Disorganized Speech

1. Overview — What Is Disorganized Speech?

Disorganized Speech is a pattern of speech that is “structurally disorganized” and “disconnected in thought” to a significant degree, to the point that listeners cannot follow it. This is not a personality trait, not shyness, and not just talking fast because of excitement. It directly reflects a “disturbance in the thought process (formal thought disorder),” which is one of the core hallmarks of the Schizophrenia Spectrum and Other Psychotic Disorders according to DSM-5-TR.

When we listen to someone with this kind of symptom, we usually feel right away that “the conversation doesn’t flow.” The second sentence does not align with the first one; topic changes occur without any logical basis; the flow of ideas is driven by strange associations, such as sound-based connections between words (clanging) or pulling in words that have nothing to do with the context at all. This makes communication very difficult, no matter how hard we try to pay attention.

In DSM-5-TR, this symptom is categorized under “Disorganized Thinking (Speech)” and is one of the “three major core symptoms” of psychosis, alongside delusions and hallucinations. At least one of these three must be present for a diagnosis of psychotic disorders such as Schizophrenia, Schizophreniform Disorder, and Brief Psychotic Disorder. Therefore, the importance of this symptom is not trivial; it is a key indicator of structural abnormalities in the brain’s thought organization.

Disorganized speech can manifest in many forms, from mildly off-topic responses all the way to “word salad” that is almost impossible to interpret. Each form reflects deeper impairments in executive control, semantic processing, and language organization, which aligns with brain research showing abnormalities in frontal and temporal language networks.

Another crucial point is that the symptom must be “severe enough to cause real impairment in communication,” not just a mild distractibility that everyone experiences from time to time. It has to reach the level where, once a person talks, the substantive content vanishes, connections between ideas break down, and the context becomes so fragmented that the listener can barely keep up.

Finally, disorganized speech is not a disorder in itself, but a symptom that can appear in many conditions, such as Schizophrenia, Schizoaffective Disorder, mania with psychosis, MDD with psychosis, delirium, dementia, and even substance-induced psychosis. The presence of this symptom is therefore a “red flag” that warrants immediate further evaluation to identify the underlying cause and perform systematic differential diagnosis.

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2. Core Symptoms — The Central Features of Disorganized Speech

On a big-picture level, think of Disorganized Speech as = a cluster of multiple abnormal speech patterns grouped together (a formal thought disorder cluster). It is not just “rambling” but a breakdown of the normal structure of thought that spills out through language.

When we listen to someone with disorganized speech, what we feel is not just “they talk a lot” or “they gossip too much,” but rather:

• The sentences do not line up in a straight, logical line.

• The question and the answer don’t really match.

• The connections between topics are “loose,” forcing us to expend a lot of effort to keep up.

• At certain points, we cannot even tell what the person is talking about.

Below are the core patterns commonly used to describe/assess formal thought disorder as manifested in disorganized speech.

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2.1 Derailment / Loose Associations

Keyword: Drifting off-topic in a way that is not very logical.

Simple definition: The person starts talking about one topic, and then suddenly switches to another topic that is “somewhat related or not related at all,” with connections that leave the listener wondering where that came from.

Each sentence, taken on its own, can still have some meaning (not yet full-blown word salad), but once they are strung together in sequence, “the storyline disappears.”

The listener has to “guess the logic” of how the narrative went from topic A to B, C, D so quickly.

Example:

Question: “What did you do this morning?”
Answer:

“This morning I woke up late because it rained. My house has a leak. I really don’t like blue. These days people use their phones too much. The bus is never on time. Yesterday the dog barked in a weird way, like it didn’t want me to leave the house.”

We can see that:

• Each sentence is “understandable” in itself, but the chain from rain → blue → phones → bus → barking dog is extremely loose.

• A typical person might drift slightly, but will be able to pull themselves back to the main question. In contrast, derailment in schizophrenia means that once the person goes off track, they stay off track.

Distinguishing from the general population:

• General population: They may go off-topic sometimes, but if we say, “Wait, hold on, can we go back to this morning?” they can pull themselves back.

• Disorganized speech: No matter how many times we try to bring them back, they keep drifting sideways → it is as if the track of their thought “turns by itself” all the time.

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2.2 Tangentiality

Keyword: They start as if they are going to answer, but never actually answer.

This occurs when there is a clear question, but the answer “goes around the world” and in the end never touches the question at all.

At the beginning, it looks like they are still within the topic, but by the time the sentence, paragraph, or entire response ends, the question still has not been answered.

This is different from circumstantiality, where the person may be verbose and circuitous, but eventually returns to give a direct answer.

Example:

Question: “What are you doing for work now?”
Answer:

“I’ve done so many kinds of jobs. It’s hard to find work these days. The government doesn’t understand that people have to eat and live. I think if this country improved the public transport system, people would be much happier. Did you see the news yesterday that…”

After one minute, we realize:
We still don’t know what job the person is currently doing.

Important point:

Tangentiality is heavily used when rating thought disorder because it reflects that the thought system cannot ‘lock onto’ the question.

For blog readers/general readers, an easy way to explain it is:

“They’re asked about topic A, but respond with a monologue about B, C, and D and never come back to answer A at all.”

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2.3 Incoherence / Word Salad

Keyword: The most severe level — sentences broken into fragments.

This is the most severe form within the disorganized speech group.

The grammatical structure collapses; words are not arranged into coherent sentences; the listener cannot “assemble the picture” of what the sentence is trying to convey.

Sometimes the words might vaguely relate to a central theme, but there is no clear subject–verb–object structure.

Raw example:

“Electricity runs fast. I am time. Orange left of the door talks glass voice. Oil heart doesn’t link the telephone pole. Other people know… they all know… cloud blocks jumping sound.”

The listener will feel that:

• The words are “in the same language,” but there is no message that can be decoded.

• No matter how hard we try, we cannot summarize what event is being described or what the main point is.

Key clinical point:

• Word salad is commonly seen in very severe psychosis or in conditions such as delirium and some organic brain syndromes.

• It is used as a sign that the level of thought organization (formal thought) has severely broken down.

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2.4 Neologisms (Newly Made-Up Words)

Keyword: Words that do not exist in the language, delivered with extreme confidence.

The patient creates words that do not exist in standard vocabulary, but they use them in a serious way, as if everyone should understand.

Sometimes these words are formed by combining several words or by modifying the sounds/structure of existing words.

They are often used repeatedly with a consistent meaning — for example, as key terms within the person’s own delusional belief system.

Example:

“Today I’m locked by a seven-layer spirit-drive system. If you don’t unlock the time-key, I can’t leave the house.”

If you follow up and ask “What is a spirit-drive?” they may go on to explain it very seriously.

Indicators:

Neologisms are different from playful puns or jokes in typical people because:

• They are used in serious contexts, without the speaker laughing at their own word.
• The person believes others should know or understand them.
• They are often anchored in the core of their delusional system or inner worldview.

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2.5 Perseveration (Repeating the Same Words/Phrases)

Keyword: Stuck in a loop, repeating the same content even when the situation has changed.

This is a pattern where the speaker seems unable to exit the previous track.

The same word/phrase is repeated in situations where it is no longer appropriate.

It is not repetition for emphasis, but rather a sign that the thought system has “slipped out of control.”

Example:

Question: “What would you like to eat today?”
They might answer:

“I didn’t do anything wrong… I didn’t do anything wrong… I didn’t do anything wrong…”

Even if you try to change the question or change the topic, they remain stuck on the same phrase.

What it tells us:

• It reflects a reduction in cognitive flexibility (the ability to shift between mental sets).

• It sometimes appears together with high anxiety or feelings of guilt in psychosis.

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2.6 Clanging

Keyword: Choosing words for their “sound,” not their “meaning.”

This refers to forming sentences by selecting words that rhyme or have similar sounds, rather than by choosing words based on their meaning within the sentence.

The result is that the sequence of words may sound pleasant or rhythmic, but the content carries no clear meaning.

Example:

“The dog barks, my heart darks, soft spark, bottle mark, aching head, body spread, sure or not, egg or not, leafy knot, don’t know, just show.”

When listening, it feels like a “meaningless poem” that is not trying to convey a specific message.

Important:

• Typical people might intentionally speak in rhymes as a joke, but in clanging associated with psychosis:
• The rhyming happens repeatedly without regard to the actual question.
• Even when reminded to return to the topic, the person continues to drift along sound-based associations.

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2.7 Illogicality

Keyword: The reasoning clearly misses the middle bridge.

This refers to conclusions that blatantly skip the logical bridge between premise and conclusion.

It is not just “thinking differently,” but rather that we see no logical chain at all from premise → conclusion.

Basic example:

“The dog barked last night → So my neighbor is definitely planning to kill me.”

If we look for “evidence/logical bridge,” we find nothing linking dog barking = neighbor wanting to kill.

How it is used in assessment:

• Illogicality is often linked with delusions (because the underlying beliefs are already false).

• In disorganized speech, we see these illogical jumps scattered throughout the conversation.

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2.8 Poverty of Content (Many Words, Very Little Information)

Keyword: Talks a lot, but you don’t actually learn anything.

The person uses many words and many sentences; on the surface, they appear active and talkative. But looking deeper, we find that no new information is conveyed.

From one question, they can talk for minutes, but at the end we feel, “We still don’t have an answer.”

Example:

Question: “How did you get to the hospital?”
Answer:

“Well… there are many ways to come here. Everyone has different lives. Some people drive, some people walk. I think people have their own reasons for everything they do. In the end, we all arrive where we’re meant to arrive. I came in the way that was meant to be…”

At the end, we have no idea:
Did they come in someone’s car? Did they walk? Did an ambulance bring them?

Key sign:

• This shows that formal thought has problems with organizing and prioritizing points.

• It is different from intentional poetic or abstract speech, where we can still grasp the main theme being expressed.

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Taken together, these eight patterns form the “skeleton” that allows us to say:

“This is not just someone who rambles — this is Disorganized Speech in the clinical sense.”

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3. Diagnostic Criteria — How Is It Used in Diagnostic Systems?

This section is very important because it addresses the question:

“When exactly does confused speech qualify as ‘Disorganized Speech’ in the DSM-5-TR sense, rather than just ‘talking unclearly due to stress or confusion’?”

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3.1 In DSM-5-TR: The Role of Disorganized Speech in the Schizophrenia Spectrum

In DSM-5/DSM-5-TR, for disorders in the Schizophrenia Spectrum and Other Psychotic Disorders, such as:

• Schizophrenia
• Schizophreniform Disorder
• Brief Psychotic Disorder

Disorganized Speech (e.g., frequent derailment or incoherence) is placed under Criterion A, which represents the “core symptoms of the disorder.”

Criterion A for Schizophrenia (practical summary):
At least 2 of the following are required, and at least one must be 1, 2, or 3:

• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (e.g., avolition, alogia, anhedonia, blunted affect, etc.)

In plain language:

• If a patient has only disorganized speech + negative symptoms, with no delusions or hallucinations at all,
  → That may still not be sufficient for Schizophrenia; the overall picture needs further evaluation.

• If there is disorganized speech + hallucinations, or disorganized speech + delusions,
  → Then there are already “at least two Criterion A features,” and if other criteria (duration, impairment, exclusion of other causes, etc.) are met, the diagnosis can be made.

What matters:

DSM does not say that disorganized speech must include all subtypes listed above. It emphasizes that significant derailment or incoherence is enough to satisfy the criterion.

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3.2 Severity Threshold — When Does It Count as Official “Disorganized Speech”?

Not every case of mild rambling should be labeled disorganized speech according to DSM. There is a crucial “threshold.”

In general, at least the following three points should be met:

1. Clearly observable “during” the interview/conversation.

• It should not require replaying a recording 10 times to detect.
• The clinician/therapist talking to the patient can clearly perceive sentences that break logic, go off-topic, or are incoherent.

2. It must genuinely impair communication.

• When listening, you “cannot grasp the main point.”
• Important clinical history cannot be obtained because every answer goes off track.
• Shared decision-making about treatment is almost impossible because the structure of speech is too disorganized.

3. It cannot be explained away by simpler causes, such as:

• Language differences (e.g., a foreigner speaking a second language they are not fluent in).
• Educational level (someone may use simple vocabulary but still communicate in a linear fashion).
• Acute intoxication with alcohol, extreme sleep deprivation, just waking from anesthesia, or delirium (which would fall under other categories like delirium or substance intoxication).

In summary, it must be a symptom that remains abnormal even after basic environmental adjustments (e.g., allowing rest, asking them to speak more slowly, etc.), and does not rapidly improve simply with sleep or sobering up.

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3.3 Differentiating from “Everyday Confused Speech” or Personality Style

This is very important for content, because lay readers will often think, “Oh, I ramble all the time — am I sick?” We need to help them differentiate.

Typical people who speak confusingly because of:

• Stress
• Excitement
• Sleepiness
• Excessive multitasking
• A personality style of speaking/thinking quickly

Usually share the following characteristics:

• The sentence structure is still linear:
• If asked to retell their story slowly, they can narrate a coherent sequence.

• They are aware that they ramble:
• Some people will laugh at themselves: “Oops, I’ve gone off-topic again,” and then pull themselves back.

• It does not wreck their life:
• Coworkers can still understand their tasks.
• Conversations with doctors/supervisors still function; communication remains effective.

In Disorganized Speech of psychosis:

• The underlying structure of thinking is flawed from the beginning. Even if they retell the story, it still comes out disorganized.

• Patients often are not very aware that their speech is disorganized.

• As a result:
• Clinical history-taking becomes very difficult.
• They do not fully understand treatment explanations.
• Work and daily functioning are severely affected.

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3.4 Differentiating from Other Conditions That Cause “Odd Speech”

Beyond “typical people who ramble,” we must distinguish disorganized speech from other conditions, such as:

Language Disorder / Aphasia (e.g., post-stroke)

• Some individuals mix up words, forget words, or substitute incorrect words, which can sound confusing.
• But the pattern is not derailment or word salad typical of psychosis.
• There is usually clear evidence of an acute or structural brain disease.

Mania + Flight of Ideas

• People in a manic episode speak very fast and jump rapidly between ideas, which can resemble derailment.
• However, if you listen closely, you can still see that their train of thought has a coherent theme, and the logic is still traceable, just very rapid.
• Disorganized speech in psychosis tends to break logic more severely than this.

Delirium / Acute Confusional State

• The entire system of consciousness and attention is impaired.
• There may be incoherent speech, but it is not a stable, long-standing formal thought disorder.
• It is linked with acute medical conditions, medications, toxins, etc.

Neurocognitive Disorders (e.g., dementia)

• Language use deteriorates due to cognitive decline.
• Other problems are usually seen too, such as short-term memory loss, impaired planning, and social difficulties.
• Psychotic thought disorder, when present, is more clearly associated with loss of reality testing plus delusions/hallucinations.

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3.5 Clinical Assessment in Practice

When a clinician writes that a patient “has disorganized speech,” they do not base this on a single sentence. They look at the overall pattern:

• Open a general conversation.
• Let the patient talk about their daily life, giving them the opportunity to use language naturally.

• Ask both open and closed questions.
• For example, “Tell me what brought you to the hospital this time.”
• Or “What do you think is happening to you right now?”

• Observe:
• How the person changes topics.
• How they connect reasons and conclusions.
• The pattern of answers to clear, direct questions.

• Ask again / Summarize back.
• Rephrase the question, then summarize their answer back to them and see whether they agree/disagree and how they respond.

• Rate (if a scale is available).
• Some teams use rating scales — e.g., positive symptom scales or formal thought disorder scales — to quantify severity.

For a web article, you can explain this in a semi-practical way, such as:

“Disorganized speech is not diagnosed by listening to a single sentence. Clinicians look at the pattern across the whole conversation — the longer you talk, the more clearly the structure of thinking appears, whether the ideas are logically connected or flying off into another universe.”

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3.6 Dimensional Severity — Not Just Present/Absent, but a Spectrum of “How Severe”

DSM-5-TR suggests viewing psychotic symptoms, including disorganized speech, in a dimensional way, using a 0–4 severity scale, for example:

• 0 = None
• 1 = Mild — occasional slips, slightly off-topic, but communication still effective.
• 2 = Moderate — sometimes hard to follow, requires repeated questions and help with focusing.
• 3 = Severe — most of the time, conversation is difficult to follow; requires significant effort to pull back.
• 4 = Very severe — essentially no meaningful verbal content; mostly noise/fragmented words.

Viewing it this way helps in two main areas:

• Treatment planning:
• If severity is high → more intensive interventions may be needed, such as medication adjustment and closer monitoring.

• Outcome tracking:
• If, after medication/therapy, scores drop from 3 → 1, this indicates real improvement in communication.

For the general audience, you can phrase it as:

“Clinicians don’t just look at whether ‘confused speech’ is present or not — they also look at how intense it is, from a little rambling here and there to the point where you can’t understand what’s being said at all.”

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Simple summary for web use:

• Core Symptoms = a list of abnormal speech patterns — derailment, tangentiality, word salad, neologisms, perseveration, clanging, illogicality, poverty of content — which together form a “thought structure that has slipped off its rails.”

• Diagnostic Criteria = the boundaries for when these behaviors are “frequent and severe enough” to be counted as a psychotic symptom in DSM-5-TR, rather than just temporary confusion or a personality style.

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4. Subtypes or Specifiers — Sub-Forms of Disorganized Thinking/Speech

In theory, we group these different patterns under the umbrella of Formal Thought Disorder (FTD), which is = a cluster of symptoms that manifest through disorganized speech. Wikipedia+1

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4.1 Positive vs Negative Thought Disorder

Some studies divide FTD into two major groups. PMC+1

Positive FTD (disorganization type)

• Derailment
• Tangentiality
• Word salad
• Clanging
• Neologisms

→ These are “add-on” phenomena — something “extra” is present, causing speech to explode into scattered fragments.

Negative FTD (impoverishment type)

• Poverty of speech
• Increased response latency
• Blocked thought
• Concrete thinking

→ These reflect “loss” — functions that should be present are missing; speech is reduced, content is sparse, and the mind cannot generate language easily.

In DSM terms, Disorganized Speech usually emphasizes the positive FTD side (fragmented/disorganized output) more than the negative aspects.

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4.2 By Dimensional Severity

DSM-5-TR recommends rating the severity of psychotic symptoms on a dimensional scale (0–4), including disorganized speech, to track symptom levels and treatment response. Rama Mahidol University+1

Approximate example:

• 0 = None
• 1 = Mild (occasional slips but communication still effective)
• 2 = Moderate (sometimes the conversation becomes incomprehensible; questions must be repeated)
• 3 = Severe (most of the time, speech is hard to follow; attention to topic is not maintained)
• 4 = Very severe (essentially no meaningful communication; almost everything is incomprehensible)

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4.3 By Comorbid Disorders

Even though disorganized speech is often a “signature” of Schizophrenia, it is also quite common in other disorders. Wikipedia+1

• Schizophrenia: found in about 27–80%, depending on the study
• Schizoaffective Disorder: up to ~60%
• Major Depressive Disorder with psychotic features: ~50%+ in some subgroups
• Bipolar Disorder (mania with psychosis)
• Neurocognitive disorders (e.g., dementia)
• Substance-induced psychosis

Some studies suggest that patients with prominent FTD form a subgroup with a more severe course and worse functional outcomes on average. SpringerLink+1

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5. Brain & Neurobiology — The Brain Mechanisms Behind Disorganized Speech

This section answers the question:

“Why does a disturbed brain → produce speech that is so structurally disorganized?”

Neuroscientists do not view disorganized speech as merely an issue of “personality” or “being disorganized by habit,” but as a symptom arising from genuinely abnormal brain networks, especially circuits involved in language, semantic integration, and executive function.

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5.1 Abnormal Language Network — Language in the Brain Falls Out of Sync

Neuroimaging studies (MRI, fMRI, DTI, etc.) examining formal thought disorder (FTD) in Schizophrenia consistently show that individuals with prominent disorganized speech/FTD often have abnormalities in the brain’s language network, particularly in the left hemisphere, including: PubMed+2 ScienceDirect+2

• Inferior Frontal Gyrus (IFG; Broca’s area)
• Involved in sentence planning, word sequencing, and control of language output.

• If its structure (gray matter) or function (activation, connectivity) is abnormal →

• Sentence construction easily “falls off-structure.”
• Narrative continuity is difficult to maintain.
• Topics jump from one point to another with little bridging.

• Superior Temporal Gyrus (STG; Wernicke’s area)
• Involved in language reception and comprehension of sounds/words.

• If dysfunctional →

• The person’s ability to grasp the main point of their own and others’ speech is distorted.
• Some words trigger “strange meanings” that spin off into new chains of thought.

• Inferior Parietal Lobule (IPL)
• A hub that integrates language + attention + working memory.

• If impaired →

• Difficulty focusing on the main topic.
• Trouble holding ongoing context in working memory.
• Frequent drifting away from the current topic.

Systematic reviews show that individuals with severe FTD have reduced gray matter and abnormal functional connectivity in IFG, STG, and IPL, especially on the left, compared with patients without prominent FTD and with healthy controls. PubMed+2 ScienceDirect+2

In simple terms:

“Language = a network system, not a single spot. If the fronto–temporal–parietal network falls out of sync, thinking and speech break into pieces.”

Additionally, newer studies indicate that fronto–temporal connectivity — the connections between frontal and temporal lobes — is abnormal, especially in tracts like the arcuate fasciculus linking Broca’s and Wernicke’s areas. If this pathway does not transmit well, the integration of “what is thought” and “what is spoken” can become misaligned and intermittent. www.elsevier.com+1

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5.2 Semantic Network & Working Memory — Semantic System Glitches + Short Attention at Brain Level

Another key concept is semantic network impairment — the brain stores and links “word/idea meanings” abnormally.

In typical individuals, when someone says a word, our brain “primes” related words/ideas in a structured way. For example:

• Saying “dog” → activates related concepts: pet, barking, walking, park, etc.
• These connections help us speak in a flow that listeners can understand.

But in people with formal thought disorder, semantic priming studies have found that: PMC+2 Cambridge University Press & Assessment+2

• Activation in the semantic network is too broad or has an abnormal pattern.
• Words retrieved may be “very loosely related” or not related to the topic at all.
• This leads to loose associations or derailment during speech.

Imagine the semantic network as a city map:

• Typical person: Starting from point A → goes to point B that is “not too far” and uses main roads.
• Person with FTD: Starts at A → shows up at Z by cutting through alleyways no one else would think to take.

Another major factor is working memory and executive control.

FTD tends to be associated with abnormalities in: ScienceDirect+1

• Working memory
• Attention
• Verbal fluency
• Overall cognitive control

When speaking, the patient must:

• Remember what question they are answering.
• Keep the context of what they’ve already said active in their mind.
• Filter out irrelevant thoughts.

If working memory/attention is weak →

• The “mental items” that should be held in mind are dropped.
• The brain grabs other ideas instead (often unrelated).
• The conversation jumps across topics, which we observe as derailment.

In summary:

Disorganized speech is not just “random thinking,” but a result of overly broad semantic activation + leaky working memory + weak executive control, combining to produce a scattered output.

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5.3 Dopamine, Glutamate, and Others — Neurochemistry Driving the Distortion

When discussing psychosis, two major axes always appear:

• Dopamine hypothesis
• Glutamate/NMDA hypothesis

The current working model is that dopamine = downstream expression, while glutamate/GABA, etc. = upstream drivers. Psychiatrist.com+3 PMC+3 PubMed+3

Dopamine

Imaging studies show that individuals with schizophrenia often have: ScienceDirect+1

• Elevated presynaptic dopamine in the dorsal striatum / nigrostriatal pathway, rather than only in the mesolimbic pathway as older models suggested.

When dopamine “sensitivity” is too high, the brain:

• Assigns “aberrant salience” — excessive importance — to certain stimuli or thoughts.
• For example, it might latch onto neutral words/sounds as if they carry “special meaning.”

If this salience system misfires, then the connections between words/ideas become “twisted” away from normal patterns into unusual associations, supporting both delusions and disorganized thinking.

Glutamate & NMDA

The Glutamate/NMDA hypofunction hypothesis proposes that:

• The glutamate system, particularly NMDA receptors, is underactive.
• NMDA antagonists like ketamine and PCP can induce in healthy people a syndrome resembling psychosis (hallucinations + disorganization + cognitive deficits). ScienceDirect+2 MDPI+2

Abnormal glutamate/NMDA function explains well:

• Why there is cognitive impairment (attention, working memory, language processing).
• Why networks, especially fronto–temporal circuits, are “disconnected.”

GABA and Excitation–Inhibition (E/I) Balance

Newer evidence points to an E/I imbalance between glutamate (excitatory) and GABA (inhibitory) in the cortex, leading to unstable information processing circuits.

If circuits involved in language/semantic processing are noisy →

• Word/meaning selection becomes distorted.
• The system struggles to distinguish “key thoughts” from “background noise.” ScienceDirect+1

In summary:

• Dopamine = causes certain thoughts/words to become “overly important.”
• Glutamate/GABA = causes networks that should smoothly arrange sentences/meanings to become shaky and fragmented.

When both are impaired together, the result is disorganized patterns of thought and language, at the levels of both meaning and sentence structure.

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5.4 Neurodevelopmental Aspect — Atypical Brain Development from Childhood

Another major conceptual framework in the field is the neurodevelopmental model of the Schizophrenia Spectrum:

• It is not a disease that suddenly appears at age 20–25.

• It is the cumulative result of:
• Genes
• Prenatal and perinatal factors
• Brain development in childhood and adolescence
• Stress and environment in later life

All of these combine into a “bent developmental trajectory” that eventually manifests as full-blown illness in late adolescence or early adulthood. ScienceDirect+2 ScienceDirect+2

For disorganized speech/FTD, the focus is:

• Language circuits (fronto–temporal–parietal) and executive networks do not develop optimally.

• Adolescent synaptic pruning — the trimming of synapses — may:
• Occur excessively, insufficiently, or with a distorted pattern in language-related regions.

As a result:

• The connectivity of the language system becomes less precise.
• The coordination of semantic processes, working memory, and top-down control is disrupted.

Some studies suggest that schizophrenia is a prototype disease of “linguistic disorganisation” — showing that when molecular neurodevelopment goes wrong → language networks become abnormal → the language we hear in clinic takes the form of FTD/disorganized speech. ScienceDirect+1

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6. Causes & Risk Factors — What Leads to Disorganized Speech?

Keep this clear:

Disorganized speech = a symptom of psychosis, not a stand-alone disorder.

Therefore, its risk factors overlap with those of the Schizophrenia Spectrum & Other Psychotic Disorders as a whole. In some individuals, however, the particular “profile of brain abnormalities” causes the language/FTD component to stand out more.

An easy way to view this is as four major layers:

• Biological / Genetic
• Neurodevelopment & Early Life
• Psychological & Cognitive
• Substance & Medical

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6.1 Biological / Genetic — Genetic Background + Vulnerable Brain Structure

Genetics

Schizophrenia/psychosis has a heritability of about ~70–80% based on meta-analyses and twin studies. Wikipedia+1

If there is a first-degree relative with a psychotic disorder → risk increases clearly:

• One parent affected → child’s risk ~10–13%
• Both parents affected → risk ~50%

There is no single “FTD gene”; instead, it is polygenic — many genes each exert small effects and combine.

Overall, the involved genes tend to involve:

• Synaptic plasticity
• Glutamatergic transmission
• Neurodevelopment

This increases the likelihood that language–executive networks will develop atypically.

Brain Structure and Neurochemistry

Individuals with severe FTD often show:

• Reduced gray matter in IFG, STG, IPL
• Functional dysconnectivity in the language network on MRI/fMRI PubMed+2 ScienceDirect+2

Dopamine and glutamate/GABA systems are abnormally regulated at baseline, making it:

• Easier to develop psychosis
• Easier for thought structure to fall apart under stress or psychoactive substances

In short:

Some people are born with a “language-and-thought-control hardware” that is more fragile than average, which increases the risk of disorganized speech when other triggers are present.

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6.2 Neurodevelopment & Early Life Factors — From Before Birth to Early Childhood

This group includes factors that affect nervous system development from the prenatal period through childhood, now considered a key “risk window” for Schizophrenia/psychosis. NeuRA+2 Psychiatry Online+2

Examples include:

• Pregnancy/birth complications:
• Hypoxia
• Premature birth
• Low birth weight
• Maternal infections during pregnancy

• Severe maternal malnutrition (e.g., famine)

• Inflammation/infections affecting the CNS during childhood

These can lead to:

• Suboptimal wiring of neural circuits involved in language/thought/attention

• Inadequate formation or abnormal pruning of synapses

Later in life → executive, language, and semantic processing become vulnerable → disorganization is more easily triggered by stress or hormonal changes in adolescence.

Key points:

• These factors increase risk, but do not mean that everyone exposed will develop psychosis.

• They act like “piles of firewood,” waiting for genes + stress + substances to ignite them.

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6.3 Psychological & Cognitive Factors — Thinking Style and Vulnerability to Disorganized Speech

Executive Function & Cognition

Many studies show that FTD/disorganized speech is linked with:

• Cognitive impairment
• Executive dysfunction (planning, shifting, inhibition)
• Deficits in attention/working memory ScienceDirect+1

Individuals with low baseline EF before full-blown illness (e.g., during the prodromal phase) often show:

• Difficulty organizing words and ideas
• Narratives that easily drift off-topic
• Loosely connected reasoning

Thinking Style + Stress

People whose cognitive style is:

• Highly associative (connecting everything to everything)
• Rigidly attached to certain thoughts

When they experience high stress, the prefrontal cortex — responsible for thought control — functions less effectively (cortisol and stress chemistry suppress PFC activity) → disorganization becomes more pronounced.

Traumatic experiences, bullying, and childhood abuse are associated with increased risk of psychosis and FTD via both biological pathways (stress system, HPA axis, dopamine) and psychological pathways (distorted schemas and beliefs). psicosis.som360.org+2 jneuropsychiatry.org+2

In summary:

Someone with “fragile EF + a semantic network that easily strays off-course + high stress” is more likely to exhibit disorganized speech than someone with robust EF, even if other risk factors are similar.

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6.4 Substance & Medical Causes — Substances and Medical Illness Can Also Produce Disorganized Speech

This is critical for diagnosis, because not every case of disorganized speech = schizophrenia.

1) Psychoactive Substances

Substances with evidence for causing psychosis and disorganization include: PMC+2 nhs.uk+2

• Cannabis (especially high-THC potency)
• Increases overall psychosis risk.
• The more frequent the use and the earlier the age (especially adolescence), the higher the risk in a dose–response fashion.
• In genetically vulnerable individuals, THC effects are more severe.

• Amphetamines / Methamphetamine / Cocaine
• Strongly stimulate dopamine → can induce hallucinations, delusions, and disorganized speech.
• In individuals with pre-existing psychosis, they raise the risk of relapse.

• Hallucinogens (LSD, ketamine, PCP, etc.)
• Directly affect the glutamate/NMDA system → can produce hallucinations and disorganization resembling schizophrenia.

If substances are the primary trigger and symptoms are closely tied to substance use, the diagnosis falls under Substance-/Medication-Induced Psychotic Disorder.

2) Medical / Neurological Conditions

Many brain/body conditions can produce disorganized speech/psychosis, such as:

• Delirium from severe infection, metabolic disturbances, withdrawal, etc.
• Certain epilepsies, especially temporal lobe epilepsy
• Brain tumors/lesions in frontal, temporal, or parietal regions
• Neurodegenerative disorders such as dementias (Alzheimer’s, Lewy body, etc.)

In these cases, disordered/fragmented speech may be part of a larger picture that includes altered consciousness, memory breakdown, and disorientation in time/place.

DSM-5-TR provides categories such as:

• Psychotic Disorder Due to Another Medical Condition
• Or a primary diagnosis of delirium/dementia with psychotic features specified.

This is important because:

• Treatment strategies differ — if the root cause is a brain tumor, delirium, or metabolic issue, these must be addressed first, rather than simply increasing antipsychotics.

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6.5 Gene–Environment Interplay — The Overall Picture

The current broad consensus is:

• There is no single cause that makes one person develop disorganized speech from psychosis.
• It is the cumulative result of genes + brain development + environment + substances/medical illness interacting.

Simple illustrative patterns:

Person A

• Has a family history of schizophrenia
• Has a history of mild obstetric complications
• Grew up in a highly stressful environment with trauma
• Regularly uses high-potency cannabis during adolescence

→ Eventually, in their 20s+, they develop psychosis + disorganized speech.

Person B

• No family history
• No clear trauma
• No substance use
• But has a brain tumor in the temporal lobe

→ Suddenly begins speaking disorganizedly, experiencing hallucinations, and having delusions → tumor is detected.

Both have the “same outward symptoms” — disorganized speech + psychosis — but the causal pathways differ, so diagnosis and treatment must also differ.

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7. Treatment & Management — How Do We Address Disorganized Speech?

7.1 Treating Psychosis as a Whole

Because disorganized speech usually appears alongside other psychotic symptoms, treatment is generally integrated into the overall treatment plan for the primary disorder.

1) Antipsychotic Medications Empendium

• First-line treatment usually involves second-generation antipsychotics (SGAs).

• The goals are to reduce:
• Delusions
• Hallucinations
• The level of disorganized thinking/speech

In many patients, disorganization improves markedly when overall psychosis is brought under control.

2) Treat Underlying Medical/Substance Causes

If disorganized speech is due to delirium, drug intoxication, or a neurocognitive disorder:

• The primary causes must be treated (e.g., stopping substances, treating infections, correcting metabolic disturbances, etc.).

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7.2 Psychosocial Interventions

1) CBT for Psychosis (CBTp)

Helps patients:

• Become aware of their disorganized thought patterns.

• Learn to “catch early warning signs” when they begin to lose focus.

• Practice organizing thoughts before speaking, such as:
• Taking slow, deliberate breaths.
• Summarizing the main point in their mind in one sentence first.
• Writing down keywords before explaining longer stories.

2) Cognitive Remediation / Cognitive Training

Focuses on training:

• Attention
• Working memory
• Cognitive flexibility

Goal: Strengthen executive control so that thought structure becomes more organized.

Some research suggests that cognitive remediation can reduce the severity of formal thought disorder to some degree. Nature+1

3) Speech-Language / Communication-Focused Therapy

Not available everywhere, but where it exists, language/communication therapists can help patients:

• Practice speaking in “short sentences with one main point per sentence.”
• Practice topic-checking with the listener (e.g., checking if they are still on topic).
• Role-play specific situations, such as talking to a doctor or a supervisor.

4) Psychoeducation for Families

Helps families understand that:

• Disorganized speech is not just “someone talking nonsense because they are lazy to think,”
• But a symptom of a brain that is misorganizing words and thoughts.

Teaches communication skills such as:

• Using short sentences and clear words.
• Asking one question at a time (not multiple questions in a single sentence).
• Giving the person time to think and respond.
• Summarizing back what they heard (rephrasing) to check mutual understanding.

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7.3 Monitoring and Follow-Up

Use formal thought disorder rating scales or psychosis severity scales (as recommended in DSM-5-TR) to:

• Assess baseline symptom severity before treatment.
• Track medication/therapy outcomes over time.

If disorganized speech worsens:

• Check medication adherence.
• Check for life stressors.
• Assess for possible relapse or substance intoxication.

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8. Notes — Key Points for Content Creation and Communication

• Disorganized speech ≈ formal thought disorder (FTD) ≈ disorganized thinking (speech).
• DSM uses the term “disorganized thinking” but asks clinicians to evaluate it via speech.
• Research literature often uses “FTD.” Wikipedia+1

• Not everyone who sometimes speaks confusingly has psychosis.
• We must consider severity, impact on communication, and other symptoms (delusions, hallucinations, negative symptoms, etc.).

• In Schizophrenia:
• FTD/disorganized speech often correlates with a more severe course and poorer functional outcomes on average. SpringerLink+1
• It may mark a subtype with more pronounced cognitive impairment and language network pathology.

• For illustration/art purposes (for your projects):

• Common visual metaphors for disorganized speech/FTD include:

• Lines of text branching into multiple directions with no endpoint.
• Overlapping speech bubbles, some cut off, some disconnected.
• Letters/sounds swirling around a character’s head like a word salad.

• Safety in public communication:

• When creating content for the general audience, emphasize that:

• Diagnosis must be made by professionals.
• People who feel their speech is disorganized along with delusions/hallucinations should see a psychiatrist.
• Avoid stigmatizing phrases such as “talking nonsense = crazy”; instead, highlight that these are symptoms of a brain condition.

Read Schizophrenia

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References

Collected sources commonly used in medical work and in research on formal thought disorder and the neurobiology of psychosis.

A. Standard Texts / Clinical Manuals

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). 2022.
• World Health Organization. ICD-11: Mental, Behavioural or Neurodevelopmental Disorders.

B. Clinical Summary Resources

• Florida Behavioral Health Collaborative. DSM-5 Criteria: Schizophrenia Spectrum and Other Psychotic Disorders.
• NCBI Bookshelf. Comparison of DSM-IV and DSM-5 Criteria for Psychotic Disorders.

C. Research on Formal Thought Disorder / Disorganized Speech

• Kircher T, et al. Formal thought disorders: from phenomenology to neurobiology. Lancet Psychiatry. 2018.
• Çokal D, et al. The language profile of formal thought disorder in schizophrenia. NPJ Schizophrenia. 2018.
• Nagels A, et al. Neural correlates of formal thought disorder: fronto-temporal dysfunction in schizophrenia. NeuroImage.
• Palaniyappan L. Dissecting the neurobiology of linguistic disorganization in schizophrenia. 2022.
• Oeztuerk OF, et al. The clinical relevance of formal thought disorder in schizophrenia. 2022.
• Docherty NM. Cognitive impairment and disordered speech in schizophrenia.

D. Research on Semantic Networks / Cognitive Mechanisms

• Kuperberg GR. Language in schizophrenia: what’s going wrong? Brain Research.
• Minor KS, et al. Semantic memory structure and thought disorder.
• Spitzer M. Semantic priming abnormalities in schizophrenia.

E. Brain Imaging Studies

• Liemburg E, et al. Structural brain correlates of formal thought disorder in schizophrenia.
• Coherman M, et al. Fronto-temporal dysconnectivity and linguistic disorganization.

F. Neurotransmitter Models

• Howes O, Kapur S. The dopamine hypothesis of schizophrenia — version III.
• Moghaddam B, Javitt D. Glutamate and schizophrenia: NMDA receptor hypofunction hypothesis.
• Lisman J. Excitation–Inhibition imbalance in schizophrenia.

G. Neurodevelopmental Risk

• Murray RM, et al. Neurodevelopmental model of schizophrenia.
• van Os J, et al. Gene–environment interplay in psychosis.

H. Substances & Psychosis

• D’Souza DC. Cannabis and psychosis: neurobiology and risk.
• Curran HV. High-potency cannabis and psychosis onset.
• Snyder SH. Psychotomimetic effects of NMDA antagonists (PCP, ketamine).

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Disorganized Speech · Formal Thought Disorder · Disorganized Thinking · Loose Associations · Tangentiality · Word Salad · Neologisms · Perseveration · Clanging · Psychosis Symptoms · Schizophrenia Spectrum · Neurobiology of Thought Disorder · Language Network Dysfunction · Semantic Network Impairment · Executive Function Deficits · Dopamine Hypothesis · Glutamate NMDA Hypofunction · Frontotemporal Connectivity · Psychotic Disorders DSM-5-TR