Substance-Induced Psychotic Disorders — MCQs
Visual hallucinations are typically seen in all of the following conditions except?
A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
CAGE questionnaire is used in:
A patient stopped alcohol consumption for 3 days and presented with irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium. What is the likely diagnosis in this case?
A patient has a history of vomiting and was given an antiemetic. The patient subsequently developed abnormal movements (likely extrapyramidal symptoms or dystonia). What medication should be given to manage these abnormal movements?
According to DSM-5 criteria, symptoms of brief psychotic disorder must resolve within what time period to differentiate it from longer-term psychotic conditions like schizophreniform disorder?
Which of the following statements is NOT true about type 1 schizophrenia?
Most reliable marker of conversion to psychosis in high-risk individuals:
Which of the following hallucinations is pathognomonic of schizophrenia?
A 25-year-old male believes that his penis is decreasing in size every day and that it will eventually disappear, leading to his death. What is the most likely diagnosis?
Substance-Induced Psychotic Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Visual hallucinations are typically seen in all of the following conditions except?
- A. Schizophrenia
- B. Alcohol withdrawal
- C. Delirium
- D. Depression (Correct Answer)
Explanation: **Depression** - While other forms of hallucinations can occur in severe depression with psychotic features (e.g., auditory), **visual hallucinations are rare**. - **Mood-congruent delusions** are more common in psychotic depression than visual hallucinations. *Delirium* - **Visual hallucinations** are a hallmark symptom of delirium, often described as polymorphic and vivid. - They are typically accompanied by **fluctuating consciousness** and cognitive impairment. *Schizophrenia* - Although **auditory hallucinations** are more common, visual hallucinations can occur in schizophrenia, particularly in advanced or severe cases. - These hallucinations are often well-formed, frequent, and can be **persecutory** or **bizarre** in nature. *Alcohol withdrawal* - **Alcohol withdrawal delirium** (delirium tremens) is characterized by prominent **visual hallucinations**, tactile hallucinations, and autonomic instability. - These hallucinations can be terrifying and are due to **CNS hyperexcitability**.
Question 2: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
- A. Schizophrenia
- B. Major depressive disorder plus psychosis (Correct Answer)
- C. Schizoaffective disorder
- D. Schizotypal personality disorder
Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.
Question 3: CAGE questionnaire is used in:
- A. Opiate poisoning
- B. Alcohol dependence (Correct Answer)
- C. Dhatura poisoning
- D. Barbiturate poisoning
Explanation: ***Alcohol dependence*** - The **CAGE questionnaire** is a widely used screening tool for identifying potential **alcohol problems** and dependence. - The acronym CAGE stands for Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers, all related to drinking habits. *Opiate poisoning* - Screening for opiate use or poisoning typically involves asking about **drug use history**, conducting **urine drug screens**, and observing specific clinical signs like **pinpoint pupils** and **respiratory depression**. - The CAGE questionnaire is not designed to screen for opiate use. *Dhatura poisoning* - **Dhatura poisoning** is characterized by anticholinergic symptoms like **dilated pupils**, **dry mouth**, **tachycardia**, and **delirium**. - Diagnosis relies on clinical presentation and a history of exposure, not a specific questionnaire like CAGE. *Barbiturate poisoning* - **Barbiturate poisoning** presents with central nervous system depression, including **sedation**, **respiratory depression**, and **hypotension**. - Diagnosis involves a clinical assessment, history of barbiturate use, and toxicology screens, not the CAGE questionnaire.
Question 4: A patient stopped alcohol consumption for 3 days and presented with irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium. What is the likely diagnosis in this case?
- A. Wernicke's encephalopathy
- B. Alcohol withdrawal delirium (Correct Answer)
- C. Korsakoff's psychosis
- D. Alcohol intoxication
Explanation: ***Alcohol withdrawal delirium*** - The combination of **irritability, disorientation, paranoid delusions, agitation, visual hallucinations, and altered sensorium** developing 3 days after cessation of alcohol is classic for **delirium tremens**, the most severe form of alcohol withdrawal. - This condition is a medical emergency that can lead to seizures, cardiovascular collapse, and death if not treated promptly. *Wernicke's encephalopathy* - Characterized by the triad of **ataxia, ophthalmoplegia, and confusion**, which is due to **thiamine deficiency** and is not fully consistent with the patient's presentation. - While it can occur in chronic alcoholics, the rapid onset of severe agitation, hallucinations, and paranoia points more towards active withdrawal. *Korsakoff's psychosis* - This is a chronic neuropsychiatric syndrome that typically follows untreated Wernicke's encephalopathy, characterized by severe **anterograde and retrograde amnesia** and **confabulation**. - It does not present with the acute delirium, agitation, and prominent hallucinations described. *Alcohol intoxication* - This occurs when a person has recently consumed a large amount of alcohol, leading to symptoms like **slurred speech, impaired coordination, mood changes, and reduced inhibition**. - The patient's symptoms are occurring *after* stopping alcohol consumption for 3 days, indicating withdrawal, not active intoxication.
Question 5: A patient has a history of vomiting and was given an antiemetic. The patient subsequently developed abnormal movements (likely extrapyramidal symptoms or dystonia). What medication should be given to manage these abnormal movements?
- A. Hyoscine
- B. Methyl dopa
- C. Benzhexol (Correct Answer)
- D. Cyproheptadine
- E. Diphenhydramine
Explanation: ***Benzhexol*** - **Extrapyramidal symptoms (EPS)** and **dystonia** are often caused by dopamine receptor blockade, and **anticholinergic medications** like benzhexol help restore the **dopamine-acetylcholine balance**. - Benzhexol is a **muscarinic antagonist** that effectively reduces drug-induced Parkinsonism, dystonia, and akathisia by acting centrally. - It is the **preferred oral agent** for ongoing management of drug-induced movement disorders. *Diphenhydramine* - Diphenhydramine is an **antihistamine** with **anticholinergic properties** that can be used for **acute dystonic reactions**, particularly when given parenterally (IV/IM). - While effective for acute management, benzhexol is generally preferred for **ongoing oral therapy** and has more potent central anticholinergic effects. *Hyoscine* - While hyoscine is also an **anticholinergic agent**, it is primarily used for preventing **motion sickness** and managing **postoperative nausea and vomiting**. - Its efficacy in reversing acute extrapyramidal symptoms induced by neuroleptics or antiemetics is generally **less pronounced** compared to agents like benzhexol. *Methyl dopa* - Methyl dopa is an **alpha-2 adrenergic agonist** primarily used in the treatment of **hypertension**, especially in pregnancy. - It works by reducing sympathetic outflow and is **not indicated** for managing extrapyramidal symptoms or dystonia. *Cyproheptadine* - Cyproheptadine is an **antihistamine** with **serotonin antagonist** properties, used to treat allergic reactions, appetite stimulation, and occasionally **serotonin syndrome**. - It does not have significant anticholinergic effects that would alleviate medication-induced extrapyramidal symptoms or dystonia.
Question 6: According to DSM-5 criteria, symptoms of brief psychotic disorder must resolve within what time period to differentiate it from longer-term psychotic conditions like schizophreniform disorder?
- A. 1 week
- B. 3 weeks
- C. 2 weeks
- D. 1 month (Correct Answer)
Explanation: ***1 month*** - According to **DSM-5 criteria**, brief psychotic disorder is characterized by symptoms lasting more than **1 day** but less than **1 month**. - If psychotic symptoms persist for **1 month or longer**, it indicates a different diagnosis, such as schizophreniform disorder or schizophrenia, requiring further evaluation. *1 week* - While psychotic symptoms may be present for 1 week in brief psychotic disorder, this duration is within the disorder's diagnostic window but not its defining upper limit. - The key differentiator for brief psychotic disorder is that symptoms resolve within **1 month**. *2 weeks* - Similar to 1 week, 2 weeks is a duration that can occur within brief psychotic disorder, but it does not represent the minimum duration that distinguishes it from longer-term conditions. - The crucial threshold for duration in brief psychotic disorder is **less than 1 month**. *3 weeks* - Three weeks also falls within the diagnostic duration for brief psychotic disorder. - The essential criteria specify that psychotic symptoms must last **less than 1 month** to be classified as brief psychotic disorder.
Question 7: Which of the following statements is NOT true about type 1 schizophrenia?
- A. It has a poor prognosis. (Correct Answer)
- B. Intellect is usually maintained.
- C. It is an acute illness.
- D. It is characterized by negative symptoms.
Explanation: ***It has a poor prognosis.*** - This statement is **NOT true** about type 1 schizophrenia, making it the correct answer to this question. - Type 1 schizophrenia is generally associated with a **better prognosis** and good response to antipsychotic medication. - It is characterized by the prominence of **positive symptoms**, which tend to be more responsive to treatment. *It is an acute illness.* - This statement is **TRUE** about type 1 schizophrenia, so it is not the answer. - Type 1 schizophrenia is often characterized by an **acute onset** of symptoms, particularly positive symptoms. - This acute presentation differentiates it from type 2, which typically has a more insidious onset. *Intellect is usually maintained.* - This statement is **TRUE** about type 1 schizophrenia, so it is not the answer. - In type 1 schizophrenia, **cognitive function**, including intellect, is usually better preserved compared to type 2 schizophrenia. - While some cognitive deficits may occur, they are generally less severe and less pervasive than in type 2. *It is characterized by negative symptoms.* - This statement is **FALSE** about type 1 schizophrenia, but it is not the best answer because the prognosis statement is more definitively incorrect. - Type 1 schizophrenia is primarily characterized by the predominance of **positive symptoms**, such as hallucinations, delusions, and disorganized thought. - **Negative symptoms** (e.g., apathy, anhedonia, alogia, blunted affect) are the hallmark of type 2 schizophrenia.
Question 8: Most reliable marker of conversion to psychosis in high-risk individuals:
- A. Cognitive decline
- B. Sleep disruption
- C. Social withdrawal
- D. Basic symptoms (Correct Answer)
Explanation: ***Basic symptoms*** - **Basic symptoms** are subtle, subjective disturbances of thought, perception, and motor control that are often precursors to full-blown psychotic episodes. - They are considered the **most reliable markers** for predicting conversion to psychosis in high-risk individuals because they directly reflect underlying neurobiological vulnerabilities. *Cognitive decline* - While **cognitive decline** can be a feature in individuals at high risk for psychosis, it is a less specific predictor as it can occur in various other neurological and psychiatric conditions. - It often represents a broader, non-specific marker of underlying brain dysfunction rather than a direct indicator of impending psychosis. *Sleep disruption* - **Sleep disruption** is a common symptom reported by individuals at high risk for psychosis and can exacerbate psychiatric symptoms. - However, **sleep disturbances** are highly prevalent in the general population and across many psychiatric disorders, making them a less specific and reliable predictor of psychosis conversion compared to basic symptoms. *Social withdrawal* - **Social withdrawal** is a frequently observed prodromal symptom in individuals who later develop psychosis. - While it indicates a change in functioning, it is a non-specific behavioral change that can be linked to depression, anxiety, or other stressors, making it less specific than basic symptoms in predicting psychosis.
Question 9: Which of the following hallucinations is pathognomonic of schizophrenia?
- A. Auditory hallucinations commanding the patient
- B. Auditory hallucinations giving running commentary (Correct Answer)
- C. Auditory hallucinations criticizing the patient
- D. Auditory hallucinations talking to patient
Explanation: ***Auditory hallucinations giving running commentary*** - **Third-person auditory hallucinations**, particularly those giving a continuous descriptive commentary on the patient's actions, thoughts, or movements, are considered **pathognomonic of schizophrenia** within Schneider's first-rank symptoms. - These are distinguished from other types of auditory hallucinations by their specific content and the perspective from which they are perceived, indicating a fundamental disruption in self-perception and reality testing. *Auditory hallucinations commanding the patient* - **Command hallucinations** involve voices instructing the patient to perform specific actions and can occur in various psychiatric conditions, including other psychoses, mood disorders with psychotic features, and even non-psychotic states. - While significant and potentially dangerous, they are **not unique to schizophrenia** and therefore not pathognomonic. *Auditory hallucinations criticizing the patient* - **Critical auditory hallucinations** involve voices that demean, scold, or negatively evaluate the patient, contributing to distress and low self-esteem. - These are also **nonspecific** and can be found in a range of mental health conditions, including depression with psychotic features and bipolar disorder. *Auditory hallucinations talking to patient* - **Second-person auditory hallucinations**, where voices communicate directly with the patient in a conversational manner, are common in various psychotic disorders. - They are a general feature of psychosis and **do not specifically indicate schizophrenia** over other conditions; the *content* and *form* of the hallucination are crucial for differential diagnosis.
Question 10: A 25-year-old male believes that his penis is decreasing in size every day and that it will eventually disappear, leading to his death. What is the most likely diagnosis?
- A. Somatic Symptom Disorder
- B. Delusional Disorder (Correct Answer)
- C. Illness Anxiety Disorder
- D. Obsessive-Compulsive Disorder
Explanation: ***Delusional Disorder*** - This patient presents with a **fixed, false belief** (penis shrinkage and disappearance) that is not amenable to change in light of conflicting evidence, which is the hallmark of a **delusion**. - This is specifically a **somatic-type delusion** involving bodily functions or sensations. - The clinical presentation is characteristic of **Koro syndrome (genital retraction syndrome)**, a culture-bound syndrome where the patient has an intense fear that their genitalia are retracting and will disappear, leading to death. - Koro is classified under **Delusional Disorder, somatic type** in standard psychiatric classification, making this the most appropriate diagnosis among the given options. *Somatic Symptom Disorder* - Characterized by **distressing somatic symptoms** accompanied by excessive thoughts, feelings, or behaviors related to the symptoms, but without a fixed, false belief. - The patient here has a **delusion** (fixed false belief about genital disappearance), not merely excessive worry about somatic symptoms. - Patients with Somatic Symptom Disorder may be partially reassured; patients with delusions cannot be reassured. *Illness Anxiety Disorder* - Involves **preoccupation with having or acquiring a serious illness** despite absence or mildness of somatic symptoms. - Unlike a delusion, the fear in Illness Anxiety Disorder is **not a fixed, false belief** and patients can often be temporarily reassured. - The patient's belief about penis disappearance is a somatic delusion, not health anxiety. *Obsessive-Compulsive Disorder* - Distinguished by **obsessions** (recurrent, intrusive thoughts recognized as irrational) and/or **compulsions** (repetitive behaviors to neutralize anxiety). - The key difference: in OCD, patients have **insight** that their thoughts are irrational; in delusional disorder, there is **no insight** - the belief is held with conviction. - The patient's fixed belief about genital disappearance is a delusion, not an obsession with doubt.
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