USMLE Step 1 Lecture Notes 2020: Behavioral Science and Social Sciences (2020)

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USMLE®Step!Lecture Notes"#"#Behavioral Science and Social Sciences00_USMLE_FM.indd17/29/198:25 PM

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USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board ofMedical Examiners (NBME), which neither sponsor nor endorse this product.This publication is designed to provide accurate information in regard to the subject matter covered asof its publication date, with the understanding that knowledge and best practice constantly evolve. Thepublisher is not engaged in rendering medical, legal, accounting, or other professional service. If medicalor legal advice or other expert assistance is required, the services of a competent professional should besought. This publication is not intended for use in clinical practice or the delivery of medical care. To thefullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/ordamage to persons or property arising out of or related to any use of the material contained in this book.© 2020 by Kaplan, Inc.Published by Kaplan Medical, a division of Kaplan, Inc.750 Third AvenueNew York, NY 10017!LLRIGHTSRESERVED4HETEXTOFTHISPUBLICATION ORANYPARTTHEREOF MAYNOTBEREPRODUCEDINANYMANNERWHATSOEVERWITHOUTWRITTENPERMISSIONFROMTHEPUBLISHER10 9 8 7 6 5 4 3 2 1Course ISBN: 978-1-5062-5472-2Retail ISBN: 978-1-5062-5470-84HISITEMCOMESASASETANDSHOULDNOTBEBROKENOUTANDSOLDSEPARATELYKaplan Publishing print books are available at special quantity discounts to use for sales promotions,employee premiums, or educational purposes. For more information or to purchase books, please call theSimon & Schuster special sales department at 866-506-1949.00_USMLE_FM.indd27/29/198:25 PM

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EditorsBehavioral ScienceAlice Akunyili, MDAssistant Professor, Department of Cell Biology and PharmacologyFIU Herbert Wertheim College of MedicineMiami, FLAlina Gonzalez-Mayo, MDPsychiatristDepartment of Veterans AdministrationBay Pines, FLMark Tyler-Lloyd, MD, MPHExecutive Director of AcademicsKaplan MedicalNew York, NYBasic Science of Patient SafetyTed A. James, MD, MS, FACSChief, Breast Surgical OncologyVice Chair, Academic AffairsDepartment of SurgeryBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MAThe editors would like to acknowledgeKevin Schuller, MD, Irfan Sheikh, MD,andKevin Yang, MDfor their contributions.00_USMLE_FM.indd39/7/183:35 PM

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We want to hear what you think. What do you like or not like about the Notes?Please email us atmedfeedback@kaplan.com.00_USMLE_FM.indd49/7/183:35 PM

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vTable of ContentsPart I: Epidemiology and BiostatisticsChapter 1:Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Chapter 2:Biostatistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Part II: Behavioral ScienceChapter 3:Developmental Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53Chapter 4:Theories of Learning and Behavioral Modification. . . . . . . . . . 65Chapter 5:Defense Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Chapter 6:Psychological Health and Testing . . . . . . . . . . . . . . . . . . . . . . . . .77Chapter 7:Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Chapter 8:Sleep and Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Chapter 9:Psychiatric (DSM-5) Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 99Chapter 10:Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Chapter 11:Brain Function and Neurocognitive Disorders . . . . . . . . . . . 125Chapter 12:Ethics, Law, and Physician Behavior . . . . . . . . . . . . . . . . . . . 135Chapter 13:Health Care Delivery Systems. . . . . . . . . . . . . . . . . . . . . . . . . 157PartIII: Social SciencesChapter 14:Basic Science of Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . 161Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193Additional resources available atwww.kaptest.com/usmlebookresources00_USMLE_FM.indd59/7/183:35 PM

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00_USMLE_FM.indd69/7/183:35 PM

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PART IEpidemiology andBiostatistics01_USMLE_PartI_Ch01.indd19/8/181:45 PM

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01_USMLE_PartI_Ch01.indd29/8/181:45 PM

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3Learning ObjectivesRAnswer questions about epidemiologic measuresRUse knowledge of screening testsRExplain information related to study designsEPIDEMIOLOGIC MEASURESEpidemiology is the study of the distribution and determinants of health-relatedstates within a population. It refers to the patterns of disease and the factors thatinfluence those patterns.•Endemic: the usual, expected rate of disease over time; the disease ismaintained without much variation within a region•Epidemic: occurrence of disease in excess of the expected rate; usuallypresents in a larger geographic span than endemics (epidemiologyis thestudy of epidemics)•Pandemic: worldwide epidemic•Epidemic curve: visual description (commonly histogram) of an epi-demic curve is disease cases plotted against time; classic signature ofan epidemic is a “spike” in timeThe tools of epidemiology are numbers; the numbers in epidemiology are ratiosconverted into rates.The denominator is key: who is “at risk” for a particularevent or disease state.To determine the rate, compare the number of actual cases with the number ofpotential cases:==Actual casesPotential casesNumeratorDenominatorRATERates are generally, though not always, per 100,000 persons by the Centersfor Disease Control (CDC), but can be per any multiplier. (Vital statistics areusually per 1,000 persons.)A disease may occur in a country at a regular annual rate, which makes itendemic. If there is a sudden rise in the number of cases in a specific month,we say that there is anepidemic. As the disease continues to rise and spread toother countries, it becomes apandemic.Thus the terminology is related to boththe number of cases and its geographical distribution.Epidemiology101_USMLE_PartI_Ch01.indd39/8/181:45 PM

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4Part IOEpidemiology and BiostatisticsMedical GeneticsBehavioral Science/Social SciencesThe graph below represents the incidence of 2 diseases (cases in 100,000).Disease 1 is endemic as the rate of disease is consistent month to month withminor variation in the number of cases. Disease 2 experiences an epidemic inMarch and April in which the number of cases is in excess of what is expected.JanuaryFebruaryMarchAprilMayJuneJulyAugust3434443355885555Figure 1.1Epidemic vs. Endemic CasesConsider the following scenario.A Japanese farmer begins to sell meat that isinfected with salmonella. Within2 days, hundreds of villagers begin to experi-encecrampy abdominal pain.This is an example ofan epidemic.The suddenrise of salmonella gastroenteritis inthis village is much higher than the averageincidence for the given timeperiod.Now what if the farmer ships 1,000 pounds ofinfected beef to other regionsof Japan before he realizes what happened?What can one anticipate wouldhappen?The answer is there would be no change to the endemic rate ofgastroenteritis.The farmer isonly shipping out 1,000 pounds of beef to a fewcities nationwide. Unlikethe earlier scenario which addressed the populationof a village, thiswould be the entire nation. Assuming that every person whoconsumes the beef gets gastroenteritis, that number would not significantly in-crease the national average of cases and would therefore not significantly changethe incidence of the disease nationwide.Incidence and PrevalenceIncidence rate (IR)is the rate at whichnew eventsoccur in a population.•The numerator is the number ofnewevents that occur in a defined period.•The denominator is the population at risk of experiencing this newevent during the same period.Although the data isin 100,000 cases, thevariation in disease 1is still consistent whencompared to disease 2.01_USMLE_PartI_Ch01.indd49/8/181:45 PM

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Chapter 1OEpidemiology5Incidence rateNumber of new events in a specified periodNumber of persons “exposed to risk”of becoming new cases during this period10n=×The IR includes onlynewcasesof the disease that occurred during the specifiedperiod, not cases that were diagnosed earlier.This is especially important whenworking with infectious diseases such as TB and malaria.If, over the course of a year, 5 men are diagnosed with prostate cancer, out of atotal male study population of 200 (with no prostate cancer at the beginning ofthe study period), the IR of prostate cancer in this population would be 0.025(or 2,500 per 100,000 men-years of study).Attack rateis the cumulative incidence of infection in a group of peopleobserved over a period of time during an epidemic, usually in relation tofood-borne illness. It is measured from the beginning of an outbreak to the endof the outbreak.=AttackrateNumberofexposedpeopleinfectedwiththediseaseTotalnumberofexposedpeopleAttack rate is also calledattack ratio; consider an outbreak of Norwalk virusin which 18 people in separate households become ill. If the population of thecommunity is 1,000, the overall attack rate is×=181,000100%1.8%.Figure1.2Reported Cases of Hepatitis C in the United StatesFigure 1.3Cumulative Incidence 2005–201501_USMLE_PartI_Ch01.indd59/8/181:45 PM

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6Part IOEpidemiology and BiostatisticsMedical GeneticsBehavioral Science/Social SciencesPrevalenceis all persons who experience an event in a population.The numeratoris all individuals who have an attribute or disease at a particular point in time (orperiod of time).The denominator is the population at risk of having the attributeor disease at that point in time or midway through the period.PrevalenceAll cases of a disease at a given point / periodTotal population “at risk” for being cases at a given point / periodn=×10Prevalence, in other words, is the proportion of people in a population whohave a particular disease at a specified point in time (or over a specified periodof time).The numerator includes both new cases and old cases (people whoremained ill during the specified point or period in time). A case is countedin prevalence until death or recovery occurs.This makes prevalence differentfrom incidence, which includes only new cases in the numerator.Prevalence is most useful for measuring the burden of chronic disease in apopulation, such as TB, malaria and HIV. For example, the CDC estimated theprevalence of obesity among American adults in 2001 at approximately 20%.Since the number (20%) includes all cases of obesity in the United States, we aretalking aboutprevalence.Point prevalenceis useful for comparing disease at different points in time inorder to determine whether an outbreak is occurring. We know that the amountof disease present in a population changes over time, but we may need to knowhow much of a particular disease is present in a population at a single point intime (“snapshot view”).Perhaps we want to know the prevalence of TB in Community A today. To dothat, we need to calculate the point prevalence on a given date.The numeratorwould include all known TB patients who live in Community A that day.Thedenominator would be the population of Community A that day.Period prevalence, on the other hand, is prevalence during a specified period orspan of time.The focus is onchronicconditions.In the“prevalence pot,” incident (or new) cases are monitored over time. Newcases join pre-existing cases to make up total prevalence.GeneralPopulationat RiskIncident CasesPrevalentCasesRecoveryMortalityRecovery with ImmunityFigure 1-4.Prevalence PotPrevalent cases leave the prevalence pot in one of 2 ways: recovery or death.NotePrevalenceis a measurement ofallindividuals (new and old) affectedby the disease at a particular time,whereasincidenceis a measurementof the number ofnewindividuals whocontract a disease during a particularperiod of time.01_USMLE_PartI_Ch01.indd69/8/181:45 PM

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Chapter 1OEpidemiology7Table 1-1. Incidence and PrevalenceWhat happens if:IncidencePrevalenceNew effective treatment is initiatedno changedecreaseNew effective vaccine gains widespread usedecreasedecreaseNumber of persons dying from thecondition increasesno changedecreaseAdditional Federal research dollars aretargeted to a specific conditionno changeno changeBehavioral risk factors are reduced inthe population at largedecreasedecreaseContacts between infected persons andnoninfected persons are reducedFor airborne infectious disease?For noninfectious disease?decreasedecreaseno changeno changeRecovery from the disease is more rapidthan it was one year agono changedecreaseLong-term survival rates for the diseaseare increasingno changeincreaseFigure 1-2.Calculating Incidence and Prevalence1/1/20061/1/200712345678109Disease course, if any, for 10 patientsDurationKey:OnsetTerminal EventLung Cancer Cases in a Cohort of Heavy SmokersFigure 1-5.Calculating Incidence and PrevalenceNoteMorbidity rateis the rate of disease ina population at risk (for both incidentand prevalent cases), whilemortalityrateis the rate of death in a populationat risk (incident cases only).01_USMLE_PartI_Ch01.indd79/8/181:46 PM

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8Part IOEpidemiology and BiostatisticsMedical GeneticsBehavioral Science/Social SciencesBased on the graph above, calculate the following:•Prevalence of lung cancer from 1/1/2006–1/1/2007–Number of patients who “had” lung cancer in this time period from thegraph: (7)–Number of patients at risk in this time period: (9) [exclude patient #2 whodied before the time period]–Prevalence: (7/9)–Type of prevalence: (period prevalence)•Incidence of lung cancer from 1/1/2006–1/1/2007–Number of patients who developed lung cancer in this time period: (4)–Number of patients at risk in this time period: (6) [exclude patients who werealready sick at the start of the time period and those who died before the timeperiod]–Incidence: (4/6)Recall QuestionPrevalence can be defined as which of the following?A.Number of new events in a specified period over thenumber of persons at risk of becoming new casesduring the same periodB.Number of exposed people infected with a disease overthe total number of exposed peopleC.All cases of a disease at a given point over the totalpopulation at risk for being cases at the same pointD.Number of actual cases over potential casesE.Rate of death in a population at riskAnswer: CCrude, Specific, and Standardized RatesCrude rateis the actual measured rate for awhole population, e.g., rate ofmyocardial infarction for a whole population.Specific rateis the actual measured rate for asubgroup of population, e.g.,“age-specific” or “sex-specific” rate. For instance, the rate of myocardial infarctionamong people age>65 in the population or the rate of breast cancer among thefemale population.If you are provided specific rates, you can calculate the crude rate.The cruderate of an entire population is a weighted sum of each of the specific rates.Theweighted specific rates that are added together is calculated in the table below.NoteUsecaution using the crude rate.Imagine that in a given city, thereare a lot of older, retired people—thecrude rate of myocardial infarction willappear higher, even though the ratefor each age group has not actuallychanged.01_USMLE_PartI_Ch01.indd89/8/181:46 PM

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