Long-acting injectable antipsychotics US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Long-acting injectable antipsychotics. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Long-acting injectable antipsychotics US Medical PG Question 1: A 24-year-old woman presents with a 3-month history of worsening insomnia and anxiety. She says that she has an important college exam in the next few weeks for which she has to put in many hours of work each day. Despite the urgency of her circumstances, she states that she is unable to focus and concentrate, is anxious, irritable and has lost interest in almost all activities. She also says that she has trouble falling asleep and wakes up several times during the night. She claims that this state of affairs has severely hampered her productivity and is a major problem for her, and she feels tired and fatigued all day. She denies hearing voices, abnormal thoughts, or any other psychotic symptoms. The patient asks if there is some form of therapy that can help her sleep better so that she can function more effectively during the day. She claims that the other symptoms of not enjoying anything, irritability, and anxiety are things that she can learn to handle. Which of the following approaches is most likely to address the patients concerns most effectively?
- A. Initiation of risperidone
- B. Psychotherapy only
- C. Trial of bupropion
- D. Phototherapy
- E. Initiation of mirtazapine (Correct Answer)
Long-acting injectable antipsychotics Explanation: ***Initiation of mirtazapine***
- The patient exhibits classic symptoms of **major depressive disorder**, including insomnia, anxiety, anhedonia (loss of interest), irritability, and fatigue, all of which would benefit from an antidepressant.
- **Mirtazapine** is particularly effective at lower doses for **insomnia** and **anxiety** due to its potent antihistaminergic properties, making it suitable given her chief complaint about sleep.
*Initiation of risperidone*
- **Risperidone** is an **antipsychotic** medication used for conditions like schizophrenia, bipolar disorder, or severe agitation, which is not indicated here given the absence of psychotic symptoms.
- Its use in this context would expose the patient to unnecessary side effects such as **extrapyramidal symptoms**, **metabolic syndrome**, and hyperprolactinemia.
*Psychotherapy only*
- While psychotherapy, particularly cognitive-behavioral therapy (CBT), is an important component of depression treatment, the severity and acute nature of her symptoms, especially the significant functional impairment and insomnia, suggest that **pharmacotherapy is also warranted** for a more effective and rapid response.
- Relying solely on psychotherapy might delay symptomatic relief, especially for her prominent **sleep disturbance** and **anxiety**.
*Trial of bupropion*
- **Bupropion** is an antidepressant that works primarily on **dopamine** and **norepinephrine** reuptake, and it tends to be **activating**, which could exacerbate the patient's existing **insomnia** and **anxiety**.
- It lacks the sedative properties that would directly address her primary concern regarding difficulty sleeping.
*Phototherapy*
- **Phototherapy** is primarily used for **seasonal affective disorder (SAD)**, which is not suggested by the patient's presentation; her symptoms have been ongoing for 3 months and are linked to significant stressors, not seasonal changes.
- While it can improve mood and sleep in SAD, it would not be the most appropriate or effective initial treatment for a non-seasonal major depressive episode with prominent insomnia and anxiety.
Long-acting injectable antipsychotics US Medical PG Question 2: A 24-year-old man presents to the emergency department after a suicide attempt. He is admitted to the hospital and diagnosed with schizoaffective disorder. A review of medical records reveals a history of illicit drug use, particularly cocaine and amphetamines. He is started on aripiprazole, paroxetine, and trazodone. At the time of discharge, he appeared more coherent and with a marked improvement in positive symptoms of hallucinations and delusions but still with a flat effect. During the patient’s first follow-up visit, his mother reports he has become increasingly agitated and restless despite compliance with his medications. She reports that her son’s hallucinations and delusions have stopped and he does not have suicidal ideations, but he cannot sit still and continuously taps his feet, wiggles his fingers, and paces in his room. When asked if anything is troubling him, he stands up and paces around the room. He says, “I cannot sit still. Something is happening to me.” A urine drug screen is negative. What is the next best step in the management of this patient?
- A. Add propranolol (Correct Answer)
- B. Increase the aripiprazole dose
- C. Stop aripiprazole and switch to clozapine
- D. Add lithium
- E. Stop paroxetine
Long-acting injectable antipsychotics Explanation: ***Add propranolol***
- The patient's symptoms of **agitation**, **restlessness**, inability to sit still, **foot tapping**, and **finger wiggling** are highly suggestive of **akathisia**, a common extrapyramidal side effect of antipsychotic medications, particularly **aripiprazole**.
- **Beta-blockers**, such as **propranolol**, are the **first-line treatment** for akathisia due to their ability to provide symptomatic relief by reducing the adrenergic hyperactivity associated with this condition.
*Increase the aripiprazole dose*
- Increasing the dose of **aripiprazole** would likely **worsen** the akathisia, as it is a dose-dependent side effect of **antipsychotic medications**.
- The patient's positive symptoms are already controlled, so increasing the dose is not indicated and could cause more harm.
*Stop aripiprazole and switch to clozapine*
- While switching antipsychotics is an option for persistent side effects, abruptly stopping an effective medication like **aripiprazole** could lead to a **relapse of psychotic symptoms**.
- **Clozapine** is typically reserved for **treatment-resistant schizophrenia** and carries risks of severe side effects like **agranulocytosis**, making it an inappropriate first step for akathisia.
*Add lithium*
- **Lithium** is primarily used as a **mood stabilizer** for bipolar disorder and in augmenting antidepressants; it is not indicated for treating **akathisia**.
- While some cases of akathisia might be mistaken for mood episodes, the classic motor restlessness points to an **extrapyramidal side effect**.
*Stop paroxetine*
- **Paroxetine**, an **SSRI**, is less likely to cause severe akathisia compared to antipsychotics, and discontinuing it would not address the most probable cause of the patient's symptoms, which is the **aripiprazole**.
- Stopping the antidepressant could also exacerbate the patient's **mood symptoms**, given his history of **schizoaffective disorder** and prior suicide attempt.
Long-acting injectable antipsychotics US Medical PG Question 3: A 35-year-old woman comes to the physician accompanied by her husband after he started noticing strange behavior. He first noticed her talking to herself 8 months ago. For the past 6 months, she has refused to eat any packaged foods out of fear that the government is trying to poison her. She has no significant past medical history. She smoked marijuana in college but has not smoked any since. She appears restless. Mental status examination shows a flat affect. Her speech is clear, but her thought process is disorganized with many loose associations. The patient is diagnosed with schizophrenia and started on olanzapine. This patient is most likely to experience which of the following adverse effects?
- A. Dyslipidemia (Correct Answer)
- B. Diabetes insipidus
- C. Agranulocytosis
- D. Myoglobinuria
- E. Seizures
Long-acting injectable antipsychotics Explanation: ***Dyslipidemia***
- **Olanzapine** is a **second-generation antipsychotic** commonly associated with significant **metabolic side effects**, including **weight gain**, **dyslipidemia**, and **insulin resistance**.
- These metabolic disturbances increase the risk of cardiovascular disease.
*Diabetes insipidus*
- This is a rare side effect, not typically associated with **olanzapine** or other **second-generation antipsychotics**.
- **Lithium** is an antimanic agent that can cause **nephrogenic diabetes insipidus**, but it is not relevant here.
*Agranulocytosis*
- While a serious side effect of some antipsychotics, **agranulocytosis** is most notably associated with **clozapine**,
- **Olanzapine** has a much lower risk of causing **agranulocytosis** compared to clozapine.
*Myoglobinuria*
- **Myoglobinuria** is associated with conditions like significant muscle damage (e.g., rhabdomyolysis).
- It is not a direct or common adverse effect of **olanzapine** therapy.
*Seizures*
- While some antipsychotics can lower the **seizure threshold**, **olanzapine** generally has a relatively low risk of inducing seizures.
- The risk is higher with certain other antipsychotics, particularly at high doses, or in patients with pre-existing seizure disorders.
Long-acting injectable antipsychotics US Medical PG Question 4: A 16-year-old girl is brought to the physician because of generalized fatigue and an inability to concentrate in school for the past 4 months. During this period, she has had excessive daytime sleepiness. While going to sleep, she sees cartoon characters playing in her room. She wakes up once or twice every night. While awakening, she feels stiff and cannot move for a couple of minutes. She goes to sleep by 9 pm every night and wakes up at 7 am. She takes two to three 15-minute naps during the day and wakes up feeling refreshed. During the past week while listening to a friend tell a joke, she had an episode in which her head tilted and jaw dropped for a few seconds; it resolved spontaneously. Her father has schizoaffective disorder and her parents are divorced. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate initial pharmacotherapy?
- A. Modafinil (Correct Answer)
- B. Venlafaxine
- C. Risperidone
- D. Oral contraceptive pill
- E. Citalopram
Long-acting injectable antipsychotics Explanation: ***Modafinil***
- This patient's symptoms (excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, cataplexy, and refreshing naps) are highly suggestive of **narcolepsy**.
- **Modafinil** is a wake-promoting agent and is a first-line treatment for excessive daytime sleepiness in narcolepsy.
*Venlafaxine*
- **Venlafaxine** is a serotonin-norepinephrine reuptake inhibitor (SNRI) that can be used to treat cataplexy in narcolepsy by suppressing REM sleep.
- While cataplexy is present, the primary and most debilitating symptom is excessive daytime sleepiness, for which modafinil is the initial choice.
*Risperidone*
- **Risperidone** is an antipsychotic medication, primarily used to treat schizophrenia and bipolar disorder.
- Although the patient experiences hypnagogic hallucinations, these are part of narcolepsy symptoms and not indicative of a primary psychotic disorder warranting antipsychotic treatment.
*Oral contraceptive pill*
- An **oral contraceptive pill** is used for contraception or managing hormonal-related conditions such as irregular menstruation, acne, or polycystic ovary syndrome.
- There is no indication in the patient's presentation that would warrant treatment with oral contraceptives.
*Citalopram*
- **Citalopram** is a selective serotonin reuptake inhibitor (SSRI) and is typically used to treat depression or anxiety disorders.
- While sometimes used off-label for cataplexy in narcolepsy due to its REM-suppressing effects, it is not the initial treatment for the primary symptom of excessive daytime sleepiness.
Long-acting injectable antipsychotics US Medical PG Question 5: A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?
- A. May cause weight gain and metabolic changes
- B. Lower risk of extrapyramidal symptoms
- C. High affinity for serotonin 5-HT2A receptors
- D. Prolongs the QT interval (Correct Answer)
- E. Generally less sedating than older antipsychotics
Long-acting injectable antipsychotics Explanation: ***Prolongs the QT interval***
- The patient presents with **first-episode psychosis** (social withdrawal, poor hygiene, bizarre behavior, academic decline in a previously high-functioning young adult)
- The family's specific concern about **"heart problems"** is the key clue pointing to **QT interval prolongation**
- Among antipsychotics used for first-episode psychosis, **ziprasidone** is most notably associated with QT prolongation and carries an FDA warning about this cardiac effect
- While other antipsychotics may also prolong QT to varying degrees, ziprasidone's association with this adverse effect is well-established and would prompt specific family counseling about cardiac risks
- QT prolongation increases risk of **torsades de pointes**, a potentially fatal arrhythmia
*May cause weight gain and metabolic changes*
- **Weight gain and metabolic syndrome** (hyperglycemia, dyslipidemia) are common adverse effects of many **atypical antipsychotics**, particularly olanzapine and clozapine
- While these are serious long-term concerns, they would typically be described as "weight" or "diabetes" problems rather than acute "heart problems"
- This is not the distinguishing feature being emphasized by the family's concern
*Lower risk of extrapyramidal symptoms*
- **Lower EPS risk** is a characteristic feature of **atypical (second-generation) antipsychotics** compared to typical (first-generation) agents
- This is actually a therapeutic advantage and would not be a concern for the family
- This property applies to most atypical antipsychotics, not specifically to the one causing family concern about cardiac effects
*High affinity for serotonin 5-HT2A receptors*
- **5-HT2A receptor antagonism** is a defining pharmacological property of **atypical antipsychotics** that contributes to their lower EPS risk and efficacy for negative symptoms
- This mechanism applies broadly to the atypical antipsychotic class
- It does not explain the specific family concern about "heart problems"
*Generally less sedating than older antipsychotics*
- Sedation profiles vary widely among antipsychotics; some atypicals (quetiapine) are quite sedating while others (aripiprazole, ziprasidone) are less so
- Sedation is not typically characterized as a "heart problem"
- This does not address the cardiac safety concern highlighted in the question
Long-acting injectable antipsychotics US Medical PG Question 6: A 44-year-old man presents to his psychiatrist for a follow-up appointment. He is currently being treated for schizophrenia. He states that he is doing well but has experienced some odd movement of his face recently. The patient's sister is with him and states that he has been more reclusive lately and holding what seems to be conversations despite nobody being in his room with him. She has not noticed improvement in his symptoms despite changes in his medications that the psychiatrist has made at the last 3 appointments. His temperature is 99.3°F (37.4°C), blood pressure is 157/88 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for rhythmic movements of the patient's mouth and tongue. Which of the following is a side effect of the next best step in management?
- A. Anxiolysis
- B. Dry mouth and dry eyes
- C. QT prolongation on EKG
- D. Infection (Correct Answer)
- E. Worsening of psychotic symptoms
Long-acting injectable antipsychotics Explanation: ***Infection***
- The patient has **tardive dyskinesia** and **persistent psychotic symptoms** despite changes in medications. The next best step is to switch to **clozapine**.
- **Clozapine** can cause **agranulocytosis**, which increases the risk of serious infections and requires regular monitoring of white blood cell counts.
*Anxiolysis*
- While some antipsychotics can have anxiolytic effects, it is not the primary side effect or the most concerning one for the "next best step" in this context.
- The patient's primary issues are persistent psychosis and tardive dyskinesia, not anxiety that would be specifically targeted as the main side effect.
*Dry mouth and dry eyes*
- These are common **anticholinergic side effects** associated with many antipsychotics, including clozapine, but they are generally less severe and life-threatening compared to the risk of agranulocytosis.
- While unpleasant, they are not the most significant or defining side effect of the "next best step" in managing this patient's complex presentation.
*QT prolongation on EKG*
- **QT prolongation** is a known cardiac side effect of several antipsychotics, including clozapine.
- However, the risk of **agranulocytosis** with **clozapine** is arguably the most critical and distinct side effect requiring stringent monitoring, making it the "next best step" related answer.
*Worsening of psychotic symptoms*
- The "next best step" would be directed at *improving* psychotic symptoms, not worsening them. **Clozapine** is specifically indicated for **treatment-resistant schizophrenia**.
- Worsening psychosis would indicate treatment failure or an adverse reaction, not a typical side effect of the intended beneficial action.
Long-acting injectable antipsychotics US Medical PG Question 7: A 23-year-old male presents to the emergency department. He was brought in by police for shouting on a subway. The patient claims that little people were trying to kill him, and he was acting within his rights to defend himself. The patient has a past medical history of marijuana and IV drug use as well as multiple suicide attempts. He is currently homeless. While in the ED, the patient is combative and refuses a physical exam. He is given IM haloperidol and diphenhydramine. The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week. Though he is no longer aggressive, he is seen making "armor" out of paper plates and plastic silverware to defend himself. The patient is switched onto risperidone. The following week the patient is still seen gathering utensils, and muttering about people trying to harm him. The patient's risperidone is discontinued. Which of the following is the best next step in management?
- A. Olanzapine
- B. Thioridazine
- C. Clozapine (Correct Answer)
- D. Chlorpromazine
- E. Fluphenazine
Long-acting injectable antipsychotics Explanation: ***Clozapine***
- This patient has demonstrated **treatment-resistant schizophrenia**, evidenced by persistent positive symptoms despite trials of haloperidol and risperidone, necessitating a trial of clozapine.
- **Clozapine** is an atypical antipsychotic that is uniquely effective for treatment-resistant schizophrenia, especially in patients with a history of **suicidality**.
*Olanzapine*
- While **olanzapine** is an effective atypical antipsychotic, it is generally considered a first-line or second-line agent, and this patient has already failed two antipsychotics (haloperidol and risperidone).
- Its efficacy in **treatment-resistant cases** is not superior to clozapine.
*Thioridazine*
- **Thioridazine** is a first-generation antipsychotic with a high risk of **QT prolongation** and other cardiac side effects, making it a less safe option.
- It is not typically reserved for **treatment-resistant schizophrenia** due to its side effect profile and lack of superior efficacy compared to newer agents.
*Chlorpromazine*
- **Chlorpromazine** is another first-generation antipsychotic that is not indicated for **treatment-resistant schizophrenia** at this stage.
- It carries significant anticholinergic and sedative side effects, similar to thioridazine, and is not significantly more effective than haloperidol for this indication.
*Fluphenazine*
- **Fluphenazine** is a potent first-generation antipsychotic, often available as a **depot injection** for adherence issues.
- However, it is not considered the best next step for **treatment-resistant schizophrenia** after failure of two different classes of antipsychotics.
Long-acting injectable antipsychotics US Medical PG Question 8: A 19-year-old male is brought to the emergency department by his roommate for 'strange' behavior over the last 48 hours. The patient states that he is hearing voices speak to him, giving him secret messages and instructions to carry out. He believes that the FBI is following him and spying on his conversations. The patient is concerned that they are listening to these messages and will find out his secrets. The patient's friend does not believe the patient ingested any substance or used any recreational drugs prior to this episode. A negative drug screen is obtained and confirms this. Physical examination does not reveal any abnormalities. Which of the following treatments might best target this patient's symptoms?
- A. Risperidone (Correct Answer)
- B. Psychotherapy
- C. Haloperidol
- D. Chlorpromazine
- E. Sertraline
Long-acting injectable antipsychotics Explanation: ***Risperidone***
- The patient presents with **auditory hallucinations** and **paranoid delusions**, suggesting an acute psychotic episode, likely the first presentation of **schizophrenia** or a related psychotic disorder.
- **Risperidone** is a second-generation (atypical) antipsychotic, an appropriate first-line treatment for acute psychosis due to its efficacy against both positive and some negative symptoms, with a generally favorable side effect profile compared to first-generation agents.
*Psychotherapy*
- While psychotherapy is a crucial component in the long-term management of psychotic disorders, it is **not sufficient as a monotherapy** for acute psychotic symptoms like prominent hallucinations and delusions, especially in the initial phase.
- Psychotherapy alone would not adequately address the **neurotransmitter imbalances** (e.g., dopamine dysregulation) believed to underlie acute psychosis.
*Haloperidol*
- **Haloperidol** is a first-generation (typical) antipsychotic that is very effective for acute psychosis and severe agitation, primarily by blocking **dopamine D2 receptors**.
- However, first-generation antipsychotics like haloperidol have a **higher risk of extrapyramidal side effects (EPS)**, such as dystonia, akathisia, and parkinsonism, compared to second-generation agents like risperidone, making them generally less preferred for initial treatment unless rapid tranquilization is the main concern or other options are ineffective.
*Chlorpromazine*
- **Chlorpromazine** is another first-generation antipsychotic known for its strong sedative effects and efficacy in treating acute psychosis.
- Similar to haloperidol, it carries a **higher risk of severe side effects**, including **orthostatic hypotension**, sedation, and EPS, making it less favorable as a first-line choice compared to atypical antipsychotics in many acute presentations.
*Sertraline*
- **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)**, primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder.
- It has **no significant antipsychotic properties** and would not be effective in treating the patient's acute psychotic symptoms such as hallucinations and delusions.
Long-acting injectable antipsychotics US Medical PG Question 9: A 27-year-old man is brought to the emergency department from a homeless shelter because of bizarre behavior. He avoids contact with others and has complained to the supervising staff that he thinks people are reading his mind. Three days ago, he unplugged every electrical appliance on his floor of the shelter because he believed they were being used to transmit messages about him to others. The patient has schizophrenia and has been prescribed risperidone but has been unable to comply with his medications because of his unstable living situation. He is disheveled and malodorous. His thought process is disorganized and he does not make eye contact. Which of the following is the most appropriate long-term pharmacotherapy?
- A. Intravenous propranolol
- B. Intramuscular benztropine
- C. Oral haloperidol
- D. Intramuscular risperidone (Correct Answer)
- E. Oral diazepam
Long-acting injectable antipsychotics Explanation: ***Intramuscular risperidone***
- Given the patient's **non-compliance** due to an unstable living situation, a **long-acting injectable antipsychotic** like intramuscular risperidone is the most appropriate choice for long-term management. This ensures consistent medication delivery regardless of daily adherence.
- This medication directly addresses the **positive symptoms of schizophrenia** (paranoia, disorganized thought) that are evident in the patient's bizarre behavior and delusional beliefs.
*Intravenous propranolol*
- Propranolol is a **beta-blocker** used to treat anxiety, hypertension, and tremors, but it is **not an antipsychotic** and does not address the core symptoms of schizophrenia.
- It could potentially be used for symptom control like akathisia if present, but not as primary long-term pharmacotherapy for psychosis.
*Intramuscular benztropine*
- Benztropine is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** induced by antipsychotics (e.g., dystonia, parkinsonism).
- It does not have antipsychotic effects and would not treat the patient's psychotic symptoms.
*Oral haloperidol*
- While haloperidol is an **effective antipsychotic**, it is an **oral formulation**. Given the patient's history of **non-compliance** with oral medication (risperidone), switching to another oral antipsychotic, even one as potent as haloperidol, is unlikely to solve the adherence issue, especially in an unstable living situation.
- Long-term management requires a strategy that overcomes the compliance barrier.
*Oral diazepam*
- Diazepam is a **benzodiazepine** primarily used for anxiety, sedation, and seizure control.
- It has **no antipsychotic properties** and would not treat the underlying psychotic symptoms of schizophrenia. It would only provide temporary sedation.
Long-acting injectable antipsychotics US Medical PG Question 10: A 21-year-old man presents to an outpatient psychiatrist with chief complaints of fatigue and “hearing voices.” He describes multiple voices which sometimes call his name or say nonsensical things to him before he falls asleep at night. He occasionally awakes to see “strange people” in his room, which frighten him but then disappear. The patient is particularly worried by this because his uncle developed schizophrenia when he was in his 20s. The patient also thinks he had a seizure a few days ago, saying he suddenly fell to the ground without warning, though he remembers the episode and denied any abnormal movements during it. He is in his 3rd year of college and used to be a top student, but has been getting C and D grades over the last year, as he has had trouble concentrating and fallen asleep during exams numerous times. He denies changes in mood and has continued to sleep 8 hours per night and eat 3 meals per day recently. Which of the following medications will be most beneficial for this patient?
- A. Haloperidol
- B. Valproic acid
- C. Risperidone
- D. Modafinil (Correct Answer)
- E. Levetiracetam
Long-acting injectable antipsychotics Explanation: ***Modafinil***
- This patient presents with **narcolepsy**, characterized by the **classic tetrad**: excessive daytime sleepiness (falling asleep during exams), **cataplexy** (sudden fall without loss of consciousness or abnormal movements), **hypnagogic hallucinations** (hearing voices before sleep), and **hypnopompic hallucinations** (seeing people upon awakening).
- The hallucinations are **not true psychotic symptoms** but rather dream-like phenomena occurring at sleep-wake transitions, which are common in narcolepsy.
- **Modafinil** is a first-line **wakefulness-promoting agent** that treats the excessive daytime sleepiness and improves alertness, addressing the primary pathology.
- The patient's family history of schizophrenia is a red herring; his symptoms are explained by narcolepsy, not a primary psychotic disorder.
*Risperidone*
- Risperidone is an **atypical antipsychotic** used for schizophrenia and other psychotic disorders.
- This patient does **not have a primary psychotic disorder**—the hallucinations are hypnagogic/hypnopompic phenomena associated with narcolepsy, not true psychotic hallucinations.
- Using an antipsychotic would be inappropriate and could **worsen daytime sleepiness** due to sedating effects, exacerbating the patient's core problem.
*Haloperidol*
- Haloperidol is a **first-generation antipsychotic** with significant risk of **extrapyramidal side effects**.
- Like risperidone, it would be inappropriate here as the patient does not have a psychotic disorder, and it would worsen sedation and daytime sleepiness.
*Valproic acid*
- Valproic acid is a **mood stabilizer and anticonvulsant** used for bipolar disorder and seizure disorders.
- The described "seizure" event is actually **cataplexy** (preserved consciousness, no abnormal movements), not a true seizure, so an anticonvulsant is not indicated.
- It would not address the narcolepsy symptoms and can cause sedation.
*Levetiracetam*
- Levetiracetam is an **anticonvulsant** medication.
- The patient's description (remembering the episode, no abnormal movements) is inconsistent with a seizure and consistent with **cataplexy**, which is treated by addressing the underlying narcolepsy, not with anticonvulsants.
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