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 40-year-old male with generalized anxiety disorder is started on an SSRI but experiences increased anxiety after one week. What is the best course of action?

Add a benzodiazepine temporarily. ***Add a benzodiazepine temporarily*** - **SSRIs** can initially worsen **anxiety symptoms** before therapeutic effects begin, which often takes 2-4 weeks. - A **benzodiazepine** can provide rapid symptomatic relief for acute anxiety during this initial phase, and can be tapered once the **SSRI** therapeutic effects are established. *Discontinue the SSRI* - Discontinuing the **SSRI** after only one week due to initial increased anxiety is premature, as this is a known, temporary side effect. - Doing so would prevent the patient from experiencing the potential long-term benefits of the medication for **generalized anxiety disorder**. *Switch to a different SSRI* - Switching to a different **SSRI** is not indicated at this stage, as the current medication has not had sufficient time to demonstrate its efficacy or full side effect profile. - A new **SSRI** would likely present the same initial increase in anxiety, restarting the acclimatization period. *Increase the SSRI dose* - Increasing the **SSRI** dose would likely exacerbate the current side effect of increased anxiety, worsening the patient's discomfort. - It's too early to assess the current dose's efficacy, and increasing it prematurely is ill-advised without established tolerance or a therapeutic window.

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: What is the next step for a patient with generalized anxiety disorder who has been on an SSRI for 8 weeks with no response?

Switch to SNRI. ***Switch to SNRI*** - If a patient with GAD shows no response to an SSRI after an adequate trial (8 weeks), switching to an **SNRI** is a recommended next step due to its different mechanism of action combining serotonin and norepinephrine reuptake inhibition. - SNRIs like **venlafaxine** or **duloxetine** are considered **first-line treatments** for GAD alongside SSRIs, and can be effective when SSRIs are not. *Increase SSRI dose* - While dose escalation is often attempted for partial response, if there has been **no response** at all after 8 weeks, a higher dose of the same medication is **unlikely to be effective**. - There is a risk of increased **side effects** without significant clinical benefit when increasing a non-responsive dose. *Switch to a different SSRI* - Switching to another SSRI might be considered for **partial response** or intolerance to the initial SSRI, but for **complete non-response**, switching to a medication with a different mechanism of action (like an SNRI) is generally preferred. - The patient has already failed one SSRI, suggesting that the **class effect** might not be sufficient for their specific presentation. *Add a benzodiazepine* - Benzodiazepines are typically used for **short-term relief** of acute anxiety symptoms due to their rapid onset of action. - They are generally **not recommended** as a first-line or add-on treatment for chronic GAD due to risks of dependence and withdrawal, and they do not treat the underlying disorder.

Q: A patient with severe anxiety requires long-term management. Which class of antidepressants, known for its efficacy in treating anxiety disorders, should be considered?

Selective serotonin reuptake inhibitors (SSRIs). ***Selective serotonin reuptake inhibitors (SSRIs)*** - SSRIs are considered **first-line agents** for the long-term management of most anxiety disorders due to their efficacy and generally favorable side-effect profile. - They work by increasing the concentration of **serotonin** in the synaptic cleft, helping to regulate mood and anxiety. - Evidence supports their use in generalized anxiety disorder, panic disorder, social anxiety disorder, and other anxiety conditions. *Tricyclic antidepressants* - While effective for some anxiety disorders, **TCAs** have a less favorable side-effect profile, including anticholinergic effects, sedation, and cardiac toxicity. - They are generally reserved for cases where SSRIs are ineffective or contraindicated. *Monoamine oxidase inhibitors* - **MAOIs** are highly effective but carry a significant risk of **hypertensive crisis** when consumed with tyramine-rich foods or certain medications. - Their strict dietary restrictions and drug interactions limit their use to **refractory cases** of anxiety. *Atypical antipsychotics* - **Atypical antipsychotics** are primarily used for psychotic disorders and severe mood disorders, sometimes as an augmentation strategy for anxiety. - They are not considered a first-line or long-term monotherapy for general anxiety due to potential side effects like metabolic syndrome and extrapyramidal symptoms.

Q: What is the long-term treatment for a patient with Bipolar I disorder who experiences both mania and depression?

Lithium. ***Lithium*** - **Lithium** is a **mood stabilizer** and is considered a first-line long-term treatment for **Bipolar I disorder**, effectively managing both manic and depressive episodes. - It helps in preventing the recurrence of episodes and reducing their severity, thereby maintaining **mood stability**. *Selective Serotonin Reuptake Inhibitors (SSRIs)* - While SSRIs are used for depression, their use in bipolar disorder, especially as monotherapy, can induce **mania** or **rapid cycling**. - They are generally avoided for long-term treatment in bipolar disorder unless carefully combined with a **mood stabilizer**. *CBT* - **Cognitive Behavioral Therapy (CBT)** is an important **adjunctive therapy** for bipolar disorder, helping patients develop coping strategies and improve functional outcomes. - However, CBT alone is not sufficient as a primary long-term treatment to manage the biological and cyclical nature of **mood episodes** in Bipolar I disorder. *Benzodiazepines (BZDs)* - **Benzodiazepines** are generally used for short-term management of acute symptoms, such as severe **agitation**, **insomnia**, or **anxiety**, during a manic episode. - They are not suitable for **long-term treatment** due to risks of tolerance, dependence, and potential for withdrawal symptoms.

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 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.

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 40-year-old male with generalized anxiety disorder is started on an SSRI but experiences increased anxiety after one week. What is the best course of action?

Accepted Answer

Add a benzodiazepine temporarily

Answer

Discontinue the SSRI

Answer

Switch to a different SSRI

Answer

Increase the SSRI dose

Question 4

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 5

What is the next step for a patient with generalized anxiety disorder who has been on an SSRI for 8 weeks with no response?

Accepted Answer

Switch to SNRI

Answer

Increase SSRI dose

Answer

Switch to a different SSRI

Answer

Add a benzodiazepine

Question 6

A patient with severe anxiety requires long-term management. Which class of antidepressants, known for its efficacy in treating anxiety disorders, should be considered?

Accepted Answer

Selective serotonin reuptake inhibitors (SSRIs)

Answer

Tricyclic antidepressants

Answer

Monoamine oxidase inhibitors

Answer

Atypical antipsychotics

Question 7

What is the long-term treatment for a patient with Bipolar I disorder who experiences both mania and depression?

Accepted Answer

Lithium

Answer

CBT

Answer

Benzodiazepines (BZDs)

Answer

Selective Serotonin Reuptake Inhibitors (SSRIs)

Question 8

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 9

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 10

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

Psychopharmacology — MCQs

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