Substance Use Disorders Practice Questions

Q: What is the recommended treatment for the management of delirium tremens?

Diazepam. **Explanation:** **Delirium Tremens (DT)** is the most severe form of alcohol withdrawal, characterized by altered sensorium, autonomic hyperactivity, and hallucinations. **Why Diazepam is Correct:** The mainstay of treatment for alcohol withdrawal and DT is **Benzodiazepines (BZDs)**. Alcohol is a CNS depressant that enhances GABAergic tone; abrupt cessation leads to GABA underactivity and NMDA overactivity. Diazepam, a long-acting BZD, acts as a cross-tolerant substitute for alcohol, stimulating GABA-A receptors to restore inhibitory tone, prevent seizures, and stabilize vital signs. It is preferred due to its rapid onset and long-acting metabolites (e.g., desmethyldiazepam), which provide a "self-tapering" effect. **Why Other Options are Incorrect:** * **Phenobarbital:** While effective for refractory withdrawal, it has a narrow therapeutic index and carries a higher risk of respiratory depression compared to BZDs. It is not the first-line agent. * **Chlorpromazine:** Antipsychotics like phenothiazines are **contraindicated** as monotherapy because they significantly lower the seizure threshold, increasing the risk of withdrawal seizures. * **Haloperidol:** It may be used as an *adjunct* for severe agitation or hallucinations but never as monotherapy, as it does not treat the underlying autonomic instability or prevent seizures. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Chlordiazepoxide or Diazepam (Long-acting). * **Liver Failure/Elderly:** Use **LOT** (Lorazepam, Oxazepam, Temazepam) as they undergo direct glucuronidation and do not have active metabolites. * **Timing:** DT typically occurs **48–96 hours** after the last drink. * **Wernicke’s Prophylaxis:** Always administer **Thiamine** before intravenous glucose to prevent precipitating Wernicke’s Encephalopathy.

Q: A person was addicted to alcohol for 10 years. He sustained an injury to his toe, and the wound was not healing. He was admitted to the hospital, where he was restless in bed, attempting to catch imaginary insects. He referred to the doctor as his brother and complained of uncontrollable fear of being murdered and insomnia. What is the likely diagnosis?

Delirium tremens. **Explanation:** The clinical presentation describes a classic case of **Delirium Tremens (DT)**, the most severe form of alcohol withdrawal. The patient was hospitalized (leading to forced abstinence), and subsequently developed a triad of **clouding of consciousness** (disorientation—referring to the doctor as his brother), **visual hallucinations** (zoopsia—catching imaginary insects), and **autonomic hyperactivity** (restlessness, insomnia, and intense fear/paranoia). **Why the other options are incorrect:** * **Alcoholic Seizures (Rum Fits):** These typically occur within 6–48 hours of abstinence and present as generalized tonic-clonic seizures. They do not involve prolonged delirium or complex hallucinations. * **Korsakoff’s Psychosis:** This is a chronic amnestic disorder caused by Thiamine (B1) deficiency. It is characterized by profound anterograde amnesia and **confabulation**, without the acute autonomic arousal or visual hallucinations seen here. * **Alcoholic Hallucinosis:** This occurs in a **clear sensorium** (the patient is oriented). While hallucinations are present (usually auditory), the patient does not exhibit the clouding of consciousness or global confusion seen in this case. **High-Yield NEET-PG Pearls:** * **Timeline:** DT typically starts **48–72 hours** after the last drink. * **Hallucinations:** Visual hallucinations of small animals or insects are termed **"Zoopsia."** * **Treatment:** The drug of choice for DT is **Benzodiazepines** (e.g., Chlordiazepoxide or Diazepam). If liver failure is present, use **LOT** (Lorazepam, Oxazepam, Temazepam). * **Mortality:** Untreated DT has a mortality rate of up to 20%, usually due to cardiovascular collapse or hyperthermia.

Q: Disulfiram should not be administered for at least how many hours after a patient has abstained from alcohol?

12 hours. **Explanation:** The correct answer is **12 hours (Option A)**. **Medical Concept:** Disulfiram is an **aldehyde dehydrogenase (ALDH) inhibitor** used as an aversive agent in alcohol dependence. It works by blocking the oxidation of acetaldehyde to acetic acid. If alcohol is present in the system when Disulfiram is administered, acetaldehyde accumulates rapidly, leading to the **Disulfiram-Ethanol Reaction (DER)**. This reaction is characterized by flushing, tachycardia, nausea, vomiting, and hypotension. To prevent an immediate, severe DER, the patient must have a blood alcohol level of zero. Clinically, this requires a minimum abstinence period of **12 hours**. **Analysis of Incorrect Options:** * **Option B (14 hours):** While waiting longer is safe, the standard medical guideline and pharmacological threshold for initiation is 12 hours. * **Option C (48 hours):** This is unnecessarily long for the initial dose. However, 48–72 hours is the timeframe often cited for how long a DER can occur *after* stopping Disulfiram (due to the irreversible binding of the enzyme). * **Option D (96 hours):** This is incorrect for initiation. Disulfiram therapy is typically started once the acute withdrawal phase (usually 24–72 hours) is managed, but the pharmacological requirement remains 12 hours of abstinence. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Irreversible inhibition of Aldehyde Dehydrogenase. * **Dose:** Usually 250 mg daily (Range: 125–500 mg). * **Duration of Action:** Effects can last up to **1–2 weeks** after the last dose because the body must synthesize new ALDH enzymes. * **Contraindications:** Severe cardiac disease, psychosis, and pregnancy. * **Monitoring:** Baseline and periodic **Liver Function Tests (LFTs)** are mandatory due to the risk of hepatotoxicity.

Q: Which of the following substances is classified as a stimulant?

Cocaine. **Explanation:** **Cocaine** is a potent central nervous system (CNS) stimulant. Its primary mechanism of action involves the inhibition of the reuptake of monoamines, specifically **dopamine, norepinephrine, and serotonin**, at the synaptic cleft. By blocking the dopamine transporter (DAT), it increases dopamine concentration in the nucleus accumbens, leading to the characteristic euphoria and high addictive potential. Clinically, it causes sympathetic overactivity (mydriasis, tachycardia, hypertension, and diaphoresis). **Analysis of Incorrect Options:** * **Alcohol:** Classified as a **CNS Depressant**. It enhances the inhibitory effect of GABA at the $GABA_A$ receptor and inhibits excitatory glutamate (NMDA) receptors. * **Nicotine:** While it has both stimulant and relaxant properties, it is primarily classified as a **cholinergic agonist** acting on nicotinic acetylcholine receptors. In the context of "pure" stimulants in psychiatry, Cocaine and Amphetamines are the classic examples. * **Cannabis:** Often classified as a **Hallucinogen** or a "mixed" substance. It can produce sedative, euphoric, or hallucinogenic effects depending on the dose, but it is not a primary CNS stimulant. **High-Yield Clinical Pearls for NEET-PG:** * **Formication (Cocaine Bugs):** The tactile hallucination that insects are crawling under the skin is a classic sign of cocaine intoxication or withdrawal. * **Pupillary Signs:** Cocaine causes **Mydriasis** (dilated pupils), whereas Opioids cause **Miosis** (pinpoint pupils). * **Management:** Benzodiazepines are the first-line treatment for cocaine-induced agitation and hypertension. **Beta-blockers are contraindicated** due to the risk of unopposed alpha-adrenergic stimulation.

Q: A young city dweller presented with a history of drug abuse and complaining of changes in perception, such as hearing sights and seeing sounds. Which substance is responsible for these effects?

LSD. ### Explanation **Correct Option: A. LSD (Lysergic Acid Diethylamide)** The clinical hallmark described in the question—"hearing sights and seeing sounds"—is known as **Synesthesia**. This is a classic perceptual distortion associated with **LSD**, a potent hallucinogen that acts primarily as a partial agonist at the **5-HT2A receptors**. LSD causes profound alterations in sensory perception, depersonalization, and derealization without significant clouding of consciousness. **Analysis of Incorrect Options:** * **B. Phencyclidine (PCP):** While PCP is a dissociative anesthetic (NMDA antagonist) that causes hallucinations, it is more characteristically associated with **nystagmus (vertical/rotatory)**, agitation, and a high tolerance for pain (belligerent behavior). * **C. Cocaine:** A stimulant that inhibits the reuptake of dopamine. Its classic perceptual abnormality is **Formication** (Cocaine bugs)—the tactile hallucination that insects are crawling under the skin. * **D. Amphetamine:** Primarily causes sympathetic overactivity. Chronic use leads to **Amphetamine Psychosis**, which closely mimics paranoid schizophrenia (delusions and auditory hallucinations), rather than synesthesia. **High-Yield Clinical Pearls for NEET-PG:** * **Synesthesia:** The "mixing of senses" is a pathognomonic board-style description for LSD. * **Bad Trip:** Acute panic reactions are common with LSD; managed with reassurance ("talking down") or benzodiazepines. * **Flashbacks (Hallucinogen Persisting Perception Disorder):** Spontaneous recurrence of the drug's effects weeks or months after use. * **Pupillary Findings:** LSD typically causes **Mydriasis** (dilated pupils), unlike opioids which cause miosis.

Q: The CRAFFT Questionnaire is used for what purpose?

Screening adolescents for drug abuse. **Explanation:** The **CRAFFT Questionnaire** is a validated behavioral health screening tool specifically designed for **adolescents (ages 12–21)** to detect high-risk alcohol and other drug use. It is widely recommended by the American Academy of Pediatrics (AAP) for use in primary care settings. The acronym **CRAFFT** stands for: * **C – Car:** Have you ever ridden in a **Car** driven by someone (including yourself) who was "high" or had been using alcohol or drugs? * **R – Relax:** Do you ever use alcohol or drugs to **Relax**, feel better about yourself, or fit in? * **A – Alone:** Do you ever use alcohol or drugs while you are **Alone**? * **F – Forget:** Do you ever **Forget** things you did while using alcohol or drugs? * **F – Friends:** Do your family or **Friends** ever tell you that you should cut down on your drinking or drug use? * **T – Trouble:** Have you ever gotten into **Trouble** while you were using alcohol or drugs? **Analysis of Incorrect Options:** * **Option A & B:** These are unrelated to psychiatric screening. Physical dexterity is assessed via neurological exams, and thyroid disorders via biochemical assays (TSH/T4). * **Option D:** Screening for abusive tendencies in parents often involves tools like the Child Abuse Potential (CAP) Inventory, not CRAFFT. **High-Yield Clinical Pearls for NEET-PG:** * **Target Population:** Adolescents (under 21). * **Scoring:** A score of **≥2** is considered a positive screen, indicating a high risk for a Substance Use Disorder (SUD). * **Comparison:** While **CAGE** is the classic screening tool for alcohol use in **adults**, **CRAFFT** is the gold standard for **adolescents** and covers both alcohol and drugs. * **Other Screens:** **AUDIT** (Alcohol Use Disorders Identification Test) is used for hazardous drinking patterns in adults.

Q: A 35-year-old male with a history of 10 years of alcoholism and a past history of ataxia with bilateral rectus palsy was admitted and treated. What changes are expected to be seen?

Progression to Korsakoff's psychosis. ### Explanation This clinical scenario describes a patient with **Wernicke’s Encephalopathy (WE)**, characterized by the classic triad of **Ataxia, Ophthalmoplegia (e.g., bilateral rectus palsy), and Confusion**. This condition results from **Thiamine (Vitamin B1) deficiency**, most commonly due to chronic alcoholism. **Why Option A is Correct:** If Wernicke’s Encephalopathy is not treated promptly or adequately, it frequently progresses to **Korsakoff’s Psychosis**. This is a chronic, often irreversible condition characterized by **anterograde and retrograde amnesia** and **confabulation**. Together, these stages are known as the Wernicke-Korsakoff Syndrome. Approximately 80% of patients with untreated or partially treated WE will progress to Korsakoff’s. **Analysis of Incorrect Options:** * **Option B:** Residual ataxia actually persists in about **25-35%** of patients, not 50%. While common, it is not the most definitive "expected change" compared to the progression to psychosis. * **Option C:** While ocular signs (like abducens palsy) are the first to improve after thiamine administration, they typically resolve within **days to weeks**, not hours. * **Option D:** Immediate relief is impossible because thiamine deficiency causes biochemical and structural brain lesions (atrophy of mammillary bodies) that take time to stabilize or may be permanent. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of WE:** Global confusion, Ataxia, and Ophthalmoplegia (CAN: Confusion, Ataxia, Nystagmus). * **Korsakoff’s Hallmark:** Confabulation (filling memory gaps with imaginary stories). * **Imaging:** MRI may show hyperintensities in the **mammillary bodies** and periaqueductal gray matter. * **Management Rule:** Always administer **Thiamine before Glucose** in a suspected alcoholic to prevent precipitating or worsening WE.

Q: In an alcoholic patient, which of the following can precipitate delirium tremens?

Acute infection. **Explanation:** **Delirium Tremens (DT)** is the most severe form of alcohol withdrawal, typically occurring 48–96 hours after the last drink. It is characterized by altered sensorium, autonomic hyperactivity, and vivid hallucinations. **Why Acute Infection is the Correct Answer:** In a chronic alcoholic, the body exists in a state of neurochemical adaptation (downregulation of GABA receptors and upregulation of NMDA receptors). **Acute infection** acts as a potent physiological stressor that increases metabolic demand and triggers a systemic inflammatory response. This stress can destabilize the fragile neurochemical balance, precipitating or worsening withdrawal symptoms into full-blown Delirium Tremens. Other common precipitants include trauma, surgery, or head injury. **Analysis of Incorrect Options:** * **A. Small consumption of alcohol:** Alcohol consumption actually suppresses withdrawal symptoms. DT is triggered by the *absence* or significant reduction of alcohol, not its intake. * **B. Gradual withdrawal from alcohol:** Gradual reduction (tapering) is a clinical strategy used to *prevent* DT. Abrupt cessation is what leads to severe withdrawal. * **C. Fatty liver:** While common in alcoholics, hepatic steatosis itself does not precipitate DT. However, advanced cirrhosis or acute alcoholic hepatitis can be associated stressors. **High-Yield Clinical Pearls for NEET-PG:** * **Timeline:** DT typically peaks at **72–96 hours** after cessation. * **Drug of Choice:** **Benzodiazepines** (e.g., Diazepam, Lorazepam) are the gold standard for management. * **Mortality:** If untreated, DT has a mortality rate of up to 20%, usually due to hyperthermia, arrhythmias, or secondary infections (Pneumonia). * **Hallucinations:** Most commonly **visual** (e.g., Lilliputian hallucinations/small crawling insects).

Q: All of the following are features of LSD intoxication except?

Flashback. **Explanation:** The correct answer is **Flashback**. In the context of psychiatry and substance use disorders, it is crucial to distinguish between **acute intoxication** and **post-hallucinogen perception disorder**. 1. **Why "Flashback" is the correct answer:** Flashbacks (technically termed Hallucinogen Persisting Perception Disorder or HPPD) are **not** a feature of acute intoxication. Instead, they are a late complication or a chronic sequela. They involve the spontaneous recurrence of sensory distortions (visual trails, macropsia, or color shifts) weeks, months, or even years after the drug has been cleared from the body, occurring during a period of sobriety. 2. **Why the other options are incorrect (Features of Acute Intoxication):** * **Synesthesia (Option D):** This is a hallmark of LSD intoxication where senses "cross over" (e.g., "hearing colors" or "seeing sounds"). * **Depersonalization (Option A) and Derealization (Option C):** These dissociative symptoms are common during the "trip." The user feels detached from their own body or perceives the external world as dreamlike and unreal. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** LSD (Lysergic acid diethylamide) is a potent **5-HT2A receptor agonist**. * **Physical Signs:** Look for marked **Mydriasis** (dilated pupils), tachycardia, tremors, and sweating during acute intoxication. * **Management:** Acute "bad trips" are managed with a calm environment ("talking down") and **Benzodiazepines**. Antipsychotics should be used with caution. * **LSD is non-addictive:** It does not cause physical dependence or withdrawal symptoms, though rapid tolerance (tachyphylaxis) occurs.

Question 1

A 36-year-old female, a chronic alcoholic, reports auditory hallucinations, specifically hearing voices commanding her to do things, and also experiences difficulty falling asleep. What is the most likely diagnosis?

Accepted Answer

Alcoholic hallucinosis

Answer

Delirium tremens

Answer

Depression

Answer

Wernicke's encephalopathy

Question 2

What is the recommended treatment for the management of delirium tremens?

Accepted Answer

Diazepam

Answer

Phenobarbital

Answer

Chlorpromazine

Answer

Haloperidol

Question 3

A person was addicted to alcohol for 10 years. He sustained an injury to his toe, and the wound was not healing. He was admitted to the hospital, where he was restless in bed, attempting to catch imaginary insects. He referred to the doctor as his brother and complained of uncontrollable fear of being murdered and insomnia. What is the likely diagnosis?

Accepted Answer

Delirium tremens

Answer

Alcoholic seizures/rum fits

Answer

Korsakoff's psychosis

Answer

Alcoholic hallucinosis

Question 4

Disulfiram should not be administered for at least how many hours after a patient has abstained from alcohol?

Accepted Answer

12 hours

Answer

14 hours

Answer

48 hours

Answer

96 hours

Question 5

Which of the following substances is classified as a stimulant?

Accepted Answer

Cocaine

Answer

Alcohol

Answer

Nicotine

Answer

Cannabis

Question 6

A young city dweller presented with a history of drug abuse and complaining of changes in perception, such as hearing sights and seeing sounds. Which substance is responsible for these effects?

Accepted Answer

LSD

Answer

Phencyclidine

Answer

Cocaine

Answer

Amphetamine

Question 7

The CRAFFT Questionnaire is used for what purpose?

Accepted Answer

Screening adolescents for drug abuse

Answer

Screening for physical dexterity

Answer

Screening for thyroid disorders

Answer

Screening parents for abusive tendencies

Question 8

A 35-year-old male with a history of 10 years of alcoholism and a past history of ataxia with bilateral rectus palsy was admitted and treated. What changes are expected to be seen?

Accepted Answer

Progression to Korsakoff's psychosis

Answer

Residual ataxia in 50% of patients

Answer

Extraocular palsy disappears in hours

Answer

Immediate relief from symptoms

Question 9

In an alcoholic patient, which of the following can precipitate delirium tremens?

Accepted Answer

Acute infection

Answer

Small consumption of alcohol

Answer

Gradual withdrawal from alcohol

Answer

Fatty liver

Question 10

All of the following are features of LSD intoxication except?

Accepted Answer

Flashback

Answer

Depersonalization

Answer

Derealization

Answer

Synesthesia

Substance Use Disorders — MCQs

Substance Use Disorders — MCQs

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