Impulsivity in the 21 st century

1. Impulsivity in the 21st century Dr. Iulian Iancu Psychiatry B. Dept. Beer Yaakov, Israel

2. It is clear that you are not an impulsive audience! • You stayed until the last day of the congress, instead of strolling in Madrid or traveling to beautiful places (Ibiza).

3. Impulsivity: historical aspects • Since the killing of Ebel by Cain in the Old Testament and the mythological quarrel between Oedipus and several travelers (one being Laius his father) which ended with murder, impulsivity and mainly impulsive aggression is a well-known, although negative, feature of mankind.

4. Impulsivity: historical aspects • In 1838 Esquirol proposed the term monomanic instinctives, to describe impulsive behaviors characterized by irresistible urges without apparent motive.

5. Impulsivity: historical aspects • Historically, impulsivity was described as an abrupt act performed to obtain gratification or pleasure, but that is maladaptive and out of the control of the individual (Frosch & Wortis, 1954; Monroe, 1970).

6. Impulsivity: historical aspects • Later theorists suggested that impulsive individuals are biologically “set” to prefer stimulation and arousal (Cloninger, 1987) and attend more specifically to pleasurable or reinforcing elements than to stimuli signaling the possibility of punishment (Eysenck, 1977).

7. Definition of Impulsivity • Eysenck & Eysenck related impulsivity to risk-taking, lack of planning, and making up one’s mind quickly. • Patton separated impulsivity in 3 components: acting on the spur of the moment (motor activation), not focusing on the task at hand (attention), and lack of planning.

8. Impulsivity- definition at present • A predisposition toward rapid, unplanned reactions to either internal or external stimuli without regard for the negative consequences of these reactions to the individual or to others. • Impulsivity is the “hard” pole of the reflection (or self-control)-impulsivity dimension.

9. Impulsivity • Virtually all living species frequently make decisions that promise a benefit on the short run, but turn out to be detrimental on the long run. At the same time, humans have developed more or less efficient ways to manage the temptation of instant gratification.

10. Psychodynamic roots • An impulse is a disposition to act to decrease heightened tension caused by the buildup of instinctual drives or by diminished ego defenses against the drives.

11. Psychodynamic roots • Freud believed that (impulsive) gambling behavior results from an unconscious desire to lose or to relieve guilt.

12. Psychodynamic roots • Fenichel described an "impulse neurosis" in which patients experienced intense ego-syntonic pathological impulses that were often irresistible. The source of these impulses was seen as a fusion of instinctual urges and defensive strivings. Patients with an impulse neurosis were further described as having a low frustration tolerance and difficulty postponing immediate reactions or actions, and to get excitement from the act (arson/theft). • Fenichel saw this as a way to master painful affects by means of action. • Otto Fenichel (The Psychoanalytic Theory of Neurosis. New York: W.W. Norton, 1945), categorized addiction as an “impulse neurosis.” Addicts used drugs to “satisfy an archaic oral longing which is sexual...

13. Psychodynamic roots • Impulsivity is associated with ego weakness. • Impulsivity is also associated with incomplete sense of self, as a way to deal with fragmentation and with narcissistic rage. • It results from derangement in early development.

14. Impulsivity as learned behavior • Socially, impulsivity has been thought of as a learned behavior, coming from a family environment in which the child learns to “react immediately to obtain what is desired for gratification”.

15. Impulsivity, psychiatric disorders, and health problems • Is important in many psychiatric disorders (substance use disorders, psychoses, affective disorders, borderline personality disorder, ADHD) and is a key factor in the Impulse Control Disorders. • Contributes to major health problems: • Violence/aggression • Suicide • Accidents

16. Impulsivity • Did you ever feel the drive to enter the corrida?

17. Impulsivity • Did it occur to you that you will end up like this?

18. Impulsivity • Did you ever want to eat so eagerly?

19. Who is the impulsive type? • The matador (who likes danger, but is very calculate)? Or • The bull, who might know that he will be hit again and does not learn from experience. Out of his pride he attacks and gets killed?

20. IMPULSIVE INDIVIDUALS?

21. IMPULSIVE INDIVIDUALS?

22. IMPULSIVE INDIVIDUALS?

23. IMPULSIVE INDIVIDUALS?

24. People with symptoms of impulsivity often • Are impatient with waiting their turn or waiting in line. • Blurt out answers before questions have been completed. • Interrupt or intrude on others, such as butting into conversations or games. • Engage in reckless, risky, or antisocial activities without thinking about the consequences. Children and teens may be suspended or expelled from school for irresponsible behavior. Impulsiveness may also affect driving skills and general safety. • Have temper outbursts.

25. Additional characteristics: - decreased sensitivity to negative consequences of behavior. • rapid reaction before complete processing of information. - lack of regard for long-term consequences.

26. Components of Impulsivity • Inability to delay immediate gratification (despite long term negative consequences) • Distractibility • Disinhibition

27. Neurochemistry of impulsivity • A low serotonergic tone definitely plays an etiological role in impulsivity (low serotonin transmission, low 5-HT in CSF, blunted response of prolactin to 5-HT agonists, high “I” with tryptophan depletion). • However, dopamine (reward and reinforcement) and norepinehrine (arousal and extroversion) systems are also essential in impulse control.

28. Brain areas involved in impulsivity: • Orbito-frontal cortex (pre-frontal cortex- Phineas Gage). • Anterior cingulate cortex (24).

29. Main measures of Impulsivity • Self-report measures (pencil and paper tests). • Behavioral laboratory measures. • Event-related potentials (P-300 waves).

30. Self-report measures of Impulsivity • Barratt Impulsiveness Scale. • Impulsivity Control Scale (Plutchik) • Eysenck Impulsiveness Questionnaire. • Advantages: easy to administer, gather info on a variety of types of acts and on whether they constitute long-term patterns of behavior • Drawback- relies on subject’s veracity and self-awareness.

31. Plutchik Impulsivity Scale- answers on a 0-3 scale from never to almost always • Is it difficult for you to stand in cue? • Do you do things on the spur of the moment? • Do you spend money in an urge? • Do you plan for the future? • Do you have temper tantrums? • Do you concentrate easily? • Do you have difficulty in controlling your sexual feelings? • Do you say everything that comes into your mind?

32. Plutchik’s Impulsivity Scale- answers on a 0-3 scale from never to almost always • Do you eat also when you are not hungry? • Do you act from impulses? • Do you finish things that you have started? • Do you have difficulty controlling your feelings? • Are you easily distractible? • Do you have difficulty sitting still? • Are you careful?

33. Assessment of Impulsivity • Impulsivity was until recently assessed in the clinical setting with self-report scales and psychiatric examination. • However, self-assessment questionnaires may be biased by low self-awareness, lack of cooperation, faking-good and other test-taking attitudes, which may lead to an inaccurate evaluation of impulsivity.

34. Assessment of Impulsivity • Lately, there has been much interest in assessing impulsivity using computerized tests.

35. Assessment of impulsivity • Impulsivity appears to be strongly related to the “rapid response” model of “answering before thinking”. • Thus, two performance measures (reaction time and number of errors) are analyzed as measures of impulsivity.

36. Assessment of impulsivity • Through the person’s response control, one should be able in his decision making process to inhibit non-relevant information. • One should be able to delay response before checking all alternatives (prepotent inhibition), to stop an inappropriate response after the context has changed (interruptive inhibition) and to avoid distraction of competing events (interference inhibition).

37. Putting it in simple words! • Subjects respond to the target stimulus (e.g. a red square) according to certain rules and press a button. • Those who respond quickly and err are said to be impulsive. • There are 4 types of responses: fast and accurate, slow and accurate (reflective type), fast and inaccurate (impulsivity), and slow and inaccurate.

50. Psychological treatment of impulsivity 1. Insight Oriented Psychotherapy. 2. Cognitive Behavior Psychotherapy (modification of cognitive process and behavior, interpersonal problem solving, DBT). 3. Contingency Management (reinforcement, token economy).