Thomas Insel: Toward a new understanding of mental illness

Translator: Joseph Geni Reviewer: Thu-Huong Ha

Translator: Ga-Wai Lau Reviewer: SHI CHEN

So let's start with some good news,

我哋先嚟啲好消息

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

呢個好消息

同生物醫學研究改善咗好多個嚴重疾病

based on biomedical research

that actually has changed the outcomes

而我哋知道當中有幾多嘢有關

for many very serious diseases?

Let's start with leukemia,

我哋就由白血病開始講

acute lymphoblastic leukemia, ALL,

急性淋巴細胞性白血病，俗稱 ALL

the most common cancer of children.

係細路仔最常見嘅癌症

When I was a student,

當我仲係學生嘅時候

the mortality rate was about 95 percent.

死亡率係大概 95%

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

25、30 年之後嘅今日，我哋講梗嘅係

a mortality rate that's reduced by 85 percent.

呢種病嘅死亡率下降咗 85%

Six thousand children each year

以致到每年六千名兒童都救得返

who would have previously died of this disease are cured.

If you want the really big numbers,

如果你想要真係大嘅數字

look at these numbers for heart disease.

我哋不妨嚟睇下心臟病嘅數字

Heart disease used to be the biggest killer,

以前，尤其是對四字頭的男性嚟講

particularly for men in their 40s.

心臟病係最犀利嘅殺手

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

依家，我哋睇到個數字跌咗 63%

from heart disease --

remarkably, 1.1 million deaths averted every year.

亦令到每年 110 萬個心臟病人 可以救得返

AIDS, incredibly, has just been named,

好開心，愛滋病喺上個月

in the past month, a chronic disease,

終於被定義為慢性病

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

意思即係話，一個人喺 20 歲時 感染到 HIV 嘅話

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

佢預期嘅壽命 唔再只係好似我哋十年前所講嘅

as we said only a decade ago,

幾個禮拜、幾個月，或者幾年

but is thought to live decades,

而依家預期嘅壽命已經延長到幾十年

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

有可能要到佢六、七十歲

佢至因為其他病因而去世

These are just remarkable, remarkable changes

現時最致命嘅幾種病未來都會有發展

in the outlook for some of the biggest killers.

And one in particular

其中一個特別嘅 你可能唔知道嘅，就係中風

that you probably wouldn't know about, stroke,

which has been, along with heart disease,

呢個病同心臟病 都係呢個國家嘅頭號殺手

one of the biggest killers in this country,

is a disease in which now we know

我哋而家知道

that if you can get people into the emergency room

只要呢個病嘅病人喺病發之內三粒鐘

within three hours of the onset,

可以送入急症室嘅話

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

大概有三成嘅人 可以喺冇殘疾嘅情況下出院

without any disability whatsoever.

Remarkable stories,

呢啲非常唔簡單嘅事、或者呢啲好消息

good-news stories,

all of which boil down to understanding

令我哋對疾病嘅認知提高咗

something about the diseases that has allowed us

從而可以提早發現、介入

to detect early and intervene early.

Early detection, early intervention,

提早發現、介入就係 依啲個案可以醫得好嘅原因

that's the story for these successes.

Unfortunately, the news is not all good.

但係好不幸，唔係全部都係好消息

Let's talk about one other story

我哋嚟講講另一個同自殺有關嘅故仔

which has to do with suicide.

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

咁當然啦，自殺本身唔係一種病

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

但佢會導致死亡

that leads to mortality.

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

你可能冇發覺到佢有幾咁普遍

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

喺美國，每一年都有 38,000 宗自殺案件

That means one about every 15 minutes.

亦即係話每 15 分鐘就有一單

Third most common cause of death amongst people

呢個亦係 15 歲到 25 歲 年齡層嘅第三大死因

between the ages of 15 and 25.

It's kind of an extraordinary story when you realize

如果你知道國家嘅自殺率 比謀殺率多出一倍

that this is twice as common as homicide

and actually more common as a source of death

同時自殺比交通事故死亡嘅人數 仲要多嘅時候

than traffic fatalities in this country.

你就會知道呢件事係幾咁唔尋常

Now, when we talk about suicide,

而家講到自殺

there is also a medical contribution here,

我哋就嚟講下疾病對自殺有咩影響

because 90 percent of suicides

因為 90% 嘅自殺案件 都係同精神病有關

are related to a mental illness:

depression, bipolar disorder, schizophrenia,

例如：抑鬱症、躁鬱症、精神分裂症

anorexia, borderline personality. There's a long list

厭食、邊緣人格

of disorders that contribute,

有好多精神病都會導致自殺

and as I mentioned before, often early in life.

而且呢啲精神病喺好早期就會出現

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

但係，呢啲病唔單止增加死亡風險

佢仲會增加病發風險

It's also morbidity.

If you look at disability,

至於殘疾方面，你會睇到世界衛生組織

as measured by the World Health Organization

with something they call the Disability Adjusted Life Years,

利用所謂「失能調整生命年」量度殘疾

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

但呢個其實只不過係

except an economist,

一種除咗經濟學家之外 冇人諗到嘅公式

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

呢條公式評估因為殘疾而損失嘅嘢

in terms of disability from medical causes,

and as you can see, virtually 30 percent

正如你所見到

有 30% 嘅殘疾可以歸因於精神病

of all disability from all medical causes

can be attributed to mental disorders,

neuropsychiatric syndromes.

同中樞神經精神症候群

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

你可能覺得頭先講嘅嘢無理

I mean, cancer seems far more serious.

我意思係話，癌症點睇 都比精神病嚴重得多

Heart disease seems far more serious.

心臟病點睇都比精神病嚴重好多

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

但係，你可以睇到心臟病同埋癌症 喺名單度仲要排後啲

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

咁係因為我哋依家講梗嘅係殘疾

What drives the disability for these disorders

究竟係乜嘢令到精神病

like schizophrenia and bipolar and depression?

譬如話精神分裂、躁鬱症，同埋抑鬱症

最終演變成殘疾呢？

Why are they number one here?

點解佢哋喺個名單度係排第一？

Well, there are probably three reasons.

咁，其實係有三個原因嘅

One is that they're highly prevalent.

第一，就係佢哋非常之流行

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

五個人當中就有一個人 喺一生之中罹患其中一種精神病

in the course of their lifetime.

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

第二，當然就係因為 當中有啲人因為個病而變咗殘疾

these become truly disabling,

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

普遍率大概係 4% 到 5%

即二十個人當中就有一個

But what really drives these numbers, this high morbidity,

但係真正令到呢啲數字咁高 令到發病率咁高、令到死亡率咁高

and to some extent the high mortality,

is the fact that these start very early in life.

係因為呢啲精神病喺生命好早期就出現

Fifty percent will have onset by age 14,

50% 嘅人喺 14 歲嘅時候有精神病

75 percent by age 24,

75% 喺 24 歲有

a picture that is very different than what one would see

呢個同我哋認為導致發病同死亡嘅 癌症、心臟病、糖尿病、高血壓

if you're talking about cancer or heart disease,

diabetes, hypertension -- most of the major illnesses

——呢啲重大疾病，係好唔同

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

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

呢啲精神病確實係年輕人嘅慢性病

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

咁，我開頭同你哋講咗會有好消息

This is obviously not one of them.

好明顯，呢個唔算好消息

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

呢個可以講係我工作裏邊 最困難嘅一部份

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

亦令我要好認真面對

My job is to actually make sure that we make progress

因為我嘅工作要確保 我哋喺呢啲疾病上高有所進展

on all of these disorders.

I work for the federal government.

我為聯邦政府做嘢

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

亦即係為你哋做嘢，係你哋俾我人工

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

可能喺呢個時候

當你知道咗我係做咩嘅 又或者係我冇做咩嘅

or maybe what I've failed to do,

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

你覺得你要炒我魷魚

and I could certainly understand that.

而我係非常之明白嘅

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

但係，我想講，我之所以會喺呢度

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

就係想同你哋講

我哋對呢啲疾病嘅認知將會好唔同

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

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

到目前為止，我同你講嘅都係精神病

diseases of the mind.

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

其實，「精神病」呢個詞依家已經過時

and people feel that, for whatever reason,

而且啲人認為無論係咩理由

it's politically better to use the term behavioral disorders

用「行為疾病」嚟稱呼會比較政治正確

and to talk about these as disorders of behavior.

Fair enough. They are disorders of behavior,

因為佢哋講到尾都係行為失常病

and they are disorders of the mind.

亦係精神上嘅疾病

But what I want to suggest to you

但係我想提醒嘅係

is that both of those terms,

呢兩個已經沿用咗一個世紀有多嘅詞 其實限制咗我哋嘅發展

which have been in play for a century or more,

are actually now impediments to progress,

that what we need conceptually to make progress here

若然要有所發展

我哋就要將呢啲疾病諗成係腦部嘅疾病

is to rethink these disorders as brain disorders.

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

嗱，而家你哋有啲人會諗：

"Oh my goodness, here we go again.

「噢，天啊，又嚟啦。

We're going to hear about a biochemical imbalance

我哋又要聽咩生化失調，

or we're going to hear about drugs

聽咩藥物嘅嘢，

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

或者聽咩簡化咗嘅概念，

that will take our subjective experience

按自己過去嘅經歷製作化學分子，

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

亦都可能借自己經驗去了解 抑鬱症或精神分裂症。」

very flat, unidimensional understanding

of what it is to have depression or schizophrenia.

When we talk about the brain, it is anything but

當我哋講到大腦嘅時候

佢絕對唔係乜嘢單維度 簡單嘅嘢或者還原論

unidimensional or simplistic or reductionistic.

It depends, of course, on what scale

當然，呢個都係要睇下 你用咩規模、用咩範圍諗

or what scope you want to think about,

but this is an organ of surreal complexity,

但係呢個器官係超現實嘅複雜

and we are just beginning to understand

而且無論你係想像緊 大腦皮質嘅一百億個神經元

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

又或者連接所有嘢嘅一百萬億個突觸

the 100 billion neurons that are in the cortex

我哋依家先至啱啱開始知道點樣研究佢

or the 100 trillion synapses

that make up all the connections.

We have just begun to try to figure out

我哋依家啱啱先開始嘗試搞清楚

how do we take this very complex machine

我哋應該點樣理解 呢個咁複雜、負責信息處理嘅機器

that does extraordinary kinds of information processing

and use our own minds to understand

同埋點樣用我哋嘅思想 去了解支持我哋有思想嘅大腦

this very complex brain that supports our own minds.

It's actually a kind of cruel trick of evolution

其實進化真係同我哋開咗個大玩嘅玩笑

that we simply don't have a brain

我哋始終冇辦法自己研究返自己嘅大腦

that seems to be wired well enough to understand itself.

In a sense, it actually makes you feel that

你或者會覺得研究行為 或者認知能力好保險

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

something you can observe,

因為你有實質嘅嘢可以觀察

that in a way feels more simplistic and reductionistic

而且行為同認知能力

相比起嘗試研究 呢個咁複雜、神祕嘅器官簡單得多

than trying to engage this very complex, mysterious organ

that we're beginning to try to understand.

Now, already in the case of the brain disorders

咁而家繼續我之前 同你哋講過嘅大腦疾病：

that I've been talking to you about,

depression, obsessive compulsive disorder,

抑鬱症、強迫症、創傷後壓力症候群

post-traumatic stress disorder,

while we don't have an in-depth understanding

雖然我哋未有辦法 可以深入了解呢啲病嘅病理

of how they are abnormally processed

or what the brain is doing in these illnesses,

或者個腦點受呢啲病影響

we have been able to already identify

但係我哋已經搵到一啲異常嘅神經連接

some of the connectional differences, or some of the ways

或者係患有呢啲病嘅病人 個腦嘅信息傳遞有咩差別

in which the circuitry is different

for people who have these disorders.

We call this the human connectome,

我哋叫呢個情況做「腦功能聯結圖譜」

and you can think about the connectome

你可以將「腦功能聯結圖譜」 當成係大腦嘅線路圖

sort of as the wiring diagram of the brain.

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

我之後會再講多啲呢樣嘢

The important piece here is that as you begin to look

最重要嘅一點就係

當你開始研究心理病 即係五個人就有一個患上嘅病

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

who struggle in some way,

you find that there's a lot of variation

你會發覺大腦嘅神經連接方式 可以好唔同

in the way that the brain is wired,

但係連接方式卻係有跡可尋

but there are some predictable patterns, and those patterns

are risk factors for developing one of these disorders.

而且某啲連接方式就係 造成心理病嘅元兇

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

呢個同我哋平時認識嘅大腦疾病

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

例如亨丁頓舞蹈症、柏金遜症 或者阿茲海默症，有啲唔同

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

呢啲病之不過損壞你部份大腦皮質

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

但我哋而家講梗嘅問題係塞車 有時候係繞道

or sometimes problems with just the way that things are connected

又或者係大腦線路本身就係咁樣連接

and the way that the brain functions.

以至大腦本身點樣運作

You could, if you want, compare this to,

如果你想嘅話，你可以攞心肌梗塞 即係心臟病

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

同心律不整嚟比較

where you have dead tissue in the heart,

心臟病表示有啲心臟組織死咗

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

而心律不整就係因為 心臟內部溝通有問題

because of the communication problems within it.

令到成個器官冇辦法運作正常

Either one would kill you; in only one of them

兩個病都可以致命

will you find a major lesion.

但係，淨係得一個有著重大毛病

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

當我哋諗到呢啲病嘅時候

我哋不妨深入啲睇下 其中一個病，精神分裂症

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

because I think that's a good case

因為我認為呢種病有助明白 點解要將精神病諗成係大腦疾病

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

These are scans from Judy Rapoport and her colleagues

呢幾張係國家心理衛生研究院嘅 Judy Rapoport 同佢啲同事

at the National Institute of Mental Health

喺研究早發性精神分裂症細路仔嘅時候

in which they studied children with very early onset schizophrenia,

掃描出嚟嘅

and you can see already in the top

你可以睇到上高，紅、橙、黃嘅地方

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

are places where there's less gray matter,

灰色神經組織比較少

and as they followed them over five years,

佢哋追查呢啲細路仔五年

comparing them to age match controls,

將佢哋同同年紀嘅細路比較

you can see that, particularly in areas like

你可以發現

特別喺好似背外側前額葉皮層 或者顳上回

the dorsolateral prefrontal cortex

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

都有大量嘅灰色神經組織損失

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

如果你想將佢諗得實質啲

you can think about normal development

你可以將正常發育諗成係皮質質量減少

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

或者皮質灰色神經組織流失

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

而精神分裂就係 呢啲灰色神經組織損失得太多

and at some point, when you overshoot,

當你損失到一定數量嘅時候 過咗一個點嘅時候

you cross a threshold, and it's that threshold

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

我哋就界定咗呢個人有呢個病

because they have the behavioral symptoms

因為佢哋有幻覺同埋妄想嘅症狀

of hallucinations and delusions.

That's something we can observe.

呢個係我哋可以觀察到嘅

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

但係，睇真啲

你會發覺佢哋已經過咗另一個臨界點

They've crossed a brain threshold much earlier,

佢哋係好早期嘅時候 就過咗個大腦嘅臨界點

that perhaps not at age 22 or 20,

應該唔使等 22 或者 20 歲

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

而係 15 或者 16 歲嘅時候

你就可以開始睇到 大腦嘅發育軌跡已經好唔同

the trajectory for development is quite different

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

但行為方面就冇

Why does this matter? Well first because,

點解呢個好重要呢？

第一，因為喺腦疾病病人當中

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

行為會係最遲受到影響嘅一樣嘢

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

我哋從阿茲海默症、柏金遜症 亨丁頓舞蹈症知道

There are changes in the brain a decade or more

大腦疾病要起碼有十年長 行為先至會有變化

before you see the first signs of a behavioral change.

The tools that we have now allow us to detect

我哋而家所用嘅工具 可以畀我哋提早好多偵測到腦嘅變化

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

早到喺症狀出現之前就偵測得到

But most important, go back to where we started.

但係最重要嘅 我哋返返去我哋一開始嗰度

The good-news stories in medicine

醫學界嘅好消息就係提早發現、介入

are early detection, early intervention.

If we waited until the heart attack,

如果我哋等到心臟病發個陣時先救

we would be sacrificing 1.1 million lives

我哋呢個國家就會有 110 萬條生命白白冇咗

every year in this country to heart disease.

That is precisely what we do today

呢個就正正係我哋而家所做嘅嘢

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

因為我哋認為一個人 只要有是旦一種呢啲腦疾病

brain circuit disorders, has a behavioral disorder.

就會有行為障礙症

We wait until the behavior becomes manifest.

我哋只能夠等到行為徵狀 出咗嚟先做到嘢

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

所以呢樣唔係提早偵測或者介入

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

我想講嘅係 我哋仲未完全準備好咁樣做

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

我哋冇全部嘅知識

我哋甚至乎唔知道個工具會係咩

what the tools will be,

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

亦都唔知道喺每一個案件中 我哋應該準確搵咩嘢

to get there before the behavior emerges as different.

先至可以喺行為症狀浮現之前 就可以知道一個人有心理病

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

但係，頭先講到嘅嘢 提示咗我哋應該點樣去諗

and where we need to go.

同埋應該點樣走

Are we going to be there soon?

我哋會不會好快就會到嗰度？

I think that this is something that will happen

我認為呢樣嘢 喺未來幾年係會發生嘅

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

但係，喺我結束之前，我想引用

with a quote about trying to predict how this will happen

一個就著觀念轉變同埋科技進步 諗咗好多嘢嘅人

by somebody who's thought a lot about changes

講到呢樣嘢會點發生，佢就係蓋茨︰

in concepts and changes in technology.

"We always overestimate the change that will occur

「我哋永遠都高估咗 未來兩年會發生嘅變化

in the next two years and underestimate

並且低估咗未來十年會發生嘅變化。」

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

Thanks very much.

多謝大家

(Applause)

（掌聲）