Psychopharmacology Practice Questions

Q: Which of the following conditions is a contraindication for ECT?

Raised ICT. ***Raised ICT*** - **Raised intracranial tension (ICT)** is an absolute contraindication for ECT due to the transient increase in **cerebral blood flow** and pressure during the procedure. - This increase in pressure can lead to **brain herniation** or further neurological compromise in patients with pre-existing elevated ICT. *Severe medical illness* - While severe medical illness can pose a risk, it is generally considered a **relative contraindication** rather than an absolute one. - The decision to proceed with ECT in such cases involves a careful **risk-benefit analysis** and close monitoring. *Severe heart disease* - **Severe heart disease**, such as **unstable angina** or **recent myocardial infarction**, is a relative contraindication. - It requires careful cardiac evaluation and management, but does not absolutely preclude ECT if the benefits outweigh the risks. *Pregnancy complications* - **Pregnancy** itself is not a contraindication for ECT; in some cases, it may be the preferred treatment for severe psychiatric illness during pregnancy. - However, complications might necessitate careful monitoring and adjustment of the procedure.

Q: In which condition is Atomoxetine primarily indicated?

ADHD. ***ADHD*** - **Atomoxetine** is a **norepinephrine reuptake inhibitor** primarily used for the treatment of **Attention-Deficit/Hyperactivity Disorder (ADHD)** in children, adolescents, and adults [1]. - It helps improve symptoms such as **inattention**, **hyperactivity**, and **impulsivity** by increasing the concentration of norepinephrine in the brain [1], [2]. *Treatment of nocturnal enuresis* - While some medications for **ADHD** (like **imipramine**) can be used off-label for **nocturnal enuresis**, atomoxetine is **not a primary indication** for this condition [3]. - Management of **nocturnal enuresis** typically involves behavioral interventions, desmopressin, or tricyclic antidepressants [3]. *Management of temper tantrums* - **Temper tantrums** are primarily behavioral issues and are generally managed through **behavioral therapy** and parenting strategies. - **Atomoxetine** is not indicated as a primary treatment for temper tantrums; if tantrums are a symptom of an underlying disorder like ADHD, addressing the ADHD might indirectly help. *Treatment of patent ductus arteriosus* - **Patent ductus arteriosus (PDA)** is a cardiovascular condition typically seen in newborns, involving a persistent opening between the aorta and pulmonary artery. - Treatment for PDA usually involves **NSAIDs (like indomethacin or ibuprofen)** or surgical ligation, not atomoxetine.

Q: A patient with treatment-resistant schizophrenia presents with excessive salivation, increased blood glucose, and hyperlipidemia after switching from haloperidol and thioridazine. Which antipsychotic medication is most likely responsible for these side effects?

Clozapine. ***Clozapine*** - Clozapine is a highly effective antipsychotic for **treatment-resistant schizophrenia** but is known for significant metabolic side effects including **hyperglycemia**, **dyslipidemia**, and dose-dependent **sialorrhea** (excessive salivation). - The combination of **excessive salivation**, **increased blood glucose**, and **hyperlipidemia** after a switch in antipsychotics strongly points to clozapine. *Ziprasidone* - Ziprasidone is considered to have a relatively **favorable metabolic profile**, with a low risk of weight gain, hyperglycemia, and hyperlipidemia. - It is not typically associated with prominent **sialorrhea**. *Risperidone* - Risperidone can cause **weight gain** and some metabolic disturbances, but it is less commonly associated with the severe metabolic dysregulation and sialorrhea seen with clozapine. - While it can cause elevated prolactin, **sialorrhea** and significant **hyperglycemia** and **hyperlipidemia** are not its most defining or severe side effects compared to clozapine. *Aripiprazole* - Aripiprazole is a **partial dopamine agonist** and generally has a **low risk of metabolic side effects**, including minimal impact on blood glucose and lipids. - It is also not typically associated with **sialorrhea**.

Q: A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is

Trihexyphenidyl. ***Trihexyphenidyl*** - The patient is exhibiting symptoms consistent with drug-induced **parkinsonism** caused by fluphenazine, an antipsychotic. - **Anticholinergics** like trihexyphenidyl are the **first-line treatment** for drug-induced parkinsonism by blocking muscarinic receptors in the striatum, restoring the dopamine-acetylcholine balance. *Selegiline (MAO-B inhibitor)* - Selegiline is used in Parkinson's disease to **increase dopamine levels** by inhibiting its breakdown, but it is not the first-line treatment for drug-induced parkinsonism where the issue is receptor blockade. - Its primary role is in **idiopathic Parkinson's disease** as an adjunctive therapy or for early symptom control, not for antipsychotic-induced extrapyramidal symptoms. *Amantadine* - Amantadine is an **NMDA receptor antagonist** and dopamine reuptake inhibitor used in Parkinson's disease. - While it has some efficacy in drug-induced parkinsonism, it is generally considered **second-line** after anticholinergics and is more effective for dyskinesia in idiopathic Parkinson's disease. *Pramipexole (Dopamine agonist)* - Dopamine agonists work by **directly stimulating dopamine receptors**, which would exacerbate the effects of D2 receptor blockade by fluphenazine. - They are used for **idiopathic Parkinson's disease** and restless legs syndrome, but are typically avoided in drug-induced parkinsonism.

Q: A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Serum lithium levels. **Serum lithium levels** - The patient's symptoms (seizures, tremors, confusion, weakness) are classic for **lithium toxicity**. - **Fasting** can lead to dehydration and electrolyte imbalance, which can increase lithium concentrations and toxicity [1]. *Serum electrolytes* - While **electrolyte imbalances** can occur with fasting and contribute to symptoms, measuring serum electrolytes alone will not directly diagnose lithium toxicity. - Electrolyte disturbances might be a predisposing factor or a concomitant issue, but not the primary diagnostic test for lithium toxicity itself [1]. *ECG* - An **ECG** can reveal cardiac effects of lithium toxicity, such as T-wave flattening or inversion, but it is not the most appropriate direct diagnostic test for the condition itself. - ECG changes are secondary manifestations and may not always be present or specific. *MRI* - While an **MRI** of the brain might be considered to rule out other causes of neurological symptoms like a stroke or brain lesion, it is not the initial or most appropriate investigation for suspected lithium toxicity. - The clinical picture strongly points to a pharmacological cause, making laboratory tests more relevant first-line diagnostics than imaging.

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: What is the treatment of choice for acute panic attacks?

Benzodiazepines. ***Correct: Benzodiazepines*** - Benzodiazepines are the **treatment of choice for acute panic attacks** due to their **rapid onset of action** (within minutes) - They work by enhancing **GABA-A receptor** activity, providing immediate anxiolytic effects - Commonly used agents include **alprazolam, lorazepam, and clonazepam** - While effective acutely, they are not recommended for long-term management due to dependence risk *Incorrect: Tricyclic antidepressants (TCAs)* - TCAs are effective for **long-term prophylaxis** of panic disorder, not acute attacks - They have a **delayed onset of action** (2-4 weeks), making them unsuitable for immediate relief - Significant **anticholinergic effects** and potential cardiotoxicity limit their use *Incorrect: Monoamine oxidase inhibitors (MAOIs)* - MAOIs can be effective for panic disorder but are reserved for **treatment-resistant cases** - **Delayed onset of action** (several weeks) makes them inappropriate for acute attacks - Require **dietary restrictions** and have risk of hypertensive crisis with tyramine-containing foods *Incorrect: Barbiturates* - Largely **obsolete** in psychiatric practice, replaced by safer benzodiazepines - **Narrow therapeutic index** with high risk of overdose and respiratory depression - Greater potential for dependence and withdrawal complications - No role in modern management of panic attacks

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 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: 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.

Question 1

Which of the following conditions is a contraindication for ECT?

Accepted Answer

Raised ICT

Answer

Severe medical illness

Answer

Severe heart disease

Answer

Pregnancy complications

Question 2

In which condition is Atomoxetine primarily indicated?

Accepted Answer

ADHD

Answer

Treatment of nocturnal enuresis

Answer

Management of temper tantrums

Answer

Treatment of patent ductus arteriosus

Question 3

A patient with treatment-resistant schizophrenia presents with excessive salivation, increased blood glucose, and hyperlipidemia after switching from haloperidol and thioridazine. Which antipsychotic medication is most likely responsible for these side effects?

Accepted Answer

Clozapine

Answer

Ziprasidone

Answer

Risperidone

Answer

Aripiprazole

Question 4

A patient was recently started on Fluphenazine. A few weeks later, he developed tremors, rigidity, bradykinesia, and excessive salivation. The first line of management for this patient is

Accepted Answer

Trihexyphenidyl

Answer

Amantadine

Answer

Selegiline (MAO-B inhibitor)

Answer

Pramipexole (Dopamine agonist)

Question 5

A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Accepted Answer

Serum lithium levels

Answer

Serum electrolytes

Answer

ECG

Answer

MRI

Question 6

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 7

What is the treatment of choice for acute panic attacks?

Accepted Answer

Benzodiazepines

Answer

Tricyclic antidepressants (TCAs)

Answer

Monoamine oxidase inhibitors (MAOIs)

Answer

Barbiturates

Question 8

Most common complication of modified ECT

Accepted Answer

Amnesia

Answer

Intracerebellar hemorrhage

Answer

Spinal fracture

Answer

Muscle pain

Question 9

What is a common medical treatment for sexual paraphilias?

Accepted Answer

Anti-androgens

Answer

Benzodiazepines

Answer

SSRIs

Answer

Opioids

Question 10

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

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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