There is currently no formal mental health diagnosis for Sluggish Cognitive Tempo (SCT). SCT is currently a sub-category of the Inattentive type of ADHD (ADHD-PI) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is published by the American Psychiatric Association. The current version of the DSM-IV is due for revision and the new DSM-V is due to be published in 2012.
The American Psychiatric Association is reconsidering the current classification of SCT and it is likely that this mental health condition will likely have its own category separate from the Inattentive ADHD category in the 2012 DSM-V.
It is unknown how many individuals with ADHD-PI have symptoms of SCT. Some researchers have put the estimate at 30% and others at as high as 50%. What is clear, however, is that the majority of people with ADHD-PI do not also have SCT. This is important because many authorities in the field of ADHD, including Russell Barkley, have proposed that these two conditions are all part of one diagnosis.
I admit to being reluctant, up until now, about writing about SCT. My first reason had to do with not wanting to give credibility to the notion that these two conditions are one and the same problem. The second reason had to do with a personal protest of sorts. When my ADHD-PI son was in second grade my son's teacher gave us this piece of paper with a narrative description of a child that needed treatment for ADHD. This narrative was to serve as an introduction to parents of an ADHD child without hyperactive ADHD. I had the same issue with this narrative as I had with Winnie the Pooh being used to describe ADHD-PI.
It is unknown how many individuals with ADHD-PI have symptoms of SCT. Some researchers have put the estimate at 30% and others at as high as 50%. What is clear, however, is that the majority of people with ADHD-PI do not also have SCT. This is important because many authorities in the field of ADHD, including Russell Barkley, have proposed that these two conditions are all part of one diagnosis.
I admit to being reluctant, up until now, about writing about SCT. My first reason had to do with not wanting to give credibility to the notion that these two conditions are one and the same problem. The second reason had to do with a personal protest of sorts. When my ADHD-PI son was in second grade my son's teacher gave us this piece of paper with a narrative description of a child that needed treatment for ADHD. This narrative was to serve as an introduction to parents of an ADHD child without hyperactive ADHD. I had the same issue with this narrative as I had with Winnie the Pooh being used to describe ADHD-PI.
Those two descriptions, in my opinion, perfectly describe a child with SCT and do not describe ADHD-PI at all. My eldest son does not have SCT symptoms and I was, as person with ADHD-PI, unhappy with a teacher (who had over 40 years of teaching experience) lumping these two conditions together. I wanted, on this site, to educate people that ADHD-PI occurs without symptoms of SCT. I wanted to separate the two conditions from one another and I therefore have, purposely, until now neglected to write about SCT.
The symptom of Sluggish Cognitive Tempo in combination with the diagnosis of Inattentive ADD is a combination of symptoms a little like the symptom of Hyperactivity in a person with the diagnosis of combined type of ADHD (ADHD-C). People with ADHD-C have significant symptoms of Inattention and impulsiveness and they are hyperactive. People with Inattentive ADD and SCT have significant symptoms of Inattention and they have sluggish processing.
People with a diagnosis of ADHD Hyperactive/Impulsive have significant symptoms of hyperactivity and Impulsiveness without a significant amount of inattention. People with ADHD-PI have significant symptoms of Inattention without hyperactivity, sluggishness, or impulsiveness.
The ADHD-PI with Sluggish Cognitive Tempo should probably have been a 4th subtype.
To Summarize:
ADHD-HI: Symptoms of hyperactivity and Impulsiveness without a significant amount of inattention.
ADHD-C: Symptoms of Inattention, hyperactivity, and impulsiveness.
ADHD-PI: Symptoms of Inattention without hyperactivity, sluggishness, or impulsiveness.
ADHD-PI/SCT: Symptoms of Inattention and slow processing without symptoms of impulsiveness
There is not much research that I have found on Sluggish Cognitive Tempo but there is some and I will attempt to summarize what we know if the next post.
The symptom of Sluggish Cognitive Tempo in combination with the diagnosis of Inattentive ADD is a combination of symptoms a little like the symptom of Hyperactivity in a person with the diagnosis of combined type of ADHD (ADHD-C). People with ADHD-C have significant symptoms of Inattention and impulsiveness and they are hyperactive. People with Inattentive ADD and SCT have significant symptoms of Inattention and they have sluggish processing.
People with a diagnosis of ADHD Hyperactive/Impulsive have significant symptoms of hyperactivity and Impulsiveness without a significant amount of inattention. People with ADHD-PI have significant symptoms of Inattention without hyperactivity, sluggishness, or impulsiveness.
The ADHD-PI with Sluggish Cognitive Tempo should probably have been a 4th subtype.
To Summarize:
ADHD-HI: Symptoms of hyperactivity and Impulsiveness without a significant amount of inattention.
ADHD-C: Symptoms of Inattention, hyperactivity, and impulsiveness.
ADHD-PI: Symptoms of Inattention without hyperactivity, sluggishness, or impulsiveness.
ADHD-PI/SCT: Symptoms of Inattention and slow processing without symptoms of impulsiveness
There is not much research that I have found on Sluggish Cognitive Tempo but there is some and I will attempt to summarize what we know if the next post.
I have most of the symptoms of SCT, co-morbid anxiety and very mild OCD (was much worse when I was a child), but I am also impulsive. Currently taking Strattera and Valdoxan, which work together really well and more or less fix everything.
ReplyDeleteIt is interesting to me that some people with SCT do not have inattentiveness as a main symptom. I have written about the individuals with hyperactivity and impulsiveness but little inattention. Is there also a subgroup with sluggish cognitive tempo symptoms and impulsiveness but little inattention?
ReplyDeleteThank you very much for writing about SCT, but i still don't get it. From what I know ADHD-PI is either SCT or a "C" missing some "H" symptoms (not enough to be classified as combined).
ReplyDeleteFor example:
This is a lecture by Russell Barkley:
http://www.youtube.com/watch?v=q3d1SwUXMc0
He shows the different PI subtypes in min 22. It is very hard to read (perhaps you can do it), but what i can read is that there are either SCT or some sort of ADHD-C - there is no "regular" PI. In addition he talks about the SCT as completely different disorder not just as a PI+sluggishness.
From Wikipedia:
"In the DSM-III, sluggishness, drowsiness, and -->daydreaming<-- were listed as characteristics of ADHD. The symptoms were removed from the ADHD criteria in DSM-IV because, although those with ADHD-PI were found to have these symptoms, this ---> only <--- occurred with the absence of hyperactive symptoms" meaning ADHD-PI without the H = SCT and that "daydreaming" is an SCT symptom.
Anyway is the PI you've talked about is hypoactive or only the SCT is?
Maybe some SCTs have qualities that compensate their sluggishness, still they are slower then they should be.
I want to clarify that I value your opinion and experience very much, so please correct me if you know other.
Thank you!
You are absolutely correct about what Russell Barkley believes to be true. He has stated that there is inattentive ADHD and that always goes along with SCT symptoms and if it does not then the person is not truly ADHD-PI. He believes that any person with Predominantly Inattentive ADHD who does not have Sluggish Cognitive symptoms is actually some sort of a 'closet' combined type.
ReplyDeleteThere are a number of researchers that very much disagree with him and studies that have shown that only 30% to 50% of people with ADHD-PI also have SCT symptoms. I have nothing but respect for Dr. Barkley and he is right about mostly everything but I believe that he got this ADHD-PI/SCT thing wrong.
The fact that the pyschiatrist writing the DSM-V are looking into separating out BOTH Sluggish Cognitive Tempo and Inattentive ADHD from the category of ADHD and giving them each their own category points to the belief that not only are these disorders different from each other but also that they can and do occur independent of each other.
You are confused about this because there is a lot of confusion regarding this subject. There are many people is Russell Barkley's camp who swear that SCT is ADHD-PI and vice-versa. Hopefully the new DSM-V will shed some light on this matter.
Thanks so much for taking the time to write. Tess
How can a 10 yr old girl be evaluated for SCT? She was ADHD diagnosed 3 years ago.A lot of SCT symptoms fits her performance. What is the treatment for this condition? Anxiety and Depression need to be addressed to? She is doing kind of good at school, according to the grades....but,... who really knows where those grades came from?.... because she will probably repeat 3rd grade by 2nd time.According with the school, she will be unable to pass the main test, although her grades are "ok" What is the path to surpass this situation?????
ReplyDeleteThe first step would be to make certain she had a complete physical by her pediatrician. Her pediatrician can perform or start the referral process for any additioanl test and evaluations if there is any concern regarding:
ReplyDeleteThyroid problems
Anemia
Vision Problems
Hearing Problems
Sensory Intergration Problems
Anxiety and Depression Problems
Allergy Issues, etc
If any of these need evaluation or addressing, they should be evaluated and addressed before a diagnosis of ADD or SCT is confirmed. Once those diagnosis are confirmed, a psychiatrist can determine if cognitive training would help or if she would benefit from medication.
I know this is a lengthy process but there ARE things that should happen before that, in the classroom, to help her.
Have her teacher sit her at the front of the classroom.
Meet with the teacher and school to form a plan to keep her engaged during school (have teacher tap her on the shoulder if she is lost in thought, keep learning active, give her frequent movement breaks, etc). If you search my site for the word 'classroom' or 'school' (search without the quotes), you will find other suggestions that work well to keep SCT and ADD kids attentive.
If you have not yet supplemented her diet with Zinc, magnesium and a Omega-3, please do so. Also try herbal preparations such as Bacopa, Ginseng Energy, Pycnogenol, coffee or tea. These all help a bit and have helped my son and I.
Please let me know if you have any other questions that I might help with.
Tess
I also believe I have ADHD-PI and SCT. Reading the information and studies on it describe me to a t. I do have one interesting question. I did full blood work to see why I was tired all the time and the only thing that came up was that I have Gilbert's syndrome. That is when you have more bilirubin in your blood than the normal person. Supposedly it is found in up to 5% of the population. The thing I am wondering about is some of the main symptoms reported by those with Gilbert's syndrome are fatigue and difficulty concentrating. See the Wikipedia link below in the "Debated signs and diffuse symptoms" section. I have always had a hunch that the two might be related. Unfortunately Gilbert's syndrome is not life threatening so not many studies have been done. What do you all think?
ReplyDeleteMy research on Pubmed found a link between Gilbert's Disease and an increase in the secretion of glutamate which in turn caused inflammation in the brain and which could cause fatigue, memory problems and learning problems. In the last five years, a link has been found between increased rates of schizophrenia in people with Gilbert's disease and researchers are speculating that what they once considered a benign problem of mildly elevated bilirubin could, in fact, be not benign. We know that bilirubin at high levels is neurotoxic and it may be likely that prolonged levels of slightly elevated bilirubin is also toxic. Common medicine such as Tyelenol as well as many antibiotics, hypertensive medications and high cholesterol treatments will further increase the levels of bilirubin in people with Gilbert's disease and this will not be conducive to healthy brain functioning either. As far as I know there is no way to lower mildly elevated bilirubin except for exposure to sunlight and I am not certain if that treatment works as well in Gilbert's disease as it does in newborn infants with elevated bilirubin levels. I found no info on possible treatment but I would be very interested to learn more as would all my readers. Thanks so much for this valuable information. This is just one more example of something that causes ADD like symptoms that is actually the result of another medical problem. Thanks again! Tess
ReplyDeleteThanks so much Tess Messer for the reply! That would make a lot of sense. I would really like to help out as many people as I can. If more people found this link between Gilbert's Syndrome and ADHD symptoms, that would be interesting. How many people have done a full extensive blood work? Not very common. I would have never know I had Gilbert's Syndrome had I not done the blood work. I wish more studies had been done on Gilbert's Syndrome. I would take part in them myself if I could. Wish I had more connections to those in the ADHD research field. Even if I could meet with an expert to do a thorough examination to make a diagnosis, that would be great. Every time I go to the doctor, they are in a rush and need to move on to the next patient. I have usually been told to just take more vitamins and such. I do have one question. Does SCT cause physical fatigue, or just mental? It is hard for me to understand by the description. It seems to be talking about energy in the sense of motivation and mental power rather than physical energy. I fit many of the symptoms of ADHD-PI and SCT, but I wonder if that is because of my Gilbert's Syndrome. I have well over double the recommended maximum amount of bilirubin in my blood. Not sure if that is common levels for this syndrome. I wonder which symptoms apply to what. If physical fatigue is not a symptom of SCT, I may be able to attribute that to Gilbert's Syndrome. A few of my siblings, and my mother have been diagnosed with ADHD. I know ADHD is highly genetic, but I do not know if the same is true for Gilbert's syndrome. My mother and some of my siblings also have physical fatigue and the symptoms of ADHD-PI and SCT. I sometimes wonder if I have ADHD-PI, SCT, Gilbert's Syndrome, and all the symptoms that go along with them. Triple whammy. Do you think it is possible to have all these? Well, a huge post already. Just a lot to take into account. I would like to understand exactly what is going on. Do I have ADHD, Gilbert's Syndrome, or both? It would be nice to be able to know. Sorry for the long and quite unorganized post. Hope it sheds some light onto more things.
ReplyDeleteAlex,
ReplyDeleteYou are right. I am in the process of writing a long blog on things that can look ike ADHD but that are actually other medical problems and I was inspired to do this by your story.
The majority of people do not get lab testing or any othe work up. SCT can cause physical fatigue for the same reason that depression can cause physical fatigue. Your body and mind are intimately connected and things that cause you to be mentally fatigued can also make you physically fatigued.
There is a genetic component to Gilbert's Syndrome and yes you can have Gilbert's syndrome and symptoms of SCT and ADHD-PI. About 30% of people with ADHD-PI symptoms also have symptoms of SCT. It seems as though Gilbert's Syndrome can cause symptoms that look just like SCT so yes you can have all of this.
Does one cause the others, maybe. We don't know enough about Gilbert's syndrome to know this but if you can afford to see a Hepatologist (liver specialist) it might be worth it as they will know more about how your levels of bilirubin are affecting you neurologically and if there is anything that can be done to lower your bilirubin levels. For years Gilbert's syndrome was considered benign but Hepatologist are now seeing it in a very different light.
The problems with ADHD, ADHD-PI and SCT is that there are other conditions that cause these symptoms or symptoms that look just like these and if we do not treat the underlying cause, in those cases, we cannot treat the ADHD, ADHD-PI or SCT symptoms.
Can you see a specialist?? General Internist have so little time but sub-specialist such as Hepatologist often spend more time with each patient and are better prepared to answer questions about rare conditions such as this one.
Let me know if I can help in any way. Tess
Tess,
ReplyDeleteWell this is all very interesting for me as I try to find out what is wrong with my 15 year old daughter. She has been diagnosed with Gilberts Syndrome when she was having bouts of reflux at about age 7 or 8. She has also had cyclic vomiting ( when she was about 4)and as I mentioned reflux , sleep apnea. In the last couple of years I became aware of Dr. Brownstein (iodine- check it out) and thyroid issues and I drove her to Michigan and she was diagnosed as hypothyroid and also her hormones (especially pregnenelone) were very low - so she is taking thyroid and pregnenlone. She takes an enormous amount of vitamins ect every day - we eat organically ect- believe me she get the fish oil, and just about every vitamin known :)
She has 2 older brothers that have both been diagnosed with inattention ADD or whatever it is called and one OCD. My oldest son was not able to finish college until he was put on Adderall and he now has a great job in the engineering field and takes his meds daily. My other son refused meds but has his own business and has strategies to deal with his issues (he also graduated in engineering from VTech) By the way I was also diagnosed about the same time but take nothing but coffee.
I guess I felt I really that ADD was a name for issues that could be treated naturally and felt there was no way I would do this to my daughter- but here I am taking her tomorrow for help because I have tried everything and she still can't seem to focus on what she is reading, memorize her math facts (although she can remember tunes easy) She like my sons works better with background music (plain weird:)
We also have 2 cousins that take meds and are doing well , so I feel almost bad that I tried everything else first. It isn't that she does not have all these other issues but she might have attention deficit disorder too? She scores high on verbal skills and is social and has not suffered a depression yet (both of my sons suffered major depressions).
Well I just appreciate your blog and I guess I wish there was a for sure test for ADD- she is all encouraged that "this might be the help for her".
P.S. She has been told by her sleep doctor that she has hypersomnia because she can't seem to wake up and she is very fatigued- she would say very sluggish. She told me the other day she would like to know what ADD-hyper felt like!
pat
I wrote this huge post and then it would not post as being too large- stress!!!! My daughter (15) has Gilberts Syndrome, is fatigued, hypo-thyroid, and being tested for inattentive ADD tomorrow. She has 2 older brothers that have the same and one just was able to graduate college when he was put on Adderall. My daughter takes a ton of vitamins and Armour thyroid but she is still not able to focus and learn as she has to (she is home-schooled) and can't get her math facts in her head.
ReplyDeletePat
Well for heavens sake I see it posted after all :) feeling like an idiot!
ReplyDeleteHi Pat,
ReplyDeleteAs I mentioned before, physicians have long considered the Gilbert's hyperbilirubinemia to be a benign condition but lately they have noticed an increased incidence of schizophrenia in people with Gilbert's and they are considering the fact that even low levels of bilirubin act on the neurotransmitters in such as way that symptoms such as fatigue, inattention and hypersomnalence are occurring.
The study that I found on the cause of this speculated that the bilirubin even at low levels was exerting a persistent negative effect on the neural brain pathways.
I am not surprised at all about the hormone issues because the Hypo-pituitary axis work in conjuction with the neurotransmitters and what afffects a neurotransmitter will often affect a hormone and vice-versa. Cortisol is the stress hormone that can make all this run amuk but the other hormones play a huge role as well.
Does anyone else in the family have Gilbert's? Have they been tested?
Thanks for your interesting comment. I am hopeful, given that you seem to be totally on top of all this, that she will get the help she needs. Let me know if I can help in any way.
Tess
Well her appointment today was with a sleep/ allergy doctor. We were there before when she had sleep apnea as a child (had tonsils out) and last August for extreme fatigue. At that time he suggested she possibly had hypersomnia and had me keep track of her sleep and how many times she could fall asleep a day when I woke her up every hour I think and kept her awake for 15 minutes. He has set up a sleep study for her on the 27th- that night she will be doing the normal sleep study to make sure there is no apnea/ restless legs ect. Then they wake her at 6:00 and start a nap study to see how many naps she takes. He told me this could mimic ADD- the drug they use he said is Nuvgil. He did say she could possible have both Add and hypersomnia. I will let you know what we find out :)
ReplyDeleteThanks Pat
Thanks for the update. Let us know how it goes.
ReplyDeleteTess
Interesting. Very, very interesting.
ReplyDeleteI am 19 years old and I was been diagnosed with Gilbert's Syndrome a couple years ago. I often noticed that usually, I'd be up and ready to take on the world, but then there were days where I simply felt like a zombie: mindlessly shuffling to classes, not paying attention, the works. In my freshman year at college, I could not focus on my work and ultimately felt sluggish and miserable. This led to me failing my freshman year. My doc diagnosed me with ADHD-PI and depression (which I'm pretty sure is actually this SCT you mentioned above, since I do not have depression). Another interesting complication is that i sustained a Traumatic Head Injury (TBI) with no complications (i literally left the hospital a few hours after arriving)the previous year and so he blames it all on that(even though I've had these "problems" all my life).
So, to wrap up: I have GS, I've been diagnosed with ADHD-PI and Depression (should be SCT), I sustained a TBI, and my life is pretty much stagnated b/c my parents and Doc believe the ADHD-PI & SCT is a result of the TBI and totally reject it having anything to do with Gilbert's Syndrome, though I know for a fact that the TBI was more of an IBI (Inconvenient Brain Injury) since all of my personal quirks were labeled "abnormal" and caused by my TBI and that i shouldn't be ashamed of myself and all that crap.
-Rob
Hey Rob,
ReplyDeleteI have answered some of your questions on the post about 'Stimulant Use in Normal Patients'.
The connection between Gilbert's disease and SCT symptoms is interesting. I don't think it is a coincidence that three people in these comments have SCT symptoms and Gilberts. There is probably a connection though the biology of this is not understood as of yet.
I will write Charles Parker about this. He has performed many lab studies on patients with ADHD symptoms and he may shed some light on this for us.
Rob, thanks for writing in and please do not lose hope. The Traumatic Brain Injury could not have helped anything but I agree with you, I doubt it is the main contributor to your symptoms.
Keep us posted and I will post in these comments when I hear from Dr. Parker.
Tess
Hi,
ReplyDeleteI too think that SCT should be labeled separately from ADD-inattentive. I have SCT and ADD-inattentive together..and it is the worst of all. I'am constantly in a fog, slow processing, slow learner, memory and concentration problems, and lack motivation and energy. All these years i feel like a idiot in school and whenever i talk to people. I was born in america, but yet my writing and talking is like a foreigner. When hanging out in a group, I'm always so quiet. Sometimes i can't keep up with what they are saying and have nothing to contribute. I can't remember new words to use for future conversations...i think this is caused by slow working memory of SCT. When i speak, i only talk in short sentences and never in a long conversation with hard vocabulary. My brain is constantly in a fog that i can't even pay attention to road, directions when sitting on the passenger side even though i really tried so hard to pay attention...it just can't get in my head. I have hard them remembering directions to go to places and often get close when trying to get back. I have mood swing that makes me feel so lifeless, depressed, slow response and shy. Which make people think that i'm not interested...and have a bad impression of me. This cause me to be anti social. I really hate feeling like a idiot all the time. I tried many supplements but still haven't find the right one yet. Tried adderall before but after it worn out, i feel worst then before..and it doesn't seem to be as effective anymore.
I think that sometimes, when i read people saying that they think they have SCT, i don't think they do..probably just have inattentive/concentration problems. They can drive and don't have speaking/writing problems... SCT is much serious and worse...
Fixed typo errors:
ReplyDeleteI have hard time remembering directions to go to places and often get lost when trying to get back. I have mood swing that makes me feel so lifeless, depressed, slow response and shy. Which make people think that i'm not interested...and have a bad impression of me. This cause me to be anti social. I really hate feeling like a idiot all the time. I tried many supplements but still haven't find the right one yet. Tried adderall before but after it worn out, i feel worst then before..and it doesn't seem to be as effective anymore.
I think that sometimes, when i read people saying that they think they have SCT, i don't think they do..probably just have inattentive/concentration problems. They can drive and don't have speaking/writing problems... SCT is much serious and worse...
I wonder if anyone has linked ADHD and sleep disorders (the combined effect of apnea and/or restless leg etc) causing a cumulative lack of quality sleep for years. Could this also account for Sluggish Cognitive Tempo. Already adhd and on meds, after few months of apnea machine, I noticed a definite reduction in the "brain fog" I got prior to taking my daily meds (Adderall). I wonder if they will do studies on sleep quality in kids before they end up adults with 40 years of low quality REM sleep. It isn't likely a complete fix, but what if the slow cog. tempo is a combination of adhd and sleep disorder. Wouldn't it help to test for sleep disorders too. I would be curious to see how correcting sleep disorders has an effect on Inattentive type adhd in kids or anyone, really.
ReplyDeleteI just wrote the last message and then read more of the ones above and the one about the woman's daughter having the sleep study on the 27th. I also read she had hypothyroidism. I also had this at birth and have been on synthroid since about 7 weeks of age. Interesting the combination of hypothyroidism, sleep issues, adhd. I have heard of others with hypothyroidism also finding out later they had ADHD. I'd love to hear how the sleep lab went for Anonymous with the little girl.
ReplyDeleteSleep disorders and thyroid disorders are some of the common conditions that are currently misdiagnosed as ADHD. I have written a few posts about the restless leg and sleep issues. It turns out that the genetic variations that bring on restless leg syndrome also bring on ADHD symptoms. Many kids with ADHD have sleep issues. Some of these kids have sleep onset problems but night terrors and restless leg syndrome are common as well. Hypothyroidism has also been seen with a bunch of auto-immune type conditions and some people (like Dr. Charles Parker) have found a significant overlap between auto-immune conditions and ADHD. Thanks for your comments!!
ReplyDelete