强迫症是细菌引起的吗？--谈谈强迫症的细菌学说

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强迫症的细菌学说

我是在美国的留学生，第一次接触到强迫症的细菌学说是在2-3年前，当时读到一位美国儿童强迫症患者的母亲写的书，叫”拯救山米”（Saving Sammy）。 故事写的是这位母亲如何通过艰难的过程诊断发现她儿子的强迫症与链球菌感染有关，然后通过抗菌素治疗治愈儿子的疾病。当时觉得非常震撼，甚至不可思议，因为以前完全闻所未闻。长期以来，医学界与人们认为强迫症就是一种精神疾病，是大脑细胞失调的问题，与细菌感染根本不搭界。但是这本书提出了一个全新的概念，对旧的学说无疑是尖锐挑战，让人大开眼界。说实话，强迫症传统的理论与治疗方法已经统治精神病学界许多年，或者说对我们不断洗脑，其实治疗效果仍然非常有限，无法让人满意，我们急需新的突破。虽然目前的细菌学说仍有争议，尚未被主流医学界完全接受，但是它无可怀疑是划破沉闷空气的一道亮光，可以促使我们从新的视角来思索与认识强迫症。

下面我决定将慢慢翻译一篇发表于美国『纽约时报』（the New York Time）的文章，该文详细介绍了强迫症的细菌学说。我会同时刊出英文与翻译的中文，为了节省时间，翻译时候会省却一些不重要的部分或者字句，当然懂英文的人可以直接阅读原文。另外，因为时间仓促，翻译的文笔难免粗燥，希望谅解。

如果有问题，可以联系我的qq1295824587.我尽可能回答。

谢谢大家！

pengxc

许多患者说，如果患上强迫症就“知道你是疯了。”这是另外一种形式的精神病，强迫的念头或者行为一直缠绕着患者，无休无止。病人形容强迫症的折磨是各种奇怪的念头在你的心里上下挣扎 -- 知道它们是不合理的，但却无法停止。患者描述那些挤占他们内心的荒唐想法，永遠缠斗不休 -- 焦虑的情绪，性的恶念，暴力的想法，有时候所有这些东西在同一时间冒出来。前门锁住了吗？我的手上是否有细菌？如果踩到一只蚂蚁，我是一个凶手吗？患者会想尽各种方法来减轻这些焦虑-– 不断的检查门锁，不停洗自己的双手，小心行走，采用缓慢和离奇的仪式，以免踩到任何东西。他们每天被强迫做这些事情，尽管知道这样做毫无意义。

To suffer from obsessive-compulsive disorder, many patients say, is to ''know you are crazy.'' Other forms of psychosis may envelop the sufferers until they inhabit the delusion. Part of the torture of O.C.D. is, as patients describe it, watching as if from the outside as they act out their obsessions -- knowing that they are being irrational, but not being able to stop. They describe thoughts crowding their minds, nattering at them incessantly -- anxious thoughts, sexual thoughts, violent thoughts, sometimes all at the same time. Is the front door locked? Are there germs on my hands? Am I a murderer if I step on an ant? And they describe increasingly elaborate rituals to assuage those thoughts -- checking and rechecking door locks, washing and rewashing hands, walking carefully, slowly and in bizarre patterns to avoid stepping on anything. They feel driven to do things they know make no sense.

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有研究者认为，一些强迫症患者 -- 特别是在儿童中发现的一种类型 –-是由一种大家 熟悉的东西所致。被称之为“与链球菌感染相关的儿科自身免疫性神经精神障碍”，这种疾病有一个英文缩写名字，称为“PANDAS”。他们肯定这种强迫症是因为链球菌咽喉炎所致 -- 或更具体说，是因为抗链球菌的抗体所致。

如果他们是正确的，这注定是一个引人注目的的突破，证明细菌和至少一个类别的精神病之间有联系。如果细菌可以导致强迫症，那么抗生素就可以减轻或防止它 。

儿童精神科医生们早就知道，有时儿童的强迫症可以突然发病，像瘟疫一样，然后症状可以持续从几天到几个月或者更长。如果一般强迫症患者的典型症状是像一条正弦曲线（渐进型） -– 症状慢慢上升，逐渐达到高峰，然后再缓慢减弱。那么急性 强迫症患者发病的曲线图是锯齿型（突发型） -–先是 平面，然后骤然升高，接着相对急剧下降，然后再平面。

There are researchers who believe that some of this disturbing cacophony -- specifically a subset found only in children -- is caused by something familiar and common. They call it Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infection, or, because every disease needs an acronym, Pandas. And they are certain it is brought on by strep throat -- or more specifically, by the antibodies created to fight strep throat.

If they are right, it is a compelling breakthrough, a map of the link between bacteria and at least one subcategory of mental illness. And if bacteria can cause O.C.D., then an antibiotic might mitigate or prevent it -- a Promised Land of a concept to parents who have watched their children change overnight from exuberant, confident and familiar to doubt-ridden, fear-laden strangers.

Child psychiatrists have long known that sometimes O.C.D. in children can be like that, that it can come on fast, out of the blue, like a plague, and then last anywhere from days to months. If the typical graph of O.C.D. symptoms is a sine curve -- with episodes that ramp up slowly, peak gradually, then abate just as slowly -- the graph of rapid-onset O.C.D. is saw-toothed -- flat, then a sudden spike, followed by a relatively sharp drop, then flat again.

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从这种模式看，肯定看起来它们像是两个独立的疾病，有类似的症状，但有不同的原因。在全美国，许多医生开始相信这一点，并对年轻，突然起病的强迫症患者治疗使用长期的抗生素。首先引起公众对强迫症儿童关注的儿童精神科医生朱拉波特说“如果我是下注，我是站在那些相信PANDAS的人一边。“

但另外一些研究人员，也是非常聪明的人，发表过许多令人印象深刻的文章，认为这个理论是错误的，至少还是为时过早。这些人警告说，PANDAS的假设是误导，也许甚至是危险的的， “模棱两可的，有争议的，未经证实，''芝加哥儿童医院的斯坦福舒尔曼博士说。

The patterns certainly look as if they could be two separate disorders, with similar symptoms but different causes. Across the country, many doctors are convinced of this and are putting young sudden-onset O.C.D. patients on long-term doses of antibiotics. ''If I were to place bets,'' says Judith Rapoport, the child psychiatrist who first brought O.C.D. to public attention with her book ''The Boy Who Couldn't Stop Washing,'' that bet would be on the side of those who believe in Pandas.

But as certain as some researchers are, there are others, just as smart, with just as many impressive publications and titles, who think the theory is wrong or, at best, that it is too early to tell. And this group is warning that the Pandas hypothesis is misguided, perhaps even dangerous. ''Equivocal, controversial, unproven,'' Dr. Stanford Shulman, chief of infectious disease at Children's Memorial Hospital in Chicago, says of the theory.

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现在PANDAS在医学上停留在一个令人尴尬的时刻 –-   卡在医生所认为的与他们所知道的差距之间。实际上几乎每一个科学突破都会通过这样一个时刻，在其中它要么被接受为事实或被当成谬误驳回。

事情一向如此，但近年来在有关过程中的几件事情已经改变。科学现在引起公众的思考，每一点科学进展都会立刻放到网上。而那些等待答案的人急于求成和更多地参与进来。现在的强迫症患者家属不是咨询他们的医生，而是带来了自己的建议。他们不希望等待一个为期两年的双盲安慰剂对照的临床试验结果，而希望马上行动。

这意味着，他们经常发现自己采取行动在所有事实弄清楚之前，链球菌的细菌真的可以引起强迫症吗？这些孩子是需要青霉素还是百忧解？我们现在回头来看看这些问题，我们是否应该相信这个理论呢？或者说，我们是否应该怀疑它呢？
Pandas stands at a familiar, necessary and utterly frustrating moment in medicine -- in the gap between what doctors think and what they know. Practically every byte of scientific knowledge passes through a moment like this, on its way to being accepted as fact or dismissed as falsehood.

It has always been so, but in recent years several things about the process have changed. Science now does its thinking in public, with each incremental advance readily available online. And those waiting for answers are less patient and more involved. They don't ask their doctors; they bring their own suggestions. They don't want to wait for the results of a two-year double-blind placebo-controlled clinical trial before they act.

Which means that they often find themselves acting before all the facts are in. Can strep bacteria cause obsessive-compulsive disorder? Do these children need penicillin or Prozac? Will we look back on these questions years from now and think, How could we have believed? Or, rather, How could we have doubted?

pengxc

文章很长，我的时间有限，如果有网友愿意翻译部分文章，请与我联系。

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最强烈支持PANDAS理论的是国家精神健康研究所的研究员与儿科医生苏珊。她是第一个确定PANDAS综合症，并且该它命名的人。在她的整个职业生涯中，她一直在研究链球菌和强迫症之间的关系。

她的工作开始于80年代，那时正是世界发现强迫症的时候。虽然人们早已经知道这个疾病，但直到30年前，研究人员开始意识到这个疾病是多么普遍，又过了十几年后，他们发现这个疾病经常发生于儿童。

1989年，拉波特医生出版了关于PANDAS的畅销书，同时这个疾病引起主流社会的关注。电视节目“20/20”介绍了关于她的书，节目播出以后收到了25万个父母的电话，他们担心自己的孩子有这个疾病。拉波特说，其中相当数量父母的担心是正确的。她估计，在美国超过一百万儿童患有强迫症。事实上，她认为，这种疾病往往开始于童年时代，这就是为什么医生面对强迫症患者应该追溯到他的童年。一半的成年强迫症.患者，回过头来看，他们通常记得儿童时候有重复的念头和仪式，其百分比显著高于其他的成年人精神疾病。

The most vocal voice in support of Pandas is Susan E. Swedo, a pediatrician and researcher at the National Institute of Mental Health. She was the first to identify the syndrome, and the one who gave it a name. She has been studying the relationship between strep and O.C.D. for her entire career.

She began her work in the 80's, a time of discovery in the world of obsessive-compulsive disorder. Although the disease had long been known, it was not until 20 years ago that researchers began to understand how prevalent it was and not until a decade later that they came to see how often it occurred in children.

In 1989, Rapoport published her best-selling book, taking the illness into the mainstream spotlight. When the television program ''20/20'' ran a segment about her book, it prompted 250,000 calls from worried parents who thought they recognized their children. And a good number of them, Rapoport says, were right. She estimates that more than one million children in the United States suffer from O.C.D. In fact, she argues, the disorder is one that often begins in childhood, which is why doctors should start looking for it then. Half of all adult O.C.D. patients look back and remember having repetitive thoughts and rituals when they were young, which is significantly higher than the percentage of adults with other psychiatric disorders who do.

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拉波特强烈怀疑，至少有一些强迫症患者有一个医学模式- - 他们的症状不是感情创伤的结果（弗洛伊德认为，它是由于儿童失宠与过于严格的厕所训练造成），而是由生物原因触发引起的。她和她在N.I.M.H.的研究员花了几年时间来寻找原因。儿科医生苏珊是这些研究员之一。

研究已经证明，O.C.D.（强迫症）症状出现的时候实际有基底节损害，基底节是一个大脑中的神经元集群，功能是控制运动，思想和情感的行为。苏珊说 “因此，我们开始寻找每一个与基底节异常有关的已知条件”。

Rapoport strongly suspected that there was a medical model for at least some percentage of O.C.D. sufferers -- that the symptoms were not a result of emotional trauma (Freud's belief that it is caused by overly strict toilet training had long since fallen out of favor) but rather were caused by a biological trigger. She and her research fellows at the N.I.M.H. spent several years looking into it. Swedo was one of those fellows.

Research had already shown that O.C.D. symptoms appear when there is damage to the basal ganglia, which is a cluster of neurons in the brain that acts as a gatekeeper for movement, thought and emotion. ''So we set out to find every known condition that involved abnormalities of the basal ganglia,'' Swedo remembers.

hust_mrzhou

可以发到我邮箱吗（原文），我可以试着翻译一下！

hust_mrzhou

hust_mrzhou@163.com

pengxc

亨廷顿氏病是其中之一。帕金森氏症也是一个。另外还有西德纳姆氏舞蹈病，这是 一个中世纪前医生就知道的运动障碍，它被称为Saint Vitus舞蹈。患有舞蹈症的患者约70％会发展成为强迫症，西德纳姆舞蹈症是由风湿热引起的，而风湿热是由A组乙型溶血性链球菌所致，换句话说，是由链球菌咽喉炎引起。

当你的身体认为在与链球菌感染做斗争时，从链球菌到西德纳姆舞蹈症的生物连锁反应就开始了，实际你启动了攻击自身的一个过程，称为分子模仿。那些包裹入侵细菌的蛋白鞘与身体的特定部分的原生细胞表面的蛋白是如此相似。在这种情况下，链球菌细菌蛋白质的代码与基底神经节细胞的代码非常接近。因此你的抗体错误地把基底节当成链球菌来攻击。 当然，这个过程不会发生于每个有咽喉炎的孩子，甚至大多数孩子都不会，同样道理，并不是每个链球菌感染的孩子都有风湿热。 “显然，这是错误的细菌在错误的时间发生于错误的孩子。” 苏珊说。她怀疑有些孩子是因为基因的偏差倾向于患强迫症。

Huntington's disease was one. Parkinson's was another. Also on the list was Sydenham's chorea -- a movement disorder known to medicine since before the Middle Ages, when it was called Saint Vitus' dance. About 70 percent of patients who develop Sydenham's also develop O.C.D. Sydenham's is caused by rheumatic fever; rheumatic fever is in turn caused by Group A beta-hemolytic streptococcal bacteria. In other words, strep throat.

The biological cascade from strep to Sydenham's starts when the body, thinking it is fighting the infection, begins to fight itself in a process known as molecular mimicry. The protein sheath that coats each invading bacterium cell is remarkably similar to the one that coats the native cells that form a particular part of the body. In this case, the protein code on the strep bacteria is a close match with the code on the cells in the basal ganglia. So the antibodies mistake the basal ganglia for strep and attack. This, of course, will not happen to every child who has strep throat, or even to most children, in the same way that every child who gets strep does not get rheumatic fever. ''It's the wrong germ in the wrong child at the wrong time,'' says Swedo, who suspects that some children are genetically predisposed toward Pandas.

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到90年代中期，苏珊已经毕业国家精神卫生研究所的实验室。当时她的研究状况是这样：她知道强迫症可以通过基底节损害来导致。西德纳姆舞蹈症也是这种损害的结果。没有疑问，链球菌是西德纳姆舞蹈症患者损害的根本原因。而西德纳姆舞蹈症的患者往往发展为O.C.D.（强迫症）。鉴于所有这一切，下一个合乎逻辑的问题似乎是显而易见：链球菌会引起强迫症吗？

苏珊把她的注意力重新转到一个亚组的患者，即那些发生强迫症症状似乎在一夜之间的病人。她和她的团队推测，这种在发病模式上的差异可能是一个重要的关键去揭开一个单独类别强迫症的原因。它可能无法解码所有OCD（强迫症）的病因，但它可能解释一定百分比的病例。

苏珊和她的研究人员开始征募那些突然发病的强迫症儿童。他们做了大量工作，然后确定了109名儿童，他们可以准确地描述急骤起病的时间。患儿的家长说，他们孩子病情细节虽然不同，但是病情的核心均极类似。他们的症状来得如此迅速，大部分家长可以告诉你，他们孩子性格改变的确切日期。用一位家长的话说，所有这些儿童一觉醒来，已经是物是人非。

By the mid-90's, Swedo had graduated to her own research laboratory at the National Institute of Mental Health. Back then the status of her research looked like this: O.C.D., she knew, could be caused by damage to the basal ganglia. Sydenham's, too, was a result of such damage. Strep, by all accounts, was the cause of the damage in Sydenham's patients. Sydenham's patients often developed O.C.D. Given all that, the next logical question seemed obvious: Can strep cause O.C.D.?

Swedo turned her attention anew to that subgroup of patients who developed their symptoms seemingly overnight. She and her collaborators hypothesized that this difference in onset could be the key to something important, a separate category, a differentiating wrinkle in a familiar pattern. It might not be the key to decoding the cause of all O.C.D., but it might explain some percentage of cases.

Swedo and her researchers put out a request among those who treat and suffer from O.C.D., looking for subjects -- children whose symptoms had come on suddenly. They received hundreds of calls and then determined that 109 of those children could accurately be described as having had a rapid onset of symptoms. The stories the parents told, while different in their particulars, were remarkably similar at their core. The symptoms came on so quickly that most parents could tell you the exact date that their children's personalities changed. All these children woke up one morning, in the words of one parent, ''full-blown somebody else.''

hust_mrzhou

英语才过4级，很烂的啦！呵呵，别见效啊，尽一份绵薄之力！

hust_mrzhou

有些人属于上一节提到的那一簇候症群，然而，另外一部分症状也会相继出现。将近一半的人抱怨，不仅仅是因为关节痛与喉咙发炎这些症状。他们烦躁，情绪化与固执。他们还有一些他们所谓的坏念头，比如：性，暴力，和一些令人恐惧的念头。这些东西令他们窒息，但无法摆脱。

孩子们经过检查表明他们最近被链状球菌所感染——可能是通过他们的嗓子获得直接的感染源，或者是通过一组“测量感染之后血液中残留下来的抗体”来检测，再或者是以前用上面任意一种测试有过感染，但至今已经过去很长时间的病例，研究人员试图从他们身体里面找出以前感染的特征。能检测出感染链球菌的患者占有相当高的比例。

分歧是推动科学的动力，证明与否定是走上共识的必经历程。哥白尼的理论，行星绕太阳公转，直到他死很久以后才被完全接受。毕达哥拉斯和亚里士多德都认为世界是圆的，但这种想法历时多个世纪没有被广泛接受。伊格纳兹·塞梅尔魏斯博士被嘲笑和排斥的仅仅是“通过简单的洗手，医生可以防止妇女在分娩期间死亡”这一如今看来再科学不过的建议。这一建议是在路易斯巴斯德和约瑟·证实“破坏细菌阻止疾病的传播”这一结论得出之前25年就提出了。最近更多的时候，医生进行的脑部手术似乎可以有效的阻止帕金森病的恶化，骨髓移植似乎能治疗乳腺癌。但进一步研究发现初始数据过于乐观让以前令人兴奋的理论变得黯淡了。或许最重要的是多年以来通过对熊猫的研究，链球菌已被提出是多种疾病的病因之一，包括川崎病，但随后的研究否定了这一理论。



The exact nature of the obsessions and compulsions differed from child to child (a fact that makes all O.C.D. tricky to diagnose). Some could not stop washing their hands or insisting they needed to use the toilet or checking to make sure that doors were closed and locked. Some developed overwhelming separation anxiety or worried that they would harm someone or do something wrong.



Some had one cluster of these symptoms during their first episode and a different set of symptoms the next time around. Nearly half complained of joint pain, but not always of a sore throat. They were fidgety and moody and obstinate. They had ''bad thoughts,'' some sexual, some violent, some frightening, that they could not get out of their heads.



The children were then tested for evidence that they had recently had strep -- either via throat culture, which would find active infection, or by a blood test that measures antibodies remaining after the actual infection is gone, or, when the episode was too long ago for either test to be effective, researchers asked about a remembered history of strep. In a striking percentage of cases, the search for strep came up positive.

Disagreement is what propels all of science. Proof and disproof seems almost a requirement on the road to consensus. Copernicus's theory that the planets revolve around the sun was not fully accepted until long after his death. Pythagoras and Aristotle each suggested that the world was round, but the idea was not widely accepted for many centuries. Dr. Ignaz Semmelweis was mocked and ostracized for suggesting that by simply washing their hands, doctors could prevent women from dying during childbirth. It would be another quarter-century before Louis Pasteur and Joseph Lister confirmed that destroying germs stops the spread of disease. Much more recently, doctors were exuberant when brain surgery seemed to halt the progression of Parkinson's disease and bone-marrow transplants seemed to beat back breast cancer. But the excitement dimmed as further study found the initial data to be overly optimistic. Perhaps most significant to the discussion of Pandas, strep has been proposed as the cause of a number of conditions over the years, including Kawaski disease, but subsequent studies have repudiated the theories.

hust_mrzhou

13# hust_mrzhou 小孩们之间都有明显的千差万别的强迫思维与强迫动作（这是一个事实，让所有的ocd很难去确诊）。一些患者不能停止洗手或者是坚持长时间的洗浴或者不停的检查以确保门关上和锁好了。一些发展成完全的分离性焦虑或者是担心伤害别人和做出一些出格的事情。