Psychopharmacology Practice Questions

Q: A patient with schizophrenia on risperidone develops akathisia. What is the next step?

Add propranolol. ***Add propranolol*** - **Propranolol**, a beta-blocker, is frequently used to treat **akathisia** associated with antipsychotic medications, offering significant symptom relief. - It helps to reduce the subjective feeling of restlessness and the objective motor symptoms, often being the **first-line treatment** for drug-induced akathisia. *Inc. dose* - Increasing the dose of **risperidone** would likely **worsen** the akathisia, as it is a dose-dependent adverse effect of antipsychotics. - Higher doses increase dopamine antagonism, exacerbating extrapyramidal symptoms like akathisia. *Switch to clozapine* - While **clozapine** has a lower risk of extrapyramidal symptoms, switching to it is a significant step due to its potential for **severe side effects** like **agranulocytosis** and requires careful monitoring. - It is generally reserved for **treatment-resistant schizophrenia** or when other antipsychotics are intolerable. *Add benztropine* - **Benztropine** (an anticholinergic) is primarily used for other extrapyramidal symptoms like **dystonia** and **parkinsonism**, but it is generally **less effective** for akathisia. - Anticholinergics can also have cognitive side effects that might be undesirable.

Q: A 35-year-old man with schizophrenia is well-controlled on risperidone but develops tremors, rigidity, and bradykinesia. What is the most appropriate management?

Add benztropine. ***Add benztropine*** - The patient is experiencing **extrapyramidal symptoms (EPS)** (tremors, rigidity, and bradykinesia) as a side effect of risperidone - Adding an anticholinergic agent like **benztropine** is the most appropriate management to counteract these dopamine-blocking effects without discontinuing the effective antipsychotic - This allows continuation of effective schizophrenia treatment while managing the side effects *Discontinue risperidone and start clozapine* - Discontinuing an effective antipsychotic for well-controlled schizophrenia is not ideal, as it risks a **relapse of psychotic symptoms** - **Clozapine** is typically reserved for **treatment-resistant schizophrenia** due to its potential for serious side effects like agranulocytosis - This would be overly aggressive management for a side effect that can be managed with adjunctive therapy *Switch to a higher dose of risperidone* - Increasing the dose of risperidone would likely **exacerbate the extrapyramidal symptoms**, as they are dose-dependent side effects of dopamine D2 receptor blockade - This would worsen the patient's motor symptoms and may lead to more severe parkinsonism *Add a mood stabilizer* - Mood stabilizers (e.g., lithium, valproate) are used to treat **bipolar disorder** or to augment antipsychotics in certain cases - They do not address or alleviate **extrapyramidal symptoms** - This intervention would be inappropriate for managing drug-induced movement disorders

Q: A 50-year-old patient with schizophrenia is prescribed clozapine after the failure of other antipsychotics. What is the most important side effect to monitor?

Agranulocytosis. ***Agranulocytosis*** - **Agranulocytosis** is a severe and potentially fatal side effect of **clozapine**, requiring strict monitoring of **white blood cell count (WBC)** and **absolute neutrophil count (ANC)**. - This adverse effect is specific to clozapine and is the primary reason for mandated regular blood tests when prescribing the medication. *Weight gain* - While **weight gain** is a common side effect of clozapine and other atypical antipsychotics, it is generally less immediately life-threatening than agranulocytosis. - It contributes to metabolic syndrome but is managed by lifestyle interventions and monitoring, not weekly blood tests. *Sedation* - **Sedation** is a common initial side effect of clozapine, often used clinically for patients with agitation or insomnia. - Although it can be bothersome, it typically improves over time and is not life-threatening. *Hyperglycemia* - **Hyperglycemia** is a known metabolic side effect of clozapine, increasing the risk of **diabetes mellitus**. - While important to monitor, it does not pose the immediate, acute life threat that **agranulocytosis** does, which can develop rapidly.

Q: A 55-year-old male with schizophrenia on clozapine presents with fever, sore throat, and fatigue. Laboratory results show a WBC count of 2.0 × 10³/μL. Analyze and choose the appropriate management.

Discontinue clozapine, admit for neutropenia. ***Discontinue clozapine, admit for neutropenia*** - A **WBC count of 2.0** combined with symptoms like **fever and sore throat** in a patient on clozapine strongly indicates **neutropenia or agranulocytosis**. - **Clozapine** can cause severe neutropenia, which requires immediate discontinuation of the drug and admission for monitoring and management to prevent life-threatening infections. *Continue clozapine, add antibiotics* - Continuing clozapine in the face of **severe neutropenia** would likely worsen the condition and expose the patient to a higher risk of **fatal infections**. - While antibiotics might be indicated for the infection, they do not address the underlying **drug-induced neutropenia**. *Lower clozapine dose, add G-CSF* - **Lowering the dose** is insufficient when there is evidence of **severe neutropenia**; complete discontinuation is necessary to allow bone marrow recovery. - **G-CSF (granulocyte colony-stimulating factor)** can be considered, but discontinuing clozapine is the crucial first step for safety. *Switch to risperidone, outpatient f/u* - Switching to another antipsychotic like **risperidone** is appropriate in the long term, but the immediate priority is managing the **neutropenia**, which requires inpatient care. - Outpatient follow-up is inadequate for a patient with **neutropenia** and potential agranulocytosis, who needs close monitoring for infection.

Q: A 28-year-old male with a history of schizophrenia is experiencing symptoms of akathisia. Which of the following is an appropriate treatment for akathisia?

Diazepam. ***Diazepam*** - **Benzodiazepines** like diazepam are effective in treating akathisia through their **GABAergic** properties, which help reduce motor restlessness and subjective distress. - They are particularly useful as **adjunctive therapy** or when beta-blockers and anticholinergics are contraindicated. - Rapid onset of action provides symptomatic relief by modulating neural activity and reducing anxiety associated with akathisia. *Trihexyphenidyl* - **Anticholinergics** like trihexyphenidyl are actually used for akathisia and other extrapyramidal symptoms, but their efficacy is **variable**. - While they work well for **parkinsonism and acute dystonia**, their response in akathisia is less predictable compared to **beta-blockers (propranolol)**. - In this scenario, benzodiazepines may be preferred for their dual action on motor symptoms and associated anxiety. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** and a common **cause** of drug-induced akathisia due to D2 receptor blockade. - Increasing antipsychotic dose would **worsen** akathisia rather than alleviate it. - Management typically involves dose reduction or switching to a lower-potency or atypical antipsychotic. *Promethazine* - **Promethazine** is an **antihistamine** with sedative and antiemetic properties, not a primary treatment for akathisia. - While it has mild anticholinergic effects, it lacks the specific pharmacological profile needed to effectively manage the motor restlessness of akathisia. - Its sedative properties might provide minimal symptomatic relief but do not address the underlying pathophysiology.

Q: A 50-year-old male with schizophrenia has been stable on olanzapine for symptom control but reports severe weight gain and hyperglycemia. Physical examination reveals a BMI of 34, and laboratory results show an HbA1c of 7.2%. What is the most appropriate next step in management?

Switch to aripiprazole, monitor weight. ***Switch to aripiprazole, monitor weight*** - **Aripiprazole** is a **second-generation antipsychotic** known for a more favorable metabolic profile compared to olanzapine. It is less likely to cause significant weight gain, hyperglycemia, or dyslipidemia. - Given the patient's severe **weight gain** and **hyperglycemia** (HbA1c of 7.2%), switching to an antipsychotic with a lower metabolic risk is a priority to manage these side effects. *Switch to clozapine, monitor glucose levels* - **Clozapine** is associated with a **high risk of metabolic side effects**, including significant **weight gain**, **hyperglycemia**, and **dyslipidemia**, similar to or even greater than olanzapine. - While effective for treatment-resistant schizophrenia, switching to clozapine would likely exacerbate the patient's existing metabolic issues. *Continue olanzapine, add metformin* - Continuing **olanzapine** means the patient would remain on a medication known for significant metabolic side effects, which are already severe in this case. - While **metformin** can help manage hyperglycemia and some weight gain, it addresses the symptom without resolving the underlying cause of the metabolic disturbance attributed to olanzapine. *Switch to risperidone, monitor glucose levels* - **Risperidone** has an intermediate risk for **metabolic side effects**, including **weight gain** and **hyperglycemia**, making it an unfavorable choice given the patient's current severe metabolic issues. - Although it might be better than olanzapine for some metabolic parameters, it still carries a significant risk compared to options with much lower metabolic impact.

Q: A 45-year-old male with a history of schizophrenia who is on clozapine presents with fever, sore throat, and fatigue. What is the most appropriate next step?

Discontinue clozapine and check white blood cell count. ***Discontinue clozapine and check white blood cell count*** - The symptoms of **fever, sore throat, and fatigue** in a patient on clozapine are highly suspicious for **agranulocytosis**, a rare but life-threatening side effect. - **Immediate discontinuation of clozapine** and urgent measurement of **white blood cell count (WBC) and absolute neutrophil count (ANC)** are critical to diagnose and manage this condition. *Continue clozapine and monitor symptoms* - Continuing clozapine in the presence of these symptoms could lead to rapid progression of **agranulocytosis** and severe, potentially fatal, infections. - Monitoring symptoms without laboratory confirmation of WBC and ANC is insufficient and **dangerous**. *Discontinue clozapine and start antibiotics* - While infection is a concern given the symptoms, blindly starting antibiotics without confirming severe neutropenia through a **WBC count** is not the primary immediate step. - The priority is to identify the underlying cause (agranulocytosis due to clozapine) and discontinue the causative agent, then manage complications like infection. *Increase clozapine dose* - Increasing the clozapine dose would exacerbate the potential **agranulocytosis** and significantly worsen the patient's condition. - This action is **contraindicated** given the presenting symptoms.

Q: A patient with a history of major depressive disorder is treated with an SSRI and presents with restlessness, hyperreflexia, and myoclonus. What is the likely diagnosis?

Serotonin syndrome. ***Serotonin syndrome*** - The constellation of **restlessness**, **hyperreflexia**, and **myoclonus** in a patient taking an **SSRI** is highly characteristic of **serotonin syndrome**, reflecting excessive serotonin activity. - This syndrome often involves a triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. *Neuroleptic malignant syndrome* - Characterized by **severe muscle rigidity**, **fever**, **autonomic dysfunction**, and altered mental status, often associated with antipsychotic use. - Though it involves autonomic and neuromuscular symptoms, the presenting symptoms of hyperreflexia and myoclonus are more indicative of serotonin syndrome rather than the rigidity seen in NMS. *Anticholinergic toxicity* - Presents with symptoms like **mydriasis**, **dry mouth**, **tachycardia**, **urinary retention**, and altered mental status due to blocking acetylcholine receptors. - The patient's symptoms of hyperreflexia and myoclonus are not typical for anticholinergic toxicity. *Alcohol withdrawal* - Symptoms range from tremors and anxiety to seizures and delirium tremens, occurring after reducing or stopping chronic alcohol intake. - While it can involve agitation, the specific combination of restlessness, hyperreflexia, and myoclonus in a patient on an SSRI points away from alcohol withdrawal as the primary diagnosis.

Q: A 28-year-old male with schizophrenia is prescribed clozapine. What is the most important laboratory test to monitor regularly?

White blood cell count. ***White blood cell count*** - **Clozapine** carries a significant risk of **agranulocytosis**, a severe reduction in **white blood cell count (neutrophils)**, making regular monitoring crucial. - Due to this life-threatening adverse effect, a **baseline WBC count** and **absolute neutrophil count (ANC)** must be established before treatment, and then monitored **weekly for the first six months**, then bi-weekly, and eventually monthly, according to established protocols. *Liver function tests* - While liver enzyme elevations can occur with clozapine, they are generally less frequent and less severe than the risk of agranulocytosis. - Routine **liver function tests (LFTs)** are typically monitored, but not with the same urgency or strictness as WBC counts. *Renal function tests* - **Clozapine** is primarily metabolized by the liver, and significant renal impairment is not a primary concern for closely monitoring during treatment initiation. - While general renal health is important, **renal function tests (RFTs)** are not part of the mandatory, life-saving monitoring protocol for clozapine. *Lipid profile* - **Clozapine** can cause metabolic side effects, including **weight gain**, **dyslipidemia**, and **glucose dysregulation**, which necessitate monitoring of the **lipid profile** and **blood glucose levels**. - However, these metabolic effects, while important for long-term health, are not as acutely life-threatening as agranulocytosis, making WBC count the most immediate and critical laboratory test.

Question 1

A patient with schizophrenia on risperidone develops akathisia. What is the next step?

Accepted Answer

Add propranolol

Answer

Switch to clozapine

Answer

Add benztropine

Answer

Increase dose

Question 2

A 35-year-old man with schizophrenia is well-controlled on risperidone but develops tremors, rigidity, and bradykinesia. What is the most appropriate management?

Accepted Answer

Add benztropine

Answer

Discontinue risperidone and start clozapine

Answer

Switch to a higher dose of risperidone

Answer

Add a mood stabilizer

Question 3

A 50-year-old patient with schizophrenia is prescribed clozapine after the failure of other antipsychotics. What is the most important side effect to monitor?

Accepted Answer

Agranulocytosis

Answer

Weight gain

Answer

Sedation

Answer

Hyperglycemia

Question 4

A 55-year-old male with schizophrenia on clozapine presents with fever, sore throat, and fatigue. Laboratory results show a WBC count of 2.0 × 10³/μL. Analyze and choose the appropriate management.

Accepted Answer

Discontinue clozapine, admit for neutropenia

Answer

Continue clozapine, add antibiotics

Answer

Lower clozapine dose, add G-CSF

Answer

Switch to risperidone, outpatient f/u

Question 5

A 28-year-old male with a history of schizophrenia is experiencing symptoms of akathisia. Which of the following is an appropriate treatment for akathisia?

Accepted Answer

Diazepam

Answer

Promethazine

Answer

Trihexyphenidyl

Answer

Haloperidol

Question 6

A 50-year-old male with schizophrenia has been stable on olanzapine for symptom control but reports severe weight gain and hyperglycemia. Physical examination reveals a BMI of 34, and laboratory results show an HbA1c of 7.2%. What is the most appropriate next step in management?

Accepted Answer

Switch to aripiprazole, monitor weight

Answer

Continue olanzapine, add metformin

Answer

Switch to clozapine, monitor glucose levels

Answer

Switch to risperidone, monitor glucose levels

Question 7

A 45-year-old male with a history of schizophrenia who is on clozapine presents with fever, sore throat, and fatigue. What is the most appropriate next step?

Accepted Answer

Discontinue clozapine and check white blood cell count

Answer

Continue clozapine and monitor symptoms

Answer

Discontinue clozapine and start antibiotics

Answer

Increase clozapine dose

Question 8

A patient with a history of major depressive disorder is treated with an SSRI and presents with restlessness, hyperreflexia, and myoclonus. What is the likely diagnosis?

Accepted Answer

Serotonin syndrome

Answer

Neuroleptic malignant syndrome

Answer

Anticholinergic toxicity

Answer

Alcohol withdrawal

Question 9

A 28-year-old male with schizophrenia is prescribed clozapine. What is the most important laboratory test to monitor regularly?

Accepted Answer

White blood cell count

Answer

Liver function tests

Answer

Renal function tests

Answer

Lipid profile

Question 10

A 60-year-old woman with schizophrenia presents with tardive dyskinesia. What is the most appropriate management?

Accepted Answer

Switch to clozapine

Answer

Discontinue antipsychotic medication

Answer

Add a benzodiazepine

Answer

Increase antipsychotic dose

Psychopharmacology — MCQs

Psychopharmacology — MCQs

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