Tobacco status impulsivity and the five-factor of the PANSS in paranoid schizophrenia

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Tobacco status, impulsivity, and the five-factor of the PANSS in paranoid schizophrenia

Mounir Ouzir, Jean Michel Azorin, Nadia Correard, Sara-Nora Elissalde, Romain Padovani, Christophe Lançon, Omar Battas & Driss Boussaoud

To cite this article: Mounir Ouzir, Jean Michel Azorin, Nadia Correard, Sara-Nora Elissalde, Romain Padovani, Christophe Lançon, Omar Battas & Driss Boussaoud (2017): Tobacco status, impulsivity, and the five-factor of the PANSS in paranoid schizophrenia, The Journal of Forensic Psychiatry & Psychology, DOI: 10.1080/14789949.2017.1375544

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Tobacco status, impulsivity, and the five-factor of the PANSS in paranoid schizophrenia

Mounir Ouzir^a, Jean Michel Azorin^b, Nadia Correard^b, Sara-Nora Elissalde^b, Romain Padovani^b, Christophe Lançon^b, Omar Battas^a and

Driss Boussaoud^c

alaboratory of clinical neuroscience and Mental health, faculty of Medicine and Pharmacy, university hassan ii, casablanca, Morocco; ^bDepartment of Psychiatry, sainte-Marguerite hospital, Mediterranean university, Marseille, france; ^cfaculty of Medicine and Pharmacy, institute of systems neuroscience, Mixed research unit 1106, inserM & aix-Marseille university, Marseille, france

ABSTRACT

There is consistent evidence that impulsivity is linked to tobacco consumption and to symptomatology in schizophrenia. In the current study, we propose a new integrative model of the relationship between impulsivity, psychopathological symptoms, and tobacco status in patients with paranoid schizophrenia. We investigated 33 paranoid schizophrenia patients and 37 healthy controls using a battery of psychopathological scales included the Structured Clinical Interview for DSM-IV (SCID), the five-factor model of the Positive and Negative Symptom Scale (PANSS), the Barratt Impulsiveness Scale (BIS-10), and the UPPS Impulsive Behavior scale (UPPS). Step-wise regression analysis revealed that positive factor of the PANSS and tobacco status contributed positively and significantly to the explained variance of impulsivity. In addition, non-planning impulsivity and sensation-seeking emerged as significant predictors of tobacco status, while smoking predicted non-planning impulsivity and sensation-seeking. Our results suggest that the relationship between sensation-seeking and tobacco use is reciprocal and proposes a new integrative model of the relationship between impulsivity, positive symptoms and tobacco status in patients with paranoid schizophrenia. However, the exact mechanisms for these relationships deserve further investigation.

ARTICLE HISTORY received 18 april 2017; accepted 4 august 2017

KEYWORDS impulsivity; psychopathology; Panss factors; tobacco status; paranoid schizophrenia

Introduction

Impulsivity is a multi-dimensional construct repeatedly identified as a major problem in schizophrenia often linked to numerous behavioral problems,

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including the risk for violence, aggression and suicidal behavior (Baup, 2007;

Ouzir, 2013). The International Society for Research on Impulsivity (ISRI) defines impulsivity as human behavior without adequate thought, the tendency to act with less forethought than do most individuals of equal ability and knowledge, or a predisposition toward rapid, unplanned reactions to internal or external stimuli with diminished regard to the negative consequences of these reactions (http://impulsivity.org/). The pathological impulsivity in schizophrenia has been reported by single item G14 (Poor Impulse Control) of the Positive and Negative Symptom Scale (PANSS), self-reports, behavioral assessments, and event-related potentials (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001; Ouzir, 2013), which raise further questions regarding the nature, the heterogeneity and the number of dimensions that compose impulsivity (Berg, Latzman, Bliwise, &

Lilienfeld, 2015).

Different multi-dimensional conception of impulsivity has been proposed by some authors. For example in 1995, Patton and colleagues measured impulsivity with the three factors of the Barrat Impulsive Scale including; cognitive impulsivity (lack of focus on the on-going task), motor impulsivity (acting without inhibition of prepotent or on-going responses), and non-planning impulsivity (lack of forethought before acting). Later, Whiteside and Lynam (2001) identified four distinct traits associated with impulsive-like behaviors; urgency (the tendency to act rashly when faced to intense negative emotions), lack of premeditation (inability to consider the potential consequences of one’s behavior), lack of perseverance (inability to remain focused on a task that may be boring or difficult), and sensation-seeking (tendency to seek new and exciting activities) and proposed the UPPS Impulsive Behavior Scale (UPPS).

Evidence suggests that psychological symptoms in schizophrenia can explain a substantial part of the variance of patient’s impulsive behavior. However, only a few studies have been performed to clarify the relation of impulsivity impairments with symptom dimensions. For example, Iancu et al. (2010) using the impulsivity control scale (IS) of Plutchik and van Praag (1989) find that the impulsivity score correlated positively with the positive subscale of the PANSS, the general psychopathology subscale of the PANSS, and the total PANSS score.

In term of PANSS items, Klingberg, Wittorf, and Wiedemann (2006) shows using neuropsychological measures of impulsivity that impulsiveness was significantly linked with several items on the positive subscale of (i.e. delusions and hallucinatory behavior) and several items from the general psychopathology PANSS subscale (i.e. unusual thought content and lack of judgment), but not with items of the negative subscale of the PANSS. In an interesting way, paranoid schizophrenia is typified by the presence of prominent positive symptoms specifically delusions or hallucinations. These thoughts disorders suggest some loss of impulse control in the more general sense because adaptive decisions and actions depend upon reality perception and rationality (Felthous, 2008).

Additionally, researchers have found that positive symptoms are important

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predictors for high levels of impulsive behavior in schizophrenia patients (Amr, Elsayed, & Ibrahim, 2016; Arce et al., 2006). It should be noted that compared to the original three PANSS subscales: positive, negative, and psychopathology (Kay, Fiszbein, & Opler, 1987), the five-factor model of the PANSS (van der Gaag et al., 2006) is thought to be more representative of the syndromes of schizophrenia in research and clinical practice. This model captures specific symptom-related change associated with improved psychosocial outcomes, functional recovery, and medication efficacy (Jerrell & Hrisko, 2013). Thus, the use of the five-factor model may enable more appropriate understanding of pathological impulsivity in individuals with this disease.

Impulsivity dimensions are believed to be the behavioral manifestation of imbalance in two neurocognitive systems; the brain’s reward system (overac- tivity), mediated by subcortical areas, such as the amygdala, and the executive control system (underactivity) mediated by the lateral prefrontal cortex which leads to risky behaviors, such as substance use (for review, see: Tomko, Bountress,

& Gray, 2016). Some of these dimensions appear to play specific roles in the etiology of cigarette smoking in individuals with schizophrenia (Dervaux et al., 2001; Dolan et al., 2004; Wing, Moss, Rabin, & George, 2012). Because nicotine has stimulating properties, researchers suggest that sensation-seeking is the most important personality trait linked to tobacco use in schizophrenia (Dervaux et al., 2004). In fact, the desire to smoke may be influenced by the anticipation of pleasure and the agreeable sensations resulting from tobacco use (Billieux, Van der Linden, & Ceschi, 2007). Otherwise, non-planning impulsivity was suggested to confer a propensity for automatic control over well-practiced drug-seeking/

behavior (Hogarth, 2011). However, the exact nature of relationships between facets of impulsivity and tobacco use still relatively difficult to disentangle as impulsivity may contribute to use and may be altered by use.

Others explanatory models have been developed to explain the high prev- alence of tobacco consumption in schizophrenia compared to the general population (Morisano, Bacher, Audrain-McGovern, & George, 2009) and other psychiatric disorders (de Leon, Diaz, Rogers, Browne, & Dinsmore, 2002; Uck, Polat, Bozkurt, & Meteris, 2004). Some data indicate that smokers with schizophrenia may find cigarette smoking more reinforcing and perhaps crave tobacco more than their non-psychiatric counterparts (Chambers, Krystal, & Self, 2001).

Alternatively, several lines of evidence suggest that patients with schizophrenia may consume tobacco to improve their psychiatric symptoms, most notably negative and cognitive symptoms and to reduce the side effects of neuroleptic medications supporting a ‘self-medication hypothesis’ (for review, see: Kumari

& Postma, 2005; Winterer, 2010). Interestingly, some researchers claim that psychiatric diseases like schizophrenia make the brain more susceptible to tobacco use and addiction supporting the ‘addiction vulnerability hypothesis’ (Ouzir &

Errami, 2016).

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On the basis of the previous studies, we suggest that sensation-seeking and non-planning impulsivity are specifically related to smoking behavior in paranoid schizophrenia. We suggest also that symptomatology may influence this relationship. We thus assume that a multidimensional approach to impulsivity might open up interesting prospects for better comprehension of this issue.

The purpose of this study was firstly to examine the correlates of the four personality traits of impulsivity (urgency, lack of perseverance, lack of premeditation, and sensation-seeking) hypothesized by Whiteside and Lynam (2001) to be related to impulsive behavior assessed by the Barratt Impulsiveness Scale (BIS-10). Secondly, to better understanding of impulsive behaviors, it’s important to examine the psychopathological symptom dimensions underlying each of the impulsivity facets. Thus, we were interested specifically in examining whether different types symptoms evaluated with the five-factor model of the PANSS was used (van der Gaag et al., 2006) would be related differentially to each facet of impulsivity, to distinct symptomatology pathways through which impulsive behavior may be manifested in paranoid schizophrenia. Finally, the present study aims to investigate in more depth the relationship between the different dimensions of impulsivity and smoking.

Materials and methods Study design

Participants were drawn from the patient population of the psychiatric department of CHU Sainte Marguerite, Marseille (France). Study inclusion criteria included age range of 19–63 years, men or women, DSM-IV criteria for paranoid schizophrenia clinically stable, informed consent to participate in the study and French as a mother tongue. Exclusion criteria included evidence of mental retar- dation, organic brain diseases, seizures, serious medical illness, past or present regular alcohol/substance abuse or addiction (except nicotine) as reported by the study participants, pregnancy or lactation, low comprehension skills and poor cooperation. To assess smoking status, participants were asked if they had ever smoked cigarettes and if they were presently smoking cigarettes.

Participants

We used a sample of 33 consecutively recruited DSM-IV schizophrenia patients (23 males, 10 females) with the paranoid type of schizophrenia and 37 non-patient control subjects (12 males, 25 females). For patients with schizophrenia (n = 17 smokers; n = 16 non-smokers) and healthy control participants (n = 7 smokers; n = 30 non-smokers), informed consent for study participation was obtained from all subjects by trained research staff.

At the time of assessment, all patients received a variety of antipsychotic medications: three patients were receiving D2 antagonist antipsychotics, three

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patients were receiving typical antipsychotics, 27 patients were treated with atyp- ical antipsychotics; clozapine (n = 12), risperidone (n = 5), olanzapine (n = 6) and amisulpride (n = 4), 13 patients were receiving a benzodiazepine, one patient receives anticonvulsant, nine patients were receiving antidepressants.

It’s interesting to mention that some of the patients with schizophrenia received more than two kinds of antipsychotics. Control subjects had no psychiatric history and were not taking any drugs that might affect cognition.

The study was approved by local Ethics Committee.

Instruments

Estimates of pre-morbid intelligence and clinical stability

All participants were administered the French version of the National Adult Reading Test (f-NART; Mackinnon & Mulligan, 2005) in order to obtain an estimate of pre-morbid intelligence. The NART is a list of 50 words presented in order of escalating reading difficulty. The words are unusual with respect to the common rules of pronunciation, which reduces the likelihood of the subject reading by phonemic decoding rather than by word recognition. The NART is one of the most commonly used tests of word-reading ability. This measure is usually used in schizophrenia as a quick way to estimate pre-morbid IQ (Russell et al., 2000).

Interviews were conducted face to face by two trained clinical investigators using the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) using the SCID-I (First, Spitzer, Gibbon, & Williams, 1998) and psychopathological symptom severity was assessed using the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987). The PANSS is a standardized 30-item rating scale evalu- ating the severity of positive (seven items) and negative (seven items) symptoms and general psychopathology (16 items) of schizophrenia. A five-factor model of the PANSS is also used according to van der Gaag et al. (2006). This model was the result of a 10-fold cross-validation over a large sample of in- and outpa- tients with schizophrenia, which generated five stable factors with little overlap, reflecting: positive symptoms, negative symptoms, disorganization symptoms, excitement, and emotional distress (van der Gaag et al., 2006).

Impulsivity assessment

The psychopathology evaluation of impulsivity included two self-administered questionnaires: the Barratt Impulsivity Scale BIS-10, which is regarded as the most commonly used self-report measure of impulsivity (Patton, Stanford, &

Barratt, 1995) and the UPPS Impulsive Behavior Scale (Whiteside & Lynam, 2001).

All participants were screened using the French version of the Barratt Impulsivity Scale BIS-10 and the UPPS Impulsive Behavior Scale.

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In its revised form, Barratt Impulsiveness Scale (BIS-10) 34 items, results in a total score and three sub-scale scores confirmed in the French version of the scale (Baylé et al., 2000): cognitive impulsivity is a lack of cognitive persistence with an inability to tolerate cognitive complexity (e.g. I get easily bored when solving thought problems), motor impulsivity is a tendency to act impulsively (e.g. I do things without thinking) and non-planning impulsivity refers to a lack of sense of the future (e.g. I am more interested in the present than the future).

The French version of the UPPS translated by Van der Linden et al. (2006) con- sists of 45 items that evaluate four different facets of impulsivity, urgency, (lack of) perseverance, (lack of) premeditation and sensation-seeking. The first pathway, urgency, assesses an individual’s tendency to give in to strong impulses, specifically when accompanied by negative emotions, such as depression, anxiety, or anger, perhaps in order to alleviate negative emotions, despite the potentially harmful longer-term consequences. (e.g. ‘I have trouble controlling my impulses’). The next pathway, (lack of) perseverance, assesses an individual’s ability to persist in completing jobs or obligations despite boredom and/

or fatigue (e.g. ‘I finish what I start’). The third pathway, (lack of) premeditation assesses an individual’s ability to think through the potential consequences of his or her behavior before acting (e.g. ‘Before I get into a new situation I like to find out what to expect from it’). The fourth pathway, sensation-seeking, measures an individual’s preference for excitement and stimulation and openness to trying new experiences that may be dangerous (e.g. ‘I generally seek new and exciting experiences and sensations’). Items of the scale are scored from 1 to 4, with 1 = ‘I agree strongly’, 2 = ‘I agree somewhat’, 3 = ‘I disagree somewhat’ and 4 = ‘I disagree strongly’. Some items are reversed such that a high score reveals an impulsive personality trait.

The questionnaires were administered without a time limit.

Data analysis

All statistical tests were carried out using the SPSS statistics software version 18.0 for Windows. The demographic and clinical variables, as well as impulsivity measures, were analyzed with parametric statistical tests. Continuous variables were compared using independent samples t-tests. Chi-square tests are used for categorical variables. Spearman correlation coefficients with Bonferroni adjustment for multiple comparisons are reported for bivariate analyses. All mean values are reported as means ± SD and all the tests were two-tailed, with alpha-risk set at .05.

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Results

Demographic and clinical data

Summary data of the demographic and clinical characteristics of paranoid schizophrenia and control groups are presented in Table 1. As expected, the analysis revealed no significant difference between-group with respect to age, level of education, and f-NART score. However, Patients and controls showed significant differences with regard to gender, marital and tobacco status. Table 1 also includes the PANSS subscales in their original categories (positive scale, negative scale, and general psychopathology), in addition to the score ranges for each five-factor of the PANSS, along with the mean and the standard deviation. As we see in the table, the sample used in the study presented a low level of symptomatology in general.

Impulsivity data

Patients with schizophrenia vs. controls

The results in Table 2, show that patients with schizophrenia have higher levels of urgency (t = –3.43, p = .001) and lack of perseverance (t = −3.02, p = .003) compared to controls. However, no signiﬁcant difference has been shown in lack of premeditation and sensation-seeking between groups. Regarding BIS-10 impulsivity, the analysis revealed that patients with paranoid schizophrenia displayed Table 1. Patients and controls characteristics (mean ± sD).

notes: na = not applicable; Panss = Positive and negative syndrome scale; f-narT = french version of the national adult reading Test, M/f= Male/female.

*p < .05; ^**p < .01; ^***p < .001.

Measure Patients with

Schizophrenia (n = 33) Healthy controls

(n = 37) Statistics

age (years) 36.78 ± 11.44 37.13 ± 13.18 t = .117, p = .907

sex* 23 M/10 f 12 M/25 f χ² = 9.86, p = .02

school education (years) 11.30 ± 2.88 12.62 ± 2.8 t = 1.93, p = .057 Pre-morbid iQ (f-narT) 106.56 ± 8.20 107.52 ± 8.35 t = .485, p = .630

Marital status*** χ² = 15.36, p = .0004

Married 1 (3.03%) 16 (43.24%)

Divorced/separated 3 (9.09%) 3 (8.1%)

single 29 (87.87%) 18 (48.64%)

Tobacco status** χ² = 8.26, p = .004

smokers 17 (51.51%) 7 (18.91%)

non-smokers 16 (48.48%) 30 (81.08%)

Panss positive 13.90 ± 4.78 na

Panss negative 15.69 ± 5.34 na

Panss general 28.97 ± 8.01 na

Panss total 57.90 ± 15.12 na

negative factor 16.60 ± 6.27 na

Positive factor 14.30 ± 5.83 na

Disorganization factor 17.18 ± 5.68 na

excitement factor 12.81 ± 4.72 na

emotional distress factor 16.93 ± 5.88 na

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significantly increased Cognitive Impulsivity (t = −3.63, p = .001) and mean total scores of BIS-10 impulsivity (t = −2.62, p = .011) than controls. However, no signiﬁcant difference has been shown in lack of premeditation (t = −.17, p = .863), sensation-seeking (t = 1.45, p = .151), motor impulsivity (t = −1.26, p = .212), and non-planning impulsivity (t = −1.24, p = .217) between groups.

As can be seen in Table 3, nine of the 16 correlations between UPPS Impulsive Behavior scale and Barratt Impulsiveness scale were significant after Bonferroni correction. However, no relationship was reported between sensation-seeking and the Barratt Impulsiveness scale compounds. It’s interesting to mention that impulsivity is not associated with age, gender, education, and f-NART in our sample.

Smokers vs. non-smokers patients

The patients sample was divided into two groups, one smokers (N = 17; 82.35%

were male and 17.65% were female) and the other non-smokers (N = 16; 56.25%

were male and 43.75% were female). Independent t-tests were conducted to identify differences between smokers and non-smokers schizophrenia group.

These two groups were statistically similar in relation to age,education, f-NART, and diagnosis. Smokers with schizophrenia demonstrated a significantly increase in sensation-seeking (t = 3.98, p = .0003) and non-planning impulsivity (t = 3.29, Table 2. summary data (Means ± s.D) for impulsivity.

Measure Patients with

Schizophrenia (n = 33) Healthy controls

(n = 37) Statistics UPPS impulsive behavior scale

lack of premeditation 19.36 ± 5.23 19.24 ± 4.54 t = –.17, p = .863 lack of perseverance** 21.15 ± 5.51 17.64 ± 4.12 t = –3.02, p = .003

urgency** 32.03 ± 8.40 26.89 ± 6.15 t = –3.43, p = .001

sensation-seeking 26.06 ± 8.87 28.97 ± 7.58 t = 1.45, p = .151

Barratt impulsiveness scale

Motor impulsivity 15.06 ± 8.44 13 ± 4.96 t = –1.26, p = .212

cognitive impulsivity** 20.06 ± 5.16 15.75 ± 4.73 t = –3.63, p = .001 non-planning impulsivity 17.45 ± 6.08 15.72 ± 5.49 t = –1.24, p = .217 Bis-10 total score* 52.57 ± 14.58 44.48 ± 11.07 t = –2.62, p = .011

Table 3. correlations between uPPs impulsivity subscales and Barratt subscales.

note: significant association at *p < .05 and **p < .01 after Bonferroni correction.

Motor impul-

sivity Cognitive impulsivity Non-planning

impulsivity BIS total score lack of

premeditation .321* – .359* .365*

lack of

Perseverance – .339* .506** .490**

urgency .444** .496** – .530**

sensation-

seeking – – – –

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p = .002) than non-smokers with schizophrenia. However, there were no sig- nificant differences in scores of the others compounds of impulsivity (Table 4).

Correlation analyses between impulsivity, PANSS five-factor and tobacco status

In patients, tobacco status was significantly and positively correlated with sensation-seeking (r = .589; p < .01), non-planning impulsivity (r = .488; p < .05), and negative factor (r = .498; p < .05). However, no significant correlations have been found for the others compounds of impulsivity and PANSS factors (Table 5). Concerning the relation between the PANSS five-factor and impulsivity, sensation-seeking was strongly related to positive factor (r = .516; p < .01) followed by, excitement factor (r = .483; p < .05) and negative factor (r = .463; p < .05) after Bonferroni correction. Additionally, non-planning impulsivity was strongly related to positive factor (r = .589; p < .01).

Two separate step-wise regression analyses were performed to determine the extent of the effects of clinical and demographic variables on impulsivity and tobacco status (Table 6). Step-wise regression analysis indicated that non-planning impulsivity remained statistically associated with positive factor and tobacco status. Sensation-seeking remained statistically associated with tobacco status. In addition, gender and sensation-seeking optimally predicted tobacco status in patients with schizophrenia. Excluded variables are not reported herein.

Discussion

The present study aimed at clarifying the relationship between multi-dimensional facets of impulsivity, symptomatology according to a five-factor model of the PANSS (van der Gaag et al., 2006) and tobacco status in clinical subgroups of paranoid schizophrenia. Consistent with prior work (Felthous, 2008; Gruzelier

Table 4. summary data (Means ± s.D) for impulsivity of smokers and non-smokers schizophrenia patients.

Measure Smokers Patients

(n = 17) Non-smokers Patients

(n = 16) Statistics

UPPS impulsive behavior scale

lack of premeditation 19.88 ± 4.48 18.81 ± 6.03 t = .580, p = .8566 lack of perseverance 22.70 ± 5.92 19.50 ± 4.67 t = 1.718, p = .094

urgency 31.29 ± 5.14 32.81 ± 11.00 t = –.513, p = .612

sensation-seeking*** 31.00 ± 8.86 20.81 ± 5.23 t = 3.989, p = .0003 Barratt impulsiveness scale

Motor impulsivity 15.29 ± 7.37 14.81 ± 9.70 t = .161, p = .873

cognitive impulsivity 19.70 ± 4.36 20.43 ± 6.02 t = –.401, p = .691 non-planning

impulsivity** 20.41 ± 5.71 14.31 ± 4.86 t = 3.291, p = .002

Bis-10 total score 55.41 ± 12.50 49.56 ± 16.37 t = 1.158, p = .256

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& Venables, 1974), our results provide further evidence for impaired impulse control in patients with paranoid schizophrenia. Patients in our sample scored higher than controls as indicated by the BIS-10 total score, the levels of urgency, lack of perseverance and cognitive impulsivity, pointing toward the consid- eration of impulsivity as a trait characteristic of schizophrenia. These results suggest that patients may have difficulty to make quick cognitive decisions, to inhibit automatic or dominant behavior and intrusive thoughts. In addition, the impulsive behaviors may occur largely in the context of affectivity and inatten- tion problems amply demonstrated in patients with schizophrenia (Carter et al., 2010; Hoptman, Antonius, Mauro, Parker, & Javitt, 2014). However, our sample did not show increased tendency to act without premeditation.

Table 5. correlations between impulsivity, the five-factor of the Panss and Tobacco status in schizophrenia (n = 33).

note: correlation is significant at *p < .05 and **p < .01 (2-tailed) after Bonferroni correction.

Five-factor of the PANSS

Tobacco status Negative Positive Disorganized Excitement Emotional

distress UPPS Impulsivity

Scale lack of

premeditation – – – – – –

lack of

perseverance – – – – – –

urgency – – – – – –

sensation-

seeking .463* .516** – .483* – .589**

Barratt impul- siveness Scale Motor

impulsivity – – – – – –

cognitive

impulsivity – – – – – –

non-planning

impulsivity – .534** – – – .488*

Bis total score – – – – – –

Tobacco status .498* – – – – –

Table 6. Multiple regressions to predict impulsivity and tobacco status.

*p < .05; ^**p < .01; ^***p < .001.

Outcome variable Predictor Standardized coefficient t p

sensation-seeking Tobacco status .582 3.989 .0003***

non-planning impulsivity Positive factor .533 3.509 .001**

Tobacco status .355 2.297 .02*

Tobacco status sensation-seeking .595 4.327 .0001***

gender .308 2.24 .03*

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On the other hand, it is noteworthy that different facets of UPPS Impulsive Behavior scale and Barratt Impulsiveness scale were associated (nine of the 16 correlations are significant), which indicates that, despite distinct construct, the scales overlap. By contrast, the absence of a relationship between sensation-seeking and the Barratt Impulsiveness scale compounds suggest that sensation-seeking may depend on other psychological processes, which is in accordance with Billieux, Rochat, and Van der Linden (2008) hypothesis.

In the current study, some aspects of the results remain to be considered.

First, sensation-seeking was associated with positive factor, excitement, and negative factor. Non-planning impulsivity was strongly related to positive factor.

These results suggest that patients with schizophrenia, with a combination of symptoms, can have more pronounced difficulties with impulsivity. Second, it should be also noted, as revealed by multiple regressions, that positive factor of the PANSS contributed positively and significantly to the explained variance of impulsivity (non-planning impulsivity) which is consistent with our hypothesis.

In other words, individuals who have a high level of positive symptoms are more clinically at risk to experience more unplanned behavior.

In addition to the multi-faceted relationship with symptomatology, we show also that impaired impulse control is more pronounced in patients who smoke than non-smokers in relation to sensation-seeking and non-planning impulsivity.

This adds further support for the hypothesis of the use of tobacco as a result of low impulse control presented by individuals with schizophrenia (Potvin, Tikasz, Dinh-Williams, Bourque, & Mendrek, 2015; Wing et al., 2012). When using step- wise regression analysis sensation-seeking emerged as a highly significant predictor of tobacco status and itself is predicted by tobacco status suggesting their relationship is reciprocal in schizophrenia. This result suggests also that sensation-seeking is a concurrent and prospective predictor of engagement in risky behavior like smoking (Maslowsky, Keating, Monk, & Schulenberg, 2011). These findings may extend and clarify previous research in general population showing that impulsivity is of central importance for the development of tobacco use and itself is exacerbated by substance exposure (for review, see Ouzir & Errami, 2016).

Moreover, gender optimally predicted tobacco status in patients with schizophrenia. This contribution of gender to tobacco consumption levels will need to be addressed in future work with a more balanced study design. More interesting, non-planning impulsivity was significantly predicted by tobacco status suggesting that tobacco consumption exacerbates unplanned behavior. Non- planning impulsivity refers to a present orientation and lack of forethought about the long-term outcomes of acts and decisions, which may lead to low medication adherence.

It remains to be acknowledged that studies in non-psychiatric populations have shown that high sensation-seeking and non-planning impulsivity are associated with poorer treatment response to smoking cessation therapies and smoking relapse (López-Torrecillas, Perales, Nieto-Ruiz, & Verdejo-García, 2014;

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Kahler, Spillane, Metrik, Leventhal, & Monti, 2009; Krishnan-Sarin et al., 2007).

This suggests that smoking cessation treatment is relevant to the management of impulsivity with the goal to increase planning and executive control.

Furthermore, tobacco use was positively associated with severity of negative symptoms despite no significant differences between smokers and non-smokers on demographic variables. This result is in accordance with previous studies showing significant positive correlation between nicotine dependence and negative symptoms severity (Hall et al., 1995; Patkar et al., 2002; Winterer, 2010) and support several lines of evidence suggesting that patients with schizophrenia may consume tobacco to self-medicate negative symptoms (Kumari & Postma, 2005; Winterer, 2010).

Overall, our findings support the fact that impulsivity interacts with symptomatology to produce higher vulnerabilities for tobacco in paranoid schizophrenia and therapies aimed at reducing impulsivity may help smokers quit and, more important, maintain abstinence.

In addition, specific pharmacotherapy may be interesting to increase will- ingness to try to quit as a result of reduced withdrawal symptoms or rewarding effects of smoking.

Methodological issues must be considered in interpreting these results. Our sample of subjects was small and studies with a larger population are required to verify these relationships. Some criticism may concern the exclusion criteria of patients. This study is limited to tobacco use, while in clinical settings; tobacco use is strongly associated with other substance use (Martínez-Ortega, Jurado, Martínez-González, & Gurpegui, 2005). These observations may limit the gener- alization of the study findings to other populations of people with the serious mental illness. Another limitation was that some potential confounding variables or factors were not completely addressed, such as duration of illness, the effect of medication and duration of treatment (no available data). In addition, the present research was limited by the use of self-administered questionnaires of impulsivity which need to be confirmed by an objective assessment. Therefore, the results presented in the current study should be viewed as pilot data.

Conclusion

The present study reflects the variable nature of impulsivity and suggests that some of its components are more clinically as risk factors for tobacco use in paranoid schizophrenia. In particular, the results suggest that smoking, like other sources of stimulation, may be of special interest for high sensation seekers. In addition, certain impulsivity facets were related to schizophrenia symptoms, highlighting the importance of symptomatology in impaired impulse control.

These preliminary findings have important implications for developing an integrative model that incorporate impulsivity, positive factor, and tobacco status. The emergence of this pattern of relationships opens new prospects for

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disentangling the different facets of impulsivity with regard to tobacco use and provides support for the development of interventions to prevent early initiation of tobacco use. Further studies should, however, specifically examine the mechanisms involved in this pattern.

Acknowledgments

The authors would like to acknowledge Dr. Pascale MAZZOLA-POMIETTO for assistance.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by ARCUS program (Ministère des Affaires Etrangères and Région PACA, France), and the European Project N€uromed, N° 245807.

References

Amr, M., Elsayed, H., & Ibrahim, I. M. (2016). Impulsive behavior and its correlates among patients with schizophrenia in a tertiary care psychiatry setting in Mansoura. Asian Journal of Psychiatry, 22, 111–115.

Arce, E., Leland, D. S., Miller, D. A., Simmons, A. N., Winternheimer, K. C., & Paulus, M.

P. (2006). Individuals with schizophrenia present hypo-and hyperactivation during implicit cueing in an inhibitory task. Neuroimage, 32, 704–713.

Baup, N. (2007). Impulsivity of schizophrenic patients. Encephale, 33(Pt 3), S380–S382.

[Article in French].

Baylé, F. J., Bourdel, M. C., Caci, H., Gorwood, P., Chignon, J. M., Ades, J., & Loo, H. (2000).

Factor structure of the French translation of the Barratt Impulsivity Scale (BIS-10).

Canadian Journal Psychiatry, 45, 156–165. [Article in French].

Berg, J. M., Latzman, R. D., Bliwise, N. G., & Lilienfeld, S. O. (2015). Parsing the heterogeneity of impulsivity: A meta-analytic review of the behavioral implications of the UPPS for psychopathology. Psychological Assessment, 27, 1129–1146.

Billieux, J., Rochat, L., & Van der Linden, M. (2008). Impulsivité et dépendances: Une approche cognitive et motivationnelle à la lumière du modèle UPPS de Whiteside et Lynam = Impulsivity and dependencies: A cognitive and motivationalapproachbased on Whiteside and Lynam’s UPPS model. In M. Van der Linden & G. Ceschi (Eds.), Traité de psychopathologie cognitive, tome 1 (pp. 137–152). Marseille: Solal. [Article in French].

Billieux, J., Van der Linden, M., & Ceschi, G. (2007). Which dimensions of impulsivity are related to cigarette craving? Addictive Behaviors, 32, 1189–1199.

Carter, J. D., Bizzell, J., Kim, C., Bellion, C., Carpenter, K. L., Dichter, G., & Belger, A. (2010).

Attention deficits in schizophrenia-preliminary evidence of dissociable transient and sustained deficits. Schizophrenia Research, 122, 104–112.

Chambers, R. A., Krystal, J. H., & Self, D. W. (2001). A neurobiological basis for substance abuse comorbidity in schizophrenia. Biological Psychiatry, 50, 71–83.

(15)

Dervaux, A., Baylé, F. J., Laqueille, X., Bourdel, M. C., Le Borgne, M. H., Olié, J. P., & Krebs, M.

O. (2001). Is substance abuse in schizophrenia related to impulsivity, sensation seeking or anhedonia? American Journal of Psychiatry, 158, 492–494.

Dolan, S. L., Sacco, K. A., Termine, A., Seyal, A. A., Dudas, M. M., Vessicchio, J. C., … George, T.

P. (2004). Neuropsychological deficits are associated with smoking cessation treatment failure in patients with schizophrenia. Schizophrenia Research, 70, 263–275.

Felthous, A. R. (2008). Schizophrenia and impulsive aggression: A heuristic inquiry with forensic and clinical implications. Behavioral Sciences & The Law, 26, 735–758.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1998). Structured clinical interview for the DSM-IV axis I disorders-non-patient edition (SCID-I/NP, Version 2.0-8/98 revision).

New York, NY: Biometrics Research Department, New York State Psychiatric Institute.

van der Gaag, M., Cuijpers, A., Hoffman, T., Remijsen, M., Hijman, R., de Haan, L., … Wiersma, D. (2006). The five-factor model of the positive and negative syndrome scale. I: Confirmatory factor analysis fails to confirm 25 published five-factor solutions.

Schizophrenia Research, 85, 273–279.

Gruzelier, J. H., & Venables, P. H. (1974). Two-flash threshold, sensitivity and β in normal subjects and schizophrenics. Quarterly Journal of Experimental Psychology, 26, 594–604.

Hall, R. G., Duhamel, M., McClanahan, R., Miles, G., Nason, C., Rosen, S., … Hall, S. M. (1995).

Level of functioning, severity of illness, and smoking status among chronic psychiatric patients. The Journal of Nervous and Mental Disease, 183, 468–471.

Hogarth, L. (2011). The role of impulsivity in the aetiology of drug dependence: Reward sensitivity versus automaticity. Psychopharmacology, 215, 567–580.

Hoptman, M. J., Antonius, D., Mauro, C. J., Parker, E. M., & Javitt, D. C. (2014). Cortical thinning, functional connectivity, and mood-related impulsivity in schizophrenia:

Relationship to aggressive attitudes and behavior. American Journal of Psychiatry, 171, 943–948.

Iancu, I., Bodner, E., Roitman, S., Piccone Sapir, A., Poreh, A., & Kotler, M. (2010). Impulsivity, aggression and suicide risk among male schizophrenia patients. Psychopathology, 43, 223–239.

Jerrell, J. M., & Hrisko, S. (2013). Utility of two PANSS 5-factor models for assessing psychosocial outcomes in clinical programs for persons with schizophrenia.

Schizophrenia research and treatment, 2013, 9.

Kahler, C. W., Spillane, N. S., Metrik, J., Leventhal, A. M., & Monti, P. M. (2009). Sensation seeking as a predictor of treatment compliance and smoking cessation treatment outcomes in heavy social drinkers. Pharmacology Biochemstry and Behavior, 93, 285–

290.

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13, 261–276.

Klingberg, S., Wittorf, A., & Wiedemann, G. (2006). Disorganization and cognitive impairment in schizophrenia: Independent symptom dimensions? European Archives of Psychiatry and Clinical Neuroscience, 256, 532–540.

Krishnan-Sarin, S., Reynolds, B., Duhig, A. M., Smith, A., Liss, T., McFetridge, A. … Potenza, M. N. (2007). Behavioral impulsivity predicts treatment outcome in a smoking cessation program for adolescent smokers. Drug Alcohol Depend, 88, 79–82.

Kumari, V., & Postma, P. (2005). Nicotine use in schizophrenia: The self-medication hypotheses. Neuroscience and Biobehavioral Reviews, 29, 1021–1034.

de Leon, J., Diaz, F. J., Rogers, T., Browne, D., & Dinsmore, L. (2002). Initiation of daily smoking and nicotine dependence in schizophrenia and mood disorders.

SchizophreniaResearch, 56, 47–54.

López-Torrecillas, F., Perales, J. C., Nieto-Ruiz, A., & Verdejo-García, A. (2014). Temperament and impulsivity predictors of smoking cessation outcomes. PloS One, 9(12), e112440.

(16)

Mackinnon, A., & Mulligan, R. (2005). The estimation of premorbid intelligence levels in French speakers. Encephale, 31, 31–43. [Article in French].

Martínez-Ortega, J. M., Jurado, D., Martínez-González, M. A., & Gurpegui, M. (2005).

Nicotine dependence, use of illegal drugs, and psychiatric morbidity. Addictive Behaviors, 31, 1722–1729.

Maslowsky, J., Keating, D., Monk, C., & Schulenberg, J. (2011). Planned versus unplanned risks: Evidence for subtypes of risk behavior in adolescence. International journal of behavioral development, 35, 152.

Moeller, F. G., Barratt, E. S., Dougherty, D. M., Schmitz, J. M., & Swann, A. C. (2001).

Psychiatric aspects of impulsivity. American Journal of Psychiatry, 158, 1783–1793.

Morisano, D., Bacher, I., Audrain-McGovern, J., & George, T. P. (2009). Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders.

Canadian Journal of Psychiatry, 54, 356–367.

Ouzir, M. (2013). Impulsivity in Schizophrenia: A comprehensive update. Agression and Violence Behavior., 18, 247–254.

Ouzir, M., & Errami, M. (2016). Etiological theories of addiction: A comprehensive update on neurobiological, genetic and behavioural vulnerability. Pharmacology Biochemistry and Behavior, 148, 59–68.

Patkar, A. A., Gopalakrishnan, R., Lundy, A., Leone, F. T., Certa, K. M., & Weinstein, S. P.

(2002). Relationship between tobacco smoking and positive and negative symptoms in schizophrenia. The Journal of nervous and mental disease, 190, 604–610.

Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the barratt impulsiveness scale. Journal of Clinical Psychology, 51, 768–774.

Plutchik, R., & van Praag, H. (1989). The measurement of suicidality, aggressivity, and impulsivity. Progress in Neuro-psychopharmacology and biological psychiatry, 13, s23–s34.

Potvin, S., Tikasz, A., Dinh-Williams, L., Bourque, J., & Mendrek, A. (2015). Cigarette cravings, impulsivity, and the brain. Frontiers in Psychiatry, 6, 125.

Russell, A. J., Munro, J., Jones, P. B., Hayward, P., Hemsley, D. R., & Murray, R. M. (2000). The National Adult Reading Test as a measure of premorbid IQ in schizophrenia. British Journal of Clinical Psychology, 39(3), 297–305.

Tomko, R. L., Bountress, K. E., & Gray, K. M. (2016). Personalizing substance use treatment based on pre-treatment impulsivity and sensation seeking: A review. Drug and Alcohol Dependence, 167, 1–7.

Uck, A., Polat, A., Bozkurt, O., & Meteris, H. (2004). Cigarette smoking among patients with schizophrenia and bipolar disorders. Psychiatry and Clinical Neurosciences, 58, 434–437.

Van der Linden, M., d’Acremont, M., Zermatten, A., Jermann, F., Laroi, F., Willems, S.,

… Bechara, A. (2006). A French adaptation of the UPPS impulsive behavior scale:

Confirmatory factor analysis in a sample of undergraduates. European Journal of Psychological Assessment, 22, 38–42.

Whiteside, S. P., & Lynam, D. R. (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and individual differences, 30, 669–689.

Wing, V. C., Moss, T. G., Rabin, R. A., & George, T. P. (2012). Effects of cigarette smoking status on delay discounting in schizophrenia and healthy controls. Addiction Behavior, 37, 67–72.

Winterer, G. (2010). Why do patients with schizophrenia smoke? Current Opinion in Psychiatry, 23, 112–119.