[基于操作性诊断标准的急性精神病的分类与维度诊断方法]

Department of Psychiatry, Tokyo Women's Medical University, School of Medicine.

Seishin Shinkeigaku Zasshi. 2011;113(12):1228-34.

"Acute psychosis" is the tentative diagnosis made for the patients presenting acute onset of delusion, hallucination, confusion and emotional instability. "Acute psychosis" was focused in view of operational diagnostic criteria, ie, DSM-IV-TR and ICD-10. The diagnostic categories in the DSM-IV-TR corresponding to "acute psychosis" were brief psychotic disorder, schizophreniform disorder, schizo-affective disorder and mood disorder with psychotic features. Although brief psychotic disorder is representative of "acute psychosis" in the DSM-TR, it lacks in clinical usefulness, because its diagnostic criteria, based on no historical background, lack clinical validity in terms of symptom definition and duration (1 month>). On the other hand, in the ICD-10, a diagnostic category of acute transient psychotic disorder was based on the traditional "acute psychosis" concept that has been bred in the European Psychiatry. Among the acute transient psychotic disorders, acute polymorphic psychotic disorder is the diagnostic category made according to traditional concept of "bouffées délirantes" and cycloid psychosis. It is a clinically useful diagnostic category, because it could predict favorable episode outcome, if a person with fairly good premorbid social adaptation presents acute onset of polymorphic psychotic symptoms. One of the most prominent points of the revision of DSM-IV-TR to DSM-5 is the adoption of dimensional approach evaluation (diagnosis) in a disorder-crossing fashion. In addition to insomnia, depressive mood and anxiety, symptomatic domain such as acute onset, bipolarity, polymorphism of psychotic symptoms, and furthermore such domain as premorbid social adaptation, life event and episode outcome should be evaluated in the course of treatment, contributing to the clinical practice of the patients with acute psychosis.

“急性精神病”是针对出现妄想、幻觉、意识模糊和情绪不稳定急性发作的患者做出的初步诊断。鉴于操作性诊断标准，即《精神疾病诊断与统计手册》第四版修订版（DSM-IV-TR）和《国际疾病分类》第十版（ICD-10），“急性精神病”成为关注焦点。DSM-IV-TR中与“急性精神病”相对应的诊断类别包括短暂精神病性障碍、精神分裂症样障碍、分裂情感性障碍以及伴有精神病性特征的心境障碍。尽管短暂精神病性障碍是DSM-TR中“急性精神病”的代表，但它缺乏临床实用性，因为其诊断标准没有历史背景依据，在症状定义和持续时间（1个月以上）方面缺乏临床效度。另一方面，在ICD-10中，急性短暂精神病性障碍的诊断类别基于欧洲精神病学中形成的传统“急性精神病”概念。在急性短暂精神病性障碍中，急性多形性精神病性障碍是根据“急性妄想发作”和循环性精神病的传统概念确定的诊断类别。它是一个具有临床实用性的诊断类别，因为如果一个病前社会适应能力相当好的人出现急性多形性精神病性症状发作，它可以预测病情的良好转归。从DSM-IV-TR修订到DSM-5最突出的一点之一是以跨障碍的方式采用维度评估（诊断）方法。除了失眠、抑郁情绪和焦虑外，在治疗过程中还应评估急性起病、双相性、精神病性症状的多形性等症状领域，以及病前社会适应、生活事件和病情转归等领域，这有助于急性精神病患者的临床实践。