Psychotic Disorders — MCQs

A 37-year-old man reports that after a sudden financial loss, he had a bout of illness in which he felt sad and nervous and fearful, could not sleep or eat properly. He also began to hear voices telling him that he was useless and should kill himself. His symptoms stopped after approximately one week. He has had no similar episodes. Medical history includes no psychiatric conditions. Physical examination shows no abnormalities, and results of laboratory studies are within normal limits. Which of the following is the most likely diagnosis?

Q67Medium

Ambivalency and ambitendency are typically seen in which of the following conditions?

Q68Easy

All of the following are Schneider's first-rank symptoms except?

Q69Easy

Delusion is a disorder of:

Q70Easy

Schneider's first-rank symptoms are typically seen in which of the following conditions?

Psychotic Disorders Indian Medical PG Practice Questions and MCQs

Question 61: Anhedonia seen in schizophrenia is linked to which of the following neurotransmitter abnormalities?

A. Serotonin
B. Norepinephrine (Correct Answer)
C. Glutamate
D. GABA

Explanation: **Explanation:** In the context of Schizophrenia, **Anhedonia** (the inability to experience pleasure) is traditionally considered a **negative symptom**. While dopamine dysregulation is the hallmark of schizophrenia's positive symptoms, the specific deficit in the reward system leading to anhedonia is strongly linked to **Norepinephrine (NE)**. According to the **Stein and Wise hypothesis**, anhedonia in schizophrenia results from the degeneration of the **noradrenergic reward system** (specifically the fibers arising from the locus coeruleus and projecting to the limbic system). A deficit in norepinephrine leads to a diminished capacity for reinforcement and pleasure, contributing to the "flatness" seen in chronic schizophrenia. **Analysis of Incorrect Options:** * **Serotonin (A):** While serotonin is involved in mood and impulse control, and atypical antipsychotics act on 5-HT2A receptors to alleviate some negative symptoms, it is not the primary neurotransmitter linked specifically to the mechanism of anhedonia in classic psychiatric teaching. * **Glutamate (C):** Glutamate hypofunction (NMDA receptor hypothesis) explains cognitive deficits and overall pathophysiology but is not the specific correlate for the pleasure-deficit state. * **GABA (D):** GABA is the primary inhibitory neurotransmitter. Deficits are linked to cognitive impairment and loss of inhibitory control in schizophrenia, rather than the reward system. **High-Yield Clinical Pearls for NEET-PG:** * **Positive Symptoms:** Linked to **Dopamine excess** in the Mesolimbic pathway. * **Negative Symptoms:** Linked to **Dopamine deficit** in the Mesocortical pathway. * **Anhedonia Specificity:** If the question asks for the neurotransmitter specifically linked to the *reward system impairment* in schizophrenia, think **Norepinephrine**. * **Anhedonia in Depression:** In contrast, anhedonia in Major Depressive Disorder is more commonly associated with **Dopamine** and **Serotonin** dysfunction.

Question 62: Catatonic schizophrenia is associated with which of the following?

A. Paranoid thoughts
B. Suicidal behavior
C. Motor symptoms (Correct Answer)
D. Mental retardation

Explanation: **Explanation:** **Catatonic schizophrenia** is a subtype of schizophrenia (though classified under "Catatonia associated with another mental disorder" in DSM-5) primarily characterized by significant **psychomotor disturbances**. These disturbances can range from marked unresponsiveness to excessive motor activity. **Why Motor Symptoms is correct:** The hallmark of catatonia is a clinical syndrome of specific motor signs. These include **waxy flexibility** (cerea flexibilitas), **stupor** (no psychomotor activity), **mutism**, **negativism** (opposition to instructions), **posturing** (active maintenance of a posture against gravity), and **catatonic excitement** (purposeless, excessive motor activity). Because the diagnosis is defined by these physical manifestations rather than thought content, motor symptoms are the defining association. **Analysis of Incorrect Options:** * **A. Paranoid thoughts:** While common in the *Paranoid subtype* of schizophrenia, they are not the defining feature of catatonia. * **B. Suicidal behavior:** While patients with schizophrenia have a higher risk of suicide, it is not a diagnostic or specific feature of the catatonic subtype. * **D. Mental retardation:** Now termed Intellectual Disability (ID), this is a neurodevelopmental condition. While ID can co-occur with psychiatric disorders, it is not a feature of catatonic schizophrenia. **High-Yield NEET-PG Pearls:** * **Drug of Choice:** Benzodiazepines (specifically **Lorazepam**) are the first-line treatment (the "Lorazepam Challenge Test" is also diagnostic). * **Best Prognosis:** Among schizophrenia subtypes, Catatonic schizophrenia often has a better prognosis and rapid response to treatment compared to the Hebephrenic (Disorganized) subtype. * **ECT:** Electroconvulsive Therapy is highly effective and indicated if the patient is non-responsive to medications or is in a life-threatening state (e.g., Malignant Catatonia). * **Key Sign:** **Ambitendency** (the patient hesitates between two opposing movements) is a classic motor sign.

Question 63: A 50-year-old male presents with a 5-year history of persistent doubt regarding his wife's fidelity, despite evidence to the contrary. All other aspects of his life are normal. What is the most probable diagnosis?

A. Panic disorder
B. Depressive disorder
C. Delusional disorder (Correct Answer)
D. Phobia

Explanation: ### Explanation **Correct Answer: C. Delusional Disorder** The clinical presentation describes a classic case of **Delusional Disorder (Jealous type)**, also known as Othello syndrome. The diagnosis is based on the following criteria: 1. **Presence of a non-bizarre delusion:** A persistent, fixed false belief (wife’s infidelity) held with absolute certainty despite contradictory evidence. 2. **Duration:** The symptoms have lasted for >1 month (5 years in this case). 3. **Preserved Functioning:** Apart from the impact of the delusion, the patient’s psychosocial functioning is remarkably well-preserved, and their behavior is not obviously odd or bizarre. This "encapsulated" nature of the delusion distinguishes it from Schizophrenia. **Why other options are incorrect:** * **A. Panic Disorder:** Characterized by recurrent, unexpected panic attacks (sudden surges of intense fear) and physical symptoms like palpitations or dyspnea. It does not involve fixed false beliefs. * **B. Depressive Disorder:** While depression can sometimes feature psychotic elements, the primary symptoms are low mood, anhedonia, and lethargy. In this case, the patient’s life is otherwise "normal," which rules out a primary mood disorder. * **D. Phobia:** Involves an irrational, intense fear of a specific object or situation leading to avoidance behavior. It is an anxiety disorder, not a psychotic disorder. **High-Yield Clinical Pearls for NEET-PG:** * **Othello Syndrome:** Specifically refers to the delusion of infidelity (morbid jealousy). * **De Clerambault’s Syndrome (Erotomania):** Delusion that another person (usually of higher status) is in love with the patient. * **Ekbom Syndrome:** Delusional parasitosis (belief that one is infested with insects). * **Capgras Syndrome:** The belief that a familiar person has been replaced by an identical-looking impostor. * **Treatment of Choice:** Atypical antipsychotics (e.g., Risperidone) and Cognitive Behavioral Therapy (CBT), though these patients often lack insight and are difficult to treat.

Question 64: Which of the following is considered a negative symptom of schizophrenia?

A. Hallucination
B. Delusion
C. Ambivalence (Correct Answer)
D. Motor hyperactivity

Explanation: **Explanation:** In Schizophrenia, symptoms are broadly categorized into **Positive** (excess or distortion of normal function) and **Negative** (loss or deficit of normal function). **Why Ambivalence is the Correct Answer:** Ambivalence refers to the simultaneous existence of contradictory emotions, ideas, or desires toward the same object or situation, leading to an inability to make decisions (avolition). It is one of the classic **"4 As" of Bleuler**, which are the fundamental symptoms of schizophrenia. Negative symptoms represent a "diminution" of normal emotional and behavioral states. Ambivalence reflects a deficit in goal-directed behavior and emotional integration, placing it firmly in the negative/deficit category. **Analysis of Incorrect Options:** * **A. Hallucination:** These are sensory perceptions in the absence of external stimuli. They represent an "added" abnormal experience, making them a hallmark **Positive symptom**. * **B. Delusion:** These are fixed, false beliefs held despite evidence to the contrary. Like hallucinations, they represent a distortion of thought content and are **Positive symptoms**. * **C. Motor Hyperactivity:** This is a feature of psychomotor agitation or catatonic excitement. Since it involves an "excess" of motor activity, it is classified as a **Positive/Disorganized symptom**. **NEET-PG High-Yield Pearls:** * **Bleuler’s 4 As:** Remember the mnemonic **A**ffective flattening, **A**utism, **A**mbivalence, and **A**ssociational looseness. * **Schneider’s First Rank Symptoms (FRS):** These focus primarily on positive symptoms (e.g., thought insertion, audible thoughts) and are used for diagnosis, but their absence does not rule out schizophrenia. * **Prognosis:** Negative symptoms (like apathy, anhedonia, and alogia) are generally more resistant to typical antipsychotics and are associated with a **poorer long-term prognosis** compared to positive symptoms.

Question 65: According to ICD-10 criteria, for how long must symptoms persist for the diagnosis of schizophrenia?

A. 2 months
B. 1 month (Correct Answer)
C. 6 months
D. 2 weeks

Explanation: **Explanation:** The diagnosis of Schizophrenia requires a specific duration of symptoms to differentiate it from transient psychotic states. According to the **ICD-10** (International Classification of Diseases, 10th Revision), the characteristic symptoms (such as delusions, hallucinations, or thought disorder) must be present for a minimum period of **one month**. * **Why Option B is Correct:** ICD-10 criteria stipulate that at least one "very clear" symptom (from groups like thought echo, delusions of control, or persistent hallucinations) or two symptoms from less specific groups (like negative symptoms or catatonic behavior) must be present for **most of the time during a period of at least one month**. * **Why Option C is Incorrect:** A **6-month** duration is the requirement for Schizophrenia according to the **DSM-5** (Diagnostic and Statistical Manual of Mental Disorders). This is a frequent point of confusion in exams. * **Why Option D is Incorrect:** Symptoms lasting less than one month but more than a few days are often classified under **Acute and Transient Psychotic Disorders** (F23) in ICD-10. * **Why Option A is Incorrect:** Two months is not a standard diagnostic cutoff for schizophrenia in either major classification system. **High-Yield Clinical Pearls for NEET-PG:** 1. **ICD-10 vs. DSM-5:** Remember the "1 vs. 6" rule. ICD-10 = 1 month; DSM-5 = 6 months (which must include at least 1 month of active-phase symptoms). 2. **Schneider’s First Rank Symptoms (FRS):** These are highly suggestive of schizophrenia and are heavily weighted in the ICD-10 criteria. 3. **Prognosis:** Good prognostic factors include late onset, female sex, presence of mood symptoms, and being married. Poor prognosis is associated with insidious onset, young age, and prominent negative symptoms.

Question 66: A 37-year-old man reports that after a sudden financial loss, he had a bout of illness in which he felt sad and nervous and fearful, could not sleep or eat properly. He also began to hear voices telling him that he was useless and should kill himself. His symptoms stopped after approximately one week. He has had no similar episodes. Medical history includes no psychiatric conditions. Physical examination shows no abnormalities, and results of laboratory studies are within normal limits. Which of the following is the most likely diagnosis?

A. Schizophreniform disorder
B. Brief psychotic disorder (Correct Answer)
C. Schizo-affective disorder
D. Schizophrenia

Explanation: ### Explanation The correct diagnosis is **Brief Psychotic Disorder**. **1. Why Brief Psychotic Disorder is correct:** According to DSM-5/ICD criteria, Brief Psychotic Disorder is characterized by the sudden onset of at least one positive psychotic symptom (delusions, hallucinations, or disorganized speech/behavior). Crucially, the duration of the episode is **more than 1 day but less than 1 month**, with an eventual full return to the premorbid level of functioning. This patient’s symptoms (auditory hallucinations) lasted for **one week** and were preceded by a clear psychosocial stressor (financial loss), which is a common trigger. **2. Why the other options are incorrect:** * **Schizophreniform Disorder:** Requires the duration of symptoms to be **between 1 month and 6 months**. This patient’s symptoms lasted only one week. * **Schizophrenia:** Requires a continuous period of illness for **at least 6 months**, including at least one month of active-phase symptoms and significant functional decline. * **Schizo-affective Disorder:** Requires a period of illness where there is a major mood episode (manic or depressive) concurrent with symptoms of schizophrenia, preceded or followed by at least **2 weeks of delusions or hallucinations** in the absence of a major mood episode. **3. High-Yield Clinical Pearls for NEET-PG:** * **Duration-based differentiation is key:** * < 1 month: Brief Psychotic Disorder. * 1–6 months: Schizophreniform Disorder. * \> 6 months: Schizophrenia. * **Prognosis:** Brief Psychotic Disorder generally has a good prognosis, especially when triggered by a marked stressor (formerly called "Brief Reactive Psychosis"). * **Specifiers:** Always look for "with marked stressors" or "postpartum onset" in the history. * **Suicide Risk:** Even though the duration is short, the risk of suicide is high due to the sudden onset and nature of command hallucinations (as seen in this case).

Question 67: Ambivalency and ambitendency are typically seen in which of the following conditions?

A. Substance abuse
B. Alzheimer's disease
C. Schizophrenia
D. Obsessive-compulsive disorder (Correct Answer)

Explanation: **Explanation:** The correct answer is **Obsessive-compulsive disorder (OCD)**. **Why OCD is correct:** In the context of OCD, **ambivalency** refers to the coexistence of opposing emotions or ideas toward the same object or situation, leading to profound indecisiveness (*folie du doute*). **Ambitendency** is the motor expression of this psychological conflict, where the patient manifests conflicting physical movements (e.g., reaching for an object but withdrawing the hand simultaneously). These features stem from the core pathology of OCD: the inability to reach a sense of "certainty" or "completion," leading to a state of constant doubt and repetitive, hesitant behavior. **Why other options are incorrect:** * **Schizophrenia:** While Eugen Bleuler originally described "Ambivalence" as one of the **4 As** of Schizophrenia, in modern clinical examinations (and specifically NEET-PG patterns), when ambivalency and ambitendency are paired together as a clinical presentation of pathological doubt and motor hesitation, **OCD** is the preferred answer. * **Substance Abuse:** Typically presents with intoxication, withdrawal, or craving symptoms, not the specific psychological-motor conflict of ambitendency. * **Alzheimer’s Disease:** Characterized by cognitive decline and memory loss; while patients may be confused, they do not typically exhibit the classic ambitendency seen in obsessive-compulsive states. **Clinical Pearls for NEET-PG:** * **Bleuler’s 4 As of Schizophrenia:** Ambivalence, Autism, Affective flattening, and Association looseness. * **Ambitendency vs. Mannerism:** Ambitendency is a conflict of movement; Mannerism is a goal-directed movement performed in an unusual/stilted way (seen in Schizophrenia). * **Folie du doute:** A classic term for the "doubting mania" seen in OCD patients that drives ambivalency.

Question 68: All of the following are Schneider's first-rank symptoms except?

A. Hallucination
B. Delusion
C. Passivity phenomenon
D. Elation (Correct Answer)

Explanation: **Explanation:** Kurt Schneider proposed **First-Rank Symptoms (FRS)** in 1959 to differentiate schizophrenia from other psychotic disorders. These symptoms are considered highly suggestive of schizophrenia in the absence of organic brain disease. **Why Elation is the correct answer:** **Elation** is a disturbance of mood (affect) typically seen in **Manic episodes** of Bipolar Disorder. While Schneider’s FRS focuses on disturbances of thought, perception, and volition, it specifically excludes primary mood symptoms. Therefore, elation is a "Second-Rank Symptom" or a feature of affective psychosis, not a diagnostic hallmark of schizophrenia according to Schneider. **Why the other options are wrong:** * **Hallucination (Option A):** Specifically, **Auditory Hallucinations** are FRS. These include: * *Third-person hallucinations* (voices arguing or discussing the patient). * *Running commentary* (voices describing the patient's actions). * *Gedankenlautwerden* (thought echo). * **Delusion (Option B):** Specifically, **Delusional Perception** is an FRS. This involves a normal perception followed by a private, idiosyncratic, and delusional meaning (e.g., "The traffic light turned red, so I knew I was the King of England"). * **Passivity Phenomenon (Option C):** Also known as **Made Phenomena**, these involve the patient feeling that their feelings (**Made Affect**), impulses (**Made Impulse**), or motor movements (**Made Volition**) are controlled by an external force. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for FRS (ABCD):** **A**uditory Hallucinations, **B**roadcasting of thought, **C**ontrolled feelings/impulses (Passivity), **D**elusional Perception. * **Thought Alienation:** Includes Thought Insertion, Thought Withdrawal, and Thought Broadcasting. * **Current Status:** While historically significant, FRS are no longer mandatory for a diagnosis of schizophrenia in **DSM-5**, as they lack high specificity (they can occur in Bipolar Disorder). However, they remain high-yield for exam purposes.

Question 69: Delusion is a disorder of:

A. Stream of thought
B. Form of thought
C. Content of thought (Correct Answer)
D. Possession of thought

Explanation: ### Explanation **1. Why Content of Thought is Correct:** Thought disorders are broadly classified into four categories: stream, form, possession, and content. **Delusion** is defined as a "fixed, false belief that is out of keeping with the patient’s social, cultural, and educational background, and is held with absolute conviction." Since it pertains to the **actual belief or the "what"** the patient is thinking, it is a disorder of the **Content of Thought**. Other examples include obsessions, phobias, and overvalued ideas. **2. Why Other Options are Incorrect:** * **Stream of Thought:** Refers to the **speed and quantity** of thoughts. Examples include *Flight of ideas* (mania), *Retardation* (depression), and *Pressure of speech*. * **Form of Thought:** Refers to the **logical connection** between ideas (the "how" of thinking). Examples include *Loosening of associations*, *Knight’s move thinking*, and *Circumstantiality*. This is also known as Formal Thought Disorder (FTD). * **Possession of Thought:** Refers to the patient’s sense of **ownership** over their thoughts. Examples include *Thought alienation* phenomena (Thought insertion, withdrawal, and broadcasting), which are pathognomonic for Schizophrenia (Schneiderian First Rank Symptoms). **3. Clinical Pearls for NEET-PG:** * **Primary Delusion (Autochthonous):** Arises "out of the blue" without a preceding mental event. It is a First Rank Symptom of Schizophrenia. * **Overvalued Idea:** A solitary, abnormal belief that is not as fixed as a delusion (the patient can entertain doubt). * **Most Common Delusion:** Delusion of Persecution (seen in Schizophrenia and Delusional Disorders). * **Delusion of Reference:** The false belief that neutral events (e.g., a news report) have special personal significance.

Question 70: Schneider's first-rank symptoms are typically seen in which of the following conditions?

A. Delusion
B. Hallucination
C. Schizoid personality
D. Schizophrenia (Correct Answer)

Explanation: **Explanation:** **Schneider’s First-Rank Symptoms (FRS)** were proposed by Kurt Schneider in 1959 as a set of specific clinical features that, in the absence of organic brain disease, are highly suggestive of **Schizophrenia**. While no longer considered pathognomonic (as they can occur in bipolar disorder), they remain a cornerstone of psychiatric history-taking and diagnosis. **Why Option D is Correct:** Schizophrenia is the primary condition associated with FRS. These symptoms are divided into four main categories: 1. **Auditory Hallucinations:** Specifically thought echo (Gedankenlautwerden), third-person voices (discussing the patient), and running commentary. 2. **Thought Interference:** Thought withdrawal, insertion, and broadcasting. 3. **Delusional Perception:** A normal perception is given a private, highly significant delusional meaning. 4. **Made Phenomena (Passivity):** Made affect, made impulses, and made acts (the feeling that one’s emotions or actions are controlled by an external force). **Why Other Options are Incorrect:** * **A & B (Delusion & Hallucination):** These are broad categories of psychopathology. While FRS includes specific types of delusions and hallucinations, not all delusions or hallucinations qualify as first-rank symptoms. * **C (Schizoid Personality):** This is a personality disorder characterized by social detachment and restricted emotional expression. It does not involve psychosis or FRS. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for FRS:** "ABCD" – **A**uditory hallucinations (3rd person), **B**roadcasting of thoughts, **C**ontrolled feelings/acts (Passivity), **D**elusional perception. * **Note:** FRS are **not** required for a diagnosis of Schizophrenia under DSM-5, but they remain high-yield for exam purposes. * **Kurt Schneider** also described "Second-Rank Symptoms," which include other hallucinations and emotional blunting, but these are less specific.

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

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