Thomas Insel: Toward a new understanding of mental illness

Translator: Joseph Geni Reviewer: Thu-Huong Ha

翻译人员: bin xue 校对人员: Zheqing Fang

So let's start with some good news,

让我们从一些好消息开始吧，

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

而这些好消息与我们所了解的

based on biomedical research

生物医学研究有关

that actually has changed the outcomes

这些生物医学研究其实已经改变了

for many very serious diseases?

许多重症的治愈结果。

Let's start with leukemia,

让我们先来谈谈白血病，

acute lymphoblastic leukemia, ALL,

急性淋巴细胞白血病，缩写ALL，

the most common cancer of children.

是一种在儿童中最常见的癌症类型。

When I was a student,

当我是学生时，

the mortality rate was about 95 percent.

它的死亡率是 95%左右。

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

30年后的今天，我们所谈论的(ALL) 的死亡率

a mortality rate that's reduced by 85 percent.

已经降低了 85%。

Six thousand children each year

每年有6000名

who would have previously died of this disease are cured.

原本会死于白血病的患儿，现今得以治愈

If you want the really big numbers,

如果你想要更有说服力的数字，

look at these numbers for heart disease.

让我们来看看心脏病的数据

Heart disease used to be the biggest killer,

心脏病曾经是最大的杀手，

particularly for men in their 40s.

尤其是对于40 多岁的男子。

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

如今，我们可以看到

from heart disease --

心脏病的死亡率减少了 63 %，

remarkably, 1.1 million deaths averted every year.

成就是如此显著，每年减少110万起心脏病死亡数

AIDS, incredibly, has just been named,

更难以置信的是，艾滋病，

in the past month, a chronic disease,

在上个月里刚被定义为一种慢性疾病，

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

也就是说一个20岁感染艾滋病毒的人，

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

要是在十年前，人们会觉得他活不过几周

as we said only a decade ago,

几个月，至多几年，

but is thought to live decades,

但现在被认为会再活数十年，

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

也许会在他六七十岁时死于其他并发症。

These are just remarkable, remarkable changes

对于这些"致命杀手"而言，

in the outlook for some of the biggest killers.

这些都是非常显著的变化。

And one in particular

特别值得一提的是

that you probably wouldn't know about, stroke,

你大概不大清楚 ---中风，

which has been, along with heart disease,

一般伴随心脏病，

one of the biggest killers in this country,

是本国最大健康杀手之一，

is a disease in which now we know

也是现在我们所知道的一种疾病

that if you can get people into the emergency room

如果病人能在发病3小时之内

within three hours of the onset,

得到紧急医治，

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

大约 30%的病人能在出院时，

without any disability whatsoever.

不留任何残疾或后遗症。

Remarkable stories,

多么非凡的成就，

good-news stories,

令人振奋的故事!

all of which boil down to understanding

所有这一切都归功于

something about the diseases that has allowed us

我们对这些疾病的研究和认识，

to detect early and intervene early.

可以让我们去“早发现”和“早治疗”。

Early detection, early intervention,

在“早发现”和“早治疗”方面的进步，

that's the story for these successes.

是取得上述成果的关键。

Unfortunately, the news is not all good.

不幸的是，并非全都是好消息。

Let's talk about one other story

我们来谈谈另外一个故事，

which has to do with suicide.

与自杀有关。

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

当然，就自杀本身而言，它不是一种疾病，

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

是一种状况或是一种现象，

that leads to mortality.

最终导致死亡。

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

你可能没有意识到这种现象是多么的普遍，

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

在美国,每年有38000起自杀事件发生，

That means one about every 15 minutes.

这意味着每15分钟就有一起。

Third most common cause of death amongst people

在导致青少年死亡的常见原因中

between the ages of 15 and 25.

排名第三位。

It's kind of an extraordinary story when you realize

这是多么的令人震惊

that this is twice as common as homicide

自杀是谋杀数量的两倍

and actually more common as a source of death

是更为普遍的死亡来源

than traffic fatalities in this country.

比本国交通事故的死亡数还要高。

Now, when we talk about suicide,

现在，当我们讨论自杀，

there is also a medical contribution here,

不能忽视医学可能带来的改善，

because 90 percent of suicides

因为 90%的自杀事件

are related to a mental illness:

与精神疾病有关：

depression, bipolar disorder, schizophrenia,

如抑郁症、 躁郁症、 精神分裂症、

anorexia, borderline personality. There's a long list

厌食症，边缘人格等等

of disorders that contribute,

（请回忆“早发现”和“早治疗”）

and as I mentioned before, often early in life.

许多精神失常的症状往往出现在幼年期。

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

这些症状不仅对应着死亡的最终结果，

It's also morbidity.

也对应着疾病的悄然萌发。

If you look at disability,

以"罹患"为例，

as measured by the World Health Organization

世界卫生组织是以

with something they call the Disability Adjusted Life Years,

"罹患调整寿命年"为指标，

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

它是一个除了经济学家

except an economist,

不会有其他人能设计出来的指标，

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

用来衡量从发病到死亡所损失的健康寿命年

in terms of disability from medical causes,

换言之，承受疾病负担的年数，

and as you can see, virtually 30 percent

如你所见，几乎有30 %

of all disability from all medical causes

因接受医疗而从此被认定为“罹患”

can be attributed to mental disorders,

是属于精神疾病，

neuropsychiatric syndromes.

神经精神性综合症。

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

你可能没想到精神疾病会排在第一，

I mean, cancer seems far more serious.

你或许觉得癌症更严重，

Heart disease seems far more serious.

还有心脏病!

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

但你可以看到在这张图表上它们排在精神疾病之后，

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

这是因为我们在说罹患（而不是死亡率）。

What drives the disability for these disorders

是什么引起了这些精神障碍

like schizophrenia and bipolar and depression?

表现出精神分裂,，躁郁和抑郁的症状?

Why are they number one here?

为什么他们排在第一位?

Well, there are probably three reasons.

这里大概有三个原因：

One is that they're highly prevalent.

首先是这些疾病非常普遍。

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

约有1/5的人在有生之年

in the course of their lifetime.

会患上此类疾病。

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

其次，对一部分患上此病的人来说，

these become truly disabling,

成为永久性残疾，

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

大约 4% 至5%，也就是20人中就有1个。

But what really drives these numbers, this high morbidity,

但真正导致这么高的发病率，

and to some extent the high mortality,

换言之，这么高的死亡率，

is the fact that these start very early in life.

是因为发病时间早。

Fifty percent will have onset by age 14,

50%的病人从14岁起患病，

75 percent by age 24,

75 %的病人从24岁起患病，

a picture that is very different than what one would see

与传统的疾病观念不同

if you're talking about cancer or heart disease,

如果你在谈论癌症、心脏病

diabetes, hypertension -- most of the major illnesses

糖尿病、 高血压 — — 这些疾病

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

被认为是发病率和死亡的来源。

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

而精神疾病，却是折磨年轻人的慢性病。

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

在演讲开始时，我告诉你们一些好的消息。

This is obviously not one of them.

它们显然不在其中。

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

这也许是最难攻克的那部分，

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

并且，在某种意义上说是我的告白。

My job is to actually make sure that we make progress

我的工作就是要为精神疾病的研究

on all of these disorders.

带来实质的进展。

I work for the federal government.

我为联邦政府工作，

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

实际上，是为你们工作，是你们付我薪水。

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

此时你已经知道我是做什么的，

or maybe what I've failed to do,

也知道了我在工作上没有取得成果，

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

如果你觉得我应该被解雇，

and I could certainly understand that.

我会完全理解。

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

但我想要说的，和我在这里的原因

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

就是想告诉你，我们将要进入一个

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

认识精神疾病的全新领域。

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

到目前为止，我所说的被称为精神失常，

diseases of the mind.

是神志上的疾病。

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

如今，精神病已经让人"谈虎色变"

and people feel that, for whatever reason,

顾及到病人的感受或其他原因，

it's politically better to use the term behavioral disorders

便采用"行为障碍"这一委婉说法

and to talk about these as disorders of behavior.

和对不正常行为的的讨论。

Fair enough. They are disorders of behavior,

倒也讲得过去，疾病的表现形式是行为失常，

and they are disorders of the mind.

也是精神失常。

But what I want to suggest to you

但是今天我要告诉诸位

is that both of those terms,

正是这两种说法，

which have been in play for a century or more,

主导医界长达一个多世纪，

are actually now impediments to progress,

正在阻碍精神疾病的研究进展，

that what we need conceptually to make progress here

若要从理念上突破精神疾病研究

is to rethink these disorders as brain disorders.

则需要重新命名为大脑失常。

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

现在，你们中的一些人会说：

"Oh my goodness, here we go again.

“哦， 我的天啊，又来了，

We're going to hear about a biochemical imbalance

我们将要听到关于生化失衡，

or we're going to hear about drugs

或者药品知识，

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

或是一些非常简单的概念，

that will take our subjective experience

(这些概念)只是凭借我们主观的经验，

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

把他们想象成生化分子，以某种

very flat, unidimensional understanding

极其简单的定向思维来解释

of what it is to have depression or schizophrenia.

造成抑郁症或精神分裂症的原因。

When we talk about the brain, it is anything but

当我们谈论大脑时，

unidimensional or simplistic or reductionistic.

绝非一维和简化。

It depends, of course, on what scale

当然，这取决于以什么尺度

or what scope you want to think about,

或什么范畴来谈此事，

but this is an organ of surreal complexity,

它是一个极其复杂的器官，

and we are just beginning to understand

我们对它的了解才刚刚起步

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

还谈不上研究它，无论是对

the 100 billion neurons that are in the cortex

大脑皮层上1000 亿的神经元，

or the 100 trillion synapses

还是连结各个“ 交通枢纽”的

that make up all the connections.

100 兆的神经突触，

We have just begun to try to figure out

我们刚刚开始，试图找出答案：

how do we take this very complex machine

我们如何运用大脑这个能够

that does extraordinary kinds of information processing

处埋惊人信息的非凡机器，

and use our own minds to understand

同时使用我们自己的头脑来解释

this very complex brain that supports our own minds.

这个非凡的大脑是如何支配我们的行为。

It's actually a kind of cruel trick of evolution

听上去十分跷舌，又很滑稽的理论，

that we simply don't have a brain

好象我们的大脑发育

that seems to be wired well enough to understand itself.

不够健全，连自己都不了解自己~

In a sense, it actually makes you feel that

从某种意义上讲，大脑有时让你感觉到，

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

在研究已知的行为或认知

something you can observe,

尤其是对你可以观察到的东西时，

that in a way feels more simplistic and reductionistic

它是简单直观的，

than trying to engage this very complex, mysterious organ

而不是让人费解 ，神秘的器官，

that we're beginning to try to understand.

使我们刚刚萌生兴趣。

Now, already in the case of the brain disorders

现在，对于“大脑失常”

that I've been talking to you about,

正如我前面所说的

depression, obsessive compulsive disorder,

抑郁症，强迫症，

post-traumatic stress disorder,

创伤后应激障碍，

while we don't have an in-depth understanding

虽然我们还不甚了解大脑是

of how they are abnormally processed

如何失灵，

or what the brain is doing in these illnesses,

或病发后做何处理，

we have been able to already identify

但我们已经能够辨别出脑部神经

some of the connectional differences, or some of the ways

在连接上的差异

in which the circuitry is different

或者脑部神经路线异样

for people who have these disorders.

这些神志错乱病人的通常症状。

We call this the human connectome,

我们把这称之为脑部神经连接组，

and you can think about the connectome

你可以把它想象成

sort of as the wiring diagram of the brain.

大脑的线路连接图，

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

下面会多次提到的。

The important piece here is that as you begin to look

重要一点是，当提及这些病人，

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

每五个健康人中就有一个，

who struggle in some way,

不同程度的患有精神疾病，

you find that there's a lot of variation

你可以发现大脑出现变异情况

in the way that the brain is wired,

是多么的纷繁复杂

but there are some predictable patterns, and those patterns

但我们还是了解到一些可预测的模式，

are risk factors for developing one of these disorders.

可以预测到发病倾向。

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

我所说的大脑失常与平时常见的稍有不同，

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

像亨廷顿氏症或帕金森症或老年痴呆症等，

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

是部分大脑皮层缺损。

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

而这里我们谈论是交通堵塞，或是绕道而行，

or sometimes problems with just the way that things are connected

或只是连接方式出了问题，

and the way that the brain functions.

或大脑功能性障碍。

You could, if you want, compare this to,

你可以这样，如果一定要比较的话，

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

那就想象心肌梗塞、突发性心脏病，

where you have dead tissue in the heart,

是由于心脏中坏死组织所致，

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

还有心律失常、心脏运行不正常，

because of the communication problems within it.

是由于其内部的输导功能出了问题。

Either one would kill you; in only one of them

任何一种病症都会导致死亡，

will you find a major lesion.

但只有一项是主要病变。

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

除了想象，最好还是举个实例，

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

个例分析， 是精神分裂症。

because I think that's a good case

我觉得这是个非常好的例子，

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

揭示进行大脑失常研究的深远意义。

These are scans from Judy Rapoport and her colleagues

国家精神健康研究所茱蒂和她的同事们

at the National Institute of Mental Health

提供了这些研究扫描图，

in which they studied children with very early onset schizophrenia,

他们研究了存在精神分裂症迹象的儿童，

and you can see already in the top

你已经能看到在顶部，

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

那些红色、橙色、黄色的区域，

are places where there's less gray matter,

取代了应有的灰质，

and as they followed them over five years,

随后追踪了五年多，

comparing them to age match controls,

再进行年龄匹配对照，

you can see that, particularly in areas like

你可以看到，特别是在

the dorsolateral prefrontal cortex

延髓背外侧前额叶皮层

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

或上级颞回，(这些孩子的)大脑灰质严重缺损。

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

这些非常重要，如果通过建模进行量化，

you can think about normal development

你可以理解在正常发育中

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

大脑皮层质量是会减少，或是灰质轻微损失，

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

但精神分裂症患者的这些损失量超标，

and at some point, when you overshoot,

在某些时候，

you cross a threshold, and it's that threshold

正是超过这个标准值，

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

我们说这个人患有精神分裂症，

because they have the behavioral symptoms

此时他的行为异常，多数呈现出

of hallucinations and delusions.

幻觉和妄想，

That's something we can observe.

这些我们肉眼所能观察到的异常行为，

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

但仔细看看这个图，你会发现其实他们跨过了不同的标准值，

They've crossed a brain threshold much earlier,

而且出现得很早，

that perhaps not at age 22 or 20,

并不是在（行为失常的）22岁或20岁，

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

其实在15岁或16岁已经出现明显迹象，

the trajectory for development is quite different

发展轨迹大不相同，

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

这是从大脑发育来说的，而不是指（后期的）行为方式，

Why does this matter? Well first because,

为什么这件事情非常重要呢? 首先，

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

对于大脑紊乱，行为异常是最后的症状，

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

我们知道，对于老年痴呆症,帕金森症和亨廷顿氏症，

There are changes in the brain a decade or more

患者的大脑在十年前或更早，

before you see the first signs of a behavioral change.

无任何迹象时已经发生了变化。

The tools that we have now allow us to detect

我们现有的仪器已经可以很早检测出

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

这些变化，远远早于症状的出现。

But most important, go back to where we started.

但最重要的是，回到我们开始讲述的

The good-news stories in medicine

医学中的良好实践：

are early detection, early intervention.

“早发现”， “早治疗”。

If we waited until the heart attack,

如果我们一直等到心脏病发作再治疗，

we would be sacrificing 1.1 million lives

每年将会有110万人

every year in this country to heart disease.

死于心脏疾病。

That is precisely what we do today

这正是我们今天的状况，

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

当我们发现某人有精神疾病，

brain circuit disorders, has a behavioral disorder.

脑残或行为障碍等，

We wait until the behavior becomes manifest.

直到他们的异常行为显而易见时才釆取措施。

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

这不是“早发现”，也无法“早治疗”。

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

确实，攻克精神疾病的时机尚未成熟，

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

我们还不淸楚所有病因，我们甚至

what the tools will be,

没有有效的检测仪器，

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

也不知道去检测什么，

to get there before the behavior emerges as different.

能够在行为异常出现前阻止病变。

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

但目前的研究成果已经

and where we need to go.

为我们指明方向。

Are we going to be there soon?

我们会达到彼岸吗?

I think that this is something that will happen

我的答案是肯定的，

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

在接下来的几年里，

with a quote about trying to predict how this will happen

我想用这段话结束并预测研究的进展，

by somebody who's thought a lot about changes

它是由一个想用观念和技术

in concepts and changes in technology.

改变世界的狂人所说的：

"We always overestimate the change that will occur

“我们总是高估今后

in the next two years and underestimate

两年的变化，但是低估

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

未来十年的变化”— — 比尔 · 盖茨

Thanks very much.

非常感谢。

(Applause)

（掌声）