Things Aren't What They Seem
Things Aren't What They Seem
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事情并不像看上去的那样
DOI：
10.1177/014107688407700904
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发表时间：
1984
影响因子：
17.3
通讯作者：
Bernard Sunley
中科院分区：
文献类型：
--
作者：
P. Higgins;Bernard Sunley
阿尔伯特·万德是一个兴趣广泛的人，他所建立的信托基金既包括社会问题，也包括医疗问题。因此，纪念他一生和工作的系列讲座中的第十五次讲座应该与社会生活和医学有同样的关系。著名的普通免疫学家、流行病学家霍普-辛普森（Hope-Simpson，1965年）做了第一次阿尔伯特·万德讲座。他的研究对象，带状疱疹，与我的研究对象几乎完全不同。带状疱疹的典型病例及其特征性皮疹、分布和病程不能被误认为是其他任何疾病;它就是它看起来的样子。我的研究对象是那些向医生呈现出暗示身体疾病的症状，但在他们身上却找不到身体疾病的个体，或者是那些身体疾病（如果存在）不能完全解释他们的症状的个体：这种情况可以被称为模仿疾病或假疾病。隐藏在疾病的伪装下，这些病人并不像他们看起来的那样。这组问题构成了医学中最困难的临床挑战之一。评估和管理这些疾病的负担主要落在全科医生身上;没有其他人能在这么长的时间内看到这么多的疾病，也没有其他人对它们负有如此广泛的责任和关心。因此，在我看来，它们既是全科医学的核心临床任务，也是全科医学最重要的研究课题。最有趣的亚组包括那些我们无法找到令人信服的心理障碍证据的人。由于缺乏令人满意的替代方案，想要理解他们的问题的渴望驱使我们不懈地追求一个物理原因或投机思维，这种思维本身既不令人满意，也不可检验。在这些人中，有些人的生活压力很大（例如Creed（1982）对接受阑尾切除术的病人的研究），但这是如何导致疾病的还没有得到令人满意的解释。在这一亚组中，也有一些病例出现在正常受试者中，如医学生（Hunter等，1964年，Woods等，1966年）和孕妇的丈夫（Lipkin和Lamb，1982年）。对解释的探索将使我们质疑我们目前在症状的因果关系中给予情绪的首要地位，以及我们对症状的指示性力量和疾病现实的假设。让我举一个例子：
Albert Wander was a man of wide interests, seeing to it that the trusts he established covered social as well as medical problems. It is fitting, therefore, that this fifteenth lecture in the series to commemorate his life and work should have as much to do with social life as with medicine. The distinguished general practitioner-epidemiologist Hope-Simpson (1965) gave the first Albert Wander Lecture. His subject, herpes zoster, could hardly be more different to mine. A typical case of zoster with its characteristic rash, distribution and course could not be mistaken for anything else; it is what it seems. My subject is those individuals who present to doctors with symptoms suggesting physical disease but in whom no physical disease can be found or in whom physical disease, if present, does not fully explain their symptoms: what might be called mimicked disease or pseudo-disease. Hidden in the camouflage of disease, these patients are not what they seem. This group of problems constitutes one of the most difficult clinical challenges in medicine. The burden of evaluating and managing them has to fall mainly upon the general practitioner; no one else sees them in such numbers or over such a long period of time or has as wide a responsibility and concern for them. They seem to me, therefore, to be both the core clinical task of general practice and its most important subject for research. The most interesting sub-group comprises those individuals in whom we cannot find convincing evidence of psychological disorder. The itch to understand their problems drives us, for lack of a satisfactory alternative, to a relentless pursuit of a physical cause or to speculative thinking that is neither satisfactory in itself nor testable. In some of these people serious life stress can be identified (see for example Creed's (1982) work on patients undergoing appendicectomy), but how this leads on to illness has yet to be satisfactorily explained. Also within this sub-group are those cases where mimicked disease appears to arise in normal subjects such as medical students (Hunter et al. 1964, Woods et al. 1966) and the husbands of expectant mothers (Lipkin & Lamb 1982). The search for an explanation will lead us to question the primacy that we currently give to emotion in the causation of symptoms and our assumptions about the indicative power of symptoms and about the reality of disease. Let me give an example: