Department of Psychiatry, OHSU, Portland, OR, USA.
J Child Psychol Psychiatry. 2023 May;64(5):711-714. doi: 10.1111/jcpp.13806.
After attention was drawn in the late 1960s to the poor reproducibility of psychiatric diagnosis between clinicians, methods and procedures used to diagnose psychiatric disorders were greatly improved. Sources of variance contributing to the poor reliability of psychiatric diagnosis were identified that included: information variance (how clinicians go about enquiring about symptoms), interpretation variance (how clinicians weigh the observed symptomatology towards diagnostic formulations), and criterion variance (how clinicians arrange symptom constellations to generate specific diagnoses). To improve the reliability of diagnosis, progresses were made in two major directions. First, diagnostic instruments were developed to standardize the way symptoms are elicited, evaluated, and scored. These diagnostic interviews were either highly structured for use in large-scale studies (e.g. the DIS), by lay interviewers without a clinical background, and with a style of questioning that emphasized adherence to the exact wording of probes, reliance on closed questions with simple response formats (Yes/No) and recording respondents' answers without interviewer's judgment contribution. By contrast, semi-structured interviews (e.g. the SADS) were designed to be used by clinically trained interviewers and adopted a more flexible, conversational style, using open-ended questions, utilizing all behavioral descriptions generated in the interview, and developing scoring conventions that called upon the clinical judgment of the interviewer. Second, diagnostic criteria and algorithms were introduced in nosographies in 1980 for the DSM and soon after in ICD. Algorithm-derived diagnoses could subsequently be tested for their validity using follow-up, family history, treatment response studies, or other external criteria.
自 20 世纪 60 年代后期，由于临床医生之间的精神科诊断再现性较差而受到关注以来，用于诊断精神障碍的方法和程序得到了极大的改进。确定了导致精神科诊断可靠性差的变异来源，包括：信息变异（临床医生如何询问症状）、解释变异（临床医生如何权衡观察到的症状表现以进行诊断制定）和标准变异（临床医生如何安排症状组合以生成特定的诊断）。为了提高诊断的可靠性，在两个主要方向上取得了进展。首先，开发了诊断工具来规范症状的采集、评估和评分方式。这些诊断访谈要么是为大规模研究设计的高度结构化访谈（例如，DIS），要么是由没有临床背景的非专业访谈者使用，并且采用强调严格遵循探针措辞、依赖简单回答格式（是/否）的提问方式，以及记录受访者的答案而不依赖访谈者的判断贡献。相比之下，半结构化访谈（例如，SADS）旨在由经过临床培训的访谈者使用，并采用更加灵活的对话式风格，使用开放式问题，利用访谈中生成的所有行为描述，并制定需要访谈者的临床判断的评分约定。其次，在 1980 年的疾病分类中引入了诊断标准和算法，随后在 ICD 中也引入了这些标准和算法。随后，可以使用随访、家族史、治疗反应研究或其他外部标准来检验算法衍生的诊断的有效性。
