Hello and welcome to the Physician Assistant Exam Review Podcast, episode 135. We’re going to be covering bipolar-related disorders and depressive disorders today. Welcome to the show. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, and I am thrilled to be here. Number one, I want to say that I was a little disappointed in last week’s episode. I was running crazy busy.

I have the launch of the 33 Days to Pass the PANCE September cohort going on. So I have a ton to do with that. My kids are off for the summer. We’re running around here and there. And it just, you know, I tried to squeeze it in at a time that I probably shouldn’t have tried to squeeze it in. So I’m going to straight up apologize for that. I am going to make that up to you today and have a much better show today as we cover this next section.

And we’ll wrap it up the whole psych thing at the end. I think it’s a good way to look at it is to go through and compare and contrast the whole thing and do sort of a wrap up at the end. And I think that’ll be a better way to revisit anxiety and the things we talked about last week and the week before. So speaking of which, if you have someone or if you are someone who is struggling in PA school, I was just reading through a couple people who were just, well, I don’t want to go into their stories. But if you’re having a problem, if your scores aren’t what you think they should be, if you are in a position that you think you should be doing better for all the work that you’re putting in, I’m here to tell you that there are some absolute things you can be doing. There’s no magic bullet, right? There’s no one thing.

People reach out to me and say, well, tell me one thing I can do to get better. Tell me, you know, what’s one thing that you think? And that’s a bad question. There’s no one thing. There are a series of things, and you’re probably doing a good chunk of them, right? You probably have a good series in place, a good stack in place. But what I find is perhaps you’re missing one or two things.

And if you’re interested in discovering what maybe one of those two things are, or in implementing the things you already know, then the 33 Days to Pass the PANCE program is a great place to learn about those and to discover some structure to how to implement these new techniques, or perhaps the things you already know but aren’t utilizing to the fullest. So the September cohort is currently, registration is open until Thursday. Registration is open at physicianassistantexamreview.com/33, and then we’ll be running another cohort in, so that one begins September 1st. So we’ll be running another cohort beginning November 1st, and that’ll be the last two for 2025. So depending on where you fall, whether you’re working on your EORs or whatever, you know, that’s a good place to be. Anyway, let’s jump in and start talking about bipolar and depressive disorders today. And we’ll start with our priming questions.

And I know that I say this a lot, but I want to make sure, especially for new listeners, that you understand the point of the priming questions. The point of the priming questions is that you know that you’re paying attention, that you’re engaged, that you’re following along, that you’re not just staring off in the space. Yeah, you can do this while you’re driving. Yeah, you can do this while you’re washing dishes or out for a walk or whatever. That’s great. But I want you with us. I don’t want you just with it running in the background.

So part of the priming questions is to create that structure in your brain that started scanning ahead, looking for the information. So even if you don’t know the questions, don’t worry about it. That’s not the point is getting them right. The point is putting in a little bit of effort up front and giving your brain something to look forward to. What episode defines bipolar one disorder? What episode defines bipolar one disorder? What symptom is required for major depressive disorder?

What symptom is required for major depressive disorder? How long must symptoms last for persistent depressive disorder? How long must symptoms last for persistent depressive disorder? For premenstrual depressive disorder symptoms occur in which menstrual phase? Which menstrual phase? What is the strongest risk risk factor for suicide? What’s the strongest risk factor for suicide?

All right. Let’s hop right in. Bipolar and related disorders. These are chronic mood disorders with episodes of mania or hypomania and depression. Onset typically late teens to 20s, equal in men and women, and a strong genetic predisposition. That equal in men versus women thing to me is important. One in your practice, but two in your test questions.

I’m always looking for what’s a little bit of an edge I can get to separate out, to define which, what are we talking about? Which disease, how are they going to be clues in a stem? And that’s going to be one way. Is is it’s going to be the more likely candidate, right? So if something is more likely in females than males, they’re they’re on the test, are going to give you a female or else it would be mean, right? I guess they could do it the other way, but it would not be right. So I’m always looking for that edge.

And that’s one of the places. So here it doesn’t help us though. Clinical presentation. So I’m going to run through the different bipolar disorders and describe their clinical presentations, describe what they look like. And then we’re going to talk about treatments because it’s kind of the same. So rather than pulling them out separately, that just doesn’t make as much sense. Bipolar one disorder, at least one manic episode.

Greater than one week, you have irritable or elevated mood with high energy, and just that manic episode where that person is high energy. They’re moving. They don’t really need sleep. They’re… they have pressured speech. They have grandiose ideas. They have impulsivity.

Again, I think this is one that most people can wrap their heads around, that you can feel like you can understand. That the person is just like, almost like they’re on cocaine. Like they’re super excited. They can’t, they have that pressured speech where they’re just talking, talking, talking. They don’t really need sleep. They’re very impulsive, et cetera. That’s a manic episode, right?

They may have a depressed episode, but not required for diagnosis. So for bipolar one disorder, all you really need is that manic episode. You don’t need a depressive episode, but you could have it. Severe impairment may include psychosis or require hospitalization. So if this person becomes a danger to themselves, they may require hospitalization. Bipolar 2 disorder, on the other hand, at least one hypomanic episode, so that’s greater than four days. It’s the same as manic symptoms, but less severe.

They’re still going about their day-to-day lives. There’s no psychosis, right? So that’s going to be your major difference. They’re also going to have at least one major depressive episode that’s required for diagnosis. Often this is, and here’s the sticking point, this is misdiagnosed as depression because they miss the hypomanic episodes. You have to make sure that you’re asking about that in the clinic. So this might be not come up on your test, but come up in your clinic if you are dealing with this sort of a situation.

So just to recap, and I’m going to recap throughout this whole thing, because to me, this is where the important parts are. Bipolar 1 is at least one manic episode. They can have depressives, but it doesn’t really matter. At least one manic episode. So greater than a week with all of the symptoms we described where they’re interfering with their daily life to that extent. Bipolar 2, at least one hypomanic episode and at least one major depressive episode. Then we complicate things and throw in cyclothymic disorder.

And with cyclothymic disorder, it’s greater than two years of fluctuating hypomanic and depressive symptoms, not meeting the full criteria for hypomania or major depression. So, to me, I get a little lost here, and we’re going to touch on this more because it’s like, this is like a catch-all category that I don’t really understand. And here, it’s like a milder but chronic bipolar. It’s like a milder, but chronic bipolar. So you get these hypomanic and depressive symptoms that cycle over greater than two years. And I talked earlier about the male versus female bit. The timeframes here are going to be major for your test questions, right?

Major for your test questions. So we already did that. A manic episode is greater than one week. For a hypomanic episode, we need greater than four days. For cyclothymic, we need greater than two years. So to me, those are the flashcards I’m building if I’m going to study this. Lab studies and physical exam findings.

This is obviously a clinical diagnosis. We’re not really going to find much in the way of labs and studies and physical exam findings, but you may want to rule out secondary causes. So thyroid dysfunction, substance abuse, like we talked about, medications that they’re on, like stimulants or something like that, that may mimic some of these or depressants that may mimic some of these. There are also screening tools like the mood disorder questionnaire and other things you could come across.

All right, let’s talk about treatments. First line is going to be mood stabilizers, right? That’s step one. So lithium is the gold standard for mania and maintenance. And again, this is one that just sticks with me. I’m not sure why, but lithium for bipolar just seems, maybe it’s because it’s the only thing we treat with lithium, I think, but it just stands out to me.

Now, the problem with lithium is that there’s a tight therapeutic window, so it has to be monitored all the time. It also can screw up the thyroid and so on. Valproic acid might be effective for mania or mixed episodes, and then there are a couple others that go down as you go down the list. You might use atypical antipsychotics, maybe an acute mania or a bipolar depression, something like that. You could use antidepressants, but they may stimulate a manic episode, so they’re kind of frowned upon, especially on their own. There is kind of behavioral therapy and family focused therapy, which is going to be important, the family focus part, because having had the pleasure of seeing this a couple times, it can cause some serious issues with family members, especially those. Well, both the depressive and the manic episodes, right?

Because of the impact those can have, you can imagine.

All right, so let’s run through real quick. I just want to touch on, I know I did this once, but I want to do it again here. I’m going to do it again later on because to me, this is the important part. Bipolar one versus bipolar two. Bipolar one, at least one manic episode. Bipolar two, at least one hypomanic episode and one major depressive episode.

Okay, so that’s the key. What about bipolar 2 versus cyclothymic disorder? Well, bipolar 2 requires at least one full major depressive episode, plus hypomania. Cyclothymic disorder is greater than two years of fluctuating hypomanic and depressive symptoms, but never quite reaching that full hypomania or major depression.

All right, so it’s that chronic but more mild. It’s that two years of sort of missing the diagnosis, but things aren’t good. What about bipolar versus major depressive disorder? Well, we’re about to get into depressive disorder, so let’s go on and talk about that. So the lifetime prevalence for major depressive disorder is about 15 to 20%. It’s more common in women, and the average onset, again, is mid-20s. Clinical presentation, at least two weeks of depressed mood, or anhedonia.

So what’s anhedonia? Anhedonia is an important one, just to round out the picture in your head so you understand what’s going on. This is the loss of pleasure or interest in the things around you. A loss of pleasure or interest in the things around you. This must include greater than five total symptoms causing functional impairment. So here’s the key. Causing functional impairment.

Does this interfere with the functions of your daily life? So this would be sleep disturbance, insomnia or hypersomnia. Interest, so loss of interest in things like anhedonia, feeling guilty or worthless, low energy or fatigue, difficulty concentrating, appetite or weight changes, psychomotor agitation or slowing down, suicidal thoughts or recurrent thoughts of death. This is the mnemonic usually used for this is SIG E CAPS, which again, I know a lot of you are. I am not a fan of mnemonics. I never found them to be helpful for me. I spend more time memorizing the stupid saying than I do just understanding what this looks like.

So, to me, the understanding part is a jump ahead than memorizing the list, but sometimes you have to start with memorizing the list. So, it’s S-I-G-E-C-A-P-S. So, sleep disturbance, interest loss, guilt or worthlessness, energy loss or fatigue, concentration, appetite, weight changes, psychomotor agitation, slowing, suicidal thoughts or recurrent thoughts of death. If you want to head, you know, you can just pull that up on Google or whatever and get that list. I think it’s probably valuable place to start. But again, to me, it’s, to me, it makes more sense to understand what this looks like and having a solid picture in your head than it does to memorize a list of symptoms. Lab studies, obviously this is a diagnosis that’s clinical, but again, you want to exclude medical causes.

So in this case, it would be not hyperthyroid, but hypothyroid might look like this. Substances or medications may cause this. And then again, we can use screening tools like the patient health questionnaire, Beck depressive inventory, and go through their symptoms, that kind of thing. Treatment’s first line is going to be SSRIs. SSRIs. So you need to start recognizing SSRIs in the wild if you don’t already. That would be things like fluoxetine, sertraline.

You can also use SNRIs, bupropion, tricyclics, that kind of thing. I’m doing my notes a little different, and I know you don’t care, but I actually printed everything out because I didn’t like how the flow was going with it on my computer. So that’s what the little pauses are for. I’m getting used to where I am in my notes. If you have severe, and I want to go back to something, if you have severe refractory cases, electroconvulsive therapy can help. And this would be useful in something like, because it’s safe in pregnancy or in the elderly, where sometimes if you’re concerned about using medications. It’s cognitive behavioral therapy, interpersonal therapy.

And then to me, and again, I know that this, I’m not talking about major depressive disorder necessarily, but the lifestyle changes are key. And again, I don’t work in psych. I don’t participate in anything. This is not in my wheelhouse, but what I’ve seen, is that exercise can have a tremendous impact on mood. Tremendous impact on mood. As little as, you know, some of the studies are showing as little as 10 minutes a day. Unbelievable.

And sleep hygiene, I think is a huge one. Social connections is a big one. So I think those lifestyle modifications, in addition to the other things that you would recommend, to me, I don’t want those, I just don’t want those to be glossed over. This isn’t necessarily something I think is going to come up strong on your exam. But I think in your practice and in your own life, if you’re looking to regulate mood and anxiety and some of the things we talked about last week, that lifestyle can play a significant role.

All right, so let’s bounce back and say, okay, so if we have major depressive disorder versus a bipolar disorder, right, how would we tell the difference? What would be the difference in a test question. If we had bipolar versus major depressive disorder, well, what’s the one thing that bipolar requires that you won’t find in major depressive disorder? A manic episode, right? Or hypomania. You won’t have those in pure major depressive disorder. You will only have those in bipolar.

All right, so let’s move on to persistent depressive disorder or dysthymia. This is a lifetime prevalence of three to six percent more common in women, often in adolescence or early adulthood. So, this these all kind of fall into that same area, right? Teenagers to 20s. So, that’s not really going to help us on an exam. Course is chronic and insidious. I love that word, insidious.

Clinical presentation. Depressed mood for greater than two years.

Okay. So, this is a persistent depressive disorder. So, we’re back to that two-year thing. So, when we see a timeline in like two years in a test question, what are the two things that should pop into your head? Well, for me right now, it’s cyclothymic disorder and persistent depressive disorder, because those are our things on that kind of a timescale. So if it’s a younger child, though, they do kind of chop that down to greater than one year. Symptoms must, I’m sorry, symptoms present most of the day, more days than not.

Most of the day, more often than not. During a two-year period, they’re never without symptoms for more than two months. So they may be without symptoms for a little while, but it’s kind of still going to be most of the time over those two years.

Now, your question is, well, what the heck are the symptoms? You’ve been saying what they should be there for two years, but what are they? So this is poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions. That sounds like some of us, poor concentration or difficulty making decisions. I love how when you go through these, you’re like me, me, me. Feeling of hopelessness? That’s not it’s not quite me yet.

Often described as gloomy, always down kind of person. So, this is like a depressive disorder, but it’s like that hypomania. It’s not quite reaching that standard. Like, it’s not interfering with the day. They can go to work, they can get in the car, they can drive their kids to school. Or that major depressive disorder, they’re they’re not doing those things, right? It’s completely interfering with their day.

So, this is more like a gloomy person. I like the way that that’s kind of phrase or someone who’s always down or someone who’s, you know, like an Eeyore. That’s actually a really good one from Winnie the Pooh. He’s not depressed, you know, but, you know, you say good morning to Eeyore and he says, is it? That kind of person. Lab studies and physical exam findings, clinical diagnosis here, right? We’re going to rule out medical causes like thyroid issues, chronic illness, substance, and other medications.

You’re going to use your screening tools. Same as for major depressive disorders. So we have Beck’s Depressive Inventory. We have the PHQ-9. But the symptoms are less severe and more chronic. So you don’t get these strong, strong episodes. You get this low-lingering depressive state.

Good news, though. Our treatments are basically the same. This is one of the reasons why when I study, I study these in groups, right? Because how are they going to ask this? Well, your treatment, your first line is going to be SSRIs, right? Fluoxetine, sertraline. And then you could do SNRIs or bupropion.

You could do cognitive behavioral therapy. You could do interpersonal therapy. Again, you could do lifestyle modifications, all these things. That’s all the same. So how are they going to ask you a question? Well, it’s going to be the diagnosis. It’s not going to be the treatment between persistent depressive disorder and major depressive disorder because the treatment is the same.

So how are they going to ask you the treatment? They’re not. So when you’re studying it, yes, you need to know the treatment. But as you’re doing this, look at how the questions are going to come. Major depressive disorder is episodic. You have greater than two weeks of depression and it’s severe. Dysthymia is chronic low-grade depression for greater than two years and often mild but persistent.

So that’s how they’re going to come. That’s the story. That’s the vignette you’re going to get.

Okay, let’s keep going. Premenstrual dysphoric disorder. This affects 3% to 8% of menstruating women. Onset, again, late teens to 20s. Symptoms recur with menstrual cycles. That’s important for our diagnosis, right? Strong association with functional impairment.

Again, strong association with functional impairment. So that’s the things we’re looking for. This is not just I’m uncomfortable. This is, I’m not doing my daily activities. I’m not going to school. It’s affecting my work, et cetera. Clinical presentation symptoms occur during the luteal phase.

Seems like an easy low-hanging fruit kind of question. Symptoms occur during the luteal phase. To me, that’s a super straightforward question. That could certainly come up on your PANCE. During what phase of menstruation does premenstrual dysphoric disorder occur? And this is one to two weeks before menses and resolves with the onset of menstruation. And that’s another big one to me.

Resolves with the onset of menstruation. I would write that one down. Although, maybe not. Because as soon as you get a depressive disorder that someone says matches their cycle, then the exact details may be less important. You must have five symptoms with at least one from the affective category. Mood swings, irritability, or anger. Depressed mood or hopelessness.

Anxiety or tension. Again, I’m just thinking about my daily life. Additional symptoms: decreased interest in usual activities, difficulty concentrating, lethargy, fatigue, appetite changes, food cravings, sleep disturbance, insomnia or hypersomnia. Physical symptoms, so you can get breast tenderness, bloating, joint and muscle pain. Again, symptoms must be severe enough, severe enough to interfere with daily functioning. So we have something that looks kind of like major depressive disorder, an episode of major depressive disorder, but it’s tied to the menstrual cycle. Labs and studies, the diagnosis here is clinical, but it may be worth in your history and maybe having the patient track when these symptoms occur in relation to their cycle.

Again, you’re going to want to rule out other mood disorders and other issues like hypo-hyperthyroidism. I’m not hyper, just hypothyroidism. You’re going to want to rule out substance abuse, dysthymia, major depressive disorder, all that stuff. Treatment. Well, again, here we go. First-line treatment. SSRIs, fluoxetine, sertraline.

Effective both continuously or just during the actual phase of the depression. Oral contraceptives may be helpful. And then again, we get to cognitive behavioral therapy and lifestyle modifications with sleep hygiene, stress reduction, regular exercise. I think those are just such low-hanging fruit with such high impact. I think those are, I you know, at this point, I would be recommending this to those to every single one of my patients. I pretty much recommend them to everyone I know. I just think that it’s so powerful, and we screw up so much of our mental state through our own habits and actions.

All right. So, our key differentiators here, premenstrual depressive disorder is that cyclical pattern, right? Major depressive or persistent is similar persistent and not cycle related. So, it’s pretty straightforward how those are going to come in a test question. We’re going to, if you study this and then do questions on it at the same time, it’s so obvious what the answers are. It gets hard when you mix everything together because you forget some of this. But as these questions come, they should not be complicated to differentiate.

Now, in the office with a real patient, when you have 300 questions mixed together over five hours, it gets exhausting. You miss some of these clues, but it should be pretty straightforward stuff. Our last topic for today is suicidal and homicidal behaviors. Suicide is the 10th leading cause of death in the U.S. That’s astounding to me. Highest risk is older white men, but attempts are more common in women. So that’s an important thing to note, that men have higher rates of suicide, but women have higher rates of attempting suicide.

Obviously, this is tied into this section because it’s commonly associated with depression, bipolar disorder, substance use, schizophrenia, and chronic medical illnesses. Clinical symptoms here. So these are basically our warning signs for expressing hopelessness or worthlessness. Talking about wanting to die or kill oneself is a bad thing, increased substance use, withdraw from friends and family, giving away possessions, and finalizing affairs. That’s always a concerning one right there that jumps out. Risk factors. So males, elderly or teens are at higher risk factors, those with depression.

Those with previous attempts, highlight that one, previous attempts. If someone’s attempted suicide previously, they’re at a high, surprisingly, they’re at a high risk for attempting it again. Alcohol or drug use, if they’re psychotic, if they’re lacking social support, social support is a huge one, absolutely tremendous. If they have an organized plan, so if they’ve put something together on how to execute this, not just a I’m depressed and I’m feeling down and I don’t know if it’s worth going on, but I actually purchased a gun. I actually have the pills. I’ve thought about exactly how to do this. I had thought about what time of day to do it so no one’s home.

And how they’ll find me, etc. That’s really a problem. That’s when the red flags go off. Chronic illness would be another one. Lab studies and physical exam findings. Obviously, there’s no lab test or diagnosis. You’re doing a clinical assessment with history.

This is why we ask direct questions about suicidal thoughts, plan, and intent. The homicide part of this is similar, but it’s so it’s really talking… And the big thing that I came across when looking up stuff on the homicide part of this is asking about the plan. Not just a generalized, you know, I hate my boss. This attending really pissed me off. I’m going to kill my brother, which I hear 10 times a day out of my children. But it’s the plan.

It’s that they’ve sat and thought and created that that really makes it tangible and concerning.

So let’s talk about treatment and management. Suicidal patient with plan and intent. So immediate psychiatric eval. That should be obvious. And then hospitalization involuntary if necessary. You want to make sure that they are safe and that, you’ve if possible, that you can remove any lethal means. Suicidal ideation without a plan.

A little bit different. This can be an outpatient referral. You want to have them have a safety plan and close follow-up. So, again, how is this going to come on a test? Well, you you will get treatment questions here, right? What’s the treatment for someone who has a plan and someone who doesn’t? Have a plan.

One is going to be inpatient. I need this person to be in a safe place. One could be outpatient with an ongoing discussion. You could treat underlying psychotic disorders, so like SSRIs for depression, mood stabilizers for bipolar disorder. You may need crisis intervention like suicide hotlines, cognitive behavioral therapy, and family intervention.

Now, here’s something I came across that I think is extremely important, especially is there with the new blueprint of the PANCE out, is the the homicide part of this is what came up very quickly for me was Tarasoff’s rule, which I didn’t know. And and I don’t know the… know the name of it, but this falls directly under your professional practice section. So, everyone’s like, what do I need to know for professional practice? How does that work? I don’t understand. What can I study for that?

And one of the things is this situation. So, if you have someone who’s a homicidal risk, then you have a duty to warn and protect and must breach the patient’s confidentiality if there is a credible threat to others. So to me, this is a great, great, what do you call it? I just lost my train of thought. This is a great professional practice question. And the principle here is that if a patient makes a credible threat of serious violence against an identifiable person, right? So they were actually like picked out a person, they have a plan, and they’re talking to you about it.

The provider must warn that potential victim. This overrides patient confidentiality. This was a Supreme Court case in 1976. So if a patient says, I’m going to kill my neighbor tomorrow with my gun, you must do something about it. That includes notifying law enforcement, warning the victim, taking reasonable steps to protect, meaning you may have to hospitalize the patient, again, or call law enforcement. But again, to me, that’s a great one for professional practice. Because at what point can I breach patient confidentiality?

We’re so drilled into patient confidentiality that we think that’s the number one rule. It is number one until it isn’t, right? There can be two different thoughts at the same time. We’re not going to go down that road right now, but just so you have that one, I think it’s important.

Okay, let’s do a quick recap of the, basically everything that we talked about. So mood disorders and suicide risk. Bipolar 1 versus bipolar 2. How do we tell them apart? So think for a minute. How do we tell bipolar 1 versus bipolar 2? If we’re going to be doing a diagnosis, how do we tell them apart?

Think, think, think. Bipolar 1 is true mania. That’s it. Greater than one week of a manic episode. Bipolar 2 is hypomania plus a major depressive disorder. So, a patient with depression plus any history of mania, hypomania. This is bipolar.

Not depression. This is bipolar. Not depression. Bipolar 2 for cyclothymic disorder. Bipolar 2 requires a major depressive disorder. It requires it. Cyclothymic is greater than two years.

Never having full mania or hypomania or major depression. Patient with mood swings for three years but never full mania or depression. Think cyclothymia. Major depressive disorder versus bipolar disorder. Major depressive disorder is depression with no history of mania. We’re going to go over that a hundred times. Bipolar must have a history of mania or hypomania.

Depression is treated with an SSRI alone. Major depressive disorder versus persistent depressive disorder or dysthymia. Major depressive disorder is greater than two weeks, often very severe. Dysthymia is greater than two years, milder, and never without symptoms. So, someone who’s always gloomy or down versus someone who has these very painful episodes. If we’re talking about premenstrual depressive disorder, we’re looking for that cyclical depression episodes. If you have on your test symptoms that disappear with menstruation or follow a patient’s cycle in any way, then you’re looking at premenstrual depressive disorder.

I’m starting to stumble through some of these. I’m sure you are too.

So let’s keep it moving. You’re going to see subtle differences in duration, severity, or triggers. That’s kind of how this is going to come. Subtle differences in duration, severity, or triggers. So those timelines, greater than two weeks, greater than two years, cyclical. And then it’s the presence or absence of mania or hypomania.

All right. We covered a lot. Whoo.

Let’s shift gears for a second before we answer our priming questions. And I do have a couple of PANCE type questions on this I want to get to, but I want to take a quick breather, rest your brain for a second, and talk for one minute about our study tip for today. Our study tip for today is going to be a way to go about practicing for exams. I have a lot of students who run out of time on exams. I have a lot of students who use the full 60 seconds per question. I have a lot of students who just don’t understand the timing of how it works. And one way to practice would be to set up a timer, a clock, you know, do 60, one minute per question, no matter when you do your questions.

And I think a lot of people recommend that. So if you’re going to do a block of 60 questions, that’s 60 minutes. And that’s cool. I like that a lot. I think it makes a ton of sense. I think it’s a really good practice. I think if you’re going to do 10 questions, you set your timer for 10 minutes and you blast through them.

It’s harder as you get shorter in the timelines, because what happens is the way questions are set up, right? Some are long and some are short. So I mean, that’s obvious, but it is and it isn’t. If you get a run of short questions, you know, you may be done in 30 seconds a question, but if you get a run of long questions, they may take two minutes a piece. So it’s one of the problems people run into with some of the question banks out there is they have very long questions. So when you do like a practice exam or a run of 60 questions, it’s almost impossible to keep it at 60 minutes because of that issue, right? And then they think that they’re not doing something wrong, but really it’s a reflection on the testing bank, not on them and something to know going in.

But anyway, that’s not the point of this study tip. That’s one way to think about it. But something I suggest from time to time with students is a completely different practice. And it’s not all about timing, but it’s rather than setting your time for a minute per question, why don’t we vary that? Why don’t we adjust it and see what happens? What if you give yourself only 30 seconds per question? Do a run of 20 or 30 questions, but only give yourself 30 seconds per question.

You may find, and I’ve had students do this, that’s all they need. That they spent that extra 30 seconds per question talking themselves out of the right answer, running over things, rereading things that were exhausting them. This doesn’t work for everyone, certainly. Like I said at the beginning, usually you have a good set of techniques and ways you’re doing things, and sometimes you just need one or two things, but that’s different for everyone. The tools you use are different from the person sitting next to you. So the next tool that you need is going to be different from the person sitting next to you. But one thing I think you can try, or I think is a good idea to try, is setting your timer for 30 minutes and doing 60 questions and seeing how you do, seeing how you feel, seeing what your answers actually are, not just the panic that sets in, but see what your results are.

I’ve had plenty of students whose scores go up when they do this. It’s one of my concerns when I see students who get extra time on the PANCE. I think it’s a good idea for a lot of people to get extra time. But again, just like everything else, it’s not a magic bullet. Just getting extra time, I know for me personally, would be worse. It wouldn’t be better. Going back a second day would not be better.

It would be worse. There are a lot of people it would be better for. But don’t just do it because someone else did it and it worked for them. Don’t just do it because someone else did it and it worked for them. Test it. Try it. See what you think.

Absolutely. I’m not dismissing any of it. But one thing you can definitely try is shorten that time frame and see what happens and do it a couple of times because initially it’s going to be uncomfortable, but you may find that one, it speeds you up. You may find two, that your scores go up. You may find that you hate it and it’s terrible, but you also may find that you can speed up on the exam if you need to.

All right, let’s answer our priming questions. What episode defines bipolar one disorder? What episode defines bipolar one disorder? Well, that was mania, right? What symptom is required for major depressive disorder? What symptom is required for major depressive disorder? Anhedonia or depressed mood.

How long the symptoms last for persistent depressive disorder? How long the symptoms last for persistent depressive disorder? Greater than two years. Premenstrual depressive disorder symptoms occur in which menstrual phase? Premenstrual depressive disorder occur in which menstrual phase? Luteal. What’s the strongest risk factor for suicide?

What’s the strongest risk factor for suicide? Previous attempts. Hopefully you were able to get those. I mean, this section can be very straightforward. It can be difficult, but it can be very, very straightforward.

All right, I’ve got two PANCE-style questions I want to run through with you. And one is just an adaptation of one of our priming questions because I want to show you how these can stack on each other. So when you have the basics, the longer questions aren’t necessarily difficult if you know the basic information. So a 29-year-old woman reports irritability, mood swings, bloating, and breast tenderness that begin about one week before her menstrual period and resolve within two to three days after onset of menses. She denies any history of mania or hypomania. Her symptoms interfere with her performance at work and relationships. Which of the following is the most likely diagnosis?

A, major depressive disorder. B, bipolar 2 disorder. C, persistent depressive disorder. D, premenstrual dysphoric disorder. Or E, cyclothymic disorder.

Now, I think most of you should hear the mood swings, bloating, breast tenderness one week before a menstrual period and resolve within two to three days after onset of menses. And that should be pretty straightforward, right? I wasn’t trying to make this super difficult. But you will get questions like this. 100% people always talk about that there are easy questions on the PANCE. It absolutely happens. So our answer here is D, premenstrual dysphoric disorder.

Now, the thing I like to do is go back and just look for a second at my other answer choices. Why aren’t they correct? Well, major depressive disorder, symptoms would have to be greater than two weeks. Nowhere in here does it say that. Bipolar disorder requires a hypomanic episode. I’m sorry, bipolar 2 requires a hypomanic episode. I don’t have that.

If it was bipolar 1, I would need a manic episode. I don’t have that either.

Now, if it were persistent depressive disorder, I would need greater than two years. There’s nothing in here that says greater than two years. If it was cyclothymic disorder, again, I would need greater than two years. I don’t have that, so I know I’m right.

Let’s do one more before we wrap up for today. A 35-year-old woman presents with a history of always feeling down. She reports low energy, poor concentration, feeling of hopelessness for the past three years. So again, this should be jumping off the page at you, and you know because we just talked about it. It’s harder when we mix it all in, I know. But for right now, you see greater than three years. So that really pushes us to cyclothymic disorder or persistent depressive disorder.

It doesn’t mean it is that, but it’s pushing us in that direction. Symptoms have been present most of the day, more days than not, and she has never been symptom-free. Which of the following is the most likely diagnosis? A, major depressive disorder. B, persistent depressive disorder. C, cyclothymic disorder. D, adjustment disorder with depressive mood.

Then we snuck one in there because we didn’t cover that yet. Premenstrual dysphoric disorder. So we know it’s not premenstrual dysphoric disorder. We know it’s not major depressive disorder because we’re not talking, we’re not getting where it is interfering with her life. She doesn’t have these episodes. We really are down to persistent depressive disorder and cyclothymic disorder, right? But what’s going to be the differentiator there?

Well, cyclothymic disorder is fluctuating between hypomanic and depressive symptoms. There’s no hypomania here. There’s nothing there to give me hypomania. So I wind up with persistent depressive disorder. There’s no major depressive symptoms. There’s no cycling issues. And an adjustment disorder with depressed mood.

Just for argument’s sake, we would need symptoms within three months of an issue and resolve within six months. So there’s timeframes there too, but we haven’t gotten to those yet.

All right, that was much, much, much, much better. So that was really good. I’m excited with how the notes came together there. And I think this section hopefully will pop off the page for you and help you to understand how these will get asked on test questions. That’s always, always what I’m looking for is I want the knowledge, but I also want the knowledge in relation to how it’s going to come both in the clinic and on my exam so that I can do the best I can possibly do in the settings I’m going to be asked to know it. Not just memorizing data points out of the air, not just memorizing random lists of mnemonics, but actually being able to use this stuff as it comes on an exam and understanding the difference between them. If you’re interested in diving deeper into that methodology, again, September 1st and November 1st, we’re starting our last two cohorts of 2025 of the 33 Days to Pass the PANCE program.

You can find out more at physicianassistantexamreview.com/33. The September cohort registration will close on Thursday of this week. I think it’s the 22nd of August. And then registration for November will open. Usually opens in the middle of October. So we’ll see you then.

All right, great. Take care. Best of luck. And I hope you got something out of today. Have a great day. We’ll see you next time.