Below is a transcript of the video – it has been edited for clarity.
Today I am going to discuss diagnostically focused questions in board exams. You want to recognize the core diagnostic features. There can be a challenge with these diagnostically focused questions as the DSM-5 has a lot of disorders and each disorder has quite a few criteria.
These challenges can make it hard to learn all of the criteria for all these disorders, especially for the disorders that you really don’t treat, you may have low or zero familiarity with them. There’s a lot of verbiage in the DSM-5, which is kind of “boilerplate,” it’s not very useful. Because of this, you need to learn to identify the core diagnostic features of each disorder and focus on those core diagnostic features.
I’m going to give you examples for all of this in addition to the core distinguishing features between the disorder that you’re studying and closely related disorders. So for example, you not only want to know the criteria for anorexia nervosa, bulimia nervosa and binge eating disorder, you need to know how they differ – specifically, you know, objectively and consciously. If I ask the question, “Tell me how bulimia differs from anorexia,” you can just tell me without hemming and hawing and having to look things up because the vignette will be written in such a way that it definitely moves you towards one disorder, but, includes information that moves you away from another disorder.
Of course, every single disorder in the DSM-5 either has to cause distress or some degree of dysfunction because if it didn’t it wouldn’t be a psychiatric disorder. In order to identify the core symptoms I’m going to give you an example of ADHD where there’s a lot of verbiage including a lot of “symptom” criteria but they’re not really symptoms they’re just examples of a core symptom.
I have four different examples. Example one, let’s look at ADHD. So it’s characterized diagnostically by a pattern of inattention and or hyperactivity-impulsivity lasting at least six months. Okay, six months – I want to note that. Several symptoms must be present before age 12 – okay, I want to note that. There’s some four, seven years but we don’t care about that anymore. Now, probably most importantly so far is the next criterion: several symptoms must be present in at least two settings – school, work, home, other-other settings, community, what have you. The reason for this is because if those hyperactive-impulsive or inattentive symptoms are present and only one scenario, maybe it’s something specific to that setting or to that main individual in that setting – the teacher or a parent or if it’s happening in grandma’s house, maybe something with grandma or by grandma. So you know these symptoms have to be at least in two settings. And you can imagine, right, a vignette being written where it says that this child is quite impulsive and hyperactive, you know, in certain class with one teacher but then the other teachers, you know, say, “No, no. I don’t see that,” and parents say, “Well, I’m surprised, I don’t see that in my child at home.” So that’s a tip-off that they’re leading you away from ADHD, right? Now, the symptoms interfere or reduce a quality of social, academic, or occupational functioning – sure, kind of “boilerplate.” Not better explained by oppositional or defiant behavior. That is an interesting way to put it. The reason is because there’s overlap, right? A lot of kids with ADHD, since they’re having trouble really controlling their behavior in a way that will be congruent with the expectations of a setting – their behaviors kind of oppositional or defiant or in some way, kind of not cooperative, so that must be distinguished.
Now, let’s look deeper into the inattention symptoms, it appears that there’s nine inattention symptoms, but that’s not really true. These are just examples of inattention: often fails to give close attention to details or makes careless mistakes, often has difficulty sustaining attention, seems not to listen, difficulties in organizing tasks or activities, avoids or dislikes tasks that require sustained mental effort, does not follow through with instructions and fails to finish work or chores, loses needed things, often forgetful, and distracted by extraneous stimuli. Again, just examples of inattention, right? Do you really need to memorize each of these? No, it’s pretty self explanatory.
We can look at the same thing with hyperactivity-impulsivity – often fidgets, leaves seat when being seated is expected, often runs or climbs excessively, has difficulty playing or engaging in leisure activities quietly, “on the go” as if “driven by a motor,” successively blurts out questions, has difficulty waiting their turn, interrupts or intrudes on others. Again, these are just examples of hyperactivity-impulsivity.
You can have predominantly inattentive type or the hyperactive-impulsive type or combined and then you can have mild, moderate, severe, and just note that ADHD can be in partial remission. All right, so you notice how you can take a huge amount of data there and kind of like, “Hey, this isn’t that hard.” Right? There’s not that much to ADHD even if you – if you don’t treat it, as there’s not much to it.
It looks like it’s somatic symptom disorder because this is an area where the somatic symptoms can seem confusing, overlapping and hard to distinguish, so let’s look at the criteria. Somatic symptom disorder is characterized by one or more somatic symptoms that are distressing or disruptive to daily life. Okay, so I need at least one somatic symptom. What is a somatic symptom? Well frankly, the easiest way to remember is to replace the word somatic with “physical” – a physical symptom pain: indigestion, bloating, diarrhea, constipation, pain during sexual activity, you know, just things like that, physical symptoms. But in addition, you also need excessive thoughts, feelings, or behaviors related to the somatic symptoms or health concerns and it has to be evidenced by one or more of the following three. Disproportionate and persistent thoughts about the seriousness of the symptoms – notice that, wow, that overlaps with illness anxiety disorder. Persistently high level of anxiety about health or symptoms – hey that overlaps with illness anxiety disorder too. Excessive time and energy devoted to these symptoms or health concerns – well, that also often times overlaps with illness anxiety disorder. So what makes somatic symptoms disorder different from illness anxiety disorder? It’s the first criterion, you have a somatic symptom and illness anxiety disorder has to exclude the possibility of a somatic symptom. Now you can have very mild ones or fleeting, you know, that’s okay there’s grey areas but your vignette is going make it clearer – it should be one or the other, you just have to recognize, the somatic symptom disorder has these two some symptoms, a somatic symptom and then some concern about it. Typically six months or longer.
Now let’s look at illness anxiety disorder. So there’s preoccupation with having or acquiring a serious illness – again, that that could overlap with somatic symptom disorder. Performance of excessive health-related behaviors – again, that could overlap with that too, but now the third one: somatic symptoms are not present or are mild, so that’s the main distinguisher right? Preoccupation but without pain, numbness, dizziness, etc. And if a medical condition is present because it can be, then the patient’s concerns are excessive to that condition and then you want to specify if it’s care seeking type or care avoidant type. So some people with illness anxiety are actually so deathly afraid of their worst fears being confirmed through a medical workup that they actually avoid seeing doctors and other clinicians.
So when we put this in a little table then this is what we get. So you see we have somatic symptom disorder, conversion disorder, illness anxiety disorder. So somatic symptom disorder and conversion disorder both have somatic symptoms. Now conversion disorder is usually pretty easy to distinguish from somatic symptom disorder because it’s going to be psuedoneurological – again some sort of disturbance in motor function or in sensory function, right? And usually that person – although the criteria don’t say anything about it one way or another – the person with a conversion disorder is not going to have excessive concern. In fact, they might kid of show this kind of like beautiful indifference, as they say. The main distinguisher, though, between those disorders and illness anxiety is that illness anxiety specifically excludes the presence of a somatic symptom, right? Unless again, it’s fleeting or mild, but again we don’t have to worry about that.
So in the first module I shared with you a vignette of illness anxiety disorder. So now let’s look at one that would – that kind of a prototypical vignette that describes somatic symptom disorder. A 38-year-old woman presents the emergency department with the chief complaint of “my awful pain is worse again.” She has had 43 previous emergency department visits for similar pain complaints in her shoulders, back, pelvis, and thighs. She has been hospitalized twice for suicidal ideation and has a diagnosis of major depression and dependent personality disorder. She endorses a mutually abusive relationship with her husband with whom she often drinks alcohol together “as our way of socializing.” Her previous work-ups for pain have yielded a diagnosis of musculoskeletal pain and she has been referred to physical therapy. What’s her most likely diagnosis? And by the way clearly when you look at the options it doesn’t ask you about dependent personality or a major depression, right? So you’re going to choose the one out of the options presented: is it body dysmorphic disorder, conversion disorder, adjustment disorder, illness anxiety disorder? No it’s going be somatic symptom disorder, right? Again, this is a vignette that includes a lot of other information. It kind of gives you a word – paints a word painting, picture, but you know a lot of the information is extraneous to what we’re really being asked about.
Now let’s look at example three: diagnostic differences between eating disorders because this is another one in addition to somatic symptom disorder. This is another area that can cause even knowledgeable candidates to get the vignettes wrong diagnostically. So we have an anorexia nervosa, bulimia nervosa, and binge- eating disorder. So know that only one is characterized by abnormally low weight – in fact, you have to have abnormally low weight in order to have anorexia. If you have normal weight, if you’re overweight or obese, it is not anorexia. While bulimia nervosa and binge-eating disorder, it doesn’t specifically mention being underweight, but it’s-it’s pretty much if you’re underweight you’re-you’re probably going to be anorexic right? So we’re looking at the core features here, we’re not trying to kind of nitpick, but you know bulimia nervosa, binge-eating disorder, the person in that vignette will be of normal weight or higher. In the vignette when the person is of low weight, it’s going to be anorexia, so that’s one thing right away you can distinguish anorexia from the other two. By the way, CDC says that the lower limit of normal weight is a BMI of 18.5 so anorexia is going to be anyone with a BMI of 18 and below. And somewhere like let’s say I can’t remember if 17 – let’s say 17 up to just below 18 and a half would be mild and then below 17 would already be moderate and then more severe.
So now let’s look at the other part though. And this is very important for you to note too because anorexia nervosa certainly can have binging behavior and also a lot of compensatory behaviors. Restriction is definitely required because you have to have low weight due to restriction, right? Restricting one’s calories. But other than that you don’t need – you can have – but you don’t’ need compensatory behaviors. So here’s the secret bulimia nervosa you need both binging behaviors and compensatory behaviors but that does not distinguish bulimia from anorexia because you can have those in anorexia too. Again, what’s going to be the main distinguisher? The low weight in anorexia. By the way, since we’re here let’s review definitions. What are compensatory symptoms? They’re purging behaviors, fasting, and excessive exercise, right? So anorexia, these talk about fasting and the abnormally low weight. And then of course purging behaviors includes several different types, it’s not just vomiting although that’s a common one, but also abuse of different substances in order to keep – to purge right – to try to undo the binging. And that includes misuse of laxatives, of diuretics, and other medications such as thyroid medications like Synthroid, psychostimulants that can suppress appetite and lead to weight loss. So those are compensatory behaviors. Again, those do not distinguish their presence, does not distinguish anorexia from-from bulimia.
All right now, let’s look at the difference between bulimia and binge eating disorder. So they’re both characterized by binging, so you have to have binging. Binging, by the way, occurs and can occur in all three, it may or may not occur in anorexia, and it has to occur in bulimia, and it has to occur in binge eating. Then the difference though is that in bulimia you have to have compensatory behaviors, and Binge-Eating disorder, compensatory behaviors are excluded. They’re not permitted; they’re excluded because if you have them, boom, the binge eating disorder is then diagnosed-re-diagnosed as bulimia nervosa, okay?
Last example, a little bit different. And this is just an example of how you can take a huge amount of information and really try to summarize it to your self and again you can speak this stuff out as you’re driving. So this is the last slide in my neurocognitive disorders lection, which is like 3 and half hours long, and this captures a substantial percentage of the knowledge that you have to have about neurocognitive disorders. Believe me, you want to go through the rest of the lecture too, it’s not like it’s useless, but this really – this one slide captures a substantial percentage of testable material. So it’s a clinical comparison of the neurocognitive disorder ideology, so for example, Alzheimer Disease it’s characterized by cortical deficits, social graces, and executive function are maintained, and no focal neurological deficits are going to be present or if they are not prominent, all right? Frontotemporal neurocognitive disorder: disinhibition, apathy, dysexecutive syndrome, and or aphasia are going to be present. Lewy body disease, it usually presents with cortical deficits, fluctuating cognition, autonomic instability, motor symptoms, antipsychotic med sensitivity and REM sleep behavior disorder – behaviors symptoms. And then that should be distinguished from neurocognitive disorder due to Parkinson’s disease, where many of those same symptoms can occur but the motor symptoms come first, at least a year before the cognitive symptoms, so it’s sort of like the neurocognitive symptoms occurring and well established Parkinson’s disease. So those are very closely related – Lewy body – neurocognitive disorder with Lewy bodies and neurocognitive disorder with Parkinson’s disease. Really is on the same spectrum, they’re both Lewy body diseases, it’s just like the order in which symptoms occur – the motor symptoms occur. Vascular disease the vignette is going to talk about focal neurological deficits and note that the presentation could be either cortical or subcortical, so it could go either way because you have smell vessel subcortical disease or a large stroke, you know, with robotics strokes in the cortex and have a cortical presentation. Now if you subcortical features that could be due to vascular disease it could be due to HIV, aids, dementia, Huntington’s disease, normal pressure hydrocephalus among others. And then classic Creutzfeldt-Jakob disease it has a couple of pathognomonic findings, which would be included in your vignette. The EEG shows how fast polyphasic waves and when you do a lumbar puncture the CSF will show evidence of a protein called 14-3-3 protein. So again this is another kind of way where you can capture a lot of information as you’re focused on these diagnostically focused questions. Again, just to highlight, most diagnostically focused questions will be actual vignettes. You’re not going to be asked like which of the following, you know, response options is a symptom criteria for somatic symptom disorder? So you’re not being tested on criteria per se you’re tested on-on recognizing, you know, a clinical vignette, a presentation, and saying, “Yes, this is most likely this disorder versus this other option or this other option.” So again the diagnostically focused questions in a standalone section, as well as, the extended vignette section will most likely be vignette style questions.
So that’s it for diagnostically focused questions. You take care of yourself. See you back soon. Thanks a lot.
Melpomeni Kavdella says
DEAR DR JACK!!
Timing is everything,
since the pooled time can be a … nauseating puzzle during the exam (no time to calculate what number of minutes left for the question you are on !!!!) perhaps creating 4 chunks, (separated by 3 x 20’breakss) and project an approximate time goal at the end of each chunk may help:
1st chunk (1st single answer + 1st vignette = 125′ – about 106 Qs) = target time left = 6h 15′
2nd (2nd s. a. + 2nd v = t. t. = 4h 10′
3rd (3rd s. a. + 3rd v = t. t. = 2h 05′
THANK YOU FOR HELPING US WITH MIND AND SPIRIT !!