Psychopharmacology Practice Questions

Q: A 50-year-old man has presented with a 2-month history of back pain, lack of interest in recreational activities, low mood, lethargy, decreased sleep, and appetite. There is no evidence of delusions or hallucinations, and he has no chronic medical illness or family history of psychiatric illness. Routine investigations, including hemogram, renal function tests, liver function tests, and electrocardiogram, did not reveal any abnormalities. This patient should be treated with:

Sertraline. ***Sertraline*** - The patient's symptoms (back pain, anhedonia, low mood, lethargy, decreased sleep, decreased appetite) are highly suggestive of **major depressive disorder**. - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)**, which is a first-line treatment for major depressive disorder due to its efficacy and relatively favorable side-effect profile. *Alprazolam* - **Alprazolam** is a **benzodiazepine** primarily used for short-term treatment of anxiety and panic disorders. - It is not indicated as a primary treatment for depression and carries a significant risk of **dependence and withdrawal symptoms**. *Olanzapine* - **Olanzapine** is an **atypical antipsychotic** used to treat schizophrenia and bipolar disorder, and sometimes as an adjunct for treatment-resistant depression. - It is not a first-line monotherapy for major depressive disorder, especially in a patient with no evidence of psychosis or bipolar symptoms. *Haloperidol* - **Haloperidol** is a **typical antipsychotic** primarily used to treat psychotic disorders like schizophrenia and acute delirium. - It is not indicated for the treatment of depression and would likely worsen symptoms or cause significant side effects like **extrapyramidal symptoms**.

Q: Among the following, which test is essential in pre-treatment evaluation for lithium therapy:

Serum creatinine. ***Serum creatinine*** - **Lithium** is almost entirely excreted by the kidneys, so baseline renal function assessed by **serum creatinine** and estimated glomerular filtration rate (eGFR) is crucial. - This helps determine the appropriate starting dose and monitor for potential **lithium-induced renal impairment** during therapy. *Fasting blood sugar* - While important for general health screening and monitoring metabolic syndrome, **lithium** does not directly impact glucose metabolism to the extent that it requires pre-treatment evaluation for dosing or safety reasons. - This test is not considered essential specifically for lithium pre-treatment. *Liver function tests* - **Lithium** is not metabolized by the liver, and **hepatotoxicity** is not a known side effect. - Therefore, baseline liver function tests are not considered essential for initiating lithium therapy. *Platelet count* - **Lithium** rarely causes significant hematological abnormalities like **thrombocytopenia** or **thrombocytosis**. - A baseline platelet count is generally not required for pre-treatment evaluation unless there are other clinical indications.

Q: A 17-year-old with schizophrenia recently started on antipsychotics is brought to casualty with neck rigidity. He has:

Dystonia. ***Dystonia*** - **Acute dystonia** is a common **extrapyramidal side effect** of antipsychotic medications, particularly typical antipsychotics or higher doses of atypical ones. - **Neck rigidity**, specifically **torticollis** (sustained contraction of neck muscles causing the head to turn to one side), is a classic presentation of acute dystonia. *Catatonia* - While catatonia can manifest with motor abnormalities, including rigidity, it is a broader syndrome involving a range of **psychomotor disturbances** (e.g., stupor, negativism, waxy flexibility, mutism) and is not solely defined by isolated neck rigidity following antipsychotic initiation. - Catatonia is often a feature of severe psychiatric illness itself or other medical conditions, rather than an acute drug-induced side effect limited to muscle spasms. *Neuroleptic malignant syndrome* - **Neuroleptic malignant syndrome (NMS)** is a life-threatening reaction characterized by a **tetrad of symptoms**: high fever, severe muscle rigidity (generalized), altered mental status, and autonomic dysfunction (e.g., tachycardia, labile blood pressure). - Isolated neck rigidity without these other severe systemic signs is not consistent with NMS. *Tardive dyskinesia* - **Tardive dyskinesia** involves repetitive, involuntary, and often stereotyped movements, typically affecting the **face, mouth, and tongue** (e.g., grimacing, lip smacking, tongue protrusion). - It usually develops after **long-term use** of antipsychotics and is rarely an acute reaction presenting as neck rigidity shortly after starting the medication.

Q: A 50-year-old woman with schizophrenia who has been taking an antipsychotic drug for the past three years has begun to exhibit involuntary chewing and lip-smacking movements. Which is the most likely possibility?

Tardive Dyskinesia. ***Tardive Dyskinesia*** - This condition is characterized by **involuntary, repetitive movements**, often involving the face (e.g., **chewing, lip-smacking, grimacing**) and extremities, that develop after prolonged use of antipsychotic medications. - The delayed onset (after three years of antipsychotic use) and the specific nature of the movements are highly suggestive of **tardive dyskinesia**. *Akathisia* - Akathisia presents as a feeling of **inner restlessness** and an inability to sit still, leading to constant pacing or fidgeting. - While it is a common side effect of antipsychotics, the cardinal symptoms are motor restlessness rather than involuntary movements like chewing and lip-smacking. *Neuroleptic Malignant Syndrome* - This is a rare, life-threatening reaction to antipsychotics characterized by **fever, severe muscle rigidity, altered mental status, and autonomic dysfunction**. - The patient's symptoms of involuntary chewing and lip-smacking do not align with the acute and severe presentation of NMS. *Restless Legs Syndrome* - RLS involves an **uncontrollable urge to move the legs**, typically worse at night and relieved by movement, often accompanied by unpleasant sensations. - The patient's symptoms are in the face (chewing, lip-smacking) and not described as an urge to move the legs or worse at night.

Q: Which of the following medications is primarily an antipsychotic rather than a mood stabilizer and is NOT typically used for long-term prophylaxis in bipolar disorder? Chlorpromazine, Lithium, Carbamazepine, Sodium Valproate.

Chlorpromazine. ***Chlorpromazine*** - **Chlorpromazine** is a **first-generation antipsychotic** primarily used to treat **psychotic symptoms** like hallucinations and delusions. - While it can be used for acute agitation in bipolar disorder, it's generally **not considered a first-line agent** for **long-term mood stabilization** or prophylaxis due to its side effect profile and limited efficacy in preventing mood episodes compared to true mood stabilizers. *Carbamazepine* - **Carbamazepine** is an **anticonvulsant medication** well-established as a **mood stabilizer** for the long-term prophylaxis and treatment of bipolar disorder. - It is particularly effective for **rapid cycling** and **mixed features**, distinguishing it from an antipsychotic. *Sodium Valproate* - **Sodium valproate** (Valproic acid) is a widely used **mood stabilizer** for both acute mania and long-term prophylaxis in bipolar disorder. - It is effective in treating or preventing both manic and depressive episodes, and is **not primarily an antipsychotic**. *Lithium* - **Lithium** is considered the **gold standard mood stabilizer** for the long-term prophylaxis of bipolar disorder, significantly reducing the risk of both manic and depressive episodes. - It is primarily a **mood stabilizer** and does not possess significant antipsychotic effects on its own.

Q: According to the classical monoamine hypothesis of depression, deficiency of which of the following neurotransmitters is MOST commonly emphasized in modern antidepressant therapy?

Serotonin. ***Serotonin*** - The **classical monoamine hypothesis** of depression posits deficiencies in monoamine neurotransmitters including **serotonin (5-HT), norepinephrine, and dopamine**. - Among these, **serotonin** is the **most commonly emphasized** in modern antidepressant therapy, given its central role in mood regulation, sleep, appetite, and cognition. - The majority of first-line antidepressants, such as **SSRIs (Selective Serotonin Reuptake Inhibitors)** and **SNRIs**, primarily target serotonergic pathways, reflecting its clinical importance. - **Clinical relevance**: Serotonin deficiency is associated with depressed mood, anxiety, sleep disturbances, and appetite changes. *Acetylcholine* - **Acetylcholine** is a neurotransmitter involved in cognitive function, memory, and muscle contraction. - It is **not a monoamine** and is not part of the classical monoamine hypothesis of depression. - Acetylcholine deficiency is primarily implicated in **Alzheimer's disease** and other cognitive disorders, not depression. *Dopamine* - **Dopamine** is one of the three monoamines implicated in the classical hypothesis and plays a role in pleasure, reward, motivation, and motor control. - Dopamine deficiency can contribute to symptoms of **anhedonia** (inability to feel pleasure) and lack of motivation in depression. - However, dopamine-targeting antidepressants (like bupropion) are less commonly used as first-line therapy compared to serotonergic agents, making serotonin the most emphasized in clinical practice. *GABA* - **GABA (gamma-aminobutyric acid)** is the primary **inhibitory neurotransmitter** in the central nervous system. - It is **not a monoamine** and is not part of the classical monoamine hypothesis of depression. - GABA dysfunction is primarily associated with **anxiety disorders, seizures, and insomnia**, not depression as per the classical hypothesis.

Q: Which mood stabilizer is known for its anti-suicidal property?

lithium. ***Lithium*** - **Lithium** is the only mood stabilizer with strong evidence of reducing **suicidal ideation** and attempts in patients with mood disorders. - Its mechanism in preventing suicidality is not fully understood but may involve neuroprotective effects and modulation of neurotransmitter systems. *Carbamazepine* - While an effective mood stabilizer for **bipolar disorder**, carbamazepine does not have a well-established anti-suicidal property compared to lithium. - It works primarily by blocking voltage-gated **sodium channels**, which stabilizes neuronal membranes. *Lamotrigine* - **Lamotrigine** is primarily used for the **maintenance treatment** of bipolar disorder, particularly for preventing depressive episodes. - It does not have significant evidence for a direct anti-suicidal effect, and there is a rare risk of **Stevens-Johnson syndrome**. *Valproate* - **Valproate** is an effective mood stabilizer for acute mania and maintenance treatment in bipolar disorder. - While it can improve mood and reduce impulsivity, its anti-suicidal effect is not as robust or consistently demonstrated as that of **lithium**.

Q: Vasanthi, a 45-year-old woman, was brought to the casualty with persistent neck deviation to the right side and abnormal movements, one day after being prescribed haloperidol 5 mg three times daily from the psychiatry OPD. She also had a recent altercation with her husband. Which of the following is the most likely cause of her symptoms?

Acute drug dystonia due to haloperidol. ***Acute drug dystonia due to haloperidol*** - The sudden onset of **persistent neck deviation** (torticollis) and **abnormal movements** one day after starting **haloperidol**, a dopamine receptor blocker, is highly characteristic of an **acute dystonic reaction** [1]. - **Haloperidol** is a **first-generation antipsychotic** known for its increased risk of **extrapyramidal symptoms**, including dystonia [1]. *Conversion disorder* - Conversion disorder involves neurological symptoms that are **incompatible with known neurological or medical conditions** and are often preceded by psychological stressors. - While she had a recent altercation, the clear temporal relationship with a known **dopamine-blocking drug** makes drug-induced dystonia more likely than a functional neurological disorder. *Acute psychotic episode* - An acute psychotic episode is primarily characterized by **delusions, hallucinations, disorganized speech, or behavior**, not focal neurological symptoms like a persistent neck deviation. - Although the symptoms followed a psychiatric consultation, the specific presentation points away from a primary psychotic exacerbation. *Cerebrovascular accident* - A **cerebrovascular accident (stroke)** would typically present with **unilateral weakness, numbness, speech difficulties, or vision changes**, depending on the affected brain region. - The sudden onset of isolated neck deviation and generalized abnormal movements is not typical for a stroke, especially in someone starting haloperidol.

Q: A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?

Clozapine. ***Clozapine*** - **Clozapine** is the drug of choice for **treatment-resistant schizophrenia** or patients who are **intolerant to conventional antipsychotics**. - Its unique efficacy often comes with a risk of **agranulocytosis**, requiring regular **blood monitoring**. *Olanzapine* - While an effective **atypical antipsychotic**, it is not specifically indicated for **treatment-resistant cases** in the same way as clozapine. - It carries a risk of significant **metabolic side effects**, such as weight gain and dyslipidemia. *Haloperidol* - This is a **first-generation (conventional) antipsychotic** and would be unsuitable for a patient described as **intolerant to conventional antipsychotics**. - It is associated with a high incidence of **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**. *Risperidone* - As an **atypical antipsychotic**, it is a good first-line option but is not typically reserved for **treatment-resistant schizophrenia** or those with conventional antipsychotic intolerance. - It has a higher propensity for **hyperprolactinemia** compared to other atypical antipsychotics.

Q: What is the most appropriate investigation for a patient with bipolar disorder on lithium therapy for 6 months, who presents with seizures, coarse tremors, confusion, and weakness of the limbs after a day of fasting?

Serum Lithium. ***Serum Lithium*** - The patient's symptoms (seizures, coarse tremors, confusion, weakness) are classic signs of **lithium toxicity**. - Fasting can lead to **dehydration** and electrolyte imbalances, which can increase lithium levels and precipitate toxicity. *Serum Electrolyte* - While electrolyte imbalances can contribute to lithium toxicity and symptoms, measuring electrolytes alone will not directly confirm **lithium overdose**. - **Hyponatremia** and **dehydration** can exacerbate lithium toxicity by increasing renal reabsorption of lithium. *ECG* - **ECG changes** (e.g., T-wave abnormalities, QTc prolongation) can occur with severe lithium toxicity, but it is not the primary diagnostic test. - ECG is a supportive investigation to assess cardiac complications, not the direct cause of the neurological symptoms. *Serum creatinine* - **Serum creatinine** is important for monitoring **renal function**, as lithium is cleared renally and renal impairment can lead to higher lithium levels. - However, assessing creatinine levels will not directly diagnose acute lithium toxicity; it helps evaluate the **renal health** and potential for toxicity.

Question 1

A 50-year-old man has presented with a 2-month history of back pain, lack of interest in recreational activities, low mood, lethargy, decreased sleep, and appetite. There is no evidence of delusions or hallucinations, and he has no chronic medical illness or family history of psychiatric illness. Routine investigations, including hemogram, renal function tests, liver function tests, and electrocardiogram, did not reveal any abnormalities. This patient should be treated with:

Accepted Answer

Sertraline

Answer

Alprazolam

Answer

Olanzapine

Answer

Haloperidol

Question 2

Among the following, which test is essential in pre-treatment evaluation for lithium therapy:

Accepted Answer

Serum creatinine

Answer

Fasting blood sugar

Answer

Liver function tests

Answer

Platelet count

Question 3

A 17-year-old with schizophrenia recently started on antipsychotics is brought to casualty with neck rigidity. He has:

Accepted Answer

Dystonia

Answer

Tardive dyskinesia

Answer

Catatonia

Answer

Neuroleptic malignant syndrome

Question 4

A 50-year-old woman with schizophrenia who has been taking an antipsychotic drug for the past three years has begun to exhibit involuntary chewing and lip-smacking movements. Which is the most likely possibility?

Accepted Answer

Tardive Dyskinesia

Answer

Akathisia

Answer

Neuroleptic Malignant Syndrome

Answer

Restless Legs Syndrome

Question 5

Which of the following medications is primarily an antipsychotic rather than a mood stabilizer and is NOT typically used for long-term prophylaxis in bipolar disorder? Chlorpromazine, Lithium, Carbamazepine, Sodium Valproate.

Accepted Answer

Chlorpromazine

Answer

Sodium Valproate

Answer

Carbamazepine

Answer

Lithium

Question 6

According to the classical monoamine hypothesis of depression, deficiency of which of the following neurotransmitters is MOST commonly emphasized in modern antidepressant therapy?

Accepted Answer

Serotonin

Answer

Acetylcholine

Answer

Dopamine

Answer

GABA

Question 7

Which mood stabilizer is known for its anti-suicidal property?

Accepted Answer

lithium

Answer

carbamazepine

Answer

lamotrigine

Answer

valproate

Question 8

Vasanthi, a 45-year-old woman, was brought to the casualty with persistent neck deviation to the right side and abnormal movements, one day after being prescribed haloperidol 5 mg three times daily from the psychiatry OPD. She also had a recent altercation with her husband. Which of the following is the most likely cause of her symptoms?

Accepted Answer

Acute drug dystonia due to haloperidol

Answer

Conversion disorder

Answer

Acute psychotic episode

Answer

Cerebrovascular accident

Question 9

A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?

Accepted Answer

Clozapine

Answer

Haloperidol

Answer

Olanzapine

Answer

Risperidone

Question 10

What is the most appropriate investigation for a patient with bipolar disorder on lithium therapy for 6 months, who presents with seizures, coarse tremors, confusion, and weakness of the limbs after a day of fasting?

Accepted Answer

Serum Lithium

Answer

Serum Electrolyte

Answer

ECG

Answer

Serum creatinine

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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