 |
| Is Sluggish Cognitive Tempo (SCT) Inattention with Anxiety and Depression? |
Psychiatrists have been trying to figure out what defines Sluggish Cognitive Tempo (SCT). They need to know, among other things, if SCT is just Inattentive ADHD (ADHD-PI) with a coexisting diagnosis of Anxiety and/or Depression and also if SCT is otherwise different from ADHD. They are trying to determine if people who are primarily inattentive need to be removed from the ADHD category all together and be placed in a separate category.
We are a year away from the publication date for the DSM V. You may remember that the DSM is the psychiatric manual, written by the American Psychiatric Association (APA) that defines disorders such as ADHD, depression and Sluggish Cognitive Tempo. The manual was last revised in 2000 and a lot has happened since then. One of the topics that we have been following very closely is the issue of how the American Psychiatric Association will label people with Inattentive ADHD and SCT.
It is clear that from an every day, ADHD-PI symptom management, standpoint, that people with ADHD-PI are different from people with combined type and hyperactive type ADHD. The question the APA is battling with is, are they sufficiently enough different to warrant a whole new disease category. As I write in this post on SCT, this is not the first time the APA has looked at people with Sluggish Cognitive Tempo symptoms and attempted to classify them.
Russell Barkley, a well respected ADHD expert believes that SCT is not ADHD with coexisting anxiety and/or depression and according to the study published in the February 2012, Journal of Attention Disorders, he is correct about this. Researchers looked at kids with Inattentive ADHD and found that these kids were more likely to suffer from depression but that SCT symptoms were independently correlated with Inattention. They concluded that SCT was not Inattentive ADHD with anxiety and/or depression.
Barkley has said that most, if not all, of "TRUE" Inattentive ADD patients should be reclassified as having Sluggish Cognitive Tempo because what defines people with this disorder is inattention and slower cognitive processing. He may be correct but this, as of yet, has not been proven.
I believe that people with Inattentive ADHD are more accurately defined as people with fewer impulsive and Emotional control issues and though about 50% of us do have slower cognitive processing, the other 50% of us with ADHD-PI, do not. I think that as more studies are done using functional magnetic resonance (fMRI) we may soon get to the bottom of this. Unfortunately this may not happen in time for the February 2013 publication deadline for the DSM V.
J Atten Disord. 2012 Feb 24. [Epub ahead of print]
Do Symptoms of Sluggish Cognitive Tempo in Children With ADHD Symptoms Represent Comorbid Internalizing Difficulties?
Garner AA, Mrug S, Hodgens B, Patterson C.
Symptoms of sluggish cognitive tempo (SCT) are correlated with inattention and internalizing difficulties. The purpose of the present study was to determine whether symptoms of SCT reflect comorbid internalizing disorder with ADHD or a separate syndrome. Method: Using a clinical sample of youth evaluated for behavioral and learning difficulties (N = 73), this study examined whether SCT remains associated with symptoms of ADHD after accounting for comorbid symptoms of anxiety and depression reported by children and parents. Results: SCT symptoms were correlated with inattention and parent reports of child depression, but not with parent-reported anxiety or child reports of internalizing problems. Inattention (in the absence of hyperactivity/impulsivity) remained uniquely associated with SCT even after accounting for internalizing problems. Conclusion: The findings confirm SCT as a correlate of inattention and support its construct validity as separate from comorbid internalizing problems. Further research on the clinical utility of SCT is needed.
I'm a psychiatrist with SCT - worse than the vast majority of my patients actually. I've met Dr. Barkley and he is a fantastic man and we are truly lucky to have such a dedicated intellectual researching ADHD. I have several of his books on the shelf above me right now. But frankly I think he is just flat-out wrong that SCT is something different than ADHD. For one thing SCTers respond *exactly* the same to medication as every other ADHD patient I have. They also almost always have some hyperactivity somewhere - it may only be fidgeting or racing thoughts at night (in adults). As Thomas Brown, PhD puts it - ADHD is in part a disorder of *regulation*. Difficulty regulating attention (too distractible or too hyper-focused), difficulty regulating affect (too moody) and difficulty regulating activity (hyperactivity or *hypo*activity). Many SCTers will report they feel much more energetic at certain times of the day (like nighttime). But also my SCTers seem to have some days that they clearly have more energy and motivation than others - with no clear reason why. They may well be a sub-group of primarily inattentive, but let’s not call it a new disorder. People still get confused by the last change from ADD to ADHD. Instead I’d like to see a robust diagnosis criteria for adults – that would go a long way to helping people.
ReplyDeleteThanks so much for your insights. The problems that I see with continuing to include SCT and ADHD-PI in the ADHD category has to do with the allocation of resources for studying the treatment, outcomes, causes, etc of these two problems.
ReplyDeleteIf the last 20 years are any indication, the current diagnostic definition of ADHD will see much of the resources for treatment and research going to the combined type of ADHD.
I think that people with SCT and ADHD-PI often respond to drug treatment for ADHD but they might respond to drug treatment for CVAs or migraine headaches, Tinnitus or you name it.
My point is that when all you have is hammer, everything becomes a nail and everyone, even people without ADHD, perform better on stimulants.
People with ADHD-PI and SCT have not been studied enough to know if, in fact, they would be better served with other treatments.
My fear is that unless the APA takes them out of current classification, we will continue to not know much.
It may be that SCT and ADHD have much in common but I do not think that we know that for sure. I think that unless we look at the subset of folks with SCT and ADHD-PI more closely, we will never know.
Thanks so much for writing in. Do you have faith that SCT and ADHD-PI will be appropriately researched if the DSM stays as is??
Hello. IMO adhd-pi should be called add. Sct, anx/dep are often cormorbid. Anti anx /dep meds do not signficantly help sct. Adderall helps pi, anx/dep and sct. Sct is not inattention w/ anx/dep.
ReplyDeleteIDK if pi's nececarily have sct. I believe one can be very attentive but still process info slowly.
Thanks for your comments! I am not sure about stimulants helping people with anxiety. ADHD-PI used to be called ADD WO or Attention Deficit Disorder without hyperactivity. I think that the APA feels that there is too much confusion regarding the fact that ADD and ADHD were supposed to be viewed as the same thing and they have spent the last 20 years trying to convince folks of that.
ReplyDeleteTo come out with just the opposite statement (that ADD is now something different) may be too much for them to manage though I agree that the simplicity of that term makes sense to me.
I am very please to read all of the post.I think it is completely different than ADHD/ADD. The two need to be separated anyway. There's nothing about my son that is hyper. ADD/SCT would direct me more to pulling up the right information. It should have it's own title and description for future parents looking to finding some answers to their childs behavior. My son is 16, and I just now heard of SCT through a group of fb. He has had this since before kindergarden. We (the teacher and I ) did not know what this was. He would lose focus and had no get up and go. Now he is in the 9th grade and is on Vyvanse 20mg. I love the fact that it perks him up, but the down side is when he is coming off the meds. It is hard to deal with my son having this.
ReplyDeleteThanks for your comment. ADD/SCT may be an acronym that fits us all.
ReplyDeleteIt is great that the Vyvanse has helped your son. I know how difficult it can be when the Vyvanse is wearing off. My son got very emotional and would cry for no reason. The son that was on Vyvanse was Combined type and he is now on short acting Adderall 10 mg, multivitamins, zinc, magnesium, omega-3 fatty acids and off of dairy. So far so good...
I also think there's quite a big difference between inattentive ADHD and ADHD combined type.
ReplyDeleteIn my view, the inattentiveness of adults with ADHD combined type looks worse than it is because those with combined ADHD are always taking on more than they can chew, which makes it very difficult for them to stay organised and focused. Conversely those with inattentive ADHD often hid their inattentiveness by avoiding many tasks and generally being more cautious.
Secondly, I think the mild hyperactivity seen among many inattentive ADDers is due to anxiety. I'm an inattentive ADDer and I've noticed that when I'm relaxed (say after a couple of wines) or tired I'm much less fidgety than when I'm busy or anxious.
Conversely, I've met classic impulsive ADDers who actually get more hyperactive when they're tired or relaxed - which would suggest their hyperactivity is driven by other factors like boredom.
Barbara Fisher has written about this difference although I'm not sure if there is are any studies to support this theory.
I'm pretty much like Mike. One really has to stay on immediate task--concentrate and get it done, as long as it takes. Keep Trying.
ReplyDeleteI was reading recently that people with Oppostional symptoms and ADHD wake up with high cortisol levels (this is the hormone that regulates fight and flight) and that their levels went down at night. people with oppositional symptoms have impulse issues and probably other issues, above and beyond their ADHD issues.
ReplyDeletePeople without oppositional symptoms start out with low levels and end the day with higher levels. Anxiety and stress makes our cortisol levels go up but for people with ADHD, it is more complicated than all that.
People with ADHD have a hypo-pituitary axis that just ain't right and they often have an atypical response to stress. The short of it is that their cortisol levels can be wacky. Some studies have found people with ADHD-PI have higher overall levels of cortisol throughout the day and some studies have failed to confirm this. It's complicated but there is probably something to all this...
J Child Psychol Psychiatry. 2012 Feb 10. doi: 10.1111/j.1469-7610.2012.02526.x. [Epub ahead of print]
Time-of-day effects in arousal: disrupted diurnal cortisol profiles in children with ADHD.
Imeraj L, Antrop I, Roeyers H, Swanson J, Deschepper E, Bal S, Deboutte D.
Source
Child and Adolescent Psychiatry Research Unit, Department of Psychiatry and Medical Psychology, Ghent University Hospital, Ghent Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium Child Developmental Centre, University of California, Irvine, CA Centre for Children and Families, Florida International University, Miami, FL, USA Biostatistics Unit, Ghent University, Ghent Collaborate Antwerp Psychiatry Research, Antwerp University, Antwerp University Centre Child and Adolescent Psychiatry, Antwerp, Belgium.
Abstract
Background: Fluctuations in attention-deficit hyperactivity disorder (ADHD) symptoms related to regulatory deficits in arousal states are themselves characterized by circadian rhythms. Although cortisol is an important circadian arousal-related marker, studies focusing on across-the-day cortisol variations in ADHD are scarce. There is no study with multiple measurements to take into account interday and intraday variability. Methods: Salivary cortisol was sampled five times a day (awakening, 30 min after awakening, noon, 4 p.m., 8 p.m.) across five consecutive days in 33 children with ADHD (22 with and 11 without oppositional defiant disorder; ODD) and 33 class- and sex-matched controls (aged 6-12). The cortisol awakening response (increase from awakening to 30 min after awakening) and the diurnal cortisol profile (across-the-day variations) were compared for ADHD with ODD (ADHD + ODD) and without ODD (ADHD) subgroups and the control group. Results: The cortisol awakening response was not significantly different between groups. However, longitudinal analyses to evaluate cortisol profiles across the day revealed a significant Group × Time effect (p < .001). More specifically, compared to each other, the ADHD subgroup showed a flatter slope with relative morning hypo-arousal and evening hyperarousal, whereas the ADHD + ODD subgroup showed a steeper slope with relative morning hyperarousal and evening hypo-arousal (p < .001). Conclusions: Findings support time-related arousal disruptions in children with ADHD associated with the presence or absence of ODD comorbidity. We recommend research on cortisol in larger samples for a better understanding of arousal mechanisms involved in ADHD not only with and without ODD but also with other comorbidities which may have implications for timing of arousal-based treatments.
Well everyone seems to have different opinions about what SCT is and isn't. It could be that in the future, when more is known about SCT, there may be serveral different types of SCT. For instance, my focus has not improved on ANY medication, so maybe I have a different type of SCT than someone who responds well to stimulants. My memory is terrible but there are some people with SCT, like the psychiatrist above, who obviously have a good memory, otherwise she wouldn't have made it through medical school. I just hope SCT makes it back into the DSM again so at least maybe the psychiatrists and doctors I run into will have, at a minimum, at least heard of SCT. It's so frustrating when I go to a psychiatrist and they haven't even heard of the disorder which I think I have and if I do it has ruined my life and they know nothing about it. So then I have to tell them about it and print out research papers on SCT for them...
ReplyDeleteIncluding SCT in the next DSM would probably lead to more correct ADHD diagnoses and thus more research; of course that assumes that SCT would still be classified as a type of ADHD. It might cut down on the number of people incorrectly diagnosed as having depression instead of SCT. BTW, stimulants can dramactically reduce anxiety for some people with ADHD; they would not for someone with a primary anxiety disorder though. You just have to be cautious when using stimulants in anxious ADHDers (frankly I prefer Strattera). Unfortunately with ADHD I find it is all trial and error. I can't predict which medicine someone will respond to, what dose they will need or how long each dose will last them. You can get tiny women on large doses and huge male body-builders on tiny doses.
ReplyDeleteI agree with adding SCT in the DSM would minor the cases who get missdiagnosed.
DeleteI was a daydreamer since very little, even befor kindergarten. I was diagnosed back and forth mainly with depression, autism and ADD. I took all kinds of antidepressions, without any positive respons. Now I found out a fiew days ago about SCT and that's totally me! That's the good news, the bad news is, that no psychiatrist knows about SCT or even how to treat it. :(
Thanks so much for letting me know!! I did not know that about the stimulants. I think that we are learning that the brain biology and physiology of inattentive symptoms is pretty different for each individual. It is not wonder the APA is having a heck of time with this.
ReplyDeletePart of me hopes that SCT is established as its own separate condition so it can get individualized attention and research. The proposed diagnosis, the symptoms, they all so perfectly encompass my experience, I feel so much relief.
ReplyDeleteI have ADHD-PI, though I would prefer to call it SCT. Adderall does little to help my focus. I have also tried Ritalin and Concerta to no avail. I have tried these medicines in conjunction with anti-depressants. I have tried them alone.
No combination or dosage seems to do enough to get me to function at a decent level. These days so much of ADHD research focuses on people with hyperactivity, and the established methods of treatment for hyperactivity mostly involve stimulants, which simply do not work for me.
Including SCT in the next DSM takes ADHD-PI out of Hyperactivity's shadow where it can be viewed anew without bias.
I would gladly volunteer as an SCT test subject if it meant we'd get a clearer idea of just what it is and how it can be treated.
Dear Ms. Messer;
ReplyDeleteThank you for posting the more recent updates on the SCT debate.
I am a middle-aged man who increasingly sees his problem as SCT. And by that I mean as a subset of ADHD, and then as subset of primarily inattentive. The sub-subset that I think I have is simply a slower brain, the prime (or only) cause of which is a limited working memory.
By analogy, it seems that I am simply missing sufficient RAM. I have been diagnosed with Dysthymia, but I think now that that after many years of self-observation, that it is only a function (side-effect) of SCT.
In short, I think that I have no imbalance, as such, but seem to have more of a mechanical issue related to human RAM. I am intelligent with a GAF of 70, but often feel my mind is like an eclipse -- litte direct light comes from the sun, but a great deal shines out sideways in wonderful ways.
Would you know if there is a professional in Ottawa, Canada who would be knowledgeable and sympathetic to my situation?
Thank you for any guidance you may give.
Sincerely,
Man in need of more RAM
Interesting take on SCT. Thanks for your great insight. I would call the office of Dr. Philippe Robaey the Research Director at the Department of Psychiatry at the University of Ottawa and ask them for a referral. I believe that the Psychiatry department will be the best referral source and his department has an excellent reputation.
ReplyDeleteThank you very much.
DeleteDear Ms. (Dr.?) Messer;
DeleteThank you for your response above. Unfortunatley, I have not been able to contact Dr. Robaey. He does not seem to answer to his University of Ottawa or Children's Hospital of Eastern Ontario e-mail addresses. Would you have another suggestion or perhaps another approach I could try?
Best Regards
I would at this point call CADDAC and ask for a referral. 416 637 8584. You are far from the only adult in this area of Canada looking for a provider. I wish I could be more help.
ReplyDeleteThank you again.
Delete