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정신과 진단체계에 대한 역사적 고찰 : 우울증 개념을 중심으로

A Historical Consideration of Psychiatric Diagnostic Systems : Focusing on the Concept of Depression

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키워드

주제분류정신과학

초록

우울증(depression)과 관련된 질병분류학(nosology)은 시대가 지나면서 많은 변화를 겪어 오늘날에 이르렀다. 우울증은 정신과에서 매우 흔히 보는 질환이어서 정신의학 전공자면 누구나 잘 알고 있는 것 같지만, 우울증이라는 용어는 정신의학의 맥락과 관계없이 일상 언어로도 흔히 사용될 만큼의미가 불분명하고 그 임상양상은 한 마디로 정의하기 어려울 정도로 다양하다. 증상의 종류, 심한 정도 및 경과, 유발요인, 유전성, 병발하는 증상들, 치료 반응 등에서 다양한 우울증들은 큰 차이가 있지만, 현재의 분류체계는 이런 다양성을 반영하지 못하고 있다. 다양성을 구분하지 않는 것은 질병분류라는 이론적 측면을 떠나서 개별 환자별 맞춤 치료계획을 수립하는 데에도 문제가 된다.1,2) 우리가 현재 우울증이라고 부르는 큰 카테고리 안에는 고전적 개념 중 (1) 멜랑콜리아, (2) 조울증, (3) 단극성 우울증, (4) 우울신경증, (5) 우울성(정동성) 인격 등이 모두 포함되어 있다. 본고에서는 이들을 포괄하는 우울증에 대한 다양한 개념의 역사를 살펴보려한다. 주 초점은 우울증을 독립적인 몇 가지의 증후군으로 나누어보려 했던 과거의 입장과, 차원적 관점에서 다양성을 통합하려는 오늘날의 추세를 비교하는 것이다. 우울증의 역사를 탐색하다 보면 조증의 역사에 대해서도 공부하지 않을 수없지만, 조증에 대한 논의는 꼭 필요한 부분에만 국한할 것이다. 또한 이 논문의 논의에 대한 보조 자료로서 DSM 및 InternalClassification of Diseases(이하 ICD) 시스템에서 우울증 분류 변천과정을 별첨하였다.

Abstract

Today’s diagnostic criteria are based on consensus, however, they are still incomplete and being changed. These unstable but temporarily dogmatic criteria have been constraining the thinking of individual psychiatrists, and invalidating painful scientific achievements based on previous ones. The limitation of the criteria system appears especially clear concerning depression due to the ambiguity of its definition. Therefore, the aim of this article was to review the history of various concepts of depression and to compare this to today’s tendency, which attempts to consolidate diversity. In addition to all Diagnostic and Statistical Manual (DSM), Internal Classification of Diseases (ICD)-9, ICD-9-CM, and ICD-10 were centrally discussed. Classic descriptions of depression were extracted from reviews of classic literature, and some salient concepts and the process by which they had been integrated, divided, and newly proposed was traced. The descriptions of depression whose prototype had been melancholia have experienced significant conceptual changes through DSM-IV and the most recent DSM-V ; they impose tasks that are yet to be resolved. Among them, whether various depressive syndromes are diverse phenotypes of one disorder or they all represent different disorders could be regarded as the most fundamental problem. In order to conduct fruitful studies and to ensure proper treatment of every patient, more precise nosologic understanding of depression must be pursued.

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