Thinking Process Abnormalities in Schizophrenia

From Distractibility to Incoherence

Some argue that thinking is the essence of what makes us human. In a specific sense, thinking refers to an individual's ability to make decisions and solve problems. In a broader sense, thinking refers to the totality of experiences that happen inside one’s mind. This includes thoughts but also emotions, sensations, memories, and fantasies, which are the essential building blocks of the thinking “function.” “Sensible” thinking usually implies that the building thinking blocks have an understandable relationship with the world out there.

Thought Content vs. Thought Process

Thinking is far from being a simple, static sum of these components. In fact, thinking is a process that links together all the disparate “thinking blocks” in a way that makes sense to both the individual and the world. While necessary, sensible building blocks are not sufficient to make for “sound thinking,” implying that the underlying thinking blocks are aligned in an orderly fashion, usually defined by attributes such as “logical” and “goal-directed.”

It then makes sense to try to understand thinking from two perspectives:

  1. Thought content
  2. Thought process

Other articles discuss thought content abnormalities in schizophrenia, which typically include abnormal sensorial perceptions, such as auditory hallucinations (hearing voices and noises that are not based in reality), or delusions (fixed, rigid, self-justified sets of ideas that are at odds with reality).

This article focuses on thought process abnormalities in schizophrenia.

What Is a Thought Process?

Thought process refers to how the building bricks of thinking (thoughts, emotions/feelings, sensations—including the sense of self, memories and fantasies) are linked to one another. From a process perspective normal thinking is logical, coherent, and goal-directed.

Simply put, it makes sense. Unfortunately, this normality is rarely encountered in patients suffering from schizophrenia. In fact, schizophrenia is often referred to as a “formal thought disorder” because disordered or illogical thinking is one of its more common signs.

Distractibility, Circumstantial Thinking, and Tangential Thinking

For some patients the degree of “disordered thinking” is mild resulting in distractibility:

"Then I left San Francisco and moved to... where did you get that tie?" (Andreasen 1986).

Alternatively, the connections might be over-inclusive, leading to the impression that the individual’s thoughts are going in circles before finally coming to the point, a process that called circumstantial thinking. Andreasen gives the example of a patient, who in response to begin asked “What is your name?” stated:

"Well, sometimes when people ask me I have to think about whether or not I will answer because some people think it's an odd name even though I don’t really because my mom gave it to me and I think my dad helped but it's as good a name as any in my opinion but yeah it's Tom" (Andreasen 1986).

Moderately disordered thinking also includes tangential thinking, seen when the thoughts continue to be somewhat connected but in a rather superficial or tangential way:

“I really got mad as I was waiting in line at the grocery store. I cannot stand lines. Waiting and waiting. I waited for a long time to get my drives license. Driving these days is just crazy.“

Derailment, Loose Associations, and Clang Associations

In cases of severely disordered thinking, thoughts lose almost all connections with one another, they become disconnected and disjointed, leading to what doctors call derailment or loose associations. The terms are self-explanatory: the thinking process is frequently derailed, characterized by very weak or loose associations:

"I always liked geography. My last teacher in that subject was Professor August A. He was a man with black eyes. I also like black eyes. There are also blue and grey eyes and other sorts, too…" (Bleuler 1911 ⁄ 1950).

A particular case of loose associations is when the individual associates unrelated concepts based on the fact they rhyme, a thinking process abnormality that is described as clang associationsAt times, made-up words or neologisms are frequently present:

"I got so angry I picked up a dish and threw it at the geshinker." (Andreasen 1986)

Inchorerence

In very severe cases, only the word structure is preserved but there are no discernable connections between words. It’s impossible to understand the individual’s thinking; this type of thought process abnormality is called incoherence or word salad:

To the question "Why do people comb their hair?" Andreasen reports that a patient stated:

"Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons. Hello, beautiful." (Andreasen 1986)

In schizophrenia disorganized thinking is classified as one of the positive symptoms.

While some degree of thought process disorders in seen in many individuals with schizophrenia, thought disorder is also seen in individuals with other psychiatric problems, most notably individuals with severe autism, severe mania, and severe depression.

Sources:

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. PMID 496551.

Bleuler, E. 1911 ⁄ 1950. Dementia praecox, or the group of schizophrenias. New York: International Universities Press.

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