The document discusses disorders of stream of thought, including disorders of tempo such as flight of ideas, retardation of thinking, and circumstantiality, as well as disorders of continuity such as perseveration and thought blocking. It provides definitions and examples of each disorder. Assessment methods are also summarized, including observation, clinical interviews, mental status examinations, scales like PANSS and BPRS, and other tools like the Rorschach ink blot test and Thought and Language Index.

1. DISORDERS OF STREAM
OF THOUGHT
By:
Syed Sajid Husain Kazmi
Clinical Psychologist & Director
Indian Mental Health & 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
• Induction 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:
1) Disorder of Tempo
2) Disorder of Continuity
Disorder of Tempo is further divide into:
i) Flight of Ideas
ii) Retardation of Thinking
iii) Circumstantialities
Disorder of Continuity is divided into:
(i) Perseveration
(ii) 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
1) 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…!!