Psychiatric emergencies, newer drugs and culture-bound syndromes

33 NEET-PG practice questions on Psychiatric emergencies, newer drugs and culture-bound syndromes, 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

   Serotonin syndrome in a man who took an overdose of escitalopram persists despite stopping the drug, IV fluids and lorazepam. Temperature is 38.6 °C and he has sustained clonus but no airway problem. Which drug is the specific antidote to add?

   1. ADantrolene
   2. BBromocriptine
   3. CPhysostigmine
   4. DCyproheptadine

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   Answer: D · Cyproheptadine

   Management of serotonin syndrome is stopping the drug, supportive care and benzodiazepines; in moderate cases that do not settle, the 5-HT2A antagonist cyproheptadine is given orally or by nasogastric tube. Severe hyperthermia above about 41 °C needs sedation, paralysis and intubation. Antipyretics do not help because the heat comes from muscle activity. Key point: Cyproheptadine, a 5-HT2A antagonist, is the antidote for serotonin syndrome.

   • A: Dantrolene has no proven benefit in serotonin syndrome.
   • B: Bromocriptine is a serotonergic dopamine agonist and can worsen serotonin syndrome.
   • C: Physostigmine treats anticholinergic toxicity.

2. Question 2 · Easy

   As the medical officer of a PHC, you see a college student who has had suicidal thoughts at night but no plan. After safety planning and referral, you want to give her a free, 24x7 government tele-mental health helpline she can call in her own language. Which service fits?

   1. AAyushman Bharat Digital Mission
   2. BTele-MANAS
   3. CNi-kshay Sampark
   4. DeSanjeevani OPD

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   Answer: B · Tele-MANAS

   Tele-MANAS (Tele Mental Health Assistance and Networking Across States), launched by MoHFW in October 2022, is the national tele-mental health programme. It offers free, round-the-clock counselling in regional languages through a toll-free number and links callers to in-person mental health services. eSanjeevani is a general teleconsultation service, not a dedicated mental health helpline. Key point: Tele-MANAS is India's free 24x7 tele-mental health helpline, started in 2022.

   • A: ABDM builds digital health records and IDs, not counselling.
   • C: Ni-kshay Sampark is the TB helpline.
   • D: eSanjeevani is general teleconsultation, not a dedicated 24x7 mental health helpline.

3. Question 3 · Easy

   Five days after starting oral haloperidol 20 mg/day, a man with schizophrenia becomes confused and sweaty. Temperature is 40 °C, he has lead-pipe rigidity of all limbs, BP swings widely and CPK is 9600 IU/L (reference 30-200). Which condition explains this picture?

   1. ANeuroleptic malignant syndrome
   2. BSerotonin syndrome
   3. CMalignant hyperthermia
   4. DAcute dystonia

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   Answer: A · Neuroleptic malignant syndrome

   Hyperthermia, lead-pipe rigidity, altered sensorium, autonomic instability and a very high CPK within days of starting a high-potency antipsychotic are neuroleptic malignant syndrome. It results from sudden dopamine D2 blockade in the hypothalamus and basal ganglia. Leucocytosis and myoglobinuria with renal failure can follow. Key point: Fever, lead-pipe rigidity, confusion and high CPK after an antipsychotic is NMS.

   • B: Serotonin syndrome shows clonus and hyperreflexia after serotonergic drugs.
   • C: Malignant hyperthermia follows volatile anaesthetics or succinylcholine.
   • D: Acute dystonia causes spasms without fever or high CPK.

4. Question 4 · Easy

   In the casualty at midnight, a young man with known mania is shouting, pacing and has just thrown a chair at the triage nurse. Talking him down has failed and he refuses oral medicine. Which combination is widely used in Indian emergency departments for rapid tranquilisation?

   1. AOral lithium with clonazepam
   2. BIntramuscular chlorpromazine with diazepam
   3. CIntramuscular haloperidol with promethazine
   4. DIntravenous ketamine with midazolam

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   Answer: C · Intramuscular haloperidol with promethazine

   When de-escalation fails and oral medicine is refused, intramuscular haloperidol with promethazine is an effective, well-studied rapid tranquilisation combination, including in Indian trials. Promethazine adds sedation and reduces the risk of acute dystonia from haloperidol. Lorazepam IM is an alternative. Vital signs, airway and ECG must be watched afterwards. Key point: IM haloperidol plus promethazine is a standard rapid tranquilisation choice after de-escalation fails.

   • A: Oral lithium takes days to act and he refuses oral medicine.
   • B: IM chlorpromazine causes marked hypotension and IM diazepam is erratically absorbed.
   • D: Ketamine is reserved for extreme agitation in prehospital or ICU settings, not routine ward use.

5. Question 5 · Medium

   Linezolid is started for MRSA pneumonia in a man who has taken fluoxetine for a year. Two days later he develops tremor, sweating, agitation, fever and ankle clonus. By what mechanism did linezolid cause this reaction?

   1. ABlockade of dopamine D2 receptors
   2. BInhibition of CYP2D6, raising fluoxetine levels
   3. CDirect stimulation of 5-HT1A receptors
   4. DReversible inhibition of monoamine oxidase

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   Answer: D · Reversible inhibition of monoamine oxidase

   Linezolid, an oxazolidinone antibiotic, is also a weak, reversible, non-selective MAO inhibitor. Combined with an SSRI it raises synaptic serotonin and can cause serotonin syndrome. Methylene blue has the same MAO-inhibiting effect. If linezolid is essential, the SSRI is stopped and the patient watched closely. Key point: Linezolid is a reversible MAO inhibitor and can cause serotonin syndrome with SSRIs.

   • A: D2 blockade causes NMS and parkinsonism, not serotonin syndrome.
   • B: Linezolid is not a significant CYP2D6 inhibitor; fluoxetine itself inhibits CYP2D6.
   • C: Direct 5-HT1A agonism is the action of buspirone, not linezolid.

6. Question 6 · Easy

   Six hours after his first dose of intramuscular haloperidol in the casualty, a 19-year-old student develops a fixed upward gaze, a twisted neck and difficulty speaking. He is conscious and afebrile. What is the best immediate treatment?

   1. AOral propranolol
   2. BOral bromocriptine
   3. CIntramuscular benztropine
   4. DIntravenous dantrolene

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7. Question 7 · Hard

   Her husband found an empty strip of amitriptyline 75 mg tablets beside a homemaker who has been treated for depression at the taluk hospital, and brought her in about three hours later, saying she may have swallowed around thirty tablets. She is drowsy and mumbling, with dilated pupils, dry flushed skin and a distended bladder. BP is 86/50 mmHg. Her monitor shows a broad-complex rhythm at 136/min; the 12-lead tracing has a QRS of 140 ms with a prominent terminal R wave in aVR. She is intubated and has had a litre of saline. Which drug should be given next?

   1. AIntravenous sodium bicarbonate
   2. BIntravenous amiodarone
   3. CIntravenous physostigmine
   4. DIntravenous flumazenil

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8. Question 8 · Hard

   On the third day of admission to the orthopaedic ward for a fractured femur after a fall from his bicycle, a man who has drunk about a bottle of arrack daily for twenty years, and had his last drink on the evening of the fall, becomes tremulous, disoriented to time and place, and picks at imaginary insects on the bedsheet. Pulse is 124/min, BP 160/96 mmHg and temperature 38.2 °C. He has ascites, serum albumin 2.4 g/dL, bilirubin 3.8 mg/dL and INR 1.9. Thiamine has been started. Which drug is the best choice to control his symptoms?

   1. AIntravenous diazepam
   2. BOral chlordiazepoxide
   3. CIntramuscular haloperidol
   4. DIntravenous lorazepam

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9. Question 9 · Medium

   A woman on sertraline 100 mg/day for depression is given tramadol for back pain by a local clinic. Twelve hours later she is in the casualty with agitation, sweating, diarrhoea and dilated pupils. Temperature is 38.4 °C. There is inducible ankle clonus, ocular clonus and brisk reflexes, more in the legs. Which drug reaction has she developed?

   1. AMalignant hyperthermia
   2. BSerotonin syndrome
   3. CNeuroleptic malignant syndrome
   4. DAnticholinergic toxicity

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10. Question 10 · Hard

    Day 5 of lorazepam, now 8 mg/day, for catatonia in a man with bipolar depression, admitted after he stopped speaking and moving at home: he remains mute, staring and rigid, has posturing of both arms, and has eaten and drunk almost nothing for a week despite IV fluids. Today his temperature is 38.6 °C, pulse 128/min, BP fluctuating between 100/60 and 170/100 mmHg, and CPK 2400 IU/L (reference 30-200). He has never received an antipsychotic. Blood and urine cultures and a chest X-ray are clear. Which is the most appropriate next step?

    1. AAdd intramuscular haloperidol
    2. BDouble the lorazepam dose
    3. CUrgent electroconvulsive therapy
    4. DStart oral lithium

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11. Question 11 · Medium

    In the postnatal ward on day 6 after delivery, a first-time mother has not slept for two nights, is confused at times, laughs and cries in turn, and tells the nurse that her baby has been swapped and is possessed. Her husband reports she once asked whether the baby should be 'sent back to God'. She had a manic episode at 22 that was treated with lithium, which she stopped before conceiving, and her mother had a similar illness after childbirth. Thyroid tests, blood glucose and electrolytes are normal and she has no fever. What is the most appropriate immediate step?

    1. ADischarge her home and send the baby to a relative
    2. BAdmit her for inpatient psychiatric care with close supervision of mother and baby
    3. CReassure the family that these are postpartum blues and will pass in a week
    4. DStart sertraline and review in the OPD after two weeks

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12. Question 12 · Medium

    A woman admitted with severe depression has lain mute and motionless in bed for three days. She holds her arm in the air for minutes when the examiner raises it, resists passive movement with equal force, and has stopped eating and drinking. Temperature, CPK and blood counts are normal and she takes no antipsychotic. Which is the best initial step?

    1. AIntramuscular haloperidol
    2. BNasogastric feeding alone and observation
    3. COral sertraline at a higher dose
    4. DIntravenous lorazepam challenge

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13. Question 13 · Easy

    First-trimester exposure to lithium is classically linked with which foetal malformation?

    1. ANeural tube defect
    2. BEbstein anomaly
    3. CPhocomelia
    4. DCleft lip and palate

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14. Question 14 · Hard

    Brought in from a bus stand at 2 a.m., an unkempt man smelling of alcohol is confused, with nystagmus, bilateral lateral rectus weakness and an ataxic gait. Capillary blood glucose is 48 mg/dL. The casualty nurse has drawn up 50 mL of 25% dextrose and asks you whether to give it. What is the most appropriate order?

    1. AGive the dextrose now and thiamine tomorrow on the ward
    2. BWithhold dextrose until thiamine has worked for 24 hours
    3. CGive oral thiamine with sweet tea and observe
    4. DGive IV thiamine, then the dextrose straight after

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15. Question 15 · Easy

    For routine monitoring, when should a blood sample for serum lithium be drawn?

    1. AOne hour after the last dose
    2. BJust before the morning dose after a missed day
    3. CAt any time, as lithium levels are stable
    4. DAbout 12 hours after the last dose

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16. Question 16 · Medium

    In suspected serotonin toxicity, which examination finding is the most important for diagnosis under the Hunter criteria?

    1. AHyperthermia
    2. BTachycardia
    3. CAgitation
    4. DClonus

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17. Question 17 · Easy

    Which single factor most strongly predicts a later completed suicide?

    1. AFemale sex in a young adult
    2. BA previous suicide attempt
    3. CLiving in a joint family
    4. DBeing married with children

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18. Question 18 · Medium

    About Tele-MANAS: 1. It was launched by MoHFW in 2022 as part of the National Mental Health Programme. 2. NIMHANS, Bengaluru, is the nodal centre. 3. It is two-tier: trained counsellors in state cells, then specialists for referral. 4. It is limited to people with a prior psychiatric diagnosis. Which statements are correct?

    1. A1 and 3 only
    2. B1, 2 and 3 only
    3. C1, 2, 3 and 4
    4. D2, 3 and 4 only

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19. Question 19 · Medium

    Intranasal esketamine is approved for treatment-resistant depression. What is its main mechanism of action?

    1. ANMDA glutamate receptor antagonism
    2. BGABA-A positive allosteric modulation
    3. CMonoamine oxidase inhibition
    4. DSerotonin reuptake inhibition

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20. Question 20 · Medium

    News of 'shrinking genitals' has spread through several villages in a district of north-east India. Over a week, dozens of men have arrived at the CHC clutching their penises in panic, some tying them with string, convinced the organ will retract and kill them. Examinations are normal. As the district mental health programme officer, what is the most appropriate response?

    1. ADistribute benzodiazepines to every household in the area
    2. BOrder testing of drinking water and food for toxins
    3. CPublic reassurance and education through local leaders, media and health workers
    4. DAdmit all affected men to the district hospital for observation

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21. Question 21 · Medium

    Urine output of 5-6 litres a day troubles a man on long-term lithium for bipolar disorder. Serum lithium is 0.7 mEq/L, sodium 146 mmol/L and urine osmolality stays low after water deprivation and after desmopressin. He and his psychiatrist want to continue lithium, which has kept him well. Which drug is preferred to treat this problem?

    1. AFurosemide
    2. BChlorpropamide
    3. CAmiloride
    4. DDesmopressin

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22. Question 22 · Hard

    Two days of vomiting and watery diarrhoea after a family wedding preceded this man's admission to the medical ward; he takes lithium 1200 mg/day for bipolar disorder and kept taking it throughout, though he could barely keep fluids down. He is now drowsy with myoclonic jerks and had a generalised seizure in the casualty. Results: serum lithium 4.3 mEq/L, creatinine 2.6 mg/dL (baseline 0.9), sodium 132 mmol/L, potassium 3.8 mmol/L. ECG shows QT prolongation. IV normal saline has been started. What is the most appropriate next step?

    1. AActivated charcoal by nasogastric tube
    2. BIntravenous sodium bicarbonate
    3. CHaemodialysis
    4. DForced diuresis with furosemide

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23. Question 23 · Medium

    At a temple festival in rural Karnataka, a young woman with recent family conflict suddenly begins swaying, speaks in a changed voice claiming to be the village goddess, and makes demands of her in-laws. After about an hour she returns to normal, with little memory of the episode. Such episodes are not accepted as normal by her community outside the festival. How is this state best classified?

    1. ABipolar disorder, manic episode
    2. BTemporal lobe epilepsy
    3. CAcute schizophrenia
    4. DPossession trance disorder

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24. Question 24 · Hard

    About neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS): 1. NMS usually develops over days, SS within 24 hours. 2. Clonus and hyperreflexia favour SS; lead-pipe rigidity favours NMS. 3. Mydriasis and diarrhoea are more typical of NMS. 4. CPK can be raised in both. Which statements are correct?

    1. A1, 2 and 3 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 4 only
    4. D2 and 3 only

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25. Question 25 · Medium

    Three weeks after a normal delivery, a new mother has low mood, poor sleep, guilt and loss of interest most of the day for two weeks, without psychotic features. Her psychiatrist reads about zuranolone, an oral drug approved in the USA for postpartum depression as a 14-day course. How does zuranolone act?

    1. AAntagonism of NMDA glutamate receptors
    2. BPositive allosteric modulation of GABA-A receptors
    3. CAgonism at melatonin MT1 and MT2 receptors
    4. DInhibition of serotonin and noradrenaline reuptake

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