Schizophrenia: Treatment — MCQs
A 72 year old lady is severely depressed. For the past 2 days she has suicidal thoughts with an actual intent to die. Which of the following is best suitable to alleviate the symptoms?
A patient of schizophrenia is being treated with clozapine. For which rare but serious side effects should he be monitored?
Which antipsychotic is preferred for treatment-resistant schizophrenia?
Maximum increase in prolactin level is caused by:-
All of the following statements are TRUE about second generation antihistaminic agents EXCEPT:
The mechanism of action of haloperidol is the blockade of
Which antipsychotic has highest risk of QTc prolongation?
A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?
A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?
A 45-year-old female presents to the OPD with complaints of "feeling tense" and experiencing stomach upset with heartburn and diarrhea. She reports having these symptoms for many years and mentions that her family members also usually feel tense and nervous. Which of the following symptoms is most likely to be seen in this patient?
Schizophrenia: Treatment Indian Medical PG Practice Questions and MCQs
Question 1: A 72 year old lady is severely depressed. For the past 2 days she has suicidal thoughts with an actual intent to die. Which of the following is best suitable to alleviate the symptoms?
- A. ECT (Correct Answer)
- B. Selegiline
- C. Haloperidol + Chlorpromazine
- D. Amitriptyline
Explanation: ***ECT (Electroconvulsive Therapy)*** - **ECT** is the most effective and rapid treatment for severe depression, especially when associated with active **suicidal ideation** and intent. - Its quick onset of action (often within days) makes it vital in situations requiring urgent symptom alleviation to ensure patient safety. - **First-line treatment** for geriatric depression with suicidal risk and when rapid response is needed. *Selegiline* - **Selegiline** is a monoamine oxidase inhibitor (MAOI) used for depression and Parkinson's disease, but its antidepressant effects are not immediate. - It would not sufficiently address the patient's acute suicidal intent due to its slower therapeutic onset (several weeks). *Haloperidol + Chlorpromazine* - This combination consists of **antipsychotics**, primarily used for conditions with psychotic features or severe agitation but not as a primary treatment for severe depression with suicidal ideation. - While they might provide some sedation, they do not treat the underlying depressive disorder effectively and rapidly enough to resolve acute suicidal intent. *Amitriptyline* - **Amitriptyline** is a tricyclic antidepressant (TCA) that can be effective for depression but has a delayed onset of action (2-4 weeks). - **Highly contraindicated in suicidal patients** due to its extreme lethality in overdose (cardiotoxic effects). - Its slow therapeutic effect would not be appropriate for an urgent situation involving active suicidal thoughts with intent.
Question 2: A patient of schizophrenia is being treated with clozapine. For which rare but serious side effects should he be monitored?
- A. Seizures
- B. Agranulocytosis (Correct Answer)
- C. Hepatomegaly
- D. Renal bleed
Explanation: ***Agranulocytosis*** - **Agranulocytosis** is a severe and potentially fatal reduction in white blood cells (specifically neutrophils) that can occur with clozapine use [2, 3]. - This is the **rare but serious side effect** that requires mandatory monitoring, occurring in **0.8-2%** of patients. - Patients on clozapine require routine **complete blood count (CBC)** monitoring: **weekly for the first 6 months**, then biweekly for months 6-12, then monthly thereafter . - This is the primary reason clozapine has restricted use despite being the most effective antipsychotic for treatment-resistant schizophrenia. *Seizures* - While clozapine can lower the **seizure threshold** (especially at higher doses), seizures occur in **1-2%** of patients and are **dose-dependent** . - Seizures are a known side effect that warrants dosage adjustment, but they are **not as rare** as agranulocytosis and do not require the same intensive blood monitoring protocol. - Management involves dose reduction or adding anticonvulsants. *Hepatomegaly* - **Hepatic dysfunction** can occur with clozapine, but **hepatomegaly** (enlarged liver) itself is not one of its rare, life-threatening side effects requiring specific monitoring above other, more severe issues. - Liver enzyme elevation may be monitored, but this is not the primary "rare but serious" concern. *Renal bleed* - **Renal complications** or **renal bleeding** are not recognized as significant or specifically monitored rare side effects of clozapine. - Clozapine's major concerns primarily involve hematologic (agranulocytosis), cardiovascular (myocarditis), and metabolic systems.
Question 3: Which antipsychotic is preferred for treatment-resistant schizophrenia?
- A. Quetiapine
- B. Olanzapine
- C. Risperidone
- D. Clozapine (Correct Answer)
Explanation: ***Clozapine*** - **Clozapine** is the only antipsychotic with proven efficacy for **treatment-resistant schizophrenia**, defined as inadequate response to two different antipsychotics. - Its unique pharmacological profile, including strong antagonism of various **dopamine** and **serotonin receptors**, contributes to its superior efficacy in these cases. *Quetiapine* - While an effective antipsychotic for many, **quetiapine** is generally not considered the first-line or preferred agent for **treatment-resistant schizophrenia**. - It has a lower propensity for **extrapyramidal symptoms** but lacks the specific efficacy demonstrated by clozapine in refractory cases. *Olanzapine* - **Olanzapine** is a potent antipsychotic and can be effective for severe symptoms, but it does not have the same established efficacy for **treatment resistance** as clozapine. - Its use can be limited by significant metabolic side effects including **weight gain** and **glucose dysregulation**. *Risperidone* - **Risperidone** is a commonly used antipsychotic, but it is not indicated as the preferred treatment for **treatment-resistant schizophrenia**. - It can be effective for positive and negative symptoms but does not offer the same **superiority** in refractory cases as clozapine.
Question 4: Maximum increase in prolactin level is caused by:-
- A. Olanzapine (Primarily blocks 5HT2 receptors)
- B. Aripiprazole (D2 partial agonist)
- C. Risperidone (Potent D2 receptor antagonist) (Correct Answer)
- D. Clozapine (Primarily blocks 5HT2 receptors)
Explanation: ***Risperidone (Potent D2 receptor antagonist)*** - Risperidone is a **potent D2 receptor antagonist**, meaning it blocks dopamine's action at these receptors. Since dopamine inhibits prolactin release, blocking D2 receptors leads to a significant increase in **prolactin levels**. - Its high affinity for D2 receptors in the **tuberoinfundibular pathway** is a primary reason for its pronounced effect on prolactin. *Olanzapine (Primarily blocks 5HT2 receptors)* - While olanzapine can cause some prolactin elevation, its primary mechanism involves **5HT2 receptor blockade**, with less potent D2 antagonism compared to risperidone. - The degree of **hyperprolactinemia** associated with olanzapine is generally milder than that seen with risperidone. *Aripiprazole (D2 partial agonist)* - Aripiprazole is a **D2 partial agonist**, meaning it acts as an antagonist when dopamine levels are high and an agonist when dopamine levels are low, effectively stabilizing dopamine activity. - Due to its partial agonism, aripiprazole typically has a **low risk of hyperprolactinemia** and can even normalize elevated prolactin levels caused by other antipsychotics. *Clozapine (Primarily blocks 5HT2 receptors)* - Clozapine primarily blocks **5HT2 receptors** and has relatively weak D2 receptor antagonism, especially transient D2 blockade. - It generally causes **minimal to no prolactin elevation** and is considered a prolactin-sparing antipsychotic.
Question 5: All of the following statements are TRUE about second generation antihistaminic agents EXCEPT:
- A. These may possess additional antiallergic mechanisms
- B. These do not impair psychomotor performance
- C. These lack anticholinergic actions
- D. These possess high anti-motion sickness activity (Correct Answer)
Explanation: ***These possess high anti-motion sickness activity*** - Second-generation antihistamines have **poor penetration** into the central nervous system (CNS), making them ineffective for treating **motion sickness**. - **First-generation antihistamines**, which readily cross the blood-brain barrier and have **anticholinergic activity**, are typically used for motion sickness. *These may possess additional antiallergic mechanisms* - Many second-generation antihistamines, such as **cetirizine** and **loratadine**, have additional anti-inflammatory and **antiallergic properties** beyond H1 receptor blockade. - These mechanisms can include inhibiting the release of inflammatory mediators and **stabilizing mast cells**. *These do not impair psychomotor performance* - Second-generation antihistamines are **non-sedating** because they have limited ability to cross the **blood-brain barrier** and thus do not significantly affect CNS function. - This characteristic makes them suitable for use without causing **drowsiness** or impairing activities like driving. *These lack anticholinergic actions* - Unlike first-generation antihistamines, second-generation agents have **minimal to no affinity** for muscarinic acetylcholine receptors. - This lack of **anticholinergic activity** means they do not cause side effects such as **dry mouth**, blurred vision, or urinary retention.
Question 6: The mechanism of action of haloperidol is the blockade of
- A. Serotonin receptor
- B. GABA receptor
- C. Dopamine receptor (Correct Answer)
- D. Adrenergic receptor
Explanation: ***Dopamine receptor*** - Haloperidol is a **first-generation antipsychotic** that primarily acts as a potent **D2 dopamine receptor antagonist**. - Its therapeutic effects in treating psychosis are largely due to blocking **dopamine D2 receptors** in the mesolimbic pathway, which helps reduce positive symptoms like hallucinations and delusions. *Serotonin receptor* - While some atypical (second-generation) antipsychotics block serotonin receptors (e.g., 5-HT2A), **haloperidol's primary mechanism of action is not serotonin receptor blockade**. - Serotonin receptor antagonism is more associated with the mechanism of action of newer antipsychotics, which also exhibit D2 antagonism but with a different receptor profile. *GABA receptor* - **Haloperidol does not primarily act on GABA receptors**; drugs like benzodiazepines are known for their GABAergic effects. - GABA (gamma-aminobutyric acid) is the main inhibitory neurotransmitter in the brain, and drugs targeting its receptors are typically anxiolytics or sedatives. *Adrenergic receptor* - Although haloperidol can have some weak alpha-1 adrenergic receptor blocking activity, this is a **secondary effect** and not its primary mechanism of action. - Its antipsychotic efficacy is overwhelmingly attributed to its potent **dopamine receptor blockade**.
Question 7: Which antipsychotic has highest risk of QTc prolongation?
- A. Ziprasidone (Correct Answer)
- B. Risperidone
- C. Olanzapine
- D. Aripiprazole
Explanation: ***Ziprasidone*** - **Ziprasidone** is known to have the highest risk of **QTc prolongation** among the commonly used atypical antipsychotics. - This effect is dose-dependent and necessitates careful monitoring, especially in patients with pre-existing cardiac conditions or those on other QTc-prolonging medications. *Risperidone* - While **risperidone** can cause **QTc prolongation**, its risk is generally considered to be lower than that of ziprasidone. - It also carries a significant risk of **hyperprolactinemia** and **extrapyramidal symptoms (EPS)**, which are important distinguishing features. *Olanzapine* - **Olanzapine** has a relatively low risk of **QTc prolongation** compared to ziprasidone. - Its primary concerns include substantial **weight gain** and **metabolic syndrome**, which are less prominent with ziprasidone. *Aripiprazole* - **Aripiprazole** is generally associated with a very low risk of **QTc prolongation** and is often considered a safer choice in this regard. - It is known for its unique partial agonist activity at dopamine D2 and serotonin 5-HT1A receptors, and antagonist activity at 5-HT2A receptors, leading to a different side effect profile.
Question 8: A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?
- A. Add antipyretic
- B. Continue clozapine
- C. Reduce dose
- D. Stop clozapine (Correct Answer)
Explanation: ***Stop clozapine*** - The presentation of **fever, confusion, muscle rigidity**, and elevated **creatine kinase (CK)** in a patient on clozapine is highly suggestive of **Neuroleptic Malignant Syndrome (NMS)**, a potentially fatal adverse reaction. - **Immediate discontinuation** of the causative antipsychotic, in this case **clozapine**, is the cornerstone of NMS management to prevent further clinical deterioration and complications. *Add antipyretic* - While a **fever** is present, simply adding an **antipyretic** would only address a symptom and not the underlying severe adverse drug reaction, potentially delaying critical intervention. - The fever in NMS is often due to **hypothalamic dysfunction** and **muscle rigidity**, not just a simple infection responsive to antipyretics alone. *Continue clozapine* - Continuing clozapine in the presence of NMS symptoms would **exacerbate the condition**, leading to increased morbidity and mortality, as it is the likely causative agent. - Further exposure to the drug would worsen the **hyperthermia, muscle rigidity**, and potential **organ damage**. *Reduce dose* - **Reducing the dose** of clozapine is insufficient if NMS is suspected, as even lower doses can maintain the toxic effect and progression of the syndrome. - The priority is to remove the offending agent completely, rather than merely decreasing its concentration.
Question 9: A young male patient is on 5 mg haloperidol for many days. Recently, for the last 4 days, he has inner restlessness and urges to move. Diagnosis is?
- A. Akathisia (Correct Answer)
- B. Rabbit syndrome
- C. Tardive dyskinesia
- D. Acute Dystonia
Explanation: ***Akathisia*** - This condition is characterized by a subjective feeling of **inner restlessness** and an objective urge to move, which is a classic side effect of **dopamine receptor blocking agents** like haloperidol. - The onset of akathisia can be acute or chronic, often occurring within days to weeks of starting or increasing the dose of antipsychotic medication. *Rabbit syndrome* - This is a rare form of **tardive dyskinesia** characterized by rapid, fine perioral movements that resemble a rabbit chewing. - It does not primarily involve the subjective feeling of restlessness or the urge to move the entire body as described in the patient's presentation. *Tardive dyskinesia* - This condition typically involves **involuntary, repetitive body movements**, often affecting the face, lips, tongue, and limbs, and usually develops after prolonged exposure to antipsychotic medications (months to years). - While it can manifest as abnormal movements, the primary symptom of inner restlessness and urge to move is not characteristic of tardive dyskinesia but rather of akathisia, and its onset is typically much later. *Acute Dystonia* - Acute dystonia presents as **sustained muscle contractions** leading to twisting and repetitive movements or abnormal fixed postures, often affecting the neck, eyes (oculogyric crisis), and trunk. - This reaction typically occurs within hours or days of initiating or increasing neuroleptic medication and is characterized by involuntary muscle spasms, not a pervasive sense of inner restlessness.
Question 10: A 45-year-old female presents to the OPD with complaints of "feeling tense" and experiencing stomach upset with heartburn and diarrhea. She reports having these symptoms for many years and mentions that her family members also usually feel tense and nervous. Which of the following symptoms is most likely to be seen in this patient?
- A. Ideas of reference
- B. Tingling of extremities (Correct Answer)
- C. Hallucination
- D. Neologism
Explanation: ***Tingling of extremities*** - The patient's presentation of "feeling tense," **stomach upset, heartburn, and diarrhea** for many years, alongside a family history of similar issues, suggests significant **anxiety**. - **Peripheral neurological symptoms** such as **tingling of extremities (paresthesia)** are common manifestations of anxiety and panic attacks due to **hyperventilation** (causing respiratory alkalosis and decreased ionized calcium) and **physiological arousal**. *Ideas of reference* - **Ideas of reference** are typically seen in **psychotic disorders** (e.g., schizophrenia) where a person believes that unrelated, external events have a special, personal meaning. - While anxiety can sometimes lead to misinterpretations, **ideas of reference** at a delusional level are not characteristic of generalized anxiety. *Hallucination* - **Hallucinations** are perceptual disturbances where an individual experiences sensory perceptions (e.g., hearing voices, seeing things) in the absence of an external stimulus. - These are core symptoms of **psychotic disorders** and are not typical findings in anxiety disorders without comorbid conditions. *Neologism* - A **neologism** is the coining of new words or phrases, often without clear meaning, which is a hallmark feature of disorganized thought in **psychotic disorders** (e.g., schizophrenia). - This symptom is related to severe thought disorganization and is not associated with anxiety disorders.
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