Mood Disorders — MCQs

A 22-year-old college student reports experiencing racing thoughts and irritability for the past week, following intense studying for finals. The patient's speech is noted to be pressured. He has been stable for the past 6 months on 500 mg of valproate twice daily. What is the initial management step for this patient's current symptoms?

Q119Medium

What is the drug of choice for rapid cycling bipolar disorder?

Q120Medium

Which of the following conditions can present with depression?

Mood Disorders Indian Medical PG Practice Questions and MCQs

Question 111: Nihilistic delusions are seen in which of the following conditions?

A. Endogenous depression (Correct Answer)
B. Dysthymia
C. Cyclothymia
D. None of the above

Explanation: **Explanation:** **Nihilistic delusions** (also known as Cotard’s syndrome in its extreme form) are specific types of delusions where a patient believes that they, a part of their body, or the world at large no longer exists. These are classic features of **Severe Depression with Psychotic Features**, historically referred to as **Endogenous Depression**. 1. **Why Option A is correct:** Endogenous depression is characterized by biological symptoms (melancholic features) and, when severe, can present with "mood-congruent" psychotic symptoms. Nihilistic delusions are the hallmark of severe depressive psychosis; the patient’s profound internal sense of emptiness and despair is projected outward as a belief in non-existence or impending doom. 2. **Why Options B and C are incorrect:** * **Dysthymia (Persistent Depressive Disorder):** This is a chronic, low-grade depression. By definition, it does not involve psychotic features like delusions. * **Cyclothymia:** This is a chronic mood instability involving periods of hypomanic and depressive symptoms that do not meet the full criteria for a Major Depressive Episode or Bipolar Disorder. Psychotic symptoms are absent in cyclothymia. **High-Yield Clinical Pearls for NEET-PG:** * **Cotard’s Syndrome:** The extreme form of nihilistic delusion where the patient claims they are "walking corpses" or have no internal organs. * **Mood Congruence:** Nihilistic delusions are considered "mood-congruent" in depression because the theme of "nothingness" matches the depressed affect. * **Treatment:** Severe depression with psychotic features (nihilistic delusions) often requires a combination of antidepressants and antipsychotics, or **Electroconvulsive Therapy (ECT)**, which is highly effective in this subset.

Question 112: Which of the following substances is not involved in panic disorder?

A. Serotonin
B. CCK
C. Glutamate
D. GABA (Correct Answer)

Explanation: **Explanation:** In the neurobiology of panic disorder, the primary neurotransmitters implicated are **Serotonin, Norepinephrine, and GABA**. The question asks which substance is **not** involved; however, based on standard psychiatric literature (Kaplan & Sadock), GABA is heavily involved via the benzodiazepine-GABA receptor complex. *Note: In many competitive exams, if this specific question appears with these options, it is often considered a "controversial" or "recall-error" question because all four substances actually play a role. However, looking at the provided key:* 1. **GABA (Correct as per key):** While GABA is the primary inhibitory neurotransmitter and GABA-A receptor dysfunction is linked to anxiety, some older curricula focused more heavily on the "excitatory" triggers of panic. If GABA is the marked answer, it implies that its role is considered secondary or modulatory compared to the direct "panicogens." 2. **Serotonin (Option A):** Definitely involved. SSRIs are the first-line treatment for panic disorder, and serotonergic dysregulation in the raphe nuclei is a core feature. 3. **CCK (Cholecystokinin) (Option B):** CCK is a potent **panicogen**. Administration of CCK tetrapeptide (CCK-4) reliably induces panic attacks in humans. 4. **Glutamate (Option C):** As the primary excitatory neurotransmitter, glutamate is involved in the "fear circuitry" (amygdala and hippocampus) and the conditioned fear response seen in panic disorder. **NEET-PG High-Yield Pearls:** * **Panicogens (Substances that induce panic):** Carbon dioxide (5-35%), Sodium Lactate, CCK, Caffeine, and Yohimbine. * **Neuroanatomy:** The **Amygdala** is the "fear center," and the **Locus Coeruleus** (norepinephrine) is the "alarm center" involved in panic. * **Treatment:** SSRIs are the long-term drug of choice; Benzodiazepines (acting on GABA) are used for acute management.

Question 113: All of the following about depression are true except?

A. Aaron T. Beck described the cognitive triad of depression.
B. Insomnia is often seen in the early part of sleep. (Correct Answer)
C. Serotonin levels are typically decreased in depression.
D. Delusions of nihilism can be a symptom of depression.

Explanation: ### Explanation **1. Why Option B is the Correct Answer (The "Except" Statement):** In Major Depressive Disorder (MDD), the most characteristic sleep disturbance is **Terminal Insomnia** (Early Morning Awakening), where the patient wakes up 2–3 hours before their usual time and cannot fall back asleep. While initial insomnia (difficulty falling asleep) can occur, **Early Morning Awakening** is a classic biological marker of melancholic depression. Additionally, sleep studies in depressed patients typically show **reduced REM latency** (entering REM sleep faster) and increased REM density. **2. Analysis of Other Options:** * **Option A:** **Aaron T. Beck** proposed the **Cognitive Triad**, which consists of negative views about the **Self, the World, and the Future**. This is a high-yield concept in cognitive behavioral therapy (CBT). * **Option C:** The **Monoamine Hypothesis** suggests that depression is associated with a deficiency of neurotransmitters, primarily **Serotonin (5-HT)** and Norepinephrine. Most antidepressants (like SSRIs) work by increasing these levels in the synaptic cleft. * **Option D:** **Nihilistic delusions** (Cotard’s syndrome), where a patient believes they are dead, rotting, or do not exist, are a severe feature of psychotic depression, particularly in the elderly. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common sleep abnormality:** Reduced REM latency (High Yield). * **Diurnal variation:** Symptoms are often worse in the morning and improve as the day progresses. * **Pseudodementia:** Depression in the elderly can mimic dementia (cognitive impairment that reverses with antidepressants). * **Masked Depression:** Physical complaints (somatization) dominate the clinical picture instead of reported low mood.

Question 114: Nihilistic ideas are typically seen in which of the following psychiatric conditions?

A. Depression (Correct Answer)
B. Schizophrenia
C. Mania
D. Obsessive-Compulsive Disorder

Explanation: **Explanation:** **Nihilistic delusions** (the belief that oneself, others, or the world no longer exists or is coming to an end) are a hallmark feature of **Severe Depression with Psychotic Features**. In the context of depression, these are considered **mood-congruent delusions**, as the theme of non-existence aligns with the patient’s profound feelings of hopelessness and worthlessness. When these nihilistic ideas become extreme—such as the patient claiming their internal organs are rotting or that they are actually dead—it is referred to as **Cotard’s Syndrome** (the "Walking Corpse" syndrome). **Analysis of Incorrect Options:** * **B. Schizophrenia:** While delusions are common, they are typically persecutory, bizarre, or involve delusions of control/passivity. Nihilistic delusions are less characteristic than in mood disorders. * **C. Mania:** Patients in a manic state exhibit **grandiose delusions** (inflated power, wealth, or identity), which is the polar opposite of nihilistic ideation. * **D. Obsessive-Compulsive Disorder (OCD):** This involves ego-dystonic obsessions (intrusive thoughts) and compulsions, not fixed false beliefs (delusions). **Clinical Pearls for NEET-PG:** * **Cotard’s Syndrome:** Most commonly associated with severe agitated depression in the elderly. * **Mood-Congruent vs. Incongruent:** Delusions in depression (guilt, poverty, nihilism) match the low mood, whereas "mood-incongruent" features in depression suggest a poorer prognosis. * **Treatment:** Severe depression with nihilistic delusions often requires **Electroconvulsive Therapy (ECT)** as it is considered a psychiatric emergency due to the high risk of self-neglect and suicide.

Question 115: What is the treatment for resistant depression?

A. Electroconvulsive Therapy (ECT) (Correct Answer)
B. Selective Serotonin Reuptake Inhibitors (SSRIs)
C. Tricyclic Antidepressants (TCAs)
D. Venlafaxine

Explanation: ### Explanation **Correct Answer: A. Electroconvulsive Therapy (ECT)** **Medical Concept:** Treatment-Resistant Depression (TRD) is clinically defined as a Major Depressive Disorder that fails to respond adequately to at least two different classes of antidepressants used at therapeutic doses for an adequate duration (usually 6–8 weeks). **Electroconvulsive Therapy (ECT)** is considered the "gold standard" and the most effective treatment for resistant depression. It works by inducing a generalized seizure under anesthesia, which leads to rapid neurochemical changes and increased neuroplasticity. It is also the treatment of choice when rapid response is required (e.g., severe suicidality or catatonia). **Analysis of Incorrect Options:** * **B. SSRIs:** These are first-line treatments for mild to moderate depression. By definition, a patient with "resistant" depression has already failed trials of first-line agents like SSRIs. * **C. TCAs:** While potent, TCAs are generally second-line due to their side-effect profile (anticholinergic effects, cardiotoxicity). They may be used before labeling a patient "resistant," but they are not the definitive treatment for TRD. * **D. Venlafaxine:** This is an SNRI. While often used in "step-up" therapy or as an augmentation strategy, it does not match the efficacy of ECT in true resistant cases. **NEET-PG High-Yield Pearls:** * **Indications for ECT:** Treatment-resistant depression, severe suicidal ideation, catatonia, and psychotic depression. * **Most common side effect of ECT:** Retrograde amnesia (usually resolves) and post-ictal confusion. * **Absolute Contraindication:** There are no absolute contraindications, but **Increased Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Pharmacotherapy for TRD:** Other options include Esketamine (nasal spray) or augmentation with Lithium, Atypical Antipsychotics (Aripiprazole), or T3 (Liothyronine).

Question 116: Which is an objective sign of depression involving the upper eyelid?

A. Veraguth sign (Correct Answer)
B. Omega sign
C. Empty delta sign
D. Hoffman's sign

Explanation: **Explanation:** **Veraguth’s sign** is a classic objective physical finding in patients with melancholic depression. It refers to a characteristic triangular fold in the nasal corner of the **upper eyelid**, caused by the contraction of the corrugator supercilii muscles. This creates a look of fixed distress or "omega-like" tension specifically localized to the upper lid area. **Analysis of Options:** * **Omega sign (Option B):** While also associated with depression, the Omega sign refers to the furrowing of the brow where wrinkles on the **forehead** (above the root of the nose) form the shape of the Greek letter Omega (Ω). It is a sign of chronic mourning or severe depression but involves the forehead, not the eyelid. * **Empty delta sign (Option C):** This is a neuroimaging finding seen on contrast-enhanced CT scans of the head, indicating **Dural Venous Sinus Thrombosis**. It represents a lack of filling in the superior sagittal sinus. * **Hoffman's sign (Option D):** This is a clinical sign used in neurology to detect **Upper Motor Neuron (UMN) lesions** involving the cervical spine. It is elicited by flicking the nail of the middle finger, resulting in involuntary flexion of the thumb and index finger. **High-Yield Clinical Pearls for NEET-PG:** * **Veraguth’s fold** and the **Omega sign** are both considered "facies of depression." * **Cotard’s Syndrome:** A severe form of depressive psychosis where the patient has nihilistic delusions (e.g., believing their organs are rotting or they are dead). * **Beck’s Cognitive Triad:** A psychological model of depression consisting of negative views about the **Self, the World, and the Future.**

Question 117: What is a common treatment for unipolar depression?

A. Fluoxetine
B. Sertraline
C. Citalopram
D. All of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. All of the above**. Unipolar depression (Major Depressive Disorder) is primarily managed using **Selective Serotonin Reuptake Inhibitors (SSRIs)** as the first-line pharmacological intervention. SSRIs work by inhibiting the presynaptic reuptake of serotonin (5-HT), thereby increasing its availability in the synaptic cleft. * **Fluoxetine (Option A):** A prototype SSRI with a long half-life (due to its active metabolite norfluoxetine). It is often preferred in children and adolescents and is useful for patients with low energy due to its slightly activating effect. * **Sertraline (Option B):** A widely used SSRI known for its safety profile in patients with cardiovascular comorbidities (post-MI). It is also a preferred choice during breastfeeding. * **Citalopram (Option C):** A highly selective SSRI. While effective, it requires monitoring for dose-dependent QTc prolongation. Since all three drugs belong to the SSRI class and are established first-line treatments for unipolar depression, "All of the above" is the correct choice. **High-Yield Clinical Pearls for NEET-PG:** * **First-line for MDD:** SSRIs (due to better tolerability and lower toxicity in overdose compared to TCAs). * **Lag period:** Antidepressants typically take **2–4 weeks** to show clinical improvement. * **Most common side effect of SSRIs:** Gastrointestinal upset (nausea/diarrhea) and sexual dysfunction (delayed ejaculation). * **Drug of choice for OCD:** Fluoxetine/Fluvoxamine (SSRIs in higher doses). * **Drug of choice for Depression with Insomnia:** Mirtazapine (due to sedative properties). * **Discontinuation Syndrome:** Least common with Fluoxetine (due to long half-life) and most common with Paroxetine.

Question 118: A 22-year-old college student reports experiencing racing thoughts and irritability for the past week, following intense studying for finals. The patient's speech is noted to be pressured. He has been stable for the past 6 months on 500 mg of valproate twice daily. What is the initial management step for this patient's current symptoms?

A. Hospitalize the patient
B. Increase the valproate by 500 mg/day
C. Prescribe clonazepam (Correct Answer)
D. Start haloperidol

Explanation: ### **Explanation** The patient is presenting with a **breakthrough manic or hypomanic episode** (racing thoughts, irritability, pressured speech) despite being on a stable dose of a mood stabilizer (Valproate). **1. Why Option C is Correct:** In the acute management of breakthrough symptoms, especially when associated with agitation, insomnia, or irritability, **Benzodiazepines (like Clonazepam or Lorazepam)** are the preferred initial adjunctive treatment. They provide rapid symptomatic relief, help restore sleep architecture, and reduce psychomotor agitation while waiting for mood stabilizers to be titrated or for the episode to subside. **2. Why Other Options are Incorrect:** * **Option A (Hospitalization):** This is reserved for patients who are a danger to themselves or others, have a total loss of functioning, or have psychotic features. This patient is currently stable enough to be managed in an outpatient setting. * **Option B (Increase Valproate):** While the dose may eventually need adjustment, Valproate has a slow onset of action for acute symptoms. Furthermore, dosage changes should ideally be guided by **serum therapeutic levels** (target: 50–125 µg/mL) rather than empirical increases. * **Option D (Start Haloperidol):** While antipsychotics are used in acute mania, Haloperidol is typically reserved for severe mania with psychosis or extreme aggression due to its high risk of Extrapyramidal Side Effects (EPS). **3. NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC) for Acute Mania:** Lithium or Valproate + Atypical Antipsychotic (e.g., Risperidone, Olanzapine). * **DOC for Rapid Cycling Bipolar Disorder:** Valproate. * **Therapeutic Range of Lithium:** 0.8–1.2 mEq/L (Acute); 0.6–1.0 mEq/L (Maintenance). * **Benzodiazepines** serve as a "bridge" in acute episodes to manage agitation and insomnia.

Question 119: What is the drug of choice for rapid cycling bipolar disorder?

A. Lithium
B. Carbamazepine
C. Sodium valproate (Correct Answer)
D. Haloperidol

Explanation: **Explanation:** **Rapid cycling bipolar disorder** is defined as the occurrence of four or more mood episodes (mania, hypomania, or depression) within a 12-month period. 1. **Why Sodium Valproate is correct:** While Lithium is the gold standard for classic Bipolar I disorder, it is notably less effective in patients with rapid cycling or mixed episodes. **Sodium Valproate (Divalproex)** is the drug of choice for rapid cycling because it has superior efficacy in stabilizing mood when cycles are frequent and is often more effective in treating "mixed" presentations. It works by increasing GABA levels and modulating glutamate and sodium channels. 2. **Why other options are incorrect:** * **Lithium:** The first-line treatment for classic mania and prophylaxis, but patients with rapid cycling often show a poor response to Lithium monotherapy. * **Carbamazepine:** Used as a second-line mood stabilizer or as an adjunct. It is effective for rapid cycling but is generally considered secondary to Valproate due to its side effect profile and enzyme-inducing properties. * **Haloperidol:** A high-potency typical antipsychotic used for acute management of manic agitation, but it has no role in the long-term stabilization or prevention of rapid cycling. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Classic Mania:** Lithium. * **DOC for Rapid Cycling/Mixed Episodes:** Sodium Valproate. * **DOC for Bipolar Depression:** Quetiapine (or Lurasidone/Lamotrigine). * **Teratogenicity:** Valproate is associated with **Neural Tube Defects** (specifically spina bifida); Lithium is associated with **Ebstein’s Anomaly**. * **Prognosis:** Rapid cycling is more common in women and is often associated with hypothyroidism or the use of antidepressants.

Question 120: Which of the following conditions can present with depression?

A. Hyperthyroidism
B. Hypoglycemia
C. Adrenal disorder
D. Pheochromocytoma (Correct Answer)

Explanation: **Explanation:** The correct answer is **Pheochromocytoma**. While traditionally associated with anxiety, panic attacks, and hypertension due to catecholamine surges, pheochromocytoma is a well-documented organic cause of **secondary mood disorders**, including depression. The chronic depletion of catecholamines following paroxysmal surges, or the psychological stress of the condition, can manifest as depressive symptoms. **Analysis of Options:** * **A. Hyperthyroidism:** Typically presents with symptoms of anxiety, irritability, restlessness, and insomnia. Depression is classically associated with **Hypothyroidism** (the "pseudodementia" of the elderly). * **B. Hypoglycemia:** Presents acutely with neuroglycopenic symptoms (confusion, agitation, seizures) and autonomic hyperactivity (tremors, sweating). It does not typically present as a sustained depressive syndrome. * **C. Adrenal Disorder:** This is a broad term. While **Cushing’s syndrome** (hypercortisolism) and **Addison’s disease** (adrenal insufficiency) are strongly linked to depression, "Pheochromocytoma" is the more specific and recognized answer in the context of this specific question's construction in psychiatric boards. **NEET-PG High-Yield Pearls:** * **Endocrine causes of Depression:** Hypothyroidism (most common), Cushing’s syndrome, Addison’s disease, and Hyperparathyroidism (Hypercalcemia leads to "moans, groans, and psychic overtones"). * **Organic Mood Syndrome:** Always rule out medical causes if a patient presents with atypical features, late-onset depression (first episode >40 years), or poor response to standard antidepressants. * **Pheochromocytoma Triad:** Episodic headache, sweating, and tachycardia. If these coexist with depression, screen for urinary vanillylmandelic acid (VMA) or metanephrines.

Practice by Chapter

Major Depressive Disorder

Practice Questions

Bipolar Disorder: Manic Episodes

Practice Questions

Bipolar Disorder: Depressive and Mixed Episodes

Practice Questions

Persistent Depressive Disorder (Dysthymia)

Practice Questions

Cyclothymic Disorder

Practice Questions

Seasonal Affective Disorder

Practice Questions

Suicide and Suicidal Behavior

Practice Questions

Pharmacotherapy of Mood Disorders

Practice Questions

Psychotherapy for Mood Disorders

Practice Questions

Brain Stimulation Therapies

Practice Questions

Treatment-Resistant Depression

Practice Questions

Mood Disorders in Special Populations

Practice Questions

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