DSM-5 放宽成人 ADHD 诊断标准，是否放得太宽？

DSM-5 loosened the criteria for adult ADHD, but did it get too lose? We look at what recent prosecutions of telehealth companies mean for those trying to diagnose this disorder on the front-lines.

Duration: 15 minutes, 10 seconds

Transcript:

KELLIE NEWSOME: Today, learn how to recognize adults with ADHD and how to rule it out in those who don’t have it. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

KELLIE NEWSOME:

Two weeks ago, the Department of Justice marked as historic first: The criminal prosecution of a telehealth practice – Done Health - for unlawful drug distribution of stimulants. At the core of the case is an accusation that we all ought to pay attention to: Prescribing stimulants without a legitimate medical reason. According to the DOJ, Done Health fabricated ADHD symptoms to justify the scripts. That kind of behavior is never OK, but where do we draw the line with off-label use? Today, we’ll look at one of the most common forms of off-label stimulant use: Adult-onset ADHD, that is, symptoms of ADHD that begin in adulthood. But first, a preview of the CME quiz for this episode. You’ll find the link to the CME quiz in the show notes, and the answer in the research update at the end of this episode.

1. In a new meta-analysis, which medication led to the most weight loss when added to an antipsychotic?

A. Metformin

B. Exenatide 

C. Melatonin

D. Semaglutide

A 43 y/o woman presents to you for an ADHD evaluation. She says her brain is overloaded, she can’t complete tasks or organize her thoughts. “There’s so much mental noise that I can’t fall asleep at night.” She did well in school, but looking back, she thinks she could have done better. “I compensated well back then, but I haven’t been able to compensate since I got promoted to regional manager.” She is not impulsive. She is not hyperactive, but she uses a lot of social media and wishes she could cut back. Six years ago, she went through surgical menopause after developing ovarian cancer.

CHRIS AIKEN:

This patient has ADHD symptoms, but does she have ADHD? She might have had some attention problems in her early years, but not the full spectrum of ADHD symptoms, and she never had impairment until now.

KELLIE NEWSOME:

Yes, but I’m looking at the DSM criteria, and they don’t actually require impairment as a child. There just needs to be impairment when they present, which can be as teens or adults. 

CHRIS AIKEN:

You’ve hit on one of the biggest controversies in DSM-5’s revision of the ADHD criteria. First, they moved the age of onset requirement from 7 to 12. They based this on a single study of 68 children that showed that shifting the onset would not change the prevalence much. Next, they eliminated the need for impairment in childhood, as long as they have impairment when presenting as an adult. This change wasn’t based on research, but was based on an idea – that ADHD affects people with all levels of IQ and family supports. We spoke with Xavier Castellanos, vice chair of the DSM committee on ADHD, and he explained it this way: the change “is to allow for cases in which the impairment only becomes problematic when the situational demands exceed the individual's ability.” Here’s how that looks in practice. Imagine a very intelligent patient who eased through elementary school with good grades. But they didn’t live up to their potential, and the report cards are filled with comments about their inconsistencies, distraction and missing deadlines. This child may not have impairment until the courses get more difficult – in high school, in college, or in law school.

KELLIE NEWSOME: But somehow, I don’t think this patient is what they had in mind. She didn’t have trouble until she got promoted at the age of 43, and that was after surgical menopause and chemotherapy. Maybe the DSM should have capped the age where impairment began, like somewhere in their schooling. Otherwise, the impairment could just be the result of an abusive boss or a competitive work environment.

CHRIS AIKEN: Or the Peter Principle.

KELLIE NEWSOME: The Peter Principle?

CHRIS AIKEN: That’s the idea that every employee tends to rise to their level of incompetence. It was laid out in a 1969 book by Laurence Peter. It’s a criticism of competitive, hierarchical work structures – suggesting that, given time, most job positions will be held by people who aren’t competent to do them. Look at our patient - She did well in high school, college, and even completed a two-year program in management. When she went to work at a large law firm, she successfully managed the HR department and was promoted to manage a single office location. She succeeded at that, and was promoted to regional manager – and that’s where she reached her maximum level of competence, where things start to fall apart.

KELLIE NEWSOME:

OK, and let’s not forget the corollary: the Paula Principle. It holds that women often work at levels far below their ability because they are less likely to get promoted than men. We see it play out in movies like Hidden Figures, Working Girl, and Erin Brockovich, and we see it in real life.

CHRIS AIKEN:

Yes, there are many Paulas covering for the incompetent Peters. So with these new job demands, this is the first time our patient has had impairment from ADHD. Besides the new job, there’s early menopause, sleep problems, and excess social media use – all of which can cause inattention. As she looks back, she’s likely to see some problems with attention in her school days. Who didn’t daydream in class? Who didn’t struggle with at least one subject, like foreign language or math? By requiring nothing more than “several ADHD symptoms” before the age of 12, the DSM has left us with a lot of liberties.

KELLIE NEWSOME: In 2019, researchers in Australia published a criticism of these changes. In it, they cited new studies suggesting the prevalence does go up when the age criteria is loosened, for example, raising the diagnostic rate by 65% in a study of college students. A few months later, Ruthia He (pronounced “Huh”) started Done, a company that would raise the prevalence of ADHD even further, and threaten to bring down the ADHD field in the process, causing shortages of stimulants, scrutiny from the government, and attrition of public trust.

CHRIS AIKEN: Done spent 40 million dollars on social media advertisements that suggested people can have ADHD without any impairment, like this young woman who has enough executive functioning to manage her symptoms. Or this testimony. Listen closely – it sounds like he had great attention as a young child:

KELLIE NEWSOME:

DSM may have blurred the lines in their criteria, but the text of the book still maintains that ADHD is a disorder that begins in early childhood; that is, it is neurodevelopmental. The manual explains that they allow a cut-off at age 12, not because the disorder begins that late, but [quote] "because of difficulties in establishing precise childhood onset retrospectively". 

CHRIS AIKEN:

The idea of adult ADHD did not come from people who were stressed out and sleep deprived and suddenly unable to concentrate in middle age. It grew out of an awareness that many children with ADHD continue to have symptoms into adulthood. Here’s a brief history:

KELLIE NEWSOME:

1968: The diagnosis first appears in DSM-II as "Hyperkinetic Reaction of Childhood," emphasizing hyperactive symptoms that [quote] "usually diminishes by adolescence."

1980: DSM-III change the name to "Attention Deficit Disorder.” The new focus on inattentive symptoms sparks greater recognition adult cases, as the hyperactive-impulsive symptoms tend to fade with time. Girls too gain greater recognition, as they too have fewer hyperactive symptoms.

CHRIS AIKEN:

Meanwhile, researchers were following hyperactive, Gen X boys into their teens and adulthood, and by the mid-1990s, the results started coming out. Around 40-60% of them continued to struggle with ADHD into their adulthood. Most of this research came from Paul Wenders at the University of Utah and Joe Biederman at Mass General, but \not all studies supported it. In Long Island, Salvatore Mannuzza and colleagues found only 4% of hyperactive boys continued to have ADHD by their mid-20’s.

KELLIE NEWSOME: For many adults, the symptoms continued at a milder level that didn’t meet the full ADHD criteria, and the hyperactive symptoms quieted down. But one thing was clear: ADHD did not get worse in adulthood, the way we’d expect bipolar or schizophrenia to. So if your patient says their cognition was much sharper in their youth, look for a different diagnosis. And this is why DSM-5’s decision to drop the requirement for childhood impairment is so controversial – it means that people who were not impaired in childhood, but now come in as adults with major cognitive problems, can still meet criteria. Sure, they may meet criteria, but how often are we overlooking the effects of sleep deprivation, drug use, concussions, or sleep apnea – just that one – sleep apnea – we find in 30-50% of adults with ADHD.

CHRIS AIKEN:

And adult ADHD is not just about cognitive problems. Paul Wender’s criteria requires symptoms of emotional swings, hot temper, stress intolerance, or impulsivity. By the mid-2000’s, the controversy over adult ADHD was largely settled. The FDA approved the first stimulant for adults, Adderall XR, in 2004, and two years later, Stephen Faraone and colleagues pulled together the research in a sweeping meta-analysis that showed ADHD dampens down in adulthood but still persists. By age 25, 15% of children still meet full diagnostic criteria, and another 40–50% didn’t meet the full symptom count but still had impairment. Seven years later, DSM-5 would lower the number of required symptoms in adults, so today these figures would look different.

KELLIE NEWSOME:

 Today's research update looks at what to do about antipsychotic weight gain: a network meta-analysis by Nicolette Stogios and colleagues in JAMA Psychiatry.

CHRIS AIKEN:

 The team pooled 95 randomized trials, nearly 6,000 patients, testing 39 different drugs against placebo. Most trials ran under six months.

KELLIE NEWSOME:

 And the results? Semaglutide came out on top, with almost 11 kg or 24 pounds more weight loss than placebo. Liraglutide came next at around 12 pounds, topiramate and metformin nearly tied at around 9 pounds, followed by the GLP-1 exenatide at about 7 pounds.

CHRIS AIKEN: Missing from the analysis was Tirzepatide. This GLP-1 has the most weight loss overall, but it just hasn’t been tested much with antipsychotics. Meta-analyses often get tripped up on these trivial points, causing them to miss the forest for the trees. In the data at hand, semaglutide and metformin were the only drugs that got a meaningful share of patients down 5% or more of their body weight. A few other drugs — switching to aripiprazole, or adding ramelteon, or nizatidine — showed some signal too, but the evidence was less robust.

KELLIE NEWSOME:

 Ramelteon for weight loss? Yes, that’s the melatonin agonist sleep medicine. Melatonin causes weight loss by improving insulin sensitivity and shifting the body from fat-storage to fat-breakdown mode. Another analysis came out this month looking at supplements for antipsychotic weight loss. Here, the research is, well, thinner, but two stood out as replicated in multiple placebo-controlled trials – melatonin 3-5 mg at night, and a probiotic with a prebiotic. The Carlat Medication Fact Book is our best-selling book, but it’s not just a book anymore. The new edition, updated for 2026, comes with a new bundle of AI and digital tools, including our popular Carlat Psychiatry Toolkit app and the new AskCarlat AI. Clinicians can get the medication facts they need quickly and easily. Danny Carlat calls it the best deal in psychiatry.