Now, let’s talk a little bit more
about the thought disorders.
There are different types
of thought disorders.
We think about disordered
This looks like disruption
in a patient’s beliefs,
ideas, and interpretations
of their surroundings.
Disordered thought process
is a manner in which the patient
links ideas and words together.
Let’s consider a couple of the
common types of thought disorder.
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.
How about thought blocking?
In clinical practice,
this is when a patient suddenly
loses their train of thought.
It’s exhibited by an
interruption in their speech
and then they have trouble
picking right back up again.
Loosening of associations describes
a speech content notable for ideas
presented in sequence that
are not closely related.
So it’s where somebody
jumps all over the place.
Tangential though process is another
type of disorganized thought.
So this is where answers
to interview questions
diverge increasingly from topic
to topic being asked about.
Some call this circumstantiality if the is
eventually returned to the original topic.
When somebody’s tangential,
they basically go off course
and can never return
to the point.
Clanging or clang association is
another type of thought disorder.
So this is where words
are used in a sentence
that are linked together by
rhyming or due to phonetics.
Here’s an example of what
a patient might say.
“I fell down the well sell bell.”
So things rhyme, but they don’t
really make any sense used together.
A word salad is another important
type of thought disorder
and this is where real words are
linked together but incoherently.
So it’s nonsensical.
An example would be a patient saying,
“Tree way of nothing house.”
It makes no sense.
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.
I want to give you this
case study to consider.
Mr. B is a 22-year-old man.
He’s been having trouble in college.
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.
So his parents come out
to college to visit him
and they find his dorm
room a complete mess.
Their son, Mr. B, is malodorous
and he has not been taking
care of is hygiene.
He talks nonsense when his
parents ask him what’s wrong.
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.
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.
All right, so you’re going to
consider general medical conditions.
Now, I can’t overemphasize
this point enough.
Whenever considering a
you must always consider
medical conditions first.
They’re easy to treat and
more likely to be reversible.
Also think about whether
or not this disorder
and whether or not these symptoms
are actually substance related.
Something else that can be quickly
treated and possibly reversed.
Beyond that, you’re going to think
of some psychiatric disorders,
like a brief psychotic disorder,
schizotypal personality disorder,
a mood disorder with
and you may think of schizoid
So when you consider that case of Mr. B,
you’ve got a broad
differential diagnosis now.
And on the top of your list, of
course, is a general medical problem.
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.
Delirium, you’re going to think of this.
Of course, delirium is a frequent
cause of psychotic symptoms, okay?
And this could be duet to fluid
or electrolyte abnormalities.
intoxication or withdrawal.
Hypoglycemia, hypercapnea, hypoxia or
infections or from other medications.
These are all possible causes of a delirious
patient that could look psychotic.
We’re also going to think
of endocrine problems,
things like thyroid disease,
parathyroid or adrenal disease.
And then the liver can be disrupted and
also present as psychotic symptoms.
So think about hepatic encephalopathy
and uremic encephalopathy.
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.
Inflammatory disorders like lupus,
anti-NMDA receptor encephalitis,
leukocytosis or leukodystrophies,
And you’re going to think
of metabolic disorders
like porphyria or
Other things to rule out are
things like Lewy body dementia, Huntington’s
disease, Parkinson’s, and Alzheimer’s.
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.
Finally, you want to rule out if there’s
a vitamin deficiency, especially B12.
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.
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.