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The aim of this paper is to review current treatments and develop a novel CBT-based treatment for Impulse control disorders (ICDs). Specifically, to conceptualize a new treatment that includes an examination of the cognitive, behavioral, affective, pharmacological, environmental, as well as neurological characteristics of impulse control disorders. There will be a review of the impulse control disorders in the Diagnostic and Statistical Manual of Mental Disorders and an examination of the current cognitive, behavioral, and/or cognitive-behavioral therapy treatments that are available for each ICD. There will also be an analysis of the neurological basis that many ICDs may have and the psychopharmacology that is related. Along with medication, CBT-based techniques could affect the biological foundation of the behaviors in a positive direction.

Impulse control disorders are distinguished by the engagement in a (possibly chemically) rewarding behavior that is difficult to resist even though it may ultimately result in harmful consequences (Olvera, 2002). The five formal ICDs include pathological gambling, trichotillomania, kleptomania, intermittent explosive disorder, and pyromania. Other ICDs that have not been included as official disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) are currently classified as 'not otherwise specified' include: compulsive buying, pathologic skin picking, and compulsive sexual behavior (American Psychiatric Association, 2000). For the purposes of this paper, there will be a focus only on the formal ICD diagnosis in the DSM-IV-TR.

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Pathological gambling is characterized by unrelenting and periodic maladaptive patterns of gambling. It has been described as a chronic and relapsing condition that affects 0.9% to 1.6% of the US population (National Opinion Research Center, 2000). The phases of pathological gambling behavior can vary depending on the authorial entity creating the phases. DeCaria & Hollander (1993) find that the first phase starts with a "big win" that inspires confidence and encourages continuation of the gambling behavior. This continuation is based on the assumption of continual wins. However, when a winning streak wanes, the second phase begins. This "losing phase" occurs when the gambler is unable to cognitively acknowledge the loss and tries to win back the loss with higher and more frequent betting. Then, the "desperation" phase begins when the gambler can no longer simply acquire the amounts of money the habit is requiring. The fourth phase becomes one of "despair" where the consequences of the gambling make the gambler feel as if there is no way out of their circumstances.

In a study by Grant & Kim (2001), they noted that both distorted cognitions and behaviors need to be addressed in pathological gambling. Since CBT aims to link awareness of one's thoughts to their behaviors (Wenzel, Brown, & Beck, 2009), cognitive restructuring can be used to improve control over gambling urges and the negative emotions associated with gambling. In addition, CBT-based strategies to directly modify behaviors and develop skills in social communications, assertiveness, and adaptive behavioral coping have been shown to help. As stated by Grant & Odlaug (2010), CBT treatments ap­pear to be effective for pathological gambling, but few studies have com­pared interventions or examined whether multiple combinations of treatments are more beneficial. In addition, no study has examined whether certain indi­viduals with pathological gambling would benefit from specific CBT treatments along with a medication (Grant & Odlaug, 2010).

Trichotillomania (TTM) is characterized by repetitive hair pulling that causes noticeable hair loss and results in clinically significant distress or functional impairment (American Psychiatric Association, 2000). It is thought that patients with TTM experience an increasing sense of tension immediately before pulling or when attempting to resist the behavior, as well as pleasure, gratification or relief when pulling. There may be a physiologically related catalyst within this building of tension. Although TTM is usually limited to hair on the head, removal of eyebrows, eyelashes, and other body hair is not unusual. This practice results in significant, and sometimes complete, hair loss (Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007).

In controlled study of trichotillomania, researchers used Acceptance and Commitment Therapy as well as Habit-Reversal Training (ACT and HRT) (Grant & Odlaug, 2010). Following treatment, the CBT group using both techniques showed significant reductions in trichotillomania symptoms compared with the group that relied only on supportive therapy. On the neurophysiological side, a study by Chamberlain et al., (2010) found that there was a reduction of brain white matter integrity, and thereby density, in individuals with trichotillomania. This study could possibly add another dimension of neurological basis of trichotillomania and possibly all impulse control disorders.

Kleptomania is characterized by repetitive, uncontrollable theft of items not needed for their personal use (American Psychiatric Association, 2000). The real kleptomaniac does not steal for personal gain - they often have enough money to buy the item that they steal. In addition, they are very aware of the criminal nature of the act. Once again, there is a feeling of increasing tension and pressure to steal, followed by immediate pleasure or relief. Some have admitted to been able to identify specific environmental or physical triggers that initiate to their urge to steal. Although, they often also experience guilt and shame consequently (Dannon, 2002). Many individuals who suffer from kleptomania develop poor self-control strategies in an effort to refrain from the act. For example, they may socially isolate themselves in an attempt to eliminate the opportunities to steal (Reid, 2006). To date, there have been no strictly controlled clinical trials of psychosocial interventions for the treatment of kleptomania (Grant & Odlaug, 2010). Although there is some evidence supporting CBT in the treatment of kleptomania, those data are also severely limited. This may be due to the research on treatment outcome in kleptomania is generally lower in quantity than in other impulse control disorders.

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Intermittent explosive disorder (IED) is characterized by recurrent, significant outbursts of aggression, which often lead to assaultive acts against people or property that are inconsistent to outside stressors and not better explained by another psychiatric diagnosis (American Psychiatric Association, 2000). While intermittent explosive disorder is the inability to control violent impulses, it is critical to distinguish this from normative episodes of bad temper (McCloskey, 2006). There have been articles by many researchers and clinicians whom dispute this disorder as a separate entity because anger and aggression are extremely common in a wide range of psychiatric conditions. However, many individuals suffering from intermittent explosive disorder regard their behavior as distressing, problematic, and unique. A great deal individuals with this ICD do not have a comorbid Axis 1 disorder. However, individuals with IED correlate positively with many personality disorders (Grant & Odlaug, 2010).

Although case reports have suggested that insight-oriented psychotherapy or behavior therapy may be beneficial, there are no published controlled psychological and psychopharmacological treatment studies for individuals with intermittent explosive disorder (Grant & Odlaug, 2010). However, there have been controlled trials of individuals with significant anger and aggression in the literature. In one study on aggression, a randomized clinical trial compared the efficacy of a 12-week CBT presented in either group or individual format (McCloskey, Noblett, Deffenbacher, Gollan, & Coccaro, 2008). The choice of CBT, and specifically cognitive restructuring, relaxation, and coping skills education was based on earlier research that used the techniques with the most empirical support. This study found that CBT was helpful in increasing the length of time between each episode.

Pyromania is mental disorder involving a compulsion to set fires (American Psychiatric Association, 2000). According to the DSM-IV-TR, a diagnosis of pyromania requires that there be several instances of deliberately set fires, and that the individual experience tension or excitement before setting a fire, have a fascination or attraction to fire and/or contexts associated with it. Specifically, they must feel pleasure, gratification, or release of tension when setting the fire, seeing its consequences, or being involved in its aftermath. In pyromania, there is an attraction with fire that goes well beyond the interest and experimentation often displayed by children. It is believed that the true pyromaniac will not feel remorse and will not be concerned with the threat their fires may pose to life and property (Relay Health, 2010). Maybe there is a separation of guilt or concern associated with this ICD or, possibly, part of a personality-based sociopathy.

There is no authoritative treatment for pyromania, but it is likely that a combination of behavior and cognitive therapy and drug treatment would help (Gale Research, 1998). Treatment of children and adolescents involved with repeated pyromania may be more effective when given an individual treatment plan rather than a medical model. Many young firesetters come from chaotic households and are attempting to repeat what they have experienced in their lives in the form of environmental destruction. Therefore, a variety of treatment approaches, including problem-solving skills, anger management, communication skills, and aggression replacement training may be essential in addressing all the emotional and cognitive issues that the individual has (Laubichler, Kuhberger, & Sedlmeier, 1996).

There is a commonality which all five formal impulse control disorders share: a buildup of tension, an action, and then an emotional release that takes place within the individual. It has been suggested that there is a close similarity between some ICD's and affective disorders (such as Bipolar), and this has led to treatment with antidepressants, ECT, lithium, and Valproic acid (Dannon, 2002). Some feel that since SSRIs are effective in the treatment of disorders in the OCD spectrum, and since they share a similar neurological biology, SSRIs should be the main treatment approach in ICDs (Ravindran, DaSilva, Ravindran, Richter, & Rector, 2009). Within the SSRIs, when fluoxetine (Prozac) is used as a sole medication, it is most often cited as having the highest beneficial effect (Dannon, 2002). However, as noted by Kim (1998), the largest documented clinical study reporting the result of biological treatment of ICD patients only had 20 participants. Of which, 12 of 20 (60%) reported a positive response to fluoxetine as a treatment.

After reviewing the literature, it appears that data regarding the psychopharmacological treatments of ICDs are limited. However, cognitive and behavioral interventions have shown some promise in treating these disorders effectively (Grant & Odlaug, 2010). As stated earlier, this paper intends to introduce an alternative and, hopefully, more effective treatment for impulse control disorders that includes a neurobiological facet. In my review of literature, I came upon an odd connection between two different disorders. Parkinson's disease is an unremitting neurodegenerative condition that results in a gradual loss of dopaminergic neurons in the Substantia Nigra, this produces disturbances in movement and balance that can become disabling (Jankovic, 2008). Generally, the cognitive and behavioral problems that arise with the dementia commonly occur in the more advanced stages of the disease due to the loss of dopamine in the brain. L-DOPA (Levodopa) is used to increase dopamine concentrations in the brain and is also the most widely used treatment for symptomatic management of Parkinson's disease (The National Collaborating Center for Chronic Conditions, 2000).

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Interestingly, there are some studies that show an increase in pathological gambling in patients with Parkinson's disease (Avanzi, Uber, & Bonfà, 2004). However, this is not due to the disease, but due to the treatment that involves dopamine replacement therapy. In these instances, the ICD is believed to happen because the dopaminergic system is linked to the brain's reward mechanism. This reward system is implicated in various kinds of addictions and obsessions (Miller & Lyon, 2003). Therefore, if there is a connection between a drug that increase dopamine and also increase impulse control issues in people with Parkinson's disease, would an individual with an impulse control disorder benefit from an anti-dopaminergic drug? I believe that it would. In this proposed treatment model of ICD treatment, a low dose atypical dopamine antagonist to treat the neurological basis of ICD would be introduced along with specific CBT-based techniques.

Consequently, if we accept the premise that these impulsive behaviors in ICDs are generally preceded by tension, then the expectation is that a dopamine antagonist would reduce the likelihood of an activation of the sympathetic nervous system. Since the sympathetic nervous system produces effects such as increased heart rate and blood pressure which are parallel to tension and anxiety, this action could reduce the likelihood that a feeling of tension would be built and would, therefore, decrease impulsive behavior. The hope is that the individual's tenseness would be stunted chemically and therefore the impulsive behavior would not take place. However, if the problematic action does take place, such as fire setting or stealing, the dopamine antagonist would also reduce the chemical reward (gratification) that takes place after the deed. Nonetheless, medication should only be offered as part of a comprehensive psychosocial treatment package for ICD.

I propose that maybe impulse control could be analogous to emotional regulation. A large conceptual part of DBT is skills training of "emotion regulation, interpersonal effectiveness, mindfulness, and distress tolerance" (Linehan & Dimeff, 2001, p. 1). DBT purposefully takes into account not only the change that needs to occur cognitively, but also the in the moment affect of the client. This is how Cognitive and Behavioral techniques can be very useful for impulsivity. Regulation of impulsivity combined with mindfulness adds a multi-dimensional approach to treating ICDs. The use of mindfulness would entail a truly "existing in the moment" feature by having the individual stop themselves prior to an outburst, a pulling of a hair, a theft, a gamble, or using a match to start a fire. Along with DBT, the use of Acceptance and Commitment Therapy (ACT) would be included as a psychological intervention. ACT also uses mindfulness but includes an aspect of personal acceptance (Hayes, 2009). Hayes coins a term called psychological flexibility, in where an individual is able to fully connect to themselves in spite of the changing situations and personal mood.

Within this flexibility, there should be an attempt to understand the complex interconnection of schemas that produce physiological and behavioral reactions in all areas of an individual (Claessens, 2010). Pyromaniacs have responded to cognitive and behavioral treatments designed to augment a person's awareness of the emotions that lead up to a fire-setting episode and also provide alternate ways of dealing with those emotions (Impulse Control Disorders, 2001). With an environmental aspect in mind, a treatment could be created that integrates with ACT. This treatment would be for individuals that have severe impulsivity issues and would contain an approach that supports their behaviors by initially allowing fire-setting individuals to literally set their own fires.

In a controlled environment individuals would be allowed to start fires, but prior to this, they would have at least some background in CBT-based psycho-education so they could be aware of the internal psychological and somatic affects that take place during the event. In turn, this treatment could be modified and expanded to treat all ICDs. Dannon (2002) notes that case studies have shown that CBT techniques are potentially in regards for treatment of kleptomania. Specifically, one case discusses a man who was able to reduce the frequency of theft after undergoing several sessions of covert sensitization combined with exposure and response evaluations over a 4-month period. Therefore, situations can be set up where a kleptomaniac can "steal" and a trichotillomaniac can pull hairs. Combined with a CBT-based habit reversal technique, treatments could be designed to eliminate or reduce urges or emotional states like depression or anxiety that add to the pulling, firesetting, or theft behaviors.

Additionally, individuals with gambling issues can be allowed to gamble with imaginary money. Those with intermittent explosive disorder could be allowed to beat on dummies or inanimate objects. Once again, all these behaviors and actions would entail a plan that deconstructs how they internally narrate their pseudo-impulsive events in relation to their affect. The hope is that they will become aware of how their behavior is manifested and redirect themselves. The combination of behavioral and cognitive aspects reinforces the idea that cognition and behavior are directly related. Accordingly, in the essence of CBT, individuals with ICD will be able to examine themselves, the world, and the future. The expectation is that the individual will work towards beneficial life changes when given the proper cognitive tools (Wenzel, Brown, & Beck, 2009).

Is there a need for a fourth wave? Within the treatment of ICD, there are (relatively) few studies published - too little to even make empirically based treatment recommendations (Grant & Odlaug, 2010). However, it does appear that CBT offers promise for the effective treatment of ICDs. Though, CBT alone may not be enough. As more studies are conducted and as more literature created, the emergence of a neurophysiological and neurobiological basis for psychological disorders are gallantly announced. Even psychopathy once though completely cognitive has been rebuked with empirical and biological data (Chamberlain et al., 2010). Descartes knew long ago that the body and mind affected each other without discrimination. There is a need for a fourth wave because there is a need of psychologists as well as society to understand that not all actions are directly controlled by the mind. What is readily perceived by others are the emotions that we visually express; however, few consider the internal "emotion" that are expressed within the physiology of all animals. The body, in a way, makes its own choices and these choices must be acknowledged…possibly not only acknowledged, but respected as well.

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