IMPULSIVITY, ADDICTION, AND OCD
From the 7th Annual Psychiatry Review: The Impulsive-Compulsive Spectrum, presented September 25-26, 2006, by
the University of Minnesota Medical School
| IMPULSIVITY AND ADDICTION —Sheila M. Specker, MD, Associate Professor, Department of Psychiatry, University
of Minnesota Medical School, Minneapolis
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| Substance use disorders: involve impulse control-disordered behavior, and impulsive and/or compulsive behaviors;
impulsivity—behavioral disinhibition; continuum of behaviors, thus impulsive behavior not necessarily pathologic;
compulsivity—repeated behaviors with goal of reducing distress, resulting in negative consequences and increased
stress; continuum of behaviors; can coexist with impulsivity; persons with addiction—impulsivity may precede
substance use or develop over time as consequence of repeated use; behavior associated with compulsivity develops
with repeated use; definitions—“use” social and nonproblematic; “misuse” (also “pathologic” or “at-risk” use) involves
excessive nonsocial use of alcohol, and/or nonmedical use of prescribed medications; “hazardous use” defined
as ≥3 drinks for men or ≥2 drinks for women; “abuse” continued use despite consequences (eg, interpersonal,
occupational, legal); also involves hazardous use; “dependence” characterized by loss of control over substance use;
decision to use or abuse—planned decisions to use environmentally influenced, impulsive spontaneous and unplanned,
compulsively driven, and/or driven by cravings
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| Etiology of addiction: influenced by biopsychosocial and genetic factors; brain disease develops after repeated use
and disrupts modulating and controlling of cognitive processes, emotions, and social behavior, resulting in bypass
of normal filters that inhibit certain negative behaviors; chronic course of relapse similar to other chronic illnesses;
denial characteristic feature
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| Development of addiction: initial drug use voluntary; over time, vulnerable users lose control over use and develop dependence;
repeated administration causes changes in brain functioning that lead to addiction; drugs of abuse activate
mesolimbic dopamine system, which mediates reward and appetite behaviors; dose and duration—quantity and frequency
of use influence vulnerability to addiction, especially when substances associated with tolerance involved (eg,
opioids, alcohol, benzodiazepines); odds of addiction after initial exposure—some substances associated with
higher risk; heroin high risk, alcohol and cocaine lower risk
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| Nonbiologic factors in alcohol and drug use and abuse: evaluation—determine how or why patient uses drugs or
alcohol; men tend to use drugs or alcohol for euphoric properties; women tend to use substances to treat symptoms
or self-medicate (eg, for depression or anxiety); substance use may develop to gain peer acceptance, as coping
mechanism, or to socialize; loss of control hypothesis—people initiate use because of euphoria or positive effect of
substance, but effect moderates over time; sensitization of neuronal system results from long-term use and may
lead to craving and compulsive need to use
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| Biologic factors: primary receptors identified for most major classes of abused drugs; neurotransmitter systems and
their activation mechanisms during substance use or abuse, craving, and withdrawal identified; most major neurotransmitter
systems involved in substance use disorders; separate mechanisms involved in drug-seeking behavior
and physical dependence; mesolimbic system primary site of dysfunction; neurobiologic factors—dopamine depletion;
decreased level of γ-aminobutyric acid (GABA); study looking at influence of impulsivity in alcohol-dependent
patients to determine if reduced GABA levels correlate with increased impulsivity; impulsivity,
neurobiology, and addiction—low serotonin levels linked to impulsivity; low levels of serotonin metabolites in
cerebrospinal fluid (CSF) related to impulsivity, aggression, and early-onset alcoholism; loss of impulse control results
from drug-induced changes in frontal cortex
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| Genetic influences: highest risk associated with opioid dependence; having alcoholic parent associated with 4-fold increased
risk for alcoholism; studies show increased risk in monozygotic twins compared to dizygotic twins; study
comparing nonalcoholic adult children of alcoholics to normal control subjects found children of alcoholics less affected
by alcohol; lower response correlates with development of alcoholism; long-term exposure to drugs leads to
changes in gene expression and affects behavior; variation in personality traits, such as impulsivity, risk taking, and
novelty seeking may contribute to development of addiction
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| Stages of addiction: initiation of use, regular use, use to abuse, abuse to dependence, relapse, and remission
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| Impulsivity and other influences: impulsivity and risk taking—impulsivity more responsible for initiation of drug
use and progression to regular substance use; Swedish study found adoptees had 9-fold greater risk for moderate alcohol
abuse if biologic father alcoholic; Korean study found adoptees with mitochondrial aldehyde dehydrogenase-
2 (ALDH2) polymorphism less likely to develop drinking problem; psychosocial factors—women more likely to
begin using substances through partner; social networks and race and culture also play role; chaotic childhood environments
can influence development of addiction; personality traits, (eg, impulsivity) involved in addiction; high
rate of physical and sexual abuse in patients with substance use disorders; craving, personality, and addiction—
Veterans Affairs (VA) study used various psychologic measures to compare gamblers to cocaine users; gamblers
scored higher than cocaine users on measures of impulsivity and inability to resist cravings; impulsivity in early-
and late-onset alcoholism—early-onset alcoholism defined as onset before age 25 yr; study of recently abstinent
patients with early- and late-onset alcoholism (subjects compared on basis of impulsivity and aggression scores
measured by addiction severity index, Barrett impulsivity scale, Zuckerman sensation-seeking inventory, and behavioral
task that measures impulsivity called “delay discounting”); patients with early-onset alcoholism exhibited
higher levels of impulsive decision-making compared to patients with late-onset alcoholism; impulsivity appears to
increase risk for early onset of substance use disorders; gender, family history of alcoholism, and impulsivity—
women with positive paternal family history of alcoholism had higher discount rates (behavioral measure of impulsivity)
than women with negative paternal family history of alcoholism; no difference found in men with negative
or positive paternal family history of alcoholism
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| Other risks to consider: individual characteristics of people and drugs—individual reactions to substances may
make one person more susceptible to addiction than another; certain drugs more highly addictive (eg, nicotine most
addictive drug); risk factors associated with agent—availability, cost, rapidity of onset of effect, and efficacy for
self-medication; environmental risk factors—risks associated with peers; outside influences; individual risk
factors—genetic predisposition, other family issues
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria: substance abuse—
recurrent use results in failure to fulfill obligations; recurrent substance use in hazardous situations; recurrent substance-related
legal problems; continued use despite persistent or recurrent social or interpersonal problems caused by
substance use; substance dependence—maladaptive pattern creating significant impairment or distress that occurs
within 12-mo period; diagnosis requires ≥3 criteria; biologic criteria involve tolerance and withdrawal; psychologic
criteria include using substance in larger amounts or over longer time than intended (related to loss of control and
compulsivity); individuals may describe persistent desire to cut down or control substance use and their inability to
achieve that goal; persons give up normal activities because of time involved in using substance; continued substance
use despite psychologic problems caused by or worsened by recurrent substance use
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| Course of disorder: age—earlier age of onset associated with more problematic course (associated with increased
impulsivity; more heavily influenced by genetic factors); individual drugs—associated with individual patterns of
development and length of time to misuse; triggering factors—associated with environment; return to problem-
free use—may occur if individual has not progressed too far down continuum of abuse; return to moderate use can
occur after period of abstinence
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| Relapse: impulsivity and cravings—significant role in substance use and relapse; study looking at relapse among various
groups (eg, alcoholics, smokers, gamblers, overeaters); relapse occurred most often when subject experienced
high level of negative emotional state and high level of social pressure to use; craving not necessarily factor in relapse;
pharmacotherapy (eg, naltrexone) directed at reducing cravings may be ineffective in patients for whom cravings not
determining factor in relapse; highest risk for relapse occurs during first 3 to 6 mo after treatment
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| Treatment: focus on reducing impulsivity and triggers to use; provide patients with skills to prevent use; educate patients
to deal with cravings; provide structure; teach patients to recognize “red flags”
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 | Pharmacotherapy: acamprosate—may attenuate glutaminergic surge after alcohol cessation; use early in recovery
period after alcohol detoxification; European study of 4000 patients found abstinence rates with acamprosate 35%,
compared to 21% with placebo; effect size moderate; abstinence rates higher when drug combined with psychosocial
intervention; greater treatment effect found in patients with abstinence as goal; naltrexone—opioid antagonist;
reduces craving for alcohol and results in fewer drinking days, limited progression to full relapse, and delayed
time to first drink; consider use in patients with strong cravings for alcohol; depot naltrexone—once-monthly injection;
attaches to opioid receptor (caution, renders pain medication ineffective); not more effective than oral
form; assists with medication compliance; indicated for patients with strong urges, chronic relapsers, and heavy
problematic drinkers; combined acamprosate and naltrexone therapy—each has different mechanism; good tolerability;
combination therapy results in increased acamprosate levels, but not side effects; studies found no additional
benefit with combined therapy; topiramate—decreases dopamine release by increasing GABA; patients
taking topiramate had fewer drinking days, fewer heavy drinking days, and more abstinent days
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| Psychosocial treatments: motivational enhancement therapy, cognitive-behavioral therapy, group therapy, marital
therapy, and family therapy; enhance motivation, teach coping skills and other behavioral changes
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| Relapse and recovery: impulsivity, antisocial personality disorder, and affective disorders associated with increased
risk for relapse; future goal orientation, frustration tolerance, and self-efficacy associated with remission and recovery;
social and family support, use of coping skills, and continued connection with treatment positive prognostic indicators
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| COGNITIVE BEHAVIOR THERAPY FOR OCD—Christopher B. Donahue, PhD, Associate Professor, Department
of Psychiatry, University of Minnesota Medical School
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| Obsessions and compulsions: obsessions—intrusive thoughts and images that result in marked distress;
compulsions—repetitive behaviors or mental acts designed to reduce mental distress; relationship—impulse control
disorders, (eg, gambling, hair-pulling, shopping, stealing) problem of approach; rewarding stimuli associated
with behavior; obsessive-compulsive disorder (OCD) problem of avoidance; behavior motivated by goal of avoiding
feared stimuli; anticipation of feared response distinguishes OCD from impulse control disorders; consequences
considered during obsessions (eg, avoiding touching object, excessive checking, constant anticipation of
danger or harm); impulse control-disordered individuals do not consider consequences before acting on impulse;
however, those with OCD and those who are, eg, pathologic gamblers, experience reduction in tension associated
with compulsions; rituals alleviate distress brought on by obsessions
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| Obsessions: pure obsession rare problem; mental rituals (eg, reciting prayer) still considered behavior ritual; distinct
from general worry because obsessive worries concern non–real-life problems; different from psychotic process
because individual recognizes obsessions as product of his or her own mind
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| Compulsive behaviors: compare with community standard (eg, how many times would someone without OCD typically
wash hands?); look for at least 1 hr of time spent on ritual behavior each day; common rituals include hand
washing, checking locks and electrical appliances, and counting and repeating words or phrases
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| Avoidance in OCD: obvious behavior includes not going to public restrooms and use of barrier when touching
feared object; subtle behaviors include wearing slip-on shoes to avoid touching laces, and keeping shoes outside to
avoid carpet contamination
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| Differential diagnosis: major depressive disorder (MDD)—common comorbid diagnosis with OCD; individuals
with MDD do not try to suppress depressive ruminations, while individuals with OCD attempt to suppress these
thoughts; phobias—eg, fear of dogs; person with phobia afraid of dog attacking him or her, while person with
OCD fears disease carried by dog; hypochondriasis (HD)—individuals with HD preoccupied with health and involved
with excessive information-seeking only (in contrast, persons with OCD preoccupied with health, use rituals
[eg, hand washing] to reduce anxiety about health )
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| Exposure and ritual prevention (ERP) for OCD: in vivo exposure—actual confrontation of feared stimuli (eg, touch
toilets, door handles); imagined exposure—exposure via imagining feared consequence (what patient believes will occur
if he or she fails to complete ritual); program—10 ERP sessions, 1 session per week; patient must refrain from rituals
within and between sessions; therapist models exposure within session, and helps to provide objectivity about what constitutes
danger; exposure performed early during session; no ritualizing for minimum of 2 hr after exposure; patient instructed
to record every ritual that occurs; exposure requires sustained and continuous contact with feared object; rules for
therapy—limit hand washing; checking of objects or situations limited to one time only; complications—“slips” in performing
ritual require reexposure to feared circumstance or situation; substituting rituals, eg, using hand lotion instead of
soap; passive avoidance, eg, not mixing clothing perceived as contaminated with other clothing; response rate—
combining exposure with ritual prevention most effective; study looking at patients receiving daily ERP and/or clomipramine
for 12 wk; better treatment response rates seen when ERP and clomipramine combined, than with clomipramine
alone or ERP alone
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Suggested Reading
Anton RF et al: Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE
study: a randomized controlled trial. JAMA 295:2003, 2006; Comer SD et al: Injectable, sustained-release naltrexone
for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry 63:210, 2006;
Dom G et al: Impulsivity in abstinent early- and late-onset alcoholics: differences in self-report measures and a discounting
task. Addiction 101:50, 2006; Foa EB et al: Randomized, placebo-controlled trial of exposure and ritual prevention,
clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry
162:151, 2005; Heilig M et al: Pharmacological treatment of alcohol dependence: target symptoms and target mechanisms.
Pharmacol Ther 111:855, 2006; Kalenscher T et al: The neuroscience of impulsive and self-controlled decisions.
Int J Psychophysiol 62:203, 2006; Kreek MJ et al: Genetic influences on impulsivity, risk taking, stress
responsivity and vulnerability to drug abuse and addiction. Nat Neurosci 8:1450, 2005; Pettinati HM et al: Choosing
the right medication for the treatment of alcoholism. Curr Psychiatry Rep 8:383, 2006; Potenza MN: To do or not to
do? The complexities of addiction, motivation, self-control, and impulsivity. Am J Psychiatry 164:4, 2007; Robinson
TE et al: Addiction. Annu Rev Psychol 54:25, 2003; Simpson HB et al: Response versus remission in obsessive-compulsive
disorder. J Clin Psychiatry 67(2):269-76. Tavares H et al: Comparison of craving between pathological gamblers
and alcoholics. Alcohol Clin Exp Res 29:1427, 2005; Volkow ND et al: Dopamine in drug abuse and addiction:
results from imaging studies and treatment implications. Mol Psychiatry 9:557, 2004.
Educational Objectives
| The goal of this program is to increase and improve treatment of impulsivity, addiction, and obsessive-compulsive
disorder (OCD). After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss the role of impulsivity and compulsivity in substance use disorders.
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| 2. Describe the etiologic factors that can lead to the development of addiction.
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| 3. Explain the role of impulsivity in relapse in substance use disorders.
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| 4. Utilize pharmacotherapy in recovery programs for substance use disorders.
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| 5. Implement the principles of exposure and ritual prevention (ERP) when treating patients with OCD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Donahue and Specker were recorded September 25-26, 2006, in Minneapolis, MN, at the 7th Annual Psychiatry
Review: The Impulsive-Compulsive Spectrum, presented by the University of Minnesota Medical School. The Audio-
Digest Foundation thanks Drs. Donahue and Specker and the sponsor for the cooperation in the production of this
program.
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