SCT: A New Type of ADHD for Next DSM?

Before my friend Jack was diagnosed with ADHD, he used to call himself “Sluggo the Wonder Boy.”  Highly educated, hard-working, and his heart set on big achievements, Jack still had problems around being, well, sluggish.

For example, when he sat in a chair, within five minutes he invariably slumped and slid  until his head was on the back of the chair and his legs were stretched out, eyes half-closed unless something thoroughly grabbed his attention. It was a miracle of physics that he didn’t slide right onto the floor. If you didn’t know any better, you’d think he was chronically sleep deprived, but he slept well and regularly.

Only after ADHD was diagnosed and he began taking stimulant medication did he start sitting in a more erect and alert manner.  Moreover, his pupils became fully visible. Finally, I could see that his eyes were a lovely shade of brown. Who knew?

Does Jack have a different type of ADHD?  A sluggish type? I can’t say. But I can offer you this guest column from Robert F. Eme, Ph.D., on the possibility of a new type of ADHD that focuses on something called Sluggish Cognitive Tempo.

Dr. Eme is a clinical psychologist and professor of clinical psychology at Argosy University, Shaumburg campus. For the past ten years, he has taught future clinical psychologists about ADHD. (Note: When I was researching my book and seeking to identify psychology programs that included courses on Adult ADHD, I found one: his. For all I know, it still might be the only one. So, kudos Dr. Eme!)  He is also the co-author, with Patrick Hurley, of  ADHD and the Criminal Justice System: Spinning Out of Control.  Look for a future post here on his work in this area.

______________________

by Robert Eme, Ph.D.

Robert Eme, Ph.D.

Something quite remarkable has occurred in one the proposed revisions to the diagnosis of ADHD for the Diagnostic and Statistical Manual-5 (DSM-5) — the creation of a new diagnosis for a new disorder: Attention-Deficit Disorder (ADD).

This disorder is characterized by an impairment in attention without hyperactivity or impulsivity. Most importantly however, this disorder is thought to be different from what is currently  known as the Primarily Inattentive Type of ADHD (ADHD-PI) in that the attentional impairment is different. In this essay, I will briefly summarize and update my review of this potential new disorder, which appeared in the 2007, Vol 1, issue 1 of the School Psychologist.

In 1993 Thomas Brown (see below for a case history from him) reported on a group of individuals who were not hyperactive but hypoactive and who demonstrated deficits in attention that were different from those typically found in ADHD. These individuals could be very bright and, in contrast to the whirling dervish “Dennis the Menace” stereotype of ADHD, better resembled the “space cadet” stereotype. It appeared that their deficits were related to the attentional dimensions of arousal and alertness with symptoms such as

  • “often stares into space”
  • “daydreamy “
  • “often appears to be low in energy, sluggish, drowsy.”

Moreover, in the field trials of symptom utility for DSM-IV, reported in 1994, two symptoms were identified that were more diagnostic of attention problems than all but one of the symptoms included in the official DSM list (i.e., “drowsy” and “daydreams”). Nevertheless, these symptoms never made it onto the list.

What this finding suggested, though it was not recognized at that time, was that there was a type of attention disorder that was different from ADHD. Subsequent research has validated this initial finding and provided evidence for a disorder that has been termed “Sluggish Cognitive Tempo” (SCT) that is different from ADHD-PI.

The three core symptoms of SCT are:

  • Slow
  • Sleepy
  • Daydreamer

Most importantly, the inattentive symptom of daydreaming (e.g., mind wanderer, spacey, zoned out, lost in thought, etc.) appears to be qualitatively different from the attentional impairment in ADHD-PI. In SCT, the distractibility is internal as the mind drifts from thought to thought rather than focusing on the task. In ADHD-PI, the distractibility is external in that there is a failure to inhibit or block out irrelevant external stimuli. The following vignette from my 2007 article illustrates this qualitative difference:

Mary (a young adult) described herself as being “more spacey than others.” She said that she has trouble paying attention when people talk to her in class. “I just feel like you are talking to me, but I don’t process the information. I look attentive and I feel attentive, but my mind is just kind of blank.

Mary explained that she also has problems during conversations with friends: “A lot of times I’m wondering what was just said. I don’t know if it’s like forgetfulness or it’s just not paying attention, but like things just don’t seem to settle in very well.

Margaret (a young adult) reported, “Sometimes no matter how hard I try to focus in class I can only focus for a few minutes at a time. By the time I realize I am not paying attention, I have no idea what is being discussed. When I talk to people, I zone out within 5 minutes and forget what they were saying. It’s like mid-sentence I blank out and am not able to continue my thoughts.”

In conclusion, only time will tell if indeed the DSM-5 (scheduled for release in 2013) contains this revision. Whether or not it does, however, there is no doubt that there are number of individuals who present with SCT type symptoms that are as impairing in academic settings as are classic cases of ADHD.

The following is a case history vignette from Thomas E. Brown, Ph.D. in The BrownLetter on ADD, a free quarterly newsletter of information and opinion about ADD/ADHD, in February, 2006. (You can read the entire newsletter here.)

Blaming the Victim:
Misguided Diagnosis for an Adult with ADHD

A 23-year-old woman recently came to me for a consultation after spending many hours and substantial income getting a neuropsychological evaluation for suspected ADHD at a major medical center in another state.

She is very bright and had no history of behavior problems or substance abuse, but she had struggled intensely with attentional and working memory problems that resulted in severe academic underachievement from 9th grade onward. She obtained a GED after she failed to meet high school graduation requirements. She then struggled for 5 years to complete a two-year degree in a community college. Meanwhile, she performed well in her job and excelled as an athlete and musician, though she often suffered from excessive perfectionism and depressed mood.

The evaluating clinician reported that although this woman reported many symptoms of ADHD during adolescence and adulthood, he could not make the diagnosis because she did not fully meet DSM-IV criteria. He refused to diagnose ADHD because the patient’s mother, when asked about ADHD symptoms during the patient’s childhood, did not recall noticing the requisite number of symptoms. Instead, he diagnosed the patient as suffering from “Self-Defeating Personality Disorder.”

This is an example of a clinician rigidly applying DSM-IV criteria for diagnosis of ADHD in a way that prevented desperately needed treatment. Adding insult to injury, by giving the patient a diagnosis of “Self-defeating Personality Disorder,” the clinician clearly implied that the she was the source and cause of her problems. In short, he was blaming the victim for her persistent suffering. I consider this not only a clinical error, but an unfortunate prejudice about ADD that is altogether too common, even among some skilled professionals.

Why Some Bright Students Fail At Yale University

Dr. Donald Quinlan and I recently completed analysis of data from 74 students aged 7 to 18 years with IQ scores above 120, in the top 9% of the population, who had been referred for chronic underachievement. Most had no behavioral problems and were not hyperactive, but did have attentional disorders. Despite excellent long-term memory and strong verbal and perceptual abilities, these very bright students showed significant weakness on standardized tests of working memory and ability to focus attention. They were unable to recall accurately what they had heard or read just a few minutes earlier. Many also showed slowed processing speed that impaired output for writing tasks.

These high IQ students reported significant difficulties in organizing and getting started on their work. They often found it necessary to re-read passages multiple times in order to comprehend the assignment. Many did well on quizzes and tests, but received low or failing grades due to inattention and persistent failure to complete homework. Parents and teachers were frustrated because these students appeared unmotivated to do assigned work. Yet everyone in the study had a favorite activity, such as computer games, tennis, drawing or playing guitar for which they regularly focused very well. Students claimed that they could focus easily on those tasks that especially interested them, though they were chronically unable to mobilize adequate attention or effort for their academic work.

29 thoughts on “SCT: A New Type of ADHD for Next DSM?”

  1. Gina,

    I just found this on your site – and I blown away! This is me.

    thank you for putting this out there! Unfortunately, when it was originally published I had just given birth so I was supremely distracted.

    -liz

    1. Hi Liz,

      Yes, this was an early report on the topic. Dr. Barkley has some excellent presentations on YouTube, on the topic of SCT.

      best,
      g

  2. Is this topic still open? My son was recently diagnosed after struggling in college for over a year. Can anyone direct me to information on meds to try? He was diagnosed by a Psychologist and not Psychiatrist, so I thought it might be good to do some medication research on my own as well. Thanks,
    Michelle

    1. Hi Michelle,

      All topics open all the time. 😉

      I encourage you to read my book. It’s chapters on medication remain the best, most comprehensive guides for consumers — and for doctors, too. There should be a method to prescribing, but many doctors take more of a seat-of-the-pants approach. That’s why I advise people with ADHD and their loved ones to do their own research and be prepared to be pro-active.

      Here is a link to Amazon:

      http://www.amazon.com/dp/0981548709/tag=wwwginaperaco-20

      Also, search this blog for “medication” and you will see many other posts on the topic.

      best,
      Gina

  3. Wow, SCT so describes most of my symptoms. I was diagnosed with primarily inattentive add last month. There are some hyper and impulsive symptoms also.

    It’s too funny because at my recent career change I immediately was nicknamed “Express” and “Nitro” because I was a lot slower and more like a large bull walking across a pasture than the others who coincidentaly are also 10-15 years younger than I and in a very physically demanding job. I can work all day just not like the little jack rabbots running and bouncing around me.

    The fog, spaciness, lethargy, confusion and lack of drive all explain how I feel to a T.

    Looking back I definitely did have the hyperactive symptoms in my youth just maybe not as destructive as some because of a very rigid and autocratic parenting style of my father.

    My question is about medication. My doc prescribed me 18 mg Concerta and follows a very low and slow regime. I am frustrated with little to no effects except for on the first two days and since my marriage is in shambles and pretty much over even after my wife read Gina’s book. Should I be looking at a different med? Should I look towards the amphetamine based? I am concerned about Vyvanse being hard on the liver and potential sexual side effects of it and Strattera. In addition to that I’m concerned that switching to Adderall XR may not be smooth and I have a stigma that maybe someone can clear up about it basically being prescribed crack.

    Please let me know your thoughts as I am open minded and value feedback before I see my doc again. I can’t afford to waste time bouncing around med to med and waiting months to step up a dosage waiting for positive effects when my marriage is hanging on by it’s last thread. Doctors are in short supply where I am so switching doctors will add further delays.

    For the record I am working on skills in addition to meds and doing some CBT.

    Thank you in advance for any insight provided as I feel lost without my kids under the same roof as me and my wife, lover and best friend showing nothing but anger, resentment and indifference to the pain and destruction that I have caused unintentionally in our lives. Even after reading Gina’s book she feels that I intentionally acted the ways that I did.

    1. Hi Nigel,

      You don’t mention how long you’ve been married. But what sometimes happens is that a couple struggles for a long time, not knowing why things are so hard, why there is so much chaos, confusion, and “miscommunication.”

      Sometimes the partners of adults with ADHD blame themselves (and are often blamed by their ADHD partners when they have little insight as to their own behavior) or otherwise keep thinking that if they just do things differently, the problems will be solved. It can be exhausting, going day to day in such chaos, feeling ineffectual at resolving the ongoing problems. And then to learn that this thing called ADHD might be at the heart of the chaos, that the problems weren’t their fault, and that, moreover, this is a lifelong, brain-based condition. Well, it’s enough to send some people over the edge. For many, the damage is just too deep and the exhaustion pervasive.

      It might take some time, and some steady proof that treatment is helping you. Best not to be desperate about it in the meantime. Take some time to take care of yourself. Get exercise. Sleep well. And focus on new strategies.

      As for the Rx, you need objective measurements of whether the Rx is having an effect or not. You can’t just go by how you “feel.” That said, 18 mg Concerta is a rather low dosage. I have covered the topic of medication in my book. If you still have a copy, please read it and share it with your MD. There are no magic bullets — only step-by-step method.

      Good luck,
      Gina

  4. I just read this post about SCT and I’m crying. Finding a name and description for this is such a relief. This feels like it really fits my situation, and I feel understood in a way that I haven’t before. SCT has been the source of so much shame and depression in my life. I’m nearly 50 now, and I’m hoping that knowledge about SCT will help me find resources to address it in the most effective way possible…and to finally do something meaningful with my life.

    I have vivid memories of being in first grade and discovering that I simply could not “stay awake” (that’s how I described it to myself) during class. Over and over, I’d find myself drifting back from daydreams, looking around at my classmates, and realizing I’d missed a lesson and failed to do my work. And no matter how determined I was to force myself to pay attention the next day, it never worked.

    Over the proceeding years, the daydreaming continued and my shame grew. I was humiliated by my inability to follow class activities or even conversations with friends. Somehow, though, I managed to make good grades and score very highly on standardized tests. My scores on IQ tests were very high too, and I was placed in gifted and accelerated classes. This really added to my shame, because my teachers, my peers, and my parents all expected such great things from me, academically, and I buried my shame deeper, terrified they would find out what a horrible student I really was. Oddly, my emotional responses to my poor classroom and homework performance — shame, and eventually, panic — established a pattern of lethargic inattention, punctuated with bursts of panicked, adrenaline-fueled attention that facilitated many last-minute essays and cram-study sessions. This carried over into adulthood and in my work, helping me to limp along through life. But I always felt I was “faking it”.

    I’ve managed to be successful at a few things despite my inattention, thanks to this lethargy-shame-panic pattern, but it has been miserable. Though I’ve been working at getting a college degree, off-and-on, for most of my adult life, I still have not accomplished that. This embarrasses me so much.

    I think this pattern of approaching work and life has contributed greatly to problems I’ve had with chronic anxiety and depression. My inability to maintain attention sometimes makes everything about life seem unmanageable. My shame and lack of energy can lead to feelings of hopelessness and thoughts of suicide, so I take antidepressants and expect to continue taking them for the rest of my life. They do help immensely with anxiety and feelings of being overwhelmed. And last year, because of a diagnosis of ADHD-PI, I began taking Concerta, which has been surprisingly effective at helping me focus well enough to study at least a few hours a day. It may not sound like much, but it’s a huge improvement over my past capabilities. 🙂

    Anyway. Thanks so much to Gina Pera, for this blog and for sharing Dr. Eme’s post about SCT. And thanks to everyone else sharing comments here.

    1. Hi Laura,

      Your story breaks my heart. I do this work — do my bit — in hopes that our society doesn’t continue to fail (in more ways than one) children such as you were. It’s just unconscionable to let a child suffer in that way. And same for adults.

      Best of luck in your future pursuits. It sounds like you have very much going for you. You started Concerta only last year, so your benefits should be growing exponentially over time. I’m glad to hear of your success thus far.

      best,
      g

    2. Laura,

      Not sure you will see this post, because it is long after you wrote yours, but I can relate to almost everything you said. I was not diagnosed until 40. The thing that made me successful when I was young was the incredible amount of guilt and embarrassment I carried thinking how dumb and slow I was.

      A question for the group is what impact PI has on relationships. I noticed several posts about being divorced etc. I’ve learned to accept my cognitive issues, but I struggle almost daily with interpersonal relationships and how I am perceived by others. I believe I am very compassionate and caring, but am perceived as being cold and hard to get to know. I think because of 40 years of negative feedback that kept telling me I was not normal.

    3. Hi Steve,

      There is so little research on ADHD and relationships, period, but it would be very helpful for future research to focus on potential differences among the subtypes (now called “presentations” in the new DSM-5).

      You say that you have learned to accept your cognitive issues, which implies that you haven’t pursued treatment? It might be worth looking into, especially for intimate relationships.

      Good luck,
      g

  5. My 20 year old daughter fits the SCT description perfectly to the excessive perfection and depression. She goes to college in Boston and she will head back to school next week. We need to have her diagnosed and treated and we would like feedback as to any research being conducte on SCT. She studies at Tufts and although she is a very bright kid she is underachieving academically because of major procrastination. She sleeps and overates and shows signs of depression. Could you guide us with a list of doctors in the Boston area that are specialist in this conditon? please let me know if testing should be done by a neurologist or a pschychiatrist? we need guidance and fast since we cant afford to waste another semester with low GPAs!!!

    1. Hi Silvana,

      You don’t need to wait for research on SCT to get help for your daughter. It sounds like you need a thorough evaluation; she might have ADHD as well as depression or anxiety. It’s often not one or the other but both.

      Massachusetts General Hospital is considered a national center for ADHD research. I suggest that you contact the hospital for referrals to clinicians in the area:
      http://www.massgeneral.org/children/adolescenthealth/articles/aa_add.aspx

    2. Hi Jane,
      Thanks for your comment. Strattera might not be the best choice for everyone but it helps many people with ADHD, sometimes in combination with a stimulant.

      best,
      g

  6. Makes me wonder if ADHD & Narcolepsy are merely different forms of the same basic condition, since SID fits inbetween.

    I find that with my ADHD, periods of hyperactivity are followed by periods of sluggishness & I’ve also thought the sluggishness was the body’s way of catching itself up on rest and renewal after a long period of high intensity hyperactive energy & activity.

  7. Oh and did I forget to mention day dreams that I have had while walking down the street that would stop me in my tracks till I realized I was letting my mind run away with the dream.

  8. Oh yeah, had to go back and glance over the article but I also wanted to comment on reading, or the reading of questions in school which basically rang to true for me. I love to read but as the ex-wife has said or commented, “How come it takes you so long to read a book?”

    Didn’t want to admit it at the time that I had to go back and re-read what I had just read about ten times. But then at the time I thought that was “normal” for everyone. How ever when I am very much into a book I don’t have that problem quite as often. In answer to my ex’s question I said something to the effect of, “It’s because I can vividly imagine/picture what I am reading.” Which of course she responded that she does to.

    But I personally don’t feel that to be accurate I think I can “see” it much more clearly than she could. Many times I would, for lack of better description, lose visual sight of the words and the visual image in my head would be like watching a movie in a theater, only more acutely, or even more clearly as a real life experience, but not quite. I was still reading the words ’cause I would go back and check to see if I miss read something but nope I had read it all.

    Any-who I’ll stop yacking now cause writing this “little bit” has taken me about 30 mins, what with organizing thoughts, re-reading what I read so it makes at least some sense, and correcting errors. Essays were always somewhat torturous.

    Ok – thats it! 😉

    gary

  9. Ha! I knew it. I was diagnosed a couple years ago after my separation, anyway, before I make a short story long for which I have been accused, I used to say I had ADHD without the H. Been told just recently at a job performance review, oh I can’t remember exactly, but the jist of it was that I appeared “slow” in movement and interest not in intelligence.

    Anywho, When people complain about how slow I walk my response over the years became “Why would I want to rush, life is short, I want to smell the roses.”

    Slumping in chairs or stretching out at any chance I can – definitely – sleeping any where absolutely. It was kind of interesting to note too when my nephew and i went to an ADD Centre where they use computerized EEG feedback of brain wave activity and got to try it out for free. My sister was watching the computer screen of the most active brain wave states. No surprise that most of my nephews activity was in the theta range. But my sister burst out laughing when I did it because the majority of my activity was in the Alpha state. Her comment being; “no wonder you always look half asleep, you are.”

    Just found that was interesting.

  10. Interesting post, g, on yet another challenging angle – created by looking at ADHD from the outside.

    My only regret upon reviewing this interesting material is that many are still standing back, en masse, trying to describe nuances from the outside rather than using the patient’s own mind perceptions as a guide for treatment.

    So many ADHD folk I see have struggled with this cognitive slowing as a downstream result of unmanageable cognitive abundance, not, as implied by the ‘sluggish’ word, a cognitive deficit. Too much looks on the outside like too little.

    I cover this point rather emphatically in my own recent book as such ‘appearance’ terms such as ‘sluggish’ or ‘slow’ represent only an outsider’s view of the more prevalent overactive PFC [‘Thinking ADHD’]- and become disdainful misrepresentations of the cognitive struggle with ADHD.
    cp
    Author: ADHD Medication Rules – Paying Attention To The Meds For Paying Attention.

    1. Yes, Dr. Parker. We need to bring more disciplines to the table, don’t we. The people who observe, the people who can measure, etc. It’s all important.

      If you’ll send me that excerpt of your book, I’ll be happy to post it on this blog.

  11. Thank you for this! I thought I was losing my mind a little. I am married to a man who 100% fits the Sluggo definition! He thankfully has been diagnosed with ADHD and is doing miraculously well on medication. He meets the Inattentive and Impulsive criteria too but when he is not on his medication he can sleep any where, any time, no matter how much sleep he had the night before. So much for the hyperactive part and this is the first thing I’ve read about anyone with ADD being sluggish or tired.

    Our bigger struggle is getting his 15-year old daughter diagnosed. She is the same Sluggo way; and day-dreamy and space-cadetish; and can’t carry on a lengthy (5 minutes or more) conversation to save her soul BUT she has a 3.75 GPA, cheers for her school, is very popular and social. No disciplinary issues at all and she doesn’t really show signs of struggling academically, though that started to change just slightly last year when she entered high school. School has just started this year so we’ll see.

    She does however, pull her hair out obsessively when she is anxious or stressed – eyelashes, eyebrows, specific areas on her head, etc. and that is heartbreaking to see. She is a beautiful girl and she has so much potential – if we can just break down those glass walls!

    Long story but we don’t have custody (yet) and can’t get her diagnosed. She has very big dreams for her life and I worry constantly she is not going to be able to realize those dreams if we don’t get her help soon. Thank you for posting this. It helps (me at least) justify some of the traits that don’t fit in with the classic diagnosed behaviors.

    1. Hi Jennifer,

      I’m glad that girl has you and her dad in her life. I hope that she can soon benefit from an evaluation and possible treatment.

      I cannot understand anyone witnessing that heartbreak and not getting help for her. Obviously, there is some “denial” in the parent and perhaps a potential diagnosis as well.

      In the meantime, the fact that you and her father understand her challenges and want to help is sure to be a help in itself.

    2. My 12 yr old has the eye lash and eye brow pulling. We read that the supplement N-acetylcysteine can help dramatically with Trichotillomania. I had her taking Gingko and the Stress Tabs (Ashwagandha with B vitamins) from Walmart and the hair pulling stopped before I started the NAC supplement. The Gingko is for the sluggishness and focus.

    3. HI Julue,

      How interesting. I’ve read a bit about Ashwagandha but don’t know many people who have tried it.

      I’m glad your daughter is feeling better!

      g

  12. This was excellent information to help us Adders understand how our mind internalizes information and how our brain functions.

    1. HI Alane,
      I’m glad you found it helpful. Yes, exactly. The more information, the more validation, the more explanation…..the less confusion and isolation.

  13. Dr. Barkley covered SCT quite well in his UCtelevision lecture “Management of ADHD”. I remember showing my mother that lecture and her (a high school teacher) being totally appalled at the name. If I remember correctly, Barkley suggested that SCT might be more effectively managed with norepinephrine reuptake inhibitor drugs like Strattera, but its probably all just theoretical at the moment.

    I think it’s great that the science is finally able to zone in on what is and isn’t ADHD. By doing so, it can only help everybody. If SCT is a seperate condition, that’s great – it can be more accurately studied and managed!

    But, wtf is “self-defeating personality disorder”? Sounds more like psychiatrist-fail disorder to me.

    1. HI Matt — Thanks for visiting. Isn’t that Barkley lecture wonderful? I agree with your mother, though: it’s a horrible name — right up there with Attention DEFICIT DISORDER.

      These folks really need to invite a marketing person, or maybe a poet, to the table. (Not too much marketing, though; that can go in very bad directions. lol!)

      I must say, though, that “Jack” in the lead-in is my husband, and that was his word for himself: Sluggo.

      When we used to bat around potential titles for my book, one of his suggestions was: “I Married ADHD: The Mollusk Years.” 😉

      And I agree with you on “self-defeating personality disorder.” Maybe you read in my book where I cite Dr. John Ratey’s early study showing that a huge percentage of patients designated “treatment failures” actually had ADHD. The term is ambiguous, but I’m thinking the people who didn’t “respond” to treatment felt like the failures.

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