Psychopharmacology — MCQs

A 78-year-old woman is brought to the clinic by her daughter due to concerns about her mother's mood. The patient's husband of 48 years passed away six months ago after a lengthy illness due to metastatic colon cancer. Since then, she reports having a poor appetite, decreased interest in activities, and frequent thoughts about dying. She is started on nortriptyline to help improve her mood and functional status. Which of the following is a common side effect of nortriptyline?

Q347

A patient diagnosed with schizophrenia presented with an acute exacerbation of symptoms. After receiving an injection of haloperidol in the casualty, the patient suddenly developed deviation of the eyeballs and torticollis. What is the diagnosis?

Q348

A patient presents with symptoms of major depressive disorder. Which medication should be prescribed for treatment?

Q349

Which of the following antidepressants can also be used as an antipsychotic?

Q350

A patient with schizophrenia was started on haloperidol 5 mg. The next day, he presented with uprolling of the eyes. A complete neurological examination revealed no spasticity or any other abnormality, and visual acuity and ophthalmoscopic findings are normal. The most likely diagnosis is:

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 341: What is a contraindication for ECT?

A. Epilepsy
B. HIV
C. Cerebral aneurysm (Correct Answer)
D. Arrhythmia

Explanation: ***Cerebral aneurysm*** * A **cerebral aneurysm** is considered a **relative contraindication** for electroconvulsive therapy (ECT) due to the increased risk of rupture from the transient, but significant, rise in **blood pressure** and **intracranial pressure** during the procedure. * The cardiovascular stress induced by the seizure can worsen pre-existing vascular pathologies in the brain, making it a high-risk condition. *Arrhythmia* * While various cardiac conditions require careful monitoring during ECT, **arrhythmias** are generally not an absolute contraindication. * Patients can often undergo ECT with proper **cardiac monitoring** and **pharmacological management** to control the heart rhythm during the procedure. *Epilepsy* * **Epilepsy** is not a contraindication for ECT; in fact, ECT *artificially induces a seizure* to achieve therapeutic effects. * The presence of epilepsy primarily impacts the choice of **anticonvulsant medications** and the need for potentially higher seizure thresholds, but it does not preclude ECT. *HIV* * **HIV infection** itself is not a contraindication for ECT. * ECT can be safely administered to HIV-positive individuals, with consideration given to the patient's overall **physical health**, **medication interactions**, and any co-morbid opportunistic infections.

Question 342: ECT is contraindicated in -

A. Very ill patients
B. Raised ICT (Correct Answer)
C. Heart disease
D. Pregnancy

Explanation: ***Raised ICT (Correct Answer)*** - An increase in **intracranial pressure (ICP)** is the **only absolute contraindication** to ECT in modern practice. - ECT causes a **transient rise in ICP** during the seizure due to increased cerebral blood flow and cerebral metabolic rate. - In patients with pre-existing raised ICP (from brain tumors, subdural hematoma, or other space-occupying lesions), this additional increase can precipitate **brain herniation**, which is potentially fatal. - This makes raised ICP an **absolute contraindication** where the risks clearly outweigh any potential benefits. *Very ill patients* - ECT is **not contraindicated** in medically ill patients; in fact, it can be **life-saving** in severe psychiatric emergencies. - With careful medical evaluation, monitoring, and management, ECT can be safely administered to medically fragile individuals. - The rapid therapeutic response of ECT makes it particularly valuable when other treatments have failed or when quick intervention is critical. *Heart disease* - Cardiac conditions are **relative contraindications**, not absolute contraindications. - While conditions like recent MI, unstable angina, or severe arrhythmias require careful evaluation, ECT can be performed safely with appropriate cardiac optimization and monitoring. - Modern anesthetic techniques and cardiovascular management allow most patients with heart disease to receive ECT when clinically indicated. *Pregnancy* - **Pregnancy is NOT a contraindication** to ECT and is considered one of the safest treatment options for severe psychiatric illness during pregnancy. - ECT can be performed safely throughout all trimesters with appropriate obstetric consultation, fetal monitoring, and positioning adjustments. - It avoids the teratogenic risks associated with many psychotropic medications, making it a preferred option for severe depression or psychosis in pregnancy.

Question 343: Which of the following is an antipsychotic drug?

A. Flupenthixol (Correct Answer)
B. Rasagiline
C. Clobazam
D. Divalproex

Explanation: ***Flupenthixol*** - **Flupenthixol** is a **first-generation (typical) antipsychotic** used primarily for managing **schizophrenia** and other psychotic disorders. - It acts by blocking **dopamine D2 receptors** in the brain, reducing positive symptoms like **hallucinations and delusions**. *Rasagiline* - **Rasagiline** is a **monoamine oxidase-B (MAO-B) inhibitor** used in the treatment of **Parkinson's disease**. - It works by preventing the breakdown of **dopamine** in the brain, thereby improving motor symptoms, and is not an antipsychotic. *Clobazam* - **Clobazam** is a **benzodiazepine** primarily indicated for the treatment of **epilepsy** (specifically Lennox-Gastaut syndrome) and **anxiety**. - Its mechanism involves enhancing the effect of **GABA** in the brain, producing sedative and anticonvulsant effects, distinct from antipsychotic action. *Divalproex* - **Divalproex** is a combination product of **valproic acid** and **sodium valproate**, typically used as a **mood stabilizer** for **bipolar disorder**, an **antiepileptic**, and for **migraine prophylaxis**. - It modulates **GABAergic** transmission and sodium channels, but it is not classified as an antipsychotic drug.

Question 344: What serum lithium level indicates severe toxicity?

A. 0.6 mEq/L
B. 12 mEq/L
C. 2.6 mEq/L (Correct Answer)
D. <0.6 mEq/L

Explanation: ***2.6 mEq/L*** - A serum lithium level of **2.6 mEq/L** falls within the **severe toxicity range (>2.5 mEq/L)**, which is the clinically relevant threshold for severe lithium toxicity. - At this level, patients typically present with severe neurological symptoms such as **seizures, altered consciousness, coma, cardiac arrhythmias, and multiorgan dysfunction**. - This represents the **most appropriate answer** as it defines the clinical threshold where severe toxicity begins and requires aggressive management. *0.6 mEq/L* - This level falls within the **therapeutic range (0.6-1.2 mEq/L)** for lithium maintenance therapy. - This is **not indicative of any toxicity** and represents an appropriate treatment level. *12 mEq/L* - While this level technically represents severe toxicity, it is **incompatible with life** and represents a lethal concentration. - Such levels are **not clinically encountered** as patients would not survive to present with this level. - The question asks for the level that **indicates** severe toxicity, which refers to the **diagnostic threshold (>2.5 mEq/L)**, not extreme outlier values. *<0.6 mEq/L* - A lithium level **below 0.6 mEq/L** is **subtherapeutic** and unlikely to provide adequate mood stabilization. - This level is **not associated with toxicity** but rather with insufficient therapeutic effect.

Question 345: Which of the following statements is true regarding akathisia?

A. Anticholinergics may be used in specific cases of akathisia.
B. Akathisia is characterized by the presence of hallucinations.
C. Behavioral therapy is the primary treatment for akathisia.
D. Patients may exhibit restlessness and an urge to move. (Correct Answer)

Explanation: ***Patients may exhibit restlessness and an urge to move.*** - **Akathisia** is a common **extrapyramidal side effect** characterized by an inner feeling of **restlessness** and an urge to move, which may manifest as pacing, fidgeting, or an inability to sit still. - This condition can be highly distressing for patients, leading to significant discomfort and non-adherence to medication. *Anticholinergics may be used in specific cases of akathisia.* - **Anticholinergics** like benztropine are typically used to treat **pseudoparkinsonism** and **dystonia**, another type of extrapyramidal symptom, but are generally **not effective** for akathisia. - **Beta-blockers** (e.g., propranolol) and **benzodiazepines** (e.g., lorazepam) are more commonly used for akathisia, although the primary approach is typically to reduce or switch the causative medication. *Akathisia is characterized by the presence of hallucinations.* - **Hallucinations** are perceptual disturbances, often associated with psychotic disorders or delirium, and are **not a defining symptom of akathisia**. - Akathisia is primarily a **motor and subjective sensory phenomenon**, distinct from psychotic symptoms. *Behavioral therapy is the primary treatment for akathisia.* - While supportive measures and **behavioral interventions** can help manage the distress, they are **not the primary treatment** for akathisia, which is generally pharmacological. - The most effective approach involves **reducing the dose** of the offending antipsychotic medication or **switching to another antipsychotic** with a lower propensity for causing akathisia.

Question 346: A 78-year-old woman is brought to the clinic by her daughter due to concerns about her mother's mood. The patient's husband of 48 years passed away six months ago after a lengthy illness due to metastatic colon cancer. Since then, she reports having a poor appetite, decreased interest in activities, and frequent thoughts about dying. She is started on nortriptyline to help improve her mood and functional status. Which of the following is a common side effect of nortriptyline?

A. weight loss
B. impaired cardiac contractility
C. heart block
D. anticholinergic side effects (Correct Answer)

Explanation: ***Anticholinergic side effects*** - **Nortriptyline** is a **tricyclic antidepressant (TCA)** known for its significant **antimuscarinic** activity, leading to anticholinergic effects. - Common anticholinergic side effects include **dry mouth, blurred vision, constipation, urinary retention**, and **tachycardia**. *Impaired cardiac contractility* - While TCAs can have **cardiac effects** (e.g., QT prolongation, arrhythmias), **impaired cardiac contractility** is not a common or typical direct side effect at therapeutic doses. - Other drug classes, such as certain **beta-blockers** or **calcium channel blockers**, are more commonly associated with this effect. *Weight loss* - **Weight gain** is a more common side effect associated with many antidepressants, including some TCAs. - While some individuals may experience initial appetite changes, **sustained weight loss** is not a characteristic side effect of **nortriptyline**. *Heart block* - TCAs can cause **conduction abnormalities** like **prolonged QRS duration** and **QT interval prolongation**, especially in overdose or in patients with pre-existing cardiac conditions. - However, direct **heart block** (e.g., AV block) is a less common side effect, usually associated with higher doses or specific patient vulnerabilities.

Question 347: A patient diagnosed with schizophrenia presented with an acute exacerbation of symptoms. After receiving an injection of haloperidol in the casualty, the patient suddenly developed deviation of the eyeballs and torticollis. What is the diagnosis?

A. Akathisia
B. Acute dystonia (Correct Answer)
C. Malignant hyperthermia
D. Drug induced parkinsonism

Explanation: ***Acute dystonia*** * **Acute dystonia** is a common **extrapyramidal side effect** of high-potency antipsychotics like **haloperidol**, characterized by sudden, involuntary muscle contractions occurring within **minutes to hours** of drug administration. * **Deviation of the eyeballs (oculogyric crisis)** and **torticollis** (spasms of neck muscles) are classic presentations of acute dystonia. * Treatment includes **anticholinergic agents** (e.g., benztropine, trihexyphenidyl) or **antihistamines** (e.g., diphenhydramine), which provide rapid relief. *Akathisia* * **Akathisia** is characterized by an internal feeling of **restlessness** and an urge to move, which is often relieved by movement. * It does not present with fixed abnormal postures or sudden, sustained muscle contractions like oculogyric crisis or torticollis. *Malignant hyperthermia* * **Malignant hyperthermia** is a rare, life-threatening reaction to certain **anesthetic drugs**, characterized by **rapidly increasing body temperature**, muscle rigidity, and metabolic acidosis. * It is not typically associated with antipsychotic use or the specific localized dystonic movements described. *Drug induced parkinsonism* * **Drug-induced parkinsonism** presents with symptoms resembling Parkinson's disease, including **tremor**, **rigidity**, **bradykinesia**, and postural instability. * These symptoms develop more **gradually** (days to weeks) and are distinct from the sudden, acute, sustained muscle contractions seen in dystonia.

Question 348: A patient presents with symptoms of major depressive disorder. Which medication should be prescribed for treatment?

A. Haloperidol
B. Olanzapine
C. Alprazolam
D. Sertraline (Correct Answer)

Explanation: ***Sertraline*** - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)**, which are first-line agents for treating major depressive disorder due to their efficacy and generally favorable side effect profile. - SSRIs work by increasing the availability of **serotonin** in the brain, helping to improve mood and reduce symptoms of depression. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** primarily used to treat psychotic disorders like **schizophrenia** and severe agitation, not major depressive disorder. - It works by blocking **dopamine D2 receptors**, and its side effects can include **extrapyramidal symptoms**. *Alprazolam* - **Alprazolam** is a **benzodiazepine** used to treat anxiety disorders and panic attacks due to its *rapid onset of action* in reducing anxiety symptoms. - While it can alleviate anxiety that co-occurs with depression, it is not an antidepressant and does not treat the underlying depressive disorder; it also carries a risk of **dependence and withdrawal**. *Olanzapine* - **Olanzapine** is a **second-generation antipsychotic** used for conditions such as **schizophrenia** and **bipolar disorder**. - While it can be used as an **adjunctive treatment** in some cases of treatment-resistant depression, it is not a first-line monotherapy for major depressive disorder.

Question 349: Which of the following antidepressants can also be used as an antipsychotic?

A. Trazodone
B. Amoxapine (Correct Answer)
C. Doxepin
D. Amitriptyline

Explanation: ***Amoxapine*** - Amoxapine is a **tetracyclic antidepressant** with a unique pharmacological profile, as it acts as a dopamine receptor antagonist, particularly at the **D2 receptor**. - Its **dopamine receptor blocking activity** confers antipsychotic properties, making it useful in treating mood disorders with psychotic features. *Amitriptyline* - Amitriptyline is a **tricyclic antidepressant (TCA)** primarily used for depression, neuropathic pain, and migraine prophylaxis. - It primarily acts by inhibiting the reuptake of **norepinephrine and serotonin**, with no significant dopamine receptor blocking activity. *Trazodone* - Trazodone is a **serotonin antagonist and reuptake inhibitor (SARI)**, commonly used for depression and insomnia. - Its main mechanism involves **blocking 5-HT2A receptors** and inhibiting serotonin reuptake, without antipsychotic effects. *Doxepin* - Doxepin is another **tricyclic antidepressant (TCA)** used for depression, anxiety, and insomnia. - It primarily inhibits the reuptake of **norepinephrine and serotonin** and has significant antihistaminic effects, but lacks antipsychotic properties.

Question 350: A patient with schizophrenia was started on haloperidol 5 mg. The next day, he presented with uprolling of the eyes. A complete neurological examination revealed no spasticity or any other abnormality, and visual acuity and ophthalmoscopic findings are normal. The most likely diagnosis is:

A. Akathisia
B. Acute dystonia (Correct Answer)
C. Seizure
D. Tardive dyskinesia

Explanation: ***Acute dystonia*** - The rapid onset of **uprolling of the eyes** (oculogyric crisis) shortly after starting **haloperidol**, a potent D2 blocker, is a classic presentation of acute dystonia. - This extrapyramidal symptom is characterized by **involuntary muscle contractions** affecting various body parts, including the eyes, neck (**torticollis**), and jaw. *Akathisia* - Akathisia is characterized by a **subjective feeling of inner restlessness** and an objective need to move, often described as an inability to sit still. - While it is an extrapyramidal symptom, it doesn't typically manifest as involuntary eye movements like oculogyric crisis. *Seizure* - Seizures typically involve **loss of consciousness**, generalized tonic-clonic movements, or altered mental status, none of which are described. - The patient's presentation of isolated eye uprolling without other neurological findings or changes in consciousness makes a seizure unlikely. *Tardive dyskinesia* - **Tardive dyskinesia** is a late-onset extrapyramidal side effect, typically developing after months or years of antipsychotic use, not within a day of starting the medication. - It is characterized by **involuntary, repetitive movements**, often involving the face, mouth, and tongue (e.g., lip smacking, grimacing).

Practice by Chapter

Principles of Psychopharmacology

Practice Questions

Antipsychotic Medications

Practice Questions

Antidepressant Medications

Practice Questions

Mood Stabilizers

Practice Questions

Anxiolytics and Hypnotics

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Stimulants and Cognitive Enhancers

Practice Questions

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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