Final Review

A 48-year-old patient with depression was recently started on 20 mg/day fluoxetine to combat his presenting symptoms of apathy, fatigue, problems concentrating, and hypersomnia. The patient reports that he is feeling much more energized and can see improvements in his cognition and attention within a day or two of starting fluoxetine. Which of the following properties of fluoxetine is theoretically most likely responsible for this patient's positive response?

5HT2C antagonism

The prevalence of ADHD in children is ______, while in adults is_________ .

7-8%, 4-5%

A 24-year-old woman has been taking lithium to treat her bipolar disorder for 6 years. Lithium's hypothesized mechanism of action is:

A & B, Inhibition of second messenger enzymes/Interaction with downstream signal transduction cascades

Neuroimaging data show that neuronal activity in the amygdala of depressed patients is:

A & B, Overreactive to induced sadness/Underactive to induced happiness

During cognitive challenges, individuals with schizophrenia demonstrate:

A and B, Hypoactivation/Hyperactivation in the DLPFC

Which of the following is a perinatal risk factors associated with a diagnosis of ADHD?

All of the Above, Maternal Substance Abuse/Maternal Stress/Low Birth Weight

A 45-year-old patient has tried unsuccessfully to quit smoking several times over the past ten years. Nicotine's actions at which receptors are considered primarily responsible for its reinforcing effects?

Alpha 4 beta 2 postsynaptic receptors in the ventral tegmental area

The most prevalent dementia is ____________ accounting for ______percentage of dementia cases.

Alzheimer's disease, 60-70%

A 19-year-old female requires a hospital consultation, after she was admitted following an attempted suicide. Her family reports that she has been suffering from severe depression for the last 3 years. What area of the brain may best be described as hypothetically involved in her feelings of worthlessness and suicidality?

Amygdala

A 22-year-old man exhibits a fear response in reaction to unexpectedly encountering a bear while hiking. The various expressions of fear are hypothetically regulated by circuitry centered around the:

Amygdala

A 45-year-old female patient continues to maintain the re-experiencing of her fear of the opposite sex, which began one year ago when she was raped on her way to a parking garage. Which two brain regions are involved in the reciprocal relationship resulting in this symptom?

Amygdala and Hippocampus

Genetic susceptibility to late-onset AD is primarily linked to ____________.

Apolipoprotein E4 genotype

A patient with schizophrenia has been stabilized on medication but is complaining that he is so tired and sleepy all the time that he no longer wants to take it. Which of the following switching options might be the least likely to cause sedation?

Aripiprazole

A 24-year-old man with moderate depression achieves remission after 16 weeks on a therapeutic dose of an antidepressant. According to the neurotrophic hypothesis of depression, which of the following is most likely true of his BDNF expression before and after his successful treatment?

BDNF expression was abnormally low while he was depressed, and increased during antidepressant treatment

A 26-year-old man is being prescribed an atypical antipsychotic for first-episode schizophrenia. What measures should be taken by the mental health professional prior to prescribing and during treatment with the antipsychotic?

Blood pressure, BMI, fasting triglycerides, and fasting glucose

A 58-year-old patient with a history of depression is currently taking agomelatine, which has what mechanism of action?

Both of the above, Binding to melatonin receptors in the suprachiasmatic nucleus/Binding to 5HT2C receptors

Which of the following drug treatments for the agitated behavior often associated with dementia is best supported by evidence?

Carbamazepine

A 25-year-old patient with first-episode major depressive disorder is being prescribed an antidepressant. The time course for therapeutic effects of antidepressants correlates with:

Change in receptor sensitivity

The age class with the worst risk/benefit ratio for suicidality with use of antidepressants is:

Children under the age 12

A clinician is considering options for a 45-year-old man with severe treatment-resistant depression who has exhibited only partial response to first line and older generation antidepressants and who is unwilling to attempt electroconvulsive therapy or other stimulation therapy. One option, with extreme caution and under expert guidance, is to combine a monoamine oxidase inhibitor (MAOI) with a tricyclic antidepressant; however, which of the following should absolutely NOT be used in combination with an MAOI, even by an expert?

Clomipramine

A 26-year-old patient with ADHD has recently entered a drug rehabilitation center following arrest for possession of cocaine. The cocaine use in this patient may be an attempt at self-medication for ADHD symptoms because:

Cocaine has the same actions at the dopamine transporter as methylphenidate

What role does the amygdala play in substance abuse?

Communicates to the ventral tegmental area when cues related to drugs of abuse are present

Children with ADHD often have a smaller ____.

Cortex

A 25-year-old woman with longstanding anxiety is currently experiencing debilitating concerns that her children will be harmed whenever they are aware from her. Such worry is associated with activity in:

Cortico-striatal-thalamic-cortical circuits

A 21-year-old man with first-episode psychosis is prescribed an antipsychotic that has serotonin 2A antagonism. According to a leading hypothesis, blockade of serotonin 2A receptors in the cortex can ultimately increase dopamine in the striatum through what initial mechanism?

Decreased glutamate and thus decreased GABA in the brainstem

Which of the following is true about depression and reproductive hormones?

Depression is linked to estrogen levels in women across their life cycles

A 36-year-old man with depression has had 3 therapeutic trials of serotonin reuptake inhibitors (SRIs) without notable improvement. His clinician is now considering switching the patient's SRI to a monoamine oxidase inhibitor (MAOI). Which of the following is an appropriate switching strategy in this situation?

Discontinue SRI, then wait 5 half-lives before initiating MAOI

What neurotransmitter is associated with decreasing impulsivity?

Dopamine

A 34-year-old patient with schizophrenia is not responding to a standard dose of an antipsychotic. Which of the following might you suspect?

Dopamine 2 receptor occupancy less than 60%

Methylphenidate mechanism of action is to block ___________ and __________ reuptake by neurons.

Dopamine, Norepinephrine

A 27-year-old male who has been treated with risperidone for the last eight weeks is now having his medication changed to quetiapine. What is the recommended switching method in this situation, assuming the need to do this expeditiously, but not urgently, as an outpatient?

Down-titrate risperidone over at least 1 week while uptitrating quetiapine over at least 2 weeks

A mother whose daughter has just been diagnosed with major depressive disorder wants to know more about the underlying cause. Recent research largely supports the hypothesis that depression is due to a measurable deficiency of monoamines in the brain. True or False

False

ADHD in adults is fairly easy to diagnose based on set criteria in the DSM-V. True or False

False

In adults diagnosed with ADHD, stimulants are often prescribed as the first line treatment of choice. True or False

False

Schizophrenia and psychosis are synonymous. True or False

False

A patient presents to a new clinician with a major depressive episode. In addition to taking a patient's history, the two factors most useful for helping to determine if a presenting depressive episode is part of a unipolar or bipolar illness include:

Family history and input from someone close to the patient

A patient recently diagnosed with Alzheimer disease (AD) is showing signs of impaired reasoning. The PMHNP suspects an alteration in which area of the brain?

Frontal Lobe

The following cholinesterase used to treat Alzheimer's disease is found naturally in snowflakes and daffodils.

Galantamine

The activation of N-methyl-d-aspartate (NMDA) receptors requires the presence of:

Glutamate and glycine

The activation of AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid) receptors requires the presence of:

Glutamate only

The syndrome of bipolar disorder:

Has many varied presentations

The majority of atypical antipsychotics:

Have higher affinity for serotonin 2A receptors than for dopamine 2 receptors

A 24-year-old male initially presents with acute auditory hallucinations and is treated with medication. Four days later he arrives at your office for evaluation. You observe that he is neatly dressed, avoids eye contact, and gives very short answers to your initial questions. Which of the following questions would be most beneficial for determining his degree of negative symptoms?

How often have you visited with friends in the past week?

A leading hypothesis of schizophrenia is:

Hypofunctioning NDMA receptors

A 34-year-old woman with posttraumatic stress disorder has been treated with exposure therapy, with partial success. Her clinician is considering an adjunct medication. The agent d-cycloserine could be efficacious for reducing symptoms in anxiety disorders because it has been shown to:

Increase glutamate neurotransmission during fear extinction

A patient with generalized anxiety disorder is taking a benzodiazepine. What role do benzodiazepines play in GABA neurotransmission?

Increase it via positive allosteric modulation

Agents that block reuptake of norepinephrine have what effect on dopamine in the prefrontal cortex?

Increase its synaptic availability

A clinician has decided to administer an alpha 2 antagonist to his patient. Alpha 2 antagonists have what effect on neurotransmission?

Increase norepinephrine and increase serotonin

A 44-year-old patient has schizophrenia and comorbid alcohol abuse disorder. Alcohol has what effect on GABA and glutamate in the ventral tegmental area?

Increases GABA and decreases glutamate

A 32-year-old man with bipolar disorder has had a partial response to divalproex and is now being augmented with an atypical antipsychotic. The effects of atypical antipsychotics in nonpsychotic mania may be due to:

Indirect effects on glutamate release via serotonin 2A antagonism

A patient with bipolar II disorder responds well to monotherapy with lamotrigine. Lamotrigine's unique therapeutic profile in bipolar depression compared to other anticonvulsants appears to be hypothetically linked to its:

Inhibition of glutamate release

A 34-year-old man presents with a major depressive episode characterized by depressed mood, insomnia, problems concentrating, weight loss, and suicidal ideation. Which of the following symptoms is the most likely to be residual following otherwise successful treatment?

Insomnia

A 39-year-old patient with major depressive disorder presents to your office after several months of trying various antidepressant drugs. It is suggested that he try augmenting his current regimen with L-methylfolate. Why might L-methylfolate hypothetically boost the therapeutic efficacy of antidepressants?

It increases synthesis of monoamines

A 51-year-old male veteran with chronic PTSD has agreed to begin pharmacotherapy for his debilitating symptoms of arousal and anxiety associated with his experiences in Iraq two years ago. Which of the following would be appropriate as first-line pharmacologic treatment?

Klonopin

A 28-year-old woman presents with a depressive episode. She has previously been hospitalized and treated for a manic episode but is not currently taking any medication. Which of the following have the best evidence of efficacy to treat bipolar depression?

Lamotrigine, quetiapine

Tricyclic antidepressants, compared to newer antidepressants such as serotonin selective reuptake inhibitors or serotonin norepinephrine reuptake inhibitors, have:

Less favorable tolerability profile

A 35-year-old patient with bipolar disorder is currently experiencing a depressive episode that involves suicidal ideation. Which of the following mood stabilizers has shown efficacy for the prevention of suicide?

Lithium

A 32-year-old woman with bipolar I disorder has just found out that she is 6 weeks pregnant. Her mania has been stable on a combination of lithium, valproate, and olanzapine, but she is unsure about the safety of maintaining her medications during her pregnancy. Which of the following is true regarding medication use for bipolar disorder during pregnancy?

Lithium and valproate are associate with known risk for various fetal toxicities

Conventional antipsychotics may worsen negative symptoms, presumably through their actions in the:

Mesocortical and Mesolimbic pathways

Symptoms of schizophrenia are hypothetically attributable to malfunctioning in the:

Mesocortical and Mesolimbic pathways

Which of the following is considered the pleasure center of the brain?

Mesolimbic dopamine pathway

A 38-year-old woman was diagnosed with schizophrenia approximately two years ago and after multiple trials of different medications has been maintained on haloperidol for the last several months with good response. Two weeks ago she began exhibiting mild motor symptoms representative of parkinsonism. Which of the following would be the most appropriate adjunct medication for this patient?

Muscarinic 1 antagonist

What is the preferred initial treatment for agitation in Alzheimer's Disease, AD?

Nonpharmacological behavior modifications and interventions

ADHD is a disorder of dysregulation of ______ and ________ in the ___________.

Norepinephrine, Dopamine, Prefrontal Cortex

A 24-year-old woman is hospitalized after an altercation in which she screamed at and attacked her neighbor when he knocked on her door. Her mother reports that she has been increasingly erratic recently, with emotional outbursts and impulsive behavior. Which of the following brain regions is theoretically most closely associated with these symptoms?

Orbital frontal cortex

A 24-year-old man was diagnosed with generalized anxiety disorder 2 years ago and is now presenting with recurrent and spontaneous panic attacks. These anxiety disorders are hypothetically associated with:

Overlapping circuitry and neurotransmitters

A 35-year-old male Army veteran has been experiencing anxiety attacks during which he has difficulty breathing and increased heart rate. His symptom of difficulty breathing is hypothetically related to activation in the:

Parabrachial nucleus

A 22-year-old woman presents with schizophrenia characterized by the presence of positive, negative, cognitive, and affective symptoms. The symptom dimension of schizophrenia most effectively treated with antipsychotics is:

Positive symptoms

A 23-year-old female college student has gotten in significant trouble for her risky and impulsive behavior, stealing a fire extinguisher, driving on the common area lawn, and hostilely addressing a professor. Which of the following monoamine projections may account for her recent behavior? Projections to the:

Prefrontal cortex

A 34-year-old man with schizophrenia has a history of side effects and/or partial response with antipsychotics, including agitation with ziprasidone, sedation with quetiapine, orthostatic hypotension with risperidone, and gastrointestinal problems with aripiprazole. His clinician elects to prescribe iloperidone and begins treatment according to the dosing schedule in the label. What is the rationale for the slow dosing schedule with iloperidone?

Prevent orthostatic hypotension

A 35-year-old cigarette smoker would like to quit but is nervous because she typically craves a cigarette approximately every 2 hrs. The craving and withdrawal are due to:

Resensitization of nicotinic receptors

A 34-year-old patient with bipolar disorder has been taking lithium with some success, but is now experiencing a depressive episode that is not responding to treatment. Her clinician is considering adding an atypical antipsychotic. What shared mechanism of some atypical antipsychotics may be partially responsible for antidepressant effects?

Serotonin 1A partial agonism and serotonin 7 antagonism

A 24-year-old schizophrenia patient with prominent cognitive symptoms and social impairment is being evaluated for treatment. Her care provider is considering initiating ziprasidone, quetiapine, or aripiprazole, all of which share the property of serotonin 1A agonism. This receptor binding property is expected to have clinical effects in schizophrenia most similar to:

Serotonin 2A antagonism

Which of the following is the most potent property of trazodone?

Serotonin 2A antagonism

Patrick is a 22-year-old male who recently experienced a psychotic-like episode after trying MDMA (""ecstasy"") while at a party. A key binding site for hallucinogens is the:

Serotonin 2A receptor

A patient who has been taking an atypical antipsychotic for six months has experienced a 22-pound weight gain since baseline. Which of the following pharmacologic properties most likely underlies this patient's weight change?

Serotonin 2C antagonism and histamine 1 antagonism

A 40-year-old woman presents with a major depressive episode. Her clinician is considering prescribing the antidepressant vilazodone, which has what two major mechanisms of action?

Serotonin reuptake inhibition and serotonin 1A partial agonism

A 45-year-old female presents with a hand-washing compulsion and an obsession with air fresheners. Based on these symptoms, which of the following would lead to an increased risk of susceptibility to worry and anxiety disorders?

She may have been born with the catechol-O-methyltransferase (COMT) Met genotype

The PMHNP is assessing an elderly female who is disoriented to both time and place. Which additional finding would support a diagnosis of delirium?

Sudden onset of these sx, Attention is impaired, Rambling speech

Which of the following statements regarding mood symptoms is true?

Symptoms related to increased negative affect are hypothetically linked to serotonergic (and noradrenergic) dysfunction

Based on thorough evaluation of a patient and his history, his care provider intends to begin treatment with a conventional antipsychotic but has not selected a particular agent yet. Which of the following is most true about conventional antipsychotics?

They are very similar in therapeutic profile but differ in side-effect profile

A patient has been taking an atypical antipsychotic for 6 months. At his current appointment, his weight is unchanged since he began taking the antipsychotic. What can be predicted regarding his fasting triglyceride levels?

They cannot be predicted based on his weight

A 29-year-old patient is morbidly obese and reports that he is ""addicted to food"". Hunger circuitry is connected to reward circuitry via dopaminergic projections from the hypothalamus to the nucleus accumbens. True or False

True

Clients diagnosed with Alzheimer's disease show a decrease in glucose metabolism. True or False

True

Dopamine 2 partial agonists cause receptor output that is less than that caused by dopamine but more than that caused by a conventional antipsychotic. True or False

True

In children diagnosed with ADHD, stimulants are often prescribed as the first line treatment of choice. True or False

True

The reactive reward system signals the immediate prospect of pleasure or pain and triggers drug-seeking behavior. True or False

True

The pathophysiology of Alzheimer's disease is theorized to be___________.

Unknown at this time but with several theories.

A 44-year-old male with schizophrenia has been taking an antipsychotic medication since initial diagnosis twelve years ago. He has recently begun experiencing difficulty with fluid movement of his arms as well as involuntary facial grimaces. Which of the following likely underlies these symptoms?

Upregulation of dopamine 2 receptors

A patient with bipolar disorder responds to treatment with a mood stabilizing anticonvulsant agent. Which of the following has the strongest evidence of direct involvement in the mechanism of action of these agents?

Voltage-sensitive sodium channels