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This chapter focuses on impairments in inhibitory control and executive function in addiction. It reviews the role of prefrontal cortical circuits in regulating impulses, evaluating consequences, and guiding goal-directed behavior. Behavioral tasks and neuroimaging studies illustrate how weakened top-down control contributes to compulsive use and relapse. Importantly, the chapter also highlights evidence for neural plasticity and the recovery of control functions with sustained abstinence and intervention.
Violence risk is elevated during the early phase of psychosis and can have significant consequences for engagement, recovery, and safety. BRAVE (Behavioral Response Against Violence Engagement) is a cognitive-behavioural intervention adapted from the PICASSO model for use in early intervention services (EIS) that targets dynamic, modifiable mechanisms associated with psychosis-related violence. This open pilot trial evaluated the feasibility, acceptability, fidelity, and preliminary target engagement of BRAVE when delivered by clinicians within routine EIS care. Seven clinician–client dyads were enrolled across OnTrackNY sites; five completed the intervention, with a mean of 11.4 sessions. Feasibility and acceptability were high: clinicians rated BRAVE as useful and deliverable within standard visit structures. Fidelity ratings were high across both clinician and client checklists. Although violent behaviour was infrequent at baseline, exploratory clinical outcomes suggested reductions in violent ideation over time. The primary hypothesized mechanistic target, impulsivity, remained stable but secondary mechanistic outcomes showed directionally positive movement across the affective, cognitive, behavioural, and physiological domains expected to shift with BRAVE, including reductions in hostility, negative self-appraisal, persecutory thinking, substance use, and sleep disturbance, alongside increased coping self-efficacy. Overall, findings indicate that BRAVE can be implemented with high fidelity and strong acceptability within participating clinician–client dyads in EIS settings, and offer preliminary descriptive patterns consistent with the hypothesized mechanistic model.
Key learning aims
(1) To describe how BRAVE was adapted for early intervention services (EIS) and delivered by clinicians within routine care, including considerations of feasibility, acceptability, and fidelity.
(2) To summarize descriptive, pre–post observations from an open pilot trial of BRAVE, including changes in impulsivity and related affective, cognitive, behavioral, and physiological processes.
(3) To identify implications for future implementation and evaluation, including lessons learned about fidelity measurement, patient-facing materials, and considerations for a larger pragmatic trial.
Gambling disorder frequently co-occurs with other psychiatric conditions, yet its relationship with obsessive-compulsive disorder (OCD) remains unclear. Emerging evidence suggests impulsivity and compulsivity may be inter-related rather than diametrically opposed constructs, warranting investigation of their clinical overlap. The aim of this study is to examine the rate of gambling disorder in adults with OCD and to explore associated clinical, behavioral, and treatment-related characteristics.
Methods
Adults with probable OCD were recruited via online Reddit groups for OCD, OCD clinics, and support groups and completed a cross-sectional survey. OCD symptom types were assessed using the Obsessive-Compulsive Inventory-Revised, and gambling disorder was identified using the Minnesota Impulsive Disorders Interview. Additional measures included gambling severity, impulsivity, and problematic internet use. Group comparisons were conducted between participants with and without gambling disorder.
Results
Among 186 adults with OCD, 34 (18.8%) met criteria for gambling disorder. Individuals with comorbid gambling disorder demonstrated significantly greater OCD severity, particularly in ordering, checking, and neutralizing symptoms, and reported later onset of OCD. The comorbid group showed higher impulsivity, greater problematic internet use, and distinct gambling behaviors, including higher rates of online gambling, esports betting, and use of artificial intelligence tools for gambling. They were also less likely to have received pharmacological treatment for OCD.
Conclusions
Gambling disorder in adults with OCD is associated with distinct clinical characteristics, greater impulsivity, problematic internet use, and concerning treatment gaps. These findings highlight the importance of screening for gambling in OCD, and vice versa, and suggest a need for integrated treatment approaches.
Edited by
Liz McDonald, East London NHS Foundation Trust,Roch Cantwell, Perinatal Mental Health Service and West of Scotland Mother & Baby Unit,Ian Jones, Cardiff University
This chapter is an essential guide to recognising and treating ADHD in the perinatal period, an increasingly common scenario which specialist community and inpatient perinatal services face. We explore issues specific to assessing and treating women with ADHD. The features of how the disorder is classified are discussed, including information on how ADHD may present differently in women. The challenges of identifying ADHD in females are considered along with common comorbidities. A summary of guidance on treating this disorder in adults is included, with information on pharmacological and non-pharmacological treatment options. An outline of the essential investigations required before initiating medication for a woman is provided, along with details on the necessary ongoing physical health monitoring. Both stimulant and non-stimulant medicines are discussed with details on the various formulations available in the UK and practical tips on prescribing in the perinatal period. Specific issues to explore at follow-up are outlined. Special consideration is given to recognising and treating ADHD in the perinatal period. This includes during the pre-conceptual period, prescribing in pregnancy and the postnatal period including breastfeeding. The impact of ADHD on parenting is also considered. This is essential reading on a commonly misunderstood disorder for all perinatal clinicians.
Negative urgency is a transdiagnostic risk factor for a plethora of mental disorders. Internalizing symptoms are embedded in theories of negative urgency, yet we know little regarding how developmental changes in each coincide, and if changes in one predict changes in the other across middle adolescence. This study filled these voids in the literature, with N = 754 (52% female) community-recruited youth from the National Consortium on Alcohol NeuroDevelopment in Adolescence (NCANDA) study reporting internalizing symptoms and negative urgency annually. Negative urgency and internalizing symptoms were highly correlated at the between-person level, and between-person correlations were nearly double in size within male versus female adolescents. At the within-person level, changes in negative urgency and internalizing symptoms co-occurred across ages 14–18 but not age 13. Age 14 within-person changes in negative urgency prospectively predicted age 15 within-person changes in internalizing symptoms, and this effect was nearly double in size within female versus male adolescents. Findings held when accounting for externalizing symptoms, other impulsive personality traits, parenting, and school transitions. Results indicate that relations between negative urgency and internalizing symptoms were demonstrated across and within adolescents, with time-varying changes in negative urgency at age 14 being particularly impactful in terms of future internalizing symptoms.
Suicidal ideation, plans and attempts, is a leading public health issues among adolescents worldwide, including in Pakistan. This study examines the effectiveness of a culturally adapted didactic strategy (CADS) in targeting suicidal ideation and associated symptomatology (ClinicalTrials.gov: NCT05324670).
Method:
Adolescents (n = 70, male) expressing suicidal ideation who recently engaged in self-harm (previous 6 months), were assigned to 6 sessions (weekly) of CADS or a control intervention (psycho-education material) and assessed pre- and post-intervention utilising the Beck Scale for Suicidal Ideation (BSS), the Depression, Anxiety and Stress Scale-21 (DASS-21) and Barratt Impulsiveness Schedule-II (BIS-II).
Results:
Participants in the CADS cohort demonstrated a significant reduction in suicidal ideation compared to controls at treatment end (F = 266.7, p < 0.001, ηp2 = 0.80), and six-weeks post intervention. Individuals receiving CADS demonstrated a modest reduction in attentional (F = 32.5, p < 0.001, ηp2 = 0.33), motoric (F = 45.9, p < 0.001, ηp2 = 0.41) and non-planning impulsivity (F = 21.9, p < 0.001, ηp2 = 0.25), in depressive (F = 142.2, p < 0.001, ηp2 = 0.68), and anxiety symptoms (F = 43.9, p < 0.001, ηp2 = 0.40) and stress levels (F = 96.4, p < 0.001, ηp2 = 0.59). These findings were maintained at six-week follow-up.
Conclusion:
CADS was an effective short-term intervention in reducing suicidal ideation, impulsivity, depressive and anxiety symptoms in a high school adolescent male population. Future studies including an active comparator and greater participant diversity would further elucidate the potential efficacy of this intervention.
Neurodevelopmental models regard impulsivity as a central risk factor for adolescent substance use. However, the practical utility of impulsivity in predicting substance use is complicated by variability among measures that encompass multiple methods and theoretical domains. Prior research has been constrained by cross-sectional designs, small sample sizes, and/or the use of a narrow subset of impulsivity measures.
Method
Leveraging the ABCD dataset (n = 11,868), we identified and replicated correlations among impulsivity measures and assessed their prospective longitudinal and concurrent predictive utility regarding adolescent substance use outcomes before 15 years old. We then used simulation to inform how associations between impulsivity and substance use vary across sampling strategies (population vs. high-risk cohorts) and sample sizes.
Findings
Correlations between questionnaire and behavioral measures of impulsivity were small, and questionnaires significantly outperformed behavioral measures in predicting substance use initiation, largely due to the contribution of the CBCL externalizing scale. Predictions of substance use based on impulsivity were statistically detectable but small according to clinical standards (AUCs 0.6–0.76), exhibiting sensitivity to sample size and base rate of substance use, and thus, poor absolute predictive performance. Large samples (n > 1,000) were needed to achieve adequate power for impulsivity measures to predict substance use initiation.
Conclusion
These results support a significant but small contribution of impulsivity in predicting the onset of early adolescent substance use, indicating that these factors alone are insufficient for clinically deployable prediction. In community samples, large sample sizes are needed for reproducible impulsivity prediction of adolescent substance use.
Investigating the relationship between behavioural addictions and mental health is essential due to their impact on well-being and the significant barriers they create to achieving lasting recovery. The aim of the study was to examine the prevalence of food addiction, problematic internet use, and internet gaming disorder among 866 high school students (grades 9–12) in Turkey, Bingöl and their associated with impulsivity, emotional regulation, depression, anxiety, and stress.
Methods:
The sample was selected using a convenience sampling approach. Data were collected via online questionnaires using validated scales and analysed with SPSS package programme.
Results:
The prevalence of food addiction was 6.9%, problematic internet use 14.3%, and internet gaming disorder 0.9%. Problematic internet use relatively high prevalence likely reflects adolescents’ increased exposure to digital devices. Mental health factors were found to be significantly related to behavioural addictions: depression, anxiety, and stress predicted food addiction; depression and stress predicted problematic internet use, and anxiety was linked to internet gaming disorder.
Conclusions:
This study contributes to the literature by examining multiple behavioural addictions and their common risk factors simultaneously and provides a comprehensive perspective. It is also one of the rare studies examining food addiction with other behavioural addictions. More research is needed to develop better intervention programmes and policies in the issue.
Skin picking disorder is characterized by repetitive excoriation of one’s skin. Although skin picking disorder is associated with substance use problems, no previous research has examined the associations of alcohol use on skin picking symptomatology.
Methods
Adults with skin picking disorder (n = 182) were recruited from the general community via an online survey. Participants completed the Alcohol Use Disorders Identification Test (AUDIT) to measure alcohol use and various self-report measures to assess clinical profiles and associated characteristics. We compared variables of interest between those with hazardous alcohol use in the past year (AUDIT ≥8) compared to those with low-risk or no alcohol use in the past year. We also examined the extent to which skin picking disorder symptoms were dimensionally related to AUDIT scores while controlling for confounders.
Results
Of the 182 adults with skin picking disorder, 62 (34.1%) met criteria for hazardous alcohol use. Hazardous drinking was associated with less frequent skin picking but higher overall picking-related severity and impairment, aggression, and rates of comorbid borderline personality disorder, gambling disorder, and compulsive sexual behavior disorder. Skin picking-related impairment predicted the degree of hazardous drinking while controlling for sex.
Conclusions
This study highlights the importance of screening for hazardous alcohol use in people with skin picking disorder. More research is needed to explore the relationship between aggression, hazardous alcohol use, and skin picking, as well as how treatments might best be adapted to treat individuals with this cluster of symptoms.
Impulsivity, a multifaceted construct, is a core feature of borderline personality disorder (BPD), associated with functional impairment and suicide mortality. Findings on motor inhibitory control, a key dimension of impulsivity, in BPD are heterogeneous.
Methods
This PRISMA-guided meta-analysis examines motor inhibitory control in adults with BPD compared to healthy controls (HCs), using Stop-Signal Task and Go/No-Go Task data. Thirty-seven datasets from 35 articles were included.
Results
Results from random-effect models suggest that BPD patients exhibit significantly higher motor inhibitory control deficits than HCs, with a small to moderate effect size. Contrary to common assumptions, a mixed-model effect found that emotional factors did not moderate inhibitory control in BPD. Finally, the meta-analysis revealed that self-reported impulsivity measures did not correlate with task performance, suggesting that subjective and objective measures of impulsivity may assess different facets of the construct.
Conclusions
These findings highlight the need for greater standardization of task-based measures of impulsivity, as methodological heterogeneity and quality currently limit replicability across studies.
Impulsivity is among the strongest correlates of substance involvement (i.e. a broad continuum of substance-related behaviors), and distinct domains (e.g. sensation seeking [SS] and urgency) are differentially correlated, phenotypically and genetically, with unique substance involvement stages. Examining whether polygenic influences for distinct impulsivity domains are differentially predictive of early substance use initiation – a major risk factor for later problematic use – may improve our understanding of the role of impulsivity in addiction etiology.
Methods
Data collected from participants of genetically inferred European ancestry enrolled in the Adolescent Brain Cognitive Development StudySM (n = 4,808) were used to estimate associations between polygenic scores (PGSs) for UPPS-P impulsivity domains (i.e. SS, lack of premeditation [LPREMED]/perseverance [LPERSEV], and negative/positive urgency [NU/PU]) and substance (i.e. any, alcohol, nicotine, and cannabis) use initiation by age 15 years. Mediation models examined whether child impulsivity (ages 9–11 years) mediated links between PGSs and substance use initiation.
Results
SS-PGS was significantly associated with any substance and alcohol use initiation (odds ratio [ORs] > 1.10, psFDR < 0.05). LPERSEV and NU/PU PGSs were nominally associated with alcohol and nicotine use initiation, respectively (ORs > 1.06, ps < 0.05, psFDR > 0.05). No significant associations were observed for LPREMED-PGS or cannabis use initiation. Measured impulsivity domains accounted for 5–9% of associations between UPPS-P PGSs and substance use initiation.
Conclusions
Genetic influences for distinct impulsivity domains have differential associations with early substance use initiation, with SS showing the most robust associations, highlighting valuable etiological insight into the earliest stages of substance involvement that may be leveraged to improve prevention and intervention strategies.
Women diagnosed with premenstrual dysphoric disorder (PMDD) report significant symptom relief when treated with selective serotonin reuptake inhibitors, but few studies have addressed the possibility of capturing this effect in behavioral, laboratory-based tests. This study examined the effects of intermittent treatment with escitalopram (vs. placebo) on a behavioral measure of impulsivity and inattentiveness in women reporting high levels of premenstrual irritability and anger.
Methods
Participants (N = 27) rated cardinal PMDD mood symptoms over three menstrual cycles using Visual Analogue Scales. In Cycles 2 and 3, participants displaying cyclicity with respect to the irritability/anger item received escitalopram (20 mg) or placebo in a randomized, single-blind, crossover design. The participants completed the Conners Continuous Performance Test (CPT 3) in the luteal phase of the intervention cycles. Additionally, they filled out the UPPS Impulsive Behavior Scale, once in the luteal phase and once in the follicular phase of the placebo cycle.
Results
In line with previous reports, escitalopram caused a significant reduction in self-rated irritability and anger in the luteal phase. When on escitalopram, the participants demonstrated a lower frequency of anticipatory responses and greater consistency in response speed in the CPT 3. With respect to self-reported impulsivity, participants reported higher levels of urgency and lower levels of sensation seeking in the luteal placebo phase versus the follicular phase.
Conclusions
The finding that escitalopram impacted the outcome of the CPT 3 test in women with premenstrual irritability highlights the possible role of impulsivity in this condition.
The significant heterogeneity among individuals who die by suicide complicates prevention, suggesting that a “one-size-fits-all” approach is insufficient. It is crucial to identify distinct subgroups for targeted strategies. This study aims to characterize suicide profiles based on trait impulsivity and related factors.
Methods
Data from the FRieNDS project (Factores de Riesgo en Defunciones por Suicidio – Risk Factors in Suicide Deaths), a psychological autopsy study of 408 suicide deaths, were used. After determining the optimal number of clusters via stability analysis through agglomerative nesting, a final cluster analysis was performed on 391 valid suicide deaths (defined as cases with no missing data on the variables used for clustering) using k-means on a lower-dimensional representation of the data encoded by an autoencoder. Key clustering variables included sex, impulsivity (Barratt Impulsivity Scale-11), aggression, intent to die, previous history of suicide attempts, history of substance abuse, psychotic and affective disorders, and the presence of a depressive episode at the time of death.
Results
We identified three clusters: (1) Impulsive-aggressive (29.8%), characterized by high rates of Cluster B disorders, substance abuse, more stressful events, and low lethal intent; (2) depressive prior attempters (24.5%), which comprised mostly women and showed greater behavioural changes before death; and (3) non-impulsive/aggressive (45.7%), a group with no clear psychopathological profile, less healthcare contact, and minimal communicated intent to die, despite having few prior attempts.
Conclusions
Our study identified three suicide clusters with varying impulsivity levels, highlighting the need for tailored interventions and community-level research for better suicide prevention strategies.
Impulsivity and aggression are known risk factors for suicide, with observed age and sex differences in their impact.
Aims
To explore variations in impulsivity and aggression based on sex and age and examine their roles in predicting suicide.
Method
We examined 582 participants (406 individuals who died by suicide, 176 non-suicidal sudden-death controls) using the psychological autopsy method. Measures of impulsivity and aggression included the Barratt Impulsiveness Scale (BIS) and the Brown–Goodwin History of Aggression (BGHA). Participants were categorised into four groups: suicide male, control male, suicide female and control female. For group comparisons, we used analyses of variance and Spearman’s rank correlation to assess the relationship between age and BIS and/or BGHA ratings. Stepwise logistic regression was used to identify predictors of suicide for each sex.
Results
Higher levels of BIS and BGHA ratings were found in the suicide group compared with controls (BIS: 51.3 v. 42.2, P = 0.002, η2 = 0.017; BGHA: 7.1 v. 4.1, P < 0.001, η2 = 0.028), with no significant sex differences. BIS and BGHA ratings decreased with age in the suicide groups (suicide male: impulsivity ρ = −0.327, P < 0.001; suicide female: aggression ρ = −0.175, P = 0.038) but not among controls. Logistic regression analysis revealed that for men, aggression (odds ratio 1.072, 95% CI: 1.032–1.112) was a key predictor. For women, younger age (odds ratio 0.970, 95% CI: 0.948–0.993), low BIS impulsivity ratings (odds ratio 1.018, 95% CI: 1.001–1.036) and living with children (odds ratio 0.448, 95% CI: 0.208–0.966) were protective factors.
Conclusions
Impulsive and aggressive behaviours are critical factors in suicide risk among younger individuals, indicating an age effect but no sex dimorphism, with aggressive behaviours being a better predictor for men and impulsive and aggressive behaviours for women.
In this chapter we examine the idea of Hoarding Disorder. This relatively new diagnosis was first described in the American Psychiatric Association’s Diagnostic and Statistical Manual which was published in 2013. Hoarding Disorder is used to describe hoarding which is associated with an extreme attachment to items which are hoarded. Although people with Hoarding Disorder may suffer from other problems such as depression and anxiety, in Hoarding Disorder it is thought that the hoarding is not due to another diagnosis or problem. However, how Hoarding Disorder can present with other diagnoses, as well as the concept of conditions with increased risk taking and impulsivity and how they can be linked, even in the same person with increased compulsivity and avoidance of risk. Because the concept of Hoarding Disorder has only been described relatively recently, there is a lack of research in this area. Whereas Hoarding Disorder is often described in the elderly or late middle-aged, it is thought to have its roots in childhood. In this chapter we will examine the presentation of Hoarding Disorder in all age groups.
As well as examining the description and diagnosis of Hoarding Disorder, in this chapter we will also look at the risks inherent in the hoarding itself as well as the risk of suicide. Theories and research about the possible causes of Hoarding Disorder will be discussed.
Impulsivity is a multidimensional trait associated with substance use disorders (SUDs), but the relationship between distinct impulsivity facets and stages of substance use involvement remains unclear.
Methods
We used genomic structural equation modeling and genome-wide association studies (N = 79,729–903,147) to examine the latent genetic architecture of nine impulsivity traits and seven substance use (SU) and SUD traits.
Results
We found that the SU and SUD factors were strongly genetically inter-correlated (rG=0.77) but their associations with impulsivity facets differed. Lack of premeditation, negative and positive urgency were equally positively genetically correlated with both the SU (rG=.0.30–0.50) and SUD (rG=0.38–0.46) factors; sensation seeking was more strongly genetically correlated with the SU factor (rG=0.27 versus rG=0.10); delay discounting was more strongly genetically correlated with the SUD factor (rG=0.31 versus rG=0.21); and lack of perseverance was only weakly genetically correlated with the SU factor (rG=0.10). After controlling for the genetic correlation between SU/SUD, we found that lack of premeditation was independently genetically associated with both the SU (β=0.42) and SUD factors (β=0.21); sensation seeking and positive urgency were independently genetically associated with the SU factor (β=0.48, β=0.33, respectively); and negative urgency and delay discounting were independently genetically associated with the SUD factor (β=0.33, β=0.36, respectively).
Conclusions
Our findings show that specific impulsivity facets confer risk for distinct stages of substance use involvement, with potential implications for SUDs prevention and treatment.
One of the most relevant risk factors for suicide is the presence of previous attempts. The symptomatic profile of people who reattempt suicide deserves attention. Network analysis is a promising tool to study this field.
Objective
To analyze the symptomatic network of patients who have attempted suicide recently and compare networks of people with several attempts and people with just one at baseline.
Methods
1043 adult participants from the Spanish cohort “SURVIVE” were part of this study. Participants were classified into two groups: single attempt group (n = 390) and reattempt group (n = 653). Different network analyses were carried out to study the relationships between suicidal ideation, behavior, psychiatric symptoms, diagnoses, childhood trauma, and impulsivity. A general network and one for each subgroup were estimated.
Results
People with several suicide attempts at baseline scored significantly higher across all clinical scales. The symptomatic networks were equivalent in both groups of patients (p > .05). Although there were no overall differences between the networks, some nodes were more relevant according to group belonging.
Conclusions
People with a history of previous attempts have greater psychiatric symptom severity but the relationships between risk factors show the same structure when compared with the single attempt group. All risk factors deserve attention regardless of the number of attempts, but assessments can be adjusted to better monitor the occurrence of reattempts.
Attention Deficit Hyperactivity Disorder (ADHD) is a heterogeneous condition presenting with hyperactivity, impulsivity, and inattention that is pervasive. ADHD is a neurodevelopmental disorder with onset during childhood. Functional impairment can be manifested in academic, occupational, or social domains (American Psychiatric Association 2013; ICD-11 (11th revision) 2019). The degree of inattention and/or hyperactivity and impulsivity is beyond what is expected for the person’s age or level of intellectual abilities and can’t be explained by another mental disorder, The chapter presents an overview of the condition, including gender or other forms of variations in presentation, the many treatments with medication available, and its relevance.
Suicide rates are rising among U.S. youth, yet our understanding of developmental mechanisms associated with increased suicide risk is limited. One high-risk pathway involves an interaction between heritable trait impulsivity and emotion dysregulation (ED). Together, these confer increased vulnerability to nonsuicidal self-injury (NSSI), suicide ideation (SI), and suicide attempts (SAs). Previous work, however, has been limited to homogeneous samples. We extend the Impulsivity × ED hypothesis to a more diverse sample of adolescents (N = 344, ages 12–15 at Baseline, 107 males and 237 females) who were treated for major depression and assessed four times over two years. In multilevel models, the impulsivity × ED interaction was associated with higher levels and worse trajectories of NSSI, SI, and SAs. As expected, stressful life events were also associated with poorer trajectories for all outcomes, and NSSI was associated with future and concurrent SI and SAs. These findings extend one developmental pathway of risk for self-harming and suicidal behaviors to more diverse adolescents, with potential implications for prevention.
Impulsivity is elevated in psychosis and during mania in bipolar disorder. Studies in unaffected relatives may help establish whether impulsivity is a heritable, state independent endophenotype. The aim of this systematic review and meta-analysis was to examine whether impulsivity is elevated in unaffected relatives of those with bipolar disorder, schizophrenia, and schizoaffective disorder, compared to controls. Databases were systematically searched up until March 2023 for articles reporting data on a behavioral or self-report measure of impulsivity in first-degree relatives and controls. Nineteen studies were included. Behavioral (10 studies, d = 0.35, p < 0.001) and self-reported impulsivity was significantly elevated in bipolar disorder relatives compared to controls (5 studies, d = 0.46, p < 0.001), with small effect sizes. Relatives of those with schizophrenia did not show significantly elevated impulsivity compared to controls on behavioral measures (6 studies, d = 0.42, p = 0.102). There were not enough studies to conduct a meta-analysis on self-report data in schizophrenia relatives or schizoaffective disorder relatives (self-report or behavioral). Study quality was good, however there was moderate to high heterogeneity in behavioral meta-analyses. Results suggest elevated impulsivity may be an endophenotype for bipolar disorder, present in an attenuated state before and after the illness and in at-risk individuals. This trait, amongst other behavioral and psychological indices, could be used to identify those who are at risk of developing bipolar disorder. Future research should refine measurement across studies and establish which components of impulsivity are affected in those at risk of psychotic and bipolar disorders.