Chapter 36
Heavy Episodic Drinking
or Binge Drinking: A Booming
Consumption Pattern
Ana Adan1,2, Irina Benaiges1, Diego A. Forero3
1Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain; 2Institute for Brain, Cognition and Behavior
(IR3C), Barcelona, Spain; 3Laboratory of NeuroPsychiatric Genetics, Biomedical Sciences Research Group, School of Medicine, Universidad Antonio
Nariño, Bogotá, Colombia
Abbreviations
AUD  Alcohol use disorder
AUDIT  Alcohol Use Disorders Identification Test
BAC  Blood alcohol concentration
BD  Binge drinking
BDNF  Brain-derived neurotrophic factor
BMI  Brief motivational intervention
CNS  Central nervous system
ERP  Event-related potentials
ESPAD  European School Survey Project on Alcohol and Other Drugs
fMRI  Functional magnetic resonance imaging
NIAAA  National Institute on Alcohol Abuse and Alcoholism
PFC  Prefrontal cortex
PM  Prospective memory
INTRODUCTION
In recent decades, a new pattern of intermittent alcohol consump-
tion has emerged involving binge intake, which happens in ses-
sions lasting just a few hours, usually during weekend evenings
and carried on by groups of peers. This pattern, known as heavy
episodic drinking or binge drinking (BD), is found especially
among adolescents and young adults in Western cultures.
BD involves the consumption of alcoholic beverages with
the primary intention of reaching a marked intoxication, with
low perception of risk and a tendency to equal intake in men and
women (Parada et al., 2011a). Intoxication is characterized by a
blood alcohol concentration (BAC) of at least 0.08 g/l. The prac-
tice of BD is increasing and expanding worldwide, and it has been
recently labeled as a new culture of intoxication.
Epidemiological research has provided very variable data on
the prevalence of BD according to the country and the sample
studied. In the United States, where it has been most researched,
BD is responsible for more than half of the deaths due to excessive
alcohol intake, and it is the most prevalent alcohol use disorder
(AUD). The data show that more than half of 12- to 17-year-olds
Neuropathology of Drug Addictions and Substance Misuse, Volume 1. http://dx.doi.org/10.1016/B978-0-12-800213-1.00036-5
Copyright © 2016 Elsevier Inc. All rights reserved.
consume alcohol with a BD pattern. Approximately 90% of the
ethanol consumed under age 21 is as BD, and 70% of BD episodes
involve adults aged 26 and older (Thiele, 2012).
A study conducted among 15- to 16-year-old adolescents in
35 European countries, the European School Survey Project on
Alcohol and Other Drugs (ESPAD), showed that BD is found not
only in Scandinavian countries, England, and Ireland—which are
typically characterized as having BD problems (Pedersen & von
Soest, 2013)—but in Mediterranean countries as well. The BD
phenomenon has extended and appears to be on the rise in Medi-
terranean countries (Portugal, France, Italy, Spain), which had
been traditionally characterized by a pattern of higher per capita
consumption, most of which derived from daily consumption
of wine during meals. On average, 43% of the ESPAD students
reported heavy episodic drinking during the previous 30 days
(Hibell et al., 2009).
In this chapter, we revise the concept of BD, which is still
ambiguous nowadays, together with the risk and/or protection fac-
tors associated with the rise and maintenance of this pattern of
alcohol intake. We highlight some consequences on health and its
impact on neuropsychological functioning, in addition to possible
early markers or endophenotypes for future use.
DEFINITION OF BINGE DRINKING
The Monitoring Future Study, carried on in the 1970s, proposed
considering the pattern of BD as the consumption of five or more
alcoholic drinks in one event, whether in men or women (Bachman,
Johnston, & O’Malley, 1981). This has been and still is the criterion
used in many studies on this topic.
The Harvard School of Public Health’s College Alcohol Study,
in the 1990s, proposed using different criteria according to sex.
The concept of BD was established as the consumption of ≥5 alco-
holic drinks for men and ≥4 drinks for women, in one single event
and at least once in the previous 2 weeks (Wechsler, Davenport,
Dowdall, Moeykens, & Castillo, 1994). This change of threshold
389
390  PART | III Alcohol
in women was justified because women generally have a smaller
stature and physiologic differences in the absorption and distribu-
tion of alcohol. In 2004, the National Institute on Alcohol Abuse
and Alcoholism (NIAAA) Advisor Council endorsed the sex con-
sideration in the definition of BD. The consumption of ≥5 drinks
for men and ≥4 drinks for women in approximately 2 h produces
a BAC of 0.08 g/l or greater, taking into account that in the USA a
standard drink has 14 g of alcohol. The new gender-specific defi-
nition increased the prevalence of women with BD pattern, due
to the change in the criteria and not to actual changes in drinking
behavior (Chavez, Nelson, Naimi, & Brewer, 2011).
There are significant differences in the amount of pure ethanol
grams in a standard drink in different countries of the world, as
published by the International Center for Alcohol Policies (2010).
As Table 1 shows, the NIAAA criteria may be valid in Portugal,
whereas in England the pattern of BD must be defined as the intake
of ≥8 drinks for men and ≥6 drinks for women. In the countries
where a standard drink contains 10 g of ethanol, the cutoff may be
set to ≥6 drinks for men and ≥5 drinks for women (Parada et al.,
2011a).
However, because teenagers may drink much larger amounts
than those considered in the general definition, it has been pro-
posed to consider several degrees of BD. Thus, the concept of
extreme BD has emerged, with two subcategories: ≥10 drinks and
≥15 drinks (Patrick et al., 2013). In the USA, from the total per-
centage of high school seniors with BD, 10.5% were assigned to
the first extreme category (≥10 drinks) and 5.6% to the second
(≥15 drinks).
Regarding the timeframe to determine the presence of BD,
there is also little agreement. Most of the studies set the fre-
quency unit as 2 weeks, while others set it as 1 week and still
others use time frames of 1–3 months or even 1 year. The time-
frame of 1 or 2 weeks may be underestimating the prevalence
of BD, while a long interval may overestimate it. The preferred
TABLE 1  Grams of Pure Ethanol in a Standard Drink
According to Country
Country Ethanol (g)
England 8 manifestations of cardiovascular risk that should be considered in
Australia, Austria, France, Hungary, 10
Ireland, Netherlands, New Zealand,
Poland, Spain
Finland 11
Denmark, Italy, South Africa 12
Canada 13.6
Portugal (unofficial), United States 14
Japan 19.75
The definition of binge drinking based on standard drinks consumed is
troublesome, because there is no international agreement on how many
grams of pure ethanol there should be in a standard drink. Measures of
standard units currently used in research can range from 8 g (England) to
19.75 g (Japan) of ethanol, making comparisons across studies difficult.
Data were revised from the International Center for Alcohol Policies
(2010), based on official government definitions.
and recommended criterion seems to be the occurrence of one
episode of BD every 2–4 weeks.
The Alcohol Use Disorders Identification Test (AUDIT;
Saunders, Aasland, Amundsen, & Grant, 1993) is the self-­
administered instrument most frequently used to detect a pattern
of BD. Using its third question (How frequently do you drink six
or more alcoholic beverages in one single event?), a cutoff line
can be established different from that proposed by the NIAAA.
However, no distinction between sexes is made, nor does it allow
quantification of extreme intakes.
Another element to be taken into account is the BD trajectory
in teenagers, from these possible four: accelerating (early onset
and increased frequency), steep increase (delayed onset and rapid
escalation), slow growth (delayed onset and gradual increase), and
stable low (abstinence). High levels of alcohol intake and more
physical health problems characterize the accelerating trajectory
(Modecki, Barber, & Eccles, 2014).
CONSEQUENCES ON HEALTH
AND POSSIBLE EARLY MARKERS
BD in the United States, Europe, and most developed countries
is regarded as a major health and social concern that is associated
with significant social and personal costs. BD elevates mortality
risk (Plunk, Syed-Mohammed, Cavazos-Rehg, Bierut, & Grucza,
2014) and is related to physical injury, motor vehicle accidents,
sexually transmitted diseases, unintended pregnancy, and medical
complications, as pointed out by the NIAAA (2000). Table 2 sum-
marizes the main effects on health that BD may cause.
The number of drinks and the BAC are good predictors of
negative alcohol-related consequences (blackouts, physical fights,
and getting physically sick) in first-year college students (Barnet
et al., 2014). The BD adolescents show more risky sexual behav-
ior (with the exception of non-condom use) and violent behavior
(Stickley, Koyanagi, Koposov, Razvodovsky, & Ruchkin, 2013;
Townshend, Kambouropoulos, Griffin, Hunt, & Milani, 2014;
Xing, Ji, & Zhang, 2006), with there being a strong association
with the number of BD days.
In healthy young binge drinkers, alterations have been found
in macro- and microcirculation; these may represent early clinical
preventive actions (Goslawski et al., 2013). A study on rats shows
that BD directly causes insulin resistance, which is a major risk fac-
tor to develop metabolic syndrome and type 2 diabetes (Lindtner
et al., 2013). Alcohol appears to disrupt insulin-receptor signaling
by causing inflammation in the hypothalamus, a nucleus of the
central nervous system (CNS), which also participates in coronary
artery disease and stroke.
Many studies have shown a link between psychological dis-
tress, such as anxiety and depression, and alcohol abuse (Balogun,
Koyanagi, Stickley, Gilmour, & Shibuya, 2014; Cheng & Furnham,
2013; Wellman, Contreras, Dugas, O’Loughlin, & O’Loughlin,
2014). Alcohol BD is more severe among individuals with mental
health problems and excessive alcohol consumption, which can in
turn increase psychological distress. Suicide ideation and attempted
suicide are also more prevalent in BD adolescents (Xing et al., 2006).
Young BD adults had several sleep problems (trouble falling sleep,
trouble staying asleep, and snoring/sleep apnea), independent of
 Heavy Episodic Drinking or Binge Drinking Chapter | 36  391

psychiatric conditions, in a dose–response relationship (Popovici & Both mechanisms may be keys in the neurobiological mechanisms
French, 2013). While insomnia seems to be significantly associated that underlie the transition from BD to ethanol dependence.
in both sexes, the snoring/sleep apnea is related to BD only in males.
Ethanol also increases neuroinflammation in the CNS, and
research has also observed persistent neuroimmune activation in RISK AND PROTECTION FACTORS
BD, which could contribute to neurocognitive dysfunction in the ASSOCIATED WITH BD
prefrontal cortex (PFC) (Vetreno & Crews, 2012), as well as in
Drawing an explicative model of BD behavior is a highly complex
myelination and white matter integrity (Jacobus, Squeglia, Bava,
task because there is a wide variety of interrelated factors in differ-
& Tapert, 2013). Brain-derived neurotrophic factor (BDNF) is a
ent domains, which in turn depend on the country, the sample, and
molecule identified as a major regulator of structural changes and
the factors to be studied. Tables 3 and 4 show the main risk and
inflammation processes in the brain related to alcohol use. The
protection factors associated with BD, respectively.
chronic BD pattern produces a decrease of BDNF, which corre-
Most works have found a higher prevalence of BD and more
lates with lower survival and neuronal differentiation of cells in
drink intake in one single episode in males (Chavez et al., 2011;
the hippocampus and the development of a depressive phenotype
Hibell et al., 2009; Pedersen & von Soest, 2013). Moreover, there
during the withdrawal period (Briones & Woods, 2013).
are differences between men and women in BD relating to their
Moreover, a critical role of the corticotropin-releasing fac-
expectations towards drinking and to positive alcohol metacog-
tor type 1 receptor in excessive ethanol intake has been observed
nitions. Women’s expectations are related to improving their
related to stress response, in both models of BD and alcohol depen-
sociability and sexual ability, while men’s are geared to reducing
dence (Kaur, Li, Stenzel-Poore, & Ryabynin, 2012). There is also
stress (Balodis, Potenza, & Olmstead, 2009). The positive alco-
evidence that BD upregulates the group 1 metabotropic glutamate
hol metacognitions about cognitive self-regulation are a signifi-
receptor signaling throughout the amygdala (Cozzoli et al., 2014).
cant predictor of weekly levels of alcohol use in BD males (Clark
et al., 2012). It is highly relevant to take into account the specific
features associated with sex in the study of BD and the design of
TABLE 2  Main Negative Consequences on Health and
possible interventions.
Neuropsychological Performance of Binge Drinking Regarding age, the range and cutoff points used in differ-
Acute negative Death by ethylic intoxication ent studies condition the data available. However alcohol intake
consequences Physical injury
Motor vehicle accidents
Physical fights
TABLE 3  Risk Factors Associated to Binge Drinking (BD)
Unplanned sex
Unintended pregnancy Behavior in Adolescents and Young People
Violent behavior Individual Sex (men)
Cardiovascular and Coronary artery disease characteristics Adolescents and young
metabolic diseases Stroke Early pubertal timing
Insulin resistance Evening-type
Metabolic syndrome Social and Easy alcohol access
Type 2 diabetes educational Cheap alcohol
Psychological distress Anxiety Low socioeconomic status
and mental disorders Depression Adverse socioeconomic conditions
Alcohol dependence Family, parents, Parental alcohol consumption
Suicide (ideation and attempts) and peers Parental BD
Insomnia (trouble falling sleep and Friends alcohol use
staying asleep)
Snoring/sleep apnea (only men) Other drug Smoking
consumption Marijuana use
Neurological diseases Neuroinflammation
Persistent neuroimmune activation Activities, beliefs, Unaware of the risk of BD
Dysfunctions in myelination cognitions Unauthorized absence from the school
Alterations in the white matter integrity (truancy)
Maladaptive response to stress Sport involvement
Use of products to enhance physique
Neuropsychological Sustained attention muscular
deficits Memory (declarative, semantic,
prospective and working) Personality traits High impulsivity
Associative learning High novelty seeking
Inhibitory control High extraversion
Decision making Low agreeableness
Low conscientiousness
The consequences are those evidenced by the research on adolescents,
young adult, and adult participants with a consumption pattern of The factors are those obtained in the studies revised, related to the practice
binge drinking. of binge drinking and/or which are predictors of sustained BD behavior.
392  PART | III Alcohol

It is very important to perform longitudinal studies to assess

TABLE 4  Protective Factors Associated to Binge Drinking the correlates of adult BD. In this sense, we want to highlight a
(BD) Behavior in Adolescents and Young People study by Cheng and Furnham (2013), who investigated the associ-
ation of several variables as predictors of BD in 50-year-old adults
Individual High intelligence
from England. The results showed that individuals who come from
characteristics morning-type
lower parental social class with adverse socioeconomic conditions
Social and Educational achievement tend to develop more alcohol abuse behavior; in addition, child-
educational Higher school grades hood intelligence, educational achievement, and occupational lev-
Occupational levels els were negatively associated with hazardous adult BD. Another
Stronger policy environment
variable related to BD in adolescents is school attachment, with
Family, parents, Parental monitoring (control and truancy (unauthorized absence from the school) being a risk fac-
and peers supervision) tor (Stickley et al., 2013). Frequent BD precedes long-term unem-
Parental support ployment, but only in women; this result has little support for
Family oriented leisure the social causation hypothesis because it appears after control-
Higher parental education (only ling for many potential confounder factors (Backhans, Lundin, &
for extreme BD)
Hemmingsson, 2012). Social exclusion is also another conse-
Activities, beliefs, School attachment quence related to BD in the long term (Viner & Taylor, 2007).
cognitions Participation in school and non- A longitudinal study by Pedersen and von Soest (2013) in
school activities Norway found that the frequency of alcohol consumption and BD
Religious involvement in parents predicted BD in their offspring at age 28, independently
Belief that alcohol produces of sex. This study also observed that parental monitoring (control
cognitive self-regulation (only men)
and supervision) and support with alcohol measures is of particu-
Belief that alcohol enhances
lar importance as a protective factor in adolescence.
sociability and sexuality (only women)
In adolescents with accelerating BD trajectory, there is
Personality traits Low impulsivity an early pubertal timing, low socioeconomic status, and more
Low novelty seeking sport involvement compared to those classified as “stable low”
High conscientiousness (Modecki et al., 2014). However, participation in organized school
The factors are those obtained in the studies revised, related to the practice or nonschool activities for early maturers protects against develop-
of non-binge drinking and/or not maintaining that behavior over time. ment of a “steep increase” trajectory. In addition, there is a higher
probability for starting BD behavior in males who are highly con-
cerned about muscularity and use supplements and other products
to enhance their physique (Field et al., 2013).
with BD behavior is a huge concern in all countries where there Finally, it is important to highlight that a large majority of
are statistics on the topic. In the United States and England, the adolescents and young adults continue the BD behavior despite
prevalence among college students ranges from 43% to 58.5% in their knowledge of health risk (Zwaluw, Kleinjan, Lemmers,
men and 32% to 54% in women (Howell et al., 2013). In Spain, a Spijkerman, & Engels, 2013). This may be explained by the theory
survey on this type of alcohol intake among teenagers and young of cognitive dissonance, which means that the drinkers’ existing
adults (Spanish Observatory on Drugs, 2013) reported an increase attitudes and cognitions will be modified to match the BD behav-
of BD, which taking into account the previous 30 days was 35% in ior. This suggests that, although knowledge and attitudes are
men and 20% in women aged 20–24. treated in prevention, these may be inefficient on BD behavior.
The study of predictors of sustained BD in young adults shows
similar determinants, being higher in males with no college/
university studies (Pedersen & von Soest, 2013; Wellman et al., PERSONALITY TRAITS, CIRCADIAN
2014). BD is related to parents and peers who also drink alco- TYPOLOGY, AND BD
hol (Weitzman, Nelson, & Wechsler, 2003; Pedersen & von Soest,
2013; Strickly et al., 2013). Higher parental education is a protec- The study of personality traits associated with BD has confirmed
tive factor for extreme BD, but it is a risk factor when considering consistently the presence of higher impulsivity (White et al., 2011;
BD for ≥5 drinks (Patrick et al., 2013). Townshend et al., 2014) and novelty seeking (Wellman et al.,
College students more exposed to “wet” environments— 2014) in youths, with both features being predictors of mainte-
defined as social, residential, and market surroundings where nance in the BD pattern. Both personality dimensions are also
drinking is prevalent and alcohol is cheap and easily accessed— related to several nonadaptive behaviors and mental disorders,
are more likely to engage in BD (Strickly et al., 2013; Weitzman mainly substance use disorders (Marquez-Arrico & Adan, 2013).
et al., 2003). Moreover, girls and boys who practice BD are more Most personality questionnaires include an impulsivity dimen-
prone to engage in all forms of substance use, with frequent poly- sion, although there are also specific instruments to measure it.
consumption. Tobacco and marijuana consumption are the most The Dickman Impulsivity Inventory (DII, Dickman, 1990) may be
frequent (Stickley et al., 2013) and are predictors of the intensity highlighted because it proposes the existence of functional impul-
of BD (Patrick et al., 2013). BD is a risk factor in the development sivity as the tendency to make quick decisions when required
of alcohol dependence (Balodis et al., 2009; White et al., 2011). by the situation to favor the person, in contrast to dysfunctional
Moreover, binge drinkers tend to be unaware of the risks of BD impulsivity, which is related to quick but irreflexive decisions that
(Strickley et al., 2013). lead to negative consequences. Youths with BD, especially men,
 Heavy Episodic Drinking or Binge Drinking Chapter | 36  393
Dysfunctional impulsivity
50 Sex
Women
Men
40
30
20
10
Control Binge drinking
Alcohol consumption
FIGURE 1  Dysfunctional impulsivity scores of binge drinking (BD)
and control groups according to sex. The scores on dysfunctional impul-
sivity are higher in the BD group than in the control group. Men obtain
higher scores in impulsivity, especially in the BD group. Dysfunctional
impulsivity was measured using the Dickman Impulsivity Inventory
(1990), with scores ranging from 12 to 60. Data from Adan (2012), with
permission from the publishers.
obtain higher scores only in dysfunctional impulsivity compared
to controls (Adan, 2012), as Figure 1 shows.
Impulsivity is the most consistent personality trait related to
early use of drugs, repetition of intake, and progression to addiction,
and it is a condition promoted with consumption that also favors
relapse (Perry & Carroll, 2008). The data available on novelty seek-
ing, defined as the need for adventure and excitement, preference
for risk and strong emotions, boredom susceptibility, and disinhibi-
tion, point in the same direction (Castellanos-Ryan, Rubia, &
Conrod, 2011). The disinhibition dimension is the best BAC predic-
tor in both sexes (Legrand, Gomà-i-Freixanet, Kaltenbach, & Joli,
2007). Impulsivity and novelty seeking may explain the poor perfor-
mance in executive tasks seen in teenagers (Castellanos-Ryan et al.,
2011) and in addiction disorders (Dolan, Bechara, & Nathan, 2009).
Using the “Big Five” model of personality traits (extraversion,
emotionality/neuroticism, conscientiousness, agreeableness, and
intellect/openness) in a longitudinal birth cohort study, Cheng and
Furnham (2013) observed that high extraversion and low agreeable-
ness were significant predictors of BD. In other research, low con-
scientiousness also appears as a predictor of weekly levels of alcohol
in BD university students (Clark et al., 2012). Perhaps not only one
but the combination of several personality traits may configure in
the future an endophenotype for the onset and maintenance of BD.
Circadian typology (morning-type, neither-type, and evening-
type) is an individual difference that affects our biological and
psychological functioning—not only in health, but also in disease
(Adan et al., 2012 for a review). Morning-type subjects go to bed
early and wake up early, and achieve their peak mental and physical
performance in the early part of the day. In contrast, evening-type
subjects go to bed and wake up late, and perform at their best
toward the end of the day and evening hours. The evening-type,
especially teenagers and young adults, show a personality pattern
of higher impulsivity, novelty seeking, extraversion, and activity,
and lower conscientiousness and harm avoidance. All the existing
data also suggest that circadian typology is related to the consump-
tion of all types of drugs and BD, with morning-type being a pro-
tective factor and evening-type a risk factor (Prat & Adan, 2011).
NEUROPSYCHOLOGICAL IMPACT OF BD
The study of the possible cognitive impact of BD is recent and
the existing studies are difficult to compare due to methodological
aspects that may influence the results (small samples, several defi-
nitions and duration of BD, use of different tasks, variable ages,
etc.). The lack of control of the educational level, the consumption
of other substances, the presence of psychopathological traits, and
personality traits may greatly affect the results. The available data
suggest that there are deficits in the cognitive performance in sus-
tained attention tasks and memory and PFC activity tasks similar
to those found in long-term alcohol abuse subjects, although to a
lesser extent and with more mixed results.
In considering the neuropsychological impact of BD, we
should distinguish between the effects of a single episode (next
day) and those that may come from a sustained BD behavior over
time (see Table 2). In both cases, the assessments are carried out
with a zero BAC.
Effects of a Single Episode of BD
Neurocognitive impairment are found in subjective alertness,
memory retrieval processes (delayed recall), and reaction time,
while performance in attention tasks is not significantly impaired
(McKinney, Coyle, & Verster, 2012; Verster, van Duin, Volkerts,
Schreuder, & Verbaten, 2003). The pattern of impulsive acting,
objectively assessed with inhibition tasks, also increases inde-
pendently from individual differences in the impulsivity trait
(McCarthy, Niculete, Treloar, Morris, & Bartholow, 2012).
Effects of BD on Learning and Memory Tasks
Studies have focused on retrospective memory in which learning,
retention, and retrieval are evaluated. The existence of memory
deficits under chronic alcohol consumption is well established,
linked to alterations in the hippocampus and PFC. BD students
perform worse in declarative memory tasks, both in immediate
and delayed recall (Parada et al., 2011b). BD young adults present
behavioral impairments in sustained attention, working memory,
and associative learning (Parada et al., 2012; Scaife & Duka, 2009;
Stephens and Duka, 2008).
For working memory, at an early age in young binge drinkers
without AUD or mental comorbidity, the performance at a behav-
ioral level is adequate. However, hypoactivation of the right ante-
rior PFC was obtained using combined event-related potentials
(ERP) and exact low-resolution brain electromagnetic tomogra-
phy (Crego et al., 2010). Using functional magnetic resonance
imaging (fMRI), higher bilateral activity in the supplementary
premotor area was observed in a BD condition, as well as a
394  PART | III Alcohol
positive correlation between the number of drinks consumed per
event and the activity in the dorsomedial PFC and the cerebellar-­
thalamic-insular regions (Campanella et al., 2013).
The assessment of prospective memory (PM), conceptualized
as the cognitive ability to remember to carry out some activity at
some future point in time, is a crucial aspect of everyday cognitive
function, and it is sensible to exhibit neuropsychological sequels
associated with BD. Adolescents and young adults with BD showed
impairments in a task of PM with fewer location–action combina-
tions to recall (Heffernann, Clark, Bartholomew, Ling, & Stephens,
2010) and reduced function on time-based tasks (Heffernann &
O’Neill, 2012) when compared with non-binge drinkers.
Effects of BD on Executive Functions
In BD university students, deficits in behavioral inhibition tasks
have been observed, reflecting impulsivity and poorer decision
making (Field, Schoenmakers, & Wiers, 2008; Scaife & Duka,
2009). This is more evident in high BD than in low BD subjects
(Townshend et al., 2014), in men, and in those who engage in
heavy BD at an early age (Goudriaan, Grekin, & Sher, 2011).
The assessment of decision-making using the Iowa Gambling
Task has found a pattern of “short-sightedness” for future con-
sequences in BD, similar to that in addiction patients, and
which implies impulsive behavior with lower inhibitory control
(Johnson et al., 2008).
Heavy binge drinkers performed worse on a battery of
tasks of executive functions compared with light social drink-
ers (Montgomery, Fisk, Murphy, Ryland, & Hilton, 2012). They
generated significantly fewer words in a word fluency task
(access to semantic memory), had worse random letter genera-
tion (inhibitory control), and had greater switch cost on a random
letter task (switching), as shown in Figure 2.
In the revision by Stephens & Duka’s (2008), BD deficits in
executive functions were found to underlie functional hyperactiv-
ity impairments in the PFC and the amygdala, which may cause
neurotoxicity with time. Because the PFC and other brain areas
involved are subject to development and maturation during ado-
lescence and emerging adulthood, BD until the age of 24 poses
a bigger harm to executive functioning than in later stages of life
(Hermens et al., 2013).
The appearance of alterations in brain functions when effects
in behavioral neurocognitive performance are not yet observable
points at early cerebral disturbances, which should be studied in
the future to check whether they persist when the BD habit ceases,
as well as the possibility that they may be considered endopheno-
types of the progression from BD to AUD. In this direction, the
longitudinal study by Dager et al. (2013) using fMRI has identi-
fied that an amplified cue-elicited brain response was the most sig-
nificant predictor of the emergence of BD and subsequent AUD.
The overactivated regions were linked to habit formation, decision
making, motivation, and attention.
FUTURE RESEARCH ON PREVENTION
AND/OR TREATMENT ON BD
Countries affected by BD should set it as a priority to promote
actions to reduce the number of persons practicing BD and the
intensity of the associated intoxications. Some strategies that have
FIGURE 2  Executive functioning performance (standardized scores)
in light and heavy alcohol social drinkers. Participants were 18–25 years
old, had never used illicit substances, and had never been diagnosed with
a substance use disorder or been advised to reduce their drinking. Heavy
social drinkers generated significantly fewer words in a word fluency task
(access to semantic memory), had worse random letter generation (RLG;
inhibitory control), and greater switch cost on a random letter task (switching).
Data re-elaborated from Montgomery et al. (2012).
proven effective in reducing alcohol consumption involve limiting
the availability of alcohol, raising its price, promoting substance
and alcohol-free environments (Naimi et al., 2014), and blocking
legal access to alcohol to a later age. Although we might acknowl-
edge that alcohol consumption may continue and that it is not
realistic to advocate abstinence, promoting less harmful drinking
patterns and their frequency is an advisable harm reduction strategy
(Plunk et al., 2014).
Preventive and therapeutic approaches should take into
account circadian rhythmicity. Involving chronobiology in pre-
vention implies not only promoting healthy leisure activities or
“what to do,” but also placing such activities in appropriate day-
time temporal moments or “when to do” them (Adan et al., 2012).
Chronobiological therapeutic strategies such as to establish regu-
lar time patterns of sleep-wake, meals, and daily activity with a
tendency towards a morning-type functioning, and exposition to
light therapy and melatonin administration, may also be effective.
Few works have assessed the efficacy of interventions aimed
at reducing dependence or intensity of BD in the population. The
brief motivational intervention (BMI) is one of the few effective
strategies for diminishing alcohol consumption. A single face-­
to-face session of BMI in a BD group was found to reduce alcohol
use among subjects who experienced one or more alcohol-related
adverse consequences (19% less drinking), whereas no preven-
tive effect was obtained in control subjects (Daeppen et al., 2011).
More research is needed in this area in the near future.
To conclude, research on pharmaceutical targets to avoid the
health consequences of BD and the progression to AUD will hope-
fully offer knowledge to be applied in the clinic in the future, based
on the promising findings from behavioral genetic approaches,
such as the reduction of the BDNF or the upregulation of glutamate
receptors in BD.
 Heavy Episodic Drinking or Binge Drinking Chapter | 36  395
APPLICATIONS TO OTHER ADDICTIONS
AND SUBSTANCE MISUSE
As we have seen in this chapter, the pattern of alcohol BD involves
significant risks to both the immediate and short-term health out-
comes of those who practice it. BD is more dangerous in the case
of adolescents because the toxic amounts of alcohol in their bod-
ies under maturation process aggravate the risks. The possible
changes in gene expression and in a wide variety of neurotrans-
mission systems should be noted, among which stands out the
reinforcement dopaminergic pathway. These changes significantly
increase biological vulnerability to progress towards the devel-
opment of a substance use disorder, not just for alcohol or other
substances with depressant pharmacological profile but in general.
Similarly, these effects on the CNS can participate in the develop-
ment of other mental disorders, such as depression and anxiety
with and without comorbidity to the addictive disorder. The need
to improve the knowledge about evidence-based treatments should
be emphasized. However, efforts should prioritize developing
preventive strategies starting in childhood in order to enhance the
protective factors of BD practice.
DEFINITION OF TERMS
Attention  Attention is a complex concept that represents a cohesive
set of processes, which include sensory, motor, and cognitive
processing.
Binge drinking  Binge drinking is an intermittent pattern of heavy alco-
hol consumption of ≥5 drinks for men and ≥4 drinks for women, in
one single event and at least once in the past two weeks.
Circadian typology  This individual difference (morning-, neither- and
evening-type) affects our biological and psychological functioning
in health and in disease. Morning-types go to bed early and wake
up early, and achieve their mental and physical peak performance in
the early part of the day, in contrast to the evening-types.
Endophenotype  This is an internal, inheritable, and measurable trait
marker of vulnerability to develop a particular disease.
Executive functioning  This set of cognitive skills is mainly linked
to the functioning of the brain frontal lobe, which includes men-
tal flexibility, planning and abstract reasoning abilities, self-
regulation, and task monitoring, which determine goal-directed
behavior.
Functional impulsivity  Functional impulsivity is a tendency to make
quick decisions to one’s benefit when required by the situation.
Inhibition  This mechanism prevents the entrance of nonpertinent
information into working memory and suppresses information that
has become irrelevant for a current task.
Impulsivity or dysfunctional impulsivity  This personality trait is
defined as the tendency to act with lack of prevision, making quick
and irreflexive decisions that lead to negative consequences.
Novelty seeking  This personality trait is characterized by a need for
adventure and excitement, preference for risk, and strong emo-
tions by the mere fact of living them, boredom susceptibility, and
disinhibition.
Prospective memory  This is the cognitive ability to remember to carry
out some activity at some future point in time.
Working memory  Working memory is the ability to hold and manipu-
late information in the mind over short periods of time—a mental
workspace that is used to store important information in the course
of our everyday lives.
KEY FACTS OF NEUROPSYCHOLOGY
IN BINGE DRINKERS
l Assessing cognitive performance is more difficult than assess-
ing biological aspects, because even in simple cognitive tasks
there are several skills involved in their resolution (attention,
motor control, etc.).
l BD behavior increases neuroinflammation in the CNS,
which may contribute to dysfunction in PFC, myelination,
and white matter integrity related to neuropsychological
deficits.
l In healthy young binge drinkers, deficits have been found in
sustained attention, learning, memory (declarative, semantic,
prospective and working), and executive functions (inhibition
control and decision making).
l Early cerebral disturbances measured by ERPs or fMRI in
brain activity may be detected when effects on behavioral per-
formance are not yet observable.
l Until the age of 24, BD behavior poses a larger harm than
in later stages of life, because the brain areas implicated in
the observed cognitive impairments (PFC, hippocampus and
amygdala) are subject to development and maturation during
adolescence and emerging adulthood.
l Future research should control factors that have a notorious
influence on cognitive performance and that have been related
to BD (level of education, consumption of other substances,
personality traits, etc.) in order to reach more robust conclu-
sions in this area.
SUMMARY POINTS
l 
This chapter focuses on the findings, mainly during the last
decade, on the impact of BD.
l BD in the United States, Europe, and most developed coun-
tries is a major health and social concern, with significant
social and personal costs.
l Mortality risk and comorbidity with physical (cardiovascular
diseases, diabetes, metabolic syndrome, neurodegeneration)
and mental (anxiety, depression, suicide, sleep disorders)
pathologies are more prevalent in binge drinkers.
l Adolescents and young binge drinkers show neurocognitive
impairments similar to those found in long-term alcohol abuse,
although to a lesser extent and with more mixed results.
l The presence of high impulsivity and novelty seeking in young
people are the best personality traits to predict the appearance
and maintenance of the BD pattern.
l Circadian typology is a remarkable individual difference in
BD and all addictive behaviors, with the morning-type being a
protective factor and the evening-type being a risk factor.
l We need more systematic research on the effects of BD,
preferably longitudinal studies incorporating biological and
behavioral measures.
l Prevention and therapeutic interventions should give priority
to BD, promoting protective factors and reducing risk factors
known to affect its appearance and maintenance.
ACKNOWLEDGMENT
This work was supported by a grant from the Spanish Ministry of
Economy and Competitiveness (PSI2012-32669).
396  PART | III Alcohol
REFERENCES
Adan, A. (2012). Functional and dysfunctional impulsivity in young binge
drinkers. Adicciones, 24, 17–22.
Adan, A., Archer, S. N., Hidalgo, M. P., Di Milia, L., Natale, V., & Randler, C.
(2012). Circadian typology: a comprehensive review. Chronobiology
International, 29, 1153–1175.
Bachman, J. G., Johnston, L. D., & O’Malley, P. M. (1981). Smoking, drink-
ing, and drug use among American high school students: correlates and
trends, 1975–1979. American Journal of Public Health, 71, 59–69.
Backhans, M. C., Lundin, A., & Hemmingsson, T. (2012). Binge drinking –
a predictor for or a consequence of unemployment? Alcoholism: Clinical
and Experimental Research, 36, 1983–1990.
Balodis, I. M., Potenza, M. N., & Olmstead, M. C. (2009). Binge drinking
in undergraduates: relationships with sex, drinking behaviours, impul-
sivity, and the perceived effects of alcohol. Behavioral Pharmacology,
20, 518–526.
Balogun, O., Koyanagi, A., Stickley, A., Gilmour, S., & Shibuya, K. (2014).
Alcohol consumption and psychological distress in adolescents: a
multi-country study. Journal of Adolescent Health, 54, 228–234.
Barnet, N. P., Clerkin, E. M., Wood, M., Monti, P. M., O’Leary Tewyan, T.,
Corriveau, D., … Kahler, W. K. (2014). Description and predictors of
positive and negative alcohol-related consequences in the first year of
college. Journal of Studies on Alcohol and Drugs, 75, 103–114.
Briones, T. L., & Woods, J. (2013). Chronic binge-like alcohol consumption
in adolescence causes depression-like symptoms possible mediated by
the effects of BDNF on neurogenesis. Neurocience, 254, 324–334.
Campanella, S., Peigneux, P., Petit, G., Lallemand, F., Saeremans, M.,
Noël, X., … Verbanck, P. (2013). Increased cortical activity in binge
drinkers during working memory task: a preliminary assessment
through a functional Magnetic Resonance Imaging. PLoS One, 8(4),
e62260. http://dx.doi.org/10.1371/journal.pone.0062260.
Castellanos-Ryan, N., Rubia, K., & Conrod, P. J. (2011). Response inhi-
bition and reward response bias mediate the predictive relationships
between impulsivity and sensation seeking and common and unique
variance in conduct disorder and substance misuse. Alcoholism: Clini-
cal and Experimental Research, 35, 140–155.
Chavez, P. R., Nelson, D. E., Naimi, T. S., & Brewer, R. D. (2011). Impact of the
new gender-specific definition for binge drinking on prevalence estimates
for women. American Journal of Preventive Medicine, 40, 468–471.
Cheng, H., & Furnham, A. (2013). Correlates of adult binge drink-
ing: evidence from a British cohort. PLoS One, 8(11), e78838.
http://dx.doi.org/10.1371/journal.pone.007838.
Clark, A., Tran, C., Weiss, A., Caselli, G., Nikčević, A. V., & Spada, M. M.
(2012). Personality and alcohol metacognitions as predictors of weekly
levels of alcohol use in binge drinking university students. Addictive
Behaviors, 37, 537–540.
Cozzoli, D. K., Courson, J., Wroten, M. G., Greentree, D. I., Lum, E. M.,
Campbell, R. N., … Szumlinski, K. K. (2014). Binge alcohol drink-
ing by mice requires intact group I metabotropic glutamate receptor
signalling within the central nucleus of the amygdale. Neuropsycho-
pharmacology, 39, 435–444.
Crego, A., Rodríguez-Holguín, S., Parada, M., Mota, N., Corral, M., &
Cadaveira, F. (2010). Reduced anterior prefrontal cortex activation in
young binge drinkers during a visual working memory task. Drug and
Alcohol Dependence, 109, 45–56.
Daeppen, J.-B., Bertholet, N., Gaume, J., Fortini, C., Faouzi, M., & Gmel, G.
(2011). Efficacy of brief motivational intervention in reducing binge
drinking in young men: a randomized controlled trial. Drug and
Alcohol Dependence, 113, 69–75.
Dager, A. D., Anderson, B. M., Rosen, R., Khadka, S., Sawyer, B.,
Jiantonio-Kelly, R. E., … Pearlson, G. D. (2013). Functional magnetic
resonance imaging (fMRI) response to alcohol pictures predicts subse-
quent transition to heavy drinking in college students. Addiction, 109,
585–595.
Dickman, S. J. (1990). Functional and dysfunctional impulsivity: person-
ality and cognitive correlates. Journal of Personality and Social Psy-
chology, 58, 95–102.
Dolan, S. L., Bechara, A., & Nathan, P. E. (2009). Executive dysfunction
as a risk marker for substance abuse: the role of impulsive personality
traits. Behavioral Sciences and the Law, 26, 799–822.
Field, A. E., Sonneville, K. R., Crosby, R. D., Swanson, S. A., Eddy, K. T.,
Camargo, C. A., … Micali, N. (2013). Prospective associations of
concerns about physique and the development of obesity, binge drink-
ing, and drug use among adolescent boys and young adult men. JAMA
Pediatrics, 168, 34–39.
Field, M., Schoenmakers, T., & Wiers, R. W. (2008). Cognitive processes
in alcohol binges: a review and research agenda. Current Drug Abuse
Reviews, 1, 263–279.
Goslawski, M., Piano, M. R., Bian, J.-T., Church, E. C., Szczurek, M., &
Phillips, S. A. (2013). Binge drinking impairs vascular function in
young adults. Journal of the American College of Cardiology, 62,
201–207.
Goudriaan, A. E., Grekin, E. R., & Sher, K. J. (2011). Decision making
and response inhibition as predictor of heavy alcohol use: a prospec-
tive study. Alcoholism: Clinical and Experimental Research, 35, 1–8.
Heffernann, T., Clark, R., Bartholomew, J., Ling, J., & Stephens, S. (2010).
Does binge drinking in teenagers affect their everyday prospective
memory. Drug and Alcohol Dependence, 109, 73–78.
Heffernann, T., & O’Neill, T. (2012). Time based prospective memory
deficits associated with binge drinking: evidence from the Cambridge
Prospective Memory Test. Drug and Alcohol Dependence, 123,
207–212.
Hermens, D. F., Lagopoulos, J., Tobías-Webb, J., Tamara De Regt, T.,
Dore, G., Juckes, L., … Hickie, I. B. (2013). Pathways to alcohol-
induced brain impairment in young people: a review. Cortex, 49,
3–17.
Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O., Bjarnason, T.,
Kokkevi, A., & Kraus, L. (2009). The 2007 ESPAD report. Substance
use among students in 35 European countries. Stockholm: The Swed-
ish Council for Information on Alcohol and Other Drugs.
Howell, N. A., Worbe, Y., Lange, I., Tait, R., Irvine, M., Banca, P., …
Voon, V. (2013). Increased ventral striatal volume in college-aged binge
drinkers. PLoS One, 8(9), e74164. http://dx.doi.org/10.1371/journal.
pone.0074164.
International Center for Alcohol Policies (ICAP). (2010). International
drinking guidelines. http://www.icap.org/Table/InternationalDrinking
Guidelines.
Jacobus, J., Squeglia, L. M., Bava, S., & Tapert, S. F. (2013). White mat-
ter characterization of adolescent binge drinking with and without
co-­occurring marijuana use: a 3-year investigation. Psychiatry Research:
Neuroimaging, 214, 374–381.
Johnson, C. A., Xiao, L., Palmer, P., Sun, P., Wang, Q., Wei, Y., … Bechara, A.
(2008). Affective decision-making deficits, linked to dysfunctional ven-
tromedial prefrontal cortex, revealed in 10th grade Chinese adolescent
binge drinkers. Neuropsychologia, 46, 714–726.
Kaur, S., Li, J., Stenzel-Poore, M. P., & Ryabynin, A. E. (2012).
Corticotropin-­releasing factor acting on corticotropin-releasing factor
receptor type I is critical for binger alcohol drinking in mice. Alcoholism:
Clinical and Experimental Research, 36, 369–376.
 Heavy Episodic Drinking or Binge Drinking Chapter | 36  397
Legrand, F. D., Gomà-i-Freixanet, M., Kaltenbach, M. L., & Joli, P. M.
(2007). Association between sensation seeking and alcohol consump-
tion in French college students: some ecological data collected in “open
bar” parties. Personality and Individual Differences, 43, 1950–1959.
Lindtner, C., Scherer, T., Zielinski, E., Filatova, N., Fasshauer, M., Tonks, N.
K., … Buettner, C. (2013). Binge drinking induces whole-body insulin
resistance by impairing hypothalamic insulin action. Science Translational
Medicine, 5, 170ra14 http://dx.doi.org/10.1126/scitranslmed.3005123.
Marquez-Arrico, J. E., & Adan, A. (2013). Dual diagnosis and personal-
ity traits: current situation and future research directions. Adicciones,
25(13), 195–202.
McCarthy, D. M., Niculete, M. E., Treloar, H. R., Morris, D. H., & Bartholow,
B. D. (2012). Acute alcohol effects on impulsivity: associations with
drinking and driving behavior. Addiction, 107, 2109–2114.
McKinney, A., Coyle, K., & Verster, J. (2012). Direct comparison of the
cognitive effects of acute alcohol with the morning after a normal
night’s drinking. Human Psychopharmacology: Clinical and Experi-
mental Research, 27, 295–304.
Modecki, K. L., Barber, B. L., & Eccles, J. S. (2014). Binge drinking tra-
jectories across adolescents: for early maturing youth, extra-curricular
activities are protective. Journal of Adolescent Health, 54, 61–66.
Montgomery, C., Fisk, J. E., Murphy, P. N., Ryland, I., & Hilton, J.
(2012). The effects of heavy social drinking on executive function:
a systematic review and meta-analytic study of existing literature and
new empirical findings. Human Psychopharmacology: Clinical and
Experimental Research, 27, 187–199.
Naimi, T. S., Blachette, J., Nelson, T. F., Nguyen, T., Oussayef, N., Heeren,
T. C., … Xuan, Z. (2014). A new scale of the U.S. alcohol policy
environment and its relationship to binge drinking. American Journal
of Preventive Medicine, 46, 10–16.
National Institute on Alcohol Abuse and Alcoholism. (2000). NIAAA: 10th
special report to the US congress on alcohol and health. Bethesda:
National Institutes of Health.
National Institute on Alcohol Abuse and Alcoholism. (2004). NIAAA council
approves definition of binge drinking. NIAAA Newsletter. No 3. Winter.
Observatorio Español sobre Drogas. Delegación del Gobierno para el
Plan Nacional sobre Drogas. (2013). Encuesta domiciliaria sobre
alcohol y drogas de España (EDADES). 2011/2012. Disponible en:
http://www.pnsd.msc.es/Categoria2/observa/pdf/EDADES2011.pdf.
Parada, M., Corral, M., Caamaño-Isorna, F., Mota, N., Crego, A.,
Rodríguez-­Olguín, S., & Cadaveira, F. (2011a). Definición del con-
cepto de consumo intensivo de alcohol adolescente (binge drinking).
Adicciones, 23, 53–63.
Parada, M., Corral, M., Caamaño-Isorna, F., Mota, N., Crego, A.,
Rodríguez-Olguín, S., & Cadaveira, F. (2011b). Binge drinking and
declarative memory in university students. Alcoholism, Clinical and
Experimental Research, 35, 1–10.
Parada, M., Corral, M., Mota, N., Crego, A., Rodríguez-Olguín, S., &
Cadaveira, F. (2012). Executive functioning and alcohol binge drink-
ing in university students. Addictive Behaviors, 37, 167–172.
Patrick, M. E., Schulenberg, J. E., Martz, M. E., Maggs, J. L., O’Malley,
P. M., & Johnston, L. D. (2013). Extreme binge drinking among 12th-
grade students in the United States. JAMA Pediatrics, 167, 1019–1025.
Pedersen, W., & von Soest, T. (2013). Socialization to binge drinking: a
population-based, longitudinal study with emphasis on parental influ-
ences. Drug and Alcohol Dependence, 133, 587–592.
Perry, J. L., & Carroll, M. E. (2008). The role of impulsive behavior in drug
abuse. Psychopharmacology, 200, 1–26.
Plunk, A. D., Syed-Mohammed, H., Cavazos-Rehg, P., Bierut, L. J., &
Grucza, R. A. (2014). Alcohol consumption, heavy drinking, and
mortality: rethinking the J-shaped curve. Alcoholism: Clinical and
Experimental Research, 38, 471–478.
Popovici, I., & French, M. T. (2013). Binge drinking and sleep problems
among young adults. Drug and Alcohol Dependence, 132, 207–215.
Prat, G., & Adan, A. (2011). Influence of circadian typology on drug con-
sume, hazardous alcohol use and hangover symptoms. Chronobiology
International, 28, 248–257.
Saunders, J. B., Aasland, G., Amundsen, A., & Grant, M. (1993). Alco-
hol consumption and related problems among primary health care
patients: WHO collaborative project on early detection of person with
harmful alcohol consumption I. Addiction, 88, 349–362.
Scaife, J. C., & Duka, T. (2009). Behavioural measures of frontal lobe
function in a population of young social drinkers with binge drinking
pattern. Pharmacology, Biochemistry and Behavior, 93, 354–362.
Stephens, D. N., & Duka, T. (2008). Cognitive and emotional consequences
of binge drinking: role of amygdala and prefrontal cortex. Philosophical
Transactions of the Royal Society of Biological Sciences, 363, 3169–3179.
Stickley, A., Koyanagi, A., Koposov, R., Razvodovsky, Y., & Ruchkin, V.
(2013). Adolescent binge drinking and risky health behaviours: findings
from northern Russia. Drug and Alcohol Dependence, 133, 838–844.
Thiele, T. E. (2012). Commentary: studies on binge-like ethanol drinking
may help to identify the neurobiological mechanisms underlying the
transition to dependence. Alcohol Clinical and Experimental Research,
36, 193–196.
Townshend, J. M., Kambouropoulos, N., Griffin, A., Hunt, F. J., & Milani,
R. M. (2014). Binge drinking, reflection impulsivity, and unplanned
sexual behavior: Impaired decision-making in young social drinkers.
Alcoholism: Clinical and Experimental Research, 30, 1143–1150.
Verster, J. C., van Duin, D., Volkerts, E. R., Schreuder, A., & Verbaten,
M. N. (2003). Alcohol hangover effects on memory functioning and
vigilance performance after an evening of binge drinking. Neuropsy-
chopharmacology, 28, 740–746.
Vetreno, R. P., & Crews, F. T. (2012). Adolescent binge drinking increases
expression of the danger signal receptor agonist HMGB1 and Toll-like
receptors in the adult prefrontal cortex. Neuroscience, 226, 475–488.
Viner, R. M., & Taylor, B. (2007). Adult outcomes of binge drinking in
adolescence: findings from a UK national birth cohort. Journal of Epi-
demiological Community Health, 61, 902–907.
Wechsler, H., Davenport, A., Dowdall, G., Moeykens, B., & Castillo, S.
(1994). Health and behavioral consequences of binge drinking in col-
lege. A national survey of students at 140 campuses. Journal of the
American Medical Association, 272, 1672–1677.
Weitzman, E. R., Nelson, T. F., & Wechsler, H. (2003). Taking up binge
drinking in college: the influences of person, social group, and envi-
ronmental. Journal of Adolescent Health, 32, 26–35.
Wellman, R. J., Contreras, G. A., Dugas, E. N., O’Loughlin, E. K., &
O’Loughlin, J. L. (2014). Determinants of sustained binge drinking
in young adults. Alcoholism: Clinical and Experimental Research,
38, 1409–1415.
White, H. R., Marmorstein, N. R., Crews, F. T., Bates, M. E., Mun, E.-Y., &
Loeber, R. (2011). Associations between heavy episodic drinking and
changes in impulsive behavior among adolescent boys. Alcoholism:
Clinical and Experimental Research, 35, 295–303.
Xing, Y., Ji, C., & Zhang, L. (2006). Relationship of binge drinking and
other health-compromising behaviors among urban adolescents in
China. Journal of Adolescent Health, 39, 495–500.
Zwaluw, C. S., Kleinjan, M., Lemmers, L., Spijkerman, R., & Engels,
R. C. M. E. (2013). Longitudinal associations between attitudes towards
binge drinking and alcohol free-drinks, and binge drinking behaviors in
adolescents. Addictive Behaviors, 38, 2110–2114.