Impulsivity and Alcohol Use Disorders Robert F. Leeman, Ph.D. Department of Psychiatry Yale School of Medicine VA (New England) VISN1 Mental Illness Research Education and Clinical Center (MIRECC)
© Alcohol Medical Scholars Program 2 Serious Alcohol Problems Relatively common Within prior year (current): 11% – – Males: 15% – – Females: 7% Costly: $185 billion/year in U.S. Lethal: 3 rd leading modifiable cause
© Alcohol Medical Scholars Program 3 Multiple factors → alcohol problems Some before heavy drinking begins Detect early factors for prevention Impulsivity an example of risk factor – –Earlier onset of alcohol use – –More severe alcohol problems Contributing Factors
© Alcohol Medical Scholars Program 4 Onset of Use & Problems Drinking usually begins in teens Heaviest drinking: yrs – – ~65% use in past month – – ~45% > 4/5 drinks/evening → risky ~18% young adults alcohol problems ↑ Impulsivity → ↑ problems
© Alcohol Medical Scholars Program 5 Lecture Covers Definitions Key characteristics & neurobiology Problems, other conditions, course Implications: prevention & treatment
© Alcohol Medical Scholars Program 6 Case 1: Phineas Gage Railroad worker Conscientious, mild manner, hard-work Accident → steel rod pierced head Changes in personality – – Profane, ↓ restraint: give in to desires – – Frequent changing of plans Role of key brain regions in impulsivity
© Alcohol Medical Scholars Program 7 Case 2: Law Student Prior DUI arrests Participating in research project Party: “spiked Gatorade” 1st day license: drives after ~4 drinks Impulsivity contribute to problems?
© Alcohol Medical Scholars Program 8 Lecture Topics Definitions Key characteristics & neurobiology Problems, other conditions, course Implications: prevention & treatment
© Alcohol Medical Scholars Program 9 Alcohol Use Disorder (AUD) Recurring problems Affecting multiple life areas DSM-5: > 2 criteria, past 12 mo. Diagnosis associated with: – –Long-term alcohol problems – –Earlier death
© Alcohol Medical Scholars Program 10 AUD Criteria – – Tolerance – – Withdrawal – – ↑ Amount/time use – – Desire/inability to ↓ use – –↓ Other due to use – – ↓ Role obligations – Hazardous use – Strong craving – Interpersonal problems – Use despite problems –↑ Time obtain/use/recover
© Alcohol Medical Scholars Program 11 Impulsivity: Usual Definition Acting rashly/without thinking Repeated bad decisions Recurrent out of control behavior Trouble frequently without planning
© Alcohol Medical Scholars Program 12 Impulsivity: Research Definition Rapid, unplanned reactions Diminished regard for outcomes Not really 1 thing More a class of characteristics 2 main types: response, choice
© Alcohol Medical Scholars Program 13 Response Impulsivity Difficulty suppressing actions Ramifications include: – –Alcohol/cues = a strong impulse – –Failure plan for future: Rx impact – –Hard to maintain behavior change – –Emotions can ↓ drinking control
© Alcohol Medical Scholars Program 14 Choice Impulsivity Immediate, definite rewards Ramifications include: – –Alcohol: immediate definite reward – –Abstinence: weak, uncertain – –Hard to see future improvement
© Alcohol Medical Scholars Program 15 Ways to Measure Cognitive tasks (computer) Clinical interviews Self-report questionnaires
© Alcohol Medical Scholars Program 16 Cognitive Tasks Stop-signal tasks – –Respond to visual cue – –No response if hear auditory cue Continuous performance tasks – –Respond to most cues (e.g., letters) – –Not to 1 cue (e.g., letter “X”)
© Alcohol Medical Scholars Program 17 Clinical Interviews For conditions related to impulsivity Childhood interviews: ADHD –Parent/teacher ratings: attention –E.g. child task: wait to eat cookie Adolescent/adult structured interviews –SCID –Conditions like bipolar disorder
© Alcohol Medical Scholars Program 18 Questionnaires Response: impulsive behavior scale – Lack planning and perseverance – Rash response to +/- emotions Choice: monetary choice questionnaire – Choices: hypothetical $ payments – Now vs. later
© Alcohol Medical Scholars Program 19 Back to Cases Case 1: Phineas Gage –Response: ↓ restraint –Choice: inability to adhere to plans Case 2: law student –Response: didn’t stop drinking –Choice: drink(immediate), DUI(later)
© Alcohol Medical Scholars Program 20 Lecture Topics Definitions Key characteristics & neurobiology Problems, other conditions, course Implications: prevention & treatment
© Alcohol Medical Scholars Program 21 Observable Early in Life Observable by age 8: – –Fidgety – –Trouble attention, directions – –Talking/acting out of turn – –Unpredictable/explosive behavior Predictive value: early alcohol onset
© Alcohol Medical Scholars Program 22 Genetic Predisposition Impulsivity: ~ 50% explained genes Alcohol : ~ 50% explained genes Alcohol & impulsivity genes overlap
© Alcohol Medical Scholars Program 23 Key Brain RegionsFrontal lobes Ventral striatum striatum Dorsal
© Alcohol Medical Scholars Program 24 Brain: Frontal Lobes Ventromedial prefrontal cortex(vmPFC) –Response inhibition –Decision-making Orbitofrontal cortex(OFC) –Linked to limbic system (reward) –Impulse control
Back to Phineas Gage © Alcohol Medical Scholars Program 25 Frontal lobes - severe injury - vmPFC, OFC Impulsive after
© Alcohol Medical Scholars Program 26 Brain: Striatum Ventral –Nucleus accumbens –Reward anticipation Dorsal –Caudate and putamen –Habit formation Caudate
© Alcohol Medical Scholars Program 27 Lecture Topics Definitions Key characteristics & neurobiology Problems, other conditions, course Implications: prevention & treatment
© Alcohol Medical Scholars Program 28 Relationship to AUD ~25% higher impulsivity scores Impulsive child (detectable early) ~ 80% ↑ heavy drinking risk
© Alcohol Medical Scholars Program 29 Alcohol → Impulsivity Alcohol ↑ impulsivity over time – –Frontal lobe volume loss in adults – –↓ White matter integrity, adolescents Alcohol ↑ impulsivity acutely – –Intoxicating dose → 70% ↑ errors – –↑ preference for definite rewards
© Alcohol Medical Scholars Program 30 Back to Case Case 2: law student – –Impulsive child: fidgety, ↓ attn span – –Early alcohol onset: pre-high school – –AUD by early adulthood – –Alcohol acutely ↓ ability resist driving
© Alcohol Medical Scholars Program 31 Other Psychiatric Disorders Attention Deficit Hyperactivity (ADHD) – ~ 60% ↑ Impulsivity score than without – ~ 2 x ↑ AUD risk than without Bipolar disorder: ↑ arousal & depression – ~ 70% ↑ Impulsivity score than without – ~ 4 x ↑ AUD risk than without
© Alcohol Medical Scholars Program 32 Lecture Topics Definitions Key characteristics & neurobiology Problems, other conditions, course Implications: prevention & treatment
© Alcohol Medical Scholars Program 33 Prevention Treatment challenging/$/time consuming Prevention/early intervention preferable Personality-based intervention ID students with high impulsivity Goals, ↑ motivation change coping ID negative coping & relation to alcohol Evidence ↓ probability heavy drinking
© Alcohol Medical Scholars Program 34 Psychosocial Treatments Response impulsivity –Teach/practice coping urges, pass –Train improve focus, ↓ distractions Choice impulsivity –↑ interest non-alcohol rewards –↓ interest in immediate rewards –↑ interest in long-term rewards
© Alcohol Medical Scholars Program 35 Pharmacologic Treatment Relation to AUD and impulsivity –↓ Alcohol use, ↓ impulsivity –Some pharm. direct evidence Examples with evidence: –Opioid antagonists Naltrexone Nalmefene –Varenicline
© Alcohol Medical Scholars Program 36 Opioid Antagonists Naltrexone FDA approved alcohol Bind to/block receptor activation Efficacy: ~ 25% ↓ drinking days Decreases rewarding effects ↓ choice impulsivity, ICD efficacy
© Alcohol Medical Scholars Program 37 Varenicline FDA approved: nicotine Partial agonist – –Binds strongly to nicotine receptors – –Triggers partial response – –Block full alcohol/nicotine response Efficacy: ~20% ↓ heavy drinking Decreases rewarding effects Improves relevant cognition
© Alcohol Medical Scholars Program 38 Conclusions Two main types – –Response impulsivity – –Choice impulsivity Strong genetics, early manifestation Measurable behavioral, brain activity ↑ impulsivity, ↑ risk AUD development
© Alcohol Medical Scholars Program 39 Conclusions Important for prevention & treatment –Can identify impulsivity before AUD –Opportunity for early intervention –Measure ↓ impulsivity—intervention –Psychosocial/pharm ↓ impulsivity