What are the effects of impulsiveness?

Facets of Impulsivity and Its Measurement

Impulsivity is a multifaceted personality trait. Factor analyses of self-report and behavioral measures that are used to assess this personality domain consistently demonstrate multiple distinct factors of impulsivity (Meda et al., 2009; Reynolds, Ortengren, Richards, & de Wit, 2006). For instance, Whiteside and Lynam (2001) identify four factors in common self-report measures of impulsivity. These include (1) lack of premeditation, (2) sensation seeking, (3) lack of perseverance, and (4) urgency. Lack of premeditation, reflecting a failure to think or plan before acting, is the most common conceptualization of impulsivity and is strongly captured by a majority of self-report measures of impulsivity. Sensation seeking refers to the pursuit of novel and exciting experiences (often despite or even because of the potential risks associated with those actions) (Zuckerman, Kolin, Pirce, & Zoob, 1964). Lack of perseverance reflects a failure to sustain attention or effort during tasks. Finally, urgency refers to a tendency to commit rash or regrettable actions in emotional contexts. Whiteside and Lynam's analysis explicitly describes this as occurring as a result of intense negative affect, for instance, being unable to resist a cigarette when anxious. The urgency domain is probably best broken down into two distinct domains of negative and positive urgency. The negative urgency domain, which occurs in the face of negative or aversive emotional states, is distinct from other facets of impulsivity as it is associated with the personality factor of neuroticism. Indeed, the most widely used Big 5 personality inventory, the NEO-PI-R, labels this negative urgency domain as impulsivity and includes it as one of the six facets of the neuroticism scale (Costa & MacCrae, 1992). This is strikingly different from other factors of impulsivity that show a greater relation to other personality factors including low conscientiousness or high extraversion (Whiteside & Lynam, 2001). Recent research indicates that a parallel domain labeled as positive urgency can be identified (Cyders et al., 2007), in which the person commits rash or regrettable actions when exposed to potential rewards.

Several self-report measures assess features of impulsivity. The Barratt Impulsivity Scale-11 (BIS11) is among the most widely used measures and distinguishes between attentional impulsivity, motor impulsivity, and nonplanning impulsivity (Patton, Stanford, & Barratt, 1995). The Urgency, Premeditation (lack of), Perseverance (lack of), Sensation Seeking (UPPS) Scale has been gaining in popularity due to its correspondence to factor analysis of the impulsivity domain (Whiteside & Lynam, 2001). Other frequently used measures include the Impulsiveness Scale developed by Eysenck and Eysenck (1978) and the Impulsiveness-Sensation-Seeking Scale by Zuckerman, Kuhlman, Joireman, Teta, and Kraft (1993).

Multiple behavioral paradigms also assess aspects of impulsivity. The most commonly used behavioral measures assess the ability to withhold or inhibit responses. For instance, in a go/no-go task, a prepotent ‘go’ response is established by having substantially more trials on which the subject should respond (go) than withhold their response (no-go) (Trommer, Hoeppner, Lorber, & Armstrong, 1988). The number of errors of commission (going on a no-go trial) is taken as an index of impulsivity. Alternatively, stop-signal reaction time tasks measure the time necessary to inhibit (countermand) a motor response (Logan, Cowan, & Davis, 1984).

A second class of behavioral measures of impulsivity assesses the ability (or inability) to wait for a delayed reward. This can be seen in terms of basic delay of gratification paradigms in which the individual is explicitly told that they can get a better reward if they do not consume a reward that is already present (Mischel, Shoda, & Rodriguez, 1992) or in more sophisticated temporal (delay) discounting paradigms in which the individual explicitly chooses between immediate or less delayed rewards relative to longer delayed rewards (Critchfield & Kollins, 2001). Arising in part from the behavioral economics literature, the temporal discounting paradigm allows for specific modeling of decision parameters, such as the discount rate, with impulsivity being reflected in steeper discount rates that reflect a greater valuation of immediate or quickly available rewards relative to long-term rewards.

Strikingly, these behavioral measures of impulsivity show at best modest associations with self-report measures of impulsivity (Meda et al., 2009; Reynolds et al., 2006). This likely is not a specific fault of either the self-report or the behavioral measures as much as they capture somewhat different psychological constructs. A critical advantage of behavioral measures of impulsivity is the ability to measure neural responses during performance of the task. Additionally, parallel tasks can be used in preclinical studies with animals. Indeed, go/no-go, stop-signal reaction time, and temporal discounting tasks have all been adopted for animal studies. Measures of premature responses, such as assessed by the 5-choice serial reaction time task (Robbins, 2002), have also proven particularly useful in examining the neuropharmacological substrates of impulsiveness.

Impulsivity

Impulsivity contributes to uncontrolled buying. Trait impulsivity has multiple components including urgency, lack of premeditation, lack of perseverance, and sensation seeking. De Sarbo and Edwards (1996) demonstrated that impulsivity is a predictor of higher scores on a compulsive buying assessment scale. The subscores for experience seeking using the Zuckerman Sensation-Seeking Scale and scores of impulsivity were higher than control participants (Lejoyeux et al., 2002).

The Impulsive Behavior Scale identifies four components of impulsivity: urgency, premeditation, perseverance, and sensation seeking. Using the Impulsive Behavior Scale, Billieux et al. (2008) found a significant correlation between compulsive buying and three of the components: urgency, lack of premeditation, and lack of perseverance. They concluded that a high level of urgency is related to a poorer ability to deliberately suppress buying impulses. Recent data suggested a complex relationship between impulsivity and compulsivity.

Abstract

Impulsivity is a temperamental risk factor for substance use and might be a fundamental mechanism in both onset of excessive substance use and relapse. Substance use may also facilitate impulsivity by interfering with normal inhibitory controls. Heroin users are more likely to show impulsivity, not because of the drug itself, but because of a preexisting premorbid impulsive disposition. Some temperament and character dimensions, like high novelty seeking (NS) and low self-directedness, are closely related to high levels of impulsivity and substance dependence. The subjects most vulnerable to substance dependency are those with high impulsivity and/or high NS. Motor impulsivity dimension especially seems to play a major role in the age of onset of drug use and may be related to relapse in heroin-dependent individuals. Measures of impulsivity dimensions seem therefore related to different measures of temperament; a combined approach to this issue could help to create more homogeneous diagnostic categories and aid in the identification of at-risk individuals for specific symptoms, behaviors, or treatment responses. When treating heroin-dependent patients, the types of impulsivity and personality dimensions must be evaluated and the treatment should be shaped accordingly.

Key Facts on Impulsivity

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Impulsivity refers to a person’s behavior without thinking about the action; it occurs in response to internal or external stimuli, to fulfill a short-term goal.

Impulsivity is present in many conditions such as mania, substance use disorder, ADHD, antisocial personality disorder, and borderline personality disorder.

ADHD has impulsivity as a core feature. Behavior manifestations of impulsivity in ADHD are not being able to wait for one’s turn in class, in the playground, and not being able to understand risk in a given situation. Impulsivity leads to aggressive behavior and results in impaired relations with peers and family.

In adults with ADHD, impulsivity can lead to various behaviors that they may regret later.

Impulsivity can be treated with behavioral methods and cognitive behavior therapy.

2.1 Impulsivity as a Personality Trait: Its Role in Different Models of Personality

Impulsivity is a prominent personality trait both in healthy subjects, psychiatric syndromes and personality disorders. According to the theoretical formulations by Eysenck and Eysenck (1975), impulsivity was originally part of the extraversion concept based on an optimal level of arousal theory. However, it was repeatedly pointed out by Schalling (1978) that Extraversion (E) in the Eysenck Personality Inventory (EPI; Eysenck & Eysenck 1964) was composed of both Sociability and Impulsiveness. Later, when the Eysenck Personality Questionnaire (EPQ; Eysenck & Eysenck 1975) was introduced, impulsiveness was included in the Psychoticism dimension, while sociability was kept in the E scale (Schalling 1978). These changes gave rise to the results that tobacco smoking, strongly related to impulsivity, correlated with E on the EPI (e.g. Eysenck et al. 1960), while in the EPQ a stronger relation was demonstrated between tobacco smoking and Psychoticism (von Knorring & Oreland 1985; McManus & Weeks 1982), indicating the importance of impulsivity as a personality trait. Additional findings suggested that the Psychoticism dimension, including impulsivity, is associated with psychopathy and lack of conformity to social norms (Robinson & Zahn 1985). Gray et al. (1983) included susceptibility to signals of reward and punishment into his model of impulsivity/anxiety in describing the dimensions of introversion-extraversion. Zuckerman (1979, 1991) also developed a psychobiological approach to impulsivity. He developed an optimal level of arousal theory of sensation seeking as a main component in disinhibitory behavior (Zuckerman 1994). In his model, impulsivity is mainly related to the Disinhibition subscale of the Sensation Seeking Scale (SSS) while Sociability and Novelty Seeking is included in the Thrill and Adventure Seeking and Experience Seeking scales. In the Karolinska Scales of Personality (KSP) constructed during the 1970s by Schalling, the dimensions of impulsivity and novelty seeking are included in the impulsiveness and monotony avoidance scales (Schalling et al. 1987). The latter scale is closely related to the SSS. The Impulsiveness scale is related to “subsolidity” in the personality dimensional system described by the Swedish psychiatrist Sjöbring (Essen-Möller 1980).

Impulsivity seems to be a very basic trait with a high genetic component (Seroczynski et al. 1999). It has been suggested that impulsivity may eventually be a more productive target for study than any of the currently available personality disorders (Ruegg & Frances 1995), and there is an ongoing discussion on impulsivity, its multidisciplinary characteristics and its psychiatric and social consequences (Barratt & Slaughter 1998; Ruegg & Frances 1995). In the present chapter, results from different research groups on the issue of impulsivity will be reviewed and related to psychosocial disturbances. However, different research groups define impulsivity differently, and impulsivity scales load on different parts of the personality spectrum. The impulsiveness scale as used in the KSP is, according to a factor analytical study reported by Zuckerman, closely related to the Psychoticism-Unsocialized Sensation Seeking factor (Figure 1).

Cognitive Control and Psychosocial Treatment of Compulsive-Impulsive Behaviors

Impulsivity is a hallmark of both substance addiction and compulsive-impulsive behaviors. In these conditions, impulsivity may arise due to dysregulation of prefrontal cortex circuitry (Jentsch & Taylor, 1999). A possible mechanism for such impulsivity is alteration in glutamate and dopamine functioning in the prefrontal cortex (as discussed in the preceding section), which compromises the transmission of inhibitory regulations, leading to increased impulsivity (Kalivas & O’Brien, 2008). Strengthening cognitive control is a key psychosocial strategy to counteract impulsivity in both substance addiction and compulsive-impulsive behaviors. Such psychosocial treatments generally rely on a relapse prevention model that promotes abstinence using a three-fold strategy: (1) identify patterns of abuse, (2) avoid or manage high-risk situations, and (3) select alternative, healthier behaviors. Specific psychosocial treatments using the relapse prevention model include motivational enhancement, cognitive behavioral therapies, and the 12-step self-help approaches. These strategies have proven to be effective in the treatment of a range of compulsive-impulsive behaviors, including kleptomania, pathological gambling, compulsive sexual behavior, pathological skin picking, and compulsive buying (Mitchell, Burgard, Faber, Crosby, & de Zwaan, 2006; Petry et al., 2006; Teng, Woods, & Twohig, 2006; Toneatto & Dragonetti, 2008).

Impulsivity

Impulsivity has consistently been associated with chemical and nonchemical addictions. Impulsivity means a tendency to get involved in rapid and unplanned reactions to stimuli before completing the processing of information, which means a decreased sensitivity to negative consequences of behavior. Impulsive people get involved in risky behaviors to ease tension or gain pleasure and do not pay attention to long-term consequences. An association between nonchemical addictions and attention deficit hyperactivity disorder (ADHD), a disorder related to poor psychosocial functioning in which impulsivity plays a major role, has often been reported.

Impulsivity and Impulsive Choice

Impulsivity, defined as action without foresight, is heritable and that brings it into the purview of geneticists. Because the brain and genome are not conveniently divided by function, neurogeneticists will discover the genes that determine, and influence, impulsivity. Impulsivity is an important dimension of normal behavior: for many of life’s challenges it is vital to be able to initiate behavior, to take action, and to explore uncertain and potentially dangerous situations.

Astonishingly and unpleasantly for some with particular political or anti-psychiatry agendas, the genomic revolution has already enabled me and my colleagues to identify what some, including some lawyers, might view as the ultimate goals in the prediction of criminal behavior due to impulsivity. These studies on the genetic underpinnings of impulsivity also have major implications for normal behavior and for several psychiatric diseases, including the addictions, bipolar depressive disorder, antisocial personality disorder and attention deficit hyperactivity disorder, in which impulsivity is a significant feature. Worldwide, suicide is a major cause of death, accounting for a million deaths a year according to the World Health Organization, and people who are impulsive are far more likely to kill themselves.

4.5.3 Impulsivity

Impulsivity is reported frequently (Clarke & Boer, 1998; Dykens & Smith, 1998; Smith et al., 1998), with prevalence rates of over 80% (Dykens et al., 1997). High proportions of clinically elevated impulsivity scores are reported in children and adults (40% and 58.3%, respectively, Oliver et al., 2011) and impulsivity has been reported to be a primary problem behavior, associated with “demands being needed to be met immediately” suggesting this may be related to intolerance of delay to reward (Clarke & Boer, 1998).

Impulsivity

Impulsivity is generally associated with a deficit in reflectiveness and planning, rapid decision-making and action, and a failure to inhibit a behavior that is likely to result in negative consequences. It is clear from the literature on substance misuse in adolescent and adult samples that impulsive traits play a prominent role in addictive behavior. Impulsivity has often been associated with substance misuse, specifically, quantity and frequency of drug use, and early experimentation with drugs. Impulsivity has also been associated with the consumption of a range of different drugs, such as cannabis, ecstasy, and heroin use, and is the personality trait that has most consistently been associated with alcohol disorders in the literature.

Longitudinal studies have also identified impulsivity/disinhibited traits as risk factors for future substance misuse. For example, impulsivity in childhood, as measured by either Eysenck's psychoticism or Cloninger's novelty seeking, has been found to predict substance misuse and alcohol-related problems in adolescence and adulthood, with a study by Cloninger and colleagues showing those reporting high scores in impulsivity to be 20 times more likely to report alcoholism in adulthood compared with those who do not report high scores on this trait. Impulsivity measured by higher-order factors or super-factors like constraint (i.e. Multidimensional Personality Questionnaire or the Minnesota Multiphasic Personality Questionnaire) or by lower-order, more specific measures of impulsivity (e.g. Substance Use Risk Profile Scale) assessed in childhood or early adolescence, have also been prospectively associated with alcohol and drug use in late adolescence and young adulthood. However, it is important to highlight that some laboratory studies have shown that severe and persistent substance use can result in deficits in behavioral and/or cognitive measures of impulsivity, such as response inhibition and decision-making, and even in increased levels of self-report trait impulsivity, suggesting the possibility that the pathway from impulsivity to substance misuse is bidirectional. This highlights the importance of assessing both measures of impulsivity and substance use simultaneously across time, so that cross-lag or bidirectional effects can be evaluated. With this in mind, a recent study by Littlefield, Sher, and Wood evaluated, using latent growth models, the extent to which changes in personality and changes in drinking behavior covary across early adulthood and showed that changes in drinking behavior from 18 to 35 years of age tend to co-occur with changes in impulsivity (as well as neuroticism). While this analysis does not provide direct evidence for causal effects between these two factors, the findings suggest that the relationship between impulsivity and drinking behavior may be more complex than a simple causal relation and may be reflecting a mutually exacerbating relationship.

There is now enough evidence – provided particularly by studies on children of alcoholics as well as by studies on nonsubstance use–related addictions such as problem gambling, where the vulnerability mechanisms underlying addiction can be studied without the confounding effects of substance use – showing that impulsivity is indeed a risk factor for addiction. For example, studies on children of alcoholics, considered to be at a higher risk for future alcohol problems due to genetic vulnerability, have found that many of these children exhibit high levels of impulsive personality traits and behaviors, with some even showing that disinhibited traits mediate the relationship between family history of alcoholism and drinking behavior.

Studies on problem gambling have shown similar results than those in the substance use field, indicating that compared with nongambling controls, problem gamblers demonstrate increased scores on a range of impulsivity-related measures. Similar to findings in the alcohol, and drug use literature, impulsivity scores have also been shown to predict gambling symptom severity in clinical samples of problem gamblers, as well as community-recruited adolescents. Finally, several studies provide evidence for the hypothesis that impulsivity is a common risk factor for (or associated with shared vulnerability to) gambling and substance use problems, as well as other addictive behaviors and externalizing problems, such as antisocial behavior.

Although there is some research showing that impulsivity (or undercontrol) assessed early in childhood is associated with alcohol problems in early adulthood in men but not women, varied research has shown that men and women tend to report similar levels of impulsivity – this is not the case though if the impulsivity measure includes “aggressive tendencies” (such as the measure of constraint) on which men score higher – and similar associations between impulsivity and later substance use or other addictive behaviors.