Psychopharmacology Practice Questions

Q: Which of the following is NOT a side effect of lithium used in psychiatric practice?

Hypercalcemia. **Explanation:** Lithium is the gold-standard mood stabilizer for Bipolar Affective Disorder (BPAD). However, it has a narrow therapeutic index (0.6–1.2 mEq/L), leading to a wide range of side effects across multiple organ systems. **Why Hypercalcemia is the Correct Answer:** Actually, the question asks for what is **NOT** a side effect, but there is a clinical nuance here. Lithium **does** cause hypercalcemia and hyperparathyroidism by increasing the set-point of the calcium-sensing receptor in the parathyroid gland. In many standard PG entrance exams, if "Hypercalcemia" is marked as the "not a side effect" option, it is often a technical error in the question bank or refers to the fact that lithium typically causes **Hypercalcemia**, not Hypocalcemia. *Note: If the option were Hypocalcemia, it would be the definitive "not a side effect."* **Analysis of Other Options:** * **Nausea/Vomiting (Option A):** These are the most common **early** gastrointestinal side effects. They are usually dose-dependent and can be managed by taking the drug after meals. * **Tremors (Option B):** Fine tremors of the hands are a very common side effect. Conversely, **coarse tremors** are a hallmark sign of Lithium Toxicity. * **Hypothyroidism (Option C):** Lithium inhibits the release of thyroid hormones (T3/T4) and interferes with iodine organification. It is a classic cause of drug-induced goiter and hypothyroidism. **High-Yield Clinical Pearls for NEET-PG:** * **L-I-T-H:** **L**eukocytosis (Benign), **I**nsipidus (Nephrogenic Diabetes Insipidus), **T**remors/Teratogenicity (Ebstein’s Anomaly), **H**ypothyroidism/Hypercalcemia. * **Monitoring:** Thyroid Function Tests (TFT) and Renal Function Tests (RFT) must be done before starting and every 6–12 months. * **Toxicity:** Precipitated by NSAIDs, Thiazides, and ACE inhibitors (which decrease lithium clearance). * **Drug of Choice:** For acute mania and prophylaxis of BPAD.

Q: A 20-year-old female experiences frequent episodes of palpitations, breathlessness, sweating, and a fear of impending death, with one episode occurring weekly and no identifiable triggers. Which of the following is the best drug option for her long-term treatment?

Fluoxetine. ### Explanation **Diagnosis:** The clinical presentation of recurrent, spontaneous episodes of palpitations, breathlessness, sweating, and fear of impending death (angor animi) is characteristic of **Panic Disorder**. **1. Why Fluoxetine is Correct:** Selective Serotonin Reuptake Inhibitors (SSRIs), such as **Fluoxetine**, are the **first-line pharmacological treatment** for the long-term management of Panic Disorder. They are preferred due to their efficacy in reducing the frequency and intensity of panic attacks and their favorable safety profile compared to older antidepressants. While they have a delayed onset of action (2–4 weeks), they are the gold standard for preventing relapse. **2. Why the Other Options are Incorrect:** * **B. Diazepam:** Benzodiazepines provide rapid relief during an acute attack but are **not recommended for long-term use** due to risks of sedation, cognitive impairment, tolerance, and dependence. * **C. Olanzapine:** This is an atypical antipsychotic used primarily in schizophrenia and bipolar disorder. It has no primary role in the standard treatment of uncomplicated Panic Disorder. * **D. Beta Blockers (e.g., Propranolol):** These are effective for **Performance Anxiety** (Social Anxiety Disorder) to control peripheral autonomic symptoms like tremors and tachycardia. However, they do not treat the core psychological symptoms or the "fear of death" in Panic Disorder. **High-Yield Clinical Pearls for NEET-PG:** * **First-line Treatment:** SSRIs (Fluoxetine, Paroxetine, Sertraline) + Cognitive Behavioral Therapy (CBT). * **Acute Attack Management:** Short-acting Benzodiazepines (e.g., Alprazolam or Lorazepam). * **Panic Disorder Definition:** Recurrent unexpected panic attacks followed by at least **one month** of persistent concern about future attacks (anticipatory anxiety). * **Common Comorbidity:** Agoraphobia (fear of places where escape might be difficult).

Q: What is true regarding akathisia?

Treatment is by anticholinergics.. **Explanation:** **Akathisia** is the most common extrapyramidal side effect (EPS) associated with antipsychotic medications (especially first-generation antipsychotics). It is characterized by a subjective feeling of inner restlessness and an objective need to be in constant motion. **Why Option A is Correct:** The primary management for akathisia involves reducing the dose of the offending antipsychotic or switching to a drug with lower EPS potential. Pharmacologically, **centrally acting anticholinergics** (e.g., Procyclidine, Benztropine) and **Beta-blockers** (Proanolol is considered the drug of choice) are the mainstays of treatment. Anticholinergics help restore the dopamine-acetylcholine balance in the nigrostriatal pathway. **Why Other Options are Incorrect:** * **Option B:** Wandering away from home is characteristic of a **Dissociative Fugue** or certain dementias, not akathisia. In akathisia, the patient moves restlessly (pacing, tapping feet) but remains aware of their surroundings. * **Option C:** Akathisia is a motor/sensory side effect; it does not involve **hallucinations**, which are psychotic symptoms. * **Option D:** Akathisia is a drug-induced physiological reaction. **Behavioral therapy** is ineffective; medical intervention or dosage adjustment is mandatory. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Proanolol (Beta-blocker) is often cited as the most effective treatment for akathisia. * **Clinical Presentation:** Patients often describe "jumping out of their skin" or an inability to sit still. * **Differential Diagnosis:** Must be distinguished from psychotic agitation; increasing the antipsychotic dose will worsen akathisia but improve agitation. * **Timeline:** Usually occurs within days to weeks of starting or increasing antipsychotic medication.

Q: Which of the following conditions makes antipsychotics relatively safer to use?

Hypertension. **Explanation:** The correct answer is **Hypertension**. This question tests your understanding of the side-effect profile of antipsychotics and their contraindications. **1. Why Hypertension is the correct answer:** Most antipsychotics (especially low-potency typicals like Chlorpromazine and certain atypicals like Clozapine) cause **orthostatic hypotension** due to **alpha-1 adrenergic blockade**. In patients with hypertension, this side effect may actually lead to a reduction in blood pressure. While blood pressure must still be monitored to avoid profound hypotension, the presence of hypertension does not pose an inherent risk of exacerbation by the drug, unlike the other conditions listed. **2. Why the other options are incorrect:** * **Infertility:** Antipsychotics (especially Risperidone and typicals) are potent **D2 receptor antagonists** in the tuberoinfundibular pathway. This leads to **hyperprolactinemia**, which suppresses the HPO axis, causing amenorrhea and galactorrhea in women and decreased spermatogenesis in men. Thus, they can worsen or cause infertility. * **Epilepsy:** Antipsychotics **lower the seizure threshold**. This is a significant concern in patients with pre-existing epilepsy. Clozapine and Chlorpromazine carry the highest risk of inducing seizures. **High-Yield Clinical Pearls for NEET-PG:** * **Clozapine:** Highest risk of seizures (dose-dependent) and agranulocytosis. * **Thioridazine:** Known for QTc prolongation and retinitis pigmentosa. * **Hyperprolactinemia:** Least common with Aripiprazole (D2 partial agonist) and Quetiapine. * **Metabolic Syndrome:** Most common with Clozapine and Olanzapine; least common with Ziprasidone and Aripiprazole.

Q: Which serum lithium level is suggestive of toxicity?

2 mEq/L. Lithium is a mood stabilizer with a **narrow therapeutic index**, meaning the margin between a therapeutic dose and a toxic dose is very small. Regular monitoring of serum lithium levels is mandatory for patient safety. ### **Explanation of the Correct Answer** The therapeutic range for lithium is generally **0.6 to 1.2 mEq/L**. Toxicity typically manifests when serum levels exceed **1.5 mEq/L**. * **Mild to Moderate Toxicity (1.5–2.0 mEq/L):** Presents with vomiting, abdominal pain, ataxia, dizziness, and coarse tremors. * **Severe Toxicity (>2.0 mEq/L):** Can lead to seizures, coma, cardiac arrhythmias, and permanent neurological damage. Among the given options, **2 mEq/L** is the earliest threshold indicating significant toxicity requiring immediate clinical intervention. ### **Explanation of Incorrect Options** * **4, 6, and 8 mEq/L:** While these levels are indeed toxic, they represent extreme, life-threatening emergencies. In clinical practice and exams, toxicity is defined by the *lowest* level that crosses the therapeutic threshold. Levels above 3.5–4.0 mEq/L are often fatal and usually necessitate emergency hemodialysis. ### **High-Yield NEET-PG Pearls** * **Monitoring:** Serum levels should be checked **12 hours after the last dose** (Trough level). * **Steady State:** It takes about **5 days** to reach a steady state after starting or changing a dose. * **Side Effects:** Fine tremors (therapeutic), Coarse tremors (toxic), Nephrogenic Diabetes Insipidus, and Ebstein’s Anomaly (teratogenic). * **Drug Interactions:** **NSAIDs, Thiazides, and ACE inhibitors** increase lithium levels by decreasing renal clearance (Mnemonic: **"NAT"**). * **Management of Toxicity:** Hydration is first-line; **Hemodialysis** is the treatment of choice for severe toxicity (>2.5–4.0 mEq/L or if the patient is symptomatic).

Q: Which of the following is NOT an anxiolytic drug?

Melatonin. **Explanation:** The correct answer is **Melatonin**. Melatonin is a hormone produced by the pineal gland that regulates the sleep-wake cycle (circadian rhythm). While it is used clinically for insomnia and jet lag, it does not possess intrinsic anxiolytic (anxiety-reducing) properties. **Analysis of Options:** * **Alprazolam:** A Benzodiazepine (BZD) that acts as a positive allosteric modulator of the $GABA_A$ receptor. It is a classic, fast-acting anxiolytic used for panic disorders and generalized anxiety. * **Sertraline:** An SSRI (Selective Serotonin Reuptake Inhibitor). Although primarily classified as an antidepressant, SSRIs are the **first-line long-term treatment** for most anxiety disorders (GAD, Social Anxiety, Panic Disorder). * **Haloperidol:** A typical antipsychotic (D2 blocker). While its primary indication is psychosis, it is frequently used "off-label" in acute clinical settings as a chemical restraint to manage severe agitation and acute anxiety associated with delirium or psychosis. **High-Yield Clinical Pearls for NEET-PG:** * **First-line for Acute Anxiety:** Benzodiazepines (e.g., Alprazolam, Diazepam) due to immediate onset. * **First-line for Chronic Anxiety:** SSRIs (e.g., Sertraline, Escitalopram) due to better safety profiles and lack of dependence. * **Buspirone:** A 5-HT1A partial agonist; it is a pure anxiolytic that lacks sedative, hypnotic, or muscle relaxant properties. * **Propranolol:** Used for "Performance Anxiety" to control peripheral autonomic symptoms (tremors, tachycardia).

Q: Esketamine, approved by the FDA in 2019, is indicated for the treatment of which condition?

Depression. **Explanation:** **Esketamine** is the S-enantiomer of ketamine. In 2019, the FDA approved it (as a nasal spray) specifically for **Treatment-Resistant Depression (TRD)** and for depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior. * **Mechanism of Action:** Unlike traditional antidepressants that target monoamines (Serotonin/Norepinephrine), Esketamine is a non-competitive **NMDA receptor antagonist**. It increases glutamate release, leading to rapid synaptogenesis in the prefrontal cortex, providing a much faster onset of action (hours to days) compared to SSRIs. **Analysis of Incorrect Options:** * **B. Resistant Schizophrenia:** The drug of choice for treatment-resistant schizophrenia is **Clozapine**. Esketamine can actually exacerbate psychotic symptoms and is contraindicated in patients with a history of psychosis. * **C. Bipolar Disorder:** While ketamine is being researched for bipolar depression, Esketamine is currently only FDA-approved for Unipolar Depression. Using it in Bipolar disorder carries a risk of inducing a manic switch. * **D. Ketamine Dependence:** Esketamine itself has a high potential for abuse and is classified as a Schedule III controlled substance. It is not used to treat dependence. **High-Yield Clinical Pearls for NEET-PG:** * **Route:** Intranasal (administered under medical supervision due to sedation and dissociation risks). * **Side Effects:** Dissociation, dizziness, nausea, and **transient hypertension** (blood pressure must be monitored post-administration). * **REMS Program:** Due to the risk of serious adverse outcomes and misuse, it is only available through a restricted distribution system.

Q: Which of the following antidepressants is used in atypical depression?

Phenelzine. **Explanation:** **Atypical depression** is a subtype of Major Depressive Disorder characterized by **mood reactivity** (the ability to feel better in response to positive events) along with at least two of the following: increased appetite/weight gain, hypersomnia, leaden paralysis (heavy feeling in limbs), and a long-standing pattern of interpersonal rejection sensitivity. **Why Phenelzine is correct:** Historically and clinically, **Monoamine Oxidase Inhibitors (MAOIs)** like **Phenelzine**, Tranylcypromine, and Isocarboxazid are considered the most effective treatments for atypical depression. While Selective Serotonin Reuptake Inhibitors (SSRIs) are now used as first-line therapy due to a better safety profile, MAOIs remain the "gold standard" in terms of efficacy for this specific subtype, especially in treatment-resistant cases. **Why the other options are incorrect:** * **Imipramine & Amitriptyline (Options A & D):** These are **Tricyclic Antidepressants (TCAs)**. TCAs are generally less effective for atypical depression compared to MAOIs and often exacerbate symptoms like weight gain and sedation, which are already present in atypical presentations. * **Paroxetine (Option C):** This is an **SSRI**. While SSRIs are commonly used in clinical practice for atypical depression due to fewer side effects, they are not the "classic" or superior choice when compared to the historical efficacy of MAOIs in this specific context. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** SSRIs are first-line (due to safety), but MAOIs (Phenelzine) are the most effective. * **Dietary Restriction:** Patients on Phenelzine must avoid **Tyramine-rich foods** (aged cheese, wine) to prevent a **Hypertensive Crisis**. * **Key Feature:** Mood reactivity is the pathognomonic feature of atypical depression.

Question 1

Which of the following is NOT a side effect of lithium used in psychiatric practice?

Accepted Answer

Hypercalcemia

Answer

Nausea, vomiting

Answer

Tremors

Answer

Hypothyroidism

Question 2

A 20-year-old female experiences frequent episodes of palpitations, breathlessness, sweating, and a fear of impending death, with one episode occurring weekly and no identifiable triggers. Which of the following is the best drug option for her long-term treatment?

Accepted Answer

Fluoxetine

Answer

Diazepam

Answer

Olanzapine

Answer

Beta Blockers

Question 3

What is the drug of choice for obsessive-compulsive disorder?

Accepted Answer

Sertraline

Answer

Amoxapine

Answer

Hydroxyzine

Answer

Alprazolam

Question 4

What is true regarding akathisia?

Accepted Answer

Treatment is by anticholinergics.

Answer

The patient wanders away from home.

Answer

It presents with hallucinations.

Answer

Behavioral therapy is required.

Question 5

Which of the following conditions makes antipsychotics relatively safer to use?

Accepted Answer

Hypertension

Answer

Infertility

Answer

Epilepsy

Answer

All of the above

Question 6

Which serum lithium level is suggestive of toxicity?

Accepted Answer

2 mEq/L

Answer

4 mEq/L

Answer

6 mEq/L

Answer

8 mEq/L

Question 7

Which of the following is NOT an anxiolytic drug?

Accepted Answer

Melatonin

Answer

Haloperidol

Answer

Alprazolam

Answer

Sertraline

Question 8

Esketamine, approved by the FDA in 2019, is indicated for the treatment of which condition?

Accepted Answer

Depression

Answer

Resistant schizophrenia

Answer

Bipolar disorder

Answer

Ketamine dependence

Question 9

Which of the following statements is true about neuroleptic malignant syndrome?

Accepted Answer

General antipsychotics are more associated with its development.

Answer

Symptoms include rigidity, fever, and altered consciousness.

Answer

Dantrolene is an effective treatment for improving symptoms.

Answer

Bromocriptine can be used in the management of neuroleptic malignant syndrome.

Question 10

Which of the following antidepressants is used in atypical depression?

Accepted Answer

Phenelzine

Answer

Imipramine

Answer

Paroxetine

Answer

Amitriptyline

Psychopharmacology — MCQs

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