Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction

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Impulsivity, compulsivity, and addiction

Recent advances in understanding the neurocircuitry of impulsivity and compulsivity has led to the notion that many different psychiatric disorders share these two dimensions of psychopathology. Here we take a look not only at drug addiction, the best-known set of disorders in this category, but also briefly at other "impulsive-compulsive disorders" including obsessive-compulsive disorder (OCD), trichotillomania, gambling, aggression, obesity, and other disorders thought to be related in part to inefficient information processing in prefrontal cortex/striatal circuitry ( and Figure 14-1 Table

). Earlier chapters have already touched upon impulsivity in attention deficit hyperactivity14-1 disorder (ADHD, discussed in ) and in bipolar mania (discussed in and ), andChapter 12 Chapters 6 7 the discussion in this chapter applies to impulsivity in these disorders as well.

Here we review the hypothetical shared neurobiology of impulsive-compulsive disorders and discuss the treatments that are available for some of these conditions. Although serotonergic treatments of OCD are well known, psychopharmacologists have generally been reluctant to embrace therapeutics for substance abuse, whereas family physicians and subspecialty substance abuse experts use the available psychopharmacological treatments more frequently. Perhaps the lack of highly effective psychopharmacologic treatments for many impulsive-compulsive disorders has led to a certain amount of therapeutic nihilism towards psychopharmacologic approaches to these conditions. Nevertheless, an explosion of neurobiological understanding of the symptom dimensions of impulsivity and compulsivity now sets the stage for novel therapeutic interventions to be discovered in the future, making it worthwhile understanding contemporary neurobiological formulations of addiction, compulsions, and impulsivity. Full clinical descriptions and formal criteria for how to diagnose the numerous known diagnostic entities should be obtained by consulting standard reference sources.

Overview of impulsive-compulsive disorders

Impulsivity and compulsivity are proposed as , namely symptoms linked to specificendophenotypes brain circuits and that are present trans-diagnostically as a dimension of psychopathology that cuts across

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Figure 14-1. . Impulsivity and compulsivity are seen in a wideImpulsive-compulsive disorder construct variety of psychiatric disorders. Impulsivity can be thought of as the inability to stop the initiation of actions and involves a brain circuit centered on the ventral striatum, linked to the thalamus (T), to the ventromedial prefrontal cortex (VMPFC), and to the anterior cingulate cortex (ACC). Compulsivity can be thought of as the inability to terminate ongoing actions and hypothetically is centered on a different brain circuit, namely the dorsal striatum, thalamus (T), and orbitofrontal cortex (OFC). Impulsive acts such as drug use, gambling, and obesity can eventually become compulsive due to neuroplastic changes that engage the dorsal habit system and theoretically cause impulses in the ventral loop to migrate to the dorsal loop.

Table 14-1 Possible categorization of impulsivity and compulsivity endophenotypes as impulsive-compulsive disorders

many psychiatric disorders ( , ). Simply put, impulsivity and compulsivity areTable 14-1 Figure 14-1 both symptoms that result from the brain having a hard time saying "no." In fact, these two symptom constructs can perhaps be best differentiated by how they both fail to control responses: impulsivity as the inability to stop actions, and compulsivity as the inability to ongoing actions.initiating terminate Both impulsivity and compulsivity are therefore forms of cognitive inflexibility.

More precisely, is defined as acting without forethought; the lack of reflection on theimpulsivity consequences of one’s behavior; the inability to postpone reward with preference for immediate reward over more beneficial but delayed reward; a failure of motor inhibition, often choosing risky behavior; or (less scientifically) lacking the willpower not to give in to temptations (see definitions in

).Table 14-2

On the other hand, is defined as actions inappropriate to the situation but whichcompulsivity nevertheless persist, and which often result in undesirable consequences. In fact, compulsions are characterized by the inability to adapt behavior after negative feedback. are a type ofHabits compulsion, and can be seen as responses triggered by environmental stimuli regardless of the current desirability of the consequences of that response ( ). Habits can be seen as Table 14-2

(such as drug seeking, food seeking, gambling) to a conditioning stimulusconditioned responses (such as being around people or places or items associated with drugs, food, or gambling in the past) that have been reinforced and strengthened either by past experience with reward (positive reinforcement) or with the omission of an aversive event (loss of the negative reinforcement that comes from withdrawal or craving). Whereas goal-directed behavior is mediated by knowledge of and desire for the consequences, in contrast, habits are controlled by external stimuli through stimulus-response associations that are stamped into brain circuits through behavioral repetition and formed after considerable training, can be automatically triggered by stimuli, and are defined by their insensitivity to their outcomes. Given that goal-directed actions are relatively cognitively demanding, for daily routines it can be adaptive to rely on habits that can be performed with minimal conscious awareness. However, habits can also represent severely maladaptive perseveration of behaviors (

, ).Figure 14-1 Table 14-1