Emergency Psychiatry — MCQs

Q: Which of the following is false regarding parasuicide?

Hanging is the most common form.. **Explanation:** **Parasuicide** (also known as Deliberate Self-Harm) refers to a non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of the prescribed dosage. **Why Option D is the correct answer (False statement):** Hanging is the most common method used in **completed suicides**, not parasuicide. In parasuicide, the intent is often not to die but to communicate distress or manipulate a situation. Therefore, the methods chosen are usually less lethal and allow for intervention. The most common method of parasuicide is **self-poisoning** (e.g., drug overdose or pesticide ingestion) or **superficial wrist cutting**. **Analysis of other options:** * **Option A:** Parasuicide is synonymous with **attempted suicide**, though the term is specifically used for acts where the intent to die is low or ambiguous. * **Option B:** It is frequently seen in individuals with **psychological disturbances**, most notably **Borderline Personality Disorder**, depression, and substance abuse. * **Option C:** It is often a **conscious and impulsive act**. It is frequently described as "manipulative" (or a "cry for help") because the goal is often to escape an intolerable emotional state or to influence the behavior of others. **High-Yield Clinical Pearls for NEET-PG:** * **Gender:** Parasuicide is more common in **females**, whereas completed suicide is more common in **males** (Gender Paradox). * **Age:** Most common in the younger age group (15–30 years). * **Strongest Predictor:** A previous history of parasuicide is the strongest predictor of a future completed suicide. * **SAD PERSONS Scale:** Used to assess the risk of suicide in clinical settings.

Q: A 20-year-old male with a known history of mental illness presented to the emergency room with aggressive behavior and a tendency to physically attack others. Following a psychiatric evaluation, he was prescribed new medications and his previous medication dosage was adjusted. Three days later, he returned to the emergency room with fever (105°F), stiff limbs, altered sensorium, and elevated serum CPK levels. What is the immediate management for this condition?

Dantrolene. **Explanation:** The patient is presenting with the classic tetrad of **Neuroleptic Malignant Syndrome (NMS)**: hyperpyrexia (105°F), muscular "lead-pipe" rigidity, altered mental status, and autonomic instability, following the initiation or dose escalation of antipsychotics. The elevated serum Creatine Phosphokinase (CPK) confirms significant muscle necrosis due to intense rigidity. **1. Why Dantrolene is Correct:** NMS is a life-threatening emergency caused by central dopamine blockade. **Dantrolene** is a direct-acting skeletal muscle relaxant that inhibits the release of calcium from the sarcoplasmic reticulum. It is the drug of choice to treat the severe muscle rigidity and hyperthermia associated with NMS, thereby preventing further rhabdomyolysis and organ failure. **2. Why Incorrect Options are Wrong:** * **Succinylcholine:** A depolarizing neuromuscular blocker used in anesthesia. It is strictly contraindicated here as it can worsen hyperkalemia and potentially trigger Malignant Hyperthermia. * **Edrophonium:** A short-acting acetylcholinesterase inhibitor used in the Tensilon test to diagnose Myasthenia Gravis; it has no role in NMS. * **Neostigmine:** An acetylcholinesterase inhibitor used to treat Myasthenia Gravis or reverse non-depolarizing muscle relaxants; it does not address the pathophysiology of NMS. **Clinical Pearls for NEET-PG:** * **Mnemonic for NMS (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated CPK/WBC, **R**igidity. * **First step in management:** Immediately stop the offending antipsychotic agent. * **Specific Pharmacotherapy:** **Dantrolene** (muscle relaxant) or **Bromocriptine/Amantadine** (Dopamine agonists). * **Differential Diagnosis:** Unlike Serotonin Syndrome, NMS is characterized by "lead-pipe" rigidity and bradyreflexia, whereas Serotonin Syndrome features hyperreflexia and myoclonus.

Q: Suicidal tendencies are least common in which of the following demographic groups or conditions?

Married individuals. **Explanation:** The risk of suicide is heavily influenced by socio-demographic factors and psychiatric comorbidities. According to **Durkheim’s theory of social integration**, individuals with strong social ties and support systems have a significantly lower risk of suicide. **Why Married Individuals is the Correct Answer:** Marriage acts as a major **protective factor** against suicide. It provides social integration, emotional support, and a sense of responsibility toward family members (especially if children are involved). Statistically, married individuals have the lowest rates of suicide compared to those who are single, divorced, widowed, or separated. **Analysis of Incorrect Options:** * **Individuals who are alone:** Social isolation is a high-risk factor. Living alone, being single, or experiencing recent bereavement increases the risk due to a lack of "social buffers." * **Individuals with depression:** Psychiatric illness is the strongest predictor of suicide. Approximately 15% of patients with severe Depressive Disorder eventually die by suicide. It is a state of high vulnerability. * **Males:** While females make more suicide *attempts*, **males are more likely to complete suicide** (the Gender Paradox). This is because men typically use more lethal methods (e.g., firearms, hanging). **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Predictor:** A previous history of suicide attempts is the single best predictor of a future completed suicide. * **Age:** Risk generally increases with age; the elderly (especially males >65) are at very high risk. * **Employment:** Unemployment and financial instability are significant risk factors. * **Protective Factors:** Marriage, pregnancy (in women), and strong religious beliefs/affiliations.

Q: What is the most common cause of parasuicide?

Drug ingestion. **Explanation:** **Parasuicide** (also known as non-suicidal self-injury or deliberate self-harm) refers to an act in which an individual mimics a suicide attempt but without a true fatal intent. The primary goal is often a "cry for help" or an expression of emotional distress rather than death. **Why Drug Ingestion is Correct:** **Drug ingestion (overdose)** is the most common method of parasuicide globally. It is preferred because it is relatively painless, less disfiguring, and allows for a "window of rescue." Common agents include benzodiazepines, analgesics (paracetamol), and antidepressants. In the Indian context, organophosphate poisoning is also frequently seen in rural areas. **Analysis of Incorrect Options:** * **B. Hanging:** This is the **most common method of completed suicide** in India. It is highly lethal and offers little chance of intervention once the act is initiated, making it rare in parasuicide. * **C. Cutting wrist:** While a common method of self-harm (especially in Borderline Personality Disorder), it ranks second to drug ingestion in overall frequency for parasuicide. * **D. Firearms:** This is a highly violent and lethal method. It is rarely used in parasuicide due to its high fatality rate and limited accessibility in the Indian subcontinent. **High-Yield Clinical Pearls for NEET-PG:** * **Most common method of Completed Suicide:** Hanging (India); Firearms (USA). * **Gender Paradox:** Suicide is more common in **males**, but parasuicide (self-harm) is significantly more common in **females**. * **Strongest Predictor:** A previous history of parasuicide/self-harm is the strongest predictor of a future completed suicide. * **Risk Factor:** Depression is the most common psychiatric illness associated with suicide.

Q: Laryngeal dystonia, which is a psychiatric emergency, can be treated with?

lorazepam. ### Explanation **Laryngeal dystonia** is a life-threatening form of **Acute Dystonia**, a common Extrapyramidal Side Effect (EPS) occurring within hours to days of starting high-potency antipsychotics (e.g., Haloperidol). It involves involuntary spasms of the laryngeal muscles, leading to airway obstruction, stridor, and potential asphyxiation, making it a true psychiatric emergency. **Why Lorazepam is the correct answer:** The first-line treatment for acute dystonia is typically parenteral anticholinergics (like Benztropine or Promethazine). However, when these are unavailable or when rapid muscle relaxation is required in an emergency setting, **intravenous Benzodiazepines (like Lorazepam or Diazepam)** are highly effective. They act by enhancing GABAergic inhibition, which helps counteract the dopamine-acetylcholine imbalance in the nigrostriatal pathway causing the spasm. **Analysis of Incorrect Options:** * **B. Milnacipran:** This is an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor) used for depression and fibromyalgia; it has no role in treating EPS. * **C. Dantrolene:** This is a peripherally acting muscle relaxant used specifically for **Neuroleptic Malignant Syndrome (NMS)** and Malignant Hyperthermia. It is not the treatment for acute dystonia. * **D. Propranolol:** This beta-blocker is the drug of choice for **Akathisia** (subjective restlessness), another form of EPS, but it is ineffective for dystonia. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Young males and those receiving high-potency first-generation antipsychotics are at the highest risk. * **Order of EPS onset:** Dystonia (hours) → Akathisia (days) → Parkinsonism (weeks) → Tardive Dyskinesia (months/years). * **Drug of Choice (General Dystonia):** Injection **Promethazine** or Benztropine. * **Oculogyric Crisis:** Another common presentation of acute dystonia involving involuntary upward deviation of the eyes.

Q: Which of the following is a common cause of delirium?

Infection. **Explanation:** Delirium is an acute, transient, and reversible syndrome characterized by a disturbance in consciousness, attention, and cognition. It is always secondary to an underlying medical condition, substance intoxication, or withdrawal. **1. Why Infection is the Correct Answer:** Infections (especially **Urinary Tract Infections (UTIs)** in the elderly and **Pneumonia**) are the most common systemic causes of delirium. The pathophysiology involves the release of pro-inflammatory cytokines that cross the blood-brain barrier, leading to neuroinflammation and neurotransmitter imbalances (primarily cholinergic deficiency and dopaminergic excess). **2. Analysis of Incorrect Options:** * **B. Liver Failure:** While hepatic encephalopathy is a known cause of delirium, it is categorized as a metabolic cause. Statistically, systemic infections are more frequent triggers in a general clinical setting. * **C. Belladonna Poisoning:** This causes anticholinergic toxicity. While it presents with "delirium-like" symptoms (the "mad as a hatter" mnemonic), it is a specific toxicological cause rather than the most common general cause. * **D. None of the above:** Incorrect, as infection is a primary etiology. **High-Yield Clinical Pearls for NEET-PG:** * **Core Feature:** Clouding of consciousness (altered sensorium) with a fluctuating course (worse at night, known as "sundowning"). * **EEG Finding:** Characterized by **generalized slowing** of background activity (except in Alcohol Withdrawal/Delirium Tremens, where there is low-amplitude fast activity). * **Visual Hallucinations:** These are the most common type of hallucinations in delirium. * **Management:** The priority is treating the **underlying cause** (e.g., antibiotics for infection). Low-dose Haloperidol is the drug of choice for symptomatic agitation (avoid benzodiazepines unless it is alcohol withdrawal).

Q: Which of the following is not used in the management of delirium?

Lithium. ### Explanation **Delirium** is an acute, fluctuating syndrome of altered consciousness and cognitive dysfunction, usually secondary to an underlying medical condition. The primary management involves treating the underlying cause and managing behavioral symptoms. **Why Lithium is the Correct Answer:** **Lithium** is a mood stabilizer used primarily for Bipolar Disorder. It is **not** used in delirium for several reasons: 1. **Neurotoxicity:** Lithium has a narrow therapeutic index and can worsen confusion or cause "Lithium-induced delirium." 2. **Renal/Electrolyte Sensitivity:** Delirious patients are often dehydrated or have electrolyte imbalances, which significantly increases the risk of Lithium toxicity. 3. **Onset:** It takes days to reach a steady state, making it useless for acute behavioral emergencies. **Analysis of Other Options:** * **Haloperidol (Option A):** The traditional **drug of choice** for delirium. It has minimal respiratory depression and few anticholinergic side effects, making it safe for elderly or medically ill patients. * **Diazepam (Option B):** While benzodiazepines can worsen delirium in most cases (due to paradoxical agitation), they are the **first-line treatment for delirium tremens** (Alcohol Withdrawal Delirium) and sedative-hypnotic withdrawal. * **Olanzapine (Option D):** An atypical antipsychotic often used as an alternative to Haloperidol. It is effective for agitation and has a lower risk of Extrapyramidal Symptoms (EPS). **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Delirium:** Haloperidol (low dose). * **DOC for Alcohol Withdrawal Delirium:** Benzodiazepines (e.g., Diazepam, Lorazepam). * **Avoid:** Drugs with strong anticholinergic properties (e.g., Chlorpromazine, Amitriptyline) as they worsen delirium. * **Non-pharmacological management:** Reorientation, adequate lighting, and correcting sleep-wake cycles are essential first steps.

Q: A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?

Benzhexol. ***Benzhexol*** - The patient's posturing (likely **acute dystonia**) is a common extrapyramidal side effect of typical antipsychotics, which are often given via injection to uncooperative schizophrenic patients. - **Benzhexol** (trihexyphenidyl) is an anticholinergic medication used to treat drug-induced extrapyramidal symptoms like dystonia, parkinsonism, and akathisia. - In acute dystonia, **parenteral anticholinergics** (IV diphenhydramine or IM benztropine) are typically preferred for faster onset, but benzhexol remains a valid anticholinergic treatment option. - The anticholinergic action reverses the dystonic reaction by restoring the dopamine-acetylcholine balance in the basal ganglia. *Propranolol* - **Propranolol** is a beta-blocker primarily used to treat essential tremor and some forms of drug-induced akathisia, but it is not the first-line treatment for acute dystonia. - While it can help with anxiety symptoms associated with akathisia, it has no role in managing acute dystonic reactions. *Dantrolene sodium* - **Dantrolene sodium** is a direct-acting skeletal muscle relaxant primarily used in the management of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - NMS is a more severe and distinct adverse reaction, involving fever, muscle rigidity, altered mental status, and autonomic dysfunction, which is not depicted here. - Acute dystonia presents much earlier (hours) compared to NMS (days to weeks) and lacks the systemic features of NMS. *Ventriculostomy* - **Ventriculostomy** is a neurosurgical procedure to relieve hydrocephalus by draining cerebrospinal fluid from the ventricles of the brain. - This procedure is entirely unrelated to the management of drug-induced extrapyramidal side effects from antipsychotic medication.

A 20-year-old male with a known history of mental illness presented to the emergency room with aggressive behavior and a tendency to physically attack others. Following a psychiatric evaluation, he was prescribed new medications and his previous medication dosage was adjusted. Three days later, he returned to the emergency room with fever (105°F), stiff limbs, altered sensorium, and elevated serum CPK levels. What is the immediate management for this condition?

Q3Medium

A patient presents to the emergency department with self-harm and indicates suicidal intent. Which of the following conditions does not warrant an immediate specialist assessment?

Q4Medium

Suicidal tendencies are least common in which of the following demographic groups or conditions?

Q5Easy

What is the most common cause of parasuicide?

Q6Easy

Laryngeal dystonia, which is a psychiatric emergency, can be treated with?

Q7Easy

Which of the following is a common cause of delirium?

Q8Easy

Which of the following is not used in the management of delirium?

Q9Medium

A 22-year-old male presented with a 2-day history of auditory hallucinations (hearing voices when no one is around) and aggressive behavior. He also reports that people are abusing him. He has had a fever for the past 2 days. There is no significant past medical history. What is the most likely diagnosis?

Q10

A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?

Emergency Psychiatry Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is false regarding parasuicide?

A. Also known as attempted suicide.
B. Mostly seen in psychological disturbances.
C. A conscious, impulsive, manipulative act to get rid of an intolerable situation.
D. Hanging is the most common form. (Correct Answer)

Explanation: **Explanation:** **Parasuicide** (also known as Deliberate Self-Harm) refers to a non-fatal act in which an individual deliberately causes self-injury or ingests a substance in excess of the prescribed dosage. **Why Option D is the correct answer (False statement):** Hanging is the most common method used in **completed suicides**, not parasuicide. In parasuicide, the intent is often not to die but to communicate distress or manipulate a situation. Therefore, the methods chosen are usually less lethal and allow for intervention. The most common method of parasuicide is **self-poisoning** (e.g., drug overdose or pesticide ingestion) or **superficial wrist cutting**. **Analysis of other options:** * **Option A:** Parasuicide is synonymous with **attempted suicide**, though the term is specifically used for acts where the intent to die is low or ambiguous. * **Option B:** It is frequently seen in individuals with **psychological disturbances**, most notably **Borderline Personality Disorder**, depression, and substance abuse. * **Option C:** It is often a **conscious and impulsive act**. It is frequently described as "manipulative" (or a "cry for help") because the goal is often to escape an intolerable emotional state or to influence the behavior of others. **High-Yield Clinical Pearls for NEET-PG:** * **Gender:** Parasuicide is more common in **females**, whereas completed suicide is more common in **males** (Gender Paradox). * **Age:** Most common in the younger age group (15–30 years). * **Strongest Predictor:** A previous history of parasuicide is the strongest predictor of a future completed suicide. * **SAD PERSONS Scale:** Used to assess the risk of suicide in clinical settings.

Question 2: A 20-year-old male with a known history of mental illness presented to the emergency room with aggressive behavior and a tendency to physically attack others. Following a psychiatric evaluation, he was prescribed new medications and his previous medication dosage was adjusted. Three days later, he returned to the emergency room with fever (105°F), stiff limbs, altered sensorium, and elevated serum CPK levels. What is the immediate management for this condition?

A. Succinylcholine
B. Dantrolene (Correct Answer)
C. Edrophonium
D. Neostigmine

Explanation: **Explanation:** The patient is presenting with the classic tetrad of **Neuroleptic Malignant Syndrome (NMS)**: hyperpyrexia (105°F), muscular "lead-pipe" rigidity, altered mental status, and autonomic instability, following the initiation or dose escalation of antipsychotics. The elevated serum Creatine Phosphokinase (CPK) confirms significant muscle necrosis due to intense rigidity. **1. Why Dantrolene is Correct:** NMS is a life-threatening emergency caused by central dopamine blockade. **Dantrolene** is a direct-acting skeletal muscle relaxant that inhibits the release of calcium from the sarcoplasmic reticulum. It is the drug of choice to treat the severe muscle rigidity and hyperthermia associated with NMS, thereby preventing further rhabdomyolysis and organ failure. **2. Why Incorrect Options are Wrong:** * **Succinylcholine:** A depolarizing neuromuscular blocker used in anesthesia. It is strictly contraindicated here as it can worsen hyperkalemia and potentially trigger Malignant Hyperthermia. * **Edrophonium:** A short-acting acetylcholinesterase inhibitor used in the Tensilon test to diagnose Myasthenia Gravis; it has no role in NMS. * **Neostigmine:** An acetylcholinesterase inhibitor used to treat Myasthenia Gravis or reverse non-depolarizing muscle relaxants; it does not address the pathophysiology of NMS. **Clinical Pearls for NEET-PG:** * **Mnemonic for NMS (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated CPK/WBC, **R**igidity. * **First step in management:** Immediately stop the offending antipsychotic agent. * **Specific Pharmacotherapy:** **Dantrolene** (muscle relaxant) or **Bromocriptine/Amantadine** (Dopamine agonists). * **Differential Diagnosis:** Unlike Serotonin Syndrome, NMS is characterized by "lead-pipe" rigidity and bradyreflexia, whereas Serotonin Syndrome features hyperreflexia and myoclonus.

Question 3: A patient presents to the emergency department with self-harm and indicates suicidal intent. Which of the following conditions does not warrant an immediate specialist assessment?

A. Formal thought disorder
B. Acute alcohol intoxication (Correct Answer)
C. Chronic severe physical illness
D. Social isolation

Explanation: **Explanation:** The management of a suicidal patient in the emergency department involves identifying high-risk factors that necessitate immediate psychiatric intervention. **Why Option B is Correct:** **Acute alcohol intoxication** is a transient state that can significantly cloud a clinical assessment. Alcohol acts as a disinhibitor, often leading to impulsive self-harm threats that may resolve once the patient is sober. Standard clinical guidelines (such as those from NICE) suggest that a formal specialist psychiatric assessment should be deferred until the patient is sober, as the "true" underlying mental state and level of intent cannot be accurately determined while intoxicated. However, the patient must be kept in a safe environment until they are fit for assessment. **Why the other options are wrong:** * **A. Formal thought disorder:** This indicates a potential psychotic illness (like Schizophrenia). Psychosis is a major risk factor for "command hallucinations" or delusional thinking, which significantly increases the risk of completed suicide. * **C. Chronic severe physical illness:** Chronic pain or terminal illness (e.g., cancer, end-stage renal disease) are well-established independent risk factors for suicide due to hopelessness and a desire to end suffering. * **D. Social isolation:** Being single, widowed, or living alone (lack of social support) is a core demographic risk factor in suicide risk stratification (e.g., the SAD PERSONS scale). **High-Yield Clinical Pearls for NEET-PG:** * **SAD PERSONS Scale:** A mnemonic for suicide risk (Sex: Male, Age: <19 or >45, Depression, Previous attempt, Ethanol/Drug use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness). * **Most common method of completed suicide:** Hanging (India and globally). * **Most common method of attempted suicide:** Poisoning/Drug overdose. * **Strongest predictor of suicide:** A previous history of self-harm or suicide attempts.

Question 4: Suicidal tendencies are least common in which of the following demographic groups or conditions?

A. Individuals who are alone
B. Individuals with depression
C. Males
D. Married individuals (Correct Answer)

Explanation: **Explanation:** The risk of suicide is heavily influenced by socio-demographic factors and psychiatric comorbidities. According to **Durkheim’s theory of social integration**, individuals with strong social ties and support systems have a significantly lower risk of suicide. **Why Married Individuals is the Correct Answer:** Marriage acts as a major **protective factor** against suicide. It provides social integration, emotional support, and a sense of responsibility toward family members (especially if children are involved). Statistically, married individuals have the lowest rates of suicide compared to those who are single, divorced, widowed, or separated. **Analysis of Incorrect Options:** * **Individuals who are alone:** Social isolation is a high-risk factor. Living alone, being single, or experiencing recent bereavement increases the risk due to a lack of "social buffers." * **Individuals with depression:** Psychiatric illness is the strongest predictor of suicide. Approximately 15% of patients with severe Depressive Disorder eventually die by suicide. It is a state of high vulnerability. * **Males:** While females make more suicide *attempts*, **males are more likely to complete suicide** (the Gender Paradox). This is because men typically use more lethal methods (e.g., firearms, hanging). **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Predictor:** A previous history of suicide attempts is the single best predictor of a future completed suicide. * **Age:** Risk generally increases with age; the elderly (especially males >65) are at very high risk. * **Employment:** Unemployment and financial instability are significant risk factors. * **Protective Factors:** Marriage, pregnancy (in women), and strong religious beliefs/affiliations.

Question 5: What is the most common cause of parasuicide?

A. Drug ingestion (Correct Answer)
B. Hanging
C. Cutting wrist
D. Firearms

Explanation: **Explanation:** **Parasuicide** (also known as non-suicidal self-injury or deliberate self-harm) refers to an act in which an individual mimics a suicide attempt but without a true fatal intent. The primary goal is often a "cry for help" or an expression of emotional distress rather than death. **Why Drug Ingestion is Correct:** **Drug ingestion (overdose)** is the most common method of parasuicide globally. It is preferred because it is relatively painless, less disfiguring, and allows for a "window of rescue." Common agents include benzodiazepines, analgesics (paracetamol), and antidepressants. In the Indian context, organophosphate poisoning is also frequently seen in rural areas. **Analysis of Incorrect Options:** * **B. Hanging:** This is the **most common method of completed suicide** in India. It is highly lethal and offers little chance of intervention once the act is initiated, making it rare in parasuicide. * **C. Cutting wrist:** While a common method of self-harm (especially in Borderline Personality Disorder), it ranks second to drug ingestion in overall frequency for parasuicide. * **D. Firearms:** This is a highly violent and lethal method. It is rarely used in parasuicide due to its high fatality rate and limited accessibility in the Indian subcontinent. **High-Yield Clinical Pearls for NEET-PG:** * **Most common method of Completed Suicide:** Hanging (India); Firearms (USA). * **Gender Paradox:** Suicide is more common in **males**, but parasuicide (self-harm) is significantly more common in **females**. * **Strongest Predictor:** A previous history of parasuicide/self-harm is the strongest predictor of a future completed suicide. * **Risk Factor:** Depression is the most common psychiatric illness associated with suicide.

Question 6: Laryngeal dystonia, which is a psychiatric emergency, can be treated with?

A. lorazepam (Correct Answer)
B. milnacipran
C. dantrolene
D. propanolol

Explanation: ### Explanation **Laryngeal dystonia** is a life-threatening form of **Acute Dystonia**, a common Extrapyramidal Side Effect (EPS) occurring within hours to days of starting high-potency antipsychotics (e.g., Haloperidol). It involves involuntary spasms of the laryngeal muscles, leading to airway obstruction, stridor, and potential asphyxiation, making it a true psychiatric emergency. **Why Lorazepam is the correct answer:** The first-line treatment for acute dystonia is typically parenteral anticholinergics (like Benztropine or Promethazine). However, when these are unavailable or when rapid muscle relaxation is required in an emergency setting, **intravenous Benzodiazepines (like Lorazepam or Diazepam)** are highly effective. They act by enhancing GABAergic inhibition, which helps counteract the dopamine-acetylcholine imbalance in the nigrostriatal pathway causing the spasm. **Analysis of Incorrect Options:** * **B. Milnacipran:** This is an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor) used for depression and fibromyalgia; it has no role in treating EPS. * **C. Dantrolene:** This is a peripherally acting muscle relaxant used specifically for **Neuroleptic Malignant Syndrome (NMS)** and Malignant Hyperthermia. It is not the treatment for acute dystonia. * **D. Propranolol:** This beta-blocker is the drug of choice for **Akathisia** (subjective restlessness), another form of EPS, but it is ineffective for dystonia. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Young males and those receiving high-potency first-generation antipsychotics are at the highest risk. * **Order of EPS onset:** Dystonia (hours) → Akathisia (days) → Parkinsonism (weeks) → Tardive Dyskinesia (months/years). * **Drug of Choice (General Dystonia):** Injection **Promethazine** or Benztropine. * **Oculogyric Crisis:** Another common presentation of acute dystonia involving involuntary upward deviation of the eyes.

Question 7: Which of the following is a common cause of delirium?

A. Infection (Correct Answer)
B. Liver failure
C. Belladonna poisoning
D. None of the above

Explanation: **Explanation:** Delirium is an acute, transient, and reversible syndrome characterized by a disturbance in consciousness, attention, and cognition. It is always secondary to an underlying medical condition, substance intoxication, or withdrawal. **1. Why Infection is the Correct Answer:** Infections (especially **Urinary Tract Infections (UTIs)** in the elderly and **Pneumonia**) are the most common systemic causes of delirium. The pathophysiology involves the release of pro-inflammatory cytokines that cross the blood-brain barrier, leading to neuroinflammation and neurotransmitter imbalances (primarily cholinergic deficiency and dopaminergic excess). **2. Analysis of Incorrect Options:** * **B. Liver Failure:** While hepatic encephalopathy is a known cause of delirium, it is categorized as a metabolic cause. Statistically, systemic infections are more frequent triggers in a general clinical setting. * **C. Belladonna Poisoning:** This causes anticholinergic toxicity. While it presents with "delirium-like" symptoms (the "mad as a hatter" mnemonic), it is a specific toxicological cause rather than the most common general cause. * **D. None of the above:** Incorrect, as infection is a primary etiology. **High-Yield Clinical Pearls for NEET-PG:** * **Core Feature:** Clouding of consciousness (altered sensorium) with a fluctuating course (worse at night, known as "sundowning"). * **EEG Finding:** Characterized by **generalized slowing** of background activity (except in Alcohol Withdrawal/Delirium Tremens, where there is low-amplitude fast activity). * **Visual Hallucinations:** These are the most common type of hallucinations in delirium. * **Management:** The priority is treating the **underlying cause** (e.g., antibiotics for infection). Low-dose Haloperidol is the drug of choice for symptomatic agitation (avoid benzodiazepines unless it is alcohol withdrawal).

Question 8: Which of the following is not used in the management of delirium?

A. Haloperidol
B. Lithium (Correct Answer)
C. Diazepam
D. Olanzapine

Explanation: ### Explanation **Delirium** is an acute, fluctuating syndrome of altered consciousness and cognitive dysfunction, usually secondary to an underlying medical condition. The primary management involves treating the underlying cause and managing behavioral symptoms. **Why Lithium is the Correct Answer:** **Lithium** is a mood stabilizer used primarily for Bipolar Disorder. It is **not** used in delirium for several reasons: 1. **Neurotoxicity:** Lithium has a narrow therapeutic index and can worsen confusion or cause "Lithium-induced delirium." 2. **Renal/Electrolyte Sensitivity:** Delirious patients are often dehydrated or have electrolyte imbalances, which significantly increases the risk of Lithium toxicity. 3. **Onset:** It takes days to reach a steady state, making it useless for acute behavioral emergencies. **Analysis of Other Options:** * **Haloperidol (Option A):** The traditional **drug of choice** for delirium. It has minimal respiratory depression and few anticholinergic side effects, making it safe for elderly or medically ill patients. * **Diazepam (Option B):** While benzodiazepines can worsen delirium in most cases (due to paradoxical agitation), they are the **first-line treatment for delirium tremens** (Alcohol Withdrawal Delirium) and sedative-hypnotic withdrawal. * **Olanzapine (Option D):** An atypical antipsychotic often used as an alternative to Haloperidol. It is effective for agitation and has a lower risk of Extrapyramidal Symptoms (EPS). **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Delirium:** Haloperidol (low dose). * **DOC for Alcohol Withdrawal Delirium:** Benzodiazepines (e.g., Diazepam, Lorazepam). * **Avoid:** Drugs with strong anticholinergic properties (e.g., Chlorpromazine, Amitriptyline) as they worsen delirium. * **Non-pharmacological management:** Reorientation, adequate lighting, and correcting sleep-wake cycles are essential first steps.

Question 9: A 22-year-old male presented with a 2-day history of auditory hallucinations (hearing voices when no one is around) and aggressive behavior. He also reports that people are abusing him. He has had a fever for the past 2 days. There is no significant past medical history. What is the most likely diagnosis?

A. Dementia
B. Acute psychosis (Correct Answer)
C. Delirium
D. Delusion

Explanation: **Explanation:** The patient presents with a classic triad of **positive psychotic symptoms**: auditory hallucinations (perception without stimulus), persecutory ideas (people abusing him), and behavioral disturbances (aggression). The acute onset (2 days) and young age (22 years) point directly toward **Acute Psychosis**. **Why Acute Psychosis is correct:** In psychiatry, an acute onset of hallucinations and delusions in a young individual, lasting less than one month, is classified under Acute and Transient Psychotic Disorder (ICD-10) or Brief Psychotic Disorder (DSM-5). While the patient has a fever, the primary presentation is dominated by clear psychotic features. In NEET-PG scenarios, unless there is a documented clouding of consciousness or disorientation, these symptoms are treated as a psychiatric emergency. **Why other options are incorrect:** * **Delirium:** Although the patient has a fever, delirium is characterized by a **clouding of consciousness**, fluctuating levels of awareness, and disorientation to time, place, and person. The question does not mention cognitive impairment or altered sensorium. * **Dementia:** This is a chronic, progressive neurodegenerative condition (usually in the elderly) involving memory loss and cognitive decline. A 2-day history in a 22-year-old rules this out. * **Delusion:** This is a *symptom* (a fixed false belief), not a diagnosis. While the patient has delusional ideas, "Acute Psychosis" is the more comprehensive clinical diagnosis. **Clinical Pearls for NEET-PG:** * **Brief Psychotic Disorder:** Symptoms last >1 day but <1 month, with a full return to premorbid functioning. * **Schizophreniform Disorder:** Symptoms last 1–6 months. * **Schizophrenia:** Symptoms must persist for >6 months (DSM-5). * **Organic Psychosis:** Always rule out medical causes (like CNS infections or metabolic issues) when fever and psychosis coexist, but choose the psychiatric label if consciousness is intact.

Question 10: A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?

A. Propranolol
B. Dantrolene sodium
C. Ventriculostomy
D. Benzhexol (Correct Answer)

Explanation: ***Benzhexol*** - The patient's posturing (likely **acute dystonia**) is a common extrapyramidal side effect of typical antipsychotics, which are often given via injection to uncooperative schizophrenic patients. - **Benzhexol** (trihexyphenidyl) is an anticholinergic medication used to treat drug-induced extrapyramidal symptoms like dystonia, parkinsonism, and akathisia. - In acute dystonia, **parenteral anticholinergics** (IV diphenhydramine or IM benztropine) are typically preferred for faster onset, but benzhexol remains a valid anticholinergic treatment option. - The anticholinergic action reverses the dystonic reaction by restoring the dopamine-acetylcholine balance in the basal ganglia. *Propranolol* - **Propranolol** is a beta-blocker primarily used to treat essential tremor and some forms of drug-induced akathisia, but it is not the first-line treatment for acute dystonia. - While it can help with anxiety symptoms associated with akathisia, it has no role in managing acute dystonic reactions. *Dantrolene sodium* - **Dantrolene sodium** is a direct-acting skeletal muscle relaxant primarily used in the management of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - NMS is a more severe and distinct adverse reaction, involving fever, muscle rigidity, altered mental status, and autonomic dysfunction, which is not depicted here. - Acute dystonia presents much earlier (hours) compared to NMS (days to weeks) and lacks the systemic features of NMS. *Ventriculostomy* - **Ventriculostomy** is a neurosurgical procedure to relieve hydrocephalus by draining cerebrospinal fluid from the ventricles of the brain. - This procedure is entirely unrelated to the management of drug-induced extrapyramidal side effects from antipsychotic medication.

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Neuroleptic Malignant Syndrome

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Psychiatric Emergencies in Children

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Crisis Intervention

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Disaster Psychiatry

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