The diagnostic strengths manual?.
The diagnostic strengths manual?.
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诊断优势手册？
DOI：
10.1093/sw/46.2.183
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发表时间：
2001
期刊：
影响因子：
2.9
通讯作者：
D. Saleebey
中科院分区：
文献类型：
--
作者：
D. Saleebey
尽管具有影响力，美国精神病学协会（1994）的DSM-IV （DSM-IV- tr刚刚出版，大约有100页关于疾病的额外文本——主要是因为增加了标准和说明符的列举）给从业人员带来了一些困境和紧张，因此，对于根据其协议和示意图进行诊断的客户和患者。对DSM- iii， -III-R和-IV的批评来自许多方面，基于各种担忧：DSM未能提供令人信服的证据来证明其他医学专业表面上需要的诊断标准和标准的可靠性和有效性（Kutchins & Kirk, 1997），并且它提供了一个不充分且难以操作的精神障碍概念化（Wakefield, 1992）。此外，由于缺乏明确的定义，导致对精神障碍的定义不断扩大，以至于所有常见的人类弱点、令人讨厌的特征和坏习惯都被视为精神障碍（Wolin & Wolin, 1993）；它有广泛的白人男性偏见和发展对某些种族群体和妇女不利的诊断类别的历史（Tavris， 1992年）；通过其数字分类系统和出现在“病例手册”中的病人的数字匿名性，DSM巧妙地鼓励精神障碍患者的客观化（Cutler, 1991）。不管它的缺点是什么，不管它对人类弱点和弱点的建构是什么特点，DSM都非常受欢迎，它的影响很难被低估。它是心理健康专业人士的通用语言。保险公司和极其强大的制药业出于截然不同的原因严重依赖它。（Goleman, 1994; Kutchins & Kirk, 1997）最后，社会、医学、科学和政治过程滋养了像DSM这样有影响力的文件的发展，反映了不断发展的社会规范（及其伴随的实践）和“渐进式虚弱”的文化动态。这种规范规定，越来越多的行为、内在情绪和精神状态以及人类状况被贴上缺陷的标签，需要药物治疗、隔离、治疗，在某些情况下还需要监禁。这产生了一种累积效应，即产生了一种迅速发展的社会等级制度，其中越来越多的个人和职业，使用“缺陷”这个词，有权评估那些被认为不合格的人并对其采取行动，削弱了更多的公共理解和对人类考验、麻烦和磨难的改善；以及“削弱”那些在新规范词汇下失败的人的自我意识（Gergen, 1994）。显然，DSM有许多个人的、学科的、专业的和机构的支持者。它的意图，就像70年前的Emil Kraepelin （Andreasen, 1984）一样，创建一本百科全书式的描述性手册，通过具体和行为标准，将特定的疾病与其他疾病明确区分开来，这反映了医学的总体意图。然而，必须指出的是，医学的其他分支也对潜在的病理（因果关系）感兴趣，因为定位和理解特定的细胞、生理或生化动态是有效治疗、治愈或预防的关键（Walker, 1996）。令人奇怪的是，DSM的制定者似乎对事业不感兴趣。我认为DSM-IV中有两个特别令人不安的问题，这两个问题对寻求心理健康专家帮助的人都有深刻的、往往不利的影响。一切都在你的脑海里！许多（如果不是大多数）严重或轻微的身体疾病，通常会产生认知、情绪和行为上的变化，这是症状的一部分。在这些疾病中，情绪和认知的变化可能是家庭成员或精神科医生首先观察到的。…
As influential as it is, the DSM-IV (the DSM-IV-TR has just been published and has approximately 100 additional pages of text on disorders--primarily because of the increased enumeration of criteria and specifiers) of the American Psychiatric Association (1994) poses some dilemmas and tensions for practitioners and, therefore, for clients and patients who are diagnosed under its protocols and schematics. Volleys of criticism of DSM-III, -III-R, and -IV have come from many fronts, based on a variety of concerns: that the DSM fails to provide convincing evidence for the reliability and validity of diagnostic criteria and standards that other medical specialties ostensibly require (Kutchins & Kirk, 1997), and that it provides an insufficient and hard-to-operationalize conceptualization of mental disorder (Wakefield, 1992). In addition, this lack of a clear definition permits an ever-widening net of definition of disorder so that all manner of common human foibles, annoying traits, and bad habits are captured as mental disorders (Wolin & Wolin, 1993); it has an extensive white male bias and a history of developing diagnostic categories that are inimical to some racial groups and to women (Tavris, 1992); and through its numeric system of taxonomy and the numerical anonymity of the patients who appear in the "casebook," the DSM subtly encourages objectification of individuals with mental disorders (Cutler, 1991). Whatever its weaknesses and whatever the character of its construction of human frailties and foibles, the DSM is enormously popular, and its influence would be hard to understate. It is the lingua franca of mental health professions. Insurance companies and the enormously powerful pharmaceutical industry rely on it heavily for very different reasons. (Goleman, 1994; Kutchins & Kirk, 1997) Finally, the social, medical, scientific, and political processes that have nourished the development of an influential document like DSM reflect an evolving social norm (and its attendant practices) and cultural dynamic of "progressive infirmity." Such a norm decrees that an expanding range of behaviors, internal emotional and mental states, and human conditions come to be labeled as deficiencies requiring medication, sequestering, treatment and, in some cases, imprisonment. This has the cumulative effect of producing a rapidly developing social hierarchy in which a growing number of individuals and professions, employing the lexicon of deficit, have the power to evaluate and act on those who are identified as not measuring up, weakening more communal understandings and melioration of human trials, troubles, and tribulations; and "enfeebling" the sense of self of those who fail under the terms of the new normative lexicon (Gergen, 1994). Obviously, the DSM has a host of individual, disciplinary, professional, and institutional supporters. Its intent to create, like Emil Kraepelin 70 years before (Andreasen, 1984), an encyclopedic, descriptive manual that clearly distinguishes a given disorder, through specific and behavioral criteria, from every other disorder reflects the intent of medicine generally. It must be pointed out, however, that other branches of medicine are interested as well in underlying pathology (causality) because locating and understanding that particular cellular, physiological, or biochemical dynamic is a key to effective treatment, cure, or prevention (Walker, 1996). The framers of DSM seem curiously uninterested in cause. There are two particular problems with DSM-IV that I think are especially disturbing, and both have profound and too often adverse effects on people who seek the help of mental health professionals. It's All in Your Head! Many, if not most physical illnesses, serious and slight, often yield cognitive, emotional, and behavioral changes as part of the symptom picture. In some of these illnesses, the emotional and cognitive changes are the first thing that might be observed by family members or a psychiatrist. …