DSM-5 Self-exam Questions: Test Questions for the Diagnostic Criteria.: Philip R. Muskin, Ed. (2014) Washington, DC: American Psychiatric Publishing. 467 pp.

Scheiber, Stephen C. MD

Journal of Nervous & Mental Disease: February 2016 - Volume 204 - Issue 2 - p 162
doi: 10.1097/NMD.0000000000000440
Book Reviews

Clinical Professor of Psychiatry and Behavioral Medicine Medical College of Wisconsin Milwaukee, WI

Article Outline

Philip Muskin has demonstrated why he is a master educator as the editor of this gem of a continuing education product. Of the 10 contributors he has enlisted to produce the multiple-choice questions and to advise how they arrived at the 1 correct answer, 8 have academic credentials at the Columbia University Medical Center, where Dr Muskin is a professor of psychiatry. The other 2 are recognized leaders in psychiatric education from Brown and the University of Michigan. The book is divided into 2 major parts. Part 1 contains 153 pages of multiple-choice questions, and part II has 311 pages in which each question in part I is repeated followed by the correct answer and in turn a paragraph-long explanation of how the authors arrived at the 1 best answer. These explanations are invaluable and are very educational. Lastly, each answer is referenced in bold print to the section and page number in the mother document, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as the primary source for the correct answer. Nothing is overlooked in this fine book! In addition to the meat of the book, namely, the 19 chapters dedicated to the diagnostic headings, the book includes questions on the Introduction to the DSM-5, Assessment Measures, Cultural Concepts of Distress, Alternative DSM-5 Model for Personality Disorders, and, lastly, the Glossary of Terms.

In addition to the traditional explanations of how the authors arrived at the 1 best answer, they also give historical information as to the basis of abandoning well-embodied principles from the DSM-IV, not the least of which were the multiaxial diagnostic formulations. Muskin gives the reader an insider’s view of how the various DSM committees arrived at and justified what in some cases could be viewed as monumental changes.

The questions in part I are in the majority type A–formatted ones with a stem followed by 5 choices with 1 correct answer and 4 distracters that are incorrect. (This is jargon from the test writing world.) The book is silent on how or where answers are to be recorded. There are neither answer sheets provided in part I, nor suggestions about the best way to record them. So it is left to the reader to decide. The reader could make up his/her own paper-and-pencil answer sheet and record answers to be compared with the ones provided in part II. Another possibility would be to set up an Excel spreadsheet and record answers on the computer. The least desirable way would be to circle answers in part I in the book. To check with the answers in part II, the reader would have to continuously flip pages between part I and part II.

This leads to a corollary question. Is the redundancy of having 153 pages of questions in part I repeated in part II truly necessary? It would be if this were a high-stakes examination. In such a situation, one could be concerned about the reader peaking at the correct answers while reading the questions in part II. Given that this is a continuing education exercise, why not eliminate part I and advise the reader to read the questions, record the answer, and then check for the correct answer?

The authors are to be commended for the many questions that test high-order thinking and not simply recall. These are found in virtually every chapter and are embodied in case presentations. An example of one such is under obsessive-compulsive disorders.

6.14: A 25-year-old man is referred to a psychiatrist by his primary care doctor after mentioning to the doctor that he routinely spends a lot of time pulling out facial hair with tweezers, even after carefully shaving. On evaluation, he admits to frequent pulling of his facial hair, consuming significant amount of time; he explains that he becomes anxious when looking at himself because his moustache, hairline, and sideburns are asymmetrical. He pulls out hairs in an effort to make them more symmetrical, but is rarely satisfied with the results. He finds this very upsetting but cannot resist the urge to try and “fix” his facial hair. What is the most appropriate diagnosis? (281)

The reader can appreciate that there is sufficient clinical information to apply his/her higher-order thinking to arrive at the appropriate diagnosis.

The authors then give the 5 alternative answers with 1 correct diagnosis as follows:

A. trichotillomania (hair-pulling disorder)

B. body dysmorphic disorder (BDD)

C. delusional disorder, somatic type

D. normal age-appropriate appearance concerns

E. obsessive-compulsive disorder (OCD) (281)

Ideally, the 5 alternatives are all plausible. One could question whether choice D rises to that standard.

The authors then give the correct answer as E. obsessive-compulsive disorder (OCD) (p281). One could also argue that the reader would be guided to that choice by virtue of the chapter heading.

The authors conclude with:

Explanation: In the case of repetitive hair pulling, distinguishing among trichotillomania, BDD and OCD can sometimes be difficult. The differential diagnosis rests on the reasons for the pulling. Trichotillomania generally stems from boredom or anxiety, whereas BDD-related hair pulling is generally associated with perceived ugliness of the hair. When the pulling is in the service of symmetry, OCD is the more appropriate diagnosis. Further examination of the individual would likely reveal additional examples of this preoccupation with symmetry. Although some amount of hair pulling may be normal, the degree and the distress caused make age-appropriate appearance concerns an unlikely explanation in this case. Psychotic disorders should be ruled out—in this vignette, the patient’s symptoms appear to be more a preoccupation than a delusion. (282)

This explanation is brilliant in that it not only educates the reader on the plausible diagnostic considerations but also guides the reader through a differential diagnosis and finally how one arrives at the correct diagnosis with the utmost confidence. If for no other reason, this book is worth its weight in gold.

In contrast, there are some question types that are less valuable. These include those that simply relate to recall of facts and require no thinking by the reader. “True or false” options are among the least valuable question types because they allow for guessing in which case the reader could by chance choose the correct answer 50% of the time. In addition negative stems are frowned upon such as “not” representative in the stem in 1.27. (11). It is preferable to state the stem in positive terms as a reader may be able to identify an incorrect answer without knowing a correct answer.

Lastly, the question format for the Glossary of Technical Terms (DSM-5 Appendix) appears to be a product of test writing fatigue or presented as a challenge to the reader as a race to the finish as a Prometheus Bound exercise. The authors take the 26 terms and then ask the reader to match them with 26 definitions. This is way too many for a matching-type question. If necessary to include questions about this glossary, the authors should first have started with the definitions and asked the reader to fish for the term that applied to the definition. The way it is formatted takes too much time to find the correct answer Also, rather than do all 26 together, the reader would benefit from dividing them up into 4 matching questions with 6 to 7 terms at a time.

This test question book is an invaluable guide for those wanting to assess their knowledge of the DSM-5 and will enhance one’s knowledge about the major changes that have taken place in psychiatric diagnoses and learn about how and why changes were made. Most of all the reader will appreciate the monumental work that went into preparing such a fine work. It is an important companion to the DSM-5.

Stephen C. Scheiber, MD

Clinical Professor of Psychiatry and

Behavioral Medicine

Medical College of Wisconsin

Milwaukee, WI

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The author declares no conflict of interest.

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