Elsevier

Addictive Behaviors

Volume 39, Issue 11, November 2014, Pages 1676-1681
Addictive Behaviors

Modifying the risk associated with an impulsive temperament: A prospective study of drug dependence treatment

https://doi.org/10.1016/j.addbeh.2014.05.001Get rights and content

Highlights

  • Impulsive personality predicts poor drug treatment outcome.

  • Increases in mindful awareness and control improve drug treatment outcomes.

  • Impulsive traits do not interfere with acquiring mindful awareness and control

Abstract

The evidence linking the personality trait of impulsivity and substance misuse is well established. Importantly, impulsivity not only predicts substance misuse problems but has an association with duration in treatment, likelihood of completing treatment and time to relapse. Treatment that focuses on increasing awareness and acceptance of thoughts and emotions may potentially address impulsive behaviour and in this respect improve treatment outcomes for substance misuse. The current paper investigated the relationship between the facet of impulsivity that taps into poor inhibitory control and treatment outcome. In addition, there was a specific focus on ascertaining the impact of an increase in awareness and attentional control measured in 144 adult substance users receiving treatment in a residential therapeutic community. Impulsivity predicted poorer treatment outcome (measured as drug use severity). Increases in awareness and acceptance of emotions and thoughts during treatment were related to better outcome although this was not associated with baseline levels of impulsivity. Clinical and theoretical implications are discussed.

Introduction

There is now extensive evidence linking impulsive personality traits to the development and maintenance of substance misuse problems (Dawe et al., 2004, Moeller et al., 2001, Moss and Lynch, 2001, Sullivan and Rudnik-Levin, 2001), with emerging evidence suggesting that the most relevant facet of impulsivity may be related to disinhibition rather than reward drive. Such impulsive traits are characterised by an inability to inhibit a prepotent response in the light of negative consequences and a failure to exert cognitive control over actions. Traits that are related to the broader construct of "disinhibition" – such as sensation seeking, impulsivity, and behavioural undercontrol – have been found to both prospectively predict substance misuse disorders in adulthood (Caspi, 2000, Fergusson et al., 2007), and are reported to be higher in people with substance misuse problems (Grau and Ortet, 1999, Kambouropoulos and Staiger, 2009, Sher et al., 2000). While the preponderance of studies has focused on alcohol use disorders, it is important to note that the relationship between impulsive traits and problematic substance misuse holds across substances. For example, impulsivity has been associated with a higher frequency of cannabis use and with cannabis problems (Simons and Carey, 2002, Simons et al., 2005, von Sydow et al., 2002; (Dévieux et al., 2002, Vangsness et al., 2005)) and ecstasy use (Egan, Kambouropoulos, & Staiger, 2010). This association also occurs across cultures with self-reported impulsivity higher in users and former users of heroin in India (Narayan, Shams, Jain, & Gupta, 1997) and China (Zhang, Zhou, Li, & Shen, 2008). The evidence for a clear relationship between impulsivity and substance misuse has additional support from studies conducted in the laboratory using behavioural tasks (see Reynold, Ortengren, Richards, & de Wit, 2006 for a review). For example, substance misusers will typically show a preference for small, immediate rewards over larger delayed rewards (Kirby et al., 1999, Madden et al., 1997, Mitchell, 1999, Petry, 2002). Finally, recent evidence from neuroimaging studies indicates that excessive substance use deleteriously affects prefrontal neural systems responsible for impulse control (e.g., Cardenas et al., 2007, Goldstein and Volkow, 2011, Verdejo-García and Bechara, 2009, Yücel and Lubman, 2007). Thus, a heightened trait level of impulsivity may confer a predisposition toward substance use (McGue et al., 2001, Tarter et al., 2003) and ongoing chronic consumption may further exacerbate rash impulsive behaviour by impairing prefrontal neural areas (e.g., Clark et al., 2009, Goldstein and Volkow, 2011, Jentsch and Taylor, 1999).

There is also an association between impulsive traits and treatment outcome. For example, Patkar et al. (2004) reported that two measures of impulsivity, Sensation Seeking (Zuckerman, 1993) and the Barratt Impulsiveness Scale-11 (BIS-11; Barratt, 1965) scores, were associated with both the number of days in treatment and negative urines and predicted drop out from treatment. Moeller et al. (2001) found that high scores on the BIS-11 were associated with shorter duration in treatment for a small sample of cocaine users (N = 35). Similar findings were reported by Winhusen et al. (2013), with psychomotor stimulant users who dropped out from residential treatment reporting higher scores on the motor control subscale of the BIS-11 and a strong trend towards a higher total BIS-11 score compared to those who completed treatment (p = .53). However, Bankston et al. (2009) failed to find an association between length of stay and impulsiveness measured using the BIS-11. Novelty-seeking (a facet of impulsivity) was also predictive of relapse in those receiving treatment for alcohol dependence (Meszaros et al., 1999) as well as higher treatment attrition in heroin dependent users (Helmus et al., 2001, Roll et al., 2004). Finally, behavioural measures of impulsivity have been investigated with higher levels of delay discounting associated with shorter periods of abstinence in opiate addicts (Passetti et al., 2011, Passetti et al., 2008), although the Stroop scores (measure of behavioural inhibition) were not associated with treatment outcome in the study by Winhusen et al. (2013).

On balance, the evidence thus far would indicate that impulsive personality traits are likely to negatively impact on treatment outcome and that treatment programs need to carefully address the behavioural consequences that include premature departure from treatment, decisions to use substances in high risk situations, and an awareness of underlying emotions and thought processes that result in poor decision making around substance use (see Staiger, Kambouropoulos, & Dawe, 2007). Awareness and acceptance of emotions and thoughts are the proposed mechanisms underlying many cognitive behavioural and group therapy programs in substance abuse treatment settings. This state of awareness or "mindfulness" is contrasted with states of mind in which attention is not focused on the present moment and behaviour occurs automatically and indeed at times impulsively. In many forms of substance abuse treatment, including individual therapy, 12-step or therapeutic communities, disengaging the emotions associated with the urge to use a substance from the behavioural response to that urge is a particular focus of the management of addiction. There is growing evidence that mindfulness based interventions are associated with reductions in substance use and preliminary evidence that there are associated improvements in both self report measures of mindfulness and craving (Chiesa & Serretti, 2013). The culture of the therapeutic community, which focuses on acceptance and a non-judgemental environment, in addition to the daily repetition and practice of new behaviours within the community, may indeed contribute to the cultivation of emotional awareness and acceptance (i.e., metacognitive insight), which may positively impact longer term treatment outcomes.

In summary, there is now a growing interest in the potential role that impulsivity plays in treatment outcome with recent evidence linking low inhibitory control to poor treatment completion (Winhusen et al., 2013), shorter stays in residential treatment (Bankston et al., 2009) and abstinence post treatment (Passetti et al., 2011, Sargeant et al., 2012). Further, while there is growing evidence that mindfulness-based approaches are associated with reductions in substance use (Chiesa & Serretti, 2013) these findings are far from consistent and leave open the question as to the potential mechanisms underpinning improvement. Hence, the overall aim of this study is to examine the relationship between self report measures of behavioural inhibition, the improvement in acceptance and management of emotional states indexed by a standardised measure of mindfulness and treatment outcome in a group of individuals undergoing residential treatment for illicit drug abuse. Impulsivity was assessed using the I7 (Eysenck, Pearson, Easting, & Allsopp, 1985), a measure designed to specifically measure level of impulse control and disinhibition which has been shown to load on the same “impulsivity” factor as other measures previously associated with treatment outcome such as the Barrett impulsiveness scale and Zukerman’s sensation seeking scale (see Dawe & Loxton, 2004 for a review). Specifically, we hypothesised that: (1) high impulsivity at the outset of treatment would be associated with greater severity of drug dependence at admission and at three months post discharge; (2) increases in awareness and acceptance will be associated with an improvement in outcome, measured as drug use severity; and (3) that an improvement in awareness and acceptance will moderate the relationship between impulsivity and treatment outcome.

Section snippets

Participants

The sample consisted of 144 illicit substance users, all of whom met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) criteria for drug dependence and were currently in residential drug treatment. Those who had a primary alcohol problem and fulfilled DSM-IV-TR criteria for alcohol dependence were excluded from this study. Dependent drinkers were excluded as this study is part of a larger evaluation of an alcohol misuse prevention program

Demographic and drug use characteristics

The majority of the sample were male (67%) and mean age was 32.5 years (SD = 6.8; range 21 to 65 years). The majority of the participants had not completed high school, were unemployed and not in a relationship (see Table 1). Means, standard deviations, internal reliability and correlations for the variables included in the main analyses are reported in Table 2, Table 3. Correlations showed significant bivariate relationships between impulsivity and severity of substance dependence at admission and

Discussion

The current study examined the relationships between impulsivity, mindful awareness, and acceptance of thoughts and emotions and drug dependence in a sample of illicit drug users who received treatment within a residential therapeutic community. Impulsivity and the severity of drug dependence at admission were associated with poor treatment outcome three months post treatment. Duration in treatment made an independent contribution to better outcome at three months. In addition, an improvement

Role of funding sources

This research was supported by a grant from the Foundation for Alcohol Research and Education (FARE). FARE had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors

PS designed the study, wrote the protocol and along with the other authors developed the hypotheses. PS and SD wrote the first draft of the manuscript. BR conducted the statistical analysis. KH wrote the clinical treatment sections. NK provided the preliminary ideas for analyses. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgments

We would like to thank Amelia Lake, Elodie O’Connor, Miranda Manning, and Stefan Gruenert for their assistance with the development of the study and/or project management.

References (66)

  • H.B. Moss et al.

    Comorbid disruptive behavior disorder symptoms and their relationship to adolescent alcohol use disorders

    Drug and Alcohol Dependence

    (2001)
  • F. Passetti et al.

    Risky decision-making predicts short-term outcome of community but not residential treatment for opiate addiction. Implications for case management

    Drug and Alcohol Dependence

    (2011)
  • F. Passetti et al.

    Neuropsychological predictors of clinical outcome in opiate addiction

    Drug and Alcohol Dependence

    (2008)
  • M.N. Sargeant et al.

    Facets of impulsivity in the relationship between antisocial personality and abstinence

    Addictive Behaviors

    (2012)
  • L. Vangsness et al.

    Impulsivity, negative expectancies, and marijuana use: A test of the acquired preparedness model

    Addictive Behaviors

    (2005)
  • A. Verdejo-García et al.

    A somatic marker theory of addiction

    Neuropharmacology

    (2009)
  • K. von Sydow et al.

    What predicts incident use of cannabis and progression to abuse and dependence? A 4-year prospective examination of risk factors in a community sample of adolescents and young adults

    Drug and Alcohol Dependence

    (2002)
  • T. Winhusen et al.

    Impulsivity is associated with treatment non-completion in cocaine-and methamphetamine-dependent patients but differs in nature as a function of stimulant-dependence diagnosis

    Journal of Substance Abuse Treatment

    (2013)
  • L.S. Aiken et al.

    Multiple regression: Testing and interpreting interactions

    (1991)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders: DSM-IV-TR

    (2000)
  • J.B. Asendorpf

    Developmental perspectives

  • R.A. Baer et al.

    Assessment of mindfulness by self-report the Kentucky inventory of mindfulness skills

    Assessment

    (2004)
  • S.M. Bankston et al.

    Substance abuser impulsivity decreases with a nine-month stay in a therapeutic community

    American Journal of Drug and Alcohol Abuse

    (2009)
  • E.S. Barratt

    Factor analysis of some psychometric measures of impulsiveness and anxiety

    Psychological Reports

    (1965)
  • S. Bowen et al.

    Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial

    Substance Abuse

    (2009)
  • S. Bowen et al.

    Mindfulness meditation and substance use in an incarcerated population

    Psychology of Addictive Behaviors

    (2006)
  • A. Caspi

    The child is father of the man: Personality continuities from childhood to adulthood

    Journal of Personality and Social Psychology

    (2000)
  • A. Chiesa et al.

    Are mindfulness-based interventions effective for substance use disorders? A systematic review of the evidence

    Substance Use & Misuse

    (2013)
  • L. Clark et al.

    Disrupted 'reflection' impulsivity in cannabis users but not current or former ecstasy users

    Journal of Psychopharmacology

    (2009)
  • S. Dawe et al.

    Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders

    (2002)
  • H. de Wit

    Impulsivity as a determinant and consequence of drug use: A review of underlying processes

    Addiction Biology

    (2009)
  • J. Dévieux et al.

    Impulsivity and HIV risk among adjudicated alcohol-and other drug-abusing adolescent offenders

    AIDS Education and Prevention

    (2002)
  • D.M. Fergusson et al.

    Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes

    British Journal of Psychiatry

    (2007)
  • Cited by (12)

    • Meta-analysis of the relationship between impulsivity and substance-related cognitive biases

      2017, Drug and Alcohol Dependence
      Citation Excerpt :

      As we have described, our results provide some support for interactive models of impulsivity and cognitive biases in relation to substance misuse. Within addiction treatment settings, psychosocial interventions for substance misuse typically address explicit thoughts, attitudes, and beliefs (e.g., Krishnan-Sarin et al., 2007; Staiger et al., 2014). However, such interventions may not have a significant impact to reduce substance-related cognitive biases themselves (e.g., Ostafin et al., 2013).

    • Personality profile of binge drinking in university students is modulated by sex. A study using the Alternative Five Factor Model

      2016, Drug and Alcohol Dependence
      Citation Excerpt :

      Many studies have demonstrated that BD is related to higher scores in Impulsivity (Adan, 2012; Balodis et al., 2009; Bauer and Ceballos, 2014; Townshend et al., 2014Whelan et al., 2014; White et al., 2011) and Sensation-Seeking, with an emphasis on its component of disinhibition (Bauer and Ceballos, 2014; Legrand et al., 2007; Pilatti et al., 2015; Wellman et al., 2014). Both personality traits seem to be predictors of quantity of alcohol consumed, maintenance of the BD pattern through the life span, development of substance use disorders (Ashenhurst et al., 2015; Cortés et al., 2014; Mackinnon et al., 2014; Marquez-Arrico and Adan, 2013), and worse adherence to treatment (Staiger et al., 2014). The high impulsivity observed in BD subjects is related to brain dysfunction in inhibitory control and reward outcome (Whelan et al., 2014), as well as poor performance in executive tasks (Bauer and Ceballos, 2014; Goudriaan et al., 2011; López-Caneda et al., 2014).

    • Personality in patients with substance use disorders according to the co-occurring severe mental illness: A study using the alternative five factor model

      2016, Personality and Individual Differences
      Citation Excerpt :

      These patients reported a higher lack of planning and acting quickly on impulse, a higher need for thrills, excitement and novelty (higher ImpSS) than SZ +, MDD + and population norms. Therefore, SUD treatment addressed to patients with BD + should especially consider strategies to manage impulsivity and neuroticism, as these traits are generally linked to poor treatment outcomes (Kotov et al., 2010; Mandelli et al., 2012), suicide attempts (Swann et al., 2004) and relapses (Staiger, Dawe, Richardson, Hall, & Kambouropoulos, 2014). Thirdly, SZ + patients informed about a preference for being alone or in small groups, while having difficulties to enjoy big parties and to interact with many people (lower Sy) compared to both BD + and population norms.

    View all citing articles on Scopus
    View full text