Διαταραχή Προσοχής στους Ενήλικες-ΔΕΠΥ

ΤΑ 6 ΕΜΠΟΔΙΑ ΣΤΗ ΔΙΑΓΝΩΣΗ ΤΗΣ ΔΕΠΥ στους ενήλικες

Το κείμενο που ακολουθεί είναι συνοπτική μεταφορά του άρθρου “Adult ADHD: A Review of the Clinical Presentation, Challenges, and Treatment Options“,των Jennifer A. Reinhold, PharmD, BCPS, BCPP που δημοσιεύτηκε στους Psychiatric Times. (accessed on 18.06.2017).

Ο τρόπος που εκδηλώνεται η Διαταραχή Ελλειματικής Προσοχής-Υπερκινητικότητας (ΔΕΠΥ) στους ενήλικες διαφέρει σημαντικά από τον τρόπο που εκδηλώνεται στα παιδιά ή στους εφήβους

Πολλές φορές θεωρούμε ότι η ΔΕΠΥ βελτιώνεται ή “ξεθωριάζει” και σβήνει ή χάνεται καθώς ο ασθενής ενηλικιώνεται και “ωριμάζει”. Αυτό όμως που συμβαίνει στην πραγματικότητα είναι ότι γίνεται μια μετάθεση και αλλαγή των συμπτωμάτων.

Η ελλειμματική προσοχή εμφανίζεται ως δυσκολία στην ολοκλήρωση διαφόρων εργασιών ή υποχρεώσεων, ως δυσκολία στη διαχείριση του χρόνου και τον προγραμματισμό, ώς δυσκολία στην παρατεταμένη προσπάθεια επίτευξης ενός στόχου, στο εύκολο ξέχασμα και τη δυσκολία στη συγκέντρωση.

Η απόδοση στις επαγγελματικές υποχρεώσεις αλλά και η σταθερότητα των διαπροσωπικών σχέσεων επηρεάζονται με αποτέλεσμα συχνές αλλαγές εργασίας, ανεργία και χαμηλές αποδοχές. Καθώς έχει προβλήματα λειτουργικότητας και μνήμης, η ανταπόκρισή του στο ρόλο που έχει στην κοινωνία και στην οικογένεια είναι δύσκολη, με αποτέλεσμα να δοκιμάζονται συχνά οι σχέσεις του με συνεργάτες, με φίλους αλλά και με μέλη της οικογένειάς του.

Η διάγνωση – Οι δυσκολίες της

Αντικειμενική διάγνωση της Διαταραχής Ελλειματικής Προσοχής σε έναν ενήλικα είναι πολύ δύσκολη για δύο κυρίως λόγους. Ο πρώτος είναι ότι, συχνά, τα συμπτώματα της ΔΕΠΥ μπορεί να επικαλυφθούν άπό συμπτώματα κατάθλιψης. Ο δεύτερος λόγος είναι ότι πολύ συχνά οι άνθρωποι με ΔΕΠΥ, έχουν επίγνωση των συμπτωμάτων τους και την εμπειριά να αναπτύξουν διάφορους αντισταθμιστικούς μηχανισμούς. Για παράδειγμα τα συχνά ξεχάσματα μπορούν να τα βελτιώσουν αναπτύσσοντας αντισταθμιστικές συνήθειες όπως σχολαστικός προγραμματισμός και δημιουργία πολλών συστημάτων υπενθύμισης (alarm στο κινητό, χαρτάκια με τις υποχρεώσεις και τα ραντεβού κλπ).

1 Ανυπαρξία έγκυρων κριτηρίων.

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Επειδή η ΔΕΠΥ θεωρείται αναπτυξιακή διαταραχή, θα πρέπει πρώτα από όλα να διαπιστωθούν συμπτώματα της διαταραχής αυτής στην παιδική ηλικία. Ετσι πρέπει να γίνει από τον ψυχίατρο, αναδρομική αξιολόγηση συμπτωμάτων που μπορεί να υπήρχαν στην παιδικη και την εφηβική ηλικία. Αυτό γίνεται ακόμη πιό δύσκολο καθώς πολλοί ασθενείς έχουν δυσκολίες στο να ξαναθυμηθούν τα συμπτώματα που μπορεί να τους ταλαιπωρούσαν όταν ήταν παιδιά ή έφηβοι. Ο γιατρός καλείται να διακρίνει άν πρόκειται για περιστατικό που είχε ΔΕΠΥ από παιδικής ηλικίας ανεξάρτητα άν το εγνώριζε ή όχι ή αν πρόκειται για περιστατικό όπου η ΔΕΠΥ εμφανίστηκε όψιμα στην ενήλικη ζωή.

2 Συν-νοσηρότητα και επικάλυψη συμπτωμάτων

bbk-comorbidityΠολύ συχνά, άτομα με αγχώδεις ή συναισθηματικές διαταραχές μπορεί να εμφανίσουν συμπτώματα που μοιάζουν με τα συμπτώματα της ΔΕΠΥ. Τα πιό συνηθισμένα είναι τα προβλήματα στο επαγγελματικό περιβάλλον, στην κοινωνική λειτουργικότητα, στην παρορμητικότητα της συμπεριφοράς κλπ. Επίσης η διπολική διαταραχή μπορεί να δημιουργήσει συμπτώματα παρορμητικής συμπεριφοράς όπως και η ΔΕΠΥ. Βέβαια στη διπολική διαταραχή έχουμε την χαρακτηριστική διακύμανση “ανεβάματα και κατεβάσματα” της συμπεριφοράς, συνήθως καλύτερη ανταπόκριση στις επαγγελματικές υποχρεώσεις και μεγαλυτερη στοχοπροσήλωση.

3 Αντισταθμιστικοί μηχανισμοί

bbk-compensatoryΑσθενεις με ΔΕΠΥ με υψηλή λειτουργικότητα και υψηλότερο του μέσου όρου δείκτη νοημοσύνης (πράγμα που δεν είναι σπάνιο) αναπτύσουν μηχανισμούς και διάφορα “κόλπα” είτε για να ξεπεράσουν είτε για να κρύψουν τα συμπτώματά τους. Σχηματίζουν αναλυτικές λίστες με τις υποχρεώσεις τους καθώς και υπενθυμιστικά μέσα (ξυπνητήρια, χαρτάκια που τα κολλούν σε επίκαιρα μέρη κλπ). Επίσης φροντίζουν να δημιουργήσουν συνήθειες καθημερινότητας που τους βοηθούν να ανταποκρίνονται στις υποχρεώσεις τους να μή χάνουν τα πράγματά τους κλπ. Η ανάπτυξη αντισταθμιστικών μηχανισμών όχι μόνο δεν είναι κακή αλλά λειτουργεί και θεραπευτικά. Το μόνο πρόβλημα που μπορει να δημιουργεί είναι το “θόλωμα της εικόνας” που δυσκολεύει την επιβεβαίωση της διάγνωσης της ΔΕΠΥ.

4 Τί σημαίνει “σοβαρές επιπτώσεις”;

bbk-soctensΣτο DSM-5 που είναι το αμερικανικό διαγνωστικό εγχειρίδιο αναφέρονται αναλυτικά τα συμπτώματα που χαρακτηρίζουν το άτομο με ΔΕΠΥ. Ταυτόχρονα αναφέρεται ότι για να τεθεί η διάγνωση πρέπει να υπάρχουν σοβαρές επιπτώσεις στη λειτουργία του ατόμου. Με τον τρόπο αυτόν όμως υπεισέρχεται ο υποκειμενικός παράγοντας στη διάγνωση που είναι το τί μπορεί να θεωρηθεί “σοβαρή επίπτωση”. Παραδείγματα “σοβαρών επιπτώσεων” είναι η απειθαρχία στην εργασία και απολύσεις, συνεχείς προστριβές στις προσωπικές σχέσεις, συχνά ατυχήματα κλπ.

5 Υπερ-διάγνωση ή μή-διάγνωση;

bbk-balanceΥπάρχουν δύο παράγοντες που μπορεί να οδηγήσουν στο ένα ή στο άλλο λάθος. Ο ένας παράγοντας είναι αλληλοεπικάλυψη των συμπτωμάτων της ΔΕΠΥ με συμπτώματα άλλων παθήσεων όταν υπάρχει συν-νοσηρότητα όπως πχ κατάθλιψη ή διπολική διαταραχή. Ο άλλος παράγοντας είναι ο φόβος μήπως τεθεί λανθασμένα η διάγνωση της ΔΕΠΥ με συνέπεια να λάβει ο ασθενής φαρμακευτική αγωγή με φάρμακα που πολλά από αυτά έχουν διεγερτικές-εθιστικές ιδιότητες. Τέλος, η έλλειψη εξειδίκευσης και εμπειρίας του γιατρού που θα αντιμετωπίσει για πρώτη φορά τον ασθενή μπορεί να οδηγήσει στο ένα από τα δύο αυτά λάθη.

6 Παραπλάνηση ιατρών;

bbk-fraudΑπό την εμπειρία στις ΗΠΑ έχουμε τα εξής δεδομένα: νεαρά άτομα μεταξύ 18-25 ετών αποτελούν την πλειοψηφία αυτών που κάνουν χρήση συνταγογραφούμενων εξαρτητικών ουσιών. Επίσης τα διεγερτικά φάρμακα αποτελούν τις “αγαπημενες ουσίες” για τις ηλικίες από τα 18 ώς 22 ετών.

Μπορούμε να θεωρήσουμε ότι, λίγο-πολύ, τα ίδια θα ισχύουν και στην Ελλάδα. Επομένως ο γιατρός θα πρέπει να μην υποτιμά τον κίνδυνο της προσποίησης προκειμένου να προμηθευτεί ένα άτομο εθιστικές ουσίες με νόμιμο τρόπο, με την (αθέλητη) βοήθεια του γιατρού που θα παραπλανηθεί ώστε να βάλει τη διάγνωση της διαταραχής ελλειματικής προσοχής.

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