我很高兴为大家介绍本学期第四个也是最后一个 I am extremely pleased to introduce the fourth and final guest lecture
客席讲座 of the semester
Susan Nolen-Hoeksema教授 Professor Susan Nolen-Hoeksema
Susan是心理系的教授 Susan is a professor in the Department of Psychology
研究生院的主任 and the Director of Graduate Studies
她在临床心理学的研究非常著名 She is well known for her work in clinical psychology
尤其是对抑郁症的研究 and especially her research in depression
抑郁症的性质和病因 the nature and causes of people with depression
她尤其专注于研究抑郁症的性别差异 with special focus on sex differences in depression
几乎方方面面她都有所涉猎 She basically does everything someone can do
她是一个著名的科学家 获奖良多 She is a noted scientist, winning many awards
在科学期刊上发表了大量的著作 and publishing massive amounts of work in scientific journals
她是一个获奖的教师 她写过 She is an award-winning teacher and has authored
她的研究领域里我认为最好的教科书 what in my mind, is the very best textbook in her area
她是一个著名的畅销作家 她写的书很受欢迎 And she's a noted popular writer who has written popular
而且通俗易懂 把临床心理学的 and accessible books bringing the message and ideas
消息 想法和理论带给普罗大众 and theories of clinical psychology to the broader public
在我们欢迎她之前 我还有一件事要说 The only other thing I'll mention before we welcome her
明年她将会开一门临床心理学的课 is that she's going to teach next year her course in clinical psychology
这门课以有趣生动著称 which has a superb reputation as an extremely interesting course
如果你对今天的内容有兴趣 If you are interested in what you hear today
想深入了解的话 and you want to learn more about it
你应该报这门课 that's the course you should take
现在 请大家欢迎Susan Nolen-Hoeksema博士 So, let's please welcome Dr. Susan Nolen-Hoeksema
谢谢你 保罗 大家听得到吗? 很好 Thank you Paul. Can everybody hear me okay? Okay
今天我想为大家简单介绍一下 So, what I want to do today is to give you a very brief overview
现在临床心理学是如何研究精神疾病的 of how modern clinical psychology looks at mental disorders
我们如何界定精神病 some of the ways we think about what constitutes a mental disorder
以及精神病普遍具有的特征 some of the characteristics that kind of cut across mental disorders
然后我会讲一些情绪障碍的病例 and then I'm going to use the case of mood disorders
包括抑郁病 以及现称的两极型异常 that is depression and what is now called bipolar disorder
它另一个更为流行的名字是躁狂抑郁症 what you may know more popularly as manic-depression
我会借这些例子告诉大家 我们是怎么看某一类 as sort of examples of how we think about a particular set
精神病的 以及我们研究理论的一些方法 of disorders and some of the ways we go about researching the theories
精神病的各种理论 以及现今一些精神病的 different theories for the disorders and some of the prominent treatments
主要疗法 明白吗? for disorders these days. Okay?
所以我既会讲很多内容 So, I'm going to do both a fair amount of lecturing
然后还会让大家看很多视频 and then I've got lots of video clips to show you as well
所以我会在各个话题间切来换去 So, I'm going to be roaming around and changing venues here fairly often
在临床心理学 第一个也是最基本的一个问题是 So, the first and most fundamental question in clinical psychology is
"什么是变态?" "What is abnormality?"
我们如何界定什么是正常 健康 典型行为 Where do we draw the line between normal, healthy, typical behavior
什么是变态 非典型 异常 不健康 and what we might want to call abnormal, atypical, deviant, unhealthy
适应性差的精神问题? maladaptive mental problems?
我们通常都会觉得 我们所说的变态 We tend to have an intuitive sense of what we mean by abnormality
我们都以为…很多来听我的课的同学会说 and we'd like to believe--a lot of people who come into my course say
"你们当然已经研究出来了 "Well, of course, you know, you guys have figured it out
你们知道怎么界定 你们有判断标准 You know where to draw the line. You have criteria
你们会检查血液 You have blood tests, right?
这样就能查出我有没有抑郁症或精神分裂 that tell me whether I have depression or schizophrenia
或者其他我听说过的病" or one of the things I've read about."
事实上 我们没有 Well, the reality is that we don't
首先 目前已知的所有精神病 First of all, there is no biological test
都没有生物测试 for any of the known mental disorders right now
我们只有一套行为标准 And instead what we have is a set of behavioral criteria
来判定各种精神病 for how to diagnose different mental disorders
我所说的行为标准是指 And what I mean by behavioral criteria is a set of symptoms
病人跟你说的一系列症状 他们有什么感觉 that the person reports to you about how they feel
他们有什么思想 以及对他们行为的一系列观察 how they think, and a set of observations about their behavior
观察什么是典型的 什么是非典型的 and how typical or atypical it is
你用这个人表现出来的 或者跟你说的 And you take the sort of set of symptoms the person
一系列症状 然后用它们 shows or reports, and you match them up
跟现存的各种精神病标准作对比 against the existing criteria for different mental disorders
而这个人符不符合这些标准 And then it comes down to a fairly subjective judgment call
最终是要由一个很主观的判断来决定的 about whether the person meets the criteria or not
很不幸 这些判断 Unfortunately, these judgment calls
因为它们太主观 because they are so subjective
可能会受到很多因素的影响 can be influenced by a lot of factors
我们今天没有时间深入讲这些因素 And we won't have a chance to go into these too much today
但我会简单提几个 but just to highlight a few of them
第一个是社会规范 The first is social norms
你会不会被打上精神病或者精神问题的标签 Whether you get labeled as having a mental disorder or a problem
很大程度上决定于你的社会和文化规范 depends very heavily on what your social or cultural norms are
所以 在穆斯林社区或文化中 女人戴面纱 So, a woman wearing a veil in a Muslim community or culture
会被视为一种典型甚至规定的行为 would be seen as typical, even prescribed, behavior
但在非穆斯林文化里 一个女人戴面纱 Whereas a woman wearing a veil in a non-Muslim culture
尤其是最近几十年 especially until fairly recently
会被视为一个非典型或者变态行为 was often looked upon as very atypical or abnormal behavior
第二个 The second kind of thing that gets
影响我们判断是正常还是变态的因素 that influences whether something is called normal or abnormal
就是目标对象的某些特征 is certain characteristics of the target person
例如 我这里高亮出来的 性别 In particular, I've highlighted here, gender
你的性别真的能决定 Whether you're a man or you're a woman really influences
某些行为到底有多异常 how unusual a certain behavior is
哭就是一个好例子 So, crying is a good example
在我们的文化里 一个男人哭是很异常的 A man crying in our culture is seen as fairly unusual
而一个女人哭就正常很多了 whereas a woman crying is seen as much less unusual
或者说 一个女人打人 On the other hand, a woman beating up someone
会被视为很异常的行为 而男人打人则没那么异常 is taken as quite unusual behavior where it's less unusual for a man
所以 我们都有性别刻板印象 So, we have gender stereotypes
可接受行为是有性别角色之分的 gender roles for what is acceptable behavior
我们判断什么行为是正常 and our judgments as to whether something is normal
或者变态 就要受这些性别角色影响 or abnormal get influenced by those gender roles
第二个能够影响 And the third thing that can influence
什么行为是变态的因素 就是环境 whether something is labeled abnormal or not is the context
我给大家举"偏执症"这个例子 And here I'm giving you the example of "paranoia."
如果你偏执 过度警觉 If you're paranoid and hyper-vigilant
在巴格达市中心提防威胁 looking for threat in downtown Baghdad
这在今天会被视为非常适应性的行为 that's considered very adaptive behavior these days
因为它能帮助你避免受伤或被杀 because it could prevent you from getting hurt or killed
但是 如果你是在康涅狄格州中央一个安静的小农场 Whereas, if you're in a quiet little farm in Central Connecticut
你表现得极度偏执 相信 being extremely paranoid and believing
有人躲在角落里用枪打你 there's someone who's going to shoot you around the corner
这就不会被视为正常 或可接受 或适应性的行为 is not considered as normal or as acceptable or adaptive behavior
所以你表现出某种行为时所处的环境 So, the context in which you exhibit a particular behavior
同样能很大程度地影响别人把你视为 also can heavily influence whether it gets labeled by others
正常还是变态 as normal or abnormal
在临床心理学领域 我们有很多 In the field of clinical psychology we have a number of different ways
探索式的方法用来判定 kind of heuristics that we use to label things
什么是变态 不健康 令人不安的行为 as abnormal or unhealthy or troubling
其中有三个特征 And three of these characteristics
我们通常称之为3Ds:痛苦 功能失常 异常 are what we often call the three Ds: distress, dysfunction, and deviance
给当事人或者他人 So, behaviors that cause the individual
造成痛苦的行为 通常都会被视为变态或不健康 or others significant distress often get labeled as abnormal or unhealthy
抑郁症就是一个好例子 Depression is a prime example
等一下我们讲到它的特征时就会知道 as we'll see when we talk about the characteristics of it
它是一种痛苦的状态 你不快乐 你悲伤 It's a miserable state of being; you're unhappy, you're sad
你甚至伤心到想自杀 you may even feel so badly you want to kill yourself
这种高度的痛苦是它被列为精神病的 And that very, very high level of distress is part of the reason
原因之一 why it's labeled as a mental disorder
其他精神病不会造成患者痛苦 Other mental disorders don't cause the individual distress
但它们会造成别人痛苦 but they may cause other people distress
其中一个例子就是我们所说的 So, one example of this is something called
反社会人格障碍 "antisocial personality disorder,"
患者不顾他人的权益 where the individual has no regard for the rights of other people
毫不犹豫地偷别人的东西 或者伤害别人 has no hesitation to steal or--steal from or hurt other people
对别人的感觉没有一点移情或同情心 has no empathy or sympathy for other people's feelings
所以他们会对别人造成伤害 and so can inflict a lot of harm on other people
而且对自己的所作所为没有丝毫痛苦 and has absolutely no distress over this whatsoever
但这种行为会造成别人痛苦 But this behavior causes other people distress
这就是它被列为变态行为或精神健康问题的 and that's one of the reasons why that's labeled an abnormal behavior
原因之一 or a mental health problem
第二个普遍标准是"功能失常" The second general criterion is "dysfunction."
如果一系列行为使个人无法在日常生活中正常运作 If a set of behaviors prevents the person from functioning in daily life
那么它会被称为变态行为 then it might be labeled as abnormal
或者精神健康问题 or might end up being labeled as a mental health problem
在这点上 抑郁症也是一个好例子 Again, depression is a good example
抑郁症患者通常会完全丧失功能 People who are depressed often become completely non-functional
他们起不了床 上不了学 上不了班 They can't get up and go to class; they can't go to work
他们无法和别人互动 they can't interact with their friends
他们退回自己的世界 完全与社会隔绝 they withdraw and become totally isolated socially
所以他们可能会丢掉工作 被学校开除 So, they might lose their job; they might flunk out of school
功能完全衰退 And this complete decline in functioning
是我们把抑郁症视为伤害力最强的 is one of the major reasons that we consider depression
精神病之一的原因之一 one of the most debilitating disorders
最后是"异常" And then finally, "deviance,"
行为或感觉非常异常 the behaviors or feelings are highly unusual
这是三个标准里最有争议的一个 This is probably the most controversial of the three
因为它受社会规范的影响太大了 because it weighs, it is so heavily influenced by the social norms
在一个文化里异常的行为 在另一个文化里并不异常 What's deviant in one culture is not deviant in another culture
但如果一种行为在一种文化里完全不可接受 But if a set of behaviors is completely unacceptable to a culture
非常异常 这种行为很可能 highly unusual, they're more likely to end up
被视为变态行为 getting labeled as abnormal
那么 怎么把它们结合起来? Okay. So, how do we pull this all together?
今天美国临床心理学和精神学的 Well, these days the manual for making diagnoses
诊断手册 in clinical psychology and psychiatry in the United States
是《诊断与统计手册》 简称DSM is called the Diagnostic and Statistical Manual or the DSM
现在已经是第四版了 and it's in its fourth revision
它是50年代出台的 It's been around since the, I believe the '50s
五六十年代的最早版本 and the early editions in the '50s and '60s
非常主观 以弗洛伊德理论为基础 were highly subjective and based on Freudian theory
但自1980年以来 学界就致力于 But since 1980 there's been real effort
让标准变得更客观 to make the criteria much more objective
规定用来诊断患者的行为和观察 to make the set of behaviors or observations
必须是观察得到的东西 that are required to diagnose someone be things that are observable
你从患者身上可以看到的 他们可以告诉你的 that you can see in other people that they can report on reliably
而且这个临床学家和那个临床学家都会同意的东西 and that one clinician and another clinician will agree upon
所以 DSM列出一系列症状 So, the DSM gives lists of symptoms
诊断某一种精神病所需要的症状 with the required symptoms for a diagnosis
某一种精神病必须要有的症状 the number of symptoms that have to be present
以及异常 and the notions of deviation
功能失常 痛苦要建立在这些标准之上 dysfunction and distress are built into these criteria
我给大家说几个标准的例子 And I'm going to give you a couple of examples of these criteria
当我们讲某种情绪障碍时 when we talk about the specific types of mood disorder
我说过 我会用情绪障碍 So as I said, I'm going to use mood disorders
作为一个病例 讲解我们怎么诊断 as kind of a case example here of how we go about diagnosing
以及了解精神病理学 and understanding psychopathology
但我也想在这里讲一下这个病 but I also just want to impart some information
因为情绪障碍是最常见的 because mood disorders are one of the most common problems
精神病之一 that people face
高达四分之一的女性 As many as one in four women will have an episode
在人生某个时期都会患上抑郁症 of serious depression at some time in her life
男性大约有13%会在人生中患上 and about 13% of men will have an episode of serious depression
严重抑郁症 in their lives
所以这是一种极度常见的疾病 So, these are extremely common kinds of problems
尤其是在你们这个年纪 that people experience, particularly at your age
大学时期是疾病初发的高峰期 The college years are one of the peak times of onset
特别是抑郁症的初发 first onset, of depression in particular
还有两极型异常 And also, for bipolar disorder
即躁郁症 通常在青春期后期 or manic-depression, the late adolescent
20出头时是这种疾病的初发高峰期 early 20s are the peak onset times for these disorders as well
情绪障碍被分为 So, the mood disorders divide into
单极抑郁症 what's called unipolar depression disorders
即抑郁症 另一种就是两极型异常 which is depression only and then bipolar disorders
一个人在抑郁和躁狂中转换 where the person cycles between depression and mania
这里是DSM给严重抑郁症列出的标准 And here are the DSM criteria for major depression
最严重的一种抑郁症 one of the most severe forms of depression
我说过 DSM规定了这些相对来说可观察的标准 And as I said, the DSM sets up these relatively observable criteria
规定患者要有几个症状 and how many you have to have and what absolutely
而且必须要有什么症状 才算患了抑郁症 has to be present in order to get the diagnosis
DSM给严重抑郁症列出的第一条标准是 So, the first criterion in the DSM for major depression
病人必须或者表现出悲伤 is that the individual has to either show sadness
或者对平时的活动兴趣和乐趣减退 or a diminished interest or pleasure in their usual activities
也就是指快感缺失 which is referred to as anhedonia
所以你必须要有其中一个 So, you have to have one or the other of these
才能通过第一条标准 to sort of pass the first criterion
所以 你可能会觉得伤心忧郁 So, you might say that you feel sad and blue and just
或者觉得抑郁 or actually say you feel depressed
有些人这样的感觉很强烈 Some people feel those feelings very strongly
但有些人不觉得伤心忧郁 Other people don't really feel so sad or blue
他们只是什么兴趣都没有了 but what they'll say is that nothing interests them anymore
就像这种情绪把他们的生活都抽空了 It's like the emotion has been sucked out of their life altogether
他们以前喜欢做的事 现在做一点都不快乐 They don't have any fun doing the activities they used to do before
他们不想和朋友出去玩 They don't want to hang with their friends
他们不想吃东西 They just--they don't care about eating
什么都觉得不对劲 觉得不好 Just nothing feels right, feels good, anymore
接着 这个人还必须要有 And then the individual has to have four of the
除了悲伤和快感缺失以外的 at least four of the following symptoms
以下另外至少四个症状 in addition to sadness or anhedonia
第一个 他们会有显著的体重或胃口变化 First, they can show significant weight or appetite change
也就是说 你可能完全失去食欲 So, you may completely lose your interest in eating
体重骤减 也有些人会狂吃狂喝 and lose a lot of weight, or some people go on eating binges
我有一个好朋友 她患了一年的抑郁症 I had a very good friend who was depressed for about a year
胖了50磅 因为她不停地吃 and she gained fifty pounds because she would just eat
她狂吃狂喝 尤其是在晚上 She would binge eat, especially at night
还会有睡眠障碍 失眠 There are sleep disturbances--insomnia
也就是难以入睡 或者嗜睡 which is having trouble sleeping, or hypersomnia
也就是不停地睡 which is sleeping all the time
患上抑郁症时 有一种失眠是特别常见的 There's a particular form of insomnia that's especially likely
你晚上能睡着 in depression where you can go to sleep at night
但你会在凌晨三四点醒来 but then you wake up at about three or four
每天晚上都如此 醒来后就再也睡不着了 in the morning every night and you can't go back to sleep at all
睁着眼睛看天亮 You're just up for the rest of the night
但有些人会整天都想睡觉 But other people want to sleep all day long
我等一下会给大家看一段视频 and in the clip I'm going to show you in just a minute
里面有个女人说她一天睡20到24个小时 the woman talks about sleeping twenty, twenty-two hours a day
起床 吃点东西 getting up, eating a little bit
然后又上床睡觉 因为她还是觉得累 and then going back to bed because she was exhausted still
第三个标准是精神运动迟缓或激越 The third criterion is psychomotor retardation or agitation
精神运动迟缓更为常见 The retardation is much more common
它的意思是 and what this means is that sort of everything
一个人的所有动作都慢下来了 about the person's movement is slowed down
他们会慢慢走路 They'll walk more slowly
他们的反应时间慢了 Their reaction times will be slowed down
因为他们的动作迟缓了很多 And because they're so much more slow moving
抑郁症患者更容易出事故 depressed people are often more prone to accidents
他们不能快速反应 They just can't react as quickly as they need
当他们开车时 或者当他们过马路时 to when they're driving or when they're crossing the road
有车突然向他们冲来 and a car is coming at them suddenly
于是他们就发生车祸了 So, they get into more accidents
他们说话也会慢下来 And their speech may be slowed down
他们会说得很慢 就像 They may talk very, very slowly and it's as though it
要花非常大的力气 just takes a tremendous amount of energy
才能说完一句平常的话 to get even a common sentence out
但也有相对很少一部分的人 A much more, much smaller number of people
会有激越 而不是迟缓 get agitated instead of slow down
他们会非常亢奋 They may be hyper and just feel like
就像他们坐不住一样 they can't sit still and such
但激越比迟缓少见得多 but the agitation is much more rare than the retardation
患者会觉得很累 People feel really tired
疲劳 就像他们一点力气都没有 fatigued and like they have absolutely no energy
他们起不了床 动不了 They can't get up and can't get moving
我说过 他们可能会想睡一整天 As I said, they may want to just sleep all of the time
第五个标准是无价值感和过分内疚 Number five is feelings of worthlessness or excessive guilt
他们可能会觉得所有事都是他们的错 They may feel as though everything is their fault
这种内疚感或者无价值感 and the guilt feelings or sense of worthlessness
可能会严重到精神错乱 can even get psychotic
他们可能会脱离现实 They can lose touch with reality
当一个抑郁症患者脱离现实时 When a person loses touch with reality when they're depressed
通常都会有一个抑郁主题的 it typically has really depressing themes
他们可能相信他们是撒旦 They may believe that they are Satan
他们必须要自杀 and that they have to commit suicide
因为他们给这个世界带来苦难 because they're inflicting evil on the world
他们可能觉得连随机事件都是他们的错 They may believe as though random events are their fault
例如刚发生的某场洪灾是他们造成的 you know, that a flood that just happened somehow they caused
所以无价值感和内疚 So, the feelings of worthlessness and guilt
可以使人完全脱离现实 变成精神错乱 can get completely out of touch with reality, psychotic
更为常见的是 他们只是不切实际 More commonly, they're just unrealistic
他们有消极自尊 看不起自己 They're negative self-esteem, just being down on yourself
觉得自己笨 没用 丑 恶毒 feeling stupid and worthless and ugly and bad
第六个标准是注意力不集中和优柔寡断 Number six is diminished ability to concentrate or indecisiveness
抑郁症患者很难集中注意力 When you are depressed it's really hard to pay attention
同一段字你会看了一遍又一遍 You'll read a passage over and over again
你根本看不进去 and you just can't process it at all
你听课不集中 所以上课都是没用的 You can't concentrate on a lecture so going to class is just useless
你要决定论文写什么题目 You have to make a decision about what a paper topic is
你会觉得这是世界上最难做的事 and it just seems like the most monumental thing on earth
你什么都决定不了 你什么都想不了 You just can't decide anything, you can't think anything
你的思想压抑 不知所措 your thoughts are completely clouded and overwhelmed
还有自杀念头或者自杀行为 And then suicidal ideation or behavior
也就是说 你想着怎么自杀 想着怎么死 it means you think about committing suicide, you think about dying
有一部分人会付诸行动 And a subset of people actually take action
伤害自己或者杀死自己 to try to hurt themselves or kill themselves
应该说 自杀念头和行为 Now, it should be said that suicidal thoughts and behavior
不限于抑郁症 don't only happen in depression
各种各样的精神病都会有 They actually happen in all types of psychopathology
但抑郁症特别常见 but they're particularly common in depression
所以你必须至少符合 So, you have to have at least one
这四个症状中的一个 再加上悲伤或快感缺失 four of those symptoms plus sadness or anhedonia
这些症状…如果你只是某天过得不顺利才有 那不算 and these symptoms--it can't just be a bad day that you're having
这些症状必须要持续 These symptoms have to be present persistently
至少两周 才算患有严重抑郁症 for at least two weeks to get the diagnosis
说实话 大部分严重抑郁症病例 Now, truth be told, most episodes of major depression
持续时间远远超过两周 actually last a lot longer than two weeks
事实上 发作一次的平均时间 In fact, the average length of an episode
如果不接受冶疗的话 至少是半年 if it's not treated, is at least six months
所以患者这种痛苦状态会持续一段很长的时间 So, people stay this miserable for a very long period of time
但DSM里的最低标准是至少两周 but the minimum criterion in the DSM is at least two weeks
我想给大家看一段视频 So, what I want to do is to just show you a short clip
一个抑郁症发作多次的女人 of a woman who has had a lot of episodes of depression
幸好 拍这段频视时她没有发作 Fortunately, at the moment she's not in an episode
她能清楚地说出抑郁症发作时 But she can speak very articulately about what it's like
是怎么样的 to be in the midst of an episode
以及她有过的一些明显症状 and some of the significant symptoms that she had
好的 她讲了几件事 Okay. There are couple of things she talks about
我想评论一下 that I just want to comment on
其中一个是日常生活的心情不好 One is this differentiation between everyday sad mood
我们都会有的郁闷 and the kind of depressions we all experience
和她患上的那种伤害力很大的 and the kind of debilitating
严重抑郁症 这两者之间的区别 overwhelming depression that she experiences
确实 我们都会出现 And it is true that there is this continuum
坏心情 可能因为你考试没考好 from getting bummed out because you didn't do well
因为你和男朋友分手了 on a test or because you broke up with a boyfriend
或者和女朋友分手了 诸如此类的原因 or girlfriend or something like this
这种坏心情会恶化为完全功能丧失 像植物人一样 and being completely not functional, vegetative
就像那个女人抑郁症发作时那样 the way that this woman becomes whenever she gets depressed
如果我们能确定地 And it would be nice if we were really sure
划清普通的日常抑郁和精神病的抑郁之间的界线 where the cutoff was between those normal everyday depressions
这会是一件好事 and what's really a disorder
但现实是 我们并没有一条清晰地界线 But the reality is we don't really have real clear demarcation lines
有很多人的抑郁症要轻于 There are a lot of people who have more moderate
视频里的Tara所说的那种抑郁症 forms of depression than Tara here talks about
但他们仍然符合抑郁症的标准 but who still would qualify for a diagnosis
仍然被他们的症状所折磨 and are still suffering and impaired by their symptoms
所以我不想你们觉得 So, I don't want you to get the sense
如果你没有Tara那种 that if you don't have the kind of horrible version
恶化到极端的严重抑郁症 on the extreme end of the continuum of depression that Tara has
那就觉得自己没问题 因为不是这样的 then there's nothing wrong with you, because that's not the case
那些真的迟缓的人 People who are really slowed
那些功能受阻的人 whom their functioning is interfered with
他们生活过得很不开心 they're just really unhappy with life
他们确实有问题 需要冶疗 have problems that can be helped and do need attention
因为如果不治疗 轻度抑郁症 And it is the case that much more moderate forms of depression
可以变为严重的抑郁症 can morph into more serious forms if they're left untreated
所以它是会恶化的 So, there is this continuum
我想评论的另一件事是 The other things I wanted to comment
她在视频里说 on that she talks about early on in this piece
她会迫使自己振作起来过完一天 is the fact that she hauls herself up and goes through her day
即使她觉得很抑郁 even when she's feeling really, really depressed
这是很多抑郁症患者的一个特点 And there is this characteristic of a lot of depressed people
我称之为"行尸走肉" that I call the "walking wounded."
他们迫使自己装作正常地过日子 They just haul themselves through the day trying to act normal
试图不让别人知道他们出了问题 trying not to let anybody know that there's anything wrong with them
试图跟上功课和工作 trying to keep up with their schoolwork or their employment
但他们很痛苦 他们无法 But they're miserable and they're not functioning
像正常那样运作 at the level that they're capable of and such
这是很常见的一种现象 And that's something that's very, very common
部分是因为这些人不觉得 and it's in part because people don't feel as though
他们应该接受治疗 或者他们羞于 they should have to get treatment or they're ashamed
求助治疗抑郁症 of getting treatment or seeking help for depression
所以他们就一直拖着 And so, they just keep going on and going on
有时一拖就是几年 病情非常差 sometimes for years, in a very sorry state before
有时他们最后会崩溃 sometimes they just--they end up actually falling apart
不得不去求助 to the point where they have to get help
好的 我提过的另一类情绪障碍 Okay. The other category of mood disorders
就是两极型异常 that I mentioned is bipolar disorders
我说过 两极型异常包括抑郁症症状 And as I said, bipolar disorder involves symptoms or periods
或一段抑郁症时期 也包括一段明显的 of depression but then also distinct periods
与抑郁症相反的时期 即我们所称的"躁狂症" of the opposite of depression, which we call "mania."
病人在这两种状态中反复转换 So, the person cycles back and forth
一时是伤害性很大的抑郁症 一时是躁狂不安 between debilitating depressions and manic episodes
现在我讲大家讲躁狂发作 So, let me describe manic episodes to you now
第一个标准时 患者没有继续 So, the first criterion is that instead of feeling down
心情低落或抑郁 而是有一个不正常的 blue or depressed the person has an abnormally
持续加强的高涨或者易怒情绪 and persistently elevated expansive or irritable mood
这种情绪不…再一次 that isn't just, again
赢了个奖 心情很兴奋 这种不算 a good day because you won a prize or got an "A," but rather
这种异常地积极 it's this unusually positive
高涨的心情至少要持续一周 expansive mood for at least one week persistently
然后这个人还要有以下三个以上的症状 And then the person has to have three or more of the following symptoms
第一个自尊膨胀或自尊自大 First, inflated self-esteem or grandiosity
患者会觉得自己是地球上最聪明 The individual may feel as though they are the smartest
最有创意 最有见解 最强大的人 the most creative, insightful, powerful person on earth
他们可以毫不犹豫地这样告诉你 and they are perfectly happy to tell you this
所以他们的自尊没有问题 "非常谢谢你 So, there is no problem with self-esteem, thank you very much
如果你帮不了我 那是你的错" "If you can't keep up with me it's your fault."
他们对睡眠的需求减少 There's a decreased need for sleep
他们可能一晚只睡几个小时 they may only sleep a couple of hours a night
然后就急切地起床了 and get up raring to go
他们往往会比平常更健谈 They tend to be more talkative than usual
而且他们说话时明显有压力 and there's a really pressure to their talk
他们说话时会很紧张 They'll talk really pressured
他们会说得很快 and they'll talk really, really fast
他们说话这么快的原因之一 And one of the reasons they're talking really, really fast
就是他们觉得 is they have this flight of ideas
想法会很快地飞过他们的头脑 The thoughts are just racing through their mind
他们说得不够快 就不能把话都说出来 and they can't talk fast enough to get them out
如果你跟不上他们 And if you can't follow them, that--well
那是因为你不够聪明 that's because you're not smart enough to follow them
他们有太多好主意了 But they've just got too many good ideas
他们必须讲出来 and they've got to get them out
他们很容易分心 They're highly distractible
还会出现越来越多 And then there is this increase in this
DSM所称的"目标性活动" what the DSM calls this "goal-directed activity."
由于他们自尊心膨胀 他们会想出很多大计 Out of their grandiosity will come these grand schemes for--
通常都是赚大钱 often for making a lot of money
他们会以极大的热情追求这些目标 and they'll pursue these with great vigor
不管这些目标有多么不切实际 no matter how totally irrational they are
所以 比较常见的是他们提光了 So, it's not at all uncommon for them to cash out
家庭银行帐户的钱 卖房了 all the family bank accounts, to sell the house
卖车 卖孩子 to sell the car, to sell the kids
这样他们就能钱资助他们的大计 so that they can finance this great scheme
明天在网上赚几百万亿的钱 for making a zillion dollars on the Internet tomorrow. Right?
他们会以极大的热情追求这个目标 Okay. And they'll pursue this with tremendous vigor
他们还会参加 They'll also get involved in all kinds of
DSM所称的"愉快但危险的活动" what the DSM discreetly calls "pleasurable but dangerous activities."
大量的性滥交 滥用药物 There's a lot of sexual promiscuity, a lot of drug abuse
到处去赌钱 a lot of, as I said, getting--going and gambling
相信自己走大运 没什么能阻止你的 believing that you're on a hot streak, there's nothing can stop you
你太聪明了 你胸怀大计 You know, you're just so brilliant and you've got this scheme
你想好计划了 你一定会成功的 you've got the plan. You're going to make it. Okay?
所以一个人如果符合了这些症状的 So, the individual has three of more of these kinds
三种以上 再加上心情高涨 of symptoms plus this elevated
通常还有易怒的情绪 expansive and often quite irritable mood
这并不是因为他们很快乐 It's not just that they're happy
很乐观 you know, and sort of upbeat
而因为他们没耐心 易怒 动不动就大发脾气 It's just that they're just impatient and irritable and trigger-fire
有时还会变得暴力 And sometimes they can become violent
因为他们太不安和易怒了 because they're just--they're so incredibly agitated and irritable
我给大家看几段视频 So, let me show you a couple of clips
有一个很短的 I have one really short one
不是高清视频 It's not a real high quality clip
但是一个很好的病例 一个老太太 but it's a very, very nice example of an older woman
正处于躁狂症发作期 who is in the midst of a manic episode
我们可以看到 这种激动 And it shows what this kind of agitation
想法 拼命地赶上他们的想法 是怎么样的 and flight of ideas and racing thoughts can look like
另一个是…我会在…放来看看 And then the other one is--I'll introduce whenever you--we do it
好的 她在发型屋时 Okay. So while she was at the hairdresser's
这是一个好例子 可以看出她在压力支配下说话 it's a nice example of how she was just pressured to speak
没有人告诉她要说这些东西 Nobody was telling her that she had to say all of these things
他们只是拿着摄像机站在那里 They were just standing there with a camera
她就不停地说这些东西 and she was going on and on and on about these things
你们可以看到她讲她的故事时 And as you could see she was getting more and more agitated
变得越来越激动 越来越不安 and more and more irritated as she was retelling her story
然后呢? And then what?
最后你们看到她从躁狂变换为 In the last little bit there you saw her flip from her mania
一种更为抑郁的状态 into a more depressed state
这个可怜的女人 很不幸 And this poor lady, unfortunately
她很难找到稳定点 is having a hard time finding a stable point
他讲了锂 He talked about lithium there
我等一下也会讲一下 and I'll talk about it in a little bit--
用锂作为一个药物去稳定这些情障变换 about the use of lithium as a drug to try to stabilize these mood swings
但在拍这段视频时 But at this point in this video
这种药对她没有效果 it's not working for this lady
所以 她还是反复变换 And so, she's flipping back and forth
他们很难找到中间点 but they're having a hard time finding that middle ground
我想让大家看另一段视频 So, I want to show you another clip--
比刚才的长了一点 一个患有躁郁症的男人 it's a little bit longer--of a man who has bipolar disorder
他拍视频时既没有抑郁症发作也没有躁狂症发作 He is not currently in an episode of either depression or mania
他也可以说一些 but again, he can talk about some of the things
他经历的事情 怎么表现在他的行为上 he got himself into and how it manifested in his behavior
刚才Bernie说的几件事 Okay. Just a couple of things that Bernie talks about
我想评论一下 that I want to comment on
其中一件是 就像抑郁症一样 One is that just as in depression
躁狂症也有一个恶化过程 mania has--runs along a continuum
它可以从比较轻微一直发展到 So, it can be relatively mild all the way
极度严重 甚至精神错乱 to extremely severe and even psychotic
当一个躁狂症患者脱离了现实 So, when a person with mania loses touch with reality
他们不会相信自己是撒旦 instead of having beliefs that they are Satan
或者自己做了什么可怕的事 or they've done some horrible thing
他们会相信自己是超自然的东西 they'll believe that they are some supernatural being
他们可能相信自己是救世主 They may believe that they are the Messiah
或者爱因斯坦 or that they are Albert Einstein
复活了 you know, come back to life
或者他们有超自然力量 诸如此类的 or that they have supernatural powers or something of this sort
所以他们的虚假信念 so that their false beliefs
他们的错觉 他们的幻觉 their delusions and their hallucinations
他们看到听到的东西 the things that they see and hear
这些不真实的东西通常主题都很夸张 that aren't really there tend to be very grandiose in their themes
Bernie的躁狂症绝对算不上严重 Bernie's mania is not on the far end of the continuum by any stretch
但你可以看到他还是因此陷入困境了 but you can see it still gets him into trouble
有些人 Now, there are people who have--
他们反复变换的是很轻微的躁狂症 who cycle between fairly low levels of mania
和很轻微的抑郁症 and fairly low levels of depression
回来反复 有人认为 back and forth. And there's been some argument
有些人长期有 that people who are kind of chronically
轻微的躁狂症 尤其是当他们是很聪明的人时 mildly manic--especially if they're really smart
或者他们有特殊才能时 这个病可以为他们所利用 or they have a special talent, can make it work for them
Kay Jamison写了一本很棒的书 And there is a wonderful book by Kay Jamison
她是约翰霍普金斯的教授 她编写了… who is a professor at Johns Hopkins where she chronicles--
她写了一本类似于历史传记的书 She does sort of historical biographies
书中写了几个著名的作家 诗人 音乐家 on a number of well-known authors and poets and musicians
修曼 还有几个政治家 Robert Schumann and a number of politicians
丘吉尔等等 Winston Churchill and such
她认为他们其实都有轻微的两极型异常 arguing that they actually had mild forms of bipolar disorder
他们能够通过非凡才能和智力 and that they were able to sort of channel the manic episodes
把躁狂症转化为 through extraordinary talent or intelligence in ways
可以利用的东西 that made it work for them
还有很多人认为 There are also a number of arguments
有些很成功的CEO都是 that very, very successful CEOs sometimes are people
长期患有轻微躁狂症的人 who are chronically slightly manic
他们可以连续几晚只睡几小时 They can go on a couple of hours a night of sleep
他们明显自尊心膨胀 自信 they're obviously really quite grandiose and self-confident
他们可以维持这种适度的躁狂症 and that they can maintain this kind of moderate level of mania
不让它们恶化 并把将之加以利用 keep it under control and channel it in ways that work for them
所以如果你们对这本书有兴趣 So, if you're interested in that book
发封邮件给我 我很乐意发里面的一些内容给你们 send me an email and I'm happy to send you the citation for it
但大多数情况下 But for the most part
躁狂症可以让人陷入可怕的困境 mania can get people into tremendous trouble
我说过 他们会有大量的性滥交 They can, as I said, get involved in sexual promiscuity
这让他们有患上性病的风险 that puts them at risk for sexually transmitted diseases
他们会滥用药物 They can get involved in drug activity
他们可能会害自己被拘捕起来 They can get themselves arrested
他们绝对可以害自己和家人破产 They can certainly send themselves and their family into bankruptcy
躁狂症的这些负面影响 And these kinds of negative consequences of the mania
通常是病人求助的原因 often are what motivates the person to get help
因为躁狂症本身可以是一种让人愉快的病 because the mania itself can be rather pleasurable to have
另一个促使他们求助的原因是抑郁症发作 Also, what motivates them to get help is the plunge into depression
他们知道在某个时候 the knowledge that they will, at some point
躁狂症会停止发作 伤害性大的抑郁症会发作 come out of the mania and go into a debilitating depression
躁郁症比抑郁症要少见得多 Bipolar disorder is much less common than depression
我说过 大约22%的女性和13%的男性 I said that about 22% of women and about 13% of men
会在一辈子当中 will have an episode of serious depression
发作一次严重抑郁症 at some time in their lives
躁郁症的发病率只占人口的1% Bipolar disorder occurs in only about 1% of the population
男女的患病率差不多 and it's equally prevalent in women and men
这是一种很多地方 So, it's a really quite different disorder
都不同于抑郁症的精神病 in many ways from depression alone
我想给大家看一下抑郁症的其他一些数据 I want to give you some other statistics about depression per se
这些数据只属于抑郁症 and this only applies to depression
抑郁症的患病情况有很大的年龄差距 There are quite large age differences in the prevalence of depression
这些是一个全国范围内展开的 These are data from a nationwide study of people
针对15到55岁年龄段的研究所得到的数据 between the ages of fifteen and fifty-five
这些是这次研究对象所占的人口百分比 and these are the percentages of people in this study
这个研究的对象有几千人 And there were several thousand people in the study
他们不是接受抑郁症治疗的人 These are not people who have sought treatment for depression
只是在社区随机抽样的 but just a random community sample
这是在过去一个月发作过 And this is the percentage who've had an episode
严重抑郁症的百分比 of major depression in the past month
你可以看到 24岁这个年龄有15%的人 And as you can see, the fifteen to twenty-four age range
是发病率最高的 然后发病率下降 has the highest rates, and then they go down somewhat
但在35到44这个年龄段 although the thirty-five to forty-four
会随着年龄增大而升高 is fairly high as well with age
你们可能会很惊讶地发现 You might be surprised to learn that
老年人的严重抑郁症发病率 the rates of major depression in the elderly
其实很低 大部分全国数据都是这样 are actually quite low by most national statistics
一直到80或85岁 都是这样 And that's true up to about age eighty or eighty-five
为什么会有这样情况 有些人提出一些有趣的解释 And the arguments for why this is the case are very interesting
有人认为人越老就越有智慧 There are some people who argue that as you get older you get wiser
所以老年人的抑郁症患病率更低 and so that's why we see lower rates of depression in older age
还有人认为 现在这一代 There are other people who argue that current generation--
现在这一代年轻人 younger generations now
你们这一代 以及你们对上的一代 your generation and the one above you--
更容易患上抑郁症 are more prone to depression and will be
跟你们祖父母那辈相比 一辈子都更容易患上 for the rest of your life compared to your grandparents
因为现代的社会支持和家庭网络 because of historical changes in the kinds of social support
已经发生了历史性的改变 and family networks available
还有其他很大的历史文化变化 and a number of other historical cultural changes
也有人认为 The other sort of side of the argument is that
因为大家都知道抑郁症 because depression is known
会对你的身体健康产生负面影响 to impact negatively your physical health
有抑郁症的人 更容易有 depression is associated with higher rates
心血管疾病 中风 免疫系统疾病 of cardio-vascular disease, stroke, immune system diseases
还有其他各种各样致命疾病 a whole host of diseases that people die from--
那些终生患有抑郁症的人 that people who have a lifelong history of depression
其实很可能比较年轻时就死了 are actually more likely to die at an earlier age
所以老年人当中的抑郁症患病率相对比较低 and that's why we see relatively low rates in older age people
我们不知道哪种解释才是正确的 We don't know yet which of these explanations is true
可能某种程度上都对 It may be that they're all true to some extent
抑郁症还有性别差异 There are also gender differences in depression
我们通过收集几百个以儿童和青少年为对象的 These are data from a compilation of hundreds of studies
研究 得出这些数据 of children and adolescents
这些研究并不是研究严重的抑郁症 looking at not full-blown depression
而是通过自答问卷调查抑郁症的程度 but levels of depression on self-report questionnaires
很可能在座大部分同学都有份回答这些问卷 Probably most of you have filled out these questionnaires
像上个月调查你们情绪的 like the Beck Depression Inventory
那个贝克抑郁量表一样 that ask you how you've been feeling in the last month
这个就像是它的儿童版 And there's a kiddy version of this
这些是从几千个孩子的问卷中得到的数据 and these are data from that, from several thousand children
大家可以看到 在13岁以前 And as you can see here, prior to the age of about thirteen
男孩和女孩的抑郁症水平相近 boys and girls have relatively similar levels of depression
但在青春期初期 But beginning around the pubertal years
女孩的抑郁症患病率发生急剧变化 girls' rates of depression go up quite dramatically
男孩的持平 或者下降 and boys' rates stay the same or go down
但当他们长到18或20岁时 And by the time they're eighteen or twenty
女孩和男孩的患病率几乎到达2:1的比例 you get almost a two-to-one ratio of depressed girls to depressed boys
在接下来的成年人时期差不多都是这个比例 And then this is true for the rest of the adult age span
我们提出了很多假设来解释这种情况 There are lots of hypotheses about this, why it's true
有些生物学的假设 认为跟荷尔蒙有关 There are biological hypotheses that have to do with hormones
有些社会学的假设 认为 There are sociological hypotheses that have to do
跟压力有关 尤其是跟 with the kinds of stress, and particularly abuse
女孩和男孩的受虐比例有关 in girls' lives relative to boys'
我们也不知道确切原因 We don't know exactly why
很可能是很因素共同作用的结果 It's probably a lot of these things coming together
使得产生了这个2:1的比例 that make this huge two-to-one ratio true
我们来讲一下几个重要理论 So, let's talk a little bit about the major theories
以及情绪障碍的治疗 and treatments for the mood disorders
我们有一些生物学理论和疗法 There are biological theories and treatments
称为认知行为理论和疗法 what are known as cognitive behavioral theories and treatments
还有人际关系理论和疗法 and then interpersonal theories and treatments
我会每个理论举一些例子 And I'll walk you through examples of each of these
第一个 基因因素 So, first, genetics
很明显情绪障碍跟基因有关 It's pretty clear that genetics are involved in the mood disorders
尤其是躁郁症 especially bipolar disorder
躁郁症有很确凿的证据 There is very strong evidence in bipolar disorder
还有几个方法… and there are a number of ways--
你们有没有讲过怎么做遗传研究? 好的 Have you talked about how you do genetic studies? Okay
所以你们知道 例如 双胞胎研究 So, you guys know about twin studies
和家庭历史研究 for example and family history studies
这里是很多研究的集合 So, this is actually a compilation of a group of studies
有些是双胞胎研究 And here you've got some of them, twin studies--compared
对于同卵双胞胎 So, in monozygotic twins
如果你的双胞胎兄弟姐妹有躁郁症 if your identical twin has bipolar disorder
你有60%的几率患上这种病 you have over a 60% chance of having the disorder yourself
相比之下 In contrast, if it's your--
如果你只是异卵双胞胎 另一个双胞胎患有躁郁症 if you're just a fraternal twin of a person with bipolar disorder
你患这种病的几率只有12% you only have about a 12% chance of having the disorder
所以这种巨大的差异是一个很明显的证据 So, that massive difference there is very strong evidence
证明这种病的传播是跟基因有关的 that there's a genetic component to the transmission of the disorder
同样道理 如果你和这个躁郁病患者的 Similarly, the more distant you get in terms of your biological relation
血缘关系越疏 to a person with bipolar disorder
你患这种病的几率就越低 the lower your rate or your risk of the disorder is
所以 躁郁症患者的 So, the of a person
二级亲属只有2%的患病几率 with bipolar disorder only have about 2% chance of getting the disorder
比平均人口患病率只高了一点点 And that's barely above what's in the general population
平均人口患病率大约为1% which is about a 1% chance of getting the disorder
所以很明显躁郁症跟基因因素有关 So, it's very clear that bipolar disorder has a genetic component to it
单就抑郁症而言 严重抑郁症 With depression alone, major depression
很可能某些类型的抑郁症 there are probably versions of the disorder
它受基因的影响会比其他类型的强 that have a stronger genetic component to them than others
举个例子 患有早发性抑郁症的人 And in particular, folks who have what's called "early onset depression,"
也就是第一次发病是在童年 where their first episodes come on in childhood
或者青春期刚开始的时候 or very early adolescence
他们的抑郁症似乎 seem to have a form of depression
受遗传的影响更强烈 that has a stronger genetic component to it
而那些明显是被人生重大事件 Whereas, people who have depression that is clearly triggered
引发的抑郁症 例如创伤或痛失… by a major life event like a trauma or a loss--
这种抑郁症与基因因素的关系 those types of depression are less clearly
就明显没有那么强烈了 linked strongly to genetic factors
还有一些神经递质 There are also a number of neurotransmitters
与情绪障碍有关 that have been implicated in the mood disorders
被研究得最多的一类神经递质 And the class of neurotransmitters that's been researched
叫做单胺 most often is what's called the monoamines
你们都听说过血清素与抑郁症的联系 I'm sure you've heard about the link between serotonin and depression
但还有两种单胺 降肾上腺素和多巴胺 but there are two other monoamines, norepinephrine and dopamine
它们也和情绪障碍有关 that have also been linked to both of the mood disorders
与躁郁症和抑郁症都有关 both bipolar disorder and depression
过去认为在抑郁症患者体内 And it used to be thought that it was just that in people
没有足够的神经递质 with depression they didn't have enough of these neurotransmitters
没有足够的血清素 尤其是在大脑 enough serotonin, in particular, in the system, in the brain
帮助他们正常运作 in order to function normally
但现在有关神经递质作用的理论 But now the theories on what the role of neurotransmitters
认为原因更在于神经递质的 is have a lot more to do with the receptors
受体和它们的运作 for these neurotransmitters and their functioning
这些理论认为 神经递质受体 And the notion is that the receptors for neurotransmitters
例如血清素 运作低效 like serotonin don't function efficiently
所以即使大脑的突触 So, even if there's enough of the chemicals
有足够的神经递质 in the synapses in the brain
神经元也用不了它们 the neurons can't make use of them
因为受体没有发挥该有的作用 because the receptors aren't functioning appropriately
所以有些缓解抑郁症的药物 And so what the drugs that help relieve depression do
就是改善这些神经递质的运作 is to improve the functioning of these neurotransmitters
目前学界有一系列非常有趣的研究 There's a very interesting line of work
专门研究基因易感性神经递质运作 that's going on right now looking at the intersection
与压力的共同作用 of genetic predisposition neurotransmitter functioning and stress
我们现在有一个世界级专家 And we have one of the world's experts
正在从事这种研究 耶鲁的Julia Kim-Cohen on this kind of work now here at Yale, Julia Kim-Cohen
她去年加入耶鲁 who just joined us in the last year
我们最近还有几个研究 But there are several recent studies
精神病学界的另一个人Joan Kaufman There's another person in psychiatry, Joan Kaufman
他已经做过一些这样的研究 who's done some of this work
最近有几个研究 But there are several recent studies
发现血清素转运基因上的 that find that certain variations
某些变异或者多态性 能够预测 or polymorphisms on the serotonin transporter gene predict
谁遇到压力时会患上抑郁症 who will become depressed in the face of stress
Avshalom Caspi和同事做了一个经典研究 So, a classic study was done by Avshalom Caspi and colleagues
他们发现血清素转运基因上有 and they found that people who have one or two
一或两个短等位基因的人 of what's called the short allele on the serotonin transporter gene--
这是血清素转运基因上的一种变异 so this is a particular variation on the serotonin transporter gene--
如果他们有一或两个这样的短等位基因 if they had one or two of these short alleles
当他们遇到压力时 and they were confronted with stress
他们更可能患上抑郁症 they were more likely to develop depression
但我们很有必要细仔分析一下这点 But it's important to sort of dissect this
有些人有…重点不在 So people who had--it didn't really matter
这些基因上 which of these genes you had
如果你从没遇到过重大压力 If you were never confronted with major kinds of stress
例如虐待 如果你从没遇到过压力 like maltreatment, if you weren't confronted with stress
你就不太可能患上抑郁症 you were no more likely to have depression regardless
即使你有这种血清素基因 of what kind of serotonin gene you had
但如果你有其中一种短等位基因 But if you had either one short allele
或者两种都有 而且你童年受过虐待 or two short alleles and you were confronted with maltreatment
你人生中某个时期患上抑郁症的 as a child, you had a much greater probability of becoming depressed
可能性就要太很多 at some time in your life
换成是其他类型的重大创伤 And this has been replicated with other samples
结果也是一样 with other forms of major trauma
所以这个理论是说 And basically the story is
既要有基因易感性 it takes the intersection of a genetic predisposition
又要有重大压力 才会使某些人患上严重抑郁症 and major stress to create full-blown depression in some people
但这个理论并不一定适用于所有的基因易感性 Now, that may not be true for all genetic predispositions
或者所有类型的抑郁症 or all forms of depression
但现在至少有四个不同的研究都得出 but this serotonin finding has actually been replicated now in
这个血清素结论 at least four different studies
所以它应该是一个很可靠的理论 So, it seems to be a pretty reliable effect
重申一次 基因决定不了抑郁症 So again, genes do not determine the disorder
但如果基因和压力同时作用 but the intersection of genes and stress
就会导致很高的抑郁症患病风险 seems to be a major risk factor for the disorder
我们有一些大脑区域 There are a number of brain areas
似乎与情绪障碍有关 that seem to be involved in the mood disorders
这些区域出现调节异常或功能障碍 where there is just dysregulation or dysfunction
大家可能学过 前额皮质层 The prefrontal cortex, as you probably have studied
是大脑里一个负责 is an area of the brain that's very involved
高阶复杂思考 解决问题 in higher order complex thinking and problem solving
目标性行为的区域 and in goal-directed behavior
抑郁症患者 In people with depression
他们的前额皮层活动减少 there's lowered activity in the prefrontal cortex
这表明也许它跟 suggesting that--which may play a role in the difficulties
注意力集中 目标性行为 in concentration, in goal-directed behavior
计划 解决问题 和调节情绪等问题有关 in planning and problem solving and in regulating emotion
杏仁体是大脑里一个 The amygdala is an area of the brain
负责处理情绪信息的区域 that is involved in the processing of emotional information
有情绪障碍的人杏仁体对情绪信息作出的反应 And people with mood disorders show overactive amygdala responses
会过度活跃 to emotional information
躁郁症和抑郁症都是这样 This is true in both bipolar and in depression
海马体是大脑里一个 The hippocampus is an area of the brain
负责处理记忆和注意力的区域 that's very involved in memory and in concentration
患有慢性抑郁症的人 And in people with chronic depression
通常海马体都会缩小 you often see shrinkage in the hippocampus
这可能与他们无法集中注意力的问题有关 and this may be related to their problems in concentration and attention
最后是前扣带回 And then finally, the anterior cingulate
这是大脑里一个负责处理不同活动的区域 is an area of the brain that's involved in a lot of different activities
但它与情绪障碍有关 but pertinent to the mood disorders
尤其是对痛苦 压力 particularly in responses to distress--
以及行为选择上作出的反应 to stress and in sort of the choice of behaviors
也许是前扣回带的功能障碍 And it may be that dysregulation of the anterior cingulate
导致病人难以 may be involved in the person's difficulty
对压力作出合适的反应 in responding appropriately to stress
选择好的应付行为 以及当他们的行为有问题时 in choosing good coping behaviors and changing their behaviors
改变他们的行为 whenever their behaviors aren't working well
所以生理学理论衍生了几种药物 So, from the biological theories come a number of different drugs
来治疗情绪障碍 to treat the mood disorders
比较早的两类是单胺氧化酶抑制剂 Two of the older classes are called the monoamine oxidase inhibitors
和三环抗抑郁药 and the tricyclic antidepressants
现在三环抗抑郁药有时还会用 The tricyclics are still used these days to some extent
它们的药效相对比较好 They're relatively effective
大约有60%的病人服用它以后取得很好的疗效 About 60% of people respond well to the tricyclics
但它们有很多副作用 but they have a lot of side effects
过量的话可能有致命危险 and they can be fatal in overdose
所以一直有人 And so there was a--has been always
在研究其他的药物 a search for other alternatives to them
真正占领了市场的 The drugs that have really taken over the market
是选择性血清素再摄取抑剂制 简称SSRIs are the selective serotonin re-uptake inhibitors or SSRIs
帕罗西汀 百忧解之类的就属于这种 This is Paxil, Prozac and the like
它们在1987年面市 百忧解是 They were introduced in 1987--Prozac was--
真正占领了美国市场 以及 in the U.S. market and truly took over the market
抑郁症和焦虑症 in the treatment of depression and anxiety
以及其他几种精神病的治疗市场 and a number of other disorders
它们的疗效并没有 Now, they're not that much more effective
比旧的抗抑郁药好很多 than the sort of old style antidepressants
但它们的副作用少了 but they have fewer side effects
而且病人的耐药性也好 and they tend to be easier for people to tolerate
最近有一些选择性血清素/降肾上腺素 More recently, there are selective serotonin/norepinephrine
再摄取抑制剂 re-uptake inhibitors
这些药 对了 这些药的作用就是 These drugs, by the way, what these drugs supposedly do
阻止传送的神经元再摄收血清素或者 is to prevent the re-uptake of serotonin or serotonin
血清素和降肾上腺素 and norepinephrine back into the sending neuron
所以它在突触上生成更多的神经递质 So, it creates more of the neurotransmitter there in the synapse
这些药的效果比较有效 但是 And these are reasonably effective drugs, although, again
还是有很多人对它们没有反应 there's a substantial number of people who don't respond to them
尤其是没有即时反应 especially immediately
他们通常要试过不同的药 And they'll often have to cycle through a number of drugs
才能找到适合的那种 before they find one that works
锂是治疗躁郁症的首选之药 Lithium is the drug of choice for the treatment of bipolar disorder
它能稳定情绪变换 It seems to stabilize the mood swings
通过稳定不同的神经递质系统 by stabilizing the number of different neurotransmitter systems
但服用锂会带来问题 But the lithium is problematic
因为它有很多副作用 because there are tremendous side effects
通常怀孕女性服用的话 It's also dangerous for women to take
会对胎儿发育造成危险 while they're pregnant in terms of fetal development
所以这种药不适合长期服用 So, it's a very tough drug to stay on
它会造成很多肠胃问题等等 There are lots of gastrointestinal side effects and such
通常服用锂的人还会服用抗抑郁药 and people are often on lithium and the antidepressants
因为锂仅仅对躁狂症有效 because lithium often only affects the manic episodes
但它不能真正的减轻抑郁症 but it doesn't really relieve the depression
最后是抗精神病类药物 And then finally anti-psychotic medications
这是脱离了现实的病人服用的药 that is those help people who've lost touch with reality
用时也会用来治疗情绪障碍 are sometimes used to treat the mood disorders
当这样的病人脱离了现实时 whenever the person has lost touch with reality
我会讲一下 I'm going to go through and talk about
一些社会心理治疗 some of the psychosocial treatments
因为我也想讲讲这些内容 because I want to get to them as well
认知行为疗法 The cognitive behavioral therapies
是基于Aaron Beck的抑郁症的消极认知理论 are based on Aaron Beck's Negative Cognitive Theory of Depression
Aaron Beck是宾夕法尼亚大学的精神学家 Aaron Beck is a psychiatrist at the University of Pennsylvania
他开创了这一系列的新研究 who really founded this whole line of work
根据Beck所说 And according to Beck, this--now
这个方法只适用于抑郁症 this applies to depression alone
它并不适用于躁郁症 It doesn't really apply to bipolar disorder
抑郁症患者对自己 未来 和世界 People who are depressed have a negative view of the self
有一个负面的看法 of the future and of the world
他称之为"消极认知三联症" and he calls this the "negative cognitive triad."
这种消极认知三联症 And this negative cognitive triad
根源就是某些认知缺陷或偏见 is fed by specific cognitive deficits or biases
所以抑郁症患者的思考出现大量扭曲 So, depressed people show a lot of distortions in thinking
"不是所有就是一无所有"思考是指 "All-or-nothing thinking" is thinking that things
事情要么全部是好的 要么全部是坏的 are either all good or all bad
他们不能看到中间的灰色地带 They can't sort of see the gray areas in between
还有"情绪推理" There's "emotional reasoning,"
举一个例子 and an example of that is just
如果我觉得自己很窝囊废 那我一定就是个窝囊废 if I feel like a loser I must be a loser
如果我觉得自己很笨 那我一定就很笨 Of if I feel stupid, I must be stupid
还有"人格化" 也就是 And then "personalization," that is the self-blame
抑郁症患者身上常见的自责 that you often see in depressed people
这些思维扭曲 And these kinds of distortions in thinking
这些对现实的扭曲理解 these distorted ways of interpreting situations
形成了对自我的全面消极看法 feed a kind of general negative view of the self
以及对未来的无望感 and hopelessness about the future
抑郁症患者还会把内心的 People who are depressed also make attributions
消极事件归因于自己 for negative events that are internal
也就是说 他们自责 这是稳定的 that is, they blame themselves--that are stable
他们会觉得坏事永远不会消失 到处都有坏事 They see bad things as lasting forever and that are global
他们觉得坏事会影响他们生活的很多方面 They see bad events as affecting many areas of their life
这就加重了他们的抑郁症 which, again, feeds their depression
和他们悲观的生活观 and their general assumption that life is terrible
这些认知理论的证据是 And evidence that these--for these cognitive theories
这些消极认知风格能够预测抑郁症 that these negative cognitive styles predict depression--
其中一个最好的预测抑郁症研究就是 one of the best studies predicting this was a study
坦普尔大学和威斯康辛大学 that was jointly done at Temple University
联合开展的一个研究 and the University of Wisconsin
他们找出大学新生中 where they identified first year college students
有消极认知的 或者有归因方式的 with a negative cognitive or attributional style
但这些人从来没有过 But these were people who had never experienced
抑郁症发作 an episode of depression yet
他们跟踪这些学生两年 They then tracked them for the next two years
这里的条形图就是在那两年半内 and the bars here--the red bars are the percent of those
有消极认知方式的学生中 with a negative cognitive style
发作过严重抑郁症的百分比 who developed an episode of major depression
以及没有消极认知方式的学生中 in that two and a half years versus the percent
发作过严重抑郁症的百分比 of those without a negative cognitive style
大家可以看到 And as you can see
两个条形图之间有很大的差异 there's quite a substantial difference between the two
所以很有可能地 这些特征 So prospectively, these characteristics
能预测你患上抑郁症的风险 seem to predict your risk for depression
反过来有一个认知行为疗法 In turn, there is a cognitive behavioral therapy
就是基于Beck的理论 that's based on Beck's theory
这疗法的重要步骤包括识别 And the major steps in this involve identifying the themes
患者消极想法的主题 以及诱因 in a person's negative thoughts and triggers for them
帮助患者推翻这些想法 and in helping the person challenge those thoughts
通过问患者用什么证据支持他们的理解 by asking them what the evidence is for their interpretations
他们是否可以从另一个角度看待一个情况 whether there are other ways of looking at the situation
如果坏的事真的发生了 how they could cope with the situation
他们会如何应付 if a bad thing really did happen
所以冶疗师帮助患者认清消极信念 So, the therapist helps the client recognize negative beliefs
或想法 然后质疑这些想法的真正价值 or assumptions and then challenges the truth value of these
然后改变与抑郁症状相关的 and then change aspects of the environment
环境因素 that are related to depressive symptoms
所以他们推翻你的非理性思考 So, they challenge your irrational thinking
但他们也认识到患者的生活中 but they also recognize that there are really bad things
真的发生了一些很不好的事 that sometimes are going on the life of a person
他们帮助患者 who is depressed, and they help them engage
更积极地参加解决问题 改变那些环境 in more active problem solving to change those environments
他们还会教患者一些方法去管理他们的情绪 They also teach the person ways to manage their mood
所以他们就不会抑郁症复发 so that they don't tumble down into depression
这些认知行为疗法 And these cognitive behavioral therapies
已经显示出非常显著的效果 have been shown to be extremely effective
某种程度上来说 和药物的效果差不多 and as effective in some ways as the drug treatments
但最后有一个研究 So, this is a recent study
这个研究里有124个严重抑郁症患者 in which they had 240 patients with major depressive disorder
他们给了他们四个月的急性治疗 They gave them four months of acute treatment
一组用认知行为疗法 一组用帕罗西汀 with either cognitive behavioral therapy or Paxil
这是一种SSRI which is an SSRI
八周后 And in eight weeks here--
他们还有一个安慰剂标准组 they also had a placebo control group
他们发给这一组的人一粒药 其实只是糖丸 where they just got a pill, but it was a sugar pill
八周后 帕罗西汀组 红色那组 At eight weeks, the Paxil group, which is in red
认知行为疗法组 黄色那组 这两组差不多 and the CBT group, which is in yellow, were relatively even
虽然帕罗西汀组稍微比认知行为疗法组 although the Paxil group had a little bit of an edge
多了一点点 over the CBT group
但十六周后 帕罗西汀组和认知行为疗法组之间 But by sixteen weeks the Paxil and CBT group
抑郁症康复率的百分比 were absolutely even in terms of the percent of people
持平 who were no longer depressed
所以两组都有大约60%的人 So, both of them resulted in about 60% of people
不再有抑郁症 not being depressed
我们研究认知行为疗法一次又一次地 And then one of the things that's been found over and over again
得出同一个结论 with cognitive behavioral therapy is that
它不仅帮助患者摆脱现在发作的抑郁症 it not only helps people get out of a current episode of depression
还能有助于阻止未来复发 it helps to prevent future episodes of depression
因为它教会了患者新的应付技巧 because it teaches the person new coping skills
如何应付新的压力 for dealing with new stressors that arise
所以 在同一个研究中 他们又再跟踪了病人 So, in this same study they followed the patients
一年的时间 for an additional twelve months
帕罗西汀那组 And of the Paxil group
有一半人继续服食全剂量的药物 half were left on full-dose medications to see
看看能不能靠吃药 if you could prevent depression
来防止复发 by just keeping people on the meds
另一半的人就改用安慰剂 and half of the Paxil group were withdrawn to a placebo
我们先来看看安慰剂那组 And let's look at the placebo group first here
这是抑郁症很不幸的一面 This is the sad news about depression
如果你光靠服食药物来摆脱目前的抑郁症 If you just take drugs to get out of a current episode
一旦你停药 也没有 and you go off of the drugs without having
接受心理疗法 any kind of psychotherapy
你的复发率会很高 your rate of relapse tends to be very high
所以在这个240人的研究组里 So, in this group of 240
第一年80%的人停止 almost 80% relapsed in the first year
服用有效药物后 复发了 after going off of the active medication
这些人都没有接受过认知行为疗法 Again, these were people who did not get any cognitive behavioral therapy
那些只吃帕罗西汀的人 有约50%的人复发了 Of those people who stayed on Paxil alone, about 50% relapsed
但那些接受了认知行为疗法的人 But of those people who got cognitive behavioral therapy
只有35%的人复法 only about 35% relapsed
一次又一次的研究都得到同样的发现 And this kind of finding has been replicated over and over again
即认知行为疗法能够显著地减低 namely that CBT can reduce the rate of relapse
抑郁症复发率 in depression quite dramatically
我想让大家了解一下认知行为疗法是怎样的 I want to give you a flavor for what CBT looks like
我准备了一段视频 片中的治疗师其实… and I've got a short clip of a therapist who is actually
非常有趣 其实就是Aaron Beck的女儿 interestingly, the daughter of Aaron Beck
他在认知行为疗法的应用 and his heir in terms of the practice
和发展上的衣钵传人 and development of cognitive behavioral therapy
她在示范认知行为疗法 And she's demonstrating CBT
这其实是一个角色扮演 This is actually a role play
但扮演得非常真实 but it's a pretty realistic role play
讲她如何设法帮助 of how she goes after and helps
和推翻这个男人对自己的消极认知 to challenge a gentleman's negative cognitions about himself
这个男人的角色是一个刚丢了工作的男人 This is a guy in the role who's recently lost his job
他因为失业的事非常抑郁 and is really depressed over his job loss
好的 不再放了 因为我们快没时间了 Okay. I'm going to stop there because we're running out of time
我想评论一下她做的几件事 But I just want to comment on a couple of things that she's doing
你们看到她让他自己质疑 So, you see that she's having him generate his own challenges
他自己的消极想法 把它们写下来 to his negative thoughts and write them down
认知行为疗法的一个主要前提是 And the whole--one of the major premises in CBT
不仅是在诊所里的时候 is it's not just what goes on
才有效 in the therapy session that is effective
诊所里的治疗是次要的 In fact, that's a minor part of it
病人平时的练习才是主要的 but what the person practices in the time between therapy sessions
所以她所做的就是帮他想出 And so, what she's doing is helping him come up
当他觉得灰心 情绪低落时 with a series of phrases he can say to himself
跟自己说的一些话 when he feels discouraged and plunging down
她还帮他做"预期应付" She's also helping him do what's called "anticipatory coping,"
预期那些会引发消极感觉和 anticipating those situations that are going to trigger
消极想法的情况 并想出 negative feelings and negative thoughts and coming up
立即对抗它们的方法 with ways of combating them in the moment
这样他就能马上付诸行动 that he can enact at the time
认知行为疗法有很强的结构性 Cognitive behavioral therapy is very structured
它针对性很强 而且疗程相对较短 it's very focused and it's designed to be relatively short-term
另一个医治抑郁症的主要心理疗法 The one other major kind of psychotherapy
是人际关系疗法 for depression is interpersonal therapy
它的理论根据是 对自我的消极看法 It's based on the theory that negative views
以及对自我和人际关系的预期 of the self and expectations about the self and relationships
是基于养成这种 are based on upbringings
消极自我观念的成长教育中 that really fostered these kinds of negative self-views
所以你要做的就是帮助患者 And so, what you need to do is to help clients
明白他们消极的自我观念 understand their negative self-views
并且这些观念是如何植根于他们以前的人际关系中 and how they're rooted in their past relationships
人际关系理论的结构性 Interpersonal therapy is less structured
没有认知行为疗法的那么强 than cognitive behavioral therapy
它更专注于过去 and it's more focused on the past
而认知行为疗法专注于现在 CBT is very focused on the present
并且应付你目前 and dealing with the current situation
正在应付和抗击的情况 that you're facing and combating that
并为这些情况建立应对方法 and developing coping styles for that
有几个比较人际关系疗法和认知行为疗法的研究 There are a few studies comparing interpersonal therapy with CBT
但研究人际关系疗法的研究要比认知行为疗法的少得多 but much less research has been done on IPT than CBT
但对有些人来说 它是一个很好的选择 But it is a positive alternative for some people
尤其是那些发现自己的抑郁症 particularly those who find that their depression
与他们的人际关系中 is very tied-up in recurrent themes in their relationships
一个重复出现的主题有关的人 that seem to happen over and over and over again
最后 抑郁症的一个好消息是 But to end, the good news about depression
有很多可以选择的疗法 is that there are these alternative therapies
有几个药物疗法 There is a number of drug therapies
有至少两个的心理疗法 and there are at least two psychotherapies
很好的参照研究都发现它们很有效果 that good controlled research has shown can be very helpful
这样病人就有了选择 So, people have a choice
病人绝对没有必要陷在抑郁症里 and there is absolutely no need for people to stay
而不寻求最适合他们 in depression but rather to seek out the kind of therapy
对他们最有疗效的疗法 that applies to and appeals to them the most
好的 谢谢大家 Good. Thanks very much