How Diagnostic Interviews Translate Situational Behavior Into Pathology
研究發現，在診斷性訪談中，臨床醫生對特定情境行為的解釋會導致人格障礙診斷。
Study finds that, in diagnostic interviews, clinician interpretations of context-specific behaviors lead to personality disorder diagnoses.
麥迪遜 Natarajan，MS-2022 年 8 月 11 日
一項在芬蘭進行並發表在《健康》雜誌上的新研究調查了對臨床醫生和被診斷患有人格障礙的患者的深入訪談，特別關注臨床醫生和患者之間關於他們行為的普遍性的差異(regarding the generalizability of their behavior.VF)。
A new study conducted in Finland and published in the journal Health examines in-depth interviews of clinicians and patients diagnosed with personality disorders, paying particular attention to the discrepancies between clinician and patient regarding the generalizability of their behavior.
通過互動研究和對話分析，結果顯示，患者經常將他們的行為背景化為一系列情境因素的結果，然後臨床醫生將其轉化為人格特徵的精神病學語言。研究結果表明，使塑造精神病學診斷過程的主觀實踐可見的重要性。
Through interactional research and conversation analysis, the results revealed that patients frequently contextualized their behavior as an outcome of an array of situational factors that clinicians then translated into the psychiatric language of personality traits. The findings suggest the importance of making visible the subjective practices that shape the diagnostic process in psychiatry.
此外，作者將患者的描述翻譯成精神病學語言以符合診斷標準的問題。
Further, the authors problematize translating patients’ accounts into psychiatric language to fit diagnostic criteria.
“我們已經展示了一些有問題的模式，其中去情境化症狀的假設受到了挑戰。我們的觀察表明，患者經常強調上下文過度概括的因素。這種解釋模型有時與 SCID-II 衝突，後者尋求導致某些行為的固有和持久特徵。”
“We have shown some problematic patterns in which the assumption of de-contextualized symptoms become challenged. Our observations show that patients often emphasize contextual over-generalizing factors. This explanatory model is sometimes in conflict with SCID-II, which seeks for inherent and long-lasting traits that cause certain behavior.”
從廣義上講，精神病學訪談沒有正式的定義，而是醫學訪談的一種變體，參與者為他們生活中的事件創造意義，從而構建現實。通常，面試官通過根據問題、沉默和重定向來引導討論來控制話題。
Broadly, a psychiatric interview has no formal definition but is a variant of a medical interview in which the participants create meanings for events in their lives and thus construct reality. Typically, the interviewer controls the topic by directing the discussion based on questions, silences, and redirection.
更正式的精神病學訪談類型是 DSM-IV Axis II 人格障礙的結構化臨床訪談，SCID-II，於 1997 年開發，以確定個人是否符合可診斷人格障礙的標準。這遵循一組預先確定的問題，但仍會根據面試官的風格而有所不同，並且旨在與“臨床判斷”結合使用。
A more formal type of psychiatric interview is the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, SCID-II, developed in 1997 to determine if an individual meets the criteria for a diagnosable personality disorder. This follows a set of predetermined questions but still has variability based on the interviewer’s style and is meant to be used in conjunction with “clinical judgment.”
由赫爾辛基大學的Maarit Lehtinen領導的作者強調了遵守醫療框架的困難，在該框架中，訪談的目的是獲得診斷的“事實”信息，這常常迫使精神科醫生將上下文相關的行為轉變為一種內在的、穩定的特性。
The authors, led by Maarit Lehtinen at the University of Helsinki, highlight the difficulties of adhering to the medical framework in which the purpose of the interview is to obtain “factual” information for the diagnosis, often forcing psychiatrists to transform context-bound behavior into an intrinsic, stable trait.
在精神病學中，西方國家有兩本主要的精神病診斷手冊：《精神疾病診斷和統計手冊》（DSM）和世界衛生組織（WHO）的《與健康問題相關的疾病國際統計分類》（ICD）。儘管這些手冊受到了很多批評，但它仍然是西方精神病學診斷的主要用途。
Within psychiatry, there are two primary manuals for psychiatric diagnoses in western countries: the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Disease Related to Health Problems (ICD) by the World Health Organization (WHO). Although these manuals have received much criticism, it remains the primary use for Western psychiatric diagnosis.
人格障礙的想法一直備受爭議。研究指出，在通常是有爭議的結構的精神病學診斷中，人格障礙尤其難以分類。在結構有效性、合併症和病因方面存在已知問題。關於邊緣性人格障礙，是否應將其視為人格障礙或創傷反應狀況尚無明確共識。此外，對反社會人格障礙歷史的分析表明，術語和定義的變化取決於 DSM 委員會小組成員對決策過程的個人影響。
The idea of a disordered personality has been highly contested. Research has pointed out that among psychiatric diagnoses, which are generally contested constructs, personality disorders are especially difficult to categorize. There are known issues with construction validity, comorbidity, and etiology. Regarding borderline personality disorder, there is no clear agreement on whether it should be treated as a personality disorder or a trauma response condition. Further, an analysis of the history of antisocial personality disorder showed that terms and definitions have changed depending on the DSM committee group member’s personal influence on the decision process.
目前的研究在芬蘭一家門診診所的一名精神病護士進行的 SCID-II 訪談中分析了 10 名視頻記錄的成年患者。該方法側重於使用話語心理學，即從參與者的角度研究心理問題，以及對話分析，這是一種研究社會互動和語言的方法。作者認為，將對話分析應用於精神病學領域可以從社會學的角度對精神病學實踐進行調查。
The current study analyzed ten video-recorded adult patients during a SCID-II interview conducted by a psychiatric nurse in an outpatient clinic in Finland. The method focused on using discursive psychology, which is the study of psychological issues from a participant’s perspective, as well as conversation analysis, which is an approach to studying social interaction and language. The authors argue that applying conversation analysis to the psychiatric field enables the investigation of psychiatric practices from a sociological view.
結果揭示了六個主要要點。
The results revealed six primary takeaways.
首先，患者對自己行為的理解常常與 SCID-II 預測的不同，並且主要將他們的行為視為許多情境因素的結果。
First, patients frequently made sense of their own behavior differently than SCID-II predicts and primarily considered their behaviors as an outcome of many situational factors.
其次，患者很少直接反對訪談問題的形式，但他們的回答有時會反駁問題的基本假設。
Second, patients rarely straightforwardly opposed the format of the interview questions, but their responses sometimes countered the underlying assumptions of the questions.
第三，當患者在解釋他們的行為時排除人格信息時，他們指的是社會背景。
Third, when patients excluded information about personality in explaining their behavior, they were referring to the social context.
第四，患者有時將急性內心狀態稱為影響他們在特定情況下行為的重要因素，因此不認為它可以推廣到其他情況。
Fourth, patients sometimes referred to acute inner states as important factors affecting their behavior for a specific context and thus did not see it as generalizable to other situations.
同樣，患者傾向於認為行為只涉及生活的一小部分，不能以此為基礎進行概括。因此，例如，在許多情況下，他們能夠提出一個他們按照要求行事的背景，但他們不會認為這是描述他們的整體個性。
Similarly, patients tended to think that behavior touches only one small area of life and cannot be generalized based on that. So, for example, in many cases, they were able to come up with a context in which they behave as asked, but they would not see this as describing their overall personality.
最後，患者不一定認為他們的性格在整個成年期都保持穩定。相反，他們可能會注意到由於生活經歷而隨著時間的推移而發生的變化。作者寫道”
Lastly, patients did not necessarily think of their personality as remaining stable across adulthood; rather, they might notice changes over time due to life experiences. The authors write”
“我們已經觀察到臨床醫生如何在以醫學為導向的精神病學中運作，因此需要在進行評估之前將患者的行為與上下文變量隔離開來。”
“We have observed how clinicians operate within medically oriented psychiatry and thus need to isolate the patient’s conduct from the contextual variables before making their evaluations.”
雖然所提供的研究沒有因果數據，但它提供了可觀察到的洞察力，以了解患者的配方如何在 SCID-II 訪談框架中出現問題。為了適應 SCID-II 訪談的範圍，必須重新制定或忽略部分患者的答案，從而將反應操縱成精神病學語言。
While the research presented has no causal data, it provides observable insight into how a patient’s formulation becomes problematic in the SCID-II interview framework. To fit within the confines of the SCID-II interview, part of the patients’ answers must be reformulated or ignored, which manipulates the response into psychiatric language.
作者強調了人格障礙的兩個不確定性水平。首先，結構本身仍然存在問題，包括人格障礙和其他精神症狀之間的重疊。這導致了一個基本問題，即為什麼某些人格特徵在我們的社會中被視為障礙，並質疑“正常”和“病態”人格之間的界限在哪裡。
The authors highlight two levels of uncertainty regarding personality disorders. First, the construct itself remains in question, including the overlap between personality disorders and other psychiatric symptoms. This leads to the fundamental question of why certain personality traits are being held as disorders in our society and questioning where the line is drawn between “normal” and “pathological” personality.
其次，診斷過程、客觀性和 SCID-II 訪談的製度基礎存在問題。學者們強調了精神衛生專業人員對精神病學診斷的批判性理解的重要性，包括對不同機構如何塑造障礙和手冊的結構的批判性認識，例如 SCID-II 的結構，以及因此人格障礙診斷的可能後果對於一個病人。
Second, there is an issue with the diagnostic process, its objectivity, and the institutional underpinnings of the SCID-II interviews. Scholars have emphasized the importance of a critical understanding of psychiatric diagnosis among mental health professionals, including critical awareness of how different institutions shape the constructs of disorders and manuals, such as that of the SCID-II, and therefore the possible consequences of personality disorder diagnosis for a patient.
最後，作者希望這裡介紹的研究將增加培養這種意識的可能性。
In closing, the authors hope that the research presented here will increase the likelihood of developing such awareness.
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Lehtinen, M.、Voutilainen, L. 和 Peräkylä, A. (2022)。“這是你的基本性格嗎？” 關於人格障礙診斷性訪談中的特徵和背景的談判。健康：健康、疾病和醫學社會研究的跨學科期刊，136345932210947。https://doi.org/10.1177/13634593221094701 （鏈接）
Lehtinen, M., Voutilainen, L., & Peräkylä, A. (2022). ‘Is it in your basic personality?’ negotiations about traits and context in diagnostic interviews for personality disorders. Health: An Interdisciplinary Journal for the Social Study of Health, Illness, and Medicine, 136345932210947. https://doi.org/10.1177/13634593221094701 (Link)
麥迪遜 Natarajan，MSMadison Natarajan 是馬薩諸塞大學波士頓分校的碩士級心理治療師和目前的博士生。作為一名研究人員，她的重點是宗教創傷對女性性發育的影響，特別是評估福音派純潔運動的亞文化。麥迪遜的家族史與精神科護理交織在一起，從被收容的家庭成員到在美國和印度從事精神病學的人，不一而足。麥迪遜尋求挑戰西方當前的精神病治療結構，並向整個社區傳播誠實和授權的信息。
Madison Natarajan, MSMadison Natarajan is a master’s level psychotherapist and current doctoral student at the University of Massachusetts Boston. As a researcher, her focus is on the impact of religious trauma on female sexual development, specifically assessing the subculture of the evangelical purity movement. Madison has a family history that has been intertwined with psychiatric care, ranging from family members who were institutionalized to those practicing psychiatry, both in the US and India. Madison seeks to challenge the current structure of psychiatric care in the West and disseminate honest and empowering information to the community at large.
