Thomas Insel: Toward a new understanding of mental illness

Translator: Joseph Geni Reviewer: Thu-Huong Ha

譯者: illusion Hung 審譯者: Dat Tran

So let's start with some good news,

讓我們用一些好消息來開始

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

這些好消息是我們

based on biomedical research

基於在生物醫學研究裏

that actually has changed the outcomes

一些確實改變了許多嚴重疾病的

for many very serious diseases?

成果所得的資訊有關

Let's start with leukemia,

我們從白血病談起

acute lymphoblastic leukemia, ALL,

急性淋巴性白血病，簡稱ALL

the most common cancer of children.

最常見的兒童癌症

When I was a student,

在我學生時期

the mortality rate was about 95 percent.

其死亡率約為 95％

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

25，30年後的今天

a mortality rate that's reduced by 85 percent.

其死亡率已下降 85％

Six thousand children each year

每年有6000名

who would have previously died of this disease are cured.

過去將死於這種疾病的兒童獲得治癒

If you want the really big numbers,

如果你想看到更顯著的進展

look at these numbers for heart disease.

請看這些心臟病統計數據

Heart disease used to be the biggest killer,

心臟病曾經是健康的頭號殺手

particularly for men in their 40s.

尤其對40多歲的男性而言

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

今天，我們發現心臟病死亡率

from heart disease --

已下降 63％

remarkably, 1.1 million deaths averted every year.

每年死亡人數減少110萬，一個值得注意的數字

AIDS, incredibly, has just been named,

上個月，愛滋病，難以置信的

in the past month, a chronic disease,

被歸類為慢性疾病

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

意味著遭受愛滋病毒感染的一個20歲年輕人

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

將不僅存活幾星期，幾個月或幾年

as we said only a decade ago,

如我們十年前所預期的

but is thought to live decades,

而有機會存活數十年

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

或許在60或70歲死於其他成因

These are just remarkable, remarkable changes

這是相當驚人的改善

in the outlook for some of the biggest killers.

對一些致命疾病的前景而言

And one in particular

尤其是其中一種

that you probably wouldn't know about, stroke,

你或許不知道－中風

which has been, along with heart disease,

它通常伴隨心臟病

one of the biggest killers in this country,

是我國死亡率最高的疾病之一

is a disease in which now we know

現在我們知道，以這種疾病來說

that if you can get people into the emergency room

如果能及時將病患者送入急診室

within three hours of the onset,

在發病三小時內

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

約 30％的 病患者能平安出院

without any disability whatsoever.

沒有任何後遺症

Remarkable stories,

令人驚嘆的故事

good-news stories,

人類的福音

all of which boil down to understanding

這一切的結果是

something about the diseases that has allowed us

瞭解某些關於疾病的資訊，使我們能

to detect early and intervene early.

早期發現、早期處理

Early detection, early intervention,

早期發現、早期處理

that's the story for these successes.

這是人類對抗疾病的勝利史

Unfortunately, the news is not all good.

不幸的是，並非全都是好消息

Let's talk about one other story

我們談談另一個故事

which has to do with suicide.

和自殺有關

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

這個，當然，本身並非疾病

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

而是導致死亡的

that leads to mortality.

條件或情況

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

你或許不知道這種情形多麼普遍

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

美國每年有38,000人自殺

That means one about every 15 minutes.

意味著大約每15分鐘一位

Third most common cause of death amongst people

它是15至25歲年齡層中

between the ages of 15 and 25.

第三大死亡原因

It's kind of an extraordinary story when you realize

這是令人震驚的故事，當你瞭解

that this is twice as common as homicide

因此死亡的人數為謀殺的兩倍

and actually more common as a source of death

事實上，以我國來說

than traffic fatalities in this country.

這是比交通事故更常見的死因

Now, when we talk about suicide,

現在，當我們談到自殺

there is also a medical contribution here,

醫學上對這方面的研究亦有貢獻

because 90 percent of suicides

因為 90％ 的自殺

are related to a mental illness:

是與精神疾病有關

depression, bipolar disorder, schizophrenia,

憂鬱症、躁鬱症、精神分裂症

anorexia, borderline personality. There's a long list

厭食症、邊緣型人格

of disorders that contribute,

許多精神疾病與此有關

and as I mentioned before, often early in life.

如我之前提過的 這些疾病往往發生於人生早期

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

但自殺不僅與這些疾病的死亡率有關

It's also morbidity.

也與其發病率有關

If you look at disability,

如果觀察致殘程度

as measured by the World Health Organization

根據世界衛生組織

with something they call the Disability Adjusted Life Years,

以所謂的「傷殘調整生命年」所做的衡量

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

沒人想到它會成為一種度量單位

except an economist,

除了經濟學家

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

它是一種估算健康壽命損失的方法

in terms of disability from medical causes,

藉由醫學因素導致的失能

and as you can see, virtually 30 percent

如各位所見

of all disability from all medical causes

在所有醫學因素導致的失能中，約30％

can be attributed to mental disorders,

歸因於精神障礙

neuropsychiatric syndromes.

精神症狀

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

你或許認為這並不合理

I mean, cancer seems far more serious.

我的意思是，癌症似乎更加嚴重

Heart disease seems far more serious.

心臟病似乎更加嚴重

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

但各位可以看見 事實上它們位於這張列表下方

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

因為我們所討論的是失能

What drives the disability for these disorders

導致這些疾病產生失能情況的原因是什麽？

like schizophrenia and bipolar and depression?

例如精神分裂症、躁鬱症和憂鬱症？

Why are they number one here?

為何它們在這張列表中獨占鰲頭？

Well, there are probably three reasons.

有三個可能原因

One is that they're highly prevalent.

第一，這些疾病非常普遍

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

大約五分之一的人將罹患其中一種

in the course of their lifetime.

在人生過程中

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

第二，當然，對某些人來說

these become truly disabling,

這會造成真正的失能

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

比例約為4％～5％，或許20人中即有1人

But what really drives these numbers, this high morbidity,

但真正造成這些數據、這種高罹患率

and to some extent the high mortality,

以某種程度來說亦是高死亡率的原因

is the fact that these start very early in life.

是在於這些疾病發生於人生早期

Fifty percent will have onset by age 14,

50％ 病患將在14歲前發病

75 percent by age 24,

75％ 病患將在24歲前發病

a picture that is very different than what one would see

這是截然不同的情形

if you're talking about cancer or heart disease,

相較於癌症或心臟病

diabetes, hypertension -- most of the major illnesses

糖尿病、高血壓等大多數主要疾病

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

即我們一般認為的罹病和死亡原因

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

這確實是屬於年輕人的慢性病

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

現在，我以一些好消息作開場白

This is obviously not one of them.

顯然這並非其中之一

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

這或許是其中最難以啟齒的部分

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

以某種意義來說，這算是我的告解

My job is to actually make sure that we make progress

我的工作是確保在這所有疾病上

on all of these disorders.

取得進展

I work for the federal government.

我為聯邦政府工作

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

事實上是為你們工作，你們付我薪水

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

或許以這點來說，當你們知道我所做的事

or maybe what I've failed to do,

或我無法做到的事之後

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

你們會認為我應該被解僱

and I could certainly understand that.

我當然明白這一點

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

但我想提出的建議 和我來在這裡的原因是

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

告訴你們，我認為我們應該以

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

截然不同的觀點看待這些疾病

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

到目前為止 我一直使用精神障礙這個詞彙

diseases of the mind.

精神方面的疾病

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

事實上，現今 這已成為一個相當不受歡迎詞彙

and people feel that, for whatever reason,

人們認為－無論出於何種原因

it's politically better to use the term behavioral disorders

原則上最好使用行為障礙這個詞彙

and to talk about these as disorders of behavior.

稱這些疾病為行為障礙

Fair enough. They are disorders of behavior,

確實，它們屬於行為障礙

and they are disorders of the mind.

亦屬於精神障礙

But what I want to suggest to you

但我想提出的建議是

is that both of those terms,

這兩個詞彙

which have been in play for a century or more,

使用超過一世紀的詞彙

are actually now impediments to progress,

事實上阻礙了進展

that what we need conceptually to make progress here

我們必須在觀念上取得的進展是

is to rethink these disorders as brain disorders.

將這些疾病歸類為腦部障礙

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

現在，有些人會說

"Oh my goodness, here we go again.

「天哪，又來了」

We're going to hear about a biochemical imbalance

「我們將聽到關於生化失衡」

or we're going to hear about drugs

「或關於藥物的知識」

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

「或聽到一些過度簡化的觀念」

that will take our subjective experience

「將我們的主觀經驗」

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

「轉變成分子層面的理解，或某種」

very flat, unidimensional understanding

「單純而簡要的概念」

of what it is to have depression or schizophrenia.

「說明它與憂鬱症或精神分裂症的關係」

When we talk about the brain, it is anything but

當我們談到大腦時，絕非

unidimensional or simplistic or reductionistic.

單純、簡要或可簡化的概念

It depends, of course, on what scale

當然，這取決於

or what scope you want to think about,

你打算以何種層面或範圍思考

but this is an organ of surreal complexity,

但大腦是一個相當複雜的器官

and we are just beginning to understand

我們才剛開始瞭解

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

如何去研究它，無論你考量的是

the 100 billion neurons that are in the cortex

皮層中上百億個神經元

or the 100 trillion synapses

或上千億個

that make up all the connections.

連接神經元的突觸

We have just begun to try to figure out

我們才剛開始試著瞭解

how do we take this very complex machine

如何研究這個複雜至極的機器

that does extraordinary kinds of information processing

它能進行驚人的訊息處理程序

and use our own minds to understand

用我們本身的大腦理解

this very complex brain that supports our own minds.

這個掌控人類心智、複雜至極的大腦

It's actually a kind of cruel trick of evolution

這可說是演化的殘酷把戲

that we simply don't have a brain

我們並未擁有

that seems to be wired well enough to understand itself.

聰明到足以理解它本身的大腦

In a sense, it actually makes you feel that

以某種程度來說，它確實使你感到

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

當你處於學習行為或認知的安全區域時

something you can observe,

你可觀察到某些東西

that in a way feels more simplistic and reductionistic

以某種較為單純和直接的方式感受

than trying to engage this very complex, mysterious organ

而非試著參與這個 複雜而神秘至極的器官運作

that we're beginning to try to understand.

我們正開始試著瞭解它

Now, already in the case of the brain disorders

現在，以腦部障礙為例

that I've been talking to you about,

如演講中提及的

depression, obsessive compulsive disorder,

憂鬱症、強迫症

post-traumatic stress disorder,

創傷後壓力症候群

while we don't have an in-depth understanding

我們尚無法深入瞭解

of how they are abnormally processed

其運作的異常之處

or what the brain is doing in these illnesses,

或大腦和這些疾病的關係

we have been able to already identify

我們已能確定

some of the connectional differences, or some of the ways

一些連接上的差異，或某些

in which the circuitry is different

通訊線路上的差異

for people who have these disorders.

對罹患這些疾病的人來說

We call this the human connectome,

我們稱之為人類連接組

and you can think about the connectome

你可以將連接組想成

sort of as the wiring diagram of the brain.

類似大腦接線圖

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

你將在幾分鐘內聽見更多相關敘述

The important piece here is that as you begin to look

其中一個重要關鍵是，當你開始觀察

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

罹患這些疾病的人，我們當中的五分之一

who struggle in some way,

以某種程度來說正與其抗爭

you find that there's a lot of variation

你將發現其中存在許多變化

in the way that the brain is wired,

以大腦接線方式而言

but there are some predictable patterns, and those patterns

但其中存在一些可預測的模式，這些模式

are risk factors for developing one of these disorders.

對這些疾病的發展來說是危險因素

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

這與我們對腦部障礙的認知稍有不同

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

例如亨丁頓氏症 帕金森氏症或阿爾海默症

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

其原因在於大腦皮層某部分受到損害

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

我們所談論的是 線路阻塞，有時是繞道而行

or sometimes problems with just the way that things are connected

有時問題僅在於線路連接方式

and the way that the brain functions.

及大腦運作方式

You could, if you want, compare this to,

如果有興趣，你可以將它與

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

心肌梗塞、心臟病發作比較

where you have dead tissue in the heart,

其原因在於心臟組織壞死

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

想比與心律不整，器官無法正常運作

because of the communication problems within it.

因為其中存在通訊問題

Either one would kill you; in only one of them

兩者均足以致命 但你僅能在其中一種當中

will you find a major lesion.

發現主要病變

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

當我們思考這一點時，或許最好

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

稍微深入探討 某種特定疾病，即精神分裂症

because I think that's a good case

因為我認為這是很好的例子

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

有助於理解為何可將其視為一種腦部障礙

These are scans from Judy Rapoport and her colleagues

這是 Judy Rapoport 和她同事所做的掃描圖

at the National Institute of Mental Health

來自美國國家心理衛生研究院

in which they studied children with very early onset schizophrenia,

他們研究罹患早發性精神分裂症的兒童

and you can see already in the top

你可以看見上方圖片中

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

已出現紅色、橙色或黃色區域

are places where there's less gray matter,

這是灰質較少的地方

and as they followed them over five years,

他們追蹤這些兒童五年

comparing them to age match controls,

將他們與同齡的控制組比較

you can see that, particularly in areas like

你可以看見 尤其在這些區域當中，例如

the dorsolateral prefrontal cortex

前額葉皮質

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

或顳葉顳上回，存在嚴重的灰質喪失情況

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

這十分重要，如果你試著將其模式化

you can think about normal development

你可將正常發展視為

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

皮質喪失、灰質喪失的過程

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

精神分裂症的情況則是超越這個標度

and at some point, when you overshoot,

在某個時刻，當超越這個標度時

you cross a threshold, and it's that threshold

相當於跨越一個門檻，而這個門檻

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

即是我們對這些精神分裂症患者的定義

because they have the behavioral symptoms

因為他們開始出現行為症狀

of hallucinations and delusions.

例如幻覺和妄想

That's something we can observe.

這是我們可觀察到的部分

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

但仔細觀察這張圖，你可以看見 事實上他們跨越了另一道門檻

They've crossed a brain threshold much earlier,

他們在相當早期即跨越大腦的門檻

that perhaps not at age 22 or 20,

也許不是在22或20歲

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

而是在15或16歲，你可以開始看見

the trajectory for development is quite different

其發展軌跡截然不同

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

以大腦層面而言，而非行為層面

Why does this matter? Well first because,

為何這十分重要？好，主要原因是

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

對腦部障礙來說 行為是最後發生改變的部分

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

我們知道阿茲海默症 帕金森氏症、亨丁頓症皆是如此

There are changes in the brain a decade or more

大腦發生變化十年或更長時間後

before you see the first signs of a behavioral change.

才能看見行為改變的最初跡象

The tools that we have now allow us to detect

目前的工具可使我們早期檢測

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

這些腦部的變化，遠早於症狀的出現

But most important, go back to where we started.

但最重要的是，回到演講開頭部分

The good-news stories in medicine

醫學上的福音是

are early detection, early intervention.

早期發現、早期處理

If we waited until the heart attack,

如果等到心臟病發作

we would be sacrificing 1.1 million lives

我國每年將因心臟病

every year in this country to heart disease.

損失110萬人的生命

That is precisely what we do today

這正是我們目前的處境

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

當我們確定每位擁有其中一種腦部障礙

brain circuit disorders, has a behavioral disorder.

大腦線路異常的病患 都將發生行為障礙時

We wait until the behavior becomes manifest.

卻等到行為發生變化才著手處理

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

這並非早期發現、早期處理

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

坦白說，我們尚未準備好進行這件事

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

我們還不明白所有事實 事實上我們甚至不知道

what the tools will be,

可使用什麼工具

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

或如何精確檢測所有病例

to get there before the behavior emerges as different.

在行為發生改變前先行處理

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

但這讓我們明白 思索這一點的必要性

and where we need to go.

及需要努力的方向

Are we going to be there soon?

我們是否很快就能達成目標？

I think that this is something that will happen

我認為將會有所進展

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

在未來幾年內，但我想

with a quote about trying to predict how this will happen

引用一句話作結語 試著預測未來發展的情形

by somebody who's thought a lot about changes

這句話來自某位

in concepts and changes in technology.

對觀念和科技變化擁有精闢見解的人

"We always overestimate the change that will occur

「我們總是高估」

in the next two years and underestimate

「未來兩年將發生的變化，低估」

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

「未來十年將發生的變化」－比爾‧蓋茲

Thanks very much.

十分感謝

(Applause)

（掌聲）