Disorders of form of thought

it contains a detailed information about thought disorders, types of thought disorder and scales for assessment of thought disorders

1. FORMAL THOUGHT
DISORDER
Sradhanjali Biswal
Tutor
Kalinga Institute Of Nursing Sciences
Bhubaneswar

2. FORM OF THOUGHT
•Conceptual / Abstract thinking
•Form: Consistent, uninterrupted and
organized flow of thinking towards its
goal (Jaspers)

3. FORMAL THOUGHT DISORDER
•The term ‘Formal thought disorder’ is
synonym for disorders of conceptual or
abstract thinking
•Once considered pathognomonic of
schizophrenia
•Occurs in :
-Schizophrenia
-Coarse brain disease.

4. Schizophrenic FTD can be divided into 2
subgroups:
Negative FTD:
Pt has lost his previous ability to think,
but does not produce any unusual concepts.
Positive FTD:
Pt produces false concepts by blending
together incongruous elements.

5. Thought, Language & Communication Disorder
•Poverty of speech
•Poverty of content of
speech
•Pressure of speech
•Distractibility of speech
•Tangentiality
•Derailment
•Incoherence
•Illogicality
•Clanging
•Neologisms
•Word Approximations
•Circumstantiality
•Loss of Goal
•Perseveration
•Echolalia
•Blocking
•Stilted Speech
•Self Reference
•Paraphasia –Phonemic
Semantic

6. Poverty of Speech
•Restriction in the amount of spontaneous speech
•Replies Brief, Concrete & Unelaborated.
Monosyllabic
Some Quests unanswered
•To elicit Must allow pt adequate time to
answer & to elaborate his answer.

7. Poverty of Content of speech (Alogia,
Verbigeration, Poverty of thought)
•RepliesalthoughspeechisAdequateinamount
•ConveysLittleInformation
•LanguageVagueness,emptiness,Repetitive,
Stereotyped,
•Exclude:Circumstantiality
-Provide a wealth of details.

8. Pressure of Speech
Increaseinamountofspontaneousspeech
Sentencesleftincompletewithnewideascomingup
Talksrapidly&Difficulttointerrupt
LoudandemphaticSpeech
Talkwithoutsocialstimuli&evennooneislistening
Morethan150words/min

9. Distractible Speech
During interview or discussion
Stops talking in the middle of sentence or idea
Changes the subject in response to nearby
stimulus

10. Tangentiality
Replies Oblique / Tangential / Irrelevant
manner
Reply : Related in distant way
Unrelated
Totally Irrelevant
Refers only to replies to questions
Not transitions in spontaneous speech

11. Derailment (Loose Associations, Flight
of Ideas)
Ideas slip off track onto another one.
-Obliquely related, or onto one which is
-Completely unrelated
“Disjointed Speech” –vague connect / No connect
MC Slow, Steady slippage
Goes farther, farther & farther off the track
No longer has any connection with question
asked

12. Derailment
(Loose Associations, Flight of Ideas)
Goal Not reached.
Characteristic --> Lack of cohesion between
clauses / sentence.
Flightofideasisaderailmentthatoccursrapidly
inthecontextofpressuredspeech.
Exclude Tangentiality :
-Occurs as Immediate response to
questions.

13. Incoherence
(Word Salad, Jargon Aphasia, Schizophasia,
Para-grammatism)
Incomprehensible Speech
Cementing words (and, although, a, an) deleted
Often accompanied by Derailment
Difference with Derailment Unclear
connections between larger units e.g. sentence /
clause

14. Contd..
Relatively rare.. But when occur Severe FTD
Similar to Jargon Aphasia ..D/D Wernickes
Aphasia…R/O by History, Lab Investigations
etc.
Exclude Mild Ungrammatical Constructions
Idiomatic use in Particular regional /
ethnic background, lack of
education, low intelligence.

15. Illogicality
Conclusions reached with No Logicality
Reaching conclusions on faulty premises
without actual delusional thinking.
Exclude… Delusions
Cultural & Religious Values

16. Clanging
Soundsgovernthewordchoice(ratherthan
meaningfulrelationships)
Redundantwordsareintroduced.
Rhymingrelationships
Punningassociations(wordsimilarinsound
bringsanewthought)
Example:I’mnottryingtomakenoise.I’m
tryingtomakesense.Ifyoucanmakesenseout
ofnonsense,wellhavefun.I’mtryingtomake
senseoutofsense.

17. Circumstantiality
Indirect Speech with delayed in reaching goal
Tedious elaboration & Need to interrupt
“Long winded”
Exclude Poverty of content of speech
Little information
Derailment
Goal not reached

18. Loss of Goal
Failure to follow chain of thought to its natural
conclusion
Begins with one subject wanders away 
Not reached the goal
Often associated with Derailment

19. Perseveration
Senselessrepetitionofagoal-directedaction/speech
whichhasalreadyserveditspurpose/beyond
relevance.
Threetypes–1.CompulsiveRepetition
2.ImpairmentofSwitching
3.Ideational/Thematic
Exclude…Stockwords--Inappropriatefortheir
usualmeaningPausefillers–youknow,like,ok

20. Echolalia
Pt echoes words / phrases of interviewer
Repetitive & Persistent
More common in children
Exclude… Habit –To formulate answer
Indic by rewording question
/ repeating last words

21. Thought blocking
Interruption of train of speech before a thought /
Idea has been completed.
Entirely new thought may then begin.
Present if… Pt voluntarily describes losing his
thought. On question, indicated that blocking was
a cause for his pausing

22. Stilted Speech
Excessive Stilted / Formal quality
Use of particular word choices (Sorry, Please, at
your convenience)
Extremely polite phraseology

23. Self -Reference
Repeatedly refers subject under discussion back
to himself
Easily observed during--Informal Conversation

24. Neologism
Completelynewword/phrasewhose
derivationcannotbeunderstood.
Alsoincludeincorrectlybuiltupwordwith
understandableorigin
FormoreclarificationUsuallyclassifiedin
WordApproximations.

25. Word Approximations
(Paraphasia, Metonyms)
Oldwordsusedinnew&unconventionalway
Newwordsformedbyconventionalrulesof
wordformation.
MaybebasedonuseofStockwords–Uses
wordsrepeatedlyinwaysthatgivethema
meaninge.g.“Vessel”

26. Contd..
•Exclude…Incoherence Formal testing for
aphasia –Negative
Metaphorical words

27. Paraphasia -Phonemic
•Recognizable mispronunciation of words
•Sounds / Syllables slipped out of sequence
•Severe… Aphasia
•Mild….. Everyday speech—Slips of tongue
•Recognizes error & may attempt to correct it.

28. Paraphasia -Semantic
•Substitution of inappropriate word when trying to
say something specific
•May / May not recognize his error
•Typically in Wernickes Aphasia & Brocas
Aphasia
•Exclude.. Incoherence --Negative formal test
Aphasia

29. More Pathological
-Poverty of Speech
-Poverty of content of
Speech
-Pressure of Speech
-Distractibility
-Derailment
-Tangentiality
-Incoherence
-Illogicality
-Clanging
-Neologisms
-Word Approximations
Less Pathological
-Circumstantiality
-Loss of goal
-Perseveration
-Blocking
-Echoloalia
-Stilted Speech
-Self Reference
Andreasen N; Scale for assesst of TLC Dis

30. Bleuler (1911)
•The outstanding feature of schizophrenic
FTD is the lack of connection between
associations, which gave rise to changeable
and unclear concepts.
•Loosening of associations was the basic
disorder on the premise of which Bleuler
described schizophrenic thought disorder

31. •Condensation: 2 ideas with something in
common are blended into a false concept.
•Displacement: one idea is used for an
associated idea.
•Misuse of symbols: using the concrete
aspects of the symbol instead of the
symbolic meaning.

32. Cameron
1) In-coordination
2) Interpenetration–Speech cont elmts which
belong to the task in hand interspersed with a
stream of fantasy which he cant stop
3) Fragmentation
4) Over-inclusion –Inablty to maint boundaries
of problem & to restrict operans to their limits.

33. Asyndesis:
The lack of adequate connections between
successive thoughts.
Metonyms:
The imprecise approximations in which pt. uses
some substitute term or phrase instead of a more
exact one.
Cameron points out that the patient developed
his own private mode of speech which is full of
personal idioms.

34. GOLDSTEIN
•Loss of abstract attitude of thinking
•Thinking becomes concrete and
superficial

35. Payne
•Tests of concrete thinking Tests of over-
inclusion… which performed badly by
schizophrenics
•Schizophrenics with marked psycho motor
slowness have impaired tests of over-
inclusion
Chapman
•Cant free himself from major meaning of
word.

36. Schneider
Featuresofhealthythinking
Constancy:
Persistenceofcompletedthoughtwhetherornotitis
simpleorcomplicatedinitscontent.
Organization:
thecontentofThoughtsrelatedtoeachother&donot
blendwitheachotherbutseparatedinorganizedway.
Continuity:
Thoughtsarearrangedinorderandareincontinuum,
sothateventhemostheterogeneoussubsidiary
thoughts,suddenideasorobservationswhichemerge
arearrangedinorderinthewholecontentof
consciousness.

37. •Constancy Derailment
Substitution
Omission
•OrganizationDrivelling
•ContinuityFusion

38. •SchneiderclaimsthatfivefeaturesFTDcouldbe
isolated.Viz.
•Derailment:Thoughtslidesontoasubsidiarythought.
•Substitution:Majorthoughtissubstitutedby
subsidiaryone.
•Omission:Senselessomissionofthoughtorpartofit.
•Drivelling:Disorderedintermixtureofconstituent
partsofonecomplexthought.
•Fusion:Heterogeneouselementsofthoughtare
interwovenwitheachother.

39. Constancy Derailment Transitory
Substitution
Omission
Organization Drivelling Drivelling
Continuity Fusion Desultory

40. Transitory thinking :
-Grammatical & syntactical structures are
both disturbed.
-Continuity is not loosened.
-Intention itself is affected.
Desultory thinking :
-Grammatically & syntactically correct
-Sudden ideas force their way time to time
-Each idea –simple & suitable thought.
. Driveling thinking:
-loses preliminary organization of thought so that
all the constituent parts get muddled together

41. 3 Symptoms groups in Schizophrenia
1.Desultory Group Affective blunting
Lack of drive
Somatic Hallucinations
Desultory thinking
2. Thought withdrawal group Transitory thinking
Thought withdrawal
Somatic Passivity
Religious & cosmic experince
Perplexity

42. Cont.
3. Drivelling Group Primary Delusional Exprinc
Loss of interest
Inadeq affective responses
Drivelling thinking.

43. Mania:CarlsonandGoodwin(1973)followed20
manicpatientsthroughanepisodeandnotedthat
100%showedpressureofspeech,75%showed
flightofideasand70%hadlooseassociations.
DubinandMartin(1977)reportedneologismina
manicpatientandpovertyofcontentofspeechin
another.

44. Depression:Incontrasttomania,studies
examiningthoughtdisordersindepressionare
few.Lewis(1934)examinedspeechpatternsof
61casesof"melancholia"andfound21patients
hadoverproductivespeech.Theoverallcontent
wascoherentalthoughtopicsmostlyrevolved
arounddepressivethemes.Distractibilitywas
alsoobservedinanumberofpatients.
AndreasenandGrove(1986)foundgreater
frequencyofpovertyofspeech,povertyof
contentofspeechandselfreferentialspeechin
theirsampleof36depressedpatients.

45. Delirium:Cutting(1987)studiedthought
disorderin74patientswhoshowedpsychosisin
thesettingofsomeclearlyidentifiedorganic
causeandcompareditwith74patientsofacute
schizophrenia.
Thoughtdisorderwaspresentin63%ofcases,
commontypesencounteredbeingillogicality
(20%),povertyofspeech(19%)and
tangentiality(8%).Fourpatientsshowed
circumstantialityandtwoshowedneologisms.
Thus,thoughtdisordersremainuncommonin
deliriumthoughtitmayshowoccasional
resemblancetoschizophrenicspeech.

46. Epilepsy:Changesinpersonalityinlong-
standingepilepsy,includingcircumstantialityand
slownessofthinking,hasbeendescribedby
Kraepelin(1923)andGruhle(1929).
Gastautandcolleagues(Gastautet
al,1953;Gastaut,1954)observedsimilarfeatures
inpatientswithtemporallobeepilepsy.
BearandFedio(1977)deviseda100-item
questionnairetovalidatetheepilepticpersonality.
Subsequentworksinthisfieldhavedemonstrated
circumstantialityandviscosityofthoughtin
epilepticpatients(HermanandRiel,1981;Bearet
al,1982)

47. Normalindividuals:SincetheworksofGruhle(1929),
Beringer(1924)andSchneider(1958),takinga
phenomenologicalapproach,emphasizedthenormality
ofseveralthoughtdisorders.Heproposedthat"thought
blocking"occurredfrequentlyinshyandembarrassed
peopleand"disjointed"or"fragmented"thinking
occurredtoalesserdegreeinnormalandinthosewho
were"scatter-brained"eitherinnormalcircumstances
orwhendrunk.

48. SCALE FOR ASSESSMENT OF FTD
Thought,languageandcommunicationscale(TLC)
(Andreasen,1979)
ThoughtDisorderIndex(TDI)(JohnstonandHolzman,
1979)
AssessmentofBizzare-idiosyncraticthinking(Harrow
andQuinlan,1985)
TheThoughtandLanguageIndex(TLI)(Liddleetal,
2002)
Whitakerindexofschizophrenicthinking(WIST)
(Whitaker,1973)
ImpairedCategoricalThinking:
IllogicalThinking:ImpairedSyllogisticReasoning(von
Domarus,1944)Objectsortingtests

49. Conclusion
ThoughtdisorderhascomealongwaysinceBleuler’s
disturbancesofassociation.Itspresenceacrossdiverse
psychiatricdisordershaspromptedresearchersinvarious
fieldstoexploreitsetiologyfromtheirownperspective.
However,noparticularcausehasbeenidentifiedalthough
severalresearcheshavebeencarriedoutinlastthree
decades.Scaleshavebeendevisedtobringuniversalityto
theconceptwhichwasriddledwithseveralconfusingand
overlappingterminologies.
Thoseexploringpsychosishaveproposedthatthe
languagespecializationofhumanracecamehandinhand
withpsychosis.Itremainstobe.

50. THANK YOU