All right, hello and welcome to episode 137 of the Physician Assistant Exam Review Podcast. Today, we’re going to be covering psychotic disorders and dissociative disorders and psychogenic non-epileptic seizures, easier for me to say. So, this is a section that has killed me on my PANCE, on my PANRE. I always struggled with it, and as I’m going through it today, putting these notes together, I realize it’s actually not complicated. It’s not hard, but it’s something that I always tended to make hard. And one of the things you’ll hear me talk about is don’t study things in as independent data points, as independent things, study them together. And when you learn this section together, it becomes a whole lot easier.

And you’ll see as we move through exactly how that works. So what else is going on? So we have the September cohort of the 33 Days to Pass the PANCE is absolutely killing it. We are having an amazing time. The group has just been so much fun. We’re really making a lot of headway. We have people from all over the gamut inside of this program, people in didactic year, people who are working on their PANRE, who are struggling with that, people who have failed the PANCE and are struggling with that, people who are just getting ready for the PANCE and saying, you know what, I didn’t love the way I was preparing for my EORs, and I want to do something different.

And I think this is the way to go. And it’s just been an absolute blast. This cohort has been so much fun. We’re making a ton of progress. We have our next meeting tonight. I’m really looking for tomorrow night, tomorrow night. So I’m really looking, actually, this will be released on Tuesday.

So it will be tonight. I’m recording it on Monday. This is really going to be a lot of fun looking forward to that meeting.

Now, if you’re interested, the November cohort is the last cohort of 2025, and I’m going to be doing a giveaway at the end of September. So September 23rd to 28th, keep your eyes peeled. I’m going to be giving away one scholarship to that program. So 100% free, plus some other things I’m putting together for that person who wins that scholarship. There’ll be information coming. I don’t have it yet, but I just want to put it on your radar. And if you want to make sure that you do receive that information and get notified, the fastest way and the most assured way to make sure that you get it is through the email updates.

That’s where I can be in contact with you. That’s where I can let you know about special promotions and when things like that are happening. So make sure that you’re signed up over there. If you go over to the website, physicianassistantexamreview.com, you will find a way to sign up for the email list there, and then I can update you as to what’s going on.

All right, so let’s jump in and get started with our priming questions for today, and then you’ll see how these pan out throughout the system.

All right, first of all, we have a 23-year-old hallucinations and social decline for eight months. What’s the most likely diagnosis? 23-year-old with hallucinations and social decline for eight months. What’s the most likely diagnosis? A man disappears after trauma, later found living under a new name with no memory of his past. What disorder does this suggest? A student feels detached, like he’s outside his body, but knows it isn’t real.

What diagnosis is this most likely? And lastly, a woman has a seizure-like episode with eyes closed and a normal EEG. What’s the most likely diagnosis? So, these are all things we’re going to hit. Hopefully, you took a second to think about those, whether you’re driving, running, folding laundry, whatever it is you do while you listen to the show. You take a second to really engage with those questions, because that’s how you create, start to build out those neural networks that you’re going to need to retain the information. Just hearing it once, not helpful, almost not helpful at all.

A little helpful, hearing it multiple times, working it through, concentrating on it, rethinking it up. Those are where it’s going to start to stick for you.

All right, so let’s start with schizophrenia, spectrum, and other psychotic disorders. Oh, I’m sorry. It’s actually schizophrenia. Spectrum is this section. I have my title wrong.

All right. So the schizophrenia spectrum is disorders of distorted perception, thought, and behavior. These are core symptoms include delusions, hallucinations, disorganized speech, behavior, negative symptoms. This exists along a timeline. So it’s a timeline plus a mood spectrum is how we define these. And this is what I never really got when I was in PA school. And I didn’t see how these worked together.

And we’re going to do that today for you. So how do these, how does the spectrum demonstrate itself? So first of all, the spectrum is brief psychotic disorder, schizophreniform, schizophrenia, and schizoaffective disorder, and then delusional disorder.

Okay, so those are our spectrum of schizophrenia.

Now, it presents with positive symptoms. Positive symptoms are things that are added in. So you get hallucinations. So generally it’s auditory more often than visual, but you still, but hallucinations in general. Then you have delusions like, you know, it always comes up in my head when I think of this because in Star Wars, it’s a line they use all the time. And my kids watch a ton of Star Wars is delusions of grandeur, right? So thinking that you’re the best, you’re amazing.

You can do things that no one else can do. Delusions of being persecuted, of people coming after you. Disorganized speech or disorganized behavior is another one. Negative symptoms would be kind of removing something. So a flat affect, anhedonia, avolition, alogia, social withdrawal, all those things fall under negative symptoms. And then you can get cognitive issues with impaired attention and impaired executive function. Usually this has an onset in late teens to mid thirties, a touch earlier in men.

I’m not sure how valuable that will be for your PANCE or for your end-of-rotation exams. So I want to touch on each of these individually because how they’re going to come is up against each other, right? Generally speaking, we’ll get into more as we go, but you’re going to get asked questions about each one of these and it’s going to say, you know, is this basically, is this a schizophreniform or schizophrenia? And you have to determine which is which. This is never, let me start out by saying this has never been my strong suit, right? Psych is not where I practice. It’s not where I function.

I struggled with it in PA school. But it’s also one of the reasons why I think I’m uniquely qualified to discuss it is because things that the sections that come easy, you know, people are often dismissive. Once in a while I hop on Reddit, which I should probably avoid. And I see people say, you know, when they ask for help studying, some people jump in and just say, you know, you should just study better or you should do this or do that or it’s fine. You don’t really need to do anything. And that’s easy to say when you’re doing well, right? You know, some kids can play sports really well, and it’s hard for them then to tell the people what to do.

Some people are really good at math, and it’s hard for them to tell them what, but the people have to work, the people have to figure it out, generally are better at explaining how to do it down the road. Right? So, I think that’s where we’re going to fall in with psych here, because I look at it from the perspective of how do I get this right on the test? Not necessarily, you know and that transfers into how we’re going to treat patients, because all the stuff is the same knowledge. But that’s where I’m coming from. So if we look at brief psychotic disorder, in that case, it’s titled a brief psychotic disorder. So the duration is less than one month.

Generally speaking, we have a sudden onset and a stress-related activity. We’ll get to some hypotheticals down the road, but that’s where we’re at. Sudden onset, stress-related activity, full recovery, right? Lasts less than one month. So it’s that timeline is really the key to this. We’ve talked about that before. With psych, they define a lot of these by the timelines.

Schizophreniform is a duration of one to six months. So, same symptoms as schizophrenia, which we’ll get to in a second, but no functional decline required. So, I’m going to get to schizophrenia in just one second, but it’s one to six months, no functional decline. So, a lot of these also have to do with, you know, like we talked about ADD. Is it something that screws up the rest of your life, or is it something that, you know, the person has a little bit of issue, but kind of manages? That’s often where we draw these lines, right? So is this a problem?

Does it make you non-functional? Does it interfere with your activities of daily living? So for schizophrenia, we have six months or more and more than one month of active symptoms. So it requires a functional decline. So for schizophrenia, really important, there’s got to be a interference in your daily life. In this case, people with schizophrenia will have positive and negative symptoms, and they generally have a worse prognosis. Schizoaffective disorder meets schizophrenia criteria plus mood disorders.

So on top of your schizophrenia, you have major depression or mania. That’s schizoaffective disorder. So it lasts greater than two weeks of psychosis without mood symptoms. So you have a patient who’s psychotic for more than two weeks without mood symptoms. Because if it’s just mood, and I’m sorry, I want to make sure I’m clear on this. So it’s the schizophrenia criteria. So they’re having this for six months.

But as far as the mood symptoms go, they have to have schizophrenia symptoms. So those positive and negative symptoms we’ve talked about before, the hallucinations, the disorganized speech, maybe the flat affect, the social withdrawal, impaired attention, all those things. But on top of that, there has to be these mood disorder symptoms, but also psychotic episodes or psychosis of greater than two weeks without the mood symptoms. So what I mean is you could conflate mania and schizoaffective disorder, right? Because the symptoms might overlap a little bit. So you might be hard to parse those out. So if it’s true psychosis only during mood episodes, then it’s a mood disorder with psychotic features.

It’s not schizoaffective. I hope that makes sense. So that’s where your line is. So schizoaffective disorder is schizophrenia with a mood disorder on top of it, but they’re still schizophrenic even without the mood disorder times. Then you have the delusional disorder, which is greater than a month of fixed delusion. And functioning is not markedly impaired here, and there’s no other psychotic features.

Now, I was I was just finishing up, I don’t know if any of you guys are watching, season two of The Sandman, which is a storyline put together by Neil Gaiman. And first of all, it’s fantastic. I’m absolutely enjoying it. But second of all, the character Delirium just hits so many of the points. I couldn’t help thinking of her as I was putting the notes together on schizophrenia. Her, the actress who portrays her is fantastic, but her ability to portray the disorganized speech, the disorganized behavior, and the impaired attention, and impaired executive function, and how she jumps from thing to thing mid-sentence, how she creates her own words for things. It’s really, been entertaining and a great view of what this might look like.

Now, she doesn’t really have schizophrenia for a couple different reasons, but the character really portrays some of these things unbelievably well. The actress really, really well. As far as how do we diagnose this, this is obviously a clinical diagnosis. There are no labs we’re going to do except really to rule out other issues. So you might do a thyroid stimulating hormone test. You might do a CBC. You might do a urine toxicity test, those kind of things.

You might look for neuroimaging if it concerned you. You’re worried about that kind of stuff. Treatment. First line is going to be atypical antipsychotics. So, risperidone, olanzapine, that sort of thing. For acute agitation only, we have haloperidol or lorazepam. Those are short, short time, just acute agitations.

Clozapine is for treatment for resistant schizophrenia. And then you have cognitive behavioral therapy, social skills, and family therapy. And then finally, you have hospitalization if it’s a real, real danger, if they danger to themselves or to others like we’ve talked about before in psych, you’re going to look to hospitalize them. So these are how we look at this stuff based off of the timeline and the symptoms. So the brief psychotic disorder is less than a month. Schizophreniform is one to six months. Schizophrenia is six months or greater.

Schizoaffective is six months or greater. Delusional disorder is usually greater than one month is what we’re looking at. But those are sort of where I would start. If I had a question, I’d start with the time frames and I’d memorize those sort of first. Then I’d memorize that each of these gets a little bit progressively or adding symptoms, right? So, the brief psychotic disorder ends pretty fast, doesn’t really affect their daily living. Schizophreniform has those same symptoms, those positive and negative symptoms, but doesn’t really affect their activities of daily living.

Schizophrenia affects their daily living, starts to become a real problem. Schizoaffective disorder adds that mood disorder on top and becomes a major issue for them, right? So we sort of move up the spectrum.

Now, just to be clear, in schizophreniform versus schizophrenia, no functional decline, right? No functional decline versus functional decline. Schizophrenia versus schizoaffective. Schizoaffective has a mood disorder, but greater than two weeks of psychosis without a mood disorder. Schizophrenia versus delusional disorder, we have a broad psychotic symptoms plus a decline instead of a single delusion with preserved function. So, delusional disorder is one delusion instead of a whole host of delusions, let’s say.

Let’s talk about dissociative disorder. So, this is like your multi-personality disorders, something that would just, it helps to wrap your head around it to use some of these term, at least for me. This is a disruption in consciousness, memory, identity, or perception. This often follows trauma or severe stress. The main types here are dissociative identity disorder, dissociative amnesia, with or without a fugue state, and depersonalization and derealization disorders. Dissociative identity disorder would be our multi-personality disorder. This is two or more distinct identities or personality states.

This individual has gaps in memory. So amnesia from everyday events, trauma, personal information. But what that means is that when they are in the other identity, they don’t have memory of, they don’t know there’s another identity there, right? So, this is, if you’ve ever seen Fight Club, Fight Club would be a great, and is a fantastic movie if you haven’t seen it, is a great portrayal of this, where you actually just don’t have the memories, don’t realize that something else is going on. So, this is someone who thinks they love, who can’t find things, or things appear, and they don’t know how they got them because they bought them as the other person. An outside person would notice a difference in the way the person speaks or in how they stand or walk, that kind of thing. So this is not schizophrenia because there’s no hallucinations or delusions.

There’s just a switching of identities. Then let’s talk about dissociative amnesia. So this is the inability to recall important personal information, usually trauma or stress-related. This is bigger than being normally forgetful, right, because it’s an impactful situation. So, maybe you can’t remember after being in a bad car accident, you can’t recall the whole day, right, that gets wiped out. That’s dissociative amnesia. And the patient sort of knows they have these holes, where in your dissociative identity disorder, the patient doesn’t know they have the holes.

They can’t figure out why things appear in their house or things get lost. But here the person knows they’re just like, I can’t remember that whole day. Then you get to depersonalization, derealization disorder. Sorry, I’m struggling with the way that these words flow together. Depersonalization is a detachment from the self. So they feel like they’re living their life outside their body, like they’re watching it on a movie. They know that that’s not true, but that’s what it feels like.

Derealization is a detachment from the surroundings, so the world feels kind of like a dream or foggy or they have trouble sort of seeing the big picture. Again, they know that it’s not true, but that’s how they feel about it. Again, this is a clinical diagnosis. Treatments for these are going to be first-line psychotherapy, cognitive behavioral therapy, eye movement desensitization, reprocessing, and supportive therapy. There are no specific medications. And then your key differentiators here.

Let’s talk about this for a second. So, dissociative identity disorder versus schizophrenia. Again, multiple identities and memory gaps versus hallucinations and delusions. Dissociative amnesia versus normal forgetting. We have a specific trauma or event that they didn’t just forget, but there’s memory loss surrounding that. Dissociative identity disorder is strongly linked to severe childhood trauma. A dissociative fugue is that same amnesia, but with the travel.

So what we’re talking about there is the dissociative amnesia with a fugue subtype is amnesia with sudden travel or wandering. So what you get here is that same car accident, but now the patient winds up a town a little over renting an apartment, not remembering anything about what happened before. So that’s your dissociative amnesia with fugue.

All right, and then our last topic for today is psychogenic non-epileptic seizure. Psychogenic non-epileptic seizure, and this is exactly what it is titled. For one of the few times, this totally makes sense, this title. This is episodes that resemble epileptic seizures, but occur without abnormal electrical brain activity. This is a seizure with normal brain function. This is classified as a functional neurological symptom disorder caused by psychological factors like stress, trauma, or psychiatric comorbidity. So they basically have a seizure that is brought on by stress or trauma rather than abnormal brain function.

Clinical presentation. This is convulsive-like episodes with features atypical for epilepsy. So you have asynchronous or thrashing limb movements. You have eyes closed during the episode, which generally in a true seizure, the eyes are open. There’s a long duration. They don’t have a postictal confusion state. And this often occurs in a stressful situation or in the presence of other people that create stress.

Again, this is just like our others, strong association with history of trauma, abuse, depression, anxiety, or dissociation. Now for this, if you’re going to really diagnose it, you would want a video EEG monitoring during an event, which shows normal brain activity despite the convulsions. That’s how you would be the gold standard for diagnosing this. One issue that I stumbled across when talking about this is that you can have this along with true epilepsy. Let me say that again, you can have this along with true epilepsy.

Now, hopefully on the PANCE, you’re not going to see that, right? That would be incredibly mean of them to do to you, and it seems unlikely. But in a patient, it’s certainly possible. So, it’s one thing I want to… we always… it’s frustrating to consider, but it’s something you always have to consider. On the PANCE, right?

Basically, patients have one diagnosis, but in real life, you can have multiple issues at once that all kind of overlap each other. So, you can have allergies and strep throat at the same time, and it’s super frustrating, both as a clinician and as a patient, but it’s very, very possible, right? So for our psychogenic non-epileptic seizures, we’re going to do psychotherapy, so cognitive behavioral therapy, trauma-focused therapy, and supportive therapy. So this is going to be very consistent throughout our whole line here today. You’re going to look to help treat the other comorbid psychiatric conditions like depression or anxiety or PTSD. These patients don’t really need anti-epileptic drugs, right, because it’s not a brain problem. So, don’t prescribe them those.

So, how are you going to be asked this on a test? Well, psychological psychogenic, non-epileptic seizure versus something like a panic attack would be the seizure like motor activity. A panic attack would be autonomic symptoms, palpitations, sweating, tremors, right? So a little… So, different presentation, but kind of the same things that bring it on. That’s why bring them up here together, because it may be a question stem that has similar symptoms, or not symptoms, but a similar staging, a similar onset. What about versus syncope?

So, that would be the brief sudden loss of all tone versus those prolonged irregular movements. Diagnosis here does require an EEG. Don’t use anti-epileptics. And again, there’s strong association with psychological stress and trauma, like everything else we have going on here. Beautiful.

All right, great. So, we’re getting towards the end of psych. We’re going to hit our priming questions. We’re going to hit our study tip for the day. We’re going to hit our PANCE questions to wrap out the day today. We have two episodes with psych left in it, and then we’re going to be done with the entire blueprint with the second time through, which is unbelievable. And I’m debating how to start over again.

So, we’re going to get into our study tip next, but I just want to point out to you, this one is going to be pulled straight from the Test Taking Rescue Kit, which is a short PDF that I put together that has five things to stop doing, five things to start doing, and then the two types of test takers so that you can help apply these to yourself. And it’s a short PDF that I put together last weekend over Labor Day that I think is really going to be helpful for a lot of people. You can get it at physicianassistantexamreview.com/testtakingkit, all one word, super easy. You can take a look at that, get through in about 10-15 minutes, but really you have a great chance of adding some extra points to your very next test without any more studying because of what we cover in there and how you can pull at least one or two of the tools out or maybe stop doing one of the two or things that I talk about stop doing in there. One of the things is going to be our study tip for today is going to be the time checks. So, a lot of people get flustered with time, and I hear more and more about people getting extra time on the exam, people going too fast, people going too slow. Time is a huge factor here.

So when you talk about how to prepare for your test, the fact that we need to prepare for the timing of it and how your pacing is, it should be very natural. It should be part of what you’re doing. And to me, you need to do some drills. You need to put some thought into it, right? So we spend so much time focused on the content. And this is where I developed, in fact, the entire 33 Days program is because we spend so much time working on the content. We don’t think about how the exam goes.

We don’t think about how we’re studying. We don’t think about how we’re going to show up that day, how we’re going to perform, what the anxiety management is going to look like, right? So the timing factor is a major, major piece here because I’ve seen, not that it’s going to, each one of these that I talk about isn’t going to boost your score by 50%, not a chance, right? It’s not even going to boost your score by 5%, but what it’ll do is stop you from tanking your scores. That’s what I run into. I run into a person who doesn’t finish the first section. Not a huge deal.

Maybe they don’t get to five of the questions. Maybe they don’t get to 10 of the questions. It’s okay. It’s not terrible. The problem comes in when they spend their entire break crying or flustered and upset, and then they start the second block a complete mess, and they can’t think straight because they’re so worried about what happened on the first one. Now they don’t finish the second one, and it just spirals down. It’s not that the time was ultimately the problem or those couple of missed questions were the ultimate problem.

It was how it affects you on that day. So we want to be prepared for each little thing that can take us down on the day of your exam. That’s a major part when I talk about peak performance. It’s about showing up on the day of the exam as the best possible version of yourself so you can get every point you can get. So you can do the things you know you can do, right? So many people come back and say, hey, when someone asks me questions, I can get them all right. I understand that.

And that’s fantastic, except that’s not the game. The game is sit down and take this test. So, let me get to the point. The point is, here we’re going to talk about timing for just a second. And one of my recommendations during your exam, and it’s something I would I practice with when I’m doing practice questions, if I’m doing a full-length exam, is do time checks. Don’t watch the clock, but check in on the time every 10 questions. And what this will do is it’ll get your mind off the clock, because checking it after every question, keeping I can’t I would just be staring at it the whole time.

So I make sure that I turn the timer off on my exam and I can’t see it. And then when I get to question 10, I click it on and say, okay, am I at 10 minutes? Am I at eight minutes? Am I at 12 minutes? Where am I? Do I need to speed up a little? Do I need to slow down a little?

Or is it okay if I slow down a little? Am I rushing? Then at question 20, I check it again. Now I have a bigger sample size because at 10 questions, you may get a bunch of short questions. You may get a bunch of long questions. You may get things you spent a lot of time thinking about. You may get things that you didn’t have to think about very much because there’s stuff you knew.

So 10 questions isn’t really a strong sample size, right? 20 questions a little better, 30 questions a little better, but it’s a way to check in and maintain your pace throughout. Again, is this a big deal? No, it’s a very, very tiny deal, but it’s something I’ve seen take multiple PA students down on exam day. So just a simple, simple tool you can use to make sure you’re on pace and whether, and to see whether you need to speed up, slow down or anything in between.

All right, let’s get to wrapping up our priming questions. 23-year-old with hallucinations and social decline. What’s the most likely diagnosis? I’m sorry, social decline for eight months. So we have two major keys in here. We have social decline, which pretty much nails it for you, and hallucinations and over eight months. So we have schizophrenia.

Again, these should be super easy after we’ve gone through it and after you think about it a little bit. A man disappears after trauma, later found living under a new name with no memory of his past. What disorder does this suggest? Well, this is dissociative amnesia with a fugue. A student feels detached like he’s outside his body, but he knows it isn’t real. What condition best fits? Depersonalization or derealization disorder.

A woman has a seizure-like episode with eyes closed and a normal EEG. Again, this should be really straightforward, although again, when we mix it in with 300 other questions, it gets hard. But right now in this setting, this is psychogenic non-epileptic seizure. Cool.

All right, let’s do a couple of PANCE questions based off these, just so you can see how it rolls right into the way the questions are going to come to you. This first one I actually take from the priming question, so you can see how they work as building blocks. A 24-year-old man is brought to the emergency department by his roommate, who reports that over the past nine months, the patient has become increasingly withdrawn, stopped attending class and often speaks in a disorganized manner. The patient describes hearing voices that comment on his actions. He denies a substance use. Mental status exam reveals flat affect and poor eye contact. What’s the most likely diagnosis?

A, brief psychotic disorder. B, schizophreniform disorder. C, schizophrenia. D, schizoaffective disorder. Now again, we get disorganized manner. We get stopped attending classes. We get hearing voices.

We get a flat affect. We get nine months. So this becomes kind of obvious to me. Again, in this setting, this is something I would normally struggle with. But in this setting, with all the data right in front of us, we can see this is going to be schizophrenia. Again, a brief psychotic disorder, we would have to be less than a month. Schizophreniform, usually one to six months.

Schizoaffective disorder, we’d have to have that mood disorder on top, which we don’t see here.

Let’s do one more. A 34 year old woman is brought to the clinic by her husband, who says she sometimes behaves as though she’s a different person, speaking in a childlike voice and using different mannerisms. She later denies this episode and has no memory of it. She reports a history of severe childhood abuse.

Now, again, these are kind of straightforward questions. For short, what’s the most likely diagnosis? A, schizophrenia. B, dissociative amnesia. C, dissociative identity disorder. D, depersonalization, derealization disorder… realization disorder.

That’s a lot of D’s all mixed in there. That’s why I’m struggling with it, I think. In this case, it’s C, dissociative identity disorder. For me, I would have to be really trying to tie dissociative identity disorder to multi-personality disorder in my head, because that’s just the way that I remember it better. You may be in a different spot, but for me, that’s going to be important. So if it were going to be schizophrenia, there’d have to be delusions and hallucinations and disorganized thought. We don’t have any of that here, right?

None of that. If it was dissociative amnesia, we do not recall a specific event related to some, usually some kind of trauma. Here, we have two distinct modalities of behaving and no memory of the other one. So that leads us to dissociative identity disorder. And in depersonalization, derealization disorder, this involves a feeling of detachment. She doesn’t express that at all. So this becomes, like I said, the questions are going to be harder than this.

I’m not trying to say that these are exactly how they’re going to be written. Some will be harder than this, but it’s very straightforward. Once you wrap your head around the table, the lines have how these are connected. But if you try to memorize them as independent data points, like I tried to do in PA school, it’s very, very difficult, really hard. And there are reasons why I didn’t do well in the psych section of my PANCE. And that’s one of them was trying to learn schizophrenia and then trying to learn schizoaffective disorder and then trying to learn dissociative amnesia and not combining them into one kind of one topic. So, anyway, that will wrap us up here today.

Really, like I said, looking forward to the last two episodes of psych and getting through the blueprint one more time. Again, that giveaway is coming up at the end of September, so you make sure that if I can contact you, then you can know that you can get in and get a chance to win that. That’s for the November cohort of 33 Days to Pass the PANCE, which is, like like I said, the September course has been a ton of fun. Really looking forward to working with them throughout the rest of this course. And if you haven’t already picked it up, another great resource for you is the Test Taking Rescue Kit, which you can pick up at physicianassistantexamreview.com/testtakingkit.

All right, perfect. Take care, good luck, and until next week. Thank you.