Addiction impulse control

SAMHSA’s National Helpline | SAMHSA

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  • SAMHSA’s National Helpline is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.

    Also visit the online treatment locator.

SAMHSA’s National Helpline, 1-800-662-HELP (4357) (also known as the Treatment Referral Routing Service), or TTY: 1-800-487-4889 is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

Also visit the online treatment locator, or send your zip code via text message: 435748 (HELP4U) to find help near you. Read more about the HELP4U text messaging service.

The service is open 24/7, 365 days a year.

English and Spanish are available if you select the option to speak with a national representative. Currently, the 435748 (HELP4U) text messaging service is only available in English.

In 2020, the Helpline received 833,598 calls. This is a 27 percent increase from 2019, when the Helpline received a total of 656,953 calls for the year.

The referral service is free of charge. If you have no insurance or are underinsured, we will refer you to your state office, which is responsible for state-funded treatment programs. In addition, we can often refer you to facilities that charge on a sliding fee scale or accept Medicare or Medicaid. If you have health insurance, you are encouraged to contact your insurer for a list of participating health care providers and facilities.

The service is confidential. We will not ask you for any personal information. We may ask for your zip code or other pertinent geographic information in order to track calls being routed to other offices or to accurately identify the local resources appropriate to your needs.

No, we do not provide counseling. Trained information specialists answer calls, transfer callers to state services or other appropriate intake centers in their states, and connect them with local assistance and support.

  • Suggested Resources

    What Is Substance Abuse Treatment? A Booklet for Families
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    It's Not Your Fault (NACoA) (PDF | 12 KB)
    Assures teens with parents who abuse alcohol or drugs that, "It's not your fault!" and that they are not alone. Encourages teens to seek emotional support from other adults, school counselors, and youth support groups such as Alateen, and provides a resource list.

    After an Attempt: A Guide for Taking Care of Your Family Member After Treatment in the Emergency Department
    Aids family members in coping with the aftermath of a relative's suicide attempt. Describes the emergency department treatment process, lists questions to ask about follow-up treatment, and describes how to reduce risk and ensure safety at home.

    Family Therapy Can Help: For People in Recovery From Mental Illness or Addiction
    Explores the role of family therapy in recovery from mental illness or substance abuse. Explains how family therapy sessions are run and who conducts them, describes a typical session, and provides information on its effectiveness in recovery.

    For additional resources, please visit the SAMHSA Store.

Last Updated: 08/30/2022

Alcohol, Tobacco, and Other Drugs

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Misusing alcohol, tobacco, and other drugs can have both immediate and long-term health effects.

The misuse and abuse of alcohol, tobacco, illicit drugs, and prescription medications affect the health and well-being of millions of Americans. NSDUH estimates allow researchers, clinicians, policymakers, and the general public to better understand and improve the nation’s behavioral health. These reports and detailed tables present estimates from the 2021 National Survey on Drug Use and Health (NSDUH).



  • Among the 133.1 million current alcohol users aged 12 or older in 2021, 60.0 million people (or 45.1%) were past month binge drinkers. The percentage of people who were past month binge drinkers was highest among young adults aged 18 to 25 (29.2% or 9.8 million people), followed by adults aged 26 or older (22.4% or 49.3 million people), then by adolescents aged 12 to 17 (3.8% or 995,000 people). (2021 NSDUH)
  • Among people aged 12 to 20 in 2021, 15.1% (or 5.9 million people) were past month alcohol users. Estimates of binge alcohol use and heavy alcohol use in the past month among underage people were 8.3% (or 3.2 million people) and 1.6% (or 613,000 people), respectively. (2021 NSDUH)
  • In 2020, 50.0% of people aged 12 or older (or 138.5 million people) used alcohol in the past month (i.e., current alcohol users) (2020 NSDUH)
  • Among the 138.5 million people who were current alcohol users, 61.6 million people (or 44.4%) were classified as binge drinkers and 17.7 million people (28.8% of current binge drinkers and 12.8% of current alcohol users) were classified as heavy drinkers (2020 NSDUH)
  • The percentage of people who were past month binge alcohol users was highest among young adults aged 18 to 25 (31. 4%) compared with 22.9% of adults aged 26 or older and 4.1% of adolescents aged 12 to 17 (2020 NSDUH)
  • Excessive alcohol use can increase a person’s risk of stroke, liver cirrhosis, alcoholic hepatitis, cancer, and other serious health conditions
  • Excessive alcohol use can also lead to risk-taking behavior, including driving while impaired. The Centers for Disease Control and Prevention reports that 29 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver daily


  • STOP Underage Drinking interagency portal - Interagency Coordinating Committee on the Prevention of Underage Drinking
  • Interagency Coordinating Committee on the Prevention of Underage Drinking
  • Talk. They Hear You.
  • Underage Drinking: Myths vs. Facts
  • Talking with your College-Bound Young Adult About Alcohol

Relevant links:

  • National Association of State Alcohol and Drug Abuse Directors
  • Department of Transportation Office of Drug & Alcohol Policy & Compliance
  • Alcohol Policy Information Systems Database (APIS)
  • National Institute on Alcohol Abuse and Alcoholism



  • In 2020, 20. 7% of people aged 12 or older (or 57.3 million people) used nicotine products (i.e., used tobacco products or vaped nicotine) in the past month (2020 NSDUH)
  • Among past month users of nicotine products, nearly two thirds of adolescents aged 12 to 17 (63.1%) vaped nicotine but did not use tobacco products. In contrast, 88.9% of past month nicotine product users aged 26 or older used only tobacco products (2020 NSDUH)
  • Tobacco use is the leading cause of preventable death, often leading to lung cancer, respiratory disorders, heart disease, stroke, and other serious illnesses. The CDC reports that cigarette smoking causes more than 480,000 deaths each year in the United States
  • The CDC’s Office on Smoking and Health reports that more than 16 million Americans are living with a disease caused by smoking cigarettes

Electronic cigarette (e-cigarette) use data:

  • In 2021, 13.2 million people aged 12 or older (or 4.7%) used an e-cigarette or other vaping device to vape nicotine in the past month. The percentage of people who vaped nicotine was highest among young adults aged 18 to 25 (14.1% or 4.7 million people), followed by adolescents aged 12 to 17 (5.2% or 1.4 million people), then by adults aged 26 or older (3.2% or 7.1 million people).
  • Among people aged 12 to 20 in 2021, 11.0% (or 4.3 million people) used tobacco products or used an e-cigarette or other vaping device to vape nicotine in the past month. Among people in this age group, 8.1% (or 3.1 million people) vaped nicotine, 5.4% (or 2.1 million people) used tobacco products, and 3.4% (or 1.3 million people) smoked cigarettes in the past month. (2021 NSDUH)
  • Data from the Centers for Disease Control and Prevention’s 2020 National Youth Tobacco Survey. Among both middle and high school students, current use of e-cigarettes declined from 2019 to 2020, reversing previous trends and returning current e-cigarette use to levels similar to those observed in 2018
  • E-cigarettes are not safe for youth, young adults, or pregnant women, especially because they contain nicotine and other chemicals


  • Tips for Teens: Tobacco
  • Tips for Teens: E-cigarettes
  • Implementing Tobacco Cessation Programs in Substance Use Disorder Treatment Settings
  • Synar Amendment Program


  • Truth Initiative
  • FDA Center for Tobacco Products
  • CDC Office on Smoking and Health
  • National Institute on Drug Abuse: Tobacco, Nicotine, and E-Cigarettes
  • National Institute on Drug Abuse: E-Cigarettes



  • Among people aged 12 or older in 2021, 3. 3% (or 9.2 million people) misused opioids (heroin or prescription pain relievers) in the past year. Among the 9.2 million people who misused opioids in the past year, 8.7 million people misused prescription pain relievers compared with 1.1 million people who used heroin. These numbers include 574,000 people who both misused prescription pain relievers and used heroin in the past year. (2021 NSDUH)
  • Among people aged 12 or older in 2020, 3.4% (or 9.5 million people) misused opioids in the past year. Among the 9.5 million people who misused opioids in the past year, 9.3 million people misused prescription pain relievers and 902,000 people used heroin (2020 NSDUH)
  • According to the Centers for Disease Control and Prevention’s Understanding the Epidemic, an average of 128 Americans die every day from an opioid overdose


  • Medication-Assisted Treatment
  • Opioid Overdose Prevention Toolkit
  • TIP 63: Medications for Opioid Use Disorder
  • Use of Medication-Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings
  • Opioid Use Disorder and Pregnancy
  • Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants
  • The Facts about Buprenorphine for Treatment of Opioid Addiction
  • Pregnancy Planning for Women Being Treated for Opioid Use Disorder
  • Tips for Teens: Opioids
  • Rural Opioid Technical Assistance Grants
  • Tribal Opioid Response Grants
  • Provider’s Clinical Support System - Medication Assisted Treatment Grant Program


  • National Institute on Drug Abuse: Opioids
  • National Institute on Drug Abuse: Heroin
  • HHS Prevent Opioid Abuse
  • Community Anti-Drug Coalitions of America
  • Addiction Technology Transfer Center (ATTC) Network
  • Prevention Technology Transfer Center (PTTC) Network



  • In 2021, marijuana was the most commonly used illicit drug, with 18. 7% of people aged 12 or older (or 52.5 million people) using it in the past year. The percentage was highest among young adults aged 18 to 25 (35.4% or 11.8 million people), followed by adults aged 26 or older (17.2% or 37.9 million people), then by adolescents aged 12 to 17 (10.5% or 2.7 million people).
  • The percentage of people who used marijuana in the past year was highest among young adults aged 18 to 25 (34.5%) compared with 16.3% of adults aged 26 or older and 10.1% of adolescents aged 12 to 17 (2020 NSDUH)
  • Marijuana can impair judgment and distort perception in the short term and can lead to memory impairment in the long term
  • Marijuana can have significant health effects on youth and pregnant women.


  • Know the Risks of Marijuana
  • Marijuana and Pregnancy
  • Tips for Teens: Marijuana

Relevant links:

  • National Institute on Drug Abuse: Marijuana
  • Addiction Technology Transfer Centers on Marijuana
  • CDC Marijuana and Public Health

Emerging Trends in Substance Misuse:

  • Methamphetamine—In 2019, NSDUH data show that approximately 2 million people used methamphetamine in the past year. Approximately 1 million people had a methamphetamine use disorder, which was higher than the percentage in 2016, but similar to the percentages in 2015 and 2018. The National Institute on Drug Abuse Data shows that overdose death rates involving methamphetamine have quadrupled from 2011 to 2017. Frequent meth use is associated with mood disturbances, hallucinations, and paranoia.
  • Cocaine—In 2019, NSDUH data show an estimated 5.5 million people aged 12 or older were past users of cocaine, including about 778,000 users of crack. The CDC reports that overdose deaths involving have increased by one-third from 2016 to 2017. In the short term, cocaine use can result in increased blood pressure, restlessness, and irritability. In the long term, severe medical complications of cocaine use include heart attacks, seizures, and abdominal pain.
  • Kratom—In 2019, NSDUH data show that about 825,000 people had used Kratom in the past month. Kratom is a tropical plant that grows naturally in Southeast Asia with leaves that can have psychotropic effects by affecting opioid brain receptors. It is currently unregulated and has risk of abuse and dependence. The National Institute on Drug Abuse reports that health effects of Kratom can include nausea, itching, seizures, and hallucinations.


  • Tips for Teens: Methamphetamine
  • Tips for Teens: Cocaine
  • National Institute on Drug Abuse

More SAMHSA publications on substance use prevention and treatment.

Last Updated: 01/05/2023

Classification of management decisions

B depending on the basis underlying the decision, distinguish:

  1. intuitive solutions;

  2. solutions, based on judgments;

  3. rational decisions.


A purely intuitive decision is a choice made only on the basis of feeling that he is correct.

The decision maker does not while consciously weighing the pros and cons for each alternative and not even needs to understand the situation. It's just that a person makes a choice. That we we call insight or "sixth sense", and there are intuitive solutions.

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Specialist on management, Peter Schoderbeck points out that, "while increasing amount of information about a problem can be of great help in making decisions to middle managers, representatives of the highest echelon of power still have to rely on intuitive judgments. Moreover, computer allow management to pay more attention to data, but do not cancel the hallowed time of managerial intuitive know-how. nine0025

Decisions based on judgment. Such decisions sometimes seem intuitive, because their logic does not obvious. Decision, based on judgment is choice based on knowledge or experience. Man uses knowledge about what has happened in similar situations before in order to predict the outcome alternative choices in an existing situation. Based on sound meaning, he chooses an alternative that has brought success in the past. However common sense is rare in humans, so this way of making decisions is also not very reliable, although it captivates with its speed and cheapness. nine0008

When, for example, you make a choice what to study - a management training program or an accounting training program, you are likely to take Judgment-based decision based on the experience of introductory courses in each subject.

Judgment as the basis of managerial decision is useful because many situations in organizations tend to be conquered frequently. In this case, the previously accepted the solution can work again just as well as before, which is the main the dignity of programmed solutions. nine0008

Another weakness is that the judgment cannot be related to the situation that did not take place before, and therefore there is simply no experience of solving it. Besides, in this approach, the leader tends to act primarily in those directions that he is familiar with, as a result of which he risks missing a good result in another area, consciously or unconsciously refusing from invading it. nine0008

Rational decisions are based on the methods of economic analysis, justification and optimization.

B depending on the personal characteristics of the manager, decision maker, it is customary to distinguish:

  1. balanced solutions;

  2. impulsive decisions;

  3. nine0007 inert solutions;

  4. risky decisions;

  5. careful solutions.

Balanced decisions are made by managers who are attentive and critical of their actions, put forward hypotheses and their testing. Usually, before starting making a decision, they have a formulated initial idea. nine0008

Impulsive decisions, whose authors easily generate a wide variety of ideas in unlimited number, but not able to properly check, clarify, estimate. Decisions therefore turn out to be insufficiently substantiated and reliable, are accepted "with a swoop", "jerks".

Inert solutions are the result of a careful search. In them, on the contrary, control and refinement actions prevail over the generation of ideas, therefore, in in such solutions it is difficult to detect originality, brilliance, innovation. nine0008

Risky decisions differ from impulsive ones in that their authors do not need careful substantiation of their hypotheses and, if they are confident in themselves, they may not be afraid any danger.

Cautious decisions are characterized by careful evaluation by the manager of all options, supercritical approach. They are even less than inert, are new and original.

Types decisions that depend on the personal characteristics of the manager are characteristic, in mainly in the process of operational personnel management. nine0025

For strategic and tactical management in any subsystem of the system management makes rational decisions based on methods of economic analysis, justification and optimization.

B depending on the degree of preliminary formalization distinguish:
  1. programmed solutions;

  2. nine0007 unprogrammed solutions.

A programmed decision is the result of implementing a certain sequence of steps or action. As a rule, the number of possible alternatives is limited and the choice must be done within the directions given by the organization.

For example, the head of the purchasing department of a production association with scheduling the procurement of raw materials and materials can be based on the formula, requiring a certain ratio between the planned volume of production and noms of raw materials and materials for the production of a unit of finished products. nine0025

If in the budget stipulates that 2 kg of raw materials are spent on the manufacture of a unit of production and materials, then the decision is made automatically - the planned volume production of 1000 pieces, therefore, it is necessary to purchase 2,000 kg of raw materials.

Similarly, if the head of the finance department was asked to invest excess cash into certificates of deposit, municipal bonds, or ordinary shares, depending on what exactly provides at a given time the highest return on investment, the choice is determined by the results simple calculation for each option and the establishment of the most profitable. nine0008

Programming can be considered an important aid in making effective management decisions. Determine what the solution should be leadership reduces the chance of error. It also saves time because subordinates do not have to develop a new correct procedure every time when the appropriate situation arises.

Not surprisingly, management often programs solutions for situations repeated with a certain regularity. nine0025

It is very important for the manager to have confidence that the acceptance procedure decisions are, in fact, correct and desirable. Obviously if the programmed procedure becomes wrong and undesirable, decisions, accepted with its help will be ineffective, and the leadership will lose respect their employees and those people outside the organization on which decisions are made affect. Moreover, it is highly desirable to provide justifications methodology for making programmed decisions for those who use this methodology enjoys rather than simply offering it for consumption. Failure to respond to questions beginning with "why" in connection with the decision-making procedure, often generates tension and offends the people who must apply this procedure. Efficient Information Sharing Improves Adoption Efficiency solutions. nine0008

Non-programmed solutions. Solutions of this type are required in situations that, in a certain least new, not internally structured, or associated with unknown factors. Since it is not possible in advance to draw up a specific sequence of necessary steps, the leader must develop a decision-making procedure. To the number non-programmed solutions can be classified as follows:

  1. nine0007 what should be the goals of the organization;

  2. as improve products;

  3. as improve the structure of the management unit;

  4. as increase the motivation of subordinates.


B each of these situations (as most often happens with unprogrammed solutions) the true cause of the problem can be any of the factors. At the same The time manager has many options to choose from.

On In practice, few managerial decisions are programmed or unprogrammed in its purest form.

Most likely, they are the extreme mappings of a certain spectrum in the case and with everyday, and with fundamental decisions. Almost all solutions are somewhere in between the extremes.

Few programmed decisions are so structured that personal the initiative of the person accepting them is completely excluded.

I even in a situation of the most difficult choice, the methodology for accepting programmed solutions may be helpful. nine0008

Indicators of the quality and effectiveness of management decisions

The purpose of management decision is to ensure movement towards the tasks set for the organization. Therefore, the most effective organizational solution is the choice that will, in fact, be implemented and will make the greatest contribution to the achievement of the final goals.

The quality of a management decision is a set of decision parameters that satisfy a specific consumer (specific consumers) and providing reality its implementation. nine0008

Quality parameters management decision:
  • indicator entropy, i.e. quantitative uncertainty of the problem. If the problem formulated only qualitatively, without quantitative indicators, then the indicator entropy approaches zero. If all indicators of the problem are expressed quantitatively, the entropy index approaches unity;

  • degree of adequacy (or degree of forecast accuracy) of the theoretical model the evidence on which it was based.

Place of impulsivity in the narcology clinic

Year of publication and journal number:

2019, No. 2

Comment: author. nine0008


Description of the phenomenon of impulsivity is presented. The features of motor and cognitive impulsivity are considered. The place of impulsivity in the clinic of narcology is shown. Typical difficulties that patients face when trying to regulate their own problematic behavior are described.

Key words: impulsivity, chemical addiction, gambling addiction, psychopathology.

Impulsivity is a multi-faceted phenomenon, which is based on a decrease in control and an intense urge to perform actions aimed at obtaining a reward. Impulsivity is largely genetically determined and is a relatively stable dynamic characteristic of an individual (Niv, Tuvblad, Raine, Wang, Baker, 2012, Verdejo-García, 2007). nine0008

Impulsive behavior refers to forms of behavior (not necessarily psychopathological) that have many different aspects. Impulsive actions are considered to be those actions that were poorly thought out in advance and were committed prematurely and hastily. These actions were swift, fast and/or unnecessarily risky. Impulsive behavior as such is labile, spontaneous, disorganized and carried out without attention to detail. Impulsive actions often jeopardize safety, do not correspond to the situation, which can lead to undesirable consequences for the individual himself and for the people around him. Impulsivity is seen as the opposite of reflexivity, self-control and patience. Impulsivity implies disorder, urgency in following one's impulses, momentary whims and desires, the desire for relaxation and for getting thrills. Impulsivity can also be defined as the inability to postpone desire "for later", the weakness of the behavioral component of self-control and the inability to change the direction of previously initiated activities. Impulsivity also implies the intention to choose for immediate gratification even at the expense of long-term gains and delayed prospects (Fenichel, 2004, Amlung, Vedelago, Acker, Balodis, MacKillop, 2017, Antonelli, Ray, Strafella, 2011, Dalley, Everitt, Robbins, 2011, Niv, Tuvblad, Raine, Wang, Baker, 2012, Verdejo-García, 2007). nine0008

Impulsivity may be a key risk factor for some forms of antisocial behavior in adolescents and adults. Impulsivity has traditionally been associated with various aspects of addictive behavior. Psychoanalysts in the first half of the 20th century associated drug addiction with impulsivity. Moreover, some psychoanalytically oriented authors believed that all addiction diseases as such are varieties (particular forms) of impulsive neurosis. Otto Fenichel (1945) believed that the most diverse addictions are variants of the same disease. “The same factors underlie the violation of drives in drug addiction as in other impulsive neuroses. Drug addicts are the most prominent representatives of the impulsive type . .. these are those who tend to respond specifically to the effects of alcohol, morphine and other drugs, namely, trying to use their effects in satisfying the archaic oral drive, which is at the same time sexual desire, the need for security and the need to maintain self-esteem . Thus, the origin and nature of drug addiction is determined not by the chemical effect of the drug, but by the psychological structure of the patient” (Fenichel, 2004). A number of modern researchers believe that impulsivity dominates at the beginning of an addictive disorder, but as the drug addiction develops and progresses, the role of compulsivity increases (Koob, Le Moal, 2001). This is due to the fact that there is a change in motivation: a decrease in the severity of hedonic responses, a shift from positive reinforcement to a gradual increase in negative reinforcement and motivation to avoid negative withdrawal states. nine0008

Despite the presence of clear positive correlations, establishing an unambiguous causal relationship between impulsivity and addictive behavior presents some difficulties. On the one hand, impulsivity often precedes the development of problematic alcohol use and drug abuse. The pronounced impulsive traits observed in children and adolescents are associated with earlier and more intense drinking, as well as earlier age of onset of experimentation with illicit psychoactive substances (SAS) (Niv, Tuvblad, Raine, Wang, Baker, 2012, Verdejo-García , 2007). But on the other hand, the use of PAS in itself also leads to the appearance or increase in the severity of impulsive reactions. The appointment of psychostimulants helps to reduce impulsivity both in experimental animals and in patients suffering from ADHD. These data may indicate that this group of drugs regulates and directly affects the neuronal substrate that is responsible for impulsivity. The fact that high baseline measures of impulsivity predict a subsequent increased risk of starting stimulant use is also consistent with the hypothesis that addictive behavior is an attempt at self-medication, which, however, may exacerbate the initial problem in the long term (Dalley, Everitt, Robbins, 2011). nine0008

Impulsivity is a complex, multi-faceted and non-unitary construct, it can be an inborn personality trait (propensity), a symptom of a disorder (e.g. ADHD), or it can be an acquired characteristic that has appeared, for example, as a result of certain negative influences, interventions or injuries . Impulsivity can be activated due to repetitive behaviors (eg, gambling) and due to the chronic pharmacological effects of PAS on the brain of a person vulnerable to this effect. It is traditional to distinguish between motor impulsivity and cognitive impulsivity (Antoine, Damasio, Damasio, 2000). nine0008

Figure 1. Motor and cognitive impulsivity

Motor impulsivity can be described in terms of disinhibition of reactions and speed of response to the presented key stimulus. That is, the individual is in a state of super readiness for the implementation of one or another, as a rule, habitual and previously already carried out by him activity. This overreadiness is manifested in reaction speed and reduced inhibition response (Antonelli, Ray, Strafella, 2011). Thus, for example, a pathological gambler is “ready” to play, and a person addicted to alcohol is “ready” to drink. Alcohol dependence refers to the loss of the ability to abstain from drinking alcohol despite the conscious intention to remain sober. An individual may not want to drink on a conscious level, deny the attraction to alcohol, but at the same time he can immediately drink when someone offers him alcohol. He can't say no to alcohol when he sees liquor, even if he made a conscious decision yesterday to stop drinking completely. In this context, impulsive behavior is initiated through hypersensitivity to the alcohol-associated trigger. Triggers in the narcology clinic are any emotional states and/or event factors that contribute to the activation of craving for PAS in patients (Avtonomov, Degtyareva, 2016). nine0008

Figure 2. Motor impulsivity. “Race Model”

Motor impulsivity can also be assessed by the subject’s ability to take under volitional control an action already initiated (the phenomenon of “cancellation of an action already performed” or the possibility of stopping), reacting to a “stop stimulus” (Antonelli, Ray, Strafella, 2011). Motor impulsivity is manifested in the fact that the subject at some point in time loses control over certain aspects of his behavior and continues to perform excessive actions, which he often regrets later. However, at the time of the realization of this type of behavior, the individual usually does not find his actions excessive, experiencing desire as a syntonic ego and carrying out activity with the expectation of pleasure. Awareness of "redundancy" conceived is only possible retrospectively, "backdating". nine0008

Motor impulsivity is expressed in the fact that, having started participating in a certain type of activity, the individual (to the limit) loses control over his actions and cannot stop until the further implementation of these actions becomes impossible due to external reasons or circumstances independent of him . So, for example, a pathological gambler, having started to play, experiences excitement, plays more intensively, as quickly as possible in terms of the pace of the game. The player raises the stakes by putting more money on the line than he can afford. Impulsivity is manifested in the fact that he not only plays more intensively, but also that the player encounters difficulties in volitional regulation of his behavior. The pathological player is often no longer able to stop and exit the game, at the moment when he wins and is "in the black". That is, the activation of the “stop stimulus” in the form of an objective assessment of the time spent on the game, the amount of money won (the expected, planned result of the game) does not lead to the initialization of the braking program, stopping and stopping the gaming activity. Internal signals act as a “stop stimulus”: somatic (fatigue from the game, signals from internal organs, including a full bladder) emotional and cognitive (the idea of ​​​​when to leave the game, based on one’s own or someone else’s experience, the initial strategy games, risk assessment, etc.). External signals to “stop” can be represented by phone calls, the words of observers, other players, and even warnings from casino employees. However, despite receiving a “stop stimulus,” the pathological player does not administer the cancellation, slowdown, or completion of an action already in progress. For this reason, the player first loses what he won earlier, and then the money with which he started the game. Loss of money, lack of funds to continue financing gambling is the final for the player of the current round of gambling. That is, the volitional regulation of voluntary behavior can be severely disturbed, even if a person receives convincing warning signals about the undesirability of continuing these actions. Such signals can be a variety of external and internal stimuli, announcing the harmfulness of further activity. Feelings of guilt may subsequently help the individual to counteract his harmful impulses, but only as long as the memory of the unpleasant event is relevant to him. Thus, motor impulsivity is not associated with choice, evaluation or decision, but with the speed of reaction and the ability to inhibit activity (“race model”). nine0008

Impulsivity can also be associated with a change (impairment) of cognitive functions: the tendency to act prematurely and without foreseeing possible negative consequences is typical for various forms of addictive behavior. Cognitive impulsivity is a more complex and multilevel process, associated with a willingness to make quick, ill-considered choices, and suggests a low ability to tolerate delay in fulfilling a desire. Cognitive impulsivity implies the presence of difficulties associated with controlling one's behavior in a situation of choosing from two or more alternatives. It can be illustrated by a simple, though not entirely accurate, example of the temporary postponement of desire—the famous “marshmallow experiment.” A child who sees candies (marshmallows) is instructed to wait 15 minutes before eating them. As a reward for his patience, he is offered a doubling of the reward. The child, having correctly understood the instructions, however, often cannot put off his desire and grabs candy (Bechara, 2000). He cannot resist the temptation and suppress his desire for a sweet for a long time. (Antoine, Damasio, Damasio, 2000). He cannot resist the temptation and suppress his desire for a sweet for a long time. Thus, he makes a choice in favor of immediate reward, even if this act may cost trouble, punishment, failure, or great loss in the future. nine0008

Figure 3. Cognitive impulsivity. “Choice model”

Impulsive choice implies a preference for immediate, but less reward, at the expense of more, but delayed pleasure (Dalley, Everitt, Robbins, 2011). That is, actual pleasure is “bought” at the expense of serious long-term negative consequences. It's like getting a loan. Another aspect of impulsive choice is to reduce the chances and opportunities for future enjoyment. Impulsive choice is likely to regulate a number of factors, including a preliminary assessment of the cost of a possible reward, an assessment of costs, time and effort. Data from the most recent meta-analysis in 2017 confirmed that this trend is widespread and typical for patients with various addictions (alcohol, tobacco, marijuana, psychostimulants, opioids), including non-chemical dependence (gambling addiction) (Amlung, Vedelago, Acker, Balodis, MacKillop, 2017) Dependent individuals seem to follow the logic: “Better a tit in the hands than a pie in the sky”, they are “myopic” in their view of the future. Patients tend to discount future rewards to a much greater extent than conventionally healthy people do, and, accordingly, overestimate the current benefit. In the clinic of narcology, there are well-known examples of the fact that many drug-addicted patients cannot refuse and choose those pleasures that are at arm's length (easy access), but at the same time they are not motivated to make efforts to achieve some distant goal. Dependent patients have difficulty imagining the future and/or the value of long-term outcomes that seem illusory and unrealistic to them, preferring more immediate, albeit less, but "guaranteed" pleasure in the present. Rather, they minimize and deny their problems, explaining their existence by chance, coincidence, external causes and “hard times”. nine0008

"Risk-taking" is another aspect of cognitive impulsivity. Risk can be viewed as the potential for acquisition - loss of value. Risk implies the possibility of both winning and losing, danger, lack of confidence in achieving the goal, unpredictability of the result of the activity. Risky is usually called actions that are performed in a situation of uncertainty. Cognitive impulsivity has to do with risk assessment and perception. Cognitive risk assessment can be expressed in a deliberate choice and even a conscious preference for a more risky strategy over a less risky one (risk actions that are obvious to the subject). In this case, the riskier method appears to individuals not only as faster, but also as more rewarding (high risk appetite). Another aspect of cognitive risk assessment is the individual's inability to assess risk at all (the degree of risk). A risky situation is presented in his eyes as not risky (implicit risk for the subject) (Antonelli, Ray, Strafella, 2011). This inability to assess risk within the framework of cognitive impulsivity is expressed in its denial and in the inability to imagine, predict the possible occurrence of unforeseen events and circumstances. That is, in fact, a person takes a big risk, not realizing that he is taking a risk. nine0008

Figure 4. Cognitive impulsivity. Impairment of time estimation and learning

The perception of the length of time between the performance of an action and the receipt of a reward is associated with a decision in favor of one or another alternative. Cognitive impulsivity is associated with perception and time estimation (estimating the duration of the delay between an action and a result). Delay drastically reduces the subjective value of the reward. Cognitive impulsivity is also associated with reverse learning (i.e., the inability to reproduce those behaviors that lead to a positive result) and to neutralize those behaviors that lead to negative consequences (Antonelli, Ray, Strafella, 2011). This kind of cognitive impulsivity is associated with difficulty acquiring new skills and learning from your own mistakes. This also includes the difficulty of patients to conclude that the current unfavorable situation is a consequence and the result of their early decisions. Ignoring causality means that it will be difficult for them to protect themselves from making the same mistakes in the future. These difficulties of understanding and evaluation are present despite the fact that patients often do not have memory impairment or cognitive impairment. Cognitive impulsivity is manifested in the fact that a person, figuratively speaking, constantly steps on the same “old rake”, cannot stop doing it, each time convincing himself “that this rake is new, but the situation is different”. nine0008

Impulsivity is a big problem in the drug treatment clinic, as patients, declaring rational intentions for treatment, often act inconsistently, dangerously and contrary to their own plans and interests in practice. A special problem in contact with such people arises from their relatives, persons interested in their recovery, doctors, psychologists and social workers. The Iraqi parable of the frog and the scorpion is widely known, in which the scorpion begs the frog to take him to the other side of the river. To which the frog replies that she will not do this for fear that the scorpion will bite her. The scorpion counters this argument by saying to the frog: “Well, why am I my own enemy, then we will both die, drown.” The frog agrees with the logic of the scorpion, puts it on its back and swims with it across the river. However, being in the middle of the river, the scorpion unexpectedly bites the frog. “What have you done, scorpion, you will also drown!” the dying frog cries to him. “I couldn’t help myself, I have such a nature!” - the scorpion managed to whisper before going to the bottom. Often, addictive patients unwittingly behave like this scorpion from the parable; they act self-destructively, to the detriment of themselves and others, not being able to cope with their own impulses. For this reason, the behavior of patients often looks irrational, causes misunderstanding, condemnation and provokes extremely ambivalent feelings in those who want to help them. On the one hand, patients evoke compassion and a desire to help others in other people, and on the other hand, the actions of patients cause a feeling that they like their suffering, which they well deserved. Otto Kernberg (1998) wrote that when committing self-destructive acts, some patients with pronounced narcissistic and borderline radical experience a feeling of "triumph in fear or pain and death and in a sense of superiority over those who are shocked or upset by his behavior" (Kernberg, 1998). Acting under the influence of impulses, patients retroactively rationalize their motives, avoid destabilizing their own beliefs, come up with not only reasonable explanations in order to maintain self-esteem, but also assert their own uniqueness through such behavior. Ego-synthonic impulsivity as a character trait, a feature of life style can be a source of pride and a mark of distinction of an individual from other people. nine0008

So, in our opinion, impulsivity occupies an important place in the clinic of narcology. On the one hand, impulsivity is largely a hereditary trait, which in children and adolescents acts as a predictor of substance use in the future. In this regard, it seems appropriate to use already tested and adapted Russian-language versions of assessment methods, for example, the Barratt Impulsivity Scale (BIS-11) in order to diagnose the presence of impulsivity and determine the degree of its severity (Enikolopov, Medvedeva, 2015). A combined approach that combines the use of self-reports and genetic analysis may allow the identification of individuals at risk from the general cohort of adolescents (Niv, Tuvblad, Raine, Wang, Baker, 2012). This may be important for subsequent interventions in secondary prevention. On the other hand, impulsivity presumably predicts a more severe course of a drug disorder if it occurs (Dalley J., Everitt B., Robbins, 2011, (Niv, Tuvblad, Raine, Wang, Baker, 2012, Verdejo-García, 2007). acting impulsively in response to negative emotional states is typical of drug treatment clinic patients (Verdejo-García, 2007) Impulsivity reduces the chances of completing drug treatment within agreed timeframes and increases the likelihood of relapse at the end of it.For this reason, it is important for patients to recognize and accept their own impulsive patterns and an understanding of the role of impulsivity in the relapse into problem behavior On a positive note, many clinicians note a natural tendency for the internal call to action to decrease as patients reach middle age, partly attributable to hormonal declines (Kernberg, 1998).

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