Thought Disorders

00:01 Now, let’s talk a little bit more about the thought disorders.

00:06 There are different types of thought disorders.

00:08 We think about disordered thought content.

00:11 This looks like disruption in a patient’s beliefs, ideas, and interpretations of their surroundings.

00:20 Disordered thought process is a manner in which the patient links ideas and words together.

00:27 Let’s consider a couple of the common types of thought disorder.

00:32 What do you think it means when we say a patient has alogia or poverty of content? Well, this is where very little information is conveyed by speech.

00:45 How about thought blocking? In clinical practice, this is when a patient suddenly loses their train of thought.

00:52 It’s exhibited by an interruption in their speech and then they have trouble picking right back up again.

00:58 Loosening of associations describes a speech content notable for ideas presented in sequence that are not closely related.

01:08 So it’s where somebody jumps all over the place.

01:11 Tangential though process is another type of disorganized thought.

01:17 So this is where answers to interview questions diverge increasingly from topic to topic being asked about.

01:26 Some call this circumstantiality if the is eventually returned to the original topic.

01:33 When somebody’s tangential, they basically go off course and can never return to the point.

01:40 Clanging or clang association is another type of thought disorder.

01:45 So this is where words are used in a sentence that are linked together by rhyming or due to phonetics.

01:52 Here’s an example of what a patient might say.

01:54 “I fell down the well sell bell.” So things rhyme, but they don’t really make any sense used together.

02:02 A word salad is another important type of thought disorder and this is where real words are linked together but incoherently.

02:11 So it’s nonsensical.

02:14 An example would be a patient saying, “Tree way of nothing house.” It makes no sense.

02:21 A perseveration is repeating words or ideas persistently often even after the interview topic has changed, so it’s where somebody really can’t let go of a point and they just keep bringing it up over and over again.

02:37 I want to give you this case study to consider.

02:40 Mr. B is a 22-year-old man.

02:42 He’s been having trouble in college.

02:45 Rather than graduating on time, he has had to repeat a few years due to an inability to get to class because he has low motivation.

02:55 So his parents come out to college to visit him and they find his dorm room a complete mess.

03:01 Their son, Mr. B, is malodorous and he has not been taking care of is hygiene.

03:07 He talks nonsense when his parents ask him what’s wrong.

03:12 The only thing they can decipher is their son saying, “My professor wants to kill me.” So you meet Mr. B in the emergence room and you start evaluating him.

03:24 If this is all you know at this point, what’s your differential diagnosis? Of course, it’s broad, so you’re going to consider all of these things.

03:33 All right, so you’re going to consider general medical conditions.

03:37 Now, I can’t overemphasize this point enough.

03:40 Whenever considering a psychiatric disorder, you must always consider medical conditions first.

03:46 They’re easy to treat and more likely to be reversible.

03:50 Also think about whether or not this disorder and whether or not these symptoms are actually substance related.

03:57 Something else that can be quickly treated and possibly reversed.

04:02 Beyond that, you’re going to think of some psychiatric disorders, like a brief psychotic disorder, schizophreniform disorder, schizoaffective, schizophrenia, schizotypal personality disorder, a mood disorder with psychotic features and you may think of schizoid personality disorder.

04:23 So when you consider that case of Mr. B, you’ve got a broad differential diagnosis now.

04:28 And on the top of your list, of course, is a general medical problem.

04:33 So when it comes to psychosis, what types of general medical problems are important to rule out in treating your patients? It’s a long list, so let’s go through it.

04:43 Delirium, you’re going to think of this.

04:46 Of course, delirium is a frequent cause of psychotic symptoms, okay? And this could be duet to fluid or electrolyte abnormalities.

04:57 Also, substance intoxication or withdrawal.

05:00 Hypoglycemia, hypercapnea, hypoxia or infections or from other medications.

05:07 These are all possible causes of a delirious patient that could look psychotic.

05:12 We’re also going to think of endocrine problems, things like thyroid disease, parathyroid or adrenal disease.

05:19 And then the liver can be disrupted and also present as psychotic symptoms.

05:24 So think about hepatic encephalopathy and uremic encephalopathy.

05:28 Other medical causes, you’re going to want to rule out our infectious diseases, things like syphilis, herpes, Lyme disease, prion disorder, and HIV or AIDS.

05:38 Inflammatory disorders like lupus, anti-NMDA receptor encephalitis, leukocytosis or leukodystrophies, multiple sclerosis.

05:52 And you’re going to think of metabolic disorders like porphyria or Wilson’s disease.

05:58 Other things to rule out are neurodegenerative diseases, things like Lewy body dementia, Huntington’s disease, Parkinson’s, and Alzheimer’s.

06:08 There are other neurological conditions include space-occupying lesions like a tumor, seizure disorder or stroke and any kind of a head injury or trauma to the brain.

06:20 Finally, you want to rule out if there’s a vitamin deficiency, especially B12.

06:25 Now, because there’s a long list, we have here a summary, an acronym that you may find useful in thinking about what categories and groups of medical conditions can present as a psychotic disorder.

06:42 At the end of this lecture, now, I hope that you appreciate how important it is to formulate a differential diagnosis for the psychotic patient especially including general medical conditions and the substance abuse problem and to rule out anything that could be easily treatable and reversible before formulating a psychiatric diagnosis.