mcq's

37. A 35-year-old man stumbles into the emergency room with pulse-100 beats/ minute, blood pressure - 170/95 mm Hg. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days. Which of the following is the most likely diagnosis?

1. Alcohol-induced psychotic disorder
2. Wernicke’s psychosis
3. Delirium tremens
4. Alcohol intoxication

Ans).c) Delirium tremens

• Delirium tremens
• most severe form of the alcohol withdrawal syndrome.
• Untreated, DTs has a mortality rate of 20 percent, usually as a result of an intercurrent medical illness
• Although withdrawal seizures commonly precede the development of alcohol withdrawal delirium, delirium can also appear unheralded.
• The essential feature of the syndrome is delirium occurring within 1 week after a person stops drinking or reduces the intake of alcohol.
• The features of alcohol intoxication delirium include autonomic hyperactivity such as tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension; perceptual distortions, most frequently visual or tactile hallucinations; fluctuating levels of psychomotor activity, ranging from hyperexcitability to lethargy and fluctuating levels of orientation and consciousness
• Episodes of DTs usually begin in a patient's 30s or 40s after 5 to 15 years of heavy drinking, typically of the binge type.
• Physical illness (e.g., hepatitis or pancreatitis) predisposes to the syndrome.

· The classic sign of alcohol withdrawal is tremulousness.

· Symptoms of alcohol withdrawal

• autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
• increased hand tremor
• insomnia
• nausea or vomiting
• transient visual, tactile, or auditory hallucinations or illusions
• psychomotor agitation
• anxiety
• grand mal seizures

· Tremulousness (commonly called the shakes or the jitters) develops 6 to 8 hours after the cessation of drinking, the psychotic and perceptual symptoms begin in 8 to 12 hours, seizures in 12 to 24 hours, and delirium tremens during 72 hours.

· Seizures associated with alcohol withdrawal are

o stereotyped, generalized, and tonic-clonic in character.

o often have more than one seizure 3 to 6 hours after the first seizure

o Status epilepticus is relatively rare and occurs in less than 3 percent of patients.

· The primary medications to control alcohol withdrawal symptoms are the benzodiazepines

38. Sleep EEG shows low-voltage, random fast activity with saw-tooth waves. The sleep stage is

1. NREM- Stage 1
2. NREM- Stage 2
3. NREM- Stage 3
4. REM sleep

Ans) d). REM sleep

Stages of Sleep: Electrophysiological Criteria

Electroencephalogram Electrooculogram Electromyogram Wakefulness Low-voltage, mixed frequency activity Alpha (8 - 13 cps) activity with eyes closed, mind wandering Eye movements and eye blinks High tonic activity and voluntary movements Nonrapid eye movement sleep Stage I Low-voltage, mixed frequency activity Theta (3 - 7 cps) activity, vertex sharp waves Slow eye movements Tonic activity slightly decreased from wakefulness Stage II Low-voltage, mixed frequency background with sleep spindles (12 - 14 cps bursts) and K complexes (negative sharp wave followed by positive slow wave) None Low tonic activity Stage III High-amplitude (75 µV) slow waves (2 cps), delta waves, occupying 20 to 50 percent of epoch None Low tonic activity Stage IV High-amplitude slow waves occupy >50% of epoch None Low tonic activity REM sleep Low-voltage, mixed frequency activity Saw-tooth waves, theta activity, and slow alpha activity, Ponto-geniculo-occipital spikes REMs Tonic atonia with phasic twitches REM, rapid eye movement. Criteria from Rechtchaffen A, Kales A.

• Alpha block:
• Alpha wave is replaced by fast irregular, low voltage activity
• Found in
• Arousal or alerting response
• Sensory stimulation
• Mental concentration or solving problem

Attention is focussed on something

39). All of the following signs are seen in cannabis intoxication except

a) conjunctival injection

b) decreased appetite

c) dry mouth

d) tachycardia

Ans). B) decreased appetite

• Increased appetite instead of decreased appetite is seen in cannabis intoxication
• Following signs can develop in cannabis intoxication within 2 hours of cannabis use:
• conjunctival injection
• increased appetite
• dry mouth
• tachycardia

· Physical withdrawal signs are absent in LSD and Cannabis.

· Characteristics of cannabis

o Run amock

o Amotivation syndrome

o Flashbacks

· Active metabolite: D-9-Tetrahydrocannabinol

40). Anosognosia is

a) Inability to identify familiar objects by touch.

b) Inability or difficulty in describing or being aware of one's emotions or moods

c) Inability to recognize a physical deficit in oneself

d) Lack or impairment of the sense of taste

Ans). C) Inability to recognize a physical deficit in oneself

· Alexithymia: Inability or difficulty in describing or being aware of one's emotions or moods.

· Astereognosis: Inability to identify familiar objects by touch.

· Ageusia: Lack or impairment of the sense of taste

· Anosognosia: Inability to recognize a physical deficit in oneself

o relatively common following brain injury

o not related to global mental confusion , cognitive flexibility, or other major intellectual disturbance.

o may occur as part of Wernicke's aphasia

41). Which of the following is not a cholinesterase inhibitor?

a) Donepezil

b) Rivastigmine

c) Galantamine

d) Memantine

Ans) d) Memantine

• Donepezil, rivastigmine, galantamine, and tacrine are cholinesterase inhibitors used to treat mild to moderate cognitive impairment in dementia of the Alzheimer's type.
• reduce the inactivation of the neurotransmitter acetylcholine and, thus, potentiate cholinergic neurotransmission, which in turn produces a modest improvement in memory and goal-directed thought.

• Memantine (Namenda) is not a cholinesterase inhibitor, producing its effects through blockade of N-methyl-D-aspartate (NMDA) receptors.
• Unlike the cholinesterase inhibitors, which are indicated for the mild to moderate stages of Alzheimer's disease, memantine is indicated for the moderate to severe stages of the disease.
• Tacrine, the first cholinesterase inhibitor to be introduced, is rarely used because of its multiple daily dosing regimens, its potential for hepatotoxicity, and the consequent need for frequent laboratory monitoring.
• Rivastigmine
• Carbamate derivative of physiostigmine
• Highly lipid soluble: enters brain easily
• Donepezil
• Cerebroselective and reversible anticholinesterase
• Galantamine
• Natural alkaloid which selectively inhibits cerebral anticholinesterase and some agonistic action on nicotinic receptor.

42).The most common form of dissociation hysteria is

a) Fugue

b) Amnesia

c) Multiple personality

d) Somnambulism

Ans). A) Amnesia

· Dissociative amnesia: reported in about 6% of population.

· Dissociative fugue: more common during natural disasters, wartime, or times of major social dislocation and violence, although no systematic data exist on this point.

43). All of the following are defence mechanisms used in OCD except

a) Reaction formation

b) Rationalisation

c) Isolation

d) Undoing

Ans). B) Rationalisation

• Freud described three major psychological defence mechanisms that are important in OCD: isolation, undoing, and reaction formation.
• Isolation is the separation of the idea and the affect that it arouses, when the patient is only aware of the affectless idea.
• Undoing is a secondary defence to combat the impulse and quiet the anxiety that its imminent eruption into consciousness arouses. Undoing is a compulsive act, performed to prevent or undo the results that the patient irrationally anticipates from a frightening obsessional thought or impulse.
• Reaction formation is related to the production of character traits rather than symptom formation (characteristic of the above defences). The trait seems highly exaggerated and inappropriate (i.e. the switch of anger and hate into exaggerated love and dedication).

44). Every 4 or 5 weeks, a usually well-functioning and mild-mannered 35-year-old woman experiences a few days of irritability, tearfulness, and unexplained sadness. During these days, she also feels fatigued and bloated and eats large quantities of sweets. Which of the following is the most likely diagnosis?

a) Cyclothymia

b) Borderline personality disorder

c) Dissociative identity disorder

d) Premenstrual dysphoric disorder

Ans d) Premenstrual dysphoric disorder

In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms from first four:

Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

Marked anxiety, tension, feelings of being keyed up or on edge

Marked affective lability (e.g., feeling suddenly sad or tearful, increased sensitivity to rejection)

Persistent and marked anger or irritability or increased interpersonal conflicts

Decreased interest in usual activities (e.g., work, school, friends, hobbies)

Subjective sense of difficulty in concentrating

Lethargy, easy fatigability, or marked lack of energy

Marked change in appetite, overeating, or specific food cravings

Hypersomnia or insomnia

A subjective sense of being overwhelmed or out of control

Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, weight gain

o Treatment

o SSRI’s

o Pyridoxine

• Cyclothymia

o For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

o During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms for more than 2 months at a time.

o No major depressive episode, manic episode, or mixed episode has been present during the first 2 years of the disturbance.

• Borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

o frantic efforts to avoid real or imagined abandonment.

o a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

o identity disturbance: markedly and persistently unstable self-image or sense of self

o impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).

o recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

o affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only hours and only rarely more than a few days)

o chronic feelings of emptiness

o inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

o transient, stress-related paranoid ideation or severe dissociative symptoms

Dissociative Identity Disorder

· presence of two or more distinct identities or personality states that recurrently take control of the individual's behavior accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

· strongly linked to severe experiences of early childhood trauma, usually maltreatment.

· Prognosis is poorer in comorbid organic mental disorders, psychotic disorders, severe medical illnesses, refractory substance abuse, eating disorders and antisocial personality features.

· Treatment: psychoanalytic psychotherapy, cognitive therapy, behavioral therapy and hypnotherapy can be used.

45). An 18 year old boy came to psychiatry OPD with a complaint of feeling changed from inside. He described himself as feeling strange as if he is different from his normal self. He was very tense and anxious yet could not point out the precise change in him. This phenomena is best called as

a) Delusional mood

b) Depersonalization

c) Autochthonous delusion

d) Overvalued idea

Ans) b) Depersonalization disorder

• Depersonalization
• Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).
• During the depersonalization experience, reality testing remains intact.
• Schneider (1959) suggested three forms of primary delusional experience: delusional mood, delusional perception and the sudden delusional idea.
• Delusional mood: the patient has the knowledge that there is something going on around him that concerns him, but he does not know what it is. Usually the meaning of the delusional mood becomes obvious when a sudden delusional idea or a delusional perception occurs
• Sudden delusional idea: a delusion appears fully formed in the patient’s mind. This is sometimes known as an autochthonous delusion.
• Delusional perception: Attribution of a new meaning, usually in the sense of self-reference, to a normally perceived object.
• Overvalued idea: False or unreasonable belief or idea that is sustained beyond the bounds of reason. It is held with less intensity or duration than a delusion but is usually associated with mental illness.

48. Nicotine receptor agonist used to stop smoking is

a. Bupropion

b. Varenacline

c. Rimonabant

d. Nabilone

ANS b. Vernacline

o Vernacline

o Varenicline is indicated for smoking cessation.

o It is an alternative to NRTs and nicotine-agonist medication and has demonstrated greater efficacy than them in comparable studies

o partial agonist of the α4β2 subtype of the nicotinic acetylcholine receptor.

o Most of the active compound is excreted renally (92–93%).

o Side effectds: Nausea occurs commonly in people taking varenicline. Other less common side effects include headache, difficulty sleeping, and abnormal dreams

o Bupropion

o norepinephrine and dopamine reuptake inhibitor.

o side-effect profile characterized by little risk of sexual dysfunction or sedation, and with modest weight loss during acute and long-term treatment.

o No withdrawal syndrome has been linked to discontinuation.

o Only medication approved by the (FDA) for the prevention of seasonal depressive episodes of patients with seasonal affective disorder (SAD)

o First line drug for tobacco cessation

o Rimonabant

o is an anorectic anti-obesity drug.

o It is an inverse agonist for the cannabinoid receptor CB1

o Its main avenue of effect is reduction in appetite.

o Withdrawn because of concerns over suicidality, depression, and other related side-effects

o

o

o Nabilone

o A synthetic cannabinoid with therapeutic use as an antiemetic and as an adjunct analgesic for neuropathic pain

o Approved by FDA for treatment of

§ chemotherapy-induced nausea and vomiting that has not responded to conventional antiemetics

§ treatment of anorexia and weight loss in patients with AIDS.

52. Drug used to treat SSRI induced sexual dysfunction is

a. Cyproheptadine

b. Papaverine

c. Phentolamine

d. Sildenafil

Ans a). Cyproheptadine

o Adverse sexual effects may occur with SSRI because of increased serotonin concentration.

o A lowering of the sex drive and difficulty reaching orgasm occur in both sexes.

o Of the SSRIs, the most frequent sexual adverse effects are seen with paroxetine (Paxil), next with fluoxetine (Prozac), and the least with sertraline (Zoloft).

o Reversal of negative sexual side effects has been achieved with

o cyproheptadine, an antihistamine with antiserotonergic effects

o amantadine, a dopamine agonist;

o yohimbine, a central α₂-adrenergic receptor antagonist

o methylphenidate and dextroamphetamine , which are dopaminergic and have adrenergic effects.

o There are reports of sildenafil, a nitric oxide enhancer used to treat erectile dysfunction, overcoming orgasmic problems associated with the SSRIs.

o Buspirone helps some patients overcome adverse sexual effects of SSRIs, possibly because it is 5-hydroxytryptamine type A (5-HT_A) agonist or because it suppresses SSRI-induced elevation of prolactin.

57. Drug of choice for narcolepsy is

a. Ephedrine

b. Modafinil

c. Amphetamine

d. Carisoprodol

Ans. B. Modafanil

Narcolepsy

• An abnormality of the sleep mechanisms, specifically, REM-inhibiting mechanisms
• Most frequently begins in adolescence or young adulthood, generally before the age of 30.
• Most common symptom is sleep attacks
• Patients cannot avoid falling asleep, leading to 10 to 20 minutes of sleep, after which the patient feels refreshed, at least briefly.
• Can occur at inappropriate times (while eating, doing sex)
• REM sleep includes
• Cataplexy: a sudden loss of muscle tone, such as jaw drop, head drop, weakness of the knees, or paralysis of all skeletal muscles with collapse.
• hypnagogic or hypnopompic hallucinations: which are vivid perceptual experiences, either auditory or visual, occurring at sleep onset or on awakening.
• sleep paralysis: most often occurring on awakening in the morning; during the episode, patients are apparently awake and conscious but unable to move a muscle.
• appearance of REM sleep within 10 minutes of sleep onset
• Diagnosis
• nighttime polysomnographic recording
• reveals a characteristic sleep-onset REM period
• daytime multiple sleep latency
• rapid sleep onset and usually one or more sleep-onset REM periods.
• HLA-DR2 is found in 90 to 100 percent of patients with narcolepsy
• deficient in neurotransmitter hypocretin, which stimulates appetite and alertness.
• Treatment

· The treatment of narcolepsy is symptomatic.

· Somnolence is treated with wake-promoting therapeutics.

o Modafinil is now the drug of choice, principally because it is associated with fewer side effects than older stimulants and has a long half-life; 200–400 mg is given as a single daily dose.

o Older drugs such as methylphenidate (10 mg bid to 20 mg qid) or dextroamphetamine (10 mg bid) are still used as alternatives, particularly in refractory patients; now available in slow-release formulations, extending their duration of action and allowing once daily dosing.

· Treatment of the REM-related phenomena cataplexy, hypnogogic hallucinations, and sleep paralysis

o requires the potent REM sleep suppression produced by antidepressant medications.

o The tricyclic antidepressants and the selective serotonin reuptake inhibitors (SSRIs) are commonly used for this purpose.

o Alternately, gamma hydroxybutyrate (GHB), given at bed time, and 4 h later, is effective in reducing daytime cataplectic episodes.

· Adequate nocturnal sleep time and planned daytime naps (when possible) are important preventative measures.

189. Loss of muscular co-ordination in also not intoxication is seen at blood alcohol level of:

a) 50 – 100 mg%

b) 300-400 mg%

c) 150 – 300mg%

d) 100 – 150 mg%

Ans). D). 100-150mg%

The acute effects that commonly occur at increasing blood alcohol concentrations (BAC)

BAC mg/dlEffects

< 80Euphoria, feeling of relaxation and talking freely, clumsy movements of handsand legs, reduced alertness but believes himself to be alert.

>80Noisy, moody, impaired judgement, impaired driving ability

100-200Electroencephalographic changes begin to appear, Blurred vision, unsteadygait, gross motor in-coordination, slurred speech, aggressive, quarrelsome,talking loudly.

200-300Amnesia for the experience – blackout.

300-350Coma

355-600May cause or contribute to death

Impairment Likely to be Seen at Different Blood Alcohol Concentrations

Level Likely Impairment 20-30 mg/dL Slowed motor performance and decreased thinking ability 30-80 mg/dL Increases in motor and cognitive problems 80-200 mg/dL Increases in incoordination and judgment errors Mood lability Deterioration in cognition 200-300 mg/dL Nystagmus, marked slurring of speech, and alcoholic blackouts >300 mg/dL Impaired vital signs and possible death

190.In ‘NDPS’ act punishment for contravention in relation of prepared opium for quantity greater than commercial quantity is:

1. 5 – 10 years
2. 1 – 5 years
3. 7 – 12 years
4. 10 – 20 years

Ans d). 10-20 years

THE NARCOTIC DRUGS AND PSYCHO-TROPIC SUBSTANCES (NDPS) ACT,1985-

Substance	Quantity	FINE	Imprisonment
Poppy, straw,prepared opium, cannabis, manufactured drugs	Small	Upto Rs 10,000 or	RI upto 6 months or both
	Small- Commercial	Upto Rs 1,00,000 +	Upto 10 years
	Commercial	Upto 2 lakh +	Upto 20 years
Coca plant & leaves		Upto 1 lakh or	Upto 10 years
Opium poppy	Small	Upto Rs 10,000 or	RI upto 6 months or both
	Commercial	Upto 2 lakh +	Upto 20 years
Notified narcotic drug		Upto 20,000 or	RI upto 1 year or both
Unnotified narcotic drug		Upto Rs 10,000 or	RI upto 6 months or both
Convicted for embezzlement of opium cultivator or external dealings of narcotic drugs and psychotropic substances or financing illicit traffic and harbouring offenders or commercial quantity of any narcotic drugs or psychotropic sub-stance and commits same offence again			Punishable with death

Small quantity of drugs defined under this act are

Hashish or Charas- 5gm

Opium-5gm

Cocaine-125mg

Ganja-500gm

Heroin/Smack/Brown Sugar-250mg