it contains a detailed information about thought disorders, types of thought disorder and scales for assessment of thought disorders

1. FORMAL THOUGHT
DISORDER
Sradhanjali Biswal
Tutor
Kalinga Institute Of Nursing Sciences
Bhubaneswar

2. FORM OF THOUGHT
• Conceptual / Abstract thinking
• Form: Consistent, uninterrupted and
organized flow of thinking towards its
goal (Jaspers)

3. FORMAL THOUGHT DISORDER
• The term ‘Formal thought disorder’ is
synonym for disorders of conceptual or
abstract thinking
• Once considered pathognomonic of
schizophrenia
• Occurs in :
- Schizophrenia
- Coarse brain disease.

4. Schizophrenic FTD can be divided into 2
subgroups:
Negative FTD:
Pt has lost his previous ability to think,
but does not produce any unusual concepts.
Positive FTD:
Pt produces false concepts by blending
together incongruous elements.

5. Thought, Language & Communication Disorder
• Poverty of speech
• Poverty of content of
speech
• Pressure of speech
• Distractibility of speech
• Tangentiality
• Derailment
• Incoherence
• Illogicality
• Clanging
• Neologisms
• Word Approximations
• Circumstantiality
• Loss of Goal
• Perseveration
• Echolalia
• Blocking
• Stilted Speech
• Self Reference
• Paraphasia – Phonemic
Semantic

6. Poverty of Speech
• Restriction in the amount of spontaneous speech
• Replies  Brief, Concrete & Unelaborated.
Monosyllabic
Some Quests unanswered
• To elicit  Must allow pt adequate time to
answer & to elaborate his answer.

7. Poverty of Content of speech (Alogia,
Verbigeration, Poverty of thought)
• Replies although speech is Adequate in amount
• Conveys Little Information
• Language  Vagueness, emptiness, Repetitive,
Stereotyped,
• Exclude : Circumstantiality
- Provide a wealth of details.

8. Pressure of Speech
Increase in amount of spontaneous speech
Sentences left incomplete with new ideas coming up
Talks rapidly & Difficult to interrupt
Loud and emphatic Speech
Talk without social stimuli & even no one is listening
More than 150 words / min

9. Distractible Speech
During interview or discussion
Stops talking in the middle of sentence or idea
Changes the subject in response to nearby
stimulus

10. Tangentiality
Replies  Oblique / Tangential / Irrelevant
manner
Reply : Related in distant way
Unrelated
Totally Irrelevant
Refers only to replies to questions
Not transitions in spontaneous speech

11. Derailment (Loose Associations, Flight
of Ideas)
Ideas slip off track onto another one.
- Obliquely related, or onto one which is
- Completely unrelated
“Disjointed Speech” – vague connect / No connect
MC  Slow, Steady slippage
Goes farther, farther & farther off the track
No longer has any connection with question
asked

12. Derailment
(Loose Associations, Flight of Ideas)
Goal  Not reached.
Characteristic --> Lack of cohesion between
clauses / sentence.
Flight of ideas is a derailment that occurs rapidly
in the context of pressured speech.
Exclude Tangentiality :
- Occurs as Immediate response to
questions.

13. Incoherence
(Word Salad, Jargon Aphasia, Schizophasia,
Para-grammatism)
Incomprehensible Speech
Cementing words (and, although, a, an) deleted
Often accompanied by Derailment
Difference with Derailment  Unclear
connections between larger units e.g. sentence /
clause

14. Contd..
Relatively rare.. But when occur  Severe FTD
Similar to Jargon Aphasia ..D/D Wernickes
Aphasia…R/O by History, Lab Investigations
etc.
Exclude  Mild Ungrammatical Constructions
Idiomatic use in Particular regional /
ethnic background, lack of
education, low intelligence.

15. Illogicality
Conclusions reached with No Logicality
Reaching conclusions on faulty premises
without actual delusional thinking.
Exclude… Delusions
Cultural & Religious Values

16. Clanging
Sounds govern the word choice (rather than
meaningful relationships)
Redundant words are introduced.
Rhyming relationships
Punning associations (word similar in sound
brings a new thought)
Example: I’m not trying to make noise. I’m
trying to make sense. If you can make sense out
of nonsense, well have fun. I’m trying to make
sense out of sense.

17. Circumstantiality
Indirect Speech with delayed in reaching goal
Tedious elaboration & Need to interrupt
“Long winded”
Exclude  Poverty of content of speech
Little information
Derailment
Goal not reached

18. Loss of Goal
Failure to follow chain of thought to its natural
conclusion
Begins with one subject  wanders away 
Not reached the goal
Often associated with Derailment

19. Perseveration
Senseless repetition of a goal-directed action / speech
which has already served its purpose / beyond
relevance.
Three types – 1. Compulsive Repetition
2. Impairment of Switching
3. Ideational / Thematic
Exclude…Stock words -- Inappropriate for their
usual meaning Pause fillers – you know, like, ok

20. Echolalia
Pt echoes words / phrases of interviewer
Repetitive & Persistent
More common in children
Exclude… Habit – To formulate answer
Indic by rewording question
/ repeating last words

21. Thought blocking
Interruption of train of speech before a thought /
Idea has been completed.
Entirely new thought may then begin.
Present if… Pt voluntarily describes losing his
thought. On question, indicated that blocking was
a cause for his pausing

22. Stilted Speech
Excessive Stilted / Formal quality
Use of particular word choices (Sorry, Please, at
your convenience)
Extremely polite phraseology

23. Self - Reference
Repeatedly refers subject under discussion back
to himself
Easily observed during-- Informal Conversation

24. Neologism
Completely new word / phrase whose
derivation can not be understood.
Also include incorrectly built up word with
understandable origin
For more clarification  Usually classified in
Word Approximations.

25. Word Approximations
(Paraphasia, Metonyms)
Old words used in new & unconventional way
New words formed by conventional rules of
word formation.
May be based on use of Stock words – Uses
words repeatedly in ways that give them a
meaning e.g. “Vessel”

26. Contd..
• Exclude…Incoherence Formal testing for
aphasia – Negative
Metaphorical words

27. Paraphasia - Phonemic
• Recognizable mispronunciation of words
• Sounds / Syllables slipped out of sequence
• Severe… Aphasia
• Mild….. Everyday speech—Slips of tongue
• Recognizes error & may attempt to correct it.

28. Paraphasia - Semantic
• Substitution of inappropriate word when trying to
say something specific
• May / May not recognize his error
• Typically in Wernickes Aphasia & Brocas
Aphasia
• Exclude.. Incoherence -- Negative formal test
Aphasia

29. More Pathological
- Poverty of Speech
- Poverty of content of
Speech
- Pressure of Speech
- Distractibility
- Derailment
- Tangentiality
- Incoherence
- Illogicality
- Clanging
- Neologisms
- Word Approximations
Less Pathological
- Circumstantiality
- Loss of goal
- Perseveration
- Blocking
- Echoloalia
- Stilted Speech
- Self Reference
Andreasen N; Scale for assesst of TLC Dis

30. Bleuler (1911)
• The outstanding feature of schizophrenic
FTD is the lack of connection between
associations, which gave rise to changeable
and unclear concepts.
• Loosening of associations was the basic
disorder on the premise of which Bleuler
described schizophrenic thought disorder

31. • Condensation: 2 ideas with something in
common are blended into a false concept.
• Displacement: one idea is used for an
associated idea.
• Misuse of symbols: using the concrete
aspects of the symbol instead of the
symbolic meaning.

32. Cameron
1) In-coordination
2) Interpenetration – Speech cont elmts which
belong to the task in hand interspersed with a
stream of fantasy which he cant stop
3) Fragmentation
4) Over-inclusion – Inablty to maint boundaries
of problem & to restrict operans to their limits.

33. Asyndesis:
The lack of adequate connections between
successive thoughts.
Metonyms:
The imprecise approximations in which pt. uses
some substitute term or phrase instead of a more
exact one.
Cameron points out that the patient developed
his own private mode of speech which is full of
personal idioms.

34. GOLDSTEIN
• Loss of abstract attitude of thinking
• Thinking becomes concrete and
superficial

35. Payne
• Tests of concrete thinking  Tests of over-
inclusion… which performed badly by
schizophrenics
• Schizophrenics with marked psycho motor
slowness have impaired tests of over-
inclusion
Chapman
• Cant free himself from major meaning of
word.

36. Schneider
Features of healthy thinking
Constancy :
Persistence of completed thought whether or not it is
simple or complicated in its content.
Organization :
the content of Thoughts related to each other & do not
blend with each other but separated in organized way.
Continuity :
Thoughts are arranged in order and are in continuum,
so that even the most heterogeneous subsidiary
thoughts, sudden ideas or observations which emerge
are arranged in order in the whole content of
consciousness.

37. • Constancy Derailment
Substitution
Omission
• Organization Drivelling
• Continuity Fusion

38. • Schneider claims that five features FTD could be
isolated. Viz.
• Derailment :Thought slides onto a subsidiary thought.
• Substitution: Major thought is substituted by
subsidiary one.
• Omission : Senseless omission of thought or part of it.
• Drivelling: Disordered intermixture of constituent
parts of one complex thought.
• Fusion: Heterogeneous elements of thought are
interwoven with each other.

39. Constancy Derailment Transitory
Substitution
Omission
Organization Drivelling Drivelling
Continuity Fusion Desultory

40. Transitory thinking :
- Grammatical & syntactical structures are
both disturbed.
- Continuity is not loosened.
- Intention itself is affected.
Desultory thinking :
- Grammatically & syntactically correct
- Sudden ideas force their way time to time
- Each idea – simple & suitable thought.
. Driveling thinking:
-loses preliminary organization of thought so that
all the constituent parts get muddled together

41. 3 Symptoms groups in Schizophrenia
1. Desultory Group  Affective blunting
Lack of drive
Somatic Hallucinations
Desultory thinking
2. Thought withdrawal group  Transitory thinking
Thought withdrawal
Somatic Passivity
Religious & cosmic experince
Perplexity

42. Cont.
3. Drivelling Group  Primary Delusional Exprinc
Loss of interest
Inadeq affective responses
Drivelling thinking.

43. Mania: Carlson and Goodwin (1973) followed 20
manic patients through an episode and noted that
100% showed pressure of speech, 75% showed
flight of ideas and 70% had loose associations.
Dubin and Martin (1977) reported neologism in a
manic patient and poverty of content of speech in
another.

44. Depression: In contrast to mania, studies
examining thought disorders in depression are
few. Lewis (1934) examined speech patterns of
61 cases of "melancholia" and found 21 patients
had over productive speech. The overall content
was coherent although topics mostly revolved
around depressive themes. Distractibility was
also observed in a number of patients.
Andreasen and Grove (1986) found greater
frequency of poverty of speech, poverty of
content of speech and self referential speech in
their sample of 36 depressed patients.

45. Delirium: Cutting (1987) studied thought
disorder in 74 patients who showed psychosis in
the setting of some clearly identified organic
cause and compared it with 74 patients of acute
schizophrenia.
Thought disorder was present in 63% of cases,
common types encountered being illogicality
(20%), poverty of speech (19%) and
tangentiality (8%). Four patients showed
circumstantiality and two showed neologisms.
Thus, thought disorders remain uncommon in
delirium thought it may show occasional
resemblance to schizophrenic speech.

46. Epilepsy : Changes in personality in long-
standing epilepsy, including circumstantiality and
slowness of thinking, has been described by
Kraepelin (1923) and Gruhle (1929).
Gastaut and colleagues (Gastaut et
al,1953;Gastaut,1954) observed similar features
in patients with temporal lobe epilepsy.
Bear and Fedio (1977) devised a 100-item
questionnaire to validate the epileptic personality.
Subsequent works in this field have demonstrated
circumstantiality and viscosity of thought in
epileptic patients (Herman and Riel,1981;Bear et
al,1982)

47. Normal individuals: Since the works of Gruhle (1929),
Beringer (1924) and Schneider (1958), taking a
phenomenological approach, emphasized the normality
of several thought disorders. He proposed that "thought
blocking" occurred frequently in shy and embarrassed
people and "disjointed" or "fragmented" thinking
occurred to a lesser degree in normal and in those who
were "scatter-brained" either in normal circumstances
or when drunk.

48. SCALE FOR ASSESSMENT OF FTD
Thought, language and communication scale (TLC)
(Andreasen, 1979)
Thought Disorder Index (TDI) (Johnston and Holzman,
1979)
Assessment of Bizzare-idiosyncratic thinking (Harrow
and Quinlan, 1985)
The Thought and Language Index (TLI) (Liddle et al,
2002)
Whitaker index of schizophrenic thinking (WIST)
(Whitaker, 1973)
Impaired Categorical Thinking:
Illogical Thinking: Impaired Syllogistic Reasoning (von
Domarus, 1944) Object sorting tests

49. Conclusion
Thought disorder has come a long way since Bleuler’s
disturbances of association. Its presence across diverse
psychiatric disorders has prompted researchers in various
fields to explore its etiology from their own perspective.
However, no particular cause has been identified although
several researches have been carried out in last three
decades. Scales have been devised to bring universality to
the concept which was riddled with several confusing and
overlapping terminologies.
Those exploring psychosis have proposed that the
language specialization of human race came hand in hand
with psychosis. It remains to be .

50. THANK YOU