Test: Schizophrenia Spectrum and Other Psychotic Disorders - 3 - NEET PG MCQ

• fear that peers may cause him harm

• belief that fellow students mock him and discuss him.

A depot formulation is accessible for imipramine, which is classified as an antidepressant.

The patient's history indicates that this is the initial episode of schizophrenia (meaning he has developed schizophrenia for the first time, and there are no records of prior relapses), and he has been stable for the past two months. It is typically advised that after the first episode, antipsychotic treatment should be maintained for a minimum of two years. If there are multiple episodes (i.e. evidence of relapses), the treatment should be extended for at least five years. For individuals with recurrent relapses, treatment is usually continued indefinitely.

The symptoms indicate the possibility of acute dystonia, with the inability to move the eyes likely resulting from an oculogyric crisis. Additionally, drug-induced parkinsonism may be present, characterised by the onset of rigidity. In both cases, it is essential to include an anticholinergic medication.

The drug with the least chance of causing extrapyramidal side effects is known to be Clozapine. This medication is part of a group called atypical antipsychotics, which are designed to minimise these side effects compared to older drugs.

Here are some key points about Clozapine:

• It is effective for patients who do not respond to other treatments.
• Clozapine can help reduce symptoms such as hallucinations and delusions.
• It is important for patients on Clozapine to have regular blood tests to monitor their health.

In contrast, other antipsychotic medications like Pimozide, Thioridazine, and Chlorpromazine are more likely to cause these side effects.

Agranulocytosis is an unusual response and is not associated with the levels of blood.

Clozapine. This inquiry aims to provide a background on treatment-resistant schizophrenia. However, treatment-resistant schizophrenia is characterised by an absence of response to two distinct antipsychotics (from different chemical classes), while this question only references one antipsychotic. This discrepancy may stem from an incorrect recollection of the question.

The patient has experienced an episode of abnormal movements, including tongue protrusion, stiffness, and unusual postures, following the use of haloperidol. These symptoms occurred without loss of consciousness and improved quickly after receiving diphenhydramine HCl. This suggests that the patient is likely suffering from:

• Acute dystonia - a sudden and sustained muscle contraction causing abnormal postures.
• Akathisia - a feeling of inner restlessness and an uncontrollable need to be in constant motion.
• Tardive dyskinesia - involuntary, repetitive body movements that can occur after long-term use of antipsychotics.
• Neuroleptic malignant syndrome - a rare but serious reaction to antipsychotic medications, characterised by muscle rigidity, fever, and altered mental status.

Given the symptoms and rapid improvement with diphenhydramine, the likely diagnosis is acute dystonia.

The sudden onset of torticollis in a 16-year-old boy who has recently started taking an antipsychotic drug is most likely due to:

• Acute muscular dystonia: This condition is characterised by involuntary muscle contractions, which can lead to abnormal postures like torticollis.
• Akathisia: This condition involves a feeling of inner restlessness and an uncontrollable need to be in constant motion, but it does not typically cause torticollis.
• Neuroleptic malignant syndrome: This is a rare but serious reaction to antipsychotic medications, presenting with severe muscle rigidity and other symptoms, yet it is less likely to present solely as torticollis.
• Tardive dyskinesia: This condition involves repetitive, involuntary movements, usually developing after long-term use of antipsychotics, but it is not characterised by acute onset.

  Therefore, the most probable diagnosis is acute muscular dystonia, as it directly relates to the sudden muscle contractions affecting the neck.

The medical history indicates a possibility of tardive dyskinesia. Clozapine is the antipsychotic associated with the lowest occurrence of this condition.

The history presented here indicates the possibility of akathisia.

Akathisia is a condition characterised by a feeling of restlessness and an uncontrollable urge to move. It is often a side effect of certain medications, particularly antipsychotics. Here are the treatments for akathisia:

• Trihexyphenidyl - This medication is used to relieve muscle stiffness and is effective for akathisia.
• Diazepam - A sedative that can help reduce anxiety and agitation associated with akathisia.
• Haloperidol - An antipsychotic that can worsen akathisia in some patients.
• Promethazine - An antihistamine that can provide relief from nausea and sedation but is not primarily used for akathisia.

Among these, Haloperidol is the medication that is not recommended for treating akathisia, as it can potentially exacerbate the symptoms.

When a patient develops torticollis after starting antipsychotic medication, it indicates a type of muscle spasm. To manage this condition effectively, the addition of a medication is necessary.

• Central anticholinergic medications help by reducing muscle spasms caused by antipsychotics.
• They work by blocking certain signals in the brain that lead to these involuntary movements.
• This treatment can alleviate the symptoms of torticollis and improve the patient's comfort.

The patient has been taking antipsychotic medication for three weeks and is now experiencing:

• High-grade fever
• Raised CPK levels
• Myoglobinuria

These symptoms suggest a serious condition known as neuroleptic malignant syndrome (NMS). NMS is a potentially life-threatening reaction to antipsychotic drugs, characterised by:

• Severe muscle rigidity
• High fever
• Altered mental status
• Autonomic dysfunction

Immediate medical attention is crucial for management and recovery.

The patient exhibits several symptoms, including:

• Fever that started suddenly
• Excessive sweating
• Confusion and difficulty communicating
• Stiffness in the limbs

During the examination, additional findings include:

• Tachycardia (rapid heart rate)
• Labile blood pressure (fluctuating blood pressure)

Tests show:

• Increased levels of CPK (creatine phosphokinase)
• Leucocytosis (high white blood cell count)

These signs and symptoms are consistent with Neuroleptic Malignant Syndrome (NMS), a serious reaction that can occur in response to antipsychotic medications like haloperidol. NMS is characterised by severe muscle stiffness, confusion, fever, and autonomic instability. Immediate medical intervention is essential in such cases.

We must exclude the possibility of neuroleptic malignant syndrome and also assess the renal functions, as NMS may lead to renal failure due to myoglobinuria.

The signs of NMS bear a strong resemblance to catatonia, particularly with symptoms such as:

• Heightened rigidity
• Stupor

In reality, catatonia serves as a crucial differential diagnosis for individuals experiencing NMS.

It is thought that an extended inhibition of D2 receptors by antipsychotic medications leads to a heightened sensitivity of these receptors, ultimately resulting in tardive dyskinesia.

The main treatment for neuroleptic malignant syndrome is dantrolene. This medication helps to relax muscles and reduce severe muscle stiffness caused by certain antipsychotic drugs. It is important to remember that other options, such as beta-blockers or anticholinergics, are not effective in treating this condition. Quick intervention with dantrolene is crucial to manage symptoms and ensure patient safety.

For patients who have a sensitivity to the extrapyramidal side effects, clozapine is the recommended antipsychotic.