Antipsychotic Medications — MCQs
Which of the following antipsychotics is a partial D2 agonist?
A patient of schizophrenia is being treated with clozapine. For which rare but serious side effects should he be monitored?
A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?
What is the most common side effect of haloperidol?
What is the treatment for extrapyramidal side effects induced by Haloperidol?
A young male patient has been on 5 mg haloperidol for many days. For the last 4 days, he has developed inner restlessness and urges to move. What is the diagnosis?
A patient is experiencing subtle involuntary movements of his hands, feet, lips, and tongue. What is the expected response of these symptoms during the tapering of antipsychotic medication?
Drug of choice for treatment of akathisia is:-
A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?
A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?
Antipsychotic Medications Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following antipsychotics is a partial D2 agonist?
- A. Clozapine
- B. Quetiapine
- C. Ziprasidone
- D. Aripiprazole (Correct Answer)
Explanation: Aripiprazole - Aripiprazole is a D2 partial agonist [1][3], meaning it acts as an agonist in areas with low dopamine and an antagonist in areas with high dopamine [3]. - This unique mechanism helps to stabilize dopamine activity, leading to fewer extrapyramidal symptoms and hyperprolactinemia compared to typical antipsychotics. Clozapine - Clozapine is a D2 antagonist with a high affinity for D4 receptors and potent antagonism of 5-HT2A receptors; it is known for its efficacy in treatment-resistant schizophrenia [2]. - It carries a risk of severe side effects such as agranulocytosis [2] and myocarditis, requiring regular blood monitoring. Quetiapine - Quetiapine is primarily a D2 antagonist with significant antagonism at histamine H1 and alpha-1 adrenergic receptors, contributing to its sedative and orthostatic hypotensive effects. - It is known for its relatively low risk of extrapyramidal symptoms due to its rapid dissociation from D2 receptors. Ziprasidone - Ziprasidone is a D2 antagonist and a serotonin 5-HT1A agonist and 5-HT2C antagonist, contributing to its antidepressant and anti-anxiety effects. - It is associated with a risk of QTc prolongation, which necessitates cardiac monitoring in susceptible patients.
Question 2: A patient of schizophrenia is being treated with clozapine. For which rare but serious side effects should he be monitored?
- A. Seizures
- B. Agranulocytosis (Correct Answer)
- C. Hepatomegaly
- D. Renal bleed
Explanation: ***Agranulocytosis*** - **Agranulocytosis** is a severe and potentially fatal reduction in white blood cells (specifically neutrophils) that can occur with clozapine use [2, 3]. - This is the **rare but serious side effect** that requires mandatory monitoring, occurring in **0.8-2%** of patients. - Patients on clozapine require routine **complete blood count (CBC)** monitoring: **weekly for the first 6 months**, then biweekly for months 6-12, then monthly thereafter . - This is the primary reason clozapine has restricted use despite being the most effective antipsychotic for treatment-resistant schizophrenia. *Seizures* - While clozapine can lower the **seizure threshold** (especially at higher doses), seizures occur in **1-2%** of patients and are **dose-dependent** . - Seizures are a known side effect that warrants dosage adjustment, but they are **not as rare** as agranulocytosis and do not require the same intensive blood monitoring protocol. - Management involves dose reduction or adding anticonvulsants. *Hepatomegaly* - **Hepatic dysfunction** can occur with clozapine, but **hepatomegaly** (enlarged liver) itself is not one of its rare, life-threatening side effects requiring specific monitoring above other, more severe issues. - Liver enzyme elevation may be monitored, but this is not the primary "rare but serious" concern. *Renal bleed* - **Renal complications** or **renal bleeding** are not recognized as significant or specifically monitored rare side effects of clozapine. - Clozapine's major concerns primarily involve hematologic (agranulocytosis), cardiovascular (myocarditis), and metabolic systems.
Question 3: A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?
- A. Haloperidol
- B. Olanzapine
- C. Clozapine (Correct Answer)
- D. Risperidone
Explanation: ***Clozapine*** - **Clozapine** is the drug of choice for **treatment-resistant schizophrenia** or patients who are **intolerant to conventional antipsychotics**. - Its unique efficacy often comes with a risk of **agranulocytosis**, requiring regular **blood monitoring**. *Olanzapine* - While an effective **atypical antipsychotic**, it is not specifically indicated for **treatment-resistant cases** in the same way as clozapine. - It carries a risk of significant **metabolic side effects**, such as weight gain and dyslipidemia. *Haloperidol* - This is a **first-generation (conventional) antipsychotic** and would be unsuitable for a patient described as **intolerant to conventional antipsychotics**. - It is associated with a high incidence of **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**. *Risperidone* - As an **atypical antipsychotic**, it is a good first-line option but is not typically reserved for **treatment-resistant schizophrenia** or those with conventional antipsychotic intolerance. - It has a higher propensity for **hyperprolactinemia** compared to other atypical antipsychotics.
Question 4: What is the most common side effect of haloperidol?
- A. Hypotension
- B. Dryness of mouth
- C. Tic disorder
- D. Akathisia (Correct Answer)
Explanation: ***Akathisia*** - **Akathisia** is one of the **most common extrapyramidal symptoms (EPS)** associated with haloperidol, occurring in **20-75% of patients**. - It is characterized by a feeling of **inner restlessness** and an **inability to stay still**, often manifesting as pacing, rocking, or shifting weight. - Haloperidol, a high-potency **first-generation antipsychotic**, has a high propensity to cause EPS, including akathisia, due to its **strong dopamine D2 receptor blockade** in the nigrostriatal pathway. - Along with drug-induced parkinsonism, akathisia is among the most frequently encountered side effects with haloperidol use. *Hypotension* - While orthostatic hypotension can occur with antipsychotics, particularly those with strong **alpha-1 adrenergic blockade** (e.g., lower potency first-generation antipsychotics like chlorpromazine, or some second-generation antipsychotics), it is not the most common side effect of haloperidol. - Haloperidol has relatively **weak alpha-1 blocking activity** compared to other antipsychotics. *Dryness of mouth* - **Dryness of mouth (xerostomia)** is a common anticholinergic side effect of some antipsychotics, but it is not the most common or prominent side effect of haloperidol. - Haloperidol has relatively **weak anticholinergic activity** compared to lower potency antipsychotics. *Tic disorder* - **Tic disorders** are characterized by sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. - While haloperidol can be used to **treat severe tics** (e.g., in Tourette syndrome), it is not a common side effect of the medication itself; rather, it is a condition that antipsychotics like haloperidol may target therapeutically.
Question 5: What is the treatment for extrapyramidal side effects induced by Haloperidol?
- A. Barbiturates
- B. SSRIs
- C. Benzodiazepines
- D. Anticholinergic drugs (Correct Answer)
Explanation: ***Anticholinergic drugs (effective treatment)*** - **Anticholinergic medications**, such as **benztropine** or **diphenhydramine**, are the primary treatment for **acute extrapyramidal symptoms (EPS)** like dystonia and parkinsonism induced by antipsychotics like haloperidol. - They work by **blocking muscarinic acetylcholine receptors**, helping to restore the balance between dopamine and acetylcholine in the basal ganglia. *Benzodiazepines (used for anxiety and muscle relaxation)* - While benzodiazepines can offer some relief for **akathisia** (a form of EPS characterized by restlessness) due to their sedative and muscle relaxant properties, they are **not the first-line treatment for other acute EPS** such as dystonia or parkinsonism. - They primarily enhance **GABAergic transmission** and are effective for anxiety and seizure control rather than direct antagonism of EPS mechanisms. *Barbiturates (used as sedative-hypnotic drugs)* - **Barbiturates** are strong central nervous system depressants used for sedation, anesthesia, and seizure control, but are **not indicated for the treatment of EPS**. - Their significant **sedative and addictive potential**, along with a narrow therapeutic index, makes them unsuitable for this purpose. *SSRIs (used for depression and anxiety)* - **SSRIs (Selective Serotonin Reuptake Inhibitors)** are antidepressants that work by increasing serotonin levels in the brain and are used to treat depression, anxiety, and obsessive-compulsive disorder. - They **do not have a direct role** in ameliorating dopamine-acetylcholine imbalance responsible for haloperidol-induced EPS.
Question 6: A young male patient has been on 5 mg haloperidol for many days. For the last 4 days, he has developed inner restlessness and urges to move. What is the diagnosis?
- A. Akathisia (Correct Answer)
- B. Acute Dystonia
- C. Rabbit syndrome
- D. Tardive dyskinesia
Explanation: ***Akathisia*** - This patient's symptoms of **inner restlessness** and an **urge to move** after several days on **haloperidol** are classic presentations of **akathisia**, a common extrapyramidal side effect of antipsychotics. - Akathisia is a **motor restlessness** that can manifest as fidgeting, pacing, or an inability to sit still, often causing significant distress for the patient. *Acute Dystonia* - **Acute dystonia** typically presents as **sustained muscle contractions** leading to abnormal postures, such as **torticollis**, oculogyric crisis, or opisthotonos. - It usually occurs within the **first few hours or days** of antipsychotic initiation, appearing earlier than the reported 4 days in this case, and its primary feature is involuntary muscle spasms, not a subjective feeling of restlessness. *Rabbit syndrome* - **Rabbit syndrome** is characterized by fine, rhythmic, **perioral tremors** resembling a rabbit chewing. - This condition is a **late-onset extrapyramidal symptom**, similar to tardive dyskinesia, and does not involve the generalized inner restlessness described. *Tardive dyskinesia* - **Tardive dyskinesia** involves involuntary, repetitive movements, primarily of the **face, mouth, tongue**, and limbs, such as lip smacking, grimacing, or writhing. - It is a **late-onset side effect** that typically develops after months or years of antipsychotic use, not within 4 days.
Question 7: A patient is experiencing subtle involuntary movements of his hands, feet, lips, and tongue. What is the expected response of these symptoms during the tapering of antipsychotic medication?
- A. It will resolve immediately after the medication is decreased.
- B. It will initially increase as the medication is decreased. (Correct Answer)
- C. It will remain the same.
- D. It will resolve in his hands but not in his feet.
Explanation: ***It will initially increase as the medication is decreased.*** - The involuntary movements described are characteristic of **tardive dyskinesia**, a side effect of long-term antipsychotic use. - When antipsychotic medication is tapered or discontinued, the **dopamine receptors**, which have been chronically blocked, become hypersensitive, leading to an initial worsening or unmasking of dyskinetic movements due to temporary dopamine overdrive. *It will resolve immediately after the medication is decreased.* - Tardive dyskinesia symptoms rarely resolve immediately upon antipsychotic reduction or discontinuation; instead, they often become **more pronounced** as receptor sensitivity changes. - The withdrawal of the medication unmasks the underlying dopamine receptor hypersensitivity, leading to an initial increase rather than immediate resolution. *It will remain the same.* - The dynamic nature of dopamine receptor hypersensitivity means that symptoms of tardive dyskinesia are unlikely to remain stable during changes in antipsychotic dosage. - **Dopamine receptor sensitivity** is altered by the change in medication levels, leading to a noticeable shift in symptom severity. *It will resolve in his hands but not in his feet.* - Tardive dyskinesia typically affects muscle groups globally, often including movements of the **face, trunk, and extremities**, rather than resolving in some areas and not others. - The pathophysiology involving **widespread dopamine receptor changes** does not usually manifest with selective resolution in specific body parts.
Question 8: Drug of choice for treatment of akathisia is:-
- A. Haloperidol
- B. Fluoxetine
- C. Propranolol (Correct Answer)
- D. Lithium
Explanation: ***Propranolol*** - **Beta-blockers** like propranolol are considered first-line for treating **akathisia**, especially in cases induced by antipsychotics. - They work by reducing the **adrenergic hyperactivity** and the sensation of inner restlessness characteristic of akathisia. *Haloperidol* - Haloperidol is a **first-generation antipsychotic** that is a common cause of drug-induced **akathisia**. - Administering it would likely **worsen** rather than treat the condition. *Fluoxetine* - Fluoxetine is a **selective serotonin reuptake inhibitor (SSRI)** used to treat depression and anxiety disorders. - It is not indicated for the treatment of **akathisia** and can sometimes induce or worsen motor restlessness. *Lithium* - Lithium is a **mood stabilizer** primarily used for bipolar disorder. - It is not a treatment for **akathisia** and can itself cause various neurological side effects, though akathisia is less common.
Question 9: A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?
- A. Akathisia (Correct Answer)
- B. Rabbit syndrome
- C. Tardive dyskinesia
- D. Acute Dystonia
Explanation: ***Akathisia*** - This condition is characterized by a subjective feeling of **inner restlessness** and an objective urge to move, which is a classic side effect of **dopamine receptor blocking agents** like haloperidol. - The onset of akathisia can be acute or chronic, often occurring within days to weeks of starting or increasing the dose of antipsychotic medication. *Rabbit syndrome* - This is a rare form of **tardive dyskinesia** characterized by rapid, fine perioral movements that resemble a rabbit chewing. - It does not primarily involve the subjective feeling of restlessness or the urge to move the entire body as described in the patient's presentation. *Tardive dyskinesia* - This condition typically involves **involuntary, repetitive body movements**, often affecting the face, lips, tongue, and limbs, and usually develops after prolonged exposure to antipsychotic medications (months to years). - While it can manifest as abnormal movements, the primary symptom of inner restlessness and urge to move is not characteristic of tardive dyskinesia but rather of akathisia, and its onset is typically much later. *Acute Dystonia* - Acute dystonia presents as **sustained muscle contractions** leading to twisting and repetitive movements or abnormal fixed postures, often affecting the neck, eyes (oculogyric crisis), and trunk. - This reaction typically occurs within hours or days of initiating or increasing neuroleptic medication and is characterized by involuntary muscle spasms, not a pervasive sense of inner restlessness.
Question 10: A 25-year-old uncooperative patient of schizophrenia was brought in to the casualty. The Casualty Medical Officer gave an injectable drug to the patient. Two hours later patient develops the following posturing. What is the best treatment?
- A. Propranolol
- B. Dantrolene sodium
- C. Ventriculostomy
- D. Benzhexol (Correct Answer)
Explanation: ***Benzhexol*** - The patient's posturing (likely **acute dystonia**) is a common extrapyramidal side effect of typical antipsychotics, which are often given via injection to uncooperative schizophrenic patients. - **Benzhexol** (trihexyphenidyl) is an anticholinergic medication used to treat drug-induced extrapyramidal symptoms like dystonia, parkinsonism, and akathisia. - In acute dystonia, **parenteral anticholinergics** (IV diphenhydramine or IM benztropine) are typically preferred for faster onset, but benzhexol remains a valid anticholinergic treatment option. - The anticholinergic action reverses the dystonic reaction by restoring the dopamine-acetylcholine balance in the basal ganglia. *Propranolol* - **Propranolol** is a beta-blocker primarily used to treat essential tremor and some forms of drug-induced akathisia, but it is not the first-line treatment for acute dystonia. - While it can help with anxiety symptoms associated with akathisia, it has no role in managing acute dystonic reactions. *Dantrolene sodium* - **Dantrolene sodium** is a direct-acting skeletal muscle relaxant primarily used in the management of **neuroleptic malignant syndrome (NMS)** and malignant hyperthermia. - NMS is a more severe and distinct adverse reaction, involving fever, muscle rigidity, altered mental status, and autonomic dysfunction, which is not depicted here. - Acute dystonia presents much earlier (hours) compared to NMS (days to weeks) and lacks the systemic features of NMS. *Ventriculostomy* - **Ventriculostomy** is a neurosurgical procedure to relieve hydrocephalus by draining cerebrospinal fluid from the ventricles of the brain. - This procedure is entirely unrelated to the management of drug-induced extrapyramidal side effects from antipsychotic medication.
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