物質相關障礙症：DSM-5診斷的改變與挑戰

The DSM-5 Changes and Challenges in Diagnosing Substance-related Disorders

DSM-5 於2013 年五月出版，除了整合科學方面的進展外，也希望透過更簡潔與方便使 用的模式來增加臨床的實用性。本文回顧從DSM-IV 到DSM-5，物質相關障礙症的診斷準則 改變，同時提出隨著這些改變可能會面臨的挑戰與難題。物質相關障礙症的主要準則變化包 括：(A) 章節名稱改變；(B) 物質重新分類；(C) 將物質依賴與物質濫用合併為物質使用障礙 症；(D) 移除物質使用障礙症診斷準則其中的法律問題；(E) 病程描述的修訂；(F) 物質引起 的障礙症的類別更動，例如將物質引起的情緒障礙症區分為雙向情緒障礙症和憂鬱症，以及 將物質引起的強迫及相關障礙症從焦慮症中獨立出來；(G) 各類物質相關障礙症的部分添增 或移除；(H) 新增加非物質相關障礙症；(I) 將仍未列入正式診斷，未來有待進一步研究的其 他物質相關及成癮障礙症加入於特殊章節中。雖然 DSM-5 有所改善，但針對物質相關及成 癮障礙症仍可能會面臨許多問題。首先，如何定義成癮行為仍無一致結論，其次，針對物質 使用障礙症的新準則－－渴求 (craving)，目前仍有許多爭議，再者，多種物質的使用仍是臨床 上一大問題。本文也回顧對於 DSM-5 的物質相關及成癮障礙症，ICD-9-CM 到ICD-10-CM 的 編碼方式的演變，同時提出 DSM-5 和 ICD-10-CM 不一致之處，以供臨床實用之便。

The DSM-5 that was released in May 2013, has incorporated scientifi c advances, and enhanced clinical utility with more concise, as well as been amenable in primary care. In this overview, the authors review the new classifi cation structure and changes in diagnosing substance related disorders from the DSM-IV to the DSM-5, and point out the new challenge with the new criteria. The major changes of the DSM-5 include (A) renaming the title of chapter; (B) substance reclassifi cation; (C) eliminating the terms of dependence and abuse, and merge the criteria of substance dependence and abuse together; (D) removing legal problem and adding craving in substance use disorder criteria; (E) course specifi er modifi cation; (F) modifying substance-specifi c disorders, such as separate substance-induced mood disorder into bipolar and depressive disorder, and separating substance-induced obsessive-compulsive disorders from anxiety disorders; (G) newly adding or removing each class diagnosis of substance related disorders; (H) adding non-substance- related disorders; and (I) adding other substance-related and addictive disorder for further study. Although the DSM-5 solves the problems of the DSM-IV, there are several challenges in diagnosing substance-related and addictive disorder: First, what behaviors could be considered as an addiction is still an ongoing debate. Second, there are some controversies on the new criterion “craving.” Third, the polysubstance is still an important issue to be discussed. In addition, this overview also covers the changes from the ICD-9-CM to the ICD-10-CM codes related to the substance-related disorder of the DSM-5, but present some discrepancies between the DSM-5 and the ICD-10-CM for more clinical conveniences and utility.