Dr. Jeremy Sharp (00:00)
All right, folks, welcome back. We are talking about ADHD, SCT, and CDS. It’s a lot of acronyms, but we’re going to dive in and make things clear. So let’s do some definitions first. All right. And little disclaimer as I get going, as with all of my episodes, right, I am not the world’s leading expert in this topic. If you are out there and you are that person or know that person, let me know if anything sounds awry. Send me a message and…
Dr. Jeremy Sharp (00:29)
I’m happy to do a little correction, but trying to give an idea of what these concepts are and what to do about them. So first of all, let’s address kind of a definition slash name change. All right. So we used to call this sluggish cognitive tempo, but I don’t think there’s anybody out there who would ⁓ argue that sluggish is ⁓ an affirming term in any way. So, you know, sluggish has always been a little problematic and kind of pejorative.
So cognitive disengagement syndrome is a little bit of a polite rebrand, but also I think is more descriptive of what is actually going on in this ⁓ circumstance. So it describes the mechanism of what’s happening in the brain a little bit better than sluggish cognitive tempo. So ⁓ these individuals are typically present, quote unquote, but kind of disengaged from the external environment. So in the DSM, I think most of us know that
CDS does not have its own code. It’s presently buried within the ADHD, predominantly inattentive presentation category. But I think the research is telling us that these are perhaps two different animals, like many people have suspected, I think, for many years, that ADHD is not quite the monolith that we have made it out to be. So a 2022 meta-analysis by Stephen Becker and his colleagues demonstrated that
While about half of the people with CDS also meet the criteria for ADHD, the other half don’t. And more importantly, CDS symptoms like mind wandering and staring into space and slow movement are actually distinct from the standard kind of inattentive symptoms like forgetfulness or losing things that we typically ascribe to ADHD. So if we look at the neurobiology, ADHD,
is, well, least the way that we see it a lot of time is a disorder of the frontal striatal circuits. So these are the parts of the brain that handle inhibition and kind of like the stop go signals. You may have heard this referred to as like the hot executive functions. CDS, on the other hand, appears to be tied a little bit more to the posterior attention system.
and maybe a failure to suppress the default mode network. So you may have heard folks refer to this as like the cool executive functions. And you can think of the default mode network as kind of like the internal daydreaming channel of your brain. So in a healthy brain, when you start a task, the default mode network turns off. You’re not daydreaming anymore. In cognitive disengagement syndrome, however, that channel stays on low volume in the background.
Dr. Jeremy Sharp (03:20)
which is constantly pulling the person’s attention inward. So it’s not that they are distracted by a noise in the hallway, which is external distraction. It’s more that they are distracted by their own thoughts or internal disengagement. So it’s a little bit of a definition, so to speak, of cognitive disengagement syndrome and of course an oversimplification, but hopefully enough to take with you. OK, so how do we map
a CDS presentation onto our existing ADHD framework, which the closest cousin, I think, is the predominantly inattentive type. But this is where the clinical nuance gets a little bit tricky. So let’s start with ADHD combined presentation, actually. There is not very much overlap here between ADHD combined and cognitive disengagement syndrome. That high energy, impulsive nature of a combined type is actually the polar opposite of the
hypoactive low energy profile of cognitive disengagement syndrome. ADHD, predominantly inattentive presentation on the other hand, is where a lot of the confusion lies. So historically, you know, we thought of ADHD-I as just ADHD without the motor. In fact, I mean, I’ve explained it like that many times over the years. But I think we now know that there are maybe some subtypes within the inattentive
presentation. So there’s the quote unquote the true inattentive. So these are the folks who are disorganized, forgetful. ⁓ They are distractible in the sense that their mind kind of jumps from one external thing to another. But then there is this ⁓ maybe CDS or cognitive disengagement syndrome inattentive. Those are more the sluggish, spacey folks who are disengaged. So they are more
internally distracted. Their mind is drifting more from an internal standpoint. So some research in 2021 ⁓ used some assessment to determine something pretty important that ADHD profiles showed deficits in the executive control network, which is like handling conflict and making decisions in this study, while CDS profiles showed specific
deficit in the ⁓ orienting network. So this is the ability to move attention to a specific stimulus. So if you can’t orient to the task, you can’t engage with it. It’s not a failure of willpower. It’s more failure of the engagement hardware, so to speak.
So going a little deeper down this clinical rabbit hole, I want to talk about how to spot this slow and accurate profile. How do you see this in your data? When you’re looking at cognitive results, let’s say from like a waste or a whisk, for example, you want to look for, you know, what I would call like the slow and accurate pattern. So in some ADHD profiles, maybe those associated with more inattentive folks, ⁓ you can see low processing speed with a high
Dr. Jeremy Sharp (06:36)
error rate. OK. So these folks are rushing. They’re making mistakes because they’re trying to manage their distractibility with speed. You can also see that I think in ADHD combined or hyperactive impulsive types because they’re more impulsive and maybe reacting or responding quickly and making mistakes. But in a CDS profile you’ll often see a processing speed score that is quite low but
error free. OK. So very low processing speed but zero errors. So these individuals may be more meticulous. They’re just slow. All right. So their quote unquote latency to respond is pretty high. In the room you’ll notice that they need a few seconds of kind of buffering time ⁓ after you give an instruction before they start moving.
So that’s how you may notice this. And again, this is not ironclad by any means. But these are some signs to look for. But let’s take this to more of a, I suppose, an actionable place, OK, where you can implement some clinical tips and change the way you practice a little bit. So if you suspect cognitive disengagement syndrome, here are a couple of things that you could do with your battery to ⁓ tweak it to be a little more
cognizant of these things. So one, you might broaden your rating scales, right? So don’t just use the Connors or the Brief, although both are fantastic, right? We use the Brief all the time in our practice. Love the Brief. You could add something like the Bars 4, which is the Barkley Adult ADHD Rating Scale. It has a specific nine-item CDS subscale. And if they score high on those nine items but low on the forgetfulness items, then that gives you an indication that
may be dealing with a CDS profile. Second thing that you can do is just kind of key into the qualitative observations. So this is where you note things like gazing into space or daydreaming during the testing. These are relatively distinguishing features for CDS, but not necessarily part of just a straight up inattentive profile. The last thing.
that you could do is kind of refine your recommendations. So this is maybe the most important part. Research would say that stimulants like Adderall or Ritalin are statistically less effective for cognitive disengagement syndrome than for quote unquote typical ADHD. So if you diagnose someone with CDS or ADHD inattentive, the report might emphasize arousal regulation. ⁓
Dr. Jeremy Sharp (09:29)
So these are more, I would say, like environmental primers. These are things like bright lights or standing desks or high intensity exercise. These are things to kind of like wake up that posterior attention system before, you know, they start work or school in some cases to try to engage those parts of brain to do a little better. So, all right. ⁓ Some clinicians may, you know, have reported that
Non-stimulants like adamoxetine, which is Stratera, might be more effective for that internal fog of CDS compared to traditional stimulants, but data is still emerging. Definitely not statistically definitive, so to speak, from a research standpoint, at least in terms of large-scale trials, but it’s something to think about. Not like we’re recommending specific medication necessarily, but just something to tuck in the back of your brain to keep in mind.
So by teasing apart these two profiles, hopefully you can maybe shift your advice from like a one size fits all ADHD recommendation set to folks who actually have this disengagement problem. can tailor recommendations a little more specifically to them.
As I mentioned, tomorrow we’re going to move to episode three in this first pillar. We’re going to be talking about performance validity testing and why we should not try to sense effort or trust our gut with effort and optimal performance. We’re going to talk more about how to tell if that poor performance is something more intentional. So thanks for listening, and I will catch you tomorrow.
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