冰锥、疟疾与电击：精神病学史家斯卡尔谈两百年疗法史与今天的用药困境｜Lex Fridman #502

《Lex Fridman Podcast》是莱克斯·弗里德曼（Lex Fridman）主持的长访谈节目，每期请一位研究者、工程师或作家坐下来谈两三个小时，问题大多落在科学、历史与人的处境上。1 2026 年 9 月 17 日这一期（第 502 期）的嘉宾是安德鲁·斯卡尔（Andrew Scull），一位研究精神病学与精神健康的历史学家。他写过《文明中的疯癫》（Madness in Civilization）和《绝望的疗法》（Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness），几十年都在研究社会怎样理解疯癫、精神病学怎样获得权威，以及这份权威有多少次是在自信满满中造成了灾难性后果。234

这期节目做的是一次历史回顾，用的是问答沿着时间线往下走的讲法：从今天精神病学的危机讲起，退回到十九世纪的精神病院，再一路讲经优生学与纳粹的灭绝计划、冰锥脑白质切除术、给梅毒患者接种疟疾、胰岛素昏迷疗法、电休克疗法，然后是弗洛伊德与荣格、二战与认知行为疗法，最后回到今天正在吃的抗精神病药和抗抑郁药。全片约 3 小时 36 分，斯卡尔在每一段里都会交代三件事：这套疗法当初为什么听起来有道理、它是怎么被推广开的、它最后因为什么被扔掉。节目的后半段把同一套追问用在了今天的药物上。

核心问题：一场持续两百年的治疗史里，绝大部分干预后来都被丢进了垃圾堆——那么我们今天凭什么相信正在用的这一批？斯卡尔把问题指向四个同时出状况的地方：诊断系统、药物的效力边界、公共卫生政策，以及被反复消耗的行业信任。

一、今天的困境由四条线合成。 诊断上，1980 年定型的 DSM 体系靠症状清单归类，本来就是为了让不同医生对同一个病人得出同样的结论；它做到了可靠，却始终没能证明自己有效。药物上，抗精神病药与抗抑郁药对一部分人有效、对相当比例的人完全无效，而医生事先无法判断病人属于哪一类。政策上，重性精神疾病患者平均比其他人早死十五到二十五年，美国的洛杉矶县监狱、芝加哥库克县监狱和纽约赖克斯岛监狱成了事实上的三大精神科病房。信任上，大型制药公司隐瞒数据、操纵研究并付出巨额赔偿，公众对精神病学的怀疑因此不断加厚。

二、二十世纪的疗法有一批共同形状。 被广泛采用、宣称治愈率八成左右、几乎没有对照试验，判断成功的标准落在病人是否安静下来；它们退场的时机，通常与一种更体面、更省事的新疗法出现同步。斯卡尔在节目里反复点出这个百分比：科顿声称治愈了八成病人，胰岛素昏迷疗法声称八成，早期精神病院声称六到八成。

三、换成今天的药，同一套认知陷阱还在。 安慰剂效应在以生命为代价的大手术面前格外强大；疗效的统计显著与临床显著是两回事；副作用由病人承担，而数据由出钱做试验的公司掌握。斯卡尔的态度落在这里：该用的药还是要用，但需要有人盯着，需要承认我们不知道的东西有多大一片。

安德鲁·斯卡尔（Andrew Scull），加州大学圣地亚哥分校社会学荣休教授，精神病学史领域的领军学者，著有《文明中的疯癫》《疯人院》（Madhouse: A Tragic Tale of Megalomania and Modern Medicine）《绝望的疗法》等。2 他在这期节目里反复强调自己的位置：他写的是历史，不做临床判断；他批评的是这个行业处理不确定性的方式，而他认为从业者中有大量真正想帮人的人。他在节目里提到，《绝望的疗法》这本书的念头起于 1981 年，他在伦敦的维尔康研究所做古根海姆访问学者时动了笔，四十年后才真正写完。

莱克斯·弗里德曼，本期主持人。他在这期节目里准备得相当细，多处引用别人整理的材料并当场追问，也讲了自己朋友靠电休克疗法走出抑郁的经历。

以下人物按出现顺序，他们构成了这期历史的骨架：

埃米尔·克雷佩林（Emil Kraepelin），十九世纪末二十世纪初的德国精神病学家。他翻检德国精神病院里成千上万份病历，归纳出两类精神疾病：早发性痴呆与躁狂抑郁性精神病。前者的走向是单向下滑，后者会缓解、甚至完全消失。

布洛伊勒（Bleuler），瑞士精神病学家，把克雷佩林的「早发性痴呆」改名为今天通用的「精神分裂症」。他坚持说的是复数形式，因为他认为这个标签下装着好几种不同的东西。斯卡尔说这是后来经常被丢掉的一个重要判断。

沃尔特·弗里曼（Walter Freeman），美国神经病学家，脑白质切除术在美国的推广者。他会开着房车巡回各州立精神病院教人做经眶手术，一边做一边手不停；他的女儿说他想当脑白质切除手术界的亨利·福特。

埃加斯·莫尼兹（Egas Moniz），葡萄牙神经学家，1930 年代中期提出前额叶白质切断术，1949 年因此获得诺贝尔生理学或医学奖。5

亨利·科顿（Henry Cotton），美国精神病学家，师从克雷佩林与美国当时最有影响的精神病学家阿道夫·迈耶，1910 年代起担任新泽西州立精神病院（特伦顿）院长，推行一套把感染病灶连根切除的疗法。

瓦格纳-尧雷格（Wagner-Jauregg），奥地利医生，1917 年前后用接种疟疾引发高热的办法治疗麻痹性痴呆，因此获得 1927 年诺贝尔生理学或医学奖。6

曼弗雷德·萨克（Manfred Sakel）、塞莱蒂与比尼（Cerletti、Bini），前者发明胰岛素昏迷疗法，后两位意大利精神病学家发明了电休克疗法。

大卫·罗森汉（David Rosenhan），美国心理学家，1973 年在《科学》上发表了那篇关于精神病院诊断的著名研究。7

托马斯·因塞尔（Thomas Insel）与史蒂文·海曼（Steven Hyman），先后执掌美国国家精神卫生研究所（NIMH）的精神病学家，他们把精神疾病当成脑部疾病来研究的路线推到了极致，后来两人又都公开承认这条路线没有兑现承诺。

阿伦·贝克（Aaron Beck），美国精神病学家，认知行为疗法的奠基人之一，2021 年去世，享年 100 岁。8

DSM（《精神疾病诊断与统计手册》）：美国精神医学学会出版的精神疾病分类手册。1952 年第一版只有 32 页、106 个诊断；1980 年第三版改成按症状清单打勾的方式，今天全世界的精神科诊断、药物审批和保险支付都绕着它转。9

可靠性（reliability）与效度（validity）：斯卡尔在节目里专门区分了这两个词。可靠性指你和我面对同样的症状会得出同样的结论；效度指这个结论对应着真实的病理。DSM 把可靠性做上去了，效度始终没有解决。

麻痹性痴呆（General Paralysis of the Insane，简称 GPI）：三期梅毒侵犯中枢神经系统后的结果，既有瘫痪、吞咽和言语障碍，也有妄想与人格改变。二十世纪初，美国精神病院的新入院者中最多时有四分之一是这个病。

病灶性感染（focal sepsis）：一种二十世纪初流行的假说，认为身体里潜伏的低度感染会向血液和淋巴释放毒素，毒素到了脑部就把人变成精神病人。

胰岛素昏迷疗法（insulin coma therapy）：用大剂量胰岛素把病人推进低血糖昏迷，几十分钟到几小时后再用葡萄糖唤醒，一个疗程最多做六十次。

电休克疗法（electroconvulsive therapy，ECT）：用电流在脑内诱发癫痫发作。今天的做法会先用肌松剂和麻醉，早期不做这些处理，因此常有脊椎和髋部骨折。

阳性症状与阴性症状：精神分裂症的阳性症状指幻觉、妄想这类「多出来的东西」，阴性症状指情感淡漠、语言贫乏、丧失主动性这类「少掉的东西」。抗精神病药主要作用于前者。

迟发性运动障碍（tardive dyskinesia）：长期服用抗精神病药后出现的、迟发的、不自主的抽动，尤其集中在面部和舌头。这个词带着「医源性」三个字的分量——它是由治疗本身造成的。

安慰剂效应：斯卡尔用它解释早期那些大手术为什么看起来有效。当治疗过程痛苦、隆重、由穿白大褂的人执行，病人和医生都会更容易看见自己想看见的效果。

SSRI（选择性血清素再摄取抑制剂）：1980 年代末上市的一类抗抑郁药，百优解（Prozac）是其中最出名的一种。它通过减慢脑内血清素的再摄取起作用，制药公司把它宣传成「脑内血清素不足」的解决方案，这套说法后来受到系统综述的质疑。10

斯卡尔先把结论摆出来：精神病学是一个面对极度复杂对象的行业，而它手里只有对症治疗，没有任何一种病有对应的「青霉素」。他列举了三种尴尬。第一，创伤后应激障碍的治疗常让病人正面重历创伤，这个过程对很多人是加重的，只对一部分人有效。第二，抗精神病药与抗抑郁药最多是部分有效，对相当比例的病人完全无效，医生事先不知道谁属于哪一类。第三，治疗本身会制造新问题——医源性损害，比如抗抑郁药的性功能副作用和停药反应。

诊断这条线的问题出在 1980 年。这一年 DSM 第三版问世，它诞生的直接刺激是精神科医生彼此之间对同一个病人的判断经常不一致，罗森汉那篇研究把这件事捅到了公众面前，而六十年代的专业文献里早就写满了同样的结果。7 由罗伯特·斯皮策（Robert Spitzer）主持的第三版工作组给出的解法，是把诊断变成打勾：符合若干条症状就归入某一类。这套办法让诊断变得可靠，也让药物公司、保险公司和病人家属都感到踏实，代价是它只能描述症状，无法说明背后的病理。

斯卡尔接着讲钱去了哪里。1990 年代起，NIMH 在因塞尔与海曼的主持下把宝押在遗传学与神经科学上，认定精神疾病就是脑部疾病。因塞尔离任后公开回顾说，他资助了大量很酷的科学，花掉二十亿美元之后，精神疾病患者的处境没有改善一点。11 海曼后来的说法是，今天这批药相比 1950 年代偶然发现的那些并没有实质进步。更尴尬的一幕发生在 DSM-5 出版前夕，因塞尔与海曼公开批评这本诊断手册既缺效度又不可用。9

药物这条线上，大型制药公司的名声被自己毁了：隐瞒不利数据、制造研究、操纵结果，最后付出数十亿美元的和解金，止痛药万络（Vioxx）就是另一场著名的五亿美元级别和解。神经科学没有给出新的药物靶点，公司算过账之后，把钱投向了别的疾病，精神病学的药物研发基本停摆。1

公共政策这条线的后果最直观。斯卡尔给出的数字是：重性精神疾病患者平均比其他人早死十五到二十五年，而这个差距还在扩大。12 美国今天最大的三个「精神科住院中心」是洛杉矶县监狱、芝加哥库克县监狱和纽约赖克斯岛监狱。13 病人反复在三者之间循环：短期住院、街头、廉价旅馆、看守所。

斯卡尔不把这一切都算在精神病学头上。他说公共卫生政策在 1960 年代后放弃了对重性精神疾病患者的照护，而代替精神病院的「社区照护」是空头支票——没有任何替代性的社区设施接住这批人。美国州立精神病院的在院人数在 1955 年达到约 55.9 万的高峰，此后一路下降。14

斯卡尔用克雷佩林开始讲分类。这位德国精神病学家在十九世纪末二十世纪初翻遍病案，把精神疾病分成两大类：早发性痴呆与躁狂抑郁性精神病。他把早发性痴呆看成一张单程票，病人一路下滑；躁狂抑郁则会缓解，有时完全消失。布洛伊勒后来把它改名成精神分裂症，并坚持用复数，因为他认为这个标签下面藏着好几种不同的病。

莱克斯在这里追问了分类的边界：精神分裂症的核心是脱离现实——听见声音、看见影像、认定别人在密谋、以为电视直接对自己说话；情绪生活随之变平，语言能力退化，与人建立关系的能力消失或者被卷进妄想。斯卡尔确认这与双相障碍、与抑郁是不同的世界。

接着他讲了一段词义的对调。古希腊与古罗马人用「忧郁症」（melancholia）指一种带有精神病性特征的严重抑郁；今天它被并进了「重度抑郁」这个什么都装的框里，既包括轻度的情绪困扰，也包括那种令人几乎无法动弹的忧郁。更有意思的是「神经症」与「精神病」这两个词：十九世纪，neurosis 指的是源自脑的东西，psychosis 指的是源自心灵（psyche）的东西；到十九世纪末，两者的含义恰好互换，一直用到今天。15

早期精神病院诞生在一股巨大的乐观情绪里。当时的设想是把病人从阁楼和牢房里救出来，给他们一个有秩序的环境、让他们干活、学会控制自己；最早自称「疯癫医生」（alienist）的那批人相信，只要病人来得早，六成、七成、八成都能治好。斯卡尔说，实际情况是每年出院的比例在 35% 到 40% 之间，留在院里的人一年年堆积，慢性病人占的比例越来越高，精神病院的形象从希望变成了终点。到了十九世纪末，重新计算出来的「治愈率」只剩 10% 到 12%，医生们需要解释这个落差。

解释的方式是怪罪病人。当时盛行的说法是：精神疾病本质上是生物学问题，病人是进化的倒退者，他们的脑有缺陷，因此失去了基本的人性，也缺乏自控力。这套「退化论」为长期关押提供了理由，也直接通向强制绝育——既然放出去会繁衍，那就先让他们不能生育。斯卡尔提到自己的家乡加州就是这场运动的先驱，加州的州立机构一直到 1960 年前后还在给精神病人做绝育。二十世纪六十年代之前，全美有超过六万人被绝育。1617

语言在这里变得非常危险。斯卡尔引用一位英国精神病学家的说法：如果来住院的病人是小狗，因为它们是不纯的杂种狗，我们会把它们装进袋子、塞上铅块、扔进池塘淹死。这种话在民主制度里还有制衡，所以即使优生学家主张「处理掉这些人」，也没能取得大众支持；纳粹掌权后，同样的念头被接了过去。他们把这些病人叫作「没用的饭桶」，说他们的生命不值得活。先是绝育，然后是屠杀：希特勒启动的 T4 计划得名于制定方案的那栋房子所在的街道名 Tiergartenstraße 4，精神病人是「最终解决方案」的第一批受害者，死者可能多达二十五万人；毒气室的技术，以及把毒气室伪装成淋浴间的做法，正是在这场屠杀中开发出来的。18

斯卡尔补了一段很少有人讲的资金线索。1930 年前后，洛克菲勒基金会把精神病学选为资助重点，一部分原因是这个领域的科学研究太落后，一部分原因是几位理事的家人正受此困扰。基金会的钱撒得很广，其中一笔给了德国遗传学家恩斯特·吕丁（Ernst Rüdin）——他后来成为希特勒大规模绝育与灭绝法律的关键设计者。斯卡尔说，吕丁正是从加州学来了绝育这套办法。

斯卡尔把二十世纪前半段的治疗实验总结为：一群动机各异的人——其中不少真心想改善病人的处境——在一群被双重关起来的人身上做没有对照的实验。病人被锁在院里，他们的话也因为出自「疯癫」而不被当回事。

最极端的一例是脑白质切除术。最早的做法是在头骨上钻孔，注入酒精，或者用一把像黄油刀的工具切断脑内的连接；1935 年，葡萄牙神经学家莫尼兹提出前额叶白质切断术，1949 年拿到诺贝尔生理学或医学奖——斯卡尔提醒听众注意这段时间差：十四年的经验就换来了一座诺奖，而这个奖今天大概没人愿意保留。5

沃尔特·弗里曼从 1936 年开始做这类手术，战后专攻经眶术式：先用电击让病人失去意识，把器械从眼眶顶进去，敲穿骨头，再搅动，切断前额叶的连接。他称自己的房车为「脑白质切除车」，夏天开到各州立精神病院教当地医生做手术。他双手都能用，右手累了换左手，有时一个下午做二三十例；他的名言是，任何傻瓜二十分钟就能学会做脑白质切除术——「连精神科医生都可以」。弗里曼是神经病学家，对精神科医生很不客气。他在二十三个州为大约两千五百名病人做过经眶手术。19

斯卡尔说这项手术的退场靠的是代际更替。一些做手术的人一直做到六十年代甚至七十年代初，而年轻一代医生见到了最坏的后果——后院病房里大小便失禁、彻底失去心智能力的病人——于是开始抗拒，同时他们手里有了看起来更像正规医学的抗精神病药。1

这一段从精神病学少有的诊断胜利讲起。十九世纪的精神科医生注意到一批同时出现瘫痪与妄想症状的病人，把他们归类为麻痹性痴呆：先是走路、吞咽、说话逐渐失灵，同时病人自称是拿破仑、耶稣、圣母玛利亚，或者是世上最富有最有魅力的男人。二十世纪初，美国精神病院的新入院者中最多时有四分之一属于这一类。后来洛克菲勒研究所确认，这些病人的脑里住着导致梅毒的病原体——这是三期梅毒。斯卡尔打了个比方：十九世纪末的梅毒像艾滋病一样无处不在，感染之后会潜伏多年，再以心脏或中枢神经受损的方式发作。

既然病因是感染，治疗就往发热上想。奥地利医生瓦格纳-尧雷格长期相信高热能治精神病，试过鼠咬热、试过注射伤寒疫苗，最后在第一次世界大战末期拿到一名患疟疾的意大利士兵的血，注射给一批麻痹性痴呆病人，宣称把他们治好了。他后来承认那些说法被大幅夸大，但这套疗法已经传到英国、德国和美国：有的医院用疟疾血液，有的干脆养着一笼笼疟疾蚊子，病人被绑在束缚衣里，任由蚊子叮咬。他凭这项疗法获得 1927 年的诺贝尔奖。6 节目里把这个年份说成 1937 年，与诺贝尔奖官方记录不符。这项疗法流行了大约二十年，直到青霉素出现才退场——斯卡尔在这里特意称赞青霉素是真正的魔法子弹。

同一时期出现了另一个更荒诞的方向。克雷佩林的一位学生、在美国精神病学家迈耶手下受训的亨利·科顿，回国后做了新泽西州立精神病院院长。他反对铁链和束缚衣，想做改革者，但病人的病情没有起色；于是他接受了「病灶性感染」的假说，开始推行他所谓的「外科细菌学」：把可能藏有感染的器官一个个摘掉。牙齿离脑子近，就先拔牙；不见好，就摘扁桃体；病人「把细菌吞下去」，那就切胃、切脾、切结肠。他宣称治愈了 80% 的病人，全国的有钱人慕名而来，普林斯顿请他做系列讲座，《纽约时报》称之为重大突破——而做了腹部手术的病人中，有 45% 在一年之内死亡。斯卡尔引用科顿论文里的原话：胃就像工地上的水泥搅拌机，可以不要。科顿 1933 年死于心脏病，接手的三位学生停止了腹部手术，改用结肠冲洗，但拔牙和摘扁桃体一直做到 1960 年；斯卡尔访问过 1916 年到这家医院、后来退休的牙医，他这辈子大概拔掉了几十万颗牙，并且坚信科顿本该拿诺贝尔奖。15

莱克斯在这里提出了整期节目最锋利的一个问题：这些人也是聪明人，为什么会在报告疗效时集体自欺？斯卡尔给出的答案指向安慰剂效应。这类干预对身体的影响极大，由穿白大褂、拿听诊器、执手术刀的人执行，病人想好、医生也想看见自己有效；因此到底有多少改善来自安慰剂、多少来自治疗本身，至今仍是精神病学要处理的问题。斯卡尔接着用胰岛素做了一个对照：胰岛素在 1920 年代让糖尿病从死刑变成了可以带着生活的慢性病，这是二十世纪医学真正的进步之一；而正是「胰岛素过量会让人失去意识」这一点，催生了下一种疗法。

曼弗雷德·萨克在德国一家戒毒诊所工作，见过用轻度昏迷帮人熬过戒断反应的做法，转到奥地利后，他把这个办法用在精神分裂症病人身上：用大剂量胰岛素把病人推进昏迷，有时持续数小时甚至数天，再用葡萄糖唤醒；昏迷中常出现癫痫发作，他把它当作治疗见效的标志。他宣称这套疗法治愈了 80% 的病人——斯卡尔提醒，八成这个数字在这些疗法里反复出现。萨克 1933 年开始做，1936 年到纽约的哈莱姆谷精神病院做示范，此后在美国定居，私人执业收入丰厚。

这项疗法没有被大规模推行，原因是护理成本：病人处在生死边缘，生命体征要一直盯着，随时要唤醒，一次疗程最多做六十次。后来有证据显示它会杀死脑细胞，萨克对此的回应是「那是在杀死精神分裂的脑细胞」。直到 1950 年代，胰岛素昏迷疗法才被拿去做随机对照试验，结果没有通过，于是退场。21 斯卡尔提到，数学家约翰·纳什（John Nash）在特伦顿州立医院接受过这种治疗，而且当时还面临被做脑白质切除术的风险；电影《美丽心灵》对这段经历有所呈现。

同一代人还在追另一条思路。奥匈帝国的一位精神病学家认定精神分裂症与癫痫互不相容——斯卡尔先声明这个前提是错的——于是推出一个逻辑：如果人为制造一次癫痫发作，也许就能把精神分裂症赶出去。他先试注射樟脑，造成脓肿又没什么效果，后来改用 Cardiazol（北美叫 Metrazol）：注射后病人会经历一次剧烈的癫痫大发作，可能造成脊椎与髋臼骨折，而且病人在注射到发作之间的几分钟里感觉自己正走向死亡。斯卡尔让听众设身处地想象这一幕，然后引出了电休克疗法。

两位意大利精神病学家塞莱蒂与比尼开始用电做实验。他们先在狗身上试，一开始把电极一个放在头上、一个放在肛门，电流经过身体，心脏停跳，狗死了，这条路看起来走不通。有人建议他们去罗马的屠宰场看看猪是怎么被宰的：猪被倒挂起来，两个电极从头部两侧夹过去，一通电，猪抽搐，然后屠宰。他们在狗身上验证电流通过大脑不会致死，然后在罗马火车站找来一位流浪汉做第一例。第一次电流不够，没什么反应；一旁的医生商量着加大电流，病人听见了，说「不，再来一次会死人的」，他们照样做了，病人发生大发作、停止呼吸，随后又自己恢复了呼吸，醒来时重新与现实接上了联系。

这套疗法推广得很快：便宜、容易操作、不需要往身体里注射东西。斯卡尔随后交代了几个必须说清的事实。无改良电休克一直用到 1950 年代、有些地方用到 60 年代，骨折是它的问题之一，记忆损害是另一个；在四五十年代的精神病院里，它更多被当作控制病人的手段，带有惩罚色彩。肌松剂（最早是箭毒）与麻醉的引入让骨折基本消失，代价是过程更复杂，需要麻醉与呼吸支持。它为什么有效，至今没有答案，属于纯粹凭经验确立的疗法，需要定期重复以维持效果。加州等地的法律对它有严格限制，比如对非自愿住院的病人几乎不能实施，必须本人同意。15

斯卡尔没有回避另一半事实。曾经有一位病人朋友靠它活了下来，他承认这是常见的故事：走到自杀边缘、长期抑郁、别的都不起作用，做了电休克，然后把它称为救命。他同时指出这段历史里的黑暗面，包括美国中情局资助加拿大精神病学家埃文·卡梅伦（Ewen Cameron）做实验，一天给病人做好几次电击，把人打到不能走路、不能说话、不能进食、大小便失禁，再声称自己把病人重新建了起来，许多人从此留下永久损伤。同样让电休克背上恶名的还有《飞越疯人院》。

肯·克西本人曾在退伍军人医院工作，这些医院是二战后大规模建起来的——二战美军的精神科减员是第一次世界大战的两到三倍。小说与 1975 年的电影讲了同一个故事，视角却不同：小说更怪、更政治，重心在布罗姆登酋长的内心世界；电影更写实，把麦克墨菲推成主角。斯卡尔说，他在课上放过的所有同类电影里，二十岁上下的学生唯一全都看过的是《飞越疯人院》，它把精神病院那种贬低病人、不听病人说话、拿病人开玩笑的氛围相当准确地拍了出来，而电击在五六十年代被当作纪律工具这一点也与事实相符。片中那位主治精神病医生，是俄勒冈州立精神病院真正的院长本人出演。

莱克斯问护士与虐待的关系。斯卡尔把原因放在人手上：病房里与病人接触最多的是收入最低、最不受尊重的护理员，连注册护士都很少；在大型州立医院里，医生与病人的比例让病人几乎见不到医生。

同一段落里，斯卡尔补了一个常被忽略的分布：除了梅毒患者（男性居多），这些实验的主要承受者是女性。科顿的病人中约 70% 是女性；他看过档案的几家医院里，脑白质切除手术 60% 到 70% 的患者是女性；电休克使用者的性别分布同样偏向女性。他同时说明这里有一层复杂因素：电休克主要用于重度抑郁和所谓的「难治性抑郁」，而抑郁的诊断本身在女性中更常见；男性更容易拿到人格障碍、注意力缺陷多动障碍一类的诊断。15

斯卡尔把谈话疗法的源头放在十九世纪末的美国社会里。当时的精神病学被锁在精神病院里，越来越生物学化；而大量情绪困扰、悲伤、社交关系断裂的人并不住院，于是宗教性的心理治疗长了起来。基督教科学派的创始人玛丽·贝克·艾迪（Mary Baker Eddy）主张疾病可以被祈祷消除；更早的基督复临安息日会办起了疗养院，后来由凯洛格家族接手，林肯的遗孀、亨利·福特都去过。波士顿的伊曼纽尔运动起初想把医学与宗教结合起来，参与的医生很快觉得它太偏向宗教而退出。

与此同时，美国内战之后成长起来的一批神经科医生开始接诊功能性的精神障碍。他们的办法包括药物、静电治疗，以及斯泰森式的「休息疗法」：西拉斯·韦尔·米切尔（Silas Weir Mitchell）要求病人绝对卧床、大量进食、停止一切智力活动，主要针对女性——弗吉尼亚·伍尔夫接受过这种治疗，并说它几乎把自己逼疯。米切尔写了两本畅销书，《消耗与磨损》（Wear and Tear）讲现代生活让人神经衰竭，《脂肪与血液》（Fat and Blood）讲怎么把力气补回来。斯卡尔提醒听众注意这种说法与今天对社交媒体、互联网的抱怨有多像。

1909 年，一位维也纳人和两位门徒坐德国轮船到纽约，再转到马萨诸塞州的伍斯特，参加克拉克大学二十周年校庆。那场会议有三十来位演讲者，包括两位诺贝尔物理学奖得主和当时的人类学领军人物弗朗茨·博厄斯，弗洛伊德只是其中一个——但后来的精神病学史常常把它写成「弗洛伊德会议」。弗洛伊德用德语讲了五场关于精神分析的报告；听众都学过德语，因为当时的德语医学文献是必读的。威廉·詹姆斯（William James）听了其中一场并与他交谈，结论是并不欣赏他；波士顿的神经学教授詹姆斯·杰克逊·帕特南（James Jackson Putnam）则在这场会议上变成了弗洛伊德派。斯卡尔说，美国主流精神病学当时对弗洛伊德的到来几乎无动于衷，此后很长一段时间也以「把精神分析当成荒谬的谈话疗法」的态度对待他。

弗洛伊德本人的路线是：在维也纳学术生涯不顺，去巴黎跟随当时最有名的神经学家夏尔科（Charcot）学习癔症几个月，回维也纳后开业行医。他的朋友约瑟夫·布罗伊尔（Josef Breuer）年长、病人多，会把病人转给他。两人共同的研究对象是癔症病人，其中最著名的一位今天被称为安娜·O——她其实是贝尔塔·帕彭海姆（Bertha Pappenheim），真实身份隐藏了很多年。她照料病重的父亲直到父亲去世，随后出现各种躯体症状和抑郁。布罗伊尔与弗洛伊德给出的解释是：被压抑的记忆与创伤在作祟，它们以扭曲的形式变成症状；病人会抗拒这些记忆浮出来，只有经过漫长而痛苦的工作，把无意识的东西带进意识，人格才会改变，病才会好。

弗洛伊德随后把这套东西越建越复杂。他早年试过把自己的心理学接到神经学上——那篇《科学心理学大纲》的手稿留了下来——后来放弃了；再往后是《梦的解析》，把梦看成被压抑材料改头换面的出口；然后是口误、是 id／ego／superego 的三重结构，是本能与性欲的变形。荣格一度被视为继承人，两人在 1913 年前后彻底翻脸；斯卡尔引用弗洛伊德身边人的说法，说他是个「很会恨人的人」，一旦决裂就是除名。

精神分析真正进入美国主流靠的是战争与移民。第一次世界大战让「弹震症」（shell shock）这个诊断进入公众视野，人们逐渐认定病根在心理，弹片与震动留下的伤口解释不了这些症状；弗洛伊德关于无意识与创伤的观点因此获得了新的分量。1930 年前后，北美大约只有三百名精神分析师，每人每周接待病人五小时，能治的人极为有限；希特勒上台后，犹太人、精神分析师的处境急转，弗洛伊德和女儿安娜在博拿巴公主出钱买通的条件下搬去伦敦，另一些人去了美国。到 1940 年前后，美国的精神分析师数量大约翻了一倍多，更重要的是培训被组织起来——但它被放在大学之外的机构里，斯卡尔把这一点称为日后的结构性弱点。

二战期间，关于这些治疗是否真的有效，洛克菲勒基金会的艾伦·格雷格与罗伯特·莫里森反复要求分析师拿出证据，分析师的回答是：我们重建的是整个人格与整个生活方式，没有简单的测量办法。斯卡尔把这种拒绝与前面那些「八成治愈」的承诺放在一起对照，听众自己就能看出两种姿态的差别。15

美国参战前，精神科医生向军方和政治人物预警：如果按一战的方式打仗，心理脆弱的士兵会在战场上崩溃。军方据此在征兵时筛查，筛掉了一百七十五万人。结果这个问题照样出现：工业化战争让人看见和做出平时无法接受的事，在作战条件下，多达四分之一的士兵出现精神崩溃，这既打击士气，也给了装病者可乘之机。战前全美大约只有两千名精神科医生，战争结束时仅美军内部就超过两千名。军队精神科由来自堪萨斯门宁格诊所的威廉·门宁格（William Menninger）主管，他判断这些士兵的问题源于创伤，治疗应当是心理治疗性质的；弗洛伊德式的思路就这样被稀释后，灌进了一批速成培训出来的军医。

同一个时期还发生了另一件事：心理治疗师不够用，心理学家被征召来做治疗工作，他们发现自己能做并且喜欢做。战后这批人组织起来，退伍军人管理局和 NIMH 出钱培训，而临床心理学设计的培养方案是两年科学心理学与研究方法的训练，加两到三年的临床工作——这让他们比精神分析师更懂得怎么写申请、拿联邦经费。临床心理学家的做法与精神分析师正相反：精神分析师说只治症状是打地鼠，临床心理学家说我们就治症状，并且要发展出能复制、能检验的技术。这条路通向认知行为疗法，以及后来的人际关系疗法等分支。斯卡尔把贝克的贡献拆成两条线：一条是他在 1960 年代就指出精神科诊断不可靠，直接推动了 DSM 第三版；另一条是他放弃「谈症状没意义」的立场，与心理学家一起研究怎样改掉病人自我伤害的反应方式。8

斯卡尔对认知行为疗法的评价很克制。他说对较轻的抑郁，认知行为疗法比药物更有效，而且没有那些副作用，英国的 NICE 也是这个结论；22 但 Cochrane 的系统综述认为，认知行为疗法在精神分裂症上的证据质量低到很低，用于较轻病症的证据也没有从业者愿意承认的那么确定。23 他承认习惯很难改，需要大量练习和家庭作业，也承认确实有一批病人从中获益明显。

在这之前，几乎没有人想过用药物去攻击精神疾病的根源；精神病院里的药主要是用来控制病人的，鸦片类、安眠药、大麻甚至酒精都试过。真正的转折来自一次偶然。法国公司罗纳-普朗克（Rhône-Poulenc）翻出一种 1880 年代在德国合成过的抗组胺化合物氯丙嗪24，不清楚它能干什么，于是到处送样试用——当时的药物试验毫无监管，属于蛮荒时代。法国海军上尉亨利·拉博里（Henri Laborit）把它当作麻醉增效剂，发现等候手术的病人不再焦虑，于是写信给在巴黎精神病院工作的亲戚，说这东西像「化学脑白质切除术」。几位同事把消息转到圣安妮医院，那里的德拉伊与德尼凯（Delay、Deniker）给精神病人试用，剂量越加越大，病人不再打砸家具，变得安静、少动，于是氯丙嗪在欧洲被叫作 Largactil，在美国被叫作 Thorazine，并被归入「强安定剂」。

斯卡尔接着讲商业这一侧：氯丙嗪的专利被卖给美国公司，头两家拒绝了，史密斯克莱恩弗兰奇（SmithKline & French）买下，两年之内就有两百万人服用，公司从一家小厂变成大公司。销售对象先是政治家——带着「躁动病人变安静」的影片去州议会游说。药物的名字也在 1960 年代初改了：从「强安定剂」变成「抗精神病药」，暗示它能攻击精神病本身。

斯卡尔对这条暗示做了限定。抗精神病药确实能减轻幻觉、妄想、激越这些阳性症状，对相当一部分病人有效；对情感淡漠、语言贫乏、丧失主动性这些阴性症状，作用很小甚至没有；还有相当比例的病人完全不应答。副作用在最初被集体忽视：静坐不能、帕金森样症状，以及最麻烦的迟发性运动障碍——长期用药后的迟发抽动，面部和舌头的动作尤其明显，走在街上会被人当成精神病人，而他们身上呈现的其实是药物造成的损害。25 这个问题被忽略了大约二十年，直到克雷恩等人在 1968 年前后公开指出。

转机来自另一种药。氯氮平（clozapine）1957 年由一家小公司开发，在欧洲上市，因为不产生迟发性运动障碍而一度被怀疑「没有攻击到病根」，又因为会造成白细胞减少致死而被迅速撤市，没有进入美国。等到迟发性运动障碍的代价越来越清楚，氯氮平被重新启用，条件是每周验血；它在难治性病例上效果更好，并在 1989 年获得美国批准，随后一批化学结构不同的药物被归入「第二代抗精神病药」，包括利培酮与奥氮平。26

2005 年，NIMH 出钱做了一项不由药厂主持的研究：第一代药已经过了专利期、便宜，第二代药受专利保护、价格有时是十倍，于是研究者把它们放在同一个试验里比较，这就是 CATIE，结果发表在《新英格兰医学杂志》上。27 两个发现值得记住：新药在疗效上没有超过老药；病人对药物的耐受度很差，不同药物组中有 67% 到 82% 的病人在试验结束前退出，原因是要么没效果，要么副作用受不了。1 第二代药的副作用换了一批：体重明显增加，接着是代谢综合征、糖尿病、心脏问题。斯卡尔在这里说了一句总结性的话——医学里没有免费午餐，每一种药都有它的主要作用和副作用，问题在于吃药之前没人知道你会落在分布的哪一段，今天也没有任何生物标记能提前告诉你。

抗抑郁药的开头同样是意外。1950 年代，医生给晚期肺结核病人用异烟肼（iproniazid），发现这些抑郁到极点的病人忽然情绪变好、四处走动。药厂当时并不看好抑郁市场，因为他们眼里的抑郁只是那种让人住进精神病院的忧郁性精神病；真正把这个市场做大的，是后来对「抑郁」这个词的重新定义，以及药厂对公众的说服工作。斯卡尔提到 DSM-5 编纂时的一场地道争论：失去父母甚至失去孩子之后的悲伤，该不该算作一种精神障碍。他把这类现象称为「诊断蔓延」，并说明它不只由精神病学的扩张推动，病人和家属也在争取——诊断是获得社会保障与教育支持的钥匙。自闭症诊断数量的增长就是他给出的例子：主持 DSM-IV 的艾伦·弗朗西斯认为，变化主要来自标准的放宽。

第一代抗抑郁药分两类：单胺氧化酶抑制剂（MAOI）与三环类。前者与奶酪、腌肉这类食物相互作用会产生危险反应，后者容易在过量时致死，给一个有自杀风险的病人开一堆吃了会死的药本身就两难。1980 年代末出现的 SSRI 避开了这两类副作用，代价是换了一批新的。斯卡尔把这类药的作用机制讲得很直白：所谓「选择性血清素再摄取抑制剂」，是通过减慢脑内血清素的再摄取来起作用，而药厂把它包装成一套病因解释——你抑郁是因为脑内血清素不足，这颗药解决的正是这个问题。这套解释后来被系统综述质疑：多项研究加在一起，也拿不出抑郁症由血清素水平低造成的证据。10

对疗效本身的评价，斯卡尔给了一段可以作为工具使用的提醒。抗抑郁药在每一次对照研究中都优于安慰剂，但优势常常停留在统计显著上，未必达到临床显著——量表的六十分里提高一两分就足以让统计检验通过，可病人的生活质量未必有多少变化。副作用方面，他引用了病人常用的说法：这类药让人变钝，正常的高潮和低谷都被抹平；性欲和性功能受损，有时停药后也不恢复；停药对一部分人极其困难，症状比服药前更糟。他还给出一个比例：大约四成以上的抑郁病人对药物没有反应。英国 NICE 因此把认知行为疗法放在一线，而美国的现状是大量抗抑郁药由初级保健医生开出，精神科医生并不参与。15

莱克斯请斯卡尔给出一个普通人能用的答案：如果正在经历精神病性症状或者抑郁，该怎么办。斯卡尔说，痛苦太强的时候还是要试药，但需要有人密切监测；更长远地看，精神病学的研究方向要拓宽——过去几十年的钱几乎全砸在药物、神经科学和遗传学上，而研究「怎么把无家可归者的处境处理得更好」「怎么减轻家属照顾幻觉病人的负担」这类问题的经费几乎没有，年轻学者也因此无法在这些方向上建立职业生涯。

谈到谈话疗法，斯卡尔认为精神分析已经变成小众产品，主要是付得起钱的人在用它并说它有效；认知行为疗法有证据、可复制、能检验，在较轻的抑郁上有它的位置，但同样有边界。莱克斯提出人工智能可能改变这件事：AI 可以陪人长时间对话、记住大量细节，让人说出口对治疗师都不敢说的秘密，这让谈话治疗有了被机械化的可能。斯卡尔回应说，新冠期间的隔离已经逼出过一段远程治疗的试验，这类东西确实可能被机制化；他同时说，精神科医生更需要拓宽视野。

公共政策这一块，斯卡尔说自己并不乐观，因为照护重性精神疾病患者要花很多钱，而它不像能把「吃税的人」变成「纳税的人」的治疗那样有动力去做。他给出的几条实际方向是：尽可能提供社会支持，帮人重建社会联系，因为孤独与隔绝本身就会伤人的精神；给常常缺乏掌控感的病人一点自主权；以及有人能做出更好的药——他明确说，他不认为重性精神疾病没有生物学成分，只是那绝不会是故事的全部。让他真正不满的是，最有钱的公司已经撤出了这个领域。

收尾时，他给出的态度是一份克制：多一点谦逊，少一点傲慢；坦白我们能做的有限；警惕热情；听到「突破」时先怀疑。他把氯胺酮和迷幻药当作眼下的例子——它们正被宣传成治疗抑郁的奇迹，而证据非常薄弱，这种剧情他见过太多次：科顿的八成、胰岛素昏迷的八成、早期精神病院的八成。他指出科学新闻和医学新闻的炒作习惯在这件事上起了坏作用，而《科学》《自然》这样的期刊本身也在挑会炸响的题目，负面结果虽然重要，却不容易发表。他说，进步通常是小步的，青霉素那样的大步很少出现。

他最后留下的是这样一层意思：这个行业里有大量真心想帮人的人，历史上的确有人切实改善过病人的处境，不要把整个领域看成一片黑暗；不犬儒、不放弃希望、也不否认进步的可能，这些是面对这个问题时该有的姿态。

莱克斯·弗里德曼（Lex Fridman）：

The following is a conversation with Andrew Scull, a historian of psychiatry and mental health. He has authored many books that I highly recommend including Madness in Civilization: A Cultural History of Insanity from the Bible to Freud, from the Madhouse to Modern Medicine and Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness. Andrew Scull has spent decades studying how societies have understood madness, how psychiatry rose to authority, and how often that authority was used with false confidence and catastrophic consequences. In this conversation we'll trace the long arc from the asylum era to eugenics, from lobotomy and insulin coma therapy to electroconvulsive therapy, psychoanalysis, antipsychotics, antidepressants and the modern crisis of mental health. It is in part a story about the terrifying history of bad ideas in medicine, but it is also about the fascinating mystery of the human mind and about the difficult journey to understand it. This is a Lex Fridman podcast. To support it, please check out our sponsors in the description where you can also find links to contact me, ask questions, give feedback, and so on. And now, dear friends, here's Andrew Scull.

以下是与精神病学和心理健康历史学家安德鲁·斯卡尔（Andrew Scull）的对话。 他写了很多我强烈推荐的书，包括《文明中的疯癫：从圣经到弗洛伊德》、从疯人院到现代医学的疯狂文化史和《绝望的疗法：精神病学对治疗精神疾病的动荡探索》。 安德鲁·斯卡尔（Andrew Scull）花了几十年的时间研究社会如何理解疯狂，精神病学如何上升到权威，以及这种权威如何经常被错误地自信和灾难性后果所利用。 在这次对话中，我们将追溯从庇护时代到 优生学 的长弧，从 脑白质切除术（lobotomy） 和 胰岛素昏迷疗法（insulin coma therapy） 到 电休克疗法（electroconvulsive therapy）、精神分析、抗精神病药、抗抑郁药 以及现代心理健康危机。 这个故事在一定程度上讲述了医学上糟糕想法的可怕历史，但它也讲述了人类心灵的迷人奥秘以及理解它的艰难旅程。 这是一个 莱克斯·弗里德曼（Lex Fridman） 播客。 为了支持它，请在描述中查看我们的赞助商，您还可以在其中找到联系我、提出问题、提供反馈等的链接。 现在，亲爱的朋友们，这是 安德鲁·斯卡尔（Andrew Scull） 。

莱克斯·弗里德曼（Lex Fridman）：

Is it fair to characterize your view on psychiatry and mental illness as that there's a crisis in modern psychiatry? We have made some progress- … over the past century, but mostly we still are not good at treating mental illness either via the drugs or talk therapy, meaning psychopharmacology or psychotherapy, or as you put it, the brain or the mind route. So let's start at the end of our story. Let's start at where we stand before we go into the rich history that you so eloquently write about.

将你对精神病学和心理疾病的看法描述为现代精神病学正处于危机之中，这公平吗？在过去的一个世纪里，我们取得了一些进展，但大多数情况下，我们在治疗心理疾病方面仍然做得不够，无论是通过药物治疗还是谈话疗法，也就是心理药理学或心理治疗，或者如你所说，脑的途径或心灵的途径。那么，让我们从故事的结尾开始。在进入你如此生动描述的丰富历史之前，让我们先从我们现在所处的立场开始。

安德鲁·斯卡尔（Andrew Scull）：

So psychiatry is a profession that tries to deal with an enormously complicated thing: the human mind, the human emotions, the human ability to attempt to understand the world. And in particular, obviously, it focuses on people where our common sense approach to the world seems to break down—people whose emotional life is filled with turmoil, people whose ability to relate to others is badly damaged, people who see things in the world that the rest of us simply think aren't there. They're illusions, they're hallucinations, they're delusions. And this is a subject that has occupied some very clever minds over the years, and there's no question that in the course of at least the last three quarters of a century there has been some limited progress in dealing with the problems that mental illness creates. Some of that is confined to the milder forms of mental distress; the more serious forms of psychosis and breakdown of emotional control, those are areas where I think again there's been some progress, but it's easy to overstate how much of that there's been. As we'll see probably later in our conversation today, the advent of modern psychopharmacology, which occurred in the early nineteen fifties, was a serendipitous event. It wasn't planned for.

因此，精神病学是一个试图处理极其复杂的事情的专业：人类的思想、人类的情感、人类尝试理解世界的能力。 显然，它特别关注的是那些我们对世界的常识似乎被打破的人——情感生活充满混乱的人，与他人交往的能力严重受损的人，看到世界上我们其他人认为不存在的事物的人。 它们是幻觉，它们是幻觉，它们是妄想。 多年来，这个话题一直占据着一些非常聪明的头脑，毫无疑问，至少在过去四分之三个世纪的过程中，在处理精神疾病造成的问题方面取得了一些有限的进展。 其中一些仅限于较轻微的精神困扰； 更严重的精神病性障碍形式和情绪控制的崩溃，我认为这些领域再次取得了一些进展，但很容易夸大其中的进展。 正如我们在今天的谈话中可能会看到的那样，发生在十九世纪五十年代初的现代精神药理学的出现是一个偶然事件。 这不是计划好的。

安德鲁·斯卡尔（Andrew Scull）：

It happened almost by accident, and it did mark in some ways an advance over some of the things that psychiatry had engaged in before that. And no question, for some people that revolution and a parallel revolution in the psychotherapeutic realm have created some advance for patients, and we should not minimize that. What we have available to us are symptomatic treatments, not cures. We don't have a psychiatric penicillin for any of the conditions we're gonna be talking about. That doesn't mean we can't do some things that help, but the help is quite limited, and it's important to understand both the ways in which we have progressed and the limits of that progress, and also to understand that when we treat something, sometimes we create new problems—what we call iatrogenic problems, things caused by the interventions that we use. That's true of some psychotherapeutic interventions and most certainly true of the drugs we use to treat mental illness these days. So for example, in treating PTSD, we often get patients to confront the episode– the trauma which provoked their distress, and that is often a very, very fraught process, and for many patients it actually makes things worse. For some patients it makes them better.

这几乎是偶然发生的，它确实在某些方面标志着精神病学比之前从事的一些事情取得了进步。 毫无疑问，对于某些人来说，这场革命和心理治疗领域的并行革命为患者带来了一些进步，我们不应该低估这一点。 我们所能提供的只是对症治疗，而不是治愈方法。 我们没有针对我们将要讨论的任何病症的精神科青霉素。 这并不意味着我们不能做一些有帮助的事情，但帮助是相当有限的，重要的是要了解我们取得进展的方式和进展的局限性，还要了解当我们治疗某些事情时，有时我们会产生新的问题——我们所说的医源性问题，由我们使用的干预措施引起的问题。 对于一些心理治疗干预措施来说是这样，对于我们现在用来治疗精神疾病的药物来说也是如此。 例如，在治疗创伤后应激障碍（PTSD）时，我们经常让患者面对这一事件——引发他们痛苦的创伤，这通常是一个非常非常令人担忧的过程，对于许多患者来说，这实际上让事情变得更糟。 对于一些患者来说，这会让他们的病情好转。

安德鲁·斯卡尔（Andrew Scull）：

So that's a situation where you could see problems. With both antipsychotics and antidepressants, the two main classes of psychotropic drugs that we use, they're at best partially effective and they don't work for a significant fraction of patients who are given them. And one of the big problems psychiatry faces is that psychiatrists don't know in advance who's gonna respond well to the drugs, who's gonna respond badly, for which group of patients in the middle the side effects and the main effects, if that's what we wanna call them, the therapeutic effect, are finely balanced, and making those judgment calls about what to do is very, very difficult. Now in terms of the crisis psychiatry faces at the moment, as I see it, there are a number of strands that point to this. Psychiatry's diagnostic system that is still used– I mean, the fundamental basis of, of psychiatric diagnosis today was really first formulated in, in 1980 with the third edition of The Diagnostic and Statistical Manual of a Profession-

所以这是一个你可能会看到问题的情况。对于抗精神病药和抗抑郁药这两类我们使用的主要精神药物，它们充其量只是部分有效的，并且对相当一部分接受这些药物的患者无效。精神病学面临的一个大问题是，精神科医生事先并不知道谁会对药物反应良好，谁会反应不佳，对于处于中间的患者群体来说，副作用和主要疗效，如果我们想这么称呼它们，即治疗效果，是很难平衡的，而做出关于该怎么做的判断非常、非常困难。现在就我所见而言，就目前精神病学所面临的危机而言，有几个方面都指向这一点。精神病学仍在使用的诊断系统——我是说，今天精神病学诊断的基本依据实际上是在 1980 年首次由第三版《《精神疾病诊断与统计手册》（Diagnostic and Statistical Manual）》提出的。

莱克斯·弗里德曼（Lex Fridman）：

DSM-III

《精神疾病诊断与统计手册》（DSM）

安德鲁·斯卡尔（Andrew Scull）：

… DSM-III, and then there's been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM-5, finally not with a Roman numeral but with an Arabic numeral. So they thought with DSM-5 when they needed to modify it it would be like a piece of software. You have Windows 10, Windows 11, and so on, right? Now that diagnostic system came into being because psychiatrists had a very hard time agreeing with one another about what was wrong with somebody, and that became embarrassingly clear in — first in the professional literature which outsiders didn't read, and then via a very famous study that's a scientific fraud by David Rosenhan called On Being Sane in Insane Places where he claimed to have sent in pseudo patients to the hospital and they all were diagnosed as schizo. All but one of them diagnosed as schizophrenic, the other as somebody with bipolar disorder, and they were fake patients. So almost in a panic after that study appeared in Science and because there was an abundant professional literature from the 1960s showing the same thing, that diagnosis was a very erratic process, the DSM-III task force led by Robert Spitzer, who was then at Columbia, was explicitly set up to try to create a sort of tick the boxes approach to deciding which box a patient belonged in. Were you schizophrenic? Were you this type of schizophrenic or that type of schizophrenic? Were you manic depressive or bipolar? Did you have various forms of depression?

… DSM-III ，然后是 DSM-III-R 、 DSM-IV 、 DSM-IV-TR ，现在是 DSM-5 ，最后不是使用罗马数字，而是使用阿拉伯数字。 所以他们认为当他们需要修改它时 DSM-5 它就像一个软件。 您有 Windows 10、Windows 11 等等，对吗？ 现在诊断系统的出现是因为精神科医生很难就某人的问题达成一致，这一点变得令人尴尬地清楚——首先是在外人不读的专业文献中，然后通过一项非常著名的研究，这是罗森汉的科学欺诈，他声称将假病人送到医院，他们都被诊断为精神分裂症。 除了一名患者外，其他人都被诊断为 精神分裂症患者 ，另一名被诊断为 双相障碍 患者，而且他们都是假患者。 因此，在这项研究发表在《科学》杂志上之后，几乎陷入了恐慌，而且由于 20 世纪 60 年代有大量专业文献显示了同样的事情，诊断是一个非常不稳定的过程，由当时在哥伦比亚的 罗伯特·斯皮策（Robert Spitzer） 领导的 DSM-III 特别工作组明确成立，试图创建一种勾选框方法来确定患者属于哪个框。你是 精神分裂症患者 吗？ 你是这种类型的精神分裂症患者还是那种类型的精神分裂症患者？ 您是躁狂抑郁还是躁郁症患者？ 你有过各种形式的抑郁吗？

安德鲁·斯卡尔（Andrew Scull）：

And to construct those boxes, what they relied upon was a list of symptoms, and if you had more than a certain number– if you had more than six of ten, six or ten or more symptoms of a certain sort, you could be diagnosed with major depression, for example. So that system came into being. It was partially embedded because it appealed to drug companies who were developing drugs to treat these various disorders. It appealed to insurance companies 'cause it gave them a stable base to look at. It appealed to, as diagnosis always does, to patients and their families who are scrambling to deal with these enormous upsets in the mental life of either themselves or a family member. So provided some sense of certainty around diagnosis.

为了构建那些分类，他们依赖的是一个症状列表，如果你具有超过某个数量的症状——例如，如果你有十种症状中的六种或更多某种类型的症状，你就可能被诊断出重度抑郁。所以这个系统就这样出现了。它之所以部分被接受，是因为它对开发治疗这些各种障碍的药物的制药公司有吸引力。它对保险公司有吸引力，因为它为他们提供了一个稳定的评估基础。它也像所有诊断一样，对患者及其家庭有吸引力，因为他们正在努力应对自己或家庭成员心理生活中的巨大动荡。因此，它为诊断提供了一定的确定性。

安德鲁·斯卡尔（Andrew Scull）：

But that was always based simply on symptoms in the way an eighteenth century doctor might diagnose dropsy or diagnose some other kind of disor— fever, for example. Well, fever and other diseases they talked about in the eighteenth century are really a constellation of very different things under one label. And I think that's what is turning out to be true of the DSM labels. But that approach was really all that psychiatry could come up with if it wanted to make sure whether you were in Walla Walla or New York or San Francisco or Atlanta, you reached the same conclusion faced by the same patient, that you had a reliable diagnostic system. That didn't mean necessarily it was a valid diagnostic system, if you understand the distinction between validity and reliability.

但那一直只是单纯基于症状，就像十八世纪的医生可能会诊断水肿或诊断其他某种疾病——比如发烧一样。嗯，十八世纪他们谈论的发烧和其他疾病实际上是在一个标签下的各种不同疾病的集合。我认为这正是《精神疾病诊断与统计手册》（DSM） 标签所呈现的情况。但如果精神病学想要确保无论你在瓦拉瓦拉（Walla Walla）、纽约、旧金山还是亚特兰大，面对同一个病人，都能得到同样的结论，有一个可靠的诊断系统，这种方法实际上是精神病学唯一能想到的方法。这并不意味着它一定是一个有效的诊断系统，如果你理解有效性和可靠性之间的区别的话。

安德鲁·斯卡尔（Andrew Scull）：

Reliability means you and I faced with the same sets of facts reach the same conclusion, but that conclusion may or may not reflect the underlying reality of things, right? So you had this diagnostic system, and it went through various iterations. Each time it went through an iteration, the number of possible psychiatric disorders you could get grew and grew and grew, and it became difficult to believe in some of those categories, shall we say, that they were really illnesses rather than some kinda social construct. But beyond that, psychiatrists wanted to be more like other medical doctors, to root their diagnoses in an understanding of the underlying pathology of the disorder. What was it that caused people to become schizophrenic? The sense was if we could grasp that we'd have a better handle on how to attack it, how to treat it. And when DSM-5 was mooted, the fifth edition in the early two thousands, NIMH, then under the leadership of Steven Hyman who's at Harvard now and succeeded by Thomas Insel who ruled NIMH for about thirteen years, the two of them had pushed psychiatry and psychiatric research in a very particular direction: on the one hand towards understanding the genetics of mental illness, and on the other to looking at what the new discipline of neuroscience could contribute to understanding things. Both of them were heavily invested in the idea that mental illness was brain disease.

可靠性意味着你和我面对相同的事实得出相同的结论，但这个结论可能反映也可能不反映事物的根本现实，对吗？ 所以你有了这个诊断系统，并且它经历了各种迭代。 每次经历一次迭代，你可能患上的精神疾病的数量就会越来越多，我们很难相信其中一些类别，容我们说，它们真的是疾病，而不是某种社会建构。 但除此之外，精神科医生希望更像其他医生，将他们的诊断植根于对这种疾病的潜在病理学的理解。 是什么让人们变成了精神分裂症患者？ 其意义在于，如果我们能够掌握它，我们就能更好地掌握如何攻击、如何治疗它。 当 DSM-5 被提出时，即两千出头的第五版，美国国家精神卫生研究所（NIMH），然后在现在在哈佛大学的 史蒂文·海曼（Steven Hyman） 的领导下，并由统治 美国国家精神卫生研究所（NIMH） 大约十三年的 托马斯·因塞尔（Thomas Insel） 接替，他们两人将精神病学和精神病学研究推向了一个非常特殊的方向：一方面是理解 遗传学 另一方面，研究神经科学的新学科可以为理解事物做出哪些贡献。 他们俩都深信精神疾病就是大脑疾病这个观点。

安德鲁·斯卡尔（Andrew Scull）：

And if it was brain disease, then the question was what was making the mechanism here go awry? What was causing people's emotions or their cognitive skills or their sense of the world to become so disordered? And they invested a lot of money in that approach. When Insel stepped down he gave an interview actually to somebody at MIT, and he's repeated it since in a– in a book he wrote about his experiences where he said, "Well, you know, as I look back on my thirteen years, I funded an enormous amount of scientific… really cool scientific research. I funded geneticists and I funded neuroscientists and they did a lot of really interesting science. And after spending twenty billion dollars, the lot of the mentally ill has improved not one bit, right?"

如果这是脑部疾病，那么问题就在于是什么让这里的机制出了问题？是什么导致人们的情绪、认知能力或对世界的感知变得如此混乱？他们在这种方法上投入了大量资金。当 Insel 辞职时，他实际上接受了麻省理工学院某人的采访，他后来又在自己写的一本关于他经历的书中重复了这件事，他说：“你知道，当我回顾自己十三年来的工作时，我资助了大量的科学研究……真正很酷的科学研究。我资助了遗传学家，我也资助了神经科学家，他们做了很多非常有趣的科学研究。可是，在花费了两百亿美元之后，精神疾病患者的状况一点都没有改善，对吧？”

莱克斯·弗里德曼（Lex Fridman）：

Wow!

哇！

安德鲁·斯卡尔（Andrew Scull）：

Which was a pretty devastating statement, I thought.

我认为那是一个相当令人震惊的声明。

莱克斯·弗里德曼（Lex Fridman）：

And NIMH is National Institute of Mental Health.

而 美国国家精神卫生研究所（NIMH） 是 美国国家精神卫生研究所（National Institute of Mental Health）。

安德鲁·斯卡尔（Andrew Scull）：

National Institute of Mental Health, yes, I shouldn't resort to jargon. But the National Institute of Mental Health had been founded in the late nineteen forties with the goal of improving, doing basic research, training people in the field, advancing the care of the mentally ill, and producing obviously cures and advances. And its mission has varied widely over the years since, but starting in the in the nineteen nineties –the period when the first George Bush declared the decade of the brain— NIMH increasingly focused on the idea that mental illness was purely a brain disease, and there's something to that and there's also some mistake in thinking about it that way.

美国国家精神卫生研究所（National Institute of Mental Health），是的，我不应该诉诸行话。但美国国家精神卫生研究所（National Institute of Mental Health）成立于二十世纪四十年代末，其目标是改进、进行基础研究、培训领域人才、提升精神病患者的护理，并显著地产生治疗方法和进展。多年来，其使命有很大变化，但从二十世纪九十年代开始——即第一个乔治·布什宣布脑十年的时期——美国国家精神卫生研究所（NIMH）越来越专注于精神疾病纯粹是脑部疾病的观点，这其中有一定道理，但也存在这种思考方式的错误之处。

莱克斯·弗里德曼（Lex Fridman）：

This is, by the way, as we will talk about this distinction between seeing mental health, the maladies of the human mind – As a problem of the brain like neurobiology Neuroscience versus the problem of the mind which is more in the cognizant psychotherapy these more less amenable to scientific rigor So I think whats appealing About studying the brain and your biology Your sciences theres data Yes It's more rigorous You can do science

顺便说一下，正如我们将要讨论的，关于将心理健康、人类心智的疾病——作为像神经生物学神经科学这样的脑问题，还是作为更多属于认知心理治疗的心智问题这一区别，这些问题较少适合科学严格研究的区别。我认为研究大脑和你的生物学科学的吸引力在于，有数据，是的，它更严格，你可以做科学研究。

安德鲁·斯卡尔（Andrew Scull）：

It's the kind of thing that really appealed to medical school deans because once NIH and the drug companies too were funding basic research on neurobiology and basic research on genetics the moneys flooded in and psychiatry Which had been Something of an orphan Became much more popular

这正是那种让医学院院长非常感兴趣的事情，因为一旦国立卫生研究院（NIH）和药品公司也开始资助神经生物学的基础研究和遗传学的基础研究，资金就涌了进来，而曾经有些被忽视的精神病学也变得更加受欢迎。

莱克斯·弗里德曼（Lex Fridman）：

and we should say That This Is something you write A Lot about There are all These Factors To consider So Theres cultural Elements Political public Policy elements Then At Certain Point Drug Companies Insurance Companies Come In Of course All Human Beings Around Somebody Who suffering With mental health issue So Family factors Thats Connected Cultural Stuff

我们应该说这是你经常写的内容，有很多因素需要考虑。因此有文化因素、政治公共政策因素，然后在某些时候药品公司、保险公司介入。当然，还有所有围绕着遭受心理健康问题的人的人类因素，所以家庭因素也与文化相关的内容有联系。

安德鲁·斯卡尔（Andrew Scull）：

it's a very complicated area and oversimplification is a real problem I think. and I think even that dichotomy you just drew between the brain and the social Or psychological Some mix of those Things I Think in someways thats category Mistake thats mistaken Way looking World Because Brain You have today Not Born With Human brains Are remarkably Plastic Things Develop response Environment Social Psychological Embedded Our brains Rigid separation Saying One Other No Abundant evidence From epidemiology That social factors Play important role Development Illness

这是一个非常复杂的领域，我认为过度简化确实是一个问题。而且我认为，即使你刚才画出的大脑与社会或心理之间的二分法，我认为在某些方面那也是一种类别错误，是一种错误的看待世界的方式。因为我们今天拥有的大脑并不是天生就有的，人类的大脑是极其可塑的，会根据环境、社会和心理因素的发展而变化。将大脑与社会或心理严格分开是不合理的。有大量流行病学证据表明，社会因素在疾病的发展中起着重要作用。

莱克斯·弗里德曼（Lex Fridman）：

Nevertheless history Psychotherapy Example Subfields Human Mind Complicated All Factors Say Anything Helpful Have Simplify Freud famously simplified Lot Towards Particular View Human mind Mm-hmm That simplification Actually Talk about Its Correct Deeper Sense Productive

然而，历史 心理治疗 例子 子领域 人类心智 复杂 所有因素 说任何有帮助的事情 有简化 弗洛伊德 著名地向特定观点简化 了很多 人类心智 嗯哼 那种简化 实际上谈论 它的正确更深层次意义 有益的

安德鲁·斯卡尔（Andrew Scull）：

yes in fact whenever you're trying to deal with a very complicated set of issues you have to simplify you have to make heuristic decisions about what you're going to neglect and what you're gonna emphasize but what im trying to say well you asked me about the crisis in psychiatry and the simplest way for me to encapsulate the issue and the problem as i see it that's arisen —one of the problems—is a quote by Leon Eisenberg who had a very long career at Harvard and Eisenberg said towards the end of his career He Said When Entered Psychiatry Was Brainless Psychiatry Leaving It mindless Psychiatry Yeah sums Up Way Field Large Degree Moved Process Insights Lost Though Ways Other Being Gained Freudians tended Neglect Biological Suggest Brain as a biological organism was not something we needed to worry about. We worried at the level of a psychological model of how our minds work. And all too often, not exclusively because some of the psychiatrists I'm friends with are very sophisticated men and women and do grasp that you can't move in these bipolar directions. You've got to meet somewhere in the middle. But that sort of got lost, I think, in all the enthusiasm for neuroscience. I mean, when antipsychotic drugs were discovered in the early 1950s, we had no clue of how they worked. And one of the things that they helped us spawn as people began to say, "Well, why did these drugs work?

是的，事实上，每当你试图处理一系列非常复杂的问题时，你就必须简化，你必须做出关于你要忽略什么和你要强调什么的启发式决定，但我想说的是，你问我关于精神病学危机的问题，以及我概括这个问题和我所看到的问题的最简单方法——其中一个问题——是艾森伯格的一句话，他在哈佛有很长的职业生涯，艾森伯格说 在他的职业生涯即将结束时，他说，当进入精神病学时，是无脑精神病学，离开它是无意识精神病学，是的，总结道领域大程度移动过程洞察力通过其他方式获得弗洛伊德倾向于忽视生物学建议大脑作为一种生物有机体不是我们需要担心的事情。 我们担心我们的思维如何运作的心理模型。 很多时候，不仅仅是因为我的一些朋友的精神科医生都是非常老练的男人和女人，他们确实明白你不能朝这些两极分化的方向发展。 你们必须在中间的某个地方见面。 但我认为，这种迷失在对 神经科学 的热情中。 我的意思是，当 抗精神病药 药物在 20 世纪 50 年代初被发现时，我们不知道它们是如何起作用的。 当人们开始说：“好吧，为什么这些药物有效？

安德鲁·斯卡尔（Andrew Scull）：

What did they do?" Was to begin to understand that the brain wasn't just a set of electrical signals, as had been thought in the first half of the 20th century and before. But rather there was this very interesting chemical soup running around in our brains with neurotransmitters that help the brain work the way it did and perhaps explained why it went awry. So it was one of the many factors that gave rise to neuroscience. The first neuroscience conventions were in the 1970s, and they attracted a few hundred people. Now it's tens of thousands of neuroscientists. It's a huge enterprise. So diagnosis has come under threat. The categories that we have all become familiar with, that we're told are real diseases like bipolar disorder, schizophrenia, major depression, are beginning to falter, and we're beginning to worry about whether those diagnoses are real ways of thinking about the world and may in fact mislead us. Because if we think there's something called schizophrenia or the schizophrenias, as the inventor of that term put it, if we think there's something like that and we try to research where it comes from, but that's not really what's going on, obviously we're probably gonna not make the progress we could be making if we had a better diagnostic system. And that's what DSM-V thought it was gonna be able to do and discovered it couldn't. So it stayed basically with the symptomatic approach.

他们做了什么？”是为了开始理解大脑不仅仅是一组电信号，就像 20 世纪上半叶及之前人们所认为的那样。而是有一种非常有趣的化学汤在我们的大脑中运行，其中含有神经递质，可以帮助大脑按照其本来的方式工作，也许可以解释为什么它会出错。所以这是引起 神经科学 的众多因素之一。第一个 神经科学 大会是在 20 世纪 70 年代，它们吸引了数百人。 因为如果我们认为有一种叫做 精神分裂症 或 精神分裂症（复数） 的东西，正如该术语的发明者所说，如果我们认为有类似的东西，并且我们尝试研究它的来源，但事实并非如此，显然，如果我们有更好的诊断系统，我们可能不会取得进展，而这就是 DSM-5 所认为的。 原本可以做，但发现做不到，所以基本上还是采用对症治疗的方法。

莱克斯·弗里德曼（Lex Fridman）：

If we can just really brief – … I would love to talk a little bit more about the DSM, but just to give a history here, looking it up on Perplexity, DSM One in 1952 was a 32 page pamphlet- ..with 106 diagnoses heavily influenced by psychodynamic concepts- ….and etiology using broad, often vague categories like reactions. DSM Two in 1968 expanded to 185 diagnoses, still psychodynamically flavored and reliability poor, but added more attention to childhood disorders and later removed homosexuality as a disorder in 1974 printing. Then to the revolution, as you mentioned, the DSM Three in 1980 introduced explicit symptom-based diagnostic criteria, a multi axial assessment system, and an officially atheoretical stance about causes aiming to improve reliability and research utility. And then DSM Three R in 1987 revised criterion expanded to around two 97 diagnoses. DSM Four in '94 and DSM Four TR in 2000 focused on literature driven empirical revisions,- …..added and deleted some disorders, increased coordination with ICD ten and goes on. And then finally in 2013 DSM Five came out which eliminated the multiaxial system, integrated most information into a single nonaxial diagnostic list than separate notations for psychological and medical factors. It reorganized chapters, e.g., neurodevelopmental, obsessive compulsive related, trauma and stress related disorders, introduced new and refined entities, and so on.

如果我们能简单地讲一下——……我很想多谈谈《精神疾病诊断与统计手册》（DSM），但只是为了在这里介绍一下历史，在 Perplexity 上查找，《精神疾病诊断与统计手册》（DSM）1952 年有一本 32 页的小册子——……其中 106 个诊断严重受到心理动力学概念的影响——……以及使用广泛的、通常模糊的类别（如反应）的病因学。 《精神疾病诊断与统计手册》（DSM） 1968 年的两次诊断扩大到 185 例，仍然具有心理动力学特征且可靠性较差，但增加了对儿童障碍的更多关注，后来在 1974 年印刷时删除了同性恋作为一种障碍。 然后是革命，正如您提到的，1980 年的 《精神疾病诊断与统计手册》（DSM） 三人引入了明确的基于症状的诊断标准、多轴评估系统以及旨在提高可靠性和研究实用性的关于原因的官方非理论立场。 然后 《精神疾病诊断与统计手册》（DSM） 1987 年修订的三 R 标准扩展到大约 2 97 个诊断。 《精神疾病诊断与统计手册》（DSM） 94 年的四个和 《精神疾病诊断与统计手册》（DSM） 2000 年的四个 TR 侧重于文献驱动的实证修订，- ….添加和删除了一些疾病，增加了与 ICD 十的协调并继续。 最后在 2013 年 《精神疾病诊断与统计手册》（DSM） 五个版本问世，消除了多轴系统，将大部分信息整合到一个非轴诊断列表中，而不是对心理和医学因素进行单独的标记。 它重新整理了章节，例如神经发育障碍、强迫相关障碍、创伤和应激相关障碍，介绍了新的和改进的实体，等等。

莱克斯·弗里德曼（Lex Fridman）：

But big picture trajectory conceptually, the DSM moved from cause focused and psychoanalytical to symptom based, theoretical, and reliability driven over time. There has been growth in the number of granularity of categories, closer alignment with ICD, ongoing controversy over medicalization validity and the balance between categorical and dimensional approaches. Yes, it feels like that description doesn't necessarily fully get to the core of why the DSM five doesn't quite get the full scope of the problem.

但从整体趋势上看，从概念上讲，《精神疾病诊断与统计手册》（DSM） 随着时间的推移，从以病因为中心和精神分析的取向，逐渐转向以症状为基础、理论驱动以及强调可靠性。分类的粒度有所增加，与 ICD 更加接近，但关于医学化的有效性以及类别方法与维度方法之间的平衡仍存在持续争议。是的，这种描述确实感觉并不完全触及《精神疾病诊断与统计手册》（DSM）五版未能全面覆盖问题核心的原因。

安德鲁·斯卡尔（Andrew Scull）：

You invest a ton of money. You invest- … $20 billion– More than $20 billion in a particular approach. And at the time you're constructing this you say finally because of all the work that's being done in genetics we now have decoded the human genome. We have PCR so we can chop it up and we can look at bits of it. We have a lot more understanding of the role of neurotransmission in the brain. Surely we're going to be able to recast our diagnostic system based on underlying pathology so that we won't be worrying about symptoms anymore. We'll be looking at the actual underlying pathological changes that have taken place. But in the event, it turned out they couldn't do that. By about 2008 they had thrown up their hands and said, no, we're going to have to continue to refine, rely upon the same basic approach that we developed in 1980.

你投了大量的钱。你投资了——……200 亿美元——在一种特定的方法上。而在你构建这个时，你会说，终于因为在遗传学上所做的所有工作，我们现在已经破译了人类基因组。我们有 PCR，所以我们可以把它切开，查看其中的片段。我们对大脑中神经传递作用的理解也多了很多。我们肯定可以根据潜在病理重新构建我们的诊断系统，这样我们就不再担心症状了。我们将关注实际发生的潜在病理变化。但是，结果证明他们做不到。到 2008 年左右，他们已经举起双手说，不，我们将不得不继续改进，依赖于我们在 1980 年开发的相同基本方法。

安德鲁·斯卡尔（Andrew Scull）：

And when that document came out, and there'd been a lot of criticism, some of it from Robert Spitzer, who had been largely in control of DSM-III and DSM-IIIR, and then his successor Allen Frances, who'd run DSM-IV, they both were fiercely critical about what was going on and said it was being done in the dark and it was done in secrecy and it wasn't scientific. And when it was about to come out, Thomas Insel and Steven Hyman, the two then existing at the preceding director of the National Institute of Mental Health, denounced the document as unscientific and useless. So if you're talking about a crisis, that's a crisis for the field. If its diagnostic system is being dissed by leading figures like that, what else was a problem?

当那份文件发布时，出现了很多批评，其中一些来自罗伯特·斯皮策（Robert Spitzer），他在很大程度上掌控了 DSM-III 和 DSM-III-R，然后是他的继任者艾伦·弗朗西斯（Allen Frances），他主持了 DSM-IV，他们都对发生的事情进行了激烈的批评，并表示这是在黑暗中进行的，是秘密进行的，并且不科学。当它即将发布时，托马斯·因塞尔（Thomas Insel）和史蒂文·海曼（Steven Hyman）——当时的前任美国国家精神卫生研究所（National Institute of Mental Health）主任——谴责这份文件不科学且无用。所以，如果你谈论的是危机，那就是该领域的危机。如果其诊断系统被像他们这样的领导人物苛评，那么还有什么问题吗？

安德鲁·斯卡尔（Andrew Scull）：

The difficulties with the drug existing therapies particularly had become more and more manifest. To make matters worse, partly because Big Pharma had sometimes behaved, shall we say, rather unethically. Sometimes with these drugs it had hidden things that undercut their claims, it had manufactured studies, it had manipulated data, and it got caught out and it paid billions of dollars in damages for some of the tricks it had got up to. Not just in psychiatry—I mean Vioxx, for example, the painkiller, was another huge scandal and it was a five billion dollar settlement—but the drug companies had suffered some reputational damage. Beyond that, they didn't have any real clues. Unfortunately neuroscience hadn't thrown up new targets for different forms of drug development, and they decided they could make

现有药物疗法的困难尤其变得越来越明显。更糟糕的是，部分原因是大型制药公司有时的行为，可以说，相当不道德。有时这些药物会隐瞒削弱其主张的内容，会制造研究，会操纵数据，结果被抓住，并为其中的一些伎俩支付了数十亿美元的赔偿金。不仅在精神病学领域——我的意思是万络（Vioxx），例如，这种止痛药，是另一个巨大的丑闻，达成了一项五十亿美元的和解——药企也因此遭受了一些声誉损失。除此之外，他们没有任何真正的线索。不幸的是神经科学并没有提供用于不同形式药物开发的新靶点，而他们决定可以继续

安德鲁·斯卡尔（Andrew Scull）：

more money with spending their money on research on other diseases, not mental illness. A crisis was you were stuck with a set of drugs that Steve Hyman says aren't really any advance on the ones by accident we found in the fifties, mm-hmm, and there isn't new research, unless it's small startups, going on to develop new ones. So, you have an increasing sense your diagnostic process is falling apart, your drug treatments' limitations are becoming more manifest, and as well, for people with serious mental illness, public policy has screwed things up badly. So, if you, a person with serious mental illness, you will die, on average, fifteen to twenty-five years before the rest of us. That gap has been growing rather than diminishing. So, that's not a good thing. It's not something I want to lay entirely at the door of psychiatry, so Don't get me wrong. I think a lot of this is public policy that has really abandoned treatment for the seriously mentally ill, and you see it on the streets of our cities. You see the sidewalk psychotics. You see people who are cycling between brief periods of inpatient care, the gutter, or the flop house, and the jail. So the three largest centers of inpatient psychiatric care, if you can call it that, in the United States today are the Los Angeles County Jail, Cook County Jail in Chicago, and Rikers Island in New York. That's shockingly because, by their very nature, of course, prisons aren't equipped to deal with serious mental illness.

更多的钱花在其他疾病的研究上，而不是精神疾病上。 一场危机是你被困在一系列药物中，史蒂夫·海曼说这些药物与我们在五十年代偶然发现的药物相比并没有任何进步，嗯，嗯，并且没有新的研究，除非是小型初创公司，正在开发新的药物。 因此，你越来越感觉到你的诊断过程正在崩溃，你的药物治疗的局限性变得更加明显，而且，对于患有严重精神疾病的人来说，公共政策已经把事情搞砸了。 所以，如果你是一个患有严重精神疾病的人，你平均会比我们其他人早十五到二十五年去世。 这种差距一直在扩大而不是缩小。 所以，这不是什么好事。 我不想把这完全归咎于精神病学，所以请不要误会我的意思。 我认为这很大程度上是公共政策真正放弃了对严重精神病患者的治疗，你在我们城市的街道上看到了这一点。 你会看到人行道上的精神病患者。 你会看到人们在短暂的住院治疗、阴沟、破房子和监狱之间骑自行车。 因此，当今美国最大的三个住院精神科护理中心（如果可以这样称呼的话）是洛杉矶县监狱、芝加哥的库克县监狱和纽约的赖克斯岛监狱。 这令人震惊，因为从它们的本质上讲，监狱当然不具备处理严重精神疾病的能力。

莱克斯·弗里德曼（Lex Fridman）：

Some dark ways to return to the asylum era.

回到精神病院时代的一些黑暗方式。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. Well, you know, the asylums had acquired a very bad reputation, and I've written about some of the reasons why that happened. But when asylums were founded, it was a period of enormous optimism that we were going to be able to cure these people, that we would rescue them from attics and from jail cells, and through providing a therapeutic environment, coaxing them to work, creating a system where they learn to control themselves, not necessarily to drive their demons out, but to keep them under some sort of wraps. The expectation was, when the asylums came along, is that they'd not only rescue people from horrendous conditions in the prisons and the jails, but they'd actively cure them. And the earliest alienists, as they called themselves then, thought that they could cure 60, 70, 80 percent, maybe even more, of patients as long as they came in early. And really, asylums were built out of that sense.

是的。你知道，精神病院的名声非常糟糕，我写过一些原因。但当精神病院成立时，是一个极度乐观的时期，我们相信我们能够治愈这些人，把他们从阁楼和牢房中救出来，通过提供治疗环境，引导他们工作，建立一个让他们学会自我控制的系统，不一定是为了驱赶他们的恶魔，而是用某种方式将他们隐藏起来。当精神病院出现时，人们的期望不仅是从监狱和拘留所的恶劣环境中救出人们，还能积极治愈他们。而最早的精神病院专家，他们当时自称，认为只要他们早点来，就能治愈 60%、70%、80%，甚至更多。实际上，精神病院正是基于这种意义而建的。

安德鲁·斯卡尔（Andrew Scull）：

Of optimism, that sense that we, you know, that so much was environmental and so much was not exacerbating the condition by treating people like animals or treating them, you know, beating them and in other ways horrifically maltreating them, that would create a sense of cure. And really, that underlay the construction of the asylums. And now having abandoned the asylums, which we did starting a little bit in the 1950s but really the late 1960s onwards, that was because there was going to be something miraculous called community care, but community care is a shell game without a pea. It's like one of those confidence tricks. There were no substitute community facilities for dealing with the really serious mentally ill.

乐观的情绪，那种感觉是，我们知道，很多情况是环境造成的，而很多情况并不是通过把人当作动物对待，或者打他们，以及以其他可怕的方式虐待他们而加剧病情，这样会产生治愈的感觉。实际上，这支撑了收容所的建立。而现在我们已经放弃了收容所，从 1950 年代开始有一点，但真正从 1960 年代后期开始，那是因为有一种被称为社区护理的奇迹般的东西，但社区护理其实是一个壳游戏，没有真正的物质基础，就像那些骗术中的花招一样。对于那些真正严重的精神病患者，并没有替代的社区设施来处理。

莱克斯·弗里德曼（Lex Fridman）：

So now we're in this truly, in this crisis- … in this essentially dark ages. And in part I think our conversation, our journey through the history of psychiatry- … is an exploration of some gigantic mistakes but also an exploration of where lay some hope for the future. So we'll talk quite a bit about this. I was wondering if you can also just lay out what are the big categories of mental illness that we're referring to. You've already hinted at them, but like levels of seriousness- … and the categories of illness- … like with psychosis and depression and so on.

所以现在我们确实处在这样一种危机中……在这本质上的黑暗时代中。在某种程度上，我认为我们的对话，我们对精神病学历史的探索……既是在探讨一些巨大的错误，也是在探讨未来的希望所在。所以我们会谈论很多这个话题。我在想，你是否也可以列出我们所指的主要心理疾病类别。你已经暗示过它们，但比如说严重程度的等级……以及疾病的类别……比如精神病性障碍、抑郁症等等。

安德鲁·斯卡尔（Andrew Scull）：

So going back to the early 20th century was when the German psychiatrist Emil Kraepelin, working with thousands of records in German asylums, inductively developed a distinction between two very broad categories of mental illness. One he called dementia praecox or early dementia, and the other he called manic depressive illness, which was a more remitting illness that sometimes went away entirely, other times went back and forth, whereas dementia praecox was a one-way ticket down. Now that label was transformed by a Swiss psychiatrist, Bleuler, into the term we use today, schizophrenia, although Bleuler talked about the schizophrenias because he thought under that broad label there were a diverse group of things running around. And I think that was an important insight that tends to get lost sometimes. This was jamming together people with very serious psychosis, that is, people who'd lost touch with what we like to think of as reality, whose emotional and cognitive lives were in total turmoil, who were — who lost the ability to connect with other human beings. So their social skills atrophied, their– Well, this is something contemporary psychiatrists would refer to as the positive and negative symptoms of schizophrenia.

回到 20 世纪初期，德国精神病学家 埃米尔·克雷佩林（Emil Kraepelin） 在研究德国精神病院的数千份记录后，归纳出两种非常广泛的精神疾病类别之间的区别。 一种他称之为早发性痴呆（dementia praecox）或早期痴呆，另一种他称之为躁狂抑郁疾病，这是一种病情较缓解的疾病，有时完全消失，有时则反复发作，而早发性痴呆（dementia praecox）是一张单程票。 现在，这个标签被瑞士精神病学家 布洛伊勒（Bleuler） 转变为我们今天使用的术语 精神分裂症，尽管 布洛伊勒（Bleuler） 谈到了 精神分裂症（复数），因为他认为在这个宽泛的标签下有各种各样的事物在运行。 我认为这是一个重要的见解，但有时往往会被迷失。 这是把患有非常严重的精神病的人挤在一起，也就是说，那些与我们所认为的现实脱节的人，他们的情感和认知生活完全混乱，他们失去了与其他人联系的能力。 所以他们的社交技能萎缩了，他们的——嗯，这就是当代精神病学家所说的精神分裂症的阳性和阴性症状。

莱克斯·弗里德曼（Lex Fridman）：

But underlying the definition of schizophrenia here is a detachment from reality. So you're hearing voices-

但这里对精神分裂症的定义的潜在含义是与现实脱节。所以你会听到声音——

安德鲁·斯卡尔（Andrew Scull）：

Yes

是

莱克斯·弗里德曼（Lex Fridman）：

… you're seeing visions.

……你正在看到幻象。

安德鲁·斯卡尔（Andrew Scull）：

You're thinking people are plotting against you. You think the television is talking directly to you.

你认为人们在密谋对付你。你觉得电视正在直接对你说话。

莱克斯·弗里德曼（Lex Fridman）：

And because of that, it has these consequences of how you're connected to the rest of the world and what your emotional life is like, all that kind of stuff.

正因为如此，这会带来这些后果，比如你与世界其他地方的联系以及你的情感生活是怎样的，所有那种事情。

安德鲁·斯卡尔（Andrew Scull）：

Yes. Your emotional life flattens out. Your language capacity deteriorates. Your ability to relate to other people either vanishes or becomes caught up in the web of delusions where you think people around you are plotting against you or doing terrible things to you.

是的。你的情感生活变得平淡无奇。你的语言能力退化。你与他人的关系能力要么消失，要么陷入妄想的网络中，你认为周围的人在密谋对付你或对你做可怕的事情。

莱克斯·弗里德曼（Lex Fridman）：

And is that a different world than the world of bipolar and the world of depression?

那是与躁郁症和抑郁症的世界不同的世界吗？

安德鲁·斯卡尔（Andrew Scull）：

Yes. The Greeks recognized and the Romans, ancient Greece and ancient Rome recognized different forms of insanity as they called it. So melancholia would have been the term the Greeks and the Romans would have used and it survived and was very much around. And I think that is a form of depression. What's happened now is major depression has become a catchall category. So it embraces both what we might think of as milder forms of emotional distress along with what melancholia referred to, which was really a kind of depression that had psychotic features. This loss of contact, as it were, with everyday reality.

是的。希腊人认识到，罗马人、古希腊人和古罗马人都把不同形式的疯狂当作一种疾病来认知。因此，忧郁症（melancholia） 可能就是希腊人和罗马人使用的术语，并且它一直存在，且非常普遍。我认为这是一种抑郁的形式。现在发生的情况是，重度抑郁 已经成为一个笼统的类别。因此，它既包括我们可能认为的较轻形式的情绪困扰，也包括 忧郁症（melancholia） 所指的那种抑郁，那实际上是一种具有 精神病性的 特征的抑郁。这种与日常现实的联系的丧失，某种程度上就是这样。

莱克斯·弗里德曼（Lex Fridman）：

Something you would talk about maybe like a clinical depression. And by the way, we should mention that this field in the 21st century is like a minefield.

你可能会谈论的一些事情，比如临床抑郁症。顺便说一下，我们应该提到，这个领域在 21 世纪就像一片雷区。

安德鲁·斯卡尔（Andrew Scull）：

Yes, very much so. So here's a very strange bit of historical record. The other distinction, and the distinction we're grappling with– so we have people who are– whose depression is of such a scale they're threatening to do away with themselves. They've retreated into complete, almost immobility. They're overwhelmed by senses of sadness and loss and they're– If they're religious, then they're damned to hell and all those kinds of things. So we have this psychosis that we've been talking about. We have something also that the ancients recognized: dementia, the loss, really the loss of our mind, as it were. But then we also have other kinds of disturbance of our mental faculties that generally we think of as more minor, but I don't want to make light of them because often people suffer from these things, genuinely suffer pretty badly. But those things we in the 20th and 21st centuries tend to talk about as neuroses, neurotic diseases, psychotic diseases. In the 19th century, neurosis was a term that meant things rooted in the brain, as you can see from the root of the word, and psychosis was stuff that came from the mind, the psyche.

是的，非常如此。 这是一段非常奇怪的历史记录。 另一个区别，也是我们正在努力解决的区别——所以我们有这样的人——他们的抑郁症严重到了他们威胁要自杀的程度。 他们已经完全退缩了，几乎一动不动。 他们被悲伤和失落的感觉压倒了，他们——如果他们有宗教信仰，那么他们就会下地狱和诸如此类的事情。 所以我们就有了我们一直在谈论的精神病。 我们也有一些古人认识到的东西：痴呆，损失，实际上是我们思想的损失。 但我们的心智也有其他类型的障碍，通常我们认为这些障碍比较轻微，但我不想轻视它们，因为人们经常遭受这些事情的痛苦，真的非常痛苦。 但我们在 20 世纪和 21 世纪倾向于将这些疾病称为神经症、神经症疾病、精神病疾病。 在 19 世纪，神经症 是一个术语，意思是根植于大脑的事物，正如你从这个词的词根中看到的那样，而 精神病性障碍 是来自思想、心灵的东西。

安德鲁·斯卡尔（Andrew Scull）：

And yet sometime in the late 19th century those things crossed over and so when we talk in the present we do tend to distinguish between the core, really the most severe forms of mental disorder, which would include things like Alzheimer's disease and other forms of dementia, would include very serious depression, would include bipolar disorder where people oscillate either have extreme mania so they're not getting any sleep. They're talking at an extraordinary rate. Their behavior is very hard to tolerate, and they're exhausting themselves, and they may even die from exhaustion if it's not controlled. And very often that alternates with periods of depression. So that was a category that was captured initially as manic depressive illness and later on evolved into bipolar disorder and then separating out depression and major depression separately. But then there are a whole bunch of other things like, for example, phobias. People can't go outside because they find it too frightening. Milder phobias: "I can't get in an airplane because it's gonna crash," "I can't go to school because it's overwhelming for me." So school phobia emerges as a diagnosis. A disorder that at first attracted Freud, hysteria.

然而，在 19 世纪末的某个时候，这些事情交叉了，所以当我们现在谈论时，我们确实倾向于区分核心的、真正最严重的精神障碍形式，其中包括 阿尔茨海默病 疾病和其他形式的 痴呆，包括非常严重的抑郁症，包括 双相障碍，人们要么有极端的躁狂，所以他们无法入睡。 他们说话的速度非常快。 他们的行为让人难以忍受，而且很累自己，如果不加以控制，甚至可能会累死。 而且这种情况常常与抑郁时期交替出现。 因此，这一类别最初被定义为 躁狂抑郁 疾病，后来演变为 双相障碍，然后分别将抑郁症和 重度抑郁 分开。 但还有很多其他的事情，例如恐惧症。 人们不敢出去，因为他们觉得外面太可怕了。 较轻的恐惧症：“我不能坐飞机，因为它会坠毁”，“我不能去学校，因为这对我来说太难以承受了。” 因此，学校恐惧症成为一种诊断。 这种病症最初吸引了弗洛伊德、歇斯底里。

莱克斯·弗里德曼（Lex Fridman）：

And now we should say you wrote a book on hysteria.

现在我们应该说你写了一本关于癔症（hysteria）的书。

安德鲁·斯卡尔（Andrew Scull）：

Oh, I did indeed, yes.

哦，我确实做了，是的。

莱克斯·弗里德曼（Lex Fridman）：

You mentioned … I mean, hysteria, every classification we're talking about has been used and abused by every layer of society including institutions- …including just culturally the word hysteria applied to different races disproportionately, to different, um-

你提到了……我是说，癔症（hysteria），我们讨论的每一种分类都被社会的每一层，包括机构，使用和滥用——……包括仅仅在文化上，癔症（hysteria）这个词被不成比例地应用于不同的种族，对不同的，嗯——

安德鲁·斯卡尔（Andrew Scull）：

Genders particularly, yes, yes.

性别尤其是的，是的，是的。

莱克斯·弗里德曼（Lex Fridman）：

…genders disproportionate- So we're in this crisis of trying to figure out what to do with this super complicated human mind- …and everybody is dogmatically creating narratives that hold, take hold, and in so doing can lead to some abuses-

……性别比例失衡——所以我们正处在试图弄清如何处理这个极其复杂的人类大脑的危机中——……而每个人都固执地创造叙事，这些叙事会生效、被采纳，并且在这样做的过程中可能导致一些滥用行为——

安德鲁·斯卡尔（Andrew Scull）：

Yes, they do. Yes, they do.

是的，他们是的。是的，他们是的。

莱克斯·弗里德曼（Lex Fridman）：

…as you document.

……正如你所记录的。

安德鲁·斯卡尔（Andrew Scull）：

If you look back at the asylum era born in this period of intense optimism, and then the claims to be able to cure these vast numbers of patients were overblown. Uh, I do believe the early asylums actually did good work and that some patients did very well and recovered as a result of their stays. But what happened, they weren't discharging 80% of their patients. They were discharging 35 or 40% of their patients, and what that meant is every year left behind were a batch of chronic patients, and then the next year you repeated it. And over time, what that means is the ratio of new patients to chronic patients gets worse and worse. And more and more the image of the asylum is defined by the chronic patient who hasn't recovered and maybe spends years or decades there and only leaves in a pine box. So the, the image of the asylum declined drastically. As they became more and more overcrowded, conditions in them deteriorated. Patients were often abused. Psychiatrists didn't know what to do with them, and they faced a problem in the late 19th century. You'd promised 70% or 80% cures, but we're not seeing that. In fact, when we calculate cures and the numbers of people in the asylum, it's more like 10% or 12%. That's the way you could play with statistics 'cause that's all the old patients mixed with the new. But still, it looks very bad. How do you explain this doctor?

如果你回顾一下诞生于这段强烈乐观主义时期的庇护时代，那么声称能够治愈这些大量患者的说法就有些言过其实了。 呃，我确实相信早期的收容所实际上做得很好，一些病人做得很好，并因住院而康复。 但实际情况是，他们没有让 80% 的病人出院。 他们让 35% 或 40% 的病人出院，这意味着每年都会留下一批慢性病人，然后第二年你又重复这样的情况。 随着时间的推移，这意味着新患者与慢性患者的比例变得越来越糟。 越来越多的精神病院的形象是由尚未康复的慢性病患者定义的，他们可能在那里度过数年或数十年，最后只能留在松木盒子里。 于是，收容所的形象急剧下降。 随着它们变得越来越拥挤，里面的条件也恶化了。 病人经常受到虐待。 精神科医生不知道该如何处理他们，他们在 19 世纪末面临着一个问题。 你曾承诺治愈 70% 或 80%，但我们没有看到这一点。 事实上，当我们计算治愈率和收容所的人数时，它更像是 10% 或 12%。 这就是你可以使用统计数据的方式，因为所有的老病人都与新病人混合在一起。 但看起来还是很糟糕。 这位医生怎么解释呢？

安德鲁·斯卡尔（Andrew Scull）：

You've promised us one thing, and you delivered something quite different. The answer came in a way of blaming the victim, in a way of saying, "Well, you know, what we didn't understand was that mental illness is a fundamentally biological condition. These people are evolutionary throwbacks." Evolution was generally thought of as a progressive onwards and upwards, but these people had fallen back into a, into a, a, a lesser form of existence. They'd lost their essential humanity because their brains were defective. So what emerged then was the idea of degeneration, the idea that these patients were degenerates. They were people with an inferior biology. You couldn't release them because they breed like rabbits. They didn't have any self-control because of their diminished humanity.

你向我们承诺了一件事，但你交付的却完全不同。答案的方式带有指责受害者的意味，仿佛在说：“嗯，你知道，我们之前没有理解的是，精神疾病从根本上是生物学上的状况。这些人是进化的返祖者。”进化通常被认为是不断向前和向上的，但这些人却退回到了一种较低的生存状态。他们失去了基本的人性，因为他们的大脑有缺陷。因此，随之出现的就是“堕落”的概念，也就是认为这些患者是堕落者。他们是拥有劣等生物学特征的人。你无法释放他们，因为他们像兔子一样繁殖。由于他们人性减弱，他们没有任何自我控制能力。

莱克斯·弗里德曼（Lex Fridman）：

This is the narrative.

这是叙述。

安德鲁·斯卡尔（Andrew Scull）：

This is the narrative. And so what it did was provide a justification for locking up people in asylums that wasn't therapeutic at all. It was just keeping them out of the way.

这是叙述。它所做的就是为将人们关进收容所提供了一个完全不具治疗性的理由。它只是把他们关起来，不让他们碍事。

莱克斯·弗里德曼（Lex Fridman）：

And then it led to the justification of sterilization- ….based on the same argument.

然后这导致了对绝育的合理化——……基于相同的论点。

安德鲁·斯卡尔（Andrew Scull）：

So if maybe we can release them if we make sure they can't breed.

所以如果我们确保它们不能繁殖，或许我们可以放生它们。

莱克斯·弗里德曼（Lex Fridman）：

This is the beginning of the darkness.

这是黑暗的开始。

安德鲁·斯卡尔（Andrew Scull）：

It is the beginning of the darkness. My own state was one of the pioneers in this process, and it continued to sterilize mental patients up until about 1960.

这是黑暗的开始。我的州在这一进程中是先锋之一，并且这一过程一直持续对精神病患者进行做绝育，直到大约 1960 年。

莱克斯·弗里德曼（Lex Fridman）：

By the 1960s, over 60,000 sterilizations have been performed in the US with California performing a disproportionally high number.

到 20 世纪 60 年代，美国已经进行了超过 60,000 次绝育手术，其中加州的手术数量 disproportionately 高。

安德鲁·斯卡尔（Andrew Scull）：

That's correct. But even more serious consequences could flow from these set of issues. When you start talking, one, one British psychiatrist said that if his patients that were coming into the asylum had been puppies, we'd have tied them up in a sack because they were some horrible mongrel, not a purebred dog, tied them up in a sack with some lead weights, and thrown them in a pond and drowned them.

没错。但这些问题可能引发的后果甚至更严重。当你开始谈论时，有一位英国精神病学家说，如果他接收的精神病院的病人是小狗的话，我们会把它们绑在麻袋里，因为它们是一些可怕的杂交狗，而不是纯种狗，把它们绑在带铅重物的麻袋里，然后扔进池塘淹死它们。

莱克斯·弗里德曼（Lex Fridman）：

Man.

男人

安德鲁·斯卡尔（Andrew Scull）：

That kind of language is very, very dangerous. And what happened, California's law surrounding sterilization was advocated for in the West. By that I mean North America and, and Britain and much of Europe. There were enough checks and balances in a democratic system that even though there were enthusiasts, the eugenicists who said, "Best get rid of these people, put them to death," uh, that never really, that never really acquired mass support. But what happened in Germany once Nazi– the Nazis came to power is they seized on these notions and that the idea that the mentally ill were, as they put it, useless eaters, people consuming resources but never gonna get better, just a burden on the state. Their lives weren't worth living because after all, they had this serious mental illness.

那种语言非常非常危险。发生的事情是，加州 关于 绝育 的法律在西方被倡导。我的意思是北美，以及英国和欧洲大部分地区。在民主制度中，有足够的制衡机制，因此即使有一些热心者，也就是那些优生学家说“最好摆脱这些人，让他们死去”，呃，这从未真正获得大众支持。但在德国，当 纳粹 上台后发生的事情是，他们利用了这些观念，并认为精神病患者，正如他们所说，是无用的吃饭者，消耗资源却永远不会好，只是国家的负担。他们的生命不值得活，因为毕竟，他们有严重的精神疾病。

安德鲁·斯卡尔（Andrew Scull）：

So first you sterilize, and then you go, "But we're still supporting all these people." And so Hitler starts something called the T4 program after the street name of the house where this was concocted, Tiergartenstraße 4. And the mentally ill were the first people to suffer from the Final Solution. It was in the mass killing of the mentally ill, which may have been as many as a quarter million people, that the technology of the gas chamber was developed, and the technology of disguising the gas chamber as showers was developed. And so patients were taken away to a number of psychiatric centers and systematically put to death, and they had, they had the crematoriums and the black smoke, and local people talked about the buses that were bringing them in as killing crates. So they were aware of what was going on.

所以首先你进行做绝育，然后你会说，“但是我们仍然在支持所有这些人。”于是希特勒发起了一个叫做 T4 计划的计划，这个名字来自策划此事的房子的街道名，Tiergartenstraße 4。精神病患者是最先在最终解决方案中受苦的人。在大规模屠杀精神病患者的过程中，可能有多达 25 万人，毒气室的技术得以开发，并且将毒气室伪装成淋浴的技术也得以发展。因此，患者被送往若干精神病中心，并被系统性地处决，他们有火葬场和黑烟，当地人谈论过那些载着他们的巴士，被称为杀人箱。所以他们知道发生了什么。

莱克斯·弗里德曼（Lex Fridman）：

Were they influenced by the narratives that were born in the United States?

他们是否受到诞生于美国的叙事的影响？

安德鲁·斯卡尔（Andrew Scull）：

Yes, absolutely. They-

是的，当然。他们-

莱克斯·弗里德曼（Lex Fridman）：

About this kind of-

关于这种-

安德鲁·斯卡尔（Andrew Scull）：

About that sort of thing, and lacking the checks and balances that at least until recently this country had, it was relatively easy for Hitler to do that. And particularly with the war looming, the idea that we're gonna support all these useless people, let's kill them. And German psychiatry for the most part collaborated with that process.

关于那类事情，并且缺乏至少直到最近这个国家所拥有的制衡机制，对于希特勒来说，这相对容易做到。特别是在战争临近的时候，支持所有这些无用的人这一想法出现了，我们干脆杀了他们。而大部分德国精神病学界在这个过程中都是合作的。

莱克斯·弗里德曼（Lex Fridman）：

I wonder how many people throughout that whole journey in the psychiatry profession sort of were brave enough to speak up like, "Hey, maybe the sack of puppies kinda language-"

我想知道在整个精神病学职业生涯中，有多少人勇敢到会站出来说，‘嘿，也许那种小狗的语言有点——’

安德鲁·斯卡尔（Andrew Scull）：

Oh, yes. Oh, yes.

哦，是的。哦，是的。

莱克斯·弗里德曼（Lex Fridman）：

… is a problem?"

……是个问题吗？

安德鲁·斯卡尔（Andrew Scull）：

That's the really nasty direction that that language could lead to. And it was symptomatic of the kind of stigma that tends to attach itself to mental illness and this sense of hopelessness. So but if you're a healing profession, if you enter psychiatry thinking, "I'm gonna do this to help people, to cure people, to make their lives better," to just become a glorified boarding housekeeper keeping them under lock and key or in the alternative to collaborate in the sorts of awfulness that the Nazis perpetrated, that's something from which decent human beings tend to recoil and decent psychiatrists tended to recoil. And so still thinking as they did by the end of the 19th century that mental illness was predominantly a biological problem, some of them began to say, "Well, maybe biology as well as being the problem could provide the solution. Maybe we should look for ways to intervene in the biological systems of these people and make them better." The same logic that applies I would say in the present- … For, for many working in the field.

这才是该语言可能导致的真正令人讨厌的方向。 这是一种往往与精神疾病和绝望感联系在一起的耻辱感的症状。 所以，如果你从事治疗职业，如果你进入精神病学领域，你会想：“我要做这件事是为了帮助人们，治愈人们，让他们的生活变得更好”，只是成为一名光荣的寄宿管家，将他们牢牢锁住，或者与纳粹所犯下的可怕罪行合作，那么正派的人类往往会畏缩，正派的精神病医生也会畏缩。 因此，他们中的一些人仍然像 19 世纪末那样认为精神疾病主要是一个生物学问题，因此开始说：“好吧，也许生物学以及问题本身都可以提供解决方案。也许我们应该寻找方法来干预这些人的生物系统，让他们变得更好。” 我想说的同样的逻辑适用于现在——……对于许多在该领域工作的人来说。

莱克斯·弗里德曼（Lex Fridman）：

But in a cruder form.

但是以一种更粗糙的形式。

安德鲁·斯卡尔（Andrew Scull）：

But in a very different form, exactly.

但以一种非常不同的形式，正是如此。

莱克斯·弗里德曼（Lex Fridman）：

Yeah. If we can just speak about the Nazis a bit more, you highlight that America financially supported the German psychiatric researchers with deep Nazi ties like Ernst Rüdin who was the key architect of Hitler's mass sterilization and extermination laws. So it seems like the Nazis borrowed the American narratives of the psychiatrist that these are lesser biological beings and then this financial support and the ties continued.

是的。如果我们能多谈一下纳粹，你强调了美国在经济上支持与纳粹有深厚联系的德国精神病学研究人员，比如鲁丁，他是希特勒大规模绝育和灭绝法律的主要设计者。所以看起来纳粹借鉴了美国精神病学家关于这些人是较低等生物的叙述，然后这种经济支持和联系得以延续。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. So one of the organizations that recognized that mental illness was an acute social problem, very costly to the state, inflicting all kinds of suffering on people, was The Rockefeller Foundation. What we don't realize today is that the involvement of the federal government in medical research and indeed scientific research is a World War II and post-war development, partly the Cold War and Sputnik and all of that. But that's when big science and big medicine got funded- in extravagant ways. Before the war, science was an orphan. It didn't get money from the government much and medicine even more so. So to the extent medical training was reformed, that was the product of investment by The Rockefeller Foundation, enormously wealthy by the standards of the time. And come about 1930, The Rockefeller Foundation decided it needed to concentrate its resources and pick priorities for the money it was investing. And it may seem a rather strange thing within the whole range of medical areas that it could choose, it chose psychiatry as the one that it was going to invest in. And I think it did so in part precisely because scientific research in psychiatry was so backward, partly because it was such a pressing public problem.

是的。 因此，The 洛克菲勒基金会（Rockefeller Foundation） 是认识到精神疾病是一个严重的社会问题的组织之一，它给国家带来了巨大的损失，给人们带来了各种痛苦。 今天我们没有意识到的是，联邦政府对医学研究和科学研究的参与是第二次世界大战和战后的发展，部分是冷战和人造卫星等等。 但就在那时，大科学和大医学得到了资助——以奢侈的方式。 战前，科学是一个孤儿。 它从政府那里得到的钱不多，药品更是如此。 因此，就医疗培训的改革而言，这是洛克菲勒基金会（Rockefeller Foundation）投资的产物，按照当时的标准，他们是非常富有的。 大约在 1930 年，洛克菲勒基金会（Rockefeller Foundation） 决定需要集中资源并选择投资的优先顺序。 在它可以选择的整个医疗领域中，它选择精神病学作为它要投资的领域，这似乎是一件相当奇怪的事情。我认为它这样做的部分原因是精神病学的科学研究非常落后，部分原因是它是一个如此紧迫的公共问题。

莱克斯·弗里德曼（Lex Fridman）：

Hmm.

嗯。

安德鲁·斯卡尔（Andrew Scull）：

And partly, and this was less public but nonetheless I think played an important role, several of the trustees of The Rockefeller Foundation had direct experience of mental illness in their families. Wives who'd been institutionalized as schizophrenic. In one case, a wife who murdered the children and killed herself, leaving her husband as a major actor in The Rockefeller Foundation, berefted and of course inclined then to support research in this area. And Rockefeller spread its money very widely precisely 'cause it didn't know where to spend most of its money. So it did some support of psychotherapeutics. It supported a number of the then extant therapeutic experiments going on, and it supported work in genetics. And one of the geneticists it supported, Ernst Rüdin in Germany, who was the leading German researcher in genetics and mental disorder. And Rüdin, because he'd absorbed the lessons from California about sterilization, became a very enthusiastic proponent of that, and then a supporter of murdering mental patients.

部分原因是，虽然这件事不太公开，但我认为发挥了重要作用，洛克菲勒基金会（Rockefeller Foundation） 的几位受托人在他们的家庭中直接经历过精神疾病。 被收容为 精神分裂症患者 的妻子。 在一个案例中，一位妻子谋杀了孩子并自杀，让她的丈夫成为《摇滚》的主要演员，她失去了亲人，当然倾向于支持这一领域的研究。 洛克菲勒将资金分散得非常广泛，正是因为它不知道把大部分钱花在哪里。 所以它对心理治疗做了一些支持。 它支持了许多当时正在进行的治疗实验，并且支持了遗传学方面的工作。 它支持的其中一位遗传学家是德国的恩斯特·吕丁（Ernst Rüdin），他是德国遗传学和精神障碍领域的领先研究员。 而恩斯特·吕丁（Ernst Rüdin），因为他吸收了加州关于绝育的教训，成为了这一点的非常热心的支持者，然后又成为了谋杀精神病人的支持者。

莱克斯·弗里德曼（Lex Fridman）：

And we should say, I mean, we'll probably talk about the complicated nature of science- …that it sometimes can be captured by certain ideologies and- …in so doing do a lot of damage to humanity. But ultimately, the beacon of hope for the future of humanity lays in the scientific method, as flawed as it is. So everything we're talking about, we get to see how you F up- In a major dark disturbing ways throughout the 20th century- …on the– in the psychiatric profession. But that should be instructive lessons of how we proceed forward to do better and better and better.

我们应该说，我的意思是，我们可能会谈到科学的复杂性……它有时会被某些意识形态所左右……在这样做的过程中对人类造成很大的伤害。但归根结底，人类未来的希望之光在于科学方法，尽管它有缺陷。所以我们讨论的所有内容，都让我们看到你们在整个 20 世纪……在精神病学领域以一种严重、黑暗、令人不安的方式搞砸了事情。但这些都应该成为如何继续前进、不断做得更好、更好的有益教训。

安德鲁·斯卡尔（Andrew Scull）：

We can discuss a series of therapeutic experiments on people who were shut up in a double sense. They were locked away, and their voices were not heeded because it was the product of their madness. And so what we see in the first five decades really of the 20th century is people with a variety of motivations including the desire to improve the lot of the mentally ill engaging in uncontrolled experiments that had terrible results. And the science behind it was shaky but nonetheless it existed. It wasn't just plucked out of the sky. And yes, eventually those things break down. I mean, the clearest case of that because it's the most extreme of these at least in the public imagination is lobotomy. The idea that you are going to solve psychotic breakdowns in people by excising part of their brain initially by drilling holes in the skull and injecting alcohol or using what looks like a butter knife to break connections between the brain. And then later when that process seems to be too slow, the Henry Ford of lobotomy — his daughter said Walter Freeman aspired to be the Henry Ford of lobotomy, the one who could mechanize the production of it and get it done fast. He invented the ice pick lobotomy where you used an ice pick in the orbit of the eye having rendered somebody unconscious after two or three electric shocks and you banged it through the bone and wiggled it about and severed — I mean, it's just hard to even describe.

我们可以讨论一系列针对被双重关押的人的治疗实验。 他们被锁起来，他们的声音没有被理会，因为这是他们疯狂的产物。 因此，我们在 20 世纪的前 50 年看到的是，人们有着各种各样的动机，包括希望改善精神病患者的命运，从事不受控制的实验，但结果却很糟糕。 虽然其背后的科学原理并不可靠，但它仍然存在。 它不只是从天上掉下来的。 是的，最终这些东西都会崩溃。 我的意思是，最清楚的例子是 脑白质切除术（lobotomy） ，因为至少在公众的想象中这是最极端的。 这个想法是，你要通过在头骨上钻孔并注射酒精或使用看起来像黄油刀的东西来切断大脑之间的连接来切除部分大脑来解决人们的精神病性崩溃问题。 后来，当这个过程似乎太慢时，脑白质切除术（lobotomy） 的亨利·福特——他的女儿说 沃尔特·弗里曼（Walter Freeman） 渴望成为 脑白质切除术（lobotomy） 的亨利·福特，一个能够实现生产机械化并快速完成的人。 He invented the ice pick 脑白质切除术（lobotomy） where you used an ice pick in the orbit of the eye having rendered somebody unconscious after two or three electric shocks and you banged it through the bone and wiggled it about and severed — I mean, it's just hard to even describe.

莱克斯·弗里德曼（Lex Fridman）：

So this is from the 1930s to the 1970s?

所以这是从 1930 年代到 1970 年代的吗？

安德鲁·斯卡尔（Andrew Scull）：

Yes. Freeman starts his work in 1936 borrowing from the work of the preceding year of a Portuguese neurologist named Egas Moniz. And Moniz wins the Nobel Prize in medicine in 1949 for lobotomy. So it's important to see that. That was 14 years of experience and yet that won a Nobel Prize. I'm sure that's one they'd like to retract.

是的。沃尔特·弗里曼（Walter Freeman） 在 1936 年开始他的工作，他借鉴了前一年一位名叫 埃加斯·莫尼兹（Egas Moniz） 的葡萄牙神经学家的研究成果。而 埃加斯·莫尼兹（Egas Moniz） 因 脑白质切除术（lobotomy） 在 1949 年获得了 诺贝尔奖 医学奖。所以看到这一点很重要。那是 14 年的经验，但却赢得了 诺贝尔奖。我相信这是他们想要撤回的一个奖项。

莱克斯·弗里德曼（Lex Fridman）：

So he popularized, Walter Freeman, the ice pick.

所以他使冰镐流行起来，沃尔特·弗里曼（Walter Freeman）。

安德鲁·斯卡尔（Andrew Scull）：

And his particular specialty after the war became this ice pick lobotomy because there were over half million patients in America's mental hospitals. Freeman was convinced this operation was a cure-all. And so he traveled around in a camper truck which he called the Lobotomobile, and he would descend in the summer on state hospitals and he would teach them how to do this ice pick lobotomy.

战后，他的特别专长变成了这种冰锥脑叶切除术脑白质切除术（lobotomy），因为美国的精神病院有超过五十万名患者。沃尔特·弗里曼（Walter Freeman） 坚信这种手术是万能疗法。因此，他开着一辆他称之为 「脑白质切除车」（Lobotomobile） 的房车周游各地，夏天时会来到州立医院，教他们如何进行这种冰锥脑叶切除术脑白质切除术（lobotomy）。

莱克斯·弗里德曼（Lex Fridman）：

This is by the way image of the tool.

顺便说一下，这是这个工具的图片。

安德鲁·斯卡尔（Andrew Scull）：

Yes, those are the tools he used. Originally, he used an actual ice pick and then he developed this-

是的，那些就是他使用的工具。起初，他使用的是实际的冰锥，然后他开发了这个——

莱克斯·弗里德曼（Lex Fridman）：

This is what he developed. This is the state-of-the-art technology.

这就是他开发的。这是最先进的技术。

安德鲁·斯卡尔（Andrew Scull）：

This is the state of the art with a hammer or a mallet.

这是使用锤子或木槌的最新技术。

莱克斯·弗里德曼（Lex Fridman）：

Oh no!

哦不！

安德鲁·斯卡尔（Andrew Scull）：

Yes, I'm sorry. It's very distressing. I don't know-

是的，对不起。这非常令人痛苦。我不知道——

莱克斯·弗里德曼（Lex Fridman）：

You having to write about this, by the way –

顺便说一下，你必须写关于这个的内容——

安德鲁·斯卡尔（Andrew Scull）：

Well, it's really-

嗯，这真的——

莱克斯·弗里德曼（Lex Fridman）：

Is a lot.

很多。

安德鲁·斯卡尔（Andrew Scull）：

…very, very, very, very difficult. I came across, for example, a picture of a woman, a naked woman being dragged away by attendants to be lobotomized, and she's resisting with all her might, and to no avail. You have a picture there of Walter Freeman lobotomizing a patient in Washington State. Freeman was ambidextrous, and when he taught neurology, he would draw simultaneously with his left and right hand, and he could do it perfectly. When he was performing lobotomy, when his right hand got tired, he switched to his left hand, and he sometimes would do 20 or 30 lobotomies in an afternoon. And he boasted, he said, "You know, I could teach any damn fool to perform a lobotomy in twenty minutes, even a psychiatrist." Because Freeman was a neurologist, and he had a lot of contempt for psychiatrists. So this was a very ugly episode. How did it die away? It really took generational change. Some of these lobotomists continued to operate into the sixties, even to the early seventies, but the younger generation who became acquainted with the really worst failures of that regime — the people on the back wards who were incontinent, who were basically zombies, had lost all mental power — they rebelled against this, and by then they had a different treatment in the form of antipsychotic drugs-

……非常、非常、非常、非常困难。 比如我看到一张女人的照片，一个裸体女人被服务员拖走去做脑叶白质切除术，她极力反抗，但无济于事。 你那里有一张沃尔特·弗里曼（Walter Freeman）在华盛顿州对一名患者进行脑白质切除术的照片。 沃尔特·弗里曼（Walter Freeman）双手灵巧，在教授神经病学时，他会用左手和右手同时画画，而且画得非常完美。 他在表演脑白质切除术（lobotomy）时，右手累了，就换左手，有时一个下午会做 20、30 个脑白质切除术（lobotomy）。 他吹嘘道，“你知道，我可以在二十分钟内教任何该死的傻瓜表演脑白质切除术（lobotomy），甚至是精神病医生。” 因为沃尔特·弗里曼（Walter Freeman）是一名神经科医生，他非常蔑视精神科医生。 所以这是一个非常丑陋的插曲。 它是怎么消亡的？ 这确实需要一代人的变革。 其中一些脑叶白质切除术医生一直持续到六十年代，甚至到七十年代初期，但年轻一代逐渐了解了该政权真正最严重的失败——那些在后院失禁的人，基本上是僵尸，已经失去了所有的精神力量——他们反抗这一点，到那时，他们以抗精神病药药物的形式接受了不同的治疗——

安德鲁·斯卡尔（Andrew Scull）：

… which looked much more like what regular medicine was doing and didn't have these horrible overtones. And of course, in the popular mind, I think the probably the most famous instance of telling the public about some of these interventions was the film of Ken Kesey's novel One Flew Over the Cuckoo's Nest, where you see Jack Nicholson, giving I think the performance of a lifetime, who is given ECT, electroconvulsive therapy, in a very dramatic rendition of what that was — not, not really what was going on by the 1970s with ECT, but nonetheless, certainly what had been going on back in the past. And then finally, when ECT doesn't smash him to bits, they lobotomize him. And, and the film ends obviously with him being smothered to death 'cause Chief can't bear to see him in, in the state that he's in. So that fixed in the public mind some of the images of these things. It is one of the things that gave electroconvulsive therapy such a bad name.

……这更像是普通医学正在做的事情，并没有这些可怕的负面意味。当然，在大众的观念中，我认为可能最著名的向公众展示其中一些干预措施的例子是根据肯·克西（Ken Kesey）的小说《飞越疯人院》（One Flew Over the Cuckoo's Nest）拍摄的电影，你会看到杰克·尼科尔森（Jack Nicholson），我认为这是他一生中最精彩的表演，被施以电休克疗法（ECT），以一种非常戏剧化的方式展现了那是什么——并不是 1970 年代施行电休克疗法（ECT）的真实情况，但无论如何，这确实是过去曾经发生过的事情。然后，最后当电休克疗法（ECT）没有把他打得粉碎时，他们就对他做脑白质切除术。电影显然以他被闷死的结局收尾，因为 Chief 无法忍受看到他处于那种状态。这在公众心中固定了对这些事情的一些印象。这也是让电休克疗法（electroconvulsive therapy）声名狼藉的原因之一。

莱克斯·弗里德曼（Lex Fridman）：

So we will actually, not to fast forward too quickly,- -… let's talk about the full journey of everything we've been talking about. So we mentioned the asylum era that began in the mid-nineteenth century going into twentieth, and we talked about the narratives-

所以我们实际上，不要太快地跳过去——……让我们谈谈我们一直在讨论的整个历程。所以我们提到了始于十九世纪中叶、进入二十世纪的精神病院时代，并且我们讨论了这些叙述——

安德鲁·斯卡尔（Andrew Scull）：

And we talked about sterilization.

我们还谈到了绝育。

莱克斯·弗里德曼（Lex Fridman）：

Sterilization. And let's look at the insulin shock therapy of nineteen thirty three to the ninteen sixties where you were putting patients in deep hypoglycemic comas using large doses of insulin.

绝育。让我们看看从 1933 年到 1960 年代的胰岛素休克疗法，当时你们使用大剂量胰岛素让患者进入深度低血糖昏迷。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. So as I mentioned for psychiatrists who went into the field and were ambitious but who also wanted to think of themselves as therapeutic agents- ….uh, to just sit there passively and contain the patients was very unattractive. And so they looked around for ways in which perhaps biological interventions could be used to ameliorate this condition that they still saw in largely biological terms. Now in some ways, one of the crucial early ways in which this thinking went and which affected a large number of patients was this: one of the few diagnostic triumphs of psychiatry in the early nineteenth century as the profession began to emerge was that it began to distinguish a group of patients who were deemed to be suffering from something called General Paralysis of the Insane. That encapsulates two things about what was going on. First of all, paralysis; the gradual loss of motor control, ability to walk, ability to swallow, ability to talk. So those are primarily what we'd think of these days as neurological issues. But those were accompanied by bizarre psychiatric symptomatology. These were people who thought they were Napoleon or Jesus Christ or the richest and sexiest man in the world-

是的。 正如我所提到的，那些进入该领域并雄心勃勃但也想将自己视为治疗剂的精神科医生——……呃，只是被动地坐在那里并遏制患者是非常没有吸引力的。 因此，他们四处寻找也许可以使用生物干预措施来改善这种情况的方法，而他们仍然在很大程度上从生物学角度看待这种情况。 从某种程度上来说，这种思想的早期影响之一是：十九世纪初期，随着精神病学专业的兴起，精神病学在诊断上取得的少数胜利之一是，它开始区分一组被认为患有麻痹性痴呆（General Paralysis of the Insane）疾病的患者。 这概括了正在发生的两件事。 首先是瘫痪； 逐渐丧失运动控制、行走能力、吞咽能力、说话能力。 所以这些主要是我们现在所认为的神经系统问题。 但这些都伴随着奇怪的精神症状。 这些人认为自己是拿破仑或耶稣基督或世界上最富有和最性感的男人 -

安德鲁·斯卡尔（Andrew Scull）：

…or Mary the mother of God. They were primarily men but there were also female victims. At the turn of the twentieth century as many as twenty five percent of the people being admitted to asylums were suffering from General Paralysis of the Insane or GPI for short. There have been a lot of suspicions about this being connected somehow to sex and to moral dissolution and so forth but what evolved in the early twentieth century was the discovery of the actual origins of this disorder. So I've said psychiatry has been looking for the underlying pathology that lies behind mental diseases. This was one that at Rockefeller Institute they discovered that the organism that causes syphilis was residing in the brains of the people who were suffering from GPI.

……或者圣母玛利亚。他们主要是男性，但也有女性受害者。在二十世纪初，住进精神病院的人中多达百分之二十五患有麻痹性痴呆（General Paralysis of the Insane），简称麻痹性痴呆（GPI）。人们一直怀疑这与性和道德堕落等有关，但在二十世纪初发展起来的是对这种疾病的实际起源的发现。所以我说过，精神病学一直在寻找精神疾病背后的潜在病理。这就是在洛克菲勒研究所（Rockefeller Institute）他们发现导致梅毒的微生物存在于患有麻痹性痴呆（GPI）的人脑中的一例。

安德鲁·斯卡尔（Andrew Scull）：

This was in fact tertiary stage of syphilis. Syphilis is still a real public health problem. It was like AIDS in the late nineteenth century. It was everywhere. And when you first contract syphilis in the primary phase you have pain, but then it goes underground and you think it's gone and it lurks the way chicken pox virus lurks and can surface years later, right? It lurks, it lurks, and it's insidiously damaging. Sometimes it attacks the um, heart and people drop dead of a heart attack in their forties. Ohh, he died of a r– You know, it's natural heart attack, but in fact it was the syphilis. Or it attacks the central nervous system, the spinal column and the brain, and then you get the paralysis – Mm-hmm …and then you get also the psychiatric symptomatology. So when that was discovered, that sort of suggested that mental illness might have an infectious origin. Tertiary syphilis, GPI, went on to win for somebody who developed a treatment for it a Nobel Prize, one of only two awarded for psychiatric innovations. One was a lobotomy, the other was giving people malaria to cure their syphilis.

这实际上是梅毒的第三阶段。 梅毒仍然是一个真正的公共卫生问题。 这就像十九世纪末的艾滋病。 它无处不在。 当你在初级阶段第一次感染梅毒时，你会感到疼痛，但随后它会转入地下，你认为它已经消失了，它像水痘病毒一样潜伏着，几年后就会浮出水面，对吗？ 它潜伏着，它潜伏着，而且具有阴险的破坏力。 有时它会攻击嗯，心脏，人们在四十多岁的时候就死于心脏病。 哦，他死于 r——你知道，这是自然心脏病发作，但实际上是梅毒。 或者它攻击中枢神经系统、脊柱和大脑，然后你就会出现瘫痪——嗯嗯……然后你也会出现精神症状。 因此，当这一点被发现时，这就表明精神疾病可能具有传染性。 三等奖 梅毒 、 麻痹性痴呆（GPI） 因开发出一种治疗方法而荣获 诺贝尔 奖，这是仅有的两项因精神病学创新而获奖的奖项之一。 一个是脑白质切除术（lobotomy），另一个是给人们疟疾来治愈他们的梅毒。

莱克斯·弗里德曼（Lex Fridman）：

In case people didn't hear that- Giving people malaria- .. In order to cure syphilis

以防有人没听到——给人们疟疾——为了治疗梅毒

安德鲁·斯卡尔（Andrew Scull）：

So there was an Austrian doctor, Wagner-Jauregg, who had long thought that fever could be used to cure mental illness. And he tried rat bite fever. He tried giving people typhoid vaccine that creates a fever to no avail. And towards the end of World War I, the Italians were fighting in World War I on the side of the British and the Americans and the French. They captured an Italian soldier who had malaria. Malaria was endemic in those years in Italy. And they brought him to him, and he extracted the malarial blood and injected it into a series of patients with GPI, with general paralysis of the insane, and claimed it cured them. We know from later on when he fessed up that those claims were wildly exaggerated, but they were widely accepted, and malarial treatment spread to Britain, it spread to Germany, it spread to the United States. Sometimes it was vials of malarial blood, but very often mental hospitals had actual colonies of malarial mosquitoes. So imagine you're a mental patient, and you're put in a straitjacket, and you're put in a room, and you can't move, and mosquitoes are buzzing around, and they bite you, and then you develop malaria.

所以有一位奥地利医生瓦格纳-尧雷格（Wagner-Jauregg），他很早就认为发烧可以用来治疗精神疾病。 他还尝试过鼠咬热。 他尝试给人们接种导致发烧的伤寒疫苗，但没有成功。 第一次世界大战即将结束时，意大利人在第一次世界大战中与英国人、美国人和法国人并肩作战。 他们抓获了一名患有疟疾的意大利士兵。 那些年，疟疾在意大利流行。 他们把他带到他身边，他提取了疟疾的血液并将其注射到一系列患有麻痹性痴呆（GPI）的患者体内，这些患者患有全身性瘫痪，并声称它治愈了他们。 后来我们知道，当他承认这些说法被严重夸大时，但它们被广泛接受，疟疾治疗传播到了英国，传播到了德国，传播到了美国。 有时是小瓶疟疾血液，但精神病院通常有真正的疟蚊群。 所以想象一下你是一个精神病人，你被穿上紧身衣，被关在一个房间里，你无法动弹，蚊子在周围嗡嗡作响，它们咬你，然后你就患上了疟疾。

莱克斯·弗里德曼（Lex Fridman）：

And he got a Nobel Prize for this?

他因为这个得了诺贝尔奖？

安德鲁·斯卡尔（Andrew Scull）：

Yes, in 1937, he got a Nobel Prize. ‘Cause this was a condition that was invariably fatal. And the claim was that somehow the malarial fever worked. Now, there are two possible ways. Von Jauregg thought it stimulated the immune system to attack whatever it was, was causing the insanity. But the other possibility was the following: When you have the malarial parasite in a test tube and you heat the test tube to about 105, 106 degrees, it dies. So the idea potentially was you were sort of burning the parasites out of the brain with this agent. And because people were pretty unsophisticated about statistics and because the idea of a controlled trial had not yet come to pass, this treatment was used extensively for a couple of decades. What caused it to stop, and you talk about the progress of science, was the discovery of penicillin, which was a real magic bullet.

是的，在 1937 年，他获得了诺贝尔奖。因为这是一个几乎致命的疾病。有人声称，不知怎么的，疟疾高热起了作用。现在，有两种可能性。冯·雅雷格认为，它刺激了免疫系统去攻击引起疯狂的原因。但另一种可能性如下：当你在试管中放入疟疾寄生虫，并将试管加热到大约 105、106 度时，寄生虫会死亡。所以这个想法可能是用这种方法把寄生虫从大脑中“烧掉”。而且因为人们在统计学方面相当不成熟，又因为当时还没有出现对照试验的概念，这种治疗方法被广泛使用了几十年。导致其停止使用的原因，并且你可以谈论科学的进步，是青霉素的发现，这才是真正的神奇子弹。

安德鲁·斯卡尔（Andrew Scull）：

So once you had penicillin, you weren't gonna continue treating people with malaria, so it died away. But it was the first such treatment, and here's the other way this feeds into the narrative of these desperate remedies that develop in this period between the mid-‘teens and, say, 1950. The discovery of the syphilitic origins of general paralysis of the insane occurred at a time when medicine had undergone a profound transformation. In the late 19th century, the work of Louis Pasteur, who was a chemist, not an MD, and the work of Robert Koch in Germany had uncovered the origins of a variety of diseases and suggested that bacteria were the reason why people sickened. And that led, of course, to a whole series of public health triumphs, because initially it didn't lead to antibiotics. But for a lot of these diseases, even viral diseases like rabies, you could develop a vaccine.

所以一旦你有了青霉素，你就不会继续用它来治疗疟疾，所以它逐渐消失了。但它是第一个这样的治疗方法，这也是它如何与这些绝望疗法的故事联系起来的另一种方式，这些疗法在‘10 年代中期到大约 1950 年之间的发展。发现精神病性麻痹的梅毒起源发生在医学经历了深刻变革的时期。在 19 世纪末，路易·巴斯德（Louis Pasteur）的工作（他是化学家，不是医学博士）以及德国罗伯特·科赫（Robert Koch）的工作揭示了多种疾病的起源，并提出细菌是人们生病的原因。当然，这导致了一系列公共卫生的重大成就，因为最初这并没有直接导致抗生素的出现。但对于许多这些疾病，甚至像狂犬病这样的病毒性疾病，你也可以研发疫苗。

安德鲁·斯卡尔（Andrew Scull）：

And the vaccines were phenomenally effective. And so that was one way in which the new germ theory of disease transformed medicine and tied it into the laboratory and into science in a new way. And the other was the adaptation of Pasteur's theories by a British surgeon named Lister, who previously when pus developed post-surgery, people had thought that was a good sign. Lister said, "No, I don't think so. This is actually these nasty germs causing this, and so we're gonna do antiseptic surgery." So he sprayed carbolic acid on the wounds to try to kill the microbes. Most of his colleagues thought he was nuts. Thought he was just– This is ridiculous, these microorganisms. You couldn't even see them, you know? Well, you could with a… But Lister prevailed. And eventually we moved from antiseptic surgery to aseptic surgery, which is what we have now, where you try to have a sterilized set of instruments in a sterilized environment, so you don't infect things, right?

疫苗的效果非常显著。这就是新疾病微生物理论改变医学，并以一种新的方式将其与实验室和科学联系起来的一种方式。另一种方式是由一位名叫李斯特（Lister）的英国外科医生采纳路易·巴斯德（Louis Pasteur）的理论。过去当手术后伤口产生脓液时，人们认为这是一个好迹象。李斯特（Lister）说：“不，我不这么认为。这实际上是这些讨厌的细菌导致的，所以我们要进行防腐手术。”于是他在伤口上喷洒酚酸以杀死微生物。他的大多数同事认为他疯了，觉得这简直荒唐，这些微生物，你甚至看不到它们，对吧？嗯，其实用……可以看到。但李斯特（Lister）取得了胜利。最终，我们从防腐手术发展到无菌手术，这也是我们现在所采用的手术方式，你尝试在无菌环境中使用一套消毒的器械，这样就不会感染东西，对吧？

莱克斯·弗里德曼（Lex Fridman）：

By the way, these are definitive examples of progress in medicine.

顺便说一下，这些是医学进步的确凿例子。

安德鲁·斯卡尔（Andrew Scull）：

Absolutely.

绝对的。

莱克斯·弗里德曼（Lex Fridman）：

Penicillin-

青霉素

安德鲁·斯卡尔（Andrew Scull）：

Yes

是

莱克斯·弗里德曼（Lex Fridman）：

…you know, making sure there's no germs in during surgery.

…你知道的，确保手术过程中没有细菌。

安德鲁·斯卡尔（Andrew Scull）：

Associated with wounds, yes.

是的，与伤口有关。

莱克斯·弗里德曼（Lex Fridman）：

So these are all just refreshingly clear examples of progress. The reason I say it's refreshingly clear that there's progress, there's not a refreshingly clear progress in the history of psychiatry. Maybe, maybe a few hints.

所以这些都是进展的清晰明了的例子。我之所以说这是令人耳目一新的清晰进展，是因为在精神病学的历史上，并没有令人耳目一新的清晰进展。也许，或许有一些暗示。

安德鲁·斯卡尔（Andrew Scull）：

Some bits, yes. There haven't been the dramatic breakthroughs that I think everybody in the field would hope for. And there's some debate about how powerful what we have done is, and I think it's reasonable to debate that and to also acknowledge that there is important progress, limited as it is. Now you have 25% of the admits to a mental hospital actually suffering from an infectious disease. Medicine in general has now tied its fortunes to the laboratory. The idea that disease is caused by bacteria, we can't yet see viruses. It is a very powerful one and that notion that disease is caused by bacterial infection acquires great momentum, but it hasn't touched psychiatry. So medicine now has interventions that work, and sometimes quite dramatically. You know, the first patient given diphtheria vaccine– Diphtheria causes a leather-like membrane to grow over your throat and you die choking to death. And if you have a child and you watch that child die like that, you will never be over it. So when you had something that warded that off, that improved medicine's image dramatically and improved its financial prospects dramatically, particularly as medical training became reformed and more involved with science. So that hasn't applied to psychiatry until syphilis comes along. Now we have the model that an infectious

有些位，是的。 我认为该领域的每个人都希望没有取得重大突破。 关于我们所做的事情有多强大存在一些争论，我认为对此进行争论并承认取得了重要进展（尽管进展有限）是合理的。 现在精神病院收治的病人中有 25% 实际上患有传染病。 医学界现在已将其命运与实验室联系在一起。 认为疾病是由细菌引起的，但我们还看不到病毒。 这是一个非常强大的观点，疾病是由细菌感染引起的这一观点获得了巨大的支持，但它还没有触及精神病学。 因此，医学现在已经有了有效的干预措施，有时甚至效果显着。 你知道，第一个注射白喉疫苗的病人——白喉会导致你的喉咙上长出一层皮革状的薄膜，然后你就会窒息而死。 如果你有一个孩子，而你看着那个孩子就这样死去，你将永远无法释怀。 因此，当你有一些东西可以避免这种情况时，就会极大地改善医学形象并极大地改善其财务前景，特别是当医疗培训进行改革并更多地涉及科学时。 因此，直到梅毒出现之前，这还没有应用于精神病学。 现在我们有了一个模型，传染性

安德鲁·斯卡尔（Andrew Scull）：

agent can cause people's minds to go amok So the very person who invents the basic distinction between kinds of psychoses we still use today, schizophrenia and bipolar disorder, Emil Kraepelin, begins to think, "You know, there may be something infectious about the mental illnesses we're treating." And one of the people he trains is a young psychiatrist from the United States named Henry Cotton, who's also been trained by Adolf Meyer, who is the leading American psychiatrist of the first forty years of the twentieth century. And when he comes back from Germany having spent a year there, Meyer secures him a position as head of the New Jersey State Mental Hospital at Trenton. And Cotton is an ambitious, reforming man. He wants to bring psychiatry back to medicine. He also wants to chuck out all the old stuff. He doesn't want chains in his hospital. He doesn't want, if he can help it, straightjackets. So that goes away, but nothing seems to change fundamentally. He still isn't curing patients. And then he comes across this idea of focal sepsis, the idea that low-grade infections can lurk in the body, and what they do is release toxins into the bloodstream and the lymph. And hey, imagine if those toxins get to the brain. What's it going to do? It's gonna poison the brain, and the brain is then gonna act up.

agent can cause people's minds to go amok So the very person who invents the basic distinction between kinds of psychoses we still use today, 精神分裂症 and 双相障碍 , 埃米尔·克雷佩林（Emil Kraepelin） , begins to think, "You know, there may be something infectious about the mental illnesses we're treating." And one of the people he trains is a young psychiatrist from the United States named 亨利·科顿（Henry Cotton） , who's also been trained by 阿道夫·迈耶（Adolf Meyer） , who is the leading American psychiatrist of the first forty years of the twentieth century. 当他从德国回来并在那里呆了一年后，迈耶为他安排了 特伦顿 的 新泽西州立精神病院 负责人的职位。 亨利·科顿（Henry Cotton） 是一位雄心勃勃、勇于改革的人。 他希望将精神病学带回医学领域。 他还想扔掉所有旧的东西。 他不想在他的医院里戴着锁链。 如果可以的话，他不想穿紧身衣。 这样就消失了，但似乎没有什么根本改变。 他仍然没有治愈病人。 And then he comes across this idea of 病灶性感染（focal sepsis） , the idea that low-grade infections can lurk in the body, and what they do is release toxins into the bloodstream and the lymph. 嘿，想象一下这些毒素是否进入大脑。 它要做什么？ 它会毒害大脑，然后大脑就会变得异常。

安德鲁·斯卡尔（Andrew Scull）：

So we don't have antibiotics. So what are we gonna do about this? Well, we can perhaps locate the bacterial infection and then we can get rid of it. We can engage in what he calls surgical bacteriology. So the first obvious target here is teeth. Your teeth look close to your brain. They're often infected. That infection often goes untreated for a time… So we pull a lot of teeth. Patients don't get better. Mm, maybe the theory's wrong? No. Um, tonsils, well, they're getting infected, so we'll remove them. Still don't get better. Well, they're swallowing the bacteria, so we remove stomachs, and we remove spleens, and we remove colons. And we claim to be curing eighty percent of our patients. And rich patients come from all over America to be treated with this novel treatment.

所以我们没有抗生素。那么我们打算怎么办呢？嗯，我们也许可以找到细菌感染的位置，然后消除它。我们可以进行他所谓的「外科细菌学」（surgical bacteriology）。所以第一个显而易见的目标是牙齿。你的牙齿离大脑很近。它们经常会感染。这种感染常常在一段时间内得不到治疗……所以我们拔掉了很多牙齿。患者并没有好转。嗯，也许理论是错的？不。嗯，扁桃体，它们也会感染，所以我们把它们切除。情况仍然没有好转。好吧，它们吞下了细菌，所以我们切除胃，我们切除脾脏，我们切除结肠。我们声称治好了百分之八十的患者。富裕的患者从美国各地赶来接受这种新治疗。

莱克斯·弗里德曼（Lex Fridman）：

Crazy

疯狂

安德鲁·斯卡尔（Andrew Scull）：

Cotton gives a series of lectures at Princeton. There were not some lectures which are given by Nobel Prize winners. There's a very prestigious series. It's published by Oxford University Press and Princeton University Press. The New York Times hails it as a great breakthrough. And in reality, forty-five percent of the people who get the abdominal surgery die within a year.

亨利·科顿（Henry Cotton） 在 普林斯顿 开设了一系列讲座。这些讲座不是由 诺贝尔奖 获奖者主讲的。它是一个非常有声望的系列。由牛津大学出版社和 普林斯顿 大学出版社出版。《纽约时报》 称其为重大突破。而实际上，接受腹部手术的人中有 45% 在一年内死亡。

莱克斯·弗里德曼（Lex Fridman）：

They're cutting out stomachs

他们正在切除腹部

安德鲁·斯卡尔（Andrew Scull）：

Yep. He's cutting out stomachs. He says –there's this passage in one of his papers where he says "stomachs are like cement mixers on a construction site and could be dispensed with." When you think oh my God. If you were released from Trenton and you had no teeth, people immediately knew you were an ex-patient because the word had spread. And this goes on for– starting in nineteen sixteen. Cotton drops dead of a heart attack in nineteen thirty-three, but he's succeeded by three people he's trained. They drop the abdominal surgery. They use colonic irrigation, but the teeth and the tonsils keep being pulled. I interviewed the dentist who had come to the hospital in nineteen sixteen and must have pulled several hundred thousand teeth, and he retired in nineteen sixty, which was when that finally stopped. And he was convinced Cotton should have won the Nobel Prize for this. Oh well.

是的。他在切除胃部。他说——在他的一篇论文中有这样一段话，他说“胃就像建筑工地上的搅拌机，可以去掉。” 当你想时，天哪。如果你从特伦顿（Trenton）释放出来并且没有牙齿，人们立刻就知道你曾是病人，因为这个消息已经传开了。从 1916 年开始，这种情况一直持续下去。亨利·科顿（Henry Cotton）在 1933 年因心脏病发作去世，但他由三位受他训练的人接任。他们放弃了腹部手术，改用结肠冲洗，但牙齿和扁桃体仍然不断被拔掉。我采访了那位在 1916 年来到医院的牙医，他肯定拔掉了几十万颗牙齿，并于 1960 年退休，那也是这项工作最终停止的时间。他坚信亨利·科顿（Henry Cotton）应该因此获得诺贝尔奖。唉。

莱克斯·弗里德曼（Lex Fridman）：

Can you just give some intuition, put ourselves in that mind space, I mean, presumably these are smart human beings, why were they fraudulent in the reporting of how effective it is? Why are all the people that are participating, both the doctors and general culture–

你能不能给一些直觉上的理解，把我们置于那种思维空间里，我的意思是，这些人应该都是聪明的人，为什么他们在报告其效果时会作假？为什么所有参与的人，无论是医生还是普通文化中的人——

安德鲁·斯卡尔（Andrew Scull）：

it's extraordinary. So obviously, many of the interventions I'm talking about are very powerful interventions conducted by people in white coats and stethoscopes and scalpels.

这很非凡。显然，我所谈论的许多干预措施都是非常强大的干预措施，由穿着白大褂、带着听诊器和手术刀的人进行。

莱克斯·弗里德曼（Lex Fridman）：

Powerful by the way by the amount of impact they have on the human body, not powerful in terms of how effective they are.

顺便说一下，是指它们对人体的影响程度很大，而不是指它们的效果有多强。

安德鲁·斯卡尔（Andrew Scull）：

Yes, powerful as well in terms of placebo effect. Look, what I am going to do to you and yes it's gonna hurt and it's very intimate, but it's going to make you better. So that's always– this is a problem that persists in contemporary psychiatry, trying to figure out how much of the improvement we're seeing is the placebo effect and how much of it is the active effect of whatever we're doing.

是的，在安慰剂效应方面也很强大。看，我接下来说的事情会对你进行，而且是会疼的，非常亲密，但它会让你变得更好。所以这总是——这是当代精神病学中持续存在的问题，试图弄清楚我们所看到的改善有多少是安慰剂效应效应，又有多少是我们所做的事情的主动效果。

莱克斯·弗里德曼（Lex Fridman）：

But by the way, on that small tangent, let's return to that perhaps often.

顺便说一句，回到那个小题外话上，让我们也许经常回到那里。

安德鲁·斯卡尔（Andrew Scull）：

Yes.

是的。

莱克斯·弗里德曼（Lex Fridman）：

I for one can tell you that for me, for my mind, the placebo effect even when you tell me it's placebo will work.

就我而言，我可以告诉你，对我来说，对我的心智来说，即使你告诉我它是安慰剂，安慰剂效应仍然会起作用。

安德鲁·斯卡尔（Andrew Scull）：

Yes!

是的！

莱克斯·弗里德曼（Lex Fridman）：

But now if you have combined an actual gigantic operation that is physically, mentally, in every way life changing – … everybody around you in lab coats, all of society's telling you this is going to be life changing. I get it. That's like the most pure kind of placebo effect.

但现在，如果你进行了一项真正巨大的手术，这在身体上、心理上、从各方面彻底改变你的生活——……实验室里穿着白大褂的每个人，整个社会都在告诉你这将改变你的生活。我明白。这就像最纯粹的安慰剂效应。

安德鲁·斯卡尔（Andrew Scull）：

It's placebo effect that comes from both the patient who wants to be better- … and wants to believe this is gonna make them, and from the person conducting. And it's easy to deceive yourself, to see what you want to see. So anyway, that was one episode. We talk about triumphs of medicine, so let me talk about one of the real triumphs of 20th century medicine, which is interesting to refer to because it wasn't a cure, just like psychiatric drugs aren't a cure for mental illness. It was a symptomatic treatment, but it transformed lives, and that was the discovery of insulin in the 1920s. Previously, particularly what we now call Type One or juvenile diabetes, was a death sentence. You got it and whatever you did, you tried various quack remedies, you tried diet, you tried all sorts of things. The inevitable thing was it killed you. And then came insulin.

这是安慰剂效应，既来自于希望自己变好并且希望相信这会让他们好起来的患者，也来自于实施治疗的人。而且很容易自我欺骗，只看到自己想看到的东西。所以无论如何，那只是其中一集。我们谈论医学的辉煌成就，那么让我谈谈 20 世纪医学的一个真正的辉煌成就，这非常有趣，因为它并不是一种治愈，就像精神药物并不能治愈精神疾病一样。这是一种对症治疗，但它改变了人们的生活，那就是 1920 年代胰岛素的发现。以前，尤其是我们现在所说的 1 型或青少年糖尿病，几乎就是死刑判决。你得了它，无论你做什么，你尝试各种庸医的疗法，尝试饮食，尝试各种方法，但结果不可避免地是它会杀了你。然后胰岛素出现了。

安德鲁·斯卡尔（Andrew Scull）：

Now insulin doesn't mean you're cured of your diabetes, but what it means is you can live a relatively normal life and your lifespan is greatly expanded. So by any measure, you have to say that's dramatic progress. But insulin is something our bodies produce, we hope, unless we're really seriously diabetic. Those of us with Type Two diabetes, our bodies resist insulin and we have to resort to other ways of trying to cope. But if you get too much insulin, it makes you unconscious and that's how another one of these desperate remedies came along. A man named Sakel working in a German clinic for drug addicts, they were putting people under mild comas to help them through the withdrawal symptoms once they got over their addiction. So he was familiar with that. And when he moved to Austria, he decided he'd try this as a treatment for schizophrenia. And so he put people into comas, sometimes comas that would last hours, days. They would be revived by giving them glucose, usually intravenously, sometimes not. During the time they were in comas, they often seized, had seizures. He saw that as a therapeutic sign. And he claimed that this Insulin Coma Treatment cured eighty percent of his– eighty percent tends to come up again and again in these treatments as a sort of percentage that you cure. And he was invited to New York and demonstrated this at the Harlem Valley Mental Hospital. It spread. This was in the thirties? This was starting in nineteen thirty-three.

现在有了胰岛素并不意味着你的糖尿病就被治愈了，而是意味着你可以过上相对正常的生活，并且你的寿命大大延长。 因此，无论以何种标准衡量，你都必须说这是巨大的进步。 但我们希望，胰岛素是我们身体产生的，除非我们真的患有严重的糖尿病。 我们这些患有二型糖尿病的人，我们的身体会抵抗胰岛素，我们必须采取其他方法来应对。 但如果你摄入过多的胰岛素，它会让你失去知觉，这就是另一种绝望疗法的出现。 一位名叫萨克尔的男子在德国一家吸毒者诊所工作，他们让人们处于轻度昏迷状态，以帮助他们克服毒瘾后的戒断症状。 所以他对此很熟悉。 当他搬到奥地利时，他决定尝试用这种方法治疗 精神分裂症 。 所以他让人们陷入昏迷，有时昏迷会持续几个小时、几天。 通过给予葡萄糖，他们可以苏醒，通常是静脉注射，有时不是。 在他们昏迷期间，他们经常癫痫发作。 他认为这是一种治疗迹象。 他声称这种胰岛素昏迷治疗治愈了他百分之八十——百分之八十往往在这些治疗中一次又一次地出现，作为治愈的百分比。 他被邀请到纽约并在哈莱姆谷精神病院展示了这一点。 它传播开来了。这是在三十年代吗？这始于一九三三年。

安德鲁·斯卡尔（Andrew Scull）：

The visit to America was I believe nineteen thirty-six, and Sakel ended up settling here. He had a very lucrative private practice in New York, and when he died, he left his partner I think an estate of about two million dollars, which in the early sixties was a very substantial amount of money that he'd earned from practice, right? So insulin coma therapy was widely adopted. What kept it from being a large scale thing was it required an enormous amount of nursing and medical attention 'cause people were literally hovering on the brink of life and death. They could go into a permanent coma, they could just die. So vital signs had to be monitored. They had to be brought around very quickly if need be. And there's some evidence that the treatment killed brain cells.

我相信访问美国是在一九三六年，Sakel 最终定居在这里。他在纽约拥有一家非常有利可图的私人诊所，当他去世时，我想他给合伙人留下了大约两百万美元的遗产，在六十年代初这是一个非常可观的数目，这是他通过行医赚到的，对吗？所以 胰岛素昏迷疗法（insulin coma therapy） 被广泛采用。但阻碍其大规模应用的原因是它需要大量的护理和医疗照顾，因为人们实际上处于生死边缘。他们可能陷入永久性昏迷，也可能直接死亡。因此必须监测生命体征，并且如果需要，必须迅速进行抢救。有一些证据表明这种治疗会杀死脑细胞。

安德鲁·斯卡尔（Andrew Scull）：

And when Sakel was told that, he said yes, that's probably true. They're killing the schizophrenic brain cells. That's just nonsense. Of course. That's just nonsense, but that's rational. Insulin comas weren't subjected to a randomized controlled trial until the nineteen fifties, and when they were subjected to a controlled trial, they failed it, and so it died out, and that's, I guess, scientific progress again in a way, but took a long time. One of the people who received insulin coma therapy, have you seen the film A Beautiful Mind? Mm hmm. He did receive insulin coma therapy. Ironically, actually at Trenton State Hospital where Cotton had been, so John Nash received– John Nash got insulin comas, and they were going to lobotomize him, and they didn't, but he was at risk of that, we should say. that this treatment, patients would thrash, moan, and convulse before falling into a coma. The treatment required a course of up to sixty comas. It turned out to have a mortality rate of one to five percent and caused significant brain damage and obesity, yeah. Yet was hailed as a miracle cure for schizophrenia. Yes, that's right, performed on John Nash, one of the great

当萨克尔被告知这一点时，他说是的，这可能是真的。 他们正在杀死精神分裂症患者脑细胞。 那只是无稽之谈。 当然。 这虽然是无稽之谈，但却是有道理的。 胰岛素昏迷直到十九世纪五十年代才接受随机对照试验，当他们接受对照试验时，他们失败了，所以它消失了，我想，这在某种程度上又是科学进步，但花了很长时间。 收到胰岛素昏迷疗法（insulin coma therapy）的人之一，你看过电影《美丽心灵》吗？ 嗯嗯。 他确实收到了胰岛素昏迷疗法（insulin coma therapy）。 具有讽刺意味的是，实际上在科顿所在的特伦顿州立医院，所以约翰·纳什接受了——约翰·纳什出现了胰岛素昏迷，他们打算做脑白质切除术他，但他们没有，但我们应该说，他面临着这种风险。 在这种治疗中，患者在陷入昏迷之前会剧烈抽搐、呻吟和抽搐。 治疗需要长达六十次昏迷的疗程。 事实证明，它的死亡率为百分之一到百分之五，并造成严重的脑损伤和肥胖，是的。 却被誉为精神分裂症的灵丹妙药。 是的，没错，是在约翰·纳什身上表演的，他是伟大的音乐人之一

莱克斯·弗里德曼（Lex Fridman）：

minds of the 20th century.

20 世纪的思想

安德鲁·斯卡尔（Andrew Scull）：

Yes, and Nash clearly did become delusional, but that was one of the treatments he was subjected to. And well represented actually in the film of A Beautiful Mind. So I mentioned seizures. Also in Austro-Hungary in this period, another psychiatrist decided that you couldn't be both schizophrenic and epileptic, that there was somehow an antagonism between the two. So if you had epilepsy, you didn't have schizophrenia. If you had schizophrenia, couldn't have epilepsy. I should say at the outset, that's not true, but that's what he believed. So then the logical next step was, "Well, if we could create an artificial epileptic seizure, maybe we would drive out the schizophrenia." So what to do? He first tries injecting camphor, a natural substance. Natural substances aren't necessarily benign substances. That caused abscesses, and it wasn't very effective. He sought an alternative, and he settled on something that was called Cardiazol or Metrazol, depended which side of the Atlantic you were on. And injecting that into a patient usually caused a seizure, a big seizure, like a grand mal seizure where your body arcs back, your legs contract dramatically.

是的，纳什显然确实产生了妄想，但那是他所接受的治疗之一。 在电影《美丽心灵》中也得到了很好的体现。 所以我提到了癫痫发作。 同样在这个时期的奥匈帝国，另一位精神病学家认为你不可能同时患有精神分裂症患者和癫痫症，两者之间存在某种对抗。 因此，如果您患有癫痫症，那么您就没有 精神分裂症 。 如果您患有 精神分裂症 ，就不可能患有癫痫。 我首先应该说，这不是真的，但他就是这么认为的。 因此，合乎逻辑的下一步是，“好吧，如果我们可以制造人工癫痫发作，也许我们可以赶走 精神分裂症 。” 那么该怎么办呢？ 他首先尝试注射樟脑，一种天然物质。 天然物质不一定是良性物质。 这导致了脓肿，而且效果不是很好。 他寻求一种替代方案，最终选择了一种叫做卡地唑（Cardiazol）或美特拉唑（Metrazol）的东西，这取决于你在大西洋的哪一边。 将其注射到患者体内通常会引起癫痫发作，一次大癫痫发作，就像大癫痫发作一样，您的身体向后弯曲，双腿急剧收缩。

莱克斯·弗里德曼（Lex Fridman）：

You can fracture spines and hips and bones.

你可以折断脊柱、臀部和骨头。

安德鲁·斯卡尔（Andrew Scull）：

and you ended up, yes, with fractures of vertebrae, fractures of the hip socket. Because when muscles in the thigh contract that badly, what happens? The thigh bone is driven into the socket at such a rate that it fractures, right? So these were among the complications that Metrazol produced. More than that, he himself conceded that between the injection and the seizure, the patient felt as though he were on—or she was on—the brink of death. Now imagine, pretend you're a mental patient. You're brought in in a straitjacket. A man in a white coat with a big hypodermic injects something into you. You feel as though you're gonna die, and maybe that lingers for two, three, ten minutes, and then you seize with those possible fractures following

最终你会出现，是的，出现了椎骨骨折、髋臼骨折。因为当大腿的肌肉收缩得那么剧烈，会发生什么？股骨会以那么大的力量撞入髋臼，导致骨折，对吧？所以这些都是甲扎醇引起的并发症之一。更重要的是，他自己也承认，在注射和癫痫发作之间，患者会感觉自己——或者她——处于死亡边缘。现在想象一下，假装你是精神病患者。你穿着紧身夹克被带进来，一个穿白大褂的人拿着大号注射器向你注射某种东西。你会感觉自己快要死了，这种感觉可能持续两分钟、三分钟、十分钟，然后你就会发作，可能还会伴随那些骨折。

莱克斯·弗里德曼（Lex Fridman）：

violent seizures.

剧烈癫痫发作

安德鲁·斯卡尔（Andrew Scull）：

violent seizures. It's violent and hard to witness and is very unpredictable. So it's used, but people are not very happy, and that's how we get electroconvulsive therapy, electroshock, as it's first called. Two Italian psychiatrists, Cerletti and Bini, experiment with electricity, and they first experiment on dogs. And they make a mistake initially: they have an electrode on the head, an electrode on the anus. The electric current passes through the body, it stops the heart, the dogs die. So that seems a dead end. And then somebody says to them, "You know, you should go to the Rome slaughterhouse and see the pigs being slaughtered 'cause you'll learn something very interesting." So they go, and the pigs are dangling by their hind legs. And as they come by, two electrodes cross their head, electroshock, they convulse, they're

剧烈的癫痫发作。它剧烈且难以目睹，且非常不可预测。所以被使用了，但人们并不高兴，这就是我们得到电休克疗法（electroconvulsive therapy），最初称为电休克的原因。两位意大利精神科医生切莱蒂和比尼，开始用电做实验，他们先在狗身上做实验。他们一开始犯了个错误：头上和肛门上都装了电极。电流通过身体，心脏停止跳动，狗就死了。所以这似乎是个死胡同。然后有人对他们说，“你应该去罗马屠宰场看看猪被宰杀，因为你会学到一些非常有趣的东西。”于是他们去了，猪就用后腿吊着。当他们经过时，两个电极横跨他们的头部，电击，他们抽搐，他们

安德鲁·斯卡尔（Andrew Scull）：

unconscious, their throats are slit, and pork arrives. So they try that on dogs, and current passing through the brain, it turns out, doesn't kill them. So decide to try it out. They pick up a transient homeless person at the Rome train station, and they bring him in, and they try it. And at first, they don't use enough current, and nothing very much happens. And they're very white-faced, they're quite worried. Off in the corner, we have descriptions of this, and they're talking, "What should we do?" "Well, we'll up the current," and the patient hears that and says, "No, another one, that's deadly." They do it anyway, and he convulses. Another grand mal seizure with the same problems of spinal fractures and hip fractures and so on. Not universally, obviously, but often enough. And he stops breathing. You can imagine the scene. And then he spontaneously starts breathing again. And when he comes around, he's in contact with reality. They got this miracle cure, and it's very easy to administer, cheap, doesn't involve injecting things into people's bodies. So that quickly spreads across the Atlantic and other parts of Europe. And ECT becomes a very widely used intervention. Couple of things to say about this. It turns out it's not very useful for schizophrenia. Remember the connection between seizures and schizophrenia that was originally posited, but it seems to work in cases of depression, suicidal depression particularly,

他们失去知觉，喉咙被割断，猪肉就到了。 因此他们在狗身上进行了尝试，结果发现电流通过大脑并不会杀死它们。 所以决定尝试一下。 他们在罗马火车站接了一个临时无家可归的人，然后把他带进来，然后尝试一下。 起初，他们没有使用足够的电流，所以什么也没有发生。 而且他们脸色都很白，很担心。 在角落里，我们有对此的描述，他们正在讨论，“我们应该做什么？” “好吧，我们会加大电流，”病人听到后说，“不，再来一个，那是致命的。” 不管怎样，他们还是这么做了，他抽搐了。 另一种大发作同样存在脊柱骨折、髋部骨折等问题。 显然，这并不普遍，但经常如此。 他停止了呼吸。 你可以想象那个场景。 然后他又自发地开始呼吸。 当他醒过来时，他就接触到了现实。 他们找到了这种神奇的疗法，而且非常容易管理，价格便宜，不涉及将东西注射到人们的体内。 因此，这种现象很快就传遍了大西洋和欧洲其他地区。 电休克疗法（ECT） 成为一种非常广泛使用的干预措施。 关于这一点有几点要说。 事实证明它对于 精神分裂症 不是很有用。 记住最初提出的癫痫发作与精神分裂症之间的联系，但它似乎在抑郁症的情况下也有效，尤其是自杀性抑郁症。

莱克斯·弗里德曼（Lex Fridman）：

Fast forwarding to the modern day—mm-hmm—and this is something I learned by reading a bunch recently, it seems to be one of the few evidence-based, like scientifically backed, methods that actually worked for clinical depression, for serious depression.

快进到现代——嗯——这是我最近通过大量阅读学到的东西，似乎这是少数几个有证据支持、像是科学验证过的方法，实际上对临床抑郁症、严重抑郁症有效。

安德鲁·斯卡尔（Andrew Scull）：

Um yes, if we fast forward, we're looking at in some respects a different animal for reasons I'll explain. Okay.

嗯，是的，如果我们快进来看，从某些方面来说，我们看到的是一个不同的东西，原因我会解释的。好的。

莱克斯·弗里德曼（Lex Fridman）：

This is unmodified ECT.

这是未修改的 电休克疗法（ECT）。

安德鲁·斯卡尔（Andrew Scull）：

Yeah, so we're talking about unmodified ECT, which rules the roost really well into the 1950s, and some places even into the 1960s. And so it is associated with all the problems of fractures that we've talked about. It's also associated with memory problems. People often lose memory. There's some dispute about how serious that is, but it's pretty widely recognized that's one of the prices you're gonna pay for that treatment. The thing is, for mental hospitals in the '40s and '50s, ECT was much more used as a device to control people's behavior than as a therapeutic intervention. It was quite punitive, seen as such. Patients didn't wanna repeat, and so they- … sort of controlled themselves a bit. But yes, we don't know why it works, but more recent work starting in probably the 1990s—and I'm gonna get in trouble with some people for saying this because you mentioned patients and psychiatrists who swear by ECT. There are others who swear at it.

是的，所以我们谈论的是未改良的电休克疗法（ECT），它在 1950 年代一直占据主导地位，有些地方甚至延续到 1960 年代。因此，它与我们之前讨论过的各种骨折问题有关。它也与记忆问题相关。人们经常会失去记忆。对于其严重程度存在一些争议，但它作为这种治疗的代价之一是被广泛认可的。问题是，对于 40 年代和 50 年代的精神病院来说，电休克疗法（ECT）更多地被用作控制人们行为的手段，而不是一种治疗干预措施。它相当具有惩罚性，被视为如此。患者不想再次经历，所以他们——在某种程度上会自我约束一下。但确实，我们不知道它为什么有效，不过从大约 1990 年代开始的更多研究——我说这个可能会让一些人不高兴，因为你提到了一些完全信赖电休克疗法（ECT）的患者和精神科医生。当然也有一些人非常反对它。

安德鲁·斯卡尔（Andrew Scull）：

Partly because of the memory problems I alluded to, and partly because of claims that it may cause brain damage. Passing an electric current through the brain is possible. What changed ECT a bit, quite a bit actually, was giving muscle relaxants so that people didn't thrash about, and the fractures were largely a thing of the past. When you introduce these muscle relaxers, originally they used curare, but then they used other more modern drugs to paralyze the muscles temporarily. Problem is, that would also paralyze your breathing muscles, so that's not too good. So it became a more complicated procedure because you needed anesthesiologist breathing support and so forth during the procedure. But you did eliminate the fractures.

部分原因是我提到的记忆问题，部分原因是有人声称它可能会造成脑损伤。通过大脑传导电流是可能的。真正改变电休克治疗（ECT）的是使用肌肉松弛剂，这样人们就不会剧烈挣扎，骨折大多也不再发生。引入这些肌肉松弛剂时，最初使用的是箭毒，后来改用了其他更现代的药物来暂时麻痹肌肉。问题是，这些药物也会使呼吸肌麻痹，所以这并不太好。因此这个程序变得更复杂，因为在治疗过程中需要麻醉师提供呼吸支持等。但确实消除了骨折的发生。

安德鲁·斯卡尔（Andrew Scull）：

It still was a very widely disdained practice, I think, particularly when they had drugs available. The thinking was that, well, we'd sooner use those, but the drugs turn out to be only partially effective and pretty ineffective very often for suicidal cases or in cases of extreme melancholia. Now, a couple things to say: Very often, ECT has to be repeated at intervals, as a kind of maintenance therapy. So it hasn't cured things, but it temporarily alleviates the symptoms, and the temporary may be fairly lengthy, but nonetheless, very often things will recur. The memory problems can be quite severe. The worries about brain damage are, I think, certainly things we have to be very cautious about. And when we talk about treatment-resistant depression, that's an interesting concept to me. What it means is those are the patients who don't respond to drugs. They may not have a different disease, but the drugs don't work for them, hence treatment resistant. And the numbers of psychiatrists who are willing to give ECT are rather small, and in many states it's hedged around with lots of legal restrictions. In California, for example, ECT now almost can't be given to involuntarily confined patients 'cause you have to volunteer for it.

我认为，这仍然是一种受到广泛鄙视的做法，特别是当他们有药物可用时。 我们的想法是，好吧，我们应该尽快使用这些药物，但事实证明这些药物仅部分有效，而且对于自杀病例或极端忧郁症（melancholia）病例通常无效。 现在，有几件事要说：很多时候，电休克疗法（ECT） 必须每隔一段时间重复一次，作为一种维持治疗。 所以它并没有治愈疾病，但它暂时缓解了症状，而且暂时的时间可能相当长，但尽管如此，很多时候事情还是会复发。 记忆问题可能相当严重。 我认为，对脑损伤的担忧当然是我们必须非常谨慎的事情。 当我们谈论难治性抑郁症时，这对我来说是一个有趣的概念。 这意味着那些对药物没有反应的患者。 他们可能没有患上不同的疾病，但药物对他们不起作用，因此对治疗产生抵抗力。 愿意提供电休克疗法（ECT）的精神科医生数量相当少，而且在许多州，它受到许多法律限制的限制。 例如，在 加州 中，电休克疗法（ECT） 现在几乎不能给予非自愿限制的患者，因为你必须自愿接受。

安德鲁·斯卡尔（Andrew Scull）：

So it's unusual in that most medical procedures aren't hedged about by legal constraints like that. And there clearly is a very powerful group of people, some of them psychiatrists, many of them ex-patients, many of them other people who just are suspicious of modern medicine and science, who form a group who are very powerfully opposed to ECT. So although it's fair to say there are trials now that seem to provide decent evidence that for some patients this works and that those patients are deeply distressed before the treatment, it's also still a controversial treatment, I think it's fair to say.

所以这很不寻常，因为大多数医疗程序并不像那样受到法律约束。而且显然有一群非常有影响力的人，其中一些是精神科医生，许多是前病人，还有许多人只是对现代医学和科学心存怀疑，他们组成了一个强烈反对电休克治疗（ECT）的团体。因此，虽然可以公平地说，现在有一些试验似乎提供了体面的证据，表明对于某些患者这种治疗有效，并且这些患者在治疗前深受痛苦，但这仍然是一种有争议的治疗，我认为可以公平地说。

莱克斯·弗里德曼（Lex Fridman）：

Like basically every single topic, treatment, problem subfield of psychiatry today.

就像几乎今天精神病学的每一个主题、治疗、问题子领域一样。

安德鲁·斯卡尔（Andrew Scull）：

Yes, yes.

是的，是的。

莱克斯·弗里德曼（Lex Fridman）：

For everything, everything we say today, there will be at least one person upset- …and writing a letter.

对于我们今天说的每一件事，都会至少有一个人生气……并写信的人。

安德鲁·斯卡尔（Andrew Scull）：

I think lots of people upset. So if we talk about drugs, there'll be two kinds of people who will be upset: those who think the drugs are more powerful than they are or who have been successfully treated by the drugs and go, "Well, it worked for me, so, you know, stop criticizing it 'cause it really is an effective treatment." And then on the other side of the coin, there are those who either the drug treatment has been used and it's failed, or they're being left with terrible side effects that don't go away, or they're part of a general group of people that unfortunately is of a growing number these days who are so suspicious of medical science and of the drug companies that no amount of evidence will sway them. They are convinced that you know, the, the drug treatments are poisonous. The Scientologists being a very extreme example of that who they have a whole museum in Los Angeles and the title is Psychiatry Industry of Death. And then if you think about all the resistance, for example, that has surfaced to vaccination in contemporary US and how the trust in vaccination has been destroyed for a substantial number of people, it's very difficult to convince them that they're mistaken.

我想很多人都感到不安。 因此，如果我们谈论毒品，会有两种人会感到不安：那些认为药物比它们本身更强大的人，或者那些已经通过药物成功治疗的人，然后说：“嗯，它对我有用，所以，你知道，停止批评它，因为它确实是一种有效的治疗方法。” 另一方面，有些人要么已经使用了药物治疗但失败了，要么留下了无法消失的可怕副作用，或者他们是一个普通人群的一部分，不幸的是，这些人现在人数不断增加，他们对医学和制药公司如此怀疑，没有任何证据可以动摇他们。 他们确信你知道，药物治疗是有毒的。 山达基教徒是一个非常极端的例子，他们在洛杉矶拥有一整座博物馆，标题是“死亡精神病学产业”。 然后，如果你考虑一下当代美国对疫苗接种所出现的所有阻力，以及相当多的人对疫苗接种的信任是如何被摧毁的，就很难让他们相信自己错了。

莱克斯·弗里德曼（Lex Fridman）：

And not just the trust in vaccination, consequence of that is a general distrust in science-

而且不仅仅是对疫苗的信任，由此产生的后果是对科学的整体不信任——

安德鲁·斯卡尔（Andrew Scull）：

A general distrust, exactly.

完全是一种普遍的不信任。

莱克斯·弗里德曼（Lex Fridman）：

… and distrust in medicine and so on.

……以及对医学的不信任，等等。

安德鲁·斯卡尔（Andrew Scull）：

That's one of my great worries about our contemporary situation, that we're only– We're less than a year in. After four years of this, first of all, the degree of mistrust will have grown exponentially, and once trust is lost, it's very hard to recover. Secondly, the science itself is being destroyed. Clinical trials that were midway through were aborted, so that knowledge has been lost. You would have to start from square one, and that's years of work. Scientists aren't being trained because funding has been cut. Scientists with successful careers no longer have the funding necessary to do their work, and it takes at least six or seven years to train a scientist at the beginning of their career. And so if you have four years with nobody being trained, you're talking about a decade being lost, and what's lost is invisible- …because it's counterfactuals. We don't know what that science will lead to or what that medical treatment might lead to, and very many times they fail. That's the nature of science. It's the nature of medicine and medical research that not every bright idea we have is going to eventuate in a breakthrough. It would be really simple and wonderful if that was opposite were the case. But the reality is we have to go down lots of blind alleys, we have to try lots of different things, and we have to take years to move from the laboratory to practical application. And when we eliminate a whole segment of that and when on top of that we diminish people's trust-

这是我对我们当前处境的最大担忧之一，我们才——我们还不到一年。四年之后，首先，不信任的程度将呈指数级增长，一旦失去信任，就很难恢复。 其次，科学本身正在被摧毁。 临床试验进行到一半就中止了，因此知识已经丢失。 你必须从头开始，这需要多年的工作。 由于资金被削减，科学家们没有接受培训。 事业成功的科学家不再拥有开展工作所需的资金，而在职业生涯初期培养一名科学家至少需要六七年的时间。 因此，如果你有四年没有人接受培训，那么你就在谈论失去了十年，而失去的东西是看不见的——……因为这是反事实的。 我们不知道科学会带来什么结果，也不知道医学治疗会带来什么结果，而且很多时候它们都会失败。 这就是科学的本质。 医学和医学研究的本质是，并非我们拥有的每一个好主意都会最终取得突破。 如果情况相反，那就真的很简单而且很棒了。 但现实是我们必须走很多死胡同，我们必须尝试很多不同的事情，我们必须花费数年时间才能从实验室转向实际应用。 当我们消除其中的一整个部分，并且在此之上我们还削弱了人们的信任——

安德鲁·斯卡尔（Andrew Scull）：

…in science, that's a really, I think, a profoundly devastating thing that probably given my advanced age, I won't live to see the consequences of, but my children and grandchildren will. It really is something cultural that you've got to build up trust. And it can be destroyed very easily. So one of the things, to go back to the very first question you asked me about, is psychiatry in crisis? Well, genetics was supposed to provide a clear picture of the origins of various mental diseases 'cause they do seem to run in families. So the expectation was once we decoded the human genome and we could examine bits and pieces of it, that we would very quickly find a Mendelian gene or set of genes for schizophrenia, let us say. Hasn't happened. We now use gene-wide association studies, that is throwing everything in the kitchen soup into, into the picture, and then without any preconditions, seeing what relates to what. And if we use three hundred small variations in the genome, we can account for about ten percent of schizophrenia.

……在科学上，我认为，这确实是一件具有深远破坏性的事情，考虑到我年事已高，我可能无法活着看到其后果，但我的子孙会。 这确实是一种文化，你必须建立信任。 而且它很容易被摧毁。 那么，回到你问我的第一个问题，精神病学是否处于危机之中？ 嗯，遗传学应该提供各种精神疾病的起源的清晰图景，因为它们似乎确实在家族中遗传。 因此，我们的期望是，一旦我们解码了人类基因组，我们就可以检查它的各个部分，我们会很快找到 精神分裂症 的一个孟德尔基因或一组基因，比方说。 没有发生过。 我们现在使用全基因关联研究，即将厨房汤中的所有东西都放入图片中，然后在没有任何先决条件的情况下，看看什么与什么相关。 如果我们使用基因组中的三百个小变异，我们可以占 精神分裂症 的大约百分之十。

安德鲁·斯卡尔（Andrew Scull）：

That's not very powerful. Beyond that, what psychiatric genetics has tended to throw up is something that undermines the distinctions that we've made based on symptomatology. So if you look, there is a great deal of overlap in the kinds of genetic abnormalities that heighten the susceptibility to bipolar disorder or schizophrenia or autism. There's a lot of overlap there. What that suggests is these aren't distinctive entities in the way that, you know… Schizophrenia, as my friend Robin Murray, a British psychiatrist, has to say, "It really seems to be the extreme end of psychosis, the most serious." But it's sort of on a continuum, you know. And so if psychiatry has to say in ten years, as some leading psychiatrists are speculating, that there's no such thing as schizophrenia, there's no such thing as bipolar disorder, that will tend, I suspect, to have pretty bad effects on people's trust-

那并不是很有力。除此之外，精神病学的遗传学往往揭示的事物是一些削弱了我们基于症状学所做的区分的东西。所以如果你观察，会发现导致对双相障碍或精神分裂症或自闭症易感性的各种遗传异常有很大的重叠。这方面有很多重叠。这表明，这些并不是像你知道的那样具有明显区别的实体……正如我的朋友、英国精神科医生 Robin Murray 所说，精神分裂症“看起来确实是精神病性障碍的极端表现，最严重的”。但它实际上是在一个连续体上。所以如果精神病学必须在十年后，如一些领先的精神科医生所推测的那样，说不存在精神分裂症，不存在双相障碍，我怀疑这将倾向于对人们的信任产生相当不好的影响——

安德鲁·斯卡尔（Andrew Scull）：

…in psychiatry, and yet that's where the science may lead them. So it's a, it's a complicated picture, but this issue of trust and its absence is vital, I think, in looking at not just what we're talking about today, but across a whole spectrum of things, even outside the medical realm altogether. If you lose trust in institutions, trust in science, trust in history. So I think more humility and less arrogance, more willingness to confess the limits of what we can do, more awareness of the dangers of enthusiasm, more skepticism when we're told something is a breakthrough. One of the things I worry about is the tendency of science journalism and medical journalism to hype things, and, and then when the hype turns out to be just that, that undermines trust. You know? So be cautious when things come along- … don't be so sure that it represents a breakthrough. I'm very worried at the moment. I see ketamine and psychedelics being propounded as a miracle cure for depression, and the evidence for that is enormously weak is the best way to put it. And I've seen this movie before too many times. You know? I mentioned that 80% cure for Cotton's work, 80% cure for insulin coma therapy, 80% cure for the early asylums. This is overblown rhetoric, and the reality is usually progress comes in small steps.

……在精神病学领域，但这正是科学可能引导他们的地方。 所以，这是一幅复杂的图景，但我认为，信任问题及其缺失至关重要，不仅考虑到我们今天所讨论的内容，而且考虑到整个范围的事物，甚至完全在医学领域之外。 如果你失去对机构的信任，对科学的信任，对历史的信任。 因此，我认为要多一点谦虚，少一点傲慢，更愿意承认我们能做的事情的局限性，更多地意识到热情的危险，当我们被告知某件事是突破时，要更多地怀疑。 我担心的一件事是科学新闻和医学新闻倾向于炒作事情，然后当炒作事实证明是这样时，就会破坏信任。 你知道？ 因此，当事情发生时要小心——……不要太确定它代表着突破。 我现在很担心。 我认为氯胺酮和致幻剂被认为是治疗抑郁症的灵丹妙药，但最好的说法是证据非常薄弱。 我以前看过这部电影太多次了。 你知道？ 我提到过 亨利·科顿（Henry Cotton） 的工作 80% 治愈， 胰岛素昏迷疗法（insulin coma therapy） 80% 治愈，早期庇护 80% 治愈。 这是言过其实的说法，现实是进步通常是小步推进的。

安德鲁·斯卡尔（Andrew Scull）：

Sometimes it comes in big steps. Penicillin, I think was a huge step. Uh, I was lucky enough to grow up in the era when penicillin and other antibiotics became widely available. They hadn't been overused by then. And so if I had a strep throat, I had something that got rid of it right away. I didn't run the risk of heart valve damage, which in previous times would've been the case. So you know, once in a while you do have these dramatic shifts, and maybe AI will help us in that regard, but maybe it won't. It's another potential double-edged sword.

有时它会以大的步骤出现。我认为青霉素就是一个巨大的进步。呃，我很幸运能在青霉素和其他抗生素广泛可用的时代长大。那时它们还没有被过度使用。所以如果我喉咙发炎，我可以立即消除它。我不用冒心脏瓣膜损伤的风险，而以前情况可能会如此。所以你知道，有时你确实会遇到这些戏剧性的变化，也许人工智能在这方面会帮助我们，但也可能不会。这是另一把潜在的双刃剑。

莱克斯·弗里德曼（Lex Fridman）：

I should mention that psychedelics, psilocybin in particular, has been demonized for a long time. And so there's studies now out of Johns Hopkins- … that are doing serious studies on cases where it is effective. I think it's nice to give a chance to the different treatments with the rigor of science, but with caution – … and basically ignoring like you're saying, science journalists who are basically hyping every new thing 'cause they have to get clicks and all- … this kind of stuff and- … Look at the actual science in the modern day. So the- … in the past, the rigor was not there. In the modern day, there's more.

我应该提到，致幻剂，特别是裸盖菇素（psilocybin），长期以来一直被妖魔化。所以现在约翰斯·霍普金斯大学有一些研究……正在对其有效的情况进行严肃研究。我认为，在科学的严格性下给不同治疗方式一个机会是件好事，但要谨慎——……基本上忽略掉你所说的那些科学记者，他们基本上是在炒作每一个新事物，因为他们必须获得点击量，诸如此类的事情——……看看现代的实际科学。因此——……过去，这种严谨性并不存在。现代则更多了。

安德鲁·斯卡尔（Andrew Scull）：

Yes. We can add beyond the realm of science journalists. I think Science and Nature make choices about what they're gonna foreground, and they too have this tendency to look for things that make a big splash.

是的。我们可以超越科学记者的领域。我认为《科学》和《自然》会选择它们要突出展示的内容，而且它们也有这种倾向，去寻找能够引起巨大影响的事物。

莱克斯·弗里德曼（Lex Fridman）：

Oh, you mean the editors and the- … the major journals.

哦，你是说编辑们和…主要期刊。

安德鲁·斯卡尔（Andrew Scull）：

I think the editors, the major journals, that's what they're looking for. As you know, I mean, negative findings are very important in science. They're the things that help us avoid mistakes, but they're not the things that are going to get you published in the journal.

我认为编辑们、主要期刊，这就是他们在寻找的东西。正如你所知，我是说，负面结果在科学中非常重要。它们帮助我们避免错误，但它们不是能让你在期刊上发表的东西。

莱克斯·弗里德曼（Lex Fridman）：

Right. So it's not just the surface level science journalism. It is also the extra journals and the conferences and the publication process.

对。所以这不仅仅是表层的科学新闻报道。它还包括额外的期刊、会议以及发表过程。

安德鲁·斯卡尔（Andrew Scull）：

Having lots of scientists working on these problems in different sites and different places turns out to be very important, I think, as a check on enthusiasm, as a check on premature claims that turn out to be unfounded. And also because you're often partially right, but you're not fully right and someone else following the same idea- … is perhaps gonna be a little closer to the truth than you were. And so it's very helpful to have multi-centered things and not everything under one all-knowing- … Thing. And that's a problem with funding agencies. The maverick scientist has a hard time- … very often- … getting a hearing. And we know of lots of examples of that in history where after the fact we go "oh well yes, we should have supported that line of research, but we didn't."

我认为，让很多科学家在不同的地点和不同的地方研究这些问题是非常重要的，这可以作为对热情的检查，也可以作为对最终证明无根据的过早声称的检查。同时，因为你往往是部分正确，但不是完全正确，而其他人跟随相同的想法——也许会比你更接近真相。所以拥有多中心的研究非常有帮助，而不是把所有事情都放在一个无所不知的地方。这也是资助机构的问题。特立独行的科学家往往很难得到重视。我们在历史上知道很多这样的例子，事后我们会说“哦，是的，我们本应该支持那条研究路线，但我们没有。”

莱克斯·弗里德曼（Lex Fridman）：

Very well put. Let us return to the origins of ECT and how it was applied. But first, if it's okay, a quick bathroom break. Quick ten second thank you to our sponsors. Check them out in the description. It really is the best way to support this podcast. Go to lexfridman.com/sponsors. And now, dear friends, back to my conversation with Andrew Scull. Now we're back just to talk a little bit more about ECT and One Flew Over the Cuckoo's Nest. So what can we say about that, that little cultural moment, one of the most famous moments about psychiatry? First of all, Ken Kesey wrote this book about his own experience in a mental institution.

说得非常好。让我们回到电休克疗法（ECT）的起源以及它是如何被应用的。但首先，如果可以的话，先快速去一下洗手间。十秒钟感谢一下我们的赞助商。详情请查看说明栏。这真的是真正支持本播客的最佳方式。访问 lexfridman.com/sponsors。现在，亲爱的朋友们，让我们回到我与安德鲁·斯卡尔（Andrew Scull）的对话。我们回来了，只是想多聊聊电休克疗法（ECT）和《飞越疯人院》（One Flew Over the Cuckoo's Nest）。那么我们能对那个小小的文化时刻、精神病学中最著名的时刻之一说些什么呢？首先，肯·克西（Ken Kesey）写了一本关于他自己在精神病院经历的书。

安德鲁·斯卡尔（Andrew Scull）：

Yeah, Menlo Park. Yes.

是的，门洛帕克。是的。

莱克斯·弗里德曼（Lex Fridman）：

How representative is it of the system at the time?

它在当时能多大程度上代表该系统？

安德鲁·斯卡尔（Andrew Scull）：

Mental hospitals have had a very patchy and complicated history. He was working actually in a hospital for veterans. Those were largely created after the Second World War when there were very many more psychiatric casualties among American troops than even the First World War. The interesting thing is we all by osmosis know that in the First World War there was something called shell shock that afflicted the troops and that the military initially resisted recognizing and ultimately were forced to grasp. But in World War II, American psychiatric casualties among the troops were two to three times as high as in World War I, and that's an important part of the history of psychiatry. But the upshot of that was that post-war the VA was heavily involved in, first of all, paying to train psychiatrists and even psychologists, and then had in its mental hospital system a considerable involvement with psychiatric disorders. Kesey– Well, the book is different than the film is the first thing to say. Obviously, the film is heavily indebted to the book, but it changes various things.

精神病院的历史非常不完整且复杂。 他实际上在一家退伍军人医院工作。 这些主要是在第二次世界大战后创建的，当时美国军队中的精神伤亡人数甚至比第一次世界大战还要多。 有趣的是，我们都潜移默化地知道，在第一次世界大战中，有一种叫做炮弹休克症的现象困扰着军队，军方最初拒绝承认这一现象，最终被迫接受。 但在第二次世界大战中，美国军队中精神病患者的伤亡人数是第一次世界大战时的两到三倍，这是精神病学历史的重要组成部分。 但其结果是，战后退伍军人事务部大量参与，首先，花钱培训精神科医生甚至心理学家，然后在其精神病院系统中大量参与精神疾病治疗。 凯西——首先要说的是，这本书与电影不同。 显然，这部电影很大程度上借鉴了原著，但它改变了很多事情。

莱克斯·弗里德曼（Lex Fridman）：

If I may just go into Perplexity, "The book and the 1975 film tell the same basic story of McMurphy challenging an oppressive psychiatric ward, but they differ sharply in point of view, tone, and what the story is about. The novel is weirder, more political, and more about Chief Bromden's inner world and the combine while the film is more naturalistic, character-driven, and turns McMurphy into the central hero."

如果我可以谈谈《困惑》，这本书和 1975 年的电影讲述了相同的基本故事：麦克墨菲挑战压迫性的精神病病房，但它们在视角、语气以及故事内容上有明显的不同。小说更奇特、更具政治性，更关注布罗姆登酋长的内心世界和社会结构，而电影则更写实、更以人物为驱动，并将麦克墨菲塑造成中心英雄。

安德鲁·斯卡尔（Andrew Scull）：

Yes, I think that's right.

是的，我认为那是对的。

莱克斯·弗里德曼（Lex Fridman）：

McMurphy is the person that received ECT, played by Jack Nicholson.

麦克默菲是接受过电休克治疗（ECT）的人，由尼科尔森饰演。

安德鲁·斯卡尔（Andrew Scull）：

Yes. And you have a nurse figure in Nurse Ratched. Louise Fletcher, I think, is an equally powerful performance.

是的。而且你有《拉切德护士》里的护士形象。我认为路易丝·弗莱彻的表演同样强有力。

莱克斯·弗里德曼（Lex Fridman）：

It's one of the greatest films of all time who happens to be– which is unfortunate for, you know, maybe psychiatry.

这是有史以来最伟大的电影之一，只是碰巧是——这对你知道的，也许是精神病学来说是不幸的。

安德鲁·斯卡尔（Andrew Scull）：

Psychiatry, yes. It's very interesting. I used to teach a class called Madness In The Movies and I didn't just use… In fact, I used relatively few contemporary films, and among all the films from back then, the one almost everybody in the class had seen was One Flew Over the Cuckoo's Nest. So eight, nineteen, and twenty-year-olds in two thousand and fifteen– if I showed them Alfred Hitchcock's Spellbound, no chance they'd ever seen that, maybe one because they were a class of people interested in film. But everybody had seen One Flew Over the Cuckoo's Nest.

精神病学，是的。非常有趣。我过去曾经教授一门课程，叫做《电影中的疯狂》，而我并不仅仅使用……事实上，我使用的当代电影相对很少，在所有那些电影中，几乎班上每个人都看过的是《飞越疯人院》。所以在 2015 年，八岁、十九岁和二十岁的学生——如果我给他们看阿尔弗雷德·希区柯克的《迷魂记》，他们根本不会看过，也许只有一个，因为他们是一群对电影感兴趣的学生。但每个人都看过《飞越疯人院》。

莱克斯·弗里德曼（Lex Fridman）：

On that tangent really quick, what is the greatest film on madness in your view?

顺着这个话题很快问一下，在你看来关于疯狂的最佳电影是什么？

安德鲁·斯卡尔（Andrew Scull）：

Oh, well…

哦，好吧…

莱克斯·弗里德曼（Lex Fridman）：

Would that be One Flew Over the Cuckoo's Nest?

那会是《飞越疯人院》（One Flew Over the Cuckoo's Nest）吗？

安德鲁·斯卡尔（Andrew Scull）：

I think One Flew Over the Cuckoo's Nest, I think oddly a very different film appeared at about the same time was I Never Promised You a Rose Garden, which is a much more sympathetic portrait of a different kind of psychiatry, a very Freudian psychiatrist, really about Frieda Fromm-Reichmann who worked at Chestnut Lodge in Maryland and treated schizophrenia with psychotherapy rather than with drugs or other forms of physical intervention. And that was a bestselling novel by a young girl who had been her patient with some fairly serious delusions and a very complicated family background. And again the film changed a lot of things in the novel. That's what films do. My book Madhouse at one point interested Hollywood and one of the two principals said to me, "I really like this story. It's got a great first act and a great second act, but where's the third act?" Meaning where's the happy ending, and I had to say there wasn't any happy ending to that story. It was just rather grim.

我认为《布谷鸟》，我认为奇怪的是，差不多同时出现的另一部电影是《我从未答应过你一片玫瑰园》，这是一部对另一种精神治疗方式更具同情心的描写，非常弗洛伊德式的精神科医生，实际上关于弗里达·弗罗姆-赖克曼，她在马里兰州的栗子旅馆工作，用心理治疗而非药物或其他身体干预来治疗精神分裂症患者。这是一位曾是她病人的年轻女孩写的畅销小说，这个女孩有一些相当严重的妄想以及非常复杂的家庭背景。同样，电影改变了小说中的很多内容。电影本来就是这样。我的书《疯人院》曾一度引起好莱坞的兴趣，其中一位主要负责人对我说：“我真的很喜欢这个故事。它有一个很棒的第一幕和很棒的第二幕，但第三幕在哪儿？”意思是问，幸福的结局在哪儿？我不得不说，这个故事没有任何幸福结局。它相当阴暗。

莱克斯·弗里德曼（Lex Fridman）：

Madhouse: A Tragic Tale of Megalomania and Modern Medicine is the book you're referring to. Yes, that's right. Now that reminds me of Flowers for Algernon. That doesn't have a happy ending, and it's not about mental health necessarily, but it's about the journey of an institution in relation to the health of a patient.

《疯人院：一部关于狂妄自大与现代医学的悲剧故事》就是你提到的那本书。是的，没错。现在这让我想起了《献给阿尔吉侬的花束》。那本书没有一个快乐的结局，而且它不一定是关于心理健康的，但它讲述了一个机构在病人健康问题上的经历。

安德鲁·斯卡尔（Andrew Scull）：

Yes, Pat Barker's trilogy of novels about World War I was turned into a film, I think it was called Regeneration and that was quite powerful. It was about World War I and the treatment of shell shock. And I thought was quite well done. And my friend Patrick McGrath, who's a novelist wrote a book called Asylum. Patrick grew up in the grounds of Broadmoor. Broadmoor is England's premier hospital for the criminally insane and he was babysat by some of the patients. And when you read his novels you can see how that upbringing affected his rather macabre imagination. But anyway, so One Flew Over the Cuckoo's Nest, the poverty of the environment room that the patients were in I think fairly successfully recreates that way in which staff very often put patients down, didn't listen to them or poke fun at them or even were physically abusive although you don't see that. Those were all features of mental hospitals. The general boredom of life sort of there, but yeah hard to– putting boredom on the screen will turn an audience off rather fast.

是的，帕特·巴克（Pat Barker）关于第一次世界大战的小说三部曲被拍成了电影，我认为它叫《再生》，非常强大。 这是关于第一次世界大战和炮弹休克症的治疗。 我认为做得很好。 我的小说家朋友帕特里克·麦格拉思（Patrick McGrath）写了一本书，名叫《庇护》（Asylum）。 帕特里克在布罗德莫长大。 布罗德莫尔医院是英格兰首屈一指的精神病罪犯医院，他负责照顾一些病人。 当你读他的小说时，你会发现这种成长经历如何影响了他相当可怕的想象力。 但无论如何，《飞越疯人院》（One Flew Over the Cuckoo's Nest），我认为患者所在的房间环境的贫困相当成功地再现了这种方式，工作人员经常贬低患者，不听他们说话或取笑他们，甚至对他们进行身体虐待，尽管你看不到这一点。 这些都是精神病院的特征。 生活中普遍存在的无聊感就在那里，但是很难——把无聊放在屏幕上会让观众很快就失去兴趣。

莱克斯·弗里德曼（Lex Fridman）：

What about nurses and this kind of abusive element, you know?

那护士和这种虐待性元素呢，你知道吗？

安德鲁·斯卡尔（Andrew Scull）：

Yeah, I think there was an abusive element in a lot of mental hospitals and it was almost inevitable. Look at who had the most contact with the patients: it was the lowest paid, least respected ward attendants, very few even RNs. And you know, ratio of doctor to patient in the large state mental hospitals meant that patients hardly ever saw a physician, you know. Remarkable about the film, there are many remarkable things about the film as well as its polemical edge, I think, is that chief psychiatrist that you see in the film is the real head of Oregon State Mental Hospital. He really was, introduction to acting, and I thought he was pretty remarkable actually. Obviously there's a lot of exaggeration there, but ECT was used in the fifties and sixties as a tool of discipline in the hospitals.

是的，我认为很多精神病院都有虐待成分，这几乎是不可避免的。看看谁与患者接触最多：是最低薪水、最不受尊重的病房护理员，真正的注册护士都很少。而且你知道，大型州立精神病院的医生与患者比例意味着患者几乎看不到医生。这部电影令人瞩目的地方，有很多令人瞩目的地方，同时也带有争议性，我认为，那部电影中你看到的首席精神科医生就是俄勒冈州立精神病院的真正负责人。他确实是，接触表演的入门，我认为他实际上相当了不起。显然那里有很多夸张，但在五六十年代，电休克疗法（ECT）确实被用作医院的纪律工具。

安德鲁·斯卡尔（Andrew Scull）：

It was also used therapeutically, but overwhelmingly it was used as a tool of discipline and control. And that's true to life. Lobotomy… One of the interesting things we haven't talked about with all these treatments we've been discussing is that almost invariably, except for the case of the syphilitic patients, for obvious reasons men were more troubled by that condition than women, it was women that got the brunt of these experiments. So Henry Cotton, about 70% of his patients who were treated were female. Lobotomy patients, it's hard to get overall numbers, but those of us who've looked at the records of a number of different hospitals again and again discover, again, 60 or 70% of the patients are female. ECT tends to be heavily female. That's complicated by the fact that it's used primarily as, as we were discussing in serious cases of depression and so-called treatment-resistant depression, and depression is a diagnosis that is more to be found among women than men. Not that there aren't very many men with depression, but again, the ratio is such. Men tend to get a different– they get different diagnoses. Personality disorders, for example, are very, very common and are more a male diagnosis. Um, ADHD-

它也被用于治疗，但绝大多数被用作纪律和控制的工具。 这就是生活的真相。 脑叶白质切除术……我们一直在讨论的所有这些治疗方法中，我们没有谈到的一个有趣的事情是，除了梅毒患者的情况之外，几乎无一例外的是，出于明显的原因，男性比女性更容易受到这种情况的困扰，在这些实验中首当其冲的是女性。 所以亨利·科顿（Henry Cotton），他接受治疗的患者中大约 70%是女性。 脑叶白质切除患者，很难得到总体数字，但我们这些一遍又一遍地查看多家不同医院的记录的人发现，60%或 70%的患者是女性。 电休克疗法（ECT） 往往以女性为主。 事实上，它主要用于治疗严重的抑郁症和所谓的难治性抑郁症，而抑郁症这种诊断在女性中比男性更常见。 并不是说患有抑郁症的男性不多，但比例确实如此。 男性往往会得到不同的结果——他们会得到不同的诊断。 例如，人格障碍非常非常常见，而且更多的是男性诊断。 嗯，多动症-

莱克斯·弗里德曼（Lex Fridman）：

Mm

嗯

安德鲁·斯卡尔（Andrew Scull）：

…is more male than female and so on. So it's good to point that out. Uh, I think it helped end interest in ECT, except for a small handful of enthusiasts for decades, that film. And probably even now it creates hesitation in people about the treatment. So it's one that has had a very powerful and long-lasting effect, I think.

……更多的是男性而不是女性，诸如此类。所以指出这一点是好的。呃，我认为它帮助结束了对电休克疗法（ECT）的兴趣，几十年来除了少数几个爱好者以外，那部电影几乎没人关注。甚至可能直到现在，它仍然让人们对这种治疗产生犹豫。所以我认为这是一个产生了非常强大且持久影响的案例。

莱克斯·弗里德曼（Lex Fridman）：

I think the surprising thing is I recently learned a friend of mine tried everything, about 20 years ago, tried everything with depression, and ECT is the last thing he tried, and it changed his life- …for the better.

我觉得令人惊讶的是，我最近得知我的一个朋友大约在 20 年前尝试了治疗抑郁症的各种方法，而电休克治疗（ECT）是他尝试的最后一种方法，它改变了他的生活——……变得更好。

安德鲁·斯卡尔（Andrew Scull）：

That's not an uncommon story. Yeah.

那并不是一个不常见的故事。是的。

莱克斯·弗里德曼（Lex Fridman）：

And then I looked online and there's a lot of stories like this. And I– before learning of that, my, I'm embarrassed to say, knowledge of ECT was just "One Flew Over the Cuckoo's Nest."

然后我上网看了，有很多类似的故事。在了解那个之前，我……很不好意思说，我对电休克疗法（ECT）的了解只是“《飞越疯人院》（One Flew Over the Cuckoo's Nest）”.

安德鲁·斯卡尔（Andrew Scull）：

It– You know, it has a terrible history- …in the, in the '40s, '50s and '60s. There are lots of-

它——你知道，它有一段可怕的历史——……在四十年代、五十年代和六十年代。有很多——

莱克斯·弗里德曼（Lex Fridman）：

Abuses

滥用

安德鲁·斯卡尔（Andrew Scull）：

The CIA funded Ewen Cameron up in Canada, and he was giving multiple ECTs a day and reducing peoples to… Well, they couldn't walk, they couldn't talk, they couldn't feed themselves, they were incontinent, and then he built them back up, or so he claimed, but in many cases, they were left permanently damaged. So I could recite lots of real horror stories about ECT, but it's also, if you're honest about the thing, what you just described, that is patients who were on the brink of suicide, who had long-running depressions, some of them had ECT and they describe it as lifesaving. And as I say when more controlled trials have been done recently, there's enough evidence now that it's hard to say, "This never works. This is just one of these desperate remedies we should consign to dark ages." The complicating thing is we'd have no clue why it works. It's a purely empirical treatment.

中央情报局在加拿大资助了尤恩·卡梅伦，他每天给人多次电休克治疗，把人们弄得……嗯，他们不能走路，不能说话，不能自理，失禁，然后他又声称把他们重新培养起来，但在很多情况下，他们被永久性地伤害了。所以我可以讲很多关于电休克治疗的真实恐怖故事，但如果说实话，你刚才描述的情况，也就是那些处于自杀边缘、长期抑郁的患者，其中一些接受了电休克治疗，他们形容这是救命的。就像我说的，最近进行的更多控制性试验表明，现在有足够的证据，很难说‘这从来不管用，这是我们应当丢进黑暗时代的绝望疗法之一。’复杂的问题是，我们根本不知道它为什么有效。这是一种纯粹的经验性治疗。

莱克斯·弗里德曼（Lex Fridman）：

Right. Right.

对。对。

安德鲁·斯卡尔（Andrew Scull）：

And that itself I think tends to put people off. If you have a curable form of cancer and the surgeon says, "Well, I'm gonna remove it," and she does, that's that. But because we understand even a little bit, even if our knowledge of human biology is pretty primitive, we do understand a little bit that cancer is cells dividing uncontrollably and taking up and doing damage to the body and eventually killing you, and the fact that we can surgically remove it is a big deal. There are lots of disorders. I have high blood pressure. If untreated, my blood pressure is like a 20-year-old's thanks to treatment. It's an ongoing thing. I take the damn pill every day and it has a few minor side effects, but for me very minor ones. And it turns what could have killed me via a stroke or a heart attack into a condition that's very well controlled. So, you know, all of these things, they're a complicated picture. It's easy with some of these things, with lobotomy, with insulin comas, deep sleep treatments, Henry Cotton's endeavors. Those you can just say, "Well, we'll throw them away." And for a long time, I think ECT would have formed part of that cast of characters. So when I first conceived the idea of writing Desperate Remedies, the book, it was back in 1981 and I was in London on a Guggenheim Fellowship at the Wellcome Institute.

我认为这本身就会让人望而却步。 如果你患有可治愈的癌症，外科医生说：“好吧，我要把它切除，”她就这么做了，就是这样。 但因为我们了解一点点，即使我们对人类生物学的了解相当原始，我们也确实了解一点点，癌症是细胞不受控制地分裂，对身体造成损害并最终杀死你，而事实上我们可以通过手术切除它是一件大事。 有很多障碍。 我有高血压。 如果不治疗的话，我的血压就像 20 岁的人治疗后的血压一样。 这是一个持续的事情。 我每天都服用该死的药丸，它有一些轻微的副作用，但对我来说非常轻微。 它使我原本可能因中风或心脏病而丧命的情况变得得到了很好的控制。 所以，你知道，所有这些事情都是一幅复杂的图景。 其中一些事情很容易，例如 脑白质切除术（lobotomy）、胰岛素昏迷、深度睡眠治疗、亨利·科顿（Henry Cotton） 的努力。 你可以直接说：“好吧，我们会把它们扔掉。” 在很长一段时间里，我认为 电休克疗法（ECT） 会成为这个角色的一部分。 因此，当我第一次萌生写《绝望的疗法》这本书的想法时，那是在 1981 年，当时我正在伦敦威康研究所 (Wellcome Institute) 获得古根海姆奖学金。

安德鲁·斯卡尔（Andrew Scull）：

And I hadn't done research in detail, but I was aware there were all these things lurking about that had happened in the 1920s and '30s and I thought that would be a very interesting thing to study. And luckily I didn't do it right away or I did it piecemeal over the years and I ended up writing a much more comprehensive look at psychiatry really from its origins to now. And I couldn't have written that book back then, and I would've missed all the developments from 1980 onwards, which are very, very important to the overall picture.

我当时还没有做过详细的研究，但我知道在 1920 年代和 30 年代发生过很多事情，我觉得研究这些事情会非常有趣。幸运的是，我没有立即去做，而是这些年来零零散散地进行，最终我写了一本关于精神病学的更全面的书，几乎覆盖了从起源到现在的整个发展。我当时不可能写出那本书，如果那样的话，我会错过从 1980 年起的所有发展，而这些发展对整体情况非常非常重要。

莱克斯·弗里德曼（Lex Fridman）：

So forty years later, 2022.

所以四十年后，2022 年。

安德鲁·斯卡尔（Andrew Scull）：

Yes. Yes, exactly.

是的。是的，完全正确。

莱克斯·弗里德曼（Lex Fridman）：

Your own Desperate Remedies: Psychiatry's- … Turmoil in Quest to Cure Mental Illness.

你自己的绝望疗法：精神病学在治愈心理疾病的探索中的混乱。

安德鲁·斯卡尔（Andrew Scull）：

I've written a lot of books and along the way– part of the way, I think I've been productive and kept interested. I always had two… at least two projects on the go at once. You can't simultaneously write two things, but I'd have one and I'd work on it, and if I got tired of it, I'd pick up the other one for a bit and then go back. And it also meant when I was working on one main project, I had other things percolating in my head, and I would come across things that were relevant to them and I'd make a note and then I'd go back. So when I finally did Desperate Remedies, I'd been thinking about those issues for forty years, and that made a big difference, I think, to the way I approached things and to what I thought. ‘Cause you just… You either like Thomas says, you say the same thing over and over and over again for forty years or you learn new things and you broaden what you know, and you think about things in a different way because you realize you haven't grasped the full complexity of what you're looking at. And so look, what I found with psychiatry is there are really a couple of fundamental things that have kept me engaged with the field. One, it's an arena where there's tremendous human suffering, and it spreads out and it's as far as I know — and I wrote a big book called Madness in Civilization about from the ancient Greeks and ancient China to now — in every society I've studied they have to cope with this. It takes different forms. It's regarded in different ways.

我写了很多书，一路走来——在某种程度上，我认为我一直富有成效并保持着兴趣。 我总是同时有两个……至少两个项目正在进行。 你不能同时写两件事，但我有一个，我会继续写，如果我厌倦了，我会拿起另一件事，然后再回去。 这也意味着当我从事一个主要项目时，我的脑海中会渗透出其他事情，我会遇到与它们相关的事情，我会记下来，然后再回去。 因此，当我最终完成《绝望的疗法》时，我四十年来一直在思考这些问题，我认为这对我处理事物的方式和我的想法产生了很大的影响。 因为你只是……你要么像托马斯说的那样，四十年来一遍又一遍地说同样的事情，要么你学习新事物，拓宽你的知识，你以不同的方式思考事物，因为你意识到你还没有掌握你所看到的事物的全部复杂性。 所以看，我在精神病学方面发现确实有一些基本的事情让我一直致力于这个领域。 首先，这是一个有人类巨大痛苦的领域，这种痛苦蔓延开来，据我所知——我写过一本名为《文明中的疯癫》的大书，内容从古希腊和古中国直到现在——在我研究过的每一个社会中，他们都必须应对这种痛苦。它以不同的形式出现，被以不同的方式看待。

安德鲁·斯卡尔（Andrew Scull）：

It's treated differently, but that there are people that deviate so far from the norm of what we regard as culturally appropriate, they exist everywhere. So the suffering, the difficulty of studying it, and then the fact that it is such a complex and difficult subject to understand. The very fact that we have such limits to our knowledge means there's space there to examine things in a, in a very– in what needs to be a very complicated way. And so it's, it's intellectual puzzles attracted some very, very smart people, but there's a long way to go.

它被以不同的方式对待，但确实有人偏离了我们认为的文化适宜的常规，他们无处不在。因此，这方面的痛苦、研究它的困难，以及它本身如此复杂且难以理解的事实。我们知识的局限性意味着有空间以非常——需要非常复杂的方式——来审视事物。因此，这种智力上的难题吸引了一些非常聪明的人，但仍有很长的路要走。

莱克斯·弗里德曼（Lex Fridman）：

Yeah, we have glimmers of insights about how the mind works but- ….if you look at the span of human history, we're probably in the very early days of understanding this particular one. I have to, if it's okay-

是的，我们对大脑是如何运作的有一些微弱的见解，但是……如果你看看整个人类的历史，我们可能才刚刚开始理解这个特定的领域。如果可以的话，我必须……

安德鲁·斯卡尔（Andrew Scull）：

Yes, of course.

是的，当然。

莱克斯·弗里德曼（Lex Fridman）：

…so that we– we've been carrying multiple threads together. One of the threads that I think is really exciting to me and really important to the history of psychiatry is the psychotherapy side. We have mentioned the psychopharmacology that will also– it would be nice to discuss when the two clash and there's a revolution where psychopharmacology kinda wins over psychoanalysis for a time. But let us start at, at the somewhat beginning, in the nineteenth century when talk therapy starts coming to life maybe in the religious context with Christian Science and then psychoanalysis context.

……因此我们——我们一直在把多条线索结合在一起。我认为其中一条让我非常兴奋、对精神病学历史非常重要的线索是心理治疗方面。我们已经提到了精神药理学，这也——当两者发生冲突的时候讨论一下会很不错，历史上曾有一次精神药理学在一段时间内对精神分析占了上风的革命。但让我们从十九世纪的某个起点开始，当时谈话疗法开始出现，也许是在宗教背景下的基督教科学中，然后才是在精神分析背景下。

安德鲁·斯卡尔（Andrew Scull）：

Yes. So I'd mentioned late nineteenth century psychiatry, confined as it was to the mental hospital and to people incarcerated in those places, had become very biological. But there were people experiencing mental troubles of various kinds, sadness, confusion, loss of social relationships that were troubling them, grief, all sorts of things like that, that didn't involve time in a mental hospital but nonetheless involved a good deal of distress as they continued to do. And one of the things that was interesting about nineteenth century America is it spawned a number of new religions, sort of variants of Christianity. So you had Seventh-day Adventists, a group that still exists, who actually spawned a sanitarium for their depressed congregants that was later taken over by two prominent members of the Adventist Church, the Kellogg family, everybody knows them through cereal. But they ran a huge sanitarium to which Abraham Lincoln's widow went, Tarzan went, Henry Ford went, lots of very prominent industrialists and politicians and, you know, it was kind of a farm to go and recover your mental stability and health, and it was all bound up also with beliefs about diet and defecation and all sorts of things. There were the Mormons, or Church of Jesus Christ of Latter-day Saints, many Christians don't believe they're really Christian, but they think they are and call themselves such.

是的。 所以我提到十九世纪末的精神病学，因为它仅限于精神病院和被监禁在这些地方的人，已经变得非常生物学。 但有些人经历着各种各样的精神问题，悲伤、困惑、困扰他们的社会关系的丧失、悲痛，诸如此类的事情，这些并不涉及在精神病院的时间，但尽管如此，他们继续这样做会带来很大的痛苦。 十九世纪的美国有趣的事情之一是它催生了许多新的宗教，有些是基督教的变体。 因此，基督复临安息日会这个团体仍然存在，他们实际上为他们抑郁的会众建立了一个疗养院，后来被复临教会的两位著名成员凯洛格家族接管，每个人都通过麦片认识他们。 但他们经营着一个巨大的疗养院，亚伯拉罕·林肯的遗孀、人猿泰山、亨利·福特都去过，还有很多非常著名的实业家和政治家，你知道，那是一个农场，可以让你恢复精神稳定和健康，而且这一切都与饮食、排便和各种事情的信仰紧密相关。 有摩门教，或耶稣基督后期圣徒教会，许多基督徒不相信他们是真正的基督徒，但他们认为自己是真正的基督徒，并自称是基督徒。

安德鲁·斯卡尔（Andrew Scull）：

So you have a number of these, and one of them was Christian Science, which was the invention of a woman named Mary Baker Eddy. Developed the idea–and there are still Christian Science churches and Christian Science reading rooms all across America–that there wasn't such a thing as disease, that it could be prayed away, that it was just a lack of sufficient faith. So faith healing tended to work, I think, better if it worked at all for psychiatric problems than it did if you had, say, cancer. But Christian Science achieved a considerable number of followers, disproportionately women, but not only women. And it began to treat many of the people suffering from what we would think of as the milder mental disorders, and it attracted both adherents and severe critics. Mark Twain, for example, was thoroughly dismissive of Mary Baker Eddy. But it was very successful for a time. There were other religiously based attempts to join in, the most important of which in New England was something called Emmanuel Movement, centered around the Church of the Emmanuel in Boston, which was an attempt actually initially to bring medical and religious approaches to helping the mentally troubled. Rather quickly, the doctors involved decided this was veering too much in the direction of medically-based therapeutics; they kind of withdrew from enterprise. It dispensed– there were talk therapies obviously with a strong religious component around them. This was also at a time when some…

所以你有很多这样的东西，其中之一是基督教科学，它是一位名叫玛丽·贝克·艾迪的女人的发明。 提出了这样的想法——美国各地仍然有基督教科学教堂和基督教科学阅览室——没有疾病这样的东西，它可以通过祈祷消失，这只是缺乏足够的信仰。 因此，我认为，如果信仰治疗对精神问题有效，那么它往往会比对患有癌症等疾病更有效。 但基督教科学派拥有相当数量的追随者，其中女性比例不成比例，但不仅仅是女性。 它开始治疗许多患有我们认为的较轻微精神障碍的人，它吸引了追随者和严厉的批评者。 例如，马克·吐温就对玛丽·贝克·艾迪完全不屑一顾。 但一时间却非常成功。 还有其他基于宗教的尝试加入其中，其中在新英格兰最重要的是所谓的“以马内利运动”，以波士顿的以马内利教堂为中心，实际上最初是试图通过医学和宗教方法来帮助精神障碍患者。 很快，参与其中的医生就认为这过于偏向基于医学的治疗方法； 他们有点退出企业了。 它提供——显然有一些带有强烈宗教成分的谈话疗法。这也是在某些……时期。

安德鲁·斯卡尔（Andrew Scull）：

guess we can call them psychiatrists they were often neurologists were beginning to get lots of patients with these kinds of difficult to treat disorders. Neurology had emerged in America after the Civil War. Civil War provided a lot of naturalistic experiments on what happens to the human brain and the human nervous system when trauma affect – I don't mean psychological trauma I mean bullets blowing holes in your brain. A group of new specialists emerged after the Civil War who claims expertise in the brain and the nervous system. Well one of the other side parts of that is insanity because insanity is also seen as a brain disease so there is a conflict that erupts in the 1870s and '80s between neurologists and psychiatrists. But the neurologist can't for the most part get into the asylum

我们可以称他们为精神科医生，他们通常都是神经科医生，并开始接诊大量这类难以治疗的疾病患者。神经学在美国内战后兴起。内战提供了许多自然实验，让人们了解当大脑和神经系统受到创伤时会发生什么——我不是指心理创伤，我是指子弹在你大脑上打出洞穴。内战后出现了一批新的专家，他们声称在大脑和神经系统方面具有专长。另一面的问题是疯狂，因为疯狂也被视为一种大脑疾病，所以在 1870 和 1880 年代，神经科医生和精神科医生之间爆发了冲突。但大多数情况下，神经科医生无法进入疯人院。

安德鲁·斯卡尔（Andrew Scull）：

where the most seriously ill patients are. Gradually what comes to their waiting room, along with people like multiple sclero– suffering from things like multiple sclerosis, are people with functional mental disorders. There's the beginning of an outpatient practice which initially involves some drugs, the use of electricity–not ECT, but the use, for example, of static electricity because it produces obvious physiological responses. Electricity is seen as dominating the workings of the body. Sometimes tonics of one sort or another. Most notoriously of all, something called the rest cure. Silas Weir Mitchell, one of the leading lights of American neurology, develops complete bedrest, lots of calories, lots of food, complete lack of intellectual stimulation. Supposedly this is going to cure you, mainly

在那里，病情最严重的病人聚集。慢慢地，像多发性硬化症患者这样的人进入他们的候诊室，还有一些患有功能性精神障碍的人。这里开始出现了门诊实践，其初期涉及一些药物、电疗——不是电休克疗法，而是例如静电的使用，因为它会产生明显的生理反应。电被认为支配着身体的运作。有时会使用某种补药。最臭名昭著的是一种叫做休息疗法的治疗方法。西拉斯·韦尔·米切尔（Silas Weir Mitchell），美国神经学的领军人物之一，提出完全卧床休息、高热量饮食、大量进食、完全缺乏智力刺激的方法。据说这主要能治愈你。

安德鲁·斯卡尔（Andrew Scull）：

aimed at women. I feel like that's another evidence backed technique that works well. Well, you know, I've partaken in this and I know it has helped me. Laying in bed doing nothing, eating snacks. Virginia Woolf was one of the people subjected to this. She claimed it practically drove her mad or made her worse, you know? Just to clarify, we're talking about laying in bed eating snacks, eating lots of snacks, very high calorie. Okay. Weir Mitchell wrote two popular bestsellers, self-help books suppose you'd call them in the modern genre. One was called Wear and Tear. The pace of modern life, the telegraph, the railway was all too much. Your nervous system was overstressed. Either your batteries ran down, that was one analogy, or you overtaxed your system and went bankrupt. Wear and tear, that was the problem. The

针对女性。我觉得这是另一个有证据支持的、很有效的技巧。你知道，我自己也尝试过，我知道它对我有帮助。躺在床上什么也不做，吃零食。弗吉尼亚·伍尔夫也是受此影响的人之一。她声称这几乎让她发疯，或者让她病情加重，你知道吗？只是澄清一下，我们说的是躺在床上吃零食，吃大量零食，非常高热量。好的。维尔·米切尔写了两本流行的畅销书，你可以称之为现代类型的自助书籍。其中一本叫《磨损》。现代生活的节奏、电报、铁路对人们来说都太过分了。你的神经系统承受过度压力。要么你的能量耗尽，这是一个比喻，要么你过度消耗系统而导致崩溃。磨损，这就是问题所在。

安德鲁·斯卡尔（Andrew Scull）：

solution was Fat and Blood. That was the title of the other book. You got scrawny, nouveau, nervous, twitchy, and what you really needed was to build back up your strength, including your nervous strength. Isn't it fascinating to look at that 120 years plus ago? They're talking about how anxiety inducing society is, how much is going on, and we in the modern day talk in exact same way about social media, the internet, all that kind of stuff. Yeah, yeah, it is. We look back on the nineteenth century and think of it in idyllic terms of a much slower pace of life, and people, they thought it was stressful in exactly the ways we do. There was a class of potential patients. Some of them were seeking help in the neurologists and a few psychiatrists who moved out of the asylum. But there were also these mental healing groups that were religious, and they're all around at the beginning of the 20th century. And in 1909, a Viennese gentleman and two of his close colleagues travel across the Atlantic on a German steamer and arrive in New York and then transport themselves up to Worcester, Massachusetts, where Clark University is celebrating its 20th anniversary. Clark University was then set up– It still exists, but it was set up to copy the German research university. The only comparable example at the time was Johns Hopkins in Baltimore, and Hopkins developed the leading medical school of the time borrowing from that German concept of mixing research and teaching and patient care.

解决方案是脂肪和血液。 这是另一本书的书名。 你骨瘦如柴、新奇、紧张、抽搐，而你真正需要的是增强你的力量，包括你的神经力量。 回顾 120 多年前的景象，是不是很有趣？ 他们谈论社会是如何引发焦虑的，正在发生多少事情，而我们现代人以完全相同的方式谈论社交媒体、互联网以及所有类似的东西。 是啊，是啊，确实如此。 我们回顾十九世纪，会以田园诗般的方式思考它，生活节奏要慢得多，人们认为这和我们一样充满压力。 有一类潜在的病人。 他们中的一些人正在向神经科医生和一些搬出精神病院的精神科医生寻求帮助。 但也有一些宗教性的心理治疗团体，它们在 20 世纪初就很普遍。 1909 年，一位维也纳绅士和他的两位亲密同事乘坐德国轮船横渡大西洋，抵达纽约，然后前往伍斯特 马萨诸塞州，克拉克大学正在那里庆祝建校 20 周年。 克拉克大学随后成立——它仍然存在，但它是模仿德国研究型大学而设立的。 当时唯一可比较的例子是巴尔的摩的约翰斯·霍普金斯大学，霍普金斯借鉴了德国将科研、教学和患者护理相结合的理念，发展了当时领先的医学院。

莱克斯·弗里德曼（Lex Fridman）：

I like how you're telling this in a cinematic way the story of Sigmund Freud and Carl Jung- … go coming to America to give a lecture. I like, I like how it's like the movie opens and there yeah Yeah Well here he is You know Like How do you feel who he is? He's fairly obscure We should say the reason you're actually telling it that way is America has been a really defining place for psychiatry Yes And then Freud had his own views on America and so on But this this was In terms of the history yes psychiatric medicine america as central Right Many of the in house histories of Psychiatry portray this as Freud conference Mm-hmm But it wasn't Freud Was almost an afterthought Of the Conference The head of Clark Was a psychologist And he was interested in Freud But Actually There were about thirty speakers At the Clark conference Two Nobel Prize Winners in physics Franz Boas

我喜欢你用电影般的方式讲述西格蒙德·弗洛伊德（Sigmund Freud）和卡尔·荣格（Carl Jung）的故事——……来美国讲座的事。我喜欢，我喜欢这种电影开场的感觉，然后就是——对，就是他来了。你知道，你觉得他是怎样的人？他相当默默无闻。我们应该说，你之所以以这种方式讲述，是因为美国对精神病学来说是一个非常决定性的地方。是的。而且弗洛伊德对美国也有自己的看法等等。但就历史而言，是的，精神医学把美国作为中心，对吧？许多精神病学内部历史都把这次会议描绘成弗洛伊德的会议，嗯哼。但实际上并不是那样。弗洛伊德几乎是会议之后才被提起的。克拉克大学的负责人是心理学家，他对弗洛伊德感兴趣，但实际上在克拉克会议上大约有三十位演讲者，其中两位是诺贝尔物理奖获得者，还有弗朗茨·博阿斯。

莱克斯·弗里德曼（Lex Fridman）：

Who was the leading anthropologist Of his generation And A host of other scholars Including a couple of Freuds Fierce critics One of whom Stern Was On the same boat As him And They avoided one another Like the plague But anyway Its important To see That And Freud It's a mark of how Important german science And German Medical Science Was In the late nineteenth Early Twentieth Century Where it was THE most advanced In the world That Freud Delivered His lectures IN GERMAN AND THE AUDIENCE THAT WASNT A PROBLEM FOR THE AUDIENCE CAUSE THEYD ALL LEARNED GERMAN SO THEY COULD READ GERMAN LITERATURE ON MEDICINE So Quite An Extraordinary Thing UM William James Attends One OF FREUDS LECTURES AND HAS A CONVERSATION WITH HIM WILLIAM JAMES IS ONE OF THE PEOPLE THINKING ABOUT THE PSYCHOLOGY OF THE HUMAN

他是他那一代的领军人类学家，还有许多其他学者，包括几个弗洛伊德的尖锐批评者，其中一位斯特恩曾和他在同一条船上，但他们避开对方如同避瘟疫。但无论如何，重要的是要看到弗洛伊德，这也显示了德国科学和德国医学在 19 世纪末到 20 世纪初的重要性，那时它是世界上最先进的。弗洛伊德用德语进行讲座，而听众对此并不成问题，因为他们都学过德语，可以阅读德语医学文献。这是一件非常非凡的事情。威廉·詹姆斯参加了弗洛伊德的一次讲座，并与他进行了一次对话。威廉·詹姆斯是思考人类心理学的人之一。

莱克斯·弗里德曼（Lex Fridman）：

MIND IN INTERESTING WAYS HES NOT IMPRESSED BY FREUD AND HE ALSO HAS A BAD HEART CONDITION HE DIES NOT All that long afterwards BUT HES NOT Impressed By Freud A handful of people are Some of the neurologists And Freuds Lectures Explicitly Attack Religiously Based Psychotherapy Says psychotherapy Is like a surgical operation on the mind And Only Us Doctors Or ONLY US THOROUGHLY TRAINED People Cause ACTually He doesnt Believe That Psychoanalysis Is Only Something That Can Be Practiced by Medically Qualified But The Lecture Is On psychoanalysis YES ITS FIVE LECTURES THEYRE PUBLISHED SUBSEQUENTLY AND HE MAKES A VERY IMPORTANT Convert THERE UM James Jackson Putnam Is A Boston Brahmin One of the Upper Class Bostonians With Whos Extremely well connected and is professor of Neurology AT Harvard

心灵以有趣的方式。他对弗洛伊德并不感兴趣，而且他还有严重的心脏病。他不久之后去世，但他对弗洛伊德并不感兴趣。少数人是一些神经学家，而弗洛伊德的讲座明确攻击基于宗教的心理治疗，认为心理治疗就像对心灵的外科手术，只有我们医生或者只有我们经过彻底训练的人才能真正实施。实际上，他并不相信精神分析只能由有医学资质的人实践，但讲座是关于精神分析的。是的，是五场讲座，它们随后出版，他做了一个非常重要的转换。詹姆斯·杰克逊·普特南是波士顿贵族，属于上层阶级波士顿人之一，非常有背景联系，并且是哈佛大学神经学教授。

莱克斯·弗里德曼（Lex Fridman）：

And he becomes A Freudian At that conference So Mainstream American Psychiatry Pays Very little attention TO To Freuds Arrival on the scene And When he BECOMes A bit more visible They tend to be very dismissive They uh They regard the idea of talk therapy For something They regard as a biological condition AS A ridiculous Idea Maybe Just Uh Mention A Few Things SIGMUND FREUD Of course Is widely acknowledged to be the father of psychoanalysis And UH He Has a bunch of ideas One of which is theres This unconscious Mind That is the source of many of our Uh Behaviors Exactly And Then Psychoanalysis Is a Way to delve deep into that mind And the tools he used to Do that is talking Yes Freud was trained as a neurologist himself Uh And studied under the most famous Late Nineteenthcentury Neurologist

然后他在那个会议上成为了一个弗洛伊德派。所以主流美国精神病学对弗洛伊德的出现几乎不予重视。当他变得稍微引人注目时，他们往往非常轻视。他们……他们认为针对某种他们认为是生物性疾病的情况做谈话疗法是一个荒谬的想法。也许只是……提到几件事。西格蒙德·弗洛伊德当然被广泛认为是精神分析的奠基人，并且他有一系列的理论，其中之一是存在一个无意识的心灵，它是我们许多行为的根源。完全正确。随后，精神分析是一种深入探究那种心灵的方式，而他用来达到这一目的的工具是谈话。是的，弗洛伊德本人受训成为神经学家，并师从十九世纪末最著名的神经学专家。

莱克斯·弗里德曼（Lex Fridman）：

Charcot in Paris and translated Charcot into German and endeared himself to Charcot by doing that. That's, um, a clever way to help your career along. But his Viennese colleagues didn't think much of Charcot. And they didn't think much of Freud's ideas either, so he had a bit of a hard time. But he did develop a successful practice in the sense that patients came to him. He was accompanied by two of his close disciples to the Clark Conference. One of them, Carl Jung, was then anointed the Crown Prince. He was supposed to inherit Freud's enterprise until the men had a very serious falling out. Mm-hmm. Uh, just a little bit later in nineteen thirteen. And Freud and Jung went their separate ways. That's a complicated story. Freud, as one of his close, uh, friends and collaborators put it, was a great hater if you fell out with Freud. It was bad news. Oh yeah, yeah. You were excommunicated if it was Adler, but Jung especially.

沙科在巴黎，并将沙科的著作翻译成德文，这样做也让他赢得了沙科的好感。这是一个促进职业发展的聪明方式。不过，他在维也纳的同事们并不太看重沙科，也不太认可弗洛伊德的观点，所以他当时遇到了一些困难。但他确实成功地开设了诊所，因为患者愿意来找他。他由两位亲密弟子陪同参加了克拉克会议。其中一位卡尔·荣格（Carl Jung），当时被任命为王储，他本该继承弗洛伊德的事业，直到他们之间发生了非常严重的冲突。嗯，在 1913 年稍晚些时候，弗洛伊德和卡尔·荣格（Carl Jung）各走各路。这是一个复杂的故事。正如弗洛伊德的一位亲密朋友和合作者所说，如果你与弗洛伊德闹翻，他会非常讨厌你，那可不是好消息。哦，是的，如果是阿德勒，你会被逐出教门，但尤其是卡尔·荣格（Carl Jung）。

安德鲁·斯卡尔（Andrew Scull）：

Jung was Swiss and he worked in the major mental hospital in Zurich, and he was attracted to psychoanalysis and to Freud. And for the first few years there, there was this obvious close alliance. Anyway, so Jung was a, the person who actually persuaded Freud to go to America. Freud initially– Freud had very low opinion of America. He said it should be renamed Dollaría because it was only interested in the dollar. And American women were far too pushy and powerful, and American food was dreadful and it poisoned him, and on and on. Um-

荣格是瑞士人，他在苏黎世的主要精神病医院工作，他被精神分析和弗洛伊德所吸引。在最初的几年里，他们之间有这种明显的紧密联盟。无论如何，荣格实际上是说服弗洛伊德去美国的人。弗洛伊德起初——弗洛伊德对美国的看法非常低。他说应该把美国改名为“美元国”，因为美国只关心美元。而且美国女性太强势、太有权力，美国的食物很糟糕，会毒害他，诸如此类。嗯——

莱克斯·弗里德曼（Lex Fridman）：

So as you said, Freud was a master hater.

所以正如你所说，弗洛伊德 是个仇恨大师。

安德鲁·斯卡尔（Andrew Scull）：

Yeah, he was. And one of the things he hated was America, even though America brought him some fairly rich patients. But- … the richest patients of all went to Jung, not to Freud. And I think that probably exacerbated this split.

是的，他确实是。 他讨厌的其中一件事是美国，尽管美国给他带来了一些相当富有的病人。 但是……最富有的病人全都去找了卡尔·荣格（Carl Jung），而不是弗洛伊德。 我认为这可能加剧了这种分裂。

莱克斯·弗里德曼（Lex Fridman）：

Let's actually focus first before the conference on the actual ideas of psychoanalysis. So Freud was the originator of psychoanalysis. This is 19th century. So tell me about the original case of Anna O. and like what is psychoanalysis?

在会议之前，让我们先真正关注一下精神分析的实际概念。所以弗洛伊德是精神分析的创始人。这是 19 世纪的事情。告诉我关于 Anna O.的最初案例，以及什么是精神分析？

安德鲁·斯卡尔（Andrew Scull）：

Yeah. So Freud's academic career had been failing in Vienna, and he faced a prospect of either having to emigrate to America, which he regarded with horror in the 1880s, or perhaps reviving his career by going and studying under the most famous neurologist of the era, Jean-Martin Charcot, who was then delivering lectures on hysteria in Paris. And so Freud went and spent some months there and came back imbued with Charcot's ideas about hysteria and found a Viennese medical establishment. He started a consulting career and that involved– He had a close friend named Josef Breuer. And Breuer was more senior, had a very large practice, and referred patients to Freud. And the two of them began to be interested in this problem of hysteria. Breuer had treated a woman who's now known as the sort of foundation patient for– the Ur patient for psychoanalysis, who was known to us as Anna O. She– We actually know she was Bertha von Pappenheim but that was hidden for a long time. There– A lot of these patients had pseudonyms because obviously the cases exposed a lot about their inner psychology and quite reasonably, even without the modern concerns about privacy, there was a reluctance to identify them.

是的。 因此，弗洛伊德在维也纳的学术生涯一直失败，他面临着要么必须移民到美国的前景，他在 1880 年代对美国感到恐惧，要么可能通过跟随当时最著名的神经学家让·马丁·夏科（Jean-Martin Charcot）学习来重振自己的职业生涯，夏科当时正在巴黎发表有关歇斯底里症的讲座。 于是弗洛伊德去那里呆了几个月，回来时带着夏科关于歇斯底里症的想法，并找到了一家维也纳医疗机构。 他开始了咨询职业生涯，其中涉及——他有一个亲密的朋友，名叫约瑟夫·布洛尔(Josef Breuer)。 布洛伊尔的资历更高，拥有非常大的诊所，并将患者转介给弗洛伊德。 而两人开始对这个歇斯底里的问题产生了兴趣。 布劳尔曾治疗过一位女士，她现在被称为精神分析的乌尔患者的基础患者，我们称她为安娜·O。她——我们实际上知道她是伯莎·冯·帕彭海姆，但这已经被隐藏了很长时间。 那里——很多病人都有化名，因为显然这些案例暴露了他们的很多内心心理，而且很合理的是，即使没有现代对隐私的担忧，人们也不愿意透露他们的身份。

安德鲁·斯卡尔（Andrew Scull）：

So Anna O. had nursed her father. She was Breuer's patient, not Freud's. She'd nursed her father through an illness, and he'd ended up dying, and she developed various physical symptoms that troubled her a great deal and was also somewhat depressed. And Breuer and Freud dealt with that by developing a notion that what she was suffering from was repressed memories and trauma. And this would become central to psychoanalysis, the idea of half-muttered memories lurking in your subconscious that emerged in distorted forms of psychological symptoms and ways of being in the world that were disruptive. Freud, of course, develops a much more elaborate theory of this in years to come. Fre- and Breuer collaborate on a book called Studies in Hysteria, and they're a series of case vignettes in there of patients Freud has treated. And he develops the notion that people have these ex– past experiences. Initially, he thinks they're real, that they're– For example, they have been sexually assaulted as a child and that they can't face that, and so they hide it away from themselves. But they can't completely, so it emerges in this tortured series of forms. And as things develop, the notion of resistances emerges, that you can't easily retrieve these memories, and indeed, you resist them surfacing, and you have a hard time acknowledging them.

所以安娜·O. 照顾了她的父亲。 她是布洛伊尔的病人，而不是弗洛伊德的病人。 她照顾生病的父亲，最后他去世了，她出现了各种身体症状，让她很困扰，也有些沮丧。 布洛尔和弗洛伊德通过发展一种观念来解决这个问题，即她所遭受的痛苦是压抑的记忆和创伤。 这将成为精神分析的核心，潜意识中潜伏着半嘀咕的记忆，这些记忆以扭曲的心理症状和破坏性的存在方式出现。 当然，弗洛伊德在未来几年里会发展出更详尽的理论。 弗雷和布洛伊尔合作写了一本名为《歇斯底里症研究》的书，其中包含弗洛伊德治疗过的患者的一系列病例小插曲。 他提出了这样一种观念：人们都有这些过去的经历。 最初，他认为他们是真实的，他们——例如，他们小时候受到过性侵犯，他们无法面对这一点，所以他们把它藏起来。 但他们不能完全做到，所以它以这一系列受折磨的形式出现。 随着事情的发展，阻力的概念出现了，你不能轻易地检索这些记忆，事实上，你抵制它们的出现，并且你很难承认它们。

安德鲁·斯卡尔（Andrew Scull）：

And only with long and painful work will it become possible for– But as you bring them into– from the unconscious into the conscious world, you learn to cope with them in a different way, and, and your personality is transformed and you're made better.

只有经过长期而痛苦的努力，它才可能实现——但是当你将它们从无意识的状态带入有意识的世界时，你会学会以不同的方式应对它们，你的人格也会因此被转变，你会变得更好。

莱克斯·弗里德曼（Lex Fridman）：

But crucially, the stuff that happens in childhood is important.

但关键是，童年发生的事情很重要。

安德鲁·斯卡尔（Andrew Scull）：

Yes. The early experiences have a dramatic effect, and I think even some biological psychiatrists would agree with that notion these days. That, you know, to the extent we abolish this distinction between mind and body and, and acknowledge that they are closely tied together, traumatic experiences in childhood, various socialization experiences, loss and so on deeply mark the human psyche, I think, and, and can have long term effects that are, are very powerful.

是的。早期经历有着显著的影响，我认为，即使是一些生物精神科医生如今也会赞同这一观点。你知道，如果我们在多大程度上废除心灵与身体的这种区分，并承认它们紧密相连，那么童年的创伤经历、各种社会化经历、失落等等都会深深烙印在人类的心灵上，我认为，这些经历可能会产生非常强大的长期影响。

莱克斯·弗里德曼（Lex Fridman）：

Of course, Freud added a bunch of stuff in the realm of psychosexual stages of childhood.

当然，弗洛伊德在儿童心理性发展阶段领域添加了许多内容。

安德鲁·斯卡尔（Andrew Scull）：

Yes. As he begins to develop his theories, he more and more comes to see at first the libido, which gets sort of transformed into the sex drive- … And sexual experiences and the repression of sexuality and the modification of sexuality as people grow. Um, all of that enters the picture. It's one of the things that ends up dividing Freud and Jung, Jung somewhat because Jung downplays that sexual side of things after the break. But so Freud develops a very complicated theory of mind initially reflecting his training as a neurologist. He tries to write an essay which survives called Project for a Scientific Psychology, and the scientific psychology is gonna tie psychology back into neurology. But he abandons that, and once he's abandoned that, he goes on to develop an increasingly elaborate theory. He writes The Interpretation of Dreams, for example, because he begins to regard dreams as an arena where these hidden memories, these suppressed- … things reemerge in disguised form in your dream life. And so that book marks an important step forward. He becomes interested in things like slips of the tongue, so-called Freudian mistakes. As seeing those as revealing what really is hidden from you. And so there's this very elaborate dissection of things that relies upon long extended talk therapy.

是的。 当他开始发展他的理论时，他越来越多地首先看到力比多，它在某种程度上转化为性欲……以及随着人们的成长，性体验、性压抑和性欲改变。 嗯，所有这些都进入了画面。 这是最终分裂弗洛伊德和卡尔·荣格（Carl Jung）的原因之一，卡尔·荣格（Carl Jung）在某种程度上是因为卡尔·荣格（Carl Jung）在休息后淡化了事物的性方面。 但因此弗洛伊德发展了一种非常复杂的心理理论，最初反映了他作为神经科医生的训练。 他试图写一篇名为“科学心理学项目”的文章，而科学心理学将把心理学重新与神经学联系起来。 但他放弃了这一点，一旦他放弃了这一点，他就会继续发展一个越来越复杂的理论。 例如，他写了《梦的解析》，因为他开始将梦视为一个舞台，在这里，这些隐藏的记忆、这些被压抑的……事物以伪装的形式重新出现在你的梦生活中。 因此，这本书标志着向前迈出了重要的一步。 他对诸如口误之类的事情产生了兴趣，即所谓的弗洛伊德错误。 将它们视为揭示了真正对你隐藏的东西。 因此，对事物的细致剖析依赖于长时间的谈话治疗。

莱克斯·弗里德曼（Lex Fridman）：

Of course underlying it he's building a model of how this whole mind thing works. There's- … three interacting parts of the personality. First, the id, which is the primitive, entirely unconscious, driven by pleasure principle, seeking immediate gratification or basic drives such as sex and aggression. There's the ego, which is the rational mediator operating under reality principle, balancing the id's demands with external reality. And finally, the superego, which is the internalized moral standards and ideals producing guilt or pride and striving for perfection. So that's the structure.

当然，在此之下，他正在构建一个关于整个人类心智如何运作的模型。有三个相互作用的人格部分。首先是本我，它是原始的、完全无意识的，由快乐原则驱动，追求立即满足或基本驱动，如性和攻击。其次是自我，它是理性的调解者，遵循现实原则，在满足本我需求与外部现实之间取得平衡。最后是超我，它是内化的道德标准和理想，会产生内疚或自豪，并追求完美。这就是结构。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. That is broadly speaking the structure that Freud ends up with, and the conflicts between these entities and the ways they interact are obviously the thing that creates your mental universe, your way of being in the world and in many cases creates pathology, which through the process of psychoanalysis you can transform grotesque unhappiness into ordinary unhappiness or something like that. You know? So- …. Yes, you get that. And initially, Jung gets one of the heirs to the International Harvester fortune as a patient, and the McCormick family are as rich as the Rockefellers and the Carnegies and the Vanderbilts of that world. This guy is a US senator who ends up committing suicide in nineteen twenty-five after a lot of treatment from Jung when he fails to win reelection to the US Senate. He kills himself in Washington in the interregnum. But he also gets another one of that brood. One of the Rockefeller daughters, Edith Rockefeller, marries a McCormick. And she has a lot of psychological issues, and she tries to get Jung to move to Chicago promising him she'll set him up in a mansion with lots of her friends as his patients, and Jung has no interest. So then she finally persuades him to come to New York and accompany her on the liner across to Zurich to be treated. She's agoraphobic, and so she has a hard time being out of her little cocoon. So she's treated there as an example of how peculiar she was. I mentioned the agoraphobia.

是的。 从广义上讲，这就是弗洛伊德最终的结构，这些实体之间的冲突以及它们相互作用的方式显然是创造你的精神宇宙、你在世界上的存在方式的东西，在许多情况下创造了病理学，通过精神分析的过程，你可以将怪诞的不快乐转化为普通的不快乐或类似的东西。 你知道？ 所以- …。 是的，你明白了。 最初，卡尔·荣格（Carl Jung） 得到了国际收割机财富的继承人之一作为病人，而麦考密克家族与洛克菲勒家族、卡内基家族和范德比尔特家族一样富有。 这家伙是一位美国参议员，在未能赢得美国参议院连任后，在卡尔·荣格（Carl Jung）的大量治疗后于十九年二十五岁结束了自杀。 他在空位期间在华盛顿自杀。 但他也得到了另一窝。 洛克菲勒的女儿之一伊迪丝·洛克菲勒嫁给了麦考密克家族的人。 她有很多心理问题，她试图让卡尔·荣格（Carl Jung）搬到芝加哥，向他保证她会把他安排在一座豪宅里，让她的很多朋友作为他的病人，但卡尔·荣格（Carl Jung）没有兴趣。 于是她终于说服他来纽约，陪她乘船前往苏黎世接受治疗。 她有广场恐惧症，所以她很难摆脱她的小茧。 所以她在那里被当作她有多奇怪的例子。我提到了广场恐惧症。

安德鲁·斯卡尔（Andrew Scull）：

So she occupies a huge array of suites with all her servants and so on in Zurich. And she takes a train journey—it's a stopping train—and her chauffeur follows the train in the Rolls Royce in case she has to jump out of the train at a station 'cause she can't bear it anymore. And she becomes a Jungian analyst, but she's very wealthy and she writes big checks to Jung, which is the important thing. And then Jung attracts Paul Mellon and his wife Mary. And so Jung's works are published by Princeton University Press with a subvention from that Mellon Foundation. So it's a long-running thing. Freud doesn't get patients quite that rich. He gets some rich Americans.

所以她在苏黎世占据了一大批套房，带着她所有的仆人等等。然后她乘坐火车旅行——是一列停站的火车——她的司机开着劳斯莱斯跟随火车，以防她在某个车站必须跳下火车，因为她再也无法忍受。后来她成为了一名荣格分析师，但她非常富有，并且给卡尔·荣格（Carl Jung）开出大额支票，这就是关键所在。然后卡尔·荣格（Carl Jung）吸引了保罗·梅隆和他的妻子玛丽。因此，卡尔·荣格（Carl Jung）的作品由普林斯顿大学出版社出版，并且得到了梅隆基金会的资助。所以这是一个长期的事情。弗洛伊德接触的病人没有那么富有。他接触到了一些富有的美国人。

莱克斯·弗里德曼（Lex Fridman）：

We should say that Freud became– Freud's ideas became quite popular among the intellectual and artist class in the nineteen twenties in America.

我们应该说，弗洛伊德 变得——弗洛伊德 的思想在二十世纪二十年代的美国在知识分子和艺术家阶层中变得非常流行。

安德鲁·斯卡尔（Andrew Scull）：

And another thing happened. World War I saw the breakdown of many soldiers from something that came to be labeled as shell shock. The label shell shock intimates its—the first theories about its origin, which was that shells bursting near you and bombs bursting near you shook up your body and your brain and created some physical damage that then accounted for the symptoms of shell shock: your mutism, your blindism, your constant shaking, your nightmares, all of that. But it became increasingly apparent that shell shock was actually a psychological thing. The trauma of war in significant number of cases brought about mental breakdowns. And in thinking about that, Freud's ideas about the unconscious mind and trauma and its connection to symptomatology acquired a new significance for a lot of people in that period. And then after the war, you're absolutely right among a certain smart section of society, those ideas developed a considerable purchase. Psychiatrists who were mostly stuck in the asylums dealing with psychotic patients wanted nothing to do with these ideas and this talk therapy. The mainstream psychotherapy which was mostly in a clinical setting, yeah, Freud's ideas were not popular. No.

还有一件事发生了。 第一次世界大战中，许多士兵因被称为炮弹休克症的疾病而崩溃。 炮弹休克症的标签暗示了它的起源——关于其起源的第一个理论，即在你附近爆炸的炮弹和在你附近爆炸的炸弹震动了你的身体和大脑，并造成了一些身体损伤，从而导致了炮弹休克症的症状：你的沉默，你的失明，你不断的颤抖，你的噩梦，所有这些。 但越来越明显的是，炮弹休克实际上是一种心理现象。 战争的创伤在很多情况下导致了精神崩溃。 考虑到这一点，弗洛伊德关于无意识心理和创伤及其与症状学的联系的观点对于那个时期的许多人来说获得了新的意义。 战后，你绝对是社会上某个聪明人的正确选择，这些想法引起了相当大的购买力。 大多数被困在精神病院处理精神病性的患者的精神科医生不想与这些想法和谈话疗法有任何关系。 主流心理治疗主要是在临床环境中，是的，弗洛伊德的想法并不流行。 不。

安德鲁·斯卡尔（Andrew Scull）：

The only partial exception to that was um, the mental hospital in Washington DC–the only federal mental hospital, St. Elizabeths. William Alanson White, who was then the superintendent, was somewhat sympathetic to Freud's ideas and tried a bit, but you're talking about thousands of patients and the idea of talk therapy for them is obviously out of reach, plus they are much more severely disturbed. So it does happen: novelists, painters, artists, playwrights, and the audience for those elite forms of culture do tend to embrace Freudian ideas. Sex sells in the theater and on the movies, obviously. But beyond that part of Freud's appeal to everybody, it was something he lamented at one point. He said, "You know my case histories read like short stories, like works of fiction, and in that

唯一的部分例外是，嗯，在华盛顿特区的精神病院——唯一的联邦精神病院圣伊丽莎白医院。当时的院长威廉·阿兰森·怀特对白鲁德的思想有些同情，并尝试了一些，但你要知道那有数千名患者，而对他们进行谈话治疗显然是难以实现的，而且他们的精神障碍也更严重。所以这种情况确实会发生：小说家、画家、艺术家、剧作家以及那些高雅文化形式的观众确实倾向于接受弗洛伊德的思想。性在戏剧和电影中显然是有吸引力的。但超出弗洛伊德对所有人的这种部分吸引力之外，有一点是他曾感叹过的。他说，“你知道，我的病例历史读起来像短篇小说，像虚构作品一样，而且在那

安德鲁·斯卡尔（Andrew Scull）：

sense people think they lack the stamp of serious science. But I'm driven to that because that's how I unpack what's going on. Well, psychoanalysis is telling stories. It's getting people to recover stories, recover memories, to rebuild, right? Um and its elements of psychological conflict and hidden motives and so forth, naturally very appealing to people writing novels, people writing plays, people doing screenplays. And for artists of the modern sort, the idea that we can extract things from the subconscious, Surrealism and the like for example, are clearly very heavily influenced by Freudian ideas. But it's important to know circa 1930 there are probably three hundred psychoanalysts in North America if they each Classical psychoanalysis involving five hours a week. They can't treat

人们觉得它缺乏严肃科学的印记。但我之所以这么做，是因为这就是我解读事情的方式。嗯，精神分析 是在讲故事。它让人们恢复故事，恢复记忆，重建，对吧？嗯，它包含心理冲突和隐藏动机等元素，自然非常吸引写小说的人、写戏剧的人、写电影剧本的人。对于现代艺术家来说，从潜意识中提取东西的想法，比如超现实主义，显然深受弗洛伊德派 理论的影响。但重要的是要知道，大约在 1930 年，北美大约有三百个精神分析学家，如果他们每人每周进行五小时的经典精神分析治疗，他们是无法治疗

安德鲁·斯卡尔（Andrew Scull）：

that many patients. A few thousand when there are hundreds of thousands in the hospitals. Right. Mm-hmm. So what changes that? Hitler starts killing off Jews and killing off psychoanalysts. The ones who can escape, some of them go to England and some come to America. Uh, the most famous escapee is Freud himself and his daughter Anna. Princess Bonaparte, who's one of Freud's great supporters, bribes the Nazis to get him out. And he travels by train to London, very sick with cancer of the jaw, as he has been since the mid-'20s. So he sets up shop in London, and Anna succeeds him really as one of the central figures in British psychoanalysis. But other analysts come here to America. So the numbers of analysts probably by 1940, America's not yet in the war, have a bit more than doubled. And more importantly,

那么多病人。当医院里有数十万病人时，只有几千人。对。嗯。那么是什么改变了这一切呢？希特勒开始杀害犹太人和精神分析师。那些能够逃脱的人，有些去了英国，有些来到了美国。最著名的逃亡者是弗洛伊德本人和他的女儿安娜。拿破仑公主是弗洛伊德的一位重要支持者，她贿赂纳粹将他救出。他乘火车前往伦敦，患有颌癌，非常虚弱，自 20 年代中期起一直如此。他在伦敦开设了诊所，安娜接替他的位置，成为英国精神分析的核心人物之一。但其他分析师也来到美国。所以到 1940 年，美国还未参战时，分析师的数量可能增加了一倍多。更重要的是，

安德鲁·斯卡尔（Andrew Scull）：

psychoanalytic training has become much more organized here. The institutes outside the universities control psych… And universities are not yet the knowledge factories they become after the war. Mm-hmm. And that's a crucial mistake that psychoanalysis makes. It's great because it controls its training completely. The bad thing is when the center of gravity moves to the university, it's not there and either resists being incorporated or the university resists incorporating it. So I think that's a structural weakness for that. But what really transforms things is World War II. Five fifty-minute hours famously–they last fifty minutes 'cause then there's ten minutes for analysts to recover before the next patient arrives. Yes. You are free associating on the couch and gradually being

精神分析的 的培训在这里变得更加有组织。大学以外的机构控制心理学……而大学还没有成为战后将成为的知识工厂。嗯嗯。这是 精神分析 所犯的一个关键错误。这很好，因为它完全控制了自己的培训。坏处是当重心转移到大学时，它不存在，要么抵制被纳入，要么大学抵制纳入它。所以我认为那是一个结构性的弱点。但真正改变事情的是第二次世界大战。五个五十分钟的小时，众所周知——它们持续五十分钟，因为接下来十分钟分析师可以在下一个病人到来前恢复。是的。你在沙发上自由联想，并且逐渐…

安德鲁·斯卡尔（Andrew Scull）：

coaxed to see as material emerges what you're hiding from yourself. I mean initially they tried–this is in their early early days–they tried hypnosis, yes. But they've… You know, this is where Freud took the big leap and expanded to free association. Right. So I mentioned Freud training under Charcot. Charcot hypnotized his hysterical patients. We now know a lot of that was fakery. Not–I don't think he was conscious of the fakery, but the patients were on display over and over again and they worked their routines up very well and they deceived him and they deceived the audience. But Freud came back from Paris bringing with him the idea that hypnosis was the way forward. But after the break with Breuer–Breuer had a general medical practice and lost interest in hysteria and didn't want anything to do with the revisions of Freud's work on hysteria. After that happened, Freud, who was a very clumsy hypnotist by his own account, began to develop this alternative of free association and getting people to speak whatever came into their head without a censor. That was the important thing, that the half-murdered memories were being hidden from you and your–uh, the constellation of psychological forces in your unconscious was squashing them down, but they were reemerging as other kinds of symptoms.

当材料出现时，你会被诱导看到你对自己隐藏的东西。 我的意思是，最初他们尝试过——这是在他们早期的早期——他们尝试过催眠，是的。 但他们……你知道，这就是弗洛伊德迈出一大步并扩展到自由联想的地方。 正确的。 所以我提到了弗洛伊德在夏科的训练。 夏科催眠了他的癔症性的病人。 我们现在知道其中很多都是伪造的。 不——我认为他没有意识到这些造假，但是病人一遍又一遍地展示，他们把自己的日常工作做得很好，他们欺骗了他，他们欺骗了观众。 但是弗洛伊德从巴黎回来，带来了催眠是前进之路的想法。 但在与布洛伊尔分手后，布洛伊尔进行了一般医学实践，对癔症（hysteria）失去了兴趣，并且不想与弗洛伊德对癔症（hysteria）工作的修订有任何关系。 在那之后，弗洛伊德（据他自己说，他是一个非常笨拙的催眠师）开始开发这种自由联想的替代方案，让人们在没有审查的情况下说出他们脑海中出现的任何内容。 重要的是，半被谋杀的记忆对你和你的——呃，你无意识中的心理力量群正在压制它们，但它们又以其他类型的症状重新出现。

莱克斯·弗里德曼（Lex Fridman）：

So how well does psychoanalysis work? How much do we understand? We've talked about all these approaches that didn't work. How well did it work at that time?

那么精神分析效果如何？我们理解了多少？我们已经讨论了所有这些没有效果的方法。当时它的效果如何？

安德鲁·斯卡尔（Andrew Scull）：

You know, one of the things after World War II, when psychoanalysis was making great strides in America and the Rockefeller Foundation was still heavily involved in promoting psychiatry and developing what it hoped would be new tools in it, the then heads of the institute–of the funding program, Alan Gregg and Robert Morison, especially Morison, kept pressing the analysts, "Provide us proof that what you do works." And the analysts kept resisting and resisting and resisting, saying, "It's much more complicated than that. There's no easy measure because what we're doing is reconstructing entire personalities, entire ways of being. People sense themselves, their ways of being in the world, and we don't have easy ways to measure that."

你知道，在二战之后的一段时间里，当精神分析在美国取得巨大进展，而洛克菲勒基金会（Rockefeller Foundation）仍然大力推广精神病学并开发他们希望成为新工具的东西时，当时该机构——资助项目的负责人，艾伦·格雷格和罗伯特·莫里森，尤其是莫里森，不断向分析师们施压，“给我们提供证据证明你们的工作有效。”而分析师们不断抵抗、抵抗、再抵抗，说，“事情要复杂得多。没有简单的衡量方法，因为我们所做的是重建整个个性、整个人的存在方式。人们能够感知自己以及他们在世界中的存在方式，而我们没有简单的方法来衡量这些。”

莱克斯·弗里德曼（Lex Fridman）：

To contrast that with the eighty percent promises over and over and over and over. Yes, yes, yes.

与此形成对比的是那八十个百分点一遍又一遍、一遍又一遍、一遍又一遍的承诺。是的，是的，是的。

安德鲁·斯卡尔（Andrew Scull）：

And it's a long and complicated pro… That was very important. Because another kind of psychotherapeutics is emerging in, in the aftermath, during and in the aftermath of the war, as a rival for both psychiatry and for psychoanalysis. Initially not terribly successful, but as time goes on, a more and more important part of the story. So to focus on the war for a minute, America's psychiatrists went to the military brass and to the politicians before America entered the war, and it had some advance warning because America didn't enter till Pearl Harbor, but the European war had been going on. And they said, look, if we have to fight, we're gonna have the same problem we had in the First World War. We're gonna train these soldiers, gonna equip them, we're gonna put them in the battlefield and the psychologically vulnerable among them are gonna break down. Mm-hmm. There'll be shell shock all over again, so we should screen all recruits to make sure they're not psychologically weak and susceptible. And they screen out one and three-quarter million people and say, "These men are not fit." So now we won't have the problems we had in World War I, except it quickly turns out that those problems reemerge. Industrial warfare exposes people to seeing things and doing things that all of us in normal life would recoil from. And when we're forced to do them as soldiers, many of us can't–I speak from experience

这是一个漫长而复杂的职业……这非常重要。 因为另一种心理治疗学正在战后、战争期间和战后出现，作为精神病学和精神分析的竞争对手。 最初并不是很成功，但随着时间的推移，故事的一部分变得越来越重要。 因此，为了集中关注这场战争，美国的精神病学家在美国参战之前就去找了军方高层和政治家，他们有一些预先警告，因为美国直到珍珠港才参战，但欧洲战争一直在进行。 他们说，看，如果我们必须打仗，我们就会遇到第一次世界大战时遇到的同样问题。 我们要训练这些士兵，装备他们，我们要把他们送上战场，他们当中心理脆弱的人将会崩溃。 嗯嗯。 炮弹休克症会再次出现，所以我们应该对所有新兵进行筛查，以确保他们不会出现心理脆弱和易受影响的情况。 他们筛选出四分之三百万人并说：“这些人不适合。” 因此，现在我们不会再遇到第一次世界大战时遇到的问题，除非这些问题很快就会再次出现。 工业战使人们看到和做一些我们在正常生活中都会畏缩的事情。 当我们被迫以士兵身份去做这些事情时，我们中很多人做不到——我从经验中说

安德鲁·斯卡尔（Andrew Scull）：

but from talking to people who've gone through all this, uh, many of them find the experiences and the memories those create intolerable. And they emerge in symptoms, and they break down. So it became a huge problem for the American Army, as it did for all the armies, actually. The Nazis just shot people who broke down. Bang, you're dead, we're not dealing with you. But, um, obviously the Allies, that was not the response. Um, and they quickly had to try to treat these troops, maybe get them back into the fighting lines, maybe get them into support positions, something to cope with the problem, which both created extraordinary morale problems among the troops, and it invited malingering, claiming you had these conditions when you didn't. It obviously cost a lot of the fighting force. In combat

但是从与经历过这一切的人交谈来看，呃，他们中有很多人发现经历和由此产生的记忆是无法忍受的。它们会以症状的形式出现，并导致他们崩溃。所以这对美军来说成为了一个巨大的问题，实际上对所有军队都是如此。纳粹只是枪毙那些崩溃的人。砰，你死了，我们不管你了。但是，呃，显然盟军不会采取这种反应。呃，他们不得不迅速尝试治疗这些部队，也许让他们重新回到战斗线上，也许让他们进入支援岗位，以应对这个问题，而这既在部队中造成了极大的士气问题，也引发了装病行为，即有人声称自己有这些病症而实际上并没有。这显然损失了很多战斗力量。在战斗中

安德鲁·斯卡尔（Andrew Scull）：

conditions, as much as twenty-five percent of the soldiers broke down. So it was a big, big problem. Before the war, there were about two thousand psychiatrists in North America, in the US. At the end of the war, there were more than two thousand psychiatrists in the US military. Okay. So you had to train people in a hurry. Mm-hmm. And even still, it was hard to get enough people trained. And it turned out that the head of the US military–not the first, but the first one died, the second one was a man named William Menninger from the Menninger Clinic in Kansas, where he and his brother ran a psychoanalytic treatment facility. So Bill Menninger became the head of army psychiatry. He concluded that the best treatment for these soldiers breaking down was psychotherapeutic in nature. The origin of their condition was trauma. Uh, and so in a watered-down way, Freud's ideas, those were the ones that the people that recruited quickly and retrained as psychiatrists absorbed. So they formed after the war a fairly coherent group of people, separate from the psychiatrists in the state hospitals who were still very biologically oriented. Another group emerged during the war precisely because you couldn't produce enough psychotherapists who were MDs quickly enough. Psychologists were drafted in and asked to treat.

在这种情况下，百分之二十五的士兵都崩溃了。 所以这是一个很大很大的问题。 战前，北美、美国大约有两千名精神科医生。 战争结束时，美军中有两千多名精神科医生。 好的。 所以你必须赶紧培训人员。 嗯嗯。 即便如此，培训足够多的人员仍然很困难。 事实证明，美国军方的首脑——不是第一个，而是第一个去世了，第二个是堪萨斯州门宁格诊所的一位名叫威廉·门宁格的人，他和他的兄弟在那里经营着一家精神分析的治疗机构。 于是比尔·门宁格成为军队精神病学的负责人。 他的结论是，对于这些崩溃的士兵来说，最好的治疗方法就是心理治疗。 他们的病情源于创伤。 呃，所以，以一种淡化的方式，弗洛伊德的想法，那些被迅速招募并接受再培训成为精神病学家的人所吸收。 因此，他们在战后形成了一个相当团结的群体，与仍然非常注重生物学的州立医院的精神科医生分开。 战争期间出现了另一个群体，正是因为你无法足够快地培养出足够多的心理治疗师来担任医学博士。 心理学家被请来并要求进行治疗。

莱克斯·弗里德曼（Lex Fridman）：

Mm-hmm.

嗯嗯。

安德鲁·斯卡尔（Andrew Scull）：

So what they disco– What the psychologists discovered was, "Hey, we could do this stuff too, and we really like it." "It's interesting-" "…it's challenging. We, we should do that." So after the war, similar kind of problem. Mental illness is a massive problem. The returning soldiers, it's a big problem, but it's also a problem in the, in the community. These guys don't… The, the psychiatrists don't go and work in the mental hospital. They start outpatient treatment. And by 1958, about 80% of psychiatrists are working in outpatient rather than in the hospitals, right? So the psychologists organize themselves and federal money–again, "We need you. We need you. We need more of you." So the VA, the Veterans Administration, and then once the National Institute of Mental Health is established, they start providing a lot of money for training, and they train not just psychiatrists, they train psychologists.

所以他们发现——心理学家们发现的是，“嘿，我们也可以做这些事情，而且我们真的很喜欢。” “这很有趣——”“……很有挑战性。我们，我们应该去做。” 所以战争结束后，也有类似的问题。心理疾病是一个巨大的问题。退伍士兵，这是一个大问题，但在社区里也是个问题。这些人不……精神科医生不会去精神病院工作。他们开始进行门诊治疗。而到 1958 年，大约 80%的精神科医生是在门诊而不是医院工作，对吧？所以心理学家们组织起来，联邦资金——再次说，“我们需要你们。我们需要你们。我们需要更多你们。” 所以退伍军人事务管理局（VA），然后一旦美国国家精神卫生研究所（National Institute of Mental Health）成立，他们开始提供大量培训资金，他们不仅培训精神科医生，也培训心理学家。

安德鲁·斯卡尔（Andrew Scull）：

So the question is: How are the psychologists gonna set up clinical training? So what the psychologists come up with, the clinically oriented ones, is a training program where would-be clinical psychologists spend two years learning basic scientific psychology and research methods, and then they have two or three years of clinical work and experience. And that's very clever because it means when they start looking for grants, they know how to do that, and the psychoanalysts don't have a clue how to apply for federal grant money, and they don't get any, almost. Beyond that, these people begin to work on treating symptoms. The psychoanalysts think to treat a symptom is to play Whac-A-Mole. If you don't deal with the underlying problems of the personality, their interaction between your id ego and superego, you suppress that symptom, and another one will pop up over here. The clinical psychologists go, "We're gonna treat the symptoms of what are troubling people. We're gonna treat the symptoms, and we're gonna develop techniques that allow people to cope with those symptoms and eliminate them." Uh, and how are we gonna do that? We're going to do it primarily through what initially is cognitive behavioral therapy and later interpersonal therapy and some other variants emerge.

所以问题是：心理学家如何进行临床培训？ 所以心理学家提出的，临床导向的，是一个培训计划，未来的临床心理学家花两年时间学习基本的科学心理学和研究方法，然后他们有两到三年的临床工作和经验。 这非常聪明，因为这意味着当他们开始寻求资助时，他们知道如何去做，而精神分析师不知道如何申请联邦资助，而且他们几乎什么也得不到。 除此之外，这些人开始致力于治疗症状。 精神分析学家认为治疗症状就像玩打地鼠游戏。 如果你不处理人格的根本问题，以及它们在你的本我和超我之间的相互作用，你就会抑制这种症状，而另一种症状就会出现在这里。 临床心理学家说，“我们要治疗那些困扰人们的症状。我们要治疗症状，我们要开发技术，让人们应对这些症状并消除它们。” 呃，我们要怎么做呢？ 我们将主要通过最初的 认知行为疗法（cognitive behavioral therapy） 来做到这一点，后来出现人际治疗和其他一些变体。

安德鲁·斯卡尔（Andrew Scull）：

But basically, what they try to do with those techniques is develop things that work relatively quickly, work specifically on one set of problems or small subset of problems, and try to get those under control. And how does, how does it work? You've developed really bad habits. You… The way you react to being socially snubbed or being ignored or you– the way you deal with your coworkers or the trouble you're having with your disruptive child will help you see the patterns that you've fallen into and will give you exercises that will work to give you a better way of coping with those things that don't produce these symptoms. I'm oversimplifying obviously, but basically that's the fundamental thrust of this.

但基本上，他们使用这些技术的目的，是开发出一些能够相对快速起效、专门针对一类问题或一小部分问题，并试图将其控制的方法。那么，这究竟是如何工作的呢？你已经养成了很坏的习惯。你……你对被社会冷落或忽视的反应方式，或者你处理同事关系的方式，或者你与调皮孩子相处时遇到的麻烦，都能帮助你看到自己已经陷入的模式，并会给你提供一些练习，让你学会以更好的方式应对这些不会产生这些症状的事情。我显然是在过于简化，但基本上这就是它的核心要旨。

莱克斯·弗里德曼（Lex Fridman）：

And one of the other contrasting things about CBT, Cognitive Behavioral Therapy, is that it doesn't have necessarily that heavy requirement of five hours a week.

而关于认知行为疗法（CBT），认知行为疗法的另一对比之处是，它不一定有每周五小时的重要求。

安德鲁·斯卡尔（Andrew Scull）：

Exactly. So these therapies could be packaged. They could be reproduced. They could be tested to see whether they worked, so they had an evidentiary foundation. The psychoanalyst would say, "It's gonna take us years, and it's hard to measure." These guys went, "Well, we'll measure what, what happens when we treat people this way?"

确切地说。所以这些疗法可以被包装，可以被复制，可以被测试以看看它们是否有效，从而有一个证据基础。精神分析师会说：“这会花我们很多年，而且很难衡量。”这些人则说，“好吧，我们来衡量一下，当我们以这种方式治疗人们时会发生什么。”

莱克斯·弗里德曼（Lex Fridman）：

Psychologists.

心理学家。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. The symptoms are what matter, not the underlying– you know, the underlying more complex thing that psychoanalysts claimed to be treating. And so it's shorter. It's reproducible whereas psychoanalytic– You know, every patient is a new patient, with a new set of complicated things going on. Here we are. We're gonna do this.

是的。重要的是症状，而不是潜在的——你知道的，精神分析师声称要治疗的更复杂的潜在问题。所以时间更短。它是可重复的，而精神分析的——你知道，每个病人都是一个新的病人，都有一套新的复杂情况在发生。我们来了。我们要开始做这个。

莱克斯·弗里德曼（Lex Fridman）：

And the key figures here is Albert Bandura, Albert Ellis, Aaron Beck.

这里的关键人物是阿尔伯特·班杜拉、阿尔伯特·艾利斯、阿伦·贝克。

安德鲁·斯卡尔（Andrew Scull）：

Yes. Um, Bandura and some other psychologists launching this movement, and then later on Aaron Beck, who went by Tim Beck who just recently died at… I think he was ninety-nine. Extraordinary.

是的。嗯，班杜拉和其他一些心理学家发起了这个运动，然后后来是艾伦·贝克，也就是蒂姆·贝克，他最近去世了……我记得他九十九岁。非凡的。

莱克斯·弗里德曼（Lex Fridman）：

No, no, I think he crossed 100.

不，不，我觉得他超过 100 了。

安德鲁·斯卡尔（Andrew Scull）：

Maybe 100. Yeah. Maybe 100.

也许 100。是的。也许 100。

莱克斯·弗里德曼（Lex Fridman）：

There's videos of him talking at that age and he's still, he's still killing it, so wise.

有他那个年纪时说话的视频，他现在仍然很棒，非常聪明。

安德鲁·斯卡尔（Andrew Scull）：

Aaron Beck is, is a remarkable figure because he was also one of the first in the 1960s to look at psychiatric diagnosis and show how unreliable it was, how difficult it was to get psychiatrists to agree on what was wrong.

亚伦·贝克是一个了不起的人物，因为他也是 1960 年代最早关注精神病学诊断并显示其不可靠性的人之一，也展示了让精神科医生对错误之处达成一致是多么困难。

莱克斯·弗里德曼（Lex Fridman）：

So he was a psychoanalyst, right?

所以他是个精神分析学家，对吗？

安德鲁·斯卡尔（Andrew Scull）：

He had been trained as a psychoanalyst, became disillusioned with it, and so there were two strands, two important strands that stemmed from his work. First, this… He was one of the ones within the community itself who said to his fellow psychiatrists, "You know, we're not very good at this diagnosis business-" "… and maybe we need to work on that." Okay? And that was very important for the movement towards DSM-III. The other side of the coin was he broke with the idea that treating symptoms was a waste of time, and joined with the psychologists who already embarked on that journey to say, "How can we develop techniques to overcome these self-destructive ways in which people are responding? How can we help with their ability to interact?" So interpersonal therapy is much– you know, much more concerned with the way in which if your relations with other people break down, that damages your emotional stability. If you repair those relationships, that helps your emotional stability come back. So all of this develops, and Americans are unusual. The– most of the rest of the world has what we call socialized medicine.

他接受过精神分析学家的培训，但对此感到幻灭，因此他的工作产生了两条重要的线索。 首先，这个……他是社区内对他的精神科医生同行说的人之一，“你知道，我们不太擅长这个诊断业务——”“……也许我们需要在这方面努力。” 好的？ 这对于 《精神疾病诊断与统计手册》（DSM） 的发展非常重要。 另一方面，他打破了治疗症状是浪费时间的想法，并与已经开始这一旅程的心理学家一起说：“我们如何开发技术来克服人们的这些自我毁灭性反应方式？我们如何帮助他们提高互动能力？” 因此，人际关系治疗更关注的是，如果你与他人的关系破裂，会损害你的情绪稳定性。 如果你修复这些关系，这有助于你的情绪恢复稳定。 所有这一切都在发展，美国人是不寻常的。 世界其他大部分地区都有我们所说的社会化医疗。

安德鲁·斯卡尔（Andrew Scull）：

America doesn't have that, so we're used to paying for medical care. And so Americans were more willing, I think, to pay for clinical psychologists, and they attacked some of the problems of everyday living, the more uh, I was gonna say minor, but these are often quite distressing things. But those were the things they were most successful at doing. If I look at the literature on CBT, for example, and its uses in cases of schizophrenia, the evidence is pretty poor that it works. And even the evidence for the milder conditions is a bit more ambiguous than we like… That they like to pretend. The Cochrane Reviews, which are a systematic attempt to assess how strong the evidence for particular approaches to disease of all sorts are, say that at best, the evidence for CBT is of low and medium confidence, you know? But I think, again, there are patients for whom this helps, and indeed, for the milder forms of depression, I think CBT works better than the drugs without some of the side effects that the, the drugs have. And indeed, NICE, which is the British organization that passes on what treatments the National Health Service will support and which ones are, are sufficiently evidence-based has come to that same conclusion.

美国没有这样的条件，所以我们习惯于支付医疗费用。 因此，我认为美国人更愿意为临床心理学家付费，他们解决了日常生活中的一些问题，呃，我想说的是小问题，但这些往往是相当令人痛苦的事情。 但这些是他们做的最成功的事情。 例如，如果我查看 认知行为疗法（CBT） 的文献，以及它在 精神分裂症 案例中的使用，那么它有效的证据非常少。 即使是较温和条件的证据也比我们想象的更加模糊……他们喜欢假装。 Cochrane 综述是一项系统性尝试，旨在评估治疗各种疾病的特定方法的证据有多强，它说，认知行为疗法（CBT） 的证据充其量只有低信度和中等可信度，你知道吗？ 但我再次认为，这对某些患者有帮助，事实上，对于较轻微的抑郁症，我认为 认知行为疗法（CBT） 比药物效果更好，而且没有药物所具有的一些副作用。 事实上，NICE 这个英国组织也得出了同样的结论，该组织以充分的证据为基础，传递了国家卫生服务将支持哪些治疗方法以及哪些治疗方法。

莱克斯·弗里德曼（Lex Fridman）：

So I think one thing to just say about cognitive behavioral therapy, I mean, it's– It has some elements of kind of surface level intuitive kind of things like- … being aware of and adjusting your thought patterns, being aware of triggers that get you- … down a negative spiral- … and then basic behavior changes, habit changes that lead to a healthier life. So I think, I think this kinda, you know, getting your life together kind of process- is, is intuitive that that would have a positive effect on some percent of the population. But as you get more serious and serious into the land of mental disorders, it starts to be a little bit less conclusive.

所以我认为，有一件事要说一下关于认知行为疗法（cognitive behavioral therapy）的，我的意思是，它有一些表面上直观的元素，比如……意识到并调整你的思维模式，意识到会让你……陷入负面螺旋的触发因素……然后进行基本的行为改变、习惯改变，从而过上更健康的生活。所以我认为，我觉得这种，你知道，把生活整理好的过程——直观上，这对某些比例的人群会产生积极影响。但当你更严肃、深入到心理障碍的领域时，它开始变得不那么确定了。

安德鲁·斯卡尔（Andrew Scull）：

Yes. I think that's an accurate statement of what– the way I read the literature. And it's not a cure-all, but for some patients, this really does seem to improve things quite a lot. And it, it does make sense that you have developed poor ways of responding to signals from the outside world, and they've become habitual, and they've — habits, as we know, are very hard to break. You know, there's a lot of homework, there's a lot of exercises you have to do to try to reconfigure the ways you deal with the world. And it's not for everybody, and it doesn't work for everybody, but there's some set, subset of people for whom this seems to have positive effects.

是的。我认为这准确地表述了我阅读文献时的理解。这不是万能的，但对一些患者来说，这确实似乎能大大改善情况。而且，这也说得通，你已经养成了应对外界信号的不良方式，这些方式已成为习惯，而我们知道，习惯很难打破。你知道，有很多家庭作业，有很多练习需要做，以尝试重新调整你对待世界的方式。这并不适合所有人，也并非对每个人都有效，但对于某些人群来说，这似乎有积极的效果。

莱克斯·弗里德曼（Lex Fridman）：

So this, this is the lay of the land. We talked about some of the darkness. Lobotomies and so on. There is some talk therapy ideas of psychoanalysis, and then there is, from the clinical psychology side, cognitive behavioral therapy. Then starts to emerge the psychopharmacology- …that challenges this whole shebang of talk therapy, period. And can you talk about the accidental origins of psychopharmacology- …that challenges this whole thing?

所以，这就是基本情况。我们讨论了一些黑暗面，比如脑叶切除术等等。也有一些关于精神分析的谈话疗法的想法，然后从临床心理学的角度，有认知行为疗法（cognitive behavioral therapy）。然后开始出现心理药理学——它挑战了整个谈话疗法体系。你能谈谈心理药理学的偶然起源吗——它挑战了整个体系？

安德鲁·斯卡尔（Andrew Scull）：

Hardly anybody had conceived of the idea that drugs could be used to treat mental illness. Drugs had been used in the mental hospitals back in the 19th and 20th centuries, but they were usually things that were used to control patients, to calm them down. Opiates, for example, various hypnotics that would put people to sleep when they were extremely agitated and so forth. Sometimes marijuana was experimented with, as was alcohol in the 19th century, interestingly enough, given the revival of psychedelics. But the idea that a drug might be used to actually attack the underlying problem, it emerged by accident in the following kind of way. The drug industry in general had emerged mostly in Germany, where I'd mentioned the most advanced medicine was being practiced in the late 19th century. From the chemical industry from, for example, refining coal tar into different substances, that's where we got aspirin. That's where we got a whole bunch of drugs. And gradually, the drug companies become more organized. They differentiate themselves from all the quack remedies that are around. And the war, I think, greatly accelerates– Again, World War II greatly accelerates things, not least because we discover a real magic bullet called penicillin and then the other antibiotics that we subsequently come across.

几乎没有人想到药物可以用来治疗精神疾病。 早在 19 世纪和 20 世纪，精神病院就已经使用过药物，但它们通常是用来控制病人、让他们平静下来的。 例如阿片类药物，各种催眠药，可以让人们在极度烦躁时入睡等等。 有趣的是，考虑到迷幻药的复兴，有时会尝试大麻，就像 19 世纪的酒精一样。 但是，药物可以用来真正解决根本问题的想法是通过以下方式偶然出现的。 总体而言，制药业主要出现在德国，我曾提到德国在 19 世纪末就开始采用最先进的医学。 例如，从化学工业中，将煤焦油提炼成不同的物质，这就是我们得到阿司匹林的地方。 那是我们得到一大堆毒品的地方。 渐渐地，制药公司变得更加组织化。 它们与周围所有的庸医疗法不同。 我认为，战争大大加速了——第二次世界大战大大加速了事情的发展，尤其是因为我们发现了一种真正的神奇子弹，称为青霉素，然后是我们随后遇到的其他抗生素。

安德鲁·斯卡尔（Andrew Scull）：

Penicillin had been observed by Alexander Fleming, famously in his lab in some Petri dishes where bacteria had been killed. Later was one of the co-winners of Nobel Prize and made a lot of capital out of that discovery. It was really Howard Florey and his team at Oxford who developed the therapeutic potential of penicillin. And actually, Florey flew some of it in his jacket across the Atlantic to America, and it was Americans that solved the critical thing. It took Florey and his team weeks to develop enough penicillin to treat a single mouse. What America learned how to do was mass produce penicillin. And that was critical because it was vital to the war effort, obviously. And after the war, it was vital to the civilian population because it was such an, an important breakthrough. So drugs, drug companies grew fatter on that. They embarked on research to try to find new substances they could use to treat things. And a French company named Rhône-Poulenc came across a chemical that had actually been synthesized back in the 1880s in Germany. It was an antihistamine, chlorpromazine. They didn't know what to do with it, but other kinds of antihistamines in the war had been used effectively, and they thought, "Well, let's look and see if we can find a market for this drug." And so they… The interesting thing to remember in those days is that investigating the property of new drugs was a Wild West phenomenon. There were no controls.

亚历山大·弗莱明（Alexander Fleming）在他的实验室的一些培养皿中观察到了青霉素，其中细菌已被杀死。 后来成为诺贝尔的共同获奖者之一，并从这一发现中赚了很多钱。 确实是霍华德·弗洛里（Howard Florey）和他在牛津的团队开发了青霉素的治疗潜力。 事实上，弗洛里把其中的一些放在他的夹克里飞越大西洋飞到了美国，是美国人解决了这个关键问题。 弗洛里和他的团队花了几周时间才开发出足够治疗一只小鼠的青霉素。 美国学会了如何大规模生产青霉素。 这很重要，因为显然这对战争努力至关重要。 战后，这对平民至关重要，因为这是一个非常重要的突破。 因此，药品、制药公司因此而发财。 他们开始研究，试图寻找可以用来治疗疾病的新物质。 一家名为 Rhone-Poulenc 的法国公司发现了一种实际上早在 1880 年代就在德国合成的化学物质。 它是一种抗组胺药，氯丙嗪（chlorpromazine）。 他们不知道该如何处理它，但战争中其他种类的抗组胺药已经被有效使用过，他们想：“好吧，让我们看看是否能为这种药物找到市场。”于是他们……值得记住的是，那些日子里，研究新药的特性是一种‘西部野性’的现象。没有任何控制。

安德鲁·斯卡尔（Andrew Scull）：

You could do whatever you wanted, and you handed stuff out and said, "Why don't you try this and see if it works?" Right? So Rhône-Poulenc did that. They thought this might work as an antiemetic. If you have a child who's prone to car sickness, you give them an antiemetic drug. So that was one possibility. Another possibility, it might work for eczema so that people didn't scratch themselves. Well, there were a number of possibilities and somebody said, "Well, maybe it will work as an anesthetic potentiator," meaning if you gave some of these, you need to use less anesthetic, or would act like a catalyst because it tended to make you sleepy. If you read the leaflets on Dramamine, one of the cautions is, "It'll make you sleepy, don't drive," right? So why don't we give it to some surgeons and see if they can find a use for it? Literally it's like that. And one of the people who gets that drug is a lieutenant in the French Navy, Henri Laborit, and he tries it as an anesthetic potentiator, and he also gives it to some of the patients who are awaiting surgery. Normally when you're awaiting surgery, you're a little bit anxious. These patients stop being anxious. This was the era of lobotomies, and he wrote to one of his relatives who worked in one of the Paris mental hospitals. He said, "This like, this works like a chemical lobotomy. These people don't care anymore about their surgery."

你可以做任何你想做的事，然后你分发东西并说：“你为什么不试试这个，看看它是否有效？” 正确的？ 所以罗纳-普朗克就这么做了。 他们认为这可能起到止吐作用。 如果你有一个容易晕车的孩子，你可以给他们服用止吐药。 所以这是一种可能性。 另一种可能性是，它可能对湿疹有效，这样人们就不会抓伤自己。 嗯，有很多种可能性，有人说，“嗯，也许它会起到麻醉增效剂的作用，”这意味着如果你给予其中一些，你需要使用较少的麻醉剂，或者会像催化剂一样发挥作用，因为它会让你昏昏欲睡。 如果你读过茶苯海明的传单，其中的警告之一就是“它会让你昏昏欲睡，不要开车”，对吧？ 那么我们为什么不把它交给一些外科医生，看看他们是否能找到它的用途呢？ 从字面上看就是这样。 获得这种药物的人之一是法国海军中尉亨利·拉博里特（Henri Laborit），他尝试将其用作麻醉增强剂，并且还将其提供给一些等待手术的患者。 通常，当您等待手术时，您会有点焦虑。 这些患者不再焦虑。 这是脑白质切除术（lobotomy）的时代，他写信给在巴黎一家精神病院工作的一位亲戚。 他说，“这就像一种化学物质 脑白质切除术（lobotomy） 一样。 这些人已经不再关心他们的手术了。

莱克斯·弗里德曼（Lex Fridman）：

And that's supposed to be a good thing, right?

那应该是件好事，对吧？

安德鲁·斯卡尔（Andrew Scull）：

Well, lobotomy hadn't become the nasty word it, it would become in a few years. So one of his colleagues contacts Delay and Deniker, who work at Saint-Anne's which is the biggest mental hospital in Paris and says, "Hey guys this might work on your psychiatric patients. You should give it a try." And they do. When it doesn't work, they give larger dose and when it doesn't work they give a large dose and sure enough patients stopped acting out. They stopped smashing furniture. They, they become– They're still sorta conscious but they're less mobile and they're much calmer. And this is why in the early stages Chlorpromazine, which becomes known as Largactil or Mighty Drug in Europe and Thorazine here, it becomes known as a major tranquilizer because it has this tranquilizing effect. The hospitals see it as a boon because it'll help control the patients. They're not yet thinking of it as more than that. So that's the accidental way it's discovered. It comes to North America via Quebec,- ….where there's a psychiatrist up there, Heinz Lehmann, who actually works in the Protestant Hospital. Québec in those days is dominated by its Anglo-speaking elite who oppressed the, the French Canadians pretty mightily. But because of the French connection, he gets amounts of the drug.-

好吧，脑白质切除术（lobotomy） 并没有变成这个令人讨厌的词，几年后它就会变成这个词。 因此，他的一位同事联系了在巴黎最大的精神病院圣安妮医院工作的迪莱和德尼克，并说：“嘿伙计们，这可能对你们的精神病患者有效。你们应该尝试一下。” 他们确实这么做了。 当它不起作用时，他们会给予更大的剂量；当它不起作用时，他们会给予更大的剂量，果然患者就停止了行动。 他们不再砸家具了。 他们，他们变得——他们仍然有一定的意识，但他们的活动能力减弱，而且更加平静。 这就是为什么在早期阶段氯丙嗪（在欧洲被称为 Largactil 或 Mighty Drug，在这里被称为氯丙嗪（chlorpromazine）），因为它具有这种镇静作用而被称为主要镇静剂。 医院认为这是一个福音，因为它有助于控制病人。 他们还没有想到更多的事情。 这就是它被发现的偶然方式。 它通过魁北克来到北美，-……那里有一位精神科医生，Heinz Lehmann，他实际上在新教医院工作。 当时的魁北克由英语精英统治，他们对法裔加拿大人进行了相当大的压迫。 但由于与法国的联系，他获得了大量的毒品。-

安德鲁·斯卡尔（Andrew Scull）：

Rhône-Poulenc has had to sell the rights to an American company. In those days, American physicians don't trust European science or European medicine- … especially European medicine. So Rhône-Poulenc sells the rights. The first two drug companies it approaches say, "No thank you. This doesn't look very interesting to us. I don't think there's much of a market." And then SmithKline & French buys it up and within two years, two million people are taking this drug. It's a bonanza for them right? Not an accident 'cause they put their best salesman on the job of selling this and they realize the hospital psychiatrists mostly aren't interested. They haven't yet gotten to this idea of a chemical cure or a chemical treatment.

罗纳-普朗克不得不将这些权利卖给一家美国公司。在那个年代，美国医生不信任欧洲的科学或欧洲的医学——尤其是欧洲的医学。所以罗纳-普朗克出售了这些权利。它接洽的前两家制药公司都说：‘不用了，谢谢。这对我们来说不太有吸引力。我觉得市场不大。’然后史密斯克莱恩与法国公司买下了它，并且在两年内，已有两百万人在服用这种药。这对他们来说是一个巨大财富，对吧？这不是偶然，因为他们派出最优秀的销售员去推销这款药，并且他们意识到医院的精神科医生大多不感兴趣。他们还没有理解到化学疗法或化学治疗的概念。

莱克斯·弗里德曼（Lex Fridman）：

So it's the companies that wake up to this?

所以是那些意识到这一点的公司吗？

安德鲁·斯卡尔（Andrew Scull）：

The companies wake up, they sell it to the politicians. They go to the state legislatures. They have moving pictures of an agitated patient who turns calm, you know.

这些公司醒来了，它们把它卖给政客。他们去州立法机构。他们有生动的画面，显示一个焦虑的病人变得平静，你知道的。

莱克斯·弗里德曼（Lex Fridman）：

So this is already the mechanism of big pharma?

所以这已经是大型制药公司的机制了吗？

安德鲁·斯卡尔（Andrew Scull）：

Yeah. So it's starting to be big pharma. It transforms SmithKline & French from a small operator into a big company, and then of course once that's successful, it turns out that chlorpromazine can be easily tweaked as a molecule, and so copycat drugs emerge on the scene. So this happens in America in 1954. The following year in 1955 we get the so-called minor tranquilizers being invented and brought to market.

是的。所以它开始变成大制药公司。这使得史密斯克莱恩与法兰西公司从一个小型经营者转变为一家大公司，当然，一旦这成功了，事实证明氯丙嗪（chlorpromazine）作为一种分子可以很容易地进行调整，于是仿制药就出现了。这在 1954 年的美国发生。第二年，即 1955 年，我们获得了所谓的轻度镇静剂的发明并推向市场。

莱克斯·弗里德曼（Lex Fridman）：

This is Miltown.

这是米尔顿。

安德鲁·斯卡尔（Andrew Scull）：

Yeah, this is Miltown heavily promoted by the first major television star of the mid-'50s, Milton Berle, who calls himself Unc- Uncle Miltown and promotes the drug heavily on his show.

是的，这就是米尔顿镇，由 50 年代中期的第一位主要电视明星米尔顿·伯尔大力推广，他称自己为‘米尔顿叔叔’，并在他的节目中大量推广这种药物。

莱克斯·弗里德曼（Lex Fridman）：

So these are mostly like tranquilizer type of effects?

所以这些大多是类似镇静剂类型的效果吗？

安德鲁·斯卡尔（Andrew Scull）：

Those work really– They're muscle relaxant types of things, and later on in the '60s we get Valium and Librium coming on adding to or re-and replacing those first generation drugs. So you have major tranquilizers, minor tranquilizers. Minor tranquilizers and guess what? The Freudians don't want really anything to do with these drugs.

那些真的有效——它们是肌肉松弛类型的药物，到了六十年代，我们有了安定（Valium）和利眠宁（Librium）出现，补充或取代那些第一代药物。所以你有主要镇静剂、次要镇静剂。次要镇静剂，猜猜看？弗洛伊德学派的人其实不想真正使用这些药物。

莱克斯·弗里德曼（Lex Fridman）：

Right. Of course.

对，当然。

安德鲁·斯卡尔（Andrew Scull）：

The hospital psychiatrist wants to wake up to the usefulness of Thorazine and its analogues do start using the drugs a lot and that's really important, and in the early '60s, they changed their name. Instead of being major tranquilizers, they become antipsychotics. So that suggests they actually attack the underlying psychosis.

医院的精神科医生希望意识到氯丙嗪（chlorpromazine）及其类似物的有用性，并开始大量使用这些药物，这是非常重要的。在 60 年代初，他们更改了名称。不再被称为主要镇静剂，而是成为抗精神病药。所以这表明它们实际上在攻击潜在的精神病。

莱克斯·弗里德曼（Lex Fridman）：

Is there any evidence of that for them?

有什么证据表明他们有那样的情况吗？

安德鲁·斯卡尔（Andrew Scull）：

They do change the forms of psychosis in important ways, some good and some they fail to attack. So they reduce the agitation, they reduce the delusions and the hallucinations, the things psychiatrists call the positive symptoms of schizophrenia, those, those they help with for not every patient, but for a significant number of patients, and they're very — That's very important.

它们确实以重要的方式改变了精神病性障碍的形式，有些是好的，有些他们未能攻击。因此，它们减少了兴奋，减少了妄想和幻觉，也就是精神科医生所说的精神分裂症的阳性症状，这些，它们对并非每个病人都有帮助，但对相当多的病人有帮助，这非常——这非常重要。

莱克斯·弗里德曼（Lex Fridman）：

Why are they called the positive?

为什么它们被称为阳性？

安德鲁·斯卡尔（Andrew Scull）：

The positive symptoms activate things. They activate the hallucinations and the delusions. Those are changing, and they're visible usually because if somebody's deluded or hallucinating, you know about it pretty quickly- ….right? The negative symptoms are things like apathy, loss of ability to interact with people, poverty of language, lack of initiative. All of those things are devastating.

阳性症状会激活某些事物。它们会激活幻觉和妄想。这些在变化，并且通常是可见的，因为如果有人有妄想或幻觉，你很快就会知道……对吧？负性症状包括冷漠、失去与人互动的能力、语言贫乏、缺乏主动性。所有这些都是毁灭性的。

莱克斯·弗里德曼（Lex Fridman）：

Just to state out loud and clear that both positive and negative affects so-called by psychologists of schizophrenia are both devastating and both negative.

只是要大声清楚地说明，心理学家所谓的精神分裂症的正面和负面影响都是毁灭性的，而且都是负面的。

安德鲁·斯卡尔（Andrew Scull）：

Yes, yes. I think that's right.

是的，是的。我觉得那是对的。

莱克斯·弗里德曼（Lex Fridman）：

In the common parlance of what negative means.

在通常的说法中，负面的意思是什么。

安德鲁·斯卡尔（Andrew Scull）：

It's a very strange choice of language, but it's been there for a long time, so it's embedded. Now, to the extent antipsychotics work, they work on the positive symptoms. They either dull them down so you're still hallucinating a bit and you're still delusional, but it's not– it's very much less, and you are you're somewhat pacified. You're less overtly disturbed. But the negative side of things, not so much or not at all. Then on top of that, the drugs work for some people and they don't work for others, and a significant number of psychotic patients are non-drug responders, just as a significant number of people with depression are not responsive to antidepressants. Moreover, initially in the enthusiasm for these drugs everybody neglects the fact that they have serious side effects, or many of them argue the side effects are an essential part of the treatment and you just have to put up with it. So what are we talking about when I say there are nasty side effects? Well, among others, you may become incurably restless. So you're constantly in motion, you're moving around, you're never, never still. If you're in the presence of somebody like that, it becomes unbearable after a fairly short while, and it's unbearable often to the person who can't control it. Other patients develop Parkinson's disease symptoms.

这是一种非常奇怪的语言选择，但它已经存在很长时间了，所以它是嵌入的。 现在，就 抗精神病药 的工作而言，他们致力于解决阳性症状。 他们要么让它们变得迟钝，所以你仍然有一点幻觉，你仍然有妄想，但事实并非如此——它要少得多，而且你是有点平静的。 你不再那么明显地受到干扰。 但事情的消极面却没有那么多，或者根本没有。 最重要的是，这些药物对某些人有效，而对其他人无效，并且大量的精神病患者是非药物反应者，就像大量的抑郁症患者对抗抑郁药没有反应一样。 此外，最初在对这些药物的热情中，每个人都忽视了它们具有严重副作用的事实，或者他们中的许多人认为副作用是治疗的重要组成部分，你只能忍受它。 那么，当我说有令人讨厌的副作用时，我们在谈论什么呢？ 好吧，除此之外，你可能会变得无可救药地焦躁不安。 所以你一直在运动，你在移动，你永远不会静止。 如果你和这样的人在一起，过不了多久就会变得难以忍受，而且往往对于无法控制的人来说是难以忍受的。 其他患者出现帕金森病症状。

安德鲁·斯卡尔（Andrew Scull）：

Is an awful affliction which unfortunately affects a significant number of people each year, and we don't have– We have through L-DOPA a means to delay its impact, but eventually that loses its efficacy and unfortunately we don't have a cure. So you have those. And then perhaps the nastiest is what's called tardive dyskinesia. Tardive because it's late developing, it doesn't happen right away, and dyskinesia because what it involves is jerky uncontrolled movements of the body and particularly of the facial muscles. So your tongue will protrude, you'll make strange noises, you'll twitch, you'll stagger about walking. If somebody like that is walking down the street towards you, you will think there's a mentally ill person and you'll cross to the other side of the street. And yes, they probably are a mentally ill person but what you're seeing is the iatrogenic effects of the drugs they're on. Okay? So that problem was ignored for about 20 years. Paper appeared in Science by George Crane, a Maryland psychiatrist, in which he said, "We as a profession have been ignoring this terrible problem." Yes, the drugs do some good, but they're also creating a lot of harm, and we need to focus more on that. And it took a few years, but by the '80s, I think the American Psychiatric Association was very worried by that problem. And the drug companies were kind of worried about it but didn't have any obvious solution till towards the end of the '80s something happened.

这是一种可怕的疾病，不幸的是，每年都会影响大量的人，而我们却没有——我们通过左旋多巴（L-DOPA）有一种方法可以延缓其影响，但最终会失去功效，不幸的是，我们没有治愈方法。 所以你有那些。 也许最令人讨厌的是所谓的迟发性运动障碍。 迟发是因为它发育较晚，不会立即发生，而运动障碍是因为它涉及身体特别是面部肌肉的不稳定的不受控制的运动。 所以你的舌头会伸出，你会发出奇怪的声音，你会抽搐，你会走路摇摇晃晃。 如果这样的人在街上朝你走来，你会认为这是一个精神病患者，然后你会穿过街道的另一边。 是的，他们可能是一个精神病患者，但你看到的是他们所服用的药物的 医源性 效果。 好的？ 所以这个问题被忽视了大约 20 年。 马里兰州精神病学家乔治·克兰 (George Crane) 在《科学》杂志上发表了一篇论文，他在文中表示：“作为一个职业，我们一直忽视了这个可怕的问题。” 是的，这些药物确实有一些好处，但它们也造成了很多伤害，我们需要更多地关注这一点。 这花了几年时间，但到了 80 年代，我认为美国精神病学协会非常担心这个问题。 制药公司对此有些担心，但直到 80 年代末才发生了一些事情，他们才有了明显的解决办法。

安德鲁·斯卡尔（Andrew Scull）：

Nineteen fifty-seven, when the people were developing copycat versions of Thorazine, clozapine was developed by a small company which was subsequently bought up by a bigger company and introduced in Europe. It never came to America because of two things. First, it tended not to produce tardive dyskinesia, and at that time many in the profession thought if you didn't get those symptoms you weren't attacking the problem. Bizarre, right? Secondly in a significant number of patients it destroyed their– the patient's white blood cells and they died. Okay? Not, not a good outcome. So it was quickly withdrawn from the market, and it never made it to this side of the Atlantic. However as this tardive dyskinesia problem became more acute there was an attempt to revive clozapine, and it tends to… It turns out it tends to work better in treatment resistant cases, meaning cases don't respond to the other antipsychotics that we have. And it could be revived but at the cost of weekly blood checks 'cause you had to be very careful if it– if your white blood cells count started to drop, you had to stop. Right? So it came to market in the late '80s, and very quickly other drug companies tried to find other compounds actually chemically not related to it, but that's hardly the point. The whole class of drugs became known as second generation antipsychotics.

十九点五十七分，当人们开发氯丙嗪（chlorpromazine）的仿制品时，氯氮平是由一家小公司开发的，随后被一家大公司收购并引入欧洲。 由于两件事，它从未来到美国。 首先，它往往不会产生迟发性运动障碍，当时许多业内人士认为，如果你没有出现这些症状，那么你就没有解决这个问题。 很奇怪吧？ 其次，在相当多的患者中，它破坏了患者的白细胞，导致他们死亡。 好的？ 不，不是一个好的结果。 因此它很快就退出了市场，再也没有到达大西洋彼岸。 然而，随着这种迟发性运动障碍问题变得更加严重，有人尝试恢复氯氮平，并且它往往......事实证明，它在治疗抵抗病例中往往效果更好，这意味着病例对我们拥有的其他抗精神病药没有反应。 它可以恢复，但代价是每周进行血液检查，因为如果你的白细胞计数开始下降，你必须非常小心，你必须停止。 正确的？ 因此它在 80 年代末进入市场，很快其他制药公司试图寻找实际上与它在化学上不相关的其他化合物，但这不是重点。 整个类别的药物被称为第二代抗精神病药。

莱克斯·弗里德曼（Lex Fridman）：

So Clozapine, Risperdal-

所以氯氮平，利培酮-

安德鲁·斯卡尔（Andrew Scull）：

Yes, those kinds of ones

是的，那种类型的

莱克斯·弗里德曼（Lex Fridman）：

Zyprexa.

齐拉西酮

安德鲁·斯卡尔（Andrew Scull）：

Zyprexa among others.

包括赛庚啶在内。

莱克斯·弗里德曼（Lex Fridman）：

Zyprexa.

齐拉西酮

安德鲁·斯卡尔（Andrew Scull）：

Yes. And so there were a number of these, and they have actually — Because they are chemically quite different from each other, but they're classed together in the public mind and – …in the professional mind. They tend to have different side effect profiles and slightly different modes of action and differing levels of efficacy, I think.

是的。所以有很多这样的药物，它们实际上——因为它们在化学上彼此相当不同，但它们在公众的认知中以及在专业人士的认知中被归为一类。我认为它们往往有不同的副作用特征、略微不同的作用方式以及不同程度的疗效。

莱克斯·弗里德曼（Lex Fridman）：

Of course, there's not a real, at that time or even now, a real science of like when you have a human come to you, what is the actual protocol of how you figure out which to give.

当然，不管是在那个时候还是现在，都没有真正的科学来说明当你有一个人来找你时，实际的流程是什么，以及你如何确定应该给哪种。

安德鲁·斯卡尔（Andrew Scull）：

Right. So in 2005 most of the– I should say once the Drugs Revolution came along increasingly the studies were funded by the drug companies who owned the data and controlled the data- …and only released what they chose to release, what was helpful for them and not what wasn't.

对。所以在 2005 年，大多数——我应该说，一旦药物革命到来，越来越多的研究是由拥有数据并控制数据的药品公司资助的……他们只发布他们选择发布的，对他们有利的信息，而不是那些对他们不利的信息。

莱克斯·弗里德曼（Lex Fridman）：

And they were heavily marketing stuff.

而且他们在大力推销东西。

安德鲁·斯卡尔（Andrew Scull）：

Oh yeah, very heavily mar– And then to get FDA approval of efficacy and safety you needed two trials. You might have conducted 15 trials and 13 of them had been failures but if you had two that worked, that was enough. That's what you needed. That was the gold standard. So 2005 National Institutes of Mental Health funds this drug study, not an industry study, and what it wants to look at, the first generation drugs are now out of patent and they're cheap. The second generation are patented and are quite expensive, ten times as expensive in some cases. So we do something called the CATIE Study, and it's published in the New England Journal of Medicine. And there are two interesting findings. So you have one first generation antipsychotic, one of those very early drugs, and you have four more recent drugs that you're looking at.

哦，是的，非常大规模的试验——然后为了获得 FDA 对疗效和安全性的批准，你需要进行两项试验。你可能进行了 15 项试验，其中 13 项都失败了，但如果有两项成功，那就足够了。这就是你所需要的，这就是黄金标准。所以在 2005 年，美国国家心理健康研究所资助了这项药物研究，而不是由工业界资助的研究，它想要研究的第一代药物现在已经没有专利，很便宜。第二代药物有专利，而且相当昂贵，有些情况下甚至贵十倍。所以我们做了一个叫做 CATIE 的研究，并在《新英格兰医学杂志》上发表。这里有两个有趣的发现。你有一种第一代抗精神病药，其中一种非常早期的药物，然后你还有四种较新的药物在研究中。

安德鲁·斯卡尔（Andrew Scull）：

And you ask a number of questions. Are the new drugs more efficacious than the old drug? No. Hmm. Were patients willing to tolerate these drugs? And that was a finding that I thought was much underreported at the time. Between 67% and 82% of the patients, depending on which drug they were on, dropped out of the trial because either the drug wasn't working or they couldn't stand the side effects. So that tells you, these are our best drugs, you know, there are real complications here. And then as we delve further into it, do they have nasty side effects? Well, less tardive dyskinesia somewhat, but a whole new set of side effects. If you take these pills, you will gain in most cases a lot of weight—10, 20, 30, 40 pounds, 50 pounds. What does that do?

你会问很多问题。新药比旧药更有效吗？不。嗯。患者愿意忍受这些药物吗？这是我当时认为被严重低估的一个发现。根据不同的药物，有 67%到 82%的患者因为药物无效或无法忍受副作用而退出了试验。所以这告诉你，这些是我们最好的药物，但确实存在真正的并发症。然后，当我们进一步深入研究时，它们有严重的副作用吗？唔，迟发性运动障碍有所减少，但会出现一整套新的副作用。如果你服用这些药片，大多数情况下会体重增加——10、20、30、40、50 磅。这会带来什么影响？

安德鲁·斯卡尔（Andrew Scull）：

That gives you metabolic syndrome; it gives you diabetes; it gives you heart trouble. So important to state when we're looking at this 'cause there is no– There is no free lunch with medicine. If you take an aspirin, it may cause your stomach to bleed sometimes enough to really put you in serious jeopardy. Most of the time it's fine. Everything… Every drug that's brought to market has the main effect we're looking, looking for and some side effects which may be minimal for most people but for some people maybe worse than that. So we've got to– It's one of these cost benefit analysis, right? You- …You're getting some relief from your psychiatric symptoms but you're courting these other dangers that may or may not arise and going in we don't know where you're gonna fall. We don't know trial and error.

这会导致你患上代谢综合征；它会导致你患上糖尿病；它会导致心脏问题。所以在我们看这个问题时说明这一点非常重要，因为没有——医学上没有免费的午餐。如果你服用阿司匹林，它有时可能会导致你的胃出血，严重时会真正危及生命。大多数时候没问题。每一种上市药物都有我们关注的主要效果，同时也有一些副作用，对大多数人来说可能很轻微，但对某些人来说可能更严重。所以我们必须——这是一个成本效益分析的问题，对吧？你——你可以缓解一些精神科症状，但你也在冒着这些可能发生也可能不发生的其他风险，而在开始时，我们不知道你会落在哪里。我们不知道，这是一种反复试验的过程。

莱克斯·弗里德曼（Lex Fridman）：

You mean every individual that walks into the picture, they don't know where on distribution they fall?

你的意思是每个走进画面的人，他们不知道自己在分布上的位置吗？

安德鲁·斯卡尔（Andrew Scull）：

Right. And we have no biological markers at the moment that would tell us. One or two of my friends in the um, psychiatric genetics industry uh if that's the right term for it, but you know, in that research area are saying, "Well, we haven't done very well to find the genetic roots of mental illness, but maybe we can learn to distinguish which patients are gonna respond well to drugs and which shouldn't be given them because they're not going to." Um, that's a promissory note. It's not something that they actually can do now. It's just we hope we'll be able to do this, and I hope they're able to do it, too. But, you know, you can't have an enormous amount of confidence in that. Maybe it'll happen, or maybe some other mechanism will emerge that allows us to see who the responders and nonresponders are. Who's gonna suffer the worst side effects if they're put on these medications? And the side effects do vary, so um though a lot of what I've described is common to this class of drugs.

正确的。 目前我们没有生物标记可以告诉我们。 我在精神科遗传学行业的一两个朋友，呃，如果这个词合适的话，但你知道，在那个研究领域，他们说，“好吧，我们在寻找精神疾病的遗传根源方面做得还不够好，但也许我们可以学会区分哪些患者会对药物产生良好的反应，哪些患者不应该接受药物治疗，因为他们不会这样做。” 嗯，这是一张期票。 这并不是他们现在真正能够做到的。 只是我们希望我们能够做到这一点，我希望他们也能够做到。 但是，你知道，你不能对此抱有极大的信心。 也许它会发生，或者也许会出现一些其他机制，使我们能够看到谁是响应者和非响应者。 如果服用这些药物，谁会遭受最严重的副作用？ 而且副作用确实各不相同，所以嗯，尽管我所描述的很多内容对于此类药物来说都是常见的。

莱克斯·弗里德曼（Lex Fridman）：

And sometimes it's hard to describe the side effect. You're talking about the human mind. Yeah, yeah. So describing the side effects, it's not like bleeding or like diarrhea or-

有时候很难描述副作用。你是在谈论人类的思维。是的，是的。所以描述副作用，并不是像出血或腹泻那样的情况。

安德鲁·斯卡尔（Andrew Scull）：

Well, yeah.

嗯，是的。

莱克斯·弗里德曼（Lex Fridman）：

Weight gain, that's describable, but like the effect on your personality.

体重增加，这是可以描述的，但就像对你性格的影响一样。

安德鲁·斯卡尔（Andrew Scull）：

Yep, that's much harder, much harder. People, you know, some of the patients who drop out, drop out because they find the richness of their mental life is completely gone and they don't want to tolerate that. They'd sooner tolerate some hallucinations. That's a hard one.

是的，那要难得多，难得多。人们，你知道的，一些退出的病人，会退出是因为他们发现自己的精神生活的丰富性完全消失了，而他们不想忍受那种状态。他们宁愿忍受一些幻觉。那真的很难。

莱克斯·弗里德曼（Lex Fridman）：

So there's a that that picture the SSRIs that also came to be Prozac, Zoloft, Paxil during that time. Yes, Paxil, all of that. Well again, they're the second generation of antidepressants. Mm-hmm. So that's a complicated story. Again, it's an accident. They're at treating patients with advanced tuberculosis in the 1950s. Now that's a very unpleasant thing that's also gonna kill you. So, tuberculosis. Very advanced cases. You're coughing your lungs up. You're depressed as all get out. And here we have two new drugs, Iproniazid, we can use that maybe will treat the condition. When you give it to the patients and these depressed tuberculosis patients start acting happy, dancing about, their mood changes. Bingo! We've got something that maybe we can use over here to treat depression. However, the drug companies in circa 1960 think of depression as a small market because what they're talking about is the kind of melancholic psychotic depressions that leads people into the mental hospital. And that's not an insignificant group, but it's not a huge group. So, it's really much later on that things begin to change. Right now, it's fair to say depression is the common cold of psychiatry. It's, you know, it's abundant there. The depressive diagnosis probably the most commonly given among psychiatrists. So, part of that is a deeper understanding of the human mind, and a big part of that is probably the drug companies convincing the world.

因此，有一个画面描绘了 SSRI 类抗抑郁药，在那段时间也成为了百优解（Prozac）、Zoloft、Paxil。 是的，帕西尔，所有这些。 好吧，他们是第二代 抗抑郁药 。 嗯嗯。 所以这是一个复杂的故事。 再说一遍，这是一次意外。 他们在 20 世纪 50 年代治疗晚期结核病患者。 这是一件非常不愉快的事情，它也会杀了你。 所以，结核病。 非常先进的案例。 你咳得肺都咳起来了。 当所有人都出去时，你会感到沮丧。 这里我们有两种新药，异丙烟肼，我们可以用它来治疗这种情况。 当你把它给病人时，这些抑郁的结核病病人开始表现得快乐，跳舞，他们的情绪发生了变化。 宾果！ 我们这里有一些东西也许可以用来治疗抑郁症。 然而，大约 1960 年的制药公司认为抑郁症是一个小市场，因为他们谈论的是那种导致人们进入精神病院的忧郁 精神病 抑郁症。 这不是一个微不足道的群体，但也不是一个庞大的群体。 所以，事情在很久以后才开始发生变化。 现在，可以公平地说，抑郁症是精神病学中的普通感冒。 你知道，那里资源丰富。 抑郁症的诊断可能是精神科医生最常给出的诊断。 所以，这其中一部分是对人类心智的更深入理解，而其中很大一部分可能是制药公司在说服世界。

安德鲁·斯卡尔（Andrew Scull）：

Well, its transforming, yes. So there were big disputes, for example, when DSM-5 was being contemplated, about whether grief, bereavement would count as a mental disorder, as count as a form of depression. If you lose a parent, if you lose, even worse, a child, um, it's a deeply, how can I put it, deeply upsetting? Yes. Some psychiatrists say yes and some no, but it's an example of what happens in psychiatry repeatedly, what I would call diagnostic creep, which is a term actually an Australian named Nick Haslam came up with. But it's a phenomenon I described before that. You start with a core of unambiguous deviations from the norm that are so serious that any competent member of the culture knows that's that. But then it– you begin to say, "Well, there's this penumbra," you see, and just outside that core, there are people who are also disturbed, not perhaps as sufficiently disturbed that you actually recognize it, but it's happening. And so that has tended to happen over and over again. Parents with an autistic child won't necessarily agree with what I'm about to say, but the chief editor of DSM-IV, Allen Frances, is convinced the huge increase in the number of diagnoses of autism is more driven by the fact he loosened the criteria for the diagnosis than it is because there are more actual cases. Autism used to be a fairly rare phenomenon, and now sadly it's a very broad one.

嗯，它正在转变，是的。 因此，例如，当考虑 DSM-5 时，关于悲伤、丧亲之痛是否算作精神障碍，是否算作抑郁症的一种形式，存在很大的争议。 如果你失去了父母，如果你失去了，更糟糕的是，失去了一个孩子，嗯，我该怎么说，非常令人沮丧？ 是的。 有些精神病学家说是，有些说不是，但这是精神病学中反复发生的事情的一个例子，我称之为诊断蠕变，这个术语实际上是一个名叫尼克·哈斯拉姆的澳大利亚人提出的。 但这是我之前描述过的一个现象。 你从一个明显偏离规范的核心开始，这种偏离是如此严重，以至于任何有能力的文化成员都知道就是这样。 但然后你开始说，“嗯，有这个半影”，你看，就在那个核心之外，有人也感到不安，也许没有那么不安，以至于你实际上认识到它，但它正在发生。 因此，这种情况往往会一而再、再而三地发生。 有自闭症孩子的家长不一定会同意我要说的话，但[《精神疾病诊断与统计手册》（DSM） 4 的主编艾伦·弗朗西斯（Allen Frances）相信，自闭症诊断数量的大幅增加更多是由于他放宽了诊断标准，而不是因为有更多的实际病例。 自闭症过去是一个相当罕见的现象，现在遗憾的是，它变得非常普遍。

安德鲁·斯卡尔（Andrew Scull）：

And I understand why parents react very negatively to that because the diagnosis is the key to all sorts of social supports and educational supports and all the rest, and they're dealing with a child who is extremely difficult. But there is a real difference between the most severe forms of autism where people lose capacity to speak and very often any ability to interact with other people and so forth, and the other cases that are of a still serious but milder sort. Diagnostic creep is not driven just by psychiatric imperialism, the desire for more territory, more patients. It's driven as well by patients and people and they resist it being pushed back very often. So families have formed organizations like NAMI, but those aren't the mentally ill. Those are the family members of the mentally ill, and there are differences in the perspectives and the interests of the family members and the patients- … And that's easy to forget.

我理解为什么父母会对此反应非常消极，因为诊断是获取各种社会支持、教育支持等的关键，而他们正面对一个极其难以应付的孩子。但最严重的自闭症形式与其他仍然严重但较轻的情况之间确实存在真正的差异。在最严重的形式中，人们会失去说话能力，而且常常丧失与他人互动的能力等等。诊断扩张不仅仅是由精神病学帝国主义、对更多领域、更多患者的渴望驱动的，它也受到患者和其他人的推动，而且他们通常会抗拒这种推行。因此，家庭成立了像全国精神疾病联盟（NAMI）这样的组织，但那些成员并非精神病患者，而是精神病患者的家庭成员，而且家庭成员与患者在观点和利益上存在差异……而这一点很容易被遗忘。

莱克斯·弗里德曼（Lex Fridman）：

I think one of the things you talk about is I mean, the quote you had was use the word madness. But that madness or mental health maladies, if you're suffering from them, it's a deeply lonely experience. And then if you're around somebody suffering from it, it's a very social experience.

我认为你谈论的其中一件事是，我的意思是，你引用的例子使用了‘疯狂’这个词。但这种疯狂或心理健康疾病，如果你正在经历它们，这是一个非常孤独的经历。而如果你身边有人正在经历它，则是一个非常社交的经历。

安德鲁·斯卡尔（Andrew Scull）：

Yeah. Yeah, this is actually that's a paraphrase of — I was quoting one of my friends and fellow historians of psychiatry, Michael MacDonald. The most solitary of afflictions for the sufferer and the most social of maladies for those around them. And there's lots of ways in which you can see that very powerfully, and that's why I think there are a ton of people who suffer in various ways from mental disturbances of one sort and another. But the effects aren't confined to them. They extend out to everybody else around them, and that's really powerful. So we had this first generation, there were actually two different kinds of antidepressants: MAOIs as they're called in the trade, and tricyclics which were called tricyclics 'cause they had a third ring of a certain element in their molecule. Those had as I say, a limited market, but also there were complications associated with them that it was easy to overdose and die. And so depressed– giving a depressed patient a bunch of pills that if they took too many of them would kill them was tricky. They also could kill you another way because for example, you couldn't– certain dietary items, cheese, cured meats, in combination with them were, were very, very health threatening, maybe even fatal.

是的。 是的，这实际上是我引用的一位朋友和精神病学历史学家迈克尔·麦克唐纳的话。 对于患者来说，这是最孤独的痛苦，对于周围的人来说，则是最具社会性的疾病。 你可以通过很多方式强烈地看到这一点，这就是为什么我认为有很多人以不同的方式遭受着这样那样的精神障碍。 但影响并不局限于他们。 他们扩展到周围的每个人，这非常强大。 所以我们有了第一代，实际上有两种不同类型的抗抑郁药：MAOIs，因为它们在行业中被称为，以及三环类化合物，之所以被称为三环类化合物，是因为它们的分子中含有某种元素的第三个环。 正如我所说，这些药物的市场有限，但也存在与之相关的并发症，很容易过量服用而死亡。 如此沮丧——给一个抑郁症患者服用一堆药，如果他们服用太多就会杀死他们，这是很棘手的。 它们也可能以另一种方式杀死你，因为例如，你不能——某些饮食项目，奶酪，腌肉，与它们结合起来，非常非常威胁健康，甚至可能致命。

安德鲁·斯卡尔（Andrew Scull）：

Now, in the late '80s, the drug companies came across a new class of antidepressants that didn't have those side effects. As we'll see, they had other side effects, but not those. And the most famous of those was Prozac. There were a class of drugs called SSRIs, and again forgive the acronyms, but what it means is selective serotonin reuptake inhibitors. Serotonin is something manufactured in our bodies, actually in our digestive system, and it performs a variety of functions in the body. But it's also one of the neurotransmitters in our brains. And the way these drugs worked was by slowing the reuptake of serotonin in the brain, which was marketed by the drug companies as the solution to depression. That when you got depressed, it was because you didn't have enough serotonin in your brain, and these pills solved that problem. It was like, well, Tipper Gore, Al Gore's ex-wife, was like many politicians' wives, depressed for reasons I fully understand or at least partially understand. And she went to her psychiatrist and that was one of the things she was given, and she became one of the big public advocates for SSRIs which still are the most prescribed antidepressants.

现在，在 80 年代末，制药公司发现了一类新的 抗抑郁药，它没有这些副作用。 正如我们将看到的，它们还有其他副作用，但不是这些。 其中最著名的是百优解（Prozac）。 有一类药物称为 SSRI 类抗抑郁药 ，再次原谅缩写词，但它的意思是选择性 血清素 再摄取抑制剂。 血清素是我们体内（实际上是我们的消化系统）产生的物质，它在体内发挥多种功能。 但它也是我们大脑中的神经递质之一。 这些药物的作用方式是减缓大脑中 血清素 的重新摄取，制药公司将其作为抑郁症的解决方案进行营销。 当你感到沮丧时，是因为你的大脑中没有足够的 血清素，而这些药丸解决了这个问题。 就像，阿尔·戈尔的前妻蒂珀·戈尔，就像许多政客的妻子一样，因为我完全理解或至少部分理解的原因而感到沮丧。 她去看了精神科医生，这是她得到的治疗之一，她成为了 SSRI 类抗抑郁药的主要公众倡导者之一，这种药物仍然是最常用的抗抑郁药。

莱克斯·弗里德曼（Lex Fridman）：

Do they work? And what are the side effects?

它们有效吗？副作用有哪些？

安德鲁·斯卡尔（Andrew Scull）：

Yeah. So here's where we get into slippery territory. Every time you do a controlled study of these antidepressants, they beat placebo in a statistically significant margin, but not necessarily in a clinically significant margin. And this is when you see drug ads, be very careful. This one significantly improves X or Y. Does that mean clinically or does it mean statistically? Because the fact– if you — When we measure improvement with depression, we tend to use rating scales of various sorts. And if you improve on one of the major scales that's used by one or two points on a 60-point scale, it may be enough to show statistical significance. This drugs looks a little better than placebo, but doesn't really affect your quality of life much. And for most patients, antidepressants are marginally better than placebo, but a lot of the effect is the placebo effect. And they come with very difficult side effects. A lot of people describe them as numbing drugs. They-

是的。那么这就是我们进入棘手领域的地方。每次你对这些 抗抑郁药 进行对照研究时，它们在统计学上都会明显优于 安慰剂，但未必在临床上显著。这也是为什么当你看到药品广告时，要非常小心。广告可能说这个药显著改善了 X 或 Y。那是指临床上显著，还是统计上显著呢？事实是——如果你——当我们测量抑郁症的改善时，通常会使用各种评分量表。如果你在一种主要量表上提高了 60 分制中的一两分，这可能足以显示统计学上的显著性。这个药看起来比 安慰剂 略好，但对你的生活质量影响不大。对于大多数患者来说，抗抑郁药 的效果只比 安慰剂 略好很多，但很大一部分效果来自 安慰剂效应。而且它们伴随非常难处理的副作用。很多人形容它们是麻木药物。它们——

安德鲁·斯卡尔（Andrew Scull）：

… flatten everything out so you can't experience the highs and lows that normally we take as part of human experience. And then the numbing extends elsewhere in your body. In particular, lots of patients find a complete loss of libido. They… They can't get an erection. They can't climax if they're a woman. Their sex life just goes away, and sometimes it doesn't come back after you stop the drugs. Next layer of problems, getting off the drugs for some people turns out to be hell on wheels. They get worse depression than they had before. They get terrible feelings. That brain is sparking; something's wrong. And so many patients find themselves trapped on those drugs for a long time, and we don't know what the effects of that are gonna be. So it's a very mixed picture, you know. That's why I think groups like NICE in England are saying, "Use CBT as the first line, not drugs." Um, but again, it's also fair to say, I think what we find and there was a recent Lancet study that I think was revealing on this point. It's like this with both antipsychotics and antidepressants. You have a group of people who respond pretty well, and, and the side effects for them are bearable or even they don't experience them. That's great. You have a group of people, and it's significant. With depressed patients, we're talking 40 or north of forty percent who aren't responding. Okay?

......将一切展平，这样你就无法体验我们通常视为人类经验一部分的高潮和低谷。 然后麻木感会延伸到身体的其他部位。 特别是，许多患者发现性欲完全丧失。 他们……他们无法勃起。 如果她们是女人，她们就无法达到高潮。 他们的性生活就会消失，有时停药后就不会再出现。 下一层问题是，对某些人来说，戒毒简直就是地狱。 他们的抑郁症比以前更严重。 他们有可怕的感觉。 那个大脑正在闪闪发光； 出问题了。 许多患者发现自己长期服用这些药物，我们不知道这会产生什么影响。 所以这是一个非常复杂的情况，你知道。 这就是为什么我认为像英国的 NICE 这样的团体会说，“使用 认知行为疗法（CBT） 作为第一线，而不是药物。” 嗯，但同样，公平地说，我认为我们发现了什么，最近的一项《柳叶刀》研究我认为揭示了这一点。 抗精神病药 和 抗抑郁药 都是这样。 有一群人反应很好，而且他们的副作用是可以忍受的，甚至他们没有经历过。 那太棒了。 你有一群人，这很重要。 对于抑郁症患者，我们所说的是 40% 或 40% 以上的人没有反应。 好的？

安德鲁·斯卡尔（Andrew Scull）：

So drugs aren't doing anything for them, and they're running a risk. And then in the middle, you have a group of people who get some positive improvement, but they also get side effects, and that's where, you know, this cost-benefit analysis, if we can call it that, comes into play, and it's very difficult. And the problem is going in, you don't know which group you're gonna fall in. And your, and your doctor doesn't know which group you're gonna fall in. And more importantly, one of the things the Drugs Revolution did was it moved the diagnosis and the prescribing of things away from psychiatry alone, so many of these things, particularly antidepressants, are dispensed by primary care docs, not, not psychiatrists.

所以药物对他们没有任何作用，而且他们还冒着风险。然后在中间，你有一群人，他们获得了一些积极的改善，但也出现了副作用，这就是所谓的成本-收益分析发挥作用的地方，非常困难。问题是，在开始时，你不知道自己会属于哪一组，你的医生也不知道你会属于哪一组。更重要的是，药物革命所做的一件事是，它将诊断和处方工作从单纯的精神科扩展开，所以很多药物，特别是抗抑郁药，是由初级保健医生开具的，而不是精神科医生。

莱克斯·弗里德曼（Lex Fridman）：

Let's zoom out. We did say that there's a real crisis. From an individual perspective suffering from psychosis or suffering from depression- … What are you supposed to do? What works, and what is the hope for the future in the next ten, twenty out?

让我们拉远视角。我们确实说过，这确实是一个真正的危机。从个体的角度来看，正在遭受精神病性障碍或抑郁症折磨的人——……你该怎么办？什么有效？未来十年、二十年的希望是什么？

安德鲁·斯卡尔（Andrew Scull）：

So you probably need to try the drugs because the suffering is very intense. But you need to be aware of things, and you need a clinician who's monitoring very carefully. More generally, psychiatric research needs to broaden. We have spent all our monies on drugs, on neuroscience, and on genetics, but there are other things we could do that would improve the lives of families and patients more immediately. So we need to spend some time on the psychosocial dimensions of mental illness and to allow psychiatrists to build careers in those fields. One of the problems if you're an academic psychiatrist, your whole future is dependent on you bringing in grant monies, and there aren't grant monies available to study: Are there better ways we could cope with the problem of homelessness? Are there better ways we could make f– ease the problem for families who are having to cope with somebody in their midst who's hallucinating? That sort of thing, I think, would help.

所以你可能需要尝试这些药物，因为痛苦非常强烈。但你需要注意一些事项，并且你需要有一位仔细监控的临床医生。更广泛地说，精神病学研究需要拓宽。我们把所有的钱都花在了药物、神经科学和遗传学上，但还有其他一些事情我们可以做，这些事情可以更直接地改善家庭和患者的生活。因此，我们需要花一些时间关注心理社会层面的精神疾病，并允许精神科医生在这些领域建立职业生涯。如果你是一名学术精神科医生，其中一个问题是，你的整个未来取决于你能获得多少研究资助，而目前没有资金支持去研究：有没有更好的方法来应对无家可归的问题？有没有更好的方法来缓解那些必须应对家中有人出现幻觉问题的家庭的困境？这类事情，我认为，会有所帮助。

莱克斯·弗里德曼（Lex Fridman）：

What about talk therapy on both the CBT, cognitive behavioral therapy, and psychoanalysis? We left psychoanalysis in this place where society left it behind.

关于在 认知行为疗法（CBT）、认知行为疗法（cognitive behavioral therapy） 和 精神分析 上进行谈话疗法怎么办？我们把 精神分析 留在了社会抛弃它的地方。

安德鲁·斯卡尔（Andrew Scull）：

I think it's become a niche product now. Only, only the very wealthy can afford to do it, and some of them indeed do make use of it, and some of them claim that it helps them.

我认为它现在已经成为一种小众产品了。只有非常有钱的人才能负担得起，而其中一些人确实利用它，还有一些人声称它对他们有帮助。

莱克斯·弗里德曼（Lex Fridman）：

Oh, do you think there's future in it? I will add an extra– I would add an extra bit to that.

哦，你觉得这有前途吗？我会再加一点——我会再加一点在那上面。

安德鲁·斯卡尔（Andrew Scull）：

Yes.

是的。

莱克斯·弗里德曼（Lex Fridman）：

Carefully is with the advent and the rapid improvement of artificial intelligence systems- …that are able to communicate with individual humans and learn a lot about them, and have a conversation about the deepest secrets that you sometimes actually would even be uncomfortable telling even a therapist. That starts to go into the realm of Freud and Jung and psychoanalysis.

随着人工智能系统的出现和快速改进——这些系统能够与个人交流，了解他们的许多信息，并就你有时甚至连对治疗师都不愿意说的最深秘密进行对话。这开始进入弗洛伊德、卡尔·荣格（Carl Jung）和精神分析的领域。

安德鲁·斯卡尔（Andrew Scull）：

Well, yes, and we did see actually COVID with the isolation that it produced and the fact people couldn't go to their therapists directly. We did see the rise of some of this distant learning of this, and some of it may indeed be mechanizable in the way you described. It's very important that psychiatrists broaden their perspective on these things, and some already have. I think public policy is in a mess when it comes to serious mental illness, but I'm pessimistic about fixing that 'cause it would cost bunches of money. If we were talking about something where we could cure people, transform them from, as they used to say, tax eaters to taxpayers, there'd be incentive to do it. But the honest answer is right now that's not where we are. And so we face dilemmas. I think helping people as much as we can with social supports –And, you know, social interaction is tremendously important to people's mental health. If they lack it, if they're lonely, if they're isolated, it does bad things to people. So somehow providing that kind of support, providing some sense of agency to people who often lack it would be very helpful. I hope somebody has a breakthrough and produces a better drug because unlike some people, I would be astonished if the major forms of mental illness didn't have a biological component to them.

嗯，是的，我们确实看到了新冠病毒带来的隔离以及人们无法直接去看治疗师的事实。 我们确实看到了一些远程学习的兴起，其中一些确实可以按照您所描述的方式实现机械化。 精神科医生拓宽对这些事情的看法非常重要，有些人已经这样做了。 我认为在严重的精神疾病方面，公共政策一团糟，但我对解决这个问题持悲观态度，因为这会花费大量资金。 如果我们谈论的事情可以治愈人们，将他们从人们常说的食税者转变为纳税人，那么就会有动力去做。 但诚实的答案是，现在这不是我们所处的位置。 所以我们面临着两难的境地。 我认为通过社会支持尽可能地帮助人们——而且，你知道，社交互动对人们的心理健康非常重要。 如果他们缺乏它，如果他们感到孤独，如果他们被孤立，就会对人们产生不好的影响。 因此，以某种方式提供这种支持，为那些经常缺乏这种支持的人提供某种代理感，将会非常有帮助。 我希望有人能够取得突破并生产出更好的药物，因为与某些人不同的是，如果主要形式的精神疾病没有生物学成分，我会感到惊讶。

安德鲁·斯卡尔（Andrew Scull）：

I don't think that's ever gonna be the whole story, but it's going to be an important part of the story, and therefore, you know, the fact that major drug companies have abandoned research in this area, they've been bad actors in many ways, but the drugs have had some positive effects, and the fact that there's no research being done by the people with the most money to develop better treatments is, well, one word for it would be depressing. You know? That's not what we wanna see.

我认为那永远不会是整个故事，但它会是故事的重要部分，因此，你知道，主要制药公司放弃了这一领域的研究，他们在很多方面行为不端，但这些药物确实有一些积极的效果，而且最有钱能够开发更好治疗方法的人没有进行研究，这，嗯，用一个词来说，就是令人沮丧。你知道吗？那不是我们想看到的。

莱克斯·弗里德曼（Lex Fridman）：

So the path forward is a mix- ….of continued research on drugs, but from a patient perspective, extreme caution in use of those drugs. Talk therapy, whether it's CBT or psychoanalysis, further investigation research on that front. Then the psychosocial component of social family- …..people around you, less loneliness, investigating how from a cultural social perspective and from a public policy perspective, can we increase the amount of social connections that people who suffer have and all of that together?

因此，前进的道路是一个混合……继续进行药物研究，但从患者的角度来看，对这些药物的使用需极其谨慎。谈话疗法，无论是认知行为疗法（CBT）还是心理社会干预（PSA），在这方面需要进一步的研究调查。然后是社会心理层面的家庭和社会支持——你周围的人，减少孤独感，从文化社会的角度以及公共政策的角度，研究如何增加受苦者的社交联系，所有这些综合起来。

安德鲁·斯卡尔（Andrew Scull）：

Yes. And breakthrough with people who have a very hard time making those connections or who've lost the ability to make them.

是的。并且要突破那些很难建立这些联系或已经失去建立这些联系能力的人群。

莱克斯·弗里德曼（Lex Fridman）：

If we can zoom out, looking back at this rich history of human beings, and we did look at the darkness, but I think there's a very large number of people that want to help those who suffer. So looking at the history of people trying to figure out- ……how to help those who suffer, what gives you hope about our future? A real hope for the future of psychiatry that we can actually help people who suffer.

如果我们能够拉远视角，回顾人类丰富的历史，我们确实看过黑暗，但我认为有非常多的人想要帮助那些受苦的人。所以，回顾人们试图弄清楚——……如何帮助那些受苦的人，这给你对我们的未来带来了怎样的希望？对精神病学未来的真正希望是，我们实际上可以帮助那些受苦的人。

安德鲁·斯卡尔（Andrew Scull）：

Well, I think we have a profession with many very well-meaning people who see the suffering on a day-to-day, face-to-face basis. And I like to think that among them will be people who move this thing forward. And the fact is we have moved things forward. We have tended to dwell a lot on some of the very unsavory aspects of the past and even some of the drawbacks of what we have available to us in the present. But it is important to see at times highly motivated people have been able to do very good things to help people with these conditions. And there is, I think, hope in the future that we will see more of that than has been the case. And that involves, in some senses, a shift in the mentality of a whole profession in a more caring kinda direction or less technocratic kind of direction, less reliance on something as simple as giving people pills, because that can help, but it's clearly not gonna be the solution to the whole thing. We need a system that is aware of and catering to the suffering that people experience and finds ways, if they can't eliminate it entirely, to ameliorate it in ways that people will sense is actually of help to them. It's a, it's a very difficult area, this one.

嗯，我认为我们这个行业有很多善意的人，他们每天都面对面地看到苦难。 我认为他们当中将会有推动这件事向前发展的人。 事实是我们已经取得了进展。 我们倾向于过多地关注过去的一些非常令人讨厌的方面，甚至我们现在所拥有的一些缺点。 但重要的是，有时积极主动的人们能够做一些很好的事情来帮助患有这些疾病的人。 我认为，未来我们有望看到比以往更多的情况。 从某种意义上说，这涉及到整个职业的心态转变，转向更关心的方向或更少的技术官僚方向，减少对像给人们吃药这样简单的事情的依赖，因为这会有所帮助，但显然不会成为整个问题的解决方案。 我们需要一个能够意识到并照顾人们所经历的痛苦的系统，如果他们不能完全消除痛苦，我们会找到方法，以人们感觉实际上对他们有帮助的方式来改善它。 这是一个非常困难的领域。

安德鲁·斯卡尔（Andrew Scull）：

It's one that touches some of the most profound aspects of ourselves as human beings, and I think as difficult as this problem is, it's very important not to be cynical. Not to give up hope, not to deny the possibility of progress, because that's always there. And has happened, and I hope will happen with increasing pace in the years ahead of us.

这是触及我们作为人类最深层次方面的问题之一，我认为尽管这个问题很困难，但非常重要的是不要变得愤世嫉俗。不要放弃希望，不要否认进步的可能性，因为它总是存在的，并且已经发生过，我希望在未来的岁月里这种进步会以越来越快的速度发生。

莱克斯·弗里德曼（Lex Fridman）：

And if you're listening to these words and you're right now in this moment of your life where you yourself are suffering, please know we're with you. We're in this together. Stay strong. There's hope, legitimately, as one human to another. I love you, brother, sister. If you're listening to this, stay strong. Andrew, thank you for this incredible work of history that you do. Incredible work of raising awareness, stepping into a difficult topic, and trying to find the wisdom, the insights in it. And thank you for this incredible conversation today.

如果你正在聆听这些话，而此刻你正处在人生中自己正在受苦的时刻，请知道我们与你同在。我们一起面对这一切。保持坚强。真心地说，有希望。从一个人到另一个人，我爱你，兄弟姐妹。如果你在听这个，保持坚强。Andrew，感谢你所做的这项令人难以置信的历史工作。提高意识的非凡工作，勇敢地踏入一个困难的话题，并尝试从中寻找智慧和见解。也感谢你今天进行的这场精彩对话。

安德鲁·斯卡尔（Andrew Scull）：

Lex, thank you for having me, and I felt you were remarkably prepared to push me in various directions. So you'd obviously done a lot of preparation to get, get this in, in the right frame. And I hope that people will get something positive from this conversation along with some of the darkness we've inevitably had to talk about.

莱克斯·弗里德曼（Lex Fridman），谢谢你邀请我，我感到你在推动我从各个方向思考方面准备得非常充分。所以很明显，你为了把这个内容呈现得恰到好处，做了大量的准备。我希望人们能从这次对话中获得一些积极的东西，同时也能理解我们不可避免地要谈到的一些黑暗面。

莱克斯·弗里德曼（Lex Fridman）：

Thank you for listening to this conversation with Andrew Scull. To support this podcast, please check out our sponsors in the description, where you can also find links to contact me, ask questions, give feedback, and so on. And now, let me leave you with some words from Friedrich Nietzsche: "To live is to suffer, to survive is to find meaning in the suffering." Thank you for listening, and I hope to see you next time.

感谢您收听与安德鲁·斯卡尔（Andrew Scull）的这段对话。为了支持这个播客，请查看描述中的赞助商信息，您还可以找到联系我、提问、提供反馈等的链接。现在，让我用弗里德里希·尼采的一句话来结束今天的节目：‘生活就是痛苦，生存则是在痛苦中寻找意义。’感谢您的收听，希望下次再见到您。