Psychopharmacology Practice Questions

Q: Which antipsychotic has the least incidence of extrapyramidal symptoms?

Thioridazine. **Explanation:** The incidence of **Extrapyramidal Symptoms (EPS)** in antipsychotics is inversely proportional to the drug's intrinsic **anticholinergic (M1 receptor) activity**. **Why Thioridazine is Correct:** Thioridazine is a low-potency typical antipsychotic. Among the options provided, it possesses the **strongest intrinsic anticholinergic activity**. In the nigrostriatal pathway, dopamine and acetylcholine exist in a reciprocal balance. While antipsychotics block D2 receptors (causing EPS), the potent anticholinergic effect of Thioridazine "re-balances" this system, significantly reducing the risk of motor side effects. Therefore, it has the lowest incidence of EPS among typical antipsychotics. **Analysis of Incorrect Options:** * **Haloperidol:** A high-potency typical antipsychotic with very low anticholinergic activity. It has the **highest risk** of EPS (especially acute dystonia and parkinsonism) among the choices. * **Thiothixene & Perphenazine:** These are high-to-medium potency typical antipsychotics. While they have lower EPS risks than Haloperidol, their anticholinergic profiles are much weaker than Thioridazine, making them more likely to cause movement disorders. **NEET-PG High-Yield Pearls:** * **The "Gold Standard":** If **Clozapine** (an atypical antipsychotic) were an option, it would be the overall correct answer for the "least EPS." * **Thioridazine Side Effects:** While low in EPS, it is high-yield for causing **Retinitis Pigmentosa** (at doses >800mg/day) and **QT interval prolongation** (Torsades de pointes). * **Potency Rule:** Generally, **Low Potency** = High Sedation, High Anticholinergic, Low EPS. **High Potency** = Low Sedation, Low Anticholinergic, High EPS.

Q: A patient presents with depressed mood, loss of sleep, loss of hope, feeling of worthlessness, and diminished concentration for the past month. Which of the following is the drug of choice in this patient?

SSRIs (Selective Serotonin Reuptake Inhibitors). ### Explanation **1. Why SSRIs are the Correct Choice:** The patient presents with classic symptoms of **Major Depressive Disorder (MDD)**: depressed mood, insomnia, hopelessness, worthlessness, and poor concentration, lasting for more than two weeks. According to current clinical guidelines (APA and NICE), **Selective Serotonin Reuptake Inhibitors (SSRIs)** are the **first-line treatment** for MDD. They are preferred because of their favorable safety profile, better tolerability, and lower risk of toxicity in overdose compared to older antidepressants. **2. Analysis of Incorrect Options:** * **B. Atypical Antidepressants:** While effective (e.g., Bupropion, Mirtazapine), these are generally considered second-line or used in specific scenarios (e.g., Bupropion if sexual dysfunction is a concern). * **C. Lithium:** This is the drug of choice for **Bipolar Affective Disorder (BPAD)** prophylaxis and acute mania. While it can augment antidepressants in treatment-resistant depression, it is not the initial drug of choice for unipolar depression. * **D. Tricyclic Antidepressants (TCAs):** Though equally effective as SSRIs, TCAs are no longer first-line due to significant side effects (anticholinergic, antihistaminic, anti-alpha-1) and high **cardiotoxicity** in overdose (prolonged QTc). **3. NEET-PG High-Yield Pearls:** * **Most common side effect of SSRIs:** Gastrointestinal upset (nausea/diarrhea). * **Most common long-term side effect:** Sexual dysfunction. * **Fluoxetine:** Has the longest half-life (ideal for patients who forget doses). * **Fluvoxamine:** Specifically indicated for Obsessive-Compulsive Disorder (OCD). * **Sertraline:** Considered the safest SSRI post-Myocardial Infarction (MI). * **Escitalopram:** Known for having the highest specificity for the serotonin transporter.

Q: Which of the following is not a symptom of neuroleptic malignant syndrome?

Hypothermia. **Explanation:** Neuroleptic Malignant Syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs (neuroleptics), primarily caused by potent dopamine (D2) receptor antagonism in the nigrostriatal pathway and hypothalamus. **Why Hypothermia is the correct answer:** The hallmark of NMS is **Hyperpyrexia (High-grade fever)**, not hypothermia. The blockade of dopamine receptors in the hypothalamus disrupts the body's thermoregulatory set-point, leading to uncontrolled heat production. This is further exacerbated by intense muscle contractions. **Analysis of Incorrect Options:** * **Autonomic dysregulation:** This is a core feature of NMS. Patients typically present with "autonomic instability," including tachycardia, labile blood pressure, profuse diaphoresis (sweating), and tachypnea. * **Muscle rigidity:** Often described as **"Lead-pipe rigidity,"** this is a classic diagnostic sign. It results from dopamine blockade in the basal ganglia and is often accompanied by elevated Creatine Kinase (CK) levels due to muscle breakdown (rhabdomyolysis). * **Catatonia and stupor:** Altered mental status is an early sign of NMS. It ranges from confusion and agitation to catatonic signs, mutism, and eventually stupor or coma. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic (FEVER):** **F**ever, **E**ncephalopathy (altered mental status), **V**itals unstable, **E**levated enzymes (CK), **R**igidity. * **Treatment of Choice:** Immediate discontinuation of the offending agent + Supportive care. Pharmacotherapy includes **Dantrolene** (muscle relaxant) or **Bromocriptine** (dopamine agonist). * **NMS vs. Serotonin Syndrome:** While both have fever and tachycardia, NMS is characterized by **"Lead-pipe" rigidity** and bradyreflexia, whereas Serotonin Syndrome features **hyperreflexia and myoclonus.**

Q: Akathisia is treated by all except?

Haloperidol. **Explanation:** **Akathisia** is a common Extrapyramidal Side Effect (EPS) characterized by a subjective feeling of inner restlessness and an objective inability to sit still. **Why Haloperidol is the correct answer:** Haloperidol is a high-potency **Typical Antipsychotic** and a potent **D2 receptor antagonist**. Since akathisia is caused by the blockade of dopamine receptors in the nigrostriatal pathway, administering Haloperidol would **worsen** the condition rather than treat it. It is, in fact, one of the most common culprits behind the development of akathisia. **Analysis of Incorrect Options:** * **Trihexyphenidyl:** This is an anticholinergic agent. While Beta-blockers are the first-line treatment for akathisia, anticholinergics are frequently used as second-line agents to manage EPS. * **Diazepam:** Benzodiazepines are effective in reducing the subjective distress and motor restlessness associated with akathisia, especially when first-line treatments are insufficient. * **Promethazine:** This is an antihistamine with significant anticholinergic properties, making it a viable option for managing antipsychotic-induced movement disorders. **Clinical Pearls for NEET-PG:** 1. **Drug of Choice (DOC):** Propranolol (Beta-blocker) is the first-line treatment for Akathisia. 2. **Most Common EPS:** Akathisia is the most common extrapyramidal side effect of typical antipsychotics. 3. **Differential Diagnosis:** It is often misdiagnosed as worsening psychosis or agitation, leading to a dangerous "vicious cycle" if the antipsychotic dose is increased. 4. **Management Strategy:** The first step is usually to reduce the dose of the offending antipsychotic or switch to a Second Generation Antipsychotic (e.g., Quetiapine).

Q: A patient on haloperidol and clonazepam for psychotic symptoms presents with agitation, requiring both oral and intramuscular administration. The patient subsequently develops fever, rigidity, confusion, elevated CPK, and liver enzymes. What is the probable diagnosis?

Neuroleptic malignant syndrome. **Explanation:** The patient is presenting with the classic tetrad of **Neuroleptic Malignant Syndrome (NMS)**: fever (hyperpyrexia), muscle rigidity ("lead-pipe"), autonomic instability (agitation/tachycardia), and altered mental status (confusion). **Why NMS is the correct answer:** NMS is an idiosyncratic, life-threatening reaction to dopamine antagonists, most commonly **high-potency typical antipsychotics** like **Haloperidol**. The risk increases significantly with high doses or rapid escalation (e.g., combined oral and IM administration). Laboratory findings characteristically show **elevated Creatine Phosphokinase (CPK)** due to rhabdomyolysis from intense muscle rigidity and elevated liver enzymes. **Why the other options are incorrect:** * **Malignant Catatonia:** While it presents similarly with fever and rigidity, it is usually preceded by a prodrome of behavioral psychosis and is often *treated* with benzodiazepines/ECT, whereas NMS is *triggered* by neuroleptics. * **Serotonin Syndrome:** This occurs due to serotonergic agents (SSRIs/MAOIs). While it features fever and agitation, it is clinically distinguished by **hyperreflexia and myoclonus** rather than the "lead-pipe" rigidity seen in NMS. * **Gegenhalten (Paratonia):** This is a form of rigidity where the patient involuntarily resists passive movement in proportion to the force applied. It is associated with frontal lobe damage or dementia, not systemic symptoms like fever or elevated CPK. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for NMS (FEVER):** **F**ever, **E**ncephalopathy, **V**itals unstable, **E**levated enzymes (CPK), **R**igidity. * **Treatment of Choice:** Immediate discontinuation of the offending agent, supportive care, and pharmacotherapy with **Dantrolene** (muscle relaxant) or **Bromocriptine** (dopamine agonist). * **Key Lab:** Elevated CPK is the most sensitive laboratory indicator.

Q: A patient on antipsychotics presents with restlessness, an irresistible urge to move, and an inability to sit or stand in one position. What is the most likely diagnosis?

Akathisia. **Explanation:** The patient is presenting with the classic triad of **Akathisia**: subjective restlessness, an irresistible urge to move, and objective motor hyperactivity (pacing, shifting weight, or inability to sit still). It is the most common Extrapyramidal Side Effect (EPS) associated with antipsychotics, particularly high-potency first-generation agents. **Why the other options are incorrect:** * **Acute Dystonia:** Characterized by sudden, involuntary, sustained muscle contractions (e.g., torticollis, oculogyric crisis). It usually occurs within hours to days of starting treatment, whereas akathisia typically appears within days to weeks. * **Tardive Dyskinesia:** A late-onset complication (months to years) involving involuntary choreoathetoid movements, most commonly orofacial (lip-smacking, tongue protrusion). Unlike akathisia, these movements are involuntary and the patient may be unaware of them. * **Rabbit Syndrome:** A rare, late-onset EPS characterized by fine, rhythmic tremors of the perioral muscles (mimicking a chewing rabbit). It does not involve generalized restlessness. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Result of dopamine (D2) blockade in the nigrostriatal pathway. * **Management:** The drug of choice for Akathisia is **Propranolol** (Beta-blocker). Centrally acting anticholinergics (e.g., Benztropine) or Benzodiazepines are second-line. * **Clinical Significance:** Akathisia is highly distressing and is a major cause of non-compliance and increased suicide risk in patients on antipsychotics. * **Rule of Thumb (Timing of EPS):** **A**cute Dystonia (4 hours) > **A**kathisia (4 days) > **P**arkinsonism (4 weeks) > **T**ardive Dyskinesia (4 months/years). *Mnemonic: ADAPT.*

Question 1

Which antipsychotic has the least incidence of extrapyramidal symptoms?

Accepted Answer

Thioridazine

Answer

Haloperidol

Answer

Thiothixene

Answer

Perphenazine

Question 2

A patient presents with depressed mood, loss of sleep, loss of hope, feeling of worthlessness, and diminished concentration for the past month. Which of the following is the drug of choice in this patient?

Accepted Answer

SSRIs (Selective Serotonin Reuptake Inhibitors)

Answer

Atypical antidepressants

Answer

Lithium

Answer

Tricyclic antidepressants

Question 3

Which of the following is not a symptom of neuroleptic malignant syndrome?

Accepted Answer

Hypothermia

Answer

Autonomic dysregulation

Answer

Muscle rigidity

Answer

Catatonia and stupor

Question 4

A 40-year-old female patient presents with a history of depressed mood, loss of appetite, insomnia, and lack of interest in her surroundings for the past year. These symptoms followed soon after a business loss one year back. Which of the following statements is true regarding the management of this patient?

Accepted Answer

Antidepressant treatment selection is primarily based on the side effect profile of the drug.

Answer

No treatment is necessary as the symptoms are due to business loss.

Answer

SSRI is the most efficacious of the available antidepressant drugs.

Answer

Combination therapy of two antidepressants should be administered.

Question 5

Akathisia is treated by all except?

Accepted Answer

Haloperidol

Answer

Trihexyphenidyl

Answer

Diazepam

Answer

Promethazine

Question 6

A 28-year-old lady was admitted to the psychiatric ward after she ran out of the house removing her clothes. She complained of feeling depressed but was speaking very fast. She did not let the resident doctor complete his questions. She was hyperactive, distractible, and often confronted people on the ward. She complained about not being able to sleep and was low in mood despite being on an antidepressant. Which of the following is the most appropriate treatment for her condition?

Accepted Answer

Stop antidepressant and start Mood Stabiliser

Answer

Stop antidepressant and start Methylphenidate

Answer

Use antidepressant and Mood Stabiliser

Answer

Use antidepressant and Typical Antipsychotic

Question 7

An elderly woman whose husband died suddenly of myocardial infarction two years ago, and with whom she had been living alone for a decade with infrequent visits from her son and grandchildren, began to hear his voice clearly conversing with her as if he were in the next room about a week after his death. She would go to check but saw nothing. Subsequently, she often heard his voice and would discuss her daily matters with him. This, however, provoked anxiety and sadness of mood, and she remained preoccupied with thoughts about him. What is the most appropriate treatment for this patient?

Accepted Answer

Haloperidol

Answer

Clomipramine

Answer

Alprazolam

Answer

Electroconvulsive therapy

Question 8

A patient on haloperidol and clonazepam for psychotic symptoms presents with agitation, requiring both oral and intramuscular administration. The patient subsequently develops fever, rigidity, confusion, elevated CPK, and liver enzymes. What is the probable diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Malignant catatonia

Answer

Serotonin syndrome

Answer

Gegenhalten

Question 9

A patient on antipsychotics presents with restlessness, an irresistible urge to move, and an inability to sit or stand in one position. What is the most likely diagnosis?

Accepted Answer

Akathisia

Answer

Acute dystonia

Answer

Tardive dyskinesia

Answer

Rabbit syndrome

Question 10

A patient on antipsychotics for 3 weeks presents with high-grade fever, elevated CPK, and myoglobinuria. What is the most probable diagnosis?

Accepted Answer

Neuroleptic malignant syndrome

Answer

Tardive dyskinesia

Answer

Acute dystonia

Answer

Akathisia

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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