抑郁癥人群的心境一致性認(rèn)知偏向*

何振宏 張丹丹 羅躍嘉

(深圳大學(xué)情緒與社會(huì)認(rèn)知科學(xué)研究所,深圳 518060)

抑郁癥是一種常見的復(fù)發(fā)性心境障礙(mood disorder),在臨床上又稱重度抑郁障礙(major depressive disorder,MDD)。在抑郁癥的諸多致病因素中,認(rèn)知因素特別是認(rèn)知偏向(對(duì)負(fù)性信息的過(guò)度關(guān)注)是抑郁癥狀產(chǎn)生、持續(xù)和發(fā)展的重要原因之一(Taylor & John,2004)。這種由于抑郁等心境障礙引起的對(duì)負(fù)性信息的過(guò)度關(guān)注被稱為心境一致性偏向(mood-congruent bias) (Delle-Vigne,Wang,Kornreich,Verbanck,& Campanella,2014)。Beck曾在其抑郁認(rèn)知模型中提出,認(rèn)知加工對(duì)心境一致性信息的偏好維持了抑郁的心境狀態(tài)(Beck,1967)。新近的抑郁認(rèn)知理論認(rèn)為抑郁癥狀是由心境一致性情緒加工偏向(Mood-congruent emotion processing bias)所引起(Beck,2008; Scher,Ingram,& Segal,2005)。這兩種理論提到的認(rèn)知加工偏向和情緒加工偏向其實(shí)是從認(rèn)知或情緒角度對(duì)抑郁癥人群心境一致性偏向的表述,為簡(jiǎn)化表述,統(tǒng)稱其為認(rèn)知偏向。Joormann等人認(rèn)為,認(rèn)知偏向可能會(huì)增加抑郁發(fā)作的易感性(vulnerability)(Joormann,Gilbert,& Gotlib,2010)。MDD病人由于注意和記憶的嚴(yán)重?fù)p害,其認(rèn)知偏向可能會(huì)妨礙言語(yǔ)信息傳遞的有效性(Everaert,Koster,&Derakshan,2012),甚至抵消治療干預(yù)的效果(Baert,Koster,& de Raedt,2011)。因此無(wú)論從理論還是臨床角度看來(lái),對(duì)抑郁癥認(rèn)知偏向進(jìn)行一個(gè)整體和深入的了解十分必要。

目前國(guó)外已有一些探討抑郁癥認(rèn)知偏向的綜述文獻(xiàn),但有的綜述并沒(méi)有將該認(rèn)知偏向當(dāng)作核心論述主題,如Mathews等人的綜述(Mathews &MacLeod,2005); 另一些綜述則引證單一,且多集中于腦成像學(xué)的證據(jù)(Roiser,Elliott,&Sahakian,2012)。類似地,國(guó)內(nèi)也有一篇依據(jù)Beck抑郁認(rèn)知模型對(duì)該認(rèn)知偏向腦成像研究的綜述(楊娟,張小崔,姚樹橋,2014)。然而,該認(rèn)知偏向還有來(lái)自其他領(lǐng)域(行為學(xué)和電生理學(xué))不容忽視的研究證據(jù),且目前國(guó)外對(duì)該認(rèn)知偏向的一些新的研究動(dòng)態(tài)值得我們關(guān)注,比如工作記憶偏向,而這是先前理論模型所不曾包含的。因此,在介紹該認(rèn)知偏向時(shí)我們更多從實(shí)證角度出發(fā),結(jié)合行為、電生理以及腦成像等多方面證據(jù)總結(jié)抑郁病人在認(rèn)知加工過(guò)程中的偏向特點(diǎn),在驗(yàn)證相關(guān)的理論模型的同時(shí),為臨床診斷提供抑郁癥認(rèn)知過(guò)程異常的有關(guān)生物指標(biāo)(biomarker)。我們從三個(gè)基本的認(rèn)知加工領(lǐng)域(知覺(jué)、注意和記憶)以及較高級(jí)的認(rèn)知領(lǐng)域(認(rèn)知解釋),對(duì)抑郁癥的認(rèn)知偏向相關(guān)研究進(jìn)行系統(tǒng)回顧,并進(jìn)一步總結(jié)了該認(rèn)知偏向的三個(gè)特點(diǎn)和相應(yīng)的腦機(jī)制,提出該領(lǐng)域研究有待回答的問(wèn)題和對(duì)未來(lái)研究的展望。

1 心境一致性知覺(jué)偏向

抑郁癥人群的知覺(jué)偏向表現(xiàn)為對(duì)負(fù)性刺激尤其是悲傷刺激有更好和更準(zhǔn)確的知覺(jué)加工,而對(duì)正性刺激則呈現(xiàn)相反模式。研究情緒知覺(jué)最常用的方法有面孔表情識(shí)別任務(wù)、面孔情緒強(qiáng)度判斷任務(wù)(intensity judgment tasks),以及測(cè)量前注意無(wú)意識(shí)加工的后掩蔽任務(wù)(backward masking)等。與正常人相比,抑郁病人對(duì)悲傷面孔有更長(zhǎng)的反應(yīng)時(shí),由于癥狀影響了他們對(duì)負(fù)性刺激的強(qiáng)度知覺(jué),因此病人更多地將中性面孔解讀為悲傷面孔,而將愉快面孔解讀為中性面孔(Bourke,Douglas,& Porter,2010; Elliott,Zahn,Deakin,& Anderson,2011; Gollan,Pane,McCloskey,& Coccaro,2008)。這種偏向悲傷情緒的面孔知覺(jué)甚至?xí)掷m(xù)到病癥的恢復(fù)期(Joormann & Gotlib,2007),增加了未來(lái)疾病復(fù)發(fā)的風(fēng)險(xiǎn)(Bouhuys,Geerts,& Gordijn,1999)。Delle等人總結(jié)了近年來(lái)抑郁癥情緒知覺(jué)研究發(fā)現(xiàn),病人對(duì)不愉快面孔有知覺(jué)偏向,并對(duì)憤怒面孔有過(guò)度反應(yīng)(Delle-Vigne et al.,2014)。而與此相應(yīng)的是,病人對(duì)快樂(lè)面孔的敏感度則降低：Jormann和 Gotlib讓被試識(shí)別不同強(qiáng)度的面孔情緒,發(fā)現(xiàn)抑郁病人要在情緒強(qiáng)度很高的情況下才能正確識(shí)別快樂(lè)面孔,而對(duì)于悲傷和憤怒面孔則不需要如此(Joormann & Gotlib,2006); Yoon等人則采用二擇一面孔情緒強(qiáng)度判斷任務(wù)發(fā)現(xiàn),抑郁病人很少將微快樂(lè)表情的情緒強(qiáng)度判斷為比中性表情更高(Yoon,Joormann,& Gotlib,2009)。

在事件相關(guān)電位(event-related potential,ERP)研究中,Dai和Feng采用情緒強(qiáng)度評(píng)價(jià)任務(wù)發(fā)現(xiàn),MDD病人對(duì)悲傷面孔有更大的P1和P2波幅,說(shuō)明病人更容易被負(fù)性情緒面孔所喚起(Dai & Feng,2012)。Yang等人的研究發(fā)現(xiàn),與積極靶刺激相比,當(dāng)消極靶刺激出現(xiàn)時(shí)病人右后腦區(qū)的 P1潛伏期縮短,反映了一個(gè)非常早期的情緒知覺(jué)偏向(Yang,Zhu,Wang,Wu,& Yao,2011)。此外,Chang等人發(fā)現(xiàn)抑郁病人與面部表情有關(guān)的早期視覺(jué)失匹負(fù)波(visual mismatch negativity,vMMN)下降,表明抑郁病人在對(duì)表情信息的前注意加工中存在功能障礙(Chang,Xu,Shi,Zhang,& Zhao,2010)。

研究者普遍認(rèn)為杏仁核涉及對(duì)情緒凸顯刺激(包括面孔)的無(wú)意識(shí)和快速檢測(cè)(Anderson & Phelps,2001; Morris,?hman,& Dolan,1998; Whalen et al.,1998),而抑郁癥患者對(duì)負(fù)性刺激的知覺(jué)偏向與杏仁核和腹內(nèi)側(cè)前額葉(ventromedial prefrontal cortex,VMPFC)的障礙有關(guān),這些腦區(qū)涉及自下而上的情緒加工(Ochsner et al.,2004; Phillips,Drevets,Rauch,& Lane,2003)。該障礙表現(xiàn)為杏仁核對(duì)負(fù)性信息過(guò)度激活,且與 VMPFC的連接性(connectivity)發(fā)生改變(Fales et al.,2008)。

綜上所述,大量行為學(xué)、電生理學(xué)研究均揭示了抑郁病人的心境一致性知覺(jué)偏向。該知覺(jué)偏向與杏仁核對(duì)負(fù)性情緒信息過(guò)度激活,以及杏仁核與VMPFC連接發(fā)生改變有關(guān)。

2 心境一致性注意偏向

研究情緒注意常用的任務(wù)包括負(fù)性情緒啟動(dòng)任務(wù)(negative affect priming task)、點(diǎn)探測(cè)任務(wù)(dot-probe task)、情緒詞Stroop任務(wù)和Oddball任務(wù)等。與正常人相比,抑郁病人對(duì)負(fù)性刺激注意增加,對(duì)正性刺激注意減少,病人會(huì)選擇與其心境一致的負(fù)性刺激進(jìn)行編碼,而過(guò)濾掉正性信息(Kellough,Beevers,Ellis,& Wells,2008; Peckham,McHugh,& Otto,2010)。在負(fù)性情緒啟動(dòng)任務(wù)中,抑郁病人表現(xiàn)出對(duì)悲傷面孔注意易化(attention facilitation)增加,即存在更強(qiáng)的情緒啟動(dòng)效應(yīng)(affective priming effect) (Dai & Feng,2011a),而注意抑制減少(Dai & Feng,2011a; Goeleven,De Raedt,Baert,& Koster,2006)。對(duì)于后者,Everaert等人認(rèn)為這是抑郁病人認(rèn)知控制受損的表現(xiàn)之一(Everaert et al.,2012)。此外,病人對(duì)負(fù)性刺激尤其是悲傷刺激的注意偏向甚至?xí)掷m(xù)到抑郁癥恢復(fù)期,表明抑郁病人對(duì)負(fù)性刺激的注意偏向是特質(zhì)性而不是狀態(tài)性的(Fritzsche et al.,2010)。值得一提的是,抑郁病人對(duì)負(fù)性刺激的注意偏向受到刺激呈現(xiàn)時(shí)長(zhǎng)調(diào)節(jié)。Zhong等人在點(diǎn)探測(cè)任務(wù)中設(shè)置了100 ms和500 ms兩種線索呈現(xiàn)時(shí)長(zhǎng),在100 ms條件下,抑郁病人傾向于把更多的注意分配到負(fù)性刺激上,但也有把少量注意分配到正性刺激上的趨勢(shì); 但在500 ms條件下,病人卻存在難以避免注意負(fù)性刺激的趨勢(shì),也就是說(shuō)刺激呈現(xiàn)時(shí)間越長(zhǎng),注意偏向就越有可能出現(xiàn)(Zhong,Zhu,Yi,Yao,& Atchley,2011)。因此,研究者認(rèn)為刺激呈現(xiàn)時(shí)間較長(zhǎng)的負(fù)性注意偏向并非是病人在負(fù)性刺激上分配了更多的注意資源,而是由于他們本身對(duì)負(fù)性刺激就存在注意解除困難(de Raedt &Koster,2010; Yoon et al.,2009)。

在ERP研究中,情緒詞Stroop任務(wù)研究發(fā)現(xiàn)負(fù)性情緒詞對(duì) MDD病人有更強(qiáng)的干擾效應(yīng),即對(duì)消極信息的注意抑制能力受損,體現(xiàn)為病人的N1波幅降低,頂葉的N450波幅升高(Dai & Feng,2011b)。一些研究者認(rèn)為：由于病人注意分心作用的增加,這種注意抑制能力的受損會(huì)使得早期認(rèn)知加工階段注意資源變少,表現(xiàn)為在執(zhí)行負(fù)性情感啟動(dòng)任務(wù)時(shí),負(fù)性刺激在病人身上誘發(fā)了更低P2波幅(Yao et al.,2010)。這些研究從ERP角度證明了先前行為學(xué)的結(jié)果,即抑郁病人對(duì)負(fù)性刺激的注意抑制減少,那么當(dāng)病人注意正性刺激時(shí),相關(guān)ERP結(jié)果又能提供哪些啟示呢？前面提及的情緒詞Stroop任務(wù)的ERP結(jié)果就發(fā)現(xiàn)正性刺激出現(xiàn)時(shí)病人的P1波幅降低,這意味著他們對(duì)積極刺激給予較少的注意資源(Dai & Feng,2011b)。在一項(xiàng) Oddball任務(wù)中,正性靶刺激在病人額區(qū)誘發(fā)出更大的P2成分,作者認(rèn)為此結(jié)果反映了病人早期階段的情緒加工偏差可能包含有對(duì)正性刺激的注意缺陷(Yang et al.,2011)。Zhong等人點(diǎn)探測(cè)實(shí)驗(yàn)的ERP結(jié)果也發(fā)現(xiàn)：當(dāng)正性-中性圖片的有效試次呈現(xiàn)時(shí),與無(wú)效試次相比,病人沒(méi)有像正常人那樣出現(xiàn)更大的 P1波,且正性-中性圖片的注意偏向分?jǐn)?shù)為負(fù)值(正常人則為正值),表明抑郁病人缺少對(duì)正性刺激的注意(Zhong et al.,2011)。此外,ERP研究還證明了行為學(xué)支持的注意解除困難效應(yīng)能持續(xù)到抑郁癥的恢復(fù)期,比如當(dāng)一個(gè)任務(wù)需要個(gè)體把注意從負(fù)性面孔中解除出來(lái)時(shí),與正常人相比抑郁癥恢復(fù)期個(gè)體反應(yīng)更慢,且 N450波幅降低,說(shuō)明抑郁癥的注意解除困難也是特質(zhì)性的(Vanderhasselt et al.,2012)。

腦成像研究發(fā)現(xiàn),與正常人相比抑郁癥病人右側(cè)腹外側(cè)前額葉(ventral lateral prefrontal cortex,VLPFC)、右側(cè)背外側(cè)前額葉(dorsal lateral prefrontal cortex,DLPFC)和右側(cè)頂上皮質(zhì)對(duì)負(fù)性刺激激活減少(Beevers,Clasen,Stice,& Schnyer,2010;Fales et al.,2008),這些區(qū)域的活動(dòng)減退可能是促成病人對(duì)負(fù)性刺激注意解除困難的原因(Disner,Beevers,Haigh,& Beck,2011)。當(dāng)正常人成功地抑制了對(duì)積極刺激的注意時(shí),他們的前扣帶回喙部(rostral anterior cingulate cortex,rACC)比抑郁病人有更大的激活; 相反的,當(dāng)抑郁病人成功地抑制了對(duì)消極刺激的注意時(shí),他們的相應(yīng)部位比正常人有更大激活(Elliott,Rubinsztein,Sahakian,&Dolan,2002; Eugène,Joormann,Cooney,Atlas,&Gotlib,2010; Mitterschiffthaler et al.,2008)。這說(shuō)明正常個(gè)體需要更多的認(rèn)知資源對(duì)積極刺激進(jìn)行注意解除,而抑郁個(gè)體則需要更多的認(rèn)知資源對(duì)消極刺激進(jìn)行注意解除(Disner et al.,2011)。在一個(gè)情緒線索任務(wù)中,當(dāng)要求被試的注意力從無(wú)關(guān)情緒線索轉(zhuǎn)移時(shí),癥狀越嚴(yán)重的病人其外側(cè)前額區(qū)與頂區(qū)激活越弱,而非情緒線索條件下則無(wú)此效應(yīng),說(shuō)明抑郁病人在對(duì)情緒信息進(jìn)行認(rèn)知控制的腦區(qū)上出現(xiàn)了加工障礙(Beevers et al.,2010)。已知 rACC與自我參照加工有關(guān)(Nejad,Fossati,&Lemogne,2013)。研究發(fā)現(xiàn)抑郁病人的rACC在負(fù)性自我參照加工中有所激活,且激活程度與癥狀的嚴(yán)重程度有顯著相關(guān)(Wagner et al.,2013)。事實(shí)上,抑郁病人的自我聚焦(self-focus),即對(duì)自我的內(nèi)部注意是增加的,反映了病人的自我注意偏向(Nejad et al.,2013)。Disner等人在其認(rèn)知模型中總結(jié)：抑郁個(gè)體在刺激選擇(與 DLPFC功能降低有關(guān))、對(duì)負(fù)性刺激的注意解除(與DLPFC和前扣帶回功能降低有關(guān))以及映射到其他潛在適應(yīng)性刺激的注視轉(zhuǎn)移(gaze shift) (與頂上皮層功能降低有關(guān))等認(rèn)知功能中缺乏效率(Disner et al.,2011)。

綜上所述,抑郁癥患者對(duì)負(fù)性刺激的注意偏向表現(xiàn)在對(duì)負(fù)性刺激注意增加且抑制減少,對(duì)正性刺激注意減少,以及對(duì)負(fù)性刺激的注意解除困難上,該偏向與額區(qū)、頂區(qū)以及前扣帶回功能異常有關(guān)。

3 心境一致性記憶偏向

抑郁癥患者以外顯長(zhǎng)時(shí)記憶偏向?yàn)闃?biāo)志性認(rèn)知偏向(Everaert et al.,2012)。它一方面表現(xiàn)為患者對(duì)負(fù)性信息有回憶偏向(Mathews & MacLeod,2005),且在回憶與自我相關(guān)的負(fù)性信息時(shí),這種偏向效應(yīng)表現(xiàn)得更強(qiáng)(Wisco,2009)。另一方面則表現(xiàn)為患者不具備正常人那樣的對(duì)積極事件的正性記憶偏向(Harmer et al.,2009)。然而除了外顯層面,負(fù)性記憶偏向在內(nèi)隱記憶層面也有表現(xiàn)。抑郁病人在檢測(cè)閾下呈現(xiàn)的負(fù)性詞時(shí)的速度比正常人更快(Phillips,Hine,& Thorsteinsson,2010),同時(shí)在曾有抑郁史(formerly depressed)個(gè)體中也出現(xiàn)了此種效應(yīng)(Romero,Sanchez,& Vazquez,2014)。元分析(meta-analysis)發(fā)現(xiàn),抑郁病人對(duì)負(fù)性信息存在內(nèi)隱回憶偏向,而正常人則對(duì)正性信息有內(nèi)隱回憶偏向; 病人在編碼自我相關(guān)信息時(shí),這種偏負(fù)性的內(nèi)隱回憶更加明顯(Gaddy & Ingram,2014)。抑郁癥的負(fù)性記憶偏向還存在于錯(cuò)誤記憶之中。研究發(fā)現(xiàn)病人在錯(cuò)誤記憶任務(wù)中比正常人更傾向于把負(fù)性情境下的新詞誤認(rèn)為是舊詞; 同樣,自我相關(guān)性因素在病人的錯(cuò)誤記憶偏向中占有重要位置(Wittekind et al.,2014)。

近年來(lái),抑郁癥患者的工作記憶成為心境一致認(rèn)知偏向研究的熱點(diǎn)。工作記憶是一個(gè)容量有限的系統(tǒng)(Baddeley,1996),它在情緒調(diào)節(jié)中維持與任務(wù)相關(guān)的情緒內(nèi)容而排除與任務(wù)不相關(guān)的情緒內(nèi)容,并且可以影響積極和消極情緒(Vanderhasselt et al.,2012)。然而,大量研究表明抑郁病人存在從工作記憶中消除無(wú)關(guān)負(fù)性想法或記憶的困難(Berman et al.,2011; Foland-Ross et al.,2013;Joormann & Gotlib,2008; Levens & Gotlib,2010;Yoon,LeMoult,& Joormann,2014)。作為認(rèn)知控制受損的又一大表現(xiàn),患者在工作記憶涉及轉(zhuǎn)移(shifting)和更新(updating)情緒及非情緒表征的過(guò)程中也存在異常(Lissnyder,Koster,& de Raedt,2012; Lo & Allen,2011)。這導(dǎo)致太多的負(fù)性信息在抑郁病人的工作記憶容量中沒(méi)有得到及時(shí)轉(zhuǎn)移和更新且一直堆積下去,使得病人沉浸在負(fù)性情緒內(nèi)容中并表現(xiàn)出對(duì)負(fù)性無(wú)關(guān)信息的提取增加,因而維持了抑郁心境(Yoon et al.,2014)。有意思的是,當(dāng)無(wú)關(guān)信息為正性時(shí),抑郁病人并不存在工作記憶解除困難,相反對(duì)它的解除比正常人更快(Levens & Gotlib,2010)。

腦成像研究發(fā)現(xiàn),當(dāng)編碼負(fù)性刺激時(shí),抑郁病人在右側(cè)杏仁核的激活上比正常人更大,且杏仁核與海馬及尾狀核-殼核的功能連接(functional connectivity)也更強(qiáng),病人右側(cè)杏仁核在編碼負(fù)性刺激時(shí)的活動(dòng)與同側(cè)海馬及尾狀核-殼核的活動(dòng)有更高的相關(guān)(Hamilton & Gotlib,2008)。Arnold等人采用彌散張量成像對(duì)恢復(fù)期抑郁病人進(jìn)行研究,也發(fā)現(xiàn)杏仁核與海馬、小腦、腦干的連接增強(qiáng),并認(rèn)為這可能導(dǎo)致情緒記憶偏向; 他們還發(fā)現(xiàn)這些病人內(nèi)側(cè)前額葉皮質(zhì)(medial prefrontal cortex,mPFC)的神經(jīng)元密度減少,可能反映了自上而下加工的減弱,即額區(qū)損傷弱化了對(duì)杏仁核的調(diào)節(jié),使得杏仁核向海馬等皮質(zhì)下區(qū)域的輸出失調(diào),因而間接誘發(fā)了負(fù)性記憶偏向(Arnold et al.,2012)。Arnold等人的另一個(gè)研究也說(shuō)明情緒性記憶偏向相關(guān)的神經(jīng)改變會(huì)持續(xù)到抑郁癥的恢復(fù)期(Arnold et al.,2011),因此這種神經(jīng)改變可能是抑郁復(fù)發(fā)的原因(Arnold et al.,2012)。Disner等人在其認(rèn)知模型中總結(jié)：抑郁癥的記憶偏向可能起因于編碼負(fù)性刺激時(shí)杏仁核活動(dòng)的增加,而回憶時(shí)海馬(負(fù)責(zé)情節(jié)記憶)、尾狀核-殼核活動(dòng)(負(fù)責(zé)技能學(xué)習(xí))增加(Disner et al.,2011)。此外,對(duì)于工作記憶中無(wú)關(guān)負(fù)性信息解除困難現(xiàn)象,功能性核磁共振成像(functional magnetic resonance imaging,fMRI)研究發(fā)現(xiàn),當(dāng)要求被試把負(fù)性詞從工作記憶中移除時(shí),病人的前扣帶回、頂上小葉以及雙側(cè)腦島都有更大激活,相反的是,當(dāng)把正性詞從工作記憶中移除時(shí)正常人的相應(yīng)腦區(qū)有更大激活(Foland-Ross et al.,2013)。此外,抑郁病人在進(jìn)行工作記憶任務(wù)時(shí)存在皮質(zhì)-邊緣系統(tǒng)-皮質(zhì)下神經(jīng)環(huán)路的功能異常,主要表現(xiàn)為額區(qū)、前扣帶回、頂葉、顳葉和枕葉等腦區(qū)的異常激活,但受限于被試的異質(zhì)性和研究方法的不同,目前尚未得到一致的激活模式(Wang et al.,2015)。

綜上所述,抑郁病人更容易回憶與自己抑郁心境一致的內(nèi)容,這種記憶偏向在內(nèi)隱記憶、錯(cuò)誤記憶中也都有表現(xiàn),負(fù)性內(nèi)容一旦與自我相關(guān)性結(jié)合還會(huì)增強(qiáng)該記憶偏向效應(yīng)。該記憶偏向主要由邊緣系統(tǒng)(杏仁核、海馬)調(diào)節(jié),但在皮層區(qū)也有激活異常。此外,病人在消除、轉(zhuǎn)換和更新工作記憶中的負(fù)性信息時(shí)還存在困難,這是認(rèn)知控制損傷的一大表現(xiàn)。

4 心境一致性解釋偏向

Beck的負(fù)性圖式模型和新近的抑郁認(rèn)知理論都提到抑郁癥與解釋偏向(interpretation bias)有關(guān)(Beck,2008; Mathews & MacLeod,2005),即抑郁癥患者傾向于消極地解釋模棱兩可事件。早期研究曾證實(shí)了該偏向的存在(Butler & Mathews,1983),但也有研究并未發(fā)現(xiàn)這一現(xiàn)象(Bisson &Sears,2007; Lawson & MacLeod,1999)。然而Lawson等人用情緒模棱兩可文字誘發(fā)意象,通過(guò)測(cè)量被試的驚反應(yīng)(the startle response)大小發(fā)現(xiàn)了解釋偏向在抑郁個(gè)體身上的存在證據(jù),并認(rèn)為解釋偏向是抑郁的一個(gè)認(rèn)知易感性因子(Lawson,MacLeod,& Hammond,2002)。Rude等人則在大學(xué)生群體中發(fā)現(xiàn)解釋偏向的大小能預(yù)測(cè)后續(xù)抑郁癥狀的嚴(yán)重程度(Rude,Wenzlaff,Gibbs,Vane,&Whitney,2002)。

目前僅發(fā)表了一篇探討抑郁癥解釋偏向的ERP研究。該研究使用了語(yǔ)法判斷任務(wù)(The grammar decision task)作為實(shí)驗(yàn)任務(wù),在聽完模棱兩可句子的前半部分后,被試會(huì)看到不同情緒類別的句尾詞,然后判斷該詞在所聽到的句子中是符合語(yǔ)法規(guī)則的(grammatical)還是不符合語(yǔ)法規(guī)則的(non-grammatical) (Moser,Huppert,Foa,& Simons,2012)。結(jié)果發(fā)現(xiàn)正性句尾詞和負(fù)性句尾詞在抑郁病人身上所誘發(fā)的 N4波幅無(wú)顯著差異,表明病人對(duì)結(jié)尾的正性或負(fù)性有同樣的期待,即不存在正性解釋偏向; 回歸分析還發(fā)現(xiàn)抑郁癥狀與 N4解釋偏向效應(yīng)有關(guān),這為抑郁癥存在負(fù)性解釋偏向提供了部分證據(jù)(Moser et al.,2012)。

綜上所述,抑郁癥患者的負(fù)性解釋偏向雖然得到一些理論模型的支持,且已存在部分行為學(xué)與電生理學(xué)證據(jù),然而該領(lǐng)域相關(guān)研究并未達(dá)成一致的結(jié)論,因此該偏向及有關(guān)的神經(jīng)機(jī)制值得深入挖掘。

5 認(rèn)知偏向的三個(gè)特點(diǎn)及腦機(jī)制

根據(jù)以上研究,結(jié)合 Rottenberg等人提出的負(fù)性增強(qiáng)假設(shè)(negative potentiation hypothesis)(該觀點(diǎn)認(rèn)為抑郁病人對(duì)負(fù)性情緒刺激反應(yīng)敏感)與正性衰減假設(shè)(positive attenuation hypothesis)(該觀點(diǎn)認(rèn)為抑郁病人對(duì)正性情緒刺激反應(yīng)遲鈍)(Rottenberg,Gross,& Gotlib,2005),我們總結(jié)出抑郁癥心境一致性認(rèn)知偏向存在三個(gè)主要特點(diǎn),且推斷該認(rèn)知偏向是這些特點(diǎn)背后的腦機(jī)制協(xié)同作用的產(chǎn)物。(1)加工偏向負(fù)性：該特點(diǎn)在知覺(jué)、注意、記憶以及解釋等認(rèn)知環(huán)節(jié)層面均存在,而原因可能是大腦杏仁核對(duì)負(fù)性信息存在過(guò)度激活。杏仁核的功能包括將注意指向情緒信息、易化情緒記憶以及產(chǎn)生自主的情緒反應(yīng)(Pessoa,2010)。當(dāng)抑郁癥患者對(duì)情緒性刺激進(jìn)行知覺(jué)、評(píng)估和反應(yīng)時(shí),負(fù)性情緒刺激(如悲傷和恐懼面孔)能使大腦自下而上的反應(yīng)增強(qiáng)(杏仁核、梭狀回等腦區(qū)過(guò)度激活) (Arnone et al.,2012; Monk et al.,2008; 廖成菊,馮正直,2010),甚至在無(wú)意識(shí)條件下也是如此(Suslow et al.,2010; Victor,Furey,Fromm,?hman,& Drevets,2010); (2)加工偏離正性或積極偏向缺失：該特點(diǎn)與負(fù)性偏向一樣,也存在于抑郁病人的各個(gè)認(rèn)知環(huán)節(jié)中,而原因則是紋狀體對(duì)正性信息激活減弱,這可能是抑郁癥核心癥狀之一——快感缺失的神經(jīng)機(jī)制(Epstein et al.,2006)。眾所周知,紋狀體是獎(jiǎng)賞環(huán)路的重要組成部分,與積極情緒的加工有關(guān)(Groenewold,Opmeer,de Jonge,Aleman,& Costafreda,2013),而 MDD病人的獎(jiǎng)賞環(huán)路以紋狀體和邊緣區(qū)活動(dòng)減少以及額區(qū)激活增加為特征(Demenescu et al.,2011)。Heller等人對(duì)抑郁病人進(jìn)行2個(gè)月的藥物治療發(fā)現(xiàn),病人伏隔核激活越大以及腦內(nèi)額中回-紋狀體環(huán)路連接增加得越多,病人體驗(yàn)到的積極情緒也越多。作者認(rèn)為抑郁癥可能部分源于伏隔核持續(xù)活動(dòng)和額區(qū)-紋狀體連接性的缺失(Heller et al.,2013); (3)認(rèn)知控制的損傷：表現(xiàn)為抑郁病人對(duì)負(fù)性信息存在抑制和解除困難,這在注意和工作記憶環(huán)節(jié)均有體現(xiàn)。原因是抑郁病人負(fù)責(zé)認(rèn)知控制的腦區(qū)激活模式異常,比如額區(qū)對(duì)負(fù)性表情激活減少,而對(duì)正性表情激活增加,這可能反映了由心境不一致刺激所觸發(fā)的情緒調(diào)節(jié)需要的增加(Demenescu et al.,2011)。DLPFC和前扣帶回對(duì)認(rèn)知控制的缺乏可能危害自上而下的情緒監(jiān)控,從而使得患者大腦調(diào)節(jié)杏仁核反應(yīng)的能力減弱(Beck,2008; Pizzagalli,2011)。此外,病人對(duì)于未知情緒效價(jià)的事件的負(fù)性預(yù)測(cè)偏向也可能是認(rèn)知控制損傷所致。Herwig等人讓被試根據(jù)線索預(yù)期并知覺(jué)具有情緒效價(jià)以及未知情緒效價(jià)的圖片,結(jié)果發(fā)現(xiàn)在預(yù)期未知情緒效價(jià)的情緒圖片時(shí),抑郁病人在DLPFC和mPFC等腦區(qū)的神經(jīng)激活模式與預(yù)期負(fù)性情緒圖片時(shí)相同(Herwig et al.,2010)。

6 現(xiàn)階段有待回答的問(wèn)題與未來(lái)展望

抑郁癥人群的心境一致性偏向在認(rèn)知加工的各個(gè)環(huán)節(jié)(知覺(jué)、注意、記憶、解釋)都有發(fā)生。根據(jù)目前的相關(guān)研究,我們發(fā)現(xiàn)此認(rèn)知偏向的特點(diǎn)為偏向負(fù)性刺激、偏離正性刺激,以及認(rèn)知控制受損。該認(rèn)知偏向在腦成像研究中表現(xiàn)為邊緣系統(tǒng)(包括杏仁核、海馬等)對(duì)負(fù)性刺激的異常激活,紋狀體對(duì)正性刺激激活不足,以及額區(qū)對(duì)皮質(zhì)下區(qū)域認(rèn)知控制的減弱,總體反映了自下而上加工的增強(qiáng)以及自上而下加工的減弱。然而,抑郁癥人群心境一致性偏向的研究仍有諸多問(wèn)題有待回答?？偨Y(jié)起來(lái)主要有以下三點(diǎn)：

第一,各環(huán)節(jié)的認(rèn)知偏向間是否存在聯(lián)系？Everaert等人認(rèn)為現(xiàn)階段研究的一個(gè)主要局限是抑郁病人的認(rèn)知偏向被單獨(dú)地、孤立地在相當(dāng)特定的信息加工階段內(nèi)進(jìn)行研究(Everaert et al.,2012)。他們的研究已證明,不同的認(rèn)知偏向(知覺(jué)、解釋、注意、認(rèn)知控制)是相互聯(lián)系的,但哪一種或哪幾種認(rèn)知偏向?qū)τ诤罄m(xù)癥狀發(fā)作更具有預(yù)測(cè)力仍然不得而知(Everaert et al.,2012)。當(dāng)前已有研究表明抑郁癥的注意偏向和記憶偏向具有密切的聯(lián)系,注意偏向的改變會(huì)影響情緒刺激的精細(xì)加工,并且是心境一致性記憶偏向的原因之一(Blaut,Paulewicz,Szastok,Prochwicz,& Koster,2013)。解釋偏向也會(huì)影響外顯記憶,積極解釋偏向訓(xùn)練還可能是改變負(fù)性記憶偏向的一個(gè)有效手段(Salemink,Hertel,& Mackintosh,2010; Tran,Hertel,& Joormann,2011)。那么,各認(rèn)知偏向之間若有聯(lián)系,這種聯(lián)系又是什么樣的關(guān)系,是序列關(guān)系還是平行關(guān)系？迄今為止這些問(wèn)題還沒(méi)有得到有效解決。

第二,心境一致性認(rèn)知偏向與抑郁癥的關(guān)系是什么？具體而言,是認(rèn)知偏向?qū)е铝艘钟舭Y,還是抑郁癥導(dǎo)致了認(rèn)知偏向(戴琴,馮正直,2008)？研究表明,認(rèn)知偏向是抑郁癥狀產(chǎn)生、持續(xù)和發(fā)展的重要原因之一(Taylor & John,2004)。這么看來(lái)似乎是認(rèn)知偏向?qū)е铝艘钟舭Y,但上述很多研究已經(jīng)證明：恢復(fù)期個(gè)體抑郁癥狀雖早已消失,卻仍然存在認(rèn)知偏向和相應(yīng)神經(jīng)變化。這該作何解釋？那可以認(rèn)為是抑郁癥導(dǎo)致了認(rèn)知偏向嗎？恐怕不能。Singh等人通過(guò)考察有家族抑郁風(fēng)險(xiǎn)的兒童發(fā)現(xiàn),認(rèn)知偏向以及結(jié)構(gòu)和功能性的神經(jīng)改變?cè)缭谝钟舭Y狀發(fā)作之前就已出現(xiàn)(Singh& Gotlib,2014)。與健康母親的健康女兒相比,罹患抑郁癥母親的健康女兒會(huì)選擇性地注視負(fù)性情緒面孔,表現(xiàn)出注意偏向(Joormann,Talbot,&Gotlib,2007),且會(huì)把模棱兩可的詞語(yǔ)和故事解釋得更消極,表現(xiàn)出解釋偏向(Dearing & Gotlib,2009)。這些患病家庭的健康兒童在產(chǎn)生認(rèn)知偏向的同時(shí)還伴隨有相應(yīng)的神經(jīng)改變：當(dāng)出現(xiàn)消極情緒時(shí),病人母親的女兒在涉及消極情緒體驗(yàn)的腦區(qū)(杏仁核與 VLPFC)比正常母親的女兒有更大的激活; 相反在回憶積極情緒時(shí),正常母親的女兒在涉及對(duì)情緒自上而下調(diào)節(jié)的區(qū)域(DLPFC與背側(cè)前扣帶回)比病人母親的女兒有更大的激活(Joormann,Cooney,Henry,& Gotlib,2012)。由此可知這些來(lái)自有抑郁風(fēng)險(xiǎn)家族的兒童雖并未被診斷有抑郁癥,卻也會(huì)出現(xiàn)抑郁癥所特有的認(rèn)知偏向和相應(yīng)腦激活改變,意味著認(rèn)知偏向并非由抑郁癥直接引起。目前看來(lái),這個(gè)問(wèn)題相當(dāng)復(fù)雜,國(guó)內(nèi)學(xué)者暫把認(rèn)知偏向視作抑郁癥的一個(gè)特征(戴琴,馮正直,2008)。

第三,如何解決研究結(jié)果的不一致？在抑郁癥認(rèn)知偏向的諸研究中,結(jié)果的不一致時(shí)有發(fā)現(xiàn)。例如,對(duì)抑郁癥工作記憶的腦成像研究通常發(fā)現(xiàn)病人額葉神經(jīng)環(huán)路的功能失調(diào)(Wang et al.,2015),同樣采用與工作記憶相關(guān)的任務(wù),有研究發(fā)現(xiàn)病人 DLPFC激活增強(qiáng)(Matsuo et al.,2007;Walter,Wolf,Spitzer,& Vasic,2007),也有發(fā)現(xiàn)該區(qū)域激活減弱(Garrett et al.,2011; Kerestes et al.,2012),甚至還有研究未發(fā)現(xiàn)該腦區(qū)被激活(Sandstr?m et al.,2012)。多數(shù)研究者把結(jié)果不一致的問(wèn)題歸結(jié)為被試和實(shí)驗(yàn)任務(wù)的異質(zhì)性,以及認(rèn)知本身的復(fù)雜性。除此之外,我們認(rèn)為還有兩個(gè)重要原因不容忽視：其一是實(shí)驗(yàn)范式的有效性。例如一個(gè)元分析研究發(fā)現(xiàn),在抑郁癥注意偏向的測(cè)量上,點(diǎn)探測(cè)范式比情緒 Stroop范式更有效,且效果量更大(Peckham et al.,2010)。其二,大部分研究只注重刺激材料的情緒效價(jià),卻忽視了刺激的自我相關(guān)性。事實(shí)上,抑郁癥不僅僅與負(fù)性偏向有關(guān),還與增加的自我聚焦(self-focus)有關(guān)(Nejad et al.,2013)。抑郁病人加工與自我有關(guān)的負(fù)性刺激時(shí),認(rèn)知偏向會(huì)增強(qiáng)(Gaddy & Ingram,2014)。部分研究極有可能讓自我相關(guān)因素混淆到實(shí)驗(yàn)刺激中,造成了與控制嚴(yán)格的實(shí)驗(yàn)研究所不一致的結(jié)果。

因此,未來(lái)研究可以從以下三個(gè)方向開展。首先,如前所述,雖然在知覺(jué)、注意、記憶和認(rèn)知解釋每個(gè)層面對(duì)抑郁癥的認(rèn)知偏向都有不少研究,但對(duì)兩個(gè)或三個(gè)環(huán)節(jié)之間的綜合性研究甚少,因此難以對(duì)抑郁癥的認(rèn)知偏向形成一個(gè)整體的認(rèn)識(shí)。所以今后對(duì)抑郁病人的知覺(jué)與注意、記憶以及解釋四個(gè)偏向進(jìn)行綜合研究是很有必要的。其次,需要進(jìn)行縱向研究以探討認(rèn)知偏向與抑郁癥的因果關(guān)系,以此確定認(rèn)知偏向究竟是抑郁癥的預(yù)測(cè)因子還是診斷標(biāo)準(zhǔn)之一。最后,亟需一個(gè)標(biāo)準(zhǔn)化的實(shí)驗(yàn)流程以盡量減少方法學(xué)、人口學(xué)上的變異,目前已有研究者在此方面作出了有益嘗試。例如Korgaonkar等人在fMRI中采用了標(biāo)準(zhǔn)化的成套測(cè)驗(yàn)和成像協(xié)議(imaging protocols),以此控制方法學(xué)和樣本所產(chǎn)生的變異,該研究發(fā)現(xiàn),抑郁病人在工作記憶更新和有意識(shí)的負(fù)性情緒加工期間,DLPFC的激活減少; 在工作記憶任務(wù)和反應(yīng)抑制任務(wù)中背內(nèi)側(cè)前額葉皮質(zhì)(dorsomedial prefrontal cortex,DMPFC)的激活增大; 在有意識(shí)的正性情緒加工期間,DMPFC激活減少(Korgaonkar,Grieve,Etkin,Koslow,& Williams,2013)。此外,檢測(cè)各研究范式的效果量,盡可能選擇大效果量的實(shí)驗(yàn)范式,排除刺激材料自我相關(guān)性對(duì)研究結(jié)果的干擾,進(jìn)而改善目前研究結(jié)論不一致的狀況。

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