Pharmacological management — MCQs

10 questions

A 37-year-old woman presents to the general medical clinic with a chief complaint of anxiety. She has been having severe anxiety and fatigue for the past seven months. She has difficulty concentrating and her work has suffered, and she has also developed diarrhea from the stress. She doesn't understand why she feels so anxious and is unable to attribute it to any specific aspect of her life right now. You decide to begin pharmacotherapy. All of the following are suitable mechanisms of drugs that can treat this illness EXCEPT:

A 31-year-old woman is brought to the emergency department by EMS, activated by a bystander who found her wandering in the street. She provides short, vague answers to interview questions and frequently stops mid-sentence and stares at an empty corner of the room, appearing distracted. Her affect is odd but euthymic. Past medical history is notable for obesity and pre-diabetes. Collateral information from her brother reveals that she left home 3 days ago because she thought her family was poisoning her and has since been listed as a missing person. He also describes a progressive 2-year decline in her social interactions and self-care. The patient has no history of substance use and has never been prescribed psychiatric medications before but is amenable to starting a medication now. Which of the following would be the most appropriate as a first line medication for her?

A 45-year-old obese man is evaluated in a locked psychiatric facility. He was admitted to the unit after he was caught running through traffic naked while tearing out his hair. His urine toxicology screening was negative for illicit substances and after careful evaluation and additional history, provided by his parents, he was diagnosed with schizophrenia and was treated with aripiprazole. His symptoms did not improve after several dosage adjustments and he was placed on haloperidol, but this left him too lethargic and slow and he was placed on loxapine. After several dosage adjustments today, he is still quite confused. He describes giant spiders and robots that torture him in his room. He describes an incessant voice screaming at him to run away. He also strongly dislikes his current medication and would like to try something else. Which of the following is indicated in this patient?

A 32-year-old man comes to the physician because of a 2 month history of difficulty sleeping and worsening fatigue. During this time, he has also had difficulty concentrating and remembering tasks at work as well as diminished interest in his hobbies. He has no suicidal or homicidal ideation. He does not have auditory or visual hallucinations. Vital signs are normal. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect with slowed thinking and speech. The physician prescribes sertraline. Three weeks later, the patient comes to the physician again with only minor improvements in his symptoms. Which of the following is the most appropriate next step in management?

A 24-year-old man with a history of schizophrenia presents for follow-up. The patient says that he is still having paranoia and visual hallucinations on his latest atypical antipsychotic medication. Past medical history is significant for schizophrenia diagnosed 1 year ago that failed to be adequately controlled on 2 separate atypical antipsychotic medications. The patient is switched to a typical antipsychotic medication. Which of the following is the mechanism of action of the medication that was most likely prescribed for this patient?

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 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient is prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?

A 30-year-old man presents to his psychiatrist for a follow-up visit. He was diagnosed with schizophrenia 6 months ago and has been taking fluphenazine. He says that his symptoms are well controlled by the medication, and he no longer has auditory hallucinations. The psychiatrist also notes that his delusions and other psychotic symptoms have improved significantly. However, the psychiatrist notices something while talking to the patient that prompts him to say, “I know the drug has effectively controlled your symptoms but I think you should discontinue it now otherwise this side effect is likely to be irreversible.” Which of the following did the psychiatrist most likely notice in this patient?

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?

Q10

A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

Pharmacological management US Medical PG Practice Questions and MCQs

Question 1: A 37-year-old woman presents to the general medical clinic with a chief complaint of anxiety. She has been having severe anxiety and fatigue for the past seven months. She has difficulty concentrating and her work has suffered, and she has also developed diarrhea from the stress. She doesn't understand why she feels so anxious and is unable to attribute it to any specific aspect of her life right now. You decide to begin pharmacotherapy. All of the following are suitable mechanisms of drugs that can treat this illness EXCEPT:

A. A drug that stimulates 5-HT1A receptors
B. A drug that blocks dopamine 2 receptors (Correct Answer)
C. A drug that acts as a GABA agonist
D. A drug that blocks 5-HT reuptake
E. A drug that blocks both serotonin and norepinephrine reuptake

Explanation: ***A drug that blocks dopamine 2 receptors*** - This option describes **first-generation antipsychotics**, which primarily block **dopamine D2 receptors**. These are generally used for psychotic disorders (e.g., schizophrenia) and severe agitation, not typically for generalized anxiety disorder as a first-line treatment. - Blocking D2 receptors can lead to **extrapyramidal symptoms** and is not a common therapeutic target for anxiety, which is more reliably treated by targeting serotonin, norepinephrine, and GABA systems. *A drug that stimulates 5-HT1A receptors* - This describes **buspirone**, an anxiolytic that is effective for **generalized anxiety disorder (GAD)**. - **Stimulation of 5-HT1A receptors** helps to modulate serotonin activity and reduce anxiety without significant sedative effects or risk of dependence associated with benzodiazepines. *A drug that acts as a GABA agonist* - This describes **benzodiazepines**, which enhance the inhibitory effects of **GABA** in the central nervous system. - They are effective for acute anxiety relief but carry risks of **sedation**, **tolerance**, and **dependence**, making them suitable mainly for short-term or intermittent use. *A drug that blocks 5-HT reuptake* - This describes **selective serotonin reuptake inhibitors (SSRIs)**, which are considered first-line treatment for various anxiety disorders, including GAD. - By increasing **serotonin levels** in the synaptic cleft, SSRIs help to regulate mood and reduce anxiety symptoms over time. *A drug that blocks both serotonin and norepinephrine reuptake* - This describes **serotonin-norepinephrine reuptake inhibitors (SNRIs)**, such as venlafaxine or duloxetine. - SNRIs are also first-line treatments for GAD, working by increasing both **serotonin** and **norepinephrine** in the brain, offering broad-spectrum anxiolytic and antidepressant effects.

Question 2: A 31-year-old woman is brought to the emergency department by EMS, activated by a bystander who found her wandering in the street. She provides short, vague answers to interview questions and frequently stops mid-sentence and stares at an empty corner of the room, appearing distracted. Her affect is odd but euthymic. Past medical history is notable for obesity and pre-diabetes. Collateral information from her brother reveals that she left home 3 days ago because she thought her family was poisoning her and has since been listed as a missing person. He also describes a progressive 2-year decline in her social interactions and self-care. The patient has no history of substance use and has never been prescribed psychiatric medications before but is amenable to starting a medication now. Which of the following would be the most appropriate as a first line medication for her?

A. Risperidone (Correct Answer)
B. Trazodone
C. Clomipramine
D. Olanzapine
E. Clozapine

Explanation: ***Risperidone*** - This patient presents with symptoms highly suggestive of **schizophrenia**, including **paranoid delusions** (family poisoning her), **disorganized thinking** (vague answers, stopping mid-sentence), **social withdrawal**, and decline in **self-care**. **Risperidone** is a **second-generation antipsychotic** and a common first-line treatment for schizophrenia due to its efficacy against both positive and negative symptoms. - It is the **best choice among first-line antipsychotics** for this patient given her **obesity and pre-diabetes**, as it has a **lower risk of metabolic side effects** compared to olanzapine, while still maintaining excellent antipsychotic efficacy. - The patient's **amenability to medication** and lack of prior treatment history make risperidone an ideal initial choice. *Trazodone* - **Trazodone** is an **antidepressant** primarily used for **major depressive disorder** and **insomnia**. - It does not have significant **antipsychotic effects** and would not be effective in treating the delusions and disorganized thought processes seen in this patient. *Clomipramine* - **Clomipramine** is a **tricyclic antidepressant (TCA)** mainly used for **obsessive-compulsive disorder (OCD)** and severe depression. - It is not indicated for psychotic disorders like schizophrenia and would not address the patient's **psychotic symptoms**. *Olanzapine* - While **olanzapine** is also a **second-generation antipsychotic** very effective for schizophrenia and considered first-line, the patient's history of **obesity** and **pre-diabetes** makes it a less ideal choice compared to risperidone. - **Olanzapine** is associated with the **highest risk of metabolic side effects** among second-generation antipsychotics, including **weight gain**, **dyslipidemia**, and **new-onset diabetes**, which could significantly exacerbate her pre-existing conditions. *Clozapine* - **Clozapine** is a highly effective **antipsychotic**, but it is typically reserved for **treatment-resistant schizophrenia** due to its potentially severe side effects, including **agranulocytosis** and **myocarditis**. - It requires **frequent blood monitoring** and is not considered a first-line agent, especially in a patient who has never received prior antipsychotic treatment.

Question 3: A 45-year-old obese man is evaluated in a locked psychiatric facility. He was admitted to the unit after he was caught running through traffic naked while tearing out his hair. His urine toxicology screening was negative for illicit substances and after careful evaluation and additional history, provided by his parents, he was diagnosed with schizophrenia and was treated with aripiprazole. His symptoms did not improve after several dosage adjustments and he was placed on haloperidol, but this left him too lethargic and slow and he was placed on loxapine. After several dosage adjustments today, he is still quite confused. He describes giant spiders and robots that torture him in his room. He describes an incessant voice screaming at him to run away. He also strongly dislikes his current medication and would like to try something else. Which of the following is indicated in this patient?

A. Haloperidol
B. Olanzapine
C. Chlorpromazine
D. Fluphenazine
E. Clozapine (Correct Answer)

Explanation: ***Clozapine*** - This patient has **treatment-resistant schizophrenia**, indicated by a lack of response to multiple trials of antipsychotics, including aripiprazole (atypical), haloperidol (typical), and loxapine (atypical). - **Clozapine** is the only antipsychotic proven effective for treatment-resistant schizophrenia, significantly reducing psychotic symptoms and suicidality. *Haloperidol* - Haloperidol is a **first-generation antipsychotic** that the patient has already tried and found to be too sedating and slow. - Continuing with haloperidol would likely result in persistent side effects and inadequate symptom control given his prior negative experience. *Olanzapine* - Olanzapine is a **second-generation atypical antipsychotic**; however, it is not typically indicated as a first-line treatment for treatment-resistant schizophrenia after failure of multiple agents. - While effective for schizophrenia, it would be less effective than clozapine in a patient who has failed several previous antipsychotic trials. *Chlorpromazine* - Chlorpromazine is a **first-generation antipsychotic** that carries a higher risk of sedation, extrapyramidal symptoms, and anticholinergic side effects. - It is unlikely to be more effective than haloperidol, which the patient already found too sedating and slow, and would not be the preferred choice for treatment-resistant schizophrenia. *Fluphenazine* - Fluphenazine is a **first-generation antipsychotic** with potent dopamine D2 receptor blockade, often leading to significant extrapyramidal side effects. - Like other first-generation antipsychotics, it is not indicated as the next step for treatment-resistant schizophrenia after failure of multiple trials.

Question 4: A 32-year-old man comes to the physician because of a 2 month history of difficulty sleeping and worsening fatigue. During this time, he has also had difficulty concentrating and remembering tasks at work as well as diminished interest in his hobbies. He has no suicidal or homicidal ideation. He does not have auditory or visual hallucinations. Vital signs are normal. Physical examination shows no abnormalities. Mental status examination shows a depressed mood and flat affect with slowed thinking and speech. The physician prescribes sertraline. Three weeks later, the patient comes to the physician again with only minor improvements in his symptoms. Which of the following is the most appropriate next step in management?

A. Augment with aripiprazole and continue sertraline
B. Provide electroconvulsive therapy
C. Continue sertraline for 3 more weeks (Correct Answer)
D. Change medication to duloxetine
E. Augment with phenelzine and continue sertraline

Explanation: ***Continue sertraline for 3 more weeks*** - Antidepressants like **sertraline** typically require **4 to 6 weeks** to reach their full therapeutic effect. - Since only three weeks have passed with minor improvements, the patient should continue the medication to allow time for the drug to work fully. *Augment with aripiprazole and continue sertraline* - **Augmentation** with an atypical antipsychotic like aripiprazole is considered if there is **no significant improvement after an adequate trial** (at least 6-8 weeks) of antidepressant monotherapy. - It is too early to consider augmentation as the patient has not completed a sufficient trial of sertraline. *Provide electroconvulsive therapy* - **Electroconvulsive therapy (ECT)** is reserved for **severe, treatment-resistant depression**, depression with psychotic features, or when rapid response is required (e.g., severe suicidality). - The patient's symptoms, while bothersome, do not meet criteria for severe, treatment-resistant depression or acute emergencies warranting ECT. *Change medication to duloxetine* - Changing antidepressants is usually considered if there is **minimal or no response** after an adequate trial of the initial medication. - Switching medications before allowing sufficient time for the current treatment to work is premature and may delay effective treatment. *Augment with phenelzine and continue sertraline* - **Phenelzine** is a **monoamine oxidase inhibitor (MAOI)**, and using it in combination with an **SSRI like sertraline** is contraindicated due to the risk of **serotonin syndrome**. - MAOIs are generally reserved for **refractory depression** due to their dietary restrictions and potential for severe drug interactions.

Question 5: A 24-year-old man with a history of schizophrenia presents for follow-up. The patient says that he is still having paranoia and visual hallucinations on his latest atypical antipsychotic medication. Past medical history is significant for schizophrenia diagnosed 1 year ago that failed to be adequately controlled on 2 separate atypical antipsychotic medications. The patient is switched to a typical antipsychotic medication. Which of the following is the mechanism of action of the medication that was most likely prescribed for this patient?

A. Dopaminergic receptor antagonist (Correct Answer)
B. Dopaminergic partial agonist
C. Serotonergic receptor agonist
D. Serotonergic receptor antagonist
E. Cholinergic receptor agonist

Explanation: ***Dopaminergic receptor antagonist*** - The patient has **treatment-resistant schizophrenia**, indicated by failure to respond to two different atypical antipsychotics. - Typical antipsychotics like **haloperidol** or **fluphenazine** are primarily **D2 dopamine receptor antagonists**, which may be used when a patient has not responded to atypical agents. - The **primary mechanism** of typical (first-generation) antipsychotics is **potent D2 receptor blockade** in the mesolimbic pathway, which reduces positive symptoms of schizophrenia. - Note: Clozapine would be the preferred choice for true treatment-resistant schizophrenia, but typical antipsychotics may still be considered in some clinical scenarios. *Dopaminergic partial agonist* - **Dopamine partial agonists**, such as **aripiprazole** or **brexpiprazole**, are **atypical antipsychotics** used for schizophrenia. - The patient has failed to respond to atypical antipsychotics already, making it unlikely that another atypical agent would be the next choice. - The question specifically states the patient is switched to a **typical antipsychotic**. *Serotonergic receptor agonist* - **Serotonin receptor agonists**, like LSD or psilocybin, are **not used** in the treatment of schizophrenia; they can, in fact, **induce psychotic symptoms**. - While some antipsychotics modulate serotonin receptors, their therapeutic effect is not through agonism of these receptors. *Serotonergic receptor antagonist* - Many **atypical antipsychotics** have significant **serotonin 5-HT2A receptor antagonist** activity, in addition to D2 antagonism. - However, the question states that the patient is being switched to a **typical antipsychotic**, whose primary and defining mechanism is **D2 antagonism**, not combined serotonin-dopamine antagonism. *Cholinergic receptor agonist* - **Cholinergic receptor agonists** are **not used** to treat schizophrenia and would likely worsen symptoms or cause significant side effects. - These agents would have no therapeutic benefit in psychosis and are not part of the antipsychotic drug class.

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

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.

Question 7: A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient is prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?

A. Ziprasidone (Correct Answer)
B. Clozapine
C. Chlorpromazine
D. Olanzapine
E. Clonazepam

Explanation: ***Ziprasidone*** - **Ziprasidone** causes minimal **weight gain** and has a lower risk of metabolic side effects compared to other antipsychotics, making it a good choice for a patient concerned about weight, especially with a BMI of 34 kg/m2. - It treats psychotic symptoms like hallucinations and can help manage anxiety associated with panic attacks. *Clozapine* - **Clozapine** is known for causing significant **weight gain** and metabolic disturbances, which would be a concern for this patient. - It is typically reserved for treatment-resistant schizophrenia due to its potential for serious side effects like **agranulocytosis**. *Chlorpromazine* - **Chlorpromazine** is a first-generation antipsychotic associated with a high risk of **extrapyramidal symptoms** (EPS) and sedation. - It can also lead to moderate **weight gain** and is generally not preferred as a first-line treatment if metabolic concerns are present. *Olanzapine* - **Olanzapine** is associated with a high risk of **weight gain** and metabolic syndrome, which would exacerbate the patient's existing weight concerns. - While effective for psychosis, its metabolic side effect profile makes it a less suitable choice in this scenario. *Clonazepam* - **Clonazepam** is a **benzodiazepine** primarily used for anxiety and panic attacks, but it is not an antipsychotic. - It would not address the patient's psychotic symptoms (seeing things not present in reality), which require an antipsychotic medication.

Question 8: A 30-year-old man presents to his psychiatrist for a follow-up visit. He was diagnosed with schizophrenia 6 months ago and has been taking fluphenazine. He says that his symptoms are well controlled by the medication, and he no longer has auditory hallucinations. The psychiatrist also notes that his delusions and other psychotic symptoms have improved significantly. However, the psychiatrist notices something while talking to the patient that prompts him to say, “I know the drug has effectively controlled your symptoms but I think you should discontinue it now otherwise this side effect is likely to be irreversible.” Which of the following did the psychiatrist most likely notice in this patient?

A. Choreoathetoid movements of face (Correct Answer)
B. Crossing and uncrossing legs constantly
C. Involuntary sustained twisting of neck
D. Resting tremors
E. Reduced spontaneous movements while walking

Explanation: ***Choreoathetoid movements of face*** - The psychiatrist is concerned about **tardive dyskinesia (TD)**, a late-onset side effect of dopamine receptor blocking agents like fluphenazine. Its hallmark symptoms include **choreoathetoid (involuntary, jerky, writhing) movements**, often affecting the face (e.g., lip smacking, grimacing, tongue protrusion). - TD can become **irreversible** if the offending medication is continued, necessitating drug discontinuation to prevent permanent motor dysfunction. *Reduced spontaneous movements while walking* - This symptom, along with a "shuffling gait" and **bradykinesia**, is characteristic of drug-induced **Parkinsonism**. - While concerning, Parkinsonism is generally **reversible** upon dose reduction or discontinuation of the antipsychotic, or with the addition of anticholinergic agents, making the psychiatrist's urgent warning about irreversibility less likely for this specific side effect. *Crossing and uncrossing legs constantly* - This behavior is indicative of **akathisia**, an inner sense of restlessness that manifests as an inability to sit still. - Akathisia is a common extrapyramidal side effect that is typically **reversible** with dose reduction, medication change, or treatment with beta-blockers, and is not usually considered irreversible like tardive dyskinesia. *Involuntary sustained twisting of neck* - This describes **dystonia**, an extrapyramidal side effect characterized by sustained or repetitive muscle contractions leading to abnormal postures, such as **torticollis** (twisting of the neck). - Dystonia, while distressing, is usually **reversible** with acute treatment (e.g., anticholinergics like benztropine) and medication adjustment, rarely becoming irreversible. *Resting tremors* - **Resting tremors** are a feature of drug-induced **Parkinsonism**, often accompanied by rigidity and bradykinesia. - Similar to other Parkinsonian symptoms, these tremors are generally **reversible** with appropriate medication management and are not typically considered an irreversible side effect if the offending drug is discontinued promptly.

Question 9: 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

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.

Question 10: A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

A. Panic Disorder (PD)
B. Generalized anxiety disorder (GAD)
C. Obsessive compulsive personality disorder (OCPD)
D. Obsessive compulsive disorder (OCD) (Correct Answer)
E. Tic disorder

Explanation: ***Obsessive compulsive disorder (OCD)*** - The patient's **recurrent distressing thoughts** about dirtiness (obsessions) and **repetitive cleaning behaviors** (compulsions) designed to reduce anxiety are hallmark symptoms of OCD. - The significant **emotional distress**, impact on daily life, and worsening stress despite the compulsions further support this diagnosis. *Panic Disorder (PD)* - Characterized by **recurrent, unexpected panic attacks** and persistent worry about additional attacks or their consequences. - While anxiety is present, the patient's primary distress is driven by specific obsessions and compulsions, not sudden episodes of intense fear. *Generalized anxiety disorder (GAD)* - Involves **excessive, uncontrollable worry** about a variety of events or activities for at least 6 months. - The anxiety symptoms are general, not focused on specific obsessions leading to compulsive behaviors as seen in this case. *Obsessive compulsive personality disorder (OCPD)* - Marked by pervasive patterns of **perfectionism, orderliness, and control** at the expense of flexibility and efficiency. - While there may be a preoccupation with rules, OCPD does not typically involve intrusive, ego-dystonic obsessions or ritualistic compulsions like repetitive cleaning to reduce anxiety. *Tic disorder* - Characterized by **sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations**. - Tics are distinct from the complex, goal-directed, and anxiety-driven compulsive behaviors described by the patient.

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