Iraqi Board Psychiatry common mistakes
Iraqi Board Psychiatry · Understand the traps and how to avoid them.
When asked to distinguish delirium from dementia, the candidate labels any acute confusion in an older patient as dementia (or vice versa) without first checking the two discriminating features: level of arousal/attention and the time course of onset.
Trainees memorise 'delirium = acute, dementia = chronic' as a slogan and then never apply it under time pressure; the vignette usually describes an elderly inpatient with confusion, and the word 'elderly' pulls the answer toward dementia. Attention testing (serial 7s, digit span, months backward) is rarely described in the stem, so candidates do not notice its absence.
What to do instead
Before answering any geriatric confusion item, write two columns on the scratch sheet: onset (hours-days vs months-years) and attention/arousal (fluctuating, inattentive vs alert and attentive). If attention is impaired and onset is short, the primary diagnosis is delirium and dementia can only be a comorbid or underlying condition. Practise 20 vignettes forcing this two-column step until it is automatic.
The candidate selects a diagnosis based on one vivid symptom (e.g., hears a voice, has low mood) and ignores the duration, functional impairment, and exclusion criteria that the stem deliberately supplies.
Stems are written with a single salient cue that maps to a familiar prototype; duration criteria (2 weeks for major depression, 6 months for schizophrenia, 1 month for brief psychotic disorder, 4 weeks for PTSD) are stated numerically and are easy to skim past. Candidates also under-weight 'no impairment in functioning' or 'not attributable to a substance' phrases.
What to do instead
Adopt a fixed checklist applied to every diagnostic stem: symptom count, duration, functional impairment, exclusions (substance, medical condition), and course specifiers. Physically tick each on the question paper. If any box cannot be ticked from the stem, the more restrictive diagnosis or 'insufficient information' option becomes more likely.
In psychopharmacology items, the candidate answers from drug-class generalisations (e.g., 'all SSRIs are the same', 'all antipsychotics cause the same metabolic risk') instead of the specific agent's receptor profile, half-life, or enzyme inhibition.
Revision is often done by class tables, and exam stems exploit within-class differences: fluoxetine and paroxetine as CYP2D6 inhibitors, fluvoxamine as a CYP1A2 inhibitor, clozapine and olanzapine metabolic burden versus aripiprazole and amisulpride, lithium's narrow therapeutic index. Candidates also confuse pharmacodynamic (receptor) and pharmacokinetic (metabolic) interactions.
What to do instead
Build a one-page grid of the agents named in your syllabus with four columns: key receptor actions, relevant CYP interactions, half-life, and signature adverse effect. Rehearse the top interaction pairs (SSRI + tramadol/MAOI/warfarin; clozapine + smoking cessation; lithium + thiazide/NSAID/ACE inhibitor). Test yourself by naming the drug from the adverse effect, not the reverse.
The candidate treats the mental state examination as a narrative to be reproduced in order, rather than mapping each finding to the phenomenological term the examiner is testing (e.g., describing thought insertion as 'he feels people put ideas in his head' and failing to label it a passivity phenomenon of thought).
Clinical teaching emphasises descriptive fluency; exams test the technical vocabulary of psychopathology (obsession vs delusion vs overvalued idea, illusion vs hallucination, flight of ideas vs loosening of associations, depersonalisation vs derealisation). Candidates know the phenomenon but not its exam label.
What to do instead
Keep a glossary card pairing each technical term with a one-line patient utterance and its defining boundary. Drill the classic confusions: obsessions are ego-dystonic and resisted, delusions are held with fixed conviction; illusions are misperceptions of real stimuli, hallucinations occur without external stimulus; flight of ideas is still logically linked, loosening of associations is not. Answer by naming the term first, then justifying it from the stem.
The candidate misclassifies a mood-congruent psychotic depression or a schizoaffective presentation as schizophrenia (or the reverse) because they do not check the temporal relationship between psychotic and mood symptoms.
The key discriminator is whether delusions/hallucinations occur exclusively during mood episodes. Stems often describe psychosis and low mood together without stating the sequence, and candidates default to the more dramatic diagnosis. ICD and DSM both hinge on this timing, so a small reading error changes the answer.
What to do instead
For any stem with both mood and psychotic features, extract the timeline explicitly: did psychosis ever occur in the absence of a mood episode for 2 weeks or more? If never, the diagnosis is a mood disorder with psychotic features; if psychosis dominates the longitudinal course with only brief mood symptoms, consider schizophrenia or schizoaffective disorder. Rehearse with three-column timelines drawn from the stem.
When an item describes alcohol withdrawal, the candidate picks the wrong agent or the wrong setting (e.g., choosing antipsychotics or antidepressants as first-line, or failing to select a benzodiazepine with thiamine and a structured withdrawal scale).
Withdrawal management is taught across medicine, emergency and psychiatry, and candidates conflate delirium tremens with alcohol intoxication or with Wernicke encephalopathy. They also forget that benzodiazepines are the evidence-based treatment for withdrawal seizures and DTs, and that antipsychotics lower the seizure threshold.
What to do instead
Memorise a fixed algorithm: assess with CIWA-Ar, give a long-acting benzodiazepine (diazepam or chlordiazepoxide) in a symptom-triggered or fixed-dose regimen, give parenteral thiamine before glucose, and reserve antipsychotics only as adjuncts for agitation. Practise distinguishing the three syndromes (intoxication, withdrawal, Wernicke) by their onset, examination findings and treatment.
On child and adolescent items, the candidate applies adult diagnostic thresholds (e.g., 2 weeks of low mood for depression, 6 months for ADHD symptoms, adult criteria for mania) without adjusting for developmental stage and age-specific criteria.
Adult psychiatry dominates training and revision, so age-specific modifications (irritability rather than sadness in depressed children, ADHD symptoms present before age 12 and across two settings, separation anxiety and school refusal as developmental presentations) are under-rehearsed. Candidates also forget that intellectual disability and autism change how symptoms are expressed and assessed.
What to do instead
Maintain a 'developmental modifications' sheet for each major disorder listing how presentation, duration thresholds and informants change in children. For every child vignette, ask: who reported the symptoms (parent, teacher, child), in how many settings, and since what age? If the stem gives only one informant or one setting for ADHD, suspect the question is testing cross-situational impairment.
The candidate answers capacity, consent and mental health law items using clinical judgement alone, skipping the formal legal test (four-stage capacity assessment, criteria for compulsory admission, criteria for treatment without consent).
Ethics and law are perceived as 'common sense' and revised last; candidates conflate capacity with insight, or assume a detained patient automatically lacks capacity to consent to treatment. They also mix up the roles of the approved clinician, the responsible clinician and the nearest relative, and the grounds for detention.
What to do instead
Learn the capacity test as four explicit questions: understand, retain, weigh and communicate. Apply it line by line to the stem. Separately memorise the statutory criteria for detention and for treatment without consent, and note that capacity and detention are independent legal questions. Write out the statutory tests from memory weekly until exact.
In consultation-liaison and organic psychiatry items, the candidate attributes psychiatric symptoms to psychological causes and misses the underlying medical or drug cause (e.g., hypothyroidism presenting as depression, steroids causing mania, hyponatraemia causing confusion, or neuroleptic malignant syndrome mistaken for catatonia).
Psychiatric training encourages formulation around psychosocial stressors, and stems often include a plausible stressor as a distractor. Physical examination and investigation findings are buried in the stem and easy to overlook, and candidates under-recall the classic medical mimics of psychiatric syndromes.
What to do instead
For every new-onset or atypical psychiatric presentation, run a mandatory medical screen: age of onset, substance and medication history, vital signs, and targeted investigations (thyroid function, electrolytes, calcium, B12, glucose, urine toxicology, neuroimaging where indicated). Keep a 'mimics' list linking each psychiatric syndrome to its top three medical causes and test yourself on it before the exam.
The candidate chooses a psychotherapy modality by name familiarity rather than matching the evidence base to the disorder, and fails to distinguish supportive, psychodynamic, CBT, exposure-based, DBT and family interventions by their active ingredients and indications.
Psychotherapy questions look like soft options and candidates answer by association ('CBT for everything', 'psychoanalysis for depression'). They also confuse exposure with flooding, and DBT with CBT, and do not know which conditions have first-line psychological treatment versus combined pharmacological treatment.
What to do instead
Build a disorder-to-first-line-treatment table with columns for psychological and pharmacological options and the level of evidence. Learn the defining mechanisms: exposure works by habituation and inhibitory learning, DBT adds distress tolerance and mindfulness to behavioural change, psychodynamic work targets transference and unconscious conflict. Answer by matching the stem's disorder and patient factors to the table, not to the most familiar label.