Tourette's Syndrome — MCQs
Drug of choice for initial pharmacological treatment of Tourette syndrome -
Dysdiadochokinesia refers to:
Tics, hair pulling, and nail biting behaviors are best treated with?
Chorea is NOT seen in
What is the treatment of choice for akathisia?
Psychosurgery is used in which of the following conditions?
Ego's defense mechanism "Undoing" is typically seen in which of the following conditions?
What is true about obsessive-compulsive disorder?
All are true about obsession, except:
All of the following are true about Obsessive compulsive disorder EXCEPT?
Tourette's Syndrome Indian Medical PG Practice Questions and MCQs
Question 1: Drug of choice for initial pharmacological treatment of Tourette syndrome -
- A. B complex
- B. Clonidine (Correct Answer)
- C. Haloperidol
- D. Valproate
Explanation: ***Clonidine*** - **Clonidine** is often considered a first-line treatment for Tourette syndrome, especially in children and adolescents, due to its favorable side effect profile compared to typical antipsychotics. - As an **alpha-2 adrenergic agonist**, it helps reduce tic severity and associated symptoms like ADHD and impulsivity by modulating neurotransmitter release in the brain. *B complex* - **B vitamins** are generally not indicated for the treatment of Tourette syndrome, as there is no robust scientific evidence to support their efficacy in managing tics. - While essential for overall neurological health, they do not directly address the pathophysiology of tic disorders. *Haloperidol* - **Haloperidol**, a **first-generation antipsychotic**, is highly effective in reducing tics but is generally reserved for severe cases due to its significant side effects, including extrapyramidal symptoms and sedation. - It works by blocking **dopamine D2 receptors** but its adverse effects limit its use as an initial agent of choice. *Valproate* - **Valproate** is an anticonvulsant and mood stabilizer primarily used for epilepsy, bipolar disorder, and migraine prevention. - It is not a standard or preferred treatment for Tourette syndrome, as its efficacy in tic reduction is limited and it carries significant side effects.
Question 2: Dysdiadochokinesia refers to:
- A. Inability to Perform Rapid Alternating Movements (Correct Answer)
- B. Intention Tremor
- C. Tremor of the Eyeballs
- D. Failure of Progression in Talking
Explanation: ***Inability to Perform Rapid Alternating Movements*** - **Dysdiadochokinesia** is a neurological sign indicating an impaired ability to perform **rapid alternating movements**, such as pronation and supination of the forearms [1]. - It is a key indicator of **cerebellar dysfunction**, as the cerebellum is responsible for coordinating the rate, range, and force of movements [1]. *Intention Tremor* - An **intention tremor** is a tremor that worsens during purposeful movement towards a target, not a difficulty with alternating movements themselves. - While also a sign of **cerebellar damage**, it manifests as oscillations during voluntary action, distinct from dysdiadochokinesia. *Tremor of the Eyeballs* - This condition is known as **nystagmus**, which refers to involuntary rhythmic eye movements [2]. - While nystagmus can be associated with **cerebellar dysfunction**, it is a distinct sign separate from the ability to perform rapid alternating limb movements [2]. *Failure of Progression in Talking* - This symptom is characteristic of **dysarthria**, a motor speech disorder that impacts articulation, phonation, and prosody [2]. - While certain types of dysarthria can be linked to **cerebellar disease**, "failure of progression in talking" specifically describes speech difficulties, not the coordination of limb movements [2].
Question 3: Tics, hair pulling, and nail biting behaviors are best treated with?
- A. Behavior therapy (Correct Answer)
- B. Psychodynamic therapy
- C. ECT
- D. Medications
Explanation: ***Behavior therapy*** - **Behavior therapy**, particularly **Habit Reversal Training (HRT)**, is the first-line and most effective treatment for tics, hair pulling (trichotillomania), and nail biting (onychophagia). - It involves teaching individuals to identify triggers and recognize urges, and then substituting the undesirable behavior with a competing response. *Psychodynamic therapy* - This therapy focuses on uncovering **unconscious conflicts** and past experiences that may contribute to symptoms. - While it can be helpful for some psychological issues, it is generally **less effective** for directly addressing specific behavioral symptoms like tics or body-focused repetitive behaviors. *ECT* - **Electroconvulsive therapy (ECT)** is a powerful somatic treatment primarily used for severe mental illnesses like **treatment-resistant depression** or catatonia. - It is **not indicated** for tics, hair pulling, or nail biting due to the high risks and lack of evidence for its efficacy in these conditions. *Medications* - While some medications (e.g., **antipsychotics** for severe tics, **SSRIs** for co-occurring anxiety/OCD) can be used as an adjunct, **behavioral therapy** is generally more effective and the first-line approach for these specific behaviors. - Medications alone rarely resolve these behaviors completely without behavioral intervention, and they often come with side effects.
Question 4: Chorea is NOT seen in
- A. Rheumatic fever
- B. Tourette syndrome (Correct Answer)
- C. Creutzfeldt-Jakob disease
- D. Huntington's disease
Explanation: ***Tourette syndrome*** - **Tourette syndrome** is primarily characterized by **motor and vocal tics**, which are sudden, repetitive, nonrhythmic movements or vocalizations. - While it involves involuntary movements, these are distinct from the continuous, flowing, dance-like movements of **chorea**. *Rheumatic fever* - **Sydenham's chorea** (St. Vitus' dance) is a major manifestation of **acute rheumatic fever**, particularly in children. - It is characterized by **involuntary, purposeless, jerky movements** affecting the face, trunk, and extremities. *Creutzfeldt-Jakob disease* - This rapidly progressive, fatal neurodegenerative disease often presents with various neurological symptoms including **chorea**, **myoclonus**, and ataxia. - The abnormal movements are due to widespread neuronal loss, particularly in the **basal ganglia**. *Huntington's disease* - **Huntington's disease** is a classic cause of **chorea**, characterized by progressive degeneration of neurons in the **caudate and putamen** [1]. - The chorea is typically generalized and worsens over time, accompanied by cognitive decline and psychiatric symptoms.
Question 5: What is the treatment of choice for akathisia?
- A. Benztropine
- B. Propranolol (Correct Answer)
- C. Dantrolene
- D. Lithium
Explanation: ***Propranolol*** - **Beta-blockers** like propranolol are considered first-line treatment for akathisia due to their ability to reduce central as well as peripheral noradrenergic hyperactivity and anxiety. - They are particularly effective in alleviating the subjective feeling of **inner restlessness** and the objective motor symptoms, especially when the akathisia is induced by antipsychotics. *Benztropine* - This is an **anticholinergic** medication primarily used to treat other extrapyramidal symptoms like **dystonia** and **pseudoparkinsonism**. - While it might provide some relief for certain motor aspects, it is generally less effective for the subjective feeling of restlessness in akathisia and can have significant side effects. *Dantrolene* - **Dantrolene** is a direct-acting **skeletal muscle relaxant** used primarily in the treatment of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - It is not indicated for the management of extrapyramidal symptoms like akathisia. *Lithium* - **Lithium** is a mood stabilizer used predominantly in the treatment of **bipolar disorder**. - It has no role in the direct treatment of akathisia; however, it can ironically sometimes induce or worsen akathisia as a side effect itself.
Question 6: Psychosurgery is used in which of the following conditions?
- A. Phobia
- B. Generalized anxiety disorder
- C. Obsessive-Compulsive Disorder (OCD) (Correct Answer)
- D. Depression
Explanation: **Explanation:** Psychosurgery, also known as functional neurosurgery for psychiatric disorders, is reserved for patients with severe, chronic, and treatment-resistant conditions who have failed to respond to multiple trials of pharmacotherapy (including high-dose SSRIs and augmentation) and intensive Cognitive Behavioral Therapy (CBT/ERP). **1. Why OCD is the Correct Answer:** OCD is the most common and well-established indication for psychosurgery today. The underlying pathophysiology involves hyperactivity in the **Cortico-Striato-Thalamo-Cortical (CSTC) circuit**. Surgical interventions aim to interrupt this circuit. Common procedures include: * **Subcaudate Tractotomy** * **Anterior Capsulotomy** (most common for OCD) * **Anterior Cingulotomy** * **Limbic Leukotomy** (combination of cingulotomy and tractotomy) **2. Why Other Options are Incorrect:** * **Phobia and GAD (Options A & B):** These anxiety disorders are primarily managed with psychotherapy (CBT) and pharmacotherapy (SSRIs/Benzodiazepines). There is no established surgical target or clinical evidence justifying psychosurgery for these conditions. * **Depression (Option D):** While "Treatment-Resistant Depression" (TRD) is a secondary indication for psychosurgery (specifically Cingulotomy), it is not the primary or most classic indication compared to OCD in the context of standard medical examinations. **High-Yield Clinical Pearls for NEET-PG:** * **Deep Brain Stimulation (DBS):** A modern, reversible alternative to ablative psychosurgery, often targeting the **Internal Capsule** or **Subthalamic Nucleus** for refractory OCD. * **Legal Aspect:** Under the **Mental Healthcare Act (MHCA) 2017** in India, psychosurgery can only be performed with the informed consent of the patient and prior approval from the State Mental Health Authority. * **Criteria:** Symptoms must be present for at least 5 years and be significantly disabling.
Question 7: Ego's defense mechanism "Undoing" is typically seen in which of the following conditions?
- A. Depression
- B. Schizophrenia
- C. Obsessive-compulsive neurosis (Correct Answer)
- D. Hysteria
Explanation: **Explanation:** The correct answer is **Obsessive-compulsive neurosis (OCD)**. **1. Why the correct answer is right:** **Undoing** is a primary defense mechanism characteristic of Obsessive-Compulsive Disorder. It is an unconscious process where an individual performs a specific action (a ritual or compulsion) to "cancel out" or "atone for" an unacceptable, anxiety-provoking thought or impulse. For example, a patient who has a blasphemous thought may compulsively recite a prayer to "undo" the perceived sin. In OCD, undoing works alongside other defense mechanisms like **Reaction Formation** and **Isolation of Affect**. **2. Why the incorrect options are wrong:** * **Depression:** The hallmark defense mechanism in depression is **Introjection** (turning anger inward). * **Schizophrenia:** Patients with schizophrenia typically use primitive defense mechanisms such as **Projection**, **Denial**, and **Splitting**. * **Hysteria (Dissociative/Conversion Disorders):** The classic defense mechanism here is **Repression** and **Conversion** (transforming psychological conflict into physical symptoms). **Clinical Pearls for NEET-PG:** * **Triad of Defense Mechanisms in OCD:** Undoing, Reaction Formation, and Isolation of Affect. * **Ego-dystonic:** OCD symptoms are recognized by the patient as irrational and unwanted (unlike OCPD, which is ego-syntonic). * **First-line Treatment:** SSRIs (at higher doses than for depression) and Cognitive Behavioral Therapy (specifically **Exposure and Response Prevention - ERP**). * **Neurobiology:** OCD is associated with structural abnormalities in the **Orbitofrontal cortex, Anterior Cingulate Cortex, and Caudate nucleus** (Cortico-striato-thalamo-cortical circuit).
Question 8: What is true about obsessive-compulsive disorder?
- A. Ego-alien
- B. The patient tries to resist against it
- C. Ego-syntonic (Correct Answer)
- D. Insight is present
Explanation: ### Explanation In the context of psychiatry, **Obsessive-Compulsive Disorder (OCD)** is traditionally characterized by symptoms that are **Ego-dystonic (Ego-alien)**. However, this specific question follows a pattern often seen in older medical entrance exams or specific textbook classifications where the focus is on the patient's internal experience of the thought. **1. Why "Ego-syntonic" is marked correct here:** While classic OCD is ego-dystonic (the patient finds thoughts intrusive and repugnant), this question likely refers to the **Obsessive-Compulsive Personality Disorder (OCPD)** or a specific examiner's view where the patient perceives the "need for order" as rational or part of their self-identity. *Note: In modern clinical practice and DSM-5/ICD-11, OCD is strictly ego-dystonic, while OCPD is ego-syntonic.* If this is a recall question where "Ego-syntonic" is the keyed answer, it highlights the distinction between the *disorder* (OCD) and the *personality* (OCPD). **2. Analysis of Incorrect Options:** * **A. Ego-alien (Ego-dystonic):** This is actually the hallmark of OCD. The patient views the obsessions as foreign and contrary to their own beliefs. * **B. Resistance:** In OCD, patients typically struggle and try to resist the obsessions/compulsions (at least initially). * **D. Insight:** Insight is usually present in OCD (the patient knows the thoughts are irrational), whereas it is often absent in OCPD. **High-Yield Clinical Pearls for NEET-PG:** * **OCD:** Ego-dystonic, insight present, resistance present, symptoms fluctuate. * **OCPD (Anankastic Personality):** Ego-syntonic, insight absent, no resistance, symptoms are pervasive traits. * **Treatment of choice for OCD:** SSRIs (High dose) + CBT (Exposure and Response Prevention). * **Most common obsession:** Contamination. * **Most common compulsion:** Checking.
Question 9: All are true about obsession, except:
- A. Recurrent foolish thoughts
- B. Associated with dim light (Correct Answer)
- C. Attempts to resist intrusive ideas
- D. Associated depression
Explanation: **Explanation:** Obsessive-Compulsive Disorder (OCD) is characterized by **obsessions** (intrusive, repetitive thoughts, urges, or images) and **compulsions** (repetitive behaviors or mental acts). **Why Option B is the correct answer (False statement):** There is no clinical or diagnostic association between obsessions and **dim light**. While some psychiatric conditions (like Seasonal Affective Disorder) are linked to light exposure, or certain phobias (like nyctophobia) involve darkness, light intensity is not a diagnostic feature or a known trigger for the phenomenology of obsessions. **Analysis of other options (True statements about obsession):** * **Option A (Recurrent foolish thoughts):** Obsessions are defined as recurrent and persistent thoughts that are often perceived by the patient as irrational, "foolish," or senseless (egodystonic). * **Option C (Attempts to resist):** A hallmark of obsession is that the individual recognizes the thoughts as a product of their own mind and typically makes active **attempts to ignore, suppress, or neutralize** them with some other thought or action (compulsion). * **Option D (Associated depression):** Comorbidity is extremely high in OCD. Approximately **60–80%** of patients with OCD will experience a Major Depressive Episode during their lifetime. **High-Yield Clinical Pearls for NEET-PG:** * **Egodystonic nature:** The patient recognizes the thoughts as irrational and contrary to their self-image (unlike delusions). * **Insight:** Usually preserved in OCD, though it can vary (good, fair, or poor insight). * **First-line Treatment:** Pharmacotherapy with **SSRIs** (often at higher doses than for depression) and psychotherapy, specifically **Exposure and Response Prevention (ERP)**. * **Neurobiology:** Associated with structural/functional abnormalities in the **Orbitofrontal Cortex, Anterior Cingulate Cortex, and Caudate Nucleus** (Cortico-striato-thalamo-cortical circuit).
Question 10: All of the following are true about Obsessive compulsive disorder EXCEPT?
- A. Washers
- B. Checkers
- C. Thought insertion causes distress
- D. Insight is absent (Correct Answer)
Explanation: In Obsessive-Compulsive Disorder (OCD), the defining characteristic is that the patient recognizes their obsessions and compulsions as **ego-dystonic** (irrational and originating from their own mind). **Explanation of Options:** * **Insight is absent (Correct Answer):** In OCD, insight is typically **preserved**. Patients are aware that their thoughts are excessive or unreasonable. While the DSM-5 allows for a specifier of "with absent insight/delusional beliefs," this is the exception rather than the rule. In contrast, absent insight is a hallmark of psychotic disorders (like Schizophrenia). * **Washers & Checkers:** These are the two most common clinical subtypes of OCD. **Washers** (Contamination obsessions) are the most frequent, followed by **Checkers** (Pathological doubt). * **Thought insertion causes distress:** In OCD, thoughts are perceived as internal but intrusive. If a patient experiences "thought insertion" (a Schneiderian First Rank Symptom), they feel the thought is alien. However, in the context of OCD-like presentations, the intrusive nature of these thoughts causes significant anxiety and distress, which the patient tries to neutralize. **High-Yield Clinical Pearls for NEET-PG:** * **Ego-dystonic vs. Ego-systonic:** OCD is ego-dystonic (distressing/unwanted), whereas Obsessive-Compulsive Personality Disorder (OCPD) is ego-syntonic (perceived as correct/ideal). * **First-line Treatment:** SSRIs (at higher doses than for depression) and Cognitive Behavioral Therapy (CBT) using **Exposure and Response Prevention (ERP)**. * **Drug of Choice (TCA):** Clomipramine (most potent serotonin reuptake inhibitor). * **Neurobiology:** Associated with hyperactivity in the **Orbitofrontal Cortex, Anterior Cingulate Cortex, and Caudate Nucleus** (Cortico-striato-thalamo-cortical circuit).
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