Psychopharmacology Practice Questions

Q: A patient on antipsychotics presents with restlessness, an irresistible urge to move, and an inability to sit or stand in one position. What is the most likely diagnosis?

Akathisia. **Explanation:** The patient is presenting with the classic triad of **Akathisia**: subjective restlessness, an irresistible urge to move, and objective motor hyperactivity (pacing, shifting weight, or inability to sit still). It is the most common Extrapyramidal Side Effect (EPS) associated with antipsychotics, particularly high-potency first-generation agents. **Why the other options are incorrect:** * **Acute Dystonia:** Characterized by sudden, involuntary, sustained muscle contractions (e.g., torticollis, oculogyric crisis). It usually occurs within hours to days of starting treatment, whereas akathisia typically appears within days to weeks. * **Tardive Dyskinesia:** A late-onset complication (months to years) involving involuntary choreoathetoid movements, most commonly orofacial (lip-smacking, tongue protrusion). Unlike akathisia, these movements are involuntary and the patient may be unaware of them. * **Rabbit Syndrome:** A rare, late-onset EPS characterized by fine, rhythmic tremors of the perioral muscles (mimicking a chewing rabbit). It does not involve generalized restlessness. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Result of dopamine (D2) blockade in the nigrostriatal pathway. * **Management:** The drug of choice for Akathisia is **Propranolol** (Beta-blocker). Centrally acting anticholinergics (e.g., Benztropine) or Benzodiazepines are second-line. * **Clinical Significance:** Akathisia is highly distressing and is a major cause of non-compliance and increased suicide risk in patients on antipsychotics. * **Rule of Thumb (Timing of EPS):** **A**cute Dystonia (4 hours) > **A**kathisia (4 days) > **P**arkinsonism (4 weeks) > **T**ardive Dyskinesia (4 months/years). *Mnemonic: ADAPT.*

Q: What is the treatment of choice for prophylaxis in patients with repeated episodes of bipolar illness?

Lithium and Valproate. **Explanation:** The management of Bipolar Affective Disorder (BPAD) often requires long-term prophylaxis to prevent relapses of both mania and depression. **Why Option C is Correct:** While Lithium and Valproate are both first-line agents individually, clinical evidence (notably the **BALANCE trial**) and various treatment guidelines (such as CANMAT) indicate that **combination therapy with Lithium and Valproate** is more effective than monotherapy for preventing relapse in patients with repeated episodes. This synergistic approach provides superior stabilization of mood, especially in patients who have failed monotherapy or those with high-frequency cycling. **Why Other Options are Incorrect:** * **Option A (Lithium):** Historically the "gold standard" for prophylaxis and excellent for preventing manic relapses and reducing suicide risk. However, as monotherapy, it may not be sufficient for patients with "repeated episodes" or rapid cycling compared to the combination. * **Option B (Valproate):** An effective first-line mood stabilizer, particularly for mixed episodes and rapid cycling. However, like Lithium, its efficacy in preventing all-cause relapse is statistically lower when used alone compared to the combination. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index. Prophylactic blood levels should be maintained between **0.6 – 0.8 mEq/L**. * **Drug of Choice (DOC):** * Acute Mania: Lithium (or Valproate). * Rapid Cycling BPAD: Valproate. * BPAD in Pregnancy: Second-generation antipsychotics (avoid Lithium/Valproate due to teratogenicity like Ebstein’s anomaly and Neural Tube Defects). * **Suicide Prevention:** Lithium is the only mood stabilizer proven to reduce the risk of completed suicide in BPAD patients.

Q: In which condition is the maximum benefit from Electroconvulsive Therapy (ECT) typically observed?

Depression with suicidal tendency. **Explanation:** The primary indication for **Electroconvulsive Therapy (ECT)** is Severe Depression, particularly when it is life-threatening or refractory to medications. **Why Option B is Correct:** ECT is considered the "gold standard" for rapid symptom relief in psychiatry. In **Depression with suicidal tendency**, the risk of self-harm is immediate. ECT works faster than antidepressants (which take 2–4 weeks to show effect), making it the treatment of choice to rapidly stabilize a patient and prevent suicide. Other high-priority indications include depressive stupor and psychotic depression. **Analysis of Incorrect Options:** * **A. Hysteria (Dissociative Disorders):** ECT has no therapeutic role here. Management involves psychotherapy and addressing underlying stressors. * **C. Chronic Schizophrenia:** While ECT is used in acute schizophrenia (especially catatonic or paranoid types), it is significantly less effective in chronic cases with negative symptoms or long-standing cognitive decline. * **D. Mania:** ECT is effective for acute mania (especially if delirious or treatment-resistant), but it is generally a second-line treatment after mood stabilizers and antipsychotics. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication:** Major Depressive Disorder (MDD). * **Most effective indication:** Catatonia (shows the fastest and most dramatic response). * **Absolute Contraindication:** Increased Intracranial Pressure (ICP) due to risk of brain herniation. * **Common Side Effect:** Retrograde amnesia (usually transient). * **Mechanism:** It is believed to work by increasing the seizure threshold and modulating neurotransmitter sensitivity (upregulation of serotonin and downregulation of β-receptors).

Q: A child with schizophrenia, who was on antipsychotic medications, suddenly developed neck stiffness and spasm. What is the best treatment for this condition?

Benzatropine. ### Explanation **Diagnosis: Acute Dystonia** The clinical presentation of sudden neck stiffness (torticollis) and muscle spasms in a patient taking antipsychotics is classic for **Acute Dystonia**. This is an Extrapyramidal Side Effect (EPS) caused by a sudden blockade of dopamine (D2) receptors in the nigrostriatal pathway, leading to a relative excess of cholinergic (acetylcholine) activity. **1. Why Benzatropine is the Correct Answer:** To restore the balance between dopamine and acetylcholine, a **centrally acting anticholinergic** drug is required. **Benzatropine** is the drug of choice (along with Trihexyphenidyl) because it effectively antagonizes muscarinic receptors in the basal ganglia, providing rapid relief from spasms. **2. Analysis of Incorrect Options:** * **Lorazepam (B):** A benzodiazepine used for Acute Akathisia (restlessness) or status epilepticus. While it has muscle-relaxant properties, it does not address the underlying cholinergic imbalance in dystonia. * **Diphenhydramine (C):** Although this antihistamine has significant anticholinergic properties and *can* be used to treat dystonia, **Benzatropine** is generally preferred in clinical guidelines and exam scenarios as the more specific first-line agent for drug-induced EPS. * **Propranolol (D):** This is a beta-blocker and is the **drug of choice for Akathisia**, not acute dystonia. **3. NEET-PG High-Yield Pearls:** * **Timeline of EPS:** Acute Dystonia (hours to days) → Akathisia (days to weeks) → Parkinsonism (weeks to months) → Tardive Dyskinesia (months to years). * **Acute Dystonia:** Most common in young males and those taking high-potency first-generation antipsychotics (e.g., Haloperidol). * **Tardive Dyskinesia:** The only EPS where anticholinergics are **contraindicated** (they worsen the condition). It is treated by switching to Clozapine or using VMAT-2 inhibitors (e.g., Valbenazine).

Q: A depressed patient does not want to take medication on a daily basis. Which selective serotonin reuptake inhibitor (SSRI) is most suitable for this patient?

Fluoxetine. **Explanation:** The correct answer is **Fluoxetine**. The primary pharmacological factor determining the suitability of an SSRI for a patient who struggles with daily adherence is the **elimination half-life**. 1. **Why Fluoxetine is correct:** Fluoxetine has the longest half-life of all SSRIs (approximately 2–4 days), and its active metabolite, **norfluoxetine**, has an even longer half-life of **7–15 days**. This long duration of action provides a "built-in" buffer; if a patient misses a dose, the plasma levels remain therapeutic for a longer period. It is also available as a once-weekly formulation in some regions, making it the drug of choice for patients with poor daily compliance. 2. **Why other options are incorrect:** * **Escitalopram:** Has a half-life of about 27–32 hours. It requires daily dosing to maintain steady-state levels. * **Fluvoxamine:** Has one of the shortest half-lives among SSRIs (approx. 15 hours) and often requires twice-daily dosing. * **Paroxetine:** Has a short half-life (approx. 21 hours) and no active metabolites. It is notorious for causing severe **discontinuation syndrome** if even a single dose is missed. **High-Yield Clinical Pearls for NEET-PG:** * **Discontinuation Syndrome:** Least common with Fluoxetine (due to long half-life) and most common with Paroxetine (due to short half-life and lack of metabolites). * **Drug Interactions:** Fluoxetine is a potent inhibitor of **CYP2D6**, which can lead to significant drug-drug interactions. * **Activating Effect:** Fluoxetine is the most "activating" SSRI; it is often taken in the morning to avoid insomnia. * **Weight Neutrality:** Fluoxetine is generally considered the most weight-neutral SSRI in the short term.

Q: Which of the following conditions is characterized by twisting and protrusion of the tongue, and chewing of the lips?

Tardive dyskinesia. **Explanation:** The clinical presentation of twisting and protrusion of the tongue (fly-catcher’s tongue) and repetitive chewing movements of the lips (bucco-linguo-masticatory movements) is a classic description of **Tardive Dyskinesia (TD)**. **1. Why Tardive Dyskinesia is correct:** TD is a delayed-onset extrapyramidal side effect (EPS) resulting from long-term blockade of dopamine (D2) receptors by antipsychotics. The underlying pathophysiology is **dopamine receptor supersensitivity** in the nigrostriatal pathway. It is characterized by involuntary, choreoathetoid movements, most commonly affecting the face, mouth, and tongue. **2. Why other options are incorrect:** * **Acute Akathisia:** Presents as subjective motor restlessness (e.g., inability to sit still, pacing). It does not involve involuntary orofacial movements. * **Acute Dystonia:** Characterized by sudden, sustained, and painful muscle contractions (e.g., torticollis, oculogyric crisis). It typically occurs within hours to days of starting medication, unlike the delayed onset of TD. * **Chronic Dystonia:** While persistent, dystonia involves sustained posturing rather than the rhythmic, repetitive "chewing" or "twisting" movements seen in dyskinesia. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Old age, female gender, and long-term use of typical antipsychotics (e.g., Haloperidol). * **Management:** The first step is to **taper/discontinue** the offending agent or switch to **Clozapine** (the antipsychotic with the lowest risk of TD). * **Specific Treatments:** VMAT-2 inhibitors like **Valbenazine** or **Deutetrabenazine** are FDA-approved for TD. * **Warning:** Anticholinergics (like Trihexyphenidyl) **worsen** Tardive Dyskinesia, whereas they help in Acute Dystonia.

Q: What is the treatment of acute manic episodes?

Sodium valproate. **Explanation:** The management of an **acute manic episode** focuses on rapid stabilization of mood and control of agitation. **Why Sodium Valproate is the correct answer:** Sodium Valproate is a first-line mood stabilizer for acute mania. It is often preferred over Lithium in clinical practice for acute episodes because it has a **faster onset of action** (usually within 3–5 days) and is highly effective for "mixed episodes" and "rapid cycling" bipolar disorder. In the context of this question, it represents the pharmacological gold standard for acute stabilization. **Analysis of Incorrect Options:** * **Lithium (Option B):** While Lithium is the "Gold Standard" for long-term maintenance and prophylaxis of Bipolar Disorder, it has a slower onset of action (5–7 days) compared to Valproate and a narrow therapeutic index, making it slightly less ideal for immediate acute control in some settings. * **Electroconvulsive Therapy (Option A):** ECT is highly effective for mania but is reserved as a **second-line** treatment. It is indicated only when pharmacological treatments fail, in cases of severe exhaustion, or during pregnancy. * **Diazepam (Option C):** Benzodiazepines like Diazepam or Lorazepam are used only as **adjuncts** to control agitation and sleep disturbance. They do not treat the underlying manic pathology. **High-Yield Clinical Pearls for NEET-PG:** * **First-line drugs for Acute Mania:** Lithium, Sodium Valproate, or Atypical Antipsychotics (e.g., Haloperidol, Risperidone, Olanzapine). * **Drug of Choice for Rapid Cyclers:** Sodium Valproate. * **Therapeutic Range for Lithium (Acute Mania):** 0.8 to 1.2 mEq/L. * **Teratogenicity:** Avoid Valproate in pregnancy (Neural Tube Defects); Lithium is associated with Ebstein’s Anomaly.

Question 1

A patient on antipsychotics presents with restlessness, an irresistible urge to move, and an inability to sit or stand in one position. What is the most likely diagnosis?

Accepted Answer

Akathisia

Answer

Acute dystonia

Answer

Tardive dyskinesia

Answer

Rabbit syndrome

Question 2

A patient on antipsychotics for 3 weeks presents with high-grade fever, elevated CPK, and myoglobinuria. What is the most probable diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Tardive dyskinesia

Answer

Acute dystonia

Answer

Akathisia

Question 3

Propranolol, a non-selective beta-blocker, can be prescribed to decrease anxiety associated with which of the following conditions?

Accepted Answer

Short-term stressful situations

Answer

Chronic neurotic disorder

Answer

Schizophrenia

Answer

Endogenous depression

Question 4

What is the treatment of choice for prophylaxis in patients with repeated episodes of bipolar illness?

Accepted Answer

Lithium and Valproate

Answer

Lithium

Answer

Valproate

Answer

None of the above

Question 5

In which condition is the maximum benefit from Electroconvulsive Therapy (ECT) typically observed?

Accepted Answer

Depression with suicidal tendency

Answer

Hysteria

Answer

Chronic schizophrenia

Answer

Mania

Question 6

Which of the following SSRIs is used in the management of pathological emotions?

Accepted Answer

Escitalopram

Answer

Paroxetine

Answer

Clomipramine

Answer

Fluoxetine

Question 7

A child with schizophrenia, who was on antipsychotic medications, suddenly developed neck stiffness and spasm. What is the best treatment for this condition?

Accepted Answer

Benzatropine

Answer

Lorazepam

Answer

Diphenhydramine

Answer

Propranolol

Question 8

A depressed patient does not want to take medication on a daily basis. Which selective serotonin reuptake inhibitor (SSRI) is most suitable for this patient?

Accepted Answer

Fluoxetine

Answer

Escitalopram

Answer

Fluvoxamine

Answer

Paroxetine

Question 9

Which of the following conditions is characterized by twisting and protrusion of the tongue, and chewing of the lips?

Accepted Answer

Tardive dyskinesia

Answer

Acute Akathisia

Answer

Acute Dystonia

Answer

Chronic dystonia

Question 10

What is the treatment of acute manic episodes?

Accepted Answer

Sodium valproate

Answer

Electroconvulsive Therapy (ECT)

Answer

Lithium

Answer

Diazepam

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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