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.

Schizophrenia
The 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 Disorder
The 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 Disorders
The 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 Disorders
Obsessive-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 Disorders
This 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.

Conclusions
Students 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.

Books For Third Year Medical Students

We previously covered books for first year medical students and second year medical students. The section on books for USMLE was important enough to merit its own post. But, as third years, you are through with Step 1, you are through with basic sciences, and you're geared up for the clinics. Alas, day 1 comes and goes and you realize: there is still a ton to learn! Where do you go to find all that information?

The books described here are meant to give you a high yield, high impact approach to each core clerkship you take. Ideally, for each clerkship, try to read one book throughly and use one book for case reviews / questions. Here is a break down of the books you should get, rotation by rotation:

Family Medicine

Family Medicine is generally a nice rotation, with students primarily rotating in outpatient clinics. If you have already done pediatrics and internal medicine, family medicine covers many of the same topics, but in the outpatient setting. Preventative care is also much more emphasized. Blueprints Family Medicine does an excellent job of covering the major topics and preparing you for the shelf exam.

Internal Medicine

As discussed in the post on Books for the Internal Medicine Rotation, the three books above are all you need. Pocket Medicine will get you through the wards on a day-to-day basis while the other two are what you need to power through on your nights and weekends to ace the internal medicine shelf exam.

Neurology

Neurology should be on the relatively lighter side of the clerkships, especially if you have taken internal medicine already. Since there are relatively few therapeutics, focus on learning how to differentiate major disease patterns.

Ob/Gyn

My recollection of OB/Gyn is somewhat fuzzy as I took it during fourth year just as interviews were starting up. The major challenge in OB/Gyn as I recall was learning the skills as well as knowing how to work up various conditions (such as an abnormal pap smear). For OB, just remember: almost always the treatment is - deliver the baby!

Pediatrics

Pediatrics is generally a fun rotation (babies!). The books you should get for pediatrics are much like the other rotations. Conceptually, again there is some overlap with internal medicine, but there is much more of an emphasis on congenital and infectious disorders.

Psychiatry

All you need is the book above - First Aid for the Psychiatry Clerkship, Third Edition. 'Nuff said.


Surgery

Surgery can be a challenging rotation for many students. Not only is there the typical fund of knowledge of disease that needs to be learned, but also anatomy needs to be refreshed as well as technical skills acquired. Many students ask - what books could possibly prepare me for the surgery shelf exam? Studying for the surgery shelf exam will be a constant challenge. If you can wait, pre-order the latest edition of Essentials of General Surgery, so that you can get it right when it is published in October 2012. For the NMS, make sure you get the casebook, not the full surgery review.

Wards

Some topics come up routinely on wards, no matter what service you are on. First Aid for the Wards: Fourth Edition is a great book to cover all those topics that might otherwise fall through the cracks.

Hopefully the books listed above will prove as valuable to you as they have to me - best of luck out there in the wilds of the wards!

Updated 2015-12-25

The Popularity Scale

Lindsay Lohan in the movie "Mean Girls" demonstrates the stereotypical view of popularity in a high school setting with a few semi-realistic twists. However, an interesting piece in the NYTimes a while back about looked at the real lives of teenagers and how one's place on the popularity scale during adolescence affects their social standing in the future, and perhaps their health. Where were you on the popularity scale?

The cult of popularity that reigns in high school can look quaint from a safe distance, like your 20th reunion. By then the social order may have turned over like an hourglass: teenagers who were socially invisible have emerged as colorful characters, confident, transformed. Others seem preserved in time, same as ever, while some former princes and queen bees are diminished or simply absent, now invisible themselves.

For years researchers focused much attention on those prominent teenagers, tracking their traits and behaviors. The studies found, to no one’s surprise, that social dominance in adolescence often involves an aggressive, selfish streak that may not play well outside the locker-lined corridors.

The cult disbands, and the rules change.

Yet high school students know in their gut that popularity is far more than a superficial, temporary competition, and in recent years psychologists have confirmed that intuition. The newer findings suggest that adolescents’ niche in school — their popularity, and how they understand and exploit it — offers important clues to their later psychological well-being.

Not too surprisingly, the kids who were the most 'social' in high school seem to do better in the long run, since a social person will (should?) always be well-liked in society, but one can only be a prom/homecoming queen once. Besides, having social skills is marketable asset. From a medicine standpoint, I wonder if more attention should be paid to such social trends by adolescent psychiatrists. Furthermore, if one can identify kids at risk, those at the lowest rungs, how does one approach them? Try to teach them social skills? Put them in an environment where they are better able to socialize? I think there will always be an "in" group and an "out" group among adolescents but the key here needs to be to identify the teens who are at risk for having a poor self-image and low self-worth, regardless of how 'popular' they seem to be, and then find a way to help them grow and achieve a lasting sense of self-worth.

Geriatrics and Antipsychotics

On the heels of my ground-scuffing post on adolescents and antidepressants, the NYTimes has published a piece on the overuse of antipsychotic medications in the elderly:

The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.

Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.

The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.

Is there anything psychiatrists won't try to cure with a scrip? Heh, just kidding, but the off-label use of psychiatric medications is disturbing, as I saw on my own psychiatry rotation. Sometimes, I wondered whether we were truly living up to the maxim of "do no harm."

Internet Addiction is a Disease. No, Really.

Apparently, internet addiction has been nominated for entry into DSM V:

First, we all had mild Asperger's. Now, Internet addiction disorder? Give a geek a break. In the March issue of the American Journal of Psychiatry, Jerald Block proposed that Web abuse be added to his field's bible, the Diagnostic and Statistical Manual of Mental Disorders. Block cites research from South Korea, where, he says, the affliction is considered a serious public health problem, and the government estimates that 168,000 children may require psychotropic medications. In China, the Beijing Military Region Central Hospital puts the number of teenage pathological computer users at 10 million.

I have mixed feelings about psychiatry. On the one hand, it was a generally chill rotation and I had a pretty good time. However, the field itself seems to be just barely scratching the surface of truly treating patients. Compared to say, oncology, psychiatry seems to lump people together and treat symptoms in a broad way, without truly addressing the underlying problems. Sure, there is the biopsychosocial formulation, but in reality, only the 'bio' gets treated while the social problems generally tend to fester. I certainly do not have any solutions, but the whole situation just strikes me as sad. I think over-medicating is a significant problem, and one that psychiatry does little to address given its own dependency on pharmaceuticals, relative to other fields.

This dependency leads to ridiculousness as described above. Why categorize this as a separate addiction? The goal here is to be able to get reimbursements from insurance companies for treating this as well as specific indications for certain drugs to treat this as well. If one thinks about it, there really shouldn't be any underlying distinction between Internet addiction vs. other forms of socially-derived addictions. What next, Dungeons&Dragons addiction? Unlike addiction to a substance, which does induce actual biological changes, it's not clear to me how the internet differs from an addiction to gambling, shopping, or other self-destructive behavior.

Psychiatrists! What'll they think of next? =)

Frontotemporal Dementia

I recently read an interesting case of a doctor/scientist who, after seeing her son make a miraculous recovery, retired from science to pursue art:

Trained in mathematics, chemistry and biology, Dr. Adams left her career as a teacher and bench scientist in 1986 to take care of a son who had been seriously injured in a car accident and was not expected to live. But the young man made a miraculous recovery. After seven weeks, he threw away his crutches and went back to school.

According her husband, Robert, Dr. Adams then decided to abandon science and take up art. She had dabbled with drawing when young, he said in a recent telephone interview, but now she had an intense all-or-nothing drive to paint.

At one stage of her illness, she became fascinated by the composer Ravel and his work Bolero, and went on to paint a piece entitled Unraveling Bolero (nice pun, eh?).

Ravel and Dr. Adams were in the early stages of a rare disease called FTD, or frontotemporal dementia, when they were working, Ravel on “Bolero” and Dr. Adams on her painting of “Bolero,” Dr. Miller said. The disease apparently altered circuits in their brains, changing the connections between the front and back parts and resulting in a torrent of creativity.

“We used to think dementias hit the brain diffusely,” Dr. Miller said. “Nothing was anatomically specific. That is wrong. We now realize that when specific, dominant circuits are injured or disintegrate, they may release or disinhibit activity in other areas. In other words, if one part of the brain is compromised, another part can remodel and become stronger.”

The evolution of our understanding of the disease is fascinating. Heh, honestly though, the description of her disease initially kind of sounded like bipolar disorder to me. Guess I still have a lot left to learn.

Adolescence and Antidepressants

As I was wrapping up my psychiatry rotation, I came across this piece about patients who had come of age on antidepressants. For most drugs, chronic use does not change how people perceive themselves, but with psychotropic drugs, this may not be the case:

“I’ve grown up on medication,” my patient Julie told me recently. “I don’t have a sense of who I really am without it.”

At 31, she had been on one antidepressant or another nearly continuously since she was 14. There was little question that she had very serious depression and had survived several suicide attempts. In fact, she credited the medication with saving her life.

But now she was raising an equally fundamental question: how the drugs might have affected her psychological development and core identity.

It is indeed an interesting question. As the author notes, for patients who are on these drugs whil their brains are still developing may not remember a time when they were not on antidepressants. Their sense of who they are is shaped in part by the medications. This can lead to interesting but distressing side effects:

Beyond these concerns, there are other important issues to consider in long-term use of antidepressants, especially in young people. One patient, a woman in her mid-20s, told me that she felt pressured by her boyfriend to have sex more often than she wanted. “I’ve always had a low sex drive,” she said.

For the past eight years she had been taking Zoloft, which like all the antidepressants in its class is known to lower libido and to interfere with sexual performance. She had understandably mistaken the side effect of the drug for her “normal” sexual desire and was shocked when I explained it: “And I thought it was just me!”

Honestly, sometimes I tend to overlook these "common" side effects as medical students are trained to know the rare / more severe reactions. However, hearing this story makes me realize how little we truly know about these medications and their impact on our patients' lives, especially over the long term.

Projection: The Politicians' Defense Mechanism

Projection is a type of psychological defense mechanism. According to Wikipedia, it is defined as:

In psychology, psychological projection (or projection bias) is a defense mechanism in which one attributes one’s own unacceptable or unwanted thoughts or/and emotions to others. Projection reduces anxiety by allowing the expression of the unwanted subconscious impulses/desires without letting the ego recognize them.

For some reason, this seems to be a fairly popular defense mechanism among celebrities, especially politicians. Here are a few notable examples:

Eliot Spitzer

The former New York Governor recently resigned after he was found to have frequented prostitutes. Why projection? Prior to being elected governor, Spitzer had served as New York's Attorney General, and was particularly aggressive in enforcing the law. Seems like he was projecting his own moral failings on others.

Larry Craig

The former Senator from Idaho resigned after he was caught in an investigation about male prostitution in the Minneapolis Airport. Why projection? Prior to this discovery, Craig was outspoken in his opposition to same-sex marriage.

Gary Hart

The former Presidential candidate and Senator was found to be having an affair after claiming not to be involved in one and challenging reporters to follow him around. I suppose this isn't really projection, but the hubris of such a challenge is something to behold.

History is filled with many more such examples, such as Henry Hyde leading the impeachment hearings against President Clinton, even though he had engaged in an affair years before himself, or noted segregationist Strom Thurmond having fathered a child with an African-American woman. I suppose there are many more politicians who have no such failings, but it almost seems like projection is part of the job description.

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What is Diogenes Syndrome?

My psychiatry attending has mentioned "Diogenes Syndrome" several times in the past two days. As the linked article states, it is a self-neglect syndrome in which elderly people who were previously high-functioning and who have no other medical issues cease to take proper care of themselves. Curious, I looked up this Diogenes fellow. Per Wikipedia, he was an "interesting" guy:

Many anecdotes of Diogenes refer to his doglike behavior, and his praise of a dog's virtues. It is not known whether Diogenes was insulted with the epithet "doggish" and made a virtue of it, or whether he first took up the dog theme himself. The modern terms cynic and cynical derive from the Greek word kynikos, the adjective form of kyon, meaning dog ^[4]. Diogenes believed human beings live artificially and hypocritically and would do well to study the dog. Besides performing natural bodily functions in public without unease, a dog will eat anything, and make no fuss about where to sleep. Dogs live in the present without anxiety, and have no use for the pretensions of abstract philosophy. In addition to these virtues, dogs are thought to know instinctively who is friend and who is foe. Unlike human beings who either dupe others or are duped, dogs will give an honest bark at the truth.

The most well-known anecdotes about Diogenes relate to his ascetic / dog-like behavior:

The stories told of Diogenes illustrate the logical consistency of his character. He inured himself to the vicissitudes of weather by living in a tub belonging to the temple of Cybele.^[16] He destroyed the single wooden bowl he possessed on seeing a peasant boy drink from the hollow of his hands.^[17] He once masturbated in the Agora; when rebuked for doing so, he replied, "If only it was as easy to soothe my hunger by rubbing my belly."^[6] He used to stroll about in full daylight with a lamp; when asked what he was doing, he would answer, "I am just looking for an honest man."^[18] Diogenes looked for an honest man and reputedly found nothing but rascals and scoundrels.

Umm... and you thought the other shoppers at your mall were bad. At least you weren't standing in the checkout line next to an antsy Diogenes at the agora...

Psychiatry in the Third World

In "Psychotherapy for All: An Experiment," the author describes a new program that trains non-physician health professionals how to diagnose and treat depression and anxiety in the Third World. The program, which is based in Goa (a region of India), addresses the huge need that exists for such services in these areas. While the Goa (see image) program is relatively limited in scope, data collected from the effort if positive may help fund more such programs in the future. As the article notes, non-physicians diagnosing psychiatric illnesses is cost-effective:

Dr. Simon, a psychiatrist who studies mental health in the developing world, said the Goa strategy grew from a crucial idea. Unlike, say, heart disease and stroke, which can require expensive interventions, depression is relatively simple to diagnose and treat. Many studies have shown that talk therapy and antidepressants lead to significant improvement in most patients.

You're telling me! Not to belittle the toll depression takes, but from a diagnostic standpoint, it's not clear to me what more the residents / attendings above me are doing besides SIGECAPS. After 2 weeks of my psychiatry rotation, I'm a SIGECAPS expert!

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Which Personality Disorder Are You?

Ever wonder what personality disorder you might have? Well, take this quiz!

It's admittedly unscientific, but at least it's only six questions (compared to the monster 50-100 q quizzes I saw elsewhere). I know that there is a role for defining these various disorders, but I think it is unfortunate that there is not a personality type called 'normal' or 'appropriate.' It seems like psychiatry always has to label patients with something, even if they are fully functional. For example, when newly-diagnosed cancer patients are in the hospital, they often feel a bit anxious about their treatment and/or a bit depressed about their situation. This seems perfectly normal, yet a psychiatrist's note will label them with "adjustment disorder." Really? Isn't that how a normal person would react? If anything, I would be more concerned if the patient were perfectly happy and did not seem emotionally affected at all by his/her diagnosis. Anyway, my 'dependent' self is too concerned about your criticism to keep writing about this.

Psychiatry or Sigh-chiatry?

My first full day on my psychiatry rotation was a minor revelation. Although each specialty has its own unique culture, I think in some ways, psychiatry is, um, "uniquer." This is not meant as a criticism or derogatory in any way; I just find it very intriguing since the approach to the patient and the manner in which they are discussed seems very different to me.

So, why do I say sigh-chiatry? Even though my one day of experience is hardly enough to draw any definitive conclusions, I did observe more sighing today than I feel I've seen in any other rotation. While medical specialties tend to always believe they are "more sinned against than sinning," the psychiatry team definitely bought into this to a higher degree. This is not to say that they do not provide quality care and a valuable service to their patients, or that they somehow infringe upon other services to a greater degree. In fact, to a certain extent, I agree with their claim that other services dump on them.

Yet, I feel there is more to the sighs than merely a sense of injustice. My sense is that, unlike most other specialties, psychiatry deals with the abstract, the gray areas, the parts of medicine that make most doctors uncomfortable. Doctors must acts with a presumption of infallibility to be effective. To do this, they are bolstered by hard science and objective fact. Psychiatry strives for this, but due to the complex nature of the problems they face, they are at a disadvantage. This vagueness is both a boon and a burden. It benefits psychiatry by forcing the doctors to treat their patients more holistically, but limits psychiatry's ability to offer definitive answers. The patients' frustrations to some degree become the doctors', if only due to human nature. As our attending was discussing today, the psychiatrist must integrate not only objective clinical data but also subjective emotional data. He described how humans have 'mirror neurons,' which are special neurons that respond to images of suffering (or any other emotion) by triggering an empathetic response in the viewer (think of a guy cringing when he sees another guy kicked in the groin). Furthering this idea, the human response of the doctor to the patient and his troubles is of course primarily empathy, but one cannot help share their exasperation as well.

Sigh.