Brain Stimulation Therapies — MCQs
An old man is diagnosed with major depressive disorder. His son reports that he always shows suicidal tendencies. What is the treatment of choice for depression with suicidal tendencies?
Which of the following will be LEAST useful in treating Obsessive Compulsive Disorder?
Electroconvulsive therapy is not useful in which of the following conditions?
Stimulation of which of the following areas of brain is experimentally used to control intractable pain -
What is a contraindication for ECT?
Most common complication of modified ECT
A 39-year-old male patient presents with waxy flexibility, negativism and rigidity. Most probable diagnosis 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 45-year-old female presents to the OPD with complaints of "feeling tense" and experiencing stomach upset with heartburn and diarrhea. She reports having these symptoms for many years and mentions that her family members also usually feel tense and nervous. Which of the following symptoms is most likely to be seen in this patient?
A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
Brain Stimulation Therapies Indian Medical PG Practice Questions and MCQs
Question 1: An old man is diagnosed with major depressive disorder. His son reports that he always shows suicidal tendencies. What is the treatment of choice for depression with suicidal tendencies?
- A. Olanzapine
- B. ECT (Correct Answer)
- C. Mirtazapine
- D. Clozapine
Explanation: ***ECT*** - **Electroconvulsive therapy (ECT)** is the **treatment of choice** for severe depression with **suicidal ideation** due to its rapid onset of action and high efficacy. - It is particularly indicated when there is an urgent need for symptom remission to prevent self-harm, as verbal therapies and medications take longer to exert their full effects. *Olanzapine* - **Olanzapine** is an **antipsychotic medication** with some antidepressant properties, but it is not the first-line treatment for severe depression with suicidal tendencies. - It is often used as an **adjunctive treatment** in treatment-resistant depression or in psychotic depression with delusions. *Mirtazapine* - **Mirtazapine** is an **antidepressant** that can be very effective in cases of major depressive disorder, especially when insomnia and appetite loss are prominent. - However, its onset of action is not as rapid as ECT, making it less suitable for situations requiring immediate intervention for **severe suicidal risk**. *Clozapine* - **Clozapine** is an **antipsychotic medication** primarily used for **treatment-resistant schizophrenia** and reducing suicidal behavior in schizophrenia. - It is highly effective but has significant side effects, including **agranulocytosis**, and is not a first-line treatment for major depressive disorder with suicidal tendencies.
Question 2: Which of the following will be LEAST useful in treating Obsessive Compulsive Disorder?
- A. Cognitive behavioral therapy
- B. SSRIs
- C. Clomipramine
- D. Systematic desensitisation (Correct Answer)
Explanation: ***Systematic desensitisation*** - This therapy is primarily used to treat **phobias** and other **anxiety disorders** where avoidance is a key feature and a clear, single trigger can be identified. - While it involves exposure, the gradual hierarchy and relaxation training are less effective for the complex, intrusive thoughts and compulsive rituals characteristic of **OCD**. *Cognitive behavioral therapy* - **CBT, particularly Exposure and Response Prevention (ERP)**, is considered the gold standard psychotherapy for OCD. - It directly addresses the **obsessions** by exposing the individual to feared thoughts or situations and then preventing the ritualistic responses. *SSRIs* - **Selective Serotonin Reuptake Inhibitors (SSRIs)** are the first-line pharmacological treatment for OCD due to their efficacy in reducing obsessive thoughts and compulsive behaviors. - They work by increasing the availability of **serotonin** in the brain. *Clomipramine* - **Clomipramine** is a tricyclic antidepressant (TCA) with potent **serotonergic effects**, making it highly effective in treating OCD, often when SSRIs are partially effective or not tolerated. - It is specifically approved for OCD and is sometimes considered a second-line or augmentation strategy.
Question 3: Electroconvulsive therapy is not useful in which of the following conditions?
- A. Panic attacks (Correct Answer)
- B. Depression
- C. Seizures
- D. Delirium
Explanation: ***Panic attacks*** - ECT has **no established role** in the treatment of panic disorder or panic attacks. - **First-line treatments** include SSRIs, benzodiazepines, and cognitive behavioral therapy (CBT). - ECT is not indicated for **anxiety-predominant disorders** and there is no evidence supporting its use in panic attacks. *Depression* - ECT is a **highly effective** treatment for **severe major depression**, particularly: - **Treatment-resistant depression** (failed multiple antidepressant trials) - **Psychotic depression** (depression with psychotic features) - **Severe melancholic or catatonic depression** - Depression with **high suicide risk** requiring rapid response - ECT is considered one of the most effective treatments in psychiatry for severe depression. *Seizures* - ECT **induces controlled therapeutic seizures** to achieve psychiatric benefits, but it is **not a treatment for epilepsy** or seizure disorders. - The therapeutic effect in psychiatric conditions is mediated through the induced seizure and its neurobiological effects. - ECT does **not treat or prevent epileptic seizures**; patients with epilepsy can safely receive ECT with appropriate precautions. *Delirium* - ECT can be used in **highly selected cases** of refractory delirium, particularly: - Delirium with **severe agitation** unresponsive to medical management - Delirium in the context of **catatonia** - While not a first-line treatment, ECT **has documented efficacy** in specific refractory cases of delirium when conventional treatments have failed.
Question 4: Stimulation of which of the following areas of brain is experimentally used to control intractable pain -
- A. Mesencephalon
- B. Subthalamic nucleus
- C. Periaqueductal grey matter (Correct Answer)
- D. Medial forebrain bundle
Explanation: ***Periaqueductal grey matter*** - The **periaqueductal grey (PAG)** is a key modulator of endogenous analgesia, and its stimulation activates descending pain inhibitory pathways. - Stimulation of the PAG leads to the release of **endogenous opioids** (e.g., endorphins, enkephalins) and other neurotransmitters that suppress pain transmission at the spinal cord level. *Mesencephalon* - While the PAG is located within the mesencephalon (midbrain), simply stimulating the broader mesencephalon is not as precise or effective for pain control. - The mesencephalon contains various structures with diverse functions, and non-specific stimulation could lead to unwanted side effects. *Subthalamic nucleus* - The **subthalamic nucleus (STN)** is primarily involved in motor control and is a common target for deep brain stimulation in Parkinson's disease. - Its direct stimulation is not a primary or established method for controlling intractable pain. *Medial forebrain bundle* - The **medial forebrain bundle (MFB)** is a complex pathway associated with reward, motivation, and pleasure, important in the limbic system. - While it plays a role in emotional aspects of pain, its direct stimulation is not a recognized technique for somatic pain management.
Question 5: What is a contraindication for ECT?
- A. Epilepsy
- B. HIV
- C. Cerebral aneurysm (Correct Answer)
- D. Arrhythmia
Explanation: ***Cerebral aneurysm*** * A **cerebral aneurysm** is considered a **relative contraindication** for electroconvulsive therapy (ECT) due to the increased risk of rupture from the transient, but significant, rise in **blood pressure** and **intracranial pressure** during the procedure. * The cardiovascular stress induced by the seizure can worsen pre-existing vascular pathologies in the brain, making it a high-risk condition. *Arrhythmia* * While various cardiac conditions require careful monitoring during ECT, **arrhythmias** are generally not an absolute contraindication. * Patients can often undergo ECT with proper **cardiac monitoring** and **pharmacological management** to control the heart rhythm during the procedure. *Epilepsy* * **Epilepsy** is not a contraindication for ECT; in fact, ECT *artificially induces a seizure* to achieve therapeutic effects. * The presence of epilepsy primarily impacts the choice of **anticonvulsant medications** and the need for potentially higher seizure thresholds, but it does not preclude ECT. *HIV* * **HIV infection** itself is not a contraindication for ECT. * ECT can be safely administered to HIV-positive individuals, with consideration given to the patient's overall **physical health**, **medication interactions**, and any co-morbid opportunistic infections.
Question 6: Most common complication of modified ECT
- A. Amnesia (Correct Answer)
- B. Intracerebellar hemorrhage
- C. Spinal fracture
- D. Muscle pain
Explanation: ***Amnesia*** - **Memory impairment**, particularly affecting **new learning (anterograde)** and **recall of past events (retrograde)**, is the most common and bothersome complication of modified ECT. - While typically transient, some patients may experience **persistent memory difficulties**, especially with autobiographical memories. *Intracerebellar hemorrhage* - **Intracerebellar hemorrhage** is an extremely rare and severe complication of ECT, not a common one. - Such an event would typically be linked to **pre-existing vascular abnormalities** or uncontrolled hypertension during the procedure. *Spinal fracture* - **Spinal fractures** were a significant concern in **unmodified ECT** due to unattenuated muscle contractions. - However, the use of **muscle relaxants** and **anesthesia** in modified ECT has significantly reduced the risk of musculoskeletal injuries, making it uncommon. *Muscle pain* - **Muscle aches** and soreness can occur after ECT due to **succinylcholine-induced fasciculations** and general muscle contraction, particularly in the neck and back. - While common, it is usually mild and easily managed with analgesics, and not considered the "most common complication" compared to cognitive effects.
Question 7: A 39-year-old male patient presents with waxy flexibility, negativism and rigidity. Most probable diagnosis is?
- A. None of the options
- B. Stuporous catatonia (Correct Answer)
- C. Paranoid schizophrenia
- D. Excitatory catatonia
Explanation: ***Stuporous catatonia*** - **Waxy flexibility**, **negativism**, and **rigidity** are classic symptoms of catatonia, specifically indicating the stuporous presentation where there is a marked decrease in reactivity to the environment. - In this subtype, the patient often exhibits features such as **immobility**, mutism, and fixed postures, alongside the mentioned symptoms. *Excitatory catatonia* - Characterized by **psychomotor agitation**, restlessness, and sometimes violent behavior, which is contrary to the reduced reactivity seen in the patient. - Patients with excitatory catatonia may present with **purposeless motor activity** and impulsivity, along with other catatonic features. *Paranoid schizophrenia* - Primarily defined by prominent **delusions of persecution** or grandeur and **auditory hallucinations**. - While catatonic features can sometimes occur in schizophrenia, they are not the hallmark symptoms; the described features are more directly indicative of catatonia itself. *None of the options* - This is incorrect because the constellation of symptoms (waxy flexibility, negativism, rigidity) clearly points to a specific and well-recognized clinical syndrome, which is stuporous catatonia. - The symptoms provided are classic for a recognized psychiatric condition, making an "all of the above" or "none of the above" option unlikely if a specific diagnosis fits perfectly.
Question 8: 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 9: A 45-year-old female presents to the OPD with complaints of "feeling tense" and experiencing stomach upset with heartburn and diarrhea. She reports having these symptoms for many years and mentions that her family members also usually feel tense and nervous. Which of the following symptoms is most likely to be seen in this patient?
- A. Ideas of reference
- B. Tingling of extremities (Correct Answer)
- C. Hallucination
- D. Neologism
Explanation: ***Tingling of extremities*** - The patient's presentation of "feeling tense," **stomach upset, heartburn, and diarrhea** for many years, alongside a family history of similar issues, suggests significant **anxiety**. - **Peripheral neurological symptoms** such as **tingling of extremities (paresthesia)** are common manifestations of anxiety and panic attacks due to **hyperventilation** (causing respiratory alkalosis and decreased ionized calcium) and **physiological arousal**. *Ideas of reference* - **Ideas of reference** are typically seen in **psychotic disorders** (e.g., schizophrenia) where a person believes that unrelated, external events have a special, personal meaning. - While anxiety can sometimes lead to misinterpretations, **ideas of reference** at a delusional level are not characteristic of generalized anxiety. *Hallucination* - **Hallucinations** are perceptual disturbances where an individual experiences sensory perceptions (e.g., hearing voices, seeing things) in the absence of an external stimulus. - These are core symptoms of **psychotic disorders** and are not typical findings in anxiety disorders without comorbid conditions. *Neologism* - A **neologism** is the coining of new words or phrases, often without clear meaning, which is a hallmark feature of disorganized thought in **psychotic disorders** (e.g., schizophrenia). - This symptom is related to severe thought disorganization and is not associated with anxiety disorders.
Question 10: A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?
- A. Alzheimer's disease
- B. Delirium (Correct Answer)
- C. Depression
- D. Post-traumatic psychosis
Explanation: ***Delirium*** - The **acute onset** of memory loss and confusion **2 days after cardiac bypass surgery** is characteristic of **postoperative delirium**. - Delirium is a disturbance in **attention**, **awareness**, and **cognition** that develops over a short period (hours to days) and is directly related to a medical condition or procedure. - **Cardiac surgery** is a well-known risk factor, with delirium occurring in **10-50%** of cardiac bypass patients due to factors like anesthesia, hypoperfusion, inflammation, and physiological stress. - Key features here: **acute onset**, **temporal relationship to surgery**, and **memory/cognitive deficits** without psychotic symptoms. *Alzheimer's disease* - Alzheimer's is a **chronic, progressive neurodegenerative disorder** with **gradual onset** over months to years. - The **sudden appearance** of symptoms immediately after surgery cannot be explained by Alzheimer's disease. - While Alzheimer's causes memory impairment, it does not present acutely in the postoperative setting. *Depression* - Depression can cause **pseudodementia** with cognitive complaints, but the primary features would be **persistent low mood**, **anhedonia**, **sleep disturbance**, and **appetite changes**. - The **acute temporal link** to surgery and absence of mood symptoms make depression unlikely. - Cognitive symptoms in depression are typically subjective complaints rather than objective deficits. *Post-traumatic psychosis* - This would involve **psychotic symptoms** such as **hallucinations**, **delusions**, or **disorganized behavior**, which are not described in this case. - The presentation of simple **memory deficits** without psychotic features does not support this diagnosis. - Surgery itself is not typically considered a psychologically traumatic event that would trigger psychosis.
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