Substance Use Disorders — MCQs
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An alcoholic patient presents with psychosis and memory loss. What is the probable diagnosis?
Methadone is used to treat withdrawal symptoms of which substance?
Jet black pigmentation of the tongue with tactile hallucinations is a feature of which substance use?
Dissociative Fugue is characterised by
Alcohol dependence is associated with all of the following except?
All of the following are true for Korsakoff's psychosis except:
Fornication and delusion of persecution are together seen in which of the following?
What is the usual sign of opioid withdrawal?
Tactile hallucinations are commonly seen in abuse with which substance?
Ekbom's syndrome is commonly associated with which of the following conditions?
Substance Use Disorders Indian Medical PG Practice Questions and MCQs
Question 1: An alcoholic patient presents with psychosis and memory loss. What is the probable diagnosis?
- A. Wernicke's encephalopathy
- B. Wernicke-Korsakoff syndrome (Correct Answer)
- C. Acute psychosis
- D. None of the above
Explanation: **Explanation:** The patient presents with the classic clinical picture of **Wernicke-Korsakoff Syndrome (WKS)**, which is a spectrum of neurological disorders caused by **Thiamine (Vitamin B1) deficiency**, most commonly seen in chronic alcoholics. **1. Why Wernicke-Korsakoff Syndrome is correct:** WKS represents the progression from an acute phase (Wernicke’s Encephalopathy) to a chronic phase (Korsakoff Psychosis). The presence of **memory loss** (specifically anterograde and retrograde amnesia) and **psychosis** (often manifesting as **confabulation**—filling memory gaps with fabricated stories) are the hallmark features of the Korsakoff component. Pathologically, this is associated with lesions in the **mammillary bodies** and the dorsomedial nucleus of the thalamus. **2. Why other options are incorrect:** * **Wernicke's Encephalopathy:** This is the acute, reversible phase characterized by a classic triad: **Ophthalmoplegia** (ataxia), **Global Confusion**, and **Ataxia**. While it is part of the spectrum, it does not typically include the permanent memory deficits or confabulation seen in this patient. * **Acute Psychosis:** While the patient has psychotic symptoms, "Acute Psychosis" is a broad psychiatric descriptor. In the context of alcoholism and memory loss, a nutritional/organic cause (WKS) is the specific medical diagnosis. **Clinical Pearls for NEET-PG:** * **The Triad of Wernicke:** Confusion, Ataxia, Ophthalmoplegia (nystagmus). * **The Pentad of WKS:** The triad + Amnesia and Confabulation. * **Treatment Rule:** Always administer **Thiamine before Glucose** in an alcoholic patient. Giving glucose first can precipitate Wernicke’s by consuming the remaining B1 stores during glycolysis. * **MRI Finding:** High signal intensity in the mammillary bodies.
Question 2: Methadone is used to treat withdrawal symptoms of which substance?
- A. Cocaine
- B. Heroin (Correct Answer)
- C. Amphetamine
- D. Barbiturate
Explanation: **Explanation:** **Correct Answer: B. Heroin** Methadone is a **synthetic, long-acting mu-opioid receptor full agonist**. In the management of Opioid Use Disorder (Heroin), it works through "cross-tolerance." Because it has a much longer half-life (24–36 hours) than heroin, it prevents withdrawal symptoms and reduces "drug hunger" (craving) without producing the significant euphoria or "rush" associated with illicit opioids. It is used both for acute detoxification and long-term maintenance therapy. **Why other options are incorrect:** * **A & C (Cocaine & Amphetamines):** These are CNS stimulants. There is no specific FDA-approved pharmacological replacement therapy for stimulant withdrawal. Management is primarily supportive, focusing on psychological interventions and treating symptoms like depression or agitation. * **D (Barbiturates):** These are sedative-hypnotics. Withdrawal is life-threatening (similar to alcohol) and is managed by a slow taper of the drug itself or by substituting with a long-acting benzodiazepine (like Diazepam) or Phenobarbital. **High-Yield Clinical Pearls for NEET-PG:** * **Buprenorphine:** A partial mu-opioid agonist and kappa antagonist; it has a "ceiling effect" on respiratory depression, making it safer than methadone. * **Naltrexone:** An opioid antagonist used for relapse prevention *after* detoxification is complete (patient must be opioid-free for 7–10 days). * **Clonidine:** An alpha-2 agonist used to treat the autonomic symptoms of opioid withdrawal (tachycardia, hypertension, sweating) but does not reduce cravings. * **Lofexidine:** The first non-opioid drug specifically approved for managing opioid withdrawal symptoms.
Question 3: Jet black pigmentation of the tongue with tactile hallucinations is a feature of which substance use?
- A. Heroin
- B. Cannabis
- C. Cocaine (Correct Answer)
- D. LSD
Explanation: **Explanation:** The correct answer is **Cocaine**. This question tests the recognition of specific physical and psychological markers associated with stimulant abuse. **1. Why Cocaine is Correct:** * **Jet Black Tongue (Melanoglossia):** Chronic smoking of "crack" cocaine can lead to a characteristic black discoloration of the dorsal surface of the tongue. This is attributed to the deposition of carbonaceous combustion products or thermal injury to the filiform papillae. * **Tactile Hallucinations:** Cocaine intoxication frequently causes **Formication** (also known as "Cocaine bugs" or Magnan’s symptom). Patients experience a distressing sensation of insects crawling under or on their skin, often leading to skin picking and excoriations. **2. Analysis of Incorrect Options:** * **Heroin (Opioid):** Typically presents with miosis (pinpoint pupils), respiratory depression, and track marks. It does not cause tongue pigmentation or tactile hallucinations. * **Cannabis:** Characterized by conjunctival injection (red eyes), increased appetite (munchies), and dry mouth. While it can cause paranoia, it is not associated with black tongue. * **LSD (Hallucinogen):** Primarily causes **visual** hallucinations, synesthesia (seeing sounds/hearing colors), and mydriasis. It does not typically produce the specific tactile hallucinations or oral findings seen with cocaine. **3. Clinical Pearls for NEET-PG:** * **Magnan’s Symptom:** A specific term for tactile hallucinations in cocaine users. * **Cocaine & Pupils:** Causes **Mydriasis** (dilated pupils), unlike Heroin (Miosis). * **Cocaine & CVS:** It is a potent vasoconstrictor; look for history of MI or perforated nasal septum in clinical stems. * **Withdrawal:** Cocaine withdrawal is characterized by "crashing" (dysphoria, hypersomnia, and intense craving) but is not life-threatening.
Question 4: Dissociative Fugue is characterised by
- A. Wandering away from home (Correct Answer)
- B. Irreversible amnesia
- C. Gradual recovery
- D. Normal recall
Explanation: **Explanation:** **Dissociative Fugue** (now classified under Dissociative Amnesia in DSM-5) is a dissociative disorder characterized by a sudden, unexpected travel away from one’s home or place of daily activities, accompanied by an inability to recall some or all of one's past. 1. **Why Option A is correct:** The hallmark of a fugue state is **purposeful wandering**. Patients often adopt a new identity and are unable to remember their previous life during the episode. The "wandering" is not aimless (like in delirium) but appears organized to an outside observer. 2. **Why Options B, C, and D are incorrect:** * **B & C:** Recovery from dissociative fugue is typically **sudden and rapid**, not gradual. Furthermore, the amnesia is **reversible**; once the fugue state ends, the individual usually recovers their original identity and memories of their past life (though they may then have amnesia for the events that occurred *during* the fugue). * **D:** **Normal recall** is absent during the episode. The patient suffers from selective or generalized amnesia regarding their identity and history. **High-Yield Clinical Pearls for NEET-PG:** * **Trigger:** Usually precipitated by severe psychosocial stressors (e.g., marital discord, financial ruin, or wartime trauma). * **Identity:** A patient in a fugue state may assume a completely new name, occupation, and personality. * **Differential Diagnosis:** Must be distinguished from **Complex Partial Seizures** (where wandering is semi-purposeful and brief) and **Transient Global Amnesia** (which lacks identity loss). * **Management:** The primary goal is to establish safety. Psychotherapy and "abreaction" (using hypnosis or barbiturates to recover memories) are traditional treatment modalities.
Question 5: Alcohol dependence is associated with all of the following except?
- A. Anxiety disorder
- B. Dementia
- C. Sexual dysfunction
- D. Alcohol amotivational syndrome (Correct Answer)
Explanation: **Explanation:** The correct answer is **D. Alcohol amotivational syndrome**. **Amotivational syndrome** is a clinical condition characterized by detachment, lack of drive, apathy, and a diminished ability to focus on long-term goals. This syndrome is classically associated with **chronic Cannabis use**, not alcohol. While chronic alcohol use can lead to depression and cognitive decline, it does not typically present as the specific "amotivational" cluster seen with cannabinoids. **Analysis of Incorrect Options:** * **Anxiety Disorder:** Alcohol has a high rate of comorbidity with anxiety. While alcohol is often used for "self-medication" (the tension-reduction hypothesis), chronic use and withdrawal states significantly exacerbate anxiety symptoms. * **Dementia:** Chronic alcohol dependence is a known cause of cognitive impairment. This can occur directly (Alcoholic Dementia) or indirectly via thiamine deficiency leading to **Wernicke-Korsakoff Syndrome**, which involves significant memory deficits and confabulation. * **Sexual Dysfunction:** Alcohol is a central nervous system depressant. Chronic use leads to erectile dysfunction, decreased libido, and delayed ejaculation. In men, it can also cause testicular atrophy and gynecomastia due to altered estrogen/testosterone metabolism. **High-Yield Clinical Pearls for NEET-PG:** * **Cannabis:** Associated with Amotivational Syndrome and increased risk of Schizophrenia in predisposed individuals. * **Cocaine:** Associated with "Formication" (Cocaine bugs/Magnan’s symptom). * **Alcohol Withdrawal:** The first symptom is usually tremors (6–12 hours); the most severe manifestation is **Delirium Tremens** (48–72 hours). * **Wernicke’s Encephalopathy Triad:** Confusion, Ataxia, and Ophthalmoplegia (due to Thiamine/B1 deficiency).
Question 6: All of the following are true for Korsakoff's psychosis except:
- A. Organic amnestic syndrome
- B. Loss of insight
- C. Deficiency of cyanocobalamin (Correct Answer)
- D. It may follow Wernicke's encephalopathy
Explanation: **Explanation:** The correct answer is **C (Deficiency of cyanocobalamin)** because Korsakoff’s psychosis is caused by a deficiency of **Thiamine (Vitamin B1)**, not Cyanocobalamin (Vitamin B12). Thiamine is a critical cofactor for carbohydrate metabolism in the brain; its depletion, most commonly due to chronic alcohol consumption, leads to neuronal damage in the mammillary bodies and dorsomedial nucleus of the thalamus. **Analysis of other options:** * **A. Organic amnestic syndrome:** This is a defining feature. Korsakoff’s is characterized by profound anterograde amnesia (inability to form new memories) and retrograde amnesia, occurring in a clear sensorium. * **B. Loss of insight:** Patients typically lack awareness of their memory deficit. To fill these "memory gaps," they often engage in **confabulation** (fabricating imaginary experiences), which they believe to be true. * **D. It may follow Wernicke's encephalopathy:** Wernicke’s encephalopathy (acute phase: ataxia, ophthalmoplegia, global confusion) and Korsakoff’s psychosis (chronic phase) are two ends of the same spectrum (**Wernicke-Korsakoff Syndrome**). If Wernicke’s is not treated promptly with parenteral thiamine, it frequently progresses to Korsakoff’s. **NEET-PG High-Yield Pearls:** * **Confabulation** is the hallmark clinical sign of Korsakoff’s. * **Brain MRI finding:** Atrophy of the **mammillary bodies**. * **Treatment:** High-dose Thiamine. Note: Always give thiamine *before* glucose in a malnourished patient to prevent precipitating Wernicke’s. * **Reversibility:** While Wernicke’s is often reversible, Korsakoff’s psychosis is frequently permanent or only partially reversible.
Question 7: Fornication and delusion of persecution are together seen in which of the following?
- A. LSD psychosis
- B. Amphetamine psychosis
- C. Cocaine psychosis (Correct Answer)
- D. Cannabis psychosis
Explanation: **Explanation:** The correct answer is **Cocaine psychosis**. **Cocaine psychosis** is a clinical syndrome that closely mimics paranoid schizophrenia. It is characterized by two hallmark symptoms: 1. **Formication (Magnan’s Symptom):** A tactile hallucination where the patient feels as if insects or small animals are crawling under or on their skin. This is also colloquially known as "cocaine bugs." 2. **Delusions of Persecution:** Intense paranoid beliefs that one is being followed, watched, or plotted against. The combination of these tactile hallucinations and paranoid delusions is highly characteristic of chronic cocaine toxicity. **Analysis of Incorrect Options:** * **LSD Psychosis:** Primarily characterized by vivid visual hallucinations, synesthesia (merging of senses, e.g., "seeing sounds"), and "bad trips" (panic/anxiety), rather than tactile formication. * **Amphetamine Psychosis:** While it causes significant paranoid delusions and can be indistinguishable from schizophrenia, formication is much more classically associated with cocaine. * **Cannabis Psychosis:** Typically presents with "Amotivational Syndrome," temporal disintegration (distorted sense of time), or acute panic. While it can cause paranoia, it does not typically present with formication. **Clinical Pearls for NEET-PG:** * **Magnan’s Sign:** Another name for formication specifically in cocaine users. * **Mechanism:** Cocaine acts by blocking the reuptake of Dopamine, Norepinephrine, and Serotonin. The excess dopamine in the mesolimbic pathway drives the psychotic symptoms. * **Physical Signs:** Look for **mydriasis** (dilated pupils) and perforated nasal septum in chronic users. * **Treatment:** Acute psychosis is managed with benzodiazepines and/or antipsychotics (e.g., Haloperidol).
Question 8: What is the usual sign of opioid withdrawal?
- A. Stupor
- B. Constipation
- C. Constricted pupil
- D. Yawning (Correct Answer)
Explanation: ### Explanation Opioid withdrawal occurs when a chronic user abruptly stops or reduces intake. The underlying mechanism is a **rebound hyperactivity of the autonomic nervous system**, particularly the locus coeruleus (norepinephrine), as the body attempts to compensate for the sudden absence of CNS depressant effects. **Why Yawning is Correct:** **Yawning** is one of the earliest and most characteristic objective signs of opioid withdrawal. It occurs alongside other "flu-like" symptoms such as lacrimation (tearing), rhinorrhea (runny nose), and piloerection (goosebumps). These symptoms are classic indicators used in clinical scales like the COWS (Clinical Opiate Withdrawal Scale). **Why Other Options are Incorrect:** * **A. Stupor:** This is a sign of **opioid intoxication** or overdose, not withdrawal. Withdrawal typically presents with irritability, anxiety, and insomnia. * **B. Constipation:** This is a classic side effect of **opioid use/intoxication** due to decreased GI motility. In withdrawal, the rebound effect causes **diarrhea** and abdominal cramps. * **C. Constricted pupil (Miosis):** This is the hallmark of **opioid intoxication**. In withdrawal, the pupils become **dilated (Mydriasis)** due to sympathetic overactivity. **High-Yield Clinical Pearls for NEET-PG:** * **Piloerection:** The origin of the term "cold turkey" (skin looks like a plucked turkey). * **Pupillary Changes:** Remember: **Miosis** = Intoxication (Pinpoint pupils); **Mydriasis** = Withdrawal. * **Treatment of Choice:** **Methadone** or **Buprenorphine** (substitution therapy). For symptomatic relief of autonomic hyperactivity, **Clonidine** (alpha-2 agonist) is used. * **Prognosis:** While extremely uncomfortable, pure opioid withdrawal is rarely life-threatening (unlike alcohol or barbiturate withdrawal, which can cause seizures and death).
Question 9: Tactile hallucinations are commonly seen in abuse with which substance?
- A. Heroin
- B. Cocaine (Correct Answer)
- C. Cannabis
- D. Alcohol
Explanation: **Explanation:** **Cocaine** is the correct answer because it is classically associated with a specific type of tactile hallucination known as **Formication**. This is the false perception of insects or bugs crawling on or under the skin, often referred to as **"Cocaine bugs"** or **Magnan’s sign**. This phenomenon occurs due to the intense dopaminergic stimulation in the central nervous system, which can lead to sensory distortions and paranoid psychosis during acute intoxication or chronic use. **Analysis of Incorrect Options:** * **Heroin (Opioids):** Intoxication typically presents with euphoria, respiratory depression, and miosis (pinpoint pupils). While withdrawal can cause "gooseflesh" (piloerection), it does not typically cause tactile hallucinations. * **Cannabis:** Primarily causes distorted sensory perception (colors/sounds), increased appetite, and conjunctival injection. While it can trigger "Cannabis-induced Psychosis," tactile hallucinations are not a hallmark feature. * **Alcohol:** While alcohol withdrawal (**Delirium Tremens**) can cause tactile hallucinations, they are more frequently accompanied by visual hallucinations (e.g., seeing small animals). Cocaine is the more "classic" association for tactile hallucinations in a standalone substance abuse context. **High-Yield Clinical Pearls for NEET-PG:** * **Magnan’s Sign:** Specifically refers to the feeling of "sand" or "bugs" under the skin in cocaine users. * **Cocaine vs. Amphetamines:** Both can cause formication, but cocaine is the most frequently tested association. * **Physical Signs of Cocaine:** Look for perforated nasal septum, dilated pupils (mydriasis), and tachycardia in clinical vignettes. * **Tactile Hallucinations in other conditions:** Also seen in **Ekbom Syndrome** (Delusional Parasitosis).
Question 10: Ekbom's syndrome is commonly associated with which of the following conditions?
- A. Cocaine intoxication (Correct Answer)
- B. Amphetamine abuse
- C. Severe depression
- D. Acute psychosis
Explanation: **Explanation:** **Ekbom’s Syndrome**, also known as **Delusional Parasitosis**, is a psychiatric condition where a patient holds a fixed, false belief that they are infested with small organisms like insects, worms, or mites crawling under their skin. 1. **Why Cocaine Intoxication is Correct:** Cocaine is a potent stimulant that increases synaptic dopamine. High levels of dopamine can trigger tactile hallucinations known as **"Cocaine Bugs" (Formication)**. When these hallucinations become a fixed delusional belief of infestation, it is termed Ekbom’s Syndrome. It is a classic "high-yield" association in toxicology and psychiatry. 2. **Analysis of Incorrect Options:** * **B. Amphetamine abuse:** While amphetamines can cause similar tactile hallucinations (formication) and "crank bugs," the term Ekbom’s Syndrome is historically and most classically linked to cocaine in medical literature and competitive exams. * **C. Severe depression:** While psychotic depression can involve delusions, they are typically mood-congruent (e.g., nihilistic delusions or Cotard’s syndrome) rather than tactile infestations. * **D. Acute psychosis:** Schizophrenia can present with various delusions; however, Ekbom’s is a specific monosymptomatic delusional disorder. Cocaine intoxication is the more specific trigger for this particular tactile phenomenon. **High-Yield Clinical Pearls for NEET-PG:** * **Matchbox Sign:** A classic clinical feature where the patient brings "evidence" of the infestation (lint, skin crusts, or dust) in a small container or matchbox to show the doctor. * **Formication:** The medical term for the sensation of insects crawling on the skin (a tactile hallucination). * **Treatment:** The primary psychiatric treatment for delusional parasitosis is low-dose antipsychotics, traditionally **Pimozide**, though Risperidone is now more commonly used. * **Note:** Do not confuse this with **Restless Leg Syndrome**, which was also described by Karl-Axel Ekbom. In the context of substance use, always look for "Cocaine Bugs."
Practice by Chapter
Neurobiology of Addiction
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Alcohol Use Disorder
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Opioid Use Disorder
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Cannabis Use Disorder
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Stimulant Use Disorders
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Sedative, Hypnotic, and Anxiolytic Use Disorders
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Tobacco Use Disorder
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Hallucinogen-Related Disorders
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Substance Withdrawal Syndromes
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Pharmacotherapy for Substance Use Disorders
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Psychosocial Interventions
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Dual Diagnosis Management
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