1. Disorder of ThoughtDisorder of Thought
By Shahnaz Syeda
14 Jun 2012
1st
Yr M & SP
Dept of Clinical Psychology
LGBRIMH

2. ThoughtThought
Thought generally refers to any mental or
intellectual activity involving an individuals
subjective consciousness.
 Act of thinking Thought
Thought underlies almost all human action and
interactions,
Understanding its physical and meta physical
origins, process and effects has been a
longstanding goal of many academic disciplines –
biology, philosophy, psychology and sociology.

3. Types of thinkingTypes of thinking
Thinking allows us to make sense of or model the
world in different ways and to represent or
interpret it in ways that are significant to us.
Fantasy – escape from reality , short duration , to
move the mind from poverty to riches. eg day
dream
Imaginative – creative, novel out puts , usually with
a end in mind .Artists,
Rationale / conceptual – scientist

4. Disorder of content of thinkingDisorder of content of thinking
Content :The color of thought.What is the person
‘thinking’?
DISORDER in content is interpreted with respect
to the general assumptions about normality and
abnormality, as it is most often done by an external
observer.

5. From ‘delude’, derived from a Latin word which
means to mock
Presence of delusion A loss of touch with
reality,
= Psychosis
Phenominologically/ subjectively indistinguishable
form a true belief
Definitions
Types of Delusions
The origin of Delusions
Types of Primary Delusions
The Content of Delusions

6. DEFINITIONSDEFINITIONS
“A false unshakeable belief
which arises from internal morbid processes. It
is easily unrecognizable when it is out of
keeping with the person’s educational and
cultural background” -Max Hamilton
False unshakeable belief
Morbid origin
Out of keeping with the cultural and social
background

7. JasperJasper
According to Jaspers
-They are held with unusual conviction
-They are not amenable to logic/external
influences
-The absurdity of their content is manifest
to other people

8. ExampleExample
A man believed that his wife was
unfaithful to him because the fifth lamp-
post along on the left was unlit.
Here belief may be culturally acceptable
or even true but clearly delusional
because of evidence evinced for holding
the belief.

9. OVERVALUED IDEASOVERVALUED IDEAS
Thought which, because of associated feeling tone,
takes precedence over all ideas and maintains this
precedence permanently or for a long period of
time.
Overvalued ideas are deeply held personal
convictions that are understandable when the
patient's background is known.
For example,
if a patient has two family members who have just
developed cancer then the patient may have the belief
that cancer is an illness that is contagious.

10. TO BE DISTINGUISED FROM AN OVERVALUED IDEATO BE DISTINGUISED FROM AN OVERVALUED IDEA
OVERVALUED IDEAS
 Associated with very
strong affect
 Not held firmly
 Person has at least some
level of doubt as to its
truthfulness
 Not recognized as absurd
 Acceptable
 Can occur in both healthy
and mentally ill people.
DELUSIONS
 Need not be associated
with affect
 Firmly sustained belief
 Person with a delusion is
absolutely convinced that
delusion is real
 Recognized as absurd
 Can not be accepted
 Occur in mentally ill
people

11. According to Conrad….According to Conrad….
The 5 stages in the development of delusions:
1) Trema: Delusional mood representing a change
in perception
2) Apophany: A search for, and finding of new
meanings to psychological events
3) Anastrophy: Heightening of psychosis
4) Consolidation: Formation of a new world based
on new meanings
5) Residuum: Remaining autistic deficit.

12. Primary DelusionPrimary Delusion
-New meaning arises in connection with
some other psychological event
-Ultimately un-understandable
-diagnostic of schizophrenia,
-may occur in epileptic psychosis

13. PRIMARY DELUSION
True delusion
Does not arise from affective state or previous attitude
Origin from :
Generally It is always self-referent, momentous,
urgent, and with overwhelming personal significance
Ultimately un-understandable.
A new symbolic meaning is attached to percept,
intuition, memory
Delusional perception
Sudden delusional idea
Delusional mood
Delusional
memory

14. DELUSIONAL MOODDELUSIONAL MOOD
Person has the knowledge that there is something
going on around him which concerns him, but does
not know what it is.
DELUSIONAL PERCEPTIONDELUSIONAL PERCEPTION
Delusional perception is the attribution of a new
meaning usually in the sense of self reference,to a
normally perceived object.
Important feature of this symptom is its two-
memberedness. memory + delusional significance
Eg: person says that he is of royal descent because he
remembers that the spoon he used as a boy had a crown
on it

15. SUDDEN DELUSIONAL IDEASUDDEN DELUSIONAL IDEA
Delusion appears fully formed in the person’s
mind.
Autochthonous delusion
Eg: person says that he is of royal descent because
when he was taken to a military parade as a little
boy the king saluted him.
(Delusion is contained within the memory and
there is no two-memberedness.)

16. Primary Delusional experiences –
reported more in acute schizophrenia
Less common in chronic schizophrenia

17. Secondary DelusionSecondary Delusion
Those that arise from some other morbid
experience
Can be understood from the person’s
cultural/emotional background
Often transient
Can occur in Schizophrenia, other psychotic
conditions
NOT an overvalued idea

18. Understandable with respect to the mood state
or after viewing psychiatric history and MSE
Originates in response to: other psychopathology -
 Mood
 Cultural contents
 Personality traits
 Primary delusions
 Hallucinations
 Formal thought disorder
SECONDARY DELUSIONSECONDARY DELUSION

19. Secondary DelusionSecondary Delusion
 In schizophrenia once primary delusional experience
have occurred they are commonly integrated into some
sort of delusional system.
 This Elaboration
 Ie .The story a deluded person builds around the
delusion ‘delusional work’. Where apparently logical
consequences and inferences are made around the
delusion.
 Systematization & Non Systematized
 There is one basic delusion. The rest of the delusional
beliefs are related to that, being systematically built
over it. Systematization is seen as more or less. The
degree depends upon the retention of integrity in the
deluded person.

20. ORIGIN OF DELUSION
The ultimate alteration from normal : Reality Perception
Pre-morbid
personality
Social
constraints
Superego
Poor
communication
A key experience
Impaired cognition + Impaired attribution
Delusion!
Adaptive
New identity/ purpose
Freedom and protection

21. Factors concerned with the origins ofFactors concerned with the origins of
delusionsdelusions
Disorder of brain functioning
Background influences of temperament and
personality
Maintenance of self esteem
Role of affect
As a response to perceptual disturbances
As a response to depersonalization
Associated with cognitive overload.
-Brockington.

22. Content of DelusionContent of Delusion
It is determined by the emotional,
social, cultural, educational
environment of the person.
Important to distinguish from the
Form, which would be determined by
the type of illness.

23. DELUSION OF PERSECUTIONDELUSION OF PERSECUTION
Harm, in any form, by an external agency, which may be
identified or just a vague influence
It may also arise from auditory hallucinations, bodily
hallucinations, passivity
Seen in Schizophrenia, Organic conditions
Associated secondary delusions –
Delusions of reference: people talking about him
Delusions of guilt : justification of persecution at times
Delusions of being poisoned/ infected : explanatory nature
Delusions of influence : from passivity feelings

24. DELUSION OF JEALOUSYDELUSION OF JEALOUSY
Morbid jealousy may be expressed in many ways
Psychotic jealousy has Delusions of infidelity
Origin autochthonous or an etiology in the deluded person :
Alcohol abuse
•Impotence
•Punch-drunk syndrome
•Previous promiscuous behavior
•Homosexual fantasies
•Internal conflicts
The perceived threat : loss of exclusive possession of
partner
Violent behavior

25. DELUSIONS OF LOVEDELUSIONS OF LOVE
Erotomania
Convinced that the person is in love with her, although the
alleged lover may never have spoken to her.
May pester the victim with letters
Also seen in Manic Depressive Psychosis
Abnormal parent-child relationships may be present
de-Clerembault’s Syndrome : Seen in women

26. DELUSIONS OF GRANDIOSITYDELUSIONS OF GRANDIOSITY
Primary : Schizophrenia, Delusions of special
purpose, Delusions of Invention
Secondary : Mania.
Supported by hallucinatory voices or confabulations
May also be seen in drug dependence, organic
syndromes.

27. Delusions of ill HealthDelusions of ill Health
Seen in Depression, Schizophrenia,
personality disorders.
In depressive patients, they feel that they have
an incurable disease.
In Schizophrenia it may be due to a bodily
hallucination or a depressed mood.
Chronic Hypochondriasis may be secondary
to a personality disorder.

28. HYPOCHONDRIACAL DELUSIONSHYPOCHONDRIACAL DELUSIONS
Delusions of Body odor/ Halitosis or Olfactory
reference syndrome
Delusion of Infestation – Ekbom Syndrome
Delusion of Ugliness or misshapenness or
Dysmorphophobic delusion
These delusions could also involve the spouse or
children
Violent behavior may be associated
Seen with affective psychosis, Depression, Paranoid
Schizophrenia, Delusional disorder, Drug abuse, CVD,
Senile Dementia, Personality disorders (Paranoid and

29. DELUSION OF NIHILISMDELUSION OF NIHILISM
Seen in Severe Depression, Delirium, Schizophrenia.
Patient denies the existence of his body, his mind, his loved ones
and the world around him.
Subjective changes in his own attitude is confused with the world.
The reverse of Grandiosity.
In persecution the extreme blame is on an external agency.
Cotard’s Syndrome : Psychotic depression in elderly, Nihilistic
and Hypochondriacal delusions, may be dramatic, grandiose;
agitation or retardation. The underlying feeling tone is of total
negativism as though nothing exists.

30. Delusions of GuiltDelusions of Guilt
Usually seen in Depression.
Patient feels he is a sinner and that he has
ruined his family’s life.
Often leads to suicide.
It may give rise to delusion of persecution.

31. DELUSIONAL MISIDENTIFICATIONDELUSIONAL MISIDENTIFICATION
Face processing disorder. Could occur with People, Animals,
Objects, Self. There is usually an important emotional
connotation involved.
Capgras’ Syndrome: A close family member replaced by a
stranger who is an exact double. Usually the deluded person
shared an ambivalent relationship with that family member
previously.
Delusion of Intermetamorphosis: A member of the family
becomes a stranger, though the deluded person cannot
describe any perceptual changes in the person.
Delusion of Fregoli: everyone else – same person in disguise
Delusion of Subjective Doubles: Another person been physically
transformed into own self.

32. Seen mostly in Schizophrenia
Also in Manic Depressive Psychosis
and in Organic Conditions

33. COMMUNICATED INSANITYCOMMUNICATED INSANITY
A delusion transferred from a psychotic
person to a person with whom they have a
close association.
The recipient shares the belief.
Psychosis of association.
The partner is usually socially deprived or
disadvantaged.

34. Disorders ofDisorders of
Possession of thoughtPossession of thought
Control byControl by
- The Self- The Self
- Others- Others
Obsessions and compulsions
Thought alienation

35. ObsessionsObsessions
Coined by Esquirol in 1838
Schneider’s definition
◦ one cannot get rid
◦ Content of consciousness
◦ Realizes senseless
◦ Persists without cause

36. ObsessionsObsessions
Individuals own thoughts
One thought/act is resisted unsuccessfully
Unpleasantly repetitive
FISH : 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.

37. CompulsionCompulsion
Prudish person – sexual thought
Religious person – blasphemous thoughts
Timid person – torture , murder
Merely obsessional motor acts
Obsessive thought compulsive act
= Relief ….. temporary

38. ObsessionsObsessions
Images – vivid images occupy the Pt mind
Ideas - why sky is blue
Impulses – touch count ,
Diff between compulsion & Ob impulsesDiff between compulsion & Ob impulses
Impulse in mind acted again & again
compulsion

39. ObsessionsObsessions
Themes
◦ Dirt & contamination
◦ Aggression
◦ Religious
◦ Sexual
◦ Inanimate-impersonal
◦ miscellaneous

40. ObsessionsObsessions
OCD
Depression
Schizophrenia
Postencephalitic states
Compulsion common in post encephalitic
parkinson

41. Thought alienationThought alienation
Thoughts are not his own
Under control of an outside agency
Others are participating in his thinking

42. Thought alienationThought alienation
Thought insertion – common in schizophrenia
though not unique
Thought deprivation – suddenly disappear or
withdrawn by foreign influence
Thought broadcasting – everyone else is thinking in
unison with them.
Others can hear his thoughts
Psychoanalytic interpretation – the boundary
between the ego and the surrounding world has
broken down

43. Disorders of form of thoughtDisorders of form of thought
Thought are :
Logical flow of ideas
Cannot be observed directly
Therefore language is relied on in form of
speech, writing or other symbolic creation

44. FormForm
Arrangement of parts – Oxford
dictionary
Formal thought disorder- disorder of
conceptual / abstract thinking
Disturbances in form are disturbances in
the logical process of thought or logical
connection between ideas

45. Clinical assessmentClinical assessment
Assessed during course of interview,
silence, by abstract questions
Need to document speech sample
- Diagnosis
-Assessment of progress
Verbatim written account or recording
audio sample

46. Types of formal thought disordersTypes of formal thought disorders
Positive and negative
positive –produces false concepts by
blending together incongruous elements
eg: derailment
negative- lost previous ability to think eg:
poverty of speech

47. SchneiderSchneider
Five features of FTD:
Derailment- slides on to a subsidiary
Substitution- major thought substituted
Omission- senseless omission
Fusion- heterogeneous elements are
interwoven
Drivelling- disordered intermixture

48. SchneiderSchneider
Features of healthy thinking
Constancy : Persistence of completed
thought
Organization :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

49. Three objective thought disordersThree objective thought disorders
Transitory thinking
Drivelling thinking- muddled parts
Desultory thinking- sudden ideas force
their way

50. Transitory thinking :
- Grammatical & syntactical structures are
both disturbed.
- Continuity is not loosened.
- Intention itself is affected.
Drivelling thinking - Pt has
- a preliminary outline of a
- - complicated thought but
- - looses preliminary organization of the thought so that all
the constituent parts get muddled together
Desultory thinking :
- Grammatically & syntactically correct
- Sudden ideas force their way time to time
- Each idea – simple & suitable thought.

51. Healthy FTD Schizophrenic
Constancy Derailment Transitory
Substitution
Omission
Organization Drivelling Drivelling
Continuity Fusion Desultory
 Scheider claims that individual with Schizo complained of 3 diff
disorders of thinking that corresspond to these 3 features of
normal / non disordered thinking

52. STREAM (progress) OFSTREAM (progress) OF
THOUGHTTHOUGHT
Disorders of tempo
 Flight of ideas
 Inhibition or retardation of
thinking
Circumstantiality

53. Disorders of continuity
 Perseveration
Thought blocking

54. Flight of ideas
The thoughts follow each other
rapidly.
There is no general direction of
thinking.
The connections between successive
thoughts appear to be due to chance
factors
Absence of determining tendency

55. Birmingham, Kingstanding see the king he is
standing king, king, sing, sing
 Mania (typical)
 excited schizophrenics (occasional)
 Organicity; especially lesions of
hypothalamus
 Mixed affective states (flight of ideas
without pressure of speech)

56. Prolixity (ordered flight of ideas)
 In hypomania ordered flight of ideas
occur – Lively embelishment
Despite many irrelevances, the patient
is able to return to the task in hand.
 The speed of emergence of thoughts
is not as fast as in flight of ideas.

57. Inhibition or retardation ofInhibition or retardation of
thinkingthinking
The train of thought is slowed down
no. of ideas and mental images which
present themselves is decreased.
Diminution of active attention – events
are poorly registered.
Retarded depression
Manic stupor

58. CircumstantialityCircumstantiality
Thinking proceeds slowly with many
unnecessary details but the point is finally
reached.
Tedious elaboration
weakness of judgment and egocentricity.
Occur in context of learning disability &
Individuals with obsessional personality
traits

59. Disorders of continuityDisorders of continuity
Thought blocking
A sudden arrest of the train of thought,
leaving a blank.
An entirely new thought may then begin.
Almost diagnostic of schizophrenia
Exhausted and anxious patients may easily
lose the thread of the conversation and may
appear to block

60. Perseveration:
 Is a senseless repetition of a goal-
directed action/speech which has
already served its purpose/beyond
relevance.
Catatonia
Coarse Brain Disease

61. Thank youThank you