Q&A:
Substance
Use and
Personality
Disorders
1. A 35-year-old homeless veteran is brought to the emergency
department by the police; he is not sure why he is there. He is
clearly euphoric but also agitated and somewhat paranoid; he says
he “feels fantastic” but is wary of answering any questions. On
physical examination, the patient exhibits a moderately elevated
blood pressure and pulse rate. He is most likely intoxicated with which of
the following substances?
A. Alcohol
B. Barbiturates
C. Benzodiazepines
D. Cocaine
E. Opiates
1. A 35-year-old homeless veteran is brought to the emergency
department by the police; he is not sure why he is there. He is
clearly euphoric but also agitated and somewhat paranoid; he says
he “feels fantastic” but is wary of answering any questions. On
physical examination, the patient exhibits a moderately elevated
blood pressure and pulse rate. He is most likely intoxicated with which of
the following substances?
A. Alcohol
B. Barbiturates
C. Benzodiazepines
D. Cocaine
E. Opiates
1. A 35-year-old homeless veteran is brought to the emergency
department by the police; he is not sure why he is there. He is
clearly euphoric but also agitated and somewhat paranoid; he says
he “feels fantastic” but is wary of answering any questions. On
physical examination, the patient exhibits with dilated pupils, a
moderately elevated blood pressure and pulse rate. He is most likely
intoxicated with which of the following substances?
A. Alcohol
B. Barbiturates
C. Benzodiazepines
D. Cocaine
E. Opiates
2. Which of the following tests would be the most useful in determining
the etiology of her symptoms?
(A) Blood glucose
(B) Catecholamine metabolites
(C) Electrocardiogram (ECG)
(D) Thyroid function
(E) Urine toxicology
2. Which of the following tests would be the most useful in determining
the etiology of her symptoms?
(A) Blood glucose
(B) Catecholamine metabolites
(C) Electrocardiogram (ECG)
(D) Thyroid function
(E) Urine toxicology
2. Which of the following tests would be the most useful in determining
the etiology of her symptoms?
(A) Blood glucose
(B) Catecholamine metabolites
(C) Electrocardiogram (ECG)
(D) Thyroid function
(E) Urine toxicology
(E) In this patient on no medications, a urine toxicology screen is most
likely to determine the cause of her current state, probably due to drug
intoxication. Blood glucose is important to test since hypoglycemia
can present with mental status changes and diaphoresis; however, it
would be unlikely in this otherwise healthy
man. Catecholamine metabolites would be premature at this time. An
ECG would be part of a workup to rule out any arrhythmias, but any
abnormalities would not necessarily identify a specific etiology or
account for his dilated pupils. Thyroid function tests are important, as
thyrotoxicosis can manifest with panic-type symptoms, but again, in a
healthy man with an acute onset of symptoms, the urine drug screen is
more likely to yield an etiology.
Cocaine Intoxication
D. Cocaine intoxication (or other stimulants like amphetamine) can
present with euphoria, irritability, anxiety, psychotic symptoms such as
paranoia, as well as with elevated vital signs. Conversely, intoxication
with alcohol, barbiturates, benzodiazepines, and opiates generally
causes depression, somnolence, and depressed vitals signs.
Cocaine Associated Behavioral and Physical
Changes
3. A frustrated mother brings her 14-year-old son to a child psychiatrist
after he is expelled from three high schools in 1 year. She reports the boy
has tried twice to set his school on fire, has slashed school bus tires, and
has broken into the principal’s office to steal athletic trophies. In addition,
he has been suspended numerous times for getting into fights with
other students. She shudders and tearfully relates that she recently
caught him singing one of the family cats with a cigarette butt.
Which of the following personality disorders is this boy most at risk of
developing in the future?
A. Antisocial
B. Borderline
C. Histrionic
D. Narcissistic
E. Schizotypal
3. A frustrated mother brings her 14-year-old son to a child psychiatrist
after he is expelled from three high schools in 1 year. She reports the boy
has tried twice to set his school on fire, has slashed school bus tires, and
has broken into the principal’s office to steal athletic trophies. In addition,
he has been suspended numerous times for getting into fights with
other students. She shudders and tearfully relates that she recently
caught him singing one of the family cats with a cigarette butt.
Which of the following personality disorders is this boy most at risk of
developing in the future?
A. Antisocial
B. Borderline
C. Histrionic
D. Narcissistic
E. Schizotypal
3. A frustrated mother brings her 14-year-old son to a child psychiatrist
after he is expelled from three high schools in 1 year. She reports the boy
has tried twice to set his school on fire, has slashed school bus tires, and
has broken into the principal’s office to steal athletic trophies. In addition,
he has been suspended numerous times for getting into fights with
other students. She shudders and tearfully relates that she recently
caught him singing one of the family cats with a cigarette butt.
Which of the following personality disorders is this boy most at risk of
developing in the future?
A. Antisocial
B. Borderline
C. Histrionic
D. Narcissistic
E. Schizotypal
A. Antisocial
(A) The case represents a child with conduct disorder. Individuals with
conduct disorder are at increased risk of later development
of antisocial personality disorder; in fact, DSM-5 criteria for antisocial
personality disorder require evidence of a conduct disorder
before the age of 15 years.
4. An 18-year-old, pregnant, human immunodeficiency virus (HIV)–
positive woman presents for the treatment of opiate use disorder. She
reports using heroin for the last 8 months with substantial (but
unsuccessful) efforts to quit for the last 4 months. She is now
homeless and has recently been arrested for shoplifting. Which of the
following pharmacological therapies would be the most appropriate
at this time?
(A) Buprenorphine
(B) Clonidine
(C) Haloperidol
(D) Methadone
(E) Naloxone
4. An 18-year-old, pregnant, human immunodeficiency virus (HIV)–
positive woman presents for the treatment of opiate use disorder. She
reports using heroin for the last 8 months with substantial (but
unsuccessful) efforts to quit for the last 4 months. She is now
homeless and has recently been arrested for shoplifting. Which of the
following pharmacological therapies would be the most appropriate
at this time?
(A) Buprenorphine
(B) Clonidine
(C) Haloperidol
(D) Methadone
(E) Naloxone
4. An 18-year-old, pregnant, human immunodeficiency virus (HIV)–
positive woman presents for the treatment of opiate use disorder. She
reports using heroin for the last 8 months with substantial (but
unsuccessful) efforts to quit for the last 4 months. She is now
homeless and has recently been arrested for shoplifting. Which of the
following pharmacological therapies would be the most appropriate
at this time?
(A) Buprenorphine
(B) Clonidine
(C) Haloperidol
(D) Methadone
(E) Naloxone
(D) Methadone
Methadone maintenance is the most appropriate pharmacological
therapy for the treatment of opiate (heroin) use disorder, even in
pregnancy. Methadone maintenance, especially when combined with
psychosocial services and obstetric
monitoring, significantly improves neonatal outcomes and obstetric
outcomes for women addicted to heroin. The lowest effective dose
should be used during pregnancy. There are no known teratogenic
effects from methadone. Women may require higher doses of
methadone in the third trimester due to increased metabolism
of the drug at that time.
(D) Methadone
Buprenorphine is a partial opiate agonist that has a role
in maintenance treatment, but its safety during pregnancy and
breastfeeding has not been definitively established, and its use in
pregnancy may lead to withdrawal symptoms in opioid-dependent
fetuses. Clonidine can be used to treat hypertension and other
symptoms during acute opiate withdrawal. While haloperidol (a firstgeneration antipsychotic) may be used safely in pregnancy, it has no
use for the treatment of severe opiate use disorder, unless agitation
from acute withdrawal is problematic. Naloxone is an opiate
antagonist, used for opiate overdose, not appropriate in this case.
5. A 37-year-old woman, who works the night shift at a local grocery store
taking inventory, reports that her childhood and college years were
uneventful but happy. She spends most of her time alone when she is not
at work. She does not venture out of her house and her social contacts
are limited to work-related interactions with coworkers. She is an
avid plant lover, and she spends most of her free time taking care of her
indoor nursery. She reports that she is quite content with her life. Which
of the following is the most likely diagnosis for this patient?
(A) Agoraphobia
(B) Autism spectrum disorder
(C) Avoidant personality disorder
(D) Schizoid personality disorder
(E) Schizotypal personality disorder
5. A 37-year-old woman, who works the night shift at a local grocery store
taking inventory, reports that her childhood and college years were
uneventful but happy. She spends most of her time alone when she is not
at work. She does not venture out of her house and her social contacts
are limited to work-related interactions with coworkers. She is an
avid plant lover, and she spends most of her free time taking care of her
indoor nursery. She reports that she is quite content with her life. Which
of the following is the most likely diagnosis for this patient?
(A) Agoraphobia
(B) Autism spectrum disorder
(C) Avoidant personality disorder
(D) Schizoid personality disorder
(E) Schizotypal personality disorder
5. A 37-year-old woman, who works the night shift at a local grocery store
taking inventory, reports that her childhood and college years were
uneventful but happy. She spends most of her time alone when she is not
at work. She does not venture out of her house and her social contacts
are limited to work-related interactions with coworkers. She is an
avid plant lover, and she spends most of her free time taking care of her
indoor nursery. She reports that she is quite content with her life. Which
of the following is the most likely diagnosis for this patient?
(A) Agoraphobia
(B) Autism spectrum disorder
(C) Avoidant personality disorder
(D) Schizoid personality disorder
(E) Schizotypal personality disorder
(D) Schizoid Personality Disorder
Persons with schizoid personality disorder are detached,
reclusive, demonstrate a restricted range of affect, and do not mind
the lack of social interaction. Agoraphobia is tied to the fear of having
panic-type symptoms in public. Such symptoms are not mentioned
in this case. Autism spectrum disorder is a developmental disorder
characterized by deficits in social communication and with
repetitive, restricted behaviors and interests. Persons with avoidant
personality disorder are shy and fearful of social rejection. However,
their lack of socialization is distressing to them. Schizotypal individuals
can have schizoid features but they also have bizarre thinking and an
odd or eccentric manner.
5. A 48-year-old man has been drinking up to 6 beers per night during the
week and up to 12 beers a night on the weekend. A year ago, he had his driver
’s license suspended for drunk driving. His marriage is failing because of these
difficulties. Last month, he was diagnosed with a gastric ulcer as a result of
alcohol consumption. He admits to an alcohol problem and has tried to stop
on numerous occasions. He finds that he experiences insomnia if he does not
drink for more than 2 days. Which of the following features of this case
suggests a severe versus moderate alcohol use disorder?
(A) High quantity of alcohol consumed on a
regular basis
(B) History of legal problems
(C) Inability to stop drinking despite knowing the harmful effects
(D) Marital conflict due to drinking
(E) Number of difficulties he is experiencing
5. A 48-year-old man has been drinking up to 6 beers per night during the
week and up to 12 beers a night on the weekend. A year ago, he had his driver
’s license suspended for drunk driving. His marriage is failing because of these
difficulties. Last month, he was diagnosed with a gastric ulcer as a result of
alcohol consumption. He admits to an alcohol problem and has tried to stop
on numerous occasions. He finds that he experiences insomnia if he does not
drink for more than 2 days. Which of the following features of this case
suggests a severe versus moderate alcohol use disorder?
(A) High quantity of alcohol consumed on a
regular basis
(B) History of legal problems
(C) Inability to stop drinking despite knowing the harmful effects
(D) Marital conflict due to drinking
(E) Number of difficulties he is experiencing
5. A 48-year-old man has been drinking up to 6 beers per night during the
week and up to 12 beers a night on the weekend. A year ago, he had his driver
’s license suspended for drunk driving. His marriage is failing because of these
difficulties. Last month, he was diagnosed with a gastric ulcer as a result of
alcohol consumption. He admits to an alcohol problem and has tried to stop
on numerous occasions. He finds that he experiences insomnia if he does not
drink for more than 2 days. Which of the following features of this case
suggests a severe versus moderate alcohol use disorder?
(A) High quantity of alcohol consumed on a
regular basis
(B) History of legal problems
(C) Inability to stop drinking despite knowing the harmful effects
(D) Marital conflict due to drinking
(E) Number of difficulties he is experiencing
(E). Number of difficulties he is experiencing
(E). Number of difficulties he is experiencing
The DSM-5 distinguishes the severity of alcohol (and other substance)
use disorders on the basis of how many criteria are met. Criteria A
include evidence of a problematic pattern of alcohol use that results in
impairment and/ or distress. The DSM-5 does not distinguish
abuse from dependence, and requires the number of problematic
symptoms to determine severity
Mild alcohol use disorder: 2-3 symptoms
Moderate alcohol use disorder: 4-5 symptoms
Severe alcohol use disorder: 6 or more (out of 11 listed)
A 31-year-old woman was admitted to a psychiatric unit after attempting
suicide by overdose. She had recently broken up with her boyfriend of 4
months. She also describes episodes of mood lability, marked by feelings
of depression and anger directed toward the psychiatric resident who
completed the rotation 5 days after her admission. When
the resident left, she reported that she was having urges to
cut her wrists. She has had numerous admissions for suicidal
gestures and a lifelong history of tumultuous romantic relationships. As
the patient nears her discharge date, she reports that “all the staff
hates me except for Dr. Johnson.” Dr. Johnson, a medical student, had
a recent difference of opinion with the nursing staff regarding
the patient’s discharge.
6. Which of the following diagnoses is the most likely for this patient?
(A) Borderline personality disorder
(B) Cyclothymic disorder
(C) Histrionic personality disorder
(D) Major depressive disorder (MDD)
(E) Schizoaffective disorder
6. Which of the following diagnoses is the most likely for this patient?
(A) Borderline personality disorder
(B) Cyclothymic disorder
(C) Histrionic personality disorder
(D) Major depressive disorder (MDD)
(E) Schizoaffective disorder
6. Which of the following diagnoses is the most likely for this patient?
(A) Borderline personality disorder
(B) Cyclothymic disorder
(C) Histrionic personality disorder
(D) Major depressive disorder (MDD)
(E) Schizoaffective disorder
(A) Borderline personality disorder
(A) This patient displays symptoms of fear of loss and abandonment,
intense interpersonal relationships, recurrent suicidal behavior
or threats, affective instability, and difficulty controlling intense anger,
consistent with borderline personality disorder.
Patients with cyclothymic disorder often present with similar
symptoms of mood changes due to hypomanic episodes and minor
depressive episodes, but they are not usually as frequent, short-lived,
or intense, and they are not associated with the other symptoms of
borderline personality disorder above.
(A) Borderline personality disorder
Patients with histrionic personality disorder, like those with borderline
personality disorder, may display excessive emotionality and attention
seeking, but their core symptoms center around superficial seductiveness
and theatricality.
While patients with borderline personality disorder may have depressive
symptoms that develop into MDD, this patient’s depressive symptoms are
fleeting and in response to stressors such as perceived abandonment.
Although this patient appears paranoid that “all the staff hates me,” there is
no other evidence for a primary psychotic illness such as schizoaffective
disorder.
Patients with borderline personality disorder may experience
temporary psychotic symptoms, such as paranoia, or severe dissociation
under times of perceived stress or substance use.
7. Which of the following would be the most appropriate
outpatient treatment for this patient?
(A) Antidepressants
(B) Benzodiazepines
(C) Group psychotherapy
(D) Individual psychotherapy
(E) Mood stabilizers
7. Which of the following would be the most appropriate
outpatient treatment for this patient?
(A) Antidepressants
(B) Benzodiazepines
(C) Group psychotherapy
(D) Individual psychotherapy
(E) Mood stabilizers
7. Which of the following would be the most appropriate
outpatient treatment for this patient?
(A) Antidepressants
(B) Benzodiazepines
(C) Group psychotherapy
(D) Individual psychotherapy
(E) Mood stabilizers
(D) Individual Psychotherapy
(D) Psychotherapy and steady social support represent the best longterm method for the management of borderline personality
disorder. Antidepressants, antipsychotics, and mood stabilizers do
have some efficacy in treating target symptoms in some patients with
borderline personality disorder, but the long-term mainstay
treatment is psychotherapy. Medication can be a useful adjunct in
managing symptoms sufficiently so that the patient can later engage
more effectively in psychotherapy. Benzodiazepines may treat anxiety
in these patients, but they have particular abuse liability in these
impulsive patients.
8. In this patient, which type of psychotherapy would be the
most efficacious?
(A) Cognitive-behavioral therapy (CBT)
(B) Dialectical behavioral therapy (DBT)
(C) Group therapy
(D) Psychoanalysis
(E) Psychodynamic therapy
8. In this patient, which type of psychotherapy would be the
most efficacious?
(A) Cognitive-behavioral therapy (CBT)
(B) Dialectical behavioral therapy (DBT)
(C) Group therapy
(D) Psychoanalysis
(E) Psychodynamic therapy
(B) Dialectical behavioral therapy (DBT)
DBT has shown to be particularly effective with borderline individuals,
especially when used in conjunction with groups. DBT is an offshoot
from CBT and focuses on mindfulness and distress tolerance.
A 36-year-old man is brought to the emergency department in respiratory
arrest. On examination, he is bradycardic and unresponsive, with
constricted pupils bilaterally. There are no other obvious injuries on the
patient, but no one is immediately available to provide collateral history.
There is suspicion that the patient’s condition may be the result of
an overdose.
9. Which of the following drugs is most likely to cause this presentation?
(A) Alcohol
(B) Cocaine
(C) Heroin
(D) Inhalants
(E) Phencyclidine (PCP)
9. Which of the following drugs is most likely to cause this presentation?
(A) Alcohol
(B) Cocaine
(C) Heroin
(D) Inhalants
(E) Phencyclidine (PCP)
(C). Heroin
(C) Heroin overdose is most likely to have caused the clinical situation
described, including the decreased level of consciousness, respiratory
depression, and pinpoint (constricted) pupils.
Alcohol intoxication and PCP may cause coma but both are associated
with nystagmus rather than pupillary size changes. Cocaine use
causes pupillary dilatation, not constriction, and is usually associated
with agitation in large amounts. Inhalants may rarely cause coma but
are not classically associated with pupillary constriction.
10. Which of the following would be most important to administer
immediately?
(A) Acetylcysteine
(B) Deferoxamine
(C) Methadone
(D) Methylene blue
(E) Naloxone
10. Which of the following would be most important to administer
immediately?
(A) Acetylcysteine
(B) Deferoxamine
(C) Methadone
(D) Methylene blue
(E) Naloxone
(E) Naloxone
Naloxone is used to reverse the acute effects
of opiate overdose by blocking CNS opioid
receptors. Acetylcysteine is administered in
acetaminophen overdose and deferoxamine is
used in iron overdose. Methadone is used for
the long-term maintenance of opiate addiction
and would only worsen the symptoms of heroin
overdose. Methylene blue is used to treat
methemoglobinemia.
A 46-year-old man with a history of hypertension and hyperlipidemia
presents to his primary care doctor with complaints that “I’m drinking
too much.” He gives a long history of binges over 4 to 5 days at a time,
where he will drink 1 to 2 pints of gin per day. He has had several DUIs
and is at risk of losing his job. In addition, his drinking has put a strain
on his marriage. Unfortunately, he has been unable to maintain sobriety
for any significant period of time. He is “stressed out” because of the
consequences of his drinking, and he admits to chronic,
intermittent insomnia. He has a good appetite, however, and his energy
is adequate unless he is significantly hungover. He feels helpless but
denies suicidal ideation.
11. Which of the following medications would be most appropriate to
prescribe for this patient?
(A) Acamprosate
(B) Bupropion
(C) Citalopram
(D) Lithium
(E) Olanzapine
11. Which of the following medications would be most appropriate to
prescribe for this patient?
(A) Acamprosate
(B) Bupropion
(C) Citalopram
(D) Lithium
(E) Olanzapine
(A) Acamprosate
This patient is suffering from alcohol use disorder. While rehabilitation
is the mainstay of treatment for addictions, several medications have
been beneficial in reducing alcohol use. Acamprosate, a glutamate
receptor modulator, has shown efficiency in reducing craving and
alcohol use.
12. Two weeks later this same patient is seen in the emergency room after
being picked up by the police for disturbing the peace and wandering. On
examination he appears confused, has nystagmus, and an unsteady gait.
Which of the following should be administered immediately?
(A) Glucose
(B) Haloperidol
(C) Lorazepam
(D) Naltrexone
(E) Thiamine
12. Two weeks later this same patient is seen in the emergency room after
being picked up by the police for disturbing the peace and wandering. On
examination he appears confused, has nystagmus, and an unsteady gait.
Which of the following should be administered immediately?
(A) Glucose
(B) Haloperidol
(C) Lorazepam
(D) Naltrexone
(E) Thiamine
(E) Thiamine
(E) This patient appears to be experiencing Wernicke encephalopathy, a
result of chronic, heavy, alcohol use, caused by acute
thiamine deficiency. It presents classically with the triad of confusion,
oculomotor abnormalities (e.g., nystagmus), and ataxia. The treatment
is IV thiamine. While glucose is often given in an emergency setting, as
well, it is imperative to give thiamine first, as giving glucose
before thiamine may worsen the encephalopathy. Haloperidol, a typical
antipsychotic, is not indicated as the patient is neither psychotic nor
agitated, and will not help the underlying condition. Neither lorazepam,
a benzodiazepine used in acute alcohol withdrawal, nor naltrexone, an
opiate antagonist used to reduce alcohol craving, will
appropriately treat Wernicke encephalopathy.
13. A 36-year-old man presents to the emergency department after being
found without clothing in the street. He has multiple excoriations all
over his body, is paranoid and agitated, and states that bugs are
crawling all over him. His vitals are as follows: T-99.1, BP-160/ 93, P105, R-20. Which of the following substances would be most likely
found in his laboratory results?
(A) Alcohol
(B) Cannabis
(C) Cocaine
(D) Opiates
(E) PCP
13. A 36-year-old man presents to the emergency department after being
found without clothing in the street. He has multiple excoriations all
over his body, is paranoid and agitated, and states that bugs are
crawling all over him. His vitals are as follows: T-99.1, BP-160/ 93, P105, R-20. Which of the following substances would be most likely
found in his laboratory results?
(A) Alcohol
(B) Cannabis
(C) Cocaine
(D) Opiates
(E) PCP
(C). Cocaine
This patient presents with disorganized behavior,
agitation, paranoia, and formication (a particular type of tactile
hallucination in which one has the sensation of bugs crawling on or
under the skin), as well as elevated vital signs and dilated pupils. These
are all consistent with acute cocaine intoxication. Intoxication with
alcohol presents with decreased level of consciousness, decreased vital
signs, slurred speech, and poor coordination. Cannabis intoxication can
present with paranoia and tachycardia, although not usually
agitation or formication.
(C). Cocaine
Opiate use classically presents with a decreased level of
consciousness, diminished vitals, pinpoint pupils, dry skin, and
constipation.
Patients who use PCP may be quite agitated and paranoid, as well as
have signs of sympathetic stimulation, but they often present with
ataxia, fever, and nystagmus (vertical, horizontal, or rotary).
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
1. A 32-year-old single, male with
injected conjunctiva can’t
concentrate at work,
laughs readily at his coworkers’
doodles, feels “relaxed,” and
speaks slowly while
seemingly focused on the air in
front of him.
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
2. A 45-year-old separated male
admitted for depression and
suicidal ideation is irritable, asks
for extra food, and spends most
of the first day sleeping. The chest
pain he had on admission has
subsided and he has no ECG
changes.
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
1. A 32-year-old single, male with
injected conjunctiva can’t
concentrate at work,
laughs readily at his coworkers’
doodles, feels “relaxed,” and
speaks slowly while
seemingly focused on the air in
front of him. (G).
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
2. A 45-year-old separated male
admitted for depression and
suicidal ideation is irritable, asks
for extra food, and spends most
of the first day sleeping. The chest
pain he had on admission has
subsided and he has no ECG
changes. (J).
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
3. A 27-year-old graduate student
woke up late and skipped
breakfast. She now has a
massive headache and is irritable
when she walks into her first
morning class. She feels like
falling asleep and as if she
“has the flu” by the end of the
morning.
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
4. A veterinarian technician
is brought to
the emergency department after
attacking what he thought was a
cougar (it was a housecat). In the
emergency room he is febrile,
appears panicked, has nystagmus,
and demonstrates unexpected
strength and rage.
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
3. A 27-year-old graduate student
woke up late and skipped
breakfast. She now has a
massive headache and is irritable
when she walks into her first
morning class. She feels like
falling asleep and as if she
“has the flu” by the end of the
morning. (F).
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
4. A veterinarian
technician is brought to
the emergency department after
attacking what he thought was a
cougar (it was a housecat). In the
emergency room he is febrile,
appears panicked, has nystagmus,
and demonstrates unexpected
strength and rage. (O).
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
5. After recess, a junior high
school student smells “funny,” is
stumbling, feels dizzy and
nauseated, yet remains smiling
and says she feels “such a rush.”
By the middle of her next class
she has a headache but otherwise
feels like she did this morning.
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
6.On the third postoperative day
your 63-year-old patient becomes
agitated, demands you remove
the snakes from his room,
and asks why it is so loud at night
(it is daytime). He is tachycardic,
hypertensive, and tremulous.
Match each
scenario
(A) Alcohol intoxication
(B) Alcohol withdrawal
(C) Amphetamine intoxication
(D) Amphetamine withdrawal
(E) Caffeine intoxication
(F) Caffeine withdrawal
5. After recess, a junior high
school student smells “funny,” is
stumbling, feels dizzy and
nauseated, yet remains smiling
and says she feels “such a rush.”
By the middle of her next class
she has a headache but otherwise
feels like she did this morning. (L).
(G) Cannabis intoxication
(H) Cannabis withdrawal
(I) Cocaine intoxication
(J) Cocaine withdrawal
(K) Hallucinogen intoxication
(L) Inhalant intoxication
(M) Opioid intoxication
(N) Opioid withdrawal
(O) Phencyclidine intoxication
6.On the third postoperative day
your 63-year-old patient becomes
agitated, demands you remove
the snakes from his room,
and asks why it is so loud at night
(it is daytime). He is tachycardic,
hypertensive, and tremulous. (B).
14. Which of the following medications would be the most useful as
a behavioral modifier to decrease his alcohol use?
(A) Acamprosate
(B) Disulfiram
(C) Flumazenil
(D) Naloxone
(E) Naltrexone
14. Which of the following medications would be the most useful as
a behavioral modifier to decrease his alcohol use?
(A) Acamprosate
(B) Disulfiram
(C) Flumazenil
(D) Naloxone
(E) Naltrexone
(B) Disulfiram
The metabolism of ethyl alcohol involves a two-step enzymatic process.
The first enzyme, alcohol dehydrogenase, metabolizes ethanol to
acetaldehyde, which is quickly metabolized by aldehyde
dehydrogenase. Disulfiram inhibits aldehyde dehydrogenase, resulting
in accumulation of acetaldehyde. Acetaldehyde causes facial flushing,
tachycardia, hypotension, nausea and vomiting, and physical
discomfort. Therefore, a patient on disulfiram has an incentive to
remain abstinent. Disulfiram works only if patients continue to take it.
Acamprosate (a GABAergic agonist) and naltrexone (an opioid
antagonist) are both used to reduce cravings for alcohol.
15. Further history reveals that he does not have a mood disorder. He tells
you that often he simply cannot control his craving to have another drink.
Which of the following agents would be the most likely to decrease his
cravings for alcohol?
(A) Bupropion
(B) Disulfiram
( C) Flumazenil
(D) Naloxone
(E) Naltrexone
15. Further history reveals that he does not have a mood disorder. He tells
you that often he simply cannot control his craving to have another drink.
Which of the following agents would be the most likely to decrease his
cravings for alcohol?
(A) Bupropion
(B) Disulfiram
( C) Flumazenil
(D) Naloxone
(E) Naltrexone
(E) Naltrexone
Multiple neurotransmitter systems have been investigated in attempts
to control alcohol cravings. One system that likely plays a role in
the reward pathway is the opioid system. Naltrexone is an opioid
antagonist that has been shown to decrease the number of days a
person with alcohol use disorder drinks and to increase the time
before relapse of heavy drinking.
16. You are the consult-liaison psychiatrist on call for the trauma surgery
team. You are asked to evaluate a 39-year-old man who was hit by a car
and severely injured. He is unable to give a history, but an acquaintance
who accompanied the patient to the hospital reports that he is a daily,
heavy drug user. On examination, the patient is noted to have track
marks on his arms. Which of the following classes of drugs do you tell the
surgeon is the most dangerous if abruptly withdrawn?
(A) Cannabinoids
(B) Hallucinogens
(C) Opiates
(D) Sedative-hypnotics
(E) Stimulants
16. You are the consult-liaison psychiatrist on call for the trauma surgery
team. You are asked to evaluate a 39-year-old man who was hit by a car
and severely injured. He is unable to give a history, but an acquaintance
who accompanied the patient to the hospital reports that he is a daily,
heavy drug user. On examination, the patient is noted to have track
marks on his arms. Which of the following classes of drugs do you tell the
surgeon is the most dangerous if abruptly withdrawn?
(A) Cannabinoids
(B) Hallucinogens
(C) Opiates
(D) Sedative-hypnotics
(E) Stimulants
(D) Sedative-hypnotics
Cessation or reduction in sedative, hypnotic, or anxiolytic medications
that have been used heavily or for a prolonged period of time may
result in a withdrawal syndrome characterized by symptoms that
develop within hours to a few days after cessation or reduction.
Autonomic hyperactivity, orthostatic hypotension, muscle weakness,
tremor, insomnia, nausea, vomiting, auditory/visual/tactile
hallucinations, agitation or anxiety may occur. By far the most serious
sequelae are grand mal seizures of delirium. Usually grand mal
seizures develop on the second or third day of withdrawal and many
have more than one seizure. Delirium may develop between the third
and eight day. Minor symptoms may persist for up to 4 weeks.
17. A patient with cocaine use disorder is subsequently admitted to a
detoxification unit in the hospital. After his euphoria and paranoia resolve, he
is able to give a more complete history. He describes a 5-year history of
almost daily crack cocaine use, with no periods of sobriety lasting for greater
than several weeks. During these periods, he felt “depressed,” with an
increased appetite, disrupted sleep, difficulty concentrating, and fatigue. He
denies alcohol or other drug use, and his psychiatric review of systems is
otherwise negative. Which of the following would be the most appropriate
initial treatment for this patient?
A. Antidepressant
B. Dopamine antagonist
C. Dopamine agonist
D. Mood stabilizer
E. Narcotics Anonymous
17. A patient with cocaine use disorder is subsequently admitted to a
detoxification unit in the hospital. After his euphoria and paranoia resolve, he
is able to give a more complete history. He describes a 5-year history of
almost daily crack cocaine use, with no periods of sobriety lasting for greater
than several weeks. During these periods, he felt “depressed,” with an
increased appetite, disrupted sleep, difficulty concentrating, and fatigue. He
denies alcohol or other drug use, and his psychiatric review of systems is
otherwise negative. Which of the following would be the most appropriate
initial treatment for this patient?
A. Antidepressant
B. Dopamine antagonist
C. Dopamine agonist
D. Mood stabilizer
E. Narcotics Anonymous
E. Narcotics Anonymous
The most beneficial approach to cocaine addiction without additional
psychopathology is to stress abstinence and relapse-prevention.
Narcotics Anonymous meetings are easily accessible, approachable,
and provide ongoing group and individual support. No medications
have been proven to prevent cocaine cravings or relapse. While the
patient admits to depressive symptoms when abstinent from cocaine,
these symptoms are quite common (and self-limiting) during withdrawal.
Also, the time period is not typical of a major depressive disorder.
After 4 to 6 weeks of sobriety, the patient should be reevaluated
for a depressive disorder with consideration to begin an antidepressant.
18. A 55-year-old woman lives on her own. She wears odd clothes and
pokes around in her neighbors’ garbage cans. She claims to have psychic
powers but does not report hearing voices. What is the most likely
diagnosis for her condition?
A. Schizoid personality disorder
B. Schizotypal personality disorder
C. Asperger syndrome
D. Avoidant personality disorder
18. A 55-year-old woman lives on her own. She wears odd clothes and
pokes around in her neighbors’ garbage cans. She claims to have psychic
powers but does not report hearing voices. What is the most likely
diagnosis for her condition?
A. Schizoid personality disorder
B. Schizotypal personality disorder
C. Asperger syndrome
D. Avoidant personality disorder
B. Schizotypal personality disorder
Schizotypal personality disorder is characterized by discomfort in close
relationships, cognitive and perceptual distortions, and
eccentric behavior. This pattern begins in early adulthood and is
present in a variety of contexts. Persons with schizotypal personality
disorder usually have ideas of reference. They may also
be superstitious or preoccupied with paranormal phenomena outside
the norms of the subculture.
19. Which of the following is true about personality disorders?
A. They rarely cause subjective distress.
B. They mellow with age.
C. They respond well to treatment.
D. They cause little or no impairment in functioning.
19. Which of the following is true about personality disorders?
A. They rarely cause subjective distress.
B. They mellow with age.
C. They respond well to treatment.
D. They cause little or no impairment in functioning.
B. They mellow with age
Personality disorders are characterized by deeply ingrained, inflexible
patterns of behavior. They cause conflict in relationships and impaired
adaptive functioning. They usually cause subjective distress. The
pervasive personality traits are evident by adolescence and persist
throughout adult life, though the features tend to mellow
or ameliorate with age.
20. Which of the following is characteristic of persons with paranoid
personality
disorder?
A. Obsession
B. Psychotic behavior
C. Litigiousness
D. Anxiety
20. Which of the following is characteristic of persons with paranoid
personality
disorder?
A. Obsession
B. Psychotic behavior
C. Litigiousness
D. Anxiety
C. Litigiousness
C. People with paranoid personality disorder show marked
suspiciousness of others and are extremely sensitive to any potential
threat or injustice. They look for any hidden motives or meanings and
are selfrighteous and quite litigious.
21. Which of the following statements regarding alcohol's effect on sleep
is false?
A. Heavy drinkers often awaken at night and have difficulty going back to
sleep.
B. Alcoholics tend to have more dreams later in the night.
C. Alcohol increases rapid eye movement (REM) sleep.
D. Alcohol can significantly impair normal sleep patterns.
E. Alcohol use tends to inhibit stage 4 sleep.
21. Which of the following statements regarding alcohol's effect on sleep
is false?
A. Heavy drinkers often awaken at night and have difficulty going back to
sleep.
B. Alcoholics tend to have more dreams later in the night.
C. Alcohol increases rapid eye movement (REM) sleep.
D. Alcohol can significantly impair normal sleep patterns.
E. Alcohol use tends to inhibit stage 4 sleep.
C. Alcohol increases REM sleep
Alcohol intoxication can help a person fall asleep more quickly, but if the
intake in an evening is more than one or two drinks, the sleep pattern can be
significantly impaired. Most heavy drinkers awaken after several hours and can
have problems falling back asleep. Alcohol also tends to depress rapid eye
movements (REMs) and inhibit stage 4 sleep and thus is likely to be associated
with frequent alternations between sleep stages (sleep fragmentation) and with
more dreams late in the night as the blood alcohol level decreases. Exaggerated
forms of similar problems are seen in alcoholics in whom sleep stages might not
return to normal for 3 or more months after abstinence.
22. In distinguishing schizophrenia from amphetamine-induced toxic
psychosis, the presence of which of the following is most helpful?
A. tactile or visual hallucinations
B. paranoid delusions
C. intact orientation
D. clear consciousness
E. auditory hallucinations
22. In distinguishing schizophrenia from amphetamine-induced toxic
psychosis, the presence of which of the following is most helpful?
A. tactile or visual hallucinations
B. paranoid delusions
C. intact orientation
D. clear consciousness
E. auditory hallucinations
22. In distinguishing schizophrenia from amphetamine-induced toxic
psychosis, the presence of which of the following is most helpful?
A. tactile or visual hallucinations
B. paranoid delusions
C. intact orientation
D. clear consciousness
E. auditory hallucinations
A. Tactile or visual hallucinations
Amphetamine-induced toxic psychosis can be exceedingly difficult to differentiate
from schizophrenia and other psychotic disorders characterized by hallucinations
or delusions. Paranoid delusions occur in about 80 percent of patients and
hallucinations in 60 to 70 percent. Consciousness is clear, and disorientation
is uncommon. The presence of vivid visual or tactile hallucinations should raise
suspicion of a drug-induced disorder. In areas where and populations in whom
amphetamine use is common, it may be necessary to provide only a provisional
diagnosis until the patient can be observed and drug test results are obtained.
23. Minor signs and symptoms of the benzodiazepine discontinuation
syndrome commonly include
A. hyperpyrexia
B. grand mal seizures
C. psychosis
D. nightmares
E. death
23. Minor signs and symptoms of the benzodiazepine discontinuation
syndrome commonly include
A. hyperpyrexia
B. grand mal seizures
C. psychosis
D. nightmares
E. death
23. Minor signs and symptoms of the benzodiazepine discontinuation
syndrome commonly include
A. hyperpyrexia
B. grand mal seizures
C. psychosis
D. nightmares
E. death
D.nightmares
Minor symptoms include anxiety, insomnia, and nightmares. Major
symptoms (which are extremely rare) include grand mal seizures,
psychosis, hyperpyrexia, and death.
24. Inhalant use most often correlates with which of the following
comorbid
conditions?
A. Borderline personality disorder
B. Conduct disorder
C. Major depression
D. Manic episode
E. Schizophrenia
24. Inhalant use most often correlates with which of the following
comorbid
conditions?
A. Borderline personality disorder
B. Conduct disorder
C. Major depression
D. Manic episode
E. Schizophrenia
B. Conduct disorder
People with adolescent conduct disorder or adult antisocial personality
disorder are prone to taking extreme risks, and many inhalant users
have these disorders. Several studies suggest an association of inhalant
use and conduct problems.
25. Cocaine
A. competitively blocks dopamine reuptake by the dopamine
transporter.
B. does not lead to physiological dependence.
C. does not induce psychotic disorders.
D. has been used by 40 percent of the United States population since
1991
E. is no longer used as a local anesthetic
25. Cocaine
A. competitively blocks dopamine reuptake by the dopamine
transporter.
B. does not lead to physiological dependence.
C. does not induce psychotic disorders.
D. has been used by 40 percent of the United States population since
1991
E. is no longer used as a local anesthetic
A. competitively blocks dopamine reuptake by
the dopamine transporter.
Cocaine competitively blocks dopamine reuptake by the dopamine transporter. This
primary pharmacodynamic effect is believed to be related to cocaine's behavioral
effects, including elation, euphoria, heightened self-esteem, and perceived
improvement on mental and physical tasks. Cocaine does lead to physiological
dependence, although cocaine withdrawal is mild compared with the effects of
withdrawal from opiates and opioids. A psychological dependence on cocaine can
develop after a single use because of its potency as a positive reinforcer of
behavior. Cocaine-induced psychotic disorders are most common in intravenous
users and crack users, not in those who snort cocaine.
26. A pervasive pattern of grandiosity, lack of empathy, and need for
admiration suggests the diagnosis of which of the following personality
disorders?
A. Borderline
B. Narcissistic
C. Paranoid
D. Passive-aggressive
E. Schizotypal
26. A pervasive pattern of grandiosity, lack of empathy, and need for
admiration suggests the diagnosis of which of the following personality
disorders?
A. Borderline
B. Narcissistic
C. Paranoid
D. Passive-aggressive
E. Schizotypal
B. Narcissistic
A pervasive pattern of grandiosity (in fantasy or behavior), lack of empathy,
and need for admiration suggests the diagnosis of narcissistic personality
disorder. The fantasies of narcissistic patients are of unlimited success,
power, brilliance, beauty, and ideal love; their demands are for constant
attention and admiration. Patients with narcissistic personality disorder are
indifferent to criticism or respond to it with feelings of rage or humiliation.
Other common characteristics are interpersonal exploitiveness and a sense
of entitlement, surprise, and anger that people do not do what the patient
wants.
27. The defense mechanism most often associated with paranoid
personality
disorder is
A. splitting
B. projection
C. isolation
D. hypochondriasis
E. dissociation
27. The defense mechanism most often associated with paranoid
personality
disorder is
A. splitting
B. projection
C. isolation
D. hypochondriasis
E. dissociation
B. Projection
The defense mechanism most often associated with paranoid
personality disorder is projection. The patients externalize their own
emotions and attribute to others impulses and thoughts that they are
unable to accept in themselves. Excessive fault finding, sensitivity to
criticism, prejudice, and hypervigilance to injustice can all be
understood as examples of projecting unacceptable impulses and
thoughts onto others.
28. Mr. S was a 45-year-old postal service employee who was evaluated
at a clinic specializing in the treatment of depression. He claimed to have
felt
constantly depressed since the first grade without a period of
normal mood for more than a few days at a time. His depression was
accompanied by lethargy; little or no interest or pleasure in anything;
trouble in concentrating; and feelings of inadequacy, pessimism, and
resentfulness. His only periods of normal mood occurred when he was
home alone, listening to music or watching TV. On further questioning,
Mr. S revealed that he could never remember feeling comfortable socially.
Even before kindergarten, if he was asked to speak in front of a group of
family friends, his mind would go blank. He felt overwhelming
anxiety at children's social functions, such as birthday parties, which he
either avoided or attended in total silence.
He could answer questions in class only if he wrote down the answers in
advance; even then, he frequently mumbled and could not get the
answer out. He met new children with his eyes lowered, fearing their
scrutiny, expecting to feel humiliated and embarrassed. He was
convinced that everyone around him thought he was \"dumb or a jerk.\"
The best diagnosis in the patient above is:
A. adjustment disorder with anxiety
B. avoidant personality disorder
C. schizoid personality disorder
D. schizotypal personality disorder
E. social phobia
He could answer questions in class only if he wrote down the answers in
advance; even then, he frequently mumbled and could not get the
answer out. He met new children with his eyes lowered, fearing their
scrutiny, expecting to feel humiliated and embarrassed. He was
convinced that everyone around him thought he was \"dumb or a jerk.\"
The best diagnosis in the patient above is:
A. adjustment disorder with anxiety
B. avoidant personality disorder
C. schizoid personality disorder
D. schizotypal personality disorder
E. social phobia
B. Avoidant personality disorder
The best diagnosis is avoidant personality disorder. Although feeling constantly
depressed caused Mr. S to seek treatment, the pervasive pattern of social
avoidance, fear of criticism, and lack of close peer relationships was of equal
importance. Persons with avoidant personality show an extreme sensitivity to
rejection, which may lead to social withdrawal. They are not asocial but are shy
and show a great desire for companionship; they need unusually strong guarantees
of uncritical acceptance. In the case presented, the patient exhibited a
long-standing pattern of difficulty in relating to others. Persons with schizoid
personality disorder do not evince the same strong desire for affection and
acceptance; they want to be alone.
29. You are asked to see a 42-year-old male patient on a surgical ward
who had a major operation 2 days ago and is now exhibiting bizarre
behavior. He expresses fears that aliens are coming to take him away and
appears to be responding to hallucinations. On examination he is
tremulous and sweating but appears oriented and denies any
hallucinations. His laboratory workup is subnormal with increased MCV
and GGT. What is the most likely cause of his symptoms?
A. Alcohol withdrawal
B. Schizophrenia
C. Severe depression
D. Delirium tremens
E. Alcoholic hallucinosis
29. You are asked to see a 42-year-old male patient on a surgical ward
who had a major operation 2 days ago and is now exhibiting bizarre
behavior. He expresses fears that aliens are coming to take him away and
appears to be responding to hallucinations. On examination he is
tremulous and sweating but appears oriented and denies any
hallucinations. His laboratory workup is subnormal with increased MCV
and GGT. What is the most likely cause of his symptoms?
A. Alcohol withdrawal
B. Schizophrenia
C. Severe depression
D. Delirium tremens
E. Alcoholic hallucinosis
D. Delirium tremens
The symptoms described are strongly suggestive of delirium tremens.
Such symptoms can arise in patients being admitted to the
hospital for an operation and hence abstaining from alcohol. The
clinical features are clouding of consciousness, difficulty sustaining
attention, disorientation, autonomic hyperactivity with tachycardia,
excess sweating, and lability of blood pressure. Patients also have
fleeting delusions and hallucinations. The symptoms should resolve
with adequate treatment.
30. A 20-year-old college student is brought into the emergency room
after a party. He has tenting of the skin on the backs of his hands, is
nauseated, and vomits, acts seductively toward the nursing staff, and
thinks the security guards are out to kill him. He tells you: "The one with
the red hair is out to slay me." The emergency medical technician tells
you the patient apparently collapsed while dancing at a party. What
substance has he most likely taken?
A. Cannabis
B. Ketamine
C. Diacetylmorphine
D. Methylenedioxyamphetamine (MDMA)
E. Inhalants
30. A 20-year-old college student is brought into the emergency room
after a party. He has tenting of the skin on the backs of his hands, is
nauseated, and vomits, acts seductively toward the nursing staff, and
thinks the security guards are out to kill him. He tells you: "The one with
the red hair is out to slay me." The emergency medical technician tells
you the patient apparently collapsed while dancing at a party. What
substance has he most likely taken?
A. Cannabis
B. Ketamine
C. Diacetylmorphine
D. Methylenedioxyamphetamine (MDMA)
E. Inhalants
D. MDMA
Methylenedioxyamphetamine (MDMA) is also known as ecstasy. It is in the amphetamine family and is a
common drug of abuse at clubs and raves. Symptoms of intoxication with amphetamines include euphoria,
changes in sociability, hypervigilance, changes in interpersonal sensitivity, anxiety, anger, and impaired
judgment. Amphetamines can induce a psychosis that includes paranoia, hyperactivity, and hypersexuality.
Physical effects include fever, headache, cyanosis, vomiting (leading to dehydration), shortness of
breath, ataxia, and tremor. More serious effects can include myocardial infarction, severe hypertension,
and ischemic colitis. Cannabis intoxication presents as impaired coordination, euphoria or anxiety, sense
of slowed time, social withdrawal, and impaired judgment. Physical signs include conjunctival injection,
increased appetite, tachycardia, and dry mouth. Ketamine is a relative of PCP. Intoxication presents as
belligerence, impulsivity, psychomotor agitation, and impaired judgment. Physical signs include nystagmus,
hypertension, ataxia, dysarthria, or muscle rigidity. Psychosis may be present and can persist for up to
2 weeks after intoxication.
D. MDMA
Diacetylmorphine is heroin. Intoxication results in euphoria followed by
apathy, psychomotor agitation or retardation, impaired judgment,
pupillary dilation, sedation, slurred speech, and impaired attention or
memory. Volatile inhalant intoxication presents as belligerence,
assaultiveness, apathy, impaired judgment, dizziness, nystagmus,
impaired coordination, unsteady gait, lethargy, tremor, psychomotor
retardation, muscle weakness, euphoria, or coma. Low doses of these
substances can cause feelings of euphoria. High doses can cause
paranoia, fearfulness, and hallucinations.
31. On your drive in to work you wonder if you will encounter any violent
patients during your day. If you encounter the following types of patients
today, which group of patients is the most likely to attack you?
A. Bipolar patients
B. Schizophrenic patients
C. Borderline patients
D. Substance abusers
E. Major depressive disorder patients
31. On your drive in to work you wonder if you will encounter any violent
patients during your day. If you encounter the following types of patients
today, which group of patients is the most likely to attack you?
A. Bipolar patients
B. Schizophrenic patients
C. Borderline patients
D. Substance abusers
E. Major depressive disorder patients
D. Substance abusers
Substance abusers have the highest risk of becoming violent. Large doses of
alcohol promote aggression, as do large doses of barbiturates. Paradoxical
aggression can be observed with anxiolytics. Opioid dependence is
associated with increased aggression. Stimulants, cocaine, hallucinogens,
and sometimes cannabis can also lead to aggression. Aggressive behavior is
more likely with those who have become acutely
psychologically decompensated. More than half of people who commit
homicide and engage in assaultive behavior are under the influence of
significant amounts of alcohol at the time the crime is committed.
Although many major psychiatric disorders can lead to aggression, you are
more likely to face substance-induced aggression simply because of the
sheer number of cases of aggression and violence that are substanceinduced.
Any questions?