Psychiatry - H.T. Sonnyk 2003

General Psychopathology and Symptomatology of Mental Illness
Thought Disorders

Thinking is a mental process that enables a person to reflect the most essential and principal aspects of reality, and to uncover regular connections between phenomena. As the cognition of The Essence of phenomena, thinking represents the highest form of reflection of reality and serves as an active function of the intellect.

Basic categories of thinking:

1) Concept — a thought expressed in one, rarely two words, which generalizes the most essential properties of an object or phenomenon. Concepts can be concrete (car, tree, chair) and Abstract, generalized (honor, love).

2) Judgment — a thought expressed in words, in which something is affirmed or denied. It is formed through the operation of concepts.

3) Inference — a Conclusion derived from two or more judgments. For example: all metals are electric current conductors, and copper is a metal, therefore copper is an electric current conductor.

Mnemonic operations include analysis, synthesis, comparison, generalization, abstraction, and concretization, followed by a transition to concept formation.

Thought disorders are classified According to the pace of association flow, their character, form, and adequacy.

I. Thought disorders according to the pace of association flow.

Tachyphrenia — an increase in the number of associations formed per unit of time and an acceleration of their flow. In this state, one idea is immediately replaced by another, and speech becomes incoherent (without finishing one thought, the patient moves on to another). It is characteristic of mania.

Mentism — an uncontrollably emerging influx of vividly colored thoughts and memories, a "whirlwind of ideas" that the patient is unable to process.

Bradyphrenia — a slowing of thinking characterized by inhibition and monotony of thoughts, limited associations, and slow, fragmented speech. It is observed in depression.

Sperrung (blocking, German) — a sudden, short-term, spontaneous arrest of the flow of thoughts, which correspondingly manifests in conversation. The patient suddenly falls silent, later explaining their silence by a mental blockage. It is observed in patients with Schizophrenia.

Pathological circumstantiality — viscosity, sluggishness of thinking, manifested by the loss of The ability to separate the main from the secondary. Random details that do not relate to the main thought predominate in judgment. It occurs in Epilepsy.

II. Thought disorders according to the character and form of associations.

Thought slipping — the patient utters phrases, several meaningful structures, and then, for no reason, switches to talking about something else—also correct, but entirely unrelated to the previous topic.

Tangentiality of thought — a thought pathology manifested by a rupture of semantic connections between concepts while preserving the grammatical and syntactic form of the sentence.

Schizophasia — tangentiality reaching the degree of incoherence, a "verbal salad," when the patient utters words or even syllables at a normal pace and with normal intonation that have no logical connection whatsoever.

Incoherent thinking — the loss of the ability to form associative connections between sensations, representations, and concepts, to reflect reality in its connections and relations, and to perform analysis and synthesis. Speech thus becomes disordered. Speech disorderliness can be: amentive, choreatic, atactic, and manic.

Ambivalent thinking — thinking in which antagonistic, mutually opposing ideas arise simultaneously in the patient.

Autistic thinking — characterized by detachment from reality. Associations arise primarily on The basis of ideas, representations, and sensations associated with the illness, during which internal experiences dominate. Patients withdraw into themselves, keep aloof, and communicate with almost no one. Answers TO QUESTIONS are formal, their fantasies coexist in consciousness with reality, and desires are perceived as reality.

Paralogic thinking — a disturbance of logic where a certain concept is replaced by a symbol or sign understandable only to the patient, who draws objectively incomprehensible inferences that do not correspond to the judgments from which they are derived. Paralogic thinking occurs in schizophrenia.

Atactic thinking — a Pathology of Thinking manifested by improper, paradoxical combinations of concepts and thoughts that are strung together without logical connections. It may manifest as speech incoherence.

Resonnement (sterile philosophizing) — barren philosophizing, the appearance in thinking of empty verbal premises that do not correspond to the topic of conversation and fail to achieve their purpose. The meaninglessness and poverty of judgments can be clothed in a correct form. Three degrees of resonnement are distinguished: extreme — it is unclear what the patient is talking about; moderate — only after prolonged questioning can an explanation be obtained; mild — may also occur in mentally healthy people, characterized by verbosity and deviation from the topic of conversation. It is observed in encephalopathy, schizophrenia, and senile mental changes.

Perseverations — prolonged dominance of a single thought or representation, externally manifested by the stereotyped repetition of the same words and answers. For example, having given the correct answer to the first question, the patient then continues to repeat it for the others. It occurs in traumatic Brain injury (TBI).

Symbolic thinking — a state of thinking in which one concept becomes a symbol of another, sometimes based on accidental, secondary features. This disorder is characteristic of schizophrenia.

Speech iterations: verbal tics, involuntary frequent repetition:

a) palilalia – the last word of a sentence;

b) logoclonia – the last syllable.

c) verbigeration – senseless, often rhythmic repetition of the same words, less frequently phrases and fragments thereof.

III. Thought disorders classified by the adequacy of associative content.

Obsessions – thoughts that arise uncontrollably, yet are accompanied by critical awareness and resistance on the part of the patient. They are predominantly observed in neuroses, schizophrenia, cerebral atherosclerosis, and anakastic personality disorder.

Obsessions are subdivided into distractible and imagery-based forms.

Distractible obsessions include sterile brooding ("mental rumination"). Such patients are prone to prolonged, subjectively highly burdensome reflections regarding events and phenomena that are objectively irrelevant at the moment. For instance, thoughts about what happens after death, autopsies, the decomposition of remains, the plants that will grow thereafter, and so on ad infinitum. This category also encompasses obsessive counting, recalling past events, names, dates, manipulating individual words and phrases, breaking them down into separate syllables, and the like.

Imagery-based obsessions include compulsive mental representations that take hold of the patient. Such individuals perceive improbable events as real and experience extreme emotional distress As a result. For example, after swimming in a river, a patient may become haunted by the thought that they accidentally kicked a child who subsequently drowned. Despite the complete absence of any evidence supporting this claim (having been alone on the beach), they cannot rid themselves of these highly vivid, pictorial, and emotionally charged mental images. Consequently, they frequently revisit the Location to search for evidence, and so forth.

Obsessive impulses – contrary to common sense, a patient may experience a sudden desire to strike someone, including a loved one, to insult, or to contaminate them, etc. Unlike impulsive actions, obsessive impulses are not acted upon, but their mere emergence in some cases induces a state of panic in the patient.

Obscene thoughts – mental representations regarding respected and beloved individuals that are morally and ethically unacceptable. Deeply religious individuals may experience such intrusive thoughts in church, looking at icons, during prayer, and so on.

Obsessive memories – irresistible, intensely agonizing recollections of past misdemeanors or mistakes. They are accompanied by a pronounced sense of remorse and shame. The patient desperately wishes to forget what happened, but is unable to do so.

Obsessive fears (phobias) – highly diverse (over 300 types have been described), intense, and resistant-to-correction fears concerning A wide variety of phenomena. The patient may recognize the absurdity of their fears and fight against them, typically without success.

Among the most common phobias are: agoraphobia – fear of open spaces, wide squares, and streets; claustrophobia – fear of enclosed spaces; hypsophobia – fear of heights; mysophobia – fear of contamination; thanatophobia – fear of sudden death; tokophobia – fear of dying in childbirth; sitophobia – fear of eating; oxyphobia – fear of sharp objects; nosophobia – fear of various diseases (cancerophobia, syphilophobia, cardiophobia, etc.); photophobia – "fear of fear"; and pantophobia – all-encompassing fear.

Obsessive doubts – doubts concerning the correctness and completion of one's actions. Patients feel uncertain whether they have performed an assigned task, and if so, whether it was done accurately and in full. They frequently return to the object of their activity, seeking numerous, often illogical means of self-verification, yet remain unsatisfied, suffering from persistent uncertainty and anticipating negative consequences.

Obsessive apprehensions – patients fear that while performing routine, frequently automatic actions, they will lose their place, make a mistake, blush, and so forth.

Obsessive actions – a sudden urge to perform a specific action, which the patient views critically—that is, recognizing its absurd nature and attempting to resist it.

This category includes various habit-like actions that are extremely difficult to quit despite significant effort and active resistance. Examples include sniffing, stereotypical leg movements, eye blinking, adjusting one's Hair, and others. Obsessive actions also encompass the inclusion of meaningless filler words in speech, such as "you know" or "frequently", and stereotypical manipulations of specific objects. If, due to any circumstances, the patient is unable or unwilling to perform the obsessive action, they experience psychological discomfort that persists until the action is carried out.

When obsessive actions arise in connection with phobias or obsessive doubts and serve as a form of psychological defense, they are termed rituals. Driven by a desire to prevent disaster or overcome agonizing doubt related to certain actions or fears, the patient may, for instance, clap their hands in a specific sequence, wash their hands with soap until a certain number of soap bubbles appear, search a crowd for bald people, and so on, which temporarily brings them relief.

Unlike delusions, obsessions may occur in healthy individuals (such as an obsessively repeating melody). The onset of obsessions can be facilitated by insomnia, fatigue, asthenia, and other factors.

Overvalued ideas – emotionally vivid thoughts that arise from real circumstances, but unjustifiably begin to dominate consciousness, prevailing over all other thoughts and dictating the overall thought process. In this state, all other thoughts are inhibited or, conversely, concentrated to reinforce the overvalued idea.

Overvalued ideas are not always fully formed phenomenological entities. As the condition progresses, they may transform into delusions (borderline delusions of reference). Intermediate states are also recognized, such as Birnbaum's so-called "overvalued delusion", which may evolve into paranoid delusions.

Unlike delusions, overvalued ideas do not involve personality changes; over time, the idea fades and the affect diminishes, and secondly, temporary or stable correction is possible.

Most frequently, overvalued ideas are encountered in psychopathic personalities, primarily those of the paranoid type, as well as within the rather amorphous group of so-called "fanatics". Unlike obsessive ideas, overvalued ideas lack the distressing feeling of being imposed upon. Patients think and feel in accordance with the idea that has captivated them.

Overvalued ideas, particularly those developed by paranoid psychopaths, are extremely difficult to correct and in some cases completely impervious to correction, even though these individuals may exhibit entirely sound judgment on all other matters.

Special attention should be paid to psychopathological states known as dysmorphophobia and dysmorphomania. Literally translated, dysmorphophobia is the fear of one's own body changing. This condition can be characterized as a delusion of "personal metamorphosis" or bodily alteration. Dysmorphophobia represents a symptom complex characterized by an active drive to correct an imaginary defect, pronounced ideas of reference, and a depressed mood.

In cases where such a disorder arises without any external cause through a paradoxical mechanism and takes the form of delusional ideas, it is more appropriate to speak of dysmorphomania. Such states are observed predominantly in schizophrenic disorders and psychopathies of the asthenic type. When the described syndrome develops reactively and has a real basis, for instance, in individuals with congenital and acquired defects, it is more appropriate to use the term dysmorphophobia. This typically occurs within the framework of neurotic reactions, pathocharakterological development, and personality disorders (psychopathies).

Dentists frequently encounter dysmorphophobic disorders both during cosmetic Procedures and in routine therapeutic practice. Such disorders may include, for example, painful preoccupations regarding a sensation of halitosis, which patients perceive as a dental pathology, or concerns related to perceived flaws in their own bodies.

Most often, however, patients feel that their face has changed: it has become different, unpleasant, and devoid of any meaning. Such a condition is exceptionally difficult to endure, given that the face plays a major role in a person's social life. It can be called a "psychological instrument" which, through expressive facial movements, reflects the internal dynamics of mental activity, thoughts, and feelings. Furthermore, the immense Significance of the face in shaping and manifesting sexual drives is widely recognized.

Patients suffering from glossalgia frequently experience obsessive thoughts about Tongue Cancer. Consequently, they constantly examine it in the mirror, consider it altered, and persistently demand "appropriate" Treatment, becoming regular clients of dental clinics. Proper psychotherapeutic tactics by the dentist are of paramount importance for the successful examination and treatment of such patients.

Delusion-like ideas are morbid ideas involving the undervaluation or overvaluation of one's personality, emerging against the Background of an altered mood (elevated or depressed). They are rooted in some minor real-life basis. To a certain extent, these ideas can be corrected, though not always and not for long. They are never overtly absurd.

Most commonly, delusion-like ideas are encountered within The Structure of manic and depressive states. In the former case, this typically involves an inflated assessment of one's own qualities, capabilities, and achievements; in the latter, it involves ideas of loss that vary in both qualitative manifestation and degree of intensity.

Delusions are a symptom of a thought disorder in which a false, erroneous judgment—arising on a pathological basis—distortedly reflects reality, completely dominates consciousness, and is resistant to correction.

A delusional idea is subjectively perceived by the patient as an absolute truth of which they have no doubt. Unlike obsessions, where patients recognize their absurd nature, delusions are characterized by high subjective certainty, do not change under METABOLISM/18.html">The Influence of experience, and are accompanied in most cases by personality alterations.

Delusions differ from overvalued ideas in that they are inherently characterized by a pathological interpretation of reality from the very beginning. As a rule, they emerge from vague delusional experiences and are completely discordant with both the patient's personality and the situation.

The boundary between delusions and delusion-like ideas is rather conventional. It is generally believed that delusion-like ideas lack a tendency toward systematization and are characterized by instability.

Delusions are subdivided into primary (interpretative) and those associated with affects or perceptual disorders (secondary, figurative delusions).

Primary delusions typically do not emerge all at once, but rather as a consequence of a series of distinct, sequentially changing stages.

First, delusional perception appears. Faces, surrounding objects, and events happening around the patient seem filled with mystery, promise something, and cause anxiety, yet nothing about this is definite. The patient simply feels as though something momentous is about to happen, which puts them on edge.

Following delusional perception, delusional conception emerges, whereby events of past life acquire new meaning, a new coloring, and a new significance. For example: "I have finally realized that I am God and everything in the world is the result of my commands and instructions," etc. At the same time, this delusional realization acquires the meaning of a "special reality" (K. Jaspers, 1923), and an intuitive understanding of the essence of ongoing events arises.

The final stage of primary delusion is termed its crystallization, during which the delusional ideas acquire "coherence and completeness."

In primary delusions, logic is impaired above all else. Delusional patients support their viewpoint with arguments selected in a biased manner. Only that which aligns with the idea defended by the patient is taken into account; opposing arguments are ignored.

Among the most frequent variants of primary delusion, depending on its plot (fabula), are:

Persecutory delusions—delusional ideas in which the patient believes they are being pursued, watched, targeted for murder, etc. Initially, these ideas are concealed from others—this is Phase I; then Phase II sets in—patients begin actively fighting their "persecutors." In doing so, they may become socially dangerous (arming themselves, attacking strangers, etc.).

Delusions of jealousy—unfounded accusations of marital infidelity and betrayal, where the facts meant to serve as proof are often unrealistic and fantastical in nature. They frequently arise in cases of chronic alcoholism.

Under the influence of these delusions, patients are capable of committing grave crimes (physical harm, murder).

Delusions of poisoning—the patient's assertion that poison is being slipped into their food or that they are being given toxic medications.

Querulent delusions (litigious paranoia)—an irresistible compulsion to vindicate interests and rights perceived by the patient as violated, through numerous Complaints, lawsuits, and appeals to courts, prosecutor's offices, and other authorities.

Delusions of reference—the patient believes that almost all surrounding events directly concern them in some way and carry a special meaning: people around them look at them significantly; all actions, gestures, utterances, radio and television broadcasts, and sometimes even natural phenomena occur not by chance, but have a direct bearing on them.

Erotic delusions—a variant of delusions of reference and influence, sometimes combined with persecutory delusions, wherein a specific person of the opposite sex is believed to be in love with the patient, harbor a deep passion for them, and therefore employ various Methods to attract them and win their affection.

Delusions of possession are peculiar hypochondriacal delusions in which the patient believes that animals, mythical creatures, or beings invented by the patient have infested their body.

Delusions of self-blame occur when patients accuse themselves of mistakes, immoral actions, thoughts, or desires for which they will receive severe punishment.

Delusions of self-deprecation are delusional ideas in which the patient considers themselves a failure, worthless, or deeply inadequate.

Delusions of loss and deprivation involve the patient's conviction that known or unknown criminals want to rob them, are robbing them, ruining them, depriving them of their apartment or earnings, and damaging their property.

Hypochondriacal delusions represent a persistent, unfounded conviction that the patient is suffering from a severe, incurable disease and is about to die. To prove this, they present absurd arguments allegedly based on their physical sensations, the observations of others, and clinical lab results. The patient refuses to believe anyone trying to convince them otherwise, including physicians.

Delusions of grandeur involve the conviction of possessing exceptional qualities, abilities, capacities, wealth, or social status. These delusional ideas emerge against the backdrop of an elevated mood.

Delusions of high Lineage are claims by the patient that they originate from a noble family and have kinship ties with world-famous figures.

Delusions of invention and discovery represent a thought disorder in which a patient without specialized education or experience "invents" devices, engines, or medicines, or "discovers" laws of universal motion, the application of which, in their view, will promote progress and bring happiness to humankind.

Reformist delusions occur when the patient claims to be transforming the world, relying on their own calculations, writings, and the like.

Imaginative-sensory delusions are delusional ideas accompanied by heightened affect and generalized bewilderment stemming from a disorder of sensory cognition. The latter lacks a coherent worldview and relies not on a system of evidence, but primarily on imagery and fantasy. The patient perceives hints directed at them everywhere—in people's smiles, newspaper articles, or glowing lightbulbs, which they interpret as signals from imaginary enemies.

Unlike interpretive delusions, imaginative-sensory delusions are secondary. Their emergence is most often associated with hallucinatory experiences or Affective Disorders. They are poorly systematized and fundamentally rooted in sensory-colored, vivid, figurative perceptions that determine the fragmentary and inconsistent nature of their manifestations.

The content of imaginative delusions varies, sometimes approaching reality and at other times taking on a fantastical character. This category includes antagonistic or Manichaean delusions, which are based on the struggle between two opposing forces—good and evil, light and darkness. The Nature and consequences of this confrontation depend on the patient's behavior, intentions, and actions.

Affective delusions have either a depressive or manic orientation. The manifestations of depressively oriented delusions are diverse (ideas of loss, Various Forms of hypochondriacal and nihilistic delusions, etc.). For instance, in Cotard's syndrome, hypochondriacal experiences acquire a megalomanic character: "My suffering will never end, the world will perish, humanity will vanish, and only I and my suffering will remain...". Affective delusions with a manic orientation manifest as delusional ideas of grandeur.

Catasthetic delusions are delusional ideas associated with impaired interoception. Painful sensations originating primarily from Internal Organs give rise to hypochondriacal complaints, as well as delusions of persecution and external control.

Residual delusions are delusional ideas constructed on the basis of perceptual errors during states of altered consciousness. After recovery, the patient retains the conviction for some time of the truth of the morbid (delusional) experiences that occurred during the acute period of the illness.

Catathymic delusions originate from an anxious-tense affect or stem from the patient's profound desires.

Holothymic delusions are caused by a depressive affect.

Induced delusions are delusional ideas that develop in individuals who are incapable of critically evaluating the delusional statements of a mentally ill person and accept them as truth. This occurs in individuals with low intellect or high suggestibility.

Conformant delusions are mechanistically similar to induced delusions. The difference lies in the fact that conformant delusions develop among mentally ill individuals who are in close proximity to one another. Patients with conformant delusions position themselves against the surrounding world as a group rather than as individuals.

Systematized and non-systematized delusional ideas are distinguished as follows:

Systematized delusions are delusional ideas that form a coherent system united by a central thought. Delusional judgments evolve into a system of views that define the overall worldview, and the patient's entire mental life becomes centered around these judgments. The reflection of internal connections between phenomena in the real world is distorted, as one morbid judgment links to another to crystallize the delusional system. Paranoid and paraphrenic delusions are typically systematized.

Non-systematized delusions are delusional ideas characterized by a lack of a consistent system of evidence. They are disjointed, unrelated, fragmented, incoherent, absurd, and rapidly changing. Non-systematized delusions are associated with perceptual disturbances (hallucinations). Paranoid delusions are typically non-systematized.

A detailed characterization of Delusional syndromes is provided in the chapter dedicated to Psychopathological Syndromes.

CONTROL QUESTIONS

1. Define THE CONCEPT OF thinking.

2. Provide a Classification of thought disorders.

3. What is paralogical thinking?

4. Define autistic thinking and argumentativeness (reasoning mania/resonerstvo).

5. Obsessive-compulsive states: classification and clinical characteristics.

6. Characteristics of overvalued ideas.

7. What delusional syndromes are distinguished in psychiatry?

8. Clinical characteristics of paranoid syndrome.

9. CHARACTERISTICS OF THE syndrome of psychic automatism.

10. Characteristics of paranoid and paraphrenic syndromes.

11. Differences between primary and figurative types of delusions.

12. Clinical Features of figurative-sensory delusions.

13. What are systematized and unsystematized delusions?

14. What is meant by induced and conformist delusions?