Disorders of Thinking- Delusions, Hallucinations, Formal Thought Disorder

1. Phenomenology
DR BK WARAICH
MD PSYCHIATRY

2. Phenomenology is the study of human experience
and of the ways things present themselves to us in
and through such experience ie the patients
Subjective experience
• Psychopathology is the systematic study of abnormal psychological
experiences, cognition, and behaviour. Th at is the study of the ‘product of
a disordered mind’.
• ‘Explanatory psychopathologies’- in which there is assumed explanations
according to theoretical constructs (e.g. on theories of cognition,
behavioural, psychodynamic, or existential psychology)
• ‘Descriptive psychopathology’ which is the precise description,
categorization, and definition of abnormal experiences as recounted by
the patient and observed in his behaviour.

3. • MOTOR
• SPEECH
• MOOD
• PERCEPTION
• THINKING
• COGNITIVE

4. SYMPTOM
Hallucinations
• Maybe Normal – eg Hypnagogic , Hypnopompic Hallucination
• Maybe Abnormal – Auditory
• Primary- Eg in Schizophrenia
• Secondary- due to Substance Use

5. PERCEPTION
• Conscious awareness of stimuli in the environment through the five
senses and their interpretation
• DISORDERS-
- Sensory Distortion- normal stimulus which is perceived in a
distorted way – Eg Micropsia, Macropsia, Hyperaesthesia,
Hypoacusis, Hyperacusis, etc
- Sensory Deception – ie A new perception which may have no
actual stimulus in the environment

6. • Illusions- Stimuli from an object in the environment combined with a
mental image to give rise to a false perception
• Pseudohallucination
• Hallucinations- A Perception Without An Object ( Esquirol)
- A False perception which is not a sensory distortion or a
misinterpretation but occurs at the same time as a real
perception(JASPERS)
-Auditory, Visual, Gustatory, Olfactory, Tactile

7. Causes of Hallucinations
• Intense Emotions- Severe Depression – Auditory hallucinations-
maybe fleeting. Grief
• Sensory Deprivation
• Suggestion
• Disorders of Sense organ – eg Auditory hallucinations in Deafness;
Charles Bonnet syndrome is visual Hallucinations in Cataract etc
• Disorders of CNS

8. • Hallucinations – Auditory are usually fleeting in Depression. In
schizophrenia typically maybe persistent and well elaborated. Voices
speaking about the person in the third person or giving a running
commentary were considered typical for Schizophrenia. Command
Hallucinations are usually seen in Schizophrenia- eg a voice telling
them to stand, sit which they feel ”Compelled” To act upon. May tell
them to kill themselves.
• Thought Echo – Thoughts are heard ie GEDENKENAUTWERDEN- ie
echo is heard at the same time or just before the thoughts occur

9. Visual
• Flashes of light,
• Entire scenes
Are more common in Epilepsy or Delirium
• Specially Temporal Lobe Epilepsy
• Charles Bonnet Syndrome

10. Smell & Taste
• Schizophrenia
• Temporal Lobe epilepsy

11. TACTILE
• Formication – Feeling of insects crawling over the skin – Eg Cocaine
bug,
• Schizophrenia
• Sexual – of being raped – Schizophrenia
• Deep Visceral hallucinations- of flesh being torn, ripped; of animals
inside the body.

12. Functional Hallucination
• A stimulus causes the hallucination and is perceived as well as the
hallucination. Eg hearing voices when the water is on.

13. Synaethesia
• A stimulus in one sensory organ causes a hallucination in another
sensory organ . Reflex hallucinations. LSD, Mescaline tec- eg seeing,
tasting and hearing a Flower
• Hypnagogic & Hypnopompic
• Hypnagogic is more common but both are normal
• Hypnopompic hallucinations are seen in Narcolepsy

14. Thinking
• Flow
• Possession
• Content
• Form

15. • Undirected Fantasy or Autistic thinking-
• Eugene Bleuler mentioned this as one of the 4 “A” of Schizophrenia
• However it is common even in peope who have multiple perceived
dissapointments

16. Flow/Stream
• Disorders in the stream ie Either in ➜ Tempo Or
➜ Continuity
• Flight of Ideas- accelerated thinking that is characteristically seen in manic and
hypomanic illness.
• Clang Associations ie where sounds govern Word choice eg may be such as puns
and rhymes. Eg “I went outside and the sky was so blue, its true blue, true so
true that swear Ill die if you catch me tell a lie, so bye bye baby sing me a lullaby.”
• Connections between sentences may seem to be due to chance factors but can
usually be made out. “Alliterations- ie same consonant sound at the
commencement of 2 or more syllables of a word group. Eg “to”, “today”, “tonight
• If the speech is recorded and analysed later a link is always found between one
strand of thought and the next.
• Easily distracted/diverted by extraneous stimuli

17. Hypomania
• A prolixity or Ordered Fight of Ideas occurs.
• Pressure of speech is not so much
• Patients eventually reach their goal despite distractions and do not
lose the thread.

18. Poverty of Thought
• Inhibition or slowness of thought
• Maybe Poverty of Speech OR Poverty of Content of Speech
• Poverty of speech- Replies maybe Monosyllabic, or ultra brief.
However allow time to the patient to speak.
• Poverty of Speech Content- Although replies are long enough, they do
not convey much ie are devoid of content.
• Language maybe vague , repetitive, stereotyped. Maybe confused
with Circumstanstiality ( Andreason, 1979)

19. • Formal Thought Disorder- disturbance in logical process of
thoughts or logical connections between ideas
• Loosening of Associations- denoting a lack of connection between ideas.Links
between ideas may be illogical or the speech may wander between trains of
thought.
• Loosening of associations is also called knight's move thinking.
• Derailment (Loose Associations, Flight of Ideas) - A pattern of spontaneous
speech in which the ideas slip off the track onto another one that is clearly but
obliquely related, or onto one that is completely unrelated… At times, there may
be a vague connection between the ideas; at others, none will be apparent. This
pattern of speech is often characterised as sounding “disjointed”. Perhaps the
commonest manifestation of this disorder is a slow, steady slippage, with no
single derailment being particularly severe, so that the speaker gets farther and
farther off the track with each derailment without showing any awareness that
his reply no longer has any connection with the question that was asked’.

20. Formal Thought Disorder- indicates a disturbance
of the organization and expression of thought.
• Circumstantiality: excessively indirect speech; speech is liable to be
overinclusive and include irrelevant detail- Schizophrenia, OCD etc
• Tangentiality: Replies to questions are off-point or totally irrelevant.
• Incoherence (word salad, schizaphasia): severe lack of speech cohesion at the
basic level of syntax and/or semantics within sentences
• Clanging: speech in which word choice is governed by word sound rather
than meaning; word choice may show rhyming or punning associations
• Neologism: the creation of new "words"
• Word approximations: unconventional and idiosyncratic word use

21. Disorders of Continuity
• Perseveration: excessive repetition of words, ideas, or subjects
• Echolalia: speech repeats words or phrases of interviewer especially
the last word or phrase
• Blocking: sudden arrest of the train of thought

22. Thought Content
• Overvalued Ideas- an acceptable idea pursued beyond the bounds of reason. Or a
thought which because of associated feeling tone takes precedence over all other
thoughts and persists over a period of time.(Paranoid personality, Hypochondriasis,
Anorexia etc)
• Delusions- Delusions false, firm fixed belief which is out of keeping with the
patient's social and cultural background.
• The main features of delusions according to Jaspers (1959) are: (1) they are held
with an extraordinary conviction and subjective certainty; (2) there is
imperviousness to other experiences and to compelling counterargument; (3) their
content is impossible.
• Sims (1988), in Symptoms in the Mind, criteria for delusion: (a) They are held with
unusual conviction. (b) They are not amenable to logic. (c) The absurdity or
erroneousness of their content is manifest to other people.

23. Stages of Delusion Formation
• Conrad proposed five stages of which are involved in the formation of delusions:
• Trema: Delusional mood representing a total change in the perception of the world
• Apophany: A search for, and the finding of new meaning for psychological events
• Anastrophy: Heightening of the psychosis
• Consolidation: Forming of a new world or psychological set based on new meaning
• Residuum: Eventual autistic state.
Psychodynamic theory
• Freud (1911) proposed that delusion formation involving Denial, Projection of
repressed homosexual impulses that break out from unconscious.

24. - Jaspers described-
1. Autochthonous delusions- which arise suddenly, out of the blue
2. Delusional perception- Where a normal perception is given a
delusional meaning. Eg The person sees a blue car and thinks the
blue men from Jupiter are taking over the world. Its two
memberedness is important ie Perception or Memory and the
delusional meaning given to it.
- Delusional mood is akin to a pre-delusional state or ‘precursor
phenomena’, during which the person has a vague feeling that
something odd is going on.
• Delusional memories- a delusion is suddenly remembered or as
defined in the Present State Examination (Wing et al 1974)
‘experiences of past events which clearly did not occur but which the
subject equally clearly remembers.

25. To elicit delusions, Ask- Do you feel as though you are in danger?
(persecutory delusions)
▪Do people watch you, or talk about you? (delusions of reference)
▪Do you feel as though you have special powers that other people
do not have? (grandiose delusions).
Mood Congruent and Mood Incongruent
Delusions driven by underlying affect (mood congruent)
may differ neurocognitively from those which have no
such connection (mood incongruent).

26. Types of Delusions-
-Grandiose
-Persecutory-
-Reference
-Jealousy- (Alcoholic Jealousy)
-Delusions of Love- Erotomania, De Clerembaults ( seen in females)
-Nihilistic- Cotards Syndrome- In psychotic depression- includesNihilistic and
hypochondriacal delusions
-Capgras ( familiar persons are impostors), Fregoli
Folie a deux, Folie familie(Shared Delusions)
-

27. • Systematization- When a delusion is elaborated, it is said to be
systematized when there is one basic delusion upon which the
remainder of the system is logically built.
• Bizarre delusions are those which are clearly implausible and not
understandable and do not derive from ordinary life experience, for
example the belief of being controlled by aliens through radiowaves.
• (In schizophrenia, striatal dopamine is elevated (Howes et al.,
2009; Kegeles et al., 2000; Laruelle et al., 1999) and prefrontal
dopamine signaling is decreased.)

28. Possession
• Control by - Self
- Others
1. Obsessions- Repeated intrusive images, ideas or thoughts. Other
features- Logical, Ego dystonic
• Images at times are so vivid they can be mistaken for
pseudohallucinations. Eg “ a woman had images of plunging a knife
into her children . She would start crying thinking she had done it.”
• (Delusions are – Ego Syntonic)

29. • Thought Alienation – Ie Thoughts are in control of an outside agency
ie Includes the following-
• Thought Insertion
• Thought Withdrawal
• Thought Broadcasting
• Thought Echo

30. Thank you