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1 2013, Vol. 21, No. 11, Advances in Psychological Science DOI: /SP.J * 从 DSM-Ⅳ 躯体形式障碍到 DSM-5 躯体症状障碍 (, ) DSM-Ⅳ 是使用最广泛的精神障碍诊断标准之一, 但其中的躯体形式障碍诊断标准在临床实践中存在应用性低, 标准模糊, 分类重叠等问题因此 DSM-5 针对这些问题将其修改为躯体症状障碍, 删去医学无法解释症状的要求, 增加心理标准, 合并和简化亚型, 以改善该诊断标准的临床应用本文分析了 DSM-5 躯体症状障碍修订的主要内容和原因, 并讨论了新标准在未来面临的问题和可能的进展躯体形式障碍 ; 躯体症状障碍 ; DSM- Ⅳ; DSM-5; 精神障碍诊断 R395 1 引言 (somatoform disorder) (somatization), (hypochondriasis) (medical unexplained symptoms, MUS) 1980, (American Psychiatric Association, APA) (Diagnostic and Statistical Manual of Mental Disorders, DSM- Ⅲ),, DSM DSM-Ⅳ DSM-Ⅲ, (International : * 09BSH044 :, Classification of Diseases, ICD), (Chinese Classification of Mental Disorders CCMD) DSM-Ⅳ-TR (2000),, (conversion disorders) (body dysmorphic disorder), DSM-Ⅲ,,, DSM DSM ;,, DSM DSM-5( DSM- Ⅴ) (somatic symptom disorders) 2 DSM-Ⅳ 躯体形式障碍诊断标准的问题及缺陷 DSM-Ⅳ,,, 1967

文分析了 DSM-5 躯体症状障碍修订的主要内容和原因, 并讨论了新标准在未来面临的问题和可能的进展躯体形式障碍 ; 躯体症状障碍 ; DSM- Ⅳ; DSM-5; 精神障碍诊断 R395 1 引言 (somatoform disorder) (somatization),

2 DSM-5, (APA, 2011) 2.1 临床应用性较低 DSM-Ⅳ Creed Barsky (2004) 10, DSM-Ⅳ 0.03% 0.84%, 0.4% APA, DSM-Ⅳ APA 2000, 0.2% 2%, 0.2% (Koopman, Gill, & Kazdin, 2000), APA, (Baumeister & Härter, 2007), DSM-Ⅳ, ICD-10, (Simon & Gureje, 1999) DSM-Ⅳ, (undifferentiated somatoform disorder) (somatoform disorder NOS) (Kuwabara et al., 2007), 119, DSM-Ⅳ 1%, DSM-Ⅳ 79% (Lynch, McGrady, Nagel, & Zsembik, 1999) DSM-Ⅳ,, (Schulte & Petermann, 2011) DSM, DSM (Mangelli et al., 2009; Fink & Schröder, 2010), (Saxena, 2005; Creed, 2006) DSM-Ⅳ (Dimsdale, Patel, Xin, & Kleinman, 2007) DSM-Ⅳ,,,, 45%, 51%, 6%(Dimsdale, Sharma, & Sharpe, 2011),,,, ( ), (Rief & Isaac, 2007) 2.2 定义和标准过于模糊 DSM-Ⅳ, (Creed & Gureje, 2012)

NOS) (Kuwabara et al., 2007), 119, DSM-Ⅳ 1%, DSM-Ⅳ 79% (Lynch, McGrady, Nagel, & Zsembik, 1999) DSM-Ⅳ,, (Schulte & Petermann, 2011) DSM, DSM (Mangelli et al.

3 11 : DSM-Ⅳ DSM ,,,,,,, (Kandel, 1999) (Browning, Fletcher, & Sharpe, 2011), DSM-Ⅳ,, (APA, 2011),,, (Rief & Rojas, 2007),, (Kroenke, 2007) ( ) (Ghanizadeh, & Firoozabadi, 2012),, ( ) 3 (Härter et al., 2007),, 2.3 诊断分类重叠, (Hanel et al., 2009), ( ), (Rief & Isaac, 2007),,,,, 52%,, 38%, 2% ; (Dimsdale et al., 2011), 20% (Escobar et al., 1998), 5 (Fink et al., 2004),, ;

( ) 3 (Härter et al., 2007),, 2.3 诊断分类重叠, (Hanel et al.

4 ,,,, DSM-Ⅳ (),, (Mayou, Kirmayer, Simon, Kroenke, & Sharpe, 2005) 3 DSM-5 躯体症状障碍诊断标准的修订 DSM-Ⅳ, DSM DSM DSM-5,, 3.1 不再依赖医学无法解释症状 DSM-5, DSM-Ⅳ, ;,,,, DSM-Ⅳ,,,,,,,,,, 3.2 相关的心理症状标准, (Martin, 2011; Jensen, Haahr, Frost, & Andersen, 2012) B (psychosocial),, DSM-5,,

5 11 : DSM-Ⅳ DSM ,,,,, (Rief, Mewes, Martin, Glaesmer, & Braehler, 2010; Martin & Rief, 2011),, (Martin, 2011), B,,, (Martin & Rief, 2011), DSM-5 (), DSM-5 DSM-Ⅳ, DSM-Ⅳ, DSM-5, B (Voigt et al., 2012; Wollburg, Voigt, Braukhaus, Herzog, & Löwe, 2013), 3.3 亚型分类的合并和简化 DSM-Ⅳ,, (Rosmalen, Tak, & de Jonge, 2011),, DSM-5 (APA, 2011) (complex somatic symptom disorder) (simple somatic symptom disorder) DSM-Ⅳ,, (APA, 2012),, DSM-Ⅳ 30,, (APA, 2000) 6, (APA, 2012) (illness anxiety disorder), (Obsessive-compulsive disorder Spectrum), DSM-5

3 亚型分类的合并和简化 DSM-Ⅳ,, (Rosmalen, Tak, & de Jonge, 2011),, DSM-5 (APA, 2011) (complex somatic symptom disorder) (simple somatic

6 DSM-Ⅳ,, (Stone et al., 2005), 3.4 新修订引发的争议 DSM-5, APA, DSM-5, (Frances, 2013) DSM-5,,,,,, 15%, 26%, 7% (Frances, 2013) DSM-5,,,,, (Dimsdale, 2011),,, DSM-5 4 展望 DSM-Ⅳ, DSM-5,, DSM-Ⅳ,,, DSM-Ⅳ DSM-5 (Dohrenwend & Skillings, 2009),, (cognitive-behavioral therapy, CBT) (Kroenke, 2007; Sumathipala, 2007),, (Allen, Escobar, Lehrer, Gara, & Woolfolk, 2002),,,,,,,, DSM

DSM-5,,,,, (Dimsdale, 2011),,, DSM-5 4 展望 DSM-Ⅳ, DSM-5,, DSM-Ⅳ,,, DSM-Ⅳ DSM-5 (Dohrenwend &

7 11 : DSM-Ⅳ DSM (Browning et al., 2011),,, DSM-5, DSM, ICD,,,,, (Mayou et al., 2005) CCMD DSM ICD (,, 2011),, (,, 2009;, 2011;,, 2012) DSM-5,,,, 李凌江, 周建松. (2009). ICD-10 神经症应激相关障碍及躯体形式障碍诊断标准在中国的应用情况与修改建议. 中国心理卫生杂志, 23(7), 王祖承, 廉彤. (2011). DSM-5 的诊断改变是否合理? 上海精神医学, 23(2), 128. 许又新. (2011). 躯体化障碍的诊断和性质. 中国心理卫生杂志, 25(7), 甄龙, 徐改玲. (2012). 躯体形式障碍就诊识别的现状和思考. 国际精神病学杂志, (3), Allen, L. A., Escobar, J. I., Lehrer, P. M., Gara, M. A., & Woolfolk, R. L. (2002). Psychosocial treatments for multiple unexplained physical symptoms: A review of the literature. Psychosomatic Medicine, 64, American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Text Revision: DSM-IV-TR (4th ed., pp ). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2011). Justification of criteria-somatic symptoms. Retrieved April 28, 2011, from mptom%20disorders%20description%20april%2018,% pdf American Psychiatric Association. (2012). DSM-5 Draft criteria: J00 somatic symptom disorder. Retrieved April 28, 2012, from proposedrevision.aspx?rid=368 Baumeister, H., & Härter, M. (2007). Prevalence of mental disorders based on general population surveys. Social Psychiatry and Psychiatric Epidemiology, 42(7), Browning, M., Fletcher, P., & Sharpe, M. (2011). Can neuroimaging help us to understand and classify somatoform disorders? A systematic and critical review. Psychosomatic Medicine, 73(2), Creed, F., & Barsky, A. (2004). A systematic review of the epidemiology of somatisation disorder and hypochondriasis. Journal of Psychosomatic Research, 56, Creed, F. (2006). Should general psychiatry ignore somatization and hypochondriasis? World Psychiatry, 5(3), Creed, F., & Gureje, O. (2012). Emerging themes in the revision of the classification of somatoform disorders. International Review of Psychiatry, 24(6), Dimsdale, J. E., Patel, V., Xin, Y., & Kleinman, A. (2007). Somatic presentations-a challenge for DSM-5. Psychosomatic Medicine, 69, 829. Dimsdale, J. E. (2011). Medically unexplained symptoms: A treacherous foundation for somatoform disorders? Psychiatric Clinics of North America, 34, Dimsdale, J., Sharma, N., & Sharpe, M. (2011). What do physicians think of somatoform disorders? Psychosomatics, 52, Dohrenwend, A., & Skillings, J. L. (2009). Diagnosisspecific management of somatoform disorders: Moving beyond vague complaints of pain. The Journal of Pain, 10(11), Escobar, J. I., Gara, M., Silver, R. C., Waitzkin, H., Holman,

中国心理卫生杂志, 25(7), 494 495. 甄龙, 徐改玲. (2012). 躯体形式障碍就诊识别的现状和思考. 国际精神病学杂志, (3), 182 185. Allen, L. A., Escobar, J. I., Lehrer, P. M., Gara, M. A., & Woolfolk, R. L. (2002).

8 A., & Compton, W. (1998). Somatization disorder in primary care. British Journal of Psychiatry, 173, Fink, P., Ørnbøl, E., Toft, T., Sparle, K. C., Frostholm, L., & Olesen, F. (2004). A new, empirically established hypochondriasis diagnosis. American Journal of Psychiatry, 161(9), Fink, P., & Schröder, A. (2010). One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. Journal of Psychosomatic Research, 68(5), Frances, A. (2013). The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ: British Medical Journal, 346, f1580. Ghanizadeh, A., & Firoozabadi, A. (2012). A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatria Danubina, 24(4), Hanel, G., Henningsen, P., Herzog, W., Sauer, N., Schaefert, R., Szecsenyi, J., & Löwe, B. (2009). Depression, anxiety, and somatoform disorders: Vague or distinct categories in primary care? Results from a large cross-sectional study. Journal of Psychosomatic Research, 67(3), Härter, M., Baumeister, H., Reuter, K., Jacobi, F., Höfler, M., Bengel, J., & Wittchen, H.-U. (2007). Increased 12-month prevalence rates of mental disorders in patients with chronic somatic diseases. Psychotherapy and Psychosomatics, 76(6), Jensen, J. C., Haahr, J. P., Frost, P., & Andersen, J. H. (2012). The significance of health anxiety and somatization in care-seeking for back and upper extremity pain. Family Practice, 29, Kandel, E. R. (1999). Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited. American Journal of Psychiatry, 156, Koopman, C., Gill, M., & Kazdin, A. E. (2000). Encyclopedia of Psychology (Vol. 7, ). Washington, DC, US: American Psychological Association; New York, NY, US: Oxford University Press. Kroenke, K. (2007). Efficacy of treatment for somatoform disorders: A review of randomized controlled trials. Psychosomatic Medicine, 69, Kuwabara, H., Otsuka, M., Shindo, M., Ono, S., Shioiri, T., & Someya, T. (2007). Diagnostic classification and demographic features in 283 patients with somatoform disorder. Psychiatry and Clinical Neurosciences, 61(3), Lynch, D. J., McGrady, A., Nagel, R. M. A., & Zsembik, R. R. N. (1999). Somatization in family practice: Comparing 5 methods of classification. Primary Care Companion to the Journal of Clinical Psychiatry, 1, Mangelli, L., Bravi, A., Fava, G. A., Ottolini, F., Porcelli, P., Rafanelli, C., & Sonino, N. (2009). Assessing somatization with various diagnostic criteria. Psychosomatics, 50(1), Martin, A. (2011). Does a somatic causal attribution style qualify for a diagnostic criterion in somatoform disorders? Journal of Psychosomatic Research, 70, Martin, A., & Rief, W. (2011). Relevance of cognitive and behavioral factors in medically unexplained syndromes and somatoform disorders. The Psychiatric Clinics of North America, 34, Mayou, R., Kirmayer, L. J., Simon, G., Kroenke, K., & Sharpe, M. (2005). Somatoform disorders: Time for a new approach in DSM-V. American Journal of Psychiatry, 162, Rief, W., & Isaac, M. (2007). Are somatoform disorders 'mental disorders'? A contribution to the current debate. Current Opinion in Psychiatry, 20, Rief, W., & Rojas, G. (2007). Stability of somatoform symptoms--implications for classification. Psychosomatic Medicine, 69, Rief, W., Mewes, R., Martin, A., Glaesmer, H., & Braehler, E. (2010). Are psychological features useful in classifying patients with somatic symptoms? Psychosomatic Medicine, 72, Rosmalen, J. G. M., Tak, L. M., & de Jonge, P. (2011). Empirical foundations for the diagnosis of somatization: Implications for DSM-5. Psychological Medicine, 41(6), Saxena, S. (2005). Somatization and conversion disorders: A forgotten public health agenda? In M. Maj, H. S. Akiskal, J. E. Mezzich, & A. Okasha (Eds.), Somatoform disorders (Vol. 9, pp ). Chichester: Wiley. Schulte, I. E., & Petermann, F. (2011). Somatoform disorders: 30 years of debate about criteria!: What about children and adolescents? Journal of Psychosomatic Research, 70(3), Simon, G. E., & Gureje, O. (1999). Stability of somatization disorder and somatization symptoms among primary care patients. Archives of General Psychiatry, 56(1), Stone, J., Smyth, R., Carson, A., Lewis, S., Prescott, R., Warlow, C., & Sharpe, M. (2005). Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ: British Medical Journal, 331, 989. Sumathipala, A. (2007). What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosomatic Medicine, 69, Voigt, K., Wollburg, E., Weinmann, N., Herzog, A., Meyer, B., Langs, G., &Löwe, B. (2012). Predictive validity and

One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders.

9 11 : DSM-Ⅳ DSM clinical utility of DSM-5 Somatic Symptom Disorder- Comparison with DSM-IV somatoform disorders and additional criteria for consideration. Journal of Psychosomatic Research, 73(5), Wollburg, E., Voigt, K., Braukhaus, C., Herzog, A., & Löwe, B. (2013). Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5. Journal of Psychosomatic Research, 74, From DSM-Ⅳ Somatoform Disorder to DSM-5 Somatic Symptom Disorder CHEN Zichen; WANG Xinjian (Department of Social Psychology, Nankai University, Tianjin , China) Abstract: DSM- Ⅳ is one of the most widely used diagnostic criteria for the assessment of mental illness. However, in clinical practice, the DSM-Ⅳcriteria of somatoform disorders have several problems, which include poor applicability, imprecise standard, and overlapping classification. These aspects have been improved in the newer version of DSM, the DSM-5. The equivalent subcategory has been renamed as somatic symptom disorders in the DSM-5 criteria, with the language concerning medically unexplained symptoms removed, psychological criteria included, and subtypes combined or simplified. In this article, we analyze the major changes of DSM-5 somatic symptom disorders criteria. We also discussed a few potential problems with the new criteria and the possibilities to further develop the diagnosis criteria. Key words: somatoform disorder; somatic symptom disorders; DSM- Ⅳ; DSM-5; diagnosis of mental disorders

Construct validity and descriptive validity of somatoform disorders in light of proposed changes for the DSM-5. Journal of Psychosomatic Research, 74, 18 24.

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