psychiatry slides

1. Disorders of thought
Presenter- Niranjan
Chairperson- Dr. Th Bihari singh

2. What if today wasn’t my
seminar!!?

3. Scenario-1
• Well it slhd have been snowfall in here. So
that i could have come by ice skating to
hospital !!!
• Could make ice balls and played with
patients
• And when tired would do sun bath lying
beside someone special !!!
• Slhd fly down to my place daily after the
work !1

4. Scenario - 2
• I hope today is again band so that i can
finish off duties soon and watch sm film
• Once im done here ll go room and do gobi
manchurian but this time i have to chop
cauliflower bit small
• How about start using history taking format
instead writing down all history.

5. Scenario - 3
• I think v can increase the dose to optimum
dose of olanzepine for pt no3
• As bed no 4 pts party has some problem
back in their home , slhd ask the
consultant for discharge on reguest
• Ll go market to buy cauliflower after im
done with the duty

6. Types of thinking
• Process of thinking was divided by fish
into 3 types
• 1. undirected fantasy thinking
• 2. imaginative thinking
• Rational / conceptual thinking

7. 1. undirected fantasy thinking
• Autistic or dereistic thinking
• Quite common process of thinking(day
dreaming etc..)
• Might be more in certain individuals with
adverse life events or when placed with
repeated disappointments
• Shizophrenia, shizotypal personalities,
psychosis, DD

8. 2. imaginative thinking
• Generation of novel ideas and creative outputs
which constitute art or discoveries in science
• 1. mental imagery-ability to create image based
mental representations of world
• 2. counterfactual thinking- capacity to disengage
from reality in order to think of events and
experiences that have not occurred or may
never occur
• 3.symbolic representation- use of concepts or
images to represent real world objects. Basis of
language, art and maths.

9. Rational / conceptual thinking
• Problem solving-set of cognitive process
that we apply to reach a goal
• Reasoning- cognitive process that we use
to make inferences from knowledge to
draw a conclusion.

10. • Thinking is more than language and language is more than
thinking
-philips dale

11. • Thinking can be defined as cognitive
rearrangement or manipulation of both
information from environment and the
symbols stored in long term memory.
• Requires
• 1. images
• 2.words
• 3. language

12. Plan to sit down associations
(thought) ask sir dhananjay
is talking
pull over the chair coffee came
this chair is dirty legs are paining
phone is ringing how abt that chair
its getting cooler
constellation
goal

13. Model of associations by jasper
• Thinking(psychological performance) and
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.
• Constellation- mass of possible associations
resulting in a psychic event.
• Determining tendency- consistent flow of
thinking towards its goal .

14. Disorders of thought
• Possesion (source of water)
• Stream ( flow of river)
• Content ( water, mud etc..)
• Form (liquid form of water)

15. stream
• Volubility- copious, pressured speech, excessive
talking. Seen in mania( tachylogia, verbomania ,
logorrhea)
• Flight of ideas- thoughts follow each other rapidly, no
general directions, connection between successive
thoughts appears due to chance factors(clang or verbal
associations) , usually understood, easily distracted,
reversible,. Seen in mania, f-20, organic states, mixed
affective states
• Prolixity- “ordered flight of ideas” or marginal flight of
ideas
Goal reached, clag or verbal associations are not so
marked, speed of emergence of thoughts are not so fast,
unlike tedious elaboration of details in circumstantiality

16. • Retardation- train of thought is slowed down , number of
ideas and mental image themselves are decreased.
Although Goal directed they proceeds so slowly with
morbid preoccupation with gloomy thoughts that the
person may fail to reach goal. Little initiation to begin
planning or spontaneous activity. Seen in F-20 ,
depression
• Circumstantiality- slow thinking with many unnecessary
and trivial details, but finally point is reached..seen in
epileptic personality, obsessional personality, person who
tires to impress, F-20, dementia
• Tangentiality- replying to a question in a
oblique,tangential or even irrelevant manner.

17. • Thought blocking( thought derivation, snapping
off ) - sudden arrest of train of thoughts leaving a
“blank” . A new thought may begin after the pause.
With no recall of what was being said or going to
be said. seen in F-20, also in anxious or
exhausted states.
• Perservation- disturbance of thought where
retaining a constellation of ideas long after they
have to be appropriate.
Organic states to be ruled out.

18. Form disorders
• Form of thought means “arrangement of thoughts”. That
is how logically they are connected(syndesis)
• Healthy thinking should have: constancy, organisation,
continuity
• Schneider claimed 5 features of formal thought disorder-
derailment, substitution, omission, fusion, drivelling
• Formal thought disorder- conceptual or abstract thinking
disorder. Characterised by loosing of associations,
neologisms, illogical constructs
• Transitory thinking- derailments, ommisions,
substitutions.
• Drivelling thinking- muddling together all the thoughts
• Desultory thinking-grammatically correct but sudden
ideas force their way from time to time

19. • Loosening of associations- disturbance in logical
progression, failure to communicate , unrelated ideas
shifting from one another
• 1. knights move thinking or derailment- odd tangential
association between the ideas. Words makes sense but
not sentences.
• 2. talking past the point- (vorbeireden)seems to get close
to the point of discussion but skirts around and never
actually reaches it.
• 3.verbigeration /word salad/ paraphrasia/ schizophasia-
senseless repetition of sounds or phrases

20. possesion
• Obsession- intrusive, ego dystonic, irrational, against
will, fails to resist, may have temporary relief by yeilding
compulsions, associated with marked dysfunction.
• Obsessional thoughts
images
ruminations, phobias, illness
doubts, impulses
Thought alienation-thoughts are under the control of
outside forces and are participating in it.
Thought insertion-thoughts are not mine inserted by
outside

21. • Ruminations- train of thoughts usually unproductive,
prolonged on particular topic, repeatedly experienced, felt
as less intrusive, no compulsions, usually involves past
incident.
seen in OCD, depression, melancholia
• Thought withdrawal- taken away against his will by
outside forces. Usually associated with thought blocking.
The experience is passive
• Thought broadcasting- thoughts are leaving himself and
being diffused widely out of his control. The experience is
passive
• thought echo- type of auditory hallucination where hears
ones own thought spoken aloud
gedenkenlautwerden- hearing ones own thought spoken
just before or at the same time as occurring
Echo de la pensee-hearing them spoken after the
thoughts have occurred.

22. content
• Worry- subjective sense of tension or uneasiness.
• Phobias- persistent, pathological, unrealistic fear of an
object, situation
• Somatic symptoms- bodily complains which are varied in
anatomical location and are usually are not associated
with any pathology
• Religious preoccupation- seen n OCD
• Excessive day dreaming- schizotypal personality
• Homicidal ideas-F-20, ASP
• Philosophical ideas
• Magical ideas

23. • Depressive cognition- ideas of worthlessness,
helplessness, hopelessness
• Suicidal ideas
• DSH-
• Inflated self esteem- mania, narsissictic personality
• Delusion-a false, firm, unshakeable belief that is out of
keeping with patients socio-cultural background

24. Vectors or dimensions of
delusion
Conviction
Extension
Bizarreness
Disorganization
Pressure
Affective
response
Deviant behavior

25. Dimensions of delusions
• Affective response- degree to which pts emotions are
involved with it.
• Bizarreness-degree to which they differ from reality
• Conviction-degree to which pt is convinced of the belief
• Disorganizations- degree to which delusions are
internally consistent, logical, and systematized.
• Deviant behaviour- acting out on beliefs
• Extension- degree to which his believes involves pts life
• Preoccupation-degree to which the pt is preoccupied
and concerned with his expressed beliefs
• Systematization- framework created around delusions

26. Origins of a Delusion- Conrad
Trema
Apophany
Anastrophy
Consolidatio
n
Residuum

27. • Trema – delusional mood
• Apophany – search for and finding a new
meaning for psychological events
• Anastrophy- heightening of psychosis
• Consolidation- forming a new world or
psychological set based on new meanings
• Residuum – eventual autistic state

28. Primary delusions
• Primary delusions- are the one that appears suddenly and
with full conviction but with out any mental events leading
upto it. Primary delusional experience (apophony) may be
of
• 1. delusional mood or atmosphere-he knows that some
thing is wrong going around him that concerns him but he
does not know what it is.
• Delusional intuition/autochthonos delusion- appears fully
formed inside his mind.seen in organic states, epileptic
psychosis, personality disorders or even in normal
individuals.
• Delusional perception- attribution of a new meaning,
usually in the sense of self reference, to a normal
perceived object. Its different from delusion of
misinterpretation.
• Delusional memories- distorted or false memories coming
spontaneously into the mind

29. • Core feature of a primary or
autochthonous delusion is that it is
ultimately “ Ununderstandable” - Jaspers
• Eg: a female patient with schizophrenia
believes that men enter her flat
anesthetize her and gang rape her every
night.

30. Secondary delusions or
delusion like ideas
• Delusions derived from apparently preceding morbid
experience. Like primary hallucinations, affective states,
existing delusions.
• Overvalued ideas-is a thought because of associated
feeling tone, takes precedence over all other ideas and
maintains for a period of time. Less fixed than delusions,
some degree of basis in reality

31. • Delusion of reference-
• Delusion of persecutions
• Delusion of misidentification-
Capgrass syndrome-familiar person is replaced by nearly
identical duplicate.
Fregoli syndromes- familiar person acquires different
physical identities while psychological identity remains
the same.
Syndrome of intermetamorphosis-changing his physical
identity
Syndrome of subjective doubles- another person has
physically transformed into pts own self.
• Delusion of control
• Delusion of infidelity
• Delusion of love(de clerambolt syndrome)

32. Content of delusions
persecution
infidelity
love
Grandiose
guilt
Nihilistic
poverty

33. • Grandiose delusions- grandiose identity, ability, mission
• Delusion of illhealth
• Delusion of guilt
• Nihilistic delusion(cotard syndrome)
• Delusions of enormity
• Delusion of poverty
• Bizarre delusions
Pathology of delusions-1. cognitive underpinnings of
delusional beliefs. Focusing on reasoning biases, attention
and attributional biases, relevance of emotional and theory
of mind .
2. Neuroimaging perspective- persecutory delusion-
cingulate gyrus activation , entorhinal cortex – positive
symptoms

34. Resolution of delusion
• Integration- show low conviction in their belief, but
remain preoccupied with ideas. Usually keen to discuss
and try understand what happened in non psychotic
terms
• Sealing over- completely reject their beliefs
preoccupation drops to zero. Reluctant to discuss their
experiences
• Encapsulation-retain high conviction but preocccupation
and interference decreases

35. •Thank you