Substance Use Disorders — MCQs
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A 44-year-old male with a history of anxiety treated with alprazolam for 3 years presented with lack of improvement and slurred speech after alcohol consumption. He decided to stop the medication to prevent dependence and was admitted with severe withdrawal symptoms. Which statement regarding alprazolam use is accurate?
Disulfiram should not be administered for at least how many hours after a patient has abstained from alcohol?
Which of the following substances is classified as a stimulant?
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?
The CRAFFT Questionnaire is used for what purpose?
Sudden onset of hallucinations in a 35-year-old man with no previous history and family history of schizophrenia may be due to what?
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?
In an alcoholic patient, which of the following can precipitate delirium tremens?
All of the following are features of LSD intoxication except?
Amotivational syndrome is seen in which of the following?
Substance Use Disorders Indian Medical PG Practice Questions and MCQs
Question 81: A 44-year-old male with a history of anxiety treated with alprazolam for 3 years presented with lack of improvement and slurred speech after alcohol consumption. He decided to stop the medication to prevent dependence and was admitted with severe withdrawal symptoms. Which statement regarding alprazolam use is accurate?
- A. Additive CNS depression occurs with ethanol.
- B. Abrupt discontinuance of alprazolam after 4 weeks of treatment may elicit withdrawal signs.
- C. Tolerance can occur with chronic use of any benzodiazepine.
- D. All of the above statements are accurate. (Correct Answer)
Explanation: This question tests the pharmacological and clinical profile of Benzodiazepines (BZDs), specifically Alprazolam, which is a high-potency, short-acting BZD. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because each statement reflects a core pharmacological property of BZDs: * **Option A (Additive CNS Depression):** Both alcohol and BZDs are positive allosteric modulators of the **GABA-A receptor**. When taken together, they produce a synergistic effect on the chloride channel, leading to profound CNS depression, respiratory depression, and symptoms like slurred speech or ataxia. * **Option B (Withdrawal Timeline):** Physical dependence can develop relatively quickly. Abrupt cessation after as little as **3–4 weeks** of regular use can trigger withdrawal symptoms (anxiety, tremors, seizures). Alprazolam is particularly notorious for severe withdrawal due to its short half-life. * **Option C (Tolerance):** Chronic use leads to the downregulation of GABA receptors. Tolerance develops rapidly to the sedative and anticonvulsant effects, though more slowly to the anxiolytic effects. **Why other options are "incorrect":** In a "Multiple Correct" style question, options A, B, and C are individually accurate statements; therefore, they are not "wrong" in a clinical sense, but "D" is the most comprehensive choice. **NEET-PG High-Yield Pearls:** * **Antidote:** Flumazenil is a competitive BZD antagonist used in acute overdose (Note: It can precipitate seizures in chronic users). * **Withdrawal Management:** Always taper BZDs slowly. Switching to a long-acting BZD like **Diazepam** (Chlordiazepoxide is also used) is the preferred strategy for detoxification. * **Alprazolam Specifics:** It is the BZD most commonly associated with "rebound anxiety" and has a high abuse potential due to its rapid onset and short duration.
Question 82: Disulfiram should not be administered for at least how many hours after a patient has abstained from alcohol?
- A. 12 hours (Correct Answer)
- B. 14 hours
- C. 48 hours
- D. 96 hours
Explanation: **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.
Question 83: Which of the following substances is classified as a stimulant?
- A. Alcohol
- B. Nicotine
- C. Cannabis
- D. Cocaine (Correct Answer)
Explanation: **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.
Question 84: 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?
- A. LSD (Correct Answer)
- B. Phencyclidine
- C. Cocaine
- D. Amphetamine
Explanation: ### 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.
Question 85: The CRAFFT Questionnaire is used for what purpose?
- A. Screening for physical dexterity
- B. Screening for thyroid disorders
- C. Screening adolescents for drug abuse (Correct Answer)
- D. Screening parents for abusive tendencies
Explanation: **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.
Question 86: Sudden onset of hallucinations in a 35-year-old man with no previous history and family history of schizophrenia may be due to what?
- A. Substance abuse
- B. Schizophrenia (Correct Answer)
- C. Frotterism
- D. Depression
Explanation: **Explanation:** The correct answer is **Schizophrenia**. While the question mentions a "sudden onset" and no family history, Schizophrenia remains the most likely primary psychiatric diagnosis for new-onset hallucinations in a 35-year-old. 1. **Why Schizophrenia is correct:** The peak age of onset for schizophrenia in males is 15–25 years, but in females and some male cohorts, it can occur up to the mid-30s. The absence of family history does not rule it out, as approximately 80% of patients with schizophrenia have no affected first-degree relatives. In the context of standard psychiatric examinations, hallucinations are a "first-rank symptom" or a core Criterion A feature of Schizophrenia. 2. **Why other options are incorrect:** * **Substance abuse:** While substances (like amphetamines or LSD) cause hallucinations, the term "Substance-Induced Psychotic Disorder" is distinct. In a general clinical question, unless a history of drug intake or withdrawal (like Delirium Tremens) is provided, Schizophrenia is the preferred academic answer for primary psychosis. * **Frotteurism:** This is a paraphilic disorder involving touching or rubbing against a non-consenting person. It does not involve hallucinations. * **Depression:** While "Psychotic Depression" exists, hallucinations are usually mood-congruent (e.g., voices telling the patient they are worthless) and occur secondary to a profound low mood, which is not described here. **High-Yield Clinical Pearls for NEET-PG:** * **Schneider’s First Rank Symptoms (FRS):** Includes audible thoughts, voices arguing/commenting, and somatic passivity. These are highly suggestive of Schizophrenia. * **Late-onset Schizophrenia:** Onset after age 45 is more common in females. * **Rule out Organicity:** In any "sudden onset" psychosis in a 35+ year old, always look for medical causes (Temporal Lobe Epilepsy, brain tumors, or metabolic issues) before confirming a functional psychiatric diagnosis.
Question 87: 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?
- A. Progression to Korsakoff's psychosis (Correct Answer)
- B. Residual ataxia in 50% of patients
- C. Extraocular palsy disappears in hours
- D. Immediate relief from symptoms
Explanation: ### 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.
Question 88: In an alcoholic patient, which of the following can precipitate delirium tremens?
- A. Small consumption of alcohol
- B. Gradual withdrawal from alcohol
- C. Fatty liver
- D. Acute infection (Correct Answer)
Explanation: **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).
Question 89: All of the following are features of LSD intoxication except?
- A. Depersonalization
- B. Flashback (Correct Answer)
- C. Derealization
- D. Synesthesia
Explanation: **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 90: Amotivational syndrome is seen in which of the following?
- A. Cannabis (Correct Answer)
- B. Cocaine
- C. Amphetamine
- D. LSD
Explanation: **Explanation:** **Amotivational Syndrome** is a clinical condition characterized by apathy, lack of ambition, diminished ability to concentrate, and a loss of interest in long-term goals. It is classically associated with **chronic, heavy use of Cannabis** (specifically delta-9-tetrahydrocannabinol or THC). 1. **Why Cannabis is correct:** Chronic cannabis use is thought to affect the brain's reward system (dopaminergic pathways). Patients exhibit "cognitive dulling," social withdrawal, and a decline in school or work performance. While its status as a distinct psychiatric diagnosis is debated, it remains a high-yield association for Cannabis in medical examinations. 2. **Why the others are incorrect:** * **Cocaine & Amphetamines:** These are CNS stimulants. Chronic use typically leads to paranoia, agitation, or "crash" symptoms (depression/hypersomnia) during withdrawal, rather than a primary amotivational state. * **LSD:** As a hallucinogen, LSD is primarily associated with perceptual distortions, synesthesia, and "flashbacks" (Hallucinogen Persisting Perception Disorder), not amotivational syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Active Ingredient:** Delta-9-tetrahydrocannabinol (THC). * **Physical Sign:** Conjunctival injection (red eyes) and increased appetite ("munchies") are hallmark signs of acute intoxication. * **Psychiatric Complications:** Cannabis is a known risk factor for the precipitation of Schizophrenia in predisposed individuals. * **Flashbacks:** Though most common with LSD, they can also occur with cannabis use. * **Run Amok:** A culture-bound syndrome traditionally associated with cannabis (though also seen in other states) involving a period of brooding followed by a violent outburst.
Practice by Chapter
Neurobiology of Addiction
Practice Questions
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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