Kawa Shadia, Giordano James
Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd., EPN 4066, Bethesda, MD 20892, USA.
Philos Ethics Humanit Med. 2012 Jan 13;7:2. doi: 10.1186/1747-5341-7-2.
The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, currently in its fourth edition and considered the reference for the characterization and diagnosis of mental disorders, has undergone various developments since its inception in the mid-twentieth century. With the fifth edition of the DSM presently in field trials for release in 2013, there is renewed discussion and debate over the extent of its relative successes - and shortcomings - at iteratively incorporating scientific evidence on the often ambiguous nature and etiology of mental illness. Given the power that the DSM has exerted both within psychiatry and society at large, this essay seeks to analyze variations in content and context of various editions of the DSM, address contributory influences and repercussion of such variations on the evolving landscape of psychiatry as discipline and practice over the past sixty years. Specifically, we document major modifications in the definition, characterization, and classification of mental disorders throughout successive editions of the DSM, in light of shifting trends in the conceptualization of psychopathology within evolving schools of thought in psychiatry, and in the context of progress in behavioral and psychopharmacological therapeutics over time. We touch upon the social, political, and financial environments in which these changes took places, address the significance of these changes with respect to the legitimacy (and legitimization) of what constitutes mental illness and health, and examine the impact and implications of these changes on psychiatric practice, research, and teaching. We argue that problematic issues in psychiatry, arguably reflecting the large-scale adoption of the DSM, may be linked to difficulties in formulating a standardized nosology of psychopathology. In this light, we highlight 1) issues relating to attempts to align the DSM with the medical model, with regard to increasing specificity in the characterization of discrete mental disease entities and the incorporation of neurogenetic, neurochemical and neuroimaging data in its nosological framework; 2) controversies surrounding the medicalization of cognition, emotion, and behavior, and the interpretation of subjective variables as 'normal' or 'abnormal' in the context of society and culture; and 3) what constitutes treatment, enablement, or enhancement - and what metrics, guidelines, and policies may need to be established to clarify such criteria.
美国精神病学协会的《诊断与统计手册》（DSM）目前为第四版，被视为精神障碍特征描述与诊断的参考依据。自20世纪中叶问世以来，它历经了多次发展。随着DSM第五版目前正在进行现场试验，将于2013年发布，人们再次就其在反复纳入有关精神疾病通常模糊的性质和病因的科学证据方面的相对成功与不足展开讨论和辩论。鉴于DSM在精神病学及整个社会中所发挥的影响力，本文旨在分析DSM各版在内容和背景方面的差异，探讨这些差异对过去六十年来作为一门学科和实践的精神病学不断演变的格局所产生的促成影响及后果。具体而言，我们根据精神病学不断演变的思想流派中心理病理学概念化的变化趋势，以及行为和精神药物治疗随着时间的进展情况，记录DSM各连续版本中精神障碍定义、特征描述和分类的主要修改。我们涉及这些变化发生时的社会、政治和金融环境，探讨这些变化对于构成精神疾病和健康的内容的合法性（及合法化）的意义，并研究这些变化对精神病学实践、研究和教学的影响及含义。我们认为，精神病学中存在的问题（可以说反映了DSM的大规模采用）可能与制定标准化的心理病理分类学的困难有关。有鉴于此，我们强调：1）与试图使DSM与医学模式保持一致相关的问题，涉及在离散精神疾病实体特征描述方面提高特异性以及在其分类框架中纳入神经遗传学、神经化学和神经影像学数据；2）围绕认知、情感和行为医学化以及在社会和文化背景下将主观变量解释为“正常”或“异常”的争议；3）什么构成治疗、赋能或增强——以及可能需要制定哪些指标、指南和政策来明确此类标准。
