Psychopharmacology — MCQs

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 311: A patient with schizophrenia on risperidone develops akathisia. What is the next step?

A. Switch to clozapine
B. Add propranolol (Correct Answer)
C. Add benztropine
D. Increase dose

Explanation: ***Add propranolol*** - **Propranolol**, a beta-blocker, is frequently used to treat **akathisia** associated with antipsychotic medications, offering significant symptom relief. - It helps to reduce the subjective feeling of restlessness and the objective motor symptoms, often being the **first-line treatment** for drug-induced akathisia. *Inc. dose* - Increasing the dose of **risperidone** would likely **worsen** the akathisia, as it is a dose-dependent adverse effect of antipsychotics. - Higher doses increase dopamine antagonism, exacerbating extrapyramidal symptoms like akathisia. *Switch to clozapine* - While **clozapine** has a lower risk of extrapyramidal symptoms, switching to it is a significant step due to its potential for **severe side effects** like **agranulocytosis** and requires careful monitoring. - It is generally reserved for **treatment-resistant schizophrenia** or when other antipsychotics are intolerable. *Add benztropine* - **Benztropine** (an anticholinergic) is primarily used for other extrapyramidal symptoms like **dystonia** and **parkinsonism**, but it is generally **less effective** for akathisia. - Anticholinergics can also have cognitive side effects that might be undesirable.

Question 312: A 35-year-old man with schizophrenia is well-controlled on risperidone but develops tremors, rigidity, and bradykinesia. What is the most appropriate management?

A. Discontinue risperidone and start clozapine
B. Add benztropine (Correct Answer)
C. Switch to a higher dose of risperidone
D. Add a mood stabilizer

Explanation: ***Add benztropine*** - The patient is experiencing **extrapyramidal symptoms (EPS)** (tremors, rigidity, and bradykinesia) as a side effect of risperidone - Adding an anticholinergic agent like **benztropine** is the most appropriate management to counteract these dopamine-blocking effects without discontinuing the effective antipsychotic - This allows continuation of effective schizophrenia treatment while managing the side effects *Discontinue risperidone and start clozapine* - Discontinuing an effective antipsychotic for well-controlled schizophrenia is not ideal, as it risks a **relapse of psychotic symptoms** - **Clozapine** is typically reserved for **treatment-resistant schizophrenia** due to its potential for serious side effects like agranulocytosis - This would be overly aggressive management for a side effect that can be managed with adjunctive therapy *Switch to a higher dose of risperidone* - Increasing the dose of risperidone would likely **exacerbate the extrapyramidal symptoms**, as they are dose-dependent side effects of dopamine D2 receptor blockade - This would worsen the patient's motor symptoms and may lead to more severe parkinsonism *Add a mood stabilizer* - Mood stabilizers (e.g., lithium, valproate) are used to treat **bipolar disorder** or to augment antipsychotics in certain cases - They do not address or alleviate **extrapyramidal symptoms** - This intervention would be inappropriate for managing drug-induced movement disorders

Question 313: A 50-year-old patient with schizophrenia is prescribed clozapine after the failure of other antipsychotics. What is the most important side effect to monitor?

A. Weight gain
B. Agranulocytosis (Correct Answer)
C. Sedation
D. Hyperglycemia

Explanation: ***Agranulocytosis*** - **Agranulocytosis** is a severe and potentially fatal side effect of **clozapine**, requiring strict monitoring of **white blood cell count (WBC)** and **absolute neutrophil count (ANC)**. - This adverse effect is specific to clozapine and is the primary reason for mandated regular blood tests when prescribing the medication. *Weight gain* - While **weight gain** is a common side effect of clozapine and other atypical antipsychotics, it is generally less immediately life-threatening than agranulocytosis. - It contributes to metabolic syndrome but is managed by lifestyle interventions and monitoring, not weekly blood tests. *Sedation* - **Sedation** is a common initial side effect of clozapine, often used clinically for patients with agitation or insomnia. - Although it can be bothersome, it typically improves over time and is not life-threatening. *Hyperglycemia* - **Hyperglycemia** is a known metabolic side effect of clozapine, increasing the risk of **diabetes mellitus**. - While important to monitor, it does not pose the immediate, acute life threat that **agranulocytosis** does, which can develop rapidly.

Question 314: A 55-year-old male with schizophrenia on clozapine presents with fever, sore throat, and fatigue. Laboratory results show a WBC count of 2.0 × 10³/μL. Analyze and choose the appropriate management.

A. Continue clozapine, add antibiotics
B. Discontinue clozapine, admit for neutropenia (Correct Answer)
C. Lower clozapine dose, add G-CSF
D. Switch to risperidone, outpatient f/u

Explanation: ***Discontinue clozapine, admit for neutropenia*** - A **WBC count of 2.0** combined with symptoms like **fever and sore throat** in a patient on clozapine strongly indicates **neutropenia or agranulocytosis**. - **Clozapine** can cause severe neutropenia, which requires immediate discontinuation of the drug and admission for monitoring and management to prevent life-threatening infections. *Continue clozapine, add antibiotics* - Continuing clozapine in the face of **severe neutropenia** would likely worsen the condition and expose the patient to a higher risk of **fatal infections**. - While antibiotics might be indicated for the infection, they do not address the underlying **drug-induced neutropenia**. *Lower clozapine dose, add G-CSF* - **Lowering the dose** is insufficient when there is evidence of **severe neutropenia**; complete discontinuation is necessary to allow bone marrow recovery. - **G-CSF (granulocyte colony-stimulating factor)** can be considered, but discontinuing clozapine is the crucial first step for safety. *Switch to risperidone, outpatient f/u* - Switching to another antipsychotic like **risperidone** is appropriate in the long term, but the immediate priority is managing the **neutropenia**, which requires inpatient care. - Outpatient follow-up is inadequate for a patient with **neutropenia** and potential agranulocytosis, who needs close monitoring for infection.

Question 315: A 28-year-old male with a history of schizophrenia is experiencing symptoms of akathisia. Which of the following is an appropriate treatment for akathisia?

A. Promethazine
B. Trihexyphenidyl
C. Haloperidol
D. Diazepam (Correct Answer)

Explanation: ***Diazepam*** - **Benzodiazepines** like diazepam are effective in treating akathisia through their **GABAergic** properties, which help reduce motor restlessness and subjective distress. - They are particularly useful as **adjunctive therapy** or when beta-blockers and anticholinergics are contraindicated. - Rapid onset of action provides symptomatic relief by modulating neural activity and reducing anxiety associated with akathisia. *Trihexyphenidyl* - **Anticholinergics** like trihexyphenidyl are actually used for akathisia and other extrapyramidal symptoms, but their efficacy is **variable**. - While they work well for **parkinsonism and acute dystonia**, their response in akathisia is less predictable compared to **beta-blockers (propranolol)**. - In this scenario, benzodiazepines may be preferred for their dual action on motor symptoms and associated anxiety. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** and a common **cause** of drug-induced akathisia due to D2 receptor blockade. - Increasing antipsychotic dose would **worsen** akathisia rather than alleviate it. - Management typically involves dose reduction or switching to a lower-potency or atypical antipsychotic. *Promethazine* - **Promethazine** is an **antihistamine** with sedative and antiemetic properties, not a primary treatment for akathisia. - While it has mild anticholinergic effects, it lacks the specific pharmacological profile needed to effectively manage the motor restlessness of akathisia. - Its sedative properties might provide minimal symptomatic relief but do not address the underlying pathophysiology.

Question 316: A 45-year-old male with a history of schizophrenia who is on clozapine presents with fever, sore throat, and fatigue. What is the most appropriate next step?

A. Continue clozapine and monitor symptoms
B. Discontinue clozapine and start antibiotics
C. Discontinue clozapine and check white blood cell count (Correct Answer)
D. Increase clozapine dose

Explanation: ***Discontinue clozapine and check white blood cell count*** - The symptoms of **fever, sore throat, and fatigue** in a patient on clozapine are highly suspicious for **agranulocytosis**, a rare but life-threatening side effect. - **Immediate discontinuation of clozapine** and urgent measurement of **white blood cell count (WBC) and absolute neutrophil count (ANC)** are critical to diagnose and manage this condition. *Continue clozapine and monitor symptoms* - Continuing clozapine in the presence of these symptoms could lead to rapid progression of **agranulocytosis** and severe, potentially fatal, infections. - Monitoring symptoms without laboratory confirmation of WBC and ANC is insufficient and **dangerous**. *Discontinue clozapine and start antibiotics* - While infection is a concern given the symptoms, blindly starting antibiotics without confirming severe neutropenia through a **WBC count** is not the primary immediate step. - The priority is to identify the underlying cause (agranulocytosis due to clozapine) and discontinue the causative agent, then manage complications like infection. *Increase clozapine dose* - Increasing the clozapine dose would exacerbate the potential **agranulocytosis** and significantly worsen the patient's condition. - This action is **contraindicated** given the presenting symptoms.

Question 317: A 50-year-old male with schizophrenia has been stable on olanzapine for symptom control but reports severe weight gain and hyperglycemia. Physical examination reveals a BMI of 34, and laboratory results show an HbA1c of 7.2%. What is the most appropriate next step in management?

A. Switch to aripiprazole, monitor weight (Correct Answer)
B. Continue olanzapine, add metformin
C. Switch to clozapine, monitor glucose levels
D. Switch to risperidone, monitor glucose levels

Explanation: ***Switch to aripiprazole, monitor weight*** - **Aripiprazole** is a **second-generation antipsychotic** known for a more favorable metabolic profile compared to olanzapine. It is less likely to cause significant weight gain, hyperglycemia, or dyslipidemia. - Given the patient's severe **weight gain** and **hyperglycemia** (HbA1c of 7.2%), switching to an antipsychotic with a lower metabolic risk is a priority to manage these side effects. *Switch to clozapine, monitor glucose levels* - **Clozapine** is associated with a **high risk of metabolic side effects**, including significant **weight gain**, **hyperglycemia**, and **dyslipidemia**, similar to or even greater than olanzapine. - While effective for treatment-resistant schizophrenia, switching to clozapine would likely exacerbate the patient's existing metabolic issues. *Continue olanzapine, add metformin* - Continuing **olanzapine** means the patient would remain on a medication known for significant metabolic side effects, which are already severe in this case. - While **metformin** can help manage hyperglycemia and some weight gain, it addresses the symptom without resolving the underlying cause of the metabolic disturbance attributed to olanzapine. *Switch to risperidone, monitor glucose levels* - **Risperidone** has an intermediate risk for **metabolic side effects**, including **weight gain** and **hyperglycemia**, making it an unfavorable choice given the patient's current severe metabolic issues. - Although it might be better than olanzapine for some metabolic parameters, it still carries a significant risk compared to options with much lower metabolic impact.

Question 318: A patient with a history of major depressive disorder is treated with an SSRI and presents with restlessness, hyperreflexia, and myoclonus. What is the likely diagnosis?

A. Serotonin syndrome (Correct Answer)
B. Neuroleptic malignant syndrome
C. Anticholinergic toxicity
D. Alcohol withdrawal

Explanation: ***Serotonin syndrome*** - The constellation of **restlessness**, **hyperreflexia**, and **myoclonus** in a patient taking an **SSRI** is highly characteristic of **serotonin syndrome**, reflecting excessive serotonin activity. - This syndrome often involves a triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. *Neuroleptic malignant syndrome* - Characterized by **severe muscle rigidity**, **fever**, **autonomic dysfunction**, and altered mental status, often associated with antipsychotic use. - Though it involves autonomic and neuromuscular symptoms, the presenting symptoms of hyperreflexia and myoclonus are more indicative of serotonin syndrome rather than the rigidity seen in NMS. *Anticholinergic toxicity* - Presents with symptoms like **mydriasis**, **dry mouth**, **tachycardia**, **urinary retention**, and altered mental status due to blocking acetylcholine receptors. - The patient's symptoms of hyperreflexia and myoclonus are not typical for anticholinergic toxicity. *Alcohol withdrawal* - Symptoms range from tremors and anxiety to seizures and delirium tremens, occurring after reducing or stopping chronic alcohol intake. - While it can involve agitation, the specific combination of restlessness, hyperreflexia, and myoclonus in a patient on an SSRI points away from alcohol withdrawal as the primary diagnosis.

Question 319: A 28-year-old male with schizophrenia is prescribed clozapine. What is the most important laboratory test to monitor regularly?

A. Liver function tests
B. White blood cell count (Correct Answer)
C. Renal function tests
D. Lipid profile

Explanation: ***White blood cell count*** - **Clozapine** carries a significant risk of **agranulocytosis**, a severe reduction in **white blood cell count (neutrophils)**, making regular monitoring crucial. - Due to this life-threatening adverse effect, a **baseline WBC count** and **absolute neutrophil count (ANC)** must be established before treatment, and then monitored **weekly for the first six months**, then bi-weekly, and eventually monthly, according to established protocols. *Liver function tests* - While liver enzyme elevations can occur with clozapine, they are generally less frequent and less severe than the risk of agranulocytosis. - Routine **liver function tests (LFTs)** are typically monitored, but not with the same urgency or strictness as WBC counts. *Renal function tests* - **Clozapine** is primarily metabolized by the liver, and significant renal impairment is not a primary concern for closely monitoring during treatment initiation. - While general renal health is important, **renal function tests (RFTs)** are not part of the mandatory, life-saving monitoring protocol for clozapine. *Lipid profile* - **Clozapine** can cause metabolic side effects, including **weight gain**, **dyslipidemia**, and **glucose dysregulation**, which necessitate monitoring of the **lipid profile** and **blood glucose levels**. - However, these metabolic effects, while important for long-term health, are not as acutely life-threatening as agranulocytosis, making WBC count the most immediate and critical laboratory test.

Question 320: A 60-year-old woman with schizophrenia presents with tardive dyskinesia. What is the most appropriate management?

A. Discontinue antipsychotic medication
B. Switch to clozapine (Correct Answer)
C. Add a benzodiazepine
D. Increase antipsychotic dose

Explanation: ***Switch to clozapine*** - **Clozapine** is an atypical antipsychotic with the **lowest propensity to cause extrapyramidal symptoms**, including tardive dyskinesia, making it an appropriate choice for patients who develop TD. - While **dose reduction or discontinuation** of the offending agent is the first-line approach when clinically feasible, switching to **clozapine or quetiapine** (antipsychotics with minimal D2 blockade) is recommended when continued antipsychotic therapy is necessary. - Clozapine is particularly useful in this case as it addresses both the **treatment-resistant nature** of schizophrenia that may have led to higher-potency antipsychotic use and the **TD complication**. - Note: Clozapine requires **regular blood monitoring** due to agranulocytosis risk. *Discontinue antipsychotic medication* - While dose reduction or discontinuation is considered **first-line management** for TD when feasible, abruptly stopping antipsychotics in schizophrenia carries **high risk of relapse**. - Complete discontinuation without an alternative is generally not recommended unless the patient is in prolonged remission. - In some cases, TD may persist even after discontinuation (persistent TD) or transiently worsen (withdrawal dyskinesia). *Add a benzodiazepine* - **Benzodiazepines** are not effective for **tardive dyskinesia** management, though they may help with acute dystonia or akathisia. - They do not address the underlying **dopaminergic-cholinergic imbalance** thought to contribute to TD. - Long-term benzodiazepine use carries risks of **tolerance, dependence, and cognitive impairment**. *Increase antipsychotic dose* - Increasing the dose of typical or high-potency antipsychotics will likely **worsen tardive dyskinesia** as TD is often a dose-dependent and duration-dependent side effect. - This approach may temporarily mask TD symptoms through increased dopamine blockade but leads to progression of the underlying condition. - Higher doses increase risk of other **extrapyramidal symptoms** and metabolic side effects.

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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