Psychopharmacology Practice Questions

Q: 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?

Tardive Dyskinesia. ***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.

Q: Which of the following medications is primarily an antipsychotic rather than a mood stabilizer and is NOT typically used for long-term prophylaxis in bipolar disorder? Chlorpromazine, Lithium, Carbamazepine, Sodium Valproate.

Chlorpromazine. ***Chlorpromazine*** - **Chlorpromazine** is a **first-generation antipsychotic** primarily used to treat **psychotic symptoms** like hallucinations and delusions. - While it can be used for acute agitation in bipolar disorder, it's generally **not considered a first-line agent** for **long-term mood stabilization** or prophylaxis due to its side effect profile and limited efficacy in preventing mood episodes compared to true mood stabilizers. *Carbamazepine* - **Carbamazepine** is an **anticonvulsant medication** well-established as a **mood stabilizer** for the long-term prophylaxis and treatment of bipolar disorder. - It is particularly effective for **rapid cycling** and **mixed features**, distinguishing it from an antipsychotic. *Sodium Valproate* - **Sodium valproate** (Valproic acid) is a widely used **mood stabilizer** for both acute mania and long-term prophylaxis in bipolar disorder. - It is effective in treating or preventing both manic and depressive episodes, and is **not primarily an antipsychotic**. *Lithium* - **Lithium** is considered the **gold standard mood stabilizer** for the long-term prophylaxis of bipolar disorder, significantly reducing the risk of both manic and depressive episodes. - It is primarily a **mood stabilizer** and does not possess significant antipsychotic effects on its own.

Q: According to the classical monoamine hypothesis of depression, deficiency of which of the following neurotransmitters is MOST commonly emphasized in modern antidepressant therapy?

Serotonin. ***Serotonin*** - The **classical monoamine hypothesis** of depression posits deficiencies in monoamine neurotransmitters including **serotonin (5-HT), norepinephrine, and dopamine**. - Among these, **serotonin** is the **most commonly emphasized** in modern antidepressant therapy, given its central role in mood regulation, sleep, appetite, and cognition. - The majority of first-line antidepressants, such as **SSRIs (Selective Serotonin Reuptake Inhibitors)** and **SNRIs**, primarily target serotonergic pathways, reflecting its clinical importance. - **Clinical relevance**: Serotonin deficiency is associated with depressed mood, anxiety, sleep disturbances, and appetite changes. *Acetylcholine* - **Acetylcholine** is a neurotransmitter involved in cognitive function, memory, and muscle contraction. - It is **not a monoamine** and is not part of the classical monoamine hypothesis of depression. - Acetylcholine deficiency is primarily implicated in **Alzheimer's disease** and other cognitive disorders, not depression. *Dopamine* - **Dopamine** is one of the three monoamines implicated in the classical hypothesis and plays a role in pleasure, reward, motivation, and motor control. - Dopamine deficiency can contribute to symptoms of **anhedonia** (inability to feel pleasure) and lack of motivation in depression. - However, dopamine-targeting antidepressants (like bupropion) are less commonly used as first-line therapy compared to serotonergic agents, making serotonin the most emphasized in clinical practice. *GABA* - **GABA (gamma-aminobutyric acid)** is the primary **inhibitory neurotransmitter** in the central nervous system. - It is **not a monoamine** and is not part of the classical monoamine hypothesis of depression. - GABA dysfunction is primarily associated with **anxiety disorders, seizures, and insomnia**, not depression as per the classical hypothesis.

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

lithium. ***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**.

Q: Vasanthi, a 45-year-old woman, was brought to the casualty with persistent neck deviation to the right side and abnormal movements, one day after being prescribed haloperidol 5 mg three times daily from the psychiatry OPD. She also had a recent altercation with her husband. Which of the following is the most likely cause of her symptoms?

Acute drug dystonia due to haloperidol. ***Acute drug dystonia due to haloperidol*** - The sudden onset of **persistent neck deviation** (torticollis) and **abnormal movements** one day after starting **haloperidol**, a dopamine receptor blocker, is highly characteristic of an **acute dystonic reaction** [1]. - **Haloperidol** is a **first-generation antipsychotic** known for its increased risk of **extrapyramidal symptoms**, including dystonia [1]. *Conversion disorder* - Conversion disorder involves neurological symptoms that are **incompatible with known neurological or medical conditions** and are often preceded by psychological stressors. - While she had a recent altercation, the clear temporal relationship with a known **dopamine-blocking drug** makes drug-induced dystonia more likely than a functional neurological disorder. *Acute psychotic episode* - An acute psychotic episode is primarily characterized by **delusions, hallucinations, disorganized speech, or behavior**, not focal neurological symptoms like a persistent neck deviation. - Although the symptoms followed a psychiatric consultation, the specific presentation points away from a primary psychotic exacerbation. *Cerebrovascular accident* - A **cerebrovascular accident (stroke)** would typically present with **unilateral weakness, numbness, speech difficulties, or vision changes**, depending on the affected brain region. - The sudden onset of isolated neck deviation and generalized abnormal movements is not typical for a stroke, especially in someone starting haloperidol.

Q: 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?

Serum Lithium. ***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.

Q: A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?

Clozapine. ***Clozapine*** - **Clozapine** is the drug of choice for **treatment-resistant schizophrenia** or patients who are **intolerant to conventional antipsychotics**. - Its unique efficacy often comes with a risk of **agranulocytosis**, requiring regular **blood monitoring**. *Olanzapine* - While an effective **atypical antipsychotic**, it is not specifically indicated for **treatment-resistant cases** in the same way as clozapine. - It carries a risk of significant **metabolic side effects**, such as weight gain and dyslipidemia. *Haloperidol* - This is a **first-generation (conventional) antipsychotic** and would be unsuitable for a patient described as **intolerant to conventional antipsychotics**. - It is associated with a high incidence of **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**. *Risperidone* - As an **atypical antipsychotic**, it is a good first-line option but is not typically reserved for **treatment-resistant schizophrenia** or those with conventional antipsychotic intolerance. - It has a higher propensity for **hyperprolactinemia** compared to other atypical antipsychotics.

Q: What is a common side effect of a selective serotonin reuptake inhibitor (SSRI) medication prescribed to a 50-year-old woman with depression?

Decreased libido and difficulty achieving orgasm. ***Decreased libido and difficulty achieving orgasm*** - **Sexual dysfunction**, including decreased libido, anorgasmia, and ejaculatory delay, is a very common and often dose-dependent side effect of SSRIs. - This is attributed to increased serotonin levels affecting **dopamine** and **norepinephrine** pathways involved in sexual response. *Hepatotoxicity* - While possible with many medications, **severe hepatotoxicity** is rare with SSRIs and not considered a common side effect in routine clinical practice. - Liver enzyme elevations can occur, but significant liver damage requiring discontinuation is infrequent. *Weight gain* - **Weight gain** is a known side effect of some antidepressants, particularly **tricyclic antidepressants (TCAs)** and some **atypical antipsychotics**, but it is less consistently associated with SSRIs. - Although some SSRIs can cause weight gain, it is not as universally common or as prominent as sexual dysfunction. *Hypertension* - **Hypertension** is not a common side effect of SSRIs; in fact, some studies suggest a potential for SSRIs to slightly lower **blood pressure**. - **Serotonin-norepinephrine reuptake inhibitors (SNRIs)**, like venlafaxine, are more likely to cause dose-dependent increases in blood pressure.

Question 1

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?

Accepted Answer

Tardive Dyskinesia

Answer

Akathisia

Answer

Neuroleptic Malignant Syndrome

Answer

Restless Legs Syndrome

Question 2

Which of the following medications is primarily an antipsychotic rather than a mood stabilizer and is NOT typically used for long-term prophylaxis in bipolar disorder? Chlorpromazine, Lithium, Carbamazepine, Sodium Valproate.

Accepted Answer

Chlorpromazine

Answer

Sodium Valproate

Answer

Carbamazepine

Answer

Lithium

Question 3

According to the classical monoamine hypothesis of depression, deficiency of which of the following neurotransmitters is MOST commonly emphasized in modern antidepressant therapy?

Accepted Answer

Serotonin

Answer

Acetylcholine

Answer

Dopamine

Answer

GABA

Question 4

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

Accepted Answer

lithium

Answer

carbamazepine

Answer

lamotrigine

Answer

valproate

Question 5

Vasanthi, a 45-year-old woman, was brought to the casualty with persistent neck deviation to the right side and abnormal movements, one day after being prescribed haloperidol 5 mg three times daily from the psychiatry OPD. She also had a recent altercation with her husband. Which of the following is the most likely cause of her symptoms?

Accepted Answer

Acute drug dystonia due to haloperidol

Answer

Conversion disorder

Answer

Acute psychotic episode

Answer

Cerebrovascular accident

Question 6

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?

Accepted Answer

Serum Lithium

Answer

Serum Electrolyte

Answer

ECG

Answer

Serum creatinine

Question 7

A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?

Accepted Answer

Clozapine

Answer

Haloperidol

Answer

Olanzapine

Answer

Risperidone

Question 8

What is a common side effect of a selective serotonin reuptake inhibitor (SSRI) medication prescribed to a 50-year-old woman with depression?

Accepted Answer

Decreased libido and difficulty achieving orgasm

Answer

Hepatotoxicity

Answer

Weight gain

Answer

Hypertension

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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