说美国精神病医生不会错诊是盲目的迷信。自从斯坦福的罗森汉用假病人实验之后,精神病医生错误诊断不断被发现

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1973年,美国斯坦福大学的研究者Rosenhan做了一个著名的实验。罗森汉恩招募了8个人来做假病人。8个假病人由1名研究生、3名心理学家、1名儿科医生、1名精神病学家、1名画家、1名家庭主妇组成。他们要完成的任务是把自己送进12所精神病院。到了医院后,所有假病人都说相同的指导语,他们说自己能听到“轰”和“砰”等声音,除了这个症状外,所有被试的言语和行为完全正常,并且提供给医院的信息都是真实的。结果,除一人外,其余被试均被诊断为“精神分裂症”。

罗森汉恩实验(RosenhanExperiment)是1973年美国心理学家大卫·罗森汉恩关于检验美国精神病患鉴定标准的一项著名实验,并当年发布在《科学》杂志上。这项研究被认为是对精神病患鉴定标准的重要批判。

一旦进入医院 ,所有被试不再表现任何症状,行为完全正常。被试不知道自己什么时候能够被释放,直到医务人员认为他们已经恢复正常才能出院。在这段时间,被试会把自己的经历记录下来。

  最初,被试们试图隐藏记录的行为,后来他们发现这种隐藏完全没有必要,因为“记录行为”本身被认为是他们精神病的另外一个症状。而他们在院内的行为完全正常:与医务人员合作,接受所有的药物治疗(但药物不下咽,扔到厕所里冲掉)。

  结果,在研究中出现了关键的发现:没有任何一个假病人被任何一个医务人员识破 !当这些人出院后,他们的心理状况被认为是“精神病恢复期”而记录在他们的病历中。除此之外,还有许多其他有趣的发现。

  当精神病医院的医生、忽视和其他工作人员没能鉴别出加病人时,其他的真病人却不那么容易被欺骗。在这个实验的第二个阶段,在假病人所在的医院,精神病医院的医生对118个真病人中的35个表示怀疑,他们怀疑被试不是真正的精神病人:“你不是疯子!你是记者或编辑,你们是来检查医院的!”

  在精神病院里,病人与医务人员之间的交流是很少的,而且常常是古怪的,双方几乎没有任何实际的交流。同时对此形 成鲜明对比的是精神药物的滥用。在研究中,医院共发给这8个假病人2100片药物(众所周知,精神药物的副作用是非常大的)。当然被试没有吃这些药,但他们注意到,许多真正的病人也偷偷把他们的药片扔到厕所里。另外一个奇闻是:一位护士,她的制服没有系扣,在白天病房里满屋子的男病人面前调整自己的胸罩。当然这不是她有意挑逗,根据被试报告,她只是没有把精神病人当成真正的人来看待。

  罗森汉恩的研究有力地证明了在精神卫生机构中正常人不能与真正的精神病人区别开来。事实上,精神病学专业 人员具有一种刻板印象,倾向于忽略病人的个性化特征,并直接给病人贴上精神病学的诊断标签,在病人被贴上如“精神分裂症”的标签后,医务人员对其所有行为都归因于标签,因此,对被试的记录行为缺乏关注和怀疑,只把它当成精神病标签的另一个行为的证据。并且,医务人员倾向与忽略影响病人的环境因素(对病人的行为具有完全内部归因的倾向)。对于假病人所提供的完全真实且正常的个人历史,他们给出完全精神病学的解释。

  他的研究发表后,震动了精神病学专业领域,这个研究说明了两个关键因素 :第一、在精神病机构中正常人并不能与精神病人区别开;第二、揭示了诊断标签的危险性,一个人一旦被贴上精神病学意义的标签,这个标签将掩盖这个人所有的其它特征,所有行为和人格特征都会被归因于标签障碍。

之后,为了验证他自己的论断,他通知精神病院的医务人员,在未来的三个月内,会有一些假病人将试图进入他们的医院。结果三个月之后,193人被确认是假病人,然而罗森汉恩在这三个月内竟然没有派任何假病人去医院!“这个实验是很有教育意义的”,罗森汉恩说,“让任何一个诊断过程本身 出现这么多错误时,它当然不会是一个让人放心的诊断过程。”事实上,从心理学角度来看,精神病学诊断的效度是非常值得怀疑的。 Rosenhan将这个看似荒谬的研究结果以’On being sane in insane places’(当正常人在不正常的地方)为题,发表在顶级学术期刊《科学》(Science)上,引起心理学界和精神病学界的轰动和强烈关注。

The Rosenhan experiment or Thud experiment was an experiment conducted to determine the validity of psychiatric diagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title "On being sane in insane places". It is considered an important and influential criticism of psychiatric diagnosis.

Rosenhan's study was done in two parts. The first part involved the use of healthy associates or "pseudopatients" (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations in an attempt to gain admission to 12 psychiatric hospitals in five states in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had no longer experienced any additional hallucinations. All were forced to admit to having a mental illness and had to agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia "in remission" before their release.

The second part of his study involved an offended hospital administration challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 250 new patients the staff identified 41 as potential pseudopatients, with 2 of these receiving suspicion from at least one psychiatrist and one other staff member. In fact, Rosenhan had sent no pseudopatients to the hospital.

 

 
新的对精神病错误诊断的总结:
 
 
 2013 Aug 6;159(3):221-2. doi: 10.7326/0003-4819-159-3-201308060-00655.

The new crisis of confidence in psychiatric diagnosis.

Comment in

  • The new crisis of confidence in psychiatric diagnosis. [Ann Intern Med. 2013]
  • ....
    The DSM-5, the recently published fifth edition of the diagnostic manual, ignored this risk and introduced several high-prevalence diagnoses at the fuzzy boundary with normality. With the DSM-5, patients worried about having a medical illness will often be diagnosed with somatic symptom disorder (5), normal grief will be misidentified as major depressive disorder, the forgetfulness of old age will be confused with mild neurocognitive disorder, temper tantrums will be labeled disruptive mood dysregulation disorder, overeating will become binge eating disorder, and the already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further.
    These changes will probably lead to substantial false-positive rates and unnecessary treatment. Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illnesses caused by a chemical imbalance and require a solution in pill form. This results in misallocation of resources, with excessive diagnosis and treatment for essentially healthy persons (who may be harmed by it) and relative neglect of those with clear psychiatric illness (whose access to care has been sharply reduced by slashed state mental health budgets) (6). Only one third of persons with severe depression receive mental health care, and a large percentage of our swollen prison population consists of true psychiatric patients with no other place to go. Meta-analysis shows that the results of psychiatric treatment equal or surpass those of most medical specialties (7), but the treatments must be delivered to patients who really need them instead of being squandered on those likely to do well on their own.
    The DSM-5 did not address professional, public, and press charges that its changes lacked sufficient scientific support and defied clinical common sense. It was prepared without adequate consideration of risk–benefit ratios and the economic cost of expanding the reach of psychiatry just when the field is about to achieve parity within an expanded national insurance system (8). I found the DSM-5 process secretive, closed, and disorganized. Deadlines were consistently missed. Field trials produced reliability results that did not meet historical standards. I believe that the financial conflict of interest of the American Psychiatric Association (APA), generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product. The APA refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations (9). Publishing profits trumped public interest.
    The APA has been responsible for the diagnostic system for 100 years, having initially accepted the task when it was too unimportant for anyone else to care. However, the DSM has since acquired perhaps too much real-world influence as the arbiter of who gets what treatment and whether it will be reimbursed; who is eligible for disability benefits, Veterans Affairs benefits, and school and mental health services; and who qualifies to receive life insurance, adopt a child, fly an airplane, or buy a gun.
    New psychiatric diagnoses are now potentially more dangerous than new psychiatric drugs. Diagnostic expansions lead to drug company promotions that dramatically increase the use of unnecessary medications, with high cost and potentially harmful side effects. In the United States, we carefully monitor new drug development but do not have an effective system to vet the safety and efficacy of new psychiatric diagnoses. The problems associated with the DSM-5 prove that the APA should no longer hold a monopoly on psychiatric diagnosis. Another mechanism for revising the diagnostic system must be developed.
    My advice to physicians is to use the DSM-5 cautiously, if at all. It is not an official manual; no one is compelled to use it unless they work in an institutional setting that requires it. The codes needed for reimbursement are available for free on the Internet (10).
     
     

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    8. Frances A. How many billions a year will the DSM-5 cost? Bloomberg View Web site. 20 December 2012. Accessed at http://bloomberg.com/news/2012-12-20/how-many-billions-a-year-will-the-dsm-5-cost-.html on 6 May 2013.
    9. Division 32 Committee on DSM-5. The Open Letter to DSM 5 Task Force. Coalition for DSM-5 Reform Web site. Accessed at http://dsm5-reform.com/the-open-letter-to-dsm-5-task-force on 6 May 2013.
    10. Centers for Disease Control and Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Atlanta, GA: Centers for Disease Control and Prevention; 2012. Accessed at www.cdc.gov/nchs/icd/icd9cm.htm on 6 May 2013.

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