MCQ Quiz: Psychotic Spectrum Disorders

Psychotic spectrum disorders, with schizophrenia as the prototype, are severe mental illnesses that can profoundly affect a person’s thoughts, perceptions, and ability to function. The pharmacotherapy for these disorders is complex, primarily revolving around antipsychotic medications that carry significant side effect burdens. The pharmacist’s role in managing these medications—ensuring adherence, monitoring for adverse effects like extrapyramidal symptoms and metabolic changes, and providing patient education—is critical for improving outcomes. This quiz will test your knowledge of the pathophysiology and pharmacologic management of psychotic disorders.

1. The “dopamine hypothesis” of schizophrenia suggests that symptoms are primarily caused by:

• a. A deficiency of dopamine in all brain pathways.
• b. An excess of dopaminergic activity in the mesolimbic pathway.
• c. A deficiency of serotonin.
• d. An excess of acetylcholine.

Answer: b. An excess of dopaminergic activity in the mesolimbic pathway.

2. Which of the following is considered a “positive” symptom of schizophrenia?

• a. Avolition (lack of motivation)
• b. Alogia (poverty of speech)
• c. Anhedonia (inability to feel pleasure)
• d. Hallucinations

Answer: d. Hallucinations

3. First-generation antipsychotics (e.g., haloperidol) primarily exert their effect by blocking which receptor?

• a. Serotonin 5-HT2A
• b. Dopamine D2
• c. Histamine H1
• d. Muscarinic M1

Answer: b. Dopamine D2

4. A patient on haloperidol develops muscle stiffness, a shuffling gait, and a pill-rolling tremor. These are known as:

• a. Anticholinergic side effects
• b. Metabolic side effects
• c. Extrapyramidal Symptoms (EPS)
• d. Cardiovascular side effects

Answer: c. Extrapyramidal Symptoms (EPS)

5. Second-generation (“atypical”) antipsychotics like olanzapine and risperidone differ from first-generation agents in that they have significant activity as antagonists at which other receptor?

• a. Dopamine D1
• b. Serotonin 5-HT2A
• c. NMDA
• d. GABA-A

Answer: b. Serotonin 5-HT2A

6. A major advantage of most second-generation antipsychotics compared to first-generation agents is a lower risk of:

• a. Weight gain
• b. Sedation
• c. Extrapyramidal Symptoms (EPS)
• d. Diabetes

Answer: c. Extrapyramidal Symptoms (EPS)

7. A significant and common adverse effect associated with many second-generation antipsychotics like olanzapine and clozapine is:

• a. Weight loss
• b. Metabolic syndrome (weight gain, dyslipidemia, hyperglycemia).
• c. Insomnia
• d. A severe rash.

Answer: b. Metabolic syndrome (weight gain, dyslipidemia, hyperglycemia).

8. Which antipsychotic requires mandatory enrollment in a REMS program to monitor for the risk of severe, potentially fatal agranulocytosis?

• a. Risperidone
• b. Aripiprazole
• c. Haloperidol
• d. Clozapine

Answer: d. Clozapine

9. A patient on a first-generation antipsychotic develops involuntary, repetitive movements of the face and tongue (e.g., lip-smacking, tongue protrusion). This potentially irreversible side effect is known as:

• a. Acute dystonia
• b. Akathisia
• c. Pseudoparkinsonism
• d. Tardive Dyskinesia (TD)

Answer: d. Tardive Dyskinesia (TD)

10. Long-acting injectable (LAI) antipsychotics are primarily used to:

• a. Provide a faster onset of action.
• b. Improve medication adherence in patients who have difficulty with oral formulations.
• c. Avoid all side effects.
• d. Be a first-line option for all new patients.

Answer: b. Improve medication adherence in patients who have difficulty with oral formulations.

11. A patient on an antipsychotic complains of a feeling of inner restlessness and an inability to sit still. This condition is known as:

• a. Dystonia
• b. Akathisia
• c. Parkinsonism
• d. Tardive Dyskinesia

Answer: b. Akathisia

12. Aripiprazole is unique in its mechanism of action because it acts as a:

• a. Full dopamine D2 antagonist.
• b. Dopamine D2 partial agonist.
• c. Selective serotonin reuptake inhibitor.
• d. Full dopamine D2 agonist.

Answer: b. Dopamine D2 partial agonist.

13. The pharmacist’s role in managing psychotic disorders includes:

• a. Counseling on the importance of adherence.
• b. Monitoring for and helping to manage side effects like weight gain and EPS.
• c. Educating patients and caregivers about the delayed onset of full therapeutic effect.
• d. All of the above.

Answer: d. All of the above.

14. An acute dystonic reaction (e.g., muscle spasm of the neck) caused by an antipsychotic can be treated emergently with:

• a. A higher dose of the antipsychotic.
• b. An anticholinergic agent like benztropine or diphenhydramine.
• c. A benzodiazepine.
• d. An opioid.

Answer: b. An anticholinergic agent like benztropine or diphenhydramine.

15. Which of the following is considered a “negative” symptom of schizophrenia?

• a. Delusions
• b. Disorganized speech
• c. Blunted affect (diminished emotional expression)
• d. Auditory hallucinations

Answer: c. Blunted affect (diminished emotional expression)

16. The negative and cognitive symptoms of schizophrenia are generally more responsive to antipsychotic treatment than the positive symptoms.

• a. True
• b. False

Answer: b. False

17. What is a key counseling point for a patient starting risperidone?

• a. It can cause significant weight loss.
• b. It has a higher risk of causing hyperprolactinemia (leading to side effects like gynecomastia) compared to other atypical antipsychotics.
• c. It is not effective for positive symptoms.
• d. It must be taken with food.

Answer: b. It has a higher risk of causing hyperprolactinemia (leading to side effects like gynecomastia) compared to other atypical antipsychotics.

18. Clozapine is often reserved for treatment-resistant schizophrenia because of:

• a. Its high cost.
• b. Its superior efficacy for both positive and negative symptoms.
• c. Its burdensome monitoring requirements and risk of severe side effects.
• d. Both b and c.

Answer: d. Both b and c.

19. Which of the following is a key component of a pharmacist’s monitoring plan for a patient on an atypical antipsychotic?

• a. Baseline and regular monitoring of weight, BMI, blood pressure, and lipids.
• b. Annual eye exams.
• c. Monthly chest x-rays.
• d. Daily EKGs.

Answer: a. Baseline and regular monitoring of weight, BMI, blood pressure, and lipids.

20. A patient with a history of QT prolongation should use which antipsychotic with caution?

• a. Aripiprazole
• b. Lurasidone
• c. Ziprasidone
• d. Olanzapine

Answer: c. Ziprasidone

21. A patient must fail trials of how many other antipsychotics before being considered a candidate for clozapine?

• a. None
• b. One
• c. Two
• d. Three

Answer: c. Two

22. The primary goal of acute treatment for a psychotic episode is:

• a. To achieve full remission of all symptoms within 24 hours.
• b. To reduce agitation, aggression, and acute positive symptoms to ensure the safety of the patient and others.
• c. To find the perfect long-term medication.
• d. To start a long-acting injectable immediately.

Answer: b. To reduce agitation, aggression, and acute positive symptoms to ensure the safety of the patient and others.

23. Non-pharmacologic therapy, such as assertive community treatment (ACT) and cognitive behavioral therapy for psychosis (CBTp), is an important part of comprehensive schizophrenia care.

• a. True
• b. False

Answer: a. True

24. The term “extrapyramidal” refers to which system in the brain?

• a. The reward system
• b. The memory system
• c. The motor system responsible for involuntary movements
• d. The visual system

Answer: c. The motor system responsible for involuntary movements

25. A key counseling point for a patient taking an orally disintegrating tablet (ODT) formulation of an antipsychotic is:

• a. To swallow it whole with water.
• b. To place it on the tongue where it will dissolve without water.
• c. To chew it thoroughly.
• d. To dissolve it in juice before taking.

Answer: b. To place it on the tongue where it will dissolve without water.

26. Which antipsychotic must be taken with a meal of at least 350 calories to ensure adequate absorption?

• a. Aripiprazole
• b. Olanzapine
• c. Lurasidone
• d. Risperidone

Answer: c. Lurasidone

27. The pharmacist is a crucial team member for managing transitions of care for patients with psychotic disorders to prevent relapse.

• a. True
• b. False

Answer: a. True

28. A patient is prescribed paliperidone palmitate. The pharmacist recognizes this as a:

• a. Short-acting oral tablet.
• b. Long-acting injectable formulation.
• c. Sublingual film.
• d. Transdermal patch.

Answer: b. Long-acting injectable formulation.

29. The management of psychotic spectrum disorders often requires lifelong treatment.

• a. True
• b. False

Answer: a. True

30. The “dopamine hypothesis” has been expanded to include the role of which other neurotransmitter system?

• a. Serotonin
• b. Glutamate
• c. Acetylcholine
• d. Both a and b.

Answer: d. Both a and b.

31. Tardive dyskinesia is managed with VMAT2 inhibitors such as:

• a. Benztropine
• b. Propranolol
• c. Valbenazine and deutetrabenazine
• d. Lorazepam

Answer: c. Valbenazine and deutetrabenazine

32. A pharmacist’s role includes helping to reduce the stigma associated with mental illness through empathetic and non-judgmental care.

• a. True
• b. False

Answer: a. True

33. The choice of an antipsychotic medication is often guided by:

• a. The patient’s side effect tolerance.
• b. The need to avoid specific drug interactions.
• c. The formulation needed to improve adherence.
• d. All of the above.

Answer: d. All of the above.

34. The term “psychosis” refers to:

• a. A specific diagnosis.
• b. A symptom characterized by a loss of contact with reality.
• c. A feeling of anxiety.
• d. A personality trait.

Answer: b. A symptom characterized by a loss of contact with reality.

35. A pharmacist counseling a patient starting an antipsychotic should discuss:

• a. The importance of not stopping the medication abruptly.
• b. The expected timeline for improvement in symptoms.
• c. Key side effects to monitor for.
• d. All of the above.

Answer: d. All of the above.

36. A key part of managing metabolic side effects for a patient on an atypical antipsychotic is:

• a. Regular monitoring of weight, glucose, and lipids.
• b. Counseling on diet and exercise.
• c. Both a and b.
• d. Neither a nor b.

Answer: c. Both a and b.

37. Which of the following is NOT a primary goal of schizophrenia management?

• a. To reduce or eliminate symptoms.
• b. To improve quality of life and social functioning.
• c. To cure the disease.
• d. To minimize adverse effects of treatment.

Answer: c. To cure the disease.

38. Smoking can ______ the metabolism of some antipsychotics like olanzapine and clozapine, potentially requiring _______ doses in smokers.

• a. inhibit, lower
• b. inhibit, higher
• c. induce, lower
• d. induce, higher

Answer: d. induce, higher

39. A patient in the hospital who quits smoking may need their dose of olanzapine to be:

• a. Increased
• b. Decreased
• c. Unchanged
• d. Switched to an injectable

Answer: b. Decreased

40. The management of psychotic disorders is a complex, lifelong process.

• a. True
• b. False

Answer: a. True

41. Which of the following is NOT a positive symptom of schizophrenia?

• a. Delusions
• b. Hallucinations
• c. Apathy
• d. Disorganized thought

Answer: c. Apathy

42. The “negative” symptoms of schizophrenia are generally more difficult to treat with medication than the “positive” symptoms.

• a. True
• b. False

Answer: a. True

43. A pharmacist’s role in adherence for patients with schizophrenia is critical because:

• a. Lack of insight into the illness is a common symptom.
• b. The side effect burden of medications is high.
• c. Non-adherence is the leading cause of relapse.
• d. All of the above.

Answer: d. All of the above.

44. What is the most important counseling point for a patient starting clozapine?

• a. The need to take it with food.
• b. The importance of adhering to the mandatory blood monitoring schedule.
• c. The risk of weight loss.
• d. The potential for insomnia.

Answer: b. The importance of adhering to the mandatory blood monitoring schedule.

45. Which of the following is a reason to choose a long-acting injectable?

• a. Patient preference.
• b. A history of non-adherence with oral medications.
• c. To ensure consistent medication delivery.
• d. All of the above.

Answer: d. All of the above.

46. The goal of treating a first episode of psychosis is:

• a. To use the highest possible dose of an antipsychotic.
• b. To use the lowest effective dose to achieve symptom control while minimizing side effects.
• c. To use combination antipsychotic therapy from the start.
• d. To avoid medication altogether.

Answer: b. To use the lowest effective dose to achieve symptom control while minimizing side effects.

47. Managing antipsychotic side effects is a key role for a pharmacist.

• a. True
• b. False

Answer: a. True

48. A patient on haloperidol suddenly develops a sustained, painful muscle spasm in their neck. This is likely:

• a. Tardive dyskinesia
• b. Akathisia
• c. An acute dystonic reaction
• d. Pseudoparkinsonism

Answer: c. An acute dystonic reaction

49. The overall management of psychotic disorders requires a team approach.

• a. True
• b. False

Answer: a. True

50. The ultimate goal of learning about the management of psychotic spectrum disorders is to:

• a. Be able to provide safe, effective, and compassionate care to a vulnerable patient population.
• b. Memorize all the antipsychotic doses.
• c. Pass the psychiatry exam.
• d. Be able to diagnose schizophrenia.

Answer: a. Be able to provide safe, effective, and compassionate care to a vulnerable patient population.