PS4.1 | Psychotic Disorders — Graded Quiz

Correct. According to ICD-11, Acute and Transient Psychotic Disorder has a duration of less than 1 month before full remission. Schizophrenia requires at least 1 month of core symptoms. This patient's 6-week duration satisfies the ICD-11 schizophrenia duration criterion. Both conditions can feature hallucinations and delusions; duration is the key differentiating factor.

ICD-11 duration threshold for schizophrenia = 1 month. This separates it from Acute and Transient Psychotic Disorder. DSM-5 uses 6 months (including prodrome/residual). In Indian primary care, use ICD-11 criteria.

Both conditions may feature auditory hallucinations, persecutory delusions, and exclusion of organic causes. The key differentiator is duration: ICD-11 Acute and Transient Psychotic Disorder resolves fully within 1 month, while Schizophrenia requires symptoms for at least 1 month.

Correct. This presentation demonstrates the 5As of negative symptoms: alogia (poverty of speech), affective flattening (blunted affect, no grief response), avolition (not washing, refusing to go out), anhedonia (implied withdrawal from pleasurable activities), and asociality (social withdrawal). Negative symptoms are often more disabling for long-term functioning than positive symptoms.

The 5As of negative symptoms — Avolition, Alogia, Anhedonia, Affective flattening, Asociality — are often the most functionally disabling features of schizophrenia and respond less well to antipsychotics than positive symptoms.

The absence of hallucinations and delusions, combined with blunted affect, poverty of speech, avolition, and social withdrawal, points to the negative symptom cluster (5As). Positive symptoms involve aberrant additions (hallucinations, delusions). Cognitive symptoms affect memory and executive function. He is not on antipsychotics.

Correct. SGAs (including risperidone) are preferred over FGAs primarily because of their lower extrapyramidal side-effect (EPS) profile. Both drugs have comparable efficacy for positive symptoms. SGAs do cause metabolic side effects; they are not EPS-free (risperidone at higher doses can cause EPS). Haloperidol is still used — it is not contraindicated.

SGAs preferred over FGAs for lower EPS risk, not superior efficacy. All antipsychotics can cause metabolic effects to varying degrees. The SGA-FGA choice is about side-effect profile, not just effectiveness.

The primary reason SGAs are preferred first-line is the lower EPS burden, not superior antipsychotic efficacy. SGAs still cause metabolic side effects (especially olanzapine/clozapine). Haloperidol is effective but carries higher EPS risk — it is not absolutely contraindicated.

Correct. Clozapine causes agranulocytosis in approximately 1% of patients. Sore throat, fever, and oral ulcers are the clinical warning signs. Urgent FBC is mandatory; if agranulocytosis (absolute neutrophil count < 500/mm³) is confirmed, clozapine must be stopped IMMEDIATELY and specialist haematology/psychiatry input sought. Clozapine must NEVER be restarted after agranulocytosis.

Clozapine agranulocytosis: sore throat + fever + mouth ulcers = emergency. Urgent FBC; if ANC < 500 → STOP clozapine immediately, never restart. Mandatory monitoring: weekly WBC for 18 weeks, then fortnightly. This is why clozapine is reserved for treatment-resistant schizophrenia only.

The clinical triad of sore throat + fever + oral ulcers in a patient on clozapine must be treated as agranulocytosis until proven otherwise. Urgent FBC is the critical first step. Reducing the dose or switching without checking the blood count first is wrong — the diagnosis must be confirmed. Empirical antibiotics are not the priority over the blood count.

Correct. Acute dystonia (early, severe, painful muscle spasm — opisthotonus, oculogyric crisis, torticollis) responds rapidly to parenteral anticholinergics: IV/IM benztropine or IM promethazine. Oral diazepam is not first-line for acute dystonia. The antipsychotic dose should also be reviewed and reduced. Doubling the dose is dangerous.

Acute dystonia management: parenteral anticholinergic (benztropine IV/IM or promethazine IM) provides rapid reversal. Oral anticholinergics (trihexyphenidyl) are used prophylactically with FGAs. Doubling the antipsychotic dose is dangerous.

Acute dystonia is treated with anticholinergic agents (benztropine IV/IM or promethazine IM) — these reverse the dystonic reaction within minutes. Diazepam has a limited role. Stopping haloperidol abruptly without managing the psychiatric condition is not complete management. Doubling the dose will worsen EPS.

Correct. The treatment gap refers to the proportion of people with a mental disorder who need treatment but do not receive it. For schizophrenia in India, this exceeds 70% — meaning the majority of patients have never had any psychiatric care. Primary care physicians are on the front line of closing this gap.

India's treatment gap for schizophrenia exceeds 70%. Primary care physicians play a critical public health role in early identification, initial management, and timely specialist referral — they are the primary point of contact for most patients who will ever be seen.

The treatment gap specifically refers to the proportion of affected individuals who need but do not receive treatment — for schizophrenia in India, this is >70%. It is not about the number of psychiatrists or the cost of medications specifically.

Correct. Dopamine normally exerts tonic inhibition of prolactin secretion via D2 receptors in the tuberoinfundibular (hypothalamic-pituitary) pathway. Antipsychotics that block D2 receptors in this pathway remove this inhibition, leading to elevated prolactin (hyperprolactinaemia). Risperidone and FGAs have the highest prolactin-elevating potential.

Antipsychotic-induced hyperprolactinaemia: D2 blockade in the tuberoinfundibular pathway disinhibits prolactin secretion. Most pronounced with FGAs and risperidone. Clinical consequences: galactorrhoea, amenorrhoea, infertility, erectile dysfunction, and long-term bone loss.

Prolactin secretion is under tonic inhibitory control by dopamine via the tuberoinfundibular pathway. D2 blockade by antipsychotics removes this inhibition → hyperprolactinaemia → galactorrhoea, menstrual disturbance, sexual dysfunction.

Correct. The primary care approach to newly presenting schizophrenia involves: (1) systematic MSE to confirm the psychotic disorder, (2) initiation of a second-generation antipsychotic (if safe and no contra-indications), and (3) referral to psychiatry for definitive management and ongoing care. Reassurance and delay are inappropriate given the duration and severity.

Primary care role in newly diagnosed schizophrenia: MSE to characterise, initiate SGA if appropriate, and refer to psychiatry. Do not delay with 'wait-and-see' when psychotic symptoms have been present for months with functional decline.

This presentation (1 year of psychotic symptoms — persecutory delusions, self-talk, social withdrawal, functional decline) is not academic stress. Benzodiazepines alone will not treat psychosis. Clozapine is reserved for treatment-resistant schizophrenia, not as a first-line agent. The correct response is MSE + SGA initiation + psychiatric referral.

Correct. This patient has two converging problems: (1) treatment-resistant schizophrenia (failure of risperidone and olanzapine) and (2) long-term trifluoperazine (FGA)-induced tardive dyskinesia. Clozapine is the treatment of choice for TRS AND has evidence for reducing tardive dyskinesia (via D2 receptor partial occupancy profile). Increasing the FGA will worsen TD.

Clozapine has a dual role: (1) treatment-resistant schizophrenia (after ≥2 antipsychotic failures) and (2) potential benefit in tardive dyskinesia (lower D2 occupancy). Primary care role = recognise TRS + TD concurrence and refer urgently for specialist clozapine initiation.

This patient has treatment-resistant schizophrenia + trifluoperazine-induced tardive dyskinesia. Clozapine is the answer for both: it is the evidence-based treatment for TRS, and it has a lower D2 affinity profile that may reduce TD. Increasing the offending FGA would worsen TD. A depot FGA would compound both problems.

Correct. Clinical guidelines recommend antipsychotic maintenance for at least 1-2 years after a first episode of schizophrenia, and indefinitely for patients with multiple episodes. Abrupt discontinuation dramatically increases relapse risk. If discontinuation is considered, it should be gradual, supervised, and discussed with the treating psychiatrist.

Antipsychotic maintenance reduces relapse risk in schizophrenia. First episode: at least 1-2 years. Multiple episodes: indefinite. If discontinuation is planned, it must be gradual, supervised, and in conjunction with the psychiatrist. Key counselling point at every primary care review.

Schizophrenia is a chronic illness with a high relapse rate on antipsychotic discontinuation. Maintenance therapy for at least 1-2 years (first episode) is recommended. Abrupt self-discontinuation is a major cause of relapse. Antipsychotics are not PRN (as-needed) medications for psychosis.