Pathological: The True Story of Six Misdiagnoses
來自今日心理學/Christopher Lane 博士：“Sarah Fay 的誤診回憶錄與 Elizabeth Wurtzel 的 Prozac Nation、  Lauren Slater 的 Prozac Diary 和 Andrew Solomon 的 The Noonday Demon 一起關注抑鬱症的原始生活經歷及其相關痛苦。
From Psychology Today/Christopher Lane PhD: “Sarah Fay’s memoir of her misdiagnoses joins Elizabeth Wurtzel’s Prozac Nation, Lauren Slater’s Prozac Diary, and Andrew Solomon’s The Noonday Demon in focusing on the raw lived experience of depression and its associated suffering.

“病態的是一切我希望我知道，”Fay 在一系列精神病學家和治療師診斷她從 12 歲開始患有厭食症，然後是強迫症，然後是多動症，然後是廣泛性焦慮，然後是重度抑鬱症之後，寫道她 25 年的磨難，在將他們的診斷改為雙相情感障礙之前。
‘Pathological is everything I wish I’d known,’ Fay writes of her 25-year ordeal after a trail of psychiatrists and therapists diagnosed her from age 12 with anorexia, then OCD, then ADHD, followed by generalized anxiety, then major depression, before altering their diagnosis to bipolar disorder.

從那裡開始，戰斗對決(battle )是轉移到正確的診斷是雙相 I 還是 II，以及她反應最好和最差的藥物治療。
From there, the battle shifts to whether the correct diagnosis is bipolar I or II, as well as the drug treatments to which she responds best and worst.

至少，每一個新的診斷都會促使 Fay 對之前的診斷進行一次重大的重新思考。在她十幾歲和二十出頭的時候，她認為它們是準確和“真實的”，甚至是自我定義的：“我相信並接受了這六種診斷——採用它們，從它們的角度思考，將自己視為它們，將我的困難醫學化和不適，使我的情緒、思想和行為病態化。
Each new diagnosis prompts in Fay, at least, a major rethink of the one preceding it. In her teens and early twenties, she views them as accurate and ‘real,’ even as self-defining: ‘I believed in and accepted those six diagnoses—adopted them, thought in terms of them, identified myself as them, medicalizing my difficulties and discomforts, pathologizing my emotions and thoughts and behaviors.’

但隨著每次誤診的後果不斷升級，包括非自願住院，這本書迫使我們問：她的醫生一直缺少什麼？每個早期診斷都忽略了什麼？而且，最根本的是，這些治療是否會導致她出現越來越多的問題？這些從“破裂(cracking)”和“分裂(splintering)”的感覺演變為飆速(racing)、“好戰、無情”的想法；脫離現實的問題；強烈的噁心，然後是“殘酷的利他林反彈”；和全面發作的靜坐不能(full-blown bouts of akathisia)——與後來給她開的抗精神病藥有關的激動的痛苦和不安，但沒有經歷過一次精神病發作。
But as the consequences of each misdiagnosis escalate, including involuntary hospitalization, the book compels us to ask: What do her doctors keep missing? What did each earlier diagnosis overlook? And, most fundamentally, are the treatments contributing to her mounting problems? These evolve from sensations of ‘cracking’ and ‘splintering’ into racing, ‘belligerent, unrelenting’ thoughts; problems with derealization; intense nausea followed by a ‘brutal Ritalin rebound’; and full-blown bouts of akathisia—agitated distress and restlessness tied to the antipsychotics she is later prescribed, without however experiencing a single psychotic episode.

. . . 儘管 Fay 看到的精神科醫生都很細心，用心良苦，總是試圖減輕她的痛苦，但他們反复犯錯的程度並沒有導致任何專業的評估，更不用說對所造成的損害進行適度的反省了。他們仍然對錯誤過於自信，無論是在他們提供的診斷和在幾分鐘內轉換，還是在他們引入和逐步淘汰的基於藥物的治療中，都存在類似的粗心大意。從本書的各個部分：
. . . Although the psychiatrists Fay sees are attentive and well-intentioned, seeking always to lessen her suffering, the scale of their repeated errors does not lead to any professional reckoning, much less to even modest introspection over the damage caused. They remain overconfident to a fault, both in the diagnoses they deliver and switch within minutes and in the drug-based treatments they introduce and phase out with similar heedlessness. From various parts of the book:

– 他點了點頭。“注意力缺陷障礙/強迫症具有一些抑鬱焦慮因素。”
— He nodded. ‘Attention deficit disorder/OCD features with some depressive anxious elements.’

——我們的時間到了，她嘆了口氣。然後她告訴我我患有重度抑鬱症。
— When our time was up, she sighed. Then she told me I had major depressive disorder.

——H博士：“我會把你歸入雙相II的範疇。”
— Dr. H: ‘I would put you in the category of bipolar II.’

— M 博士：“具有混合特徵的雙相 I。”
— Dr. M: ‘Bipolar I with mixed features.’

——R博士“第三次改變了我的診斷。”
— Dr. R ‘had changed my diagnosis—for the third time.’

‘ DSM診斷很容易獲得，而且不值得信任，’Fay 相當合理地總結道。與自始至終一樣，在一本附有索引和 32 頁參考文獻的回憶錄中，她用大量證據支持這一斷言，這一次來自 2005 年國家合併症調查復制，最近，疾病預防控制中心：“超過 46% 的美國人成人和 20% 的兒童和青少年將在其一生中接受 DSM診斷。”
‘DSM diagnoses are easy to get and aren’t to be trusted,’ Fay concludes quite reasonably. As throughout, in a memoir published with an index and 32 pages of references, she backs up the assertion with mountains of evidence, this time from the 2005 National Comorbidity Survey Replication and, more recently, the CDC: ‘More than 46 percent of American adults and 20 percent of children and adolescents will receive a DSM diagnosis in their lifetimes.’”

文章→
https://www.psychologytoday.com/us/blog/side-effects/202206/pathological-the-true-story-six-misdiagnoses

病理：六次誤診的真實故事
Pathological: The True Story of Six Misdiagnoses
一篇關於精神病錯誤和狂妄自大的引人入勝的新回憶錄的回顧。
A review of a compelling new memoir on psychiatric error and hubris.

關鍵點

• 超過 46% 的美國成年人和 20% 的兒童和青少年將在其一生中接受 DSM 診斷。
• 一本新的回憶錄大量借鑒了診斷手冊及其各種版本，以挑戰其可靠性和有效性。
• 這本書要求臨床醫生在分配強大的診斷代碼之前暫停。
  

KEY POINTS

• More than 46 percent of American adults and 20 percent of children and adolescents will receive a DSM diagnosis in their lifetime.
• A new memoir draws heavily from the diagnostic manual and its various editions to challenge their reliability and validity.
• The book asks clinicians to pause before assigning powerful diagnostic codes.

Sarah Fay 的誤診回憶錄與 Elizabeth Wurtzel 的Prozac Nation、 Lauren Slater 的Prozac Diary和 Andrew Solomon 的The Noonday Demon一起關注抑鬱症的原始生活經歷及其相關痛苦。
Sarah Fay’s memoir of her misdiagnoses joins Elizabeth Wurtzel’s Prozac Nation, Lauren Slater’s Prozac Diary, and Andrew Solomon’s The Noonday Demon in focusing on the raw lived experience of depression and its associated suffering.

“病理是我希望我知道的一切，”Fay 在一系列精神病學家和治療師診斷她從 12 歲開始患有厭食症，然後是強迫症，然後是多動症，然後是廣泛性焦慮，然後是重度抑鬱症之後，寫下了她 25 年的磨難，在將他們的診斷改為雙相情感障礙之前。
“Pathological is everything I wish I’d known,” Fay writes of her 25-year ordeal after a trail of psychiatrists and therapists diagnosed her from age 12 with anorexia, then OCD, then ADHD, followed by generalized anxiety, then major depression, before altering their diagnosis to bipolar disorder.

從那裡開始，戰斗轉移到正確的診斷是雙相 I 還是 II，以及她反應最好和最差的藥物治療。
From there, the battle shifts to whether the correct diagnosis is bipolar I or II, as well as the drug treatments to which she responds best and worst.

至少，每一個新的診斷都會促使 Fay 對之前的診斷進行一次重大的重新思考。在她十幾歲和二十出頭的時候，她認為它們是準確和“真實的”，甚至是自我定義的：“我相信並接受了這六種診斷——採用它們，從它們的角度思考，將自己認同為它們，將我的困難醫學化和不適，使我的情緒、思想和行為病態化。”
Each new diagnosis prompts in Fay, at least, a major rethink of the one preceding it. In her teens and early twenties, she views them as accurate and “real,” even as self-defining: “I believed in and accepted those six diagnoses—adopted them, thought in terms of them, identified myself as them, medicalizing my difficulties and discomforts, pathologizing my emotions and thoughts and behaviors.”

但隨著每次誤診的後果不斷升級，包括非自願住院，這本書迫使我們問：她的醫生一直缺少什麼？每個早期診斷都忽略了什麼？而且，最根本的是，這些治療是否會導致她出現越來越多的問題？這些從“破裂”和“分裂”的感覺演變為競速、“好戰、無情”的想法；脫離現實的問題；強烈的噁心，然後是“殘酷的利他林反彈”；和全面發作的靜坐不能——與後來給她開的抗精神病藥有關的激動的痛苦和不安，但沒有經歷過一次精神病發作。
But as the consequences of each misdiagnosis escalate, including to involuntary hospitalization, the book compels us to ask: What do her doctors keep missing? What did each earlier diagnosis overlook? And, most fundamentally, are the treatments contributing to her mounting problems? These evolve from sensations of “cracking” and “splintering” into racing, “belligerent, unrelenting” thoughts; problems with derealization; intense nausea followed by a “brutal Ritalin rebound”; and full-blown bouts of akathisia—agitated distress and restlessness tied to the antipsychotics she is later prescribed, without however experiencing a single psychotic episode.

在每種情況下，新的診斷都不穩定地位於以前的診斷之上，重新塑造了她生活的整個篇章，但也引發了關於她的精神科醫生的跨評估者可靠性的緊迫問題。“我認為是強迫症（過度警覺、強迫思維、社會孤立），”她寫道，“是多動症（多動、過度專注、社會孤立）。” 同樣清楚的是，她的精神科醫生在再次改變她的診斷之前也是如此。
In each case, the new diagnosis sits precariously atop the previous ones, recasting entire chapters of her life but also raising urgent questions about her psychiatrists’ inter-rater reliability. “What I’d thought was OCD (hypervigilance, obsessive thoughts, social isolation),” she writes, “was ADHD (hyperactivity, overfocus, social isolation).” Just as clearly, so had her psychiatrists before they altered her diagnosis again.

從 1980 年代的“厭食症時代”開始，Fay 陷入了每一種新的診斷時尚，十年後，許多患者的 ADHD 診斷被大量更改為雙相情感障礙，此舉恰逢大眾-第二代抗精神病藥的營銷：“那時，我正在接受三種[藥物治療]：SSRI（我還沒有停藥）、苯二氮卓類藥物（用於治療因戒斷引起的腦震盪和驚恐發作）和抗驚厥藥/情緒穩定劑拉莫三嗪。鋰，神奇的情緒穩定劑，可以製造四個。”
Caught up in each new diagnostic fad, beginning with the “Age of Anorexia” in the 1980s, Fay is one of many patients whose ADHD diagnoses were altered en masse to bipolar disorder a decade later, in a move timed to coincide with the mass-marketing of second-generation antipsychotics: “By then, I was on three [drug treatments]: the SSRI (which I still wasn’t off), a benzodiazepine (for the brain zaps and panic attacks caused by withdrawal), and the anticonvulsant/mood stabilizer lamotrigine. Lithium, the miracle mood stabilizer, would make four.”

在 Fay 的案例中，多重用藥導致了一連串的戒斷問題和交叉效應，儘管她被告知在藥物治療方案中進行了一次轉換，以一種揭示所有人的方式：“這是一個簡單的調整。就像戴眼鏡一樣。”
The polypharmacy in Fay’s case leads to a cascade of withdrawal problems and cross-effects, though she is told of one switch in a drug regimen in a manner revealing of all: “It’s a simple adjustment. It will be like wearing glasses.”

然而，摘下“眼鏡”遠非易事。對於藥物的長期副作用，她反復被告知：“……不，沒有嚴重的風險。” 在一封經許可引用的後續電子郵件中，Fay 證實：“沒有人建議我們重新評估我的病情，因為我生活中的情況發生了變化，藥物開始生效。”
Removing the “glasses,” though, proves far from easy. Of the drugs’ long-term adverse effects, she is repeatedly advised: “…No, there are no serious risks.” In a follow-up email quoted with permission, Fay confirms: “No one ever suggested we reassess my condition as the circumstances in my life changed and the medication took effect.”

儘管 Fay 看到的精神科醫生都很細心，用心良苦，總是試圖減輕她的痛苦，但他們反复犯錯的程度並沒有導致任何專業的評估，更不用說對所造成的損害進行適度的反省了。他們仍然對錯誤過於自信，無論是在他們提供的診斷和在幾分鐘內轉換，還是在他們引入和逐步淘汰的基於藥物的治療中，都存在類似的粗心大意。從本書的各個部分：
Although the psychiatrists Fay sees are attentive and well-intentioned, seeking always to lessen her suffering, the scale of their repeated errors does not lead to any professional reckoning, much less to even modest introspection over the damage caused. They remain overconfident to a fault, both in the diagnoses they deliver and switch within minutes and in the drug-based treatments they introduce and phase out with similar heedlessness. From various parts of the book:

– 他點了點頭。’注意力缺陷障礙/強迫症特徵與一些抑鬱焦慮因素。

——我們的時間到了，她嘆了口氣。然後她告訴我我患有重度抑鬱症。

——H博士：“我會把你歸入雙相II的範疇。”

— M 博士：“具有混合特徵的雙相 I。”

——R博士“第三次改變了我的診斷。”

— He nodded. ‘Attention deficit disorder/OCD features with some depressive anxious elements.’

— When our time was up, she sighed. Then she told me I had major depressive disorder.

— Dr. H: ‘I would put you in the category of bipolar II.’

— Dr. M: ‘Bipolar I with mixed features.’

— Dr. R ‘had changed my diagnosis—for the third time.’

“ DSM診斷很容易獲得，而且不可信，”Fay 相當合理地總結道。與自始至終一樣，在一本帶有索引和 32 頁參考文獻的回憶錄中，她用大量證據支持了這一斷言，這一次來自2005 年全國合併症調查復制，最近又來自疾病預防控制中心：“超過 46% 的美國人成年人和 20% 的兒童和青少年將在其一生中接受DSM診斷。”
“DSM diagnoses are easy to get and aren’t to be trusted,” Fay concludes quite reasonably. As throughout, in a memoir published with an index and 32 pages of references, she backs up the assertion with mountains of evidence, this time from the 2005 National Comorbidity Survey Replication and, more recently, the CDC: “More than 46 percent of American adults and 20 percent of children and adolescents will receive a DSM diagnosis in their lifetimes.”

回憶錄一次又一次地回到診斷有效性這個令人不安的問題，包括“精神科藥物被用來說服患者他們確實患有精神障礙”的事後方式。藥物作為診斷證明定理是，”Fay 評論道，“診斷等價於鞋子是否合腳，就穿上它。”
Over and again, the memoir returns to the troubling question of diagnostic validity, including the post-hoc manner in which “psychiatric medications are used to convince patients that they do indeed have a mental disorder. The medication-as-proof-of-diagnosis theorem is,” Fay remarks, “the diagnostic equivalent of if the shoe fits, wear it.”

當然，準確的診斷可以識別醫療狀況並加速適當的治療。但它也可以使仍然通常不用藥物治療的行為病態化，並且在 Fay 的案例中——由於DSM的循環邏輯和權力——成為自我實現的預言：“我發現了作者列出的幾乎所有症狀的證據……。更多的證據我有，我越確定。我越確定，我就越願意接受治療。”
Accurate diagnosis can, of course, identify medical conditions and accelerate appropriate treatment. But it can also pathologize behaviors still commonly treated without medication and, in Fay’s case—due to the DSM’s circular logic and power—become self-fulfilling prophecies: “I found evidence for almost every symptom the authors listed….The more evidence I had, the more certain I became. The more certain I became, the more willing I was to undergo treatments.”

“我稱它們為誤診，”費伊推斷了這本頗具影響力的手冊中的代碼和內容，這仍然決定了保險公司是否會承擔治療費用，並在法庭、監獄和學校中發揮著巨大的作用。“所有DSM診斷都是誤診——即不正確、不准確、不充分。它們是通過放寬標準、添加說明符、改變症狀、擴大定義和降低閾值來創建的。”
“I call them misdiagnoses,” Fay extrapolates the codes and content that fill the influential manual, which still determines whether insurance companies will cover treatment and plays an outsized role in courts, prisons, and schools. “All DSM diagnoses are misdiagnoses—i.e., incorrect, inaccurate, inadequate. They were created by loosening criteria, adding specifiers, shifting symptoms, broadening definitions, and lowering thresholds.”

在一部部分致力於語言和標點符號在描述健康和疾病中的作用的回憶錄中，Fay對DSM的幾個版本和許多文本修訂的一絲不苟的關注為她提供了很好的服務。正如她在談到她提供寶貴背景的其中一種情況時所說的那樣，“我對雙相情感障礙的了解比任何外行人都應該知道的多。” 該領域的領先學者可能會感到驚訝——有些人可能會感到沮喪——看到他們的工作被引用和挑戰。
In a memoir partly devoted to the role of language and punctuation in describing health and illness, Fay’s scrupulous attention to the DSM’s several editions and many textual revisions serves her well. As she remarks on just one of the conditions for which she provides invaluable context, “I learned more about bipolar disorder than any layperson should know.” Leading scholars in the field may be surprised—and some perhaps dismayed—to see their work cited and challenged.

病態對相關形式的文化信息同樣精明，包括小說如何提供其他心理健康和疾病模型。在 Steven Levenkron 2013 年流行的關於厭食症的小說中，Fay 寫道，“世界上最好的小女孩給了我一條 [to anorexia] 但沒有出路的方法。” 有一段時間，威廉斯泰倫的黑暗可見：瘋狂回憶錄對她有類似的決定性力量，儘管她最終拒絕了：
Pathological is similarly astute on related forms of cultural messaging, including how fiction provides other models of mental health and illness. Of Steven Levenkron’s popular 2013 novel about anorexia, Fay writes, “The Best Little Girl in the World offered me a way in [to anorexia] but no way out.” For a while, William Styron’s Darkness Visible: A Memoir of Madness has similar determinative power over her, though it is one she ends up rejecting:

Styron 讓我對抑鬱症有了第一次了解。他將其稱為“情緒障礙”——聽起來很嚴重——並將其定義為“大腦神經遞質”中的“系統性壓力”導致血清素耗盡的生化故障。聽起來很科學。如此可靠。如此有效。… 1990 年，當黑暗可見出版時，斯泰隆可能會研究DSM-III-R。
Styron gave me my first understanding of depression. He referred to it as a “mood disorder”—which sounded serious—and defined it as a biochemical malfunction that resulted from “systemic stress” amid “neurotransmitters of the brain” that caused the depletion of serotonin. It sounded so scientific. So reliable. So valid. … In 1990, when Darkness Visible was published, Styron likely would have studied the DSM-III-R.

這是一個引人注目的點：我們繼承的疾病模型不僅涉及DSM本身，還涉及它產生的版本以及它們所象徵的各個十年和“時代”。例如，關於她自己和她當時所見的心理學家，Fay 諷刺地說：“勞拉和我處於
DSM-III時代。”
It’s a striking point: the disease models we inherit involve not just the DSM per se, but the editions it has spawned and the various decades and “eras” they have come to symbolize. Of herself and the psychologist she is seeing at the time, for example, Fay remarks wryly: “Laura and I were in the DSM-III era.”

“精神疾病是非常真實的，”Fay 通過電子郵件向我保證。“ DSM的診斷並非如此。正確的判斷是，我患有精神疾病已經二十五年了。”
“Mental illness is very real,” Fay assures me over email; “DSM diagnoses are not. A correct assessment is that I suffered from mental illness for twenty-five years.”

深刻、有見地和深入研究的《病理學》敦促克制DSM鼓勵的醫療化和過度診斷。它要求臨床醫生在分配之前暫停使用強大的診斷代碼。它指出了我們過度依賴的診斷手冊的許多缺陷，並贊同2015 年DSM-5
智能臨床醫生指南中的警告：“在沒有獨立措施的情況下……我們無法確定任何手冊中的類別有效。”

Incisive, insightful, and deeply researched, Pathological urges restraint on DSM-encouraged medicalization and overdiagnosis. It asks clinicians overeager with powerful diagnostic codes to pause before assigning them. It points up the many flaws of a diagnostic manual on which we are over-reliant and endorses the caveats of The Intelligent Clinician’s Guide to the DSM-5 from 2015: “In the absence of independent measures…we cannot be sure that any category in the manual is valid.”

參考
Fay, S. 2022。病理：六次誤診的真實故事。哈珀一號。[鏈接]
Fay, S. 2022. Pathological: The True Story of Six Misdiagnoses. HarperOne. [Link]
Paris, J. 2015。DSM-5 智能臨床醫生指南，第二版。牛津大學。[鏈接]
Paris, J. 2015. The Intelligent Clinician’s Guide to the DSM-5, Second Edition. Oxford UP. [Link]

關於作者


克里斯托弗萊恩博士 ，曾獲得 Prescrire 醫學寫作獎，並在西北大學任教。
他是《害羞：正常行為如何變成病態》的作者。
Online： 克里斯托弗萊恩-作者網站，臉譜網，推特