Disorders of thinking

Disorders of thinking

Classification of disorders of thinking
Disorders of the stream of thought
Disorders of the possession of thought
Disorders of the content of thinking
Disorders of the form of thinking
Disorders of the stream of thought Disorders of the stream of thought can be further divided into
disorders of tempo and
disorders of continuity.
Disorders of thought tempo
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.
Flight of ideas is typical of mania.
Flight of ideas occasionally occurs in individuals with schizophrenia when they are excited and in individuals with organic states, including, for example, lesions of the hypothalamus
flight of ideas associated with pressure of speech
Inhibition or slowing of thinking
With inhibition or slowing of thinking, the train of thought is slowed down and the number of ideas and mental images that present themselves is decreased.
This is experienced by the patient as difficulty in making decisions,
lack of concentration and
loss of clarity of thinking.
There is also a diminution in active attention, 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.
Slowing of thinking is seen in both depression and the rare condition of manic stupor.
Circumstantiality
Circumstantiality occurs when thinking proceeds slowly with many unnecessary and trivial details, but finally the point is reached.
Circumstantiality, however, can also occur in the context of learning disability and in individuals with obsessional personality traits.
Disorders of the continuity of thinking
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.
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.
Perseveration is common in generalised and local organic disorders of the brain, and, when present, provides strong support for such a diagnosis.
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.
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.
Disorders of the possession of thought
Obsessions and compulsions
An obsession (also termed a rumination) is 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.
One of the most important features of obsessions is that their content is often of a nature as to cause the sufferer great anxiety and even guilt.
The thoughts are particularly repugnant to the individual; thus the prudish person is tormented by sexual thoughts, the religious person by blasphemous thoughts, and the timid person by thoughts of torture, murder and general mayhem.
The essential feature of the obsession is that it appears against the patient’s will.
It naturally follows that we can only call a mental event an obsession if it is normally under the control of the patient and can be resisted by the patient.
Obsessions occur in obsessional states, depression, schizophrenia, and occasionally in organic states;
compulsive features appear to be particularly common in post-encephalitic parkinsonism
Thought alienation
In thought alienation the patient has the experience that their thoughts are under the control of an outside agency.
In thought insertion the patient knows that thoughts are being inserted into their mind and they recognize them as being foreign and coming from without; this symptom, although commonly associated with schizophrenia, is not unique to schizophrenia
In thought deprivation, the patient finds that as they are thinking, their thoughts suddenly disappear and are withdrawn from their mind by a foreign influence.
In thought broadcasting, the patient knows that as they are thinking, everyone else is thinking in unison with them. There are also a number of other different definitions. For example, the 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.
All these three types of thought alienation, are of Schniderian first rank symptoms for diagnosis of schizophrenia.
Disorders of the content of thinking
Delusion is a false, unshakeable belief that is out of keeping with the patient’s social and cultural background.
Another important variety of false belief, which can occur in individuals both with and without mental illness, is the overvalued idea. Overvalued ideas tend to be less fixed than delusions and tend to have some degree of basis in reality, it may at times be difficult to distinguish between overvalued ideas and delusions.
Primary delusions
It was previously held that primary delusional experiences were diagnostic of schizophrenia, although it is now recognised that similar experiences are described in other conditions, including certain organic states as well as psychotic illnesses.
The essence of the primary delusional experience is that a new meaning arises in connection with some other psychological event.
There are three forms of primary delusional experience:
delusional mood, delusional perception and the sudden delusional idea.
In the delusional mood the patient has the knowledge that there is something going on around him that concerns him, but he does not know what it is.
In the sudden delusional idea a delusion appears fully formed in the patient’s mind.
The delusional perception is the attribution of a new meaning, usually in the sense of self-reference, to a normally perceived object.
Primary delusional experiences tend to be reported in acute schizophrenia but are less common in chronic schizophrenia, where they may be buried under a mass of secondary delusions arising from primary delusional experiences, hallucinations, formal thought disorder and mood disorders.
Secondary delusions
Secondary delusions can be understood as arising from some other morbid experience.
Delusions can be secondary to depressive moods and hallucinations. Personality can also play a role in the genesis of delusional states.
It is still common among some practitioners to divide delusions into
systematized and
non-systematized.
In the completely systematized delusions:
there is one basic delusion and the remainder of the system is logically built on this error.
the level of systematization may vary over time,
with systematization being generally more common in older patients
The content of delusions
Delusions of persecution
Delusions of persecution may occur in the context of primary delusional experiences, auditory hallucinations, bodily hallucinations or experiences of passivity.
Delusions of persecution can take many forms.
delusions of reference
In delusions of reference the patient knows that people are talking about him, slandering him or spying on him. Ideas and delusions of reference can occur in schizophrenia & depressive illness and other psychotic illnesses.
The supposed persecutors of the deluded patient may be people in the environment (such as members of the family, neighbors or former friends) or may be political or religious groups, of varying degrees of relevance to the patient.
Some patients believe that they or their loved ones are about to be killed, or are being tortured. The belief that the family is being harmed may be deduced from the content of the hallucinatory voices or the patient may claim that their relatives appear to be strange in some way and are obviously suffering from some interference.
In other cases, delusions of poisoning are based on hallucinations of smell and taste.
Delusions of influence are a ‘logical’ result of experiences of passivity in the context of schizophrenia. These passivity feelings may be explained by the patient as the result of hypnotism, demonical possession, witchcraft, radio waves, atomic rays or television.
Delusions of infidelity
The commonly used term ‘delusion of jealousy’
Delusions of infidelity may occur in both organic and functional disorders.
Often the patient has been suspicious, sensitive and mildly jealous before the onset of the illness.
Delusions of marital infidelity are not uncommon in individuals with schizophrenia and have been reported in many different varieties of organic brain disorders, but are especially associated with alcohol dependency syndrome. Delusions of infidelity are also seen in the affective psychosis, where they may again represent a morbid exaggeration of a premorbid mildly jealous attitude.
Delusions of infidelity may develop gradually, as a suspicious or insecure person becomes more and more convinced of their spouse’s infidelity and finally the idea reaches delusional intensity. The severity of the condition may also fluctuate over the course of time, and during episodes of marked disturbance, the spouse may be interrogated unceasingly and may be kept awake for hours at night. A jealous husband, for example, may interpret common phenomena as ‘evidence’ of infidelity; for example, he may insist that his wife has bags under her eyes as a result of frequent sexual intercourse with someone else, or may search his wife’s underclothes for stains and claim that all stains are due to semen.
This behavior may progress to violence against the spouse and even to murder.
Apart from delusions of infidelity, these patients tend not to show any other symptoms that would suggest schizophrenia.
Delusions of love
This condition has also been described as ‘the fantasy lover syndrome’ and ‘erotomania’. The patient is convinced that some person is in love with them although the alleged lover may never have spoken to them.
They may pester the victim with letters and unwanted attention of all kinds.
If there is no response to their letters, they may claim that their letters are being intercepted, that others are maligning them to their lover, and so on.
Occasionally, isolated delusions of this kind are found in abnormal personality states.
Sometimes, schizophrenia may begin with a circumscribed delusion of a fantasy lover and subsequently delusions may become more diffuse and hallucinations may develop.
Grandiose delusions
There is considerable variability in the extent of grandiosity associated with grandiose delusions in different patients. Some patients may believe they are God, the Queen of England, a famous rock star and so on. Others are less expansive and believe that they are skilled sportspersons or great inventors.
The expansive delusions may be supported by auditory hallucinations, which tell the patient that they are important.
In the past, delusions of grandeur were associated with ‘general paralysis of the insane’ (neurosyphilis) but are now most commonly associated with manic psychosis in the context of bipolar affective disorder.
The patient may believe that they are an important person who is able to help others, or may report hearing the voice of God and the saints, confirming their elevated status.
Delusions of ill health
Delusions of ill health are a characteristic feature of depressive illnesses, but are also seen in other disorders, such as schizophrenia.
Delusions of ill health may develop on a background of concerns about health; many people worry about their health and when they become depressed they naturally develop delusions or overvalued ideas of ill health.
Individuals with delusions of ill health in the context of depression may believe that they have a serious disease, such as cancer, tuberculosis, acquired immune-deficiency syndrome (AIDS), a brain tumour, and so on.
Depressive delusions of ill health may involve the patient’s spouse and children. Thus the depressed mother may believe that she has infected her children or that she is mad and her children have inherited incurable insanity. This may lead her to harm or even kill her children in the mistaken belief that she is putting them out of their misery.
Somewhat similar to these delusions are the delusional preoccupations with facial or bodily appearances, when the subject is convinced that their nose is too big, their face is twisted, or disfigured with acne, and so on. Sometimes these preoccupations with ill health or the appearance of the body have a somewhat obsessional quality, so that the patient cannot stop thinking about the supposed illness or deformity, although they realise it is ridiculous in times of quiet reflection. In other cases the belief is of delusional intensity and the patient is never able to admit that their belief is genuinely groundless, which includes delusional dysmorphophobia.
Delusions of guilt
In mild cases of depression the patient may be somewhat self-reproachful and self-critical.
In severe depressive illness self-reproach may take the form of delusions of guilt, when the patient believes that they are a bad or evil person and have ruined their family.
In very severe depression, the delusions may even appear to take on a grandiose character and the patient may assert that they are the most evil person in the world, the most terrible sinner who ever existed and that they will never die but will be punished for all eternity.
Nihilistic delusions
Nihilistic delusions or delusions of negation occur when the patient denies the existence of their body, their mind, their loved ones and the world around them.
They may assert that they have no mind, no intelligence, or that their body or parts of their body do not exist; they may deny their existence as a person, or believe that they are dead, the world has stopped, or everyone else is dead.
These delusions tend to occur in the context of severe, agitated depression and also in schizophrenia and states of delirium.
Sometimes nihilistic delusions are associated with delusions of enormity, when the patient believes that they can produce a catastrophe by some action (e.g. they may refuse to urinate because they believe they will flood the world.
Delusions of poverty
The patient with delusions of poverty is convinced that they are impoverished and believe that destitution is facing them and their family.
These delusions are typical of depression but appear to have become steadily less common over the past decades.
Disorders of the form of thinking
The term ‘formal thought disorder’ is a synonym for disorders of conceptual or abstract thinking that are most commonly seen in schizophrenia and organic brain disorders.
In schizophrenia, disorders in the form of thinking may coexist with deficits in cognition.
Loosening of association
It denotes a loss of the normal structure of thinking. Lack of continuity in thinking, thought and speed proceed at random, no logical connection between elements of speech & thinking
It appears as incoherent, muddled and illogical.
Loosening of association can take several form:
Knights move or derailment
Transition from one topic to another, either between sentences or in mid-sentence, with no logical relationship between the two topics
When it occur in extreme way word salad
Circumsta-ntiality
An inability to answer a question without giving excessive, unnecessary detail.
TLE,AIPD, LD, OP
tangent-ially
Wandering from the topic and never returning to it or providing the information requested.
The patient never reaches the point.
Neologism
Are wards or phrases, invented by the patient, often to describe a morbid experience. It occurs most often in chronic schizophrenia.