Kendler K S
Departments of Psychiatry, and Human and Molecular Genetics,Virginia Institute of Psychiatric and Behavioral Genetics, Medical College of Virginia/Virginia Commonwealth University,Richmond, VA,USA.
Psychol Med. 2017 Sep;47(12):2054-2060. doi: 10.1017/S0033291717000678. Epub 2017 Apr 4.
While the changes in psychiatric diagnosis introduced by Diagnostic and Statistical Manual third edition (DSM-III) have had major benefits to the field of psychiatry, the reification of its diagnostic criteria and the widespread adoption of diagnostic literalism have been problematic. I argue that, at root, these developments can be best understood by contrasting two approaches to the relationship between DSM disorders and their criteria. In a constitutive relationship, criteria definitively define the disorder. Having a disorder is nothing more than meeting the criteria. In an indexical relationship, the criteria are fallible indices of a disorder understood as a hypothetical, tentative diagnostic construct. I trace the origins of the constitutive model to the philosophical theory of operationalism. I then examine a range of historical and empirical results that favor the indexical over the constitutive position including (i) evidence that individual criteria for DSM-III were selected from a broader pool of possible symptoms/signs, (ii) revisions of DSM have implicitly assumed an indexical criteria-disorder relationship, (iii) the indexical position allows DSM criteria to be wrong and misdiagnose patients while such a result is incoherent for a constitutive model, an implausible position, (iv) we assume an indexical criteria-scale relationships for many personality and symptom measures commonly used in psychiatric practice and research, and (v) empirical studies suggesting similar performance for DSM and non-DSM symptoms for major depression. I then review four reasons for the rise of the constitutive position: (i) the 'official' nature of the DSM criteria, (ii) the strong investment psychiatry has had in the DSM manual and its widespread use and success, iii) lack of a clear pathophysiology for our disorders, and (iv) the absence of informative diagnostic signs of minimal clinical importance. I conclude that the constitutive position is premature and reflects a conceptual error. It assumes a definitiveness and a literalism about the nature of our criteria that is far beyond our current knowledge. The indexical position with its tentativeness and modesty accurately reflects the current state of our field.
虽然《精神疾病诊断与统计手册》第三版（DSM - III）引入的精神科诊断变化给精神病学领域带来了重大益处，但其诊断标准的具体化以及诊断字面主义的广泛采用一直存在问题。我认为，从根本上说，通过对比DSM疾病与其标准之间关系的两种方法，能最好地理解这些发展。在构成性关系中，标准明确界定了疾病。患有某种疾病无非就是符合这些标准。在索引性关系中，标准是对一种被理解为假设性、试探性诊断结构的疾病的易错指标。我将构成性模型的起源追溯到操作主义的哲学理论。然后我考察了一系列支持索引性而非构成性立场的历史和实证结果，包括：（i）有证据表明DSM - III的各个标准是从更广泛的可能症状/体征中挑选出来的；（ii）DSM的修订隐含地假定了索引性的标准 - 疾病关系；（iii）索引性立场允许DSM标准出现错误并误诊患者，而这种结果对于构成性模型来说是不连贯的、不可信的立场；（iv）我们在精神病学实践和研究中常用的许多人格和症状测量中假定了索引性的标准 - 量表关系；（v）实证研究表明，对于重度抑郁症，DSM症状和非DSM症状的表现相似。接着我回顾了构成性立场兴起的四个原因：（i）DSM标准的“官方”性质；（ii）精神病学对DSM手册的大力投入及其广泛使用和成功；（iii）我们的疾病缺乏明确的病理生理学；（iv）缺乏具有最小临床重要性的信息性诊断体征。我得出结论，构成性立场为时过早，反映了一种概念错误。它对我们标准的性质假设了一种确定性和字面主义，这远远超出了我们目前的知识范围。索引性立场的试探性和适度性准确地反映了我们领域的当前状态。
