By the book

　　照本宣科

　　The American Psychiatric Association s latestdiagnostic manual remains a flawed attempt tocategorise mental illness

　　美國(guó)精神醫(yī)學(xué)會(huì)最新診斷手冊(cè)在精神疾病分類上仍有欠缺

　　A BOOK with the title Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition doesnot sound destined to be a bestseller, particularly at $199 a pop.

　　《精神疾病診斷與統(tǒng)計(jì)手冊(cè)，第五版》這個(gè)書名聽上去注定成不了暢銷書，尤其一本竟要199美元。

　　But DSM-5, as it is known for short, is almost certain to become one.

　　但是DSM-5幾乎肯定會(huì)成為一本暢銷書。

　　Its predecessor, DSM-IV, which was published in 1994, has sold more than 1m copies.DSM-5, which will go on sale on May 22nd, is likely to do at least as well.

　　其上一版，1994年出版的DSM-4已售出超過(guò)一百萬(wàn)冊(cè)。DSM-5將于5月22日開售，很可能至少也會(huì)賣到這個(gè)數(shù)。

　　The reason is that the DSM series, which is published by the American Psychiatric Association,has become the global standard for the description of mental illness.

　　美國(guó)精神醫(yī)學(xué)會(huì)出版的DSM叢書如此大賣的原因是其已經(jīng)成為精神疾病癥狀描述的全球標(biāo)準(zhǔn)。

　　Indeed, the DSM is treated by many people less as a medical handbook and more as holywrit.

　　實(shí)際上，許多人把DSM更多是當(dāng)成圣經(jīng)，而非一本醫(yī)學(xué)手冊(cè)。

　　Insurers use it to decide whether or not to cover ailments.

　　保險(xiǎn)公司用其來(lái)確定是否涵蓋一些病癥。

　　And diagnoses based on it determine whether people get special services at school;whether they qualify for disability benefits; whether they are stigmatised in their careers;even whether they are able to adopt children.

　　據(jù)其做出的診斷會(huì)決定一個(gè)人是否會(huì)在學(xué)校受到特殊照顧;是否能得到傷殘撫恤金;是否會(huì)在自己的職業(yè)生涯中蒙受污名;甚至是否能夠領(lǐng)養(yǎng)小孩。

　　Doctors, patients, drug companies and insurers have all thus been waiting for the latestedition of what has become known as the psychiatric bible.

　　因此醫(yī)生，患者，制藥公司及保險(xiǎn)公司都在翹首期盼這本被當(dāng)作精神病學(xué)圣經(jīng)的最新版。

　　The DSM s purpose is to set strict criteria for identifying mental disorders.

　　DSM的目的是設(shè)立鑒別精神疾病的嚴(yán)格標(biāo)準(zhǔn)。

　　This is supposed to make diagnoses more reliable: a laudable aim.

　　這應(yīng)該會(huì)使診斷更為可靠，這一個(gè)值得稱道的目標(biāo)。

　　To that end, more than 1,500 experts have spent over a decade labouring.

　　為了這個(gè)目標(biāo)，1500多名專家耗費(fèi)了多年勞動(dòng)。

　　In doing so, though, they have succeeded in adding to, rather than subtracting from, criticismthat the DSM has become a monster.

　　然而這些辛勞讓他們順利地在DSM中增加了標(biāo)準(zhǔn)，而非減少，這使DSM成為了一個(gè)龐然大物。

　　In the eyes of many critics it is a vehicle for misdiagnosis, overdiagnosis, the medicalisationof normal behaviour and the prescription of a large number of unnecessary drugs.

　　在許多批評(píng)家眼中，DSM是誤診，過(guò)度診斷，正常行為醫(yī)療化以及開出大量不必要藥物處方的罪魁禍?zhǔn)住?/p>

　　Chapter and verse

　　引經(jīng)據(jù)典

　　The DSM, the first version of which was published in 1952, has always attractedcontroversy.

　　DSM自1952年第一版出版起便一直引發(fā)爭(zhēng)論。

　　That version, and the second edition, published in 1968, relied on the premise that mentalillness was a neurotic response to a patient s experience and environment.

　　第一版及1968年出版的第二版有賴于精神疾病是對(duì)病人的經(jīng)歷及環(huán)境的神經(jīng)質(zhì)反應(yīng)這一前提。

　　People with the same symptoms could therefore receive wildly different diagnoses.

　　然而具有相同癥狀的人會(huì)受到截然不同的診斷。

　　Different interpretations of experience and environment also meant that cultural differencesaffected diagnosis.

　　經(jīng)歷及環(huán)境的不同解讀也意味著文化差異會(huì)影響診斷。

　　In 1971 Robert Kendell demonstrated this by showing that, faced with the same patients,American psychiatrists were much more likely to diagnose them as schizophrenic than wereBritish psychiatrists.

　　羅伯特肯德爾于1971年證明了這點(diǎn)，他指出，面對(duì)同一個(gè)病人，美國(guó)的精神病醫(yī)生比英國(guó)精神病醫(yī)生更可能將其診斷為精神分裂患者。

　　The third DSM, published in 1980, introduced a new approachalso followed in the fourth in1994.

　　DSM第三版于1980年出版，引入了一種新的方法，1994年出版的第四版也遵循了該方法。

　　DSM-III acknowledged that psychiatrists had a poor understanding of the physiological causeof mental illness.

　　DSM第三版承認(rèn)精神病醫(yī)生對(duì)于精神疾病的生理病因不甚了了。

　　Instead specific, observed symptoms became the diagnostic criteria, and clusters of them,known medically as syndromes, that appeared to coexist in individual patients were givenlabels.

　　觀察到的癥狀而非具體病因被當(dāng)成診斷標(biāo)準(zhǔn)，貌似存在于同一患者的癥狀集群-醫(yī)學(xué)上稱之為綜合癥-被冠以名稱。

　　The hope was that biological markers of such syndromes would be discovered as physiologicalunderstanding increased.

　　希望是在于這些綜合癥的生物學(xué)標(biāo)記會(huì)隨著生理學(xué)知識(shí)的增加而得以發(fā)現(xiàn)。

　　This was a reasonable approach in principle.

　　這在原則上是一個(gè)合理的方法。

　　In practice, though, the lines dividing different disorders are blurry.

　　但實(shí)際上，劃分不同精神疾病的界限模糊不清。

　　The symptoms used to define them often do not cluster neatly in the way that those of truesyndromes would, and the statistical evidence for their existence is sometimes sparse.

　　用來(lái)定義精神疾病的癥狀與綜合癥真正的癥狀時(shí)常并非一一對(duì)應(yīng)，這些癥狀存在的統(tǒng)計(jì)證據(jù)有時(shí)也很匱乏。

　　Nor, in most cases, have the hoped-for biological markers turned upand to the extent thatthey have, they have muddied the waters, rather than clarifying them.

　　在大多數(shù)情況下，期望的生物學(xué)標(biāo)記并未被發(fā)現(xiàn)，從某種程度而言，已發(fā)現(xiàn)的生物學(xué)標(biāo)記把水越攪越渾，而不是越攪越清。

　　The biggest muddyings have come from brain scanning and genetics.

　　最大的一趟渾水來(lái)自于腦部掃描術(shù)及遺傳學(xué)。

　　Most psychiatrists, even those sceptical of the DSM s approach, would accept the idea thatthings like autism, major depression and schizophrenia are different from each other.

　　大多數(shù)精神病醫(yī)生，甚至是那些對(duì)DSM的方法持懷疑態(tài)度的醫(yī)生也會(huì)接受如自閉癥、重度抑郁癥及精神分裂癥這些疾病互不相同這一概念。

　　However, a study published this year by a group called the Psychiatric Genomics Consortium,which has looked for links between genetic variations and psychiatric disorders in tens ofthousands of patients, has found that variations in four places were common to peoplediagnosed, using the DSM s criteria, with attention deficit hyperactivity disorder, autism,bipolar disorder, major depression and schizophrenia.

　　然而有一家叫做精神疾病基因體聯(lián)盟的團(tuán)體于今年發(fā)表了一份研究報(bào)告，在數(shù)以萬(wàn)計(jì)的患者中尋找了基因變異及精神疾病的聯(lián)系，發(fā)現(xiàn)在按照DSM的標(biāo)準(zhǔn)確診的患有注意力不足過(guò)動(dòng)癥、自閉癥、躁郁癥、重度抑郁癥及精神分裂癥的人中有四處變異很普遍。

　　Likewise, a series of papers over the past decade have shown similar abnormal activationof part of the brain called the amygdala in people diagnosed with anxiety, majordepression and post-traumatic stress disorder.

　　同樣，過(guò)去十年中的一系列論文證實(shí)了確診患有焦慮癥，重度抑郁癥及創(chuàng)傷后應(yīng)激障礙的人的大腦中叫做杏仁核的部分有類似的異常活化。

　　Such results suggest that the DSM s approach of placing patients in diagnostic silos isquestionable.

　　這樣的結(jié)果表明DSM將患者按診斷癥狀分類的方法值得商榷。

　　As Dan Blazer of Duke University, who served on DSM-5 s task-force, puts it, We re basicallydrawing artificial lines, and the body and the mind do not work like that.

　　正如DSM第五版的編寫組成員，杜克大學(xué)的丹?布雷澤所說(shuō)，我們正從大體上勾勒人為的分類界線，身體和精神都不會(huì)如此運(yùn)作。

　　The new DSM aspires to include objective criteria in its manual.It also seeks to scrapnonsensical, strict lines between certain disorders.

　　新版的DSM渴望將客觀標(biāo)準(zhǔn)也囊括在其手冊(cè)中，也尋求將某些病癥中荒謬的，嚴(yán)苛的條文去掉。

　　It has, for example, chunked together four previously separate diagnoses, including autismand Asperger s syndrome, into one disorder of varying severity, known as autismspectrum disorder.

　　例如，新版中將之前四種單獨(dú)的病癥，包括自閉癥及阿斯伯格綜合癥合并成一種嚴(yán)重程度不一的神經(jīng)疾病，叫做自閉癥譜系障礙。

　　In this, it is following clinical practice, for the idea of an autistic spectrum has been aroundfor a long time.

　　由于自閉癥譜系的概念已經(jīng)出現(xiàn)很久了，所以對(duì)該病癥的診斷是遵循臨床實(shí)踐。

　　And the unfortunate truth is that it is still far too early to use biological markers as criteriafor diagnosis.

　　但事實(shí)令人遺憾，使用生物學(xué)標(biāo)記作為診斷標(biāo)準(zhǔn)仍然太早。

　　The human brain is the most impossibly complex thing in the universe, says Allen Frances,who led the development of DSM-IV.

　　人腦是宇宙中復(fù)雜到無(wú)可附加的事物，DSM第四版的編寫組組長(zhǎng)阿倫?弗朗西斯稱，

　　It does not yield its secrets easily.

　　它不會(huì)輕易把自己的秘密交出來(lái)。

　　Worse, argues Dr Frances, DSM-5 has not stopped the rise in the number of allegedlyrecognisable and nameable mental conditions, many of which annex into psychiatry thingsthat the man in the street would think normal, if not always desirable, behaviour.

　　更糟的是，弗朗西斯博士提出，DSM第五版中所謂可以識(shí)別及命名的精神狀況的數(shù)量還在增加，許多連路人都會(huì)認(rèn)為屬于正常，但不一定適當(dāng)?shù)男袨楸粴w為精神疾病。

　　Children may now, for example, be diagnosed with disruptive mood dysregulationdisorderwhat used to be known as temper tantrums.

　　例如，兒童現(xiàn)在可能會(huì)被診斷患有破壞性情緒失調(diào)癥-曾被稱為亂發(fā)脾氣。

　　Past versions of the DSM stipulated that those mourning a death should not be classified asdepressed. DSM-5 scraps this bereavement exclusion.

　　之前版本的DSM規(guī)定那些哀痛逝者的行為不應(yīng)該歸為抑郁，但DSM第五版刪掉了排除喪親之痛這條。

　　It also includes a new binge-eating disorder, defined as eating to excess at least once aweek over the previous three months.

　　第五版還加入了一種新的暴食癥，將其定義為在過(guò)去三個(gè)月內(nèi)至少每星期飲食過(guò)量一次。

　　Such a diagnosis covers millions of Americans, roping in people who would not remotelyconsider that they were mentally ill.

　　按此診斷的話會(huì)將數(shù)百萬(wàn)美國(guó)人涵蓋其內(nèi)，將那些從未想過(guò)自己患有精神病的人圈了進(jìn)去。

　　DSM-5 does not, after some debate among those who put it together, make addiction tointernet gaming a formal disorder. But it recommends further research into the condition.

　　在經(jīng)過(guò)其編寫者的一些爭(zhēng)論后，DSM第五版并未將網(wǎng)游成癮歸為正式的精神疾病，但其建議針對(duì)病情進(jìn)一步研究。

　　Grief. Indulgence. Unhealthy habits.

　　悲痛、上癮、不良習(xí)慣，

　　All, it seems, may be classified as mental derangement, and treated as such.

　　所有這些看來(lái)都會(huì)被歸為精神錯(cuò)亂，并按此治療。

　　And the sets of symptoms described by the DSM are often common.

　　DSM中描述的各類癥狀都非常常見。

　　More than one American child in ten has been diagnosed, using the DSM s definition, withADHDand about two-thirds of those so diagnosed are now prescribed drugs.

　　按照DSM的定義，每十名美國(guó)兒童中便至少會(huì)有一名被診斷患有ADHD-這些所謂患兒中有三分之二正在接受藥物治療。

　　It is this overdiagnosis and overtreatment that is the chief criticism of the DSMor, rather, ofthe power it wields in the profession of psychiatry. That power, however, may be waning.

　　這種過(guò)度診斷及過(guò)度治療正是針對(duì)DSM的主要詬病-或者，更確切的講，是針對(duì)DSM賦予精神病醫(yī)生職業(yè)的權(quán)力的詬病。然而這種權(quán)力或許正在減弱。

　　Literary criticism

　　專業(yè)評(píng)論

　　DSM categories have long been used in research.

　　DSM的分類已經(jīng)用于研究很久了。

　　That is changing.

　　但情況正在改變。

　　Other areas of medicine, cancer in particular, have been transformed by betterunderstanding of the biological drivers of disease.

　　其它的醫(yī)學(xué)領(lǐng)域，特別是癌癥領(lǐng)域，已經(jīng)通過(guò)對(duì)疾病的生物學(xué)驅(qū)動(dòng)機(jī)制的更深入了解而發(fā)生了轉(zhuǎn)變。

　　America s National Institute of Mental Health hopes that will transform psychiatry, too.

　　美國(guó)國(guó)家心理衛(wèi)生研究所希望這也將使精神病學(xué)發(fā)生改變。

　　The NIMH seeks to use genetics, imaging and cognitive science to create new diagnosticcriteria.

　　NIMH尋求使用遺傳學(xué)，成像及認(rèn)知科學(xué)來(lái)建立新的診斷標(biāo)準(zhǔn)。

　　Thomas Insel, the NIMH s director, has specifically implored researchers not to be confinedby DSM-5 s strict rules.

　　NIMH的主任托馬斯英索爾特別懇請(qǐng)研究人員不要被DSM第五版嚴(yán)苛的條文限制住。

　　Abiding by DSM categories may prevent scientists from understanding the underlyingcauses of sickness.

　　墨守DSM的分類可能會(huì)妨礙科學(xué)家了解疾病的根本原因。

　　Still, objective laboratory measures for mental illness are a long way off.

　　距離對(duì)精神疾病進(jìn)行客觀的實(shí)驗(yàn)室評(píng)估仍舊很遠(yuǎn)。

　　The APA says DSM-5 will be continuously updated to respond to new discoveries.

　　APA稱DSM第五版將會(huì)不斷更新以對(duì)新的發(fā)現(xiàn)做出反應(yīng)。

　　For now, however, patients treatment will be guided by the imperfect manual.

　　然而目前對(duì)病人的診療還要接受并不完美的手冊(cè)指導(dǎo)。

　　The DSM is purely a product of the state of our knowledge at this point in time, says JeffreyLieberman, the chairman of Columbia University s psychiatry department andpresident-elect of the APA.