Disorders Stream of Thought

Disorders of Thought.
Includes Disorders of Stream, Content, Possession and Form.

1. DISORDERS OF STREAM OF THOUGHT B y : Syed Sajid Husain Kazmi Clinical Psychologist & Director Indian Mental Hea lth & Research Centre, Lucknow www.imhrc.org

2. Do Not Read If already read, then do not think.. If already thinking…….then don’t think about an ice-cream.

3. Thinking: Thinking is the base of all cognitive activities or processes and is unique to human beings. It is a higher mental process which involves manipulation and analysis of information received from the environment which occurs by means of abstracting, reasoning, imagining, problem solving, judging, and decision-making .

4. For example , while seeing a painting, you are not simply focusing on the colour of the painting or the lines and strokes, rather you are going beyond the given text in interpreting its meaning and you are trying to relate the information to your existing knowledge. Understanding of the painting involves creation of new meaning that is added to your knowledge.

5. Definition Thinking consists of cognitive rearrangement or manipulation of both information from the environment and the symbols stored in long term memory. It is the form of information processing that goes on during the period between a stimulus event and response to it. (Morgan et al, 1993)

6. Types of thinking The process of thinking was divided by F. Fish (1967) into the following three types: 1. Fantasy Thinking - Dereistic - Autistic Thinking 2. Imaginative Thinking 3. Rational or Conceptual Thinking.

7. Fantasy Thinking Fantasy is usually understood to be the creation of images or ideas that have no external reality. This may be of short duration/for example the daydream before going to sleep, or it may become an established way of life. Fantasy thinking denies unpleasant reality, even though the fantasy itself may also be unpleasant. This rearranging or transformation of reality is shown by neurotic patients habitually and all people occasionally.

8. Imaginative Thinking Imaginative thinking refers to the generation of novel ideas and the creative outputs that constitute art or discoveries in science. Three components of imagination (Roth, 2004) : 1) Mental imagery 2) Counterfactual thinking 3) Symbolic representation

9. Maternal reverie ( Bion , 1962) The mother, while in the situation of holding the baby, both physical and mental, ( Winnicott , 1957), has a capacity for reverie or daydreaming on the baby's behalf; this usually concerns the future happiness and achievements of the baby. Bion , regards this as a necessary factor in the healthy development of the 'self-sensation of the baby; when maternal reverie ‘breaks down, for example in puerperal depression, the baby experiences this as distress. The process of maternal reverie is clearly analogous in some ways to the prayers of a religious person on another's behalf.

10. Rational or Conceptual Thinking Rational thinking attempts to solve a problem and has two key aspects: 1. Problem solving: The set of cognitive processes that we apply to reach a goal while overcoming obstacles to reach that goal. 2. Reasoning: The cognitive process that we use to make inferences from knowledge and to draw conclusions. These aspects of thinking are distinct but related, so that reasoning can be involved in problem solving (Smith and Kosslyn , 2007).

11. Reasoning involves: Analogies I nduction or deduction . Analogic Reasoning involves the application of solutions to already known problems to new problems with similar characteristics. For example , if you loose the keys to your locked briefcase, you can apply the previously acquired knowledge that sharp ended implements can be used to open padlocks to this new problem.

12. Inductive Reasoning: Use of specific known instances to draw an inference about unknown instances. Also known as generalizing from a single instance to all instances . Example - my cat has four legs', therefore 'all cats have four legs'.

13. Deductive Reasoning : It involves an argument in which if the premises are true, the conclusion cannot be false. This is usually studied by way of syllogism. Example: (a) all Martians are green, (b) my father is a Martian (c) my father is green.

14. Features of healthy thinking Constancy: Thought content is persistence, simple or complicated Organization : Contents are related, do not blend Continuity: The whole content is arranged and continuous

15. Model of Associations: Jaspers The whole idea is that “a concept or a psychological event, that results in the formation of a number of other concepts, one of which is given prominence by operation of the determining tendency.” As per this model of thinking i.e. psychological performance, thoughts (psychological events) flow in an uninterrupted sequence so that one or more associations, with resulting further psychological events, may arise from each thought.

16. The cluster of associations is called a constellation. There are an enormous number of possible associations, but thinking usually proceeds in a definite direction for various immediate and compelling reasons. This consistent flow of thinking towards its goal is ascribed to the determining tendency. (Jaspers).

17. Thought Possible Thought Actual Thought Possible Thought Possible Thought Possible Thought Possible Thought Possible Thought Actual Thought Determining Tendency Goal Constellation Associations Associations Model of Association

18. Thinks as he sits in a room Must talk to A I feel cold Uncomfortable chair Sort out Accounts There is draught I am developing Flu Put on a pullover I can hear a Drip in the roof Get a ladder And take a bucket Constellation Associations Associations Model of Association

19. Disorder of Thought Disorder of thought refers to the disturbance in the processing , organization and relevance of thoughts manifested as illogical, bizarre, unorganized and irrelevant language or communication. Frank Fish, the first professor for Psychiatry at the University of Liverpool, in 1967, classified disorder of thought into:

20. Disorders of Thought Stream Content Possession Form Disorder of Tempo Disorder of Continuity Flight of Ideas Inhibition or Retardation of Thinking Circumstantiality Perseveration Thought Blocking

21. Disorder of Stream: It has two main categories: Disorder of Tempo Disorder of Continuity Disorder of Tempo is further divide into: Flight of Ideas Retardation of Thinking Circumstantialities Disorder of Continuity is divided into: Perseveration Thought Blocking

22. Disorder of Tempo

23. i ) Flight of Ideas Thoughts follow each other rapidly There is no general direction of thinking Connections between successive thoughts appear to be due to chance factors which, however, can usually be understood. Absence of a determining tendency Associations of the train of thought is determined by chance relationships. Verbal associations of all kinds such as: assonance, alliteration, clang associations, proverbs, maxims and clichés.

24. Abnormal flow of thinking: Flight of ideas (SIMS) X X X X X

25. Example of flight of ideas: 1) From a manic patient who was asked where she lived and she replied: ‘Birmingham, King standing; see the king he’s standing, king, king, sing, sing, bird on the wing, wing, wing on the bird, bird, turd , turd . 2) The respondent was asked about his future job prospects- esjs Hkfo "; esa lcls igyh bPNk gS fd eSa dEI;wVj bathfu;j cuuk pkgrk gw ¡ tc eSa dEI;wVj bathfu;j cu tkmaxk rks tks esjh ru [ kk feysxh mlls eSa lhvkbMh dh i <+ kbZ d#axk tc eSa lhvkMh cu tkmaxk rc eSa cM+s fØfeuyl dks idM+qaxk vkSj vius ns'k dks Lo{k cukmaxk eSa vius ns'k is tku Hkh ns ldrk gw ¡ vxj eSa tku ns nwaxk rks ' khgn dgykmaxk vkSj tc eSa vehj cu tkmaxk rks lcls igys bPNk gS fd vius xkao esa tks efLtn VwV xbZ gS mls cukokmaxk vkSj vius [ ksr ds fy , Hkh dqN d#axk ] eq >s ,d gh ckr ; kn jgrk gS fd Honesty is the best policy­ bekunkjh ,d lPph furh gS eSa vius Hkfo "; esa vPNk O;fDr cuuk pkgrk gw ¡¡ tgka rd esjh rkdr gksxh ogka rd d#axk vkSj ftanxh Hkj vius ek ¡ cki dh lsok d#axk ] vius HkkbZ cgu ds lkFk eksgCcr ls jgw¡xk vkSj lHkh ls eksgCcriwoZd thuk pkgrk gw¡A

26. Flight of ideas is typical of mania. 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. In hypomania, ‘ordered flight of ideas’ occurs in which, despite many irrelevances, the patient is able to return to the task in hand. In this condition clang and verbal associations are not so marked and the speed of emergence of thoughts is not as fast as in flight of ideas, so that this marginal variety of flight of ideas has been called ‘ prolixity .

27. Flight of ideas occasionally occurs in: Individuals with schizophrenia when they are excited. Individuals with organic states, including, for example, lesions of the hypothalamus, which are associated with a range of psychological effects, including features of mania and disturbances of personality. * It has been claimed that flight of ideas without pressure of speech occurs in some mixed affective states. (Casey& Kelly, 2007)

28. Clanging A pattern of speech in which sounds rather than meaningful relationships appear to govern word choice. The speech becomes impaired and redundant words are introduced in addition to rhyming relationships, so that a word similar in sound brings in a new thought ( Andreason , 1986 ). In echolalia , the patient repeats a sentence just uttered by the examiner. Repetition of only the last uttered word or phrase is called palilalia .

29. Alliteration It is a literary or rhetorical stylistic device that consists in repeating the same consonant sound at the beginning of several words in close succession. An example is “cha” in " चंदू के चाचा ने चंदू की चाची को चांदी के चमचे से चटनी चटाई ".

30. Pressure of Speech It is an increase in the amount of spontaneous speech as compared to what is considered ordinary or socially customary. The patient talks rapidly and is difficult to interrupt. If a quantitative measure is applied to the rate of speech, then a rate greater than 150 words/minute is usually considered rapid or pressured. ( Andreason , 1986)

31. Video: Pressure of Speech

32. ii) Inhibition/Retardation 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 difficulty in making decisions, lack of concentration and loss of clarity of thinking. So that events are poorly registered. This leads the patient to complain of loss of memory and to develop an overvalued or delusional idea that they are going out of their mind.

33. The lack of concentration and the general fuzziness in thinking are often associated with a strange indescribable sensation ‘in the head,’ so that at times it is difficult to decide whether the patient is complaining about a physical or a psychiatric symptom. Slowing of thinking is seen in both depression and the rare condition of manic stupor.

34. Many individuals with depression, however, may not have slowing of thinking but may experience difficulties with thinking owing to anxious preoccupations and increased distractibility due to anxiety. (Casey& Kelly, 2007) The apparent cognitive deficits in individuals with slowing of thinking in depression may lead to a mistaken diagnosis of dementia.

35. X X X Retardation (SIMS)

36. iii) Circumstantiality Occurs when thinking proceeds slowly with many unnecessary and trivial details, but finally the point is reached. The goal of thinking is never completely lost and thinking proceeds towards it by an intricate and convoluted path. Historically, this disorder has been regarded as a feature of the constellation of personality traits occasionally associated with epilepsy. Circumstantiality , however, can also occur in the context of learning disability and in individuals with obsessional personality traits. (Casey& Kelly, 2007)

37. X X X X X X X X X X X X X X Model of Circumstantial Thinking

38. Tangentiality It may be described as replying to a question in an oblique , tangential , or even irrelevant manner. The reply may be related to the question in some distant way. Or the reply may be unrelated and seem totally irrelevant. The concept of tangentiality has been partially redefined so that it refers only to replies to questions and not to transitions in spontaneous speech . (Casey& Kelly, 2007)

39. Disorders of the Continuity of Thought

40. i) Perseveration Perseveration occurs when mental operations persist beyond the point at which they are relevant and thus prevent progress of thinking. Perseveration may be mainly verbal or ideational. Perseveration is common in generalised and local organic disorders of the brain . In the early stages of perseveration, as in the above case, the patient may recognise their difficulty and try to overcome it. Example: a patient is asked the name of the previous prime minister and he replies ‘John Major.’ On being asked the name of the present prime minister he may reply ‘John Major. No, I mean John Major.’ This symptom is related to the severity of the task facing the patient, so that the more difficult the problem, the more likely it is that perseveration will occur.

41. ii) Thought blocking There is a sudden arrest of the train of thought, leaving a ‘blank’. An entirely new thought may then begin. When thought blocking is clearly present it is highly suggestive of schizophrenia. However, patients who are exhausted and anxious may also lose the thread of the conversation and may appear to have thought blocking. Blocking should only be judged to be present either if a person voluntarily describes losing his thought or if upon questioning by the interviewer, the person indicates that that was his reason for pausing. (Casey& Kelly, 2007)

42. X X X X Model of thought blocking

43. Video: Thought Block

44. Assessment: Observation Clinical Interview Mental Status Examination (MSE) It is one of the most important clinical evaluations in psychiatry. It is structured observation and description of patient’s current state of mind. It cover the domains of general appearance and behaviour, attitude, motor behaviour, speech, cognitive functioning mood, thought in terms of its stream, form, possession, and content, perceptual disorders, judgement and finally the insight.

45. Positive and Negative Syndrome Scale (PANSS) The positive and Negative Syndrome Scale was developed by Kay et al, (1989). It consist of 30 items in which 7 measure positive symptoms, 7 negative symptoms, and 16 general psychopathology symptoms including behavioural changes like hostility, suspiciousness that can accompany delusions.

46. Brief Psychiatric Rating Scale (BPRS) The Brief Psychiatric Rating Scale (BPRS) was devised to measure the different clinical symptoms associated to schizophrenia. Two items out of total 18 items were dedicated to thought disorders (Overall and Gorham, 1962). Rorschach Ink Blot Test (RIBT) In Exner’s system there are 15 special scores for assessing disordered thought, these are an empirically reliable measure of formal thought disorder.

47. The Thought and Language Index (TLI) ( Liddle et al, 2002) Relatively new instrument. It assess formal thought disorder under certain standardized conditions. The patient is asked to generate eight speech samples in response to specific standardized stimuli from either the Thematic Apperception Test (Murray, 1943) or the Rorschach Inkblot Test. The speech samples of the patient are assessed for the presence of eight types of abnormality, under defined glossary and according to specified scoring criteria.

48. Management Pharmacological Antipsychotics: Benzodiazepines ( Lorazepam ) etc. i ) Lithium Rapidly absorbed through the gastro-intestinal tract No metabolism in body, entirely excreted Accelerates the pre-synaptic reuptake of catecholamines ( norepinephrine ) Inhibits the release of catecholamines at synapse, resulting in decreased catecholamine activity, thus decreasing the mania symptoms. Used in: Acute Mania Bipolar Mood Disorder Schizo -affective disorder

49. ii) Valproate : Valproic acid Increases GABA Acute Mania and Bipolar mood disorder Antiepileptic Rapidly and completely absorbed after oral administration Dose: 1000-3000mg/day in divided doses ** Addition of Valproate to Lithium has been recognised as a useful treatment for mania refractory.

50. Psychotherapeutic i ) Psychoanalysis Faulty Defense Mechanism Example: As in obsessional thoughts Isolation (neurotic/immature defense mechanism)- of the idea of an unconscious impulse from its appropriate affect, thus allowing only the idea and not the associated affect to enter awareness. Found in grief: ability to discuss traumatic events without the associated disturbing emotions with passage of time :

51. ii) Cognitive Behavior Therapy Correcting the maladaptive methods of thinking

52. Typically 15 visits over a 3 month period. i ) Cognitive techniques such as: Recognising and correcting negative automatic thoughts Teaching reattribution techniques Increasing objectivity in perspectives Identifying and testing maladaptive assumptions and decentering .

53. ii) Behavioral techniques: Activity scheduling Homework assignments Task assignment Role playing Diversion techniques. iii) Teaching problem solving skills iv) Mindfulness

54. References Fish’s Clinical Psychopathology A short textbook of Psychiatry: Niraj Ahuja SIMS’ Symptoms in the Mind Singh, T. K., Ahmad, A., & Chowdhury , A. (2014). Differences of thought.

55. “We are what we think. All that we are, arises with our thoughts. With our thoughts, we make the world” Gautam Buddha Thank You…!!