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精神病学史:人类认识了世界,但依然认不清自己

精神病学史:人类认识了世界,但依然认不清自己

我们翻译这篇文章的理由

“精神病”这一标签对人的影响是巨大的,被认定为精神病的人不仅要面对自身生理或精神上的困扰,而且其民事权利也会受到极大的限制。正是因为这样,精神病的判定就极为关键:有怎样的症状就可以判定为精神病?精神病的发病机制是什么?有没有科学的方法来证实?对于个人而言,被错误认定为有精神病无疑是一种毁灭性的打击(如历史上把同性恋认定为精神疾病)。回顾精神病学发展过程,我们发现,精神病的认定并非是完全科学的,它受到了时代观念、文化、历史乃至利益团体的影响。

——邹世昌

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精神病学史:人类认识了世界,但依然认不清自己

作者:Jerome Groopman

译者:李静轩& 邵海灵

校对:邹世昌

策划:李静轩& 邹世昌

Challenges to the legitimacy of the profession have forced it to examine itself, including the fundamental question of what constitutes a mental disorder.

对精神病学合法性的种种质疑迫使这门学科重新审视自身,包括审视那个最基本的问题:什么才是精神病?

Modern medicine can be seen as a quest to understand pathogenesis, the biological cause of an illness. Once pathogenesis—the word comes from the Greekpathos(suffering) andgenesis(origin)—has been established by scientific experiment, accurate diagnoses can be made, and targeted therapies developed. In the early years of theaidsepidemic, there were all kinds of theories about what was causing it: toxicity from drug use during sex, allergic reactions to semen, and so on. Only after the discovery of the human immunodeficiency virus helped lay such conjectures to rest did it become possible to use specific blood tests for diagnosis and, eventually, to provide antiviral drugs to improve immune defenses.

现代医学可被视为一个探索发病机制的学科,即探索造成疾病的生理学原因。“发病机制”的英文单词是由两个希腊语单词“受苦”和“起源”拼合而成的。一旦通过科学实验确定了发病机制,医学人员就能作出准确的诊断,并研发出针对该病的疗法。艾滋病肆虐的头几年,出现了各种各样关于其病因的理论,如性行为过程中因使用药物而产生了致病的毒素,或是对精液的过敏反应等。直到人类免疫缺陷病毒的发现平息了这些猜测,人们才得以通过特定的血液检测来进行诊断,最终研发出了抗病毒药物来增强人体的免疫力。

Sometimes a disease’s pathogenesis is surprising. As a medical student, I was taught that peptic ulcers were often caused by stress; treatments included bed rest and a soothing diet rich in milk. Anyone who had suggested that ulcers were the result of bacterial infection would have been thought crazy. The prevailing view was that no bacterium could thrive in the acidic environment of the stomach. But in 1982 two Australian researchers (who later won a Nobel Prize for their work) proposed that a bacterium calledHelicobacter pyloriwas crucial to the onset of many peptic ulcers. Although the hypothesis was met with widespread scorn, experimental evidence gradually became conclusive. Now ulcers are routinely healed with antibiotics.

某些疾病的发病机制有时会让人大吃一惊。作为一个医学生,老师告诉我们,消化性溃疡一般是由压力引起的;治疗方法包括卧床养病以及食用富含牛奶且易于消化的食物。如果有人说溃疡是由细菌感染引起的,大家肯定认为他疯了。当时人们认为没有细菌能够在酸性的胃液中存活。但是1982年,两个澳大利亚研究员(后来因其研究获得了诺贝尔奖)提出,一种叫幽门螺旋杆菌的细菌是很多消化性溃疡的罪魁祸首。尽管当时大多数人都对这个假设不屑一顾,但是实验证据渐渐打消了人们的疑虑。现在,抗生素已经成为了治疗溃疡的常规药物。

But what can medicine do when pathogenesis remains elusive? That’s a question that has bedevilled the field ofpsychiatryfor nearly a century and a half. In “Mind Fixers” (Norton), Anne Harrington, a history-of-science professor at Harvard, follows “psychiatry’s troubled search for the biology of mental illness,” deftly tracing a progression of paradigms adopted by neurologists, psychiatrists, and psychologists, as well as patients and their advocates.

但是,如果找不到发病机制,医学应该怎么办?一个半世纪以来,这个问题一直困扰着精神病学科。哈佛大学科学史教授安妮·哈灵顿在《精神修复者》一书中,沿着“精神病学探索精神疾病产生机理的坎坷道路”,巧妙地追溯了神经科学家、精神病学家、心理学家、精神病患者及那些为患者权益奔走游说的人士对精神疾病的认知框架是如何发展演变的。

Her narrative begins in the late nineteenth century, when researchers explored the brain’s anatomy in an attempt to identify the origins of mental disorders. The studies ultimately proved fruitless, and their failure produced a split in the field. Some psychiatrists sought nonbiological causes, including psychoanalytic ones, for mental disorders. Others doubled down on the biological approach and, as she writes, “increasingly pursued a hodgepodge of theories and projects, many of which, in hindsight, look both ill-considered and incautious.” The split is still evident today.

她从十九世纪末期开始讲起,当时为了找到精神疾病的源头,研究人员开始研究大脑的结构。这些研究最终没有取得任何成果,反而加剧了精神病学科的分裂。一部分心理学家致力于为精神疾病寻找非生理学层面的病因,包括心理层面的原因。其他精神病学家则决心继续从生理学层面找原因,用哈灵顿的话说:“他们深究各种杂乱无章的理论和课题,其中大部分用今天的眼光看,可谓既糊涂又草率。”直到今天,精神病学科内部的分裂倾向仍然十分明显。

The history that Harrington relays is a series of pendulum swings. For much of the book, touted breakthroughs disappoint, discredited dogmas give rise to counter-dogmas, treatments are influenced by the financial interests of the pharmaceutical industry, and real harm is done to patients and their loved ones. One thing that becomes apparent is that, when pathogenesis is absent, historical events and cultural shifts have an outsized influence on prevailing views on causes and treatments. By charting our fluctuating beliefs about our own minds, Harrington effectively tells a story about the twentieth century itself.

哈灵顿笔下的精神病学发展史犹如钟摆一般,从一个极端滑向另一个极端。名扬一时的新突破很快就让人大失所望,不足为信的说法让位于完全相反的理论,治疗手段被经济利益和医药行业左右,而真正受到伤害的,是精神病人和他们的至亲好友。日益明朗的一点是,如果发病机制不明确,那么历史事件和文化转向就会对当时盛行的病因理论和治疗手段产生巨大的影响。人类对自身头脑的认识就这样在两个极端中摇摆,通过对这一过程的描绘,哈灵顿实则讲述了一个关于二十世纪的故事。

In 1885, theBoston Medical and Surgical Journalnoted, “The increase in the number of the insane has been exceptionally rapid in the last decade.” Mental asylums built earlier in the century were overflowing with patients. Harrington points out that the asylum may have “created its own expanding clientele,” but it’s possible that insanity reallywason the rise, in part because of the rapid spread of syphilis. What we now know to be a late stage of the disease was at the time termed “general paralysis of the insane.” Patients were afflicted by dementia and grandiose delusions and developed a wobbly gait. Toward the end of the century, as many as one in five people entering asylums had general paralysis of the insane.

1885年,《波士顿医学和外科学杂志》指出:“在过去十年中,精神病人数量的增加速度异常之快。”十九世纪建立的精神病院人满为患。哈灵顿指出,这些精神病院可能将正常的人也确诊为了精神病人,但精神病人数量也可能真的在增加,部分原因可能与梅毒的肆虐有关。现今我们熟知的梅毒末期在当时称为“麻痹性痴呆”。这些病人精神错乱,夸大妄想,连路都走不稳。二十世纪后期,精神病院中每五个病人中就有一个是麻痹性痴呆。

Proof of a causal relationship between the condition and syphilis came in 1897, and marked the first time, Harrington writes, that “psychiatry had discovered a specific biological cause for a common mental illness.” The discovery was made by the neurologist Richard von Krafft-Ebing (today best known for “Psychopathia Sexualis,” his study of sexual “perversion”) and his assistant Josef Adolf Hirschl. They devised an experiment that made use of a fact that was already known: syphilis could be contracted only once. The pair took pus from the sores of syphilitics and injected it into patients suffering from general paralysis of the insane. Then they watched to see if the test subjects became infected. Any patient who did could be said with certainty not to have had the disease before. As it turned out, though, none of the subjects became infected, leading the researchers to conclude that the condition arose from previous infection with syphilis.

1897年,人们证实了这种疾病和梅毒之间的因果关系,哈林顿写道,这标志着“精神病学首次发现了一种常见精神疾病的具体生物学病因”。这项发现是由理查德·克拉夫特·埃宾(因其性变态著作《性精神病态》而为人熟知)及其助手约瑟夫·阿道夫·赫希得出的。他们利用已知事实设计了一个实验:一个人一生只会感染一次梅毒。他们从梅毒患者的疮里抽取了脓水,然后将脓水注射到患有麻痹性痴呆的患者身上,观察实验对象是否会被感染。参与实验的所有病人之前都肯定没有得过这种疾病。然而实验结果显示,病人们都没有被感染。他们从而得出结论,这种疾病是由以前感染梅毒导致的。

This apparent validation of the biological approach was influential. “If it could be done once,” Harrington writes, “maybe it could be done again.” But the work on syphilis proved to be something of a dead end. Neurologists of the time, knowing nothing of brain chemistry, were heavily focussed on what could be observed at autopsy, but there were many mental illnesses that left no trace in the solid tissue of the brain. Harrington frames this outcome in the Cartesian terms of a mind-body dualism: “Brain anatomists had failed so miserably because they focused on the brain at the expense of the mind.”

这种生物学方法的表观验证极具影响力。哈灵顿写道:“如果这种方法能进行一次,或许就能进行第二次。”但是梅毒研究后来被证明是一个死胡同。当时的精神病学家对于脑化学一无所知,只是一股脑地研究解剖过的大脑,但是很多精神疾病在大脑的固体组织中是无迹可寻的。哈灵顿用笛卡尔的身心两元论来描写这种方法的结局:“脑解剖学家彻底失败了,因为他们只注重大脑,却忽略了心灵。”

Meanwhile, two neurologists, Pierre Janet andSigmund Freud, had been exploring a condition that affected both mind and body and that left no detectable trace in brain tissue: hysteria. The symptoms included wild swings of emotion, tremors, catatonia, and convulsions. Both men had studiedunder Jean-Martin Charcot, who believed that hysteria could arise from traumatic events as well as from physiological causes. Janet contended that patients “split off” memories of traumatic events and manifested them in an array of physical symptoms. He advocated hypnosis as a means of accessing these memories and discovering the causes of a patient’s malady. Freud believed that traumatic memories were repressed and consigned to the unconscious. He developed an interview method to bring them to consciousness, interpreted dreams, and argued that nearly all neuroses arose from repressed “sexual impressions.”

在同一时期,两位精神病学家皮埃尔·让内和西格蒙德·弗洛伊德正在研究一种影响精神和身体并且在大脑组织中毫无痕迹可寻的疾病:癔病。癔病的症状包括情绪的剧烈起伏、战栗、紧张和抽搐。这两位精神病学家都在让-马丁·沙可手下做研究,沙可认为癔症可能由创伤事件和生理学原因导致。让内认为癔症病人将其创伤事件的记忆分离出自己的精神,然后将这部分记忆用一系列身体症状表现出来。他提倡使用催眠术进入病人的这部分记忆,寻找病因。弗洛伊德认为创伤性记忆会被抑制并被传送到病人的潜意识中。他研发了一个交谈法来将这些记忆带回病人的意识中并解释病人的梦境。他认为几乎所有的神经机能症都来自于被抑制的“性幻想”。

Freud acknowledged the fact “that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science.” He justified the approach by pointing to the inefficacy of other methods and asserting that there was “an intimate connection between the story of the patient’s sufferings and the symptoms of his illness.” Many neurologists, responding to the demand for confessional healing, gave up on anatomy and adopted psychotherapeutics.

弗洛伊德自己承认,“我写的病历读起来都像短篇小说,有人可能会说它们缺乏科学的严肃性。”他为自己的方法辩解,指责其他的方法都没有疗效,坚定地认为“病人痛苦的经历与其疾病症状有着密切的联系”。为了迎合对告解治疗的需求,很多精神病学家都抛弃了解剖学,转而投向了心理治疗术。

Soon, however, the limits of this approach, too, were exposed. During the First World War, men who returned from the trenches apparently uninjured displayed physical symptoms associated with hysteria. Clearly, they couldn’tall be manifesting neuroses caused by repressed sexual fantasies. The English physician Charles Myers coined the term “shell shock,” proposing a physiological cause: damage to the nervous system from the shock waves of artillery explosions. Yet that explanation wasn’t entirely satisfactory, either. Sufferers included soldiers who had not been in the trenches or exposed to bombing.

然而不久后,这种方法的局限性也暴露了出来。在第一次世界大战期间,一些从战壕中回到祖国的士兵显然没有受伤,但却表现出于癔症相关的身体症状。显而易见,他们并不是因为被压抑的性幻想而导致了这些神经症状。英国医生查尔斯·迈尔斯创造了“炮弹休克症”这一术语,提出这些症状是由生理学原因导致的:士兵们的神经系统被炮弹爆炸产生的冲击波损坏了。但是这一解释也并不具有说服力。有些士兵并不曾在战壕中打过仗,也没有受到过炮弹的冲击。

Harrington commends physicians who charted a middle course. Adolf Meyer, a Swiss-born physician who, in 1910, became the first director of the psychiatry clinic at the Johns Hopkins Hospital, advocated an approach he called, variously, “psychobiology” and “common sense” psychiatry—the gathering of data without a guiding dogma. Meanwhile, in Europe, Eugen Bleuler, credited with coining the term “schizophrenia,” took a view somewhat similar to Meyer’s and incurred the wrath of Freud. In 1911, Bleuler left the International Psychoanalytical Association. “Saying ‘he who is not with us is against us’ or ‘all or nothing’ is necessary for religious communities and useful for political parties,” he wrote in his resignation letter. “All the same I find that it is harmful for science.”

哈灵顿比较欣赏走中庸之道的医生。出生在瑞士的医生阿道夫·迈耶于1910年成为了约翰霍普金斯医院精神病学中心的第一任院长,他提倡一种他称为精神生物学的方法,或称“常识”精神病学——不参照任何理论指导,只收集数据。同时期的欧洲医学家厄根·布洛伊勒也与迈耶有相似的观点,他创造了“精神分裂症”这个术语,这引起了弗洛伊德的震怒。1911年,布洛伊勒从国际精神分析协会辞职,他在辞职信中写道:“‘不与我们相和的,就是与我们为敌的’、‘要么都信,要么都别信’,这种极端思维对于宗教团体是必要的,对政治党派也是有用的,但我认为它对科学来说却有百害而无一利。”

As the century progressed, the schism between the biological camp and the psychoanalytic camp widened. With advances in bacteriology, the biological camp embraced the idea that microbes in the intestine, the mouth, or the sinuses could release toxins that impaired brain functions. Harrington writes of schizophrenia treatments that included “removing teeth, appendixes, ovaries, testes, colons, and more.”

随着时间的推移,精神病学中生物学阵营和精神分析阵营之间的裂缝越来越宽。随着细菌学的发展,生物学阵营开始认为,肠道、口腔或鼻窦中的微生物会释放毒素,损伤脑部功能。哈灵顿提到了当时治疗精神分裂症的手段,包括“拔牙,摘除阑尾、卵巢、睾丸、结肠等人体组织”。

The most notorious mid-century surgical intervention was the lobotomy. Pioneered in the thirties, by Egas Moniz, whose work later won him the Nobel Prize, the treatment reached a grotesque apogee in America, with Walter Freeman’s popularization of the transorbital lobotomy, which involved severing connections near the prefrontal cortex with an icepick-like instrument inserted through the eye sockets. Freeman crisscrossed the country—a trip he called Operation Icepick—proselytizing for the technique in state mental hospitals.

二十世纪中叶最臭名昭著的外科手术是脑叶切断术。二十世纪三十年代,埃加斯·莫尼兹(后来获得了诺贝尔奖)开创了这项手术。随着美国人沃尔特·弗里曼的穿眶叶切除术的普及,这种治疗方法达到了荒谬的顶点。在这项手术中,医生用类似碎冰锥的器具插入病人的眼窝,切断前额叶皮层附近的连接。弗里曼奔波于国家各个地区,极力在各个州的精神病院推广此方法,他将这次行动称为碎冰锥手术。

On the nonbiological, analytic side of the discipline, world events again proved pivotal. The postwar period, dubbed “The Age of Anxiety” by W.H. Auden, was clouded by fears about the power of nuclear weapons, the Cold War arms race, and the possibility that communist spies were infiltrating society. In 1948, President Harry Truman told the annual meeting of the American Psychiatric Association, “The greatest prerequisite for peace, which is uppermost in the minds and hearts of all of us, must be sanity—sanity in its broadest sense, which permits clear thinking on the part of all citizens.”

对精神病学中倾向于精神分析的非生物学阵营来说,世界性事件再次起到了关键作用。战后时期被W.H.奥登称为“焦虑年代”,这个时代被一团团阴云笼罩着,这些阴云包括对核武器的恐惧、冷战中的军备竞赛以及共产主义间谍渗入社会的可能性。1948年,美国总统哈里·杜鲁门在美国精神病学会年会上发言称:“和平的最重要前提是最广义上的理智,理智是我们所有人头脑和心灵中最重要的东西,它让所有的公民都能保持清醒的头脑。”

Accordingly, American neo-Freudians substituted anxiety for sex as the underlying cause of psychological maladies. They replaced Freudian tropes with a focus on family dynamics, especially the need for emotional security in early childhood. Mothers bore the brunt of this new diagnostic scrutiny: overprotective mothers stunted their children’s maturation and were, according to a leading American psychiatrist, “our gravest menace” in the fight against communism; excessively permissive mothers produced children who would become juvenile delinquents; a mother who smothered a son with affection risked making him homosexual, while the undemonstrative “refrigerator mother” was blamed for what is now diagnosed autism. May27,2019

于是,美国新弗洛依德学派不再关注性,而是将焦虑看作精神疾病的诱因。他们将佛洛伊德的比喻改头换面,将家庭动力学,尤其是儿童早期对情感的需要,看作导致精神疾病的原因。母亲成为了这种新诊断方式的替罪羊:过度保护孩子的母亲阻碍了孩子的发育,当时一流的美国精神病学家将这些母亲看作是对抗社会主义“最大的威胁”;极度纵容孩子的母亲会将孩子培养成少年犯;过度溺爱孩子,让孩子感到不自在的母亲会让孩子变成同性恋;感情不外露的“冰箱”母亲会使孩子患上自闭症。

In 1963, Betty Friedan’s “Feminine Mystique” denounced neo-Freudian mother blamers. She wrote, “It was suddenly discovered that the mother could be blamed for almost everything. In every case history of a troubled child… could be found a mother.” Her indictment was later taken up by the San Francisco Redstockings, a group of female psychotherapists who distributed literature to their A.P.A. colleagues which declared, “Mother is not public enemy number one. Start looking for the real enemy.”

1963年,贝蒂·弗里丹在其著作《女性的奥秘》中,谴责将母亲看成是精神疾病罪魁祸首的新弗洛伊德派。她写道:“突然之间,几乎所有的精神疾病都是由母亲导致的。每一个问题儿童的病历中都写着母亲的过错。”她的观点后来被旧金山红袜组织所接受,这个组织的成员都是女性心理治疗师,她们将资料分发给A.P.A.同事,称“母亲不是头号公敌。我们要找到真正的敌人。”

Feminism furnished just one of several sweeping attacks on psychiatry that saw the enterprise as a tool of social control. In 1961, three influential critiques appeared. “Asylums,” by the sociologist Erving Goffman, compared mental hospitals to prisons and concentration camps, places where personal autonomy was stripped from “inmates.” Michel Foucault’s history of psychiatry, “Madness and Civilization,” cast the mentally ill as an oppressed group and the medical establishment as a tool for suppressing resistance. Finally, Thomas Szasz, in “The Myth of Mental Illness,” argued that psychiatric diagnoses were too vague to meet scientific medical standards and that it was a mistake to label people as being ill when they were really, as he termedit, “disabled by living”—dealing with vicissitudes that were a natural part of life.

女权主义只是对精神病学发起的几次全面进攻之一,这些批判者把精神病学视为社会控制的工具。1961年,三篇具有影响力的评论文章出版。社会学家尔文·戈夫曼在其著作《避难所》中,将精神病院看作监狱和集中营,病人的个人自主权被“病友们”剥夺殆尽。米歇尔·福柯在其精神病学历史著作《疯癫与文明》中,将精神病人看作一个被压迫的群体,将精神病院看作镇压反抗势力的工具。最后,托马斯·萨斯在其著作《精神疾病的奥秘》一书中提出,精神疾病诊断过于模糊,无法达到科学的医学标准。他认为,将人诊断为精神病人是错误的,因为这些人只是“被生活致残”了——他们正在面对人生的沉浮,而这是生活中再自然不过的一部分。

By the early seventies, such critiques had entered the mainstream. Activists created the Insane Liberation Front, the Mental Patients’ Liberation Project, and the Network Against Psychiatric Assault. Psychiatry, they argued, labelled people disturbed in order to deprive them of freedom.

到七十年代早期,这类批判已经成为了主流。激进人士创办了“精神病解放前线”、“精神病患者解放计划”以及“反精神病治疗侵犯网”等组织。他们称,精神病学给人们贴上“心理失常”的标签,为的是剥夺他们的自由。

Challenges to the legitimacy of psychiatry forced the profession to examine the fundamental question of what did and did not constitute mental illness. Homosexuality, for instance, had been considered a psychiatric disorder since the time of Krafft-Ebing. But, in 1972, the annual A.P.A. meeting featured a panel discussion titled “Psychiatry: Friend or Foe to Homosexuals?” One panelist, disguised with a mask and a wig, and using a voice-distorting microphone, said, “I am a homosexual. I am a psychiatrist. I, like most of you in this room, am a member of the A.P.A. and am proud to be a member.” He addressed the emotional suffering caused by social attitudes, and called for the embrace of “that little piece of humanity called homosexuality.” He received a standing ovation.

对精神病学合法性的质疑迫使该学科重新审视那个最为根本的问题:什么是造成精神疾病的原因,而什么不是?拿同性恋来说吧,自从冯·克拉夫-艾宾(1840-1902,奥地利精神病学家,性学研究创始人,早期性病理心理学家)的时代以来,同性恋就一直被视作一种精神疾病。但在1972年,美国精神医学学会(A.P.A)年会专门成立了一个讨论组,叫做“精神病学与同性恋:是敌还是友?”其中一个与会者戴着面具和假发,还用了一个变声器,在会上发言说:“我是同性恋,也是一个精神病学家。我和在座大部分人一样,都是A.P.A的成员,我也以自己是这个组织的一员为傲。”他强调,社会对同性恋者的敌对态度让这个群体受到了情感上的折磨,并呼吁人们对同性恋者给予更多包容,因为“同性恋也是人性的一部分”。他的发言赢得了全场的起立鼓掌。

Homosexuality was still listed as a disorder in theDiagnostic and Statistical Manual of Mental Disorders, even as many psychiatrists clearly held a different view.Robert Spitzer, an eminent psychiatrist and a key architect of theDSM, was put in charge of considering the issue, and devised what has become a working criterion for mental illness: “For a behavior to be termed a psychiatric disorder it had to be regularly accompanied by subjective distress and/or ‘some generalized impairment in social effectiveness of functioning.’” Spitzer noted that plenty of homosexuals didn’t suffer distress (except as a result of stigma and discrimination) and had no difficulty functioning socially. In December, 1973, the A.P.A. removed homosexuality from theDSM.

当时在A.P.A出版的《精神疾病诊断与统计手册》中,同性恋仍被列为精神疾病的一种,尽管许多精神病学家已经对此持有明确的反对态度。罗伯特·斯皮策是一位声名显赫的精神病学家,也是该手册的核心撰写人之一,他受命处理这项争议。他想出了一条定义,后来成为精神疾病领域工作准则:“凡被定义为精神疾病的症状,都必须伴有规律性的主观情感上的痛苦,并/或‘会对社交能力造成总体损害’。”斯皮策注意到相当数量的同性恋者并未感到痛苦抑郁(除非是社会偏见或歧视导致了痛苦抑郁),社交能力也不受影响。1973年12月,A.P.A将同性恋从手册中移除。

Today, around one in six Americans takes a psychotropic drug of some kind. The medication era stretches back more than sixty years and is the most significant legacy of the biological approach to psychiatry. It has its roots in the thirties, when experiments on rodents suggested that paranoid behavior was caused by high dopamine levels in the brain. The idea that brain chemistry could offer a pathogenesis for mental illness led researchers to hunt for chemical imbalances, and for medications to treat them.

如今,大约每六个美国人中就有一个人在服用某种类型的精神病药物。医药时代的兴起要追溯到六十多年前,这也是精神疾病的生物学疗法留给后世的最大遗产。这一疗法起源于上个世纪三十年代,在啮齿目动物身上进行的试验表明,妄想症行为是由大脑中的多巴胺分泌过多导致的。脑化学有助于寻找精神疾病的发病机制,这一想法让很多研究者开始研究大脑中化学成分的失衡现象,从而研发治疗失衡的相应药物。

In 1954, the F.D.A., for the first time, approved a drug as a treatment for a mental disorder: the antipsychotic chlorpromazine (marketed with the brand name Thorazine). The pharmaceutical industry vigorously promoted it as a biological solution to a chemical problem. One ad claimed that Thorazine “reduces or eliminates the need for restraint and seclusion; improves ward morale; speeds release of hospitalized patients; reduces destruction of personal and hospital property.” By 1964, some fifty million prescriptions had been filled. The income of its maker—Smith, Kline & French—increased eightfold in a period of fifteen years.

1954年,F.D.A.首次认证了一种用于治疗精神疾病的药物:盐酸氯丙嗪(商品名Thorazine,又称冬眠灵)。制药企业把它作为一种解决脑化学问题的生物学手段来大力推广,其中一则广告称,氯丙嗪能“减少或免除将患者控制或隔离起来的必要,鼓舞病友的士气,让患者得以更快出院,并减少患者对个人和医院财产造成的损害。”到1964年,医院已经开出了高达五千万张药方。药品制造商史克制药的收入在十五年里翻了八倍。

Next came sedatives. Approved in 1955, meprobamate (marketed as Miltown and Equanil) was hailed as a “peace pill” and an “emotional aspirin.” Within a year, it was the best-selling drug in America, and by the close of the fifties one in every three prescriptions written in the United States was for meprobamate. An alternative, Valium, introduced in 1963, became the most commonly prescribed drug in the country the next year and remained so until 1982.

下一个登场的是镇静剂。1955年,氨甲丙二酯(商品名Miltown and Equanil,又称眠尔通)获得认证,被誉为“安宁药丸”和“情绪上的阿司匹林”。不到一年,其销售量就跃居全美第一,到了五十年代末,美国医生开出的每三张药方中,就有一张是眠尔通。1963年,同类药物“安定”面世,第二年就成为了全国最常见的处方药,一直持续到1982年。

One of the first drugs to target depression was Elavil, introduced in 1961, which boosted available levelsof norepinephrine, a neurotransmitter related to adrenaline. Again there was a marketing blitz. Harrington mentions “Symposium in Blues,” a promotional record featuring Duke Ellington, Louis Armstrong, and Artie Shaw. Released by RCA Victor, it was paid for by Merck and distributed to doctors. The liner notes included claims about the benefits that patients would experience if the drug was prescribed for them.

1960年面市的阿米替林是首批针对抑郁症的药物之一,它能大大提高去甲肾上腺素分泌水平,这是一种和肾上腺素相关的神经传递素。这又带来了一场闪电营销战。哈灵顿提到了“蓝调研讨会”,一张由著名音乐人杜克·艾灵顿、路易斯·阿姆斯特朗和阿蒂·肖领衔演唱的广告唱片,由美国广播唱片公司(RCA)的前身胜利唱机公司(Victor)发行,由默克集团出资买断并免费派发给所有医生。歌词内容包括了病人服用这种药物的各种好处。

Focus shifted from norepinephrine to the neurotransmitter serotonin, and, in 1988, Prozac appeared, soon followed by other selective serotonin reuptake inhibitors (SSRIs). Promotional material from GlaxoSmithKline couched the benefits of its SSRI Paxil in cozy terms: “Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance.”

再后来,医学界关注的焦点从去甲肾上腺素转移到了另一种神经传递素:血清素。1988年,抗抑郁药“百忧解”问世了,紧随其后的是其他类型的选择性5羟色胺再吸收抑制剂(译者注:治疗强迫症的抗抑郁药的主要成分)。葛兰素史克制药公司的营销广告中用温情脉脉的语言描述了其抗抑郁药帕罗西汀的疗效:“正如做蛋糕配方需要以正确的比例来调和面粉、糖和发酵粉,大脑也需要一个平衡的化学配方。”

Yet, despite the phenomenal success of Prozac, and of other SSRIs, no one has been able to produce definitive experimental proof establishing neurochemical imbalances as the pathogenesis of mental illness. Indeed, quite a lot of evidence calls the assumption into question. Clinical trials have stirred up intense controversy about whether antidepressants greatly outperform the placebo effect. And, while SSRIs do boost serotonin, it doesn’t appear that people with depression have unusually low serotonin levels. What’s more, advances in psychopharmacology have been incremental at best; Harrington quotes the eminent psychiatrist Steven Hyman’s assessment that “no new drug targets or therapeutic mechanisms of real significance have been developed for more than four decades.” This doesn’t mean that the available psychiatric medication isn’t beneficial. But some drugs seem to work well for some people and not others, and a patient who gets no benefit from one may do well on another. For a psychiatrist, writing a prescription remains as much an art as a science.

然而,尽管百忧解和其他抗抑郁药获得了现象级的巨大成功,却并没有确切的实验数据能够证明:大脑中神经化学物质失调就是精神疾病的发病原因。相反,不少证据都对让这一假设受到了质疑。临床实验引发了激烈的争议:抗抑郁药的所谓药效真的比安慰剂效应强了很多吗?(译者注:安慰剂效应又名伪药效应、假药效应、代设剂效应,指病人虽然获得无效的治疗,但却“预料”或“相信”治疗有效,从而让病患症状得到舒缓的现象。)此外,虽然抗抑郁药的确可以大大提升5羟色胺的分泌,但抑郁症患者的5羟色胺水平貌似也没有特别低。不但如此,精神药理学的发展已经遭遇了瓶颈,哈灵顿引用了著名精神病专家史蒂芬·海曼的评价:“我们已经有近半个世纪没有研发出任何具有显著疗效的新药物或新疗法了。”这不是说现有的精神疾病治疗药物没有效果,但问题在于,有些药似乎对某些人有效,对其他人却毫无作用,而一个病人服了一种药可能没有用,但改服另一种就会有明显的效果。对于精神病医生而言,开处方既是一门讲究科学的技术活儿,也是一种仰赖灵感和直觉的艺术创作。

Harrington’s book closes on a sombre note. In America, the final decade of the twentieth century was declared the Decade of the Brain. But, in 2010, the director of the National Institute of Mental Health reflected that the initiative hadn’t produced any marked increase in rates of recovery frommental illness. Harrington calls for an end to triumphalist claims and urges a willingness to acknowledge what we don’t know.

哈灵顿的书以沉重而严肃的笔调收尾。在美国,二十世纪的最后十年被称为“大脑的十年”,但2010年,美国国家心理健康研究所主任反思说,这项计划并没有显著提升精神疾病的康复率。哈灵顿呼吁人们别再空喊胜利的口号,而是要甘愿承认我们所不知道的事。

Although psychiatry has yet to find the pathogenesis of most mental illness, it’s important to remember that medical treatment is often beneficial even when pathogenesis remains unknown. After all, what I was taught about peptic ulcers and stress wasn’t entirely useless; though we now know that stress doesn’t cause ulcers, it can exacerbate their symptoms. Even in instances where the discovery of pathogenesis has produced medical successes, it has often worked in tandem with other factors. Without the discovery of H.I.V. we would not have antiretroviral drugs, and yet the halt in the spread of the disease owes much to simple innovations, such as safe-sex education and the distribution of free needles and condoms.

尽管大部分精神疾病的发病机理还有待探索,但我们要记得,很重要的一点是:即使在发病机理尚不明确的情况下,药物治疗往往也是有益的。毕竟我在学校学的那些关于溃疡和焦虑的知识并非完全没有用。尽管我们现在知道焦虑不是溃疡发作的原因,但它无疑会加重溃疡的症状。即使在发病机理已经明确、药物治疗也大获成功的领域中,药物也是和其他因素共同发挥作用的。若不是发现了艾滋病,我们就不会研发出抗逆转录病毒的药物,但这一疾病之所以能被迅速控制,很大程度上要归功于一些简单的新方法,比如性爱教育的普及和免费安全套的发放。

Still, the search for pathogenesis in psychiatry continues. Genetic analysis may one day shed light on the causes of schizophrenia, although, even if current hypotheses are borne out, it would likely take years for therapies to be developed. Recent interest in the body’s microbiome has renewed scrutiny of gut bacteria; it’s possible that bacterial imbalance alters the body’s metabolism of dopamine and other molecules that may contribute to depression. Meanwhile, Edward Bullmore, the chief of psychiatry at Cambridge University, argues that the pathogenesis of mental disorders will be deciphered by linking the workings of the mind to that of the immune system. Bullmore’s evidence, presented in his recent book, “The Inflamed Mind” (Picador), is largely epidemiological: inflammatory illness in childhood is associated with adult depression, and people with inflammatory autoimmune disorders like rheumatoid arthritis are often depressed.

饶是如此,精神病学对发病机理的探究仍然在继续。或许在将来的某一天,基因分析能为精神分裂症的致病原因揭开迷雾,虽然目前的种种假说就算都能被证实,相应的疗法也要等上好多年才能研发出来。最近对人体菌群基因组的研究刷新了人们对肠道菌群的认识。也可能是菌群失衡影响了多巴胺和其他分子的新陈代谢,从而诱发了抑郁症。与此同时,剑桥大学精神病学院主任爱德华·布尔莫尔称,如果把头脑和免疫系统的工作原理联系起来,就能破解精神紊乱的致病机理。布尔莫尔在他最近出版的《发炎的大脑》一书中展示了自己的证据,其中大部分都与流行病学有关:儿童时期发过的炎症和成人时期的抑郁症之间有关联,那些患有炎性自身免疫性疾病的人群,比如类风湿关节炎患者,也往往患有抑郁症。

It’s too early to say whether any of these hypotheses could hold the key to mental illness. More important, we’d do better not to set so much store by the idea of a single key. It’s more useful to think in terms of cumulative advances in the field. Many people have been helped, and the stigma both of severe mental illness and of fleeting depressive episodes has been vastly reduced. Practitioners and potential patients are more knowledgeable than ever about the range of treatments available. In addition to medication and talk therapy, there have been other approaches, such as cognitive-behavioral therapy, which was propounded in the seventies by the psychiatrist Aaron Beck. He posited that depressed individuals habitually felt unworthy and helpless, and that their beliefs could be “unlearned” with training. An experiment in 1977 showed that cognitive-behavioral therapy outperformed one of the leading antidepressants of the time. Thanks to neuroscience, we can demonstrate that cognitive-behavioral therapy causes neuronal changes in the brain. (This is also true of learning a new language or a musical instrument.) It may be that the more we discover about the brain the easier it will be to disregard the apparent divide between mind and body.

这些假说是否能够成为治疗精神疾病的关键,现在定论还为时尚早。更重要的是,我们最好不要把全部希望都寄托在这一个可能的关键因素上,把其他进展也纳入考虑的范围,才是更加有用的做法。目前的疗法已经帮助了许多人,严重的精神疾病和突然发作的抑郁症状已经得到了大幅的缓解。执业医生和疾病潜在患者对于治疗手段的了解程度也是空前广泛。除了药物疗法和谈心治疗以外,还出现了许多其他治疗方法,比如精神病学家亚伦·贝克于七十年代提出的认知行为疗法。他假定抑郁症患者会习惯性地感到无助,觉得人生不值得,但这种想法也能通过训练来“去除”。1977年进行的一项实验表明,认知行为疗法的功效大大超越了当时广泛使用的抗抑郁剂。感谢神经科学,让我们得以证明认知行为疗法能够使大脑中的神经元产生变化。(学习一门新的语言或乐器也会有同样的效果。)或许我们对大脑的认识越深入,就越容易跨越身体与心灵之间那貌似存在的鸿沟。

In the late nineties, as an oncologist, I treated a teacher in her fifties suffering from metastatic melanoma. It had spread from her upper arm to lymph nodes in one of her armpits and her neck. The surgeon had removed as much of the disease as he could, and referred her to me because I had previously conducted early clinical trials of an agent called interferon. Interferon is a naturally occurring protein that our bodies produce as part of the immune response to infection. Initially hailed as a possible panacea for all cancers, interferon eventually proved beneficial for some twenty per cent of patients with metastatic melanoma. But the treatment required high doses, which sometimes caused considerable side effects, including depression.

90年代末,当时身为肿瘤学家的我接收了一位年届五旬的教师,她患有转移性黑素瘤,从上臂一直蔓延到了其中一个腋下淋巴和脖子上的淋巴结。医生已经尽量摘除了长瘤的组织,然后把她转交给我,因为我之前做过一种名为干扰素的药剂的早期临床试验。干扰素是人体自然产生的一种蛋白质,是免疫系统对抗感染的一种反应。起初它被奉为治疗一切癌症的灵丹妙药,但最终证明只对约百分之二十的转移性黑素瘤患者有效。但这一疗程需要服用大量药剂,有时会造成严重的副作用,包括抑郁症。

My patient had been widowed and she had no children. “My pupils are my kids,” she said. Unable to teach, she missed the uplift of the classroom. She told me that she was anxious and had been unable to sleep well; she knew that the treatment might not help, and would make her feel sick. In the past, she had experienced depression, and, before I administered interferon, I wanted her to consult a psychiatrist at the hospital who served as a liaison between his department and the oncology unit. He was in his early sixties, with a graying beard and a wry sense of humor: the staff often remarked that he reminded them of Freud. But, unlike Freud, he was not dogmatic. He treated his patients, variously, with medications, talk therapy, hypnosis, and relaxation techniques, often combining several of these.

我的病人是个寡妇,无儿无女。“学生就是我的孩子。”她说。因为不能再教书,所以她非常怀念在教室渡过的时光。她告诉我她非常焦虑,睡眠质量也一直欠佳。她知道这种治疗方法可能没有用,也会让她产生不适的感觉。过去她也经历过抑郁,在我给她服用干扰素之前,我让她去咨询医院的一位精神病专家,那位专家是专门代表他们部门负责跟肿瘤部接洽的。他当时六十刚出头,长着花白胡子,有种古怪的幽默感。医院的人经常说他让人想起了弗洛伊德。但跟弗洛伊德不同的是,他这人一点也不教条。他会对患者采取不同的疗法,有时是药物,有时是谈话,有时是催眠,有时是放松,很多时候是上述所有疗法的结合。

It was a pragmatic, empirical approach, trying to find what worked for each patient. I admired his humility and reflected that his field was not so unlike my own, where, despite a growing knowledge of the pathogenesis of cancer, one could not precisely predict whether a patient would benefit from a treatment or suffer pointlessly from its side effects. In some sense, everything my colleague and I did for the patient was in the end biological. Words can alter, for better or worse, the chemical transmitters and circuits of our brain, just as drugs or electroconvulsive therapy can. We still don’t fully understand how this occurs. But we do know that all these treatments are given with a common purpose based on hope, a feeling that surely has its own therapeutic biology.

这是一种基于经验主义但非常实用的方式,试图找出最适合每个病人的疗法是什么。我很钦佩他的谦卑,也通过反思发现,其实他的专业领域和我的并没有不同:尽管对癌症的致病原理了解得越来越透彻,我们却仍然无法准确预测某个病人是否能从某种疗法中获益,以及是否会因副作用而平白无故地受苦。从某种程度上来说,我和我同时为病人所做的一切归根到底都是生物学层面的。话语可以改变我们大脑中的化学介质和脑电波,使之朝更好或更糟的方向发展,就如药物或电击的疗法一样。我们仍然无法完全理解这是为什么,但我们确实知道的一点是:所有这些疗法都要以康复的盼望为基础,而这种盼望本身肯定对身体有治愈的效果。

精神病学史:人类认识了世界,但依然认不清自己

  • 本文原载于 The New Yorker

  • 原文链接:https://www.newyorker.com/magazine/2019/05/27/the-troubled-history-of-psychiatry

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精神病学史:人类认识了世界,但依然认不清自己

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