《动力取向精神医学 第五版》(Glen O. Gabbard,M.D.)

  Psychodynamic Psychiatry in Clinical Practice

  Fifth   Edition

  动力取向精神医学 第五版

  To my teachers, my patients, and mystudents

  献给我的老师、我的病人和我的学生
 

  一、作者简介:

  Glen O. Gabbard, M.D., is Professor ofPsychiatry at State University of New York—Upstate Medical University,Syracuse, New York, and Clinical Professor of Psychiatry at Baylor College ofMedicine in Houston, Texas. He is also Training and Supervising Analyst at theCenter for Psychoanalytic Studies in Houston, and he is in private practice atThe Gabbard Center in Bellaire, Texas.

  格伦•O•加巴德,医学博士,她是纽约州锡拉丘兹市州立医科大学的精神病学教授,也是德克萨斯州休斯顿贝勒医学院的临床精神病学教授。他还在休斯敦的精神分析研究中心(Center for sychoanalytic Studies)培训和监督分析师,并在德克萨斯州贝尔莱尔(Bellaire)的加巴德中心(Gabbard Center)私人执业。

  The author has indicated that he has nofinancial interests or other affiliations that represent or could appear torepresent a competing interest with his contribution to this book.

  作者表示,他没有经济利益或其他附属机构,代表或可能代表与他对本书的贡献相竞争的利益。

  第一章 动力取向精神病学的基本原理 1

  二、本书前言:

  PREFACE TO THE FIFTH EDITION

  第五版前言

  This new edition of PsychodynamicPsychiatry in Clinical Practice is appearing 9 years after the fourth edition.Since I first starting writing this text a quarter century ago, this is thelongest span of time between revisions. Both American Psychiatric Publishingand I felt it was best to postpone this fifth edition until DSM-5 was in widecirculation. As always, I wanted the chapter organization to be compatible withthe DSM-5 categories, even though I do not agree with all of the decisions madeby the DSM-5 work groups. My major concern is that the DSM-5 system widelytaught to trainees is deliberately atheoretical, and I want to help cliniciansfind a way to keep psychodynamic thinking alive in their work with patients. Wemust not lose the complexities of the person if we are to help our patients tothe fullest. As Hippocrates once noted, “it is more important to know theperson with the illness than the illness the person has.” Hence, after theusual introductory chapters in Section I that update the reader on matters oftheory, evaluation, formulation, and forms of psychotherapy, I have reorganizedthe subsequent chapters so that they are simpatico with the DSM-5 categories.

  新版《动力取向精神医学》在第四版出版9年后出版。自从25年前我第一次开始写这篇文章以来,这是两次修订之间最长的时间跨度。美国精神病学出版社和我都认为最好将第五版推迟到DSM-5广泛发行。一如既往,我希望章节组织与DSM-5类别相兼容,尽管我不同意DSM-5工作组做出的所有决定。我主要担心的是,广泛传授给学员的DSM-5系统是刻意理论化的,我想帮助临床医生找到一种方法,让他们在与患者打交道的过程中保持精神动力思维的活力。如果我们要最大限度地帮助我们的病人,我们就不能失去这个人的复杂性。希波克拉底曾经说过,“了解一个什么样的人生病比了解一个人生了什么样的病更重要。”因此,在第一节通常的介绍性章节向读者更新理论、评估、构想和心理治疗形式的内容之后,我重新组织了后面的章节,使它们与DSM-5的类别保持一致。

  In some cases I added discussions of newentities, such as the application of psychodynamic thinking to the treatment ofpatients on the autism spectrum in Chapter 13. I also removed certaindiscussions from the text so that I could keep the length of the textbook moreor less the same as the last edition in the service of keeping costs down. InChapter 10 I included both posttraumatic stress disorder and dissociativedisorders so that the chapter was based on the primary psychiatric disordersrelated to trauma and stressors. Because DSM-5 abolished the multiaxial systemendorsed in DSM-IV, I have eliminated all references to the various axes. Thoseresponsible for the final version of DSM-5 chose to keep personality disordersthe same as in DSM-IV, but they no longer reside on a separate axis. This newdevelopment has both positive and negative implications, in my opinion. On theone hand, it undoes the problem of marginalizing personality disorders on aseparate axis (as though they do not carry the same importance to psychiatristsas all of the other psychiatric disorders). On the other hand, the specialrecognition of the role of the personality in psychiatry may be diminishedsomewhat without an axis that calls particular attention to that domain.

  在某些情况下,我增加了对新实体的讨论,例如在第13章中,将精神动力思维应用于自闭症患者的治疗。我还删除了文本中的某些讨论,这样我就可以保持教科书的长度或多或少与上一版相同,以降低成本。在第10章中,我将创伤后应激障碍和分离障碍都包括在内,所以这一章是基于与创伤和应激源相关的主要精神障碍。由于DSM-5废除了DSM-IV中认可的多轴系统,所以我已经消除了对各个轴的所有引用。那些负责DSM-5最终版本的人选择保持与DSM-IV相同的人格障碍,但他们不再位于一个单独的轴上。我认为,这一新的发展既有积极的影响,也有消极的影响。一方面,它在一个单独的轴上解决了边缘化人格障碍的问题(好像它们对精神病学家的重要性不像所有其他精神疾病一样)。另一方面,对人格在精神病学中所起作用的特殊认识可能会有所减弱,因为没有一个轴能引起对该领域的特别关注。

  In preparing this version of the text, Icollected relevant material over many years since the fourth edition in 2005 soI could systematically update each chapter. In fact, all 19 of the chaptershave new references and new material as a result. As noted above, material hasbeen deleted as well to keep the length manageable. In an era of reductionismin society as a whole and in medicine in particular, I have tried to keep thelife of the mind alive. Dynamic psychiatrists must be biopsychosocial thinkerseven if our emphasis is on such matters as internal conflict, the impact oftrauma on one’s thinking, unconscious fantasies, internal object relations,self structures, and defense mechanisms. Hence, we are guardians of a “flame”that reminds us that we are far more than our genome or our neurocircuitry. Theemphasis of the psychodynamic clinician is on what is unique and idiosyncraticabout each of us as well as what neurobiology brings to bear on that uniquestamp and how the environment influences the brain.

  在准备这个版本的文本时,我收集了2005年第四版以来多年的相关资料,以便能够系统地更新每一章。事实上,所有的19章都有新的参考文献和新的材料。如上所述,材料已被删除,并保持长度可控。在整个社会的还原论时代,特别是在医学领域,我一直在努力保持头脑的活力。即使我们的重点是诸如内部冲突、创伤对思维的影响、无意识的幻想、内部对象关系、自我结构和防御机制等问题,动态精神病学家也必须是生物、心理、社会思考者。因此,我们是“火焰”的守护者,它提醒我们,我们远不止是我们的基因组或我们的神经回路。精神动力临床医生的重点在于我们每个人的独特之处,以及神经生物学对这种独特印记的影响,以及环境如何影响大脑。

  As always, I have a great debt to mytrainees at Baylor College of Medicine and State University of New York–UpstateMedical University in Syracuse, whom I have been privileged to teach in recentyears. Just as a psychotherapist’s best teachers are his or her patients,students are the best teachers of educators. This edition of the book reflectsmy continued learning from my young trainees, who will be future colleagues. Ialso wish to express my deep gratitude to those at American PsychiatricPublishing who have supported me through nearly 30 years in my efforts tocommunicate my ideas to clinicians throughout the world. PsychodynamicPsychiatry in Clinical Practice has now been translated into 11 languages andis used as a textbook worldwide. I owe special thanks to Rebecca Rinehart,Robert Hales, John McDuffie, Greg Kuny, and Bessie Jones for all the help theyhave provided me in the production of this book. Jill Craig in Houston hasmeticulously prepared new versions of the manuscript with an efficiency that isremarkable. Finally, I wish to express my appreciation to my family, andparticularly to my wife, Joyce, who throughout the production of five differenteditions of this textbook has provided me the support, time, and spacenecessary to concentrate on the integration of an enormous amount ofinformation in a relatively brief time.

  和往常一样,我要感谢我在贝勒医学院和纽约州立大学-雪城北部医科大学的学员,我有幸在最近几年教他们。正如心理治疗师最好的老师是他或她的病人一样,学生也是教育者最好的老师。这本书反映了我不断向我的年轻学员学习,他们将是我未来的同事。我也要向美国精神病学出版社的工作人员表示深深的感谢,他们在近30年的时间里支持我向全世界的临床医生传达我的想法。《动力取向精神医学》现已被翻译成11种语言,并在世界范围内作为教材使用。我要特别感谢丽贝卡·莱因哈特、罗伯特·黑尔斯、约翰·麦克杜菲、格雷格·库尼和贝茜·琼斯,感谢他们为我编写这本书所提供的帮助。休斯敦的吉尔·克雷格以惊人的效率精心准备了新版本的手稿。最后,我想表达我的感谢我的家人,特别是我的妻子,乔伊斯,整个生产的五个不同版本的教科书所提供给我的支持,时间和空间需要专注于大量的信息的集成在一个相对短暂的时间。

  Glen O. Gabbard, M.D.

  Bellaire, Texas

  SECTION I BASICPRINCIPLES AND TREATMENT APPROACHES IN DYNAMIC PSYCHIATRY

  三、精彩内容:

  第一部分 动力取向精神医学的基本原理和治疗方法

  CHAPTER 1 BASIC PRINCIPLES OF DYNAMIC PSYCHIATRY

  第一章 动力取向精神医学的基本原理

  It would be far easier if we could avoidthe patient as we explore the realm of psychopathology; it would be far simplerif we could limit ourselves to examining the chemistry and physiology of hisbrain, and to treating mental events as objects alien to our immediateexperience, or as mere variables in impersonal statistical formulae. Importantas these approaches are for the understanding of human behavior, they cannotalone uncover or explain all the relevant facts. To see into the mind ofanother, we must repeatedly immerse ourselves in the flood of his associationsand feelings; we must be ourselves the instrument that sounds him.

  如果我们只顾着探索精神病理上的现象而不理会病人,事情会容易许多;如果我们让自己局限于检视病人脑子里的化学与生理变化,把心智表现当成好像是身外之物、与我们当下的体验全然无关,或当成只是无关乎人性之计算公式中的一个变项,那么事情也会单纯许多。虽然这些对于了解人类行为都很重要,但是,单靠它们并无法发掘或解释全部的真相。要深入了解另一人的心智,我们必须一次又一次地将自己投入他人思考与情绪的洪流当中——我们必须让自己成为聆听他人的工具。

  ——约翰•内米亚(John Nemiah 1961)

  Psychodynamic psychiatry (usedinterchangeably with dynamic psychiatry in this volume) has a diverse set ofancestors, including Leibniz, Fechner, the neurologist Hughlings Jackson, andSigmund Freud (Ellenberger 1970). The term psychodynamic psychiatry generallyrefers to an approach steeped in psychoanalytic theory and knowledge. Modernpsychodynamic theory has often been viewed as a model that explains mentalphenomena as the outgrowth of conflict. This conflict derives from powerfulunconscious forces that seek expression and require constant monitoring fromopposing forces to prevent their expression. These interacting forces may beconceptualized (with some overlap) as 1) a wish and a defense against the wish,2) different intrapsychic agencies or “parts” with different aims andpriorities, or 3) an impulse in opposition to an internalized awareness of thedemands of external reality.

  精神动力取向精神医学源自于一群多样性的始祖,包括莱布尼兹(德国哲学家和数学家),费希纳(德国物理学及心理学家,为实验心理学鼻祖),神经学家休林•杰克森,与佛洛伊德。一般而言,精神动力取向精神医学一词指的是深受精神分析理论与知识所影响的一种取向,现代的精神动力学理论,通常被视为一种以内在冲突之结果来解释心理现象的理论模型,而这内在冲突则源自两股力量,一是寻求突围的强大的无意识力量,另一则是持续进行监督、以扼止无意识力量浮现台面的对抗力量。这些交互作用的力量可以归类为(各类别间有所重叠):1.欲望,以及阻止欲望浮现出来的防卫机制;2.不同的心灵内在动源或是“零件”(agencies or “parts”),各自有着不同的目标和优先重点;或者3.对外在现实之要求的内在觉知,以及与其相抗衡的冲动。

  Psychodynamic psychiatry has come toconnote more than the conflict model of illness. Today’s dynamic psychiatristmust also understand what is commonly referred to as the “deficit model” ofillness. This model is applied to patients who, for whatever developmentalreasons, have weakened or absent psychic structures. This compromised stateprevents them from feeling whole and secure about themselves, and as a resultthey require inordinate responses from persons in the environment to maintainpsychological homeostasis. Also contained within the purview of psychodynamicpsychiatry is the unconscious internal world of relationships. All patientscarry within them a host of different mental representations of aspects ofthemselves and others, many of which may create characteristic patterns ofinterpersonal difficulties. These representations of self and others form aworld of largely unconscious internal object relations.

  精神动力取向精神医学已经不再局限于疾病的冲突模式,当代的动力精神医学也了解到什么是通称为疾病之“缺陷模式”的论理架构。这种缺陷模式是用在心灵结构较为脆弱或有所缺失的病人身上,不论他在发展过程中遇到的是什么病因。由于本身有所不足与欠缺,使这些病人觉得自己是不完整或不安稳的,因此,为了维持心理衡定,他们对周遭的人有着异乎寻常的过度需求。同样也涵盖在精神动力取向精神医学之概念下的,还有无意识的内在关系模式。所有的病人都有一箩筐各式各样的心理表征,是他们对自己以及他人之各种面向的内在重现,其中有许多会造成人际关系困扰的典型模式。这些对自己和别人的内在表征,共同组成了一个大体上存在于无意识当中的内在客体关系世界。

  Today’s psychodynamic clinician can nolonger practice a type of psychiatry divorced from the body and socioculturalinfluences. Indeed, psychodynamic psychiatry must be regarded today as situatedwithin the overarching construct of biopsychosocial psychiatry. Dramaticprogress in genetics and neuroscience has paradoxically strengthened theposition of the psychodynamic psychiatrist. We now have more persuasiveevidence than ever before that much of mental life is unconscious, that socialforces in the environment shape the expression of genes, and that the mindreflects the activity of the brain. We now practice in a situation of“both/and” rather than “either/or.” Although it is true that all mentalfunctions ultimately are products of the brain, it does not follow that thebiological explanation is the best or most rational model for understandinghuman behavior (Cloninger 2004; LeDoux 2012).Contemporary neuroscience does notattempt to reduce everything to genes or biological entities. Well-informedneuroscientists focus on an integrative rather than a reductive approach andrecognize that psychological data are just as valid scientifically asbiological findings (LeDoux 2012).

  当代精神动力取向的临床工作者,在执业时也不能再豁免于生理与社会文化方面的影响。的确,在今天,精神动力精神医学必须被放在生物心理社会精神医学的大架构底下来看待,遗传学和神经科学的蓬勃进展,反而吊诡地强化了动力取向精神科医师的地位,我们现在有比以往更多具说服力的证据,可以左证: 心理内涵有一大部分是无意识的;生活环境中的社会力可以形塑基因的表现;而且,心智正是大脑活动的展现。我们当今的临床实务,是在一种“既此且彼”(“borh/and”)而非“非此即彼”(“eirher/or”) 的情境下运作。虽然所有的精神功能最终都是大脑的产物,但这并不意味着生物学上的解释是理解人类行为的最佳或最合理的模型(Cloninger 2004;勒杜2012)。当代神经科学并不试图把一切都归结为基因或生物实体。消息灵通的神经科学家注重综合而不是还原的方法,并认识到心理数据和生物学发现一样是科学有效的(LeDoux 2012)。

  Above all, psychodynamic psychiatry is away of thinking—not only about one’s patients but also about oneself in theinterpersonal field between patient and treater. In fact, to characterize theessence of dynamic psychiatry, one might well use the following definition:Psychodynamic psychiatry is an approach to diagnosis and treatmentcharacterized by a way of thinking about both patient and clinician thatincludes unconscious conflict, deficits and distortions of intrapsychicstructures, and internal object relations and that integrates these elementswith contemporary findings from the neurosciences.

  最重要的是,精神动力取向精神医学是一种思考的方式——不只是思考我们的病人,也涉及到身处在医病人际互动情境下的我们自身。事实上,如果要为动力取向精神医学的本质下定义,我们可以这么说:精神动力取向精神医学是一种用于诊断与治疗的切入途径,其特色为一种关乎病人与临床工作者双方的思考方式,包括无意识的冲突、心灵内在结构的缺陷与扭曲,与内在的客体关系等,以及思考如何应用当代神经科学的发现,来整合上述这些要素。

  This definition raises a challenge to thepsychodynamic clinician. How does one integrate the domain of mind with thedomain of brain? Psychiatry has moved well beyond the Cartesian notion ofsubstance dualism. We recognize that mind is the activity of the brain(Andreasen 1997) and that the two are inextricably linked. To a large extent,references to mind and brain have become a form of code for different ways tothink about our patients and their treatment (Gabbard, 2005). Presumedpolarities such as genes versus environment, medication versus psychotherapy,and biological versus psychosocial are often glibly subsumed under thecategories of brain and mind. These dichotomies are problematic and tend tobreak down when we study clinical problems in psychiatry. Genes and environmentare inextricably connected in shaping human behavior.  The promise of the human genome and“personalized medicine” has not been fulfilled. Terms such as heritability havebecome increasingly meaningless and reductive in light of the environmentalinfluence on genes (Keller 2011). The flurry of initial excitement aboutpersonalized medicine as genomics-based knowledge has begun to be challenged bya series of critiques. Horwitz et al. (2013), for example, refer to this trendas “de-personalized medicine” because without environmental, social, andclinical considerations that affect disease outcomes, genomics information isdisappointing. The “person” needs to be taken into account. Experience shutsdown the transcriptional function of some genes while turning others on.Psychosocial stressors, such as interpersonal trauma, may have profoundbiological effects by changing the functioning of the brain. Furthermore,thinking of psychotherapy as a treatment for “psychologically based disorders”and medications as a treatment for “biological or brain-based disorders” is aspecious distinction. The impact of psychotherapy on the brain is wellestablished (see Gabbard 2000).

  以上定义对精神动力取向的临床工作者而言,可说是一大挑战。我们要如何整合心智与大脑这两个领域呢?精神医学早已扬弃笛卡儿的心智二元论了,我们已体认到心智其实是大脑活动的展现,而且两者紧密地互相纠结在一起。进一步说,当人们论及心智与大脑这两者时,其实是代表着两种思考病人及其治疗的不同方式。一般视为理所当然的二元对立,如遗传与环境、药物治疗与心理治疗,以及生物学与心理社会学等等,常常都可以各自归结为大脑与心智这两者。其实,这种二分法是大有问题的,在我们研究精神医学的临床问题时,这种二分法经常会土崩瓦解、完全失效。遗传与环境两者是以互相纠结、紧密相连的方式来形塑人类的行为:生活经验会关闭某些基因的转录功能[是指遗传讯息从DNA转录到RNA上。],但却开启另一些基因的功能;心理社会压力源,例如人际关系所造成的创伤,也会经由改变大脑功能而产生极大的生理作用;更甚者,将心理治疗当成是“心因性疾病”的治疗方式,而把药物治疗视为“生物学病因或脑部疾病”的治疗方式,其实是一种似是而非的区分方法,目前已有充分的证据显示,心理治疗可以对大脑造成影响。

上一篇:《美国精神病学教科书第5版》(RobertE.Hales,M.D.,M.B.A./Stuart C.Yudofsky)
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