Psychopharmacology Practice Questions

Q: What adverse effect can sodium valproate cause in a patient with bipolar mood disorder?

Hepatotoxicity. **Explanation:** **Sodium Valproate** is a broad-spectrum antiepileptic drug also used as a first-line mood stabilizer in Bipolar Mood Disorder. **Why Hepatotoxicity is the Correct Answer:** Valproate is metabolized in the liver. Its most serious and potentially fatal adverse effect is **idiosyncratic hepatotoxicity**. This typically occurs within the first six months of therapy. It is caused by the formation of toxic metabolites (like 4-pentenoic acid) that interfere with mitochondrial beta-oxidation. Risk is highest in children under two years old and those on polytherapy, but it remains a critical monitoring parameter for all psychiatric patients on long-term valproate. **Analysis of Incorrect Options:** * **A. Peripheral neuropathy:** This is more commonly associated with drugs like **Phenytoin** or **Isoniazid**, not Valproate. * **B. Renal failure:** Valproate is not nephrotoxic. In contrast, **Lithium** (another mood stabilizer) is known for causing nephrogenic diabetes insipidus and chronic interstitial nephritis. * **D. Cystitis:** Specifically **Hemorrhagic Cystitis** is a classic side effect of **Cyclophosphamide** (due to acrolein), not valproate. **High-Yield NEET-PG Pearls:** * **Teratogenicity:** Valproate is highly teratogenic, causing **Neural Tube Defects** (specifically Spina Bifida) due to interference with folate metabolism. * **Other Side Effects:** Remember the mnemonic **VALPROATE**: **V**omiting, **A**lopecia (transient), **L**iver toxicity, **P**ancreatitis (acute), **R**etention of weight (Weight gain), **O**edema, **A**ppetite increase, **T**hrombocytopenia, and **E**ncephalopathy (due to hyperammonemia). * **Monitoring:** Baseline and periodic **Liver Function Tests (LFTs)** are mandatory.

Q: Tardive dyskinesia is least common with which of the following medications?

Olanzapine. **Explanation:** The risk of **Tardive Dyskinesia (TD)** is directly related to the potency of dopamine (D2) receptor blockade and the duration of treatment. **1. Why Olanzapine is correct:** Olanzapine is a **Second-Generation Antipsychotic (SGA)** or atypical antipsychotic. Atypical antipsychotics have a lower affinity for D2 receptors and a higher affinity for 5-HT2A receptors. They also exhibit "fast dissociation" from D2 receptors. These properties significantly reduce the risk of Extrapyramidal Side Effects (EPS) and long-term complications like Tardive Dyskinesia compared to First-Generation Antipsychotics (FGAs). Among the options provided, Olanzapine carries the lowest risk of inducing TD. **2. Why the other options are incorrect:** * **Flupenthixol (Option A):** This is a typical (First-Generation) antipsychotic of the thioxanthene class. It is a potent D2 receptor antagonist and is associated with a significantly higher risk of TD. * **Penfluridol (Option B):** This is a long-acting oral typical antipsychotic. Due to its high potency and long half-life, it maintains a sustained blockade of D2 receptors, making the risk of TD much higher than with atypical agents. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** TD is characterized by involuntary choreoathetoid movements, most commonly involving the orofacial region (e.g., tongue protrusion, lip-smacking). * **Pathophysiology:** It is thought to be caused by **dopamine receptor supersensitivity** in the nigrostriatal pathway following chronic blockade. * **Drug of Choice for TD:** If TD develops, the offending agent should be switched to **Clozapine** (the antipsychotic with the lowest overall risk of TD). * **FDA-Approved Treatment:** **VMAT-2 inhibitors** (e.g., Valbenazine, Deutetrabenazine) are now the standard treatment for managing TD symptoms. * **Risk Hierarchy:** Clozapine < Quetiapine < Olanzapine < Risperidone < Typical Antipsychotics (Haloperidol).

Q: A patient diagnosed with depression, currently on treatment, presents to the emergency department with altered sensorium, seizures, and palpitations. ECG shows sinus tachycardia. How do you treat this patient?

IV Sodium bicarbonate. ### Explanation The clinical presentation of **altered sensorium, seizures, and sinus tachycardia** in a patient being treated for depression is a classic description of **Tricyclic Antidepressant (TCA) overdose** (e.g., Amitriptyline). **Why IV Sodium Bicarbonate is the Correct Answer:** TCAs cause cardiotoxicity primarily by blocking **fast sodium channels** in the myocardium, leading to QRS prolongation, arrhythmias, and hypotension. * **Mechanism:** IV Sodium Bicarbonate increases extracellular sodium concentration and raises serum pH. The alkaline pH decreases the affinity of the TCA molecule for the sodium channel, while the sodium load helps overcome the channel blockade. This stabilizes the cardiac membrane and prevents fatal arrhythmias. **Analysis of Incorrect Options:** * **A. Aspirin + clopidogrel:** These are antiplatelets used for Acute Coronary Syndrome (ACS). While the patient has tachycardia, the underlying cause is toxicological, not thrombotic. * **B. IV Lorazepam:** While benzodiazepines are the first-line treatment for TCA-induced **seizures**, they do not address the life-threatening cardiac conduction delays, which is the priority in management. * **D. IV Haloperidol:** This is contraindicated. Antipsychotics can lower the seizure threshold and further prolong the QT interval, worsening the clinical state. **NEET-PG High-Yield Pearls:** * **The "3 Cs" of TCA Poisoning:** **C**oma, **C**onvulsions, and **C**ardiotoxicity. * **ECG Hallmark:** QRS duration **>100 ms** is predictive of seizures; **>160 ms** is highly predictive of ventricular arrhythmias. Look for a terminal R wave in lead aVR. * **Anticholinergic Toxidrome:** Patients often present with "dry as a bone, red as a beet, hot as a hare, blind as a bat, and mad as a hatter."

Q: Which is the first symptom to improve with the treatment of schizophrenia?

Auditory hallucination. **Explanation:** In the pharmacological management of Schizophrenia, symptoms are broadly categorized into **Positive symptoms** (hallucinations, delusions, disorganized behavior) and **Negative symptoms** (apathy, anhedonia, alogia). The correct answer is **Auditory hallucination** because antipsychotic medications (D2 receptor antagonists) are significantly more effective and faster at resolving positive symptoms than negative symptoms. Among positive symptoms, agitation and sleep disturbances often improve first, followed closely by the reduction in the intensity and frequency of hallucinations and delusions. **Analysis of Options:** * **Auditory Hallucination (Correct):** As a "Positive Symptom" mediated by mesolimbic dopamine hyperactivity, it responds relatively quickly to antipsychotic intervention. * **Apathy, Anhedonia, and Paucity of thoughts (Incorrect):** These are "Negative Symptoms." Negative symptoms are associated with decreased dopaminergic activity in the mesocortical pathway and structural brain changes. They are notoriously resistant to typical antipsychotics and show only marginal, slow improvement with atypical antipsychotics. **NEET-PG High-Yield Pearls:** * **Order of Improvement:** Positive symptoms (Hallucinations/Delusions) improve **before** Negative symptoms (Apathy/Withdrawal). * **Prognostic Indicator:** The presence of predominant negative symptoms at the time of diagnosis is a predictor of a **poor prognosis**. * **Treatment Resistance:** If a patient does not respond to two different antipsychotic trials (one being atypical), **Clozapine** is the drug of choice. * **Most Common Hallucination:** Auditory hallucinations are the most common type in Schizophrenia; if visual hallucinations predominate, always rule out organic causes/delirium.

Q: Which of the following medications is NOT used in the management of bipolar disorder?

Phenytoin. ### Explanation The management of Bipolar Disorder (BD) primarily involves **Mood Stabilizers**, which are drugs effective in treating mania, depression, or preventing relapses. While several anticonvulsants serve as excellent mood stabilizers, not all anti-epileptics possess psychotropic properties. **Why Phenytoin is the Correct Answer:** **Phenytoin** is a classic anti-epileptic drug used for tonic-clonic seizures. Unlike other anticonvulsants, it has **no proven efficacy** as a mood stabilizer in Bipolar Disorder. It does not possess the specific neuromodulatory effects (such as GABA enhancement or glutamate inhibition in the limbic system) required to stabilize mood fluctuations. **Analysis of Incorrect Options:** * **Carbamazepine (Option A):** An effective mood stabilizer, particularly useful in **Rapid Cycling Bipolar Disorder** and acute mania. It acts by blocking voltage-gated sodium channels. * **Sodium Valproate (Option C):** Often considered a first-line treatment for **Acute Mania** and mixed episodes. It works by increasing GABA levels and modulating intracellular signaling. * **Lamotrigine (Option D):** Specifically indicated for the **maintenance phase** of Bipolar Disorder to prevent **Bipolar Depression**. It is less effective for acute mania. --- ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard:** **Lithium** remains the gold standard for Bipolar Disorder, especially for suicidal ideation prophylaxis. * **Drug of Choice for Rapid Cycling:** Sodium Valproate or Carbamazepine. * **Bipolar Depression:** Quetiapine, Lurasidone, or Lamotrigine are preferred. * **Teratogenicity:** Avoid Valproate in pregnancy (Neural Tube Defects); Lithium is associated with **Ebstein’s Anomaly**. * **Lamotrigine Warning:** Always monitor for **Stevens-Johnson Syndrome (SJS)**; the dose must be titrated slowly.

Q: What is the absolute contraindication for Electro-Convulsive Therapy (ECT)?

Raised Intra-Cranial Tension. **Explanation:** **Why Raised Intra-Cranial Tension (ICT) is the Correct Answer:** Raised ICT is considered the only **absolute contraindication** for Electro-Convulsive Therapy (ECT). During the procedure, the induced seizure and the physiological response to the electrical stimulus cause a transient but significant increase in cerebral blood flow and blood pressure. In a patient with already elevated ICT (e.g., due to a space-occupying lesion), this further surge can lead to **brain herniation**, which is life-threatening. **Analysis of Incorrect Options:** * **Vascular Dementia:** This is not a contraindication. While patients with cognitive impairment may experience transient post-ictal confusion, ECT is often safely used in elderly patients with comorbid neurological conditions if depression is severe. * **Diabetic Retinopathy:** This is a **relative contraindication**. The transient rise in blood pressure during ECT could theoretically cause retinal hemorrhage, but it can be managed with pharmacological blood pressure control. * **Peripheral Neuropathy:** This has no bearing on the central nervous system effects of ECT and does not pose a risk during the procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Relative Contraindications:** Recent Myocardial Infarction (less than 3 months), unstable angina, pheochromocytoma, and retinal detachment. * **Gold Standard Indication:** Severe depression with high suicidal risk or catatonia. * **Most Common Side Effect:** Retrograde amnesia (memory loss for events just before the treatment). * **Pre-medication:** Atropine (to prevent bradycardia/secretions), Thiopentone/Propofol (anesthetic), and Succinylcholine (muscle relaxant to prevent fractures).

Q: Which antidepressant is known to cause Tardive dyskinesia?

Amoxapine. ### Explanation **Correct Option: D. Amoxapine** **Why Amoxapine is the correct answer:** Amoxapine is a secondary amine tricyclic antidepressant (TCA) with a unique pharmacological profile. It is a metabolite of the antipsychotic drug **Loxapine**. Unlike other antidepressants, Amoxapine possesses significant **dopamine D2 receptor blocking activity**. Because it acts as a dopamine antagonist in the nigrostriatal pathway, it can cause the same extrapyramidal side effects (EPS) typically associated with antipsychotics, including **Tardive Dyskinesia (TD)**, parkinsonism, and neuroleptic malignant syndrome. **Why other options are incorrect:** * **A. MAO inhibitors:** These drugs (e.g., Phenelzine, Selegiline) increase synaptic levels of serotonin, norepinephrine, and dopamine. They do not block dopamine receptors and are therefore not associated with TD. * **B. Mianserin:** A tetracyclic antidepressant that primarily acts as an alpha-2 adrenergic antagonist. It lacks D2 receptor blocking properties. * **C. Imipramine:** A classic TCA that primarily inhibits the reuptake of serotonin and norepinephrine. While it has anticholinergic and antihistaminic effects, it does not block D2 receptors and does not cause TD. **High-Yield Clinical Pearls for NEET-PG:** * **Amoxapine = "Antidepressant with Antipsychotic properties."** It is sometimes used in psychotic depression. * **Loxapine Connection:** Remember that Amoxapine is structurally related to the typical antipsychotic Loxapine. * **Tardive Dyskinesia:** Characterized by involuntary, choreoathetoid movements (commonly orofacial) due to prolonged dopamine blockade and subsequent receptor supersensitivity. * **Other EPS-causing non-antipsychotics:** Always remember **Metoclopramide** (antiemetic) as another high-yield cause of drug-induced TD.

Q: A patient with major depressive disorder is brought in by her mother, complaining that the patient attempted suicide by hanging. She has a history of multiple suicide attempts and frequently talks about death. Electroconvulsive therapy (ECT) is suggested. Which of the following is an absolute contraindication to ECT?

No absolute contraindication. **Explanation:** The correct answer is **D. No absolute contraindication.** In modern psychiatry, **Electroconvulsive Therapy (ECT)** is considered one of the safest procedures performed under general anesthesia. While several conditions significantly increase the risk of complications, current medical consensus (including guidelines from the APA) maintains that there are **no absolute medical contraindications** to ECT. If the psychiatric condition (e.g., severe suicidal intent or catatonia) is life-threatening, ECT can be performed even in high-risk patients, provided they are stabilized and monitored by a multidisciplinary team. **Analysis of Incorrect Options:** * **A. Brain tumor:** Previously considered an absolute contraindication due to the risk of increased intracranial pressure (ICP) and herniation. It is now a **relative contraindication**; with the use of steroids and antihypertensives, ECT can be safely administered. * **B. Myocardial disease:** Recent myocardial infarction (within 3 months) is a major **relative contraindication** due to the transient tachycardia and hypertension during the seizure. However, it is not absolute if the cardiac status is optimized. * **C. Aortic aneurysm:** This is a **relative contraindication** because the surge in blood pressure during the convulsion could lead to rupture. It is managed with beta-blockers and careful pressure control. **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Retrograde amnesia (usually resolves within 6 months). * **Most common cause of death:** Cardiovascular complications (arrhythmias/MI). * **Drug of choice for anesthesia:** Methohexital (Gold standard); Thiopentone is also used. * **Muscle relaxant of choice:** Succinylcholine. * **Indications:** Severe depression with suicidal risk (fastest response), Catatonia, and Treatment-resistant Schizophrenia.

Q: Which drug is primarily used to decrease suicidal tendencies in manic bipolar disorder?

Lithium. **Explanation:** **Lithium** is the gold standard treatment for Bipolar Disorder and is uniquely recognized for its **anti-suicidal properties**. While many medications treat the symptoms of mania or depression, Lithium is one of the few drugs in psychiatry (along with Clozapine) proven to significantly reduce the risk of completed suicide and suicidal attempts. It achieves this independently of its mood-stabilizing effect, likely by reducing impulsivity and aggression. **Analysis of Incorrect Options:** * **Fluoxetine (A):** An SSRI used for depression. In Bipolar Disorder, antidepressants can actually worsen the condition by inducing "mood switching" into mania and may potentially increase suicidal ideation in younger patients. * **Carbamazepine (C):** An anticonvulsant used as a second-line mood stabilizer. While effective for rapid cycling or acute mania, it does not possess the specific evidence-based anti-suicidal benefits that Lithium offers. * **Risperidone (D):** An atypical antipsychotic used to control acute psychotic symptoms in mania. While it stabilizes the acute phase, it is not the primary drug indicated for long-term suicide prevention. **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 **0.6–0.8 mEq/L** for maintenance. * **Monitoring:** Before starting Lithium, always 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** (tricuspid valve malformation). * **Drug of Choice:** Lithium remains the first-line treatment for classic "euphoric" mania.

Question 1

What adverse effect can sodium valproate cause in a patient with bipolar mood disorder?

Accepted Answer

Hepatotoxicity

Answer

Peripheral neuropathy

Answer

Renal failure

Answer

Cystitis

Question 2

Tardive dyskinesia is least common with which of the following medications?

Accepted Answer

Olanzapine

Answer

Flupenthixol

Answer

Penfluridol

Answer

None of the above

Question 3

Which of the following is the drug of choice for long-term management of panic disorder?

Accepted Answer

Selective serotonin reuptake inhibitor

Answer

Phenothiazine

Answer

Azapirone

Answer

Beta blocker

Question 4

A patient diagnosed with depression, currently on treatment, presents to the emergency department with altered sensorium, seizures, and palpitations. ECG shows sinus tachycardia. How do you treat this patient?

Accepted Answer

IV Sodium bicarbonate

Answer

Aspirin + clopidogrel

Answer

IV Lorazepam

Answer

IV Haloperidol

Question 5

Which is the first symptom to improve with the treatment of schizophrenia?

Accepted Answer

Auditory hallucination

Answer

Apathy

Answer

Anhedonia

Answer

Paucity of thoughts

Question 6

Which of the following medications is NOT used in the management of bipolar disorder?

Accepted Answer

Phenytoin

Answer

Carbamazepine

Answer

Sodium valproate

Answer

Lamotrigine

Question 7

What is the absolute contraindication for Electro-Convulsive Therapy (ECT)?

Accepted Answer

Raised Intra-Cranial Tension

Answer

Vascular Dementia

Answer

Diabetic Retinopathy

Answer

Peripheral Neuropathy

Question 8

Which antidepressant is known to cause Tardive dyskinesia?

Accepted Answer

Amoxapine

Answer

MAO inhibitors

Answer

Mianserin

Answer

Imipramine

Question 9

A patient with major depressive disorder is brought in by her mother, complaining that the patient attempted suicide by hanging. She has a history of multiple suicide attempts and frequently talks about death. Electroconvulsive therapy (ECT) is suggested. Which of the following is an absolute contraindication to ECT?

Accepted Answer

No absolute contraindication

Answer

Brain tumor

Answer

Myocardial disease

Answer

Aortic aneurysm

Question 10

Which drug is primarily used to decrease suicidal tendencies in manic bipolar disorder?

Accepted Answer

Lithium

Answer

Fluoxetine

Answer

Carbamazepine

Answer

Risperidone

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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