Disorders of Thought

1. Disorders of Thought
Presenter : Dr. Arpit Koolwal
Resident,
Department of Psychiatry
Subharti Medical College,
Meerut

2. Introduction
• Thought generally refers to any mental or
intellectual activity involving an individual’s
subjective consciousness.
• Act of Thinking Thought.
• Thought underlies almost all human action and
interactions.
• Understanding its physical and metaphysical
origins, process and effects has been a
longstanding goal of many academic disciplines –
biology, philosophy, psychology and sociology.

3. • Thinking allows us to make sense of or model the
world in different ways and to represent or interpret
it in ways that are significant to us.
• Three legitimate uses of the word ‘think’ -
1. Undirected Fantasy Thinking (which, in the past,
has also been termed autistic or dereistic
thinking)
2. Imaginative Thinking - Does not go beyond the
rational possible.
3. Rational thinking or conceptual thinking - which
attempts to solve a problem.

4. Classification
(Acc. to Fish’s Clinical Psychopathology)
• Include –
1. Disorders of Thinking –
a) Stream of Thought –
i. Thought Tempo,
ii. Continuity of Thinking
b) Obsessions, Compulsions and Disorders of the
Possession of thought,
c) Content of the thought, and
d) Form of Thinking.
2. Disorders of Intelligence

5. Disorders of Thinking
• Undirected fantasy or ‘autistic’ thinking –
Quite common.
Individuals with repeated disappointments
or adverse life circumstances – Excessive
Feature of Schizophrenia – Bleuler included
it as one of his 4 A’s of Schizophrenia.
Bleuler believed that excessive autistic
thinking in schizophrenia was partly the
result of formal thought disorder.

6. • Classification of Disorders of Thinking
A. Disorders of stream of thought,
B. Disorders of the possession of thought,
C. Disorders of the content of thought
D. Disorders of the form of thought.

7. • Proper consideration to the intelligence,
education and cultural background.
• Ask open ended questions.
• Record verbatim examples.
• At times, silence can help!.

8. Disorders of the stream
of thought
1. Disorders of thought tempo

9. FLIGHT OF IDEAS
• Thoughts follow each other rapidly; there is no
general direction of thinking;
• Easily diverted to external stimuli and by internal
superficial associations.
• Absence of a determining tendency to thinking allows
the associations of the train of thought to be
determined by chance relationships, verbal
associations of all kinds (such as assonance,
alliteration and so on), clang associations, proverbs,
maxims and clichés.
• Reverse the sequence of the record – Progression of
the thought can be understood.
(Fish’s Clinical Psychopathology)

10. Clang Associations - A pattern of speech in which sounds rather
than meaningful relationships appear to govern word choice, so
that the intelligibility of the speech is impaired and redundant
words are introduced.
• In addition to rhyming relationships, may also include punning
associations.
• Example.—"I'm not trying to make noise. I'm trying to make
sense. If you can make sense out of nonsense, well, have fun. I'm
trying to make sense out of sense. I'm not making sense (cents)
anymore. I have to make dollars.“
(Andreasan, 1979)
Alliterations - The same consonant sound at the commencement
of two or more stressed syllables of a word group.
• Example - “ill, illegitimate, illusion”.
• Some believe that Clang Associations include both rhyming as
well as alliterations.

11. • Andreasen (1979) states “flight of ideas is a
derailment that occurs rapidly in the context of
pressured speech”.
• Recommends –
i. Absence of pressure of speech - ‘derailment’,
and
ii. Presence of pressure of speech – ‘flight of
ideas’.
• The argument then becomes, acc. to her, not
about derailment and flight, but about the
presence or absence of pressure of speech.

12. Pressure of Speech - An increase in the amount of
spontaneous speech as compared with what is
considered ordinary or socially customary. The patient
talks rapidly and is difficult to interrupt.
• Even when interrupted, the speaker often continues to
talk.
• Loud and emphatic.
• Talk without any social stimulation.
• May be even though no one is listening.
• Rate - >150 words per minute is usually considered rapid
or pressured.
(Andreasan, 1979)

13. Examples of FOIs
• A manic patient who was asked where she lived and
she replied: ‘Birmingham, Kingstanding; see the king
he’s standing, king, king, sing, sing, bird on the wing,
wing, wing on the bird, bird, turd, turd.’

14. This was written by a 25 year old woman with
bipolar disorder during her second manic
episode.
The following analysis is reasonable:
Up and Down like a very rough sea – the patient
may have been referring to the ups and downs
of her mood (characteristic of bipolar disorder);
Psycho-log-i-cal – is split into beats which give
the word an up and down rhythm;
eye – was suggested by the letter i ;
log – suggested logarithm, a mathematical
concept in which a base must be raised in order
to produce a given number. Perhaps this notion
triggered the words “raising the number”, which
then suggested the raising of an anchor, and she
moved on to write about “smooth sailing”
(returning to her nautical theme);
Am I psycho or logical – the patient splits the
word psychological a second time to reveal
apparent opposites “psycho” colloquially
synonymous with psychotic/insane, and logical;
Now I hope I’m logical – the patient ends with
humour, which is a frequently observed feature
of mania.

15. Found in
1. Mania - Typically
2. Schizophrenia - When they are excited.
3. Organic states –
a. Intoxication
b. Lesions of the hypothalamus,
which are associated with a range of psychological
effects, including features of mania and disturbances
of personality.
• In Acute Mania, flight of ideas can become so severe
that incoherence occurs, because before one thought is
formulated into words another forces its way forward.

16. Prolixity - In hypomania so-called ‘ordered flight of
ideas’ occurs in which, despite many irrelevances,
the patient is able to return to the task in hand.
• Clang & verbal associations are not so marked, and
• the speed of emergence of thoughts is not as fast as in
flight of ideas.
• Although these patients cannot keep accessory
thoughts out of the main stream, they only lose the
thread for a few moments and finally reach their goal.

17. INHIBITION OR SLOWING OF
THINKING
• The train of thought is slowed down and the number of ideas and
mental images that present themselves is decreased.
• Experienced by the patient as
1. Difficulty in making decisions,
2. Lack of concentration and
3. Loss of clarity of thinking.
• Also a diminution in active attention, so that events are poorly
registered.
• Patient complains of –
1. Loss of memory
2. May lead to development of an overvalued or delusional idea that
thoughts are going out of his mind.
• The apparent cognitive deficits in individuals with slowing of thinking
in depression may lead to a mistaken diagnosis of dementia (Pseudo-
dementia).
• Seen in –
1. Depression, and
2. Manic stupor (very rare).
(Fish’s Clinical Psychopathology)

18. Poverty of Thought
• Commonly used in clinical practice - Similar to
‘inhibition or slowing of thinking’.
• Not mentioned in Fish’s Clinical
Psychopathology.
• Andreasan (1979) has mentioned two
concepts which can be placed under Poverty
of Thought –
1. Poverty of Speech
2. Poverty of Content of Speech

19. Poverty of Speech –
• Restriction in the amount of spontaneous speech,
so that replies to questions tend to be brief,
concrete, and unelaborated. Unprompted
additional information is rarely provided.
• Replies may be monosyllabic, and some
questions may be left unanswered altogether.
• Interviewer may find himself frequently
prompting the patient to encourage elaboration
of replies.
• Must allow the patient adequate time to answer
and to elaborate his answer.
(Andreasan, 1979)

20. Example of Poverty of Speech –
• Interviewer: "Do you think there's a lot of corruption in government?"
• Patient: "Yeah, seem to be."
• I: "Do you think Haldeman and Ehrlichman and Mitchell have been fairly
treated?"
• P: "I don't know."
• I: "Were you working at all before you came to the hospital?"
• P: "No."
• I: "What kind of jobs have you had in the past?"
• P: "Oh, some janitor jobs, painting."
• I: "What kind of work do you do?"
• P: "I don't. I don't like any kind of work. That's silly."
• I: "How far did you go in school?"
• P: "I'm still in 11th grade."
• I: "How old are you?" Patient: "Eighteen.“
Found in – 1. Depression
2. Schizophrenia
3. Organic conditions – Hypothyroidism
Dementia

21. Poverty of Content of Speech –
• Although replies are long enough so that speech is
adequate in amount, it conveys little information.
• Alternatively, the patient may provide enough
information to answer the question, but require many
words to do so, so that a lengthy reply can be
summarized in a sentence or two.
• Language - Vague, often overabstract or overconcrete,
repetitive, and stereotyped.
• Sometimes the speech may be characterized as "empty
philosophizing“.
• Can be confused with — Circumstantiality –
Difference- Circumstantial patient tends to provide a
wealth of detail.
(Andreasan, 1979)

22. Example of Poverty of Content of Speech —
Interviewer: "Tell me what you are like, what kind of person you are."
Patient: "Ah one hell of an odd thing to say perhaps in these particular
circumstances, I happen to be quite pleased with who I am or how I
am and many of the problems that I have and have been working on I
have are difficult for me to handle or to work on because I am not
aware of them as problems which upset me personally. I have to get
my feelers way out to see how it is and where that what I may be or
seem to be is distressing, too painful or uncomfortable to people who
make a difference to me emotionally and personally or possibly on an
economic or professional level. And I am I think becoming more aware
that perhaps on an analogy the matter of some who understand or
enjoy loud rages of anger, the same thing can be true for other people,
and I have to kind of try to learn to see when that's true and what I can
do about it.“
• If after listening to the patient talk, an attempt is made to make a
summary - the product will be a very small summary.
• There is almost no information to summarise.

23. • Found in –
1. Schizophrenia
2. Mania
3. Intoxication
4. Normally in narcissistic individuals

24. CIRCUMSTANTIALITY
• Thinking proceeds slowly with many unnecessary and
trivial details, but finally the point is reached.
• Goal of thinking is never completely lost and thinking
proceeds towards it by an intricate and convoluted
path.
• Seen in context with learning disability and in
individuals with obsessional personality traits.
• Historically regarded as a personality trait associated
with epilepsy.
• Circumstantial replies or statements may last for many
minutes if the speaker is not interrupted and urged to
get to the point.

25. 2. Disorders of Continuity of Thinking

26. PERSEVERATION
• Mental operations persist beyond the point at which they are
relevant and, thus, prevent progress of thinking.
• Related to the severity of the task – The more complicated the
task , more the chances that he will persevere.
• Found in - Organic disorders of the brain.
• Not a problem of volition – Which differentiates it from verbal
stereotypy - Frequent spontaneous repetition of a word or
phrase that is not in any way related to the current situation.
• Example – On being asked the name of the previous Prime
Minister the patient replies John Major, on being asked the
name of the present Prime Minister the patient replies ‘John
Major. No I mean John Major’.
• Two types - Logoclonia & Palilalia
(Fish’s Clinical Psychopathology)

27. • According to Andreasan (1979) – Perseveration is —
Persistent repetition of words, ideas, or subjects so
that, once a patient begins a particular subject or uses
a particular word, he continually returns to it in the
process of speaking.
• Examples –
1. "I think I'll put on my hat, my hat, my hat, my hat.“
2. Interviewer: "Tell me what you are like, what kind of
person you are." Patient: "I'm from Marshalltown,
Iowa. That's 60 miles northwest, northeast of Des
Moines, Iowa. And I'm married at the present time.
I'm 36 years old. My wife is 35. She lives in Garwin,
Iowa. That's 15 miles southeast of Marshalltown,
Iowa. I'm getting a divorce at the present time. And I
am at presently in a mental institution in Iowa City,
Iowa, which is a hundred miles southeast of
Marshalltown, Iowa."

28. Echolalia - A pattern of speech in which the patient echoes
words or phrases of the interviewer.
• The echo is often uttered with a mocking, mumbling, or
staccato intonation though there is no such intention in
true echolalia.
• Example - Doctor says to the patient, "I'd like to talk with
you for a few minutes." The patient responds with a
staccato intonation, "Talk with you for a few minutes.“
(Andreasan, 1979)
• Both perseveration and echolalia have –
1. Repetition as their core feature (one’s own words or
another’s words)
2. Similar conditions in which they are found –
 Organic conditions
 Schizophrenia & Mania (very rarely)

29. THOUGHT BLOCKING
• Thought blocking occurs when there is a sudden arrest of the
train of thought, leaving a ‘blank’.
• An entirely new thought may then begin.
• May be a terrifying experience;
• Differs from the more common experience of suddenly losing
one’s train of thought, which tends to occur when one is
exhausted or very anxious.
• Should only be judged to be present if a person voluntarily
describes losing his thought or if on questioning by the
interviewer he indicates that that was his reason for pausing.
• May give rise to the delusion that thoughts have been
withdrawn from the head.
• Highly suggestive of schizophrenia.
• Thought can be seen in both speech and in the motor act
which is being performed when the thought block occurred,
‘Sperrung’.

30. Obsessions, compulsions and disorders of the
possession of thought

31. 1. Obsessions and compulsions
– Obsession - Thought that persists and dominates an individual’s
thinking despite the individual’s awareness that the thought is
either entirely without purpose or else has persisted and
dominated their thinking beyond the point of relevance or
usefulness.
• Content is often such that can cause the sufferer great
anxiety and even guilt.
• Appears against the person’s will.
• Normally under control and can resisted, thus we have
obsessional fears, ideas, images and impulses but not
obsessional hallucinations or mood.
• Particularly repugnant to the individual (Ego-dystonic) -
Prudish person------------Sexual thoughts,
Religious person----------Blasphemous thoughts,
Timid person-------------Torture, murder and general
mayhem.
• It is customary to distinguish between obsessions and
compulsions.

32. Forms of Obsessions -
1. Obsessional Images - Vivid images that occupy the
patient’s mind. At times so vivid that they can be mistaken
for pseudohallucinations.
Example - One patient was obsessed by an image of his own
gravestone that clearly had his name engraved on it.
2. Obsessional ideas - Take the form of ruminations on all
kinds of topics ranging from why the sky is blue to the
possibility of committing fellatio with God.
3. Contrast thinking in which the patient is compelled to
think the opposite of what is said.
Example - Compulsive blasphemy, in case of a devout patient
who was compelled to make blasphemous rhymes, so that
when the priest said ‘God Almighty’, she was compelled to
think ‘Sod Allshitey’.
4. Obsessional impulses may be impulses to touch, count or
arrange objects, or impulses to commit antisocial acts.
5. Obsessional fears or phobias consist of a groundless fear
that the patient realises is dominating without a cause,
and must be distinguished from the hysterical and learned
phobias.

33. • Compulsions - Merely obsessional motor acts. May
result from
1. an obsessional impulse that leads directly to the
action, i.e. Compulsions can occur without
obsessions as well, or
2. they may be mediated by an obsessional mental
image or thought, as, for example, when the
obsessional fear of contamination leads to
compulsive washing.

34. • Obsessions occur in
–obsessional states,
–depression,
–schizophrenia,
–occasionally in organic states;
• Compulsive features appear to be
particularly common in post-encephalitic
parkinsonism

35. 2. Thought alienation
– The patient has the experience that their thoughts are under the control of an outside
agency or that others are participating in their thinking.
1. Thought insertion - The patient knows that thoughts are being inserted into their mind
and they recognize them as being foreign and coming from without; commonly
associated with schizophrenia but not unique to it.
2. Thought Withdrawal - the patient finds that as they are thinking, their thoughts
suddenly disappear and are withdrawn from their mind by a foreign influence. It has
been suggested as the subjective experience of ‘thought blocking’ and ‘omission’.
3. Thought broadcasting, the patient knows that as they are thinking, everyone else is
thinking in unison with them.
– Psychoanalytic Interpretation – Boundary between the ego and the surrounding world
has broken down.
– An experience is described as ego-syntonic if it is consistent with the goals and needs of
the ego and/or consistent with the individual’s ideal self-image; the reverse is the case
for ego-dystonicity.
•

36. Disorders of the form of thinking

37. • ‘Formal Thought Disorder’ - synonym for
disorders of conceptual or abstract thinking.
• Most commonly seen in schizophrenia and
organic brain disorders. Historically, considered
pathognomic for Schizophrenia.
• In schizophrenia, disorders in the form of
thinking may coexist with deficits in cognition.
• There never has been a consensus on what
exactly constitutes the normal thinking.
• Consequently no consensus on what are the
formal thought disorders. Hence,
• Different schools of thoughts.

38. Bleuler (1911) – Regarded schizophrenia as a
disorder of associations between thoughts,
characterised by the processes of
1. Condensation – Two ideas with something in
common are blended into one false concept.
2. Displacement – One idea is used for an
associated idea.
3. Misuse of symbols – Using concrete aspects
of the symbol instead of the symbolic
meaning (concrete thinking).

39. Cameron (1944) –
• Asyndesis – Lack of adequate connections between
successive thoughts.
• Metonyms – Imprecise expressions instead of more
exact ones.
• Inclusion of excessive personal idiom and fantasy
material in the speech of schizophrenia.
• ‘Over-inclusive thinking’ – Inability to narrow down the
operations of thinking and bring into action the
organised attitudes and specific responses relevant to
the task at hand.
Goldstein (1944) – Emphasised loss of abstract attitude in
patients with schizophrenia, which leads to a concrete
style of thinking, despite the fact that the patient has
not lost their vocabulary.

40. Schneider (1930) - Claimed that five features of
formal thought disorder could be identified:
1. Derailment – The thought slides on to a
subsidiary thought.
2. Substitution – A major thought is substituted
by subsidiary one.
3. Omission – Senseless omission of a thought or
a part of it.
4. Fusion – Heterogeneous elements of thought
are interwoven with each other.
5. Drivelling - Disordered intermixture of
constituent parts of one complex thought.

41. Schneider suggested there were three features of healthy
thinking:
1. Constancy: Characteristic of a completed thought
that does not change in content unless and until it is
superseded by another consciously-derived thought.
2. Organisation: the contents of thought are related to
each other in consciousness and do not blend with
each other, but are separated in an organised way.
3. Continuity: There is a continuity of the sense
continuum, so that even the most heterogenous
subsidiary thoughts, sudden ideas or observations
that emerge are arranged in order in the whole
content of consciousness.
Schneider claimed that individuals with schizophrenia
complained of three different disorders of thinking
that correspond to these three features of normal or
non-disordered thinking.

42. 1. Transitory thinking
– Transitory thinking is characterised by derailments, substitutions and
omissions.
– The grammatical and syntactical structures are both disturbed in transitory
thinking.
2. Drivelling thinking
– With drivelling thinking, the patient has a preliminary outline of a complicated
thought with all its necessary particulars, but loses preliminary organisation of
the thought, so that all the constituent parts get muddled together.
– The patient with drivelling have a critical attitude towards their thoughts, but
these are not organised and the inner material relationships between them
become obscured and change in significance.
3. Desultory thinking
– In desultory thinking speech is grammatically correct but sudden ideas force
their way in from time to time.
– Each one of these ideas is a simple thought that, if used at the right time
would be quite appropriate.

43. Neologisms
• Included under Speech disorders in Fish’s Clinical
Psychopathology.
• New words that are constructed by the patient or
ordinary words that are used in a new way.
• Term ‘Neologism’ is applied usually to new word
formation by schizophrenia patient.
• Patients with aphasia, particularly motor aphasia,
use wrong words, invent new or distort the
phonetic structure of words – Paraphasia – can
superficially resemble neologisms.

44. • When an individual with schizophrenia produces a new word, it may be a –
1. Completely new and its derivation not understood.
2. Distortion of another word;
3. Word that has been incorrectly constructed by the faulty use of the
accepted rules of word formation.
4. Mannerisms or Stereotypies - The patient may distort the pronunciation
of some words in the same way as they distort some movements of their
body.
5. Use of a stock word instead of the correct one. For example, a patient
may use the word ‘car’ and call an airplane an ‘air car’ and a boat a ‘sea
car’.
6. Result of a severe positive formal thought disorder, so that words are
fused together in the same way as concepts are blended with one
another.
7. Result of a derailment; for example, a patient used the word ‘relativity’
instead of the word ‘relationship.’
8. Technical Neologism - An attempt to find a word for an experience that is
completely outside the realms of normal and is a term to describe a
private experience that cannot be expressed in ordinary words.
9. In some patients hallucinatory voices seem to play a great part in the
formation of neologisms. The ‘voices’ may use neologisms and this may
lead the patient to use them as well. Sometimes the patient feels forced
to use new words in order to placate the ‘voices’ or to protect
themselves from them.

45. • According to Andreasan (1979), a neologism is
defined here as a completely new word or
phrase whose derivation cannot be
understood.

46. Word Salad
• Also called as Word Salad, Schizophasia, Jargon Aphasia, Incoherence, etc.
• A pattern of speech that is essentially incomprehensible at times.
• Can be due to different mechanisms, which may all occur simultaneously –
1. Rules of grammar and syntax are ignored, and a series of words or
phrases seem to be joined together arbitrarily and at random.
2. Portions of coherent sentences may be observed in the midst of a
sentence that is incoherent as a whole.
3. The word choice may seem totally random or may appear to have some
oblique connection with the context.
4. Sometimes "cementing words" (coordinating and subordinating
conjunctions such as "and" and "although" and adjectival pronouns such
as "the," "a," and "an") are deleted.
• May sound similar to wernicke’s aphasia and hence, neurological
assessment should be done to rule out organic cause.
• May be accompanied by derailment.
• Differs from derailment – The abnormality occurs at the level at the
sentence in word salad while it is between two different sentences in
derailment.

47. Example of Word Salad –
• Interviewer: "What do you think about current
political issues like the energy crisis?"
• Patient: "They're destroying too many cattle and
oil just to make soap. If we need soap when you
can jump into a pool of water, and then when you
go to buy your gasoline, my folks always thought
they should get pop, but the best thing to get is
motor oil, and money. May as well go there and
trade in some pop caps and, uh, tires, and
tractors to car garages, so they can pull cars away
from wrecks, is what I believed in."

48. Limitations to the Approach
• Assumption that thinking can be inferred from language -
Thought and language are perfectly correlated.
• Deaf children who have not as yet developed any speech
show definite abilities to think conceptually, for example.
• Aphasic patients often become frustrated with their
inability to articulate in language thoughts that are clearly
formulated in their minds.
• Further, anyone can exert conscious control over his
language behavior and manipulate it in various ways to
conceal or obscure his thoughts.
• Thus, one cannot in fact infer with certainty that normal
language reflects normal thinking or conversely that
disordered language reflects disordered thinking.

49. Disorders of intelligence
• Intelligence is the ability to think and act rationally and logically.
• Measured with tests of the ability of the individual to solve problems and
to form concepts through the use of words, numbers, symbols, patterns
and non-verbal material.
• The most common way of measuring intelligence is in terms of the
distribution of scores in the population.
• The person who has an intelligence score on the 75 percentile has a score
that is such that 75% of the appropriate population score less and 25%
score more.
• Some intelligence tests used for children give a score in terms of the
Mental Age, which is the score achieved by the average child of the
corresponding chronological age.
• For historical reasons, most intelligence tests are designed to give a mean
IQ of the population of 100 with a standard deviation of 15.
• Even if the distribution of scores is not normal, percentiles can be
converted into standard units without difficulty and this is probably the
best way of measuring intelligence.
• Intelligence scores in a group of randomly chosen subjects of the same age
tends to have a normal distribution, but this only applies over most of the
range of scores.

50. • Two groups of subjects with low intelligence
‘Learning Disability or Intellectual Disability’ -
1. Individuals whose intelligence is at the lowest
end of the normal range and is therefore a
quantitative deviation from the normal.
2. With learning disability comprise individuals
with specific learning disabilities.
• Learning disability tends to be categorized as
– borderline (IQ=70−90),
– mild (IQ=50−69),
– moderate (IQ=35−49),
– severe (IQ=20−34)
– profound (IQ <20).

51. Dementia -
• Loss of intelligence resulting from brain
disease,
• Characterized by disturbances of multiple
cortical functions, including -
1. Thinking,
2. Memory,
3. Comprehension, and
4. Orientation, among others (World Health
Organization, 1992).

52. • Individuals with schizophrenia tend to exhibit
specific deficits in multiple cognitive domains.
• Not represent a true dementia; best
considered as part of the psychopathology of
schizophrenia.
• Dysfunction of the temporal cortex, frontal
cortex and hippocampus.

53. Thank yo