Control Disorders

Wernicke encephalopathy is an acute, reversible, neurologic condition that arises because of a severe deficiency of thiamine (vitamin B1). This condition is most commonly seen in people with excessive alcohol use. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in ⅓ of patients. Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathy. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Both Wernicke encephalopathy and Korsakoff syndrome may be diagnosed clinically. Treatment includes absolute abstinence from alcohol and thiamine supplementation.

In the human brain, information is transmitted in the form of bioelectrical impulses and chemical signaling molecules. These molecules, called neurotransmitters, are protein molecules used by neurons to emit a specific signal. The signals are picked up in the plasma membrane of adjacent neurons by receptors, which are complexes of protein subunits responsible for sensing relevant stimuli and setting in motion the cellular machinery required to produce the desired response.

Opioid use disorder (OUD) is a substance use disorder characterized by pathologic consumption of opioids. Opioids are central nervous system depressants that are used medically as potent analgesics. However, they are often misused for their euphoric effects. Features of opioid intoxication include respiratory depression, drowsiness, and pinpoint pupils. Intoxication can be managed with administration of naloxone. If discontinued, patients may develop withdrawal symptoms such as irritability, piloerection, and stomach cramps. Withdrawal may be managed by methadone or buprenorphine. Chronic OUD is managed with psychotherapy as well as medications. Prognosis is poor without adequate management and prevention of relapse and overdose.

Cocaine use disorder is a substance use disorder defined by pathologic consumption of the recreational drug cocaine. Cocaine is an indirect sympathomimetic that blocks the reuptake of dopamine, serotonin, and norepinephrine from the synaptic cleft. This process causes stimulant effects on the body and mind such as euphoria, increased energy, irritability, psychosis, decreased appetite, and weight loss. Cocaine overdose can cause death secondary to cardiac arrhythmia, myocardial infarction, seizure, or respiratory depression. Prognosis is poor as there is no approved pharmacological treatment, but psychosocial interventions have been associated with improved outcome.

Amphetamine use disorder (AUD) is a condition characterized by pathologic use of psychostimulants. Amphetamines produce their effect by increasing the release and blocking the reuptake of neurotransmitters (dopamine, norepinephrine, serotonin). Medically, they are used for the treatment of ADHD and narcolepsy. Methamphetamines and so-called designer drugs have no clinical use. Intoxication results in euphoria, pupillary dilation, hypertension, skin excoriation, paranoia, and severe aggression. Fatal complications can arise from myocardial infarction and coma. The prognosis for AUD is poor, as there is no FDA-approved pharmacotherapy, but psychosocial interventions have been associated with improved outcomes.

Pica is an eating disorder characterized by a desire or recurrent compulsion to eat substances that are nonnutritive and not food. These compulsions and ingested substances are inappropriate for age or culture. Pica manifests most commonly during childhood and pregnancy and, therefore, carry a high risk for malnutrition and anemia. Patients usually present with nutritional deficiencies or complications from ingesting nonfood substances. Management aims are to stabilize patients medically and then provide appropriate behavioral therapy as a 1st-line option.

Hallucinogen use disorder is defined by the pathologic consumption of hallucinogenic substances that cause perceptual distortions (visual or auditory). Examples include psilocybin (mushrooms), lysergic acid diethylamide (LSD), and phencyclidine (PCP). These drugs are used for their psychedelic effects, i.e., a temporarily altered state of consciousness. Most hallucinogens produce nausea, vomiting, and mild sympathomimetic effects such as tachycardia, hypertension, mydriasis, hyperthermia, and diaphoresis. Although hallucinogens may cause hyperthermia in severe cases, they don’t result in dependence or withdrawal symptoms.

Inhalant use disorder is a substance use disorder defined by pathologic consumption of inhalant substances—such as glue, paint, or lighter fluid—in order to reach a euphoric feeling. Individuals administer inhalers through the mouth (commonly known as huffing) or sniff them through the nose. The effect lasts for only several minutes. Signs of acute intoxication range from intense transient euphoria up to loss of consciousness. The abuse of inhalants results in CNS inhibition and may lead to coma and even death during acute intoxication and long-term cognitive impairment with chronic use. Management varies depending on the type of inhalant and ranges from supportive measures, including psychologic counseling, to intensive medical treatment to address and prevent further organ damage.

Kleptomania and pyromania are impulse control disorders, which are psychiatric conditions characterized by the inability to resist an impulsive action that can lead to harmful results. People suffering from these disorders experience a feeling of increased anxiety prior to committing the action. Once the action is completed, patients feel relief in spite of the potentially dangerous consequences. Treatment includes psychotherapy and some medications.

Rumination disorder is a behavioral disorder marked by repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is not due to a medical disorder (GERD or pyloric stenosis) or other eating disorders (avoidant/restrictive food intake disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa). Treatment is multifactorial, focused on treating underlying mood disorders and accompanied by antispasmodic therapy only when refractory to behavioral modification.

Tobacco use is the leading cause of preventable death in the world. Tobacco use is directly related to a higher risk of chronic obstructive pulmonary disease (COPD), cardiovascular diseases, and various cancers. Nicotine, the psychoactive component of tobacco, stimulates nicotinic receptors in the autonomic ganglia of the sympathetic and parasympathetic nervous systems. Nicotine is highly addictive through its effects on the dopaminergic system. Treatment includes medications to prevent cravings, nicotine-replacement therapy, and psychotherapy.

Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. The episodes must have been present for at least 3 months. These erratic and explosive outbursts can cause significant distress in the person and have a negative impact on their life. The disorder is usually diagnosed in young men. Treatment includes medications and behavioral modifications.

Gambling disorder is chronic, recurrent, maladaptive gambling behavior that results in impairment in social or personal life. The disorder fits under the umbrella of addictive disorders due to a strong compulsion to gamble as well as tolerance and withdrawal effects that are similar to substance use disorder. Gambling disorder differentiates itself from nonpathologic gambling by the level of tolerable risks. The disorder can be managed with psychotherapy and medications. The prognosis is usually poor, with high rates of relapse and complications.

Trichotillomania (hair-pulling disorder (HPD)) is defined as repetitive pulling of one’s hair resulting in hair loss that may be visible to others. This disorder is classified under obsessive-compulsive and related disorders, as there is tension prior to the act that is relieved after the hair-pulling. Diagnosis is made clinically through history taking and physical exam. Treatment is multimodal, using behavioral interventions to recognize and properly respond to the tension and pharmacotherapy, which is beneficial in some cases.

Anorexia nervosa is an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low BMI and diverse physiological and psychological complications. The condition is most commonly seen in adolescent girls. Treatment consists of psychotherapy (CBT) and patient hospitalization for intensive care and management of complications. Pharmacotherapy has a limited role.

Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by inappropriate compensatory behaviors (laxatives or diuretics use, self-induced vomiting, fasting, or excessive exercise) to counteract the effects of binge eating and prevent weight gain. These episodes occur at least twice weekly for at least 3 months. Patients have normal body weight (or are slightly overweight). Treatment consists of a combination of psychotherapy and pharmacotherapy.

Binge eating disorder is an eating disorder marked by recurrent episodes of binge eating without inappropriate compensatory behavior. Episodes occur at least weekly for 3 consecutive months. There is a loss of control during the episodes of binging as well as distress after. Treatment consists of a combination of psychotherapy and pharmacotherapy.

Alcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care. Withdrawal from chronic alcohol use can have fatal consequences, including delirium and seizures, and is managed with benzodiazepines. Chronic AUD affects almost every part of the human body and has serious impacts on a person’s mental and physical health. Alcohol user disorder can be managed with psychotherapy as well as medications; however, the prognosis is usually poor, with high rates of relapse and complications.

Wernicke encephalopathy is an acute, reversible condition that is caused by severe thiamine deficiency. This condition is most commonly seen in alcohol abusers. The classic triad of symptoms is encephalopathy, oculomotor dysfunction, and gait ataxia, although all 3 features are only present in one-third of patients. Korsakoff syndrome is a severe and late neuropsychiatric manifestation of Wernicke encephalopathy. Korsakoff syndrome presents with personality changes, anterograde and retrograde amnesia, and confabulation. Some of these changes are irreversible. Both Wernicke encephalopathy and Korsakoff syndrome may be diagnosed clinically. Treatment includes absolute abstinence from alcohol and thiamine supplementation.

Substance use disorders are a significant cause of morbidity and mortality, especially among adolescents and young adults. A substance-related and addictive disorder is the continued use of a substance despite harmful consequences; these include significant impairment to one’s health or relationships or failure to fulfill major responsibilities at work, school, or home because of substance use. There are several individual substance use disorders, and they are linked by their chronicity and the significant impairment they cause. Most substance use disorders have associated intoxication and withdrawal symptoms. Treatment options include pharmacotherapy and behavioral interventions; however, individuals with substance use disorders have frequent relapse/remission as well as low compliance with treatment.