Impulsivity as a predictor of treatment outcome in substance use disorders: Review and synthesis

COMPREHENSIVE REVIEW

Impulsivity as a predictor of treatment outcome in substance usedisorders: Review and synthesis

AMY M. LOREE, LESLIE H. LUNDAHL & DAVID M. LEDGERWOOD

Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, USA

AbstractIssues. Impulsivity is a widely studied personality trait and research construct that has been implicated as a risk factor forsubstance use, including initiating and continuing use. However, relatively few studies have examined impulsivity as a predictorof treatment outcome. Because impulsivity has been operationalised in many different ways, cross-comparisons of empiricalstudies have been difficult. Approach. The PubMed database was searched in September 2013. Reference lists of papersretrieved from this search were also manually scanned for additional resources. Studies were included if they presented data thatassessed impulsivity as a predictor of treatment outcomes. Key Findings. The body of literature reviewed in this paper suggeststhat higher pretreatment impulsivity, regardless of how it is measured, usually is associated with poorer treatment outcomes.Recent data indicate that some psychosocial and pharmacological treatments may directly impact impulsivity and thus representan interesting avenue for further research. Conclusions. Impulsivity appears to be a key predictor of substance use treatmentoutcomes and warrants more attention in the improvement of treatment outcomes. Suggestions for future research on the role ofimpulsivity in substance use treatment are provided. [Amy M. Loree AM, Leslie H. Lundahl LH, David M. LedgerwoodDM. Impulsivity as a predictor of treatment outcome in substance use disorders: Review and synthesis. Drug AlcoholRev 2014]

Key words: impulsivity, personality, relapse, substance use, treatment.

Introduction

Impulsivity, as a personality trait, is broadly defined asa tendency to act without adequate forethought [1],but as a research construct, impulsivity has beenoperationalised in many different ways. Impulsivitymeasures include primary measures of inattention,response inhibition, delay discounting, risk-taking, sen-sation seeking and others. Despite the multifacetednature of impulsivity, several studies have demonstratedthat substance use disorders are strongly associatedwith elevated impulsivity scores on various measures[2–4]. Furthermore, several studies have revealed thatimpulsivity may be an important variable in predictingtreatment outcomes and relapse risk (e.g. [5–8]).

However, there are many gaps in our understandingof the relationship between impulsivity and recovery

from substance use disorders. Thus, in this review ourmain aims are to: (i) describe the current research onimpulsivity as a predictor of treatment outcomes andrelapse; (ii) identify the important gaps in the empiricalliterature; and (iii) provide suggestions for futureresearch to address these gaps. To accomplish theseaims, we also provide a brief overview of the generalresearch on impulsivity in substance use disorders.

Operationalisation of impulsivity

The use of the term ‘impulsive’ to describe an indivi-dual’s tendency to be moved to action through emotionor sudden impulse dates back at least to the mid-1800s[9]. Since that time, the concept of impulsivity as apersonality trait has received a tremendous amountof study. Examination of the PsycInfo database, for

Amy M. Loree MA, Leslie H. Lundahl PhD., David M. Ledgerwood PhD., Correspondence to Dr David Ledgerwood, Department of Psychiatryand Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Drive, Suite 2A, Detroit, MI 48201, USA. Tel: +313993 1380; Fax: +313 993 1372; E-mail. [email protected]

Received 27 August 2013; accepted for publication 9 February 2014.

bs_bs_banner

R E V I E W

Drug and Alcohol Review (2014)DOI: 10.1111/dar.12132

© 2014 Australasian Professional Society on Alcohol and other Drugs

mailto:[email protected]

https://www.researchgate.net/publication/12749381_Varieties_of_Impulsivity?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

https://www.researchgate.net/publication/12164740_Novelty_seeking_as_a_predictor_of_treatment_retention_for_heroin_dependent_cocaine_users?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

https://www.researchgate.net/publication/11579715_The_impact_of_impulsivity_on_cocaine_use_and_retention_in_treatment?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

https://www.researchgate.net/publication/8344936_Impulsivity_and_smoking_relapse?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

https://www.researchgate.net/publication/5556098_Verdejo-Garcia_A_Lawrence_JA_Clark_L_Impulsivity_as_a_vulnerability_marker_for_substance-use_disorders_review_of_findings_from_high-risk_research_problem_gamblers_and_genetic_association_studies_Neuro?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

https://www.researchgate.net/publication/26695208_Early_recovery_from_alcohol_dependence_Factors_that_promote_or_impede_abstinence?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

example, finds the terms impulsive, impulsiveness orimpulsivity have been mentioned in over 15 000 publi-cations [10].

Perhaps because of its long history of use, impulsivityas a trait has been operationalised in myriad ways, withmost studies utilising self-report measures of impulsiv-ity. Some of the more frequently used self-report meas-ures include the Barratt Impulsiveness Scale [11,12],Eysenck’s Impulsiveness Scale [13] and the UPPSImpulsive Behavior Scale [14]. Furthermore, impulsiv-ity subscales are found in several more lengthy per-sonality assessments, such as the TridimensionalPersonality Questionnaire [15] and the NEO Personal-ity Inventory-Revise [16]. Individual self-report meas-ures have also been designed to assess different aspectsof impulsivity. For example, Barratt’s measure has beenfactor analysed to devise scales to assess attention,motor and non-planning aspects of impulsiveness [12].The UPPS, which was based on the Five Factor Modelof personality and derived from a handful of impulsivitymeasures via factor analysis, includes four distinct per-sonality facets: urgency, lack of premeditation, lack ofperseverance and sensation-seeking [14]. Other con-structs, such as rash impulsivity [17] and functionaland dysfunctional impulsivity, have also been examined[18]. Self-report measures also assess closely relatedconstructs, such as sensation seeking, which is a traitcharacterised by a need for novel, varied and complexexperiences that are often associated with significantrisk taking [19]. The lack of consistency across meas-ures purporting to assess impulsivity makes it difficultto directly compare the findings of these studies.

Although self-report measures are generally acceptedas valid instruments to assess impulsivity among manypopulations, they are not without limitations.The valid-ity of self-report measures is sometimes questionedbecause these assessments are subjective and may beinfluenced by distorted perceptions of one’s own traits[20].To this end, behaviourally based impulsivity meas-ures may better capture the different dimensions ofimpulsivity because they elicit impulsive behaviourrather than relying on individuals to accurately charac-terise their behaviours through self-report.

There are several task-based measures of impulsivity,including those that assess discounting of delayedrewards, behavioural response inhibition, attention andmemory, and decision making. Delay discounting isdefined as a tendency to discount larger, delayedrewards in favour of smaller, more immediate ones[21]. In a typical monetary discounting task, partici-pants are asked to choose between a smaller rewarddelivered immediately and a larger reward deliveredafter some period of delay. As the delay duration of areward increases, the subjective value of that rewarddecreases [22]. Impulsivity is considered to be a func-

tion of the rate at which a delayed larger reward isdiscounted with greater rate of discounting associatedwith greater impulsivity [22].

Several studies have found significant congruencebetween response inhibition tasks and scores on paperand pencil measures of impulsivity [23–26]. Responseinhibition tasks measure a participant’s ability to holdback responding when required by the rules of the taskand often after receiving a signal to respond. Moreimpulsive individuals have greater difficulty inhibiting aresponse when they are presented with a ‘stop’ signal,especially as the latency between the target stimulusand the ‘stop’ signal increases [26,27].

Attention and memory measures have also been usedto assess impulsivity. Similar measures that use atten-tion and working memory operationalise impulsivity asa deficit in one’s ability to withhold responding untilaccurate processing of environmental stimuli hasoccurred [28,29]. The continuous performance task isone of the most frequently used examples of attention/memory assessments of impulsivity and has demon-strated significant relationships with attention andinhibition difficulties observed in attention deficithyperactivity disorder [30].

Laboratory measures of decision making and risktaking are also relevant to the study of impulsivity. Themost commonly used decision-making task is the IowaGambling Task, which measures a participant’s abilityto maximise positive consequences and minimise nega-tive consequences of decisions based on feedback [31].Other decision-making tasks include the CambridgeGambling Task and the Risky Gains Task [32,33].Several measures, such as the balloon analogue risk task[34,35], are computer-based measures of risk takingthat are also correlated with self-report measures ofimpulsivity and sensation seeking.

As with self-report measures, laboratory-based beha-vioural assessments of impulsivity measure severaldifferent constructs (e.g. attention, risky behaviours,decision making). Furthermore, although some studieshave found that the interrelationship among thesemeasures is modest [3,20,36,37], others have foundsignificant overlap between self-report and laboratory-based behavioural measures [38]. Thus, the variousimpulsivity measures likely reflect distinct underlyingprocesses with no single measure fully capturing thismultidimensional construct. Therefore, researchersmay want to consider choosing both laboratory-basedbehavioural measures and self-report measures basedon their guiding theoretical framework.

Impulsivity research in substance use disorders

Impulsivity has been almost invariably linked to addic-tive diseases, including both substance use disorders

2 A. M. Loree et al.


https://www.researchgate.net/publication/222707741_The_Five-Factor_Model_and_Impulsivity_Using_a_Structural_Model_of_Personality_to_Understand_Impulsivity?el=1_x_8&enrichId=rgreq-cd0bd11a-2791-4a71-b0cb-af125ece8b52&enrichSource=Y292ZXJQYWdlOzI2MTI1NDU0MjtBUzoxNDA3MzA0MjkzNDk4ODhAMTQxMDU2NDE1Nzc4Nw==

and behavioural addictions (e.g. pathological gam-bling). In this paper, we provide only a brief overview.For a thorough review of the relationship betweenimpulsivity and addictive disorders, we refer the readerto several recent sources [2–4]. Although causal pro-cesses remain unclear, it is likely that impulsivity inaddictive diseases includes a component of pre-existingtrait impulsivity that acts as a risk factor for the devel-opment of addiction, as well as a component that devel-ops or intensifies as a consequence of chronic drug use[38].

Compared with control participants, higher levelsof impulsivity have been found in individualswith regular stimulant, opiate, alcohol and 3,4-methylenedioxymethamphetamine use [3]. Severalstudies, for example, have found that substancedependence is associated with greater discountingof delayed rewards among individuals dependent onalcohol [39], cocaine [40,41], opiates [41,42] andmethamphetamine [43]. However, some studies havefound that discounting levels may vary by substance,with some substances, including marijuana, heroinand cocaine, being associated with greater impulsivitythan others [41,44].

Studies examining self-report and response inhibi-tion measures of impulsivity have found similar results.Self-reported impulsivity has been found to be elevatedamong alcohol [45], cocaine [46], opiate [47] andcannabis-dependent [44] individuals. Finn et al. foundthat response inhibition was associated with impulsivitymeasures in participants with early onset alcoholismand conduct disorder [24]. Another investigationobserved response inhibition deficits in chronic meth-amphetamine users who were abstinent for 5–7 days[48]. A study using a laboratory decision-making taskalso found impaired performance among drug abusersrelative to controls [49].

Overall, higher levels of impulsivity are associatedwith substance use disorder severity across various sub-stances of abuse. For example, impulsivity is associatedwith greater self-reported quantity of cocaine use andmore severe withdrawal symptoms among cocaine-dependent individuals [8]. Recent attention has alsofocused on the relationship between impulsivity andcraving, with evidence suggesting that self-reportedimpulsivity is associated with craving among individ-uals dependent on alcohol [50,51], cocaine [52,53] andmethamphetamine [53]. Furthermore, abuse of morethan one substance is associated with greater impulsiv-ity than is abuse of a single substance [54].

Impulsivity has also been shown to be elevatedamong tobacco users. Current smokers have beenshown to discount delayed monetary rewards at signifi-cantly higher rates than never smokers and ex-smokers[55]. Indeed, a review of the smoking literature suggests

that choice measures (such as delay discounting) maymore consistently distinguish smokers from non-smokers than response inhibition measures of impul-sivity [56]. Furthermore, nicotine deprivation amongsmokers appears to increase the frequency with whichsmokers will discount delayed choices [57]. Thus,increasing withdrawal may increase impulsive decisionmaking. Impulsivity may also be positively related tosensitivity to the rewarding aspects of nicotine in non-smokers, particularly among men [58].

In summary, most studies have found that impulsiv-ity is elevated among people with addictions, regardlessof whether self-report, delay discounting, responseinhibition or other behavioural measures are used.Furthermore, some have suggested that high levels ofimpulsivity precede the development of substance usedisorders [3,56]. Therefore, impulsivity may be acommon risk factor for substance use disorders.

Treatment outcomes

Studies that examine putative pretreatment predictorsof treatment outcomes are important because they canultimately inform both the treatment type and magni-tude needed for success [59]. Below, we review studiesthat have examined impulsivity as a putative predictorof treatment outcomes among substance-abusingpopulations.

Search strategy

A comprehensive literature search was conducted onthe PubMed database for the period of 1950 to Sep-tember 2013. Key search terms were: impulsivity,impulsiveness, novelty seeking, sensation seeking, delaydiscounting and disinhibition each in combination withthe key words nicotine, tobacco, smoking, opiate,opioid, heroin, cocaine, marijuana, amphetamine andalcohol, as well as treatment terms treatment outcomeand relapse. Abstracts produced from the databasesearch were examined, and those that presented dataassessing impulsivity as a predictor of treatment out-comes were reviewed. Additional articles that were notidentified through the database search were retrievedfrom reference lists of relevant articles.

Results

According to the above criteria, a search of PubMedreturned 1828 results, of which 33 papers examiningimpulsivity as a predictor of substance use treatmentoutcomes were identified. Year of publication rangedfrom 1997 to 2012. Although studies prior to 1997examined impulsivity and substance use, prior to thisyear, no published studies appeared to directly address

Impulsivity in substance use treatment 3


impulsivity as a predictor of treatment outcome. Acomprehensive list of the relevant studies for each sub-stance is presented in Tables 1–5. The studies arereviewed below, and the consistencies between them aresummarised in the section that follows.

Impulsivity as a Predictor of Substance AbuseTreatment Outcomes

In this review, we cover studies that examine pretreat-ment assessments of impulsivity as predictors of treat-ment outcomes for nicotine, marijuana, cocaine,alcohol and opioid use disorders; no studies were iden-tified for amphetamine treatment.

Nicotine studies. Fifty per cent of the studies to dateexamined nicotine dependence and the relationshipbetween impulsivity and cessation rates or relapseamong cigarette smokers. Doran et al. found that traitimpulsivity, measured using the Barratt ImpulsivenessScale (BIS-11) prior to participation in a clinical trialfor smoking cessation, predicted more rapid relapsefollowing a 48-h abstinence period [6]. Impulsivityremained a significant predictor even after controllingfor treatment condition, participant age and level ofnicotine dependence. Furthermore, negative affect,positive affect and tobacco craving did not mediate therelationship between impulsivity and relapse rate.

Krishnan-Sarin et al. examined four impulsivitymeasures (BIS-11, Kirby Delay Discounting Measure,Experiential Discounting Task and Conners’ Continu-ous Performance Task) as possible predictors ofsmoking outcomes among adolescents in a cessationprogramme [64]. At post-treatment, non-abstinent par-ticipants (n = 14) discounted more significantly on theExperiential Discounting Task and had fewer commis-sion errors on the Continuous Performance Task thandid the smoking abstinent adolescents (n = 16). Theother two impulsivity measures did not distinguishgroups. In a study utilising both self-report measuresand laboratory tasks, Sheffer et al. found that delaydiscounting and cognitive impulsivity (as measured bythe BIS-11) predicted relapse among a group of lowersocioeconomic status smokers [69].

Another study examined smoking cessation amongadolescents randomly assigned to a one-session moti-vational enhancement condition or a control tobaccopsychoeducation session [63]. Although these authorsdid not find significant differences between their twointerventions, they did find differential treatmentresponse based on impulsivity. Participants with higherlevels of impulsivity reported greater reduction in self-reported smoking in the tobacco education controlcondition than in the motivational session, whereasparticipants with lower levels of impulsivity experi-

enced the opposite effect. Thus, in some cases, impul-sivity may mediate the relationship between treatmenttype and outcome.

Rukstalis et al. examined whether increases in inatten-tion and hyperactive-impulsive attention deficit disordersymptoms during the first week of nicotine replacementtreatment predicted relapse at the end of eight weeks oftreatment [68]. End of treatment abstinence rates were41% for participants who reported either no change or adecline in their inattention and hyperactive-impulsivesymptoms, compared with 29% among those whoreported an increase in these symptoms.

A handful of other studies have examined delay dis-counting as a predictor of outcome among smokers.One study examined delay discounting rates as a pre-dictor of relapse in heavy drinking smokers who wereparticipating in a clinical trial to examine combinedbrief smoking cessation and alcohol use interventions[65]. Using survival analysis, the authors found thatgreater rates of discounting delayed dollar amountswere associated with shorter time to smoking lapse.Sensation seeking, level of nicotine dependence,income and treatment condition were then enteredalong with discounting value into a regression model.Lower rates of discounting were found for participantsabstinent at 2- and 8-weeks post-quit date but not for16- and 26-weeks after the quit date.

Yoon et al. examined whether baseline delay dis-counting predicted post-partum relapse among preg-nant smokers enrolled in a clinical trial of contingencymanagement versus non-contingent reinforcement whohad spontaneously quit smoking upon learning of theirpregnancy [70].Women who continued to abstain fromsmoking discounted delayed rewards at significantlylower rates than those who had relapsed to smoking atthe 24-week post-partum assessment. This study dif-fered from past ones in that: (i) the 24-week period wasapproximately a year after initial baseline assessment;and (ii) repeated measurements of delay discountingrevealed that this value is relatively stable across time.Thus, this study shows that delay discounting may be aparticularly robust predictor of long-term abstinence.

Two laboratory studies have also examined impulsiv-ity as a predictor of smoking relapse. In one, Powellet al. examined impulsivity, inhibitory control and cuereactivity measures as predictors of relapse to smokingduring a pharmacologically unaided quit attempt [67].Behavioural measures of behavioural-response inhibi-tion, including the Stroop interference test, anantisaccade task and the continuous performance task(as a measure of motor impulsivity) predicted relapseafter one week. Self-report measures (which includedthe Impulsivity, Venturesomeness and Empathy Ques-tionnaire,TPQ Novelty Seeking and Sensation SeekingScales) did not predict relapse. At 1- and 3-months



Tab

le1.

Nic

otin

est

udie

s

Aut

hors

Sub

stan

ceR

esea

rch

desi

gnS

ampl

esi

zean

dfo

llow

-up

Impu

lsiv

ity

mea

sure

sF

indi

ngs

Car

lton

etal

.[6

0]N

icot

ine

Cor

rela

tion

al25

smok

ers

part

icip

atin

gin

an12

0-da

yop

entr

ial

for

nico

tine

repl

acem

ent

ther

apy

SS

S(F

renc

hve

rsio

n)S

ensa

tion

seek

ing

did

not

pred

ict

smok

ing

cess

atio

n.

Dal

lery

&R

aiff

[61]

Nic

otin

eR

ando

mis

edco

ntro

lled

tria

l,la

bora

tory

anal

ogue

stud

y

30sm

oker

sw

ith

noin

tent

ion

toqu

it;

nofo

llow

-up

DD

TL

owan

dhi

ghco

ntin

genc

yco

ndit

ions

incr

ease

dla

tenc

yto

smok

ing,

but

nico

tine

patc

hdi

dno

t.In

divi

dual

sw

hosm

oked

duri

ngth

eco

ntin

genc

yco

ndit

ions

disp

laye

dhi

gher

rate

sof

disc

ount

ing.

Dor

anet

al.

[6]

Nic

otin

eR

ando

mis

edco

ntro

lled

tria

l45

regu

lar

smok

ers

wit

ha

hist

ory

ofm

ajor

depr

essi

on;

follo

w-u

p4

wee

ksaf

ter

base

line

BIS

-11

Ele

vate

dim

puls

ivit

ypr

edic

ted

shor

ter

tim

eto

rela

pse

follo

win

ga

skill

str

aini

ngw

orks

hop,

afte

rco

ntro

lling

for

trea

tmen

tco

ndit

ion,

base

line

nico

tine

depe

nden

cean

dag

e.R

elat

ions

hip

betw

een

impu

lsiv

ity

and

rapi

dre

laps

eco

uld

not

beex

plai

ned

bypo

siti

veor

nega

tive

affe

ct,

orcr

avin

g.H

all

etal

.[6

2]N

icot

ine

Pro

spec

tive

coho

rtde

sign

8845

adul

tsm

oker

sfr

omA

ustr

alia

,C

anad

a,U

nite

dK

ingd

om,

and

the

US

A;

follo

w-u

p8

mon

ths

late

r

4it

ems:

‘You

like

toex

plor

est

rang

epl

aces

;’‘Y

oulik

eto

doth

rilli

ngth

ings

;’‘Y

oulik

ene

wan

dex

citi

ngex

peri

ence

s,ev

enif

you

have

tobr

eak

the

rule

s;’‘

You

like

tobe

wit

hfr

iend

sw

hoar

eex

citi

ngan

dun

pred

icta

ble.

’

Sen

sati

onse

ekin

gdi

dno

tpr

edic

tqu

itat

tem

pts

orfa

ctor

skn

own

toen

hanc

equ

itti

ng,

such

asst

reng

thof

quit

inte

ntio

n,pe

rcei

ved

bene

fits

ofqu

itti

ng,

orhe

alth

-rel

ated

smok

ing

conc

erns

.

Hel

stro

met

al.

[63]

Nic

otin

eR

ando

mis

edco

ntro

lled

tria

l81

adju

dica

ted

adol

esce

ntsm

oker

s;fo

llow

-up

at1

and

6m

onth

spo

st-t

reat

men

t

ImpS

SP

arti

cipa

nts

wit

hlo

wer

leve

lsof

alco

hol

use

and

impu

lsiv

ity

had

asi

gnifi

cant

lygr

eate

rre

spon

seto

mot

ivat

iona

len

hanc

emen

tth

erap

y,w

here

aspa

rtic

ipan

tsw

ith

high

erra

tes

ofal

coho

lus

ean

dim

puls

ivit

yre

spon

ded

bett

erto

the

toba

cco

educ

atio

nco

ntro

l.K

rish

nan-

Sar

inet

al.

[64]

Nic

otin

eC

orre

lati

onal

32ad

oles

cent

smok

ers;

follo

w-u

pat

four

thw

eek

ofst

udy.

BIS

-11,

DD

M,

ED

T,

CP

TC

ompa

red

wit

had

oles

cent

sw

hore

mai

ned

abst

inen

tat

the

end

ofth

e4-

wee

kst

udy,

thos

eno

tac

hiev

ing

abst

inen

cedi

scou

nted

mor

em

onet

ary

rew

ards

onth

eE

DT

and

mad

em

ore

com

mis

sion

erro

rson

the

CP

T;

nogr

oup

diff

eren

ces

obse

rved

onth

eB

IS-I

Ior

DD

M.

Mac

Kill

op&

Kah

ler

[65]

Nic

otin

eR

ando

mis

edco

ntro

lled

smok

ing

cess

atio

ntr

ial

57tr

eatm

ent-

seek

ing

smok

ers;

follo

w-u

p2,

8,16

and

26w

eeks

post

-tre

atm

ent

MC

Q,

SS

S-B

Del

ayed

rew

ard

disc

ount

ing

pred

icte

dda

ysto

rela

pse

beyo

ndni

coti

nede

pend

ence

,se

nsat

ion-

seek

ing

and

inco

me.

Nie

vaet

al.

[66]

Nic

otin

eC

orre

lati

onal

103

smok

ers

part

icip

atin

gin

aw

orkp

lace

cess

atio

npr

ogra

mm

e;fo

llow

-up

at12

mon

ths.

ImpS

SH

igh

leve

lsof

impu

lsiv

ity

pred

icte

dre

laps

ein

mal

es,

but

not

fem

ales

.

Pow

ell

etal

.[6

7]N

icot

ine

Sin

gle

grou

p,pr

e-po

stde

sign

141

smok

ers;

follo

w-u

pat

1w

eek,

1m

onth

and

3m

onth

spo

st-q

uit

date

SS

S,T

PQ

-NS

,I7

-Im

p,S

troo

p,A

ntis

acca

deta

sk,

CP

T

At

the

1-w

eek

follo

w-u

p,ab

stin

ence

was

pred

icte

dby

saliv

ary

coti

nine

,at

tent

iona

lbi

asto

smok

ing

cues

,an

dan

tisa

ccad

eer

rors

.A

tth

e1-

and

3-m

onth

follo

w-u

ps,

saliv

ary

coti

nine

,C

PT

mot

orim

puls

ivit

y,an

dcu

ere

acti

vity

indi

vidu

ally

pred

icte

dab

stin

ence

.N

one

ofth

ese

lf-r

epor

tim

puls

ivit

ym

easu

res

pred

icte

dre

laps

e.R

ukst

alis

etal

.[6

8]N

icot

ine

Ran

dom

ised

smok

ing

cess

atio

ntr

ial

454

smok

ers;

follo

w-u

pat

8w

eeks

post

-qui

tda

teC

SS

Ear

lyin

crea

ses

inin

atte

ntio

nan

dhy

pera

ctiv

e-im

puls

ive

sym

ptom

sdu

ring

nico

tine

repl

acem

ent

ther

apy

pred

icte

dsm

okin

gre

laps

e.S

heff

eret

al.

[69]

Nic

otin

eC

orre

lati

onal

97ni

coti

ne-d

epen

dent

part

icip

ants

;fo

llow

-up

at4,

8,12

and

28w

eeks

afte

rta

rget

quit

date

BA

RT

,B

IS-1

1,3

DD

Ts,

I7,

Go/

No-

Go

Tas

kT

hree

mea

sure

sof

dela

ydi

scou

ntin

gpr

edic

ted

abst

inen

ce,

such

that

thos

ew

hodi

scou

nted

mor

est

eepl

yw

ere

less

likel

yto

beab

stin

ent.

Gre

ater

impu

lsiv

enes

son

the

BIS

-11

cogn

itiv

eim

puls

iven

ess

scal

eal

sopr

edic

ted

redu

ced

likel

ihoo

dof

abst

inen

ce.

Yoo

net

al.

[70]

Nic

otin

eR

ando

mis

edco

ntro

lled

tria

l48

preg

nant

wom

en;

follo

w-u

pat

24w

eeks

post

-par

tum

DD

TB

asel

ine

dela

ydi

scou

ntin

gpr

edic

ted

smok

ing

stat

usat

24w

eeks

post

-par

tum

Not

e:B

AR

T,B

allo

onA

nalo

gue

Ris

kT

ask

[34,

35];

BIS

-11,

Bar

ratt

Impu

lsiv

enes

sS

cale

[11,

12];

CS

S,C

urre

ntS

ympt

oms

Sca

le[7

1];D

DT

,Del

ayD

isco

unti

ngT

ask;

ED

T,E

xper

ient

ialD

isco

unti

ngT

ask

[72]

;Im

puls

ivit

y,V

entu

reso

men

ess,

and

Em

path

yqu

esti

onna

ire

[74]

;I7-

Imp,

Impu

lsiv

ity

scal

efr

omth

eIm

puls

ivit

y,V

entu

reso

men

ess,

and

Em

path

yqu

esti

onna

ire

[74]

;Im

pSS

,Im

puls

ivit

y/S

ensa

tion

See

king

Sca

le[7

5];D

DM

,Kir

byD

elay

Dis

coun

ting

Mea

sure

[42]

;M

CQ

,M

onet

ary

Cho

ice

Que

stio

nnai

re[4

2];

SS

S,

Sen

sati

onS

eeki

ngS

cale

[76]

;S

SS

-B,

Sen

sati

onS

eeki

ngS

cale

-Bri

ef[7

7].



Tab

le2.

Alc

ohol

stud

ies

Aut

hors

Sub

stan

ceR

esea

rch

desi

gnS

ampl

esi

zean

dfo

llow

-up

Impu

lsiv

ity

mea

sure

sF

indi

ngs

Cha

rney

etal

.[5

]A

lcoh

olC

orre

lati

onal

175

pati

ents

wit

hal

coho

lus

edi

sord

ers

ente

ring

trea

tmen

t;fo

llow

-up

at12

wee

ksin

totr

eatm

ent

BIS

-11

Tho

sew

hore

laps

edw

ere

mor

elik

ely

toha

vea

high

erle

vel

ofim

puls

ivit

y(B

ISco

gnit

ive

subs

cale

),in

addi

tion

toC

lust

erB

pers

onal

ity

diso

rder

diag

nose

s,an

dm

ore

seve

reso

cial

prob

lem

sat

inta

ke.

Evr

enet

al.

[50]

Alc

ohol

Cor

rela

tion

al10

2m

ale

alco

hol-

depe

nden

tpa

tien

tsin

terv

iew

ed12

mon

ths

afte

rdi

scha

rge

BIS

-11,

TC

I-N

SA

mon

gth

ose

who

rela

psed

,m

ean

scor

eson

BIS

-11

and

nove

lty

seek

ing

subs

cale

sof

the

TC

Iw

ere

high

erco

mpa

red

wit

hth

eno

n-re

laps

edgr

oup.

BIS

-11

non-

plan

ning

and

nove

lty-

seek

ing

fact

ors

(exp

lora

tory

exci

tabi

lity

and

extr

avag

ance

)w

ere

also

sign

ifica

ntly

rela

ted

tocr

avin

g.E

win

get

al.

[78]

Alc

ohol

Ran

dom

ised

cont

rolle

dtr

ial

67em

ergi

ngad

ult

prob

lem

drin

kers

;fo

llow

-up

30da

ysaf

ter

inte

rven

tion

TP

Q-N

S,

ImpS

SP

arti

cipa

nts

low

inim

puls

ivit

yan

dno

velt

yse

ekin

gex

hibi

ted

grea

ter

beha

viou

rch

ange

,as

evid

ence

dby

taki

ngst

eps

tow

ards

redu

cing

drin

king

,fo

llow

mot

ivat

iona

len

hanc

emen

tth

erap

y.Jo

oset

al.

[103

]A

lcoh

olR

ando

mis

ed,

doub

le-b

lind,

plac

ebo-

cont

rolle

dtr

ial

83al

coho

l-de

pend

ent

pati

ents

;fo

llow

-up

3an

d6

mon

ths

post

-tre

atm

ent

BIS

-11,

Sta

teIm

puls

ivit

yQ

uest

ionn

aire

,S

ST

,D

DT

Mod

afini

lsi

gnifi

cant

lyim

prov

edsc

ores

onse

lf-r

epor

tm

easu

res

ofim

puls

ivit

y,bu

tha

dno

effe

cton

beha

viou

ral

mea

sure

sof

impu

lsiv

ity.

Mod

afina

lal

soha

dno

over

all

effe

cton

drin

king

outc

omes

(per

cent

age

ofab

stin

ent

days

,pe

rcen

tage

ofhe

avy

drin

king

days

).A

mon

gth

ose

wit

hpo

orre

spon

sein

hibi

tion

atba

selin

e,m

odafi

nil

prol

onge

dti

me

tore

laps

ean

dte

nded

toin

crea

sepe

rcen

tage

ofab

stin

ent

days

;ho

wev

er,

amon

gth

ose

wit

hbe

tter

resp

onse

inhi

biti

onat

base

line,

mod

afini

lre

duce

dpe

rcen

tage

ofab

stin

ent

days

and

incr

ease

dpe

rcen

tage

ofhe

avy

drin

king

days

.K

ravi

tzet

al.

[79]

Alc

ohol

Ran

dom

ised

,do

uble

-blin

d,pl

aceb

o-co

ntro

lled

tria

l17

0al

coho

l-de

pend

ent

men

;fo

llow

-up

6m

onth

spo

st-b

asel

ine

TP

Q-N

SD

ropo

uts

had

sign

ifica

ntly

high

erno

velt

y-se

ekin

gsc

ores

.H

ighe

rno

velt

yse

ekin

gw

asal

soas

soci

ated

wit

hin

crea

sed

risk

ofdr

oppi

ngou

tan

dea

rlie

rdr

opou

t.M

esza

ros

etal

.[8

0]A

lcoh

olR

ando

mis

edco

ntro

lled

tria

l52

1de

toxi

fied,

alco

hol-

depe

nden

tpa

tien

ts;

follo

w-u

pat

2,4,

6,8,

12,

16,

24,

32,

40an

d52

wee

ksaf

ter

base

line.

TP

QN

ovel

tyse

ekin

gw

asa

stro

ngpr

edic

tor

ofre

laps

efo

rm

ales

but

not

fem

ales

.

Mul

ler

etal

.[8

1]A

lcoh

olC

orre

lati

onal

146

alco

hol-

depe

nden

tpa

tien

ts;

follo

w-u

p12

mon

ths

afte

rtr

eatm

ent

disc

harg

e

NE

O-F

FI,

TC

I,E

PQ

,IV

E,

SS

SIn

addi

tion

tohi

ghsc

ores

onps

ycho

tici

sm,

low

scor

eson

pers

iste

nce

wer

esi

gnifi

cant

lyre

late

dto

risk

ofre

laps

e.H

igh

scor

eson

nove

lty

seek

ing

and

impu

lsiv

enes

sal

sosi

gnifi

cant

lydi

ffer

enti

ated

rela

psed

vers

usab

stin

ent

pati

ents

at12

-mon

ths

post

-tre

atm

ent.

Rub

ioet

al.

[82]

Alc

ohol

Ran

dom

ised

cont

rolle

dtr

ial

63m

ales

wit

hal

coho

lde

pend

ence

rand

omis

edto

rece

ive

topi

ram

ate

orpl

aceb

o;fo

llow

-up

at12

wee

kspo

st-b

asel

ine

CP

T,

BIS

-11,

SS

T,

DR

LR

Pat

ient

sw

hore

ceiv

edto

pira

mat

ere

port

edlo

wer

rate

sof

alco

hol

cons

umpt

ion,

decr

ease

dcr

avin

gan

dex

hibi

ted

impr

oved

perf

orm

ance

onth

eC

PT

and

SS

T.T

opir

amat

ere

duce

ddr

inki

ng,

perh

aps

via

mod

ulat

ion

ofbe

havi

oura

lin

hibi

tion

.

Sel

lman

etal

.[8

3]A

lcoh

olC

orre

lati

onal

87al

coho

l-de

pend

ent

men

wit

han

tiso

cial

pers

onal

ity

diso

rder

part

icip

atin

gin

am

ulti

mod

alth

erap

euti

cpr

ogra

mm

e;fo

llow

-up

for

6m

onth

s.

TP

QN

ovel

tyse

ekin

gw

asno

tas

soci

ated

wit

hre

laps

e.

BIS

-11,

Bar

ratt

Impu

lsiv

enes

sS

cale

[11,

12];

CP

T,

Con

tinu

ous

Per

form

ance

Tas

k;D

DT

,D

elay

disc

ount

ing

task

;D

RL

R,

Diff

eren

tial

rein

forc

emen

tof

low

-rat

ere

spon

ding

;E

PQ

,E

ysen

ckP

erso

nalit

yQ

uest

ionn

aire

[84]

;I7

,Im

puls

ivit

y,V

entu

reso

men

ess,

and

Em

path

yqu

esti

onna

ire

[74]

;Im

pSS

,Im

puls

ivit

y/S

ensa

tion

See

king

Sca

le[7

5];

NE

O-F

FI,

NE

OF

ive

Fac

tor

Inve

ntor

y[1

6];

SS

S,

Sen

sati

onS

eeki

ngS

cale

[76]

;S

ST

,S

top-

sign

alT

ask;

TC

I,T

empe

ram

ent

and

Cha

ract

erIn

vent

ory

[85]

;TC

I-N

S,

nove

lty

seek

ing

dim

ensi

onof

TC

I[8

5];T

PQ

,Tri

dim

ensi

onal

Per

sona

lity

Que

stio

nnai

re[1

5].



follow-up, only the continuous performance task waspredictive among the impulse control tasks.

In the other laboratory study, Dallery and Raiff con-ducted an analogue study of delayed discounting as apredictor of relapse in smokers who had no intention ofquitting [61]. Specifically, they assessed the relationshipbetween delay discounting and return to smoking fol-lowing a period of nicotine deprivation. They alsoassessed the effects of monetary contingency and nico-tine patch on time to ‘relapse’. Contingency conditions(both a high $20 and low $5 magnitude) increasedlatency to smoking but assignment to active (vs.placebo) nicotine patch did not. Furthermore, regard-less of group assignment, individuals who discountedmonetary rewards at a greater rate at baseline weremore likely to return to smoking.

Similar to the finding by Powell et al. [67] that sen-sation seeking did not predict relapse, several studieshave also failed to find an association between self-reported sensation seeking and treatment outcome[62,66,97]. In testing an alternative five-factor model ofpersonality applied to nicotine dependence, Nieva et al.found that gender moderated the relationship betweenimpulsivity and smoking relapse. Among a sample ofsmokers receiving combination cognitive behaviouraltherapy and medication (nicotine replacement therapy,bupropion or varenicline) as part of a workplacesmoking cessation programme, high-levels of sensationseeking assessed by the Zuckerman-Kuhlman Person-ality Questionnaire predicted relapse but only in males[66]. Another open trial study of transdermal nicotinepatches failed to find an association between sensationseeking and smoking cessation [60]. Finally, in Hallet al.’s longitudinal cohort study of adult smokers inAustralia, Canada, United Kingdom and the USA, sen-sation seeking was not a significant predictor of quitattempts or factors that have been shown to enhancequitting, including quit intention, perceived benefitsof quitting and perceived health risks to smoking.Notably, however, this survey study utilised four Likertscale items to assess sensation seeking (e.g. ‘You like toexplore strange places,’You like to do thrilling things‘)that had not undergoing rigorous validation studies[62].

Alcohol studies. Impulsivity has been linked to earlyinitiation of alcohol use as well as increased risk ofmisuse later in life [98,99]. Higher levels of self-reported impulsivity also have been linked to earlier ageof onset of alcohol-related negative consequences[100,101], and this finding itself has been found to bea robust predictor of later alcohol dependence severity[102]. Despite the clear role that impulsivity plays inalcohol use and misuse, very few studies have examinedits impact on alcohol treatment outcome.

Tab

le3.

Mar

ijuan

ast

udie

s

Aut

hors

Sub

stan

ceR

esea

rch

desi

gnS

ampl

esi

zean

dfo

llow

-up

Impu

lsiv

ity

mea

sure

sF

indi

ngs

Car

pent

eret

al.

[86]

Mar

ijuan

aC

orre

lati

onal

25m

ariju

ana-

depe

nden

tpa

rtic

ipan

ts;

follo

w-u

pva

ried

acco

rdin

gto

indi

vidu

altr

eatm

ent

com

plet

ion

Mod

ified

Str

oop

Tas

kC

ocai

ne-

and

hero

in-r

elat

edst

imul

iin

terf

eren

cesc

ores

wer

eas

soci

ated

wit

ha

sign

ifica

ntly

grea

ter

prop

orti

onof

mar

ijuan

apo

siti

veur

ine

drug

scre

ens

and

asi

gnifi

cant

lylo

wer

prop

orti

onof

trea

tmen

tw

eeks

com

plet

ed.

Sta

nger

etal

.[8

7]M

ariju

ana

Ran

dom

ised

clin

ical

tria

l16

5ad

oles

cent

sm

eeti

ngcr

iter

iafo

rm

ariju

ana

abus

eor

depe

nden

ce;

follo

w-u

pth

roug

h14

wee

ks

DD

TD

elay

disc

ount

ing

ofhi

gher

mon

eyre

war

ds($

1000

)pr

edic

ted

abst

inen

ceou

tcom

esov

eran

dab

ove

type

oftr

eatm

ent

rece

ived

.H

owev

er,

disc

ount

ing

beca

me

ano

n-si

gnifi

cant

pred

icto

ron

cede

mog

raph

icco

vari

ates

(e.g

.so

cioe

cono

mic

stat

us,

race

)w

ere

incl

uded

.

DD

T,

Del

aydi

scou

ntin

gta

sk.



Tab

le4.

Coc

aine

stud

ies

Aut

hors

Sub

stan

ceR

esea

rch

desi

gnS

ampl

esi

zean

dfo

llow

-up

Impu

lsiv

ity

mea

sure

sF

indi

ngs

Bal

l&

Sch

otte

nfiel

d[8

8]C

ocai

neC

orre

lati

onal

/ran

dom

ised

clin

ical

tria

l92

preg

nant

orpo

st-p

artu

mco

cain

eus

ing

wom

enpa

rtic

ipat

ing

inou

tpat

ient

trea

tmen

t;fo

llow

-up

unti

ltr

eatm

ent

com

plet

ion

ordr

opou

t

ImpS

SA

ltho

ugh

scor

eson

the

ImpS

Sw

ere

corr

elat

edw

ith

num

ber

ofdr

ugs

used

,im

puls

ivit

yw

asno

tre

late

dto

rece

ncy,

quan

tity

,fr

eque

ncy

ordu

rati

onof

use,

nor

was

itre

late

dto

trea

tmen

tou

tcom

es,

incl

udin

gpe

rce

ntpo

siti

veur

ine

drug

scre

ens,

num

ber

ofcl

inic

alco

ntac

tsor

num

ber

ofw

eeks

intr

eatm

ent.

Car

pent

eret

al.

[86]

Coc

aine

Cor

rela

tion

al45

coca

ine-

depe

nden

tpa

tien

ts;

follo

w-u

pva

ried

acco

rdin

gto

indi

vidu

altr

eatm

ent

com

plet

ion

Mod

ified

Str

oop

Tas

k

Com

pare

dw

ith

mar

ijuan

a-de

pend

ent

part

icip

ants

,co

cain

e-de

pend

ent

part

icip

ants

resp

onde

dm

ore

slow

lyto

all

stim

ulus

wor

ds.

Fur

ther

mor

e,am

ong

coca

ine-

depe

nden

tpa

rtic

ipan

ts,

mod

ified

Str

oop

perf

orm

ance

inth

epr

esen

ceof

coca

ine

stim

uli

pred

icte

dw

orse

trea

tmen

tou

tcom

es.

Hel

mus

etal

.[7

]C

ocai

neR

ando

mis

edco

ntro

lled

tria

l68

opia

te-d

epen

dent

trea

tmen

tse

eker

sw

hous

eco

cain

e;fo

llow

-up

thro

ugh

wee

k17

oftr

eatm

ent

TP

Q-N

SC

ompa

red

wit

hlo

wno

velt

yse

eker

s,hi

ghno

velt

yse

eker

sw

ere

mor

elik

ely

todr

opou

tby

the

end

oftr

eatm

ent,

but

had

high

erre

tent

ion

rate

sdu

ring

the

earl

yph

ases

oftr

eatm

ent.

Moe

ller

etal

.[8

]C

ocai

neC

orre

lati

onal

/ran

dom

ised

cont

rolle

dtr

ial

50co

cain

e-de

pend

ent

trea

tmen

tse

eker

s;fo

llow

-up

12w

eeks

into

trea

tmen

t

BIS

-11

BIS

-11

tota

lsc

ores

sign

ifica

ntly

corr

elat

edw

ith

self

-rep

ort

aver

age

daily

coca

ine

use

and

coca

ine

wit

hdra

wal

sym

ptom

s.A

mon

gth

ose

who

agre

edto

part

icip

ate

ina

sepa

rate

doub

le-b

lind

plac

ebo

cont

rolle

dtr

ial

ofm

edic

atio

nan

dgr

oup

ther

apy,

thos

ew

ith

high

erba

selin

eim

puls

ivit

ydr

oppe

dou

tsi

gnifi

cant

lyea

rlie

r.P

atka

ret

al.

[46]

Coc

aine

Cor

rela

tion

al14

1A

fric

an-A

mer

ican

coca

ine-

depe

nden

tpa

tien

tsen

teri

ngtr

eatm

ent

and

60co

ntro

ls;

follo

w-u

pat

end

of12

-wee

ktr

eatm

ent

BIS

-11

Coc

aine

-dep

ende

ntpa

rtic

ipan

tsre

port

edsi

gnifi

cant

lyhi

gher

BIS

scor

esth

anco

ntro

ls.

BIS

was

sign

ifica

ntly

asso

ciat

edw

ith

days

intr

eatm

ent

and

drop

out

rate

s.

Was

hio

etal

.[8

9]C

ocai

neR

ando

mis

edco

ntro

lled

tria

l36

coca

ine-

depe

nden

tou

tpat

ient

s;fo

llow

-up

12an

d24

wee

ksaf

ter

base

line.

DD

TD

elay

disc

ount

ing

was

rela

ted

num

ber

ofco

ntin

uous

wee

ksin

trea

tmen

t,ev

enaf

ter

cont

rolli

ngfo

rtr

eatm

ent

cond

itio

n(l

ow-

vs.

high

-mag

nitu

deC

Mvo

uche

rs).

Par

tici

pant

sin

the

low

-mag

nitu

de(b

utno

thi

gh-m

agni

tude

)vo

uche

rco

ndit

ion

who

exhi

bite

dst

eepe

rdi

scou

ntin

gac

hiev

edsh

orte

rpe

riod

sof

abst

inen

ce.

BIS

-11,

Bar

ratt

Impu

lsiv

enes

sS

cale

[11,

12];

DD

T,

Del

aydi

scou

ntin

gta

sk;

ImpS

S,

Impu

lsiv

ity/

Sen

sati

onS

eeki

ngS

cale

[75]

;TP

Q-N

S,

Nov

elty

See

king

Sca

leof

the

Tri

dim

ensi

onal

Per

sona

lity

Que

stio

nnai

re[1

5].



Tab

le5.

Opi

ate

stud

ies

Aut

hors

Sub

stan

ceR

esea

rch

desi

gnS

ampl

esi

zean

dfo

llow

-up

Impu

lsiv

ity

mea

sure

sF

indi

ngs

Car

pent

eret

al.

[86]

Opi

ates

Cor

rela

tion

al10

hero

in-d

epen

dent

pati

ents

;fo

llow

-up

vari

edac

cord

ing

toin

divi

dual

trea

tmen

tco

mpl

etio

n

Mod

ified

Str

oop

Tas

kN

osi

gnifi

cant

rela

tion

ship

sbe

twee

nm

odifi

edS

troo

ppe

rfor

man

cean

dtr

eatm

ent

outc

omes

.

Pas

sett

iet

al.

[90]

Opi

ates

Cor

rela

tion

al37

opia

te-d

epen

dent

trea

tmen

tse

eker

s;fo

llow

-up

at3

mon

ths

into

trea

tmen

t

IGT

;C

GT

;D

DT

;TO

L;

IST

;S

ST

;G

o/N

o-G

ota

sk

Per

form

ance

onde

cisi

on-m

akin

gte

sts,

but

not

plan

ning

,m

otor

inhi

biti

on,

refle

ctio

nim

puls

ivit

yor

dela

ydi

scou

ntin

g,pr

edic

ted

abst

inen

ceat

3m

onth

sin

totr

eatm

ent

wit

hhi

ghsp

ecifi

city

and

mod

erat

ese

nsit

ivit

y.P

oire

ret

al.

[91]

Opi

ates

Cor

rela

tion

al73

opia

te-d

epen

dent

pati

ents

rece

ivin

ghi

gh-d

ose

bupr

enor

phin

e;fo

llow

-up

thro

ugh

3-m

onth

trea

tmen

tpe

riod

SS

SG

ood

trea

tmen

tre

spon

se(i

.e.

75%

opia

te-n

egat

ive

urin

edr

ugsc

reen

sdu

ring

last

mon

thof

trea

tmen

tan

dpa

rtic

ipat

ion

in3-

mon

thst

udy)

was

pred

icte

dby

anu

mbe

rof

fact

ors,

incl

udin

glo

wdi

sinh

ibit

ion

and

bore

dom

susc

epti

bilit

yfa

ctor

sfr

omth

eS

SS

.R

oll

etal

.[7

3]O

piat

es&

Coc

aine

Cor

rela

tion

al21

hero

in-d

epen

dent

coca

ine

user

sin

trea

tmen

t;fo

llow

-up

at17

wee

ks/e

ndof

trea

tmen

t

TP

QT

hose

who

scor

edhi

ghon

the

TP

QN

ovel

tyS

eeki

ngS

cale

atte

nded

sign

ifica

ntly

few

ersc

hedu

led

appo

intm

ents

,m

isse

dm

ore

appo

intm

ents

and

had

shor

ter

trea

tmen

tre

tent

ion

tim

es.

Sch

mit

zet

al.

[92]

Opi

ates

Ran

dom

ised

cont

rolle

dtr

ial

75co

cain

e-de

pend

ent

trea

tmen

tse

eker

s;fo

llow

-up

aten

dof

trea

tmen

t(1

2-w

eeks

post

-bas

elin

e)

Imm

edia

tean

dD

elay

edM

emor

yT

ask,

BIS

-11,

IGT

Impu

lsiv

ity

was

not

pred

icti

veof

trea

tmen

tre

tent

ion.

Abs

tine

ntpa

rtic

ipan

tsw

ere

mor

eim

puls

ive,

asm

easu

red

byth

eB

IS-1

1,bu

tal

som

ore

likel

yto

use

adva

ntag

eous

deci

sion

-mak

ing

stra

tegi

es,

asm

easu

red

byth

eIG

T.

Zoc

cali

etal

.[9

3]O

piat

esC

orre

lati

onal

144

opia

te-d

epen

dent

pati

ents

inre

side

ntia

ltr

eatm

ent;

follo

w-u

pth

roug

h6-

mon

thst

udy

peri

od

TC

IN

ovel

tyse

ekin

gw

asno

tre

late

dto

trea

tmen

tdr

opou

t.

BIS

-11,

Bar

ratt

Impu

lsiv

enes

sS

cale

[11,

12];

CG

T,C

ambr

idge

Gam

blin

gT

ask

[94]

;CP

T,C

onti

nuou

sP

erfo

rman

ceT

ask;

DD

T,D

elay

disc

ount

ing

task

;EP

Q,E

ysen

ckP

erso

nalit

yQ

uest

ionn

aire

[84]

;I7

,Im

puls

ivit

y,V

entu

reso

men

ess,

and

Em

path

yqu

esti

onna

ire

[74]

;Im

pSS

,Im

puls

ivit

y/S

ensa

tion

See

king

Sca

le[7

5];

IGT

,Io

wa

Gam

blin

gT

ask

[95]

;IS

T,

Info

rmat

ion

Sam

plin

gT

ask;

NE

O-F

FI,

NE

OF

ive

Fac

tor

Inve

ntor

y[1

6];

SS

S,

Sen

sati

onS

eeki

ngS

cale

[76]

;S

ST

,S

top-

sign

alT

ask;

TC

I,T

empe

ram

ent

and

Cha

ract

erIn

vent

ory

[85]

;TO

L,T

ower

ofL

ondo

nT

est

[96]

;TP

Q,T

ridi

men

sion

alP

erso

nalit

yQ

uest

ionn

aire

[15]

;TP

Q-N

S,

Nov

elty

See

king

Sca

leof

the

Tri

dim

ensi

onal

Per

sona

lity

Que

stio

nnai

re[1

5].



Impulsivity likely exerts an influence early in thetreatment process. In their study of 175 alcoholdependent individuals, Charney et al. found that higherscores on the BIS-11 were associated with higher ratesof slips and relapse within the first 28 days of treatment[5]. The authors hypothesised that impulsivity mayprecede the onset of alcohol problems, and one mecha-nism of action by which impulsivity might impact thecourse of alcohol treatment is via an impulsive decisionto enter treatment when not sufficiently motivated. Inaccordance with this finding, Kravitz et al. found thathigher novelty seeking was associated with increasedrisk of early treatment dropout [79]. Meszaros et al.similarly found that novelty seeking was a strong pre-dictor of relapse in detoxified male alcoholics; however,novelty seeking did not predict relapse among females[80]. Finally, Sellman et al. failed to find a relationshipbetween novelty seeking and relapse among a sample ofmales in treatment for alcohol dependence [83].

Greater impulsivity also has been associated withincreased risk for relapse after treatment in alcohol-dependent individuals. Muller et al. revealed that higherscores on the Impulsiveness subscale of the EysenckImpulsiveness-Venturesomeness-Empathy Scale (I7)distinguished between relapsed and abstinent alcohol-dependent patients one year after treatment discharge[81]. A similar finding was reported by Evren et al., whofound that higher scores on the BIS-11 differentiatedbetween relapsed and non-relapsed groups one yearafter detoxification. Interestingly, scores on the BIS-11were positively correlated with severity of self-reportedcraving for alcohol in this treatment sample, a findingthat has been reported by others (e.g. [51]). Thus, itmay be that impulsivity mediates the relationshipbetween craving and relapse [50,103].

Impulsivity may also directly mediate the effects oftreatment. Ewing et al. randomised a sample of 67emerging adult problem drinkers to receive eitheralcohol education or a single session of MotivationalEnhancement Therapy (MET) [78]. Although METincreased behaviour change during the first 30 dayspost-intervention, these effects were stronger for thoseindividuals who were lower in impulsivity, as measuredby the Impulsivity/Sensation-Seeking Scale [75]. METwas less effective for individuals with higher impulsivity.

The notion that impulsivity may mediate the effectsof pharmacotherapy on alcohol consumption was sup-ported by Rubio et al., who administered the anti-convulsant topiramate to alcohol-dependent males in a12-week, double-blind, placebo-controlled trial [82].Patients who received topiramate demonstratedimprovement on several alcohol use measures, includ-ing fewer alcohol drinks per drinking day, greaternumber of days of abstinence and reduced craving. Inaddition, topiramate significantly improved perfor-

mance on several behavioural impulsivity tasks, as wellas reduced BIS-II scores, compared with placebo. Theauthors concluded that the reduction in alcohol intakeobserved in the topiramate group may be associatedwith the medication’s effect on impulsivity. That is,topiramate may modulate alcohol use via improvementof inhibitory control. Unfortunately, it is not possible todetermine whether topiramate decreased impulsivity,which in turn decreased alcohol consumption, or viceversa.

In another pharmacotherapy treatment study, base-line impulsivity appeared to moderate the effect ofmodafinil on treatment outcome. Specifically, amongalcohol-dependent patients with poor response inhibi-tion at baseline, modafinil prolonged time to relapseand tended to increase percentage of abstinence days;however, among those with better response inhibitionat baseline, modafinil seemed to predict poorer treat-ment outcomes, including fewer abstinent days andgreater heavy drinking days [104]. These findingssuggest that modafinil may only be a useful treatmentfor alcohol dependence among individuals with greaterimpulsivity.

Marijuana studies. Fewer studies have focused on therole of impulsivity in response to treatment for mari-juana, and these reveal that other mediating or moder-ating factors may need to be included in any model ofimpulsivity and marijuana use. In one study, Carpenteret al. examined performance on a modified Stroop testamong marijuana-, cocaine-, and heroin-dependentpatients in a time-limited outpatient treatment pro-gramme utilising pharmacotherapy and cognitive-behavioural coping skills therapy [86]. Interferencescores on cocaine and heroin stimulus words (but notmarijuana or polydrug stimulus words) were signifi-cantly positively associated with a greater proportion ofmarijuana positive urine drug screens and significantlynegatively associated with the proportion of treatmentweeks completed.

Stanger et al. examined whether delay discountingpredicted treatment outcomes among adolescent mari-juana users participating in a randomised clinical trialcomparing three behavioural treatments—cognitivebehavioural therapy, cognitive behavioural therapy andcontingency management, and a combined cognitivebehavioural therapy/contingency management andfamily management curriculum [87]. Regardless oftreatment condition, delay discounting of $1000 inhypothetical money predicted treatment abstinence.However, once demographic covariates, such as socio-economic status and race, were included in regressionanalyses, discounting no longer significantly predictedto treatment outcome. Thus, there may be importantmediating and moderating relationships between



impulsivity, other patient characteristics and treatmentoutcomes that need to be further examined to betterunderstand the role of impulsivity on treatmentoutcome for marijuana use.

Cocaine studies. Moeller et al. found that higher base-line scores on the BIS-11 predicted greater treatmentdropout and lower retention among individuals seekingtreatment for cocaine dependence [8]. No significantfindings were identified for urine toxicology results butthe authors suggest that the small sample size mayaccount for this negative finding. In another study,higher impulsivity and sensation seeking were associ-ated with fewer days in treatment among patientsseeking intensive outpatient treatment for cocainedependence [46]. Higher sensation seeking was alsoassociated with fewer negative urine drug screens andhigher dropout rate.

Carpenter et al. found that cocaine-dependentpatients responded more slowly to both drug andneutral stimulus words compared with marijuana-dependent patients. Furthermore, performance on themodified Stroop task containing cocaine-related wordswas associated with worse treatment outcome forcocaine-dependent patients, including significantlymore positive urine drug screens and earlier treatmentdropout [86]. Another laboratory study examiningdelay discounting among cocaine-dependent outpa-tients receiving contingency management found thatdelay discounting was significantly associated withnumber of weeks of continuous abstinence, even aftercontrolling for treatment condition. Furthermore,among participants in the low magnitude voucher con-dition (but not the high magnitude condition), steeperdiscounting predicted shorter periods of abstinence[89].

In a contrary finding, cocaine-dependent outpatientsin a placebo-controlled trial of the selective serotoninreuptake inhibitors citalopram who were consideredabstainers (four or more consecutive cocaine-negativeurine drug screens) endorsed higher impulsivity scoreson the BIS-11 but demonstrated more advantageousdecision making on the Iowa Gambling Task than didnon-abstainers (fewer than three consecutive negativedrug screens) [92]. All participants received the samecognitive-behavioural and contingency managementtreatment regardless of medication treatment condition.The authors suggest that the contingency managementtreatment, which results in immediate reinforcementthat may circumvent problems of discounting delayedrewards, and intact decision-making resulting in anability to benefit from cognitive therapy, may account forthese somewhat counterintuitive findings.

Finally, in contrast to the above studies, one studyfocusing on pregnant and post-partum cocaine users in

outpatient treatment found no association betweenimpulsive sensation seeking (as measured by theZuckerman-Kuhlman Personality Questionnaire) andtreatment outcomes. Specifically, sensation seeking wasnot related to per cent of cocaine-positive urines,number of treatment sessions attended or duration oftreatment [88].

Opiate studies. Carpenter et al. failed to find any sig-nificant link between impulsivity and treatment-relatedoutcomes among heroin-dependent patients using amodified Stroop Task [86]; however, this may in parthave been due to their limited sample size of only 10heroin-dependent patients. Others, however, havefound impulsivity to be related to treatment outcomeamong heroin and other opiate users.

Helmus et al. examined novelty seeking as a predictorof treatment retention among opioid-dependentcocaine-abusing patients in a study examining the effi-cacy of combined buprenorphine and voucher contin-gency management treatments [7]. They found thathigh novelty seekers were significantly more likely todropout of treatment before week 17 (78%) than werelow novelty seekers (50%). Using survival analysis, theauthors demonstrated that high novelty seekers hadhigher retention rates than low novelty seekers early intreatment, but lower retention rates later in treatment.The authors suggested that the buprenorphine andcontingency management treatments may have beenexperienced as novel, which may have contributed tothe early success of high novelty-seeking participants. Asimilar study conducted by the same group [73] foundthat buprenorphine-treated opioid-dependent cocaineusers who scored high on the Novelty Seeking scale ofthe Tridimensional Personality Questionnaire attendedfewer scheduled visits, had more no-shows and werein treatment for fewer weeks than participants whoscored lower on this measure. Conversely, amonga sample of high-dosage buprenorphine opioid-dependent patients—a significant proportion of whomalso met dependence criteria for alcohol, cocaine,marijuana—Poirer et al. found that low sensationseeking (low disinhibition in particular) predicted posi-tive treatment response [91]. Finally, Zoccali et al.failed to find an association between novelty seekingand treatment dropout among opioid-dependentpatients residing in therapeutic communities [93].

In a study utilising laboratory measures of impulsiv-ity, decision making (e.g. Iowa Gambling Task), plan-ning (Tower of London), delay discounting andimpulsivity (e.g. Go-NoGo response inhibition) taskswere used to predict treatment outcome amongmethadone-maintained opioid-dependent patients[90]. At three months, participants were divided into‘abstinent’ (from all illicit drugs; n = 10) and ‘non-



abstinent’ (n = 27) groups. Individuals in the non-abstinent group were more likely than those in theabstinent group to have baseline scores reflectingimpairment on the Iowa Gambling Task. On a seconddecision-making task (the Cambridge Gambling Task),all of the abstinent individuals were categorised ashaving ‘unimpaired’ decision making, compared withonly about half of those in the non-abstinent group.Non-abstinent patients discounted delayed rewards athigher rates than abstinent patients, but this differencemet only marginal significance. Group differences werenot found for theTower of London planning task, or forcognitive and motor impulsivity tasks.

Gaps in the literature and future directions

Although initial work has, for the most part, found thatimpulsivity is associated with poorer treatment out-comes among substance abusing populations, thecurrent research literature is limited in several ways.First, the total number of studies examining the rela-tionship between impulsivity and treatment outcomesis small. In this review, we identified only 33 studies ofsubstance use disorders or nicotine dependence. Thefew studies that have been conducted show that impul-sivity is likely a robust predictor of treatment outcomesand thus should be a focus of treatment development.

Second, as mentioned above, there are several diverseways of operationalising impulsivity. Although mostforms of impulsivity studied thus far have been found tobe associated with addictive disorders, there are severalfactors to consider with regard to how impulsivity ismeasured: (i) self-report measures differ from behav-ioural measures in that they fundamentally measure theindividual’s perception of their own behaviours ratherthan the actual phenotype being exhibited; (ii) impul-sivity measures are surprisingly modestly intercor-related [3,20,36]; and (iii) different measures of impul-sivity may also be associated with differential brainfunctioning [105].Thus, even though several impulsiv-ity measures may converge on similar outcomes (e.g.predicting treatment outcome or relapse), we do not yetknow whether different impulsivity measures are assess-ing the same underlying constructs that affect theseoutcomes. Indeed, several studies have found that whilesome measures predict outcomes, others that are meas-uring similar constructs do not [67,69]. Sensationseeking in particular did not appear to consistentlypredict treatment outcomes [60,62,66,67]. Further-more, others have argued the need to distinguishbetween impulsivity phenotypes [104] and endophe-notypes (e.g. [104,105]) when conducting predictivestudies [106]. Ultimately, studies of endophenotypes(e.g. underlying genetic variability to impulsivity) maybe more informative than studies of phenotypes (i.e.

observable characteristics of impulsivity) given thecomplex aetiology of addictive disorders [107].

Third, there is nearly a complete lack of researchrelated to the implications of impulsivity on the effec-tiveness of different types of treatment, or treatmentintensity. Two studies utilising MET, for example,found it to be less effective for those who had higherlevels of self-reported impulsivity [63,78]. Additionally,a pharmacotherapy trial found modafinil to be effica-cious in treating alcohol dependence but only amongindividuals with poor response inhibition [71]. Further-more, findings from two other studies examining con-tingency management indicated that level of noveltyseeking and the availability of immediate rewardsin contingency management may impact treatmentoutcome [7,92]. Clearly, more research is needed toexamine moderators and mediators of treatmentoutcome and whether there may be different treatmenttypes, treatment intensity/duration, co-occurring psy-chiatric or substance use disorders, or other factorsthat may interact with impulsivity to affect treatmentoutcomes.

Fourth, there is also a lack of data on whether certaintypes of treatments reduce state impulsivity. It is impor-tant to note, for example, whether some types of treat-ment lead to better decision making. Studies thatexamine the effect of treatment on impulsivity are rare.Dallery and Raiff found that, although nicotine replace-ment reduced negative affect among recently abstinentsmokers, this form of treatment did not affect delaydiscounting [61]. Similarly,Yoon et al. found no reduc-tions in impulsivity as a result of contingency manage-ment treatment [70]. On the other hand, topiramatewas found in one study to reduce impulsivity levelsamong individuals treated for alcohol use disorder [82].No studies, to our knowledge, have extended thesefindings on topiramate to other drugs of abuse.Furthermore, future studies may identify whether othermedications may result in similar reductions in impul-sivity.

Nevertheless, abstinence from substance use disor-ders may result in lower levels of impulsivity amongsome individuals. Some investigations, for example,show that former substance users discount delayedmoney rewards at rates much less than current users,and often comparable with never-users (e.g. [55]).Because impulsivity often is associated with higher riskof relapse, it is important to understand the interrela-tionship between impulsivity, abstinence and relapse asit pertains to treatment outcomes.

Conclusions

Impulsivity, a widely studied personality trait andresearch construct, has been implicated as a risk factor



for initiating and continuing drug use. Given thatimpulsivity has been operationalised in many differentways, cross-comparisons of empirical studies have beendifficult. In addition, relatively few studies have exam-ined the use of impulsivity as a predictor of treatmentoutcome. Taken together, the studies reviewed in thispaper reveal that higher pretreatment impulsivity,regardless of how it is measured, usually is associatedwith poorer treatment outcomes. There were only afew exceptions to this finding. Psychosocial andpharamacological treatments that may positivelyimpact impulsivity appear to be worthy of furtherexamination, including contingency management, andtopiramate. Future studies should continue to examinethe relationship between impulsivity and substance usetreatment outcomes. Finally, treatment studies shouldfurther examine the impact of impulsivity on treatmentintensity and outcome.

Acknowledgements

This paper was supported by Lycaki-Young fundingthrough the State of Michigan.

References

[1] Evanden JL. Varieties of impulsivity. Psychopharmacology(Berl) 1999;146:348–61.

[2] Petry NM, Madden GJ. Discounting and pathologicalgambling. In: Madden GJ, Bickel WK, eds. Impulsivity:the behavioral and neurological science of discounting.Washington, DC: American Psychological Association,2010:273–294.

[3] Verdejo-Garcia A, Lawrence AJ, Clark L. Impulsivity as avulnerability marker for substance-use disorders: review offindings from high-risk research, problem gamblers andgenetic association studies. Neurosci Biobehav Rev2008;32:777–810.

[4] Yi R, Mitchell SH, Bickel WK. Delay discounting andsubstance abuse-dependence. In: Madden GJ, Bickel WK,eds. Impulsivity: the behavioral and neurological science ofdiscounting. Washington, DC: American PsychologicalAssociation, 2010:191–211.

[5] Charney DA, Zikos E, Gill KJ. Early recovery from alcoholdependence: factors that promote or impede abstinence.J Subst Abuse Treat 2010;38:42–50. doi: 10.1016/j.jsat.2009.06.002.

[6] Doran N, Spring B, McChargue D, Pergadia M,Richmond M. Impulsivity and smoking relapse. NicotineTob Res 2004;6:641–7.

[7] Helmus TC, Downey KK, Arfken CL, Henderson MJ,Schuster CR. Novelty seeking as a predictor of treatmentretention for heroin dependent cocaine users. DrugAlcohol Depend 2001;61:287–95.

[8] Moeller FG, Dougherty DM, Barratt ES, Schmitz JM,Swann AC, Grabowski J. The impact of impulsivity oncocaine use and retention in treatment. J Subst AbuseTreat 2001;21:193–8.

[9] Oxford University Press. Oxford English Dictionaryonline. 2013 Available at: http://www.oed.com/view/Entry/92922?redirectedFrom=impulsive# (accessed December2013).

[10] American Psychological Association. PsychInfo. 2013Available at: http://www.apa.org/pubs/databases/psycinfo/index.aspx (accessed June 2013).

[11] Barratt ES. Impulsiveness subtraits: arousal and informa-tion processing. Motivation, emotion and personality.1985:137–46.

[12] Patton JH, Stanford MS, Barratt ES. Factor structure ofthe Barratt Impulsiveness Scale. J Clin Psychol 1995;51:768–74.

[13] Eysenck SBG, Eysenck HJ. Impulsiveness and venture-someness: their position in a dimensional system of per-sonality description. Psychol Rep 1978;43:1247–55.

[14] Whiteside SP, Lynam DR. The five factor model andimpulsivity: using a structural model of personality tounderstand impulsivity. Pers Individ Dif 2001;30:669–89.

[15] Cloninger RC. A systematic method for clinical descrip-tion and classification of personality traits: a proposal.Arch Gen Psychiatry 1987;44:573–88.

[16] Costa PT, McCrae RR. Revised NEO Personality Inven-tory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI). Odessa, FL: Psychological Assessment Resources,1992.

[17] Dawe S, Gullo MJ, Loxton NJ. Reward drive and rashimpulsiveness as dimensions of impulsivity: implicationsfor substance misuse. Addict Behav 2004;29:1389–405.

[18] Dickman SJ. Functional and dysfunctional impulsivity:personality and cognitive correlates. J Pers Soc Psychol1990;58:95–102.

[19] Zukerman M. Sensation seeking: beyond the optimal levelof arousal. Hillsdale, NJ: Lawrence Erlbaum Associates,1979.

[20] Ledgerwood DM, Alessi SM, Phoenix N, Petry NM.Behavioral assessment of impulsivity in pathological gam-blers with and without substance use disorder historiesversus healthy controls. Drug Alcohol Depend 2009;105:89–96.

[21] Rachlin H, Raineri A, Cross D. Subjective probability anddelay. J Exp Anal Behav 1991;55:233–44.

[22] Green L, Fry AF, Myerson J. Discounting of delayedrewards: a life-span comparison. Psychol Sci 1994;5:33–6.

[23] Finn PR, Justus A, Mazas C, Steinmetz JE. Workingmemory, executive processes and the effects of alcohol onGo/No-Go learning: testing a model of behavioral regula-tion and impulsivity. Psychopharmacology (Berl) 1999;146:465–72.

[24] Finn PR, Mazas CA, Justus AN, Steinmetz J. Early-onsetalcoholism with conduct disorder: go/no go learning defi-cits, working memory capacity, and personality. AlcoholClin Exp Res 2002;26:186–202.

[25] Horn N, Dolan M, Elliott R, Deakin J, Woodruff P.Response inhibition and impulsivity: an fMRI study.Neuropsychologia 2003;41:1959–66.

[26] Marsh DM, Dougherty DM, Mathias CW, Moeller FG,Hicks LR. Comparisons of women with high and lowtrait impulsivity using behavioral models of response-disinhibition and reward choice. Pers Individ Dif 2002;33:1291–310.

[27] Dougherty DM. Laboratory behavioral measures ofimpulsivity: general information manual. Houston, TX:Neurobehavioral Research Laboratory and Clinic, Univer-sity of Texas Health Science Center, 2003.

[28] Dougherty DM, Marsh DM. Immediate and delayedmemory tasks (IMT/DMT 2.0): a research tool for study-ing attention, memory, and impulsive behavior. Houston,TX: Neurobehavioral Research Laboratory and Clinic,University of Texas Health Center at Houston, 2003.



http://www.oed.com/view/Entry/92922?redirectedFrom=impulsive#

http://www.oed.com/view/Entry/92922?redirectedFrom=impulsive#

http://www.apa.org/pubs/databases/psycinfo/index.aspx

http://www.apa.org/pubs/databases/psycinfo/index.aspx

[29] Swann AC, Bjork JM, Moeller FG, Dougherty DM.Two models of impulsivity: relationships to personalitytraits and psychopathology. Biol Psychiatry 2002;51:988–94.

[30] Epstein JN, Erkanli A, Connors CK, Klaric J, Costello JE,Angold A. Relations between continuous performance testperformance measures and ADHD behaviors. J AbnormChild Psychol 2003;31:543–54.

[31] Bechara A, Damasio H, Tranel D, Damasio AR. Decidingadvantageously before knowing the advantageous strategy.Science 1997;275:1293–5.

[32] Rogers RD, Everitt BJ, Baldacchino A, et al. Dissociabledeficits in the decision-making cognition of chronicamphetamine abusers, opiate abusers, patients with focaldamage to the prefrontal cortex, and tryptophan-depletednormal volunteers: evidence for monoaminergic mecha-nisms. Neuropsychopharmacology 1999;20:322–39.

[33] Rogers RD, Owen AM, Middleton HC, et al. Choosingbetween small, likely rewards and large, unlikely rewardsactivates inferior and orbital prefrontal cortex. J Neurosci1999;19:9029–38.

[34] Lejuez CW, Read JP, Kahler CW, et al. Evaluation of abehavioral measure of risk taking: the Balloon AnalogueRisk Task (BART). J Exp Psychol Appl 2002;8:75–84.

[35] Lejuez CW, Aklin WM, Zvolensky MJ, Pedulla CM.Evaluation of the Balloon Analogue Risk Task (BART) asa predictor of adolescent real-world risk-taking behaviors.J Adolesc 2003;26:475–9.

[36] Lijffijt M, Bekker EM, Quik EH, Bakker J, Kenemans JL,Verbaten MN. Differences between low and high traitimpulsivity are not associated with differences in inhibi-tory motor control. J Atten Disord 2004;8:25–32.

[37] Reynolds B, Ortengren A, Richards JB, de Wit H. Dimen-sions of impulsive behavior: personality and behavioralmeasures. Pers Individ Dif 2006;40:305–15.

[38] Meda SA, Stevens MC, Potenza MN, et al. Investigatingthe behavioural and self-report constructs of impulsivitydomains using principal components analysis. BeahvioralPharmacology 2009;20:390–9.

[39] Vuchinich RE, Simpson CA. Hyperbolic temporal dis-counting in social drinkers and problem drinkers. ExpClin Psychopharmacol 1998;6:292–305.

[40] Coffey SF, Gudleski GD, Saladin ME, Brady KT. Impul-sivity and rapid discounting of delayed hypotheticalrewards in cocaine-dependent individuals. Exp ClinPsychopharmacol 2003;11:18–25.

[41] Kirby KN, Petry NM. Heroin and cocaine abusers havehigher discount rates for delayed rewards than alcoholicsor non-drug-using controls. Addiction 2004;99:461–71.

[42] Kirby KN, Petry NM, Bickel WK. Heroin addicts havehigher discount rates for delayed rewards than non-drug-using controls. J Exp Psychol Gen 1999;128:78–87.

[43] Hoffman WF, Moore M, Templin R, McFarland B,Hitzemann RJ, Mitchell SH. Neuropsychological functionand delay discounting in methamphetamine-dependentindividuals. Psychopharmacology (Berl) 2006;188:162–70.

[44] Johnson MW, Bickel WK, Baker F, Moore BA, Badger GJ,Budney AJ. Delay discounting in current and formermarijuana-dependent individuals. Exp Clin Psychophar-macol 2010;18:99–107.

[45] Cangemi S, Giorgi I, Bonfiglio NS, Renati R, Vittadini G.Impulsiveness and time perception in alcohol dependentpatients in alcoholic rehabilitation treatment. G Ital MedLav Ergon 2010;32(3, Suppl. B):B23–8.

[46] Patkar AA, Murray HW, Mannelli P, Gottheil E,Weinstein SP, Vergare MJ. Pre-treatment measures ofimpulsivity, aggression and sensation seeking are associ-ated with treatment outcome for African-AmericanCocaine-Dependent patients. J Addict Dis 2004;23:109–22.

[47] Nielsen DA, Ho A, Bahl A, et al. Former heroin addictswith or without a history of cocaine dependence are moreimpulsive than controls. Drug Alcohol Depend 2012;124:113–20.

[48] Monterosso JR, Aron AR, Cordova X, Xu J, London ED.Deficits in response inhibition associated with chronicmethamphetamine abuse. Drug Alcohol Depend 2005;79:273–7.

[49] Grant S, Contoreggi C, London ED. Drug abusers showimpaired performance in a laboratory test of decisionmaking. Neuropsychologia 2002;38:1180–7.

[50] Evren C, Durkaya M, Evren B, Dalbudak E, Cetin R.Relationship of relapse with impulsivity, novelty seekingand craving in male alcohol-dependent inpatients. DrugAlcohol Rev 2012;31:81–90. doi: 10.1111/j.1465-3362.00303.x.

[51] Joos L, Goudriaan AE, Schmaal L, et al. The relationshipbetween impulsivity and craving in alcohol dependentpatients. Psychopharmacology (Berl) 2013;226:273–83.doi: 10.1007/s00213-012-2905-8.

[52] Roozen HG, van der Kroft P, van Marle HJ, Franken IHA.The impact of craving and impulsivity on aggression indetoxified cocaine-dependent patients. J Subst AbuseTreat 2011;40:414–18.

[53] Tziortis D, Mahoney JJ, Kalechstein AD, Newton TF,De La Garza R. The relationship between impulsivity andcraving in cocaine- and methamphetamine-dependent vol-unteers. Pharmacol Biochem Behav 2011;98:196–202.

[54] Patkar AA, Thornton CC, Mannelli P, et al. Comparisonof pretreatment characteristics and treatment outcomesfor alcohol-, cocaine-, and multisubstance-dependentpatients. J Addict Dis 2004;23:93–109.

[55] Bickel WK, Odum AL, Madden GJ. Impulsivity and ciga-rette smoking: delay discounting in current, never andex-smokers. Psychopharmacology (Berl) 1999;146:447–54.

[56] Mitchell SH. Measuring impulsivity and modeling itsassociation with cigarette smoking. Behav Cogn NeurosciRev 2004;3:261–75.

[57] Field M, Santacangelo M, Sumnall H, Goudie A, Cole J.Delay discounting and the behavioral economics of ciga-rette purchases in smokers: the effects of nicotine depriva-tion. Psychopharmacology (Berl) 2006;186:255–63.

[58] Perkins KA, Lerman C, Coddington SB, et al. Initial nico-tine sensitivity in humans as a function of impulsivity.Psychopharmacology (Berl) 2008;200:529–44.

[59] Rounsaville BJ, Dolinsky ZS, Babor TF, Meyer RE. Psy-chopathology as a predictor of treatment outcome in alco-holics. Arch Gen Psychiatry 1987;44:505–13.

[60] Carlton S, Le Houzec J, Lagrue G, Jouvent R. Relation-ships between sensation seeking and emotional symptoma-tology during smoking cessation with nicotine patchtherapy. Addictive Behaviors 2000;25:653–62.

[61] Dallery J, Raiff BR. Delay discounting predicts cigarettesmoking in a laboratory model of abstinence reinforce-ment. Psychopharmacology (Berl) 2007;190:485–96.

[62] Hall PA, Fong GT, Young H, Sansone G, Borland R,Siahpush M. Do time perspective and sensation-seekingpredict quitting activity among smokers? Findings from



the International Tobacco Control (ITC) Four CountrySurvey. Addict Behav 2012;37:1307–13.

[63] Helstrom A, Hutchinson K, Bryan A. Motivationalenhancement therapy for high-risk adolescent smokers.Addict Behav 2007;32:2404–10.

[64] Krishnan-Sarin S, Reynolds B, Duhig AM, et al.Behavioral impulsivity predicts treatment outcome in asmoking cessation program for adolescent smokers. DrugAlcohol Depend 2007;88:79–82.

[65] MacKillop J, Kahler CW. Delayed reward discountingpredicts treatment response for heavy drinkers receivingsmoking cessation treatment. Drug Alcohol Depend2009;104:197–203.

[66] Nieva G, Valero S, Bruguera E, et al. The alternative five-factor model of personality, nicotine dependence andrelapse after treatment for smoking cessation. AddictBehav 2011;36:965–71.

[67] Powell J, Dawkins L, West R, Powell J, Pickering A.Relapse to smoking during unaided cessation: clinical,cognitive and motivational predictors. Psychophar-macology (Berl) 2010;212:537–49.

[68] Rukstalis M, Jepson C, Patterson F, Lerman C. Increasesin hyperactive impulsive symptoms predict relapse amongsmokers in nicotine replacement therapy. J Subst AbuseTreat 2005;28:297–304.

[69] Sheffer C, MacKillop J, McGeary J, et al. Delay discount-ing, locus of control, and cognitive impulsiveness indepen-dently predict tobacco dependence treatment outcomesin a highly dependent, lower socioeconomic group ofsmokers. Am J Addict 2012;21:221–32.

[70] Yoon JH, Higgins ST, Heil SH, Sugarbaker RJ, ThomasCS, Badger GJ. Delay discounting predicts postpartumrelapse to cigarette smoking among pregnant women. ExpClin Psychopharmacol 2007;15:176–86.

[71] Murphy K, Barkley RA. Attention deficit hyperactivitydisorder adults: comorbidities and adaptive impairments.Compr Psychiatry 1996;37:393–401.

[72] Reynolds B, Schiffbauer R. Measuring state changes inhuman delay discounting: an experiential discounting task.Behav Process 2004;67:43–56.

[73] Roll JM, Saules KK, Chudzynski JE, Sodano R. Relation-ship between Tridimensional Personality Questionnairescores and clinic attendance among cocaine abusing,buprenorphine maintained outpatients. Subst Use Misuse2004;39:1025–40.

[74] Eysenck HJ, Eysenck SBG. Adult IVE. London: Hodder &Stoughton, 1991.

[75] Zuckerman M, Kuhlman DM, Joireman J, Teta P, KraftM. A comparison of three structural models for personal-ity: the big three, the big five, and the alternative five. J PersSoc Psychol 1993;65:757–68.

[76] Zuckerman M, Eysenck S, Eysenck HJ. Sensation seekingin England and America: cross-cultural age and sex com-parisons. J Consult Clin Psychol 1978;46:139–49.

[77] Stephenson MT,Hoyle RH,Palmgreen P,Slater MD.Briefmeasures of sensation seeking for screening and large-scalesurveys. Drug Alcohol Depend 2003;72:279–86.

[78] Ewing SWF, LaChance HA, Bryan A, Hutchinson KE.Do genetic and individual risk factors moderate the effi-cacy of motivational enhancement therapy? Drinking out-comes with an emerging adult sample. Addict Biol2009;14:356–65. doi: 10.1111/j.1369-1600.2009.00149.x.

[79] Kravitz HM, Fawcett J, McGuire M, Kravitz G, WhitneyM. Treatment attrition among alcohol-dependent men: is

it related to novelty seeking personality traits? J ClinPsychopharmacol 1999;19:51–6.

[80] Meszaros K, Lenzinger E, Hornik K, et al. The Tridimen-sional Personality Questionnaire as a predictor of relapsein detoxified alcohol dependents. Alcohol Clin Expe Res1999;23:483–86.

[81] Muller SE, Weijers H-G, Boning J, Wiesbeck GA. Person-ality traits predict treatment outcome in alcohol-dependent patients. Neuropsychobiology 2008;57:159–64. doi: 10.1159/000147469.

[82] Rubio G, Martinez-Gras I, Manzanares J. Modulation ofimpulsivity by topiramate: implications for the treatmentof alcohol dependence. J Clin Psychopharmacol2009;29:584–9. doi: 10.1097/JCP.0b013e3191bfdb79.

[83] Sellman JD, Mulder RT, Sullivan PF, Joyce PR. Lowpersistence predicts relapse in alcohol dependence follow-ing treatment. J Stud Alcohol 1997;58:257–63.

[84] Ruch W. The Eysenck Personality Questionnaire-Revisedand the construction of German standard and short ver-sions (EPQ-R and EPQ-RK). Z Diagn Psychol 1999;20:1–24.

[85] Cloninger CR, Pryzbeck TR, Svaric DM, Wentzel RD.The Temperament and Character Inventory (TCI): aguide to its development and use. St. Louis: WashingtonUniversity, 1994.

[86] Carpenter KM, Schreiber E, Church S, McDowell D.Drug Stroop performance: relationships with primarysubstance of use and treatment outcome in adrug-dependent outpatient sample. Addict Behav2006;31:174–81.

[87] Stanger C, Ryan SP, Hongyun F, et al. Delay discountingpredicts adolescent substance abuse treatment outcome.Exp Clin Psychopharmacol 2012;20:205–12. doi:10.1037/a0026543.

[88] Ball SA, Schottenfield RS. A five-factor model of person-ality and addiction, psychiatric, and AIDS risk severity inpregnant and postpartum cocaine misusers. Subst UseMisuse 1997;32:25–41.

[89] Washio Y, Higgins ST, Heil SH, et al. Delay discounting isassociated with treatment response among cocaine-dependent outpatients. Exp Clin Psychopharmacol2011;19:243–48.

[90] Passetti F, Clark L, Mehta MA, King JM. Neuro-psychological predictors of clinical outcome in opiateaddiction. Drug Alcohol Depend 2008;94:82–91.

[91] Poirer M, Laqueille X, Jalfre V, et al. Clinical profile ofresponders to buprenorphine as a substitution treatmentin heroin addicts: results of a multicenter study of 73patients. Prog Neuropsychopharmacol Biol Psychiatry2004;28:267–72.

[92] Schmitz JM, Mooney ME, Green CE, et al. Baselineneurocognitive profiles differentiate abstainers and non-abstainers in a cocaine clinical trial. J Addict Dis 2009;28:250–7.

[93] Zoccali R, Muscatello MRA, Bruno A, et al. Temperamentand character dimensions in opiate addicts: Comparingsubjects who completed inpatient treatment in therapeuticcommunities vs. incompleters. Am J Drug Alcohol Abuse2007;33:707–15.

[94] Bechara A, Damásio AR, Damásio H, Anderdon SW.Insensitivity to future consequences following damage tohuman prefrontal cortex. Cognition 1994;50:7–14.

[95] Manes F, Sahakian BJ, Clark L, et al. Decision-makingprocesses following damage to the prefrontal cortex. Brain2002;125:624–39.



[96] Culbertson WC, Zillmer EA. TheTower of London (DX):A standardized approach to assessing executive function inchildren. Arch Clin Neuropsychol 1998;13:285–301.

[97] Rubio G, Jimenez M, Rodriguez-Jimenez R, et al. The roleof behavioral impulsivity in the development of alcoholdependence: a 4-year follow-up study. Alcohol Clin ExpRes 2008;32:1681–7.

[98] Soloff PH, Lynch KG, Moss HB. Serotonin, impulsivity,and alcohol use disorders in the older adolescent: a psycho-biological study. Alcohol Clin Exp Res 2000;24:609–19.

[99] Bjork JM, Hommer DW, Grant SJ, Danube C. Impulsivityin abstinent alcohol-dependent patients: relation tocontrol subjects and type 1-/type-2 like traits. Alcoholism2004;34:133–50.

[100] Dom G, Hulstijn W, Sabbe B. Differences in impulsivityand sensation seeking between early- and late-onset alco-holics. Addict Behav 2006;31:289–308.

[101] Irwin M, Schuckit M, Smith TL. Clinical importance ofage at onset ofType 1 andType 2 primary alcoholics. ArchGen Psychiatry 1990;47:320–4.

[102] Tracy JI. Assessing the relationship between craving andrelapse. Drug Alcohol Rev 1994;13:71–7.

[103] Joos L, Goudriaan AE, Schmaal L, et al. Effect ofmodafinil on impulsivity and relapse in alcohol-dependentpatients: a randomized placebo-controlled trial. EurNeuropsychopharmacol 2013;23:948–55.

[104] Dalley JW, Everitt BJ, Robbins TW. Impulsivity,compulsivity, and top-down cognitive control. Neuron2011;69:680–94.

[105] Chamberlain SR, Sahakian BJ. The neuropsychiatry ofimpulsivity. Curr Opin Psychiatry 2007;20:255–61.

[106] Goudriaan AE, Oosterlaan J, DeBeurs E, Van DenBrink W. The role of self-reported impulsivity and rewardsensitivity versus neurocognitive measures of disinhi-bition and decision-making in the prediction of relapsein pathological gamblers. Psychol Med 2008;38:41–50.

[107] Gottesman II, Gould TD. The endophenotype concept inpsychiatry: etymology and strategic intentions. Am J Psy-chiatry 2003;160:636–45.



Impulsivity as a predictor of treatment outcome in substance use disorders: Review and synthesis

Documents

Transcript of Impulsivity as a predictor of treatment outcome in substance use disorders: Review and synthesis