Acute Psychosis — MCQs
Which of the following will have an organic cause?
In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :
Which of the following hallucinations is pathognomonic of schizophrenia?
Which of the following tests is not required for the diagnosis of multiple sclerosis?
A patient diagnosed with schizophrenia presented with an acute exacerbation of symptoms. After receiving an injection of haloperidol in the casualty, the patient suddenly developed deviation of the eyeballs and torticollis. What is the diagnosis?
Which antipsychotic drug is approved for the management of psychosis in Parkinsonian patients?
Behavioural problems caused by senility, drug damage, brain injury or disease, and the toxic effects of poisons are classified as __________ disorders
The most specific test to detect blood stains is:
A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
A 25-year-old male believes that his penis is decreasing in size every day and that it will eventually disappear, leading to his death. What is the most likely diagnosis?
Acute Psychosis Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following will have an organic cause?
- A. Schizophrenia
- B. Delirium (Correct Answer)
- C. Anxiety
- D. Obsessive compulsive disorder
Explanation: ***Delirium*** - Delirium is an **acute, fluctuating disturbance of consciousness** and cognition that is directly caused by a **medical condition**, substance intoxication/withdrawal, or medication side effect [1], [2], [3]. - It always has an **underlying organic etiology** such as infection, metabolic derangements, drug toxicity, or neurological disorders [1], [2]. *Schizophrenia* - Schizophrenia is a **chronic psychiatric disorder** characterized by psychosis (hallucinations, delusions), disorganized thinking, and negative symptoms. - While it has a neurobiological basis, it is considered a **primary mental illness** and not typically caused by an acute, identifiable organic illness in the way delirium is. *Anxiety* - Anxiety disorders are characterized by excessive worry, fear, and physical symptoms of arousal. They are considered **primary mental health conditions**. - Although stress can precipitate anxiety, it is not primarily due to a **specific acute organic cause** that resolves with treatment of that cause. *Obsessive compulsive disorder* - Obsessive-compulsive disorder (OCD) is an anxiety-related disorder characterized by **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors (compulsions) aimed at reducing distress. - Like other primary mental health conditions, it has a neurobiological basis but is not classified as having an **acute organic cause** in the medical sense.
Question 2: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :
- A. 20% Mannitol (Correct Answer)
- B. Lasix
- C. Glycine
- D. Steroids
Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.
Question 3: Which of the following hallucinations is pathognomonic of schizophrenia?
- A. Auditory hallucinations commanding the patient
- B. Auditory hallucinations giving running commentary (Correct Answer)
- C. Auditory hallucinations criticizing the patient
- D. Auditory hallucinations talking to patient
Explanation: ***Auditory hallucinations giving running commentary*** - **Third-person auditory hallucinations**, particularly those giving a continuous descriptive commentary on the patient's actions, thoughts, or movements, are considered **pathognomonic of schizophrenia** within Schneider's first-rank symptoms. - These are distinguished from other types of auditory hallucinations by their specific content and the perspective from which they are perceived, indicating a fundamental disruption in self-perception and reality testing. *Auditory hallucinations commanding the patient* - **Command hallucinations** involve voices instructing the patient to perform specific actions and can occur in various psychiatric conditions, including other psychoses, mood disorders with psychotic features, and even non-psychotic states. - While significant and potentially dangerous, they are **not unique to schizophrenia** and therefore not pathognomonic. *Auditory hallucinations criticizing the patient* - **Critical auditory hallucinations** involve voices that demean, scold, or negatively evaluate the patient, contributing to distress and low self-esteem. - These are also **nonspecific** and can be found in a range of mental health conditions, including depression with psychotic features and bipolar disorder. *Auditory hallucinations talking to patient* - **Second-person auditory hallucinations**, where voices communicate directly with the patient in a conversational manner, are common in various psychotic disorders. - They are a general feature of psychosis and **do not specifically indicate schizophrenia** over other conditions; the *content* and *form* of the hallucination are crucial for differential diagnosis.
Question 4: Which of the following tests is not required for the diagnosis of multiple sclerosis?
- A. Gadolinium-enhanced MRI
- B. Visual evoked potential
- C. Lumbar puncture
- D. Electronystagmogram (Correct Answer)
Explanation: ***Electronystagmogram*** - An **electronystagmogram (ENG)** measures eye movements and nystagmus, which can be affected by MS but is not a **diagnostic criterion** for the disease. - While vestibulo-ocular dysfunction can occur in MS, an ENG is not required to establish the diagnosis. *Gadolinium-enhanced MRI* - **Gadolinium-enhanced MRI** of the brain and spinal cord is crucial for diagnosing MS as it identifies active lesions (enhancing lesions) and disseminated lesions in space and time [1]. - The presence of both **active and inactive lesions** on MRI helps fulfill the McDonald criteria for MS diagnosis [1]. *Visual evoked potential* - **Visual evoked potentials (VEPs)** measure electrical activity in the brain in response to visual stimuli, detecting subtle damage to the **optic nerve** even in the absence of clinical symptoms [1]. - Abnormal VEPs indicate demyelination and can contribute to fulfilling the **dissemination in space** criterion when lesions are not clearly visible on MRI in specific locations [1]. *Lumbar puncture* - A **lumbar puncture** to analyze **cerebrospinal fluid (CSF)** is often performed to look for **oligoclonal bands** and an **elevated IgG index**, which are characteristic findings in MS. - Although not always mandatory, CSF analysis can support the diagnosis, especially in cases where MRI findings are equivocal or incomplete.
Question 5: A patient diagnosed with schizophrenia presented with an acute exacerbation of symptoms. After receiving an injection of haloperidol in the casualty, the patient suddenly developed deviation of the eyeballs and torticollis. What is the diagnosis?
- A. Akathisia
- B. Acute dystonia (Correct Answer)
- C. Malignant hyperthermia
- D. Drug induced parkinsonism
Explanation: ***Acute dystonia*** * **Acute dystonia** is a common **extrapyramidal side effect** of high-potency antipsychotics like **haloperidol**, characterized by sudden, involuntary muscle contractions occurring within **minutes to hours** of drug administration. * **Deviation of the eyeballs (oculogyric crisis)** and **torticollis** (spasms of neck muscles) are classic presentations of acute dystonia. * Treatment includes **anticholinergic agents** (e.g., benztropine, trihexyphenidyl) or **antihistamines** (e.g., diphenhydramine), which provide rapid relief. *Akathisia* * **Akathisia** is characterized by an internal feeling of **restlessness** and an urge to move, which is often relieved by movement. * It does not present with fixed abnormal postures or sudden, sustained muscle contractions like oculogyric crisis or torticollis. *Malignant hyperthermia* * **Malignant hyperthermia** is a rare, life-threatening reaction to certain **anesthetic drugs**, characterized by **rapidly increasing body temperature**, muscle rigidity, and metabolic acidosis. * It is not typically associated with antipsychotic use or the specific localized dystonic movements described. *Drug induced parkinsonism* * **Drug-induced parkinsonism** presents with symptoms resembling Parkinson's disease, including **tremor**, **rigidity**, **bradykinesia**, and postural instability. * These symptoms develop more **gradually** (days to weeks) and are distinct from the sudden, acute, sustained muscle contractions seen in dystonia.
Question 6: Which antipsychotic drug is approved for the management of psychosis in Parkinsonian patients?
- A. risperidone
- B. clozapine (Correct Answer)
- C. olanzapine
- D. haloperidol
Explanation: ***Correct: Clozapine*** - **Clozapine** is the only antipsychotic extensively studied and approved for the treatment of **psychosis in Parkinson's disease (PDP)** due to its low propensity to exacerbate motor symptoms. - Its unique pharmacological profile, including lower **D2 receptor blockade** compared to other antipsychotics, makes it suitable for this vulnerable population. - Clozapine has the strongest evidence base for efficacy without worsening motor function in PDP. *Incorrect: Olanzapine* - **Olanzapine** has a significant **risk of worsening motor symptoms** in Parkinson's patients due to its potent **D2 receptor antagonism**. - It is generally contraindicated for treating psychosis in Parkinson's disease. *Incorrect: Haloperidol* - **Haloperidol** is a high-potency typical antipsychotic with strong **D2 receptor blockade**, which can severely **worsen Parkinsonian motor symptoms** (e.g., rigidity, bradykinesia). - Its use is strictly avoided in patients with Parkinson's disease. *Incorrect: Risperidone* - **Risperidone** also carries a considerable risk of **exacerbating motor symptoms** in Parkinson's disease due to its **D2 receptor antagonism**, although less severe than haloperidol. - It is generally not recommended as a first-line treatment for PDP.
Question 7: Behavioural problems caused by senility, drug damage, brain injury or disease, and the toxic effects of poisons are classified as __________ disorders
- A. Psychosomatic
- B. Substance use
- C. Organic (Correct Answer)
- D. Psychotic
Explanation: ***Organic*** - **Organic disorders** are characterized by behavioral or psychological symptoms that are directly attributable to a **physiological dysfunction** or structural change in the brain. - This category includes conditions arising from **senility**, drug-induced damage, brain injury, disease (e.g., **dementia**), or exposure to **neurotoxins**. *Psychosomatic* - **Psychosomatic disorders** involve physical symptoms that are caused or aggravated by **psychological factors**, like stress. - The primary cause is not a direct physiological injury or disease of the brain itself. *Substance use* - **Substance use disorders** describe maladaptive patterns of substance use leading to clinically significant impairment or distress. - While drug damage is mentioned in the question, this category focuses specifically on the **addiction** and related behaviors, not the broad range of organic causes. *Psychotic* - **Psychotic disorders** are characterized by a significant loss of contact with reality, often involving **hallucinations** or **delusions**. - While some organic conditions can cause psychotic symptoms, the term "psychotic disorders" refers to a specific symptom cluster rather than the underlying physical cause.
Question 8: The most specific test to detect blood stains is:
- A. Benzidine test
- B. Teichmann's test
- C. Spectroscopic test (Correct Answer)
- D. Orthotoluidine test
Explanation: ***Spectroscopic test*** - The **spectroscopic test** is considered the most specific for detecting blood stains because it identifies the characteristic absorption bands of **hemoglobin** and its derivatives. - This test is highly definitive due to the unique **light absorption properties** of blood components, making it less prone to false positives compared to chemical tests. *Benzidine test* - The **benzidine test** is a sensitive preliminary test for blood but is **not specific**, as it reacts with other oxidizing agents (e.g., rust, certain plant peroxidases). - It works by detecting the **peroxidase-like activity of hemoglobin**, leading to color changes but lacks confirmation of blood origin. *Teichmann's test* - **Teichmann's test** (hemin crystal test) is a moderately specific confirmatory test that produces **rhombic crystals of hemin** when heated with glacial acetic acid and a halide salt. - While more specific than presumptive tests, it can sometimes produce **false-negative results** with old or degraded bloodstains and may be less sensitive than spectroscopy. *Orthotoluidine test* - Similar to the benzidine test, the **orthotoluidine test** is another **presumptive test** that detects the peroxidase-like activity of hemoglobin, resulting in a blue-green color change. - It is **highly sensitive but not specific**, meaning it can also give positive reactions with other substances that have similar peroxidase activity, leading to potential false positives.
Question 9: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
- A. Schizophrenia
- B. Major depressive disorder plus psychosis (Correct Answer)
- C. Schizoaffective disorder
- D. Schizotypal personality disorder
Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.
Question 10: A 25-year-old male believes that his penis is decreasing in size every day and that it will eventually disappear, leading to his death. What is the most likely diagnosis?
- A. Somatic Symptom Disorder
- B. Delusional Disorder (Correct Answer)
- C. Illness Anxiety Disorder
- D. Obsessive-Compulsive Disorder
Explanation: ***Delusional Disorder*** - This patient presents with a **fixed, false belief** (penis shrinkage and disappearance) that is not amenable to change in light of conflicting evidence, which is the hallmark of a **delusion**. - This is specifically a **somatic-type delusion** involving bodily functions or sensations. - The clinical presentation is characteristic of **Koro syndrome (genital retraction syndrome)**, a culture-bound syndrome where the patient has an intense fear that their genitalia are retracting and will disappear, leading to death. - Koro is classified under **Delusional Disorder, somatic type** in standard psychiatric classification, making this the most appropriate diagnosis among the given options. *Somatic Symptom Disorder* - Characterized by **distressing somatic symptoms** accompanied by excessive thoughts, feelings, or behaviors related to the symptoms, but without a fixed, false belief. - The patient here has a **delusion** (fixed false belief about genital disappearance), not merely excessive worry about somatic symptoms. - Patients with Somatic Symptom Disorder may be partially reassured; patients with delusions cannot be reassured. *Illness Anxiety Disorder* - Involves **preoccupation with having or acquiring a serious illness** despite absence or mildness of somatic symptoms. - Unlike a delusion, the fear in Illness Anxiety Disorder is **not a fixed, false belief** and patients can often be temporarily reassured. - The patient's belief about penis disappearance is a somatic delusion, not health anxiety. *Obsessive-Compulsive Disorder* - Distinguished by **obsessions** (recurrent, intrusive thoughts recognized as irrational) and/or **compulsions** (repetitive behaviors to neutralize anxiety). - The key difference: in OCD, patients have **insight** that their thoughts are irrational; in delusional disorder, there is **no insight** - the belief is held with conviction. - The patient's fixed belief about genital disappearance is a delusion, not an obsession with doubt.
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