Part 4.2 - CNS-PYSCHOSIS

Proverbs 16:3

c. Schizophrenia

Research suggests that a combination of physical, genetic, psychological, environmental factors can make a person more likely to develop this condition

a. MDD

b. Parkinsonism

c. Schizophrenia

d. Bipolar Disorder

c. Schizophrenia

It is a type of disorder characterized by several types of symptoms, including positive and negative symptoms

a. MDD

b. Parkinsonism

c. Schizophrenia

d. Bipolar Disorder

a. ↑ dopamine ↑ serotonin

Have been reported to cause the symptoms of schizophrenia

a. ↑ dopamine ↑ serotonin

b. ↓ dopamine ↓ serotonin

c. ↑ dopamine ↓ serotonin

d. ↑ serotonin ↓ dopamine

a. Positive symptoms

-auditory: most common type

Hallucinations

a. Positive symptoms

b. Negative symptoms

a. Positive symptoms

-paranoia or grandeur delusions

Delusions

a. Positive symptoms

b. Negative symptoms

a. Positive symptoms

-random rumbling of words)

Disorganized speech

a. Positive symptoms

b. Negative symptoms

a. Positive symptoms

Bizzare behavior

a. Positive symptoms

b. Negative symptoms

b. Negative symptoms

-inability to speak because of mental defect, mental confusion, or aphasia

Alogia

a. Positive symptoms

b. Negative symptoms

b. Negative symptoms

-lack of interest pleasure

Anhedonia

a. Positive symptoms

b. Negative symptoms

b. Negative symptoms

-lack of motivation

Avolition

a. Positive symptoms

b. Negative symptoms

b. Negative symptoms

-isolate themselves

Asociality

a. Positive symptoms

b. Negative symptoms

b. Negative symptoms

Flattening of affect (poor eye contact)

a. Positive symptoms

b. Negative symptoms

b. Traditional/Classical/Typical antipsychotics

First-generation antipsychotics are also known as ________.

a. Atypical antipsychotics
b. Traditional/Classical/Typical antipsychotics
c. Selective serotonin antagonists
d. Mood stabilizers

a. Atypical antipsychotics

Second-generation antipsychotics are also known as ________

a. Atypical antipsychotics
b. Traditional/Classical/Typical antipsychotics
c. Selective serotonin antagonists
d. Mood stabilizers

a. Block D₂ receptors (non-selective)

The primary mechanism of action (MOA) of first-generation antipsychotics is ________.

a. Block D₂ receptors (non-selective)
b. Stimulate D₂ receptors
c. Activate 5-HT₂A receptors
d. Open Cl⁻ channels

a. first-generation antipsychotics

-(antiHistamine, anti-Alpha receptor, anti-Muscarinic receptor)

Block HAM receptors

a. first-generation antipsychotics

b. second-generation antipsychotics

b. second-generation antipsychotics

Block D2 < D4 receptors

a. first-generation antipsychotics

b. second-generation antipsychotics

b. second-generation antipsychotics

Block 5-HT2A receptors

a. first-generation antipsychotics

b. second-generation antipsychotics

a. Reduction of positive symptoms

Blockade of D2 receptors in the mesolimbic pathway → reduction of positive symptoms

Blockade of D2 receptors in the mesocortical pathway → worsening of negative symptoms

Blockade of D2 receptors in nigrostriatal pathway → Extrapyramidal Symptoms

Blockade of D2 receptors in tuberoinfundibular → inc prolactin released

[1^st Generation Antipsychotics]

Blockade of D2 receptors in the mesolimbic pathway

a. Reduction of positive symptoms

b. Worsening of negative symptoms

c. Extrapyramidal Symptoms

d. Increases prolactin release

b. Worsening of negative symptoms

Blockade of D2 receptors in the mesolimbic pathway → reduction of positive symptoms

Blockade of D2 receptors in the mesocortical pathway → worsening of negative symptoms

Blockade of D2 receptors in nigrostriatal pathway → Extrapyramidal Symptoms

Blockade of D2 receptors in tuberoinfundibular → inc prolactin released

[1^st Generation Antipsychotics]

Blockade of D2 receptors in the mesocortical pathway

a. Reduction of positive symptoms

b. Worsening of negative symptoms

c. Extrapyramidal Symptoms

d. Increases prolactin release

d. Increases prolactin release

Blockade of D2 receptors in the mesolimbic pathway → reduction of positive symptoms

Blockade of D2 receptors in the mesocortical pathway → worsening of negative symptoms

Blockade of D2 receptors in nigrostriatal pathway → Extrapyramidal Symptoms

Blockade of D2 receptors in tuberoinfundibular → inc prolactin released

[1^st Generation Antipsychotics]

Blockade of D2 receptors in tuberoinfundibular

a. Reduction of positive symptoms

b. Worsening of negative symptoms

c. Extrapyramidal Symptoms

d. Increases prolactin release

c. Extrapyramidal Symptoms

Blockade of D2 receptors in the mesolimbic pathway → reduction of positive symptoms

Blockade of D2 receptors in the mesocortical pathway → worsening of negative symptoms

Blockade of D2 receptors in nigrostriatal pathway → Extrapyramidal Symptoms

Blockade of D2 receptors in tuberoinfundibular → inc prolactin released

[1^st Generation Antipsychotics]

Blockade of D2 receptors in nigrostriatal pathway

a. Reduction of positive symptoms

b. Worsening of negative symptoms

c. Extrapyramidal Symptoms

d. Increases prolactin release

b. -azine

[1^st Generation Antipsychotics]

Phenothiazines are commonly identified by the suffix ________.

a. -thix
b. -azine
c. -peridol
d. -ridone

c. -peridol

[1^st Generation Antipsychotics]

Butyrophenones are commonly identified by the suffix ________.

a. -azine
b. -thix
c. -peridol
d. -curonium

c. -thix

[1^st Generation Antipsychotics]

Thioxanthenes are commonly identified by the suffix ________.

a. -azine
b. -ridazine
c. -thix
d. -olol

b. Chlorpromazine (-promazine)

[1^st Generation Antipsychotics]

Which of the following is an aliphatic phenothiazine?

a. Fluphenazine
b. Chlorpromazine
c. Thioridazine
d. Haloperidol

a. Fluphenazine (-phenazine)

[1^st Generation Antipsychotics]

Which of the following is a piperazine phenothiazine?

a. Fluphenazine
b. Droperidol
c. Thiothixene
d. Chlorpromazine

b. Thioridazine (-ridazine)

[1^st Generation Antipsychotics]

Which of the following is a piperidine phenothiazine?

a. Haloperidol
b. Thioridazine
c. Fluphenazine
d. Thiothixene

b. Butyrophenones = Piperazines > Piperidines ≥ Thioxanthenes > Aliphatic

[1^st Generation Antipsychotics]

The potency of first-generation antipsychotics

a. Aliphatic > Thioxanthenes > Piperidines > Piperazines > Butyrophenones
b. Butyrophenones = Piperazines > Piperidines ≥ Thioxanthenes > Aliphatic
c. Piperidines > Butyrophenones > Aliphatic > Thioxanthenes
d. Thioxanthenes > Piperazines > Aliphatic > Butyrophenones

b. Butyrophenones and Piperazines

[1^st Generation Antipsychotics]

________ and ________ are considered the most potent first-generation antipsychotics.

a. Aliphatics and Piperidines
b. Butyrophenones and Piperazines
c. Thioxanthenes and Aliphatics
d. Piperidines and Aliphatics

b. Directly

Inversely = HAM receptor affinity.

[1^st Generation Antipsychotics]

Potency of first-generation antipsychotics is ________ proportional to D₂ receptor affinity.

a. Inversely
b. Directly

b. Inversely

Directly = D₂ receptor affinity.

[1^st Generation Antipsychotics]

Potency of first-generation antipsychotics is ________ proportional to HAM receptor affinity.

a. Directly
b. Inversely

b. -zapine

[2^nd Generation Antipsychotics]

Atypical antipsychotics

a. -peridol
b. -zapine
c. -azine
d. -thix

a. -xapine

[2^nd Generation Antipsychotics]

Atypical antipsychotics

a. -xapine

b. -peridol

c. -azine
d. -thix

a. -peridone

[2^nd Generation Antipsychotics]

Atypical antipsychotics

a. -peridone

b. -peridol

c. -azine
d. -thix

b. Reduced side effects, especially EPS

[2^nd Generation Antipsychotics]

An advantage of atypical antipsychotics over typical antipsychotics is ________.

a. Increased EPS
b. Reduced side effects, especially EPS
c. Complete absence of adverse effects
d. Reduced efficacy in schizophrenia

b. Therapy-resistant schizophrenia

[2^nd Generation Antipsychotics]

Atypical antipsychotics have greater affinity and activity in ________.

a. Acute asthma
b. Therapy-resistant schizophrenia
c. Hypertension
d. Motion sickness

b. Negative symptoms

[2^nd Generation Antipsychotics]

Compared with first-generation antipsychotics, second-generation antipsychotics are more effective in treating ________.

a. Positive symptoms
b. Negative symptoms

c. 2nd generation > 1st generation

[2^nd Generation Antipsychotics]

Efficacy in treatment of negative symptoms is ________.

a. 1st generation > 2nd generation
b. 1st generation = 2nd generation
c. 2nd generation > 1st generation
d. Neither generation is effective

b. 1st generation = 2nd generation

[2^nd Generation Antipsychotics]

Efficacy in treatment of positive symptoms is ________.

a. 1st generation > 2nd generation
b. 1st generation = 2nd generation
c. 2nd generation > 1st generation
d. Neither generation is effective

c. Clozapine

[2^nd Generation Antipsychotics]

_______ is the only antipsychotic drug that does NOT cause EPS.

a. Haloperidol
b. Risperidone
c. Clozapine
d. Olanzapine

b. SAM (Seizure, Agranulocytosis, Myocarditis)

[2^nd Generation Antipsychotics]

Clozapine is never given as a first-line drug because of ________.

a. Severe bronchoconstriction
b. SAM (Seizure, Agranulocytosis, Myocarditis)
c. Renal toxicity only
d. Complete treatment failure

a. Haloperidol

[2^nd Generation Antipsychotics]

Management of phencyclidine intoxication

a. Haloperidol
b. Olanzapine
c. Quetiapine
d. Amisulpride

a. Haloperidol

[2^nd Generation Antipsychotics]

Used in management of Tourette’s syndrome

a. Haloperidol
b. Risperidone
c. Ziprasidone
d. Loxapine

c. Both acute mania and severe depression

[2^nd Generation Antipsychotics]

Antipsychotic drugs may also be used in management of ________.

a. Acute mania
b. Severe depression
c. Both acute mania and severe depression
d. Hyperthyroidism

b. Dopamine and acetylcholine

[ADR: Due to Dopamine Blockade]

Extrapyramidal syndrome (EPS) is a movement disorder caused by imbalance between ________.

a. Dopamine and serotonin
b. Dopamine and acetylcholine
c. Histamine and dopamine
d. GABA and glutamate

b. Decreasing acetylcholine

[ADR: Due to Dopamine Blockade]

Management of EPS generally involves ________.

a. Increasing acetylcholine
b. Decreasing acetylcholine
c. Blocking dopamine completely
d. Increasing serotonin

All

“BBT”

[ADR: Due to Dopamine Blockade]

Anticholinergics (centrally acting)

I. Biperiden

II. Benztropine

III. Trihexyphenidyl

b. Akathisia

[ADR: Due to Dopamine Blockade]

Characterized by uncontrolled restlessness

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

b. Akathisia

[ADR: Due to Dopamine Blockade]

most difficult EPS to treat

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

b. Akathisia

[ADR: Due to Dopamine Blockade]

Only EPS not treated by Anticholinergic drugs

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

b. Beta blockers and benzodiazepines (BZP’s)

[ADR: Due to Dopamine Blockade]

Management of akathisia

a. Anticholinergic drugs
b. Beta blockers and benzodiazepines (BZP’s)
c. IV diphenhydramine
d. Dantrolene

a. Dystonia

[ADR: Due to Dopamine Blockade]

Usually the 1st EPS seen

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

a. Dystonia

[ADR: Due to Dopamine Blockade]

Torticollis/Retrocollis (twisting of the neck)

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

a. Dystonia

[ADR: Due to Dopamine Blockade]

Easier to treat but FATAL

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

b. IV diphenhydramine and anticholinergic agents

[ADR: Due to Dopamine Blockade]

Management of dystonia

a. Beta blockers and BZPs
b. IV diphenhydramine and anticholinergic agents
c. Dantrolene
d. Clozapine

b. Low dopamine levels

[ADR: Due to Dopamine Blockade]

Pseudoparkinsonism is associated with ________.

a. High dopamine levels
b. Low dopamine levels
c. High serotonin levels
d. Increased histamine activity

c. Pseudoparkinsonism

[ADR: Due to Dopamine Blockade]

Tremors, rigidity, akinesia, and postural instability are features of ________.

a. Dystonia
b. Akathisia
c. Pseudoparkinsonism
d. Hyperprolactinemia

c. Tardive dyskinesia

[ADR: Due to Dopamine Blockade]

Potentially irreversible

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

c. Tardive dyskinesia

[ADR: Due to Dopamine Blockade]

Due to hypersensitivity of D2 receptor

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

c. Tardive dyskinesia

[ADR: Due to Dopamine Blockade]

Characterized by Tic-like motion

a. Dystonia
b. Akathisia
c. Tardive dyskinesia
d. Pseudoparkinsonism

a. Clozapine or Olanzapine

[ADR: Due to Dopamine Blockade]

Management of tardive dyskinesia includes discontinuing the drug and using ________.

a. Clozapine or Olanzapine
b. Haloperidol only
c. Dantrolene only
d. Diphenhydramine only

a. Amenorrhea, galactorrhea, and impotence

[ADR: Due to Dopamine Blockade]

Hyperprolactinemia due to dopamine blockade may cause ________.

a. Amenorrhea, galactorrhea, and impotence
b. Bronchodilation and tachycardia
c. Hypertension and insomnia
d. Hyperglycemia only

b. Prolactin-inhibiting hormone

↓ Dopamine = ↑ Prolactin = Hyperprolactinemia

[ADR: Due to Dopamine Blockade]

Dopamine acts as a ________.

a. Prolactin-enhancing hormone
b. Prolactin-inhibiting hormone
c. Growth hormone stimulator only
d. Histamine antagonist

a. Bromocriptine

[ADR: Due to Dopamine Blockade]

D₂ agonist is used in mothers who wish to stop breastfeeding and in hyperprolactinemia

a. Bromocriptine
b. Haloperidol
c. Benztropine
d. Olanzapine

b. Malignant hyperthermia

[ADR: Due to Dopamine Blockade]

Neuroleptic malignant syndrome (NMS) resembles ________.

a. Parkinson disease
b. Malignant hyperthermia
c. Migraine
d. Tourette syndrome

a. Dantrolene and Bromocriptine

Dantrolene (Ca+ antagonist; muscle relaxant)

Bromocriptine (D2 agonist)

[ADR: Due to Dopamine Blockade]

Management of neuroleptic malignant syndrome

a. Dantrolene and Bromocriptine
b. Haloperidol only
c. Diphenhydramine only
d. Benztropine only

a. Due to Dopamine receptor blockade

Extrapyramidal syndrome (EPS) is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

a. Due to Dopamine receptor blockade

Hyperprolactinemia is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

a. Due to Dopamine receptor blockade

Neuroleptic malignant syndrome (NMS) is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

b. Due to Histamine receptor blockade

Sedation is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

c. Due to Alpha 1 receptor blockade

Orthostatic hypotension is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

d. Due to Muscarinic blockade

Anticholinergic is an ADR due to

a. Due to Dopamine receptor blockade

b. Due to Histamine receptor blockade

c. Due to Alpha 1 receptor blockade

d. Due to Muscarinic blockade

b. Clozapine

[Other ADR of antipsychotics]

antipsychotic is most commonly associated with seizures

a. Haloperidol
b. Clozapine
c. Risperidone
d. Ziprasidone

b. Clozapine

“SAM”

(Seizure, Agranulocytosis, Myocarditis)

[Other ADR of antipsychotics]

Agranulocytosis is strongly associated with ________.

a. Ziprasidone
b. Clozapine
c. Haloperidol
d. Aripiprazole

a. 3 weeks

“Weekly for 6 months, then every 3 weeks.”

[Other ADR of antipsychotics]

After count monitoring every week for the first 6 months of clozapine therapy, WBC count monitoring should continue every ________.

a. 3 weeks
b. 3 days
c. 6 months
d. 12 weeks

b. Myocarditis

“SAM”

(Seizure, Agranulocytosis, Myocarditis)

[Other ADR of antipsychotics]

Cardiac adverse effect is associated with clozapine

a. QT prolongation only
b. Myocarditis
c. Retinal deposits
d. Bronchospasm

a. Myositis

Myositis

• Inflammation of skeletal muscles

Myocarditis

• Inflammation of the heart muscle

[Other ADR of antipsychotics]

Cardiac adverse effect is associated with clozapine

a. Myositis
b. Hypertension
c. Cataracts
d. Hyperthyroidism

a. Ziprasidone

[Other ADR of antipsychotics]

QT prolongation is associated with:

a. Ziprasidone
b. Benztropine
c. Trihexyphenidyl
d. Molindone

b. Mioridazine

[Other ADR of antipsychotics]

QT prolongation is associated with:

a. Clozapine
b. Mioridazine
c. Trihexyphenidyl
d. Molindone

d. Thioridazine

[Other ADR of antipsychotics]

QT prolongation is associated with:

a. Molindone
b. Benztropine
c. Trihexyphenidyl
d. Thioridazine

c. Thioridazine

reTinal =Thioridazine = causes blindness

Corneal = Chlorpromazine = doesn’t cause blindness

[Other ADR of antipsychotics]

Retinal deposits causing blindness

a. Clozapine
b. Chlorpromazine
c. Thioridazine
d. Thiothixene

b. Chlorpromazine

reTinal =Thioridazine = causes blindness

Corneal = Chlorpromazine = doesn’t cause blindness

[Other ADR of antipsychotics]

Corneal deposit doesn’t cause blindness

a. Clozapine
b. Chlorpromazine
c. Thioridazine
d. Thiothixene

b. Second-generation antipsychotics

[Other ADR of antipsychotics]

Weight gain is common among ________.

a. First-generation antipsychotics only
b. Second-generation antipsychotics
c. Anticholinergics only
d. Benzodiazepines only

b. Amisulpride

“AMA”

Amisulpride, Molindone, Aripiprazole

[Other ADR of antipsychotics]

Exception to weight gain among second-generation antipsychotics

a. Olanzapine
b. Amisulpride
c. Quetiapine
d. Clozapine

a. Molindone

“AMA”

Amisulpride, Molindone, Aripiprazole

[Other ADR of antipsychotics]

Exception to weight gain among second-generation antipsychotics

a. Molindone
b. Risperidone
c. Paliperidone
d. Ziprasidone

a. Aripiprazole

“AMA”

Amisulpride, Molindone, Aripiprazole

[Other ADR of antipsychotics]

Exception to weight gain among second-generation antipsychotics

a. Aripiprazole
b. Olanzapine
c. Clozapine
d. Quetiapine

a. Olanzapine

[Other ADR of antipsychotics]

Risk of diabetes mellitus is especially associated with ________.

a. Olanzapine
b. Haloperidol
c. Benztropine
d. Thioridazine

a. Chlorpromazine

Chlorpromazine=Moderate to high

Fluphenazine=High (if Oral)

Haloperidol=High

[ADR of 1^st Generation]

Moderate to high potential for EPS

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

c. Haloperidol

Chlorpromazine=Moderate to high

Fluphenazine=High (if Oral)

Haloperidol=High

[ADR of 1^st Generation]

High potential for EPS

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

b. Fluphenazine

Chlorpromazine=Moderate to high

Fluphenazine=High (if Oral)

Haloperidol=High

[ADR of 1^st Generation]

Oral formulation has a high potential for EPS

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

a. Chlorpromazine

Chlorpromazine=Moderate to high

Fluphenazine=Low

Haloperidol=Low

[ADR of 1^st Generation]

Moderate to high potential for weight gain, orthostasis, and sedation

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

b. Fluphenazine &

c. Haloperidol

Chlorpromazine=Moderate to high

Fluphenazine=Low

Haloperidol=Low

[ADR of 1^st Generation]

Low potential for weight gain, orthostasis, and sedation

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

a. Chlorpromazine

Chlorpromazine=Moderate to high

Fluphenazine=Low to Moderate

Haloperidol=Low

[ADR of 1^st Generation]

Moderate to high potential for antimuscarinic effects

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

b. Fluphenazine

Chlorpromazine=Moderate to high

Fluphenazine=Low to Moderate

Haloperidol=Low

[ADR of 1^st Generation]

Low to moderate potential for antimuscarinic effects

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

c. Haloperidol

Chlorpromazine=Moderate to high

Fluphenazine=Low to Moderate

Haloperidol=Low

[ADR of 1^st Generation]

Low potential for antimuscarinic effects

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

b. Fluphenazine

[ADR of 1^st Generation]

Common use is in the LAI formulation administered every 23 weeks in patients with schizophrenia and a history of noncompliance with oral antipsychotic regimens

a. Chlorpromazine

b. Fluphenazine

c. Haloperidol

c. Aripiprazole &

d. Olanzapine

[ADR of 2^nd Generation]

Low potential for EPS

a. Paliperidone

b. Clozapine

c. Aripiprazole

d. Olanzapine

c. Aripiprazole

[ADR of 2^nd Generation]

low potential for weight gain

a. Paliperidone

b. Clozapine

c. Aripiprazole

d. Olanzapine

c. Aripiprazole

[ADR of 2^nd Generation]

low potential for sedation and antimuscarinic effects

a. Paliperidone

b. Clozapine

c. Aripiprazole

d. Olanzapine