Psychopharmacology Practice Questions

Q: Psychotic patient on antipsychotic drugs develops torticollis within 4 days of therapy. What is the treatment?

Central anticholinergic drugs. ***Central anticholinergic drugs*** - The patient is experiencing an **acute dystonic reaction**, a common extrapyramidal side effect of antipsychotics, such as **torticollis**, which requires immediate treatment with central anticholinergic agents. - Medications like **benztropine** or **diphenhydramine** are indicated to quickly reverse these symptoms by blocking acetylcholine activity in the basal ganglia. *Peripheral anticholinergic drugs* - These agents primarily act outside the central nervous system and are not effective in treating centrally mediated extrapyramidal symptoms like **acute dystonia**. - Their main use is for conditions like **bradycardia** or to reduce **gastrointestinal motility**. *Beta blockers* - **Beta-blockers** are primarily used to treat **akathisia** (restlessness) associated with antipsychotic medication, not acute dystonic reactions like torticollis. - They work by reducing the somatic manifestations of anxiety and motor restlessness. *Dantrolene* - **Dantrolene** is a **direct skeletal muscle relaxant** primarily used in the treatment of **neuroleptic malignant syndrome** or **malignant hyperthermia**. - It is not the first-line treatment for acute dystonic reactions as it does not address the underlying neurochemical imbalance.

Q: Weight gain is seen with all of the following antipsychotic medications except?

Molindone. ***Molindone*** - **Molindone** is an antipsychotic known for its **low risk of weight gain** and has even been associated with weight loss in some patients. - Its mechanism of action, involving **dopamine D2 antagonism** without significant antagonism of histamine H1 or serotonin 5-HT2C receptors, contributes to its favorable metabolic profile. *Quetiapine* - **Quetiapine** is a common second-generation antipsychotic associated with a **moderate to high risk of weight gain**. - Its affinity for **histamine H1** and **serotonin 5-HT2C receptors** is thought to contribute to its weight-increasing effects. *Risperidone* - **Risperidone** carries a **moderate risk of weight gain**, especially at higher doses, making it a less desirable option if metabolic side effects are a major concern. - This effect is linked to its antagonism of **serotonin 5-HT2C receptors** and, to a lesser extent, **histamine H1 receptors**. *Clozapine* - **Clozapine** is associated with the **highest risk of weight gain** among all antipsychotics, often leading to significant metabolic disturbances. - Its strong antagonism of multiple receptors, including **histamine H1**, **serotonin 5-HT2C**, and **alpha1-adrenergic receptors**, plays a role in its profound metabolic side effects.

Q: A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

Discontinue Imipramine and start Valproate. ***Discontinue Imipramine and start Valproate*** - The patient's symptoms (increased excitement, colorful clothes, increased talking) after starting an antidepressant like **Imipramine** suggest a **manic switch**, indicating undiagnosed **bipolar disorder**. - **Imipramine** should be discontinued as it can exacerbate mania, and a mood stabilizer like **Valproate** is necessary to treat the manic episode. *Continue Imipramine alone* - Continuing Imipramine would likely worsen the manic symptoms, leading to increased agitation and potential harm. - Antidepressants can trigger or worsen manic episodes in individuals with underlying bipolar disorder. *Manage with Valproate alone* - While Valproate is an appropriate treatment for acute mania, simply managing with Valproate alone without discontinuing the offending antidepressant would be suboptimal. - The continued presence of Imipramine would counteract the mood-stabilizing effects of Valproate. *Antipsychotic with Imipramine continued* - Adding an antipsychotic might manage some acute manic symptoms, but continuing Imipramine would maintain the driving force behind the manic switch. - The primary action should be to remove the causative agent (Imipramine) and replace it with a mood stabilizer.

Q: Which of the following antipsychotics is known to increase prolactin secretion?

Risperidone. ***Risperidone*** - **Risperidone** has a high affinity for **D2 dopamine receptors** in the tuberoinfundibular pathway, which leads to significant **prolactin elevation**. - **Dopamine** typically inhibits prolactin release; blocking D2 receptors disinhibits this process, causing increased secretion. *Olanzapine* - **Olanzapine** is a **second-generation antipsychotic** that generally causes **less prolactin elevation** compared to risperidone. - Its D2 receptor antagonism is transient or weaker in the tuberoinfundibular pathway, allowing less significant impact on prolactin. *Ziprasidone* - **Ziprasidone** is known for its **low risk of prolactin elevation** compared to other antipsychotics. - It has a unique receptor binding profile that includes 5-HT1A agonism and moderate D2 antagonism, which mitigates prolactin increase. *Clozapine* - **Clozapine** is associated with a **very low risk of prolactin elevation** and is often used in patients who experience prolactin-related side effects with other antipsychotics. - Its **weak and transient D2 receptor blockade** in the tuberoinfundibular pathway explains its minimal impact on prolactin levels.

Q: What is a common medical treatment for sexual paraphilias?

Anti-androgens. ***Anti-androgens*** - **Anti-androgens are the established first-line pharmacological treatment** for paraphilias when medication is indicated. - Medications like **medroxyprogesterone acetate (MPA)** and **cyproterone acetate (CPA)** reduce testosterone levels, thereby reducing sexual drive and paraphilic urges. - They are particularly effective in **reducing the frequency and intensity of deviant sexual fantasies and behaviors**. - Used in combination with psychotherapy for comprehensive management of paraphilic disorders. *SSRIs* - May have a role as **adjunctive therapy** for compulsive sexual behaviors or when comorbid OCD, depression, or anxiety is present. - They can help reduce obsessive thoughts but are **not considered the primary treatment** for paraphilias themselves. - More useful for comorbid mood and anxiety symptoms than for core paraphilic symptoms. *Benzodiazepines* - Primarily used for **anxiety and insomnia** due to their sedative effects. - They do not address sexual urges or paraphilic behaviors and have no role in paraphilia treatment. *Opioids* - Prescribed for **pain management** and associated with risk of dependence. - They have **no established role** in the treatment of sexual paraphilias.

Q: Most common complication of modified ECT

Amnesia. ***Amnesia*** - **Memory impairment**, particularly affecting **new learning (anterograde)** and **recall of past events (retrograde)**, is the most common and bothersome complication of modified ECT. - While typically transient, some patients may experience **persistent memory difficulties**, especially with autobiographical memories. *Intracerebellar hemorrhage* - **Intracerebellar hemorrhage** is an extremely rare and severe complication of ECT, not a common one. - Such an event would typically be linked to **pre-existing vascular abnormalities** or uncontrolled hypertension during the procedure. *Spinal fracture* - **Spinal fractures** were a significant concern in **unmodified ECT** due to unattenuated muscle contractions. - However, the use of **muscle relaxants** and **anesthesia** in modified ECT has significantly reduced the risk of musculoskeletal injuries, making it uncommon. *Muscle pain* - **Muscle aches** and soreness can occur after ECT due to **succinylcholine-induced fasciculations** and general muscle contraction, particularly in the neck and back. - While common, it is usually mild and easily managed with analgesics, and not considered the "most common complication" compared to cognitive effects.

Q: What is the primary cause of death in Neuroleptic Malignant Syndrome?

None of the options. ***None of the options*** - The **primary cause of death** in Neuroleptic Malignant Syndrome is **renal failure secondary to rhabdomyolysis**, which is not listed among the options. - **Severe muscle rigidity** in NMS leads to massive muscle breakdown (rhabdomyolysis) → release of myoglobin → myoglobinuria → acute tubular necrosis → acute renal failure. - Mortality in NMS ranges from **10-20%**, with renal complications being the leading cause of death. - Other significant causes include **cardiovascular collapse, arrhythmias, DIC**, and **respiratory complications**, but renal failure remains the most common fatal outcome. *Respiratory failure* - While respiratory complications occur in NMS (aspiration pneumonia, respiratory muscle rigidity), this is **not the primary cause of death**. - Respiratory failure can contribute to mortality but is typically **secondary** to other complications or occurs less frequently than renal failure as the direct cause. - It is a serious complication but not the most common fatal outcome. *Liver failure* - **Hepatotoxicity** is not a characteristic feature or primary cause of death in NMS. - Though elevated liver enzymes may occur, liver failure is **not a typical cause of mortality** in NMS. - The pathophysiology centers on **dopamine blockade**, autonomic instability, and muscle breakdown, not hepatic dysfunction. *Drug toxicity* - NMS is an **idiosyncratic reaction** to dopamine antagonists (typical and atypical antipsychotics), not a dose-dependent toxic effect. - Death results from the **physiological complications of the syndrome** (renal failure, cardiovascular collapse, hyperthermia), not from direct drug toxicity or overdose. - The mechanism is related to dopamine receptor blockade and subsequent dysregulation, not toxic poisoning.

Q: Which first-line conventional drug is commonly used in the treatment of delirium?

Haloperidol. ***Haloperidol*** - **Haloperidol** is a first-generation antipsychotic widely considered the **first-line conventional drug** for managing **agitation and psychotic symptoms** in delirium (particularly in the context of this 2015 exam). - Its efficacy in controlling these symptoms promptly, coupled with its availability in oral, intramuscular, and intravenous forms, makes it a preferred choice, especially in acute settings. - **Note:** Current evidence (post-2018) emphasizes non-pharmacological interventions first, with antipsychotics reserved for severe agitation when non-pharmacological measures fail. *Lithium carbonate* - **Lithium carbonate** is primarily used as a **mood stabilizer** for bipolar disorder, not for acute management of delirium. - It has a narrow therapeutic window and requires **careful monitoring of blood levels** to prevent toxicity, making it unsuitable for acute delirium management. *Opioids* - **Opioids** are mainly used for **pain management** and can actually **exacerbate delirium** due to their sedative and central nervous system depressant effects. - They are not indicated for treating the core symptoms of delirium, such as disorientation, fluctuating consciousness, or psychotic features. *Selective Serotonin Reuptake Inhibitors (SSRIs)* - **SSRIs** are primarily used for the treatment of **depression and anxiety disorders**, and their therapeutic effects take several weeks to manifest. - They are not effective for the immediate management of acute delirium and may even **worsen confusion or agitation** in some delirious patients.

Q: Which of the following is NOT a known side effect of lithium?

Hyperthyroidism. ***Hyperthyroidism*** - Lithium commonly causes **hypothyroidism** by interfering with thyroid hormone synthesis and release, not hyperthyroidism. - Patients on lithium often require **thyroid function monitoring** and may need thyroid hormone supplementation. *Polyuria* - **Nephrogenic diabetes insipidus**, characterized by polyuria and polydipsia, is a common side effect of lithium. - Lithium interferes with the kidney's ability to respond to **vasopressin (ADH)**, leading to increased water excretion. *Nephropathy* - Chronic lithium use can lead to **interstitial nephropathy**, characterized by a reduction in glomerular filtration rate. - Long-term monitoring of **renal function** is crucial for patients on lithium therapy. *Ebstein's anomaly* - While not a general "side effect" in adults, **Ebstein's anomaly** is a congenital heart defect associated with lithium exposure during the first trimester of pregnancy. - It involves displacement of the **tricuspid valve leaflets** into the right ventricle.

Q: Indications for ECT are all except?

Severe manic attack. ***Severe manic attack*** - While **severe mania IS a recognized indication for ECT**, it is generally considered **less commonly used as first-line therapy** compared to the other options listed. - In clinical practice, **acute severe mania** is typically managed initially with **antipsychotics and mood stabilizers** (lithium, valproate), with ECT reserved for **treatment-resistant cases** or when rapid response is critical. - ECT is highly effective for severe mania, particularly with **psychotic features** or **medication intolerance**, but is not the **most typical first-choice indication** compared to severe depression or catatonia. - This question reflects the **relative clinical priority** of ECT indications rather than absolute contraindication. *Severe depression with suicidal risk* - This is the **most common and well-established indication for ECT**. - ECT provides **rapid antidepressant effect** (often within 1-2 weeks) and is particularly indicated when there is **imminent suicide risk**, **psychotic depression**, or **treatment-resistant depression**. - Response rates exceed 70-90% in severe depression, making it a primary indication. *Catatonic schizophrenia* - **Catatonia is one of the strongest indications for ECT**, regardless of underlying etiology (schizophrenia, mood disorders, or medical conditions). - ECT rapidly resolves **catatonic symptoms** including mutism, stupor, posturing, and waxy flexibility. - Often considered **first-line treatment** for severe or malignant catatonia due to life-threatening complications. *Severe psychosis* - ECT is indicated for **severe psychotic disorders** that are **treatment-resistant** or when patients cannot tolerate antipsychotic medications. - Particularly effective in **acute psychotic agitation**, **treatment-refractory schizophrenia**, and psychosis with high risk of harm. - Provides rapid symptom control when pharmacotherapy has failed or is contraindicated.

Question 1

Psychotic patient on antipsychotic drugs develops torticollis within 4 days of therapy. What is the treatment?

Accepted Answer

Central anticholinergic drugs

Answer

Peripheral anticholinergic drugs

Answer

Beta blockers

Answer

Dantrolene

Question 2

Weight gain is seen with all of the following antipsychotic medications except?

Accepted Answer

Molindone

Answer

Risperidone

Answer

Clozapine

Answer

Quetiapine

Question 3

A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colorful clothes, and increased talking. What is the next step in management?

Accepted Answer

Discontinue Imipramine and start Valproate

Answer

Continue Imipramine alone

Answer

Manage with Valproate alone

Answer

Antipsychotic with Imipramine continued

Question 4

Which of the following antipsychotics is known to increase prolactin secretion?

Accepted Answer

Risperidone

Answer

Olanzapine

Answer

Ziprasidone

Answer

Clozapine

Question 5

What is a common medical treatment for sexual paraphilias?

Accepted Answer

Anti-androgens

Answer

Benzodiazepines

Answer

SSRIs

Answer

Opioids

Question 6

Most common complication of modified ECT

Accepted Answer

Amnesia

Answer

Intracerebellar hemorrhage

Answer

Spinal fracture

Answer

Muscle pain

Question 7

What is the primary cause of death in Neuroleptic Malignant Syndrome?

Accepted Answer

None of the options

Answer

Respiratory failure

Answer

Liver failure

Answer

Drug toxicity

Question 8

Which first-line conventional drug is commonly used in the treatment of delirium?

Accepted Answer

Haloperidol

Answer

Lithium carbonate

Answer

Opioids

Answer

Selective Serotonin Reuptake Inhibitors (SSRIs)

Question 9

Which of the following is NOT a known side effect of lithium?

Accepted Answer

Hyperthyroidism

Answer

Polyuria

Answer

Nephropathy

Answer

Ebstein's anomaly

Question 10

Indications for ECT are all except?

Accepted Answer

Severe manic attack

Answer

Severe psychosis

Answer

Catatonic schizophrenia

Answer

Severe depression with suicidal risk

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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