DISORDERS OF THOUGHT AND SPEECH IN PSYCHOPATHOLOGY.pptx

THOUGHT AND SPEECH PSYCHOPATHOLOGY

1. DISORDERS OF THOUGHT AND SPEECH

2. INTELLIGENCE

3. If a person scores 75 percentile in intelligence tests it is such as that 75 percent of the appropriate population score less and 25 percent score more. In Intelligence tests, children gives99 score in terms of mental age in which score is achieved by average child of the corresponding chronological age. Intelligence tests usually gives the Mean IQ of the population of 100 with Standard Deviation of 15. lower range of score denotes lower intelligence denotes brain damage due to inherited disorders, birth trauma, infections.

4. There are two types of disability called ‘learning disability’ and ‘intellectual disability’. Learning disability in which the individual scores the lowest range of marks in normal average Intellectual disability Is a specific learning disability. BORDERLINE [IQ=70-90] MILD [IQ=50-69] MODERATE [IQ=35-49] SEVERE[ IQ=20-34] PROFOUND[ IQ>20]

5. Dementia is a loss of intelligence from brain disease. It is disturbances in cortical functions, thinking, memory, comprehension, orientation. In schizophrenia specific deficits in multiple cognitive domains[schizophrenic dementia] in the past. But it is not a true dementia simply the pathophysiology of the disease. DISORDERS OF THINKING 1]Undirected fantasy thinking 2]Imaginative thinking 3]Rational thinking/conceptual thinking The boundaries between thinking is very thin .

6. 887 UNDIRECTED FANTASY/AUTISTIC THINKING It is quite a lot more common in persons who faced disappointments in life or adverse life circumstances. BLEULER[1911]believed autistic thinking is prevalent in schizophrenia was partly a thought form disorder. Although delusions in chronic schizophrenia can be explained in this way,other forms of schizophrenia this is not helpful.

7. CLASSIFICATION OF DISORDERS OF THINKING

8. DISORDERS OF STREAM OF THOUGHT

9. FLIGHT OF IDEAS

10. FLIGHT OF IDEAS occurs in Mania Schizophrenia Lesions of hypothalamus Organic states. In flight of ideas, thoughts follow each other rapidly. There is no general direction of thinking. The patient’s speech is easily diverted by external stimuli. The absence of determining tendency to thinking allows train of thought to be determined by chances[clang associations,cliché,proverbs] etc IT IS TYPICAL IN MANIA. In acute mania,Patient talks so fast that the words become incoherent.

11. In hypomania, flight of ideas occurs in which after many irrelevant talks returns to task at hand. In this,Clang associations and verbal associations are not that marked. Unlike tedious elaboration of details in circumstantiality, these patients add some details to their speech just to make it interesting even though it is not necessarily true. CLANG ASSOCIATION is rhyming of words INHIBITION OR SLOWING OF THINKING The thought process is slowed down. The number of ideas, images present themselves is decreased. Patient experiences lack of concentration, loss of memory, decreased registration.

12. Patient develops a delusional idea that they are losing their mind. Sometimes in depression also slowing of thinking occurs. It may lead to a mistaken diagnosis of dementia. Slowing of thinking is found in both manic stupor and depression. CIRCUMSTANTIALITY It occurs when thinking proceeds slowly with many unnecessary and trivial details, but the point is finally reached. The goal of thinking is never completely lost. It occurs in obsessional personality traits,schizophrenia,schizoaffective disorder Also in epilepsy

13. Disorders in continuity of thinking PERSVERATION THOUGHT BLOCKING

14. PERSEVERATION It occurs when mental operations persist beyond the point at which they are relevant and thus prevent progress of thinking. It is mainly verbal or ideational. It is more common in generalised and local disorders of brain. In Alzheimer’s disease, perseveration is related to working memory deficits. Important to differentiate between verbal stereotypy and perseveration. In verbal stereotypy, the same word or phrase is used regardless of the situation,whreas in perseveration a word, phrase or idea persists beyond the point at which it is relevant.

15. THOUGHT BLOCKING THOUGHT BLOCKING occurs when there is a sudden arrest on the train of thought, leaving a blank. An entirely new thought may then begin. It can happen when a person is exhausted or anxious. When thought blocking is clearly present, it may be suggestive of schizophrenia . It can happen when a person is exhausted or anxious. When thought blocking is clearly present, it may be suggestive of schizophrenia.

16. OBSESSIONS,COMPULSIONS,DISORDERS OF POSSESSION OF THOUGHT

17. Normally one experience their thinking as their own but sometimes in psychiatric illnesses, there is a loss of control or sense of possession of thinking. OBSESSIONS AND COMPULSIONS An obsession is a thought that persists and dominates an individuals thinking, despite the individual’s awareness that the thoughts is entirely without purpose or else dominated their thought process beyond the period of relevance. One of the most important feature of obsession is anxiety and guilt. The feature of obsession is that appears against patient’s will.

18. Normally under control, obsession can be resisted by the individual. It can be obsessional images, idea, fear, impulse. Sometimes images are so vivid that they can be mistaken as pseudo hallucinations. Obsessional impulses such as impulse to touch ,count or arrange objects, impulse to commit antisocial acts. There is also an obsession of suicide/death in depressed patients. Occurs in obsessional states such as depression,schzizophrenia,organic states,post encephalitic parkinsonism.

19. In OCD patients,15 percent of the people have psychotic phenomena such as delusions, hallucinations or thought disorder.[DOWLING 1995,EISEN AND RASMUSSEN 1993] These psychotic symptoms affect the patient’s thinking about the obsessions and compulsions hence these will have an affect on CBT.[ kozak and foa,1994] It is important to distinguish between obsession and compulsions. Compulsions are merely obsessional motor acts. They result from obsessional impulse that leads to action or mediated by obsessional thought or mental image such as obsessional fear of contamination leads to compulsive washing.

20. THOUGHT ALIENATION

21. Patient has the experience that their thoughts are under the control of outside agency,others are participating in their thinking. PURE THOUGHT INSERTION: Thoughts are inserted into their mind, the patient recognize it as foreign and coming from without. This symptom is associated with schizophrenia and related phenomena.[ mullins and spence 2003] THOUGHT DEPRIVATION Thoughts suddenly disappear withdrawn from their mind by foreign influence. It is the subjective experience of thought blocking and omission. THOUGHT BROADCASTING Patient knows that what they are thinking, everyone is thinking in unison with them.[fish]

22. One’s thought is escaping from their mind and other people can access them and hear them.[ Pawar and Spence 2003] Patients can also describe other variants of different experiences and we can note it down by their own words. Thought alienation is a important component of the diagnostic criteria for schizophrenia in ICD 10. Thought alienation is ego dystonic. EGO SYNTONICITY AND DYSTONICITY EGO SYNTONICITY- the goals of the person or needs are consistent with the person’s self image EGO DYSTONICITY: response and behaviour against the person’s beliefs and will and it is distressing

23. DISORDERS IN CONTENT OF THINKING

24. DELUSION is a false unshakeable belief that it is out of keeping with patient’s social and cultural background. Common delusion is the patient thinks that their spouse is unfaithful. In some cases, it really could be true making it as true delusions. But it is coincidental. TRUE DELUSIONS It is a result of primary delusional experience, no morbid phenomena Secondary delusions occur secondary to some morbid psychological phenomena.

25. The idea takes precedence over all other ideas sometimes for longer periods of time also. It is usually less fixed than delusion. It is difficult to know when an overvalued idea turns into an delusion. Delusions and overvalued ideas can be distinguished. Delusions are abrupt in onset. They are implausible, has indifferences to the opinions of others[MULLEN AND LINSCOTT 2010] Overvalued ideas

26. PRIMARY DELUSIONS

27. BEFORE primary delusions are diagnostic of schizophrenia now it also includes other conditions. Primary delusions/apophony Schneider described delusional mood, delusional perception, sudden delusional ideas. Delusional mood Patient has a knowledge that something is going on, but they don’t know what it is. The meaning of this mood becomes obvious when a sudden delusional idea or perception occurs. In sudden delusional idea, delusion appears fully formed in patient’s mind. It is called autochthonous delusion. It also occur in depressive disorders or personality disorders. In sudden grandiose or bizarre ideas the diagnosis of schizophrenia is made.

28. SEONDARY DELUSIONS

29. SECONDARY DELUSIONS Can be understood as arising from morbid experience. Excessive projection occurs in delusions. Especially delusion of persecution. Role of projection occurs in delusions but it can occur in non psychotic persons too. Sigmund Freud for an example, tried to explain delusions of persecution and grandeur as the result of latent homosexuality. Delusions can be secondary to depression,hallucinations . Abnormally suspicious personalities tend to develop delusion of persecution or slowly may develop delusion of infidelity or ill health. This can happen in abnormal personality traits or the background of a personality disorder.

30. Certain paranoid psychosis develop from sensitive personalities. Full blown psychosis develops from a stressful event. Sensitiver Beziehungswahn is now classified as delusional disorder in ICD 10. Some delusions are need to be elaborated. It is called ‘delusional work’ Some practiontioners divide delusions into systematized and non systematised. Systematized delusion is one basic delusion and rest is built on this logical error. It is more common in older patients and in persistent delusions .

31. CONTENT OF DELUSION DELUSION OF PERSECUTION DELUSION OF INFIDELITY DELUSION OF LOVE GRANDIOSE DELUSIONS DELUSION OF ILL HEALTH DELUSION OF GUILT NIHILISTIC DELUSIONS DELUSIONS OF POVERTY.

32. IN DELUSION OF PERSECUTION/REFERENCE, patient knows that people are talking about him, slandering him, spying on him. It is difficult to differentiate between delusion of reference and self- referential hallucinations. It occurs in schizophrenia,depression,psychosis. Delusion of guilt also can happen while patient believes they are extremely wicked or should be put to death or imprisoned. Some patients justify the delusions while some do not and say depression is the reason. It also depends upon the environment. Some patients believe that their loved ones can be harmed in some way.. Some believe that they are robbed of their inheritance. Delusions about being poisoned by their spouse assuming that they mix it in food. It can happen secondary to hallucinations of smell and taste.

33. Delusions of influence are a logical result of passivity in the context of schizophrenia. These passivity feelings may be explained by the patient as result of hypnotism, demonical possession, television etc. DELUSIONS OF INFIDELITY Patients have morbid jealousy. DELUSIONS of infidelity seen in organic states, functional disorders, schizophrenia,Alcohol dependence syndrome. The persons are already suspicious, jealous even before the onset of the illness. Suspicious or insecure person who is convinced of spouse’s infidelity. This becomes an overvalued idea which later turns to delusion. The episodes often fluctuate in intensity. Episodes of marital disturbance present.

34. Husband might insist that wife is having an affair just after seeing her eye bags. This is dangerous since it can escalate to violence and then even to murder. DELUSIONS OF LOVE: ‘Fantasy lover syndrome’ or ‘Erotomania ’ A person is convinced that some person is in love with them even though they might have never spoken with them before.[Munro 1999,Kelly (2005,2018] Usually it can be with famous people. They might write them letters or stalk them and pester them. They might take everything they do as sending them personal messages. Isolated delusion of love also occurs in abnormal personality states. Schizophrenia might develop with delusion of love which later can escalate to hallucinations.

35. EROTOMANIA

36. GRANDIOSE DELUSIONS Some believe that they are god,queen of England,Rockstar,sportspersons etc. these delusions are supported by auditory hallucinations. The voices tells the patient that they are important. Delusions of grandeur previously associated with general paralysis of the insane[neurosyphilis] now associated with manic psychosis in BPD.[Knowles 2011] Patient might even report to have been hearing voices from god.

37. GRANDIOSE DELUSIONS

38. DELUSIONS OF ILL HEALTH Seen in schizophrenia, depressive illness. Worries about health gradually escalate to overvalued idea to delusion of ill health. They believe that they have AIDS, TB, cancer, brain tumour etc. Delusion of ill health sometimes involves spouse and children too. Many depressed women believe that their children have learning disabilities. It could be primary, secondary delusions of incurable insanity. Some women might believe they inherited some disease to their children and try to kill her babies mistakenly believing it as mercy.

39. HYPOCHONDRIACAL DELUSION It occurs in somatic hallucinations which occurs in chronic schizophrenia or depressive mood. Insecure individuals develop overvalued idea which can develop into delusion. It also can be apparent after operation or complication of a drug therapy. Sometimes people have delusional thinking that their body is disfigured. It is called body- dysmorphophobia[WHO,1992] Or body dy9smorphic disorder.[American Psychiatric Society,2013,Oyebode.]

40. DELUSIONS OF POVERTY Believing that the person is bad and they committed a sin and they are going to hell for that. In severe depression, delusions get grandiose. the patient reports that they are the most evil person existed. Delusion of guilt is often associated with delusion of persecution.

41. NIHILISTIC DELUSION

42. In this delusion, patient denies the existence of body, mind, loved ones, world around them. They believe they themselves are dead. The world has stopped or everyone else is dead. It also happens in schizophrenia, delirium, depression. Sometimes associated with delusions of enormity. Patient feels like they can bring about an catastrophe of some kind. For an example, if they urinate, they might flood the world. DELUSIONS OF POVERTY In this, patient believes that they are living in impoverished conditions. It happens more in depression. It is less common in general.

43. THE REALITY OF DELUSIONS Not all people with delusions act on their delusional beliefs. Hypochondriacal delusions might even lead to suicide. patients with delusions of guilt might go to police. Patients with delusions of infidelity might resort to violence or even murder. Patients with delusions of grandiosity believes that they are god but might get admitted to psychiatric hospital as a patient. Patients with delusions of persecution believes that their food is poisoned but happily eat the hospital food.

44. PATHOPHYSIOLOGY OF UNDERLYING DELUSIONS To find out developing models of the cognitive underpinnings of delusional beliefs Using neuroimaging techniques to identify brain areas involved in developing and maintaining delusions Delusional individuals tend to change their mind quickly makes guesses quickly with less evidence compared to patients without delusions. In neuroimaging associations between abnormalities of cingulate gyrus activation and persecutory delusions. To work with both cognitive and neuroimaging approach might shed a light on the various pathologies that underlie delusions.[Thoreson,2014]

45. DISORDERS OF FORM OF THINKING Formal thought disorder in which the individual have disorders of conceptual or abstract thinking. Present in schizophrenia it is present along with cognitive deficits.[Sharma and Antonova,2003] Bleuler[1911] regarded schizophrenia as disorder of associations between thoughts, characterized by process of condensation ,displacement and misuse of symbols. Cameron[1944] used the term Asyndesis to describe lack of connections between two thoughts. Goldstein[1944] emphasized loss of abstract attitude which leads to concrete style of thinking. They don’t lose their vocabulary like patients of organic brain disorders.

46. SCHNEIDER[1930] claimed five features of formal thought disorder. Derailment, substitution, omission, fusion, driveling. There are three features of healthy thinking, 1]Constancy- completed thought doesn’t change in content unless it is followed by another thought. 2]Organization-thoughts are connected with one another. Do not blend in with each other. Separated in organized way. 3]Continuity-thoughts are continuous, even the sudden ideas, observations are arranged in order in the whole content of consciousness. Schneider complained three disorders of thinking. 1]Transitory thinking 2] Drivelling thinking 3]Desultory thinking

47. TRANSITORY THINKING Derailments, substitutes, omission. The intension is interrupted and there is a gap. Grammar and syntactical structural disturbance is present. DRIVELLING THINKING Patient has a outline of complicated thought, but loses organization of thought, everything gets muddled together.it gets obscured and changed in its significance. DESULTATORY THINKING speech is grammatically correct but suddenly ideas force into it from time to time. But if used at right time these ideas are quite appropriate. Genetic influenze on schizophrenia in formal thought disorder. Decreased cortical volume of left superior temporal gyrus,reversed hemisphere[right than left] activation during speech production. These neurobiological changes are important in schizophrenia

48. SPEECH DISORDERS STAMMERING AND STUTTERING MUTISM TALKING PAST THE POINT NEOLOGISMS SCHIZOPHASIA APHASIA

49. Stammering and stuttering: In stammering, normal flow of speech is interrupted by pauses or by repetition of a fragments of word.it is often accompanied by grimacing and tic like movements in body seen. It starts in four years of age. Sometimes can gradually disappear. More common in boys than girls. The stuttering is increased when the person is anxious. It can persists in adult life leading to a social disability. MUTISM: It is a complete loss of speech. Can happen in children with associated psychiatric disorders or in adults with depression ,hysteria, organic brain diseases etc.

50. ELECTIVE MUTISM: in children where for an example, the child speaks freely at home but doesn’t utter a word in school. HYSTERICAL MUTISM: hysterical disorder of speech, in aphonia. In severe depression with retardation of psychomotor activity, mutism and poverty of speech is present. CATATONIC STUPOR mutism is present. Patient might think their words are too valuable to be uttered. And can remain mute for years altogether. They can communicate via gestures or answer questions via writing. In SEVERE MOTOR APHASIA, words are restricted, complete mutism does not occur. In PURE WORD DUMBNESS, patient is mute, but can read and write. AKINETIC MUTISM happens in case of upper midbrain lesions or post diencephalon.

51. TALKING PAST THE POINT[VORBEIREDEN] It occurs in hysterical pseudodementia. Now it is termed as dissociative disorder/conversion disorder. Found in acute schizophrenia among adolescents, especially, hebephrenic type. In catatonic states also, the patients might talk past the point. usually this can occur in acute onset of schizophrenia also.

52. NEOLOGISM NEOLOGISMS New words are constructed by the patient or ordinary words are used in new way. Found in schizophrenia. Motor aphasia, use of wrong words or invent new words or distort the phonetic structure it is called paraphasia. But it resembles neologism. For an example, instead of saying airplane, patient might include car and say air car. Or boat as sea car etc. Sometimes thoughts blend together. Ex: patient uses relativity instead of relationships. TECHNICAL NEOLOGISM: patient uses completely new words.

53. SPEECH CONFUSIONS AND SCHIZOPHASIA In schizophrenia patients produce speech which is profoundly confused. Schizophasia has superficial resemblance to aphasia. in aphasia The disorder of speech is much greater than deficit in intelligence. Schizophasia, there happens speech confusion also called ‘word salad’ Schizophasia is a form of thought disorder. Poor linguistic performance appears to be mor related to the illness process rather than the effects of institutionalization.[Thomas et.al.1990] this warrants more study into this topic.

54. APHASIA: Aphasia or dysphasia is a disorder of speech from interference with functioning of certain areas of brain. Aphasias more likely to have organic origin. Receptive aphasia, intermediate aphasia, expressive aphasias. RECEPTIVE APHASIA/WERNICKE’S APHASIA: 1]PURE WORD DEAFNESS- In this patient hears words, but cannot understand them. It is attributable to lesion in dominant temporal lobe. 2]AGNOSTIC ALEXIA- in this patient cannot read words but can see them. It is due to lesions of left visual cortex and corpus callosum. 3]VISUAL ASYMBOLIA/cortical visual aphasia- there is disorganization of visual words. Due to lesions in angular and supramarginal gyri. They find it difficult to read or write. Depending upon the extension of lesion, it can affect neighbouring structures too.

55. It can cause neurological disorders such as acalculia, spatial disorientation, visual agnosia, nominal aphasia, etc. In agnostic alexia, they can copy the writing but cannot write spontaneously. In visual asymbolia, they are able to understand words if read out aloud or they read it out loud incorrectly also. Also in visual agnosia, they can feel the objects and recognise them. They can neither describe or use the object so there is both apraxia[loss of ability to carry out skilled movements and gestures] and aphasia. These conditions can be mistaken as dissociative or conversion disorder when occurs in isolation. INTERMEDIATE APHASIA IN NOMINAL APHASIA, patient cannot name the objects, although they have plenty words in disposal. They find it difficult to carry out verbal and written commands, cannot write spontaneously. But can copy the writing.

56. Nominal aphasias are found in diffuse brain damage, or with focal brain lesions involving dominant temporoparietal region. CONDUCTION APHASIA Disturbances in language function and impairments of speech and writing. Speech is faulty in grammar and syntax there is paraphasia. Both receptive speech and expressive aspects are affected. EXPRESSIVE APHASIA Cortical motor aphasia, also known as Broca's aphasia, verbal aphasia, expressive aphasia. Caused by the lesions of Broca's area and also lesions affecting association fibres running towards speech centre. Patient has difficulty putting thoughts into words. Severe cases, speech is restricted. Patient might use one word, phrase or yes or no question. Often there is recurring utterances or verbal stereotypies are produced with different intonations to produce different meanings.

57. If the lesion is less severe, patient understands the words, but finds difficult to get the words out. Words are mispronounced and abbreviated. WORDS ARE OMITTED. It is called TELEGRAM STYLE OF SPEECH. Serial responses are intact hence patient can count the days of the week etc. In pure word dumbness, patient is unable to speak spontaneously, repeat words or read out loud. But they can write spontaneously, to repeat words and to copy and write without dictation. This is probably due to the lesion beneath the region of the insula.

58. THANK YOU REFERENCE: FISH’S PSYCHOPATHOLOGY CHAPTER 4: DISORDERS OF THOUGHT AND SPEECH.