Psychopharmacology Practice Questions

Q: A 30-year-old patient with mania, prescribed haloperidol one week ago, has become restless and has been pacing for the last day. On examination, hand tremors are noted. What is the most likely diagnosis?

Akathisia. ### Explanation **Correct Answer: D. Akathisia** **Why it is correct:** Akathisia is a common **Extrapyramidal Side Effect (EPS)** associated with high-potency first-generation antipsychotics like Haloperidol. It is characterized by a subjective feeling of inner restlessness and an objective need to move. Clinically, this manifests as pacing, inability to sit still, or shifting weight from foot to foot. It typically occurs within days to weeks of starting or increasing the dose of an antipsychotic. The presence of hand tremors in this patient suggests concurrent drug-induced parkinsonism, which often co-exists with akathisia. **Why the other options are incorrect:** * **A. Anhedonia:** This refers to the inability to feel pleasure, a core symptom of depression or negative symptoms of schizophrenia, not a motor side effect. * **B. Dystonia:** Acute dystonia involves sudden, involuntary, sustained muscle contractions (e.g., torticollis, oculogyric crisis). It usually occurs within hours to the first few days of treatment, rather than presenting as continuous pacing. * **C. Restless Leg Syndrome (RLS):** While clinically similar, RLS typically occurs at night, is associated with uncomfortable sensations in the legs, and is relieved by movement. Akathisia is persistent throughout the day and is specifically linked to dopamine-blocking agents. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC):** For Akathisia, the first-line treatment is **Propranolol** (Beta-blocker). Centrally acting anticholinergics (like Benztropine) are less effective for akathisia than for dystonia. * **Timeline of EPS:** 1. **Acute Dystonia:** Hours to days. 2. **Akathisia:** Days to weeks. 3. **Parkinsonism:** Weeks to months. 4. **Tardive Dyskinesia:** Months to years (long-term use). * **Mechanism:** Akathisia is thought to result from dopamine (D2) blockade in the nigrostriatal pathway.

Q: Which of the following drug classes is most useful for acute depression and has a good side effect profile?

Selective Serotonin Reuptake Inhibitors (SSRIs). **Explanation:** **Selective Serotonin Reuptake Inhibitors (SSRIs)** are considered the first-line treatment for acute depression. Their primary mechanism involves inhibiting the presynaptic reuptake of serotonin (5-HT), thereby increasing its availability in the synaptic cleft. They are preferred because they possess a **high therapeutic index**, lack significant anticholinergic or cardiotoxic effects, and are safe in overdose, making them the gold standard for both efficacy and tolerability. **Analysis of Incorrect Options:** * **Tricyclic Antidepressants (TCAs):** While highly effective, they have a narrow therapeutic index. They cause significant side effects (sedation, weight gain, dry mouth) and are **lethal in overdose** due to cardiotoxicity (arrhythmias via sodium channel blockade). * **Non-selective MAO-Is:** These are rarely used first-line due to the risk of **Hypertensive Crisis** ("Cheese Reaction") when taken with tyramine-rich foods and the risk of Serotonin Syndrome. * **RIMA (e.g., Moclobemide):** Although safer than non-selective MAO-Is, they are generally considered second-line or adjunctive and do not have the extensive clinical evidence base or "all-rounder" profile of SSRIs for acute depression. **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect of SSRIs:** Gastrointestinal upset (nausea/diarrhea) and sexual dysfunction. * **Drug of choice (DOC)** for Depression in patients with recent Myocardial Infarction: **Sertraline**. * **Fluoxetine** has the longest half-life, reducing the risk of discontinuation syndrome. * **Fluvoxamine** is specifically preferred for Obsessive-Compulsive Disorder (OCD).

Q: Which of the following psychotropic drugs requires monitoring for hematotoxic effects?

Clozapine. **Explanation:** **Clozapine** is the correct answer because it is associated with a significant risk of **agranulocytosis** (a severe decrease in white blood cell count), which occurs in approximately 1% of patients. It is an atypical antipsychotic reserved for treatment-resistant schizophrenia. Due to its hematotoxic potential, mandatory monitoring of the **Absolute Neutrophil Count (ANC)** is required (weekly for the first 6 months, then biweekly, then monthly) to prevent life-threatening infections. **Analysis of Incorrect Options:** * **Buspirone:** An anxiolytic (5-HT1A partial agonist) primarily known for lacking sedative or addictive properties; it does not cause bone marrow suppression. * **Haloperidol:** A typical antipsychotic (D2 blocker) known for Extrapyramidal Side Effects (EPS) and Hyperprolactinemia, but it is not associated with hematotoxicity. * **Lithium Carbonate:** Used in Bipolar Disorder. While it requires monitoring, it is for **renal, thyroid, and serum drug levels**. Interestingly, Lithium causes *leukocytosis* (increased WBC count), the opposite of hematotoxicity, and is sometimes used to treat clozapine-induced neutropenia. **High-Yield Clinical Pearls for NEET-PG:** * **Clozapine Monitoring:** Treatment must be interrupted if ANC falls below **1500/mm³**. * **Side Effect Profile:** Clozapine is the only antipsychotic that **reduces suicide risk** but carries a "5-Black Box Warning" for: Agranulocytosis, Seizures, Myocarditis, Orthostatic Hypotension, and Increased mortality in elderly patients with dementia. * **Sialorrhea:** Hypersalivation is a unique and common side effect of Clozapine.

Q: A 28-year-old patient presents with a 3-month history of suspiciousness, auditory hallucinations, aggression, and poor sleep and appetite. An ECG revealed a QTc of 480 ms. Which of the following medications should be avoided in this patient?

Ziprasidone. **Explanation:** The patient presents with symptoms of psychosis (suspiciousness, hallucinations, aggression) and an **ECG showing a QTc interval of 480 ms**. In clinical practice, a QTc interval >450 ms in men or >470 ms in women is considered prolonged. Starting medications that further prolong the QT interval increases the risk of **Torsades de Pointes (TdP)**, a life-threatening ventricular arrhythmia. **Why Ziprasidone is the correct answer:** Among the atypical antipsychotics, **Ziprasidone** is most strongly associated with dose-dependent QTc prolongation. It is contraindicated in patients with a known history of QT prolongation, recent myocardial infarction, or uncompensated heart failure. Given this patient’s baseline QTc of 480 ms, Ziprasidone must be avoided. **Analysis of Incorrect Options:** * **Aripiprazole:** This is considered one of the "QT-neutral" antipsychotics. It has a very low risk of cardiac conduction issues and is often a preferred choice in patients with cardiac concerns. * **Clozapine:** While Clozapine can cause myocarditis or tachycardia, its effect on the QTc interval is significantly less than that of Ziprasidone. * **Risperidone:** Risperidone can cause mild QTc prolongation, but the effect is generally negligible at standard doses compared to Ziprasidone. **High-Yield Clinical Pearls for NEET-PG:** * **Highest QTc Risk (IV):** IV Haloperidol (highest risk among all). * **Highest QTc Risk (Oral):** Thioridazine (Typical) and Ziprasidone (Atypical). * **Safest/QT-Neutral:** Aripiprazole, Lurasidone, and Olanzapine. * **Monitoring:** Always check electrolytes (Hypokalemia and Hypomagnesemia) as they exacerbate drug-induced QT prolongation.

Q: A 21-year-old student with schizophrenia is currently asymptomatic after two months of treatment with 3 mg of risperidone. The patient had no prior psychiatric episodes and no family history of psychiatric illness. For how long should risperidone be continued?

At least 12 months of symptom remission. **Explanation:** The management of a first-episode psychosis (FEP) requires a balance between preventing relapse and minimizing long-term side effects of antipsychotics. According to standard psychiatric guidelines (APA and NICE), for a patient with a **first episode of schizophrenia** who has achieved symptom remission, maintenance therapy should be continued for **at least 12 months**. 1. **Why Option B is Correct:** In a first-episode patient like this 21-year-old, the risk of relapse is highest in the first year following the acute phase. Continuing Risperidone for 12 months post-remission significantly reduces the risk of recurrence. If the patient remains stable after this period, a gradual tapering of the dose can be considered. 2. **Why Options A, C, and D are Incorrect:** * **6 months (Option A):** This duration is generally considered too short for schizophrenia; it is more characteristic of the treatment duration for a single episode of Major Depressive Disorder. * **2 years (Option C):** This is often recommended for patients who have had **multiple episodes** (recurrent schizophrenia) but are not yet considered "chronic." * **5 years (Option D):** This prolonged duration is reserved for patients with a history of frequent relapses, violent behavior, or severe functional impairment. **High-Yield Clinical Pearls for NEET-PG:** * **First Episode:** Treat for 1–2 years post-remission. * **Multiple Episodes:** Treat for 2–5 years. * **Chronic/Relapsing:** May require lifelong therapy. * **Risperidone Fact:** It is a second-generation antipsychotic (SGA) that blocks both $D_2$ and $5-HT_{2A}$ receptors. At doses >6 mg, it carries a higher risk of Extrapyramidal Symptoms (EPS) and Hyperprolactinemia compared to other SGAs.

Q: Which of the following drugs is used as a general anesthetic in Electroconvulsive Therapy (ECT)?

Methohexital. **Explanation:** **1. Why Methohexital is Correct:** Methohexital (a ultra-short-acting barbiturate) is considered the **gold standard** anesthetic agent for Electroconvulsive Therapy (ECT). The primary goal of anesthesia in ECT is to provide rapid induction and quick recovery without significantly interfering with seizure activity. Methohexital is preferred because it has a **minimal effect on the seizure threshold** compared to other induction agents (like propofol, which significantly shortens seizure duration). It ensures a rapid onset of action and a predictable, short duration of anesthesia, allowing for efficient post-ictal recovery. **2. Why the Other Options are Incorrect:** * **Labetalol & Propranolol:** These are beta-blockers. While they are sometimes used *adjunctively* during ECT to control the transient hypertensive surge and tachycardia that occurs during the tonic-clonic phase, they are not anesthetic agents and cannot induce unconsciousness. * **Amiodarone:** This is a Class III antiarrhythmic drug. It has no role in anesthesia induction and is not used in the standard ECT protocol. **3. High-Yield Clinical Pearls for NEET-PG:** * **Muscle Relaxant of Choice:** **Succinylcholine** is the preferred muscle relaxant in ECT to prevent musculoskeletal injuries (fractures/dislocations) during the seizure. * **Propofol vs. Methohexital:** While Propofol is commonly used, it is known to **shorten seizure duration** more than methohexital, which may potentially reduce the therapeutic efficacy of the treatment. * **Pre-medication:** Atropine or Glycopyrrolate (anticholinergics) may be given to prevent vagally-mediated bradycardia and reduce secretions. * **Absolute Contraindication:** The only absolute contraindication to ECT is **Increased Intracranial Pressure (ICP)**.

Q: A patient on anti-psychotic drugs develops a temperature of 104°F, a blood pressure of approximately 150/100 mmHg, and abnormal behavior. What is the likely diagnosis?

Neuroleptic malignant syndrome. ### Explanation The patient is presenting with the classic triad of **Neuroleptic Malignant Syndrome (NMS)**: hyperpyrexia (104°F), autonomic instability (hypertension), and altered mental status (abnormal behavior), occurring in the context of antipsychotic use. **1. Why Neuroleptic Malignant Syndrome (NMS) is correct:** NMS is a life-threatening idiosyncratic reaction to dopamine antagonists (typically high-potency typical antipsychotics like Haloperidol). The underlying mechanism involves **severe dopamine (D2) blockade** in the nigrostriatal pathway (leading to "lead-pipe" rigidity) and the hypothalamus (causing impaired thermoregulation and hyperpyrexia). Autonomic dysfunction leads to fluctuating blood pressure and tachycardia. **2. Why other options are incorrect:** * **Aggravation of psychosis:** While abnormal behavior occurs, psychosis alone does not cause high-grade fever or significant autonomic instability. * **Parkinsonism:** This is an Extrapyramidal Side Effect (EPS) characterized by tremors, bradykinesia, and rigidity, but it lacks the systemic toxicity (fever/autonomic collapse) seen here. * **Dystonia:** This involves acute, painful muscle spasms (e.g., torticollis, oculogyric crisis) usually occurring within hours of drug administration, without systemic symptoms. **3. NEET-PG High-Yield Pearls:** * **Clinical Marker:** Elevated **Creatine Kinase (CK)** levels due to intense muscle rigidity. * **Treatment of Choice:** Immediate drug withdrawal + Supportive care + **Dantrolene** (muscle relaxant) or **Bromocriptine** (D2 agonist). * **Differential Diagnosis:** Differentiate from *Serotonin Syndrome* (which presents with hyperreflexia and myoclonus) and *Malignant Hyperthermia* (triggered by inhalational anesthetics/succinylcholine). * **Mnemonic (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated enzymes (CK), **R**igidity.

Q: A patient with acute psychosis, who is on haloperidol 20mg/day for the last 2 days, presents with an episode characterized by tongue protrusion, oculogyric crisis, stiffness, and abnormal posture of limbs and trunk without loss of consciousness for 20 minutes. The episode improved within a few minutes after administration of diphenhydramine HCl. What is the most likely diagnosis?

Acute dystonia. ### Explanation **Correct Answer: A. Acute dystonia** **Why it is correct:** Acute dystonia is an Extrapyramidal Side Effect (EPS) characterized by sudden, involuntary muscle spasms. This patient exhibits classic signs: **oculogyric crisis** (upward gaze deviation), **glossospasm** (tongue protrusion), and **torticollis/retrocollis** (abnormal posture). * **Mechanism:** It is caused by a sudden blockade of dopamine (D2) receptors in the nigrostriatal pathway, leading to a relative excess of acetylcholine. * **Timeline:** It typically occurs within hours to **days** (usually <5 days) of starting high-potency antipsychotics like Haloperidol. * **Management:** It is a medical emergency that responds rapidly to **anticholinergics** (e.g., Benztropine, Promethazine) or antihistamines with anticholinergic properties like **Diphenhydramine**. **Why the other options are wrong:** * **B. Akathisia:** Presents as subjective motor restlessness (inability to sit still). It does not involve muscle spasms or abnormal postures. * **C. Tardive dyskinesia:** Occurs after **long-term** (months to years) use of antipsychotics. It presents with choreoathetoid movements (e.g., lip-smacking), not acute sustained spasms. * **D. Neuroleptic malignant syndrome (NMS):** A life-threatening reaction characterized by "lead-pipe" rigidity, high fever, autonomic instability, and altered sensorium. The rapid reversal with diphenhydramine and lack of fever rule this out. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Young males and those receiving high-potency first-generation antipsychotics are at highest risk. * **The "Rule of 4" for EPS Timeline:** * **4 Hours:** Acute Dystonia * **4 Days:** Akathisia (can also occur in weeks) * **4 Weeks:** Parkinsonism * **4 Months:** Tardive Dyskinesia (usually >6 months) * **Drug of Choice:** Intravenous or Intramuscular **Promethazine** or Benztropine.

Q: Which of the following medications is NOT used in the treatment of schizophrenia?

Pemoline. **Explanation:** The treatment of schizophrenia primarily involves **Antipsychotics**, which work by modulating dopaminergic pathways (specifically blocking D2 receptors). **Why Pemoline is the correct answer:** **Pemoline** is a sympathomimetic amine and a central nervous system (CNS) stimulant. It acts by increasing dopamine levels in the synaptic cleft. Because schizophrenia is associated with dopamine overactivity in the mesolimbic pathway, stimulants like Pemoline can actually **exacerbate or induce psychotic symptoms**. Historically, Pemoline was used for ADHD and narcolepsy, but it is not used for schizophrenia. (Note: It has been largely withdrawn globally due to hepatotoxicity). **Why the other options are incorrect:** * **Olanzapine:** An **Atypical (Second-Generation) Antipsychotic**. It blocks both D2 and 5-HT2A receptors and is a first-line treatment for schizophrenia due to its lower risk of extrapyramidal side effects (EPS). * **Sulpiride:** A **Substituted Benzamide** that acts as a selective D2 receptor antagonist. It is used as an antipsychotic, particularly effective in treating the negative symptoms of schizophrenia at lower doses. * **Chlorpromazine:** A **Typical (First-Generation) Antipsychotic** (Low potency). It was the first antipsychotic discovered (1952) and remains a standard treatment for schizophrenia. **High-Yield Clinical Pearls for NEET-PG:** * **Dopamine Hypothesis:** Schizophrenia is linked to *increased* dopamine in the mesolimbic pathway (positive symptoms) and *decreased* dopamine in the mesocortical pathway (negative symptoms). * **Chlorpromazine** is known for causing significant sedation and skin/eye pigmentation (corneal opacities). * **Olanzapine** is highly associated with metabolic syndrome (weight gain, dyslipidemia, and diabetes).

Question 1

A 30-year-old patient with mania, prescribed haloperidol one week ago, has become restless and has been pacing for the last day. On examination, hand tremors are noted. What is the most likely diagnosis?

Accepted Answer

Akathisia

Answer

Anhedonia

Answer

Dystonia

Answer

Restless leg syndrome

Question 2

Which of the following drug classes is most useful for acute depression and has a good side effect profile?

Accepted Answer

Selective Serotonin Reuptake Inhibitors (SSRIs)

Answer

Reversible Inhibitors of Monoamine Oxidase A (RIMA)

Answer

Tricyclic Antidepressants

Answer

Non-selective Monoamine Oxidase Inhibitors (MAO-inhibitors)

Question 3

A 30-year-old patient with schizophrenia on antipsychotics presents with amenorrhea and galactorrhea. Which of the following antipsychotics should she be shifted to?

Accepted Answer

Aripiprazole

Answer

Haloperidol

Answer

Olanzapine

Answer

Risperidone

Question 4

Which of the following psychotropic drugs requires monitoring for hematotoxic effects?

Accepted Answer

Clozapine

Answer

Buspirone

Answer

Haloperidol

Answer

Lithium carbonate

Question 5

A 28-year-old patient presents with a 3-month history of suspiciousness, auditory hallucinations, aggression, and poor sleep and appetite. An ECG revealed a QTc of 480 ms. Which of the following medications should be avoided in this patient?

Accepted Answer

Ziprasidone

Answer

Aripiprazole

Answer

Clozapine

Answer

Risperidone

Question 6

A 21-year-old student with schizophrenia is currently asymptomatic after two months of treatment with 3 mg of risperidone. The patient had no prior psychiatric episodes and no family history of psychiatric illness. For how long should risperidone be continued?

Accepted Answer

At least 12 months of symptom remission

Answer

At least 6 months of symptom remission

Answer

2 years

Answer

5 years

Question 7

Which of the following drugs is used as a general anesthetic in Electroconvulsive Therapy (ECT)?

Accepted Answer

Methohexital

Answer

Labetalol

Answer

Amiodarone

Answer

Propranolol

Question 8

A patient on anti-psychotic drugs develops a temperature of 104°F, a blood pressure of approximately 150/100 mmHg, and abnormal behavior. What is the likely diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Aggravation of psychosis

Answer

Parkinsonism

Answer

Dystonia

Question 9

A patient with acute psychosis, who is on haloperidol 20mg/day for the last 2 days, presents with an episode characterized by tongue protrusion, oculogyric crisis, stiffness, and abnormal posture of limbs and trunk without loss of consciousness for 20 minutes. The episode improved within a few minutes after administration of diphenhydramine HCl. What is the most likely diagnosis?

Accepted Answer

Acute dystonia

Answer

Akathisia

Answer

Tardive dyskinesia

Answer

Neuroleptic malignant syndrome

Question 10

Which of the following medications is NOT used in the treatment of schizophrenia?

Accepted Answer

Pemoline

Answer

Olanzapine

Answer

Sulpiride

Answer

Chlorpromazine

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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