WAPCP Part I cheat sheet

Neurotransmitter logic: dopamine D2 blockade correlates with antipsychotic efficacy and EPS; serotonin 5-HT2A blockade reduces EPS; muscarinic blockade causes cognitive and anticholinergic effects.

Mesolimbic pathway: dopamine excess hypothesized in positive symptoms; mesocortical dopamine deficit hypothesized in negative and cognitive symptoms.

Nigrostriatal pathway (A9, substantia nigra to striatum): D2 blockade here produces extrapyramidal symptoms and tardive dyskinesia.

Tuberoinfundibular pathway: D2 blockade removes tonic inhibition of prolactin release, causing hyperprolactinemia, galactorrhea, and amenorrhea.

Kindling model: repeated subthreshold limbic stimulation lowers seizure threshold over time; used to explain progressive bipolar course and anticonvulsant prophylaxis.

HPA axis: CRH from paraventricular nucleus drives ACTH, which drives cortisol; dexamethasone nonsuppression reflects impaired negative feedback in melancholic depression.

Monoamine hypothesis limits: antidepressant response takes 2-4 weeks despite immediate transporter blockade, implicating downstream neuroplasticity (BDNF, TrkB).

Heritability benchmarks: schizophrenia and bipolar disorder roughly 60-80 percent, major depression roughly 30-40 percent; concordance in monozygotic twins is well below 100 percent.

Thought disorder descriptors: flight of ideas (bipolar mania), loosening of associations (schizophrenia), circumstantiality (goal retained with detours), tangentiality (goal lost).

Delusion vs overvalued idea: delusion is fixed and held despite contrary evidence; overvalued idea is understandable, ego-syntonic, and resisted with less conviction.

Hallucination vs illusion: hallucination is perception without external stimulus; illusion is misperception of a real stimulus.

First-rank (Schneiderian) symptoms include thought insertion, withdrawal, broadcasting, made feelings/impulses, and voices commenting or discussing the patient.

Insight domains: awareness of illness, need for treatment, and attribution of symptoms; poor insight predicts nonadherence and involuntary admission risk.

MSE sequence: appearance and behavior, speech, mood and affect, thought form and content, perception, cognition, insight, judgment.

MMSE and MoCA: MMSE is heavily verbal and education-sensitive; MoCA is more sensitive to mild cognitive impairment and executive dysfunction.

Suicide risk factors: prior attempt, male sex, older age, access to lethal means, substance use, hopelessness, and recent loss or discharge.

Clozapine is indicated for treatment-resistant schizophrenia (failure of two adequate antipsychotic trials) and for suicidality in schizophrenia; requires regular ANC monitoring for agranulocytosis.

Antipsychotic potency: high-potency agents (haloperidol, fluphenazine) carry more EPS and less sedation; low-potency agents (chlorpromazine, thioridazine) carry more anticholinergic and orthostatic burden.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia; triggered by combinations such as SSRI plus MAOI, tramadol, or linezolid.

Neuroleptic malignant syndrome: rigidity, hyperthermia, autonomic instability, elevated CK; treat by stopping the agent, supportive care, dantrolene or bromocriptine.

Lithium: narrow therapeutic index (roughly 0.6-1.2 mEq/L); toxicity risk rises with dehydration, NSAIDs, thiazides, ACE inhibitors, and renal impairment.

Valproate: contraindicated in pregnancy (neural tube defects); monitor LFTs, CBC, and ammonia; check for polycystic ovary syndrome in women.

SSRI discontinuation syndrome: dizziness, paresthesias, flu-like symptoms; more likely with short half-life agents (paroxetine, venlafaxine).

ECT: indications include severe melancholic depression, catatonia, and life-threatening illness in pregnancy; cognitive effects are usually transient.

Assertive Community Treatment (ACT): multidisciplinary team, low caseloads (roughly 10-15), high-frequency outreach, 24-hour availability, targeting high utilizers.

Supported employment (IPS): rapid job search in competitive settings, integration with mental health treatment, time-unlimited support; strong evidence for competitive employment outcomes.

Recovery model principles: hope, person-centeredness, empowerment, peer support, and community inclusion rather than symptom elimination alone.

Housing First: unconditional housing with support services, without sobriety or treatment prerequisites; reduces homelessness and emergency service use.

Psychiatric rehabilitation domains: social skills training, cognitive remediation, family psychoeducation, and supported education/employment.

Community psychiatry legal tools: involuntary outpatient commitment, community treatment orders, and guardianship; all require statutory authority and periodic review.

Deinstitutionalization consequences: transinstitutionalization into jails and shelters; forensic and homelessness services absorb untreated severe mental illness.

Peer support workers: lived-experience roles with formal training and supervision; evidence for engagement and hope, less consistent for symptom change.

CBT model: situation, automatic thought, emotion, behavior; interventions target cognitive distortions and behavioral avoidance via graded exposure and behavioral experiments.

Behavioral activation for depression: activity scheduling and monitoring to increase reinforcement from the environment; comparable efficacy to full CBT.

Exposure therapy: habituation and inhibitory learning; must be prolonged, repeated, and without safety behaviors to be effective for anxiety disorders.

DBT for borderline personality disorder: skills modules of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; targets self-harm and therapy-interfering behavior.

Psychodynamic concepts: transference, countertransference, defense mechanisms, and working alliance; interpretation links present patterns to past relationships.

Motivational interviewing: OARS (open questions, affirmations, reflections, summaries); addresses ambivalence and sustains talk about change rather than confrontation.

Systemic and family therapy: circular causality, boundaries, triangulation, and structural interventions; family psychoeducation reduces relapse in schizophrenia.

Common factors: alliance, empathy, expectancy, and therapist adherence predict outcome across modalities; dodo bird verdict remains debated.

Informed consent elements: capacity (understanding, appreciation, reasoning, choice), voluntariness, and disclosure of risks, benefits, and alternatives.

Confidentiality limits: imminent danger to self or others (duty to protect), child or elder abuse reporting, court order, and statutory communicable disease reporting.

Involuntary admission criteria typically require mental disorder plus danger to self or others or grave disability, with periodic judicial or clinical review.

Fitness to stand trial (Dusky standard) concerns present capacity to understand proceedings and assist counsel; insanity concerns mental state at the time of the act.

Advance directives and psychiatric wills document treatment preferences and surrogate decision-makers before loss of capacity.

Boundary crossings vs violations: crossings may be benign or therapeutic; violations exploit the patient and breach the fiduciary relationship.

Research ethics: IRB approval, informed consent, minimization of risk, equipoise, and special protections for vulnerable populations such as prisoners.

Documentation standards: contemporaneous, factual, and specific notes; record risk assessment, capacity determinations, and rationale for involuntary measures.