Schizophrenia and antipsychotic side effects

34 NEET-PG practice questions on Schizophrenia and antipsychotic side effects, part of Psychiatry. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 28-year-old man with schizophrenia that did not respond to risperidone or olanzapine was started on clozapine 6 weeks ago and is improving. He now has fever of 38.8°C and a painful sore throat. There is no rigidity, and he is fully oriented. What is the next best step?

   1. AStart oral amoxicillin and continue clozapine
   2. BCheck creatine kinase for neuroleptic malignant syndrome
   3. CWithhold clozapine and urgently check the neutrophil count
   4. DReduce the clozapine dose and review in a week

   Show answerHide answer

   Answer: C · Withhold clozapine and urgently check the neutrophil count

   Clozapine is the drug for treatment-resistant schizophrenia, but it can cause agranulocytosis, most often in the first 18 weeks. Fever or sore throat in a patient on clozapine is treated as neutropenia until proven otherwise: a full blood count with absolute neutrophil count is done the same day and the drug is held. That is why regular blood counts are mandatory during clozapine treatment. If agranulocytosis is confirmed, clozapine is stopped permanently and the infection treated urgently.

   • A: Treating the throat alone could miss life-threatening agranulocytosis.
   • B: NMS needs rigidity, altered consciousness and autonomic instability, which are absent.
   • D: Reducing the dose does not address possible agranulocytosis.

2. Question 2 · Easy

   A 52-year-old man with schizophrenia from Nagpur has taken haloperidol 15 mg daily for 2 months. He now has a mask-like face, a slow shuffling gait, cogwheel rigidity and a resting tremor of both hands. Blockade of dopamine receptors in which pathway causes these features?

   1. ANigrostriatal
   2. BTuberoinfundibular
   3. CMesocortical
   4. DMesolimbic

   Show answerHide answer

   Answer: A · Nigrostriatal

   Drug-induced parkinsonism results from D2 blockade in the nigrostriatal pathway, which runs from the substantia nigra to the striatum and controls movement. Antipsychotic action comes mainly from blocking the mesolimbic pathway, while tuberoinfundibular blockade raises prolactin and mesocortical blockade may worsen negative and cognitive symptoms. Parkinsonism is managed by lowering the dose, adding an anticholinergic such as trihexyphenidyl, or switching to an atypical drug. Levodopa is avoided because it can worsen psychosis.

   • B: Tuberoinfundibular blockade causes hyperprolactinaemia.
   • C: Mesocortical blockade is linked to negative and cognitive symptoms, not parkinsonism.
   • D: Mesolimbic blockade is the source of the antipsychotic effect on positive symptoms.

3. Question 3 · Hard

   A 22-year-old woman in Chennai developed sudden odd behaviour, insomnia and persecutory ideas a week after a flu-like illness and was started on haloperidol for 'first-episode schizophrenia'. Ten days later she has two seizures, repetitive orofacial dyskinesias, fluctuating BP and pulse and reduced responsiveness. CK is mildly raised; CSF shows 30 lymphocytes/µL with normal glucose. Which investigation is most likely to confirm the diagnosis?

   1. ASerum creatine kinase every 6 hours
   2. BSerum haloperidol level
   3. CBrain CT scan without contrast
   4. DCSF anti-NMDA receptor antibodies

   Show answerHide answer

   Answer: D · CSF anti-NMDA receptor antibodies

   A young woman with acute psychosis after a viral-like prodrome, followed by seizures, orofacial dyskinesias, autonomic instability and falling consciousness, with CSF lymphocytosis, fits anti-NMDA receptor encephalitis. It is often first labelled as primary psychosis, and patients may tolerate antipsychotics poorly, so it can mimic NMS. CSF antibodies to the GluN1 subunit confirm it, and she must be screened for an ovarian teratoma with pelvic imaging. Immunotherapy and tumour removal give a good chance of recovery.

   • A: Serial CK monitors muscle injury but cannot identify the encephalitis.
   • B: Haloperidol levels do not explain seizures and CSF pleocytosis.
   • C: CT is usually normal in this encephalitis; MRI and EEG are more informative.

4. Question 4 · Medium

   A 21-year-old college student in Hyderabad has, for the past 2 months, believed his classmates are filming him for a TV show, hears voices commenting on his actions and has stopped attending classes. He has no mood episode, no substance use, and investigations are normal. Under DSM-5 criteria, what is the most appropriate diagnosis at present?

   1. ABrief psychotic disorder
   2. BSchizophrenia
   3. CDelusional disorder
   4. DSchizophreniform disorder

   Show answerHide answer

   Answer: D · Schizophreniform disorder

   DSM-5 classifies psychotic illness by duration: brief psychotic disorder lasts at least a day but less than a month, schizophreniform disorder at least 1 month but less than 6 months, and schizophrenia at least 6 months including prodromal and residual phases. His 2-month illness with delusions and hallucinations is therefore schizophreniform disorder. ICD-10 required only 1 month of symptoms for schizophrenia, so the stated system matters. Treatment is the same: an antipsychotic with psychosocial support.

   • A: Brief psychotic disorder lasts less than a month.
   • B: Under DSM-5, schizophrenia needs at least 6 months of disturbance.
   • C: Delusional disorder has non-bizarre delusions without prominent hallucinations or functional decline.

5. Question 5 · Medium

   A 30-year-old man with schizophrenia was started on clozapine 3 weeks ago after two other antipsychotics failed. He now has fever of 38.2°C, chest discomfort and breathlessness, with a resting pulse of 130/min. Troponin I and CRP are raised, the ECG shows diffuse T-wave changes, and his neutrophil count is normal. What is the most appropriate next step?

   1. AReduce clozapine and repeat troponin in a week
   2. BContinue clozapine and add propranolol
   3. CContinue clozapine and start antibiotics
   4. DStop clozapine and refer for cardiac evaluation

   Show answerHide answer

   Answer: D · Stop clozapine and refer for cardiac evaluation

   Fever, tachycardia, chest pain and a raised troponin and CRP in the first weeks of clozapine treatment point to clozapine-induced myocarditis, which mostly occurs in the first 2 months. Clozapine is stopped immediately and he needs echocardiography and cardiology care; he is not usually re-challenged. Tachycardia is a common benign effect of clozapine, but when it comes with fever, chest pain or breathlessness, myocarditis must be excluded. That is why some centres monitor troponin and CRP in the first weeks.

   • A: Continuing clozapine while myocarditis develops risks heart failure and death.
   • B: Propranolol treats benign clozapine tachycardia, not myocarditis.
   • C: The normal neutrophil count and raised troponin point to myocarditis, not infection.

6. Question 6 · Easy

   A 23-year-old man with schizophrenia from Thrissur no longer hears voices on treatment, but his mother says he sits idle all day, speaks very little, shows no emotion and has stopped bathing. Which of the following is a negative symptom?

   1. AAuditory hallucinations
   2. BPersecutory delusions
   3. CThought broadcasting
   4. DAlogia

   Answer and explanation in LearnFree account

7. Question 7 · Medium

   A 35-year-old daily-wage worker from a village near Varanasi has schizophrenia and has been admitted three times in 2 years, each time after stopping his tablets at home. He denies being ill, and his family cannot supervise his medicines. Oral risperidone controlled his symptoms well. What is the most appropriate step to prevent relapse?

   1. AStop treatment and review if he relapses
   2. BLong-acting injectable antipsychotic
   3. CAdd oral sodium valproate
   4. DSwitch to oral clozapine

   Answer and explanation in LearnFree account

8. Question 8 · Medium

   A 28-year-old woman with schizophrenia stopped her medicines 2 months ago. She is brought in mute and motionless, staring, keeping her arm raised in the position the doctor places it in for minutes, and refusing food for 2 days. Temperature, pulse and CK are normal. What is the most appropriate initial treatment?

   1. AIntramuscular haloperidol
   2. BOral fluoxetine
   3. CIntravenous lorazepam
   4. DOral trihexyphenidyl

   Answer and explanation in LearnFree account

9. Question 9 · Medium

   A 34-year-old man with schizophrenia has been well on olanzapine 20 mg daily for 18 months. He has gained 14 kg; his waist is 102 cm, fasting glucose 118 mg/dL, triglycerides 260 mg/dL and BP 136/88 mmHg. He wants to stay on medication but is unhappy about his weight. Which change is most appropriate, along with diet and exercise?

   1. ASwitch gradually to aripiprazole
   2. BSwitch gradually to clozapine
   3. CStop olanzapine and observe
   4. DSwitch gradually to quetiapine

   Answer and explanation in LearnFree account

10. Question 10 · Medium

    Two men are admitted with a first episode of schizophrenia. A is 32, married and working, became ill over 2 weeks after his father's death, and has prominent persecutory delusions with marked anxiety. B is 18, unemployed, has a family history of schizophrenia, and has slowly withdrawn over 2 years with flat affect and poverty of speech. Which feature of A's illness predicts a better outcome?

    1. AProminence of persecutory delusions
    2. BAcute onset after a clear precipitant
    3. CMale sex at the onset of illness
    4. DNeed for inpatient admission

    Answer and explanation in LearnFree account

11. Question 11 · Medium

    A 27-year-old woman with schizophrenia was started on haloperidol 10 mg daily a week ago. She now paces the ward, cannot sit through a meal, keeps crossing and uncrossing her legs and says she feels an inner urge to move. There is no rigidity or tremor and her voices have lessened. What is the most appropriate drug to add?

    1. AAdditional haloperidol
    2. BPropranolol
    3. CBromocriptine
    4. DDantrolene

    Answer and explanation in LearnFree account

12. Question 12 · Hard

    A 45-year-old man with schizophrenia, stable for 3 years on clozapine 400 mg daily, smokes 25 cigarettes a day. He is admitted to a medical ward for a fracture and cannot smoke there. Ten days later he is very drowsy, drooling and has a generalised seizure; he takes no other medicine. What best explains this?

    1. AWithdrawal of nicotine lowered the seizure threshold
    2. BHospital food reduced clozapine absorption
    3. CNicotine replacement inhibited clozapine metabolism
    4. DLoss of CYP1A2 induction raised clozapine levels

    Answer and explanation in LearnFree account

13. Question 13 · Hard

    A 32-year-old man with schizophrenia received haloperidol decanoate 2 weeks ago and has been eating and drinking poorly in hot weather. He is now confused, with temperature 40.1°C, pulse 128/min, labile BP, profuse sweating and generalised lead-pipe rigidity without clonus. TLC is 16,000/µL, CK 18,000 U/L and creatinine 2.1 mg/dL. What is the most appropriate first step in management?

    1. AGive IM haloperidol and lorazepam for agitation
    2. BStop antipsychotics, start IV fluids and cooling
    3. CGive cyproheptadine and oral fluids
    4. DGive IM promethazine and continue haloperidol

    Answer and explanation in LearnFree account

14. Question 14 · Medium

    A 25-year-old man is assessed for psychosis in a psychiatry OPD in Bhopal. The postgraduate lists four of his symptoms: 1. Voices discussing him among themselves in the third person. 2. Seeing shadowy figures in the corner of the room at night. 3. A belief that his thoughts are being taken out of his head. 4. Seeing a red traffic light and knowing at once that he was chosen to save the world. 5. A belief that neighbours are plotting to poison him. Which are Schneider's first-rank symptoms?

    1. A1, 2, 3, 4 and 5
    2. B1, 2 and 5 only
    3. C1, 3 and 4 only
    4. D3, 4 and 5 only

    Answer and explanation in LearnFree account

15. Question 15 · Medium

    A 26-year-old woman with treatment-resistant schizophrenia is about to start clozapine in a teaching hospital. The resident prepares four statements for her family: 1. Clozapine causes more extrapyramidal side effects than haloperidol. 2. Her blood counts will be checked before starting and regularly during treatment. 3. The risk of seizures rises with higher doses. 4. Excess salivation, especially at night, is common. Which statements are correct?

    1. A1, 3 and 4 only
    2. B2, 3 and 4 only
    3. C2 and 3 only
    4. D1, 2, 3 and 4

    Answer and explanation in LearnFree account

16. Question 16 · Easy

    A 62-year-old woman has taken oral haloperidol for schizophrenia for 12 years. Her daughter notices repetitive lip smacking, chewing movements and the tongue darting in and out of her mouth, which disappear during sleep. What is the most likely diagnosis?

    1. AAkathisia
    2. BAcute dystonia
    3. CTardive dyskinesia
    4. DHuntington disease

    Answer and explanation in LearnFree account

17. Question 17 · Medium

    Consider these statements on dopamine pathways and antipsychotics: 1. Overactivity of the mesolimbic pathway is linked with positive symptoms. 2. Reduced activity in the mesocortical pathway is linked with negative and cognitive symptoms. 3. Dopamine blockade in the tuberoinfundibular pathway lowers prolactin. 4. Partial agonism at D2 receptors, as with aripiprazole, causes less hyperprolactinaemia. Which are correct?

    1. A1 and 3 only
    2. B1, 2 and 3
    3. C2, 3 and 4
    4. D1, 2 and 4

    Answer and explanation in LearnFree account

18. Question 18 · Medium

    Records of a patient admitted four times over 6 years show the same pattern: each time, prominent manic symptoms (elation, no sleep, grandiosity) occur together with third-person voices and delusions of control, and on one admission the voices and delusions persisted for 3 weeks after her mood had settled. Between episodes she works as a nurse. Which diagnosis best explains this course?

    1. ASchizoaffective disorder, bipolar type
    2. BBipolar I disorder with psychotic features
    3. CAcute and transient psychotic disorder
    4. DParanoid schizophrenia

    Answer and explanation in LearnFree account

19. Question 19 · Medium

    On the ward, a man with schizophrenia has a QTc of 505 ms on two ECGs, with normal potassium and magnesium, and a cardiologist has diagnosed congenital long QT syndrome. He needs an antipsychotic to stay well. Which drug carries the least risk of further QT prolongation?

    1. AAripiprazole
    2. BIntravenous haloperidol
    3. CZiprasidone
    4. DPimozide

    Answer and explanation in LearnFree account

20. Question 20 · Medium

    Four weeks after starting haloperidol 10 mg/day, a farmer with schizophrenia has a mask-like face, a slow shuffling gait, cogwheel rigidity and a resting tremor. His psychosis is much better and he does not want the drug changed. Which drug is most appropriate to add?

    1. ATrihexyphenidyl
    2. BTetrabenazine
    3. CPropranolol
    4. DLevodopa

    Answer and explanation in LearnFree account

21. Question 21 · Medium

    Clozapine 400 mg/day has kept a man with schizophrenia well for a year. He now has abdominal distension, vomiting and no bowel movement for 6 days; bowel sounds are sparse, and an erect X-ray shows dilated bowel loops with fluid levels. His ANC is normal. Which property of clozapine best explains this complication?

    1. AAlpha-1 adrenergic blockade
    2. BStrong antimuscarinic action
    3. CHistamine H1 blockade
    4. DBlockade of D2 receptors

    Answer and explanation in LearnFree account

22. Question 22 · Hard

    Eight months on risperidone 4 mg/day have kept a young woman with schizophrenia free of voices for the first time, but she has had no periods for 5 months and has a milky nipple discharge. Urine pregnancy test is negative, TSH is normal, serum prolactin is 142 ng/mL (normal under 25) and MRI of the pituitary is normal. She fears relapse and does not want to stop risperidone. Which step is most appropriate?

    1. ASwitch to haloperidol
    2. BAdd bromocriptine
    3. CSwitch to amisulpride
    4. DAdd low-dose aripiprazole

    Answer and explanation in LearnFree account

23. Question 23 · Medium

    Despite 6 weeks each of risperidone 6 mg/day and then olanzapine 20 mg/day, taken under his mother's watch, a young man with schizophrenia still hears voices and is suspicious and withdrawn. He uses no substances, and his diagnosis has been reviewed and confirmed. Which drug is now indicated?

    1. AClozapine
    2. BAripiprazole
    3. CQuetiapine
    4. DHaloperidol

    Answer and explanation in LearnFree account

24. Question 24 · Easy

    A shopkeeper's wife brings him because for 8 months he has been convinced she is having an affair with a neighbour; he checks her phone, follows her and examines her clothes. Otherwise he runs his shop well, has no hallucinations, and his speech and affect are normal. He does not drink alcohol. Which diagnosis fits best?

    1. ADelusional disorder
    2. BObsessive-compulsive disorder
    3. CParanoid schizophrenia
    4. DParanoid personality disorder

    Answer and explanation in LearnFree account

25. Question 25 · Medium

    A transcript from the ward round: asked how he slept, a calm patient answers at a normal pace, 'I slept well, the government owns the colour green, and my uncle's bicycle needs prayers before the exam.' Each phrase is grammatical, but the ideas have no link to each other or to the question. Which formal thought disorder does this best show?

    1. ADerailment
    2. BFlight of ideas
    3. CCircumstantiality
    4. DTangentiality

    Answer and explanation in LearnFree account