Silver School of Social Work, New York, NY 10003, USA.
Compr Psychiatry. 2012 Feb;53(2):130-9. doi: 10.1016/j.comppsych.2011.03.001. Epub 2011 May 11.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) definition of mental disorder requires that symptoms be caused by a dysfunction in the individual; when dysfunction is absent, symptoms represent normal-range distress or eccentricity and, if diagnosed as a mental disorder, are false positives. We hypothesized that because of psychiatry's lack of direct laboratory tests to distinguish dysfunction from normal-range distress, the context in which symptoms occur (eg, lack of imminent danger in a panic attack) is often essential to determining whether symptoms are caused by a dysfunction. If this is right, then the DSM diagnostic criteria should include many contextual criteria added to symptom syndromes to prevent dysfunction false positives. Despite their potential importance, such contextual criteria have not been previously reviewed. We, thus, systematically reviewed DSM categories to establish the extent of such uses of contextual criteria and created a typology of such uses.
Of 111 sampled categories, 68 (61%) used context to prevent dysfunction false positives. Contextual criteria fell into 7 types: (1) exclusion of specific false-positive scenarios; (2) requiring that patients experience preconditions for normal responses (eg, requiring that individuals experience adequate sexual stimulation before being diagnosed with sexual dysfunctions); (3) requiring that symptoms be disproportionate relative to circumstances; (4) for childhood disorders, requiring that symptoms be developmentally inappropriate; (5) requiring that symptoms occur in multiple contexts; (6) requiring a substantial discrepancy between beliefs and reality; and (7) a residual category.
Most DSM categories include contextual criteria to eliminate false-positive diagnoses and increase validity of descriptive criteria. Future revisions should systematically evaluate each category's need for contextual criteria.
《精神障碍诊断与统计手册》（DSM）对精神障碍的定义要求症状是由个体功能障碍引起的；当功能障碍不存在时，症状代表正常范围内的痛苦或怪癖，如果将其诊断为精神障碍，则为假阳性。我们假设，由于精神病学缺乏直接的实验室测试来区分功能障碍和正常范围的痛苦，因此症状出现的背景（例如，在惊恐发作中没有迫在眉睫的危险）通常对于确定症状是否由功能障碍引起至关重要。如果这是正确的，那么 DSM 诊断标准应该包括许多添加到症状综合征中的上下文标准，以防止功能障碍的假阳性。尽管它们可能很重要，但此类上下文标准以前尚未得到审查。因此，我们系统地审查了 DSM 类别，以确定此类上下文标准的使用程度，并创建了此类使用的分类法。
在抽样的 111 个类别中，有 68 个（61%）使用上下文来防止功能障碍的假阳性。上下文标准分为 7 种类型：（1）排除特定的假阳性情况；（2）要求患者经历正常反应的前提条件（例如，要求个体在被诊断为性功能障碍之前经历足够的性刺激）；（3）要求症状与情况不成比例；（4）对于儿童障碍，要求症状在发育上不合适；（5）要求症状出现在多个环境中；（6）要求信仰和现实之间存在实质性差异；以及（7）剩余类别。
大多数 DSM 类别都包括上下文标准，以消除假阳性诊断并提高描述性标准的有效性。未来的修订应该系统地评估每个类别的上下文标准需求。
