Psychotic Disorders — MCQs

A schizophrenic patient exhibits avolition, anhedonia, flat affect, and alogia. He neglects personal hygiene and shows limited engagement with daily activities, although he has chronic delusions of persecution that have less impact on his functioning. Which of the following antipsychotics would be most appropriate to use in treating this patient?

Q248Easy

"I am dead" is a form of?

Q249Easy

What is "Folie à deux"?

Q250Medium

Which of the following is NOT a good prognostic factor for schizophrenia?

Psychotic Disorders Indian Medical PG Practice Questions and MCQs

Question 241: Ekbom syndrome is referred to as:

A. Delusion of infestation (Correct Answer)
B. Delusion of persecution
C. Delusion of love
D. Delusion of infidelity

Explanation: **Explanation:** **Ekbom syndrome**, also known as **Delusional Parasitosis** or **Delusion of Infestation**, is a monosymptomatic hypochondriacal psychosis. Patients hold a fixed, false belief (delusion) that they are infested with small living organisms like insects, lice, worms, or mites, despite medical evidence to the contrary. * **Why Option A is correct:** The hallmark of Ekbom syndrome is the patient's conviction of being infested. Patients often present with the **"Matchbox Sign"** (or "Ziploc bag sign"), where they bring samples of skin debris, lint, or dust to the clinic, claiming they are the parasites. * **Why Option B is incorrect:** **Delusion of persecution** is the belief that one is being conspired against or harmed (common in Schizophrenia). * **Why Option C is incorrect:** **Delusion of love** is known as **De Clerambault’s syndrome** (Erotomania), where a patient believes a person of higher status is in love with them. * **Why Option D is incorrect:** **Delusion of infidelity** is known as **Othello syndrome**, characterized by the irrational belief that one’s partner is being unfaithful. **High-Yield Clinical Pearls for NEET-PG:** 1. **Formication:** The tactile hallucination of insects crawling on or under the skin (often associated with Ekbom syndrome or Cocaine/Amphetamine withdrawal). 2. **Treatment:** The drug of choice is typically an atypical antipsychotic like **Risperidone**. Historically, **Pimozide** was the gold standard. 3. **Differential:** It must be distinguished from organic causes like Vitamin B12 deficiency or drug-induced states.

Question 242: Monosymptomatic hypochondriasis means:

A. Paranoid type delusional disorder
B. De Clerambault syndrome
C. Somatic type delusional disorder (Correct Answer)
D. Othello syndrome

Explanation: **Explanation:** **Monosymptomatic hypochondriasis** is a term historically used to describe a condition where a patient holds a single, fixed, false belief (delusion) regarding their physical health or bodily functions, despite medical reassurance. In modern psychiatric classification (DSM-5/ICD-11), this is categorized as **Somatic type Delusional Disorder**. **Why the correct answer is right:** In Somatic type delusional disorder, the delusion is limited to physical sensations or abnormalities (e.g., believing one emits a foul odor, is infested with parasites, or has misshapen body parts). Unlike "Hypochondriasis" (Illness Anxiety Disorder), where there is a *fear* of having a disease, in Monosymptomatic Hypochondriasis, there is a *conviction* that the disease or defect is present. **Analysis of incorrect options:** * **Paranoid type (Persecutory):** The central theme is being conspired against, cheated, or harassed. * **De Clerambault syndrome (Erotomania):** The delusion that another person, usually of higher status, is in love with the patient. * **Othello syndrome (Morbid Jealousy):** The delusion that one’s spouse or partner is unfaithful. **High-Yield Clinical Pearls for NEET-PG:** * **Ekbom Syndrome:** A specific form of somatic delusional disorder where patients believe they are infested with insects (Delusional Parasitosis). * **Key Distinction:** Delusional disorder is characterized by **non-bizarre delusions** (situations that could occur in real life) and the absence of other prominent psychotic symptoms like hallucinations or thought disorder. * **Treatment:** Second-generation antipsychotics (e.g., Risperidone) are the first-line treatment. Historically, Pimozide was considered the drug of choice for the somatic type.

Question 243: What is the incidence rate of schizophrenia in the general population?

A. 0.50% (Correct Answer)
B. 1%
C. 1.50%
D. 2%

Explanation: **Explanation:** The correct answer is **0.50%**. In psychiatry, it is crucial to distinguish between **incidence** (the rate of new cases occurring over a specific period) and **prevalence** (the total number of cases existing in a population at a given time). 1. **Why A is correct:** The annual **incidence** of schizophrenia is relatively low, typically cited as **0.5 to 1 per 10,000 adults**, which translates to a cumulative incidence of approximately **0.5%** over a lifetime. While some older texts used broader ranges, current epidemiological standards for NEET-PG emphasize this lower figure for incidence. 2. **Why B is incorrect:** **1%** is the classic figure for the **Lifetime Prevalence** of schizophrenia worldwide. This is a common "trap" in exams; students often confuse the total burden of the disease (prevalence) with the rate of new cases (incidence). 3. **Why C & D are incorrect:** Rates of **1.5% to 2%** are significantly higher than the established global average for schizophrenia. Such high figures are generally only seen in specific high-risk cohorts (e.g., children of one affected parent) rather than the general population. **High-Yield Clinical Pearls for NEET-PG:** * **Prevalence:** ~1% (Lifetime); ~0.5% (Point prevalence). * **Incidence:** ~0.5% (Cumulative). * **Gender:** Incidence is roughly equal in males and females, but males have an earlier onset (15–25 years) compared to females (25–35 years). * **Genetic Risk:** The highest risk is in **Monozygotic twins (47-50%)**, followed by children of two affected parents (40-46%). If one sibling has schizophrenia, the risk to another sibling is ~10%.

Question 244: Psychosis is NOT associated with which of the following?

A. Delusion
B. Depression
C. Phobia (Correct Answer)
D. Mania

Explanation: ### Explanation The core feature of **Psychosis** is the **loss of contact with reality**. This is clinically characterized by the presence of delusions, hallucinations, and a lack of insight. **1. Why Phobia is the Correct Answer:** A **Phobia** is an **Anxiety Disorder**, not a psychotic one. In phobias, the patient experiences an irrational, persistent fear of an object or situation. Crucially, the **insight is preserved**—the patient recognizes that their fear is excessive or unreasonable. Because reality testing remains intact, it is classified as a neurotic disorder rather than a psychotic one. **2. Analysis of Incorrect Options:** * **Delusion (A):** This is a hallmark of psychosis. It is defined as a fixed, false belief that is out of keeping with the patient’s social and cultural background and cannot be corrected by logic. * **Depression (B):** Severe depression can present with **psychotic features** (e.g., nihilistic delusions or auditory hallucinations). This is termed "Psychotic Depression." * **Mania (C):** Acute manic episodes in Bipolar Disorder often involve psychotic symptoms, most commonly **delusions of grandeur** or flight of ideas reaching a psychotic intensity. **Clinical Pearls for NEET-PG:** * **Insight:** The presence of insight usually distinguishes Neurosis (Anxiety, Phobia, OCD) from Psychosis (Schizophrenia, Mania). * **Schneider’s First Rank Symptoms (FRS):** These are high-yield diagnostic criteria for Schizophrenia (a primary psychotic disorder). * **Formal Thought Disorder:** Often seen in psychosis (e.g., loosening of associations), whereas thought processes in phobias are logical but anxiety-driven.

Question 245: A 40-year-old air-conditioner technician is referred to a psychiatrist because of a change in behavior and deterioration in functioning. When he feels the gust of cold air coming from the air conditioner, he interprets the cold air as poison gas from Mars. This phenomenon can be described as?

A. Delusional memory
B. Delusional perception (Correct Answer)
C. Tactile hallucination
D. Primary delusion

Explanation: ### Explanation The correct answer is **Delusional perception**. **1. Why Delusional Perception is Correct:** Delusional perception is a **primary delusion** and one of **Schneider’s First Rank Symptoms (SFRS)** of schizophrenia. It occurs in two stages: * **Stage 1:** A normal, real perception occurs (the technician feels the cold air). * **Stage 2:** A delusional, private, and highly significant meaning is attached to that perception (the air is "poison gas from Mars"). There is no logical connection between the perception and the interpretation. In this case, the sensory stimulus (cold air) is real and correctly identified, but the meaning attributed to it is delusional. **2. Analysis of Incorrect Options:** * **A. Delusional memory:** This is a delusion triggered by a past memory (e.g., "I remember when I was five, the doctor gave me a shot; that’s when they implanted the tracking chip"). * **C. Tactile hallucination:** A hallucination is a perception in the *absence* of an external stimulus. Here, the stimulus (cold air) is present; the error lies in the *interpretation*, not the perception itself. * **D. Primary delusion:** While delusional perception is a *type* of primary delusion, "Delusional perception" is the most specific and accurate phenomenological term for this two-stage process. **3. Clinical Pearls for NEET-PG:** * **Schneider’s First Rank Symptoms (SFRS):** Includes delusional perception, somatic passivity, thought insertion/withdrawal/broadcast, and specific auditory hallucinations (third-person, running commentary). * **The "Two-Membered" Process:** Always look for the link between a real stimulus and a bizarre meaning to identify delusional perception. * **Primary vs. Secondary Delusions:** Primary delusions (Autochthonous) arise suddenly ("out of the blue"), whereas secondary delusions are understandable in the context of other symptoms like mood or hallucinations.

Question 246: Which symptom of schizophrenia responds earliest to treatment?

A. Negativism
B. Paranoid delusions
C. Auditory hallucinations (Correct Answer)
D. Apathy

Explanation: ### Explanation In the pharmacological management of schizophrenia, symptoms are categorized into **Positive** (hallucinations, delusions, agitation) and **Negative** (apathy, withdrawal, poverty of speech). Antipsychotic medications, which primarily act by blocking Dopamine (D2) receptors in the mesolimbic pathway, are significantly more effective and faster at resolving positive symptoms than negative ones. **Why Auditory Hallucinations is correct:** Among the positive symptoms, **agitation and combativeness** usually improve within the first 24–48 hours. However, among the core psychotic features, **auditory hallucinations** typically show the earliest measurable improvement, often responding within the first 1–3 weeks of treatment. **Analysis of Incorrect Options:** * **Paranoid Delusions (Option B):** While also a positive symptom, delusions are "fixed false beliefs." They are cognitively more complex and deeply ingrained than hallucinations, typically requiring a longer duration of treatment (several weeks to months) to resolve or become "less systematized." * **Negativism (Option A) & Apathy (Option D):** These are **Negative Symptoms**. Negative symptoms are notoriously resistant to first-generation antipsychotics and show a much slower, often incomplete response to second-generation antipsychotics. They represent a deficit in function rather than an excess of behavior. ### Clinical Pearls for NEET-PG: * **Order of Improvement:** Agitation/Hyperactivity → Hallucinations → Delusions → Negative Symptoms. * **The "Rule of Thirds":** Approximately 1/3 of patients have a good response, 1/3 have a partial response, and 1/3 show poor response to treatment. * **Treatment Resistance:** If a patient fails two adequate trials of antipsychotics (at least 4–6 weeks each), the drug of choice is **Clozapine**. * **Prognosis:** Positive symptoms are associated with a better prognosis, while negative symptoms are the strongest predictors of poor long-term functional outcome.

Question 247: A schizophrenic patient exhibits avolition, anhedonia, flat affect, and alogia. He neglects personal hygiene and shows limited engagement with daily activities, although he has chronic delusions of persecution that have less impact on his functioning. Which of the following antipsychotics would be most appropriate to use in treating this patient?

A. Molindone
B. Haloperidol decanoate
C. Chlorpromazine
D. Olanzapine (Correct Answer)

Explanation: ### Explanation **1. Why Olanzapine is the Correct Answer:** The patient presents with prominent **negative symptoms** (avolition, anhedonia, flat affect, alogia) and social/occupational dysfunction, alongside chronic positive symptoms (delusions). * **Mechanism:** Second-Generation Antipsychotics (SGAs) like Olanzapine act as **Serotonin-Dopamine Antagonists (SDAs)**. By blocking 5-HT2A receptors in the mesocortical pathway, they increase dopamine release in the prefrontal cortex, which is theorized to improve negative symptoms and cognitive deficits. * **Clinical Utility:** Unlike First-Generation Antipsychotics (FGAs), SGAs are the preferred first-line treatment for patients where negative symptoms and functional impairment predominate. **2. Why the Other Options are Incorrect:** * **A. Molindone:** A typical (first-generation) antipsychotic. It is primarily effective against positive symptoms but can worsen negative symptoms due to potent D2 blockade in the mesocortical tract. * **B. Haloperidol Decanoate:** This is a long-acting injectable (LAI) typical antipsychotic. While useful for non-adherence, it is associated with a high risk of Extrapyramidal Side Effects (EPS) and "neuroleptic-induced deficit syndrome," which mimics negative symptoms. * **C. Chlorpromazine:** A low-potency typical antipsychotic. It causes significant sedation and anticholinergic effects, which can further impair the patient’s daily functioning and "alogia-like" presentation. **3. NEET-PG Clinical Pearls:** * **Negative Symptoms (The 5 A's):** Affective flattening, Alogia (poverty of speech), Avolition (lack of motivation), Anhedonia, and Asociality. * **Dopamine Pathways:** * *Mesolimbic:* Overactivity causes Positive symptoms. * *Mesocortical:* Underactivity causes Negative symptoms. * **Side Effect Profile:** While Olanzapine is excellent for negative symptoms, it has the highest risk of **metabolic syndrome** (weight gain, dyslipidemia, and diabetes) among SGAs (second only to Clozapine).

Question 248: "I am dead" is a form of?

A. Nihilistic delusion (Correct Answer)
B. Somatic delusion
C. Delusion of infidelity
D. Delusion of reference

Explanation: **Explanation:** The statement "I am dead" is a classic example of a **Nihilistic delusion**. This is a psychopathological conviction concerning the non-existence of the self, parts of the body, or the external world. When a patient believes they are dead, decomposing, or that their internal organs have vanished, it is specifically referred to as **Cotard’s Syndrome** (also known as "Walking Corpse Syndrome"). This is most commonly associated with severe psychotic depression but can also occur in schizophrenia. **Analysis of Incorrect Options:** * **B. Somatic delusion:** These involve false beliefs about the functioning or appearance of one's body (e.g., believing one is infested with parasites or emitting a foul odor). While nihilistic delusions involve the body, the specific belief of being "dead" or "non-existent" categorizes it as nihilistic. * **C. Delusion of infidelity (Othello Syndrome):** The pathological belief that one's spouse or partner is being unfaithful without any evidence. * **D. Delusion of reference:** The false belief that insignificant remarks, events, or objects in the environment (like news anchors or billboards) have personal meaning or are directed specifically at the patient. **High-Yield Clinical Pearls for NEET-PG:** * **Cotard’s Syndrome:** Characterized by the triad of nihilistic delusions, melancholic depression, and ideas of immortality (paradoxically believing they cannot die because they are already dead). * **Capgras Syndrome:** A "delusional misidentification" where the patient believes a familiar person has been replaced by an identical-looking impostor. * **Fregoli Syndrome:** The belief that different people are actually a single person in disguise. * **Treatment:** Severe nihilistic delusions in depression often require **Electroconvulsive Therapy (ECT)** as they are associated with a high risk of self-neglect and suicide.

Question 249: What is "Folie à deux"?

A. Delusion of doubles
B. Substance abuse disorder
C. Shared delusion with another person (Correct Answer)
D. Dissociative disorder

Explanation: **Explanation:** **Folie à deux** (literally "madness of two") is a rare clinical syndrome, now classified in the DSM-5 under "Other Specified Schizophrenia Spectrum and Other Psychotic Disorder." It occurs when a symptom of psychosis—most commonly a **delusion**—is transmitted from one individual (the "primary" or "inducer") to another (the "secondary" or "recipient"). This typically happens between two people who share a close emotional bond and live in relative social isolation. **Why the other options are incorrect:** * **Option A (Delusion of doubles):** This refers to **Capgras Syndrome**, a delusional misidentification where a person believes a close relative or friend has been replaced by an identical-looking impostor. * **Option B (Substance abuse disorder):** While substance use can induce psychosis, Folie à deux is a primary psychological phenomenon based on interpersonal dynamics, not chemical intoxication. * **Option D (Dissociative disorder):** These disorders involve a breakdown of memory, identity, or perception (e.g., Dissociative Amnesia or DID) and do not typically involve the shared delusional content characteristic of Folie à deux. **NEET-PG High-Yield Pearls:** * **Synonym:** It is also known as **Shared Psychotic Disorder**. * **Management:** The primary step in management is **separating the two individuals**. Often, the delusion in the "secondary" person resolves once they are removed from the influence of the "primary" inducer. * **The Inducer:** Usually has a chronic psychotic illness (like Schizophrenia) and is the more dominant personality in the relationship. * **Variations:** If shared by more than two people, it is called *folie à trois*, *folie à quatre*, or *folie à plusieurs* (madness of many).

Question 250: Which of the following is NOT a good prognostic factor for schizophrenia?

A. Onset at age 12 years (Correct Answer)
B. Catatonic type
C. Female gender
D. More positive symptoms

Explanation: **Explanation:** Prognosis in schizophrenia is determined by several clinical and demographic factors. Understanding these is crucial for NEET-PG, as they frequently appear in clinical vignettes. **Why Option A is the Correct Answer:** **Early age of onset** (especially childhood or early adolescence, like age 12) is a **poor prognostic factor**. Early-onset schizophrenia is typically associated with a higher genetic loading, more structural brain abnormalities, more prominent negative symptoms, and a more chronic, deteriorating course. In contrast, a late onset (older age) is associated with better outcomes. **Why the other options are wrong (Good Prognostic Factors):** * **B. Catatonic type:** Among the subtypes of schizophrenia, the catatonic type generally carries the best prognosis because it often responds rapidly to treatment (ECT or Benzodiazepines) and is frequently associated with an acute onset. * **C. Female gender:** Females generally have a better prognosis than males. This is attributed to a later age of onset, better premorbid social functioning, and the protective effects of estrogen on dopamine receptors. * **D. More positive symptoms:** Patients presenting with "positive symptoms" (hallucinations, delusions) tend to respond better to antipsychotic medications compared to those with "negative symptoms" (apathy, social withdrawal, blunted affect), which are often refractory to treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Best Prognostic Factors:** Acute onset, identifiable precipitating stressor, married status, presence of mood symptoms (depression/anxiety), and good premorbid adjustment. * **Worst Prognostic Factors:** Insidious onset, family history of schizophrenia, single/divorced status, and presence of neurological soft signs. * **Subtype Prognosis:** Catatonic (Best) > Paranoid > Disorganized/Hebephrenic (Worst).

Practice by Chapter

Schizophrenia: Epidemiology and Etiology

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Schizophrenia: Clinical Features

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Schizophrenia: Treatment

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Schizoaffective Disorder

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Delusional Disorders

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Brief Psychotic Disorder

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Substance-Induced Psychotic Disorders

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Psychosis in Medical Conditions

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First Episode Psychosis

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Treatment-Resistant Psychosis

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Rehabilitation in Psychotic Disorders

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Outcome and Prognosis

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