This document is a research proposal that aims to investigate whether the intensity of alcohol hangover symptoms can serve as a marker for future development of alcohol use disorders. The proposal provides background on alcohol hangover and alcohol use disorder. It reviews previous research that has found associations between family history of alcohol use disorder and increased hangover symptoms. The proposed study aims to build on this by investigating how hangover symptoms influence near-term drinking behaviors and whether personal traits like guilt are associated with hangover and alcohol use disorder. The study will use an online naturalistic design to compare university and MTurk samples.

1. Mathew Mark Aspey
9400765201
PSY-40034
Research Proposal.
Does Intensity of Alcohol Hangover Symptoms Serve as
a Marker for Future Development of Alcohol Use
Disorders?
Word Count: 4,958 Words

2. Research Proposal:
Does Intensity of Alcohol Hangover Symptoms Serve as a Marker for Future
Development of Alcohol Use Disorders?
Introduction.
Alcohol hangover, according to Verster et al. (2010) may be defined as
adverse effects experienced after a night of alcohol consumption, once a sufficient
amount of time has passed for the blood alcohol concentration (BAC) to fall
considerably until it approaches zero. The effects of hangover may last for up to 24
hours and may consist of any combination of the following symptoms: headache,
tiredness, lack of concentration, dehydration, dizziness, nausea, cognitive
impairment, and mood changes.
Alcohol Use Disorder (AUD) is described by the American Psychological
Association (APA) as either alcohol abuse; drinking patterns that result in significant
and recurrent negative consequences, whereby drinking may affect their personal or
professional life in negative way, or alcohol dependence; drinking patterns that are
characterised by the inability to stop, increased tolerance and withdrawal symptoms
once drinking is stopped (American Psychological Association, 2012). According to
the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 1 in 12 Americans
has alcohol use disorder (National Institute on Alcohol Abuse and Alcoholism, 2007).
It is important to conduct research into alcohol hangover in order to gain a
better understanding of its effects. A number of studies have found hangover to have
adverse negative effects on various aspects of everyday life. A survey conducted
among Dutch university students reported over half of the students had been unable
to study when feeling the effects of hangover often (Verster, 2006). The students

3. reported an average hangover frequency of 2.7 days per month, therefore it was
found that an average of one month per year is lost among university students due to
hangovers every year (Verster et al., 2003). This figure, when coupled with the
finding that one symptom of hangover can be cognitive impairments, particularly with
regards to memory functioning, is disturbing when taking into account that the core
business of students in learning and retaining information.
Hangovers have also shown negative effects in the workplace, McFarlin and
Fals-Stewart (2002) reported a significant relationship between alcohol consumption
and next day absence from work, in their survey of 280 employees, they found that
the likelihood of absence from work increased two-fold the day after a night of
drinking. Besides from causing workers to miss days from work, hangover has also
been found to have an adverse effect over productivity. Frone (2006) reported that
9.23% (11.6 million workers) of the American workforce have been hung over at
work in the last year. Ames et al. (1997) found that around half of the workers that
they interviewed had attended work with a hangover. They reported feeling sick,
having conflicts with co-workers, having difficulty getting their work done and falling
asleep at work. As hangover has been found to have such an impact of productivity,
it is no surprise to find that hangover has a major economic impact on society.
Harwood (2000) estimated that the cost of alcohol hangover in the US is around
$185 billion, however this figure has been criticised for being inaccurate. If hangover
has a socioeconomic impact anywhere close to this figure, it is important to build a
greater understanding of the mechanisms of alcohol hangover.
There is an argument that hangover may be a marker for developing alcohol
dependence. Span and Earlywine (1999) proposed two contrasting models that may
help explain the link between hangover and familial risk for hangover; the Traditional

4. Punishment Model and the Withdrawal Relief Model. It has, in the Traditional
Punishment Model, been postulated that a bad hangover may serve as a
punishment in order to reduce future alcohol consumption, therefore high risk
individuals must experience less hangover. Rohsenow et al. (2012) found that more
severe hangover was associated with experiencing fewer alcohol problems 1 to 4
years later, suggesting that a heightened susceptibility may protect against problem
drinking.
The Withdrawal Relief Model, on the other hand, suggests that hangover
represents an acute withdrawal syndrome (Newlin and Pretorius, 1990) and that high
risk individuals may actually experience a more severe hangover and also employ
“hair of the dog” drinking with the intention of alleviating hangover symptoms. Survey
studies of university students have found that 25 to 56% of drinkers have employed
hair of the dog drinking and that this behaviour is typically associated with heavier
alcohol consumption (Hunt-Carter et al., 2005; Verster, 2009). This may serve as a
negative reinforcement to further drinking behaviour (Piasecki et al., 2005).
It has been suggested that a family history of alcohol use disorder may lead to
alcohol use disorders in their offspring. Dawson (1992) investigated a sample of
23,152 drinkers on the effects of family history of AUD on the possibility of past year
alcohol dependence. 40% of the sample reported a positive family history of AUD.
The study found that the possibility of an individual developing AUD increased by
86% when their mother or father had a history of alcohol abuse. There have been
several studies which have suggested a link between the severity of hangover
symptoms and a family history of alcohol dependence. These studies will be
discussed here.

5. Newlin and Pretorius (1990) suggested that hangover symptoms may reflect
an acute withdrawal syndrome, in which hangover sufferers may drink in order to
alleviate hangover symptoms, which may reflect an addictive process which may
promote further drinking. They compared 13 sons of alcoholics (SOAs) with 25 sons
of non-alcoholics (SONAs) in terms of their self-reported hangover symptoms.
Participants were separated into SOA and SONA groups using the Short Michigan
Alcohol Screening Test (F-SMAST), those scoring 7 or more were placed into the
SOA group and those scoring less than 2 were placed into the SONA group. They
were given two-part questionnaires, looking at their hangover experiences within the
last twelve months and their hangover experiences early on in their drinking career.
They were also given a quantity frequency measure of their alcohol consumption.
They found that SOAs reported significantly greater hangover symptoms in the past
year than SONAs. From these findings, they suggested that SOAs may be
“dependence-prone” with regards to alcoholism.
McCaul, Turkkan, Svikis, Bigelow (1991), conducted a study with the objective
of establishing risk factors for males with a positive family history (FHP) of
alcoholism to develop dependencies themselves, compared with males with a
negative family history (FHN) of alcoholism. The sample consisted of 32 white male
students aged 18 – 25 years, 16 of which were FHP and 16 were FHN. Participants
were sorted into either FHP or FHN groups using the Family History-Research
Diagnostic Criteria (FH-RDC), being placed in the FHP group if the father met the
FH-DRC criteria for alcohol abuse based on the participants reports. In separate
sessions subjects were given two doses, either 100 or 200mg, of secobarbital, a
medication used to treat insomnia by slowing activity in the brain, ethanol (1.0g/kg)
and placebo in separate sessions in a semi-random order. In each of the sessions,

6. participants completed three hour laboratory sessions whereby a series of
physiological and psychomotor measures were taken once prior to and four times
after drug administration. The findings showed that FHP participants reported greater
intoxication and FHP greater withdrawal effects following high dose secobarbital and
ethanol tests. FHP also reported that withdrawal effects and alcohol craving lasted
much longer than FHNs. FHPs also showed greater impairment in psychomotor
performance.
Span and Earlywine (1999) sought to build on these findings by examining the
relation between personality risk for alcoholism and hangover by looking at 20 sons
of alcoholics (SOAs) and 20 sons of non-alcoholics (SONAs) and having them
complete the MacAndrew Scale as an index of personality risk for hangover.
Participants were allocated into either the SOA or SONA groups using the Michigan
Alcohol Screening Test (MAST) for the father, those whose father scored more than
8 were placed in the SOA group and those scoring less than 4 were placed in the
SONA group. They also completed a self-report questionnaire, looking at average
quantity and frequency of alcohol consumption along with the largest number of
drinks consumed in one session during the past six months and a time-line follow
back to assess their drinking habits of the past two weeks. Participant were given
two questionnaires relating to anticipation of hangover, in which they were asked to
imagine drinking four drinks, either beer, wine or spirits, in an hour and a half and
were asked questions on how they would feel the following morning. Participants
consumed a placebo in the first session and alcohol in the next two sessions and
were asked to provide breath samples every ten minutes. The finding showed that
SOAs reported significantly greater hangover symptoms after consuming controlled
dose of alcohol than SONAs. Participants at greater familial risk for alcoholism

7. experiences more acute withdrawal symptoms which may develop into problem
drinking.
Robertson et al. (2012) expanded on the Hangover Symptoms Scale (HSS)
developed by Slutske et al (2003). They examined the construct validity of the HSS
in an ecological momentary assessment investigation. They gave 404 frequent
drinkers electronic diaries to carry around with them to track their daily experiences
over a three week period. An alarm was set to go off at random times, four times a
day to prompt diary entries. One of the entries was completed each morning to
assess drinking behaviours of the previous night, and presence and intensity of any
current hangover symptoms.
They concluded that the HSS has great efficacy in hangover research. Higher
HSS scores tend to identify people who suffer hangovers and who may be likely to
show specific symptoms the morning after drinking. The fact that drinkers reporting
more hangovers in the past year were also likely to report hangovers during a three
week period of self-monitoring suggests hangover does not discourage subsequent
heavy episodic drinking or that past-year hangover does not particularly discourage
drinking to the point of eliminating future hangover experiences. They suggested a
need to develop and evaluate complementary measures that can more directly index
individual differences in hangover susceptibility in survey designs.
Piasecki et al. (2010) developed a five item version of HSS; the HSS-5. They
investigated the frequency and predictors of hangover during a two week period of
self-monitoring. The sample consisted of 127 students, 61% of whom were females
and 27% reported parental alcohol problems, based on a series of questions.
Participants were given electronic diaries in order to record their drinking

8. experiences. Alarms were set to go off at random times, four times a day in order to
prompt assessments. The first prompted entry of the day recorded the previous
nights’ drinking; whether they had drank and if so how much they had drank and any
subsequent hangover-like experience (HLE). The findings showed that parental
alcohol problems were associated with more frequent HLE and possible increased
susceptibility to hangover.
Epler et al. (2014) used an Ecological Momentary Assessment (EMA) to
investigate whether or not hangover influences the time to next drink (TTND) and to
identify whether the TTND is increased or decreased. They gave 386 frequent
drinkers electronic diaries (the EMA) to carry around for 21 days to record drinking
behaviours and other experiences. The diaries were programmed with an alarm that
would go off every morning whereby participants would record how they felt each
morning. They would also have to record at the start of a drinking session and were
asked to respond to time based follow ups after completion of the first drink. They
found that when tested as the sole predictor, hangover was associated with an
increase in TTND. It was found that the median survival time was 6 hours longer
when participants were hung over than in instances when they were not. They also
found no association between morning reports of hangover and likelihood of drinking
later that same day based on diary ratings. However, if participants were expected to
remember to log the start of the next drinking session, given the nature of hangover
and the effects that it may have on memory, it may have been the case that
participants forgot to record the start of their drinking session had they decided to
drink later on the same day as experiencing hangover symptoms in the morning.

9. From the research discussed here, there are many potential gaps that the
proposed study may be able to address; one of which is whether or not hangover
has an effect on near term drinking. Research by Newlin and Pretorius (1990),
McCaul et al (1991) and Span and Earlywine (1999) all found a significant
association between a family history of alcohol use disorder and hangover, but none
of these particularly investigated how that association caused an effect on
participants with regards to their current drinking patterns. One recent study that has
looked into time to next drink is Epler et al (2014), who found that hangover is was
associated with near time drinking, but was not found to promoted further drinking
later that day. The proposed study will build on this by asking questions regarding
both alcohol craving and how long participants would leave it before having another
drink when experiencing hangover symptoms. By doing this, I will be able to
investigate whether hangover serves as a punisher for drinking, by discouraging or
delaying future drinking, or does hangover encourage future drinking by promoting
“hair of the dog” drinking, in order to alleviate hangover symptoms. Alternatively, it
may be the case that this differs from person to person, if this is the case, the
proposed study sets out to investigate how it differs and whether or not a family
history of AUD plays a role in that. Furthermore, as it is hypothesised that individuals
with a family history of AUD are more likely to develop alcohol use disorders
themselves, it may be the case that people with a family history of AUD experience
more hangovers, not because they are more susceptible, but simply because they
tend to drink more.
The proposed study will also attempt to identify any personal traits that are
associated with AUD and hangover measures. One trait that has crept into the
literature is guilt, Harburg (1993) used a question from the SMAST, asking whether

10. participants every felt guilty about their drinking. There has since been developed the
Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire, developed by Ewing
(1984) which has been used to measure guilt, among other things. Although a
standard questionnaire has been developed, it has been used very often to measure
guilt and investigate the link between guilt about drinking and whether it relates to an
increase or decrease in hangover intensity and whether hangover serves as a link
between guilt and AUD or does it merely serve as a marker?
According to Stephens et al. (2008), there are currently two main approaches
to researching the effects of alcohol hangover, laboratory studies and naturalistic
studies. Typically in lab studies a controlled dose of alcohol is administered and
assessments are carried out the morning after, generally after a 10 – 12 hour delay.
Naturalistic studies explore the cognitive effects of hangover on participants
the morning after a night of normal drinking. Although both designs compare against
control groups, both may be subject to expectancy effects (Finnigan and
Hammersley, 1992), therefore innovations are required to make clearer distinctions
between true effects and expectancy effects (Stephens et al., 2008).
An online study may employ the methodology of naturalistic research as
participants are asked to remember a major session of drinking and rate the severity
of their hangover experiences the following morning. Online studies can be very
useful to psychological research, due to their cheap design and are often easy to set
up with survey creators such as surveymonster.com, they allow researchers to reach
a widespread population without having to have participants attend a laboratory
session, and participants can take part in a study in the comfort of their own home.

11. The proposed study will be an online study using a naturalistic approach. The
study will compare samples gathered from University populations, such as Keele,
Manchester and London, with additional samples gathered using Amazon’s
Mechanical TURK (MTURK). The MTURK is a relatively new website that contains
all the major elements required to conduct research online. Buhrmester, Kwang and
Gosling (2011) from the University of Texas wrote a paper discussing the efficacy of
using MTURK samples within Psychological research and describe it as a “novel,
open online marketplace for getting work done by others”. The MTURK offers an
integrated participant compensation system whereby participants can earn a small
amount of money for taking part in your research. The site offers a large participant
pool as the MTURK is currently being used by over 100,000 users in over 100
countries around the world, offering a streamlined study design, participant
recruitment and data collection, making it a perfect match for online psychological
research.
Typically, psychological research uses samples derived from university
populations in order to gain a vast amount of participants with relative ease, by using
MTURK, researchers can collect data from a different data set but still reach out to a
large sample size. The research conducted by Buhrmester et al. found that MTurk
participants are slightly more demographically diverse than standard Internet
samples. As MTURK reaches over 100 countries, the samples are found to be
significantly more diverse than typical University samples. Participants can still be
recruited rapidly and inexpensively and the data obtained has been found to be at
least as reliable as those obtained via traditional methods.
Casler et al. (2013) took a behavioural, face-to-face task and converted it into
an online test in order to compare responses in samples gained via typical social

12. media (Facebook etc.) with a sample recruited via MTURK. They also tested a
university sample in the traditional face-to-face manner. They found that the MTURK
sample was significantly more socio-economically diverse than the other two
samples but yielded the same results as the other two samples, to the point that they
were almost indistinguishable. They concluded that online recruitment and testing
can be a valid and potentially superior counterpart to traditional data collection. For
these reasons an MTURK sample will be trialled in the proposed study as the first
hangover study of its kind to use an MTURK sample against typical university
samples.
The proposed study will use the Short Michigan Alcohol Screening Test,
developed by Selzer et al (1975), to assess the drinking habits of participants’
mothers and fathers (M-SMAST and F-SMAST) in order to assess familial risk for
alcoholism.
The proposed study will implement aspects of the Acute Hangover Scale
(AHS) devised by Rohsenow (2007). The AHS looks at many aspects such as
demographic information, therefore participants will be asked their age, gender,
approximate height, approximate weight and ethnic origin. Demographic information
can be used to calculate a person’s Blood Alcohol Concentration (BAC), Seidl et al
(2000) produced an equation whereby an individual’s height and weight along with
the amounts of alcohol drank can be used to estimate be used to estimate their
peak BAC during the drinking session.
The AHS asks how much a person has drank in the past 30 days and how
much alcohol they drank on a specific day within that 30 day period. In this study,
participants will be given a “recent experiences” questionnaire, which will ask

13. participants to recall the last major drinking session they took part in. the
questionnaire will contain items for the number and types of alcoholic beverages
consumed within the evening along with the approximate start and finish time start
and finish time of the drinking session. They will then be asked the number and
types of alcoholic beverages consumed on a typical night out in order to see how
that compared with their most recent night of drinking. Participants will also be asked
how many drinks they would typically drink on an average night out and also how
many times in the last month they drank more than 10 units of alcohol. This will be in
order to counter any effects that may occur from the possibility that individuals with a
family history of AUD may experience more severe hangovers simply because they
tend to drink more than those with no family history of AUD.
Participants will be asked to read a standard definition of a hangover and its
symptoms and will be asked to complete anticipation of hangover questionnaires.
They will be asked to imagine themselves drinking certain amounts of alcohol in a
specified amount of time, they will be asked to report on a Likert Scale from 1 – 7, 1
being not hung over and 7 being very hung over based upon the definition of
hangover that has been presented to them.
Participants will then be given the Hangover Symptoms Scale (HSS). The
HSS was developed by Slutske et al (2003) in order to assess the occurrence of
hangover symptoms retrospectively. They created the scale in order to address the
lack of standard measures of hangover symptoms that address both the
physiological and subjective effects of hangover. It contains 13 items: thirst,
tiredness, headache, difficulty concentrating, nausea, weakness, sensitivity to light
and sound, sweating, trouble sleeping, vomiting, anxiousness, trembling and
depression. The sample consisted 1,230 college students, all of whom were current

14. drinkers, 38% males and 62% females and 91% were Caucasian. They were given a
self-report inventory and were asked to rate the frequency of each of the 13
hangover symptoms in the past 12 months. They were also asked to report their
drinking history, any personal alcohol-related problems and any familial alcohol-
related problems. It was predicted that those with family history of alcoholism would
report more frequent hangover.
Participants experienced 5 out of the 13 hangover symptoms in the past 12
months, the three most common being dehydration, feeling tired and headache.
Higher HSS scores were positively associated with frequency of drinking, quality of
alcohol consumed and a personal and familial history of alcohol related problems.
The findings showed that 34% of participants experienced at least 1 of 4 alcohol
related problems and these gave significantly higher scores on the HSS, 23%
reported that one or both parents had a history of at least 1 of 4 alcohol related
problems and these also scored significantly higher on the HSS. It is worth noting
that women had scored higher on the HSS than men after controlling for sex
differences in alcohol involvement. They concluded that the HSS appears to capture
a reasonably valid set of adjectives to describe the effects of hangover. They
suggested that a re-worded version of the HSS may produce more valid findings,
bridging the gap between laboratory and survey studies oh hangover.
In order to investigate whether guilt plays a role in the intensity of a hangover,
the Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire, developed by
Ewing (1984) will be added to the proposed study. The CAGE asks four questions:
Have you ever felt you should cut down on your drinking? Have people annoyed you
by criticizing your drinking? Have you ever felt bad or guilty about your drinking?

15. Have you ever had a drink first thing in the morning to steady your nerves or to get
rid of a hangover (eye-opener)?
The aims of the proposed study will be to investigate the link between alcohol
hangover and risk for Alcohol Use Disorder. To trial the efficacy of using an MTURK
sample within a hangover study against conventional university samples.
The experimental hypothesis is that participants with a family history of
alcohol abuse (scoring positive for one or both parents on the SMAST) will
experience greater hangover symptoms. Furthermore, I hypothesise that the MTURK
sample will show data equally valid, if not more so, to the conventional university
sample. A further hypothesis is that participants with FHP will report greater
quantities of alcohol on the recent experiences questionnaire. Participants with a
positive family history of AUD will report greater hangover symptoms than those with
a negative family history of AUD. One further hypothesis is that participants who
report higher guilt score on the CAGE, will report greater hangover symptoms.
Methodology.
Participants.
The study will recruit a sample from various universities around the UK.
Adverts will be placed on social media at Keele University, Staffordshire University,
Manchester University, the University of Birmingham, Liverpool John Moores and
various Universities in the London area, the study will be looking to recruit between
50 and 60 participants from each university, with an age range from 18 – 30, both
males and females who are current drinkers. If obtaining samples from other

16. Universities proves difficult, I will acquire a larger sample from Keele University to
account for it. The other sample will be recruited via the Amazon Mechanical TURK
(MTURK) using a small financial incentive to aid in recruitment. I will be looking to
recruit around 300 participants from the MTURK in order for it to match up to the
sample attained from the various universities.
Design.
The proposed study will employ a between-subjects design, employing two
independent variables. These will consist of the samples used (MTURK sample vs.
University sample) and family history of alcohol use disorder (Positive family history
(FHP) vs. negative family history (FHN). The dependent variable will be participants’
self-reported hangover scores.
Participants will be asked how many drinks they would typically drink on an
average night out and also how many times in the last month they drank more than
10 units of alcohol. This will be in order to counter any effects that may occur from
the possibility that individuals with a family history of AUD may experience more
severe hangovers simply because they tend to drink more than those with no family
history of AUD.
Procedure.
Participants will be invited to take part in the study either via the Amazon
Mechanical TURK website or via various University Facebook pages which will link
them to the online study. Participants gathered using the MTURK will receive a small
monetary incentive for their participation and participants gathered from the
university samples will be entered into a prize draw to win one of 2 £25 Love2shop

17. gift vouchers as an incentive to participate in the study. All participants will be
informed of the purpose of the study from the outset, they will be told that the
purpose of the study is to investigate the link between alcohol hangover and familial
risk for Alcohol Use Disorder. The procedure will stay the same for both the MTURK
group and the University sample groups.
Firstly, participants will be asked to provide demographic information; this will
include age, gender, approximate height (cm), weight (kg) and ethnic origin
(including country of origin and country of residence. Conversions will be available to
account for differences between imperial and metric measurement systems with
regards to the MTURK sample.
Participants will then be asked to complete the Short Michigan Alcohol
Screening Test, one to describe the drinking habits of their mother (M-SMAST) and
one to describe the drinking habits of their father (F-SMAST). The SMAST asks a
series of 13 yes or no answer questions such as “Do you feel your mother/father has
been a normal drinker?” and “Has your mother/father ever been to hospital because
of drinking?”
Participants will then be given the “recent experiences” questionnaire, which
will ask participants to recall the last major drinking session they took part in. They
will be asked what time they started drinking, what time they finished drinking, how
many alcoholic beverages they drank and what types of beverages they drank. If
they drank spirits with mixers, they will say how many spirits they drank and roughly
how much of the mixer was in the drink.
Participants will then be given a standard definition of a typical hangover and
its symptoms and will be asked to complete an anticipation of hangover

18. questionnaire. They will be asked to imagine themselves drinking certain amounts of
alcohol in a specified amount of time (i.e. 4 double rum and cokes and 2 pints of
lager within a 3 hour period), they will be asked to report how hung over they would
expect to feel, the following morning on a Likert Scale from 1 – 7, 1 being not hung
over and 7 being very hung over based upon the definition of hangover that has
been presented to them.
Participants will then be asked to think back to that last session of major
drinking they had described and will be given the hangover symptoms scale (HSS).
They will be asked to rate on a Likert scale from 1 to 7 (1 being none at all and 7
being incapacitating) how they felt on 13 different symptoms of alcohol hangover.
The symptoms include: dehydrated, tired, headache, nausea, vomited, weakness,
difficulty concentrating, sensitivity to light and sound, sweating, trouble sleeping,
anxiety, depressed and experiencing trembling or shaking.
Finally, participants will be given the CAGE Guilt Scale. The CAGE will ask
participants four questions: Have you ever felt you should cut down on your
drinking? Have people annoyed you by criticizing your drinking? Have you ever felt
bad or guilty about your drinking? Have you ever had a drink first thing in the
morning to steady your nerves or to get rid of a hangover (eye-opener)? Participants
will be asked to rate how much these questions apply to them on a Likert scale from
1 to 7, 1 being not at all and 7 being very much so.
Analysis.
As the proposed study will be looking at two factors; family history, comparing
positive family history of alcohol use disorder (FHP) with negative family history
(FHN), and sample group, comparing University samples with the MTURK sample,

19. the analysis for the proposed study will be an Analysis of Covariance (ANCOVA) and
the effect they have over the severity of hangover experienced.
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