Psychopharmacology Practice Questions

Q: A patient was given an antipsychotic drug, haloperidol, and the patient developed acute dystonia. Which is the next best step?

Give Benztropine. ***Give Benztropine***- **Acute dystonia** is a severe extrapyramidal symptom (EPS) requiring rapid intervention, often treated intramuscularly or intravenously.- **Benztropine** (an anticholinergic agent) is the drug of choice for the immediate management of acute dystonia, working to restore the balance between dopamine and acetylcholine.*Change to clozapine*- While **clozapine** has a significantly lower risk of causing acute dystonia, it is not the initial treatment for an acute episode due to its slow titration requirements and side-effect profile.- Switching to clozapine is a long-term strategy for patients intolerant to other antipsychotics, not an acute rescue medication.*Give Fluphenazine*- **Fluphenazine** is a high-potency first-generation antipsychotic, similar to haloperidol, which also carries a high risk of EPS.- Administering another high-potency antipsychotic would perpetuate the excessive **dopaminergic blockade** responsible for the acute dystonia.*Increase dose of haloperidol*- **Acute dystonia** is a direct dose-related side effect of D2 receptor blockade by haloperidol in the nigrostriatal pathway.- Increasing the dose of **haloperidol** would worsen the underlying neurochemical imbalance, thereby intensifying the dystonic symptoms.

Q: A patient with schizophrenia, developed muscular dystonia and was treated for it. The patient now presents with complaints of dry mouth, dizziness, and hypotension. What is the most likely drug causing these side effects?

Benzotropine. ***Benzotropine***- This drug is an **anticholinergic agent** administered specifically to treat **extrapyramidal symptoms (EPS)** like acute muscular dystonia caused by antipsychotics.- **Dry mouth** is a characteristic manifestation of its peripheral **anticholinergic side effects**, while **dizziness and hypotension** can occur due to central effects or potentiation of adrenergic blockade, particularly when co-administered with antipsychotics.*Risperidone*- Although Risperidone (an atypical antipsychotic) commonly causes EPS and strong **orthostatic hypotension** due to **alpha-1 adrenergic blockade** (dizziness/hypotension), it has moderate anticholinergic activity, making it less likely to be the sole cause of prominent dry mouth.- The patient's presentation suggests a new medication was introduced *after* the dystonia developed; Risperidone was likely the cause of the *initial* dystonia.*Haloperidol*- Haloperidol, a high-potency typical antipsychotic, is a common cause of **muscular dystonia** (EPS).- It has relatively **low anticholinergic activity** and is therefore an improbable cause of severe **dry mouth** compared to agents like Benzotropine.*Propranolol*- Propranolol is a **beta-blocker** typically used to treat antipsychotic-induced **akathisia** or tremor, not acute dystonia.- Its most prominent side effects are related to beta-blockade, such as **bradycardia** and fatigue; it is not routinely associated with significant **dry mouth**.

Q: A 28-year-old woman diagnosed with schizophrenia had been compliant with her prescribed olanzapine for several months. However, she discontinued the treatment. Which of the following is the most likely reason for her discontinuation?

Weight gain. ***Weight gain*** - **Olanzapine** is associated with one of the highest propensities among all antipsychotics for causing significant **weight gain** and metabolic syndrome (dyslipidemia, hyperglycemia). - For young women, this effect is often highly stigmatizing and is the leading cause for non-adherence and treatment discontinuation after several months of successful compliance. *Acute dystonia* - This is an acute **Extrapyramidal Symptom (EPS)** characterized by sudden, sustained muscle contractions, typically appearing within the first few days or weeks of starting treatment. - Olanzapine has a low rate of acute dystonia, and it would likely have caused discontinuation much earlier than several months into therapy. *Akathisia* - **Akathisia** is characterized by distressing subjective restlessness and motor agitation; although possible, it usually manifests early in the treatment course or after dose increases. - While bothersome, weight gain accumulated over several months is a statistically more frequent reason for patient-led drug discontinuation in this population than chronic akathisia. *Tardive dyskinesia* - **Tardive dyskinesia (TD)** is an involuntary movement disorder that is a late-onset side effect, typically developing after years of cumulative antipsychotic exposure. - Given that she was compliant for only several months, the development of severe TD causing discontinuation is highly improbable compared to chronic, rapidly accumulating metabolic side effects like weight gain.

Q: A 38-year-old professor with depression requests you to prescribe an antidepressant that would be least likely to cause sexual dysfunction. Which of the following drugs would you prescribe?

Bupropion. ***Bupropion***- Bupropion is a **norepinephrine-dopamine reuptake inhibitor (NDRI)** that differs structurally and mechanically from SSRIs and SNRIs. - It is known for its relatively neutral effect on sexual function, often having the **lowest incidence** of sexual side effects among commonly prescribed antidepressants, and is sometimes used to treat SSRI-induced sexual dysfunction.*Escitalopram*- As a **selective serotonin reuptake inhibitor (SSRI)**, escitalopram frequently causes sexual side effects such as decreased libido, delayed orgasm, and anorgasmia.- This class of drugs elevates **serotonin levels**, which is strongly implicated in causing sexual dysfunction.*Venlafaxine*- Venlafaxine is a **serotonin-norepinephrine reuptake inhibitor (SNRI)**, and its serotonergic component carries a medium-to-high risk of causing sexual dysfunction.- The common sexual side effects include **erectile dysfunction** in men and reduced arousal in women.*Fluoxetine*- Fluoxetine is a commonly prescribed **SSRI** with a significant association with sexual side effects, including inhibited orgasm and reduced libido.- Its long half-life means that these adverse effects, if they occur, can persist following **discontinuation**.

Q: A patient on haloperidol for 2 years presents with orofacial dyskinesia and extrapyramidal symptoms. What is the appropriate treatment?

Tardive dyskinesia - valbenazine. ***Tardive dyskinesia - valbenazine*** - The patient's presentation of **orofacial dyskinesia** following **long-term use** (2 years) of a high-potency antipsychotic like haloperidol is highly characteristic of **Tardive Dyskinesia (TD)**, a chronic EPS. - **Valbenazine** (a VMAT2 inhibitor) is one of the primary, FDA-approved treatments specifically used to reduce the severity of abnormal movements in TD. *Acute dystonia - ropinirole* - **Acute dystonia** is an immediate reaction (hours to days) involving severe muscle spasms, not a delayed presentation of dyskinesia. - The treatment for acute dystonia is typically an **anticholinergic** (e.g., benztropine) or diphenhydramine; **ropinirole** is a dopamine agonist used for Parkinson's disease. *Akathisia - propranolol* - **Akathisia** is defined by a subjective feeling of restlessness and an objective inability to sit still, which is different from the involuntary, choreiform movements of **dyskinesia**. - Although **propranolol** is the appropriate treatment for akathisia, the symptom cluster (orofacial dyskinesia) indicates a diagnosis of **TD**. *Parkinsonism - amantadine* - Drug-induced **Parkinsonism** involves bradykinesia, rigidity, and resting tremor, rather than the prominent abnormal mouth and face movements (dyskinesia) seen here. - While **amantadine** is used for drug-induced parkinsonism, it is generally ineffective or potentially worsens the movements associated with **Tardive Dyskinesia**.

Q: A patient on long-term antipsychotics develops involuntary mouth and lip movements (perioral dyskinesia). What is the best treatment?

Stop antipsychotic and give tetrabenazine. ***Stop antipsychotic and give tetrabenazine*** - Managing **Tardive Dyskinesia (TD)** involves either switching to a less potent antipsychotic (like clozapine) or, ideally, reducing or discontinuing the offending antipsychotic if clinically feasible. - **Tetrabenazine** (or its analogues valbenazine/deutetrabenazine) are **VMAT2 inhibitors** that decrease presynaptic dopamine release, making them the **first-line pharmacological treatment** for established TD. - This combination represents the most definitive approach when the underlying psychiatric condition allows antipsychotic discontinuation. *Increase the antipsychotic dose* - Increasing the antipsychotic dose temporarily masks TD by increasing central dopamine receptor blockade, but this worsens the underlying **striatal dopamine receptor upregulation** that causes TD. - This strategy only delays definitive treatment and prolongs the risk of severe, irreversible dyskinesia. - While it may suppress movements transiently, it is **never** appropriate long-term management. *Start benzodiazepines* - **Benzodiazepines** (GABA agonists) are generally ineffective for the core involuntary movements of established **Tardive Dyskinesia**. - They may be useful for acute movement disorders or anxiety but lack efficacy against chronic, persistent dopamine-related dyskinesia. *Give anticholinergics* - **Anticholinergic drugs** (e.g., benztropine, trihexyphenidyl) are the treatment of choice for **acute dystonia** and drug-induced Parkinsonism. - These agents are generally **contraindicated** in Tardive Dyskinesia because they often worsen or reveal underlying dyskinetic movements.

Q: Which of the following psychoactive substances is a new, rapidly acting antidepressant?

Ketamine. ***Ketamine*** - It is an **NMDA receptor antagonist** that produces a rapid and often sustained antidepressant effect, typically within hours, making it a new class of rapidly acting antidepressants. - **Esketamine** (a derivative) is specifically approved for **treatment-resistant depression** and acute suicidal ideation. *Bupropion* - This is a traditional antidepressant classified as a **Norepinephrine and Dopamine Reuptake Inhibitor (NDRI)**. - Like most conventional antidepressants (SSRIs, SNRIs), Bupropion has a **delayed onset of action**, usually requiring weeks for clinical efficacy. *Haloperidol* - This substance is a typical or first-generation **antipsychotic** used primarily to treat conditions involving psychosis, such as schizophrenia and acute mania. - Its primary function involves potent blockade of **Dopamine D2 receptors**, and it is not used in the management of primary depression. *Cannabinoids* - These agents primarily modulate the **endocannabinoid system (CB1 and CB2 receptors)**, and while they have CNS effects, they are generally not used as primary, rapid-acting antidepressants. - Research into cannabinoids for mood is complex, and they may sometimes lead to dysphoria or **anxiety/psychosis exacerbation**.

Q: Which drug has propensity to cause such involuntary movements?

Flupenthixol. ***Flupenthixol*** - The image displays various **involuntary movements** of the face, characteristic of **tardive dyskinesia**. - **Flupenthixol** is a **typical (first-generation) antipsychotic** with **high D2 receptor blockade**, giving it the **highest propensity** among the options to cause **extrapyramidal symptoms** including tardive dyskinesia. - Typical antipsychotics are the **most common cause** of drug-induced tardive dyskinesia due to chronic dopamine receptor blockade. *Risperidone* - **Risperidone** is an atypical antipsychotic with **moderate risk** of extrapyramidal symptoms and tardive dyskinesia, particularly at higher doses. - While it can cause TD, its risk is **lower than typical antipsychotics** like flupenthixol but **higher than other atypical antipsychotics** like clozapine or quetiapine. *Tetrabenazine* - **Tetrabenazine** is a **monoamine depletor** (VMAT2 inhibitor) used to **treat tardive dyskinesia and chorea** in Huntington's disease. - It can cause **drug-induced parkinsonism and akathisia**, but does **not typically cause tardive dyskinesia** itself. - It works by depleting presynaptic dopamine rather than blocking postsynaptic receptors. *Clozapine* - **Clozapine** is an atypical antipsychotic with the **lowest risk of extrapyramidal symptoms** and tardive dyskinesia among all antipsychotics. - It has **weak D2 receptor affinity** and strong 5-HT2A antagonism, making it protective against TD. - Often chosen specifically for patients at high risk of or with existing movement disorders.

Question 1

A patient was given an antipsychotic drug, haloperidol, and the patient developed acute dystonia. Which is the next best step?

Accepted Answer

Give Benztropine

Answer

Give Fluphenazine

Answer

Increase dose of haloperidol

Answer

Change to clozapine

Question 2

A patient with schizophrenia, developed muscular dystonia and was treated for it. The patient now presents with complaints of dry mouth, dizziness, and hypotension. What is the most likely drug causing these side effects?

Accepted Answer

Benzotropine

Answer

Propranolol

Answer

Risperidone

Answer

Haloperidol

Question 3

A 28-year-old woman diagnosed with schizophrenia had been compliant with her prescribed olanzapine for several months. However, she discontinued the treatment. Which of the following is the most likely reason for her discontinuation?

Accepted Answer

Weight gain

Answer

Tardive dyskinesia

Answer

Acute dystonia

Answer

Akathisia

Question 4

A 38-year-old professor with depression requests you to prescribe an antidepressant that would be least likely to cause sexual dysfunction. Which of the following drugs would you prescribe?

Accepted Answer

Bupropion

Answer

Venlafaxine

Answer

Fluoxetine

Answer

Escitalopram

Question 5

Which among the following psychoactive substances has antidepressant properties?

Accepted Answer

Ketamine

Answer

Cannabidiol

Answer

Mephedrone

Answer

Bupropion

Question 6

Which of the following drugs are used in the management of acute mania?

Accepted Answer

1, 2 & 3 (Lithium, Valproate & Haloperidol)

Answer

Only 1 (Lithium)

Answer

1, 2 & 4 (Lithium, Valproate & Amitriptyline)

Answer

2 & 4 (Valproate & Amitriptyline)

Question 7

A patient on haloperidol for 2 years presents with orofacial dyskinesia and extrapyramidal symptoms. What is the appropriate treatment?

Accepted Answer

Tardive dyskinesia - valbenazine

Answer

Akathisia - propranolol

Answer

Parkinsonism - amantadine

Answer

Acute dystonia - ropinirole

Question 8

A patient on long-term antipsychotics develops involuntary mouth and lip movements (perioral dyskinesia). What is the best treatment?

Accepted Answer

Stop antipsychotic and give tetrabenazine

Answer

Start benzodiazepines

Answer

Give anticholinergics

Answer

Increase the antipsychotic dose

Question 9

Which of the following psychoactive substances is a new, rapidly acting antidepressant?

Accepted Answer

Ketamine

Answer

Bupropion

Answer

Haloperidol

Answer

Cannabinoids

Question 10

Which drug has propensity to cause such involuntary movements?

Accepted Answer

Flupenthixol

Answer

Clozapine

Answer

Risperidone

Answer

Tetrabenazine

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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