Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 181: What is the treatment of choice for akathisia?

A. Phenytoin
B. Propranolol (Correct Answer)
C. Dantrolene
D. Lithium

Explanation: **Explanation:** **Akathisia** is the most common and distressing Extrapyramidal Side Effect (EPS) associated with antipsychotic medication. It is characterized by a subjective feeling of inner restlessness and an objective need to move (e.g., pacing, foot tapping). **1. Why Propranolol is the Correct Answer:** **Propranolol**, a non-selective beta-blocker, is the **first-line treatment of choice** for akathisia. It works by crossing the blood-brain barrier and blocking beta-adrenergic receptors in the central nervous system, effectively reducing the physiological symptoms of restlessness. Unlike other EPS (like dystonia), akathisia often responds poorly to anticholinergics alone, making beta-blockers the gold standard. **2. Why the Other Options are Incorrect:** * **A. Phenytoin:** This is an antiepileptic drug used for generalized tonic-clonic seizures. it has no role in treating movement disorders induced by antipsychotics. * **C. Dantrolene:** This is a muscle relaxant used specifically for **Neuroleptic Malignant Syndrome (NMS)** and Malignant Hyperthermia. It acts on ryanodine receptors to inhibit calcium release. * **D. Lithium:** This is a mood stabilizer used for Bipolar Disorder. It does not treat EPS and can actually cause a fine tremor as a side effect. **Clinical Pearls for NEET-PG:** * **First-line:** Propranolol (40–120 mg/day). * **Second-line:** Benzodiazepines (e.g., Lorazepam) or anticholinergics (e.g., Benztropine). * **Differentiate:** Do not confuse akathisia with psychotic agitation; increasing the antipsychotic dose will worsen akathisia but improve agitation. * **NMS Treatment:** Bromocriptine (Dopamine agonist) and Dantrolene. * **Acute Dystonia Treatment:** Promethazine or Benztropine (IV/IM).

Question 182: Lithium is not used in the treatment of which of the following conditions?

A. Major depression
B. Vascular headache
C. Neutropenia
D. Generalized anxiety disorder (Correct Answer)

Explanation: **Explanation:** Lithium is a monovalent cation primarily used as a mood stabilizer. The correct answer is **Generalized Anxiety Disorder (GAD)** because Lithium has no established efficacy in treating primary anxiety disorders. GAD is typically managed with SSRIs, SNRIs, or benzodiazepines. **Analysis of Options:** * **Major Depression (A):** Lithium is a well-recognized **augmentation agent** for treatment-resistant depression. When added to an antidepressant, it can enhance the therapeutic response. It also significantly reduces the risk of suicide in patients with mood disorders. * **Vascular Headache (B):** Lithium is an effective prophylactic treatment for **Cluster Headaches** (a type of vascular headache), particularly the chronic variety. It helps regulate the circadian rhythm of the hypothalamus, which is implicated in cluster attacks. * **Neutropenia (C):** A common side effect of Lithium is **leukocytosis** (specifically increasing the neutrophil count by stimulating granulopoiesis). This "side effect" is utilized therapeutically to treat idiopathic neutropenia or chemotherapy-induced neutropenia. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index (0.6–1.2 mEq/L). Toxicity starts >1.5 mEq/L. * **Drug of Choice:** Lithium remains the gold standard for the long-term prophylaxis of Bipolar Affective Disorder (BPAD). * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Monitoring:** Before starting Lithium, always check **Renal Function Tests (RFT)** and **Thyroid Function Tests (TFT)**, as it can cause nephrogenic diabetes insipidus and hypothyroidism.

Question 183: Which is the most widely used antidepressant?

A. Duloxetine
B. Trazadone
C. Phenelezine
D. Fluoxetine (Correct Answer)

Explanation: **Explanation:** **Fluoxetine** is the correct answer because it belongs to the **Selective Serotonin Reuptake Inhibitors (SSRIs)** class, which is currently the first-line pharmacological treatment for major depressive disorder, anxiety disorders, and OCD. Fluoxetine was the first SSRI to gain widespread clinical use due to its favorable safety profile, lack of anticholinergic side effects compared to older drugs, and long half-life (reducing withdrawal symptoms). **Analysis of Options:** * **A. Duloxetine:** This is an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor). While effective, it is generally considered second-line or used specifically when depression is comorbid with chronic pain (e.g., diabetic neuropathy or fibromyalgia). * **B. Trazodone:** A Serotonin Antagonist and Reuptake Inhibitor (SARI). It is highly sedating and is now more commonly used off-label as a hypnotic for insomnia rather than as a primary antidepressant. * **C. Phenelzine:** A non-selective MAO Inhibitor (MAOI). These are rarely used today due to dangerous dietary interactions (tyramine/cheese reaction) and the risk of hypertensive crisis. **High-Yield Clinical Pearls for NEET-PG:** * **SSRIs** are the drug of choice (DOC) for most psychiatric conditions including Depression, OCD, Panic Disorder, and Bulimia. * **Fluoxetine** has the longest half-life among SSRIs (due to its active metabolite, norfluoxetine), making it the safest choice if a patient occasionally misses a dose. * **Side Effects:** Common SSRI side effects include GI upset and sexual dysfunction (most common long-term reason for non-compliance). * **Drug Holiday:** Fluoxetine requires a 5-week washout period before starting an MAOI to avoid **Serotonin Syndrome**.

Question 184: What is the treatment of choice for bipolar mood disorder?

A. Fluoxetine
B. Imipramine
C. Lithium (Correct Answer)
D. Chlorpromazine

Explanation: **Explanation:** **Lithium** is the established **gold standard** and treatment of choice for Bipolar Mood Disorder (BMD). It is a mood stabilizer effective in treating acute manic episodes and, more importantly, serves as the mainstay for long-term maintenance therapy to prevent the recurrence of both mania and depression. Its unique clinical value lies in its proven **anti-suicidal properties**, a high-yield fact for NEET-PG. **Analysis of Incorrect Options:** * **Fluoxetine (SSRI) & Imipramine (TCA):** These are antidepressants. Using them as monotherapy in BMD is contraindicated because they can trigger a **"manic switch"** (precipitating a manic episode) or lead to rapid cycling. They are only used in bipolar depression when combined with a mood stabilizer. * **Chlorpromazine:** This is a typical antipsychotic. While it may be used to manage acute agitation in severe mania, it does not stabilize mood or prevent future episodes, making it a secondary or adjunctive treatment rather than the primary choice. **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. * **Monitoring:** Before starting Lithium, check **Thyroid Function Tests (TFT)** and **Renal Function Tests (RFT)**, as it can cause hypothyroidism and nephrogenic diabetes insipidus. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Drug of Choice for Rapid Cyclers:** Valproate is preferred over Lithium for patients with rapid-cycling BMD (>4 episodes/year).

Question 185: Which of the following is an antipsychotic drug?

A. Clomipramine
B. Carbamazepine
C. Sodium valproate
D. Chlorpromazine (Correct Answer)

Explanation: **Explanation:** The correct answer is **Chlorpromazine**. **1. Why Chlorpromazine is correct:** Chlorpromazine is a **Typical (First-Generation) Antipsychotic** belonging to the Aliphatic Phenothiazine class. It works primarily by blocking **D2 receptors** in the mesolimbic pathway of the brain. Historically, it was the first antipsychotic discovered (1952), revolutionizing the treatment of Schizophrenia and other psychotic disorders. **2. Why the other options are incorrect:** * **A. Clomipramine:** This is a **Tricyclic Antidepressant (TCA)**. It is highly serotonergic and is considered the gold standard pharmacological treatment for **Obsessive-Compulsive Disorder (OCD)**. * **B. Carbamazepine:** This is an **Anticonvulsant** also used as a **Mood Stabilizer** in Bipolar Disorder. Its mechanism involves blocking voltage-gated sodium channels. * **C. Sodium Valproate:** Like carbamazepine, this is an **Anticonvulsant and Mood Stabilizer**. It is frequently used as a first-line treatment for Acute Mania and prophylaxis in Bipolar Affective Disorder (BPAD). **3. NEET-PG High-Yield Pearls:** * **Chlorpromazine Side Effects:** It is a "Low Potency" antipsychotic, meaning it has a high incidence of **sedation, orthostatic hypotension** (alpha-1 blockade), and **anticholinergic effects** (dry mouth, constipation), but a lower risk of Extrapyramidal Symptoms (EPS) compared to Haloperidol. * **Ocular Side Effects:** Long-term use of Chlorpromazine is associated with **deposits in the anterior lens and cornea** (Stellate cataracts). * **Dermatological:** It can cause photosensitivity and a "blue-grey" skin discoloration. * **Drug of Choice:** While Chlorpromazine was the first, **Risperidone** or **Olanzapine** are now more common first-line choices, and **Clozapine** remains the drug of choice for **Treatment-Resistant Schizophrenia**.

Question 186: Which of the following statements is not true regarding Tardive Dyskinesia (TD)?

A. Clozapine is useful in its treatment.
B. Dopaminergic supersensitivity is believed to be the cause.
C. It is usually observed in the perioral area.
D. Combining anticholinergics with antipsychotics prevents TD. (Correct Answer)

Explanation: **Explanation:** **Tardive Dyskinesia (TD)** is a delayed-onset extrapyramidal side effect (EPS) resulting from long-term blockade of dopamine (D2) receptors. **Why Option D is the correct answer (False Statement):** Anticholinergics (like Trihexyphenidyl) are effective for treating *acute* EPS, such as dystonia or parkinsonism. However, they **do not prevent** TD. In fact, anticholinergics can **exacerbate or unmask** TD symptoms by further upsetting the dopamine-acetylcholine balance in the nigrostriatal pathway. Prophylactic use of anticholinergics is generally discouraged for this reason. **Analysis of other options:** * **Option A (True):** Clozapine is the drug of choice for patients with severe TD who still require antipsychotic medication. It has low D2 affinity and may even help suppress existing dyskinetic movements. * **Option B (True):** The most widely accepted pathophysiology is **dopamine receptor supersensitivity**. Chronic blockade leads to an upregulation (increase in number and sensitivity) of D2 receptors in the striatum. * **Option C (True):** TD characteristically involves involuntary, choreoathetoid movements of the **perioral region** (tongue protrusion, lip-smacking, puckering), though it can affect the trunk and extremities. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Old age, female gender, and presence of mood disorders. * **AIMS Scale:** The Abnormal Involuntary Movement Scale (AIMS) is used for screening and monitoring TD. * **Management:** First, reduce the dose or switch to a second-generation antipsychotic (Quetiapine or Clozapine). * **FDA Approved Treatments:** VMAT2 inhibitors like **Valbenazine** and **Deutetrabenazine** are now first-line for TD management.

Question 187: What is the current agent of choice for the treatment of bipolar affective disorder?

A. Chlorpromazine
B. Haloperidol
C. Diazepam
D. Lithium carbonate (Correct Answer)

Explanation: **Explanation:** **Lithium carbonate** remains the "gold standard" and the agent of choice for the long-term maintenance treatment of Bipolar Affective Disorder (BPAD). Its primary mechanism involves the inhibition of the inositol monophosphatase pathway and modulation of G-proteins, leading to mood stabilization. It is uniquely effective in treating acute mania, preventing bipolar depression, and—most importantly for NEET-PG—it is the only drug proven to significantly **reduce the risk of suicide** in these patients. **Analysis of Incorrect Options:** * **Chlorpromazine & Haloperidol (Options A & B):** These are typical antipsychotics. While they are used for rapid tranquilization in cases of acute manic excitement or psychosis, they are not first-line for long-term mood stabilization. Prolonged use carries a high risk of Extrapyramidal Side Effects (EPS) and Tardive Dyskinesia. * **Diazepam (Option C):** This is a benzodiazepine used as an adjunct for sedation or to manage acute anxiety and insomnia. It has no mood-stabilizing properties and does not treat the underlying pathophysiology of BPAD. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index. Prophylactic levels are **0.6–1.2 mEq/L**, while levels >1.5 mEq/L indicate toxicity. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Side Effects:** Common high-yield side effects include fine tremors, polyuria (Nephrogenic Diabetes Insipidus), hypothyroidism, and weight gain. * **Alternative:** Valproate is often preferred for "Rapid Cyclers" or "Mixed Episodes," but Lithium remains the overall classic answer for BPAD.

Question 188: Which of the following tricyclic antidepressants is used in the management of nocturnal enuresis?

A. imipramine (Correct Answer)
B. fluoxetine
C. bupropion
D. sertraline

Explanation: **Explanation:** **Imipramine** is a tertiary amine Tricyclic Antidepressant (TCA) that has been traditionally used in the management of nocturnal enuresis (bedwetting) in children aged 6 years and older. Its efficacy is attributed to a dual mechanism: 1. **Anticholinergic effect:** It increases the bladder capacity by relaxing the detrusor muscle. 2. **Noradrenergic effect:** It increases the tone of the internal urethral sphincter. 3. **Sleep architecture:** It alters the sleep-wake pattern, making the child more easily arousable by a full bladder. **Analysis of Incorrect Options:** * **Fluoxetine and Sertraline (Options B & D):** These are Selective Serotonin Reuptake Inhibitors (SSRIs). While they are first-line for depression and anxiety, they do not possess the potent anticholinergic properties required to treat enuresis. * **Bupropion (Option C):** This is an Atypical Antidepressant (NDRI) used primarily for smoking cessation and depression. It lacks anticholinergic activity and is contraindicated in patients with seizure disorders. **Clinical Pearls for NEET-PG:** * **First-line treatment** for nocturnal enuresis is **Behavioral Therapy** (e.g., Bed-alarm/Enuresis alarm). * **Desmopressin (ADH analogue)** is the first-line pharmacological agent due to a better safety profile. * **Imipramine** is considered second-line or third-line due to its narrow therapeutic index and risk of **cardiotoxicity** (QT prolongation) in overdose. * **Other TCAs:** Clomipramine is the drug of choice for OCD; Amitriptyline is commonly used for neuropathic pain and migraine prophylaxis.

Question 189: Which of the following extrapyramidal effects is seen on chronic use of antipsychotics?

A. Dystonia
B. Akathisia
C. Tardive dyskinesia (Correct Answer)
D. Parkinsonism

Explanation: **Explanation:** Extrapyramidal Side Effects (EPS) of antipsychotics are classified based on their time of onset. The key to this question lies in the word **"chronic."** **1. Why Tardive Dyskinesia is correct:** Tardive Dyskinesia (TD) is a **late-onset** (tardive means "late") movement disorder occurring after months or years of antipsychotic use. It is characterized by involuntary, choreoathetoid movements, most commonly involving the mouth and tongue (e.g., lip-smacking, tongue protrusion). The underlying pathophysiology is believed to be **dopamine receptor supersensitivity** in the nigrostriatal pathway following prolonged blockade. **2. Why the other options are incorrect:** * **Dystonia (Acute Dystonia):** This is the earliest EPS, occurring within hours to days of starting treatment. It involves sustained muscle contractions (e.g., torticollis, oculogyric crisis). * **Akathisia:** This typically occurs within days to weeks. It is characterized by subjective feelings of inner restlessness and an inability to sit still. It is the most common EPS. * **Parkinsonism (Drug-induced):** This usually develops within weeks to months. It mimics Parkinson’s disease with tremors, rigidity, and bradykinesia due to acute dopamine blockade. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of TD:** The first step is to reduce the dose or switch to a second-generation antipsychotic (Clozapine is the drug of choice). VMAT-2 inhibitors (e.g., Valbenazine) are FDA-approved for treatment. * **Rule of Thumb for EPS Onset:** * **4 hours:** Acute Dystonia (Rx: Benztropine/Promethazine) * **4 days:** Akathisia (Rx: Propranolol) * **4 weeks:** Parkinsonism (Rx: Trihexyphenidyl) * **4 months/years:** Tardive Dyskinesia (Rx: Switch to Clozapine) * **Anticholinergics** (like Trihexyphenidyl) can **worsen** Tardive Dyskinesia and should be avoided in its management.

Question 190: A psychiatric patient on regular treatment presents with fundus findings of pigmented retinal epithelium. Which of the following drugs is most likely implicated?

A. Thioridazine (Correct Answer)
B. Haloperidol
C. Chlorpromazine
D. Clozapine

Explanation: **Explanation:** The correct answer is **Thioridazine**. This is a classic high-yield association in psychopharmacology regarding ocular side effects of antipsychotics. **1. Why Thioridazine is correct:** Thioridazine, a low-potency typical antipsychotic, is uniquely associated with **Retinitis Pigmentosa** (pigmentary retinopathy). This occurs due to the accumulation of the drug and its metabolites in the uveal tract, leading to melanin-related toxicity. Clinically, this presents as "brownish" vision and can lead to permanent visual loss if the dose exceeds the safe threshold (typically **>800 mg/day**). Fundus examination reveals characteristic pigmentary deposits on the retinal epithelium. **2. Why other options are incorrect:** * **Chlorpromazine:** While it also causes ocular side effects, it typically causes **lenticular and corneal opacities** (whitish-brown granular deposits) rather than retinal pigmentation. It is often described as "star-shaped" cataracts. * **Haloperidol:** A high-potency antipsychotic that is more commonly associated with Extrapyramidal Side Effects (EPS) and has a negligible risk of significant ocular toxicity. * **Clozapine:** An atypical antipsychotic primarily known for agranulocytosis and seizures; it does not cause pigmentary retinopathy. **Clinical Pearls for NEET-PG:** * **Thioridazine:** Remember the "800 mg rule"—never exceed this dose to avoid irreversible retinopathy. It is also the antipsychotic most associated with **QT interval prolongation**. * **Mnemonic:** **C**hlorpromazine = **C**ornea/Lens; **T**hioridazine = **T**errible **R**etina. * **Quetiapine:** Historically linked to cataracts in animal studies (requires periodic eye exams in some protocols).

Practice by Chapter

Principles of Psychopharmacology

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Antipsychotic Medications

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Antidepressant Medications

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Mood Stabilizers

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Anxiolytics and Hypnotics

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Stimulants and Cognitive Enhancers

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Pharmacokinetics and Pharmacodynamics

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Drug Interactions

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Adverse Effects and Management

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Pharmacogenomics in Psychiatry

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Special Populations Considerations

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Treatment Algorithms and Guidelines

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