Is "formal thought disorder" treatable?
Dear [name withheld]:
Surprisingly, to me at least, I get more ask the psychologist letters on this topic than on any other except for the eternal questions about penis size.
Formal thought disorder is one of the symptoms of schizophrenia. Generally, symptoms of schizophrenia fall into four basic categories. First there are the behavior disorders such as catatonia in which the ill person may hold the same position for hours on end, unable to speak or to eat. A second category of schizophrenic symptoms involves disturbances to feeling and emotion, the classic one of these being so called "flat affect," in which events that in normal people would produce obvious emotional responses (very good news, for example, or sudden death of a loved one) produce no emotional response at all. A third category of schizophrenic symptoms is disorders of perception such as hearing voices or seeing things which are not apparent to healthy people. Finally, there is the collection of symptoms called "formal thought disorder."
In formal thought disorder, people may give voice to strange or unrealistic thoughts. These may reach the level of fixed delusions such as the idea that a government agency has a way of implanting thoughts in one's mind, that hidden cameras are recording every movement, or that one is endowed with special, superhuman powers. Often in formal thought disorder the disturbed thinking becomes obvious to observers through speech or writing that sounds strange or disconnected, even to the point of being impossible to understand.
Nancy Andreasen* has broken down into subcategories examples of the disordered speech associated with formal thought disorder. I take the liberty of quoting them here:
- Pressure of speech - An increase in the amount of spontaneous speech compared to what is considered customary.
- Distractible speech - During mid speech, the subject is changed in response to a stimulus. e.g. "Then I left San Francisco and moved to... where did you get that tie ?"
- Tangentiality - Replying to questions in an oblique, tangential or irrelevant manner. e.g. "What city are you from ?", "Well, that's a hard question. I'm from Iowa. I really don't know where my relatives came from, so I don't know if I'm Irish or French".
- Derailment - Ideas slip off the track on to another which is obliquely related or unrelated. e.g. "The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California".
- Incoherence (word salad) - Speech that is unintelligible due to the fact that, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish, e.g. the question "Why do people believe in God?" elicits a response like "Because make a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons, hello."
- Illogicality - Conclusions are reached that do not follow logically (non sequiturs or faulty inductive inferences).
- Clanging - Sounds rather than meaningful relationships appear to govern words. e.g. "I'm not trying to make noise. I'm trying to make sense. If you can't make sense out of nonsense, well, have fun".
- Neologisms - New word formations. e.g. "I got so angry I picked up a dish and threw it at the geshinker".
- Word approximations - Old words used in a new and unconventional way. e.g. "His boss was a seeover".
- Circumstantiality - Speech that is very delayed at reaching its goal. Excessive long-windedness.
- Loss of goal - Failure to show a chain of thought to a natural conclusion.
- Perseveration - Persistent repetition of words or ideas. e.g. "I'll think I'll put on my hat, my hat, my hat, my hat, my hat, my hat, my hat, my hat..."
- Echolalia - Echoing of other people's speech e.g. "Can we talk for a few minutes?", "Talk for a few minutes".
- Blocking - Interruption of train of speech before completed.
- Stilted speech - Speech excessively stilted and formal. e.g. "The attorney comported himself indecorously".
- Self-reference - Patient repeatedly and inappropriately refers back to self. e.g. "What's the time?", "It's 7 o'clock. That's my problem".
- Phonemic paraphasia - Mispronounciation; syllables out of sequence. e.g. "I slipped on the lice broke my arm".
- Semantic paraphasia - Substitution of inappropriate word. e.g. "I slipped on the coat, on the ice I mean, and broke my book".
If a person falls into a sustained period of formal thought disorder, and if the symptoms are serious enough so that even a determined and sympathetic person cannot understand the speech, writing, or other communications of the ill person, you will understand that the ill person is now lost in a world of his or her own, unable to understand or be understood by people living in the ordinary world of consensual reality. This is total and complete isolation; a lonelier state cannot be imagined.
Now, you ask if formal thought disorder can be treated. This is the same, you see, as asking if schizophrenia can be treated.
The answer is yes. Not only can schizophrenia be treated, but it must be treated, and treated promptly and aggressively, because schizophrenia is a progressive condition which almost always worsens with time so that without treatment the schizophrenic person will likely end up totally disabled, often requiring custodial care merely in order to survive.
Before beginning treatment of schizophrenia, it is important to rule out organic factors, such as brain tumor, which can produce the same kinds of symptoms as schizophrenia. Once these are ruled out, treatment usually involves trying to stabilize the patient, in other words, to bring the patient back into some useful contact with reality, and then trying to prevent relapses.
Since we still do not know the etiology (the causes) of schizophrenia--the best contemporary thinking blames a genetic predisposition (an inborn imbalance of brain chemistry, that is) later potentiated by environmental factors such as family pressures--it cannot be said that there is a cure for schizophrenia, or even that a cure is in the offing. In other words, so far it is not known what schizophrenia really is, much less how to cure it. This leaves aggressive treatment of symptoms as the only option. The best treatment involves suppression of symptoms with such medicines as haloperidol decanoate (Haldol Decanoate) or fluphenazine decanoate (Prolixin Decanoate), combined with counseling and psychotherapy aimed at helping the patient to understand and deal with his or her situation.
If you or anyone you care for shows symptoms of schizophrenia, whether they be disordered thinking, or any of the other indications, I urge you to seek expert advice immediately. You should begin with a visit to a physician who will move to rule out organic causes. Once these are ruled out, your physician will be able to arrange for the expert psychiatric care needed in all cases of schizophrenic illness.
*Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Archives of General Psychiatry 1979;36(12):1315-21
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