Formal Thought Disorder in Schizophrenia

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The Schizophrenia Spectrum

The schizophrenia spectrum is a set of related disorders with distinct symptoms associated with each diagnosis. Some disorders on the schizophrenia spectrum include schizophrenia, schizotypal personality disorder, schizoaffective disorder, and a few others.

The dysfunction that schizophrenia causes affects thought processes, mood, the senses, and, more broadly, the ability to easily speak and think with clarity and logic.

What Is Formal Thought Disorder?

Formal thought disorders disrupt the flow of regular thinking and communication processes, causing widespread dysfunction that can extend to emotions, behavior, and the development of a sense of self.

These subtypes are not unique to schizophrenia, nor do all people with schizophrenia experience formal thought disorder.

The National Institute of Health estimates that 50% of people with schizophrenia can be diagnosed with formal thought disorder.

Subtypes of Thought Disorders

The portion of people with schizophrenia who experience formal thought disorder have a variation or combination of some of the following types:

Thought Blocking

Thought blocking happens often while people with schizophrenia speak, abruptly blocking what they mean to express.

Linear thought sharply curves into misdirection, leaving a sentence unfinished or obscured, beyond the person’s ability or comfort to continue.

While awareness of the present moment remains clear, the person experiencing the block can quickly abandon the line of thought after the block occurs.

Loose Associations

Here, a line of thought derails, as well, but results in many ideas only loosely connected (or wholly disconnected) and offered rapidly.

Leaps in loosely tied meanings lead to unclear speech, with an obscure connection between the starting points and the conclusions the person intends to reach.

Word Salad

Word salad is an uncommon formal thought disorder subtype that often appears in people on the spectrum who experience intense symptoms. Words spoken or written may have no connection and be strung together randomly (or so it appears to others).

Phrases may hold a hidden and significant meaning that only the person on the spectrum knows (but has no discernible meaning to those who hear it).

Neologisms

Put simply, neologisms are invented words by some people living with schizophrenia spectrum disorders.

These unique creations of language may also show a deeply held belief or an idea singular to the person’s experience.

The invented word may have structure and meaning that others can understand to some degree, but even so, neologisms may create difficulty in gaining social acceptance due to the perception of the strange and unfamiliar word (or biases along the spectrum more broadly).

Clang Associations

This formal thought disorder subtype relies on the phonetic effect or the pure sound of words.

Director of the Saks Institute for Mental Health Law, Policy, and Ethics at USC, Dr. Elyn Saks, wrote of a clang association in her memoir The Center Cannot Hold: My Journey Through Madness.

Recalling an episode in her time as a student at Yale Law School, studying with friends, she proclaimed, “We’ve got to case the joint! I don’t believe in joints, but they do hold your body together.”

The same word or phoneme may be repeated, but the only link is the different meanings or forms that are close in sound.

Rhyming may also guide the flow of speech in clang associations, additionally, but with an ambiguous meaning throughout articulation.

Formal Thought Disorder VS. Delusion

Formal thought disorder focuses on the visible signs of dysfunctional thinking, such as difficult-to-follow speech, derailed lines of thought, and meanings perhaps hidden from a listener. Here, formal thought disorder can be observed through speech and other physical and behavioral communication.

To discern formal thought disorder from delusions involving thoughts, separating their content from their form reveals the origin of the symptom.

In brief, delusional thinking differs in the content of thoughts and the beliefs behind them.

For example, people on the schizophrenia spectrum often experience delusions that emotions, sensations felt in the body, or an appeal to take an action from unseen, outside forces.

Delusions About Thoughts

Delusions about thought are experienced as losses of agency, either by imposed thoughts or external influences inspiring a feeling of loss of control.

Two primary examples include:

Thought Broadcasting

Thought broadcasting is strongly tied to the processes of delusion.

The person affected by thought broadcasting believes that others around them can hear their thoughts; in effect, their thoughts are “broadcast” silently from the person’s mind and beyond the person’s control to others.

The perceived broadcasting of thoughts is troubling for people on the schizophrenia spectrum. It can create a sense of anxiety and loss of privacy that defies the freedom to think and be as they choose without external influences.

Thought Withdrawal

This delusion is strongly indicative of schizophrenia spectrum disorders.

By an unconscious and unforeseen force, a person with schizophrenia can suddenly become silent and withdrawn, gripped by thought withdrawal and removed from external input.

Speech and responsiveness become absent, and the person may remain unaware of their surroundings despite intervention. This loss of cognitive control is seen as a thought removed or withdrawn by an external overpowering force.

Historical Changes in Thought Disorder: Ambivalence

In this previously included thought disorder type, a person simultaneously holds two opposite or contradictory thoughts or feelings, and the thought or feeling processes do not resolve through reasoning or mental effort alone.

Ambivalence creates a roadblock to decision-making and acting decisively. It can be a source of frustration in communication, in feeling fulfilled in goal setting, and in acting freely in ways that provide positive emotions that others come by as a matter of course, or without awareness.

This can be a common human experience, though. Many people feel ambivalent about events, conversations, and their responsibilities. As a result, ambivalence was removed from the criteria of formal thought disorder and is now recognized as a phenomenon in the ordinary course of living.

The Cognitive Symptom Domain in the Schizophrenia Spectrum

A mix of the neurobiology and behavioral traits of schizophrenia underlies the appearance of the cognitive symptom domain on the schizophrenia spectrum.

When the brain’s biology causes cognitive processes to collide, distortions in thought and communication emerge, affecting observable behavior and speech in people with cognitive dysfunction.

Types of Symptoms in the Cognitive Domain

The cognitive symptom domain is differentiated from formal thought disorder by definition, but they’re tied to one another.

Though not all people living on the schizophrenia spectrum experience formal thought disorder, the subtypes of formal thought disorder may develop from the primary and underlying cognitive symptom domain that is featured broadly across the schizophrenia spectrum.

Some examples of the cognitive symptom domain include:

Social Cognition

The journal Nature reports that social processes follow particular neural pathways that can overlap throughout affected areas of the brain in people on the schizophrenia spectrum.

As a result, cognition is affected by symptoms of the spectrum, spanning various aspects of socializing, and while some strengths are retained, others can be challenging.

The challenges people on the schizophrenia spectrum often face extend primarily to reflective rather than reflexive aspects of social engagement, such as determining facial expression, understanding changes in vocal qualities, and mentalizing how thoughts relate interpersonally.

Contrasting the reflective processes of socializing, the reflexive actions taken in conversation and socializing remain intact. The preserved cognitions include things like discerning social cues, showing mutual emotion, and matching shared body language.

Attention and Vigilance

“Sustained attention” (as attention and vigilance are often called) is heavily affected by the sleep-wake cycle, Science Direct reports here. It is inseparable from physiology (or the functional processes of biology), as noted, and factors that complicate sustaining attention include sleep deprivation, drowsiness, and prescription drugs that affect the central nervous system.

Difficulties in sustaining attention manifest in various day-to-day circumstances. For example, determining signals in the environment and separating them from background noise remains difficult for those on the schizophrenia spectrum.

Even though attention and vigilance can be challenging, they do not appear to relate to the severity of overall symptoms, providing a partial means to manage and sustain attention through lifestyle and sleep management.

Executive Function

Planning and problem solving, cognitive flexibility, and self-regulating behavior in goal-directed action are a few of the areas of executive function.

Organizing the ins and outs of achieving goals, switching between tasks or ideas, and managing emotion and behavior greatly affect the well-being of people on the schizophrenia spectrum.

Managing relationships becomes difficult here as well, as does sustaining employment, due to barriers in decision-making and time management (and how those factors affect people’s perceptions and the demands of business operations).

Medications for Treatment of the Cognitive Symptom Domain 

Cognitive symptoms of the schizophrenia spectrum have resisted the thresholds necessary for the development of targeted treatments; namely, due to the late failures of cognitive agents in clinical trials, skepticism from drug makers (who expect modest to moderate therapeutic results), and patients and families who see little value in new drugs that may have inadequate benefit for the high cost.

Currently, second-generation antipsychotics (expected to have pro-cognitive benefits previously) produce results often overshadowed by metabolic side-effects and only small improvements in cognition, or at best, prevention from decline in cognition.

Patients have reported experiencing reduced positive symptoms and a small improvement in a sense of stability on previous and new drug therapies; however, reports of sedation, slowed thinking, and emotional detachment or flattening are often among the results, creating mixed incentives to risk the trade-off.

Researchers have had difficulty proving that improvements in cognition may result from

overall symptom improvement, thereby creating the potential for inaccurate assessment.

Diagnosis of Formal Thought Disorder in Schizophrenia

Formal thought disorders do not always show up with consistency in people on the schizophrenia spectrum’s symptoms, and the severity of symptoms and formal thought disorder can vary over time.

Interviewing people who may have a schizophrenia spectrum disorder is one of the first courses of action healthcare professionals take, in addition to clinical personality or cognitive tests.

In patient interviews and tests, identifying an appropriate diagnosis will focus partly on the presence of formal thought disorder.

Considering formal thought disorder as a target to treat specifically can be helpful, as clinicians use the presence of formal thought disorder to devise treatment plans and supportive services that better treat them.

Psychotherapeutic Treatments for Formal Thought Disorder

Psychotherapy improves the health of people living on the schizophrenia spectrum with some success, even extending into resolving delusions.

Similar interventions to treat formal thought disorder focus on examining thought processes or finding solutions through communication-based treatments that target social and daily functioning challenges.

Some of the psychotherapeutic treatments developed include: 

Cognitive Remediation Therapy (CRT)

This treatment consists of a structured program of drills and techniques to improve cognitive deficits in memory, attention, and executive function (planning, organizing, and regulating emotions).

Cognitive Behavioral Therapy (CBT)

This therapy involves challenging people’s automatic thoughts and how those thoughts affect emotions and behavior.

Patients undergoing CBT treatment work through written exercises that help challenge distorted thought processes, which can improve thinking efficiency and reduce difficult emotions. Patients also attend therapy sessions based on principles of talk therapy.

Aerobic Exercise with Cognitive Training

This therapy combines aerobic exercise with cognitive remediation to leverage the enhanced effects of physical activity on mental resilience.

Communication-based Therapy or Group Therapy

These treatments are prescribed to improve psychosocial skills in a structured setting; their design aims to support daily living and practices that promote healthy social bonds and communication.

The Schizophrenia Spectrum, Self-understanding, and Communication

Humans depend on communication and engaging with others to develop their personality and sense of self. However, the breakdown of communication and thought processes in some people who live on the schizophrenia spectrum prohibits the natural processes that build self-understanding and how others relate.

Experts have believed that formal thought disorder in schizophrenia are partly an issue of communication, even in early observations.

Clinicians and researchers noted this in a review of communication on the schizophrenia spectrum, quoting Eugen Bleuler (the psychiatrist who invented the word schizophrenia):

“Bleuler classically confirms this perspective when he notes that the primary symptoms of schizophrenia ‘find their expression in language.’”

Language is strongly linked to schizophrenia spectrum disorders, and following that trait, the concurrent effect on identity:

A recent examination by the National Institute of Health adds the dimensions of self-perception to the equation:

“…Thus, the data are now robust and unequivocally point to self-disorders as crucial trait phenomena, perhaps defining the extension of the schizophrenia spectrum… the diagnostic comparisons consistently show that self-disorders selectively hyper aggregate in schizophrenia.”

Effects of Genes and Environment on the Schizophrenia Spectrum

Genetic factors can play a role in the development of schizophrenia (and the potential for formal thought disorder), but schizophrenia spectrum disorders are not strictly genetic.

Stressors in the environment can play an equally important role due to the conditions in which a person living on the schizophrenia spectrum experiences them.

If environmental conditions impose stressors that overwhelm the brain’s ability to withstand them, the potential for disorder may arise.

The added vulnerabilities to stressors create difficulty in daily functioning and have effects on communication and self-perception.

Social acceptance may be restricted or withdrawn by people in the community due to the views of behavioral signs of schizophrenia spectrum disorders, and consequently, a reduced frequency of communication.

Sense of self can become disordered by circumstance in this way, and also by available resources for care in the regions where people on the schizophrenia spectrum live.

Attitudes on Mental Disorders as a Positive Impact on Wellbeing

Mental health and advocacy for people with mental disorders have become a fair public and media topic, and people continue to take action on social media to advocate for the schizophrenia spectrum.

Brief social-contact-style stories about the schizophrenia spectrum and other conditions suggest real potential for online advocacy to foster support and understanding and reduce social differences in. experimental studies.

As a result, the chance to fight stereotypes and stigma reaches a broader audience and may inspire people to reach out to a person who deals with a mental disorder to offer support.

People with schizophrenia and disorders that cause distorted thought processes are especially vulnerable to isolation, stereotypes, and prejudice. But with greater support, they may live healthier, more rewarding lives and increase their likelihood of recovery.

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