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1、Human Behavior in Health and Illness 健康和疾病中的人类行为 Human Behavior in Health and Illness精神分析精神分析认知行为学习认知行为学习神经认知神经认知应激反应应激反应神经生物学神经生物学行为行为目目 标标学习理解人的正常与异常行为有关的生物、行为、认知、心理学的原理、过程理解行为、认知、思维、心境的异常如何可能源于这些过程的变异，引发精神疾病理解这些过程如何有可能被用于治疗异常的情绪状态，减少心理疾病的负担 Todays Outline今日的概要临床相关案例的讨论Case 1案件1史先生，45岁，餐厅老板，妻子怀疑其有
2、药物滥用问题，由妻子陪同作常规医学检查-妻子疑其使用可卡因，但他否认-当家人问其药物使用问题时，他发怒-医生单独和他谈话，他承认使用可卡因，但不多-他说用可卡因是为了逃避，获得快感，用药后有强烈的愉快感，感到不可思议的力量感-他说他一天里常想可卡因，想怎样抽空出去用它，感到有些苦恼-他承认过去一个月由于使用可卡因，他有几天耽误了工作，脾气变坏，还与妻子发生口角Case 1。史密斯一个45岁餐馆老板，访问他的医生为他做了一个例行体检，伴随着他的妻子怀疑他有一个“毒品问题”，认为他可能有那种授权进一步评价的精神障碍?Case 1Accordingtocurrentpsychiatricnosolo
3、gy(classificationofdisease),whatsuggeststhathemayhaveapsychiatricdisorderthatwarrantsfurtherevaluation?据据当前精神病学的疾病分类学(疾病的分类)，认为他可能有那种授权进一步评价的精神障碍-Hiswifesuspectsthathemayhavebeenusingcocaine,buthehasdeniedittoherandfamilymemberswhohaveinquired他的妻子怀疑他可能已经使用可卡因，但他在妻子和调查的家庭成员面前否认了-Hegetsannoyedwhenaske
4、dabouthisdruguse.当询问他的吸毒时他很生气-Whenalone,Mr.Smithadmitstousingcocaine,“butnotmuchatall”.当医生单独和他谈话时史密斯承认使用可卡因，“但不多”。-Mr.Smithsaysheusescocaine“forescape”andto“gethigh”andendorsesanintenseeuphoriaonitandfeelsan“incrediblesenseofpower”。史密斯说他用可卡因“为了逃避”，“获得快感”，感觉它有一有激烈欣快感，感觉一个“难以置信力量感”-Hesayshethinksabout
5、cocainemuchofthedayandhowhewillbeabletogettimeawaytouseit;hefeelsthatthiscausesquiteabitofdistress他说他一天中很多时候惦记着可卡因及如何能够得到时间去使用它;他觉得这引起相当大的痛苦-Headmitsthathisuseofcocainehasmadehimmissworkseveraldaysthispastmonth,andthathistemperhasgottenworseleadingtoverbalfightswithhiswife他承认自己用过可卡因使他耽误了几天工作，这过去一个月,
6、他的脾气变得更糟,而导致了打他的妻子并和妻子发生了口角。Case 1(contd)案件1Uponfurtherinquiry,Mr.Smithadmitstousingcocaineonaregularbasis(4-5timesperweek),and经过进一步的调查,史密斯先生决定定期有规律使用可卡因(每周45次),-Besideseuphoria,hehasalsohadperceptualdisturbancesduringacutecocaineintoxication(除了人兴奋,他曾在可卡因急性中毒时有感知失调）Whatsymptomswouldconstitutepsychos
7、is?Why?精神病会有什么症状?为什么?What neurotransmitter is likely responsible for these perceptualdisturbances?Inwhichtract/pathwayisthisneurotransmitterexertingitseffects?是什么神经递质可能导致感知失调?在这神经递质域/途径发挥什么作用?Case 1(contd)Whatsymptomswouldconstitutepsychosis?Why?什么症状将构成精神病?为什么?-Auditoryhallucinations(hearingvoicesin
8、sidehisheadwhenalone)幻听(当独自一人时在他脑子里听到声音）-Impaired reality testing sensory perception in the Paranoiddelusions(thinkingthathisco-workersarespyingonhimdespitenoevidencetosupportsuchsuspicions)absence of true input(hallucination)and fixed,inflexible false belief(delusion)现实感知受损测试-偏执妄想(认为他的同事们监视他,尽管没有证据
9、能支持这种怀疑)缺乏真正的输入(幻觉)和固定,呆板的错误信念(幻觉)Whatneurotransmitterislikelyresponsiblefortheseperceptualdisturbances?Inwhichtract/pathwayisthisneurotransmitterexertingitseffects?什么神经递质可能负责这些知觉的的骚乱?，什么管道/通路是这个神经递质施加它的影响?-Dopamine-Mesolimbicand/ormesocorticaltract(VTAtolimbicventralstriatum,amygdalaand/orfrontalco
10、rtex,respectively)-多巴胺-Mesolimbic和/或mesocortical区域,到边缘VTA神经元,杏仁核前部纹状体和/或额叶皮质,分别)Case 1(contd)Upon further inquiry about job dysfunction at work and interpersonalconflictsathomeandregularuseoverthepastfewyears,Mr.Smithdoesntbelievethathehasaproblemwithhiscocaineuse,sayshecan quit at any time.He says
11、that the cocaine has“helped meconcentrate”andthathisperformanceisenhancedbycocainehehasreadthatusingcocaineislike“drinkingalotofcoffee”.Mr.Smithinformsthedoctorthathiswifehasbeencryingregularly,isdepressedanddistraughtabouthisspiralinguse,theirdeterioratingmarriage,andherfearofpotentialviolencewhenh
12、eisintoxicated.Whenhearingthis,heappearsindifferent,andemotionallynon-expressive.经过进一步的对就业障碍和家庭人际冲突调查工作和经常使用。过去几年来史密斯先生不相信他有问题，问他吸上了可卡因,说他能在任何时候辞职。他表示,“可卡因帮助我集中精力”,他的表现就有所提高了是由于使用了可卡因他已经读了使用可卡因就像“喝很多咖啡。”史密斯先生告诉医生当他使用可卡因事他的妻子哭了,感到沮丧和悲痛欲绝,他们的婚姻不断恶化,当他陶醉使用可卡因时,她担心潜在的暴力。当听到这个消息,他显得冷漠,而且情绪没有改变。Whatdefens
13、emechanismsarebeingexhibitedbyMr.Smith?Aretheyconsideredmaturedefenses?史密斯先生表现出的什么防御机制?他们被认为是成熟的防御吗?Case 1(contd)WhatdefensemechanismsarebeingexhibitedbyMr.Smith?Aretheyconsideredmaturedefenses?什么防御机制被展现?他们是成熟防卫吗?DenialRefusaltoperceivetheharshaspectsofrealityRationalizationConstructionofalogicalexp
14、lanationforadecisionthatwasderivedviaanothermentalprocessIntellectualization/IsolationofAffectDistancingoneselffromthenegativeemotionsevoked对严酷的现实观点否定拒绝建设的合理化-逻辑性的解释是一个决定,通过另一个心理过程,推导出了智能化/隔离自己的影响-使自己远离负面情绪Alltheabovearenotconsideredasmature.所有以上不考虑是成熟的Levelsofdefenses:防御的水平:I.Psychotic:denial,fanta
15、sy,hallucinations精神病的:拒绝，幻想，幻觉II.Immature:splitting,regression,dissociation,idealization,actingout未成熟的:分裂，回归，离解，理想化，表演III.Neurotic:displacement,intellectualization/isolationofaffect,rationalization,repression,undoing,reactionformation神经质的:移位，理智化/隔离的影响，合理化，压迫，复原，反向形成IV.Mature:humor,suppression,antici
16、pation,sublimation,altruism成熟:幽默，抑制，预期，升华，利他主义Case 1(contd)How would you describe a Freudian structural model of Mr.Smithsbehaviors?如何将你描述一个弗洛伊德先生的结构模型。史密斯的行为?Id:Cocaineuseforpleasureservesastheselfish,primitive,childish,pleasure-orientedpartofthepersonalitywithnoabilitytodelaygratification Superego
17、:Attimesfeelsandknowsthathiscocaineuseis“bad”/”wrong”basedoninternalizedsocietalandparentalstandardsEgo:themoderatorbetweentheidandsuperegowhichseekscompromisestopacifybot可卡因用为了取乐作为自私，原始，幼稚，pleasure-oriented部分个性同没有的能力延迟满足超我:有时感觉，知道那个他的可卡因用“坏”/”错”以内化为依据社会的，父母的标准自我:中古英语h.Defensemechanismsservewhichoft
18、heabove?Whichoftheabovearebelievedtobeprimarilyunconscious?防御机制,上述服务吗?以上的被认为是主要的无意识?EgoIdCase 1(contd)Uponfurtherinquiry,Mr.Smithsaysthathehadtriedtoquitcocaineuse,but has continued to relapse.He finds himself craving(intensifiedwanting)whenhedrivesintotheparkingstructureatworkbecauseheoftensnortsco
19、cainethere,orwhenhesitsdownatthisdeskbecausethereisavialofcocaineinhisdeskdrawer,orwhenherunsintohisofficemateJoe(whooftenjoinshimintheparkingstructuretousecocaine)经过进一步的调查,史密斯先生说他曾试图放弃古柯碱的使用,但不断的复发。他发现自己渴望(增强)：当他开车到工作点的停车厂时,因为他经常在那里吸食可卡因;当他坐在这张桌子时,因为那里有一只碗的可卡因在他的书桌的抽屉里,或者当他到他的办公室伙伴乔那时(经常和他在停车厂使用可卡因
20、)Accordingtobehavioraltheory,hiscravingassociatedwiththevisualcuesisknownaswhatprocess?根据行为理论,他渴望与之关联的视觉线索称为什么过程?Classicalconditioning(associativelearning):US:CS:UR:PairingUS+CSleadstolearningSubsequentCS(eventwithUS)evokesanticipationandcraving随后(与我们)CS事件唤起期望和渴求.cocaineparkingstructure,desk,Joeeuph
21、oriafromcocaineintoxication古柯碱中毒兴奋Case 1(contd)Mr.Smithisconsideringenteringpsychodynamicpsychotherapytouncoverhispastexperiencesinordertogaininsightintohiscurrentbehaviors(self-destructive drug use)and defense mechanisms in order toeradicatehis“falseself”andaccepthis“trueself.”史密斯先生正在考虑进入精神动力疗法来掀开他
22、过去的经历,以洞察他目前的行为(自我毁灭的用药)和防御机制以消除他的“假我”与接受他的“真实的自我。”Whatarethemajorfociofthistypeoftherapy?有什么主要的局灶性这种类型的治疗吗?Case 1(contd)Whatarethemajorfociofpsychodynamicpsychotherapy?有什么主要的局灶性精神动力疗法吗?Uncoverandlearnaboutunconsciousmechanisms(freeassociation,behavior,relationship,mistakes)揭示和了解无意识机制(自由联想、行为、人际关系、错
23、误）Workontransferenceandcountertransference转变和反向移情的研究Example?Workonresistance/ambivalencetochange阻碍和矛盾引起改变的研究Example?Case 1(contd)Example of transference:Mr.Smith grew up in an authoritarianhouseholdwithstrictrulesandpunishmentimposeduponhimbyhisfather.Intherapy,herelateshispastrelationshipwithhisfat
24、herwithhiscurrent relationship with his male therapist.At the initial stages oftherapy,he accuses the therapist:“You are being too tough onmewhat do you expect from me?Are you getting upset that Icontinuetousecocainedespiteourtreament?”Exampleofcountertransference:Thetherapist,Dr.Jones,istheoldestof
25、4sons,andhadbeentheprimarycaretakertakerofhisyoungerbrotherswhohavehadexhibiteddefianceandoppositionto“brotherly”guidance.Intherapy,hegetsupsetwithMr.Smithbecauseheisnotcompliantwithtreatmentrecommendations.Example of resistance:Mr.Smith begins to miss or comes lateappointmentsoncehiscocaineusebecom
26、eslessfrequentandmoreundercontrol迁移实例：史密斯先生成长在一个严格的规章制度和父亲独裁的家庭中。在治疗中,他把过去与他的父亲的关系转移到他与治疗师的关系。在初始阶段的治疗,他指责治疗师:“你过于严厉了你期望从我这里得到什么?尽管我们在治疗中我将继续使用可卡因，这样你会很心烦吗?”反向移情实例：治疗师,琼斯博士是4个儿子中最大的,已经主要看守他的弟弟调查员有展出,反对“兄弟蔑视”指导。在治疗中,他就会心烦意乱,因为他不赞成史密斯先生治疗建议。抵抗实例:当他吸可卡因变得更少更规律且更在控制之下时，史密斯先生开始想念、抵制、迟来。Case 1(contd)Mr.Sm
27、ith is considering entering cognitive behavioral psychotherapy touncoverhispastexperiencesinordermodifyhisrecurrentdruguse.。史密斯先生正在考虑进入认知行为疗法来掀开他过去的经历以便于他反复修改用药。Whatarethemajorfociofthistypeoftherapy?主要焦点的这种治疗的类型是什么?Mr.Smithisconsideringenteringcognitivebehavioralpsychotherapytouncoverhispastexperie
28、ncesinordermodifyhisrecurrentdruguse.Case 1(contd)What are the major foci of cognitive behavioral therapy and/or sociallearningtherapy?什么是主要关键的认知行为治疗或社会学习疗法?Identifycue-inducedcravingpatterns模式识别cue-induced渴望Establishoperantconditioning(instrumentallearning)treatment建立操作条件反射(工具性学习)治疗Modifyattributio
29、noflocusofcontrol(fromcocainebacktoself)修改轨迹控制的归因(从可卡因后面的对自我)Correctdistortedthinking/beliefsaboutself,others,world关于自己、他人、世界的正确或错误的认识/信仰.。Establish group treatment with sponsors(Narcotics Anonymous)inwhich behavior is modified by observation of a role model(e.g.,sponsor)andthroughenhancingself-effi
30、cacy对赞助者进行团体治疗(麻醉治疗匿名)在这个治疗中行为被标准模式观察监测（赞助者)和通过强化自我效能感。Case 1(contd)In an operant conditioning-based type therapy,Mr.Smith engages incontingency/token treatment,in which he receives a token(to beexchangedfortangiblegoods/rewards)foreachcleanurinesampleheprovides to the clinic on random checks.在一个操作性
31、conditioning-based类型治疗中，史密斯从事应变/象征性的的治疗，他收到一个象征暗示(被交换有形货物/报酬)为每个清洁尿样他提供随机的诊所支票。Thisisanexampleofwhattypeofreinforcement?这是一个典型的信息加强的类型?What would be the optimal reinforcement schedule to maintainabstinencefromcocaineuse?什么是较佳强化程序去在可卡因利用中保持节制?Case 1(contd)In an operant conditioning-based type therapy
32、,Mr.Smith engages incontingency/tokentreatment,在一个操作性conditioning-based类型治疗，。史密斯从事应变/象征性的的治疗。Thisisanexampleofwhattypeofreinforcement?这是一个典型的信息加强的类型?Positivereinforcement(tokens/reward)topromoteabstinence.Whatwouldbetheoptimalreinforcementscheduletomaintainabstinencefromcocaineuse?什么是较佳强化程序去在可卡因利用中保
33、持节制?Variabletokenamountandvariableintervalsofurinedrugscreens,whichwouldresultinslowerlearning,butslowerextinction尿液药物变化的数量和变量区间变量将会引起学习,但是执行速度较慢消失。Case 2Mr.Bonine is a 44-year-old,single,unemployed,man is brought to theemergency room by the police for striking an elderly woman in hisapartmentbuildi
34、ng.。博尼恩一个44岁，单身，失业的男性，因为在他的公寓大楼打一个老年女子被警察送到苏醒急诊室。-Lastyearhesufferedatraumaticbraininjuryfollowinghead-onmotorvehiclecollisioninwhichhisheadhitthiswindshielduponcontact.去年他被迎面的的马达车辆碰撞，他的头击中这个挡风玻璃，得了创伤性脑损伤。Whattypeofcognitiveandemotionalsymptomswouldyouexpect?你认为将有什么认知的的类型，情绪化的症状?Suchinjuriesaresimil
35、artowhattypeofneuropsychiatricdisorders?这样外伤类似于什么神经精神系统的紊乱类型?Cognitive,Emotional,and Behavioral Changes following Frontal Lobe Injury认知的，情绪化，行为的变动遵循额叶受伤认知的，情绪化，行为的变动遵循额叶受伤Impulsiveness(actingbeforethinking)冲动性(做在想之前）Disinhibition(lackofself-control)去抑制(缺乏自我控制)Inappropriatesexualactivity不当性行为Apathy/P
36、oorinitiation(troublegettingstarted)冷漠/贫乏的动机(困难开始出现)Frustrationandlossoftemper挫折和发脾气Poorinsight(lackofself-awarenessofchanges)眼光差(缺乏自我意识的变化）Emotionalproblems:depression,anxiety,irritability,anger,moodswings情绪化问题:失望，焦虑，易怒，愤怒，情绪波动Changes in Frontal Lobe Disorders变动在额叶紊乱变动在额叶紊乱DorsolateralPrefrontalCor
37、texDysexecutiveSyndrome(unabletoplanorchangeplansflexibly,perseveration,unabletoshiftbehavior)背侧前额叶皮层-dysexecutive综合症(无法对计划或灵活变动计划，持续言语，无法对转换行为)OrbitofrontalCortexDisinhibitedSyndrome(impulsive,labileaffect,poorjudgment)眶额皮层-disinhibited综合症(浮躁，不稳定的影响，判断力差)MedialFrontalCortexApatheticSyndrome(apathet
38、ic,behaviorallyinert,poorspontaneity)中间的额叶皮质-麻木不仁综合症(麻木不仁，惰性的行为活动，自发性差)Personality Changes in Frontal Lobe Disorders人格改变在额叶紊乱Headinjuries(TraumaticBrainInjury)头部受伤(创伤性脑损伤)FrontotemporalDementia(PicksDisease,额颞痴呆(皮克症）FrontotemporalLobarDegeneration)AnteriorStroke(CerebralVascularAccidentfromanteriorp
39、ortionofmiddlecerebralarteries)前面的的行程(前中的一部分脑动脉脑血管意外)Case 2(contd)44-year-oldmalewithtraumaticbraininjuryfollowinghead-onmotorvehiclecollision一个44岁男性被迎面的的马达车辆碰撞而患创伤性脑损伤What neuropsychological tests could you administer to examine hisexecutivefunction?什么神经心理的测试可以有助于检查他的执行功能?Thefunctionofwhichareasoft
40、hebrainareprobedwiththesetests?哪一个脑的地区功能，被探测同这些测试有关?Case 2(contd)44-year-oldmalewithtraumaticbraininjuryfollowinghead-onmotorvehiclecollisionWhat neuropsychological tests could you administer to examine hisexecutivefunction?Thefunctionofwhichareasofthebrainareprobedwiththesetests?WisconsinCardSortTe
41、st,TrailMakingPartB,N-BackTestsDorsolateralPrefrontalCortexintermsofcognitiveflexibility(goal-directedbehavior,planning),workingmemoryStroopTaskTestsAnteriorCingulateCortexintermsofselectiveattention威斯康辛卡片分类测试,连线N-Back-B部分背外侧前额叶皮层测试方面的认知灵活性(目标导向行为、规划),工作记忆Stroop任务测试前扣带皮质选择性注意力方面Go-NoGoTaskTestsAnter
42、iorCingulateandPrefrontalcortexforimpulsecontrol测试前扣带，前额叶皮层控制脉冲DecisionMaking(ondailytasksofjudgment;finances)Tests Orbitofrontal/Ventromedial Prefrontal Cortex for decisionmaking决策(每日的判决任务表;金融)测试orbitofrontal/腹前额叶皮层控制决策Tounderstandthementalprocessinvolvedtrythisexperiment.Lookatthefollowingletterso
43、nthescreen:tree.Ifyouarelikemostpeopleitisdifficultforyounottoquicklyreadtheword“tree.”Mosthumansaresoproficientatreadingprintedwordsthattheycannoteasilyignorethem.Infactittakesconsiderableattentionalefforttoignorethem.ThistendencytoquicklyreadawordisusedintheStroopTask理解心理过程涉及尝试这个试验。观看下面屏幕上的词:树。如果你
44、像大多数人一样那对于你来说，很快读出“树”不是很困难的。“大多数人在阅读打印方面如此熟练，所以他们不易忽视他们。实际上，要花费相当的精力去忽略它们。在Stroop任务中这种很快读出单词的趋势被运用。TheStroopTaskisapsychologicaltestofourmental(attentional)vitalityandflexibility.Thetasktakesadvantageofourabilitytoreadwordsmorequicklyandautomaticallythanwecannamecolors.Ifawordisprintedordisplayedina
45、colordifferentfromthecoloritactuallynames;forexample,iftheword“green”iswritteninblueink(asshowninthefiguretotheleft)wewillsaytheword“green”morereadilythanwecannamethecolorinwhichitisdisplayed,whichinthiscaseis“blue.”stroop任务一个我们的精神活力和灵活性的心理测试(attentional)。任务利用我们的能力去比在我们能命名的颜色下更快自动读出单词活力和灵活性。如果一个字在一个
46、颜色异于它其实名称的颜色下被打印或显示;如果字“绿色”被写在蓝墨水(如左边图所示)我们会读出“绿色”比在我们更容易能命名的填色显示下在这种情况下是“蓝色”。Thecognitivemechanisminvolvedinthistaskiscalleddirectedattention,youhavetomanageyourattention,inhibitorstoponeresponseinordertosayordosomethingelse.Althoughthefunctionsoftheanterior cingulateareverycomplex,broadlyspeakingi
47、tactsasaconduitbetweenlower,somewhatmoreimpulse-drivenbrainregionsandhigher,somewhatmorethought-drivenbehaviors.TheStroopeffectssensitivitytochangesinbrainfunctionmayberelatedtoitsassociationwiththeanterior cingulate参与这任务的认知机制被叫做直接关注，你必须掌控你的注意力，为了了说或做其他事情而抑制或停止一种反应。尽管功能的前扣带高度的复杂，广义地说它在降低之间，或更多impuls
48、e-driven脑地区，或更高部位充当一个通道，有些更多思想驱动行为。stroop效应的敏感性在大脑功能变动可能同前扣带协同有关。TheStroopTestprovidesinsightintocognitiveeffectsthatareexperiencedasaresultofattentionalfatigue.stroop测验提供认知的洞察影响，那个被认为是attentional疲劳的结果。ForadiscussionofthecapacitytodirectattentionanditsfatigueseeKaplan,S.(1995).Therestorativebenefits
49、ofnature:Towardanintegrativeframework.Journal of Environmental Psychology,15,169-182andKaplan,S.(2001).Meditation,restorationandthemanagementofmentalfatigue.Environment and Behavior,33,Case 2(contd)44-year-oldmalewithtraumaticbraininjuryfollowinghead-onmotorvehiclecollision.Theaccidentalsocauseashea
50、ringinjurytotheleftinferiorfrontalgyrusofthefrontallobe(BrodmannArea44,45).44岁男性被迎面的的马达车辆碰撞至创伤性脑损伤。意外也导致左边的额下回额叶剪力性损伤(布罗德曼区44，45)。Howwouldhislanguagebedisturbed?如何干扰他的语言功能?Case 2(contd)44-year-oldmalewithtraumaticbraininjuryfollowinghead-onmotorvehiclecollision.Theaccidentalsocauseashearinginjurytot