Substance Use Disorders — MCQs

A patient with a history of alcohol dependence, 3 days after their last drink, develops behavioral changes. They report seeing 5 cm people throwing stones at them and acting as if they are working in their workshop. They are frightened and pace in and out of the house, with symptoms worsening at night. What is the most likely diagnosis?

Q27Medium

A 55-year-old man presents with a 10-day history of confusion. His friend mentions that he drinks 15 units of alcohol per day. Which of the following strongly suggests a diagnosis of Korsakoff's psychosis?

Q28Medium

Cove sensitization is mainly used in which condition?

Q29Easy

A 60-year-old man presents to the OPD with a history of opium addiction for the last 20 years. He has stopped taking opium for 2 days. Which of the following withdrawal symptoms will be expected?

Q30Easy

Onanism is a disorder of

Substance Use Disorders Indian Medical PG Practice Questions and MCQs

Question 21: What is exhibitionism?

A. Shameless exposure of genitals (Correct Answer)
B. Exhibiting one's possessions
C. A type of mania
D. Not a sexual persuasion

Explanation: **Explanation:** **Exhibitionism** is a type of **Paraphilic Disorder** characterized by the recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person (usually a stranger). * **Why Option A is Correct:** The core clinical feature of exhibitionism is the "shameless" or intentional exposure of genitals in public or semi-public settings. The arousal is derived from the act of exposure itself and the observed reaction of the victim (such as shock, fear, or disgust), rather than a desire for sexual activity with the victim. * **Why Option B is Incorrect:** Exhibiting possessions is a personality trait or a social behavior related to narcissism or materialism, but it lacks the sexual deviance required for a psychiatric diagnosis of a paraphilia. * **Why Option C is Incorrect:** While patients in a manic episode may exhibit disinhibited behavior or public nudity due to poor judgment and hypersexuality, this is a symptom of a **Mood Disorder**, not a primary Paraphilic Disorder. * **Why Option D is Incorrect:** Exhibitionism is classified as a sexual persuasion/preference (specifically a paraphilia) in both the ICD-11 and DSM-5. **High-Yield Clinical Pearls for NEET-PG:** 1. **Demographics:** It is almost exclusively diagnosed in males; the victims are usually females or children. 2. **Diagnosis:** According to DSM-5, the behavior must persist for at least **6 months** and cause significant distress or impairment. 3. **Treatment:** The mainstay of treatment is **Cognitive Behavioral Therapy (CBT)**, specifically relapse prevention. Pharmacotherapy includes **SSRIs** (to reduce impulsive sexual urges) or **Anti-androgens** (like Medroxyprogesterone or Cyproterone acetate) in severe cases. 4. **Legal Aspect:** It is a common forensic psychiatric issue often categorized under "indecent exposure."

Question 22: Which of the following is NOT a feature of alcohol withdrawal?

A. Hallucinations
B. Tremor
C. Hypersomnolence (Correct Answer)
D. Autonomic hyperactivity

Explanation: **Explanation:** Alcohol is a Central Nervous System (CNS) depressant that enhances GABAergic (inhibitory) activity and inhibits NMDA (excitatory) receptors. Chronic consumption leads to down-regulation of GABA receptors and up-regulation of NMDA receptors to maintain homeostasis. When alcohol is abruptly stopped, this results in **CNS hyperexcitability**, which is the hallmark of withdrawal. **Why Hypersomnolence is the Correct Answer:** Hypersomnolence (excessive sleepiness) is **not** a feature of alcohol withdrawal. Instead, patients typically experience **insomnia** and agitation due to the lack of CNS depression. Hypersomnolence is more characteristic of withdrawal from CNS stimulants (like cocaine or amphetamines) or intoxication with sedatives. **Analysis of Incorrect Options:** * **B. Tremor:** This is the **most common** and earliest sign of withdrawal (appearing within 6–12 hours), often referred to as "the shakes." * **D. Autonomic Hyperactivity:** Withdrawal triggers a massive sympathetic surge, leading to tachycardia, hypertension, diaphoresis (sweating), and fever. * **A. Hallucinations:** Alcoholic hallucinosis can occur 12–24 hours after the last drink. These are typically visual (e.g., seeing small animals/insects) but can be auditory or tactile, occurring in a clear sensorium. **High-Yield Clinical Pearls for NEET-PG:** * **Delirium Tremens (DT):** The most severe form of withdrawal (48–96 hours). Key features: Clouding of consciousness, disorientation, and autonomic instability. * **Withdrawal Seizures:** Usually generalized tonic-clonic (GTC) type, occurring within 6–48 hours ("Rum fits"). * **Drug of Choice:** **Benzodiazepines** (e.g., Lorazepam, Chlordiazepoxide) are the gold standard for managing withdrawal symptoms and preventing seizures/DT.

Question 23: Magnan's symptom is seen in which type of hallucination?

A. Visual hallucination
B. Auditory hallucination
C. Gustatory hallucination
D. Tactile hallucination (Correct Answer)

Explanation: **Explanation:** **Magnan’s symptom** (also known as the "cocaine bug" or formication) is a specific type of **tactile hallucination** associated with chronic cocaine use. Patients experience a distressing sensation of insects, bugs, or worms crawling under or on their skin. This often leads to "excoriation disorder" as patients may scratch or pick at their skin to remove the non-existent parasites, resulting in characteristic skin lesions. * **Why Option D is correct:** Magnan’s symptom is defined as a tactile (haptic) hallucination where the sensation of touch or movement on the skin occurs without an external stimulus. It is a hallmark sign of cocaine psychosis. * **Why Options A, B, and C are incorrect:** * **Visual hallucinations** (seeing things) are common in Delirium Tremens but are not referred to as Magnan’s symptom. * **Auditory hallucinations** (hearing voices) are most characteristic of Schizophrenia. * **Gustatory hallucinations** (tasting things) are rare and often associated with temporal lobe epilepsy or organic brain lesions. **High-Yield Clinical Pearls for NEET-PG:** * **Formication:** The technical term for the sensation of insects crawling on the skin. * **Cocaine Psychosis:** Can mimic paranoid schizophrenia but is distinguished by the presence of tactile hallucinations and sympathetic overactivity (mydriasis, tachycardia). * **Ekbom Syndrome:** Also known as Delusional Parasitosis; while similar in presentation, it is a fixed false belief (delusion) rather than a sensory perception (hallucination). * **Other Tactile Hallucinations:** Can also occur in alcohol withdrawal (Delirium Tremens).

Question 24: Which defense mechanism is commonly used by substance abusers?

A. Dissociation
B. Introjection
C. Denial (Correct Answer)
D. Projection

Explanation: **Explanation:** **Denial** is the most characteristic defense mechanism associated with substance use disorders. It is a primitive (narcissistic) defense mechanism where the individual refuses to acknowledge the reality of their addiction or the negative consequences it has on their life, health, and relationships. By using denial, the patient protects themselves from the anxiety and guilt associated with their substance use, often stating, "I can stop whenever I want" or "I don't have a problem." **Analysis of Incorrect Options:** * **Dissociation (A):** This involves a temporary, drastic modification of one’s character or sense of identity to avoid emotional distress (common in PTSD or Dissociative Identity Disorder). * **Introjection (B):** This is the internalizing of the qualities of another person. While it can be a part of normal development, in pathology, it is often seen in depression (turning anger inward). * **Projection (D):** This involves attributing one’s own unacknowledged feelings or impulses to others. While substance abusers may use projection (e.g., "My boss is the one with the temper"), **Denial** is the primary and most pervasive defense mechanism identified in clinical psychiatry for this population. **Clinical Pearls for NEET-PG:** * **The "Big Three" in Addiction:** Denial, Rationalization (justifying use), and Projection are often seen together, but **Denial** is the hallmark. * **Treatment Implication:** Breaking through denial is the primary goal of **Motivational Interviewing (MI)** and the first step in the 12-step program of Alcoholics Anonymous (AA). * **Defense Mechanism Hierarchy:** Denial is classified as a **Level I (Pathological/Narcissistic)** defense mechanism.

Question 25: All of the following are true about Alcoholic hallucinosis except?

A. Seen after 12-24 hours of alcohol cessation
B. Auditory hallucinations are commonly seen
C. Disturbance of consciousness is present (Correct Answer)
D. All are true

Explanation: ### Explanation **Alcoholic Hallucinosis** is a specific alcohol withdrawal syndrome characterized by vivid hallucinations in a state of clear consciousness. **Why Option C is the correct answer (The Exception):** The hallmark of Alcoholic Hallucinosis is that **consciousness remains clear** and the patient is oriented to time, place, and person. This is the primary clinical feature that distinguishes it from **Delirium Tremens (DT)**, where global confusion and clouded consciousness are mandatory diagnostic criteria. Therefore, the statement "Disturbance of consciousness is present" is false. **Analysis of other options:** * **Option A (Onset):** This is a true statement. Alcoholic hallucinosis typically develops within **12 to 24 hours** after the last drink or a significant reduction in intake. * **Option B (Nature of Hallucinations):** This is a true statement. **Auditory hallucinations** (often accusatory or threatening voices) are the most common. While visual hallucinations can occur, they are less frequent than auditory ones in this specific condition. --- ### High-Yield Clinical Pearls for NEET-PG: 1. **Sensorium:** In Alcoholic Hallucinosis, the sensorium is **clear**. In Delirium Tremens, the sensorium is **clouded**. 2. **Vital Signs:** Autonomic hyperactivity (tachycardia, hypertension, fever) is minimal or absent in hallucinosis but severe in Delirium Tremens. 3. **Timeline of Withdrawal:** * **6–12 hours:** Insomnia, tremors, anxiety. * **12–24 hours:** Alcoholic Hallucinosis. * **24–48 hours:** Withdrawal Seizures (Rum Fits). * **48–72 hours:** Delirium Tremens (Peak onset). 4. **Prognosis:** Most cases of alcoholic hallucinosis resolve within 24–48 hours, though a small percentage may progress to a chronic state resembling schizophrenia.

Question 26: A patient with a history of alcohol dependence, 3 days after their last drink, develops behavioral changes. They report seeing 5 cm people throwing stones at them and acting as if they are working in their workshop. They are frightened and pace in and out of the house, with symptoms worsening at night. What is the most likely diagnosis?

A. Delirium tremens (Correct Answer)
B. Seizure disorder
C. Rum fits
D. Wernicke's encephalopathy

Explanation: ### Explanation **Correct Option: A. Delirium Tremens (DT)** The clinical presentation is classic for Delirium Tremens, the most severe form of alcohol withdrawal. * **Timeline:** DT typically occurs **48–96 hours (2–4 days)** after the last drink, matching the "3 days" mentioned. * **Visual Hallucinations:** "Seeing 5 cm people" refers to **Lilliputian hallucinations** (micropsia), which are pathognomonic for DT. * **Occupational Delirium:** Acting as if working in a workshop is a specific sign where patients perform habitual professional tasks in a state of confusion. * **Diurnal Variation:** Symptoms characteristically **worsen at night** (sundowning). The patient’s fear and pacing indicate autonomic hyperactivity and agitation. **Why Incorrect Options are Wrong:** * **B & C. Seizure disorder / Rum fits:** Alcohol withdrawal seizures (Rum fits) typically occur **6–48 hours** after cessation. They are usually generalized tonic-clonic seizures and do not present with prolonged hallucinations or occupational delirium. * **D. Wernicke's encephalopathy:** This is caused by Thiamine (B1) deficiency. While it involves confusion, it is characterized by the triad of **Ophthalmoplegia/Nystagmus, Ataxia, and Confusion**. It does not typically present with vivid Lilliputian hallucinations or the specific timeline of withdrawal delirium. **High-Yield NEET-PG Pearls:** * **Drug of Choice (DOC):** Benzodiazepines (e.g., **Chlordiazepoxide** or Diazepam). If liver failure is present, use **LOT** (Lorazepam, Oxazepam, Temazepam). * **Mortality:** If untreated, DT has a mortality rate of up to 20% (usually due to cardiovascular collapse or hyperthermia). * **Order of Withdrawal:** Tremors (6-12h) → Seizures (6-48h) → Hallucinosis (12-48h) → Delirium Tremens (48-96h). * **Alcoholic Hallucinosis vs. DT:** In hallucinosis, the sensorium is clear (patient is oriented); in DT, there is clouded consciousness/disorientation.

Question 27: A 55-year-old man presents with a 10-day history of confusion. His friend mentions that he drinks 15 units of alcohol per day. Which of the following strongly suggests a diagnosis of Korsakoff's psychosis?

A. Delusional beliefs
B. Poor long-term memory
C. Auditory hallucinations
D. Confabulation (Correct Answer)

Explanation: **Explanation:** **Korsakoff’s Psychosis** is a chronic neuropsychiatric condition resulting from a deficiency of **Thiamine (Vitamin B1)**, typically following untreated or inadequately treated Wernicke’s Encephalopathy in chronic alcoholics. **Why Confabulation is the Correct Answer:** The hallmark of Korsakoff’s syndrome is **anterograde amnesia** (inability to form new memories). To compensate for these gaps in memory, patients unconsciously fill them with fabricated, distorted, or misinterpreted stories. This phenomenon is known as **confabulation**. While the patient is not intentionally lying, they provide these false accounts with full conviction. **Analysis of Incorrect Options:** * **A & C (Delusional beliefs and Auditory hallucinations):** These are psychotic symptoms more characteristic of Alcohol-Induced Psychotic Disorder or Delirium Tremens. They are not core features of Korsakoff’s syndrome. * **B (Poor long-term memory):** In Korsakoff’s, **retrograde amnesia** (loss of past memories) is usually limited. Remote (long-term) memories are often relatively preserved compared to the profound deficit in forming new memories (short-term/anterograde memory). **High-Yield Clinical Pearls for NEET-PG:** * **Wernicke’s Encephalopathy (Acute):** Characterized by the triad of **Ophthalmoplegia** (most common: Abducens nerve palsy), **Ataxia**, and **Confusion**. * **Korsakoff’s Psychosis (Chronic):** Characterized by profound anterograde amnesia and confabulation. * **Neuroanatomy:** The primary lesions are found in the **mammillary bodies** and the dorsomedial nucleus of the thalamus. * **Management:** Always administer **Thiamine before Glucose** in a suspected alcoholic to prevent precipitating Wernicke’s Encephalopathy.

Question 28: Cove sensitization is mainly used in which condition?

A. Schizoid personality
B. Substance use (Correct Answer)
C. Mania
D. Schizophrenia

Explanation: **Explanation:** **Covert Sensitization** is a form of **Aversion Therapy** based on the principles of classical conditioning. Unlike standard aversion therapy, which uses physical stimuli (like electric shocks or emetic drugs), covert sensitization is a **verbal/imaginal procedure**. 1. **Why Substance Use is correct:** In this technique, the patient is asked to vividly imagine the pleasurable stimulus (e.g., drinking alcohol or using a drug) and immediately pair it with an imagined unpleasant or repulsive consequence (e.g., intense nausea, vomiting in public, or social humiliation). Over time, the substance becomes associated with these negative mental images, leading to a decrease in craving and consumption. It is most commonly used in **Alcohol Use Disorder**, paraphilias, and smoking cessation. 2. **Why other options are incorrect:** * **Schizoid Personality:** This is a personality disorder characterized by detachment from social relationships. Treatment focuses on social skills training, not aversion techniques. * **Mania:** This is a mood state requiring pharmacological intervention (Mood stabilizers/Antipsychotics). Behavioral therapy like sensitization has no role in acute mania. * **Schizophrenia:** This is a primary psychotic disorder treated with antipsychotics. Aversion therapy is ineffective for hallucinations or delusions. **Clinical Pearls for NEET-PG:** * **Aversion Therapy** is based on **Classical Conditioning**. * **Antabuse (Disulfiram)** is a form of chemical aversion therapy. * **Contingency Management** is another behavioral therapy for substance use based on **Operant Conditioning** (rewarding positive behavior). * Covert sensitization is preferred by some clinicians because it is safer and more ethical than using physical pain or emetics.

Question 29: A 60-year-old man presents to the OPD with a history of opium addiction for the last 20 years. He has stopped taking opium for 2 days. Which of the following withdrawal symptoms will be expected?

A. Drowsiness
B. Constricted pupils
C. Rhinorrhea (Correct Answer)
D. Decreased blood pressure

Explanation: **Explanation:** Opium is an opioid agonist. Opioid withdrawal occurs when a chronic user abruptly stops or reduces intake, leading to a state of **autonomic hyperactivity** and CNS irritability. **1. Why Rhinorrhea is Correct:** Opioids normally cause "drying" effects (constipation, dry mouth). During withdrawal, the body experiences a "rebound" effect of secretomotor activity. **Rhinorrhea** (runny nose), along with lacrimation (tearing), yawning, and sweating, are among the earliest and most characteristic signs of opioid withdrawal. This is due to the loss of opioid-mediated inhibition of the autonomic nervous system. **2. Why the Other Options are Incorrect:** * **A. Drowsiness:** Opioids are CNS depressants that cause sedation. Withdrawal, conversely, causes **insomnia**, anxiety, and agitation. * **B. Constricted Pupils:** Miosis (pinpoint pupils) is a classic sign of opioid *intoxication*. In withdrawal, the sympathetic nervous system is overactive, leading to **Mydriasis** (dilated pupils). * **C. Decreased Blood Pressure:** Opioids typically lower BP and heart rate. Withdrawal results in **Hypertension** and **Tachycardia** due to the surge in noradrenergic activity (from the Locus Coeruleus). **Clinical Pearls for NEET-PG:** * **Objective Signs:** Piloerection ("Gooseflesh" – the origin of the term "cold turkey"), mydriasis, and tremors. * **Subjective Symptoms:** Intense drug craving, muscle aches (myalgia), and abdominal cramps/diarrhea. * **Timeline:** For short-acting opioids (heroin), symptoms peak at 36–72 hours. For long-acting (methadone), they peak at 72–96 hours. * **Management:** **Clonidine** (alpha-2 agonist) is used to treat autonomic symptoms; **Methadone** or **Buprenorphine** are used for detoxification/maintenance.

Question 30: Onanism is a disorder of

A. Stealing
B. Gambling
C. Sexual behavior (Correct Answer)
D. Hair pulling

Explanation: **Explanation:** **Onanism** is an archaic medical and historical term primarily used to describe **masturbation** or, more broadly, "coitus interruptus" (withdrawal). In the context of psychiatry and behavioral medicine, it is classified as a disorder or habit related to **sexual behavior**. The term originates from the biblical figure Onan and was historically viewed through a pathological lens, though modern psychiatry focuses on it only if it becomes compulsive or causes significant functional impairment. **Analysis of Options:** * **A. Stealing:** This refers to **Kleptomania**, an impulse control disorder characterized by the recurrent inability to resist urges to steal items that are not needed for personal use or monetary value. * **B. Gambling:** This refers to **Pathological Gambling** (Gambling Disorder), now classified under "Substance-Related and Addictive Disorders" in DSM-5 due to its impact on the brain's reward system. * **D. Hair pulling:** This refers to **Trichotillomania**, which is classified under "Obsessive-Compulsive and Related Disorders." It involves the recurrent pulling out of one's own hair, leading to noticeable hair loss. **Clinical Pearls for NEET-PG:** * **Impulse Control Disorders:** While Onanism is a historical term for sexual behavior, remember that **Paraphilic Disorders** (e.g., Exhibitionism, Voyeurism) are the more frequently tested sexual behavioral disorders. * **Key Terminology:** * **Pyromania:** Deliberate and purposeful fire-setting. * **Trichophagia:** The compulsive eating of hair (often associated with Trichotillomania), which can lead to a **Rapunzel syndrome** (gastric trichobezoar). * **DSM-5 Update:** Most traditional "impulse control disorders" are now categorized under *Disruptive, Impulse-Control, and Conduct Disorders*.

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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