Formal Thought Disorder in Schizophrenia
Updated: Oct 19
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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?
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 disorders are not unique to schizophrenia, nor do all people with schizophrenia experience thought disorders.
The National Institute of Health estimates that 50% of people with schizophrenia can be diagnosed with a formal thought disorder.
Subtypes in Formal 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
Stated 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 gaining social acceptance due to perceptions of the strange and unfamiliar (or biases along the schizophrenia spectrum more broadly).
Clang Associations
This formal thought disorder subtype relies on the phonetic effect or the pure sound of words.
Dr. Elyn Saks, Director of the Saks Institute for Mental Health Law, Policy, and Ethics at USC, wrote of a clang association she experienced in her memoir The Center Cannot Hold: My Journey Through Madness.
Recalling her time as a student at Yale Law School studying with friends in the campus library and in great distress, she stood up unexpectedly and proclaimed, “We’ve got to case the joint! I don’t believe in joints, but they do hold your body together.”
The same words or phonemes may be repeated (as in the word “joint”) but the only link are the different meanings or forms that are close or identical in sound.
Rhyming may also guide the flow of speech in clang associations, as well, but with an ambiguous meaning throughout articulation.
Historical Changes in Formal 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.
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.
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 is 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 difficulties in daily functioning and affect 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 Force
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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