Psychopharmacology — MCQs
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Which of the following statements is true regarding Clozapine?
All of the following are characteristic features of Neuroleptic Malignant Syndrome EXCEPT:
Which of the following drugs are used in the treatment of ADHD?
Depression is not a known side effect of which of the following medications?
Which mood stabilizer is used in the management of drug-induced neutropenia?
Sudden development of a severe throbbing headache is a characteristic side effect of which psychotropic medication?
Which antidepressant drug is known to have both high sedative and anticholinergic activity?
A child with schizophrenia was on medications and suddenly developed neck stiffness and spasm. What is the most probable cause?
Which serotonin-norepinephrine reuptake inhibitor is predominantly used in the condition shown above?
Which of the following medications is not used in the management of delirium?
Psychopharmacology Indian Medical PG Practice Questions and MCQs
Question 51: Which of the following statements is true regarding Clozapine?
- A. It is a traditional antipsychotic.
- B. It can cause agranulocytosis. (Correct Answer)
- C. It is given parenterally.
- D. It is not useful in resistant schizophrenia.
Explanation: **Explanation:** **Clozapine** is the prototype of **Atypical Antipsychotics** (Second Generation Antipsychotics). It is uniquely effective but carries a significant side-effect profile that requires strict monitoring. **Why Option B is correct:** The most serious and life-threatening adverse effect of Clozapine is **agranulocytosis** (a severe decrease in white blood cell count, specifically neutrophils), occurring in approximately 1% of patients. Due to this risk, mandatory hematological monitoring (ANC - Absolute Neutrophil Count) is required weekly for the first 6 months, biweekly for the next 6 months, and monthly thereafter. **Why other options are incorrect:** * **Option A:** Clozapine is an **Atypical** antipsychotic, not traditional. Unlike traditional drugs (like Haloperidol), it has a higher affinity for D4 and 5-HT2A receptors than D2 receptors, leading to fewer Extrapyramidal Side Effects (EPS). * **Option C:** Clozapine is administered **orally**. There is no standard parenteral (injectable) formulation used in clinical practice. * **Option D:** Clozapine is the **Gold Standard** and the drug of choice for **Treatment-Resistant Schizophrenia** (defined as failure to respond to at least two other antipsychotic trials). **High-Yield Clinical Pearls for NEET-PG:** * **Seizures:** Clozapine has a dose-dependent risk of seizures (highest among antipsychotics). * **Sialorrhea:** Paradoxical hypersalivation is a common, highly characteristic side effect. * **Metabolic Syndrome:** It causes significant weight gain, dyslipidemia, and diabetes. * **Myocarditis:** A rare but fatal complication; monitor for chest pain or tachycardia. * **Benefit:** It is the only antipsychotic proven to **reduce the risk of suicide** in schizophrenic patients.
Question 52: All of the following are characteristic features of Neuroleptic Malignant Syndrome EXCEPT:
- A. Decreased creatine phosphokinase (CPK) levels (Correct Answer)
- B. Myoclonus
- C. Hyperthermia
- D. Increased blood pressure
Explanation: **Explanation:** Neuroleptic Malignant Syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs (neuroleptics), primarily caused by potent dopamine (D2) receptor blockade in the nigrostriatal pathway and hypothalamus. **Why Option A is the Correct Answer:** In NMS, there is intense, generalized muscular rigidity (often described as "lead-pipe rigidity"). This extreme muscle contraction leads to rhabdomyolysis (muscle breakdown), which causes a significant **increase in serum Creatine Phosphokinase (CPK) levels**, not a decrease. Elevated CPK is a hallmark laboratory finding in NMS and is used to gauge the severity of muscle damage. **Analysis of Incorrect Options:** * **B. Myoclonus:** While "lead-pipe" rigidity is the classic sign, various movement abnormalities including myoclonus, tremors, and choreoathetosis can occur due to basal ganglia dysfunction. * **C. Hyperthermia:** This is a core diagnostic criterion. Central dopamine blockade in the hypothalamus disrupts thermoregulation, leading to high-grade fever (often >38°C/100.4°F). * **D. Increased blood pressure:** Autonomic instability is a key feature of NMS. This manifests as labile blood pressure (hypertension or hypotension), tachycardia, tachypnea, and diaphoresis. **NEET-PG Clinical Pearls:** * **Mnemonic (FEVER):** **F**ever, **E**ncephalopathy (altered sensorium), **V**itals unstable, **E**levated enzymes (CPK), **R**igidity. * **Drug of Choice:** **Dantrolene** (muscle relaxant) or **Bromocriptine** (dopamine agonist). * **NMS vs. Serotonin Syndrome:** NMS is characterized by "lead-pipe" rigidity and bradyreflexia, whereas Serotonin Syndrome presents with hyperreflexia and clonus. * **Most common offending agent:** Haloperidol (High-potency typical antipsychotic).
Question 53: Which of the following drugs are used in the treatment of ADHD?
- A. All the above (Correct Answer)
- B. Modafinil
- C. Methylphenidate
- D. Amphetamine
Explanation: **Explanation:** Attention-Deficit Hyperactivity Disorder (ADHD) is primarily managed using stimulants that increase synaptic concentrations of dopamine and norepinephrine in the prefrontal cortex. 1. **Methylphenidate:** This is the **first-line pharmacological treatment** for ADHD. It acts by inhibiting the reuptake of dopamine and norepinephrine (NDRI). It is preferred due to its efficacy and relatively manageable side-effect profile. 2. **Amphetamines:** These are potent stimulants that both block the reuptake and increase the release of catecholamines from storage vesicles. They are highly effective and FDA-approved for ADHD. 3. **Modafinil:** While primarily used for narcolepsy, Modafinil is considered a **second-line or "off-label" treatment** for ADHD, particularly in adults or when stimulants are poorly tolerated. It promotes wakefulness and improves focus with a lower risk of abuse compared to traditional stimulants. Since all three drugs are utilized in the clinical management of ADHD, **Option A (All the above)** is the correct choice. **High-Yield Clinical Pearls for NEET-PG:** * **Non-Stimulant of Choice:** **Atomoxetine** (a selective norepinephrine reuptake inhibitor) is the preferred non-stimulant, especially in patients with a history of substance abuse or tics. * **Alpha-2 Agonists:** Guanfacine and Clonidine are used as adjunctive treatments or when stimulants fail. * **Side Effects:** Common side effects of stimulants include insomnia, decreased appetite, weight loss, and potential growth retardation (requiring "drug holidays"). * **Cardiac Screening:** Always screen for underlying cardiac arrhythmias before starting stimulants.
Question 54: Depression is not a known side effect of which of the following medications?
- A. Propranolol
- B. Oral contraceptives
- C. Reserpine
- D. Flupenthixol (Correct Answer)
Explanation: **Explanation** The correct answer is **Flupenthixol**. **1. Why Flupenthixol is the correct answer:** Flupenthixol is a typical antipsychotic of the thioxanthene class. Unlike many other antipsychotics that can cause "neuroleptic-induced deficit syndrome" (mimicking depression), flupenthixol is unique because, at **low doses (0.5 mg – 3 mg)**, it exerts **antidepressant and anxiolytic effects**. It is frequently used clinically in the management of mild-to-moderate depression and dysthymia, often in combination with melitracen. Therefore, it is a treatment for depression rather than a cause. **2. Analysis of incorrect options:** * **Propranolol:** Beta-blockers (especially lipophilic ones like propranolol) are classically associated with depressive symptoms, fatigue, and sleep disturbances due to their ability to cross the blood-brain barrier and interfere with central adrenergic signaling. * **Oral Contraceptives (OCPs):** Hormonal fluctuations caused by OCPs can lead to mood changes. Progestogen-only components, in particular, have been linked to an increased risk of developing depressive symptoms in susceptible individuals. * **Reserpine:** This is a classic "textbook" cause of depression. It works by irreversibly inhibiting the Vesicular Monoamine Transporter (VMAT), leading to the depletion of norepinephrine, serotonin, and dopamine. This observation historically contributed to the "Monoamine Hypothesis" of depression. **3. NEET-PG High-Yield Pearls:** * **Drugs causing depression:** Steroids (most common), Isotretinoin, Interferon-alpha, Methyldopa, L-dopa, and Ethionamide. * **Flupenthixol dosage:** Low dose = Antidepressant; High dose = Antipsychotic. * **Reserpine-induced depression** is often used as an animal model to test new antidepressant drugs.
Question 55: Which mood stabilizer is used in the management of drug-induced neutropenia?
- A. Lithium (Correct Answer)
- B. Valproate
- C. Carbamazepine
- D. Lamotrigine
Explanation: **Explanation:** The correct answer is **Lithium**. **1. Why Lithium is correct:** Lithium is unique among mood stabilizers because it induces **leukocytosis** (specifically neutrophilia). It stimulates the production of granulocyte colony-stimulating factor (G-CSF) in the bone marrow, leading to an increase in the absolute neutrophil count (ANC). While this is technically a side effect, it is utilized therapeutically to counteract drug-induced neutropenia, most notably that caused by **Clozapine**. In patients who develop mild to moderate neutropenia on Clozapine, Lithium can be "co-prescribed" to boost white blood cell counts and allow the continuation of antipsychotic therapy. **2. Why the other options are incorrect:** * **Valproate:** While generally bone-marrow neutral, it can occasionally cause dose-related thrombocytopenia (low platelets), but it does not treat neutropenia. * **Carbamazepine:** This is a high-yield "distractor" because it is actually a **cause** of blood dyscrasias. It can cause benign leukopenia and, in rare cases, life-threatening **aplastic anemia** or agranulocytosis. It is contraindicated if the baseline WBC is low. * **Lamotrigine:** Primarily associated with dermatological side effects (SJS/TEN); it has no significant effect on increasing neutrophil counts. **3. High-Yield Clinical Pearls for NEET-PG:** * **Lithium-induced Leukocytosis:** It is a reversible, non-malignant increase in WBCs (typically 10,000–15,000/mm³). * **Monitoring:** When using Lithium for this purpose, clinicians must ensure they are not masking a true infection or a worsening Clozapine-induced agranulocytosis. * **Other Lithium Side Effects:** Ebstein’s anomaly (teratogenicity), Nephrogenic Diabetes Insipidus, Hypothyroidism, and Fine Tremors. * **Drug of Choice:** Lithium remains the gold standard for classic Bipolar Disorder (Manic-Depressive Illness).
Question 56: Sudden development of a severe throbbing headache is a characteristic side effect of which psychotropic medication?
- A. Lithium carbonate
- B. Phenelzine (Correct Answer)
- C. Diazepam
- D. Thioridazine
Explanation: **Explanation:** The correct answer is **Phenelzine**. The sudden development of a severe throbbing headache in a patient taking Phenelzine is a classic presentation of a **Hypertensive Crisis** (also known as the "Cheese Reaction"). **1. Why Phenelzine is correct:** Phenelzine is a non-selective **Monoamine Oxidase Inhibitor (MAOI)**. MAO is the enzyme responsible for breaking down tyramine in the gut. When a patient on MAOIs consumes tyramine-rich foods (e.g., aged cheese, red wine, smoked meats), tyramine enters the systemic circulation and acts as an indirect sympathomimetic, causing a massive release of stored norepinephrine. This leads to severe hypertension, characterized by a sudden, "explosive" occipital headache, palpitations, and neck stiffness. **2. Why other options are incorrect:** * **Lithium carbonate:** Common side effects include tremors, polyuria (nephrogenic diabetes insipidus), and hypothyroidism. While toxicity can cause neurological symptoms, a sudden throbbing headache is not characteristic. * **Diazepam:** As a benzodiazepine, its primary side effects are sedation, ataxia, and respiratory depression in overdose. It is actually used to *treat* anxiety-related tension, not cause acute headaches. * **Thioridazine:** This low-potency antipsychotic is most famous for causing **retinitis pigmentosa** (at high doses) and QTc prolongation. **Clinical Pearls for NEET-PG:** * **Antidote:** The drug of choice for an MAOI-induced hypertensive crisis is **Phentolamine** (an alpha-blocker). * **Dietary Restriction:** Patients must follow a low-tyramine diet for at least 2 weeks after stopping MAOIs. * **Drug Interaction:** Avoid combining MAOIs with SSRIs or Pethidine to prevent **Serotonin Syndrome**.
Question 57: Which antidepressant drug is known to have both high sedative and anticholinergic activity?
- A. Phenelzine
- B. Amitriptyline (Correct Answer)
- C. Fluoxetine
- D. Trazodone
Explanation: **Explanation:** **Amitriptyline** is a classic **Tricyclic Antidepressant (TCA)** of the tertiary amine subclass. Its pharmacological profile is characterized by potent antagonism at multiple receptors beyond serotonin and norepinephrine reuptake inhibition: * **Anticholinergic activity:** Due to high affinity for Muscarinic (M1) receptors, leading to side effects like dry mouth, blurred vision, and urinary retention. * **Sedative activity:** Due to potent antagonism of Histamine (H1) and alpha-1 adrenergic receptors. Among TCAs, Amitriptyline is considered one of the most sedating, making it useful for depressed patients with insomnia. **Analysis of Incorrect Options:** * **Phenelzine:** An irreversible MAO inhibitor. It lacks significant direct anticholinergic or sedative properties; its main risks are hypertensive crisis (tyramine reaction) and serotonin syndrome. * **Fluoxetine:** An SSRI. These are generally devoid of sedative and anticholinergic effects. In fact, Fluoxetine is often "activating" and can cause insomnia. * **Trazodone:** A SARI (Serotonin Antagonist and Reuptake Inhibitor). While it is **highly sedative** (often used for insomnia), it has **minimal anticholinergic activity**, making it safer for elderly patients regarding cognitive impairment or glaucoma. **High-Yield Clinical Pearls for NEET-PG:** * **Tertiary Amines (Amitriptyline, Imipramine, Clomipramine):** Higher sedation and anticholinergic effects compared to Secondary Amines (Nortriptyline, Desipramine). * **TCA Overdose Triad:** Cardiac arrhythmias (prolonged QTc), Convulsions, and Coma (The "3 Cs"). * **Antidote for TCA toxicity:** Sodium Bicarbonate (to manage QRS widening). * **Drug of Choice:** Amitriptyline is also used for chronic pain prophylaxis (migraine, neuropathic pain).
Question 58: A child with schizophrenia was on medications and suddenly developed neck stiffness and spasm. What is the most probable cause?
- A. Conversion disorder
- B. Acute dystonia (Correct Answer)
- C. Akathisia
- D. Tardive dyskinesia
Explanation: **Explanation:** The clinical presentation of sudden onset neck stiffness and muscle spasms in a patient taking antipsychotics is a classic description of **Acute Dystonia**, a type of Extrapyramidal Side Effect (EPS). **1. Why Acute Dystonia is correct:** Acute dystonia is caused by a sudden blockade of dopamine (D2) receptors in the nigrostriatal pathway, leading to a relative excess of cholinergic activity. It typically occurs within hours to days of starting or increasing the dose of typical antipsychotics (e.g., Haloperidol). Common manifestations include **torticollis** (neck spasm), **retrocollis**, **oculogyric crisis** (upward gaze deviation), and **opisthotonus**. It is most common in young males and children. **2. Why other options are incorrect:** * **Conversion disorder:** This is a psychiatric condition where neurological symptoms (like paralysis or seizures) occur without a medical cause, usually triggered by psychological stress. It does not typically present as isolated muscle spasms following medication. * **Akathisia:** This presents as a subjective feeling of inner restlessness and an inability to sit still. It involves motor restlessness (pacing) rather than involuntary muscle spasms. * **Tardive dyskinesia:** This is a late-onset EPS occurring after months or years of treatment. It involves choreoathetoid movements, most commonly orofacial dyskinesia (lip-smacking, tongue protrusion), rather than acute spasms. **Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Intravenous or intramuscular **Promethazine** or **Benztropine** (anticholinergics). * **Risk Factors:** High-potency first-generation antipsychotics, young age, and male gender. * **Timeline Mnemonic (ADAPT):** **A**cute **D**ystonia (hours), **A**kathisia (days), **P**arkinsonism (weeks), **T**ardive dyskinesia (months/years).
Question 59: Which serotonin-norepinephrine reuptake inhibitor is predominantly used in the condition shown above?
- A. Venlafaxine
- B. Duloxetine (Correct Answer)
- C. Citalopram
- D. Escitalopram
Explanation: ***Duloxetine*** - **FDA-approved** specifically for **fibromyalgia** treatment, making it the preferred SNRI for this condition with proven efficacy in clinical trials. - Works by inhibiting both **serotonin and norepinephrine reuptake**, providing dual mechanism for **pain relief** and **mood stabilization** in fibromyalgia patients. *Venlafaxine* - While it is an **SNRI**, it is **not specifically FDA-approved** for fibromyalgia treatment, unlike duloxetine. - Primarily indicated for **depression** and **anxiety disorders**, with less established evidence for fibromyalgia pain management. *Citalopram* - This is a **selective serotonin reuptake inhibitor (SSRI)**, not an SNRI, making it the wrong drug category. - Lacks the **norepinephrine reuptake inhibition** component that is beneficial for **neuropathic pain** management in fibromyalgia. *Escitalopram* - Also an **SSRI**, not an SNRI, so it doesn't fit the question's requirement for a serotonin-norepinephrine reuptake inhibitor. - Primarily used for **depression** and **anxiety disorders** without specific indication for fibromyalgia pain relief.
Question 60: Which of the following medications is not used in the management of delirium?
- A. Haloperidol
- B. Lithium (Correct Answer)
- C. Diazepam
- D. Olanzapine
Explanation: **Explanation:** Delirium is an acute neuropsychiatric syndrome characterized by a waxing and waning level of consciousness and cognitive deficits. The primary goal of management is treating the underlying cause, but pharmacological intervention is often required for behavioral control. **Why Lithium is the Correct Answer:** **Lithium** is strictly contraindicated in delirium. It is a mood stabilizer with a narrow therapeutic index and significant neurotoxic potential. In a delirious patient, Lithium can worsen confusion, cause tremors, and potentially induce seizures or a "Lithium-induced encephalopathy." Furthermore, delirium is often associated with dehydration and electrolyte imbalances, which can lead to toxic Lithium levels due to decreased renal clearance. **Analysis of Other Options:** * **Haloperidol (Option A):** This is the **drug of choice (DOC)** for delirium. It is a high-potency typical antipsychotic with minimal anticholinergic and sedative effects, making it ideal for managing agitation and psychosis in delirious patients. * **Diazepam (Option C):** While benzodiazepines are generally avoided in delirium (as they can cause paradoxical agitation or worsen confusion), they are the **first-line treatment** for specific types of delirium, namely **Alcohol Withdrawal Delirium (Delirium Tremens)** and sedative-hypnotic withdrawal. * **Olanzapine (Option D):** Atypical antipsychotics (like Olanzapine, Quetiapine, or Risperidone) are frequently used as alternatives to Haloperidol, especially when a lower risk of extrapyramidal side effects (EPS) is desired. **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Delirium:** Haloperidol (Low dose). * **DOC for Delirium Tremens:** Benzodiazepines (e.g., Diazepam, Lorazepam). * **Avoid:** Drugs with strong anticholinergic properties (e.g., Amitriptyline, Diphenhydramine) as they worsen delirium. * **Key Feature:** Delirium is characterized by a **fluctuating** course and **impaired consciousness** (unlike Dementia).
Practice by Chapter
Principles of Psychopharmacology
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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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