Changes in alcohol craving and consumption by phase of menstrual cycle in alcohol dependent women

Transcription

1 Journal of Substance Use, October 2006; 11(5): ORIGINAL ARTICLE Changes in alcohol craving and consumption by phase of menstrual cycle in alcohol dependent women E. E. EPSTEIN 1, K. C. RHINES 2, S. COOK 1, B. ZDEP-MATTOCKS 1, N. K. JENSEN 1, & B. S. MCCRADY 1 1 Center of Alcohol Studies, Department of Psychology and Women Study Program, Rutgers, The State University of New Jersey, Piscatawy, USA, and 2 Seton Hall University Abstract The current study examines the menstrual cycle alcohol relationship during 6 months of weekly outpatient sessions as part of a larger treatment outcome study for alcohol-dependent females. Twelve premenopausal women in the clinical trial who were menstruating regularly and not on oral contraceptives kept a daily log of menstruation days, alcohol consumption and cravings. Three menstrual cycle phases were defined: menses, premenstrual, and other. Within subjects repeated measures analyses on the subsample of 12 women showed that, despite a lower average number of cravings, drinking frequency was higher in the premenstruum than the other phase in the first 3 months of treatment. In addition, according to a self-report item on a measure given to 96 women in the larger study, 48 (69%) women under the age of 50 endorsed the premenstrual phase of the menstrual cycle as a drinking cue. Of these 48, 44% considered it a major drinking cue. These preliminary data support the value of continuing to investigate the relationship between phases of the menstrual cycle and alcohol consumption among female alcoholics. Keywords: Menstrual cycle, alcohol consumption, alcohol craving, alcoholism and menstrual cycle, premenstrual drinking. Introduction Research on antecedents to alcohol consumption among women has lagged due to the predominant use of male samples in research on alcohol use problems. However, a consistent finding is that alcoholic women report that they drink to manage mood changes and alleviate negative affect (Connors, Maisto, & Zywiak, 1998; Miller & Cervantes, 1997; Olenick & Chalmers, 1991). Sex differences in the daily event drinking relationship have been noted in several studies. Women tend to experience more negative events on a daily basis than do men (Carney, Armeli, Tennen, Affleck, & O Neil, 2000), but data are mixed about the degree of relation between negative events, and increased alcohol craving or drinking for women (e.g. Armeli, Carney, Tennen, Affleck, & O Neil, 2000; Carney et al., 2000). One limitation of the literature is that these studies have not considered phase of the menstrual cycle. The endocrine system has important implications for regulation of mood for Correspondence: E. E. Epstein, Center of Alcohol Studies, 607 Allison Road, Rutgers, The State University of New Jersey, Piscataway, New Jersey 08854, USA. Tel: (732) Fax: (732) bepstein@rci.rutgers.edu ISSN print/issn online # 2006 Informa UK Ltd. DOI: /

2 324 E. E. Epstein et al. approximately 40% of women (Mello, Mendelson, & Lex, 1990), which in turn may impact the initiation of drinking and interact with subjective stress in response to daily events. A small literature addresses the link between hormone-based cyclical mood symptoms and co-varying levels of alcohol consumption among women. Early clinical evidence was used to support a menstrual cycle-alcoholism hypothesis that for some women drinking to relieve premenstrual symptoms led to the development of an alcohol problem (Lolli, 1953; Podolsky, 1963; Wall, 1937). Subsequent empirical research examined the relationship between phases of the menstrual cycle and changes in alcohol consumption, primarily among non-alcoholic women, with a focus on phase of the menstrual cycle as a maintenance factor for alcohol use (Harvey & Beckman, 1985; Mello et al., 1990; Sutker, Libet, Allain, & Randall, 1983; Tate & Charette, 1991). In aggregate, the findings are mixed, with some studies reporting an association between either the premenstruum and/or the menses phases, and increased alcohol consumption for a portion of the sample, but one study finding no association. Harvey & Beckman (1985) studied 69 socially drinking women (i.e. drank at least twice per week) daily across three menstrual cycles and found that frequency of drinking did not vary across five menstrual phases, but drinking quantity peaked in the luteal phase. Sutker et al. (1983) reported a lack of relationship between five menstrual cycle phases and alcohol consumption in nine female social drinkers, but subjects reported increased frequency of drinking to relieve tension and depression, and more solitary drinking during menstruation than in the premenstruum or ovulation phases. Mello et al. (1990) studied 14 women ages 21 34, with no late luteal phase dysphoric disorder and no history of alcohol use disorder. Defined as social drinkers, the sample included three women considered to be heavy drinkers (averaging 24.7 drinks per month), six women considered to be moderate drinkers (12.8 drinks/month) and five women who were called occasional drinkers (6.8 drinks/month). Subjects lived on a research hospital ward for 35 days and were trained for an operant task, with access to alcohol or money as a reinforcer. Five of the 14 women drank more intensely on 3 premenstruum days, six women did not change their drinking during premenstruum and three subjects decreased alcohol consumption during this phase. The five women who increased their alcohol consumption obtained higher scores on 12 of 18 Premenstrual Assessment Form subscales. Tate & Charette (1991) followed 75 nonalcoholic women (ages 18 28) over two menstrual cycles, and found no relationship between menstrual distress and alcohol intake. Much of the research described above has been done using samples of women who are social (i.e. regular) drinkers, however, the methodologies for determining social drinking versus alcohol abuse or dependence diagnoses in the older studies are vague, and it is not clear if the samples were, indeed, non-alcoholic by contemporary standards. This inconsistency in sample definition may contribute to the disparate findings among studies. Alcohol consumption also has been studied in relation to menstrual cycle in nonalcoholic women subgrouped by other factors. Griffin, Mello, Mendelson, & Lex (1987) followed 30 regular alcohol and marijuana users with no history of alcohol abuse over three menstrual cycles, and found no relationship between alcohol consumption and menstrual phase. However, the sample drank minimally, did not report severe menstrual distress, and moreover, was selected for the study based on regular marijuana use. Likewise, no association was found between alcohol intake and menstrual phase in a sample of 22 female cigarette smokers; however, women with a history of premenstrual complaints were excluded from the study (Pomerleau, Cole, Lumley, Marks, & Pomerleau, 1994). There were no inclusion/exclusion criteria related to alcohol diagnosis or problem drinking. A

3 Menstrual cycle and alcohol consumption 325 different subset of the same larger study was included for a study of nine female smokers who met criteria for Late Luteal Phase Dysphoric Disorder (LLPDD; DSM-III-R, 1987), in which Marks, Hair, Klock, Ginsburg, & Pomerleau (1994) reported that alcohol consumption increased during the menses, even though menstrual distress peaked during the premenstruum. The Pomerleau et al. (1994) and Marks et al. (1994) studies highlight the need to assess menstrual distress and suggest that only a subset of women, perhaps those affected with premenstrual dysphoric disorder (DSM-IV, 1997) or who score relatively high on premenstrual distress, may show corresponding increases in alcohol consumption. Another subgrouping dimension used to study menstrual cycle and alcohol consumption among non-problem female drinkers has been family history of alcoholism (FH+ or FH2; Charette, Tate, & Wilson, 1990). In this study, young, non-alcoholic women ages were followed for two menstrual cycles. Data were analysed by family history risk, to detect changes in alcohol consumption over five menstrual phases. No differences in alcohol consumption across FH+ versus FH2 groups were noted in relation to the five menstrual phases and no mood changes over the menstrual phases were reported. In the most sophisticated study to date, McLeod, Foster, Hoehn-Saric, Svikis, & Hipsley (1994) followed 41 women (ages 21 45) who had no history of alcohol use disorder, but did drink at least two times per week, who had premenstrual syndrome (PMS), and also had Generalized Anxiety Disorder (GAD) with or without paternal and/or maternal alcoholism, for one menstrual cycle. Seventy-four per cent of the women with a paternal family history of alcoholism versus 22% of those without increased alcohol consumption during the premenstruum. This study illustrates the need to account for potentially relevant variables such as mood disorders, tendency to experience premenstrual distress, and family history, when evaluating the complex relationship between alcohol consumption and menstrual cycle. Only two empirical studies have examined the menstrual cycle alcohol relationship among alcoholic women and neither used daily diary methodology. In an early empirical study, Belfer, Shader, Caroll, & Harmatz (1971) reported that 67% of 21 menstruating female alcoholics said they initiated or increased their drinking during the premenstruum. More recently, Allen (1996) conducted a retrospective study of 48 women with moderate or severe alcohol dependence; 33% of the sample reported an increase in alcohol consumption premenstrually and these women also reported more menstrual distress than the others. In summary, although basic endocrine differences between men and women are involved in the regulation of mood for almost one half of women, and mood regulation consistently has been identified as an antecedent to drinking among alcoholic women, the wider research on gender differences in antecedents to drinking generally has not included menstrual cycle events as a topic of inquiry. The dearth of research in this area is unfortunate and is due, perhaps, to the complexity involved in studying biological phenomena in the context of psychosocial or treatment research. The lack of research also may result from the discouraging inconsistencies found in the menstrual cycle and alcohol consumption literature, which primarily has studied non-alcoholic, social drinking women. Though the daily recording methodology of most of these studies is adequate, the definitions of social drinkers in such studies are questionable, and reliable definitions of three to five menstrual phases have not been established or verified with biological indices. The current study As part of a larger randomized clinical trial of individual or couples cognitive-behavioral therapy for female alcoholics, the participants kept a daily log of alcohol consumption, as

4 326 E. E. Epstein et al. well as frequency and intensity of cravings to drink. In the process of discussing triggers for cravings and drinking, study clinicians noted that their patients seemed to experience increased and more intense cravings for alcohol during the premenstrual phase of their menstrual cycle, and to be at higher risk for relapse during the premenstrual and menses phase. Thus, approximately halfway through subject recruitment, consecutive subjects were asked to record each day on their daily drinking log whether or not they were menstruating. Of these women, only those who were premenopausal, menstruating regularly, and not taking oral contraceptives (n512) were included in the current sample. The current study is a preliminary investigation of several hypotheses: N alcohol-dependent women will report the premenstruum as a drinking trigger; N cravings for alcohol will be cyclical and will be most frequent in the premenstrual phase of the menstrual cycle; N cravings for alcohol will be most intense in the premenstrual phase of the menstrual cycle; N alcohol consumption will be more frequent and heavier during the premenstrual phase of the menstrual cycle. Materials and methods Participants One-hundred-and-two women diagnosed with alcohol abuse (1%) or dependence (99%) were involved in a randomized clinical trial of 6 months of weekly outpatient individual versus couples therapy. Of these, 96 completed the Drinking Patterns Questionnaire (Zitter & McCrady, 1979). Inclusion criteria for the randomized trial included consumption of alcohol in the past 60 days, being in a committed heterosexual relationship and having a male partner who was willing to participate in the study. Exclusion criteria included a diagnosis of current psychosis, other substance dependence, or domestic violence in the previous 12 months requiring medical attention. Participants kept a daily log of alcohol consumption, as well as frequency and intensity of cravings to drink while in treatment. Beginning approximately 60% of the way through recruitment for the larger study, an item was added to the daily drinking log for women to record whether they were menstruating each day or not. Forty-two consecutive female subjects completed this version of the daily log. Of these, women who were premenopausal, menstruating regularly (every days), and not taking oral contraceptives were included in the current sample (n512). Table I shows demographic information for the 96 women, as well as the subsample of 12 women. Using a Bonferroni correction to set the significance level at 0.007, there were no significant differences between the 12 and 84 women on any demographic variables. Procedures Participants were recruited from the community via newspaper advertisements and were assessed for initial eligibility in a brief telephone screen interview. Participants then attended an in-person conjoint clinical screening interview with a study clinician to confirm eligibility. Eligible couples signed an informed consent approved by the Rutgers Institutional Review Board and were scheduled for a Baseline (BL) research interview.

5 Menstrual cycle and alcohol consumption 327 Table I. Demographic information showing mean (SD) or percentage. Full sample (n596) Daily diary sample (n512) Age (9.13) (6.85) Education: total years (2.62) (2.07) Total household income $96, ($57,310) $129, ($74,967)* Marital status 88.5% Married 83.3% Married Ethnic background 94.8% Caucasian, 5.2% Black 100% Caucasian Percentage drinking days (28.58) (29.39) 90 days pre-bl Drinks per drinking day 8.01 (4.54) ounces 7.74 (3.68) 90 days pre-bl ( grammes) ( grammes) *p , t-test between 12 women and 84 (i.e. 96 minus 12) other women in sample, not significant with Bonferroni correction of significance level at At the BL interview, participants were administered a battery of semi-structured and selfreport questionnaires by trained interviewers, and were paid $50 for participation in this interview. Participants were then randomized to either Alcohol Behavioral Couples Therapy (ABCT) or Alcohol Behavioral Individual Therapy (ABIT). Each treatment condition consisted of twenty 90-minute (ABCT) or 60-minute (ABIT) weekly therapy sessions delivered over 6 months. Therapy included common cognitive-behavioral, skills training interventions to help the patient become and remain sober, enhance motivation to stop drinking, increase general coping skillfulness, and prevent relapse. The ABCT condition also included relationship enhancement interventions, spouse coping skills training, and a focus on increasing spousal support for abstinence. For the 12 women in the current study, span of daily data collection ranged from one to seven menstrual cycles (average 3.8). Three menstrual cycle phases were defined: menses (days of menstruation), premenstrual (7 days prior to onset of menses, following Pomerleau et al., 1994) and other. It was decided to compare these three phases, rather than more subtle differentiation into ovulation, luteal, follicular, premenstrual, and menses, due to the lack of biological measures in the study to confirm five phases. Measures Demographic questionnaire. A brief self-report questionnaire assessed basic identifying information, such as age, marital status, occupational status, income, religion, and education. Structured clinical interview for DSM IV. (SCID; First, Gibbon, Spitzer, & Williams, 1997). The SCID brief psychotic screening questions were used to identify and exclude psychotic subjects. The SCID also was used to assess current and lifetime alcohol/drug abuse or dependence, as well as current and past mood disorders. Daily drinking and drug use log. Each participant was asked to maintain a daily log of alcohol use, as well as frequency and intensity of alcohol cravings during treatment. Women also were asked to note on each daily log if they had their menstrual period. Variables derived from this measure included: percentage drinking days, mean drinks per drinking day, percentage crave days (days on which subject reported at least one craving), mean number of cravings per crave day, and mean intensity of craving per crave day.

6 328 E. E. Epstein et al. Menstrual Distress Questionnaire, Form C. (MDQ; Moos, 1991). The MDQ measures cyclical perimenstrual symptoms by assessing symptoms in each of three phases of the menstrual cycle. It is a 47-item self report inventory with 8 subscales, including pain, water retention, autonomic reactions, negative affect, impaired concentration, behavior change, arousal, and control. Internal consistencies for these scales range from alpha For the present study the MDQ was given to the participants by their clinician when they reported their first menstrual period after entering treatment. Menstrual history was assessed at baseline with a number of paper and pencil questions about type of birth control used, menstrual status, etc. The Time-Line Followback Interview. (TLFB; Sobell, Maisto, Sobell, Cooper, Cooper & Saunders, 1980). The TLFB is a structured interview designed to obtain alcohol use data for each day in a specified time period. For the present study, the time period used was the 3 months prior to the baseline interview. Correlations between drinkers self-report on the TLFB and collateral reports range from r50.84 to r50.94 (Maisto, Sobell, & Sobell, 1982). For the current study, variables included were percentage drinking days and mean drinks per drinking day. Drinking Patterns Questionnaire. (DPQ; Zitter & McCrady, 1979). The DPQ is a self-report measure of drinking cues organized by categories of cues such as environment, interpersonal, and physiological. Cues were rated on a 3-point scale, Did not drink in this situation, Sometimes drank in this situation, or Major drinking situation. Results Of a total sample of 96 women who completed the DPQ, 48.9% endorsed I sometimes drink before my menstrual period as a drinking cue. Of those 48.9%, 21 (43%) identified this as a major drinking cue. When the sample was further broken down by age, among the 70 women younger than 50 years old (most likely to be premenopausal), 48 (69%) endorsed the premenstruum as a drinking cue. Of those 48 women, 21 (44%) endorsed the premenstruum as a major drinking cue. In other words, 30% of women under 50 endorsed menstrual cycle as a major drinking antecedent. Using data aggregated over the 12 women, repeated measures MANOVAs were done to compare within subjects drinking and craving across three menstrual phases premenstruum, menses, and other across six menstrual cycles. Effect sizes were calculated for these MANOVAs as well. These within-subjects repeated measures analyses were done for the first 3 months and then the second 3 months of treatment to accommodate treatment-related changes in frequency and strength of cravings, and alcohol consumption in the beginning versus end of treatment. Results are shown in Table II. For the first 3 months of treatment, a contrast analysis showed that subjects drank more frequently during the premenstrual phase (26.73% of the days in that phase) than the other phase (20.29% of the days), F(1,11)56.16, p A contrast analysis showed that subjects recorded higher average number of cravings per crave day in the other phase than in the premenstrual phase, F(1,10)54.52, p Although not statistically significant, differences in mean drinks per drinking day were evident at moderate effect sizes between the premenstrual and other phases, and between the menses and other phases. For the second 3 months of treatment, a contrast analysis showed that percentage crave days was higher in the other than in the premenstrual phase at a F(1,6)54.46,

7 Table II. Repeated measures by phase of menstrual cycle, first and second 3-month period of treatment (mean, sd). All non-significant unless noted. Premenstrual day Menses Other days Effect size Effect size Effect size (PMD) PMD vs. menses PMD vs. other Menses vs. other First 3 months treatment Percentage drink days (n512)* Mean drinks/drink day (n57) % Crave days (n512) Average # cravings per crave day (n511) Average crave intensity (n511) Second 3 months treatment 4 Percentage drink days (n57) % Crave days (n57) Average # cravings per crave day (n53) Average crave intensity (n53) (28.27) (28.81) (27.09) (1.15) 3.45 (1.69) 2.89 (1.33) (47.43 grammes) (48.27 grammes) (40.43 grammes) 47.3 (29.93) (28.82) (26.02) (1.67) (.73) 1.84 (.72) (1.14) 4.38 (1.51) 4.36 (1.06) (15.35) 9.48 (20.11) 9.10 (15.56) (21.37) (12.90) (24.45) (.62) 2.67 (2.47) 1.18 (.31) (1.26) 3.67 (.58) 2.20 (1.38) *Trend toward significance at level for 3-phase repeated measures analysis, F(2,10) Contrast analysis, premenstrual with other, F(1,11)56.16, p Contrast analysis, premenstrual with other, F(1,10)54.52, p Contrast analysis, premenstrual with other, F(1,6)54.46, p Mean drinks/drink day (n51) because all others were abstinent so no mean drinks per drinking day; data not shown. Menstrual cycle and alcohol consumption 329

8 330 E. E. Epstein et al. p level of significance. Although not statistically significant, a medium effect size showed the same relationship between the menses and other phase for percentage crave days, and large effect sizes were noted for the relationships between the menses and premenstrual, and menses and other days for crave frequency per crave day and crave intensity; these were highest in the menses phase, during the second half of treatment. Discussion This study examined the relationship between menstrual cycle phase and increased craving for and consumption of alcohol in a sample of treatment seeking alcohol dependent females. This study is the only one to date in the menstrual cycle alcohol literature that uses a daily diary method of data collection in a sample of alcoholic women. The sample size was small, since it was limited to menstruating women who were not on oral contraceptives, to match other samples in the literature. Though the sample size was similar to other studies in this literature, these results must be considered preliminary and exploratory, however, they support the value of continuing to investigate the relationship between menstrual cycle phases and alcohol consumption among female alcoholics. The first hypothesis, that alcoholic women would view the premenstruum as a drinking trigger, was supported. Two-thirds of the women under age 50 in the sample reported the premenstruum as a drinking trigger and almost one half of all women under age 50 reported the premenstruum as a major drinking trigger. Using a daily diary technique, data were collected for alcohol cravings and consumption on a daily basis in a subsample of 12 regularly menstruating women who were not on oral contraceptives. The hypotheses that cravings and alcohol consumption would be cyclical, and most frequent and intense in the premenstrual phase were supported partially. During the first 3 months of outpatient treatment, in the sample of 12 women, there was a higher percentage of drinking days during the premenstruum (versus the other phase), despite more cravings per crave day in the other phase, implying perhaps that during the premenstruum phase of the menstrual cycle some alcoholic women who are trying to stop drinking find it more difficult to fight cravings. During the second 3 months of treatment, subjects recorded a higher frequency of crave days during the other phase, but more intense craving during the menses phase, at moderate to large effect sizes. In general, findings indicated that patterns of craving and alcohol consumption need to be examined as possibly peaking not only during the premenstrual phase, but also during the menses. Though drinking does not seem to be elevated during the other phase, frequency of craving (either across days or within days) does. Study limitations As mentioned above, the sample size is small and findings must be interpreted as exploratory. In addition, the fact that the current sample of alcohol dependent women was in a 6-month outpatient cognitive-behavioral treatment program may have impacted menstrual cycle phase related fluctuations in alcohol consumption and craving. In contrast to a sample of actively drinking women not in treatment, the women in this sample were in a treatment specifically designed to help them identify and learn coping skills to deal with alcohol cues, possibly including physiological triggers, such as the premenstruum or menstrual period. The act of noting their menstruation days on the daily self-recording cards may have influenced the women to pay more attention to menstrual cycle as a cue,

9 Menstrual cycle and alcohol consumption 331 thus perhaps increasing or even perhaps reducing their premenstrual cravings and thoughts about alcohol. Also, the women were actively seeking to alter their drinking patterns to reduce the quantity and frequency of their alcohol consumption in this abstinence-based program. Two women were not drinking and two had very low drinking frequency during the first 3 months, and more women had drastically reduced or stopped their alcohol consumption by the second 3-month segment of days analysed. Studying a sample of alcohol dependent women not in treatment would be important to address the drinking/ craving menstrual cycle relationship. Summary The findings echo the general findings in the literature that for a portion of women in the sample there seems to be increased alcohol consumption during either the premenstrual or menstrual phases. Taken as a whole, the current study and the extant literature seem to indicate that the phase of the menstrual cycle has impact only for approximately one-quarter to one-third of the women. Thus, further research on individual differences among women in the influence of menstrual phase on alcohol consumption and craving is indicated. Using a larger sample it would be possible to examine potential moderators of this relationship, such as premenstrual dysphoria, physical discomfort during the menses, possible elevated marital distress during the premenstruum, personal and family history of major depression as a risk factor for premenstrual dysphoria and associated drinking changes. Acknowledgements This research was funded by National Institute on Alcohol Abuse and Alcoholism grant number R37 AA07070 to B. McCrady. The authors would also like to thank Jumi Hayaki, Brit Haver, Jennifer Knapp, Greta Kugler, Maureen McGuire, Thomas Morgan, Helen Raytek, Dipak Sakar, Rene Sell, Janine Swingle, and Danielle Walker, for their valuable contributions to this research. References Allen, D. (1996). Are alcoholic women more likely to drink premenstrual? Alcohol and Alcoholism, 31, pp American Psychiatric Association (APA). (1987). Diagnostic and statistical manual of method disorders, III-R (DSM-III-R). Armeli, S., Carney, M. A., Tennen, H., Affleck, G., & O Neil, T. P. (2000). Stress and alcohol use: A daily process examination of the stressor-vulnerability model. Journal of Personality and Social Psychology, 78, Belfer, M. L., Shader, R. I., Carroll, M., & Harmatz, J. S. (1971). Alcoholism in women. Archives of General Psychiatry, 25, Carney, J. A., Armeli, S., Tennen, H., Affleck, G., & O Neil, T. P. (2000). Positive and negative daily events, perceived stress, and alcohol use: A diary study. Journal of Consulting and Clinical Psychology, 68(5), Charette, L., Tate, D. L., & Wilson, A. (1990). Alcohol consumption and menstrual distress in women at higher and lower risk for alcoholism. Alcoholism: Clinical and Experimental Research, 14, Connors, G. J., Maisto, S. A., & Zywiak, W. H. (1998). Male and female alcoholics attributions regarding the onset and termination of relapses and the maintenance of abstinence. Journal of Substance Abuse, 10, First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1997). The Structured Clinical Interview for DSM-IV: Axis I Disorders (SCID-I). Washington, DC: American Psychiatric Press. Griffin, M. I., Mello, N. K., Mendelson, J. H., & Lex, B. W. (1987). Alcohol use across the menstrual cycle among marijuana users. Alcohol, 4, Harvey, S. M., & Beckman, L. J. (1985). Cyclic fluctuation in alcohol consumption among female social drinkers. Alcoholism: Clinical and Experimental Research, 9,

10 332 E. E. Epstein et al. Lolli, G. (1953). Alcoholism in women. Connecticut Review on Alcohol, 5, Maisto, S. A., Sobell, M. B., & Sobell, L. C. (1982). Reliability of self-reports of low ethanol consumption by problem drinkers over 18 months of follow up. Drug and Alcohol Dependence, 9, Marks, J. L., Hair, C. S., Klock, S. C., Ginsburg, B. E., & Pomerleau, C. S. (1994). Effects of menstrual phase on intake of nicotine, caffeine, and alcohol and nonprescribed drugs in women with late luteal phase dysphoric disorder. Journal of Substance Use, 6, McLeod, D. R., Foster, G. V., Hoehn-Saric, R., Svikis, D. S., & Hipsley, P. A. (1994). Family history of alcoholism in women with generalized anxiety disorder who have premenstrual syndrome: Patient reports of premenstrual alcohol consumption and symptoms of anxiety. Alcoholism: Clinical and Experimental Research, 18, Mello, N. K., Mendelson, J. H., & Lex, B. W. (1990). Alcohol use and premenstrual symptoms in social drinkers. Psychopharmacology, 101, Miller, W. R., & Cervantes, E. A. (1997). Gender and patterns of alcohol problems: Pretreatment responses of women and men to the Comprehensive Drinker Profile. Journal of Clinical Psychology, 53, Moos, R. H. (1991). Menstrual Distress Questionnaire Manual. Los Angeles: Western Psychological Services. Olenick, N. L., & Chalmers, D. K. (1991). Gender-specific drinking styles in alcoholics and nonalcoholics. Journal of Studies on Alcohol, 52, Podolsky, E. (1963). The woman alcoholic and premenstrual tension. Journal of the American Medical Women s Association, 18, Pomerleau, C. S., Cole, P. A., Lumley, M. A., Marks, J. L., & Pomerleau, O. F. (1994). Effects of menstrual phase on nicotine, alcohol, and caffeine intake in smokers. Journal of Substance Abuse, 6, Sobell, M. B., Maisto, S. A., Sobell, L. C., Cooper, A. M., Cooper, T., & Saunders, B. (1980). Developing a prototype for evaluating alcohol treatment effectiveness. In L. C. Sobell, M. B. Sobell, & E. Ward (Eds.), Evaluating alcohol and drug abuse treatment effectiveness: Recent advances. New York: Pergamon. Sutker, P. B., Libet, J. M., Allain, A. N., & Randall, C. L. (1983). Alcohol use, negative mood states, and menstrual cycle phases. Alcoholism: Clinical and Experimental Research, 7, Tate, D. L., & Charette, L. (1991). Personality, alcohol consumption, and menstrual distress in young women. Alcoholism: Clinical and Experimental Research, 15, Wall, J. H. (1937). A study of alcoholism in women. American Journal of Psychiatry, 93, Zitter, R., & McCrady, B. S. (1979). The Drinking Patterns Questionnaire, unpublished manuscript.

11