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軽度発達障害について思うこと(6)

 さて、発達障害の診断に関しては、もう一つ大きな問題があります。

 先週、ある病院のスタッフミーティングに参加した時、一人のケースワーカーがある新規の患者さんについて短い報告をしました。「適応障害」の診断がある不登校の高校生で、人前での緊張が強くて学校を長期で休んでいて…と、大まかなこれまでのいきさつと簡単な生育歴の紹介があり、それから皆で今後の援助について話し合いました。

 私はその患者さんの生育歴を聞いていて、思い当たることがあったので、ミーティングの時に「適応障害であることは間違いないが、発達障害が背後にある可能性も考えた方がいいのではないか」と提案しました。

 ところが、あるベテランのスタッフから「先生(精神科の主治医)はそういうことは一切言ってなかったので、それはここで触れる必要はない」とばっさり切られてしまいました。

 こういう事は、病院ではよく起こります。Sanaさんはすぐ発達障害に結びつけるから、と皮肉を言われることもあります。同業者や精神科医と意見が合わないことはしょっちゅうです。

 小児科医や発達障害を専門にする精神科医でない限り、思春期以降、発達障害が診断の候補に挙がることは、極めて少ないです。そして、S先生によれば、多くの場合、特に自閉症スペクトラムについては、二次障害がないのに別の病気として誤診されているケースが多いというのです。それは、気分障害、統合失調症、人格障害…と様々なのだそうです。

 一般の精神科の見方は、symptoms-based(症状が基本)です。今ある症状がどの疾患の基準に当てはまるかで判断するので、似たような症状をもつ別の疾患として取り扱われることは不思議なことではありません。

 一般的に、小児科に比べると精神科の発達障害への感心が低いのも事実です。「発達障害があるかもしれないと思うので、調べて下さい」とこちらから言っても、医師によっては一蹴されることもあります。私は以前、うつの治療のために行った病院で、「調べても気休めにしかならないですよ」と言われたことがあります。(アメリカで間違いなくそうだ、と言われたにもかかわらず)

  ここに「二次障害」が加わるとさらに複雑になります。元来発達障害が存在し、その結果としての二次障害なのか、あるいは別の原因で発達障害に極めて似た行動上の問題が起きているのかを判断しなければならないからです。

  発達障害かどうかを診断する上での基本情報の大半は、生育歴を含む、生活史の詳細な聞き取りから得られます。発達障害かどうかを判断するためにはまず家庭環境を念頭に置かなければならず、虐待が明らかな場合、子供の行動が発達障害によるものなのか、あるいは虐待の結果として生じた行動障害なのか、あるいは両方からくるものなのかを判断しなければなりません。

 例えばADHDの場合、不注意なのか解離症状なのかの鑑別が必要ですし、多動については虐待やDVの影響による可能性を考えなければなりません。発達障害を持つ子どもたちの多くは、虐待の被害者でもあります。その場合はまず虐待に対する対応が優先されるのはしかるべきことです。さらに、先天的には発達障害がなくても、虐待の程度によっては後天的に発達障害が生じる可能性もあるので、子供の診断にはまず虐待の有無を確認してから発達障害についての診断を考える必要があります。

 虐待がない場合、二次障害が起きるのは日常のストレスが原因となることが多いです。そして年齢が上に行くほど、二次障害の方に精神医療の注意が向いてしまい、大元のところにある発達障害が見えにくくなってしまうのです。それは障害の多様性だけの問題ではありません。複数の精神疾患に共通する症状というのが思いの外多いからなのです。

 多動や不注意は、ADHDだけのものではなく、うつ病や不安障害でも同じような行動が起こります。高機能自閉症やアスペルガー症候群の人に多い、過度の緊張やパニックは、統合失調症の破瓜型の初期でも同じような状態が見られます。従って、精神医学の立場からは、「これはうつ病の症状」「これは統合失調症の発病期だ」と判断されることは何ら不自然ではありません。

 発達障害の可能性を証明するには、生育歴が有力な助っ人になるのですが、年齢が上がると本人も家族も詳しいことをあまり思い出せなくなっていることも多く、「特に何も問題なく成長し…」となると、もうお手上げなのです。

 そうならないためには、虐待などの大きなトラウマがない場合に、それぞれの発達障害に合併しやすい精神疾患が何であるのかを前もってきちんと把握しておく必要があります。

 LDや自閉症スペクトラムの当事者が診断されることが多い疾患は、パニック障害、強迫性障害、全般性不安障害、気分障害(単極性うつ)、社会不安障害、などです。

 アスペルガー症候群は、気分障害(双極性障害)の割合が高い、という報告もあります。個人的には、心身症(身体表現性疾患)も多いかなと感じています。

 ADHDは、過剰適応があると不安障害になりやすく、気分障害(単極性うつ)も多いです。大人になってからADHDかどうかを判断する場合、うつとの関係を明らかにするのは難しいです。

 その上で、「ある精神疾患の診断を受け、その診断に見合った薬物治療を行うときに、処方薬が頻繁に変わったり、あるいは期待していたような効果が3ヶ月以上投薬をしても見られない場合は発達障害を疑ってみる」ようにすると言う方法を、私は普段使って対応しています。

 「難治例」と呼ばれる患者さんたちの中に、何らかの発達障害を抱える人が含まれる可能性は否定できません。そして面接を進める中で、特にこちらから指摘することをしていないのに、後から生育歴が少しずつ明らかになることもあり、診断とは一度決定したからそれが全てと思わない方がいいと、いろんな人の例から学ばせてもらっています。


 
 
 

 

 

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