Improvement In Impulsivity Research Articles

Effects of yoga on impulsivity in patients with and without mental disorders: a systematic review

BackgroundYoga can be used as a complementary intervention to conventional treatments, whether pharmacological or non-pharmacological. Sustained practice of yoga can generate a series of benefits for individuals' quality of life and improve their physical fitness.ObjectiveTo investigate the potential effects of yoga as an adjunct intervention in conditions involving impulse control issues, such as attention deficit hyperactivity disorder (ADHD), borderline personality disorder, bipolar affective disorder, and substance use disorders.MethodsWe performed a systematic review of placebo-controlled, randomized trials of yoga in patients with impulsivity. PubMed, Web of Science, and Science Direct databases were searched for trials published up to January, 2023. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations.ResultsOut of 277 database results, 6 RCT were included in this systematic review. To assess the level of attention and impulsiveness, the following scales were analyzed: Barratt Impulsiveness, UPPS-P Impulsive Behavior scale, Conners’ Continuous Performance Test IIª and Conners’ Parent Rating Scale–Revised: Long.ConclusionsYoga didn’t have a significant improvement in impulsivity when compared to placebo. There are many tools to assess impulsivity, but they mean different concepts and domains consisting in a weakness on comparison of yoga effects.PROSPERO registrationCRD42023389088.

Effect of a sensory diet smartphone application on the symptoms of children with attention deficit hyperactivity disorder (ADHD): A feasibility study

IntroductionSensory integration and sensory diet can improve the symptoms of children with attention deficit/hyperactivity disorder (ADHD). This feasibility study aimed to evaluate the effect of using a sensory diet smartphone application by mothers on the main symptoms of their children with ADHD, including hyperactivity, attention deficit, and impulsivity. MethodsWe conducted a need assessment study with the collaboration of 15 occupational therapists, developed an Android-based prototype, and evaluated it in terms of usability with the participation of 12 available mothers of children with ADHD. 12 other selected children were divided into control and experimental groups. At first, these children were evaluated using the hyperactivity subscale of the fourth version of the Pediatric Symptoms Questionnaire, and after two months of using the application by the mothers of the children in the experimental group, both groups were re-evaluated using the same questionnaire. We compared the mean score of this questionnaire before and after the mothers’ use of the application. ResultsThe application included 105 sensory diet exercises presented in animated format with accompanying text explanations. According to mothers' feedback, the usability of the application was rated at a high level with an average score of 8.35 out of 9. In the experimental group, attention deficit significantly improved compared to the pre-intervention stage (Mean ± SD = 13.67 ± 6.86 vs. 22 ± 6.13, P-value<0.0001) and compared to the control group after the intervention (P-value = 0.048). Additionally, after the intervention, the experimental group showed significant improvements in impulsivity (mean difference = −1.33) and hyperactivity (mean difference = −4.67) compared to the pre-intervention (P-value = 0.025 and 0.034, respectively). However, these improvements were not statistically significant when compared to the control group (P-value = 0.937 and 0.58, respectively). ConclusionThe findings suggest that sensory diet smartphone applications have the potential to help alleviate symptoms related to attention deficit in children with ADHD.

The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders

Impulsivity is considered a core feature of substance use disorders (SUDs), including personological (i.e., negative urgency, positive urgency, lack of premeditation) and neuropsychological (i.e., cognitive and motor disinhibition, impulsive choice) dimensions. Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone treatment is an effective intervention for alcohol use disorder (AUD) and other SUDs. However, there are no studies that have investigated changes in impulsivity levels during a DBT-ST program, especially testing the therapeutic effects of DBT skills. Twenty-nine patients with AUD and other SUDs were admitted to a 3-month DBT-ST program. Self-report (i.e., UPPS-P) and computerized neuropsychological (i.e., Attentional Network test; Go/No-Go task; Iowa Gambling Task) measures of impulsivity were administered at the beginning and end of the DBT-ST. Distress tolerance (DTS), mindfulness (MAAS, FFMQ) and emotion regulation (DERS) were also assessed pre- and post-intervention. The study included two age- and gender-matched control groups: (a) untreated patients with SUDs (N = 29); (b) healthy controls (HCs) (N = 29). Twenty-four (82.7%) patients concluded the DBT-ST program. Emotion-based forms of impulsivity significantly improved during the program. At the end of treatment, impulsivity levels were significantly lower than those of untreated patients with SUDs and they were not significantly different from HCs. Cognitive disinhibition significantly decreased during the treatment. The improvement in impulsivity was explained by pre- posttreatment changes in distress tolerance, mindfulness and emotion regulation. Motor disinhibition did not improve during the treatment. These findings supported the initial efficacy of the DBT-ST program for addressing different features of impulsivity among individuals with AUD and other SUDs. Future follow-up studies should demonstrate the role of impulsivity domains in long-term relapse prevention.

Yoga as an Adjunct Treatment for Attention Deficit Hyperactivity Disorder (ADHD)

IntroductionAttention Deficit Hyperactivity Disorder (ADHD) affects about 9.4% (6.4 million) children in the United States. Pharmacological treatment, including stimulants, is a known therapy for ADHD. However, its possible subtherapeutic effectiveness, residual symptoms, and adverse effects have prompted us to explore the current evidence of Yoga as an add-on therapy that has shown synergistic effects in recent studies.Objectives1) We aim to assess Yoga’s efficacy as an add-on treatment for ADHD.2) Assess the current evidence of Yoga as an add-on therapy for ADHD.MethodsWe searched PubMed, PubMed Central, Medline, Web of Science, and Biosis databases with the keywords “Attention Deficit Disorder with Hyperactivity” (MeSH) and “ADHD” in the context of “Yoga” (MeSH). Identified 4 relevant studies that were published until September 30, 2022.ResultsA study by Jensen et al. found improvement in impulsivity, hyperactivity, and restlessness in the ADHD with medications patient group after 20 Yoga sessions. Study utilized Conners’ Parents Rating Scales and found improvement in the Yoga group on Oppositional, Global Index Emotional Lability, Global Index Total, Global Index Restless/Impulsive, and ADHD Index scale, changes associated with the number of sessions (Jensen et al. J Atten Disord 2004; 7 205-216). In another study, children with ADHD showed significant improvement after 8 weeks of 16 Yoga sessions in accuracy rate and reaction time in the Visual Pursuit Test and Determination Test (Chou et al. Peer J 2017; 5 e2883). A nine-year-old male case showed improvement in inattentive and hyperactive-impulsive symptoms on Vanderbilt Assessment Scales from parents and teachers after 6 months of Yoga practice (Gunaseelan et al. Cureus 2021; 5, e2883). Another 6-week Yoga intervention randomized trial in pre-school ADHD children showed significant improvement in hyperactivity and inattention with fewer distractibility errors of omission and faster reaction time (Cohen et al. J Dev Behav Pediatr 2018; 39 200).ConclusionsThe results suggest that Yoga has beneficial effects as an adjunct treatment to pharmacotherapy in ADHD for reducing hyperactivity and inattentiveness. Additionally, studies indicate its effectiveness in managing stress, anxiety, energy levels, and impulse control by staying focused with the help of breath and mind control. To explore the full spectrum of benefits and effectiveness of Yoga as an add-on therapy for ADHD patients, we recommend robust well-design future studies.Disclosure of InterestNone Declared

Psychosocial Intervention for Youth With High Externalizing Behaviors and Aggression Is Associated With Improvement in Impulsivity and Brain Gray Matter Volume Changes.

Background: Stop, Now And Plan (SNAP) is a cognitive behavioral-based psychosocial intervention that has a strong evidence base for treating youth with high aggression and externalizing behaviors, many of whom have disruptive behavior disorders. In a pre-post design, we tested whether SNAP could improve externalizing behaviors, assessed by the parent-rated Child Behavior Checklist (CBCL) and also improve behavioral measures of impulsivity in children with high aggression and impulsivity. We then investigated whether any improvement in externalizing behavior or impulsivity was associated with gray matter volume (GMV) changes assessed using structural magnetic resonance imaging (sMRI). We also recruited typically developing youth who were assessed twice without undergoing the SNAP intervention.Methods: Ten children who were participating in SNAP treatment completed the entire study protocol. CBCL measures, behavioral measures of impulsivity, and sMRI scanning was conducted pre-SNAP and then 13 weeks later post-SNAP. Twelve healthy controls also completed the study; they were rated on the CBCL, performed the same behavioral measure of impulsivity, and underwent sMRI twice, separated by 13 weeks. They did not receive the SNAP intervention.Result: At baseline, SNAP participants had higher CBCL scores and performed worse on the impulsivity task compared with the healthy controls. At the second visit, SNAP participants still had higher scores on the CBCL compared with normally-developing controls, but their performance on the impulsivity task had improved to the point where their results were indistinguishable from the healthy controls. Structural magnetic resonance imaging in the SNAP participants further revealed that improvements in impulsivity were associated with GMV changes in the frontotemporal region.Conclusion: These results suggest that SNAP led to improvement in behavioral measures of impulsivity in a cohort of boys with high externalizing behavior. Improvement in impulsivity was also associated with increased GMV changes. The mechanism behind these brain changes is unknown but could relate to cognitive behavioral therapy and contingency management interventions, important components of SNAP, that target frontotemporal brain regions. Clinically, this study offers new evidence for the potential targeting of brain regions by non-invasive modalities, such as repetitive transcranial magnetic stimulation, to improve externalizing behavior and impulsivity.

Sex differences in noradrenergic modulation of attention and impulsivity in rats.

Noradrenaline (NE) is closely related to attentive performance and impulsive control. However, the potential sex differences regarding attention and impulsivity under the noradrenergic modulation have been largely neglected. Therefore, our study aimed to investigate whether male and female rats exhibit differential responses to NE-related drugs during the five-choice serial reaction time task (5CSRT). Male and female rats were trained in 5CSRT and administered with different NE drugs after obtaining stable baseline performance: atipamezole, a highly selective α2 receptor antagonist; prazosin, an α1 receptor antagonist; and atomoxetine, a selective NE reuptake inhibitor. Later, prazosin was selected to co-administration with atomoxetine. Male and female rats exhibited equal learning speed, and no significant baseline differences were found as measured by the 5CSRT. Atomoxetine decreased premature responses in both sexes, but the extent of this reduction was different, with the reduction greater in males. Besides, atomoxetine (1.8 mg/kg) increased the error of omissions in females. The high dose of prazosin (0.5 mg/kg) decreased the accuracy only in male rats, but this was ameliorated by the co-administration with atomoxetine. Atomoxetine showed significant improvement in impulsivity, but atomoxetine had less beneficial effects on impulsive control in females than in males, and it even impaired attentional performance in female rats. The α1 receptors were mainly responsible for NE drug-related sex differences in attention rather than impulsivity. The results obtained in this study indicate that the sex differences exist in both attention and impulsivity by the modulation of noradrenaline and raise the concern to improve sex-specific treatments.

Use of selective serotonin and norepinephrine reuptake inhibitors (SNRIs) in the treatment of autism spectrum disorder (ASD), comorbid psychiatric disorders and ASD-associated symptoms: a clinical review.

It is challenging to treat symptoms of autism spectrum disorder (ASD), comorbid psychiatric disorders and ASD-associated symptoms. Some of the commonly used medications to treat these can, and frequently do have serious adverse side effects. Therefore, it is important to identify medications that are effective and with fewer side effects and negative outcomes. In this review, we looked at current evidence available for using the serotonin and norepinephrine reuptake inhibitors (SNRIs) class of medications in treating some of these often difficult to treat symptoms and behaviors. An extensive literature search was conducted using EBSCO.host. Our search algorithm identified 130 articles, 6 of which were deemed to meet criteria for the purpose of this review. Each of these six articles was independently reviewed and critically appraised. As a prototype of the SNRIs family, venlafaxine was found to be a useful adjuvant in children and adults with ASD for the treatment of self-injurious behaviors, aggression, and ADHD symptoms when used in doses lower than its antidepressant dosage. However, duloxetine was not found to show any added benefit in treatment of any of the comorbid symptoms and behaviors in ASD when compared to other antidepressants. On the other hand, milnacipran was reported to produce improvements in impulsivity, hyperactivity symptoms, and social functioning through reduction of inattention of ADHD when comorbid with ASD. Overall, SNRIs were shown variable effectiveness in treatment of these comorbid symptoms and behaviors in ASD.

Cariprazine in Autism Spectrum Disorder and Intellectual Disability Disorder

This is the first clinical report of the use of Cariprazine, a second generation orally administered atypical antipsychotic compound, in patients with Autism Spectrum Disorder (ASD) and Intellectual Disability (ID). Risperidone and Aripiprazole have been studied in autistic patients and are FDA approved for the treatment of irritability associated with autism, but studies of newer agents are limited. We studied eight patients diagnosed with ASD and/or ID from our developmental disability clinic, some of whom have concomitant severe behavioral issues characterized by aggression, impulsivity, and self-injurious behavior. One case was co-morbid with cerebral palsy and three cases were co-morbid with seizure disorder or epilepsy. Cases were retrospectively chart ¬reviewed for Clinical Global Impression Severity Scale (CGI-S) before initiating Cariprazine and Clinical Global Impression Improvement Scale (CGI-I) and Clinical Global Impression Efficacy Scale (CGI-E) after initiating Cariprazine. Overall, 87.5% of patients treated with Cariprazine showed improvement in clinical functioning. Cariprazine may function as an alternative compound for improvement in impulsivity, aggression, and self-injurious behavior in the treatment of patients diagnosed with ASD or ID who have failed currently approved compounds. This retrospective chart review indicates the potential need for more controlled studies to evaluate Cariprazine in these diagnostic groups.

Dialectical behavior therapy (DBT) for the treatment of stalking offenders: A randomized controlled study.

The objective was to evaluate the relative efficacy of dialectical behavior therapy modified for stalking offenders (DBT-S) versus a cognitive-behavioral anger management intervention for the treatment of stalking offenders. We expected DBT to result in significantly lower rates of renewed stalking behavior and significantly greater improvements in impulsivity, aggression, anger, and empathy. We randomly assigned individuals charged with stalking-related offences (N = 109) to one of two study interventions: DBT-S and anger management. Recidivism (renewed stalking, violence, and other offences) was monitored for 1 year following the baseline assessment, and participants completed a battery of self-report questionnaires before and after treatment and at a 1-year follow-up assessment. We found relatively low rates of reoffence when compared to past studies of untreated stalking offenders in the U.S., but type of treatment had no impact on the likelihood of reoffence, nor did completion of the treatment program. Likewise, there was no between-groups difference in rates of treatment completion, or on changes in self-report measures. Intensive treatment focused on reducing problematic behaviors in stalking offenders may be effective regardless of treatment modality, but the mechanism by which treatment impacts criminal behavior is not yet clear. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trajectories of Self-control in a Forensic Psychiatric Sample: Stability and Association with Psychopathology, Criminal History, and Recidivism

The current study examined trajectories of two indicators of self-control—impulsivity and coping skills—in 317 forensic psychiatric patients, as well as associations with psychopathology, crime, and recidivism. Violent recidivism was positively associated with coping skills at admission to the clinic and with impulsivity at discharge. Only a small correlation was found between self-control and criminal history, and there was no association with psychopathology. We found multiple trajectories of self-control using Latent Class Growth Models: more than 89% improving over time. In addition, patients with Cluster C personality disorders showed greater improvement in coping skills. Patients showing less improvement in impulsivity had greater rates of crime and recidivism. We conclude that self-control can be influenced by interventions or treatment, and that both starting values and trajectories of self-control provide valuable information. Interestingly, the associations between self-control and psychopathology, crime and recidivism were not as strong as reported in other populations.

Adolescent binge drinking disrupts normal trajectories of brain functional organization and personality maturation.

Adolescent binge drinking has been associated with higher risks for the development of many health problems throughout the lifespan. Adolescents undergo multiple changes that involve the co-development processes of brain, personality and behavior; therefore, certain behavior, such as alcohol consumption, can have disruptive effects on both brain development and personality maturation. However, these effects remain unclear due to the scarcity of longitudinal studies. In the current study, we used multivariate approaches to explore discriminative features in brain functional architecture, personality traits, and genetic variants in 19-year-old individuals (n = 212). Taking advantage of a longitudinal design, we selected features that were more drastically altered in drinkers with an earlier onset of binge drinking. With the selected features, we trained a hierarchical model of support vector machines using a training sample (n = 139). Using an independent sample (n = 73), we tested the model and achieved a classification accuracy of 71.2%. We demonstrated longitudinally that after the onset of binge drinking the developmental trajectory of improvement in impulsivity slowed down. This study identified the disrupting effects of adolescent binge drinking on the developmental trajectories of both brain and personality.

Beneficial Effects of School-based Mindfulness Training On Impulsivity in Healthy Adolescents: Results From a Pilot Randomized Controlled Trial

Since impulsivity is associated with unhealthy behaviors in adolescents, interventions targeting impulsivity could positively affect such behaviors. Whether integrating mindfulness training (MT) into standard school-based health education could improve impulsivity is unknown. To obtain preliminary estimates of effect of MT integrated in standard high school health education on impulsivity. Two high schools in Massachusetts were randomized to school-based health education plus MT (HE-MT) or to health education plus attention control (HE-AC). The outcome was change in impulsivity at end of treatment (EOT) and 6 months after EOT. Students (n=53; 30 HE-MT, 23 HE-AC) were on average 14.5 years old and 40% belonged to ethnic minorities. Compared to the control condition, HE-MT had significant effects on impulsivity at EOT (beta = -9.7; SE = 3.8, p = 0.01), while smaller, non-significant differences were seen 6 months after EOT. This rigorous pilot study suggests that MT could have a beneficial effect on impulsivity in adolescents. Improvements in impulsivity could have important implications should future larger studies show that such improvements result in healthier behaviors.

The efficacy of Motivational Intervention and Cognitive-Behavioral Therapy for Pathological Gambling.

The aim of the current study is to determine the effectiveness of an individual psychological intervention based on the motivational interview and cognitive-behavioral therapy for the treatment of pathological gambling. A sample of 18 participants, diagnosed of pathological gambling and without any other associated comorbidity, were assessed, attended at the publicly-funded Gambling and Behavioral Addictions Unit (Consorci Sanitari de Terrassa). Median age was 46 years (SD = 12). All the patients achieved abstinence and completed follow-up. The Screen for Gambling Problems (NODS), Quality of Life Enjoyment and Satisfaction (Q-LES-Q), Impulsive Behavior Scale (UPPS-P), Sheehan Disability Inventory (SDI), Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) were administered pre- and posttreatment. Results showed that patients significantly reduced the problems related to gambling behavior according to the NODS score (p &lt; .000). Regarding impulsive behavior (UPPS-P), we found significant differences in negative urgency (p &lt; .001), positive urgency (p &lt; .001), (lack of) premeditation (p &lt; .029) and (lack of) perseverance (p &lt; .048). Some relevant aspects of quality of life as assessed by the Q-LES-Q had improved. In conclusion, the study shows that psychological intervention based on the motivational interview and cognitive-behavioral therapy not only significantly reduces gambling-related behavior problems but also leads to improvements in impulsivity and quality of life.&nbsp.

Impulsivity and attentional bias as predictors of modafinil treatment outcome for retention and drug use in crack-cocaine dependent patients: Results of a randomised controlled trial.

High impulsivity and attentional bias are common in cocaine-dependent patients and predict poor treatment outcomes. The pharmacological agent modafinil is studied for its cognitive-enhancing capacities and may therefore improve clinical outcomes in crack-cocaine dependent patients. In this study, we investigated first whether pre-treatment impulsivity and attentional bias predict treatment outcome; next whether the drug modafinil given as an add-on treatment to cognitive behavioural therapy (CBT) improves impulsivity and attentional bias; and last, whether changes in impulsivity and attentional bias are related to improvements in treatment outcome. Crack-cocaine dependent outpatients (n = 65) were randomised to 12 weeks CBT plus modafinil (400 mg/day) or only CBT. Self-reported impulsivity was assessed at baseline using the Barratt Impulsiveness Scale. At baseline and Week 12, we assessed inhibitory control as a behavioural measure of impulsivity, in terms of cognitive interference (Stroop task) and response inhibition ('stop-signal task'), and attentional bias with the addiction Stroop task. Clinical outcomes were CBT-retention and crack-cocaine use. At baseline, self-reported impulsivity predicted better CBT-retention; low self-reported and behavioural impulsivity and attentional bias predicted less crack-cocaine use. Changes in cognitive performance were not modafinil-related, but most likely due to low adherence. Improvements in impulsivity or attentional bias were not associated with CBT-retention nor changes in crack-cocaine use. Baseline impulsivity and attentional bias predicted clinical outcomes in crack-cocaine dependent patients. There were no firm indications that modafinil reduced impulsivity nor attentional bias in this population. Future studies involving cognitive-enhancing medications should include strategies to optimise adherence, to be better able to evaluate their potential.

Psychological intervention with working memory training increases basal ganglia volume: A VBM study of inpatient treatment for methamphetamine use.

BackgroundProtracted methamphetamine (MA) use is associated with decreased control over drug craving and altered brain volume in the frontostriatal network. However, the nature of volumetric changes following a course of psychological intervention for MA use is not yet known.Methods66 males (41 MA patients, 25 healthy controls, HC) between the ages of 18–50 were recruited, the MA patients from new admissions to an in-patient drug rehabilitation centre and the HC via public advertisement, both in Cape Town, South Africa. 17 MA patients received 4 weeks of treatment as usual (TAU), and 24 MA patients completed TAU plus daily 30-minute cognitive training (CT) using an N-back working memory task. Magnetic resonance imaging (MRI) at baseline and 4-week follow-up was acquired and voxel-based morphometry (VBM) was used for analysis.ResultsTAU was associated with larger bilateral striatum (caudate/putamen) volume, whereas CT was associated with more widespread increases of the bilateral basal ganglia (incorporating the amygdala and hippocampus) and reduced bilateral cerebellum volume coinciding with improvements in impulsivity scores.ConclusionsWhile psychological intervention is associated with larger volume in mesolimbic reward regions, the utilisation of additional working memory training as an adjunct to treatment may further normalize frontostriatal structure and function.

Safety of High Frequency rTMS and dTMS with Clozapine: Case Series

s / Brain Stimulation 8 (2015) e1ee6 e6 We report on the treatment of two unmedicated patients with severe ADHD, combined type, using the dTMS H7 coil over the right prefrontal cortex. Methods: dTMS was administered 6 cm anterior to the motor strip on the right prefrontal cortex using the H7 coil at 120% of the motor threshold of the left hand at 20 Hz, 2 second stimulation, 20 second intertrain interval for 3000 total pulses. Patients completed an objective computerized measure (IVA+) before and after treatment. The IVA+ has two primary diagnostic scales, the response control quotient and the attention quotient. Response control is a measure of impulsivity, consistency, and reaction time and the attention quotient measures inattention and mental processing speed. Results: Both patients demonstrated significant improvement in response control scores indicating substantial improvement in impulsivity, consistency and reaction time. The male patient received 22 treatments and his response control scores moved from the moderately impaired range to above average range with twoweek durability. The female patient received 10 treatments and her response control scores improved from the moderately impaired range to the average range. Both patients had some improvement in attention, but their scores continued to be in the impaired range. Conclusion: dTMS with the H7 coil over the right prefrontal cortex is efficacious in treating response control symptoms of ADHD including impulsivity, consistency, and reaction time. Dr. Tendler has a financial interest in Brainsway.

The development and preliminary evaluation of a thinking skills programme for adults with learning disabilities at risk of offending

Purpose– The purpose of this paper is to outline and evaluate the development of a thinking skills programme for adults with learning disabilities at risk of offending.Design/methodology/approach– The programme was evaluated over three years using self-report clinical measures related to treatment targets and feedback from participants.Findings– Results showed a statistically significant improvement in general empathy (t=1.800, df=15,p=&lt;0.05) and perspective taking (t=1.898, df=15,p=&lt;0.05). Improvement in impulsivity and locus of control was not significant. Feedback from service users was positive.Practical implications– Findings suggest that thinking skills programmes can be of benefit to adults with learning disabilities at risk of offending.Originality/value– There is a need to provide opportunities for adults with learning disabilities to address generic deficits and factors supporting offending behaviour and to increase readiness for offence-specific treatment.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

Efficacy and Tolerability of Pharmacotherapies for Borderline Personality Disorder

Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, affects and self-image, as well as marked impulsivity. Although psychotherapy is needed to attain lasting improvements in a patient's personality and overall functioning, practice guidelines state that pharmacotherapy is indicated to manage state symptoms and trait vulnerabilities. Three psychopathological dimensions are the main targets for pharmacotherapy of borderline personality disorder: affective dysregulation, impulsive-behavioural dyscontrol and cognitive-perceptual symptoms. Guidelines recommend the use of antidepressant agents and mood stabilizers for affective dysregulation and impulsive-behavioural dyscontrol, and antipsychotics for cognitive-perceptual symptoms. This review aims to report and discuss data from clinical trials, reviews and meta-analyses concerning drug efficacy and tolerability in the treatment of borderline personality disorder. Investigations that considered antidepressant agents mainly focused on SSRIs, which are recommended as first-line treatments for affective instability and impulse dyscontrol. Both open-label and randomized controlled studies have been performed, predominantly concerning the efficacy of fluoxetine and fluvoxamine. Other classes of antidepressants, such as TCAs and MAOIs, were investigated as alternative treatments for borderline personality disorder, but the risk of adverse effects and toxicity is a limitation to their use in clinical practice. Increasing amounts of data have recently been collected on the use of mood stabilizers to control mood instability and impulsivity in patients with borderline personality disorder. More substantial data were derived from controlled trials of valproate semisodium, although other drugs such as lithium, carbamazepine, oxcarbazepine and lamotrigine were tested with promising results. Several first-generation antipsychotics were studied in open-label and controlled trials, with good effects on behavioural dyscontrol and psychotic-like symptoms. Selection biases and heterogeneity of drugs and methods somewhat limited the value of these results. More recent investigations have examined atypical antipsychotics, with most of these studies being open-label trials with small sample sizes; however, a few controlled studies have been performed using olanzapine, showing improvements in impulsivity, anger and hostility. In conclusion, a large number of different drugs have been evaluated in the treatment of patients with borderline personality disorder. Initial findings are encouraging for many of these drugs. However, data need to be replicated in further controlled studies with head-to-head comparisons and long-term follow-ups. Many questions remain to be answered.

A follow-up pilot study of objective measures in children with attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) is a common childhood problem requiring stimulant medications in a significant proportion of cases. The aim of this pilot study was to assess the effects of prolonged stimulant medication therapy on a continuous performance test, the Test of Variables of Attention (TOVA), which measures objectively features of ADHD. Eighteen children aged 8 to 16 years who were diagnosed with ADHD, based on the Diagnostic and Statistical Manual of Mental Disorders 4th edn criteria, were included in the study. Assessment on a continuous performance test (TOVA) was performed initially and the children were administered stimulant medications for at least 12 months. The medications were stopped for 1 week, followed by a repeat TOVA assessment which was compared to the initial TOVA assessment. Follow up TOVA scores showed a significant improvement in mean commission errors (impulsivity) after the stimulant medication therapy. No significant improvement was found in omission errors (inattention), response time and variability. There was a significant positive correlation between commission and omission scores (P value 0.0001). The results of this pilot study indicate that there is objective improvement in impulsivity in children with ADHD after a prolonged period of stimulant medication therapy. The study suggests that it would be useful to perform formal studies to investigate this further and also to assess the role of continuous performance test (TOVA) as a method for monitoring the need for ongoing therapy.