Psychopharmacology Practice Questions

Q: A patient was on lithium therapy for bipolar disorder for 6 months. She fasted for few days due to religious reasons and presented with coarse tremors, abdominal pain, nausea, dizziness & confusion. Which of the following should be done to assess her condition?

S. lithium levels. ***S. lithium levels*** - The patient's symptoms (coarse tremors, abdominal pain, nausea, dizziness, confusion) are classic for **lithium toxicity**, which is exacerbated by **dehydration** from fasting [1], [2]. - Measuring **serum lithium levels** is crucial for confirming the diagnosis and guiding immediate management [1]. *ECG* - While lithium toxicity can cause **cardiac arrhythmias** (QT prolongation, T-wave changes), an ECG is a secondary assessment to evaluate for complications, not the primary diagnostic test for toxicity itself. - An ECG doesn't directly measure lithium concentration, which is essential for diagnosing toxicity. *S. electrolyte* - **Electrolyte imbalances**, particularly **hyponatremia**, can worsen lithium toxicity by affecting its renal excretion [2]. - While important to check for contributing factors and guide supportive care, measuring electrolytes is secondary to confirming elevated lithium levels as the cause of symptoms. *MRI* - An **MRI of the brain** is not indicated for the initial assessment of suspected lithium toxicity. - It would only be considered if there were concerns for focal neurological deficits or other structural brain abnormalities, which are not directly suggested by the presented symptoms of lithium toxicity.

Q: 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?

Akathisia. ***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.

Q: A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?

Stop clozapine. ***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.

Q: A patient with bipolar disorder shows poor response to lithium. Which feature best explains this?

Mixed episodes. ***Mixed episodes*** - The presence of **mixed episodes** (simultaneous manic and depressive symptoms) in bipolar disorder predicts a poorer response to **lithium** monotherapy. - Patients experiencing mixed features often require **antipsychotics** or **mood stabilizers** like valproate or carbamazepine in addition to or instead of lithium. *Early age of onset* - While an early age of onset can indicate a more severe course of bipolar disorder, it doesn't specifically predict **poor response to lithium**. - In fact, lithium can be effective in reducing the frequency of episodes for many patients with early-onset bipolar disorder. *Classical mania* - **Classical mania** (euphoric, agitated, pressured speech) is generally associated with a **good response to lithium**. - Lithium is considered a first-line treatment for classic euphoric mania. *Family history of bipolar* - A **family history of bipolar disorder** suggests a genetic predisposition but does not inherently predict a poor response to lithium. - Genetic factors can influence treatment response, but a positive family history alone is not a contraindication or predictor of lithium failure.

Q: Z tracking technique is used in?

Administering long acting antipsychotic. ***Administering long acting antipsychotic*** - The **Z-track technique** is a method of intramuscular injection used to prevent medication from leaking back into the subcutaneous tissue, which is particularly important for irritating or discoloring medications like **long-acting antipsychotics**. - This technique involves pulling the skin and subcutaneous tissue to one side before injection, then releasing it after the needle is withdrawn, creating a **zigzag path** that seals the medication within the muscle. *Carbamazepine monitoring* - **Carbamazepine monitoring** involves regularly checking blood levels of the drug to ensure therapeutic efficacy and avoid toxicity. - This is a **laboratory process**, not an administration technique, and does not involve Z-tracking. *Lithium monitoring* - **Lithium monitoring** requires periodic blood tests to maintain therapeutic levels and prevent adverse effects due to its narrow therapeutic index. - Like carbamazepine monitoring, this is a **laboratory-based task** and not related to drug administration methods. *Nicotine patch* - A **nicotine patch** is a transdermal delivery system applied to the skin, which releases nicotine slowly into the bloodstream. - This is a **topical application method** and does not involve injections or the Z-track technique.

Q: Which drug for ADHD has a risk of growth retardation in children?

Methylphenidate. ***Methylphenidate*** - **Methylphenidate** (a stimulant) can cause a **transient reduction in growth velocity** due to effects on appetite suppression and potentially growth hormone secretion [1]. - While this reduction is often temporary and catch-up growth typically occurs, it is a **well-documented and clinically significant risk** requiring growth monitoring in children [1, 2]. - Among ADHD medications, stimulants like methylphenidate have the **most pronounced effect on growth** [1].*Modafinil* - **Modafinil** is primarily used for narcolepsy and other sleep disorders, not a first-line treatment for ADHD. - It works through different mechanisms than traditional stimulants and is not typically associated with growth retardation in the ADHD population.*Clonidine* - **Clonidine** is an alpha-2 adrenergic agonist used to treat ADHD, particularly for hyperactivity, impulsivity, and sleep problems. - It does **not have a known risk of growth retardation** in children.*Atomoxetine* - **Atomoxetine** is a non-stimulant medication for ADHD that works by selectively inhibiting norepinephrine reuptake. - While atomoxetine can also affect growth velocity in some children (FDA labeling includes growth monitoring recommendations), the effect is **generally less pronounced than with stimulants like methylphenidate**. - Methylphenidate remains the **most recognized** for this adverse effect among ADHD medications.

Q: Which antipsychotic is preferred for treatment-resistant schizophrenia?

Clozapine. ***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.

Q: Which of the following is the treatment of choice for PTSD?

SSRIs. ***SSRIs*** - **Selective serotonin reuptake inhibitors (SSRIs)** are considered first-line pharmacological treatment for **Post-Traumatic Stress Disorder (PTSD)** due to their efficacy in reducing core PTSD symptoms like re-experiencing, avoidance, and hyperarousal. - They work by increasing the availability of **serotonin** in the brain, positively impacting mood, anxiety, and sleep regulation. *Benzodiazepines* - While benzodiazepines can provide rapid relief for acute anxiety, they are generally **not recommended as a primary treatment for PTSD** due to risks of dependence and masking underlying symptoms. - They do not address the core symptoms of PTSD and can worsen long-term outcomes, especially in individuals with a history of substance abuse. *Mood stabilizers* - Mood stabilizers, such as lithium or valproate, are primarily used for conditions like **bipolar disorder** or certain **personality disorders** characterized by significant mood swings. - They are **not a first-line treatment for PTSD** and are typically reserved for cases with prominent **affective dysregulation** not managed by other medications, or comorbid bipolar disorder. *Antipsychotics* - Antipsychotics are primarily indicated for conditions with **psychotic features**, such as schizophrenia or severe bipolar disorder with psychosis. - They are **not routinely used as monotherapy for PTSD** but may be considered as an augmentation strategy in severe, refractory cases, especially when there are prominent **dissociative symptoms**, paranoia, or aggression.

Q: Which antipsychotic drug is known for its effectiveness in managing schizophrenia but requires monitoring due to its risk of metabolic side effects?

Quetiapine. ***Quetiapine*** - **Quetiapine** is a **second-generation antipsychotic** effective for schizophrenia, but it is well-known for its metabolic side effects. - These side effects include **weight gain**, **dyslipidemia**, and **hyperglycemia**, necessitating careful metabolic monitoring. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** primarily associated with **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**, rather than significant metabolic disturbances. - While effective for psychosis, its side effect profile is distinct from metabolic concerns. *Risperidone* - **Risperidone** is a **second-generation antipsychotic** that also carries a risk of metabolic side effects, specifically **weight gain** and **hyperprolactinemia**. - However, **quetiapine** generally has a more pronounced risk of the full spectrum of metabolic syndrome compared to risperidone. *Chlorpromazine* - **Chlorpromazine** is a **first-generation antipsychotic** notable for **sedation**, **hypotension**, and **anticholinergic side effects**. - While it can cause some weight gain, its metabolic risk is not as prominent as that of certain second-generation antipsychotics like quetiapine.

Q: A 30-year-old female with a history of bipolar disorder presents with symptoms of acute mania. She is currently on lithium with therapeutic serum levels (0.8 mEq/L). What additional medication should be considered?

Consider adding valproate. ***Consider adding valproate*** - For acute mania that is not responding adequately to lithium monotherapy, **adding an antipsychotic or another mood stabilizer like valproate** is a common and effective strategy. - Valproate is particularly useful for **mixed episodes** and rapid cycling, but also effective for acute manic episodes. *Consider switching to carbamazepine* - While **carbamazepine** is an alternative mood stabilizer, switching from lithium would mean abandoning an agent that might still have some efficacy or therapeutic potential, especially if the patient previously responded well. - Adding a second agent rather than switching is generally preferred to address acute manic symptoms when monotherapy is insufficient. *Consider increasing lithium dose with monitoring* - The question implies the patient is already on lithium and experiencing breakthrough manic symptoms, suggesting the current dose or monotherapy is insufficient. **Increasing the lithium dose** might be considered, but only after checking current lithium levels to ensure they are subtherapeutic and within a safe range for upward titration. - **Lithium has a narrow therapeutic index**, and increasing the dose without careful monitoring could lead to toxicity. *Consider discontinuing lithium* - **Discontinuing lithium** would remove the existing mood stabilization and potentially worsen the manic symptoms or precipitate a more severe episode, especially given the patient's history of bipolar disorder. - Abrupt discontinuation of mood stabilizers is generally avoided due to the **risk of relapse**.

Question 1

A patient was on lithium therapy for bipolar disorder for 6 months. She fasted for few days due to religious reasons and presented with coarse tremors, abdominal pain, nausea, dizziness & confusion. Which of the following should be done to assess her condition?

Accepted Answer

S. lithium levels

Answer

ECG

Answer

MRI

Answer

S. electrolytes

Question 2

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?

Accepted Answer

Akathisia

Answer

Rabbit syndrome

Answer

Tardive dyskinesia

Answer

Acute Dystonia

Question 3

A patient on clozapine develops fever, confusion, and muscle rigidity. CK is elevated. Most appropriate next step?

Accepted Answer

Stop clozapine

Answer

Add antipyretic

Answer

Continue clozapine

Answer

Reduce dose

Question 4

A patient with bipolar disorder shows poor response to lithium. Which feature best explains this?

Accepted Answer

Mixed episodes

Answer

Early age of onset

Answer

Classical mania

Answer

Family history of bipolar

Question 5

Z tracking technique is used in?

Accepted Answer

Administering long acting antipsychotic

Answer

Carbamazepine monitoring

Answer

Lithium monitoring

Answer

Nicotine patch

Question 6

Which drug for ADHD has a risk of growth retardation in children?

Accepted Answer

Methylphenidate

Answer

Modafinil

Answer

Clonidine

Answer

Atomoxetine

Question 7

Which antipsychotic is preferred for treatment-resistant schizophrenia?

Accepted Answer

Clozapine

Answer

Quetiapine

Answer

Olanzapine

Answer

Risperidone

Question 8

Which of the following is the treatment of choice for PTSD?

Accepted Answer

SSRIs

Answer

Benzodiazepines

Answer

Mood stabilizers

Answer

Antipsychotics

Question 9

Which antipsychotic drug is known for its effectiveness in managing schizophrenia but requires monitoring due to its risk of metabolic side effects?

Accepted Answer

Quetiapine

Answer

Haloperidol

Answer

Risperidone

Answer

Chlorpromazine

Question 10

A 30-year-old female with a history of bipolar disorder presents with symptoms of acute mania. She is currently on lithium with therapeutic serum levels (0.8 mEq/L). What additional medication should be considered?

Accepted Answer

Consider adding valproate

Answer

Consider switching to carbamazepine

Answer

Consider increasing lithium dose with monitoring

Answer

Consider discontinuing lithium

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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