تشخیص موقعیت هراس در زمینه اختلال هراسی: بررسی اثر معیارهای DSM-IV بر روی تشخیص تصمیم گیری

A diagnostic and statistical manual (DSM)-IV diagnosis of agoraphobia in the context of panic disorder (PD) is based on three nosologically sufficient criteria: (1) avoidance, (2) use of companions, and (3) endurance of situations despite distress. Therefore, an agoraphobia diagnosis can be made across an extremely broad range of cases including when there are no avoidance behaviors (e.g., the patient endures the situation). It was hypothesized that clinicians do not weight these criteria equally and that the DSMs individual, sufficient criteria lead to poor inter-rater reliability. Clinicians (N=48N=48) rated hypothetical patients with symptom profiles emphasizing each of these three criteria. Consistent with expectation, clinicians differentially weighted these criteria. Avoidance was relatively more apt to produce a diagnosis when only one criterion was emphasized in clinical vignettes. Inter-rater reliability was poor in instances when only one sufficient criterion was highlighted. Knowledge concerning DSM criteria resulted in a greater rate of agoraphobia endorsement, but knowledge did not account for the overall pattern of findings

The classification of agoraphobia within the diagnostic and statistical manual for mental disorders (DSM) has undergone significant changes over time and continues to be a controversial issue (Cerny, Himadi, & Barlow, 1984). In particular, the DSM has substantially changed its description of the relationship between panic disorder (PD) and agoraphobia. Marks (1970) originally suggested that agoraphobia was a phobic disorder arising from fears of public places that may or may not occur with panic attacks. Consistent with Marks’ (1970) contentions, the DSM-III (American Psychiatric Association (APA), 1980) classified agoraphobia as a phobic disorder that could occur with or without panic attacks whereas PD was considered to be a separate class of anxiety disorders called anxiety states or anxiety neuroses. Moreover, agoraphobia received primary consideration since PD could not be diagnosed if the patient met criteria for agoraphobia. Over time, as researchers increasingly recognized that agoraphobia is often a consequence of experiencing panic attacks, the DSM has reversed the relationship between these conditions such that in the DSM-III-R (American Psychiatric Association (APA), 1987) and DSM-IV (American Psychiatric Association (APA), 1994), agoraphobia is typically considered secondary to PD. In fact, in the DSM-IV, agoraphobia is only coded in the context of either PD or limited-symptom panic attacks (agoraphobia without history of PD). Thus, agoraphobic behaviors are now more commonly conceptualized as panic-related sequelae (Frances et al., 1993; Goldstein & Chambless, 1978). Technically, Agoraphobia without a History of PD can also be diagnosed in the context of concerns regarding incapacitation due to a medical condition or fear of embarrassment because of unpredictable medical symptoms. In this report, we are specifically dealing with making an agoraphobia diagnosis in the context of panic. In more recent iterations of the DSM, there has also been some modification of the diagnostic specification of agoraphobia. In the DSM-III-R (American Psychiatric Association (APA), 1987), an agoraphobia diagnosis is indicated when the person is so fearful of having a panic attack that they restrict travel (avoidance), need a companion to travel with them (use of companions), or endure agoraphobic situations despite intense anxiety (distress). Of note, according to the definition offered in the DSM-III-R, agoraphobia is not technically restricted to individuals exhibiting avoidance behavior; these individuals might be able to travel extensively but need a companion to do so, or they might even be able to travel alone while experiencing significant distress. The broad scope of these three sufficient criteria has been criticized as being overinclusive (Cox, Endler, & Swinson, 1995). However, the DSM-III-R provides some clarification about the assessment of agoraphobia in the form of a severity specifier highlighting avoidance behavior. In the specifier, patients are rated as mild, moderate, or severe (or in a state of remission). In each instance, avoidance is the central issue to be considered. For example, a mild specifier is given when there is some avoidance or endurance with distress, and when the patient is able to travel alone when necessary. The moderate specifier is given when avoidance results in significant lifestyle changes, such as being able to travel unaccompanied only a few miles from home. The severe specifier is indicated when the person is nearly housebound or can only leave the home if he or she is accompanied. In the DSM-IV (American Psychiatric Association (APA), 1994), the criteria for making an agoraphobia diagnosis in the context of PD are relatively unchanged with one important exception. In the DSM-IV, there are no longer severity specifiers for agoraphobia. The omission of the severity specifier is potentially important for diagnostic decision-making, since the level of avoidance behavior is no longer clearly highlighted for clinicians. It might be assumed that this omission is designed to encourage a reduced emphasis on avoidance relative to the other two sufficient diagnostic criteria (companions and distress). However, the DSM-IV (p. 782) does not provide a rationale for this change. Thus, clinicians must decide whether they should give equal weight to these three dimensions or, as was somewhat more clearly implied in the DSM-III-R (American Psychiatric Association (APA), 1987), give somewhat greater weight to avoidance. Of course, the diagnostic reliability of agoraphobia is also related to this discussion. Increased problems with inter-rater reliability are expected since the DSM-IV (American Psychiatric Association (APA), 1994) has removed some clinical guidance regarding this diagnosis. Reliability is likely to be less of an issue in cases where patients exhibit uniformly high or low levels of avoidance, distress, and the use of companions. However, it is unclear whether patients with more intermediate levels of impairment along these dimensions can be reliably diagnosed. Similarly, it is unclear whether reliability can be achieved for patients exhibiting symptoms that primarily emphasize only one of the three sufficient criteria. In the DSM-IV, agoraphobia diagnoses are likely to be affected by a variety of decision-making biases. Decision-making research suggests that clinicians often do not equally weight sufficient diagnostic criteria. Instead, clinicians appear to rely upon various rule-based approaches such as the use of prototypes (Rosch, 1978) or theories (Murphy & Medin, 1985) in categorization. For example, clinicians are less accurate when diagnosing atypical versus prototypic patients (Cantor, Smith, French, & Mezzich, 1980). Also, psychopathology theories that relate symptom features of a disorder will often lead to differential weighting of symptoms. Clinicians are more apt to diagnose a patient possessing more causally central versus peripheral symptoms (Kim & Ahn, 2002). This work would suggest that clinicians may be more likely to diagnose agoraphobia in the context of avoidance. In other words, clinicians are unlikely to think about agoraphobia in the same manner that the DSM-IV defines it. In addition, raters would be less reliable in diagnosing patients with less prototypic features (e.g., distress). The purpose of the present report was to evaluate the effects of DSM-IV (American Psychiatric Association (APA), 1994) diagnostic criteria for agoraphobia on clinical decision-making. It was hypothesized that clinicians would not give equal weight to each of the three sufficient criteria (avoidance, use of companions, and distress). Specifically, and in line with typical descriptions of agoraphobia, including the emphasis on avoidance in past iterations of the DSM, clinicians were expected to diverge from the DSM-IV equal emphasis of criteria and be more likely to endorse agoraphobia in the context of avoidance relative to the use of companions or distress. Our second main hypothesis was reliability would be poor for patients exhibiting less prototypic symptoms (e.g., distress) particularly in instances emphasizing as a single sufficient criterion.