ANCC PMHNP cheat sheet

Neurotransmitter map: serotonin (5-HT) from raphe nuclei regulates mood, sleep, appetite; dopamine from VTA/substantia nigra regulates reward, motivation, psychosis; norepinephrine from locus coeruleus regulates arousal and vigilance.

HPA axis: CRH (hypothalamus) → ACTH (anterior pituitary) → cortisol (adrenal cortex); cortisol feeds back negatively on hippocampus, hypothalamus, and pituitary; chronic stress blunts this feedback.

Kindling model: repeated episodes lower the threshold for future episodes, supporting early and sustained mood stabilization in bipolar disorder.

Dopamine pathways: mesolimbic (positive symptoms, reward), mesocortical (negative/cognitive symptoms), nigrostriatal (EPS), tuberoinfundibular (prolactin inhibition).

Pharmacogenetics: CYP2D6 and CYP2C19 poor metabolizers have higher plasma levels of many antidepressants and antipsychotics; CYP3A4 is the major oxidative pathway for many psychotropics.

Erikson stages: trust vs mistrust (0-1), autonomy vs shame (1-3), initiative vs guilt (3-6), industry vs inferiority (6-12), identity vs role confusion (12-18), intimacy vs isolation (young adult).

Piaget: sensorimotor (0-2), preoperational (2-7), concrete operational (7-11), formal operational (11+); object permanence emerges in sensorimotor stage.

Attachment: secure, avoidant, ambivalent/resistant, disorganized; disorganized attachment is associated with caregiver maltreatment and later dissociative symptoms.

Mental status exam elements: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment.

Screening cutoffs: PHQ-9 ≥10 suggests moderate depression; GAD-7 ≥10 suggests moderate anxiety; AUDIT-C ≥4 (men) or ≥3 (women) is positive; C-SSRS stratifies suicide risk by ideation, intent, plan, and behavior.

CIWA-Ar guides alcohol withdrawal treatment; scores ≥8-10 generally warrant pharmacologic management with benzodiazepines.

CAGE is a 4-item alcohol screen; a single positive answer warrants further assessment.

Mini-Mental State Examination: score ≤23 suggests cognitive impairment; MoCA is more sensitive to mild cognitive impairment (cutoff ~26).

Therapeutic communication techniques: reflection, clarification, summarization, confrontation (used cautiously), silence; avoid false reassurance, giving advice, and changing the subject.

Suicide risk assessment: inquire directly about ideation, plan, intent, access to means, prior attempts, and protective factors; asking about suicide does not increase risk.

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

Major depressive disorder: ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia, causing impairment; rule out bipolar disorder before starting an antidepressant.

Bipolar I requires ≥1 manic episode (≥1 week or hospitalization); bipolar II requires hypomania (≥4 days) plus major depression, with no mania.

Schizophrenia: ≥2 of delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms, with ≥1 from the first three, for ≥6 months.

First-line pharmacotherapy for MDD: SSRI, SNRI, mirtazapine, or bupropion; continue for 6-12 months after remission and longer if recurrent.

Serotonin syndrome triad: mental status change, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia); stop serotonergic agents and provide supportive care.

Neuroleptic malignant syndrome: fever, rigidity, autonomic instability, altered mental status, elevated CK; stop antipsychotic, provide supportive care, consider dantrolene or bromocriptine.

Lithium requires monitoring of levels (target ~0.6-1.2 mEq/L), renal function, thyroid function, and calcium; toxicity presents with tremor, ataxia, vomiting, and confusion.

ADHD first-line: stimulants (methylphenidate, amphetamines); non-stimulants include atomoxetine, guanfacine, and clonidine.

CBT model: thoughts → feelings → behaviors; interventions include cognitive restructuring, behavioral activation, exposure, and homework.

DBT four modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness; targets self-harm and emotional dysregulation (e.g., borderline personality disorder).

Psychodynamic therapy focuses on transference, countertransference, defense mechanisms, and repetition of relational patterns.

Motivational interviewing: OARS (open questions, affirmations, reflections, summaries); rolling with resistance rather than confronting it.

Behavioral activation targets avoidance and inactivity by scheduling mastery and pleasure activities.

Exposure therapy: graded, repeated, and prolonged exposure to feared stimuli without avoidance, allowing habituation and extinction learning.

Group therapy therapeutic factors (Yalom): universality, altruism, instillation of hope, universality of experience, interpersonal learning, catharsis, and cohesiveness.

Family therapy systems view: symptoms are maintained by circular patterns; interventions target communication, boundaries, and homeostasis.

USPSTF: screen adults for depression when systems are in place; screen for unhealthy alcohol use in adults; screen for tobacco use and offer cessation.

USPSTF: screen adults 18-79 for hepatitis C; screen adults 35-70 with overweight/obesity for prediabetes/diabetes; screen adults 45-75 for colorectal cancer.

USPSTF: low-dose aspirin for primary prevention of CVD in adults 40-59 with ≥10% 10-year risk (individualized); not routinely for adults ≥60.

Suicide risk screening: USPSTF recommends screening for anxiety in adults ≤64 and for depression in adults; universal suicide screening is recommended in some settings but evidence is limited.

Metabolic monitoring for second-generation antipsychotics: weight/BMI, waist circumference, blood pressure, fasting glucose, and lipids at baseline and periodically.

Tobacco cessation first-line: varenicline, bupropion, or nicotine replacement; combine behavioral counseling with pharmacotherapy.

Immunizations: annual influenza for adults; COVID-19 per current schedule; pneumococcal for adults ≥65 or with risk conditions; Tdap every 10 years.

Prenatal/postpartum: Edinburgh Postnatal Depression Scale is a validated screen; postpartum psychosis is a psychiatric emergency.

Tarasoff duty: when a patient makes a serious threat of violence against an identifiable victim, the clinician has a duty to protect (warn the victim and/or notify authorities) per state law.

Confidentiality exceptions: imminent danger to self or others, suspected child/elder/dependent adult abuse, court order, and certain communicable disease reporting.

Involuntary commitment criteria generally include mental illness plus danger to self or others and/or grave disability, per state statute.

Informed consent: patient must have capacity, be given information, and consent voluntarily; emergencies allow treatment without consent to prevent harm.

HIPAA permits disclosure for treatment, payment, and operations; psychotherapy notes have stricter protections and require specific authorization.

Mandatory reporting: clinicians must report suspected child abuse, elder abuse, and dependent adult abuse; reporting is generally required even if the patient objects.

Scope of practice: PMHNPs practice under state nurse practice act and collaborative/supervisory requirements; prescriptive authority varies by state.

Documentation: record assessment, diagnosis, plan, medication rationale, informed consent, and risk assessment; avoid altering records after the fact.

Neurotransmitter map: serotonin (5-HT) from raphe nuclei regulates mood, sleep, appetite; dopamine from VTA/substantia nigra regulates reward, motivation, psychosis; norepinephrine from locus coeruleus regulates arousal and vigilance.

HPA axis: CRH (hypothalamus) → ACTH (anterior pituitary) → cortisol (adrenal cortex); cortisol feeds back negatively on hippocampus, hypothalamus, and pituitary; chronic stress blunts this feedback.

Kindling model: repeated episodes lower the threshold for future episodes, supporting early and sustained mood stabilization in bipolar disorder.

Dopamine pathways: mesolimbic (positive symptoms, reward), mesocortical (negative/cognitive symptoms), nigrostriatal (EPS), tuberoinfundibular (prolactin inhibition).

Pharmacogenetics: CYP2D6 and CYP2C19 poor metabolizers have higher plasma levels of many antidepressants and antipsychotics; CYP3A4 is the major oxidative pathway for many psychotropics.

Erikson stages: trust vs mistrust (0-1), autonomy vs shame (1-3), initiative vs guilt (3-6), industry vs inferiority (6-12), identity vs role confusion (12-18), intimacy vs isolation (young adult).

Piaget: sensorimotor (0-2), preoperational (2-7), concrete operational (7-11), formal operational (11+); object permanence emerges in sensorimotor stage.

Attachment: secure, avoidant, ambivalent/resistant, disorganized; disorganized attachment is associated with caregiver maltreatment and later dissociative symptoms.

Mental status exam elements: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment.

Screening cutoffs: PHQ-9 ≥10 suggests moderate depression; GAD-7 ≥10 suggests moderate anxiety; AUDIT-C ≥4 (men) or ≥3 (women) is positive; C-SSRS stratifies suicide risk by ideation, intent, plan, and behavior.

CIWA-Ar guides alcohol withdrawal treatment; scores ≥8-10 generally warrant pharmacologic management with benzodiazepines.

CAGE is a 4-item alcohol screen; a single positive answer warrants further assessment.

Mini-Mental State Examination: score ≤23 suggests cognitive impairment; MoCA is more sensitive to mild cognitive impairment (cutoff ~26).

Therapeutic communication techniques: reflection, clarification, summarization, confrontation (used cautiously), silence; avoid false reassurance, giving advice, and changing the subject.

Suicide risk assessment: inquire directly about ideation, plan, intent, access to means, prior attempts, and protective factors; asking about suicide does not increase risk.

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

Major depressive disorder: ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia, causing impairment; rule out bipolar disorder before starting an antidepressant.

Bipolar I requires ≥1 manic episode (≥1 week or hospitalization); bipolar II requires hypomania (≥4 days) plus major depression, with no mania.

Schizophrenia: ≥2 of delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms, with ≥1 from the first three, for ≥6 months.

First-line pharmacotherapy for MDD: SSRI, SNRI, mirtazapine, or bupropion; continue for 6-12 months after remission and longer if recurrent.

Serotonin syndrome triad: mental status change, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia); stop serotonergic agents and provide supportive care.

Neuroleptic malignant syndrome: fever, rigidity, autonomic instability, altered mental status, elevated CK; stop antipsychotic, provide supportive care, consider dantrolene or bromocriptine.

Lithium requires monitoring of levels (target ~0.6-1.2 mEq/L), renal function, thyroid function, and calcium; toxicity presents with tremor, ataxia, vomiting, and confusion.

ADHD first-line: stimulants (methylphenidate, amphetamines); non-stimulants include atomoxetine, guanfacine, and clonidine.

CBT model: thoughts → feelings → behaviors; interventions include cognitive restructuring, behavioral activation, exposure, and homework.

DBT four modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness; targets self-harm and emotional dysregulation (e.g., borderline personality disorder).

Psychodynamic therapy focuses on transference, countertransference, defense mechanisms, and repetition of relational patterns.

Motivational interviewing: OARS (open questions, affirmations, reflections, summaries); rolling with resistance rather than confronting it.

Behavioral activation targets avoidance and inactivity by scheduling mastery and pleasure activities.

Exposure therapy: graded, repeated, and prolonged exposure to feared stimuli without avoidance, allowing habituation and extinction learning.

Group therapy therapeutic factors (Yalom): universality, altruism, instillation of hope, universality of experience, interpersonal learning, catharsis, and cohesiveness.

Family therapy systems view: symptoms are maintained by circular patterns; interventions target communication, boundaries, and homeostasis.

USPSTF: screen adults for depression when systems are in place; screen for unhealthy alcohol use in adults; screen for tobacco use and offer cessation.

USPSTF: screen adults 18-79 for hepatitis C; screen adults 35-70 with overweight/obesity for prediabetes/diabetes; screen adults 45-75 for colorectal cancer.

USPSTF: low-dose aspirin for primary prevention of CVD in adults 40-59 with ≥10% 10-year risk (individualized); not routinely for adults ≥60.

Suicide risk screening: USPSTF recommends screening for anxiety in adults ≤64 and for depression in adults; universal suicide screening is recommended in some settings but evidence is limited.

Metabolic monitoring for second-generation antipsychotics: weight/BMI, waist circumference, blood pressure, fasting glucose, and lipids at baseline and periodically.

Tobacco cessation first-line: varenicline, bupropion, or nicotine replacement; combine behavioral counseling with pharmacotherapy.

Immunizations: annual influenza for adults; COVID-19 per current schedule; pneumococcal for adults ≥65 or with risk conditions; Tdap every 10 years.

Prenatal/postpartum: Edinburgh Postnatal Depression Scale is a validated screen; postpartum psychosis is a psychiatric emergency.

Tarasoff duty: when a patient makes a serious threat of violence against an identifiable victim, the clinician has a duty to protect (warn the victim and/or notify authorities) per state law.

Confidentiality exceptions: imminent danger to self or others, suspected child/elder/dependent adult abuse, court order, and certain communicable disease reporting.

Involuntary commitment criteria generally include mental illness plus danger to self or others and/or grave disability, per state statute.

Informed consent: patient must have capacity, be given information, and consent voluntarily; emergencies allow treatment without consent to prevent harm.

HIPAA permits disclosure for treatment, payment, and operations; psychotherapy notes have stricter protections and require specific authorization.

Mandatory reporting: clinicians must report suspected child abuse, elder abuse, and dependent adult abuse; reporting is generally required even if the patient objects.

Scope of practice: PMHNPs practice under state nurse practice act and collaborative/supervisory requirements; prescriptive authority varies by state.

Documentation: record assessment, diagnosis, plan, medication rationale, informed consent, and risk assessment; avoid altering records after the fact.