Thinking Process Abnormalities in Schizophrenia

From Distractibility to Incoherence

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It's fairly common for people with schizophrenia to have trouble keeping their thoughts straight and expressing what's in their minds. Disorganized thinking is one of the primary symptoms of schizophrenia and it can lead to a variety of thought process disorders that cause disjointed thoughts, a collapse or sudden stop in thought process, randomly spoken words, and complete incoherence.

In fact, schizophrenia is often referred to as a “formal thought disorder” because disordered or illogical thinking is one of its more common signs. Thought disorders are also seen in individuals with other psychiatric illness, including autism, bipolar disorder, mania, and major depressive disorder.

What Is a Thought Process?

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.”

Thought process refers to how the building blocks of thinking 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 people with schizophrenia.

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 to the world.

In other words, "sound thinking" requires the thinking blocks to be aligned in an orderly fashion, or in a "logical" or "goal-directed" way. It makes sense to try to understand thinking from two perspectives: thought content and thought process.

Thought Content Abnormalities
  • Auditory hallucinations (hearing voices and noises not based in reality)

  • Delusions (fixed, rigid, self-justified sets of ideas that are at odds with reality)

  • Depersonalization/Derealization

  • Grandiosity

Thought Process Abnormalities
  • Circumstantial/Tangential thinking

  • Clang associations

  • Derailment

  • Distractibility

  • Word salad (incoherence)

Here is a closer look at some of the specific types of thought process abnormalities in people with schizophrenia.

Distractibility

For some patients, the degree of “disordered thinking” is mild and this often results in distractibility. A person can begin talking about one thing and then completely shift topics before completing his or her sentence. This is often due to nearby stimuli that interfere with the thought process.

  • For example: "I moved to New York after college ... what are you eating for lunch?"

Circumstantial Thinking

The process of circumstantial thinking refers to when a person talks in circles, providing excessive and unnecessary detail before getting to the point. Here's an example from neuroscientist and neuropsychiatrist researcher Nancy Coover Andreasen:

  • Question: “What is your name?”
  • Response: "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."

Tangential Thinking

Moderately disordered thinking includes tangential thinking, which is when someone moves from thought to thought but never seems to get to the main point. In this case, the thoughts are somewhat connected but in a superficial or tangential way.

  • For example: “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 driver's license. Driving these days is just crazy.“

Derailment or Loose Associations

In cases of severely disordered thinking, thoughts lose almost all connections with one another and become disconnected and disjointed. This illogical thinking is called derailment or "loose" associations.

In simple terms, the thinking process is frequently derailed, characterized by very weak or loose associations.

Here's an example from Swiss psychiatrist and eugenicist Paul Eugen Bleuler: 

"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…"

Clang Associations

A type of loose association, clanging is when the individual chooses words based on sound (rhyming or pun associations) rather than meaning. Clang associations are part of a language disorder condition called schizophasia (often called "word salad"). At times, made-up words or neologisms are frequently present and the person may speak in a flat- or unusual-sounding voice.

  • An example by Andreasen: "I got so angry I picked up a dish and threw it at the geshinker."

Incoherence

In very severe cases, only the word structure is preserved but there are no discernible connections between words. This is incoherence (also known as "word salad") makes it impossible to understand the individual’s thought process.

Here's an example by Andreasen:

  • Question: "Why do people comb their hair?"
  • Response: "Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons. Hello, beautiful."

Treating Thought Process Abnormalities

Treating thought process abnormalities in schizophrenia often includes medication, psychotherapy, life skills training, and family support.

  • Medication: The right medication can help to reduce disordered thinking and improve "thinking" functioning. This may include antidepressants, mood stabilizers, or anti-anxiety medication alongside antipsychotics for long-term management of the symptoms of schizophrenia.
  • Psychotherapy: Talk therapy, including cognitive-behavioral therapy (CBT), can help you better identify thought process abnormalities and find ways to cope with unusual or dysfunctional ways of thinking.
  • Social skills training: An inability to communicate your thoughts and feelings clearly can certainly take a toll on your family and social life as well as your work relationships. Social skills training can help you learn how to better communicate with others, despite your symptoms, so you can better navigate these relationships.

Coping with Thought Disorders

Family support is also a crucial part of treating and coping with thought disorders. It is important to become educated so you can better understand what it is like to live with schizophrenia and its many frightening and debilitating symptoms.

Participating in individual or family therapy, or joining an in-person or online support group, can provide an outlet to express your emotions and frustrations. It can also give you strategies to better communicate with and support your loved one.

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