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What is Impulsivity

A predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to themselves or others Moeller Am J Psychiatry 2001

Other features of impulsivity

Equated with impatience Motor and Non-planning component Sudden wish/urge/drive that prompts action/feeling Usually thought of as irrational but can be beneficial Diffuse versus targeted

Where do we see Impulsivity in DSM-IV?

Personality Disorders ADHD Substance Abuse Mania Neurological Syndromes Impulse Control Disorders Dementia

DSM-IV Recognized Impulse Control Disorders

Pathological Gambling Kleptomania Pyromania Trichotillomania Intermittent Explosive Disorder Impulse Control Disorders NOS

Common features of Impulse Control Disorders


Failure to resist impulses, urges to perform an act; no brakes in the brain Rise in tension or arousal before committing the act and relief/pleasure after Most start in adolescence and are chronic Almost never is just one problem -

comorbid psychiatric condtiions (depression, anxiety, OCD) and other impulsive conditions

Addiction & Impulse Control Disorders

Similarities to Addictions:

Loss of control Preoccupation, urges, pathological wanting Negative impact on major areas of life Major impacts on mood. Judgment and insight Tolerance/ Withdrawal

Addiction & Impulse Control Disorders

Differences from Addictions

No toxicology test to diagnosis it; easier to hide Behaviors are not due to drug effects (thus, makes it more open to shame/guilt) Greater uncertainty of outcome (i.e. anything can happen) Ego Dystonic or Ego Syntonic Mix of impulsive and compulsive

Spectrums of Impulsivity
Impulsivity Harm Minimization, underestimation Pleasure Seeking Sensitive to reward, insensitive to punishment Acts too quickly Compulsivity Harm Avoidance, overestimation Pleasure Avoiding Insensitive to reward, sensitive to punishment Acts too slowly

Neurobiology of Impulse Control Disorders

Neuroanatomical Neurochemical Genetic Differences Treatment Responses

Neurobiology of Impulsivity (Neuroanatomy)

Lesions in Nucleus Accumbens

Induces hyperactivity

Neurobiology of Impulsivity (Neuroanatomy)

Lesions in the Amygdala


Impaired decision making Increased impulsive choice

Neurobiology of Impulsivity

Lesions in the Anterior Cingulate Preclinical

Increased motor activity, over responding Assessment of response effort

Neurobiology of ICD (Neuroanatomy)

Potenzas Imaging Studies (PG vs Normals) Decreased activity in:


Left ventromedial PFC (Decision-making) Orbitofrontal cortex (processing of rewards, dealing with uncertainty, inhibiting responses) Anterior Cingulate (Decision-making) Ventral striatum (NA, Limbic system)

Neurobiology of Impulsivity Neurochemicals


Serotonin

Dopamine

Norepinephrine

Serotonin in Impulse Control Disorders


Serotonin (Raphe Nuclei, Hypothalamus)

decreased levels associated with


- suicide - personality disorders - gamblers - impulsive aggression

treatment response with SSRIs

Dopamine and Impulsivity


Known to code for reward, promotion of motivational drives, Amphetamine decreases impulsivity in ADHD
How? - 5-HT:DA balancing - Alter reinformcement patterns (delayed rewards become more meaningful)

Dopamine in impulse control


Dopamine - Altered levels found in pathological gamblers - urge to gamble activates same circuits as drug craving - higher metabolites found in the urine - too low in mesocortical areas and too high in mesolimbic areas - impaired acoustic startle

Neurobiology of Impulse Control Disorders Other Neurotransmitters


Noradrenergic deficit states GABA lack of proper inhibitory process
Opiate Systems Improper control of rewarding processes and regulatory mechanisms

Neurobiology of Impulse Control Disorders Genetics


Genetic Vulnerability - Twin and Family studies - Same genes for both substance use disorders and pathological gambling (Dopamine Receptors) - Serotonin (Impulsive Aggression)
Tryptophan Hydroxylase Serotonin Transporter Serotonin Receptor

Pathological Gambling
Biological: - Rapidity of Response (Slots, Betting Patterns, no time to screen and think) - Chasing behaviors; failure to inhibit behaviors, no brakes in the brain

Psychological: - Sensation-seeking, risk taking (naturally)


- Excessive sensitivity to rewards (Jackpots) - Excessive insensitivity to punishment (Continued playing despite losses) - Present-day orientation: (dont think about the future)

Social:
Environmental setting prime for impulsive behaviors (no clocks, fast-paced, quick decisions, supposed to be impulsive) Society values risk-taking, spontaneity and impulsiveness

Neurotransmitters
- Endogenous Opiates (Urges / Cravings)
Medications that block gambling urges (Naltrexone and Nalmefene) Epinephrine (Arousal) or Cortisol (Stress) PG may have disruptions in attention, sensation-seeking: juice

Meyer (2000) N= 10 male pathological gamblers Blackjack versus control game, 2 hours, in the casino Measured: Salivary Cortisol at 0, 30 min and 60 min Findings: increased cortisol of BJ > Control

Meyer (2004)
N= 14 male PG, 15 male non-PG Blackjack vs. Card Game Increased NE, Dopamine. (PG>Non-PG) Increased cortisol both groups (NS) at baseline and over time

Impulsivity and Pathological Gamblers: Research Questions

Does impulsivity worsen gambling? Does gambling worsen impulsivity? Does impulsivity lead to gambling? What are the factors that make gamblers more impulsive (sleep, drugs?) Can impulsivity be a target for interventions

Medications Strategies for Pathological Gamblers


- Usually start with: SSRIs, - To reduce impulsive behaviors? Topiramate 25mg 300 mg - To reduce cravings/urges, block the high Naltrexone (50200 mg) - Gamblers who are hyperthymic or with cyclical gambling patterns: Mood Stabilizers - To treat comorbid disorders / presenting symptoms use: SSRIs

Kleptomania Pathological Stealing

Characterized by:

Failure to resist impulses to steal objects that are NOT needed for personal use or for their monetary value. Increasing tension BEFORE stealing and then pleasure/relief at the time or AFTER stealing

Kleptomania

Mean age of onset is 20 years old. Prevalence estimated at 0.6% of the population and only 8% of shoplifters Women 4x more than men Very different from premeditated stealing or robbery (where money or personal use is the goal). Usually not fun.

Pharmacotherapy of Kleptomania

Case Series: Flouxetine Li & flouxetine Valproate

Pharmacotherapy of Kleptomania

Open Labeled:

Grant (2002) n= 10, Naltrexone 145 mg/day, 11 wk improved over all measures compared to baseline:

Pyromania

Characterized by:

Deliberate and purposeful fire setting Tension or arousal BEFORE setting fire and then pleasure/relief when setting fires or watching the aftermath Fascination with fire

Pyromania

Based on arsonists, true pyromania is rare.

Ritchie (1999) 3/283 cases of arsonists were pyromaniacs. Motives were: anger, delusions, revenge, money

Usually men more than women Associated with decreased 5-HIAA (although high PD comorbidity) Involvement with fire early on in life

Trichotillomania Craving to pull out hair

Characterized by:

Recurrent pulling out of hair resulting in noticeable hair loss Tension BEFORE pulling out the hair and pleasure/relief when or AFTER pulling.

Trichotillomania

Women more than men Prevalence somewhere between 0.6-3% of population Children more frequent than adults and oftentimes starts in teenage years

Alopecia areata.

Tinea capitus in a young male due to Microsporum audouinii.

Trichotillomania with a mixture of short and long hairs with hair loss in a linear fashion.

Pharmacotherapy of Trichotillomania

SSRIs : Symptom Remission

Lithium : Symptom Remission Typical Antipsychotics : Symptom Remission Atypicals : OLP, RISP, QTP: Symptom Remission Augmentation Risp + SSRI: Symptom Remission

Intermittent Explosive Disorder

Best Exemplified by Homer Simpson, Characterized by:

Failure to resist aggressive impulses that result in destroying stuff or assaultive acts Degree of aggressiveness is out of proportion to the triggering event All other Axis I/ II ruled out Recurrent Tends to be more ego dystonic,

Intermittent Explosive Disorder

McElroy (1999)

Interviewed 27 IED Accompanied by affective symptoms -- increased energy, racing thoughts and subsequent depression and reduction in energy 12/20 got better (50% less episodes)

50% response rate to SSRI 75% response rate to Mood stabilizer

Compulsive Shopping/Buying

Pathological Shopping

Characterized by excessive, and uncontrolled preoccupations regarding shopping and spending. Tension before, relief after Causes marked distress 2-8% of population, almost 80% female

Compulsive Sexual Behaviors

Characterized by excessive or uncontrolled sexual behaviors

Paraphilias vs. Conventional

Key is subjective distress and continued behavior despite negative consequences Rise in tension before, pleasure after Prevalence 5%? No good genetic studies

CSB Pharmacotherapy

Case Reports:

Lithium (3) TCAs 1) SSRIs (>15) Atypicals (1) Naltrexone (1) Antiandrogens: Progesterone (lower testosterone) GNRH Agonists (IM)

Other Agents:

What is the role of meds in Impulse Control Disorders?

What are the goals of medications?

To treat comorbid disorders like depression or anxiety disorders Can help with sleep, appetite and concentration May reduce urges and cravings Lays the groundwork for psychosocial treatments NO MAGIC PILLS

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