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【medical-news】精神医学界内战爆发
Updated 18:18 11 December 2009 by Peter Aldhous
Editorial: Psychiatry's bible: Its time has passed
Since this article was first posted, the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013. "Extending the timeline will allow more time for public review, field trials and revisions," says APA president Alan Schatzberg.
When doctors disagree with each other, they usually couch their criticisms in careful, measured language. In the past few months, however, open conflict has broken out among the upper echelons of US psychiatry. The focus of discord is a volume called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, which psychiatrists turn to when diagnosing the distressed individuals who turn up at their offices seeking help. Regularly referred to as the profession's bible, the DSM is in the midst of a major rewrite, and feelings are running high.
Two eminent retired psychiatrists are warning that the revision process is fatally flawed. They say the new manual, to be known as DSM-V, will extend definitions of mental illnesses so broadly that tens of millions of people will be given unnecessary and risky drugs. Leaders of the American Psychiatric Association (APA), which publishes the manual, have shot back, accusing the pair of being motivated by their own financial interests - a charge they deny. The row is set to come to a head next month when the proposed changes will be published online. For a profession that exists to soothe human troubles, it's incendiary stuff.
Psychiatry suffers in comparison with other areas of medicine, as diseases of the mind are on the whole less well understood than those of the body. We have, as yet, only glimpses into the fundamental causes of the common mental illnesses, and there are no biological tests to diagnose them. This means conditions such as depression, schizophrenia and personality disorders remain difficult to diagnose with precision. Doctors can only question people about their state of mind and observe their behaviour, classifying illness according to the most obvious symptoms.
We have only glimpses into the causes of mental illnesses and there are no biological tests for them
First published in 1952, the DSM has its origins in a book used by the US military to determine if recruits were mentally fit for combat. The difficulty of separating mental disorders from normal variation in behaviour made it controversial from the start. Over the years, the book's influence has grown, and today it is used by doctors across the globe.
The wording used in the DSM has a significance that goes far beyond questions of semantics. The diagnoses it enshrines affect what treatments people receive, and whether health insurers will fund them. They can also exacerbate social stigmas and may even be used to deem an individual such a grave danger to society that they are locked up.
Some of the most acrimonious arguments stem from worries about the pharmaceutical industry's influence over psychiatry. This has led to the spotlight being turned on the financial ties of those in charge of revising the manual, and has made any diagnostic changes that could expand the use of drugs especially controversial. "I think the DSM represents a lightning rod for all kinds of groups," says David Kupfer of the University of Pittsburgh, Pennsylvania, who heads the task force appointed by the APA to produce the revised manual.
Few would claim that the DSM's current version is perfect. With each revision, the number of conditions it defines has swelled, many surrounded by bewildering lists of symptoms that must be checked to assign a diagnosis. Using current DSM checklists, for example, 114 different combinations of symptoms can lead to a diagnosis of schizophrenia. At the same time, many patients prove hard to fit into the framework.
One aim of the work groups compiling DSM-V is to cut through this chaos. They are streamlining diagnoses by removing various subtypes of schizophrenia, for example, and intend to address the confusion created by the fact that many people with one condition meet criteria for other disorders as well. The DSM-V task force is expected to propose a series of "dimensions" to be considered with a patient's main diagnosis. So as well as deciding whether someone has, say, bipolar disorder, doctors would determine whether they are suffering from problems such as anxiety and sleeping disturbances, and assess them on a simple scale of severity.
Grandiose claims
This is widely seen as a first step towards a future in which psychiatric diagnosis has a more scientific base, where sprawling checklists of symptoms are replaced by sliding-scale measurements of the underlying determinants of mental health. Yet critics worry that even a limited embrace of this "dimensional" approach is running ahead of the science. Until we understand more about the biological basis of psychiatric disease, this approach will not be helpful, they say.
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作者:admin@医学,生命科学 2011-02-13 23:37
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