2: Self-Assessment Questions and Answers


Self-Assessment Questions and Answers

Select the single best response for each question.


  1. The rationale for using metformin to counteract psychotropically induced weight gain involves which of the following?

    1. Decreasing insulin sensitivity.

    2. Direct appetite suppression via the hypothalamic satiety center.

    3. Blockade of postsynaptic 5-HT2C receptors.

    4. Agonism of H1 receptors.

  2. Which one of the following statements about antidepressant-associated hyponatremia is true?

    1. Risk appears lower with mirtazapine or tricyclics than with other antidepressants.

    2. Risk appears lower with SNRIs than with SSRIs.

    3. SIADH during antidepressant therapy is more common in men < 65 years old.

    4. Replacement of one SSRI with another is likely to resolve the condition.

  3. All of the following have been shown to potentially diminish or help manage SSRI-induced bruxism except

    1. Risperidone 0.25–0.5 mg at night.

    2. An acrylic dental bite guard.

    3. Buspirone 10 mg bid or tid.

    4. Clonazepam 1 mg at night.

  4. Signs of lamotrigine toxicity include all of the following except

    1. Ataxia.

    2. Tremor.

    3. Downbeat nystagmus.

    4. Ventricular arrhythmia.

  5. A medically healthy woman successfully treated for major depression with sertraline 150 mg/day complains of anorgasmia. Which of the following would be the most evidence-based intervention to help remedy her SSRI-associated sexual dysfunction?

    1. Adjunctive sildenafil 50–100 mg/day.

    2. Adjunctive buspirone 10 mg tid.

    3. Adjunctive mirtazapine 7.5–15 mg at night.

    4. Adjunctive methylphenidate 5–10 mg before sex.

  6. Priapism has been associated with all of the following medications except

    1. Citalopram.

    2. Quetiapine.

    3. Divalproex.

    4. Trazodone.

  7. A 28-year-old man with bipolar disorder and unintelligible speech presents to the medical emergency department with fever and blisters in his oropharynx and skin exfoliation on his palms and soles. All of the following would be consistent with his history except

    1. Presence of the HLA-B*1502 allele.

    2. Han Chinese ancestry.

    3. Presently taking carbamazepine.

    4. Early age at onset of bipolar disorder.

  8. Which of the following adverse drug effects commonly occurs early during treatment with escitalopram but is unlikely to spontaneously remit during continued therapy?

    1. Orgasmic dysfunction.

    2. Headache.

    3. Nausea.

    4. Dizziness.

  9. A 32-year-old man with bipolar disorder has been taking topiramate 150 mg/day for 2 months in an effort to counteract a 13.5-kg weight gain caused by psychotropic drugs. He also has been following the Atkins diet, has begun a program of regular exercise, and has lost 5 kg in 3 weeks. He calls to report sharp lower back pain and blood-tinged urine. What is the likely formulation?

    1. Lumbosacral strain and probable myoglobinuria from excessive exercise; he should take an NSAID and, if no better in several days, contact his internist.

    2. Probable nephrolithiasis that may be caused by topiramate, compounded by hypocitraturia and hypercalciuria from his ketogenic diet; he should stop the topiramate and his Atkins diet, hydrate, and be evaluated for renal calculi.

    3. Unclear etiology; discontinue the topiramate and observe for several days.

    4. Likely nephrotic syndrome from possible drug-induced lupus.

  10. You newly begin treating a 61-year-old man with bipolar disorder who is on a stable regimen of lithium carbonate 900 mg/day and divalproex 1,500 mg/day. His medical history is notable for asthma and diabetes. You notice a bilateral upper-extremity tremor that appears worse with movement and ask if it is new and whether it has previously been addressed. He remarks that he has noticed it for several years but his prior doctor never suggested any type of treatment. What would be the most appropriate next steps in management?

    1. Ignore the tremor if it does not bother the patient.

    2. Measure serum creatinine, lithium, and divalproex levels to assure that the tremor does not reflect toxicity.

    3. Begin propranolol 10 mg tid.

    4. Begin primidone 100 mg bid or tid.

  11. Alopecia has been reported to occur with each of the following medications except

    1. Lithium carbonate.

    2. Carbamazepine.

    3. Fluoxetine.

    4. Modafinil.

  12. Which of the following would be the most appropriate intervention for lower-extremity edema in an otherwise healthy 31-year-old woman with bipolar disorder who is psychiatrically stable on lithium monotherapy 900 mg/day with a 12-hour serum lithium level of 0.9 mEq/L?

    1. Amiloride 5 mg bid with monitoring of serum potassium.

    2. Hydrochlorothiazide 100 mg/day.

    3. Reduce lithium by 300 mg/day.

    4. Reduce salt intake and increase free water intake.

  13. Paresthesias are commonly associated with which of the following anticonvulsants?

    1. Gabapentin.

    2. Topiramate.

    3. Oxcarbazepine.

    4. Lamotrigine.

  14. Predictors of more severe adverse effects caused by placebo include all of the following except

    1. Hypochondriacal features.

    2. Phobic and obsessive traits.

    3. Severity of depression at baseline.

    4. High suggestibility and expectancy about treatment outcomes.

  15. Patients who identify side-effect burden as a reason for poor adherence to psychotropic medications have been shown from research studies to have all of the following characteristics except

    1. Female sex.

    2. High baseline somatization.

    3. Psychosis.

    4. Younger age.

  16. Interventions that may help to manage dry mouth caused by anticholinergic drugs include all of the following except

    1. Glycopyrrolate 1 mg bid.

    2. Pilocarpine 20 mg/day.

    3. Carboxymethyl cellulose solution.

    4. Cevimeline 30 mg/day.

  17. A 23-year-old psychotropically naive South African black woman presents for treatment of social anxiety and generalized anxiety disorder. She identifies herself as being “especially sensitive” to side effects in general and asks that you prescribe “the lowest possible dose” of any medication you think appropriate. One week after beginning paroxetine at 10 mg/day, she calls to complain of severe nausea, headaches, and dizziness, and asks for your guidance. What is your impression and recommendation?

    1. Her anxiety is likely exacerbating her sensitivity to side effects; encourage her to stay with the medication at this dose to overcome the very problem for which she is seeking treatment.

    2. Suspect that her adherence is spotty and she is having withdrawal symptoms; emphasize to her the importance of regular daily dosing and full adherence.

    3. Recognize that she has a 1 in 5 likelihood of being a poor CYP2D6 metabolizer and is probably supratherapeutic on a paroxetine dose of 10 mg/day; advise her to lower the dose to 5 mg/day and reassess after several days.

    4. Declare her a “negative therapeutic reactor” and refer her for more intensive psychotherapy.

  18. A 24-year-old man with treatment-resistant depression is taking a regimen of pramipexole 2.5 mg/day, lisdexamfetamine 60 mg/day, vortioxetine 10 mg/day, and bupropion XL 300 mg/day. He reports several episodes of almost falling asleep at the wheel while driving. Which of the following would be the most appropriate next step in his evaluation and treatment?

    1. Increase his lisdexamfetamine to 70 mg/day.

    2. Add armodafinil 150 mg/day to his regimen.

    3. Discontinue pramipexole.

    4. Measure a serum vortioxetine level to determine if it is supratherapeutic due to a drug interaction with bupropion.

  19. In studies of aripiprazole for adults with schizophrenia, which of the following adverse effects demonstrated a dose relationship?

    1. Sedation or somnolence.

    2. Extrapyramidal adverse effects.

    3. Akathisia.

    4. Nausea.

  20. All of the following statements regarding skin rashes associated with lamotrigine are true except

    1. Rapid dose escalation is a known risk factor for the emergence of serious rashes.

    2. Systemic steroids are sometimes used to treat serious rashes soon after their emergence.

    3. Lamotrigine should always be immediately discontinued whenever any skin rash emerges.

    4. Cotherapy with divalproex may increase the risk of rash because divalproex inhibits the Phase II hepatic metabolism of lamotrigine.

  21. Identified risk factors for the development of type 2 diabetes during treatment with SSRIs include which of the following?

    1. High baseline body mass index.

    2. Lengthy exposure and high dosing.

    3. Severity of depression symptoms.

    4. Atypical depressive symptoms.

  22. Sexual dysfunction has been shown to be a dose-related phenomenon with all of the following medications except

    1. Fluoxetine.

    2. Citalopram.

    3. Venlafaxine.

    4. Risperidone.

  23. All of the following are more common in women than men except

    1. Higher rates of anorgasmia from SSRIs.

    2. Greater risk for SSRI-associated osteoporosis.

    3. More extensive hyperprolactinemia from antipsychotic medications.

    4. Higher risk of weight gain from olanzapine or risperidone.

  24. Which of the following adverse drug effects is usually a transient phenomenon?

    1. Cognitive impairment associated with topiramate.

    2. Tremor associated with divalproex.

    3. Sexual dysfunction during SSRI therapy.

    4. Nausea associated with SSRI initiation.

  25. Which of the following physical signs would be useful in differentiating serotonin syndrome from NMS?

    1. Tremor.

    2. Clonus.

    3. Muscle rigidity.

    4. Fever.

  26. Differences between valbenazine and tetrabenazine include all of the following except

    1. VMAT2 inhibition is irreversible with tetrabenazine but reversible with valbenazine.

    2. Tetrabenazine must be dosed more frequently than valbenazine because of its shorter half-life.

    3. Valbenazine’s predominant metabolite, [α]-+-dihydrotetrabenazine, has minimal binding affinity at D1 and D2 receptors, whereas tetrabenazine’s multiple active metabolites include some with high D1 and D2 binding affinities.

    4. Depression and suicidality have not been observed as adverse effects in clinical trials of valbenazine, in contrast to tetrabenazine.

  27. Which of the following agents has demonstrated over a 5-kg weight loss as compared with placebo over 16 weeks in overweight, prediabetic patients taking olanzapine or clozapine?

    1. Metformin.

    2. Topiramate.

    3. Liraglutide.

    4. Bupropion.

  28. Which of the following statements is true for a 38-year-old male nonsmoker with schizophrenia who is about to start taking clozapine 200 mg/day and whose pooled cohort risk equation score is 7.5%?

    1. The potential benefits of taking an SGA with high metabolic risk are outweighed by his relatively high risk for a heart attack in the next 10 years.

    2. He has a 92.5% risk of having an MI before age 65.

    3. His score of 7.5% warrants cotherapy with a statin, especially if he is about to begin clozapine.

    4. His risk of a heart attack in the next 10 years is no greater than would be expected for anyone else of his age and sex, posing little increased baseline risk if he begins an SGA that has high metabolic risk.

  29. Which of the following SGAs carries the lowest risk for QTc prolongation?

    1. Aripiprazole.

    2. Iloperidone.

    3. Ziprasidone.

    4. Quetiapine.

  30. Improvement in dimensions of cognitive functioning in euthymic bipolar disorder patients has been demonstrated in randomized trials with all of the following agents except

    1. Lurasidone.

    2. Withania somnifera.

    3. Pramipexole.

    4. Divalproex.

  31. Logical strategies to manage nausea associated with vortioxetine include all the following except

    1. Dosage reductions.

    2. Adjunctive ondansetron 4–8 mg orally once or twice daily as needed.

    3. Adjunctive trimethobenzamide 300 mg orally every 4–6 hours as needed.

    4. Adjunctive prochlorperazine 10 mg orally every 4–6 hours as needed.

  32. Evidence-based strategies to minimize the risk for renal insufficiency during long-term lithium therapy include which one of the following?

    1. Once-per-day lithium dosing.

    2. Three-times-per-day lithium dosing.

    3. Use of lithium citrate rather than lithium carbonate.

    4. Favoring serum lithium levels no higher than 0.9 mEq/L when clinically feasible.

  33. Pharmacogenetic testing reveals that a 24-year-old white man with major depression and comorbid attention-deficit disorder is a CYP450 2D6 slow metabolizer. Usual maximal dosing should be halved for all of the following drugs except

    1. Mixed amphetamine salts.

    2. Citalopram.

    3. Venlafaxine.

    4. Vortioxetine.

  34. A 37-year-old man with stable schizoaffective disorder and a history of akathisia on previous low doses of antipsychotics is taking iloperidone 8 mg twice daily, divalproex 1,000 mg/day, vilazodone 40 mg/day, and primidone 100 mg/day for tremor. His internist also prescribes him celecoxib 200 mg/day for chronic back pain as well as hydroxyzine 50 mg/day and medical marijuana (cannabidiol) for anxiety. He has been complaining of palpitations, and his internist obtains an ECG, which shows a QTc of 493 msec. Alarmed, the internist calls you and demands that you immediately stop the patient’s iloperidone altogether. Why might this intervention be unnecessary?

    1. The vilazodone is likely raising levels of iloperidone and should be stopped.

    2. The primidone is likely raising levels of iloperidone and should be stopped.

    3. Iloperidone levels could be elevated by celecoxib, hydroxyzine, and cannabidiol, and consideration should be given to stopping those prescriptions if they are not essential.

    4. Divalproex is likely raising levels of iloperidone, and a stat valproic acid level should be checked to rule out valproate toxicity.

  35. A 54-year-old African American male with sickle cell trait has been started on escitalopram 10 mg/day for major depression. He complains of anorgasmia and diminished libido. Which one of the following would be the safest evidence-based strategy to counteract this problem?

    1. Add bupropion.

    2. Add sildenafil.

    3. Add trazodone.

    4. Add vardenafil.

  36. A 28-year-old married woman with a history of two prior depressive episodes is now 36 weeks pregnant. She had been taking sertraline consistently since it was begun for postpartum depression after the birth of her first child 3 years earlier. Her obstetrician advised her to taper off the medication before delivery in order to avert withdrawal in the newborn. She now seeks a second opinion about her pharmacotherapy. Which one of the following would you likely do?

    1. Agree with her obstetrician that it is wisest to discontinue an SSRI before delivery so as to minimize the risk for neonatal abstinence syndrome.

    2. Tell her that in the unlikely event neonatal abstinence syndrome occurs, it carries a high chance that the baby would require admission to a neonatal intensive care unit and possible endotracheal intubation, but her risk for a recurrence of postpartum depression by stopping sertraline clearly outweighs the possibility of severe withdrawal in the newborn.

    3. Tell her that neonatal abstinence syndrome in the newborn is usually a mild, transient phenomenon occurring only in about a third of women who take an SSRI during pregnancy, but if it occurs it is typically self-limited and requires no special intervention.

    4. Switch the patient’s medication now from sertraline to fluoxetine preemptively to minimize the chances of SSRI discontinuation in the newborn.

  37. A 41-year-old man with bipolar disorder well controlled on lithium carbonate is training to run a marathon. His primary care doctor noticed that his serum creatinine had recently increased from its usual level of about 0.9 ng/dL to 1.1 ng/dL and is concerned about the rise of >20% in just 3 months. His lithium level remains steady at 0.7 mEq/L. The patients says he drinks “tons of water.” He has now been sent to his psychiatrist with the request that the lithium be stopped and another drug used instead. Which one of the following would be the most appropriate response by the psychiatrist?

    1. While preparing for the marathon, advise the patient that he probably is nevertheless dehydrated despite his assumptions to the contrary, and advise him just to increase his fluid intake even further before making any changes to his regimen.

    2. Discontinue the lithium over a 2-week period because of the sudden deterioration in his renal function, and cross-taper to divalproex.

    3. Measure a serum cystatin C from which to recalculate his estimated glomerular filtration rate (eGFR).

    4. Reassure both the patient and the primary care doctor that a serum creatinine of 1.1 ng/dL is still well within the usual normal reference range, and advise just rechecking it again in a month or two.

  38. A 29-year-old man with bipolar II disorder and comorbid generalized anxiety disorder takes lithium 900 mg/day and gabapentin 600 mg/day and complains of feeling sedated. His psychotherapist suggested to him that he may have a “slow metabolism” and ought to ask you to please order a phamacogenetic test on him to affirm this. You smile politely and gently state your opinion that pharmacogenetic testing would have no value in this instance. Why?

    1. Lithium can cause sedation at a usual dose such as his, and it would be more prudent to check a serum lithium level to make sure that his complaints of sedation do not reflect lithium neurotoxicity.

    2. Gabapentin can cause sedation at a usual dose such as his, and one could consider whether a lower dose would be better tolerated.

    3. Neither lithium nor gabapentin undergoes hepatic metabolism.

    4. All of the above.

  39. This same psychotherapist calls you about another female patient with bipolar II disorder on an oral contraceptive who takes lamotrigine 150 mg/day and is clinically stable but feels slight cognitive dulling. The patient obtained pharmacogenetic testing from her current psychiatrist, who determined that she is a CYP450 2D6 poor metabolizer, and the psychotherapist is concerned the lamotrigine may, for the patient, be supratherapeutically dosed. What would you advise?

    1. Suggest measuring a serum lamotrigine level to determine if it is in the toxic range.

    2. Obtain neuropsychological testing to document the nature and extent of possible cognitive deficits.

    3. Gently state your opinion that the pharmacogenetic testing results are not relevant.

    4. Tell her that the oral contraceptive is probably inhibiting the metabolism of lamotrigine and causing a supratherapeutic dosing effect, for which a lower lamotrigine dose may be worth considering.

  40. A 44-year-old man with binge-eating disorder, generalized anxiety disorder, obesity, and hypercholesterolemia is taking lisdexamfetamine 60 mg/day, topiramate 100 mg/day, fluoxetine 40 mg/day, and atorvastatin 40 mg/day. He calls to complain of leg pains. He also feels his panic attacks are becoming worse and says he sometimes finds it harder to breathe comfortably. He is afebrile, has a clear sensorium, and denies feeling stiff when asked by telephone. A serum CK level, ordered 2 days earlier by the patient’s internist, was 236 IU/L (normal reference range is 60–174 IU/L). BUN and creatinine are within the normal reference range. Which one of the following is the most plausible explanation for his symptom?

    1. Statin-induced myositis.

    2. Neuroleptic malignant syndrome.

    3. Serotonin syndrome.

    4. Acute rhabdomyolysis likely secondary to myotoxicity.

  41. A patient who demonstrates myoclonic jerking movements would be suspected of having any of the following except

    1. Serotonin syndrome.

    2. Epilepsy.

    3. Lithium toxicity.

    4. An adverse effect of levetiracetam.

  42. An 83-year-old normotensive man with chronic depression that has been well controlled with sertraline 100 mg/day for the past 6 months presents with somnolence and confusion. He has no recent gastrointestinal complaints. Which one of the following interventions would be the most useful in the diagnosis and management of his acute mental status change?

    1. Obtain serum electrolytes.

    2. Obtain a serum sertraline level.

    3. Switch from generic sertraline to brand name Zoloft.

    4. Augment his regimen with a low-dose stimulant to help overcome sedation and possible cognitive dulling from sertraline.

  43. A patient with multi-drug-resistant major depression responds well to tranylcypromine 60 mg/day plus aripiprazole 5 mg/day. He complains of dizziness and lightheadedness on standing and has orthostatic blood pressure changes on examination. All of the following interventions would be appropriate except

    1. Cautiously lower the tranylcypromine dose to see if the antidepressant response is retained at a lower dose, because orthostatic hypotension from MAOIs can be dose-dependent.

    2. Discontinue the aripiprazole as the probable cause of the orthostatic hypotension because of its α1 antagonism.

    3. Begin oral midodrine 5 mg three times per day.

    4. Begin oral fludrocortisone 0.1 mg/day.

  44. The second-generation antipsychotic with the least likelihood for causing weight gain in schizophrenia, based on short-term clinical trials, is which of the following?

    1. Ziprasidone.

    2. Iloperidone.

    3. Asenapine.

    4. Lurasidone.

  45. A 51-year-old man with schizoaffective disorder has been stabilized on clozapine 250 mg/day recently augmented with armodafinil 150 mg/day to counteract sedation, sublingual atropine sulfate 1% solution for sialorrhea, and divalproex sodium 500 mg/day targeting irritability and affective instability. At routine follow-up, he presents with persistent sedation and new gait instability and dizziness. What is the most likely explanation for these symptoms?

    1. Likely additive general side-effect burden of clozapine plus divalproex; check a serum valproate level to ensure it is not toxic and possibly lower the divalproex dose, or else possibly increase the armodafinil dose to promote greater wakefulness effect.

    2. Systemic vagolytic effects caused by systemic absorption of sublingual atropine.

    3. Increase in serum clozapine levels due to pharmacokinetic inhibition caused by modafinil.

    4. Increase in serum clozapine levels due to pharmacokinetic inhibition caused by divalproex.

  46. A 24-year-old obese man with major depression has been treated with duloxetine 120 mg/day, lithium carbonate 900 mg/day, and topiramate 100 mg/day. For the past 3 years, he has also used a specially compounded intranasal formulation of ketamine four to five times a week. In the course of his initial evaluation, he mentions having frequent urination, nocturia, and occasional suprapubic pain. Which of the following is the least likely iatrogenic explanation for his urinary complaints?

    1. Ulcerative cystitis.

    2. Nephrogenic diabetes insipidus.

    3. Renal calculus.

    4. Urinary retention.

  47. All of the following medications can be associated with anticholinergic (antimuscarinic or antinicotinic) adverse effects except

    1. Carbamazepine.

    2. Paroxetine.

    3. Atomoxetine.

    4. Bupropion.

  48. A single-agent overdose of which of the following medications would least expectably be associated with fatality?

    1. 8,000 mg of divalproex in an 84-kg male.

    2. 27,000 mg of lithium carbonate in a 75-kg male.

    3. 240 mg of dextroamphetamine in an 80-kg male.

    4. 49,000 mg of gabapentin in a 62-kg female.

  49. A 46-year-old Vietnamese man has for over 3 years been taking lamotrigine 400 mg/day for bipolar II disorder and carbamazepine 600 mg/day for trigeminal neuralgia. He presents with an itchy, tingling, burning, rather linear rash, of 1 week’s duration, with some crusting running from below the midline base of his rib cage across his trunk. There is no fever and no oropharyngeal lesions. Which of the following would be the most appropriate next step in his assessment and management?

    1. Obtain pharmacogenetic testing to determine the presence of the DQB1*06:02 gene.

    2. Immediately discontinue both lamotrigine and carbamazepine.

    3. Recommend an as-needed nonsteroidal anti-inflammatory drug for pain but otherwise do nothing.

    4. Recommend an oral antihistamine such as diphenhydramine 50 mg every 6 hours and a topical over-the-counter steroid cream.

  50. A 17-year-old male with a suspected drug overdose presents to an emergency department with fever, vomiting, muscle twitching, sweating, tachycardia, and mydriasis. If this presentation occurred from a single-agent toxicity, which of the following would be the most likely causal agent?

    1. Lorazepam.

    2. Methylphenidate.

    3. Buspirone.

    4. Mirtazapine.

Answer Guide

  1. The rationale for using metformin to counteract psychotropically induced weight gain involves which of the following?

    1. Decreasing insulin sensitivity.

    2. Direct appetite suppression via the hypothalamic satiety center.

    3. Blockade of postsynaptic 5-HT2C receptors.

    4. Agonism of H1 receptors.

    The correct response is option A.

    Metformin is thought to promote weight loss by decreasing insulin sensitivity. None of the other answers is a correct or plausible explanation for its presumed mechanism of action.

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Sep 1, 2019 | Posted by in PSYCHOLOGY | Comments Off on 2: Self-Assessment Questions and Answers
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