Assessment and Diagnosis
22%of exam
Planning
21%of exam
Client-Centered CareCultural CompetenceCommunication BarriersTreatment PlanningSMART Goals
Implementation
46%of exam
Treatment ModalitiesPsychopharmacologyMilieu ManagementTherapeutic CommunicationCrisis InterventionNeurostimulation
Evaluation
10%of exam
Legal + EthicalOutcome MeasurementProcess ImprovementConfidentiality
Quick Facts
- Exam
- PMH-BC
- Credential Body
- ANCC
- Level
- RN (not NP)
- Questions
- 150 (125 scored + 25 pretest)
- Time
- 3 hours
- Pass
- Scaled 350/500
- Validity
- 5 years
- Eligibility
- 2yrs RN, 2000hrs psych, 30hrs CE
- Fee
- $395 (non-member)
SIG E CAPS (Depression Symptoms)
Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidality
S: Sleep changeI: Interest lossG: Guilt/worthlessnessE: Energy lossC: ConcentrationA: Appetite changeP: Psychomotor changeS: Suicidal ideation
Delirium vs Dementia
Delirium
- Acute onset, hours to days
- Fluctuating attention/awareness
- Often reversible medical cause
Dementia
- Gradual onset, months to years
- Stable attention, progressive memory loss
- Usually irreversible/degenerative
Sudden-fluctuating vs slow-progressive
Suicide Risk -> Intervention Level
- Vague ideation, no plan-or-means, protective factors→Outpatient safety plan + close follow-up
- Plan, no access to means; ambivalent→Raise care level, remove means, safety-contract
- Specific plan, access to means, clear-intent→1:1 observation + immediate psychiatric evaluation
- Attempt in progress or just occurred→Emergency medical stabilization first(Then psychiatric evaluation)
- Command hallucinations to harm self→Treat as high risk(Regardless of stated intent)
- Chronic risk factors, no acute ideation→Ongoing risk monitoring + safety planning
- Meets danger criteria, refuses voluntary care→Initiate involuntary commitment(Per state law)
DSM-5-TR Mood Disorders
- MDD
- ≥5 Sx, ≥2wks, mood-or-anhedonia
- Bipolar I
- Full manic episode, 7+ days
- Bipolar II
- Hypomania + MDE, no full mania
- Cyclothymic D/O
- 2+ yrs subthreshold highs/lows
- Persistent Depressive D/O
- Depressed mood most days, 2+ yrsDysthymia
- PMDD
- Mood symptoms tied to luteal phase
DIGFAST (Mania Symptoms)
Distractibility, Indiscretion, Grandiosity, Flight-of-ideas, Activity increase, Sleep deficit, Talkativeness
D: DistractibilityI: IndiscretionG: GrandiosityF: Flight of ideasA: Activity increaseS: Sleep deficitT: Talkativeness
Bipolar I vs Bipolar II
Bipolar I
- Full manic episode, 7+ days
- Hospitalization can define episode
- Depressive episode not required for diagnosis
Bipolar II
- Hypomanic episode, 4+ days
- Requires 1+ major depressive episode
- No history of full mania
Mania present vs mania absent
DSM-5-TR Anxiety and Trauma Disorders
- GAD
- Excessive worry, 6+ months, multi-domain
- Panic Disorder
- Recurrent unexpected attacks + 1mo worry
- Social Anxiety D/O
- Fear of social-performance situations, ≥6mo
- Specific Phobia
- Marked fear of object-situation, ≥6mo
- PTSD
- Symptoms 1+ month after trauma exposure
- Acute Stress D/O
- Symptoms 3 days-1 month post-trauma
- OCD
- Obsessions-compulsions, ≥1hr-day or distress
CAGE (Alcohol Use Screening)
Cut-down, Annoyed, Guilty, Eye-opener; 2+ yes screens positive
C: Cut down attemptsA: Annoyed by criticismG: Guilty about drinkingE: Eye-opener drink
Positive vs Negative Symptoms
Positive
- Hallucinations
- Delusions
- Disorganized speech/behavior
Negative
- Flat affect
- Avolition/anhedonia
- Alogia, social withdrawal
Added experiences vs lost functions
Personality Disorders
- Cluster A
- Odd/eccentricParanoid, Schizoid, Schizotypal
- Cluster B
- Dramatic/erraticAntisocial, Borderline, Histrionic, Narcissistic
- Cluster C
- Anxious/fearfulAvoidant, Dependent, OCPD
- Borderline PD
- Unstable relationships/self-image, splitting, self-harm
- Antisocial PD
- Disregard, deceit, no remorse, conduct-before-15
- Narcissistic PD
- Grandiosity, need for admiration, low empathy
- Histrionic PD
- Excessive emotionality, attention-seeking
- Avoidant PD
- Social inhibition, inadequacy, criticism-sensitive
Substance Use and Withdrawal
- Alcohol Withdrawal
- Onset 6-24h: tremor, anxiety, tachycardia
- CIWA-Ar
- Standardized alcohol withdrawal severity scale
- Delirium Tremens
- Peaks 48-96h, autonomic instability, hallucinations, emergency
- Opioid Withdrawal
- Flu-like, not life-threatening
- Benzo Withdrawal
- Seizure risk; taper, don't stop abruptly
- Wernicke-Korsakoff
- Confusion-ataxia-ophthalmoplegia triad; give thiamine first
Defense Mechanisms
- Denial
- Refusing to acknowledge reality
- Projection
- Attributing own feelings to others
- Rationalization
- Logical excuse for unacceptable behavior
- Displacement
- Redirecting feelings to a safer target
- Regression
- Reverting to earlier developmental behavior
- Reaction Formation
- Opposite behavior to unacceptable impulse
- Sublimation
- Channeling impulse into productive activity
- Splitting
- All-good or all-bad thinking, no gray
Therapeutic Communication Techniques
- Active Listening
- Full attention, verbal + nonverbal cues
- Open-Ended Questions
- Encourage elaboration, not yes/no
- Reflection
- Mirror feeling back to client
- Restating
- Repeat main idea in own words
- Clarification
- Check understanding of a vague statement
- Broad Openings
- Invite client to choose topic
- Silence
- Allow processing time, show patience
- Summarizing
- Review key points near session end
NMS vs Serotonin Syndrome
NMS
- Antipsychotic (D2 blockade) cause
- Slow onset over days
- Lead-pipe rigidity + hyporeflexia
Serotonin Syndrome
- Serotonergic drug combo cause
- Rapid onset, under 24h
- Hyperreflexia + clonus
Rigid-and-slow vs hyperreflexic-and-fast
Adverse Reaction -> Drug Class / Syndrome
- Rapid onset, hyperreflexia, clonus, agitation, diarrhea→Serotonin syndrome(Stop serotonergic agents; supportive care)
- Slow onset, lead-pipe rigidity, hyperthermia, dysautonomia→Neuroleptic malignant syndrome (NMS)(Stop antipsychotic; check CK)
- Tremor, ataxia, confusion, GI-upset on lithium→Lithium toxicity(Check level, hold dose, hydrate)
- Subjective restlessness, pacing, can't sit still→Akathisia(May mimic worsening anxiety)
- Sudden muscle spasm, torticollis, oculogyric crisis→Acute dystonia(IM benztropine or diphenhydramine)
- Shuffling gait, tremor, rigidity, mask-like face→Pseudoparkinsonism(Anticholinergic or dose reduction)
- Fever, sore throat, low WBC on-clozapine→Agranulocytosis(Stop drug; hematology consult)
- Repetitive lip-smacking-tongue movement, long-term antipsychotic→Tardive dyskinesia(May be irreversible; consider switch)
Antidepressants: SSRIs and SNRIs
- SSRIs
- First-line; 4-6 wk onsetfluoxetine, sertraline, escitalopram
- SNRIs
- Dual reuptake; may raise BPvenlafaxine, duloxetine
- Common Side Effects
- GI upset, sexual dysfunction, insomnia
- Black Box Warning
- Increased suicidality risk under age 25
- Discontinuation Syndrome
- Flu-like, dizzy, 'brain zaps' if abrupt-stop
- Serotonin Syndrome Risk
- Danger combining w/ MAOIs, triptans, tramadol
Typical vs Atypical Antipsychotics
Typical
- D2 blockade only
- High EPS/TD risk
- e.g. haloperidol, chlorpromazine
Atypical
- D2 + 5-HT2A blockade
- Lower EPS, higher metabolic risk
- e.g. risperidone, olanzapine, clozapine
EPS risk vs metabolic risk
Antipsychotics: Typical and Atypical
- Typical (1st-gen)
- D2 blockade, high EPS/TD riskhaloperidol, chlorpromazine
- Atypical (2nd-gen)
- D2 + 5-HT2A, lower EPS, metabolic riskrisperidone, olanzapine, quetiapine, aripiprazole
- Clozapine
- Treatment-resistant; requires ANC monitoring
- Metabolic Syndrome
- Weight gain, dyslipidemia, hyperglycemia risk
- LAI/Depot
- Long-acting injectable improves adherence
- EPS Risk Hierarchy
- High-potency-typicals highest, atypicals lowest except-risperidone
- Prolactin Elevation
- Risperidone notably raises prolactin
Mood Stabilizers
- Lithium Therapeutic
- 0.6-1.2 mEq/L (maintenance ~0.6-1.0)
- Lithium Toxic
- >1.5; severe >2.0 mEq/L
- Lithium Monitoring
- Trough 12h post-dose; renal + thyroid function
- Valproic Acid
- 50-125 mcg/mL; hepatotoxic, teratogenic
- Carbamazepine
- Agranulocytosis/aplastic anemia risk; monitor CBC
- Lamotrigine
- Slow titration; Stevens-Johnson syndrome risk
Benzodiazepines and Anxiolytics
- Benzodiazepines
- Short-term anxiety/agitation, dependence risklorazepam, diazepam, alprazolam
- Buspirone
- Non-benzo; onset 2-4wks, no PRN
- Flumazenil
- Benzodiazepine antagonist/reversal agent
- Respiratory Depression Risk
- Danger combining benzos w/ opioids/alcohol
- Long-Term Use
- Tolerance-withdrawal risk; taper, don't stop-abruptly
Psychiatric Emergency Syndromes
- Serotonin Syndrome
- Rapid onset, hyperreflexia/clonus, hyperthermia
- NMS
- Slow onset, lead-pipe rigidity, autonomic instability
- Acute Dystonia
- Sudden spasm, torticollis; give IM anticholinergic
- Akathisia
- Subjective/observed motor restlessness
- Tardive Dyskinesia
- Involuntary orofacial movements; may be irreversible
- Anticholinergic Toxicity
- Confusion, dry mucosa, urinary retention
- Clozapine Agranulocytosis
- ANC under 500; fever-sore-throat warns
Therapeutic Modalities
- CBT
- Restructure distorted thoughts, present-focused
- DBT
- Emotion-regulation + distress-tolerance; built for BPD
- Milieu Therapy
- Structured, safe therapeutic environment
- ECT
- Severe-treatment-resistant depression; main effect memory-loss
- TMS
- Noninvasive neurostimulation, no anesthesia
- Motivational Interviewing
- Client-centered, resolves ambivalence
- Trauma-Informed Care
- Recognize trauma, avoid re-traumatization
SAD PERSONS (Suicide Risk Factors)
Checklist of risk factors that raise suicide concern
S: Sex (male)A: Age (young or old)D: DepressionP: Previous attemptE: Ethanol/substance useR: Rational thought lossS: Social support lackO: Organized planN: No spouseS: Sickness
Legal/Ethical Trigger -> Correct Action
- Patient threatens an identifiable third party→Duty to warn/protect (Tarasoff)(Notify victim or law-enforcement per-state)
- Patient lacks capacity, refuses emergency care→Use emergency-implied consent for imminent danger
- Escalating/aggressive behavior, other options exhausted→Least restrictive intervention first(De-escalate before restraint/seclusion)
- Restraint or seclusion in use→Time-limited order + continuous monitoring(Document per policy)
- Third party requests medical record disclosure→Verify signed release before disclosing(Confidentiality/HIPAA)
- Suspected documentation/safety error observed→Report through incident/quality process(Process improvement)
Legal and Ethical Principles
- Informed Consent
- Voluntary, competent, informed of risks/benefits
- Confidentiality
- HIPAA-protected; exceptions incl. duty to warn
- Duty to Warn
- Notify identifiable victim of credible threatTarasoff
- Involuntary Commitment
- Danger to self-others or grave disability
- Least Restrictive Environment
- Use least restrictive intervention necessary
- Restraint/Seclusion
- Time-limited order, continuous monitoring, last resort
- Capacity vs Competency
- Capacity = clinical/situational; competency = legal
- Advance Psychiatric Directive
- Documents future mental health treatment preferences
Common Traps
Onset speed trap
Serotonin syndrome develops fast, under 24h ≠ NMS develops slowly, over days
Therapeutic level does not mean safe
Normal lithium level still toxic-if-dehydrated ≠ Assess symptoms, not just the number
EPS isn't typical-only
Atypicals cause EPS too, especially-risperidone high-dose ≠ Don't rule out EPS for atypicals
Duty to warn is not blanket disclosure
Applies to specific, identifiable, credible threats ≠ Routine records still need consent-to-release
Pretest questions are invisible
25 of 150 questions are unscored-pretest ≠ Cannot be identified during exam; answer-all
Bipolar II is not 'mild bipolar I'
Bipolar II requires a major-depressive episode ≠ Full mania reclassifies it as Bipolar-I
Capacity vs competency confusion
Capacity is a clinical, situational judgment ≠ Competency is a court's legal determination
Last Minute
- 1.22-21-46-10: Assess-Plan-Implement-Eval weight order
- 2.150 total, 125 scored, 25 pretest
- 3.3-hour limit; passing 350-of-500 scaled-score
- 4.Lithium 0.6-1.2 mEq-L; toxic above 1.5
- 5.Serotonin-syndrome fast-onset-hyperreflexia; NMS slow-onset-rigidity
- 6.Clozapine: ANC monitoring; agranulocytosis under 500
- 7.Bipolar-I needs mania; Bipolar-II needs hypomania-MDE
- 8.Tarasoff: warn identifiable, credible victim threats
- 9.Use least-restrictive intervention before restraint-seclusion
- 10.PMH-BC is RN-level; PMHNP-BC is advanced-practice
- 11.Valid 5yrs; needs 2yrs-RN, 2000hrs-psych, 30CE
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