Psychopharmacology Practice Questions

Q: All of the following are indications for Electroconvulsive therapy except?

Residual schizophrenia. **Explanation:** Electroconvulsive therapy (ECT) is a highly effective biological treatment primarily indicated for conditions requiring a rapid clinical response or when pharmacological treatments have failed. **Why Residual Schizophrenia is the correct answer:** Residual schizophrenia is characterized by a history of at least one episode of schizophrenia, but the current clinical picture is dominated by "negative symptoms" (e.g., emotional blunting, social withdrawal, psychomotor retardation) and lack of prominent "positive symptoms" (delusions/hallucinations). ECT is primarily effective for **acute** psychotic symptoms, mood disturbances, and catatonia. It has no proven efficacy in treating the chronic, negative symptoms seen in the residual phase, making it the "except" option. **Analysis of Incorrect Options:** * **Depression with suicidal tendencies:** This is the **most common** and strongest indication for ECT. When a patient is actively suicidal, the rapid onset of ECT (faster than antidepressants) is life-saving. * **Catatonia:** ECT is the treatment of choice for catatonia (especially lethal catatonia) if the patient does not respond to intravenous benzodiazepines (Lorazepam). * **Psychotic depression:** Severe depression with psychotic features often shows a poor response to monotherapy with antidepressants. ECT is highly effective in these cases. **Clinical Pearls for NEET-PG:** * **Absolute Contraindication:** There are no absolute contraindications for ECT, but **Raised Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Most Common Side Effect:** Retrograde amnesia (usually resolves within weeks). * **Mechanism:** The therapeutic effect depends on the induction of a generalized tonic-clonic seizure lasting at least 25–30 seconds. * **Drug of Choice:** Methohexital (Anesthetic) and Succinylcholine (Muscle relaxant).

Q: All of the following medications have mood-stabilizing action EXCEPT:

Paroxetine. **Explanation:** The core concept in managing Bipolar Affective Disorder (BPAD) is the use of **Mood Stabilizers**. These are medications that treat at least one phase of the illness (mania or depression) without increasing the frequency or severity of the opposite phase. **Why Paroxetine is the correct answer:** Paroxetine is a **Selective Serotonin Reuptake Inhibitor (SSRI)**, which is an antidepressant. While it treats the depressive phase of BPAD, it is not a mood stabilizer because it carries a risk of inducing **"treatment-emergent affective switch"** (triggering a manic episode) and does not prevent future relapses when used alone. **Analysis of Incorrect Options:** * **Lithium (Option C):** The "Gold Standard" mood stabilizer. It is effective in treating acute mania, bipolar depression, and is the most effective agent for preventing suicide in psychiatric patients. * **Carbamazepine (Option A):** An anticonvulsant used as a second-line mood stabilizer, particularly effective in rapid cycling bipolar disorder and acute mania. * **Lamotrigine (Option B):** An anticonvulsant mood stabilizer specifically effective for the **maintenance/prevention of bipolar depression**. It is not effective for acute mania. **High-Yield Clinical Pearls for NEET-PG:** 1. **Valproate** is often the first-line treatment for acute mania (especially mixed episodes). 2. **Lithium Toxicity:** Occurs at levels >1.5 mEq/L; characterized by coarse tremors, ataxia, and vomiting. 3. **Lamotrigine Warning:** Must be titrated slowly to avoid **Stevens-Johnson Syndrome (SJS)**. 4. **Drug of Choice (DOC):** Lithium is the DOC for prophylaxis of BPAD.

Q: A 30-year-old pregnant woman presents with decreased sleep, increased appetite, and hyperactivity for the past two weeks. A diagnosis of mania is made. Further probing reveals four episodes of major depression in the past two years. What medication would you prescribe for this patient?

Haloperidol. ### **Explanation** **1. Why Haloperidol is the Correct Choice:** The patient is presenting with an acute manic episode during pregnancy. In the management of acute mania in pregnancy, **First-Generation Antipsychotics (FGAs)** like **Haloperidol** are considered the first-line treatment. Haloperidol has a long-standing safety record in pregnancy; it is not associated with significant teratogenic risks (unlike mood stabilizers) and effectively controls hyperactivity and behavioral disturbances rapidly. **2. Why Other Options are Incorrect:** * **Lithium (Option B):** While Lithium is a gold-standard mood stabilizer, it is generally avoided in the first trimester due to the risk of **Ebstein’s Anomaly** (tricuspid valve malformation). Even in later stages, it requires intensive monitoring of fetal echoes and maternal serum levels. * **Promethazine (Option C):** This is an antihistamine with sedative properties. While it may help with sleep, it is not an antimanic agent and cannot treat the underlying core symptoms of mania. * **Clonazepam (Option D):** Benzodiazepines are used as adjuncts for sedation in mania but are not primary treatments. There is also a potential risk of "floppy infant syndrome" if used near term. **3. Clinical Pearls for NEET-PG:** * **Rapid Cycling:** This patient has had four episodes of depression in two years, meeting the criteria for **Rapid Cycling Bipolar Disorder** (≥4 episodes of mood disturbance in 12 months). * **Teratogenicity High-Yields:** * **Valproate:** Highest risk; causes Neural Tube Defects (NTDs). **Strictly contraindicated** in pregnancy. * **Carbamazepine:** Also causes NTDs and craniofacial defects. * **Treatment of Choice (TOC):** * Acute Mania in Pregnancy: Haloperidol. * Bipolar Depression in Pregnancy: Quetiapine or Lurasidone. * Severe/Refractory Mania in Pregnancy: Electroconvulsive Therapy (ECT) is considered safe and highly effective.

Q: What is the drug of choice for Generalized Anxiety Disorder?

Sertraline. **Explanation:** **Generalized Anxiety Disorder (GAD)** is characterized by excessive, uncontrollable worry about various aspects of daily life for at least 6 months. **1. Why Sertraline is Correct:** The first-line pharmacological treatment for GAD consists of **Selective Serotonin Reuptake Inhibitors (SSRIs)** or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). **Sertraline**, an SSRI, is considered a drug of choice due to its superior safety profile, low potential for abuse, and efficacy in managing both the psychic and somatic symptoms of anxiety over the long term. **2. Analysis of Incorrect Options:** * **Benzodiazepines (e.g., Alprazolam):** While they provide rapid symptomatic relief, they are **not** the drug of choice due to risks of sedation, cognitive impairment, tolerance, and physical dependence. They are typically reserved for short-term "bridge therapy" until SSRIs reach therapeutic levels (usually 2–4 weeks). * **Buspirone:** This is a 5-HT1A partial agonist. While indicated for GAD, it is generally considered a second-line agent because it has a slower onset of action and is often less effective than SSRIs in patients previously treated with benzodiazepines. * **Olanzapine:** This is an atypical antipsychotic. It is not a first-line treatment for GAD and is only used as an off-label augmentation strategy in treatment-resistant cases. **High-Yield Clinical Pearls for NEET-PG:** * **First-line:** SSRIs (Sertraline, Escitalopram, Paroxetine) or SNRIs (Venlafaxine, Duloxetine). * **Duration of treatment:** Once symptoms are controlled, medication should be continued for **6–12 months** to prevent relapse. * **Psychotherapy:** Cognitive Behavioral Therapy (CBT) is the most effective non-pharmacological treatment and is often combined with SSRIs for the best outcomes. * **Propranolol:** Used only for **Performance Anxiety** (a subtype of Social Anxiety Disorder), not for GAD.

Q: What is the drug of choice in Manic Depressive Psychosis (MDP)?

Lithium. **Explanation:** **Manic Depressive Psychosis (MDP)**, now clinically referred to as **Bipolar Affective Disorder (BPAD)**, is characterized by cyclic episodes of mania and depression. **Why Lithium is the Correct Answer:** Lithium remains the **gold standard** and the drug of choice for both the treatment of acute mania and the long-term prophylaxis of MDP. It is a mood stabilizer that acts by modulating neurotransmitters (inhibiting dopamine and glutamate while enhancing GABA) and inhibiting the inositol monophosphatase pathway. Crucially, Lithium is one of the few drugs in psychiatry proven to **reduce the risk of suicide** in patients with mood disorders. **Analysis of Incorrect Options:** * **B. Amphetamine:** This is a CNS stimulant that increases synaptic dopamine. It can actually **precipitate** a manic episode and is contraindicated in MDP. * **C. Diazepam & D. Alprazolam:** These are Benzodiazepines. While they may be used as adjuncts to manage acute agitation or insomnia in a manic patient, they have **no mood-stabilizing properties** and do not treat the underlying pathology of MDP. **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. * **Side Effects:** Common side effects include fine tremors, polyuria (nephrogenic diabetes insipidus), and hypothyroidism. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Alternative:** If Lithium is contraindicated (e.g., renal failure), **Sodium Valproate** is the preferred alternative for acute mania.

Q: Which of the following SSRIs is used in the management of panic disorder?

Paroxetine. **Explanation:** **1. Why Paroxetine is Correct:** Selective Serotonin Reuptake Inhibitors (SSRIs) are the **first-line pharmacological treatment** for Panic Disorder due to their superior safety profile and efficacy. **Paroxetine** is specifically FDA-approved for panic disorder. It works by inhibiting the reuptake of serotonin at the presynaptic cleft, leading to down-regulation of postsynaptic receptors, which eventually reduces the frequency and intensity of panic attacks. **2. Why Other Options are Incorrect:** * **Clomipramine & Imipramine (Options B & C):** These are **Tricyclic Antidepressants (TCAs)**. While they are effective in treating panic disorder (Imipramine was historically the gold standard), they are no longer first-line due to their significant side effect profile (anticholinergic effects, cardiotoxicity in overdose, and weight gain). The question specifically asks for an SSRI; TCAs do not belong to this class. * **Trazodone (Option D):** This is a Serotonin Antagonist and Reuptake Inhibitor (SARI). It is primarily used as a sedative-hypnotic for insomnia or as an adjunct in depression, but it is not indicated for the management of panic disorder. **High-Yield Clinical Pearls for NEET-PG:** * **First-line for Panic Disorder:** SSRIs (e.g., Paroxetine, Sertraline, Fluoxetine) and SNRIs (e.g., Venlafaxine). * **The "Jitteriness Syndrome":** When starting SSRIs in panic disorder, patients may experience an initial increase in anxiety. Therefore, therapy should be started at **half the usual antidepressant dose**. * **Acute Management:** For immediate relief of a panic attack, **Benzodiazepines** (e.g., Alprazolam, Clonazepam) are used, but they are avoided for long-term maintenance due to dependence risk. * **Most Sedating SSRI:** Paroxetine (also has the most anticholinergic activity among SSRIs). * **Shortest Half-life SSRI:** Fluvoxamine/Paroxetine (highest risk of discontinuation syndrome).

Q: A 32-year-old patient with schizophrenia was started on haloperidol 15 mg per day. A week later, he was found to have high-grade fever, rigidity, and blood tests revealed leucocytosis and increased CPK levels. What is the usual cause of death in such patients?

Acute renal failure. **Explanation:** The patient is presenting with the classic tetrad of **Neuroleptic Malignant Syndrome (NMS)**: high-grade fever, "lead-pipe" muscle rigidity, autonomic instability, and altered mental status, triggered by a high-potency antipsychotic (Haloperidol). **Why Acute Renal Failure (ARF) is the correct answer:** The hallmark of NMS is intense, generalized muscle rigidity. This extreme muscle contraction leads to **Rhabdomyolysis** (breakdown of skeletal muscle), which releases massive amounts of **myoglobin** into the bloodstream. Myoglobin is nephrotoxic; it precipitates in the renal tubules, causing acute tubular necrosis. **Acute Renal Failure** secondary to myoglobinuria is the most common cause of mortality in NMS patients. **Analysis of Incorrect Options:** * **Myocardial Infarction:** While the heart is under stress due to tachycardia and hyperthermia, primary ischemia is not the typical cause of death. * **Respiratory Failure:** Can occur due to chest wall rigidity or aspiration pneumonia, but it is statistically less common as the primary cause of death compared to renal failure. * **Cardiac Arrhythmias:** These can occur due to electrolyte imbalances (like hyperkalemia from muscle breakdown), but they are usually secondary complications. **Clinical Pearls for NEET-PG:** * **Key Lab Findings:** Elevated Creatine Phosphokinase (CPK) is the most sensitive lab marker; Leucocytosis is also common. * **Treatment of Choice:** Immediate discontinuation of the offending drug, aggressive hydration, and cooling. Pharmacotherapy includes **Dantrolene** (muscle relaxant) or **Bromocriptine** (D2 agonist). * **Differential Diagnosis:** Unlike Serotonin Syndrome, NMS is characterized by "lead-pipe" rigidity and bradyreflexia (rather than hyperreflexia and myoclonus).

Q: What is true about neuroleptic malignant syndrome?

All of the above.. **Neuroleptic Malignant Syndrome (NMS)** is a life-threatening idiosyncratic reaction to antipsychotic medications, characterized by a tetrad of clinical features: mental status changes, muscular rigidity, hyperthermia, and autonomic instability. **Explanation of Options:** * **Option A:** While all dopamine antagonists can cause NMS, **first-generation (typical) antipsychotics** (e.g., Haloperidol, Fluphenazine) are more frequently associated with the condition due to their potent D2 receptor antagonism. * **Option B:** The clinical presentation typically includes "lead-pipe" **rigidity**, high-grade **fever** (hyperpyrexia), and signs of autonomic dysfunction such as **palpitations** (tachycardia), labile blood pressure, and diaphoresis. * **Option C:** Management begins with immediate discontinuation of the offending agent and supportive care. Pharmacologically, **Dantrolene** (a direct-acting muscle relaxant) is used to reduce hyperthermia and rigidity. Dopamine agonists like **Bromocriptine** or Amantadine are also used to restore dopaminergic tone. Since all statements are clinically accurate, **Option D** is the correct answer. **High-Yield NEET-PG Pearls:** 1. **Laboratory Hallmark:** Significantly elevated **Creatine Phosphokinase (CPK)** levels due to rhabdomyolysis. Leukocytosis and metabolic acidosis are also common. 2. **Mnemonic (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated CPK, **R**igidity. 3. **Differential Diagnosis:** Unlike Serotonin Syndrome (which presents with hyperreflexia and myoclonus), NMS is characterized by **hyporeflexia** and "lead-pipe" rigidity. 4. **Risk Factors:** Rapid dose escalation, high-potency drugs, and dehydration.

Question 1

All of the following are indications for Electroconvulsive therapy except?

Accepted Answer

Residual schizophrenia

Answer

Depression with suicidal tendencies

Answer

Catatonia

Answer

Psychotic depression

Question 2

All of the following medications have mood-stabilizing action EXCEPT:

Accepted Answer

Paroxetine

Answer

Carbamazepine

Answer

Lamotrigine

Answer

Lithium

Question 3

A 30-year-old pregnant woman presents with decreased sleep, increased appetite, and hyperactivity for the past two weeks. A diagnosis of mania is made. Further probing reveals four episodes of major depression in the past two years. What medication would you prescribe for this patient?

Accepted Answer

Haloperidol

Answer

Lithium

Answer

Promethazine

Answer

Clonazepam

Question 4

Which of the following is a contraindication for the use of ECT?

Accepted Answer

Pheochromocytoma

Answer

Catatonic schizophrenia

Answer

Mania

Answer

Schizophrenia

Question 5

What is the drug of choice for Generalized Anxiety Disorder?

Accepted Answer

Sertraline

Answer

Benzodiazepines

Answer

Buspirone

Answer

Olanzapine

Question 6

What is the drug of choice in Manic Depressive Psychosis (MDP)?

Accepted Answer

Lithium

Answer

Amphetamine

Answer

Diazepam

Answer

Alprazolam

Question 7

Which of the following SSRIs is used in the management of panic disorder?

Accepted Answer

Paroxetine

Answer

Clomipramine

Answer

Imipramine

Answer

Trazodone

Question 8

A 32-year-old patient with schizophrenia was started on haloperidol 15 mg per day. A week later, he was found to have high-grade fever, rigidity, and blood tests revealed leucocytosis and increased CPK levels. What is the usual cause of death in such patients?

Accepted Answer

Acute renal failure

Answer

Myocardial infarction

Answer

Respiratory failure

Answer

Cardiac arrhythmias

Question 9

What is true about neuroleptic malignant syndrome?

Accepted Answer

All of the above.

Answer

General antipsychotics are more associated.

Answer

Symptoms include rigidity, fever, and palpitations.

Answer

Dantrolene improves symptoms.

Question 10

A patient on antipsychotic for the past 4 weeks presents to the emergency department with acute onset of fever, excessive sweating, confusion, rigidity of limbs, and decreased communication. Examination reveals a temperature of 104°F, pulse rate of 120/min, blood pressure of 150/100 mmHg, and disorientation. What is the most probable diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Lithium toxicity

Answer

Aggravation of psychosis

Answer

Dystonia

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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