Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 121: Akathisia is best treated by:

A. Lithium
B. Fluoxetine
C. Propanolol (Correct Answer)
D. Haloperidol

Explanation: **Explanation:** **Akathisia** is a common and distressing Extrapyramidal Side Effect (EPS) characterized by a subjective feeling of inner restlessness and an objective inability to sit still. It most frequently occurs as a side effect of typical (first-generation) antipsychotics. **Why Propranolol is the Correct Answer:** The drug of choice for treating akathisia is **Propranolol**, a non-selective beta-blocker. While the exact pathophysiology is not fully understood, it is believed that beta-adrenergic receptors in the peripheral and central nervous systems play a role in the manifestation of restlessness. Propranolol effectively crosses the blood-brain barrier to alleviate both the subjective tension and physical movements. **Analysis of Incorrect Options:** * **A. Lithium:** This is a mood stabilizer used primarily for Bipolar Affective Disorder. It has no role in treating movement disorders and can actually cause tremors. * **B. Fluoxetine:** An SSRI used for depression/anxiety. It can occasionally *cause* akathisia as a side effect but does not treat it. * **D. Haloperidol:** This is a high-potency typical antipsychotic and is one of the most common **causes** of akathisia due to potent D2 receptor blockade. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC):** Propranolol (usually 30–90 mg/day). * **Second-line treatments:** Benzodiazepines (e.g., Lorazepam) or anticholinergics (though anticholinergics are less effective for akathisia than for acute dystonia). * **Clinical Presentation:** Patients are often misdiagnosed as having "worsening psychosis/agitation," leading to an incorrect increase in antipsychotic dosage, which worsens the condition. * **Timeline:** Akathisia typically develops within days to weeks of starting or increasing an antipsychotic.

Question 122: Which antidepressant drug can cause neuroleptic malignant syndrome and tardive dyskinesia?

A. Amineptin
B. Carbamazepine
C. Amoxapine (Correct Answer)
D. Trazodone

Explanation: **Explanation:** The correct answer is **Amoxapine**. **Why Amoxapine is the correct answer:** Amoxapine is a secondary amine tricyclic antidepressant (TCA). Its unique pharmacological profile stems from its metabolism: it is metabolized into **7-hydroxyamoxapine**, a potent **dopamine D2 receptor antagonist**. Because it possesses neuroleptic-like properties (similar to antipsychotics), it can cause side effects typically associated with dopamine blockade, specifically **Extrapyramidal Symptoms (EPS)**, **Tardive Dyskinesia**, and **Neuroleptic Malignant Syndrome (NMS)**. This makes it distinct from almost all other antidepressants. **Analysis of Incorrect Options:** * **Amineptine:** A dopamine reuptake inhibitor (DRI). While it acts on the dopamine system, it increases synaptic dopamine rather than blocking receptors; thus, it does not cause NMS or tardive dyskinesia. * **Carbamazepine:** Primarily an anticonvulsant and mood stabilizer. While it can cause various neurological side effects (like ataxia), it is not an antidepressant and is not typically associated with D2 blockade-induced NMS or tardive dyskinesia. * **Trazodone:** A Serotonin Antagonist and Reuptake Inhibitor (SARI). Its most notorious high-yield side effect is **priapism**, but it does not possess significant D2 blocking activity. **High-Yield Clinical Pearls for NEET-PG:** * **Amoxapine** is often described as a "neuroleptic-antidepressant" hybrid. * **Loxapine** (an antipsychotic) is the parent compound from which Amoxapine is derived. * If a question mentions an antidepressant causing **galactorrhea** or **hyperprolactinemia**, think Amoxapine (due to D2 blockade in the tuberoinfundibular pathway). * **NMS Mnemonic (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated CPK, **R**igidity ("Lead-pipe").

Question 123: Which of the following is not a mood stabilizer?

A. Lithium
B. Valproate
C. Carbamazepine
D. Fluoxetine (Correct Answer)

Explanation: **Explanation** The core concept in this question is the classification of psychotropic medications based on their therapeutic indications. **Why Fluoxetine is the correct answer:** Fluoxetine is a **Selective Serotonin Reuptake Inhibitor (SSRI)**, which is classified as an **antidepressant**, not a mood stabilizer. While mood stabilizers are used to treat Bipolar Disorder (BD) by preventing both manic and depressive episodes, antidepressants like Fluoxetine can actually trigger **"mood switching"** (inducing mania) in patients with Bipolar I disorder if used without a mood stabilizer. **Why the other options are incorrect:** * **Lithium (Option A):** The "Gold Standard" mood stabilizer. It is the only drug proven to reduce the risk of suicide in patients with Bipolar Disorder. * **Valproate (Option B):** An anticonvulsant that acts as a potent mood stabilizer. It is often the first-line treatment for **Acute Mania** and **Mixed Episodes**. * **Carbamazepine (Option C):** Another anticonvulsant used as a second-line mood stabilizer, particularly effective in patients who do not respond to Lithium or those with "Rapid Cycling" Bipolar Disorder. **High-Yield Clinical Pearls for NEET-PG:** 1. **Definition:** A mood stabilizer is a drug that treats mania/depression without increasing the frequency or severity of the opposite episode. 2. **Lamotrigine:** Another high-yield anticonvulsant mood stabilizer, primarily used for the **prevention of Bipolar Depression** (not effective for acute mania). 3. **Teratogenicity:** Remember the "Ebstein’s Anomaly" associated with Lithium and "Neural Tube Defects" (Spina Bifida) associated with Valproate. 4. **Therapeutic Range:** Lithium has a narrow therapeutic index (0.6–1.2 mEq/L). Toxicity typically begins above 1.5 mEq/L.

Question 124: Which of the following is NOT true about clozapine?

A. Should be discontinued if WBC count is < 3500/dl.
B. Has no anti-suicide property. (Correct Answer)
C. Should not be used along with carbamazepine.
D. The action is more on D4 receptors than D2 receptors.

Explanation: **Explanation:** **Clozapine** is a unique "atypical" antipsychotic reserved for treatment-resistant schizophrenia. 1. **Why Option B is the correct answer (The False Statement):** Clozapine is one of the few psychotropic drugs with proven **anti-suicide properties**. It is FDA-approved specifically for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. Therefore, stating it has "no anti-suicide property" is clinically incorrect. (Note: Lithium is the other major drug with anti-suicide effects in mood disorders). 2. **Analysis of Incorrect Options (True Statements):** * **Option A:** Clozapine carries a risk of **agranulocytosis**. Strict hematological monitoring is required. If the Total Leukocyte Count (WBC) falls below **3000–3500/mm³** or the Absolute Neutrophil Count (ANC) falls below **1500/mm³**, the drug must be discontinued to prevent fatal infections. * **Option C:** **Carbamazepine** is a potent bone marrow suppressant. Combining it with Clozapine synergistically increases the risk of agranulocytosis. Additionally, Carbamazepine is a CYP3A4 inducer which lowers Clozapine levels. * **Option D:** Unlike typical antipsychotics that bind strongly to D2 receptors, Clozapine has a high affinity for **D4 receptors** and 5-HT2A receptors, with relatively weak D2 blockade. This explains its low incidence of Extrapyramidal Side Effects (EPS). **High-Yield Clinical Pearls for NEET-PG:** * **Drug of choice:** Treatment-resistant schizophrenia (failed 2 trials of other antipsychotics). * **Side Effects:** Sialorrhea (hypersalivation), seizures (dose-dependent), myocarditis, and significant weight gain. * **Benefit:** It is the only antipsychotic that does not cause Tardive Dyskinesia and rarely causes Prolactin elevation.

Question 125: Electroconvulsive therapy (ECT) is indicated in which of the following conditions?

A. Hypomania
B. Severe depression (Correct Answer)
C. Obsessive-compulsive disorder (OCD) with mixed features
D. Generalized anxiety disorder

Explanation: **Explanation:** **Correct Answer: B. Severe depression** Electroconvulsive therapy (ECT) is one of the most effective biological treatments in psychiatry. Its primary indication is **Major Depressive Disorder (MDD)**, particularly when it is severe, treatment-resistant, or accompanied by psychotic features or high suicide risk. ECT works by inducing a generalized tonic-clonic seizure, which leads to a massive release of neurotransmitters and neurotrophic factors (like BDNF), rapidly improving mood and reducing suicidal ideation. **Analysis of Incorrect Options:** * **A. Hypomania:** While ECT is highly effective for *acute mania* (especially if life-threatening or treatment-resistant), it is not indicated for hypomania, which is a milder form of mood elevation that typically responds well to mood stabilizers or antipsychotics. * **C. OCD with mixed features:** ECT is generally not a first- or second-line treatment for OCD. It is only considered in extremely rare, refractory cases where a comorbid severe depression is present. * **D. Generalized Anxiety Disorder (GAD):** Psychotherapy (CBT) and pharmacotherapy (SSRIs/SNRIs) are the mainstays for GAD. ECT has no established role in treating primary anxiety disorders. **NEET-PG High-Yield Pearls:** * **Absolute Contraindication:** There are no absolute contraindications, but **Increased Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Drug of Choice for Pre-medication:** Atropine (to prevent vagal bradycardia). * **Anesthetic of Choice:** Methohexital (Gold standard); Thiopentone is also commonly used. * **Muscle Relaxant:** Succinylcholine (to prevent musculoskeletal injury during seizure). * **Most Common Side Effect:** Retrograde amnesia (usually transient). * **Other Indications:** Catatonia (ECT is the treatment of choice if Benzodiazepines fail), Schizophrenia (especially with catatonic or affective symptoms), and Severe Mania.

Question 126: Which of the following are atypical (second generation or newer) antipsychotics?

A. Aripiprazole
B. Risperidone (Correct Answer)
C. Pimozide
D. Olanzapine

Explanation: **Explanation:** Antipsychotics are classified into **Typical (First Generation)** and **Atypical (Second Generation)** based on their mechanism of action and side-effect profile. **Why Risperidone is correct:** Risperidone is a prototypical **Atypical Antipsychotic**. Unlike typical agents that primarily block Dopamine (D2) receptors, atypical antipsychotics are **Serotonin-Dopamine Antagonists (SDAs)**. They block both 5-HT2A and D2 receptors. This dual action reduces Extrapyramidal Side Effects (EPS) and is more effective in treating the negative symptoms of schizophrenia (e.g., apathy, social withdrawal). **Analysis of other options:** * **Aripiprazole:** This is a **Third Generation** antipsychotic. It acts as a **D2 partial agonist** (Dopamine System Stabilizer). While often grouped with atypicals in broad categories, it is pharmacologically distinct. * **Olanzapine:** This is also an **Atypical Antipsychotic**. (Note: In many MCQ formats, if multiple options are correct, the "most" representative or the one specified in the key is chosen; however, clinically, both Risperidone and Olanzapine are Second Generation). * **Pimozide:** This is a **Typical (First Generation)** antipsychotic belonging to the Diphenylbutylpiperidine class. It is highly potent and specifically used in Tourette’s syndrome and Delusional Parasitosis (Ekbom syndrome). **High-Yield NEET-PG Pearls:** * **Clozapine:** The first atypical antipsychotic; gold standard for **treatment-resistant schizophrenia**. Watch for **agranulocytosis** (requires mandatory WBC monitoring). * **Metabolic Syndrome:** Olanzapine and Clozapine carry the highest risk of weight gain and diabetes. * **Hyperprolactinemia:** Among atypicals, **Risperidone** has the highest risk of increasing prolactin levels. * **Ziprasidone:** Associated with **QT interval prolongation**; avoid in patients with cardiac history.

Question 127: A 26-year-old man with schizophrenia and tardive dyskinesia. Which is the most appropriate pharmacotherapeutic agent?

A. Clozapine (Correct Answer)
B. Valproic acid
C. Haloperidol
D. Paroxetine

Explanation: **Explanation:** The correct answer is **Clozapine**. **Why Clozapine is the drug of choice:** Tardive Dyskinesia (TD) is a late-onset extrapyramidal side effect (EPS) caused by the long-term blockade of dopamine (D2) receptors, leading to receptor supersensitivity. When a patient with schizophrenia develops TD, the primary strategy is to switch them to an atypical antipsychotic with the lowest risk of EPS. **Clozapine** is the gold standard in this scenario because it has a very low affinity for D2 receptors and a high affinity for D4 and serotonin (5-HT2A) receptors. It is the only antipsychotic that does not cause TD and may even suppress existing dyskinetic movements. **Why other options are incorrect:** * **Haloperidol:** This is a high-potency typical antipsychotic with strong D2 antagonism. It is a leading cause of TD and would worsen the condition. * **Valproic acid:** This is a mood stabilizer/anti-epileptic. While it may be used as an adjunct in schizoaffective disorders, it has no role in treating the core symptoms of schizophrenia or reversing TD. * **Paroxetine:** This is an SSRI used for depression and anxiety. It does not treat psychosis and can occasionally worsen movement disorders through indirect serotonergic effects on dopamine. **High-Yield Clinical Pearls for NEET-PG:** * **VMAT2 Inhibitors:** Drugs like **Valbenazine** and **Deutetrabenazine** are now FDA-approved specifically for the treatment of TD. * **Clozapine Monitoring:** Remember the "No Blood, No Drug" rule. Clozapine requires mandatory monitoring of Absolute Neutrophil Count (ANC) due to the risk of **agranulocytosis** (most common in the first 18 weeks). * **Other Side Effects:** Clozapine is associated with seizures (dose-dependent), myocarditis, and significant weight gain/metabolic syndrome.

Question 128: What is the primary treatment for Neuroleptic Malignant Syndrome?

A. Dantrolene (Correct Answer)
B. Corticosteroids
C. Diazepam
D. Hemodialysis

Explanation: **Explanation:** **Neuroleptic Malignant Syndrome (NMS)** is a life-threatening idiosyncratic reaction to antipsychotic drugs (dopamine antagonists). It is characterized by the "tetrad" of muscle rigidity (lead-pipe), hyperthermia, autonomic instability, and altered mental status. **Why Dantrolene is Correct:** The primary pharmacological treatment for NMS is **Dantrolene**, a direct-acting skeletal muscle relaxant. It works by inhibiting the release of calcium ions from the sarcoplasmic reticulum, thereby reducing muscle contraction and heat production. This addresses the peripheral hypermetabolic state and rigidity that drive the syndrome's morbidity. **Why Other Options are Incorrect:** * **Corticosteroids:** These are used for inflammatory or autoimmune conditions. NMS is a neurochemical/metabolic crisis, not an inflammatory one; steroids have no role here. * **Diazepam:** While benzodiazepines can help control agitation or mild muscle spasms, they do not treat the underlying pathophysiology of NMS as effectively as specific muscle relaxants or dopamine agonists. * **Hemodialysis:** Antipsychotics are highly protein-bound and have a large volume of distribution; therefore, they are not dialyzable. Dialysis is only used in NMS if secondary acute renal failure occurs due to rhabdomyolysis. **High-Yield Clinical Pearls for NEET-PG:** * **First Step in Management:** Immediate discontinuation of the offending antipsychotic agent and supportive care (cooling, IV fluids). * **Drug of Choice (Dopamine Agonist):** **Bromocriptine** is often used alongside Dantrolene to restore dopamine balance. * **Key Lab Finding:** Significantly elevated **Creatine Phosphokinase (CPK)** levels due to muscle necrosis. * **Differential Diagnosis:** Unlike Serotonin Syndrome, NMS presents with **"lead-pipe" rigidity** and **bradyreflexia**, whereas Serotonin Syndrome presents with hyperreflexia and myoclonus.

Question 129: Depot preparations are available for which of the following antipsychotic medications?

A. Haloperidol
B. Risperidone
C. Olanzapine
D. All of the above (Correct Answer)

Explanation: **Explanation:** Depot antipsychotics are long-acting injectable (LAI) formulations designed to improve treatment adherence in patients with chronic psychotic disorders, such as schizophrenia. These preparations release the medication slowly into the bloodstream over weeks or months. * **Haloperidol (Option A):** This is a first-generation (typical) antipsychotic. Its depot form, **Haloperidol Decanoate**, is administered intramuscularly every 4 weeks and is one of the most commonly used LAIs in clinical practice. * **Risperidone (Option B):** A second-generation (atypical) antipsychotic. It is available as **Risperidone Consta** (microspheres), usually administered every 2 weeks. Newer formulations like Perseris (subcutaneous) also exist. * **Olanzapine (Option C):** Also an atypical antipsychotic, available as **Olanzapine Pamoate**. While effective, it requires mandatory post-injection monitoring for 3 hours due to the risk of Post-injection Delirium Sedation Syndrome (PDSS). Since all three medications have established depot formulations, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Fluphenazine Decanoate** was the first-ever depot antipsychotic introduced. * **Zuclopenthixol** is another common typical antipsychotic available as a depot (Acuphase for short-term, Decanoate for long-term). * **Paliperidone Palmitate** is a popular LAI with monthly (Invega Sustenna) and 3-monthly (Invega Trinza) dosing schedules. * **Indication:** Depot preparations are primarily indicated for patients with poor compliance or those who prefer the convenience of infrequent dosing. * **Contraindication:** They should never be used to treat acute psychosis or "rapid tranquilization" because their effects cannot be immediately reversed.

Question 130: Lithium is best used in which of the following conditions?

A. Manic-depressive disorder (bipolar) (Correct Answer)
B. Unipolar depression
C. Manic-depressive disorder with rapid cycling
D. Major depressive disorder

Explanation: **Explanation:** **Lithium** is the gold-standard treatment and the "drug of choice" for the prophylaxis and maintenance of **Bipolar Affective Disorder (BPAD)**, historically referred to as **Manic-depressive disorder**. It is highly effective in treating acute manic episodes and preventing future relapses of both mania and depression. * **Why Option A is correct:** Lithium’s primary mechanism involves modulating second messenger systems (inhibiting inositol monophosphatase) and stabilizing neurotransmission. It is uniquely effective in classic BPAD, particularly in patients with a "mania-followed-by-depression" sequence and a positive family history of lithium response. * **Why Options B & D are incorrect:** While Lithium can be used as an **augmentation strategy** in treatment-resistant Unipolar or Major Depressive Disorder, it is not the first-line treatment. Selective Serotonin Reuptake Inhibitors (SSRIs) are the preferred initial therapy for these conditions. * **Why Option C is incorrect:** Rapid cycling (defined as ≥4 mood episodes in 12 months) is a known predictor of **poor response** to Lithium. In such cases, **Valproate** or Carbamazepine are considered superior and are the preferred mood stabilizers. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index. Target serum levels are **0.8–1.2 mEq/L** for acute mania and **0.6–1.0 mEq/L** for maintenance. * **Anti-suicidal Property:** Lithium is one of the few psychotropic drugs (along with Clozapine) proven to reduce the risk of suicide in bipolar patients. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Side Effects:** Common issues include fine tremors, polyuria (nephrogenic diabetes insipidus), and hypothyroidism.

Practice by Chapter

Principles of Psychopharmacology

Practice Questions

Antipsychotic Medications

Practice Questions

Antidepressant Medications

Practice Questions

Mood Stabilizers

Practice Questions

Anxiolytics and Hypnotics

Practice Questions

Stimulants and Cognitive Enhancers

Practice Questions

Pharmacokinetics and Pharmacodynamics

Practice Questions

Drug Interactions

Practice Questions

Adverse Effects and Management

Practice Questions

Pharmacogenomics in Psychiatry

Practice Questions

Special Populations Considerations

Practice Questions

Treatment Algorithms and Guidelines

Practice Questions

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