Sluggish Cognitive Tempo – A New Diagnosis?

Philip Hickey, PhD
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On April 11, 2014, journalist Alan Schwarz (brief bio here) published an article in the New York Times on this topic, titled Idea of New attention Disorder Spurs Research, and Debate.  Alan has written extensively on the rising rates of the condition known as ADHD, and on the abuse of the drugs that are used to “treat” this condition. He has drawn a good deal of criticism from psychiatry’s believers.

In the NY Times article Alan draws attention to the fact that sluggish cognitive tempo (SCT) is being promoted as a new disorder  “… characterized by lethargy, daydreaming and slow mental processing.”  He makes the obviously valid point, that the formalization of such an entity  “… could vastly expand the ranks of young people treated for attention problems.”

The article was prompted by the fact that the Journal of Abnormal Psychology featured this emerging “diagnosis” in its January 2014 issue.  The issue contained eleven articles on the topic.  These articles addressed questions like:

  • Is SCT a sub-domain of ADHD?
  • Is SCT a disorder in its own right?
  • What are the symptoms of SCT?
  • What are SCT’s co-morbidities?
  • In what ways does SCT differ from ADHD, inattention type?
  • How does SCT differ from depression and anxiety, etc.?

It is a central theme of my website that mental illnesses/disorders, including ADHD and SCT, have no ontological or explanatory significance, are not a helpful way to conceptualize human existence, and in fact are intrinsically disempowering and stigmatizing.  The fact that these so-called illnesses are adduced by their psychiatric inventors to legitimize toxic treatments adds to their destructiveness.  The details of these critiques need not be repeated here.

History of SCT

Sluggish cognitive tempo is not a new concept.  ADHD has long been criticized, even by psychiatrists, as embracing two very different kinds of presentations:  inattentiveness, on the one hand, and hyperactivity/impulsivity on the other.  DSM-III-R (1987) acknowledged this problem and created the new “diagnosis” 314.00 Undifferentiated Attention-Deficit Disorder (p 95).  The manual describes this condition as follows:

“This is a residual category for disturbances in which the predominant feature is the persistence of developmentally inappropriate and marked inattention that is not a symptom of another disorder, such as Mental Retardation or Attention-deficit Hyperactivity Disorder, or of a disorganized and chaotic environment.” [Emphasis added]

DSM-IV (1994) also acknowledged this issue, and split ADHD into three distinct “diagnoses.”

  • ADHD Combined type
  • ADHD Predominantly inattentive type
  • ADHD Predominantly hyperactive-impulsive type

DSM-IV-TR (2000) created the “diagnosis” 314.9  Attention –Deficit/Hyperactivity Disorder Not Otherwise Specified

“This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.  Examples include:

1.  Individuals whose symptoms and impairment meet the criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type but whose age at onset is 7 years or after.

2. Individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria of the disorder but have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity.” [Emphasis added]

DSM-5 has two residual categories in this area:

  • Other Specified ADHD (314.01)
  • Unspecified ADHD (314.01)

These “diagnoses” do not mention sluggishness, daydreaming and hypoactivity specifically, but these attributes are clearly embraced by the definitions.  This is particularly the case in that practitioners working with DSM-IV-TR would have become accustomed to conceptualizing this particular presentation as a “sub-diagnosis” of ADHD and, in addition, DSM-5 did not repudiate the SCT example given in DSM-IV-TR.  DSM-5 offers no examples of the residual diagnoses, the most reasonable interpretation of which is that the older examples are still to be considered valid as well as any others that individual practitioners encounter/invent as they go about their work.

It is noteworthy also that the DSM-5 main entry on ADHD contains the phrases: “mind seems elsewhere” and “may include unrelated thoughts.”  These phrases did not occur in the DSM-IV-TR main entry, and are clearly intended to embrace the notion of daydreaming.

So it is clear that the APA’s notion of ADHD (predominantly inattentive type) has long embraced daydreaming and lethargy, and it was probably inevitable that psychiatry, with its ever-expanding agenda, would eventually begin to conceptualize this as a distinct “illness.”  So today we have sluggish cognitive tempo emerging as a “diagnosis” in its own right, and attracting comment and attention.

Current Status of SCT

Earlier this year, Catherine Saxbe MD, a psychiatrist, and Russell Barkley PhD, a psychologist, wrote a paper reviewing the history of research on sluggish cognitive tempo.  The paper, The second attention disorder? Sluggish cognitive tempo vs. attention-deficit/hyperactivity disorder: update for clinicians, was published in the Journal of Psychiatric Practice.  Here’s a quote:

“Sluggish cognitive tempo (SCT) refers to an impairment of attention in hypoactive-appearing individuals that first presents in childhood. At this time, it exists only as a research entity that has yet to debut in official diagnostic taxonomies. However, it seems likely that a constellation of characteristic features of SCT may form the criteria for a newly defined childhood disorder in the foreseeable future, provided limitations in the extant findings can be addressed by future research.”

The authors expressed the belief that sluggish cognitive tempo is an unfortunate name for the disorder  “…since the term sluggish is associated with connotations of being retarded, slow-witted or just plain lazy.”  They remind us that

“More than semantics is at stake here.  The nosology reflects the way we conceptualize a disorder, view our patients, and how they understand themselves.”

They suggest that “concentration deficit disorder” or “developmental concentration disorder” or “focused attention disorder” would be better names for the problem, and appear to be entirely blind to the fact that the negative effects of referring to a child as “sluggish” pale to nothing compared with the stigma and disempowerment inherent in the notion that he is a “patient” with a “mental illness” (regardless of the name given to this illness).  In addition to which, of course, must be reckoned the destructive effects of the “treatments.”

Here are some more quotes from the Saxbe and Barkley article:

“No large-scale medication trials have examined response to stimulants specifically in SCT, but one recent investigation shows promise for the potential use of atomoxetine.”

and

“This is an exciting finding and warrants further investigation as it is the first published report to show improvement in SCT with any medication.”

and

“Given the overlap of SCT with anxiety and depression, perhaps selective serotonin reuptake inhibitors (SSRIs) might be [another] possible treatment.”

The study in question is Wietecha L. et al., titled Atomoxetine improved attention in children and adolescents with attention-deficit/hyperactivity disorder and dyslexia in a 16 week, acute, randomized, double-blind trial.  This appeared in the November 2013 issue of Journal of Child and Adolescent Psychopharmacology.  The paper is a study of the efficacy of atomoxetine in the “treatment” of various attention problems including SCT.  Atomoxetine is a selective norepinephrine reuptake inhibitor (NRI) marketed as Strattera by Eli Lilly.  The study (Wietecha et al.) found that:

“The atomoxetine-treated ADHD-only subjects significantly improved from baseline to Week 32 on…all K-SCT [Kiddie-Sluggish Cognitive Tempo Interview] subscales…”

and

“This is the first study to report significant effects of any medication on SCT.”

All of this is particularly interesting because:

  1. Ritalin, which is now off patent, and other stimulants, are reportedly ineffective in the “treatment” of SCT “symptoms.” (Saxbe and Barkley, 2014, p. 47)
  2. Atomoxetine, which is still on-patent, is now “proven” effective in this area.
  3. Linda Wietecha works as a Clinical Research Scientist for Lilly USA, LLC
  4. According to Dollars for Docs, the following co-authors on the study have also received money from Eli Lilly in the period 2009-2012: Bennett Shaywitz, MD, $963,003; Stephen Hooper, PhD, $16,540; David Dunn, MD, $56,886; and Keith McBurnett, PhD, $5,000.
  5. Russell Barkley, PhD, co-author of the article cited earlier, received $120,283 from Eli Lilly for consulting, speaking, and travel between 2009 and 2012 (Dollars for Docs), and as recently as February of this year gave a lecture tour in Japan sponsored by Eli Lilly.

All of which raises the interesting question:  is SCT disorder being promoted at the present time by Eli Lilly’s paid hacks as a way of increasing sales of atomoxetine (Strattera) while it is still on patent?

Psychiatry’s Credibility

Interestingly, and sadly, most of the research and promotion of SCT has been done by psychologists rather than psychiatrists.  This fact prompted Jeffrey Lieberman, MD, President of the APA, and very eminent psychiatrist to  tweet on April 11 “no credible psychiatrist takes this [SCT] seriously” in response to Alan Schwartz’s article in the New York Times.  Dr. Lieberman seems to be unaware that in DSM-IV-TR (2000), the APA created a specific “diagnosis” for the sluggishness/daydreaming/hypoactivity presentation (using those exact words), and that this “diagnosis” has been clearly retained in DSM-5 (though without those specific words).  I’ve never been aware of any great outcry from organized psychiatry, or from individual practitioners, on this matter.  So, if we are to take Dr. Lieberman at his word (and why would we not do that?), there must be an enormous dearth of “credible psychiatrists” within the APA’s ranks.

In this context, it is also noteworthy that the Wietecha et al. article was published in the Journal of Child and Adolescent Psychopharmacology, which suggests – at least to me – that the journal takes SCT seriously.  The editor-in-chief is Harold Koplewicz, MD, psychiatrist, founding member and President of the Child Mind Institute.  Dr. Koplewicz has held many prestigious positions, and has received numerous awards, including the 2009 American Psychiatric Association McGavin Award for lifetime contributions to child psychiatry.  But alas, he must now be considered a psychiatrist with no credibility.

And

The Saxbe and Barkley article was published by the Journal of Psychiatric Practice, the editor of which is John Oldham, MD, Senior VP and Chief of Staff at the Menninger Clinic, and a psychiatry professor at Baylor College of Medicine.  Dr. Oldham is a past President of the APA (2010-2011), and of the American College of Psychiatrists (2010-2011).  He has also been President of the International Society for the Study of Personality Disorders, and was a member of the DSM-5 Personality Disorders workgroup.  But, here again, no credibility!

The general point here is that psychiatry has embraced the concept of medicalizing daydreaming. Dr. Lieberman either doesn’t realize this, or is trying to conceal the fact.

Discussion

It would be easy to get distracted by this recent attempt to promote childhood daydreaming as a mental illness.  As mentioned earlier, daydreaming, or to use psychiatric terminology, “the persistence of developmentally inappropriate and marked inattention,” has been a specific “mental illness” since DSM-III-R, 1987, (p 95).

The fact is that any human presentation can be considered a mental illness.  All that is needed is the APA’s say so.  And the APA made their position absolutely clear in the foreword to DSM-II (1968).  In the paragraph where they discuss what “diagnoses” should be included in the manual, they state:

“The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today.” (p viii)

In other words:  if we say it’s a mental illness, then it’s a mental illness!

In subsequent editions of the manual, they offer a definition of a mental disorder, which when stripped of verbiage boils down to:  any significant problem of thinking, feeling, and/or behaving.  And who decides something is a problem?  A psychiatrist, of course.

Sluggish Cognitive Tempo (or concentration deficit disorder, as Drs. Barkley and Saxbe would prefer to call it) is more psychiatric nonsense.  But that’s all it is – more of the same; another inevitable result of psychiatry’s fundamentally flawed, spurious, and destructive medicalization of human existence.  Psychiatry continues to expand its net of entrapment into all aspects of life and into every corner of the globe.

By all means let’s speak out against this latest encroachment, but let us not lose sight of the corrupt and spurious engine that has been driving this endeavor since the 1950’s, or of the trail of human suffering and destruction that it has left, and continues to leave, in its wake.

Nor let use lose sight of the fact that many of the greatest writers, scientists, and artists were chronic daydreamers.  We can only imagine how much better the world would be today if these individuals had received the benefits of modern psychiatric treatment. We can also look forward to a better future – a future where daydreaming will be routinely recognized as the illness that it is, its victims will be “treated” appropriately with psychiatric drugs, and this plague, that has beset humanity since pre-historic times, will finally be eradicated.
There is absolutely no facet of human existence that psychiatry will not pathologize in the pursuit of its own self-serving agenda.

* * * * *

This post first appeared on Philip Hickey’s website,
Behaviorism and Mental Health

22 COMMENTS

  1. I’ve been daydreaming of a post-therapeutic, post-psychiatric future for more than 30 years and I don’t think that psychotropic medication of the kind prescribed by psychiatrists is ever going to cure my daydreaming! The only thing sluggish here is the cognitive constriction of the APA and the reductionistic worldview of biological psychiatry, not to mention their symbiotic ties with the pharmaceutical-industrial complex. Nice article!

  2. It was mandated I take antipsychotics because I questioned the meaning of a powerful nighttime dream. And I was likely having powerful nighttime dreams because of the withdrawal from a “safe smoking cessation med” / actual dangerous antidepressant.

    After being weaned off the antipsychotics, I suffered from super sensitivity manic psychosis, which for me was an awakening to the story of my nighttime dreams. And my dreams are a fascinating story, and I hope my dreams do come true, so I now sometimes daydream about the love story from my nighttime dreams. But my dreams inspired a lot of artwork, and since I’m an artist, that’s a good thing, not a “mental illness.” Inspiration is good, not a “mental illness.”

    The bottom line is, however, the psychotropic drugs affect one’s dreaming and dreaming should not be considered a mental illnesses. Psychiatry is insanity. Thank you for another truthful article, Dr. Hickey.

  3. i happened to have spent this entire day discussing with my brother in law why my nephew has been on adhd drugs for the last 6 or so years and how they’ve all been bamboozled by psych/drug comp. i’m ready to tear my hair out so i came to MIA to read some sense on the topic.
    so- thanks to everybody here for providing this dose.

    i want all the adhd drugging parents to follow this sluggish tempo crap closely so they see how their own kids’ made-up diagnoses came to be.

    keep up the good work

    erin

    • Erin,

      You say that you’re ready to tear your hair out. I think all of us on this side of the debate know that feeling.

      History is going to judge these generations harshly and with amazement. How can we be willing to sacrifice literally millions of children for the sake of psychiatric turf and pharma profits?

      You probably won’t convince your brother-in-law, but do keep speaking out. The civilization you save may be our own!

      • ty for the reply. the speaking out and (for now, limited, due to our having to be careful for our kids and my husband’s career) activism are the only things that seem to help with my tremendous anger. long story short, my husband got caught in a ten year” mind drug” nightmare that has in many ways destroyed our lives. so ty for your contributions. i’m just hoping to save someone(s) else from our brand of hell.

        • Activism is the only thing that helps my anger too. Doing something, however small, to change the current system seems like the only productive way to deal with it. Realising that there is no justice for what was done to you because all their crimes are perfectly legal isn’t a nice way to wake up…

          • glad to hear it helps you, too, b. i keep thinking about all the times in history and in life when “everybody” was/is wrong. change takes time. but i see it is no ok to be silent about our experiences. it is really our obligation as humans to raise our voices and try to protect others.

  4. My son has congenital heart disease and had his first open heart surgery when he was 5 days old. He recovered very well physically, but I wondered how his early life experiences would affect his brain development. He had some mild developmental delays, but caught up. When he started elementary school, he had problems with the motor aspects of writing, and some mild behavior issues. That led to testing, and multiple diagnoses — what was clear to me was that his brain worked differently, and even though he was highly intelligent, he had some challenges. After a second heart surgery at age 9, he was frightened of the dark, and had nightmares — a real post traumatic stress response.

    When we sought therapy for him, he was quickly assessed and diagnosed with ADHD. That wasn’t what we were looking for — nevertheless, we tried medications (methylphenidate). At first, he said it made him feel less bored at school, but it came with horrible daily withdrawal effects. He would be an emotional wreck as the medication wore off. After his teachers told me they saw no difference on or off meds, he stopped taking them.

    My son is a daydreamer. He is highly emotionally sensitive, funny, and a budding actor. He is so much like me. Yet I know that he has some brain differences, based on his early experiences (perhaps some anoxia, and alot of morphine during his first days after birth). He is also very much like my brother as young teenager — who hid in his room and read science fiction novels. I have no doubt that my son has a rich interior life. It may be more interesting than what he learns in school.

    What works best for him? Lots of emotional support. A keyboard to overcome his challenges with handwriting. And teachers willing to give him credit for what he accomplishes.

    • You are fortunate they did not kill him with the stimulants – they really should not be used for kids with heart problems!

      I think the much more interesting question is not what to do with kids who have a hard time paying attention to the teacher, but why does school have to be so darned BORING!!! Most classrooms would send the average adult running screaming from the room after half an hour. The only reason the kids put up with it is because they can’t escape.

      We avoided all that by homeschooling or enrolling our kids in alternative schools with a child-centered approach that allowed flexibility and maximum self-direction. Two of them were classic “ADHD” kids, but no one at their alternative schools ever mentioned it to us. They just worked with them as they were, and adapted to what worked for them. That’s how schools should be.

      There is no excuse for the “SCT” crap. Honestly, if I hadn’t been allowed to daydream in school, I would have slit my wrists. There was literally nothing else to do, and I was bored to tears. Thank the Lord they let me doodle on my notebook!

      Learning should not be boring. If it is, it’s the school’s and the teacher’s fault. I’m tired of kids getting blamed because the schools are too inflexible and insensitive to notice when the kids are bored out of their minds. Stimulants aren’t the answer – a more stimulating educational environment is the answer.

      —- Steve

      • I remember whole lessons spent in observing the pair of birds making a nest on a tree next to the school background. It was really interesting, more than the teacher at times. Also I was drawing pictures all the time, sometimes satirical caricatures of the teacher that were passed around for fun. Today me and half of my class would be on meds for ADHD, depression, ODD or whatever bs. To be honest, the biggest factor in how kids did at school seems to be how much their parents were willing to take part and be interested in the kid’s schoolwork. Now you can give kids drugs and expect they will be doing what they’re told.

      • Steve,

        I agree. Learning should not be boring. It should be exciting! It’s nice to learn that you found appropriate alternatives for your children. Tragically, a great many parents just accept the “expert” pronouncements and go along with the pills. Keep speaking out. This tide is starting to turn.

  5. This is a classic political move, both on the part of a company and the APA; the ADHD discredited APA “distancing” from the new disorder while psychologists take it seriously, and gleefully anticipating the money rolling in. See also Chrys Muirhead’s recent post “Clinical Psychology in Scotland, a Handmaiden to Psychiatry.” Anyone for some reruns of Yes, Minister?

    “All of which raises the interesting question: is SCT disorder being promoted at the present time by Eli Lilly’s paid hacks as a way of increasing sales of atomoxetine (Strattera) while it is still on patent?”

    “Interestingly, and sadly, most of the research and promotion of SCT has been done by psychologists rather than psychiatrists. This fact prompted Jeffrey Lieberman, MD, President of the APA, and very eminent psychiatrist to tweet on April 11 “no credible psychiatrist takes this [SCT] seriously” in response to Alan Schwartz’s article in the New York Times.”

    • Rossa,

      Thanks for coming in. Tragically many psychologists, especially in the US, are willing to accept the “psychiatric handmaiden” role, and to scoop up the crumbs that fall from the table. This is particularly ironic in that psychology courses routinely provide instruction on the negative effects of labeling, and indeed on the dangers of “seeing” patterns and structures that don’t really exist.

  6. “Sluggish Cognitive Tempo” could also exist in some situations as a result of a person’s mother being on SSRIs or other meds. during pregnancy which are known to produce learning and ‘processing’ issues in her children…This is so infuriating and sad…pharmaceuticals cause the problem only to be given another opportunity to market drugs to the next generation of victims!

  7. I was a strong anti-medication advocate until my son was diagnosed with SCT and I gave in. This is a very type b personality kid who has been exceptionally lazy since he was born. No desire to crawl or roll over. Extremely happy but never energetic. He loved school but the teachers complained he was not motivated. I didn’t worry much – he was bored and he was smart. But by the 4th grade – he was falling behind and was starting to really have troubles at school because he didn’t do the work. He had more days that he just sat in a catatonic state. He did this at other times – I had called it the “possum” starting when he was little. He has done it at Disney World, at friends’ houses and school. He just stares and doesn’t talk. He acts uninterested but he is not unhappy. It is not about being interested. It was whether he was having a foggy day. He became more withdrawn and more scared. He constantly talked about being afraid because he couldn’t understand. I felt he had anxiety. I had all kinds of theories. But the doctor pushed 20 mg of Vyvanse. I resisted and then gave in. I don’t know what is wrong with my son. I do know this: he is a different kid that is extremely thankful to his doctor. He has slept 11 hours since he was little and it is not a sleep problem. That kid is a sleeper and continues to be a sleeper on the medication. He eats exceptionally well and has done 1 hour of exercise every day of his life because I felt it was important due to family heart disease. It is not something that only happens at school. That is what bothers him – he will have trouble with going into a fog at birthday parties and at times that it is really inconvenient. If it is anxiety – I will say this. A really small dose of Vyvanse does great things for his anxiety. My son hates the sluggishness but choses to not take the medication when he is not going to school. He is smart enough to research it all and he doesn’t want to “end up short.” He told me yesterday that he hates the summer months when he feels like he can’t keep up. But he would never go to school without the assistance because he knows the difference it makes for him. We are working on other solutions. There is some advantage to running (heavy cardio) in the mornings. But on a really foggy day – it is hopeless. Just an opposing viewpoint. Not everyone is just blindly drugging their kid. It kills me that he has to take this. But I will say that watching him sit in a catatonic state that you can’t get him to answer even simple questions is so much more horrible than my worries on what the medication is doing to him.

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