6th November 2023

Psychopathology of Thought Content

What is Thought?

‘A man is but the product of his thoughts. What he thinks, he becomes.’

– Mahatma Gandhi

As human beings, we have thoughts every day; in fact, this is something that makes us quintessentially human and differentiates us from other living things. Our thoughts range from the mundane to the genius. They are an expression of our individual self.

Thought content is an essential element of the mental state examination (MSE). The content of others’ thoughts manifests in two ways: firstly, observing behaviour (another element of the mental state examination), and secondly, listening to their communication. However, the relationship between thought and observable behaviour is complex. The content of the patient’s thoughts may be expressed directly by the patient, or it may require probing by the examiner during an interview in the form of focused questions. Some psychologists view thought as an internal monologue involving a separate language of the mind. However, others view language and thought as highly interlaced. This is a very interesting topic, but for the purposes of the MRCPsych papers, we do not need to delve into this too much.

Before we look at what happens when thinking ‘becomes disturbed’, let’s first consider ‘normal thinking’.

References

• Gosney, P., & Kumar, S. (n.d.). Thought. Trainees Online (TrON). Available online at: https://mylearning.rcpsych.ac.uk/d2l/home/7589 [Accessed Jan 2023]

Normal Thinking

In 1967, the British Psychiatrist Frank Fish published the first edition of what would become an extensively re-editioned book: Clinical Psychopathology: Signs and Symptoms in Psychiatry. Within this, he described 3 types of thinking which can be viewed as the functions of thinking, i.e. the reasons why we think:

• Undirected fantasy thinking – Also known as autistic or dereistic thinking. This is essentially like daydreaming, and an example would include: ‘I wonder what elephants would eat if they had fingers.’ It usually only lasts a short time, such as when one is bored or about to go to sleep. It can allow us to get away from reality temporarily. Different types of experiences fall into fantasy thinking, including pathological lying (pseudologia fantastica), conversion disorder, dissociative disorder and delusions in affective psychoses (the content of which are dependent on the patient’s affective state at the time).
• Imaginative thinking – This remains within the realms of possibility and extends up to the rational. For example, ‘What will I eat for dinner?’ Imaginative thinking comprises a) Mental imagery: thinking of an image in one’s mind; b) Counterfactual thinking: shifting one’s thinking of reality to think of things that have not happened yet in life; and c) Symbolic representation: the use of concepts to exemplify real world objects, such as what happens when we use algebra in mathematics or symbols in sheet music.
• Rational thinking – Also known as conceptual thinking. This type of thinking is an attempt to solve a problem, i.e. it is logical. For example, ‘What ingredients do I need to make dinner tonight?’. Another example is heuristics, or put simply mental shortcuts. These are shortcuts that our mind creates without conscious effort, using rational thinking to make our lives easier. They are not guaranteed to succeed, but there’s a good chance that they will. For example, if losing one’s phone at home, one could explore every room, and we would be guaranteed success. However, what we actually do to save time is create a mental shortcut by starting our search in the room we were in last or the room we are in most often, as the chance of finding the phone with this method is likely to be faster. Rational thinking requires the person to have the capacity to form mental concepts.

References

• Fish, F. (1967). Clinical Psychopathology: Signs and Symptoms in Psychiatry Bristol: John Wright.

The Mental State Examination

The MSE is an essential clinical tool in psychiatry. It forms the building blocks of a psychiatrist’s ability to evaluate a patient’s mental state, which paves the way for diagnosis, treatment, risk assessment, mental state monitoring and prognosis.

The MSE provides the examiner with a snapshot in time, otherwise known as a cross-sectional account, of the patient’s psychological and behavioural functioning. It consists of the following domains, a selection of which are covered in the chapters of this book: appearance, behaviour, mood and affect, thought content, thought form, perception, insight, cognition and judgement.

Serial MSEs taken over time or longitudinally allow the clinician to monitor the psychopathology of a patient, which helps us evaluate the patient’s progress from the treatment they are being prescribed, which subsequently guides treatment decisions.

The MSE comes from a psychological method called descriptive psychopathology or descriptive phenomenology, which was developed by the philosopher and psychiatrist Karl Jaspers. He believed that to understand a patient’s mental state, it was necessary for the patient to provide their own description (through non-judgmental questioning) rather than a psychoanalytic approach, which was based on interpretation of the patient’s account and exploring unconscious processes. The modern approach to performing MSEs has evolved to be based on this original descriptive psychopathology combined with observing the patient to build a complete picture.

References

• Häfner, H. (2015). Descriptive psychopathology, phenomenology, and the legacy of Karl Jaspers. Dialogues in Clinical Neuroscience. 17(1), 19–29

Disorders of Thought

Within the MSE, the subsection of thought content probably forms the largest section. Disorder of thought is divided into disorders of thought content (i.e. any abnormal beliefs the patient expresses) and disorders of thought form (i.e. the reasoning and manner in which their thoughts are expressed).

Two other components of thought disorder also exist, but these are more minor and don’t specifically appear within the MSE: control of thought and stream of thought. We discuss control of thought at the end of this chapter, and stream of thought is discussed in the next chapter.

The table below briefly describes each of these components. Don’t worry if some of these terms in the table are unfamiliar; they will all be discussed over the course of this chapter and the next.

When performing an MSE in clinical practice, one often refers to a thought stream within the component of thought form, but for academic purposes, the discrepancy is detailed in the table above.

Thought form will be discussed as the subject of the next chapter. For now, let’s look at the different disorders of thought content.

Thoughts of harming oneself

This is one of the most critical elements within thought content and contributes to a patient’s risk assessment.

The thoughts to harm oneself may vary in severity from superficial laceration (e.g. of the thigh with a razor blade) to thoughts of suicide, also known as suicidal ideation).

The patient may just present with self-harm or suicidal ideation; or, more concerningly, they may inform you of specific plans about how they would commit suicide; or at the most severe end of the spectrum, the patient may demonstrate suicidal intent whereby they have both a plan in mind and are demonstrating the intent to fulfil that plan.

Thoughts of harming others

Similar to the previous subsection, these thoughts may be associated with behavioural actions, and therefore, this also forms an essential part of an ongoing risk assessment.

Restricted thinking

The range of thought content is limited as the patient becomes fixated on one or a small number of topics. Any attempt at changing the topic of conversation is usually in vain as the patient will redirect the conversation back to their chosen topic.

Neologism

The formation of a newly coined word that’s meaning is unique to the patient. It is seen in schizophrenia, as well as in organic conditions such as stroke.

For example, ‘I was walking along the street, and when I looked down on the pavement, I saw a Fajunud.’

Thought control

Normally, the thoughts we experience are recognised as being our own. However, with thought control, also known as thought alienation, the thoughts experienced are under external control. Thought control and thought alienation have, in clinical practice, been replaced by these first rank symptoms of schizophrenia (Schneider, 1959):

• Thought insertion – The experience of foreign thoughts being put into one’s head by an external agency.
• Thought withdrawal – The experience of thoughts being taken out of one’s head by an external agency.
• Thought broadcasting – The experience of one’s thoughts being broadcast out loud so that others can hear and access them.

Overinclusive thinking

Patients with schizophrenia often demonstrate overinclusive thinking, that is, the tendency to incorporate ideas that are only tenuously related. For example, if asked about the essential elements of a pizza: ‘base, topping, or pizza box’, they might reply ‘pizza box’. This can be demonstrated by sorting tests. The lack of a meaningful bridge between two consecutive thoughts is called asyndesis.

Overvalued ideas

Defined by ICD-11 as unreasonable and sustained beliefs that are maintained with less than delusional intensity (i.e. the person is able to acknowledge the possibility that the belief may not be true).

Overvalued ideas are emotionally charged and sufficient to influence that person. They have been shown to differ from delusions in that people expressing overvalued ideas are more likely to identify what might modify their belief, they are more preoccupied, and they are more concerned about others’ reactions. Furthermore, overvalued ideas are more plausible, and their presence is more logical.

Interestingly, a comparative study on delusions and overvalued ideas found that ‘abrupt onset, implausible content and relative indifference’ were more reliable discriminating factors rather than the person’s insight (Mullen & Linscott, 2010).

Similar to delusions, over time, the beliefs may strengthen in intensity as the patient’s thinking becomes more concrete, and they find more of what they believe to be evidence to fuel these beliefs. Furthermore, they are similar to delusions in that they are not shared by others in their cultural or subcultural group.

Examples include hypochondriasis – an overvalued idea that one has a specific illness; and somatisation – an overvalued idea that one is experiencing a symptom or cluster of symptoms.

Preoccupations

Persistent worry or feelings of guilt about something are often seen in anxiety spectrum disorders and depression.

Obsessions

An obsession is any unwanted, intrusive thought, image, or urge that repeatedly enters the person’s mind. It is also known as a rumination. Obsessions induce high levels of anxiety in the patient.

It is important to understand the difference between obsessions and compulsions; the latter are obsessional motor acts that are compensatory, such as cleaning or staring. With compulsions, the patient often acknowledges that they don’t want to do the behaviour or action but that they feel compelled to do it to reduce the anxiety caused by the obsession.

An obsession is referred to as being ego-dystonic, meaning it is perceived by the patient as unreasonable and undesirable. For example, the most common obsession is that one is contaminated. An associated compulsion would be to wash repeatedly or repeat the phrase ‘I’ve showered’. It is most commonly associated with obsessive compulsive disorder; however, it may also be present in depression or schizophrenia.

Delusions

A delusion can be defined briefly as – A fixed, unshakeable belief held by a person contrary to evidence and not in keeping with their religious or cultural beliefs.

The content of delusions varies across time and culture. Some have remained consistent in their narrative, like delusions of love. Others, such as delusions of persecution, are continually evolving; for example, with technology such as mobile phones and the internet, the content has evolved to include beliefs around ‘hacking’ and ‘monitoring’.

Before we look at the different types of delusions, it is important to understand that delusions can be divided into two types, according to Karl Jaspers (the 20th Century German-Swiss psychiatrist and philosopher):

Primary delusions

Delusions that arise ‘out of the blue’ with no psychopathology like a mood disorder. In other words, we cannot understand how they were formed. They are only present in schizophrenia. To complicate it slightly further, according to Jaspers, primary delusions can be further subcategorised into 4 types:

Autochthonous delusion.

These refer to delusions that arise spontaneously ‘out of the blue’ with nothing preceding it.

Delusional percept.

This is when a normal perception is interpreted with a delusional meaning and holds a significance which is not understandable to others. Unlike an autochthonous delusion, there are 2 stages: the perception and the interpretation. For example, a person sees two freckles near each other on his skin, declaring that he has been bitten by a poisonous snake and refusing to acknowledge any other explanation. It is a first rank symptom of schizophrenia. A sudden delusional idea may occur, in which a new delusion becomes fully formed in the patient’s mind.

Delusional atmosphere.

This refers to the patient feeling that ‘something strange is going on’. They feel like there are things happening around them that are building up and about to present themselves in some sort of significant manner. It may be exciting or terrifying. The mood of the atmosphere is significant, and patients may begin their journey of psychosis with a delusional mood: they have a sensation that something is not quite right. They may start to perceive certain senses more strongly, and they might appear perplexed or confused as they struggle to piece together this new world around them. When a delusion is finally formed, it might be a relief to the patient that finally, now, they have made sense of what they have been experiencing, of course, in their distorted reality.

Delusional memory.

This is simply the delusional interpretation of a normal memory. For example, a patient experiencing auditory hallucinations in the form of voices asserting that these voices arose after a radio emitter was placed in his ear by a doctor last year. In fact, a grommet was inserted into that ear 20 years ago whilst the patient was a child for recurrent otitis media. The patient continues to demand CT scans of his head so that we can identify and remove the emitter.

Primary delusions are more common in acute schizophrenia. These will often develop to become increasingly elaborate, evolving to become enmeshed together. This concept is known as a systematised delusion. Primary delusions are less common in chronic schizophrenia, which is more characterised by secondary delusions, which we shall discuss now.

Secondary delusions

Delusions that arise from some form of morbid experience, for example, depression, hallucinations, psychosocial stressors or abnormal personality traits (like a paranoid personality giving rise to persecutory delusional beliefs). In other words, the delusion is understandable, given the current circumstances, because of a pervasive mood state. Secondary delusions occur in many conditions, including schizophrenia and bipolar affective disorder. They can also occur in organic conditions such as drug intoxication, withdrawal and epilepsy. For example, a patient experiencing a manic episode who believes they are a rockstar can be understood as their manic state invoking an expansive and elated mood. Conversely, a depressed patient with psychotic features may believe they are rotting inside.

Now that you have an understanding of primary and secondary delusions, the next part of this chapter looks at specific delusions that are likely to come up in the MRCPsych exam.

References

• Prathap, S. (2019). SPMM Smart Revise. SPMM Course.
• Schneider, K. (1959). Clinical Psychopathology. New York: Grune & Stratton
• World Health Organization. (2019). ICD-11: International classification of diseases (11th revision).
• Oyebode, F. (2015). Sims’ Symptoms in the Mind. Textbook of Descriptive Psychopathology. Elsevier: 5th Ed.
• Mullen, R., Linscott, R. (2010). A comparison of delusions and overvalued ideas.The Journal of Nervous and Mental Disease. 198(1): 35-8.
• Jaspers, K. Allgemeine Psychopathologie. Berlin: Springer. 1913. English translation of the 7th edition General Psychopathology. Baltimore. Johns Hopkins University Press; 1997.

Specific Delusions

Delusion of love

It is also known as erotomania or de Clérambault’s syndrome. The patient comes to believe that a specific other person is in love or infatuated with them, although this is, in fact, not the case. The other person may have not even had any previous contact with them. The disorder is more common in women. The other person is more commonly a male of high social status or already in a relationship.

Delusion of love is associated with personality disorders and other delusional disorders such as schizophrenia.

If severe enough, it can be associated with problematic behaviours such as sending letters/emails or other forms of communication, stalking and unwanted physical contact.

Delusion of unfaithfulness

Also known as Othello syndrome. Jealousy is a common emotion that everyone has experienced, but this diagnosis is made when there is a delusional and irrational component to the person’s jealousy.

It has mixed aetiology, often appearing in both functional and organic disorders. In fact, it has been demonstrated that at least 30% of cases have neurological underpinnings, frequent alcohol dependency and dementia (Cipriani et al., 2012).

Pre-morbidly, the person is typically described as being suspicious, sensitive and mildly jealous.

The presenting person may misinterpret the ordinary actions of their partner as being indicative of their unfaithfulness. For example, if the partner buys new underwear, the person may become convinced that the reason behind this is to show off to the partner’s new spouse.

The disorder may result in problematic behaviours, such as a reprisal attack against the partner, which may occur with little predictability.

Delusion of ill health

The patient is convinced that they are not physically well. This is most associated with depressive disorder but is also seen in schizophrenia. It often takes a significant length of time to respond to treatment. Pre-morbidly, the patient frequently exhibits some health anxieties, which are magnified along the course of their depressive/schizophrenic illness.

The individual’s delusion may even extend to their family, such that a person may become convinced that their parent or child is dying, and so murder them with the thought that they are helping to end their suffering.

These delusions can result in hypochondriasis, the belief that one is unwell with a specific medical condition.

They may also result in a sense of incurable insanity, in which the person believes their mental illness is resistant to any form of treatment and refuses to accept any form of help from their psychiatric team, resulting in problems with engagement and treatment compliance problems.

Delusions of guilt

This is observed in depression. The intensity of the delusion and magnitude of the guilt is proportional to the severity of the depression.

In mild depression, a patient may feel guilty about a specific past event in their life and say something like: ‘Not being present enough in my daughter’s upbringing made her fail that exam.’

In moderate depression, the consequence of their guilt about something specific may be extended. For example: ‘Not being present enough in my daughter’s upbringing ruined her whole life.’

In severe depression, the delusions of guilt may even absorb a grandiose flavour, with such content as: ‘I’m the most wicked person in the world.’ They often lead to suicide (Higgins, 1990).

Delusional misidentification

Delusional misidentification includes both Capgras’ syndrome, Frégoli’s syndrome and the Syndrome of subjective doubles.

Capgras’ syndrome refers to the condition whereby someone believes with delusional intensity that another person, usually someone closely related to them, has been replaced by an exact double.

Frégoli’s syndrome denotes a person believing that someone unfamiliar to them is actually familiar, even though there bears no physical resemblance.

Syndrome of subjective doubles is the belief that doubles of the person exist, although, in fact, these other people have no relation to him.

Syndromes of delusional misidentification occur in a variety of both functional and organic conditions. Functional conditions include both schizophrenia and bipolar affective disorder. Organic include dementia, acquired brain injury, epilepsy, and stroke (Edelstyn et al., 1999). In cases of organic aetiology, the right frontal and temporal regions have been found to be pathological, which are areas associated with facial recognition.

Religious delusions

Often, the setting for these delusions is a person with some religious background. The religious beliefs become delusional when they become amplified beyond what is reasonable in the context of that religion. For example, a person who believes that members of her church have become possessed by Satan. This is clearly not a view that would be held by the majority of that congregation.

Nihilistic delusions

The patient will deny they exist, that they have a body and may even deny that others exist or the world around them exists. It most commonly occurs in severe depression but is also seen in schizophrenia and delirium.

An example of a nihilistic delusion is Cotard’s syndrome, in which the person believes they are dead or does not exist. Nihilistic delusions are the opposite of grandiose delusions, and feelings of guilt and hypochondriasis are prominent.

Delusions of infestation

The patient believes that they are infested with insects or small organisms. Also known as Ekbom’s syndrome. They may experience this as a tactile hallucination or a delusion. The syndrome has different aetiologies, including depressive psychosis, paranoid schizophrenia, delirium tremens, cocaine addiction, stroke and dementia.

Pseudocyesis

A delusion whereby a woman believes that she is pregnant, although she is not. However, there can be clinical symptoms and signs that convince the person that they are, including menstrual disturbance, nausea, breast changes and abdominal distension.

Grandiose delusion

Grandiose delusions are delusional beliefs that one is special in some way, either in the form of identity or ability. For example, a grandiose delusion of identity could be the belief that one is Superman, the Prime Minister, or even God. Beliefs that one is rich can result in excessive spending, and therefore, protecting the patient’s finances is important, even if it means preventing them from having access to their bank account or spending means whilst they are unwell.

Grandiose delusions of ability could include the belief that one is a talented singer, a brilliant inventor, or that one can fly. As a result of delusions such as the latter, mania results in a significant risk profile and harm to self or even death can result from recklessness and feelings of invincibility.

Grandiose delusions are associated with manic presentations, for example, in bipolar affective disorder or schizoaffective disorder. These delusions may develop in response to auditory hallucinations, for example, a voice telling the person that they are a talented musician. This is a good example of how some auditory hallucinations can be non-distressing, occasionally resulting in patients avoiding treatment.

Persecutory (paranoid) delusion

This is a delusional belief that one is being harmed in some way. It is most associated with paranoid schizophrenia. However, this can also be present in depression with psychosis, whereby the patient may feel he is so evil that he deserves to be spied on. Examples include the belief that one is being poisoned, their mobile or computer is being hacked, they are being monitored by another person or external organisation, or they are being tortured.

Often, in psychiatry, we see paranoid and persecutory being used interchangeably to describe delusions of this nature. However, strictly speaking, the correct meaning of the word ‘paranoid’ is ‘delusional’, and therefore, it is correct to use the term ‘persecutory’. Paranoid simply refers to the person believing that the delusion is referring to themselves. It is not, therefore, the same as persecutory.

Hypochondriacal delusion

A hypochondriacal delusion is a delusional belief that one is suffering from a specific medical condition.

The patient will classically approach their medical practitioner requesting to be investigated for a specific condition, although no organic pathology will be identified. The patient refuses to accept the advice and evidence put forward to them by the medical practitioner and so will return requesting further investigations or will seek another practitioner’s advice, convinced that something must be wrong.

Referential delusion

A referential delusion, or idea of reference, is the false belief by the patient that everything occurring around them is related. This can manifest by the patient thinking that a news anchor on the TV is talking directly to them, or that a singer on the radio, or a journalist in a newspaper are doing the same thing, to name a few examples.

Folie à deux

This can be translated from the French as ‘madness by two’.

This fascinating syndrome occurs when a delusion is transmitted from a psychotic person to another person. The other person is most commonly a partner, family relative, or close friend.

Treatment involves treating the person who transmitted the psychosis and separating them from the other person. These two actions indirectly result in the treatment of the other person.

References

• Prathap, S. (2019). SPMM Smart Revise. SPMM Course.
• Oyebode, F. (2015). Sims’ Symptoms in the Mind. Textbook of Descriptive Psychopathology. Elsevier: 5th Ed.
• Fish, F., Casey, P., Kelly, B. Fish’s Clinical Psychopathology. Signs and Symptoms in Psychiatry. Cambridge University Press. 4th Ed 2019.
• De Clérambault GG (1942) Les psychoses passionelles. Oeuvre psychiatrique. Paris: Presses Universitaire.
• Edelstyn., N, Riddoch, M., and Oyebode, F. (1999) A review of the phenomenology and cognitive neuropsychological origins of the Capgras syndrome. International Journal of Geriatric Psychiatry 14, 48–59
• Berrios GE (1985) Delusional parasitosis and physical disease. Comprehensive Psychiatry 26, 395–403.
• Higgins, J. (1990). Affective psychoses. In Bluglass R and Bowden P (eds.) Principles and Practice of Forensic Psychiatry. Edinburgh: Churchill Livingstone.
• Berson RJ (1983) Capgras’ syndrome. American Journal of Psychiatry 140, 969–78.
• Cipriani, G., Vedovello, M., Nuti, A., di Fiorino, A. (2012). Psychiatry Dangerous passion: Othello syndrome and dementia. Psychiatry and Clinical Neurosciences. 66(6): 467-73.
• Christodoulou GN (1991) The delusional misidentification syndromes. British Journal of Psychiatry 159 (suppl. 14), 65–9.
• Christodoulou GN (1978) Syndrome of subjective doubles. American Journal of Psychiatry 135, 249–51.