Psychopharmacology Practice Questions

Q: A schizophrenic patient on antipsychotic drugs may develop which of the following side effects?

Increased prolactin. **Explanation:** The correct answer is **B. Increased prolactin**. **Mechanism of Action:** Antipsychotic drugs (especially typical antipsychotics like Haloperidol and certain atypicals like Risperidone) work by blocking **D2 receptors** in the brain. Prolactin secretion is regulated by the **Tuberoinfundibular pathway**, where dopamine normally acts as a "Prolactin Inhibiting Factor" (PIF). By blocking D2 receptors in this pathway, antipsychotics remove the inhibitory effect of dopamine, leading to **hyperprolactinemia**. **Analysis of Incorrect Options:** * **A. Decreased prolactin:** This is incorrect because dopamine blockade increases prolactin levels. Dopamine agonists (like Bromocriptine) would decrease prolactin. * **C. Hypertension:** Most antipsychotics actually cause **orthostatic hypotension** due to alpha-1 adrenergic receptor blockade, rather than hypertension. * **D. Wakefulness:** Antipsychotics generally cause **sedation** and somnolence due to their antihistaminic (H1 blockade) and anti-adrenergic properties. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Features of Hyperprolactinemia:** In females, it leads to galactorrhea, amenorrhea, and infertility. In males, it causes gynecomastia, decreased libido, and erectile dysfunction. * **Drug Exception:** **Aripiprazole** (a D2 partial agonist) is unique because it can actually lower prolactin levels or remain prolactin-neutral. * **Quetiapine and Clozapine** are the atypical antipsychotics with the lowest risk of causing hyperprolactinemia ("prolactin-sparing"). * **Tuberoinfundibular Pathway:** Remember this specific dopaminergic pathway for exams, as it is the site responsible for endocrine side effects.

Q: Which of the following is a recently approved drug for postpartum depression?

Brexanolone. **Explanation:** **Brexanolone (Option A)** is the correct answer. It is a first-in-class medication specifically approved by the FDA for the treatment of **Postpartum Depression (PPD)**. **Medical Concept:** Brexanolone is a synthetic formulation of **allopregnanolone**, a major metabolite of progesterone. During pregnancy, allopregnanolone levels rise significantly and drop abruptly after childbirth. In women susceptible to PPD, this rapid withdrawal triggers depressive symptoms. Brexanolone acts as a **positive allosteric modulator of GABA-A receptors**, helping to stabilize the neuroendocrine imbalance. It is administered as a single 60-hour continuous intravenous infusion under medical supervision. **Analysis of Incorrect Options:** * **Caplacizumab (Option B):** An anti-von Willebrand factor humanized antibody used for the treatment of acquired Thrombotic Thrombocytopenic Purpura (aTTP). * **Solriamfetol (Option C):** A dopamine and norepinephrine reuptake inhibitor (DNRI) used to improve wakefulness in patients with narcolepsy or obstructive sleep apnea. * **Siponimod (Option D):** A sphingosine-1-phosphate (S1P) receptor modulator used for the treatment of secondary progressive multiple sclerosis (SPMS). **High-Yield Clinical Pearls for NEET-PG:** * **Zuranolone:** A newer, **oral** neuroactive steroid (also an allopregnanolone analogue) recently approved for PPD, offering a more convenient alternative to intravenous Brexanolone. * **Screening:** The **Edinburgh Postnatal Depression Scale (EPDS)** is the gold standard screening tool for PPD. * **Timing:** PPD typically occurs within 4 weeks to 6 months postpartum, unlike "Postpartum Blues," which is self-limiting and peaks at 3–5 days.

Q: What is the drug treatment for tardive dyskinesia?

Valbenazine. **Explanation:** **Tardive Dyskinesia (TD)** is a late-onset extrapyramidal side effect caused by long-term use of dopamine receptor blockers (antipsychotics). It is characterized by involuntary, repetitive movements, most commonly orofacial dyskinesia. **Why Valbenazine is correct:** The pathophysiology of TD involves dopamine receptor supersensitivity. **Valbenazine** is a highly selective **Vesicular Monoamine Transporter 2 (VMAT2) inhibitor**. By inhibiting VMAT2, it prevents the packaging of dopamine into presynaptic vesicles, thereby reducing synaptic dopamine release and alleviating the hyperkinetic movements of TD. It is FDA-approved specifically for this condition and is preferred over older agents due to its once-daily dosing and better side-effect profile. **Analysis of Incorrect Options:** * **Ropinirole:** A dopamine agonist used in Parkinson’s disease and Restless Leg Syndrome. It would likely worsen TD by further stimulating supersensitive dopamine receptors. * **Tetrabenazine:** While also a VMAT2 inhibitor, it is primarily used for Huntington’s Chorea. It has a shorter half-life and a higher risk of causing depression and parkinsonism compared to Valbenazine. (Note: While sometimes used off-label for TD, Valbenazine is the more specific, modern answer). * **Biperiden:** An anticholinergic used to treat *acute* dystonia and drug-induced parkinsonism. Anticholinergics are **contraindicated** in TD as they can worsen the symptoms. **NEET-PG High-Yield Pearls:** * **First step in management:** Gradually taper/discontinue the offending antipsychotic or switch to **Clozapine** (the antipsychotic with the lowest risk of TD). * **VMAT2 Inhibitors:** Valbenazine and Deutetrabenazine are the first-line FDA-approved treatments. * **Risk Factor:** Elderly females are at the highest risk for developing TD.

Q: What is the most effective treatment for psychosis induced by levodopa?

Quetiapine. **Explanation:** The management of psychosis in Parkinson’s Disease (PD) is clinically challenging because traditional antipsychotics block dopamine (D2) receptors, which significantly worsens motor symptoms (rigidity and tremors). **Why Quetiapine is the correct answer:** Quetiapine is considered a first-line treatment for levodopa-induced psychosis because it has a **low affinity for D2 receptors** and a rapid dissociation rate. This allows it to treat psychotic symptoms (hallucinations and delusions) without significantly exacerbating the underlying motor deficits of Parkinson’s disease. While **Clozapine** is technically the most effective drug, it is often reserved for refractory cases due to the risk of agranulocytosis and the need for mandatory blood monitoring. Therefore, Quetiapine is the preferred practical choice in clinical practice and exams. **Why the other options are incorrect:** * **Chlorpromazine (Option B):** A typical antipsychotic with significant D2 blockade and sedative properties; it would severely worsen Parkinsonian motor symptoms. * **Trifluoperazine (Option C):** A high-potency typical antipsychotic that carries a very high risk of Extrapyramidal Side Effects (EPS). * **Haloperidol (Option D):** A potent D2 antagonist. It is strictly contraindicated in Parkinson’s disease as it can lead to acute worsening of motor function and potentially trigger a "frozen" state. **High-Yield Clinical Pearls for NEET-PG:** 1. **Drug of Choice:** Clozapine is the "Gold Standard," but **Quetiapine** is the most commonly used first-line agent. 2. **Pimavanserin:** A newer, FDA-approved drug for PD-psychosis that acts as a selective serotonin inverse agonist (5-HT2A) without any D2 blockade. 3. **Management Strategy:** Always attempt to reduce the dose of anti-Parkinsonian drugs (starting with anticholinergics, then amantadine, then dopamine agonists) before adding an antipsychotic.

Q: Akathisia is best treated by:

Propanolol. **Explanation:** **Akathisia** is a common and distressing Extrapyramidal Side Effect (EPS) characterized by a subjective feeling of inner restlessness and an objective inability to sit still. It most frequently occurs as a side effect of typical (first-generation) antipsychotics. **Why Propranolol is the Correct Answer:** The drug of choice for treating akathisia is **Propranolol**, a non-selective beta-blocker. While the exact pathophysiology is not fully understood, it is believed that beta-adrenergic receptors in the peripheral and central nervous systems play a role in the manifestation of restlessness. Propranolol effectively crosses the blood-brain barrier to alleviate both the subjective tension and physical movements. **Analysis of Incorrect Options:** * **A. Lithium:** This is a mood stabilizer used primarily for Bipolar Affective Disorder. It has no role in treating movement disorders and can actually cause tremors. * **B. Fluoxetine:** An SSRI used for depression/anxiety. It can occasionally *cause* akathisia as a side effect but does not treat it. * **D. Haloperidol:** This is a high-potency typical antipsychotic and is one of the most common **causes** of akathisia due to potent D2 receptor blockade. **NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC):** Propranolol (usually 30–90 mg/day). * **Second-line treatments:** Benzodiazepines (e.g., Lorazepam) or anticholinergics (though anticholinergics are less effective for akathisia than for acute dystonia). * **Clinical Presentation:** Patients are often misdiagnosed as having "worsening psychosis/agitation," leading to an incorrect increase in antipsychotic dosage, which worsens the condition. * **Timeline:** Akathisia typically develops within days to weeks of starting or increasing an antipsychotic.

Q: ECT is not useful in the treatment of which of the following conditions?

Chronic Schizophrenia. **Explanation:** Electroconvulsive Therapy (ECT) is a highly effective biological treatment in psychiatry, but its efficacy depends significantly on the **acuity** and **nature** of the symptoms. **1. Why Chronic Schizophrenia is the correct answer:** ECT is primarily indicated for acute, severe, or life-threatening psychiatric conditions. In **Chronic Schizophrenia**, where negative symptoms (apathy, withdrawal) and cognitive deficits predominate over a long period, ECT has shown poor results. It does not reverse the long-standing structural or functional changes associated with the chronic phase of the illness. **2. Analysis of Incorrect Options:** * **Catatonic Schizophrenia:** This is a **prime indication** for ECT. Patients in a catatonic stupor or excitement often respond rapidly to ECT, which can be life-saving if they are not eating or drinking. * **Endogenous Depression:** Severe depression (especially with psychotic features or suicidal ideation) is the **most common indication** for ECT. It provides a faster response than antidepressants. * **Acute Psychosis:** ECT is effective in managing acute psychotic episodes, especially when there is a risk of exhaustion, aggression, or when rapid symptom control is required. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindication:** There are no absolute contraindications for ECT, but **Increased Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Most Common Side Effect:** Retrograde amnesia (usually transient). * **Mechanism:** The therapeutic effect is derived from the **generalized tonic-clonic seizure**, not the electrical current itself. * **Electrode Placement:** Bilateral (Gold standard for efficacy) vs. Unilateral (fewer cognitive side effects).

Q: Which of the following medications is NOT used for the treatment of anxiety?

Haloperidol. **Explanation:** The correct answer is **Haloperidol**. **Why Haloperidol is the correct choice:** Haloperidol is a high-potency **typical antipsychotic** that acts primarily by blocking Dopamine (D2) receptors in the mesolimbic pathway. It is indicated for schizophrenia, acute psychosis, and Tourette syndrome. It is **not** an anxiolytic; in fact, it can sometimes cause restlessness (akathisia) as an extrapyramidal side effect, which may mimic or worsen the feeling of agitation. **Analysis of other options:** * **Propranolol:** A non-selective beta-blocker used to treat the **peripheral autonomic symptoms** of anxiety (tachycardia, tremors, sweating). It is particularly high-yield for "performance anxiety" or stage fright. * **Alprazolam:** A Benzodiazepine (BZD) that enhances GABA-A receptor activity. It is a first-line agent for the acute management of **Panic Disorder** and Generalized Anxiety Disorder (GAD) due to its rapid onset. * **Buspirone:** A selective **5-HT1A partial agonist**. It is used for chronic GAD. Unlike BZDs, it lacks sedative, hypnotic, or muscle relaxant properties and has no abuse potential, but it takes 2–4 weeks to show effects. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of choice for GAD:** SSRIs (Long-term); Benzodiazepines (Acute). * **Buspirone Advantage:** No "hangover" effect, no interaction with alcohol, and no withdrawal symptoms. * **Performance Anxiety:** Propranolol is the drug of choice, taken 30–60 minutes before the event. * **Haloperidol Side Effects:** Highly associated with Extrapyramidal Symptoms (EPS) and Neuroleptic Malignant Syndrome (NMS).

Q: Laryngeal dystonia, which is a psychiatric emergency, can be treated with?

lorazepam. ### Explanation **Laryngeal dystonia** is a life-threatening form of **Acute Dystonia**, a common Extrapyramidal Side Effect (EPS) occurring within hours to days of starting high-potency antipsychotics (e.g., Haloperidol). It involves involuntary spasms of the laryngeal muscles, leading to airway obstruction, stridor, and potential asphyxiation, making it a true psychiatric emergency. **Why Lorazepam is the correct answer:** The first-line treatment for acute dystonia is typically parenteral anticholinergics (like Benztropine or Promethazine). However, when these are unavailable or when rapid muscle relaxation is required in an emergency setting, **intravenous Benzodiazepines (like Lorazepam or Diazepam)** are highly effective. They act by enhancing GABAergic inhibition, which helps counteract the dopamine-acetylcholine imbalance in the nigrostriatal pathway causing the spasm. **Analysis of Incorrect Options:** * **B. Milnacipran:** This is an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor) used for depression and fibromyalgia; it has no role in treating EPS. * **C. Dantrolene:** This is a peripherally acting muscle relaxant used specifically for **Neuroleptic Malignant Syndrome (NMS)** and Malignant Hyperthermia. It is not the treatment for acute dystonia. * **D. Propranolol:** This beta-blocker is the drug of choice for **Akathisia** (subjective restlessness), another form of EPS, but it is ineffective for dystonia. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Young males and those receiving high-potency first-generation antipsychotics are at the highest risk. * **Order of EPS onset:** Dystonia (hours) → Akathisia (days) → Parkinsonism (weeks) → Tardive Dyskinesia (months/years). * **Drug of Choice (General Dystonia):** Injection **Promethazine** or Benztropine. * **Oculogyric Crisis:** Another common presentation of acute dystonia involving involuntary upward deviation of the eyes.

Q: A 22-year-old college student reports experiencing racing thoughts and irritability for the past week, following intense studying for finals. The patient's speech is noted to be pressured. He has been stable for the past 6 months on 500 mg of valproate twice daily. What is the initial management step for this patient's current symptoms?

Prescribe clonazepam. ### **Explanation** The patient is presenting with a **breakthrough manic or hypomanic episode** (racing thoughts, irritability, pressured speech) despite being on a stable dose of a mood stabilizer (Valproate). **1. Why Option C is Correct:** In the acute management of breakthrough symptoms, especially when associated with agitation, insomnia, or irritability, **Benzodiazepines (like Clonazepam or Lorazepam)** are the preferred initial adjunctive treatment. They provide rapid symptomatic relief, help restore sleep architecture, and reduce psychomotor agitation while waiting for mood stabilizers to be titrated or for the episode to subside. **2. Why Other Options are Incorrect:** * **Option A (Hospitalization):** This is reserved for patients who are a danger to themselves or others, have a total loss of functioning, or have psychotic features. This patient is currently stable enough to be managed in an outpatient setting. * **Option B (Increase Valproate):** While the dose may eventually need adjustment, Valproate has a slow onset of action for acute symptoms. Furthermore, dosage changes should ideally be guided by **serum therapeutic levels** (target: 50–125 µg/mL) rather than empirical increases. * **Option D (Start Haloperidol):** While antipsychotics are used in acute mania, Haloperidol is typically reserved for severe mania with psychosis or extreme aggression due to its high risk of Extrapyramidal Side Effects (EPS). **3. NEET-PG High-Yield Pearls:** * **Drug of Choice (DOC) for Acute Mania:** Lithium or Valproate + Atypical Antipsychotic (e.g., Risperidone, Olanzapine). * **DOC for Rapid Cycling Bipolar Disorder:** Valproate. * **Therapeutic Range of Lithium:** 0.8–1.2 mEq/L (Acute); 0.6–1.0 mEq/L (Maintenance). * **Benzodiazepines** serve as a "bridge" in acute episodes to manage agitation and insomnia.

Q: What is the drug of choice for rapid cycling bipolar disorder?

Sodium valproate. **Explanation:** **Rapid cycling bipolar disorder** is defined as the occurrence of four or more mood episodes (mania, hypomania, or depression) within a 12-month period. 1. **Why Sodium Valproate is correct:** While Lithium is the gold standard for classic Bipolar I disorder, it is notably less effective in patients with rapid cycling or mixed episodes. **Sodium Valproate (Divalproex)** is the drug of choice for rapid cycling because it has superior efficacy in stabilizing mood when cycles are frequent and is often more effective in treating "mixed" presentations. It works by increasing GABA levels and modulating glutamate and sodium channels. 2. **Why other options are incorrect:** * **Lithium:** The first-line treatment for classic mania and prophylaxis, but patients with rapid cycling often show a poor response to Lithium monotherapy. * **Carbamazepine:** Used as a second-line mood stabilizer or as an adjunct. It is effective for rapid cycling but is generally considered secondary to Valproate due to its side effect profile and enzyme-inducing properties. * **Haloperidol:** A high-potency typical antipsychotic used for acute management of manic agitation, but it has no role in the long-term stabilization or prevention of rapid cycling. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Classic Mania:** Lithium. * **DOC for Rapid Cycling/Mixed Episodes:** Sodium Valproate. * **DOC for Bipolar Depression:** Quetiapine (or Lurasidone/Lamotrigine). * **Teratogenicity:** Valproate is associated with **Neural Tube Defects** (specifically spina bifida); Lithium is associated with **Ebstein’s Anomaly**. * **Prognosis:** Rapid cycling is more common in women and is often associated with hypothyroidism or the use of antidepressants.

Question 1

A schizophrenic patient on antipsychotic drugs may develop which of the following side effects?

Accepted Answer

Increased prolactin

Answer

Decreased prolactin

Answer

Hypertension

Answer

Wakefulness

Question 2

Which of the following is a recently approved drug for postpartum depression?

Accepted Answer

Brexanolone

Answer

Calpacizumab

Answer

Solriamfetol

Answer

Siponimod

Question 3

What is the drug treatment for tardive dyskinesia?

Accepted Answer

Valbenazine

Answer

Ropinirole

Answer

Tetrabenazine

Answer

Biperiden

Question 4

What is the most effective treatment for psychosis induced by levodopa?

Accepted Answer

Quetiapine

Answer

Chlorpromazine

Answer

Trifluoperazine

Answer

Haloperidol

Question 5

Akathisia is best treated by:

Accepted Answer

Propanolol

Answer

Lithium

Answer

Fluoxetine

Answer

Haloperidol

Question 6

ECT is not useful in the treatment of which of the following conditions?

Accepted Answer

Chronic Schizophrenia

Answer

Catatonic Schizophrenia

Answer

Endogenous depression

Answer

Acute psychosis

Question 7

Which of the following medications is NOT used for the treatment of anxiety?

Accepted Answer

Haloperidol

Answer

Propranolol

Answer

Alprazolam

Answer

Buspirone

Question 8

Laryngeal dystonia, which is a psychiatric emergency, can be treated with?

Accepted Answer

lorazepam

Answer

milnacipran

Answer

dantrolene

Answer

propanolol

Question 9

A 22-year-old college student reports experiencing racing thoughts and irritability for the past week, following intense studying for finals. The patient's speech is noted to be pressured. He has been stable for the past 6 months on 500 mg of valproate twice daily. What is the initial management step for this patient's current symptoms?

Accepted Answer

Prescribe clonazepam

Answer

Hospitalize the patient

Answer

Increase the valproate by 500 mg/day

Answer

Start haloperidol

Question 10

What is the drug of choice for rapid cycling bipolar disorder?

Accepted Answer

Sodium valproate

Answer

Lithium

Answer

Carbamazepine

Answer

Haloperidol

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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