Spitzer R L, Wakefield J C
Department of Psychiatry, Columbia University and the New York State Psychiatric Institute, NY 10032, USA.
Am J Psychiatry. 1999 Dec;156(12):1856-64. doi: 10.1176/ajp.156.12.1856.
A major change in DSM-IV is the inclusion in almost one-half of the diagnostic criteria sets of a clinical significance criterion, which requires that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." In response to concerns that the DSM criteria are overly inclusive, the clinical significance criterion attempts to minimize false positive diagnoses in situations in which the symptom criteria do not necessarily indicate pathology. This article examines whether the clinical significance criterion achieves its purpose and considers its broader impact on diagnostic validity.
The effect of the clinical significance criterion on the diagnostic validity of DSM-IV criteria for a wide range of disorders was examined.
For many diagnoses to which the clinical significance criterion was added, the symptom criteria are inherently associated with significant impairment, so the clinical significance criterion is redundant and therefore does not affect caseness. For some diagnoses, the clinical significance criterion is potentially helpful in eliminating false positives by elevating the level of required distress. However, there may be advantages to obtaining the same results by modifying some of the symptom criteria. Often the clinical significance criterion has led to the possibility of false negative diagnoses.
In the process of revising DSM-IV, the generic use of the clinical significance criterion should be reconsidered. For each DSM diagnosis, it should be determined whether there is a need to raise the threshold of any of the existing symptom criteria or to add a criterion that excludes normal reactions to psychosocial stress.
《精神疾病诊断与统计手册》第四版（DSM-IV）的一项重大变化是，几乎在一半的诊断标准集中纳入了临床意义标准，该标准要求症状导致“临床上明显的痛苦或在社会、职业或其他重要功能领域的功能损害”。针对对DSM标准包容性过强的担忧，临床意义标准试图在症状标准不一定表明存在病理状况的情况下，尽量减少假阳性诊断。本文探讨临床意义标准是否达到了其目的，并考虑其对诊断效度的更广泛影响。
研究临床意义标准对DSM-IV中多种障碍诊断标准效度的影响。
对于许多添加了临床意义标准的诊断，症状标准本身就与显著损害相关，因此临床意义标准是多余的，因而不影响病例诊断。对于某些诊断，临床意义标准可能有助于通过提高所需痛苦程度来消除假阳性。然而，通过修改一些症状标准获得相同结果可能有其优势。临床意义标准常常导致假阴性诊断的可能性。
在修订DSM-IV的过程中，应重新考虑临床意义标准的普遍使用。对于DSM中的每一种诊断，都应确定是否有必要提高任何现有症状标准的阈值，或添加一项排除对心理社会压力正常反应的标准。
