我從事醫生工作已超過30年，其中25年作為神經科醫生(neurologist)。最近，我特別擔憂被轉診給我的年輕人數量龐大，他們被診斷出患有四、五種疾病(four or five diagnoses)，這些疾病似乎無法治癒。這些疾病包括自閉症(Autism)、妥瑞氏症(Tourette syndrome)、注意力缺陷多動症(ADHD)、偏頭痛(migraines)、纖維肌痛症(fibromyalgia)、多囊卵巢症候群(polycystic ovary syndrome)、抑鬱症(depression)、飲食障礙(eating disorders)、焦慮症(anxiety)等等。
心理健康障礙(mental health disorders)、行為問題(behavioural difficulties)和學習困難(learning difficulties)的診斷人數激增，經常出現在報紙頭條和我們的對話中：“注意力缺陷多動症(ADHD)：近期診斷激增背後的原因是什麼？研究發現”，《紐約時報》(New York Times)，2023年3月。其他多類心理健康障礙的情況也是如此。“大學生中的創傷後壓力症候群(PTSD)激增”，《紐約時報》，2024年5月。“抑鬱症(depression)和焦慮症(anxiety)病例上升5%”，《福布斯》(Forbes)，2023年2月。
這些令人震驚的統計數據說明了我們的健康狀況如何？表面上看，它們似乎表明我們的心理和身體健康狀況比過去顯著惡化。然而，是否還有其他解釋？我們是否在識別醫療問題和確定需要治療的人群方面變得更加擅長？像自閉症這樣的疾病可能因為人們終於得到了正確的診斷(right diagnosis)並獲得支持而增加。但這些診斷是否完全如表面所示？可能是邊緣性的醫療問題(borderline medical problems)正被轉化為確鑿的診斷(iron-clad diagnoses)，而正常的差異(normal differences)正被病理化(pathologised)。這些統計數據可能表明，普通的生活經歷(ordinary life experiences)正被納入醫療障礙(medical disorder)的範疇。換句話說：我們並沒有變得更病態——我們只是將更多現象歸因於疾病(sickness)。
患有慢性病(Chronic Conditions)的人數正在飆升。我們比以前更不健康了嗎？還是我們在過度診斷(Overdiagnosing)疾病(Illness)？
三月 3, 2025
文章來源:https://www.madinamerica.com/2025/03/the-number-of-people-with-chronic-conditions-is-soaring-are-we-less-healthy-than-we-used-to-be-or-overdiagnosing-illness/
衛報文章全文:
患有慢性病(Chronic Conditions)的人數正在飆升。我們比以前更不健康了嗎？還是我們在過度診斷(Overdiagnosing)疾病(Illness)？
普通的生活經歷(ordinary life experiences)、身體缺陷(bodily imperfections)和正常差異(normal differences)是否正在被不必要地病理化(pathologised)？一位醫生正是這麼認為的。
作者：Suzanne O’Sullivan
School was a difficult time for Anna. It still haunts her. She recalls being a sociable child, good at making friends. But she also remembers becoming hyperfixated on one friend, then another and another in succession. She tended to be impulsive and, wanting to please others, easily led. One distressing incident in particular has never left her. On the first day after moving to a new school, she was relieved to be taken under the wing of two girls. At lunchtime, in fits of giggles, the girls egged each other on to do naughty things. Anna spat orange juice at the boys. She did it with relish, only to reproach herself later. She feels the episode coloured her whole school experience.
學校對Anna來說是一段艱難的時光，至今仍讓她感到困擾。她回憶自己小時候是個善於交際的孩子，擅長結交朋友。但她也記得自己會對某一個朋友過分著迷(hyperfixated)，然後一個接一個地換朋友。她傾向於衝動行事(impulsive)，為了取悅他人而容易被牽著走(easily led)。特別是一件令人痛苦的事件(distressing incident)始終讓她無法忘懷。在搬到新學校的第一天，她鬆了一口氣，因為有兩個女孩將她納入她們的小圈子(taken under the wing)。午餐時間，兩個女孩一邊咯咯笑，一邊慫恿彼此做淘氣的事(naughty things)。Anna朝男孩子們吐了橙汁(spat orange juice)，她當時還挺享受(relish)，但事後卻深深自責(reproach herself)。她覺得這件事影響了她整個學校經歷(coloured her whole school experience)。
As a child and an adult, Anna felt sanctioned, judged and misunderstood. She considers herself a chameleon who adapts to new environments and survives by being funny, but all too often regrets things she has said. Her self-esteem is low. Anna is a nurse and, although she loves her job and is good at it, she still often feels inadequate. “People don’t think I’m as clever as I feel. I can’t get the words out quickly enough,” she says.
無論是童年還是成年，Anna總覺得自己被制裁(sanctioned)、被評判(judged)且被誤解(misunderstood)。她認為自己像一隻變色龍(chameleon)，適應新環境並通過幽默來生存，但常常後悔自己說過的話。她的自尊心(self-esteem)很低。Anna是一名護士(nurse)，雖然她熱愛自己的工作且表現出色，但她仍然經常感到自己不夠好(inadequate)。她說：“人們不認為我像我自己感覺的那樣聰明。我無法快速地把話說清楚。”
When she was in her early 20s, she remembers being exhausted all the time. She couldn’t control her emotions and complained of a poor memory. She left her keys in ridiculous places – one time in the fridge. She forgot to turn off the hob and unplug the iron. “I can never remember things people tell me, like how many children they have. I hate it because it makes me look as if I don’t care, and I do.”
在她20多歲時，她記得自己總是感到筋疲力盡(exhausted)。她無法控制自己的情緒(complain of a poor memory)，記憶力很差。她把鑰匙忘在荒唐的地方，比如冰箱裡(fridge)。她忘了關掉爐灶(hob)和拔掉熨斗(iron)的插頭。“我從來記不住別人告訴我的事，比如他們有幾個孩子。我討厭這樣，因為這讓我看起來好像不在乎，但其實我很在乎。”
Anna has sought medical advice many times throughout her life. In her 20s, her GP diagnosed her with depression and put her on antidepressants. They made her feel numb, so she stopped them. She saw a nutritionist who told her she had a yeast infection and put her on a restrictive diet. It helped but only for a few months. She saw a therapist weekly for 10 years and found that beneficial, but still her mood fluctuated.
Anna一生中多次尋求醫療建議。在她20多歲時，她的家庭醫生(GP)診斷她患有抑鬱症(depression)，並給她開了抗抑鬱藥(antidepressants)。這些藥讓她感到麻木(numb)，於是她停藥了。她去看了一位營養師(nutritionist)，對方告訴她有酵母菌感染(yeast infection)，並讓她遵循嚴格的飲食(restrictive diet)。這幫助了她幾個月，但效果不持久。她每周看一次治療師(therapist)長達十年，覺得這對她有幫助，但她的情緒(mood)仍然起伏不定(fluctuated)。
Anna came to wonder if she was neurodivergent only when she was in her 40s, after a conversation with a friend who had been diagnosed with attention deficit hyperactivity disorder (ADHD). “I have always been lovingly teased as somebody who would trip over the pattern in the carpet,” she says with a smile. “I was quirky. So when my friend sent me a newspaper article about neurodivergence, the description hit me like a bus. The article could have been written about me.”
Anna直到40多歲時，才在一場與一位被診斷患有注意力缺陷多動症(ADHD)的朋友的對話後，開始懷疑自己是否屬於神經多樣性(neurodivergent)。她笑著說：“我一直被親切地嘲笑為那種會被地毯上的圖案絆倒的人(trip over the pattern in the carpet)。”她自認古怪(quirky)。當她的朋友寄給她一篇關於神經多樣性(neurodivergence)的報紙文章時，文章的描述讓她震驚不已(hit me like a bus)。她覺得那篇文章彷彿是為她而寫的。
After some research, Anna paid to have an online assessment for ADHD. The diagnostic interview took 90 minutes. The assessor, who Anna thought was a psychiatrist but wasn’t sure, drew her attention to things she hadn’t noticed about herself. When asked if she was excessively fidgety, Anna said she was not, but the assessor pointed out that she had twiddled with her hair repeatedly during their consultation. Anna realised that she was unusually fidgety, remembering how she always doodled during meetings.
在做了一些研究後，Anna花錢進行了一次線上ADHD評估(online assessment)。診斷訪談(diagnostic interview)持續了90分鐘。評估者（Anna認為可能是精神科醫生(psychiatrist)，但不確定）讓她注意到自己從未察覺的特徵。當被問及是否過分坐立不安(excessively fidgety)時，Anna說她不是，但評估者指出她在諮詢期間反覆撥弄頭髮(twiddled with her hair)。Anna這才意識到自己確實異常地坐立不安(unusually fidgety)，並回想起她總是在會議中塗鴉(doodled during meetings)。
Anna now realises she has underplayed her ADHD traits all her life. The diagnosis made so much sense to her. Slow neurological processing explained why she had such a bad memory and could not communicate her ideas to other people as clearly as she wished to. No wonder she was exhausted, with all the effort required to camouflage her difficulties and hide her mistakes.
Anna現在意識到，她一生都在淡化自己的ADHD特徵(underplayed her ADHD traits)。這個診斷對她來說非常合理。緩慢的神經處理(slow neurological processing)解釋了她為何記憶力差(bad memory)，也無法像她希望的那樣清楚地向他人表達自己的想法(communicate her ideas)。難怪她總是感到筋疲力盡(exhausted)，因為她需要付出巨大努力來掩飾自己的困難(camouflage her difficulties)和隱藏錯誤(hide her mistakes)。
Anna now takes the stimulant drug methylphenidate (Ritalin). “The first time I took it, I couldn’t believe how clearly I could think.” She could make decisions more quickly, prioritise, and had more energy. I wondered how this affected the practical aspects of her life, in work and relationships. “Is my life better? Yes and no.”
Anna現在服用興奮劑藥物甲基苯idate(methylphenidate，商品名Ritalin)。她說：“第一次服用時，我簡直不敢相信自己能思考得那麼清晰。”她能更快地做決定、排列優先順序(prioritise)，並擁有更多能量(energy)。我好奇這對她生活中的實際層面（如工作和人際關係）有何影響。“我的生活變得更好了嗎？既是又不是。”
Anna’s workplace have been supportive. They have made adjustments, such as giving her a private, low-ceilinged office, which she feels reduces noise reverberation and provides quiet when she needs it. She is also allowed to wear noise-cancelling headphones if she is in a busy environment. Colleagues have been taught not to burst into her office without warning. Despite this, Anna still finds work challenging and feels she has to constantly remind people that she has a disability. So much so that she is off work now and does not see herself ever returning. Part of the ongoing problem is that neither Anna nor her employer know what she really needs. “When somebody asks if I want help, I don’t know what to ask for,” she tells me.
Anna的職場對她很支持。他們做出了調整，例如為她提供了一個私人的低天花板辦公室(low-ceilinged office)，她覺得這減少了噪音回響(noise reverberation)，並在需要時提供安靜環境(quiet)。在繁忙的環境中，她也被允許佩戴降噪耳機(noise-cancelling headphones)。同事們被教導不要在未經警告的情況下突然闖入她的辦公室(burst into her office)。儘管如此，Anna仍然覺得工作具有挑戰性，並感到需要不斷提醒別人她有殞疾(disability)。這讓她壓力很大，以至於她現在已經停止工作(off work)，也看不到自己會回去工作的可能性。持續的問題在於，Anna和她的雇主都不知道她真正需要什麼。她告訴我：“當有人問我是否需要幫助時，我不知道該要求什麼。”
I ask how family and friends received her diagnosis. A common response when she describes her symptoms is “everybody has that”. Everybody is a bit disorganised. Everybody finds work hard. “The difference is I feel like that all day, every day,” Anna says. “I never feel OK.”
我問她的家人和朋友對她的診斷有何反應。她描述症狀時，常聽到的回應是“每個人都會這樣”(everybody has that)。每個人都有些許雜亂無章(disorganised)。每個人都覺得工作很難(hard)。Anna說：“不同的是，我整天、每天都感覺這樣。我從來沒有感覺正常(OK)。”
Ihave been a doctor for more than 30 years and a neurologist for 25 of those. I have recently grown particularly worried about the large number of young people referred to me with four or five pre-existing diagnoses of chronic conditions, only some of which can be cured. Autism, Tourette syndrome, ADHD, migraines, fibromyalgia, polycystic ovary syndrome, depression, eating disorders, anxiety and many more.
The startling rise in people diagnosed with mental health disorders, behavioural and learning difficulties features regularly in newspaper headlines and in our conversations: “ADHD: what’s behind the recent explosion in diagnoses?”, New Scientist, May 2023. “Autism prevalence rises again, study finds”, the New York Times, March 2023. The story is the same for multiple categories of mental health disorder. “PTSD has surged among college students”, the New York Times, May 2024. “Depression and anxiety rates have increased by 25% in the past year”, Forbes, February 2023.
What do these astonishing statistics say about the state of our health? On the surface, they make it seem as if we are considerably less mentally and physically healthy than we used to be. But there are other ways of interpreting them. Could they simply reflect the fact that we are much better at recognising medical problems and identifying people in need of treatment? Disorders such as autism may be on the rise because people are finally getting the right diagnosis and being given support. But there is a third possibility. It could be that not all these new diagnoses are entirely what they seem. It could be that borderline medical problems are becoming iron-clad diagnoses and normal differences are being pathologised. These statistics could indicate that ordinary life experiences, bodily imperfections, sadness and social anxiety are being subsumed into the category of medical disorder. In other words: we are not getting sicker – we are attributing more to sickness.
Which of these explanations is most likely to be correct is a matter on which it is hard to find agreement. But it is very much in our interest to find the answer because the trend of detecting health issues in milder and earlier forms, and the assumption that is always the right thing to do, is pressing forward relentlessly.
I would make a case for possibility number three: that we are becoming victims of too much medicine and it is time to turn back the dial. That we are living in the age of diagnosis for mental and physical health conditions. And there is no better illustration of this than the recent explosion of people diagnosed with ADHD.
我從事醫生工作已超過30年，其中25年作為神經科醫生(neurologist)。最近，我特別擔憂被轉診給我的年輕人數量龐大，他們帶有四、五種既存的慢性病診斷(pre-existing diagnoses of chronic conditions)，其中只有部分可以治癒(cured)。這些疾病包括自閉症(Autism)、妥瑞氏症(Tourette syndrome)、注意力缺陷多動症(ADHD)、偏頭痛(migraines)、纖維肌痛症(fibromyalgia)、多囊卵巢症候群(polycystic ovary syndrome)、抑鬱症(depression)、飲食障礙(eating disorders)、焦慮症(anxiety)等等。
心理健康障礙(mental health disorders)、行為問題(behavioural difficulties)和學習困難(learning difficulties)的診斷人數激增，經常出現在報紙頭條和我們的對話中：“ADHD：近期診斷激增背後的原因是什麼？”，《新科學家》(New Scientist)，2023年5月。“自閉症流行率再次上升，研究發現”，《紐約時報》(New York Times)，2023年3月。其他多類心理健康障礙的情況也是如此。“大學生中的創傷後壓力症候群(PTSD)激增”，《紐約時報》，2024年5月。“抑鬱症(depression)和焦慮症(anxiety)病例在過去一年增加25%”，《福布斯》(Forbes)，2023年2月。
這些令人震驚的統計數據說明了我們的健康狀況如何？表面上看，它們似乎表明我們的心理和身體健康狀況比過去顯著惡化(considerably less mentally and physically healthy)。但還有其他解釋方式。這些數據是否僅僅反映了我們在識別醫療問題(recognising medical problems)和確定需要治療的人群(identifying people in need of treatment)方面變得更加擅長？像自閉症這樣的疾病可能因為人們終於得到了正確的診斷(right diagnosis)並獲得支持(support)而增加。但還有一種第三種可能性：這些新診斷(new diagnoses)並非完全如表面所示。可能是邊緣性的醫療問題(borderline medical problems)正被轉化為確鑿的診斷(iron-clad diagnoses)，而正常的差異(normal differences)正被病理化(pathologised)。這些統計數據可能表明，普通的生活經歷(ordinary life experiences)、身體缺陷(bodily imperfections)、悲傷(sadness)和社交焦慮(social anxiety)正被納入醫療障礙(medical disorder)的範疇。換句話說：我們並沒有變得更病態(sicker)——我們只是將更多現象歸因於疾病(sickness)。
哪一種解釋最可能是正確的，是一個難以達成共識的問題。但找到答案對我們來說至關重要，因為檢測出更輕微、更早期的健康問題(detecting health issues in milder and earlier forms)的趨勢，以及認為這總是正確做法的假設，正在無情地推進(relentlessly)。
我認為第三種可能性最有說服力：我們正成為過度醫療(too much medicine)的受害者，是時候調低診斷的刻度(turn back the dial)。我們正生活在心理和身體健康狀況的診斷時代(age of diagnosis)。而近期ADHD診斷人數的激增(explosion of people diagnosed with ADHD)就是這一現象的最佳例證。
ADHD started out as a defined medical condition in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-2) in 1968, in which it was referred to as hyperkinetic reaction in children, described in a single line as distractibility and restlessness that went away in adolescence. In 1980, the DSM-3 introduced the term attention deficit disorder (ADD), with hyperactivity added in the revised edition of the DSM-3 in 1987. The DSM-5 describes ADHD as a pattern of inattention or hyperactivity that interferes with social functioning or development. The diagnosis requires that the difficulties be present before the age of 12, that they are present in two or more settings, and reduce the quality of social, academic or occupational functioning. The distinction between mild, moderate and severe ADHD is very vague.
Like all medical problems, ADHD has a range of severities. One of my most vivid encounters with it was not with a patient, but in spending time with Kendra, the young daughter of a friend. Aged eight, Kendra, who had severe ADHD, had a level of energy and lack of focus that was impossible to keep up with. She pinged from person to person in a group, speaking quickly and jumping from topic to topic. She was a wonderfully affectionate child and I had the sense she was also very intelligent, but it was hard to test that theory because she couldn’t apply her attention to anything for long. I once joined her and her mother for a shopping trip. Such was her energy that no one could relax. I was sure she’d dash away and we’d lose her. She didn’t. She grew up safe and well cared for to become a creative adult. She still has problems with lack of focus. She found education hard, but she found her place. She’s an artist, which allows her to work at her own pace, in her own way, and which makes the most of her flexible thinking.
Diagnostic rates of severe ADHD, as Kendra had, are actually quite stable. But those with severe ADHD are now vastly outnumbered by those with mild ADHD. As with autism, there have been staggering increases in the number of people diagnosed with ADHD in the last 30 years, but that growth is almost all at the milder end of the spectrum.
New diagnosis in adulthood has gone from being very rare to as high as one in 20 adults in some places. These are almost all in the mild domain. The UK has seen a 400% increase in adults seeking an ADHD diagnosis between 2020 and 2023.
ADHD最初在1968年的《精神疾病診斷與統計手冊第二版》(Diagnostic and Statistical Manual of Mental Disorders, DSM-2)中被定義為一種醫療狀況，當時稱為兒童多動反應(hyperkinetic reaction in children)，僅用一行文字描述為注意力分散(distractibility)和躁動(restlessness)，並認為這些症狀會在青春期消失。1980年，《DSM-3》引入了注意力缺陷障礙(attention deficit disorder, ADD)的術語，1987年的《DSM-3修訂版》加入了多動性(hyperactivity)。《DSM-5》將ADHD描述為一種注意力不集中(inattention)或多動(hyperactivity)的模式，會干擾社交功能(social functioning)或發育(development)。診斷要求這些困難在12歲之前出現，存在於兩個或更多場景(two or more settings)，並降低社交、學業或職業功能(social, academic or occupational functioning)的質量。輕度(mild)、中度(moderate)和重度(severe)ADHD之間的區分非常模糊(vague)。
與所有醫療問題一樣，ADHD的嚴重程度(severities)各不相同。我對ADHD最鮮明的體驗並非來自患者，而是與朋友的年幼女兒Kendra相處的時光。Kendra八歲時患有重度ADHD(severe ADHD)，她的能量和注意力缺失(lack of focus)讓人難以跟上。她在人群中從一個人跳到另一個人(pinged from person to person)，說話很快，從一個話題跳到另一個話題(jumping from topic to topic)。她是一個非常親切(wonderfully affectionate)的孩子，我感覺她也非常聰明，但很難驗證這一點，因為她無法長時間專注於任何事物。我曾與她和她母親一起去購物。她的能量如此之大，沒有人能放鬆。我確信她會跑掉，我們會找不到她。但她沒有。她安全地長大，受到良好照顧，成為了一個有創造力的成人。她仍然有注意力缺失的問題。教育對她來說很困難，但她找到了自己的位置。她成為了一名藝術家(artist)，這讓她能以自己的節奏和方式工作，充分利用她靈活的思維(flexible thinking)。
像Kendra這樣的 heavy ADHD診斷率實際上相當穩定。但現在，重度ADHD患者被輕度ADHD(mild ADHD)患者大大超過。與自閉症(autism)一樣，過去30年中ADHD的診斷人數激增(staggering increases)，但增長幾乎全部集中在輕度範圍(milder end of the spectrum)。
成人新診斷(new diagnosis in adulthood)從非常罕見到在某些地方高達20分之一(one in 20 adults)。這些幾乎全是輕度範圍(mild domain)。英國在2020年至2023年間，尋求ADHD診斷的成人增加了400%。
Every new DSM volume suggests potential future ‘conditions’. The committee suggested ‘caffeine use disorder’ for the next edition
每一個新的《精神疾病診斷與統計手冊》(DSM)版本都會提出潛在的未來“病症”(conditions)。該委員會建議在下一版本中加入“咖啡因使用障礙”(caffeine use disorder)。
The diagnosis is less formalised than for autism. It involves a detailed clinical evaluation by a qualified professional. In addition, various rating scales are available to help quantify symptoms present that might indicate either inattention or hyperactivity. Many of these rely on self-reported symptoms. That makes the diagnosis inherently subjective. The DSM lists examples of the sort of difficulties that might be expected, including “often loses things”, “often does not seem to listen when spoken to directly”, “often avoids … tasks”, “often talks excessively”, “often fidgets”. The word “often” is open to interpretation. A diagnosis requires that symptoms interfere with the quality of social, academic or occupational functioning. That is very difficult to measure. Presumably any person who seeks out an assessment for ADHD will do so only because they are struggling in some aspect of their life.
A large number of people who have ADHD also have one or more other related diagnoses, such as autism, anxiety and depression. One study found 87% of adults with ADHD had a second psychiatric diagnosis and 56% had a third. The DSM-5 allowed a diagnosis of both ADHD and autism in the same person for the first time in 2013. Before that, these diagnoses were mutually exclusive. Since the DSM-5, the number of people with both is rising steadily. Anna has a history of depression and is considering asking for an assessment for autism.
The frank truth of it is that, despite decades of work, no biomedical research project has succeeded in finding any brain abnormality common to ADHD sufferers. There are no biomarkers that allow behaviours exhibited by people with ADHD to be distinguished from other disorders or from normal human experience. Even those researchers intent on finding the biological “cause” for ADHD will admit it is a condition that manifests in many ways in a wide range of people, and has lots of different long-term outcomes. Yet we gather people who have the traits considered consistent with ADHD under one medical category, studying and treating them as if they were a single group, all of whom unequivocally have a brain development disorder.
The biologising – or more accurately the pathologising – of mental health problems and behavioural disorders is a trend right now, within medicine and in society. It is not unusual to hear depression described as a serotonin deficiency rather than as a reaction to life circumstances. In that atmosphere, concentrating too much on the social or psychological aspects of illness is increasingly referred to as medical gaslighting by some patients – it is seen as denying somebody else’s truth.
Forgetfulness, lack of motivation, noise intolerance, social anxiety, low mood, distractibility and concentration difficulties are all part of the human experience. Each of these has become increasingly pathologised, in part because of their inclusion in categories in the DSM.
ADHD的診斷不如自閉症(autism)那樣正式化(formalised)。它涉及由合格專業人士進行的詳細臨床評估(detailed clinical evaluation)。此外，還有各種評分量表(rating scales)可用於量化可能表明注意力不集中(inattention)或多動(hyperactivity)的症狀。許多這些量表依賴於自我報告的症狀(self-reported symptoms)，這使得診斷本質上帶有主觀性(inherently subjective)。《DSM》列舉了可能預期的困難示例，包括“經常丟東西”(often loses things)、“經常在被直接對話時似乎沒在聽”(often does not seem to listen when spoken to directly)、“經常迴避任務”(often avoids … tasks)、“經常過度說話”(often talks excessively)、“經常坐立不安”(often fidgets)。其中“經常”(often)一詞的解釋空間很大。診斷要求症狀干擾社交、學業或職業功能的質量(interfere with the quality of social, academic or occupational functioning)，這一點非常難以衡量(very difficult to measure)。可以推測，任何尋求ADHD評估的人通常是因為他們在生活的某個方面感到掙扎(struggling)。
許多患有ADHD的人還同時患有一種或多種其他相關診斷(related diagnoses)，如自閉症(autism)、焦慮症(anxiety)和抑鬱症(depression)。一項研究發現，87%的ADHD成人有第二種精神病診斷(second psychiatric diagnosis)，56%有第三種。《DSM-5》在2013年首次允許同一個人同時診斷ADHD和自閉症。在此之前，這兩個診斷是互斥的(mutually exclusive)。自《DSM-5》以來，同時患有這兩者的診斷人數穩步上升(steadily)。Anna有抑鬱症的病史，且正在考慮要求進行自閉症評估(assessment for autism)。
坦白說，儘管經過數十年的研究，沒有任何生物醫學研究項目(biomedical research project)成功找到ADHD患者共有的腦部異常(brain abnormality)。目前沒有生物標記(biomarkers)可以將ADHD患者的行為與其他障礙或其他正常的人類經歷(normal human experience)區分開來。即使是那些致力於尋找ADHD生物“原因”(biological “cause”)的研究者也承認，ADHD是一種在不同人群中以多種方式表現(manifests in many ways)的病症，且具有多種不同的長期結果(long-term outcomes)。然而，我們將具有ADHD特徵(traits)的人群歸入一個醫療類別(medical category)，研究和治療他們時，彷彿他們是一個明確患有腦發育障礙(brain development disorder)的單一群體。
將心理健康問題(mental health problems)和行為障礙(behavioural disorders)生物化(biologising)—更準確地說是病理化(pathologising)—是當前醫學和社會的趨勢(trend)。將抑鬱症(depression)描述為血清素缺乏(serotonin deficiency)而非對生活環境(life circumstances)的反應並不罕見。在這種氛圍下，過多關注疾病的社會或心理面向(social or psychological aspects)越來越被一些患者稱為醫療煤氣燈操縱(medical gaslighting)—被視為否認他人的真相(denying somebody else’s truth)。
健忘(forgetfulness)、缺乏動機(lack of motivation)、噪音不耐受(noise intolerance)、社交焦慮(social anxiety)、低情緒(low mood)、注意力分散(distractibility)和專注困難(concentration difficulties)都是人類經歷(human experience)的一部分。這些現象越來越被病理化(pathologised)，部分原因是它們被納入《DSM》的診斷類別(categories)。
Systems that classify illness and disease are essential, and I can’t see how health services or research facilities would operate in their absence. The problem with the DSM is not that it exists but that it is taken more literally than intended. It also seems to be very hard to dial back DSM categories, even when it is clear they have gone too far. Whenever a tightening of criteria risks taking a diagnosis away from some people, a new diagnostic label is usually created so nobody will be without a diagnosis. That is what happened in the DSM-5, when a “social (pragmatic) communication disorder” category was developed to account for people who might no longer qualify as having autism according to the newest criteria. Every new volume even suggests problems worth considering as future “conditions”. The DSM-5 committee suggested “caffeine use disorder” as a potential category for the next edition. This is defined as problematic caffeine use leading to impairment and distress. And the biologising is already under way: studies on twins show caffeine overuse is heritable and variants in the ADORA2A gene have been associated with it.
The DSM approach is not the only way. Many fear, as I do, that biologising mental distress and behavioural problems can get in the way of an examination of life and society that might lead to personal insights that could contribute to more lasting improvement. There is a growing feeling among some medical professionals that there should be a move away from an overly biologising approach. Vocal among that group is psychologist Lucy Johnstone, who sees the diagnosis of mental health conditions as obscuring personal meaning, damaging personal identity and removing agency.
Johnstone prefers to conceptualise mental health problems as survival strategies rather than brain disorders. In this theory, experiences that are described as “symptoms” are actually a reaction to threats and a manifestation of what a person needs to do to overcome that threat. Humans are essentially social beings. Troubled behaviour and low mood are inseparable from their social environment and relationships. As Johnstone says, what is classed as mental illness can be a person’s attempt to be protected, valued or to find their place. For Anna, this might mean examining how events such as the need to change schools in the middle of an academic year affected her. Her subsequent feelings and actions might be better regarded as a survival strategy rather than as a brain disorder. “Our behaviour is an intelligible response to our circumstance, history, belief systems and bodily capacities,” Johnstone says.
分類疾病和病症的系統至關重要(essential)，我無法想像沒有這些系統，醫療服務(health services)或研究機構(research facilities)如何運作。《DSM》的問題不在於它的存在，而在於它被過於字面化(taken more literally than intended)。同時，縮減《DSM》類別(dial back DSM categories)似乎非常困難，即使這些類別顯然已經走得太遠(gone too far)。每當收緊診斷標準(tightening of criteria)可能讓某些人失去診斷時，通常會創造一個新的診斷標籤(diagnostic label)，以確保沒有人會沒有診斷。這種情況在《DSM-5》中發生了，當時開發了“社交（實用）溝通障礙”(social (pragmatic) communication disorder)類別，以涵蓋那些根據最新標準可能不再符合自閉症(autism)診斷的人。每個新版本甚至會提出值得考慮作為未來“病症”(conditions)的問題。《DSM-5》委員會建議將“咖啡因使用障礙”(caffeine use disorder)作為下一版的潛在類別。這被定義為導致功能損害和痛苦(problematic caffeine use leading to impairment and distress)的問題性咖啡因使用。生物化(biologising)已經開始：雙胞胎研究顯示咖啡因過度使用具有遺傳性(heritable)，並與ADORA2A基因的變體(variants in the ADORA2A gene)相關。
《DSM》的做法並非唯一途徑。許多人，包括我在內，擔憂將心理痛苦(mental distress)和行為問題(behavioural problems)生物化(biologising)可能阻礙對生活和社會(life and society)的審視，而這種審視可能帶來個人洞察(personal insights)，有助於更持久的改善(lasting improvement)。一些醫療專業人士越來越感覺應當遠離過度生物化的方法(overly biologising approach)。其中，心理學家Lucy Johnstone的聲音尤為突出，她認為心理健康狀況的診斷(diagnosis of mental health conditions)掩蓋了個人意義(personal meaning)，損害了個人身份(personal identity)，並剝奪了主體性(agency)。
Johnstone傾向於將心理健康問題概念化為生存策略(survival strategies)，而非腦部障礙(brain disorders)。在這一理論中，被描述為“症狀”(symptoms)的經歷實際上是對威脅(threats)的反應，以及一個人為克服該威脅所需的表現(manifestation)。人類本質上是社會性存在(social beings)。問題行為(troubled behaviour)和低情緒(low mood)與其社會環境(social environment)和人際關係(relationships)密不可分。正如Johnstone所說，被歸類為精神疾病(mental illness)的，可能是一個人試圖獲得保護、價值或找到自己位置(find their place)的努力。對Anna來說，這可能意味著審視諸如學年中途轉學(change schools in the middle of an academic year)的事件如何影響了她。她隨後的感受和行為可能更應被視為一種生存策略(survival strategy)，而非腦部障礙(brain disorder)。Johnstone說：“我們的行為是對環境、歷史、信念系統和身體能力(intelligible response to our circumstance, history, belief systems and bodily capacities)的可理解回應。”
When mental health problems are viewed in this way, recovery starts to seem far more possible. The importance of this is illustrated by the story of Prof Paul Garner, a UK-based senior medical doctor and researcher. In March 2020, Garner caught Covid-19 and was shocked to find himself severely fatigued weeks after the acute infection seemed to have passed. His initial infection had been mild but the aftermath left him feeling as if he had been hit “around the head with a cricket bat”. At points, he felt he was dying. He had a new symptom every day: muggy head, upset stomach, tinnitus, pins and needles, breathlessness, dizziness. In a blog for the British Medical Journal, he described his illness as like “an Advent calendar, every day there was something new”.
Garner is an infectious disease specialist. He expected that he, of all people, should be able to explain what was happening to his own body, but found he couldn’t. He wondered if the virus had triggered some novel immunological disorder that did not exist in medical textbooks. So he turned to the internet for answers and found he was not alone. In long Covid support groups, there were lots of people who shared his exact experience. Marathon runners who could no longer walk after mild Covid. Through the long Covid groups, he found his way to communities of people who had developed chronic fatigue syndromes after other infections. Many of these people had been ill for decades. His original expectation, based on his medical knowledge, was that he should get steadily better with time, recuperation and gentle increases in activity. But that was not marrying with his unfolding reality. A 10-minute bike ride taken on a good day had provoked a three-day relapse. So Garner decided to learn from the narratives of those who had been dealing with non-recovery for much longer than him. They recommended pacing: working within the limits of his energy levels rather than trying to exercise his way out of the situation. He took advice from a friend: “Stop trying to dominate the virus … accommodate it.” He learned to do less. That brought him to a baseline in which he was not getting worse – but he was not getting better, either.
當心理健康問題(mental health problems)以這種方式被看待時，康復(recovery)開始顯得更加可能。英國資深醫生暨研究者Paul Garner教授的故事說明了這一點的重要性。2020年3月，Garner感染了新冠病毒(Covid-19)，並震驚地發現急性感染(acute infection)似乎過去數週後，他仍感到極度疲憊(severely fatigued)。他的初始感染屬於輕症(mild)，但後續影響讓他感覺彷彿“被板球棒擊中頭部”(hit around the head with a cricket bat)。有時，他甚至覺得自己要死了。他每天都有新的症狀(new symptom)：頭腦昏沉(muggy head)、胃部不適(upset stomach)、耳鳴(tinnitus)、針刺感(pins and needles)、呼吸困難(breathlessness)、頭暈(dizziness)。他在《英國醫學期刊》(British Medical Journal)的博客中形容他的疾病像“一個降臨曆”(an Advent calendar)，每天都有新的驚喜(something new)。
Garner是一名傳染病專家(infectious disease specialist)。他認為自己作為專業人士，應該能夠解釋自己身體發生的事情，但發現自己無法做到。他懷疑病毒是否引發了某種醫學教科書中不存在的新型免疫疾病(novel immunological disorder)。於是，他轉向網絡尋找答案，發現自己並不孤單。在長期新冠支持團體(long Covid support groups)中，許多人分享了與他完全相同的經歷。馬拉松跑者(marathon runners)在輕症新冠後無法行走。他通過長期新冠團體接觸到因其他感染而患上慢性疲勞症候群(chronic fatigue syndromes)的人群，其中許多人已經病了數十年。他最初的預期，基於他的醫學知識，是隨著時間、休養(recuperation)和逐步增加活動(gentle increases in activity)，他應該會逐漸好轉。但這與他正在經歷的現實不符。在感覺良好的一天進行10分鐘的自行車騎行(10-minute bike ride)，卻引發了三天的復發(three-day relapse)。因此，Garner決定向那些比他更久未康復的人學習經驗。他們建議採取節能策略(pacing)：在能量水平限度內活動(working within the limits of his energy levels)，而不是試圖通過運動(exercise)來擺脫困境。他接受了一位朋友的建議：“停止試圖支配病毒……適應它”(Stop trying to dominate the virus … accommodate it)。他學會了減少活動(do less)。這讓他達到了不再惡化的基線(baseline)，但他也沒有好轉。
I suddenly believed I’d recover completely. I stopped reading about illness and discussing symptoms. I spent time seeking joy
That could have been where Garner’s story ended. By September 2020, he had improved but he was no longer recovering further. So he started searching beyond the non-recovery stories, for those with more positive outcomes. That was how he found Recovery Norway, a group of people who once had chronic fatigue syndrome but had beaten it. The group gave him a recovery mentor as well as another perspective and, crucially, a recovery identity. He realised that while pacing had helped him at the start, he had then become obsessed with it. As he described in his blog, he had started to unconsciously monitor signals from his body until he became paralysed with fear. He believed long Covid was a metabolic disease that had damaged his mitochondria, but the Norway group made him think differently. He didn’t doubt the virus had triggered the fatigue but felt he had later become caught in a vicious cycle of illness driven by his fear. Viruses cause fatigue in order to make people rest, which promotes recovery. But, in Garner’s case, his recovery had gone awry because he inadvertently conditioned his body to stay tired. Garner realised he had to retrain his brain to react differently to the fatigue if he was to get better.
“I suddenly believed I would recover completely,” he writes. “I stopped my constant monitoring of symptoms. I avoided reading stories about illness and discussing symptoms, research or treatments by dropping off the Facebook groups with other patients. I spent time seeking joy, happiness … and overcame my fear of exercise.” By the end of 2020 he had made a full recovery.
我突然相信我會完全康復(I would recover completely)。我停止閱讀關於疾病的故事和討論症狀(stopped reading about illness and discussing symptoms)。我花時間尋求快樂(seeking joy)。這本可能是Garner故事的終點。到2020年9月，他的狀況有所改善，但不再進一步康復(recovering further)。於是，他開始尋找超越非康復故事(non-recovery stories)的內容，尋找那些更積極的結果(positive outcomes)。這讓他發現了“挪威康復團體”(Recovery Norway)，一群曾患有慢性疲勞症候群(chronic fatigue syndrome)但已克服它的人。這個團體為他提供了一位康復導師(recovery mentor)和另一種視角，以及至關重要的康復身份(recovery identity)。他意識到，雖然節能策略(pacing)在一開始幫助了他，但他後來對其過分執著(obsessed with it)。正如他在博客中描述，他開始無意識地監測身體信號(unconsciously monitor signals from his body)，直到被恐懼癱瘓(paralysed with fear)。他曾認為長期新冠(long Covid)是一種代謝疾病(metabolic disease)，損害了他的線粒體(mitochondria)，但挪威團體讓他改變了想法。他不否認病毒引發了疲憊(triggered the fatigue)，但感覺自己後來陷入了一個由恐懼驅動的疾病惡性循環(vicious cycle of illness)。病毒引起疲憊(fatigue)是為了讓人休息，從而促進康復。但在Garner的案例中，他的康復出了差錯(gone awry)，因為他無意中讓身體習慣了疲憊狀態(conditioned his body to stay tired)。Garner意識到，如果要好轉，他必須重新訓練大腦(retrain his brain)以不同方式應對疲憊。
他寫道：“我突然相信我會完全康復。”他停止了對症狀的不斷監測(constant monitoring of symptoms)，避免閱讀關於疾病的故事或討論症狀、研究或治療，退出了與其他患者的臉書團體(dropping off the Facebook groups)。他花時間尋求快樂和幸福(seeking joy, happiness)，並克服了對運動的恐懼(fear of exercise)。到2020年底，他完全康復(made a full recovery)。
ADHD USED TO HAVE a recovery identity. In the 1960s and 70s, the DSM described it as condition that went away in adolescence. By the 90s, it was recognised that the symptoms did not always disappear completely but did lessen as people got older. Some studies found remission in up to 60% of people. Severe ADHD lessened but often persisted, while people with mild ADHD could expect a chance of full recovery. But ADHD is slowly being incorporated into the identities of many young people. Some support groups discourage the attempt to overcome ADHD traits. People are told to unmask and to share their ADHD selves with others. But learning to control our moods, behaviour and impulses is part of growing up, whether one has ADHD or not. We all become more socially competent, gain focus and are better able to cope through practice. Encouraging young people to do otherwise may be well-intentioned but potentially sets them up for non-recovery. The rise in subtler ADHD presentations in adults may also undermine a young person’s expectation that their difficulties will disappear in time. A growing population of adults have incorporated ADHD into their self-concept. When a medical problem is part of a person’s identity, it becomes inescapable.
ADHD 過去被認為是一種會隨著時間消退的病症（recovery identity）。在 1960 年代和 70 年代，DSM（Diagnostic and Statistical Manual of Mental Disorders）將其描述為一種在青春期會消失的狀況。到了 90 年代，人們認識到 ADHD 的症狀並不總是完全消失，但隨著年齡增長會有所減輕。一些研究發現，高達 60% 的人可能出現症狀緩解（remission）。嚴重的 ADHD 雖然減輕但往往持續存在，而輕度 ADHD 患者則有機會完全康復（full recovery）。然而，ADHD 正逐漸被許多年輕人納入自我認同（self-identity）的一部分。一些支持團體不鼓勵人們試圖克服 ADHD 的特徵（traits）。他們被鼓勵「脫下面具」（unmask）並向他人展示他們的 ADHD 自我（ADHD selves）。但無論是否患有 ADHD，學會控制情緒、行為和衝動是成長的一部分（part of growing up）。我們都通過練習變得更具社交能力（socially competent）、更專注（gain focus），並且更能應對挑戰（better able to cope）。鼓勵年輕人反其道而行可能是出於好意，但可能會讓他們陷入無法康復的境地（non-recovery）。成人中較輕微的 ADHD 表現（subtler ADHD presentations）增加，也可能削弱年輕人對症狀會隨時間消失的期望（expectation）。越來越多的成年人將 ADHD 融入他們的自我概念（self-concept）。當一個醫療問題成為個人認同的一部分時，它就變得難以擺脫（inescapable）。
Neurodiversity was coined in 1998 by the Australian sociologist Judy Singer. It is not actually a medical term but it sounds like one. In an interview, Singer described how she came up with it: “I got it from a combination of biodiversity, which is a political term saying it’s good to have diversity in the environment. I noticed that psychotherapy was becoming a bit of a joke and neuroscientists were the new priesthood, so I thought, let’s put them together.”
The term has come to be used to encompass a range of conditions, including depression, ADHD, autism, dyslexia, dyspraxia and Tourette syndrome. There is certainly a lot that is positive to be said about its use to remind us that all our brains are different and that, as a consequence, we perceive the world and function differently. There is no right or wrong way to behave or feel, and all ways of being should be embraced.
神經多樣性（Neurodiversity）這個詞由澳洲社會學家朱迪·辛格（Judy Singer）於1998年創建。它其實並非一個醫學術語，但聽起來像是一個醫學詞彙。在一次採訪中，辛格描述了她是如何想到這個詞的：「我從『生物多樣性』（biodiversity）這個政治術語中得到靈感，這個詞認為環境中的多樣性是件好事。我注意到心理治療（psychotherapy）正變得有些像個笑話，而神經科學家（neuroscientists）則像是新的『神職人員』（priesthood），所以我想，何不把這兩個概念結合起來。」
這個詞後來被用來涵蓋一系列狀況，包括抑鬱症（depression）、ADHD、自閉症（autism）、閱讀障礙（dyslexia）、運動協調障礙（dyspraxia）和妥瑞氏症（Tourette syndrome）。它的使用確實有許多正面意義，提醒我們每個人的大腦都不相同，因此我們感知世界和運作的方式也各異。行為或感受沒有所謂的對錯，所有存在的方式都應該被接納（embraced）。
However, the problem is that the term is not used in that way. Instead, it is used as a counterpoint to the term “neurotypical”. A neurotypical person is said to organise their thoughts and behave in a “typical” way. A very common explanation for the difference between neurodivergent and neurotypical people is that the latter were born with an inbuilt handbook for life, which gives them an innate sense of social rules. Neurodivergent people did not receive the handbook and therefore have to work much harder to learn and fit in. The division of people into typical and diverse immediately contradicts the sensible statement that we are all different. It brings to mind George Orwell’s Animal Farm, where the pigs decide that “all animals are equal, but some animals are more equal than others”.
然而，問題在於「神經多樣性（neurodiversity）」這個詞並未被如此使用。相反，它被用來與「神經典型（neurotypical）」一詞形成對比。據說神經典型的人以「典型」的方式組織思維和行為。一個很常見的解釋是，神經典型的人天生擁有一本「人生手冊」（inbuilt handbook for life），這讓他們對社交規則（social rules）有天生的直覺。而**神經多樣（neurodivergent）**的人則沒有這本手冊，因此需要付出更多努力來學習和適應。將人分成「典型」和「多樣」立刻與「我們都不同」的合理說法相矛盾。這讓人想起喬治·奧威爾（George Orwell）的《動物農莊》（Animal Farm），其中豬宣稱「所有動物一律平等，但有些動物比其他動物更平等」。
Neurodivergent conditions are still finding their place but what is clear is that people with that label are suffering. Their hardship is real or they would not have sought a diagnosis. Anna has struggled for a very long time. She’s had a lot of internal pain and needs support. But the question arises as to whether the benefits to those diagnosed with ADHD outweigh the drawbacks of being labelled with a brain disorder. If they do not, then this is an example of overdiagnosis – the diagnosis might be right but it is not beneficial.
神經多樣的狀況仍在尋找其定位，但顯而易見的是，被貼上這個標籤的人正在承受痛苦。他們的困難是真實的，否則他們不會尋求診斷。安娜（Anna）長期以來一直在掙扎，她內心承受了很多痛苦（internal pain），需要支持。但問題在於，被診斷為 ADHD 的人所獲得的好處，是否超過了被標籤為**腦部疾病（brain disorder）的弊端。如果答案是否定的，這就是過度診斷（overdiagnosis）**的例子——診斷可能是正確的，但對當事人並無益處。
The issue with overdiagnosis is always around the benefit of diagnosis and value of special accommodations to those mildly affected. One Canadian study compared university students with ADHD, some of whom received no special accommodations and some of whom were given help, such as extended time for tests and separate test-taking rooms. The students who got extra support perceived it as helpful but there was no measurable benefit in terms of academic performance. Several studies have looked at school-age children and students in higher education who were given various allowances, including a reduced distraction environment, use of a calculator, more frequent breaks and oral presentation of written information. Again, people with ADHD who received this extra support performed no better than pupils with ADHD who did not. One study found children screened for ADHD in school did not benefit but raised the concern that they were harmed by being labelled at such a young age. Similarly, special accommodations made to support adults with ADHD have yet to be proved to make a useful difference to their lives.
過度診斷的問題總是圍繞診斷的益處以及對輕度受影響者的特殊安排（special accommodations）的價值。一項加拿大研究比較了患有 ADHD 的大學生，其中一些人沒有得到特殊安排，另一些人則獲得了幫助，例如延長考試時間（extended time for tests）和單獨的考試環境（separate test-taking rooms）。接受額外支持的學生認為這有幫助，但學業表現（academic performance）上並沒有可衡量的益處。其他幾項研究調查了學齡兒童和高等教育學生，他們被給予各種特殊安排，包括減少干擾的環境（reduced distraction environment）、使用計算器（use of a calculator）、更頻繁的休息（more frequent breaks）以及口頭呈現書面信息（oral presentation of written information）。同樣，接受這些額外支持的 ADHD 患者表現並不比未接受支持的 ADHD 學生更好。一項研究發現，在學校篩查 ADHD 的兒童並未從中受益，反而擔心他們因年幼被貼上標籤而受到傷害（harmed by being labelled）。同樣，為了支持 ADHD 成人而做出的特殊安排，尚未被證明對他們的生活產生實質性的正面影響（make a useful difference）。
Stimulants are not first-line treatment for ADHD in children. They are reserved for when behavioural treatments and support are not enough. The short-term efficacy of stimulants in children is considered to be well-established in reducing symptoms such as hyperactivity. They improve concentration and teachers perceive better behaviour in children taking them. However, most studies have followed the children for only a short period of time. What is less clear is whether or not that symptom reduction translates to something more meaningful in the long term, such as a better quality of life or academic performance. Stimulant medication reduces symptoms only while you are taking it. For a more lasting treatment effect, behavioural interventions are needed. Again, children with severe ADHD are the ones who stand to gain from stimulant medication, because their disability is such that medication has a more palpable effect on their ability to concentrate on tasks such as reading so they have time to learn. At the mild end, there is doubt that stimulant use has enough of an impact to offset either the negative effects of labelling or the low expectation that can be inferred from a mental health diagnosis.
**興奮劑（Stimulants）**不是兒童 ADHD 的首選治療（first-line treatment）。它們通常在行為治療（behavioural treatments）和支持不足以應對時才會使用。興奮劑在短期內減少症狀（如過動症，hyperactivity）的效果被認為是確立的。它們能改善注意力（concentration），教師也認為服用興奮劑的兒童行為有所改善（better behaviour）。然而，大多數研究僅對兒童進行了短期的追蹤。尚不清楚的是，症狀的減輕是否能轉化為長期更有意義的結果，例如更好的生活品質（quality of life）或學業表現（academic performance）。興奮劑僅在服用期間能減少症狀（reduces symptoms only while you are taking it）。要實現更持久的治療效果（lasting treatment effect），需要行為介入（behavioural interventions）。嚴重 ADHD 的兒童（severe ADHD）是最有可能從興奮劑中受益的群體，因為他們的障礙（disability）程度使得藥物對其專注於閱讀等任務（concentrate on tasks such as reading）的能力有更明顯的效果，從而為學習爭取時間。然而，對於輕度 ADHD（mild end），興奮劑的使用是否足以抵消標籤化（negative effects of labelling）或心理健康診斷（mental health diagnosis）所帶來的低期望（low expectation）的負面影響，仍存在疑問。
It is only anecdotal, but the lack of palpable life improvements for people diagnosed with either ADHD or autism is something that concerned me many times as I interviewed people about this subject. Of the scores of people I spoke to, all of whom were adults, all perceived their lives to be better off thanks to a diagnosis. Every person welcomed the diagnosis into their lives. But almost all had left their job, dropped out of education and lost many old friends. Several were housebound. The same can be said about those I spoke to with chronic Lyme disease and long Covid. I saw a worrying gap between the perceived benefit of being diagnosed and any actual improvements in quality of life. In most conversations, I was left wondering how long the positive impact of validation would last.
雖然只是軼事證據（anecdotal），但對 ADHD 或**自閉症（autism）患者的診斷未能帶來顯著的生活改善（palpable life improvements），這在我採訪相關人士時多次讓我感到擔憂。我與數十位成人交談過，他們都認為診斷讓他們的生活變得更好（perceived their lives to be better off）。每個人都欣然接受了診斷（welcomed the diagnosis）。但幾乎所有人都離開了工作（left their job）、放棄了學業（dropped out of education），並失去了許多老朋友（lost many old friends）。有些人甚至足不出戶（housebound）。我與患有慢性萊姆病（chronic Lyme disease）和長新冠（long Covid）的人交談時，也觀察到類似的現象。診斷的感知益處（perceived benefit）**與生活品質（quality of life）的實際改善之間存在令人擔憂的差距（worrying gap）。在大部分對話中，我不禁思考，診斷帶來的認可（validation）的正面影響能持續多久。
The people I talked to each got great psychological relief from their diagnosis and were sure it had made their lives better. Perhaps what they actually needed from a diagnosis was permission to do less in a world that values only very particular types of success. For some, medical diagnosis is a means to take the pressure off, so they no longer feel forced to continue chasing after an overly idealistic social and work life.
我交談過的人都從診斷中獲得了巨大的心理慰藉（psychological relief），並確信這讓他們的生活變得更好。或許他們真正需要的，是診斷允許他們在一個只重視特定成功類型（particular types of success）的世界中減少壓力（do less）。對一些人來說，醫療診斷（medical diagnosis）是一種減壓的方式（take the pressure off），讓他們不再感到必須追逐過於理想化的社交和工作生活（overly idealistic social and work life）。
One woman’s story stood out. She’s an artist who has had some significant successes, but not the success she wanted. She would prefer to be an academic, she told me, but it wasn’t her talent. As a teenager, she imagined her adult self quoting poetry off the cuff. The pain of not turning out to be that adult was terrible for her. It stopped her enjoying the success she had. Eventually, a diagnosis of ADHD helped her accept that she could not be equally talented in every way she wanted. The diagnosis gave her some comfort but also caused stagnation in her life. It reinforced her belief in a lesser version of herself. Rather than being defined by a successful art career that others would envy, she became a woman whose life revolved around ADHD and was defined by the things she could not do because she was neurodevelopmentally different. I worry that a child told they are different in this way will underestimate themselves and limit their future.
一位女性的故事尤其突出。她是一位取得了一些重要成就的藝術家，但這些成就並非她想要的。她告訴我，她更希望成為一名學者（academic），但這不是她的天賦（talent）。在她青少年時期，她想像成年後的自己能隨口引用詩歌（quoting poetry off the cuff）。未能成為這樣的成年人的痛苦（pain of not turning out to be that adult）對她來說非常嚴重，這讓她無法享受已有的成功（enjoying the success she had）。最終，ADHD 的診斷幫助她接受了自己無法在每個她期望的領域都同樣出色（equally talented in every way）。這診斷給了她一些安慰（comfort），但也導致了她生活的停滯（stagnation）。它強化了她對一個「較差版本的自己」（lesser version of herself）的信念。她不再是被他人羨慕的成功藝術事業（successful art career）所定義，而是成為一個生活圍繞 ADHD、被她因**神經發育差異（neurodevelopmentally different）**而無法做到的事情所定義的女性。我擔心，以這種方式被告知自己與眾不同的孩子，會低估自己（underestimate themselves）並限制自己的未來（limit their future）。
Excessive medical diagnosis risks robbing people of a recovery identity and promoting intolerance by othering; by dividing the world into neurodivergents and neurotypicals. It must be very hard to set out or continue on life’s big journey if your aspirations have been narrowed by a diagnosis that is uncertain or offers very little. Let’s find a way to be more tolerant of difference and imperfections that still allows people to live a life unencumbered by a diagnosis.
過度的醫療診斷（excessive medical diagnosis）可能會剝奪人們的康復認同（recovery identity），並通過他者化（othering）——將世界分為神經多樣（neurodivergents）和神經典型（neurotypicals）——來助長不寬容（promoting intolerance）。如果一個人的志向（aspirations）被一個不確定或幫助甚微的診斷所限制（narrowed by a diagnosis），要踏上或繼續人生的重大旅程（life’s big journey）必定非常困難。讓我們找到一種更寬容差異和不完美（tolerant of difference and imperfections）的方式，讓人們能過上不受診斷束縛（unencumbered by a diagnosis）的生活。