School of Social Work, Department of Psychiatry, and InSPIRES (Institute for Social and Psychiatric Initiatives-Research, Education and Services), New York University, New York, USA.
Am J Psychiatry. 2010 Mar;167(3):298-304. doi: 10.1176/appi.ajp.2009.09040553. Epub 2010 Jan 15.
To reduce false positive diagnoses, DSM-IV added a clinical significance criterion to many diagnostic criteria sets requiring that symptoms cause significant distress or impairment. The DSM-V Task Force is considering whether clinical significance should remain a diagnostic threshold or become a separate dimension, as it is in ICD. Yet, the criterion's effectiveness in validly reducing the prevalence of specific disorders remains unclear. Critics have argued that for some categories, notably major depression, the criterion is redundant with symptoms, which are inherently distressing or impairing. The authors empirically evaluated the criterion's effect on the prevalence of major depression in the community. This report also considers more broadly the relationship of symptoms to impairment in diagnosis.
Subjects were respondents, aged 18 to 54 years, who participated in the National Comorbidity Survey Replication (N=6,707). The effect of the clinical significance criterion's distress and impairment components on major depression was assessed in this sample. Distress questions were administered to all respondents reporting persistent sadness (> or = 2 weeks) or the equivalent. Questions pertaining to role impairment were asked of all respondents satisfying major depression symptom-duration criteria.
Of 2,071 individuals reporting persistent sadness or the equivalent, 97.2% (N=2,016) satisfied criteria for distress. Of 1,542 individuals satisfying depression symptom-duration criteria, 96.2% (N=1,487) satisfied criteria for impairment.
These findings support the redundancy thesis. Distress is virtually redundant with symptoms of persistent sadness, even in the absence of major depression, and impairment is almost always entailed by major depression-level symptoms. Thus, the clinical significance criterion does not substantially reduce the prevalence of major depression in the community. The DSM-V Task Force should consider eliminating the criterion and explore alternative ways to identify false positives in the diagnosis of depression. The criterion's status for other disorders should be evaluated on a disorder-by-disorder basis because the diagnostic relationship between symptoms and impairment varies across categories.
为了减少误诊，DSM-IV 在许多诊断标准集中增加了一个临床意义标准，要求症状引起明显的痛苦或损害。DSM-V 工作组正在考虑临床意义是否应该仍然是一个诊断标准，还是像 ICD 一样成为一个单独的维度。然而，该标准在有效降低特定疾病的患病率方面的有效性仍不清楚。批评者认为，对于某些类别，特别是重度抑郁症，该标准与症状重复，而症状本身就是痛苦或损害的。作者通过实证评估了该标准对社区中重度抑郁症患病率的影响。本报告还更广泛地考虑了症状与诊断中损害的关系。
研究对象为年龄在 18 至 54 岁之间的受访者，他们参加了全国共病调查再调查（N=6707）。在这个样本中，评估了临床意义标准的痛苦和损害组成部分对重度抑郁症的影响。所有报告持续悲伤（>或=2 周）或同等症状的受访者都接受了痛苦问题的调查。所有符合重度抑郁症症状持续时间标准的受访者都被问到与角色损害有关的问题。
在 2071 名报告持续悲伤或同等症状的个体中，97.2%（N=2016）符合痛苦标准。在 1542 名符合抑郁症症状持续时间标准的个体中，96.2%（N=1487）符合损害标准。
这些发现支持冗余假说。即使没有重度抑郁症，痛苦也几乎与持续悲伤的症状完全重复，而损害几乎总是与重度抑郁症水平的症状有关。因此，临床意义标准并没有实质性地降低社区中重度抑郁症的患病率。DSM-V 工作组应考虑删除该标准，并探索在诊断抑郁症时识别假阳性的替代方法。应根据具体疾病对其他疾病的标准进行评估，因为症状和损害之间的诊断关系因类别而异。
