经济学人281:照本宣科

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　　科学技术

　　By the book

　　照本宣科

　　The American Psychiatric Association's latest diagnostic manual remains¹ a flawed attempt to categorise mental illness

　　美国精神医学会最新诊断手册在精神疾病分类上仍有欠缺

　　A BOOK with the title Diagnostic and Statistical² Manual of Mental Disorders⁴, Fifth Edition does not sound destined⁵ to be a bestseller, particularly at $199 a pop.

　　《精神疾病诊断与统计手册，第五版》这个书名听上去注定成不了畅销书，尤其一本竟要199美元。

　　But DSM-5, as it is known for short, is almost certain to become one.

　　但是DSM-5（书名的简称）几乎肯定会成为一本畅销书。

　　Its predecessor⁶, DSM-IV, which was published in 1994, has sold more than 1m copies. DSM-5, which will go on sale on May 22nd, is likely to do at least as well.

　　其上一版，1994年出版的DSM-4已售出超过一百万册。DSM-5将于5月22日开售，很可能至少也会卖到这个数。

　　The reason is that the DSM series, which is published by the American Psychiatric Association, has become the global standard for the description of mental illness.

　　美国精神医学会出版的DSM丛书如此大卖的原因是其已经成为精神疾病症状描述的全球标准。

　　Indeed, the DSM is treated by many people less as a medical handbook and more as holy writ⁷.

　　实际上，许多人把DSM更多是当成圣经，而非一本医学手册。

　　Insurers use it to decide whether or not to cover ailments⁸.

　　保险公司用其来确定是否涵盖一些病症。

　　And diagnoses based on it determine whether people get special services at school; whether they qualify for disability benefits; whether they are stigmatised in their careers; even whether they are able to adopt children.

　　据其做出的诊断会决定一个人是否会在学校受到特殊照顾；是否能得到伤残抚恤金；是否会在自己的职业生涯中蒙受污名；甚至是否能够领养小孩。

　　Doctors, patients, drug companies and insurers have all thus been waiting for the latest edition of what has become known as the psychiatric bible.

　　因此医生，患者，制药公司及保险公司都在翘首期盼这本被当作精神病学圣经的最新版。

　　The DSM's purpose is to set strict criteria⁹ for identifying mental disorders.

　　DSM的目的是设立鉴别精神疾病的严格标准。

　　This is supposed to make diagnoses more reliable: a laudable aim.

　　这应该会使诊断更为可靠，这一个值得称道的目标。

　　To that end, more than 1,500 experts have spent over a decade labouring.

　　为了这个目标，1500多名专家耗费了多年劳动。

　　In doing so, though, they have succeeded in adding to, rather than subtracting from, criticism that the DSM has become a monster.

　　然而这些辛劳让他们顺利地在DSM中增加了标准，而非减少，这使DSM成为了一个庞然大物。

　　In the eyes of many critics it is a vehicle for misdiagnosis, overdiagnosis, the medicalisation of normal behaviour and the prescription¹¹ of a large number of unnecessary drugs.

　　在许多批评家眼中，DSM是误诊，过度诊断，正常行为医疗化以及开出大量不必要药物处方的罪魁祸首。

　　Chapter and verse

　　引经据典

　　The DSM, the first version of which was published in 1952, has always attracted controversy¹².

　　DSM自1952年第一版出版起便一直引发争论。

　　That version, and the second edition, published in 1968, relied on the premise¹³ that mental illness was a neurotic¹⁴ response to a patient's experience and environment.

　　第一版及1968年出版的第二版有赖于精神疾病是对病人的经历及环境的神经质反应这一前提。

　　People with the same symptoms could therefore receive wildly different diagnoses.

　　然而具有相同症状的人会受到截然不同的诊断。

　　Different interpretations¹⁵ of experience and environment also meant that cultural differences affected¹⁶ diagnosis¹⁰.

　　经历及环境的不同解读也意味着文化差异会影响诊断。

　　In 1971 Robert Kendell demonstrated this by showing that, faced with the same patients, American psychiatrists¹⁷ were much more likely to diagnose them as schizophrenic than were British psychiatrists.

　　罗伯特·肯德尔于1971年证明了这点，他指出，面对同一个病人，美国的精神病医生比英国精神病医生更可能将其诊断为精神分裂患者。

　　The third DSM, published in 1980, introduced a new approach—also followed in the fourth in 1994.

　　DSM第三版于1980年出版，引入了一种新的方法，1994年出版的第四版也遵循了该方法。

　　DSM-III acknowledged that psychiatrists had a poor understanding of the physiological¹⁸ cause of mental illness.

　　DSM第三版承认精神病医生对于精神疾病的生理病因不甚了了。

　　Instead specific, observed symptoms became the diagnostic criteria, and clusters of them, known medically as syndromes²⁰, that appeared to coexist in individual patients were given labels.

　　观察到的症状而非具体病因被当成诊断标准，貌似存在于同一患者的症状集群-医学上称之为综合症-被冠以名称。

　　The hope was that biological markers of such syndromes would be discovered as physiological understanding increased.

　　希望是在于这些综合症的生物学标记会随着生理学知识的增加而得以发现。

　　This was a reasonable approach in principle.

　　这在原则上是一个合理的方法。

　　In practice, though, the lines dividing different disorders are blurry²¹.

　　但实际上，划分不同精神疾病的界限模糊不清。

　　The symptoms used to define them often do not cluster neatly²² in the way that those of true syndromes would, and the statistical evidence for their existence is sometimes sparse²³.

　　用来定义精神疾病的症状与综合症真正的症状时常并非一一对应，这些症状存在的统计证据有时也很匮乏。

　　Nor, in most cases, have the hoped-for biological markers turned up—and to the extent that they have, they have muddied the waters, rather than clarifying them.

　　在大多数情况下，期望的生物学标记并未被发现，从某种程度而言，已发现的生物学标记把水越搅越浑，而不是越搅越清。

　　The biggest muddyings have come from brain scanning and genetics.

　　最大的一趟浑水来自于脑部扫描术及遗传学。

　　Most psychiatrists, even those sceptical of the DSM's approach, would accept the idea that things like autism, major depression and schizophrenia are different from each other.

　　大多数精神病医生，甚至是那些对DSM的方法持怀疑态度的医生也会接受如自闭症、重度抑郁症及精神分裂症这些疾病互不相同这一概念。

　　However, a study published this year by a group called the Psychiatric Genomics Consortium, which has looked for links between genetic²⁴ variations and psychiatric disorders in tens of thousands of patients, has found that variations in four places were common to people diagnosed, using the DSM's criteria, with attention deficit²⁵ hyperactivity disorder³, autism, bipolar disorder, major depression and schizophrenia.

　　然而有一家叫做精神疾病基因体联盟的团体于今年发表了一份研究报告，在数以万计的患者中寻找了基因变异及精神疾病的联系，发现在按照DSM的标准确诊的患有注意力不足过动症、自闭症、躁郁症、重度抑郁症及精神分裂症的人中有四处变异很普遍。

　　Likewise, a series of papers over the past decade have shown similar abnormal activation²⁶ of part of the brain called the amygdala in people diagnosed with anxiety, major depression and post-traumatic stress disorder.

　　同样，过去十年中的一系列论文证实了确诊患有焦虑症，重度抑郁症及创伤后应激障碍的人的大脑中叫做杏仁核的部分有类似的异常活化。

　　Such results suggest that the DSM's approach of placing patients in diagnostic silos is questionable²⁷.

　　这样的结果表明DSM将患者按诊断症状分类的方法值得商榷。

　　As Dan Blazer of Duke University, who served on DSM-5's task-force, puts it, We're basically drawing artificial lines, and the body and the mind do not work like that.

　　正如DSM第五版的编写组成员，杜克大学的丹?布雷泽所说，我们正从大体上勾勒人为的分类界线，身体和精神都不会如此运作。

　　The new DSM aspires²⁸ to include objective criteria in its manual.It also seeks to scrap²⁹ nonsensical, strict lines between certain disorders.

　　新版的DSM渴望将客观标准也囊括在其手册中，也寻求将某些病症中荒谬的，严苛的条文去掉。

　　It has, for example, chunked together four previously³⁰ separate diagnoses, including autism and Asperger's syndrome¹⁹, into one disorder of varying severity, known as autism spectrum³¹ disorder.

　　例如，新版中将之前四种单独的病症，包括自闭症及阿斯伯格综合症合并成一种严重程度不一的神经疾病，叫做自闭症谱系障碍。

　　In this, it is following clinical practice, for the idea of an autistic spectrum has been around for a long time.

　　由于自闭症谱系的概念已经出现很久了，所以对该病症的诊断是遵循临床实践。

　　And the unfortunate truth is that it is still far too early to use biological markers as criteria for diagnosis.

　　但事实令人遗憾，使用生物学标记作为诊断标准仍然太早。

　　The human brain is the most impossibly complex thing in the universe, says Allen Frances, who led the development of DSM-IV.

　　人脑是宇宙中复杂到无可附加的事物，DSM第四版的编写组组长阿伦?弗朗西斯称，

　　It does not yield its secrets easily.

　　它不会轻易把自己的秘密交出来。

　　Worse, argues Dr Frances, DSM-5 has not stopped the rise in the number of allegedly recognisable and nameable mental conditions, many of which annex³² into psychiatry³³ things that the man in the street would think normal, if not always desirable, behaviour.

　　更糟的是，弗朗西斯博士提出，DSM第五版中所谓可以识别及命名的精神状况的数量还在增加，许多连路人都会认为属于正常，但不一定适当的行为被归为精神疾病。

　　Children may now, for example, be diagnosed with disruptive mood dysregulation disorder—what used to be known as temper tantrums.

　　例如，儿童现在可能会被诊断患有破坏性情绪失调症-曾被称为乱发脾气。

　　Past versions of the DSM stipulated³⁴ that those mourning a death should not be classified as depressed³⁵. DSM-5 scraps³⁶ this bereavement³⁷ exclusion³⁸.

　　之前版本的DSM规定那些哀痛逝者的行为不应该归为抑郁，但DSM第五版删掉了排除丧亲之痛这条。

　　It also includes a new binge-eating disorder, defined as eating to excess at least once a week over the previous three months.

　　第五版还加入了一种新的暴食症，将其定义为在过去三个月内至少每星期饮食过量一次。

　　Such a diagnosis covers millions of Americans, roping in people who would not remotely consider that they were mentally ill.

　　按此诊断的话会将数百万美国人涵盖其内，将那些从未想过自己患有精神病的人圈了进去。

　　DSM-5 does not, after some debate among those who put it together, make addiction³⁹ to internet gaming a formal disorder. But it recommends further research into the condition.

　　在经过其编写者的一些争论后，DSM第五版并未将网游成瘾归为正式的精神疾病，但其建议针对病情进一步研究。

　　Grief. Indulgence. Unhealthy habits.

　　悲痛、上瘾、不良习惯，

　　All, it seems, may be classified as mental derangement⁴⁰, and treated as such.

　　所有这些看来都会被归为精神错乱，并按此治疗。

　　And the sets of symptoms described by the DSM are often common.

　　DSM中描述的各类症状都非常常见。

　　More than one American child in ten has been diagnosed, using the DSM's definition, with ADHD—and about two-thirds of those so diagnosed are now prescribed drugs.

　　按照DSM的定义，每十名美国儿童中便至少会有一名被诊断患有ADHD-这些所谓患儿中有三分之二正在接受药物治疗。

　　It is this overdiagnosis and overtreatment that is the chief criticism of the DSM—or, rather, of the power it wields⁴¹ in the profession of psychiatry. That power, however, may be waning⁴².

　　这种过度诊断及过度治疗正是针对DSM的主要诟病-或者，更确切的讲，是针对DSM赋予精神病医生职业的权力的诟病。然而这种权力或许正在减弱。

　　Literary criticism

　　专业评论

　　DSM categories have long been used in research.

　　DSM的分类已经用于研究很久了。

　　That is changing.

　　但情况正在改变。

　　Other areas of medicine, cancer in particular, have been transformed by better understanding of the biological drivers of disease.

　　其它的医学领域，特别是癌症领域，已经通过对疾病的生物学驱动机制的更深入了解而发生了转变。

　　America's National Institute of Mental Health hopes that will transform psychiatry, too.

　　美国国家心理卫生研究所希望这也将使精神病学发生改变。

　　The NIMH seeks to use genetics, imaging and cognitive⁴³ science to create new diagnostic criteria.

　　NIMH寻求使用遗传学，成像及认知科学来建立新的诊断标准。

　　Thomas Insel, the NIMH's director, has specifically implored⁴⁴ researchers not to be confined by DSM-5's strict rules.

　　NIMH的主任托马斯·英索尔特别恳请研究人员不要被DSM第五版严苛的条文限制住。

　　Abiding⁴⁵ by DSM categories may prevent scientists from understanding the underlying⁴⁶ causes of sickness.

　　墨守DSM的分类可能会妨碍科学家了解疾病的根本原因。

　　Still, objective laboratory measures for mental illness are a long way off.

　　距离对精神疾病进行客观的实验室评估仍旧很远。

　　The APA says DSM-5 will be continuously updated to respond to new discoveries.

　　APA称DSM第五版将会不断更新以对新的发现做出反应。

　　For now, however, patients' treatment will be guided by the imperfect manual.

　　然而目前对病人的诊疗还要接受并不完美的手册指导。

　　The DSM is purely⁴⁷ a product of the state of our knowledge at this point in time, says Jeffrey Lieberman, the chairman of Columbia University's psychiatry department and president-elect of the APA.

　　DSM仅仅是我们在此时此刻的知识水平下的产物，哥伦比亚大学精神医学系主任，APA新当选的会长杰弗里·利伯曼说。

　　The state of our knowledge is not complete.

　　我们的知识水平还比较有限。

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