thoughtdisorderpsychiatryppt .pptx

thought disorders

1. Disorders of THOUGHT Dr. RAJVI ANAJWALA 1 st Year Resident Dept. of Psychiatry Dr. M k shah Medical college and Research Institute

2. Definition Thought : Linear and goal directed flow of ideas, symbols and associations which is initiated by task or problem, characterized by rational idea which leads to a reality based conclusions.

3. Disorders of Thought Disorders of Intelligence Disorders of stream / flow of thought Disorders of form of thought Disorders of content of thought Disorders of possession of thought

4. Disorders of Intelligence Intelligence : capacity for learning and ability to recall, to integrate constructively and to apply what one has learned . Intelligence is the ability to think and act rationally and logically. The measurement of intelligence is both complex and controversial (Ardila, 1999). In practice, intelligence is measured with tests of the ability of the individual to solve problems and to form concepts through the use of words, numbers, symbols, patterns and non-verbal material. Two groups of subjects with low intelligence or what is now termed ‘Specific learning disability’ & ‘intellectual disability ’

5. Thinking There are three legitimate uses of the word ‘think’. Undirected fantasy / autistic/ dereistic thinking Imaginative thinking Rational/conceptual thinking Undirected fantasy thinking( which, in the past, has also been termed autistic or dereistic thinking): Fantasy I usually understood to be the creation of images or ideas that have no external reality. Undirected fantasy thinking is quite common, but certain individuals when faced with repeated disappointments or adverse life circumstances may engage in excessive undirected fantasy thinking.

6. Imaginative thinking, which does not go beyond the rational and the possible: There are at least three components of imagination: 1) Mental imagery : Refers to the ability to create image-based mental representations of the world. 2) Counterfactual thinking: Refers to the capacity to disengage from reality in order to think of events and experiences that have not occurred and may never occur. 3) Symbolic Representation : Refers to the use of concepts or images to represent real world objects or entities (Roth, 2004). This is of course, the basis of language, art and mathematics. Rational thinking or conceptual thinking, which attempts to solve a problem.

7. Disorders of stream /flow of thought Disorders of Tempo : Flight of ideas Prolixity Slowing/ retardation Circumstantiality Tangentiality

8. Flight of Ideas : In flight of ideas thoughts follow each other rapidly; there is no general direction of thinking; and the connections between successive thoughts appear to be due to chance factors which,however,can usually be understood. The patient’s speech is easily diverted to external stimuli and by internal superficial associations. The progress of thought can be compared to a game of dominoes in which one-half of the first piece played determines one half of the next piece to be played.The absence of a determining tendency to thinking allows the associations of the train of thought to be determined by chance relationships, verbal associations of all kinds (such as assonance, alliteration and so on), clang associations, proverbs, maxims and clichés.

9. The chance linkage of thoughts in flight of ideas is demonstrated by the fact that one could completely reverse the sequence of the record of a flight of ideas, and the progression of thought would be understood just as well (or just as poorly). Seen in Mania, Schizophrenia & in lesions of Hypothalamus An example of flight of ideas from a manic patient who was asked where she lived , she replied “Birmingham, kingstanding , see the king is standing ,king, king, sing, sing, bird on the wing, wing on the bird, bird, turd , turd .”

10. Prolixity : ‘Ordered flight of ideas’ or marginal variety of flight of ideas has been called as prolixity. In prolixity, despite many irrelevances, the patient is able to return to the task in hand; clang and verbal associations are not so marked; the speed of emergence of thoughts is not as fast as in flight of ideas; although patients cannot keep accessory thoughts out of the main stream, they only lose the thread for a few moments and finally reach their goal; unlike the tedious elaboration of details in circumstantiality, there is a lively embellishment of the thinking. Seen in Hypomania

11. Inhibition or Slowing of Thinking : Retardation (Bradyphrenia): The train of thought is slowed down and the number of ideas and mental images which present themselves is decreased. This is experienced by the patient as difficulty in making decisions, loss of concentration and loss of clarity of thinking. In retardation (as occur in depression), thinking, although goal directed, proceed so slowly with such morbid preoccupation with gloomy thoughts that the person may fail to achieve these goals. The patient is likely to show very little initiative to begin planning or spontaneous activity . Seen in Schizophrenia, depression.

12. Circumstantiality 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 . A pattern of speech which is very indirect and delayed in reaching its goal idea. In the process of explaining something, the speaker brings in many tedious details and sometimes make parenthetical remarks . Seen in epileptic personality change, in learning disability, pedantic obsessional personality, Schizophrenia, schizoaffective , certain cases of dementia

13. Tangentiality- Refers to 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. Thought is related to the goal in distant way, but the goal is never reached.

14. Disorders of Continuity of thinking : Crowding of thought Thought blocking Perseveration

15. Crowding of thought occurs in schizophrenia. The patient describes his thoughts as being passively concentrated and compressed in his head. The associations are experienced as being excessive in amount, too fast, inexplicable and outside the person’s control. The patient may even locate his thinking anatomically as being ‘crowded into the back of my head’ or elsewhere. It becomes a head long chase or dance of thoughts and has some of the characteristics of flight of ideas, but it also shows a schizophrenic quality of passivity, being controlled from outside.

16. Thought Blocking: Thought blocking occurs when there is a sudden arrest of the train of thought, leaving a ‘blank’. An entirely new thought may then begin . Interruption of a train of speech before a thought or idea has been completed. After a period of silence which may be from a few seconds to minutes, the person indicates that he can not recall what he had been saying or meant to say. Abrupt interruption in train of thinking before a thought or idea is finished; after a brief pause, person indicates no recall of what was being said or was going to be said; also called as thought deprivation. “Snapping off” is the experience that a patient with Schizophrenia has, of his chain of thoughts quite unexpectedly and unintentionally breaking off or ceasing. It may occur in the middle of sorting out a problem or even mid-sentence . While they are flowing freely, the respondent experiences a sudden unexpected stopping of thought. When this occurs, it is dramatic and usually happens on several occasions. The experience is passive . When thought blocking is clearly present it is a terrifying experience and highly suggestive of Schizophrenia. However, similar thing may occur in persons who are exhausted and anxious and may appear to have thought blocking.

17. 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. It is a disturbance in the flow of thinking in which the patient retains a constellation of ideas long after they have to be appropriate. Seen in Local or generalized organic disorders of brain. Eg. Q: where do you live? A: Rowley regis . Next Q: What is the capital of France? A: Rowley regis . Further Q: Who lives at home with you? A: Rowley regis …. My son and wife . Verbal stereotypy , which is a frequent spontaneous repetition of a word or phrase that is not in any way related to the current situation. In verbal stereotypy, the same word or phrase is used regardless of the situation,whereas in perseveration a word, phrase or idea persists beyond the point at which it is relevant.

18. Disorders of form of thought This is disorder of conceptual or abstract thinking , which occur in Schizophrenia and coarse brain disease. Formal thought disorder, from the subjective phenomenological standpoint is abnormality in the mechanism of thinking described by the patient in his own words as a process of thinking which is clearly abnormal to the outside observer. Means “the arrangement of parts”. Disturbance in the form of thought are disorder in the logical connections between ideas.

19. Loosening of association : Characteristic Schizophrenic thinking or speech disturbance involving a disorder in the logical progression of thoughts, manifested as a failure to communicate verbally adequately; unrelated and unconnected ideas shift from one subject to another . Loosening of association denotes a loss of normal structure of thinking. Three kinds of loosening of association have been described: Knight’s move thinking or derailment where there are odd tangential associations between ideas. Talking past the point ( vorbeireden ) where the patient seems to get close to the point of discussion, but skirts around it and never actually reaches it Verbigeration ( word salad/schizophasia/ paraphrasia ) where speech is reduced to a senseless repetition of sounds and phrases Derailment: A pattern of speech in which a person’s idea slip off from one track to another that is completely unrelated or only obliquely related. In moving from one sentence or clause to another, the person shifts the topic idiosyncratically from one point of reference to another and things may be said in juxtra position that lack a meaningful relationship. This disturbance occurs between clauses, in contrast to incoherence, where the disturbance is within clauses

20. Schneider (1930) claimed that five features of formal thought disorder could be identified: derailment, substitution, omission, fusion and drivelling In derailment the thought slides on to a subsidiary thought , in substitution a major thought is substituted by a subsidiary one, In Omission consists of the senseless omission of a thought or part of it. in fusion , heterogeneous elements of thought are interwoven with each other, In drivelling there is disordered intermixture of constituent parts of one complex thought. the patient has a preliminary outline of a complicated thought with all its necessary particulars, but loses preliminary organisation of the thought, so that all the constituent parts get muddled together. In desultory thinking speech is grammatically correct but sudden ideas force their way in from time to time. Each one of these ideas is a simple thought that, if used at the right time, would be quite appropriate. Transitory thinking is characterized by derailments , substitutions and omissions. Omission is distinguished from desultory thinking because in desultoriness the continuity is loosened but in omission the intention itself is interrupted and there is a gap. The grammatical and syntactical structures are both disturbed in transitory thinking.

21. Disorders of Content of thought The contents of thought may include: Worry: it is a subjective sense of tension or uneasiness. Phobia: fears restricted to a specific object , situation or idea. Impulse: Antisocial urges Homicidal ideas Suicidal ideas Death wishes

22. Delusion English word ‘delude’ means -to mock , cheat,defrauding etc. False unshakeable belief that is out of keeping with the patient’s social and cultural background ( FISH ) False , fixed beliefs strongly held and immutable in the face of refuting evidence that are not consonant with the person’s educational , social and cultural background.( CTP ) False belief based on incorrect inference about external reality that is firmly held despite objective and obvious contradictory proof o evidence and despite the fact that other members of the culture do not share the belief.( SYNOPSIS )

23. Classification of delusions:

24. TRUE DELUSIONS (PRIMARY DELUSION) The essence of the primary delusional experience (also termed apophany ) is that a new meaning arises in connection with some other psychological event. They are the result of a primary delusional experience that cannot be deduced from any other morbid phenomenon. They are primary Understandable . Arises ‘de novo’. Reported in acute Schizophrenia

25. THREE FORMS OF PRIMARY DELUSIONAL EXPERIENCE: Delusional Mood (atmosphere): the patient has the knowledge that there is something going on around him that concerns him, but he does not know what it is. 2.Delusional Perception : It is the attribution of a new meaning, usually in the sense of self- reference, to a normally perceived object. The new meaning cannot be understood as arising from the patient’s affective state or previous attitudes. Two memberedness : there is a link from the perceived object to the subject’s perception of this object and a second link to the new significance of this perception. Schneider divided delusional memory into delusional perception and sudden delusional idea The Sudden Delusional Idea(delusional Intuition) : A delusion appears fully formed in the patient’s mind. This is also known as an autochthonous delusion. It is not in itself diagnostic of schizophrenia because sudden ideas ‘out of blue’ or ‘brain- waves’ occur in various mental illnesses such as depression, personality disorders, organic and epileptic psychosis and even in normal individuals.

26. SECONDARY DELUSIONS Secondary delusions are derived apparently from a preceding morbid experience. They may accumulate until there is a complicated and stable delusional system. The morbid experiences leading to secondary delusions may be of many kinds- including: Hallucinations- e.g. a person who hears voices may believe that he is being followed. Low mood- e.g. a profoundly depressed woman may believe people think she is worthless. An existing delusion e.g. a person convinced he’s being framed may come to believe he will be imprisoned. Systematization? Completely systematized delusion-there is one basic delusion and the remainder of the system is logically built on this error.

27. DELUSION OF PERSECUTION : The person thinks that he/she is being conspired or plotted against,cheated,spied or harassed. most common type of delusion. DELUSION OF REFERNCE : the patient knows that people are talking about him, slandering him or spying on him. Ideas and delusion of reference are not confined to schizophrenia and can also occur in depressive illness and other psychotic illness. DELUSION OF GUILT , the patient believes that he is about to be put to death or imprisoned for life. DELUSION OF BEING POISONED , patient feels that their food or cigarettes have been poisoned,it is based on hallucinations of taste or smell. DELUSION OF INFLUENCE : these passivity feelings may be explained by the patient as a result of hypnotism, demonical possession, witchcraft, radio waves,atomic rays or television.

28. DELUSION OF INFIDELITY( othello syndrome or morbid jealousy syndrome) ; common theme of having a spouse or lover being unfaithful. Even if there is evidence to the contrary the person is certain that their partner is having affair. Seen in Alcohol withdrawal , affective psychosis and schizophrenia. For eg : the patient may interpret that his wife has bags under the eyes as a result of frequent sexual intercourse with someone else. DELUSION OF LOVE(DE CLEREMBOULT SYNDROME,FANTASY LOVER SYNDROME,EROTOMANIA) : Seen in personality disorders and early cases of schizophrenia The patient is convinced that some person is in love with them, although the alleged lover may never have spoken to them.

29. DELUSION OF GRANDIOSITY: Seen in Organic brain syndrome , Mania , Schizophrenia , Drug dependence E.g. some patients may believe they are God, queen of England, a famous rockstar etc. The expansive delusions may be supported by auditory hallucinations or confabulations. NIHILISTIC DELUSION The patient denies the existence of their body, their mind , their world and their loved ones around them. seen in Severe depression,Schizophrenia.delirium .

30. HYPOCHONDRIACAL DELUSION/DELUSION OF ILL HEALTH/SOMATIC DELUSION : Recurrent or persistent belief that one might be having one of the serious mental or physical illness in spite of repeated assurance by the doctor and negative test reports. Seen in hypochondriasis, depression. The patients may believe that they have a serious disease such as cancer, TB, AIDS , brain tumor and so on. The depressed mother may believe that she has infected her children and this may lead to harm her children. Delusion of ill health may take form of incurable insanity. Some similar delusions are delusional preoccupation with facial or bodily appearances ( nose is too big, face is twisted or disfigured).

31. DELUSION OF MISIDENTIFICATION SYNDROMES : Capgras Syndrome: Belief that a familiar person or object has been replaced by a nearly identical duplicate or imposter. Fregoli Syndrome: Belief that a familiar person acquires different physical identities while the psychological identity remains the same, i.e., the familiar person disguises himself as others. DELUSION OF CONTROL : A Delusion in which feelings, impulses, thoughts or actions are experienced as being under the control of some external force rather being under one’s own control . DELUSION OF INFESTATION : The patient believes he is infested with small but macroscopic organisms. seen in HYPOCHONDRIASIS DELUSIONAL DISORDER. ORGANIC BRAIN SYNDROMRES.

32. OTHER DELUSIONS DELUSION OF REFERENCE DELUSION OF GUILT DELUSION OF POVERTY DELUSION OF ENORMITY

33. OVERVALUED IDEA It is a thought that ,because of the assosciated feeling tone , takes precedence over all other ideas and maintains this precedence permanently or for a long period of time . Less fixed than delusion. Have some degree of basis in reality.

34. DELUSIONS need not be associated with affect. firm sustained belief. absolutely convinced that the delusion is real. recognized as absurd cannot be accepted occur in mentally ill people. OVERVALUED IDEA associated with very strong affect. not held firmly. some level of doubt to its truthfulness. not recognized as absurd. acceptable. occur in both healthy and mentally ill people.

35. DISORDERS WITH OVERVALUED IDEAS PARANOID STATE MORBID JEALOUSY HYPOCHONDRIASIS DYSMORPHOPHOBIA PARASITOPHOBIA(EKBOM’S SYNDROME) ANOREXIA NERVOSA TRANSSEXUALISM Abnormality of personality is usually present with overvalued ideas in all these conditions.

36. Disorder of Possession of thought Obsessions and Compulsions : Obsessions are intrusive and unwanted repetitive thoughts, urges, or impulses that often lead to a marked increase in anxiety or distress. The essential feature of the obsession are: the essential feature of the obsession are Own and ego-dystonic ,Intrusive , Deemed as irrational or senseless ,Appears against the will (involuntary) ,Tries to resist May have temporary relief by yielding to compulsions, but the thoughts recur Associated with dysfunction

37. Compulsions are repetitive behaviors or mental acts that are done in response to obsessions, or in a rigid, rule-bound way. These recurrent obsessions or compulsions cause severe distress to the person. The obsessions or compulsions are time-consuming and interfere significantly with the person’s routine, occupational functioning, usual social activities, or relationships. Obsessions occur in obsessional states, depression, schizophrenia and occasionally in organic states; compulsive features appear to be particularly common in post-encephalitic parkinsonism

38. Rumination: It is a train of thoughts, usually unproductive and prolonged, on a particular topic, repeatedly experienced and is felt to be less intrusive. Ruminations are linked to abnormal emotion, the valence typically reflected in the content of the thoughts. Ruminations can occur in OCD, depression, melancholia. Depressive ruminations (in comparison to obsessive ruminations)- Depressive individuals ruminate about every day, real-life events whereas obsessive- compulsive individuals will tend to have obsessions about unusual and neutral topics which are mostly unrelated to the individual. Obsessive thoughts tend to center around a current or future event, whereas depressive rumination typically involves a past incident. OCD individuals often describe their thoughts as intrusive, senseless and unwanted, and often report an attempt to resist them. In direct contrast, depressive ruminators maintain that their thoughts are non- intrusive and are rarely resisted. Another distinction between ruminations and obsessions, prima facie, is the behavioural outcome: obsessions lead to compulsions.

39. Thought Alienation: In thought alienation the patient has the experience that their thoughts are under the control of an outside agency or that others are participating in their thinking. The Schizophrenic experiences his thoughts as foreign or alien; not emanating from himself and not within his control. In all these experiences of thought alienation the psychoanalytic interpretation is that the boundary between the ego and the surrounding world has broken down so that he can no longer discriminate between the two. The experience of thought alienation may seem increasingly ego-dystonic and distressing to them.

40. Thought insertion : The person experiences thoughts that do not have feeling of familiarity, of being his own, but he feels that those have been put in his mind, without his volition, from outside himself . In thought insertion, the patient knows that the thoughts are being inserted into his mind and he recognizes those as being foreign and coming from without . Thought Deprivation/Withdrawal: The patient finds that as they are thinking, their thoughts suddenly disappear and are withdrawn from their mind by a foreign influence. It has been suggested that this is the subjective experience of thought blocking and ‘omission’. The patient may describe his thoughts being taken away from himself against his will . Thought Broadcasting : The patient knows that as they are thinking, everyone else is thinking in unison with them . T he term has been used to describe the belief that one’s thoughts are quietly escaping from one’s mind and that other people might be able to access them, and the experience of hearing one’s thoughts spoken aloud and believing that, as a result, other people can hear them. Thought echo- One type of auditory hallucination is hearing one’s own thoughts spoken aloud and is also one of the first rank symptom of Schizophrenia. Known in German as Gedankenlautwerden , it describes hearing one’s thoughts spoken just before or at the same time as they are occurring. Echo de la pensée (French) is phenomenon of hearing them spoken after the thoughts have occurred. Best English term for them is ‘thought echo’ or ‘thought sonorisation

41. References Synopsis FISH’s clinical Psychopathology Sims’ Symptoms in the Mind

42. Thank you