What topics should be focused on when preparing for psychiatry board exams?

Psychiatry Board Exam Preparation: Essential Focus Areas

Core Clinical Assessment Skills

Master the comprehensive psychiatric evaluation as your foundation—this is the most heavily tested competency across all board examinations. 1, 2, 3

Psychiatric History Components

• Document chief complaint in the patient's own words, chronology of symptom development, and circumstances leading to presentation 1, 3
• Assess complete psychiatric treatment history including past diagnoses, hospitalizations, emergency visits, medication trials with doses and durations, treatment responses, and adherence patterns 1, 2
• Evaluate suicide risk systematically: current ideation, specific plans, past attempts (including aborted/interrupted attempts), context, method, damage, potential lethality, and intent of each attempt 1, 2, 3
• Assess violence risk: current aggressive or psychotic ideas, thoughts of physical/sexual aggression or homicide, past aggressive behaviors (homicide, domestic violence, threats), and history of violent behaviors in biological relatives 1, 2, 3
• Conduct thorough substance use assessment covering tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and misuse of prescribed/over-the-counter medications or supplements 1, 2, 3

Medical and Psychosocial History

• Document all current medications (prescribed, non-prescribed, supplements, vitamins), allergies, drug sensitivities, and medication side effects 1, 2, 3
• Assess past/current medical illnesses, hospitalizations, surgeries, neurological disorders, head injuries, cardiopulmonary status, endocrinological disease, and infectious diseases (STDs, HIV, tuberculosis, hepatitis C) 1, 2, 3
• Evaluate psychosocial stressors (financial, housing, legal, occupational, relationship problems, lack of social support), trauma history, exposure to violence or combat, and legal consequences of past aggressive behaviors 1, 2, 3
• Assess family psychiatric history, including suicidal behaviors in biological relatives for patients with current suicidal ideation and violent behaviors in relatives for patients with aggressive ideas 1, 2, 3

Mental Status Examination

• Document general appearance, behavior, coordination, speech fluency and articulation, current mood state, affect, thought content and process, perception, and cognition 1, 2, 3
• Measure and record vital signs, height, weight, and BMI as baseline physical parameters 1, 2, 3
• Examine skin for stigmata of trauma, self-injury, or drug use 1

Pharmacotherapy Mastery

Know the evidence-based first-line agents, FDA-approved indications, and when to escalate treatment—this separates passing from failing scores. 1, 2, 4

Acute Agitation Management

• Use benzodiazepines (lorazepam or midazolam) or conventional antipsychotics (droperidol or haloperidol) as effective monotherapy for initial treatment of acutely agitated undifferentiated patients 1
• Consider droperidol instead of haloperidol when rapid sedation is required 1
• Use antipsychotics (typical or atypical) as monotherapy for agitation in patients with known psychiatric illness where antipsychotics are indicated 1
• Administer combination of oral lorazepam and oral risperidone for agitated but cooperative patients 1
• Recognize that parenteral benzodiazepine plus haloperidol may produce more rapid sedation than monotherapy 1

Schizophrenia Treatment

• Initiate FDA-approved antipsychotic medications for schizophrenia, starting with appropriate agents and monitoring for effectiveness and side effects 2, 4
• Recognize treatment-resistant schizophrenia (failure to respond to adequate trials of other antipsychotics) and initiate clozapine therapy as the evidence-based treatment 2
• Understand that olanzapine is FDA-approved for schizophrenia, bipolar I disorder (manic or mixed episodes), and agitation associated with schizophrenia and bipolar I mania 4

Mood Disorder Pharmacotherapy

• Prescribe FDA-approved mood stabilizers, including lithium, for acute mania and maintenance therapy in bipolar disorder 2
• Exercise caution with antidepressants in bipolar disorder—use only as adjuncts when patients are also taking at least one mood stabilizer 2
• Recognize that SSRIs and SNRIs are first-line pharmacotherapy for generalized anxiety disorder, with high-certainty evidence showing antidepressants produce treatment response (≥50% reduction in Hamilton Anxiety Rating Scale) with number needed to treat of 7 5
• Understand that antidepressants have similar acceptability to placebo overall, but more patients drop out due to adverse effects (NNTH=17) while fewer drop out due to lack of efficacy (NNTB=27) 5

Depression Treatment

• Use second-generation antidepressants (SSRIs, SNRIs, serotonin modulators, atypical antidepressants) as first-line therapy for depression 6
• Consider combination of medication and psychotherapy for severe depression 6
• Base antidepressant selection on treatment history, comorbidities, costs, and risk of adverse effects 6
• Recognize weak evidence for antidepressant efficacy in schizophrenic patients with depression, with only sertraline tested among SSRIs and mixed results 7

Therapeutic Drug Monitoring

• Know that therapeutic drug monitoring is mandatory for lithium safety 1
• Consider TDM for suspected noncompliance, drug interactions, switching between original and generic preparations, or presence of pharmacogenetic poor metabolizer/ultra-rapid metabolizer status 1
• Use TDM when lack of clinical response occurs despite adequate dosing, when adverse effects occur at recommended doses, or in elderly patients, children/adolescents, and patients with hepatic/renal insufficiency 1

Diagnostic Formulation and Differential Diagnosis

Always rule out medical causes before attributing symptoms to primary psychiatric disorders—this is a critical board exam principle. 1, 2

Medical Workup Requirements

• Rule out acute intoxication, delirium, CNS lesions, tumors or infections, metabolic disorders, and seizure disorders through thorough physical examination before diagnosing primary psychiatric conditions 2
• Never skip systematic symptom assessment even when patients drive the agenda, as patients may be reluctant to reveal emotional problems due to stigma, leading to missed diagnoses 2
• Maintain careful attention to abnormal vital signs and complete neurologic examination, always considering education level, language barriers, and cultural factors when interpreting mental status findings 2

Assessment Tools

• Incorporate standardized rating scales to identify and determine severity of symptoms and functional impairments that may be treatment targets 1, 2
• Understand that psychological testing should not be used to diagnose schizophrenia, though intellectual assessment may be indicated when developmental delays are evident 2

Treatment Planning and Documentation

Create documented, comprehensive, person-centered treatment plans with clear rationale—board examiners specifically look for evidence-based justification. 1, 2, 3

Treatment Plan Components

• Include evidence-based nonpharmacological and pharmacological treatments in documented treatment plans 2
• Document rationale for treatment selection, including discussion of specific factors that influenced the treatment choice 2
• Consider patient's treatment preferences and goals in formulation 1, 2, 3
• Tailor psychiatric evaluation to unique patient circumstances, using clinical judgment to determine which questions are most important for initial assessment 2

Psychotherapy Integration

• Recognize that psychotherapy (including cognitive behavioral therapy and other individual/group therapy) is first-line treatment for depression alongside pharmacotherapy 6
• Understand that brief psychosocial interventions incorporating motivational principles are effective for cannabis and psychostimulant use disorders and can be delivered by non-specialists 1
• Know that parent education/training should be considered before starting medication for ADHD, with initial interventions including CBT and social skills training when feasible 1
• Consider methylphenidate for ADHD after careful assessment, preferably in consultation with specialists and considering preferences of parents and children 1

Critical Clinical Pitfalls to Avoid

These represent the most common reasons candidates fail board questions—memorize these scenarios. 1, 2

Assessment Errors

• Never assume stable symptoms mean psychosocial assessment is unnecessary, as psychosocial factors predict healthcare utilization and relapse independent of symptom severity 2
• Never misinterpret mental status findings without considering education level, language barriers, or cultural factors 2
• Always ask about suicide thoughts, plans, or acts of self-harm in persons with chronic pain, acute emotional distress, or any priority psychiatric condition—asking does not increase suicide risk 1

Medication Errors

• Never use thioridazine or chlorpromazine for behavioral and psychological symptoms of dementia 1
• Do not use haloperidol or atypical antipsychotics as first-line management for dementia-related agitation; consider short-term use only when there is clear and imminent risk of harm with severe symptoms, preferably in consultation with a specialist 1
• Recognize that antipsychotics have limited positive effect in treating dementia symptoms but can cause significant harm 1

Documentation and Safety

• Use safety planning rather than no-suicide contracts for patients with suicidal ideation 3
• For patients with aggression, conduct specific assessment of triggers and response to interventions 3
• Document all sections clearly with date, time, and authentication by the evaluating clinician 3

Emerging and Novel Treatments

While traditional agents dominate board exams, understanding limitations of current research demonstrates advanced clinical reasoning. 8

Current State of Novel Agents

• Recognize the relative dearth of novel medications under investigation for anxiety disorders compared to PTSD, depression, and schizophrenia 8
• Understand that recent randomized controlled trials for novel agents including neuropeptides, glutamatergic agents (ketamine, d-cycloserine), and cannabinoids (cannabidiol) in GAD or SAD have been largely negative, with only some promise for kava and PH94B (inhaled neurosteroid) 8
• Know that there is a lack of randomized double-blind placebo-controlled trials for anxiety disorders and few studies comparing novel treatments to existing anxiolytic agents 8