Psychopharmacology Practice Questions

Q: Which of the following neuroleptics is not an atypical antipsychotic?

Zuclopenthixol. **Explanation:** The distinction between antipsychotics is based on their receptor binding profiles and side-effect risks. Antipsychotics are classified into **Typical (First Generation)** and **Atypical (Second Generation)**. **Why Zuclopenthixol is the correct answer:** Zuclopenthixol is a **Typical Antipsychotic** belonging to the thioxanthene class. Its primary mechanism of action is the potent blockade of post-synaptic **D2 receptors** in the mesolimbic and nigrostriatal pathways. Because of this high D2 affinity, it carries a significant risk of Extrapyramidal Side Effects (EPS) and hyperprolactinemia, which is characteristic of first-generation neuroleptics. It is commonly used in clinical practice as a long-acting "Acuphase" injection for acute psychosis. **Analysis of Incorrect Options:** * **Clozapine (A):** The prototype atypical antipsychotic. It has a low affinity for D2 receptors and high affinity for D4 and 5-HT2A receptors. It is the gold standard for treatment-resistant schizophrenia. * **Ziprazidone (B):** An atypical antipsychotic known for its 5-HT2A/D2 antagonism. It is unique for its low risk of weight gain but requires monitoring for QTc interval prolongation. * **Quetiapine (D):** An atypical antipsychotic with a "fast-off" D2 dissociation rate, making it the drug of choice for psychosis in Parkinson’s disease due to its very low EPS risk. **High-Yield NEET-PG Pearls:** 1. **Atypicality Definition:** Atypicals are defined by a high **5-HT2A to D2 receptor blockade ratio**, which reduces the risk of EPS and improves negative symptoms. 2. **Clozapine Warning:** Associated with **agranulocytosis** (requires regular CBC monitoring) and lowering of the seizure threshold. 3. **Metabolic Syndrome:** Atypicals (especially Clozapine and Olanzapine) are highly associated with weight gain, dyslipidemia, and diabetes.

Q: A 31-year-old female patient has been diagnosed with bipolar affective disorder. She is planned to be started on Lithium. Before starting the medication, which of the following laboratory tests should be performed?

Thyroid function tests, serum creatinine, pregnancy test. **Explanation:** Lithium is the gold-standard mood stabilizer for Bipolar Affective Disorder, but it has a narrow therapeutic index and significant systemic side effects, necessitating a thorough baseline workup. **Why Option A is Correct:** 1. **Serum Creatinine (Renal Function):** Lithium is almost exclusively excreted by the kidneys. Impaired renal function can lead to toxic accumulation. Baseline creatinine is essential to calculate the GFR and monitor for potential nephrogenic diabetes insipidus or chronic interstitial nephritis. 2. **Thyroid Function Tests (TFTs):** Lithium inhibits the release of thyroid hormones and can cause goiter or hypothyroidism (in up to 10-20% of patients). Baseline levels are needed to monitor for treatment-induced thyroid dysfunction. 3. **Pregnancy Test (hCG):** Lithium is teratogenic, specifically associated with **Ebstein’s Anomaly** (downward displacement of the tricuspid valve) if taken during the first trimester. **Why Other Options are Incorrect:** * **Options B & C:** While a CBC (specifically WBC count) may show benign leukocytosis under Lithium, it is not a mandatory pre-treatment screening test compared to pregnancy status. * **Options C & D:** Lithium is not metabolized by the liver; therefore, Liver Function Tests (ALT/LFTs) are not required. LFTs are instead mandatory for patients starting Valproate. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Range:** 0.6–1.2 mEq/L (Acute mania: 0.8–1.2; Maintenance: 0.6–0.8). * **Toxicity Level:** >1.5 mEq/L. Dialysis is indicated if levels exceed 4.0 mEq/L (acute) or 2.5 mEq/L (chronic with symptoms). * **ECG Changes:** Lithium can cause T-wave flattening or inversion (similar to hypokalemia). * **Drug Interactions:** **NSAIDs, Thiazides, and ACE inhibitors** increase Lithium levels by decreasing renal clearance. (Mnemonic: **N**o **S**alt **A**t **T**he **A**CE).

Q: Which of the following serum levels of lithium is considered therapeutic?

0.8-1.1 mmol/L. **Explanation:** Lithium is the gold standard mood stabilizer for Bipolar Affective Disorder (BPAD). It has a **narrow therapeutic index**, meaning the difference between a therapeutic dose and a toxic dose is very small, necessitating Therapeutic Drug Monitoring (TDM). **1. Why Option C is Correct:** The standard therapeutic range for lithium in the **acute phase of mania** is generally **0.8 to 1.2 mmol/L** (or mEq/L). Option C (0.8-1.1 mmol/L) falls squarely within this range, providing optimal efficacy in stabilizing mood without immediate high risk of toxicity. **2. Analysis of Incorrect Options:** * **Option A (0.1-0.4 mmol/L):** These levels are sub-therapeutic. They are insufficient to provide clinical improvement in mood symptoms. * **Option B (0.5-0.7 mmol/L):** While this range is often used for **maintenance therapy** (prophylaxis) in stable patients to minimize side effects, it is generally considered too low for treating an acute manic episode. * **Option D (1.2-1.5 mmol/L):** This range approaches the threshold of toxicity. While some refractory cases may require levels up to 1.5 mmol/L under strict supervision, levels above 1.5 mmol/L are clinically defined as **Lithium Toxicity**. **High-Yield Clinical Pearls for NEET-PG:** * **Sampling Time:** Serum levels should be measured **12 hours after the last dose** (Trough level). * **Steady State:** It takes approximately **5 days** (5 half-lives) to reach a steady state after starting or changing a dose. * **Toxicity Thresholds:** * **>1.5 mmol/L:** Mild toxicity (Tremors, nausea, diarrhea). * **>2.0 mmol/L:** Moderate/Severe toxicity (Ataxia, confusion, seizures). * **>3.5 mmol/L:** Life-threatening; requires **Hemodialysis** (Treatment of choice). * **Pre-Lithium Workup:** Always check Renal Function Tests (RFT), Thyroid Function Tests (TFT), and ECG (due to risk of T-wave flattening/inversion).

Q: Which of the following medications is known to cause seizures as a side effect?

Clozapine. **Explanation:** **Clozapine** is the correct answer because it is well-documented for its dose-dependent risk of lowering the seizure threshold. It is an atypical (second-generation) antipsychotic reserved for treatment-resistant schizophrenia. The risk of seizures is approximately 1% at doses below 300 mg/day but increases significantly to about 5% at doses above 600 mg/day. This pro-convulsant effect is thought to be due to its potent antagonistic action at multiple receptors, particularly its effect on GABAergic and glutamatergic neurotransmission. **Incorrect Options:** * **Olanzapine:** While structurally related to clozapine, it has a much lower risk of seizures. Its primary side effects are significant weight gain and metabolic syndrome. * **Aripiprazole:** This is a partial D2 agonist with a very low seizure profile. It is generally considered weight-neutral and is less likely to cause sedation or extrapyramidal symptoms (EPS). * **Amisulpride:** A substituted benzamide that selectively blocks D2/D3 receptors. It is not typically associated with seizures; its main concerns are hyperprolactinemia and QTc prolongation. **High-Yield Clinical Pearls for NEET-PG:** 1. **Clozapine Monitoring:** The most feared side effect is **agranulocytosis** (requires mandatory ANC monitoring), but seizures and **myocarditis** are also critical life-threatening risks. 2. **Management:** If a patient on clozapine develops seizures, the dose should be reduced, and an anticonvulsant (usually **Valproate**) is added. 3. **Other Pro-convulsant Drugs in Psychiatry:** **Bupropion** (antidepressant) is the other high-yield drug known for causing seizures, especially in patients with eating disorders (bulimia/anorexia). 4. **Sialorrhea:** Clozapine is unique for causing excessive salivation (hypersalivation) despite its anticholinergic profile.

Q: Which of the following SSRIs has a sedating property?

Paroxetine. ### Explanation **Correct Option: C. Paroxetine** Paroxetine is unique among Selective Serotonin Reuptake Inhibitors (SSRIs) because it possesses significant **antimuscarinic (anticholinergic) activity**. This mild blockade of cholinergic receptors, combined with its weak inhibition of the norepinephrine transporter, results in a **sedating effect**. Consequently, it is often prescribed for patients with depression associated with significant anxiety or insomnia. **Analysis of Incorrect Options:** * **A. Fluoxetine:** Known as the most "activating" SSRI. It has a long half-life and can cause insomnia and agitation; therefore, it is typically administered in the morning. * **B. Mianserin:** While it is highly sedating, it is a **Tetracyclic Antidepressant (TeCA)**, not an SSRI. It acts as an alpha-2 antagonist. * **D. Clomipramine:** This is a **Tricyclic Antidepressant (TCA)**, specifically a potent serotonin reuptake inhibitor used in OCD. While sedating, it does not belong to the SSRI class. **High-Yield Clinical Pearls for NEET-PG:** * **Weight Gain:** Paroxetine is the SSRI most commonly associated with weight gain and the highest risk of **discontinuation syndrome** due to its short half-life and lack of active metabolites. * **Teratogenicity:** Paroxetine is generally avoided in pregnancy as it is linked to **fetal cardiac malformations** (ASD/VSD). * **Drug Interactions:** It is a potent inhibitor of the **CYP2D6** enzyme. * **Fluvoxamine:** Another SSRI that can be sedating (often used in OCD), but Paroxetine remains the classic textbook answer for sedating SSRIs.

Question 1

Which of the following neuroleptics is not an atypical antipsychotic?

Accepted Answer

Zuclopenthixol

Answer

Clozapine

Answer

Ziprazidone

Answer

Quetiapine

Question 2

A 43-year-old male is diagnosed with Schizophrenia but refuses treatment. Which of the following antipsychotic drugs is the treatment of choice for this patient?

Accepted Answer

Fluphenazine

Answer

Clozapine

Answer

Risperidone

Answer

Olanzapine

Question 3

A 31-year-old female patient has been diagnosed with bipolar affective disorder. She is planned to be started on Lithium. Before starting the medication, which of the following laboratory tests should be performed?

Accepted Answer

Thyroid function tests, serum creatinine, pregnancy test

Answer

Thyroid function tests, serum creatinine, complete blood count

Answer

Thyroid function tests, serum creatinine, ALT

Answer

Thyroid function tests, liver function tests, pregnancy test

Question 4

A 25-year-old male with a life-threatening depressive illness that has not responded adequately to medication is scheduled for electroconvulsive shock therapy (ECT). He is currently taking tranylcypramine. What is the recommended course of action?

Accepted Answer

Proceed with the ECT with caution, using the usual anesthetic drugs.

Answer

Cancel the procedure, cease the tranylcypramine, and perform the ECT in 2 weeks.

Answer

Proceed with the ECT, but induce with midazolam and remifentanil.

Answer

Proceed with the ECT, but pre-treat with esmolol.

Question 5

Which of the following serum levels of lithium is considered therapeutic?

Accepted Answer

0.8-1.1 mmol/L

Answer

0.1-0.4 mmol/L

Answer

0.5-0.7 mmol/L

Answer

1.2-1.5 mmol/L

Question 6

Which of the following are features of serotonin syndrome associated with SSRIs and MAOIs?

Accepted Answer

Tremors, Agitation, Cardiovascular collapse

Answer

Agitation, Cardiovascular collapse

Answer

Tremors, Cardiovascular collapse, Hypothermia

Answer

Agitation, Cardiovascular collapse, Hypothermia

Question 7

Which of the following medications is known to cause seizures as a side effect?

Accepted Answer

Clozapine

Answer

Olanzapine

Answer

Aripiprazole

Answer

Amisulpride

Question 8

Which of the following is the treatment of choice for patients with schizophrenia who refuse to take treatment?

Accepted Answer

Fluphenazine

Answer

Clozapine

Answer

Thioridazine

Answer

Olanzapine

Question 9

Which of the following drugs is both effective and safe to use in a pregnant patient suffering from bipolar disorder?

Accepted Answer

Olanzapine

Answer

Carbamazepine

Answer

Lithium

Answer

Valproic acid

Question 10

Which of the following SSRIs has a sedating property?

Accepted Answer

Paroxetine

Answer

Fluoxetine

Answer

Mianserin

Answer

Clomipramine

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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