HealthyGamerGG - The Most Misdiagnosed Condition In Mental Health (Cognitive Disengagement Syndrome)

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Starting point is 00:01:03 I'm Dr. Alokinoja, but you can call me Dr. K. I'm a psychiatrist, gamer, and co-founder of Healthy Gamer. On this podcast, we explore mental health and life in the digital age, breaking down big ideas to help you better understand yourself and the world around you. So let's dive right in. Today, we're going to talk about one of the most misdiagnosed conditions, cognitive disengagement syndrome, which used to be known as sluggish cognitive tempo. Now, the reason that these are so misdiagnosed is because many people who have,

Starting point is 00:01:37 these things, get diagnosed with ADD or ADHD. And these conditions are sort of characterized by an internal drifting. So people have difficulty paying attention because they daydream too much. They have difficulty completing tasks because they have a lot of difficulty getting started. They have difficulty with motivation. So these are conditions that are characterized by sluggishness overall and hypoactivity. The reason they get misdiagnosed for ADHD is because they create a lot of the same symptoms on the surface. So if we look at an ADHD kid, this kid has difficulty paying attention, right? So if they're in school, the teacher is talking and they're easily distracted.

Starting point is 00:02:23 They're paying attention to what somebody is moving their leg over there. There's a bird that flies out the window. So they're unable to sustain focus because their mind is going in a thousand different directions. cognitive disengagement syndrome is an inability to maintain focus, but for an opposite reason. Whereas the ADHD kid is highly distractible by things outside of them, the kid with cognitive disengagement syndrome is highly distractible by a thing inside of them. So their mind tends to drift, their mind tends to wander. They get described as very spacey.

Starting point is 00:02:59 And so I want you all to understand that this is like kind of the same problem, right? So in both cases, I can't pay attention to the teacher. But the mechanism for why I can't pay attention is actually the exact opposite. One is externalized and associated with hyperactivity. And one is internalized and associated with hypoactivity. Another key feature of cognitive disengagement syndrome is hypoactivity. So when we look at ADD or ADHD, the H in ADHD is hyperactivity. So these kids tend to be very, very active.

Starting point is 00:03:30 They're restless. They move around a lot. they have difficulty sitting still. They get excited easily. They run around a lot. Whereas someone with cognitive disengagement syndrome is hypoactive. They have difficulty moving around. It's hard to get out of bed.

Starting point is 00:03:43 It's hard to get up and start doing things. We'll get into this a little bit more. But they also just have a basic motivational block. Okay. same result, which is like in ADHD, people have difficulty completing tasks, right? And so when we look at ADHD, why do they have difficulty completing tasks? Well, they have difficulty getting started. They have difficulty staying on task.

Starting point is 00:04:08 But the reason they have difficulty getting started is because they're too distracted. It's hard for me to sit and focus on this because I'm thinking about this, thinking about this, in cognitive disengagement syndrome, it's actually the opposite. I have difficulty getting started, but that's because my mind is so wandering away that it's hard for me to focus on this. In terms of sustained focus and task completion, once again, ADHD has distractions, right? So I start to work. I work for 15 minutes.

Starting point is 00:04:35 And then my mind wanders away, starts thinking about this, thinking about that. And cognitive disengagement syndrome, the mind sort of drifts away from the task and flows into sort of a daydreaming kind of state. And so the three key features of cognitive disengagement syndrome are daydreaming, mental confusion and hypoactivity. Now, even though this looks like ADHD on the outside, it's really important to understand the mechanism on the inside. Because as we'll discover, there are actually several things that are different about

Starting point is 00:05:06 these people's brains and physiology that lead us in a different direction for treatment. So a lot of times what will happen with these people is they'll get diagnosed with ADD or ADHD. They'll get started on treatment and they'll get a very suboptimal response. And that's because we're not targeting the right etiology. So if you think about ADHD, it is hyperactivity. So our treatments are designed to slow things down. So even when we give someone a stimulant medication, what the stimulant medication is stimulating is the brakes in their brain. Right. So we have the frontal lobes,

Starting point is 00:05:43 which restrain our impulses, calm down our emotions, actually suppress sensory input that distracts us. Right? So in ADHD, we're increasing the strength of the brakes because the mind gets easily distracted and runs in a bunch of directions. You can think about stimulant medication like a leash that is on an animal, and the animal runs this way and we yank it back. Runs this way, we yank it back, okay? Hey, y'all, if you're interested in applying some of the principles that we share to actually create change in your life, check out Dr. K's guide to mental health. And if you kind of tunnel down, okay, why aren't you motivated? And they're like, well, there's no point.

Starting point is 00:06:18 And if you get underneath, there's no point. What you ultimately find is hopelessness. So what the yogis discovered is that what we call motivation, they actually called a concentrated mind. What's the difference between someone who actually does stuff and someone who just tries to do stuff? So check out the link in the bio and start your journey today. The challenge is that in sluggish cognitive tempo or cognitive disengagement syndrome, the problem is not that the dog is running in a thousand directions. the problem is that the dog is sitting still and refuses to move. So we actually need a different set of treatments.

Starting point is 00:06:55 Some of them overlap with ADHD treatment. There's some overlap here to kind of get the dog moving. Okay? And you can sort of use a leash to do that, right? Like you can yank on a dog to try to get it to move. And so stimulants do work a little bit. But it's important to understand how cognitive disengagement syndrome is different because that'll give us an idea of how we actually address the problem.

Starting point is 00:07:14 So the first thing that we're going to talk about is internalization versus is externalization. So if you look at human beings, some human beings are more externally oriented, right? So I pay attention to stimuli around me. I get excited by sight, smell, sounds, et cetera. What we tend to find with cognitive disengagement syndrome is that these are people who are highly internalizing. So if you sort of literally look at where their attention goes, what are they focused on? They are focused on things inside of themselves. So daydreaming is a good example of this. The other really interesting thing is that people with cognitive disengagement syndrome who have a high level of internalization are also way more prone to depression, anxiety, and social difficulties. So oftentimes what happens with these people is they get diagnosed with ADHD, autism plus ADHD.

Starting point is 00:08:05 And why is that? That's because they appear to have some of the social difficulties that are consistent with autism. So they have difficulty with social relationships. they have difficulty engaging in social behaviors. People who have cognitive disengagement syndrome have been shown to be more shy, more introspective and internally focused when it comes to social situations. And I don't know if you guys sort of know this like, you know, picture, like kind of classic picture of someone with autism, but they are so in their own head that they have difficulty

Starting point is 00:08:37 engaging with other people. People on the autism spectrum will also be very anxious about social situations. And so both of these things sort of overlap with this idea of cognitive disengagement syndrome. But the mechanism is different. So in one case, it's the autism spectrum. But in cognitive disengagement syndrome, what tends to happen is I'm highly internalized, which means first, my feelings of anxiety are really, really intense because I'm looking inward,

Starting point is 00:09:06 right? So if we think about where does anxiety exist, it exists within us. And since I'm so drifty and internally focused, when someone's, you know, it's not. may experience, let's say, a certain amount of anxiety. If I'm zoomed in, internally, that anxiety will feel way stronger. We also see there's a lot of evidence of social problems with people with cognitive disengagement syndrome, which once again has to do with an internalizing behavior, a sense of shyness. But what these people really experience is that when they're in social situations, their mind will start to wander. Their mind will drift, right? They don't get distracted by something,

Starting point is 00:09:44 in the environment, and that's why they can't pay attention, their mind literally like floats away from a social situation. And then that cascades into problems over time. So socially, they're considered spacey. It's hard to have a conversation with them. If you're like playing a game with them, they'll like forget that it's their turn. And so this will start to create further problems, right? Because now as a human child realizes people don't like to spend time with me, they realize, oh my God, I should be paying attention. That's starts to create an additional anxiety because now you realize, now you know that you're not very good socially. So cognitive disengagement syndrome has these features that kind of look like

Starting point is 00:10:25 ADHD, difficulty paying attention, but it's heavily internalizing. So I tend to daydream. I can't get myself motivated to start. And since I'm internalizing, I have difficulty in social situations because I'm hypersensitive to my anxiety. I have difficulty sort of paying attention to the conversation because I'm internally preoccupied. So the most natural, question is, okay, what do we do about it? And this is what is sort of scary about cognitive disengagement syndrome is that if you go to a provider and you describe these symptoms, you are likely to get diagnosed with ADHD. And what I found working with these people is that ADHD treatment doesn't work great. So this is where sometimes people would come to me. I'd get referrals from other

Starting point is 00:11:04 psychiatrists who have ADHD patients for whom treatment is not working, so they'd send them to me to do the alternative medicine stuff. And when I assessed these people, what I really noticed is is their hypoactivity. So a sluggishness of the mind, a sluggishness of the body. And this is what we're going to target with cognitive disengagement syndrome. So the first thing is that if we look at studies on medications on cognitive disengagement syndrome, what we find is that atomoxetine is more effective than methylvenidate. So we have to understand a bit about atomoxetine and methylphenidate. So methylphenidate is a stimulant medication. And what that means is it stimulates the brain, but it stimulates the brain in a very specific way. It stimulates the brakes in our brain. So we have this part of our brain called the frontal lobes. And the frontal lobes are basically what provide the leash to other parts of our brain. So when I have an impulse to get distracted, my frontal lobes are like, no, no, no, we're going to focus on this thing over here. We're going to do our homework. We're not going to look at short form content on the internet. The other thing that the frontal lobes do, so they allow us to reduce distractions. They also pull the leash on our emotions. So oftentimes people with ADHD will,

Starting point is 00:12:14 feel emotionally dysregulated, but once we give them stimulants, their brain is able to restrain their emotions. So it kind of tones down our emotions. But methalphenidate doesn't work as well in cognitive disengagement syndrome as it does in ADHD. And that's because the problem in cognitive disengagement syndrome is fundamentally different. It is not hyperactivity of the brain. It is hypoactivity of the brain. So the studies show that there's this medication called atomoxetine, which works better. And atomoxetine is interesting because it is actually more noradrenergically active. Now, what does that mean? So we have epinephrine and norephenephrine, which epinephrine is also adrenaline. We have another hormone called noradrenaline. These are,

Starting point is 00:13:02 adrenaline is what wakes us up, right? Activates us, allows us to respond to danger. And so it's really interesting that when we have all of this hypoactivity, what works better is something that stimulates our noradrenergic system, our adrenaline system, right? Gives our activation a boost, and that seems to work better. Because what we're shooting for is not restraining a hyperactive mind. That's what stimulants do. We are boosting a hypoactive mind. So when I work with these people, medications have a role, executive function training

Starting point is 00:13:33 absolutely has a role. This is a shared thing with ADHD, where we're training our mind to sustain its attention, focus on one thing. we talk about a lot of these things in Dr. Kay's guide ADHD and doing stuff. We teach people how to set appropriate goals, get organized. We sort of address the executive function there. What I'm going to focus on for this video, and just to be clear, this doesn't mean that that stuff isn't important.

Starting point is 00:13:57 This is a thing that separates cognitive disengagement syndrome for ADHD, and that is focusing on your hypoactivity. So what we find in people who have cognitive disengagement syndrome is sort of what I would like to call a functional hypoactivity. So their body and brain's ability to rise to the challenge is impaired. So for most of us, if we're neurotypical, we sort of, you know, are active throughout the day and then we calm down in the evening and we'll get more to that. So most of us, if we're neurotypical, when we're faced with challenges, our body and our brain respond, right? So basically, when we're like sitting and trying to do a test, our body and our brain are like, oh, my God, it's a test.

Starting point is 00:14:37 let's go into hyperactive mode, right? So we engage with the world around us. There are times where we are calm and there are times where we are engaged. And what we see in cognitive disengagement syndrome is sort of a failure of that system, that even in a test will continue to daydream. There is no difference between trying to do your homework and taking your final exam. Our brains sort of responds hypoactively in both of those situations. So this is where there's some really interesting research on motivation and hormones. And so this is a study that basically found that people who are highly motivated, not a study, several studies have shown this, people who are highly motivated have a cortisol system that adapts to our circumstances. And people who have

Starting point is 00:15:23 low quality motivation basically have a cortisol system that is unresponsive. So cortisol is our basic stress hormone. I kind of view it as an analog of adrenaline and noradrenaline, all three of these hormones work together. So when adrenaline is malfunctioning, oftentimes cortisol will malfunction. The two are really connected. So these people with cognitive disengagement syndrome almost have like a functional adrenal insufficiency, which means that their cortisol system doesn't activate in the right way. Okay. So how do we fix this? What I tend to find when I work with these patients is that they're under a state of chronic stress. They're under a state of sort of chronically elevated cortisol. So this means that they're always falling behind. They feel lazy.

Starting point is 00:16:04 we kind of get this message of like, am I trying? They try to try hard, but it's difficult for them to actually try hard, right? When their mind tells them, hey, man, it's time to, like, kick it into gear. Their body sluggishly responds. So as they fall further behind in life, as they have social difficulties, their chronic level of stress elevates. Once our stress level is chronically elevated, we lose our cortisol's responsive state. Okay. So this is basically what happens.

Starting point is 00:16:35 Like if you think about, okay, I need to focus on a test. But if I'm chronically stressed out, that becomes my baseline. And once chronically elevated stress becomes my baseline, then there's no way for me to do more. And even scarier than that, I start to run ragged. So these people feel incredibly frayed to me. Like they're falling apart at the edges. You know, the seams are kind of coming apart. they're right on the verge of like collapsing and splitting open and everything is on the verge of falling apart all the time.

Starting point is 00:17:07 So when I work with these people, there are a couple of really important things that I do. And basically what we're going to try to do is restore that cortisol rhythm. Okay. Now, I'm not doing cortisol salivary cortisol tests on all my patients. This is sort of the functional work of a psychiatrist, okay? So first thing that has been associated with cognitive disengagement syndrome is sleepiness. So one of the key things that we really need to do is focus on, going to sleep at the right time and waking up at the right time.

Starting point is 00:17:34 So oftentimes the people that I work with who have these problems have really bad sleep hygiene. They stay awake because they're kind of sluggish throughout the day. They haven't done enough during the day. So they kind of stay awake at night, hoping that they'll kind of work at some point. Maybe I'll get that second wind. I really need to do all this kind of stuff. They have really bad like sleep time, bedtime procrastination. So we have a whole video about, you know, key principles of restoring your sleep cycle,

Starting point is 00:17:57 which I would strongly recommend you all check out. The other problem that these people have with their sleep is that since they feel so sluggish during the day, they will oftentimes have high levels of caffeine intake, which sort of stimulates you some, but then makes it hard for you to sleep. So going to bed on time and falling asleep is a really, really, really important part. And this is the other key thing. Waking up usually around dawn can be incredibly helpful. So go to bed around dusk, wake up around dawn.

Starting point is 00:18:25 Now, there are all kinds of real life problems that happen if you try to do. this. I'm just telling y'all, if we're talking about an ideal situation for restoring your sleep schedule, this is what it is. Social life becomes a mess. Sometimes job and work and things like that become hard, so I get that, okay? So restoring your sleep schedule is a huge part of it. And the reason it's a huge part of it is because we want to restore that fluctuation in cortisol. We want a nice, healthy cortisol that rises in the morning and then calms down in the evening. And we can use sleep to kind of get that back into the right rhythm. The other thing that is very helpful for these people is robust aerobic exercise, usually early in the morning. So remember that your body is kind of sluggish,

Starting point is 00:19:09 and this is what's so challenging, is that robust aerobic exercise, so high intensity interval training, I think is fantastic for this, is exactly what you need to activate your physiology, and then once you are absolutely wiped and absolutely exhausted, you will then deactivate your physiology. So you'll kind of have this energetic crash, which is exactly what we want. We want an energy spike and an energy crash instead of this chronic level of stress where we're sort of trying to focus all day, but it's never really working. Okay. So this is really challenging because if you have cognitive disengagement syndrome, there's a really good chance that physical exercise will feel incredibly hard to you. But that's actually what you need. The next thing that we want to talk

Starting point is 00:19:54 about is sort of this weird energetic stuff. So when I work with people who, you know, have cognitive disengagement syndrome, they're referred by psychiatrists. Treatments don't seem to be working very well. So I kind of look at them and I look at their sluggishness and I say, okay, your chi or your prana, your vital life energy appears to be sluggishly moving. So there's like some limited evidence of this stuff, but I've seen a large clinical benefit. This is the work that I was doing at Harvard. I was trying to develop energy-based protocols. Brani and and Chi-Gong protocols for particular mental illnesses. And was developing those protocols,

Starting point is 00:20:29 was studying them, but then I started doing this. Okay? So this is where there are a couple of practices, revitalizing practices, energetic practices. Yoga and Tai Chi tend to work really well. So what I would recommend is, like, you wake up, you know, around dawn, you're going to feel like crap.

Starting point is 00:20:45 Do whatever amount of exercise you can manage for about 20 to 30 minutes. You know, you can go through your morning routine and then maybe in the evening or in the morning, if you can swing it, doing 20 to 30 minutes of yoga or Tai Chi, and then 20 to 30 minutes of brown iam or chie gong. I'll share with y'all a key brown iam that I teach to people who have problems with their energy levels, and that is called Bustrika brown iam. So Bustrika brown iam is a bellow's breath, okay? And so what we want to do is breathe like a set of bellows at a blacksmith. So we want strong, rapid inhalations with contraction of the diaphragm, followed by strong rapid exhalations with the diaphragm pushing the air out. Okay. So I want you all to kind of focus on

Starting point is 00:21:29 your stomach. And when we inhale, we're going to push our stomach out. And when we exhale, I want you to imagine your navel, your belly button, contracting towards your spine. Okay. And then we want to breathe in such a way through our nose, ideally, where it makes a sound. So pastrica kind of goes like this. One cycle is about 10 rounds of breath. And what you really want to do is like rapid cycles, right? So I'm feeling a little bit dizzy. I'm feeling a little bit activated. I'm feeling a little bit lightheaded, which is exactly what we want to do. So you can do Prostridoron. I am fast, rapid inhalation. Not without moving the shoulders. And like, yank the air in and throw the air out. And you can do something as simple as three rounds of 10 breaths each along with your yogic practice.

Starting point is 00:22:33 And that will sort of energize and revitalize you. So when it comes to cognitive disengagement syndrome. If you're someone who feels like you're a neurodivergent dumer, key thing is to balance your energy levels, allow yourself to rest when it's time to rest, and allow yourself to wake up when it's time to wake up. Now, this is going to feel absolutely like an uphill climb, right? But any situation where we are deconditioned, if I haven't exercised for five years and I start jogging, it's going to feel terrible. But that is the process of your brain and your body reconditioning. And as always, when it comes to diagnoses, really good idea to work with a professional. If you guys want more resources on structured meditation practices or things like executive function, goal setting,

Starting point is 00:23:18 sustaining your attention, check out Dr. Kay's guide. Thanks for joining us today. We're here to help you understand your mind and live a better life. If you enjoy the conversation, be sure to subscribe. Until next time, take care of yourselves and each other. Are you one of those media strategy people clicking through slides, scrolling, spreadsheet, Sheets. Yes? Good. This is for you.

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HealthyGamerGG - The Most Misdiagnosed Condition In Mental Health (Cognitive Disengagement Syndrome)

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