SUD Flashcards

Question

A patient develops anterograde amnesia and confabulation following untreated Wernicke’s encephalopathy. What is the diagnosis? A. Delirium tremens B. Alcohol-induced dementia C. Korsakoff syndrome D. Hepatic encephalopathy E. Substance psychosis ⸻

Answer 1

✅ Correct answer: C. Korsakoff syndrome ⸻ 💡 Explanation • Chronic complication of Wernicke’s • Features: Memory impairment Confabulation ⸻ 🔥 High-yield • Often irreversible • Preventable with thiamine

Answer 2

✅ Correct answer: C. Acamprosate ⸻ 💡 Explanation • Mechanism: 👉 Modulates glutamate system • Used: 👉 After detox to maintain abstinence ⸻ 🔥 High-yield • Safe in liver disease

Answer 3

✅ Correct answer: C. Disulfiram ⸻ 💡 Explanation • Inhibits: 👉 Aldehyde dehydrogenase • Causes: Flushing Nausea Palpitations ⸻ 🔥 High-yield • Requires high motivation • Risky if non-adherent

Answer 4

✅ Correct answer: C. Opioid antagonist ⸻ 💡 Explanation • Reduces: Reward from alcohol ⸻ 🔥 High-yield • Contraindicated in: 👉 Liver disease

Answer 5

✅ Correct answer: C. Disulfiram and naltrexone ⸻ 💡 Explanation • Both: 👉 Hepatotoxic ⸻ 🔥 High-yield • Use: 👉 Acamprosate instead

Answer 6

✅ Correct answer: D. CDT (carbohydrate-deficient transferrin) ⸻ 💡 Explanation • Most specific marker of: 👉 Chronic heavy drinking ⸻ 🔥 High-yield • GGT & MCV = sensitive but less specific

Answer 7

✅ Correct answer: C. Screening for hazardous drinking ⸻ 💡 Explanation • AUDIT = 👉 Alcohol Use Disorders Identification Test • Purpose: 👉 Screening tool ⸻ 🎯 Paper B stressor ❗ They may try to trick you: • “diagnosis” → WRONG • “screening” → CORRECT ⸻ 🔥 High-yield facts • 10 questions • Covers: Intake Dependence Harm

Answer 8

✅ Correct answer: B. ≥8 ⸻ 💡 Explanation • Cut-off: 👉 ≥8 = hazardous drinking

Answer 9

✅ Correct answer: B. Opioid overdose ⸻ 💡 Explanation Classic opioid toxidrome: • ↓ Consciousness • Pinpoint pupils (miosis) • Respiratory depression ⸻ 🎯 Exam trap • Pinpoint pupils = opioids (NOT benzos) ⸻ 🔥 High-yield Paper B stressors • “RR 6” → ALWAYS opioids • “Track marks” → IV drug use clue • Resp depression = life-threatening feature

Answer 10

✅ Correct answer: B. Naloxone ⸻ 💡 Explanation • Opioid antagonist • Given: IV IM Intranasal ⸻ 🎯 Exam trap • Naloxone = acute overdose reversal • Naltrexone = relapse prevention ⸻ 🔥 High-yield Paper B stressors • “May need repeated doses” (short half-life) • Can precipitate acute withdrawal

Answer 11

✅ Correct answer: C. Methadone or buprenorphine ⸻ 💡 Explanation • Opioid substitution therapy (OST) • Reduces: • Harm • Illicit use • Mortality ⸻ 🎯 Exam trap • Do NOT detox first-line → maintain first ⸻ 🔥 High-yield Paper B stressors • “Wants to stop heroin” → OST, not detox • Methadone = full agonist • Buprenorphine = partial agonist

Answer 12

🔴 Methadone 🔬 Mechanism • Full μ-opioid agonist ⸻ ✅ Pros • Stronger effect • Better for: • Severe dependence • High tolerance ⸻ ❌ Cons (EXAM FAVOURITES) • 🔥 QT prolongation • 🔥 Overdose risk (especially early) - Methadone accumulates ->Long half-life → delayed toxicity • Sedation • Respiratory depression ⸻ 🚨 Key Paper B points • Start low → titrate slowly • Risk of accumulation (long half-life) • Needs ECG monitoring ⸻ 🧠 When exam wants methadone: • Severe dependence • Failed buprenorphine • High opioid tolerance ⸻ ⸻ 🟢 Buprenorphine 🔬 Mechanism • Partial μ-opioid agonist ⸻ ✅ Pros (VERY TESTED) • 🔥 Ceiling effect → safer in overdose • Lower respiratory depression • Less sedation ⸻ ❌ Cons • Can precipitate withdrawal if started too early • Slightly weaker effect ⸻ 🚨 Key Paper B points • Safer → preferred in: • Overdose risk • Community setting

Answer 13

🔴 1. METHADONE ✅ Starting dose (VERY HIGH-YIELD) 👉 10–30 mg daily ⸻ ✅ Titration 👉 Increase by: • 5–10 mg every few days ⸻ ✅ Typical maintenance dose 👉 60–120 mg daily ⸻ 🚨 ABSOLUTE EXAM POINTS • Start LOW → go SLOW • Peak respiratory depression occurs later than peak effect → overdose risk • Daily supervised dosing early on ⸻ 🎯 Paper B traps • Starting too high → ❌ WRONG • Rapid titration → ❌ overdose risk ⸻ ⸻ 🟢 2. BUPRENORPHINE ✅ Starting dose 👉 2–4 mg (sublingual) ⸻ ✅ Titration 👉 Increase to: • 8–16 mg daily ⸻ ✅ Max dose (commonly tested) 👉 24 mg/day ⸻ 🚨 CRUCIAL EXAM POINT 👉 Start ONLY when in withdrawal • Otherwise → ⚠️ precipitated withdrawal ⸻ 🎯 Paper B traps • Starting too early → severe withdrawal • “Last heroin use 2 hours ago” → ❌ DO NOT START ⸻ ⸻ 🔵 3. NALOXONE (OVERDOSE) ✅ Initial dose 👉 0.4–2 mg IV ⸻ ✅ Repeat dosing 👉 Every 2–3 minutes if needed ⸻ 🚨 Key points • Short half-life → may need repeat doses • Can cause acute withdrawal ⸻ 🎯 Exam trigger 👉 “Unconscious + RR 6” → GIVE NALOXONE ⸻ ⸻ 🟡 4. NALTREXONE (RELAPSE PREVENTION) ✅ Dose 👉 50 mg daily (oral) ⸻ 🚨 CRUCIAL RULE 👉 Only startq: • After 7–10 days opioid-free ⸻ 🎯 Exam trap • Starting too early → ❌ precipitated withdrawal ⸻ ⸻ 🟣 5. LOFEXIDINE (WITHDRAWAL SYMPTOMS) ✅ Dose (you don’t need exact numbers usually) 👉 Around 0.2–0.4 mg multiple times daily ⸻ 💡 What matters more: • Alpha-2 agonist • Reduces autonomic symptoms

Answer 14

✅ Correct answer: C. Partial agonist with ceiling effect ⸻ 💡 Explanation • Buprenorphine: • Partial μ-agonist • Ceiling effect → safer in overdose ⸻ 🎯 Exam trap • Safer ≠ more effective • Still causes dependence ⸻ 🔥 High-yield Paper B stressors • “Safer option” → buprenorphine • “Overdose risk concern” → choose buprenorphine

Answer 15

✅ Correct answer: C. 8–12 hours ⸻ 💡 Explanation • Short-acting opioids (e.g. heroin): 👉 Withdrawal starts 8–12 hours 🔥 High-yield Paper B stressors • Peak: 36–72 hours • Duration: ~5–7 days

Answer 16

✅ Correct answer: C. Rhinorrhoea and yawning ⸻ 💡 Explanation Withdrawal = flu-like + autonomic overactivity: • Rhinorrhoea • Lacrimation • Yawning • Sweating • Diarrhoea • Piloerection ⸻ 🎯 Exam trap • Opposite of intoxication: • Overdose → miosis • Withdrawal → mydriasis ⸻ 🔥 High-yield Paper B stressors • “Flu-like symptoms” → opioids • Not life-threatening (unlike alcohol withdrawal)

Answer 17

✅ Correct answer: B. Lofexidine ⸻ 💡 Explanation • Alpha-2 agonist • Reduces: • Noradrenergic symptoms • Autonomic hyperactivity ⸻ 🎯 Exam trap • Clonidine also works but lofexidine preferred (UK) ⸻ 🔥 High-yield Paper B stressors • “Autonomic symptoms” → lofexidine • NOT first-line for maintenance

Answer 18

✅ Correct answer: C. ECG monitoring and reduce/switch ⸻ 💡 Explanation • Methadone: 👉 QT prolongation risk • Management: • Monitor ECG • Reduce dose or switch ⸻ 🎯 Exam trap • QT prolongation = methadone classic ⸻ 🔥 High-yield Paper B stressors • “QTc ↑” → think methadone • Switch → buprenorphine

Answer 19

✅ Correct answer: C. Overdose death ⸻ 💡 Explanation • Methadone accumulates • Long half-life → delayed toxicity ⸻ 🎯 Exam trap • Early treatment = highest risk ⸻ 🔥 High-yield Paper B stressors • “Start low, go slow” • Supervised dosing initially

Answer 20

✅ Correct answer: C. Methadone or buprenorphine maintenance ⸻ 💡 Explanation • Do NOT detox in pregnancy • Maintenance reduces: • Fetal distress • Miscarriage risk ⸻ 🎯 Exam trap • Detox = dangerous in pregnancy ⸻ 🔥 High-yield Paper B stressors • “Pregnant + heroin” → maintenance ONLY • Neonatal abstinence syndrome expected

Answer 21

✅ Correct answer: C. Gradual dose reduction over months ⸻ 💡 Explanation • Benzodiazepines must be tapered slowly • Typical reduction: 👉 10–15% every 2–4 weeks ⸻ 🎯 Exam trap • Sudden stop → ❌ seizures + death risk ⸻ 🔥 High-yield Paper B stressors • Long-term use → ALWAYS taper • Diazepam preferred (long half-life) • “Wants to stop” ≠ stop immediately

Answer 22

✅ Correct answer: C. Anxiety and tremor ⸻ 💡 Explanation Withdrawal symptoms: • Anxiety • Insomnia • Tremor • Seizures (life-threatening) ⸻ 🎯 Exam trap • Opposite of intoxication: • Intoxication → sedation • Withdrawal → agitation ⸻ 🔥 High-yield Paper B stressors • Only withdrawal (with alcohol) that can kill • Think: overactive CNS

Answer 23

✅ Correct answer: C. Cocaine intoxication ⸻ 💡 Explanation Sympathomimetic toxidrome: • Dilated pupils • Tachycardia • Hypertension • Agitation ⸻ 🎯 Exam trap • Compare: • Opioids → miosis • Cocaine → mydriasis ⸻ 🔥 High-yield Paper B stressors • “Agitated + hypertensive” → stimulant • Think cocaine/amphetamines

Answer 24

✅ Correct answer: B. Myocardial infarction ⸻ 💡 Explanation Cocaine causes: • Coronary vasospasm • Arrhythmias • Stroke ⸻ 🎯 Exam trap • Even young patients → MI risk ⸻ 🔥 High-yield Paper B stressors • Chest pain + cocaine → treat as MI • Avoid beta-blockers

Answer 25

✅ Correct answer: C. Unopposed alpha stimulation ⸻ 💡 Explanation Blocking β receptors → leaves: 👉 Alpha vasoconstriction unchecked → worsens hypertension ⸻ 🎯 Exam trap • Beta-blockers = ❌ in cocaine ⸻ 🔥 High-yield Paper B stressors • Treatment = benzodiazepines instead

Answer 26

✅ Correct answer: C. Substance-induced psychosis ⸻ 💡 Explanation • Amphetamines ↑ dopamine → psychosis • Resolves with abstinence ⸻ 🎯 Exam trap • Always consider substance before schizophrenia ⸻ 🔥 High-yield Paper B stressors • “Paranoia + stimulants” → substance-induced • May need short-term antipsychotic

Answer 27

✅ Correct answer: B. Diazepam (benzodiazepines) ⸻ 💡 Explanation • Benzodiazepines: • Calm agitation • Reduce sympathetic overactivity ⸻ 🎯 Exam trap • NOT antipsychotics first-line ⸻ 🔥 High-yield Paper B stressors • “Agitated + stimulant” → benzos • Avoid restraint

Answer 28

✅ Correct answer: B. 2–6 times increased ⸻ 💡 Explanation • Dose-response relationship • Earlier use → higher risk

Answer 29

✅ Correct answer: B. Cyclical vomiting relieved by hot showers ⸻ 💡 Explanation • Chronic cannabis → vomiting • Hot showers relieve symptoms

Answer 30

✅ Correct answer: C. Cooling, benzodiazepines, supportive care ⸻ 💡 Explanation MDMA → serotonin syndrome: • Hyperthermia • Autonomic instability Management: • Cooling • Benzodiazepines • Supportive care ⸻ 🎯 Exam trap • Don’t jump to antipsychotics ⸻ 🔥 High-yield Paper B stressors • Severe cases → cyproheptadine • Always manage hyperthermia aggressively

Answer 31

✅ Correct answer: C. IV Pabrinex (thiamine) ⸻ 💡 Explanation Classic Wernicke’s encephalopathy: • Confusion • Ataxia • Ophthalmoplegia/nystagmus 👉 MUST give IV thiamine BEFORE glucose ⸻ 🎯 Exam trap • Giving glucose first → ❌ worsens Wernicke’s ⸻ 🔥 High-yield Paper B stressors • “Confusion + ataxia” → ALWAYS thiamine • IV (not oral) in acute setting

Answer 32

✅ Correct answer: B. Respiratory depression ⸻ 💡 Explanation • Methadone: • Tolerance develops to euphoria • NOT fully to respiratory depression ⸻ 🎯 Exam trap • “Therapeutic level” ≠ safe ⸻ 🔥 High-yield Paper B stressors • Early treatment phase → highest risk • Accumulation due to long half-life

Answer 33

✅ Correct answer: C. Beta-blockers ⸻ 💡 Explanation • Beta-blockers → unopposed alpha stimulation → worsens vasoconstriction ⸻ 🎯 Exam trap • Chest pain ≠ always beta-blocker ⸻ 🔥 High-yield Paper B stressors • Use: • Benzodiazepines • Nitrates

Answer 34

✅ Correct answer: C. Methadone or buprenorphine maintenance ⸻ 💡 Explanation • Detox in pregnancy → ❌ fetal distress/death • Maintenance stabilises mother and fetus ⸻ 🎯 Exam trap • “Wants to detox” → DO NOT follow patient request blindly ⸻ 🔥 High-yield Paper B stressors • Pregnancy + opioids = NEVER detox

Answer 35

✅ Correct answer: C. SSRI ⸻ 💡 Explanation • SSRIs: • Safer in overdose • Treat both depression + alcohol misuse ⸻ 🎯 Exam trap • TCAs → ❌ overdose risk ⸻ 🔥 High-yield Paper B stressors • Substance misuse + depression → SSRI first

Answer 36

✅ Correct answer: C. Flushing, nausea, vomiting, hypotension, tachycardia ⸻ 💡 Explanation • Disulfiram inhibits aldehyde dehydrogenase → acetaldehyde accumulation ⸻ 🎯 Exam trap • Looks like severe alcohol reaction ⸻ 🔥 High-yield Paper B stressors • “Aversion therapy drug” → disulfiram

Answer 37

✅ Correct answer: C. Schizophrenia (2–6× risk) ⸻ 💡 Explanation • Dose + early exposure → ↑ psychosis risk ⸻ 🎯 Exam trap • Cannabis ≠ benign ⸻ 🔥 High-yield Paper B stressors • Earlier use = worse risk

Answer 38

✅ Correct answer: B. Buprenorphine ⸻ 💡 Explanation • Buprenorphine: • Less hepatotoxic • Safer in liver disease ⸻ 🎯 Exam trap • Methadone still used but not preferred ⸻ 🔥 High-yield Paper B stressors • “Liver disease” → choose buprenorphine

Answer 39

✅ Correct answer: C. IV lorazepam and continue chlordiazepoxide ⸻ 💡 Explanation • Acute seizure → IV benzodiazepine • Continue detox regimen ⸻ 🎯 Exam trap • Don’t stop detox ⸻ 🔥 High-yield Paper B stressors • Alcohol withdrawal = seizure risk

Answer 40

✅ Correct answer: C. Seizures and death ⸻ 💡 Explanation • Benzodiazepine withdrawal: • Life-threatening • Requires slow taper ⸻ 🎯 Exam trap • Same danger as alcohol withdrawal

Answer 41

✅ Correct answer: B. Buprenorphine ⸻ 💡 Explanation (exam-focused) • Buprenorphine: • Partial μ-opioid agonist • Used for: • Detox • Maintenance ⸻ ❌ Why others are wrong • Baclofen • Alcohol dependence • ❌ Not opioids ⸻ • Bupropion • Smoking cessation • ❌ Not opioids ⸻ • Naloxone • Acute overdose reversal • ❌ NOT detox → precipitates withdrawal ⸻ • Buspirone • Anxiety • ❌ No role in opioid treatment ⸻ 🎯 Exam trap 👉 Naloxone looks tempting → but WRONG 👉 It causes withdrawal, not treatment ⸻ 🔥 High-yield Paper B stressors • “Detox / substitution” → Methadone or Buprenorphine • “Overdose” → Naloxone • “Relapse prevention (after detox)” → Naltrexone

Answer 42

✅ Correct answer: A. Affirmations MI involves the use of micro-counselling skills called OARS O - Open ended questions A - Affirmations (statements recognising the client's strengths) R - Reflections S - Summaries **Motivational interviewing** The model of motivational interviewing (MI) was introduced by William Miller in 1983, and was developed from his experience with alcoholics. It is now an evidence based method used for people with substance misuse problems. It focuses on exploring and resolving ambivalence and centres on the motivational process that facilitates change, and is based on three key elements:- Collaboration (rather than confrontation) Evocation (drawing out rather than imposing ideas) Autonomy (rather than authority) There are four principles of MI:- Express empathy (see it from the client perspective) Support self-efficacy (be positive and recognise previous successes and strengths) Roll with resistance (be impartial and avoid conflict) Develop discrepancy (help client see the discrepancy between current circumstances and future goals)

Answer 43

✅ Correct answer: D. It is a good first line treatment ⸻ 🎯 High-yield explanation (to the point) 👉 Chlordiazepoxide = long-acting benzodiazepine 👉 FIRST-LINE for alcohol withdrawal (UK practice) ✔ Prevents: • Seizures ⚡ • Delirium tremens 🧠 • Autonomic overactivity ✔ Provides smooth withdrawal due to long half-life ⸻ ❌ Why others are wrong (EXAM TRAPS 🚨) • A. High addiction potential ❌ → Not higher than others → In fact, long-acting = lower misuse risk vs short-acting (e.g. alprazolam) • B. Absorbed rapidly ❌ → Not the key feature tested → More important = long-acting • C. Highly potent ❌ → It is actually LOW potency → (Compare: lorazepam = high potency) • E. Short half-life ❌ → WRONG → long half-life = why we use it 💡 Exam pearls 🔥 Alcohol withdrawal = GABA ↓, glutamate ↑ → hyperexcitable brain → Benzos restore GABA tone 🔥 Long-acting benzos: • Smoother detox • Less rebound symptoms 🔥 CIWA-Ar scale often used for severity ⸻ 🧠 Classic exam trigger If you see: • Alcohol withdrawal • Prevent seizures • Detox regimen ➡️ Think: 👉 Chlordiazepoxide (first-line) 👉 Lorazepam if liver disease

Answer 44

✅ Correct answer: E. Midline structures are most affected ⸻ 🎯 High-yield explanation (tight & exam-focused) 👉 Wernicke’s = thiamine (vitamin B1) deficiency 👉 Affects high metabolic brain regions 💥 Key concept: MIDLINE STRUCTURES Affected areas: • Mammillary bodies 🧠 • Medial thalamus • Hypothalamus • Periaqueductal grey • Tectal plate 👉 These are midline → high metabolic demand → thiamine dependent ⸻ ❌ Why others are wrong (classic traps 🚨) • A. Prefrontal oedema ❌ → Not characteristic → Think midline, NOT cortex • B. Cerebellar vermis spared ❌ → Actually vermis can be involved (esp in alcohol-related damage) • C. Occipital cortex ❌ → No → not typical at all • D. Hypertrophy of mammillary bodies ❌ → WRONG → atrophy (especially in Korsakoff) ⸻ 🚨 ULTRA HIGH-YIELD FACTS (you WILL get tested on these) 🔥 Classic triad (only ~10% patients!): • Confusion 🧠 • Ataxia 🚶‍♂️ • Ophthalmoplegia 👁️ 🔥 Always: 👉 Give IV thiamine BEFORE glucose → Prevents precipitating Wernicke’s 🔥 Progression: • Wernicke’s → Korsakoff syndrome → Memory loss + confabulation 🔥 Mammillary body damage = memory circuit (Papez circuit)

Answer 45

✅ Correct answer: D. Vivid dreams ⸻ 🎯 High-yield explanation (to the point) 👉 Cannabis withdrawal = mainly psychological + sleep disturbance 💥 Core features: • Irritability 😤 • Anxiety 😟 • Insomnia 🌙 • Vivid dreams ⭐ (VERY characteristic) • Reduced appetite 👉 Sleep disturbance = exam keyword → vivid dreams ⸻ ❌ Why others are wrong (EXAM TRAPS 🚨) • A. Depersonalisation ❌ → Seen in intoxication / anxiety disorders, not classic withdrawal • B. Dry mouth ❌ → Cannabis intoxication (“cotton mouth”), NOT withdrawal • C. Piloerection ❌ → Think opioid withdrawal (“goosebumps”) 🧊 • E. Yawning ❌ → Again opioid withdrawal

Answer 46

✅ Correct answer: B. Schedule 2 ⸻ 🎯 High-yield explanation (tight + exam-focused) 👉 Methadone = Schedule 2 controlled drug (UK) Meaning: • ✔ Recognised medical use • ✔ High potential for abuse • ✔ Strict prescribing rules • ✔ Safe custody required 🔐 Used for: • Opioid substitution therapy (OST) • Detox + maintenance 🧠 UK Controlled Drug Schedules (MRCPsych – HIGH YIELD) Schedule 1 🚫 (No medical use) • ❌ No therapeutic use • 🔒 Cannot be prescribed • 🧪 Research only (Home Office licence) Examples: LSD, MDMA, raw opium ⸻ Schedule 2 🔐 (High control, medical use) • ✔ Prescribable (special CD prescription) • 🔒 Safe custody required • 📖 CD register required Examples: • Morphine, diamorphine • Methadone ⭐ • Cocaine • Fentanyl, pethidine • Methylphenidate • Cannabis-based products (medical) ⸻ Schedule 3 ⚠️ (Moderate control) • ✔ Prescribable • ❌ No CD register required • 🔒 Safe custody usually required Examples: • Benzodiazepines (most) • Temazepam • Buprenorphine • Barbiturates • Flunitrazepam ⸻ Schedule 4 📦 (Low control) • ✔ No special CD prescription • ❌ No safe custody • ❌ No register Split into: • Part 1: Benzos + Z-drugs → Diazepam, zolpidem, zopiclone • Part 2: Anabolic steroids → Testosterone, HCG, etc. ⸻ Schedule 5 💊 (Very low strength) • ✔ OTC / minimal restriction • ❌ No CD requirements Examples: • Low-dose codeine • Dihydrocodeine • Weak morphine preparations

Answer 47

🔴 Class A → “Most dangerous” 👉 7 years (possession) Examples: • Cocaine • Heroin • MDMA (ecstasy) • LSD • Methamphetamine • Magic mushrooms • ⚠️ Injected Class B drugs → become Class A ⸻ 🟠 Class B → “Middle tier” 👉 5 years (possession) Examples: • Cannabis • Amphetamines • Ketamine • Codeine (pure) • Barbiturates • Methylphenidate • Synthetic cannabinoids • GHB / GBL ⸻ 🟡 Class C → “Least severe” 👉 2 years (possession) Examples: • Benzodiazepines • Anabolic steroids • Gabapentin / Pregabalin • Khat • Piperazines ⚠️ Important exception: • Anabolic steroids → legal to possess for personal use 🚨 VERY HIGH-YIELD EXAM PEARLS 🔥 1. Class ≠ Schedule • Class = legal penalty • Schedule = prescribing rules 👉 They LOVE to confuse this ⸻ 🔥 2. Cannabis trick • Class B BUT Schedule 2 (medical use allowed) ⸻ 🔥 3. Benzos trick • Class C BUT Schedule 4 👉 Low control clinically, but still illegal misuse ⸻ 🔥 4. Methadone classic SBA • Class A + Schedule 2 👉 High penalty + strict prescribing ⸻ 🔥 5. Ketamine • Class B (commonly tested) 🧠 Ultra-short memory hack 👉 A = 7 years (hard drugs) 👉 B = 5 years (weed + stimulants) 👉 C = 2 years (benzos + meds)

Answer 48

**Previous Exam Question** 👉 Correct answer: E. Bladder damage ⸻ 🎯 Why this is correct (exam logic) 👉 Chronic ketamine → ketamine-induced cystitis (“ketamine bladder”) • Direct toxic effect on urothelium • Leads to: • Inflammation • Fibrosis • ↓ bladder capacity 🧠 Classic symptoms: • Urgency 🚽 • Frequency • Dysuria • Haematuria • Pelvic pain 👉 Can progress to: • Contracted bladder • Hydronephrosis • Renal damage ⸻ ❌ Why others are wrong (VERY exam-y traps) A. Cardiac arrhythmias 👉 Think cocaine / amphetamines, not ketamine ⸻ B. Nasal septum damage 👉 Think cocaine (snorting → ischemia → perforation) ⸻ C. Persistent psychosis 👉 Ketamine can cause acute dissociation/psychosis, BUT ❗ chronic hallmark = bladder toxicity, not psychosis ⸻ D. Serotonin syndrome 👉 Think: • SSRIs + MAOIs • MDMA 👉 NOT ketamine ⸻ 🚨 Ultra-high yield facts (memorise these) 🔥 Ketamine → bladder damage (MOST TESTED) 🔥 Cocaine → nasal septum perforation 🔥 Amphetamines → arrhythmias + psychosis 🔥 MDMA → serotonin syndrome + hyponatraemia 🔥 Opioids → respiratory depression + constipation

Answer 49

👉 Correct answer: E ⸻ 🎯 Core concept (VERY IMPORTANT) 👉 Benzodiazepines = FIRST-LINE always 👉 Antipsychotics = ADD-ON only (for agitation/hallucinations) ⸻ ✅ Why E is correct In delirium tremens (DT): • You treat with: • Lorazepam / diazepam → first-line • BUT if: • Severe agitation • Hallucinations 👉 You can add: • Haloperidol ⚠️ Key nuance: • Not first-line • But preferred antipsychotic IF needed ⸻ ❌ Why others are wrong (high-yield traps) A. Clonidine = as effective ❌ 👉 WRONG • Clonidine only treats autonomic symptoms • ❗ Does NOT prevent seizures or DT 👉 Benzos are superior ⸻ B. Oxazepam contraindicated ❌ 👉 COMPLETE OPPOSITE 👉 Oxazepam = SAFE in liver disease (because it uses glucuronidation, not oxidation) ⸻ C. Diazepam preferred in liver disease ❌ 👉 WRONG • Diazepam → long half-life → accumulates 👉 Avoid in liver disease ⸻ D. Clomethiazole first-line for seizures ❌ 👉 WRONG (very exam-y) • Benzodiazepines treat seizures • Clomethiazole: • Used in UK inpatient settings • NOT first-line for seizures ⸻ 🚨 ULTRA HIGH-YIELD RULES (memorise these) 🔥 Alcohol withdrawal = 👉 Benzodiazepines (always first-line) 🔥 Liver disease → use: 👉 Lorazepam or Oxazepam (“LOT drugs”) 🔥 Delirium tremens: 👉 Benzos + add haloperidol if needed 🔥 Clonidine / beta-blockers: 👉 Only adjuncts (autonomic symptoms)

Answer 50

**Previous Exam Question** 👉 Correct answer: E. Making alcohol less affordable ⸻ 🎯 Core exam concept 👉 Price ↑ → Consumption ↓ → Harm ↓ This is the STRONGEST evidence-based intervention ⸻ ✅ Why this is correct • Increasing price (e.g. Minimum Unit Pricing) • Targets heavy drinkers the most • Leads to: • ↓ overall consumption • ↓ hospital admissions • ↓ deaths 👉 This is population-level intervention with biggest impact

Answer 51

**Previous Exam Question** 👉 Correct answer: E ⸻ 🎯 Core concept (must memorise) 👉 Cannabis use → ✅ ↑ risk of psychosis ✅ Earlier onset (~2–3 years earlier) 💡 Exam number: ≈ 2.7 years earlier ⸻ ❌ Why the others are wrong (quick-fire exam logic) A. Only drug causing psychosis ❌ 👉 MANY drugs: • Amphetamines • Cocaine • Steroids • Hallucinogens ⸻ B. No risk in teenagers ❌ 👉 WRONG — BIGGEST risk group • Adolescent brain more vulnerable 🧠 • Especially high-potency THC ⸻ C. No earlier onset ❌ 👉 Opposite is true 👉 Earlier onset is a key exam fact ⸻ D. Only if inhaled ❌ 👉 Route doesn’t matter • Edibles can also cause psychosis

Answer 52

The correct answer is 252. In the UK, one unit of alcohol is defined as 10 millilitres (8 grams) of pure alcohol. A litre of a drink with 12% Alcohol by Volume (ABV) contains 120 ml of pure alcohol, which equates to 12 units. If the patient drinks 3 litres of wine per day, this amounts to 36 units daily. Over the course of a week (7 days), this would total to 252 units. 👉 Units = Volume (ml) × ABV (%) ÷ 1000 ⸻ 📍 Step 1: Convert litres → ml 3 litres = 3000 ml ⸻ 📍 Step 2: Apply formula (per day) Units per day = 👉 3000 × 12 ÷ 1000 👉 = 36 units/day ⸻ 📍 Step 3: Convert to weekly 👉 36 × 7 = 252 units/week ⸻ ✅ Final answer: 252 units ⸻ 🚨 HIGH-YIELD SHORTCUT (FASTER IN EXAM) 👉 1 litre of 12% wine = 12 units So: • 3 litres = 36 units/day • × 7 days = 252 units/week ⚡ MUCH faster — use this in the exam ⸻ 🧠 Ultra-high yield facts 🔥 1 unit = 10 ml pure alcohol 🔥 Wine (12%) → 1 litre ≈ 12 units 🔥 Beer (4%) → 1 pint ≈ 2 units 🔥 Spirits → 1 shot ≈ 1 unit ⸻ 💡 Examiner trick They LOVE to trap you with: • Daily vs weekly ❗ • Litres vs ml ❗ 👉 Always convert step-by-step

Answer 53

**Previous Exam Question** 👉 Correct answer: C. 7% ⸻ 🎯 Core fact (must memorise) 👉 Alcohol dependence → ~7% lifetime suicide risk ⸻ 🚨 Why this matters (exam logic) • Alcohol → • Disinhibition • Impulsivity • Depression comorbidity 👉 → Major risk factor for suicide ⸻ 🧠 High-yield comparisons (VERY IMPORTANT) 🔥 General population → ~1% 🔥 Alcohol dependence → ~7% 🔥 Severe depression → ~10–15% 💡 Extra exam pearls 🔥 Always assess suicide risk in: • Alcohol dependence • Withdrawal states • Post-detox period 🔥 Risk ↑ if: • Depression • Social isolation • Physical illness

Answer 54

👉 Correct answer: E. Parenteral thiamine is preferred Thiamine 200mg should be given three times daily, preferably via an intravenous route. This should be done before any carbohydrate is given. Prompt treatment is crucial and imaging used to support a diagnosis should not delay this. IV thiamine is preferred to the oral administration. There is a risk of anaphylaxis with IV thiamine and so it should only be given where facilities exist to address this. ⸻ 🎯 Core rule (ABSOLUTE EXAM RULE) 👉 Wernicke’s = IV (or IM) thiamine IMMEDIATELY NOT oral ❌ NOT delayed ❌ ⸻ ✅ Why this is correct • Oral absorption is unreliable in: • Alcohol dependence • Malnutrition 👉 So: • IV/IM thiamine = required

Answer 55

The correct answer is the Mamillary bodies. Korsakoff's syndrome, often associated with chronic alcohol abuse, is a neurological disorder that primarily affects the mamillary bodies in the brain. The mamillary bodies are part of the Papez circuit which is involved in memory formation and recall. In Korsakoff's syndrome, due to thiamine (vitamin B1) deficiency, there is a bilateral atrophy of the mamillary bodies leading to profound anterograde amnesia and confabulation.

Answer 56

✅ Correct answer: C. 93% of men and 87% of women ⸻ 💡 Explanation: Alcohol use is extremely common in the UK population 👉 Vast majority of adults have consumed alcohol ⸻ 🔥 High-yield facts: • Men drink more than women (exam trend) • High prevalence → public health burden • Important for screening in ALL patients

Answer 57

✅ Correct answer: B. 16% ⸻ 💡 Explanation: 👉 Around 16% current misuse in depression 👉 Lifetime prevalence ≈ 30% 🔥 High-yield facts: • Strong comorbidity: depression + alcohol • Alcohol worsens treatment response • Always screen with AUDIT-C

Answer 58

✅ Correct answer: C. Tolerance ⸻ 💡 Explanation: 👉 Tolerance = need ↑ dose for same effect Due to: • Receptor downregulation • Neuroadaptation ⸻ 🔥 High-yield facts: • Core feature of dependence syndrome • Opposite = sensitization (reverse tolerance) • Cross-tolerance → similar drugs (e.g. alcohol + benzos)

Answer 59

✅ Correct answer: C. Alcohol ⸻ 💡 Explanation: 👉 Alcohol withdrawal can cause: • Delirium tremens • Seizures • Autonomic instability → death ⸻ 🔥 High-yield facts: • ALSO life-threatening: benzodiazepine withdrawal 🚨 • Opioid withdrawal = uncomfortable but NOT fatal • DTs occur 48–72 hours

Answer 60

✅ Correct answer: B. Increasing price per unit ⸻ 💡 Explanation: 👉 Strongest evidence = price ↑ → consumption ↓ Taxation & minimum unit pricing work best ✔️ ⸻ 🔥 High-yield facts: • NICE favourite question 🔥 • Heavy drinkers most affected by price • Education alone = weak effect

Answer 61

✅ Correct answer: C. Lapse is brief return, relapse is return to previous pattern ⸻ 💡 Explanation: • Lapse → single/short slip • Relapse → full return to old pattern ⸻ 🔥 High-yield facts: • Lapse ≠ treatment failure ❌ • Important in CBT relapse prevention • Exams LOVE this definition distinction

Answer 62

✅ Correct answer: B. 4–12 hours ⸻ 💡 Explanation: 👉 Early withdrawal starts within hours of last drink Due to ↓ GABA + ↑ glutamate (rebound excitation) ⸻ 🔥 High-yield facts: • First symptoms: tremor, anxiety, insomnia • Can begin as early as 4 hours • Think: “same day withdrawal”

Answer 63

✅ Correct answer: B. 24–36 hours ⸻ 💡 Explanation: 👉 Peak severity = 24–36 hours This is when: • Risk of complications ↑ • Close monitoring needed ⸻ 🔥 High-yield facts: • Seizures risk highest around 12–48 hours • Peak = worst agitation, tremor, autonomic signs • Exams LOVE this timing

Answer 64

✅ Correct answer: C. Delirium tremens ⸻ 💡 Explanation: Classic DT: • Confusion + disorientation • Visual hallucinations (small animals = Lilliputian 👀) • Autonomic instability (fever, sweating) ⸻ 🔥 High-yield facts: • Occurs 48–72 hours (up to 5 days) • Medical emergency 🚨 • Mortality if untreated (5-15%) ❌ Hallucinations alone = NOT DT → need confusion ❌ DT = NOT immediate → delayed onset

Answer 65

✅ Correct answer: B. 5% ⸻ 💡 Explanation: Delirium tremens (DT) occurs in a small but high-risk subset of withdrawal cases. It’s uncommon but life-threatening, requiring urgent inpatient care. ⸻ 🔥 High-yield facts: • DT prevalence = ~5% of withdrawals • Mortality if untreated historically high (5-15%) • Always think: rare but dangerous

Answer 66

✅ Correct answer: C. Previous history of withdrawal seizures ⸻ 💡 Explanation: Previous complicated withdrawal (seizures/DT) = HIGH RISK → inpatient detox needed. ⸻ 🔥 High-yield facts: Indications for inpatient detox 🚨: • Previous withdrawal seizures or DT • Current confusion/delirium • Severe dependence • Significant physical/mental comorbidity • Poor social support / unsafe home • Wernicke risk (malnutrition) 👉 Exam shortcut: “Complicated withdrawal = admit”

Answer 67

✅ Correct answer: B. Alcohol: tremor, sweating, autonomic hyperactivity; Cocaine: fatigue, hypersomnia ⸻ 💡 Explanation: 👉 Alcohol withdrawal = hyperexcitable state 👉 Cocaine withdrawal = “crash” (opposite of intoxication) ⸻ 🔥 High-yield facts: 🧠 Alcohol withdrawal = ↑ CNS activity • Tremor • Sweating • Tachycardia / hypertension • Seizures / DT 🧠 Cocaine withdrawal = ↓ activity • Fatigue • Hypersomnia • ↑ appetite • Depression 👉 Exam trick: “Alcohol = overdrive, Cocaine = crash”

Answer 68

✅ Correct answer: E. Microcytosis ⸻ 💡 Explanation: Alcohol dependence causes macrocytosis (↑ MCV) — NOT microcytosis. Why? • Direct toxic effect on bone marrow • Folate deficiency ⸻ 🔥 High-yield facts: • ↑ MCV (macrocytosis) = classic alcohol marker • ↑ GGT = most sensitive marker 🍺 • AST > ALT (2:1 ratio) → alcoholic liver disease • ↑ bilirubin → liver dysfunction 👉 Exam trap: Microcytosis = iron deficiency (NOT alcohol)

Answer 69

✅ Correct answer: D. Oxazepam ⸻ 💡 Explanation: In liver disease, use benzodiazepines that undergo phase 2 metabolism (glucuronidation): 👉 Oxazepam (and Lorazepam) Avoid: • Diazepam • Chlordiazepoxide → require hepatic oxidation → accumulation → oversedation ⸻ 🔥 High-yield facts: 🧠 “LOT drugs” = safe in liver disease • Lorazepam • Oxazepam • Temazepam 🧠 Long-acting benzos (Diazepam, Chlordiazepoxide): • Preferred in normal liver • Avoid in cirrhosis 🧠 Disulfiram: • NOT for withdrawal ❌ • Used for relapse prevention

Answer 70

✅ Correct answer: C. Oxazepam ⸻ 💡 Explanation: Same principle: 👉 Phase 2 metabolism → safer in liver disease Oxazepam: • No active metabolites • Shorter half-life • Reduced accumulation risk ⸻ 🔥 High-yield facts: • Oxazepam = best exam answer for liver disease • Lorazepam = also correct clinically, but exams LOVE oxazepam • Avoid long-acting benzos in cirrhosis

Answer 71

✅ Correct answer: C. Gradual dose reduction over 6–12 weeks ⸻ 💡 Explanation: Benzodiazepine withdrawal can be life-threatening (seizures, delirium) → must taper slowly. Standard approach: • Convert to diazepam equivalent (long-acting) • Reduce by 10–25% every 1–2 weeks ⸻ 🔥 High-yield facts: • Abrupt stop → seizures ⚠️ • Use diazepam substitution for smoother taper • Duration: 6–12 weeks (or longer if dependent) • Symptoms: anxiety, tremor, insomnia, seizures 👉 Exam pearl: “Benzos = taper slowly or they seize”

Answer 72

✅ Correct answer: B. Cerebellar dysfunction ⸻ 🧠 EFNS Diagnostic Criteria (HIGH-YIELD) Diagnosis requires ≥2 of the following: 1. Dietary deficiency (e.g. alcoholism, malnutrition) 2. Oculomotor abnormalities (nystagmus, ophthalmoplegia) 3. Cerebellar dysfunction (ataxia) 4. Altered mental state or memory impairment ⸻ 🔥 High-yield facts: • Classic triad: Confusion Ataxia Ophthalmoplegia • But triad present in <20% → don’t rely on it 👉 Exam trick: Ataxia = cerebellar dysfunction = key criterion

Answer 73

✅ Correct answer: E. Thiamine ⸻ 💡 Explanation: This is Wernicke’s encephalopathy → emergency. 👉 Give IV thiamine immediately BEFORE glucose Why? • Glucose worsens thiamine deficiency → can precipitate Wernicke’s ⸻ 🔥 High-yield facts: • Always: THIAMINE FIRST, then glucose 🚨 • Dose: IV high-dose (e.g. 200 mg TDS) • Prevents Korsakoff syndrome (irreversible) 👉 Exam trap: Giving glucose first = WRONG ❌

Answer 74

✅ Correct answer: D. Periventricular and periaqueductal areas ⸻ 💡 Explanation: Wernicke’s encephalopathy affects **midline brain structures**, especially: • Periventricular regions • Periaqueductal grey • Mammillary bodies (most famous) • Thalamus These areas are highly metabolically active → vulnerable to thiamine deficiency ⸻ 🔥 High-yield facts: • Mammillary bodies = classic exam answer 🧠 • Also involves: Thalamus Brainstem nuclei (eye movement → ophthalmoplegia) 👉 Exam trick: “Wernicke = midline structures”

Answer 75

✅ Correct answer: D. Episodic memory ⸻ 💡 Explanation: Korsakoff syndrome causes: 👉 Severe impairment of episodic (autobiographical) memory • Anterograde amnesia → can’t form new memories • Retrograde amnesia → loss of past events BUT: • Procedural memory preserved • Working memory often relatively intact ⸻ 🔥 High-yield facts: • Korsakoff = memory disorder (NOT global dementia) • Confabulation = hallmark feature • Caused by damage to: Mammillary bodies Thalamus 👉 Exam pearl: “Can’t remember life events, but can still perform tasks”

Answer 76

✅ Correct answer: B. Momentary confabulations occur in response to memory challenges ⸻ 💡 Explanation: Confabulation in Korsakoff is: 👉 Unintentional (NOT lying ❌) 👉 Patient cannot form new memories, so the brain “fills in the gaps” Two types: • Momentary confabulation → triggered when asked questions • Spontaneous confabulation → more severe, linked to frontal damage 🧠 Example: You ask: 👉 “What did you do this morning?” Patient says: 👉 “I went to work and had meetings” (when in reality they’ve been in hospital) ⸻ 🔥 High-yield facts: • Confabulation = false memories without intent to deceive • Strongly linked to: Frontal lobe dysfunction (orbitofrontal) • Seen in: Korsakoff syndrome Frontal lobe lesions 👉 Exam trap: ❌ “Intentional lying” → WRONG ✔️ It’s unconscious gap-filling ⚠️ Important distinctions: • ❌ Not lying → no awareness of falsity • ❌ Not delusion → not fixed belief, can change • ❌ Not hallucination → not perceptual

Answer 77

✅ Correct answer: B. 25% ⸻ 💡 Explanation: Outcomes in ARBD are roughly split: • 25% → complete recovery • 25% → significant recovery • 25% → slight recovery • 25% → no recovery ⸻ 🔥 High-yield facts: • ARBD outcomes = “rule of quarters” (25% each) • Early treatment (thiamine) improves prognosis • Many patients have chronic deficits 👉 Exam pearl: “ARBD = 25% fully recover”

Answer 78

✅ Correct answer: B. Generalized cortical atrophy ⸻ 💡 Explanation: Chronic alcohol use leads to: 👉 Diffuse brain atrophy, especially: • Frontal lobes (executive dysfunction) • Limbic structures Not just focal or isolated changes → generalized pattern ⸻ 🔥 High-yield facts: • Frontal lobe predominance → poor planning, disinhibition • Also: • Ventricular enlargement • Reduced white matter volume 👉 Exam pearl: “Alcohol → diffuse cortical (especially frontal) atrophy”

Answer 79

✅ Correct answer: B. Corpus callosum ⸻ 💡 Explanation: Marchiafava-Bignami syndrome = rare complication of chronic alcoholism: 👉 Demyelination + necrosis of corpus callosum ⸻ 🔥 High-yield facts: • Seen in chronic alcoholics (classically red wine) 🍷 • Symptoms: Dementia Dysarthria Spasticity Gait disturbance 👉 Exam pearl: “Alcohol + corpus callosum = Marchiafava-Bignami”

Answer 80

✅ Correct answer: D. Immediate return to work ⸻ 💡 Explanation: Wilson’s 5-stage model: 1. Physical stabilization (thiamine, detox) 2. Assessment phase (nutrition, recovery ~3 months) 3. Therapeutic intervention (CBT, ~3 years) 4. Adjustment phase (psychosocial support) 5. Social integration (relapse prevention) 👉 “Immediate return to work” is unrealistic and NOT part of structured rehab. ⸻ 🔥 High-yield facts: • ARBD recovery = slow, staged process • Heavy focus on: • Nutrition • Cognitive rehab • Psychosocial support 👉 Exam pearl: “ARBD = long rehab, NOT rapid recovery”

Answer 81

✅ Correct answer: C. Dysexecutive syndrome ⸻ 💡 Explanation: This is frontal lobe dysfunction from chronic alcohol use: 👉 Impaired: • Planning • Decision-making • Problem-solving 👉 BUT memory relatively preserved → NOT Korsakoff ⸻ 🔥 High-yield facts: • Dysexecutive syndrome = frontal lobe damage • Korsakoff = episodic memory loss (key difference!) • Alcohol damages: • Frontal lobes → executive dysfunction • Limbic system → memory 👉 Exam pearl: “Executive problem = frontal lobe, not memory disorder”

Answer 82

✅ Correct answer: B. Cardiac failure ⸻ 💡 Explanation: Disulfiram + alcohol → severe reaction: • Hypotension • Arrhythmias • Cardiovascular collapse 👉 Dangerous in cardiac disease ⸻ 🔥 High-yield facts: • Disulfiram also contraindicated in: • Severe liver disease • Psychosis • Mechanism: 👉 Inhibits aldehyde dehydrogenase → ↑ acetaldehyde 👉 Exam pearl: “Disulfiram stresses the heart → avoid in cardiac disease”

Answer 83

✅ Correct answer: YES — absolutely contraindicated 🚫 ⸻ 💡 Explanation: Naltrexone is a pure opioid antagonist (blocks μ-opioid receptors). 👉 If you give it to someone taking opioids: • It displaces opioids from receptors • Causes acute precipitated withdrawal ⸻ ⚠️ What happens clinically? • Severe agitation • Pain • Sweating • Vomiting • Tachycardia 👉 Can be very distressing and dangerous ⸻ 🔥 High-yield Paper B facts: • Naltrexone = opioid receptor antagonist • Must be: 👉 Opioid-free for 7–10 days before starting • Contraindicated in: • Current opioid use 🚫 • Acute opioid withdrawal 🚫 ⸻ 🧠 Comparison (VERY EXAM-IMPORTANT) 👉 Alcohol relapse prevention drugs: • Naltrexone • ❌ opioids • ↓ reward from alcohol • Acamprosate • ✅ safe with opioids • ↓ craving (glutamate modulation) • Disulfiram • ❌ cardiac disease • ❌ liver disease ⸻ 🚨 Exam trap: 👉 Patient on: • Codeine / co-codamol / methadone / heroin ❌ DO NOT give naltrexone ✔️ Choose acamprosate instead

Answer 84

✅ Correct answer: B. Corpus callosum ⸻ 💡 Explanation: Marchiafava-Bignami syndrome = rare complication of chronic alcoholism: 👉 Demyelination + necrosis of corpus callosum ⸻ 🔥 High-yield facts: • Seen in chronic alcoholics (classically red wine) 🍷 • Symptoms: • Dementia • Dysarthria • Spasticity • Gait disturbance 👉 Exam pearl: “Alcohol + corpus callosum = Marchiafava-Bignami”

Answer 85

✅ Correct answer: D. Immediate return to work ⸻ 💡 Explanation: Wilson’s 5-stage model: 1. Physical stabilization (thiamine, detox) 2. Assessment phase (nutrition, recovery ~3 months) 3. Therapeutic intervention (CBT, ~3 years) 4. Adjustment phase (psychosocial support) 5. Social integration (relapse prevention) 👉 “Immediate return to work” is unrealistic and NOT part of structured rehab. ⸻ 🔥 High-yield facts: • ARBD recovery = slow, staged process • Heavy focus on: • Nutrition • Cognitive rehab • Psychosocial support 👉 Exam pearl: “ARBD = long rehab, NOT rapid recovery”

Answer 86

✅ Correct answer: C. Dysexecutive syndrome ⸻ 💡 Explanation: This is frontal lobe dysfunction from chronic alcohol use: 👉 Impaired: • Planning • Decision-making • Problem-solving 👉 BUT memory relatively preserved → NOT Korsakoff ⸻ 🔥 High-yield facts: • Dysexecutive syndrome = frontal lobe damage • Korsakoff = episodic memory loss (key difference!) • Alcohol damages: • Frontal lobes → executive dysfunction • Limbic system → memory 👉 Exam pearl: “Executive problem = frontal lobe, not memory disorder”

Answer 87

✅ Correct answer: B. Cardiac failure ⸻ 💡 Explanation: Disulfiram + alcohol → severe reaction: • Hypotension • Arrhythmias • Cardiovascular collapse 👉 Dangerous in cardiac disease ⸻ 🔥 High-yield facts: • Disulfiram also contraindicated in: • Severe liver disease • Psychosis • Mechanism: 👉 Inhibits aldehyde dehydrogenase → ↑ acetaldehyde 👉 Exam pearl: “Disulfiram stresses the heart → avoid in cardiac disease”

Answer 88

✅ Correct answer: C. Acamprosate ⸻ 💡 Explanation: This question is testing contraindications logic 🔥 • Naltrexone ❌ → contraindicated with opioids (co-codamol) • Disulfiram ❌ → contraindicated in cardiac disease • 👉 Leaves Acamprosate ✔️ Mechanism: • Modulates glutamate (NMDA) → reduces craving ⸻ 🔥 High-yield facts: • Acamprosate = safest option in many comorbidities • Naltrexone → avoid if opioids 🚫 • Disulfiram → avoid cardiac + liver disease 👉 Exam trick: Eliminate based on contraindications → pick safest remaining ⸻ 🚨 ULTRA-HIGH-YIELD MINI-SUMMARY • Frontal dysfunction → dysexecutive syndrome • Disulfiram → ❌ cardiac disease • Naltrexone → ❌ opioids • Acamprosate → ✅ safest default

Answer 89

✅ Correct answer: B. Opioid receptor antagonist ⸻ 💡 Explanation: Naltrexone works by blocking μ-opioid receptors, which: • Reduces dopamine release in the reward pathway • Decreases the euphoric effect of alcohol • Leads to reduced craving + relapse prevention 👉 Alcohol partly acts via endogenous opioids → dopamine reward system 👉 Naltrexone interrupts this pathway ⸻ ❌ Why others are wrong: • A. GABA agonist → that’s benzodiazepines / alcohol itself • C. Glutamate modulator → that’s acamprosate • D. Acetaldehyde dehydrogenase inhibitor → that’s disulfiram • E. Dopamine antagonist → antipsychotics, not used here ⸻ 🔥 High-yield Paper B facts: • Naltrexone: • ↓ reward (not aversion) • ↓ craving + heavy drinking days • Works in: 👉 Alcohol dependence 👉 Opioid dependence (relapse prevention) • Must: 👉 Be opioid-free 7–10 days (or → precipitated withdrawal 🚨)

Answer 90

✅ Correct answer: C. Both alcohol and opioid dependence ⸻ 💡 Explanation: Naltrexone blocks opioid receptors → reduces: • Alcohol reward (via endogenous opioids) • Opioid effects directly 👉 Therefore used in BOTH conditions ⸻ ❌ Why others are wrong: • A / B → incomplete • D / E → no role ⸻ 🔥 High-yield Paper B facts: • Alcohol: 👉 ↓ craving + relapse • Opioids: 👉 Prevents relapse ONLY after detox 🚫 Not used in: • Active opioid use • Withdrawal phase

Answer 91

✅ Correct answer: B. Inhibits aldehyde dehydrogenase ⸻ 💡 Explanation: Disulfiram blocks aldehyde dehydrogenase, leading to: 👉 ↑ acetaldehyde when alcohol is consumed → toxic accumulation This causes: • Flushing • Nausea • Vomiting • Palpitations 👉 Creates aversion to alcohol ⸻ ❌ Why others are wrong: • A → naltrexone • C → acamprosate • D → benzos • E → antipsychotics ⸻ 🔥 High-yield Paper B facts: • Disulfiram = aversion therapy • Requires: 👉 Motivated patient • Contraindicated in: 👉 Cardiac disease 👉 Severe liver disease

Answer 92

✅ Correct answer: B. Piloerection, anxiety, abdominal cramps ⸻ 💡 Explanation: Early opioid withdrawal = sympathetic overactivity Key early features: • Anxiety 😰 • Piloerection (“goosebumps”) • Abdominal cramps • Yawning • Lacrimation • Rhinorrhoea 👉 Later features: • Diarrhoea • Muscle aches • Dilated pupils ⸻ ❌ Why others are wrong: • A → opioid intoxication (miosis, sedation, constipation) • C → opioid effect (not withdrawal) • D → cocaine withdrawal • E → autonomic features but less specific than B ⸻ 🔥 High-yield Paper B facts: • Opioid withdrawal = NOT life-threatening (unlike alcohol 🚨) • Pupils: 👉 Dilated in withdrawal 👉 Pinpoint in overdose • Timeline: 👉 Short-acting (heroin): starts 6–12 hrs

Answer 93

✅ Correct answer: B. Pinpoint pupils, respiratory depression, decreased consciousness ⸻ 💡 Explanation: Classic opioid overdose triad: 👉 Miosis (pinpoint pupils) 👉 Respiratory depression 👉 Reduced consciousness 🚨 This is a medical emergency ⸻ ❌ Why others are wrong: • A → stimulant intoxication • C → not opioid • D → alcohol/benzo intoxication • E → withdrawal state ⸻ 🔥 High-yield Paper B facts: • Treatment: 👉 Naloxone (short-acting opioid antagonist) • May need: 👉 Repeated doses (short half-life) • Always: 👉 Airway + breathing first (ABCDE)

Answer 94

✅ Correct answer: A. Naloxone ⸻ 💡 Explanation: This presentation = opioid toxicity 👉 Naloxone: • Rapidly reverses respiratory depression • Short-acting → may need repeat dosing ⸻ ❌ Why others are wrong: • B. Naltrexone → long-acting → NOT for acute overdose • C. Flumazenil → benzo overdose (⚠️ seizure risk) • D. Atropine → bradycardia only, not cause • E. Adrenaline → cardiac arrest context ⸻ 🔥 High-yield Paper B facts: • Naloxone: 👉 Works within minutes 👉 Can precipitate acute withdrawal • Naltrexone: 👉 Relapse prevention ONLY 🚨 EXAM TRAP: 👉 Naloxone = emergency 👉 Naltrexone = maintenance

Answer 95

✅ Correct answer: A. Heroin ⸻ 💡 Explanation: This is neonatal opioid withdrawal (NAS) Key features: • Irritability • High-pitched cry • Tremors • Poor feeding • Diarrhoea 👉 Occurs within hours after birth (if maternal opioid use) ⸻ ❌ Why others are wrong: • Nicotine → mild irritability only • Cocaine → neurobehavioural issues, not classic withdrawal • Cannabis → minimal neonatal withdrawal • Alcohol → fetal alcohol syndrome (not acute withdrawal like this) ⸻ 🔥 High-yield Paper B facts: • NAS = opioid withdrawal in newborn • Treatment: 👉 Morphine or methadone (taper) • Timing: 👉 Heroin → early onset (hours) 👉 Methadone → later onset (1–3 days)

Answer 96

✅ Correct answer: B. Heroin: high-pitched crying, tremors; Cocaine: jitteriness, overarousal ⸻ 💡 Explanation: 👉 Heroin (opioid) → TRUE withdrawal (NAS): • High-pitched cry • Tremors • Irritability • Feeding difficulty • Diarrhoea 👉 Cocaine → NOT true withdrawal (toxicity/exposure): • Jitteriness • Overarousal • Tachypnoea • Vomiting 📌 Key distinction: • Opioids = withdrawal syndrome • Cocaine = neurostimulation/toxicity ⸻ ❌ Why others are wrong: • A → incorrect (presentations differ clearly) • C → opioid withdrawal is more classic/severe • D → heroin withdrawal is VERY symptomatic • E → opioids definitely cause neonatal withdrawal ⸻ 🔥 High-yield Paper B facts: • NAS = opioid withdrawal in neonates • Onset: 👉 Heroin → within hours 👉 Methadone → 1–3 days • Treatment: 👉 Morphine/methadone taper

Answer 97

✅ Correct answer: C. Methadone ⸻ 💡 Explanation: Methadone = long-acting full μ-opioid agonist 👉 Used for: • Maintenance therapy • Reducing cravings • Preventing withdrawal • Harm reduction ⸻ ❌ Why others are wrong: • A (Naloxone) → overdose reversal • B (Naltrexone) → relapse prevention only • D/E → not standard substitution therapy ⸻ 🔥 High-yield Paper B facts: • Methadone: 👉 Full agonist 👉 Long half-life • Alternative: 👉 Buprenorphine (partial agonist) • Goal: 👉 Stabilise → reduce illicit opioid use

Answer 98

✅ Correct answer: B. Optimize the dose of methadone ⸻ 💡 Explanation: Persistent cravings/withdrawal = dose too low 👉 First step: ➡️ Increase/optimise methadone dose ⸻ ❌ Why others are wrong: • A → dangerous (withdrawal + relapse) • C → not first-line if methadone still effective • D → requires full detox (not now) • E → unnecessary ⸻ 🔥 High-yield Paper B facts: • Methadone dosing: 👉 Aim = no cravings + no withdrawal • If symptoms persist: 👉 Dose too low (EXAM GOLD ⚡)

Answer 99

🔴 Opioids (e.g. heroin, morphine, methadone): • Act on μ-opioid receptors • Effects: Analgesia Euphoria Respiratory depression •Pinpoint pupils (miosis) ⸻ 🔵 Cocaine (completely different class): • Stimulant • Mechanism: 👉 Blocks reuptake of dopamine, noradrenaline, serotonin • Effects: Euphoria Increased energy Dilated pupils (mydriasis) Tachycardia, hypertension 🔥 High-yield Paper B facts: • Opioid overdose triad: 👉 Miosis + respiratory depression + ↓ consciousness • Cocaine toxicity: 👉 Agitation + hypertension + hyperthermia • Withdrawal difference: 👉 Opioids → physical (painful but not fatal) 👉 Cocaine → psychological (crash: depression, hypersomnia) 👉 “Opioids slow you down — cocaine speeds you up.”

Answer 100

✅ Correct answer: C. It is a partial agonist with ceiling effect ⸻ 💡 Explanation: Buprenorphine = partial μ-opioid agonist 👉 Key concept: • Has a ceiling effect on respiratory depression • Beyond a certain dose → no further respiratory suppression 👉 Methadone: • Full agonist • No ceiling → higher overdose risk 🚨 ⸻ ❌ Why others are wrong: • A → methadone (full agonist) • B → incorrect (it DOES have opioid activity) • D → not purely antagonist • E → not the key safety factor ⸻ 🔥 High-yield Paper B facts: • Buprenorphine: 👉 Partial agonist 👉 Safer in overdose • Methadone: 👉 Full agonist 👉 Higher overdose risk 🚨 EXAM TRAP: 👉 “Ceiling effect” = buprenorphine

Answer 101

✅ Correct answer: C. Optimized oral methadone ⸻ 💡 Explanation: Before escalating → always check: 👉 Was the dose adequate? Persistent use/cravings often = ➡️ Subtherapeutic methadone dose So: 👉 First step = optimize dose (increase / supervised dosing) ⸻ ❌ Why others are wrong: • A/D → specialist settings ONLY after optimisation • B → symptomatic withdrawal treatment only • E → requires detox (not suitable here) ⸻ 🔥 High-yield Paper B facts: • If treatment “fails”: 👉 First think dose issue ⚡ • Injectable opioids: 👉 Last-line / specialist only

Answer 102

✅ Correct answer: E. Methadone ⸻ 💡 Explanation: Methadone is first-line in pregnancy because: 👉 Most evidence 👉 Stabilizes maternal opioid levels 👉 Reduces: • Withdrawal • Illicit use • Fetal stress ⸻ ❌ Why others are wrong: • A → buprenorphine = alternative (NOT first-line in exams) • B → naltrexone requires detox • C → contains naloxone (avoid) • D → not maintenance therapy ⸻ 🔥 High-yield Paper B facts: • Pregnancy + opioid dependence: 👉 Methadone = gold standard • Avoid: 👉 Withdrawal → risk to fetus 🚨

Answer 103

✅ Correct answer: B. Refer to local service for substitution treatment ⸻ 💡 Explanation: 👉 In pregnancy: • Opioid substitution therapy (OST) = standard of care → Methadone (first-line) → Buprenorphine (alternative) 🚨 DO NOT detox: • Risk of: • Fetal distress • Miscarriage • Preterm labour ⸻ ❌ Why others are wrong: • A → dangerous (withdrawal harms fetus 🚨) • C → unsafe • D → requires detox first • E → irrelevant ⸻ 🔥 High-yield Paper B facts: • Pregnancy + opioid use: 👉 Methadone = gold standard • Principle: 👉 Stability > abstinence during pregnancy

Answer 104

✅ Correct answer: B. Naltrexone ⸻ 💡 Explanation: 👉 Naltrexone: • Opioid antagonist • Blocks euphoric effects → prevents relapse 🚨 Important: • Must be fully detoxed first • Otherwise → precipitated withdrawal ⸻ ❌ Why others are wrong: • A → emergency overdose reversal only • C → maintenance therapy, not post-detox relapse prevention • D/E → opioids → not relapse prevention ⸻ 🔥 High-yield Paper B facts: • Naltrexone: 👉 Used AFTER detox only • Key exam phrase: 👉 “maintain abstinence” = naltrexone

Answer 105

✅ Correct answer: C. Gradually taper to minimize withdrawal ⸻ 💡 Explanation: 👉 Chronic opioid use → dependence Stopping suddenly: • Causes withdrawal symptoms • Very uncomfortable (but not life-threatening) 👉 Therefore: ➡️ Gradual taper is safest approach ⸻ ❌ Why others are wrong: • A → no attempt to stop • B → withdrawal symptoms • D → worsens dependence • E → unnecessary ⸻ 🔥 High-yield Paper B facts: • Opioid withdrawal: 👉 Not fatal but distressing • Always: 👉 Taper slowly

Answer 106

✅ Correct answer: B. Screen for Hepatitis C, HIV if required ⸻ 💡 Explanation: 👉 Patients in drug services (especially IV drug users) are at high risk of: • Hepatitis B & C • HIV 👉 Therefore routine screening for blood-borne viruses (BBVs) is essential Also: • Provide harm reduction advice • Vaccinate for Hep B if needed ⸻ ❌ Why others are wrong: • A → too limited • C → unsafe • D → not enough (misses BBVs) • E → irrelevant ⸻ 🔥 High-yield Paper B facts: • IV drug use → BBV risk 🚨 • Always think: 👉 Hep B, Hep C, HIV • Harm reduction: 👉 Needle exchange + education

Answer 107

✅ Correct answer: C. Monitoring treatment effectiveness ⸻ 💡 Explanation: Urine drug screens are used to: 👉 Objectively assess: • Adherence • Abstinence • Relapse 👉 Purpose is therapeutic, NOT punitive ⸻ ❌ Why others are wrong: • A/E → secondary reasons • B → not primary purpose • D → ❌ big exam trap → NEVER punitive ⸻ 🔥 High-yield Paper B facts: • Urine testing: 👉 Clinical tool, not punishment ⚡ • Helps: 👉 Detect relapse early 👉 Guide treatment adjustments

Answer 108

✅ Correct answer: B. Relapse ⸻ 💡 Explanation: 👉 Definitions (VERY EXAM HIGH-YIELD): • Lapse: 👉 Brief, isolated use • Relapse: 👉 Return to previous pattern of use 👉 Here: • 1 week abstinence → then heroin use → ➡️ suggests return to pattern → RELAPSE ⸻ ❌ Why others are wrong: • A → too mild (single brief use) • C → incorrect • D → too absolute • E → pain-related behaviour ⸻ 🔥 High-yield Paper B facts: • Lapse vs relapse = classic exam question ⚡ • Key distinction: 👉 Pattern vs isolated event

Answer 109

✅ Correct answer: B. The highest levels of binge drinking occur in people aged 16–24 ⸻ 💡 Why this is correct: 👉 UK epidemiology consistently shows: • Peak binge drinking = young adults (16–24) • This group has: Highest episodic heavy drinking Social drinking patterns (weekends, nightlife) 👉 This is VERY HIGH-YIELD exam fact Binge drinking refers to a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL; this typically occurs after consuming five or more drinks (for men), or four or more drinks (for women), in about two hours.

Answer 110

✅ Correct answer: E. Bladder fibrosis ⸻ 💡 Why this is correct (EXAM CORE) 👉 Chronic ketamine → Ketamine-induced cystitis This leads to: • Chronic inflammation 🚨 • Ulceration • ↓ bladder capacity • → fibrosis (scarring) 👉 End result = “contracted fibrotic bladder” ⸻ 🧠 Pathophysiology (they LOVE this) Ketamine metabolites in urine → ➡️ direct urothelial toxicity ➡️ chronic inflammation ➡️ fibrosis + thickened bladder wall ⸻ 🚨 Clinical picture (VERY TESTABLE) Patients present with: • Severe LUTS: • Frequency • Urgency • Dysuria • Pelvic pain • Haematuria • ↓ bladder capacity (tiny bladder!) 👉 Think: “painful, small bladder” 🔥 ULTRA HIGH-YIELD PEARL 👉 If you see: • Young person • LUTS + pelvic pain • History of recreational drugs 💥 → Think KETAMINE → fibrosis

Answer 111

✅ Correct answer: B. Amphetamine ⸻ 💡 Core concept (THIS is what they’re testing) 👉 There are TWO key mechanisms for stimulants: 1️⃣ Reuptake BLOCKERS (don’t release) 👉 e.g. Cocaine • Blocks DAT, NET, SERT • ↑ neurotransmitters by preventing reuptake ❌ NO transporter reversal ⸻ 2️⃣ RELEASERS (reverse transporters) 👉 e.g. Amphetamine 🔥 • Enters neuron via transporter • Reverses DAT, NET, SERT • Pushes neurotransmitters OUT into synapse ⚠️ What about MDMA? (Important nuance) 👉 MDMA ALSO: • Causes serotonin release • Has some transporter reversal BUT: • Exam answer for “classic transporter reversal of all monoamines” = Amphetamine 👉 MDMA = more serotonin-heavy + emotional effects ⸻ ❌ Others quickly: • Ketamine → NMDA antagonist • GHB → GABA-B agonist

Answer 112

✅ Correct answer: E. 30 days ⸻ 💡 Why this is correct (core concept) 👉 Cannabis (THC) is: • Highly lipophilic 🧈 • Stored in fat tissue • Released slowly over time ➡️ Leads to prolonged detection 👉 Urine detects: • THC-COOH (inactive metabolite) ⚠️ Exam trick They LOVE comparing: 👉 Occasional vs chronic • Occasional → 3 days • Chronic → 30 days 💥 This is a classic differentiation question

Answer 113

✅ Correct answer: E. Shoplifting ⸻ 💡 Why this is correct (EXAM LOGIC) 👉 NTORS shows: ➡️ Most common crime = SHOPLIFTING Why? • Quick • Low planning • Immediate reward • Directly funds drug use 👉 Think: 💥 “Need drug → need money fast → steal small items” ⸻ 🧠 Underlying pattern (HIGH-YIELD) Drug dependence → ➡️ Financial pressure ➡️ Impulsivity ➡️ Opportunistic crime 👉 → Shoplifting > other crimes ⸻ ❌ Why others are wrong ❌ Fraud • Requires planning • Less immediate • Not typical for dependent users ⸻ ❌ Actual bodily harm • Violence is NOT the most common • Substance use → more acquisitive crime than violent crime ⸻ ❌ Criminal damage • Occurs, but not the most frequent ⸻ ❌ Vehicle theft • Seen (esp. heroin users), but still < shoplifting ⸻ 🔥 ULTRA HIGH-YIELD PEARLS 🧠 In substance misuse: • Most common crime → Shoplifting • Type of crime → Acquisitive (NOT violent)

Answer 114

✅ Correct answer: C. Disulfiram ⸻ 💡 Core concept (MUST MEMORISE) 👉 Alcohol metabolism: Ethanol → Acetaldehyde → Acetic acid • Step 1: Alcohol dehydrogenase • Step 2: Aldehyde dehydrogenase ⸻ 👉 Disulfiram blocks STEP 2 ➡️ Inhibits aldehyde dehydrogenase ➡️ Acetaldehyde builds up 🚨 ⸻ 🔥 What happens clinically? (VERY TESTABLE) Acetaldehyde accumulation → • Flushing 🔴 • Nausea 🤢 • Vomiting • Palpitations ❤️ • Hypotension • Headache 👉 Patients feel awful → stop drinking

Answer 115

✅ Correct answer: E. The recommended course of varenicline is 12 weeks ⸻ 💡 Why this is correct (HIGH-YIELD NICE FACT) 👉 Varenicline • First-line smoking cessation drug • Given for 12 weeks initially • Can extend another 12 weeks if successful 👉 This is straight from NICE + exam favourite ⸻ ❌ Why the others are wrong (EXAM GOLD ⚡) ⸻ ❌ A. “Start bupropion on quit day” 👉 WRONG 👉 Bupropion • Start 1–2 weeks BEFORE quit date • Allows drug levels to build up 💥 VERY common exam trap ⸻ ❌ B. “Most common SE = abnormal dreams” 👉 WRONG 👉 Most common = • Insomnia 🔥 (Abnormal dreams → more varenicline) ⸻ ❌ C. “Bupropion is partial agonist” 👉 WRONG 👉 Bupropion: • Norepinephrine + dopamine reuptake inhibitor 👉 Partial agonist = 💥 Varenicline (α4β2 receptor) ⸻ ❌ D. “Avoid varenicline in bipolar” 👉 OUTDATED / WRONG 👉 Previously thought → neuropsychiatric risk 👉 Now: • Safe in stable psychiatric illness (including bipolar) 💥 NICE allows use with monitoring

Answer 116

✅ Correct answer: D. Withdrawal symptoms may develop upon abrupt discontinuation of opioids after 5 days of regular and uninterrupted opioid use ⸻ 💡 Why this is correct (Exam-focused explanation) • Physical dependence to opioids can develop rapidly (within ~5 days) • After this, stopping abruptly → withdrawal syndrome 👉 This is a classic MRCPsych concept: Dependence ≠ addiction duration → it can develop quickly ⸻ ❌ Why the other options are wrong (High-yield elimination) ⸻ ❌ A. Bradycardia is a common sign of withdrawal WRONG • Opioid withdrawal = sympathetic overdrive • Tachycardia • Hypertension • Sweating • Dilated pupils 👉 Bradycardia = opioid intoxication, not withdrawal ⚠️ Key features of withdrawal • Dilated pupils • Sweating • Diarrhoea • Yawning • Piloerection (“goosebumps”) • Tachycardia 👉 Opposite of intoxication ⸻ ❌ B. Buprenorphine is not associated with withdrawal WRONG • Buprenorphine = partial opioid agonist • Still causes: • Dependence • Withdrawal (milder than full agonists) ⸻ ❌ C. Methadone withdrawal resolves in 4–5 days WRONG • Methadone = long-acting opioid • Withdrawal: • Starts later • Lasts longer (up to 2–3 weeks) 👉 4–5 days = more like heroin peak, NOT methadone ⸻ ❌ E. Withdrawal begins within 12–18 hours (short-acting opioids) WRONG (very common trap) • Short-acting opioids (e.g. heroin): • Withdrawal begins 6–12 hours • NOT 12–18 hours

Answer 117

✅ Correct answer: D. Pseudoephedrine ⸻ 💡 Why this is correct (Exam-focused explanation) • Pseudoephedrine is a sympathomimetic structurally similar to amphetamines • Immunoassay urine drug screens rely on antibody cross-reactivity • → Structural similarity → false positive for amphetamines 👉 Classic MRCPsych concept: “Cold & flu meds → false amphetamine positive” ⸻ ❌ Why the other options are wrong (High-yield elimination) ⸻ ❌ A. Carbamazepine • Does NOT cause false positive for amphetamines • Instead → can cause false positive for TCAs 👉 Very common exam trap ⸻ ❌ B. Dextromethorphan • Causes false positives for: • PCP • Sometimes opioids • NOT amphetamines ⸻ ❌ C. Ketamine • NMDA antagonist • Detected separately (not via amphetamine assay cross-reactivity) ⸻ ❌ E. Risperidone • Can cause false positive for: • LSD (rarely) • Not amphetamines 👉 “Pseudoephedrine = fake amphetamine”

Answer 118

✅ Correct answer: D. Cannabis ⸻ 💡 Why this is correct (Exam-focused explanation) • Cannabis is by far the most commonly used illicit drug in Europe • Lifetime prevalence ≈ 25–30% (EMCDDA data) • Much higher than: • Cocaine (~5–10%) • Amphetamines (~3–5%) • Heroin (<1%) 👉 Key reason: • Availability + social acceptability + lower perceived harm

Answer 119

**Previous Exam Question** ✅ Correct answer: D. Buprenorphine ⸻ 💡 Why this is correct (Exam-focused explanation) • Buprenorphine = partial opioid agonist • Used for: • Maintenance (substitution therapy) • Reducing cravings • Preventing withdrawal 👉 It replaces heroin/opioids safely → stabilises patient ⸻ ❗ Why NOT Naltrexone (THIS is the key exam point) 🔴 Naltrexone = opioid antagonist • Blocks opioid receptors completely • Has NO opioid effect • Cannot relieve withdrawal or cravings ⸻ 🚨 Critical rule: 👉 Must be opioid-free before starting (7–10 days) Otherwise → ❗ precipitated withdrawal ⸻ 🧠 So its role is: • Relapse prevention ONLY • After detox • In highly motivated patients 👉 NOT suitable for ongoing dependence / maintenance

Answer 120

✅ Correct answer: C. It is an NMDA glutamate receptor antagonist ⸻ 💡 Why this is correct (Exam-focused explanation) • Acamprosate modulates glutamatergic transmission • Acts mainly as: • NMDA receptor antagonist • Enhances GABA balance indirectly 👉 Restores neurochemical balance after alcohol dependence

Answer 121

**Previous Exam Question** ✅ Correct answer: D. 24–48 hours ⸻ 💡 Why this is correct (Exam-focused explanation) • Alcohol withdrawal follows a predictable timeline • Symptoms: • Start → 6–12 hours • Peak → 24–48 hours • DTs → 3–4 days 👉 Peak = maximum autonomic hyperactivity • Tremor • Sweating • Anxiety • Tachycardia 🔥 HIGH-YIELD TIMELINE (MUST MEMORISE) ⏱️ Alcohol Withdrawal Timeline • 6–12 hrs → tremor, anxiety • 12–24 hrs → hallucinations, seizures may begin • 24–48 hrs → 🔥 PEAK symptoms • 3–4 days → delirium tremens

Answer 122

✅ Correct answer: D. Vitamin B3 ⸻ 💡 Why this is correct (Exam-focused explanation) • Niacin = Vitamin B3 • Also called nicotinic acid / nicotinamide • Essential for: NAD / NADP production Cellular energy metabolism 👉 Clinically important in psychiatry because: • Deficiency → pellagra • Seen in: Alcohol dependence 🍺 Malnutrition Carcinoid syndrome 🧠 Classic triad = “3 Ds” • Dermatitis • Diarrhoea • Dementia 👉 + 4th D sometimes = Death ⸻ 🎯 Key psychiatric relevance • Depression • Psychosis (“pellagra psychosis”) • Cognitive impairment ⸻ Primary pellagra due to a deficient diet is common particularly in developing countries where corn (maize) is a major food source or following prolonged disasters including famine or war. In developed countries many foods, such as bread and cereal, are fortified with niacin, making pellagra rare. Alcoholism is the commonest cause of pellagra in developed countries. Alcohol dependence can induce or aggravate pellagra by inducing malnutrition, gastrointestinal disturbances and B vitamin deficiencies, inhibiting the conversion of Trp to niacin and promoting the accumulation of 5-ALA and porphyrins. ⸻ 🧬 Pathophysiology pearl (VERY HIGH-YIELD) • Niacin derived from tryptophan • Alcohol → ↓ absorption + ↓ conversion ⸻ 📸 Classic exam image • Photosensitive dermatitis • Casal’s necklace (neck rash 🔥) • Symmetrical, sun-exposed areas

Answer 123

**Previous Exam Questions** ✅ Correct answers 1. d-amphetamine → 3 days 2. Cocaine → 5 days 3. Cannabis (heavy user) → 30 days 🔹 Amphetamine → 3 days • Rapid metabolism • Usually detectable 1–3 days 👉 exam answer = 3 days (max) ⸻ 🔹 Cocaine → 5 days • Detected as benzoylecgonine (longer-lasting metabolite) • Typical: 2–4 days 👉 Exam pushes to upper limit = 5 days ⸻ 🔹 Cannabis → 30 days (IMPORTANT ⚠️) • Lipophilic → stored in fat • Slow release → prolonged detection 👉 Depends on use: • Single use → ~3 days • Regular → ~10 days • Heavy chronic → 30 days (EXAM FAVOURITE)

Answer 124

✅ Answer: 3 days 💡 Explanation: Most opioids have short detection windows. 🔥 High-yield facts: • Heroin → morphine metabolite • Codeine also ~3 days • Exception: methadone (longer)

Answer 125

✅ Answer: 5–28 days 💡 Explanation: Depends on half-life and lipid solubility. 🔥 High-yield facts: • Diazepam → long detection • Short-acting (e.g. lorazepam) → shorter • Very variable → exam likes range

Answer 126

✅ Answer: <1 day 💡 Explanation: Rapid metabolism → very short detection window. 🔥 High-yield facts: • Difficult to detect • Rarely shows on routine screens • Often missed in exams

Answer 127

✅ Answer: <3 or >11 💡 Explanation: Extreme pH values are not physiologically possible → indicate chemical tampering. 🔥 High-yield facts: • Normal urine pH = 4.5–8 • Acid → vinegar • Alkali → ammonia/detergent

Answer 128

✅ Answer: 32–38°C 💡 Explanation: Urine should be tested within 4 minutes; outside this range suggests tampering or substitution. 🔥 High-yield facts: • Temperature is checked immediately after voiding • Cold urine = possible substitution • Very hot = possible heating attempt

Answer 129

**Previous Exam Question** ✅ Correct answer: B. Cannabis ⸻ 💡 Explanation (Exam-focused) Cannabis has the lowest overall dependence potential compared to the other options. • It can still cause dependence, but: • Physiological withdrawal is mild (irritability, insomnia, decreased appetite) • Psychological craving is less intense than stimulants or opioids 👉 In comparison: • Heroin (A) → very high physical + psychological dependence • Cocaine (C) → very high psychological dependence • Alcohol (D) → high physical + psychological dependence (dangerous withdrawal) • Amphetamine (E) → high psychological dependence

Answer 130

💡 ICD-11 Core Features (EXACT EXAM LANGUAGE) 👉 You need ≥2 of the following: 1. Impaired control over alcohol use • Difficulty controlling onset, frequency, amount, or termination 2. Increasing priority given to alcohol • Alcohol takes precedence over other interests, responsibilities, or activities 3. Physiological features • Tolerance • Withdrawal • OR use to avoid withdrawal 4. Persistence despite harm • Continued use despite clear evidence of harmful consequences ⸻ 🔥 High-yield facts 1. ICD-11 = only 2 features needed (VERY EXAMINABLE ⚠️) 2. Priority of substance use = key ICD-11 concept 3. Physiological features NOT required (differs from old ICD-10 thinking)

Answer 131

✅ Answer: Diarrhoea ⸻ 💡 Explanation (Exam-focused) Acamprosate commonly causes gastrointestinal upset, with diarrhoea being the most frequent side effect. • Usually dose-related • Often transient but can persist • Important counselling point for patients ⸻ 🔥 High-yield facts 1. Most common side effect = diarrhoea (EXAM FAVOURITE) 2. Acamprosate is not hepatically metabolised → safe in liver disease 3. Acts on NMDA (glutamate) system → reduces craving

Answer 132

✅ Correct answer: A. Motor neurone disease ⸻ 💡 Why this is correct (Exam-focused) Wernicke–Korsakoff syndrome (WKS) is caused by thiamine (vitamin B1) deficiency. 👉 It occurs in conditions causing: • Malnutrition • Poor intake • Poor absorption ✔ Alcoholism → ↓ absorption + ↓ intake ✔ Hyperemesis gravidarum → prolonged vomiting ✔ Anorexia nervosa → severe malnutrition ✔ AIDS → malnutrition + malabsorption ❌ Motor neurone disease → does NOT cause thiamine deficiency → therefore NOT associated

Answer 133

✅ Correct answer: C. Cocaine ⸻ 💡 Why this is correct (Exam-focused) Cocaine directly blocks the dopamine transporter (DAT) → prevents reuptake → ↑ dopamine in synapse → intense euphoria + addiction 👉 This is a direct dopaminergic effect (VERY testable distinction) ⸻ ❌ Why others are wrong A. Alcohol → indirect (↑ GABA, ↓ glutamate → secondary dopamine ↑) B. Opioids → inhibit GABA → disinhibit dopamine (indirect) D. Cannabinoids → CB1 receptor → indirect dopamine modulation E. Ketamine → NMDA antagonist (glutamate system) ⸻ 🔥 High-yield facts 1. Cocaine = DAT blocker 2. Amphetamines = increase dopamine release (NOT reuptake block) 3. Both → high addiction risk but different mechanisms ⚠️

Answer 134

✅ Correct answer: A. Cocaine withdrawal ⸻ 💡 Why this is correct Cocaine withdrawal = “crash” phase 👉 Opposite of intoxication: • Dysphoria • Fatigue • Hypersomnia • ↑ appetite • Vivid unpleasant dreams ⸻ ❌ Why others are wrong B. Amphetamine intoxication → agitation, insomnia (NOT ↑ appetite) C. Alcohol withdrawal → tremor, seizures, delirium tremens D. Cannabis intoxication → euphoria, anxiety, NOT withdrawal pattern E. Opioid withdrawal → diarrhoea, yawning, lacrimation (NOT ↑ appetite) ⸻ 🔥 High-yield facts 1. Cocaine withdrawal = not medically dangerous (unlike alcohol/opioids) 2. Key symptom = depression/crash 3. ↑ appetite = classic clue 🍔

Answer 135

✅ Correct answer: B. Cocaine ⸻ 💡 Why this is correct Cocaine → strong dopaminergic stimulation → 👉 during withdrawal or heavy use → • Paranoia • Hallucinations • Delusions ⸻ ❌ Why others are wrong A. Cannabis → psychosis mainly during intoxication C. Heroin → withdrawal = physical symptoms (NOT psychosis) D. LSD → intoxication → hallucinations (NOT withdrawal) E. Nicotine → irritability, anxiety only ⸻ 🔥 High-yield facts 1. Cocaine psychosis = paranoid + hallucinations 2. Can mimic schizophrenia 3. “Cocaine bugs” (formication) = classic 🐜

Answer 136

✅ Correct answer: B. Sustained attention ⸻ 💡 Why this is correct (Exam-focused) Chronic cocaine use → prefrontal cortex dysfunction → 👉 Most consistently impairs: • Sustained attention (TOP HY fact) • Response inhibition • Working memory ⸻ ❌ Why others are wrong A. Language → not primary deficit C. Procedural memory → more basal ganglia (not main cocaine effect) D. Visuospatial skills → not typical E. Verbal fluency → may be affected but NOT most prominent ⸻ 🔥 High-yield facts 1. Cocaine → executive dysfunction 2. Most sensitive domain = attention 3. ~30% show clinically significant impairment

Answer 137

✅ Correct answer: D. Hypersomnia ⸻ 💡 Why this is correct Cocaine intoxication = stimulant state 👉 Features: • Euphoria • ↑ energy • Paranoia • Tachycardia • Hypertension • Hyperthermia ❌ Hypersomnia = withdrawal (crash phase) ⸻ ❌ Why others are wrong All are classic intoxication features except hypersomnia ⸻ 🔥 High-yield facts 1. Intoxication = sympathetic overdrive 2. Withdrawal = opposite (sleepy, hungry, depressed) 3. Tachycardia + paranoia = classic combo

Answer 138

✅ Correct answer: C. Cocaine ⸻ 💡 Why this is correct Cocaine = short-acting stimulant 👉 Key features: • Euphoria • Confidence • ↓ need for sleep • Tachycardia ⸻ ❌ Why others are wrong A. Cannabis → relaxation, NOT stimulant B. Heroin → sedative/opioid D. LSD → hallucinogen (not classic stimulant profile) E. Ketamine → dissociative ⸻ 🔥 High-yield facts 1. Cocaine = short-acting stimulant 2. Amphetamine = longer-acting stimulant 3. Short-acting → binge pattern use ⸻ ⚠️ Exam trap 👉 Cocaine vs amphetamine: • Cocaine → short + intense • Amphetamine → long + sustained

Answer 139

✅ Correct answer: B. Cocaine withdrawal ⸻ 💡 Why this is correct (Exam-focused) This is the classic stimulant “crash”: 👉 Key cluster: • Low mood (dysphoria) • Hypersomnia • Fatigue • ↑ appetite ➡️ Seen in cocaine AND amphetamine withdrawal, but cocaine is most commonly tested ⸻ ❌ Why others are wrong A. Alcohol withdrawal → tremor, seizures, delirium tremens C. Opioid withdrawal → diarrhoea, yawning, lacrimation D. Benzodiazepine withdrawal → anxiety, seizures E. Nicotine withdrawal → irritability, cravings (NO hypersomnia + ↑ appetite combo)

Answer 140

✅ Correct answer: B. Fatigue, depression, increased appetite ⸻ 💡 Why this is correct Amphetamine withdrawal = same crash pattern as cocaine 👉 Features: • Fatigue • Depression • Hypersomnia • ↑ appetite ⸻ ❌ Why others are wrong A. Alcohol/benzo withdrawal C. Opioid withdrawal D. Hallucinogen intoxication E. FALSE — symptoms are significant ⸻ 🔥 High-yield facts 1. Cocaine & amphetamine withdrawal = identical exam pattern 2. Psychological > physical 3. May last days–weeks

Answer 141

✅ Answer: B. Dental problems and psychosis ⸻ 💡 Explanation (Exam-focused) Methamphetamine is a potent dopamine-releasing stimulant → chronic use leads to: • “Meth mouth” → severe dental decay due to: • Xerostomia • Poor hygiene • Teeth grinding (bruxism) • Psychosis → due to excess dopamine (similar to schizophrenia) ⸻ ⚠️ Why others are wrong • A → opposite (stimulants → weight loss, not gain) • C → stimulants cause hyperthermia + tachycardia • D → cognition worsens long-term • E → that’s opioids/benzodiazepines ⸻ 🔥 High-yield facts • Meth psychosis = paranoia + tactile hallucinations (“bugs crawling”) • Severe dental decay = classic OSCE / SBA buzzword • Long-term: dopamine neurotoxicity → cognitive impairment

Answer 142

✅ Answer: C. Stimulants/Cathinones ⸻ 💡 Explanation Mephedrone = synthetic cathinone (“bath salts”) → structurally similar to amphetamines + khat Acts by: • ↑ dopamine • ↑ serotonin • ↑ noradrenaline ⸻ ⚠️ Why others are wrong • A → depressant • B → GABAergic sedatives • D → LSD-type drugs (different mechanism) • E → cannabinoid system ⸻ 🔥 High-yield facts • Nickname: “meow meow” • Causes: agitation, tachycardia, hyperthermia • Can mimic MDMA + cocaine

Answer 143

✅ Answer: B. Fishy odor ⸻ 💡 Explanation Mephedrone has a distinct fishy smell → classic exam association. ⸻ 🔥 High-yield facts • “Fishy smell” → think mephedrone immediately • Cathinones = stimulant effects + agitation • Common in club drug / party drug scenarios ⸻

Answer 144

✅ Answer: B. Cathinone ⸻ 💡 Explanation Khat = natural plant chewed in East Africa & Yemen → active ingredient = cathinone (amphetamine-like stimulant) ⸻ ⚠️ Why others are wrong • A → mushrooms • C → cannabis • D → peyote • E → LSD ⸻ 🔥 High-yield facts • Khat → mild stimulant → euphoria + increased alertness • Linked to psychosis + dependence • Synthetic versions = mephedrone

Answer 145

✅ Answer: C. Cannabis ⸻ 💡 Explanation (Exam-focused) Cannabis intoxication classically presents with: • Euphoria + relaxation • Laughter / giggling • Altered time perception • Increased appetite (“munchies”) • Usually smoked ⸻ ⚠️ Why others are wrong • Cocaine/amphetamine → agitation, not relaxation • Heroin → sedation, not giggling • LSD → hallucinations, not simple relaxation ⸻ 🔥 High-yield facts • Cannabis = relaxed + giggly + hungry • Causes red eyes + dry mouth • Can cause acute anxiety/paranoia

Answer 146

✅ Answer: B. Irritability, sleep difficulties, decreased appetite ⸻ 💡 Explanation Cannabis withdrawal is mild but real: • Irritability • Anxiety • Insomnia • ↓ appetite • Restlessness Onset: 24–72 hours Peak: 2–6 days ⸻ ⚠️ Why others are wrong • A → alcohol/benzo withdrawal • C → opioids • D → hallucinogens • E → alcohol/benzo ⸻ 🔥 High-yield facts • Cannabis withdrawal = psychological > physical • No seizures (key exam point) • Often overlooked → exam trap

Answer 147

✅ Answer: C. Cannabis ⸻ 💡 Explanation Chronic cannabis use → amotivational syndrome: • ↓ motivation • ↓ goal-directed behaviour • Apathy • Social withdrawal ⸻ ⚠️ Exam trap This can persist after stopping cannabis ⸻ 🔥 High-yield facts • Classic phrase: “loss of drive” • Associated with chronic heavy use • Important in functional decline cases

Answer 148

✅ Answer: B. Psychosis ⸻ 💡 Explanation High THC cannabis (skunk) → strong link to: • Acute psychosis • Schizophrenia risk (especially in vulnerable individuals) Mechanism: → THC ↑ dopamine → psychotic symptoms ⸻ ⚠️ Why others are wrong • Liver damage → alcohol • Arrhythmias → stimulants • Seizures → alcohol withdrawal • Respiratory arrest → opioids ⸻ 🔥 High-yield facts • Cannabis can cause: Acute psychosis Worsen schizophrenia • Risk ↑ with: High potency (skunk) Early use Genetic vulnerability

Answer 149

✅ Answer: C. They are full receptor agonists with unpredictable effects ⸻ 💡 Explanation (Exam-focused) • Natural cannabis (THC) = partial CB1 agonist • Synthetic cannabinoids (e.g. Spice, K2) = full CB1 agonists 👉 Result: • Much stronger effects • Unpredictable toxicity • Higher risk of: Psychosis Agitation Seizures ⸻ ⚠️ Why others are wrong • A → they are MORE potent • B → ↑ psychosis risk • D → withdrawal DOES occur • E → absolutely false (dangerous exam trap) ⸻ 🔥 High-yield facts • Synthetic cannabinoids = “Spice / K2” • Cause severe agitation + psychosis • Much higher ED presentations than natural cannabis

Answer 150

✅ Answer: B. Synthetic cannabinoid ⸻ 💡 Explanation • Full CB1 agonism → strong dopaminergic effects → leads to: • Paranoia • Hallucinations • Severe psychosis ⸻ ⚠️ Exam trap Natural cannabis = partial agonist → milder effects ⸻ 🔥 High-yield facts • Synthetic cannabinoids = more psychosis than cannabis • Often present with violent/agitated behaviour • Think: “unexpected severe reaction

Answer 151

✅ Answer: B. Cannabis withdrawal ⸻ 💡 Explanation Cannabis withdrawal can (rarely) cause: • Psychotic symptoms • Irritability • Anxiety • Sleep disturbance 👉 This is unusual → high-yield exam point ⸻ ⚠️ Why others are wrong • Opioids → flu-like symptoms • Nicotine → irritability only • Caffeine → headache • Alcohol → YES causes psychosis (delirium tremens) BUT: • This question is about typical association in exam framing • Cannabis is the “unexpected” answer they want ⸻ 🔥 High-yield facts • Only withdrawals causing psychosis: • Alcohol (DTs) • Benzodiazepines • Cannabis (rare but tested!) Exam loves testing exceptions

Answer 152

✅ Answer: C. Ketamine ⸻ 💡 Explanation (Exam-focused) Ketamine: • Primary action → NMDA receptor antagonist (glutamate system) • Also has GABA-A effects 👉 Leads to: • Dissociation • Analgesia • Hallucinations ⸻ ⚠️ Why others are wrong • Alcohol → GABA ↑ + NMDA ↓ BUT not the best answer here (exam trick — ketamine is more specific NMDA antagonist) • Benzos → GABA only • Opioids → μ receptors • Cannabis → CB1 receptors ⸻ 🔥 High-yield facts • Ketamine = “dissociative anaesthetic” • Acts at PCP binding site • Used in treatment-resistant depression (very exam hot)

Answer 153

✅ Answer: C. Cystitis and bladder damage ⸻ 💡 Explanation Classic complication = “Ketamine bladder”: • Severe cystitis • Ulceration • Haematuria • Urinary frequency + urgency ⸻ ⚠️ Exam buzzword 👉 Young patient + LUTS + drug use → think ketamine ⸻ 🔥 High-yield facts • Can lead to permanent bladder damage • May require surgery (cystectomy in severe cases) • VERY commonly tested

Answer 154

✅ Answer: C. Ketamine ⸻ 💡 Explanation Ketamine toxicity can cause: • Sympathetic overdrive • Tachycardia • Hypertension • Neurological features • Seizures • Rigidity • Agitation ⸻ ⚠️ Important differentiation • Cocaine → similar but more cardiac + agitation • Ketamine → dissociation + rigidity + hallucinations ⸻ 🔥 High-yield facts • Ketamine intoxication: Dissociation (“out of body”) Analgesia Hallucinations • Known as: “Special K” Club drug

Answer 155

✅ Answer: C. Ketamine ⸻ 💡 Explanation (Exam-focused) Ketamine intoxication causes: • Ataxia (unsteady gait) • Hallucinations • Muscle rigidity • Dissociation 👉 This combination = VERY characteristic ⸻ ⚠️ Why others are wrong • Cannabis → relaxed, giggly, no rigidity • Heroin → sedation + pinpoint pupils • Alcohol → ataxia BUT no hallucinations early • Nicotine → stimulant, mild effects ⸻ 🔥 High-yield facts • Ketamine = dissociative + motor disturbance • Think: “ataxia + hallucinations = ketamine” • PCP has similar features (NMDA antagonists)

Answer 156

✅ Answer: D. LSD ⸻ 💡 Explanation LSD: • Causes hallucinations + perceptual distortion • NO significant physical dependence • Minimal psychological dependence 👉 But: • Tolerance can develop • No withdrawal syndrome ⸻ ⚠️ Why others are wrong • Cocaine → HIGH psychological dependence • Heroin → HIGH physical dependence • Alcohol → both physical + psychological • Nicotine → VERY addictive

Answer 157

✅ Answer: C. Alprazolam ** Alprazolam = most addictive benzo** ⸻ 💡 Explanation (Exam-focused) Dependence risk in benzos is highest with short-acting agents: • Alprazolam = short half-life → rapid onset → high dependence • Causes: Frequent dosing Interdose withdrawal Reinforcement ⸻ ⚠️ Why others are wrong • Diazepam / chlordiazepoxide → long-acting → lower dependence risk • Oxazepam → shorter but less reinforcing • Nitrazepam → intermediate ⸻ 🔥 High-yield facts • Short-acting = HIGH addiction risk • Long-acting = safer for withdrawal (diazepam) • Alprazolam = MOST tested high-risk benzo

Answer 158

✅ Answer: B. Half-life of the benzodiazepine ⸻ 💡 Explanation Withdrawal onset is determined by how fast the drug leaves the body: • Short-acting → early withdrawal (1–2 days) • Long-acting → delayed withdrawal (5–10 days) ⸻ ⚠️ Exam trap They LOVE testing: 👉 “early withdrawal → short half-life drug” ⸻ 🔥 High-yield facts • Benzo withdrawal can cause: • Seizures (VERY important) • Anxiety, tremor, insomnia • Can be life-threatening (like alcohol)

Answer 159

✅ Answer: C. Combined behavioural support and pharmacotherapy ⸻ 💡 Explanation Best outcomes = combination approach: • Behavioural support → coping strategies • Pharmacotherapy → reduces cravings Options: • NRT • Varenicline • Bupropion

Answer 160

✅ Answer: B. Partial nicotinic receptor agonist ⸻ 💡 Explanation Varenicline: • Partial agonist at α4β2 nicotinic receptors → does TWO things: 1. Reduces cravings 2. Blocks nicotine reward ⸻ ⚠️ Exam trap • Bupropion = dopamine/noradrenaline reuptake inhibitor • Varenicline = partial nicotinic agonist ⸻ 🔥 High-yield facts • Most effective pharmacological option • Can cause: Nausea Mood changes (monitor!) • Reduces both: Craving Reinforcement

Answer 161

✅ Answer: C. MDMA ⸻ 💡 Explanation (Exam-focused) MDMA (ecstasy) causes: • Tactile enhancement (tingling, “skin sensations”) • Jaw clenching (bruxism) ← VERY classic • Euphoria + empathy • Hyperthermia ⸻ ⚠️ Why others are wrong • Cannabis → relaxation, not bruxism • Alcohol → sedation • Heroin → pinpoint pupils, sedation • LSD → hallucinations, not jaw clenching ⸻ 🔥 High-yield facts • MDMA = serotonin + dopamine release • Key buzzwords: Jaw clenching Hyperthermia Hyponatraemia (water intoxication!) • Can cause serotonin syndrome

Answer 162

✅ Answer: C. Preparation ⸻ 💡 Explanation Stages of change (EXAM GOLD): • Precontemplation → not thinking • Contemplation → thinking (within 6 months) • Preparation → planning within 1 month • Action → actively changing • Maintenance → sustaining change ⸻ ⚠️ Exam trap 👉 “Within 1 month” = ALWAYS Preparation ⸻ 🔥 High-yield facts • Preparation includes: Setting a quit date Planning strategies • VERY commonly tested phrasing: “next month” → Preparation “next 6 months” → Contemplation

Answer 163

✅ Answer: A. Precontemplation ⸻ 💡 Explanation Precontemplation = • No intention to change • May not recognise problem • Resistant or unaware ⸻ ⚠️ Clinical link 👉 This is where motivational interviewing is most useful ⸻ 🔥 High-yield facts • Key phrases: “Not ready” “No problem” • DO NOT push change → use: Empathy Exploration of ambivalence

Answer 164

✅ Answer: B. Novelty-seeking behavior ⸻ 💡 Explanation Gaming addiction is strongly linked to: • Dopamine reward pathways • Traits like: Impulsivity Sensation-seeking Novelty-seeking (MOST IMPORTANT) These individuals seek: • stimulation • competition • reward ⸻ 🔥 High-yield facts • Novelty-seeking = core addiction personality trait • Linked to dopaminergic dysregulation • Also predicts: substance misuse gambling disorder

Answer 165

✅ Answer: C. Indicated ⸻ 💡 Explanation (EXAM CLASSIC) Prevention types: • Universal → whole population • Selective → high-risk groups (no symptoms yet) • Indicated → early symptoms present ← KEY • Secondary → early diagnosis • Tertiary → reduce complications

Answer 166

✅ Answer: C. Shoplifting ⸻ 💡 Explanation Drug-dependent individuals commonly commit: 👉 Low-level acquisitive crimes to fund substance use Most common = shoplifting ⸻ ⚠️ Exam trap They will try to trick you with: • burglary • violent crime 👉 but answer = petty crime ⸻ 🔥 High-yield facts • “Acquisitive crime” = theft-related • Includes: shoplifting (MOST COMMON) minor theft • Violence more linked to: alcohol stimulants

Answer 167

✅ Answer: C. Substance misuse ⸻ 💡 Explanation Substance misuse: • ↑ impulsivity • ↓ inhibition • ↑ risk-taking • often coexists with depression 👉 strongest overall association with completed suicide 🔥 High-yield facts • Alcohol is a MAJOR contributor • Substance misuse: ↑ suicide attempts ↑ completion risk • Highest risk = dual diagnosis

Answer 168

✅ Answer: B. Pylorospasm ⸻ 💡 Explanation Alcohol is mainly absorbed in the small intestine, not the stomach. 👉 Anything that delays gastric emptying (like pylorospasm) → slows delivery to small intestine → reduces rate of absorption ⸻ 🔥 High-yield facts • Food also slows absorption → but not the best single answer • Faster gastric emptying → ↑ intoxication • Carbonated drinks → ↑ absorption speed 🚨 exam favourite

Answer 169

✅ Answer: C. Urine drug screen ⸻ 💡 Explanation Young patient + acute confusion + normal basic workup 👉 Think drug intoxication first Urine drug screen: • quick • non-invasive • high diagnostic yield ⸻ ⚠️ Exam trap • LP → only if infection suspected (fever, meningism) • CT → already normal ⸻ 🔥 High-yield facts • Adolescents → drugs = commonest cause of acute confusion • Always rule out substance use early • Especially: cannabis stimulants MDMA

Answer 170

✅ Answer: D. Naloxone ⸻ 💡 Explanation Key features: • Drowsiness • Respiratory depression (accessory muscle use) 👉 Classic opioid overdose Naloxone: • opioid antagonist • reverses respiratory depression • life-saving ⸻ ⚠️ Exam traps • ❌ Flumazenil → dangerous in mixed overdose (seizures) • ❌ Diazepam → would worsen respiratory depression ⸻ 🔥 High-yield facts • Give naloxone immediately (don’t wait for confirmation) • May need repeated dosing • Shorter half-life than many opioids → relapse risk

Answer 171

✅ Answer: C. Acamprosate ⸻ 💡 Explanation Acamprosate: • reduces craving via glutamate modulation • NO opioid receptor action → safe with opioids (e.g. tramadol) • NO cardiovascular risk → safe in cardiac disease ⸻ ⚠️ Exam traps • ❌ Naltrexone → opioid antagonist → contraindicated with tramadol • ❌ Disulfiram → cardiac risk + severe reactions ⸻ 🔥 High-yield facts • First-line for maintaining abstinence • Safe in: liver disease ✔️ • NOT safe in: severe renal impairment ❌

Answer 172

✅ Answer: B. Inhalants/solvents ⸻ 💡 Explanation Inhalants (e.g. nitrous oxide, glue): • rapid onset • short duration • cause: euphoria giggling disinhibition ⸻ ⚠️ Exam clue 👉 “inhaled + giggling” = classic inhalants ⸻ 🔥 High-yield facts • Risk: sudden sniffing death 💀 (arrhythmias) • Seen in: adolescents • Effects are: short-lived → repeated use 👉 In exams: • smoked → cannabis • inhaled → solvents/inhalants

Answer 173

✅ Answer: B. Increase dopamine release from vesicles ⸻ 💡 Explanation Amphetamines: • enter presynaptic neuron via DAT • enter vesicles via VMAT • displace dopamine from vesicles • cause reverse transport of dopamine into synapse 👉 Result = massive dopamine release ⸻ ⚠️ Exam trap (VERY COMMON) • ❌ Cocaine → blocks reuptake • ✅ Amphetamine → increases release 👉 This distinction is tested AGAIN and AGAIN ⸻ 🔥 High-yield facts • Amphetamine = release + reverse transport • Cocaine = reuptake inhibition only • MDMA = serotonin > dopamine release

Answer 174

✅ Answer: C. Fluoxetine ⸻ 💡 Explanation Fluoxetine: • longest half-life (VERY IMPORTANT) • self-tapers → minimal withdrawal Others: • Paroxetine → worst withdrawal • Venlafaxine → also BAD withdrawal ⸻ ⚠️ Exam trap • They love pairing: Paroxetine = worst Fluoxetine = safest 🔥 High-yield facts • Fluoxetine active metabolite = norfluoxetine • Withdrawal symptoms: dizziness electric shocks (“brain zaps”) • Short half-life = ↑ withdrawal risk

Answer 175

✅ Answer: B. Tolerance is needing more; dependence includes withdrawal; addiction is compulsive use despite harm ⸻ 💡 Explanation Tolerance: • ↓ effect with same dose • → need higher dose Dependence: • physiological adaptation • → withdrawal on stopping Addiction: • behavioural syndrome • → compulsive use despite harm ⸻ ⚠️ Exam traps • ❌ Dependence ≠ addiction • ❌ Patients can be dependent without addiction (e.g. opioids in pain) ⸻ 🔥 High-yield facts • Addiction = loss of control • Dependence = physiological • Tolerance = dose escalation

Answer 176

✅ Answer: B. CB1 receptors (partial agonist) ⸻ 💡 Explanation The active compound in cannabis = THC (tetrahydrocannabinol) 👉 THC: • acts as a partial agonist at CB1 receptors • CB1 receptors are mainly in the CNS This leads to: • euphoria • altered perception • relaxation ⸻ ⚠️ Exam traps (VERY IMPORTANT) 🔴 Synthetic cannabinoids (Spice, K2) • FULL agonists at CB1 • → much stronger effects • → ↑ psychosis risk 👉 This is a classic comparison question ⸻ 🔴 Dopamine confusion • Cannabis affects dopamine indirectly • NOT via D2 receptors ⸻ 🔥 High-yield facts • CB1 → CNS (psychoactive effects) • CB2 → immune/peripheral • THC = partial agonist • Synthetic cannabinoids = full agonists → more dangerous

Answer 177

✅ Answer: B. Alcohol Use Disorder ⸻ 💡 Explanation Arson is most strongly linked to: 👉 substance misuse (especially alcohol) Why? • ↓ inhibition • ↑ impulsivity • poor judgment ⸻ ⚠️ Exam traps • ❌ Antisocial personality disorder → associated but NOT most common • ❌ Schizophrenia → possible but rare compared to alcohol ⸻ 🔥 High-yield facts • Arson → substance misuse > personality disorder > psychosis • Alcohol = strongest association • Fire-setting often occurs during intoxication

Answer 178

✅ Answer: C. Magic mushrooms ⸻ 💡 Explanation 👉 Magic mushrooms contain psilocybin/psilocin 👉 These are Class A drugs in the UK ⸻ ⚠️ Exam traps (VERY IMPORTANT) ❌ Amphetamine • Class B (unless prepared for injection → Class A ⚠️ tricky detail) ❌ Ketamine • Class B ❌ Synthetic cannabinoids • Usually Class B ❌ Anabolic steroids • Class C ⸻ 🔥 High-yield classification table (MUST MEMORISE) 🔴 Class A (MOST IMPORTANT) • Cocaine • Heroin • LSD • Psilocybin (magic mushrooms) • MDMA ⸻ 🟠 Class B • Amphetamine • Cannabis • Ketamine ⸻ 🟡 Class C • Benzodiazepines • Anabolic steroids

Answer 179

✅ Answer: D. Global confusion is a common feature ⸻ 💡 Explanation Wernicke’s encephalopathy = acute thiamine (vitamin B1) deficiency 👉 Classic triad: • Confusion (MOST COMMON 🔥) • Ophthalmoplegia • Ataxia ⚠️ Full triad only in ~10% → exam loves this ⸻ ❌ Why the others are wrong (EXAM LOGIC) A. Insidious onset ❌ 👉 WRONG — onset is acute/subacute, not gradual ⸻ B. IV vitamin B12 ❌ 👉 WRONG — treatment = IV thiamine (Pabrinex) ⸻ C. Only alcohol ❌ 👉 WRONG — also seen in: • malnutrition • hyperemesis gravidarum • anorexia • cancer ⸻ E. Rare neurological signs ❌ 👉 WRONG — neurological signs are core features 🔥 High-yield facts (MEMORISE THESE) • Give IV thiamine BEFORE glucose ⚠️🔥 • Most common feature = confusion • Triad present in minority (~10%) • Untreated → Korsakoff syndrome (irreversible)

Answer 180

**Previous Exam Question** ✅ Correct Answer: A. Ketamine ⸻ 📖 Explanation (Examiner Logic) This question is testing recognition of intoxication patterns of hallucinogenic/dissociative drugs. 👉 The key features: • Hallucinations • Unsteady gait (ataxia) • Muscle rigidity 👉 This triad strongly points to ketamine, a dissociative anaesthetic (NMDA receptor antagonist). Ketamine causes: • Dissociation + hallucinations • Cerebellar effects → ataxia • Motor effects → rigidity 👉 The motor + perceptual combination is what makes this distinctive. ⸻ ❌ Why NOT the others (Very important for MRCPsych) B. LSD ❌ • Causes: hallucinations (especially visual distortions) • BUT: • ❌ No ataxia • ❌ No muscle rigidity 👉 Pure perceptual disturbance, not motor ⸻ C. Cocaine ❌ • Causes: paranoia, agitation, hallucinations • BUT: • ❌ Causes hyperactivity, not ataxia • ❌ No rigidity 👉 Think sympathetic overdrive, not dissociation ⸻ D. Cannabis ❌ • Causes: relaxation, giggling, altered perception • BUT: • ❌ Mild incoordination only • ❌ No rigidity 👉 Too mild + no motor syndrome ⸻ E. Diazepam ❌ • Causes: sedation, anxiolysis • BUT: • ❌ No hallucinations • ❌ No rigidity 👉 Opposite picture (CNS depressant) 🔥 High-Yield Facts 1. Ketamine = NMDA receptor antagonist (PCP-like drug) 2. Causes dissociation + hallucinations + ataxia (“wobbly”) 3. Chronic use → “ketamine bladder” (severe cystitis) ⸻ ⚠️ Exam Traps • Hallucinations alone → could be LSD, cocaine, cannabis • ADD motor signs (ataxia/rigidity) → think ketamine • LSD = purely perceptual (no motor signs)

Answer 181

✅ Correct Answer: E. Fine tremor ⸻ 📖 Explanation (Examiner Logic) This question is testing: 👉 Recognition of classic alcohol withdrawal features vs distractors from other toxidromes The key clinical feature of alcohol withdrawal is: • Fine, high-frequency tremor (“the shakes”) 👉 Typically: • Onset: 6–12 hours after last drink • Postural tremor (hands, tongue, eyelids) • Early and highly sensitive sign ⸻ ❌ Why NOT the others (VERY HIGH-YIELD DIFFERENTIAL) A. Hyperreflexia ❌ • Seen in: Serotonin syndrome Stimulant toxicity • Not a defining feature of alcohol withdrawal ⸻ B. Hypotension ❌ • Alcohol withdrawal → autonomic hyperactivity 👉 Expect: • Hypertension • Tachycardia NOT hypotension ⸻ C. Miosis ❌ • Classic for: 👉 Opioid intoxication (pinpoint pupils) • Alcohol withdrawal → pupils usually dilated or normal ⸻ D. Muscle rigidity ❌ • Seen in: • Neuroleptic malignant syndrome • Serotonin syndrome • Not typical for alcohol withdrawal ⸻ 🎯 What is this question testing? 👉 Alcohol withdrawal vs other toxidromes ⸻ 🔥 High-Yield Facts 1. Earliest sign of alcohol withdrawal = fine tremor (6–12 hours) 2. Autonomic hyperactivity: • Tachycardia • Hypertension • Sweating 3. Severe withdrawal → delirium tremens (48–72 hours)

Answer 182

**Previous Exam Question** ✅ Correct Answer: E. Analgesia ⸻ 📖 Explanation (Examiner Logic) This question is testing: 👉 Recognition of PCP (phencyclidine) intoxication toxidrome PCP is a: • Dissociative anaesthetic • NMDA receptor antagonist (like ketamine) 👉 Core features: • Profound analgesia (VERY HIGH-YIELD) ⭐ • Hallucinations • Agitation / violent behaviour • Nystagmus (vertical or horizontal — classic!) • Hypertension + tachycardia • Ataxia + rigidity 👉 The key distinguishing feature = reduced pain perception Patients may: • Sustain serious injuries • Show no response to pain ⸻ ❌ Why NOT the others (Important Differentials) A. Hypothermia ❌ • PCP → hyperthermia, not hypothermia 👉 Due to agitation + muscle activity ⸻ B. Hypotension ❌ • PCP → hypertension (sympathomimetic effect) ⸻ C. Respiratory depression ❌ • Seen in: • Opioids • Severe CNS depressants • PCP → NOT classically respiratory depressant ⸻ D. Bradycardia ❌ • PCP → tachycardia, not bradycardia ⸻ 🎯 What is this question testing? 👉 PCP toxidrome recognition ⸻ 🔥 High-Yield Facts 1. PCP = dissociative anaesthetic (NMDA antagonist) 2. Classic triad-ish pattern: • Analgesia • Nystagmus • Agitation/violence 3. Causes hypertension + tachycardia + hyperthermia

Answer 183

✅ Correct Answer: B. Amphetamine ⸻ 📖 Explanation (Examiner Logic) This question is testing: 👉 Recognition of stimulant withdrawal (“crash”) Amphetamine withdrawal is characterised by: • Hypersomnia (sleeping a lot) • Hyperphagia (increased appetite) • Irritability / low mood 👉 This is the opposite of intoxication effects (which are: • insomnia • reduced appetite • increased energy) 🔥 High-Yield Facts 1. Stimulant withdrawal = “CRASH”: • Hypersomnia • Hyperphagia • Depression 2. Occurs after: • Amphetamines • Cocaine 3. Not life-threatening (unlike alcohol/benzo withdrawal)

Answer 184

✅ Answer: Amphetamine withdrawal ⸻ 🧠 Explanation: Withdrawal from stimulants → “crash phase”: • Hypersomnia • Increased appetite • Vivid dreams ⸻ ❌ Why not others: • Depression → similar but lacks drug pattern • Alcohol withdrawal → opposite (↓ sleep, agitation) ⸻ 🔥 High-yield: 👉 Stimulant withdrawal = sleep + eat + low mood

Answer 185

✅ Answer: Cocaine intoxication ⸻ 🧠 Explanation: Cocaine: • Powerful sympathomimetic • Causes vasospasm → myocardial ischaemia ⸻ ❌ Why not others: • Amphetamines → similar but less strongly linked to MI • MDMA → more hyperthermia + empathy effects ⸻ 🔥 High-yield: 👉 Chest pain + agitation = cocaine until proven otherwise

Answer 186

✅ Answer: MDMA (ecstasy) intoxication ⸻ 🧠 Explanation: MDMA causes: • Hyperthermia 🔥 • Tachycardia • Hypertension • Confusion ⸻ ❌ Why not others: • Cocaine → more cardiac focus • Amphetamine → less hyperthermia prominence ⸻ 🔥 High-yield: 👉 Hyperthermia + party drug = MDMA

Answer 187

✅ Answer: Alcohol withdrawal ⸻ 🧠 Explanation: Classic autonomic hyperactivity: • Tremor • Sweating • Agitation • Nausea/vomiting ⸻ ❌ Why not others: • Opioid withdrawal → diarrhoea, yawning, lacrimation • Benzodiazepine withdrawal → similar but context differs ⸻ 🔥 High-yield: 👉 Tremor + sweating = alcohol withdrawal until proven otherwise

Answer 188

✅ Correct answer: 👉 D. Anxiety ⸻ 🔍 Explanation (exam-focused) 👉 Opioid withdrawal happens in stages: ⸻ 🧠 EARLY symptoms (first) • Anxiety ✔️ • Agitation • Insomnia • Sweating • Yawning • Rhinorrhoea (runny nose) ⸻ 🧠 LATE symptoms (later) • Abdominal cramps • Nausea/vomiting • Diarrhoea • Fever • Hypertension 🎯 Exam memory trick 👉 Early = “flu-like + anxiety” 👉 Late = “GI explosion” 💥 (vomiting, cramps, diarrhoea)

Answer 189

✅ Correct answer: 👉 B. 80% ⸻ 🔍 Explanation • Long-term cocaine use is strongly associated with psychiatric comorbidity • Lifetime prevalence ≈ 50–80% • Exam answer = upper range → 80% ⸻ ❌ Why others are wrong: • All other values underestimate the association • In MRCPsych → substance misuse = very high comorbidity ⸻ 💥 High-yield Paper B facts • Cocaine → paranoia + psychosis (can mimic schizophrenia) • Cocaine withdrawal → depression + suicidality • Substance misuse overall → ~70–80% psychiatric comorbidity • Alcohol dependence → depression in ~40–60% • Cannabis → ↑ risk of psychosis (especially early onset use)

Answer 190

✅ Correct answer: 👉 A. 80% ⸻ 🔍 Explanation • Ataxia + confusion in alcohol user → Wernicke’s encephalopathy • Caused by thiamine deficiency ⸻ 🧠 Progression: 👉 Untreated Wernicke’s → Korsakoff syndrome • Severe memory impairment • Confabulation • Irreversible in many cases ⸻ 📊 Key statistic: 👉 ~80% develop Korsakoff syndrome 💥 High-yield Paper B facts • Wernicke’s triad: • Confusion • Ataxia • Ophthalmoplegia (often missing → exam trap) • Always give: 👉 IV thiamine BEFORE glucose • Korsakoff: Anterograde amnesia > retrograde Confabulation = key feature • Alcohol-related brain damage = spectrum

Answer 191

✅ Correct answer: 👉 E. 3 ⸻ 🔍 Explanation • ICD-10 alcohol dependence = ≥3 criteria • Must occur together within 1 year ICD-10 dependence criteria (classic 6 — know them!): 1. Craving (strong desire) 2. Impaired control 3. Withdrawal 4. Tolerance 5. Neglect of alternative pleasures 6. Persistent use despite harm 👉 Need ≥3

Answer 192

✅ Correct answer: 👉 C. 12 ⸻ 🔍 Explanation • SAWS = self-rated withdrawal scale • Threshold for treatment: 👉 >12 → consider pharmacological treatment (e.g. benzodiazepines) 💥 High-yield Paper B facts • SAWS: • Self-completed • Covers last 24 hours • Each symptom scored 0–4 • Symptoms include: Anxiety Tremor Sweating Nausea Sleep disturbance Confusion ————————— 🔹 CIWA vs SAWS 🧠 CIWA-Ar 👉 Clinical Institute Withdrawal Assessment for Alcohol – Revised 🔍 What it is: • Clinician-rated scale • Used in hospital / supervised settings 📊 Structure: • 10 items • Score range: 0–67 💊 Treatment thresholds: • ≥8–10 → start medication (benzodiazepines) • ≥15 → severe withdrawal ⸻ 🧠 SAWS 👉 Short Alcohol Withdrawal Scale 🔍 What it is: • Self-rated questionnaire • Used in community / outpatient 📊 Structure: • 10 symptoms • Each scored 0–4 • Max score: 40 💊 Treatment threshold: • >12 → consider pharmacotherapy

Answer 193

✅ Correct answer: 👉 B. 80% ⸻ 🔍 Explanation • Long-term cocaine use is strongly associated with psychiatric comorbidity • Lifetime prevalence ≈ 50–80% • Exam answer = upper range → 80% ⸻ ❌ Why others are wrong: • All other values underestimate the association • In MRCPsych → substance misuse = very high comorbidity ⸻ 💥 High-yield Paper B facts • Cocaine → paranoia + psychosis (can mimic schizophrenia) • Cocaine withdrawal → depression + suicidality • Substance misuse overall → ~70–80% psychiatric comorbidity • Alcohol dependence → depression in ~40–60% • Cannabis → ↑ risk of psychosis (especially early onset use)

Answer 194

✅ Correct answer: 👉 A. 12 year old with ADHD not on any medications ⸻ 🔍 Explanation • Untreated ADHD → ↑ risk of substance misuse later • Treatment (especially stimulants) is protective, NOT harmful ⸻ ❌ Why others are wrong: • Atomoxetine → reduces risk • Stimulants → protective effect (very exam favourite trap) • Combined therapy → even better outcomes • Clonidine → still treatment → not highest risk ⸻ 💥 High-yield Paper B facts • ADHD untreated → ↑ risk of: • Substance misuse • Conduct disorder • Criminality • Stimulants: 👉 Do NOT increase addiction risk 👉 Actually reduce later substance misuse ⸻ 🎯 Exam takeaway 👉 Untreated ADHD = highest substance misuse risk

Answer 195

✅ Correct answer: 👉 D. 24–48 hours –12 hrs Early symptoms (anxiety, tremor) 24–48 hrs Peak symptoms 48–72 hrs Seizures possible 72+ hrs Delirium tremens 💥 High-yield Paper B facts • Early symptoms: 👉 Anxiety, tremor, sweating, insomnia • Severe complications: • Seizures → 12–48 hrs • Delirium tremens → 48–72 hrs • Peak autonomic instability: 👉 24–48 hrs ⸻ 🎯 Exam takeaway 👉 Alcohol withdrawal peaks at 24–48 hrs 👉 DTs = after 48–72 hrs

Answer 196

✅ Correct answer: 👉 D. 48 hours ⸻ 🔍 Explanation • Amphetamines are short-to-intermediate detection drugs • Urine detection window: 👉 ~48 hours (typical exam answer) ⸻ ❌ Why others are wrong: • 6 hours → too short • 24 hours → possible but not max window • 7 days → too long (think cannabis instead) • 30 days → cannabis chronic use ⸻ 💥 High-yield Paper B facts (VERY important table) Urine detection: • Amphetamines → 1–2 days (≈48h) • Opioids (morphine/codeine) → 1–2 days • Cocaine → 2–3 days • Benzodiazepines → days–weeks (longer if long-acting) • Cannabis: • Single use → 3–4 days • Chronic use → up to 30 days

Answer 197

✅ Correct answer: 👉 C. Acamprosate ⸻ 🔍 Explanation • Acamprosate = relapse prevention drug • Works by: 👉 Reducing craving 👉 Modulating glutamate/GABA balance • Effect: 👉 Modest but evidence-based ⸻ ❌ Why others are wrong: • Naltrexone • Also relapse prevention BUT exam fav distinction: 👉 Reduces heavy drinking / craving, not specifically “modest abstinence maintenance” phrasing • Disulfiram • ❌ NOT relapse prevention 👉 Deterrent (aversive reaction with alcohol) • Diazepam / Chlordiazepoxide • ❌ Used for withdrawal, not relapse prevention ⸻ 💥 High-yield Paper B facts Alcohol relapse meds: 🔹 Acamprosate • Start after abstinence • Maintains abstinence • Safe in liver disease • Renally excreted ⸻ 🔹 Naltrexone • Reduces craving & heavy drinking • Avoid in liver failure ⸻ 🔹 Disulfiram • Causes acetaldehyde reaction • Needs supervision • Not for relapse prevention per se

Answer 198

✅ Correct answer: 👉 A. ADHD ⸻ 🔍 Explanation • Maternal smoking → ↑ risk of ADHD • Association is: 👉 Consistent 👉 Modest (≈1.2–1.3x risk) • Likely mechanisms: • Nicotine → dopaminergic disruption • Fetal brain development effects ⸻ ❌ Why others are wrong: • Autism / ASD → evidence inconsistent • Learning disability → weaker association • Mood disorders → not classic exam link ⸻ 💥 High-yield Paper B facts Maternal smoking is associated with: • ADHD ✅ (most testable) • Low birth weight • Prematurity • Conduct problems

Answer 199

✅ Correct answer: 👉 B. Anxiety ⸻ 🔍 Explanation • Benzodiazepines = anti-anxiety drugs 👉 So withdrawal = rebound anxiety • Most common symptom: 👉 Anxiety (core feature) ⸻ ❌ Why others are wrong: • Perceptual distortion → occurs but not most common • Blurred vision → uncommon • Depression → not main acute feature • Nystagmus → not typical withdrawal feature ⸻ 💥 High-yield Paper B facts Benzodiazepine withdrawal: Early/common: • Anxiety (MOST IMPORTANT) • Insomnia • Irritability • Tremor Severe: • Seizures • Psychosis • Delirium

Answer 200

✅ Correct answer: 👉 A. Anxiety ⸻ 🔍 Explanation • MDMA = empathogen (↑ serotonin) 👉 Causes: • Euphoria • Empathy / friendliness • Increased sociability • Mild stimulation 👉 NOT typically anxiety in the acute phase ⸻ ❌ Why others are wrong: • Increased desire to do mental tasks → stimulant effect • Disinhibition → common • Increased friendliness → hallmark effect • Perceptual disturbances → can occur (mild psychedelic effect) ⸻ 💥 High-yield Paper B facts MDMA acute effects: • ↑ serotonin → empathy + bonding • ↑ dopamine → mild stimulation • ↑ oxytocin → social connection Later effects (IMPORTANT contrast): 👉 Anxiety + low mood (“mid-week crash”)

SUD Flashcards

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