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.”
“This is an exciting finding and warrants further investigation as it is the first published report to show improvement in SCT with any medication.”
“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…”
“This is the first study to report significant effects of any medication on SCT.”
All of this is particularly interesting because:
- Ritalin, which is now off patent, and other stimulants, are reportedly ineffective in the “treatment” of SCT “symptoms.” (Saxbe and Barkley, 2014, p. 47)
- Atomoxetine, which is still on-patent, is now “proven” effective in this area.
- Linda Wietecha works as a Clinical Research Scientist for Lilly USA, LLC
- 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.
- 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?
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.
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.
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.
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This post first appeared on Philip Hickey’s website,
Behaviorism and Mental Health
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.