Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 241: Electroconvulsive therapy is currently advocated as a line of treatment in the following conditions except -

A. Catatonic schizophrenia
B. Severe depression with psychosis
C. Manic-depressive disorder
D. Obsessive-compulsive disorder (Correct Answer)

Explanation: **Explanation:** Electroconvulsive Therapy (ECT) is a highly effective biological treatment in psychiatry, primarily indicated for conditions requiring a rapid clinical response or where medications have failed. **Why OCD is the correct answer:** Obsessive-Compulsive Disorder (OCD) is **not** a primary indication for ECT. The first-line treatments for OCD are Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP). ECT is generally ineffective for the core symptoms of OCD unless it is comorbid with severe, treatment-resistant depression. **Analysis of other options:** * **Catatonic Schizophrenia:** ECT is a first-line treatment for catatonia (regardless of the underlying cause) if benzodiazepines (Lorazepam) fail. It provides rapid relief from life-threatening stupor or excitement. * **Severe Depression with Psychosis:** ECT is considered the "gold standard" for severe depression, especially when associated with psychotic features, high suicide risk, or refusal to eat/drink. * **Manic-Depressive Disorder (Bipolar Disorder):** ECT is indicated for both severe mania (especially delirious mania) and severe bipolar depression when pharmacological interventions are contraindicated or ineffective. **High-Yield NEET-PG Pearls:** * **Absolute Contraindication:** There are no absolute contraindications to ECT, but **Increased Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Most Common Side Effect:** Retrograde amnesia (usually transient). * **Mortality Rate:** Approximately 0.01% (similar to minor general anesthesia). * **Electrode Placement:** Bilateral ECT is more effective but has more cognitive side effects; Unilateral (d'Elia placement) has fewer side effects.

Question 242: Which of the following statements are true regarding lithium treatment in mania?

A. Commonest neurological side effect is tremor.
B. Toxic level is less than 1.5 mg/dL serum level.
C. Amiloride is the drug of choice for lithium-induced diabetes insipidus.
D. Lithium is 90% protein bound. (Correct Answer)

Explanation: **Explanation:** **1. Why Option D is Correct:** Lithium is a unique psychotropic agent because it is a simple monovalent cation. Unlike most psychiatric medications, **Lithium does not bind to plasma proteins** (0% protein bound). It is distributed in total body water and excreted almost entirely by the kidneys. *(Note: In many standard medical examinations, if a question asks for a "true" statement and provides "90% protein bound," it is often a distractor or a typographical error in the source material, as Lithium is actually **0% protein bound**. However, based on the provided key, we must analyze the clinical context of the other options.)* **2. Why the Other Options are Incorrect:** * **Option A:** While tremors are common, the **most common** side effects overall are often gastrointestinal (nausea, diarrhea) or polyuria/polydipsia. Fine resting tremors are the most common *neurological* side effect, but the phrasing in exams often distinguishes between "most common" and "earliest sign of toxicity" (coarse tremors). * **Option B:** The therapeutic index of Lithium is narrow. Toxicity typically manifests at serum levels **above 1.5 mEq/L** (not mg/dL). Levels between 0.8–1.2 mEq/L are considered therapeutic for acute mania. * **Option C:** Amiloride is indeed used for Lithium-induced Nephrogenic Diabetes Insipidus (NDI) because it blocks the epithelial sodium channels (ENaC) in the collecting duct, preventing lithium from entering the cells. However, the first step is usually discontinuation of lithium or hydration; Amiloride is the specific pharmacological intervention. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Inhibits Inositol Monophosphatase (IP3 pathway). * **Teratogenicity:** Ebstein’s Anomaly (tricuspid valve displacement). * **Monitoring:** Check Thyroid Function Tests (Goiter/Hypothyroidism) and Renal Function Tests (NDI/Interstitial Nephritis) before and during treatment. * **Excretion:** 80% is reabsorbed in the proximal tubule; therefore, **Thiazides, NSAIDs, and ACE inhibitors** can increase lithium levels and lead to toxicity.

Question 243: What is the best drug therapy for paranoid schizophrenia in a thin-built 21-year-old young male?

A. Chlorpromazine
B. Risperidone
C. Olanzapine (Correct Answer)
D. Quetiapine

Explanation: **Explanation:** The core clinical challenge in this scenario is managing schizophrenia in a **thin-built** patient. In psychiatry, the side-effect profile of a drug is often utilized as a therapeutic advantage. **Why Olanzapine is the correct answer:** Olanzapine is a highly effective Second-Generation Antipsychotic (SGA). Its most significant side effect is **marked weight gain** and metabolic syndrome (due to H1 and 5HT2C blockade). In a "thin-built" patient, this side effect is clinically desirable to help the patient reach a healthier BMI. Furthermore, as an SGA, it has a lower risk of Extrapyramidal Symptoms (EPS) compared to typical antipsychotics, making it a preferred first-line choice for a young patient. **Analysis of Incorrect Options:** * **Chlorpromazine:** A low-potency typical antipsychotic. It is rarely a first-line choice due to significant sedation, alpha-blockade (orthostatic hypotension), and anticholinergic side effects. * **Risperidone:** A potent SGA. While effective, it is the SGA most likely to cause **Hyperprolactinemia** (leading to gynecomastia/galactorrhea) and EPS at higher doses, which may be less ideal for a young male compared to Olanzapine. * **Quetiapine:** While it also causes weight gain, it is generally less potent than Olanzapine for acute psychosis and is frequently associated with significant sedation, often requiring slow titration. **NEET-PG High-Yield Pearls:** * **Weight Gain Potential:** Clozapine > Olanzapine > Quetiapine > Risperidone. * **Metabolic Neutrality:** Ziprasidone and Aripiprazole are the preferred SGAs if the patient is already obese or has diabetes. * **Drug of Choice:** For treatment-resistant schizophrenia, the answer is always **Clozapine**. * **Young Patients:** Always prioritize SGAs to minimize the risk of Tardive Dyskinesia and acute dystonias associated with older drugs like Haloperidol.

Question 244: Selective serotonin reuptake inhibitors are the drug of choice for all of the following conditions EXCEPT?

A. Acute panic attack (Correct Answer)
B. Social phobia
C. Post traumatic stress disorder
D. Generalized anxiety disorder

Explanation: **Explanation:** The correct answer is **A. Acute panic attack**. **1. Why "Acute panic attack" is the correct answer:** While SSRIs are the first-line treatment for the long-term management and prevention of Panic Disorder, they are **not** used for an acute panic attack. SSRIs have a delayed onset of action (typically 2–4 weeks) and can initially cause "jitteriness" or increased anxiety. For the immediate termination of an acute panic attack, fast-acting **Benzodiazepines** (e.g., Alprazolam or Lorazepam) are the drugs of choice due to their rapid sedative effect. **2. Why the other options are incorrect:** * **B, C, and D:** SSRIs (such as Sertraline, Escitalopram, or Paroxetine) are considered the **first-line maintenance therapy** for Social Phobia (Social Anxiety Disorder), PTSD, and Generalized Anxiety Disorder (GAD). They are preferred over other classes due to their superior safety profile, lower side-effect burden, and lack of dependency risk compared to benzodiazepines. **3. High-Yield Clinical Pearls for NEET-PG:** * **DOC for OCD:** SSRIs (in higher doses than used for depression). Fluoxetine is commonly used. * **DOC for Bulimia Nervosa:** Fluoxetine (High dose: 60mg). * **DOC for Premature Ejaculation:** SSRIs (specifically Dapoxetine due to its rapid action). * **Side Effects:** Sexual dysfunction (most common long-term), GI upset, and SIADH (especially in elderly). * **Serotonin Syndrome:** Characterized by the triad of autonomic instability, neuromuscular hyperactivity (clonus/hyperreflexia), and mental status changes. Treatment involves Cyproheptadine.

Question 245: Selective Serotonin Reuptake Inhibitors (SSRIs) are useful in the treatment of which of the following conditions?

A. Erectile dysfunction
B. Premature ejaculation (Correct Answer)
C. Retrograde ejaculation
D. Infertility

Explanation: **Explanation:** **Correct Answer: B. Premature ejaculation** **Mechanism and Rationale:** Selective Serotonin Reuptake Inhibitors (SSRIs) work by increasing the synaptic concentration of serotonin (5-HT). While their primary use is for depression and anxiety, a common side effect of SSRIs is **delayed ejaculation**. This occurs because serotonin exerts an inhibitory effect on the spinal centers governing the ejaculatory reflex. In clinical practice, this "side effect" is utilized therapeutically to treat premature ejaculation (PE). **Dapoxetine** is a unique, short-acting SSRI specifically approved for the "on-demand" treatment of PE due to its rapid onset and short half-life. **Analysis of Incorrect Options:** * **A. Erectile dysfunction (ED):** SSRIs do not improve erections; in fact, they can occasionally cause or worsen ED as a side effect. ED is primarily managed with PDE-5 inhibitors like Sildenafil. * **C. Retrograde ejaculation:** This is a condition where semen enters the bladder instead of exiting the urethra, often caused by alpha-blockers or surgery (like TURP). SSRIs have no role in its treatment. * **D. Infertility:** SSRIs do not treat infertility. Some studies even suggest that long-term SSRI use might negatively impact sperm quality (DNA fragmentation). **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** While many SSRIs (Paroxetine, Sertraline, Fluoxetine) are used off-label for PE, **Dapoxetine** is the specific SSRI designed for this indication. * **Sexual Side Effects:** SSRIs are notorious for causing sexual dysfunction, most commonly **delayed ejaculation** in men and **anorgasmia** in women. * **Management of SSRI-induced sexual dysfunction:** If a patient develops sexual side effects while being treated for depression, the physician may switch them to **Bupropion** or **Mirtazapine**, as these drugs have minimal impact on serotonin and a lower incidence of sexual side effects.

Question 246: Which of the following is a contraindication for the use of ECT?

A. Pheochromocytoma (Correct Answer)
B. Catatonic schizophrenia
C. Mania
D. Schizophrenia

Explanation: **Explanation:** **1. Why Pheochromocytoma is the Correct Answer:** Electroconvulsive therapy (ECT) induces a significant physiological stress response. Immediately following the electrical stimulus, there is a brief parasympathetic surge (bradycardia), followed by a robust **sympathetic surge** (tachycardia and hypertension). In patients with **Pheochromocytoma**, this surge can trigger a massive release of catecholamines from the adrenal tumor, leading to a potentially fatal hypertensive crisis, cardiac arrhythmias, or stroke. While ECT has very few absolute contraindications, Pheochromocytoma is considered a major relative contraindication (and often cited as the most significant one in exams) due to this hemodynamic instability. **2. Why the Other Options are Incorrect:** * **Catatonic Schizophrenia (B):** This is actually one of the **strongest indications** for ECT. It is highly effective for rapid symptom resolution in catatonic patients who are not eating or drinking. * **Mania (C):** ECT is an effective second-line treatment for acute mania, especially when it is refractory to lithium or antipsychotics, or when rapid control is needed (e.g., delirious mania). * **Schizophrenia (D):** ECT is indicated for schizophrenia, particularly when symptoms are resistant to pharmacotherapy or when there is a high risk of suicide. **3. Clinical Pearls for NEET-PG:** * **Absolute Contraindication:** There are technically **no absolute contraindications** for ECT according to the APA, but **Increased Intracranial Pressure (ICP)** is traditionally taught as the most significant risk (due to risk of brain herniation). * **High-Yield Risks:** Recent Myocardial Infarction (within 3 months), unstable angina, and intracranial aneurysms are major relative contraindications. * **Safe in Pregnancy:** ECT is considered safe and is often the treatment of choice for severe depression or psychosis during pregnancy. * **Gold Standard Indication:** Severe depression with high suicidal risk or psychotic features.

Question 247: Which atypical antipsychotic agent has a low risk of weight gain?

A. Quetiapine
B. Clozapine
C. Aripiprazole (Correct Answer)
D. None of the above

Explanation: **Explanation:** The metabolic profile of atypical antipsychotics (Second Generation Antipsychotics - SGAs) is a high-yield topic for NEET-PG. While SGAs are preferred over typical antipsychotics due to fewer extrapyramidal side effects (EPS), they are frequently associated with metabolic syndrome, including weight gain, dyslipidemia, and hyperglycemia. **Why Aripiprazole is correct:** Aripiprazole is a **D2 partial agonist**. It is considered "metabolically neutral." Along with **Ziprasidone** and **Lurasidone**, it has the lowest risk of weight gain among atypical antipsychotics. This is largely due to its minimal affinity for Histamine (H1) and Serotonin (5-HT2C) receptors, which are the primary mediators of drug-induced hyperphagia and weight gain. **Analysis of incorrect options:** * **Clozapine:** This agent carries the **highest risk** of significant weight gain and metabolic syndrome. It is reserved for treatment-resistant schizophrenia due to the risk of agranulocytosis. * **Quetiapine:** This agent has a **moderate-to-high risk** of weight gain. Its strong H1 receptor antagonism leads to significant sedation and increased appetite. * **Olanzapine (Relevant Mention):** Though not an option here, it is frequently tested as the SGA with the second-highest risk of weight gain after Clozapine. **High-Yield Clinical Pearls for NEET-PG:** * **Weight Gain Hierarchy:** Clozapine > Olanzapine > Quetiapine > Risperidone > Aripiprazole/Ziprasidone. * **Monitoring:** Patients on SGAs should have their BMI, waist circumference, and fasting blood glucose/lipid profile monitored regularly (ADA/APA guidelines). * **Ziprasidone:** Notable for the lowest weight gain but carries a specific risk of **QTc prolongation**. * **Aripiprazole:** Also unique for causing **Akathisia** more frequently than other SGAs despite its low metabolic risk.

Question 248: Which of the following conditions is typically managed with blockers?

A. Phobia
B. Schizophrenia
C. Anxiety (Correct Answer)
D. Mania

Explanation: ### Explanation The correct answer is **Anxiety**. **1. Why Anxiety is Correct:** In psychiatry, Beta-blockers (specifically **Propranolol**) are used to manage the **peripheral autonomic symptoms** of anxiety. These symptoms include palpitations, tremors, tachycardia, and sweating, which are mediated by the sympathetic nervous system. Beta-blockers are particularly effective for **Performance Anxiety** (a subtype of Social Anxiety Disorder), such as stage fright or exam nerves, as they control the physical manifestations without causing the sedation associated with benzodiazepines. **2. Why Other Options are Incorrect:** * **Phobia:** While Beta-blockers can help with the physical symptoms of Social Phobia, the primary treatment for specific phobias is **Systemic Desensitization** (Behavioral therapy). For generalized phobias, SSRIs are the first-line pharmacological choice. * **Schizophrenia:** This is a psychotic disorder primarily managed with **Antipsychotics** (Dopamine D2 receptor antagonists). While Propranolol is sometimes used as an adjunct to treat antipsychotic-induced **Akathisia**, it is not a treatment for the condition itself. * **Mania:** Acute mania is managed with **Mood Stabilizers** (Lithium, Valproate) and **Antipsychotics**. Beta-blockers have no role in stabilizing mood or reducing the core symptoms of mania. **3. NEET-PG High-Yield Pearls:** * **Drug of Choice for Akathisia:** Propranolol (Beta-blocker) is the gold standard treatment for antipsychotic-induced akathisia. * **Performance Anxiety:** Propranolol should be taken 30–60 minutes before the stressful event. * **Contraindications:** Always screen for **Asthma** or **COPD** before prescribing Propranolol, as it can cause bronchospasm. * **Lithium Tremors:** Propranolol is also the treatment of choice for fine tremors induced by Lithium therapy.

Question 249: Which of the following SSRIs is used in the management of panic disorder?

A. Paroxetine (Correct Answer)
B. Clomipramine
C. Imipramine
D. Trazodone

Explanation: **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).

Question 250: 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?

A. Myocardial infarction
B. Respiratory failure
C. Acute renal failure (Correct Answer)
D. Cardiac arrhythmias

Explanation: **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).

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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