Psychopharmacology Practice Questions

Q: Drug of choice in Tourette syndrome is -

Haloperidol. ***Haloperidol*** - **Haloperidol**, a **first-generation antipsychotic**, is highly effective in blocking dopamine receptors and reducing the severity of tics in Tourette syndrome. - It is considered a **drug of choice** for managing severe tics due to its strong dopamine antagonism, which helps control **motor and vocal tics**. *Valproate* - **Valproate** is primarily an **anticonvulsant** and **mood stabilizer**, used in epilepsy and bipolar disorder. - While it has some efficacy in reducing tics, it is generally **less effective** than dopamine-blocking agents like haloperidol and is not considered a first-line treatment for Tourette syndrome. *Carbamazepine* - **Carbamazepine** is an **anticonvulsant** used for seizures and trigeminal neuralgia. - It is generally **not efficacious** for the treatment of tics in Tourette syndrome and does not target the dopaminergic pathways involved in tic generation. *Methadone* - **Methadone** is an **opioid analgesic** used for pain management and opioid dependence treatment. - It has **no role** in the management of Tourette syndrome as its mechanism of action is unrelated to the pathophysiology of tics.

Q: Maximum increase in prolactin level is caused by:-

Risperidone (Potent D2 receptor antagonist). ***Risperidone (Potent D2 receptor antagonist)*** - Risperidone is a **potent D2 receptor antagonist**, meaning it blocks dopamine's action at these receptors. Since dopamine inhibits prolactin release, blocking D2 receptors leads to a significant increase in **prolactin levels**. - Its high affinity for D2 receptors in the **tuberoinfundibular pathway** is a primary reason for its pronounced effect on prolactin. *Olanzapine (Primarily blocks 5HT2 receptors)* - While olanzapine can cause some prolactin elevation, its primary mechanism involves **5HT2 receptor blockade**, with less potent D2 antagonism compared to risperidone. - The degree of **hyperprolactinemia** associated with olanzapine is generally milder than that seen with risperidone. *Aripiprazole (D2 partial agonist)* - Aripiprazole is a **D2 partial agonist**, meaning it acts as an antagonist when dopamine levels are high and an agonist when dopamine levels are low, effectively stabilizing dopamine activity. - Due to its partial agonism, aripiprazole typically has a **low risk of hyperprolactinemia** and can even normalize elevated prolactin levels caused by other antipsychotics. *Clozapine (Primarily blocks 5HT2 receptors)* - Clozapine primarily blocks **5HT2 receptors** and has relatively weak D2 receptor antagonism, especially transient D2 blockade. - It generally causes **minimal to no prolactin elevation** and is considered a prolactin-sparing antipsychotic.

Q: A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?

Akathisia. ***Akathisia*** - This condition is characterized by a subjective feeling of **inner restlessness** and an objective urge to move, which is a classic side effect of **dopamine receptor blocking agents** like haloperidol. - The onset of akathisia can be acute or chronic, often occurring within days to weeks of starting or increasing the dose of antipsychotic medication. *Rabbit syndrome* - This is a rare form of **tardive dyskinesia** characterized by rapid, fine perioral movements that resemble a rabbit chewing. - It does not primarily involve the subjective feeling of restlessness or the urge to move the entire body as described in the patient's presentation. *Tardive dyskinesia* - This condition typically involves **involuntary, repetitive body movements**, often affecting the face, lips, tongue, and limbs, and usually develops after prolonged exposure to antipsychotic medications (months to years). - While it can manifest as abnormal movements, the primary symptom of inner restlessness and urge to move is not characteristic of tardive dyskinesia but rather of akathisia, and its onset is typically much later. *Acute Dystonia* - Acute dystonia presents as **sustained muscle contractions** leading to twisting and repetitive movements or abnormal fixed postures, often affecting the neck, eyes (oculogyric crisis), and trunk. - This reaction typically occurs within hours or days of initiating or increasing neuroleptic medication and is characterized by involuntary muscle spasms, not a pervasive sense of inner restlessness.

Q: A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?

Stop clozapine. ***Stop clozapine*** - The presentation of **fever, confusion, muscle rigidity**, and elevated **creatine kinase (CK)** in a patient on clozapine is highly suggestive of **Neuroleptic Malignant Syndrome (NMS)**, a potentially fatal adverse reaction. - **Immediate discontinuation** of the causative antipsychotic, in this case **clozapine**, is the cornerstone of NMS management to prevent further clinical deterioration and complications. *Add antipyretic* - While a **fever** is present, simply adding an **antipyretic** would only address a symptom and not the underlying severe adverse drug reaction, potentially delaying critical intervention. - The fever in NMS is often due to **hypothalamic dysfunction** and **muscle rigidity**, not just a simple infection responsive to antipyretics alone. *Continue clozapine* - Continuing clozapine in the presence of NMS symptoms would **exacerbate the condition**, leading to increased morbidity and mortality, as it is the likely causative agent. - Further exposure to the drug would worsen the **hyperthermia, muscle rigidity**, and potential **organ damage**. *Reduce dose* - **Reducing the dose** of clozapine is insufficient if NMS is suspected, as even lower doses can maintain the toxic effect and progression of the syndrome. - The priority is to remove the offending agent completely, rather than merely decreasing its concentration.

Q: Which antipsychotic is preferred for treatment-resistant schizophrenia?

Clozapine. ***Clozapine*** - **Clozapine** is the only antipsychotic with proven efficacy for **treatment-resistant schizophrenia**, defined as inadequate response to two different antipsychotics. - Its unique pharmacological profile, including strong antagonism of various **dopamine** and **serotonin receptors**, contributes to its superior efficacy in these cases. *Quetiapine* - While an effective antipsychotic for many, **quetiapine** is generally not considered the first-line or preferred agent for **treatment-resistant schizophrenia**. - It has a lower propensity for **extrapyramidal symptoms** but lacks the specific efficacy demonstrated by clozapine in refractory cases. *Olanzapine* - **Olanzapine** is a potent antipsychotic and can be effective for severe symptoms, but it does not have the same established efficacy for **treatment resistance** as clozapine. - Its use can be limited by significant metabolic side effects including **weight gain** and **glucose dysregulation**. *Risperidone* - **Risperidone** is a commonly used antipsychotic, but it is not indicated as the preferred treatment for **treatment-resistant schizophrenia**. - It can be effective for positive and negative symptoms but does not offer the same **superiority** in refractory cases as clozapine.

Q: Which antipsychotic drug is known for its effectiveness in managing schizophrenia but requires monitoring due to its risk of metabolic side effects?

Quetiapine. ***Quetiapine*** - **Quetiapine** is a **second-generation antipsychotic** effective for schizophrenia, but it is well-known for its metabolic side effects. - These side effects include **weight gain**, **dyslipidemia**, and **hyperglycemia**, necessitating careful metabolic monitoring. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** primarily associated with **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**, rather than significant metabolic disturbances. - While effective for psychosis, its side effect profile is distinct from metabolic concerns. *Risperidone* - **Risperidone** is a **second-generation antipsychotic** that also carries a risk of metabolic side effects, specifically **weight gain** and **hyperprolactinemia**. - However, **quetiapine** generally has a more pronounced risk of the full spectrum of metabolic syndrome compared to risperidone. *Chlorpromazine* - **Chlorpromazine** is a **first-generation antipsychotic** notable for **sedation**, **hypotension**, and **anticholinergic side effects**. - While it can cause some weight gain, its metabolic risk is not as prominent as that of certain second-generation antipsychotics like quetiapine.

Q: A 25-year-old female with obsessive-compulsive disorder has not responded to 8 weeks of sertraline 50mg daily. What is the next step in pharmacotherapy?

Increase the dose of SSRIs. ***Increase the dose of SSRIs*** - For **OCD**, **SSRIs** often require **higher doses** (typically 2-3 times higher than for depression) and longer treatment durations to achieve a therapeutic effect. - **Sertraline 50mg is subtherapeutic** for OCD; the therapeutic range is **150-200mg daily** (up to 200mg maximum). - Since the current dose is inadequate despite appropriate duration (8 weeks), **dose optimization is the most appropriate next step** before considering other interventions. *Switch to a different class of antidepressant* - **SSRIs** are considered **first-line pharmacotherapy** for OCD, and switching to a different antidepressant class is typically reserved for cases where multiple SSRI trials at adequate doses and duration have failed. - This option is premature before optimizing the current SSRI dosage. *Start psychotherapy* - **Cognitive Behavioral Therapy (CBT)**, especially **Exposure and Response Prevention (ERP)**, is a highly effective treatment for OCD and is often recommended alongside medication. - While beneficial, the question specifically asks for the "next step in **pharmacotherapy**," implying a drug-related intervention. *Add an antipsychotic* - Augmentation with an **antipsychotic** (e.g., risperidone, aripiprazole) is usually considered when there has been a partial or non-response to **adequate trials of high-dose SSRIs** (typically after 2-3 SSRI trials at therapeutic doses). - This step is too aggressive given that the initial SSRI dose was not optimized.

Q: A patient diagnosed with bipolar disorder is on lithium therapy and presents with coarse tremors, polyuria, and confusion. What is the most appropriate next step?

Discontinue lithium therapy. ***Discontinue lithium therapy*** - The patient presents with **coarse tremors, polyuria, and confusion** - classical signs of **lithium toxicity**. - **Immediate discontinuation** of lithium is the priority to prevent progression to severe toxicity (seizures, renal failure, coma). - In symptomatic lithium toxicity, **stopping the drug takes precedence** over diagnostic confirmation. - **Serum lithium levels should be checked simultaneously**, but this should not delay stopping the medication. - Supportive care including **hydration and monitoring** should be initiated immediately. *Check serum lithium levels* - While checking serum levels is important for **confirming the diagnosis and guiding further management**, it should not delay discontinuation. - Levels help determine severity and need for **hemodialysis** (typically if >4 mEq/L with severe symptoms). - This is an essential step but is done **concurrently with**, not **instead of**, stopping lithium. *Increase the dose of lithium therapy* - This would dangerously **exacerbate lithium toxicity** and could lead to life-threatening complications. - Completely contraindicated in a patient showing clear signs of toxicity. *Switch to valproate therapy* - While valproate is an alternative mood stabilizer, switching therapy is **not the immediate priority** in acute toxicity. - The urgent concern is **managing the current toxicity**, not replacing the mood stabilizer. - Alternative treatments can be considered after the patient stabilizes.

Q: A 30-year-old male with schizophrenia who has been stable on antipsychotic medication now presents with muscle stiffness, fever, and confusion. What is the most likely diagnosis?

Neuroleptic malignant syndrome. ***Neuroleptic malignant syndrome*** - The combination of **muscle rigidity**, **fever (hyperthermia)**, and **altered mental status (confusion)** in a patient on antipsychotic medication is a classic presentation of **neuroleptic malignant syndrome (NMS)**. - NMS is a **life-threatening idiosyncratic reaction** to antipsychotic drugs, characterized by **autonomic dysfunction** (e.g., labile blood pressure, tachycardia) and often elevated **creatine kinase (CK)** levels. *Serotonin syndrome* - This syndrome typically results from an excess of **serotonergic activity**, often due to drug interactions (e.g., SSRIs with MAOIs) or overdose. - While it can present with fever and altered mental status, it is more commonly associated with **hyperreflexia**, **clonus**, and myoclonus, rather than severe rigidity, and is not usually triggered by antipsychotics alone. *Malignant hyperthermia (triggered by anesthetics)* - **Malignant hyperthermia** is a genetic disorder primarily triggered by **volatile anesthetic agents** (e.g., halothane, succinylcholine) during surgery. - Its clinical presentation, though similar with hyperthermia and muscle rigidity, is specific to perioperative exposure to these particular drugs, which is not indicated in this case. *Acute dystonia* - **Acute dystonia** is an extrapyramidal symptom (EPS) characterized by **sustained involuntary muscle contractions**, leading to abnormal posturing or repetitive movements. - While it can occur shortly after initiating or increasing antipsychotic medication, it typically presents as specific muscle spasms (e.g., torticollis, oculogyric crisis) and does **not involve fever or significant altered mental status**.

Q: A 30-year-old man with schizophrenia develops persistent involuntary movements of the face and tongue after long-term use of antipsychotics. What is the diagnosis?

Tardive dyskinesia. ***Tardive dyskinesia*** - This condition is characterized by **involuntary movements of the face and tongue**, often appearing after **long-term use of antipsychotic medications**. - Its **persistent nature** differentiates it from other extrapyramidal symptoms, as it often continues even after discontinuing the offending drug. *Parkinsonism* - This typically presents with a **triad of symptoms**: **bradykinesia**, **rigidity**, and **tremor**, which are not the primary features described here. - While it can be drug-induced, it typically manifests differently than the described **oro-facial dyskinesia**. *Akathisia* - This involves a feeling of **inner restlessness** and a compelling need to **move**, often manifesting as pacing or rocking. - It does not involve the specific involuntary movements of the face and tongue observed in the patient. *Acute dystonia* - This is characterized by **sudden, sustained muscle contractions** leading to **abnormal postures or movements**, often occurring soon after starting or increasing an antipsychotic dose. - Unlike tardive dyskinesia, these dystonic reactions are typically **acute** and resolve with specific treatments like anticholinergics.

Question 1

Drug of choice in Tourette syndrome is -

Accepted Answer

Haloperidol

Answer

Valproate

Answer

Carbamazepine

Answer

Methadone

Question 2

Maximum increase in prolactin level is caused by:-

Accepted Answer

Risperidone (Potent D2 receptor antagonist)

Answer

Olanzapine (Primarily blocks 5HT2 receptors)

Answer

Aripiprazole (D2 partial agonist)

Answer

Clozapine (Primarily blocks 5HT2 receptors)

Question 3

A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?

Accepted Answer

Akathisia

Answer

Rabbit syndrome

Answer

Tardive dyskinesia

Answer

Acute Dystonia

Question 4

A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?

Accepted Answer

Stop clozapine

Answer

Add antipyretic

Answer

Continue clozapine

Answer

Reduce dose

Question 5

Which antipsychotic is preferred for treatment-resistant schizophrenia?

Accepted Answer

Clozapine

Answer

Quetiapine

Answer

Olanzapine

Answer

Risperidone

Question 6

Which antipsychotic drug is known for its effectiveness in managing schizophrenia but requires monitoring due to its risk of metabolic side effects?

Accepted Answer

Quetiapine

Answer

Haloperidol

Answer

Risperidone

Answer

Chlorpromazine

Question 7

A 25-year-old female with obsessive-compulsive disorder has not responded to 8 weeks of sertraline 50mg daily. What is the next step in pharmacotherapy?

Accepted Answer

Increase the dose of SSRIs

Answer

Switch to a different class of antidepressant

Answer

Start psychotherapy

Answer

Add an antipsychotic

Question 8

A patient diagnosed with bipolar disorder is on lithium therapy and presents with coarse tremors, polyuria, and confusion. What is the most appropriate next step?

Accepted Answer

Discontinue lithium therapy

Answer

Check serum lithium levels

Answer

Increase the dose of lithium therapy

Answer

Switch to valproate therapy

Question 9

A 30-year-old male with schizophrenia who has been stable on antipsychotic medication now presents with muscle stiffness, fever, and confusion. What is the most likely diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Malignant hyperthermia (triggered by anesthetics)

Answer

Serotonin syndrome

Answer

Acute dystonia

Question 10

A 30-year-old man with schizophrenia develops persistent involuntary movements of the face and tongue after long-term use of antipsychotics. What is the diagnosis?

Accepted Answer

Tardive dyskinesia

Answer

Parkinsonism

Answer

Akathisia

Answer

Acute dystonia

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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