Schwartz J E, Fennig S, Tanenberg-Karant M, Carlson G, Craig T, Galambos N, Lavelle J, Bromet E J
Department of Psychiatry and Behavioral Science, State University of New York at Stony Brook, 11794-8790, USA.
Arch Gen Psychiatry. 2000 Jun;57(6):593-600. doi: 10.1001/archpsyc.57.6.593.
Diagnostic changes may reflect evolution of an illness, emergence of newly disclosed information, or unreliability of assessment. This study evaluates the stability of research diagnoses in a heterogeneous first-admission sample with psychosis.
A group of 547 subjects initially diagnosed with a psychosis were reassessed 6 and 24 months after enrollment. The DSM-IV consensus diagnoses were formulated by psychiatrists blind to previous research diagnoses. The analysis focuses on agreement over time and the effects of demographic, family history, and clinical variables on the shift from a nonschizophrenia diagnosis to schizophrenia.
Seventy-two percent of 6- and 24-month diagnoses were congruent. The most temporally consistent 6-month categories were schizophrenia (92%), bipolar disorder (83%), and major depression (74%); the least stable were psychosis not otherwise specified (44%), schizoaffective disorder (36%), and brief psychosis (27%). The most frequent shift in diagnosis at 24 months was to schizophrenia spectrum (n=45). These 45 subjects had a similar illness course after 6 months as the 171 subjects in this category at both assessments, but their prior clinical functioning was better. Risk factors predicting change to a schizophrenia spectrum diagnosis include facility variables (schizophrenia diagnosis, longer stays, and given antipsychotic medication on hospital discharge); prehospital features (psychotic > or =3 months before admission, poorer adolescent adjustment, lifetime substance disorder); and negative symptoms.
Changes in diagnosis, particularly to schizophrenia, are mostly attributable to the evolution of the illness. Rigid adherence to DSM-IV requirements may have led to underdiagnosis of schizophrenia. The findings support the need for a longitudinally based diagnostic process in incidence samples.
诊断变化可能反映疾病的演变、新披露信息的出现或评估的不可靠性。本研究评估了一组首次入院的异质性精神病患者样本中研究诊断的稳定性。
对一组最初被诊断为精神病的547名受试者在入组后6个月和24个月进行重新评估。DSM-IV共识诊断由对先前研究诊断不知情的精神科医生制定。分析重点在于随时间的一致性以及人口统计学、家族史和临床变量对从非精神分裂症诊断转变为精神分裂症的影响。
6个月和24个月诊断的一致性为72%。在6个月时时间上最一致的类别是精神分裂症（92%）、双相情感障碍（83%）和重度抑郁症（74%）；最不稳定的是未另行说明的精神病（44%）、精神分裂症性情感障碍（36%）和短暂精神病性障碍（27%）。24个月时最常见的诊断转变是转为精神分裂症谱系（n = 45）。这45名受试者在6个月后的病程与两次评估中该类别中的171名受试者相似，但他们之前的临床功能更好。预测转变为精神分裂症谱系诊断的危险因素包括机构变量（精神分裂症诊断、住院时间更长、出院时给予抗精神病药物）；院前特征（入院前精神病发作≥3个月、青少年适应能力较差、有终生物质使用障碍）；以及阴性症状。
诊断变化，尤其是转变为精神分裂症，大多归因于疾病的演变。严格遵循DSM-IV要求可能导致精神分裂症诊断不足。这些发现支持在发病率样本中需要基于纵向的诊断过程。
