Cyclothymic Disorder — MCQs
Which of the following is a characteristic of Bipolar II disorder?
Indications for ECT are all except?
A patient inventing new words is a feature of?
Which of the following disorders is classified under somatic symptom and related disorders in the DSM-5?
Which is not a feature of ADHD?
All of the following are tricyclic antidepressants except?
In depression, there is a deficiency in which neurotransmitter?
A 41-year-old woman presented with a four-year history of widespread aches and pains, generalized weakness, insomnia, loss of appetite, lack of interest in work, and social withdrawal. She denies feelings of sadness. What is the most likely diagnosis?
A 17-year-old boy is diagnosed with schizophrenia. What is the risk that one of his siblings will develop the disease?
An 18-year-old student complains of a lack of interest in studies for the last 6 months. He has frequent quarrels with his parents and experiences frequent headaches. What is the most appropriate clinical approach?
Cyclothymic Disorder Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is a characteristic of Bipolar II disorder?
- A. Dysthymia
- B. Major depression and hypomania (Correct Answer)
- C. Single manic episode
- D. Cyclothymic disorder
Explanation: ***Major depression and hypomania*** - Bipolar II disorder is characterized by the occurrence of at least one **major depressive episode** and at least one **hypomanic episode**. - Crucially, it does not involve full-blown **manic or mixed episodes**. *Dysthymia* - **Dysthymia**, or persistent depressive disorder, involves chronic low-grade depression lasting at least two years, but without manic or hypomanic symptoms. - It is a form of depression and does not include the characteristic mood elevations seen in bipolar disorders. *Single manic episode* - A single manic episode is characteristic of **Bipolar I disorder**, which involves at least one manic episode, with or without previous depressive or hypomanic episodes. - Bipolar II disorder specifically excludes the presence of a **manic episode**. *Cyclothymic disorder* - **Cyclothymic disorder** involves numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode. - It is a milder but chronic form of bipolar spectrum disorder, distinct from the full major depressive and hypomanic episodes of Bipolar II.
Question 2: Indications for ECT are all except?
- A. Severe psychosis
- B. Catatonic schizophrenia
- C. Severe manic attack (Correct Answer)
- D. Severe depression with suicidal risk
Explanation: ***Severe manic attack*** - While **severe mania IS a recognized indication for ECT**, it is generally considered **less commonly used as first-line therapy** compared to the other options listed. - In clinical practice, **acute severe mania** is typically managed initially with **antipsychotics and mood stabilizers** (lithium, valproate), with ECT reserved for **treatment-resistant cases** or when rapid response is critical. - ECT is highly effective for severe mania, particularly with **psychotic features** or **medication intolerance**, but is not the **most typical first-choice indication** compared to severe depression or catatonia. - This question reflects the **relative clinical priority** of ECT indications rather than absolute contraindication. *Severe depression with suicidal risk* - This is the **most common and well-established indication for ECT**. - ECT provides **rapid antidepressant effect** (often within 1-2 weeks) and is particularly indicated when there is **imminent suicide risk**, **psychotic depression**, or **treatment-resistant depression**. - Response rates exceed 70-90% in severe depression, making it a primary indication. *Catatonic schizophrenia* - **Catatonia is one of the strongest indications for ECT**, regardless of underlying etiology (schizophrenia, mood disorders, or medical conditions). - ECT rapidly resolves **catatonic symptoms** including mutism, stupor, posturing, and waxy flexibility. - Often considered **first-line treatment** for severe or malignant catatonia due to life-threatening complications. *Severe psychosis* - ECT is indicated for **severe psychotic disorders** that are **treatment-resistant** or when patients cannot tolerate antipsychotic medications. - Particularly effective in **acute psychotic agitation**, **treatment-refractory schizophrenia**, and psychosis with high risk of harm. - Provides rapid symptom control when pharmacotherapy has failed or is contraindicated.
Question 3: A patient inventing new words is a feature of?
- A. Schizophrenia (Correct Answer)
- B. Aphasia
- C. Neurotic disorders
- D. Obsessive-Compulsive Disorder (OCD)
Explanation: ***Schizophrenia*** - The invention of new words, known as **neologisms**, is a characteristic symptom of **thought disorder** in schizophrenia. - These words often have personal meaning to the patient but are unintelligible to others, reflecting disturbed communication. *Neurotic disorders* - These disorders, such as anxiety and phobias, primarily involve **distress and maladaptive coping mechanisms** but do not typically feature neologisms. - **Thought content** may be ruminative or anxious, but not disorganized to the extent of inventing new words. *Aphasia* - Aphasia is a **language disorder caused by brain damage** (e.g., stroke), resulting in difficulty with language production or comprehension. - While it can involve word-finding difficulties or paraphasias (word substitutions), it is distinctly different from the deliberate invention of new, non-existent words seen in psychosis. *Obsessive-Compulsive Disorder (OCD)* - OCD is characterized by **recurrent, intrusive thoughts (obsessions)** and repetitive behaviors (compulsions). - It does not involve thought disorganization or the creation of neologisms; language remains structured, though often focused on obsessive themes.
Question 4: Which of the following disorders is classified under somatic symptom and related disorders in the DSM-5?
- A. Post-Traumatic Stress Disorder (PTSD)
- B. Phobic disorders (e.g., social anxiety disorder)
- C. Conversion disorder (functional neurological symptom disorder) (Correct Answer)
- D. Obsessive-Compulsive Disorder (OCD)
Explanation: ***Conversion disorder (functional neurological symptom disorder)*** - **Conversion disorder** is characterized by neurological symptoms (e.g., paralysis, blindness) that are **incompatible with recognized neurological or medical conditions**, yet are not intentionally produced. - It falls under **somatic symptom and related disorders** because the primary features are physical symptoms causing distress or functional impairment, rather than being malingered or feigned. *Phobic disorders (e.g., social anxiety disorder)* - **Phobic disorders** are classified under **anxiety disorders** in the DSM-5, not somatic symptom and related disorders. - They are primarily characterized by **intense, irrational fears** of specific objects or situations, leading to avoidance rather than prominent physical symptoms without a medical cause. *Post-Traumatic Stress Disorder (PTSD)* - **PTSD** is classified under **trauma- and stressor-related disorders** in the DSM-5, distinguished by symptoms developing after exposure to a traumatic event. - Its core features include **intrusive memories, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity**, rather than unexplained physical symptoms. *Obsessive-Compulsive Disorder (OCD)* - **OCD** is classified under **obsessive-compulsive and related disorders** in the DSM-5. - It is primarily characterized by the presence of **obsessions (recurrent, intrusive thoughts)** and/or **compulsions (repetitive behaviors or mental acts)**, which are distinct from somatic symptoms.
Question 5: Which is not a feature of ADHD?
- A. Impulsiveness
- B. Hyperactivity
- C. Dyslexia (Correct Answer)
- D. Inattention
Explanation: ***Dyslexia*** - While individuals with **ADHD** may have comorbid learning disabilities, **dyslexia** itself is a specific learning disorder primarily characterized by difficulties with accurate and/or fluent word recognition, and poor spelling and decoding abilities, not a core feature of ADHD. - Dyslexia can occur alongside ADHD, but it is a distinct condition with its own diagnostic criteria and is not considered a symptom or feature of ADHD. *Impulsiveness* - **Impulsiveness** is a core diagnostic criterion for ADHD, particularly in the **hyperactive-impulsive presentation**, where individuals often act without thinking or have difficulty awaiting their turn. - This can manifest as blurting out answers, interrupting others, or engaging in risky behaviors. *Hyperactivity* - **Hyperactivity** is a hallmark symptom of ADHD, especially in childhood, and is reflected in excessive motor activity, fidgeting, restlessness, and difficulty staying seated. - This symptom can persist into adulthood, although it may present as an internal sense of restlessness rather than overt physical movement. *Inattention* - **Inattention** is a primary diagnostic feature of ADHD, characterized by difficulty sustaining attention, easily being distracted, making careless mistakes, and problems with organization. - This aspect of ADHD can significantly impair academic, occupational, and social functioning.
Question 6: All of the following are tricyclic antidepressants except?
- A. Mianserin (Correct Answer)
- B. Imipramine
- C. Protriptyline
- D. Maprotiline
Explanation: **Explanation:** The correct answer is **A. Mianserin**. **Why Mianserin is the correct answer:** Mianserin is classified as a **Tetracyclic Antidepressant (TeCA)**, not a Tricyclic Antidepressant (TCA). Chemically, it contains four fused rings. Pharmacologically, it acts as an alpha-2 adrenergic receptor antagonist and a serotonin receptor antagonist (NASSA—Noradrenergic and Specific Serotonergic Antidepressant). Unlike TCAs, it lacks significant anticholinergic side effects and is relatively safer in overdose. **Analysis of Incorrect Options:** * **B. Imipramine:** This is the prototypical **Tricyclic Antidepressant**. It is a tertiary amine that inhibits the reuptake of both serotonin and norepinephrine. It is historically significant as the first antidepressant discovered. * **C. Protriptyline:** This is a **Secondary Amine TCA**. It is unique among TCAs because it is more activating/stimulating rather than sedating, making it useful for patients with lethargy. * **D. Maprotiline:** While Maprotiline is technically a tetracyclic compound (like Mianserin), in the context of standard medical examinations and the NEET-PG curriculum, it is traditionally grouped with **TCAs** (specifically as a secondary amine-like drug) because its side effect profile and mechanism (potent Norepinephrine Reuptake Inhibition) closely mimic TCAs. However, between Mianserin and Maprotiline, Mianserin is the definitive "non-TCA" due to its unique NASSA mechanism. **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Enuresis:** Imipramine is the drug of choice for nocturnal enuresis in children (though behavioral therapy is first-line). * **OCD Treatment:** Clomipramine is the most serotonin-selective TCA and is highly effective for OCD. * **Toxicity:** TCA overdose presents with the **3 C's**: Coma, Convulsions, and Cardiac arrhythmias (due to sodium channel blockade). The antidote is **Sodium Bicarbonate**. * **Amitriptyline:** The most sedating TCA, often used for chronic pain and migraine prophylaxis.
Question 7: In depression, there is a deficiency in which neurotransmitter?
- A. 5-HT (Serotonin) (Correct Answer)
- B. Acetylcholine (Ach)
- C. Dopamine
- D. GABA (Gamma-aminobutyric acid)
Explanation: ### Explanation **Correct Option: A. 5-HT (Serotonin)** The pathophysiology of depression is primarily explained by the **Monoamine Hypothesis**, which suggests that a deficiency in monoamine neurotransmitters—specifically **Serotonin (5-HT)** and **Norepinephrine (NE)**—leads to depressive symptoms. Serotonin is crucial for regulating mood, sleep, appetite, and impulse control. Most first-line antidepressants, such as SSRIs (Selective Serotonin Reuptake Inhibitors), work by increasing the synaptic concentration of 5-HT, reinforcing its central role in the disorder. **Incorrect Options:** * **B. Acetylcholine (Ach):** Increased cholinergic activity is sometimes associated with depression, while decreased levels are linked to cognitive deficits (e.g., Alzheimer’s). It is not the primary deficiency in depression. * **C. Dopamine:** While dopamine deficiency is linked to **anhedonia** (loss of pleasure) and is central to Parkinson’s disease, serotonin remains the hallmark neurotransmitter associated with the core diagnosis of Major Depressive Disorder (MDD). * **D. GABA:** GABA is the primary inhibitory neurotransmitter. Its deficiency is more classically associated with **Anxiety Disorders** and seizure activity rather than the primary etiology of depression. **Clinical Pearls for NEET-PG:** * **Metabolite Marker:** The primary metabolite of Serotonin is **5-HIAA** (5-Hydroxyindoleacetic acid). Low levels of 5-HIAA in the cerebrospinal fluid (CSF) are strongly associated with **impulsive suicide attempts**. * **Neuroendocrine Change:** Depression is often associated with **Hypercortisolism** (failure to suppress cortisol in the Dexamethasone Suppression Test). * **Sleep Changes:** High-yield findings in depression include **decreased REM latency** (REM sleep starts sooner) and increased REM intensity.
Question 8: A 41-year-old woman presented with a four-year history of widespread aches and pains, generalized weakness, insomnia, loss of appetite, lack of interest in work, and social withdrawal. She denies feelings of sadness. What is the most likely diagnosis?
- A. Somatoform pain disorder
- B. Major depression (Correct Answer)
- C. Somatization disorder
- D. Dissociative disorder
Explanation: ### Explanation The correct answer is **Major Depression**. This case highlights a classic presentation of **Masked Depression**, a clinical phenomenon where a patient experiences the core symptoms of a depressive episode but denies feeling "sad" or "depressed." Instead, the patient presents with prominent somatic complaints and neurovegetative symptoms. **Why Major Depression is correct:** The patient exhibits several criteria from the DSM-5/ICD-10 for a depressive episode: 1. **Anhedonia:** "Lack of interest in work and social withdrawal." 2. **Somatic/Vegetative symptoms:** Insomnia and loss of appetite. 3. **Psychomotor changes:** Generalized weakness and widespread aches. In many cultures and age groups, patients may not report a depressed mood (subjective sadness) but will demonstrate a clear loss of interest and significant functional impairment, which are sufficient for a diagnosis of Major Depressive Disorder (MDD). **Why other options are incorrect:** * **Somatoform Pain Disorder:** While the patient has "aches and pains," this diagnosis is reserved for cases where pain is the *primary* focus. It does not typically account for the cluster of biological symptoms like loss of appetite and social withdrawal seen here. * **Somatization Disorder:** This requires a long history (starting before age 30) of multiple, clinically significant physical complaints across different organ systems (GI, sexual, neurological). The pervasive lack of interest and biological symptoms in this patient point more strongly toward a primary mood disorder. * **Dissociative Disorder:** This involves a disruption of identity, memory, or consciousness (e.g., amnesia, fugue, or motor deficits). It does not present with the chronic biological and interest-related decline described. **Clinical Pearls for NEET-PG:** * **Masked Depression:** Common in the elderly and in certain South Asian populations where somatic symptoms (body aches, "gas," weakness) are more culturally acceptable than expressing emotional distress. * **Core Symptoms of MDD:** Remember the triad—Depressed mood, Anhedonia, and Low energy (Anergia). * **Rule of Thumb:** If a patient presents with multiple vague somatic complaints *plus* biological symptoms (sleep/appetite) and social withdrawal, always screen for Depression first.
Question 9: A 17-year-old boy is diagnosed with schizophrenia. What is the risk that one of his siblings will develop the disease?
- A. 2%
- B. 5%
- C. 9% (Correct Answer)
- D. 20%
Explanation: **Explanation:** The risk of developing schizophrenia is heavily influenced by genetic proximity. In the field of psychiatric genetics, the risk increases as the percentage of shared genes with an affected individual increases. **1. Why 9% is Correct:** For a sibling of an affected individual (who shares approximately 50% of their genes), the lifetime risk of developing schizophrenia is approximately **8–10%** (standardized at **9%** for examination purposes). This is nearly 10 times higher than the risk in the general population. **2. Analysis of Incorrect Options:** * **A (2%):** This is too low for a first-degree relative. However, the risk for a **second-degree relative** (uncles, aunts, nephews, nieces) is approximately **2–3%**. * **B (5%):** This is an intermediate value but does not align with established epidemiological data for siblings. It is closer to the risk for a parent (approx. 6%). * **D (20%):** This is too high for a single sibling. This value is more representative of the risk when **both parents** have schizophrenia (approx. 40%) or for a **dizygotic (fraternal) twin** of an affected individual (approx. 12–17%). **Clinical Pearls & High-Yield Facts for NEET-PG:** * **General Population Risk:** 1% (Baseline). * **Monozygotic (Identical) Twin:** ~47–50% (Highest risk; proves it is not 100% genetic). * **Dizygotic (Fraternal) Twin:** ~12–17%. * **Child of one affected parent:** ~12–13%. * **Child of two affected parents:** ~40–46%. * **Sibling of affected individual:** ~8–10% (9%). **Key Concept:** Schizophrenia is a **polygenic** disorder. The more closely related a person is to a patient, the higher the risk, with the highest concordance seen in monozygotic twins.
Question 10: An 18-year-old student complains of a lack of interest in studies for the last 6 months. He has frequent quarrels with his parents and experiences frequent headaches. What is the most appropriate clinical approach?
- A. Consider it a normal adolescent problem.
- B. Rule out depression. (Correct Answer)
- C. Rule out migraine.
- D. Rule out oppositional defiant disorder.
Explanation: **Explanation:** The correct answer is **Rule out depression (Option B)**. In adolescents, depression often presents atypically compared to adults. While adults typically manifest "low mood" or sadness, adolescents frequently present with **irritable mood**, behavioral issues (quarrels with parents), and **somatic complaints** (frequent headaches). The patient’s "lack of interest in studies" for 6 months signifies **anhedonia** or a decline in socio-occupational functioning, which are core diagnostic criteria for Depressive Disorder under DSM-5 and ICD-11. **Why other options are incorrect:** * **Option A:** Attributing a 6-month decline in functioning and persistent somatic symptoms to "normal adolescent behavior" is a common clinical error. Any significant change in baseline behavior warrants a pathological workup. * **Option C:** While he has headaches, the presence of behavioral changes and academic decline suggests the headache is likely a somatic manifestation of an underlying psychiatric condition rather than a primary neurological disorder like migraine. * **Option D:** Oppositional Defiant Disorder (ODD) involves a pattern of angry/irritable mood and vindictiveness, but it does not typically explain the "lack of interest in studies" or the somatic symptoms as effectively as depression does. **Clinical Pearls for NEET-PG:** * **Atypical Presentation:** Irritability and somatic symptoms (headache, stomach ache) are the hallmarks of pediatric and adolescent depression. * **Duration:** For a diagnosis of Major Depressive Disorder, symptoms must persist for at least **2 weeks**. This patient has been symptomatic for 6 months. * **Pseudodementia:** In elderly patients, depression often mimics dementia; in adolescents, it often mimics "laziness" or "rebellion." Always screen for mood symptoms in cases of sudden academic decline.
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