Psychopharmacology — MCQs

A patient is brought to the casualty in a state of altered sensorium, having been treated with lithium for an affective disorder. On examination, the patient exhibits tremors, increased deep tendon reflexes, urinary incontinence, and has experienced an episode of epileptic fits. The patient had an episode of severe gastroenteritis two days prior. The patient's serum lithium level is 1.95 mmol/L. What is the direct cause of the patient's current clinical presentation?

Q355

A patient is experiencing subtle involuntary movements of his hands, feet, lips, and tongue. What is the expected response of these symptoms during the tapering of antipsychotic medication?

Q356

Among the following, which test is essential in pre-treatment evaluation for lithium therapy:

Q357

A 17-year-old with schizophrenia recently started on antipsychotics is brought to casualty with neck rigidity. He has:

Q358

A 50-year-old woman with schizophrenia who has been taking an antipsychotic drug for the past three years has begun to exhibit involuntary chewing and lip-smacking movements. Which is the most likely possibility?

Q359

Which mood stabilizer is known for its anti-suicidal property?

Q360

What is the most appropriate investigation for a patient with bipolar disorder on lithium therapy for 6 months, who presents with seizures, coarse tremors, confusion, and weakness of the limbs after a day of fasting?

Psychopharmacology Indian Medical PG Practice Questions and MCQs

Question 351: Atypical depression is managed with:

A. NDRI
B. MAOI (Correct Answer)
C. SSRI
D. SNRI

Explanation: ***MAOI*** - **MAOIs** (Monoamine Oxidase Inhibitors) are the **most effective treatment** for atypical depression, as demonstrated by multiple clinical studies including the landmark Columbia study. - They show **superior efficacy** compared to other antidepressants for the characteristic features of atypical depression: **mood reactivity**, **increased appetite/weight gain**, **hypersomnia**, **leaden paralysis**, and **rejection sensitivity**. - While requiring **dietary restrictions** (avoiding tyramine-rich foods) and careful monitoring for drug interactions, MAOIs remain the **gold standard treatment** when treating atypical depression specifically. - Examples include phenelzine and tranylcypromine. *SSRI* - **SSRIs** are commonly used as **first-line treatment in clinical practice** due to their favorable safety profile and ease of use. - However, they are **less effective than MAOIs** for atypical depression specifically, though they are still beneficial and widely prescribed due to tolerability. - Preferred when safety, tolerability, and patient compliance are prioritized over maximal efficacy. *SNRI* - **SNRIs** (Serotonin-Norepinephrine Reuptake Inhibitors) are effective for various forms of depression but are not the most effective option for atypical depression. - May be beneficial for patients with **comorbid pain** or **fatigue symptoms** due to their dual mechanism of action. *NDRI* - **NDRIs** (Norepinephrine-Dopamine Reuptake Inhibitors), such as bupropion, are useful for depression with **low energy** or **anhedonia**. - Not specifically indicated for the characteristic features of atypical depression like **mood reactivity** or **leaden paralysis**. - Often chosen when avoiding sexual side effects or weight gain is important.

Question 352: The patient presented with a contraction of the neck, describing it as painful, which started after an injection given at the psychiatry hospital for his psychosis. What type of side effect was caused by the drug?

A. dystonia (Correct Answer)
B. neuroleptic malignant syndrome
C. tardive dyskinesia
D. akathisia

Explanation: ***Dystonia*** - **Dystonia** involves sustained or repetitive muscle contractions, often causing twisting and repetitive movements or abnormal fixed postures. - An acute onset of painful neck contraction (like **torticollis**) following an injection of antipsychotics points to an acute dystonic reaction. *Neuroleptic Malignant Syndrome* - **Neuroleptic Malignant Syndrome (NMS)** is characterized by **fever**, **muscle rigidity**, **altered mental status**, and **autonomic instability**. - While serious, NMS presents with a constellation of symptoms far beyond just a neck contraction. *Akathisia* - **Akathisia** is a subjective feeling of inner restlessness and the need to move, often manifesting as pacing or fidgeting. - It does not typically involve painful, fixed muscle contractions as described in the patient's presentation. *Tardive Dyskinesia* - **Tardive dyskinesia** involves involuntary, repetitive movements, most often of the face and mouth (e.g., lip smacking, grimacing). - It typically develops after **prolonged exposure** to antipsychotics and is generally not an acute reaction to a single injection.

Question 353: Best use of lithium is in:

A. Treatment of schizophrenia
B. Treatment of recurrent depression
C. Treatment of first depressive episode
D. Prophylaxis of bipolar mood disorder (Correct Answer)

Explanation: ***Prophylaxis of bipolar mood disorder*** - **Lithium** is a highly effective mood stabilizer primarily used for the **long-term prevention of both manic and depressive episodes** in bipolar disorder. - Its prophylactic benefits include reducing the **frequency and severity of mood swings**, thereby improving overall stability and functioning. *Treatment of schizophrenia* - While lithium can sometimes be used as an **adjunctive treatment** in schizophrenia, it is not a primary agent and is not the best use. - **Antipsychotics** are the first-line treatment for schizophrenia. *Treatment of recurrent depression* - Lithium can be used as an **augmentation strategy** for recurrent unipolar depression that hasn't responded to antidepressants. - However, for unipolar depression, it is not considered the **best or primary treatment**, which typically involves antidepressants. *Treatment of first depressive episode* - For a first depressive episode, **antidepressants** are the first-line pharmacotherapy. - Lithium is generally not indicated as a primary treatment for initial episodes of unipolar depression.

Question 354: A patient is brought to the casualty in a state of altered sensorium, having been treated with lithium for an affective disorder. On examination, the patient exhibits tremors, increased deep tendon reflexes, urinary incontinence, and has experienced an episode of epileptic fits. The patient had an episode of severe gastroenteritis two days prior. The patient's serum lithium level is 1.95 mmol/L. What is the direct cause of the patient's current clinical presentation?

A. Elevated serum lithium level (Correct Answer)
B. Dehydration due to gastroenteritis
C. Manic episode
D. Depressive stupor

Explanation: ***Elevated serum lithium level*** - The patient's serum lithium level of **1.95 mmol/L** is significantly above the therapeutic range (0.6-1.2 mmol/L) and indicates **severe lithium toxicity** (toxic level >1.5 mmol/L). - The clinical features are **classic manifestations of lithium toxicity**: altered sensorium (CNS toxicity), **epileptic seizures** (severe neurotoxicity), coarse tremors, hyperreflexia, and urinary incontinence. - This elevated lithium level is the **direct cause** of all the presenting neurological symptoms. - The gastroenteritis caused dehydration, which **precipitated** the lithium accumulation by reducing renal clearance, but the **toxic lithium level itself** is what directly caused these symptoms. *Dehydration due to gastroenteritis* - While gastroenteritis-induced dehydration is an important **precipitating factor** that led to reduced renal lithium clearance and subsequent accumulation, it is not the **direct cause** of the neurological symptoms. - Dehydration alone does not cause **epileptic seizures**, altered sensorium, or hyperreflexia in this specific pattern—these are caused by the **toxic lithium level**. - This represents a contributory factor in the causal chain, not the direct pathophysiological cause of the presentation. *Manic episode* - Mania presents with **elevated/expansive mood**, increased goal-directed activity, decreased need for sleep, pressured speech, and grandiosity. - The patient's presentation of **altered sensorium**, seizures, and coarse tremors with hyperreflexia is inconsistent with mania and instead indicates **toxic encephalopathy**. - Lithium is used to treat bipolar disorder, but these symptoms represent drug toxicity, not the underlying psychiatric condition. *Depressive stupor* - Depressive stupor involves severe psychomotor retardation, mutism, and stupor without **seizures**, tremors, or hyperreflexia. - The neurological signs (seizures, hyperreflexia, coarse tremors) point to **neurotoxicity** from lithium rather than a primary depressive syndrome. - This presentation is clearly toxic/organic rather than functional psychiatric pathology.

Question 355: A patient is experiencing subtle involuntary movements of his hands, feet, lips, and tongue. What is the expected response of these symptoms during the tapering of antipsychotic medication?

A. It will resolve immediately after the medication is decreased.
B. It will initially increase as the medication is decreased. (Correct Answer)
C. It will remain the same.
D. It will resolve in his hands but not in his feet.

Explanation: ***It will initially increase as the medication is decreased.*** - The involuntary movements described are characteristic of **tardive dyskinesia**, a side effect of long-term antipsychotic use. - When antipsychotic medication is tapered or discontinued, the **dopamine receptors**, which have been chronically blocked, become hypersensitive, leading to an initial worsening or unmasking of dyskinetic movements due to temporary dopamine overdrive. *It will resolve immediately after the medication is decreased.* - Tardive dyskinesia symptoms rarely resolve immediately upon antipsychotic reduction or discontinuation; instead, they often become **more pronounced** as receptor sensitivity changes. - The withdrawal of the medication unmasks the underlying dopamine receptor hypersensitivity, leading to an initial increase rather than immediate resolution. *It will remain the same.* - The dynamic nature of dopamine receptor hypersensitivity means that symptoms of tardive dyskinesia are unlikely to remain stable during changes in antipsychotic dosage. - **Dopamine receptor sensitivity** is altered by the change in medication levels, leading to a noticeable shift in symptom severity. *It will resolve in his hands but not in his feet.* - Tardive dyskinesia typically affects muscle groups globally, often including movements of the **face, trunk, and extremities**, rather than resolving in some areas and not others. - The pathophysiology involving **widespread dopamine receptor changes** does not usually manifest with selective resolution in specific body parts.

Question 356: Among the following, which test is essential in pre-treatment evaluation for lithium therapy:

A. Fasting blood sugar
B. Serum creatinine (Correct Answer)
C. Liver function tests
D. Platelet count

Explanation: ***Serum creatinine*** - **Lithium** is almost entirely excreted by the kidneys, so baseline renal function assessed by **serum creatinine** and estimated glomerular filtration rate (eGFR) is crucial. - This helps determine the appropriate starting dose and monitor for potential **lithium-induced renal impairment** during therapy. *Fasting blood sugar* - While important for general health screening and monitoring metabolic syndrome, **lithium** does not directly impact glucose metabolism to the extent that it requires pre-treatment evaluation for dosing or safety reasons. - This test is not considered essential specifically for lithium pre-treatment. *Liver function tests* - **Lithium** is not metabolized by the liver, and **hepatotoxicity** is not a known side effect. - Therefore, baseline liver function tests are not considered essential for initiating lithium therapy. *Platelet count* - **Lithium** rarely causes significant hematological abnormalities like **thrombocytopenia** or **thrombocytosis**. - A baseline platelet count is generally not required for pre-treatment evaluation unless there are other clinical indications.

Question 357: A 17-year-old with schizophrenia recently started on antipsychotics is brought to casualty with neck rigidity. He has:

A. Tardive dyskinesia
B. Dystonia (Correct Answer)
C. Catatonia
D. Neuroleptic malignant syndrome

Explanation: ***Dystonia*** - **Acute dystonia** is a common **extrapyramidal side effect** of antipsychotic medications, particularly typical antipsychotics or higher doses of atypical ones. - **Neck rigidity**, specifically **torticollis** (sustained contraction of neck muscles causing the head to turn to one side), is a classic presentation of acute dystonia. *Catatonia* - While catatonia can manifest with motor abnormalities, including rigidity, it is a broader syndrome involving a range of **psychomotor disturbances** (e.g., stupor, negativism, waxy flexibility, mutism) and is not solely defined by isolated neck rigidity following antipsychotic initiation. - Catatonia is often a feature of severe psychiatric illness itself or other medical conditions, rather than an acute drug-induced side effect limited to muscle spasms. *Neuroleptic malignant syndrome* - **Neuroleptic malignant syndrome (NMS)** is a life-threatening reaction characterized by a **tetrad of symptoms**: high fever, severe muscle rigidity (generalized), altered mental status, and autonomic dysfunction (e.g., tachycardia, labile blood pressure). - Isolated neck rigidity without these other severe systemic signs is not consistent with NMS. *Tardive dyskinesia* - **Tardive dyskinesia** involves repetitive, involuntary, and often stereotyped movements, typically affecting the **face, mouth, and tongue** (e.g., grimacing, lip smacking, tongue protrusion). - It usually develops after **long-term use** of antipsychotics and is rarely an acute reaction presenting as neck rigidity shortly after starting the medication.

Question 358: A 50-year-old woman with schizophrenia who has been taking an antipsychotic drug for the past three years has begun to exhibit involuntary chewing and lip-smacking movements. Which is the most likely possibility?

A. Akathisia
B. Neuroleptic Malignant Syndrome
C. Restless Legs Syndrome
D. Tardive Dyskinesia (Correct Answer)

Explanation: ***Tardive Dyskinesia*** - This condition is characterized by **involuntary, repetitive movements**, often involving the face (e.g., **chewing, lip-smacking, grimacing**) and extremities, that develop after prolonged use of antipsychotic medications. - The delayed onset (after three years of antipsychotic use) and the specific nature of the movements are highly suggestive of **tardive dyskinesia**. *Akathisia* - Akathisia presents as a feeling of **inner restlessness** and an inability to sit still, leading to constant pacing or fidgeting. - While it is a common side effect of antipsychotics, the cardinal symptoms are motor restlessness rather than involuntary movements like chewing and lip-smacking. *Neuroleptic Malignant Syndrome* - This is a rare, life-threatening reaction to antipsychotics characterized by **fever, severe muscle rigidity, altered mental status, and autonomic dysfunction**. - The patient's symptoms of involuntary chewing and lip-smacking do not align with the acute and severe presentation of NMS. *Restless Legs Syndrome* - RLS involves an **uncontrollable urge to move the legs**, typically worse at night and relieved by movement, often accompanied by unpleasant sensations. - The patient's symptoms are in the face (chewing, lip-smacking) and not described as an urge to move the legs or worse at night.

Question 359: Which mood stabilizer is known for its anti-suicidal property?

A. carbamazepine
B. lamotrigine
C. valproate
D. lithium (Correct Answer)

Explanation: ***Lithium*** - **Lithium** is the only mood stabilizer with strong evidence of reducing **suicidal ideation** and attempts in patients with mood disorders. - Its mechanism in preventing suicidality is not fully understood but may involve neuroprotective effects and modulation of neurotransmitter systems. *Carbamazepine* - While an effective mood stabilizer for **bipolar disorder**, carbamazepine does not have a well-established anti-suicidal property compared to lithium. - It works primarily by blocking voltage-gated **sodium channels**, which stabilizes neuronal membranes. *Lamotrigine* - **Lamotrigine** is primarily used for the **maintenance treatment** of bipolar disorder, particularly for preventing depressive episodes. - It does not have significant evidence for a direct anti-suicidal effect, and there is a rare risk of **Stevens-Johnson syndrome**. *Valproate* - **Valproate** is an effective mood stabilizer for acute mania and maintenance treatment in bipolar disorder. - While it can improve mood and reduce impulsivity, its anti-suicidal effect is not as robust or consistently demonstrated as that of **lithium**.

Question 360: What is the most appropriate investigation for a patient with bipolar disorder on lithium therapy for 6 months, who presents with seizures, coarse tremors, confusion, and weakness of the limbs after a day of fasting?

A. Serum Electrolyte
B. ECG
C. Serum Lithium (Correct Answer)
D. Serum creatinine

Explanation: ***Serum Lithium*** - The patient's symptoms (seizures, coarse tremors, confusion, weakness) are classic signs of **lithium toxicity**. - Fasting can lead to **dehydration** and electrolyte imbalances, which can increase lithium levels and precipitate toxicity. *Serum Electrolyte* - While electrolyte imbalances can contribute to lithium toxicity and symptoms, measuring electrolytes alone will not directly confirm **lithium overdose**. - **Hyponatremia** and **dehydration** can exacerbate lithium toxicity by increasing renal reabsorption of lithium. *ECG* - **ECG changes** (e.g., T-wave abnormalities, QTc prolongation) can occur with severe lithium toxicity, but it is not the primary diagnostic test. - ECG is a supportive investigation to assess cardiac complications, not the direct cause of the neurological symptoms. *Serum creatinine* - **Serum creatinine** is important for monitoring **renal function**, as lithium is cleared renally and renal impairment can lead to higher lithium levels. - However, assessing creatinine levels will not directly diagnose acute lithium toxicity; it helps evaluate the **renal health** and potential for toxicity.

Practice by Chapter

Principles of Psychopharmacology

Practice Questions

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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