Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.
National Center for PTSD, VA Connecticut Healthcare System, West Haven.
JAMA Psychiatry. 2024 Nov 1;81(11):1101-1107. doi: 10.1001/jamapsychiatry.2024.2047.
DSM criteria are polythetic, allowing for heterogeneity of symptoms among individuals with the same disorder. In empirical research, most combinations were not found or only rarely found, prompting criticism of this heterogeneity.
To elaborate how symptom-based definitions and assessments contribute to a distinct probability pattern for the occurrence of symptom combinations.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study involved a theoretical argument, simulation, and secondary data analysis of 4 preexisting datasets, each consisting of symptoms from 1 of the following syndromes: posttraumatic stress disorder, depression, schizophrenia, and anxiety. Data were obtained from various sources, including the National Institute of Mental Health Data Archive and Department of Veteran Affairs. A total of 155 474 participants were included (individual studies were 3930 to 63 742 individuals in size). Data were analyzed between July 2021 and January 2024.
For each participant, the presence or absence of each assessed symptom and their combination was determined. The number of all combinations and their individual frequencies were assessed.
Probability or frequency of unique symptom combinations and their distribution.
Among the 155 474 participants, the mean (SD) age was 47.5 (14.8) years; 33 933 (21.8%) self-identified as female and 121 541 (78.2%) as male. Because of the interrelation between symptoms, some symptom combinations were significantly more likely than others. The distribution of the combinations' probability was heavily skewed with most combinations having a very low probability. Across all 4 empirical samples, the 1% most common combinations were prevalent in a total of 33.1% to 78.6% of the corresponding sample. At the same time, many combinations (ranging from 41.7% to 99.8%) were reported by less than 1% of the sample.
This study found that within-disorder symptom heterogeneity followed a specific pattern consisting of few prevalent, prototypical combinations and numerous combinations with a very low probability of occurrence. Future discussions about the revision of diagnostic criteria should take this specific pattern into account by focusing not only on the absolute number of symptom combinations but also on their individual and cumulative probabilities. Findings from clinical populations using common diagnostic criteria may have limited generalizability to the large group of individuals with a low-probability symptom combination.
DSM 标准是多态的，允许同一障碍患者的症状存在异质性。在实证研究中，大多数组合并未被发现，或仅偶尔被发现，这引发了对这种异质性的批评。
详细说明基于症状的定义和评估如何为症状组合的发生提供独特的概率模式。
设计、设置和参与者：本横断面研究涉及理论论证、模拟以及对 4 个现有数据集的二次数据分析，每个数据集均由以下综合征之一的症状组成：创伤后应激障碍、抑郁、精神分裂症和焦虑症。数据来自多个来源，包括美国国立精神卫生研究院数据档案和美国退伍军人事务部。共纳入 155474 名参与者（各研究的个体数量为 3930 至 63742 人）。数据分析于 2021 年 7 月至 2024 年 1 月进行。
对于每个参与者，确定评估症状的存在或缺失以及它们的组合。评估了所有组合的数量及其个体频率。
独特症状组合及其分布的概率或频率。
在 155474 名参与者中，平均（SD）年龄为 47.5（14.8）岁；33933（21.8%）自我认定为女性，121541（78.2%）为男性。由于症状之间的相互关系，一些症状组合的出现概率明显高于其他组合。组合概率的分布严重偏斜，大多数组合的概率非常低。在所有 4 个实证样本中，1%最常见的组合在相应样本的 33.1%至 78.6%中普遍存在。同时，许多组合（范围为 41.7%至 99.8%）仅报告了不到 1%的样本。
本研究发现，同一障碍内的症状异质性遵循一种特定模式，包括少数常见的、典型的组合和许多出现概率非常低的组合。未来关于诊断标准修订的讨论应考虑到这种特定模式，不仅要关注症状组合的绝对数量，还要关注它们的个体和累积概率。使用常见诊断标准的临床人群的研究结果可能对低概率症状组合的大多数个体的普遍性有一定的限制。
