Formal thought disorders

psychiatry

1. FORMAL THOUGHT DISORDERS CHAIR PERSON: DR JEYASEELAN PRESENTOR: DR USHA NANDHINI DATE: 18/07/2018

2. TOPICS Thought definition Types of thinking Healthy thinking Thought disorders Assessment of thought disorders Formal thought disorders Researches References

3. THOUGHT Thought - what we think Language of the mind[propositional thought - hear in the mind, imaginal thought – see in the mind] Goal oriented flow of ideas and associations that leads to reality oriented conclusion. An idea or opinion produced by thinking or occurring suddenly in the mind

4. TYPES OF THINKING Fantasy [ autistic or dereistic ] Imaginative Rational or conceptual

5. FANTASY THINKING There is very little contact with reality. Day dreaming Carrying on day to day activities To compensate for disappointments in life or to escape from unpleasant situations. Neurotic triats initially deliberate and sporadic ↓ more established ↓ believes the contents ↓ accepted as fact. Pathological lying dissociative disorder Delusion like ideas Denial of external events- ego defense mechanisms Bleuler – excessive autistic thinking in schizophrenia is part of thought disorder

6. FANTASY THINKING

7. IMAGINATIVE THINKING Contact with reality Components 1. Mental imagery: create image based mental representations of the world 2. Counterfactual thinking: capacity to disengage from the reality and think of events and experiences that haven’t occurred 3. Symbolic representation: use of concepts or images to represent real world objects. Maternal reverie

8. IMAGINATIVE THINKING

9. RATIONAL OR CONCEPTUAL THINKING Problem solving and reasoning Problem solving- cognitive process used to overcome the obstacles to reach a goal Reasoning- cognitive process used to make inferences from knowledge and to draw conclusions Analogical reasoning: application of solutions to already known problems. Inductive reasoning: use of specific known instances to draw inferences about unknown instances. Deductive reasoning: argument in which if the premises are true conclusion cannot be false

10. ANALOGICAL REASONING

11. INDUCTIVE REASONING

12. DEDUCTIVE REASONING

13. HEALTHY THINKING Described by Schneider Constancy: characteristic of a completed thought that doesn’t change in content Organization: contents of thought are related to each other in consciousness and do not blend with each other and separated in organized way Continuity: heterogeneous subsidiary thoughts, sudden ideas or observations that emerge are arranged in order in the content of conciousness .

14. THOUGHT - ASPECTS Thought content: thoughts occurring in mind. Thought process: thoughts are formulated , organized and expressed. Normal thoughts are linear ,organized and goal directed.

15. THOUGHT DISORDERS Any disturbance of thinking that affects language , communication and thought content Disturbances of thoughts : change in nature of individual thoughts i.e. disorder of content of thoughts [ obsession& compulsions, delusions and overvalued idea] Disturbances of thinking process: change in speed or form of relationships between thoughts, individual thoughts are unremarkable in nature[ formal thought disorders]

16. THOUGHT DISORDERS Disorders of stream Disorders of form Disorders of content Disorders of possession

17. Formal thought disorders Disruption of normal flow of thought Disturbances in organization and expression of thoughts BLEULER – formal thought disorders are core feature of schizophrenia. Syndrome with different symptoms resulting in thought , language and communication problems . FTD – abnormality in amount and form of speech Amount: poverty and pressure of speech Form : disconnection symptoms[distractible speech, loss of goal, loose associations, illogicality and incoherence]

18. SCHNEIDER Derailment : thought slides on to subsidiary thought Substitution: major thought is substituted by subsidiary one Omission : senseless omission of a thought or part of it Fusion: heterogeneous elements of thoughts are interwoven with each other Driveling: disordered intermixture of constituent part of one complex thought

19. POSITIVE FTD: false concepts by blending together of incongruous elements NEGATIVE FTD: Loss of previous ability to think

20. CLINICAL ASSESSMENT Assessed during the course of interview Patients speech, writings and behaviour Sample of speech Verbatim record

21. FORMAL THOUGHT DISORDERS Flight of ideas Retarded thinking Circumstantiality Preservation Thought blocking Tangentiality Incoherence Derailment Loosening of associations Neologisms Poverty of speech Pressure of speech

22. FLIGHT OF IDEAS Acceleration of flow of thinking Rapid succession of thoughts No general direction of thinking Logical connection present Easy distractibility [ external stimulus & internal superficial associations] Associations – chance factors or verbal Verbal – clang , puns and rhymes Clang – a 2 nd word with sound similar to 1st Puns – a 2 nd meaning of first word Typical of mania Also in schizophrenia, organic brain disease

23. FLIGHT OF IDEAS/ ACCELERATED THINKING

24. Example பேர் என்னம்மா ? ஜீவ மணி , ஹெலன் ஜீவ மணி , ஹெலனா கிரிஸ்டியன் , நான் ஹிந்து , நான் இப்ப பார்வதி , பார்வதி நெத்தியில பொட்டு செவப்பு கலர்ல இருக்கும் , உன் ஷால் கூட சிவப்புதான் , எனக்கு ஒரு ஷால் கொடு .

25. PROLIXITY Prolixity – ordered flight of ideas Marginal variety of flight of ideas Associations are not so marked and acceleration is not as fast in flight of ideas Patients lose thread only for a few moments and finally reach their goal In hypomania

26. PRESSURE OF SPEECH Amount of spontaneous speech is increased which is difficult to interrupt Variety of thoughts Thought process is accelerated Loud and emphatic > 150 words per minute.

27. INHIBITION OR SLOWING OF THINKING Thought process slowed down Few thoughts [ ideas and mental images] Lack of concentration, loss of clarity and difficulty in making decisions Defective attention- poor registration Loss of memory and cognitive deficits [ Difficult to differentiate from dementia] Depression and manic stupor Depression – anxious preoccupations and increased distractibility due to anxiety.

28. RETARDATION OF THINKING

29. POVERTY OF SPEECH Patient has few thoughts that lack in variety and richness Thoughts move slowly through the mind Spontaneous speech is restricted Answers are brief, concrete and uneloborated Example: பெயர் என்னம்மா ?........... எழிலரசி . எதுக்கு ஹாஸ்பிட்டல் வந்து இருக்கீங்க ?................ எதுக்கு ஹாஸ்பிட்டல் வந்து இருக்கீங்க ?……… உடம்பு சரி இல்லை . என்ன ஆச்சும்மா ?………… என்ன ஆச்சும்மா ? …………… வயிறு வலி

30. CIRCUMSTANTIAL THINKING Non linear thought pattern Thinking proceeds slowly with unnecessary and trivial details but finally the goal is reached. Goal of thinking not lost completely Proceeds in intricate and convoluted path In OCD – excess detail is introduced anxiously to avoid any omissions Learning disabilities and temporal lobe epilepsy[ Geschwind syndrome- interictal changes in personality progressing over time. Includes hypergraphia , hyperreligiosity , atypical sexuality, circumstantiality and intensified mental life]

31. CIRCUMSTANTIALITY

32. TANGENTIALITY Train of thought wanders away , goal is lost and is never reached At first the patients give answers that is appropriate to the general topic but not answering the questions . Seen in anxiety, schizophrenia, dementia and delerium .

33. TANGENTIALITY

34. PERSEVERATION Disturbance of flow of thinking mental operations persist beyond the point at which they are relevant and thus prevent progress of thinking. Persistence of response to an earlier stimulus even after new stimulus has been presented may be mainly verbal or ideational. Organic disorders- frontal lobe injury Example:1. Who is our CM? EPS 2. Where are you from? EPS 3. Are you married? EPS

35. THOUGHT BLOCKING Sudden arrest of the train of thought, leaving a ‘blank’. An entirely new thought may begin Snapping off Not caused by any distractions Normal persons- anxious and exhausted Schizophrenia- thought withdrawal

36. THOUGHT BLOCKING

37. DERAILMENT Characterized by discourse consisting of sequence of unrelated or remotely related ideas. Slippage of ideas further and further away from point of discussion. Euphoria , hysteria and schizophrenia Entgleisen [ derailment]- Schneider Asyndesis - Cameron Knight’s move thinking- Peter McKellar

38. DERAILMENT

39. LOOSENING OF ASSOCIATIONS Coined by Bleuler pattern of spontaneous speech in which things said in juxtaposition lack a meaningful relationship . there is idiosyncratic shifting from one frame of reference to another. The speech is often described as being ‘disjointed’

40. INCOHERNCE[ WORD SALAD] Pattern of speech that is incomprehensible confused or unintelligible mixture of seemingly random words and phrases Set of words or phrases used together without any arbitrary connection or grammatical rules Schizophasia - speech confusion or word salad occurs in schizophrenia

41. NEOLOGISMS New words are constructed by the patient or ordinary words are used in a new way mainly in schizophrenia. Catatonia - mannerisms or stereotypes. The patient may distort the pronunciation of some words in the same way as they distort some movements of their body. Stock word instead of the correct one. Example- patient may use the word ‘car’ and call an airplane an ‘air car’ and a boat a ‘sea car’ Severe positive formal thought disorder- words are fused together in the same way as concepts are blended with one another. Derailment: example - a patient used the word ‘relativity’ instead of the word ‘relationship.’ Technical neologism- using a technical term for a private experience that cannot be expressed in ordinary words. Hallucinations: The ‘voices’ may use neologisms and this may lead the patient to use them as well. Malapropisms- conspicuously misused words Paraphasia :motor aphasia- use the wrong word, invent new words, or distort the phonetic structure of words.,

42. VORBEIREDEN -TALKING PAST THE POINT Patient understands what has been asked but responds by talking about an associated topic Example: what is the color of grass? – white what is the color of snow?- green Pseudodementia : hebephrenic schizophrenia Dissociative disorders Gansers syndrome: approximate answers Catatonia

43. CLANG ASSOCIATIONS A 2 nd word with sounds similar to first word is used rather than by meaning

44. VERBIGERATION Verbigeration : speech is reduced to senseless repetition of words, sounds or phrases A form of stereotypy A type of incoherence

45. OVER INCLUSIVENESS Ideas that are remotely linked to the concept become incorporated within it in the patients thinking Inability to preserve conceptual boundaries [Cameron] Schizophrenia Example: what are the essentials of room? Wall , doors, chairs and window

46. CONCRETE THINKING Abstractions and symbols are interpreted superficially without tact, finesse and awareness of nuance Goldstein Schizophrenia Proverb testing

47. THOUGHT DISORDERS IN SCHIZOPHRENIA Psychological theories : CAMERON: Asyndesis : lack of adequate connection between two sucessive thoughts Metonyms: imprecise expressions or use of substitute term or phrase instead of exact one Interpenetration of themes: patients speech contain elements which belong to task in hand interspersed by stream of fantasy Over inclusion: inability to maintain the boundaries of problem and to resist operations within correct limits GOLDSTEIN: concrete thinking: there is a loss of abstract attitude. The patient is unable to free himself from the superficial concrete aspects of thinking

48. SCHNEIDER: 3 types of disordered thinking Transitory thinking: characterized by derailments, omissions and substitutions. Grammatical and syntactical structures distorted Drivelling thinking: patient has a preliminary outline of complicated thought but loses all preliminary organisations , so that all constituent part gets muddled Desultory thinking: speech is grammatically correct but sudden ideas force their way from time to time. Conversations leap from one topic to other

49. Frith : failure of self monitoring resulting in thought disorder Inability to edit out irrelevant or perseverating phrases Thought is undermined by absence of goal or plan Intrusion of thoughts that do not fit into overall goal Above results in disorganized thought

50. Bleuler’s 4 A’s Affective disturbance Ambivalence Autism Disturbances of thought association

51. DELUSIONS OF CONTROL OF THOUGHT Patient ascribes his own internal thought process to outside influences – passivity Thoughts as foreign or alien, not emanating from himself and not within his control Unable to discriminate between himself and outside world Passivity of thought, thought withdrawal, thought broadcasting and thought insertion[ first rank symptoms of schizophrenia]

52. RESEARCHES FTD- lack of hemispheric asymmetry in language areas FTD: Structural abnormalities in left STG, left planum temporale and orbito frontal cortex FTD ; schizophrenia trait marker Eotaxin – ECDC [ endogenous cognitive deteriorating chemokine ] is increased in patients with FTD’s

53. REFERENCES SIMS- symptoms in the mind- Femi Oyebode Fish clinical psychopathology Kaplon and Sadock’s synopsis of psychiatry Shorter oxford textbook of psychiatry – Paul Harrison, Philip Cowen, Mina Fazel , Tom burns internet

54. THANK YOU