Drug for ADHD/Drugs for OCD 3rd year 2nd semester Flashcards
Which of the following is the most effective standalone treatment for ADHD?
A) Cognitive-behavioral therapy (CBT)
B) Stimulant medications
C) Dietary elimination of artificial additives
D) Alpha-2 adrenergic agonists
Correct Answer: B) Stimulant medications because stimulant medications are the first-line treatment for ADHD, with approximately 70% of patients experiencing symptom reduction.
A is incorrect because CBT alone is not strongly supported by evidence for reducing core ADHD symptoms.
C is incorrect because while dietary elimination helps some children, there is no strong evidence supporting its use as a general treatment.
D is incorrect because alpha-2 adrenergic agonists (e.g., clonidine, guanfacine) primarily reduce aggression and impulsivity but are less effective for inattention.
DRUG OPTIONS - STIMULANTS
* Long-acting formulations are considered first-line agents
- Mixed salts amphetamine
- Methylphenidate
- Lisdexamfetamine
* Approximately 70% of patients receiving stimulant therapy experience a significant decrease in core symptoms
If a child with ADHD does not respond to a stimulant within 3-4 weeks, what is the recommended next step?
A) Increase the dose of the stimulant
B) Continue the same stimulant for at least 6 months
C) Switch to a different stimulant
D) Discontinue all pharmacologic treatment
Correct Answer: C) Switch to a different stimulant because if a patient does not respond to a stimulant within 3-4 weeks, trying a different stimulant is recommended.
A is incorrect because increasing the dose may not help if the stimulant itself is ineffective.
B is incorrect because ineffective treatment should not be continued for months without adjustments.
D is incorrect because stimulant therapy remains the mainstay of treatment, and discontinuing all treatment would likely leave symptoms unmanaged.
** What to do for patient response to medication**
If the patient responds well with minimal adverse effects, it is recommended to continue therapy for 6- 12 months
* If the patient does not respond in 3-4 weeks, an alternative stimulant should be used
- Weaning stimulant use for a 2 to 3-week period during the summer provides an opportunity to determine continued need
- Extended drug holidays are not recommended unless adverse effects are severe
- Growth suppression or weight loss >10% of initial body weight
Which of the following ADHD medications has no abuse potential and is a good option for patients with comorbid depression or substance use disorder?
A) Methylphenidate
B) Atomoxetine
C) Lisdexamfetamine
D) Clonidine
Correct Answer: B) Atomoxetine because atomoxetine is a norepinephrine reuptake inhibitor, not classified as a stimulant, and has no abuse potential.
Efficacy approaches that of stimulants but is not conclusively considered a first-line option. Good choice if the patient has comorbid depression or substance use disorder
A and C are incorrect because methylphenidate and lisdexamfetamine are stimulants, which have abuse potential.
D is incorrect because clonidine is an alpha-2 adrenergic agonist, which primarily reduces impulsivity and aggression but does not work well for inattention.
Drug Options
Patients with ADHD have an increased risk of suicidality compared to the general population. This risk is influenced by coexisting psychiatric conditions such as depression, anxiety, and substance use disorders.
Stimulants and atomoxetine have been associated with increased suicidality in some cases, though the overall risk remains low. Atomoxetine carries a black box warning for increased suicidal ideation in children and adolescents. Monitoring for mood changes, suicidal thoughts, or unusual behaviors is essential when initiating or adjusting these medications.
Stimulants have potential for abuse, particularly in individuals with a history of substance use disorder. If misuse or diversion is suspected, switching to a non-stimulant medication such as atomoxetine or guanfacine may be appropriate.
Which of the following is a serious adverse effect of stimulant medications that would require discontinuation?
A) Mild weight loss
B) Insomnia
C) Zombie-like effects (somber, expressionless, overly quiet)
D) Irritability
Correct Answer: C) Zombie-like effects (somber, expressionless, overly quiet)
C is correct because “zombie-like” effects indicate that the child is overly compliant and emotionally blunted, which may require discontinuing or adjusting the medication.
A and B are incorrect because mild weight loss and insomnia are common but manageable side effects.
D is incorrect because irritability can occur but does not necessarily require stopping the medication.
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Zombie-like effects, such as being somber, expressionless, or overly quiet, can happen with stimulant medications due to a variety of factors related to how these drugs work in the brain. Here’s why it might occur:
Overstimulation of the Nervous System: Stimulant medications (like Adderall or Ritalin) increase levels of neurotransmitters like dopamine and norepinephrine in the brain. In some cases, if the dosage is too high or if the individual has a heightened sensitivity to the medication, it can overstimulate certain brain pathways, causing a person to appear detached, overly subdued, or flat in their emotional expression.
Overactivation of the Dopamine System: Dopamine is responsible for feelings of motivation and pleasure. Stimulants increase dopamine activity, but in some people, this can lead to an imbalanced dopamine response. The individual may become so overwhelmed by the increased dopamine levels that they seem unresponsive, withdrawn, or “zombie-like.”
Emotional Numbing: Some individuals may experience emotional blunting or numbing, where their ability to feel or express emotions is dulled. This can result in the somber or expressionless appearance, which is often described as “zombie-like.”
Sensitivity or Adverse Reactions: Some people are more sensitive to stimulant medications due to factors like genetics, other medications they are taking, or underlying health conditions. This can make them more likely to experience severe or unusual side effects like the zombie-like behavior.
Misuse or Overdose: If someone takes too much of a stimulant medication, they may experience a range of extreme effects, including a “zombie-like” state. This could be due to the overstimulation of brain pathways or an overload of chemicals, leading to severe emotional and cognitive effects.
Why are extended drug holidays (long-term discontinuation of ADHD medication) generally not recommended?
A) ADHD symptoms are likely to return and disrupt daily functioning
B) ADHD medications permanently affect growth and weight
C) Stimulants cause irreversible changes to the brain if stopped for too long
D) Patients become addicted to ADHD medication and cannot stop
A) They may lead to a loss of symptom control, negatively affecting daily life. ✅ (Correct Answer)
ADHD is a chronic condition, and stimulant medications help manage symptoms like inattention, impulsivity, and hyperactivity.
If the medication is stopped for an extended period, symptoms return and can affect school, work, relationships, and daily responsibilities.
This is why long breaks (drug holidays) are generally not recommended, unless carefully planned with a doctor.
B) They permanently stunt growth and cause lasting weight loss. ❌ (Incorrect)
Why it seems correct: Stimulants can temporarily suppress appetite and slow growth in some children.
Why it’s wrong: These effects are typically temporary and reversible once the medication is stopped. Growth patterns usually catch up over time.
If a doctor is concerned about growth suppression, they may adjust the dosage rather than stop the medication for an extended period.
C) They increase the risk of stimulant addiction. ❌ (Incorrect)
Why it seems correct: People sometimes worry that stimulant medications are addictive because they are controlled substances.
Why it’s wrong: When used as prescribed for ADHD, stimulants do not typically cause addiction.
In fact, research suggests that properly treated ADHD may actually reduce the risk of substance abuse later in life.
D) They make future stimulant treatment ineffective. ❌ (Incorrect)
Why it seems correct: Some medications, like antidepressants, take time to work and stopping them suddenly can cause problems.
Why it’s wrong: Stimulants work immediately, and stopping them does not make them less effective when restarted.
However, inconsistent use could make it harder to find the right dosage again or cause adjustment issues when restarting.
Final Thoughts
A is correct because the main risk of stopping ADHD meds for too long is loss of symptom control.
B is wrong because growth and weight effects are usually temporary.
C is wrong because ADHD treatment does not cause addiction when used correctly.
D is wrong because medication remains effective even after a break.
Which of the following statements about ADHD and suicidality risk is true?
A) ADHD itself increases the risk of suicidality, but stimulant medications do not
B) Stimulants and atomoxetine may contribute to an increased risk of suicidality
C) Atomoxetine lowers the risk of suicidality compared to stimulants
D) Patients on stimulants do not require monitoring for suicidality
Correct Answer: B) Stimulants and atomoxetine may contribute to an increased risk of suicidality because ADHD itself is associated with increased suicidality, and stimulant or atomoxetine use may contribute to this risk. Patients need monitoring.
A is incorrect because stimulant medications may also play a role in increasing risk, not just ADHD itself.
C is incorrect because atomoxetine does not necessarily lower the risk compared to stimulants.
D is incorrect because all patients should be monitored for suicidality.
Which of the following non-stimulant medications is most selective for neuronal activity and has a longer duration of action?
A) Clonidine
B) Guanfacine
C) Atomoxetine
D) Bupropion
Correct Answer: B) Guanfacine because guanfacine is more selective for neuronal activity than clonidine and has a longer duration of action.
A is incorrect because clonidine is less selective and has a shorter duration of action.
C is incorrect because atomoxetine is a norepinephrine reuptake inhibitor, not an alpha-2 agonist.
D is incorrect because bupropion is an antidepressant and does not function similarly to guanfacine.
Which ADHD medication is most appropriate for a child with ADHD and comorbid tic disorder?
A) Lisdexamfetamine
B) Methylphenidate
C) Atomoxetine
D) Clonidine
Correct Answer: D) Clonidine because clonidine, an alpha-2 adrenergic agonist, can help reduce ADHD symptoms and is beneficial in patients with tics.
A and B are incorrect because stimulants can sometimes worsen tic disorders.
C is incorrect because atomoxetine does not have strong evidence for tic disorders.
When might an antipsychotic like risperidone be used in ADHD treatment?
A) As a first-line option for core ADHD symptoms
B) To manage hyperactivity and impulsivity in children with comorbid conduct disorder
C) To replace stimulants when a child experiences mild insomnia
D) To improve attention span in patients with ADHD
Correct Answer: B) To manage hyperactivity and impulsivity in children with comorbid conduct disorder because risperidone is sometimes used when ADHD coexists with conduct disorder, oppositional defiant disorder, or other impulse control disorders.
A is incorrect because antipsychotics are not first-line ADHD treatments.
C is incorrect because mild insomnia does not warrant an antipsychotic switch.
D is incorrect because risperidone has little effect on inattention.
What is the main reason why stimulant medication use should be reevaluated during summer breaks?
A) To give the child a break from side effects and assess continued need
B) To prevent the child from becoming addicted to stimulants
C) To improve the long-term effectiveness of the medication
D) Because ADHD symptoms naturally improve in the summer
Correct Answer: A) To give the child a break from side effects and assess continued need because a 2-3 week stimulant break during summer helps determine if continued treatment is necessary.
B is incorrect because stimulant addiction is not the primary reason for reevaluation.
C is incorrect because taking breaks does not necessarily improve long-term medication effectiveness.
D is incorrect because ADHD symptoms persist year-round.
Which of the following ADHD treatments has the highest potential for abuse?
A) Guanfacine
B) Atomoxetine
C) Methylphenidate
D) Bupropion
Correct Answer: C) Methylphenidate because methylphenidate is a stimulant with a risk of misuse and abuse.
A and B are incorrect because guanfacine and atomoxetine have no known abuse potential.
D is incorrect because bupropion, while sometimes misused, is not a stimulant.
Which of the following antidepressants has the strongest evidence for ADHD treatment?
A) Fluoxetine
B) Venlafaxine
C) Bupropion
D) Sertraline
Correct Answer: C) Bupropion because bupropion has the most evidence supporting its use for ADHD.
A, B, and D are incorrect because fluoxetine, venlafaxine, and sertraline are mainly used for depression and anxiety, with limited ADHD benefit.
DRUG OPTIONS -
ANTIDEPRESSANTS
* Less effective than stimulants
* May be beneficial if comorbid depression, anxiety, enuresis or
tic disorders
* Bupropion has evidence supporting use for ADHD
* Venlafaxine evidence is limited to adults but may be helpful
* TCAs have been studied as short-term treatments but are not widely recommended unless other drugs fail
Which of the following statements about the effectiveness of behavioral therapy in ADHD is true?
A) Behavioral therapy alone is more effective than stimulant therapy alone
B) Behavioral therapy alone is equally effective as stimulant therapy
C) Behavioral therapy alone is inferior to stimulant therapy in reducing core ADHD symptoms
D) Behavioral therapy is not recommended for ADHD treatment
Correct Answer: C) Behavioral therapy alone is inferior to stimulant therapy in reducing core ADHD symptoms because studies suggest that behavioral therapy alone is not as effective as stimulant therapy in reducing ADHD symptoms.
A and B are incorrect because stimulant therapy has been shown to be more effective than behavioral therapy alone.
D is incorrect because behavioral therapy can still be useful, especially when combined with medication.
Which of the following dietary triggers has been clinically reported to affect some children with ADHD, despite a lack of strong evidence?
A) Gluten and dairy
B) Sugars, food additives, artificial coloring, and preservatives
C) High-fat foods
D) Excessive protein intake
Correct Answer: B) Sugars, food additives, artificial coloring, and preservatives because while evidence does not strongly support dietary elimination, some children show improvement when these triggers are removed.
A is incorrect because gluten and dairy are not commonly associated with ADHD symptom worsening.
C and D are incorrect because fat and protein intake do not have established links to ADHD symptoms.
What is a major concern regarding long-term stimulant use in children with ADHD?
A) Increased risk of cardiovascular disease
B) Potential growth suppression
C) Liver toxicity
D) Increased risk of neurodegenerative diseases
Correct Answer: B) Potential growth suppression because long-term stimulant use may lead to growth suppression.
A is incorrect because while stimulants can cause hypertension, they are not directly linked to long-term cardiovascular disease in children.
C is incorrect because stimulants are not known to cause liver toxicity.
D is incorrect because ADHD treatments do not increase the risk of neurodegenerative diseases.
Which of the following is a serious adverse effect of stimulant medications?
A) Mild insomnia
B) Anorexia
C) Hypertension
D) Psychotic reactions
Correct Answer: D) Psychotic reactions because stimulants can, in rare cases, cause psychotic symptoms, requiring discontinuation of the drug.
A, B, and C are incorrect because while insomnia, anorexia, and hypertension are common side effects, they are not considered serious unless severe.
Why are extended drug holidays (stimulant breaks longer than 2-3 weeks) not generally recommended for ADHD patients?
A) ADHD symptoms may worsen significantly
B) The body becomes dependent on stimulants, making withdrawal dangerous
C) Stimulants need to be taken continuously to prevent addiction
D) ADHD is a progressive condition that worsens without continuous medication
Correct Answer: A) ADHD symptoms may worsen significantly because extended drug holidays can lead to a worsening of ADHD symptoms, making management more difficult.
B is incorrect because stimulants do not cause physiological dependence like addictive substances.
C is incorrect because stimulant medication does not need to be taken continuously to prevent addiction.
D is incorrect because ADHD is not a progressive condition in the way that diseases like Parkinson’s or Alzheimer’s are.
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A) ADHD symptoms may worsen significantly. ✅ (Correct Answer)
Why it’s right: ADHD is a chronic condition, meaning symptoms don’t just go away when medication is stopped.
Stimulants help manage ADHD symptoms, so when they are discontinued for a long time, those symptoms can return and even worsen in certain situations (e.g., school, work, relationships).
While short breaks (like weekends or summers off for kids) may be okay in some cases, long breaks can make it harder to function normally.
B) The body becomes dependent on stimulants, making withdrawal dangerous. ❌ (Incorrect)
Why it seems correct: Stimulants are a controlled substance, so people might assume stopping them suddenly could cause withdrawal symptoms.
Why it’s wrong: When taken as prescribed for ADHD, stimulants do not cause physical dependence like opioids or alcohol.
Some people might feel tired, sluggish, or moody for a few days after stopping, but this is not dangerous withdrawal—it’s just the body adjusting.
C) Stimulants need to be taken continuously to prevent addiction. ❌ (Incorrect)
Why it seems correct: There’s a common misconception that stopping and restarting stimulants could increase the risk of addiction.
Why it’s wrong: When used properly for ADHD, stimulants do not cause addiction. In fact, research shows that proper ADHD treatment reduces the risk of substance abuse in the long run.
D) ADHD is a progressive condition that worsens without continuous medication. ❌ (Incorrect)
Why it seems correct: Some conditions, like Alzheimer’s or Parkinson’s, get progressively worse over time, so it’s natural to wonder if ADHD works the same way.
Why it’s wrong: ADHD is not a progressive disorder—it doesn’t necessarily get worse over time. However, untreated ADHD can lead to more difficulties (e.g., academic struggles, work problems, emotional distress).
Medication doesn’t “stop progression,” but it helps manage symptoms so they don’t interfere as much with daily life.
Which non-stimulant ADHD medication is most appropriate for a patient with ADHD and comorbid substance use disorder?
A) Methylphenidate
B) Lisdexamfetamine
C) Atomoxetine
D) Mixed salts amphetamine
Correct Answer: C) Atomoxetine because atomoxetine has no abuse potential and is a good choice for patients with comorbid substance use disorder.
A, B, and D are incorrect because all are stimulant medications, which have the potential for abuse.
Which class of ADHD medications is most likely to be prescribed for a patient whose primary symptoms are aggression and impulsivity?
A) Stimulants
B) Antidepressants
C) Alpha-2 adrenergic agonists
D) Antipsychotics
Correct Answer: C) Alpha-2 adrenergic agonists because clonidine and guanfacine help reduce aggression and impulsivity.
A is incorrect because while stimulants treat core ADHD symptoms, they are not the best choice for aggression.
B is incorrect because antidepressants are not primarily used for aggression in ADHD.
D is incorrect because antipsychotics like risperidone are only used in severe cases with comorbid conditions.
DRUG OPTIONS - ALPHA 2 ADRENERGIC AGONISTS
* Clonidine and guanfacine
* Primarily reduce aggression, impulsivity, and
hyperactivity but have less effect on inattention
* Guanfacine is the better option between the two as it is more selective for neuronal activity and has a longer duration of action
* Comparative data (to stimulants or atomoxetine) is
lacking
This is similar to Muscarinic receptors follow the general rule:
Odd-numbered (M₁, M₃, M₅) = Excitatory
Even-numbered (M₂, M₄) = Inhibitory
For alpha-adrenergic receptors, there’s a similar pattern:
Alpha-1 (α₁) = Stimulatory (vasoconstriction, increased BP)
Alpha-2 (α₂) = Inhibitory (reduces norepinephrine release, lowers BP & HR)
So, in both cases:
Odd numbers = excitatory/stimulatory
Even numbers = inhibitory
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How Clonidine Lowers Blood Pressure Using These Locations:
1. Clonidine Acts on Alpha-2 Receptors in the Brainstem (Medulla) → Decreased Sympathetic Outflow
The medulla controls autonomic functions, including blood pressure regulation.
Normally, the sympathetic nervous system (SNS) increases heart rate and constricts blood vessels by releasing norepinephrine (NE).
Clonidine stimulates alpha-2 receptors in the medulla, which inhibits sympathetic nerve activity.
This results in reduced NE output, leading to:
✅ Lower heart rate (bradycardia)
✅ Reduced vascular resistance (less vasoconstriction)
2. Clonidine Reduces Norepinephrine Release from Sympathetic Nerve Endings
In the peripheral nervous system, alpha-2 receptors function as presynaptic autoreceptors.
When clonidine binds to these receptors, it tells the nerve to stop releasing norepinephrine.
Less NE in circulation means:
✅ Less vasoconstriction → Blood vessels relax → Lower blood pressure
3. Clonidine May Cause Some Direct Vasodilation in Blood Vessels
Alpha-2 receptors are also found on vascular smooth muscle, but their effect is weaker compared to alpha-1 receptors.
In some cases, clonidine may directly cause mild vasodilation, but the primary way it lowers blood pressure is by reducing sympathetic tone rather than acting directly on the blood vessels.
Which of the following antidepressants is most likely to be used in an adult patient with ADHD?
A) Fluoxetine
B) Sertraline
C) Venlafaxine
D) Bupropion
Correct Answer: D) Bupropion
D is correct because bupropion has evidence supporting its use in ADHD treatment.
A, B, and C are incorrect because fluoxetine, sertraline, and venlafaxine are mainly used for mood and anxiety disorders, with limited benefit in ADHD.
What is the most common pediatric neuropsychiatric disorder in North America?
A) Autism Spectrum Disorder
B) ADHD
C) Oppositional Defiant Disorder
D) Anxiety Disorders
Correct Answer: B) ADHD
B is correct because ADHD affects 4-12% of North American school-aged children, making it the most common pediatric neuropsychiatric disorder.
A is incorrect because Autism Spectrum Disorder (ASD) is less prevalent than ADHD.
C is incorrect because Oppositional Defiant Disorder (ODD) is less common and often coexists with ADHD rather than being more prevalent.
D is incorrect because while anxiety disorders are common, ADHD is specifically noted as the most prevalent pediatric neuropsychiatric disorder.
Which of the following is not a core symptom of ADHD?
A) Inattention
B) Hyperactivity
C) Impulsivity
D) Mood instability
Correct Answer: D) Mood instability because mood instability is not a defining symptom of ADHD, though emotional dysregulation can sometimes be present.
A, B, and C are incorrect because inattention, hyperactivity, and impulsivity are the three core symptoms of ADHD.
What percentage of adults are affected by ADHD?
A) 1-2%
B) 3-4%
C) 10-12%
D) 15-20%
Correct Answer: B) 3-4% because ADHD affects 3-4% of adults.
A is incorrect because the prevalence is slightly higher than 1-2%.
C and D are incorrect because ADHD is less common in adults than in children, with a prevalence significantly lower than 10-20%.
ADHD Has become the most common pediatric neuropsychiatric disorder affecting 4-12% of North American school-aged children.
* Characterized by 3 main symptoms
- Inattention
- Hyperactivity
- Impulsivity
* Affects 3-4% of adults
* ADHD tends to be a lifelong condition, however, symptoms often
dissipate with age (especially entering adolescence)
Which statement about ADHD symptoms over time is true?
A) ADHD symptoms tend to completely disappear by adulthood.
B) ADHD symptoms persist for life, but often lessen with age.
C) Hyperactivity increases with age, while inattention decreases.
D) ADHD symptoms remain unchanged throughout a person’s lifetime.
Correct Answer: B) ADHD symptoms persist for life, but often lessen with age because ADHD is a lifelong condition, but symptoms—particularly hyperactivity—tend to dissipate as people enter adolescence and adulthood.
A is incorrect because ADHD does not completely disappear in most cases.
C is incorrect because hyperactivity tends to decrease, while inattention may persist into adulthood.
D is incorrect because symptom intensity often changes with age.
Which of the following is not a goal of ADHD therapy?
A) Eliminate core ADHD symptoms
B) Improve self-esteem and social functioning
C) Minimize adverse effects of medications
D) Increase stimulant medication doses over time
Correct Answer: D) Increase stimulant medication doses over time because increasing stimulant doses is not a treatment goal; instead, the goal is to find the lowest effective dose.
A, B, and C are incorrect because eliminating core symptoms, improving self-esteem, and minimizing side effects are key treatment goals.
Which statement about nonpharmacologic treatments for ADHD is true?
A) Cognitive Behavioral Therapy (CBT) is the primary treatment for ADHD.
B) Counseling and CBT have strong evidence as standalone ADHD treatments.
C) Behavioral therapy alone is inferior to drug therapy alone in reducing ADHD symptoms.
D) ADHD should only be treated with medication, as nonpharmacologic treatments are ineffective.
Correct Answer: C) Behavioral therapy alone is inferior to drug therapy alone in reducing ADHD symptoms because research suggests that behavioral therapy alone is less effective than medication alone in treating ADHD symptoms.
A is incorrect because CBT is not the primary treatment for ADHD.
B is incorrect because while therapy can be beneficial, there is limited strong evidence supporting its use alone.
D is incorrect because nonpharmacologic treatments can be helpful, particularly in combination with medication.
NONPHARMACOLOGIC OPTIONS
* That said, most studies suggest a combination of pharmacological and non-pharmacological interventions and that behavioural modification therapy alone is inferior to drug therapy alone at reducing core ADHD symptoms
* Dietary trigger elimination is not supported by evidence but clinically makes a difference in some children where the trigger can be identified and eliminated
- Sugars, food additives, artificial colouring, and
preservatives are common culprits
Why is there limited evidence supporting behavioral therapy as a standalone ADHD treatment?
A) ADHD is not a psychological disorder, so therapy is ineffective.
B) Most studies on behavioral therapy have small sample sizes.
C) Medication alone is 100% effective, making therapy unnecessary.
D) Behavioral therapy worsens symptoms in ADHD patients.
Correct Answer: B) Most studies on behavioral therapy have small sample sizes because existing studies on behavioral therapy for ADHD have relatively small sample sizes (~600 children), limiting strong conclusions.
A is incorrect because ADHD has psychological components, and therapy can be beneficial.
C is incorrect because no treatment is 100% effective, and multimodal approaches are often best.
D is incorrect because behavioral therapy does not worsen ADHD symptoms.
Which of the following best describes the current understanding of dietary interventions for ADHD?
A) There is strong scientific evidence that diet plays a significant role in ADHD.
B) Dietary elimination is not supported by strong evidence but may help some children.
C) Sugar and food additives are proven to cause ADHD.
D) All children with ADHD should follow a strict diet to improve symptoms.
Correct Answer: B) Dietary elimination is not supported by strong evidence but may help some children because while there is no strong scientific proof, some children benefit from dietary changes when specific triggers are identified.
A is incorrect because evidence for dietary interventions is not strong.
C is incorrect because sugar and food additives do not cause ADHD, though they may affect some individuals.
D is incorrect because not all children with ADHD respond to dietary changes.
Which of the following dietary components are commonly reported to exacerbate ADHD symptoms in some children?
A) Dairy and gluten
B) Sugar, artificial coloring, preservatives, and food additives
C) High-protein foods
D) Low-carbohydrate diets
Correct Answer: B) Sugar, artificial coloring, preservatives, and food additives because these substances are frequently reported by parents as triggers for worsening ADHD symptoms, even though strong scientific evidence is lacking.
A is incorrect because gluten and dairy are not commonly associated with ADHD symptoms.
C and D are incorrect because high-protein and low-carb diets are not linked to ADHD.
Which of the following is true regarding the classification of obsessive-compulsive disorder (OCD)?
A) OCD is classified under anxiety disorders in DSM-5
B) OCD is classified separately from anxiety disorders in DSM-5
C) OCD is not classified in the DSM-5
D) OCD is classified under mood disorders in DSM-5
Obsessive-compulsive disorder (OCD) is classified separately from anxiety disorders in the DSM 5
OCD frequently starts early in life and often becomes a chronic condition if inadequately treated
The mean age of onset is about 20 years with 25% of cases beginning by age 14
B) Correct – DSM-5 categorizes OCD in its own section, distinct from anxiety disorders.
Explanation:
A) Incorrect – While OCD shares characteristics with anxiety disorders, DSM-5 classifies it separately.
C) Incorrect – OCD is included in DSM-5 under the category “Obsessive-Compulsive and Related Disorders.”
D) Incorrect – OCD is not classified as a mood disorder, which includes conditions like depression and bipolar disorder.
At what age does OCD most commonly begin?
A) Before age 10
B) Mean onset age is about 20 years, with 25% of cases beginning by age 14
C) Around age 30-40
D) After age 50
B) Correct – The average onset age is around 20 years, and 25% of cases start by age 14.
Explanation:
A) Incorrect – OCD can start early but does not most commonly begin before age 10.
C) Incorrect – OCD typically begins much earlier, usually in adolescence or young adulthood.
D) Incorrect – Late-onset OCD is rare.
Which of the following is NOT a goal of OCD therapy?
A) Decrease symptoms of OCD
B) Improve financial status
C) Prevent recurrence
D) Restore quality of life
B) Correct – While OCD treatment may improve life quality, financial status is not a direct goal of therapy.
Explanation:
A) Incorrect – Reducing OCD symptoms is a primary goal.
C) Incorrect – Preventing recurrence is an important goal in OCD management.
D) Incorrect – Restoring quality of life is a major aim of treatment.
GOALS OF OCD THERAPY
* Eliminate or decrease symptoms of OCD
* Eliminate or decrease OCD-associated disability
* Prevent recurrence
* Restore quality of life
* Treat comorbid conditions
Which of the following is the first-line pharmacologic treatment for OCD?
A) Benzodiazepines
B) SSRIs (e.g., fluoxetine, sertraline)
C) Lithium
D) Antipsychotics
B) Correct – SSRIs are the recommended first-line treatment for OCD.
Explanation:
A) Incorrect – Benzodiazepines are not effective for OCD treatment.
C) Incorrect – Lithium is not useful for OCD treatment.
D) Incorrect – Antipsychotics are used as augmentation but not first-line.
First line drugs for OCD
* The SSRIs citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline are recommended as first-line treatment for OCD
How long should a clinician wait before considering an alternative therapy if there is no response to SSRIs?
A) 2 weeks
B) 4 weeks
C) 6 weeks
D) 12 weeks
C) Correct – The clinician should continue treatment for at least 6 weeks at the maximum tolerated dose before switching.
Explanation:
A) Incorrect – This is too short to assess SSRI effectiveness.
B) Incorrect – While 4 weeks of no response predicts low success, therapy should continue longer.
D) Incorrect – By 12 weeks, a lack of response should have already been addressed.
OCD DRUG RESPONSE
* Roughly 80% of medication benefits appear in the initial 6 weeks of treatment, although it may take up to 12 weeks for maximum improvement
* Lack of response after 4 weeks predicts a low likelihood
of improvement at 12 weeks
* Clinicians should start at the lowest dose for 1 week, gradually increasing to the maximum tolerated dose for at least 6 weeks before considering alternative therapy
Which second-line medication is often poorly tolerated due to anticholinergic and antihistaminergic effects?
A) Venlafaxine
B) Clomipramine
C) Mirtazapine
D) Fluoxetine
B) Correct – Clomipramine has anticholinergic and antihistaminergic effects and is less tolerated.
Explanation:
A) Incorrect – Venlafaxine is a second-line treatment but does not have significant anticholinergic effects.
C) Incorrect – Mirtazapine has side effects like weight gain but not strong anticholinergic effects.
D) Incorrect – Fluoxetine is an SSRI and not a second-line treatment.
2nd line DRUG OPTIONS for OCD
* Venlafaxine, clomipramine and mirtazapine have also been investigated as monotherapy for OCD
* They may be more effective than SSRIs for comorbid chronic pain and/or comorbid major depressive disorder
* Clomipramine has similar effectiveness to SSRIs in OCD but has poorer tolerability due to anticholinergic and antihistaminergic effects; it is also lethal in overdose
DRUG OPTIONS – 2ND LINE
* Mirtazapine often causes problematic weight gain, but has a lower risk of causing sexual dysfunction
* The evidence for using mirtazapine in monotherapy is weak; it may be considered for individuals who cannot tolerate an SSRI
* Mirtazapine may also be considered as an augmentation agent in combination with SSRIs
Which of the following statements is true regarding augmentation therapy for OCD?
A) Aripiprazole and risperidone are often used when SSRI monotherapy is ineffective.
B) Augmentation therapy is ineffective and rarely used in OCD treatment.
C) Aripiprazole and risperidone are first-line treatments for OCD.
D) Augmentation therapy benefits nearly all patients who do not respond to SSRIs.
A) Correct – Aripiprazole (dopamine receptor partial agonist) and risperidone (dopamine receptor antagonist) are used as augmentation agents for patients who do not achieve adequate improvement with SSRIs.
B) Incorrect – Augmentation therapy has been shown to benefit about 30% of patients, making it a useful strategy in some cases.
C) Incorrect – SSRIs, not antipsychotics, are the first-line treatment for OCD.
D) Incorrect – Augmentation therapy helps about 30% of patients, not nearly all.
DRUG OPTIONS – AUGMENTATION
* Aripiprazole (a dopamine receptor partial agonist) and risperidone (a dopamine receptor antagonist) are frequently used as augmentation agents in patients who do not achieve adequate improvement with SSRI monotherapy.
* It may benefit about 30% of patients
Which class of medications has shown preliminary benefits for refractory OCD when combined with SSRIs?
A) Benzodiazepines
B) Glutamate-modulating drugs (e.g., lamotrigine, memantine)
C) Lithium
D) Beta-blockers
** B) Correct – Glutamate-modulating drugs, including lamotrigine, memantine, topiramate, and amantadine, have demonstrated some benefits for refractory OCD.**
A) Incorrect – Benzodiazepines are not effective for OCD treatment.
C) Incorrect – Lithium is not useful for treating OCD unless there is a comorbid mood disorder.
D) Incorrect – Beta-blockers are used for anxiety symptoms like tremors but do not treat OCD directly.
REFRACTORY OCD
* Preliminary studies demonstrated some benefit with glutamate- modulating drugs such as lamotrigine, memantine, topiramate , and amantadine in combination with SSRIs for refractory OCD
* Memantine, lamotrigine, and amantadine are generally well tolerated and may be reasonable next-step options for patients who cannot tolerate or do not benefit from dopamine antagonist augmentation
* Topiramate has poorer tolerability but may be considered if a patient has comorbid migraines, binge eating disorder, or drug-induced weight gain
Which of the following statements is true regarding benzodiazepines and lithium in OCD treatment?
A) Benzodiazepines are the most effective monotherapy for OCD.
B) Lithium is the preferred second-line treatment for OCD.
C) Both benzodiazepines and lithium are ineffective for OCD and only used for severe comorbid mood or anxiety disorders.
D) Benzodiazepines are a first-line treatment for OCD.
C) Correct – Neither benzodiazepines nor lithium are effective for treating OCD, though they may be used in cases of severe comorbid mood or anxiety disorders.
A) Incorrect – Benzodiazepines are not effective for OCD monotherapy.
B) Incorrect – Lithium is not considered a treatment option for OCD.
D) Incorrect – Benzodiazepines are not first-line treatment for OCD.
NOT DRUG OPTIONS for OCD
* Benzodiazepines and lithium are not helpful in treating OCD and are usually used only for patients with severe comorbid mood or anxiety disorders
Which non-pharmacologic treatment is considered the first-line psychotherapeutic approach for OCD?
A) Hypnotherapy
B) Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP)
C) Psychoanalysis
D) Support groups
B) Correct – The first-line psychotherapy for OCD is specialized CBT, specifically exposure and response prevention (ERP).
A) Incorrect – Hypnotherapy is not a primary treatment for OCD.
C) Incorrect – Psychoanalysis is not effective for treating OCD.
D) Incorrect – Support groups may be helpful but are not considered first-line treatment.
NON-PHARMACOLOGIC INTEGRATION for OCD
* Most patients do not achieve minimal OCD symptoms with medications alone
* specialized CBT should be combined with pharmacologic treatment to optimize outcomes
* The first-line psychotherapeutic treatment of choice for OCD is specialized CBT, including exposure and response prevention (ERP)
How does pregnancy typically affect OCD symptoms?
A) OCD symptoms always improve during pregnancy.
B) Pregnant patients with OCD have an increased risk of harming their child.
C) OCD symptoms may worsen, particularly obsessional fears about harming the baby.
D) Medications should always be avoided in pregnancy.
C) Correct – OCD symptoms, especially obsessional fears of harming the baby, may worsen during pregnancy.
A) Incorrect – OCD symptoms do not always improve; they may worsen.
B) Incorrect – Patients with OCD are not at higher risk of harming their children.
D) Incorrect – Medications, particularly SSRIs, can be used if symptoms cause significant impairment.
CHOICES DURING PREGNANCY AND BREASTFEEDING
* During pregnancy, obsessive-compulsive symptoms, particularly obsessional ideas about causing harm to the baby, may worsen and can be extremely disturbing
* Patients are not at higher risk of harming their children compared with the general population
* If symptoms are severe and producing significant impairment, pharmacotherapy with SSRIs is appropriate
OCD AND
BREASTFEEDING
* In the postpartum period, patients with OCD may experience severe anxiety that can impede sleep and erode confidence in caring for the child.
* A patient with severe OCD can be so tormented by thoughts of potentially harming their child that they may refuse to be involved with caring for the child at all
* If drug therapy is necessary,
consider escitalopram and sertraline, since both have minimal
concentrations in breast milk
Which SSRI is recommended for an OCD patient who is breastfeeding?
A) Fluoxetine
B) Paroxetine
C) Escitalopram
D) Clomipramine
C) Correct – Escitalopram and sertraline are preferred due to their minimal concentrations in breast milk.
Why? Escitalopram and sertraline have low relative infant doses (RID), meaning they pass into breast milk in minimal amounts.
Sertraline: Considered the safest SSRI for breastfeeding due to its low transfer into milk and minimal infant side effects.
Escitalopram: Has low infant plasma levels compared to fluoxetine and paroxetine.
A) Incorrect – Fluoxetine has a long half-life and can accumulate in breast milk.
Why? Fluoxetine has a long half-life (4-6 days for the parent drug and 4-16 days for its active metabolite, norfluoxetine). This means it can accumulate in breast milk over time, leading to higher infant exposure.
Risks: Case reports suggest irritability, poor feeding, and colic in breastfed infants exposed to fluoxetine.
B) Incorrect – Paroxetine is not preferred due to concerns about infant exposure.
Why? While paroxetine has a shorter half-life than fluoxetine, it is still not preferred due to some reports of withdrawal-like symptoms in infants, including jitteriness and irritability.
Risks: Some data suggest it has a low concentration in breast milk, but given alternative safer options (escitalopram, sertraline), it is not the first choice.
D) Incorrect – Clomipramine is not a first-line choice due to its side effects.
Why? Clomipramine is a tricyclic antidepressant (TCA), not an SSRI. While TCAs generally have low milk transfer, clomipramine has been linked to higher sedation risks and possible cardiovascular effects in infants.
Risks: Compared to SSRIs, clomipramine has more side effects, including anticholinergic effects (dry mouth, constipation, dizziness) and cardiac concerns.
Bottom Line:
Preferred in breastfeeding: Sertraline, Escitalopram (low milk transfer, minimal infant risk).
Avoid or use with caution: Fluoxetine (accumulates in milk), Paroxetine (possible infant withdrawal symptoms), Clomipramine (side effects, not first-line).
