Descriptive Psychopathology: The Signs and Symptoms of ...

233 Chapter 9: Disturbances in speech and languagePerseveration of speechPerseveration of speech is identified when the patient repeats phrases and sentencesbeyond the point of the conversation. It sometimes appears as a compensationfor the inability to think and articulate ideas clearly, and is most commonlyassociated with degenerative brain disease and mood disorders. It can be mistakenfor stereotypy of speech, which is more autonomous with words andphrases uttered automatically. Speech associations by sound (clang speech) arecommonly perseverated. An example of perseveration follows:“I have wondered about why I’m here and so on and so forth. It’s a strategic move. My businessand so forth and so on ...I was working in the city, with the food service and that’s how I gotinvolved, and so forth and so on ...”.Disturbances of speech organizationCircumstantial speechIn circumstantial speech associations are linked, but are interspersed with nonessentialdetails and asides. Speech takes a circuitous route before reaching the point.The goal or the main idea of the expressed thoughts is not lost. Circumstantial speechis associated with the early stages of mania, hypomania, personality changes associatedwith chronic epilepsy and manic-depressive illness, 13 the chronic use of drugsthat elicit limbic system sensitization (e.g. cocaine, alcohol), and in the frontal lobedisinhibited syndrome. Fish also associated mild circumstantiality with “dullardswho are trying to be impressive, and pedantic obsessional personalities.” 14Example:Q: “What happened that you had to be hospitalized last year?”A: “Well, you know, all that’s been going on with my health, and the work at thefactory, business has increased enormously since we got the new machines, and thenproblems that I was having with my wife, and she’s got that new job, I wasn’t gettingenough sleep and sort of slipped, became irritable and needed my meds adjusted.”Flight-of-ideas, tangential speech, and looseness of associationsFlight-of-ideas is speech that jumps from topic to topic. The patient appearsdistracted by his own associations and ambient stimuli, and may incorporatewhat is taking place in his immediate surroundings into his speech in a seeminglyunrelated string of utterances. When most severe this word salad is incomprehensible.It is unhelpful in delineating patients with mania from those withschizophrenia. In Manic-Depressive Insanity and Paranoia, Kraepelin describedflight-of-ideas: 15