Thought Disorder, Subjectivity, and the Self

Thought disorder, a.k.a. “formal thought disorder,” has historically been treated as a key feature of severe mental illness, and closely linked with the paradigmatic form of “madness”: schizophrenia. In recent decades formal “thought disorder”—understood as disturbance in the organization and expression of thought—has increasingly come to be viewed in behavioral terms. Operationalist demands1,2 have led many to reduce thinking largely to overt linguistic expression or so-called “disorganized speech,” defined as difficult to comprehend.3(p88),4 Demands for high inter-rater reliability (potentially at expense of validity) have encouraged simple formulations—which can preclude forms of subtle pattern recognition required for grasping styles of thinking and speaking. Under these circumstances, it is not surprising that “formal thought disorder” has been homogenized: viewed as a single, unidimensional phenomenon not distinctive of any particular disorder but present cross-diagnostically at different degrees of severity.5 Thought disorder now seems, in fact, to be a grossly neglected concept, and many younger psychiatrists are, unfortunately, not familiar with the concept.6 These trends are at odds, however, with what is widely regarded as the best research on thought disorder in psychosis: Holzman et al’s investigations using the TDI: Thought Disorder Index, which does show distinctive signatures of schizophrenic-vs-schizoaffective-vs-manic patients, albeit with fuzzy boundaries.5