Formal thought disorder

Just like when a physician sees a patient and looks for signs of physical illness, when a psychiatrist meets a patient they are looking for signs of psychiatric illness.  This is important because when people are suffering a deterioration in their mental health, they often describe similar experiences and these signs of mental illness are referred to as psychopathology.  When different psychopathological signs are identified and grouped together they can lead to the formation of a psychiatric diagnosis.

One of the most interesting psychopathology signs is formal thought disorder (FTD) which refers to the sort of disorganised speech which is a manifestation of psychosis

When people are describing a patient’s mental state they often write ‘no FTD’ when they wish to convey that the patient is coherent and can make themselves understood.  It’s a little bit more subtle than that; if a patient is intoxicated or delirious they will be incoherent but they will not necessarily be thought disordered.  Thought disorder refers to a particular set of language errors which are seen in psychosis. 

The name is rather strange.  Although it is called ‘formal thought disorder’ it actually refers to what a patient is saying.  The name is historical as when disorders of speech due to psychiatric illness were first being described (Bleuler, amongst others, was important in this), it was felt that disorders of thought form (disorganised speech) and content (delusions) should be considered separately.  Formal thought disorder therefore is a disorder of speech rather than content*.  

Normal human thinking has three characteristics

1. Content: what is being thought about – this would include delusions and obsessional thoughts

2. Form: in what manner, or shape, is the the thought about; abnormalities of the way thoughts are linked together

3. Stream or flow: how it is being thought about – the amount and speed of thinking

Different elements of formal thought disorder have been described. With his early work, Bleuler considered FTD to be when there was a loosening of associations which lead to fragmentary ideas being connected illogically.  This is seen clearly in the picture above.  Confusingly though, there appears to be no consensus about exactly what can be included formal thought disorder; it appears that most people would now use the term ‘thought disorder’ which refers to both errors of form and stream. Content is still considered separately.  

 

Disorder of stream of thought 

(I’ve split up these into disorder of thought form and stream, but several could be argued both ways)

Flight of ideas is when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.  The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have been spoken.  These verbal distractions may be of three kinds: clang associations, puns and rhymes.

Retardation of thinking is often seen in depression, the train of thought is slowed down, although still goal directed.  The opposite is pressure of speech and this is often seen in mania.

Peseveration is the persistent and inappropriate repetition of the same thoughts.  In reply to a question a person may give the correct answer to the first but continue to give the same answer inappropriately to subsequent questions.  This is especially seen in ‘organic’ brain disorders like dementia.

 

Disorders of thought form:

Overinclusion refers to a widening of the boundaries of concepts such that things are grouped together that are not often closely connected.

Loosening of associations denotes a loss of the normal structure of thinking.  The patient’s discourse seems muddled and illogical and does not become clearer with further questioning; there is a lack of general clarity, and the interviewer has the experience that the more he/she tries to clarify the patient’s thinking the less it is understood.  Loosening of associations occurs mostly in schizophrenia

Three kinds of loosening of association have been described:

Knight’s move thinking or derailment where there are odd tangential associations between ideas. 

Talking past the point (= vorbeireden) where the patient seems to get close to the point of discussion, but skirts around it and never actually reaches it

Verbigeration (= word salad = schizophasia = paraphrasia) where speech is reduced to a senseless repetition of sounds and phrases  (this is more of a disorder of thought form)

Circumstantiality is where thinking proceeds slowly with many unnecessary details and digressions, before returning to the point.  This is seen in epilepsy, learning difficulties and obsessional personalities 

Neologisms are words and phrases invented by the patient or a new meaning to a known word

Metonyms are word approximations e.g. paperskate for pen

Derailment (aka entgleisen) is where there is a change in the track of thoughts.  There is perserved, but misdirected determining of tendency/goal of thought)

With drivelling there is a disordered intermixture of the constituent parts of one complex thought

Fusion is where various thoughts are fused together, leading to a loss of goal direction.

Omission is where a thought or part of a thought it is senselessly omitted

Substitution is where one thought fills the gap for another appropriate more ‘fitting-in’ thought.

Concrete thinking is seen as a literalness of expression and understanding, with failed abstraction.  Can be tested by the use of proverbs.

Thought block  refers to the sudden arrest in the flow of thoughts.  The previous idea may then be taken up again or replaced by another thought.

 

As you can tell this is a big subject and I haven’t got onto the historical attempts to characterize schizophrenic thought processes (by Kraepelin, Bleuler, Goldstein, Cameron and Schneider) or the linguistic classification of speech abnormalities in psychosis. 

Further reading

Andreasen NC. Thought, language, and communication disorders. I. A Clinical assessment, definition of terms, and evaluation of their reliability. Archives of General Psychiatry 1979;36(12):1315-21

*Quite why they choose this name though it unclear to me, and if anyone else can shed more light on it I would be grateful. 

21 Responses to “Formal thought disorder”

  1. Paul says:

    I just wrote a short something on this for my thesis which may or may not be of interest!

    Is thought disorder a mood disorder?

    There is good evidence suggesting thought disorder, one of the supposed cardinal symptoms of ‘schizophrenia’, is not unique to people who receive this diagnosis or to non-affective psychosis generally, but is also experienced by people given diagnoses of manic depression (Pope and Lipinski, 1978), mania (Wilcox, 1992) and depression (Donnelly and Waldman, 1980; Ianzito, Cadoret and Pugh, 1974; Wilcox, Ramirez and Baida-Fragoso, 2000).

    Little research has been carried out on the prevalence of thought disorder in depression. However Wilcox et al., (2000) reported that 30 (78%) out of 38 people with psychotic depression and 11 (28%) out of 40 people with non-psychotic depression displayed thought disorder, and Ianzito et al (1974) reported 12 (20%) out of 60 inpatients with unipolar depression had this phenomena.

    In reviewing these and other studies Lake (2008) has recently suggested thought disorder may be more appropriately viewed as a symptom of severe mood disorder. Evidence supporting the link with affective disturbance comes from Haddock and colleagues (1995) who demonstrated that the amount of thought disorder displayed by people with a diagnosis of schizophrenia increased when discussing emotionally salient material (Haddock, Wolfenden, Lowens, Bentall et al., 1995).

    Lake (2008)
    http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/34/1/109

  2. Paul says:

    Regarding the image you used to illustrate thought disorder, here’s some more which are not too dissimilar:

    http://www.angelidakis.com/2blog/DSC02167.jpg
    http://www.stagisblog.com/stagis/images/2007/10/19/david1.jpg
    http://www.davidshrigley.com/draw_htmpgs/the_beast/1_a_bedtime_story.html

    They are by Glasgow artist David Shrigley. If he was sectioned and started to produce this stuff, how would it be interpreted? I’m not saying the patient who produced the scribbles in the image you used was not distressed or ‘psychotic’, but are his or her writings any more incomprehensible than Shrigley’s stuff if it was presented out of context?

  3. Frontier Psychiatrist says:

    Paul, thanks for the links for David Shrigley. I’d not heard of him and I like his stuff. There are two things to say about the links you present:

    First a judgement of someone’s mental health is not an absolute thing. Therefore, to a large extent, the way someone acts is only indicative of mental illness if it represents a change from how they are normally. If Shrigley had never produced these pieces before, but had been an accountant in Reading and they were seen on the background of a significant deterioration in psychosocial function then they might be used as evidence for a disorder in mental health. But on their own? Do you see how much I’m having to qualify this?

    Second, the three links you give are to text that is not to my mind thought disordered. They all contain a single theme and are written in a stylistically, if not grammatically, coherent way and show none of the loosening of associations that characterises thought disorder. You won’t get a erudite linguistic breakdown from me, but if you read the piece above out loud and then the Shrigley pieces you’ll see that the one above is significantly more chaotic.

    I should say also that thought disorder normally applies to language spoken, written language is not transcribed verbatim and a lot of people write in note form, which is not meant to be understood by others. I present the above to give a flavour of what thought disordered speech is like.

  4. Nutty says:

    I’ve seen this from the inside. When I’m like that, it always seems odd that some people can see when my thoughts are wonky and others can’t. I remember having a sense of incredulity that a psychiatrist could tell that I was psychotic when another didn’t seem to have noticed.

  5. Paul says:

    Fair points… And of course I’m not suggesting that people who become patients are actually minunderstood artists!

    Now, there’s an interesting study showing that when you ask people who have recovered from ‘thought disorder’ what they actually meant at the time, they are often able to provide pretty decent explanations. As Nutty indicates, it’s often the case that people diagnosed with thought disorder report having found it very difficult to communicate – not necessarily ‘think’.

    It might be more appropriately referred to as communication disorder, or disordered speech.

    Nutty, if you don’t mind me asking was that the case with your experiences? Looking back, did it seem like your thoughts weren’t making sense, or was it more that you found it difficult to communicate them? No pressure to answer, but it would very interesting to hear a first-hand account.

  6. Nutty says:

    Bother, I just typed a reply and lost it!

    It varies.

    When I am manic, it seems to me like my thinking is great, but others quickly spot from things like flight of ideas, clang associations and pressure of speech that my thinking is out of kilter. I’m slowly learning to recognise these for myself.

    When I am depressed, it varies. Sometimes, I am agitated and the paranoia is predominent, and I am getting better at recognising it. When I am retarded, it can be very difficult to construct a sentence and I have been described as talking in shorthand. I am aware then that my thoughts aren’t working.

    There are times when I have problems which I only recognise when someone points them out to me. For example, one day, someone said to me “I’ll kill you” meaning something like “I’m annoyed with you” and I took her literally. I screamed for help, hid under a table and called the police on my mobile. As soon as someone explained to me that it was just a figure of speech, I could understand what had gone wrong. That sort of thing has happened many times. I am getting better at spotting that sort of wonky thinking for myself now.

    I think that there are a number of factors that make it difficult for others to spot when my thinking has gone awry. Firstly, I am articulate; secondly, I could talk the hind leg off a donkey; and thirdly, I have many years of experience of dealing with professional clients and engaging in smooth conversation with them whilst being a mess inside.

    In short, it varies. Sometimes my thinking is wonky and I know it, sometimes I don’t; sometimes other people can spot it, sometimes they can’t. The people that appear to spot it best are fellow manic-depressives. I daresay psychiatrists are good at it, but they do seem to be pretty cagey about what they’re observing. I wonder if it’s not the done thing to tell a patient that you think their thinking is disordered?

  7. Paul says:

    Thank you very much for that – very interesting! A main thing I take from what you said and also from my reading of the research is that the relationship between ‘disordered thinking’ and ‘disordered speech’ is very complex and far from straightforward.

    Also useful to know that the best people to spot problems are sometimes those who have had similar experiences… Also interesting to hear how if people are explicit with you that they are having problems understanding you then that can help.

    Obviously I don’t know if this applies to your situation but I guess some possible reasons for mental health professionals being cagey about what they’re observing is that (1) they don’t want to offend people or say they don’t understand, (2) they want to observe the behaviour without attempting to intervene so that they get a good clear picture of what’s going on, or (3) they don’t know what to say! For evidence supporting the latter, see here:

    http://bmj.bmjjournals.com/cgi/content/abstract/325/7373/1148

  8. Frontier Psychiatrist says:

    Paul, I’ve just fished the above comment out of the spam filter….

    It may help to embed your links in the text rather than pasting the full path. To do this you can use some HTML when writing a comment to make a word a hyperlink.  This is done using the "href" attribute

    Check out this link here for how to do it.

    (If you try this and it doesn’t work, don’t worry, I’ll delete or correct them and no one need know) FP

  9. Paul says:

    Ah – sorry about that!

  10. I could be "Nutty" says:

    Nutty has explained with accuracy my experiences with this. I am a perfectly normal? person, but I cannot seem to get control of my thoughts in order to speak extemporaneously without flightiness and disconnectedness. I get frustrated easily when talking with others, because I forget quickly what I wanted to say especially after the other person changes topic without leaving me time for response.

    I have worked in professional environments for years, I am CFO of a family business and a controller for a business. I deal with clients and affiliates and no one has really noticed this or they keep quite about it. I am mostly introverted to avoid this.

    My inner thoughts are always fragmented or disconnected. I struggle to consciously stream them in my mind. I have no problems writing, because I can back up anytime, and also have the luxury of having a visual reference of what I am writing to keep it ordered.

    It seems the older I get, I am 39, that this is getting to be more of a struggle and I feel confused often and I struggle to remember. As I was studying this subject for answers I came across these postings and decided to add mine.

    Some of the symptoms I recognize are fragments, changing stream mid sentence; such as: mid sentence throwing in an idea that popped into my head like “I like that necklace, where did you get it?” when I didn’t even finish the first sentence. I have even found myself forming new words unintentionally, when the word I was looking for just comes out different.

    I do not think I have had any serious injury to my head that could have caused this, although I have in the past taken falls from horses, etc.

    It has also gotten to the point that I talk less freely and that is causing trouble in my marriage and relationships, since people think I do not want to communicate. But it is difficult to communicate if you can’t keep track of what you or the other party said. I suppose I am having memory issues as well. Where can I get assistance with this?

  11. Frontier Psychiatrist says:

    I could be “Nutty” –

    that sounds like a difficult and distressing situation for you. If you live in the UK then I’d recommend that you go and see your GP and discuss your concerns. If this doesn’t appeal then you could try contacting MIND at http://www.mind.org.uk who will be able to offer more informal help.

    If you ever feel that things have really got out of control for you, or you feel suicidal then you must go to accident and emergency at your local hospital.

    If you are elsewhere then then I’m less able to point you in the correct direction. From what you’ve written you seem very concerned, and so I would recommend that you seek a consultation from a professional involved in mental health and/or a doctor/psychiatrist so that you can be given help or reassurance.

    Hope this helps – FP

  12. Nicole says:

    After a year of being treated for anxiety disorder, my psychiatrist, last week, mentioned that she thought I have either a thought disorder or a thought/emotional expression disorder. What would you say is the difference?
    .. by the way great song

  13. Frontier Psychiatrist says:

    I’m not familiar with this ‘emotional expression’ terminology. A quick websearch turns up something called involuntary emotional expression disorder, but this seems to be associated with neurological disease, so it’s unlikely that your psychiatrist meant this. Probably the best thing to do is to ask him/her what they mean by these terms as they may not be using them exactly/appropriately.

  14. :( says:

    I DEFINITELY! have this!!
    how do i change and be normal! it’s so frustrating! at work the most basic of tasks like answering door/fone/email, r so hard. i get told to do simple things now really patronisingly by my manager and i think to myself ‘ im not stupid….i can so that…and then i just go off and do the oposite. i cant focus.
    then i get paranoid &stressed because i think everyone thinks im stupid.
    when im with my friends its okay…but i always go into tangents and confersation topics go round in circles.
    when im nervous it’s get so bad, so i stop talking randomly mid sentance.
    i always feel i need to snap out of it, my head.
    defo get obsessive thoughts [one same thought 2 years], made up words, mental blocks out of nowhere.

    realised, i usually only every ask ppl questions….and poke there confersation rather than talk myself.

    friends always joke and say ‘i cant form sentances’ or ‘how do i function’

    This ruined 2 relationships &effects my work life definitely and makes me depressed and long for isolation.

    but im happy to have found this blog…as theres other freaks like me!

  15. grgrm says:

    I recently came across a written piece posted on the internet by someone I know. This person had written what they called a political column. The article was about an animal who is king. Off it went, with the animal striking other animals down with lightning, and nuclear power, and the power of the sun. Then it went on about what a shame it is that people can’t change their minds when they vote for a political leader. And the poor animal — others should be picking its nits and having babies with it, instead of with the younger animals.

    This person had threatened me twice in writing (anonymously) a couple of years ago, with a warning that I should make a safety escape plan. My spouse and I have since relocated with our family and taken an unlisted phone number.

    I am glad to see the bizarre article posted on the internet. I’ve copied it, and sent links to other people who know this person, too. It validates what I experienced at the hands of this person. Now anyone can see it for themselves.

    I am keeping a copy as a sort of insurance policy, in case this person ever finds us. It may prove helpful if we need a restraining order. A lawyer has advised us that this may be necessary.

  16. irritated says:

    To grgm or whatever your stupid f***ing call name is. Are you f***ing retarded? Go f*** yourself. Why don’t you go post on some lawyer’s or paralegal blog-site rather than get on a potential mental health support commentary to act like you are afraid of us. Why didn’t you get this person help. What if they would have killed themselves? Or IF they do? How would you feel about yourself. Guiltless? F***ING RETARDED YOU ARE. And I only use the word “retarded” meaning you are f***ing ignorant, inglorious, and disgusting. And a part of me kind of wishes you would fall on your face and scab up. What are you going to do? Save this post and sue me? Call the cops on me? Go f*** yourself.

  17. my name is required says:

    Hi I’m 18 and people keep sending me to doctors, well it started years back I got raped a lot and it was scary but I got away in care. And I was in and out of being sectioned in hospital then I got out and was fine and stopped the tablets cos I didn’t need them anyway, but I’d been taking them cos they made me. well now I’m sent to early intervention after talking to a million people (I hate talking to the doctors don’t care how I feel, they just wanna poison me) and they all keep telling me I’m not well and I know I’m not, cos I’d know if I was ill I’m not stupid you know?, and the tv sends messages, everyone hates me and I’m sick of it really it just tires me! They asked how thay could help and I asked for a brain surgeon cos I want the intercom out or I’ll take it out myself and I told them and they wanted to do a brain scan to prove me I was right I know. Now my IQ is really good because I’m not thick and these people are not thick, the docs don’t know the technology they have and they could easily make it untraceable. I write messages they are in code, which I am leaving to somebody when I find someone I can trust (lots of people are tricksters) I don’t know why people are saying I’m ill when I’m scared these people I hear a lot the time and they listen to me my thoughts, which I hate, that should be private, and they put me on loudspeaker, and they are following me I asked for help not poison and I worry perhaps these people are being paid/tricked into poisoning me, or they just like to say everyone is ill when this is real, I want to know I google what’s happening this stuff comes up I want to hire assassinss or detective I can with the all the money I make finding them when I find. Because I’d like to not have to count everything til I can’t breath all the time please thank you is anybody else finding out these people are hurting you too, I think it may be spies or agents I’m finding proof I need ur help

  18. maddy says:

    I have all of these symptoms very badly, so bad that i struggle to type. The sentences that im thinking and writing are not making sense to me, although they may make sense to the reader. But these symptoms come and go. I find when an especially bad episode occurs random images appear in my head, strange images that seconds later i forget. The most frustrating part of it all is my conscious awareness of these symptoms, like i can feel myself going crazy and i know what it’s like to be normal. It has severely affected my school work, and i find that I often resort to the thesaurus for basically every other word. I, like paul was saying, have lost the ability to think freely, and in turn, speak freely, and relationships with friends and family have really suffered. This paragraph hardly makes sense.
    These symptoms can be dated to about 6 months ago, after a bad experience with weed, but like i said they come and go. I dont know if im just being paranoid, or if its the weed that induced this horrible disease.
    Is there any medication to treat this? i am desperate and have lost the ability to sleep due to racing, incoherent thoughts

  19. Mishaa says:

    i am 15 years old . and i have the same symptoms more like nutty.most of my conversation does not have a goal. topics switch and while talking i form a word salad.while writing i have to check many times if it makes sense or not. it is very difficult to communicate.i rarely have any friend.people think i don’t like to talk much.

  20. [...] when he wrote the piece. His writing at times demonstrates some pretty classic symptoms of formal thought disorder that people can exhibit during manic episodes – loosening of associations, flight of ideas, [...]

  21. George says:

    Paul, its not a secret that thought disorder can appear in mood disorders. DSM makers are well aware of that; in fact this is what DSM-5 criteria says for schizophrenia:

    http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/jpn/vol-29/issue-2/pdf/pg102.pdf

    http://www.healthcentral.com/schizophrenia/c/120/150461/schizophrenia/2

    “D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the activephase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.”

    http://schizophreniabulletin.oxfordjournals.org/content/37/6/1136.abstract

    Its not the presence of the thought disorder that distinguishes schizophrenia from mood disorders, its the amount of thought disorder. As link below says:

    http://www.psychosis-bipolar.com/understanding-psychoses-01.html

    “Schizophrenic (cognitive) and affective psychosis

    Each psychosis is different and filled with very personal contents, just like each dream and every human being is different. Distinctions in psychiatry concern above all formal aspects and the issue what psychological areas are most influenced. The following are distinguished:

    schizophrenic / cognitive psychoses, if primarily perception, thought and speech are altered, and
    affective psychoses, if primarily mood, feeling of being alive and drive are altered and the cognitive changes in this connection remain (unipolar or in the event of swings in both directions bipolar).

    At the same time perception and mood cannot be completely separated but influence each other: We can “see everything black” and “float on pink clouds”, can develop “tunnel vision” or keep a low profile. (Source: T. Bock, Basiswissen: Psychosen, Psychatrieverlag, Germany) ”

    Lack of emotions can also cause thought disorder which has been shown with experiments with Ketamine that causes emotional numbness and emotional detachment leading to thought disorder. This can be easily tested because schizophrenic episode can be easily induced with sensory deprivation. If you sit down in a totally dark and totally silent room for 30 minutes, you will experience apathy, blunted affect, alogia, avolition, anhedonia, hallucinations, illusions, paranoia and of course thought disorder.

    Through this simple experiment at home, you can easily test Paul’s claim whether formal thought disorder is a “communication disorder.”

    In fact Dissociative Hallucinogens like Ketamine work through sensory deprivation leading to schizophrenic episodes, while Psychedelic Hallucinogens more imitate affective psychoses by causing sensory overload:

    http://www.ncbi.nlm.nih.gov/pubmed/19829208

    http://en.wikipedia.org/wiki/Flotation_tank

    http://en.wikipedia.org/wiki/Sensory_deprivation#Negative_effects

    http://en.wikipedia.org/wiki/Ganzfeld_effect

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