood that alcohol relieves or creates).
Memory and learning in relation to drinking decisions.
Reward, aversion and associated behaviors.
Expectancies (when some of the actions of alcohol occur because they are expected).
How variations in human drinking behavior affect the etiology and course of alcohol abuse and alcoholism.
The effects of subjective states (such as stress or fear) on drinking and alcoholism.
The effects of lifestyle change (such as beginning a career or marriage) on risk for alcohol abuse and alcoholism.
A second trend is the growing reciprocal work between biological and behavioral scientists. This trend is evident in the study of fetal alcohol syndrome (FAS), where we have excellent behavioral studies of children with FAS and scanning technology that shows alcohol-induced brain structural changes. We also are learning about connectivity among neurons and how alcohol may actually prevent the expression of certain genes. FAS is a research area where the tools of behavioral science, imaging, neuroscience and genetics are working in concert to prevent alcohol damage.
An eye on practice
The overriding goal of alcohol research is to find improved ways to prevent and treat alcohol disorders and reduce the huge societal cost of alcohol problems. In clinical and prevention research, we do this by evaluating existing methods--some of which grew up outside the scientific mainstream --and identifying new ones. We have learned much in recent years about the value of existing interventions. For example, Project MATCH demonstrated the effectiveness for treating alcohol disorders of cognitive-behavioral and motivational enhancement treatments, as well as professionally guided participation in mutual-help programs such as AA.
But even before Project MATCH reported results, naltrexone arrived on the scene as the first medication in almost 50 years approved for use in alcoholism treatment. The advent of medications that target the biochemical mechanisms of alcohol addiction means a promising but sometimes uncomfortable shift in clinical practice. NIAAA's "Research-to-Practice" initiative and other efforts are geared to help clinicians meld naltrexone use with proven behavioral treatments. Meanwhile, we await the results of COMBINE (see page 36), the new trial that in several years will define the best available behavioral and medication combinations.
An eye to the future
Optimal preventive and treatment interventions await full explication of the biological and environmental factors that produce and perpetuate alcohol disorders. In populations where risk is great and understanding is incomplete, behavioral researchers and practitioners are making perhaps the most meaningful contributions. Psychologists are defining why so many adolescents fall prey to early drinking and future addiction and why heavy drinking is rampant on college campuses. From this knowledge, psychologists will develop interventions for high-risk young people identified by their genes or their behavior. Through efforts to explain whether alcohol craving exists intrinsically, results from environmental cues, or both, psychologists also are helping to prevent relapse--the greatest impediment to alcoholism remission. These and other contributions point to the vanishing line as the front line of alcohol research and practice.