greetings everyone I'm Russ Markley welcome to my YouTube channel in this lecture I want to concentrate on a new attention disorder one that is often confused with ADHD sometimes called add but as we're learning now is a distinct disorder of attention quite different from ADHD though it can overlap with it I'm going to break this lecture down into several parts so that the videos are relatively short and easier to view and you'll see these posted under their own playlist so let's get started the current name for this attention disorder is cognitive disengagement syndrome and as you can see in this series of slides CDs as all abbreviated used to be called sluggish cognitive tempo or SCT in fact if you were to Google the research on SCT using Google Scholar that is the term you should use because there's probably just one or two papers using the term cognitive disengagement syndrome and the reason for that is that the name was recently changed by a work group of leading experts in the world who focus on SCT now CDs and they changed the name back in October of 2022 in a review article on which I'm one of the authors I participated in that work group and the reason for the name change is that SCT had a very demeaning pejorative implication and many people just didn't like its association with sort of sluggish thinking stupidity or some other rather demeaning terms and they're right and so the work group focused on trying to come up with a new name for this disorder that captured its Essence better than the term SCT did and was not so demeaning to others when it was being used to describe their symptoms so that's the reason for the new term of CDs disengagement syndrome now in part one we're going to take a look at just what is this syndrome so I'm going to go through some of the research findings in detail in these lectures on CDs uh and I apologize for that but it's a new disorder and we want to understand it better so CDs is characterized first of all by an appearance of cognitive or mental confusion added to that is also the appearance of staring daydreaming a very Spacey look to the individual as if the individual is not attending to ongoing external or exogenous events the individual also presents with a somewhat drowsy or sleepy appearance at times more of a mental fogginess or distancing kind of like an absent-minded Professor might look so to speak and then periodically with these attention deficits we see low motor activity sluggish responding to events around them passivity or withdrawal as if the individual simply isn't engaging the world and others around them and to some extent a rather lethargic or sluggish reactivity to those events now most of these low activity sluggish responses seem to occur during the episodes that the individual is disengaged from the environment at other times when they're as engaged with the environment as anybody else then their activity level and responsiveness to events is the same as other people so it's kind of an episodic problem with motor activity it's the opposite of ADHD it's not hyperactive it's hypoactive but it's periodic usually during the time of daydreaming or staring so in essence we can summarize CDs as involving a decoupling of attention from the external world and instead a recoupling of attention with mental events mental information now one of the questions we have to answer is just what's going on in there what is the individual attending to when they have disconnected from the external environment I'll come back in another lecture with a few suggestions about what that might be but in this part we just want to talk about what is CDs now there's a case report of a child with a parent CDs going back to the days in the 1800s of the pediatrician Heinrich Hoffman who wrote various stories for children and in this one he describes Johnny head in the air it was a boy who wanders around town who's not paying attention to what's going on around him seems to have his head in the clouds so to speak that was a way of sort of describing somebody who simply wasn't engaged with the environment a very Spacey sort of daydreamy appearance to the kid and he wanders around town and accidentally falls into a canal and has to be fished out by the fishermen so when you read this description it seems a lot like what today we would call CDs but the first occurrence of the mention of this kind of attention disorder actually isn't a paper written by Scottish physician Alexander Creighton in his medical textbook there he described two disorders of attention one that looks a lot like ADHD and the second which is what he called a low power of attention and arousal and a more limited engagement with the environment now of course Creighton didn't call it either SCT or CDs but that was the attention deficit he described in contrast to another one that is today ADHD combined type now as I mentioned there is this one report by a pediatrician and a child story back in the 1800s and then the first real scientific information about CDs doesn't begin to occur really until the mid-1980s and it began in research studies that we're trying to distinguish between what was then called add with hyperactivity we now simply call it ADHD and add without hyperactivity which we have abandoned we don't use that term anymore but nonetheless back then those two terms were being used in the DSM criteria and people were trying to understand how they differed and in those research studies van Leahy Karen Carlson Nipper and others developed a set of symptoms of ADHD and another set of symptoms of other attention deficits and threw them all into a research study and looked at how good were they at detecting these adds with and without hyperactivity and they weren't the DSM criteria were very good at picking up ADHD but these symptoms of daydreaming spaciness and mental confusion formed their own construct their own Dimension that was the first signal that we had that there was a second dimension of attention deficits in people that was not ADHD and did not load on the same Dimension or construct as ADHD so it goes back into the 1980s now subsequent research showed that there were very few differences between ADD with and without hyperactivity and So eventually they were combined back into ADHD and we came up with these three different presentations the combined presentation excuse me the hyperactive and the inattentive presentation more on that in just a moment but if you want to know where the real science begins it's right around the 1980s but there are medical references that go back into the late 1700s now little research occurred on CDs or what was then SCT during the remaining 0-16 to 25 years and then people like myself and others started to get interested in CDs in its own right and we began to study it separately from ADHD but it originated in the science of ADHD and trying to come up with new symptoms and as it turned out the symptoms of CDs don't work well at identifying people with ADHD and so they were set aside for a while until some of us kept coming back to it and saying there was this other retention deficit out there that doesn't look like ADHD and we need to study it in its own right and so we did so for about the last 15 years researchers many and you'll see them listed on the research review on CDs many researchers began to do separate studies of CDs in the literature and began publishing their work and that led to the research review now you'll find that research review in the thumbnail sketch it was published last October in the Journal of the American Academy of Child and Adolescent Psychiatry and by the way you can read the entire review on the website of that journal so that's the history now how does CDs fit into the DSM well it doesn't really but here's how people are forcing it into the DSM inappropriately they're often calling it inattentive presentation or ADD when it really isn't so let's take a quick look here the DSM-5 says that we have three presentations not subtypes there are no types of ADHD any longer they're just presentations on any given day the patient presents with this set of symptoms or that set or both sets so we've got the hyperactive presentation which is predominantly those symptoms we've got the inattentive presentation predominantly inattentive and then we have the combined presentation in which both dimensions of symptoms are significantly represented so add or CDs is actually being forced into the inattentive presentation and it really shouldn't so let's take a look at that presentation so here we have people coming into clinics who are being diagnosed as inattentive presentation of ADHD we can split them into several groups one are people who used to be in the combined presentation but because of their age their hyperactive symptoms are declining that's natural and it's going to reach a point where those hyperactive symptoms are no longer significant there's not enough of them and according to the DSM decision rules you would need to rename them from the combined presentation to the inattentive presentation that's a lot of people by the way because that's the natural course of ADHD is to go from the combined to the inattentive as hyperactivity wanes there's a second group of individuals who just barely Miss meeting criteria for the combined presentation so they've got six inattention symptoms maybe four hyperactive symptoms they look a lot like ADHD combined presentation they're just a milder version of it we would call them sub-threshold combined presentations but they're just like the combined presentation they're just a little milder in their symptoms so these two groups here are ADHD they differ only in the sense that they don't quite have enough hyperactive symptoms to get into or stay in the combined presentation but then there is this other group which comprises about 30 to 50 percent of people being called inattentive ADHD but they're not they have cognitive disengagement syndrome and that as we will see is a qualitatively different disorder so I hope that helps you understand where CDs seems to be fitting into the DSM even though it doesn't belong there is no diagnosis called cognitive disengagement syndrome at the moment that's officially recognized and so clinicians needing to make a diagnosis if only to get paid for their clinical diagnosis are using the inattentive predestination or are continuing to use the term add I wish they wouldn't do that add is an old outdated term for ADHD but some clinicians continue to use it now here's the question we're going to answer in the remaining parts of these lectures on CDs is it a new disorder how would you know what are the criteria that scientists like myself use to identify a new distinct condition from all the other neurodevelopmental and mental disorders well here's a checklist does it have its own set of symptoms it's a symptom complex and do they cohere do they correlate and form a dimension does the new disorder differ in terms of patterns of comorbidity with other disorders like oppositional disorder conduct disorder anxiety does it have different demographic correlates different age or sex representations or socioeconomic status representations does it have different cognitive deficits different patterns of impairment in major life activities is the developmental course the same or different from the other disorders what about its etiologies its causes how do they differ is there a different pattern to family history in people with this disorder what about biological correlates when we look at various biological measures from neuroimaging to blood work to cerebral spinal fluid to EEG and other kinds of psychophysiological measures is it different and then finally does the new disorder differ in its response to existing treatments so scientists are now examining all of these differences in their research projects on CDs but we already have information on many of them that we can use to infer that CDs is a new distinct condition even though that's not yet definitive by official standards and so it's not in the DSM but maybe it will be by dsm-6 now here's a list of the best symptoms for identifying SCT or CDs we've already gone through them in my description this is from Steve Becker's review of the symptoms and you can see that he found 16 symptoms that were good at identifying these people but four of them in yellow were just as good at identifying people with ADHD so these are not good symptoms to differentiate CDs from ADHD even though they occur in a lot of people with CDs they also occurred a lot of people with ADHD so not useful this is my set of symptoms from my studies very similar to the work of Becker and others here's a list of 14 symptoms and we found that the first 12 were very good at separating CDs from ADHD whereas the last two just like Becker's study were found in both attention disorders and so we're not useful at discriminating ADHD but you can see the symptoms Daydreams easily confused has trouble staying alert Spacey appearance seems to be in a fog scares a lot lethargic underactive slow-moving sluggish and so on you can see why this used to be called sluggish cognitive Tempo but as I've said now we've changed the ner the name because CDs is much more accurate and less demeaning so CDs symptoms form a coherent dimension of symptoms separate from ADHD so check that criteria has been met to suggest that this is a new disorder not some ADHD knockoff or subtype so CDs forms two symptom Dimensions just like ADHD there's an attention cognitive dimension and there is a motor dimension in the case of ADHD it's inattention and hyperactivity in the case of CDs it's daydreaming staring confusion and hypoactivity sort of an under responsiveness we have found this construct these dimensions in research using various types of assessment procedures rating scales direct observations and so on as well as across different sources parents teachers self-reports adult reports and so on CDs symptoms do show a moderate correlation with ADHD inattention but they also show no correlation or even a negative correlation with the hyperactive symptoms from ADHD so they're not the same even though they overlap someone with adhing attention they're quite different and indeed if we look at how the symptoms correlate with each other the two dimensions of CDs correlate very highly with each other they belong together whereas they don't correlate nearly as highly with the ADHD inattention and may not correlate at all with ADHD hyperactivity research shows that in very early childhood as CDs symptoms are appearing they kind of fluctuate and aren't very stable but within a year or two and certainly by school age and later these symptoms become much more stable and trait-like excuse me we need to go back here so as I said down here CDs symptoms start out state-like somewhat unstable but begin to cohere stabilize and persist and in that sense CDs symptoms are trait like as we see here so sorry for the slide confusion that sometimes happens with my computer if you touch the mouse things kind of skip ahead okay these CDs symptoms are also distinct from the symptom dimensions of other disorders so when we examine anxiety depression oppositional disorder conduct disorder and the many other disorders the CDs symptoms stay by themselves they don't load onto these other forms of mental disorders we still have our work to do in separating CDs from other possible causes not other disorders but other causes what about stress would that make you inattentive what about lack of sleep would that make you daydreamy with a sleepy appearance what about hormonal changes diet vitamin deficiencies and so on so we have lots of work to do to see how CDs links up with these various other medical physical and other conditions so time will tell but in the meantime psychiatrically or psychologically CDs appears to be different from other mental and neurodevelopmental conditions so now we have found that CDs symptoms are somewhat correlated with the more reflective brooding ruminative forms of thinking that we see in depression where people become inwardly preoccupied with their thoughts problems and so on so there's a little bit of correlation between CDs and that which makes sense people with CDs appear to be disengaged inwardly preoccupied so no surprise there would be some overlap with the appearance of inattention in depression CDs symptoms also appear to correlate with research on conditions known as pathological daydreaming or pathological mind wandering indeed those two conditions might well be the same or very similar to CDs we need to do some more research on that as well so here's a final study it's called a network analysis and it shows how SCT differs from depression because that became a very important question given that there was some correlation between the two and a network analysis shows us that the symptoms of depression up here cohere with each other more than they correlate with the symptoms of SCT which we see down here and that becomes evident in the Gap here in the networks so that's how Science And scientists know that CDs is not just depression under a different name it's actually distinct from depression okay so in the next lecture we're going to talk about other differences in this case cognitive differences between CDs and ADHD so I hope you'll join me for that lecture thank you