Any substance use disorder is a biopsychosocial phenomenon with risk and protective at these various levels interacting. At the biological level, Koren did not have a familial history of alcoholism. She also possessed a number of social influences that were protective. She came from a middle-to upper class two-parent household, and her parents were supportive. She was a good student in school and was involved in variety of extra-curricular activities, such as ballet camp, horseback riding, piano lessons, young writers, and diplomacy camp. Koren maintained a religious connection (Catholic) and attended Sunday School. On the risk side, her parents were fairly permissive about teenage experimentation and the use of alcohol. Psychologically, Koren struggled to fit in with her peers and drinking provided that venue.
These issues only intensified when she started college. Depression, anxiety and loneliness spurred the use of drinking to cope. The college environment was also conducive to alcohol as a way of socializing.