Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 271: Which of the following is an indication for the use of Clozapine?

A. Resistant schizophrenia (Correct Answer)
B. Akathisia
C. First drug to be used for schizophrenia
D. Schizophrenia with depression

Explanation: **Explanation:** **Clozapine** is a unique atypical antipsychotic and is considered the "gold standard" for **Treatment-Resistant Schizophrenia (TRS)**. 1. **Why Option A is Correct:** Resistance is defined as a lack of satisfactory clinical improvement despite the use of adequate doses of at least two different antipsychotics (including one atypical) for a duration of 6–8 weeks each. Clozapine is the only drug proven effective in these cases due to its complex receptor profile (D2, D4, 5-HT2A, etc.). It is also specifically indicated for reducing suicidal behavior in patients with schizophrenia. 2. **Why Other Options are Incorrect:** * **Option B (Akathisia):** Clozapine has a very low affinity for D2 receptors in the nigrostriatal pathway, making it less likely to cause Extrapyramidal Symptoms (EPS) like akathisia. In fact, it is often used to manage patients who cannot tolerate other drugs due to severe EPS. * **Option C (First drug):** Due to its side effect profile (specifically agranulocytosis), it is never used as a first-line agent. It is reserved for third-line use after two failed trials. * **Option D (Schizophrenia with depression):** While it may help, the primary indication remains resistance. Depression in schizophrenia is typically managed with SSRIs or other atypical antipsychotics like Quetiapine. **High-Yield Clinical Pearls for NEET-PG:** * **Adverse Effects:** Most serious is **Agranulocytosis** (requires mandatory WBC monitoring). Most common is **Sialorrhea** (excessive drooling). It also lowers the seizure threshold (dose-dependent). * **Monitoring:** Absolute Neutrophil Count (ANC) must be checked weekly for the first 6 months. * **No Prolactin Elevation:** Unlike most antipsychotics, Clozapine does not cause hyperprolactinemia.

Question 272: Which of the following conditions is considered a first-line treatment with Selective Serotonin Reuptake Inhibitors (SSRIs)?

A. Obsessive-Compulsive Disorder (OCD)
B. Panic Disorder
C. Social Phobia
D. All of the above (Correct Answer)

Explanation: Selective Serotonin Reuptake Inhibitors (SSRIs) are the most widely prescribed class of antidepressants due to their favorable safety profile and broad therapeutic index. They work by inhibiting the presynaptic reuptake of serotonin (5-HT), thereby increasing its availability in the synaptic cleft. **Explanation of the Correct Answer:** SSRIs are considered the **first-line pharmacological treatment** for a wide spectrum of psychiatric conditions beyond Major Depressive Disorder. * **Obsessive-Compulsive Disorder (OCD):** SSRIs are the gold standard. Note that OCD often requires higher doses of SSRIs compared to depression. * **Panic Disorder:** SSRIs are preferred over benzodiazepines to avoid dependence and over TCAs due to fewer anticholinergic side effects. * **Social Phobia (Social Anxiety Disorder):** SSRIs are the first-line long-term treatment, helping to reduce both the psychological and physical symptoms of social distress. Since all three conditions listed (OCD, Panic Disorder, and Social Phobia) utilize SSRIs as the primary evidence-based treatment, **Option D (All of the above)** is correct. **High-Yield Clinical Pearls for NEET-PG:** * **Lag Period:** SSRIs typically take 2–4 weeks for an antidepressant effect and up to 6–12 weeks for a full response in OCD. * **Side Effects:** The most common side effects are GI upset (nausea/diarrhea) and **sexual dysfunction** (delayed ejaculation/anorgasmia). * **Drug of Choice (DOC) Summary:** * **OCD:** SSRIs (Fluoxetine, Fluvoxamine). * **Panic Disorder:** SSRIs (Paroxetine, Sertraline). * **Bulimia Nervosa:** Fluoxetine (High dose - 60mg). * **Premature Ejaculation:** Dapoxetine (Short-acting SSRI). * **Serotonin Syndrome:** A dangerous interaction when SSRIs are combined with MAOIs; characterized by the triad of autonomic instability, neuromuscular hyperactivity, and altered mental status.

Question 273: What is the absolute contraindication for Electro-Convulsive Therapy (ECT)?

A. Raised Intra-Cranial Tension (Correct Answer)
B. Vascular Dementia
C. Diabetic Retinopathy
D. Peripheral Neuropathy

Explanation: **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).

Question 274: A 26-year-old lady has been on Olanzapine for the treatment of Schizophrenia. All of the following are the Adult Treatment Panel III (ATP III) criteria for metabolic syndrome, except?

A. Abdominal obesity
B. Triglyceride > 150 mg/dl
C. Blood pressure > 130/85 mmHg
D. LDL > 150 mg/dl (Correct Answer)

Explanation: **Explanation:** The question tests your knowledge of the **NCEP Adult Treatment Panel III (ATP III)** criteria for Metabolic Syndrome, which is a critical clinical consideration when prescribing Second-Generation Antipsychotics (SGAs) like **Olanzapine**, known for its high risk of metabolic side effects. **1. Why Option D is the correct answer:** The ATP III criteria do **not** include LDL (Low-Density Lipoprotein) levels. Instead, the lipid components focused on are **Triglycerides** and **HDL-C** (High-Density Lipoprotein). While elevated LDL is a cardiovascular risk factor, it is not a diagnostic criterion for Metabolic Syndrome. **2. Analysis of Incorrect Options (Criteria for Metabolic Syndrome):** To diagnose Metabolic Syndrome, at least **three** of the following five criteria must be present: * **Abdominal Obesity (Option A):** Defined as Waist Circumference >102 cm (40 in) in men or >88 cm (35 in) in women. * **Hypertriglyceridemia (Option B):** Triglycerides ≥150 mg/dL (or on treatment). * **Low HDL Cholesterol:** <40 mg/dL in men or <50 mg/dL in women. * **High Blood Pressure (Option C):** BP ≥130/85 mmHg (or on antihypertensive medication). * **High Fasting Glucose:** Fasting blood sugar ≥100 mg/dL (including Diabetes Mellitus). **Clinical Pearls for NEET-PG:** * **Olanzapine and Clozapine** carry the highest risk of weight gain, dyslipidemia, and Type 2 Diabetes among antipsychotics. * **Monitoring:** Patients on Olanzapine require baseline and periodic monitoring of weight (BMI), waist circumference, BP, fasting glucose, and lipid profile. * **Ziprasidone and Aripiprazole** are considered "metabolically neutral" SGAs with the lowest risk for metabolic syndrome.

Question 275: Which antidepressant is known to cause Tardive dyskinesia?

A. MAO inhibitors
B. Mianserin
C. Imipramine
D. Amoxapine (Correct Answer)

Explanation: ### 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.

Question 276: Which of the following is NOT true regarding olanzapine?

A. It causes marked anti-muscarinic action.
B. It causes weight gain.
C. It causes a mild increase in prolactin.
D. It has less epileptogenic action than phenothiazines. (Correct Answer)

Explanation: **Explanation:** Olanzapine is a potent **Second-Generation Antipsychotic (SGA)** or atypical antipsychotic. Understanding its side-effect profile is crucial for NEET-PG. **Why Option D is the Correct Answer (The "False" Statement):** Olanzapine, along with Clozapine, is known to **lower the seizure threshold** significantly. In fact, olanzapine has a **higher epileptogenic potential** compared to many typical antipsychotics like phenothiazines (e.g., Chlorpromazine) and other SGAs like Risperidone. Therefore, stating it has "less" epileptogenic action is incorrect. **Analysis of Other Options:** * **Option A (Anti-muscarinic action):** Olanzapine has a high affinity for M1 receptors, leading to marked anticholinergic side effects such as dry mouth, constipation, and urinary retention. * **Option B (Weight gain):** Olanzapine is notorious for causing significant **metabolic syndrome**, characterized by profound weight gain, dyslipidemia, and type 2 diabetes mellitus. It is second only to Clozapine in this regard. * **Option C (Prolactin levels):** Unlike Risperidone or typical antipsychotics, Olanzapine causes only a **mild and transient** increase in prolactin levels, rarely leading to clinical galactorrhea or gynecomastia. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** It acts as a 5-HT2A and D2 receptor antagonist (SDA). * **Metabolic Monitoring:** Patients on Olanzapine must have regular monitoring of BMI, blood glucose, and lipid profiles. * **Smoking Interaction:** Smoking induces the **CYP1A2** enzyme, which can decrease olanzapine plasma levels. * **Drug of Choice:** It is highly effective for negative symptoms of schizophrenia and as a mood stabilizer in Bipolar Disorder.

Question 277: Neuroleptic malignant syndrome is characterized by which of the following?

A. Bradycardia
B. Labile hypertension (Correct Answer)
C. Hypotonia
D. Hypothermia

Explanation: **Explanation:** Neuroleptic Malignant Syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic medications (neuroleptics), primarily caused by potent **dopamine (D2) receptor blockade** in the nigrostriatal pathway and hypothalamus. **Why Labile Hypertension is correct:** Autonomic instability is a hallmark of NMS. This manifests as **labile hypertension** (fluctuating blood pressure), tachycardia, diaphoresis, and cardiac arrhythmias. The dysregulation of the autonomic nervous system leads to unpredictable shifts in vascular tone and heart rate. **Analysis of Incorrect Options:** * **A. Bradycardia:** Patients typically present with **tachycardia** due to autonomic hyperactivity and as a physiological response to hyperthermia and stress. * **C. Hypotonia:** NMS is characterized by severe **"Lead-pipe" rigidity** (extrapyramidal symptom). Hypotonia is not seen; in fact, the intense muscle contraction contributes to hyperthermia and rhabdomyolysis. * **D. Hypothermia:** **Hyperpyrexia** (fever >104°F or 40°C) is a core diagnostic criterion. It results from both hypothalamic dysfunction and excessive heat production from muscle rigidity. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic (FEVER):** **F**ever, **E**ncephalopathy (altered sensorium), **V**itals unstable, **E**levated CPK/Enzymes, **R**igidity. * **Laboratory Findings:** Significantly elevated **Creatine Phosphokinase (CPK)** and leukocytosis are classic markers. * **Treatment:** Immediate cessation of the offending agent, aggressive cooling, and pharmacological intervention with **Dantrolene** (muscle relaxant) or **Bromocriptine** (dopamine agonist). * **Differential Diagnosis:** Unlike Serotonin Syndrome, NMS presents with "lead-pipe" rigidity and bradyreflexia, whereas Serotonin Syndrome features hyperreflexia and myoclonus.

Question 278: What is an absolute contraindication to ECT?

A. Glaucoma
B. Brain tumor (Correct Answer)
C. Aortic aneurysm
D. Myocardial infarction

Explanation: **Explanation:** Electroconvulsive Therapy (ECT) is a highly effective treatment in psychiatry, but it involves physiological changes—specifically a transient increase in intracranial pressure (ICP) and a brief cardiovascular surge (initial bradycardia followed by tachycardia and hypertension). **Why Brain Tumor is the Correct Answer:** A **Brain tumor with increased intracranial pressure** is traditionally considered the only **absolute contraindication** to ECT. During the seizure, cerebral blood flow and ICP rise significantly. In the presence of a space-occupying lesion, this can lead to **uncal or transtentorial herniation**, which is fatal. While some modern literature suggests ECT can be performed on stable tumors without mass effect, for the purpose of NEET-PG, "Brain Tumor" remains the classic absolute contraindication. **Analysis of Incorrect Options:** * **Glaucoma:** This is a **relative contraindication**. ECT can cause a transient rise in intraocular pressure, but it can be managed with pre-treatment miotic drops. * **Aortic Aneurysm:** This is a **relative contraindication**. The hypertensive surge during ECT poses a risk of rupture, but this can be mitigated using short-acting beta-blockers (e.g., Esmolol) to control blood pressure. * **Myocardial Infarction (MI):** Recent MI (usually within the last 3 months) is a high-risk **relative contraindication** due to increased cardiac workload, but it is not absolute if the psychiatric condition is life-threatening and the patient is cardiac-stabilized. **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Retrograde amnesia (usually resolves). * **Most common cause of death:** Cardiovascular complications (Arrhythmias). * **Drug of choice for anesthesia:** Methohexital (Barbiturate). * **Muscle relaxant used:** Succinylcholine (to prevent fractures). * **Safe in Pregnancy:** ECT is considered safe and often preferred for severe depression/psychosis in pregnant patients.

Question 279: All of the following drugs are indicated in the treatment of bipolar disorder except?

A. Carbamazepine
B. Vigabatrin (Correct Answer)
C. Sodium valproate
D. Lamotrigine

Explanation: **Explanation:** The treatment of Bipolar Disorder (BD) relies heavily on **Mood Stabilizers**, which primarily include Lithium and certain anticonvulsants. **Why Vigabatrin is the Correct Answer:** Vigabatrin is an anticonvulsant that acts as an irreversible inhibitor of GABA transaminase. While it increases GABA levels, it has **no proven efficacy** in treating mania or depression associated with bipolar disorder. Furthermore, it is associated with a high risk of permanent visual field defects (vigabatrin-associated visual field loss), limiting its use primarily to refractory focal seizures and infantile spasms (West Syndrome). **Analysis of Other Options:** * **Carbamazepine (Option A):** An established mood stabilizer particularly effective 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 glutamate/sodium channels. * **Lamotrigine (Option D):** A key mood stabilizer specifically indicated for the **maintenance phase** of bipolar disorder to **prevent bipolar depression**. It is not effective for acute mania. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC) for Acute Mania:** Lithium (classic) or Sodium Valproate (especially for irritable/mixed mania). * **DOC for Bipolar Depression:** Quetiapine, Lurasidone, or Lamotrigine. * **Teratogenicity:** Valproate is highly associated with **Neural Tube Defects** (avoid in pregnancy); Lithium is associated with **Ebstein’s Anomaly**. * **Lamotrigine Caution:** Must be titrated slowly to avoid **Stevens-Johnson Syndrome (SJS)**.

Question 280: Which of the following antidepressants causes hypertensive crisis?

A. Dapoxetine
B. Duloxetine
C. Clomipramine
D. Phenelzine (Correct Answer)

Explanation: **Explanation** The correct answer is **Phenelzine**. Phenelzine is a non-selective, irreversible **Monoamine Oxidase Inhibitor (MAOI)**. **Why Phenelzine causes Hypertensive Crisis:** MAOIs inhibit the enzyme monoamine oxidase, which is responsible for breaking down tyramine in the gastrointestinal tract and liver. When a patient taking an MAOI consumes **tyramine-rich foods** (e.g., aged cheese, red wine, cured meats), tyramine enters the systemic circulation and acts as an indirect sympathomimetic. It displaces large amounts of stored norepinephrine from presynaptic vesicles into the synaptic cleft, leading to severe vasoconstriction and a potentially fatal **hypertensive crisis** (the "Cheese Reaction"). **Analysis of Incorrect Options:** * **A. Dapoxetine:** A short-acting Selective Serotonin Reuptake Inhibitor (SSRI) used primarily for premature ejaculation. It does not significantly affect norepinephrine levels. * **B. Duloxetine:** A Serotonin-Norepinephrine Reuptake Inhibitor (SNRI). While it can cause a modest increase in blood pressure, it does not trigger a sudden hypertensive crisis via the tyramine pathway. * **C. Clomipramine:** A Tricyclic Antidepressant (TCA) that primarily inhibits serotonin reuptake. Its main side effects are anticholinergic and cardiac arrhythmias, not hypertensive crisis. **NEET-PG High-Yield Pearls:** * **Antidote:** The treatment of choice for an MAOI-induced hypertensive crisis is **Phentolamine** (an alpha-blocker). * **Washout Period:** When switching from an MAOI to an SSRI, a **2-week washout period** is required (5 weeks for Fluoxetine) to prevent **Serotonin Syndrome**. * **Other MAOIs:** Isocarboxazid and Tranylcypromine are also non-selective MAOIs associated with this risk.

Practice by Chapter

Principles of Psychopharmacology

Practice Questions

Antipsychotic Medications

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Antidepressant Medications

Practice Questions

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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