Behavioral Addictions _ _______________________________________________________________________
Impulsivity is complex. It is broadly defined as a predisposition for rapid, unplanned reactions to internal or external stimuli without forethought or regard for negative consequences to self or others [25]. In persons with early-stage substance or behav- ioral addiction, impulsivity is a powerful mechanism thought to drive pursuit of immediate reward, and it is a temperament vulnerability factor for substance use disorders [26; 27; 28]. Those with prominent impulsivity traits tend to favor immedi- ate rewards over long-term gains, to have poor capacity to delay gratification or resist urges, to quickly react with poorly planned response to stimuli, to be unreflective in decision-making, to dismiss the negative consequences of one’s actions, and to be disinhibited, novelty- and thrill-seeking, and impatient [29]. Impulsivity includes several distinct neurocognitive mecha- nisms and domains. Domains of Impulsivity The four major domains of impulsivity are motor, choice, reflection, and delay discounting. Motor impulsivity (also known as response/rapid-response impulsivity) is defined as an impaired ability to stop motor response following changes in environmental circumstances. Impaired motor response inhibition is highly prominent in attention deficit hyperactiv- ity disorder (ADHD) (the archetypal disorder of impulsivity), pronounced in trichotillomania, and observed in gambling disorder [30; 31]. The dimensions of impulsivity are closely associated with behavioral addictions such as social media addiction and problematic smartphone use. For example, motor impulsivity was found to have a strong connection with the components of mood modification and relapse in social media addiction and with the components of conflict and withdrawal in problematic smartphone use, suggesting that motor impulsivity may be a promising and effective target for the prevention and treatment of select behavioral addic- tions [32].Choice impulsivity is characterized by difficulty in delaying gratification and a tendency to choose immediate small rewards at the expense of larger but delayed rewards. This type of impulsivity is consistently observed in substance use disorder and when money, health, and/or freedom are rewards [33; 34; 35].
Reflection impulsivity is the diminished ability to collect salient information from the environment before a decision. Reflectively impulsive persons make choices rapidly, rather than waiting for more relevant information to become avail- able. Reflection impulsivity commonly occurs in substance use disorder and gambling disorder [36]. The subjective value of a reward decreases as a function of delay in its delivery; the value of reward is discounted with longer delay. With Internet gaming disorder, the immediate reward of online gaming increasingly comes at the cost of abandoned social and professional activities that yield greater long-term rewards [31; 37]. This is referred to as delay discounting. Measuring Impulsivity Impulsivity-related behaviors are measured by neuropsycho- logic testing, personality scales, and neuroimaging. These assessments can be repeated over time to evaluate treatment response [38]. Neuropsychologic tests measure performance (i.e., function- ing) in specific cognitive domains ( Table 1 ). Testing during neuroimaging can identify the functional integrity of brain regions that mediate performance on specific neuropsychologic tasks. Personality scales measure the extent that statements involving impulsive behaviors are endorsed. These statements include: “I make decisions quickly,” “I often buy things I cannot afford,” or “I act without thinking” [25]. Neuroimaging uses non-invasive technologies to identify brain regions involved in inhibitory control, presence of abnormal- ity, and possible changes with treatment [25]. Neuroimaging has helped identify frontostriatal circuitry as contributing to action inhibition, affective inhibition, cognitive flexibility, and delay discounting. It is now known that frontostriatal circuitry and dopaminergic transmission are common neural substrates that underlie inhibitory control function [39; 40].
COMMON IMPULSIVITY DOMAINS AND NEUROPSYCHOLOGIC TESTS
Impulsivity Domain Motor inhibitory control
Neuropsychologic Test
Cognitive Function Measured
Stop-signal task
Ability to withhold or cancel a planned motor response Ability to suppress a default emotional response to unpleasant stimuli Perseverative response to previously rewarding stimuli when stimulus association rules have changed Degree of preference for smaller immediate rewards over larger delayed rewards
Affective inhibitory control
Emotion regulation task
Cognitive flexibility
Reversal learning task
Delay discounting
Delay discounting task
Source: [25]
Table 1
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