Ponowna ocena roli dziedziczenia
W latach dziewięćdziesiątych nastąpiły pewne zmiany poglądów na temat roli podłoża dziedzicznego w zaburzeniach psychicznych. Można tu wyróżnić kilka, z pozoru sprzecznych, tendencji. Przede wszystkim, coraz więcej danych dowodzi kluczowej roli dziedziczenia w większości zaburzeń psychicznych, występujących zarówno w dzieciństwie, jak i u dorosłych (Rutter i wsp., 1999a,b). Jednak wiele przemawia za tym, że udział dziedziczenia zmienia się w zależności od rodzaju zaburzeń psychicznych. Ponadto wykazano, że etiopatogeneza większości zaburzeń psychicznych jest wieloczynnikowa, przy czym znaczną rolę odgrywają właśnie czynniki środowiskowe. Zgłębienie mechanizmów owej współgry czynników genetycznych i środowiskowych jest o wiele ważniejsze niż poszukiwanie jakiejś niewielkiej liczby schorzeń, warunkowanych wyłącznie genetycznie. Po wtóre – rośnie liczba danych przemawiających za tym, że współgra czynników genetycznych i środowiskowych (korelacje i interakcje) decyduje o wielu objawach psychopatologicznych. I w tym zakresie potrzebne są dalsze badania nad wzajemnymi wpływami i zależnościami. Z pewnością chodzi o wiele rozmaitych mechanizmów przyczynowych, które wymagają dokładnego poznania. Sama wiedza, że w danym przypadku odgrywa rolę czynnik czy to genetyczny czy środowiskowy, nie ma większego znaczenia. Praktycznie, we wszystkich zaburzeniach psychicznych działają obydwie kategorie czynników – potrzebne są więc dokładniejsze badania, by szczegółowo określić ich rolę. Chodzi tu o ustalenie, w jakim stopniu działają geny, a na co i w jakim zakresie wpływa środowisko, a także, jakie są zależności między tymi czynnikami i w jaki sposób one na siebie nawzajem wpływają. Po trzecie – co najważniejsze – z całą pewnością w przyszłości rozpracuje się i pozna wiele swoistych mechanizmów wzajemnego oddziaływania środowiska i dziedziczenia, w różnych zaburzeniach psychicznych. Przesadny jest entuzjazm genetyków, którzy ponownie wykryli rolę dziedziczenia w indywidualnej podatności na działanie szkodliwych czynników środowiskowych. Równie nieuzasadniona jest nazbyt obronna postawa badaczy roli środowiska na tym polu. Należy sobie jasno uświadomić, że źródła zagrożenia to często zupełnie coś innego niż sposób ich oddziaływania (Rutter i wsp., 1993). Dobrym przykładem takiej rozbieżności jest palenie tytoniu. Skoro jednak genetycy utożsamiają obydwa zjawiska, to musi dojść do błędu i przecenienia roli czynników genetycznych, a niedoszacowanie znaczenia środowiska. Genetycy w swoich dociekaniach muszą uznać ogromną rolę pośrednich wpływów genetycznych, które są nie mniej istotne od bezpośrednich skutków. Także badacze roli środowiska nie są bez winy i nie wolno im zapominać, że nie można zrozumieć mechanizmu działania czynników psychosocjalnych bez uwzględnienia korelacji i interakcji gen-środowisko.

Rzut oka w przyszły wiek
Nadchodzący koniec millennium skłania do zastanowienia się nad dotychczasowymi osiągnięciami i dalszymi wyzwaniami na polu badań dotyczących psychicznych i społecznych zagrożeń. Obecnie już wiadomo, że w większości przypadków zaburzeń psychicznych u dzieci i młodzieży bardzo istotną rolę odgrywają czynniki psychosocjalne, zarówno te zagrażające, jak i zapobiegające odchyleniom. Nie ma żadnych podstaw do podważania ich roli, jak to czynią fanatycznie usposobieni genetycy. Już sam wzrost wskaźników wielu zaburzeń psychicznych u młodych osób w okresie ostatniego półwiecza wyraźnie wskazuje na to, że czynniki środowiskowe muszą w tym odgrywać jakąś rolę. Również badania bliźniąt i adopcyjne dowodzą wyraźnego wpływu otoczenia. Coraz więcej badań, przeprowadzanych najróżniejszymi metodami, potwierdza wpływ czynników psychosocjalnych na objawy psychopatologiczne. Widać więc, że zagadnienie jest bardzo ważne i aktualne.
Trzeba jednak przyznać, że nie wszystko jest takie jasne w badaniach nad rolą czynników psychosocjalnych. Wprawdzie dokonał się znaczny postęp w metodologii badań, ale nie wszyscy badacze stosują się do rygorystycznych wymagań. Sporo wiemy o wskaźnikach zagrożenia ze strony otoczenia, natomiast znacznie mniej wiadomo o mechanizmach i procesach w środowisku, które przyczyniają się do wzrostu ryzyka wystąpienia zaburzeń. Niewiele też wiadomo na temat swoistości działania czynników psychosocjalnych ryzyka. Większość badań skupia się na zachowaniach antysocjalnych (Rutter i wsp. 1998b), natomiast znacznie skromniejsza jest wiedza na temat znaczenia czynników psychosocjalnych w rozwoju np. zaburzenia depresyjnego (Harrington, 1994) czy lękowego (March, 1995) u dzieci.
Jak dotąd poświęcono za mało uwagi czynnikom odpowiedzialnym za różnice indywidualne pod względem podatności na odziaływania czynników szkodliwych otoczenia. Konieczne jest przy tym opracowanie dokładniejszych metod badania, by możliwe było rozróżnienie wpływu środowiska na osobę od skutków oddziaływania osoby na otoczenie. W bardzo wielu badaniach nie doceniano rangi wzajemnych powiązań czynników genetycznych i środowiskowych, które przesądzają o indywdualnych różnicach reakcji na stres i inne niekorzystne wpływy. Od dawna jednak wiadomo, że te indywidualne różnice są bardzo ważne. W programach badawczych należy zająć się nie tylko problemem podatności i odporności, ale również mechanizmami ich powstawania. Chodzi zatem o poszukiwanie nie tylko czynników wyzwalających chorobę, ale przede wszystkim o poznanie procesów leżących u podłoża zaostrzeń, nawrotów i remisji zaburzeń psychicznych na przestrzeni długiego okresu.
Niezwykle ważne są również rozmaite towarzyszące i pośrednio działające zmienne, ciągle mało poznane. Właśnie w związku z taką złożonością problemu, bardzo niewiele wiadomo co właściwie powodują szkodliwe czynniki psychosocjalne w organizmie. W jaki sposób doprowadzają one do zmian, co decyduje o tym, czy są one trwałe czy tylko przemijające? Znalezienie odpowiedzi na te pytania jest możliwe tylko w ramach psychiatrii biologicznej. Dopiero po ich uzyskaniu, będzie możliwe ostateczne przezwyciężenie ciągle istniejącego, choć pozbawionego sensu, dualizmu w psychiatrii.


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Michael L. Rutter
Tłum. Sławomir Sidorowicz (WP)
(sponsor Wiadomości Psychiatryczne)