Disorders of Thought 1.pptx in psychiatry

Nmcth birgunj nepal

1. DISORDERS OF THOUGHT Dr. Ruchi Mittal 1 ST Year Resident, Department of Psychiatry NMCTH- Birgunj

2. Introduction of Thought Any idea or opinion produced by thinking or, Process of thinking or An idea occurring suddenly in mind

3. DISORDERS OF THOUGHT DISORDERS OF INTELLIGENCE DISORDERS OF THINKING A)Disorders of STREAM of thought B) Obsessions, Compulsions & Disorders of the POSSESSION of thought C) Disorders of the CONTENT of thought D) Disorders of the FORM of thought

4. DISORDERS OF INTELLIGENCE Intelligence is the ability to think and act rationally and logically Does not continue to develop after 15yrs age IQ=100*MA/CA Mental age=score achieved by an average child of the corresponding chronological age A slow decline in intelligence can be detected for the first time at about 35yrs of age Most intelligence tests are designed to give a mean IQ of the population of 100 with a standard deviation of 15 as the arbitrary divisor.

5. LEARNING / INTELLECTUAL  DISABILITY Two groups of subjects with low intelligence are- 1)Sub cultural mental defect -Individuals whose intelligence is at the lowest end of normal range and is therefore a quantitative deviation from the normal 2)with learning disability comprise individuals with specific learning disabilities Learning disability is categorised as – Borderline IQ=70-90 Mild - 50-69 Moderate- 35-49 Severe - 20-34 Profound - <20

6. Dementia is   loss of intelligence resulting from brain disease characterised by disturbances of multiple cortical functions including - Thinking - Memory - Comprehension - Orientation Schizophrenic deterioration - Individuals with schizophrenia tend to exhibit specific deficits in multiple cognitive domains. It do not represent true dementia, (past termed as schizophrenic dementia ) Amentia - was synonym for mental sub normality

7. DISORDERS OF THINKING TYPES OF THINKING- 1) Undirected Fantasy Thinking - which in the past was also termed Autistic/ Dereistic thinking Allows the person to deny reality (escape from reality, short duration eg - day dream) 2) Imaginative thinking – which does not go beyond the rational possible (creative, artists) 3) Rational thinking /Conceptual thinking – which attempts to solve a problem,(scientist)

8. UNDIRECTED FANTASY/AUTISTIC THINKING It is Quite Common But certain individuals when faced with repeated disappointments or adverse life circumstances may engage in EXCESSIVE Undirected fantasy thinking It is a feature of schizophrenia- Bleuler included it as one of his 4 “A”s of his schizophrenia The excessive autistic thinking in schizophrenia is partly the result of FTD

9. DISORDERS OF STREAM  OF THOUGHT Disorders of TEMPO 1) Flight of Ideas 2) Inhibition or slowing of thinking 3) Circumstantiality Disorders of Continuity of thinking 1)Perseveration 2)Thought Blocking

10. 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. Connections between successive thoughts appear to be due to chance factors. Absence of Determining Tendency to thinking allows the association of the train of thought to be determined by chance relationships, verbal associations of all kinds (such as assonance(repeats vowel sounds ), alliteration(repeat consonant sounds), etc., Clang associations, proverb, maxims, cliches.

11. Example- A  maniac patient was asked where she lived, and she replied Birmingham, Kingstanding , see the king, he’s standing, king, king, sing, sing, bird on the wing, bird, turd, turd. Seen in - MANIA - typically Schizophrenia- when they are excited (occasional) Organic states – 1) Intoxication 2) Lesions of the hypothalamus , which are associated with a range of psychological effects, including features of mania & disturbances of personality In Acute mania - these are so severe that incoherence occurs because one thought is formulated into words other forces its way forward

12. CLANG ASSOCIATIONS- A pattern of speech in which sounds rather than meaningful relationships appear to govern word choice so that intelligibility of speech is impaired and redundant(not useful) words are introduced. - S ome believe clang associations have rhyming as well as alliterations

13. PROLIXITY In HYPOMANIA  –so called “Ordered Flight of ideas” occurs in which, despite many irrelevances ,patient is able to return to the task in hand. Here clang & verbal associations are not marked Speed of emergence of thoughts is not as fast as in flight of ideas Although these patients cannot keep accessory thoughts out of main stream they only lose the thread for a few moments and finally reach their goal Patient have Lively embellishment of their thinking (untrue detail is added to make story interesting ).

14. INHIBITION /SLOWING/ RETARDATION OF  THINKING Train of thought is slowed down & the number of ideas and mental images that present themselves is decreased. Person may fail to reach the goal Experienced by pt as – - 1)Difficulty in making decisions -2)Lack of concentration - 3)Loss of clarity of thinking  Loss of memory  May lead to the development of overvalued/delusional idea that thoughts are going out of his mind Seen in DEPRESSION & MANIC STUPOR(rare ) Apparent cognitive defects in slowing thinking in depression may lead to a mistaken diagnosis of dementia

15. CIRCUMSTANTIALITY It occurs  when thinking proceeds slowly with unnecessary and trivial details, but finally the point is reached The goal is never lost but the thinking proceeds towards it by an intricate and convoluted path Explained as a result of the weakness of judgment and egocentricity 1. Epileptic personality change 2. Dullards who are trying to be impressive 3. Pedantic obsessional personalities  Tedious elaboration and need to interrupt. Tangentiality –replying to questions in an oblique /tangential/ Irrelevant manner.

16. DISORDER OF CONTINUITY OF THINKING 1)Perseveration 2)Thought Blocking

17. PERSEVERATION Perseveration occurs  when the mental operations persist beyond the point at which they are relevant and thus prevent the progress of thinking. It may be mainly verbal or ideational Eg - Pt may be asked the name of the previous prime minister he replies K.P. Oli. On being asked who’s the current one he replies –K.P. Oli .no I mean K.P. Oli. Seen in organic disorders of the brain, catatonia. V erbal stereotypy -frequent spontaneous repetition of a word or phrase that is not in a way related to the current situation .

18. ECHOLALIA - a pattern  of speech in which the pt echoes words or phrases of the interviewer It is often uttered with mocking and mumbling though there is no such intention in true echolalia Both perseveration and echolalia have – 1)Repetition as their core feature (one own word or another word) 2) Both found in similar conditions – a )Organic states b )Schizophrenia& mania (very rare ) Palilalia - (automatic repetition of owns own words) pt repeats the perseverated word with increasing frequency Logoclonia –the last syllable of the last word is repeated Palilala & Logoclonia- occur in organic states, especially Alzheimers

19. THOUGHT BLOCKING(SNAPPING OFF) Occurs when there is a sudden arrest of the train of thought leaving a blank. An entirely new thought may then begin. In patients who have some insight this may be a terrifying experience Highly suggestive of schizophrenia Also seen in pts who are exhausted and anxious may lose the thread of conversation and appear to have thought blocking.

20. OBSESSIONS, COMPULSIONS& DISORDERS OF POSSESSION OF THOUGHT 1)OBSESSIONS & COMPULSIONS 2)THOUGHT ALIENATION - Thought Insertion -Thought With drawl - Thought Broadcasting

21. OBSESSIONS A 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. Unpleasantly Repetitive, intrusive, ego-dystonic, against person’s will Leads to cause the sufferer great anxiety and even guilt. E.g - A prudish person is tormented by Sexual thought Religious person-Blasphemous thought Timid person-Torture/murder Nowadays most common form of obsession –a mother with an obsession that she may harm the baby(concerns of fears of doing harm)

22. FORMS OF OBSESSIONS 1) Obsessional Images -these are vivid images that occupy the patient’s mind. At times they may be so vivid they can be mistaken for pseudo hallucinations. Eg – pt was obsessed with 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(sex)with god. 3) Contrast Thinking -in which the pt is compelled to think the opposite of what is said Eg -Compulsive Blasphemy-case of devout pt who was compelled blasphemous rhymes so that when the priest says –God Almighty, he was compelled to think-Sod Allshitey

23. 4) Obsessional impulses- may be impulses to touch, count, arrange objects or impulses to commit antisocial acts Impulse in mind acted again &again Compulsion 5) Obsessional fears or phobias -consist of groundless fear that the patient realizes is dominating without a cause, must be distinguished from hysterical and learned phobias

24. COMPULSIONS Merely Obsessional motor acts . May result from 1)an obsessional impulse that leads directly to the action i.e compulsions occur without obsessions as well 2)they may be mediated by an obsessional mental image or thought E.g - obsessional fear of contamination leads to compulsive washing . Obsessional thought compulsive act = relief ...... temporary

25. Obsessions occur  in:- -Depression - Obsessional states - Schizophrenia -Occasionally in organic states -Post-encephalitic states Compulsive features appear to be particularly common in Post-encephalitic parkinsonism

26. THOUGHT ALIENATION Here  the pt has experience that their thoughts are under the control of outside agency or others are participating in their thinking 1) Thought Insertion- common in Schizophrenia though not unique. here pt knows the thoughts are being inserted into their mind and they recognise as foreign. 2) Thought Deprivation -thoughts suddenly disappear and are withdrawn from their mind by a foreign Influence. it is subjective experience of thought blocking & omission

27. 3) Thought Broadcasting- pt knows that as they are thinking , everyone else is thinking in unison with them. Fish (Hamilton, 1974). Pawar and Spence(2003)-a belief that one’s thoughts are quietly escaping from one’s mind and others are able to access, hearing one’s thought spoken aloud and that other can hear it Psychoanalytic Interpretation- LOSS OF EGO BOUNDARIES i.e. boundary between ego and the surrounding world has broken down. Nowadays thought alienation forms an important component of diagnostic criteria for schizophrenia in ICD-10

28. DISORDERS OF THE  FORM OF THINKING Form of thought mean- arrangement of thoughts . i.e how logically they are connected ( syndesis ) Formal Thought Disorder-disorder of organizing, conceptual or abstract thinking - difficulty in concept formation -loss of goal directedness -neologism -incoherence -poverty of speech and content -loss of abstract more common in schizophrenia and coarse brain disease

29. Bleuler- regarded  schizophrenia as a disorder (lack)of associations between thoughts, characterized by process of condensation, displacement, and misuse of symbols 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 - whenever a proverb or abstract thinking is given to a PT. HE MISUSES IT AN GIVES DIFFERENT MEANING ( Concrete thinking) E.g.- pt with schizophrenia said – ‘I was feeling high and I do not want to fly off so I have tied these dumbells to my ankle’.

30. Cameron- grouped the symptoms of disorganization resulting from functional or organic states into Inco-ordination=causes complete incoherent speech and pt. wont be able to convey anything. Interpretation Fragmentation Over inclusion-an inability to maintain the boundaries of the problem and to restrict operations within their normal limits Asyndesis -lack of adequate connections between successive thoughts Metonyms-the imprecise approximations in which the pt uses some substitute term or phrase instead of a more exact one

31. Goldstein –in schizophrenia and in coarse brain disease there is loss of abstract attitude so that the thinking becomes concrete. In the former the pt has not lost their vocabulary . Chapman –the schizophrenic cannot free himself from the major meaning of the word Payne - ‘tests of concrete thinking which are performed badly by schizophrenics with FTD are in fact tests of over inclusion. Schizophrenics who showed over inclusion showed more psychomotor slowness

32. Schneider isolated 5 features of FTD 1) Derailment - thought slides on to subsidiary thought 2) Substitution -a major thought is substituted by a subsidiary one 3) Omission -the senseless omission of thought or part of it 4) Fusion -heterogeneous elements of though are interwoven with each other 5) Drivelling -there is disordered intermixture of constituent parts of one complex thought.

33. Schneider-3 features  of healthy thinking Constancy –characteristic persistence of a completed thought whether or not it is simple or complicated in its content. Organisation -contents of thought are related to each other in consciousness and do not blend with each other but are separated in an organised way Continuity –even the most heterogeneous thoughts ,sudden ideas or observation which emerge are arranged in order in the whole content of consciousness

34. Transitory thinking-   problem of constancy - derailment, substitution,omissions occur. Both grammatical and syntactical structures are disturbed Drivelling thinking -problem of organisation Pt loses his preliminary organisation of thought so that all the constituent parts gets muddled up. Desultory thinking -problem of continuity - grammatical and syntactically correct but sudden ideas force their way in from time to time - Here continuity is loosened - In omission –intention itself is interrupted & there is gap

35. REFERENCES  FISH’S clinical  psychopathology- 4 TH edition (Page no-42-56)