Seminar PPT.pptx

DISORDERS OF THOUGHT
Moderator
Dr. Deoshree Akhouri
Presented By
Maria Madiha

• Disorders of thought include disorders of
intelligence, stream of thought and possession of
thought, obsessions and compulsions and
disorders of the content and form of thinking.

DISORDERS OF INTELLIGENCE
• Intelligence is the ability to think and act rationally and
logically.
• 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.
• The most common way of measuring intelligence is in terms of
the distribution of scores in the population.

• Some intelligence tests used for children give a score
in terms of the mental age, which is the score
achieved by the average child of the corresponding
chronological age.
• Intelligence scores in a group of randomly chosen
subjects of the same age tends to have a normal
distribution.

• There are 2 groups of subjects with low intelligence-
• ‘learning disability’- individuals whose intelligence is at
the lowest end of the normal range and is therefore a
quantitative deviation from the normal.
• ‘intellectual disability’- with learning disability comprise
individuals with specific learning disabilities.

• Learning disability tends to be categorized as-
a) borderline (IQ=70−90)
b) mild (IQ=50−69)
c) moderate (IQ=35−49)
d) severe (IQ=20−34)
e) profound (IQ <20)

• Dementia is a loss of intelligence resulting from brain
disease, characterized by disturbances of multiple
cortical functions, including thinking, memory,
comprehension and orientation (World Health
Organization, 1992).

• Individuals with schizophrenia tend to exhibit specific
deficits in multiple cognitive domains, earlier known as
‘schizophrenic dementia’.
• Impairments in working and semantic memory has been
linked to dysfunction of the temporal cortex, frontal
cortex and hippocampus.

DISORDERS OF THINKING
 The process of thinking was divided by Fish (1967)
into the following three types:
a) undirected fantasy thinking (which, in the past, has also
been termed autistic or dereistic thinking)
b) imaginative thinking, which does not go beyond the
rational and possible
c) conceptual thinking, which attempts to solve a problem.

FANTASY THINKING
• Fantasy has an important function in the way we all carry
out our everyday activities, for instance we model our
speech and behaviour in imagination before an important
encounter or event, and afterwards we rehearse our
performance in fantasy to evaluate it and assess whether
we could have done better.

• Shy, reserved people, not suffering from mental illness, may
use dereistic thinking to compensate for the disappointments
of life.
• Bleuler (1911) saw this isolation from the real world into
autistic thinking as characteristic of schizophrenia: which was
partly the result of formal thought disorder.

• Various types of experience come into the category of acting
out fantasy, such as pathological lying (pseudologia
fantastica), hysterical conversion and dissociation (somatic and
psychological dissociative symptoms) and the delusion-like
ideas occurring in affective psychoses.
• These types can be understood as arising from the patient’s
affective and social setting.

• Fantasy thinking may also reveal itself in the denial of external
events.
• The slip of the tongue, or the ‘forgetting’ of the emotionally
laden word is not accidental; it is a form of self-deception.
• The obvious, significant, but unpleasant, object of perception
may be ‘overlooked’, and this often reveals fantasy denial.
• 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.

IMAGINATIVE THINKING
• There are at least 3 components of imagination-
• Mental imagery refers to the ability to create image-based on
mental representations of the world.
• 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.
• Symbolic representation is the use of concepts or images to
represent real world objects or entities (Roth, 2004).

• A facet of this type of thinking that comes from a
psychoanalytic theoretical stance is the concept of maternal
reverie (Bion, 1962).
• The mother, while in the situation, both physical and mental,
of ‘holding the baby’ (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.

RATIONAL OR CONCEPTUAL THINKING
• Problem solving and reasoning are two key aspects of rational
thinking.
• Problem solving is defined as the set of cognitive processes
that we apply to reach a goal when we must overcome
obstacles to reach that goal.
• Reasoning is 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).

• Strategies for problems involve the use of heuristics, that is,
rules of thumb that usually give the correct answer.
• Typically, reasoning involves analogies, induction or
deduction.
• Analogy reasoning involves the application of solutions to
already known problems to new problems with similar
characteristics.
• For example, if you lose the keys to your locked briefcase, you
can apply the knowledge to this new problem that sharp-ended
implements can be used to open padlocks.

• Inductive reasoning is formulated as generalizing from a single
instance to all instances.
• An example is ‘my cat has four legs’, therefore ‘all cats have
four legs’.
• Deductive reasoning involves an argument in which if the
premises are true, the conclusion cannot be false.
• This is usually studied by way of syllogism: (a) all Martians
are green, (b) my father is a Martian, (c) my father is green.

CLASSIFICATION OF DISORDERS OF THINKING
Disorders of thought have been classified as-
a) Disorders of stream of thought
b) Disorders of the possession of thought
c) Disorders of the content of thinking
d) Disorders of the form of thinking

DISORDERS OF STREAM OF THOUGHT
It is of 2 types-
a) disorders of thought tempo
b) disorder of continuity

Disorders of Thought Tempo-
 Flight of Ideas-
 thoughts follow each other rapidly
 there is no general direction of thinking
 the connections between successive thoughts appear to be due
to chance factors which can usually be understood.
 patient’s speech is easily diverted to external stimuli and by
internal superficial associations.
 For example- 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.

 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.
 An example of flight of ideas, typical in mania, where a
patient was asked where she lived and she replied:
‘Birmingham, Kingstanding; see the king he’s standing,
king, king, sing, sing, bird on the wing, wing, wing on
the bird, bird, turd, turd.’

 In hypomania so-called ‘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.’

 Although these patients cannot keep accessory thoughts out of
the main stream, they only lose the thread for a few moments
and finally reach their goal.
 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.
 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, which are associated with a range of
psychological effects, including features of mania and
disturbances of personality.

 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.

 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.
 The apparent cognitive deficits in individuals, with slowing of
thinking in depression, may lead to a mistaken diagnosis of
dementia.
 Individuals with depression may experience such difficulties
owing to anxious preoccupation and increased distractibility.
 Slowing of thinking is seen in both depression and the rare
condition of manic stupor.

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.
 Circumstantiality, however, can also occur in the context
of learning disability and in individuals with obsessional
personality traits.

Disorders of Continuity of Thinking
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.

 Common in generalized and local organic disorders of the
brain, and, when present, provides strong support for such
a diagnosis.
 It is clear that this is not a problem of volition, which
helps differentiate it from verbal stereotypy, which is a
frequent spontaneous repetition of a word or phrase that is
not in any way related to the current situation.

Thought Blocking-
 occurs when there is a sudden arrest of the train of
thought, leaving a ‘blank’.
 entirely new thought may then begin.
 In patients who retain some insight, this may be a
terrifying experience; this suggests that thought blocking
differs from the more common experience of suddenly
losing one’s train of thought, which tends to occur when
one is exhausted or very anxious.
 When thought blocking is clearly present it is highly
suggestive of schizophrenia.

DISORDERS OF POSSESSION OF THOUGHT
Obsessions and Compulsions-
 Obsession (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.

 It is of interest that the earlier writers emphasized the
predominance of sexual obsessions, whereas nowadays it
would appear that the most common forms of obsession
tend to be concerned with fears of doing harm (for
example, a mother with an obsession that she may harm
her baby).
 This may reflect social change; the Victorians were
particularly worried about sex, while modern man is more
preoccupied with aggression and risk.
 It is important to distinguish between obsessions and
compulsions.

• Compulsions are merely obsessional motor acts.
 They may result from an obsessional impulse that leads
directly to the action, or may be mediate by an
obsessional mental image or thought.
 For example- when the obsessional fear of contamination
leads to compulsive washing.

 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.
 Thus, we have obsessional mental images, ideas, fears and
impulses, but not obsessional hallucinations or moods.

 Obsessional images are vivid images that occupy patient’s
mind. At times they may be so vivid that they can be
mistaken for pseudo-hallucinations.
 For example- One patient was obsessed by an image of
his own gravestone that clearly had his name engraved on
it.

 Obsessional ideas take the form of ruminations on all
kinds of topics ranging from why the sky is blue to the
possibility of committing fellatio with God.
 Sometimes obsessional thinking takes the form of contrast
thinking in which the patient is compelled to think the
opposite of what is said.
 This can be compulsive blasphemy, for example, God
Almighty becomes Sod Allshitey.

 Obsessional impulses may be impulses to touch, count or
arrange objects, or impulses to commit antisocial acts.
 Obsessional fears or phobias consist of a groundless fear
that the patient realizes is dominating without a cause,
and must be distinguished from the hysterical and learned
phobias.

 Obsessions occur in-
a) obsessional states
b) depression
c) schizophrenia
d) occasionally in organic states
 Compulsive features appear to be particularly common in
post-encephalitic parkinsonism.

Thought Alienation-
 patients experience that their thoughts are under the control of
an outside agency or that others are participating in their
thinking.
 In pure 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, is commonly
associated with 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. This is the subjective
experience of thought blocking and 'omission’.

 In thought broadcasting, the patient knows that as they are
thinking, everyone else is thinking in unison with them.
 These phenomena can be approached through the prism
of egosyntonicity/ egodystonicity.
 Egosyntonic is experience that is consistent with the goals
and needs of the ego and/or consistent with the
individual’s ideal self-image; the reverse is the case for
egodystonicity.

DISORDERS OF CONTENT OF THINKING
 Delusion is a false, unshakeable belief that is out of
keeping with the patient’s social and cultural background.
 True delusions are the result of a primary delusional
experience that cannot be deduced from any other morbid
phenomenon.
 Delusion like idea is secondary and can be understandably
derived from some other morbid psychological
phenomenon – these are also described as secondary
delusions (Sims, 1995).

 Overvalued idea (occurs with/without mental illness)
takes precedence over all other ideas and maintains this
precedence permanently or for a long period of time.
 At times, it may be difficult to distinguish between
overvalued ideas and delusions even though overvalued
ideas tend to be less fixed and have some degree of basis
in reality.

Primary Delusions-
 The essence of the primary delusional experience
(apophany) is that a new meaning arises in connection
with some other psychological event.
 Schneider (1959) suggested that these experiences can be
reduced to 3 forms of primary delusional experience-
a) delusional mood
b) delusional perception
c) 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. This is sometimes known as
autochthonous delusion.

 In patients with depressive disorders or severe personality
disorders sudden ideas of the nature of delusion-like ideas
or overvalued ideas can occur.
 If a patient has a very grandiose or bizarre sudden idea, a
diagnosis of schizophrenia should be actively considered.

 The delusional perception is the attribution of a new
meaning, (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.
 For example- stairs creak perceived as someone spying.

• Schneider emphasized the importance of this symptom’s
‘two memberedness’, as there is a link from the perceived
object to the subject’s perception of that object, and a
second link to the new significance of that perception.
• For example- if the patient says that they are of royal
descent because they remember that the spoon they used
as a child had a crown on it, this is really a delusional
perception because there is the memory and also the
delusional significance, i.e. the ‘two memberedness’.

 If the patient says that they are of royal descent because when
they were taken to a military parade as a child the king saluted
them, then this is a sudden delusional idea because the delusion
is contained within the memory and there is no ‘two
memberedness’.
 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 and Systematization-
 can be understood as arising from some other morbid
experience.
 There is now considerable acceptance that delusions can be
secondary to depressive moods and hallucinations and that
psychogenic or stress reactions can give rise to psychotic states
with delusions.
 For example- acute polymorphic psychotic disorders in ICD−10
and brief psychotic disorder with stressor in the DSM−IV.

• Personality also play a role in the genesis of delusional
states; abnormally suspicious personalities can react to
difficulties with deepening ideas of persecution, or may
slowly develop delusions of marital infidelity or bodily ill
health.
• Certain paranoid psychoses have been explained as
‘understandable’ developments of sensitive personalities.

 In schizophrenia, once primary delusional experiences have
occurred, they are commonly integrated into delusional system.
This elaboration of delusions is known as ‘delusional work’.
 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.

CONTENT OF DELUSIONS
 Delusions of Persecution- may occur in the context of primary
delusional experiences, auditory hallucinations, bodily
hallucinations or experiences of passivity.
 Delusion of reference, where patient knows that people are
talking about him or spying on him.
 Ideas and delusions of reference are not confined to
schizophrenia and can occur in depressive illness and other
psychotic illnesses.

 Delusion of guilt, patient believes he is about to be put to
death- generally justified by patient.
 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.

 Delusions of influence are a ‘logical’ result of experiences of
passivity in the context of schizophrenia.
 Passivity feelings are explained by the patient as the result of
hypnotism, demonical possession, witchcraft, radio waves,
atomic rays or television.
 In day-to-day clinical practice it is common for the word
‘paranoid’ to be used as a substitute for the word ‘persecutory,’
but the correct meaning of the word paranoid is ‘delusional.

 Delusions of infidelity- delusion of jealousy
 may occur in both organic and functional disorders-
a) schizophrenia
b) organic brain disorders
c) alcohol dependency syndrome
d) affective psychosis
 It may develop gradually, as suspicious or insecure person
becomes more and more convinced of their spouse’s infidelity
and finally reaches delusional intensity.

 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.

 Grandiose Delusions-
 Some patients may believe they are God, the Queen of England,
a famous rock star, etc. 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, or
confabulations, when, for example, the patient gives a detailed
account of their coronation or marriage to the king.
 Grandiose and expansive delusions may also be part of fantastic
hallucinosis in which all forms of hallucination occur.

 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-
 are a characteristic feature of depressive illnesses, but are also
seen in other disorders, such as schizophrenia.
 It may develop on a background of concerns about health;
many people worry about their health and when they become
depressed they may naturally develop delusions or overvalued
ideas of ill health (cancer, tuberculosis, AIDS).
 Depressive delusions of ill health may involve the patient’s
spouse and children.

 Depressed mood, somatic hallucinations or a sense of
subjective change may result in hypochondriacal delusions in
schizophrenia.
 Chronic hypochondriasis may also be linked with personality
development.
 Delusional dysmorphophobia is delusional preoccupations
with facial or bodily appearance.

 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.
 Furthermore, delusions of guilt may also give rise to delusions of
persecution.

 Nihilistic Delusions- 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.
 It occurs in severe, agitated depression, schizophrenia,
delirium.

 Delusions of enormity, 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 is convinced that they
are impoverished and believe that destitution is facing
them and their family.
 These delusions are typical of depression.

DISORDERS OF 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.
 Bleuler (1911) regarded schizophrenia as a disorder of
associations between thoughts, characterized by process of
condensation, displacement and misuse of symbols.
 Cameron (1944), used the term ‘asyndesis’ to describe the lack
of adequate connections between successive thoughts.
 He placed particular emphasis on ‘over-inclusion’, the
inability to narrow down the operations of thinking and bring
into action the organized attitudes and specific responses
relevant to the task at hand.

 Schneider (1930) claimed that 5 features of formal thought
disorder could be identified-
a) derailment
b) substitution
c) omission
d) fusion
e) drivelling- is disordered intermixture of constituent parts of
one complex thought (talking rubbish, babbling, etc.)

 Schneider suggested there were 3 features of healthy thinking-
a) Constancy- characteristic of a completed thought that does
not change in content unless and until it is superseded by
another consciously-derived thought.
b) Organization- contents of thought are related to each other in
consciousness and do not blend with each other, but are
separated in an organized way.
c) Continuity- there is a continuity of the sense continuum, so
that even the most heterogeneous subsidiary thoughts, sudden
ideas or observations that emerge are arranged in order in the
whole content of consciousness.

 Schneider claimed that individuals with schizophrenia
complained of 3 different disorders of thinking that correspond
to these 3 features of normal or non-disordered thinking.
a) a peculiar transitoriness of thinking
b) driveling thinking - the lack of normal organization of
thought
c) desultory thinking

 Transitory Thinking-
 It 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.

 Drivelling Thinking-
 The patient has a preliminary outline of a complicated thought
with all its necessary particulars, but loses preliminary
organization of the thought, so that all the constituent parts get
muddled together.
 The patient with drivelling have a critical attitude towards their
thoughts, but these are not organized and the inner material
relationships between them become obscured and change in
significance.

 Desultory Thinking-
 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.

THE PROCESSES OF DISORDERED THINKING
A MODEL OF ASSOCIATIONS
• In this model of thinking (psychological performance),
thoughts (psychological events) can be seen to flow in an
uninterrupted sequence so that one or more associations,
with resulting further psychological events, may arise
from each thought.
• The mass of possible associations resulting from a
psychic event 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.
• The idea of associations is not intended to imply that one
psychological event evokes another by an automatic,
unintelligent, non-verbal reflex, but that the thought, which
may be expressed verbally or not, is a concept that results in
the formation of a number of other concepts, one of which is
given prominence by operation of the determining tendency.

ACCELERATION OF THINKING
• Acceleration of flow of thinking occurs as flight of ideas. In
this, there is a logical connection between each of two
sequential ideas expressed.
• However, the goal of thinking is not maintained for long. It is
continuously changing because of the effect of frivolous affect
and a very high degree of distractibility.
• The determining tendency is weakened, but associations are
still formed normally. The speed of forming such associations,
and therefore of the pattern of thought, is grossly accelerated.

• Confusion psychosis where thinking is disordered while mood
and psychomotor activity are unimpaired.
• In the excited form of this, incoherent pressure of speech is
prominent, the context of which is out of keeping with the
situation.
• There may be transient, almost playful, misidentifications of
people; fleeting ideas of reference; and auditory hallucinations.
In the inhibited state of confusion psychosis, there is poverty
of speech, almost mutism.
• There may also be perplexity, ideas of reference, ideas of
significance, illusions and hallucinations – auditory, visual or
somatic.

RETARDATION
• In retardation (such as occurs in depression), thinking,
although goal-directed, proceeds so slowly, with such morbid
preoccupation with gloomy thoughts, that the person may fail
to achieve those goals.
• Depression, although usually associated with retardation of
thought, may occur with agitation; there may be a complex
situation with impaired concentration from retardation and a
subjective experience of restless, anxious thoughts.

CIRCUMSTANTIAL THINKING
• In circumstantial thinking, the slow stream of thought is not
impeded by affect but by a defect of intellectual grasp, a
failure of differentiation of the figure from ground.
• Characteristically, this occurs in patients with epilepsy, and it
is seen in other organic states and in mental retardation.
• A somewhat similar process occurs with obsessional
personality, but here the excess of detail is introduced
anxiously to avoid any possible omissions: I’s are dotted, t’s
crossed to such an extent that the process of reaching a goal is
substantially impaired.

INTERRUPTION TO THE FLOW OF THOUGHT
• Carl Schneider (1930) has described some of these
abnormalities: fusion or ‘melting’ (verschmelzung), muddling
(faseln), snapping off (entgleiten), derailment (entgleisen).
These processes (and others) occur together to give the patient
a feeling of confusion and bewilderment.
• In derailment, there is a breakdown in association so that there
appears to be an interruption of thoughts bearing no
understandable connection with the chain of thoughts.
• With derailment, the subject is unable to link the ideas and
describes a change in his direction of thinking.

• With fusion, there is some preservation of the normal chain of
associations, but there is a bringing together of heterogeneous
elements. These form links that cannot be seen as a logical
progression from their constituent origins towards the goal of
thought.
• Schneider’s mixing or muddling implies a grossly disordered
amalgam of the constituent parts of a single thought process
and represents extreme degrees of fusion and derailment. The
resultant speech disorder has been called drivelling.

CHANGES IN THE FLOW OF THINKING
• Two further abnormalities of the flow of thought are crowding
of thought and perseveration.
• 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.

• Perseveration is characteristically an organic symptom. The
patient retains a constellation of ideas long after they have
ceased to be appropriate.
• In perseveration, a correct response is given by the patient to
the first stimulus, for example ‘Where do you live?’ – ‘Rowley
Regis’.
• However, any subsequent stimuli that demand different
responses may get this same, by now inappropriate, first
response, for instance, ‘What is the capital of France?’ –
‘Rowley Regis’, ‘Who lives at home with you?’ – ‘Rowley …
my son and his wife’.

DISTURBANCE OF JUDGEMENT
• A judgement is a thought that expresses a view of reality.
• Assessment of faulty judgement is not made solely on the
basis of that particular belief or argument but on taking the
whole of the person’s behaviour and opinions into account.

• Delusions are, of course, a disturbance of judgement.
• Various forms of thought disorder and intellectual deficit may
also result in disturbance of judgement.
• Although it is usual to describe delusions as disorders of
thought content, it is important to be aware that primary
delusions are not merely to be understood in this way.
• The whole process of thought in primary delusion is
disordered, not just the content.

CONCRETE THINKING
• Abnormal processes of thinking in schizophrenia and organic
states may result in a literalness of expression and
understanding.
• Abstractions and symbols are interpreted superficially without
tact, finesse or any awareness of nuance; the patient is unable
to free himself from what the words literally mean, excluding
the more abstract ideas that are also conveyed. This
abnormality is described as concrete thinking
(Goldstein,1936).
• For example, a female patient with schizophrenia came into
the room for interview and promptly took her shoes off,
saying, ‘I always like to keep my feet on the ground when I’m
talking’.

SUMMARY
• Thinking is the process of considering or reasoning about
something.
• Disorders of thought includes disorder of stream of
thought, possession, content and form.
• Disorder of stream of thoughts include disorder of tempo
(flight of idea, inhibition, circumstantiality) and disorder
of continuity of thinking (perseveration, thought blocking).
• Disorder of possession includes obsessions and
compulsions and thought alienation.

• Disorders of content includes primary delusions,
secondary delusions and systematisation.
• Content of delusions include delusion of persecution,
infidelity, love, grandiosity, ill health, guilt, nihilistic
delusions and delusions of poverty.
• Disorders of form includes transitory thinking, drivelling
thinking and desultory thinking.

• In model of associations, thoughts can be seen to flow in
an uninterrupted sequence so that one or more
associations may arise from each thought. The sequence
of thoughts, with the associations linking them, forms the
framework of this model.
• Thought interruption includes fusion, derailment,
muddling, etc.
• Changes in flow of thinking includes perseveration and
crowding thoughts.

REFERENCES
Fish’s Clinical Psychopathology
SIMS’ Symptoms in the Mind
Synopsis of Psychiatry, Kaplan and Sadock

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