Antipsychotic Agents

A 50 year old noncompliant schizophrenic patient is being seen in your office after frequent and recurrent symptom exacerbations. He is currently prescribed 10mg of haloperidol and 100mg of depakote. You do not seen any evidence of TD or other EPS. The patient agrees to a trial of injectable haloperidol decanoate. Which of the following is the most appropriate starting dose of haloperidol decanoate? A. 100mg B. 50mg C. 300mg D. 200mg E. 250mg

A. 100mg The recommended dose of haldol decanoate is 10 to 15 times the previous daily oral dose administered IM monthly or every 4 weeks. In cases where the patient is at high risk for relapse, a starting dose of 20 times the previous oral dose can be utilized.

What is the effect of food on the bioavailability of ziprasidone (Geodon)? A. Increase in bioavailability B. Minimize gastric disease C. Decrease in bioavailability D. No change in bioavailability of ziprasidone E. None of the above

A. An increase in bioavailability Ziprasidones bioavailability increases by 2- fold when administered with food.

All of the following statements regarding neuroleptic-induced TD are true EXCEPT: A. Anticholinergic medications can decrease TD movements B. Clonazepam has shown to be useful in TD C. Clozapine can decrease TD movements D. Botulinum toxin is not a general treatment for TD E. Recognition of TD should be followed by immediate discontinuation of the antipsychotic medication

A. Anticholinergic medications can decrease TD movements. Anticholinergic medications are used in the treatment of EPS symptoms but may worsen TD movements by increasing the supersensitivity of dopamine receptors.

The typical, older antipsychotics would be least effective for which psychotic symptom? a. Apathy b. Pressured speech c. Paranoia d. Hallucinations e. Hearing voices

A. Apathy

All of the following are FDA-approved indications for aripiprazole EXCEPT: A. Bipolar disorder, depressed phase B. Bipolar disorder, manic phase C. Autistic disorder, psychomotor agitation D. Schizophrenia E. Adjunctive treatment in MDD

A. Bipolar disorder, depressed phase

Which of the following statements is/are TRUE regarding Clozapine (Clozaril)? A. Clozapine improves negative symptoms in schizophrenia B. Clozapine is effective in the management of treatment refractory (resistant) bipolar depression C. Clozapine is not associated with the development of neuroleptic malignant syndrome (NMS) D. The incidence of clozapine-induced agranulocytosis is about 5% E. All of the Above

A. Clozapine improves negative symptoms in schizophrenia Clozapine is effective in treatment-resistent schizophrenia and improves negative symptoms. Clozapine can cause NMS, although the presentation may be different from that of traditional antipsychotics. Clozpaine-induced NMS is less likely to manifest with extrapyramidal features such as rigidity and tremor. The incidence of clozapine-induced agranulocytosis is between 1 and 2%

A 26-year-old man is brought to the hospital by his wife who complains that her husband has been behaving oddly for the past few hours. The patient's wife says that she has known him for only 4 months. The wife is unable to give any past medical history. The patient's speech is difficult to follow, and he seems very distracted. After 15 minutes, he becomes agitated and starts to bang his head on a nearby pillar. He is admitted to the psychiatric ward and is given an emergency medication, after which he calms down. In the next 2 days, he continues to become agitated at times and required 2 more doses of the same drug. On the 4th day of admission, he appears very weak, confused, and does not respond to questions appropriately. His vital signs include: temperature 40.0°C (104.0°F), blood pressure 160/95 mm Hg, and pulse 114/min. On physical examination, he is profusely diaphoretic. He is unable to stand upright or even get up from his bed. Which of the following is the mechanism of action of the drug which most likely caused this patient's current condition? A. Dopamine receptor blocking B. Serotonin reuptake inhibition C. Agonistic effect on dopamine receptors D. Histamine H2 receptor blocking E. Skeletal muscle relaxation

A. Dopamine Receptor blocking

Which of the following antipsychotic medications is LEAST likely to cause orthostatic hypotension? A. Fluphenazine B. Thioridazine C. Clozapine D. Chlorpromazine (Thorazine) E. Olanzapine (Zyprexa)

A. Fluphenazine Fluphenazine belongs to the piperazine-phenothiazine class of antipsychotics. The drug has minimal alpha-adregeneric blocking effect and thus is less likely to cause postural hypotension

The concurrent use of risperidone and the lipid lowering agent simvastatin can lead to which of the following clinical scenarios? A. Increased risk of myopathy B. Reduction in the cholesterol lowering effectiveness of simvastatin C. Increased risk of EPS D. Lower serum risperidone concentrations and necessitate an increase dose of risperidone E. Additive cognitive side effects

A. Increased risk of myopathy

A 26 year-old female arrives in the emergency department with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and handing out $100 bills to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had a similar episode two years ago. Which of the following is the most appropriate treatment? A. Inpatient olanzapine (Zyprexa) therapy B. Inpatient electroconvulsive therapy C. Outpatient paroxetine (Paxil) therapy D. Outpatient psychotherapy

A. Inpatient olanzapine (Zyprexa) therapy Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants.

All of the following are risk factors of tardive dyskinesia (TD) EXCEPT: A. Male Sex B. Old age C. Affective disorder D. Diabetes mellitus E. Neuroleptic exposure for > 6 months

A. Male Sex Women are more at risk than men for Tardive dyskinesia. Elderly people, mental retardation, patients with substance abuse are also at increased risk. Diabetes has also been implicated as a risk factor.

Dantrolene has a role in the management of which of the following conditions? A. NMS B. Serotonin syndrome C. Catatonia D. Heat Stroke E. Metabolic myopathy

A. NMS

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 has 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 B. Olanzapine C. Clozapine D. Clonazepam E. Chlorpromazine

A. Ziprasidone

A patient is taking clozapine (Clozaril) and has showed to have a WBC of 1,800 and ANC of 700. The decision to stop Clozapine is made. You inform the patient that he may experience agitation, headache, nausea, or vomiting after the discontinuation of the medication. These symptoms are most likely to occur as a result of clozapine's action on which of the following receptors? A. Dopamine B. Muscuarinic C. Serotonergic D. Adrenergic E. Histaminergic

B Muscuarinic This is the classic presentation of cholinergic rebound associated with the abrupt cessation of clozapine

Peak plasma concentrations of IM olanzapine are typically reached in: A. 45 to 60 minutes B. 15 to 30 minutes C. 60 to 90 minutes D. < 15 minutes E. None of the above

B. 15 to 30 minutes

What is the estimated mortality rate with NMS? A. < 5% B. 20-30% C. 50-60% D. 5-10% E. 10-20%

B. 20-30%

What is the maxium recommended daily dose of intramuscular ziprasidone (Geodon)? A. 60mg per day B. 40mg per day C. 160mg per day D. 100mg per day E. 250mg per day

B. 40mg per day The recommended dose of IM ziprasidone is 10 to 20mg . The maximum recommended daily dose of IM ziprasidone is up to 40mg per day.

As per the ADA/APA consensus management guidelines, what is the recommended monitoring schedule for BMI for patients receiving atypical antipsychotics? A. Baseline, 12 weeks and annually B. Baseline, 4 weeks, 8 weeks, 12 weeks and quarterly C. Baseline, 4 weeks, 8 weeks, 12 weeks and annually D. Baseline, 8 weeks, quarterly and annually E. Baseline, quarterly and annually

B. Baseline, 4 weeks, 8 weeks, 12 weeks and quarterly

Which of the following atypical neuroleptic agents is known to have the LEAST EPS side effects? A. Olanzapine B. Clozapine C. Aripiprazole D. Ziprasidone E. Risperidone

B. Clozapine

Which of the following psychotropic drugs has the best evidence for decreasing the suicide risk in schizophrenia? A. Lithium B. Clozapine C. Aripiprazole D. Fluoxetine E. Olanzapine

B. Clozapine Clozapine reduces the risk of suicide by 75-80% in schizophrenic patients.

Treatment with which of the following antipsychotics has shown to have either a very rapid (< 6 weeks) or a delayed (6 weeks to 6 months) clinical response? A. Aripiprazole B. Clozapine C. Paliperidone D. Molindone E. Haloperidol

B. Clozapine In as study about Clozapine and it's effectiveness, about 30% of patients would respond by 6 weeks, a further 20% by 3 months and an additional 10-20% by 6 months.

A 45-year old man with treatment-resistant schizophrenia is started on clozapine. After 12 weeks of treatment with clozapine, his symptoms improve. However, his most recent WBC count is 1,800 per mm and his absolute neutrophil count is 900 mm. What is the most appropriate next step? A. Taper clozapine over 7 days and monitor his WBC and ANC for an additional 2 weeks B. Discontinue clozapine immediately and monitor WBC and ANC for 4 weeks C. Continue clozapine but obtain daily blood cell counts until WBC count is > 3,000 and the ANC is > 1,500 D. Continue clozapine and request a hematology consult E. Add recombinant granulocyte-monocyte-colony stimulating factor to his regimen

B. Discontinue clozapine immediately and monitor his WBC and ANC for 4 weeks. After discontinuation of clozapine, monitor WBC and AMNC for at least 4 weeks from day of discontinuation until they normalize. The following schedule is recommended until WBC > 3,000 and ANC > 1,500, twice weekly until WBC count is >3,500 and ANC count is > 2,000 and weekly after WBC count is > 3,500

A 22-year-old man presents to the emergency room after an altercation with the police. The police were called because the man was acting erratically in public. On physical examination, the patient is disoriented, does not respond to questioning, and appears to be reacting to internal stimuli. Laboratory tests are performed, which are all within normal limits, including a toxicology screen. The patient becomes aggressive and is given a medication to address his acute psychotic episode. An hour later, he is found in a sustained rigid posture in his bed, with his eyes in a fixed upward gaze. Which of the following medications was most likely given to this patient? A. Citalopram B. Haloperidol C. Phenelzine D. Olanzapine E. Alprazolam

B. Haloperidol

Which of the following mood stabilizers carries the risk of worsening psoriasis? A. Topiramate B. Lithium C. Risperidone D. Clonazepam E. Aripiprazole

B. Lithium

Postinjection delirium sedation syndrome (PDSS) is associated with which of the following depot antipsychotics? A. Risperidone depot preparation B. Olanzapine extended release injectable suspension C. Paliperidone palmitate D. Haloperidol deconate E. Zuclopenthixol acetate

B. Olanzapine extended release injectable suspension

All of the following statements regarding dystonia are true EXCEPT: A. It generally occurs within 4 to 7 days B. Old age is a major risk factor C. It is not seen with clozapine therapy D. Tardive dystonia responds well to clozapine E. Dystonia generally occurs after an increase in the neuroleptic dose.

B. Old age is a major risk factor Neuroleptic induced acute dystonia occurs frequently in young men. Risk factors are prior dystonic reactions to neuroleptic agents and the use of high potency typical antipsychotics. The signs and symptoms start within 7 days or when rapidly raising the dose of the antipsychotic. Generally, neuroleptic induced dystonia is not seen with clozpaine therapy and Tardive Dystonia usually responds well to clozapine.

Which of the following antipsychotic medications has the highest selectivity and potency for dopamine D2 receptors? A. Quetiapine B. Pimozide C. Loxapine D. Thioridazine E. Ziprasidone

B. Pimozide Pimozide is a highly selective blocker of D2 receptors. Quetiapine, Loxapine, Thioridazine and Ziprasidone all antagonize D2 receptors however, not as strongly as Pimozide.

Which of the following plasma clozapine (Clozaril) levels may be a useful guide to optimally efficacious dosage? A. Plasma levels > 200 B. Plasma levels > 350 C. Plasma levels > 450 D. Plasma levels > 500 E. Plasma levels > 550

B. Plasma levels > 350 Plasma levels > 350 suggests efficacious dosage.

A 55 year old white male with major depression and new onset psychotic features is started on risperidone. He has been taking 40mg citalopram for the past 4 months with partial symptom relief. His medical history is significant for closed-angle glaucoma and nocturnal polyuria. Within a week of taking risperidone, he develops perioral tremors. What is the most appropriate diagnosis of his tremor? A. Akinesia B. Rabbit syndrome C. TD D. Akathisia E. Drug-induced parkinsonism

B. Rabbit Syndrome Rabbit syndrome presents as focal perioral tremor that develops in patients taking dopamine antagonists

Which of the following medications is FDA approved for the treatment of irritability associated with autistic disorder? A. Olanzapine B. Risperidone C. Quetiapine D. Ziprasidone E. Asenapine

B. Risperidone Risperidone is FDA approved for the treatment of irritability associated with autistic disorder.

A patient is started on a new antipsychotic medication for his disorder. Three days later he develops altered consciousness, lead-pipe rigidity, diaphoresis and catatonia. Vital signs reveal respiratory rate of 20, temperature of 105.6 degrees F, and pulse oximetry of 95% room air. Which of the following would be the most appropriate initial intervention in this patient? A. Immediate oral SSRI's and Benadryl B. Supportive care with fluids and antipyretics C. IV antibiotics and naloxone D. Intubation and mechanical ventilation

B. Supportive care with fluids and antipyretics Neuroleptic malignant syndrome is characterized by extrapyramidal signs, blood pressure changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, cardiovascular instability, fever, pulmonary congestion and diaphoresis. Controlling fever and fluid support are the best initial management. With a normal pulse oximetry mechanical ventilation is not indicated.

Which of the following drugs has shown to cause the most QTc prolongation at therapeutic doses? A. Olanzapine B. Thioridazine C. Haloperidol D. Ziprasidone E. Risperidone

B. Thioridazine Thioridazine causes the MOST QTc prolongation at therapeutic doses. Haloperidol causes the LEAST QTc prolongation at therapeutic doses.

Which of the following antipsychotic drugs can cause pigmentary retinopathy? A. Chlorpromazine B. Thioridazine C. Quetiapine D. Molindone E. Olanzapine

B. Thioridazine Thioridazine is known to cause retinal pigmentation and visual impairment and is usually dose related.

A 34-year old man presents with major depressive features and psychotic symptoms. He has comorbid OCD symptoms. He is currently on 40mg citalopram and 10mg zolpidem. You decide to start him on 2mg of risperidone (Risperdal). He has no personal or family history of diabetes or other metabolic problems. Per the American Diabetes Association/ American Psychiatric Association consensus management guidelines, what is the recommended monitoring schedule for fasting plasma glucose levels in this patient? A. Baseline, 4 weeks, 12 weeks and annually B. Baseline, 8 weeks, 12 weeks and annually C. Baseline, 12 weeks and annually D. Baseline, 8 weeks, quarterly and annually E. Baseline, quarterly and annually

C Baseline, 12 weeks and annually The monitoring protocol for patients on atypical antipsychotics include fasting plasma glucose at baseline, 12 weeks and then annually. This should be done more frequently in patients with a higher baseline risk for diabetes.

Risperidone's therapeutic efficacy is related to its antagonism of dopamine type 2 and serotonin type 2 receptors. The drugs side effect of orthostatic hypotension is related to its binding affinity for which of the following receptor sites? A. H1 histaminergic receptors B. M1 muscuarinic receptors C. Alpha-adrenergic receptors D. Beta-adrenergic receptors E. Serotonin 5HT3 receptors

C. Alpha-adrenergic receptors Some side effects of risperidone may be explained by antagonistic effects at Histamine (somnolence) and alpha-adrenergic receptors (orthostatic hypotension).

What is the treatment for new onset perioral tremors after starting an antipsychotic medication? A. Trihexyphenidyl B. Benztropine C. Amantadine D. Procyclidine E. Diphenhydramine

C. Amantadine

All of the following statements accurately describe the neuromolecular effects of asenapine (Saphris) EXCEPT: A. Antagonism at serotonergic receptor B. Antagonism at dopaminergic receptor C. Antagonism at muscarinic receptors D. Antagonism at adrenergic receptor E. Partial agonist at the 5-HT 2A receptor

C. Antagonism at muscuarinic receptors Asenapine is an antagonist at the D2 and 5-HT receptors. It antagonizes adrenergic receptors but has no affinity towards muscarinic receptors.

All of the following antipsychotic agents have the potential to increase prolactin levels EXCEPT: A. Risperidone (Risperdal) B. Ziprasidone (Geodon) C. Aripiprazole (Abilify) D. Paliperidone (Invega) E. Quetiapine (Seroquel)

C. Aripiprazole

Which of the following medications carries a BLACK BOX warning for suicidal thinking and behavior in adults? A. Risperidone B. Ziprasidone C. Aripiprazole D. Olanzapine E. All of the above

C. Aripiprazole Aripiprazole is FDA approved for use as adjunctive treatment to antidepressants for major depressive disorder and it carries the Black Box warning for suicide risk.

Which of the following is used in the management of neuroleptic-induced dystonia? A. Phencyclidine B. Propranolol C. Benztropine D. Phenobarbital E. All of the above

C. Benztropine

All of the following are true regarding aripiprazole EXCEPT: A. It is a dopamine-serotonin system stabilizer B. Partial agonist at D2 C. Full agonist at 5-HT 2A D. Partial agonist at 5-HT 1A E. None of the above

C. Full agonist at 5 HT 1A

Which of the following antipsychotic medications when given orally causes the LEAST QTc prolongation at therapeutic doses? A. Risperidone B. Quetiapine C. Haloperidol D. Ziprasidone E. Olanzapine

C. Haloperidol

Which of the following antipsychotic medications has the lowest propensity to lower the seizure threshold? A. Haloperidol B. Chlorpromazine C. Molindone D. Clozapine E. None of the above

C. Molindone Molindone has the lowest propensity to lower the seizure threshold. Among the atypical antipsychotics, Clozapine has the greatest risk of inducing seizures

All of the following antipsychotic-induced adverse effects related to dopamine antagonism EXCEPT: A. Galactorrhea B. NMS C. Premature ejaculation D. Bone loss E. None of the above

C. Premature ejaculation

Which of the following medications is the best choice in the treatment for psychosis in Parkinson disease? A. Ziprasidone B. Olanzapine C. Quetiapine D. Risperidone E. Haloperidol

C. Quetiapine

Which of the following statements regarding dosing guidelines for long-acting risperidone depot preparation is/are TRUE? A. Dose adjustments can be made every 2 weeks B. Oral supplementation with oral antipsychotic must continue for the first week of therapy C. The maximum dose should not exceed 50mg every 2 weeks D. Clinical effect from dosage adjustment can be expected within a week following the injection of the higher dose E. All of the Above

C. The maximum dose should not exceed 50mg every 2 weeks. Oral supplementation with oral risperidone must continue for the first 3 weeks of therapy. When dose adjustment is made, clinical effects are expected after 3 weeks of the change. Steady plasma concentrations are achieved after the 4th injection, therefore dose adjustment cannot be made every 2 weeks.

All of the following are antipsychotics belonging to the phenothiazine class EXCEPT: A. Trifluoperazine B. Chlorpromazine C. Thiothixene D. Mesoridazine E. Fluphenazine

C. Thiothixene Thiothixene is a typical antipsychotic medication of the thioxanthene class. All of the others listed are phenothizaine class of neuroleptics.

All of the following are low-potency typical (conventional) antipsychotic drugs EXCEPT: A. Thioridazine B. Chlorpromazine C. Trifluperzine D. Mesoridazine E. Triflupromazine

C. Trifluperzine Trifluperazine, thiothixene, haloperadol and pimozide are all high potency antipsychotics.

Which of the following drugs has the greatest risk of QTc prolongation? A. Risperidone B. Quetiapine C. Ziprasidone D. Olanzapine E. Aripiprazole

C. Ziprasidone

Which of the following statements is FALSE regarding creatinine phosphokinase (CPK) elevations associated with NMS? A. Significant CPK elevations can occur with IM injections, physical restraints and agitation B. Mild to moderate CPK elevation is not specific for NMS C. CPK elevation > 1000 is more specific for NMS D. Absence of CPK elevation rules out diagnosis of NMS E. CPK elevation in NMS may vary between 1,000 and as high as 10,000

D. Absence of CPK elevation RULES out diagnosis of NMS All of the other answers are TRUE regarding CPK levels and NMS.

Your 28-year old male cousin has recently been diagnosed with schizophrenia. Select the TRUE statement. A. Untreated schizophrenics have low levels of brain dopamine B. Untreated schizophrenics have high levels of serotonin receptors C. All drugs in schizophrenia act at the D2 receptor D. An unintended side effect of high doses of antipsychotic medications can be Parkinson's disease kind of syndrome with bradykinesia and masked face

D. An unintended side effect of high doses of antipsychotic medications can be Parkinson's disease kind of syndrome with bradykinesia and masked face

Which of the following is NOT a characteristic of the typical antipsychotic medications? a. Delayed effect (weeks) b. Blocks D2 receptors c. Long half-life d. Blocks D1 and D2 receptors e. Easily cross the blood-brain barrier

D. Blocks D1 AND D2 receptors

A 37-year-old woman presents with a 3-day history of fever. Past medical history is significant for chronic schizophrenia, managed with an antipsychotic medication. The patient has a low-grade fever and is slightly tachycardic. Physical examination is significant for the presence of tonsillar exudates. A CBC shows a markedly decreased WBC count. The patient's antipsychotic medication is immediately discontinued. Which of the following is the antipsychotic medication that could have caused this problem? A. Quetiapine B. Olanzapine C. Risperidone D. Clozapine E. Haloperidol

D. Clozapine

A 25 year-old male on a behavioral medicine unit is given haloperidol (Haldol) IM for a violent psychotic outburst. Initially he quiets down, but about an hour later develops confusion, an inability to open his mouth, and a temperature of 40 degrees C. Initial treatment should consist of which of the following? A. Additional Haldol B. Corticosteroid C. Benzodiazepine D. Dantrolene

D. Dantrolene In addition to supportive treatment, the most commonly used medications for neuroleptic malignant syndrome are dantrolene (Dantrium) and bromocriptine (Parlodel).

Phentolamine is the treatment of choice for which of the following conditions? A. Serotonin syndrome B. Malignant hyperthermia C. NMS D. Hypertensive crisis associated with MAOI and tyramine ingestion E. Catatonia

D. Hypertensive crisis associated with MAOI and tyramine ingestion

By measuring their plasma drug levels, all of the following psychotropic agents may be clinically useful for optimal efficacious dosing EXCEPT: A. Lithium B. Valproic Acid C. Notriptyline D. Lamotrigine E. Clozapine

D. Lamotrigine By measuring the plasma serum levels of Lithium, Valproic Acid, Nortriptyline and Clozapine optimal efficacious dosing may be assessed. Plasma levels for Lamotrigine are no checked/ monitored.

A patient with treatment resistant schizophrenia is being considered for clozapine therapy. His current medications are risperidone, clonazepam, lithium, quetiapine and benztropine. Which of the following medications when given with clozapine has the potential to increase the risk of asterixis (hand tremors when the wrist is flexed)? A. Clonazepam B. Benztropine C. Risperidone D. Lithium E. Quetiapine

D. Lithium Risperidone when administered with clozapine may decrease the risperidone clearance. Concurrent use of clozapine and benztropine may result in increased anticholinergic effects. There is no drug-drug interactions noted with quetiapine. Clozapine when taken concurrently with Lithium can increase the risk of asterixis.

Weight gain is NOT a problem with which of the following antipsychotics? A. Olanzapine B. Risperidone C. Quetiapine D. Molindone E. Chlorpromazine

D. Molindone Molindone causes weight loss and chlorpromazine causes weight gain. the other antipsychotics are also known to cause weight gain.

Which of the following antipsychotics has the lowest risk of weight gain as a side effect after treatment? A. Aripiprazole (Abilify) B. Ziprasidone (Geodon) C. Quetiapine (Seroquel) D. Molindone (Moban) E. Paliperidone (Invega)

D. Molindone Molindone is an intermediate potency conventional antipsychotic that tends to decrease appetite and even cause weight loss.

Which of the following drugs is first-line therapy for schizophrenia? A Chlorpromazine (Thorazine) B Clozapine (Clozaril) C. Haloperidol (Haldol) D. Olanzapine (Zyprexa)

D. Olanzapine (Zyprexa) Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.

All of the following can be used in the treatment of neuroleptic induced akathisia EXCEPT: A. Benzodiazepines B. Propranolol C. Clonidine D. Prochlorperazine E. Benztropine

D. Prochlorperazine Neurolpetic induced akathisia is the least well understood EPS. Prochlorperazine can actually cause akathisia and hence cannot be used in the management of it.

Which of the following antipsychotics is approved as monotherapy for bipolar depression? A. Ziprasidone B. Aripiprazole C. Olanzapine D. Quetiapine E. Lurasidone

D. Quetiapine

A 43-year-old woman presents for a routine checkup. She says she has been uncontrollably grimacing and smacking her lips for the past 2 months, and these symptoms have been getting progressively worse. Past medical history is significant for schizophrenia, managed medically with clozapine. Which of the following is the most likely diagnosis in this patient? A. Torticollis B. Oculogyric crisis C. Tourette's syndrome D. Tardive dyskinesia E. Trismus

D. Tardive dyskinesia

Atypical antipsychotics increase the risk of which of the following? A. Type 2 diabetes mellitus B. Weight gain C. Risk of strokes in elderly patients D. Hyperlipidemia E. All of the above

E. All of the above

Clozapine is associated with which of the following cardiovascular effects? A. QTc prolongation B. Myocarditis C. Cardiomyopathy D. Pericarditis E. All of the above

E. All of the above

Management of akathisia includes the following: A. Propranolol B. Lowering the neuroleptic dose C. Clonazepam D. Diphenhydramine E. All of the above

E. All of the above

Under which of the following conditions would ziprasidone be life threatening? A. QTc > 500 milliseconds B. Heart failure C. Arrhythmias D. Recent myocardial infarction E. All of the above

E. All of the above

Which of the following features is associated with Postinjection Delirium Sedation Syndrome? A. General malaise B. Ataxia C. Dysarthria D. Disorientation E. All of the above

E. All of the above

Which of the following is TRUE regarding Neuroleptic Malignant Syndrome (NMS)? A. The risk for recurrence on re-exposure to neuroleptic is approximately 30% B. Recurrence of NMS may be minimized by delaying re-challenge by 2 weeks post NMS C. A comorbid diagnosis of affective disorder is a risk factor for NMS D. Dehydration is a risk factor for NMS E. All of the above

E. All of the above

Which of the following is TRUE regarding prolactin level during neuroleptic therapy? A. Risperidone increases the prolactin level the MOST among the atypical neuroleptics B. Clozapine has the least effect on prolactin therapy C. Aripiprazole can be used to minimize neuroleptic-induced prolactin elevation D. Typical antipsychotics are associated with persistently elevated prolactin level E. All of the above

E. All of the above

Which of the following is a dopamine receptor agonist? A. Pergolide B. Ropinirole C. Bromocriptine D. Pramipexole E. All of the above

E. All of the above

Which of the following is the most appropriate treatment for clozapine induced hyper-salivation ? A. Dose reduction B. Chewing gum C. Anticholinergic agents D. alpha-agonist E. All of the above

E. All of the above

Which of the following is/are TRUE regarding drug interactions with olanzapine extended release injectable suspension? A. Carbamazepine increases the clearance of olanzapine B. Fluvoxamine might increase olazapine levels C. Valproic Acid may result in decreased olanzapine plasma concentrations D. Injections are only for IM use and should not be given intravenously E. All of the above

E. All of the above

Which of the following neurotransmitters is postulated to mediate changes in weight associated with psychotropic drugs? A. Histamine B. Serotonin C. Dopamine D. Norepinephrine E. All of the above

E. All of the above

Which of the following statements is TRUE regarding clozapine? A. Improve polydipsia and hyponatremia B. Improve negative symptoms of schizophrenia C. Stablize mood D. Reduce hostility and aggression E. All of the above

E. All of the above

Which of the following medications should be avoided in a patient taking clozapine? A. Captopril B. Carbamazepine C. Sulfonamides D. Propylthiouracil E. All of the above

E. All of the above Clozapine when combined with catopril, sulfonamides, prophyltiouracil or carbamazepine inceases the risk of bone marrow suppression and agranulocytosis. Carbamazepine may decrease the level of clozapine by up to 60% when administered together.

Electrocardiographic (ECG) changes occur with which of the following antipsychotic drugs' therapy? A. Thioridazine B. Pimozide C. Chlorpromazine D. Ziprasidone E. All of the above

E. All of the above EKG changes occur with all of the listed medications.

All of the following are risk factors for NMS: A. Dehydration B. Agitation C. Low serum iron D. Potency of neuroleptic E. All of the above

E. All of the above Suggested risks for NMS include male sex, young age, previous NMS agitation requiring restraints, low serum iron and prolonged use of high potency neuroleptics.

A 56-year-old man presents with constipation and trouble urinating for the past day. He says that he tried drinking a lot of water but that did not help. He also says that he has been tired all the time recently. Past medical history is significant for schizophrenia, diagnosed 3 months ago, and being managed on antipsychotic medication. Current medications also include sildenafil. The vital signs include blood pressure 80/45 mm Hg, respiratory rate 23/min, heart rate 86/min and temperature 38.7°C (101.7°F). On physical examination, the patient appears agitated and confused. Which of the following medications is the most likely cause of this patient's presentation? A. Lithium B. Haloperidol C. Ziprasidone D. Aripiprazole E. Chlorpromazine

E. Chlorpromazine RATIONALE Chlorpromazine is 1 of the older typical antipsychotic drugs. It also acts as a muscarinic antagonist, so it would lead to typical atropine-like effects noticed in this patient (i.e. constipation, urinary retention, etc.). ---Chlorpromazine causes strong sedation and orthostatic hypotension due to its blockade of histamine and alpha receptors, respectively. There are 2 groups of antipsychotics: typical and atypical antipsychotic drugs. -Haloperidol, ziprasidone, and aripiprazole do not affect muscarinic receptors. The use of haloperidol would not cause constipation or urinary retention, but, on the contrary, would lead to strong extrapyramidal effects.

All of the following are criteria for treatment-refractory schizophrenia EXCEPT: A. No episodes of good functioning in the previous 5 years B. Total Brief Psychiatric Rating Scale score of >45 C. Failure to respond to at least 3 antipsychotic trials from two different chemical class of adequate duration and dose D. Failure to tolerate trial of haloperidol E. Failure to respond to a trial of long-acting injectable psychotic agent

E. Failure to respond to a trial of long-acting injectable psychotic agent.

As per the ADA/APA consensus guidelines, all of the following are recommended metabolic monitoring guidelines for patients either starting or changing atypical antipsychotics EXCEPT: A. Monitor BMI at baseline, 4,8 and 12 weeks and quarterly thereafter B. Monitor fasting blood glucose at baseline, 12 weeks and annually C. Monitor fasting lipid profile at baseline, 12 weeks and annually D. Monitor BP at baseline, 12 weeks and annually E. Monitor TSH at baseline and annually

E. Monitor TSH at baseline and annually. One of the major concerns with atypical antipsychotic usage is their metabolic side effects such as weight gain, hyperglycemia, and diabetes. ADA/APA consensus guidelines recommend monitoring fasting plasma glucose and lipid profile at baseline, 3 months and annually. BMI should also be measured on a monthly basis for 3 months and then quarterly thereafter. TSH is not monitored.