DSM-5是字典、不是聖經
權威不再的精神醫學參考手冊？DSM-5 是字典、不是聖經
中國醫藥大學 蘇冠賓
(全文刊登於「科學月刊」 2016年 8月號，第500期：618-621)
眾所矚目的DSM-5（全名The fifth edition of Diagnostic and Statistical Manual of Mental Disorders，第五版精神疾病診斷與統計手冊）終於在2013年的美國精神醫學會（American Psychiatric Association，即APA）年會中登場。其實近20年來，主流期刊就持續注意DSM-5改革的方向，而台灣在2010年也由精神醫學會成立DSM-5小組來關注其發展。經過20年漫長的改版，DSM-5的出現，究竟一般的評價為何？對精神醫學又會產生怎樣的影響呢？
精神醫學專家對DSM-5改版的批判
大致來說，精神醫學界對DSM-5的評價大多是負面的，而來自各方攻擊中，以Duke大學Allen Frances的強烈批判最受注目，他曾任DSM-IV Task Force（專家委員會）的主席，是當年主導發表第四版最重要的靈魂人物，由於高度的學術地位，使得他在各大期刊中發表直接但理性的批判，讓APA顏面盡失。他在個人部落格「DSM-5 in Distress（陷入災難的DSM-5）(psychologytoday.com/blog/dsm5-in-distress)」中提出許多的重要問題，大多是對於改版後精神疾病會被過度診斷的擔心，例如「脾氣不好」的一位正常人可能會被放到DSM-5新的診斷「破壞性情緒失調疾患」（Disruptive Mood Dysregulation Disorder，DMDD），然後被建議參加藥物的臨床試驗，創造出新藥的市場；而正常喪親之痛也可能會被放到憂鬱症去吃藥…、其他如輕度認知障礙症（Minor Neurocognitive Disorder）、成人注意力缺陷症（Adult Attention Deficit Disorder）、暴食症（Binge Eating Disorder）、自閉症（Autism）、行為成癮（Behavioral Addictions，例如網路成癮或性成癮）、廣泛焦慮症（Generalized Anxiety Disorder）…的改變，都有可能造成過度診斷的危險。
DSM-5改版的內容大多沒有實証依據，只用專家共識來改變準則的結果，可以讓千萬人在一夕之間從沒病到有病。Frances甚至直接上美國的國家電視台呼籲（NBC News 2013/5/16）：「我的忠告是別買DSM-5、別用DSM-5、別教DSM-5（“My advice for people is not to buy the DSM-5, not to use it, not to teach it…” ）」，他也建議大家用歐洲慣用且免費的International Statistical Classification of Diseases and Related Health Problems (ICD)來做取代。
DSM-5改版的內容大多沒有實証依據，只用專家共識來改變準則的結果，可以讓千萬人在一夕之間從沒病到有病。Frances甚至直接上美國的國家電視台呼籲（NBC News 2013/5/16）：「我的忠告是別買DSM-5、別用DSM-5、別教DSM-5（“My advice for people is not to buy the DSM-5, not to use it, not to teach it…” ）」，他也建議大家用歐洲慣用且免費的International Statistical Classification of Diseases and Related Health Problems (ICD)來做取代。
DSM-5 Task Force對改版的辯護
David Kupfer則是DSM-5專家委員會的主席，他為DSM的改版辯護並宣稱：「…臨床經驗以及不斷發展的實證研究，增長了我們對於自閉症譜系疾患、雙極性疾患、及精神分裂症等疾患的瞭解。這類進展即將呈現於DSM-5…（psychiatry.org）」。然而，這樣的陳述顯然誇大了這些疾患從DSM-IV到DSM-5許多無關痛癢的改變，APA拒絕了眾多心理健康專業協會要求對DSM-5的所謂「實證研究」進行外部審查、APA取消了DSM-5田野測試的一些重要步驟、最後更撤下許多無證據支持的創新診斷…，David Kupfer宣稱「DSM-5是根據實証」的辯護可能需要多一點實証。
其實DSM的好或壞都已經數十年，就是好用、有必要用，我們才會一直用，現在爭論核心可能不是DSM的好不好，而是需不需改，維基百科有列出DSM-5改版的內容（en.wikipedia.org/wiki/DSM-5），大家也可以看一下改的對不對、好不好、沒有沒實証，更重要的是，值不值得從DSM-IV改到DSM-5！
其實APA修改的內容比例其實很小，但趨勢是匯整新研究把新診斷列進來，例如Prolonged grief disorder。雖然「早期發現、早期治療」的方向是對的。但是現實中醫療資源不足且集中在藥物給付，造成「早期診斷」後，缺乏可近的整合性之「早期治療」，必然造成疾病藥物化的效果 (國內外都一樣)。精神醫學界應該反思在「初級預防」上的訓練及研究的嚴重不足，而非抵制「早期發現早期治療」。
DSM-5為何要更新？
波士頓Tufts 醫學中心的Nassir Ghaemi也毫不保留提到他對DSM-5的失望。他的失望不是來自DSM-5改變的部分，而是與DSM- IV的大同小異，他認為DSM-5沒有改善DSM-IV效、信度不佳的嚴重問題，因此將持續阻礙精神醫學研究的進步。事實上，今年一月在APA的官方期刊American Journal of Psychiatry（美國精神醫學雜誌）中，也刊登了DSM-5第一階段的田野調查，新版中大多數診斷的施測者間信度火（inter-rater reliability）都出乎意料的差（就是和DSM-IV相當），其中以憂鬱症及焦慮症相關疾患特別嚴重。有人開玩笑說這個改版最大的改變，就是把V變為5！
然而，DSM-5改版和銷售，估計最少可以為APA賺進1000萬美金，所以，就像Windows系統硬要從XP到Vista、Win7到Win8一樣，不管你喜不喜歡，還是會去用。來自DSM-5相關書籍銷售的巨大利潤，可能是導致這一次沒有必要的改版最主要的原因。Nassir Ghaemi說：「如果DSM的目的只是為了達到一些臨床的方便性或甚至之經濟上的利益，那麼自然科學何必要跟著起舞（“If DSM categories are devised primarily because professional leaders want to achieve some clinical or even economic goals, there is no reason why nature should play along”）」 (Medscape on 2013/5/18)。
然而，DSM-5改版和銷售，估計最少可以為APA賺進1000萬美金，所以，就像Windows系統硬要從XP到Vista、Win7到Win8一樣，不管你喜不喜歡，還是會去用。來自DSM-5相關書籍銷售的巨大利潤，可能是導致這一次沒有必要的改版最主要的原因。Nassir Ghaemi說：「如果DSM的目的只是為了達到一些臨床的方便性或甚至之經濟上的利益，那麼自然科學何必要跟著起舞（“If DSM categories are devised primarily because professional leaders want to achieve some clinical or even economic goals, there is no reason why nature should play along”）」 (Medscape on 2013/5/18)。
出版前夕─NIMH的致命一擊
在DSM-5問世之前數日，美國國家精神衛生研究院（NIMH）的院長Thomas Insel公開宣稱，由於DSM「作業系統」缺乏效度（validity），美國國家精神衛生研究院將不再支持以DSM-5分類導向為主的研究，同時要推動一個新的研究取向準則─Research Domain Criteria (RDoC)，來做為NIMH贊助研究計畫之重點，期待做為未來新分類系統的基礎。
這真是對DSM-5最致命的一擊！各大媒體的搧情報導，逼得APA新選上的主席Jeffrey Lieberman必須要動用與Thomas Insel的個人情誼，聯合做出一份「很難看」的官方宣言─DSM-5和RDoC共同的關心（Shared Interests），Lieberman同時在文章指出，NIMH會繼續支持DSM仍是病患照顧的黃金標準（不是研究！Insel宣告不支持DSM導向的研究依然成立），而APA則全力協助NIMH發展RDoC成為2023年以後的精神診斷之標準。Shared Interests（也可以翻譯成共同利益）─說得好！
DSM是字典，不是聖經！
DSM是字典，不是聖經，對於精神醫學的專業訓練而言，精神疾病診斷學應以精神病理學訓練為依據，DSM的重要性本來就不如一本好的精神病學教科書。「診斷」與「瞭解」，是精神病理學中兩項基本過程，「診斷」是以某一參照性的概念架構為基準，再去尋找患者描符合判定標準的表徵，進而加以類別化。而「瞭解」則是試圖進入患者的經驗中，將其精神狀態用生物－心理－社會的整體架構來描述。「診斷」是對患者的「差異」加以定位，「瞭解」卻是試著使差異得以在病理學狀況下被理解。
DSM模式是試著讓病理診斷的過程中有一個基本的標準，其目的並不是在於瞭解病人內在的精神病理狀態，而是讓眾多的專家和研究者能夠用幾個統計上最常見的指標症狀，來讓診斷的一致性盡量提高，意即「根據統計的診斷（Diagnostics Based on Statistics）」。DSM的使用者如果欠缺專業（複雜）的精神病理評估訓練，很可能會曲解DSM字面上症狀的描述。無論是忽略精神病理的澄清或過分強調症狀的排列組合，都會妨害到精神病理學最基本的精神。
DSM模式是試著讓病理診斷的過程中有一個基本的標準，其目的並不是在於瞭解病人內在的精神病理狀態，而是讓眾多的專家和研究者能夠用幾個統計上最常見的指標症狀，來讓診斷的一致性盡量提高，意即「根據統計的診斷（Diagnostics Based on Statistics）」。DSM的使用者如果欠缺專業（複雜）的精神病理評估訓練，很可能會曲解DSM字面上症狀的描述。無論是忽略精神病理的澄清或過分強調症狀的排列組合，都會妨害到精神病理學最基本的精神。
妨害精神病理學最基本的精神，就會妨害精神醫學的科學發展
從生物精神醫學的角度而言，DSM分類無法符合分類原則中，對於確定診斷同質性及治療預測性的最低標準，例如以全基因體的掃瞄研究（genome-wide association study，GWAS）皆顯示，在DSM分類下的思覺失調症（schizophrenia）和雙極性情感疾患（bipolar disorder）在基因層次根本無法區分。如果利用現行的DSM分類無法讓診斷的同質性更高，便無法找到新的生物指誌，就無法促進精神醫學的新發現。
從藥物研發的角度而言，DSM分類下的異質性減低臨床試驗的效價，造成新藥研發的失敗。從臨床治療準則的角度而言，DSM分類下的異質性使得第一線應該接受心理社會治療的患者，被治療指引建議去吃藥。因此，DSM也不見得是病患照顧的黃金標準（或者說：治療指引也應減少對DSM的盲從）。
DSM的定位？
精神醫學有其局限，若用極端案例來攻擊它，不免全然抹煞其貢獻。同樣的，DSM有其局限，但用極端案例來攻擊它，亦全然抹煞其功能。DSM-5不適宜地推出，正好給予「反精神醫學人士」再次被大眾注意的機會，他們一定會借這個題目再次出擊，攻擊精神醫學較為不足的面向。而我認為這個潮流一定會持續下去，所以我們最好的立場就是辨清DSM的用途及目的。
若從多元角度來，大家會想到精神醫學還有非精神科醫師的專業，我們的合作者還包括一般科醫師（在美國開出80%精神科用藥）、心理師、社工師、教育者、基礎科學及神經科學家、甚至於私人及公家保險給付者。而精神醫學的作用也不只在醫療，我們也貢獻科學研究、教育、司法…等。如果大家想到非精神科醫師的專業人員及精神醫學的其他用途，說不一定也是會覺得DSM和Guideline也是很好的溝通工具。我的重點是：DSM和Guideline本身沒有錯，常常是使用者（故意或不小心）用錯其用途。
同理，若為了反對DSM而來理想化RDoC也是不智的。RDoC的目的是用來取代DSM做為生物精神醫學研究工具的不足，更也不可能成為診斷學的聖經。從生物精神醫學的角度而言，RDoC的精神在於提高精神病中之生物學同質性及治療可預測性，在找到新的生物指誌及新的治療方面，RDoC會比DSM更好些。
台灣精神醫學界如何面對DSM-5更新？
台灣精神醫學界非盲目的信眾，也沒有從APA得到好處，不用把DSM奉為聖經。DSM可以做為各國研究時確認病患篩選的工具，或保險給付時的溝通依據，但不應該是臨床診斷、專科考試、或決定治療方式的終極標準。
或許，台灣的精神醫學在中文社會仍有領先的優勢，若從經濟效益的層面，我們或許可以考慮結合出版業，把DSM-5的全球中文化做為重要產業，和APA一起推廣這本好用又常更新的參考書。
最後，做為一個精神科醫師，我很希望精神醫學能以更包容的心胸來面對多元的批判，畢竟精神醫學未知的領域仍多，精神醫學可以被質疑，也應該被質疑，如果質疑的動機是「進步、辯證、而非從中獲利」，我們則不應急著去貼上「反精神醫學」的標籤。更期許自己能做為一個行為科學的神經科學家，能夠「從做研究中學習智慧，從做學問中學習謙卑」。
— 「腦病理」研究的方向如果偏差，「腦生理」的研究就事倍功半
— 再過幾年「用DSM做診斷」會被認為是盲從和粗糙！
— 再過幾年「用DSM做診斷」會被認為是盲從和粗糙！
（蘇冠賓。權威不再的精神醫學參考手冊？DSM-5 是字典、不是聖經。
科學月刊 2016年 8月號，第500期：618-621）
（張倍禎、蘇冠賓等人。DSM的台灣觀點。
Acta Psychiatrica Scandinavica 2014; 129(3): 235）
延伸閱讀
1.
Allen Frances: DSM5 in Distress
(psychologytoday.com)
2.
Statement from DSM by Chair David
Kupfer (psychiatry.org/advocacy--newsroom/news-releases on 2013/5/3)
3.
DSM-5: Past Imperfect, by
Nassir Ghaemi (medscape.com on 2013/5/18)
4.
DSM-5: Setting the Record
Straight, by Jeffrey Lieberman (medscape.com on 2013/5/18)
5.
DSM-5 and RDoC: Shared Interests,
by Thomas Insel & Jeffrey Lieberman (nimh.nih.gov on 2013/5/13 &
(psychiatry.org on 2013/5/14)
6.
DSM-5 field trials (Freedman et
al., 2013, Narrow et al., 2013, Regier et al., 2013)
7.
孔繁鐘醫師的部落格也有數篇關於DSM評論文章之精準譯文及其精闢的評論(tw.myblog.yahoo.com/kfj36-kfj36/)
參考資料
Frances, A. (2009a).
Issues for DSM-V: the limitations of field trials: a lesson from DSM-IV. Am J Psychiatry 166, 1322.
Frances, A. (2009b).
Whither DSM-V? Br J Psychiatry 195, 391-2.
Frances, A. (2013). The
new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally
ill. BMJ 346, f1580.
Frances, A. & Chapman, S. (2013). DSM-5 somatic symptom disorder mislabels medical illness as
mental disorder. Aust N Z J Psychiatry
47, 483-4.
Frances, A. & Wollert, R. (2012). Sexual sadism: avoiding its misuse in sexually violent
predator evaluations. J Am Acad
Psychiatry Law 40, 409-16.
Frances, A. J. & Widiger, T. (2012). Psychiatric diagnosis: lessons from the DSM-IV past and
cautions for the DSM-5 future. Annu Rev
Clin Psychol 8, 109-30.
Freedman, R., Lewis, D. A., Michels, R., Pine, D. S.,
Schultz, S. K., Tamminga, C. A., Gabbard, G. O., Gau, S. S., Javitt, D. C.,
Oquendo, M. A., Shrout, P. E., Vieta, E. & Yager, J. (2013). The initial field trials of DSM-5: new blooms and old
thorns. Am J Psychiatry 170, 1-5.
Friedman, R. A. (2012).
Grief, depression, and the DSM-5. N Engl
J Med 366, 1855-7.
Hyman, S. E. (2007). Can
neuroscience be integrated into the DSM-V? Nat
Rev Neurosci 8, 725-32.
McHugh, P. R. & Slavney, P. R. (2012). Mental illness--comprehensive evaluation or checklist? N Engl J Med 366, 1853-5.
Miller, G. (2010a). Psychiatry.
Anything but child's play. Science 327, 1192-3.
Miller, G. (2010b).
Psychiatry. Beyond DSM: seeking a brain-based classification of mental illness.
Science 327, 1437.
Miller, G. (2012).
Psychiatry. Criticism continues to dog psychiatric manual as deadline
approaches. Science 336, 1088-9.
Miller, G. & Holden, C. (2010). Psychiatry. Proposed revisions to psychiatry's canon
unveiled. Science 327, 770-1.
Narrow, W. E., Clarke, D. E., Kuramoto, S. J.,
Kraemer, H. C., Kupfer, D. J., Greiner, L. & Regier, D. A. (2013). DSM-5 field trials in the United States and Canada, Part
III: development and reliability testing of a cross-cutting symptom assessment
for DSM-5. Am J Psychiatry 170, 71-82.
Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer,
H. C., Kuramoto, S. J., Kuhl, E. A. & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II:
test-retest reliability of selected categorical diagnoses. Am J Psychiatry 170,
59-70.
您好，
ReplyDelete我在我的網站裡引用連結了您的這篇文章，
如果您不希望被引用，
請告知我，我會立刻拿掉這則引用。
我的文章有關於PTSD的說明，
不過我本身是行外人，
畢竟醫學領域攸關生死，
為了避免錯誤知識的再散佈，
若是您有空的話，
也希望可以看一下該文是否有不妥之處。
以下是該文連結
http://www.tpintrts.tpin.idv.tw/index.php?blog_id=86#blogstart
DSM-5-TR: overview of what’s new and what’s changed
ReplyDeletehttps://onlinelibrary.wiley.com/doi/10.1002/wps.20989?af=R
First published: 07 May 2022 https://doi.org/10.1002/wps.20989
The DSM-5 Text Revision (DSM-5-TR)1 is the first published revision of DSM-5 since its original publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of DSM-5-TR is to comprehensively update the descriptive text that is provided for each DSM disorder based on reviews of the literature since the release of the prior version. However, in contrast to DSM-IV-TR, in which updates were confined almost exclusively to the text2, there are a number of significant changes and improvements in DSM-5-TR that are of interest to practicing clinicians and researchers. These changes include the addition of diagnostic entities, and modifications and updated terminology in diagnostic criteria and specifier definitions.
The updates to the diagnostic criteria and text in DSM-5-TR are the product of two separate but concurrent processes: the iterative revision process that allows the addition or deletion of disorders and specifiers as well as changes in diagnostic criteria to be made on an ongoing basis3, which commenced soon after the publication of DSM-5, and a complementary text revision process which began in 2019.
While most of the changes instituted since publication of DSM-5 and included in this text revision involve relatively minor changes and serve to correct errors, clarify ambiguities, or resolve inconsistencies between the diagnostic criteria and text, some are significant enough to have an impact on clinical practice4. Here we outline the main changes in DSM-5-TR, subdivided into four categories: addition of diagnostic entities and symptom codes; changes in diagnostic criteria or specifier definitions; updated terminology; and comprehensive text updates.
Diagnostic entities added to DSM-5-TR include Prolonged Grief Disorder, Unspecified Mood Disorder, and Stimulant-Induced Mild Neurocognitive Disorder.
Prolonged Grief Disorder is characterized by the continued presence, for at least 12 months after the death of a loved one, of intense yearning for the deceased and/or persistent preoccupation with thoughts of the deceased, along with other grief-related symptoms such as emotional numbness, intense emotional pain and avoidance of reminders that the person is deceased, that are sufficiently severe to cause impairment in functioning5, 6.
Unspecified Mood Disorder is a residual category for presentations of mood symptoms which do not meet the full criteria for any of the disorders in either the bipolar or the depressive disorders diagnostic classes, and for which it is difficult to choose between Unspecified Bipolar and Related Disorder and Unspecified Depressive Disorder (e.g., acute agitation).
Stimulant-Induced Mild Neurocognitive Disorder has been added to the existing types of substance-induced mild neurocognitive disorders (alcohol, inhalants, and sedative, hypnotics or anxiolytic substances), in recognition of the fact that neurocognitive symptoms, such as difficulties with learning and memory and executive function, can be associated with stimulant use7.
DSM-5-TR: overview of what’s new and what’s changed
ReplyDeletehttps://onlinelibrary.wiley.com/doi/10.1002/wps.20989?af=R
First published: 07 May 2022 https://doi.org/10.1002/wps.20989
Autism Spectrum Disorder is defined by persistent difficulties in the social use of verbal and nonverbal communication (criterion A) along with restricted repetitive patterns of behavior (criterion B). While the minimum threshold for the restricted repetitive behavior component was straightforward (at least two of four), the minimum required number of types of deficits in social communication was ambiguous. Specifically, the criterion A phrase “as manifested by the following” could be interpreted to mean “any of the following” (one of three) or “all of the following” (three of three). Since the intention of the DSM-5 Work Group was always to maintain a high diagnostic threshold by requiring all three, criterion A was revised to be clearer: “as manifested by all of the following”.
The “mild” severity specifier for Manic Episode (few, if any, symptoms in excess of required threshold; distressing but manageable symptoms, and the symptoms result in minor impairment in social or occupational functioning) was inconsistent with Manic Episode criterion C, which requires that the mood disturbance be sufficiently severe to cause marked impairment in social or occupational functioning, necessitate hospitalization, or include psychotic features. The severity specifiers from DSM-IV have now been adopted: “mild” if only minimum symptom criteria are met; “moderate” if there is a very significant increase in activity or impairment in judgment, and “severe” if almost continual supervision is required.
Specifiers indicating the duration of symptoms in Adjustment Disorder were inadvertently left out of DSM-5 and have now been reinstated: “acute” if symptoms have persisted for less than 6 months, and “persistent” if symptoms have persisted for 6 months or longer after the termination of the stressor or its consequences.
The essential cognitive features in Delirium are disturbances of attention and awareness of the environment. While the nature of the attentional disturbance – characterized in criterion A as a reduced ability to direct, focus, sustain, and shift attention – is clear, the characterization of the awareness component as “reduced orientation to the environment” is confusing, given that “disorientation” already appears as one of the “additional disturbances in cognition” listed in criterion C. Consequently, criterion A has been reformulated to avoid using “orientation”, so that it now reads “A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) accompanied by reduced awareness of the environment”.
Three cross-cutting Review Groups (Sex and Gender, Culture, Suicide) reviewed every chapter, focusing on material involving their specific expertise. Revisions to the text also underwent a forensic review. Finally, an Ethnoracial Equity and Inclusion Work Group reviewed the entire text to ensure among other things that explanations of ethno-racial and cultural differences in symptomatic presentations and prevalence took into consideration the impact of experiences such as racism and discrimination.
Most disorder texts had at least some revisions, with the overwhelming majority having significant revisions. Text sections most extensively updated were Prevalence, Risk and Prognostic Factors, Culture-Related Diagnostic Features, Sex- and Gender-Related Diagnostic Features, Association with Suicidal Thoughts and Behaviors, and Comorbidity. The text sections with the fewest updates were Diagnostic Features and Differential Diagnosis.
The American Psychiatric Association continues to welcome empirically-grounded proposals for change. Guidelines for submitting such proposals can be found at www.dsm5.org.
DSM每次改版和銷售，估計最少可以為美國精神醫學會 (APA) 賺進1000萬美金，其他相關產品銷售的巨大利潤也很驚人 (教育、講座、系統更新)。所以，就像Windows系統硬要從XP到Win78910一樣，不管我們喜不喜歡，還是會去用。
ReplyDeletehttps://cobolsu.blogspot.com/2013/06/dsm-5_11.html
精神醫學界應該反思在「初級預防」上的訓練及研究的嚴重不足，而非抵制「早期發現早期治療」。
APA修改的內容比例其實很小，但趨勢是匯整新研究把新診斷列進來，例如Prolonged grief disorder。雖然「早期發現、早期治療」的方向是對的。但是現實中醫療資源不足且集中在藥物給付，造成「早期診斷」後，缺乏可近的整合性之「早期治療」，必然造成疾病藥物化的效果 (國內外都一樣)。
https://onlinelibrary.wiley.com/doi/10.1002/wps.20989?af=R