Psychotherapy, as a prescribing PMHNP uses it

A 16-year-old with anorexia nervosa is in family-based treatment. After 6 months, BMI has risen from 15.2 to 17.8, but the parents say the therapist often implies they caused the illness. The PMHNP recognizes that this conflicts with the FBT principle of:

1. returning control of eating to the adolescent early
   FBT hands eating back to the teen only in phase 2, after weight is largely restored; early return of control is not its principle.
2. an agnostic and non-blaming stance toward the cause
   Family-based (Maudsley) treatment takes no position on what caused the illness and explicitly does not blame parents, who are put in charge of refeeding; a therapist implying fault undermines that alliance.
3. separating the adolescent from the family during refeeding
   Separating the teen from the family is the older approach FBT replaced; FBT keeps parents at the center of refeeding.
4. exploring the family dynamics that caused the illness
   Searching for family dynamics that 'produced' anorexia is the causal framing FBT rejects.

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Six months after clinic-wide motivational interviewing training, retention in the clinic's substance use program is unchanged. To decide what to do next, the PMHNP first:

1. repeats the full MI training for the staff
   Retraining assumes a knowledge gap without evidence; fidelity data show whether coaching, not more workshops, is needed.
2. concludes that MI does not improve retention
   Judging an evidence-based method ineffective before checking how it was delivered confuses an implementation failure with a treatment failure.
3. codes sample sessions for MI fidelity
   Training does not guarantee skilled use, so the first step is to check whether clinicians actually deliver MI, for example by coding recorded sessions with the MITI.
4. changes the outcome measure to satisfaction
   Switching to a softer outcome hides the problem rather than diagnosing it.

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A 34-year-old patient with body dysmorphic disorder is preoccupied with a perceived nasal deformity, checks mirrors for hours, and avoids social events. The patient asks for a referral for a third rhinoplasty. The psychiatric-mental health nurse practitioner's MOST appropriate plan is:

1. referral to a plastic surgeon for a consultation
   Cosmetic procedures rarely relieve BDD and often shift or worsen the preoccupation; a third rhinoplasty would feed the disorder.
2. an SSRI plus CBT for the appearance concerns
   First-line treatment for body dysmorphic disorder is an SSRI, often at high doses, plus CBT with exposure and ritual prevention, even when insight is poor.
3. an antipsychotic alone because insight is poor
   Poor or absent insight is a BDD specifier, not a delusional disorder; antipsychotic monotherapy is not effective, and SSRIs still work.
4. reassurance that the nose looks normal
   Reassurance gives brief relief and becomes part of the checking cycle.

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A 32-year-old patient has distressing intrusive thoughts of harming loved ones, no intent to act, and spends hours a day on mental neutralizing rituals. The patient starts ERP and an SSRI. Compared with treatment of depression, the psychiatric-mental health nurse practitioner anticipates that SSRI treatment for OCD usually requires:

1. higher doses and an 8- to 12-week trial
   OCD usually needs SSRI doses at the upper end of the range and responds more slowly, so an adequate trial runs 8 to 12 weeks at a therapeutic dose.
2. lower doses and a 4-week trial
   Lower doses and a short trial label patients nonresponders before the SSRI has had a fair chance.
3. an antipsychotic added from the start
   Antipsychotic augmentation is reserved for partial response after an adequate SSRI trial.
4. the same dose and duration used for depression
   Carrying depression dosing and timelines over to OCD is the common error that ends trials too early.

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A 29-year-old woman has a 3-year history of fear of abandonment, recurrent superficial cutting, chronic emptiness, impulsive spending, and two suicide attempts in the past year. Medication trials and weekly supportive therapy have not helped. She is not at imminent risk today. Which treatment plan best addresses her presentation?

1. Standard DBT with individual therapy, a skills group, and phone coaching
   Comprehensive DBT, with weekly individual therapy aimed at life-threatening behavior, a skills group, and between-session coaching, has the strongest evidence for borderline personality disorder with recurrent self-harm.
2. Weekly CBT targeting automatic thoughts and behavioral activation
   Standard CBT is built for depression and does not target emotion dysregulation and self-injury as DBT does.
3. Add an SSRI and continue her weekly supportive individual therapy
   No medication treats borderline personality disorder itself, and more of the supportive therapy that has failed adds nothing.
4. A twice-weekly DBT skills group, without individual therapy or coaching
   Skills group alone drops the individual component that works directly on suicidal and self-harm behavior.

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A patient with schizophrenia says, “I won't take that medication. It's poison and you're trying to control me.” Which response by the PMHNP best preserves the therapeutic alliance?

1. Ask about the patient's concerns and past experiences
   Exploring what lies behind the refusal, such as past akathisia or feeling controlled, avoids arguing with a possibly paranoid belief and keeps the alliance open.
2. Explain that the medication is not poison and is essential
   Contradicting the belief head-on tends to entrench it and casts the clinician as the controller he fears.
3. Provide a detailed psychoeducation session on antipsychotics
   Information delivered before the objection is understood rarely lands and can feel like pressure.
4. Accept the refusal and document an informed decision
   Documenting refusal before exploring its reasons skips the conversation that could change it, and capacity has not been assessed.

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A 45-year-old with somatic symptom disorder has received CBT and duloxetine 60 mg daily for 8 weeks. Her PHQ-15 score fell from 18 to 10, but she still sees multiple specialists weekly and says she cannot return to work. Which outcome measure should the PMHNP prioritize?

1. PHQ-9 depression severity score
   The PHQ-9 tracks a possible comorbid depression, not the disability that now defines her outcome.
2. WHODAS 2.0 disability assessment
   In somatic symptom disorder the target is function, and her inability to work points to the WHODAS 2.0, which measures disability in work, self-care, and participation.
3. GAD-7 anxiety severity score
   The GAD-7 measures anxiety symptoms; it does not capture whether she can work or carry out daily roles.
4. Repeat PHQ-15 somatic symptom score
   Re-measuring symptoms that have already fallen misses the remaining problem, which is impairment.

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A 35-year-old with PTSD reports fewer nightmares and better sleep after 12 weeks of prazosin and trauma-focused CBT. His spouse, present with consent, says he still has explosive anger at home, punched a wall last week, and refuses to discuss his deployment. He attributes the wall incident to "frustration with a broken appliance." What should the PMHNP do next?

1. Accept the patient's account and continue the current plan
   Accepting a minimizing account ignores collateral that points to residual PTSD and possible risk to the family.
2. Refer the couple to marital therapy
   Couples work before a safety assessment is premature when violence may be present.
3. Increase prazosin to target the remaining irritability
   Prazosin targets trauma nightmares, which have improved; it is not a treatment for anger.
4. Assess residual symptoms and family safety
   The spouse describes persistent hyperarousal and avoidance, and punching a wall raises safety concerns at home, so residual symptoms and safety are assessed using both accounts.

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A patient with PTSD and moderate alcohol use disorder wants help with intrusive trauma memories but has not yet cut down on drinking. The psychiatric-mental health nurse practitioner recommends:

1. 6 months of abstinence before trauma-focused therapy
   Requiring prolonged abstinence first is the traditional rule, but it is not evidence-based and often ends in dropout.
2. prazosin, deferring psychotherapy until drinking stops
   Prazosin addresses nightmares, not intrusive memories, and deferring therapy repeats the same unsupported waiting rule.
3. Seeking Safety in place of exposure
   Present-focused therapy can help, but exposure-based therapy is not contraindicated with active alcohol use disorder.
4. trauma-focused therapy alongside AUD treatment
   VA/DoD guidance supports trauma-focused psychotherapy delivered together with treatment for alcohol use disorder, because untreated PTSD drives drinking and waiting delays effective care.

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After 12 sessions of CBT for major depressive disorder with good attendance, a patient has minimal improvement and describes constant, unresolved conflict with a partner. The patient declines medication. The psychiatric-mental health nurse practitioner recommends:

1. twice-weekly sessions of the same CBT protocol
   Doubling a protocol that has not worked after 12 sessions with good adherence is more of the same.
2. supportive therapy to strengthen the alliance first
   Attendance and engagement are already good; nonspecific support does not address the interpersonal driver.
3. interpersonal therapy targeting the role dispute
   Interpersonal psychotherapy treats depression through one focal area, and a constant unresolved partner conflict is a role dispute.
4. behavioral activation focused on pleasant events
   Behavioral activation is a core part of the CBT she has received, and it ignores the relationship conflict.

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A 31-year-old with moderate methamphetamine use disorder wants to stop using and asks which treatment has the best evidence. He has no psychosis, depression, or other substance use. Which treatment should anchor his plan?

1. Disulfiram to make stimulant use aversive
   Disulfiram is an alcohol deterrent with mixed results in cocaine use and no benefit shown for methamphetamine.
2. Buprenorphine-naloxone maintenance therapy
   Buprenorphine treats opioid use disorder; it has no established role in methamphetamine use disorder.
3. Contingency management that rewards negative urine tests
   Contingency management, with vouchers or prizes for verified stimulant-free urine tests, has the strongest evidence for stimulant use disorder and is the first-line psychosocial treatment in the ASAM/AAAP guideline.
4. A daily benzodiazepine for the withdrawal phase
   Stimulant withdrawal brings fatigue, hypersomnia, and dysphoria rather than dangerous physiological withdrawal, so a scheduled benzodiazepine adds misuse risk without benefit.

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A 34-year-old veteran with PTSD has started prolonged exposure therapy with a psychologist. At a medication visit he asks the PMHNP for alprazolam to take before sessions because imaginal exposure leaves him very anxious. Which response is most consistent with the VA/DoD PTSD guideline?

1. Start scheduled clonazepam for the length of the therapy
   A scheduled benzodiazepine adds dependence and disinhibition risk without treating PTSD, and veterans with PTSD have high rates of co-occurring substance use.
2. Prescribe alprazolam 0.5 mg 30 minutes before each session
   Pre-session benzodiazepines are a form of avoidance that can blunt the fear activation exposure needs to work.
3. Pause exposure until a benzodiazepine controls his anxiety
   Delaying a first-line trauma-focused therapy to chase symptom relief with a non-recommended drug reverses the evidence.
4. Recommend against it and continue exposure therapy without it
   VA/DoD PTSD guidance recommends against benzodiazepines for PTSD; they do not treat the disorder, add dependence risk, and may weaken the extinction learning that exposure relies on.

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