Drug-Induced Psychiatric Symptoms — MCQs
A 45-year-old patient with a history of depression was initially being treated with sertraline, but his symptoms were not adequately controlled. His medication regimen was changed to include an MAO inhibitor and amitriptyline. Shortly after the change in medication, the patient developed agitation, seizures, hyperreflexia, and tremor. Which of the following is the most appropriate treatment for this patient?
What is the treatment for extrapyramidal side effects induced by Haloperidol?
Delusion of persecution and formication occur together in
The use of levodopa is avoided in which of the following patients?
A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
Choose the correctly matched pairs regarding the drugs used in schizophrenia: 1. D2 antagonism: Reduces positive symptoms 2. 5HT2A antagonism: Reduces negative symptoms 3. 5HT1A agonism: Weight loss 4. Muscarinic antagonism: Reduces extrapyramidal symptoms
Which of the following dementia is associated with visual hallucinations?
Caution is taken while doing Inter-maxillary Fixation (IMF) for which of these types of patients?
A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is
Sedation as an adverse effect is most commonly associated with which of the following atypical antipsychotics?
Drug-Induced Psychiatric Symptoms Indian Medical PG Practice Questions and MCQs
Question 1: A 45-year-old patient with a history of depression was initially being treated with sertraline, but his symptoms were not adequately controlled. His medication regimen was changed to include an MAO inhibitor and amitriptyline. Shortly after the change in medication, the patient developed agitation, seizures, hyperreflexia, and tremor. Which of the following is the most appropriate treatment for this patient?
- A. Cyproheptadine (Correct Answer)
- B. Lorazepam
- C. L-carnitine
- D. Leucovorin
- E. Dantrolene
Explanation: ***Cyproheptadine*** - This patient exhibits symptoms of **serotonin syndrome** (agitation, seizures, hyperreflexia, tremor) due to the combination of an **MAO inhibitor** and **amitriptyline**. - **Cyproheptadine** is a **serotonin antagonist** and is the most appropriate treatment for reversing the effects of serotonin syndrome. - Treatment also includes discontinuing offending agents and supportive care. *Lorazepam* - **Lorazepam** is a **benzodiazepine** that can help manage agitation and seizures, but it does not address the underlying serotonin overstimulation. - It would be used as an adjunct for symptom control, not as the primary treatment for serotonin syndrome. *Dantrolene* - **Dantrolene** is a **muscle relaxant** used for **neuroleptic malignant syndrome (NMS)** and **malignant hyperthermia**. - While NMS and serotonin syndrome can have overlapping features (hyperthermia, rigidity), dantrolene is not indicated for serotonin syndrome. - Cyproheptadine is the specific serotonin antagonist needed for this condition. *L-carnitine* - **L-carnitine** is a supplement often used for conditions like **carnitine deficiency** or certain **metabolic disorders**. - It has no role in the treatment of serotonin syndrome. *Leucovorin* - **Leucovorin** (folinic acid) is used to **rescue bone marrow** from the toxic effects of **methotrexate** or to enhance the effects of **fluorouracil**. - It is not indicated for the treatment of serotonin syndrome.
Question 2: What is the treatment for extrapyramidal side effects induced by Haloperidol?
- A. Barbiturates
- B. SSRIs
- C. Benzodiazepines
- D. Anticholinergic drugs (Correct Answer)
Explanation: ***Anticholinergic drugs (effective treatment)*** - **Anticholinergic medications**, such as **benztropine** or **diphenhydramine**, are the primary treatment for **acute extrapyramidal symptoms (EPS)** like dystonia and parkinsonism induced by antipsychotics like haloperidol. - They work by **blocking muscarinic acetylcholine receptors**, helping to restore the balance between dopamine and acetylcholine in the basal ganglia. *Benzodiazepines (used for anxiety and muscle relaxation)* - While benzodiazepines can offer some relief for **akathisia** (a form of EPS characterized by restlessness) due to their sedative and muscle relaxant properties, they are **not the first-line treatment for other acute EPS** such as dystonia or parkinsonism. - They primarily enhance **GABAergic transmission** and are effective for anxiety and seizure control rather than direct antagonism of EPS mechanisms. *Barbiturates (used as sedative-hypnotic drugs)* - **Barbiturates** are strong central nervous system depressants used for sedation, anesthesia, and seizure control, but are **not indicated for the treatment of EPS**. - Their significant **sedative and addictive potential**, along with a narrow therapeutic index, makes them unsuitable for this purpose. *SSRIs (used for depression and anxiety)* - **SSRIs (Selective Serotonin Reuptake Inhibitors)** are antidepressants that work by increasing serotonin levels in the brain and are used to treat depression, anxiety, and obsessive-compulsive disorder. - They **do not have a direct role** in ameliorating dopamine-acetylcholine imbalance responsible for haloperidol-induced EPS.
Question 3: Delusion of persecution and formication occur together in
- A. LSD
- B. Cocaine (Correct Answer)
- C. Amphetamine
- D. Cannabis
Explanation: ***Cocaine*** - **Chronic cocaine abuse** can lead to **paranoid delusions** (delusions of persecution) and tactile hallucinations such as **formication** (sensation of insects crawling under the skin, called "**cocaine bugs**"). - These symptoms occur together in **cocaine-induced psychosis**, which can mimic **paranoid schizophrenia**. - The combination of **paranoid delusions with formication** is a classical presentation of **stimulant psychosis**, seen with cocaine. *Amphetamine* - **Amphetamine/methamphetamine abuse** can also cause **psychotic symptoms** including paranoia, delusions of persecution, and formication ("**meth mites**"). - While both cocaine and amphetamine can cause this combination, **cocaine** is the **traditional answer** in medical examinations for this specific combination of symptoms. - Clinically, amphetamine-induced formication is increasingly recognized. *LSD* - **Lysergic acid diethylamide (LSD)** primarily causes **visual hallucinations**, altered perceptions, and synesthesia. - While LSD can induce paranoia and anxiety, **delusions of persecution** and **formication** are not typical features. - LSD effects are more perceptual distortions than true psychotic symptoms. *Cannabis* - **Cannabis use** can sometimes induce **acute psychotic episodes** in vulnerable individuals, particularly with high-potency preparations. - Cannabis effects include **anxiety**, **paranoia**, and **depersonalization**. - **Formication** and prominent **delusions of persecution** are not characteristic of cannabis intoxication.
Question 4: The use of levodopa is avoided in which of the following patients?
- A. Amyotrophic lateral sclerosis
- B. Psychosis (Correct Answer)
- C. Alzheimer's disease
- D. Essential tremor
Explanation: ***Psychosis*** - Levodopa increases **dopaminergic activity** in the brain, which can significantly worsen or induce **psychotic symptoms** like hallucinations and delusions. - Patients with pre-existing psychosis or a history of psychotic episodes are at high risk, making levodopa a **contraindicated** treatment. *Alzheimer's disease* - While Alzheimer's patients may experience motor symptoms, levodopa is generally not avoided unless there are specific **parkinsonian features** responsive to dopamine. - The primary symptoms of Alzheimer's are **cognitive decline**, which levodopa does not treat and could potentially worsen agitation or confusion in advanced stages. *Amyotrophic lateral sclerosis* - **ALS** is a progressive neurodegenerative disease affecting motor neurons, leading to muscle weakness and atrophy. - Levodopa is **not effective** in treating ALS because the disease pathology does not involve dopamine deficiency. *Essential tremor* - Essential tremor is a movement disorder primarily treated with **beta-blockers** or **anti-seizure medications**. - Levodopa has **no established efficacy** in treating essential tremor, and its use is unrelated to its pathophysiology.
Question 5: A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
- A. Calcium administration
- B. Prophylactic carbamazepine administration
- C. Prophylactic phenytoin administration
- D. Prophylactic diazepam administration (Correct Answer)
Explanation: ***Prophylactic diazepam administration*** - The patient presents with symptoms highly suggestive of **Wernicke-Korsakoff syndrome** (memory loss, ataxia, nystagmus) superimposed on chronic alcohol abuse with a history of alcohol withdrawal, indicating a high risk for further withdrawal seizures or delirium tremens [1], [3]. - **Benzodiazepines** like diazepam are the cornerstone of treatment for alcohol withdrawal syndrome due to their anxiolytic, anticonvulsant, and sedative properties, preventing progression to more severe withdrawal manifestations [2]. *Prophylactic phenytoin administration* - **Phenytoin** is generally not recommended for the prevention or treatment of alcohol withdrawal seizures unless there is an underlying seizure disorder unrelated to alcohol. - Its efficacy in preventing recurrent alcohol withdrawal seizures is limited compared to benzodiazepines. *Prophylactic carbamazepine administration* - While **carbamazepine** can be used in some cases of alcohol withdrawal, particularly to reduce seizure risk and improve sleep, it is not considered first-line for acute prophylaxis against severe withdrawal or delirium tremens, especially in a patient with active tremulousness and autonomic hyperactivity. - Benzodiazepines offer a broader spectrum of action against the diverse symptoms of alcohol withdrawal. *Calcium administration* - There is no indication that the patient has a **calcium deficiency** or hypocalcemia related to alcohol withdrawal symptoms. - Calcium administration would not address the underlying neurochemical imbalances associated with acute alcohol withdrawal or the progression to Wernicke-Korsakoff syndrome.
Question 6: Choose the correctly matched pairs regarding the drugs used in schizophrenia: 1. D2 antagonism: Reduces positive symptoms 2. 5HT2A antagonism: Reduces negative symptoms 3. 5HT1A agonism: Weight loss 4. Muscarinic antagonism: Reduces extrapyramidal symptoms
- A. 1,4
- B. 1,2,4
- C. 1,2,3,4
- D. 1,2 (Correct Answer)
Explanation: ***1,2*** - **D2 antagonism** is the primary mechanism by which antipsychotics reduce **positive symptoms** of schizophrenia, such as hallucinations and delusions. - **5HT2A antagonism** is a key mechanism of atypical antipsychotics contributing to the reduction of **negative symptoms** (e.g., apathy, anhedonia, flat affect) and cognitive deficits, while also reducing the risk of extrapyramidal symptoms. *1,2,3,4* - This option is incorrect because **5HT1A agonism** is not associated with **weight loss**. While 5HT1A partial agonism (as seen with aripiprazole and brexpiprazole) may improve negative symptoms, anxiety, and cognitive function, it does not directly cause weight loss. - Additionally, **muscarinic antagonism** does not reduce extrapyramidal symptoms as a primary mechanism. Rather, anticholinergic (muscarinic antagonist) drugs like benztropine are used to **treat** EPS after it occurs. The reduction of EPS in atypical antipsychotics primarily comes from 5HT2A antagonism and lower D2 binding affinity. *1,2,4* - This option is incorrect because **muscarinic antagonism** is not a mechanism that reduces EPS. Anticholinergic agents are used therapeutically to counteract EPS caused by dopamine blockade, but anticholinergic effects themselves do not prevent or reduce EPS. - The reduction of EPS with atypical antipsychotics is mainly due to **5HT2A antagonism** balancing dopaminergic blockade, selective limbic over striatal binding, and fast D2 dissociation kinetics. *1,4* - This option is incorrect because it omits **5HT2A antagonism**, which is crucial for reducing **negative symptoms** in schizophrenia. - It also incorrectly includes muscarinic antagonism as a mechanism that reduces EPS, when in reality anticholinergics are used to treat EPS rather than prevent it.
Question 7: Which of the following dementia is associated with visual hallucinations?
- A. Lewy body dementia (Correct Answer)
- B. AIDS related Dementia
- C. Mixed dementia
- D. Huntington's disease
Explanation: ***Lewy body dementia*** - **Visual hallucinations**, particularly of well-formed and detailed images, are a **core clinical feature** of Lewy body dementia (LBD). - Other key features include **fluctuating cognition** with pronounced variations in attention and alertness, and **spontaneous parkinsonism**. *AIDS related Dementia* - Primarily presents with cognitive and motor slowing, **apathy**, and difficulty with complex tasks, rather than prominent visual hallucinations. - It is a subcortical dementia caused by **HIV infection** directly affecting the brain. *Mixed dementia* - This typically refers to a combination of **Alzheimer's disease** and **vascular dementia**, where hallucinations are not a prominent or early feature. - While visual hallucinations can occur in advanced stages of any dementia, they are not a defining characteristic of mixed dementia. *Huntington's disease* - Characterized by **chorea**, psychiatric disturbances, and cognitive decline, primarily affecting executive function. - **Visual hallucinations** are not a typical feature of Huntington's disease, although psychiatric symptoms like psychosis can occur.
Question 8: Caution is taken while doing Inter-maxillary Fixation (IMF) for which of these types of patients?
- A. Psychiatric disorders
- B. All of the options (Correct Answer)
- C. Substance abusers
- D. Epileptics
Explanation: ***All of the options*** - All of these patient groups require extra caution during IMF due to potential complications during the period of jaw immobilization. - For patients with **psychiatric disorders**, **substance abuse**, or **epilepsy**, the risks associated with IMF often outweigh the benefits, necessitating careful assessment and alternative treatment strategies. *Psychiatric disorders* - Patients with psychiatric disorders may have difficulty tolerating the **entrapment** feeling of IMF. - They also have a higher risk of **non-compliance** and may attempt to remove the fixation. *Substance abusers* - **Vomiting** is common in substance abusers, which can lead to **aspiration** if the jaw is wired shut. - These patients may also be **non-compliant** with post-operative care instructions, jeopardizing treatment outcomes. *Epileptics* - **Seizures** during IMF can lead to serious complications, including **aspiration** if vomiting occurs. - The forceful jaw movements during a seizure can also cause **fracture of the teeth** or damage to already **repaired jaw bones**.
Question 9: A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is
- A. Pramipexole
- B. Trihexyphenidyl (Correct Answer)
- C. Selegiline
- D. Amantadine
Explanation: ***Trihexyphenidyl*** - The patient is exhibiting symptoms of **drug-induced parkinsonism** (tremors, rigidity, bradykinesia, excessive salivation) due to **fluphenazine**, an antipsychotic. - **Anticholinergic medications** like trihexyphenidyl are the **first-line treatment** for drug-induced parkinsonism as they help restore the balance between dopamine and acetylcholine. *Pramipexole* - This is a **dopamine agonist** primarily used in the management of idiopathic **Parkinson's disease** and restless legs syndrome. - While it addresses dopamine deficiency, it is not the first-line treatment for **drug-induced parkinsonism**, where the issue is often dopamine receptor blockade rather than primary dopamine depletion. *Selegiline* - **Selegiline** is a selective **MAO-B inhibitor** used to treat idiopathic Parkinson's disease by preventing the breakdown of dopamine in the brain. - It is not the most appropriate first-line choice for **drug-induced parkinsonism** as it does not directly counteract the dopamine receptor blockade caused by antipsychotics. *Amantadine* - **Amantadine** is an antiviral drug with mild **dopaminergic properties** that can be used to treat **Parkinson's disease** and drug-induced extrapyramidal symptoms, particularly dyskinesia. - While sometimes used, it is generally considered **second-line** to anticholinergics for the acute management of **drug-induced parkinsonism**.
Question 10: Sedation as an adverse effect is most commonly associated with which of the following atypical antipsychotics?
- A. Risperidone
- B. Olanzapine
- C. Quetiapine (Correct Answer)
- D. Aripiprazole
Explanation: ***Quetiapine*** - **Quetiapine** is known for its strong **H1 histamine receptor blockade**, which directly contributes to its prominent sedating effects. - This sedation is often dose-dependent and can be beneficial for patients with insomnia or agitation, but it is also a common complaint and reason for discontinuation. - Among the options listed, quetiapine is classically taught as the **most sedating** atypical antipsychotic. *Risperidone* - While risperidone can cause some sedation [1], it is generally less sedating than quetiapine or olanzapine and is more commonly associated with **extrapyramidal symptoms (EPS)**, especially at higher doses [1]. - Its mechanism of action primarily involves **D2 dopamine receptor blockade** and **5-HT2A serotonin receptor blockade** [1]. *Olanzapine* - **Olanzapine** also causes significant sedation [1] due to its strong antagonism of **H1 histamine receptors** and **alpha-1 adrenergic receptors**. - Clinically, olanzapine's sedative effects are comparable to quetiapine, though quetiapine is traditionally emphasized in exam contexts as the most sedating among these options. - Olanzapine is additionally notable for significant **metabolic side effects** like weight gain and dyslipidemia. *Aripiprazole* - **Aripiprazole** acts as a **partial agonist** at D2 dopamine receptors and 5-HT1A serotonin receptors, and an antagonist at 5-HT2A serotonin receptors, which results in minimal sedation. - It is often considered to be more **activating** or have a **neutral** effect on sedation compared to other atypical antipsychotics.
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