This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference, that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada

1. Impulsivity, Attention Deficits and
Addiction: Perspectives on Concepts,
Diagnoses, and Treatment
Christian G. Schütz MD PhD MPH
Associate Professor
Institute of Mental Health, Dep. of Psychiatry
Email: christian.schutz@ubc.ca
Medical Manager
The Burnaby Centre for Mental Health & Addiction

2. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

3. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

5. The Four Quadrant Framework for
Co-Occurring Disorders
Less severe More severe
mental disorder/ mental disorder/
more severe more severe
substance substance
abuse disorder abuse disorder
Less severe More severe
mental disorder/ mental disorder/
less severe less severe
substance substance
abuse disorder abuse disorder
High
severity

6. Mood disorders

7. Psychosis

8. Addiction

9. Anxiety disorders

10. Adult ADHD Self-Report Scale
ADHD screener >50%
18 questions Adler et al.

11. CGS

12. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

13. genes environment

14. CGS
www.thelancet.com Published online February 28, 2013

15. CGS
www.thelancet.com Published online February 28, 2013

16. CGS

17. Consistent with a pleiotropic role of CACNA1C variants ,
neuro-imaging studies have documented effects of
voltage gated calcium channels on a range of
structural and functional brain phenotypes, including
circuitry involved in:
• emotion processing,
• executive function,
• attention, and
• memory.
CGS
www.thelancet.com Published online February 28, 2013

18. genes environment

19. Childhood predictors of adult ADHD: Results from the
WHO World Mental Health (WMH) Survey Initiative
Lara et al.
An average of 50% of children with ADHD continued to meet
DSM-IV criteria for ADHD as adults.
Persistence was strongly related to:
• attentional plus hyperactive type,
• symptom severity,
• comorbid major depressive disorder,
• high comorbidity,
• paternal anxiety-mood disorder
• parental antisocial personality disorder.
Childhood adversity predicted ADHD, but not persistence into adulthood
CGS

20. Lifetime trauma experience

21. Stahl
Essential
Psychopharmacology

22. *
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23. *
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24. *
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*

25. ADHD
Addiction
Bipolar
Schizophrenia
Stahl
Essential
Psychopharmacology

26. SJ
Lupien,
BS
McEwen,
MR.
Gunnar
and
C
Heim.
Nature
Reviews
Neuroscience
10,
434-­‐445
(2009)
adapted

27. SJ
Lupien,
BS
McEwen,
MR.
Gunnar
and
C
Heim.
Nature
Reviews
Neuroscience
10,
434-­‐445
(2009)
adapted

28. BL
Thompson,
P
Levitt
&
GD
Stanwood
Nature
Reviews
Neuroscience
10,
303-­‐312
(April
2009)

29. |
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Substance use disorder
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|
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30. SJ
Lupien,
BS
McEwen,
MR.
Gunnar
and
C
Heim.
Nature
Reviews
Neuroscience
10,
434-­‐445
(2009)
adapted

31. •
The
prefrontal
cortex
subserves
conscious
decision
making
(thoughtful
reflective
resp
•
PFC
is
the
brain
region
most
sensitive
to
detrimental
effects
of
stress
exposure.
•
Even
mild
acute
uncontrollable
stress
can
cause
a
dramatic
loss
of
cognitive
abilities
•
Prolonged
stress
exposure
causes
architectural
changes
in
prefrontal
dendrites
AFT
Arnstein
Nature
Reviews
Neuroscience
10,
410-­‐422
(June
2009)

32. Multi-causality and
Pleiotropy is the
standard
genes

33. Overview
• introduction and context
• etiological considerations
• impulsivity and attention deficits
• interventions considerations
• summary
CGS

34. Questionnaire
Behavioral Tests
CGS

35. Barratt Impulsivity Scale-11 (BIS)
Patton et al., 1995
• motor impulsivity
• non-planning
• attentional impulsivity
30 items, likert scale
CGS

36. UPPS-P Impulsive Behavior Scale
Perales et al. 2009
• lack of premeditation
• lack of perseverance
• “negative” urgency
• "positive” urgency
• sensation-seeking
59-item likert scale
CGS

37. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

38. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

39. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

40. fronto-parietal–pre-motor circuits
prefrontal–striatal
CGS Tüscher et al 2012

41. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

42. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

43. Latent Discounting
CGS
Peters 2011

44. DERS: Difficulties in emotional regulaton scale DDT: Delayed Disounting
SST Stop Signal Task SWM: Spatial working memory
CGS
UPPS+P Chao 2013

45. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Harriet De Wit (2008)
CGS

46. Subcomponents attention:
Top down:
Prefrontal Cortex: sustain, switch
divide
inhibit distraction
Inferior temporal cortex: focus
Posterior parietal association cortex: orienting
CGS

47. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

48. CGS

49. Mood stabilizers have been used extensively to treat impulsive disorders.
Moderate efficacy in at least half of patients studied have been reported.
Results differ across specific mood stabilizers. Positive data have been published
for Valproate, Phenytoin, Carbamazepine, Topiramate and Lithium.
(not for Gabapentin and Levotireacetam). Some positive results for atypical
neuroleptics (Olanzapine, Aripiprazole, Quetiapine) and antidepressant
(Bupropion) have been reported.
Based on ADHD treatment Stimulants (Modafinil, Methylphenidate,
Amphetamine) Atomoxetine, have lead to positive results in some patients.
Cognitive Behavior Therapies, Dialectical Behavior Therapy and Contingency
Management seem to be more promising psychotherapeutic approaches.
CGS

50. Glutamate
Brain (cell)
Executive
Behavior
GABA Relapse
Control
Dopamine Reward/
Motivation Addiction
Serotonin Emotional Mood
regulation episode
Medication

51. Psychosocial
Psychotherapy
setting
Abstract
Environment
Executive
Behavior
ADH
Brain
Information Control
Reward/
Incentives Motivation Addiction
Trust/threat Emotional
signals regulation Mood
episode

52. DLPC
Brain (anato.)
Executive
Behavior
OFPC Relapse
Control
Striatum Reward/
VMPC Addiction
Motivation
Amygdala
Insula Emotional Mood
regulation episode
ECT, TMS,
DBS..

53. Executive
Psychotherapy
Brain
Behavior
CBT, DBT,
ME ADHD
Control
CM SCT, Reward/
GNG Addiction
Motivation
Mindfulness, Emotional Mood
Grounding regulation episode

54. SCT: Several researchers tried to improve trait self-control.
Successful training generalized to other tasks.
To this end, participants were asked to brush their teeth or use
the computer mouse with the non-dominant hand, keep a good
posture, avoid slang words, perform Stroop tasks, keep a
financial diary, or adhere to study or exercise plans
(Azor Hui et al., 2009; Gailliot, Plant, Butz, & Baumeister, 2007; Muraven, Baumeister, & Tice,
1999; Oaten & Cheng, 2006a, 2006b, 2007).
GNG: One program aimed at fostering response inhibition.
In this study, participants completed an adapted Go/No-Go
task.
(Houben, Nederkoorn, Wiers, & Jansen, 2010)
CGS

55. •
The
prefrontal
cortex
subserves
conscious
decision
making
(thoughtful
reflective
resp
•
PFC
is
the
brain
region
most
sensitive
to
detrimental
effects
of
stress
exposure.
•
Even
mild
acute
uncontrollable
stress
can
cause
a
dramatic
loss
of
cognitive
abilities
•
Prolonged
stress
exposure
causes
architectural
changes
in
prefrontal
dendrites
AFT
Arnstein
Nature
Reviews
Neuroscience
10,
410-­‐422
(June
2009)

56. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

57. Overview
• introduction and context
• etiological considerations
• attention deficits and impulsivity
• interventions considerations
• summary
CGS

58. TREATMENT: diagnosis versus syndrome (domain-specific) informed
PSYCHO-
engagement in meaningful activities and relationships
SOCIAL
SETTING
self organization, structuring, healthy living

59. TREATMENT: diagnosis versus syndrome (domain-specific) informed
Cognitive Contingency Avoidance
SPECIFIC
INTERVENTION
Behaviour Management Training
PSYCHO-
engagement in meaningful activities and relationships
SOCIAL
SETTING
self organization, structuring, healthy living

60. Evidence based:
Medication
Regular systematic off-label
Cognitive Contingency Avoidance
SPECIFIC
INTERVENTION
Behaviour Management Training
PSYCHO-
engagement in meaningful activities and relationships
SOCIAL
SETTING
self organization, structuring, healthy living

61. Thank you
for your attention
CGS