Borderline Personality Disorder, Bulimia Nervosa, Antisocial Personality Disorder, ADHD, Substance Use: Common Threads, Common Treatment Needs, and the Nature of Impulsivity
Our intent in offering this contribution is to share with independent practitioners recent advances in clinical psychology research that shed light on the nature of a wide range of disorders related to impulsivity, as well as information on treatment decisions to be made with individuals suffering from such disorders. We come from academic training programs designed to integrate clinical research and clinical practice (the last author is a member of division 42). We hope that the findings we describe prove useful to the many practitioners who encounter some form of problems related to impulsive behavior in their work.
There are a great many diverse disorders in the DSM-IV that include some aspect of impulsive behavior in their diagnositic criteria. Other than subjective distress, impulsivity may be the most common diagnostic criterion in the manual. It appears among the criteria for borderline personality disorder, antisocial personality disorder, bulimia nervosa, attention deficit/hyperactivity disorder, mania, dementia, substance use disorders, and the paraphilias, along with the whole section devoted to impulse-control disorders (e.g., intermittent explosive disorder, kleptomania, and pyromania). For many of these forms of psychopathology, impulsivity is understood to contribute to their emergence. Perhaps more importantly, successful treatment of impulsive tendencies is a difficult, if not daunting, task.
Two things were striking to clinical scientists who investigated the nature of impulsive behavior. The first was that many apparently quite different disorders share the common component of impulsivity, so clarifying the nature of impulsivity could prove beneficial to a number of clinicians addressing a wide variety of problems. Perhaps paradoxically, the second was that, as researchers investigated further, it became clear that the term “impulsivity” was being used by different people to mean different things. Some have used the term to refer to distractibility and short attention span, others to refer to the need to seek stimulation and novelty, others to susceptibility to boredom, others to acting without forethought, and others to emotionally triggered rash action (Depue & Collins, 1999; Whiteside & Lynam, 2001). Clinical researchers recognized that these different processes may not be highly related, and may in fact require different forms of intervention. Thus, impulsivity appears to be a common thread to many behavior disorders but at the same time, different types of impulsivity may underlie different disorders.
Over about a seven year period, through a series of factor analytic studies of existing measures of “impulsivity,” researchers have identified five different personality pathways to impulsive behavior (Cyders & Smith, 2007, 2008; Whiteside & Lynam, 2001). These different pathways describe substantively different psychological processes, they appear to be associated with different kinds of rash action, and they appear to require different forms of treatment.
Two pathways to rash action are emotion-based. Negative urgency refers to the tendency to engage in rash acts when experiencing intense, negative emotion, and positive urgency refers to the tendency to engage in rash acts when experiencing intense positive emotion. Two other pathways are based on different aspects of low levels of conscientiousness. Lack of planning refers to the tendency to act without care or forethought, and lack of perseverance refers to a failure to tolerate boredom or remain focused despite distraction. The fifth is sensation seeking, or the tendency to seek out novel or thrilling stimulation (Cyders & Smith, 2007, 2008; Whiteside & Lynam, 2001). These five traits are distinct from each other. There is not an overall psychological trait called “impulsivity,” of which each of these traits is a type. Rather, there are five separate pathways to rash, ill-advised action that are only moderately correlated with each other (Cyders & Smith, 2007). These five different personality pathways are associated with different forms of rash action, and hence different types of involvement in maladaptive behavior.
Sensation seeking predicts involvement in highly stimulating risky behaviors (in children, behaviors such as riding roller coasters and jumping out of trees; in adults, behaviors such as bungee jumping, parachuting, and the number of sexual partners) and the frequency with which one engages in risky behaviors such as alcohol use and gambling. Lack of persistence correlates with difficulties paying attention in school, and both it and lack of planning correlate with poor academic performance. The tendency to act in rash or impulsive ways when experiencing intense emotions (as reflected in negative and positive urgency) is, not surprisingly, associated with a number of maladaptive behaviors and expressions of poor judgment. Aggressive behavior, suicide attempts, problem drinking, high quantity drinking, risky sexual behavior, binge eating, drug use, smoking, and even pre-adolescent onset of many of these behaviors are all uniquely associated with these two emotion-based traits (Cyders & Smith, 2008; Linehan, 1993).
These findings have clear implications for treatment. First, many apparently different disorders require treatment for what have turned out to be common factors. For individuals suffering from disorders as diverse as borderline personality disorder, antisocial personality disorder, bulimia nervosa, and substance abuse, it is often the case that their engagement in rash, impulsive, ill-advised action when distressed requires intervention by the practitioner (Cyders & Smith, 2008; Fischer, Smith, & Cyders, 2008). In some contexts, similarly regrettable behaviors, such as drug use or risky sexual behavior, are undertaken in a celebratory context, when individuals are unusually happy or excited (Cyders & Smith, 2008). Second, clinicians can profitably distinguish among the different personality dispositions. An adolescent client engaging in drug use and early sex may be doing so as a function of his or her intense affect, but he or she may, instead, be expressing an intense need to seek new, thrilling stimulation. Making these distinctions is useful, because different preventive or treatment interventions are needed for the different personality underpinnings to the problem behavior, as we describe next.
In the accompanying table, we have summarized what we currently know about the appropriate interventions for the different dispositions to rash action. Negative urgency seems to characterize a number of behaviors that have successfully been addressed by dialectical behavior therapy (DBT: Linehan, 1993). Training on understanding one’s emotions, on how to tolerate one’s distress or one’s intense emotions without engaging in immediate action, and on stopping and adjusting one’s emotional reactions by considering the context, have all proven helpful.
|Negative Urgency||Emotion regulation, distress tolerance, interpersonal effectiveness; adjust emotional reactions by considering the context, experience the emotions without acting, adjust reactions through relaxation, prayer, and other soothing activities, learn to effectively communicate feelings to others; SSRIs; identify precipitating events or triggers to emotional reactivity and learn adaptive alternatives similar to those provided in distress tolerance modules; learn to evaluate behavioral choices in terms of one’s long-term goals.|
|Positive Urgency||Teach adaptive techniques for savoring success and positive mood; identify alternative, safer means of celebrating; learn to use cues indicating risk for maladaptive behavior; provide client with reminders or cues of the alternative behaviors identified.|
|Sensation Seeking||Highly stimulating media messages suggesting alternative, safe ways to pursue stimulation; development of a bank of safe, stimulating activities as behavioral options.|
|Lack of Planning||Cognitive mediation training; specifying all steps necessary to complete a task and the time necessary for each step; learn to anticipate the consequences of one’s presence in situations and settings.|
|Lack of Perseverance||Stimulant medications plus cognitive-behavioral therapy; behavioral paradigms to reinforce task completion; learn to gauge attention span and distractibility delay, modify environment, learn techniques to reduce procrastination and increase follow-through.|
There is less research on positive urgency-based maladaptive behavior. Clinical researchers have been a bit slow to recognize the degree to which risky, regrettable behaviors are undertaken in celebratory contexts (common examples include excessive alcohol consumption or ill-considered sexual activity in contexts such as happy hour, parties after a weekend of work, celebrations of a work success, holiday parties, college parties, and celebrations after sports wins). Possibilities include (a) creative efforts to help individuals appreciate that maintenance of their positive mood might be facilitated by careful consideration of the consequences of prospective actions; (b) teaching clients how to savor one’s success in an integrative cognitive-affective way, by replaying or reviewing the success with colleagues or friends; (c) working with clients to identify alternative, safer behaviors that can enhance one’s existing positive mood; and (d) helping clients identify warning signs that they are at risk to behave impulsively, and develop reminder cues to help them remain cognizant of their long-term interests and goals. The use of reminder cues has been found to be effective for challenges as diverse as condom use and dieting (Dal Cin, MacDonald, Fong, Zanna, & Elton-Marshall, 2006; Horan & Johnson, 1971).
High sensation interventions, for those high in sensation seeking, represent one of the great successes of selective intervention. For example, the use of media messages with high sensation value that encourage alternative, safe means of seeking stimulation, and development of a repertoire of stimulating activities that are safer provides clients with behavioral options at key choice points appear to be effective in reducing drug use (Stephenson, 2003).
For individuals who tend to act without forethought, problem solving interventions that teach individuals to engage in cognitive enterprises before acting may reduce some rash acts; that is, teaching individuals cognitive mediation, so they can anticipate both the positive and negative consequences of possible actions, appears effective (Eyberg, Nelson, & Boggs, 2008). For non-persistent, highly distractible individuals, it may be the case that stimulant medications such as Ritalin help them maintain focus on the task at hand (Prince & Wilens, 2002). In fact, studies with children suffering from attention deficit/hyperactivity disorder (ADHD) indicate that both stimulant medications and rigorous behavior therapy appear to be equally effective for that group (Waxmonsky et al., 2008).
To help practitioners assess the specific nature of the personality contributor to a client’s rash, impulsive action, a simple, easy to use scale is available. Based on the work of Whiteside and Lynam (2001) and Cyders et al. (2007), the scale (called the UPPS-P: Lynam, Smith, Cyders, Fischer, & Whiteside, 2007) was created. It is available without charge from either Don Lynam (Purdue University) or Greg Smith (University of Kentucky); the latter author’s contact information is provided at the end of this article. The scale is brief: with a total of 59 items, it can be completed within 10 minutes. There is a child version with 32 items and interview versions of both scales. Our experience using the interview assessment has suggested that individuals can pretty readily describe whether they engage in rash acts when intensely emotional, out of a need to seek stimulation, or out of a lack of planning or perseverance. The distinctions among these traits make sense to clients. We believe that assessment of the five traits in collaboration with the client can help both the practitioner and client clarify the nature of the client’s risk process.
We hope that our communication of these recent clinical research findings proves useful for practitioners. We also hope that by sharing this information, we can enlist help from practitioners in the future, as we seek to develop these ideas more fully. We think that communications such as case study reports can shed further light on the personality processes underlying rash action, the assessment of those processes, and the nature of effective interventions for problematic involvement in risky behaviors. We would love to hear reactions to this article, suggestions for processes we have not considered, and any other comments.
Tamika Zapolski, M.S., is a doctoral student in clinical psychology at the University of Kentucky; her advisor is Gregory Smith. Tamika seeks to conduct research of direct relevance to clinical practice.
Tamika C. B. Zapolski, University of Kentucky.
Regan E. Settles, University of Kentucky.
Melissa A. Cyders, Indiana University Purdue University Indianapolis.
Gregory T. Smith, University of Kentucky.
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