KELLIE NEWSOME: Today, we interview Richard Brown on 3 cognitive problems that don’t improve with stimulant treatment of ADHD.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor in chief of the Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Up to 50% of people with ADHD have other cognitive problems that get in the way of full recovery. We caught up with psychiatrist Richard Brown at his home in upstate New York to understand them.

RICHARD BROWN: I feel like we can help patients with ADD better than any other diagnostic group in psychiatry. I mean stimulants work for many people. I mean I think you know you’ll see different things in the literature 60-80%, but of course there are side effects and I get to see the ones who don’t respond. Or you know the other thing is they only help certain aspects of ADHD and a lot of other stuff remains.

CHRIS AIKEN: What kind of symptoms tend to remain after stimulant use?

RICHARD BROWN: Well I think there’s still a lot of executive system dysfunction and higher level cognitive issues. And then, of course, there are comorbid conditions whether it’s dyslexia or processing things. Two things I try to ask all of my patients to get neuropsych testing one way or another. I mean it can be expensive privately, but like in New York I have them go to a graduate school of psychology and be tested by somebody who’s got a really good supervisor, for example. That’s one way of bringing the price down. And what I look for is processing deficits and which kind of processing problems they have as well as working memory. 

So two of the biggest comorbid problems I seen are slow processing of certain kinds of material either visual or verbal or both, and that can be really tough in school or at work. And then dyslexia often relates to that because I see it as partly a processing problem and there are alternative things that can be helpful for that. 

And then the other thing is decreased working memory. And decreased working memory correlates with poor performance in work or school.

CHRIS AIKEN: So for those of us who haven’t done the testing, can you tell us what would give you a hint in a patient that they had each of these three deficits from their everyday life?

RICHARD BROWN: Right. So it requires a tester who doesn’t just do what some testers do these days, which is kind of a battery of kind quick ratings of stuff like there’s trail making kind of testing; there’s the Tower of London testing of abstract thinking; there’s a number of tests they can do. And there are tests of how they’re processing and working memory. So when patients or parents often ask, “What is working memory?” I say, “On your computer there’s a clip board and your own brain has a clip board and it can keep certain things in active play when you’re trying to solve a problem. And the average for most people is around three to seven things at one time. But you do better if you keep it toward the higher end of the range and not the lower end.” And so many of the people I see with ADHD or ADD (inattentive) have major problems you know. They may have a hard time keeping three things in mind. So, you know, and I ask for a history of dyslexia. I ask them do they have trouble taking notes in class. Do they do better if they see it? Do they do better if they hear it and those kinds of things.

KELLIE NEWSOME: People with dyslexia have difficulty reading or processing what they hear in a lecture. Their mind reverses letters and numbers as they read (visual dyslexia) or doesn’t accurately process sounds (verbal dyslexia). About 1 in 3 people with ADHD have dyslexia, and the rate is higher if we count all learning disorders like slow processing speed (Handler SM and Fierson WM, Pediatrics 2011;127(3):e818–e856). To screen for dyslexia, ask your patient if they have trouble reading or taking notes in class? If they do, ask if they do you do better when they are hearing the information or reading it.

RICHARD BROWN: Sometimes they can’t follow a spoken lecture, but they can read it better. And that can also make a different in terms of career choices. I remember years ago a patient – it might have been a case example in the book under Treatments for ADHD – where the guy came to me; he was sent by a clinician for treatment-resistant depression. And I interviewed him and I felt like he’s not depressed, but he’s very unhappy with his life and his career. And this was a good bit of time ago, but he was a photographer and his parents had to keep giving him money to keep it going. And when I interviewed him I began to feel that there was something subtly wrong, and when I looked at his pictures it was like he wasn’t good at creating the picture for his clients. And I sent him for neuropsych testing and said, “I think there is some brain damage her and let’s see how he actually compares to other people in terms of processing visual information.” And it was interesting that they found a spot in the cortex in the vertex where he was like zero ability at looking at and observing visual information, and if you’re trying to have a career as a photographer that would be the last deficit you’d want to have. And his parents somehow – I guess he liked taking pictures when he was a child - and they thought, oh, he’d be a good photographer, and they pushed him to do that. And it was just the wrong thing and he had to get some career counseling and change careers and then he was totally fine. It wasn’t a matter of giving him a more powerful set of antidepressants in other words.

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Start earning CME through the link in the show notes. 

1. What cognitive domain describes the small amount of information that can be held in the mind while performing a task?

A. Processing speed

B. Auditory processing

C. Anterograde memory

D. Working memory

KELLIE NEWSOME: Dr. Brown highlighted 3 areas of executive dysfunction that he looks for in ADHD. Each of these problems can occur on their own, but they are also more common in ADHD, and they don’t respond as well to stimulants as the classic ADHD symptoms. To recap, they were: Working memory deficits, Auditory or Visual Dyslexia, and Slow Processing Speed. Dr. Brown estimates that about ½ of people with ADHD have at least one of these deficits.

CHRIS AIKEN: Let’s get into that last one more. On the one hand, processing speed is simple – it is the time it takes to perceive, process and respond to information, and it reflects how quickly someone can get things done. We see problems with slow processing in ADHD, autism, and other psychiatric disorders. But it’s slightly different from another word you’ll hear tossed around in ADHD-world: Sluggish Cognitive Tempo. This has been proposed as a subtype of ADHD, and though it’s not recognized in ADHD research is building on it, including a recent controlled trial where Vyvanse improved it. 

Sluggish Cognitive Tempo includes slow processing speed, but is broader. Its core features are excessive mind-wandering, zoning or spacing out, mental confusion and fogginess, low physical activity, and drowsiness. 

KELLIE NEWSOME: Part of the art of psychiatric nomenclature is choosing neutral names that don’t imply any blame or judgment, and the word “Sluggish,” doesn’t really fit that bill. This year, an international group gathered to think of a better name, and new term they’ve arrived at is cognitive disengagement syndrome. I guess they think it’s better to be disengaged than sluggish… well, I’m not sure I agree, but for now understand that both mean the same thing.

CHRIS AIKEN: How would slow processing speed show up in work or the classroom, what everyday examples?

RICHARD BROWN: Often they will have trouble completing an assignment or test on time. They are always late and they don’t have enough time to answer the questions. Now there can be other reasons for that.

CHRIS AIKEN: Yeah, like I would just think that was ADHD, but it could be slow processing in addition.

RICHARD BROWN: Oh yeah, but they go together often. And the other thing is often they don’t understand, “Well, I’m getting by,” especially if they’re intelligent if they have a pretty high I.Q. You know, “Why should I work on my processing?” And I’m like, “Well, it doesn’t just go into your work at school. Is there a sport you like to play whether it’s tennis or soccer, and you will be able to make a connection with the ball much better when you’re processing is better.”

CHRIS AIKEN: There are some new studies on vitamin D in ADHD; are you familiar with those?

RICHARD BROWN: Yeah, it’s interesting. You know many researchers in the area, most of whom are PhDs or MD/PhDs see vitamin D as a hormone.

CHRIS AIKEN: Interesting.

RICHARD BROWN: Yeah, yeah, yeah, yeah and there’s been a lot of research showing that vitamin D levels are low in many different health conditions, and there have been many studies giving large amounts of vitamin D in those conditions and very, very few have shown positive results. And so a recent review of the vitamin D data was titled “D is for Disappointment” and what a lot of the researchers are coming down to is that your vitamin D level can vary depending on (A) what latitude you live at; (B) how much you are outdoors and how much skin you’ve got exposed, and that it’s more importantly probably a marker for health than being outside and doing the right healthy things. I know a lot of people think it’s gonna cure everything right now and I have patients that come in; they are being given 50,000 units of vitamin D every week or every month and you know I think that there’s gonna be a big reassessment of it. If you test somebody in Africa their vitamin D level is sky high, but it’s hard to show…I mean let’s say different populations adapt to their sun exposure in different parts of the world depending on their climate, and we know most everybody in the upper tier of the U.S. and most Canadians who live close to the border actually demographically or geographically we’re gonna have low vitamin D levels, and besides most of us live like moles working as professionals indoors except for a few weeks where we can get outside more. And one thing that is quite clear: your exposure to sunlight correlates with your risk of prostate cancer.

CHRIS AIKEN: How about light box? Do you look for seasonal ADHD?

RICHARD BROWN: Oh okay, that’s really important; I’m glad that you brought that up. So I found years ago I was using light box because I was doing research on melatonin and I did nothing big but I learned from some amazing researchers on melatonin a lot about those systems in the brain and the pineal gland and what I found was that I started prescribing light boxes and I was getting referred a lot of patients with wintertime worsening of depression, especially bipolar II depression or wintertime worsening of bulimia. But what I also found was a lot of my patients with ADD who also had wintertime worsening of depression and, of course, some researchers believe and I believe that ADD correlates more than randomly with bipolar spectrum disorders. It’s not a 1:1 thing by any means, but it’s more than random. And a lot of my ADD patients said, “Doc, that light is helping my brain work better with my ADD.” And I was like, “Okay, it’s probably working at multiple levels and so it’s not a simple 1-transmitter thing, but it’s organizing the brain to work better.”

KELLIE NEWSOME: Richard Brown is a Clinical Professor of Psychiatry at Columbia University and the author of over 80 peer reviewed articles and books including Non-Drug Treatments for ADHD by WW Norton. He has a private practice in New York and is also a certified teacher of yoga and meditation. Read his full interview in our August 2022 issue.

Want more from the Carlat Podcast? Search for the podcast series The Anti-Hero's Journey by Ben "Doc" Askins. The November 1 episode features an interview with Dr. Aiken where he reveals how he got into psychiatry and what keeps him inspired in this work. They dig into ketodiet, circadian rhythms, psychiatric blunders, punk rock, good parenting, and psychedelics. As always, earn your CME for this episode through the link in the show notes.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.