DSM-IV

精神障害の診断と統計マニュアル第4版

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Diagnostic and Statistical Manual of Mental Disorder

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1. the 9th letter of the Roman alphabet (同)i
2. the 4th letter of the Roman alphabet (同)d

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1. 『私は』私が
2. iodineの化学記号
3. deuteriumの化学記号

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/09/14 16:34:48」(JST)

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精神障害の診断と統計の手引き（せいしんしょうがいのしんだんととうけいのてびき、Diagnostic and Statistical Manual of Mental Disorders、DSM）は、精神障害に関するガイドライン。精神科医が患者の精神医学的問題を診断する際の指針を示すためにアメリカ精神医学会が定めたもので、世界保健機関による疾病及び関連保健問題の国際統計分類とともに、世界各国で用いられている。

概要

DSMは、精神医学の方面で革命的なアプローチをもたらしたものとして知られている。普及した理由は、

• 病因論などに余り踏み込まずに精神症状のみを論理的推察と統計学的要素を取り入れ分類した事で、
• 診断基準が明確になり、今まで医師の主観的な傾向にあった精神障害の判断に対して、客観的な判断を下せる様になり、
• 医療スタッフ側の意見や伎倆の差異による診断の違いが最小限となった

事にある。

来歴

1952年に初版 (DSM-I) が出されて以降、随時改定され、現在は第四版用修正版 (DSM-IV-TR) となっている。2013年5月に (DSM-5) の発表が予定されている。アメリカ合衆国を主に、世界で50万部以上が普及している。

DSM-I

1952年発表。「反応」(reaction) の面から精神障害を3群に大別したものであった。

DSM-II

1968年発表。DSM-Iの基本概念を継承しているが、「反応」の言葉を廃し、「障害」を10群に大別した。

DSM-III

1980年発表。症候学的記述および量的基準を導入した新しい診断基準を採用、さらに多軸評定という新しい手法を導入した。障害概念も追加され、診断項目はほぼ倍増した。

DSM-III-R

1986年発表。DSM-IIIを基にした小改正版である。

DSM-IV

1994年発表。DSM-IIIの基本概念を踏襲しつつ、ICD-10との整合性確保を図るなどした改訂版。精神障害を16群に大別した。

DSM-IV-TR ('Text Revision' of the DSM-IV)

2000年発表。

DSM-5

2013年発表予定。ICD-10との統合も検討されている。なお、この回から算用数字で表すようになる予定である。あわせて序数詞読みから基数詞読みに変更予定（従来は、first, second, third, fourthと読んでいたが、5以降はfiveの読みとなる）。

診断

DSMにおいては、各障害についてA・B・Cの診断基準が示され、「AからCの全てが当てはまる場合」その精神障害であると診断される。

A・Bは具体的な病像が列挙されるが、C基準は「その症状が原因で職業・学業・家庭生活に支障を来している」となっている。

C基準が無ければ、世間の誰もがDSMに挙げられたいずれかの精神障害の基準を満たしてしまうからである。特にパーソナリティ障害においてはその傾向が強い。

本書には、「DSM-IVは、臨床的、教育的、研究的状況で使用されるよう作成された精神障害の分類である。診断カテゴリー、基準、解説の記述は、診断に関する適切な臨床研修と経験を持つ人によって使用されることを想定している。重要な事は、研修を受けていない人にDSM-IVが機械的に用いられてはならない事である。DSM-IVに取り入れられた各診断基準は指針として用いられるが、それは臨床的判断によって生かされるものであり、料理の本のように使われるものではない。」と書かれており、非専門家による使用を禁じている。

なお、日本国内には、診断基準にDSMではなく、ICD-10を採用している病院もある。

障害定義

一般的には「Mental Illness（心の病、精神病）」と呼ばれるが、専門的には「Mental Disorder（精神障害）」が使われる。DSM-IVやDSM-IV-TRの前文では、disease（疾患）ではなくdisorder（障害）という言葉を使うと断っており、また、「どのような定義によっても『精神障害』の概念に正確な境界線を引くことができないことを認めなければならない」とdisorder（障害）の概念の曖昧さを認めている。「精神障害の定義」と題した文章で精神障害を定義できないと述べており、拡大解釈に警告がなされている。アレン・フランセス編纂委員長もWIRED英語版で「精神障害の定義は存在しません。戯言です。つまり、定義などできないということです」などと発言している。

DSMの著者らによれば、各種精神障害の患者が実在するわけではない。統合失調症患者が存在するのではなく、「統合失調症 (schizophrenic disorder)」の診断基準を満たす症状を有する人々がいるだけである。その為、ミシガン大学の調査ではアメリカ人の半数が何らかの精神障害に該当するとの結果が出ている。また、DSM-IV発表以降の精神障害の増加率が当初の予想を越えており、アレン・フランセス編纂委員長は「米国では数多くの勢力が（DSMの）変更点を丹念に研究しながら、どのようにしたら自分たちが考えている特定の目的に合わせて曲解できるかと待ちかまえているのです」と述べている。

なお、日本語版ではDSM-IV以降、「Mental Disorder（精神障害）」が「精神疾患」に訳し変えられたため、診断が確立されたかのような誤解が蔓延している。精神医学用語の「疾患」は本項の「障害 (disorder)」という概念であり、医学用語の「疾患 (disease)」とは異なる概念である。

障害概念

DSM-IVには、16個の障害 (Disorder) の概念が含まれている。

1. 通常、幼児期、小児期、または青年期に初めて診断される障害 (Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence)
2. せん妄、痴呆、健忘性障害、および他の認知障害 (Delirium, Dementia, and Amnestic and Other Cognitive Disorders)
3. 一般身体疾患による精神障害 (Mental Disorders Due to General Medical Condition)
4. 物質関連障害 (Substance-Related Disorders)
5. 統合失調症および他の精神病性障害 (Schizophrenia and Other Psychotic Disorders)
6. 気分障害 (Mood Disorders)
7. 不安障害 (Anxiety Disorders)
8. 身体表現性障害 (Somatoform Disorders)
9. 虚偽性障害 (Factitious Disorders)
10. 解離性障害 (Dissociative Disorders)
11. 性障害および性同一性障害 (Sexual and Gender Identity Disorders)
12. 摂食障害 (Eating Disorders)
13. 睡眠障害 (Sleep Disorders)
14. 他のどこにも分類されない衝動制御の障害 (Impulse-Control Disorders Not Elsewhere Classified)
15. 適応障害 (Adjustment Disorders)
16. パーソナリティ障害 (Personality Disorders)

多軸評定

DSM-III以来、多軸評定という手法を採用している。これは、下記の5つの軸によって障害を分析することで、障害を多面的に捉えるという狙いに基づいている。

第1軸

臨床的障害、ないしは臨床的関与の対象となりうる他の状態。パーソナリティ障害および知的障害を除く14個の障害概念がここに含まれる。

第2軸

パーソナリティ障害および精神遅滞。

第3軸

一般身体疾患 (General Medical Conditions)。DSM-IIIにおいては身体状態と呼ばれていた。

第4軸

心理社会的および環境上の問題。DSM-IIIにおいてはストレス強度と呼ばれていた。

第5軸

全体的機能評定 (GAF: Global Assessment of Functioning)。DSM-IIIにおいては社会適応水準と呼ばれていた。

問題点

あくまでも症状、あるいは患者との問診で診断が行われているため、例えば手引きを読んで症状を偽られる詐病との区別がつかないと言う意味では科学的な根拠は無いと批判が存在する。また、近年の目覚しい脳解析学や脳神経科学等の進展により、精神科医によるDSMを基準とした問診による診断が時代遅れになりつつあるとの主張も存在する。日米などで精神科医による精神鑑定結果や診断名が異なることは往々にしてあり、誤診や患者の詐病もあることなどから、日本においては精神科での診断を問診から脳科学的な客観的根拠を持たせるように切り替えようと各大学や研究機関で研究が始まっているただし脳解析学や脳神経科学等はいまだに初期の段階であり脳内の物理現象がどのように心理的現象として具現化するかは因果関係はいまだはっきりしていないことが多い。

DSM-IVには374の病名があるが、病名及びその病名の症状はアメリカ精神医学会の委員の挙手による多数決によって決められている、権威のある“曖昧なマニュアル”であるとの批判がある。アメリカの臨床精神医学教授のローレン・モシャーは「DSM-IVは、精神医学が概して医学によって認められるように模造して作ったものである。内部の者はそれが科学的というよりも政治的な書物であると知っています。DSM-IVはその最大の欠陥にもかかわらず権威ある書物となり、カネを生み出すベストセラーになった。」と述べるなど、アメリカ国内ではDSMを批判する声も多い。

DSMは、精神科医が患者と関わり受け止める力量を著しく低下させる危険性を持っている。アメリカではDSM-IIIが登場した1980年頃から、精神科を志望する医師が減少している。この事象は、DSMのマニュアル化された診断がかえって精神医学の面白みをなくしてしまったからだとする意見もある。

また近代精神分析学や近代精神医学が分類・診断を始めたことで、それまでは個性や属性の一つと捉えられていたものが、疾病や障害や症状とされ、治療の対象にされるようになるなど、人間の世界に新たな差別が持ち込まれることとなった。その点、血液型性格論と酷似している。また、書店に溢れる心理学や精神医学関係の類書が、一般の人に危うい読まれ方をされているのも事実である。素人が聞きかじりの知識で周囲の人を診断してしまうなど、差別や偏見を広めている面もあるからである。その一例が、M・スコット・ペックの『平気でうそをつく人たち～虚偽と邪悪の心理学～』（草思社 1996）である。雑誌『諸君』（文藝春秋 1997年8月号）で香山リカは『「平気でうそをつく人たち」の危ない読まれ方』と題して、その危険性を批判した。

DSMの日本語名

「Diagnostic and Statistical Manual of Mental Disorders」の訳語として「精神障害の診断と統計の手引き」があるが、定訳と呼べるものは無い。多くの場合、単に DSM と呼ばれる。

• DSM-III 精神障害の分類と診断の手引 (ISBN 978-4260116824)
• DSM-III-R 精神障害の診断・統計マニュアル (ISBN 978-4260117388)
• DSM-III-R 精神障害の分類と診断の手引 (ISBN 978-4260117333)
• DSM-IV 精神疾患の分類と診断の手引 (ISBN 978-4260117937)
• DSM-IV-TR 精神疾患の診断・統計マニュアル (ISBN 978-4260118637) (ISBN 978-4260118897)
• DSM-IV-TR 精神疾患の分類と診断の手引 (ISBN 978-4260118866)

脚注

出典

参考文献

• 南山堂医学大辞典CD-ROM プロメディカ，2007
• 高橋 三郎 (翻訳), 染矢 俊幸 (翻訳), 大野 裕 (翻訳) 『DSM‐IV‐TR 精神疾患の診断・統計マニュアル』 医学書院、2003年。ISBN 978-4260118897。
• 高橋 茂樹 (著), 岸本 年史 (監修) 『STEP精神科』 海馬書房、2002年。ISBN 978-4907704186。
• 野村 総一郎 『標準精神医学 第4版』 医学書院、2009年。ISBN 978-4260007078。

関連項目

• 精神障害
• ICD-10
• パーソナリティ障害
• 誤診

外部リンク

• DSM - アメリカ精神医学会
• プロフェッサーマサルの１ポイント講座 - DSMコードの一覧。
• 機能の全体的評定（GAF）尺度

wiki en

[Wiki en表示]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association provides a common language and standard criteria for the classification of mental disorders. The DSM is used in the United States and to various degrees around the world. The DSM is comparable to a dictionary; mental illness concepts and definitions change over time, just as words do. As data confirming hypotheses of mental illness is replicated, concepts and definitions of mental illness change. It is used or relied upon by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers. The current version, published on May 18, 2013, is the DSM-5 (fifth edition).

The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, although also removing those no longer considered to be mental disorders.

The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO), is another commonly used manual which includes criteria for mental disorders. This is in fact the official diagnostic system for mental disorders in the US, but is used more widely in Europe and other parts of the world. The coding system used in the DSM is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Critics, which include the National Institute of Mental Health, argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.

Uses and definition

Many mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.

DSM-5, and all previous editions, are registered trademarks owned by the American Psychiatric Association (APA).

The current version of the DSM characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress...or disability...or with a significant increased risk of suffering." It also notes that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions". It states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder" (APA, 1994 and 2000). There are attempts to adjust the wording for the upcoming DSM-V.

History

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category, "idiocy/insanity". Three years afterwards the American Statistical Association made an official protest to the U.S. House of Representatives stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation" and pointing out that in many towns African-Americans were all marked as insane, and the statistics were essentially useless.

The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844, changing its name in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association.

Edward Jarvis and later Francis Amasa Walker helped expand the census, from 2 volumes in 1870 to 25 volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume called "Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880)" (published 1888). Wines used seven categories of mental illness: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania and paresis. These categories were also adopted by the Association.

In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the Association developed a new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane". This included 22 diagnoses and would be revised several times by the American Psychiatric Association over the years. Along with the New York Academy of Medicine, the Association also provided the psychiatric nomenclature subsection of the US general medical guide, the Standard Classified Nomenclature of Disease, referred to as the "Standard".

DSM-I (1952)

World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the US Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces", and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of Medical 203.^{[citation needed]} In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature." An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system, and the Standard's Nomenclature to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic). In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was widely influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study that compared the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a hero to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.

DSM-II (1968)

In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was merely another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.

Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although they also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.

An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. They found that different practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".

Seventh printing of the DSM-II, 1974

As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled, "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."

This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.

Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".

DSM-III (1980)

In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued that "mental disorders are a subset of medical disorders" but the task force decided on the DSM statement: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." The personality disorders were placed on axis II along with mental retardation.

The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. A number of the unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some capacity; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".

Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. However, Robert Spitzer later criticized his own work on it in an interview with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:

Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator...

DSM-III-R (1987)

In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. "Sexual orientation disturbance" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which can include "persistent and marked distress about one’s sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated that for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" (p. xxiii).

DSM-IV (1994)

In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality disorder diagnoses were deleted or moved to the appendix.

DSM-IV-TR (2000)

A "text revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.

DSM-IV-TR

DSM-IV-TR, the predecessor to the most current DSM edition, the DSM-5

The term "psychosis" has many meanings, and the definitions that have been put forward are controversial. Even the DSM-IV-TR, says that "the term psychosis has historically received a number of definitions, none of which has achieved universal acceptance".

Categorization

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning," although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:

• Axis I: All diagnostic categories except mental retardation and personality disorder
• Axis II: Personality disorders and mental retardation
• Axis III: General medical condition; acute medical conditions and physical disorders
• Axis IV: Psychosocial and environmental factors contributing to the disorder
• Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

Cautions

The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion". The APA notes diagnostic labels are primarily for use as a "convenient shorthand" among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered "illnesses".

Sourcebooks

The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.

DSM-5

Main article: DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in twenty years, and the Roman numerals numbering system has been discontinued to allow for greater clarity in regard to revision numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of schizophrenia. During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.

Criticism

Reliability and validity concerns

The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability--the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability (accurate measurement) or validity (do these disorders really exist) was settled. However, most psychiatric education post DSM-III focused on issues of treatment--especially drug treatment--and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, has recently stated the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity.

Superficial symptoms

By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."

The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system.^{[citation needed]} Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.

Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."

Dividing lines

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias

Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.

Medicalization and financial conflicts of interest

It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".

However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients. William Glasser, however, refers to the DSM as "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the American Psychiatric Association.

Consumers and survivors

A consumer is a person who accesses psychiatric services and may have been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, while a survivor self-identifies as having survived psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some are relieved to find that they have a recognized condition to which they can give a name. Indeed, many people self-diagnose. Others, however, feel they have been given a "label" that invites social stigma and discrimination (i.e. mentalism), or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process. Some in the Psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.

DSM-5 critiques

Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 article, Frances warned that if this DSM version is issued unamended by the APA, it will "medicalize normality and result in a glut of unnecessary and harmful drug prescription." In a December 2, 2012 blog post in Psychology Today, Frances lists the ten "most potentially harmful changes" to DSM-5:

• Disruptive Mood Dysregulation Disorder, for temper tantrums
• Major Depressive Disorder, includes normal grief
• Minor Neurocognitive Disorder, for normal forgetting in old age
• Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
• Binge Eating Disorder, for excessive eating
• Autism change, classifying "introversion" as a form of autism
• First time drug users will be lumped in with addicts
• Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
• Generalized Anxiety Disorder, includes everyday worries
• Post-traumatic stress disorder, changes opening "the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."

Frances and others have published debates on what they see as the six most essential questions in psychiatric diagnosis:

• are they more like theoretical constructs or more like diseases
• how to reach an agreed definition
• whether the DSM-5 should take a cautious or conservative approach
• the role of practical rather than scientific considerations
• the issue of use by clinicians or researchers
• whether an entirely different diagnostic system is required.

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.

See also

• Relational disorder (proposed DSM-5 new diagnosis)
• Classification of mental disorders
• Chinese Classification and Diagnostic Criteria of Mental Disorders
• DSM-IV Codes
• Global Assessment of Functioning (GAF) Scale
• International Statistical Classification of Diseases and Related Health Problems (ICD)
• Psychodynamic Diagnostic Manual
• Structured Clinical Interview for DSM-IV (SCID)
• Diagnostic classification and rating scales used in psychiatry
• Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health
• Rosenhan experiment

References

External links

• Official DSM-5 development website
• Topic Center from the Psychiatric Times: DSM-5
• DSM-IV-TR Official Site - American Psychiatric Association
• Diagnostic Criteria from DSM-IV-TR
• The Multiaxial System of Diagnosis in DSM-IV Criteria
• American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Pub. ISBN 978-0-89042-025-6. 
• Robert L. Spitzer (2002). Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Pub. ISBN 978-1-58562-059-3. 
• DSM-IV-TR In Action Powerpoint slide handouts by G. Scott Sparrow

UpToDate Contents

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• 1. 成人における単極性うつ病：評価および診断 unipolar depression in adults assessment and diagnosis
• 2. アルコールおよびその他の薬物の有害な使用のスクリーニング screening for unhealthy use of alcohol and other drugs
• 3. 成人における精神病に対する臨床症状、鑑別診断および初期マネージメント clinical manifestations differential diagnosis and initial management of psychosis in adults
• 4. 認知障害および認知症の評価 evaluation of cognitive impairment and dementia
• 5. 自閉症スペクトラム障害：診断 autism spectrum disorder diagnosis

English Journal

• Symptom Profile and Etiology of Delirium in a Referral Population in Northern India: Factor Analysis of the DRS-R98.

• Mattoo SK, Grover S, Chakravarty K, Trzepacz PT, Meagher DJ, Gupta N.AbstractDelirium is understudied in developing countries, where there tends to be a lower proportion of older persons and comorbid dementia. The authors assessed 100 consecutive cases of DSM-IV delirium (patients' mean age: 44.4 [standard deviation: 19.4] years; mean DRS-R98 score: 25.6 [3.6]) referred to an adult Consultation-Liaison Psychiatry service in Northern India. Disturbances of attention, orientation, visuospatial ability, and sleep disturbance were the most frequent symptoms, followed by language, thought-process abnormality, and motor agitation. A three-factor solution was identified, representing domains for cognition, higher-order thinking, and circadian rhythm/psychosis. These domains can guide studies addressing the relationship between symptom profile, therapeutic needs, and outcomes and are consistent with core domains previously identified in other countries.
• The Journal of neuropsychiatry and clinical neurosciences.J Neuropsychiatry Clin Neurosci.2012 Dec 1;24(1):95-101.
• Delirium is understudied in developing countries, where there tends to be a lower proportion of older persons and comorbid dementia. The authors assessed 100 consecutive cases of DSM-IV delirium (patients' mean age: 44.4 [standard deviation: 19.4] years; mean DRS-R98 score: 25.6 [3.6]) referred to a
• PMID 22450619

• Effects of rumination on intrusive memories: Does processing mode matter?

• Santa Maria A, Reichert F, Hummel SB, Ehring T.SourceDepartment of Clinical Psychology, University of Amsterdam, Roetersstraat 15, 1018 WB Amsterdam, The Netherlands.
• Journal of behavior therapy and experimental psychiatry.J Behav Ther Exp Psychiatry.2012 Sep;43(3):901-9. Epub 2012 Feb 1.
• BACKGROUND AND OBJECTIVES: Excessive rumination following traumatic or highly distressing experiences has been proposed to be an important maintaining factor of posttraumatic stress symptoms. However, not all forms of repetitive thinking about a negative event appear to be dysfunctional. It has been
• PMID 22343035

Japanese Journal

• 難治性幻聴にブロナンセリンが有効だった「特定不能の精神病性障害(DSM-IV-TR)」の3症例 : 2つの薬理作用からの考察

• 深津 尚史,加藤 裕子,星野 有美 [他]
• 臨床精神医学 41(8), 1049-1054, 2012-08
• NAID 40019400872

• Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care

• Inoue Takeshi,Tanaka Teruaki,Nakagawa Shin,Nakato Yasuya,Kameyama Rie,Boku Shuken,Toda Hiroyuki,Kurita Tsugiko,Koyama Tsukasa
• BMC Psychiatry 12, 73, 2012-07-03
• … Methods: We compared operational characteristics of PHQ-9 as a screening and diagnostic instrument to DSM-IV-TR diagnosis by a trained psychiatrist as a reference standard. …
• NAID 120004710988

Related Links

• 精神障害の診断と統計の手引き - Wikipedia

本書には、「DSM-IVは、臨床的、教育的、研究的状況で使用されるよう作成された精神 障害の分類である。診断カテゴリー、基準、解説の記述は、診断に関する適切な臨床 研修と経験を持つ人によって使用されることを想定している。重要な事は、研修を受け てい ...

• DSM-IVとは - はてなキーワード - はてなダイアリー

「DSM-IV」とは - 「アメリカ精神医学会」で定義している精神疾患の分類と診断の マニュアルと基準。 The Diagnostic and Statistical Manual of Mental Disorders「 精神障害の分類と診断の手引き」(DSM)の第4版[1994...

Related Pictures

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★リンクテーブル★

リンク元	「神経症性障害」「精神障害の診断と統計マニュアル第4版」「Diagnostic and Statistical Manual of Mental Disorder」
拡張検索	「DSM-IV-TR」
関連記事	「D」「I」「DSM」「IV」「DS」

「神経症性障害」

　　[★]

英

neurotic disorder, neurotic disorders

分類

ICD-10

• F40 - F48 Neurotic, stress-related and somatoform disorders

• F40 Phobic anxiety disorders 恐怖症性不安障害
• F41 Other anxiety disorders 他の不安障害
• F42 Obsessive-compulsive disorder 強迫性障害
• F43 Reaction to severe stress, and adjustment disorders
• F44 Dissociative disorders 解離性障害, conversion disorders てんかん性障害
• F45 Somatoform disorders 身体表現性障害
• F48 Other neurotic disorders

比較

PSY.197

古典的分類	ICD-10		DSM-IV
恐怖症	恐怖症性不安障害		不安障害	広場恐怖症 パニック障害 社会恐怖
不安神経症	他の不安障害	パニック障害 全般性不安障害	不安障害	パニック発作 全般性不安障害
強迫神経症	強迫性障害		不安障害	強迫性障害
ヒステリー神経症	解離性障害, 転換性障害		解離性障害
			身体表現性障害	転換性障害
	身体表現性障害	身体化障害	身体表現性障害	身体化障害
心気神経症	身体表現性障害	心気障害 身体表現性自律神経機能不全 持続性身体表現性疼痛障害	身体表現性障害	転換性障害 心気症 疼痛性障害
離人神経症	他の神経症性障害	離人・現実感喪失症候群	解離性障害	離人症性障害

教科書的分類

• 不安障害
• 強迫性障害
• 解離性障害/転換性障害
• 身体表現性障害
• その他の神経症性障害

「精神障害の診断と統計マニュアル第4版」

　　[★]

英

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV

同

精神疾患の診断と分類の手引き

関

DSM-IV-TR

• DSM-IV? Multiaxial System ( Made easy )
• http://psyweb.com/Mdisord/DSM_IV/jsp/dsm_iv.jsp

「Diagnostic and Statistical Manual of Mental Disorder」

　　[★]

精神障害の診断と統計マニュアル

関

DSM、DSM-IV

「DSM-IV-TR」

　　[★]

関

DSM-IV

• http://allpsych.com/disorders/index.html

「D」

　　[★]

• アスパラギン酸
• ジヒドロウリジン
• 遠位の distal,
• うつ病 depression
• 下行結腸 descending colon(大腸内視鏡検査の結果を記載するときに用いる)

　 　

「I」

　　[★]

• イソロイシン isoleucine
• イノシン inosine
• 阻害剤 inhibitor
• iodine
• ヨード iodide
• I因子 factor I

　 　 　

「DSM」

　　[★]

• 精神障害の診断と統計マニュアル

関

Diagnostic and Statistical Manual of Mental Disorder

「IV」

　　[★]

• adj.

• 静脈内の

関

i.v.、intravascular、intravenous、intravenously

「DS」

　　[★] ダウン症候群 Down syndrome