How it sits within the MSE Thought structure

Definition

Omission: A thought disorder in which the patient omits or skips over part of a topic or sentence - leaving out words or whole portions of an idea - while continuing the flow of speech. The missing material is not recovered or explained.

• Thought blocking - an abrupt, complete cessation of the thought stream (often attributed by the patient to thought withdrawal), where speech stops entirely mid-sentence
• Poverty of speech - an overall reduction in the quantity of speech
• Condensation - the merging of two or more ideas into one
• Tangentiality or loosening of associations - the train of thought drifts away but content is not simply deleted

Context in Kaplan & Sadock

Another example (mid-sentence omission):

How to distinguish it from similar phenomena:

Example:

Another example:

How it differs from similar phenomena:

Clinical context

Example:

Another example (word-level substitution):

• "Umbrella" substituted for the expected word (perhaps "symptoms" or "problem")
• "Wednesday" substituted for the expected outcome (perhaps "prescription" or "tablet")

Relation to other thought form abnormalities:

Clinical notes

• Substitution is seen in schizophrenia and reflects a breakdown in the selection and monitoring of appropriate thought units.
• When substitution occurs consistently at the word level, it overlaps with the concept of paraphasia seen in aphasia - but in psychiatric thought disorder the substitutions tend to be semantically bizarre rather than phonemically similar.
• The patient typically shows no awareness of the substitution, which distinguishes it from deliberate metaphor or imprecise word choice.

Example:

Another example (less severe, closer to clinical reality):

How drivelling differs from similar phenomena:

Clinical context

• Drivelling represents a severe disruption of the form of thought.
• It is most associated with schizophrenia, particularly in acute psychotic states.
• The term is used in the European/Jasperian phenomenological tradition (it appears in Fish's Clinical Psychopathology, a key reference for MSE terminology in that tradition).
• It sits on a spectrum: loosening of associations → drivelling → word salad, with increasing severity of disorganisation.
• The patient is typically unaware that their speech is incomprehensible and may seem satisfied that they have communicated something meaningful.

Example - Nepali clinical context:

"Ramro chha, ekdam ramro! Ma ta raja jasto chhu - raja... Prithvi Narayan Shahले Nepal एकता गर्नुभयो, एकता भनेको एक, एक रुपैयाँ, rुपैयाँमा त ठूला मान्छेको अनुहार हुन्छ, मेरो अनुहार पनि ठूलो छ, मान्छेहरुले मलाई हेर्छन्, टेलिभिजनमा पनि आउँछु म, टेलिभिजन भनेको त विद्युत, विद्युत मेरो शरीरमा पनि छ, म बिजुली जस्तै छु, बिजुली चाँडो दौड्छ, म पनि दौड्न सक्छु, दौड भनेको Olympics, Olympics मा Nepal जानुपर्छ..."

Tracing the links:

Key features present in the example:

• Pressure of speech - rapid, hard to interrupt
• Grandiosity - raja, television, Olympics
• Clang/wordplay - एकता → एक → एक रुपैयाँ
• Environmental stimuli - any word triggers the next association
• Culturally anchored content - Prithvi Narayan Shah, Nepali rupee, Nepal in Olympics (realistic preoccupations for a Nepali patient)

Distinguishing flight of ideas from similar phenomena:

Example - Nepali clinical context:

"Suina garo... haina, suina ta pehile ni garo thiyo, sano hudai dekhi nai. Gau ma hunthyo ni hamro, त्यहाँ त राति कुकुर भुक्थ्यो, छिमेकीको कुकुर थियो, कालो रङको, ठूलो थियो। त्यो छिमेकी पनि राम्रो मान्छे थिएन, बाबासँग झगडा गर्थ्यो जग्गाको कुरामा। जग्गाको झगडा अहिले पनि छ कि छैन थाहा छैन, भाइलाई सोध्नुपर्छ। भाइ त काठमाडौँमा छ अहिले, Baneshworमा बस्छ, उसको छोरो पनि राम्रो पढ्छ। जाँचमा राम्रो नम्बर ल्यायो रे। जाँच भनेपछि मलाई पनि याद आयो - जब SLC दिएको थिएँ, त्यो बेला पनि सुइनँ राति, tension भएर। अनि यसपटक पनि त्यस्तै भयो - करिब... तीन हप्ता जति भयो होला।"

Tracing the structure:

Key features:

• The goal is reached (unlike tangentiality)
• The logical thread is never broken - each step connects to the next
• The journey is over-inclusive - details that a normal speaker would filter out are included
• The patient shows no awareness of having gone off-track
• Interrupting and redirecting is difficult but possible

Comparison with similar phenomena:

Clinical note

Example - Nepali clinical context:

"Kati din... haina, timile bujhdainau. Ma hospital aau bhanda ni ghar ma sabai le rokeko thiyo. Ghar ma malai koi le bujhdaina. Baa le bhannu bhannu - 'आफ्नै कमजोरी हो, मान्छे भएपछि दुःख त हुन्छ नै।' त्यस्तो भन्ने मान्छे बुवा हुन् भने के गर्नु। अनि छिमेकीहरु पनि कुरा काट्छन्। यहाँ Nepal मा मानसिक रोग भनेपछि मान्छेलाई हेर्ने तरिका नै फरक छ। समाजले स्विकार गर्दैन। मलाई त लाग्छ - सरकारले पनि mental health मा ध्यान दिँदैन, budget नै छैन..."

What happened:

Key features:

• Initial contact with the question - there is a brief moment of relevance
• The reply then veers off obliquely - not randomly, but at an angle
• The original goal is never reached - the patient does not answer
• Each step may connect loosely to the previous one, but the overall direction moves further from the question
• Redirecting the patient back to the question is difficult - they may veer off again even after being redirected

The geometry analogy made explicit:

Question (circle) ●
                    \
                     \  ← Patient's reply touches here
                      \__________________________→
                           then goes off in this direction, never returning

Comparison with closely related phenomena:

Clinical note

• Redirectability - culturally indirect speakers respond to a gentle, direct re-question and answer it; tangential patients veer off again
• Awareness - the indirect speaker knows they are avoiding the topic; the tangential patient typically does not
• Severity and persistence - pathological tangentiality recurs consistently throughout the interview, not just on sensitive topics

Example - Nepali clinical context:

Another example - within a single answer:

Types of perseveration:

Key features:

• The repeated element was appropriate the first time - it is the persistence that is pathological
• The patient typically shows no awareness of the repetition
• It is not the same as rumination - in rumination the patient voluntarily and distressfully returns to a theme; in perseveration the repetition is automatic and involuntary
• It is not the same as echolalia - echolalia is repetition of the examiner's words; perseveration is repetition of the patient's own previous words

Comparison with similar phenomena:

Clinical associations:

1. Organic brain disease - frontal lobe damage, dementia, delirium, traumatic brain injury. Here it reflects failure of the frontal executive system to inhibit a previous response and shift to a new one. It is one of the classic signs of frontal lobe dysfunction.
2. Schizophrenia - where it appears as part of broader formal thought disorder and cognitive disorganisation.

Example - Nepali clinical context:

The phenomenology in detail:

• Speech stops abruptly mid-sentence - not at a natural pause
• A period of blank silence - the patient stares, looks puzzled or vacant
• When speech resumes, the original thread is gone - a new, unrelated topic may begin, or the patient asks what they were saying

• The thought was there and then suddenly vanished
• It feels as though the thought was removed from outside - "कसैले लगेजस्तो," "बाहिरबाट हटाइयो"
• Distinct from forgetting - forgetting is gradual; blocking is sudden and complete
• This subjective experience of thought withdrawal is a Schneiderian first-rank symptom of schizophrenia

Another example - within dialogue:

Key features:

Why thought blocking is clinically significant:

• Thought blocking = the observable phenomenon (stream of thought stops suddenly)
• Thought withdrawal = the patient's subjective explanation (someone took my thoughts)

Comparison with similar phenomena:

Clinical note - eliciting thought blocking:

• Shyness or hesitation - a patient from a rural background may pause frequently out of deference or unfamiliarity with the clinical setting. The distinction: shyness produces hesitation before answering; blocking produces abrupt cessation mid-sentence in a patient who was already speaking fluently.
• Language difficulty - searching for a Nepali word. The distinction: word-finding pauses are gradual and the patient looks effortful; blocking is sudden and the patient looks blank or puzzled.
• Hearing difficulty - the patient did not hear the question. The distinction: blocking occurs mid-answer, not before it.

The spectrum of thought content:

Preoccupation → Overvalued idea → Obsession → Delusion
    (normal          (abnormal         (ego-          (fixed, false,
    intensity,        intensity,       dystonic,       unshakeable)
    reality-based)    understandable)  resisted)

Example - Nepali clinical context:

What makes this a preoccupation and not something else:

Distinguishing preoccupation from the neighbouring phenomena:

Common themes of preoccupation in Nepali patients:

• Children's education and future - as in the example above
• Financial debt - particularly after taking loans for weddings, land, or migration
• Son's foreign employment (Bidesh) - worry about a family member working in Qatar, Malaysia, or Gulf countries
• Land and inheritance disputes - chronic family conflict
• Daughter's marriage - pressure around dowry and social expectation
• Physical health - particularly somatic concerns (heart, liver, kidneys) without organic cause
• Karma and sin - concern that current suffering is a result of past wrongdoing

When preoccupation becomes clinically significant:

• Dominates the interview - the patient returns to it regardless of what is being discussed
• Impairs functioning - cannot concentrate on work, disrupts sleep, affects appetite
• Causes significant distress - beyond what the situation warrants
• Begins to intensify - moving along the spectrum toward overvalued idea or delusion

• Understandable in origin - it arose from a real experience or culturally comprehensible concern
• Held with excessive intensity - beyond what is reasonable or proportionate
• Ego-syntonic - the patient does not experience it as alien; they pursue it as a personal mission or conviction
• Not resisted - unlike an obsession
• Not fully fixed or unshakeable - unlike a delusion, there is at least a theoretical possibility the patient can acknowledge doubt, even if they rarely do in practice

The spectrum, revisited:

Preoccupation → Overvalued Idea → Obsession → Delusion
                      ↑
                  HERE - understandable origin,
                  excessive intensity, ego-syntonic,
                  dominates and directs the person's life

Example - Nepali clinical context:

"Mero bau le jo garyo त्यो bilkul galat thiyo. Sano bhai lai dherai jagga diyera malai thitho garyo. Ma jyesthha po, ma le nai dherai paaunu parthyo. Yо न्याय होइन। Ma yо कुरा सबैलाई भन्छु - gaau ma, ward office ma, court ma पनि gaeko chhu. Manchhe haasko gare pani malai thaha chha - ma sahi chhu. Mero budi le pani 'bisranu' bhanni, chhoraa le pani bhanncha - tara tiniharulai bujdaina ki न्याय भनेको ke ho. Yo court bata ni justice naapaaye भने ma UN samma janchhu."

Analysis - why this is an OVI and not a delusion:

Why it is not a delusion:

• The land dispute actually happened - the content is not false
• The injustice is real but overinterpreted
• If confronted with a court ruling against him, he might escalate ("the court is corrupt") - at that point it may be transitioning toward a delusion
• The boundary between OVI and delusion is not always sharp and requires careful clinical judgement

Common clinical examples of overvalued ideas:

Nepali cultural note:

• Whether the belief is shared by the community or idiosyncratic to the patient
• Whether the intensity and behavioural consequences are proportionate even within the cultural frame
• Whether the belief is progressive and worsening despite cultural interventions
• Whether it is causing significant dysfunction beyond what the cultural group would consider normal

Distinguishing OVI from its neighbours - final summary:

Intelligence (in the MSE)

• Fund of general knowledge ("Who is the Prime Minister of Nepal?", "What is the capital of India?")
• Arithmetic ("Ekattar ma saat jodda kati hunchha?")
• Abstraction ("Suryodaya ra diya ma ke samanta chha? / What is similar between the sun and a lamp?")
• Vocabulary and complexity of speech throughout the interview
• Estimated as: above average / average / below average - with note of formal education level

Judgment (in the MSE)

• Test judgment (hypothetical scenarios): "Agar tapai bazaar ma hidda koi leआफ्नो wallet haraayo bhane tapai ke garnuhunthyo? (If you saw someone drop their wallet in the market, what would you do?)"
• Real-life judgment (from history - more valid): Has the patient been making reasonable decisions? Have they been managing finances, relationships, safety appropriately? Have they done things that put themselves or others at risk?
• Real-life judgment is always more informative than test judgment

The core difference:

Why the dissociation matters clinically:

High intelligence, poor judgment:

Low intelligence, sound judgment:

Nepali clinical example illustrating the dissociation:

• Names current PM correctly
• Solves arithmetic quickly
• Gives good abstract answers: "Suryodaya ra diya - duitai उज्यालो даउछ" (Both give light)
• Estimated: above average

• Over the past two weeks: sold his motorbike for cash, gave money to a stranger "to start a business together," stopped attending school, told his wife he no longer needs to sleep, plans to stand for election next month
• When asked about the motorbike: "त्यो साना कुरा हो, म अब ठूलो मान्छे बन्छु" (That is a small matter, I will become a great man)
• Judgment: severely impaired

One-line summary:

Intelligence is knowing what the right answer is. Judgment is actually acting on it appropriately in real life. Mental illness can destroy judgment while leaving intelligence completely intact.