Irresistible Impulse vs Impulse not Resisted

Impulse Control Disorders are a collection of clinical entities where patients know the wrongfulness or inappropriateness of their behaviors but have great difficulties controlling them. They fail to control urges or impulses that may end up harming themselves or others. They do not suffer from irresistible impulses, but do struggle to resist them.

KleptomaniaTrichotillomania and Pyromania are among the most well-known of these disorders. When severe, Internet Addiction and Compulsive Shopping can also become the focus of clinical attention.

Those suffering from kleptomania are often wrongly perceived as thieves or shoplifters who steal from personal profit. In reality, kleptomaniacs steal objects of little value (or objects which they can certainly afford) in response to intense urges.  Stealing for personal use or profit is not kleptomania. Patients report an escalating sense of pressure immediately prior to performing the theft that is followed by relief of the pressure immediately after performing the theft. The Indian psychiatrist Vasudeo Paralikar describes an "increase in heart rate, close to an adrenaline rush after committing a crime and getting away with it."  This adrenaline rush may play a role in the addictive/compulsive nature of kleptomania.

Pyromaniacs are not arsonists, just like kleptomaniacs are not shoplifters. Arsonists set fires for personal, monetary or political gains. Pyromaniacs engage in deliberate, multiple and purposeful firesetting only to induce euphoria. They tend to fixate on fire stations and firefighters, and seem to be fascinated by fire. They also experience a sense of tension and emotional buildup prior to starting the fire, followed by relief of tension and intense satisfaction right after the act. When firesetting is associated with sexual gratification, the correct diagnosis is Pyrophilia.  Pyromania is a rare condition and over 90% of cases are male.

In general, Impulse Control Disorders carry little (if any) weight in the legal system. An exception is the highly publicized case of Lorena and John Wayne Bobbitt. In her 1994 trial, Lorena was found not guilty due to "insanity causing an irresistible impulse to sexually wound her husband" (cutting off her penis while he was asleep). As a result, she could not be held liable for her actions.  Nowadays, attempts to use Impulse Control Disorders as the psychiatric basis of insanity pleas routinely fail to succeed.  The American Psychiatric Association does not support the use of these diagnoses as evidence of insanity since patients are fully aware of the wrongfulness of their acts.

Compulsive GamblingPathological Gambling or Ludomania is the inability to resist impulses to gamble, which can lead to severe personal or social consequences. Current psychiatric classification has moved this condition from an Impulse Control Disorder to an Addiction, and its successful treatment includes 12-step programs (Gambler Anonymous) that are also used in other addictive  disorders. Early onset of problem gambling increases the lifetime risk of suicide. Gambling-related suicide attempts are usually made by older people with problem gambling who incur catastrophic financial losses.

Five behavioral stages characterize impulsivity:

  • an impulse
  • growing tension
  • pleasure from acting
  • relief from the urge
  • guilt (which may or may not arise)

These poorly understood conditions can cause severe disruption in patients and families, serious legal problems, emotional turmoil and financial ruin.  Without excusing their behaviors, sufferers are more likely to engage in treatment if approached in a firm but empathic and non-judgemental way.

Content reprinted with permission:  Clayton Behavioral