强迫症的科学与治疗

然后，测试通常会转到关于目标症状的问题。

And then the test generally transitions over to questions about target symptoms.

他们真正努力让患者识别出自己是否有强迫观念，以及具体的强迫观念是什么。

They really try and get people to identify if they have obsessions, what are their exact obsessions?

这实际上非常重要，因为当我们讨论一些真正有效的疗法时，我会稍微透露一下为什么它们在某些情况下效果最好，而在其他情况下效果较差——这取决于临床医生和患者不仅要一般性地识别出强迫观念和强迫行为，还要强烈鼓励甚至迫使患者精确地定义出最严重、最灾难性的恐惧是什么，强迫观念真正关联的是什么。

Now, turns out to be really important because as we talk about some of the therapies that really work, I'll just give away a little bit of why they work best in certain cases and why they don't work as well in other cases, it turns out that it becomes very important for the clinician and the patient to not just identify the obsessions and the compulsions generally in a kind of a generic or top contour way, but to really encourage or even force the patient to define very precisely what the biggest, most catastrophic fear is, what the obsession really relates to.

这一点对于打破皮质-纹状体-丘脑回路、缓解症状至关重要。

That turns out to be very important in disrupting this corticostriatal thalamic loop and getting relief from symptoms one way or the other.

因此，耶鲁-布朗强迫症量表，也就是这个Y框，内容非常详尽。

So the Yale Brown Obsessive Compulsive Scale, this Y box, again, is very extensive.

它实际上长达数十页，包含所有这些不同的类别，其目的不仅仅是 pinpoint 患者 obsess 什么或被迫做什么，还要试图识别出驱动这一切的恐惧是什么，对吧？

It goes on for dozens of pages actually and has all these different categories, not so much designed to just pinpoint what people obsess about or what they feel compelled to do, but to also try and identify what is the fear that's driving all this, right?

到目前为止，我们一直将强迫观念和强迫行为视为存在于真空中的现象。

In the way that we've set this up thus far, we've been talking about obsessions and compulsions as kind of existing in a vacuum.

你对细菌有强迫观念，因此强迫自己洗手；对细菌有强迫观念，就强迫自己洗手；或者对对称性有强迫观念，因此强迫自己把所有东西都摆成直角；或者对计数有强迫观念，因此不断计数，等等。

You're obsessed about germs and you're compelled to wash your hands, obsessed about germs, compelled to wash your hands, or obsessed about symmetry, compelled to put right angles on everything, or obsessed about counting and therefore counting, etcetera.

但在表面之下，还存在一个认知层面，仅凭一个人描述他们的强迫观念或展示他们的强迫行为是无法明显看出的。

But beneath that is a cognitive component that is not at all apparent from someone describing their obsession and from someone describing or displaying their compulsion.

这一切更深层的问题是：如果一个人不执行强迫行为，他们究竟害怕什么？

The deeper layer to all that is what is the fear exactly if one were to not perform the compulsion?

也就是说，是什么样的恐惧在驱动着这些强迫观念？

Meaning what is the fear that's driving the obsession?

这就引出了一个非常有效的治疗类别——我必须说明，这种疗法并非对所有强迫症患者都有效，但它对许多患者有效，并且深刻揭示了产生强迫症的潜在神经回路以及如何打断它。

So that brings us to a very powerful category of treatments that I should say does not work in everybody with OCD, but works in many people with OCD and really speaks to the underlying neural circuitry that generates OCD and how to interrupt it.

这种疗法就是认知行为疗法，特别是基于暴露的认知行为疗法。

And that is the treatment of cognitive behavioral therapy and in particular exposure based cognitive behavioral therapy.

我们现在将讨论认知行为疗法和暴露疗法，但首先，我想明确区分用于治疗强迫症的认知行为疗法和暴露疗法，与用于其他类型心理问题和障碍的同类疗法之间的区别。

So we're going talk about cognitive behavioral therapy and exposure therapy now, but right at the outset, I want to distinguish the kinds of cognitive behavioral therapy and exposure therapies that are done for obsessive compulsive disorder, the sorts of cognitive behavioral therapies that are done for other types of mental challenges and disorders.

因为针对强迫症的认知行为疗法，核心完全在于识别最深层的恐惧。

Because cognitive behavioral therapy for OCD really has everything to do with identifying the utmost fear.

从某种意义上说，可以将恐惧看作是一个层级结构，对吧？

In some sense, can think of fears as kind of along a hierarchy, right?

在之前那个例子中，有人害怕向左转，因此感到必须向右转，你需要让这个人深入理解，他们最害怕的是向左转的什么。

In the example earlier of somebody being afraid to turn left and therefore feeling compelled to turn right, you would want to take that person and really understand what do they fear most about turning left.

他们自己可能并没有意识到，也不清楚那到底是什么，但如果你在临床环境中仔细追问，最终会得到一个答案。

Now, might not be aware of it, they might not be conscious to what that really is, but if you were to probe them in a clinical setting, you would eventually get to an answer.

这个答案一开始可能是：我不知道，就是感觉不好。

That answer could be at first, I don't know, it's just bad.

我不知道为什么不好。

I don't know why it's bad.

这毫无道理，但就是感觉不好。

It makes no sense, but it's just bad.

我不想向左走。

I do not want to go left.

我不知道为什么，我不知道为什么。

I don't know why, I don't know why.

但如果你以一种尊重、温和、关心治疗的方式稍微推动一下这个人，问他们：‘你说的不好，具体是指什么？’

But if you were to push that person a little bit in a respectful and kind and caring way aimed at their treatment, if you were to push them and say, Well, what do you mean by bad?

如果你向左转，你觉得世界会毁灭吗？

If you turn left, do you think the world would end?

他们可能会说：不，世界不会毁灭，但会有人突然死去。

They might say, No, the world's not going to end, but someone is going to die suddenly.

我知道这听起来很疯狂，但就是会有人突然死去。

I know that sounds crazy, but somebody's going to die suddenly.

这听起来几乎像迷信。

This almost sounds like superstition.

我们稍后会讨论迷信，但确实有点迷信的成分。

We'll talk about superstitions later, but indeed it is somewhat superstitious.

所以，比如你会问：谁会死？

So for instance, you would say, Who's going to die?

他们会说：我不知道。

And they'd say, I don't know.

你会说：不，认真说，谁会死？

And you'd say, No, really, who's going to die?

如果你仔细想想，你会死吗？

If you think about this, are you going to die?

某某人会死吗？

Is so and so going to die?

而且经常，非常经常，你会发现人们会开始以惊人的细节揭示这种潜在的执念，无论是对临床医生还是对他们自己而言，这种细节都可能令人惊讶，尽管他们早已在心中长期存在这种细节。

And very often, very often, what you find is that people will start to reveal the underlying obsession at a level of detail that both to the clinician and to them can be somewhat astonishing, even though they've been living with that detail in their mind for a very long time.

那么，一个人怎么可能开始揭示那些在脑海中存在已久却从未意识到的内容呢？

Now, how could somebody start to reveal detail about something that's existed in their mind for a very long time, but not known about it, right?

从未意识到过它。

Not been aware of it.

现在，你们中有些人可能会想，哦，这是被压抑了什么的。

Now, some of you might think, oh, it's repressed or something.

这完全不是正在发生的情况。

That's not at all what's happening.

如果你思考一下强迫症的结构，通常人们会先有强迫观念，然后会尽快采取强迫行为来缓解这种观念。

If you think about the architecture of OCD, typically people will have an obsession and then they'll engage in the compulsion as quickly as they can to relieve that obsession.

因此，在很多方面，这种疾病本身阻止了人们真正深入到那个低谷的底部，阻止他们清晰地向自己阐明究竟害怕的是什么。

So in many ways, the disease itself prevents people from ever getting to the bottom of that trough, ever getting to the point where they really clearly articulate to themselves exactly what it is that they fear.

但以一种看似反直觉的原因，清晰地表达出他们所恐惧的内容变得至关重要。

But it becomes so essential to articulate exactly what it is that they fear for a somewhat counterintuitive reason.

你可能会想，哦，一旦他们意识到自己究竟害怕什么，一切就会立刻缓解，神经回路关闭，他们就会感觉好起来，因为他们终于明白了。

You might think, oh, the moment they realize exactly what they fear, everything lifts, the circuit turns off and they just feel better because they realized it.

我多希望能告诉你这是真的，但事实恰恰相反。

I wish I could tell you that's the case, but it turns out it's the opposite.

临床医生实际上试图做的是让患者感受到更多的焦虑，而不是更少。

What the clinician is actually trying to do is get people to feel more anxiety, not less.

他们试图让患者打断——这里不是开玩笑——打断他们自己的神经回路，也就是在因执行强迫行为而获得短暂焦虑缓解时进行干预。

What they're trying to get them to do is to short circuit, no pun intended, to intervene in their own neural circuit, I should say, with that relief of anxiety, however brief, brought on by engaging in the compulsion related to the obsession.

通常情况下，一个人会感到强迫思维，比如‘我不敢向左转，因为会发生坏事，有人会死’，然后立刻转向右边，他们从未获得机会或可能性去真正探索如果向左转，或无法向右转，会发生什么。

So whereas typically someone would feel the obsession with, oh, I don't want to turn left because something bad's going to happen, someone's going to die, and then they turn right, they never get the option or the opportunity to really explore what would happen were they to turn left or to not be able to turn right.

通过强迫他们走向探究之路，这会引导他们清晰地识别出恐惧和焦虑，从而加剧他们的焦虑感，而这正是临床医生所追求的目标。

By forcing them down the path of inquiry, that leads them to the place where they very clearly identify the fear, the anxiety, it raises the anxiety in them and that's actually what the clinician is after.

在强迫症的背景下，认知行为疗法和暴露疗法通常旨在帮助人们学会忍受焦虑，而不是缓解焦虑。

Cognitive behavioral therapy and exposure therapy in the context of OCD most often involves trying to get people to tolerate, not relieve their anxiety.

这一点至关重要。

This is extremely important.

我意识到，根据认知行为疗法和暴露疗法的不同风格，这会有一些差异，但几乎普遍的目标都是让患者体验那些他们通常能通过强迫行为至少部分缓解的焦虑，哪怕这种缓解只是短暂的。

And I realize there's variation to this depending on the style of cognitive behavioral therapy, the style of exposure therapy, but almost across the board, the goal again is to get people to feel the anxiety that normally they are able to at least partially relieve, however briefly, by engaging in the compulsion.

那么，如果我们回想起皮质-纹状体-丘脑回路，这里发生了什么？

So if we think back to that circuit of corticostriatal thalamic, what's going on here?

认知行为疗法在哪个环节进行了干预？

Where is CBT intervening?

这个回路的哪一部分被中断了？

What part of the circuit is getting interrupted?

正如你所记得的，皮层参与意识感知，丘脑及其网状核负责将某些类型的经验传递到我们的意识层面，而其他经验则被过滤掉，纹状体则参与这种‘行动’或‘抑制’类型的行为。

Well, as you recall, the cortex is involved in conscious perception, the thalamus and that thalamic reticular nucleus are involved in the passage of certain types of experience up to our conscious perception and not others, and the striatum is involved in this go, no go type behavior.

当强迫症充分表现时，人们会对某个特定想法感到焦虑，并产生‘行动’反应，比如洗手，或‘抑制’反应，比如不能向左转。

When OCD is really expressing itself in its fullness, people feel an anxiety around a particular thought and they either have a go, for instance, wash hands, or a no go, do not turn left type reaction.

通过让患者以一种逐步的、层级化的方式暴露于他们最具体的焦虑源和最大恐惧，他们会体验到强烈的自主神经唤醒。

By having people progressively in a kind of hierarchical way reveal their precise source of anxiety, their utmost fear in this context, what happens is they feel enormous amounts of autonomic arousal.

在焦虑治疗或其他类型的治疗中，目标通常是教人们通过呼吸技巧、想象技巧、自我对话或社会支持等方式来缓解和减轻焦虑，这些方法都被广泛认为有助于人们自我调节焦虑。

Now, in the context of anxiety treatment or other types of treatments, the goal would be to teach people to dampen, to lessen their anxiety through breathing techniques or through visualization techniques or through self talk or through social support, any of the number of things that are well known to help people self regulate their own anxiety.

但在这里，情况恰恰相反。

Here, it's the opposite.

他们试图让患者真正体验到最大程度的焦虑，然后去做与正常强迫行为完全相反的事情。

What they're trying to get the patient to do is to really feel the anxiety at its maximum, but then do the exact opposite of whatever the normal compulsion is.

因此，如果正常的强迫行为是洗手，那么目标就是在这种极度焦虑的状态下抑制洗手的行为。

So if normally the compulsion is to wash one's hands, then the idea is to suppress hand washing while being in the experience of the utmost anxiety.

或者在不向左转的情况下，患者被期望，或者 hopefully 能够真正向左转。

Or in the case of not turning left, the person is expected to or would hopefully be able to actually turn left.

正如你所想象的，这会引发巨大的焦虑，但目标是去承受这种焦虑。

And as you can imagine, that would evoke tremendous anxiety and yet to tolerate that anxiety.

现在，我要明确一点：这绝不是你自己或为朋友可以随意尝试的事情，它必须由受过专业训练的持证心理学家和精神科医生来实施，但无论如何，这清楚地表明，作为一种与焦虑相关的障碍，强迫症与其他类型的焦虑和焦虑相关障碍（如创伤后应激障碍、恐慌障碍等）是不同的，因为其目标是再次将患者直接带到他们最恐惧的事物面前，并打断这一神经回路。

Now, I want to be very clear, this is not the sort of thing you want to do on your own, this is not the sort of thing you to do for a friend, this is done by trained licensed psychologists and psychiatrists, but nonetheless, it really points to the fact that as a anxiety related disorder, OCD is distinct from other types of anxiety and anxiety related disorders, things like PTSD and panic disorder, etcetera, because the goal again is to bring the person right up close to the thing that they fear the most and then to interrupt the circuit.

现在你应该能够直观地理解了，因为你已经了解了这些机制，你试图打断的回路是来自大脑思考部分和感知部分——即大脑皮层——到纹状体的信息流模式，对吧？

And now you should be able to know just intuitively, because you understand the mechanisms, that the circuit you're trying to disrupt is the pattern of information flow from the thinking part of the brain, the perception part of the brain, which is the cortex, to the striatum, right?

纹状体中有这些活跃的神经元，它们本质上是在试图让人产生某种行为或抑制某种行为，我知道这听起来有点像在讨论自由意志，但确实如此。

The striatum has these neurons which are active that essentially are, I know it sounds a little bit like a discussion about free will, but they're trying to get the person to generate a certain behavior or suppress a certain behavior.

随着焦虑加剧，这就像一种液压压力，迫使他们去做那些他们长期重复、深受其苦的行为。

And as anxiety ramps up, it's sort of a hydraulic pressure to do that very thing that they've done for so long and they suffer from so much.

我们曾在关于攻击性的那一集中讨论过液压压力。

We talked about hydraulic pressure in the context of aggression in the aggression episode.

这非常相似，对吧？

This is very similar, right?

当我说液压压力时，其实并不是真正的液压压力，而是许多不同系统共同作用的结果。

There's a kind of a, now when I say hydraulic pressure, it's not actual hydraulic pressure, it's the confluence of a lot of different systems.

正如我们很快会了解到的，它涉及神经化学、荷尔蒙、电活动等多种因素，这些因素同时并行运作。

It's neurochemical as we'll soon learn, it's hormonal, it's electrical, it's a lot of different things operating in parallel.

因此，我们无法将它归因于某一种化学物质或神经递质。

So we can't point to one chemical or transmitter.

人们感到被迫不断行动，以缓解焦虑，这是通过一种渐进式的暴露疗法实现的，对吧？

What's happening is the person is feeling compelled to act, act, act to relieve the anxiety and through a progressive type of exposure, right?

在这种疗法中，你不会一开始就让人直接面对最极端的情境。

You don't throw people in the deep end in this kind of therapy right off the bat.

你会逐步引导他们面对自己最恐惧的事情，然后最终在他们经历极度焦虑时，帮助他们中断强迫行为——当然，这一切都发生在支持性的临床环境中。通过这种方式，你教会人们：焦虑可以存在，而无需通过强迫行为来应对。

You gradually ratchet them toward or move them toward the discussion of exactly what they fear the most, and then eventually move them toward the interruption of the compulsion as they're feeling this extremely elevated anxiety, of course, within the context of a supportive clinical setting, but in doing that, what you are teaching people is that the anxiety can exist without the need to engage in the compulsion.

对有些人来说，这听起来可能像是用一堆高深的心理学和神经科学术语来描述一件本来很直观的事情，但我认为对大多数人来说，这并不直观。

Now, of this might sound to people like, oh, this is a lot of kind of fancy psychological neuroscience speak around something that's kind of intuitive, but I think for most people, this is not intuitive.

对于强迫症患者来说，无法用其他方式来形容：回避焦虑的冲动和强迫行为是一种极其强大的驱动力，因此现在你应该能理解，为什么能够承受焦虑、真正与之共处，并做与你平时被强迫去做的完全相反的事，会成为治疗的关键路径。

And for people with OCD, there's no really other way to put it, the impulse, the compulsion to avoid anxiety is such a powerful driving force that it should now make sense to you as to why being able to tolerate anxiety and really sit with it and do the exact opposite of what you're normally compelled to do is going to be the path to treatment.

事实上，认知行为疗法已被证明对大量强迫症患者非常有效，但并非对所有人都有效。

And indeed, CBT has been shown to be enormously effective, again, for a large number of people with OCD, but not all of them.

而且，它常常需要与其他药物治疗相结合，我们稍后会讨论这些药物。

And oftentimes it requires that it also be used in concert with certain drug treatments, which we're going to talk about in a moment.

接下来，我们来谈谈认知行为疗法和暴露疗法在强迫症治疗中一些独特的特点，这些特点通常在其他类型的精神疾病或心理问题的CBT治疗中并不常见。

Next, let's talk about some of the really unique features of cognitive behavioral therapy and exposure therapy in the context of OCD that you often don't see in the use of CBT, that is cognitive behavioral therapy for other types of psychiatric challenges and disorders.

第一个要素是逐步递增，我之前已经提到过，这是指在治疗过程中逐步、渐进地增加患者所经历的焦虑程度。

The first element is one of staircasing, and I already mentioned this before, but this gradual and progressive increase in the anxiety that you're trying to evoke from the patient, from the person suffering from OCD.

这种逐步增加是在诊所或实验室中，由经过培训且持证的临床医生进行的，但之后患者会离开，对吧？

That's done in the context of the office or the laboratory, again, by a trained and licensed clinician, but then the person leaves, right?

他们离开诊所、离开实验室，而对于患有强迫症的人来说，认知行为疗法和暴露疗法中一个非常关键的组成部分就是所谓的‘家庭作业’，字面意思就是家庭作业。

They leave the office, they leave the laboratory And a very vital component of CBT and exposure therapy for people with OCD is that they have and perform what's called homework, is literally what they call.

这在其他类型的治疗中也可能存在，但对于强迫症而言，家庭作业极其重要，因为在实验室实验或诊所环境中，患者往往感受到很强的支持，因此能够承受这些高度的焦虑并中断强迫行为。

This might be seen in other sorts of treatments, but for OCD, homework is extremely important because within the context of a laboratory experiment or the clinic, patients often feel so much support that they can tolerate those heightened levels of anxiety and interrupt their compulsions.

但当他们回到家时，环境的熟悉感往往会让他们重新陷入同样的强迫思维和行为模式，此时他们很难抑制这些行为。

Whereas when they get home, oftentimes the familiarity of the environment brings them to a place where all of a sudden those obsessions and compulsions start interacting the same way and they have a very hard time suppressing the behaviors.

为什么会这样呢？

Why would that be?

在神经科学中，我们有一个术语，叫做‘条件性场所偏好’和‘条件性场所回避’。

Well, in neuroscience, we have a phrase, it's called conditioned place preference and conditioned place avoidance.

还有其他一些术语，但本质上都涉及一个简单的原理：当你在某个环境中反复体验某种感受，有时即使只经历一次，当你再次回到该环境或类似环境时，你往往会再次产生同样的感受，明白吗？

There's some other phrases too, but basically it all has to do with a simple thing, which is when you feel something repeatedly in a given environment, sometimes even once within a given environment, you tend to feel that same thing again when you return to that or similar environments, okay?

所以，条件性地点偏好或条件性地点回避，这只是个高大上的说法，意思是当你在某个地方经历了好事，再次回到那个地方或类似的地方时，你就会感到愉快；而如果在某个地方经历了坏事，再次回到那个地方或类似的地方时，你就会感到不快。

So condition place blank or condition place that is simply fancy nerd speak for the fact that when you're in a place and something good happens, you tend to feel good if you return to that place or a place like it, or if something bad happens in a given place, you tend to feel bad when you return to that place or a place like it.

我认为最明显的例子不幸属于负面类别：几年前，我有些朋友去旧金山旅行。

I think the most salient example that leaps to mind is unfortunately the category of bad, but I had some friends years ago visit San Francisco.

那里一直存在持续不断的白天和夜间入车盗窃事件，似乎已经持续了很久，但最近十年尤为严重，小偷会偷走车里任何东西，从电脑到一盒纸巾。

There's been an ongoing, it seems like it's been happening forever, but this is really in the last decade of daytime break ins and nighttime break ins into cars to steal anything from computers to what seems to be like a box of tissues.

这其中有很多原因，我不想展开讲，因为这不是今天播客的主题，但我借此机会提醒一下：如果你去湾区任何地方，请千万不要把任何东西留在车里，因为即使在大白天，车窗也可能会被砸破。

And there are numerous reasons for this I don't want to get into, it's not the topic of today's podcast, but I will use this as an opportunity to say, if you're visiting anywhere in the Bay Area, do not leave anything in your car because the window will get broken into sometimes in broad daylight.

我一些很好的朋友去湾区旅行时，我发消息给他们说：‘顺便提醒一下，你们去吃晚饭的时候，不管多麻烦，都要把所有行李和电脑带进去。’

Some good friends of mine were visiting the Bay Area and I texted them and said, Hey, by the way, when you're headed to dinner, guys, make sure you bring in all your luggage and computers at however inconvenient that might be.

他们回我说：‘太晚了，所有东西都被偷了。’

They wrote back, Too late, everything got stolen.

所以，大约五六年以前，这种事情发生了。

So some years ago now, I think five, six years ago, this happened.

不幸的是，所有东西都被偷走了。

Sadly, everything got stolen.

大部分东西都可以替换，但有些对他们来说非常有感情价值。

Most of it could be replaced, but some of it was very sentimental to them.

每次我们聊天，每次考虑在某个城市开会时，这个问题都会冒出来：我不想去那里，我不再喜欢那个城市了，等等。

Every time we talk, every time we consider having a meeting in a particular city, this comes up as I don't want to be there, I don't like that city anymore, etcetera.

当然，旧金山也有一些很棒的亮点，但只要在一个地方发生一次糟糕的事件，就足以让整个印象变得黯淡。

And of course, San Francisco has some wonderful redeeming features, but it only takes one bad incident in one location to kind of color the whole picture dark, so to speak.

大脑就是这样运作的，它会进行概括，它并不是一个非常精确的器官。

The brain works that way, the brain generalizes, it's not a very specific organ.

再说一遍，它除了其他功能外，还是一个预测机器。

Again, it's a prediction machine in addition to other things.

因此，在认知行为疗法（CBT）中，之所以布置家庭作业，是因为当人们回到家时，往往最容易复发——如果你愿意这么称呼的话——重新陷入他们的强迫思维和行为中，而那个地点、那个条件性场所，正是最需要挑战焦虑、应对焦虑的地方，不要试图通过强迫行为或其他方式压抑焦虑。

So in the case of CBT therapy, the reason there's homework is that when people go home, oftentimes that's when they relapse, if you want to call it that, back into their obsessions and compulsions and that location, that conditioned place is where it becomes most important to challenge the anxiety and to deal with the anxiety, to not try and suppress the anxiety through compulsions or other means.

当我提到其他方式时，我想强调一点，稍后在播客中我们还会再提到：物质滥用在强迫症患者中非常普遍，这既是因为焦虑因素，也因为人们觉得根本无法摆脱那些典型的强迫症思维和行为模式。

And when I say other means, I want to highlight something, we'll come up again a little bit later in the podcast that substance abuse is very common in people with OCD because of the anxiety component and also because of people's feelings that they just can't escape from the thoughts or behavioral patterns that are so characteristic of OCD.

因此，酒精滥用、大麻滥用或其他形式的药物滥用在强迫症患者中非常常见。

So alcohol abuse or cannabis abuse or other forms of narcotics abuse are very common in OCD.

稍后我们会讨论大麻是否能帮助缓解强迫症，但毋庸置疑，如果目标是最终缓解或消除强迫症，压抑焦虑恰恰是错误的方向。

Later, we'll talk about whether or not cannabis can or cannot help with OCD, but needless to say, suppressing anxiety is exactly the wrong direction that one should take if the goal is to ultimately relieve or eliminate the OCD.

因此，我们现在有了CBT暴露疗法中两个对强迫症极为重要且在强迫症治疗中相对独特的特点：那就是逐步升级，直面最严重的恐惧，深入、具体地理解和感受，如果一个人做出某种行为或回避某种行为，事情究竟会糟糕到什么地步。

So we now have two characteristics of CBT exposure therapy that are extremely important for OCD and somewhat unique to the treatment of OCD, and that's the staircasing up towards the really bad fear, the really severe and specific articulation and understanding and feeling of how bad things really would be if someone engaged in a particular behavior or avoided a particular behavior.

此外，治疗师还会布置家庭作业，帮助患者在更多样化的环境中练习应对焦虑，而不去进行强迫行为。

Then there's the component of homework given by the clinician for the person to be able to create a broader set of contexts in which they can deal with the anxiety, not engage in the compulsions.

然后，强迫症治疗中一个非常独特、在其他许多精神疾病中很少见的特征，就是家访。

And then a very unique feature of treatment of OCD that you don't see in many other psychiatric disorders are home visits.

我觉得这非常有趣。

I find this fascinating.

我认为，精神病学和心理学传统上并不允许或鼓励家访，但这种情境与地点对强迫症治疗和缓解如此关键，已经促使许多精神科医生和心理学家获得许可，亲自前往患者家中，在他们日常生活的环境中进行治疗，对吧？

I think that the field of psychiatry and psychology traditionally doesn't allow for or invite home visits, but this component of context, location and context being so vital to the treatment and relief of OCD has inspired many psychiatrists and psychologists to get permission to do home visits where they actually go visit their patients in their native setting, in their home cages, right?

他们不是小鼠，但在他们自己的‘家笼’里，对吧？

They're not mice, but in their home home cages, right?

我这话是带点幽默的，毕竟老鼠生活在笼子里——至少在实验室里是这样，而人类通常住在家里或其他地方。

I'm being facetious here, but people, mice live in cages, at least in the laboratory and humans generally live in houses or elsewhere.

因此，他们会到患者家中拜访，以观察患者如何与环境互动，以及哪些特定地点最容易或最不容易引发焦虑。

So they visit them in their home in order to see how they're interacting and the particular locations that evoke the most anxiety and the least anxiety.

有些工具，我不想称它们为拐杖，但确实是人们用来应对强迫思维和强迫行为的手段，特别是用来识别那些试图回避高度焦虑的技巧和方法。

Some of the, I don't want to call them crutches, but some of the tools that people are using to confront and deal with the obsessions and compulsions, and in particular, to try and identify some of the tools and tricks that people are using to try and avoid that heightened anxiety.

因为再次强调，我知道我在重复，但这一点对强迫症及其治疗来说至关重要且独特：患者必须能够耐受极高水平的焦虑，这一点极为关键。

Because once again, and I know I'm repeating myself, but I think this is just so vital and so unique about OCD and the treatment of OCD, the critical need for the patient to be able to tolerate extremely elevated levels of anxiety is so crucial.

如果人们回避家中的某些房间，或回避某些食物、厨房里的某些区域，临床医生仅通过观察就能发现这些模式。

So if people are avoiding certain rooms in the house, or if people are avoiding certain foods or certain locations in the kitchen, the clinician can start to identify that by mere observation.

我在这里要提一下，患者并不总是意识到自己是如何与家居环境互动的。

And I should mention here that patients are not always aware of how they are interacting with their home environment.

这些模式在一些人身上根深蒂固，以至于他们甚至没有意识到自己总是向左转，或者根本没有意识到自己只在水槽的一侧洗手。

Some of these patterns are so deeply ingrained in people that they don't even realize that they're constantly turning to the left, or they don't even realize that they're only washing their hands on one side of the sink.

因此，临床医生通过家访可以以礼貌、友好、支持的方式，温和地询问：‘你有没有想过，为什么你总是把水龙头往左拧，或者往右拧？’等等。

And so the clinician by visiting the home can start to interrogate a bit in a polite way, in a friendly, in a supportive way as to, hey, do you ever think about why you always flip the faucet to the left or flip the faucet to the right, etcetera?

现在，我们所有人其实都有很多习惯性行为。

Now, we all do a lot of things that are habitual.

我们每个人每天都会做一些比较固定的事情。

We all do things that are somewhat regular from day to day.

事实上，我建议你问问自己：你是不是总把牙刷放在同一个地方？

In fact, I would invite you to ask yourself, do you always put your toothbrush in the same location?

你是不是总在使用牙刷前后盖上盖子？

Do you always cap the toothbrush before or after you use it?

你都会做哪些类似的事情？

What sorts of things do you do?

你会不会擦掉牙膏管口的螺纹？

Wipe the little threading on the toothpaste or not?

我这个人，坦白说，大概有3500个让人不爽的小事，但其中一件就是牙膏沾在牙膏管口的螺纹上。

I'm somebody, I confess that I have, well, I have about 3,500 pet peeves, but one of my pet peeves is toothpaste kind of on the thread of the toothpaste.

这真的让我很困扰，我不知道为什么。

It really bothers me, I don't know why.

几乎和试图擦掉它一样让我烦恼，而这又带来了一定的挑战。

Almost as much as trying to wipe it off bothers me, which creates a certain challenge.

如果我再继续谈下去，我想我可能符合强迫性人格障碍的诊断了。

And if I talk about this any further, then I think I would qualify for obsessive compulsive personality disorder.

但我必须说，我对这件事并没有太多焦虑。

But I have to say, I don't experience a ton of anxiety about it.

它并没有主宰我的生活。

It doesn't govern my life.

事实上，我现在意识到，世界上到处都有牙膏管的螺纹上沾着牙膏，但这其实并不会让我困扰。

In fact, I realize that right now there are tubes of toothpaste that have toothpaste along the thread everywhere in the world and it doesn't really bother me.

我依然可以坐在这里，向你们提供一些关于强迫症的信息。

I can still sit here and provide some information about OCD to you.

这并没有侵入我的意识，至少对我来说是这样。

It's not intrusive, at least not to my awareness.

因此，通过家访，治疗师可以通过直接提问深入探索，让患者通过自我提问，去发现那些他们有意识和无意识中可能符合强迫症的行为。

So by the home visit, the therapist can really start to explore through direct questioning and can allow the patient to explore through direct questioning of themselves, the things that it might be conscious of and the things that they might not be conscious of that would qualify for OCD.

因此，我想简要总结一下认知行为疗法和暴露疗法的关键要素，以及它们如何与非常有效的药物治疗相结合。

So I'd like to just briefly summarize the key elements of cognitive behavioral therapy and exposure therapy and how they can be combined with drug treatments that are very effective.

我接下来要讨论的大部分内容都与一位杰出的研究科学家和临床医生的数据和实践有关。

Much of what I'm going to talk about next relates to the data and indeed the practice of an incredible research scientist and clinician.

这位是海伦·布莱尔·辛普森，或者我该称她为医生。

So this is Helen Blair Simpson, or I should say Doctor.

海伦·布莱尔·辛普森，因为她确实是一位医学博士（MD）和哥伦比亚大学医学院的哲学博士（PhD）研究科学家。

Helen Blair Simpson, because she is indeed an MD medical doctor and a PhD research scientist at Columbia University School of Medicine.

她是全球最顶尖的专家之一，甚至可以说是顶尖的几位之一，对强迫症的机制有着最深入的了解，正在积极研究人类强迫症，试图发现新的治疗方法，揭示新的机制，拓展我们当前的理解，同时也在自己的诊所中积极治疗强迫症患者。

And one of the world's foremost experts, if not the expert, I would put her in a category of maybe just one to three people who is most knowledgeable about the mechanisms of OCD, is actively researching OCD in humans, trying to find new treatments, trying to unveil new mechanisms and expand on our current understanding, and who also treats OCD quite actively in her own clinic.

医生。

Doctor.

辛普森医生做了一场精彩的演讲，总结了认知行为疗法和暴露疗法在治疗强迫症中的核心要素。

Simpson gave a beautiful presentation in which she summarized some of the core elements of CBT and exposure therapy for the treatment of obsessive compulsive disorders.

她指出，关键的程序是暴露疗法，当然，必须亲自进行，并针对真正引发强迫观念和行为的实际事物。

She describes that the key procedures are exposures, of course, done in person and with the actual thing that evokes the obsessions and compulsions.

这可能是前面提到的汗毛巾，也可能是其他任何多种触发物，都是在患者面前实时进行的，也就是我们所说的‘在体暴露’。

So this could be the sweaty towel as described earlier, or could be any number of different triggers done with the patient in real time, so in vivo, as we say.

也可能是想象性的，让患者坐在办公室的椅子上，告诉他们：‘我想让你想象那个引发侵入性想法的事物’，或者直接聚焦于浮现的侵入性想法，通过这种方式让患者接触并暴露于他们的强迫观念和行为。

And it could also be things that are imaginal, sitting somebody down in a chair in an office and saying, okay, I want you to imagine the thing that triggers the intrusive thought, or let's just focus on the intrusive thought as it arises and then to explore and expose the patient to their obsessions and compulsions that way.

所以这可以是真实的，也可以是想象的。

So it can be real or it can be imaginal.

当然，目标是逐步、渐进地提高焦虑水平，同时进行所谓的仪式阻止，防止患者实施强迫行为。

And the goal of course then is to gradually and progressively increase the level of anxiety, but then to intervene in so called ritual prevention to prevent the person from engaging in the compulsion.

目标再次说明一下，我这里是在转述她的观点：要驳斥恐惧，挑战对强迫观念和行为的信念，干预这些想法和行为，并打破仪式化和回避的习惯。

The goals, again, I'm paraphrasing here, are to, as she states, disconfirm fears and challenge the beliefs about the obsessions and compulsions to intervene in the thoughts and the behaviors and to break the habit of ritualizing and avoiding.

那么，这通常是如何进行的呢？

Now, how is this typically done?

这个过程的具体步骤是什么？

What are the nuts and bolts of this procedure?

通常，这需要与患者进行两次规划性会谈。

Typically this is done through two planning sessions with the patient.

向患者说明将要发生什么、何时发生以及持续多久，以免他们毫无准备地被突然投入其中。

So describing to the patient what will happen and when it will happen and how long it will happen so that they're not just thrown into this out of the blue.

然后进行15次暴露治疗，每周两次或更多。

And then 15 exposure sessions done twice a week or more.

因此，关于认知行为疗法，你需要明白的一点是，它可能需要一段时间，几周甚至更久，长达十到十二周。

So the one thing to really understand about cognitive behavioral therapy is that it can take some period of time, several or more weeks, as many as ten or twelve weeks.

然而，正如你很快会了解到的，许多用于治疗强迫症的有效药物疗法，无论是单独使用还是与行为疗法联合使用，也需要八、十、十二周或更长时间，而且许多药物根本无效。

However, as you'll soon learn, many of the drug treatments that are effective in treating OCD either alone or in combination with behavioral therapies also can take eight, ten, twelve weeks or longer, and many of those never work at all.

所以，尽管十到十二周看起来很长，但实际上这已是相当标准的疗程。

So even though ten to twelve weeks seems like a long period of time, it's actually pretty standard.

如果你想了解更多关于认知行为疗法和暴露疗法治疗强迫症的完整方案，我会提供两篇论文的链接：Kozak和Foa（F O A）于1997年发表的论文，虽然这看起来有些久远，但这些方案至今仍非常有用。

If you'd like to see more complete description of the protocols for cognitive behavioral therapy and exposure therapy for OCD, I'll provide links to two papers, Kozak and Foe, F O A, which is published in 1997, which might seem like a long time ago, but nonetheless, the protocols are still very useful.

第二篇论文是由最后一位作者Foa等人于2012年发表的，我们会提供这两篇论文的链接。

And then the second paper is by that last author, Fowe et al in 2012, and we'll provide links to both of those.

此外，医生。

In addition, Doctor.

布莱尔·辛普森及其他研究者通过比较仅使用认知行为疗法、安慰剂（即无干预，或一种耗时相当但被认为无效的干预）以及选择性血清素再摄取抑制剂，探索了治疗强迫症患者的最佳方案。

Blair Simpson and others have explored what are the best treatments for patients with OCD by comparing cognitive behavioral therapy alone, placebo, so essentially no intervention or something that takes an equivalent amount of time, but is not thought to be effective in treatment, as well as selective serotonin reuptake inhibitors.

那么，SSRI是什么？

So what is an SSRI?

SSRI是一种阻止血清素在突触处再摄取的药物。

An SSRI is a drug that prevents the reuptake of serotonin at the synapse.

什么是突触？

What are synapses?

它们是神经元之间的微小间隙，神经元通过向间隙（即突触）释放少量化学物质来进行交流，这些化学物质会激发或抑制下一个神经元的电活动。

They're the little spaces between neurons where neurons communicate with one another by vomiting little bits of chemical into the space, the synapse, and then those chemicals either evoke or suppress the electrical activity of the next neuron across the synapse.

在这种情况下，我们所指的神经递质是血清素，SSRI（选择性血清素再摄取抑制剂）会阻止突触中残留的化学物质（在此为血清素）被再摄取，我用‘释放’这个词是为了强调，但其实并不是呕吐，而是化学物质被排出到突触中，因此突触中会有更多的血清素留存，随着时间推移，整体效果是增强了血清素能传递，使血清素总量增加。

And in this case, the neurotransmitter, the chemical that we're referring to is serotonin, SSRIs, selective serotonin reuptake inhibitors, prevent the reuptake of the chemical that's left, in this case, the serotonin that's left in the synapse after that, I called it vomiting to be dramatic, but it's not actually a vomiting, the extrusion of the chemical into the synapse, and as a consequence, there's more serotonin around to have more of an effect over time, the net effect being more serotonergic transmission, more serotonin overall.

并不是产生更多的血清素，而是让更多的血清素可供使用。

So not more serotonin being made, more serotonin being available for use.

这就是SSRI的作用。

That's what an SSRI does.

因此，他们比较了认知行为疗法、SSRI，还设置了安慰剂组，以及认知行为疗法联合选择性血清素再摄取抑制剂的组别。

So they compared cognitive behavioral therapy, SSRIs, they also had the placebo group and they had cognitive behavioral therapy plus the selective serotonin reuptake inhibitor.

这是一项为期十二周的研究，如前所述，每周进行两次，持续十二周。

This was a twelve week study done as described before, two times a week over the course of twelve weeks.

首先，最重要的是，安慰剂没有任何效果。

First of all, the most important thing, of course, placebo did nothing.

它并没有显著缓解强迫症，对吧？

It did not relieve the OCD to any significant degree, right?

他们是怎么知道的？

How did they know that?

他们使用了我们之前提到的Y量表测试，也就是耶鲁-布朗量表，其中包含了许多问题，我之前读过其中几个。

They gave them the Y box test that we talked about before, the Yale Brown test with all those questions of which I read a few.

因此，Y量表所衡量的强迫症严重程度是一个从8到28的评分指数，这个数字本身没有实际意义。

So the OCD severity that one has to have on the Y box is measured in terms of an index that goes from any here from eight all the way up to 28, that shouldn't mean anything.

所以这里的数字8实际上是没有意义的。

So that number eight is kind of meaningless here.

这个分数只是Y量表特有的评分标准，仅在该量表中有意义。

It's in terms of an index that's only meaningful for the Y box.

但如果某人的阈值达到16或更高，意味着他们仍存在一定程度的致残症状或非常严重的症状。

But if somebody has a threshold of 16 or higher, it means that they're still having somewhat debilitating symptoms or very debilitating symptoms.

安慰剂并未显著减少强迫观念或强迫行为。

Placebo did not reduce the obsessions or compulsions to any significant degree.

然而，令人兴奋的是，认知行为疗法在减少强迫观念和强迫行为方面产生了显著效果，以至于在四周时，原本范围为8到28的评分从25大幅下降至约11。

However, and I think quite excitingly, cognitive behavioral therapy had a dramatic effect in reducing the obsessions and compulsions, such that by four weeks, that score that in this case range from eight to twenty eight dropped all the way from twenty five down to about eleven.

因此，症状严重程度出现了巨大下降。

So it's a huge drop in the severity of the symptoms.

真正有趣的是，当观察SSRIs在治疗强迫症症状中的效果时，它们在四周时开始显著减轻强迫症症状，并在八周时持续改善。

Now, what's really interesting is that when you look at the effects of SSRIs in the treatment of OCD symptoms, they had a significant effect in reducing the symptoms of OCD that showed up first at four weeks and then continued to eight weeks.

事实上，从四周到八周期间，强迫症症状进一步逐步减轻。

In fact, there was a progressive and further reduction in OCD symptoms from the four to eight week period.

这些只是服用SSRI的人群。

Again, these are the people just taking the SSRI.

随后效果趋于平稳，到十二周时，服用SSRI的人群相比安慰剂组仍表现出显著的症状减轻，但他们的症状严重程度仍远高于仅接受认知行为疗法的群体。

And then it sort of flattened out a little bit such that by twelve weeks, there was still a significant reduction in OCD symptoms for people taking SSRIs as compared to placebo, but the severity of their symptoms was still much greater than those receiving cognitive behavioral therapy alone.

所以至少在这项研究中，我应该告诉你们这是哪项研究——这是Faux Leibowitz等人2005年发表在《美国精神病学杂志》上的研究，我们也会提供链接，方便你们自行查阅数据，但至少在这项研究中，认知行为疗法是最有效的，选择性血清素再摄取抑制剂的效果则较差。

So at least in this study, and I should tell you which study it is, this is Faux Leibowitz et al, 2005 in the American Journal of Psychiatry, we'll also provide a link to this so you can peruse the data if you like, but at least in this study, cognitive behavioral therapy was the most effective, selective serotonin reuptake inhibitors less effective.

那么，当把它们结合起来时会发生什么？

So what happens when you combine them?

他们也对此进行了探索。

Well, they explored that as well.

认知行为疗法与SSRIs联合使用，并未进一步降低强迫症症状。

And the combination of cognitive behavioral therapy and the SSRIs together did not lead to any further decrease in OCD symptoms.

这表明认知行为疗法是最有效的治疗方法。

This points to the idea that cognitive behavioral therapy is the most effective treatment.

而且，当我提到认知行为疗法时，我仍然指的是之前详细描述过的认知行为暴露疗法，即每周两次，持续十二周或更长时间。

And again, when I say cognitive behavioral therapy, now I'm still referring to cognitive behavioralexposure therapy done in the way that I detailed before, twice a week for twelve weeks or more.

因此，所有这些数据——至少在这项研究中——都表明认知行为疗法非常有效，且是最有效的。

So all of the data, at least in this study, point to the fact that cognitive behavioral therapy is really effective and the most effective.

它能缓解所有人的强迫症症状吗？

Does it alleviate OCD symptoms for everybody?

不。

No.

这很耗时吗？

Is it very time consuming?

是的，每周两次，每次十五分钟或更长时间，有时在诊所进行，再加上家庭作业，理想情况下还可能有精神科医生或心理学家的家访。

Yes, twice a week for two sessions or more of fifteen minutes, sometimes in the office, plus there's homework, plus there can, in an ideal case, there's also home visits from the psychiatrist or psychologist.

这需要大量的投入，不仅是时间上的投入，还有潜在的经济投入。

That's a lot of investment, a lot of time investment to say nothing of the potential financial investment.

现在，医生。

Now, Doctor.

布莱尔·辛普森博士做过一些精彩的演讲，她不仅描述了这些数据，还强调了一个事实：尽管认知行为疗法在治疗强迫症方面已被证明非常有效，但大多数人仍仅因药物治疗更容易获得而被给予药物治疗。

Blair Simpson has given some beautiful talks where she describes these data and also emphasizes the fact that despite the demonstrated power of cognitive behavioral therapy for the treatment of OCD, most people are given drug treatments simply because of the availability of those drug treatments.

现在，当我提到大多数人时，我想强调我指的是那些确实寻求治疗的人，因为一个非常重要的事实是，大多数强迫症患者实际上并没有寻求循证治疗。

Now, when I say most people, I want to emphasize that I'm referring to most people who actually go seek treatment because a really important thing to realize is that most people with OCD do not actually go seek evidence based treatment.

我想再重复一遍，大多数强迫症患者并未寻求循证治疗，这是一件令人痛心的事。

I want to repeat that, most people with OCD do not seek evidence based treatment, which is a tragic thing.

制作这一期播客的一个动机，是希望鼓励那些认为自己可能存在持续性强迫思维和行为的人寻求治疗，但大多数人由于我们前面提到的各种原因——如羞耻感等——并未这样做。

One of the motivations for doing this podcast episode is to try and encourage people who think they may have persistent obsessions and compulsions to seek treatment, but most people don't for a variety reasons we spelled out earlier, shame, etcetera.

在那些确实寻求治疗的人中，首选的治疗方法通常是开具处方药，最常见的是SSRI类药物，但也不仅限于SSRI，因为接下来我们会谈到，医生也常会联合开具低剂量的神经安定药或抗精神病药，虽然并非总是如此，但这种情况很常见。

Of those that do, the first line of attack is typically a prescription, most often an SSRI, although not always just SSRIs because soon we'll talk about the somewhat common use of also prescribing a low dose of a neuroleptic or an antipsychotic, not always, but often.

因此，这里需要理解的重要一点是，像Simpson医生这样的优秀研究者们明白，尽管根据数据我们可以称某些疗法为最佳或理想方案，但这并不意味着这些疗法在公众中被最广泛地采用。

So the important thing to understand here is that excellent researchers like Doctor.

Simpson医生明白，尽管存在一些基于数据可称为最佳或理想的治疗方法，但这并不一定意味着这些方法在普通人群中被最常使用。

Simpson understand that while there are treatments that we could say are best or are ideal based on the data, that doesn't necessarily mean that's what's being deployed most often in the general public.

因此，Simpson医生指出，

As a consequence, Doctor.

Simpson医生和其他研究者以非常务实的方式探讨了这样一个问题：如果一个人正在接受SSRI治疗，并且体验到了OCD症状的减轻——正如你可能记得的，这种减轻程度超过安慰剂，但不如认知行为疗法那么显著——这是否真的重要？

Simpson and others have explored in a very practical way whether or not it matters if somebody is getting SSRI treatment and is experiencing that reduction in OCD symptoms that as you may recall is more than what they would experience with placebo alone, but not as dramatic a reduction in OCD symptoms as they would get with cognitive behavioral therapy.

正如我之前提到的，他们不仅研究了从一开始就联合使用药物治疗和认知行为疗法的情况，还令人印象深刻地探索了那些已经在服用SSRI的人，若再开始接受认知行为疗法，会发生什么。

And as I mentioned before, there was this exploration of combining drug treatment cognitive behavioral therapy from the outset, but they also quite impressively explored what happens when people who are already taking SSRIs initiate cognitive behavioral therapy.

他们这样做非常了不起，因为这首先承认了：有许多人已经寻求了治疗，并从SSRI中获得了一定程度的缓解，但这种缓解可能并未达到他们本可获得的最大效果。

This is a really wonderful thing that they've done this because in doing that, first of all, they're acknowledging that there are many people out there who have sought treatment and are getting some relief from those SSRIs, but it perhaps is not as much relief as they could get.

他们明确承认，许多人首先接受的是药物治疗。

And they are actively acknowledging that many people are getting these drug treatments first.

事实上，大多数人首先接受的是药物治疗。

In fact, most often people are getting these drug treatments first.

那么，当你加入认知行为疗法时，会发生什么？

So what happens when you add in cognitive behavioral therapy?

好消息是，当为已经服用SSRI的人添加认知行为疗法时，他们的症状会进一步改善。

Well, the good news is when you add cognitive behavioral therapy to someone who's already taking SSRIs, that further improves their symptoms.

这与我之前从同一实验室描述的结果不同——如果从一开始就将认知行为疗法与SSRI结合使用，SSRI并不会带来额外益处。

Now that's different than the results that I described before from the same laboratory, in fact, that if you combine cognitive behavioral therapy with SSRIs from the outset, there's no additional benefit of SSRI.

然而，正如我刚才所说，如果一个人已经服用SSRI并经历了强迫症状的减轻，再加入认知行为疗法，就能进一步减少强迫症状。

However, as I just described, if someone is already taking an SSRI and they're experiencing a reduction in their OCD symptoms, by adding in cognitive behavioral therapy, there's a further reduction in the symptoms of OCD.

因此，这非常重要。

So it's very important.

所以，对于那些已经寻求治疗并正在服用SSRI的人，或者正在考虑治疗并被开具了SSRI处方的人，最理想的情况是将药物治疗与认知行为疗法结合，或者在某些情况下，仅使用认知行为疗法。但这一决定必须在持证医生的密切建议和监督下做出，因为这些毕竟是处方药。

So for those of you that have sought treatment and you're taking a SSRI, or if you're thinking about treatment and you're prescribed an SSRI, the ideal scenario really would be to combine the drug treatment with cognitive behavioral therapy, or in some cases, maybe cognitive behavioral therapy alone, although that's a decision that you really have to make with the close advice and oversight of a licensed physician because of course these are prescription drugs.

无论何时你要添加或停用处方药，或调整剂量，都务必与你的医生充分沟通并遵循其建议。

And anytime you're going to add or remove a prescription drug or change dosage, you really want to do that in close discussion with and on the advice of your physician.

我这样说不是为了保护自己，而是为了保护你，因为这本来就是应该做的正确事情。

I don't just say that to protect me, say that to protect you and because it's just the right thing to do.

所以，认知行为疗法非常有效。

So again, cognitive behavioral therapy is extremely powerful.

药物治疗似乎效果较弱，但如果你已经在服用药物，加入认知行为疗法确实能带来显著帮助。

Drug treatments seem less powerful, though if you're already on a drug treatment, adding cognitive behavioral therapy can really help.

我之前谈到了SSRIs，并简单介绍了它们的工作原理：通过让更多的血清素留在突触间隙，从而增加其作用，而不是被神经元重新吸收。

So I've been talking about SSRIs and I described a little bit about how they work at a kind of superficial level of keeping more serotonin in the synapse so that more serotonin can be in action as opposed to gobbled back up by those neurons.

我应该提一下一些选择性血清素再摄取抑制剂有哪些。

I should just mention what some of the selective serotonin reuptake inhibitors are.

比如氯米帕明，它并非完全选择性，我需要说明的是，这类药物通常属于非选择性类别，可能影响或增强其他神经递质和神经调质系统，如肾上腺素等。

So things like clomipramine, which is not entirely selective, I should say that that one generally falls into a category of less selective, so it can impair or can enhance some of the other neurotransmitter and neuromodulator systems like epinephrine, etcetera.

选择性血清素再摄取抑制剂，至少经典的包括氟西汀（百忧解）、氟伏沙明、帕罗西汀、舍曲林、西酞普兰等等。

The selective serotonin reuptake inhibitors are, at least the classic ones are fluoxetine, Prozac, fluvoxamine, fluvox, paroxetine, sertraline, citalopram, etcetera, etcetera.

大约有六种经典的SSRI类药物。

There are about six classic SSRIs.

其中一些，如西酞普兰，可用于儿童，并有儿童剂量版本。

Some of them like citalopram are used in children and are available in pediatric doses.

像百忧解这样的药物，可能使用也可能不用于儿童。

Some like Prozac may or may not be used in children.

关于哪些SSRI药物等的详细信息，有着非常丰富的文献和讨论。

The details of which SSRIs, etcetera, is a very extensive literature and discussion.

我认为可以安全地说，使用哪种药物、剂量多少，以及是否维持相同剂量，很大程度上取决于个体差异和他们的反应。

I think it's safe to say that which drugs to use and at which dosage and whether or not to continue, excuse me, the same dosage over time depends a lot on the individual variation that people express and the responses that they have.

事实上，我认为所有这些药物——实际上所有药物——都有副作用。

All of these drugs, in fact, I think we can say all drugs have side effects.

关键在于这些副作用对日常生活有多大的负面影响。

The question is how detrimental those side effects are to daily life.

SSRI类药物众所周知会影响食欲。

The SSRIs are well known to have effects on appetite.

在某些情况下，它们会完全抑制食欲。

In some cases, they abolish appetite.

在某些情况下，它们只是稍微减少食欲。

In some cases, they just reduce it a little bit.

在某些情况下，它们会增加食欲，这确实因人而异。

In some cases, they increase appetite, really is highly individual.

它们可能影响性欲。

They can have effects on libido.

例如，它们会降低性欲，有时与剂量相关，有时则像一种阶梯式变化：人们在5或10毫克时还好，但达到15毫克时，性欲就会急剧下降。

For instance, they can reduce sex drive, sometimes in a dose dependent way, sometimes in a way that's more like a step function where people are fine at say five or ten milligrams, but then they get to fifteen milligrams and there's a cliff for their libido.

这种情况确实可能发生，具体因人而异。

That can happen, it really depends.

请不要把这些剂量当作精确数值，因为这取决于药物的用途——是治疗抑郁、焦虑还是强迫症，同时也取决于具体的药物种类等。

Please don't take those dosages as exact values because this is going to depend on what they're being used for, depression or anxiety or OCD, and it's also going to depend on the drug, etcetera.

我只是举这些数字为例，来说明什么是阶梯式变化。

I just threw out those numbers as a way to illustrate what a kind of a step function would look like.

这不是渐进的，而是指在某一特定剂量下会立即发生。

It's not gradual, it's immediate at a given dose is what that means.

另一点是，这些药物中的一些会产生暂时性影响，也就是说副作用会出现然后消失；或者遗憾的是，有些人服用这些药物一段时间后，原本不存在的副作用会后来才出现，这取决于生活因素、营养状况等，总体而言情况非常复杂。

The other thing is that some of these drugs will have transient effects, so side effects that show up and then disappear, or sadly, people will sometimes take these drugs for a while and then side effects will surface later that weren't there previously, depending on life factors, nutrition factors, so it's a very complicated landscape overall.

因此，无论选择哪种药物治疗，比如SSRI或其他药物，都必须与真正了解药代动力学、并拥有丰富患者病史和用药经验的精神科医生保持密切沟通。

And that's why it's really important to explore any kind of drug treatment, SSRI or otherwise, really in close communication with a psychiatrist who really understands the pharmacokinetics and has a lot of patient history and experience with them.

接下来我要告诉你们的内容，肯定会让你们大吃一惊：尽管选择性血清素再摄取抑制剂在减轻强迫症症状方面确实有效——至少在一定程度上有效，而且明显优于安慰剂——但关于强迫症患者血清素系统是否存在紊乱，却几乎没有或根本没有证据。

So what I'm about to tell you next is most certainly going to come as a big surprise, which is that despite the fact that the selective serotonin reuptake inhibitors can be effective in reducing the symptoms of OCD, at least somewhat, and certainly more than placebo, there is very little, if any evidence that the serotonin system is disrupted in OCD.

我必须指出，这在精神病学领域是一个相当一致的现象。

And I have to point out that this is a somewhat consistent theme in the field of psychiatry.

也就是说，某种药物可能非常有效，或至少部分有效，能减轻症状或改变精神障碍的整体状况，但关于该系统是否是导致强迫症、焦虑或抑郁等疾病的直接原因，却几乎没有或根本没有证据。

That is a given drug can be very effective or even partially effective in reducing symptoms or in changing the overall landscape of a psychiatric disorder or illness, and yet there is very little, if any evidence that that particular system is what's causal for OCD or anxiety or depression, etcetera.

这就是我们当前在理解大脑、精神病学以及治疗脑部疾病方面所处的现实环境。

This is just the landscape that we're living in, in terms of our understanding of the brain and psychiatry and the ways of treating brain disorders.

因此，结果就是，临床医生和科研人员已经撰写了大量学术综述，并不断阅读和分享这些文献。

So as a consequence, there are a huge number of academic reviews that clinicians and research scientists have generated and read and share.

近年来较为全面的一篇综述发表于2021年。

One of the more, I think, thorough ones in recent years was published in 2021.

我会提供这篇文献的链接。

I'll provide a link to this.

这篇综述出自耶鲁大学医学院一位杰出的、真正卓越的研究者之手。

This is by an excellent, truly excellent researcher from Yale University School of Medicine.

我应该说，他不仅是一位研究者，更是一位临床科学家，拥有医学博士和哲学博士学位。

I should say not just a researcher, but a clinician scientist, again, an MD PhD.

这位研究者是克里斯托弗·皮滕格，这篇综述的标题是《强迫症的药物治疗策略与新靶点》。

This is Christopher Pittenger, and the title of the review is Pharmacotherapeutic Strategies and New Targets in OCD.

我们同样会提供这篇文献的链接。

And again, we'll provide a link to it.

这篇综述精彩地阐述了，正如我刚才所说，血清素系统在强迫症中并未真正紊乱，但SSRI类药物却可能非常有效。

This is a just gorgeous review describing, as I just told you, that the serotonin system isn't really disrupted in OCD and yet SSRIs can be very effective.

这篇综述进一步探讨了，如果血清素确实是引发强迫症症状的元凶，那么究竟是哪些血清素受体可能参与其中。

The review goes on to explore even what sorts of receptors for serotonin might be involved if it's in fact the case that serotonin is a culprit in the creation of OCD symptoms.

谈谈血清素2A受体和血清素1A受体。

Talk about the serotonin 2A receptor and the serotonin 1A receptor.

如果血清素是否参与尚不明确，我为什么提到这么多细节？

Why am I mentioning all that detail if in fact it's not clear serotonin is involved?

因为我要直接告诉你，目前人们对某些致幻剂，特别是裸盖菇素，在治疗强迫症方面的效果非常感兴趣。

Because I'll just tell you right now, there is currently a lot of interest in whether or not some of the psychedelics, in particular psilocybin, can be effective in the treatment of OCD.

裸盖菇素已在多项临床试验中显示出效果，特别是约翰霍普金斯大学医学院马修·约翰逊等人开展的试验。

Psilocybin has been shown in various clinical trials, in particular the clinical trials done at Johns Hopkins School of Medicine by Matthew Johnson and others.

马修曾做客休伯曼实验室播客，也上过蒂姆·费里斯播客和莱克·弗里德曼播客，他是研究致幻剂治疗抑郁症及其他精神健康问题的世界级专家。

Matthew was on the Huberman Lab Podcast, he's been on the Tim Ferriss Podcast, he's been on the Lex Friedman Podcast, he's a world class researcher on the use of psychedelics for depression and other psychiatric challenges.

在这些试验中，裸盖菇素治疗被证明对某些类型的重度抑郁症非常有效。

And there, psilocybin treatment has been seen, at least in those trials, to be very effective in the treatment of certain kinds of major depression.

目前，关于裸盖菇素治疗强迫症的研究尚未得出类似的结果，尽管相关研究仍在进行中。

Currently, the exploration of psilocybin for the treatment of OCD has not yielded similar results, although the studies are ongoing.

同样，尚未显示出类似的疗效，但研究仍在继续。

Again, has not yielded similar effectiveness, but the studies are ongoing.

血清素2A受体和血清素1A受体是裸盖菇素的主要作用靶点。

And the serotonin 2A receptor and the serotonin 1A receptors are primary targets for the drug psilocybin.

所以我猜你们可能会问，致幻剂是否对强迫症有帮助。

So I figured there were going be some questions about whether or not psychedelics help with OCD.

到目前为止，结果还不明确。

Thus far, it's inconclusive.

如果你们中有谁参与过临床试验，或者对裸盖菇素或其他致幻剂与强迫症之间的这种（或潜在）关系有任何了解或直觉，请在评论区分享，我们非常期待听到你们的看法。

If any of you have been part of clinical trials or have knowledge or intuition about this relationship or potential relationship, I should say, between psilocybin or other psychedelics and OCD, please put them in the comment section, we'd love to hear from you.

我应该指出的是，尽管血清素并未被直接证实与强迫症有关，但血清素及其在大脑中传递血清素并依赖它的神经回路，已被证明会影响认知灵活性和僵化性，而这两者正是强迫症的典型特征。

One thing I should point out is that even though serotonin has not been directly implicated in OCD, serotonin and the general systems of serotonin, the circuits in the brain that carry serotonin and depend on it, have been shown to impact cognitive flexibility and inflexibility, which are kind of hallmark themes of OCD.

因此，在血清素被耗竭的动物身上，或在血清素水平极低的人类身上，可以观察到认知僵化的迹象，比如任务切换困难、改变游戏规则的困难，以及任何认知领域切换的障碍。

So in animals that have their serotonin depleted or in humans that have very low levels of serotonin, you can see evidence of cognitive inflexibility, challenges in task switching, challenges in switching the rules by which one performs a game, challenges in any kind of cognitive domain switching.

因此，这间接表明血清素与强迫症的某些方面有关。

And so that does indirectly implicate serotonin in some of the aspects of OCD.

再次强调，当人们开始探索在动物模型和人类中研究过的不同神经递质系统时，会发现这是一个极其广阔的领域，但尽管再次强调，没有直接证据表明血清素系统是强迫症的病因，血清素类药物仍然是治疗强迫症最有效的药物。

Again, when one starts to explore the different transmitter systems that have been explored in animal models and in humans, it's a vast, vast landscape, but serotonergic drugs do seem to be the most effective drugs in treating OCD despite the fact, again, despite the fact that there's no direct evidence that serotonin systems are the problem in OCD.

如果你还记得皮质-纹状体-丘脑回路，它在强迫症的病因、症状表现和模式中起着核心作用。

If you recall the corticostriatal thalamic loop that is so central to the etiology, the presence and the patterns of symptoms in OCD.

当然，血清素正在影响这个系统。

Of course, serotonin is impacting that system.

血清素影响着大脑中的几乎所有系统，但目前没有证据表明，专门调节该网络中的血清素水平是导致强迫症症状改善的原因。

Serotonin is impacting just about every system in the brain, but there's no evidence that tinkering with serotonin levels specifically in that network is what's leading to the improvements in OCD.

然而，如果让患有强迫症的人进入fMRI扫描仪，并诱发他们的强迫观念和强迫行为，你会看到皮质-纹状体-丘脑回路的活动；而像SSRIs这样的治疗方法，通过减轻强迫症症状，也对应着该回路活动的减弱。

However, if people go into a fMRI scanner and those people have OCD and they evoke the obsessions and compulsions, you see activity in that corticostriatal thalamic loop, treatments like SSRIs that reduce the symptoms of OCD equate to a situation where there is less activity in that loop.

我还应该指出，认知行为疗法，我们没有理由认为它仅仅作用于血清素系统。

And I should point out cognitive behavioral therapy, which we have no reason to believe only taps into the serotonin system.

说认知行为疗法只作用于血清素系统，那是极其牵强的，实际上这种说法是错误的。

Think it would be, an extreme stretch, it would be false actually to say that cognitive behavioral therapy taps only into the serotonin system.

显然，它会影响大量神经回路和神经化学系统。

Clearly, it's going to affect a huge number of circuits and neurochemical systems.

那些接受认知行为疗法并获得强迫症缓解的人，同样也表现出皮质-纹状体-丘脑回路活动的降低。

Well, people who do cognitive behavioral therapy and find some relief for OCD, they also show reductions in those corticostriatal thalamic loops.

所以，我们面临的情况是，行为疗法对许多人有效，但并非所有人，而且我们对它为何有效有相当好的理解。

So basically we have a situation where we have a behavioral therapy that works in many people, not all, and we have a pretty good understanding about why it works.

它提高了对焦虑的耐受性，并干扰了模式的执行，帮助人们不再从事那些对他们有害的相同行为。

It increases anxiety tolerance and interference with pattern execution, getting people to not engage in the same sorts of behaviors that are detrimental to them.

我们还有药物治疗，至少在一定程度上有效，但我们不知道它们是如何起作用的，也不清楚它们在大脑中的作用位置。

And we have drug treatments that work at least to some degree, but we don't know how they work or where they work in the brain.

行为治疗和药物治疗真正共同的一点是，它们都需要一定的时间才能见效。

One of the things that really unifies the behavioral treatments and the drug treatments is that they take some period of time.

症状的缓解似乎在四周左右开始出现，到八周时对认知行为疗法和SSRIs都明显可见，但真正显著的强迫症状减轻通常要到十到十二周时才显现——此时患者已经坚持每周两次的认知行为治疗，并且连续服用了十到十二周的SSRI。

Some relief from symptoms seems to show up around four weeks and certainly by eight weeks for both cognitive behavioral therapy and the SSRIs, but it's really at the ten to twelve week stage when someone's been doing these twice a week cognitive behavioral sessions when they've been taking a SSRI for ten to twelve weeks, that the really significant reduction in OCD symptoms starts to really show up.

到目前为止，我一直谈论的是人们从这些治疗中获得的缓解，但遗憾的是，在强迫症的情况下，有一部分人群对CBT、SSRIs或它们的联合治疗完全无效，这就是为什么精神科医生还会尝试将SSRIs与抗精神病药，或作用于所谓多巴胺系统或谷氨酸系统的药物联合使用。

Now, up until now, I've been talking about the fact that people are getting relief from these treatments, but sadly, in the case of OCD, there is a significant population that simply does not respond to CBT or to SSRIs or to their combination, which is why psychiatrists also explore the combination of SSRIs and neuroleptics or drugs that tap into the so called dopamine system or the glutamate system.

这些是影响大脑不同回路的其他神经递质和神经调质。

These are other neurotransmitters and neuromodulators that impact different circuits in the brain.

为了帮助你们更好地理解这一切，我再强调一下神经递质和神经调质的作用，这一点非常重要。

And just to really remind you what neurotransmitters and neuromodulators do, because this is important to contextualize all this.

神经递质通常参与神经元之间的快速通信。

Neurotransmitters are typically involved in the rapid communication between neurons.

其中最常见的两种神经递质是谷氨酸，我们称之为兴奋性递质，即当它释放到突触时，会使下一个神经元更活跃或激活；以及GABA，这是一种抑制性神经递质，通常（并非总是）当它释放到突触时，会促使下一个神经元电活动减弱，甚至使其沉默。

And the two most common neurotransmitters for that are the neurotransmitter glutamate, which we say is excitatory, meaning when it's released into the synapse, it causes the next neuron to be more active or active, and GABA, which is a neurotransmitter that is inhibitory, meaning when it's released into the synapse, typically, not always, but typically that GABA is going to encourage the next neuron to be less electrically active or even silence its activity.

相比之下，神经调质，如多巴胺、血清素、肾上腺素、乙酰胆碱等，并非神经递质，它们的作用方式略有不同。

The neuromodulators by contrast, so not neurotransmitters, but neuromodulators like dopamine, serotonin, epinephrine, and acetylcholine and others operate a little bit differently.

它们的作用范围通常更广泛。

They intend to act a little bit more broadly.

它们可以在突触内发挥作用，但也能够改变大脑的整体活动模式，使某些神经回路更可能活跃，而其他回路则更不可能活跃。

They can act within the synapse, but they can also change the general patterns of activity in the brain, making certain circuits more likely to be active and other circuits less likely to be active.

因此，当我们说多巴胺做X或做Y，或血清素做X或做Y时，它们其实并不只做某一件事。

So when we say dopamine does X or dopamine does Y or serotonin does X or serotonin does Y, they don't really do one thing.

它们改变的是整体的基调。

They change the sort of overall tonality.

它们使某些神经回路更可能或更不可能被激活。

They make it more likely or less likely that certain circuits will be active.

你可以把它们想象成激活大脑中某种活动的播放列表或类型，而不是参与特定的通信或在这个类比中的特定歌曲，或者说特定神经元之间的具体对话。

You can think of them as kind of activating playlists or genres of activity in the brain rather than being involved in the specific communication or specific songs, if you will, in this analogy, or discussions between particular neurons.

所以当我们听说SSRIs增加血清素并减轻强迫症症状，或抗精神病药减少多巴胺使人们感觉更平静，例如，或能消除某些刻板重复的运动行为——它们既可以引发也可以减少运动行为——事实正是如此。

So when we hear that SSRIs increase serotonin and reduce the symptoms of OCD or a neuroleptic reduces the amount of dopamine and makes people feel calmer, for instance, or can remove some stereotyped repetitive motor behavior, which they can either generate or reduce motor behavior, it turns out.

因此，当我这么说时，我指的是这些神经调质在某种程度上是调高某些神经回路的音量，同时调低其他回路的音量。

So when I say that, what I'm referring to is the fact that these neuromodulators are kind of turning up the volume on certain circuits and turning down the volume on other circuits.

我这样说是因为，如果你要探索药物治疗——再次强调，必须由持证医生指导——如果你正在尝试治疗强迫症，特别是当你服用SSRIs或认知行为疗法没有效果，或者你正在服用的药物副作用让你难以承受，那么理解这一点就很重要：每当你服用这类药物时，它们并不是专门作用于皮质-纹状体-丘脑回路。

I say that because if you are going to explore drug treatments, again, a licensed physician, if you're going to explore drug treatments for OCD, and in particular, if you are not getting results from SSRIs or you're not getting results from cognitive behavioral therapy or the side effect profiles of the drugs that you're taking for OCD are causing problems that you don't want to take them, well, then it's important to understand that anytime you take one of these drugs, they're not acting specifically on the corticostriatal thalamic circuit.

那将会很棒。

That would be wonderful.

那是精神医学的未来。

That's the future of psychiatry.

但目前，当你服用药物时，它是全身性起作用的，因此它会影响你肠道中的血清素，也会影响大脑其他区域的血清素，从而对消化、性欲或血清素参与的其他多种功能产生影响。

But as now, when you take a drug, it acts systemically, so it's impacting serotonin in your gut, it's also impacting serotonin in other areas of the brain, hence the effects on things like digestion or libido or any number of different things that serotonin is involved in.

同样，如果你服用像氟哌啶醇这样的抗精神病药，或任何减少多巴胺传递的药物，那么它会产生一些运动方面的效应，因为多巴胺参与了运动序列的生成和肢体的流畅运动。

Likewise, if you take a neuroleptic like haloperidol or something that reduces dopamine transmission, well, then it's going to have some motor effects because dopamine is involved in the generation of motor sequences and smooth limb movement.

这就是为什么帕金森患者由于多巴胺不足会出现静止性震颤，难以产生流畅的运动。

That's why people with Parkinson's who don't have much dopamine will get a resting tremor, have a hard time generating smooth movement.

因此，考虑到这些神经调质参与了如此多不同的神经回路，它们的副作用也就说得通了。

And so the side effects start to make sense given the huge number of different neural circuits that these different neuromodulators are involved in.

我说这些并不是为了让人气馁，而是为了鼓励患者和医生系统性地探索针对强迫症的不同药物治疗方案，而且一定要在精神科医生的谨慎密切指导和监督下进行，因为精神科医生真正了解哪些副作用特征会决定你是否能、是否能长期、或是否永远无法服用某种药物及其剂量，他们才真正掌握这些知识。

I don't say that to be discouraging, I say that to encourage patients and careful systematic exploration of different drug treatments for OCD, always again, with the careful and close guidance and oversight of a psychiatrist, because psychiatrists really understand which side effect profiles make it likely that you can or cannot or will never, or maybe someday will be able to take a given drug at a given dose, they are the ones that really have that knowledge.

这种事你绝不能自己瞎折腾、擅自尝试。

This is not the sort of thing that you want to cowboy and go try and figure out yourself.

现在，我也想指出，还有其他类型的药物治疗方法。

Now, I also want to acknowledge that there are other forms of drug treatments.

我们曾简要提到过裸盖菇素，但还有其他一些被探索用于治疗强迫症的药物疗法。

We touched on psilocybin briefly, but there are other forms of drug treatments that have been explored for OCD.

之前，我们稍微谈到了大麻。

Earlier, we talked a little bit about cannabis.

为什么大麻会成为一个值得探索的方向呢？

Why would cannabis be a place of exploration at all?

首先，有许多人尝试自行用药来治疗强迫症。

Well, first of all, a number of people try and self medicate for OCD.

有一些临床证据——我不是在谈论娱乐性使用，而是在谈临床证据——表明大麻可以减轻焦虑。

There is some clinical evidence, I'm not talking about recreational use, I'm talking about clinical evidence that cannabis can reduce anxiety.

之前我们讨论过，不是要减少焦虑，而是要学习耐受焦虑，以便在认知行为疗法的框架下应对和治疗强迫症。

Now, earlier we were talking about not reducing anxiety, but learning anxiety tolerance in order to deal with and treat OCD in the context of cognitive behavioral therapies.

疗法。

Therapies.

这并不排除大麻作为强迫症治疗候选药物的可能性，事实上，这一点已经被探索过。

That doesn't necessarily rule out cannabis as a candidate for the treatment of OCD, and in fact, this has been explored.

一项来自布莱尔·辛普森博士的研究。

A study from Doctor.

辛普森博士本人对此进行了研究。

Blair Simpson herself looked at this.

这是一项规模较小的研究，因此首先，我会再念一遍标题，我们会提供链接。

This was a fairly small scale study, so first of all, I'll give you the title again, we'll provide a link.

这项研究题为《大麻素对强迫症症状的急性影响：一项人体实验室研究》。

This is entitled Acute Effects of Cannabinoids on Symptoms of Obsessive Compulsive Disorder, a Human Laboratory Study.

简要来说，这项研究涉及14名强迫症患者。

Very briefly, this was 14 adults with OCD.

他们此前都有使用大麻的经验。

They had prior experience with cannabis.

这项研究采用随机、安慰剂对照设计。

This was randomized, placebo controlled.

大麻是通过吸烟方式摄入的。

The cannabis was smoked.

他们使用了不同的品种，也就是所谓的品系。

They had different varietals as they're called.

他们设置了安慰剂组，也就是说，一部分受试者吸食不含THC的香烟，另一些人吸食含7% TH的香烟，还有一些组则吸食含有0.4% CBD和THC的香烟，因此他们研究了CBD的作用。

They had a placebo, so this is basically a condition in which certain subjects consumed a cigarette that had 0% THC, others had 7% THC, other groups that is, or some had 0.4% CBD and THC, so they looked at CBD.

我知道很多人对CBD很感兴趣，这是我能找到的为数不多的几项研究之一，它们探讨了这些大麻或大麻香烟中不同比例的THC和CBD。

I know a lot of people out there are interested in CBD, It's one of the few studies I could find where they explore different percentages of THC and CBD in these cannabis or marijuana cigarettes basically.

他们摄入的总量，我认为是800毫克。

The total amount that they consumed, I believe was 800.

这些都不是建议。

These again are not suggestions.

这仅仅是报告这项研究中的内容。

This is just simply reporting what's in this study.

我会提供一个链接。

Again, I'll provide a link.

他们评估了强迫症症状的评分。

They looked at OCD symptoms ratings.

他们研究了心血管效应。

They looked at cardiovascular effects.

他们探索了大量不同的指标。

They had a large number of different things that they explored.

我应该说明，这项研究是在2020年进行的，是首个针对患有强迫症的成年人的安慰剂对照大麻研究。

And I should say this study was done in 2020 and it was the first placebo controlled investigation of cannabis in adults with obsessive compulsive disorder.

挺有意思的。

Pretty interesting.

我只是在引用他们的结论。

And I'm just reading from their conclusions here.

数据显示，无论是主要含THC还是CBD的吸食大麻（请注意，他们研究了不同浓度），对强迫症症状的急性影响很小，且相比安慰剂，焦虑缓解程度更小。

The data suggests that smoked cannabis, whether containing primarily THC or CBD, remember they looked at different concentrations of those, has little acute impact, meaning immediate impact on OCD symptoms and yield smaller reductions in anxiety compared to placebo.

所以，他们并没有观察到大麻或CBD对强迫症症状有积极的改善作用——我的意思是，没有减轻症状的效果。你知道，任何治疗方法无效都令人遗憾，但数据就是如此。

So they did not see a, when I say a positive effect, I mean a ameliorative effect, an effect in reducing symptoms of OCD from cannabis or CBD, which, you know, it's unfortunate, I think it's unfortunate anytime a treatment doesn't work, but nonetheless, those are the data.

我相信还会有一些其他研究。

I'm sure there are going to be other studies.

我肯定也会有人在YouTube评论区说大麻和CBD对他们的强迫症症状有帮助。

I'm sure there are also going to be people in the YouTube comments section saying that cannabis and CBD helps their OCD symptoms.

至少我预计会有人这么说。

At least I anticipate they're probably will.

我在这里说的几乎每一件事，都会有人根据自己的经验提出反驳，不过，我其实很鼓励这种做法。

Almost everything I say here, somebody will contradict it with something from their experience, which I encourage, by the way.

我想听听你们对某些事情的体验，即使这些不是来自随机对照试验，了解人们在做什么、有什么感受依然非常有趣。

I want to hear about your experience with certain things, even if it's not from randomized placebo controlled studies, still find it very interesting to know what people are doing and what they're experiencing.

我认为社交媒体评论区一个更好的用途就是分享这些信息，不是以提供建议或指导的方式，而是作为一种分享和鼓励不同探索方式的途径。

I think that's one of the better uses of social media comment sections is to be able to share some of that, not in an advice giving way or prescriptive way, but simply as a way to share and encourage different types of exploration.

还有一些其他类型的药物治疗正在研究领域中逐渐流行起来，用于治疗强迫症。

There are other sorts of drug treatments that are gaining popularity for OCD, at least in the research realm.

有一种治疗方法是合法的，L E G A L，对吧？

One treatment that is a legal, L E G A L, right?

有时候我说‘合法’，有些人会误以为我说的是‘非法’，但这种治疗在美国至少是可以通过处方合法使用的，那就是氯胺酮。

Sometimes when I say legal, sometimes people think I say illegal, but that is legal, at least by prescription in The United States, is ketamine.

氯胺酮的作用机制相当复杂。

The actions of ketamine are somewhat complex.

虽然我们知道氯胺酮作用于谷氨酸系统，它通常会干扰谷氨酸（不是谷氨酰胺，不是氨基酸，而是神经递质谷氨酸）与所谓的NMDA受体（N-甲基-D-天冬氨酸受体）之间的关系，这种受体在神经系统中非常特殊，因为当谷氨酸与NMDA受体结合时，往往会促进该突触的强化，也就是所谓的神经可塑性。

Although we know for instance that ketamine acts on the glutamate system, it tends to disrupt the transmission or the relationship I should say between glutamate, right, not glutamine, not the amino acid, but glutamate, the neurotransmitter and the so called NMDA, the N methyl D aspartate receptor, which is a receptor that's very special in the nervous system because when glutamate binds to the NMDA receptor, it tends to offer the opportunity for that particular synapse to get stronger, so called neuroplasticity.

而氯胺酮本质上是一种拮抗剂，尽管它的作用机制很复杂，但它通常会阻断谷氨酸与NMDA受体的结合，或削弱这种结合的效果。

And ketamine is essentially an antagonist, although it works through a complicated mechanism, it tends to block that binding of glutamate to the NMDA receptor or the effectiveness of that.

氯胺酮疗法现在被广泛用于治疗创伤和抑郁症，它会引发一种解离状态。

Ketamine therapy is now being used quite extensively for the treatment of trauma and for depression, it leads to a dissociative state.

它是一种所谓的解离性镇痛剂。

It's a so called dissociative analgesic.

这种状态的发生有多种方式。

And there are a variety of ways in which that happens.

我们之前做过一期关于抑郁症的节目。

We did an episode on depression.

我们即将推出一期完全关于氯胺酮的节目，详细讲解氯胺酮影响的神经网络等。

We're going to do another entire episode all about ketamine, describing the networks that ketamine impacts, etcetera.

氯胺酮疗法正在被探索用于治疗强迫症。

Ketamine therapies are being explored for OCD.

截至目前，数据看起来有些前景，但仍需进行大量进一步研究。

As of now, the data look somewhat promising, but there's still a lot more work that needs to be done.

根据我对现有数据的解读，更大规模的临床试验尚未开展。

My read of the data are that the more extensive clinical trials have not happened yet.

已进行的小规模研究显示，一些患者在接受氯胺酮治疗后确实获得了一定程度的缓解，但并没有强有力的证据表明氯胺酮是治疗强迫症的灵丹妙药。

The smaller studies that have happened reveal that some patients do get some relief from ketamine therapy for OCD, but there was nothing overwhelmingly pointing to the fact that ketamine is a magic bullet for OCD treatment.

因此，目前大麻中的CBD，即使只有一项小型研究，也缺乏确凿证据证明它能缓解强迫症症状。

So cannabis CBD, at least now, even though it's one smaller study, there's no real evidence that it can alleviate OCD symptoms.

如果近期有新的研究发表，我一定会及时更新你。

If there are new studies published soon, I'll be sure to update you.

如果你看到了这些研究，请发给我。

And if you see those studies, please send them to me.

氯胺酮治疗，目前尚无定论。

Ketamine therapy, the jury is still out.

裸盖菇素治疗，目前尚无定论。

Psilocybin, the jury is still out.

这还处于早期阶段。

These are early days.

另一种日益普遍、且备受人们关注的治疗方法是经颅磁刺激。

Another treatment that's becoming somewhat common or at least people are commonly excited about is transcranial magnetic stimulation.

所以这是使用磁线圈。

So this is the use of a magnetic coil.

这是一种完全无创的技术，将线圈放置在头骨的某一区域，可以将磁能导向大脑的特定区域，以抑制或如今也可以激活特定脑区。

This is completely non invasive placed on one portion of the skull and one can direct magnetic energy toward particular areas of the brain to either suppress or nowadays you can also activate particular brain regions.

有一些有趣的数据表明，如果将TMS应用于与运动行为生成相关的脑区，即所谓的运动区或辅助运动区，当人们产生侵入性思维时，TMS线圈可以中断运动行为和强迫行为；在少数研究和少量患者中，这种干预已被证明有效——不仅在磁线圈作用期间有效，而且在治疗结束后，也能通过打断强迫行为的自动化倾向来减轻强迫症症状。

There are some interesting data showing that if TMS is applied to areas of the brain involved in the generation of motor action, so the so called motor areas or supplementary motor areas as they're called, while people think about or have intrusive thoughts, We know that the TMS coil can interrupt the motor behaviors, the compulsive behaviors, and at least in a small cohort of studies, in a small number of patients within those studies, this has been shown to be effective, not just while the coil is on the head, of course, but after the study has been performed or the treatment's been performed in reducing OCD symptoms by disrupting the tendency for the compulsive behavior to be so automatic.

强迫症的一个关键特征是，尤其是当病程较长、患者长期应对时，并不存在一种清晰的模式，即患者先想：‘我有污染恐惧’或‘我需要对称’或‘我强迫自己数到七’，然后停下来想：‘哦，我该停了’，再继续做。

One of the key features of obsessive compulsive disorder is that, especially if it's been around for a while, the person's been dealing with it for a while, there isn't a pattern in which the person thinks, oh, I have this contamination fear or I need symmetry or I'm kind of obsessed to count to the number seven, and then they pause and they go, oh, and then they do it.

不，通常强迫观念和强迫行为在时间上紧密相连，比如有人走在街上，心里默念：一、三、四、五，试图压抑焦虑，但焦虑立刻又以更强的势头反弹，正如我前面所描述的。

No, typically there's a very close pairing of the obsession and the compulsion in time so that somebody's walking down the street thinking one, three, four, five, try and suppress that anxiety, and then it comes right back up again at even stronger as I described earlier.

因此，经颅磁刺激似乎能干预这些非常快速的过程。

So transcranial magnetic stimulation seems to intervene in these very fast processes.

目前，我认为说TMS是万能药并不公平。

Right now, I don't think it's fair to say that TMS is a magic bullet either.

我对TMS充满期待，尤其是我想特别强调一点：人们对TMS与药物治疗结合、或TMS与认知行为疗法结合的前景尤为兴奋。

I think there's a lot of excitement about TMS and in particular, I really want to nail this point home, in particular, there's excitement about the combination of TMS with drug treatments or the combination of TMS with cognitive behavioral therapy.

这是一个非常重要的观点，不仅对于讨论强迫症有意义，对于抑郁症、注意力缺陷多动障碍、精神分裂症以及许多其他精神健康问题也是如此。在大多数情况下，这些疾病在接受持续的行为治疗时效果最佳，这种治疗既包括在实验室和临床环境中的干预，也包括在家庭环境中进行的作业，甚至家访。

And this is a really important point, not just for sake of discussion about obsessive compulsive disorder, but also depression, ADHD, schizophrenia, any number of different psychiatric challenges and disorders, in most cases are going to respond best to a combination of behavioral treatment that's ongoing that occurs in the laboratory and clinical setting, but also in the home setting where there's homework, maybe even home visits.

药物治疗通常——虽然并非总是——能很好地增强认知行为疗法或其他行为疗法的效果。

Drug treatments often, not always, are a terrific augment to those cognitive behavioral therapies or other behavioral therapies.

而我们现在正生活在脑机接口的时代。

And then now we are living in the age of brain machine interface.

像Neuralink这样的公司，我认为可以合理地说，它们将首先通过治疗某些综合征进入脑机接口领域，对吧？

You have companies like Neuralink that I think it's fair to say are going to enter the brain machine interface world first through the treatment of certain syndromes, right?

它们可能会先针对运动综合征或精神综合征，而不是一开始就将电极植入大脑以增强记忆或认知能力。

Movement syndromes or psychiatric syndromes, probably before they start putting electrodes into the brain to stimulate enhanced memory or enhanced cognition.

谁知道呢？

Who knows?

我不清楚Neuralink墙后具体在做什么，但我必须想象，事实上我敢打赌——哪怕不赌双臂，我也敢押上我的左臂——Neuralink这类公司最早获得FDA批准的技术，将是用于治疗帕金森病、运动障碍和认知障碍的方案，而不是所谓的娱乐性认知增强之类的东西。

I don't know exactly what they're doing behind the walls of Neuralink, but I have to imagine, in fact, I would wager, maybe not both arms, but I'll wager my left arm that the first set of FDA approved technologies to come out of companies like Neuralink are going to be those for the treatment of things like Parkinson's and movement disorders and cognitive disorders rather than, shall we say kind of recreational cognitive enhancement or things of that sort.

因此，经颅磁刺激是非侵入性的，不需要穿透颅骨，也能产生一定效果。但据我所知，斯坦福大学及其他机构的大多数实验室在探索TMS治疗强迫症和其他精神疾病时，都是将TMS与药物疗法结合使用。例如，斯坦福大学的一个实验室——希望未来能邀请他们上节目——精神科医生诺兰·威廉姆斯正在研究TMS与致幻疗法的结合，虽然不一定同时进行，但仍在探索它们如何共同影响大脑回路。

So transcranial magnetic stimulation is non invasive, it doesn't involve going down below the skull, can have some effect, but most laboratories that I'm aware of at Stanford and elsewhere that are exploring TMS for things like OCD and other types of psychiatric challenges are using TMS in combination with drug therapies, using, in some cases, for instance, a laboratory at Stanford, hope to get them on the podcast, a psychiatrist, Nolan Williams, is exploring TMS in combination with psychedelic therapies, not necessarily at the same time, but nonetheless combining them or exploring how they impact brain circuitry.

所以，如果你患有强迫症，你应该马上去接受经颅磁刺激治疗，还是尝试氯胺酮疗法？

So if you have OCD, should you run out and get TMS or should you try ketamine therapy?

当然，必须在持证医生的指导下进行，我认为现在还太早下结论说可以。

Of course, with a licensed physician, I think it's too early to say yes.

我认为答案是我们需要耐心等待并观察。

I think the answer is we need to wait and see.

我认为，认知行为疗法、SSRI类药物，以及像神经阻滞剂这类与SSRI联合使用的药物，才是目前数据最充分的治疗方式。

I think cognitive behavioral therapy, the SSRIs and some other drug treatments like neuroleptics combined with SSRIs and cognitive behavioral therapy are where the real bulk of the data are.

我想再补充一点关于大麻CBD与强迫症的关系。

I want to make one additional point about cannabis CBD as it relates to obsessive compulsive disorder.

对我来说，大麻CBD未能改善强迫症症状一点也不令人意外，因为在我几周前与孔特医生的讨论中。

To me, it's not at all surprising that cannabis CBD did not improve symptoms of OCD because in my discussion with Doctor.

我应该提一下，孔特医生确实是一位医学博士、精神科医生，我们当时在讨论大麻及其各种用途，因为它确实具有一些临床应用。

Paul Conte a few weeks ago, and I should mention Doctor.

孔特医生确实是一位医学博士、精神科医生，我们当时在讨论大麻及其各种用途，因为它确实具有一些临床应用。

Conte is indeed a medical doctor, a psychiatrist, We were talking about cannabis and its various uses because it does have some clinical applications.

他提到，大麻的主要作用之一是增强专注力，让人更加集中于某一特定事物的想法。

And he mentioned that one of the main effects of cannabis is to tighten focus and to enhance concentration on and thoughts about one particular thing.

在某些情况下，这可能具有临床益处，而在其他情况下则可能产生临床危害。

And in some cases that can be clinically beneficial and in other cases that can be clinically detrimental.

如果你接受大麻能增强专注力这一观点，并考虑到强迫症及其相关神经网络、焦虑以及强迫思维与强迫行为之间的关系，那么大麻未能改善强迫症症状也就不足为奇了——因为事实上，它可能会加剧对强迫思维和强迫行为的专注。

If you accept the idea that cannabis increases focus and you think about OCD and the networks involved and you think about the anxiety and the relationship between the obsession and compulsion, well, then it shouldn't come as any surprise that cannabis did not improve the symptoms of OCD because if anything, it would increase focus on the obsessions and the compulsions.

但这并不是他们观察到的结果。

Now that's not what they observed.

他们并未发现大麻导致强迫症症状加重或恶化。

They did not see an exacerbation or a worsening of the symptoms of OCD with cannabis.

至少根据我的解读，数据并未显示大麻或CBD能改善强迫症症状。

At least that's not my read of the data, but they did not see an improvement in OCD symptoms with cannabis or CBD.

鉴于大麻或CBD似乎会增强专注力，这一点对我来说并不意外。

And to me, that's not surprising given that cannabis CBD seems to increase focus.

接下来，我想谈谈一些关于激素在强迫症中的研究及其作用，因为这背后的关系非常有趣。

Next, I'd like to talk about some of the research on and the roles of hormones in OCD, because it turns out to be a very interesting relationship there.

但在那之前，我想指出一件事，我意识到我本该早点说：对于患有强迫症的人来说，如果他们想要获得任何症状缓解，无论是否接受药物治疗、行为治疗或其他方式，关键是要明白：想法并不像行动那样糟糕，对吧？

But before I do, I want to point out something that I realized I probably should have said earlier, which is one of the key things for someone with OCD to come to understand if they're going to experience any relief of their symptoms, whether or not they're doing drug treatments or behavioral treatments or otherwise, is that thoughts are not as bad as actions, right?

想法并不像行动那样糟糕。

Thoughts are not as bad as actions.

强迫症患者常常为自己设定一条规则，认为想法实际上等同于行动。

One of the kind of rules that people with OCD seem to adopt for themselves is that thoughts are really truly the equivalent of actions.

因此，他们会经历侵入性想法，今天我们没有太多时间讨论这一点，但之前我提到过，强迫症患者的一些侵入性想法其实非常令人不安。

So they'll have an intrusive thought and we haven't spent too much time on this today, but earlier I touched on the fact that some of the intrusive thoughts that people have in OCD are really disturbing.

这些想法可能非常恶心，或者至少对当事人来说是令人反感的。

They can be really gross or at least gross to that person.

它们可能引发有毒、传染性或高度性化的意象，而这些对当事人来说是令人困扰的，甚至非常禁忌。

They can evoke imagery that is toxic or infectious or is highly sexualized in a way that is disturbing to them, can be very taboo.

当你开始与强迫症患者交谈，并深入挖掘时，这种情况并不罕见。

This is not uncommon when you start talking to people with OCD and you start pulling on the thread.

这需要一位受过专业训练、懂得如何提出正确问题并赢得患者信任与安全感的精神科医生。

Again, this would be a psychiatrist who was trained to ask the right questions and gain the comfort and trust of a patient.

他们开始透露，这些想法非常侵入性且令人不安，因此他们感到强烈地想要通过行为来抑制它们。

They start to reveal that these thoughts are really intrusive and kind of disturbing, which is why they feel so compelled to try and suppress them with behaviors.

治疗强迫症的一个关键要素是真正支持患者，让他们明白想法只是想法，每个人都会产生令人不安的想法。

One of the powerful elements of treatment for OCD is to really support the patient and make them realize that thoughts are just thoughts and that everyone has disturbing thoughts.

而且这些令人不安的想法常常在最不方便、有时甚至看似最不恰当的情况下出现。

And that oftentimes those disturbing thoughts arise at the most inconvenient and sometimes what seems like the most inappropriate circumstances.

这涉及到一个更广泛的讨论，我们可以探讨：什么是想法？为什么它们会浮现？为什么当你站在桥边时，即使你并不想跳下去，也会想到跳下去。

And this relates to a whole larger discussion that we could have about what are thoughts and why do they surface and how come when you stand at the edge of a bridge, even if you do not want to jump off, you think about jumping off.

这与你的神经系统作为一台预测机器，常常在测试各种可能性有关。

And this has to do with the fact that your nervous system as a prediction machine is oftentimes testing possibilities.

而有时这种测试会远远偏离我们内心所有人的思维模式和情绪模式，甚至跑到荷兰去了。

And sometimes that testing goes way off into The Netherlands of the thought patterns and emotional patterns that we all have inside of us.

想法与行动之间的巨大区别在于，神经系统在一种情况下并不会将这些思维模式转化为运动序列。

The big difference between a thought and an action is that, of course, the nervous system is in one case not translating those patterns of thinking into motor sequences.

用这种略显枯燥的方式来说‘想法不是行动’，出人意料地，如果人们真正去思考并以此为契机，会很有帮助——首先，他们并不疯。

That nerdy way of saying thoughts aren't actions, believe it or not, can be helpful for people if they really think about that and use it as an opportunity to realize that, first of all, they're not crazy.

他们并不是因为自己坏或邪恶才产生这些想法和感受。

They're not thinking and feeling this stuff because they're bad or evil.

当然，有时这会与其他生活领域交叉，我们在这些领域对某些行为进行道德评判。

And of course, sometimes this can cross over with other elements of life where we place moral judgment on people for certain behaviors.

我认为这是健康社会的一部分，当然，我们通过法律、惩罚以及对某些行为的奖励来体现这一点。

I think that's part of a healthy society, of course, that's where we have laws and punishments and rewards for that matter for certain types of behaviors.

但这种观念——即想法并不等同于行为，想法是可以被接纳的，围绕想法的焦虑也是可以被接纳的，并且随着时间推移会逐渐减弱——这是治疗强迫症的一个非常核心的主题，如果我不提这一点，那就失职了。

But this idea that thoughts are not as bad actions and that thoughts can be tolerated and the anxiety around thoughts can be tolerated and over time can diminish, that's a very powerful hallmark theme of the treatment of OCD, so I'd be remiss if I didn't mention it.

想法不是行为。

Thoughts are not actions.

行为可能会伤害我们，伤害他人，也可能消耗大量时间。

Actions can harm us, they can harm other people, they can soak up enormous amounts of time.

想法同样可能消耗大量时间。

Thoughts can soak up enormous amounts of time.

它们可能非常令人困扰，非常有害，我们当然需要对此保持敏感，但归根结底，治疗强迫症的第一步就是认识到或逐步接受：想法并不像行为那样糟糕。

They can be very troubling, they can be very detrimental, we of course want to be sensitive to that, but when it really comes down to it, the first step in treatment for OCD is this realization or the approach to the realization that thoughts are not as bad as actions.

那么，激素在强迫症中扮演什么角色呢？

So what about hormones in OCD?

这个问题确实被研究过，尽管我原本希望找到更多相关文献，但当我查阅资料时，发现了一项特别有趣的研究，题为《强迫症患者的神经类固醇水平》，作者是Sothar Erbe。和往常一样，我们会提供这项研究的链接。

Well, has been explored, albeit not as extensively as I would have liked to find, but when I went into the literature, I found one particularly interesting study entitled Neurosteroid Levels in Patients with Obsessive Compulsive Disorder for Sothar Erbe, and as always, we'll provide a link to this study.

这项研究的目的是探讨强迫症患者血液中的神经类固醇水平，为什么要做这个研究呢？

The objective of this study was to explore serum within blood, neurosteroid levels in people with OCD, why?

这是因为强迫症与焦虑密切相关，而在压力相关的疾病如焦虑和抑郁中，激素已被广泛研究，但在强迫症中却研究较少，至少在这一研究之前是这样。

Well, because of the relationship between OCD and anxiety and the fact that in stress related disorders such as anxiety and depression, the hormones have been extensively explored, but not so much in OCD, at least until this study.

因此，他们比较了多种激素的血清水平，包括孕酮、孕烯醇酮、DHEA、皮质醇和睾酮。

So they compared to serum levels of a number of different hormones, progesterone, pregnenolone, DHEA, cortisol, and testosterone.

这项研究在30名强迫症患者和30名健康对照组中进行。

This was done in 30 patients with OCD and 30 healthy controls.

这虽然不是一项大规模的研究，但已经足以得出一些相当不错的结论。

So it's not a huge study, but it's enough to draw some pretty nice conclusions.

这些受试者年龄在18至49岁之间，对照组则是年龄和性别匹配的健康志愿者，同样没有强迫症。

These subjects were 18 to 49 years old and the controls were age and sex matched healthy volunteers, again, no OCD.

这项研究的主要结论是什么？

What was the basic takeaway from the study?

这项研究的主要结论是，在患有强迫症的女性中，皮质醇和DHEA水平显著升高。

The basic takeaway from the study was that in females with OCD, there was evidence for significantly elevated cortisol and DHEA.

这很有趣，因为皮质醇众所周知与压力系统相关，不过需要指出的是，无论男女，每个人在醒来后不久都会经历皮质醇的正常升高，这是一种健康的皮质醇上升。

Now that's interesting because cortisol is well known to be associated with the stress system, although every day, should mention, we all, male or female, everybody experiences an increase in cortisol shortly after awakening, that's a healthy increase in cortisol.

皮质醇的峰值通常在一天后期出现，而这种峰值向更晚时段的偏移，是抑郁和焦虑障碍的已知相关因素。

Late shifted, mean late in the day peaks in cortisol, where a shift in that cortisol peak to later in the day is a known correlate of depression and anxiety disorders.

因此，强迫症女性患者皮质醇和DHEA水平升高，表明皮质醇要么反映了焦虑的增加，要么就是导致焦虑的原因。

So the fact that cortisol is elevated in DHEA or elevated in female patients with OCD suggests that the cortisol is either reflective of or causal for the increase in anxiety.

我们还不清楚这种效应的方向。

We don't know the direction of that effect.

在患有强迫症的男性患者中，也发现了皮质醇水平升高，这并不令人意外，因为皮质醇在焦虑中扮演重要角色——或者说，焦虑的增加与皮质醇密切相关；但同时，他们的睾酮水平也显著下降，这也不应让我们惊讶，因为皮质醇和睾酮在某种程度上会竞争各自的合成途径，两者都来源于胆固醇分子，而某些生化通路只能将胆固醇导向皮质醇合成或睾酮合成中的一种，不能同时进行，因此它们相互竞争。

Now, in the male patients with OCD, there was evidence for increased cortisol, again, not surprising given the role of anxiety in cortisol, or I should say, given the role of cortisol in anxiety and the increasing anxiety seen in OCD, but there were also significant reductions in testosterone, which should also not surprise us because cortisol and testosterone more or less compete in some fashion for their own production, both are derived from the molecule cholesterol, and there are certain biochemical pathways that can either direct that cholesterol molecule toward cortisol synthesis or testosterone synthesis, but not both, so they compete.

因此，一般来说，当皮质醇上升时，睾酮往往会下降，反之亦然。

So when cortisol goes up in general, not always, but in general, testosterone goes down and vice versa.

如果你想了解更多关于皮质醇和睾酮之间的关系，还有一些方法可以尝试优化男性和女性体内的这些激素比例。

If you want to learn more about the relationship between cortisol and testosterone, and there are even some tools to try and optimize those ratios in both males and females.

你可以在我们关于优化睾酮和雌激素的那期节目中找到相关信息，网址是 hubermanlab dot com。

You can find that in our episode on optimizing testosterone and estrogen, that's at hubermanlab dot com.

现在，我认为这项研究最有趣的地方不在于 OCD 女性患者体内 DHEA 和皮质醇升高，也不在于男性 OCD 患者体内皮质醇升高而睾酮降低这种相反效应，而在于 DHEA、皮质醇和睾酮三者与 GABA 之间的关系。

Now, I would say the most interesting aspect of this study is not that DHEA and cortisol are elevated in females with OCD or that cortisol and testosterone have this opposite effect, cortisol up and testosterone down in males with OCD, but rather the relationship between all of those, DHEA, cortisol, and testosterone, in terms of GABA.

GABA 是一种抑制性神经递质，通常能抑制某些神经通路的活动，它在不同突触处的作用不同，但总体而言，GABA 越多，抑制作用越强，神经活动也就越受抑制。

GABA again being this inhibitory neurotransmitter that tends to quiet certain neuronal pathways, it does different things at different synapses, but in general, the more GABA that's present, the more inhibition that's present and therefore the more suppression of neural activity.

而 DHEA 被证实是 GABA 系统的强效拮抗剂，明白吗？

And DHEA is known to be a potent antagonist of the GABA system, okay?

因此，在女性体内 DHEA 水平升高，我还应该提到，睾酮也被证实会影响 GABA 系统。

So here we have elevated DHEA in females, and I should also mention that testosterone is also known to tap into the GABA system.

通常情况下，当睾酮水平升高时，GABA 的传递至少会轻微增强。

Typically when testosterone is elevated, GABA transmission at least is slightly elevated.

因此，在 OCD 患者中，男性和女性的激素模式与健康人群不同，导致 GABA 传递发生改变，总体效果是 GABA 水平下降。

So here we have a situation in which the pattern of hormones in females and males with OCD are different from those in people without OCD, such that GABA transmission is altered and the net effect would be an overall reduction in GABA.

GABA作为一种抑制性神经递质，总体上与较低的焦虑水平相关，并有助于维持大脑各神经回路的平衡。

Now, GABA as an inhibitory neurotransmitter and broadly speaking is associated with lower levels of anxiety and it tends to create balance within various neural circuits.

这是一个非常宽泛的说法，但我们知道，例如在癫痫中，GABA水平会降低，从而导致大脑某些回路出现过度兴奋，引发癫痫发作，可能是小发作（轻微发作）、大发作（严重发作），或是跌倒发作——患者会突然倒地不起。

Now that's a very broad statement, but we know for instance, in epilepsy, that GABA levels are reduced and therefore you get runaway excitation of certain circuits in the brain and therefore seizures, either petite mal, mini seizures, or grand mal, massive seizures, or even drop seizures where people completely collapse to the floor in seizure.

你可能以前见过这种情况。

You may have seen this before.

我当然见过，这非常震撼，而且对患者来说相当致残，因为他们通常无法预知癫痫何时发作，可能会在做饭时跌入炉灶，或是在开车时发作等等。

I certainly have, it's very dramatic and it actually is quite debilitating for people because obviously they don't know when these seizures are coming on most often, and then they can fall into a stove or while driving, etcetera.

因此，强迫症的情况是：无论出于何种原因，我们尚不清楚因果方向，女性体内某些激素水平升高，男性体内另一些激素水平升高，而这些激素在男女之间有所不同，但它们都作用于同一个系统——通过抑制GABA的作用，导致大脑中的GABA传递减少，结果是大脑某些神经网络的整体兴奋性升高。这又让我们回到皮质-纹状体-丘脑回路，这个重复循环似乎不断强化：强迫思维引发焦虑，焦虑引发强迫行为，强迫行为带来短暂的焦虑缓解，但随后焦虑加剧、强迫思维加重、焦虑、强迫行为、焦虑、强迫行为、焦虑、强迫行为，如此循环往复。

So the situation with OCD is one in which, for whatever reason, we don't know the direction of effect, certain hormones are elevated in females and certain hormones are elevated in males and those hormones differ between males and females, and yet they both funnel into a system where GABAergic or GABA transmission in the brain is reduced because of this ability for those particular hormones to be antagonists to GABA, and as a consequence, there's likely to be overall levels of increased excitation in certain networks in the brain, and that brings us back to this corticotriatal thalamic loop, this repetitive loop that seems to reinforce, or we can say reinforces obsession leads to anxiety, leads to compulsion, leads to transient relief of anxiety, but then increase in anxiety, increased obsession, anxiety, compulsion, anxiety, compulsion, anxiety, compulsion, and so on and so forth.

我尚未发现任何研究探讨过通过外源性补充（如乳膏或注射）调节睾酮水平，或专门针对女性降低DHEA水平的研究。

So I have not found studies that have explored adjusting testosterone levels through exogenous administration, cream or injection or otherwise, or that have focused on reducing DHEA in females.

如果有人了解此类研究，请在YouTube的评论区留言，或直接发送给我们。

If anyone is aware of such studies, please put them in the comment section on YouTube or send them to us.

我们的网站hubermanlab.com上有联系方式，但YouTube的评论区会是最佳渠道。

We have a contact site on the website at hubermanlab.com, but the comment section on YouTube would be best.

但既然我们知道激素会影响神经调质和神经递质，正如我刚才所描述的，而这些神经调质和神经递质在强迫症的产生和治疗中起着关键作用，因此可以合理推断，对这些激素系统的干预——无论多么细微或剧烈——都可能有助于缓解强迫症的症状。我特别想强调的是，这值得研究，我希望研究人员能在不久的将来深入探索这一领域，因为许多降低DHEA、提高睾酮或降低皮质醇的治疗方法，早已通过了FDA批准。

But because we know that hormones impact neuromodulators and neurotransmitters, as I just described, and that those neuromodulators and neurotransmitters play an intimate role in the generation and the treatment of things like OCD, it stands to reason that manipulations of those hormone systems, however subtle or dramatic, might, I want to highlight, might prove useful in adjusting the symptoms of OCD, and I hope that this is an area that researchers are going to pursue in the very near future because many of the treatments for reducing DHEA or increasing testosterone or reducing cortisol have already made it through FDA approval.

这些药物已经存在，医生经常开具处方，其中许多已进入仿制药阶段，这意味着这些药物的原始专利已经过期。

They're out there, they're readily prescribed, many of them are already in generic form, which means that the patents have already lapsed on the first versions of those drugs.

所以当这些药物以仿制药形式上市时，通常价格会显著降低，对吧？

So when they're available as generic drugs, very often they're available at significantly lower cost, right?

关于专利法和处方药，还有很多值得讨论的地方，但由于这些药物大多已作为处方仿制药广泛可用，我认为这是一个绝佳的机会，去探索激素——不仅仅是皮质醇、睾酮和DHEA——而是整个庞大的激素类别——如何影响强迫症的症状，尤其是因为许多强迫症症状恰好在青春期前后出现。

There's a whole discussion to be had there about patent laws and prescription drugs, but because these drugs are largely available in prescription yet generic form, I think there's a great opportunity to explore how hormones, not just cortisol, testosterone, and DHA, but the huge category of hormones might impact the symptoms of OCD, especially since many of the symptoms of OCD show up right around the time of puberty.

我们还没有深入讨论儿童期的强迫症，因为我们计划专门做一期关于儿童精神障碍与挑战的系列内容，但许多孩子在很小的时候就会患上强迫症，甚至三、四岁，你可能难以置信，或者六、七岁、十岁左右；而在青春期和年轻成年期，强迫症非常常见。虽然罕见，但确实有人在40岁甚至更晚时突然自发出现强迫症症状。

We haven't talked a lot about childhood OCD because we're going to do an entire series on childhood psychiatric disorders and challenges, but many children develop OCD early, as young as three or four, believe it or not, or even six or seven and 10, and in adolescence and certainly around puberty and in young adulthood, It is rare, although it does happen that people will develop OCD very late in life, around 40 or older, just kind of spontaneously.

大多数情况下，当你查看他们的临床病史时，会发现他们此前一直隐瞒症状，或以某种方式压抑了症状；如果强迫症真的在中年后期（如30多岁或40多岁）突然出现，通常与创伤性脑损伤有关，比如中风、头部外伤或其他类似情况。

Most often when you look at their clinical history, you find that either they were hiding it or is being suppressed in some way, or if it does spontaneously show up late in life, like mid-30s or in one's 40s, typically there's a traumatic brain injury, it could be due to stroke or physical injury to the head or something of that sort.

尽管如此，青春期的开始与某些类型的强迫症之间存在有趣的关联。

Nonetheless, there is a interesting correlation between the onset of puberty in certain forms of OCD.

更准确地说，更年期的某些方面可能与强迫症有关。

There's certain forms of, or I should say, there's certain aspects of menopause that can relate to OCD.

你可以在文献中找到所有这些内容。

You can find all these things in the literature.

所有这些都说明，激素会影响神经递质和神经调质，而这些物质显然会影响与强迫症相关的神经回路，因此我期望在不久的将来，人们会深入研究这些激素如何影响强迫症。

All this to say that hormones impact neurotransmitters and neuromodulators, which clearly impact the kinds of circuits that are involved in OCD, and it makes sense that, and I would hope that there would be an exploration of how these hormones impact OCD in the not too distant future.

目前已有大量文献探讨了睾酮疗法在男性和女性中对某些焦虑相关障碍的治疗效果，但据我所知，至少在强迫症本身方面尚未有明确证据。

Now, is an extensive literature exploring how testosterone therapy, both in males and females, can be effective in some cases in the treatment of anxiety related disorders, but not, at least to my knowledge, in OCD in particular.

因此，关于使用睾酮、雌激素疗法、DHEA、皮质醇抑制或可能的增强来治疗强迫症的整个领域，目前仍是一个巨大的黑箱，但我相信它很快就会被照亮。

So this whole area of the use of testosterone and estrogen therapies, DHEA, cortisol suppression, or maybe even enhancement for the treatment of OCD is essentially a big black box that very soon I believe will be lit.

我意识到，许多这个播客的听众可能对强迫症的非常规或整体疗法感兴趣。

I realize that a number of listeners of this podcast are probably interested in the non typical or holistic treatments for OCD.

医生。

Doctor.

布莱尔·辛普森的实验室至少有一项研究探讨了正念冥想在治疗强迫症中的作用。

Blair Simpson's lab has at least one study exploring the role of mindfulness meditation for the treatment of OCD.

那里的数据有些复杂。

There the data are a little bit complicated.

我应该提到，至少在美国，正在发生一些积极的变化，其他地方可能也是如此：由于美国国立卫生研究院新成立了补充健康部门，关于冥想及其他所谓非传统或整体疗法在精神疾病治疗中的探索正在取得进展。

And I should mention that good things are happening, at least in The United States, probably elsewhere as well, but good things are happening in terms of the exploration of things like meditation and other, let's call them nontraditional or holistic forms of treatment for psychiatric disorders because of the division of complementary health that's now been launched by the National Institutes of Health.

过去，人们可能会认为冥想、瑜伽睡眠，甚至CBD补充疗法属于边缘、玄乎或至少是非传统的，但现在美国国立卫生研究院已专门设立了一个部门，专门研究呼吸练习、冥想等方法。

So whereas before people would think about meditation or Yoga Nidra or even CBD supplementation for that matter as kind of fringe maybe, or kind of woo or non traditional at the very least, the National Institutes of Health in The United States has now devoted an entire division, an entire institute purely for the exploration of things like breathing practices, meditation, etcetera.

这里有癌症研究所、听力与耳聋研究所、视力研究所，现在又新增了补充健康研究所，我认为这是对传统医学的重要补充。

So there's a Cancer Institute, there's a Hearing and Deafness Institute, there's a Vision Institute, and now there's this Complementary Health Institute, which I think is a wonderful addition to the more traditional aspects of medicine.

在我看来，只要能够安全地进行，任何可能有效的治疗方法都不应被忽视或未经研究。

Think no possible useful treatment should be overlooked or unresearched in my opinion, provided that can be done safely.

正如我之前提到的，医生。

And as I mentioned, Doctor.

布莱尔·辛普森的实验室研究了正念冥想在治疗强迫症中的作用。

Blair Simpson's lab has looked at the role of mindfulness meditation in the treatment of OCD.

我们应该牢记，无意中提到的是，关于正念冥想的大多数研究显示，它能增强专注力。

Now we should all keep in mind, no pun intended, that most of the data on mindfulness meditation shows that it increases the ability to focus.

这让我们回到了今天反复出现的一个主题：对于强迫症患者来说，增强专注力可能并非好事，因为它可能加剧对强迫思维或强迫行为的专注。

Now, brings us back to a kind of repeating theme today, which is that increased focus may not be the best thing for somebody with OCD because it might increase focus on the obsession and or compulsion.