Psychopharmacology Practice Questions

Q: An elderly woman suffering from schizophrenia is on antipsychotic medication. She developed purposeless involuntary facial and limb movements, constant chewing and puffing of cheeks. Which of the following drugs is least likely to be involved in this side effect?

Clozapine. **Explanation:** The clinical presentation described—purposeless involuntary facial movements, constant chewing, and puffing of cheeks—is characteristic of **Tardive Dyskinesia (TD)**. This is a late-onset extrapyramidal side effect (EPS) caused by long-term blockade of dopamine (D2) receptors, leading to receptor supersensitivity. **Why Clozapine is the correct answer:** Clozapine is an atypical (second-generation) antipsychotic with a unique pharmacological profile. It has a **low affinity for D2 receptors** and a high affinity for D4 and serotonin (5-HT2A) receptors. Because it dissociates rapidly from D2 receptors, it carries the **lowest risk** of causing EPS and Tardive Dyskinesia among all antipsychotics. In fact, Clozapine is often the drug of choice for patients who have already developed TD. **Analysis of Incorrect Options:** * **Haloperidol & Fluphenazine:** These are high-potency, first-generation (typical) antipsychotics. They have a very high affinity for D2 receptors in the nigrostriatal pathway, making them the most common culprits for TD. * **Loxapine:** This is a mid-potency typical antipsychotic. While it has some serotonin-blocking properties, it behaves primarily like a first-generation drug and carries a significant risk of TD, especially in elderly patients. **Clinical Pearls for NEET-PG:** * **Risk Factors for TD:** Old age (highest risk), female gender, and long-term use of typical antipsychotics. * **Pathophysiology:** Dopamine receptor supersensitivity in the nigrostriatal pathway. * **Management:** The first step is to reduce the dose or switch to **Clozapine** or **Quetiapine**. * **Newer Treatments:** VMAT-2 inhibitors like **Valbenazine** or **Deutetrabenazine** are now FDA-approved for TD. * **Warning:** Anticholinergics (like Trihexyphenidyl) often **worsen** the symptoms of Tardive Dyskinesia, unlike acute dystonia.

Q: Which of the following indications of deep brain stimulation is not FDA approved?

Major depression. **Explanation:** Deep Brain Stimulation (DBS) involves the surgical implantation of electrodes into specific brain nuclei, connected to a pulse generator. While it is a revolutionary tool in neuromodulation, its FDA approval status varies significantly across psychiatric and neurological conditions. **Why Major Depression is the Correct Answer:** Although DBS (targeting the **Subgenual Cingulate Cortex/Area 25**) has shown promise in clinical trials for treatment-resistant depression, it is **not yet FDA-approved**. It remains an experimental treatment. In contrast, other neuromodulation techniques like ECT, rTMS, and Vagus Nerve Stimulation (VNS) *are* FDA-approved for depression. **Analysis of Incorrect Options:** * **Parkinsonism (Option C):** This was the first FDA-approved indication for DBS (1997). It typically targets the **Subthalamic Nucleus (STN)** or **Globus Pallidus interna (GPi)** to manage motor fluctuations and tremors. * **Dystonia (Option D):** Approved in 2003 under a Humanitarian Device Exemption (HDE) for chronic, intractable primary dystonia. * **OCD (Option A):** Approved in 2009 (HDE) for treatment-resistant OCD. The common target is the **Ventral Striatum** or the **Anterior Limb of the Internal Capsule (ALIC)**. **NEET-PG High-Yield Pearls:** * **DBS Targets:** * Parkinson’s: STN (most common) or GPi. * Essential Tremor: Ventral Intermediate Nucleus (Vim) of the Thalamus. * OCD: Internal Capsule/Ventral Striatum. * **FDA Status:** Remember that for psychiatric disorders, only **OCD** has FDA approval for DBS; Depression and Addiction are still under investigation. * **Contraindication:** DBS is generally avoided in patients with active psychosis or severe cognitive impairment.

Q: What is the drug of choice for a schizophrenic patient with poor oral absorption?

Clozapine. **Explanation:** The correct answer is **Clozapine**. **Why Clozapine is the Correct Choice:** The question addresses a specific pharmacokinetic challenge: **poor oral absorption**. While most antipsychotics are available in oral forms, Clozapine is unique in its pharmacological profile. In clinical scenarios where a patient fails to respond to standard antipsychotics (often due to poor absorption, high first-pass metabolism, or treatment resistance), Clozapine remains the **Gold Standard**. From a NEET-PG perspective, Clozapine is the only antipsychotic proven to be effective in **Treatment-Resistant Schizophrenia (TRS)**. If a patient has poor oral absorption leading to subtherapeutic plasma levels despite standard dosing, Clozapine is indicated because of its superior efficacy and the requirement for mandatory therapeutic drug monitoring (TDM) to ensure therapeutic levels are reached. **Analysis of Incorrect Options:** * **Haloperidol & Fluphenazine:** These are typical (first-generation) antipsychotics. While they are available as long-acting injectables (depots) to bypass the GI tract for *compliance* issues, they are not the "drug of choice" for absorption-related treatment failure. * **Olanzapine:** An atypical antipsychotic similar to Clozapine but with lower efficacy in resistant cases. It does not offer a specific advantage over Clozapine in the context of malabsorption-induced treatment failure. **High-Yield Clinical Pearls for NEET-PG:** * **Clozapine Side Effects:** Agranulocytosis (requires weekly CBC monitoring for the first 6 months), seizures (dose-dependent), myocarditis, and hypersalivation (sialorrhea). * **Indication:** Treatment-resistant schizophrenia (failure of 2 different antipsychotics for 6 weeks each) and reducing suicidal behavior in schizophrenia. * **Note:** Clozapine is the only antipsychotic that **does not** cause Tardive Dyskinesia and has minimal Extrapyramidal Side Effects (EPS).

Q: Estimation of serum levels is important for which of the following drugs?

Lithium. **Explanation:** **Lithium** is the correct answer because it has a **narrow therapeutic index**, meaning the difference between a therapeutic dose and a toxic dose is very small. Regular Therapeutic Drug Monitoring (TDM) is mandatory to ensure efficacy and prevent life-threatening toxicity. * **Why Lithium?** Lithium is not metabolized; it is excreted unchanged by the kidneys. Its serum levels are highly sensitive to hydration status, sodium intake, and drug interactions (e.g., NSAIDs, Diuretics, ACE inhibitors). The standard therapeutic range is **0.6–1.2 mEq/L**. Levels above 1.5 mEq/L are generally considered toxic. * **Why other options are incorrect:** * **Haloperidol & Chlorpromazine (Antipsychotics):** While plasma levels can be measured, they do not correlate strongly with clinical response or side effects. Dosing is primarily guided by clinical symptoms and the emergence of extrapyramidal side effects (EPS). * **Benzodiazepines:** These have a wide therapeutic window. Monitoring is based on clinical sedation and respiratory status rather than serum concentrations. **High-Yield Clinical Pearls for NEET-PG:** * **Sampling Time:** Serum Lithium levels should be measured **12 hours after the last dose** (Trough level). * **Monitoring Frequency:** Initially every 5–7 days until stable; then every 3–6 months. * **Target Levels:** * Acute Mania: 0.8–1.2 mEq/L * Maintenance: 0.6–0.8 mEq/L * Toxicity: >1.5 mEq/L (Severe toxicity >2.0 mEq/L may require hemodialysis). * **Other drugs requiring TDM in Psychiatry:** Valproate, Carbamazepine, and Clozapine (in specific refractory cases).

Q: Which of the following antismoking drugs can lead to suicidal ideation?

Varenicline. **Varenicline** is a high-yield topic in NEET-PG psychopharmacology. It is a **selective nicotinic acetylcholine receptor (nAChR) partial agonist** (specifically at the $\alpha_4\beta_2$ subtype). By partially stimulating these receptors, it reduces withdrawal symptoms, while its antagonistic property blocks the "reward" effect of nicotine if a patient relapses. ### Explanation of Options: * **Varenicline (Correct):** In 2009, the FDA issued a **Black Box Warning** (later updated but still clinically significant) regarding serious neuropsychiatric events, including **suicidal ideation**, depression, agitation, and hostility. Patients must be monitored closely for mood changes during treatment. * **Baclofen:** A $GABA_B$ agonist primarily used as a muscle relaxant. While sometimes used off-label for alcohol or cocaine dependence, it is not a primary antismoking drug and is not classically associated with suicidal ideation. * **Rimonabant:** A CB1 cannabinoid receptor antagonist. While it was used for weight loss and smoking cessation, it was withdrawn globally because it caused severe depression and anxiety, but it is not the *standard* answer for antismoking-induced suicidality in the context of current psychiatric exams compared to Varenicline. * **Naltrexone:** An opioid antagonist used primarily in alcohol and opioid dependence. It does not have a primary role in smoking cessation. ### High-Yield Clinical Pearls for NEET-PG: 1. **Mechanism of Action:** $\alpha_4\beta_2$ Nicotinic receptor partial agonist. 2. **Most Common Side Effect:** **Nausea** (often dose-dependent; taking it with food helps). 3. **Vivid Dreams:** Patients frequently report abnormal or vivid dreams. 4. **Bupropion:** Another antismoking drug (NDRI) that also carries a risk of neuropsychiatric side effects and is contraindicated in patients with a **seizure disorder** or eating disorders.

Q: A patient was given an antipsychotic drug, haloperidol, and the patient developed acute dystonia. Which is the next best step?

Give Benztropine. ***Give Benztropine***- **Acute dystonia** is a severe extrapyramidal symptom (EPS) requiring rapid intervention, often treated intramuscularly or intravenously.- **Benztropine** (an anticholinergic agent) is the drug of choice for the immediate management of acute dystonia, working to restore the balance between dopamine and acetylcholine.*Change to clozapine*- While **clozapine** has a significantly lower risk of causing acute dystonia, it is not the initial treatment for an acute episode due to its slow titration requirements and side-effect profile.- Switching to clozapine is a long-term strategy for patients intolerant to other antipsychotics, not an acute rescue medication.*Give Fluphenazine*- **Fluphenazine** is a high-potency first-generation antipsychotic, similar to haloperidol, which also carries a high risk of EPS.- Administering another high-potency antipsychotic would perpetuate the excessive **dopaminergic blockade** responsible for the acute dystonia.*Increase dose of haloperidol*- **Acute dystonia** is a direct dose-related side effect of D2 receptor blockade by haloperidol in the nigrostriatal pathway.- Increasing the dose of **haloperidol** would worsen the underlying neurochemical imbalance, thereby intensifying the dystonic symptoms.

Q: A patient with schizophrenia, developed muscular dystonia and was treated for it. The patient now presents with complaints of dry mouth, dizziness, and hypotension. What is the most likely drug causing these side effects?

Benzotropine. ***Benzotropine***- This drug is an **anticholinergic agent** administered specifically to treat **extrapyramidal symptoms (EPS)** like acute muscular dystonia caused by antipsychotics.- **Dry mouth** is a characteristic manifestation of its peripheral **anticholinergic side effects**, while **dizziness and hypotension** can occur due to central effects or potentiation of adrenergic blockade, particularly when co-administered with antipsychotics.*Risperidone*- Although Risperidone (an atypical antipsychotic) commonly causes EPS and strong **orthostatic hypotension** due to **alpha-1 adrenergic blockade** (dizziness/hypotension), it has moderate anticholinergic activity, making it less likely to be the sole cause of prominent dry mouth.- The patient's presentation suggests a new medication was introduced *after* the dystonia developed; Risperidone was likely the cause of the *initial* dystonia.*Haloperidol*- Haloperidol, a high-potency typical antipsychotic, is a common cause of **muscular dystonia** (EPS).- It has relatively **low anticholinergic activity** and is therefore an improbable cause of severe **dry mouth** compared to agents like Benzotropine.*Propranolol*- Propranolol is a **beta-blocker** typically used to treat antipsychotic-induced **akathisia** or tremor, not acute dystonia.- Its most prominent side effects are related to beta-blockade, such as **bradycardia** and fatigue; it is not routinely associated with significant **dry mouth**.

Question 1

An elderly widow reports auditory hallucinations of her deceased husband speaking to her. She often discusses daily matters with him, which provokes anxiety and sadness. What is the most appropriate initial treatment for this patient?

Accepted Answer

Haloperidol

Answer

Clomipramine

Answer

Alprazolam

Answer

Electroconvulsive therapy

Question 2

A patient undergoing treatment for a psychiatric disorder takes an overdose of a drug and develops bradycardia, hypotension, decreased sweating, and salivation. What is the likely drug?

Accepted Answer

Amitriptyline

Answer

Lithium

Answer

Selegiline

Answer

Amphetamine

Question 3

An elderly woman suffering from schizophrenia is on antipsychotic medication. She developed purposeless involuntary facial and limb movements, constant chewing and puffing of cheeks. Which of the following drugs is least likely to be involved in this side effect?

Accepted Answer

Clozapine

Answer

Haloperidol

Answer

Fluphenazine

Answer

Loxapine

Question 4

Which of the following indications of deep brain stimulation is not FDA approved?

Accepted Answer

Major depression

Answer

OCD

Answer

Parkinsonism

Answer

Dystonia

Question 5

What is the drug of choice for a schizophrenic patient with poor oral absorption?

Accepted Answer

Clozapine

Answer

Haloperidol

Answer

Fluphenazine

Answer

Olanzapine

Question 6

Estimation of serum levels is important for which of the following drugs?

Accepted Answer

Lithium

Answer

Haloperidol

Answer

Benzodiazepines

Answer

Chlorpromazine

Question 7

Which of the following antismoking drugs can lead to suicidal ideation?

Accepted Answer

Varenicline

Answer

Baclofen

Answer

Rimonobant

Answer

Naltrexone

Question 8

Regarding the use of Lithium in maniac-depressive psychosis, what is the true statement?

Accepted Answer

Lithium can result in leucocytosis.

Answer

Lithium is indicated for monotherapy of acute episodes.

Answer

Monitoring of serum concentration is not useful for guiding dose adjustment.

Answer

Lithium can result in hypothyroidism on long-term use.

Question 9

A patient was given an antipsychotic drug, haloperidol, and the patient developed acute dystonia. Which is the next best step?

Accepted Answer

Give Benztropine

Answer

Give Fluphenazine

Answer

Increase dose of haloperidol

Answer

Change to clozapine

Question 10

A patient with schizophrenia, developed muscular dystonia and was treated for it. The patient now presents with complaints of dry mouth, dizziness, and hypotension. What is the most likely drug causing these side effects?

Accepted Answer

Benzotropine

Answer

Propranolol

Answer

Risperidone

Answer

Haloperidol

Psychopharmacology — MCQs

Psychopharmacology — MCQs

On this page

Practice by Chapter

Want unlimited practice?