How to elicit thought disorder during clinical interviews: a practical guide

Hello, and welcome to another edition of the BJ Psych Advances podcast. My name is Oliver Girlground, and I'm joined today by Lena Parniapam and Oli Delgaram Nijad to discuss their new paper "How to Elicit Thought Disorder" during clinical interviews, a practical guide, also published with co-author Eric Chen in BJ Psychopath Advances. Lena and Oli, thank you both so much for being here. Thank you very much, Oli. We're having us. So, tell us, what's this paper all about? Yeah, perhaps I can start. So, this is a paper aimed at clinicians and trainees in psychiatry primarily, as well as clinical psychology, where you come across people who have serious mental illnesses like psychosis, bipolar disorder, or depression. In this group, you know, we often see a very important group of symptoms and signs, and this is called "thought disorder" or "formal thought disorder" in textbooks. And this is a very interesting collection of observable signs. This is not something patients actually report to us. People do not come to us to say, "I have a problem in ordering my thoughts." This is something we have to observe very carefully, and we have to see, we have to hear during the interview. But interestingly, this is not something that clinical training teaches how exactly to see and how exactly to hear. This paper is all about a structure for seeing and hearing thought disorder during a clinical interview. Yes, I think this is, as you say, such a kind of a core topic in psychiatry, and probably something where lots of different clinicians have their own kind of ideas about what formal thought disorder does or doesn't mean, and as you say, it's something that's observed rather than asked. So talk us through a little bit the background here, because as you say in the paper, there's sort of this gap between the academic theoretical ability to observe this and the real world's clinical reality of observing it. So talk us through a little bit, what's going on there. Yeah, this is, I mean, as you correctly put, there is a big gap between the academic reality, reading in textbooks about what thought disorder is, and actually talking to people and observing it. In fact, Oli here has done quite a lot of interviewing with the people who have notable thought disturbance. So I will let you Oli to say a few words about, you know, the whole concept of observing and recording thought disorder in interviews. Sure. So, yeah, I interviewed 15 people with schizophrenia as part of my PhD research, and I also interviewed 14 people with no psychiatric history. And then I did a computational psycho-linguistic analysis of the speech. And when I was interviewing one of the main challenges was how to elicit thought disorder. And in the literature, there wasn't very much when I was working on this problem. There was a reference from a 1985 study that suggested the abstract topics would be useful. So that was a big driver in YB, the resulting data set, took one that it did. It's called the Discussing Abstract Ideas in schizophrenia corpus, the Daisy. And so, participants were interviewed on the topic of creativity. And within the first few interviews, it was obvious to me that open questions on abstract topics were a real challenge for people with schizophrenia. You would get questions like, "What are you actually asking me? What do you mean?" They needed scaffolding. They needed something, a frame of reference. The question was too broad, and that was for a lot of participants quite destabilizing. And then, when they were given some prompts, you know, like saying, "Okay, well, when you think about poetry or music or art, do you?" That sort of thing. Just like talking, that's when the observable signs of thought disorder started to come out. So you got deviations from the topic. One of the core findings from my research was that in the schizophrenia group, participants, reference topics of emotional or personal concern up to 16 or 32 times more often than the comparison participants. So, in practice, what that means is, when you interview people with schizophrenia on a neutral non-contentious abstract topic, like creativity, they tend to default to adverse childhood experiences, social cognition issues, interactions with other people that were difficult, family history stuff. So, for them, creativity triggers a much more introspective and idiosyncratic conversation, whereas the comparison participants would have a much more coherent conversation about John Keith's poetry or something like that. So, that data set is freely available. It's open source. Anyone can download it from the UK Data Services Re-Share repository. It's good for trainees. Anybody who wants to just dig up some transcripts and see what thought sort of in 2024 looks like, because a lot of the textbooks will tell you, even now, there are vignettes from Crapline, and they're great, they're very helpful, but they are situated in their historical context. And from a linguist's perspective, that means to be accounted for when trying to apply some of Crapline's opposite observations to contemporary interviewing. So, it's more as to how a kind of newer data set. So, if we can follow up on that, but only that what you mentioned, the example of giving abstract ideas and drawing out signs of thought disorder is an excellent example. You know, this also tells you you need to practice and manifest during the interview in order to really get a good quality assessment of thought disorder. And this comes back to the question you asked Oliver, what is the gap between theory, textbook, and practice? When in research, we use standardized rating scales for thought disorder. And if you look at the performance of these rating scales, they're very, you know, they have high reliability, they have like 0.9, 0.8 reliability reported, they're very coherent, but then it comes to practice between two clinicians on the same day, seeing the same patient, one will pick up the thought disorder and the other will not. So, this gap comes from the fact that standardized rating scales prescribe some procedures for us to, you know, elicit the thought disorder. And in clinical practice, we don't often do these kind of things. A fine example in addition to what Ollie said here is our co-author Eric Chen, he has a scale called Clang, and one of the questions in that scale, this is a scale to elicit thought disorder. And one of the question is asking patients, what do you think about God? Does God exist? So, quite an open question, very broad and really abstract and draws out many, many thoughts that people might have aboard the topic. Such maneuvers are really important. And, you know, making clinical trainees and clinicians appreciate it and use it regularly is the real target of this paper? Yeah, I think that's a really good point. I think, you know, what you're kind of getting to here in the first, the paper is almost, there's like a seven step process or a seven dimensional framework that can be used in clinical interview to try and actively encourage participants to, you know, sort of display the thought sort of the earplucking for. How, you know, how might you kind of actualize that in real life? Those seven different steps there. Yeah. Well, you know, the first thing to think about is we already do these seven steps in, you know, clinical interviews. We probably don't think of them in that structured way. Take, for example, almost all clinical, well-conductive clinical, psychiatric psychology interviews start with an open-ended discourse. We try to minimize the external structure so that some kind of internal, you know, thought problems people have can come up. And then we move to provoking thinking a little bit. So thought provocation, abstract questions. Sometimes we ask for problems asking people to interpret problems. We recommend also, for thought disorder, to give some reference like objects, pictures or, you know, something that people can talk about because one of the challenges you often see in established long-term series mental illnesses is the total productivity of speech comes down. So people actually stay one word, say one word answer is a stay quiet during clinical interviews. So provoking thinking is an important maneworth to do. So that's the second step. You also recommend doing a bit of cognitive loading, you know, putting demands on the memory, putting demands on interpretation of words. One good way of doing that is story recall. You know, it's a classic technique that goes back to boiler. I remember what you said earlier about crippling. This is an old technique, but still very useful. You don't give people something to think about and then ask them to recall. In addition to this kind of, you know, provocations and cognitive loading, also very important to gradually introduce them emotionally, the element content and watching, you know, whether coherence holds or it fragments. Because effective reactivity is a very well known phenomena in thought disorder. When people are under emotional influences, the thought disorder comes up quite observably for clinicians. So it's important to gently do that. And often, questions about delusions, even the content of voices are sufficient in a symptomatic person. A couple of other things we talk about in this list of maneuvers is actually inducing, talking about other people. So inducing mental states talk. This explains Visitingly asks the person to take another person's perspective. This helps us to probe the social cognition piece that Ali, you mentioned, the theory of mind difficulties. And we always do that in a subtle way in clinical practice. So we ask something about, say, if a patient lives with her mother, we ask her, what do you think your mother thinks of what's going on with you? And that's a very good mental state in using talk, because you have to talk about what your mother thinks about you. And those kind of questions are really important to build in, if you want an illicit formal talk disorder. And finally, very importantly, two more things that we often miss in regular practice, but it's important to use in clinical examination of talk disorder. Number one is clarifying any instances where you think there is a talk disorder. People might do slip ups in sentences, especially this is very culturally important as well. Someone like me, English is not my first language, I could put sentences in a way that is not because of my thought disturbances. It could be because of my schooling where I grew up in, you know, how I speak English. So it's important that if we do not understand, always like do some targeted clarification, ask people, this is what you said, is that what you mean? And that's really helpful to confirm. In fact, if a person has a notable thought disturbance, the clarification may actually provoke a little bit more observable phenomena as well for us. Finally, the second part of what we don't usually ask, we need to ask, is subjective experiences of thought disorder, you know, things like blocking, things like thoughts suddenly getting jumbled in your mind. These are not covered in most rating scales, only if you do that, but people with subjective experiences of thought disorder can actually articulate them well if we ask them, often we don't ask them and we assume they don't exist. Yeah, I think that's a great description. I think it's really important what you said there, right? Which is that a lot of people are probably doing a lot of these steps consciously or subconsciously in their clenocrine to be already. There probably are a few things in there though that certainly I personally am not doing when I see patients at a great deal that are interesting, right? Like this idea of having an active recall task, this idea of kind of having these like deliberate emotional provocations, that's probably completely wrong words. I think, you know, those are some kind of interesting things and in the paper here you've got these really nice like clinical application, almost like demos of how this can fit into an interview and how this probably actually wouldn't be a massive change to what people are already doing. Yeah, that's right. I mean, you know, when you, when we talk about assessments, the biggest worry for clinicians is, is this going to take more time from, you know, what I'm already offering? The fact is, things like thought disorder doesn't have to be a time consuming assessment. If we practice the right maneuvers, of course, you know, you can do most of this within 15 minutes of your usual follow-up time. Yes. I think, you know, it's also really something I think is worth refreshing in a lot of people's minds, is that the subjective dimensions of thought disorder, plus obviously the, you know, very obvious difficulty in expressing what's in one's head is probably the two things that most clinicians would think about when they think about thought disorder. So they've explicit questions like, you know, are your thoughts being taken away from your thoughts, being put into your head? This is maybe what people are asking and I think you can sort of see here that actually some of these maneuvers that have come before, you know, probably would elicit something quite similar or maybe even elicit something in a more kind of natural way. So I think this is, yeah, like a super nice framework for people to have in their heads. It doesn't get a lot of attention in the literature, the subjective aspects, but I am involved in some social media groups, people who live with schizophrenia and a large number of the posts are people checking their understanding, a lot of people saying, you know, sometimes it feels like my train thought ends abruptly, does anyone else have this? So within social media communities around psychosis and schizophrenia, there is a lot of reference to the subjective experience of thought disorder, but it hasn't become an object of research interest in a mainstream sense. That's how I make sense of it at the moment. I think that's really interesting. I think something I should have asked you at the start and what I'll ask you now is when people are doing this in a research context, there's the current light guys, just the use of these rating scales. If so, what is kind of the current gold standard thought disorder rating scale, if there is one? I'm going to say quite a few ago, Lane knows how I feel about rating scale. Yeah, this is, you know, the two aspects to that question, Oliver, one is what are people currently using, secondly, are they good enough, right? So people are, you know, most research groups interested in relating thought disorder to the brain phenomena or you know, some sort of outcome and clinical trial phenomena usually go for standard rating scales like TLC, which is a scale, TLC stands for thought language and communication index produced by Nancy Andreessen many years ago. Other people use general rating scales for psychosis like pants, which has one or two items of disorganization and then try to use that for measuring it. That's what commonly happens. There are many scales. We did recently some reviews of these scales, there are at least 16 commonly, like 16, not commonly, but you know, reasonably often use scales in some sense. And they are capturing different aspects of what the phenomena of thought disorder really is. So we use this phrase in one of our recent reviews of scales. We say there is a pinch and zoom problem in measuring thought disorder, which means you can actually put this spot in the whole space of thought disorder. You can focus on any spot and you can zoom it and it will only measure the zoomed part in your rating scale and you'll be missing the other parts. And those other parts may be the most important ones for the person in front of you, but you may not be able to capture it. So there is no comprehensive way of rating thought disorder and this is where clinicians like ourselves who see people on a regular basis should be ready to capture the phenomena on a longitudinal basis. Every time you see a person try to document it and I would say not to write in notes thought disorder absent or present. That's really like a very reduction, that's take way of thinking about thought disorder. Describe the phenomena, you know, write a book in what situation the disturbance occurred and also the patient's own subjective experiences of this phenomena. Those are very rich descriptions and that's exactly what we need. We cannot depend on rating scales to capture this phenomena. Yeah, I think that's, you know, fascinating kind of insight there into how some of these racing stales maybe are not capturing everything. I mean, you are right though that in lots of lots of research fields, the desirable thing to have as a number, you know, because that is that is then going to feed so nicely down to other analyses. Only I feel like you have to tell us what you think now after saying that you could possibly tell us. A large part of my PhD was focused on critiquing Andreas's TLC scale, which is why that paper was never published because if you look at the literature on thought disorder, the majority of researchers, they do the literature of you, they identify the TLC scale as a highly influential instrument, then they do their study with the TLC scale. In my research, I picked up that there was an enormous methodological shift in the landscape in the 70s. Everything that Crapline and Cameron and Wing and Bloiler and Cliced had said about thought disorder was brought together in the TLC scale and a lot of their observations were discarded and a lot of new things that no one had ever mentioned before were brought in. And from a methodological standpoint, I was quite blown away by that. And the rationale at the time was, well, I haven't seen this in clinical practice. So therefore it doesn't exist. And what I did in my research was I took the pre-TLC position and the post-TLC position and I tested both. And I found that a lot of the pre-TLC stuff was actually useful, still useful. So when it comes to rating scales and also as a linguist, there was a trend in the 70s and 80s in psychological and similar social science research to do subjective qualitative things but package them as objective measures. So fundamentally, when you're scoring the TLC scale, you're guessing, you know, but because it's part of a standardized instrument, it feels like you're doing something much more concrete and so to me, personally, coming out of the other side of that research, I think actually clinical judgment is probably a lot more helpful as in, like, per clinician clinical judgment. Following their clinical instincts is probably a lot more productive than sitting down and trying to do a TLC scale score. I mean, one of my clinical supervisors was supervised by Dr. Peter McCannot and he taught me his story once about how Peter McCannot would do training sessions for training psychiatrists on the TLC scale and it was chaos. Everybody got different scores and that sort of thing. So I think, and one of my field supervisors at forensic psychiatrists, we were talking about thought disorder and rating scales and she said, "Well, you know it when you see it." And I think that's at the heart of the clinical reality, isn't it, but the rating scales are great for papers, but for clinicians, none was going to sit down and do the TLC scale on the fly with a patient, it's too time and labour intensive and it's, that's before all the methodological complaints I have. So I did develop a friend. framework for clinicians because one of the things that came up in the course of writing the thesis was, and the feedback I was getting from clinicians was, look, this is all well and good, but can you give us something we can actually use, right? So I distilled everything that had ever been said about thought disorder in the literature that I can find down to its common components and I came up with a framework for four things that clinicians can look for, that don't require you to do a linguistics degree to apply, grammatical disturbances, word selection errors, thought completion problems, and difficulty tracking the discourse. If you look for those four things, you're probably looking at thought disorder. And that was the theoretical piece and then Lain is obviously done a much larger study with the rating scales that arrives at a very similar idea that you can get it down to a few common features. Yeah, I think that's such a kind of a, has such good face validity as a clinician, these are four things you're looking for. You know, I don't want to say it and I'm glad you said it, but if you'd asked me last week before we were doing a podcast, what do you think about thought disorder? I probably could have made you up some definition in my mind, but probably what I really would have wanted to say is what you said, which is like, I just know, I just see someone and I just know the guys thought sort of like, I just know, and I can't kind of put it into words, but you put it into words so nicely there. You know, what it is actually is making you think it. And listen, I think this is a wonderful paper. It's a really important topic that is so universal for so many people with serious mental illness. And you know, in a way, you kind of so underthought about by the clinician population. So I think this is a really good one for everyone to have a look at. And so that was Lena Palaniapan, a professor of psychiatry at McGill University in Canada, and Oli Delgarham Rajad, who's an independent researcher based in the UK. We were discussing their new paper, how to elicit thought disorder during clinical interviews of practical guys, published with co-author Eric Chen in BJ Psych Advances. Now, Lena and Oli, thank you both so much for being with us. Thank you very much, Oliver. This is good fun. Thank you for listening to this BJ Psych Advances podcast. For the latest updates, follow us on Twitter at the BJ Psych. To listen to more podcasts from the BJ Psych Journal portfolio, visit us on SoundCloud or search for us online.