Personality Disorders Still Hard to Define

人格異常如何界定 仍無共識

By Benedict Carey

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes include such well-known types as narcissistic personality disorder and avoidant personality disorder, as well as dependent and histrionic personalities.
在精神病學中，人格異常是其中棘手的一支。目前公定的人格異常症候群有10種，包括自戀型、逃避型、依賴型及歇斯底里型等人們熟知的人格異常。

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.
但這些異常在完全展現時，很難描繪其特性，也很難治療，醫師很少審慎評估，以致遺漏或低估了一些行為模式，這些行為模式潛藏在沮喪和焦慮這些千百萬人都有的問題之下。

The American Psychiatric Association has recently confronted one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem? The association has been trying to clarify these diagnoses and better integrate them into clinical practice.
美國精神病學學會最近就選擇面對精神病學界一個最基本，卻仍然懸而未決的問題：到底什麼是人格問題？該學會一直致力釐清對異常症狀的診斷，並將診斷與臨床實務做更好的整合。

Personality problems aren’t new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its collection of vainglorious, murderous dictators.
人格問題並非新近才出現或隱而不顯。希臘神話中就已有人格問題 ─ 從溺死後化成水仙的美少年納西瑟斯，到殘酷成性的戰神愛力士。這問題在聖經故事裡也俯拾皆是，瘋子、強迫性格者，以及具有神奇領袖魅力的人。在整個20世紀，這種人更是層出不窮，一個又一個自大而殘忍的獨裁者。

Yet it turns out that producing precise definitions of extreme behavior patterns is exhausting work. It took more than a decade before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression.
但事實證明，給極端行為模式訂出精確的定義，是讓人費盡心思的事。德國精神病學家克雷普林耗時逾10年，才在精神分裂症這種精神異常，和憂鬱症這種情緒問題之間，劃出明確界線。

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who described people with the sort of “confounded identities” that are now considered personality disorders. Their problems were not periodic symptoms, but issues rooted in longstanding habits of thought and feeling.
同樣地，精神分析大師佛洛伊德也花費多年，才有系統地對各種精神官能症候群的起源提出他的理論。佛洛伊德派分析醫師主要是那些把病患描述成具有某種「認同混淆」的人，這些認同現在被視為人格異常。這些人的問題並非各種周期性出現的症狀，而是源於思想、感受方面存在已久的習慣問題。

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic.”
賓漢頓紐約州立大學心理學教授藍茲維格說：「這些佛洛伊德派治療師發現求診者表面上看來中規中矩，但躺下來接受治療時變得毫無條理且能力殘缺。他們的問題既非精神病，也非精神官能症。」

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”
很快地，幾種人格異常的原型開始浮現。佛洛伊德派分析專家賴希在他1933年的開創性著作《性格分析》中說：「強迫性格者的特徵是對於次序過分講究，無論大事小事，這種人都根據先入為主、不可更改的模式過活。」

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.
其他類型也合併出現，一般人視為常見的極端人格有：自戀型，脆弱而浮誇的自我認可；依賴型，令人窒息的依戀；歇斯底里型，永遠置身某種戲劇之中，亟盼成為他人注目的焦點。

Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders and turned it into a set of 10 standardized types for the psychiatric association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.
人格及精神病理學高等研究所科學主任米倫，曾把大部分跟人格異常有關的研究做了番整理，歸結出一套分為10種的標準化人格異常，列入美國精神病學學會的第三版診斷手冊。這本手冊1980年出版，在全球精神健康工作者的圈子裡大受歡迎。

These diagnostic criteria led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies. Today there are several approaches that can relieve borderline symptoms and one that has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.
手冊中的診斷標準使得某些人獲得更好的治療，如邊緣性人格異常者。邊緣性人格異常的特徵是極端空虛，且有傷害自己的強烈衝動，往往包括出現自殺念頭。許多因憂鬱症而就醫的人後來也證明具有邊緣人格模式，以致他們的情緒問題很難以一般方法治療。如今有一些辦法可緩解邊緣性人格者的症狀，其中一種治療法，辯證行為療法，已可減少病患住院的必要並幫助病患復元。

But many in the field began to argue that the diagnostic catalog needed a rewrite. “Personality Disorder-Not Otherwise Specified,” an encompassing label meaning little more than “this person has problems” became the most common of the diagnoses. It’s a murky area, and many therapists didn’t have the time or training to evaluate personality. Assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.
但業內許多人開始主張，這套診斷手冊需要改寫。「有待分類的人格異常」這種包山包海的標籤，已成為最普遍的診斷，而這無異於說「這人有問題」。這是模糊地帶，許多治療師沒時間評估人格，或未受過人格評估訓練。診斷評估的面談會花費許多小時，且針對多數異常人格提供的治療又涉及長期而專門的交談治療。

The most central, and knowable element of any person – personality – still defies consensus.
於是各方對於一個人最核心最可知的成分 ─ 人格，至今仍無共識。

A team of experts appointed by the psychiatric association has worked for over five years to find some unifying system of diagnosis for personality problems.
美國精神病學學會指派的一個專家團隊花了五年時間，想要找出一個統一的系統來診斷人格問題。

The team’s final proposal for narcissistic personality disorder involved rating a person on two traits, among them “manipulativeness,” “histrionism,” and “callousness.” The current definition includes nine possible elements.
該團隊最後對自戀型人格異常診斷標準提出的提議，涉及為病患的兩組特性評分，看病患是否「操控他人」、「歇斯底里」及「麻木不仁」。而目前的定義中，自戀型人格異常包括九種可能的成分。

Thomas Widiger, a professor of psychology at the University of Kentucky, likens the process of reaching a consensus to the parable of the six blind men from Hindustan, each touching different parts of the elephant. “Everyone’s working independently, and each has their perspective, their own theory,” he said. “It’s a mess.”
肯塔基大學心理學教授威德格把達成共識的程序比作一則印度寓言，寓言中說的是，六個盲人分別摸了大象身上的不同部位。威德格說：「每個人都獨立行事，人人都有自己的觀點和理論，一團混亂。」

原文參照：
http://www.nytimes.com/2012/11/27/health/clearing-the-fog-around-personality-disorders.html

2012-12-11聯合報/G9版/UNITEDDAILYNEWS 馮克芸譯 原文參見紐時週報十版上