Scientific Foundation
22%of exam
PathophysiologyPharmacologyNeurobiologyPsychogenomicsPhysical assessment
Advanced Practice Skills
27%of exam
Clinical interviewingMental status examRisk assessmentScreening toolsRecovery planning
Diagnosis and Treatment
22%of exam
DSM-5-TR diagnosisDifferential diagnosisPsychopharmacologyComplementary careTreatment planning
Psychotherapy and Related Theories
11%of exam
Therapy modalitiesBehavior changeDevelopmental theoryFamily systemsTherapeutic alliance
Ethics, Legal Principles, and Cultural Care
17%of exam
Patient rightsConfidentialityEthical principlesCultural humilityAdvocacy
Quick Facts
- Credential
- PMHNP-BC
- Total questions
- 175
- Scored questions
- 150
- Pretest questions
- 25 unscored
- Exam time
- 3.5 hours
- Passing score
- 350 scaled
- Testing vendor
- Prometric
- Testing window
- 120 days
- Credential term
- 5 years
- Clinical minimum
- 500 supervised hours
- Current fees
- $220-$395 by membership
Serotonin Syndrome vs NMS
Serotonin syndrome
- Clonus and hyperreflexia
- Rapid onset
- GI symptoms common
NMS
- Lead-pipe rigidity
- Slower onset
- Elevated CK common
Neuromuscular pattern separates them
Adverse Effect Triage
- Clonus and hyperreflexia→Suspect serotonin syndrome(Stop serotonergic agents)
- Fever and severe rigidity→Suspect malignant syndrome(Urgent medical treatment)
- Painful sustained contraction→Treat acute dystonia(Protect airway)
- Distressing inner restlessness→Assess for akathisia(Do not mislabel agitation)
- Delayed involuntary movements→Assess tardive dyskinesia(Use structured scale)
- Coarse tremor and ataxia→Assess lithium toxicity(Check level and kidneys)
- Rash with mucosal lesions→Stop culprit medication(Urgent medical evaluation)
- Fever with neutropenia→Escalate infection care(Review clozapine management)
Neurotransmitters and Dopamine Pathways
- Mesolimbic pathway
- Positive psychotic symptoms
- Mesocortical pathway
- Negative and cognitive symptoms
- Nigrostriatal pathway
- Movement and EPS effects
- Tuberoinfundibular pathway
- Prolactin regulation
- Serotonin
- Mood, anxiety, sleep, appetite
- Norepinephrine
- Arousal, attention, energy
- Dopamine
- Reward, motivation, movement
- GABA
- Primary inhibitory signaling
- Glutamate
- Primary excitatory signaling
- Acetylcholine
- Attention, memory, learning
- HPA axis
- Coordinates stress response
Positive vs Negative Symptoms
Positive
- Hallucinations
- Delusions
- Disorganized speech
Negative
- Avolition
- Anhedonia
- Diminished expression
Added versus diminished function
Psychotropic Mechanism Essentials
- SSRIs
- Inhibit serotonin reuptake
- SNRIs
- Inhibit serotonin and norepinephrine reuptake
- Bupropion
- Inhibits norepinephrine and dopamine reuptake
- Mirtazapine
- Blocks alpha-2, H1, serotonin receptors
- Benzodiazepines
- Modulate GABA-A receptors
- Typical antipsychotics
- Primarily block D2 receptors
- Atypical antipsychotics
- Modulate dopamine and serotonin
- Partial D2 agonists
- Stabilize dopamine signaling
- Stimulants
- Increase catecholamine signaling
- Cholinesterase inhibitors
- Reduce acetylcholine breakdown
- CYP inhibitor
- May raise substrate levels
- CYP inducer
- May lower substrate levels
High-Risk Adverse Syndromes
- Serotonin syndrome
- Clonus, hyperreflexia, fever, diaphoresis
- Neuroleptic malignant syndrome
- Rigidity, fever, elevated CK
- Acute dystonia
- Sustained painful muscle contractions
- Akathisia
- Distressing inner restlessness
- Drug-induced parkinsonism
- Rigidity, tremor, bradykinesia
- Tardive dyskinesia
- Delayed involuntary movements
- Lithium toxicity
- GI upset, coarse tremor, ataxia
- SJS or TEN
- Rash plus mucosal involvement
- Severe neutropenia
- Infection risk; urgent evaluation
- Anticholinergic toxicity
- Delirium, dryness, retention, hyperthermia
- Valproate pregnancy risk
- Major fetal harm risk
CAGE Alcohol Screen
Cut down, Annoyed, Guilty, Eye-opener
Cut downCriticism annoyedFeel guiltyMorning eye-opener
Mood vs Affect
Mood
- Patient reports it
- Sustained internal state
- Quote patient when useful
Affect
- Clinician observes it
- Range and reactivity
- Congruence matters
Mood reported; affect observed
Suicide Safety Triage
- Current plan, intent, means→Emergency evaluation now(Maintain immediate safety)
- Recent attempt disclosed→Escalate level of care(Assess medical needs)
- Intoxication impairs assessment→Stabilize and reassess(Risk remains dynamic)
- Command hallucinations threaten harm→Protect and evaluate urgently(Assess ability to resist)
- Means remain accessible→Create lethal-means plan(Use collaborative counseling)
- No imminent danger→Build collaborative safety plan(Document risk formulation)
- Outpatient disposition chosen→Arrange timely follow-up(Specify crisis resources)
Mental Status Examination
- Appearance
- Grooming, dress, apparent age
- Behavior
- Activity, cooperation, eye contact
- Speech
- Rate, volume, fluency, latency
- Mood
- Patient-reported emotional state
- Affect
- Observed emotional expression
- Thought process
- Organization and associations
- Thought content
- Beliefs, preoccupations, safety themes
- Perception
- Hallucinations and illusions
- Cognition
- Orientation, attention, memory
- Insight
- Understanding illness and needs
- Judgment
- Anticipating choices and consequences
ASEPTIC Mental Status
Appearance, Speech, Emotion, Perception, Thought, Insight, Cognition
Appearance behaviorSpeechMood affectPerceptionThoughtInsight judgmentCognition
Screening and Assessment Tools
- PHQ-9
- Depression symptom severity
- GAD-7
- Generalized anxiety symptom severity
- C-SSRS
- Suicidal ideation and behavior
- SAFE-T
- Structures suicide evaluation
- AIMS
- Tardive dyskinesia monitoring
- CIWA-Ar
- Alcohol withdrawal severity
- COWS
- Opioid withdrawal severity
- AUDIT
- Hazardous alcohol use
- DAST
- Drug-related problem screening
- CAM
- Delirium detection
- MoCA
- Brief cognitive screening
- Vanderbilt scales
- Child ADHD symptom ratings
Suicide and Violence Formulation
- Prior attempt
- Key historical suicide risk
- Current ideation
- Ask frequency and intensity
- Plan
- Assess specificity and lethality
- Intent
- Assess expected action
- Means access
- Assess firearms and medications
- Dynamic factors
- Intoxication, agitation, acute loss
- Protective factors
- Do not erase acute risk
- Collateral information
- Clarifies baseline and access
- Safety plan
- Steps through lethal-means safety
- Level of care
- Match acuity and supports
- Follow-up
- Specify timing and responsibility
Medication Monitoring Map
- Lithium baseline
- Renal, thyroid, calcium, pregnancy
- Lithium levels
- Use timed trough concentrations
- Valproate
- CBC, liver tests, pregnancy
- Carbamazepine
- CBC, liver tests, sodium
- Antipsychotic metabolic
- Weight, pressure, glucose, lipids
- Antipsychotic movement
- Structured movement assessment
- Clozapine
- ANC per current labeling
- Stimulants
- Pressure, pulse, growth, misuse
- SSRIs and SNRIs
- Suicidality, sodium, bleeding, activation
- Urine immunoassay
- Treat result as presumptive
- Pharmacogenomics
- Adjunct, not diagnostic replacement
DIG FAST Mania
Distractibility, Indiscretion, Grandiosity, Flight, Activity, Sleep, Talk
DistractibleRisky behaviorGrandioseFlight of ideasGoal activitySleep decreasedTalkative
Mania vs Hypomania
Mania
- Marked impairment
- Hospitalization may occur
- Psychosis may occur
Hypomania
- Observable functional change
- No marked impairment
- No psychosis
Severity outranks duration alone
Diagnostic Duration Picker
- Psychosis under one month→Consider brief psychosis(Minimum one day)
- Psychosis one to six months→Consider schizophreniform disorder(Exclude mood and substances)
- Disturbance at least six months→Consider schizophrenia(Check active-phase criteria)
- Trauma symptoms under one month→Consider acute stress(Minimum three days)
- Trauma symptoms exceed one month→Consider PTSD(Confirm full clusters)
- Elevation lasts four days→Consider hypomania(No marked impairment)
- Elevation lasts one week→Consider mania(Hospitalization overrides duration)
Diagnostic Time Anchors
- Major depression
- Two weeks; five symptoms
- Mania
- One week or hospitalization
- Hypomania
- Four consecutive days
- Generalized anxiety
- Six months excessive anxiety
- Acute stress disorder
- Three days through one month
- PTSD
- Symptoms exceed one month
- Brief psychotic disorder
- One day under one month
- Schizophreniform disorder
- One through six months
- Schizophrenia
- Continuous disturbance six months
- Persistent depressive disorder
- Two years in adults
- Cyclothymic disorder
- Two years in adults
SIGECAPS Depression
Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicide
Sleep changeInterest lossGuiltLow energyPoor concentrationAppetite changePsychomotor changeSuicidality
Delirium vs Neurocognitive Disorder
Delirium
- Acute and fluctuating
- Attention impaired
- Medical cause likely
Neurocognitive disorder
- Usually gradual decline
- Attention often preserved early
- Independence may decline
Acute inattention signals delirium
High-Yield Diagnostic Discriminators
- Delirium
- Acute fluctuating inattention
- Major neurocognitive disorder
- Decline impairs independence
- Bipolar I
- Mania defines diagnosis
- Bipolar II
- Hypomania plus major depression
- Schizoaffective disorder
- Psychosis persists without mood episode
- OCD
- Usually ego-dystonic symptoms
- OCPD
- Usually ego-syntonic traits
- ADHD
- Childhood onset; multiple settings
- Substance-induced disorder
- Symptoms track substance exposure
- Normal grief
- Waves with preserved self-worth
- Major depression
- Pervasive symptoms and impairment
Obsession vs Delusion
Obsession
- Intrusive recurring thought
- Usually unwanted
- Often resisted
Delusion
- Fixed false belief
- Held despite evidence
- Insight often absent
Assess conviction and insight
Evidence-Based Treatment Pairings
- OCD
- ERP plus serotonergic medication
- PTSD
- Trauma-focused psychotherapy
- Borderline personality
- Dialectical behavior therapy
- Chronic insomnia
- CBT-I first-line
- Panic disorder
- CBT plus SSRI or SNRI
- Acute mania
- Mood stabilizer or antipsychotic
- Bipolar depression
- Use bipolar-specific treatment
- Treatment-resistant schizophrenia
- Consider clozapine after adequate trials
- Severe catatonia
- Benzodiazepine or ECT
- ADHD
- Stimulant or approved nonstimulant
- Major depression
- Match treatment to severity
Substance-Related Care
- Alcohol withdrawal
- Benzodiazepines reduce seizure risk
- Suspected Wernicke
- Give thiamine promptly
- Hypoglycemia
- Never delay emergent glucose
- Opioid overdose
- Ventilation plus naloxone
- Opioid use disorder
- Buprenorphine, methadone, or naltrexone
- Alcohol use disorder
- Match approved medication individually
- Benzodiazepine dependence
- Avoid abrupt discontinuation
- Stimulant intoxication
- Reduce stimulation; manage complications
- Nicotine dependence
- Medication plus behavioral support
- Positive immunoassay
- Confirm when clinically consequential
OARS Interviewing Skills
Open questions, Affirmations, Reflections, Summaries
Ask openlyAffirm strengthsReflect meaningSummarize change talk
Transference vs Countertransference
Transference
- Patient reactions
- Past patterns enter therapy
- Explore therapeutically
Countertransference
- Clinician reactions
- May distort judgment
- Use reflection and supervision
Direction identifies the concept
Psychotherapy Modality Picker
- Obsessions and compulsions→Choose ERP(Prevent ritual response)
- Chronic emotion dysregulation→Choose DBT(Balance acceptance and change)
- Insomnia maintains itself→Choose CBT-I(Target sleep behaviors)
- Ambivalence blocks change→Choose motivational interviewing(Elicit change talk)
- Interpersonal loss or transition→Choose interpersonal therapy(Target current relationships)
- Trauma drives symptoms→Choose trauma-focused therapy(Assess readiness and safety)
- Family interactions maintain symptoms→Choose family therapy(Map relational patterns)
Psychotherapy Modality Map
- CBT
- Links thoughts, feelings, behaviors
- DBT
- Balances acceptance and change
- ERP
- Exposure while preventing rituals
- Motivational interviewing
- Elicits intrinsic change language
- Interpersonal therapy
- Targets relationships and role transitions
- Psychodynamic therapy
- Explores unconscious relational patterns
- Supportive therapy
- Strengthens coping and functioning
- Family systems
- Treats relational interaction patterns
- Group therapy
- Uses shared therapeutic factors
- CBT-I
- Restructures insomnia-maintaining behaviors
- Trauma-focused therapy
- Processes trauma safely
CBT vs DBT
CBT
- Restructures biased thoughts
- Changes behavior patterns
- Uses collaborative experiments
DBT
- Balances acceptance and change
- Builds four skill modules
- Targets behavioral hierarchy
DBT adds dialectical skills
Therapeutic Process Concepts
- Alliance
- Bond, goals, tasks
- Transference
- Patient projects prior relationship patterns
- Countertransference
- Clinician reactions require reflection
- Boundary
- Protects therapeutic relationship
- Validation
- Acknowledges understandable experience
- Open question
- Invites elaboration
- Reflection
- Returns meaning or feeling
- Cognitive distortion
- Biased thinking pattern
- Negative reinforcement
- Removal increases behavior
- Universality
- Others share similar struggles
- Exposure
- Approaches feared stimuli gradually
UARC Capacity Elements
Understand, Appreciate, Reason, Communicate
Understand informationAppreciate consequencesReason about optionsCommunicate a choice
Capacity vs Competency
Capacity
- Clinical determination
- Decision-specific
- May fluctuate
Competency
- Court determination
- Legal status
- Jurisdiction controls
Clinicians assess capacity
Confidentiality Disclosure Picker
- Valid authorization covers request→Disclose authorized scope(Verify identity and expiration)
- Treatment disclosure is permitted→Share clinically necessary information(Follow organizational policy)
- Serious threat emerges→Apply state protection law(Document consultation and action)
- Reportable abuse suspected→Follow state mandate(Report reasonable suspicion)
- Substance-use records requested→Apply Part 2(Check current exceptions)
- Psychotherapy notes requested→Apply special protections(Separate from progress notes)
- Legal demand arrives→Seek legal review(Do not release reflexively)
- Minor requests confidential care→Check state rules(Explain privacy limits)
Ethics and Decision Capacity
- Autonomy
- Respect informed patient choices
- Beneficence
- Promote patient welfare
- Nonmaleficence
- Avoid preventable harm
- Justice
- Distribute care fairly
- Veracity
- Communicate truthfully
- Fidelity
- Keep professional commitments
- Capacity
- Clinical and decision-specific
- Competency
- Legal court determination
- Informed consent
- Disclosure, understanding, voluntariness, authorization
- Least restrictive care
- Preserve liberty when safe
- Substituted judgment
- Apply patient's known preferences
Confidentiality and Legal Boundaries
- HIPAA treatment use
- Disclosure may not need authorization
- Minimum necessary
- Limit non-treatment disclosures
- Psychotherapy notes
- Receive special HIPAA protection
- Part 2 records
- Apply federal substance-use protections
- Duty to protect
- Follow applicable state law
- Mandatory reporting
- Requirements vary by jurisdiction
- Minor consent
- Follow state-specific rules
- Involuntary treatment
- Criteria vary by jurisdiction
- Scope of practice
- State law controls authority
- Telehealth practice
- Patient location governs licensure
- Controlled substances
- Apply federal and state rules
Cultural and Recovery-Oriented Care
- Cultural humility
- Practice lifelong self-reflection
- Cultural formulation
- Elicit identity and explanatory model
- Qualified interpreter
- Avoid family interpretation
- Social determinants
- Assess structural barriers
- Trauma-informed care
- Safety, choice, collaboration, empowerment
- Recovery model
- Hope, agency, meaningful life
- Shared decision-making
- Integrate evidence and preferences
- Identity-affirming care
- Use respectful patient language
- Spiritual assessment
- Explore meaning and supports
- Structural competence
- Recognize systemic health effects
- Advocacy
- Address access and inequity
Common Traps
Pretest Items Look Identical
Twenty-five items are unscored ≠ Answer every question
Scaled Score Is Not Percentage
Passing score is 350 ≠ Raw score gets converted
Screening Is Not Diagnosis
Tools estimate symptom burden ≠ Clinical assessment confirms diagnosis
Contracts Are Not Safety Plans
No-harm promises provide little protection ≠ Build actionable safety steps
Mood Is Not Affect
Mood comes from patient ≠ Affect comes from observation
Capacity Is Not Competency
Capacity is clinical ≠ Competency is legal
Law Is Jurisdiction-Specific
Check current state requirements ≠ Avoid universal legal deadlines
Avoid Antidepressant Monotherapy
Screen for bipolar disorder ≠ Use bipolar-specific treatment
Do Not Delay Glucose
Give thiamine promptly ≠ Treat hypoglycemia immediately
Clozapine REMS Was Removed
FDA ended REMS requirements ≠ Continue label-based safety monitoring
Genomics Remains Adjunctive
Results may inform prescribing ≠ They do not diagnose
Last Minute
- 1.Memorize five domain weights
- 2.Separate mood from affect
- 3.Know dopamine pathways
- 4.Differentiate serotonin syndrome and NMS
- 5.Review psychosis duration anchors
- 6.Compare mania and hypomania
- 7.Match screening tools correctly
- 8.Prioritize suicide safety
- 9.Recognize lithium toxicity
- 10.Review metabolic monitoring
- 11.Match disorders to therapies
- 12.Separate capacity from competency
- 13.Apply jurisdiction-specific law
- 14.Answer every exam item
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