SCHIZOPHRENIA
Definition
• Schizophrenia: A psychiatric disorder involving chronic or recurrent psychosis. It is a
burdensome condition that leads to significant functional disability.
• Psychiatry: The branch of medicine dealing with the diagnosis and treatment of mental
disorders related to psychosis and other conditions.
• Psychosis: A disturbance in the perception of reality, evidenced by symptoms like
hallucinations, delusions, or thought disorganization. Psychotic states are periods of high
risk for agitation, aggression, and impulsivity.
• Overall Syndrome: Schizophrenia is a heterogeneous syndrome characterized by
disorganized and bizarre thoughts, delusions, hallucinations, inappropriate affect, and
impaired psychosocial functioning.
Epidemiology
• Lifetime Prevalence: Ranges from 0.28% to 0.6% globally.
• Global Impact: Over 26 million people worldwide live with schizophrenia.
• Onset: Usually occurs in late adolescence or early adulthood (15-25 years old). Onset is
rare before adolescence or after age 40.
• Gender Differences:
• Prevalence is equal in males and females.
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• The onset of illness tends to be earlier in males (early 20s) compared to females
(late 20s).
• Prognosis is generally worse in men.
• Social Impact: Schizophrenia is a disabling disease, with high rates of homelessness
(50%), mental health admissions (50%), and unemployment (80%).
Etiology and Pathophysiology
The exact cause is unknown, but it is considered multifactorial.
• Genetic Base:
• 10% risk for first-degree relatives of a patient.
• 40% risk if both parents have the diagnosis.
• ~50% concordance rate for monozygotic (identical) twins.
• Environmental Factors: Prenatal difficulties (e.g., malnutrition in the first trimester),
perinatal complications, substance use, and immigration have been linked.
• Neuroanatomy: Brain abnormalities include increased ventricular size and decreased
gray matter.
Neurotransmitter Hypotheses:
1. Dopaminergic Hypothesis: The central theory, suggesting that psychosis results from
hyperactivity or hypoactivity of dopaminergic processes in specific brain regions.
• Positive Symptoms (hallucinations, delusions) are linked to hyperactivity of
dopamine in the mesolimbic pathway.
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• Negative and Cognitive Symptoms are linked to hypoactivity of dopamine in the
mesocortical pathway.
• Evidence: Drugs that increase dopamine (agonists like L-Dopa, amphetamines) can
induce psychosis, while drugs that decrease dopamine (antagonists like neuroleptics)
reduce psychosis.
2. Glutamatergic Dysfunction: A deficiency in glutamatergic activity, particularly at the
NMDA receptor, can produce symptoms similar to dopamine hyperactivity. Drugs that
block NMDA receptors (like PCP and ketamine) can induce a schizophrenic-like state.
3. Serotonin (5-HT) Abnormalities: Schizophrenic patients may have higher blood 5-
HT concentrations, which correlate with increased ventricular size. 5-HT2A antagonists
are a key component of atypical antipsychotics.
Clinical Presentation
• Acute Episode: Characterized by being "out of touch with reality."
• Symptom Categories:
1. Positive Symptoms: The presence of abnormal functions.
• Delusions: Fixed false beliefs (e.g., paranoia, grandiosity).
•Hallucinations: Sensory experiences without external stimuli. Auditory
hallucinations (hearing voices) are most common (40-80%).
• Disorganized Speech: Loose associations, tangentiality.
• Disorganized or Catatonic Behavior.
2. Negative Symptoms: The absence or reduction of normal functions.
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• Alogia: Poverty of speech.
• Avolition: Lack of motivation.
• Anhedonia: Inability to experience pleasure.
• Flat Affect: Diminished emotional expression.
• Asociality: Social withdrawal.
3. Cognitive Symptoms:
• Impaired attention and working memory.
• Difficulty with executive function (planning, problem-solving).
• Residual Features: After an acute psychotic episode resolves, patients may experience
anxiety, suspiciousness, lack of motivation, and poor insight.
Diagnosis (DSM-5 Abbreviated Criteria)
• Criterion A: At least two of the following symptoms, each present for a significant
portion of time during a 1-month period (at least one must be 1, 2, or 3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
• Criterion B: Significant impairment in functioning (work, social relations, self-care).
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• Criterion C: Continuous signs of the disturbance persist for at least 6 months, including
at least 1 month of active-phase symptoms.
Treatment Principles and Phases
• Desired Outcomes: Alleviate target symptoms, prevent relapse, improve psychosocial
functioning, and avoid side effects.
• Phases of Treatment:
1. Acute Phase (<7 days): Goal is to decrease agitation, hostility, and normalize
sleep/eating patterns.
2. Stabilization Phase (6-8 weeks): Goal is to improve socialization, self-care, and
formal thought processes.
3. Maintenance Phase: Goal is to avoid relapses. Antipsychotics should be continued
for at least 18 months (2-3 years) after remission from a first episode. For patients with
recurrent episodes, treatment is often indefinite.
Pharmacotherapy: Antipsychotics
A. First-Generation (Typical) Antipsychotics (FGAs)
• Mechanism: High D2 receptor antagonism, low 5-HT2A antagonism.
• Efficacy: Primarily effective for positive symptoms.
• Side Effects: High risk of Extrapyramidal Symptoms (EPS) and Tardive Dyskinesia
(TD).
• Potency:
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• High Potency (e.g., Haloperidol, Fluphenazine): Higher risk of EPS.
• Low Potency (e.g., Chlorpromazine, Thioridazine): Higher risk of sedation,
anticholinergic effects, and orthostatic hypotension.
B. Second-Generation (Atypical) Antipsychotics (SGAs)
• Mechanism: Moderate-to-high 5-HT2A antagonism and lower D2 antagonism.
• Efficacy: Effective for positive, negative, and cognitive symptoms.
• Role: Considered first-line treatment (except clozapine).
• Side Effects: Lower risk of EPS and TD, but a higher risk of metabolic side effects
(weight gain, hyperlipidemia, hyperglycemia).
• Examples: Risperidone, Olanzapine, Quetiapine, Aripiprazole, Ziprasidone, Clozapine.
C. Clozapine: The most effective antipsychotic, but reserved for treatment-resistant
schizophrenia due to the risk of severe agranulocytosis (requires weekly blood
monitoring initially).
D. Long-Acting Injectable Antipsychotics (LAIAs) / Depot Dosing:
• Use: Considered for patients with partial or poor adherence.
• Formulation: An ester form of the drug is attached to a fatty acid chain and dissolved in
an oil vehicle, allowing for slow, gradual release over time.
• Examples: Haloperidol Decanoate, Fluphenazine Decanoate, Risperidone Microspheres,
Paliperidone Palmitate, Aripiprazole Monohydrate.
Key Adverse Effects
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• Extrapyramidal Symptoms (EPS):
1. Dystonia: Sudden, sustained muscle spasms (e.g., torticollis).
2. Akathisia: An intense feeling of inner restlessness and an inability to sit still.
3. Pseudo-Parkinsonism: Tremor at rest, rigidity, bradykinesia.
• Tardive Dyskinesia (TD): Involuntary, repetitive movements of the face, limbs, and
trunk. Often irreversible. Incidence is ~20%.
• Neuroleptic Malignant Syndrome (NMS): A rare but life-threatening emergency
characterized by fever, muscle rigidity, autonomic instability, and altered mental status.
• Metabolic Side Effects: Weight gain, hyperglycemia, and dyslipidemia are most
prominent with clozapine and olanzapine.
• Endocrine: Hyperprolactinemia (increased prolactin level), leading to sexual
dysfunction, gynecomastia, and galactorrhea. Highest risk with FGAs and risperidone.
• Cardiovascular: Orthostatic hypotension and QTC prolongation (especially with
thioridazine and ziprasidone).
• Anticholinergic Effects: Dry mouth, blurred vision, constipation, urinary retention
(common with low-potency FGAs and clozapine).
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Standard Multiple-Choice Questions (50)
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1. Schizophrenia is a psychiatric disorder primarily characterized by chronic or recurrent:
a) Anxiety
b) Psychosis
c) Depression
d) Mania
2. The Dopaminergic Hypothesis suggests that positive symptoms of schizophrenia are
related to:
a) Hyperactivity of dopamine in the mesolimbic pathway
b) Hypoactivity of dopamine in the mesolimbic pathway
c) Hyperactivity of dopamine in the mesocortical pathway
d) Hypoactivity of dopamine in the mesocortical pathway
3. According to the DSM-5, a diagnosis of schizophrenia requires continuous signs of
disturbance for at least:
a) 2 weeks
b) 1 month
c) 6 months
d) 1 year
4. Which of the following is considered a negative symptom of schizophrenia?
a) Hallucinations
b) Delusions
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c) Disorganized speech
d) Avolition (lack of motivation)
5. The most common type of hallucination experienced by individuals with schizophrenia
is:
a) Visual
b) Olfactory
c) Tactile
d) Auditory
6. First-Generation (Typical) Antipsychotics (FGAs) primarily work by blocking which
receptor?
a) 5-HT2A
b) D2 (Dopamine)
c) H1 (Histamine)
d) M1 (Muscarinic)
7. Second-Generation (Atypical) Antipsychotics (SGAs) are considered first-line
treatment mainly because they have:
a) Higher efficacy for positive symptoms
b) A lower risk of Extrapyramidal Symptoms (EPS)
c) No metabolic side effects
d) A faster onset of action
8. Which of the following is a high-potency FGA?
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a) Chlorpromazine
b) Thioridazine
c) Haloperidol
d) Clozapine
9. Which adverse effect is characterized by an intense inner restlessness and an inability
to sit still?
a) Dystonia
b) Akathisia
c) Tardive Dyskinesia
d) Pseudo-Parkinsonism
10. Neuroleptic Malignant Syndrome (NMS) is a life-threatening condition characterized
by muscle rigidity, autonomic instability, altered mental status, and:
a) Hypothermia
b) Fever
c) Bradycardia
d) Severe rash
11. Tardive Dyskinesia (TD) is a long-term side effect involving involuntary movements
that is often:
a) Easily treated with anticholinergics
b) A sign of treatment success
c) Irreversible
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d) An acute reaction to the first dose
12. Clozapine is reserved for treatment-resistant schizophrenia due to its risk of:
a) Severe EPS
b) Agranulocytosis
c) QTC prolongation
d) Tardive Dyskinesia
13. Which two SGAs are most associated with a high risk of metabolic side effects like
weight gain and diabetes?
a) Aripiprazole and Lurasidone
b) Ziprasidone and Iloperidone
c) Clozapine and Olanzapine
d) Risperidone and Paliperidone
14. Blocking dopamine in which pathway is thought to lead to Extrapyramidal Symptoms
(EPS)?
a) Mesolimbic pathway
b) Mesocortical pathway
c) Nigrostriatal pathway
d) Tuberoinfundibular pathway
15. Blocking dopamine in the tuberoinfundibular pathway leads to what adverse effect?
a) EPS
b) Sedation
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c) Increased prolactin levels (Hyperprolactinemia)
d) Weight gain
16. What is the usual age of onset for schizophrenia?
a) Childhood (5-10 years)
b) Late adolescence/early adulthood (15-25 years)
c) Middle age (40-50 years)
d) Late life (>65 years)
17. The Glutamatergic Dysfunction hypothesis of schizophrenia focuses on which
receptor?
a) D2
b) 5-HT2A
c) GABA-A
d) NMDA
18. The acute phase of schizophrenia treatment typically lasts:
a) < 7 days
b) 6-8 weeks
c) 4-9 months
d) 1-2 years
19. Long-Acting Injectable Antipsychotics (LAIAs) are primarily used to:
a) Provide a faster onset of action
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b) Reduce metabolic side effects
c) Improve adherence in patients with poor compliance
d) Treat negative symptoms only
20. Which FGA is particularly known for causing significant QTc prolongation?
a) Haloperidol
b) Fluphenazine
c) Thioridazine
d) Chlorpromazine
21. A sudden, sustained, involuntary muscle spasm, often in the head and neck area, is
called:
a) Akathisia
b) Dystonia
c) Tremor
d) Myoclonus
22. What is the approximate risk of developing schizophrenia if one's identical twin has
the disorder?
a) 10%
b) 25%
c) 50%
d) 90%
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23. Which term describes a state of diminished emotional expression?
a) Alogia
b) Avolition
c) Anhedonia
d) Flat affect
24. Which SGA loses its "atypical" properties and acts more like an FGA at higher doses
(>6mg)?
a) Olanzapine
b) Quetiapine
c) Risperidone
d) Aripiprazole
25. According to the treatment algorithm, if a treatment-naïve patient fails their first
antipsychotic, the next step is often to:
a) Add a second antipsychotic
b) Refer for ECT
c) Switch to a different antipsychotic
d) Augment with an antidepressant
26. Which of the following is a cognitive symptom of schizophrenia?
a) Delusions
b) Impaired working memory
c) Flat affect
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d) Auditory hallucinations
27. The term "psychosis" refers to:
a) A state of extreme sadness
b) A pattern of impulsive behavior
c) A disturbance in the perception of reality
d) A chronic lack of motivation
28. Low-potency FGAs like chlorpromazine are associated with a higher risk of:
a) EPS
b) Sedation and anticholinergic effects
c) Akathisia
d) Tardive Dyskinesia
29. The initial goal of the stabilization phase of treatment (6-8 weeks) is:
a) Complete remission of all symptoms
b) Improvement in socialization and self-care habits
c) Finding a suitable long-acting injectable
d) Preventing future relapses
30. The maintenance treatment after a first episode of schizophrenia should be continued
for at least:
a) 6 months
b) 1 year
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c) 18 months (2-3 years)
d) 5 years
31. Which of the following is NOT a second-generation (atypical) antipsychotic?
a) Risperidone
b) Olanzapine
c) Quetiapine
d) Fluphenazine
32. What is the primary management strategy for Dystonia?
a) Increasing the antipsychotic dose
b) Administering an anticholinergic agent or a benzodiazepine
c) Switching to a low-potency FGA
d) Waiting for it to resolve on its own
33. Which SGA is known to be a partial agonist at the D2 receptor?
a) Clozapine
b) Olanzapine
c) Risperidone
d) Aripiprazole
34. A delusion is best defined as:
a) A sensory perception without an external stimulus
b) A diminished range of emotional expression
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c) A fixed, false belief that is resistant to evidence
d) A severe disorganization of speech
35. Which side effect requires regular monitoring of ANC (Absolute Neutrophil Count)?
a) Tardive Dyskinesia
b) Neuroleptic Malignant Syndrome
c) Agranulocytosis with clozapine
d) Akathisia
36. In the treatment algorithm, what is the recommended monotherapy for a patient who
has had an inadequate response to two appropriate antipsychotic trials?
a) Haloperidol
b) Risperidone
c) Clozapine
d) Aripiprazole
37. Aripiprazole lauroxil is a long-acting injectable that can be administered at what
frequency?
a) Every day
b) Every week
c) Every 6 weeks or every 2 months
d) Every 6 months
38. Sialorrhea (drooling), especially at night, is a prominent side effect of which
antipsychotic?
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a) Haloperidol
b) Aripiprazole
c) Clozapine
d) Risperidone
39. The term "alogia" refers to:
a) Lack of pleasure
b) Lack of motivation
c) Poverty of speech
d) Social withdrawal
40. High-potency FGAs have a higher binding affinity to which receptor?
a) 5-HT2A
b) D2
c) H1
d) Alpha-1
41. Which of the following is a predictor of a good antipsychotic response?
a) Insidious onset
b) Onset in childhood
c) Acute onset and short duration of illness
d) Enlarged ventricles
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42. The "FARM" acronym for NMS presentation stands for Fever, Autonomic instability,
Rigidity, and:
a) Myoclonus
b) Malaise
c) Mental status change
d) Muscle weakness
43. Which antipsychotic requires a meal of at least 350-500 calories for proper
absorption?
a) Olanzapine
b) Risperidone
c) Lurasidone and Ziprasidone
d) Aripiprazole
44. Depot formulations of FGAs, like haloperidol decanoate, utilize what kind of
chemical structure to allow for slow release?
a) A salt complex
b) An ester form attached to a fatty acid chain
c) A microsphere encapsulation
d) A liposomal delivery system
45. Which of the following is NOT a positive symptom of schizophrenia?
a) Delusions
b) Hallucinations
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c) Flat affect
d) Disorganized speech
46. Which of the following is a key component of a diagnostic workup for schizophrenia?
a) A trial of antipsychotic medication
b) A thorough patient history and mental status examination
c) An EEG to confirm the diagnosis
d) A genetic test
47. Anticholinergic side effects are caused by the blockade of which receptors?
a) Dopamine
b) Serotonin
c) Histamine
d) Muscarinic
48. A patient on an FGA develops a shuffling gait, stooped posture, and a tremor at rest.
This is known as:
a) Dystonia
b) Akathisia
c) Pseudo-Parkinsonism
d) Tardive Dyskinesia
49. Olanzapine pamoate, a long-acting injectable, carries a risk of what rare but serious
post-injection syndrome?
a) Serotonin syndrome
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b) Hypertensive crisis
c) Sedation/delirium
d) Agranulocytosis
50. What is a key reason that SGAs are thought to be effective for negative symptoms,
unlike FGAs?
a) Their high D2 antagonism
b) Their blockade of histamine receptors
c) Their high 5-HT2A antagonism
d) Their partial D2 agonism
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Case-Based Multiple-Choice Questions (50)
1. A 19-year-old male is brought to the emergency department by his family. For the past
month, he has been expressing beliefs that the FBI is monitoring his thoughts. He also
reports hearing voices commenting on his actions. He has become socially withdrawn.
This is his first psychotic episode. What is the most likely diagnosis?
a) Bipolar I Disorder
b) Major Depressive Disorder with Psychotic Features
c) Schizophrenia
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d) Delusional Disorder
2. A 22-year-old patient is diagnosed with schizophrenia. As he is treatment-naïve, which
medication would be an appropriate first-line choice?
a) Risperidone
b) Clozapine
c) Haloperidol
d) Thioridazine
3. A patient on haloperidol develops a sudden, painful spasm in his neck where his head
is twisted to one side. This is an example of:
a) Akathisia
b) Tardive Dyskinesia
c) Dystonia
d) Pseudo-Parkinsonism
4. A 45-year-old patient with chronic schizophrenia has failed adequate trials of
olanzapine and risperidone. According to the treatment algorithm, what is the next
recommended step?
a) Augmenting risperidone with an antidepressant
b) Switching to a low-potency FGA like chlorpromazine
c) Discontinuing all medications
d) Initiating monotherapy with clozapine
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5. A patient on a high dose of an antipsychotic is brought to the ER with a temperature of
104°F (40°C), "lead-pipe" muscle rigidity, and confusion. This presentation is most
consistent with:
a) Akathisia
b) Tardive Dyskinesia
c) Neuroleptic Malignant Syndrome (NMS)
d) Serotonin Syndrome
6. A 30-year-old woman with schizophrenia is stable on risperidone but complains of
missing her menstrual periods and breast tenderness. This is most likely due to:
a) Anticholinergic effects
b) Hyperprolactinemia
c) Weight gain
d) Akathisia
7. A patient with poor adherence to oral antipsychotics is being considered for a long-
acting injectable (LAIA). The team chooses paliperidone palmitate. This is an example of
what type of antipsychotic?
a) A low-potency FGA
b) A high-potency FGA
c) An SGA
d) An anticholinergic
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8. A 65-year-old patient on an antipsychotic develops involuntary, repetitive chewing and
lip-smacking movements. These symptoms have been present for several months. This is
most characteristic of:
a) Dystonia
b) Akathisia
c) Pseudo-Parkinsonism
d) Tardive Dyskinesia
9. A patient is started on olanzapine. What is the most important parameter to monitor at
baseline and regularly thereafter?
a) Prolactin levels
b) Absolute neutrophil count
c) Weight, blood glucose, and lipids
d) QTc interval
10. An acutely agitated and psychotic patient in the ER refuses oral medication. Which of
the following would be an appropriate immediate intervention?
a) IM olanzapine
b) Oral clozapine
c) IM paliperidone palmitate (LAIA)
d) Oral chlorpromazine
11. A patient on chlorpromazine complains of severe dizziness upon standing. This is
most likely due to:
a) EPS
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b) Orthostatic hypotension from alpha-1 blockade
c) Hyperprolactinemia
d) Anticholinergic effects
12. A patient comes to the clinic and is constantly pacing, shifting their weight, and states
"I feel like I'm crawling out of my skin." This is a classic presentation of:
a) Akathisia
b) Dystonia
c) Anxiety
d) Psychosis
13. A patient with schizophrenia also has a significant seizure disorder. Which
antipsychotic should be used with the most caution due to its potential to lower the
seizure threshold?
a) Aripiprazole
b) Risperidone
c) Clozapine
d) Haloperidol
14. A young man on a high dose of haloperidol is being assessed for EPS. Which of the
following would be the most appropriate prophylactic treatment to consider?
a) A beta-blocker
b) An antidepressant
c) An anticholinergic like benztropine
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d) A mood stabilizer
15. A patient's positive symptoms have resolved, but they still exhibit flat affect, alogia,
and avolition. Which medication class is generally considered more effective for these
symptoms?
a) SGAs
b) FGAs
c) Benzodiazepines
d) Anticholinergics
16. A patient is stable on clozapine but their weekly WBC/ANC monitoring shows a
critically low ANC. What is the most appropriate action?
a) Lower the dose of clozapine
b) Add a second antipsychotic
c) Immediately discontinue clozapine
d) Recheck the labs in one week
17. A patient with a first episode of schizophrenia has achieved remission and completed
the acute and stabilization phases. How long should their maintenance treatment
continue?
a) 6 months
b) 1 year
c) At least 18 months (2-3 years)
d) For life
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18. A patient's family reports that the onset of his schizophrenic symptoms was very
gradual over several years, starting in early adolescence. This is considered a:
a) Good prognostic indicator
b) Poor prognostic indicator
c) Predictor of response to FGAs
d) Sign of a misdiagnosis
19. A patient is being initiated on paliperidone palmitate (LAIA). What is a key
consideration for the initial dosing?
a) A 2-week oral overlap is required.
b) It must be given in the abdomen.
c) An initial loading dose is given, followed by a second dose one week later in the
deltoid muscle.
d) The dose must be tapered up over 4 weeks.
20. A patient on an FGA presents with a tremor that is most noticeable at rest, along with
a slow, shuffling gait. This is best described as:
a) Akathisia
b) Dystonia
c) Tardive Dyskinesia
d) Pseudo-Parkinsonism
21. A patient on thioridazine needs to have which of the following monitored closely due
to a specific risk associated with this drug?
a) ANC
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b) Blood pressure
c) ECG for QTc prolongation
d) Liver function tests
22. A patient who is a heavy smoker is started on olanzapine. The clinician should be
aware that smoking can:
a) Increase the risk of EPS
b) Decrease the blood levels of olanzapine by inducing CYP1A2
c) Increase the risk of NMS
d) Block the absorption of the drug
23. A patient with schizophrenia has a partial response to aripiprazole. Which of the
following is the most appropriate next step?
a) Stop the medication immediately
b) Switch to clozapine
c) Maximize the dose of aripiprazole before considering a switch or augmentation
d) Add a second SGA
24. A patient reports that an external force is controlling their actions. This is an example
of what type of symptom?
a) A hallucination
b) A negative symptom
c) A delusion of influence
d) An illusion
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25. The first antipsychotic drug, discovered in the 1950s, was:
a) Haloperidol
b) Clozapine
c) Chlorpromazine
d) Risperidone
26. A patient on quetiapine experiences significant sedation. What is the most likely
receptor responsible for this side effect?
a) D2
b) 5-HT2A
c) H1 (Histamine)
d) Alpha-1
27. An 18-year-old male is started on a high-potency FGA. He is at highest risk for which
acute side effect?
a) Weight gain
b) Dystonia
c) Agranulocytosis
d) Tardive Dyskinesia
28. A patient taking an antipsychotic is also prescribed an SSRI. This combination
increases the risk of drug interactions, especially involving which enzyme system?
a) CYP450
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b) Glucuronidation
c) Renal clearance
d) Biliary excretion
29. A patient with schizophrenia has been stable on a low dose of an antipsychotic for 5
years. They ask if they can stop the medication. What is the best advice?
a) Yes, they can stop immediately since they have been stable for a long time.
b) They can stop the medication but should restart it if symptoms return.
c) They should be advised that lifelong maintenance is likely necessary and stopping
could lead to a severe relapse.
d) They can switch to a less potent medication like a benzodiazepine.
30. A patient on an FGA is treated for akathisia. Which of the following would be an
appropriate medication choice?
a) Benztropine
b) Propranolol
c) Haloperidol
d) Donepezil
31. A patient with a history of heart disease needs an antipsychotic. Which SGA is
associated with a higher risk of QTC prolongation and should be used with caution?
a) Aripiprazole
b) Lurasidone
c) Ziprasidone
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d) Brexpiprazole
32. A patient is diagnosed with tardive dyskinesia. What is the first step in management?
a) Increase the dose of the antipsychotic
b) Add an anticholinergic agent
c) Consider switching to an agent with a lower TD risk, like clozapine or a VMAT2
inhibitor
d) Reassure the patient that it will resolve on its own
33. A patient is being initiated on risperidone microspheres (Risperdal Consta). What is a
critical counseling point?
a) No oral antipsychotic is needed.
b) A 3-week overlap with an oral antipsychotic is required.
c) The injection is given in the abdomen.
d) The injection is given every 6 months.
34. A patient is found to have enlarged ventricles on a brain scan. In the context of
schizophrenia, this finding is considered:
a) A predictor of good response
b) A diagnostic criterion
c) A poor prognostic indicator
d) A result of medication side effects
35. Which of the following is NOT a first-line treatment for schizophrenia?
a) Risperidone
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b) Aripiprazole
c) Quetiapine
d) ECT (Electroconvulsive Therapy)
36. A patient is taking a low-potency FGA and complains of blurred vision and urinary
retention. These are due to the drug's effect on which system?
a) Dopaminergic
b) Serotonergic
c) Anticholinergic
d) Histaminergic
37. The management of NMS includes discontinuing the offending agent, supportive
care, and potentially using which medication to reduce rigidity and fever?
a) Benztropine
b) Propranolol
c) Bromocriptine or Dantrolene
d) Lorazepam
38. A patient is being started on olanzapine. They should be counseled that weight gain is
most likely to be significant during:
a) The first year of treatment
b) The first 12 weeks of treatment
c) After 2 years of treatment
d) Weight gain is not a common side effect
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39. A patient with a history of poor adherence has agreed to an LAIA. They want the one
with the longest dosing interval. Which of the following offers an every-2-month option?
a) Risperidone microspheres
b) Paliperidone palmitate
c) Aripiprazole lauroxil
d) Haloperidol decanoate
40. A patient reports a belief that television commercials are sending them secret
messages. This is an example of a:
a) Hallucination
b) Delusion
c) Negative symptom
d) Cognitive deficit
41. Which pathway, when blocked by antipsychotics, is responsible for the therapeutic
effect on positive symptoms?
a) Mesolimbic
b) Mesocortical
c) Nigrostriatal
d) Tuberoinfundibular
42. A patient with schizophrenia and comorbid diabetes is being started on an
antipsychotic. Which of the following would be a metabolically safer choice?
a) Clozapine
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b) Olanzapine
c) Ziprasidone
d) Quetiapine
43. A patient is administered an LAIA and experiences an adverse reaction. A key
challenge in this situation is that:
a) The reaction will be milder than with oral medication.
b) The medication cannot be quickly removed from the body.
c) The adverse reaction can be reversed with an antidote.
d) The patient will not be aware of the reaction.
44. The first step in the treatment algorithm for a newly diagnosed, treatment-naïve
individual is:
a) Clozapine monotherapy
b) Any antipsychotic monotherapy except clozapine
c) Combination therapy with an FGA and SGA
d) Augmentation with an antidepressant
45. A patient on a high-potency FGA is also taking a medication for allergies. This
combination could worsen which side effect?
a) EPS
b) Anticholinergic effects (sedation, dry mouth)
c) Weight gain
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d) Akathisia
46. A patient with schizophrenia has a diagnosis of glaucoma. Which side effect would
be most concerning?
a) EPS
b) Anticholinergic effects (which can worsen narrow-angle glaucoma)
c) Metabolic syndrome
d) Akathisia
47. An acutely agitated patient is given an IM injection of haloperidol. Within an hour,
they develop a fixed upward deviation of their eyes. This is an oculogyric crisis, a form
of:
a) Akathisia
b) Dystonia
c) Tardive Dyskinesia
d) NMS
48. A patient has been on a stable dose of an antipsychotic for 10 years. They have never
experienced EPS. Are they still at risk for Tardive Dyskinesia?
a) No, the risk disappears after the first 5 years.
b) No, if they didn't get EPS, they won't get TD.
c) Yes, the risk of TD increases with the duration of treatment.
d) Yes, but only if they switch to a different medication.
49. A patient with schizophrenia wants to try a non-pharmacologic therapy. Which of the
following has the strongest evidence base as an adjunct to medication?
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a) Herbal remedies
b) Psychosocial rehabilitation programs (e.g., social skills training)
c) Acupuncture
d) Dietary changes alone
50. A patient is described as having "alogia." This means they are experiencing:
a) A poverty of speech
b) A lack of pleasure
c) An inability to sit still
d) A fixed false belief
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### Answer Key
Standard Multiple-Choice Questions (50)
1. B
2. A
3. C
4. D
5. D
6. B
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7. B
8. C
9. B
10. B
11. C
12. B
13. C
14. C
15. C
16. B
17. D
18. A
19. C
20. C
21. B
22. C
23. D
24. C
25. C
26. B
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27. C
28. B
29. B
30. C
31. D
32. B
33. D
34. C
35. C
36. C
37. C
38. C
39. C
40. B
41. C
42. C
43. C
44. B
45. C
46. B
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47. D
48. C
49. C
50. C
Case-Based Multiple-Choice Answer (50)
1.C
2. A
3. C
4. D
5. C
6. B
7. C
8. D
9. C
10. A
11. B
12. A
13. C
14. C
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15. A
16. C
17. C
18. B
19. C
20. D
21. C
22. B
23. C
24. C
25. C
26. C
27. B
28. A
29. C
30. B
31. C
32. C
33. B
34. C
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35. D
36. C
37. C
38. B
39. C
40. B
41. A
42. C
43. B
44. B
45. B
46. B
47. B
48. C
49. B
50. A
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