Monday, June 16, 2014

The DSM-5 on the USMLE: What Should You Know?

Wondering how the new DSM will affect the Step exams/ Check out this guest post from Vincent Stevenson to find out more details: 

The American Psychiatric Association officially released its latest version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, in May 2013. The APA made several significant changes in to the diagnostic criteria in the DSM-5 even changed several diagnostic categories themselves. While these changes will have broad effects on the practice of psychiatry, the more immediate concern to medical students and recent medical school graduates is the effect that these changes will have on the USMLE boards.

The USMLE’s Stance on the DSM-5
On November 4, 2013, the United States Medical Licensing Examination directors announced that they would be moving from the DSM-IV to the DSM-5 immediately. However, since Step 1, Step 2 CK, and Step 3 of the USMLE are each derived from a large pool of questions developed over a long period. In actuality, the transition between DSM versions will actually be far from “immediate.” In fact, the USMLE publishers acknowledge that the complete change will likely take several years.

According to sources at the USMLE, the first goal was to purge questions from the existing content pool that are based on the DSM-IV. In fact, they have insisted that any psychiatric diagnosis content not based on new, DSM-5 criteria has already been eliminated from all three steps of the USMLE. On the other hand, they admit that the transition clinical psychiatric terminology from fourth to fifth edition standards will merely begin in 2014. So it is quite possible that someone taking a USMLE exam within the next three years may be tested on questions from both the DSM-IV and DSM-5.


What is new in the DSM-5?One of the main changes (mostly important for clinicians and those who are interested in billing for psychiatric services) is that the axis system of the DSM-IV has been largely revised. The DSM-5 now follows a multiaxial system in which diagnoses from Axis I, II, and III are all included on a single “axis” for purposes of diagnostic coding. Axis IV and Axis V, as they were known previously, have been eliminated. Clinicians now use a rubric called “dimensional assessments” to assess the severity of the particular patient's symptoms or disorder and response to treatment. For medical students studying for the USMLE, changes in terminology will be the greatest “high yield” topics.

Intellectual Disability
An example of a change in terminology is that the DSM-5 no longer uses the term mental retardation. The term mental retardation is potentially pejorative and offensive to some people. For this and other reasons, the term mental retardation has been replaced by “intellectual disability.” Intellectual disability is a condition in which deficits in cognitive ability first occur during development and are consistent with a mental disorder as defined by criteria listed in the DSM-5.

Attention-Deficit/Hyperactivity Disorder
The diagnostic criteria for ADHD are largely similar in the fifth DSM version. The 18 symptoms listed in the DSM-IV are still used in the newest edition and are split into the domains of inattention and hyperactivity/impulsivity. It is now possible for patients to be diagnosed with ADHD and autism spectrum disorder at the same time. There have also been some changes with the age cutoffs—in essence, younger children need to exhibit fewer symptoms in early life in order to meet new diagnostic criteria.

SchizophreniaThe diagnostic criteria and guidelines for schizophrenia have changed rather significantly with the recent update. Because they are not useful from the diagnostic or treatment perspectives, schizophrenia subtypes (e.g., paranoid, catatonic ) have been eliminated from the new edition. Patients must exhibit at least one of the so-called positive symptoms (delusions, hallucinations, or disorganized speech) in order to qualify for a diagnosis. Also, some of the more structured requirements for hallucinations or delusions have been eliminated (e.g., bizarre delusions).

Bipolar DisorderThe biggest change to bipolar and related disorders is in Criterion A. Specifically, patients do not need to exhibit "classic" symptoms of major depressive episode and mania. Instead, the criteria has been “softened” a bit to include the concept of "mixed features." Mixed features are intended to account for cases in which mania exists with only depressive features (rather than frank unipolar depression). On the other hand, it may also apply if the patient has clear depression with some manic or hypomanic behaviors.

Depressive DisordersThe diagnostic criteria for major depressive episode have remained more or less identical between the two versions. Of note, the bereavement exclusion of DSM-IV has been eliminated from DSM-5. This means that prolonged bereavement now qualifies as major depression, essentially. Also added to the DSM-5 were a number of specifiers, especially for suicidal thoughts and tendencies.

Anxiety DisordersObsessive-compulsive disorder, post-traumatic stress disorder, and acute stress disorder are no longer included under the categorical umbrella of anxiety disorders. Instead, anxiety disorders are mainly limited to generalized anxiety disorder, panic disorder, phobias, and social anxiety disorder. Changes within anxiety disorders, while great in number, are not likely to be tested on the USMLE because they are somewhat subtle. That said, it is important to note that panic disorder and agoraphobia represent two separate diagnoses in the DSM-5. Moreover, patients are no longer required to recognize that their anxiety is excessive or unreasonable. The newest edition requires only that the anxiety is out of proportion to the realities of the provocative situation.

Trauma- and Stressor-Related DisordersThis category is the new home to posttraumatic stress disorder and acute stress disorder, among others. It has undergone broad changes – perhaps as dramatic as any section of the DSM. The diagnosis of acute stress disorder, for example, no longer contains some of the more restrictive stipulations of earlier versions. Patients may qualify for a diagnosis of acute stress disorder if they exhibit 9 of 14 symptoms in certain diagnostic categories.

PTSD has changed dramatically in the DSM-5. Clinicians must specifically identify if the trauma was experienced by the patient, witnessed by the patient, or in some other way in directly experienced. There are four symptom clusters rather than three, including re-experiencing, avoidance, persistent negative alterations in cognitions and mood, and arousal. Certain features of PTSD, such as irritable/aggressive behavior or reckless/self-destructive behavior, are now more prominent among the diagnostic criteria for PTSD.

ConclusionsStudents who are planning on taking the USMLE will need to consider how to study for the psychiatric portion of the test. The makers of the USM LE have attempted to adapt to the newest edition of the DSM, but these changes will take time. Therefore, examinees should focus on the high-yield changes listed in this article. The highest yield material are changes in terminology that appear in the DSM-5. Because the questions may still come up in an actual examination, students should also recall what these terms meant in the DSM-IV. While diagnostic criteria are different in the DSM-5, especially for disorders such as PTSD, most of the questions included on the USMLE will not drill down to this level of detail. On the other hand, top students will be aware of the key changes that were made to the DSM in the most recent update and be able to answer questions based on the DSM-5.

Vincent Stevenson is the creator of Scrub Wars (www.scrubwars.com and @scrubwarsapp), an innovative medical gaming app targeting the USMLE Step I and COMLEX Level I exams.

Sunday, June 15, 2014

How Social Media is Changing Patient Care


Your patients tweet from your waiting room. They describes their symptoms on Facebook. They ask about that 'funny rash' on Quora. They looked you up on LinkedIn.

Your patients are engaging in social media --- are you?

Not just personally, but professionally - the expectations have changed. Medicine ultimately is a service industry, and like all service industries, the expectations of our customer, our patients, have changed. They are online and expect us to be as well. The question facing most practices is, to what degree? With practices stretched thin already managing work in the office, how can they devote resources to having an online presence?

These questions do not have simple answers, but like any medical problem you encounter, the first step is to gather more information. Think about your patient population - how active online are they in general? Clearly, there will be a big difference between a pediatrics practice and a geriatrics one. If your patient population is quite broad, another approach is to [drum roll] ask them! Many patients would be happy to let you know where they look for medical information and what ways they find convenient to communicate with your office.

As you have determine what your patients want, you also have to ask yourself how much are you willing to devote. In this day and age, being absent online is no longer an option. At a minimum, you should post basic information about your practice such as the address, telephone number, and office hours. I highly suggest that you have at least a static website that offers this information, and definitely make it accesible on sites that people use to find locations such as Google Maps, Bing Maps, and Yelp.

However, this post is about 'social' media, and static information is not very social. Look into creating  a presence on Facebook and Twitter. You will have to judge whether you want these channels to be more one-way, with patients sending information to you, versus two-way with you or your office actively responding. You also have to judge how 'medical' you want your communications to be, keeping confidentiality and liability issues in mind. Avoid discussing specific medical issues in these forums. However, they function great for communicating general health tips, answering general health questions, and providing specific office information such as hour changes or new medication / treatment options available. Images showing when preventative care should be performed, or basic management algorithms, can be very helpful for patients. If you are particularly intrepid, ask a patient with a 'success' story if you can share their story on your social site. Draw your patients into the conversation with you.

Social media is an unchartered territory for most physicians so don't fear - explore! Learn what kinds of pages and accounts work best on these sites. Try different types of comments and posts. Including engaging content that your patients/fans would want to share with each other. In the social media world, something being 'viral' is a good thing! Help your users catch the bug! Chart your own course in the social media waters. Your patients will benefit and sing your praises - online and off.

Saturday, June 14, 2014

Scrub Notes Site Update

This site has experienced benign neglect for longer than I care to recount. There are thousands of excuses, and it is certainly my fault. The reality is that this was no longer the priority for me it once was. However, now, it is time to change the game.



As the saying goes though, the best thing to do if you fall off a horse is to get back on. I will start by going through each old post and editing it for content, broken links, and other problems. Next, I will slowly start adding new content again. If there is anything in particular you would like to see more posts about (or less), please leave a comment or contact us. Cheers!

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