Disorders of Thinking
Disorders of Thinking
Disorders of Thinking
Disorders of Intelligence:
Intelligence is the ability to think and act rationally and logically.
The precise age at which the intellectual growth appears to slow down depends upon on
the type of tests used, but it now appears that intelligence, as measured by intelligence
tests begins its slow decline in middle-age and proceeds significantly less rapidly than
previously believed.
The most common way of measuring intelligence in terms of distribution of scores in the
population.
Mental age: is the score achieved by the average child of the corresponding age.
For historical reasons, most intelligence tests are designed to give a mean IQ of the
population of 100 with a SD of 15.
2 groups of subjects with low intelligence:
1. Intellectual Disability
2. Learning Disability
Dementia: Loss of intelligence resulting from brain disease, characterized by disturbances
of multiple cortical functions, including thinking, memory, comprehension and
orientation, among others.
Schizophrenic dementia: specific deficits in multiple cognitive domains exhibited by
schizophrenics. These deficits however do not represent a true dementia and are best
considered as part of the psychopathology of schizophrenia than as a form of dementia; in
particular, impairments of working and semantic memory seen in schizophrenia have
been linked to the dysfunction of:
Temporal cortex
Frontal cortex
Hippocampus
Disorders of Thinking:
3 legitimate uses of the word ‘think’:
1. Undirected fantasy thinking: aka autistic/ dereistic thinking
2. Imaginative thinking: does not go beyond the rational and the possible
3. Rational/conceptual thinking: attempts to solve a problem
Classification of DoT:
A. Disorders of Stream of thought
I. Disorders of thought tempo
1. 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.
The patient’s speech is easily diverted by external stimuli and by internal superficial
associations.
The 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.
Psychiatric conditions:
Mania: lively embellishment of their thinking.
Hypomania: ‘ordered flight of ideas’ despite many irrelevances, the patient is able
to return to the task in hand; the clang and verbal associations are not so marked and
the speed of emergence of thoughts is not as fast as in flight of ideas, known as
proloixity.
Schizophrenia
Organic states
2. 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.
Experienced by the patient as:
difficulty in making decisions,
lack of concentration
loss of clarity of thinking
a diminution in active attention, so that events are poorly registered.
Psychiatric conditions:
Depression
Manic stupor (rare condition)
3. Circumstantiality:
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.
Psychiatric conditions:
Learning disability
Obsessional personality traits
II. Disorders of continuity of thinking
1. Perseveration:
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.
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.
In the early stages of perseveration, the patient may recognise their difficulty and try
to overcome it.
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. In verbal stereotypy, the same word or
phrase is used regardless of the situation, whereas in perseveration a word, phrase or
idea persists beyond the point at which it is relevant.
2. Thought blocking:
occurs when there is a sudden arrest of the train of thought, leaving a ‘blank’.
An entirely new thought may then begin.
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.
Highly suggestive of schizophrenia.
B. Obsessions, compulsions and disorders of the possession of thought
I. Obsessions and compulsions
Obsession aka rumination: 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.
Features of obsessions:
Content often causes the sufferer great anxiety and even guilt
Thoughts are particularly repugnant to the individual
It appears against the patient’s will
Forms:
Obsessional images: vivid images that occupy the patient’s mind. At times
they may be so vivid that they can be mistaken for pseudohallucinations. Thus
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.
Obsessional impulses: impulses to touch, count or arrange objects, or impulses
to commit antisocial acts. Apart from obsessions with suicide and homicide in
depressed patients, it is very unusual for the obsessed patient to carry out an
obsessive impulse.
Obsessional fears or phobias: consist of a groundless fear that the patient
realises is dominating without a cause and must be distinguished from the
hysterical and learned phobias.
Compulsions: merely obsessional motor acts.
May result from:
An obsessional impulse that leads directly to the action or
May be mediated by an obsessional mental image or thought.
Psychiatric conditions (obsessions):
Obsessional states
Depression
Schizophrenia
Organic states (occasionally)
Psychiatric conditions (compulsions):
Post-encephalitic parkinsonism
OCD
II. Thought alienation
The patient has the experience that their thoughts are under the control of an outside
agency or that others are participating in their thinking.
Ego-dystonic
Forms:
1. Thought insertion: the patient knows that thoughts are being inserted into their mind
and they recognise them as being foreign and coming from without; this symptom,
although commonly associated with schizophrenia, is not unique to schizophrenia.
2. Thought deprivation: the patient finds that as they are thinking, their thoughts
suddenly disappear and are withdrawn from their mind by a foreign influence. It has
been suggested that this is the subjective experience of thought blocking and
‘omission’.
3. Thought broadcasting: the patient knows that as they are thinking, everyone else is
thinking in unison with them; 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;
C. Disorders of content of thinking
I. Over-valued ideas
The overvalued idea, first described by Wernicke, refers to a solitary, abnormal belief that
is neither delusional nor obsessional in nature, but which is preoccupying to the extent of
dominating the sufferer's life.
thought that, because of the associated feeling tone, takes precedence over all other ideas
and maintains this precedence permanently or for a long period of time.
Less fixed than delusions
Tend to have some degree of basis in reality.
II. Delusions:
delusion as a false, unshakeable belief that is out of keeping with the patient’s social and
cultural background.
Forms:
1. True delusions/ primary delusions
The essence of the primary delusional experience (also termed apophany) is that a new
meaning arises in connection with some other psychological event.
Schneider (1959) suggested that these experiences can be reduced to three forms of
primary delusional experience:
i. 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. Usually, the meaning
of the delusional mood becomes obvious when a sudden delusional idea or a
delusional perception occurs.
ii. Delusional idea: Delusion appears fully formed in the patient’s mind. This is
sometimes known as an 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.
iii. Delusional perception: a sudden, idiosyncratic, and often self-referential delusion
triggered by a neutral perceptual content. Refers to the attribution of a new meaning,
usually in the 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. The symptom’s ‘two memberedness’, as there is a link from the perceived
object to the subject’s perception of this object, and a second link to the new
significance of this perception. Using this criterion, Schneider (1959) divided
delusional memories into delusional perceptions and sudden delusional ideas.
2. Secondary delusions
as arising from some other morbid experience.
delusions can be secondary to depressive moods and hallucinations, and that psychogenic
or stress reactions can give rise to psychotic states with delusions.
Delusional work: once the primary delusions have occurred they are commonly integrated
into some sort of delusional system, this elaboration of delusions is ka ‘delusional work’.
i. Systematised: there is one basic delusion and the remainder of the system is
logically built on this error.
ii. Non-systematised
Content of delusions:
1. Delusions of persecution:
May occur in the context of primary delusional experiences, auditory hallucinations,
bodily hallucinations or experiences of passivity
Forms:
i. Delusion of reference: the patient knows that the people are talking about him,
slandering him or spying on him. Can occur in schizophrenia, depressive illness
and other psychotic illnesses.
ii. Delusions of guilt: can be so marked that the patient believes that he is about to
put to death or imprisoned for life.
iii. Delusion of family/ loved one getting harmed or killed
iv. Delusions of being poisoned or infected
v. 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.
2. Delusions of infidelity:
Aka delusion of jealousy
May occur in both organic and functional disorders.
Often the patient has been suspicious, sensitive and mildly jealous before the onset of
the illness.
Forms:
i. Delusions of marital infidelity: schizophrenia, organic brain disorders and
especially alcohol dependency syndrome, affective psychosis.
3. Delusions of love:
Aka ‘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.
Found in abnormal personality states, schizophrenia.
4. Grandiose delusions:
The expansive delusions may be supported by:
Auditory hallucinations
Confabulations
Grandiose and expansive delusions may also be part of fantastic hallucinosis in which
all forms of hallucinations occur.
Most common in: Manic psychosis in the context of BAD
5. Delusions of ill-health:
A characteristic feature of depressive illnesses, but also seen in schizophrenia.
May develop on a background of concerns about health
Depressive delusions of ill-health may
involve the patient’s spouse and children.
Take the form of primary or secondary delusions of incurable insanity: a
significant no of individuals with depression may develop the belief that they are
incurably insane.
Hypochondriacal delusions in schizophrenia may be the result of a depressed mood,
somatic hallucinations or a sense of subjective change.
Delusional preoccupation with facial or bodily appearances/ delusional
dysmorphophobia.
6. Delusions of guilt
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. They may claim to have committed an unpardonable sin and insist that they
will rot in hell for this.
In very severe depression, the delusions may even appear to take on a grandiose
character and the patient may assert that they are the evillest person in the world, the
most terrible sinner who ever existed and that they will never die but will be punished
for all eternity. These extravagant delusions of guilt are often associated with
nihilistic ones.
Furthermore, delusions of guilt may also give rise to delusions of persecution.
7. 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.
8. 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
The Pathology underlying delusions
A. The cognitive perspective:
individuals with delusions tend to make guesses based on less evidence than
individuals with psychiatric illness who do not have delusions.
Individuals with delusions tended to change their minds more rapidly than individuals
without delusions.
Gilleen & David (2005) provide a valuable review of the cognitive neuropsychiatry of
delusions, focusing on reasoning biases, attentional and attributional biases, and the
relevance of emotion and theory of mind.
B. Neuroimaging perspective:
associations between abnormalities of cingulate gyrus activation and persecutory
delusions (Blackwood et al, 2004),
between entorhinal cortex pathology and positive symptoms, especially delusions
(Prasad et al, 2004).
Blackwood et al (2000) suggest that anomalous connectivity or activity within defined
brain regions may be related to the formation of delusions,
Szeszko et al (1999) point to a possible neurodevelopmental aspect to the aetiology of
delusions.
D. Disorders of form of thinking
Aka formal thought disorder
Disorders of abstract or conceptual thinking
Most common in: schizophrenia and organic brain disorders
Formal thought disorder and schizophrenia:
1. Bleuler (1911) regarded schizophrenia as a disorder of the associations between thoughts,
characterised by the processes of condensation, displacement and misuse of symbols:
In condensation, two ideas with something in common are blended into one false concept,
In displacement one idea is used for an associated idea.
The faulty use of symbols involves using the concrete aspects of the symbol instead of the
symbolic meaning (‘concrete thinking’).
2. Cameron (1944): used the term ‘asyndesis’ to describe the lack of adequate connections
between successive thoughts.
He pointed out that the patient with schizophrenia may demonstrate particular
difficulty focusing on the issue at hand;
may use imprecise expressions (‘metonyms’)instead of more exact ones; and
may include excessive personal idiom and fantasy material in their speech.
Cameron placed particular emphasis on ‘over-inclusion’, which is an inability to
narrow down the operations of thinking and bring into action the organised attitudes
and specific responses relevant to the task at hand.
3. Goldstein (1944):
emphasised the loss of abstract attitude in patients with schizophrenia, which leads to
a ‘concrete’ style of thinking, despite the fact that the patient has not lost their
vocabulary
4. Schneider (1930):
claimed that five features of formal thought disorder could be identified:
i. derailment: the thought slides on to a subsidiary thought
ii. substitution: a major thought is substituted by a subsidiary one
iii. omission: consists of the senseless omission of a thought or part of it
iv. fusion: heterogeneous elements of thought are interwoven with each other
v. drivelling: disordered intermixture of constituent parts of one complex thought.
3 features of healthy thinking:
i. constancy: this is characteristic of a completed thought that does not change in
content unless and until it is superseded by another consciously-derived thought
ii. organisation: the contents of thought are related to each other in consciousness
and do not blend with each other, but are separated in an organised way
iii. continuity: there is a continuity of the sense continuum, so that even the most
heterogenous 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 three different
disorders of thinking that correspond to these three features of normal or non-
disordered thinking:
i. Transitory thinking: characterised 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.
ii. Drivelling thinking: the patient has a preliminary outline of a complicated thought
with all its necessary particulars, but loses preliminary organisation 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 organised and the
inner material relationships between them become obscured and change in
significance.
iii. 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.