Psychotic Disorders — MCQs

Psychotic Disorders Indian Medical PG Practice Questions and MCQs

Question 371: A 45-year-old man is suspicious of others, believing that his coworkers are plotting against him, with no other psychotic symptoms. What is the most likely diagnosis?

A. Schizophrenia
B. Delusional disorder (Correct Answer)
C. Paranoid personality disorder
D. Schizoid personality disorder

Explanation: ***Delusional disorder*** - This condition is characterized by the presence of **non-bizarre delusions** that persist for at least one month, in the absence of other prominent psychotic symptoms. The man's belief that his coworkers are plotting against him fits the criteria for a non-bizarre delusion. - The key here is the **absence of other psychotic symptoms** (e.g., hallucinations, disorganized speech), which differentiates it from other psychotic disorders like schizophrenia. *Schizophrenia* - Schizophrenia involves a broader range of psychotic symptoms, including **hallucinations, disorganized speech, negative symptoms**, or grossly disorganized behavior, in addition to delusions. - While delusions can be a feature, the isolated nature of the delusion without other prominent psychotic symptoms makes schizophrenia less likely. *Paranoid personality disorder* - Individuals with paranoid personality disorder have a pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent, but these beliefs are typically at the level of suspicion or preoccupation rather than fixed, unshakeable delusions. - The intensity and fixed nature of the belief described (coworkers *are* plotting against him) suggest a delusional level of conviction, transcending the level of personality trait. *Schizoid personality disorder* - This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression. - It does not typically involve suspiciousness or delusions, but rather a lack of interest in social interaction and emotional warmth.

Question 372: A 45-year-old man with a history of schizophrenia presents with flat affect, alogia, and avolition. Which of the following best describes his symptoms?

A. Negative symptoms (Correct Answer)
B. Positive symptoms
C. Cognitive symptoms
D. Affective symptoms

Explanation: ***Negative symptoms*** - **Flat affect**, **alogia** (poverty of speech), and **avolition** (lack of motivation) are classic examples of negative symptoms in schizophrenia. - These symptoms represent a **reduction or absence of normal functions** and are often more disabling and harder to treat than positive symptoms. *Positive symptoms* - These symptoms involve an **excess or distortion of normal functions**, such as **hallucinations**, **delusions**, and disorganized thought or behavior. - The patient's presentation of flat affect, alogia, and avolition does not include these exaggerated or distorted experiences. *Cognitive symptoms* - **Cognitive symptoms** involve difficulties with attention, memory, executive functions (e.g., planning, problem-solving), and processing speed. - While common in schizophrenia, the described symptoms (flat affect, alogia, avolition) do not primarily fall under the cognitive domain. *Affective symptoms* - **Affective symptoms** relate to disturbances in mood, such as **depression**, **anxiety**, or **irritability**. - While emotional blunting (flat affect) is a negative symptom, the term "affective symptoms" typically refers to broader mood disorders, which are not explicitly described here.

Question 373: What is the most appropriate treatment for a 45-year-old male presenting with severe acute agitation and aggression due to schizophrenia?

A. Haloperidol (Correct Answer)
B. Fluoxetine
C. Lithium
D. Lorazepam

Explanation: ***Haloperidol*** - **Haloperidol**, a **first-generation antipsychotic**, is the **most appropriate single-agent treatment** for **severe acute agitation and aggression** in the context of schizophrenia. - It addresses **both the underlying psychotic symptoms** (hallucinations, delusions) **and the acute agitation**, making it superior to medications that only address sedation. - Its **rapid onset of action** and availability in parenteral formulations (IM/IV) make it ideal for urgent situations requiring immediate intervention. - Haloperidol is widely used in emergency settings and has a well-established safety profile for acute management. *Fluoxetine* - **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)** primarily used to treat **depression** and **anxiety disorders**. - It is generally *not* effective for acute agitation associated with schizophrenia and can sometimes worsen psychotic symptoms or induce agitation as a side effect, especially in acute psychotic phases. - SSRIs have a **delayed onset of action** (weeks), making them completely unsuitable for acute management. *Lithium* - **Lithium** is a **mood stabilizer** primarily used for the treatment and prevention of episodes in **bipolar disorder**. - While it can help with mood stabilization and reduce aggression in chronic settings, it has a **slow onset of action** (requires therapeutic levels over days to weeks) and is *not* indicated for the rapid control of acute agitation and aggression in schizophrenia. - Lithium does not address the psychotic symptoms underlying the agitation. *Lorazepam* - **Lorazepam**, a **benzodiazepine**, is effective for **acute sedation** and is often used as an **adjunct to antipsychotics** for rapid tranquilization in severe agitation. - However, as a **sole agent**, it has significant limitations: it does *not* treat the **underlying psychotic symptoms** (hallucinations, delusions) driving the agitation, only provides sedation. - Lorazepam can sometimes cause **disinhibition** or **paradoxical agitation** in vulnerable individuals. - **Current practice:** The combination of **haloperidol + lorazepam** is often used together for optimal rapid tranquilization, but when selecting a **single most appropriate agent**, haloperidol is preferred because it addresses both psychosis and agitation.

Question 374: A 35-year-old male with schizophrenia experiences persistent delusions despite being on antipsychotic medication and does not show significant improvement. What is the most appropriate next step?

A. Start cognitive-behavioral therapy
B. Switch to clozapine (Correct Answer)
C. Switch to a long-acting injectable antipsychotic
D. Increase the dose of the current antipsychotic

Explanation: ***Switch to clozapine*** - The patient has **persistent delusions despite antipsychotic medication**, suggesting treatment-resistant schizophrenia. - **Clozapine** is the gold standard for treatment-resistant schizophrenia (failure to respond to at least two adequate trials of different antipsychotics). - It is superior to all other antipsychotics for treatment-resistant cases, with **30-60% response rates** in previously non-responsive patients. - Requires **regular blood monitoring** (weekly for first 18 weeks, then biweekly) for agranulocytosis risk. - According to **NICE guidelines** and major psychiatric textbooks, clozapine should be considered when a patient shows inadequate response to standard antipsychotics. *Increase the dose of the current antipsychotic* - This would be appropriate only if the current medication is at a **subtherapeutic dose** and hasn't been given an adequate trial. - The stem indicates "persistent delusions despite being on antipsychotic medication," suggesting an adequate trial has been attempted. - Arbitrary dose increases without evidence of subtherapeutic levels can increase **side effects** (extrapyramidal symptoms, metabolic syndrome) without improving efficacy. - If dose optimization were needed, this would be done before labeling as treatment-resistant. *Start cognitive-behavioral therapy* - **CBT for psychosis** is a valuable adjunctive treatment for schizophrenia, particularly for residual positive symptoms. - However, it should complement, not replace, optimization of pharmacological management in treatment-resistant cases. - Most effective when used **alongside clozapine** rather than as an alternative to appropriate medication adjustment. *Switch to a long-acting injectable antipsychotic* - Long-acting injectables (LAIs) primarily address **medication adherence** issues and reduce relapse rates. - Useful when non-adherence is suspected, but the stem doesn't suggest compliance problems. - Switching to an LAI of the same medication doesn't address treatment resistance if the drug itself is ineffective at adequate doses.

Question 375: A 45-year-old woman with schizophrenia presents with persistent delusions and hallucinations despite adequate trials of risperidone and olanzapine at therapeutic doses. What is the most appropriate next step?

A. Increase the risperidone dose
B. Switch to clozapine (Correct Answer)
C. Add a benzodiazepine
D. Start cognitive-behavioral therapy

Explanation: ***Switch to clozapine*** - **Clozapine** is an **atypical antipsychotic** indicated for **treatment-resistant schizophrenia**, defined as inadequate response to two different antipsychotics (one of which should be a second-generation antipsychotic) taken at adequate doses and duration. - Given the patient's persistent delusions and hallucinations despite adherence to risperidone, clozapine is the most appropriate next step for better symptom control. *Increase the risperidone dose* - While dose escalation is often an initial strategy, continued symptoms despite adherence to an existing antipsychotic suggest that the patient may be experiencing **treatment-resistant schizophrenia**, and merely increasing the dose may not be sufficient. - Moving to a medication with a different mechanism or higher efficacy in such cases, like **clozapine**, is typically more effective than simply increasing the dose of a drug that has already failed. *Add a benzodiazepine* - **Benzodiazepines** are generally used for acute agitation or anxiety in schizophrenia, but they do not address the **primary psychotic symptoms** like delusions and hallucinations. - Adding a benzodiazepine would *not* treat the underlying psychosis and carries risks of dependence and sedation. *Start cognitive-behavioral therapy* - **Cognitive-behavioral therapy (CBT)** can be a helpful adjunct for managing symptoms, reducing distress, and improving functioning in schizophrenia. - However, it is not a primary treatment for actively psychotic symptoms and would not be the first-line intervention when pharmacological treatment has failed to control delusions and hallucinations.

Question 376: A 45-year-old male with a history of schizophrenia presents with poor adherence to oral medication. What is the most appropriate management?

A. Switch to a different oral antipsychotic
B. Add a benzodiazepine
C. Switch to a long-acting injectable antipsychotic (Correct Answer)
D. Start cognitive-behavioral therapy

Explanation: ***Switch to a long-acting injectable antipsychotic*** - **Long-acting injectable (LAI) antipsychotics** improve medication adherence by reducing the frequency of administration, which is crucial for patients with a history of poor oral medication adherence. - This approach ensures consistent therapeutic drug levels, reducing the risk of **relapse** and rehospitalization in patients with schizophrenia. *Switch to a different oral antipsychotic* - Switching to another **oral antipsychotic** does not address the fundamental issue of poor adherence, as the patient may still struggle with taking daily pills. - While a different oral medication might offer a better side effect profile or efficacy, it won't resolve the primary problem of **non-adherence**. *Add a benzodiazepine* - **Benzodiazepines** are primarily used for acute agitation, anxiety, or insomnia and are not a long-term treatment for schizophrenia or a solution for antipsychotic non-adherence. - Their use carries risks of **dependence** and sedation, and they do not address the positive or negative symptoms of schizophrenia itself. *Start cognitive-behavioral therapy* - While **cognitive-behavioral therapy (CBT)** can be beneficial for managing symptoms and improving coping skills in schizophrenia, it is not the most immediate or direct solution for poor medication adherence. - Adherence often requires a more tangible intervention to ensure medication is taken, especially in patients with **insight difficulties** or organizational challenges.

Question 377: A 45-year-old man presents with auditory hallucinations and paranoid delusions. He has been on risperidone for 6 months with a partial response. What is the next best step in management?

A. Add a mood stabilizer
B. Start cognitive-behavioral therapy
C. Switch to clozapine
D. Increase the dose of risperidone (Correct Answer)

Explanation: ***Increase the dose of risperidone*** - Since the patient has shown a **partial response** to risperidone after 6 months, the key consideration is whether the medication has been given at an **adequate therapeutic dose**. - If the dose has not been optimized (e.g., patient remains on a low dose), increasing it within the therapeutic range is appropriate before considering a medication switch. - **Standard approach**: Optimize the current medication to maximum therapeutic dose before switching, unless there are intolerable side effects or complete non-response. - While 6 months is a substantial duration, if dose optimization has not occurred, this remains the next logical step. *Switch to clozapine* - **Clozapine** is reserved for **treatment-resistant schizophrenia (TRS)**, defined as inadequate response to at least **two adequate trials** of different antipsychotics (each at therapeutic doses for 4-6 weeks). - This patient has only had one antipsychotic trial with risperidone, making it premature to initiate clozapine. - Clozapine requires intensive monitoring (weekly blood counts initially) due to risk of **agranulocytosis** and should only be used after documented failure of multiple first-line agents. *Add a mood stabilizer* - Mood stabilizers (lithium, valproate) are indicated when there are prominent **mood symptoms** suggesting **bipolar disorder** or **schizoaffective disorder**. - This patient's presentation focuses on positive psychotic symptoms (hallucinations, delusions) without mention of mood episodes, making augmentation with a mood stabilizer not the primary next step. - While augmentation strategies exist for partial response, optimizing the primary antipsychotic takes precedence. *Start cognitive-behavioral therapy* - **CBT for psychosis** is an evidence-based adjunctive treatment that helps patients cope with persistent symptoms, challenge delusional beliefs, and improve functioning. - However, with ongoing active psychotic symptoms and suboptimal pharmacological management, **medication optimization is the priority**. - CBT is most effective when used **in conjunction with** optimized pharmacotherapy, not as a replacement for inadequate medication management.

Question 378: In the treatment of schizophrenia, why might a switch from a typical antipsychotic to an atypical antipsychotic be considered?

A. Reduced risk of extrapyramidal symptoms (Correct Answer)
B. Increased dopamine receptor antagonism
C. Longer half-life allowing less frequent dosing
D. Some atypical antipsychotics may improve cognitive function

Explanation: ***Reduced risk of extrapyramidal symptoms*** - Atypical antipsychotics (second-generation) have a **lower affinity for D2 dopamine receptors** and a higher affinity for **serotonin 5-HT2A receptors** compared to typical antipsychotics. - This receptor profile results in a **significantly reduced risk of extrapyramidal symptoms (EPS)** like dystonia, akathisia, and parkinsonism, which are common with typical antipsychotics. *Increased dopamine receptor antagonism* - Atypical antipsychotics actually have **less potent D2 dopamine receptor antagonism** compared to typical antipsychotics, which is why they cause fewer extrapyramidal symptoms. - While they still block dopamine receptors, their **serotonin 5-HT2A antagonism** is believed to mitigate the severe D2 blockade effects. *Longer half-life allowing less frequent dosing* - The half-life of an antipsychotic is a property of the specific drug, not a defining characteristic that differentiates atypical from typical antipsychotics as a class. - Both typical and atypical antipsychotics include drugs with varying half-lives, and **extended-release formulations** are available for both types, not exclusively for atypical ones. *Some atypical antipsychotics may improve cognitive function* - While some atypical antipsychotics may show **modest improvements or stabilization of cognitive function** in some patients, this is not the primary or most common reason for switching from typical antipsychotics. - The most compelling reason for the switch is often to **reduce the burden of debilitating side effects** like EPS, which directly impact a patient's quality of life and adherence.

Question 379: A 45-year-old man believes that he has been receiving secret messages through the television for the past year. He is otherwise functioning well and has no other psychiatric symptoms. What is the most likely diagnosis?

A. Schizophrenia
B. Delusional disorder (Correct Answer)
C. Major depressive disorder with psychotic features
D. Bipolar disorder

Explanation: ***Delusional disorder*** - The presence of a **fixed, false belief** (receiving secret messages) lasting over a month, without other significant psychiatric symptoms or functional impairment, is characteristic of **delusional disorder**. - In this case, the patient is "otherwise functioning well" and has "no other psychiatric symptoms," pointing away from more pervasive psychotic disorders. *Schizophrenia* - Schizophrenia typically involves a broader range of symptoms, including **disorganized thought and speech**, **negative symptoms** (e.g., flat affect, anhedonia), and significant functional impairment, none of which are described here. - While delusions are a core feature of schizophrenia, they are usually accompanied by other psychotic symptoms and a decline in overall functioning. *Major depressive disorder with psychotic features* - This diagnosis would require prominent symptoms of a **major depressive episode**, such as depressed mood, anhedonia, and vegetative symptoms, alongside psychotic features. - The patient is described as "otherwise functioning well" and having "no other psychiatric symptoms," ruling out a primary mood disorder. *Bipolar disorder* - Bipolar disorder involves episodes of both **mania/hypomania** and **depression**, often with psychotic features occurring during severe mood episodes. - The patient's presentation of isolated delusions without mood cycling or the full symptom constellation of either manic or depressive episodes does not fit bipolar disorder.

Question 380: Which of the following statements is not true regarding delusional disorder?

A. Held with some conviction
B. Usually false (Correct Answer)
C. Not easily amenable to reasoning
D. Occurs at a later age

Explanation: ***Usually false*** ✓ Correct Answer - This statement is **NOT TRUE** because delusions are **by definition always false beliefs**, not "usually false" - Delusions are **fixed false beliefs** that are firmly held despite evidence to the contrary - Saying "usually false" suggests they could sometimes be true, which contradicts the fundamental definition of a delusion - A true belief, no matter how unusual, is **not a delusion** by psychiatric criteria *Held with some conviction* - This is TRUE - Delusional disorder is characterized by the presence of **non-bizarre delusions** held with strong conviction - Patients do not recognize their beliefs as problematic and will **defend their delusional ideas** when challenged *Not easily amenable to reasoning* - This is TRUE - A key feature of delusional disorder is the patient's **resistance to logical argument** or conflicting evidence - This inflexibility is a hallmark of **delusional thinking**, distinguishing it from overvalued ideas or obsessions *Occurs at a later age* - This is TRUE - Delusional disorder typically has a **later age of onset** compared to schizophrenia - Often appearing in **middle to late adulthood** (40-49 years), distinguishing it from disorders that manifest in late adolescence or early adulthood

Practice by Chapter

Schizophrenia: Epidemiology and Etiology

Practice Questions

Schizophrenia: Clinical Features

Practice Questions

Schizophrenia: Treatment

Practice Questions

Schizoaffective Disorder

Practice Questions

Delusional Disorders

Practice Questions

Brief Psychotic Disorder

Practice Questions

Substance-Induced Psychotic Disorders

Practice Questions

Psychosis in Medical Conditions

Practice Questions

First Episode Psychosis

Practice Questions

Treatment-Resistant Psychosis

Practice Questions

Rehabilitation in Psychotic Disorders

Practice Questions

Outcome and Prognosis

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free