Circumstantiality

Thinking is circuitous; minor matters cannot be separated from essential matters. The main point gets lost in the description of details, without losing the intentional goal completely (long-winded speech). Insufficient capacity to process abstract information might be one of several causes for Circumstantiality, as well as the inability to omit minor matters even when the patient knows them to be inessential.

Scenario: Circumstantiality

Psychiatrist (The Question): “I understand you recently had a brief stay in the general hospital for a minor infection. Could you please describe for me how you got there?”

Patient : “Oh, the hospital. Yes, well, that was an event. It all started on a Tuesday, I think, because I remember it wasn’t the day the garbage truck comes, which is Thursday, and my son, Mark—you remember Mark, he works in accounting, he’s very good with numbers, not like my daughter, who is an artist—anyway, Mark called me up. He always calls around 8:30 in the morning, which is after he drops his kids at school, a new school they started actually, very modern building, lots of glass.

So, Mark calls, and he asks me how I’m feeling. I told him I had a bit of a funny feeling in my leg, right here, just above the ankle. It wasn’t painful, exactly, more like a dull ache, the kind you get when the weather is about to change, which I noticed it was, because the barometer had dropped quite a bit the night before. I had to go to the hardware store—the one on Elm Street, not the new one—to get a new set of batteries for the barometer, which reminds me, they only had the industrial grade ones, which were expensive, but you can’t skimp on batteries.

Anyway, when Mark heard about the leg, he said, ‘You need to get that checked immediately.’ He didn’t trust the doctor I usually see—Dr. Henderson, who is a good man, he just takes too long with appointments—so Mark insisted on calling the other place, the urgent care center. He looked up the address on his phone, which is one of those big new models, very fast, and he drove me himself. That’s how I got to the hospital, in his silver Honda Civic, which, by the way, needed a wash, but we didn’t have time because of the traffic on the main street that morning.”

Analysis

The patient was asked, “How did you get there?” The essential answer (“My son drove me to urgent care”) is eventually delivered, but only after an extensive, detailed, and unnecessary digression covering the day of the week, the garbage truck schedule, the son’s career, the daughter’s career, the son’s children’s new school building, the exact location and quality of the leg ache, the change in the weather, the purchase of expensive batteries for the barometer, and the condition of the son’s car. The goal-directed thought process is intact, but the circuitous and overly detailed path demonstrates Circumstantiality.

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Derailment

A pattern of spontaneous speech in which ideas slip off the track onto other thoughts which are clearly but obliquely related. Things may be said in juxtaposition which lack a meaningful relationship, or the patient may shift idiosyncratically from one frame of reference to another. At times there may be vague connections between the ideas. The objective characteristic of Derailment should be coded as if the interviewer were talking to the patient for the first time (unaware of potential personal associative connections between the thoughts). One manifestation of this disorder is a slow steady slippage, with no single Derailment being particularly severe, so that the speaker gets farther and farther off the track with each Derailment without any awareness that his reply no longer has any connection to the question being asked.

Scenario

Psychiatrist (the question): “Can you describe what a typical morning is like for you since you started your new routine?“

Patient: “A typical morning starts when the alarm rings, usually at seven. I get up, I make my coffee, and I sit by the window to see the light. The light on the window is very bright. I was thinking that windows are a huge feature in old churches, and the glass is so difficult to make. My neighbor is a carpenter, he cuts wood. He told me his wood is sustainably sourced so the trees are being looked after. I put out the recycling on Tuesday; the trees give us paper for the recycling. I should buy a new notebook. It needs to be lined paper, not plain, because the lines help keep everything straight, and that’s important for my diet.“

Analysis of Derailment

In this version, the patient’s speech itself demonstrates the slip, one sentence triggering the next in an associative chain that rapidly moves away from the initial goal (“morning routine”) and never returns, ending on “diet.”

• Initial: Starts with routine (alarm, coffee, light).
• Slip 1 (visual link): Light ==> Windows ==> Churches (An intrusive, visually-linked thought about stained glass).
• Slip 2 (oblique association/shared concept): Glass/Cutting ==> Carpenter/Wood (A loose link via the general concept of materials/craftsmanship).
• Slip 3 (thematic link): Wood ==> Trees ==> Recycling (A thematic jump from wood-source to an unrelated chore based on the product of trees, paper).
• Slip 4 (conceptual link): Recycling/Paper ==> Notebook/Lined Paper ==> Straight ==> Diet (The idea of “straightness” provides the final, obscure link, connecting organised paper to organised eating).

The consistent, oblique associative connection between each thought segment—rather than a chaotic jump (Dissociation) or an eventual return (Circumstantiality)—is the hallmark of Derailment.

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Tangentiality:

Ideas do not follow a straight path. Within longer speech passages, content slowly drifts away from where it originally started. The patient does not return to the initial topic.

Scenario: Tangentiality

Psychiatrist (The Question): “Thank you. Let’s switch topics. Could you describe for me what you found most challenging about being in the hospital this past week?”

Patient (The Response Demonstrating Tangentiality):“The most challenging thing about the hospital is the food. They serve everything on those little trays, and the cutlery is plastic, which is terrible for the environment, you know. Plastic is everywhere now. The oceans are full of it. I read an article just last month—or maybe it was the month before, time is hard to track here—about how tiny pieces of microplastic are being found in fish, even the ones way out in the deep sea. It makes you really think about what we’re doing to the world, and what kind of a world my grandchildren will inherit. They have such a nice little cat, a striped tabby, and I wonder what it eats. It must be eating plastic dust, too, you can’t escape it. I had a cat when I was a kid, named Mittens, and she was always bringing me things from the garden, like little dead mice, which is natural, but plastic isn’t natural. They should really use metal trays. Metal is easy to recycle, and recycling is the best way to fight back against all this pollution.”

Psychiatrist (Follow-up): “I understand the concern about plastic. But going back to the hospital itself—was there a specific difficulty, perhaps with the staff or your treatment, that was most challenging for you?“

Patient (The Response): “Staff are usually fine, but they don’t seem to recycle at all. And that’s really the heart of the matter, isn’t it? If we can’t be responsible for our waste, then we can’t be responsible for anything else.“

Analysis:

• Initial Goal: Describe the most challenging aspect of the hospital stay.
• Deviation: The patient starts with the food/trays but immediately drifts to the environment, plastic in the ocean, a specific article, grandchildren, a childhood cat, and finally, general thoughts on responsibility and recycling.
• Failure to Return: The patient never returns to the original topic of the hospital stay challenge. The follow-up question merely causes the patient to incorporate the interviewer’s new focus (“staff”) into the already-deviated theme of “recycling,” confirming the tangential path.

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Dissociation of Thinking (Incoherence/Distraction):

The content of a phrase, sentence or thought has no reference to what has been said before. In contrast to Derailment where associative bridges are still recognisable, Dissociation of Thinking refers to the state in which words, sentences and thoughts have no relation to each other. In less severe occurrences, single sentences may still make sense; however, coherence between sentences is absent. In the severest occurrences, coherence within a sentence or even within individual words is absent (scattered speech). Kircher et al. use Dissociation of Thinking interchangeably with Incoherence or sometimes Distraction in this context, and which is also known as “word salad” in its severest form—is precise and correctly draws the distinction from other disorders:

• Distinction from Circumstantiality: In Circumstantiality, the goal is eventually reached.
• Distinction from Tangentiality: In Tangentiality, the goal is never reached, but the content slowly drifts away, often via recognizable (though inappropriate) associative links.
• Dissociation of Thinking: The content lacks internal reference and jumps suddenly and chaotically, without recognisable bridges, making the speech incomprehensible at the sentence-to-sentence level (or within sentences in severe cases).

Scenario: Dissociation of Thinking

Psychiatrist (The Question): “I’m interested in how you feel about your treatment plan. Can you give me your opinion on the medications we have discussed and whether you feel they are helping?“

Patient (The Response Demonstrating Dissociation of Thinking): “Oh, the helping is what the clock says. The medications are blue, yes, but the box is made of paper. My opinion is seven degrees north. We must go sailing soon, or else the curtains will rustle too loudly, and the fish is boiling under the hat. You see, the plan is to connect all the wires, but the wires are yellow and the cat only meows on Wednesdays. That is why the treatment is a bicycle; it has two wheels, but only one can catch the light.“

Psychiatrist (Follow-up): “It is difficult for me to understand you right now. Can you try to put your thoughts about the treatment into simpler words?“

Patient (The Response): “Simpler? The simpleness is the snow that falls on the roof. The roof is too tall for a simple thing. If the doctor wears stripes, then the medicine works for the bell. Yesterday was a chair, but today is the time for the velvet rope.“

Analysis:

• Absence of Coherence: The ideas presented (clocks, blue medications, seven degrees north, sailing, fish boiling, wires, the cat, the roof, velvet rope) follow no discernible logical or thematic path.
• No Associative Bridges: Unlike Derailment, where a skilled listener might guess the link, the connections between “medications are blue” and “box is made of paper” or “seven degrees north” are completely fragmented.
• Goal Completely Lost: The original question about the treatment plan is utterly lost in a chaotic stream of unrelated concepts, demonstrating the severest break in the logical and goal-directed flow of thought.

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Crosstalk:

The response of the patient misses the point at hand, although he has understood the question. The evaluation of this item does not depend on whether the answer to the question is wrong or not (like a wrong answer in an examination), but that the patient is talking past the question. If the interviewer has any kind of suspicion with regard to the presence of Crosstalk, it must be verified that the patient has understood the question correctly. Therefore, the patient should be asked to repeat the question. Intentional ignoring of the question (beating around the bush) should not be considered.

Scenario

Psychiatrist (The Question): “Good. Now, I’d like to understand a little more about your mood lately. Can you describe for me what your energy levels have been like over the past two weeks, and how that’s affected your desire to go out and socialize?”

Patient (Initial Response – Crosstalk): “The energy is a tricky thing, because the sun is out, mostly. I mean, you look out the window, and you see the cars going by, and you think, ‘Well, they’re going somewhere, so they must have the energy for it.’ You know, my neighbor, he drives a blue car, not a red one, and he’s retired, so he has all the time in the world, energy or not. We all need to be a bit careful with our energy. It’s like a battery, you can’t just keep draining it, you have to find a good plug, but all the good plugs are taken nowadays, it seems.”

Psychiatrist: “I appreciate that insight. Just to make sure, could you repeat the question I just asked you?“

Patient (Confirming Understanding): “You asked me about my energy levels in the last two weeks, and if that’s been affecting my desire to see people.“

Patient (Continuing Crosstalk): “And that’s important, you know, seeing people. You see people on the TV all the time, they’re always in groups, big happy groups, but those are just actors. They’re paid to be there. Real people, out on the street, they don’t look very happy, they’re mostly rushing, carrying big bags. If you see them, are you really ‘socializing’? I don’t know. The bags are full of things they need, and you need things too, but needing things isn’t the same as wanting to talk to people. It’s all about what you carry.“

Analysis

The patient correctly repeated the question, confirming cognitive understanding, but immediately returned to talking about a related but irrelevant general topic (people on TV, rushing on the street, and carrying bags) rather than describing their own specific energy or social desire. This maintains the essential feature of Crosstalk—talking past the point—which cannot be attributed to a failure to comprehend the original query.

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Perseveration:

Adherence to previously mentioned ideas and topics that no longer fit the current context.

Scenario

The topic that is introduced and then perseverated upon is: The weather and the color blue.

Psychiatrist (Question 1): “Can you tell me about what you had for breakfast this morning?”

Patient (Response 1 – Establishes the initial idea): “I had a bowl of oats. They were healthy. It was a good start. It was very bright today when I woke up, a perfectly blue sky. That’s a good sign, isn’t it? A blue sky means a good day.”

Psychiatrist (Question 2 – Shifts to a new, unrelated topic: sleep): “That sounds fine. How have you been sleeping lately? Have you found yourself feeling rested?”

Patient (Response 2 – Perseverates on the previous topic: The color blue and the sky): “Sleeping is fine, mostly fine. But the sky is what matters. When the sky is that clear blue, that deep blue, it makes you feel like everything is blue and clear. The sky, the sky is so blue today. I need to make sure I see the blue sky.”

Psychiatrist (Question 3 – Shifts to a third, unrelated topic: family history): “I understand. I’d like to ask you a separate question now. Does anyone in your immediate family have a history of mental health challenges?”

Patient (Response 3 – Perseverates on the previous topic, despite the new context): “Oh, my family? Well, they’re not here right now. But I remember that picture of my mother, and she was wearing a blue dress. It was a really vibrant blue, almost the exact shade of the sky when it’s totally clear, and she always said that blue was her favorite color. It’s important to have a favorite blue.”

Analysis

The patient repeatedly returns to the theme of “blue” and the “sky,” even though the interviewer has clearly changed the subject twice (to sleep, then to family history). This inability to fluidly transition and generate new, context-appropriate content demonstrates Perseveration.

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Verbigeration

Unnecessary repetition of a single word.

Scenario: Verbigeration

Psychiatrist (The Question): “Before we conclude, how would you describe your overall level of anxiety or worry right now?”

Patient (The Response Demonstrating Verbigeration): “My anxiety is bad, very bad. It’s always bad. The feeling is bad, because the thoughts are bad, and the worries are bad. People are bad. Everything is bad. I think about what happened yesterday, and that was bad. And today? Today is a bad day, a truly bad day. It is so very bad. I just want the bad feelings to stop being so bad.“

Analysis

• Unnecessary repetition: The patient unnecessarily and relentlessly repeats the single word “bad” multiple times in quick succession.
• Contextual fit: The word is semantically related to the topic of anxiety and worry, but its excessive, rhythmic, and persistent repetition disrupts the fluid, natural expression of thought. The patient adheres to the one word, failing to use synonyms or vary their expression, which is the hallmark of Verbigeration.

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Rupture of Thought:

Objectively observed sudden interruption of a previously fluid line of thought. The phenomenon may occur in the middle of a sentence and for no apparent reason. Rupture of thought is objective sign and related to an earlier conceptualisation of ‘loss of thought’. The subjective recognition of it, is the symptom of ‘Thought blocking’?

Scenario: Rupture of Thought

Psychiatrist (The Question): “Let’s talk about your discharge plan. Given what we discussed about your return home, what do you think is the most crucial step for you to take next week to maintain your stability?”

Patient (The Response Demonstrating Rupture of Thought): “The most crucial step is making sure I stick to the schedule. A good schedule keeps everything anchored, like a ship in a storm. I plan to wake up at seven, have breakfast, and then I will immediately call my case worker to arrange the appointment for—”

(A sudden, noticeable, and externally unprovoked pause of several seconds occurs. The patient appears to be staring off or searching for a word, then simply stops.)

Psychiatrist: “You stopped speaking just now. What was the reason for that?”

Patient (The Response – Clinician notes the objective phenomenon, and the patient offers the subjective explanation, Blocking (s)): “I… I was going to say something important, but it just went. It was right there, but it just vanished. It was gone. I don’t remember what I was going to say about the appointment.”

Analysis: The observable break in the patient’s fluid, goal-directed speech is the Rupture of Thought. The patient’s verbalisation that the thought “vanished” or was “gone” confirms the presence of Blocking (a subjective symptom) as the underlying cause.

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Pressured Speech

The speed of speech production is increased.

Scenario: Pressured Speech

Psychiatrist (The Question): “I wanted to briefly ask you about how you manage your day-to-day finances and paying bills.“

Patient (The Response Demonstrating Pressured Speech) – in a few seconds: “Finances are fine they’re just absolutely fine I mean look the bank statement comes and it’s right there the number is on the bottom line and I check it every morning as soon as I get up sometimes before the alarm even goes off because you can’t trust the alarms nowadays they’re always late or they lie and you’ve got to be early for everything and early means getting the money counted and the bills are all digital now which is faster but also dangerous because the numbers they just fly away on the screen and I have to print them all out every single one and staple them by date which is a lot of paper a huge amount of paper but it’s the only way to be certain absolutely certain that everything is accounted for I need to know where every single penny is and then the paper goes into the blue folder not the red one oh no never the red one that’s for tax documents which are completely different and they need a separate pen for signing because you can’t mix the inks you see—“

Psychiatrist (Attempting Interruption): “I see, so you—”

Patient (Interrupting and Continuing): “—and I was going to buy a new shredder because the old one kept jamming every time I fed it more than three sheets which is totally useless when you have this much paperwork but I need to make sure I get the heavy-duty one the industrial one that can handle the volume because the volume is the key thing in all of this you can’t let the volume get ahead of you and that’s how I manage the bills it’s a system a solid system a lot of work but it works perfectly I’m always on time and ahead of time always always always ahead of the time.“

Analysis

• Increased Speed/Quantity (Textual Cue): The paragraph is dense, with minimal standard sentence breaks, long run-on clauses connected by “and” and “because,” and a repetition of ideas (“fine,” “absolutely certain,” “always ahead of time”). This simulates the rapid, continuous flow of speech.
• Uninterruptibility: The patient immediately cuts off the psychiatrist’s attempt to interject (“I see, so you—”) and seamlessly continues their monologue, which is a hallmark of clinically significant pressured speech.

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Logorrhoea

An excessively strong urge to speak. Logorrhoeic speech itself may be coherent and logical. Accelerated speech production need not be present. Communication with the patient is hindered. The patient is either not able to recognise when he is being interrupted or simply ignores such interruptions.

Symptom	Defining Feature in TALD Context
Logorrhoea (o)	Excessive urge to speak that prevents interruption or conversational turn-taking, regardless of speech speed.
Pressured Speech (o)	Accelerated speed of speech production (rapid-fire, often breathless).
Perseveration (o)	Adherence to a previous topic despite a change in context (inability to switch).

Scenario

Psychiatrist (The Question): “Let’s talk about your hobbies. What do you enjoy doing in your free time, perhaps over the weekends?“

Patient: “Hobbies are very important, aren’t they? Especially now that I’ve retired. Before, I was always busy with work, you know, being an engineer for thirty years, it takes up a lot of time, and then coming home, there wasn’t much left. But now, I have plenty of free time. My wife, bless her heart, she says I should take up gardening, but I don’t have a green thumb. I tried once with some petunias, and they just… wilted. It was quite sad, actually. So, gardening is out. I prefer reading. I go to the library every Tuesday, and they have a fantastic collection of historical novels, especially those set in the Victorian era. I find the language so rich, and the way they describe society back then is just fascinating. The social hierarchies, the strict etiquette, it’s all so different from today, but you can still see reflections of it, if you look closely enough. And the plots! Sometimes a bit convoluted, but always a good mystery. I was just reading one about a detective in London—“

Psychiatrist (Attempting to Interject): “That sounds interesting. So, you find reading to be a—“

Patient (Ignoring Interruption and Continuing): “—and he was trying to solve this bizarre case involving a missing jewel and a secret society, and the clues were so subtle, you had to really pay attention to every detail. It made me think about how much attention we pay in our own lives, or how little. And then, after reading, I sometimes like to watch documentaries, especially about space. The universe is just so vast, isn’t it? It puts everything else into perspective. And the technology they use now, for the telescopes and the probes, it’s just mind-boggling how far we’ve come. I remember when I was a boy, we thought landing on the moon was science fiction, but now look—“

Psychiatrist (Attempting another Interruption): “I see you have a real passion for these topics, but I wanted to—“

Patient (Ignoring Interruption and Continuing): “—and that’s really what free time is about, isn’t it? Expanding your mind, learning new things, not just sitting around. Though sometimes, I do just sit, and I watch the birds in the garden, and they’re always so busy, flying here and there, building their nests. It’s a whole little world out there, right in your own backyard, if you just stop and look.”

Analysis

• Excessive urge to speak: The patient launches into a long, continuous monologue.
• Coherent and logical speech: The content, while detailed, remains coherent and logically connected within its own flow (from retirement to gardening to reading Victorian novels, to a specific novel, to documentaries about space, to birds).
• Ignores interruptions: Crucially, the patient completely bypasses two clear attempts by the psychiatrist to interject and steer the conversation, demonstrating an inability or unwillingness to cede the conversational floor. This is the hallmark of Logorrhoea.

Note: a politician’s filibuster is a conscious rhetorical tactic to control the floor, whilst Logorrhoea is a pathological loss of control over the flow and quantity of one’s speech, which the Kircher TALD scale rates as an objective disturbance in the process of communication.

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Manneristic Speech

For the observer, speech (word selection, sentence structure, articulation or prosody) seems affected and ornate, eccentric, unnatural, pompous, overblown, fancy , stylised or flowery.

Scenario A

Psychiatrist (The Question): “Mr. J, I noticed you mentioned your apartment is quite old. Could you tell me what you find most appealing about living in an older building?”

Patient (The Response Demonstrating Manneristic Speech): “Ah, Doctor, you have touched upon a most pertinent and philosophical query. To inhabit an edifice of venerable antiquity is to partake in a grand theatre of historical resonance, you see. The allure is not merely architectural, for such a notion would be woefully pedestrian. Nay! The genuine appeal lies in the unblemished character—the exquisite patina of years, the sonorous creak of the ancient floorboards, which, I must insist, possess a depth of narrative utterly beyond the grasp of these modern, sterile, and altogether tasteless concrete behemoths that pierce the sky with such inconsiderate velocity.

Furthermore, the windows! They are not mere apertures of glass, but rather portals of contemplation, providing a translucent membrane between my inner sanctum of reflective calm and the vulgar cacophony of the metropolitan sphere. One does not simply live in such a dwelling; one presides over its history, becoming a connoisseur of its enduring silence. It is an honorific distinction, a refuge from the unrefined banalities of contemporary existence, which one embraces with appropriate gravity.”

Scenario B

Psychiatrist (The Question): “I understand you didn’t much enjoy the group therapy session this morning. Could you tell me why you didn’t want to participate?”

Patient (The Response Demonstrating Manneristic Speech):

“I had to make an executive decision not to attend the assembly. I am an individual and do not favor the conflation of my personhood with the group. The staff instructed that I must attend, but I formally disagreed. My privacy is a paramount concern. Furthermore, those chairs are not up to standard. They are dis-appointing. They need to be properly cushioned for a person of my elevated status. So, I had to make my position clear and withdraw my attendance. That is my final report on the matter of the group.”

Presentation Across the Intelligence Spectrum

The observable manifestation of Manneristic Speech varies significantly based on the patient’s underlying vocabulary and intelligence:

Intelligence Level	Presentation Style	Linguistic Mechanism
High Intelligence/Wide vocabulary	Ornate or Flowery: The speech is characterized by an overuse of sophisticated, academic, or archaic lexicon and complex syntax (e.g., “edifice of venerable antiquity”).	The pathology lies in the misapplication of complex linguistic tools; the style is highly unnatural and exaggerated for the context.
Average or lower intelligence	Affected or Pompous Formality: The speech relies on the overemphasis and inappropriate inclusion of a limited set of formal, rigid, or technical vocabulary (e.g., “executive decision,” “elevated status”).	The pathology lies in the unnatural adoption of an artificial, superior tone, using words that are either slightly misused or overly bureaucratic for simple communication.

The Link to Grandiosity

Regardless of the patient’s intelligence level, clinically significant Manneristic Speech often carries a strong hint of grandiosity because the affected style aims to elevate the speaker or the topic beyond its actual relevance.

• The intentional effect: The use of an unnaturally “pompous” or “overblown” style (as described in the TALD definition) implies that the speaker is a person of superior status, intellect, or insight whose mundane actions deserve special, formal linguistic treatment.
• The core disturbance: When manneristic speech is pathological, it reflects a disturbance in the pragmatic control of language (how language is used in social context), where the internal state of inflated self-concept (grandiosity) is inappropriately translated into an affected verbal presentation.

Manneristic Speech can easily be confused with an affected or overly academic style in a normal context. The distinction, particularly in the TALD, lies in its unnaturalness and eccentricity for the speaker and the setting, rather than just being verbose. When it is clinically pathological, Manneristic Speech (or Mannerism of Speech) is primarily connected to conditions involving disorganisation of thought and behaviour.

Mental Disorders Associated with Manneristic Speech

The pathological manifestation of Manneristic Speech is chiefly a sign of Formal Thought Disorder (FTD) and is most strongly associated with the following psychiatric disorders:

1. Schizophrenia and Psychotic Disorders (Core Association)

Manneristic Speech is categorized within the broader disorganised symptoms of schizophrenia. In this context, it is not merely a choice of vocabulary; it reflects a break from conventional, reality-based communication.

• Mechanism: It is thought to reflect a disturbance in the cognitive or pragmatic control of language, leading to an affected, sometimes ritualistic or bizarre, style of expression.
• Context: It often occurs alongside other disorganisation symptoms like Derailment, Circumstantiality, and Tangentiality.

2. Bipolar Disorder (During Manic Episodes)

While often overshadowed by Pressured Speech and Logorrhoea, Manneristic Speech can appear in severe manic episodes.

• Mechanism: The grandiose thought content and excessive self-importance often present in mania can manifest as a pretentious, flowery, or pompous speech style designed to impress or overwhelm the listener, matching the “overblown” and “pompous” descriptors in the TALD.

3. Schizotypal Personality Disorder (STPD)

As a personality disorder, STPD often involves features related to the schizophrenia spectrum but in an attenuated form.

• Mechanism: Patients with STPD frequently exhibit oddness or eccentricities in their behaviour and appearance. This is often mirrored in their communication, where speech is overly elaborate, vague, or expressed in a highly idiosyncratic way that strikes others as unnatural or strained.

Clinical vs. Stylistic Distinction

To avoid confusing Manneristic Speech with a learned, formal style (like the one I demonstrated), a clinician assesses the following:

1. Contextual appropriateness: Is the patient speaking to a doctor in a clinical interview with the same hyper-formal, ornate language they would use to order coffee? If so, it is highly unnatural.
2. Deviance from baseline: If the patient’s typical speech is observed to be simple and direct, and they suddenly adopt a “flowery” style, the change is more likely pathological.
3. Presence of other symptoms: If the Manneristic Speech co-occurs with other FTD symptoms (like vague thinking or tangentiality) or bizarre behaviours, it is much more likely to be a clinical sign of disorganization.

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Semantic Paraphasia

Substitution of an inappropriate word ( the substitute is semantically related to the appropriate word .) The speaker may or may not recognise his error and attempt to correct it.

Scenario

Psychiatrist: “Have you been able to take your new medication regularly since you were discharged?“

Patient: “Yes, Doctor. I put the little cupboard [intended: bottle] of pills right next to my eating place [intended: plate] at breakfast. I never forget. I take one tiny white rock [intended: pill] every single morning. I have to be careful with the dosage, because if I take too much, I start feeling happy [intended: anxious] and my chest gets tight. But mostly, I remember the door [intended: bottle].“

Analysis

The patient uses several words that are related in meaning to the correct word but are inappropriate for the context. The substitutions are errors that disrupt the precise communication of their thoughts, but a listener can generally infer the intended meaning due to the underlying semantic connection. The patient does not show any attempt to self-correct in this instance.

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Phonemic Paraphasia: Mispronunciation (with regard to phonetic articulation) of a word. Milder forms may occur as slips of the tongue in everyday speech. The speaker usually recognises his error and may attempt to correct it.

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Neologisms

New word formations, which do not correspond to lexical conventions. Most Neologisms are not directly intelligible. In extreme cases a new artificial language can be formed or used by the patient. Expressions or slang words used in particular groups or subcultures (e.g. youth culture, the drug scene) are not to be classified as Neologisms. Insufficient language abilities (e.g. in a non-native speaker) should be excluded as well.

Scenario

Psychiatrist (The Question): “How are you feeling about your future, and what do you hope to achieve when you leave the hospital?”

Patient (The Response Demonstrating Subtle Neologisms): “I feel determined, Doctor. I really do. I want to get back to my job, and start earning my living again. But first, I have to figure out how to manage all the pressure. The world outside seems to be moving at such a high veloxity, and it’s hard to keep up. I think the key to my recovery is mastering this new kind of time—this chrono-grid. If I can just find the right setting on the chrono-grid, then I can finally feel unshavvered and get back to being normal. I’m aiming for full recuperation by the end of next month, once I’ve fixed the chrono-grid issue.”

Analysis

In this revised response, the speech is largely coherent and goal-directed (returning to work, recovery), but it is punctuated by two invented words:

1. Veloxity: An invented noun, likely meaning “speed” or “swiftness,” used to describe the pace of the outside world.
2. Chrono-grid: A new, invented compound word combining a root for “time” (chrono) and “grid,” suggesting a complex, artificial system for organizing time.
3. Unshavvered: Is a new word. It can easily be missed if mistaken for unshattered (which could be allowable).

These isolated, non-conventional words disrupt the listener’s understanding just enough to signal a breakdown in the patient’s internal lexicon, without dissolving the entire sentence into “word salad,” making it a more realistic demonstration of the TALD criteria for Neologisms.

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Clanging

A pattern of speech in which sounds, rather than meaningful relationships, appear to govern word choice, so that the intelligibility of the speech is impaired and redundant words are introduced. In addition to rhyming relationships, this pattern of speech may also include punning associations, so that a word similar in sound (polysemy/homophony) brings in a new thought.

Scenario

Psychiatrist (The Question): “Have you had a chance to connect with your support group yet, or have you just been staying home?”

Patient (The Response Demonstrating Subtle Clanging): “I’ve mostly been staying home, Doctor. I really need to get out and start to mingle, but the city is just one big jingle. I know I should feel free, but I just keep getting stuck on the key. I think about the group meeting, and it feels like a very big thing I have to bring with me, and that makes me sing a different tune.”

Analysis

In this example:

• Goal: The patient is attempting to discuss the support group and staying home.
• Subtle Clang 1: The word “mingle” spontaneously triggers the rhyming word “jingle” to describe the city. The connection is sound-based, not logical, and temporarily derails the flow.
• Subtle Clang 2: The discussion of feeling “free” is followed by a sound link to “key,” which is then used in a confused metaphor (“stuck on the key”).
• Subtle Clang 3: The idea of the meeting being a “thing” is followed by the rhyme-driven association “bring” and “sing.”

Clanging can easily be missed, or misinterpreted as the patient being ‘poetic’. The patient’s speech remains mostly comprehensible, but the recurring, inappropriate, and unnecessary rhyming links clearly demonstrate that sound has occasionally hijacked the logical thought process, fulfilling the TALD criteria for Clanging in a subtle, real-world presentation.

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Echolalia: Senseless repetitions of words and sentences with no regard to their meanings and semantic functions. The patient echoes the words or sentences of the interviewer. Exclusion: Some people habitually echo questions, apparently to clarify the question and formulate their answer. This is usually indicated by rewording the question or repeating the last several words.

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Poverty of Content of Speech: Although replies are long enough that speech is adequate in amount, it conveys little information. Language tends to be vague, often overly abstract or overly concrete, repetitive, and stereotyped. The interviewer may recognise this finding by observing that the patient has spoken at some length but has not given adequate information to answer the question. Alternatively, the patient may provide enough information, but require many words to do so, so that a lengthy reply can be summarised in a sentence or two.

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Restricted Thinking (o): Restriction in the range of content, adherence to one topic or a few topics, or fixation on a few key ideas. During the conversation, the patient experiences difficulties in switching from one topic to another, or constantly returns to the initial topic. For a successful exploration, it is necessary that the examiner offers the patient a variety of topics. This is important since the topic of illness always forms part of a psychiatric exploration, but this should not automatically be treated as resulting from Restricted Thinking. When exploring the topic of illness, it is only possible to refer to Restricted Thinking when the patient is fixed on single aspects of his illness, and when he is not able to detach from these aspects despite being offered other topics of discussion (e.g. a depressive patient who is preoccupied with his indigestion).

Slowed Thinking: From the observer’s perspective, the patient’s thought process seems to be slowed down (objective). As a result of this sluggish thinking process, the conversation is languid and torpid.

Poverty of Speech (o): Restriction in the amount of spontaneous speech, so that answers to given questions tend to be brief, concrete and unelaborated. Unprompted additional information is rarely provided. Replies may be monosyllabic, and some questions may be left unanswered altogether. When confronted with this speech pattern, the interviewer may find himself frequently prompting the patient in order to encourage elaboration of replies. To elicit this finding, the examiner must allow the patient adequate time to answer and to elaborate his answer.

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Concretism

Concretism refers to difficulty in the comprehension of abstract (figurative) sentences or phrases (e.g. the understanding/interpretation of proverbs, metaphors, jokes). The patient adheres to the concrete meaning of the words/utterances.

Scenario

Psychiatrist (The Question): “Mr. A, I’d like to test your ability to think about things abstractly. Can you tell me what the common saying ‘Don’t cry over spilt milk’ means?”

Patient: “It means that you should not make a big mess. If the milk is on the table, and it falls over, it is now on the floor. It is spilt. It is wet. You cannot put it back into the jug. So, if you cry, you will be making your face wet for no reason, because the milk is still spilt on the floor. You should get a cloth and clean the mess.”

Psychiatrist: “That is a very literal answer. Let’s try another one: ‘A rolling stone gathers no moss.’ What do you think that means?“

Patient: “That is correct. If the stone is rolling, it cannot pick up the green moss. The moss needs the stone to be still. So, a moving stone stays clean. It is about friction and weight. The stone has to be heavy to roll, and if it is too small, it will stop, and then the moss will start to grow on it.“

Analysis of Concretism

• Adherence to literal meaning: In both instances, the patient completely fails to grasp the figurative, general meaning of the proverb (i.e., “don’t worry about past, irreversible events” or “a person who is always moving or changing jobs won’t settle down or accumulate wealth/stability”).
• Focus on concrete properties: Instead, the patient focuses exclusively on the physical, concrete components of the phrase: the wetness of the milk, the cleaning of the floor, the physical properties of a stone, moss, friction, and weight.

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Blocking: Perceived and reported blocking of an ongoing line of thought, also known as losing one’s train of thought. Blocking is subjectively noticed by the patient. Included is the phenomenon of Fading, which refers to a slow dimming away of a thought, as opposed to a sudden termination (in the sense of Rupture of Thought). Fading can also occur in a fluctuating manner, which means that the thought becomes weaker at first, then becomes clearer again, then fades away once more. In contrast to a loss of thought, Fading can only be assessed if the patient himself reports this phenomenon. Blocking and Fading may occur either with or without Thought Interference.

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Rumination

The patient is constantly occupied with mostly unpleasant topics. These thoughts centre around the same topics without leading to any conclusion. For the patient, it is hard to interrupt these negative thought processes. Rumination is experienced as unpleasant and in some cases even torturous.

Scenario

Psychiatrist: “What kinds of things are occupying your mind right now? What are your thoughts typically focused on?”

Patient: “I keep thinking about the router in my flat. It’s not the broadband speed that’s the problem; it’s the light. The light is red, and it should be green. Why is it red? It means they are watching. The Government is rerouting everything through the red light, and I can’t stop thinking about what they’re seeing. Are they seeing me just sitting here? Are they recording this interview through the light? It must be the Government, because who else has the power to change the light from green to red, and to tap the router? It’s not a neighbor; it’s too systematic, too organised. It has to be GCHQ. They are using the red light to track my movements. I can’t leave the flat, because they’ve got the satellite link to the red light, and they know where I’m going before I even put my shoes on. That light… it’s just a constant worry. I need to know why the Government needs to watch me through that red light. Why me?“

Analysis of Rumination

• Dominant and fixed idea: The entire response is immediately consumed by and fixed on a single, core idea: being watched by the Government via the router’s red light.
• Circular thinking: The patient continuously cycles through the same elements without reaching a conclusion: the red light, spying, the Government, systematic tracking, the red light. The idea does not progress; it simply reiterates the worry.
• Uninterruptible quality: The intensity and fixation on this narrow topic demonstrate the “hard to interrupt” quality.

Rumination can easily be missed if a psychiatrist is overly occupied with ‘content’, and misses the form and flow of thoughts.

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Poverty of Thought: The patient has the sense that his thinking is unimaginative and restricted to just a few themes. This may or may not be accompanied by unpleasant feelings.

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Inhibited Thinking: The process of thinking is experienced by the patient as being slowed down, braked or inhibited, as if he is thinking against an internal resistance. The patient is not able to overcome this inhibition of his thoughts. Inhibited Thinking can extend to the point that the patient has the subjective experience of not being able to think at all anymore.

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Receptive Speech Dysfunction: The meanings of words, word sequences or sentences (for example, in conversations, movies and radio programs) can only be grasped or understood incompletely, with effort, or not at all. In some instances, the phenomenon may only occur after some time of mental strain.

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Expressive Speech Dysfunction: The patient notices that it is difficult for him to find the right words. While the patient is speaking, he notices that word choice, linguistic precision and word fluency are affected. Appropriate words are not quickly accessible or are completely unavailable. In some cases only imprecise and unclear formulations come to mind. In severe manifestations of this phenomenon, self-experienced Crosstalk phenomena can occur, which may result in tactless or inappropriate utterances. Some patients may try to compensate for the disorder by repeating empty phrases and verbiages, or they may even avoid conversation altogether.

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 Dysfunction of Thought Initiative and Intentionality: The patient subjectively experiences a lack of thought initiative, thought energy and intentionality; he is aware of the dysfunction. The impairment in initiating or structuring the thought process may result (due to the lack of an overarching concept) in the inability to perform activities of daily living (e.g. making coffee) .

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Thought Interference

Interfering thoughts or ideas that do not belong to the current line of thought. Thought Interference may or may not be triggered by or linked to external stimuli. The interfering thoughts are more or less neutral in terms of their affective weighting.

Scenario

Psychiatrist (The Question): “Before we finish, can you tell me what you plan to do this afternoon once you leave the clinic?”

Patient: “I wish to get to the bus station. The number 45 will be there. Hmmm, the clatter of diesel engines and what does my life mean. You know, the engine sound is a heavy, metallic thing, but my thoughts are just dust. Tippy toe tippy toe (whispered, mimicking quiet footsteps in the corridor). I should buy a new pair of shoes. But if my life has no meaning, why bother with the shoes? The diesel is so loud; they can’t possibly hear my dust-thoughts. I must get on the bus, but I must also solve the whole question of life’s value before the number 45 leaves.“

Analysis

This demonstration illustrates the TALD criterion for intrusive, irrelevant thoughts that disrupt the line of thinking:

1. Goal disruption: The original goal (getting to the bus station) is constantly interrupted.
2. External incorporation: The sound of footsteps in the corridor outside the interview room, is immediately incorporated through the mimicked speech (“Tippy toe tippy toe”), and the sound of the bus (“clatter of diesel engines”) is introduced, with neither observation belonging to the plan.
3. Intrusive internal themes (neutral affect): These external observations are instantly interpenetrated by a deep, irrelevant, and often abstract internal theme (“what does my life mean,” “my thoughts are just dust,” “existential value”). These thoughts are intrusive and disrupt the action plan but are presented without the intense, torturous affect of Rumination.
4. Interpenetration of themes: The flow shows an unintegrated jump between reality (bus), the external environment (sound/footsteps), and an abstract internal idea (meaning/value), which is the essence of Thought Interference.

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Pressure/Rush of Thoughts: Numerous thoughts with varied content jump into or impose on the patient’s mind, alternating rapidly. The patient is able to neither control nor suppress these appearing and disappearing thoughts.