MCQ Quiz: Anxiety and Sleep-Wake Disorders

Welcome, pharmacy students! This quiz focuses on the management of anxiety and sleep-wake disorders, a core topic within the Patient Care VII: Brain and Behavior module. A pharmacist’s expertise is crucial for ensuring the safe and effective use of anxiolytics, hypnotics, and other related medications. The following 50 questions will test your knowledge of the background, etiology, medicinal chemistry, pharmacology, and management of these prevalent conditions, aligning with the principles taught in your PharmD curriculum. Let’s assess your understanding of these complex therapeutic areas.

1. What is the primary mechanism of action for benzodiazepines in treating anxiety?

• A. They are direct agonists at the GABA-A receptor.
• B. They are positive allosteric modulators of the GABA-A receptor, increasing the frequency of chloride channel opening.
• C. They block the reuptake of serotonin and norepinephrine.
• D. They are antagonists at the dopamine D2 receptor.

Answer: B. They are positive allosteric modulators of the GABA-A receptor, increasing the frequency of chloride channel opening.

2. Which class of medications is considered first-line for the long-term management of Generalized Anxiety Disorder (GAD)?

• A. Benzodiazepines
• B. Typical Antipsychotics
• C. SSRIs and SNRIs
• D. Barbiturates

Answer: C. SSRIs and SNRIs

3. The non-benzodiazepine hypnotics, or “Z-drugs” (e.g., zolpidem), show more selectivity for which subunit of the GABA-A receptor, contributing to their sedative effects with less anxiolytic action?

• A. Alpha-1 subunit
• B. Alpha-2 subunit
• C. Gamma subunit
• D. Beta subunit

Answer: A. Alpha-1 subunit

4. A patient presents with a prescription for prazosin to be taken at bedtime. This medication is often used in the management of Post-Traumatic Stress Disorder (PTSD) to target which specific symptom?

• A. Depressive mood
• B. Flashbacks
• C. Nightmares
• D. Avoidance behaviors

Answer: C. Nightmares

5. Buspirone is a unique anxiolytic. What is its primary mechanism of action?

• A. Partial agonism at the serotonin 5-HT1A receptor.
• B. Potentiation of GABAergic neurotransmission.
• C. Inhibition of norepinephrine reuptake.
• D. Blockade of histamine H1 receptors.

Answer: A. Partial agonism at the serotonin 5-HT1A receptor.

6. From a medicinal chemistry perspective, the core structure of all benzodiazepines includes:

• A. A benzene ring fused to a seven-membered diazepine ring.
• B. A tricyclic dibenzazepine system.
• C. A phenethylamine skeleton.
• D. A triazolopyridine ring.

Answer: A. A benzene ring fused to a seven-membered diazepine ring.

7. Which of the following is a key non-pharmacological counseling point for a patient with insomnia?

• A. Drink a caffeinated beverage before bed.
• B. Engage in stimulating activities like watching TV in bed.
• C. Maintain good sleep hygiene, such as having a consistent sleep-wake schedule.
• D. Take long naps late in the afternoon.

Answer: C. Maintain good sleep hygiene, such as having a consistent sleep-wake schedule.

8. Suvorexant (Belsomra) is a hypnotic with a novel mechanism of action. It works by:

• A. Antagonizing orexin receptors, which promotes wakefulness.
• B. Agonizing melatonin receptors.
• C. Blocking histamine H1 receptors.
• D. Potentiating GABA.

Answer: A. Antagonizing orexin receptors, which promotes wakefulness.

9. The pharmacotherapy for Obsessive-Compulsive Disorder (OCD) often requires what dosing strategy with SSRIs compared to their use in depression?

• A. Lower doses
• B. The same doses
• C. Higher doses
• D. Pulsed dosing

Answer: C. Higher doses

10. Which over-the-counter (OTC) medication is commonly used for sleep and exerts its effect through H1 histamine receptor antagonism?

• A. Ibuprofen
• B. Melatonin
• C. Diphenhydramine
• D. Pseudoephedrine

Answer: C. Diphenhydramine

11. A major counseling point for a patient taking any benzodiazepine or Z-drug is to avoid concomitant use of what substance due to the risk of profound CNS depression?

• A. Grapefruit juice
• B. Leafy green vegetables
• C. Alcohol
• D. High-protein meals

Answer: C. Alcohol

12. The pharmacologic management of narcolepsy, a sleep-wake disorder, often involves the use of which type of agent to improve wakefulness?

• A. Sedating antidepressants
• B. Stimulants, such as modafinil or armodafinil
• C. Benzodiazepines
• D. Antihistamines

Answer: B. Stimulants, such as modafinil or armodafinil

13. A patient who has been taking alprazolam 1mg three times a day for six months should be counseled to:

• A. Stop the medication abruptly when they feel better.
• B. Not stop the medication without consulting their prescriber due to the risk of withdrawal symptoms.
• C. Double the dose if they feel anxious.
• D. Take the medication only when needed for panic attacks.

Answer: B. Not stop the medication without consulting their prescriber due to the risk of withdrawal symptoms.

14. What is a key pharmacodynamic difference between buspirone and benzodiazepines?

• A. Buspirone has a rapid onset of action for anxiety.
• B. Buspirone has a high potential for abuse and dependence.
• C. Buspirone’s anxiolytic effects may be delayed for several weeks.
• D. Buspirone is also an effective hypnotic.

Answer: C. Buspirone’s anxiolytic effects may be delayed for several weeks.

15. Restless Legs Syndrome (RLS) is a sleep-wake disorder. First-line therapy often includes:

• A. High-dose SSRIs.
• B. Dopamine agonists like pramipexole or ropinirole.
• C. Typical antipsychotics.
• D. Orexin receptor antagonists.

Answer: B. Dopamine agonists like pramipexole or ropinirole.

16. Which benzodiazepines undergo Phase II metabolism (glucuronidation) directly, making them potentially safer choices in elderly patients or those with liver impairment?

• A. Diazepam and chlordiazepoxide
• B. Lorazepam, oxazepam, and temazepam (LOT)
• C. Alprazolam and clonazepam
• D. Flurazepam and quazepam

Answer: B. Lorazepam, oxazepam, and temazepam (LOT)

17. A patient should be counseled about the risk of complex sleep-related behaviors, such as sleep-driving or sleep-eating, with which class of medication?

• A. SNRIs
• B. Z-drugs (e.g., zolpidem)
• C. Beta-blockers
• D. Statins

Answer: B. Z-drugs (e.g., zolpidem)

18. What is the role of beta-blockers, like propranolol, in the management of anxiety?

• A. They are first-line for long-term treatment of GAD.
• B. They can be used to control the peripheral autonomic symptoms of anxiety, such as tremor and tachycardia, especially in performance anxiety.
• C. They work by modulating GABA receptors.
• D. They are primarily used to treat the underlying cause of anxiety.

Answer: B. They can be used to control the peripheral autonomic symptoms of anxiety, such as tremor and tachycardia, especially in performance anxiety.

19. Which herbal supplement is commonly used for anxiety but carries a significant risk of hepatotoxicity and should be used with extreme caution, if at all?

• A. Melatonin
• B. St. John’s Wort
• C. Valerian
• D. Kava

Answer: D. Kava

20. The management of panic disorder involves both pharmacotherapy and psychotherapy. Which type of therapy is highly effective for panic disorder?

• A. Psychoanalysis
• B. Cognitive Behavioral Therapy (CBT)
• C. Hypnotherapy
• D. Art therapy

Answer: B. Cognitive Behavioral Therapy (CBT)

21. Ramelteon (Rozerem) is a hypnotic that is not a controlled substance. Its mechanism of action is:

• A. Potentiation of GABA.
• B. Selective agonism at melatonin (MT1 and MT2) receptors.
• C. Blockade of histamine H1 receptors.
• D. Partial agonism at the 5-HT1A receptor.

Answer: B. Selective agonism at melatonin (MT1 and MT2) receptors.

22. Which of the following is a common activating side effect when starting an SSRI for an anxiety disorder, often requiring a “start low, go slow” approach?

• A. Sedation
• B. Initial increase in anxiety or jitteriness
• C. Weight gain
• D. Constipation

Answer: B. Initial increase in anxiety or jitteriness

23. From a medicinal chemistry standpoint, the anxiolytic, sedative, and muscle relaxant effects of benzodiazepines are all mediated through their interaction with:

• A. A single, uniform receptor type.
• B. The same allosteric site on different subtypes of the GABA-A receptor complex.
• C. The norepinephrine transporter.
• D. Voltage-gated calcium channels.

Answer: B. The same allosteric site on different subtypes of the GABA-A receptor complex.

24. Which tricyclic antidepressant is often used at low doses for insomnia due to its potent antihistaminic properties?

• A. Desipramine
• B. Protriptyline
• C. Doxepin
• D. Imipramine

Answer: C. Doxepin

25. A patient with a history of substance use disorder requires treatment for GAD. Which medication would be a safer long-term option than a benzodiazepine?

• A. An SSRI or buspirone
• B. Alprazolam
• C. Clonazepam
• D. A high-potency opioid

Answer: A. An SSRI or buspirone

26. The half-life of a benzodiazepine determines its duration of action and its potential for certain side effects. A drug with a long half-life, like diazepam, has a higher risk of:

• A. Inter-dose rebound anxiety.
• B. A severe but short-lived withdrawal syndrome.
• C. Next-day sedation and accumulation, especially in the elderly.
• D. Requiring multiple daily doses.

Answer: C. Next-day sedation and accumulation, especially in the elderly.

27. The management of anxiety disorders often follows the Pharmacists’ Patient Care Process (PPCP). The first step, “Collect,” would involve gathering information on:

• A. Only the patient’s insurance.
• B. The specific symptoms, their duration and severity, and any triggers.
• C. The pharmacist’s opinion on the best treatment.
• D. The pharmacy’s inventory of anxiolytics.

Answer: B. The specific symptoms, their duration and severity, and any triggers.

28. Flumazenil is a medication that acts as a:

• A. Benzodiazepine receptor agonist.
• B. Benzodiazepine receptor antagonist, used to reverse benzodiazepine overdose.
• C. Positive allosteric modulator of the GABA-A receptor.
• D. Negative allosteric modulator of the GABA-A receptor.

Answer: B. Benzodiazepine receptor antagonist, used to reverse benzodiazepine overdose.

29. The self-care/OTC treatment of sleep disorders with antihistamines like diphenhydramine is not recommended for which patient population due to the high risk of anticholinergic side effects?

• A. Adolescents
• B. Young adults
• C. Elderly patients
• D. Athletes

Answer: C. Elderly patients

30. Which of the following is a symptom of benzodiazepine withdrawal?

• A. Sedation and muscle relaxation
• B. Rebound anxiety, insomnia, and seizures
• C. Euphoria and calmness
• D. Dry mouth and constipation

Answer: B. Rebound anxiety, insomnia, and seizures

31. The primary pharmacologic treatment for cataplexy associated with narcolepsy is:

• A. Modafinil
• B. Amphetamine
• C. Sodium oxybate (Xyrem)
• D. Zolpidem

Answer: C. Sodium oxybate (Xyrem)

32. According to the syllabus for Patient Care VII, the management of anxiety disorders like GAD, Panic, and Social Anxiety are covered together because they share what common treatment principle?

• A. They are all primarily treated with benzodiazepines long-term.
• B. They all respond best to antipsychotic medication.
• C. They all have SSRIs and SNRIs as first-line pharmacotherapy options.
• D. They do not require any medication.

Answer: C. They all have SSRIs and SNRIs as first-line pharmacotherapy options.

33. The “Z-drugs” were developed with the medicinal chemistry goal of creating hypnotics that:

• A. Had a higher affinity for the benzodiazepine-1 (BZ-1) receptor subtype, to be more selective for sedation.
• B. Were less potent than benzodiazepines.
• C. Had a longer duration of action than any benzodiazepine.
• D. Also treated depression effectively.

Answer: A. Had a higher affinity for the benzodiazepine-1 (BZ-1) receptor subtype, to be more selective for sedation.

34. Hydroxyzine is an antihistamine used for anxiety. Its anxiolytic effect is primarily due to:

• A. Serotonin reuptake inhibition.
• B. Dopamine antagonism.
• C. Its sedating properties from H1 receptor blockade.
• D. Partial agonism at the 5-HT1A receptor.

Answer: C. Its sedating properties from H1 receptor blockade.

35. A key difference between GAD and Panic Disorder is that Panic Disorder is characterized by:

• A. Chronic, excessive worry about multiple things.
• B. Recurrent, unexpected panic attacks and fear of future attacks.
• C. A fear of social situations.
• D. The presence of obsessions and compulsions.

Answer: B. Recurrent, unexpected panic attacks and fear of future attacks.

36. A patient taking zolpidem should be counseled to take it:

• A. In the morning with breakfast.
• B. With a large, high-fat meal to enhance absorption.
• C. Immediately before getting into bed, with at least 7-8 hours to sleep.
• D. At the dinner table.

Answer: C. Immediately before getting into bed, with at least 7-8 hours to sleep.

37. The FDA-approved indications for benzodiazepines in anxiety disorders are generally for:

• A. Long-term, indefinite treatment.
• B. The management of comorbid depression.
• C. Short-term or adjunctive treatment while waiting for a first-line agent like an SSRI to become effective.
• D. The treatment of performance anxiety only.

Answer: C. Short-term or adjunctive treatment while waiting for a first-line agent like an SSRI to become effective.

38. Which of the following herbal supplements has some evidence for treating anxiety, but its active constituents, the kavalactones, are associated with significant liver toxicity?

• A. St. John’s Wort
• B. Ginkgo Biloba
• C. Kava
• D. Echinacea

Answer: C. Kava

39. Augmentation of an SSRI with which type of agent can be effective for treatment-resistant anxiety disorders?

• A. A second-generation antipsychotic
• B. A stimulant
• C. Another SSRI
• D. An antibiotic

Answer: A. A second-generation antipsychotic

40. The pharmacology of tolerance to benzodiazepines involves:

• A. A permanent change in the patient’s DNA.
• B. Downregulation or conformational changes in GABA-A receptors, requiring a higher dose to produce the same effect.
• C. Increased metabolism of the drug over time.
• D. A decrease in drug absorption.

Answer: B. Downregulation or conformational changes in GABA-A receptors, requiring a higher dose to produce the same effect.

41. The primary advantage of buspirone over benzodiazepines in the management of GAD is that it:

• A. Has a much faster onset of action.
• B. Lacks potential for dependence, withdrawal, and abuse.
• C. Is also effective for panic attacks.
• D. Causes significant sedation.

Answer: B. Lacks potential for dependence, withdrawal, and abuse.

42. Which class of medication is first-line for both PTSD and OCD?

• A. Benzodiazepines
• B. TCAs
• C. SSRIs
• D. MAOIs

Answer: C. SSRIs

43. A pharmacist counseling on an OTC sleep product containing diphenhydramine should warn a patient with which condition to avoid its use due to anticholinergic effects?

• A. Hypertension
• B. Benign Prostatic Hyperplasia (BPH)
• C. Hyperlipidemia
• D. Diabetes

Answer: B. Benign Prostatic Hyperplasia (BPH)

44. What is the role of the pharmacist in “means restriction” counseling for a patient with anxiety and depression who receives a large quantity of a benzodiazepine?

• A. Dispense the full quantity without comment.
• B. Collaborate with the prescriber to consider dispensing a smaller, safer quantity at a time.
• C. Refuse to fill the prescription.
• D. Tell the patient to store the medication in an unlocked cabinet.

Answer: B. Collaborate with the prescriber to consider dispensing a smaller, safer quantity at a time.

45. Long-term management of most anxiety disorders emphasizes:

• A. Using the highest possible dose of a benzodiazepine.
• B. Monotherapy with an SSRI/SNRI and adjunctive psychotherapy.
• C. Using hypnotics on a nightly basis indefinitely.
• D. An “as needed” approach with multiple CNS depressants.

Answer: B. Monotherapy with an SSRI/SNRI and adjunctive psychotherapy.

46. Which Z-drug has the longest half-life and is most associated with next-day impairment?

• A. Zaleplon
• B. Zolpidem
• C. Eszopiclone
• D. Ramelteon

Answer: C. Eszopiclone

47. When assessing a patient’s sleep problems, it is crucial to first:

• A. Recommend a prescription hypnotic immediately.
• B. Identify and address any underlying causes or poor sleep hygiene practices.
• C. Order a sleep study.
• D. Assume the patient needs lifelong medication.

Answer: B. Identify and address any underlying causes or poor sleep hygiene practices.

48. Clomipramine, a TCA, is highly effective for OCD due to its potent inhibition of:

• A. Dopamine reuptake.
• B. Norepinephrine reuptake.
• C. Serotonin reuptake.
• D. Histamine receptors.

Answer: C. Serotonin reuptake.

49. A patient taking lorazepam for anxiety wishes to discontinue it. A tapering schedule is essential to prevent:

• A. Severe weight gain.
• B. Withdrawal symptoms, including potential seizures.
• C. Hypertensive crisis.
• D. Agranulocytosis.

Answer: B. Withdrawal symptoms, including potential seizures.

50. The ultimate goal of communicating with a patient about their anxiety or sleep disorder is to:

• A. Tell them what to do.
• B. Create a collaborative partnership to improve their symptoms and quality of life.
• C. Fill a prescription as quickly as possible.
• D. Avoid discussing any difficult topics.

Answer: B. Create a collaborative partnership to improve their symptoms and quality of life. Sources