Thomas Insel: Toward a new understanding of mental illness

Translator: Joseph Geni Reviewer: Thu-Huong Ha

Prevoditelj: Senzos Osijek Recezent: Mladen Barešić

So let's start with some good news,

Počnimo s dobrim vijestima...

and the good news has to do with what do we know

Dobra vijest ima veze s time što,

based on biomedical research

na temelju biomedicinskih istraživanja,

that actually has changed the outcomes

znamo o onome što je promijenilo ishode

for many very serious diseases?

mnogih ozbiljnih bolesti?

Let's start with leukemia,

Počnimo s leukemijom...

acute lymphoblastic leukemia, ALL,

Akutna limfoblastična leukemija, ALL,

the most common cancer of children.

najčešći je rak u djece.

When I was a student,

Kada sam bio student,

the mortality rate was about 95 percent.

stupanj smrtnosti bio je oko 95%.

Today, some 25, 30 years later, we're talking about

Danas, nekih 25-30 godina kasnije, govorimo o

a mortality rate that's reduced by 85 percent.

stupnju smrtnosti koji je smanjen za 85%.

Six thousand children each year

Svake se godine šest tisuća djece

who would have previously died of this disease are cured.

koja bi prije umrla od ove bolesti - izliječi.

If you want the really big numbers,

Ako želite stvarno velike brojeve,

look at these numbers for heart disease.

pogledajte brojeve u vezi s bolestima srca.

Heart disease used to be the biggest killer,

Srčane bolesti bile su najveći ubojica,

particularly for men in their 40s.

posebno muškaraca u njihovim 40-ima.

Today, we've seen a 63-percent reduction in mortality

Danas vidimo 63%-tno smanjenje smrtnosti

from heart disease --

uslijed srčanih bolesti.

remarkably, 1.1 million deaths averted every year.

Izvanredno! 1,1 milijun smrtnih slučajeva izbjegnutih svake godine.

AIDS, incredibly, has just been named,

AIDS je, nevjerojatno, tek prošlog mjeseca

in the past month, a chronic disease,

nazvan kroničnom bolesti,

meaning that a 20-year-old who becomes infected with HIV

što znači da se ne očekuje da će 20-godišnjak koji se zarazi HIV-om

is expected not to live weeks, months, or a couple of years,

živjeti tjednima, mjesecima ili par godina,

as we said only a decade ago,

kao što smo rekli prije samo jednog desetljeća,

but is thought to live decades,

već se pretpostavlja da će živjeti desetljećima

probably to die in his '60s or '70s from other causes altogether.

te vjerojatno umrijeti u svojim 60-ima ili 70-ima iz posve drugih razloga.

These are just remarkable, remarkable changes

To su jednostavno izvanredne, izvanredne promjene

in the outlook for some of the biggest killers.

u izgledima u slučaju nekih od najvećih ubojica.

And one in particular

A jedan poseban,

that you probably wouldn't know about, stroke,

za kojeg vjerojatno ne znate - moždani udar -

which has been, along with heart disease,

koji je, zajedno sa srčanim udarom,

one of the biggest killers in this country,

jedan od najvećih ubojica u ovoj zemlji,

is a disease in which now we know

bolest je za koju danas znamo da,

that if you can get people into the emergency room

dovedete li osobu do hitne službe

within three hours of the onset,

unutar tri sata od početka napada,

some 30 percent of them will be able to leave the hospital

oko 30% njih moći će napustiti bolnicu

without any disability whatsoever.

bez ikakvih posljedica.

Remarkable stories,

Izvanredne priče,

good-news stories,

one sa sretnim završecima,

all of which boil down to understanding

sve se svode na razumijevanje

something about the diseases that has allowed us

nečega o bolestima, što nam je omogućilo

to detect early and intervene early.

njihovo ranije otkrivanje i ranije djelovanje.

Early detection, early intervention,

Ranije otkrivanje, ranije djelovanje -

that's the story for these successes.

to je bilanca ovih uspjeha.

Unfortunately, the news is not all good.

Nažalost, vijesti nisu u potpunosti dobre.

Let's talk about one other story

Porazgovarajmo o jednoj drugoj priči,

which has to do with suicide.

onoj vezanoj uz samoubojstvo.

Now this is, of course, not a disease, per se.

Ono, naravno, samo po sebi nije bolest.

It's a condition, or it's a situation

To je stanje, ili situacija

that leads to mortality.

koja vodi k smrti.

What you may not realize is just how prevalent it is.

Ono čega možda niste svjesni jest koliko su ona rasprostranjena.

There are 38,000 suicides each year in the United States.

Svake se godine u SAD-u dogodi 38.000 samoubojstava.

That means one about every 15 minutes.

Znači, jedno samoubojstvo svakih 15 minuta.

Third most common cause of death amongst people

Treći najčešći uzrok smrti ljudi

between the ages of 15 and 25.

u dobi od 15 do 25 godina.

It's kind of an extraordinary story when you realize

Nevjerojatna je to priča kad shvatite

that this is twice as common as homicide

da je to dvaput češće od ubojstva

and actually more common as a source of death

i, zapravo, puno češći uzrok smrti

than traffic fatalities in this country.

no što su to prometne nesreće u ovoj zemlji.

Now, when we talk about suicide,

Kada govorimo o samoubojstvima,

there is also a medical contribution here,

njima doprinose i medicinski razlozi,

because 90 percent of suicides

jer 90% samoubojstava

are related to a mental illness:

povezano je s duševnim bolestima:

depression, bipolar disorder, schizophrenia,

depresijom, bipolarnim poremećajem, shizofrenijom,

anorexia, borderline personality. There's a long list

anoreksijom, graničnim poremećajem osobnosti. Dug je popis

of disorders that contribute,

poremećaja koji doprinose,

and as I mentioned before, often early in life.

kao što sam ranije spomenuo, često i u mlađoj dobi.

But it's not just the mortality from these disorders.

Ali, ne radi se samo o smrtnosti uslijed ovih poremećaja.

It's also morbidity.

Radi se i o pobolijevanju.

If you look at disability,

Razmotrimo invalidnost

as measured by the World Health Organization

koju Svjetska zdravstvena organizacija mjeri

with something they call the Disability Adjusted Life Years,

nečime što oni nazivaju "Stopom izgubljenih godina zdravoga života".

it's kind of a metric that nobody would think of

To je vrsta mjerenja kakvog se nitko ne bi dosjetio

except an economist,

osim ekonomista,

except it's one way of trying to capture what is lost

samo što je ovo jedan od načina da se otkrije što je izgubljeno

in terms of disability from medical causes,

u smislu medicinski uzrokovane invalidnosti.

and as you can see, virtually 30 percent

Kao što vidite, gotovo 30%

of all disability from all medical causes

svih invalidnosti uzrokovanih svim medicinskim uzrocima

can be attributed to mental disorders,

može se pripisati psihičkim bolestima,

neuropsychiatric syndromes.

neuropsihijatrijskim sindromima.

You're probably thinking that doesn't make any sense.

Vjerojatno mislite kako to nema smisla.

I mean, cancer seems far more serious.

Mislim, rak izgleda puno ozbiljnije...

Heart disease seems far more serious.

Srčane bolesti čine se puno ozbiljnijima...

But you can see actually they are further down this list,

No, možete vidjeti da su one niže na ovom popisu,

and that's because we're talking here about disability.

što je razlog tome da ovdje govorimo o invaliditetima.

What drives the disability for these disorders

Što je uzrok invaliditeta kod bolesti

like schizophrenia and bipolar and depression?

poput shizofrenije, bipolarnosti i depresije?

Why are they number one here?

Zašto su one prve na ovom popisu?

Well, there are probably three reasons.

Vjerojatno postoje tri razloga...

One is that they're highly prevalent.

Kao prvo, vrlo su raširene.

About one in five people will suffer from one of these disorders

Otprilike svaka peta osoba bolovat će od jednog od ovih poremećaja

in the course of their lifetime.

tijekom svog života.

A second, of course, is that, for some people,

Drugi je razlog, naravno, taj što neke ljude

these become truly disabling,

ove bolesti istinski onesposobljuju,

and it's about four to five percent, perhaps one in 20.

i to iznosi oko 4-5%, možda 1 od 20.

But what really drives these numbers, this high morbidity,

Međutim, ono što uistinu potiče ovakve razmjere, ovako visoko pobolijevanje,

and to some extent the high mortality,

a donekle i visoku smrtnost,

is the fact that these start very early in life.

činjenica je da se te bolesti očituju vrlo rano u životu.

Fifty percent will have onset by age 14,

Bolest će se u 50% slučajeva pojaviti prije 14. godine,

75 percent by age 24,

u 75% slučajeva prije 24. godine...

a picture that is very different than what one would see

Poprilično različito od onoga što mislimo

if you're talking about cancer or heart disease,

kada govorimo o raku ili o bolestima srca,

diabetes, hypertension -- most of the major illnesses

o dijabetesu, visokom krvnom tlaku – o većini bolesti

that we think about as being sources of morbidity and mortality.

koje smatramo glavnim izvorima pobolijevanja i smrtnosti.

These are, indeed, the chronic disorders of young people.

One su doista kronični poremećaji u mladih ljudi.

Now, I started by telling you that there were some good-news stories.

Započeo sam rekavši vam da postoje dobre vijesti.

This is obviously not one of them.

Ovo očito nije jedna od njih.

This is the part of it that is perhaps most difficult,

Ovo je možda najteži dio,

and in a sense this is a kind of confession for me.

i, na neki način, moje priznanje.

My job is to actually make sure that we make progress

Moj posao je, zapravo, osigurati napredak

on all of these disorders.

u vezi sa svim ovim poremećajima.

I work for the federal government.

Radim za federalnu vladu.

Actually, I work for you. You pay my salary.

Zapravo, radim za vas. Vi me plaćate.

And maybe at this point, when you know what I do,

Možda ćete u ovom trenutku, kada znate što radim,

or maybe what I've failed to do,

ili možda ono što nisam uspio učiniti,

you'll think that I probably ought to be fired,

pomisliti da bih vjerojatno trebao dobiti otkaz.

and I could certainly understand that.

To svakako mogu razumjeti.

But what I want to suggest, and the reason I'm here

Ali, ono što želim predložiti, i razlog zašto sam ovdje jest

is to tell you that I think we're about to be

reći vam da mislim da ćemo uskoro biti

in a very different world as we think about these illnesses.

u veoma drugačijem svijetu, što se ovih bolesti tiče.

What I've been talking to you about so far is mental disorders,

Dosad sam vam govorio o mentalnim poremećajima,

diseases of the mind.

o bolestima uma.

That's actually becoming a rather unpopular term these days,

Danas to, zapravo, postaje prilično nepopularan izraz

and people feel that, for whatever reason,

i ljudi misle da je, iz kojeg god razloga,

it's politically better to use the term behavioral disorders

politički korektnije koristiti izraz "ponašajni poremećaji"

and to talk about these as disorders of behavior.

i govoriti o njima kao o poremećajima ponašanja.

Fair enough. They are disorders of behavior,

Pošteno. Oni jesu poremećaji ponašanja,

and they are disorders of the mind.

i oni jesu poremećaji uma.

But what I want to suggest to you

Međutim, ono što vam želim predložiti je

is that both of those terms,

to da oba ova izraza,

which have been in play for a century or more,

koja koristimo i dulje od stoljeća,

are actually now impediments to progress,

zapravo danas priječe napredak.

that what we need conceptually to make progress here

Ono što moramo pojmovno učiniti da bismo uznapredovali jest

is to rethink these disorders as brain disorders.

promisliti o ovim poremećajima kao o poremećajima mozga.

Now, for some of you, you're going to say,

Neki od vas će reći:

"Oh my goodness, here we go again.

„O moj Bože, evo ga opet.

We're going to hear about a biochemical imbalance

Slušat ćemo o biokemijskoj neravnoteži,

or we're going to hear about drugs

ili o lijekovima,

or we're going to hear about some very simplistic notion

ili o veoma pojednostavljenom shvaćanju

that will take our subjective experience

koje će pretvoriti naše subjektivno iskustvo

and turn it into molecules, or maybe into some sort of

u molekule, ili možda u neku vrstu

very flat, unidimensional understanding

vrlo plošnog, jednodimenzionalnog shvaćanja

of what it is to have depression or schizophrenia.

što znači imati depresiju ili shizofreniju.

When we talk about the brain, it is anything but

Kada govorimo o mozgu, on je sve samo ne

unidimensional or simplistic or reductionistic.

jednodimenzionalan, pojednostavljen ili redukcionistički.

It depends, of course, on what scale

Ovisi, naravno, o tome na kojoj razini

or what scope you want to think about,

ili u kolikom opsegu želite razmišljati...

but this is an organ of surreal complexity,

No, mozak je organ nadrealne složenosti.

and we are just beginning to understand

Tek počinjemo shvaćati

how to even study it, whether you're thinking about

kako ga uopće proučavati, bilo da mislimo o

the 100 billion neurons that are in the cortex

100 milijardi neurona u kori velikog mozga,

or the 100 trillion synapses

ili o 100 bilijuna sinapsi

that make up all the connections.

koje sve povezuju.

We have just begun to try to figure out

Tek smo počeli pokušavati iznaći načine

how do we take this very complex machine

kako razumjeti taj veoma složeni stroj

that does extraordinary kinds of information processing

koji na izvanredne načine procesira informacije,

and use our own minds to understand

i kako upotrijebiti naš um da bismo razumjeli

this very complex brain that supports our own minds.

taj vrlo složeni mozak koji podržava naše vlastite misli.

It's actually a kind of cruel trick of evolution

Doista je okrutan evolucijski trik

that we simply don't have a brain

što jednostavno nemamo mozak

that seems to be wired well enough to understand itself.

udešen dovoljno dobro da bi razumio samoga sebe.

In a sense, it actually makes you feel that

Na neki način, čini se da

when you're in the safe zone of studying behavior or cognition,

kada ste u sigurnoj zoni proučavanja ponašanja ili spoznavanja,

something you can observe,

nečega što možete promatrati,

that in a way feels more simplistic and reductionistic

to se na neki način čini pojednostavljenijim i reduciranijim

than trying to engage this very complex, mysterious organ

od pokušaja da se pozabavimo ovim vrlo složenim, zagonetnim organom

that we're beginning to try to understand.

kojega tek započinjemo pokušavati shvaćati.

Now, already in the case of the brain disorders

U slučaju moždanih poremećaja

that I've been talking to you about,

o kojima sam vam govorio -

depression, obsessive compulsive disorder,

depresije, opsesivno-kompulzivnog poremećaja,

post-traumatic stress disorder,

posttraumatskog stresnog poremećaja -

while we don't have an in-depth understanding

iako ne razumijemo u potpunosti

of how they are abnormally processed

o kakvim se abnormalnim procesima radi,

or what the brain is doing in these illnesses,

ili kako se mozak ponaša kod ovih bolesti,

we have been able to already identify

uspjeli smo dosad identificirati

some of the connectional differences, or some of the ways

neke od razlika u poveznicama, ili neke od oblika

in which the circuitry is different

po kojima se razlikuju "sklopovlja"

for people who have these disorders.

kod ljudi s takvim poremećajima.

We call this the human connectome,

To zovemo ljudski konektom...

and you can think about the connectome

Možete ga zamisliti

sort of as the wiring diagram of the brain.

kao živčani dijagram mozga.

You'll hear more about this in a few minutes.

Čut ćete više o tome za nekoliko minuta...

The important piece here is that as you begin to look

Ovdje je važno da kada počnete promatrati

at people who have these disorders, the one in five of us

ljude s ovakvim poremećajima - svakog petog među nama

who struggle in some way,

koji na neki način pati -

you find that there's a lot of variation

otkrit ćete mnogo raznolikosti

in the way that the brain is wired,

u strukturi mozga.

but there are some predictable patterns, and those patterns

No, postoje neki predvidljivi uzorci, i ti su uzorci

are risk factors for developing one of these disorders.

rizični čimbenici u razvitku jednog od ovih poremećaja.

It's a little different than the way we think about brain disorders

Ovo se malo razlikuje od toga kako zamišljamo moždane poremećaje

like Huntington's or Parkinson's or Alzheimer's disease

poput Huntingtonove, Parkinsonove ili Alzheimerove bolesti,

where you have a bombed-out part of your cortex.

kod kojih je uništen dio moždane kore.

Here we're talking about traffic jams, or sometimes detours,

Ovdje govorimo o prometnim gužvama, ponekad i o obilaženjima,

or sometimes problems with just the way that things are connected

a ponekad o problemima zbog toga kako su neke stvari povezane,

and the way that the brain functions.

i toga kako mozak funkcionira.

You could, if you want, compare this to,

Ako želite, možete to usporediti,

on the one hand, a myocardial infarction, a heart attack,

s infarktom miokarda, srčanim udarom,

where you have dead tissue in the heart,

kod kojega je dio srčanog tkiva mrtav,

versus an arrhythmia, where the organ simply isn't functioning

naspram aritmije, kod koje organ jednostavno ne funkcionira

because of the communication problems within it.

zbog komunikacijskih problema unutar njega.

Either one would kill you; in only one of them

I jedan i drugi će vas ubiti, no samo u jednom

will you find a major lesion.

pronaći ćete veliku leziju.

As we think about this, probably it's better to actually go

Dok razmišljamo o ovome, vjerojatno je, zapravo, bolje

a little deeper into one particular disorder, and that would be schizophrenia,

zadubiti se malo u određeni poremećaj, recimo, u shizofreniju.

because I think that's a good case

Mislim da je ona dobar primjer

for helping to understand why thinking of this as a brain disorder matters.

koji će nam pomoći razumjeti zašto je važno smatrati je moždanim poremećajem.

These are scans from Judy Rapoport and her colleagues

Ovo su snimke Judy Rapoport i njezinih kolega

at the National Institute of Mental Health

iz Nacionalnog instituta za mentalno zdravlje,

in which they studied children with very early onset schizophrenia,

na kojima su proučavali djecu s vrlo rano manifestiranom shizofrenijom.

and you can see already in the top

Na samom vrhu možete uočiti

there's areas that are red or orange, yellow,

područja koja su crvena, narančasta, žuta...

are places where there's less gray matter,

Na tim mjestima manjka sive tvari.

and as they followed them over five years,

Pratili su ih tijekom 5 godina i

comparing them to age match controls,

uspoređivali s kontrolnom dobnom skupinom.

you can see that, particularly in areas like

Možete vidjeti, posebno u područjima poput

the dorsolateral prefrontal cortex

dorzolateralnog prefrontalnog korteksa

or the superior temporal gyrus, there's a profound loss of gray matter.

ili gornjeg temporalnog girusa... Popriličan je gubitak sive tvari!

And it's important, if you try to model this,

I važno je, pokušate li ovo nekako uobličiti,

you can think about normal development

zamislite normalan razvoj

as a loss of cortical mass, loss of cortical gray matter,

kao gubitak moždane mase, gubitak sive tvari...

and what's happening in schizophrenia is that you overshoot that mark,

Ono što se kod shizofrenije zbiva jest prevelik gubitak.

and at some point, when you overshoot,

I jednom, kad previše tvari propadne,

you cross a threshold, and it's that threshold

prijeđete granicu, a radi se o pragu

where we say, this is a person who has this disease,

na kojemu kažemo da je osoba oboljela,

because they have the behavioral symptoms

jer pokazuje ponašajne simptome

of hallucinations and delusions.

poput halucinacija i deluzija.

That's something we can observe.

To možemo promatrati.

But look at this closely and you can see that actually they've crossed a different threshold.

Međutim, pažljivije pogledajte i vidjet ćete da su prešli različite pragove.

They've crossed a brain threshold much earlier,

Prešli su moždani prag mnogo ranije,

that perhaps not at age 22 or 20,

ne u 22. ili 20. godini,

but even by age 15 or 16 you can begin to see

već i u 15. ili 16. može se zamijetiti

the trajectory for development is quite different

da je razvojni tok poprilično različit

at the level of the brain, not at the level of behavior.

na razini mozga, ne na razini ponašanja.

Why does this matter? Well first because,

Zašto je to važno? Pa, najprije zato što je

for brain disorders, behavior is the last thing to change.

kod moždanih poremećaja ponašanje zadnje koje se mijenja.

We know that for Alzheimer's, for Parkinson's, for Huntington's.

To nam je poznato kod Alzheimerove, Parkinsonove i Huntingtonove bolesti.

There are changes in the brain a decade or more

U mozgu se promjene zbivaju i više od desetljeća

before you see the first signs of a behavioral change.

prije no što zamijetite prve znakove promjena u ponašanju.

The tools that we have now allow us to detect

Današnja nam tehnologija dopušta da otkrijemo

these brain changes much earlier, long before the symptoms emerge.

te moždane promjene puno ranije, puno prije no što se simptomi pojave.

But most important, go back to where we started.

Ali najvažnije, vratimo se na početak.

The good-news stories in medicine

Dobre su vijesti u medicini

are early detection, early intervention.

rana dijagnostika, rano djelovanje.

If we waited until the heart attack,

Kad bismo čekali sve do srčanog udara,

we would be sacrificing 1.1 million lives

žrtvovali bismo 1,1 milijun života

every year in this country to heart disease.

svake godine u ovoj zemlji.

That is precisely what we do today

Upravo to činimo danas

when we decide that everybody with one of these brain disorders,

kad odlučimo da svatko s jednim od ovih moždanih poremećaja,

brain circuit disorders, has a behavioral disorder.

poremećaja moždanih sklopova, ima poremećaj ponašanja.

We wait until the behavior becomes manifest.

Čekamo da se ponašanje manifestira.

That's not early detection. That's not early intervention.

To nije rana dijagnostika. To nije rano djelovanje.

Now to be clear, we're not quite ready to do this.

Da raščistimo - nismo još uvijek posve spremni za ovo.

We don't have all the facts. We don't actually even know

Ne raspolažemo svim činjenicama. Ne znamo čak ni

what the tools will be,

kakve ćemo alate koristiti,

nor what to precisely look for in every case to be able

niti što ćemo točno svaki put tražiti

to get there before the behavior emerges as different.

kako bismo djelovali prije no što se ponašanje promijeni.

But this tells us how we need to think about it,

Ali, ovo nam govori kako trebamo razmišljati,

and where we need to go.

i kamo bismo trebali krenuti.

Are we going to be there soon?

Hoćemo li uskoro stići onamo?

I think that this is something that will happen

Mislim da će se to dogoditi

over the course of the next few years, but I'd like to finish

tijekom sljedećih nekoliko godina... Ali, želio bih završiti

with a quote about trying to predict how this will happen

s citatom o nastojanju da se predvidi kako će se to dogoditi,

by somebody who's thought a lot about changes

mišlju nekoga tko je puno razmišljao o promjenama

in concepts and changes in technology.

u pojmovima i u promjenama u tehnologijama.

"We always overestimate the change that will occur

„Uvijek precjenjujemo promjenu koja će se dogoditi

in the next two years and underestimate

u sljedeće dvije godine, a podcjenjujemo

the change that will occur in the next 10." -- Bill Gates.

promjenu koja će se dogoditi u sljedećih deset.“ (Bill Gates)

Thanks very much.

Puno hvala.

(Applause)

(Pljesak)