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Assessment Instruments for Impulsivity and Impulse Control Disorders

Article · September 2012

DOI: 10.1093/oxfordhb/9780195389715.013.0141

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 Assessment Instruments for Impulsivity and Impulse Control Disorders

in

THE OXFORD HANDBOOK OF IMPULSE CONTROL DISORDERS

Edited by Jon E. Grant, JD, MD, MPH, and Marc N. Potenza, MD, PhD

Alexis K. Matusiewicz,

Department of Psychology, University of Maryland, College Park, MD 20742, USA

Center for Addictions, Personality, and Emotion Research, University of Maryland, College

Park, MD 20742, USA

Brady Reynolds,

Research Institute at Nationwide Children’s Hospital & Department of Pediatrics, The Ohio

State University, Columbus, OH, USA

C. W. Lejuez

Department of Psychology, University of Maryland, College Park, MD 20742, USA

Center for Addictions, Personality, and Emotion Research, University of Maryland, College

Park, MD 20742, USA

 The aim of this chapter is to describe and review the psychometric properties of measures

used to assess the impulse control disorders (ICDs) included in the Diagnostic and Statistical

Manual of Mental Disorders IV (DSM-IV; APA) and those proposed for DSM-V, as well as

measures used to assess the related psychological construct of impulsivity. The first part of this

chapter is focused on the instruments used to assess ICDs. This review includes diagnostic

interviews, as well as self-report and clinician-rated measures of symptom severity. This review

is not exhaustive, given the large number of measures for some disorders and the absence of

published measures for others. Rather, our aim was to present a representative sample of reliable,

valid and commonly used measures for each of the ICDs. The second part of the chapter focuses

on the measurement of impulsivity, a construct implicated in the development and maintenance

of ICDs, as well as other forms of psychopathology. In this section we describe and present

widely used behavioral measures of impulsivity with psychometric data for each measure; it is

notable that psychometric data for behavioral measures are less consistently available than for

self-report measures. It is our hope that this chapter will provide an empirically- and clinically-

useful review of measures of impulse control disorders and impulsivity.

Assessment of Impulse Control Disorders

Impulse control disorders are characterized by repetitive engagement in behavior despite

negative consequences; 2) perceived lack of control over the behavior; 3) a strong urge to

perform the behavior; and 4) enjoyment or a sense of relief when the behavior is performed

(Grant & Potenza, 2004). Impulse Control Disorders (ICDs) represent a compelling clinical

challenge, and our understanding of these disorders and our effectiveness in treating them

depend on the ability to conduct accurate and through assessments. A variety of instruments and
assessment modalities have been developed to evaluate ICDs. The purpose of the structured

clinical interviews is to provide a diagnosis of ICDs, and they contain questions related to the

symptom domains out lined above. On the other hand, the functions of self-report measures are

more varied, including screening for psychopathology, assessing symptom severity, distress or

functional impairment, and identifying disorder subtypes. Accordingly, some self-report

measures assess symptoms directly, while others assess correlates of problem severity. In this

section, each measure will be presented and its psychometric properties will be reviewed to the

extent that this information is available. Table 2 contains basic properties and descriptive data

and ICD for some of the measures included in this section (this list includes only measures for

which descriptive data was available). We will begin with a diagnostic interview developed to

screen for all impulse control disorders, and the remainder of this section will be organized by

disorder. Intermittent explosive disorder and pyromania are not included because of the

unavailability of clinical measures specific to these disorders.

General Assessment of Impulse Control Disorders

Minnesota Impulsive Disorders Interview (MIDI; Christenson, Faber, de Zwaan, Raymond,

Specker et al., 1994)

The MIDI is a semi-structured interview developed to screen and diagnose impulse

control disorders, including the disorders included in the DSM-IV (i.e., pyromania, kleptomania,

trichotillomania, intermittent explosive disorder, pathological gambling) as well as those

proposed for inclusion in the DSM-V (i.e., pathological skin picking, compulsive buying and

compulsive sexual behavior). The MIDI is the only diagnostic interview that provides a

comprehensive assessment of ICDs.

 The MIDI consists of 36-items and contains modules for each of the ICDs. Each module

consists of a preliminary screening question and follow-up questions that correspond to the

DSM-IV diagnostic criteria for each disorder. If the respondent endorses the screening question,

the interviewer assesses: (1) urges to perform the behavior, (2) efforts to resist the urges, (3)

feelings of tension prior to performing the behavior, (4) feelings of release after performing the

behavior, and (5) distress and impairment associated with the behavior. Most modules also

include disorder-specific questions to assess clinically relevant details (e.g., the purpose of theft

in kleptomania, the location of hair pulling in trichotillomania). The modules include a

combination of closed-ended questions (e.g., yes/no) and open-ended questions (e.g., the

function or impact of the behavior). The MIDI is widely used in clinical and research settings

(Lejoyeux, Arbaretaz, McLoughlin & Ades, 2002; Black & Moyer, 1998; Grant, Kim &

McCabe, 2006; Weintraub, Siderowf, Potenza, Goveas, Morales et al., 2006; Isaias, Benti, Cilia,

Canesi, Marotta, Gerundini et al., 2007). It requires 20 minutes to administer and does not

require the interviewer to have extensive training or experience with ICDs.

Reliability

Neither the internal consistency of the items nor the inter-rater reliability of diagnoses

made on the basis of this measure has been published.

Validity

Grant and colleagues examined the validity of the MIDI in a sample of psychiatric

inpatients with a range of diagnoses (Grant, Levine, Kim & Potenza, 2005). Probable cases were

identified by the MIDI and followed-up with disorder-specific diagnostic interviews. Based on

concordance of diagnoses made on the basis of these interviews, the MIDI demonstrated good to

excellent sensitivity and specificity for each of the disorders assessed: pathological gambling
(sensitivity: 1.0 specificity: .98), kleptomania (sensitivity: .90, specificity: .93), IED (sensitivity:

1.00, specificity: .97), pyromania (sensitivity: 1.00, specificity: 1.00), trichotillomania

(sensitivity: 1.00, specificity: .99), compulsive sexual behavior (sensitivity: .80, specificity: .97;

Grant et al., 2005). Compulsive skin picking and compulsive shopping were not assessed in this

study, although they are included on the MIDI. Despite promising data, little other psychometric

data are available; accordingly, continued research is warranted to establish the psychometric

properties of this instrument in psychiatric and non-clinical samples.

Pathological Gambling

The Structured Clinical Interview for Pathological Gambling (SCI-PG; Grant, Steinberg, Kim,

Rounsaville & Potenza, 2004)

The SCI-PG is a semi-structured interview designed to provide a diagnosis of

pathological gambling. The format and scoring of the SCI-PG was developed to be compatible

with the SCID-IV (First, Spitzer, Gibbon & Williams, 1995). The SCI-PG consists of 11 items

corresponding to each of the DSM-IV diagnostic criteria for pathological gambling (10 inclusion

criteria and one exclusion criterion). Symptom presence is scored on a scale from one to three,

where one reflects the absence of a symptom, two reflects a subthreshold symptom, and three

indicates a clinically significant symptom. Five or more symptoms (out of 11) must be scored a

three to make a diagnosis of pathological gambling. The SCI-PG requires approximately 15

minutes to administer and the authors recommend that the interview be familiar with problem

gambling because the respondent’s answers may require clarification with appropriate follow-up

questions (Grant et al., 2004).

 Reliability

The reliability of the SCI-PG was evaluated in a sample of adult outpatients seeking

pharmacological treatment for pathological gambling (Grant et al., 2004). The test-retest

reliability (stability) of diagnoses was examined over a period of less than a week. Overall, test-

retest stability of the diagnosis was excellent for the presence versus absence of pathological

gambling (κ = 1.00); the test-retest reliability for the number of symptoms endorsed was also

excellent (r = . 97). Further, the individual items demonstrated good to excellent test-retest

stability (r = .87-1.00), with the exception of the question assessing preoccupation with gambling

(r = .65), which demonstrated marginal stability.

Inter-rater reliability was evaluated in a randomly selected subsample of participants. To

determine inter-rater reliability, both the interviewer and an observer scored the same

assessment. The SCI-PG demonstrated excellent interrater reliability overall (κ = 1.00) in

establishing the presence versus absence of the diagnosis. However, several of the items,

specifically those questions pertaining to legal, interpersonal and professional consequences of

gambling showed only marginal inter-rater reliability (κs = .55-.66). These findings highlight

the need for the interviewers to have a shared operational definition of functional impairment.

Validity

SCI-PG diagnostic status (dichotomously scored) was moderately to strongly correlated

with other measures of gambling symptom severity, including a clinician-rated interview (r =

.38) and a self-report measure (r = .78). The SCI-PG-derived diagnosis was not significantly

correlated with measures of anxiety (r = .23) or depression (r = .19), providing evidence for the

divergent validity.
 Classification accuracy was examined in a separate sample of outpatients seeking

treatment for impulse control disorders at a specialty clinic. To establish classification accuracy,

SCI-PG diagnosis was compared to diagnosis made by experts on the basis of longitudinal

clinical observation. The SCI-PG demonstrated high sensitivity (.88) and specificity (1.00), as

well as excellent positive predictive value (1.00) and adequate negative predictive value (.66).

Whereas the psychometric properties of the SCI-PG are well-characterized in clinical,

treatment-seeking samples, future research should evaluate its reliability and validity in

community samples, as well as general psychiatric samples. Additionally, research is needed to

examine the sensitivity of the SCI-PG to symptom change over the course of treatment.

South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987)

Based on the DSM-III diagnostic criteria, the SOGS was developed to identify probable

cases of pathological gambling. The SOGS is the most widely used self-report assessment

instrument for pathological gambling (Petry & Arementano, 1999) and consists of 20 items that

assess patterns of gambling, family and occupational disruption, use of deception to hide

gambling losses, financial problems (e.g., defaulting on debts, borrowing from others to repay

debts) and engagement in criminal activity to support gambling. Most items are scored either as

yes/no, although two require the participant to report the relative frequency of certain behaviors.

The measure is scored by summing affirmative responses. A score of five or greater suggests

probable pathological gambling.

Reliability

Stinchfield (2002) conducted principal components analyses to examine the factor

structure of the SOGS in the general population and among problem gamblers. The analysis
indicated a single primary factor for each group, which accounted for 21% of the variance in the

general population sample, and 31% of the variance in sample of pathological gamblers.

However, when this data was re-analyzed, Strong and colleagues (2004a) identified a small

second factor that consisted of subjective self-evaluations (e.g., “Do you feel you have ever had a

problem with gambling?”; Strong, Daughters, Lejuez & Breen, 2004b). This factor appeared to

be related to problem severity among pathological gamblers, but unrelated to severity in non-

clinical groups (Strong, Lesieur, Breen, Stinchfield & Lejuez, 2004a). They suggested that

omission of these five subjective items could improve the reliability of the SOGS in non-clinical

groups, but this modification has not been adopted widely in analogue sample studies.

Lesieur and Blume (1987) examined the internal consistency of the SOGS in a combined

sample of pathological gamblers, students and hospital employees. The measure demonstrated

excellent internal validity (Cronbach’s α = .97). In a subsequent sample of pathological gamblers

and controls, the measure showed marginal internal consistency in a combined sample

(Cronbach’s α = .69) but good internal consistency in the subsample of pathological gamblers

(Cronbach’s α = .86).

Test-retest reliability was examined over a period of 30 or more days, in a separate

sample of inpatients and outpatients in treatment for substance use disorders (Lesieur & Blume,

1987). The SOGS was scored dichotomously (i.e., presence-absence of diagnosis). Overall, test-

retest reliability was adequate (r = .71), with greater reliability for outpatients (r = 1.0) than for

inpatients (r = .61). The authors suggested that this discrepancy reflected the inpatients’

awareness that their responses would be used as part of treatment planning (Lesieur & Blume

1987).
 Validity

Construct validity was evidenced by the high rates of probable pathological gamblers

identified in the sample recruited from Gamblers Anonymous (96.7%), and the low rates of

probable pathological gamblers in the student and hospital employee samples (3.9% and 0.7%

respectively; Lesieur & Blume, 1987)).

Evidence for the concurrent validity of the measure was provided by correlations of the

SOGS-based diagnosis with other indicators of problem gambling. For example, Lesieur and

Blume (1987) reported high correlations between SOGS score and DSM-III diagnostic criteria

for pathological gambling. Similarly, Stinchfield found that the SOGS total score was

significantly correlated with number of DSM-IV diagnostic criteria in the general population (r =

.77) and in the sample of pathological gamblers (r = .83). Further, the largest amount of money

spent gambling in one day was significantly associated with SOGS score in the general

population (r = .32) and among pathological gamblers (r = .35).

Initial classification accuracy11 analyses suggest a score of five as the cutoff for probable

pathological gambling (Lesieur & Blume, 1987). This cutoff correctly classified 98.1% of

pathological gamblers, 96.3% of students and 99.3% of hospital employees based on the DSM-

III diagnostic criteria (Lesieur & Blume, 1987). Similarly, Stinchfield found the cutoff of five

demonstrated high positive predictive value (.96) and negative predictive value (.90) in the

sample of pathological gamblers, when evaluated against the DSM-IV diagnostic criteria. On the

other hand, in Stinchfield’s (2002) general population sample, this cutoff demonstrated marginal

positive predictive value (.67) and poor negative predictive value (.50). Despite these findings,

Stinchfield reported that the cutoff of five remains the best indicator of probable pathological
gambling in combined samples with an overall correct classification rate of 94% in the combined

sample (Stinchfield, 2002).

In summary, the SOGS is a self-report measure that can be used to identify probable

cases of pathological gambling. Evidence largely supports its reliability and validity, but the

measure is not particularly sensitive to change over time and its use to detect symptom

improvement or exacerbation (i.e., in a treatment outcome study) is questionable. Furthermore,

scores of five or six in the general population should be interpreted with caution, as they are

associated with only a 50% chance of correctly classifying the individual.

Gambling Symptom Assessment Scale (G-SAS; Kim, Grant, Potenza, Blanco & Hollander,

2009).

The G-SAS is a self-report measure of pathological gambling symptom severity, which

was developed to be sensitive to changes in symptoms over time. The G-SAS is modeled after

the Yale-Brown Obsessive Compulsive Scale for Pathological Gambling (PG-YBOCS;

Hollander et al., 2005), and does not provide a diagnosis, but rather, assesses the average

intensity, frequency and/or duration of symptoms over the past seven day period. The G-SAS

includes items to assess urges, thoughts, behaviors as well as anticipatory tension and

excitement, mental distress and functional impairment associated with gambling. The G-SAS

consists of 12-items, scored on a scale from zero (minimal symptom presence) to four

(maximum symptom presence, although the qualitative values vary for each item). Total scores

range from zero to 48 with higher scores reflecting greater symptom severity. It notable that the

version of the G-SAS described here deviates from the original measure (Grant & Kim, 2001),

which consisted of 10 items, scored from zero to eight. To our knowledge, the earlier version did
not undergo extensive psychometric evaluation, however, it has been in use for nearly a decade.

Readers should be aware of this difference and use caution in interpreting G-SAS scores across

studies.

Reliability

Kim and colleagues evaluated the internal consistency and test-retest reliability of the G-

SAS in a sample of outpatients participating in a pharmacological study of treatment for

pathological gambling (all participants were in the placebo condition). The G-SAS demonstrated

good internal consistency (Cronbach’s alpha = .87) at the baseline assessment.

Participants completed the G-SAS seven days apart, during the first and second weeks of

the treatment study. The mean G-SAS score demonstrated poor test-retest reliability (ρ = .56) in

the full sample. However, when outliers were removed, the test-retest reliability of the mean

score was stronger (ρ = .79). Kim and colleagues also examined the test-retest stability for each

of the individual items. Seven items demonstrated moderate test-retest reliability over one week

(κs = .48 to .61), while five items showed only marginal test-retest reliability (κs = .34 to .39).

The lowest reliability coefficients were observed in items assessing urges, control over

gambling-related thoughts and distress associated with gambling. The low test-retest reliability

may reflect the fact that, as a patient-rated scale, the G-SAS vulnerable to idiosyncratic response

styles. This possibility could be addressed by ensuring that participants understand the scoring

system. On the other hand, the lower reliability may be due to perceived symptom improvement

(even in the placebo group) early in treatment. Future research should examine test-retest

reliability in an untreated sample.

 Validity

Validity analyses were conducted in a sample of outpatients seeking pharmacological

treatment for pathological gambling. G-SAS total scores were moderately correlated with a

clinician-rated scale of symptom severity (ρ = .51) at baseline, suggesting good concurrent

validity. Moreover, in the sample that received the active drug (n = 125) change score on the G-

SAS was significantly correlated with change score on the physician’s rating of global

improvement (ρ = .69) and with the participant’s rating of global improvement (ρ = .71).

Similarly, in the active drug group, change score on the G-SAS was significantly associated with

change score on the clinician-rated measure (ρ = .81). Taken together, findings suggest the

validity of the G-SAS as a measure of change in symptom severity over the course of treatment.

However, steps should be taken to improve the test-retest reliability of the G-SAS before the

measure is adopted as a primary outcome measure.

As noted above, the G-SAS total scores range from 0 to 48. Kim and colleagues (2009)

have proposed the following cutoffs to indicate symptom severity. A score of 8-20 suggests

minimal symptoms, 21-30 reflects moderate symptoms, 31-40 indicates severe symptoms and

41-48 reflects extreme symptoms. However, it is unclear how these cutoffs were determined, and

their classification accuracy has yet to be demonstrated.

Trichotillomania

Trichotillomania Diagnostic Interview (TDI; Rothbaum & Ninan, 1994)

The TDI is a clinician-administered semi-structured interview developed to provide a

diagnosis of trichotillomania based on the DSM-III-R criteria for the disorder. Following

revisions in the DSM-IV and DSM-IV-TR, questions must be added to the TDI to reflect the
current diagnostic criteria. Specifically, the modifications include the addition of a question to

assess mounting tension before hair-pulling and a question to assess clinically significant distress

or impairment as a result of excessive hair-pulling (Franklin & Tolin, 2007). The TDI was

developed to be compatible with the Structured Clinical Interview for DSM-III-R (SCID; Spitzer

et al., Williams & Gibbon, 1987) and remains compatible with the SCID-IV (Spitzer, Williams

& Gibbon, 1995).

In its updated form, the TDI consists of six questions, which correspond to the DSM-IV-

TR symptoms. The first question establishes whether the participant has ever engaged in hair-

removal for non-cosmetic reasons; the second question asks about mounting feelings of tension

before hair pulling or when the participant tries to resist hair pulling. The third question asks the

participant to report whether hair pulling is relieving or pleasurable. The fourth question asks the

participant to describe the reason for hair-pulling to rule out medical (e.g., inflammation) or

psychiatric (e.g., hallucinations or delusions) bases for the behavior. The fifth question

establishes that hair pulling is associated with clinically significant distress or impairment, and

the final question asks the participant to report the sites of hair pulling (Franklin & Tolin, 2007).

Questions are scored one (absent), two (subthreshold) or three (clinically significant). To make a

diagnosis of trichotillomania, the first five questions must be scored three. Although is still

widely used to diagnose trichotillomania, there is no psychometric information available for this

interview (Franklin & Tolin, 2007).

Massachusetts General Hospital Hair pulling Scale (MGH-HPS; Keuthen, O’Sullivan, Ricciardi

& Shera, 1995).

 The MGH-HPS is a commonly used self-report measure of trichotillomania symptom

severity. The MGH-HPS is a seven-item scale modeled after the Yale-Brown Obsessive

Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen & Mazure, 1989). The scale consists

of seven items, which assess the frequency, intensity and control over urges, as well as

frequency, resistance and control over actual hair pulling. The final item assesses distress related

to hair pulling (Keuthen et al., 1995; Keuthen, O’Sullivan, Goodchild, Rodriguez, Jenike et

al.,1998; Diefenbach, Tolin, Hannah, Maltby & Crocetto, 2006). Participants rate the severity of

their symptoms on a scale from zero (no symptoms) to four (extreme symptoms). Total scores

range from 0 to 28, with higher scores indicating greater symptom severity.

Reliability

The factor structure of the MGH-HPS was evaluated in the large, internet-based sample

of individuals seeking support for trichotillomania (Keuthen, Flessner, Woods, Franklin, Stein et

al., 2007). Exploratory factor analyses revealed two factors: Factor 1 was labeled “Severity” and

consisted of urge frequency and severity, hair pulling frequency and distress. This factor had an

eigenvalue of 3.73, accounted for 53.2% of the variance in the total scale score, and

demonstrated adequate internal consistency (Cronbach’s α = .83). Factor 2 was termed

“Resistance and Control” and consisted of control over hair pulling, resistance to hair pulling and

control over urges. This factor had an eigenvalue of 1.26, accounted for 17.9% of the variance in

the total scale score and also demonstrated adequate internal consistency (Cronbach’s α = .81).

The authors speculated that these factors may reflect different pathways to symptom

improvement, noting that medication may reduce symptom severity, whereas motivational or
behavioral treatments may enhance resistance and control. Although this suggestion is intriguing,

it does not yet have empirical support.

Internal consistency has been replicated in a sample of adults seeking treatment for

trichotillomania. The overall measure demonstrated adequate internal consistency (Cronbach’s

α = .80) in the sample of treatment-seeking individuals with trichotillomania. Keuthen and

colleagues (2005) reported similar internal consistency for the overall measure (Cronbach’s α =

.84), and for each subscale (Keuthen, Bohne, Himle & Woods, 2005).

Validity

The validity of the MGH-HPS was examined in a study of adults seeking treatment for

trichotillomania. These participants completed the MGH-HPS as well as three clinician-rated

measures of trichotillomania symptom severity, alopecia and global symptom severity, and self-

report measures of depression and anxiety. The MGH-HPS total score correlated moderately

with two clinician-rated measures of trichotillomania (rs = .52-.55) providing evidence of

convergent validity. However, the MGH-HPS total score was not significantly associated with

clinicians’ ratings of alopecia (r = .10), impairment due to trichotillomania (r = .19) or clinical

global impression (r = .13), suggesting the divergent validity of the MGH-HPS. Further, the

MGH-HPS was not significantly associated with depressive symptoms (r = .26), but was

moderately, though not significantly, associated with anxiety (r = .56). Thus, the MGH-HPS

appears to assess the severity of hair-pulling behavior, rather than the extent of impairment

associated with hair pulling.

The validity of the two-factor structure of the MGH-HPS was examined in an internet-

based sample of adults seeking support for trichotillomania. All participants completed the
MGH-HPS and self-reports of depression and anxiety, total disability, time spent resisting hair

pulling, and time and money spent hiding hair loss. The total disability score was significantly

positively associated with Severity (r = .23), but not was not associated with Resistance and

Control (r = .05). Similarly, time spent resisting urges to pull hair was significantly and

positively associated with Severity (r = .22), but negatively and quite modestly associated with

Resistance and Control (r = -.10). Finally, the two factors were significantly correlated with one

another (r = .50), and with the total score (Factor 1: r = .91; Factor 2: r = .82), suggesting

internal validity.

Milwaukee Inventory for Subtypes of Trichotillomania—Adult Version (MIST-A; Flessner et al.,

2008)

The MIST-A is a self-report measure used to identify subtypes of trichotillomania,

designed as a supplement to diagnostic and symptom severity instruments. Previous research has

identified two subtypes of trichotillomania. “Automatic” hair-pullers are unaware of the hair

pulling while it is taking place, and often engage in other, sedentary activities at the time of the

hair pulling. In contrast, “focused” hair-pullers are more likely to engage in hair pulling during

negative emotional states, using the behavior as a way to reduce tension or anxiety (Begotka,

Woods, & Wetterneck, 2004; Diefenbach, Mouton-Odum, & Stanley, 2002). In one study of

chronic hair-pullers, approximately 47% of research participants reported primarily automatic

hair-pulling and 34% reported predominantly focused hair-pulling, while the remaining 19%

reported a combination of the two (du Toit, van Kradenburg, Niehaus & Stein, 2001). Franklin

and colleagues (2006) suggest that different subtypes may benefit from different interventions,

highlighting the clinical relevance of this distinction (Franklin, Tolin & Diefenbach, 2006).
 The MIST-A consists of 15 items that assess the antecedents and consequences of hair

pulling. The measure consists of two orthogonal subscales: the Automatic subscale consists of 5

items (e.g., “I am usually not aware of pulling my hair during a pulling episode”) and the

Focused subscale consists of 10 items (e.g., “I pull my hair to control how I feel”). The measure

is rated on a scale from zero (“not true of any of my hair pulling) to nine (“true for all of my hair

pulling). Because the subscales are thought to reflect distinct functions, the total score should not

be interpreted (Flessner et al., 2008). Subscale scores range from zero to 45 for Automatic, and

zero to 90 for Focused, with higher scores indicating more frequent hair pulling of that type.

Reliability

Exploratory and confirmatory factor analyses of the MIST-A have been conducted using

a internet-based sample of adults seeking support for trichotillomania (Flessner et al., 2008).

Exploratory factor analyses conducted on 24 items revealed two orthogonal factors. The five-

item Automatic factor had an eigenvalue of 3.13 and accounted for 13.0% of the variance in the

total scale score. The 10-item Focused factor had an eigenvalue of 4.11 and accounted for 17.1%

of the variance in total scale score. Nine items did not load strongly on either factor and were

eliminated; many of these items related to hair-pulling urges and resistance to urges.

Confirmatory factor analysis conduced on the remaining 15 items revealed a fair fit to the data.

The Automatic subscale demonstrated acceptable internal consistency (Cronbach’s αs = .73-.77)

as did the Focused subscale (Cronbach’s α = .77-.78). Future research is needed to support the

factor structure of this measure, and to investigate the test-retest stability of these subtypes.
 Validity

The validity of the measure was assessed in an internet-based sample of adults seeking

support for trichotillomania. Consistent with expectations, the automatic subscale was

significantly negatively correlated with the proportion of time participants reported being aware

of their hair-pulling (r = -.46), providing support for the concurrent validity of this subscale. As

evidence of its divergent validity, the Automatic subscale was not significantly associated with

hair pulling to establish symmetry or experience a specific bodily sensation, nor was it associated

with physical or mental anxiety prior to hair-pulling (rs<.01). Further, the Automatic subscale

was only weakly associated with stress (r = .15) and anxiety (r = .12), and was unrelated to

depression (r = .05). On the other hand, the focused subscale was significantly associated with

the frequency of hair-pulling episodes accompanied by a sense of physical and mental anxiety (rs

= .25 and .32, respectively). The Focused subscale was associated with proportion of pulling

episodes initiated with the goal of establishing symmetry (r = .20) and the proportion of pulling

episodes initiated to experience a specific bodily sensation (r = .35). In addition, focused pulling

was associated with greater depression (r = .32), anxiety (r = .32) and stress (r = .36), indicating

an association between this form of hair-pulling and emotional distress. Finally, the subscales

were not correlated with one another (r = .01), supporting the independence of these subtypes.

There is considerable evidence for the reliability and validity of the MIST-A. Future

psychometric development should include establishing the reliability and validity of this measure

in clinical samples. Further development will provide insight into the clinical utility of the

measure, and provide support for the validity of the subtypes.

Kleptomania

Structured Clinical Interview for Kleptomania (SCI-K; Grant, Kim & McCabe, 2006)

The SCI-K is a semi-structured interview developed to provide a standardized diagnosis of

kleptomania based on the DSM-IV diagnostic criteria. The SCI-K was developed to be consistent

with the SCID-IV in terms of format and scoring. The SCI-K consists of nine probes and related

follow-up questions, which correspond to the DSM-IV diagnostic criteria for kleptomania. The

first five probes query: (1) recurrent impulses to steal, (2) recurrent failure to resist impulses, (3)

Stealing items not needed for personal or financial reasons, (4) increasing tension before

stealing, (5) and relief or pleasure after stealing. The final four probes assess rule-out criteria: (6)

Stealing is not committed to express anger or take revenge, (7) stealing is not committed in

response to delusions or hallucinations, (8) stealing is not better accounted for by a manic

episode and (9) stealing is not better accounted for by antisocial personality disorder (Grant et

al., 2006). Questions are scored one (absent), two (subthreshold) or three (true or threshold). The

interview requires approximately 20 minutes to administer. To make a diagnosis of

trichotillomania, the first five questions must be scored three. The interview requires

approximately 20 minutes to administer.

Reliability

Internal consistency of the SCI-K was examined in a sample of adults seeking

pharmacotherapy or psychotherapy for kleptomania (Grant et al., 2006). Overall, the measure

demonstrated excellent internal consistency (Cronbach’s α = .96). The internal consistency of

the five inclusionary items was excellent (Cronbach’s α = .93) as was the internal consistency of

the four exclusionary items (Cronbach’s α = .98).

The SCI-K was administered at two time points, 2-3 weeks apart, prior to beginning

treatment. The reliability of the diagnosis (kleptomania vs. non-kleptomania) was extremely high

(Φ = .96).

Inter-rater reliability was based on a single interview, rated by the interviewer and an

observer. The SCI-K demonstrated fair inter-rater reliability (Φ = .72) for the diagnosis of

kleptomania. Grant and colleagues (2006) noted that there is disagreement over the validity of

this diagnostic criterion, suggesting that the psychometric problems associated with this item

may reflect as much as a weakness in the conceptualization of kleptomania, as any particular

limitation of the SCI-K,.

Validity

Concurrent and divergent validity were assessed in a randomly selected subsample of the

full patient sample. SCI-K-based diagnoses were highly and significantly correlated with the

number of symptoms endorsed on self-report measure of kleptomania (Φ = .77), providing

evidence of good concurrent validity. SCI-K diagnosis was not significantly associated with

clinician-rated depression severity (r = -.02), indicating good divergent validity.

As noted previously, classification accuracy was examined in a separate sample of

outpatients in treatment at an impulse control disorder specialty clinic (n = 46; 52.2% female).

Clinical judgment based on the DSM-IV diagnostic criteria for kleptomania served as the

standard against which the SCI-K was evaluated (Grant et al., 2006). The SCI-K showed good

sensitivity (.90) and specificity (.94). It correctly classified 81.8% of true cases (i.e., adequate
positive predictive value) and 97.1% of those without kleptomania (i.e., good negative predictive

value).

The preliminary psychometric data for the SCI-K are limited but encouraging. Findings

suggest strong internal consistency, good concurrent and divergent validity, and adequate

classification accuracy. However, it should be noted that the reliability and validity of the

standards against which the SCI-K was judged (e.g., self-report measure based on diagnostic

criteria, clinical impressions) have not been established. Continued research is necessary to

support the reliability and validity of this measure in patient and non-patient samples.

Kleptomania Symptom Assessment Scale (K-SAS; Grant & Kim, 2002; Grant et al., 2005)

The K-SAS is a self-report measure of kleptomania symptom severity, developed to be

sensitive to changes over time in kleptomania symptom severity. The K-SAS consists of 11

items, which assess severity, duration and control over urges to steal (items 1-4), frequency,

duration and control over thoughts about stealing (items 5-7), excitement prior to and pleasure

during theft (items 8 and 9), and distress and functional impairment caused by stealing (items 10

and 11). Each item is rated on a scale from zero (no symptoms) to four (severe symptoms),

though the qualitative values vary across questions. Possible scores range from zero to 44, with

higher scores indicating greater kleptomania symptom severity.

Reliability

The K-SAS demonstrated good internal consistency (Cronbach’s alpha = .90) in a sample

of outpatients seeking treatment for kleptomania (Grant & Kim, 2002). Participants completed
the K-SAS at baseline and again seven days later, following a weeklong placebo lead-in. Test-

retest reliability was poor (r = .57), which may be due to the nature of the study (i.e., treatment).

Validity

As evidence of the construct validity of the K-SAS, participants receiving

pharmacological treatment for kleptomania demonstrated significant decreases in K-SAS scores

from baseline to the end of treatment (Grant & Kim, 2002).

Over the course of the pharmacological treatment study, symptoms were assessed on a

weekly basis using the K-SAS and clinician-rated measures (Global Assessment of Functioning,

Clinical Global Impression). The K-SAS showed good concurrent validity with physician-rated

Clinical Global Impression (rs = .63 to .87 over 10 weeks) and Global Assessment of

Functioning (rs = -.88 to -.62). In another study of outpatients with kleptomania, K-SAS was

significantly associated with deficits in executive function (r = -.69), such that greater symptom

severity was associated with fewer correct responses on the Wisconsin Card Sorting Task (Grant,

Odlaug, & Wozniak, 2007). Taken together, there is limited evidence for the validity of the K-

SAS as a measure of symptom severity specifically, and further psychometric evaluation is

warranted.

Compulsive Skin Picking

Skin Picking Scale (SPS, Keuthen, Wilhelm, Deckersbach, Engelhard, Forker, et al., 2001a)

The SPS is a brief self-report instrument that aids in the identification of compulsive skin

picking. The six-item scale is modeled after the Y-BOCS, and assesses the frequency and

intensity of urges, time spent picking, interference due to picking, as well as associated distress
and impairment. Respondents rate each item on a five-point scale from zero (none) to four

(extreme), with total scores ranging from 0-24. Higher scores suggest greater severity of

compulsive skin picking.

Reliability

The psychometric properties of this measure were examined in a clinical sample of self-

injurious skin-pickers (i.e., patients who experienced significant tissue damage and distress or

functional impairment due to their skin picking) and in a college sample of non-self-injurious

skin pickers. The SPS demonstrated adequate internal consistency in the clinical sample

(Cronbach’s α = .80). Internal consistency was not reported for the non-clinical group.

Validity

As evidence of construct validity, higher scores are associated with tension prior to

picking and relief after picking, as well as objective measures of skin picking such as duration

and distress and impairment related to skin picking. Self-injurious skin pickers scored

significantly higher on the measure than non-self-injurious skin pickers. Sensitivity and

specificity analyses identified a score of seven as the optimal cutoff to identify probable cases of

compulsive skin picking. This cutoff correctly classified 96.4% of the self-injurious skin pickers

and 92.2% of the non-self-injurious skin pickers. These results are promising, but continued

psychometric development should focus on the test-retest reliability of this measure, its factor

structure, and its ability to detect changes in symptoms over time.

Skin Picking Impact Scale (SPIS; Keuthen, Deckersbach, Wilhelm, Engelhard, Forker et al.,

2001b).

Keuthen and colleagues (2001b) developed the Skin Picking Impact Scale (SPIS), a

measure of psychosocial consequences associated with compulsive skin picking. The SPIS was

designed to be used as part of a larger functional assessment of skin picking behavior,

acknowledging the need to conduct independent evaluations of symptom severity and degree of

impairment. The measure assesses emotional (e.g., “I feel embarrassed because of my skin

picking”), social (e.g., “I don’t like people looking at me because of my skin picking”) and

behavioral (e.g., “It takes me longer to go out because of my skin picking”) consequences of skin

picking behavior. The 10-item measure is scored using a scale from zero (none) to five (severe),

with possible scores ranging from 0-50. Higher scores indicate greater psychosocial impairment.

Reliability

The measure demonstrated excellent internal consistency in a sample of self-injurious

skin-pickers (Cronbach’s α = .93) and good internal consistency in a student sample of non-self-

injurious skin-pickers (Cronbach’s α = .88).

Validity

As expected, the clinical sample scored significantly higher than the student sample on

the SPIS. All SPS items were significantly correlated with the total score (rs = .60 to .80),

suggesting that the SPIS was assessing a common construct. Participants completed self-reports

of symptoms of depression and anxiety and characteristics of their skin picking behavior, in

addition to the SPIS. Among self-injurious skin pickers, the SPIS total score was positively

correlated with anxiety symptoms (r = .52) and depressive symptoms (r = .42), and with duration

of daily skin picking (r = .42), satisfaction during picking (r = .36) and self-reported shame after
picking (r = .51). In the non-self-injurious sample, SPIS score was not significantly correlated

with any index of psychological distress (depression: r = .-04, anxiety: r = -.02, shame: r = .18),

nor was it associated with daily duration of skin picking episodes (r = .01). These findings

provide support for the validity of the SPIS as a measure of distress and impairment among self-

injurious skin pickers.

Sensitivity and specificity analyses were conducted to determine the optimal cutoff to

differentiate compulsive from normal skin picking. A cutoff of seven correctly classified 83.9%

of participants with self-injurious skin picking and 96.2% of participants non-self-injurious skin

picking.

Compulsive Buying

Compulsive Buying Scale (CBS; Faber & O’Guinn, 1992)

The CBS is a widely used self-report measure used to identify probable cases of

compulsive buying. The CBS consists of seven items that address three aspects of problematic

consumer behavior identified by Faber, O’Guinn and Kyrch (1987): (1) excessive spending (e.g.,

“If I have any money left at the end of the pay period, I just have to spend it”); (2) strong urges

to shop (e.g., “Felt anxious or nervous on the days I didn’t go shopping”); and (3) feelings of

guilt after buying (e.g., “Felt others would be horrified if they knew of my spending habits”).

Several items were developed to capture symptoms unique to compulsive buying, while others

reflect symptoms common to all impulse control disorders (e.g., difficulty controlling urges,

tension prior to engaging in the behavior). The CBS is scored on a scale from one (strongly

agree, very often) to five (strongly disagree or never) and total scores are calculated based on an
equation with each item weighted by its difficulty. More negative scores reflect greater problem

severity. A scaled score below –1.34 is classified as a compulsive buyer.

Reliability

Reliability of the CBS was examined in a sample of self-referred, treatment-seeking (but

yet untreated) individuals with compulsive shopping and a comparison sample recruited from the

general population (Faber & O’Guinn, 1992). Factor analysis indicated a single factor

(eigenvalue 4.45), which accounted for 64% of the variance in CBS score. All items loaded

strongly on to the factor (mean factor coefficient was .79). The CBS demonstrated excellent

internal consistency in the clinical sample (Cronbach’s alpha = .95; Faber & O’Guinn, 1992).

Validity

The sample recruited for validity analyses included probable compulsive buyers

identified by the CBS in the general population screening, self-referred compulsive buyers, and

general consumers (Faber & O’Guinn, 1992). Compulsive buyers differed significantly from

general consumers on all psychological variables including lower self-esteem, greater obsessive

compulsive symptomatology, and greater emotional lift and remorse following buying (Faber &

O’Guinn, 1992). Concerning the financial outcomes, compulsive buyers had more debt and

carried a monthly balance on more credit cards than did general consumers. Additionally, the

CBS demonstrated good classification accuracy, correctly classifying 87.5% of participants with

and without compulsive shopping.

The CBS appears to be a reliable and valid instrument to screen for cases of compulsive

buying in the general population. The test-retest stability of this measure was not evaluated in the

initial validation study due to the anonymous nature of this questionnaire-based study, and
should be explored in future research. Moreover, in light of recent trends in consumer spending

and household debt (see Cynamon & Fazzari, 2008; Bernthal, Crockett & Rose, 2005), it may be

worthwhile to confirm the validity of the clinical cutoff identified by Faber and O’Guinn in

1992.

Compulsive Sexual Behavior

Compulsive Sexual Behavior Inventory (CSBI; Coleman, Miner, Ohlerking & Raynmond, 2001)

The CSBI is a self-report measure of compulsive sexual behavior that assesses the

severity of compulsive sexual behavior. The measure assesses hypersexuality, dyscontrol of

sexual impulses and behavior, and theoretically relevant risk factors for compulsive sexual

behavior. The CSBI is a 28-item instrument that consists of three subscales: Control, Abuse and

Violence. The Control subscale consists of 13 questions related to control of sexual urges and

behavior (e.g., “have you felt unable to control your sexual behavior?”) as well as interpersonal,

professional and financial consequences (e.g., “How often have your sexual thoughts or

behaviors interfered with the formation of friendships?” and distress associated with compulsive

sexual behavior (e.g., “How often have you had sex or masturbated more than you wanted to?”).

The Abuse subscale consists of 8 questions related to history of sexual and physical abuse (e.g.,

“Were you sexual abused as a child?”), history of sexual perpetration and victimization (e.g.,

“Have you forced anyone against his or her will?”) and incest (e.g., “Did you have sexual

experiences with either of your parents?”). The Violence subscale consists of 7 questions related

to physical and sexual aggression between sexual partners (e.g., “Have you been forced to have

sex with your husband, wife or lover?”), sadistic and masochistic sexual experiences (e.g., “Have

you given others physical pain for sexual pleasure?”), and exchange of sex for money (e.g.,
“Have you received money to have sex?”). The scale is scored from one (very frequently) to five

(never), with total scores ranging from 28 to 140. Lower scores indicate greater sexual

compulsivity.

Exploratory factor analysis revealed the three-factor solution (Control, Abuse and

Violence), which accounted for 58% of the variance in symptom severity in a combined sample

of men with nonparaphilic sexual behavior, pedophilia, and healthy controls (Coleman et al.,

2001). The Control subscale accounted for 42% of the variance (eigenvalue = 16.66), the Abuse

subscale accounted for 10.1% of the variance (eigenvalue = 4.26), and the Violence subscale

accounted for 5.9% of the variance (eigenvalue = 2.46). The CSBI demonstrated good to

excellent internal consistency for each subscale (Control: Cronbach’s α = .96, Abuse:

Cronbach’s α = .91, Violence: Cronbach’s α = ..88). The CSBI was administered twice to an

internet-based sample of men who have sex with men (Miner, Coleman, Center, Ross & Rosser,

2007). The CBSI showed good test-retest reliability over 7-10 days (r = .86).

Validity

In Coleman et al (2001), pedophilic participants scored significantly lower on the Control

subscale than participants with nonparaphilic compulsive sexual behavior or controls, suggesting

greater difficulties with control of sexual thoughts and behaviors, and providing evidence

construct validity (Coleman et al., 2001). As further evidence, individuals designated as high in

sexual compulsivity based on a median-split reported more lifetime sexual partners, more sexual

partners in the past three months, and more unprotected sexual encounters in the past three

months (Miner et al., 2007). Pedophilic participants also scored lower on the Violence subscale

than controls, suggesting greater engagement in problematic sexual behavior among the
pedophilic group (Coleman et al., 2001), whereas sexual compulsives did not differ significantly

from either group on this subscale. No group differences were found for the abuse subscale

(Coleman et al., 2001).

The CSBI demonstrated satisfactory reliability and validity among male participants with

histories of sexually compulsive behavior (Coleman et al., 2001) and men who have sex with

men (Miner et al., 2007). Continued research, using more varied samples that include female

participants, is needed to identify the optimal clinical cutoff to differentiate individuals with and

without compulsive sexual behavior. The concurrent and divergent validity of the measure

should also be explored. Finally, continued psychometric evaluation is necessary to determine

whether the factor structure, reliability and validity of the CSBI apply to females with sexually

compulsive behavior.

Assessment of Impulsivity

In the previous sections, we have reviewed the assessment instruments for the ICDs

included in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV; APA) and

those proposed for DSM-V. In the remainder of this chapter we will shift our focus to the

assessment of the construct of impulsivity, a trait implicated in problematic behaviors that

characterize each of the ICDs and other forms of psychopathology. Impulsivity is defined as an

individual’s tendency to behave impulsively, that is, rapidly, without forethought and without

regard for the consequences (Moeller, Barratt, Dougherty, Schmitz & Swann, 2001) across a

range of situations. Impulsivity is a broad, multidimensional construct and there is no single,

agreed-upon definition (Evenden, 1999). Indeed, the dimensions of impulsivity vary

considerably, as a function of discipline, theory and of measurement approach. In this section,

we will describe the psychometric properties of three widely used self-report measures of

impulsivity, followed by a review of behavioral instruments used to assess impulsivity.

Self-Report Measures

Self-report instruments have long been the dominant approach to the measurement of

impulsivity. These measures rely on an individual to provide a subjective account of how they

usually act, think and feel across a range of situations. Due to space constraints, we have chosen

to present an in-depth review of three of the most widely used measures of impulsivity,

acknowledging that this brief list omits many influential and widely cited measures including

EASI II Impulsivity Scales (Buss & Plomin, 1975), Dickman’s Functional and Dysfunctional

Impulsivity Scales (Dickman, 1990), the Impulsive Sensation Seeking scale of the Zuckerman-

Kuhlman Personality Questionnaire (Zuckerman, Kuhlman, Joireman, Teta & Kraft, 1993), the

Impulsiveness subscale of the Temperament and Character Inventory (Cloninger et al., 1991),

and the Control subscale of the Multidimensional Personality Questionnaire (Tellegen, 1982).

We refer the reader to Schmidt (2003) for a thorough review of the psychometric properties of

self-report measures of impulsivity. Table 3 contains a summary of normative data for each of

the measures presented here.

Barratt Impulsiveness Scale (BIS-11; Patton, Barratt & Stanford, 1995)

The BIS-11 is the most widely used measure of trait impulsiveness, defined as an

individual’s tendency to think and behave impulsively across a range of situations. The BIS was

developed to be orthogonal to anxiety-related traits, to distinguish multiple dimensions of

impulsivity, and to differentiate this trait from related but distinct constructs, such as sensation
seeking and risk-taking (Stanford, Mathias, Dougherty, Lake, Anderson et al., 2009). Originally

published in 1959 (Barratt, 1959), the BIS is currently is in its eleventh revision (BIS-11).

The BIS-11 is a 30-item measure, scored on a scale from one (rarely/never) to four

(almost always/always). Total scores range from zero to 120 with greater scores indicating

greater impulsivity. The BIS-11 consists of six first-order factors (attention, motor, self-control,

cognitive complexity, perseverance and cognitive instability), and three second-order factors

(motor, non-planning and attentional; Stanford et al., 2009). Motor impulsiveness, comprised of

the first order factors motor and perseverance, consists of 11 items and assesses the tendency to

act quickly or on the spur of the moment and to give up easily (e.g., “I act ‘on impulse’”). Non-

planning impulsiveness, comprised of the first order factors of self-control and cognitive

complexity, consists of 11 items and assesses the tendency to act without consideration for the

future and preference for challenging cognitive tasks (e.g., “I am a careful thinker” is reverse

scored). Attentional impulsiveness, comprised of the first-order factors attention and cognitive

instability, consists of 8 items and assesses the ability to focus attention and concentrate (e.g., “I

squirm at plays or lectures.”).

Reliability

An exploratory principal components analyses conducted on the BIS-10 revealed six first

order factors (attention, motor impulsiveness, self-control, cognitive complexity, perseverance,

and cognitive stability) and three second order factors (Attentional, Motor, Non-Planning).

Notably, the statistically-derived factor structure of the BIS-11 (Motor, Attentional, Non-

Planning) was found to differ somewhat from the theory-based structure of the BIS-10 (Motor,

Cognitive, Non-Planning; Barratt, 1985; Patton et al., 1995). Specifically, a number of items
related to rapid or hasty decision making, which were initially conceptualized as part of the

cognitive impulsiveness factor in the BIS-10, loaded on the non-planning factor in subsequent

principal components analyses (Patton et al., 1995). The revised cognitive factor was renamed

“attentional impulsiveness” to reflect the remaining items (e.g., racing thoughts, difficulty

concentrating; Stanford et al., 2009). Despite consistent support for the modified factor structure,

many sources continue to refer to the Attentional subscale as Cognitive impulsiveness. The

second order factors (i.e., Attentional, Motor and Non-Planning) have been found to correlate

modestly with one another (rs = .39- .51) and with the total score (rs = .76-.89), suggesting that

despite the existence of well defined factors, the BIS-11 reflects a single, underlying construct

(Stanford et al., 2009).

In a recent, large-scale study of the BIS-11, the overall scale demonstrated good internal

consistency (Cronbach’s α = .83). The internal consistencies for each of the first- and second-

order subscales were poor to fair (see Table 2). This likely reflects the small number of items in

each first- and second-order subscale. For the scale total, test-retest reliability was satisfactory (ρ

= .83) over a one month test-retest interval. The test-retest reliability of each of the second order

factors was fair (Attentional: ρ = .61, Motor: ρ = .67, Non-planning: ρ = .72), while the test-

retest reliabilities for the first order subscales ranged from poor to fair (ρs = .23 to .72; Stanford

et al., 2009).

Validity

A common use of the BIS-11 is to examine whether purportedly impulsive groups (i.e.,

offenders, patients with disinhibitory psychopathology) report greater impulsivity than healthy

controls. BIS-11 total scores have been found to be higher among cocaine dependent adults and
ecstasy users relative to controls (Pleskac, Wallsten, Wang & Lejuez, 2008; Lane, Moeller,

Steinberg, Buzby & Kosten, 2007; Bond, Verheyden, Wingrove & Curran, 2004), and have been

found to be higher among early-onset alcoholics relative to late-onset alcoholics (Dom, D’haene,

Hulstijn & Sabbe, 2006). Similarly, BIS-11 scores were elevated among individuals with

borderline personality disorder (Ferraz, Vallez, Navarro, Gelabert, Martin-Santos & Subira,

2009) and antisocial personality disorder (Warren & South, 2006; Dolan & Fullam, 2004)

relative to healthy controls. In forensic samples, violent offenders scored higher than non-violent

offenders (Smith, Waterman & Ward, 2006). Group differences have also been found for specific

subscales: for example, suicide attempters have been found to score higher than controls on

Motor (Dougherty, Mathias, Marsh, Moeller & Swann, 2004) and Attentional subscales

(Quednow, Westheide, Kuhn, Werner, Maier et al., 2006), while Non-Planning has been shown

to be elevated in both unipolar and bipolar depression (Peluso, Hatch, Glahn, Monkul, Sanches et

al., 2007). Taken together, findings provide strong support for the construct validity of the BIS-

11.

BIS-11 total score has been found to be significantly associated with other self-report

measures of impulsivity (r = .63) and disinhibition (r = .36), providing evidence of convergent

validity (Stanford et al., 2009). Non-significant correlations with similar but theoretically unique

personality traits (e.g. reward responsiveness: r = -.04; thrill-seeking, r = .11) support the

divergent validity of the measure. In addition, the BIS-11 has been found to be associated with

indices of impulsive behavior. For example, among abstinent drug users in residential treatment,

higher BIS-11 scores were associated with greater crack cocaine use (total: r=.28, motor: r=.18,

attentional r=.24, non-planning: r=.28; Lejuez, Bornovalova, Reynolds, Daughters, & Curtin,

2007). Similarly, BIS total score was significantly associated with frequency of clinically
significant impulsive behavior (r=.51) and distress (r=.46) and impairment (r=.55) resulting from

impulsive behavior (Schmidt, 2004).

In their recent review, Stanford and colleagues (2009) made a number of

recommendations with regard to scoring and interpretation of the BIS-11. First, they suggest that

total scores between 52 and 71 should be considered within the normal range of impulsivity.

Scores of 72 or greater (i.e., one or more standard deviations above the mean of the validation

sample) can be used to designate high trait impulsivity, while scores below 52 (i.e., one or more

standard deviations below the mean) may reflect either extreme inhibition or dishonesty

(Knyazev & Slobodskaya, 2006; Helfritz & Stanford, 2006). Notably, the cutoff of 74 represents

a slight revision to the cutoff suggested of 72 suggested by Stanford and colleagues (1995). To

our knowledge, sensitivity and specificity analyses have not been conducted to establish the

validity of this cutoff. However, there is evidence that young adults designated as high in

impulsivity using this criterion were more than twice as likely to engage in risk behavior (e.g.,

deliberate self-harm, shoplifting) than individuals who scored in the normal range (Stanford et

al., 2009), providing preliminary evidence for the construct validity of this cutoff.

Bearing in mind these recommendations, Stanford and colleagues suggest that the BIS-11

total score should be neither over-interpreted nor reported alone, given the multidimensional

nature of this construct. Rather, in assessment contexts, each subscale provides unique

information about the facets of impulsivity that characterize groups or individuals, which should

be considered in conjunction with the total score. For example, different psychiatric groups may

demonstrate elevations on certain subscales but not others (e.g., Tamam, Zengin, Karakus &

Ozturk, 2008). However, despite the potential clinical utility of these subtraits, continued
research is warranted to evaluate and improve upon the psychometric properties of the first- and

second-order factors (Stanford et al., 2009).

Eysenck Impulsiveness Scale (I-7; Eysenck, Eysenck & Barrett, 1985)

The I-7 is a 54-item measure of impulsivity derived from the Eysenck and colleagues’

tridimensional model of personality (Eysenck et al., 1985). Within this framework, personality is

defined by the biologically-influenced traits neuroticism, extraversion and psychoticism. Trait

impulsivity is thought to consist of two broad underlying factors: impulsiveness, which is related

to psychoticism, and venturesomeness, which is related to extraversion (Eysenck et al., 1985;

Whiteside & Lynam, 2001). Accordingly, two of the three I-7 subscales include: Impulsiveness

(19 items, e.g., “Do you generally do any say things without stopping to think?”),

Venturesomeness (16 items, e.g., “Do you sometimes like doing things that are a bit

frightening?”). A third subscale, Empathy (19 items, e.g., “Do you become more irritated than

sympathetic when you see someone cry?”), was originally included to avoid monotony (Luengo,

de la Peña & Otero, 1991) and is not thought to comprise a dimension of impulsivity. Low

correlations of Impulsiveness and Empathy and Venturesomeness and Empathy support this

assertion (Eysenck et al., 1985; Miller, Joseph & Tudway, 2004). For all items, the participant

responds either yes or no to each item and affirmative responses are scored as one and negative

responses are scored as zero (12 items are reverse scored). Scores range from zero to 54 with

higher scores indicating greater impulsivity.

 Reliability

Principal components analyses conducted in a sample of college students indicated 19

factors with eignevalues greater than 1, which together accounted for 64.4% of the total variance

(Luengo, Carillo-de-la-Peña & Otero, 1991). However, when the model was limited to only three

factors, results supported the original factor structure. Impulsiveness had an eigenvalue of 5.89

and accounted for 10.9% of the variance, Venturesomeness had an eigenvalue of 4.76 and

accounted for 8.8% of the variance and empathy had an eigenvalue of 2.73 and accounted for

5.1% of the variance. The three factor solution explained 24.8% of the total variance. While

these findings have been interpreted as support for the factor structure of the I-7, others have

noted that that this leaves a troubling amount of unexplained variance (Tinsley & Tinsley, 1987;

Merenda, 1997). The factors were modestly correlated (Impulsiveness and Venturesomeness: r =

.18, Impulsiveness and Empathy: r = .15, Venturesomeness and Empathy: r = -.20), indicating

their general independence.

The I-7 demonstrated good internal consistency for Impulsiveness (Cronbach’s α = .83

for females, .84 for male) and Venturesomeness (Cronbach’s α = .84 for females, .85 for males).

The Empathy subscale demonstrated fair internal consistency (Cronbach’s α = .69). Across

studies, findings indicate good internal consistency of these Impulsiveness and Venturesomeness

subscales (Luengo, Carillo-de-la-Peña & Otero, 1991; Miller et al., 2004).

Test-retest reliability was found to be fair to good for all subscales (r = .76 for

Impulsiveness, r = .80 for Venturesomeness and r = .63 for Empathy) over a one year test-retest

interval (Luengo et al., 1991).

Validity
 Modest correlations between Impulsiveness and Venturesomeness (r = .24 for men, r =

.11 for women) provide some support for the independence of these constructs. Consistent with

the Eyesencks’ conceptualization of the dimensions of impulsivity, Venturesomeness was

associated with Extraversion (r = .39 for males, r = .22 for females) and Impulsiveness was

associated with Psychoticism (r = .46 for males, r = .45 for female). As further evidence of

construct validity, participants designated high in impulsivity on their basis of the I-7 score

(based on a median split) were found to score significantly higher on all subscales of the BIS-11,

and reported greater hostility, anger and physical and verbal aggression than the low impulsivity

group (Marsh, Dougherty, Mathias, Moeller & Hicks, 2002). The I-7 also was found to be

associated with to early substance use among adolescents (r=.24; Lejuez, Aklin, Daughters,

Zvolensky, Kahler et al., 2005) and has been found to mediate the relationship between crack

cocaine (vs. heroin) and risky sexual behavior (Lejuez, Bornovalova, Daughters, & Curtin,

2005).

The I-7 subscales consistently demonstrate strong convergent validity with other

measures of impulsivity. For example, Miller and colleague (2004) examined the associations

among subscales of four measures of impulsivity and disinhibition. They found that I-7

Impulsiveness was significantly associated with Motor, Non-Planning and Cognitive Impulsivity

on the Barratt Impulsiveness Scale (rs = .52 to .58) and Dysfunctional Impulsivity on the

Dickman Impulsivity Inventory (r = .78). Venturesomeness demonstrated a different pattern of

correlations, and was associated with Functional Impulsivity (r = .43) and the Fun subscale of

the BIS/BAS (r = .47). Evidence of divergent validity was provided by nonsignificant

correlations between Impulsiveness and Empathy (r = .03 for males, r = .06 for females) and

Venturesomeness and Empathy (r = .01 for males, r = -.04 for females; Aluja & Blanch, 2007).
UPPS Impulsive Behavior Scale (UPPS; Whiteside & Lynam, 2001).

The UPPS Impulsive Behavior Scale is a more recently developed and widely adopted

measure that addresses conceptual heterogeneity in theories of impulsivity and models of

personality by identifying personality processes common across theories and assessment

instruments. In contrast to the BIS-11, the UPPS is not considered a measure of trait impulsivity;

rather, the scales reflect distinct personality traits that lead to impulsive-type (i.e., disinhibited)

behavior (Whiteside & Lynam, 2001; Lynam & Miller, 2004 ).

The UPPS is a 45-item measure1 scored on a scale from one (strongly agree) to four

(strongly disagree), with higher scores indicating greater impulsivity. It yields four subscale

scores but, but the total score is not interpretable. A series of factor analyses revealed four factors

(urgency, lack of premeditation, lack of perseverance and sensation seeking thought to reflect

distinct pathways to impulsive-type behavior. The urgency subscale consists of 12 items and

assesses the tendency to engage in undercontrolled behavior during periods of emotional

distress2 (e.g., “When I feel upset, I will often say things that I later regret”). The lack of

premeditation subscale consists of 11 items and assesses the tendency to act without considering

the potential consequences of their actions (e.g., “My thinking is usually careful and purposeful”

is reverse scored.) Lack of perseverance consists of 10 items and assesses an individual’s ability

to persist on a task that is difficult or boring (“There are so many little jobs to be done that

sometimes I just ignore them all”). Sensation seeking consists of 12 items and assesses the

tendency to pursue novel experiences and the tendency to seek and enjoy activities that are

exciting (“I’ll try anything once”).

 Reliability

As described above, exploratory factor analysis conducted on multiple self-report

measures of impulsivity revealed four factors: Urgency, (lack of) Perseverance, (lack of)

Premeditation and Sensation Seeking, which together accounted for 66% of the variance in the

total score (Whiteside & Lynam, 2001). Subsequent exploratory and confirmatory factor

analyses, Magid and Colder (2007) found support for this factor structure, with eigenvalues

ranging from 6.94 to 2.25. Sensation seeking was found to explain 54% of the variance, (lack of)

Premeditation and Urgency each explained 52% of the variance and (lack of) Perseverance

accounted for 43% of the variance. The magnitude of correlations among the factors varies

considerably across samples (e.g., Whiteside & Lynam, 2001; Magid and Colder, 2007;

Whiteside, Lynam, Miller & Reynolds, 2005), but the direction of the relationships is fairly

consistent. In general, correlations of Sensation Seeking and (lack of) Perseverance have been

lowest (r = .00 to.03) and the association of (lack of) Premeditation with (lack of) Perseverance

has been the highest (r = .38 to .65; Whiteside & Lynam, 2001; Magid & Colder, 2007).

The subscales demonstrated good to excellent internal consistencies (Cronbach’s αs =

.82-.91; Whiteside & Lynam, 2000), which have been replicated in subsequent studies (e.g.,

Anestis, Selby & Joiner, 2007). The subscales were moderately to strongly correlated across two

assessments, three to four weeks apart (Urgency: r = .73; Premeditation: r = .73, Perseverance: r

= .64; Sensation Seeking: r = .86), suggesting adequate to good test-retest reliability (Anestis et

al., 2007).
 Validity

As evidence of the construct validity of this measure, the UPPS subscales have been

found to differentiate among individuals with and without various forms of disinhibitory

psychopathology (e.g., bulimia nervosa, substance use and borderline personality disorder,

antisocial personality disorder; Magid & Colder, 2007; Anestis et al., 2007; Fischer, Smith,

Anderson & Flory, 2003; Whiteside & Lynam, 2003), as well as individuals with and without

lifetime histories of aggression (Whiteside et al., 2005; Ray, Blanco, Sullivan & Holliman,

2009).

Preliminary evidence of convergent and divergent validity comes from the associations of

the UPPS subscales with distinct facets of personality, as measured by the NEO-PI-R (Costa &

McCrae, 1992). For instance, Whiteside and Lynam (2001) found that Urgency loaded on a

factor with neuroticism, Sensation Seeking loaded with extraversion and both (lack of)

Perseverance and (lack of) Premeditation loaded negatively on a factor with conscientiousness.

Further support comes from studies examining the relationship of the UPPS subscales to

clinically relevant variables. For example, Anestis and colleagues found that urgency was

positively correlated with depression (r = .28), anxiety (r = .35), bulimic symptoms (r = .52) and

interpersonal difficulties (e.g., reassurance seeking; r = .36). In contrast, (lack of) Perseverance

was associated with bulimic symptoms (r = .37), but none of the other psychopathology

variables. Neither (lack of) Premeditation nor Sensation Seeking was associated with any of the

clinical variables, suggesting the particular relevance of urgency to certain forms of

psychopathology. In a study examining the relationships of the UPPS subscales to eating

disorder symptoms, Mobbs and colleagues (2008) found that Urgency was uniquely associated

with concern for dieting (r = .22), while only (lack of) Perseverance was significantly associated
with weight fluctuation (r = . 25; Mobbs, Ghisletta & Van der Linden, 2008). None of the other

subscales were significantly associated with other problematic eating, suggesting the divergent

validity of these measures. Further, in a study examining the relationship of impulsivity to

alcohol use, sensation seeking was positively associated with an index of frequency and quantity

of alcohol consumption (r = .27) and positively associated with alcohol related problems (r =

.21). Sensation seeking was also associated with motivations for substance use including a

moderate association with enhancement motives (r = .30) and social motives (r = .21), while

sensation seeking was not associated with conformity motives (r = -.03; Magid, MacLean &

Colder, 2007).

Behavioral Measures of Impulsivity

Despite various strengths and a large body of empirical support for self-report measures

of impulsivity, a variety of limitations also have been documented. Most notably, there are

multiple threats to the accurate reporting of one’s impulsivity, including poor self-evaluation

skills, an inability to report accurately on personal characteristics, or unwillingness to disclose

information that may be perceived negatively by others (Lejuez, Read, Kahler, Richards, Ramsey

et al., 2002). Considering these limitations, there is great value in the use of behavioral

measurement to complement self-report data. Behavioral measures of impulsivity include

measures that directly assess specific behaviors of interest using standardized laboratory-based

computerized tasks. Recent evidence indicates these assessments can be organized into three

broad behavioral domains: impulsive decision-making, inattention, and disinhibition (de Wit,

2009; Reynolds, Penfold & Patak, 2008). Measures of decision-making generally involve the

participant making choices between rewards that are delayed/immediate or probabilistic/certain.

Comparatively, measures of inattention do not involve the participant making choices but rather

evaluate the participant’s ability to maintain alertness and receptivity for a particular set of

stimuli or stimuli changes over time. Finally, measures of disinhibition emphasize ability to

inhibit pre-potent motor responses or unwanted behaviors. These three categories of measures

are statistically independent (Reynolds et al., 2008), and each is uniquely sensitive to acute drug

effects (see below) and drug-using behavior (e.g., cigarette smoking; Fields, Collins, Leraas, &

Reynolds, in press). Such findings illustrate the importance of a multidimensional

conceptualization of these behavioral measures, similar to the factor structures identified with

self-report measures of impulsivity.

Behavioral measures of impulsivity have several advantages over self-report measures for

certain types of research questions. A strength of behavioral measures is their suitability for

repeated use in treatment studies and within-subjects designs (Dougherty, Mathias, Marsh &

Jagar, 2005), following appropriate methodological and/or statistical correction for learning

effects and test-retest stability (e.g., employing reliable change index or using alternate forms;

Halperin, Sharma, Greenblatt & Schwartz, 1991). These measures of impulsivity are sensitive to

state-dependent change in behavior, including pharmacological, physiological and environmental

manipulation (Dougherty, Marsh-Richard, Hatzis, Nouvion & Mathias, 2008; Swann, Pazzaglia,

Pham, Dougherty & Moeller, 2005). For example, behavioral measures reveal that

administration of dopamine antagonists, alcohol and MDMA, uniquely affect particular

dimensions of impulsivity (Dougherty et al., 2008; Dougherty et al., 2005; Ramaekers &

Kuypers, 2006) as does phase of illness in bipolar disorder (Swann, Pazzaglia, Nicholls,

Dougherty & Moeller, 2003). Self-report measures of impulsivity are relatively less sensitive to
such state changes in behavior because these assessments evaluate self perceptions of behavior

(i.e., the participant’s ratings of his or her own behaviors) rather than the behavior itself.

Other advantages of using behavioral measures of impulsivity include their

appropriateness for use with young children and adolescents, and the availability of non-human

animal models for many of the measures used with humans. Compared with self-report

measures, behavioral procedures do not require the capacity for abstraction during the

assessment beyond the task itself. Therefore, young children who may have trouble accurately

completing a self-report measure can still complete most behavioral measures. For this same

reason (i.e., lack of need for abstraction), many of the behavioral measures used with humans

have non-human animal counterpart procedures (see Richards, Mitchell, de Wit & Seiden, 1997).

This ability to extend research to non-human animal models allows researchers to more feasibly

explore certain types of questions that may be difficult to address in human studies, for example,

what are the specific neural mechanisms associated with a type of impulsive behavior or drug

effects on that behavior?

There also are disadvantages to using laboratory behavioral measures of impulsivity.

Chief among these difficulties is that the measures are labor intensive and time consuming to

administer. Most tasks require up to 15 minutes to complete (with some being considerably

longer), and multiple measures must be administered to assess distinct dimensions of impulsivity

(Dougherty et al., 2005). Adding to this complication is the fact that these assessments are state

sensitive (the downside of the advantage noted above), meaning it is important that the testing

environments be non-distracting and consistent across participants. Because of these

considerations, many of the research studies that include these assessments have small

participant samples that are recruited from a small geographic area near the research facility.
Consequently, there are little psychometric data available for most of the measures described in

this section. Thus, we will begin with a review of commonly used measures, and consider

psychometric properties for each measure, to the extent that this information is available.

In the following sections we review specific behavioral measures and how each measure

operates. This review is not intended to be exhaustive but only a description of some of the more

commonly-reported behavioral measures. We have organized these measures according to the

three dimensions of impulsive behavior described above. However, some of these measures have

not been formally evaluated to determine which dimension of behavior they would best represent

and in these cases we base our categorization on conceptual and methodological similarities.

Further, we include measures of risk-taking and decision-making, related constructs that bare

some relevance to impulsivity. Although constructs reflecting risk-taking, decision-making and

impulsivity are separable and conceptually distinct (Lejuez, Aklin, Bornovalova, & Moolchan,

2005; Bechara, 2003), they can be meaningfully conceptualized together under a broader

umbrella of disinhibition (Patterson, Kosson & Newman, 1987; Lejuez et al., 2002).

Furthermore, whereas all of these measures can broadly be considered assessments of

impulsivity (i.e., by virtue of associations with impulsive behaviors like addiction, pathological

gambling, or clinical conditions otherwise) each still includes unique features. This qualification

even applies to measures within a single dimension. For example, the Balloon Analogue Risk

Task (BART) and Experiential Discounting Task (EDT) are both broadly considered here to be

measures of decision-making because each involves the participant making decisions; however,

the BART is an assessment of risk-taking propensity and the EDT an assessment of discounting

by delay (see Shashwath, Stevens, Potenza, Pittman, Gueorguievad et al., 2009, for comparison

of these two measures). Therefore, measures that are grouped together dimensionally should not
be considered one and the same but rather similar (or sharing certain characteristics) when

compared against measures in other dimensions.

Impulsive Decision-Making

Kirby Delay Discounting Measure (Kirby & Marakovic, 1996). The Kirby is a widely

used and brief measure of delay discounting. The measure, which has both pencil-and-paper and

computerized forms, consists of 21 fixed choices between a smaller, immediate reward and a

larger, delayed reward (Kirby & Marakovic, 1996). The Kirby can be administered as either a

hypothetical or real-reward measure. For the real-reward option, the participant is informed that

completing the questionnaire will make him or her eligible for a prize corresponding to one of

the choices on the questionnaire. Typically one of the 27 choice questions is selected at random

and the participant receives whatever he or she chose for that question. For both hypothetical

and real-reward administrations of the Kirby, the participant is encouraged to make each choice

as if he or she will actually receive the chosen reward.

The delays for this measure range from 7 to 186 days. The Kirby is scored in a manner

that results in k values (an index of delay discounting) assigned to participants along a range of

10 discrete steps: .00016, .00025, .00063, .0016, .0039, .010, .0126, .065, .16, and .25. This

measure provides three separate k values for each participant for large ($85, $80, and $75),

medium ($60, $55, and $50), and small ($35, $30, and $25) delayed monetary amounts. Values

of k are assigned according to choice patterns across the 27 items, with more choices for the

smaller immediate amounts associated with larger k values. Therefore, larger k values indicate

greater delay discounting of value for the delayed options, which is associated with heightened

impulsivity (Ainslie, 1975).

 Although the Kirby is a widely cited and commonly used instrument, there is little

psychometric data available for this measure specifically. There are many variations on the delay

discounting procedure, most of which follow the basic structure of the Kirby, and differ only in

the value of rewards used or the length of delay intervals. Because psychometric properties are

generally consistent across these measures, we will review the psychometric evidence for delay

discounting measures more broadly.

Reliability

Three studies have examined the test-retest stability of delay discounting paradigms. One

study employed a hypothetical standard amount of $1000 (Simpson & Vuchinich, 2000). Over a

one week test-retest period, there was poor stability for individual equivalence points for short

delays (one week: r = .03, one month: r = .24), but good to excellent stability for equivalence

points at longer delays (six month: r = .83; 25 year: r = .95). In addition, the test-retest stability

of the k value was excellent (r = .91; Simpson & Vuchinich, 2000). However, test-retest stability

for hypothetical rewards was lower for smokers compared to non-smokers (non-smokers: r =

.90, smokers: r = .76) suggesting that hypothetical delay discounting measures may be less

reliable among more impulsive individuals (Bickel & Johnson, 2003). However, when rewards

were real (rather than hypothetical), test-retest stability was not found not differ across smokers

and non-smokers over a one week period (r = .76-.77; Bickel & Johnson, 2003). Another study

used hypothetical rewards over a three month test-retest period. Findings suggested poor stability

for individual indifference points at short delay intervals (one week: r = .16) but stability was

found to improve at longer delays (five years: r = .76, 25 year: r = .67; Ohmura, Takahashi,

Kitamura & Wehr, 2006). Log k values were moderately correlated at three months (r = .61),

indicating marginal test-re-test stability. Overall, findings suggest good test-retest stability for k
when the test-retest period is brief, rewards are hypothetical, and the sample is relatively lower in

impulsivity. Test-retest stability for k is marginal to fair at longer test-retest periods and when

rewards are real. The test-retest reliability of individual indifference points is poor for brief

delays and good for long delays, so conclusions should be drawn cautiously from these data.

Consistency, which refers to the proportion of choices that are consistent with the

assigned discount rate (k) is another index of reliability for delay discounting procedures (Kirby,

Petry & Bickel,1999). Consistency was found to be high among opioid dependent inpatients

(94%) and healthy controls (96%; Kirby et al., 1999). Although this index of reliability is

somewhat unconventional, provides some support for the consistency of delay discounting

procedures and for the hyperbolic estimation of k (Kirby et al., 1999).

Validity

As evidence of construct validity, substance-using participants who were designated as

high in impulsivity on the basis of their clinical diagnoses, demonstrated greater delay

discounting than controls. For example, heroin users, smokers, and binge drinkers have all been

found to have higher (i.e., more impulsive) discounting rates than healthy volunteers (Kirby et

al., 1999; Madden, Petry, Badger & Bickel, 1997; Vuchinich & Simpson, 1998; Bickel &

Johnson, 2003; Reynolds & Schiffbauer, 2004). However, there is mixed evidence as to whether

discounting rates can differentiate among high impulsivity groups. For example, in one study,

discounting rates did not differ among groups with childhood conduct disorder, alcohol

dependence and alcohol dependence with childhood conduct disorder (Bobova, Finn, Rickert &

Lucas, 2009; Johnson, Bickel & Baker, 2007), while other findings suggest pathological
gamblers with substance use disorders discount more steeply than pathological gamblers without

substance use disorders (Petry, 2001), suggesting an additive effect.

Associations with other measures of impulsivity and disinhibition support the concurrent

validity of the discount rate, k. For example, log transformed k was modestly but significantly

associated with subscales of the Eysenck Impulsiveness Questionnaire (impulsiveness: r = .27;

venturesomeness: r = .19, p<.05; empathy: r = -.19, p<.05) and the BIS-10 (nonplanning: r = .25,

cognitive: r = .19) in a combined sample of opioid dependent inpatients and healthy controls.

Similar associations have been found in samples of young adults (Richards, Zhang, Mitchell &

De Wit, 1999): log transformed k was correlated with disinhibition (r = .45) as measured by the

Sensation Seeking Scale, as well as impulsivity (r = .35) and extraversion (r = .36) on the

Eysenck Personality Inventory. Discounting rate is also correlated with a range of problematic

behaviors, including severity of problems associated with alcohol (r=.24), marijuana (r=.19),

other drug use (r=.20) and childhood conduct disorder (r=.31; Bobova et al., 2009). Moreover,

discounting rate value was found to prospectively predict postpartum relapse to smoking among

women who quit smoking during pregnancy (Yoon, Higgins, Heil, Sugarbaker, Thomas &

Badger, 2007), providing support for the predictive validity12 of the measure. Taken together,

delay discounting rate appears to have good construct and concurrent validity with measures of

impulsivity and extent of impairment related to disinhibitory psychopathology.

Experiential Discounting Task (EDT; Reynolds & Schiffbauer, 2004).

The EDT is a computerized behavioral task that assesses an individual’s propensity to

discount the value of a reinforcer as a function of delay (i.e., delay discounting). Until recently,

delay discounting measures relied largely on hypothetical question-based paradigms, such as the
Kirby. Critics of the hypothetical measures have questioned whether hypothetical scenarios

based on long delays and large sums of money are ecologically valid, particularly in the absence

of choice-contingent consequences and learning (e.g., Critchfield & Kollins, 2001). In addition,

questions have been raised about the state-dependence of delay discounting, as it has for other

aspects of impulsivity (e.g., Dougherty et al., 2005, 2008). The EDT was developed in response

to these concerns.

Consistent with the Kirby and other delay discounting paradigms, the EDT requires the

participant to decide between a reward that is immediate and certain but smaller, and one that is

delayed and uncertain but larger. Unlike self-report measures, the participant experiences the

consequences of his or her choice (including delay, probability and reward from a coin

dispenser) before making his or her next choice (Reynolds & Schiffbauer, 2004). The EDT is a

forced-choice paradigm, wherein the value of the rewards and the length of the delay vary across

trials and choice blocks based on the participant’s responses. Therefore, a participant’s choices

can be used to examine his or her discounting of reward value as a function of increasing delay.

Of the two choice options, the delayed standard amount is a larger, delayed and

probabilistic reward value (i.e., 30 cents at a 35% chance) against which all other response

options are weighed. The only aspect of the delayed standard option that varies across choice

sessions is the delay interval (e.g., 0, 7, 14, 28 seconds). Alternatively, the adjusting immediate

option is always delivered immediately and is 100% certain. The value of this immediate option

begins at 15 cents (i.e., half the value of the delayed standard option), but it is adjusted by a set

percentage during a session according to the participant’s choices. If the participant chooses the

delayed standard option, the value of the adjusting amount increases for the next choice trial,

thus increasing its choice value and making it more attractive for the next choice. However, if the
participant chooses the immediate adjusting option, the value of the adjusting amount decreases

for the next choice trial, thus making the standard option comparatively more attractive for the

next choice. Adjusting the value of the immediate option in this way allows the determination of

an indifference point for a given delay to the standard option, which is defined as the reward

value of the adjusting option (determined by the participants choices) at which the participant

chooses each choice option equally often (i.e., 50% of the time). At the point of indifference, the

participant’s choice pattern holds the adjusting option constant across choices (due to the manner

in which adjustments are made), indicating each choice option is of equal subjective value for the

participant at the specified delay of the standard option. Indifference points are determined for

each of the four delay intervals to the standard option and plotted to form a discount function.

For each participant the pattern of discounting reflected across his or her indifference points is

characterized with either a hyperbolic decay model (e.g., Reynolds & Schiffbauer, 2004;

Reynolds, 2006; Voon, Reynolds, Brezing, Gallea, Skaljic, Ekanayake et al., in press) or area

under the curve (e.g., Reynolds et al., 2008; Melanko, Leraas, Collins, Fields & Reynolds, 2009;

Shields et al., in press) method.

Reliability

The reliability of the EDT is the subject of ongoing research; however, the similarities to

reliable conventional measures of delay discounting suggest promise in this regard.

Validity

As evidence of its construct validity, delay discounting values from the EDT have been

found to be steeper among adolescent smokers than non-smokers low in psychopathy traits
relative to controls (Melanko et al., 2009), and in adult smokers compared to non-smoking

controls (Reynolds, 2006). Furthermore, among adolescents attempting to quit smoking, those

who relapsed demonstrated greater discounting on the EDT. Consistent with predictions,

participants performed more impulsively on the EDT when they were sleep deprived (Reynolds

& Schiffbauer, 2004), and were less impulsive on the EDT following methylphenidate

administration in children diagnosed with Attention Deficit Hyperactivity Disorder (AD/HD;

Shiels, Hawk, Reynolds, Mazzullo, Rhodes et al., in press). These findings provide support for

the construct validity of the EDT, and demonstrate its sensitivity to state-dependent fluctuations

in impulsivity.

In support of its concurrent validity, EDT demonstrated significant correlations with

conventional (i.e., question-based) measures of delay discounting (r=.52) among adults

(Reynolds, 2006). Notably, the association between these measures was attenuated or absent in

adolescents (r=.10-.26; Reynolds et al., 2008; Melanko et al., 2009), suggesting developmental

differences in the relationships between measures. It has been suggested that this decreased

association in younger participants may be caused by measurement error for the question-based

measure, which was one reason the EDT was developed to be used with children. Nonetheless,

even among adolescent participants, question-based delay discounting, probability discounting

and the EDT were found to load onto a single factor, suggesting that a similar form of impulsive

decision-making underlies all three measures (Reynolds et al., 2008). Not unexpectedly, EDT is

not significantly associated with the BIS-11 total score (Melanko et al., 2009). Evidence for the

divergent validity of this measure was provided by nonsignificant correlations of EDT with

behavioral measures of impulsive disinhibition and impulsive inattention (Reynolds et al., 2008).
 The EDT has demonstrated good construct concurrent and divergent validity in adults

and adolescents. Moreover, its association with treatment response highlights its potential

clinical utility beyond conventional measures of delay discounting. However, continued research

is needed to determine its reliability.

Balloon Analogue Risk Task (BART; Lejuez et al., 2002).

The BART is a computerized measure of risk taking propensity that models real world

risk behavior with the potential for reward as well as the risk of harm (Leigh, 1999). In the task,

the participant is presented with a small balloon and asked to pump the balloon by clicking a

button on the screen. With each click, the balloon inflates .3 cm and actual money is added to the

participant’s temporary winnings. At any point, the participant has the option to press a button

labeled “Collect $$$” which deposits the amount in temporary winnings to the bank (i.e., it can

no longer be lost) and ends the trial, at which point new trial begins. However, each balloon is

programmed to pop somewhere between 1 and 128 pumps, with an average breakpoint of 64

pumps. If the participant fails to press “Collect $$$” before the balloon pops, all earnings for that

balloon are lost and the next balloon is presented. Risk-taking is defined as the average number

of pumps on un-popped balloons (Lejuez et al., 2002; Bornovalova, Daughters, Hernandez,

Richards & Lejuez, 2005), with higher scores indicating greater risk-taking. In addition, this task

provides a measure of latency in milliseconds between pumps number/percentage popped

balloons.

One critique of the BART is that repeated pumping needed to inflate a balloon might

actually be working against impulsive processes (i.e., a more impulsive response may actually be

to collect earnings more quickly, rather than delaying reward as the balloon grows larger). For
this reason Pleskac and colleagues (2008) developed an automatic version in which the

participant enters the desired number of pumps, then watches the balloon inflate. If the number

entered is less than the pre-determined explosion point, the participant receives the amount of

money associated with the number of pumps, whereas if the number entered is greater than the

popping point, the balloon pops and the reward is lost.

Reliability

There are two types of reliability data for the BART. Split-half reliability (or more

accurately, split-third), comparing scores across the first third, middle third, and final third of

trials, typically indicate strong correlations >.7 among the blocks (Lejuez et al., 2002; Lejuez,

Aklin, Zvolensky, & Pedulla, 2003). Adult participants tend to demonstrate modest increases

over the blocks (typically between 1-3 pumps; Lejuez et al., 2002; 2003), while scores tend to

decrease among adolescents (Lejuez et al., 2007). Data also have indicated test-retest reliability

among young adults when administered three times in the same session with modest significant

increases across administrations (T2-T1_ = 2.2, T3-T1_ = 2.3) and reasonably robust correlations

among these administrations (T1/T2 r = .79, T1/T3 r = .62; T2/T3 r = .82; Lejuez et al., 2003).

Additional evidence of reliability was indicated with the task presented twice across a 2-week

period with a nonsignificant increase across administrations (T2-T1_ = 1.2) and a reasonably

robust test-retest correlation (T1/T2 r = .77; White, Lejuez, & De Wit, 2008).

Validity

The BART is considered to be one of a small number of gold-standard measures of risk

taking (Harrison et al., 2005), with adult data indicating its link to risky sexual behavior (Lejuez
et al., 2002; Lejuez, Simmons, Aklin, Daughters & Dvir, 2004) and risky substance use

(Bornovalova et al., 2005; Lejuez et al., 2002; Lejuez et al., 2003; Lejuez et al., 2005; Pleskac et

al., 2008). In adolescent studies, performance on the BART (a youth version; Lejuez et al., 2007)

was found to significantly correlate with a variety of real world risk behaviors; namely, an

increase in RTP is associated with an increased frequency of substance use, gambling,

delinquency behaviors, and risky sexual behavior (Aklin, Lejuez, Zvolensky, Kahler, & Gwadz,

2005; Lejuez et al., 2005; Lejuez et al., 2007). It is notable that relationship of the BART to self-

report measures of disinhibition are inconsistent; findings indicate modest, though significant,

relationships found with sensation seeking (r=.20) , but nonsigificant relationships with self-

report and other behavioral measures of impulsivity (Bornovalova et al., 2005; Lejuez et al.,

2007).

The Iowa Gambling Task (Bechara, Damasio, Damasio & Anderson, 1994).

The IGT is a decision-making task, originally developed to examine decisional processes

associated with neuropsychological impairment (e.g., Bechara, Damasio, Damasio, & Anderson,

1994; Rogers, Everitt, Baldacchino, Blackshaw, Swainson et al., 1999). At the start of the IGT,

the participant is given $2000 and instructed to maximize earnings over the course of 100

decision-making trials. The participant provided with four decks of cards on a computer screen.

As described by Bechara et al. (2001), the decks are labeled A, B, C, and D at the top end of each

deck. All cards are identical and each card is associated with hypothetical payoffs or losses

(although versions with real financial contingencies are available). Cards from decks A and B

pay an average of $100 but also contain cards with higher losses, and cards from decks C and D

pay an average of $50, but the losses are smaller in magnitude. Accordingly, ten draws from
decks A and B (the “disadvantageous” decks) lead to a net loss of $250, while ten draws from

decks C and D (the “advantageous” decks) lead to a net gain of $250 (Bechara et al., 1994;

Buelow & Suhr, 2009). Several dependent variables from the IGT indicate risky decision

making, but the most widely reported indices are number or percentage of disadvantageous

choices over 100 trials, where larger values represent greater riskiness.

During the task, the participant clicks on a card from any of the four decks. Once

selected, the computer emanates a sound similar to that of a slot machine. The selected card

appears as either red or black, indicating whether money was lost or gained, and the value of the

reward or loss appears at the top of the screen. Following this feedback, the card disappears and

the participant selected another card. Each deck of cards is programmed to have 60 cards (30 red

and 30 black), although the participant is unaware of how many cards of each type are in each

deck. Losses are equally frequent in each deck.

Reliability

Data supporting the reliability of the IGT is limited. Findings have shown modest test-

retest stability over the course of three administrations in a single testing session (rs =.57-.59;

Lejuez et al., 2003). Moreover, repeated administrations have been found to lead to marked

practice effects in neurologically healthy participants, with the percentage of disadvantageous

decks dropping from 46 to 34 to 28 in the three administrations (Lejuez et al., 2003; see also for

a review Buelow & Suhr, 2009). For example, smokers and abstinent cocaine and marijuana

users showed improvements similar to controls (Lejuez et al., 2003), while adolescents with

disruptive behavior disorders failed to show improvement over one week (Ernst, Grant, London,

Contoreggi, Kimes et al., 2003). No test-retest data is available for individuals with more
compromised functioning (e.g., current substance users) who might display differential patterns

of learning across multiple administrations compared to controls.

Validity

The IGT originally was developed as a way to examine the processes underlying real-

world decision-making deficits observed in neurologically impaired patients (e.g., Bechara,

Damasio, Damasio, & Anderson, 1994; Rogers et al., 1999). However, there is a growing

literature to support IGT impairments among clinical groups characterized by impulsive and high

risk behavior. For instance, IGT impairments have been found among individuals dependent on

alcohol, cocaine, opioids and marijuana relative to healthy controls (Bartzokis, Lu, Beckson,

Rapoport, Grant, Contoreggi & London, 2000; Bechara, Dolan, Denburg, Hindes, Anderson et

al., 2001; Bechara & Damasio, 2002; Bolla, Eldreth, London, Kiehl, Mouratidis et al., 2003;

Bolla, Eldreth, Matochik & Cadet, 2005, Ernst et al., 2003, Goudriaan, Oosterlaan, de Beurs &

van den Brink, 2006; Monterosso, Ehrman, Napier, O’Brien & Childress, 2001, Verdejo-Garcia

& Perez-Garcia, 2007) with polysubstance users demonstrating even greater impairment

(Bechara & Martin, 2004; Grant et al., 2000). Pathological gamblers also have been found to

perform more poorly than controls on the IGT (Goudriaan et al., 2006). Findings with regard to

ADHD are inconsistent (e.g., Ernst et al., 2003; Malloy-Diniz, Fuentes, Leite, Correa & Bechara,

2007).

Although impulsive groups have been found to exhibit deficits on the IGT, Bechara (2003)

has argued that impulsivity and decision-making are cognitively and anatomically distinct

processes, both of which may be involved in the initiation and maintenance of disinhibited

behavior (Petry, 2001). In decision-making paradigms there is a problem that needs to resolved
by weighing competing options, a function associated with the ventral-medial cortex and the

orbitofrontal cortex (Bechara, 2003; Rahman, Sahakian, Rudolph, Rogers, & Robbins, 2001). In

contrast, impulsivity does not require a solution, but rather, inhibition of a dominant cognitive,

motor or behavioral response, functions associated with the lateral orbital and frontal cortices

and the anterior cingulate (Konishi, Nakajima, Uchida, Kikyo, Kameyama et al., 1999;

Lombardi, Andreason, Sirocco, Rio, Gross, Umhau et al., 1999). Consistent with these findings,

IGT was found to be associated with rate of delay discounting (r=.29-.37; Monterosso et al.,

2001), but not with behavioral measures of impulsive disinhibition (r= .08) or impulsive

inattention (r=.05; Stanford et al., 2009). Only a weak association was found between IGT and

BART (r=.14; Lejuez et al., 2003), with other unpublished work often showing negative

correlations. Further, despite findings of IGT deficits in clinical and non-clinical groups

characterized by risky, disinhibited behavior, IGT is weakly associated with lifetime engagement

in clinically relevant impulsive behavior in adults (r = .13; McCloskey, New, Siever, Goodman,

Koenigsberg, Flory et al., 2009) and adolescents (substance use: r = .22; delinquency: r = .12;

Aklin et al., 2005). Thus, the IGT has shown strong convergent validity with decision-making

tasks, and good divergent validity with measures of other facets of impulsivity. Data supporting

the relationship among the IGT and real-world risk behavior is evident, but a handful of

published studies fail to find such relationships.

Impulsive Inattention

Conners’ Continuous Performance Test (CPT-II; Conners, 1994, 2000)

The CPT-II is a computerized measure that assesses the ability to inhibit an ongoing

motoric response. Stimuli consist of single letters, which are presented for 250 ms at a variable
rate of one every 600-1500 ms. The task consists of 360 trials and requires 14 minutes to

administer. Participants are instructed to press the spacebar as quickly as possible in response to

each stimulus presentation unless the stimulus is an X. Impulsive responses are defined as errors

of commission (i.e., responses to X).

Generally, continuous performance tasks require the detection of relatively infrequent

target stimuli, and are therefore used as measures of attention, vigilance or executive processing

(Strauss, Sherman & Spreen, 2006). In contrast, the CPT-II is considered a measure of

impulsivity because it consists of 90% target stimuli (i.e., 90% of trials are letters other than X),

which establishes responding as the dominant response, making response inhibition more

difficult (Epstein, Conners, Sitarenios & Erdhardt,1998; Edwards, Gardner, Chelonis, Schulz,

Flake & Diaz, 2007).

Reliability

Internal consistency of the CPT-II was assessed using split-half reliability in a large

sample of adults, adolescents and children (Conners, 1994). For errors of commission, internal

consistency was found to be good (r=.83). Test-retest stability was assessed in a small sample of

healthy and clinical adults over approximately three months. Test-retest stability of errors of

commission was found to be marginal (r=.60-.69; Strauss et al., 2006). Practice effects have not

been examined. Low test-retest stability may limit interpretability of data from repeated

administrations of the CPT-II (e.g., as a clinical outcome or in repeated measures designs).

Validity

As noted previously, errors of commission (“false alarms” ) are the only dependent

variable from the CPT-II thought to reflect impulsivity. However, most validation studies of the
CPT-II have examined other performance indices as measures of attention and vigilance deficits

associated with ADHD; accordingly there is limited data to support its use as a measure of

impulsivity specifically. As general evidence of construct validity, several clinical groups

characterized by impulsivity have been found to demonstrate increased errors of commission.

The most robust findings come from ADHD samples, where both children and adults with

ADHD have been found to make more errors of commission than controls (Malloy-Diniz,

Fuentes, Borges Leite, Correa & Bechara, 2007; Rizzo, Bowerly, Buckwalter, Schultheis,

Matheis et al., 2002, Losier, McGrath & Klein, 1996). Adults with alcohol dependence

demonstrated a similar pattern of deficits (Salgado, Malloy-Diniz, Campos, Abrantes, Fuentes et

al., 2009), as did patients with bipolar disorder in the manic, but not euthymic phase of illness

(Bora, Vahip & Akdeniz, 2006). Taken together, the CPT-II appears to differentiate among

certain clinical groups characterized by impulsivity, providing preliminary support for its

construct validity.

Commission errors were found to be modestly correlated with all ADHD symptom

clusters in both children and adults (Angold & Costello, 1995; Rybak, McNeely, Mackenzie,

Jain & Levitan, 2007), providing some support for commission errors as a marker of impulsive

inattention, although commission errors do not appear to be uniquely related to impulsive

symptoms, indicating a lack of specificity. Bolstering these findings, commission errors were

significantly associated with BIS-11 total score (r=.44) and discounting rate on a measure of

delay discounting (r=.41) in a sample of adolescent smokers (Krishnan-Sarin, Reynolds, Duhig,

Smith, Liss, McFetridge et al., 2007), although other studies have failed to replicate this

relationship (Malloy-Diniz et al., 2007). As evidence of divergent validity, no association has

been found between commission errors and the Wisconsin Card Sorting Task or the Iowa
Gambling Task (Salgado et al., 2009), suggesting the independence of commission errors from

executive function and impulsive decision-making.

Immediate Memory Test and Delayed Memory Test (IMT/DMT; Dougherty, Bjork,

Harper, Mathias, Moeller & Marsh, 2003).

The IMT and DMT are variations on the continuous performance test paradigm,

developed to assess rapid response impulsivity. Like the other continuous performance tests, the

IMT and DMT require the participant to respond only when they detect a matched pair of stimuli

(a target trial). The IMT requires participants to compare successive stimuli, while the DMT

requires participants to compare every fourth stimuli, disregarding three presentations of filler

stimuli (Dougherty, Bjork, Moeller, Harper, Marsh et al., 2003). Therefore, there is a 500 ms

delay between comparison stimuli in the IMT and a 3500 ms delay between comparison stimuli

in the DMT (Dougherty et al., 2003b). Stimuli consist of five digit numbers, presented for 500

ms at a rate of one per second. The IMT and DMT are administered as a single task, with

alternating blocks of IMT and DMT. The entire task consists of 1100 trials (550 of each type),

and requires 21.5 minutes to administer. The measure yields two indices of impulsivity:

percentage commission errors (i.e., false alarms), defined as responding to a stimulus that

matches four of five digits, and the ratio of commission errors to correct detections (henceforth

referred to as IMT ratio and DMT ratio).

Of note, the Continuous Performance Task—Identical Pairs version (CPT-IP; Cornblatt,

Risch, Faris & Friedman,1988), which was initially developed as a test or vigilance, attention

and effortful processing, has also been employed as a measure of impulsivity (Ferraz et al., 2009;

Walderhaug, Lunde, Nordvik, Landro, Refsum & Magnusson, 2002). This task is highly similar
to the IMT, but has a lower number of “catch trials” (i.e., stimuli that are similar but not

identical to the previously presented stimulus). The IMT and DMT have a greater percentage of

target and “catch trials” than the CPT-IP (33% vs. 20% target, 33% vs. 18% false alarms), which

allows for greater variation in performance over 1,100 trials. As a result, the IMT and DMT are

sensitive to impulsivity and performance deficits in higher functioning populations (Dougherty et

al., 2003b), whereas the CPT-IP shows the greatest sensitivity in more impaired or

neurologically vulnerable samples (e.g., Cornblatt et al., 1988; Cornblatt, Lenzenweger, &

Erlenmeyer-Kimling, 1989).

Reliability

The IMT and DMT are commonly employed in repeated measure designs, and the authors have

suggested that evidence for test-retest reliability is provided by the consistency of scores across

multiple administrations within the same day and over multiple days (e.g., Dougherty, Bjork,

Marsh & Moeller, 2000; Dougherty, et al., 2005). However, because the authors have not

reported test-retest correlations, it is difficult to determine the stability of scores in relation to

conventional standards of test-retest reliability.

Validity

There is considerable literature to support the construct validity of both indices of

impulsivity derived from the IMT and DMT. Percentage commission errors and IMT/DMT

ratios on both tasks have been found to differentiate patients with bipolar disorder, borderline

personality disorder and other personality disorders, and disruptive behavior disorders from

healthy controls (Dougherty, Bjork, Huckabee, Moeller & Swann, 1999; Dougherty, et al.,
2003a; McCloskey et al., 2009). Among patients with bipolar disorder, IMT and DMT ratios and

percentage commission errors have been found to differentiate those with and without a history

of suicide attempt; further, among bipolar suicide attempters, patients with more medically

severe attempts demonstrated greater impulsivity on the IMT and DMT (Swann et al., 2005).

However, patients with schizophrenia did not differ from healthy controls in errors of

commission on the IMT, and actually made fewer errors of commission on the DMT (Dougherty,

Steinberg, Wassef, Medearis, Cherek et al., 1998), which may indicate the specificity of this

deficit to disinhibitory psychopathology.

As further evidence of construct validity, participants designated high in impulsivity on

the basis of the I-7 score (Eysenck et al., 1985) made a larger percentage of commission errors

on both IMT and DMT relative to participants low in impulsivity (Marsh, Dougherty, Mathias,

Moeller & Hicks, 2002). Moreover, IMT ratio was found to increase following alcohol

consumption (Dougherty et al., 2008), suggesting the measure’s sensitivity to state-dependent

variability in impulsivity. In all, both indices of impulsivity (i.e., percentage errors of

commission and IMT and DMT ratios) have shown strong evidence of construct validity.

On the other hand, support for the concurrent validity of the IMT and DMT is somewhat

inconsistent. The association of the BIS-11 subscales to the ratio of commission errors to correct

detections has been found to vary considerably, from non-significant associations among healthy

adults (Stanford et al., 2009), to modest (motor: r=.21, attentional: r=.17, non-planning: r=.18) in

a combined sample of individuals with personality disorders and healthy controls (McCloskey et

al., 2009). The association of IMT and DMT ratios to the BIS-11 was stronger among

hospitalized adolescents with disruptive behavior disorders (total: r=.35-.37, motor: r=.08-.14,

attentional: r=.25-.27, non-planning: r=.32-.35). Given the inconsistency of findings, it is

difficult to draw conclusions about the concurrent validity of the IMT and DMT based on its

associations with the BIS-11.

With regard to behavioral impulsivity measures, IMT and DMT indices were found to

correlate moderately with one another (percentage commission errors: r=.62, IMT and DMT

ratios: r=.71; Dougherty et al., 2003b; Marsh et al., 2002), suggesting that IMT and DMT assess

related, but not overlapping, constructs. Higher percentages of IMT and DMT commissions were

associated with likelihood of inhibitory failure on behavioral tasks of impulsive disinhibition

(r=.24-.33; Marsh et al., 2002), as are IMT and DMT ratios (r=.39-.46; Dougherty et al., 2003b).

IMT ratio was not associated with performance on tasks of impulsive decision making (i.e., IGT

or Two Choice Impulsivity Paradigm; Stanford et al., 2009; Dougherty, Mathias, Marsh-Richard,

Furr, Nouvion & Dawes, 2009), providing evidence of divergent validity.

In summary, IMT and DMT are commonly used measures of impulsive behavior that

have been used in a wide range of clinical and non-clinical populations. Despite their widespread

use, including in repeated measures designs, there is limited information available regarding the

reliability of these measures. Both the IMT and DMT demonstrate strong construct validity, and

good concurrent and divergent validity with behavioral impulsivity measures in normal and

clinical samples.

Impulsive Disinhibition

Stop-Signal Procedure (Logan, 1994; Logan & Cowan, 1984)

The Stop-Signal Procedure is a computerized measure designed to study inhibitory

control over an already-initiated response. Logan and Cowan (1984) suggest that inhibitory

control reflects competing go and stop processes; behavior depends on the finishing times of
each process. If the stop process begins early enough, the response will be inhibited, and if the

process begins late, the response will be executed. The Stop-Signal Procedure was developed to

examine the conditions under which inhibition is likely to fail or succeed.

Stimuli consist of four letters: two are assigned to one response and two are assigned to

another response. Participants respond by pressing keyboard keys with the index and middle

finger of their dominant hand. Each stimulus presentation is preceded by a presentation of a

fixation point for 500 ms. Stimuli are presented for 500 ms at a rate of one every three seconds.

The stop signal is a 500 ms, 900 Hz tone, which occurs at one of 10 delays (50-500 ms in 50 ms

increments) following the presentation of the target stimulus. The Stop Signal Procedure consists

of 800 trials, 25% of which are stop trials. Each delay was used 10% of the time. The measure

yields two indices of impulsivity: 1) probability of responding at any given delay, with higher

proportions indicating greater impulsivity; 2) stop-signal reaction time, or the latency to respond

in stop-signal trials, with slower (larger) response times indicating greater impulsivity.

Stop-signal reaction time cannot be observed directly, and is therefore derived. Because of the

theoretical complexity of some scoring approaches, Logan and colleagues have proposed an

alternate stop-signal procedure to estimate this value (Logan, Schachar & Tannock, 1997; the

reader is referred to Logan & Cowan, 1984 for the standard computational methods). Unlike the

original procedure, this modified Stop-Signal Procedure uses adjusting values for the delays,

based on the participant’s performance. That is, the delay increases by 50 ms if the participant

inhibits successfully, and decreases by 50 ms if the participant responds, eventually converging

on the delay interval at which the participant inhibits correctly 50% of the time. This value

represents the estimated stop-signal reaction time.

 Of note, a related test of disinhibition is the GoStop Task (Dougherty et al., 2005), which

builds off of the Stop-Signal Procedure. GoStop uses only visual stimuli (rather than visual and

auditory stimuli) and incorporates a motivational component; participants earn money for fast,

correct responses, and lose money for slow or incorrect responses. We focus on the SSRT

primarily because it has been used in a wider range of subject populations.

Reliability

To our knowledge, the test-retest stability of the Stop Signal task has only been evaluated

in children with (Kindlon, Mezzacappa & Earls, 1995) and without (Kuntsi, Stevenson,

Oosterlaan & Sonuga-Barke, 2001) externalizing disorders. As a brief review, the Stop Signal

task yields two indices of impulsivity: SSRT refers to the length of time the time it takes to

inhibit a go response 50% of the time on stop trials. The second index, probability of inhibition,

refers to the likelihood that the individual will inhibit successfully on a stop trial. The test-retest

stability for probability of responding has been found to be poor (r = .60), as was the test-retest

stability of stop signal reaction time (r = .23) over a two-week test-retest period (Kuntsi et al.,

2001). Moreover, participants tend to improve significantly (i.e., demonstrated less impulsivity)

on both indices from the first to second testing, suggesting the likelihood of practice effects

(Kuntsi et al., 2001; Rodriguez-Fornells, Lorenzo-Seva & Andres-Pueyo, 2002). These findings

highlight the need for future research into the reliability of this measure, particularly in adult

samples. Further, they raise questions about the utility of this instrument in repeated measures

designs or as an indicator of treatment response.

 Validity

The concerns regarding the reliability of SSRT impulsivity indices should not be ignored,

as an instrument cannot be valid without being reliable. However, the Stop Signal Procedure is

widely used and has a considerable body of research to support its utility as a measure of a

certain dimension of impulsivity. Impulsivity is implicated in the development and maintenance

of many forms of psychopathology and problematic behavior, yet prolonged SSRT appears to be

specific to certain forms of psychopathology, providing support for the construct validity of this

measure. The most consistent findings support the specificity of this type of impulsivity to

ADHD: adults with ADHD have shown longer stop signal reaction times than healthy controls

(Bekker, Overtoom, Kenemans, Kooij, De Noord et al., 2005; Lampe, Konrad, Kroener, Fast ,

Kunert et al., 2007; Chamberlain, del Campo, Dowson, Muller, Clark, Blackwell, Aron, Turner,

Dowson, Robbins et al., 2007; Aron, Dowson, Sahakian & Robbins, 2003). There is preliminary

evidence suggesting that this deficit is apparent in patients with trichotillomania and obsessive

compulsive disorder, but not in anxiety disorders more broadly (Chamberlain, Fineberg,

Blackwell, Robbins & Sahakian, 2006; Oosterlaan, Logan & Sergeant, 1998). Pathological

gamblers with a history of childhood ADHD demonstrated prolonged SSRTs, while pathological

gamblers without childhood ADHD did not differ from controls (Rodriguez-Jimenez, Avila,

Jimenez-Arriero, Ponce, Monasor et al., 2006). Prolonged SSRTs have also been found in groups

with cocaine dependence, alcohol dependence and methamphetamine use, although it is unclear

whether these deficits are the result of substance use, premorbid inhibitory deficits or a

combination of the two (Fillmore & Rush, 2002; Monterosso, Aron, Cordova, Xu & London,

2005; Goudriaan, Oosterlaan, de Beurs & van den Brink, 2008).

 The construct validity of likelihood of inhibition is somewhat less definitive. Whereas

children with ADHD demonstrate a clear deficit on this index relative to healthy controls (see

Oosterlaan et al., 1998 for a review) there has been little evidence of impairment on this index in

adult patients with ADHD, borderline personality disorder, or bipolar disorder (manic phase;

Clark et al., 2007; Bekker et al., 2005; Gruber, Rathgeber, Braunig & Gauggel, 2007;

Strakowski, Fleck, DelBello, Adler, Shear et al., 2009). Given the lack of findings with these

disorders and other forms of psychopathology commonly associated with significant cognitive

impairment (e.g., schizophrenia, depression; Huddy, Aron, Harrison, Barnes, Robbins et al.,

2009; Gruber et al., 2007), it is possible that this index is not sufficiently sensitive to impairment

in most adult samples. Although the construct validity of this index of impulsivity was upheld by

its relationship with childhood ADHD, continued research is needed to clarify the relationship of

this index of impulsivity with other variables of interest.

To evaluate the concurrent validity of SSRT, a number of studies have examined its

associations with self-report and other behavioral measures of impulsivity. Consistent with

findings across behavioral assessment measures, there was limited concordance in self-reports of

impulsivity and Stop Signal indices. For example, in most studies SSRT has not been found to

correlate with self-report measures of impulsivity (e.g., total score or any single factor of the

BIS-11, the I-7 or the Control subscale of the Multidimensional Personality Questionnaire; e.g.,

Reynolds, et al., 2006; Enticott, Ogloff & Bradshaw, 2006), although rare studies have found

associations (e.g., Lampe et al., 2007). On the other hand, SSRT has been found to correlate with

several behavioral indices of impulsivity, including errors of commission on a Go/No Task (r =

.28; Reynolds, Ortengren, Richards & De Wit, 2006) and errors of commission on a degraded

CPT (rs = .34-.50; Strakowski et al., 2009), both measures of impulsive inattention. Notably,
SSRT has not demonstrated associations with other behavioral measures of impulsivity (e.g.,

delay discounting, BART) or performance-based measures of executive function (e.g., WCST)

supporting its divergent validity (Reynolds et al., 2006; Wodushek & Neumann, 2003). Findings

suggest good concurrent validity with other measures of impulsive inattention.

Several of studies have examined the associations of the SSRT with clinical outcomes.

SSRT has been found to correlate with self-reported ADHD symptom severity, anger and

aggression in children and adults (Oosterlaan & Sergeant, 1996; Lampe et al., 2007; Wodushek

& Neumann, 2003) as a predictor of clinical outcomes, providing preliminary support for its and

its clinical utility. For example, SSRT combined with performance on a card-playing task

predicted 53% of the variance in relapse following treatment for pathological gambling, whereas

self-reported impulsivity was not predictive (Goudriaan et al., 2008). These findings are

especially surprising given that pathological gamblers have not been found to differ from

controls on SSRT (Rodriguez-Jimenez et al., 2006). In another study, SSRT was associated with

poorer outcomes among obese children participating in a weight reduction intervention. The

extent of overweight was correlated with SSRT throughout the study (rs = .46-.50), and was

associated with less weight loss at the end of treatment and at 12-month follow-up (Nederkoorn,

Jansen, Mulkens & Jansen, 2006). In general, findings support the potential predictive validity of

SSRT in a number of clinical outcomes, although continued research is needed to determine

whether it is associated with treatment outcome above and beyond other clinically relevant

variables.
Endnotes
1
Since its initial development, the UPPS has been used as a 44-item measure (Lynam & Miller,
2004), a 45-item measure (Anestis et al., 2007; Magid & Colder, 2007) and a 46-item measure
(Whiteside et al., 2005). We are not sure how to account for this variation, though it may reflect
minor variations in the factor loadings of certain items across samples. We have chosen to
include validity data from all UPPS, as we do not believe that the removal or addition of single
item would markedly alter the pattern of the findings. In Table 1, we present the means and
internal consistencies for the original 45-item measure using the largest sample available (n = 70,
82.9% female; Anestis et al., 2007). The reader is referred to Lynam and Miller (2004) for
normative data for the 44-item measure in college and community samples.
2
Notably, recent work has expanded the urgency construct to include positive urgency, the
tendency to behave rashly during positive mood . The Positive Urgency Measure (PUM; Cyders
& Smith, 2007) is often used in conjunction with the UPPS to understand relationships among
impulsivity-related constructs and engagement in risk behavior (e.g., Cyders, Flory, Rainer &
Smith, 2009).

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Table 1. Means, Standard Deviations and Internal Consistencies for Self-Report Symptom Assessments

for Impulse Control Disorders

# of Range Clinical Control Internal

Items M (SD) M (SD) Consistency

Gambling Symptom Assessment Scale a 12 0-48 23.9 (8.2) .87

Massachusetts General Hospital Hair 7 0-28 17.3 (5.1) .85

pulling Scale b

MGH-HPS: Severity 4 0-16 9.5 (3.4) .83

 MGH-HPS: Control 3 0-12 7.7 (2.5) .81

Milwaukee Inventory for Subtypes of

Trichotillomania—Adult Version c

MIST-A: Automatic 10 0-90 25.7 (9.0) .73

MIST-A: Focused 5 0-45 45.4 (16.2) .77

Kleptomania Symptom Assessment Scale d 11 0-44

Skin Picking Scalee 6 0-24 12.8 (3.8) 2.8 (2.6) .80

Skin Picking Impact Scale f 10 0-50 27.5 (16.6) 1.2 (3.5) .88-.93

Compulsive Sexual Behavior Inventory g

CBSI: Control 13 13-65 31.7 (9.8) 57.2 (3.4) .96

CBSI: Abuse 8 8-40 37.7 (2.8) 39.6 (.7) .91

CBSI: Violence 7 7-35 33.7 (2.0) 34.7 (.8) .88

a
Grant & Kim, 2009
b
Keuthen et al., 1995
c
Flessner et al., 2007
d
Grant & Kim, 2002
e
Keuthen et al., 2001a
f
Keuthen et al., 2001b
g
Coleman et al., 2001
Table 2. Means, Standard Deviations and Internal Consistencies for Commonly Used Self-Report

Measures of Impulsivity

# of Range Male M Female M Total M Internal

Items (SD) (SD) (SD) Consistency

BIS-11 Total a 30 0-120 62.8 (9.2) 62.1(10.6) 62.3 (10.3) .83

Second Order Subscales

BIS-11 Attentional 8 0-32 16.8 (3.9) 16.7 (4.1) 16.7 (4.1) .74

BIS-11 Motor 11 0-44 22.4 (3.4) 21.8 (4.1) 22.0 (4.0) .59

BIS-11 Non-Planning 11 0-44 23.6 (4.5) 23.6 (5.0) 23.6 (4.9) .72

First Order Subscales

BIS-11 Attention 5 0-20 10.3 (2.8) 10.4 (2.9) 10.4 (2.9) .72

BIS-11 Motor 7 0-28 15.2 (2.8) 15.0 (3.4) 15.0 (3.2) .64

BIS-11 Self-Control 6 0-24 12.4 (3.1) 12.0 (3.3) 12.1 (3.3) .72

BIS-11 Cognitive Complexity 5 0-20 11.3 (2.4) 11.6 (2.6) 11.5 (2.6) .48

BIS-11 Perseverance 4 0-15 7.2 (1.8) 6.8 (1.7) 6.9 (1.8) .27

BIS-11 Cognitive Instability 3 0-12 6.4 (1.8) 6.3 (1.9) 6.4 (1.9) .55

UPPS Urgency b 12 0-48 30.7 (9.4) .91

UPPS (lack of) Perseverance 10 0-40 31.8 (6.6) .87

UPPS (lack of) Premeditation 11 0-44 36.7 (7.7) .81

UPPS Sensation Seeking 12 0-48 38.1 (11.1) .91

I-7 Impulsiveness c 19 0-19 8.8 (4.3) 8.2 (4.4) .84

I-7 Venturesomeness 16 0-16 10.6 (3.2) 8.3 (3.8) .85

I-7 Empathy 19 0-19 11.2 (3.5) 14.3 (3.1) .69

a
Stanford et al., 2009
b
Anestis et al., 2007
c
Eysenck et al., 1985

Recommended Readings
1. Bechara, A. (2003). Risky Business Emotion, Decision-Making, and Addiction. Journal of
Gambling Studies, 19(1), 23-51.
2. Bornovalova, M.A., Daughters, S.B. B., Hernandez, G. D. Richards, J. R., & Lejuez, C.W.
(2005). Differences in impulsivity and risk-taking propensity between primary users of
crack/cocaine and primary users of heroin in a residential substance use program.
Experimental and Clinical Psychopharmacology, 13, 311-318.

3. Buelow, M.T. & Suhrl, J.A. (2009). Construct validity of the Iowa gambling task.
Neuropsychology Review, 19(1), 102-114.

4. Dougherty, D. M., Bjork, J. M., Harper, R. A., Mathias, C. W., Moeller, F. G., & Marsh, D.
M.(2003). Validation of the immediate and delayed memory tasks in hospitalized
adolescents with disruptive behavior disorders. Psychological Record, 53, 509-532.

5. Goudriaan, A., Oosterlaan, J., de Beurs, E., & van den brink, W. (2008). The role of self-
reported impulsivity and reward sensitivity versus neurocognitive measures of
disinhibition and decision-making in the prediction of relapse in pathological gamblers.
Psychological Medicine, 38(1), 41-50.

6. Lejuez, C.W., Read, J., Kahler, C., Richards, J., Ramsey, S., Stuart, G., et al. (2002).
Evaluation of a behavioral measure of risk taking: The Balloon Analogue Risk Task
(BART). Journal of Experimental Psychology: Applied, 8(2), 75-84.

7. Logan, G., & Cowan, W. (1984). On the ability to inhibit thought and action: A theory of an
act of control. Psychological Review, 91(3), 295-327.

8. Lynam, D., & Miller, J. (2004). Personality Pathways to Impulsive Behavior and Their
Relations to Deviance: Results from Three Samples. Journal of Quantitative
Criminology, 20(4), 319-341.

9. Reynolds, B., Penfold, R.B. & Patak, M. (2008). Dimensions of Impulsive Behavior in
Adolescents: Laboratory Behavioral Assessments. Experimental and Clinical
Psychopharmacology, 16(2), 124-131.

10. Stanford, M.S., Mathias, C.W., Dougherty, D.M., Lake, S.L., Anderson, N.E. & Patton, J.H.
 (2009). Fifty years of the Barratt impulsiveness scale: An update and review. Personality
and Individual Differences, 47, 385-395.

11. Whiteside, S., & Lynam, D. (2001). The Five Factor Model and impulsivity: Using a
structural model of personality to understand impulsivity. Personality and Individual
Differences, 30(4), 669-689.

Glossary

Classification Accuracy: The ratio of correct identifications to total number of cases assessed
(Gunnarsson & Lanke, 2002).

Concurrent validity: The extent to which a measure correlates with other measures of the same or
similar constructs, when measurement occurs at the same time, reported as r (Groth-Marnat,
2005).

Construct validity: The broadest type of validity, the extent to which hypothesized relationships
exist among the measure and other variables (Groth-Marnat, 2005).

Divergent validity: The extent to which a measure does not demonstrate correlations with
theoretically unrelated variables (Groth-Marnat, 2005).

Internal consistency: The extent to which the items on a single measure are associated with one
another. The extent to which a measure is assessing a single construct, reported as Cronbach’s α
(Groth-Marnat, 2005).

Inter-rater reliability: The extent to which two scorers agree in their ratings of a single item or
the measure as a whole, reported as κ (parametric) or Φ (nonparametric; Groth-Marnat, 2005).

Negative predictive value: Of all negative cases identified by a measure, the percentage that are
correctly classified (Gunnarsson & Lanke, 2002).

Positive predictive value: Of all positive cases identified by a measure, the percentage that are
correctly classified (Gunnarsson & Lanke, 2002).

Predictive validity: The extent to which a measurement taken at Time 1 correlates with the
measurement of another variable at Time 2, reported as r (Groth-Marnat, 2005).
 Sensitivity: The percentage of true positives identified by a measure Gunnarsson & Lanke,
2002).

Specificity: The percentage of true negatives identified by a measure (Gunnarsson & Lanke,
2002).

Split-half reliability: The extent to which scores from one half of a measure are correlated with
scores from the other half (e.g., odd and even items), reported as r (Groth-Marnat, 2005).

Test-retest reliability (stability): The extent to which the measure produces consistent (i.e.,
correlated) scores over two or more administrations, reported as r (parametric) or ρ
(nonparametric; Groth-Marnat, 2005).

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