Substance Use Disorders — MCQs
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Which of the following is the most common adverse effect of LSD and its related substances?
A patient presents with altered consciousness, tremors, and visual hallucinations. What is the probable diagnosis?
A 45-year-old chronic alcoholic male is brought to the emergency department with an alleged history of assaulting his neighbor. On examination, he is found to have irrelevant talk. He had not consumed alcohol for the past 4 days and is diagnosed as a case of delirium tremens. In this condition, the person is:
Withdrawal delirium, hallucinations, and amnestic disorder are typically seen with which substance?
In an uncomplicated case of alcohol withdrawal, which drug can be given safely?
Withdrawal syndrome is associated with which of the following substances?
Synesthesia is commonly seen with which of the following substances?
A male started alcohol at 20 years of age and has been consuming 3quarters daily for the past 30 years. He now complains that he gets the 'kick' in the first quarter. What is the diagnosis?
Sexual gratification obtained by contact of private parts in public places without consent is known as?
In Korsakoff psychosis, which of the following is NOT seen?
Substance Use Disorders Indian Medical PG Practice Questions and MCQs
Question 111: Which of the following is the most common adverse effect of LSD and its related substances?
- A. Bad trip (Correct Answer)
- B. Flashbacks
- C. Synaesthesia
- D. Papillary dilatation
Explanation: **Explanation:** LSD (Lysergic acid diethylamide) is a potent hallucinogen that primarily acts as a partial agonist at 5-HT2A receptors. **Why "Bad Trip" is correct:** A **"Bad Trip" (Acute Panic Reaction)** is clinically documented as the **most common adverse effect** of LSD. It is characterized by intense anxiety, fear of losing control, terrifying hallucinations, and a sense of impending doom. While the experience is subjective, it is the most frequent reason users seek emergency medical attention. Management is primarily supportive, often involving a "talking down" technique or benzodiazepines. **Analysis of Incorrect Options:** * **Flashbacks (Hallucinogen Persisting Perception Disorder):** This is a classic and unique long-term complication where the user re-experiences the drug's effects weeks or months later. While high-yield, it is less frequent than acute bad trips. * **Synaesthesia:** This is a **perceptual phenomenon** (e.g., "hearing colors" or "seeing sounds") rather than an adverse effect. It is a characteristic feature of the LSD experience itself. * **Pupillary dilatation (Mydriasis):** This is a common **physical sign** of LSD intoxication due to sympathomimetic stimulation, but it is considered a physiological effect rather than a clinical "adverse effect" or complication. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** 5-HT2A receptor agonism. * **Physical Signs:** Mydriasis, tachycardia, tremors, and hyperthermia. * **Tolerance:** Develops very rapidly (tachyphylaxis) but there is no physical dependence or withdrawal syndrome. * **Fatal Dose:** LSD has a high therapeutic index; deaths are usually due to behavioral accidents rather than direct toxicity.
Question 112: A patient presents with altered consciousness, tremors, and visual hallucinations. What is the probable diagnosis?
- A. Delirium tremens (Correct Answer)
- B. Korsakoff's psychosis
- C. Major depressive disorder
- D. Wernicke's encephalopathy
Explanation: ### Explanation The correct answer is **Delirium Tremens (DT)**. **Why it is correct:** Delirium tremens is the most severe form of alcohol withdrawal, typically occurring 48–96 hours after the last drink. It is characterized by a "clouding of consciousness" (altered sensorium), autonomic hyperactivity (tachycardia, tremors, hypertension), and vivid **visual or tactile hallucinations** (e.g., Lilliputian hallucinations). The presence of altered consciousness combined with tremors and hallucinations is the classic triad for DT. **Why the other options are incorrect:** * **Korsakoff’s Psychosis:** This is a chronic neurological condition resulting from Thiamine (B1) deficiency. It is characterized by **anterograde amnesia** and **confabulation**, but consciousness remains clear, and tremors/hallucinations are not primary features. * **Major Depressive Disorder:** This is a mood disorder characterized by persistent low mood and anhedonia. While psychotic features can occur, they do not present with acute altered consciousness or physical tremors. * **Wernicke’s Encephalopathy:** This is an acute precursor to Korsakoff’s, characterized by the triad of **Ophthalmoplegia (ataxia), Confusion, and Ataxia**. While it involves altered consciousness, it lacks the prominent visual hallucinations and autonomic instability seen in DT. **High-Yield Clinical Pearls for NEET-PG:** * **Timeline:** Alcohol withdrawal seizures (Rum fits) occur at 6–48 hours; DT occurs at 48–96 hours. * **Drug of Choice:** **Benzodiazepines** (Chlordiazepoxide or Diazepam) are the gold standard for management. In patients with liver failure, use **LOT** (Lorazepam, Oxazepam, Temazepam). * **Mortality:** If untreated, DT has a mortality rate of up to 20%, usually due to cardiovascular collapse or hyperthermia. * **Hallucinations:** In Alcohol Hallucinosis, the sensorium is **clear**; in Delirium Tremens, the sensorium is **clouded**.
Question 113: A 45-year-old chronic alcoholic male is brought to the emergency department with an alleged history of assaulting his neighbor. On examination, he is found to have irrelevant talk. He had not consumed alcohol for the past 4 days and is diagnosed as a case of delirium tremens. In this condition, the person is:
- A. Criminally responsible for his act
- B. Partially responsible for his act
- C. Has diminished responsibility for his act
- D. Not responsible for his act under section 84, IPC (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Not responsible for his act under section 84, IPC** The core medical concept here is **Involuntary Intoxication** and **Insanity**. In forensic psychiatry, Delirium Tremens (DTs) is considered a state of "temporary insanity" caused by the withdrawal of alcohol. Under **Section 84 of the Indian Penal Code (IPC)**, an act does not constitute an offense if, at the time of doing it, the person—by reason of **unsoundness of mind**—is incapable of knowing the nature of the act or that it is wrong or contrary to law. While voluntary drunkenness is generally not a defense (Section 86 IPC), a disease state triggered by alcohol (like Delirium Tremens or Alcoholic Hallucinosis) is treated as legal insanity. Since the patient was in a state of delirium (clouding of consciousness and irrelevant talk), he lacked the *mens rea* (guilty mind) required for criminal liability. **Why Incorrect Options are Wrong:** * **Option A:** This would apply to "Voluntary Intoxication" where the person is presumed to have the same knowledge as a sober person. * **Options B & C:** Indian Law follows the "All or Nothing" principle regarding criminal responsibility. Unlike some Western jurisdictions, the IPC does not formally recognize "diminished" or "partial" responsibility in cases of insanity; a person is either responsible or protected under Section 84. **High-Yield Clinical Pearls for NEET-PG:** * **Section 84 IPC:** Deals with the "McNaughten Rule" (Legal Insanity). * **Delirium Tremens:** Typically occurs 48–96 hours after the last drink. Key features include autonomic hyperactivity, global confusion, and vivid visual hallucinations. * **Section 85 IPC:** Protection for involuntary intoxication (administered without knowledge/against will). * **Section 86 IPC:** Liability for voluntary intoxication (presumption of knowledge).
Question 114: Withdrawal delirium, hallucinations, and amnestic disorder are typically seen with which substance?
- A. Cannabis
- B. Opiates
- C. Alcohol (Correct Answer)
- D. Amphetamines
Explanation: **Explanation:** The correct answer is **Alcohol**. Alcohol is a central nervous system (CNS) depressant that acts primarily via GABA-A receptors. Chronic use leads to neuroadaptation, and its cessation results in a spectrum of withdrawal symptoms and associated neuropsychiatric syndromes. * **Withdrawal Delirium:** Also known as **Delirium Tremens (DTs)**, this is a medical emergency occurring 48–92 hours after the last drink. It is characterized by clouded consciousness, autonomic hyperactivity (tachycardia, hypertension), and tremors. * **Hallucinations:** Alcohol withdrawal can cause **Alcoholic Hallucinosis**, typically visual or auditory, occurring within 12–24 hours while the patient has a clear sensorium. * **Amnestic Disorder:** Chronic alcohol use leads to Thiamine (Vitamin B1) deficiency, resulting in **Wernicke-Korsakoff Syndrome**. The "Korsakoff" component is a chronic amnestic disorder characterized by anterograde amnesia and confabulation. **Why other options are incorrect:** * **Cannabis:** Withdrawal is mild (irritability, insomnia) and does not typically cause delirium or a specific amnestic disorder. * **Opiates:** Withdrawal is extremely painful ("flu-like" symptoms: rhinorrhea, lacrimation, yawning, dilated pupils) but is **not** life-threatening and does not cause delirium or amnesia. * **Amphetamines:** Intoxication causes psychosis/hallucinations, but withdrawal typically leads to a "crash" (dysphoria, hypersomnia, increased appetite) rather than delirium. **High-Yield Clinical Pearls for NEET-PG:** * **Delirium Tremens Treatment:** Benzodiazepines (Chlordiazepoxide or Diazepam) are the gold standard. * **Wernicke’s Triad:** Confusion, Ataxia, and Ophthalmoplegia (GOA). * **Confabulation:** A hallmark of Korsakoff psychosis where the patient fills memory gaps with fabricated stories. * **Formication:** The sensation of insects crawling on the skin (Cocaine bugs), also seen in alcohol withdrawal.
Question 115: In an uncomplicated case of alcohol withdrawal, which drug can be given safely?
- A. Benzodiazepines (Correct Answer)
- B. Clonidine
- C. Morphine
- D. Disulfiram
Explanation: **Explanation:** **Benzodiazepines (BZDs)** are the gold standard and first-line treatment for alcohol withdrawal. The underlying medical concept is **cross-tolerance**. Alcohol is a CNS depressant that enhances GABAergic activity; chronic use leads to down-regulation of GABA receptors. Abrupt cessation causes a "hyperexcitable state." BZDs (like Diazepam or Lorazepam) act on the same GABA-A receptors, effectively substituting for alcohol and allowing for a tapered, safe reduction in CNS excitability. This prevents progression to severe complications like seizures or delirium tremens. **Analysis of Incorrect Options:** * **Clonidine:** While this alpha-2 agonist can help manage autonomic hyperactivity (tachycardia, hypertension), it **does not prevent seizures or delirium**. It is used only as an adjunct, never as monotherapy. * **Morphine:** This is an opioid agonist. It has no role in alcohol withdrawal and carries a high risk of respiratory depression and addiction. * **Disulfiram:** This is an **aversion therapy** agent used for *maintenance of abstinence*, not acute withdrawal. Giving it during withdrawal is dangerous as it inhibits aldehyde dehydrogenase, leading to toxic acetaldehyde buildup if any alcohol remains in the system. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (General):** Long-acting BZDs like **Chlordiazepoxide** or **Diazepam** (due to self-tapering effect). * **Drug of Choice (Liver Failure/Elderly):** **Lorazepam**, Oxazepam, or Temazepam (mnemonic: **LOT**) as they undergo direct glucuronidation and do not have active metabolites. * **Wernicke’s Encephalopathy:** Always give **Thiamine** before Glucose to prevent precipitating acute Wernicke’s.
Question 116: Withdrawal syndrome is associated with which of the following substances?
- A. Alcohol
- B. Methadone
- C. Morphine
- D. All of the above (Correct Answer)
Explanation: **Explanation:** The correct answer is **D. All of the above**. Withdrawal syndrome occurs when a person who has developed physiological dependence on a substance suddenly stops or significantly reduces their intake. This leads to a substance-specific constellation of signs and symptoms that are typically opposite to the acute effects of the drug. * **Alcohol (Option A):** Alcohol is a CNS depressant. Chronic use leads to the downregulation of GABA receptors and upregulation of NMDA receptors. Sudden cessation causes CNS hyperexcitability, manifesting as tremors, tachycardia, seizures, and potentially life-threatening Delirium Tremens. * **Morphine (Option C):** Morphine is a short-acting opioid agonist. Withdrawal symptoms include "flu-like" features: rhinorrhea, lacrimation, yawning, piloerection (cold turkey), and intense abdominal cramping. While distressing, opioid withdrawal is generally not life-threatening. * **Methadone (Option B):** Methadone is a long-acting synthetic opioid agonist used in maintenance therapy. Because it has a much longer half-life than morphine, its withdrawal syndrome is slower in onset, less intense, but more prolonged. **High-Yield Clinical Pearls for NEET-PG:** 1. **Substances WITHOUT significant withdrawal:** Hallucinogens (LSD) and Inhalants generally do not present with a clinically significant withdrawal syndrome. 2. **Life-threatening withdrawal:** Withdrawal from CNS depressants (Alcohol, Benzodiazepines, and Barbiturates) can be fatal due to seizures and autonomic instability. 3. **Cocaine Withdrawal:** Characterized primarily by psychological symptoms ("Crash") including dysphoria, vivid dreams, and psychomotor retardation, rather than gross physiological disturbances. 4. **Management:** Alcohol withdrawal is managed with Benzodiazepines (Chlordiazepoxide/Diazepam), while Opioid withdrawal is managed with Methadone, Buprenorphine, or Clonidine.
Question 117: Synesthesia is commonly seen with which of the following substances?
- A. Cocaine
- B. LSD (Correct Answer)
- C. Opioids
- D. Methadone
Explanation: **Explanation:** **LSD (Lysergic Acid Diethylamide)** is the correct answer because it is a potent hallucinogen that acts primarily as a partial agonist at **5-HT2A receptors**. **Synesthesia** is a hallmark clinical feature of LSD intoxication, characterized by a "blending of senses" or "cross-sensory perception." Patients often describe "hearing colors" or "seeing sounds." This occurs due to increased functional connectivity between sensory regions of the brain that are normally segregated. **Analysis of Incorrect Options:** * **Cocaine:** A stimulant that inhibits the reuptake of dopamine, norepinephrine, and serotonin. It typically causes euphoria, tachycardia, and pupillary dilation, but not synesthesia. * **Opioids (e.g., Morphine, Heroin):** These are CNS depressants that act on mu-opioid receptors. They cause miosis (pinpoint pupils), respiratory depression, and sedation. * **Methadone:** A long-acting synthetic opioid used in detoxification and maintenance therapy for opioid dependence. Like other opioids, it does not induce hallucinogenic sensory blending. **High-Yield Clinical Pearls for NEET-PG:** * **LSD:** Does **not** cause physical dependence or withdrawal symptoms. It is associated with "Bad Trips" (panic reactions) and "Flashbacks" (Hallucinogen Persisting Perception Disorder). * **Pupillary Signs:** LSD causes **Mydriasis** (dilated pupils), whereas Opioids cause **Miosis** (constricted pupils). * **Other Hallucinogens:** Psilocybin (magic mushrooms) and Mescaline (peyote) can also cause similar sensory distortions. * **Management:** Acute LSD intoxication is generally managed with reassurance ("talking down") and benzodiazepines if the patient is severely agitated.
Question 118: A male started alcohol at 20 years of age and has been consuming 3quarters daily for the past 30 years. He now complains that he gets the 'kick' in the first quarter. What is the diagnosis?
- A. Withdrawal
- B. Mellanby phenomenon
- C. Reverse tolerance (Correct Answer)
- D. Cross tolerance
Explanation: ### Explanation **Correct Answer: C. Reverse tolerance** **Why it is correct:** Tolerance is defined as the need for increased amounts of a substance to achieve the same effect. However, in chronic, heavy alcohol users (like this patient with a 30-year history), **Reverse Tolerance** (also known as "inverted tolerance") occurs. This happens due to severe **liver damage (cirrhosis)**. The damaged liver can no longer produce sufficient alcohol dehydrogenase enzymes to metabolize alcohol. Consequently, even a small amount of alcohol remains in the bloodstream for a longer duration, causing the patient to feel the "kick" or intoxication with much lower doses than previously required. **Why other options are incorrect:** * **A. Withdrawal:** This refers to the physical and psychological symptoms (e.g., tremors, seizures, delirium tremens) that occur when a person suddenly stops or reduces heavy alcohol intake. It does not describe a change in the level of intoxication. * **B. Mellanby phenomenon:** This describes a situation where the impairment from alcohol is greater when the blood alcohol concentration (BAC) is **rising** than when it is falling at the same absolute BAC level. It relates to acute intoxication, not chronic consumption changes. * **D. Cross tolerance:** This occurs when tolerance to one drug (e.g., alcohol) leads to tolerance to another drug in the same class (e.g., benzodiazepines or barbiturates) because they act on the same receptors (GABA-A). **High-Yield Clinical Pearls for NEET-PG:** * **Tolerance:** Associated with receptor down-regulation (pharmacodynamic) and enzyme induction (pharmacokinetic). * **Reverse Tolerance:** A hallmark of **end-stage liver disease** in alcoholics. * **CAGE Questionnaire:** The most sensitive screening tool for alcohol dependence (Cut down, Annoyed, Guilty, Eye-opener). * **Wernicke’s Encephalopathy Triad:** Ophthalmoplegia, Ataxia, and Confusion (due to Thiamine/B1 deficiency).
Question 119: Sexual gratification obtained by contact of private parts in public places without consent is known as?
- A. Masochism
- B. Transvestism
- C. Fetichism
- D. Frotteurism (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Frotteurism** **Frotteurism** is a paraphilic disorder characterized by achieving sexual arousal and gratification through touching or rubbing one's genitals against a non-consenting person. This behavior typically occurs in crowded public places (such as buses, trains, or elevators) where the perpetrator can easily escape or attribute the contact to the crowd. According to the DSM-5, for a diagnosis, these urges/behaviors must persist for at least 6 months and cause significant distress or impairment. **Analysis of Incorrect Options:** * **A. Masochism:** This involves sexual arousal derived from being humiliated, beaten, bound, or otherwise made to suffer. The focus is on receiving pain or subjugation. * **B. Transvestism:** This refers to sexual arousal from cross-dressing (wearing clothes of the opposite sex). It is distinct from gender dysphoria as the primary motivation is sexual excitement. * **C. Fetishism:** This involves the use of non-living objects (e.g., shoes, stockings) or a highly specific focus on non-genital body parts (e.g., feet) as the primary source of sexual interest. **High-Yield Clinical Pearls for NEET-PG:** * **Voyeurism:** Watching an unsuspecting person who is naked, disrobing, or engaging in sexual activity ("Peeping Tom"). * **Exhibitionism:** Exposing one's genitals to an unsuspecting stranger in public. * **Sadism:** Deriving sexual pleasure from inflicting physical or psychological pain on others. * **Treatment:** The mainstay of treatment for paraphilic disorders is **Cognitive Behavioral Therapy (CBT)**, specifically "Relapse Prevention." Pharmacotherapy includes **SSRIs** (to reduce impulsive sexual urges) and **Anti-androgens** (like Medroxyprogesterone or Cyproterone acetate) in severe cases.
Question 120: In Korsakoff psychosis, which of the following is NOT seen?
- A. Loss of remote memory
- B. Loss of intellectual function but preservation of memory
- C. Lack of insight, unable to understand the disability
- D. Reversible state (Correct Answer)
Explanation: **Explanation:** Korsakoff Psychosis (or Korsakoff Syndrome) is a chronic neuropsychiatric condition resulting from a deficiency of **Thiamine (Vitamin B1)**, most commonly seen in chronic alcoholics. It often follows an untreated or inadequately treated episode of Wernicke’s Encephalopathy. **Why "Reversible state" is the correct answer:** Korsakoff Psychosis is characterized by structural damage to the **mammillary bodies** and the dorsomedial nucleus of the thalamus. Unlike Wernicke’s Encephalopathy, which is an acute and reversible medical emergency, Korsakoff Psychosis is typically a **chronic, irreversible, or permanent state**. Only about 20% of patients show significant recovery with thiamine treatment; the majority remain with permanent cognitive deficits. **Analysis of other options:** * **Loss of remote memory:** While anterograde amnesia (inability to form new memories) is the hallmark, **retrograde amnesia** (loss of past/remote memories) is also a core feature, often following a temporal gradient. * **Loss of intellectual function but preservation of memory:** This option is technically phrased to be "not seen" in a confusing way, but in the context of this specific question's construction, it highlights that while memory is profoundly destroyed, other aspects of IQ (like language or motor skills) may appear relatively preserved compared to global dementia. * **Lack of insight:** Patients typically exhibit **anosognosia** (lack of insight into their memory deficit) and frequently use **confabulation** (filling memory gaps with fabricated stories) to compensate. **High-Yield Clinical Pearls for NEET-PG:** * **The Triad of Wernicke’s:** Ataxia, Ophthalmoplegia (6th nerve palsy), and Confusion (Global Encephalopathy). * **The Tetrad of Korsakoff:** Anterograde amnesia, Retrograde amnesia, Confabulation, and Lack of insight. * **Pathology:** Hemorrhagic lesions in the **mammillary bodies**. * **Treatment Rule:** Always give Thiamine **before** Glucose in a suspected alcoholic to prevent precipitating Wernicke’s.
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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