专家视点：成人ADHD的诊断

科罗拉多州埃斯蒂斯帕克——成人注意力缺陷/多动障碍(ADHD)是一种常见且可治但诊断难度较大的精神疾病，原因是其表现与儿童患者有较大区别。

科罗拉多大学精神病学系的Robert D. Davies医生在该校主办的内科学会议上指出，将精神障碍诊断与统计手册(DSM)ADHD诊断标准用于成人是有问题的。DSM-Ⅳ症状主要关注儿童期活动，尤其是学校和游戏。而且，多动——儿童期ADHD的最明显症状——有随着年龄增加而减弱的趋势，在成人中更偏向内心不安的主观体验。

根据定义，ADHD总是首先发生于儿童期，即使成人患者此前并未获得诊断且回忆不起早期损害。“患者常常在成年期才由于生活中的某些变化而首次表现出ADHD症状，但是假如你仔细回顾过往，仍能在儿童期找到蛛丝马迹。假如一名前来就诊的患者对你说‘这几年，我突然无法集中注意力了，我在工作方面不大顺利’而且此前没有任何线索，虽然我不知道问题在哪，但我敢肯定这不是ADHD。”

成人ADHD患者的表现比儿童患者更加微妙，包括没有条理和时间管理能力差；自控力差、容易冲动，常常表现为言语粗鲁、频繁打断别人的话；源于自卑和情绪调节能力不足的情绪困难；以及难以集中精力和完成任务(甚至是简单任务)。


Robert D. Davies医生

“成人ADHD患者可以成为业绩优异的销售人员，他们真的能做到。但是我也确实遇到了很多从事销售工作却遭受挫折的患者，原因是他们不能静下心来处理案头工作和将文件归档。他们往往起初表现优异，而之后就越来越不顺利。”

ADHD中的多动成分有可能非常类似躁狂：追求快感、思维跳跃、滔滔不绝和难以入睡。Davies医生指出，所有这些成人ADHD症状会共同增加离婚、工作困难、物质滥用、犯罪和交通违章的风险，而且由国立精神卫生研究所发起的一项里程碑式的全国性研究已证实，成人ADHD患者易合并抑郁症和焦虑症。这项名为全国合并症调查答复的研究显示，一般人群中的成人ADHD患病率高达4.4%。

在作出成人ADHD的诊断之前，必须排除物质滥用、听力丧失和甲状腺功能亢进的可能性。更具挑战性的是，从多种常见精神疾病中梳理出成人ADHD，最多见的是双相情感障碍、广泛性焦虑障碍和人格障碍。

患者的睡眠模式有可能为鉴别诊断提供有价值的信息。成人ADHD以一种相位迁移为特征：内在多动性会导致患者难以入睡，直至周围环境变得极为安静，而清晨又难以苏醒。与此相对应的是，双相情感障碍躁狂期的标志是睡眠需求下降。与双相躁狂患者不同的是，广泛性焦虑障碍患者确实想要睡觉，却因为担心未来可能发生的事情而难以入睡。成人ADHD患者通常是因为反复思考自己已经犯下的错误而无法入睡。“他们担心的事情是确实已经发生了的，例如忘了做某件事，或者冒犯了某人。而与此形成对比的是，当患者说‘如果……就会……’之类的话时，可视为广泛性焦虑障碍的一条线索。”

ADHD是从儿童期开始、贯穿终身的疾病，而双相情感障碍是阵发性的，往往从青春期后期或更晚的时候才开始。

与边缘型人格障碍患者相比，成人ADHD患者通常能意识到自己的失败和缺点，并且对于别人如何看待自己有比较负面的判断。很多成人ADHD患者从儿童期就开始因为冲动性和不专注而生活一团糟，而边缘型人格障碍患者的混乱生活常常是从青春期开始的，并且是由糟糕的人际关系和死板的想法导致的。

很多成人自认为患上了ADHD而向初级保健医生或精神科医生求助，他们可能会向医生展示自己填写的大众杂志上的自我报告筛查问卷，将其作为自己罹患ADHD的证据。Davies医生建议不要太在意这类自评量表。“我不会常规使用这类量表。事实上，几乎所有人都会在生命中的某个时间点符合量表上的诊断标准。我们医生应该做的是询问患者是否具有明显、关键的ADHD症状，以及这些症状是否给他们的生活带来很大困扰。”

Davies医生承认，尽管成人ADHD是一种发病率较高、后果较严重且可以治疗的疾病，但它仍受到一些质疑。“这是一个在精神科内外都存在较大争议的领域。我的一位精神科同事曾经将一名患者诊断为ADHD，然后又将这名患者转给我。当我问他为什么转给我时，他的回答是‘因为我不太肯定是不是ADHD’。”

Davies医生报告称无相关利益冲突。

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By: BRUCE JANCIN, Internal Medicine News Digital Network

ESTES PARK, COLO. – Adult attention-deficit/hyperactivity disorder is a common and treatable psychiatric condition the diagnosis of which is made more challenging because the disorder looks different than the classic picture in children.

Trying to apply the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) to adults is problematic. The DSM-IV symptoms focus mainly on childhood activities, particularly school and play. Plus, hyperactivity – the most recognizable symptom of ADHD in childhood – tends to diminish with age, becoming a more subjective experience of internal restlessness, Dr. Robert D. Davies explained at a conference on internal medicine sponsored by the University of Colorado.
 
Yet ADHD by definition always first develops in childhood, even if an affected adult hasn’t previously been diagnosed and doesn’t recall the early impairment.

"Very often patients first present in adulthood because things have changed in their life, but if you go back and look carefully, it has been there since childhood. If you have a patient who comes in saying, ‘In the last few years all of a sudden I can’t concentrate, I can’t focus, I’m not doing well at work’ and there’s never been any hint of that before, I don’t know what it is, but it’s not ADHD," declared Dr. Davies, a psychiatrist at the university.

The adult presentation of ADHD is more subtle than in children. It includes disorganization and poor time-management skills; impulsivity with poor self-control often demonstrated via rude comments and frequent interruption of others; emotional difficulties rooted in low self-esteem and poor affect regulation; and difficulty in concentrating and completing even simple tasks.

"Adults with ADHD make great salespeople. They can really close the sale. But I’ve had so many salespeople I’ve treated who are failing at work because they never get the paperwork in and actually file the order. They don’t follow up on those things, but they’re great at the beginning," he observed.

The hyperactivity component can look much like mania: thrill seeking, racing thoughts, excessive talking, and difficulty in falling asleep.

All these adult ADHD symptoms add up to increased risks of divorce, difficulties at work, substance abuse, incarceration, a poor driving history – "lots of fender benders," according to Dr. Davies – and high rates of comorbid depression and anxiety that have been well documented in a landmark national study sponsored by the National Institute of Mental Health. The study, the National Comorbidity Survey Replication, placed the prevalence of adult ADHD among the general population at 4.4% (see accompanying graphic).

Substance abuse, hearing loss, and hyperthyroidism need to be ruled out before arriving at the diagnosis of adult ADHD. More challenging is to sort out adult ADHD from several commonly comorbid psychiatric conditions, most notably bipolar disorder, generalized anxiety disorder, and personality disorder.

The patient’s sleep pattern can provide useful information in this regard. Adult ADHD is characterized by a phase shift: The internal hyperactivity leads to difficulty in falling asleep until quite late, with subsequent trouble in waking up in the morning. In contrast, the manic phase of bipolar disorder is marked by a decreased sleep requirement. Patients with generalized anxiety disorder, unlike those with bipolar mania, really need their sleep, but their difficulty in falling asleep stems from worries about what might happen in the future. Individuals with adult ADHD typically can’t sleep because they’re ruminating about mistakes they’ve made.

"They’re worried about things that are real: what they forgot to do, who they’ve offended. In contrast, anytime you’re talking to a patient and they’re saying a lot of ‘what ifs,’ that’s a clue that the problem is generalized anxiety disorder," he explained.

While ADHD is a lifelong condition that begins in childhood, bipolar disorder is episodic and starts in the late teen years or later.

As for the differential between adult ADHD and borderline personality disorder, patients with ADHD typically have a sense of self as being harmed by their own failures and shortcomings coupled with the negative way others perceive them. In contrast, individuals with personality disorders often don’t have any real sense of self. The chaotic life that figures so prominently in the personal histories of many patients with adult ADHD dates back to childhood and results from their impulsivity and inattention, whereas the chaotic life of the patient with borderline personality disorder often starts in adolescence and is the result of their poor interpersonal relationships and rigid thinking.

Lots of adults are coming to the offices of primary care physicians and psychiatrists seeking help for what they believe is ADHD, brandishing their scores on self-report screening scales they find in popular magazines. Dr. Davies advises not attaching much weight to the self-report scales.

"I don’t use them routinely," he said. "If you think about the symptoms of ADHD, especially the ones that come out of magazines that they’re going to bring in to you, almost everybody at some point is going to fill these criteria. You want to ask people about those big, core ADHD symptoms: Are they really causing problems in your life?"

Dr. Davies acknowledged that adult ADHD is a disorder surrounded by considerable professional skepticism, even though the prevalence, serious consequences, and treatment responsiveness of adult ADHD are now well established.

"It’s a very controversial area outside of psychiatry but also inside psychiatry," according to Dr. Davies. "A psychiatric colleague of mine had diagnosed an adult patient with ADHD and then wanted to refer him to me. I asked why. He said, ‘Because I don’t believe in it.’"

Dr. Davies reported having no financial conflicts.