Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York; Research Psychiatrist, Division of Clinical Phenomenology, New York State Psychiatric Institute, New York, New York.
Professor of Social Work, Silver School of Social Work, New York University, New York, New York; Professor of Psychiatry, Department of Psychiatry, School of Medicine, New York University, New York, New York.
Can J Psychiatry. 2013 Dec;58(12):663-9. doi: 10.1177/070674371305801203.
According to the introduction to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, each disorder must satisfy the definition of mental disorder, which requires the presence of both harm and dysfunction. Constructing criteria sets to require harm is relatively straightforward. However, establishing the presence of dysfunction is necessarily inferential because of the lack of knowledge of internal psychological and biological processes and their functions and dysfunctions. Given that virtually every psychiatric symptom characteristic of a DSM disorder can occur under some circumstances in a normally functioning person, diagnostic criteria based on symptoms must be constructed so that the symptoms indicate an internal dysfunction, and are thus inherently pathosuggestive. In this paper, we review strategies used in DSM criteria sets for increasing the pathosuggestiveness of symptoms to ensure that the disorder meets the requirements of the definition of mental disorder. Strategies include the following: requiring a minimum duration and persistence; requiring that the frequency or intensity of a symptom exceed that seen in normal people; requiring disproportionality of symptoms, given the context; requiring pervasiveness of symptom expression across contexts; adding specific exclusions for contextual scenarios in which symptoms are best understood as normal reactions; combining symptoms to increase cumulative pathosuggestiveness; and requiring enough symptoms from an overall syndrome to meet a minimum threshold of pathosuggestiveness. We propose that future revisions of the DSM consider systematic implementation of these strategies in the construction and revision of criteria sets, with the goal of maximizing the pathosuggestiveness of diagnostic criteria to reduce the potential for diagnostic false positives.
根据《精神障碍诊断与统计手册》(DSM)第五版的介绍,每种障碍都必须符合精神障碍的定义,这需要既有伤害又有功能障碍。构建要求伤害的标准相对简单。然而,由于缺乏对内部心理和生物过程及其功能和功能障碍的了解,建立功能障碍的存在必然是推理性的。鉴于 DSM 障碍的几乎每种精神病症状在正常功能的人在某些情况下都可能出现,基于症状的诊断标准必须构建得使症状表明内部功能障碍,因此本质上是病态暗示的。在本文中,我们回顾了 DSM 标准集中用于提高症状病态暗示性的策略,以确保该障碍符合精神障碍定义的要求。策略包括以下几点:要求有最小的持续时间和持久性;要求症状的频率或强度超过正常人;要求在特定情况下,症状的不成比例;要求症状在整个情境中普遍存在;添加特定的排除,以将症状理解为正常反应的情境;将症状组合起来以增加累积的病态暗示性;并要求从整体综合征中获得足够的症状以达到最小的病态暗示性阈值。我们建议 DSM 的未来修订考虑在标准集的构建和修订中系统地实施这些策略,目标是最大限度地提高诊断标准的病态暗示性,以减少诊断假阳性的可能性。