word salad

Perseveration Inability to shift from one idea to the next

Pressure of thought Increased rate and quantity of thoughts

322 • The patient with mental disorder

The main difference between them is that delusions either

lack a cultural basis for the belief or have been derived from

abnormal psychological processes.

Overvalued ideas

These are usually beliefs of great personal significance. They

fall short of being full delusions but are abnormal because of

their effects on a person’s behaviour or wellbeing. For example,

in anorexia nervosa, people may still believe they are fat when

they are seriously underweight – and then respond to their belief

rather than their weight, by further starving themselves.

Delusional beliefs

These beliefs also matter greatly to the person, resulting in

powerful emotions and important behavioural consequences;

they are always of clinical significance. They are classified by

their content, such as:

• paranoid

• religious

• grandiose

• hypochondriacal

• of guilt

• of love

• of jealousy

• of infestation

• of thought interference (broadcasting, insertion and

withdrawal)

• of control.

Bizarre delusions are easy to recognise, but not all delusions

are weird ideas: a man convinced that his partner is unfaithful

may or may not be deluded. Even if a partner were unfaithful,

it would still amount to a delusional jealousy if the belief were

held without evidence or for some unaccountable reason, such

as finding a dead bird in the garden.

may be understandable but unusually rapid, as in the flight of

ideas that characterises hypomania, or unduly ‘single track’ and

perseverative, as in some cases of dementia. Sometimes thinking

appears to be very circumstantial, and the patient hard to pin

down, even when asked simple questions.

More severe disruption of the train of thought is termed

loosening of associations or formal thought disorder, in which

the patient moves from subject to subject via abrupt changes of

direction that the interviewer cannot follow. This is a core feature

of schizophrenia. Concrete thinking, in the sense of difficulty

handling abstract concepts, is a common feature of dementia,

and can be assessed by asking the patients to explain the

meaning of common proverbs.

It may help to illustrate your assessment with verbatim examples

from the interview, chosen to illustrate the patient’s manner of

thinking and speaking.

Thought content

Thought content refers to the main themes and subjects occupying

the patient’s mind. It will become apparent when taking the history

but may need to be explored further via specific enquiries. It

may broadly be divided into preoccupations, ruminations and

abnormal beliefs. These are defined in Boxes 16.7 and 16.8.

Preoccupations

Preoccupations occur in both normal and abnormal mood states.

Sadly dwelling on the loss of a loved one is entirely normal in

bereavement; persisting disproportionate guilty gloom about the

state of the world may be a symptom of depression.

Ruminations

These are preoccupations that are in themselves abnormal –

and therefore symptoms of mental disorder – by reason of

repetition (as in obsessional disorders) or groundlessness (as

in hypochondriasis).