Descriptive Psychopathology: The Signs and Symptoms of ...

234 Section 3: Examination domainsthey [manic patients] are not able to follow systematically a definite train of thought, but willcontinually jump from one series of ideas to a wholly different one and then let this one dropagain immediately. Any question directed to them is at first perhaps answered quite correctly,but with that are associated a great many side remarks which have only a very loose connection,or some not at all, with the original subject (page 13) ... the flight-of-ideas only representsa partial phenomenon of heightened distractibility (page 14).Fish wrote: “the thoughts follow each other rapidly, there is no general directionof thinking and the connections between successive thoughts appear to be due tochance factors, which can easily be understood” and that the train of thought isdetermined by “chance relationships, verbal associations of all kinds, such asassonance, alliteration ... clang associations” (page 36). 16Flight-of-ideas is also associated with drug intoxications (phencyclidine, ecstasy,cocaine and other stimulants), and the frontal lobe disinhibited syndrome. Themore quiet and controlled the situation, i.e. the fewer distractions, the less likelyflight-of-ideas will be elicited. Conversing with such patients in inpatient commonareas rather than a quiet examination room can stimulate flight-of-ideas.Example:Q: “How are you feeling today Mr. Jones?”A: “The food here is terrible. I’ve been dieting to keep the red meat out of mybody. I’m no commie, but it’s like the Berlin wall in here. You’re drugging me ...ruining my health, my wealth. I’m gonna buy the hospital, fix social security.I wrote many books on the subject. I’ve written mysteries and novels. Oh manynovels ...”.Because the flight-of-ideas continuously leads the speaker away from the topic,it is sometimes described as tangential speech. Because it may incorporate manythemes, it is sometimes described as interpenetration of theme. Because the flightof-ideasreflects a distractibility that prevents the patient from focusing on onetopic and its salient details, it is associated with speech that includes many topicsand details, sometimes described as over-inclusive thinking. Tangential speech,interpenetration of theme, and over-inclusive thinking are descriptors that defineaspects of flight-of-ideas, not separate forms of speech problems. Some cliniciansalso infer schizophrenia from these descriptors rather than mood disorder,making diagnostic discrimination unnecessarily difficult.When the flight-of-ideas is an expression of an excitement state the patientmay repeatedly alliterate, clang, pun, speak in a series of proverbs, old saws, andclichés. Echolalia occurs.Jaspers offers this example of flight-of-ideas:When a patient was asked if she had changed during the past year, sheresponded: