Study guide
High-Yield Psychiatry & Behavioral Health for the PANCE
Psychiatry/Behavioral Health accounts for roughly 7% of the current NCCPA PANCE blueprint (effective Jan 2025, increased from 6% under the prior blueprint), with mood, anxiety, psychotic, and substance-use disorders the most heavily tested. This guide distills DSM-5-TR diagnostic thresholds and first-line, board-correct pharmacotherapy.
Mood Disorders
- ◆Major depressive disorder: ≥5 of 9 SIG-E-CAPS symptoms (must include depressed mood OR anhedonia) for ≥2 weeks; persistent depressive disorder (dysthymia) = depressed mood most days for ≥2 years.
- ◆First-line MDD therapy = SSRI (sertraline, escitalopram, fluoxetine); allow 4-6 weeks for full effect; combine with CBT for best outcomes. Bupropion avoids sexual side effects but lowers seizure threshold (avoid in eating disorders/seizure hx).
- ◆Bipolar I requires ≥1 manic episode (≥1 week, or any duration if hospitalized): DIG-FAST symptoms + marked impairment/psychosis; bipolar II = hypomania (≥4 days, no marked impairment) plus a major depressive episode.
- ◆Bipolar first-line = lithium (also reduces suicide risk), valproate, or second-gen antipsychotics (quetiapine, lurasidone for bipolar depression). NEVER give an antidepressant alone in bipolar—can precipitate mania.
- ◆Lithium: narrow therapeutic index (0.6-1.2 mEq/L); monitor renal function, TSH (hypothyroidism), and levels; toxicity → tremor, ataxia, confusion; NSAIDs, thiazides, and ACE inhibitors raise levels.
- ◆Postpartum depression (onset in pregnancy or within 4 weeks–months) vs postpartum blues (self-limited, <2 weeks) vs postpartum psychosis (emergency—risk of infanticide, often bipolar-related). SSRIs (sertraline, escitalopram) remain first-line; the oral neurosteroid zuranolone (Zurzuvae, FDA-approved 2023) is now an option for severe postpartum depression—brexanolone was withdrawn from the market in Jan 2025.
Anxiety, OCD & Trauma-Related Disorders
- ◆Generalized anxiety disorder: excessive worry most days ≥6 months plus ≥3 somatic symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance).
- ◆Panic disorder: recurrent unexpected panic attacks + ≥1 month of anticipatory worry/behavior change; peaks within 10 minutes. First-line = SSRI/SNRI + CBT; benzodiazepines only for short-term/acute rescue.
- ◆SSRIs are first-line for GAD, panic, social anxiety, and OCD; buspirone is an option for chronic GAD (non-sedating, non-addictive, no acute relief).
- ◆OCD requires higher SSRI doses and longer trials (8-12 weeks); add exposure and response prevention (ERP); clomipramine (TCA) is second-line.
- ◆PTSD: exposure to trauma + intrusion, avoidance, negative cognitions/mood, and hyperarousal for >1 month. First-line = SSRI/SNRI (sertraline, paroxetine) + trauma-focused CBT; prazosin for nightmares. Acute stress disorder = same picture lasting 3 days to 1 month.
- ◆Avoid benzodiazepines in PTSD and long-term anxiety management—risk of dependence and worsened outcomes.
Psychotic Disorders & Antipsychotics
- ◆Schizophrenia: ≥2 of (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for ≥6 months total with ≥1 month active. Schizophreniform = 1-6 months; brief psychotic disorder = <1 month.
- ◆Schizoaffective = mood episode concurrent with psychosis PLUS ≥2 weeks of psychosis WITHOUT mood symptoms (distinguishes from mood disorder with psychotic features).
- ◆Second-generation antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) are first-line; monitor for metabolic syndrome (weight, glucose, lipids). First-gen (haloperidol) → more extrapyramidal symptoms.
- ◆Clozapine is reserved for treatment-resistant schizophrenia and reduces suicidality; requires ANC monitoring for agranulocytosis (also risk of myocarditis, seizures, ileus).
- ◆Extrapyramidal effects: acute dystonia (hours-days, treat benztropine/diphenhydramine), akathisia (treat propranolol), parkinsonism, and tardive dyskinesia (late, treat VMAT2 inhibitor valbenazine or deutetrabenazine; may be irreversible).
- ◆Neuroleptic malignant syndrome = fever, lead-pipe rigidity, autonomic instability, altered mental status, elevated CK. Stop the antipsychotic; treat with dantrolene/bromocriptine and supportive cooling.
Substance Use Disorders
- ◆Alcohol withdrawal: tremor/anxiety at 6-24h, seizures at 12-48h, delirium tremens (autonomic instability, confusion) at 48-96h. Treat with benzodiazepines (CIWA-guided) + thiamine before glucose to prevent Wernicke.
- ◆Alcohol use disorder maintenance: naltrexone (reduces craving; avoid with opioids/liver failure), acamprosate (good in renal-normal, hepatic disease), disulfiram (aversion, requires abstinence commitment).
- ◆Opioid overdose = miosis, respiratory depression, decreased consciousness → naloxone. Maintenance = buprenorphine (partial agonist, precipitates withdrawal if given too early) or methadone; naltrexone after detox.
- ◆Opioid withdrawal is uncomfortable but not life-threatening: yawning, lacrimation, rhinorrhea, myalgias, diarrhea, mydriasis, piloerection; treat symptomatically or with buprenorphine/clonidine.
- ◆Stimulant (cocaine/amphetamine) intoxication: mydriasis, hypertension, hyperthermia, agitation, chest pain—use benzodiazepines; avoid beta-blocker monotherapy in cocaine (unopposed alpha).
- ◆Benzodiazepine withdrawal (like alcohol) can cause seizures and be lethal; taper slowly. Flumazenil reversal is generally avoided (seizure risk in chronic users).
High-Yield Special Topics
- ◆ADHD: ≥6 inattentive and/or hyperactive symptoms before age 12 in ≥2 settings for ≥6 months. First-line = stimulants (methylphenidate, amphetamines); atomoxetine or alpha-2 agonists (guanfacine) if stimulants contraindicated.
- ◆Serotonin syndrome: rapid onset with clonus, hyperreflexia, agitation, autonomic instability (vs NMS's slower onset and rigidity). Stop serotonergic agents; cyproheptadine if needed.
- ◆Anorexia nervosa: restriction, low body weight, intense fear of gaining weight; watch refeeding syndrome (hypophosphatemia). Bulimia nervosa: binge + compensatory behaviors, usually normal weight—SSRI (fluoxetine) is first-line; bupropion contraindicated.
- ◆Suicide risk: highest with prior attempt, male sex, access to firearms, substance use, and specific plan. Always ask directly; escalate to inpatient care for imminent risk. SSRIs carry a black-box warning for suicidality in patients <25.
- ◆Neurocognitive: delirium is acute, fluctuating, with inattention (treat underlying cause; low-dose antipsychotic for agitation) vs dementia (chronic, progressive). Avoid benzodiazepines in delirium except alcohol/benzo withdrawal.
- ◆Somatic symptom disorder = distressing somatic symptoms + excessive thoughts/behaviors; illness anxiety disorder = preoccupation with having illness with minimal symptoms; conversion (functional neurologic) = neurologic deficit incompatible with disease.