1. Answer: D. Alcohol abuse/dependence is thought to result from the interaction of genetic and environmental factors. History of alcohol problems in biological relatives increases the risk of alcoholism even when nonalcoholic parents raise them. If the biological relatives of a child are nonalcoholics, however, the risk is not increased if the adoptive parents are alcoholics. History of other substance abuse, PTSD, and attention-deficit hyperactivity disorder is found to increase the risk of alcohol abuse or dependence.

2. Answer: E. Alcohol withdrawal symptoms can result in serious medical complications, which can be life threatening. Some of the recognized medical complications include tremors, delirium, seizures, hypertension, hypomagnesemia, coma, agitation, and autonomic hyperactivity. Hypoglycemia (hyperglycemia) is commonly seen in patients with alcohol intoxication and withdrawal.

3. Answer: E. Miller and Rollnick proposed the motivational interview to assess the patient’s motivation to change, which is often used in the treatment of subjects with substance abuse/dependence. According to this theory, there are five stages that help to understand patient’s reasons for seeking treatment and help clinicians make effective interventions. The stages are precontemplation, contemplation, determination, action, and maintenance.

4. Answer: D. Opiate withdrawal symptoms can be very uncomfortable with symptoms of rhinorrhea, lacrimation, nausea, vomiting, diarrhea, yawning, sweating, and irritability. Flashbacks, however, is not a symptom of opiate withdrawal. It is associated with hallucinogen abuse.

5. Answer: E. HPPD is recognized in the DSM-IV and has a distinct code. It is a rare disorder characterized by persisting perceptual disturbances following hallucinogen abuse in some individuals. The exact cause of persistence of perception problems (sometimes for years) is unknown. Visual problems are often reported and consist of halos/hues around objects. Visualization of vivid floaters as well as trails on following a moving object are also often reported. Interestingly, risperidone is found to make the symptoms worse in some individuals. Benzodiazepines are often found to be helpful.

6. Answer: A. Amotivational syndrome is a recognized feature of chronic marijuana use. It is characterized by severe fatigue, a lack of motivation and energy, as well as a lack of interests. Seizures are associated with acute alcohol withdrawal, and Wernicke’s encephalopathy is associated with chronic alcohol abuse. HPPD is associated with hallucinogen abuse in some individuals, and stroke is associated with abuse of stimulants such as cocaine and amphetamines.

7. Answer: C. Opiate intoxication is characterized by decreased level of consciousness, stupor, coma, pruritus, anorexia, miosis, and constipation. Bradycardia and not tachycardia is a feature of opiate intoxication.

8. Answer: A. Amphetamines and other stimulants such as cocaine abuse can lead to life-threatening complications including seizures, stroke, and myocardial ischemia. Mydriasis is a feature of amphetamine abuse (not miosis).

9. Answer: C. PCP intoxication can lead to violent behavior and paranoia. Often, these individuals smoke marijuana to control the agitation associated with PCP. Hyperacusis and increased pain threshold (i.e., decreased response to pain) are also noted.

10. Answer: C. PCP abuse intoxication is associated with paranoia and extreme, unpredictable violence. Hence, until PCP is cleared out of the system, it is wise not to talk the patient down. When these patients are admitted to an inpatient unit, they should be monitored closely, and the room should not be shared with other patients (again, because of extreme, intermittent undirected violence associated with PCP). PCP acts as an NMDA receptor antagonist.

11. Answer: D. Campbell de Morgan spots are small red spots that tend to occur in people older than 40 years. They are also called cherry angioma or hemangioma. They are usually not removed unless they bleed recurrently or if they are unsightly. All of the other features listed are associated with chronic alcoholism.

12. Answer: B. Alcohol flush reaction, caused by aldehyde dehydrogenase deficiency is common in Asians but also occurs in some Caucasians. Degrees of flushing can range from slightly pink to bright red. The reaction has been found to be caused by a mutation in the structural gene for the mitochondrial aldehyde dehydrogenase. In addition to flushing of the face, other unpleasant effects can also occur. These include tachycardia or increased heart rate, low blood pressure, headache, hyperventilation, and nausea.

13. Answer: C. Once disulfiram is stopped, the liver has to produce enough acetaldehyde dehydrogenase to convert acetaldehyde to acetic acid. This process usually requires about 1 week after disulfiram is stopped.