British Joumal of Addiction (1986) 81, 641-649

The Impulsivist: a multi-impulsive

personality disorder

J. HUBERT LACEY,' M.Phil., E.R.C.Psych. & C. D. H. EVANS,^ B.A.,

M.B., B.S.*
^Senior Lecturer and Honorary Consultant Psychiatrist and ^Research Registrar, Academic
Department of Psychiatry, St George's Hospital Medical School, Cranmer Terrace, Tooting,
London SW17 ORE

Summary
The authors report a literature review of impulsivity in the substance abuse disorders, eating disorders, classical
disorders of impulse control, self-harm and personality disorders. They suggest that within each of these clinic
populations there is a significant number of patients who have a very poor prognosis and are characterised not
just by the specific presenting symptom but by multiple impulsive behaviours. It is suggested that this group, who
place very large demands both on the psychiatric and emergency services, form a unitary 'multi-impulsive
personality' group and that they would repay detailed research which cuts across the boundaries of the
specialist services.

"Moral insanity, however, is not present in
Verlaine. He sins through irresistible impulse. He
is an Impulsivist."'
We report a literature survey of impulsivity in
substance abuse and dependence, in eating dis-
orders, specific disorders of impulse control and the
personality disorders. Impulsive forms of all these
conditions are well recognized and we will refer to
these as the 'uni-impulsive disorders'. We have
included the eating disorders and concentrated on
impulsivity in women as we think this is of
considerable importance currently and as we feel
that the problems of impulsivity in male sociopaths
have previously dominated this area concealing the
general importance of impulsive behaviours.
We suggest that within each clinical population of
'uni-impulsive' disorders there are significant num-
* Correspondence should be addressed to Dr Evans.
bers of patients displaying more than one such
problem. This is summarized in Table 1 which gives
the percentages of such overlaps. We argue that
these multi-impulsive patients represent a distinct
group with a 'multi-impulsive personality disorder'
which is being treated inappropriately by specialist
clinics unable to grapple with the protean manifes-
tations of their fundamental personality problems.
Links between compulsion and substance depen-
dence and eating disorders^ are recognized but how
do impulses differ from compulsions? Clearly an
impulse is more sudden and less predictable than a
compulsion but the distinction between repeated
impulses and obsessions can be a fine one. Although
some authors talk of impulsive forms of substance
abuse and self-harm as 'compulsive behaviours'
(e.g. CuUari & Redman') we feel that a dimension
from the obsessional to the impulsive is of impor-
tance and throws light on the relationship between a
variety of disorders.

641
642 J. Hubert Lacey & D. H. Evans

Table 1. Reported Percentages of Multiple Impulsive Behaviours

Ref Target group Numbers EV Arson Theft Gamb, Drugs Ale Eatg. SH

8 Explosive gp 130 100 >9 >19 >41

16 Arsonists 25M2F 100 33
19 Arsonists 27F 100 19 55 >7
20 Arsonists 56F 100 52
77 Arsonists 38M 5 100 35 ,6
9 Shoplifters 19M 31F 100 8
24 Path, gamblers 50 100 36
31 Opiate addicts 80 100 21
78 Opiate addicts 625 100 25
34 Treated opiate 403M 100 37
addicts 130F 100 27
79 Opiate addicts 212 100 27
37 Drug abusers 50M 14 100
50F 33 100
39 Opiate addicts 30F 100 10
Alcohoi abusers 30F 100 20
38 Alcoholics (f) 27F 100 40
80 Alcoholics 565M 12 100 1
36 Alcoholics 293F 38 100 39
43 Bulimic anorec. 105F 24 100
44 Bulimic anorec. 66F2M 12 29 >6 100 23
48 Bulimics 34F 65 >24 >3 100
52 Bulimics 112F 41 28 26 100
64 Self-harm 103M 176F 39 10 100
53 Parasuicides 18M 53F 3 15 100

Key:
EV, explosive violence; Gamb., pathological gambling.
Eatg, eating disorder; SH, self harm.
Ale, alcohol abuse; Ref, number of reference.

The Specific Disorders of Impulse Control
DSM-IIP recognizes a category of illnesses known
as 'Impulse control disorders not elsewhere classi-
fied' including: Pathological Gambling, Klepto-
mania, Pyromania, Intermittent Explosive Disorder,
and Isolated Explosive Disorder.
These impulse control disorders have a long
history. 'Impulsive incendiarisme' was mentioned
by Meckel in 1820. In 1837 Pinel and Esquirol
talked of the 'instinctive impulses' or 'instinctive
monomanias'; alcoholism, arson and homicide.
'Kleptomania' was added to the 'instinctive mono-
manias' by Mathey in 1838.''° Despite this long
history, categorizing this group of prevalent human
behaviours as psychiatric illnesses is fraught with
difficulty. The related behaviours, gambling or risk-
taking, stealing, fire-setting, and violent outbursts
are all very common but 'psychiatric' versions are
rarer and difficult to demarcate.
Monopolis & Lion' found that the diagnosis of
'Intermittent Explosive Disorder' alone was made in
2.5% of admissions but they noted the need to
improve diagnostic specificity. Bach-Y-Rita et al.^
evade the diagnostic dilemma describing the 'episo-
dic dyscontrol syndrome' which seems similar to
the explosive disorders. They emphasize the signi-
ficance of these patients for emergency services
and the prevalence of other impulsive behaviours
(Table 1).
In their classic work on shoplifting, Gibbens &
Prince (op cit.) found no true cases of kleptomania
among over a thousand shoplifters (not all inter-
viewed in detail) but they describe forms of
'compulsive' and impulsive shoplifting. Other au-
thors also find low rates of'true kleptomania','''" but
comment on the importance of shoplifting as a
symptom of psychiatric illness, particularly depres-
sion. Gibbens & Prince note a similarity with forms
of self-harm: "It is like a miniature suicide or moral
suicide." A gamble with humiliation at the hands of
the store detective is seen in a number of their
vignettes and is reminiscent of those cases of
parasuicide which seem motivated at least partly by
a desire to put survival in the lap of fate.
Keutzer" reports the successful use of behav-
ioural technique of 'impulse control' in kleptomania

and Coid'2 reports a case apparently precipitated by
the tension and dysphoria of Diazepam withdrawal.
He, like Keutzer, acknowledges the apparent rele-
vance of psychodynamic factors in the case and
notes the similarity with the descriptions of relief of
tension brought about by bingeing in bulimia" and
by some forms of recurrent self-harm.
Like violence and stealing, arson is common and
important.'* Many authors"-" suggest that 'true
pyromania' accounts for only a small proportion of
arson: Crossley & Guzman" suggest only 2-3%
which contrasts with the figure of 25-40% found in
the 1940s,"' they suggest that true pyromania and its
association with sexual motivations may have di-
minished as sexual mores changed. Concurrent
alcohol and substance abuse are common and
previous convictions for theft and assault are not
uncommon." Links with sexuality are often derided,
but a survey of all the female arsonists in special
hospitals in the U.K.™ found a remarkable preva-
lence of promiscuity and a much larger number of
unwanted pregnancies than in a control group of
women in special hospitals for other reasons.
Pathological gambling, the last of the specific
disorders of impulse control again accounts for only
very small proportion of total gambling which, is
another multi-billion dollar concern. There are clear
links between pathological gambling and substance
dependence, e.g. Moran^'-^^, and Custer" calls
pathological gambling a 'drugless impulse disorder'
(see reference 24 in Table 1).
Greenberg & Rankin" noted the similarity with
alcohol abuse and the difficulty measuring outcome.
Rankin^' suggested that controlled gambling may
sometimes be a wise goal for treatment. We note the
resemblance to the eating disorders, particularly
bulimia, where control is the goal and the battle-
ground and where the indulgence, eating, is not only
not intrinsically pathological but is actually physio-
logically necessary.
This short review has shown that the specific
impulse control disorders are a venerable conceptual
area, that these impulsive behaviours are common
and important in society but that diagnosis of
'psychiatric' cases can be unreliable. Overlaps with
substance abuse are clearly important.
Impulsivity and the Substance Abuse Dis-
orders
The concept of the alcohol dependence syndrome"
includes a subjective 'compulsion' to drink. It has
recently been suggested that the DSM-III distinc-
The Impulsivist 643
tion between alcohol abuse and dependence is of
little prognostic importance,^' however the range
from low levels of dependence to higher levels, and
the conceptual difficulties in delineating 'pathologi-
cal' positions on this spectrum seem important." A
spectrum from 'compulsive' to 'impulsive' drinking
may be found, with either extreme containing
patients with poor prognosis.
Multiple substance abuse is an important area.
Belenko*" suggested that alcohol abuse often pre-
ceded opiate abuse but that it may also follow on the
stabilization, for example by a methadone mainte-
nance programme. Cohen et al." showed that an
alcoholism screening test on entry to a methadone
maintenance programme identified most of those
dropping out from the programme through alcohol
abuse (which was a major source of attrition from
the programme). There is convincing evidence that
alcohol use amongst opiate addicts is a major
predictor of poor outcome and premature death."-''
Rounsaville et a/.," confirmed that alcohol depen-
dence among addicts in a methadone treatment
programme was more prevalent than in the general
population and that, among the addicts, alcohol
dependence was associated with fewer assets and
more liabilities, including more disrupted child-
hoods, more legal problems, more polydrug abuse
and higher rates of other psychiatric diagnoses
including depression. Other independent studies
have shown impressively similar results."-"
It is clear that forms of multiple substance abuse
are important. We suspect that links with other
impulsive behaviours may be of similar significance
but the evidence is less readily available. The high
prevalence of theft and crimes against property
amongst drug addicts have become truisms and it is
difficult to sort out what might be impulsive
crimes." Links with the eating disorders are becom-
ing more clear. Eleven of 47 alcoholic women (40%)
gave histories of binge eating at some point in their
lives." These women reported the onset of problem
drinking at a younger age than the remainder of the
group. Most described onset of binge eating preced-
ing that of problem drinking. Myles & Hill" found
diagnostic levels of abnormality on the Eating
Attitudes Test in 20% female alcoholics attending a
voluntary service and in 10% of female opiate
addicts attending an NHS clinic.
Impulsivity in the Eating Disorders
A number of authors have recently discussed
similarities and overlaps between the eating and
644 J. Hubert Lacey & D. H. Evans
substance abuse disorders (e.g. Scott*"). There are
similarities in the terms used both by patients and
professionals when describing anorexia nervosa and
the substance dependence disorders and it may be
that anorectics become dependent on the physiolog-
ical effects of starvation.'" Brisman & Segal*^ link
bulimia and alcohol dependence specifically. They
note high prevalence figures for alcohol abuse in
bulimic patients and comment that their own
clinical experience has included examples of 'dually
directional symptom substitution'.
Strong associations between binge eating and
other forms of impulsivity are very clear. Casper et
al." compared bulimic and abstaining subgroups of
anorectics. The bulimics showed more 'kleptomania'
and scored significantly higher on the depression,
hysteria, psychopathic deviate, paranoia and psycha-
esthenia scales of the MMPI. Garfinkel et a/."
comment on the 'variety of impulsive behaviours' in
the bulimic subgroup in their series: they abused
alcohol, used 'street drugs' more often, had stolen,
mutilated themselves and made other suicidal acts
more frequently. They also showed more labile
affect and had a significantly worse prognosis.
Yellowlees'" reported similar results recently in a
British population of hospitalized anorectics.
Palmer,'" noted the 'erratic and unstable behav-
iour' of bulimics and said: "the impulse to eat is
experienced aj out of control". One of his three case
vignettes was of a woman who abused alcohol in
parallel with bingeing on food. Russell" noted that
many of his bulimic patients themselves drew a
parallel between their bingeing and addictions, and
he commented on the rates of suicide attempts,
completed suicide, laxative abuse, abuse of drugs,
stealing and sexual disinhibition. He concluded that
personality problems occurred with considerable
frequency but that no characteristic premorbid
Table 2. Diagnostic Criteria for the Multi-impulsive Form of Bulimia
1. Bulimia is associated with one or more of the following:
gross alcohol abuse,
'street drug' abuse,
multiple overdoses,
repeated self-damage,
sexual disinhibition,
shoplifting.
2. Each behaviour is associated with a similar sense of being out of control.
3. Bach of these patterns of behaviour may fluctuate, and they are interchangeable and impulsive.
4. The patients' affects are of depression and intense anger which are declared when the behaviours are controlled.
personality type could be described. Pyle et a/.'"
report similar results (see Table 1). A number of his
34 patients describe sensations prior to bingeing
reminiscent of those in the DSM-III definition of
impulse control disorders. The family histories
suggested high rates of alcoholism and affective
disorder.
It has become clear that some degree of eating
disorder is extremely common in women and that
only a small percentage of this comes to the
attention of psychiatrists.'""" The first author has
suggested that bulimics presenting for treatment can
be divided into a neurotic group, generally without
other patterns of impulsive behaviour, who do well
in time-limited out-patient treatment; and another,
personality disordered group with multiple patterns
of impulsivity.
Figures for 112 consecutive attenders at the
eating disorders clinic in St George's Hospital^^ also
show this very high prevalence of impulsive behav-
iours in bulimics. The main information is shown in
Table 1 but it should be noted that, by the mean
presenting age of 25, 31% reported 10 or more
sexual partners; 16%, 20 or more and 3.5%, over
100. 37% reported that, in their judgement, they had
gone through a period of 'promiscuity'. 46% de-
scribed a family history of alcohol problems. These
data and the clinical impressions led the first author
to formulate diagnostic criteria for the multi-
impulsive form of bulimia (Table 2).
It would seem that there is a large body of
evidence suggesting that multiple patterns of impul-
sivity are common in the eating disorders; that they
are very strongly associated with the presence of
binge eating, overlap with substance abuse disorders
and the uni-impulsive disorders (at least klepto-
mania); that they are associated with poor prognosis
and particularly parasuicide.

Impulsivity and Self-harm
Although the diagnoses most associated with para-
suicidal or self-harm are depression and 'hysteria'"
there is an extensive literature on self-harm which
has often focused on a group of young women who
repeatedly and impulsively cut themselves or take
non-fatal overdoses (e.g. Clendenin & Murphy &
Weissman"'"); their cutting is often, but not always,
relatively superficial which led Pao'' to talk of 'the
syndrome of delicate self-cutting'. These women
tend to be heavy alcohol and drug users and a
number show marked promiscuity and eating dis-
orders." Davidson & Montgomery,'' found that 40%
of two large series of parasuicides reported less than
5 minutes premeditation before the event. They
noted that this group was less depressed than the
remainder of the series and more often motivated by
a desire to reduce tension.
Spittle et aW showed that comparison of the
acute psychiatric inpatients who had and had not
made a suicidal gesture or gesture of self-harm in
the month prior to admission revealed no difference
in levels of depression but a markedly higher rating
of risk-taking propensity*" among those who had
attempted suicide.
These patients pose enormous problems for the
health services. Pallis & Birtchnell" showed an
inverse association between disturbed personality
profiles on the MMPI and seriousness of suicide
attempt. Despite the low suicidal risk, many authors
have noted that these patients put an enormous
strain on the emergency services while their reten-
tion in formal psychiatric treatment seems very
difficult*^'" and estimates of the efficacy of treat-
ment are often bleak.
Impulsivity in the Personality Disorders
The International Classification of Diseases (ICD-
9), like DSM-II, includes a category of 'Explosive
personality disorder'. Apart from this specifically
impulsive personality disorder there are also ele-
ments of impulsivity in brief descriptions of the
ICD Hysterical personality disorder. DSM-III gives
longer and more detailed description of the perso-
nality disorders and specifically mentions unstable
patterns of behaviour and substance abuse in
histrionic personality disorder.
Impulsivity has frequently been cited as a funda-
mental element of the psychopathic or sociopathic
personality disorders in the psychiatric literature. It
formed the first factor in the factor analysis of
Hare's checklist for psychopathy."-"
The Impulsivist 645
Impulsivity and the Borderline Personality
Disorder
DSM-III defines a much-debated personality disor-
der—the borderline personality disorder (BPD).
Multiple impulsive behaviours, affective instability
and self-harm are diagnostic features.
It has been suggested that diagnostic reliability of
the BPD is poor. However the DSM-III definition
has been shown to have discriminant validity" and
temporal stability." Goldstein" in a study of
impulse control in borderline patients noted that
they had statistically more admissions for loss of
control or impending loss of control than control
groups of depressed and schizophrenic patients.
They suggested that borderline patients' impulse
control is qualitatively different from that of
schizophrenics and quantitatively different from
that of the depressed patients.
Hostility and impulsive anger are important
aspects of the BPD,™ and this hostility and impul-
sivity link with the high rates of impulsive self-
harm, substance abuse and eating disorders.^' In
Britain, Coid et aV^ were able to gather a group of
20 patients meeting diagnostic criteria for BPD who
mutilated themselves at least three times. These 20
patients also showed diagnoses of bulimia (3),
anorexia (4), substance abuse (4), 'promiscuity' (1),
'stealing' (1), gender-identity disturbance (3) and
'unprovoked assaults' (1). In a study of alcoholics
Nace et a/." found 13% of alcoholics in an inpatient
programme to have BPD, they were younger than
the remainder and more likely to have a diagnosis of
drug abuse, suicide attempts and accidents.
It is clear that the BPD is linked with disorders of
impulse control, self-harm, sudden mood swings
and anger. It appears to be quite prevalent amongst
alcoholics and simultaneous diagnoses of eating
disorders, mood disorders and substance abuse are
common.
Many patients with diagnoses of substance abuse
(e.g. Schukit & Morrissey'*), eating disorders (e.g.
Hudson et aV^) or disorders of impulse control have
simultaneous diagnoses of personality disorders.
This distinction between psychiatric illness behav-
iour and 'personality disorder' can be problematic
and the decision to place any such behaviours as a
disease or a characteristic personality problem is
related to the difficult distinctions between criminal
and psychiatric behaviours mentioned above.
Discussion
We have presented a summary review of literature
646 J. Hubert Lacey & D. H. Evans
on impulsivity, disorders of impulse control and
disorders that we consider to be related to impulse
control. We have noted evidence of similarities in
theoretical work on these conditions and of
subgroups of patients with multiple impulsivity and
poor prognoses. We suggest, wielding Occam's razor
to cut through the normal categorical diagnostic
system, that these latter patients form a unitary
subgroup with a 'multi-impulsive personality dis-
order'. There are a number of possible objections to
this hypothesis.
One objection is that our review is selective and
may have been biased toward our hypotheses. We
attempted to minimize this possibility by using
computerized searches of the medical and psycholo-
gical indices using keywords relating to impulsivity.
Another objection is that most clinical series that
we have found have made no attempt to assess the
full range of conditions we have mentioned so that
most cells in Table 1 are empty. A related problem
is that different authors have used very different
diagnostic criteria and figures for 'kleptomania' and
'theft' might bear little relationship to each other.
We would certainly endorse the need for greater
standardization of diagnostic criteria. However,
these are problems facing all exploratory reviews
and that so many different authors have reported
findings not predicted by their particular perspec-
tives lends some weight to the figures in the table.
These objections can really only be answered by
prospective surveys with standardized diagnostic
criteria but they are perhaps of less importance than
alternative ways of explaining these data.
It is possible that the frequencies of multiple
impulsivity we found are statistically expected
intersections among groups of problems which are
common in the general population and it is certainly
true that alcohol abuse, eating disorders, shoplifting,
gambling and experimentation with illicit drugs are
all prevalent. We have not been able to find reliable
figures for national prevalence for all these condi-
tions but some of the figures are far too high to be
explained on this basis.
It could be argued that all these impulsive
behaviours are not features of a personality disorder
but neurotic illnesses or phenomena secondary to a
neurotic illness such as depression. However, the
remarkable chronicity of some of these problems
seems to argue for placing multiple impulsivity
amongst the personality disorders, even though the
relationship with dysphoria in various forms is an
important one. The first author has commented
upon the emergence of quite significant depression
as bulimics bring their eating under control in
treatment and dysphoric symptoms often emerge in
alcoholics in or after treatment." We feel that
transient mood swings are part of the impulsivity
and a crucial part, nevertheless we believe that the
fundamental problem is a deficit in impulse control
which is closely related to difficulty coping with
depressive emotions and anxiety. This is a relation-
ship that demands further study.
We have argued that the presence of multiple
impulsive behaviours in one person refiects a 'multi-
impulsive personality disorder' but it could be that
we are simply noting variants of borderline perso-
nality disorder. This needs to be tested. It seems
likely that behavioural impulsivity will be more
measurable than psychodynamic aspects of border-
line disorders even if the latter are primary.
Even if they are interested in our hypothesis,
sceptical readers will also ask "So what if there is
such a disorder? Would that be of any importance?".
We argue that the multiple impulsivity of a minority
of patients attending specialist clinics or casualty is
already a problem of such significance as to justify
consideration of a general model of impulsivity.
This would facilitate development of treatment
methods giving more importance to the management
of delayed gratification and control of impulsivity.
In particular it would allow the development of
treatments to deal with the interchangeable nature
of the symptoms. Thus for example, if alcohol abuse
is addressed in the alcohol treatment unit, the
patient may stop drinking but move to food or
cutting. These protean symptoms tend to be infec-
tious making these patients unpopular so that they
drift from clinic to clinic. Only by concentrating on
all the symptoms can the underlying psychopatho-
logy be tackled. In particular, awareness of the many
secretive forms of impulsivity, such as theft and
bulimia, could alert the clinicians to symptom
substitutions which tend to thwart focused thera-
pies. We suspect that current treatment methods for
this unhappy, disordered and ambivalent group are
frustrated by a lack of cross-fertilization between
specialists. Our hypothesis is testable on many of its
facets and merits serious attention.
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