Helping you to get help, bilingual mental health info
Discovery Channel 属下的健康卫生电视台 (Discovery Health) 五月初将播出一个短系列 Psych Week，内容包括焦虑症，极度愤怒的习惯，上瘾，多重人格症，童年精神分裂症，躁郁症。他们的网站上有节目片段可以在网上观看。看样子，我觉得选题有点猎奇，涵盖面不够全面，例如精神分裂症大多数发病与青春期，极早期的schizophrenia 是相当罕见的病例，有些上瘾的症状，例如晒紫外线灯过量是否病理性上瘾，还没有定论。不过 Discovery Channel 做的节目内容一般都比较负责，应该是准确的，值得看看。
另外过去推荐过的好节目，再拿出来重新推荐一下：
HBO series: Addiction. 获得电视艾米奖，请了非常权威的专家，提供非常全面的资料，制作精良。
http://www.psych.org/share/parents-med-guide.aspx
Published by American Psychiatric Association, the two free online guides provide parents with credible, scientific information about the safety and indications of medications commonly prescribed to treat ADHD and depression in children and adolescents.
Think of your husband or wife, or your romantic relationship, or a close friend. Think about some important characteristic of that individual’s personality - a characteristic or trait in that person to which you have a strong emotional reaction, positive OR negative…. Now think about one of your parents, or perhaps a sibling. Do they have that very same characteristic, and are the reactions you have to that aspect of them similar to those concerning your current close relationship?
The phenomenon of “transference” is one of the cornerstones of psychoanalytic theory. Rows of bookshelves could be filled with what has been written about it. The basic premise is that we tend to recreate in our current relationships the patterns of thinking, feeling, and behaving that were formed early in our life, most importantly in the relationships with our parents and siblings when we were children.
Critics challenge this idea. They accuse psychoanalytic theory of dwelling too much on the effects of childhood and family dynamics on the evolution of one’s personality. Surely, one’s personality does develop and change throughout the course of one’s life as a result of our friends, lovers, and new life experiences. It is not solely determined by how our parents raised us as children.
I think this is a perfectly valid criticism. We are not SIMPLY the products of our families. Nevertheless, our parents (or other parental figures) and siblings did indeed spend a great deal of time with us during those formative years, when our minds were young, impressionable, and eager to learn about how we humans relate to each other. Based on our relationships with them, we created models or templates in our mind about what constitutes the expected ways in which people will behave in relationships. We formed basic impressions about the kinds of needs, wishes, fears, and hopes that shape relationships and our image of ourselves in those relationships. Often we don’t realize these are OUR OWN models. They may be very different than the models taking shape in the heads of other people. Think of a time when, as a young person, you went to a friend’s house and were totally surprised, maybe even shocked, at how differently that family behaved as compared to your own family.
As we grow up we take these models with us. Often operating at an unconscious level, they affect the choices we make in the kinds of people we get involved with as well as how we experience those people. For example, think of your first boyfriend or girlfriend, and how similar that person might have been to one of your parents (usually your opposite sex parent). How often have young men said to their girlfriends “You’re just like my mother!”… or vice versa.
These models also shape how people select and experience things in their lives that are NOT human, but so closely touch our needs and emotions that we want to imbue them with human characteristics. We humans can’t help but anthropomorphize the elements in the world around us. It’s in our blood. We use our internal models to humanize and shape our experience of cars, houses, pets, careers, the weather…. and COMPUTERS.
Yes, computers can be a prime target for transference because they may be perceived as human-like. They are complex machines that almost seem to “think” like humans think. In fact, some people say they WILL someday be able to “think” like us. Unlike TV, movies, or books, they are highly interactive. We ask them to do something and they do it - at least, they usually do (like humans they sometimes disobey and surprise us). With the new generation of highly visual, auditory, and customizable operating systems and software applications, we also have a machine that can be tailored to reflect what we expect in a companion. The science fiction fascination with robots and androids is the culmination of this perception of machines as being almost like one of us.
What makes computers especially enticing targets for transference is that they are VAGUELY human and PROGRAMMABLE to be whatever we make them out to be. Psychoanalysts discovered that if they remain relatively ambiguous and neutral in how they behaved with their clients, the clients would begin to shape their perceptions of the analyst according to their internal models from childhood. When faced with an indistinct, seemingly malleable “other”, we instinctively fall back on our familiar mental theories about relationships and use those theories to shape how we think, feel, and react to this new, somewhat unclear relationship. This whole process often is unconscious. We are so used to these old templates that they automatically start to mold our perceptions and actions without our really thinking about it.
So now we go back to the exercise at the beginning of this article. Only now we substitute in “computer” for husband, wife, lover, or friend. Do we unconsciously experience the computer as being like our mother or father, or sibling? At first glance the question may seem silly. Keep in mind, though, that I am not saying that we think the computer IS our parent or sibling, but rather that we recreate in our relationship with the computer some ASPECT of how we related to our family members. Still, even if you apply the exercise to an important person in your life or to your computer, you may insist that they are nothing like your mother or father! Here’s where we need to examine the process of transference more carefully - for there are curious twists and turns in this phenomenon that make it considerably more complex than what I have described so far. We’ll see that the same pattern of relating to a family member can be played out in various ways in one’s relationship to the computer. In the descriptions that follow, I’ll focus mostly on relationships with parents, though these also could apply to other family members.
You as You, Computer as Parent
This is the most basic, obvious type of transference - the type I’ve already described. You experience the other as being like your parent and yourself as the child you once were.
So let’s say Leonard had a mother who had many rules for how he should behave as a child, but the rules always seemed to be changing. Even though he tried to figure out and obey his mother’s requests, he never quite succeeded and never satisfied her. He could never seem to do anything right. As a result, he felt frustrated, helpless, and defeated whenever he tried his best but ultimately failed in the eyes of his mother. As an adult, Leonard experiences his computer in the same light. He is intimidated by it, is never quite sure how to please it. When he tries to accomplish something, the computer doesn’t seem to like what he does. It won’t respond. He gets error messages. He has failed once again. His computer makes him feel frustrated, helpless, and defeated. Maybe he even tries to avoid it, just like he did with his mother.
Jenny had a father who was frail and not quite competent as a person. She loved him, and so took care of him and was very attentive to his needs. Perhaps she sometimes sacrificed her own needs in order to attend to his. As an adult, she perceives her computer as something that is a bit fragile and vulnerable. She is very careful about how she uses it because she doesn’t want to cause damage. She is very conscientious about running diagnostics and anti-virus programs. The health and well-being of her computer, she feels very earnestly, is in her hands. Some might even say she is bit over-protective of her machine.
Leonard and Jenny are only two examples. This first type of transference can take many different forms. Traditional psychoanalysis (”Freudian” theory) often described it in terms of sexual wishes and fantasies towards the parent. The child hopes to possess the opposite sex parent as someone to satisfy their sensual/emotional desires. Later, after resolving the conflicts associated with these wishes, the child learns to identify with the sexuality of the same sex parent. In his article “The Internet Regression,” Norman Holland focuses on these types of transferences towards computers. The computer is seen as seductive, as a sex object, a satisfier of desire, as a symbol of sexual power and prowess. As an illustration, consider this real conversation from a cyberspace chat room in which the members are discussing how one of their friends “Suzy” on CUseeme (internet video conferencing) was flashed by a exhibitionist.
Daisy: so all she sees is a big penis on her screen! lol!
Hawkeye: lol
Daisy: I can’t figure out why he wanted to see *Suzy’s* penis!
Dragon: next ur gonna say she has a 15 inch monitor, right?
Daisy: 20 inch, Dragon
THR: geez and black and white haha
Mr. Tops: 17 in rotating
Daisy: hahahahhahah
Tweety: bigger is… bigger!
Dragon: wow, no wonder you gals like macs so much
Daisy: doesn’t have to be bigger, just better
Daisy: and rechargeable
Tweety: or plugged in the wall…
Hawkeye: what about bigger AND better?
Mr. Tops: its not the size of the monitor, but the driver behind it
Tweety: with loads of amps
Hawkeye: as one of my friends like to say, “How hard is your big drive?”
Daisy: lol!
Dragon: more importantly, Hawkeye, is it compressed?
Daisy: more importantly, is it unzipped
Hawkeye: and how often do you optimize it?
Lola: or is it backed up?
Dragon: only in san francisco
Daisy: LOL!
Freud would have a field day with this dialogue. It’s not too difficult to detect themes about phallic power, penis envy, castration fears, and a miscellaneous collection of heterosexual and homosexual issues. However, I don’t want to dwell on the idea of computers as powerful (parental) sex objects. This type of transference applies to some people, but not all. I’m not even convinced that it is a prominent type of transference. The language of classical Freudian theory also gets downright sexist and culturally biased.
What I think is most important about this “erotic” transference is not the sexual feelings towards computers, but rather the perception of the computer as POWERFUL, perhaps in ways similar to how parents are perceived as powerful. This perception of power is obvious in the dialogue from the chat room. The computer can think faster than us, often has more knowledge on a subject, can perform tasks that we couldn’t do alone… and now, in the age of the internet, is a link and guide to a vast, wondrous “outside” world. For some people, these qualities may stir up feelings of admiration, awe, fear, competition - not unlike transferential feelings towards any authority figure.
You as Parent, Computer as You
In this type of transference, a person’s mind reverses the roles played by the child and parent. A clearly visible, and pathological, example of this is when the abused child grows up to become a child abuser. This is a process of “turning the passive into the active” where the child’s feelings of helplessness and anxiety in the face of being controlled, manipulated, and used is warded off in adulthood by assuming the role of one who is powerful and in command.
It’s possible that some users might abuse their computers just as they might have been abused, to a greater or lesser extent, within their family of origin. But computers are expensive. For most people, the possibility of damaging them would not be very satisfying in the long run. On a more subtle level, people who once were controlled, dominated, and manipulated within their family - as if they were not really people at all, but just objects to be used - may very well as adults treat their computers in the same manner. Anger and outright rage at the computer, when it doesn’t behave the way YOU want it to, may be a symptom of this kind of transference. This may have been the same emotional reaction of the disappointed, “betrayed” parent.
The computer also can be perceived, almost lovingly, as one’s baby. You attend to it’s needs, nurture it, help it develop and grow (by adding software and hardware). Not unlike Jenny, who assumed a parental role towards her father, you feel protective and responsible for the computer’s well-being. You become invested in it’s strivings and achievements, even taking pride in the new things it can do. With delight and wonder, you take part in the creation of a new individual with it’s own unique abilities and personality. It is a reflection of you, YOUR abilities and personality, but you also realize that much of what you have done is to direct and shape the raw qualities and potentials that already existed inherently in your “baby.” And quite unlike real life babies, this silicone substitute will never become independent and leave you. For some people, that may be a very attractive proposition.
You as You, Computer as Wished-For Parent
Many people wish, consciously or unconsciously, that their parents could have been different in some way. That wish may shape their perception of the computer as possessing those desired characteristics.
Sam’s mother was, to use a less than technical term, “crazy.” Her behavior and emotions were unpredictable. One moment she would be caring and loving, and the next harsh, critical, and punishing. Never being able to tell what was coming his way next, Sam became a hypervigilant, paranoid child. He needed always to be on the lookout for subtle cues indicating how his mother would behave. He tried to anticipate her moves, but often was not successful. Feeling helpless and angry (in some ways similar to Leonard), he experienced life as unpredictable, dangerous, and beyond his control.
As an adult, Sam takes comfort in his computers. They possess the qualities he wished his mother had - predictable, reliable, non-judgmental, and no unexplained emotional outbursts. If he applies his hard-earned skills at analyzing the subtle details of how it behaves, almost all of the time he CAN predict and control how it will behave. There is very little intimacy and “loving” feelings towards his computer. But that’s quite OK by him. Those things only got him entangled in trouble with his mother. In fact, he takes some pleasure in his cold dominance over the submissive machine.
Lorna experiences her computer quite differently. She sees it as a benign presence. It is always there, waiting for her. It pays attention to what she wants and gives immediate feedback. It allows her to express her thoughts, her feelings, her creativity. It takes and accompanies her wherever she wants to go on the internet. She almost sees it as a very responsive, compassionate companion who recognizes her value and individuality as a person. It even HELPS her develop her individuality…. How unlike her parents who were so busy and preoccupied that they often neglected to show an interest in her life.
You as Wished-For Parent, Computer as You
In this last type of transference, a reversal once again occurs - only this time the user acquires the wished-for parental qualities and the computer becomes like the child. Often people strive for the benign qualities that were missing in their parents - which is often a matter of reversing some characteristic of the parent. Sometimes that reversal may go too far. If your parents were too strict, you may become too liberal with your child. If your parents were uninvolved in your life, you may become too intrusive in your child’s life.
Becoming the wished-for parent of one’s computer may follow the same pattern. Users strive to be “good” to their computer in ways that their own parents were not “good” to them. In some cases they carry that effort too far. One user is careful about making sure her computer is safe and healthy. Another becomes so worried about viruses and possible damage to his machine that he refuses to explore the internet, is wary of installing new software, and rarely lets anyone else use it. One user takes interest in what goes on “inside” his computer and so tries to learn about its hardware and software. Another becomes so invested in the technology of her machine that it becomes an obsession that rules her life.
You are Me, I am You, We are All Together
Some type of transferences (called “selfobject” transferences) involve a bolstering and enhancing of one’s sense of self. When the parent admires the child’s painting, acknowledges her thoughts about a TV program, or empathizes with her feelings of anger, sadness, and delight, the child’s identity is fortified through this “mirroring.” When a boy imitates his father mowing the lawn, or a girl plays with Mommy’s briefcase, this identifying with the parent in an “idealizing” relationship augments their self-esteem and sense of self. So too in a “twinship” relationship when siblings play and work with each other. The feeling that “we are doing this together” satisfies their thirst for knowing who they are by what they do with others. In these forms of transference, there is a blending of oneself with the other, so that the other person is not necessarily experienced as a separate person, but as part of oneself.
Users may rely on their computers to clarify and strengthen their sense of identity. The computer is attentive and accommodating to their needs. It mirrors them. As users customize its hardware and software, the computer becomes more and more like a responsive reflection of their needs, feelings, and ambitions. It is part of them, a reflection of who they are, a world created from within themselves. By idealizing it, by participating in all the amazing, powerful things a computer can do, users strengthen their own confidence and feelings of success. By spending time together with their computer, it becomes a reassuring extension of their motivations, personality, and inner psychological life - like a good buddy, a sibling…. a twin.
But there is a danger in relying too heavily on the computer as a support to one’s identity. Placing all your eggs in one basket is never a good idea. The system may crash at exactly the wrong moment. The hard-drive may fail. For any of a wide variety of reasons, your treasured machine may be taken from you. The rug has been pulled out from under your feet. You feel betrayed, abandoned, lost….. resulting in anger and depression.
Perhaps all computer transferences involve a blending of the user’s mind with the “cyberspace” created by the machine. Cyberspace indeed is a psychological space, an extension of the user’s intrapsychic world. Using psychoanalytic terms, we would say that computers create a transitional space - an intermediate zone between self and other - where identifications, partial identifications, internalizations, and introjects interact with each other. In more plain language, we would say that cyberspace is a zone where the big and little bits of our parents and siblings that we’ve taken into our own minds and personalities become free to express themselves, to play, work, fight, and, ideally, make peace with each other.
How Do You Know It’s Transference?
Psychological reactions to one’s computer (and any significant “other”) may be a complex combination of some or all of the types of transference described above. Mother, father, and sibling transferences can interact and change over time. It’s often difficult detecting the interpersonal origin of one’s thoughts or feelings towards the silicone-other. When thinking about transferences in real life, clinicians often ask themselves, “Who is doing what to whom?”
So how do you know when you’re having one of these transference reactions to your computer? …. There are some tell-tale signs. When you want to throw the damn thing against the wall. When it “makes you” feel betrayed and disappointed. When you feel lonely and empty because you have not had enough time to spend with it. When you often want to be at your keyboard more than you want to be with family and friends, or when those people comment on how attached or emotional you get towards it. Any seemingly exaggerated or “inappropriately” strong feelings towards your machine probably means you think of it as more than just a machine.
Transference also may be rearing its head whenever one feels addicted (see “Why is This Thing Eating My Life”). Computer addictions often mean that the user is attempting to use the cyberworld to satisfy some strong internal need, but the strategy never quite works. One never feels fully satisfied or complete because the frustrated need arises from something that was or is missing from one’s relationship to real world people. The computer has become an inadequate substitute target for that unfulfilled need.
Adult and Machine
Growing up into a mature adult is a gradual process of realizing how the mental models from our childhood have shaped our relationships and our lives. Sometimes these models steer us in the right direction - towards the right people and activities - and thereby enrich our lives. Sometimes not. We may need to challenge, develop, or outright abandon some of them. In all cases, the enlightening path is to see these models for what they are - simply models. After all, the computer is not Mom, Dad, Sister, or Brother. It’s just a computer.
Online Others in the Machine
All of the transference reactions described in this article also can explain how the user reacts to other people that he or she encounters in cyberspace. Communicating only by typed text in e-mail, chat rooms, and newsgroups results in a highly ambiguous environment. We can’t see or hear other people. They become a shadowy figure, a screen onto which we may launch any of the variety of transference reactions.
Because we experience online others THROUGH the computer, it’s also possible that the transference reactions to them may interact with the transference reactions to the computer. Transference to the computer may spill over to, amplify, or be contradicted by the perception of the online other. For example, if William perceives the computer as a passive thing to be manipulated (like Dad manipulated him), he might extend that perception to other people he meets online, treating them as weaker people to be controlled. If they happen to say something that sounds passive, or if their personality style is indeed a bit passive, William may greatly amplify in his own mind how passive they seem to be. As a result, his reactions to them may be inappropriate. If others do something that grossly contradicts William’s perception of the computer as passive - if they act assertive or independent - William may react with severe disappointment or anger at the perceived “betrayal.”
Healthy online relationships are those in which we realize that our perceptions are not always accurate. Other people are other people, not extensions of our beliefs or ghosts in our machine. Given the complexities of transference reactions, this isn’t always easy to do. As Otto Kernberg was fond of saying about unraveling transference in psychotherapy, one must continually ask, “Who is doing what to whom?” Once we fully realize that the computer AND online others aren’t our Moms, Dads, Sisters, or Brothers, we become free to enjoy cyberspace in the ways that we wish, without any unconscious strings attached.
今天正巧看到一篇有意思的文章，转过来给大家看看。文章是英文的，但是不专业，很好懂，是 New Jersey 的一个大学心理学教授写的，虽然是1996年的文章，但是对今天如火如荼的网上人生仍然适用。
Transference to Computers by John Suler
其中 transference 是心理学上专用的一个术语，指一个人在无意识中把自己跟亲密关系者（主要是父母和兄弟姐妹）的关系（即幼年时期建立的关系）转移到陌生人（例如新认识的同事朋友上司或者心理治疗师）身上。如果这个陌生人让你回忆起你的母亲（例如她的地位和身份甚至容貌让你产生代入感），那么你对于她的态度和相处方式会不自觉地模仿你跟母亲相处的方式。
郑重推荐一下 HBO 制作的系列节目 Addiction 。网站上不仅有 HBO 制作放映的纪录片（含九段短片），而且有很多辅助资料，访问了很多酒精和药物上瘾的患者，也访问了很多在美国和全世界都是最权威、参与最尖端研究的医生和科学家。我没有全看，只看了几个video，就足够看得出这个节目的质量非同一般。第一很中肯，很客观，不煽情，不以娱乐观众为目的，而是诚恳坦白地传递真实的信息。第二，很科学，里面的专家讲的研究成果和治疗方法，都是符合最新科学的道理，推翻了很多过去错误的观念，包括医学界本身对上瘾和治疗方法的误解。第三，很实用，含有很多具体的指导和建议，直接告诉酒精和药物上瘾的患者和患者的家人怎样寻求治疗，什么样的治疗有效，什么治疗无效，为什么青少年和成年人需要不同的治疗方法和环境。
另一个很重要的话题是对这个话题的误解和偏见。吸烟喝酒，社会大多数人觉得没什么，很正常，甚至是有性格的表现；使用非法毒品，抽大麻，被普遍认为是意志薄弱或性格缺陷或道德败坏。介乎二者之间的是几乎隐形的滥用处方药的问题，因为上瘾者服药者常常是中产阶级家庭，又是“合法药物”，常常被忽视或者不当作问题。
脑神经和基因研究表明，上瘾是一个因人而异的生理化学过程。举个例子，越战时期，美国士兵在东南亚大量接触到麻醉品，很多人都用过 heroin, cocaine, 但是回国以后，90% 以上的人说戒就戒了，剩下只有不到10% 的人长期上瘾并且很难戒掉。即使是长期上瘾的人，有些经过治疗就戒成功了，而有些怎么戒也戒不掉。这是因为前者意志坚强或者道德高尚么？不，每个人的大脑结构和功能不同（这些差别有很大一部分是基因遗传，也有一部分是早年环境的影响造成的），神经系统本身的 vulnerability 让少数人受到外界化学物质的刺激后，很快重组，大脑里的关键线路和机制发生重大变化，使人对外界药物产生强烈的需要和依赖。这个重组过程本身也会破坏大脑的自控能力，就是明知继续滥用酒精或者药物会带来很糟的后果也无法停止。而多数人，即使接触到这些物质也不容易有这样恶性循环的后果，或者戒掉相对容易，那是因为他们的大脑结构原本就没有这些 vulnerability。但是这个过程非常复杂，牵涉的神经机制也很多，现在我们知道的还只是冰山一角。
虽然社会和法律把这些刺激和影响大脑快感的物质分成合法的，违法的，管制的各种类别，但是这些物质，酒精、尼古丁、大麻、止痛药 （narcotics）、非法药物（例如安非他命、古柯碱或鸦片类），等等，制造上瘾和依赖性的生理过程很类似，而且现在有研究发现某些暴食症（binge eating）患者的大脑对食物信号的处理也跟上瘾的过程类似。
药物上瘾也好，合法的吸烟酗酒也好，对患者的正常生活都可能产生严重的负面后果，虽然也有程度的差别。上瘾严重不能自拔，会给家人带来深刻长期的痛苦和创伤，特别是羞辱和掩饰。 One person’s addiction destroys many lives. 但是因为社会的恐惧和偏见，道德挂帅的误解，治疗手段的落后，病患的抵触心情，大多数人没有得到应该的治疗和帮助。大家都需要更多的教育和知识传播。
青少年时期，大脑正在快速而大规模地重组，是个特别 vulnerable 的时刻，特别容易受到破坏。中学和大学阶段，又是特别接触到大量外界影响的时期，在学校和同龄人之间很容易接触到酒精和其他成瘾物质，而家长还一无所知。虽然大多数人试验一下，因为基因和固有结构比较强硬，不会上瘾，但滥用试验本身就很容易出事，例如酒后开车；同时青春期也是自控力和判断力特别弱的时期。而且原本大脑 vulnerable 的人（没人事先知道自己是否容易上瘾），如果这时候上瘾，成年以后就很难治好脱身，但是如果青春期安全度过，不接触这些物质，就很可能度过一劫，成年以后，大脑长结实了，倒不太会上瘾了。
很多时候，上瘾跟其他精神疾病有很强的联系，bipolar disorder （躁郁症），抑郁症，attention deficit/hyperactivity disorder （多动症），都会使人更容易对外来刺激物（从酒精到非法毒品）上瘾和产生依赖性。关注和及时治疗精神疾病，也是防止滥用和成瘾的重要一步，特别是在青春期！
一直在收集一些网上自我测试的资料，现在把手上有的一些网站贴出来。不过都是英文的，如果有人知道中文网站请补充提供，谢谢。
Depression screening:
http://www.med.nyu.edu/psych/screens/depres.html
Bipolar disorder screening:
http://www.healthyplace.com/Communities/Depression/nimh/bipolar_screening_test.asp
Anxiety disorders screening (multiple subtypes):
http://www.adaa.org/GettingHelp/SelfHelpTests.asp
Personality disorder screening (multiple subtypes):
http://www.4degreez.com/misc/personality_disorder_test.mv
Eating disorder screening:
http://eatingdisorders.about.com/od/riskfactors/a/eat26test.htm
Alcohol abuse screening (how much is too much?):
http://www.psychologicaladvice.com/pages/alcohol.html
Substance abuse screening (including abuse of prescription drugs):
http://counsellingresource.com/quizzes/drug-abuse/index.html
Disclaimer: 这些自我测试是最入门最基本的一些问答，准确率很有限，仅供 screening 使用，不能代替专业人士的询问和诊断。如果疑心自己有心理健康问题，请务必找专业人士咨询诊断。
去年去听一个psychopharmacologist 学会的讲座，里面好几个专家说，见到病患，第一先问“你最近睡得好吗？” 如果睡眠发生紊乱，“我会马上治疗失眠症状，因为根据经验，如果不调整过来，其他一切精神症状都会前后脚跟上来。”
睡眠这个生理活动至今仍然困扰科学家，跟其他大脑机构一样，我们知道一点但只是冰山一角而已。不过，已经有越来越多的研究表明，睡眠的健康牵涉到全身的生理和心理健康，从心血管疾病到糖尿病都跟睡眠不足有关。几乎每个精神疾病都牵涉到睡眠功能的失调：焦虑症患者多数睡不着，忧郁症患者一半睡不着一半睡不醒，躁郁症患者在狂躁周期中几天几夜不睡觉，而且失眠能够诱发狂躁周期的出现，其他疾病也有各种扰乱睡眠的症状，而且，失眠能恶化精神方面的症状，由此恶性循环。
反之，患者或者普通人如果睡得好，对健康大大的有益。研究表明，在所有的人里面，睡得好跟睡得不好的差别在醒着时统统都显出来。睡得好的人，记忆，判断分析能力，反应速度，情绪好坏，血压和心跳指标，什么都强。
现代人的生活环境打破了长期进化来的日出而作日落而息的规律，各种电视电脑的刺激，城市的光污染，工作压力，等等，让越来越多的人失眠或者睡眠紊乱。我一直怀疑，睡眠的错乱跟日照减少、户外体力活动减少等因素加起来，是忧郁症人数年年升高的罪魁祸首。
睡眠好，有规律，时间充足，这么自然这么重要的事，却不那么容易做到。越是为自己的失眠问题焦虑，就越容易对卧室和床产生条件反射的抵触和忧虑心理，更加睡不着了。另一个重要的方面是，重视睡眠，把它当作一个 commitment ，坚持好习惯，而不要轻易地从睡眠里“偷”时间用来工作和玩儿。
如果失眠，晚上睡不好，早上起不来，以下是几条很容易执行的方法帮助你改善状况：
1. 定时上床，定时起床，周末不要睡懒觉，否则你的身体都迷糊了。不要随便牺牲“上床时间”。
2. 白天多晒晒太阳，以调整体内的生物钟。这对嗜睡也有好处。
3. 遇到睡不着的情况不要惊慌，不要躺在床上翻来覆去，起来离开卧室干点平缓的事，例如看看书，看看电视，听听音乐什么的，让心情恢复平静，感到困意了再回床上去。记住，一夜不睡没什么大不了的，第二天自然会感到困。但是切记！第二天一定要挺着不在白天补觉，而是撑到平时的上床时间才睡，否则就会打乱生物钟。
4. 白天花点时间让身体疲劳些，锻炼也好，多站俩钟头也好，干点体力活也好，晚上就睡得香。
5. 卧室里的温度最好比外面低一点，先洗个热水澡，然后让体温慢慢下降。睡前体温下降是正常周期 (circadian rhythm) ，人为地降低温度等于告诉身体该休息了。
6. 避免睡前一定时间内喝茶喝咖啡或剧烈运动，这些东西刺激交感神经，让人兴奋，扰乱睡眠规律。这个一定时间范围因人而异，有些人是六个钟头，有些人是四个钟头，可以自己尝试寻找规律。
7. 不要睡前喝酒。酒精能够让人困倦入睡，但是对大脑有作用，干扰到深度睡眠，所以其实睡得不好，醒来也觉得累。
8. 如果你已经很久都是上床睡不着，翻来覆去很久，很焦躁，可以试着将上床时间推迟半小时，比较容易入睡，但按照平常时间起来，让自己先困着一两天，然后把上床时间提前。
9. 卧室里保持黑暗和整洁，尽可能地灭除产生distraction 的因素，没有电视，没有电脑，没有账本，没有勾起你的烦恼和焦虑的线索。卧室就是用来做爱和睡觉的。
想找更多资料可以去看看National Sleep Foundation 的网站。最要紧的是，要重视，不要take it for granted。
忧郁症跟大脑里 serotonin, norepinephrine 的传递固然有推卸不掉的关系，但绝不是这么简单。基因的变异使得很多人“抵抗力”下降，证据越来越多，牵涉面也远远超过跟serotonin有关的receptors。我们一早就怀疑stress hormone 例如肾上腺分泌的一堆 glucocorticosteroids 可能诱发大脑中信号传递故障，长期下来导致焦虑症和忧郁症。制造阻塞 corticosteroid receptor 的药物（例如mifepristone) 的厂家正在研究是否对忧郁症有效。
生理机制不怎么清楚，治疗的研究还得进行下去。最近NIMH 的科学家，发现麻醉药 ketamine 有快速抗忧郁的作用。 一针下去，几个钟头内立刻产生明显的效果，两个礼拜内达到的疗效跟六个礼拜普通药物差不多。Ketamine 本身副作用十分严重，所以不能就拿来用，但重要的是，它告诉科学家，glutamate 传递系统，似乎在 mood regulation 的电化学过程中，位于serotonin 的下游，作用更快跟直接。下一步当然就是要寻找类似于ketamine 那样的分子，要么阻断NMDA receptor，要么激活AMPA receptor，看看它效果如何。
即使是ketamine，也跟其他药物类似，对 60% 到 70% 病患有效。为什么总是有一批患者对药物没有反应呢？其实这个现象并不仅限于忧郁症，高血压，高血脂 之类的问题，也常见到不同的人对同样的药产生不同反应，有些人药到病除，有些人重剂量下去也效果甚微。原理五花八门，而大多数我们并不知道，只能一个个试验过去。研究表明，跟各人的基因组合差异很有关系。
NIMH 前几年做了一个至今最全面的clinical trial，STAR*D，用实践和数据表明，第一个药没效果，换一个可能会有效，即使是同类型的SSRI，也值得换掉试一试。为什么？去年有德国科学家发现，在某些人当中，药效的差别跟一个管分子出入大脑的蛋白质有关。因为小分子不能直接在脑液跟血液之间自由穿来穿去，很多都得依赖细胞膜上的把门的某些特定蛋白质放它们出入。一个叫做ABCB1 的大门，就直接影响到某些抗忧郁症药物进出大脑的过程。大部分人里，这个门是通的，少数人当中，它就不怎么通，只放过某些药物（mirtazepine)，另一些就过不去（venlafaxine）。过不去当然就没效果。。。
除了化学治疗法以外，物理抗忧郁治疗法的研究也正在如火如荼地进行。电痉挛疗法 (electroconvulsive therapy, ECT) 已经使用了五十年，治愈率仍然高过药片，但它的短期失忆副作用吓退了很多人。其实完全不痛，危险也小，但人们对ECT 仍有偏见和恐惧。ECT是给整个大脑通电，刷地一下暂时抹掉所有的电流传递（十分短暂），等于reboot the brain，不知什么原因，多reboot 几次，大脑线路会adapt，某些线路会重新调整走向，结果是减轻了或者治愈了忧郁症的，疗效有时高达80%。但也需要持续治疗，停止以后，线路会慢慢恢复过去的错误状态，那么症状可能复发。
与其全面reboot，一些科学家在探索定点进行电讯号干扰。一种是从脑壳外面加电磁场干扰特定部位的脑电波活动，叫做 transcranial magnetic stimulation；一种是implanted cortical stimulation，把一个电极插进dorsal, lateral prefrontal cortex，直接对着里面的神经线路放电信号，似乎也有效果；第三种是deep brain stimulation（DBS)，在最严重的病人中进行过几次clinical trials，效果十分神奇。
DBS 是把很小的电极插进大脑深部的某个关键部位，电极通过皮肤下的线路连接到埋在胸前的电池，就像心脏起搏器一样，不停地放电，抑制这个神经交错点的信号传递。这个过程需要十分精确但并不复杂的开颅手术。我听过此项研究的一个专家Helen Mayberg (Emory University) 的讲座，她说，效果很神奇，这些长期患严重忧郁症的病人，吃过六七八种药物，用过ECT，都没有作用，无法工作，正常生活的功能严重破坏。在手术室里，当外科医生把电极放好，通上电流，病人忽然说，“你们开灯了？” 他们在做手术时都是用局部麻醉，病人是清醒的，随时汇报有什么异样感受。最初的几个手术，他们都没有料到，本来麻木呆滞虚弱无力的病人，就在手术台上忽然话多起来，对周围的医务人员产生交流的欲望。并不是每个病人都有效果，但是在参加临床试验病人（注意他们都是其他治疗手段无效的严重病人）中三分之二有显著疗效，而且他们在手术室里的自述有惊人的相似之处：“我感到胸口一块大石落地”，“肩上忽然轻了”，“环境忽然明亮很多”，“四周色彩忽然鲜艳起来”，感官忽然尖锐而不再灰蒙蒙。我听着她的叙述，再次深切感到，忧郁症毫无疑问是生理的病变，而健康人对病患的生理感受，实在是一无所知。
未来十年，我十分期待有效的忧郁症疗法问世，让更多人重新看见明亮的世界，鲜艳的色彩，听见动听的旋律，尝到舌头上陈杂的五位，好奇心大增，享受跟别人谈话，肩上的大石头消失不见。
（7月4日经专家指出错误部分特此修改。）
说到底，人就是个庞大而超复杂的机器，而大脑这个部件里面的运转，虽然只靠了电和化学两样信号传递，却无比复杂。跟其他器官的疾病同理，外表看上去的生病，其实是里面的零件和线路发生了故障。从外面看，忧郁症就是一个病，很简单，就好象机器外面只能看见转不动的现象，打开一看里面却是千丝万缕，很多环节都有可能出了毛病，也有可能是一块管路出了毛病，不可避免地影响到与之关联的其他的部件，或者给本来正常的部件带来过重的负担。
如果不是有这些偶然发现的抗忧郁症药物，医学发现不了，原来在抑郁症的病理过程中，有几个关键的 neurotransmitters： serotonin, norepinephrine, 这几年发现的 glutamate。自从Prozac (fluoxetine) 风靡世界开始，SSRI 类型的抗忧郁药物帮我们提供了一些线索。SSRI, selective serotonin reuptake inhibitor，是干什么的呢？我们拿着这只钥匙，在实验室里对着各种门锁捅啊捅的，发现SSRI 这只钥匙（其实有很多个，不过只有小小不同，归为一类）堵住的锁不在 synapse 对岸神经细胞B 的墙上的门里，而是在此岸细胞A的墙上，这个锁就是serotonin reuptake receptor，这个receptor 的功能是把已经倒出来的serotonin 回收起来。这个锁堵上了，那么synapse 的缝隙中就会有更多的serotonin 钥匙呆下来，多呆一会儿，跟对岸的接受大门多碰撞。
这时你可能会跳起来：啊，我知道了，serotonin 跟细胞B 墙上的接受门多撞几次，多打开几扇，那就加强传递信号喽，那就改善忧郁情绪喽？科学家本来也这么想，但后来一推理发现不对。因为SSRI 药物，一吃下去就立刻堵死了很多回收门，但却并不是立刻有效果，要吃上四到八个星期才感到症状减轻，人也有精神了。所以调整和改善depressed mood，并不是1+1=2，有信号或者信号强就立刻好了的。其实，忧郁症病人是否缺乏serotonin 我们都还不知道呢。可能性更大的是，病人缺的不是serotonin，而是receptor，或者因为基因和外界的联合因素，使得某些脑细胞制造 receptors 的过程失去平衡，或者制造出来的是伪劣产品。当某些细胞发生了故障时，本身虽然不直接让人忧郁，但却影响到下游的某些线路，间接损害这个人处理外界压力的能力。
经过更多的研究后，目前的认识加猜想是，当synapse 的空间充满了serotonin 之后，在B墙上撞啊撞的，给细胞B一个NT泛滥的错觉，细胞B 开始减少制造大门 receptors 。然后下面的过程就更神奇了，大门少岂不是坏事？但并不是的，门少了，留下来的大门却更加灵敏。而增加的 serotonin 浓度并不会持久，即使继续吃药，细胞A 也会减少生产达到原先的平衡，只是现在的细胞B 的接受方面sensitivity 增加了。然后。。。（中间填空黑箱子里的许多步骤），忧郁症状就改善了。
别以为这么简单就能讲清楚，后来又发现，其实不光是serotonin，另一个neutrotransmitter, norepinephrine，也有类似的作用。象 Effexor (venlafaxine) 和 Wellbutrin (bupropion) 这些药物，形状比较“大同”（也是因为serotonin 跟norepinephrine 长得有点像），既能堵住serotonin reuptake receptor，也能堵上norepinephrine reuptake receptor，也增加了norepi 在缝隙中的数目。多奇怪啊，两个不同的 neurotransmitters 在脑子某些地方各有不同的作用，但在另一些线路中又似乎有重叠或者互相促进的作用，在不同的细胞、区域、和线路中，即使是同一NT也会干不同的事。
现在市场上的抗忧郁症药物们基本上都是影响 serotonin 和 norepi 传递线路和receptors 的。效果是有的，但仍有20% 到35% 的病人吃了完全无疗效。这多半是因为忧郁症可能不是一种receptor 有问题，而是，症状看上去差不多的忧郁症，其实不同的人脑子里出问题或者数量不够的是不同的receptors。出问题的不同线路在上游，影响到的却是一样的下游线路，所以症状相同。但治疗起来，在上游治疗就效果参差不齐，同样的药对甲有用，对乙则完全浪费了。。。
我们现在知道，serotonin 和 norepi 也只是忧郁症病理的庞大网络中的一环而已。吞下药片后，只有一部分的药物分子吸收到血液中，更小一部分渗透进入大脑（因为大脑的脑液跟循环的血液绝不混合的，只能靠分子渗透），而这些外来的 “假钥匙” 随便什么神经细胞，只要含有serotonin/norepi 的门锁就塞进去，可不管线路跟mood 有没有关系。这个过程效率其实很低，有点像大炮打蚊子，难免伤及无辜，所以有很多的副作用。。。
这就是为什么现在的药物效果难以预测，而且失败例子也很多。
（待续，明天讲讲serotonin/norepinephrine 之外的新动向。）
The Noonday Demon: An Atlas of Depression 这本关于忧郁症的书虽然有一点旧了，但我仍然喜欢和推荐给别人，包括得过和没有得过忧郁症的人。
作者Andrew Solomon 是个记者/作者，没有受过专业医学训练，书中的医学和生理方面的知识是他自己搜集和访问得来的，所以并不系统，也不精确，更不深刻，但好处是他把复杂的一些医学概念解释得很通俗易懂。读者应该知道，从本书出版到现在已经七年，期间科学上对于忧郁症的病因和治疗已有很大的进步，有些内容已经过时，新治疗方法虽然尚未被批准和广泛使用，但是有不少希望很大的治疗手段（例如ketamine, transcranial stimulation, deep brain stimulation）正在如火如荼地进行研究。
这本书里最有价值的部分是作者对于忧郁症的描述。因为是亲身经历，而且他的文笔细腻精确，写出来非常真实有说服力，让没有得过忧郁症的读者几乎身临其境地了解到患者的感受。 这一点非常重要，因为从未经历过忧郁症的健康人习惯用自己心情不好和感到悲伤的经历来以己度人，推论“如果我能从烦恼和郁闷中振作起来，你们为什么不能？” Solomon 的贡献就是把真实的忧郁症症状生动地展现给你看，跟健康时候的状态有多么强烈的差别。
一个人如果没有经历过癌症化学疗法，就无法想象那么严重和持久的虚弱是怎样的感受。忧郁症的虚弱是脑子里的，却也有相似之处。要把这种类似瘫痪的虚弱形容出来，Solomon 的一支笔给我留下深刻的印象，那是我第一次对忧郁症有了感性认识，对患者产生了亲切感，比医学专业书上的定义更加有用。
Noonday Demon 获得2001年美国National Book Award。
特此推荐。
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