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 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.

They're paying attention to what

somebody is 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

distractable by things outside of them.

The kid with cognitive disengagement

syndrome is highly distractable by a

thing inside of them. So their mind

tends to drift, their mind tends to

wander, they get described as very

spacey. And so I want y'all to

understand 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. 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. 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. So, in both cases, we see

the 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. 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, 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 and then my mind

wanders away, starts thinking about

this, thinking about that. And in

cognitive disengagement syndrome, the

mind sort of drifts away from the task

and 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 these people's brains

and physiology

that lead us in a different direction

for treatment. So, a lot of times

what'll 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 ideology. 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 breaks

in their brain, right? So we have this

the frontal loes 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 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.

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. 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. So the first thing

that we're going to talk about is

internalization versus 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, smells, sounds, etc. 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

often times what happens with these

people is they get diagnosed with ADHD,

autism plus ADHD. 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

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 right so if we think

about where does anxiety exist it exists

within us and since I'm so drifty and

internally focused when when someone 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 internal s uh 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

in the environment and that's why they

can't pay attention. their mind

literally like floats away from a 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 is a a

human child realizes people don't like

to spend time with me. They realize, oh

my god, I should be paying attention.

that 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

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 hyper

sensitive 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

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

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 atamoxitine is more effective than

methylenadate. So we have to understand

a bit about adamoxitine and

methylenadate. So methylenadate 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 loes and the frontal

loes are basically what provide the

leash to other parts of our brain. So

when I have an impulse to get distracted

my frontal loes are like no no no we're

going to focus on this 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 loes do, so they allow

us to reduce distractions, they also

pull the leash on our emotions. So

oftentimes people with ADHD will feel

emotionally disregulated, but once we

give them stimulants, their brain is

able to restrain their emotions. So it

kind of tones down our emotions. But

methylenadate 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 this is so

the studies show that there's this

medication called adamoxitine which

works better. And adamoxitine is

interesting because it is actually more

noradinurgically

active. Now what does that mean? So we

have epinephrine and norepinephrine

which is epinephrine is also adrenaline.

We have another uh uh hormone called

noradrenaline. These are 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 noradinergic 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 an 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

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 um in Dr. K's guide to 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 and just to be clear,

this is this doesn't mean that that

stuff isn't important. 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 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 we'll continue to to daydream there

is no difference between trying to do

your homework and taking your final

exam. Our brain 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 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 often times

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 with 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. We kind of get this message of

like, am I trying? They like try they

try to try hard, but it's difficult for

them to actually try hard, right? When

they 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. 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 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's on the verge of falling

apart all the time. 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?

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. So often

times 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,

you know, 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, uh, bedtime

procrastination. So, we have a whole

video about, you know, key principles of

restoring your sleep cycle, which I

would strongly recommend y'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 often time have times 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. 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 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 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 and this is what's so

challenging is that robust aerobic

exercise. So highintensity 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 about is sort of this weird

energetic stuff. So when I work with

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 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, Bronnam and Chiang protocols

for particular mental illnesses and was

developing those protocols, was studying

them, but then I started doing this.

Okay, so this is where there are a

couple of practices, revitalizing

practices, energetic practices. Um, yoga

and taichi 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. 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 ta chi and then 20 to 30 minutes of

pranayam or chiong. I'll share with

y'all a key pranayam that I teach to

people who have problems with their

energy levels and that is called

bastrika pranayam. So bustria pranayam

is bellows 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 your

stomach and when we inhale we're going

to push our stomach out. And when we

exhale I want you to imagine your naval

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 pasta

kind of goes like this. [snorts]

[snorts]

[snorts]

[cough and laughter]

Uh 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 brown

fast rapid inhalation [snorts]

and not without without moving the

shoulders

and like pull 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. 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

neurode divergent doomer, 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 5 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 diagnosis, 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,

sustaining your attention, check out Dr.

K's guide.

[music]

You know,

the

>> [music]