A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient.

Impulsiveness in personality disordered forensic patients is associated with poor treatment completion and high risk of re-offending. A biofeedback training protocol, previously found to reduce impulsiveness and improve attention in children with Attention Deficit Hyperactivity Disorder, was used in an initial attempt to reduce impulsiveness in a severely personality disordered man with borderline, antisocial and histrionic features. Electrocortical, behavioural and self-report measures of impulsiveness were taken before and immediately following 6 weeks of biofeedback training and at 3 months follow-up. The patient successfully engaged with the intervention. His self-reports of reduced impulsiveness and improved attention were corroborated by behavioural and electrocortical measures that indicated reduced impulsiveness and better focused attention. Results suggest this intervention might prove useful in improving behavioural and emotional self-regulation in severely personality disordered patients.

Impulsivity and home-cage activity are decreased by lentivirus-mediated silencing of serotonin transporter in the rat hippocampus.

Brain serotonin (5-HT) systems modulate emotional, motivational and cognitive processes. Mutations in the serotonin transporter (SERT) gene have been associated with susceptibility towards the development of several psychiatric disorders, both in humans and animal models. Present approach exploited a bilateral intra-hippocampus stereotaxic inoculation of lentiviruses, for enduring in vivo silencing of SERT. Control rats were bilaterally inoculated with heat-inactivated lentiviruses. These Lenti-SERT vectors were intended to eventually manipulate the neurotransmitter reuptake at synaptic level, thus enhancing tonic 5-HT transmission. We investigated whether such manipulation could induce behavioural alterations relevant to the modelling of ADHD, in particular symptoms of hyperactivity and impulsivity. Wistar rats were monitored for spontaneous home-cage locomotor activity and studied for impulsivity (Intolerance-to-Delay task). Results show that rats inoculated with Lenti-SERT vectors exhibited less pronounced circadian peaks of activity than controls. Moreover, Lenti-SERT compared to control rats exhibited a transient increase in choice for a delayed-larger reward over an immediate-small reward. This suggests that enhanced hippocampal serotonergic transmission produced a profile of restfulness and a decrease in cognitive impulsivity. This phenotype is consistent with available data both on 5-HT manipulations and hippocampal lesions. In conclusion, present findings may possibly disclose novel avenues towards the development of innovative therapeutical approaches for behavioural symptoms relevant to ADHD.

A double-blind trial of the effect of docosahexaenoic acid and vitamin and mineral supplementation on aggression, impulsivity, and stress.

OBJECTIVES: Although a series of well-designed studies have reported that supplementation with vitamins/minerals and omega-3 fatty acids reduces the incidence of aggressive behavior, to date, the relative contribution and interaction between these nutrients has not been examined. The aim was therefore to consider the relative contribution of supplementation with multivitamins/minerals and/or docosahexaenoic acid (DHA) on laboratory-based measures of aggression, impulsivity, and stress. METHODS: In a double-blind randomized trial, four groups of young adult men without a history of aggressive or impulsive behavior received a placebo (n = 42), multivitamins/minerals (n = 43), DHA (n = 47) or both (n = 41) for 3 months. RESULTS: With the Picture-Frustration Task, DHA decreased the display of aggressive behavior. DHA also decreased impulsivity as measured using the GoStop Impulsivity Paradigm that examines the ability to inhibit already initiated behavior. Although a multivitamin and mineral supplement did not influence these measures, it did decrease perceived stress. CONCLUSIONS: The influence of supplementation on aggression and impulsivity can be conveniently studied in a sample without a history of antisocial behavior, using laboratory-based measures. No evidence was found of a synergistic interaction between vitamins/minerals and DHA.

Effects of the Youth Empowerment Seminar on impulsive behavior in adolescents.

PURPOSE: Because impulsivity during adolescence predicts health-risk behaviors and associated harm, interventions that attenuate impulsivity may offer protection. We evaluated effects of the Youth Empowerment Seminar (YES!), a biopsychosocial workshop for adolescents that teaches skills of stress management, emotion regulation, conflict resolution, and attentional focus, on impulsive behavior. METHODS: High school students (14-18 years of age) in the United States participated in YES! during their physical education classes. Students in a control group attended their usual curriculum and were tested in parallel. We used items from the Barratt Impulsiveness Scale (framed to reflect recent behavior) to assess students' behavior before and after they underwent the program. RESULTS: Compared with the control group, YES! participants reported less impulsive behavior after the program. CONCLUSIONS: The results suggest that YES! can promote mental health in adolescents, potentially protecting them from harmful coping behaviors.

Baseline-dependent effects of cocaine pre-exposure on impulsivity and D2/3 receptor availability in the rat striatum: possible relevance to the attention-deficit hyperactivity syndrome.

We have previously shown that impulsivity in rats predicts the emergence of compulsive cocaine seeking and taking, and is coupled to decreased D2/3 receptor availability in the ventral striatum. As withdrawal from cocaine normalises high impulsivity in rats, we investigated, using positron emission tomography (PET), the effects of response-contingent cocaine administration on D2/3 receptor availability in the striatum. Rats were screened for impulsive behavior on the five-choice serial reaction time task. After a baseline PET scan with the D2/3 ligand [(18)F]fallypride, rats were trained to self-administer cocaine for 15 days under a long-access schedule. As a follow-up, rats were assessed for impulsivity and underwent a second [(18)F]fallypride PET scan. At baseline, we found that D2/3 receptor availability was significantly lower in the left, but not right, ventral striatum of high-impulsive rats compared with low-impulsive rats. While the number of self-administered cocaine infusions was not different between the two impulsivity groups, impulsivity selectively decreased in high-impulsive rats withdrawn from cocaine. This effect was accompanied by a significant increase in D2/3 receptor availability in the left, but not right, ventral striatum. We further report that D2/3 receptor availability was inversely related to baseline D2/3 receptor availability in the ventral striatum of high-impulsive rats, as well as to the left and right dorsal striatum of both low-impulsive and high-impulsive rats. These findings indicate that the reduction in impulsivity in high-impulsive rats by prior cocaine exposure may be mediated by a selective correction of deficient D2/3 receptor availability in the ventral striatum. A similar baseline-dependent mechanism may account for the therapeutic effects of stimulant drugs in clinical disorders such as ADHD.

European, randomized, phase 3 study of lisdexamfetamine dimesylate in children and adolescents with attention-deficit/hyperactivity disorder.

This study evaluated the efficacy and safety of lisdexamfetamine dimesylate (LDX) compared with placebo in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in Europe. Osmotic-release oral system methylphenidate (OROS-MPH) was included as a reference arm. Patients (6-17 years old) with a baseline ADHD Rating Scale version IV (ADHD-RS-IV) total score ≥ 28 were randomized (1:1:1) to dose-optimized LDX (30, 50, or 70 mg/day), OROS-MPH (18, 36, or 54 mg/day) or placebo for 7 weeks. Primary and key secondary efficacy measures were the investigator-rated ADHD-RS-IV and the Clinical Global Impressions-Improvement (CGI-I) rating, respectively. Safety assessments included treatment-emergent adverse events (TEAEs), electrocardiograms, and vital signs. Of 336 patients randomized, 196 completed the study. The difference between LDX and placebo in least squares mean change in ADHD-RS-IV total score from baseline to endpoint was -18.6 (95% confidence interval [CI]: -21.5 to -15.7) (p<0.001; effect size, 1.80). The difference between OROS-MPH and placebo in least squares mean change in ADHD-RS-IV total score from baseline to endpoint was -13.0 (95% CI: -15.9 to -10.2) (p<0.001; effect size, 1.26). The proportions (95% CI) of patients showing improvement (CGI-I of 1 or 2) at endpoint were 78% (70-86), 14% (8-21), and 61% (51-70) for LDX, placebo, and OROS-MPH. The most common TEAEs for LDX were decreased appetite, headache, and insomnia. Mean changes in vital signs were modest and consistent with the known profile of LDX. LDX was effective and generally well tolerated in children and adolescents with ADHD.

Memantine reduces stealing behavior and impulsivity in kleptomania: a pilot study.

Kleptomania is characterized by repetitive stealing behavior and has been associated with deleterious unwanted outcomes including forensic contact and increased rates of suicidal behavior. Very few trials have been conducted to investigate pharmacological treatment options for this neglected condition. Memantine is an NMDA-receptor antagonist that has shown promising results in the treatment of other behavioral addictions and substance addictions. Twelve individuals with kleptomania received memantine (10 mg/day, titrated to 30 mg/day maximum depending on clinical response and tolerability) over the course of 8 weeks, in an open-label trial. The effects of treatment were quantified using well-validated measures and select neurocognitive tests (last observation carried forward analyses). Kleptomania disease severity scores decreased across all measures considered, and 11 (91.7%) of the participants met the responder criteria (35% improvement on the primary effectiveness measure plus CGI improved/very much improved; significant improvements were also observed in terms of mood, anxiety, and disability scores along with a significant improvement in stop-signal response inhibition. Memantine was generally well tolerated. This study shows the effectiveness of memantine in reducing urges to shoplift and shoplifting behavior along with improving impulsivity, mood, anxiety, and psychosocial functioning.

Differential effects of dopamine transporter inhibitors in the rodent Iowa gambling task: relevance to mania.

RATIONALE: The Iowa Gambling Task (IGT) can be used to quantify impulsive and risky choice behaviors in psychiatric patients, e.g., bipolar disorder (BD) sufferers. Although developing treatments for these behaviors is important, few predictive animal models exist. Inhibition of the dopamine transporter (DAT) can model profiles of altered motor activity and exploration seen in patients with BD. The effect of DAT inhibition on impulsive choices related to BD has received limited study however. We used a rodent IGT to elucidate the effects of similarly acting drugs on risky choice behavior. OBJECTIVES: We hypothesized that (1) C57BL/6 mice could adopt the "safe" choice options in the IGT and (2) DAT inhibition would alter risk preference. METHODS: Mice were trained in the IGT to a stable risk-preference and then administered the norepinephrine/DAT inhibitor amphetamine, or the more selective DAT inhibitors modafinil or GBR12909. RESULTS: Mice developed a preference for the "safe" option, which was potentiated by amphetamine administration. GBR12909 or modafinil administration increased motor impulsivity, motivation significantly, and risk preference subtly. CONCLUSIONS: The rodent IGT can measure different impulse-related behaviors and differentiate similarly acting BD-related drugs. The contrasting effects of amphetamine and modafinil in mice are similar to effects in rats and humans in corresponding IGT tasks, supporting the translational validity of the task. GBR12909 and modafinil elicited similar behaviors in the IGT, likely through a shared mechanism. Future studies using a within-session IGT are warranted to confirm the suitability of DAT inhibitors to model risk-preference in BD.

Effect of modafinil on impulsivity and relapse in alcohol dependent patients: a randomized, placebo-controlled trial.

Poor impulse control plays an important role in the development, course and relapse of substance use disorders. Therefore, improving impulse control may represent a promising approach in the treatment of alcohol dependence. This study aimed to test the effect of modafinil on impulse control and alcohol use in alcohol dependent patients (ADP) in a randomized, double-blind, placebo-controlled trial. Eighty-three abstinent ADP were randomized to 10 weeks modafinil (300 mg/d) or placebo. Alcohol use was quantified using the timeline follow-back method and was assessed until 6 months after treatment discontinuation. Impulsivity was assessed using self-report questionnaires (Barratt Impulsiveness Scale; State Impulsivity questionnaire) and neurocognitive tasks (Stop Signal Task; Delay Discounting Task) administered before, during and after treatment. Modafinil significantly improved self-report measures of state impulsivity, but had no effect on percentage of abstinent days or percentage of heavy drinking days, nor on the behavioral measures of impulsivity. However, subgroup analysis revealed that modafinil prolonged the time to relapse (p=.022) and tended to increase the percentage of abstinent days (p=.066) in ADP with poor response inhibition at baseline, whereas modafinil increased the percentage of heavy drinking days (p=.003) and reduced the percentage of abstinent days (p=.002) in patients with better baseline response inhibition. Overall results do not favor the use of modafinil in order to reduce relapse or relapse severity in ADP, and caution is required in prescribing modafinil to a non-selected sample of ADP. Further research on the effect of modafinil in ADP with poor baseline response inhibition is warranted.

Antagonism of L-type Ca(v) channels with nifedipine differentially affects performance of wildtype and NK1R-/- mice in the 5-Choice Serial Reaction-Time Task.

Mice with functional ablation of the substance P-preferring receptor gene ('Nk1r' in mice ('NK1R-/-'), 'TACR1' in humans) display deficits in cognitive performance that resemble those seen in patients with Attention Deficit Hyperactivity Disorder (ADHD): namely, inattentiveness, impulsivity and perseveration. A recent report suggested that the L-type Ca(v) channel blocker, nifedipine, can ameliorate behavioral abnormalities of this type in humans. In light of evidence that NK1R antagonists modulate the opening of these L-type channels, we investigated whether nifedipine modifies %premature responses (impulsivity), perseveration or %omissions (inattentiveness) in the 5-Choice Serial Reaction-Time Task (5-CSRTT) and whether the response differs in NK1R-/- and wildtype mice. %Premature responses and perseveration were reduced in both genotypes, although wildtype mice were more sensitive to the effects of nifedipine than NK1R-/- mice. By contrast, nifedipine greatly increased %omissions but, again, was more potent in wildtypes. %Accuracy and locomotor activity were unaffected in either genotype. We infer that behavior of mice in the 5-CSRTT depends on the regulation of striato-cortical networks by L-type Ca(v) channels and NK1R. We further suggest that disruption of NK1R signaling in patients with ADHD, especially those with polymorphisms of the TACR1 gene, could lead to compensatory changes in the activity of L-type channels that underlie or exacerbate their problems. This article is part of a Special Issue entitled 'Cognitive Enhancers'.

The power of social influence over food intake: examining the effects of attentional bias and impulsivity.

Numerous studies have shown that people adjust their intake directly to that of their eating companions. A potential explanation for this modelling effect is that the eating behaviour of others operates as an external eating cue that stimulates food intake. The present study explored whether this cue-reactive mechanism can account for modelling effects on intake. It was investigated whether attentional bias towards dynamic eating cues and impulsivity would influence the degree of modelling. Participants completed one individual session and one session in which an experimental confederate accompanied them. In the first session, eye movements were recorded as an index of attentional bias to dynamic eating cues. In addition, self-reported impulsivity and response inhibition were assessed. The second session employed a between-participants design with three experimental conditions in which participants were exposed to a same-sex confederate instructed to eat nothing, a low or a large amount of M&Ms. A total of eighty-five young women participated. The participants' self-reported impulsivity determined the occurrence of modelling; only low-impulsive women adjusted their intake to that of their eating companion. Attention towards eating cues and response inhibition, however, did not moderate modelling of food intake. The present study suggests that cue-reactive mechanisms may not underlie modelling of food intake. Instead, the results emphasise the importance of social norms in explaining modelling effects, whereas it is suggested that the degree of impulsivity may play a role in whether or not women adhere to the intake norms set by their eating companion.

Using stop signals to reduce impulsive choices for palatable unhealthy foods.

OBJECTIVE: Exposure to palatable foods in the environment can trigger impulsive reactions to obtain them, which may lead to unhealthy food choices and eating behaviour. Two studies tested the fundamental question whether impulsive unhealthy food choices can be altered by means of linking unhealthy palatable foods to behavioural stop signals. DESIGN: Study 1 adopted a 2 (signal condition: stop signal vs. control) by 2 (appetite: low vs. high) between-subjects design. Study 2 adopted a 2 (signal condition: stop signal vs. control) between-subjects design with frequency to consume unhealthy palatable foods as a continuous factor. METHODS: Participants performed a task in which behavioural stop signals were either consistently (or not) presented in close temporal proximity to unhealthy palatable snack foods. Next, participants were given the opportunity to select snacks that they would like to consume. RESULTS: Two studies showed that participants were less likely to select unhealthy palatable foods that had been presented near stop signals, and that they selected healthy foods instead. Importantly, this reduction in choices for palatable foods was especially observed when participants' appetite was relatively high (Study 1), or when this food was part of their habit to frequently consume this food (Study 2). CONCLUSION: These findings show that a short stop signal intervention in which palatable foods are presented in close temporal proximity of stop signals can reduce palatable food choices by modifying an impulsive determinant of eating behaviour. STATEMENT OF CONTRIBUTION: What is already known on this subject? Exposure to unhealthy palatable foods in the environment can lead to impulsive food choices. People's habits towards unhealthy palatable foods and their current state of appetite are important determinants of such impulsive food choices. This impulsive behaviour is hard to change. What this study add? Linking unhealthy palatable foods to behavioural stop signals reduces choices for these foods, and increases healthy food choices. This effect is particularly strong when people's food choices are driven by their current state of appetite or habits. Behavioural stop signals foster healthy eating behaviour by modifying an impulsive determinant of behaviour.

[Repetitive impulse-associated behavioral disorders in Parkinson's disease]. / Repetitive impulsassoziierte Verhaltensstörungen beim Morbus Parkinson.

Parkinson's disease (PD) is associated with a number of behavioral disorders which may cause considerable social, professional or financial problems. Impulse control disorders (ICDs), such as pathological gambling, binge eating, compulsive shopping and hypersexuality occur in approximately 13-14% of PD patients. Further behavioral disorders are the dopamine dysregulation syndrome (DDS), a substance dependence characterized by craving for dopaminergic substances and punding (prolonged repetitive activities which are not goal-oriented).Treatment-related risk factors are dopamine agonists for ICDs and a high total dopaminergic dose for DDS and punding. Shared risk factors are young age at onset, impulsive personality traits, depression and possibly dyskinesia. At the neuronal level these behavioral disorders seem to be associated with changes in the reward system and dysfunction of the orbitofrontal cortex. The evidence level for management strategies is at present insufficient. For ICDs current clinical practice consists of discontinuation or reduction of dopamine agonists.

The role of impulsivity in the relationship between anxiety and suicidal ideation.

BACKGROUND: The purpose of the present study was to examine the degree to which trait and cognitive (looming cognitive style) measures of anxiety are associated with suicidal ideation (SI), as well as whether trait and cognitive (time misperception) measures of impulsivity moderate the association between these variables. METHODS: The sample included 100 undergraduate students (72% female) who completed the Spielberger State-Trait Anxiety Inventory, Looming Maladaptive Style Questionnaire, Barratt Impulsiveness Scale, Time Paradigm Version 1.0 Task, Beck Scale for Suicidal Ideation, and the Brief Symptom Inventory. RESULTS: Trait anxiety and looming cognitive style were found to be positively associated with SI. Further, both trait impulsivity and time misperception moderated the association between these variables and SI, but in a different manner. Consistent with study hypotheses, among those high in trait anxiety, greater overestimation of time was associated with a higher likelihood of SI. Contrary to study hypotheses, among those low in trait anxiety, high trait impulsivity was associated with a greater likelihood of SI. The same pattern of results was found when looming cognitive style served as the independent variable. LIMITATIONS: The use of a cross-sectional design limits the ability to determine the temporal relationship of the study variables. Further, the sample included predominantly Caucasian undergraduates and thus study results may not generalize to other populations. CONCLUSIONS: Clinically, results suggest that high trait anxiety, looming cognitive style, time misperception, and trait impulsivity may be important risk factors for SI among college students and thus should be assessed when students present for treatment. Treatments that focus on problem solving, cognitive restructuring, and affect regulation strategies may help decrease anxiety and impulsivity, which in turn may help reduce the likelihood of suicidal thoughts.

Changing attitudes about self-injury prevention management: lessons learned.

In the behavioral health environment, nurses often use continuous staff monitoring and, at times, physical restraints, to manage the severity of patients' self-injury. Both options put staff in control, are the most restrictive in nature, and can be financially draining on the hospital's budget. This can result in negative reactions by both patients and staff. It is important to develop a program that will empower patients to control their behavior and allow staff to be aware of their perceptions and attitudes toward patients who self-injure. This article describes the leadership initiative that drove the development, training, and implementation of a self-injury prevention project and the lessons learned by staff.

Training children with ADHD to minimize impulsivity in auditory contralateral masking.

OBJECTIVE: Impulsivity and distractibility are among the important symptoms of attention deficit hyperactivity disorder (ADHD). In this study, impulsivity is operationally measured using false-alarm rates in an auditory, contralateral-masking task. Intensive auditory training was attempted to decrease false alarm rates. METHODS: In contralateral masking there is a distracting noise in one ear on every trial and a threshold-level tone in the other ear on half of those trials. Participants indicated whether the tone was present or not and received immediate feedback. The intensity of the masked tone was adaptively varied to track threshold. False alarms are the error of commission, saying that a stimulus is present when it is not. Seven school-aged children with ADHD (ages 10-16) and four adults without ADHD were trained on this task for 900 trials per day over four consecutive days. RESULTS: False alarms from the children with ADHD decreased over the four days of training, beginning at the high level and ending at the low level expected from previous studies. There was no generalization to a different masking task. Results from the four adults were unexpected: soon after the training began they behaved no differently than the children with ADHD. CONCLUSION: Children with ADHD can be trained to become less impulsive in an auditory detection task.

Chronic corticosterone exposure during adolescence reduces impulsive action but increases impulsive choice and sensitivity to yohimbine in male Sprague-Dawley rats.

Chronic stress during adolescence is associated with an increased risk for alcoholism and addictive disorders. Addiction is also associated with increased impulsivity, and stress during adolescence could alter cortical circuits responsible for response inhibition. Therefore, the present study determined the effect of chronic exposure to the stress hormone corticosterone (CORT) during adolescence on tests of impulsivity in adulthood and examined possible biochemical mechanisms. Male Sprague-Dawley rats were exposed to CORT by their drinking water during adolescence (post-natal day 30-50). The rats were then tested in adulthood to assess behavior on the 5-choice serial reaction time task (5CSRTT), stop-signal reaction time task (SSRTT), and the delay-discounting task, which differentially assess attention, impulsive action, and impulsive choice. Yohimbine-induced impulsivity on the 5CSRTT and biochemical analysis of the lateral orbital frontal cortex (lOFC) was also assessed owing to the ability of yohimbine to activate the hypothalamic-pituitary-adrenal axis and influence impulsivity. Adolescent CORT-treated rats were found to behave largely like controls on the 5CSRTT, but did show reduced premature responses when the intertrial interval was increased. Nevertheless, the CORT-treated rats tended to have more yohimbine-induced impulsive responses at low doses on this task, which was not found to be due to increased pCREB in the lOFC, but could be related to a higher expression/activity of the AMPA receptor subunit GluR1. Adolescent CORT-treated rats performed more accurately on the SSRTT, but showed greater impulsivity on the delay-discounting task, as indicated by steeper discounting functions. Therefore, adolescent CORT exposure reduced impulsive action but increased impulsive choice, indicating that chronic stress hormone exposure in adolescence can have long-term consequences on behavior.

Design and development of a Telephone-Linked Care (TLC) system to reduce impulsivity among violent forensic outpatients and probationers.

Forensic services face the challenge of reducing relapse among clients with a history of violent crime. An automated interactive voice response (IVR) service of the complex Telephone-Linked Care (TLC) type, with a focus on reducing impulsivity, could improve the adequacy of service responses to client needs. Theoretically based in Dialectical Behavior Therapy (DBT), Cognitive Behavior Therapy (CBT) and Motivational Interviewing (MI), the forensic TLC system offers interactive conversations on coping with the emotions of anger, shame and loneliness; activities of daily life such as getting out of bed, asking for help, visiting social services and taking medication; and other areas such as hearing voices, drinking alcohol and self-critical thoughts. We describe the user's flow through the system, with an in-depth synopsis of the hearing voices intervention. Issues regarding voluntary versus mandatory use of the system are addressed in connection with prospective introduction of the system in forensic settings.