Test 3 Substance-Related and Addictive Disorders DSM-5 Self-Exam Questions

Which of the following is the only non-substance-related disorder to be included in the DSM-5 chapter "Substance-Related and Addictive Disorders"? A. Gambling disorder. B. Internet gaming disorder. C. Electronic communication addiction disorder. D. Compulsive computer use disorder. E. Compulsive shopping.

Ans: A Explanation: In addition to the substance-related disorders, the DSM-5 Substance- Related and Addictive Disorders chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders. Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. (Proposed criteria for Internet gaming disorder have been placed in DSM-5 Section III ["Conditions for Further Study"] in order to encourage further research.) Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as "sex addiction," "exercise addiction," or "shopping addiction," are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.

Which of the following statements about alcohol withdrawal is true? A. Fewer than 10% of individuals undergoing alcohol withdrawal experience dramatic symptoms such as severe autonomic hyperactivity, tremors, or alcohol withdrawal delirium. B. Delirium occurs in the majority of individuals who meet criteria for alcohol withdrawal. C. Approximately 80% of all patients with alcohol use disorder will experience alcohol withdrawal. D. Tonic-clonic seizures occur in about 15% of individuals who meet criteria for alcohol withdrawal. E. Alcohol withdrawal symptoms typically begin between 24 and 48 hours after alcohol use has been stopped or reduced.

Ans: A Explanation: It is estimated that approximately 50% of middle-class, highly functional individuals with alcohol use disorder have ever experienced a full alcohol withdrawal syndrome. Among individuals with alcohol use disorder who are hospitalized or homeless, the rate of alcohol withdrawal may be greater than 80%. Fewer than 10% of individuals who develop alcohol withdrawal will ever develop dramatic symptoms (e.g., severe autonomic hyperactivity, tremors, alcohol withdrawal delirium). Tonic-clonic seizures occur in fewer than 3% of individuals. Withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been stopped or reduced.

Which of the following symptoms is a recognized consequence of the abrupt termination of daily or near-daily cannabis use? A. Hallucinations. B. Delusions. C. Hunger. D. Irritability. E. Apathy.

Ans: D Explanation: Cannabis withdrawal is a newly recognized disorder in DSM-5. Common symptoms of cannabis withdrawal include irritability, anger, or aggression; nervousness or anxiety; sleep difficulty; decreased appetite or weight loss; restlessness; and depressed mood. Although typically not as severe as withdrawal from alcohol, sedative/hypnotics, or opioids, cannabis withdrawal can cause significant distress, contribute to difficulty quitting, and increase the risk of relapse.

The Criterion A symptoms listed for other hallucinogen use disorder are the same as those listed for use disorders of most other substance classes, with one exception. Which of the following is not a recognized symptom associated with hallucinogen use? A. Withdrawal. B. Tolerance. C. A persistent desire or unsuccessful efforts to cut down or control use of the substance. D. Recurrent use of the substance in situations in which it is physically hazardous. E. Craving, or a strong desire or urge to use the substance.

Ans: A Explanation: The Criterion A symptoms listed for other hallucinogen use disorder are the same as those listed for use disorders of most other substance classes, with the exception of withdrawal. A clinically significant withdrawal syndrome associated with hallucinogens has not been consistently documented in humans, and therefore the diagnosis of other hallucinogen withdrawal is not included in DSM-5.

Which organ system or anatomical function is most commonly affected by chronic use of 3,4-methylenedioxymethamphetamine (MDMA [Ecstasy])? A. Neurological. B. Respiratory. C. Cardiopulmonary. D. Oral cavity. E. Immunological/infectious.

Ans: A Explanation: There is significant evidence for long-term neurotoxic effects of MDMA use, including memory impairment, neuroendocrine function, sleep disturbance, psychological functioning, and serotonin system. Damage to brain microvasculature, white matter maturation, and axonal connections are included among neurotoxic events.

In most substance/medication-induced mental disorders (with the exception of substance/medication-induced major or mild neurocognitive disorder and hallucinogen persisting perception disorder), if the person abstains from substance use, the disorder will eventually disappear or no longer be clinically relevant even without formal treatment. In what time frame is this likely to happen? A. One hour. B. One month. C. Three months. D. One year. E. "Relatively quickly" but no specific period of time.

Ans: B Explanation: Although the symptoms of substance/medication-induced mental disorders can be identical to those of independent mental disorders (e.g., delusions, hallucinations, psychoses, major depressive episodes, anxiety syndromes), and although they can have the same severe consequences (e.g., suicide), most induced mental disorders are likely to improve relatively quickly with abstinence and are unlikely to remain clinically relevant for more than 1 month after complete cessation of use.

A 25-year-old woman is brought to the emergency department by her friends after a party. They report that the woman had been seen ingesting some unknown pills earlier in the evening. She became increasingly confused throughout the course of the night. She eventually had a witnessed seizure on the street, prompting activation of emergency medical services. Vital signs indicate that the patient is tachycardic and hypertensive. On evaluation, the patient is observed to be thin with dilated pupils. She is smiling to herself, is fidgety, and is oriented to self, place, and date. When queried about auditory hallucinations, the patient admits that she is hearing voices but is unconcerned, stating, "I only hear them while I'm partying, Doc." Which diagnosis best fits this clinical presentation? A. Stimulant-induced manic episode. B. Stimulant-induced psychotic disorder. C. Stimulant intoxication, with perceptual disturbances. D. Other hallucinogen-induced psychotic disorder. E. Other hallucinogen intoxication.

Ans: C Explanation: Although both other hallucinogen intoxication and stimulant intoxication can present with hallucinations, pupillary dilation, and tachycardia, only the stimulant intoxication criteria include development of confusion and seizures. The diagnosis of stimulant intoxication with perceptual disturbances is made when a person does not have delirium but has either hallucinations with intact reality testing—such as in this vignette—or auditory, visual, or tactile illusions.

Which of the following substances is most likely to be associated with polydrug use? A. Cannabis. B. Tobacco. C. 3,4-Methylenedioxymethamphetamine (MDMA [Ecstasy]). D. Methamphetamine. E. Alcohol.

Ans: C Explanation: Both adults and adolescents who use MDMA are more likely than those who use other drugs to be polydrug users and to have other substance use disorders.

Which substance use disorder of an illicit substance is the most prevalent in the United States? A. Alcohol use disorder. B. Caffeine use disorder. C. Cannabis use disorder. D. Opioid use disorder. E. Stimulant use disorder.

Ans: C Explanation: Cannabinoids are the most widely used illicit psychoactive substances in the United States. The 12-month prevalence of cannabis use disorder is approximately 3.4% among 12- to 17-year-olds and 1.5% among adults age 18 years or older. Alcohol use disorder is the most prevalent of all of the substance use disorders in the United States. The 12-month prevalence of alcohol use disorder is estimated to be 4.6% among 12- to 17-year-olds and 8.5% among adults age 18 years or older in the United States. Although caffeine is the most widely used behaviorally active substance in the world, there are insufficient data to determine the clinical significance of caffeine use disorder and its prevalence at this time. Thus, caffeine use disorder is not an officially recognized DSM-5 diagnosis but rather is included in "Conditions for Further Study" (Section III) as a proposed diagnostic set. The 12-month prevalence of opioid use disorder is approximately 0.37% among adults age 18 years or older in the community population. Regarding stimulant use disorders, the 12-month prevalence of cocaine use disorder in the United States is approximately 0.2% among 12- to 17-year-olds and 0.3% among adults age 18 years or older, and the 12-month prevalence of amphetamine-type stimulant use disorder in the United States is approximately 0.2% among 12- to 17-year-olds and 0.2% among adults age 18 years or older.

What is the hallmark feature of caffeine withdrawal? A. Vomiting. B. Drowsiness. C. Flu-like symptoms. D. Headache. E. Dysphoria.

Ans: D Explanation: Headache is the hallmark feature of caffeine withdrawal. The remaining options are also symptoms of caffeine withdrawal and could occur in absence of headache. Caffeine is the most widely consumed behaviorally active drug in the world. Because caffeine ingestion is often integrated into social customs and daily rituals (e.g., coffee break, tea time), some caffeine consumers may be unaware of their physical dependence on caffeine and thus withdrawal symptoms could be unexpected and misattributed to other causes (e.g., the flu, migraine). Caffeine withdrawal symptoms may occur when individuals are required to abstain from foods and beverages prior to medical procedures or when a usual caffeine dose is missed because of a change in routine (e.g., during travel, weekends).

Which of the following laboratory tests can be used in combination with gamma-glutamyltransferase (GGT) to monitor abstinence from alcohol? A. Alanine aminotransferase (ALT). B. Alkaline phosphatase. C. Carbohydrate-deficient transferrin (CDT). D. Mean corpuscular volume (MCV). E. Triglycerides.

Ans: C Explanation: Elevation of GGT is a sensitive laboratory indicator of heavy drinking. At least 70% of individuals with a high GGT level are persistent heavy drinkers (i.e., consuming eight or more drinks daily on a regular basis). A second test with comparable or even higher levels of sensitivity and specificity is CDT, with levels of 20 units or higher useful in identifying individuals who regularly consume eight or more drinks daily. Since both GGT and CDT levels return toward normal within days to weeks of stopping drinking, both state markers are useful in monitoring abstinence, especially when the clinician observes increases, rather than decreases, in these values over time. The combination of CDT and GGT may have even higher levels of sensitivity and specificity than either test used alone. Although the MCV can be used to help identify those who drink heavily, it is a poor method of monitoring abstinence because of the long half-life of red blood cells. Liver function tests (e.g., ALT and alkaline phosphatase) can reveal liver injury that is a consequence of heavy drinking. Nonspecific elevations of lipid levels in the blood (e.g., triglycerides and lipoprotein cholesterol) may also be observed due to decreases in gluconeogenesis associated with heavy drinking.

What are the three main chemical classes of hallucinogens? A. Ethnobotanical compounds, ergolines, and phenylalkylamines. B. Ethnobotanical compounds, ergolines, and indoleamines. C. Indoleamines, ergolines, and phenylalkylamines. D. Tryptoamines, indoleamines, and ergolines. E. Tryptoamines, phenylalkylamines, and hydrocarbons.

Ans: C Explanation: Hallucinogens comprise a diverse group of substances that, despite having different chemical structures and possibly involving different molecular mechanisms, produce similar alterations of perception, mood, and cognition in users. Hallucinogens included are phenylalkylamines (e.g., mescaline, DOM [2,5-dimethoxy-4-methylamphetamine], and MDMA [3,4-methylenedioxymethamphetamine; also called Ecstasy]); the indoleamines, including psilocybin (i.e., psilocin) and dimethyltryptamine (DMT); and the ergolines, such as LSD (lysergic acid diethylamide) and morning glory seeds. In addition, miscellaneous other ethnobotanical compounds are classified as hallucinogens, of which Salvia divinorum and jimsonweed are two examples. Volatile hydrocarbons are included among the inhalants.

Which mental disorder or disorder class has the highest prevalence among individuals with cannabis use disorder? A. Major depressive disorder. B. Bipolar I disorder. C. Anxiety disorders. D. Schizophrenia spectrum and other psychotic disorders. E. Conduct disorder.

Ans: C Explanation: Individuals with past-year or lifetime diagnoses of cannabis use disorder have high rates of concurrent mental disorders. Anxiety disorders are the most prevalent (24%), followed by bipolar I disorder (13%) and major depressive disorder (11%).

What is the most common co-occurring psychiatric diagnosis among individuals with a history of significant prenatal alcohol exposure? A. Major depressive disorder. B. Generalized anxiety disorder. C. Attention-deficit/hyperactivity disorder. D. Oppositional defiant disorder. E. Substance use disorder.

Ans: C Explanation: Mental health problems have been identified in more than 90% of individuals with histories of significant prenatal alcohol exposure. The most common co-occurring diagnosis is attention-deficit/hyperactivity disorder. Other high-probability co-occurring disorders include oppositional defiant disorder and conduct disorder. Mood symptoms have been described, including symptoms of bipolar disorder and depression. History of prenatal alcohol exposure is associated with an increased risk of later nicotine, alcohol, and drug misuse or dependence.

Because opioid withdrawal and sedative, hypnotic, or anxiolytic withdrawal can involve very similar symptoms, distinguishing between the two can be difficult. Which of the following presenting symptoms would aid in making the correct diagnosis? A. Nausea or vomiting. B. Anxiety. C. Yawning. D. Restlessness or agitation. E. Insomnia.

Ans: C Explanation: Opioid withdrawal is characterized by a pattern of signs and symptoms that are opposite to the acute agonist effects. The first of these are subjective and consist of complaints of anxiety, restlessness, and an "achy feeling" that is often located in the back and legs, along with irritability and increased sensitivity to pain. Three or more of the following must be present to make a diagnosis of opioid withdrawal: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or increased sweating; diarrhea; yawning; fever; insomnia (Criterion B). Piloerection and fever are associated with more severe withdrawal and are not often seen in routine clinical practice because individuals with opioid use disorder usually obtain substances before withdrawal becomes that far advanced. Sedative, hypnotic, or anxiolytic withdrawal also includes anxiety and psychomotor agitation among its DSM-5 symptom criteria. These are not criteria included in the DSM-5 definition of opioid withdrawal, but withdrawal from opioids is nonetheless often accompanied by anxiety and restlessness. Only opioid withdrawal presents with yawning, rhinorrhea or lacrimation, pupillary dilation, or muscle aches, any of which may be used to fulfill Criterion B for a withdrawal diagnosis.

A 25-year-old medical student presents to the student health service at 7 A.M. complaining of having a "panic attack." He reports that he stayed up all night studying for his final gross anatomy exam, which starts in an hour, but he feels too anxious to go. He reports vomiting twice. The patient is restless and appears flushed, with visible muscle twitching. He is urinating excessively, has tachycardia, and his electrocardiogram shows premature ventricular complexes. His thoughts and speech appear to be rambling in nature. His urine toxicology screen is negative. What is the most likely diagnosis? A. Panic disorder. B. Amphetamine intoxication, amphetamine-like substance. C. Caffeine intoxication. D. Cocaine intoxication. E. Alcohol withdrawal.

Ans: C Explanation: This patient is exhibiting signs of restlessness, flushed face, gastrointestinal disturbance, muscle twitching, diuresis, rambling flow of speech, and cardiac abnormalities, all of which are consistent with caffeine intoxication. While a panic episode might be associated with tachycardia or gastrointestinal distress, it would not cause muscle twitching or cardiac arrhythmias. Intoxication with stimulants such as amphetamine or cocaine would present very similarly with psychomotor agitation and cardiac arrhythmias, but these substances would not cause diuresis and would be expected to show up on a urine toxicology screen. Alcohol withdrawal could also present similarly but is typically characterized by tremor rather than muscle twitching, and it also does not cause diuresis.

A 27-year-old woman presents for psychiatric evaluation after almost hitting someone with her car while driving under the influence of marijuana. She reports that she was prompted to seek treatment by her husband, with whom she has had several conflicts over the past year about her ongoing marijuana use. She has continued to smoke two joints daily and drive while under the influence of marijuana since this event. What is the appropriate diagnosis? A. Cannabis abuse. B. Cannabis dependence. C. Cannabis intoxication. D. Cannabis use disorder. E. Unspecified cannabis-related disorder.

Ans: D Explanation: The patient described in this vignette meets criteria for cannabis use disorder, which is manifested by recurrent cannabis use in situations in which it is physically hazardous and continued use despite having persistent interpersonal problems due to cannabis. Although this particular patient would have met DSM-IV criteria for cannabis abuse, in DSM-5 the separate diagnoses of cannabis abuse and cannabis dependence are subsumed under the diagnosis of cannabis use disorder. There is no information in the vignette to suggest that the patient is currently intoxicated. Because she meets criteria for a specific cannabis-related disorder, the diagnosis "unspecified cannabis related disorder" would not be appropriate.

Which personality disorder has the highest prevalence among individuals with cannabis use disorder? A. Obsessive-compulsive personality disorder. B. Paranoid personality disorder. C. Schizotypal personality disorder. D. Borderline personality disorder. E. Antisocial personality disorder.

Ans: E Explanation: Antisocial personality disorder is the most prevalent (30%) personality disorder among individuals with cannabis use disorder, followed by obsessive-compulsive personality disorder (19%) and paranoid personality disorder (18%).

A 22-year-old university student presents to his primary care physician complaining of progressive worsening of numbness, tingling, and weakness in both of his legs over the past several weeks. His gait is unsteady, and he has difficulty grasping objects in his hands. He did not use any substances on the day of presentation but admits that over the past 3 months he has been consistently using one particular substance on a daily basis. Which substance use disorder most likely accounts for this patient's symptoms? A. Cannabis use disorder. B. Other hallucinogen use disorder. C. Inhalant use disorder. D. Opioid use disorder. E. Other (or unknown) substance use disorder.

Ans: E Explanation: Because of increased access to nitrous oxide ("laughing gas"), membership in certain populations is associated with diagnosis of nitrous oxide use disorder. The role of this gas as an anesthetic agent leads to misuse by some medical and dental professionals. Its use as a propellant for commercial products (e.g., whipped cream dispensers) contributes to misuse by food service workers. With recent widespread availability of the substance in "whippet" cartridges for use in home whipped cream dispensers, nitrous oxide misuse by adolescents and young adults is significant, especially among those who also inhale volatile hydrocarbons. Some continuously using individuals, inhaling from as many as 240 whippets per day, may present with serious medical complications and mental conditions, including myeloneuropathy, spinal cord subacute combined degeneration (as seen in the patient in this vignette), peripheral neuropathy, and psychosis. These conditions are also associated with a diagnosis of nitrous oxide use disorder.

Alcohol intoxication, inhalant intoxication, and sedative, hypnotic, or anxiolytic intoxication have which of the following Criterion C signs/symptoms in common? A. Depressed reflexes. B. Generalized muscle weakness. C. Blurred vision. D. Impairment in attention or memory. E. Nystagmus.

Ans: E Explanation: Nystagmus is a Criterion C sign of alcohol, inhalant, and sedative, hypnotic, or anxiolytic intoxication. Depressed reflexes, generalized muscle weakness, and blurred vision are Criterion C signs of inhalant intoxication but are not associated with either alcohol intoxication or sedative, hypnotic, or anxiolytic intoxication. Impairment in attention or memory is a Criterion C sign of both alcohol intoxication and of sedative, hypnotic, or anxiolytic intoxication but is not a diagnostic feature of inhalant intoxication.

To meet proposed criteria for the Section III condition neurobehavioral disorder associated with prenatal alcohol exposure, an individual's prenatal alcohol exposure must have been "more than minimal." How is "more than minimal" exposure defined, in terms of how much alcohol was used by the mother during gestation? A. Fewer than 7 drinks per month, and no more than 1 drink per drinking occasion. B. Fewer than 7 drinks per month, and no more than 2 drinks per drinking occasion. C. Fewer than 7 drinks per month, and no more than 3 drinks per drinking occasion. D. Fewer than 14 drinks per month, and no more than 1 drink per drinking occasion. E. Fewer than 14 drinks per month, and no more than 2 drinks per drinking occasion.

Ans: E Explanation: Proposed criteria for neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) have been placed in DSM-5 Section III ("Conditions for Further Study") in order to encourage further research. Data suggest that a history of more than minimal gestational exposure (i.e., more than light drinking) prior to pregnancy recognition and/or following pregnancy recognition may be needed to significantly impact neurodevelopmental outcome. "Light drinking" is defined as 1-13 drinks per month during pregnancy with no more than 2 of these drinks consumed on any 1 drinking occasion. Confirmation of gestational exposure to alcohol may be obtained from maternal self-report of alcohol use in pregnancy, medical or other records, or clinical observation.

A 45-year-old man with a long-standing history of heavy alcohol use is referred for psychiatric evaluation after his recent admission to the hospital for acute hepatitis. The patient reports that he drank almost daily in college. Over the past 10 years, he has gradually increased his nightly alcohol intake from a single 6-pack to two 12-packs of beer, and this nightly drinking habit has resulted in his frequently oversleeping and missing work. He has tried to moderate his alcohol use on numerous occasions with little success, particularly after developing complications associated with alcoholic cirrhosis. The patient admits that he becomes anxious and gets hand tremors when he doesn't drink. This patient meets the criteria for which of the following diagnoses? A. Alcohol abuse. B. Alcohol dependence. C. Alcohol use disorder, mild. D. Alcohol use disorder, moderate. E. Alcohol use disorder, severe.

Ans: E Explanation: Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed. As a general estimate of severity, a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Changing severity across time is also reflected by reductions or increases in the frequency and/or dose of substance use, as assessed by the individual's own report, report of knowledgeable others, clinician's observations, and biological testing. The patient described in this vignette meets criteria for alcohol use disorder, severe. Alcohol abuse and alcohol dependence are DSM-IV diagnoses that have been eliminated from DSM-5.