注意力缺陷神经心理学（ADHD）第1部分与Russell Barkley的返场

这些功能大约需要三十年才能成熟，而ADHD患者的发展会延迟数年，我认为大约延迟了25%到30%。

They take about thirty years to mature and they're delayed in people with ADHD by several years or what I estimate to be probably around twenty five, thirty percent.

但你知道，具体数字并不重要。

But, you know, the number doesn't matter.

事实是，别人正在发展的这些能力，你却没有获得。

The fact is these abilities that everybody else is getting, you're not getting.

它们是什么？

What are they?

说说看。

Let's have it.

第一，抑制力，自我约束。

Number one, inhibition, self restraint.

第二，自我意识，能够监控和关注自己的行为。

Number two, self awareness, the ability to monitor and attend to your own behavior.

这两项能力在生命早期就开始发展。

Both of these start very early in life.

每项能力至少需要十年才能成熟，甚至更久。

Each takes at least ten years to mature, if not more.

当这些能力开始发展时，你会获得接下来的两项，它们与工作记忆有关。

And then when those start to kick off, you get the next two, which has to do with working memory.

第一项是非语言工作记忆，但你更熟悉它作为视觉想象，即想象事物的能力。

And the first one is nonverbal working memory, but you know it as visual imagery, which is a capacity to imagine things.

你会在脑海中回忆过去的画面，称之为 hindsight（事后洞察），并用这些画面来预测接下来可能发生的事情。

You recall images in your mind from your past, call it hindsight, and you use those to anticipate what could happen next.

预见力。

Foresight.

第四项是你将获得的内心声音。

The fourth thing you're going to get is the mind's voice.

你会开始对自己使用语言。

You're going to start to develop language to yourself.

这一切都是大声说出来的。

It's all out loud.

小孩子会大声对自己说话。

Little children talk out loud to themselves.

但到了八到十岁的时候，这种自我对话就应该在脑子里进行了。

But by the time you're eight to 10, that should be in your head.

你应该能够不被人听见、不移动嘴唇就对自己说话。

You should be able to talk to yourself without people hearing and without you moving your lips in your face.

现在你已经有了四种执行能力。

And so now you've got four executive abilities.

你可以自我克制，可以监控自己，可以对自己进行视觉想象，也可以对自己说话。

You can self restrain, you can monitor yourself, you can visualize to yourself, and you can talk to yourself.

这就像一把多功能的思维工具，能让你掌控自己。

And that's a little Swiss army knife of mind tools that allows you to control yourself.

接下来你会获得另外三种能力。

Then you get the next three.

你利用这四种能力来管理情绪，因此情绪自我调节随之而来，与之相伴的还有自我激励。

You use those four to manage your emotions, so emotional self regulation comes next and with that, right along with it is self motivation.

最后，你获得了最重要的能力——计划与解决问题。

And then finally, you get the biggie, the last one, which is planning and problem solving.

能够在脑海中操控信息，找到应对障碍的方法，帮助你实现目标并解决问题。

The ability to manipulate stuff in your head to come up with solutions to get around obstacles and help you get to your goals and solve your problems.

医生。

Doctor.

巴克利引用了医生的研究。

Barkley cites the work of Doctor.

乔尔·尼格，他认为注意力缺陷多动障碍更像是一种谱系障碍，其损害程度范围广泛。

Joel Nieg, who argues that ADHD is more of a spectrum disorder with wide ranges in impairment.

一个极其简化的六万英尺视角是，大脑有两种信号系统。

An incredibly oversimplified 60,000 foot view is that the brain has two kinds of signaling.

自下而上的信号：我们的感知影响注意力和情绪，我们会对此做出反应。

Bottom up, where what we sense influences our attention and our emotion, we react to it.

以及自上而下的信号：我们对自下而上的信号做出回应，并从前额叶皮层向大脑内部和后部发出指令，说：‘别紧张。’

And then top down, where we respond to that bottom up signaling and toss a command back from our prefrontal cortex to the interior and the back of the brain to say, Hey, it's cool.

我们没事。

We're good.

我们没事。

We're good.

别担心。

Don't worry about it.

所以，在《态度》杂志的一篇文章中，尼格博士写道：

So in an article in Attitude Magazine, Doctor.

在神经典型的大脑中，上下行信号保持良好的平衡。

Nigg writes that in a neurotypical brain, there's a good balance of top down and bottom up signals.

但在ADHD大脑中，下行信号相对较弱，可能被对刺激作出反应的强烈上行信号所压倒。

But in the ADHD brain, the top down signals are relatively weak and possibly overpowered by the screaming bottom up signals that are reacting to stimuli.

那么结果是什么？

So what is the result?

比如注意力不集中、冲动和情绪失调，导致这七种缺陷的谱系表现。

Things like inattention, impulsivity, and emotional dysregulation leading to a spectrum of those seven deficits.

就是我们几分钟前提到的那些。

You know, ones we mentioned a couple minutes ago.

所以小测验一下，它们是什么？

So pop quiz, what were they?

来吧。

Come on.

你没在听吗？

Were you not listening?

你能说出这七个吗？

Can you not name the seven?

好吧。

Okay.

开玩笑的。

Just kidding.

可能没人能说出来。

Probably no one can.

它们是什么？

What were they?

它们是自我意识、抑制能力、非语言工作记忆（即心理意象）、语言工作记忆或内心独白、情绪自我调节、自我激励，第七个是计划和解决问题。

They were self awareness, inhibition, nonverbal working memory, aka mental imagery, verbal working memory or your inner monologue, emotional self regulation, self motivation, and then planning and problem solving was number seven.

本集不会有任何小测验。

There will be no pop quizzes in this episode.

那样太苛刻了，也不有趣。

That would be mean and not fun.

这些是ADHD患者不同程度上所具备的七种缺陷。

Those are the seven deficits that people with ADHD have to varying degrees.

你该如何识别它们？

How would you recognize that?

你会看到，首先，他们非常冲动，表现出极差的自控力和自我调节能力。

You would see that because number one, they're very impulsive and show very poor self control and self regulation.

其次，他们对自己的困难不如周围人那么敏感，因为他们不像你那样进行充分的自我监控。

Two, they're not as aware of their difficulties as are the people around them because they're not self monitoring to the extent that you do.

第三，他们的时间管理能力极差，因为工作记忆系统在一定程度上赋予你对时间与节奏的感知，让你能够思考未来，预判接下来会发生什么，并据此调整自己的行为。

Three, they are horrible at time management because the working memory system in part gives you your sense of time and timing and allows you to think about the future to deliberate what is coming next and then to use that to inform your own behavior.

因此，时间管理成为一项主要缺陷，且随着年龄增长而越来越严重，因为生活随着年龄增长变得越来越依赖时间。

So time management, it becomes a major deficit that just gets worse and worse with age because life becomes more time sensitive with age.

三岁的孩子不需要管理时间。

Three year olds don't have to manage time.

三十岁的人则对时间极其敏感。

30 year olds are incredibly time sensitive.

你一天中的大部分时间都被截止日期、日程安排、承诺、义务、账单填满，每件事都有明确的时间标签。

Most of your day is filled with deadlines, schedules, promises, commitments, bills, everything has a time tag on it.

因此，我创造了‘时间盲’这个词，正如你在我的书中所看到的那样。

And so that's when I came up with the word, as you saw in my book, time blind.

患有注意力缺陷多动障碍的成年人——儿童也是如此，但尤其是成年人——在理解时间概念以及如何应对和管理自身与时间的关系方面存在困难。

Adults with ADHD, kids are too, but especially adults, struggle with this concept of time and how you cope with this and manage yourself relative to it.

当然，你还会看到情绪自我调节的问题，比如情绪冲动、难以像其他人那样控制自己的情绪。

And then, of course, you're going to see the emotional self regulation problems, impulsive emotion, difficulties getting control over your emotions, the way other people can do.

你会在自我激励方面遇到很大困难。

You're going to have a lot of trouble with self motivation.

你会拖延。

You're going to procrastinate.

任何没有即时回报的事情，你都很难坚持下去，你会不断被那些承诺立即满足感的事物分散注意力。

Anything that doesn't have an immediate payoff is very hard for you to stay with, and you'll keep being distracted by anything that offers you a promise of immediate gratification.

当你面对问题时，不会坚持下去并尝试解决问题，而是容易放弃。

And then when you're faced with problems, instead of sticking it out and trying to problem solve, people with ADHD tend to quit.

他们往往会直接转向去做别的事情。

They tend to simply shift over and go do something else.

因此，他们的生活充满了半途而废的项目、永远无法实现的目标，以及别人轻而易举就能完成、而他们却做不到或难以完成的成就。

And so they have a life that's, you know, filled with half completed projects and goals they could never reach and accomplishments everybody else is able to do and they can't do or they struggle to do.

到了青少年或成年阶段，这种情况会变得非常打击士气，因为这些问题年复一年地累积，而当其他人逐步获得这些执行功能时，你却不断新增新的缺陷。

And so it really gets very demoralizing by the time you're a teenager or an adult because all these problems are piling on year after year as other people get each of those executive abilities, you get another deficit.

因此，到成年时，你至少会有七项或更多自我调节方面的困难，而其他人却没有这些问题。

So by adulthood, you have at least seven or more problems with self regulation that other people don't have.

这会导致一系列下游问题，影响人们的重要生活活动，而人们却往往意识不到。

And it leads to a whole swath of downstream problems in major life activities that people just don't realize.

ADHD 是我们在成人门诊治疗中最具有破坏性的疾病之一。

ADHD is one of the most impairing disorders we treat in an adult outpatient basis.

人们以为这只是一个微不足道的小问题，喝杯星巴克就能解决。

And people think it's just some trivial little problem that a cup of Starbucks is going to solve.

你有注意到临床医生是如何分类它的吗？

Have you seen the way clinicians classify it?

我明白这是一种缺陷，是一种障碍。

I understand it's a deficit, it's a disorder.

它是被更多地视为一种残疾，以便提供相应的支持，还是这种表述正在发生变化？

Is it looked at as a disability more so accommodations can be made or how is that language changing?

临床医生称之为障碍，因为这是我们用来描述任何导致过度、持续且严重症状并损害个体的状况的术语。

Well, the clinicians call it a disorder because that's our term for anything that creates excessive, persistent, and severe symptoms that lead to harm to the individual.

所以有两个标准。

So there are two criteria.

首先，你必须有严重且持续的症状，这些症状远远超出了你的年龄、性别和性别的正常范围。

First, you have to have serious and persistent symptoms that go well beyond your age, and your sex, your gender.

其次，这些症状必须导致功能损害或伤害。

So, second is it must be producing impairment, harm.

你必须正在遭受痛苦。

You must be suffering.

环境必须对你做出负面反应，使你经历困难。

The environment must be kicking back so that you're experiencing hardships.

当这两个标准都满足时，你就被诊断为一种障碍。

And when those two criteria are met, you have a disorder.

这就是临床术语。

So that's the clinical term.

然而，政府创造了‘残疾’这个概念。

Now, the government, however, invented the concept of disability.

因此，政府介入并提出：你的障碍程度有多严重？

So the government comes in and says, How disordered are you?

你的障碍是否严重到让我们认为你在主要生活活动中属于残障，比如学习、工作或自我照顾？所谓自我照顾，指的是你能自己穿衣、洗澡、独立生活等等。

Are you disordered enough that we would consider you to be disabled in various major life activities, like school or work or self support, or, you know, by self support, mean that you can dress yourself and bathe yourself and support yourself and so on.

所以，‘残障’这个词实际上是政府用来判断你的障碍是否达到了需要提供便利支持、社会保障残障补助、ADA合理便利、IDEA学校支持等标准的术语。

So, you know, the term disability is really a government term for whether or not your disorder rises to the level that you deserve accommodation support, social security disability, ADA accommodations, IDEA school accommodations, all these other things.

所以，这其实就是两者的区别。

So that's really the difference.

临床领域使用‘障碍’一词，政府使用‘残障’一词，而这两者常常混在一起。

Clinicians use disorder, governments use disabilities, and the two of them blend together.

关于这一点，我再简单追问一下。

Just a quick follow-up on that.

我曾在Ologies的Twitter上询问过神经多样性人群如何自我认同。

I asked the Ologies Twitter how neuro atypical people self identify.

我发现大家的观点基本一致。

And I found the sentiments essentially echoed.

AnnaGeorge说：‘我的经验是，在学术便利方面，残障的认定优先于障碍的诊断。’

AnnaGeorge said that, quote, my experience is that disability trumps disorder in terms of academic accommodations.

而且似乎你需要拥有一个所谓的‘残疾’才能申请便利支持。

And that it seems like you need to have a, quote, disability in order to seek accommodations as well.

我有一个朋友，大卫·拉德克利夫，他是电视编剧，担任WGA西部分会‘残障作家委员会’主席，这可是个重要职位。

And I have a friend, David Radcliffe, a TV writer, who is the chair of the Disabled Writers Committee at the WGA West, which is a big deal.

他回应说，是的，这正是推动消除‘残疾’一词污名化的一部分，因为将某人认定为‘残疾’（而非‘特殊需求’或‘不同能力者’）能使其依据《美国残疾人法案》获得法律保护等权益。

And he chimed in and said, yes, this is part of the push to destigmatize the word disabled because recognizing someone as disabled, not special needs or differently abled, offers them legal protections, etcetera, under the Americans with Disabilities Act.

我觉得这很有趣。

And I thought this was interesting.

Olegite Quinsquirks指出，这取决于个人以及该社群的看法。

Olegite Quinsquirks noted that they think it depends on the person and what that community thinks.

他们说，有些社群更倾向于用‘状况’代替‘障碍’这个词。

And some communities prefer the term condition in place of disorder, they say.

自闭症社群写道，他们一直在讨论将‘自闭症谱系障碍’重新表述为‘自闭症谱系状况’。

The autistic community, they write, has been talking about reframing autism spectrum disorder to autism spectrum condition.

但总体而言，便利支持和援助是公平且有益的。

But in general, accommodations and support are a good, equitable thing.

请多一些这样的例子。

Please more of them.

当你具有神经多样性时，以让你感到舒适的方式描述自己的经历非常重要。

And when you are neurodivergent, framing your own experience in a way that is comfortable to you is important.

贾雷特把他的注意力缺陷多动障碍称为他的‘好脑坏脑’。

And Jarrett refers to his ADHD as his good, bad brain.

我们不断为他的大脑及其运作方式喝彩，同时也承认患有注意力缺陷多动障碍并不总是一场该死的恐慌。

And we're constantly celebrating his brain for what it is and what it does while also acknowledging that having ADHD is not always a fucking panic.

现在，让我们谈谈我丈夫称他为‘糊涂蛋’的朋友。

And now let's talk about, as my husband calls it, his friend Dopey.

多巴胺，他一直在与‘糊涂蛋’周旋。

Dopamine, he's constantly wrangling with Dopey.

多巴胺在注意力缺陷多动障碍中扮演什么角色？

What is the role of dopamine in ADHD?

我们曾经认为它能解释一切，但现在我们知道事情要复杂得多。

Well, we used to think it explained everything, and now we know that things are a lot more complicated.

但早在上世纪70年代和80年代我刚进入这一领域时，人们猜测ADHD一定是由于多巴胺缺乏造成的，因为当时我们发现的所有治疗药物都能增加大脑中的多巴胺水平。

But back in the day, when I came in in the 70s and 80s, the guessing was that ADHD had to be due to dopamine deficiency because the drugs we've discovered to manage it all produced increases in dopamine availability in the brain.

它们通过不同的机制实现这一点。

And they did it through various mechanisms.

它们的作用方式并不完全相同，但最终结果都是让大脑中多出一些多巴胺，来完成ADHD患者体内原本无法有效执行的任务。

They don't all do it the same, but at the end of the day, the net result is that there's more dopamine in the brain to do the job that it's not doing in people with ADHD.

结果发现，虽然这一观点没错，但我们也开始意识到，与多巴胺相关的去甲肾上腺素也参与了这种疾病。

And it turned out that while that is true, we also began to discover that norepinephrine, which is related to dopamine, also is implicated in the disorder.

因此，礼来公司推出了斯特拉特拉，这是一种通过增加大脑中去甲肾上腺素起作用的药物。

Hence, you have Eli Lilly coming out with Strattera, which is a norepinephrine, drug that increases norepinephrine in the brain.

接着，今年四月刚上市的KELBRE也是一种新型去甲肾上腺素类药物。

Then you have the new KELBRE that, came out just this past April, and that's a new drug, that's a norepinephrine drug.

但随后我们开始意识到：等等，大脑里可能还有其他机制在起作用。

But then we also began to realize, now wait a second, there's other things going on in the brain here.

我们发现，前额叶中被称为α2受体的这些结构——我姑且称它们为‘括约肌’。

We're discovering that these alpha two ports, as they're called, in the frontal lobe, which are little, I'll call them sphincters.

括号说什么？

A sphincter says what?

但大脑前额叶神经元上的孔洞会开合，以控制神经细胞中的噪音，这些被称为α-2受体的孔洞对α-2药物有反应，也能改善多动症，因为它们能精细调节前额叶的神经信号。

But portholes on neurons in the frontal lobe that open and close to determine how much noise is in the nerve cell, that these alpha-two ports, which are responsive to alpha-two drugs, also are beneficial for ADHD because they fine tune the nerve signals in the executive brain.

因此，我们现在可以通过至少三种，甚至更多种神经递质来治疗多动症。

So we can get at ADHD now through at least three and probably more neurotransmitters.

多巴胺是其中之一，这也是兴奋剂的作用机制。

Dopamine being one and that's what the stimulants are doing.

去甲肾上腺素是另一种，而非兴奋剂正是作用于此。

Norepinephrine being the other and that's what the non stimulants are doing.

而管理前额叶的α-2受体和噪音，则是降压药如可乐定和胍法辛的作用。

And then managing the alpha two ports and the noise in the frontal lobe and that's what the antihypertensive drugs are doing, clonidine and guanfacine.

因此，目前市面上有六种不同的药物，以及许多种新的药物递送系统。

So we've got six different medications out there and we've got many, many new delivery systems for those medications.

但这些就是我们目前使用的三类药物。

But those are the three classes of medicines that we're using.

所以你可以看到，不仅仅是多巴胺在起作用。现在我们意识到，这已经超出了神经化学的范畴，因为我们发现的与注意力缺陷多动障碍相关的基因，目前已经发现了12个，我们推测至少有45到50个。

So you can see that there's more than just dopamine And now we realize that it goes beyond neurochemistry because the genes we're discovering for ADHD, of which we've already found 12, we're guessing there's at least 45 to 50.

上周还有一篇最新论文表明，这个数字可能接近500个。

There's actually a recent paper from last week that shows that it's probably closer to 500.

但在人类基因组中，有多个基因位点参与构建和调控你的大脑。

But there are multiple genetic sites in the human genome that build and operate your brain.

而注意力缺陷多动障碍的产生，是因为你拥有的这些基因组合与其他人不同。

And ADHD results from having different pairs of these genes than other people have.

所以你和我可能都拥有多巴胺基因DAT1，但你的版本和我的版本不同。

So you and I both might have the dopamine gene DAT1, but your version is different than my version.

你可能拥有七个、八个或九个DAT1基因拷贝，而普通人通常只有四个或五个。

You might have seven, eight or nine copies of the DAT1 gene, whereas the average person has four or five.

这些变异在大脑的构建过程中造成了严重混乱。

And those extraversions are, wreaking havoc in building the brain.

它们造就了一个与常人截然不同的大脑。

They're creating a very different brain than other people get.

我们在大脑发育早期就能看到，受这些基因调控的神经细胞未能正常迁移。

And we see this very early in the development of the brain where nerve cells that are under the control of these genes are not migrating properly.

它们未能正常生长。

They're not growing properly.

它们未能到达大脑中本应正确连接的终点区域。

They're not reaching the endpoints in the brain where they should be connecting properly.

这导致了大脑不同区域之间的连接问题。

And it leads to problems with connectivity in different brain centers.

昨天刚发表了一项针对三万两千名ADHD患者的论文，明确证实了正在发展ADHD的儿童存在这些功能连接障碍。

There was literally a paper yesterday published on thirty two thousand people with ADHD demonstrating beyond a shadow of a doubt these functional connection difficulties in children developing ADHD.

看到这么多本应良好连接的区域却未能正常连接，真是令人震惊。

So it was just staggering to see the number of different regions that are not connecting as well as they should.

即使它们形成了连接，这些连接在功能效率上也存在很大差异，从而导致行为表现的高度多样性。

And even when they connect, the connections are quite variable in how well they function, creating a lot of variability in behavior.

因此，仅仅说我们将行为与大脑、大脑与基因、基因与大脑的功能连接联系起来，你就不得不坐下来感叹：我完全没想到复杂程度会达到这种地步。

So just to say that we're linking behavior with brain, brain with genes, genes with functional connectedness in the brain, and you just have to sit back and go, wow, I had no idea at the level of complexity.

所以这远不止是笨拙。

So it's beyond dopey.

是的。

Yes.

我一定会告诉他。

I will definitely tell him.

而且你知道，在制定治疗方案的架构时，无论是药物治疗还是决定使用哪种药物，人们该如何确定从兴奋剂到非兴奋剂，甚至可能包括降压药这三类药物中的哪一种呢？

And you know, when it comes to creating the architecture of a treatment plan, whether it's medication or rather deciding medication, how does someone go about figuring out which of those three types of medication from stimulant to nonstimulant to maybe even hypertension drugs?

你推荐试错法吗？

Do you recommend trial and error?

所以目前，除了临床试错和医生的偏好之外，我们要明白，有些医生更习惯使用某些药物而非其他药物。

So at this point, besides clinical trial and error, as well as clinician preference, let's understand some clinicians prefer, they're more comfortable with working with certain drugs than other drugs.

我们知道，在研究中，我们可以创建一份详细的清单，列出选择药物时可能需要考虑的不同因素。

We know in research that we can create literally a checklist of different issues that one might want to contemplate in choosing a medication.

比如，其中一个因素是紧迫性。

You know, one would be urgency.

我需要多快控制住你的问题，因为你正在经历很多痛苦？

How fast do I got to get control over your problem because you are experiencing a lot of suffering?

兴奋剂会是首选，因为它们比非兴奋剂起效快得多。

Well, the stimulants would be the choice because they work much, much faster than the non stimulants do.

好的，但另一方面，你有焦虑症。

Okay, but on the other hand, you have an anxiety disorder.

哦，是的，我觉得我有。

Oh yes, I think I do.

等等，稍等一下。

Well, hold on a second.

我们知道，在一部分人中，兴奋剂可能会加重焦虑。

We know that in a subset of people, stimulants can make anxiety worse.

这存在争议，并不是每个人都会这样，但发生频率足够高，让临床医生对此感到担忧，这时我们可能会考虑使用非兴奋剂，比如择思达或可乐定，因为它们在治疗ADHD的同时也能缓解焦虑。

That's arguable, it doesn't happen in everybody, but it happens enough that clinicians get a little concerned about that and that's where we might want to go with a non stimulant like a Strattera or a Calbri because that actually treats anxiety in the context of ADHD as well.

那么，我们可能还会遇到一些表现出极高水平多动、攻击性以及过度兴奋行为的人。

Well, then we might also have somebody who's showing very high levels of hyperactive aggressive and just sort of over aroused behavior.

嗯，你知道，我可能会更倾向于使用降压药，或者建议我的同事使用，因为我作为心理学家不开药，但我们会考虑这一点，因为这种药物在控制多动、冲动和攻击性行为方面效果非常好。

Well, you know, I might prefer to use an antihypertensive drug or would recommend to my colleague because I don't prescribe, being a psychologist, but that's where we would look and say, well, that drug actually does very well at managing hyperactive impulsive aggressive behavior.

也许我们会朝这个方向走。

Maybe we'll go there.

我可以把15种都讲一遍，但我就不说了。

I could go through all 15, I won't.

但你知道，经验丰富的临床医生会仔细思考，根据你疾病的特征以及其他共病情况，我们要记住，80%以上的ADHD患者还伴有第二种疾病。

But you know, sophisticated clinicians will think that through and say, you know, given your portrait of your disorder as well as your other disorders, let's remember that eighty percent of people with ADHD or more have a second disorder.

50%的患者还伴有另外两种疾病。

Fifty percent have two more disorders.

所以我们实际上面对的是多种疾病的组合，而很少会遇到单纯的ADHD病例。

So, we're really dealing with disorder combinations here and very, rarely are we dealing with ADHD alone.

大约每七例中才有一例是纯粹的ADHD。

It's about one out of every seven cases is a pure ADHD case.

所以对我来说，真正的临床工作在于你到底有多少种疾病？

So to me, the real clinical work here is in how many disorders do you have?

它们如何影响我的治疗计划？

How do they affect my treatment planning?

考虑到您的各种问题和紧急情况，我应该使用哪些药物？

What drugs should I be using given your constellation of issues and urgency?

您是离家上大学的学生吗？

Are you a college student living away from home?

这些孩子中，每四个人就有一个会转卖药物。

Well, one in four of those kids diverts the medication.

在看到您对二类兴奋剂的使用是否负责任之前，我可能不会立即开具阿得拉或维万斯到这样的环境中。

Maybe I'm not going to send Adderall or Vyvanse into that environment just yet until we see how responsible you are with a schedule two stimulant.

这只是在仔细思考，了解您的处方去向、谁在使用它、身边有哪些人，以及您能有多负责任，等等。

It's just thinking it through and knowing where your prescription's going and who's using it and who's around you, and how responsible you can be, etcetera, etcetera.

因此，这其中有很多复杂性需要梳理，但许多临床医生只是简单地尝试错误法。

So, there's a lot of complexity to walk through but many clinicians simply go trial and error.

我会先从这个药开始，如果无效，就换下一个，再下一个，最终大约93%的情况下我们能找到适合您的药物，但并非总是如此。

I'll start with this one, if that doesn't work, I'll go to the next one, then the next one and eventually about ninety three percent of the time we find a drug that works for you but not always.

希望如此。

Fingers crossed.

你听说过哪些最近被诊断或开始服药的人的反应吗？关于这如何改变了他们的生活方式？

What are some of the reactions you've heard from people who have been either recently diagnosed or recently medicated in terms of how that changes the way that they live their life?

天啊。

Oh my God.

我的意思是，大约有百分之八到十的人，这些药物对他们完全没有帮助，或者他们出现了不良反应，我们必须停药。

I mean, let's understand, about eight to ten percent, the drugs don't help them at all or they have adverse reactions that we have to stop.

但对于剩下的百分之九十，我们发现的是，你猜怎么着，百分之五十五的人在服药后完全恢复正常。

But for the remaining ninety percent, what we find is that, now get this, fifty five percent are completely normalized on the medication.

哇。

Wow.

恢复正常，我的意思是，他们和普通人没有任何区别。

Normalized, I mean, they're no different from anybody else.

那些人会说：你救了我，天啊。

And those are the people who say, You saved Oh my my gosh.

我能够完成大学学业。

I can finish my college.

我挽救了我的婚姻。

I saved my marriage.

我能照顾好我的孩子。

I can manage my children.

我 literally 能够进行一场有条理的对话，不再东拉西扯、心神涣散，也不会记不住我们在聊什么。

I literally can have an intelligent conversation without going all over the map and mind wandering and not being able to even remember what we were talking about.

顺便说一句，如果你还没搜索过丹妮·多诺万，现在就去搜她。

By the way, just as an aside, if you have not Googled Dani Donovan, Google her.

她是一位插画师，创作了一些关于成人多动症生活体验的搞笑漫画和插图。

She's an illustrator who's created some hysterical cartoons and illustrations about what it's like to have adult ADHD.

丹妮·多诺万的网站是adhddd.com，我会在我的网站上提供链接。

Dani Donovan's website is adhddd.com, and that'll be linked on my site.

如需更多优秀的多动症漫画，也可以关注Twitter上的ADHD_aliens，作者是皮娜·巴内尔。

And for more great ADHD comics, also see ADHD underscore alien on Twitter, and that's by Pina Barnell.

所以，你去看看Dani，也可以去How to ADHD的网站看看。

And so, you know, have a look at Dani, and you can also go over to the website How to ADHD.

杰西卡的网站也非常好。

Jessica's got a great website over there as well.

敬请期待下周特别第二部分，邀请到How to ADHD的杰西卡·麦凯布，以及Black Girl Lost Keys的雷妮·布鲁克斯，她还运营着一个为边缘化性别黑人群体提供的在线支持小组，名为“独角兽小队”。

And stay tuned for Jessica McCabe of How to ADHD in a special part two next week, along with Renee Brooks of Black Girl Lost Keys, who also runs an online support group for black people of marginalized genders, and that's called the Unicorn Squad.

我们将与她们两人聊天，还会采访Black and Neuro的贾伊拉·奥斯本，她是一位ADHD研究者。

So we'll be chatting with both of them and also Jaila Osborne of Black and Neuro, who is an ADHD researcher.

所以我跟你说，这就是为什么这一集花了这么长时间。

So I'm telling you, this is why this episode took so long.

因为实在太精彩了。

It was too exciting.

我不断添加更多内容。

I kept adding more and more things.

这些都是一些真正理解ADHD的资源。

So these are just resources that get it.

当你看到他们时，你会说：天啊，这不就是我吗。

And when you see them, you say, oh my god, that is me in spades.

你知道吗，丹妮有一幅插画，上面写着：现在做，或者不做。

You know, like Dani has an illustration where she said, It's either now or not now.

她有一个开关。

She's got a light switch.

就是这样，你知道吗？

That's it, you know?

她对时间的理解就是：现在或不现在。

That's her concept of time, is now or not now.

如果现在不是，我就不在乎。

And if it's not now, I don't care.

如果是现在，我就会全身心投入，你知道的，我可以对此高度专注。

And if it's now, I'm all over it, you know, so I can hyper focus on it.

所以她画了一张图，描述了和她交谈时是什么样子。

So she has a diagram of what it's like to have a conversation with her.

而普通人对话的图示是：我从A点开始，想解释某件事，然后直接到达B点。

And the diagram for the typical person is, I start at A and I want to explain this and I get to B.

这是一条直线。

And it's a straight line.

她的对话图却像一个迷宫，到处跳跃，容易分心，谈论无关的事情，记不清我们刚才在说什么，还得问你我们之前聊到哪儿了，你知道吗？

Hers looks like a maze of all over the place, getting distracted, talking about irrelevant things, can't remember what we were describing, have to ask you what we were talking about, you know?

所以她总是东奔西跑。

And so she's just everywhere.

这正是ADHD的典型表现。

And that is so typical of ADHD.

所以，所有这些想说明的是：那些被确诊的人，首先，确诊本身就有治疗作用，因为它把你从道德评判的范畴带入了神经科学的范畴。

So, all of that is to say that people who get diagnosed, first of all, the diagnosis alone is therapeutic because it takes you out of the realm of moral judgment and puts it in the realm of neuroscience.

在那之前，你一直觉得自己是个坏人。

You know, up until then, you thought you were a bad person.

你是个懒散、无所作为的人。

You were a layabout ne'er do well.

你懒惰，缺乏动力。

You were lazy, unmotivated.

你妈妈说得对。

Your mother was right.

你知道，你就是没能起步。

You know, you just failed to launch.

你知道，我们就是没法让你前进。

You know, we just can't get you out of here.

而你相信了这一点。

And you buy that.

你变得极度沮丧，因为别人都在成功，而你却陷在泥潭里，无法从A点到达B点。

You become so demoralized about yourself because everybody else is succeeding and here you are stuck, you know, in quicksand and you can't seem to get from A to B.

于是你开始责怪自己，真正接受了社会对你的污名化，认为你的性格、道德和自律都有问题。

And so you start blaming yourself and you literally buy into the societal stigma that there's something wrong with you, in terms of your personality and your morality and your self discipline.

你就是没有意志力。

You just have no willpower.

当你得到诊断时，这已经进入了神经科学的范畴，你明白了。

When you get the diagnosis, it's now in the realm of neuroscience and you get it.

你正在经历一种神经发育障碍或残疾。

You are experiencing a neurodevelopmental disorder or disability.

仅凭这一点，对我来说，这种心态就变得非常具有治疗性，因为这不是你造成的，你也不是选择成为这样，你不可能明天一觉醒来就变成另一个人。

And that alone to me, that mindset becomes very therapeutic because you didn't cause this, you're not choosing to be this way, you can't get up and smell the coffee tomorrow and become a different person.

你正在挣扎，就像自闭症谱系或双相情感障碍患者一样，面对着你未曾要求过、但因基因或其他因素而拥有的东西，你必须学会应对。

You are struggling, as are people with autism spectrum or bipolar disorder, with something you didn't ask for, but that you've been blessed because of your genes or other factors that you now have to cope with.

所以一方面，我让你从责备中解脱出来。

So on the one hand, I'm taking you off the hook.

这不是你造成的，你的父母在抚养你的方式上也没有错。

You didn't cause this and neither did your parents in terms of how they raised you.

另一方面，我会让你重新承担责任，因为只有你才能对此采取行动。

On the other hand, I'm going to put you back on the hook because you're the person that has to do something about this.

这并没有什么不对。

And there's nothing wrong with that.

这就是神经多样性运动的极致体现。

That's the neurodiversity movement in spades.

你只是一个神经多样性的人。

You're just a neurodiverse person.

但你必须停止否认、指责和把问题的根源归咎于你的配偶、伴侣、老板、母亲或朋友，因为你是这里的共同因素。

But you've got to stop denying and blaming and shifting the source of the problem to your spouse or partner or boss or mother or friend, because you're the common denominator here.

要知道，我双胞胎兄弟花了三十七年才醒悟，他的生活是他自己决策的结果，而不是他想归咎的那些人造成的。

Know, it took my twin brother thirty seven years to wake up and realize that his life was the result of his decision making and not all the other people he wanted to blame for that.

我经常看到这种情况。

And I see that all the time.

所以我非常认同这个观点：在我能帮助你之前，你必须先承担责任。

So I really love that idea about, you you got to own it before I can help you.

所以，医生。

So Doctor.

巴克利提到，魔力红乐队的歌手亚当·莱文，我想他也在那个你按下按钮让椅子移动的节目里。

Barkley notes that Maroon five singer, Adam Levine, I think he's also on the show where you push the button with the chair.

他是一名注意力缺陷多动障碍（ADHD）患者，几年前参与了一项名为‘正视你的ADHD’的制药宣传活动，旨在消除神经多样性污名化，并帮助成年ADHD患者积极管理自己的治疗。

He is a person with ADHD and he participated in this pharma campaign a few years back called Own Your ADHD to destigmatize neurodivergence, but also empower people with adult ADHD to be active stewards of their treatment.

考虑到美国约有1000万成年人被估计患有ADHD，这一点非常重要。

And given that approximately ten million adults in The United States are estimated to have ADHD, that's an important thing.

但谁又不曾感到压力山大、分心、健忘，甚至情绪波动呢？尤其是在当下？

But who's not feeling overwhelmed and distracted and forgetful sometimes and maybe a little emotional, particularly these days?

那么，你如何知道自己是否真的患有ADHD？

So how do you know if you actually have ADHD?

如果你对每一个TikTok视频都有共鸣，但又觉得每个人都对每个TikTok视频有共鸣，该怎么办？

What if you relate to every TikTok, but you feel like everyone relates to every TikTok?

我能直接尿在试纸上，等一条线出现吗？

Can I just pee on something and wait for a line to materialize?

是或不是？

Yes or no?

就像过去执行功能的幽灵。

Like the ghost of executive function past.

而且，你知道，你提到了诊断的过程。

And, you know, you mentioned that that process toward diagnosis.

我听过这种说法：如果你吃了利他林有效，那你就有ADHD；如果没效，那你就没有ADHD。

I've heard it from everything as if I give you Ritalin and it works, you have ADHD.

如果没效，你就没有ADHD。

If it doesn't work, you don't have ADHD.

我听过这种说法，但这并不正确。

I've heard that, which is not true.

不正确。

Not true.

还有我表妹，她在三十多岁时通过一个漫长的诊断过程才意识到自己患有ADHD，这个过程包括采访她的亲人，了解她的成长背景。

And to my cousin who in her thirties finally realized that she had ADHD through a long diagnostic process that involved interviewing her loved ones to ask about her background.

当谈到诊断时，我觉得，如果你真的有ADHD，光是这个过程本身就已经非常令人畏惧和不堪重负了。

It was a huge So when it comes to diagnosis, I feel like that in itself, I think if you have ADHD, there's a lot that can already about life be really intimidating and overwhelming.

是啊，

Yeah,

确实可能。

there can.

我知道我丈夫每个月要续开阿得拉药，得跑六家药房，还要处理各种文件，他常说：这正是我最不擅长的事。

I know that my husband, just the struggle to get his Adderall refilled every month involves like going to six pharmacies and getting paperwork mailed and he's like, this is the one thing I'm already bad at.

是啊。

Yeah.

我明白。

I know.

而且这是二类管制药物。

And it's a schedule two drug.

不幸的是。

Unfortunately.

其他药物不是，但兴奋剂属于二类管制药物，这意味着它们有滥用潜力，因此才会有如此严格的管控和繁复的文书工作。

The other drugs are not, but the stimulants are Schedule II, which means they have the potential to be abused and that's why they clamp down on them and all the paperwork.

然后你还会遇到一些药剂师，他们相信汤姆·克鲁斯和山达基教，可能会对你试图配的处方大加指责，说它邪恶有害。

And then you're going run into the occasional pharmacist who, you know, believes in Tom Cruise and Scientology and may lecture you about the evils and the wickedness of the prescription you're trying to fill.

让我告诉你，曾有家庭打电话给我们说：你绝对想不到这个药剂师对我家孩子说了什么。

Let me tell I've had families call us and say, You're not gonna believe what this pharmacist is telling my god.

你知道的，那就换家药店吧。

You know, and it's like, Well then switch pharmacies.

我们可不想跟汤姆和他的信徒们打交道。

We're not going to deal with Tom and his disciples here.

哦，对了。

Oh, that's right.

所以，有些人认为这根本就是个神话，你只是在拿这个当借口，其实根本不存在。

So, you know, there are other people who think this is just a myth and you're using this as a crutch and it really doesn't exist.

这些想法都如此天真，不言而喻。

And all of which is so naive, it goes without saying.

我的意思是，每当我听到有人说这是个神话，或者觉得这微不足道，我就觉得这反映出他们对真实科学、对成千上万篇研究论文的惊人无知，这其实更多反映的是你本人，而不是这种障碍。

I mean, every time I hear somebody say, you know, this is a myth or, it's just so trivial, it reflects to me a stunning ignorance of the real science, of the hundreds of thousands of research papers and it really tells me more about you than about the disorder.

那么，说了这么多，我能跟你梳理一下我认为应对这种障碍真正必须做的五件事吗？

So, that said, can I walk through just what I think are the five things you really got to do to deal with this disorder?

我会说得很快，因为我知道我们还有其他事情要聊。

And I'll make them very quick because I know we have other things to chat about.

第一，要获得正确的诊断，识别可能存在的各种疾病，因为通常不止一种，我们必须治疗所有疾病。

But number one is get a proper diagnosis and identify the various disorders that may be there because there's often more than one and we have to treat them all.

所以我称之为评估。

So I call it evaluation.

这是第一步。

That's step one.

哦，好的，太好了。

Oh, okay, great.

第二步，教育。

Step two, education.

多读书，广泛阅读。

Read, read widely.

小说家大卫·林赛在他的某部小说中说过一句很棒的话：真理是拼凑而成的东西。

David Lindsay, the novelist, had a great phrase in one of his novels, Truth is an assembled thing.

你不能只从一个导师、一个网站或一本书中获得它。

You don't get it from one guru, one website, one book.

我希望你广泛阅读，但要阅读可信的来源。

I want you to read widely but read credible sources.

基础机构、慈善组织、美国国立卫生研究院（NIH）、CHAD组织、加拿大CADRA组织、这里的add.org以及世界ADHD联合会。

The foundations, the charities, the NIH, the CHAD organization, and Canada, the CADRA organization, the add.org here, the World Federation for ADHD.

至少有十个网站提供大量信息，包括我的网站，上面有许多免费的事实手册。

There are at least 10 websites with lots of information, including my website, which has a lot of free fact sheets on it.

广泛阅读，看书籍，去YouTube，观看我的视频，获取信息，因为你将会把这些整合起来。

Just read widely, read the books, go to YouTube, look at my videos, acquire the information because you're going to assemble.

从中，真相会不断浮现，而谬误则会逐渐被淘汰，因为它们不会在这些网站之间相互印证。

Out of that, the truth keeps popping its head up and the nonsense will fall by the wayside because it won't be replicated across these websites.

你将开始对自己和自己的障碍获得真正核心的理解。

And you'll begin to get a really core understanding of yourself and your disorder.

第三，药物治疗。

Number three, medication.

在所有治疗手段中，这是最有效的一种。

Of all the treatment components, that's the most effective we have.

不管你喜不喜欢，是否同意，都无关紧要。

And it doesn't matter whether you like that, whether you agree with it.

药物不是一种你需要信仰的宗教。

Medication's not a religion that you believe in.

事实就是事实。

The facts are the facts.

它的效果是其他任何方法的三倍。

It's three times better than anything else out there.

虽然它并非对所有人都有效，但对大多数人有极大的帮助，正如我所说，一旦找到合适的药物，它实际上能让超过一半的患者恢复正常。

And while it doesn't help everybody, it helps most people to an incredible degree and as I've said, it can actually normalize over half of the people who take it once we find the right medicine.

关于‘正常化’这个词，我要补充一点：这是一个临床术语，指的是使用药物使心理功能或表现符合主流文化规范，而不是追求能力提升。

Just a note on the word normalization, that's a clinical term that means the use of medication to bring mental functioning or performance in line with a prevailing cultural norm, as opposed to trying to achieve performance enhancement.

所以，‘正常’指的是普遍情况。

So the norm is the typical.

正常化可以很容易地称为典型化。

Normalization could be easily called typicalization.

所以是药物。

So medication.

我把注意力缺陷多动障碍看作精神病学中的糖尿病。

And I look at ADHD as the diabetes of psychiatry.

如果我告诉你你是糖尿病患者，你绝不会拒绝胰岛素，而你的生物问题与糖尿病患者一样严重。

You would never turn away insulin if I told you you were a diabetic and yet you have as much a biological problem as the diabetic has.

你为什么拒绝它呢？

Why are you turning this down?

这是因为你认为药物在掩盖问题，认为它们只是权宜之计，但事实并非如此。

It's because you think the medicines are covering something up, that they're a band aid and they're not.

这些药物恰恰就像胰岛素一样。

The medicines are exactly like insulin.

它们直接纠正了大脑中导致你症状的神经遗传基础。

They literally are correcting the neurogenetic basis in the brain that is giving rise to your symptoms.

所以，正视这个问题的一部分，就是意识到如果这是神经生物学问题，那么在治疗方案中使用生物制剂并没有什么不对。

So part of owning it is realizing if this is neurobiological, there is nothing wrong with a biological agent being part of the treatment package.

它并不是我们做的唯一事情，但却是最有效的组成部分之一。

It's not the sole thing we do, but it's an effective component, one of the most.

我会在我的网站 aliwar.com/ologies/adhd 上链接所有这些内容以及他提到的其他资料，链接也在节目笔记中。

I'll link all that and the other sources he mentioned on my website at aliwar.com/ologies/adhd, which is linked in the show notes.

另外，曾经有一位药剂师告诉我，我不需要抗抑郁药。

Also, once a pharmacist told me that I didn't need the antidepressant.

我被开这个药是为了应对卵巢衰竭引起的情绪波动。

I was prescribed to deal with mood swings from my ovarian failure.

我只需要耶稣。

I just needed Jesus.

这位药剂师在洛杉矶，所以拉塞尔不会明白。

And this was a pharmacist in LA, so Russell's not getting.

总之。

Anyway.

好的，我们已经有了评估、教育和药物治疗。

Okay, so we've got evaluation, education, medication.

接下来是调整。

Next, modification.

我该如何调整自己的行为，以更好地应对这种障碍的要求？

What can I do to modify my behavior in order to cope better with the demands of this disorder?

这就是针对执行功能缺陷的认知行为疗法发挥作用的地方。

That's where cognitive behavior therapy for executive function deficits come in.

这就是成人ADHD辅导发挥作用的地方。

That's where adult ADHD coaching comes in.

这就是学习正念冥想方法的地方，比如约翰·米切尔和莉迪亚·齐拉斯卡新出版的关于成人ADHD正念实践的书。

That's where learning mindfulness meditative approaches like in John Mitchell and Lydia Zylaska's new book that just came out on mindfulness based practices for adult ADHD.

这些是我们希望你参与的活动，如果你正在服药，你从这些方法中获益的可能性会更大，因为它们正是药物帮助你组织自己、坚持和激励自己的方式。

These are the things we want you to participate in and if you're on medication, you're more likely to benefit from them than if you're off your medication because they're just what the medication does to help you with organizing yourself and persisting and motivating yourself.

因此，第四点是尽可能进行调整，同时记住这是神经生物学的。

So number four is modification to the extent that you can, remembering it's neurobiological.

但这里有一定的灵活性，你在对待自己时可以有所妥协和调整。

But there's some latitude there that, you know, some give and take in how you deal with yourself.

第五点，合理调整。

Number five, accommodations.

合理调整指的是，如何在不消除疾病的情况下，通过改变物理环境来避免它对我的影响？

Accommodation refers to how can I physically change my environment so that while my disorder is still there, I'm not impaired by it?

这意味着要审视你的工作空间和电脑，说：好吧，所有游戏都放在地下室的电脑上，而我办公室的电脑只安装工作应用程序。

And that means looking at your workspace, looking at your computer and saying, okay, all games go on the computer over in my den and only the computer in my office has work apps on it.

即便如此，我也会下载一些用于时间管理和自我调节的应用程序，屏蔽那些干扰性的网站，但这台电脑上绝对不安装游戏。

Even then, I'm going to download apps that deal with time management and self regulation, that block out distracting websites, but no gaming on this computer.

这就是一种合理调整。

That's an accommodation.

就像为身体残疾人士设置的建筑入口坡道。

It's like a ramp coming into a building for somebody physically disabled.

你并没有消除身体上的残疾，但你让它能够有效参与我们其他人能做的事情。

You didn't get rid of the physical disability, but you allowed them to participate effectively in the things that the rest of us can do.

所以，像时间管理、使用日程计划本、每周概览日历、Outlook，以及对自己承诺的事情向同事、上司、主管或配偶负责，并每周多次与成年ADHD教练核对目标、策略和你正在努力做的事情。

So, you know, things like time management and using a day planner and a week at a glance calendar and Outlook and making yourself accountable to your colleague, your boss, your supervisor, your spouse for the things that you commit and checking in with your adult ADHD coach several times a week on your goals and your strategies and what you are trying to do.

这些都是重新安排你环境的方式，让你能够做那些如果没有这种障碍本可以做到的事情。

These are all ways of rearranging your environment so that you get to do the things your disorder otherwise would preclude you from doing.

但你仍然是ADHD患者。

But you're still ADHD.

你仍然需要承认它，但天啊，我的书里有数百种方法，我们讨论过如何改变环境以减轻这种障碍的影响。

You still have to own it, but oh my god, there's hundreds of things in my book that we talk about of ways of altering environments to lessen the impact of the disorder.

一些小贴士：蓝牙降噪耳机，或许还可以向宇宙祈祷，希望你的雇主不会认为一大间全是开放工位的办公室能促进企业凝聚力，因为研究表明，在这种开放式办公环境中，人们的工作效率只有三分之一，焦虑、疾病和离职率也更高。

A few tips, Bluetooth noise canceling headphones, maybe prayers to the universe that your employer doesn't think a bunch of open tables all in one giant room fosters corporate community because it doesn't studies show that people get about a third of the work done and have higher rates of anxiety, illness, and turnover in a bullpen type of office environment.

所以，如果可能的话，选择有不透明隔板的隔间，或者带门的办公室。

So cubicles with opaque walls or an office with a door, if possible.

向雇主争取这些条件可能需要你为自己争取，但这是值得的。

Getting those things from an employer might require advocacy on your own behalf, but it can be worth it.

但如果你不承认自己的障碍，你就不会去采取这些措施。

But you won't do those if you don't own that disorder.

所以，再次重申一下，评估、教育、药物治疗、环境调整、合理便利。

So again, to reiterate, evaluation, education, medication, modification, accommodation.

全部做到，你们五个人就能做得很好。

Do all and five of you will be doing a great job.

那这个评估呢？

What about that evaluation?

关于这个评估需要深入到什么程度，有什么建议吗？

Any tips on how in-depth that evaluation needs to be?

我认为，准确且可靠地做出诊断，至少需要两到三个小时。

I don't think the diagnosis can be, accurately or reliably made in less than two to three hours.

这可能意味着，由于医生和精神科医生的排班方式，我需要见你三次，每次四十五分钟到一小时。

Now, that may mean that I'm going to see you three times for forty five minutes to an hour because of the way physicians and psychiatrists schedule their time.

另一方面，心理学家习惯一次性预留三到五小时来完成整个评估。

Psychologists, on the other hand, are used to blocking out three to five hours to do their evaluations all at once.

所以请理解，评估可能不会一次性完成，但通常需要这么长时间，因为我必须回顾你的病史。

So just understand, it may not be done all at once but it usually takes that long because I've got to go back through your history.

我必须全面调查这些症状。

I've got to survey all of these symptoms.

我需要审视所有这些障碍。

I have to look across all these disorders.

我需要让你完成这些量表，进行评分，然后解读结果。

I have to have you complete these rating scales and score them up and then I have to interpret those.

我可能还需要对你进行一些心理测试，评估你的智力和学业成就，因为排除工作和学习问题的两个关键因素是：你的智力是否足以应对所处环境，以及你是否存在学习障碍。

I may need to do some psychological testing with regard to your intelligence and your achievement because two of the rule outs for having problems in work and education are do you have adequate intelligence for the environment that you're in and do you have any learning disabilities?

因为百分之五十的注意力缺陷多动障碍患者也同时患有与ADHD无关的学习障碍。

Because fifty percent of people with ADHD also have a learning disability that's not their ADHD.

如果我没有意识到这一点，我就错过了对你在学校、大学或职场中遇到困难的部分解释。

And if I don't realize that, then I've missed part of the explanation for why you're struggling in school or college or in the workplace.

还有一些其他测试，比如QB测试或Tova测试，它们可能会追踪你进行计算机测验时额头上佩戴的红外线小球。

There are other tests like the QB test or Tova, which may track an infrared ball attached to your forehead as you undergo some computer quizzes.

但是医生。

But Doctor.

巴克利说不。

Barkley says nah.

嗯，实际上他说这是胡说八道。

Well, actually says nah, nonsense.

这完全是胡说。

That's nonsense.

胡说。

Nonsense.

首先，这些测试的准确性不足以诊断ADHD，尽管它们的开发者会告诉你它们可以或不可以。

First of all, things are not sufficiently accurate to diagnose ADHD, even though their test developers will tell you they are or they're not.

其次，这些测试具有误导性，因为有一半的ADHD成人即使通过了这些测试，仍然确实患有ADHD。

And secondly, they're misleading because half of adults with ADHD can pass those tests and still be legitimately ADHD.

所以，我只是告诉人们，别太在意测试分数，因为很多时候它们是错的，病史才是关键。

So, I just tell people, you know, forget the test scores because a lot of the time they're wrong and the history tells the story.

此外，正如你所指出的，我们需要采访了解你的人。

Plus, as you pointed out, we need to interview people who know you well.

这是我们诊断标准的一部分。

That's part of our diagnostic criteria.

我们需要通过其他来源来核实你告诉我们的信息。

We need to corroborate what you're telling us through other sources.

希望这些信息来自你的父母、兄弟姐妹、好朋友或配偶或伴侣，但在某些情况下，我只能依赖档案记录，比如你的学校成绩单、驾驶记录、工作记录或犯罪记录。

Hopefully that's gonna be your parents or siblings or good friends or a spouse or a partner, but in some cases, all I have are the archival records, your school report cards, your driving record, your work record, your criminal record.

所有这些都可能是我需要查看的材料，以寻找证据，证明这个问题对你来说已经持续很久了。

All of those are things I may need to take a look at in order to look for evidence that this has been a longstanding problem for you.

所以，是的，这需要时间，但正如我所说，至少需要两到三个小时。

So yeah, it takes time, but as I said, no less than two to three hours.

而且你在书中专门有一节关于如何寻找临床医生，我觉得这非常有帮助。

And you have a whole section in the book, which I think is great about finding a clinician too, which is so helpful.

你是否曾经需要向那些已经确诊或尚未确诊的人提供建议？

Do you ever have to recommend to people who either have a diagnosis or don't?

比如，如果他们要阅读这方面的资料，有没有推荐的阅读方式？

Like, if they're going to digest literature on this, is there a preferred way to do it?

比如，你做笔记、录音时，最好的方式是什么？

Like, as you take notes, audio, like what's the best way?

好吧，我在写这本书时，听取了人们的反馈，我们实际上对这本书进行了实地测试。

Well, I tell you what we heard from people when I was writing the book, and we actually field tested that book.

如果你把这本书和我其他的书比较一下，会发现它的组织结构与我其他书大不相同。

If you look at that book compared to all my other books, it's organized vastly differently than my other books.

原因是，我们把这本书的手稿拿给患有多动症的成年人进行了实地测试。

And the reason is we field tested the manuscript on adults with ADHD.

所以你才会看到它被分成了很多小部分。

And that's why you see that it's all broken up.

书中有一些小边栏、醒目的小显微镜图标、突出显示的提示框和加粗的重点内容。

There's little sidebars and there's glitzy little microscopes and there's callouts and bold emphasis.

你知道，这种排版方式足以让普通人看了抓狂。

And you know, it's enough to drive a typical person crazy when they look at this thing.

你该怎么集中注意力看这些东西呢？

How do you pay attention to this?

因为他们习惯于阅读连续的散文和叙事，而这本书与之截然不同，你知道的。

Because they're used to reading like continuous prose and narrative and this is so far from that, as you know.

所以这是经过实地测试的。

So that was field tested.

我们发现，至少如果你要阅读，这种形式比传统的叙事更能吸引你的注意力。

We found that at least if you're going to read, that captured your attention better than typical narrative does.

做得好。

Well done.

我们做的第二件事是，许多成年人告诉我，电子书对他们来说比纸质书更好。

The second thing that we do, of course, is a lot of adults tell me that the e book is better for them than that.

我每天也会收到五到十封邮件，说我是通过你的YouTube讲座发现你的。

I also get five to 10 e mails a day of people saying, I discovered you through your YouTube lectures.

这是我第一次真正能坐下来听完这些内容。

And that's the first time I was actually able to sit through and listen to this stuff.

所以也许现在我会去购买电子书，或者看看你和其他人一起做的播客，从而逐步了解这些内容。

So maybe now I'll go and get the e book or look at some of your podcasts that you've with other people like you and start to pick it up that way.

最终，他们还是会回到书本上。

Then eventually they wind up back at the book.

但我们理解，对于患有注意力缺陷多动障碍的成年人来说，阅读非常困难，因为他们存在工作记忆问题。

But we understand that reading is very hard for adults with ADHD because of their working memory problems.

他们无法像其他人那样记住所读的内容，阅读时容易走神，不得不反复回到页面顶部七次。

They can't retain what they read the way other people can and they find themselves mind wandering while they're reading and then they got to go back to the top of the page seven times.

所以我理解，我知道文字并不总是成年人患注意力缺陷多动障碍时学习的最佳方式。

So I understand, I get it that text isn't always the best way for adults with ADHD to learn stuff.

我翻阅电子书时，非常兴奋地发现里面有便利贴和侧边栏。

I was looking through the ebook and I was so excited to see like, oh, there's a Post it note and a sidebar.

这确实能很好地吸引注意力。

It really does kind of engage it.

我甚至听过你说过，要给自己贴便利贴。

I've even heard you say like, leave post it notes for yourself.

让它们用不同的颜色。

Have them be different colors.

能吸引你并让你感到新鲜的事物会有帮助。

Something that engages you and is novel will will help.

没错。

And That's right.

显然，我们在节目前收到了听众的大量问题。

Obviously, we got a lot of questions from from listeners ahead of time.

真的是有史以来最多的问题。

Literally the most questions ever.

为了避免向你们罗列太多赞助者的名字，我会只读一些首次提问者的名字。

So to avoid overloading you with names of patrons, I'm just gonna read the names of first time question askers for some of these.

但在开始之前，让我们支持一些正在帮助ADHD人群的事业。

But before we do, let's support some causes that are supporting people with ADHD.

因此，本期和下期节目的捐款将用于几个机构，特别是本期，我们将捐赠给CHAD（儿童与成人注意力缺陷多动障碍协会），该组织在美国每个州都有本地支持小组，通过倡导、支持、交流和信息提供，帮助父母、儿童、青少年和成人。

So donations for this and next week's episodes are going to a few places, namely for this episode, CHAD, Children and Adults with Attention Deficit Hyperactivity Disorder, which has local support groups in every state in The United States and offers assistance for parents, children, young adults, and adults via advocacy and support and networking and information.

更多关于他们的信息请访问chad.org。

More information about them is available at chad.org.

Chad 有两个 D。

Two Ds in Chad.

下周我们还将捐赠给其他几个机构。

We're gonna be donating to a few more places next week as well.

这一切都得益于节目的赞助商，你们现在可能会听到他们的名字。

All of that was made possible by sponsors of the show who you may hear about now.

好的。

Okay.

不再拖延或分心，直接进入你们的问题。

Without further delay or distraction, your questions.

作为一个焦虑症患者，我发现你们中有这么多人询问焦虑症与 ADHD 或其他共病，这让我感到安慰。

So as a person with anxiety, I found it soothing that so many of you asked about anxiety and ADHD or other comorbidities.

所以，我看着你们这些首次提问的人：贝基·尼斯、奥蕾莉亚、希瑟·E。

So I'm looking at you, first time question askers, Becky Niesl, Aurelia, Heather E.

斯图尔特、艾莉森·巴兹利、泽妮娅·霍尔姆、EJ·沃纳、布里特·克莱因、安娜贝尔·马克斯、丹·阿温、基琳·杰克曼、萨拉·阿尔布雷希特、玛雅·鲁普纳因、埃琳·西穆诺·奥佐夫斯基，还有阿德莱·梅索诺夫，别忘了伊诺耶，就像我上次说的。

Stewart, Alison Bardsley, Xenia Holm, EJ Warner, Britt Klein, Annabelle Marks, Dan Arwin, Keelyn Jackman, Sarah Albrecht, Maya Rupnerin, Erin Simuno Ozowski, and Adelae Mesonov, not miss Inouyeve, like I said last time.

他们都有一个共同的问题。

They all had a common question.

我觉得特别有趣的是，我们收到了很多这样的问题，比如贝基·内塞尔说：我想知道广泛性焦虑症和注意力缺陷多动障碍之间有什么区别。

One thing that I thought was really interesting we got a lot of was, like, Becky Nessel says, I'd like to know some differences between general anxiety disorder and having ADHD.

对。

Right.

它们有很多相似的症状。

They have a lot of the same symptoms.

斯凯拉、斯蒂芬妮，还有很多人问了这个问题。

Skella, Stephanie, a bunch of people asked about this.

在诊断时，你如何区分它们？

How do you parse that out during diagnosis?

对。

Right.

我认为，表面上看，人们可能会认为，因为焦虑和抑郁都会伴随注意力问题。

Well, I think superficially people would assume that because there are attention problems that go with anxiety and depression.

因此，人们自动认为所有的注意力缺陷都是多动症。

And so people automatically think that all attention deficits are ADHD.

这实在是过于简化了。

And that is way oversimplifying.

我们现在知道，至少有两种类型的注意力不集中，最终可能会有五种，但至少有两种。

We now know that there are at least least two and eventually there'll be five, but at least there are two kinds of inattentiveness.

与多动症相关的那种是受外界干扰。

The one that goes with ADHD is being externally distracted.

所以我从一件事跳到另一件事，周围所有无关的事件都在把我拉向各个方向。

So I'm skipping from one thing to another and all of the irrelevant events going on around me are pulling me in various directions.

因此，我与环境过度耦合，却与自己关于目标、计划、待办事项以及今天承诺要做的事情的内心信息联系不足。

So I am overly coupled to my environment and not coupled enough to my mental information about my goals, my plans, my do list, the things I said I was going to do today.

我不像其他人那样受内心信息的引导。

I'm not governed by mental information the way other people are.

我过度受情境和当下支配。

I'm overly governed by context and the now.

所以这就是多动症。

And so that's ADHD.

现在，让我们来看看焦虑和抑郁。

Now, let's look at anxiety and depression.

我们看到的情况正好相反。

What we see with them is the opposite.

他们过度沉浸在心理信息中，如反复思考、强迫、恐惧、预期和担忧。

They are overly coupled to mental information, rumination, obsession, fear, anticipation, worry.

听起来真有趣。

Sounds like fun.

因此，他们虽然注意力不集中，但表现方式是呆滞、走神、思绪飘忽。

So they're inattentive, but they're gonna be inattentive in a staring, daydreaming, mind wandering kind of way.

就像一位心不在焉的教授，他们并不多动。

Like an absent minded professor, they're not hyperactive.

他们也不是容易分心。

They're not distracted.

他们只是太沉浸在自己的思绪里了。

They're just in their head way too much.

而ADHD患者并没有那么沉浸在自己的思绪中，即使有，也是因为他们的想法四处跳跃。

And ADHD people are not in their head that much and if they are, it's because their ideas are skipping all over the place.

所以这两种障碍并不难区分。

So the two disorders are not that hard.

我的意思是，ADHD最初并不会导致恐惧、担忧或焦虑。

I mean, ADHD does not lead to fear, worry, anxiety initially.

但在未经治疗约十年到二十年后，焦虑障碍会开始与ADHD共存，到三十多岁时，30%到50%的ADHD成人会发展出焦虑障碍。

Now, after about ten to twenty years of not being treated, anxiety disorders begin to become a coexisting disorder with ADHD such that by the time you're in your 30s, thirty five to fifty percent of adults with ADHD have developed an anxiety disorder.

但这正是因为ADHD导致的长期失败。

But that's because of the chronic failure that ADHD is leading to.

你不需要在社交场合或工作中屡屡失败，就会在这些环境中变得极度焦虑。

So you don't have to fail in social situations or at work too many times before you get really anxious in those environments.

但这种焦虑是另一种类型，源于过度暴露于他人不会经历的负面甚至创伤性后果。

But that's a different kind of anxiety that comes from overexposure to negative consequences and even traumatic consequences that other people don't experience.

另一方面，如果你确实患有焦虑症，你的焦虑更多是面向未来的。

On the other hand, if you have a legitimate anxiety disorder, yours is much more forward looking.

你会过度预想惩罚、负面后果、别人对你的看法，比如你上车时会死，父母出门后不会回家。

You are over anticipating punishment, negative consequences, what people think about you, you know, that you're going to die when you get in the car, that your parents aren't coming home when they leave the house.

这些都是预期性焦虑，而我们在成人ADHD中看不到这种表现。

Those are anticipatory anxieties and that's not what we see in adult ADHD.

成人ADHD的焦虑更多是后天习得的。

Adult ADHD, it's more learned anxiety.

所以，一种是由过去驱动的，即我在这个情境中经常失败，或者是由工作记忆缺陷引起的。

So, you know, one is driven by the past, that is I frequently fail in this situation, or it's driven by the working memory deficit.

亚特兰大有一位摄影师对此描述得非常贴切。

There was a photographer in Atlanta who put it beautifully.

他说，我正在外拍照，却想不起来今天是我去托儿所接五岁的孩子，还是我妻子去接，而现在已经下午四点了。

He said, I'm out on a photo shoot and I can't remember whether I agreed to pick up our five year old at daycare today or my wife and it's 04:00.

所以孩子已经放学一小时了。

So the kid's been out of school an hour.

他是不是正坐在路边，和老师一起，因为我不在场？

Is he sitting at a curb with his teacher because I'm not there?

然后他崩溃了，明白吗？

And he freaks out, okay?

所以你明白我的意思了吗？

So you see what I mean?

他质疑自己的记忆力和健忘，因为这种事情以前就发生过，你知道吧？

He's questioning his memory, his forgetfulness because it's happened before, you know?

这些人会从车里出来，却把儿童安全座椅忘在车顶上，然后走进去，心里想：等等，不对吧？

These are the people who get out of the car and leave the car seat on top of the car walk and into it's like, wait a second, right?

你的孩子在车顶上，对吧？

Your kid's on top of the car, right?

因为他们被周围的一切分心了，正如我所说，当下的一切牵着他们的鼻子走，这和真正焦虑障碍的人截然不同。

Because they're just so distracted by everything going on around them that, you know, as I say, the now pulls them along by the nose, and so that's a lot different than somebody with a legitimate anxiety disorder.

但你要明白，到了中年，这两种障碍比我们愿意承认的更常同时出现。

But understand that by the time you're in midlife, the two disorders go together more than we like to think.

现在，有谁质疑过性别和出生时指定性别在诊断或荷尔蒙影响中的作用？

Now who out there questioned the role of gender and assigned sex at birth in diagnosis or hormonal influences.

很多人。

So many.

首次提问者Brittany Twenter说：我非常想了解更多关于女性和女孩常常被漏诊的情况。

First time question askers, Brittany Twenter, who said, I would love to hear more about how women and girls often go undiagnosed.

Alyssa Williams Pierce、Marisol、Brynn、Roman Robin、Dakota P、Allie Vessels、Rosalyn Hesby、Rebecca Hatherley、Keira、Elizabeth Traylor、Garron Robinson、Caitlin、Heidi Wismuth、Leila Green Touche 和 Tara Allen 都写道：如果能早点知道就好了。

Alyssa Williams Pierce, Marisol, Brynn, Roman Robin, Dakota P, Allie Vessels, Rosalyn Hesby, Rebecca Hatherley, Keira, Elizabeth Traylor, Garron Robinson, Caitlin, Heidi Wismuth, Leila Green Touche, and Tara Allen who wrote, it would have been awesome to know sooner.

还有Eva Hayazova，她刚刚写道：天啊，天啊，天啊。

Oh, and Eva Hayazova, who just who wrote, OMG OMG OMG.

这太令人兴奋了。

This is exciting.

你有没有注意到，在诊断上存在性别偏见，比如女孩可能被诊断为焦虑，而男孩则被诊断为多动症？

Do you ever see that there is a gender bias in terms of diagnosis where maybe girls would be diagnosed with anxiety or boys ADHD?

是的，情况正在好转。

Yes, it's getting better.

但我必须告诉你，多年来女孩一直是沉默的大多数。

But I have to tell you that girls were the silent majority for many years.

在我刚入行的时候，每推荐一名女孩，就有六到七名男孩被推荐。

Back in the day when I came in, was six to seven boys referred for every girl.

现在这个比例已经下降到大约三比一，这差不多是真实的性别比例。

That's now fallen down to about three to one, which is about the legitimate sex ratio.

这种障碍在小男孩中比小女孩中更常见。

The disorder is more common in little boys than little girls.

但话又说回来，即使女孩确实患有这种障碍，她们也得不到推荐。

But having said that, right, girls were not getting referred even when they had legitimate disorder.

这其中有一些社会学原因，我们不需要深入讨论，因为虽然这些原因属实，但可能会让人觉得冒犯。

There are various sociological reasons for that that we don't need to go into, because, you know, people might find them, although they're factual, they're offensive.

人们更担心儿子而不是女儿，因为归根结底，女儿总可以嫁出去，但儿子必须独立成家。

People worry more about their sons than their daughters because the bottom line is you can always marry your daughter off, but your son has got to become independent.

如今，生活已经改变了。

Now life has changed.

我讲的是上世纪60年代和70年代，那时情况确实如此。

I'm speaking back in the 60s and 70s when that was clearly the case.

提醒一下。

Just a heads up.

这是一个有趣的事实。

This is a fun fact.

在《平等信贷机会法》通过之前，银行可以拒绝向未婚女性发放信用卡。

So until the Equal Credit Opportunity Act, a bank could refuse a credit card to an unmarried woman.

但如果她已婚，那就没问题。

But if she was married, it was okay.

只要她的丈夫同意并共同签字即可。

Her husband just had to give permission and cosign.

这种情况发生在1974年，那时我们早已把人类和火箭送上了月球。

This was in 1974, years after we launched human people and rockets to the moon.

女性终于可以拥有自己的银行账户了。

Ladies could finally get their own bank accounts.