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1.  Utility of Machine-Learning Approaches to Identify Behavioral Markers for Substance Use Disorders: Impulsivity Dimensions as Predictors of Current Cocaine Dependence 
Background
Identifying objective and accurate markers of cocaine dependence (CD) can innovate its prevention and treatment. Existing evidence suggests that CD is characterized by a wide range of cognitive deficits, most notably by increased impulsivity. Impulsivity is multidimensional and it is unclear which of its various dimensions would have the highest predictive utility for CD. The machine-learning approach is highly promising for discovering predictive markers of disease. Here, we used machine learning to identify multivariate predictive patterns of impulsivity phenotypes that can accurately classify individuals with CD.
Methods
Current cocaine-dependent users (N = 31) and healthy controls (N = 23) completed the self-report Barratt Impulsiveness Scale-11 and five neurocognitive tasks indexing different dimensions of impulsivity: (1) Immediate Memory Task (IMT), (2) Stop-Signal Task, (3) Delay-Discounting Task (DDT), (4) Iowa Gambling Task (IGT), and (5) Probabilistic Reversal-Learning task. We applied a machine-learning algorithm to all impulsivity measures.
Results
Machine learning accurately classified individuals with CD and predictions were generalizable to new samples (area under the curve of the receiver-operating characteristic curve was 0.912 in the test set). CD membership was predicted by higher scores on motor and non-planning trait impulsivity, poor response inhibition, and discriminability on the IMT, higher delay discounting on the DDT, and poor decision making on the IGT.
Conclusion
Our results suggest that multivariate behavioral impulsivity phenotypes can predict CD with high degree of accuracy, which can potentially be used to assess individuals’ vulnerability to CD in clinical settings.
doi:10.3389/fpsyt.2016.00034
PMCID: PMC4785183  PMID: 27014100
cocaine; addiction; substance dependence; impulsivity; machine learning; LASSO
2.  Temperament and Impulsivity Predictors of Smoking Cessation Outcomes 
PLoS ONE  2014;9(12):e112440.
Aims
Temperament and impulsivity are powerful predictors of addiction treatment outcomes. However, a comprehensive assessment of these features has not been examined in relation to smoking cessation outcomes.
Methods
Naturalistic prospective study. Treatment-seeking smokers (n = 140) were recruited as they engaged in an occupational health clinic providing smoking cessation treatment between 2009 and 2013. Participants were assessed at baseline with measures of temperament (Temperament and Character Inventory), trait impulsivity (Barratt Impulsivity Scale), and cognitive impulsivity (Go/No Go, Delay Discounting and Iowa Gambling Task). The outcome measure was treatment status, coded as “dropout” versus “relapse” versus “abstinence” at 3, 6, and 12 months endpoints. Participants were telephonically contacted and reminded of follow-up face to face assessments at each endpoint. The participants that failed to answer the phone calls or self-reported discontinuation of treatment and failed to attend the upcoming follow-up session were coded as dropouts. The participants that self-reported continuing treatment, and successfully attended the upcoming follow-up session were coded as either “relapse” or “abstinence”, based on the results of smoking behavior self-reports cross-validated with co-oximetry hemoglobin levels. Multinomial regression models were conducted to test whether temperament and impulsivity measures predicted dropout and relapse relative to abstinence outcomes.
Results
Higher scores on temperament dimensions of novelty seeking and reward dependence predicted poorer retention across endpoints, whereas only higher scores on persistence predicted greater relapse. Higher scores on the trait dimension of non-planning impulsivity but not performance on cognitive impulsivity predicted poorer retention. Higher non-planning impulsivity and poorer performance in the Iowa Gambling Task predicted greater relapse at 3 and 6 months and 6 months respectively.
Conclusion
Temperament measures, and specifically novelty seeking and reward dependence, predict smoking cessation treatment retention, whereas persistence, non-planning impulsivity and poor decision-making predict smoking relapse.
doi:10.1371/journal.pone.0112440
PMCID: PMC4256301  PMID: 25474540
3.  Impaired decision-making, higher impulsivity, and drug severity in substance dependence and pathological gambling 
Journal of addiction medicine  2015;9(4):273-280.
Objectives
Substance use disorder is characterized by impaired decision-making, impulsivity, and risk-taking. Pathological gambling shares many of these characteristics and having both diagnoses may be associated with greater problems than either diagnosis alone. We investigated whether among substance dependent individuals, co-morbid pathological gambling would be associated with worse decision-making, greater impulsivity, risk-taking, and drug severity.
Methods
Ninety-six substance dependent individuals were recruited from a residential treatment program and divided into one of two groups depending on whether they met DSM-IV criteria for pathological gambling (SDPG, n=26) or not (SD, n=70). Ninety-two controls were recruited from the community. Participants completed a decision-making task (modified Iowa Gambling Task), measures of impulsivity (Barratt Impulsivity Scale and Delay Discounting), and risk-taking (Balloon Analog Risk Task). Decision-making was analyzed using a computational model. We tested for group differences using ANCOVA or Kruskal-Wallis and appropriate post-hoc tests.
Results
The groups differed in decision-making parameters (p<0.001) and self-report impulsivity (p<0.001). All post-hoc comparisons were significant on these measures, and indicated stepwise changes in controls, followed by SD, followed by SDPG, with SDPG performing worse on decision-making and being more impulsive. Compared to SD, SDPG had greater drug severity (p<0.001). No group differences were observed in delay discounting or risk-taking.
Conclusions
Compared to individuals with substance dependence without pathological gambling, those with both disorders demonstrated worse decision-making and significantly more drug-related symptoms. When evaluating patients with substance dependence, clinicians should consider diagnostic assessments for gambling, as the co-occurrence of both disorders may impact clinical characteristics.
doi:10.1097/ADM.0000000000000129
PMCID: PMC4523448  PMID: 25918968
Substance Dependence; Pathological Gambling; Decision-Making; Impulsivity; Computational Modeling
4.  Impulsivity and cognitive distortions in pathological gamblers attending the UK National Problem Gambling Clinic: a preliminary report 
Psychological Medicine  2011;41(12):2625-2635.
Background
Pathological gambling (PG) is a form of behavioural addiction that has been associated with elevated impulsivity and also cognitive distortions in the processing of chance, probability and skill. We sought to assess the relationship between the level of cognitive distortions and state and trait measures of impulsivity in treatment-seeking pathological gamblers.
Method
Thirty pathological gamblers attending the National Problem Gambling Clinic, the first National Health Service clinic for gambling problems in the UK, were compared with 30 healthy controls in a case-control design. Cognitive distortions were assessed using the Gambling-Related Cognitions Scale (GRCS). Trait impulsivity was assessed using the UPPS-P, which includes scales of urgency, the tendency to be impulsive in positive or negative mood states. Delay discounting rates were taken as a state measure of impulsive choice.
Results
Pathological gamblers had elevated impulsivity on several UPPS-P subscales but effect sizes were largest (Cohen's d>1.4) for positive and negative urgency. The pathological gamblers also displayed higher levels of gambling distortions, and elevated preference for immediate rewards, compared to controls. Within the pathological gamblers, there was a strong relationship between the preference for immediate rewards and the level of cognitive distortions (R2=0.41).
Conclusions
Impulsive choice in the gamblers was correlated with the level of gambling distortions, and we hypothesize that an impulsive decision-making style may increase the acceptance of erroneous beliefs during gambling play.
doi:10.1017/S003329171100095X
PMCID: PMC3206226  PMID: 21733207
Behavioural addiction; decision making; delay discounting; problem gambling; risk taking
5.  Time Devours Things: How Impulsivity and Time Affect Temporal Decisions in Pathological Gamblers 
PLoS ONE  2014;9(10):e109197.
Impulsivity is associated with several psychiatric disorders in which the loss of control of a specific behavior determines the syndrome itself. One particularly interesting population characterized by reported high impulsivity and problematic decision-making are those diagnosed with pathological gambling. However the association between impulsivity and decision making in pathological gambling has been only partially confirmed until now. We tested 23 normal controls and 23 diagnosed pathological gamblers in an intertemporal choice task, as well as other personality trait measurements. Results showed that gamblers scored higher on impulsivity questionnaires, and selected a higher percentage of impatient choices (higher percentage of smaller, sooner rewards), when compared to normal controls. Moreover, gamblers were faster in terms of reaction times at selecting the smaller, sooner options and discounted rewards more rapidly over time. Importantly, regression analyses clarified that self-reported measures of impulsivity played a significant role in biasing decisions towards small but more rapidly available rewards. In the present study we found evidence for impulsivity in personality traits and decisions in pathological gamblers relative to controls. We conclude by speculating on the need to incorporate impulsivity and decision biases in the conceptualization of pathological gambling for a better understanding and treatment of this pathology.
doi:10.1371/journal.pone.0109197
PMCID: PMC4189922  PMID: 25296184
6.  Money for nothing — Atrophy correlates of gambling decision making in behavioural variant frontotemporal dementia and Alzheimer's disease☆ 
NeuroImage : Clinical  2013;2:263-272.
Neurodegenerative patients show often severe everyday decision making problems. Currently it is however not clear which brain atrophy regions are implicated in such decision making problems. We investigated the atrophy correlates of gambling decision making in a sample of 63 participants, including two neurodegenerative conditions (behavioural variant frontotemporal dementia — bvFTD; Alzheimer's disease — AD) as well as healthy age-matched controls. All participants were tested on the Iowa Gambling Task (IGT) and the behavioural IGT results were covaried against the T1 MRI scans of all participants to identify brain atrophy regions implicated in gambling decision making deficits. Our results showed a large variability in IGT performance for all groups with both patient groups performing especially poor on the task. Importantly, bvFTD and AD groups did not differ significantly on the behavioural performance of the IGT. However, by contrast, the atrophy gambling decision making correlates differed between bvFTD and AD, with bvFTD showing more frontal atrophy and AD showing more parietal and temporal atrophy being implicated in decision making deficits, indicating that both patient groups fail the task on different levels. Frontal (frontopolar, anterior cingulate) and parietal (retrosplenial) cortex atrophy covaried with poor performance on the IGT. Taken together, the atrophy correlates of gambling decision making show that such deficits can occur due to a failure of different neural structures, which will inform future diagnostics and treatment options to alleviate these severe everyday problems in neurodegenerative patients.
Highlights
► bvFTD and AD patients are both impaired in gambling decision making. ► However, atrophy correlates for gambling decision making differ between groups. ► Poor performance in decision making covaried with frontal atrophy in bvFTD. ► Poor performance in decision making covaried with parietal/temporal atrophy in AD. ► Gambling decision deficits can occur due to atrophy in different brain regions.
doi:10.1016/j.nicl.2013.01.011
PMCID: PMC3778267  PMID: 24179781
Behavioural variant frontotemporal dementia; Alzheimer's disease; Voxel-based morphometry; Gambling decision making; Iowa Gambling Task
7.  Risk-taking and pathological gambling behavior in Huntington’s disease 
Huntington’s disease (HD) is a genetic, neurodegenerative disorder, which specifically affects striatal neurons of the indirect pathway, resulting in a progressive decline in muscle coordination and loss of emotional and cognitive control. Interestingly, predisposition to pathological gambling and other addictions involves disturbances in the same cortico-striatal circuits that are affected in HD, and display similar disinhibition-related symptoms, including changed sensitivity to punishments and rewards, impulsivity, and inability to consider long-term advantages over short-term rewards. Both HD patients and pathological gamblers also show similar performance deficits on risky decision-making tasks, such as the Iowa Gambling Task (IGT). These similarities suggest that HD patients are a likely risk group for gambling problems. However, such problems have only incidentally been observed in HD patients. In this review, we aim to characterize the risk of pathological gambling in HD, as well as the underlying neurobiological mechanisms. Especially with the current rise of easily accessible Internet gambling opportunities, it is important to understand these risks and provide appropriate patient support accordingly. Based on neuropathological and behavioral findings, we propose that HD patients may not have an increased tendency to seek risks and start gambling, but that they do have an increased chance of developing an addiction once they engage in gambling activities. Therefore, current and future developments of Internet gambling possibilities and related addictions should be regarded with care, especially for vulnerable groups like HD patients.
doi:10.3389/fnbeh.2014.00103
PMCID: PMC3980094  PMID: 24765067
Huntington’s disease; risk-taking; gambling; prefrontal cortex; basal ganglia; disinhibtion
8.  Problem gamblers share deficits in impulsive decision-making with alcohol-dependent individuals 
Addiction (Abingdon, England)  2009;104(6):1006-1015.
Aims
Problem gambling has been proposed to represent a ‘behavioural addiction’ that may provide key insights into vulnerability mechanisms underlying addiction in brains that are not affected by the damaging effects of drugs. Our aim was to investigate the neurocognitive profile of problem gambling in comparison with alcohol dependence. We reasoned that shared deficits across the two conditions may reflect underlying vulnerability mechanisms, whereas impairments specific to alcohol dependence may reflect cumulative effects of alcohol consumption.
Design
Cross-sectional study.
Setting
Out-patient addiction treatment centres and university behavioural testing facilities.
Participants
A naturalistic sample of 21 male problem and pathological gamblers, 21 male alcohol-dependent out-patients and 21 healthy male control participants.
Measurements
Neurocognitive battery assessing decision-making, impulsivity and working memory.
Findings
The problem gamblers and alcohol-dependent groups displayed impairments in risky decision-making and cognitive impulsivity relative to controls. Working memory deficits and slowed deliberation times were specific to the alcohol-dependent group.
Conclusions
Gambling and alcohol-dependent groups shared deficits in tasks linked to ventral prefrontal cortical dysfunction. Tasks loading on dorsolateral prefrontal cortex were selectively impaired in the alcohol-dependent group, presumably as a consequence of long-term alcohol use.
doi:10.1111/j.1360-0443.2009.02533.x
PMCID: PMC2773538  PMID: 19466924
Addiction; alcohol; decision-making; impulsivity; pathological gambling; prefrontal cortex; risk-taking; vulnerability
9.  Study protocol: the JEU cohort study – transversal multiaxial evaluation and 5-year follow-up of a cohort of French gamblers 
BMC Psychiatry  2014;14:226.
Background
There is abundant literature on how to distinguish problem gambling (PG) from social gambling, but there are very few studies of the long-term evolution of gambling practice. As a consequence, the correlates of key state changes in the gambling trajectory are still unknown. The objective of the JEU cohort study is to identify the determinants of key state changes in the gambling practice, such as the emergence of a gambling problem, natural recovery from a gambling problem, resolution of a gambling problem with intermediate care intervention, relapses or care recourse.
Methods/design
The present study was designed to overcome the limitations of previous cohort study on PG. Indeed, this longitudinal case–control cohort is the first which plans to recruit enough participants from different initial gambling severity levels to observe these rare changes. In particular, we plan to recruit three groups of gamblers: non-problem gamblers, problem gamblers without treatment and problem gamblers seeking treatment.
Recruitment takes place in various gambling places, through the press and in care centers.
Cohort participants are gamblers of both sexes who reported gambling on at least one occasion in the previous year and who were aged between 18 and 65. They were assessed through a structured clinical interview and self-assessment questionnaires at baseline and then once a year for five years. Data collection comprises sociodemographic characteristics, gambling habits (including gambling trajectory), the PG section of the DSM-IV, the South Oaks Gambling Screen, the Gambling Attitudes and Beliefs Survey – 23, the Mini International Neuropsychiatric Interview, the Wender-Utah Rating Scale-Child, the Adult ADHD Self-report Scale, somatic comorbidities (especially current treatment and Parkinson disease) and the Temperament and Character Inventory – 125.
Discussion
The JEU cohort study is the first study which proposes to identify the predictive factors of key state changes in gambling practice. This is the first case–control cohort on gambling which mixes non-problem gamblers, problem gamblers without treatment and problem gamblers seeking treatment in almost equal proportions. This work may help providing a fresh perspective on the etiology of pathological gambling, which may provide support for future research, care and preventive actions.
Trial Registration
(ClinicalTrials.gov): NCT01207674.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0226-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-014-0226-7
PMCID: PMC4147162  PMID: 25141820
Gambling; State changes; Cohort; Problem gambling; Recourse to treatment; Predictive factors
10.  Impulsivity in bipolar disorder: relationships with neurocognitive dysfunction and substance use history 
Bipolar disorders  2013;15(8):10.1111/bdi.12124.
Objectives
Impulsivity is a core feature in bipolar disorder. Although mood symptoms exacerbate impulsivity, self-reports of impulsivity are elevated even during euthymia. Neurocognitive processes linked to impulsivity (e.g., attention, inhibition) are also impaired in patients with bipolar disorder and a high frequency of comorbidities associated with impulsivity, such as substance use disorders, further highlight the clinical relevance of this dimension of the illness. Our objective was to assess the relationship between impulsivity and cognition in bipolar disorder.
Methods
We evaluated impulsivity in 98 patients with bipolar disorder and its relationship with symptoms, cognition, and substance use history. We assessed self reports of trait-impulsivity [Barrett Impulsiveness Scale (BIS)] and impulsive behaviors on the Iowa Gambling Task (IGT). A comprehensive clinical and neurocognitive battery was also completed. Patients were compared with 95 healthy controls.
Results
Patients with bipolar disorder had higher scores versus healthy controls on all BIS scales. Performance on the IGT was significantly impaired and patients showed a tendency toward more erratic choices. Depressive symptoms were positively correlated with trait-impulsivity and with an increased tendency to attend more readily to losses versus gains on the IGT. We found no significant associations between impulsivity and neurocognition in the full bipolar sample; however, when sub-grouped based on substance abuse history, significant relationships were revealed only in subjects without a substance abuse history.
Discussion
Our data support prior reports of increased trait-impulsivity and impairment on behavioral tasks of impulsiveness in bipolar disorder and suggest a differential relationship between these illness features that is dependent upon history of substance abuse.
doi:10.1111/bdi.12124
PMCID: PMC3855192  PMID: 24028391
decision making; depression; impulsivity; Iowa Gambling Task; substance use
11.  Iowa Gambling Task (IGT): twenty years after – gambling disorder and IGT 
The Iowa Gambling Task (IGT) involves probabilistic learning via monetary rewards and punishments, where advantageous task performance requires subjects to forego potential large immediate rewards for small longer-term rewards to avoid larger losses. Pathological gamblers (PG) perform worse on the IGT compared to controls, relating to their persistent preference toward high, immediate, and uncertain rewards despite experiencing larger losses. In this contribution, we review studies that investigated processes associated with poor IGT performance in PG. Findings from these studies seem to fit with recent neurocognitive models of addiction, which argue that the diminished ability of addicted individuals to ponder short-term against long-term consequences of a choice may be the product of an hyperactive automatic attentional and memory system for signaling the presence of addiction-related cues (e.g., high uncertain rewards associated with disadvantageous decks selection during the IGT) and for attributing to such cues pleasure and excitement. This incentive-salience associated with gambling-related choice in PG may be so high that it could literally “hijack” resources [“hot” executive functions (EFs)] involved in emotional self-regulation and necessary to allow the enactment of further elaborate decontextualized problem-solving abilities (“cool” EFs). A framework for future research is also proposed, which highlights the need for studies examining how these processes contribute specifically to the aberrant choice profile displayed by PG on the IGT.
doi:10.3389/fpsyg.2013.00665
PMCID: PMC3786255  PMID: 24137138
gambling disorder; Iowa Gambling Task; decision-making; dual-process model; willpower
12.  The Relationship between Impulsivity and Problem Gambling in Adolescence 
Frontiers in Psychology  2016;7:1931.
Gambling has become one of the most frequently reported addictive behaviors among young people. Understanding risk factors associated with the onset or maintenance of gambling problems in adolescence has implications for its prevention and treatment. The main aim of the present study was to examine the potential relationships between impulsivity and problem gambling in adolescence. Participants were 874 high school students (average age: 15 years old) who were surveyed to provide data on gambling and impulsivity. Self-reported gambling behavior was assessed using the South Oaks Gambling Screen – Revised for Adolescents (SOGS-RA) and impulsivity was measured using the Impulsive Sensation Seeking Questionnaire (ZKPQ), the Barratt Impulsiveness Scale (BIS-11-A), and a delay discounting task. The data were analyzed using both a prospective-longitudinal and a cross-sectional design. In the longitudinal analyses, results showed that the impulsivity subscale of the ZKPQ increased the risk of problem gambling (p = 0.003). In the cross-sectional analyses, all the impulsivity measures were higher in at-risk/problem gamblers than in non-problem gamblers (p = 0.04; 0.03; and 0.01, respectively). These findings further support the relationship between impulsivity and gambling in adolescence. Moreover, our findings suggest a bidirectional relationship between impulsivity and problem gambling in adolescence. These results have consequences for the development of prevention and treatment programs for adolescents with gambling problems.
doi:10.3389/fpsyg.2016.01931
PMCID: PMC5143594  PMID: 28008322
adolescence; gambling; impulsivity; delay discounting; risk factors
13.  Elucidating Poor Decision-Making in a Rat Gambling Task 
PLoS ONE  2013;8(12):e82052.
Although poor decision-making is a hallmark of psychiatric conditions such as attention deficit/hyperactivity disorder, pathological gambling or substance abuse, a fraction of healthy individuals exhibit similar poor decision-making performances in everyday life and specific laboratory tasks such as the Iowa Gambling Task. These particular individuals may provide information on risk factors or common endophenotypes of these mental disorders. In a rodent version of the Iowa gambling task – the Rat Gambling Task (RGT), we identified a population of poor decision makers, and assessed how these rats scored for several behavioral traits relevant to executive disorders: risk taking, reward seeking, behavioral inflexibility, and several aspects of impulsivity. First, we found that poor decision-making could not be well predicted by single behavioral and cognitive characteristics when considered separately. By contrast, a combination of independent traits in the same individual, namely risk taking, reward seeking, behavioral inflexibility, as well as motor impulsivity, was highly predictive of poor decision-making. Second, using a reinforcement-learning model of the RGT, we confirmed that only the combination of extreme scores on these traits could induce maladaptive decision-making. Third, the model suggested that a combination of these behavioral traits results in an inaccurate representation of rewards and penalties and inefficient learning of the environment. Poor decision-making appears as a consequence of the over-valuation of high-reward-high-risk options in the task. Such a specific psychological profile could greatly impair clinically healthy individuals in decision-making tasks and may predispose to mental disorders with similar symptoms.
doi:10.1371/journal.pone.0082052
PMCID: PMC3855331  PMID: 24339988
14.  Selective decision-making deficits in at-risk gamblers 
Psychiatry Research  2011;189(1):115-120.
Despite reasonable knowledge of pathological gambling (PG), little is known of its cognitive antecedents. We evaluated decision-making and impulsivity characteristics in people at risk of developing PG using neuropsychological tests. Non-treatment seeking volunteers (18-29 years) who gamble ≥5 times/year were recruited from the general community, and split into two groups: those “at risk” of developing PG (n=74) and those social, non-problem gamblers (n=112). Participants undertook the Cambridge Gamble and Stop-signal tasks and were assessed with the Mini-International Neuropsychiatric Interview and the Yale Brown Obsessive Compulsive Scale Modified for Pathological Gambling. On the Cambridge Gamble task, the at- risk subjects gambled more points overall, were more likely to go bankrupt, and made more irrational decisions under situations of relative risk ambiguity. On the Stop-signal task, at- risk gamblers did not differ from the social, non-problem gamblers in terms of motor impulse control (stop-signal reaction times). Findings suggest that selective cognitive dysfunction may already be present in terms of decision-making in at-risk gamblers, even before psychopathology arises. These findings implicate selective decision-making deficits and dysfunction of orbitofronto-limbic circuitry in the chain of pathogenesis between social, non-problematic and pathological gambling.
doi:10.1016/j.psychres.2011.05.034
PMCID: PMC3401062  PMID: 21715016
Pathological Gambling; Pathogenesis; Addiction; Cognitive Dysfunction; Cognition; Inhibition
15.  Neurocognitive Dysfunction in Strategic and Non-Strategic Gamblers 
Objective
It has been theorized that there may be subtypes of pathological gambling, particularly in relation to the main type of gambling activities undertaken. Whether or not putative pathological gambling subtypes differ in terms of their clinical and cognitive profiles has received little attention.
Method
Subjects meeting DSM-IV criteria for pathological gambling were grouped into two categories of preferred forms of gambling – strategic (e.g., cards, dice, sports betting, stock market) and non-strategic (e.g., slots, video poker, pull tabs). Groups were compared on clinical characteristics (gambling severity, and time and money spent gambling), psychiatric comorbidity, and neurocognitive tests assessing motor impulsivity and cognitive flexibility.
Results
Seventy-seven subjects were included in this sample (45.5% females; mean age: 42.7±14.9) which consisted of the following groups: strategic (n=22; 28.6%) and non-strategic (n=55; 71.4%). Non-strategic gamblers were significantly more likely to be older, female, and divorced. Money spent gambling did not differ significantly between groups although one measure of gambling severity reflected more severe problems for strategic gamblers. Strategic and non-strategic gamblers did not differ in terms of cognitive function; both groups showed impairments in cognitive flexibility and inhibitory control relative to matched healthy volunteers.
Conclusion
These preliminary results suggest that preferred form of gambling may be associated with specific clinical characteristics but are not associated dissociable in terms of cognitive inflexibility and motor impulsivity.
doi:10.1016/j.pnpbp.2012.05.006
PMCID: PMC3389298  PMID: 22613186
cognition; impulsivity; gambling
16.  Reward-Related Decision-Making Deficits and Elevated Impulsivity Among MDMA and Other Drug Users 
Drug and alcohol dependence  2008;96(1-2):99-110.
Background
The recreational drug, MDMA (3,4-methylenedioxymethamphetamine; ‘Ecstasy’), is a synthetic amphetamine derivative and a serotonin neurotoxin. MDMA use is associated with cognitive dysfunction and impulsivity, but since polydrug abuse is common among users it is difficult to attribute these problems specifically to MDMA. Moreover, few studies have examined reward-related cognitive processes. Our aim was to examine reward-related decision-making and impulsivity among MDMA users while controlling for polydrug use via appropriate comparison groups.
Methods
We examined decision-making (Iowa Gambling Task; IGT; Bechara et al., 1994), self-reported impulsivity (Multidimensional Personality Questionnaire – Brief Form [Constraint subscale]; Barratt Impulsiveness Scale; Zuckerman Sensation Seeking Scale), and drug use among 22 abstinent MDMA users, 30 other drug users, and 29 healthy non-drug controls.
Results
MDMA and other drug users showed comparable patterns of decision-making and impulsivity. However, both drug groups demonstrated poorer IGT performance and elevated self-reported impulsivity relative to controls. Poorer decision-making was related to heavier drug use in the past year, heavier weekly alcohol use, and meeting lifetime substance use disorder (SUD) criteria for more drug classes. Elevated impulsivity was associated with heavier drug use, heavier weekly alcohol use, more lifetime SUDs, and higher self-reported depression levels.
Conclusions
These findings contradict the idea that MDMA is specifically associated with deficient decision-making. Drug users, in general, may be at risk for decision-making deficits and elevated impulsivity. Such behaviors may represent trait factors that lead to the initiation of drug and alcohol use, and/or they may represent behavior patterns that are exacerbated by extensive use.
doi:10.1016/j.drugalcdep.2008.02.003
PMCID: PMC2492887  PMID: 18384979
MDMA; drug use; alcohol use; executive functions; decision-making; impulsivity
17.  Childhood Symptoms of ADHD and Impulsivity in Abstinent Heroin Users 
Journal of dual diagnosis  2015;11(3-4):174-178.
Objectives
Heroin dependence is associated with deficits in impulsivity, which is also a core feature of ADHD. This study aimed to explore the association between childhood ADHD symptoms and cognitive/choice and motor/action impulsivity among abstinent individuals with a history of heroin dependence.
Methods
Thirty-two abstinent Bulgarian males with a history of heroin dependence participated in the study. Self-rated childhood ADHD symptoms were obtained using the Wender-Utah Rating Scale. Cognitive/choice impulsivity was measured using the Iowa Gambling Task (IGT), an index of impulsive decision-making and the Delayed Reward Discounting Task (DRDT), a measure of inter-temporal choice. Motor/action impulsivity was indexed with the Stop Signal Task (SST), a measure of response inhibition.
Results
Participants, whose average age was 27.66 years (SD = 2.7), had an average ADHD symptom score of 36.6 (SD = 18.6), roughly 7 years (SD = 2.9) of heroin use, and been abstinent for just over a year (M = 402.5 days, SD = 223.8). Linear regression analyses revealed that self-reported ADHD symptoms predicted impulsive decision-making (IGT), but not delay discounting (DRDT) or response inhibition (SST).
Conclusions
Self-reported childhood ADHD symptoms do not uniformly predict impulsivity among abstinent individuals with heroin dependence. Results suggest the IGT may be more sensitive to externalizing psychopathology among individuals with heroin dependence than other measures of impulsivity.
doi:10.1080/15504263.2015.1104482
PMCID: PMC4859310  PMID: 26457770
ADHD; heroin; impulsivity; decision-making; addiction; abstinence
18.  Performance of Young Adult Cannabis Users on Neurocognitive Measures of Impulsive Behavior and their Relationship to Symptoms of Cannabis Use Disorders 
Recent studies suggest that abstinent cannabis users show deficits on neurocognitive laboratory tasks of impulsive behavior. But results are mixed and less is known on the performance of non-treatment seeking, young adult cannabis users. Importantly, relationships between performance on measures of impulsive behavior and symptoms of cannabis addiction remain relatively unexplored. We compared young adult current cannabis users (CU, n = 65) and non-using controls (NU, n = 65) on several laboratory measures of impulsive behavior, as well as on a measure of episodic memory commonly impacted by cannabis use. The CU group performed more poorly than the NU group on the Hopkins Verbal Learning Test-Revised Total Immediate Recall and Delayed Recall. No significant differences were observed on the measures of impulsive behavior (i.e., Iowa Gambling Task [IGT], Go-Stop Task, Monetary Choice Questionnaire, Balloon Analogue Risk Task). We examined relationships between neurocognitive performance and symptoms of cannabis use disorder symptoms (DSM-IV CUD) among the CU group, which revealed that poorer IGT performance was associated with more symptoms of DSM-IV CUD. Our results show poorer memory performance among young adult cannabis users relative to healthy controls, but no differences on measures of impulsive behavior. However, performance on a specific type of impulsive behavior (i.e., poorer decision-making) was associated with more cannabis use disorder symptoms. These results provide preliminary evidence to suggest that decision-making deficits may be more strongly associated with problems experienced from cannabis use, rather than solely being a consequence of cannabis use, per se.
doi:10.1080/13803395.2012.703642
PMCID: PMC3488122  PMID: 22882144
cannabis; addiction; decision-making; neuropsychology; memory; cognitive effects
19.  Interactions between risky decisions, impulsiveness and smoking in young tattooed women 
BMC Psychiatry  2013;13:278.
Background
According to previous studies, one of the common problems of everyday life of persons with tattoos is risky behavior. However, direct examination of the decision making process, as well as factors which determine women’s risk-taking decisions to get tattoos, have not been conducted. This study investigates whether risk taking decision-making is associated with the self-assessment impulsiveness in tattooed women.
Methods
Young women (aged 18–35 years) with (N = 60) and without (N = 60) tattoos, performed the Iowa Gambling Task (IGT), as a measure of decision-making processes, as well as completing the Barratt Impulsivity Scale (BIS-11).
Results
Tattooed women showed significantly higher scores in the BIS-11 and preference for disadvantageous decks on the IGT compared to non-tattooed women. There was no significant correlation between risky decision-making in the IGT and BIS-11 impulsivity measures. A significantly higher rate of smoking was observed in the tattooed women. However, the analysis did not reveal a group effect after adjustment for smoking in the IGT and the BIS-11 measures.
Conclusions
The present study was specifically designed to resolve questions regarding associations between impulsiveness and risky decision-making in tattooed women. It shows that in tattooed women, risky decisions are not a direct result of their self-reported impulsiveness. Smoking does not explain the psychometric differences between tattooed women and controls.
doi:10.1186/1471-244X-13-278
PMCID: PMC3829656  PMID: 24180254
Tattoo; The Iowa Gambling Task; Impulsivity; Smoking
20.  Baseline neurocognitive profiles differentiate abstainers and non-abstainers in a cocaine clinical trial 
Previous studies have shown that cocaine users have higher levels of impulsivity and impaired decision making; however few have examined these factors as predictors of treatment success. We obtained baseline neurocognitive measures from 75 cocaine-dependent individuals participating in a 12-week clinical trial targeting impulsivity with behavioral therapies and pharmacotherapy. Subjects treated with citalopram (versus placebo) had higher cocaine abstinence rates compared to placebo-treated subjects (Moeller et al., 2007). The aim of this secondary analysis study was to determine whether profiles of performance on neurocognitive measures administered at baseline discriminated among patients who achieved abstinence and those who did not. Subjects completed the Immediate and Delayed Memory Task (IMT/DMT), Barratt Impulsiveness Scale (BIS-11), and Iowa Gambling Task (IGT). Profile analysis results showed different patterns of performance on these baseline measures as a function of outcome. Compared with non-abstinent participants, abstinent subjects had higher scores on the BIS-11 Non-Planning subscale and better performance on the IGT. Profile differences for the two outcome groups did not vary as a function of treatment condition. Results suggest that cocaine dependent patients entering treatment with higher impulsivity and less impaired decision-making abilities may respond favorably to targeted behavioral interventions. Neurocognitive profiles may be useful in understanding population heterogeneity and predicting differential outcomes in subgroups of cocaine abusers.
doi:10.1080/10550880903028502
PMCID: PMC2822995  PMID: 20155594
impulsivity; decision making; cocaine; cognitive behavioral therapy; contingency management; citalopram; profile analysis
21.  Longitudinal patterns of gambling activities and associated risk factors in college students 
Addiction (Abingdon, England)  2009;104(7):1219.
Aims
To investigate which clusters of gambling activities exist within a longitudinal study of college health, how membership in gambling clusters change over time and whether particular clusters of gambling are associated with unhealthy risk behaviour.
Design
Four-year longitudinal study (2002–2006).
Setting
Large, public university.
Participants
Undergraduate college students.
Measurements
Ten common gambling activities were measured during 4 consecutive college years (years 1–4). Clusters of gambling activities were examined using latent class analyses. Relations between gambling clusters and gender, Greek membership, alcohol use, drug use, personality indicators of behavioural undercontrol and psychological distress were examined.
Findings
Four latent gambling classes were identified: (1) a low-gambling class, (2) a card gambling class, (3) a casino/slots gambling class and (4) an extensive gambling class. Over the first college years a high probability of transitioning from the low-gambling class and the card gambling class into the casino/slots gambling class was present. Membership in the card, casino/slots and extensive gambling classes were associated with higher scores on alcohol/drug use, novelty seeking and self-identified gambling problems compared to the low-gambling class. The extensive gambling class scored higher than the other gambling classes on risk factors.
Conclusions
Extensive gamblers and card gamblers are at higher risk for problem gambling and other risky health behaviours. Prospective examinations of class membership suggested that being in the extensive and the low gambling classes was highly stable across the 4 years of college.
doi:10.1111/j.1360-0443.2009.02573.x
PMCID: PMC2818490  PMID: 19438422
College student population; gambling; gambling activities; longitudinal; risk factors
22.  A biopsychological review of gambling disorder 
The present review is an overview of previous experimental work on biopsychological aspects of gambling disorder. It includes the topics 1) gambling disorder from the neuroimaging and electroencephalography (EEG) perspective, 2) cognitive, executive functioning, and neuropsychological aspects of gambling disorder, and 3) rodent models of gambling disorder. Penalties and losses in gambling can differ in terms of brain activity. Also, specific patterns of brain activity, brain anatomical traits, EEG responses, and cognitive and executive performance can discriminate pathological gamblers from nonpathological gamblers. Also, pathological gamblers can display dysfunction in such brain areas as the insula, frontal lobe, and orbitofrontal cortex. Pathological gambling is a heterogeneous disorder that can vary depending on the severity of cognition, the style of gambling (strategic or not), the prospect of recovery, proneness to relapse, and proneness to treatment withdrawal. Finally, based on rodent models of gambling, the appropriateness of gambling decision is influenced by the presence of cues, the activity of dopamine receptors, and the activity of some brain areas (infralimbic, prelimbic, or rostral agranular insular cortex). Pathological gamblers differed in terms of frontoparietal brain activation compared to nonpathological gamblers (if winning or losing a game). Pathological gamblers had dysfunctional EEG activity. The severity of gambling was linked to the magnification and content of cognitive distortions. The insula was fundamental in the distortion of cognitions linked to result analysis during gambling activity.
doi:10.2147/NDT.S118818
PMCID: PMC5207471  PMID: 28096672
pathological gambling; biopsychology; human; rodent
23.  A counselling line for problem and pathological gambling in South Africa: Preliminary data analysis 
Journal of Behavioral Addictions  2014;3(3):199-202.
Abstract
Objective: Various countries and states have established telephone counselling lines for people with pathological or problem gambling. Data from such services may contribute to describing systematically the nature of gambling problems in a particular area. To date, however, few data have been published on such a telephone counselling line in a low or middle income country. Method: Data on calls to the telephone counselling line of the National Responsible Gambling Foundation of South Africa were captured over a 6-month period. Such data include socio-demographic variables, the primary reason for calling, the source of the referral, preferred method of gambling, impairment as a consequence of gambling, and history of treatment for psychiatric disorders, comorbid alcohol abuse and illicit drug use. Results: Calls were received from a broad range of people; the mean age of callers was 37 years, the majority were male (62%) and many were married (45%). Primary reasons for calling included the feeling of being unable to stop gambling without the help of a professional (41%), financial concerns (32%), legal problems (13%), pressure from family (10%), and suicidal thoughts (2%). The majority of callers contacted the counselling line after having heard about it by word of mouth (70%). The most common forms of gambling were slot machines (51%) and casino games (21%). Fourteen percent of callers reported having received help for other psychiatric disorders, 11% reported alcohol use disorders and 6% illicit drug use. Conclusion: These data from South Africa are consistent with prior research indicating that pathological and problem gambling are seen in a range of socio-demographic groups, and that such behaviour is associated with significant morbidity and comorbidity. More work is needed locally to inform younger gamblers, gamblers using the informal gambling sector, and unemployed gamblers of the existing telephone counselling lines.
doi:10.1556/JBA.3.2014.017
PMCID: PMC4189313  PMID: 25317344
behaviour addictive/therapy; counselling; comorbidity; gambling/psychology; South Africa
24.  The Neural Basis of Decision-Making and Reward Processing in Adults with Euthymic Bipolar Disorder or Attention-Deficit/Hyperactivity Disorder (ADHD) 
PLoS ONE  2012;7(5):e37306.
Background
Attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) share DSM-IV criteria in adults and cause problems in decision-making. Nevertheless, no previous report has assessed a decision-making task that includes the examination of the neural correlates of reward and gambling in adults with ADHD and those with BD.
Methodology/Principal Findings
We used the Iowa gambling task (IGT), a task of rational decision-making under risk (RDMUR) and a rapid-decision gambling task (RDGT) which elicits behavioral measures as well as event-related potentials (ERPs: fERN and P3) in connection to the motivational impact of events. We did not observe between-group differences for decision-making under risk or ambiguity (RDMUR and IGT); however, there were significant differences for the ERP-assessed RDGT. Compared to controls, the ADHD group showed a pattern of impaired learning by feedback (fERN) and insensitivity to reward magnitude (P3). This ERP pattern (fERN and P3) was associated with impulsivity, hyperactivity, executive function and working memory. Compared to controls, the BD group showed fERN- and P3-enhanced responses to reward magnitude regardless of valence. This ERP pattern (fERN and P3) was associated with mood and inhibitory control. Consistent with the ERP findings, an analysis of source location revealed reduced responses of the cingulate cortex to the valence and magnitude of rewards in patients with ADHD and BD.
Conclusions/Significance
Our data suggest that neurophysiological (ERPs) paradigms such as the RDGT are well suited to assess subclinical decision-making processes in patients with ADHD and BD as well as for linking the cingulate cortex with action monitoring systems.
doi:10.1371/journal.pone.0037306
PMCID: PMC3356275  PMID: 22624011
25.  Clinical and Cognitive Correlates of Suicide Attempts in Bipolar Disorder: Is Suicide Predictable? 
The Journal of clinical psychiatry  2011;72(8):1027-1033.
Objective
We conducted a retrospective investigation of potential clinical, demographic, and neuropsychological risk factors for suicide attempts in patients diagnosed with bipolar disorder.
Method
Participants included 67 adult inpatients and outpatients aged 18–60 years meeting DSM-IV criteria for bipolar disorder (bipolar I and II disorders, bipolar disorder not otherwise specified). We assessed demographic factors, mood symptoms, psychosis, trauma history, trait impulsivity, trait aggression, and reasons for living. The primary outcome measures were the Barratt Impulsiveness Scale-version II, Aggression Questionnaire, and 10 cognitive outcome variables. The cognitive outcome variables assessed cognitive performance across several domains, including processing speed, attention, verbal learning, and executive function. Another aspect of cognitive function, decision making, was assessed using the Iowa Gambling Task. The study was conducted from July 2007–July 2009.
Results
We found that nonattempters reported significantly higher trait impulsivity scores on the Barratt Impulsiveness Scale compared to attempters (t57 = 2.2, P = .03) and that, among attempters, lower trait impulsivity score was associated with higher scores of lethality of prior attempts (r25 = −0.53, P = .01). Analyses revealed no other group differences on demographic, clinical, or neurocognitive variables when comparing attempters versus nonattempters. Regression models failed to identify any significant predictors of past suicide attempt.
Conclusions
The largely negative results of our study are particularly important in highlighting the clinical dilemma faced by many clinicians when trying to predict which patients will make serious suicide attempts and which patients are at a lower risk for acting on suicidal thoughts. A limitation of our work is that we examined stable trait measures of impulsivity among a euthymic sample rather than mood state or the impact of mood state on traits. Overall, we conclude that suicidal behavior is extremely difficult to predict, even when comprehensive clinical and neurocognitive information is available.
doi:10.4088/JCP.10m06410
PMCID: PMC4035109  PMID: 21813075

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