Chris Aiken, MD. Editor-in-Chief of TCPR. Practicing psychiatrist. Winston-Salem, NC.
Tony Thrasher, DO, DFAPA. Immediate past president, American Association for Emergency Psychiatry (AAEP). Medical Director of Crisis Services, Milwaukee County Behavioral Health. Milwaukee, WI. Clinical Associate Professor, Medical College of Wisconsin. Milwaukee, WI.
Dr. Aiken and Dr. Thrasher have no financial relationships with companies related to this material.
Patients are increasingly diagnosing themselves with syndromes that are prominent on the internet but not noted in the DSM. You may have heard mention of sensory processing disorder, slow cognitive speed, or “ring of fire” ADHD, but how valid are these constructs?
Concepts of psychiatric diagnoses have varied by time and culture, but our current age is perhaps most influenced by an idea put forth by John Feighner and his neo-Kraepelinian colleagues in 1972 (Feighner JP et al, Arch Gen Psychiatry 1972;26(1):57–63). They called for five validators of psychiatric diagnoses: clinical description, laboratory studies, delineation from other disorders, course of illness, and family studies. Most psychiatric disorders fall short in the laboratory category, so a different biological marker was later suggested in its place: treatment response.
Feighner’s paper influenced the transition from DSM-II to DSM-III, although many disorders that are recognized in DSM-5 do not meet his strict criteria. Still, his paper provides a useful framework to evaluate these newer concepts.
Sensory processing disorder
Sensory processing disorder (SPD) is intended to describe patients with symptoms of sensory over-reactivity that do not meet the criteria for autism spectrum disorders (ASD) (Tavassoli T et al, Dev Cog Neurosc 2018;29:72–77). These patients find everyday sensations overwhelming or painful: the tags on clothing, the hum of radiators, or the glare of fluorescent lights. Poor coordination is also common.
SPD has reliable symptoms and a stable course, but it misses the mark on the Feighner criterion of delineation from other disorders. Sensory processing symptoms are often seen in autism, OCD, and ADHD, so SPD is not clearly a disorder in its own right.
Slow cognitive speed
Slow cognitive speed is characterized by a cluster of symptoms that include slow processing, daydreaming, and mental fogginess (it is sometimes called sluggish cognitive tempo). These symptoms are overrepresented in patients with ADHD (Brewe AM et al, Autism 2020;24(6):1373–1383). That said, there is not full agreement on whether slow cognitive speed is a separate diagnosis or if it falls under the umbrella of ADHD.
These symptoms have a particular effect on the patient’s social world, as they tend to make others feel the patient is disinterested or ignoring them. Slow cognitive speed also influences the course of ADHD. Patients with slow cognitive speed tend to have more depression and anxiety, and less disruptive and oppositional behaviors, compared to patients with pure ADHD (Barkley RA. A Review of Research on SCT. In: Barkley RA. Barkley Sluggish Cognitive Tempo Scale—Children and Adolescents (BSCTS-CA). New York, NY: Guilford Press; 2018:3–24). Of psychopharmacological interest is the fact that atomoxetine and lisdexamfetamine (Vyvanse) improve slow cognitive speed independently of their effects on ADHD.
Slow cognitive speed meets a few of Feighner’s diagnostic markers, including a stable clinical description and predictable pharmacologic response, but it may be better thought of as a subtype of ADHD.
“Ring of fire” ADHD
In 1991, psychiatrist Daniel Amen began including SPECT brain scans in routine psychiatric evaluations at his practice in Northern California. The idea has since grown into a database of over 200,000 brain scans across 10 Amen Clinics, but it has not produced any clinical evidence that SPECT scans inform diagnosis or treatment.
Dr. Amen has also proposed seven variants of ADHD: classic, inattentive, overfocused, temporal lobe, limbic, anxious, and “ring of fire.” That last one, also known as “ADHD plus,” has gained particular traction on the internet, although our Medline search did not turn up a single reference.
“Ring of fire” describes a particularly debilitating form of ADHD with prominent externalizing symptoms, such as aggression, overtalkativeness, and mood swings. Those symptoms have led some to suggest that this subtype is on a continuum with bipolar disorder. ADHD and bipolar disorder overlap at a rate that’s greater than expected by chance, but it’s not clear what the “ring” designation adds beyond recognizing the comorbidity.
DSM-5 applies the same PTSD classification to very different types of trauma, whether it is sexual abuse from a parent or a bicycle accident as an adult. Complex PTSD aims to bring more specificity to this diagnosis by identifying patients who experienced severe interpersonal traumas that the person cannot escape from, including childhood physical or sexual abuse, domestic violence, torture, genocide, captivity, and slavery.
Complex PTSD has been recognized in ICD-11 since 2018 as code 6B41. The ICD criteria require a trauma of the type described above, along with the three core symptoms of PTSD (re-experience, avoidance, and hyperarousal). In addition, patients must have:
The DSM-IV committee left out the disorder because field trials failed to separate it from regular PTSD. Complex PTSD was also rejected from DSM-5, although many of its symptoms were incorporated into the revised criteria for PTSD. The ICD committee based their decision on more recent data that support complex PTSD as a valid and unique disorder.
Specifically, clinician- and patient-rated scales were developed, and they reliably identified a population that was distinct from regular PTSD (one scale is available at www.traumameasuresglobal.com). Studies also suggest that complex PTSD is distinct from borderline personality disorder (BPD). Compared to BPD, patients with complex PTSD have a stable, but negative, identity. They are less impulsive and less likely to engage in self-harm. Laboratory studies also support the diagnosis. Compared to other patients with PTSD, these patients have more extensive structural brain abnormalities and more dysregulation in the areas of the brain involved in emotion regulation. In terms of treatment, some studies suggest they are less likely to respond to traditional psychotherapies for PTSD (Reed GM et al, World Psychiatry 2022;21(2):189–213).
When a patient identifies with a novel diagnosis, approach it with humility and use it as an opportunity to better understand them. After all, many of the DSM-5 disorders don’t meet the strict Feighner criteria for a valid diagnosis, and some of these novel syndromes may prove to be valid diagnoses over time.
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