Racing Thoughts?

From the DSM-5 under criteria B.4. for a manic episode: "Flight of ideas or subjective experience that thoughts are racing." (p.124). In a previous post I discussed how easy it was to make a reliable diagnosis of bipolar disorder because the patient needs to describe a clear cut episode of mania. The main problem becomes determining whether they are actually describing a manic episode or not. There are a significant number of confounding factors in that determination. The best way to illustrate what I am talking about is to focus on how the term racing thoughts is used in psychiatric evaluations by patients rather than psychiatrists. DSM technology gives surprisingly little guidance on what a racing thought is. In clinical practice that is very problematic, especially if psychiatrists are depending on the observations of untrained observers. People who appear to be hyperactive or agitated and hypertalkative are frequently described as having racing thoughts. In many cases when asked directly they will reply: "My thoughts are always fast." or "This is normal for me." or "What do you mean by racing thoughts?  I don't know what that means."  At the observer level, many observers have reported to me: "The patient states he is having racing thoughts" as though that is diagnostic.  It may be - but it also might not be.

One of the commonest scenarios for racing thoughts doesn't involve mania at all.  It involves anxiety and insomnia.  Initial insomnia is a case in point as in: "I try to fall asleep but as soon as my head hits the pillow my thoughts are racing and I am thinking about a million things. After a while I look at the clock and it is 2AM." In the sleep literature the experience of racing thoughts here is associated with the phenomenon of hyperarousal and it is the commonest form of initial insomnia.  In other words, when I go to bed to sleep at night - I have really trained myself to think about all of my problems for several hours before I fall asleep.  It is not about sleep at all. Subjectively a person may thinking about every hypothetical in order to prevent mistakes - a common cognitive error of the anxious.  Many people experience this high arousal and excessive worry state as racing thoughts, but the main difference is probably in the time domain. The insomniac experiences a compression of time.  The worry is continuous and at least initially there is some surprise that hours have passed and there is no onset of sleep.  When the insomniac wakes up in the morning the racing thoughts are probably not there. With an episode of mania the racing thoughts are usually phasic change until the manic episode resolves or a different cognitive process occurs like increasing incoherence and distractability.

One of the best modern sources of information on psychiatric phenomenology remains Andrew Sims' Symptoms in the Mind. His discussion of racing thoughts is more comprehensive than most and far superior to anything that you will find in the DSM.  I am sure that the DSM authors will point out that this is why psychiatric training is necessary to use the book and that the book is not a substitute for training in phenomenology. Without that training racing thoughts on the part of the patient or the observer is often anyone's best guess. The best example I can think of was a patient who was being presented to me as "histrionic and overly dramatic" who was in fact manic. It is difficult if not impossible to sustain a dramatic presentation of mania, racing thoughts and pressured speech for any length of time.

The Sims discussion of racing thoughts occurs in his chapter: Disorder of the Thinking Process. In it he uses what he refers to as Jaspers model of thought association.  As illustrated in the tables, people tend to proceed from one constellation of thought to another unless they have specific disorders of thinking.  Sims diagrams out the thought disorders using a very nice graphic to illustrate these clusters and how a person moves from one cluster to another.  I have included a couple of examples in the tables here and how the thoughts proceed as indicated by the red arrow.  As I thought about it there are some differences with anxiety and mania.  The anxious person will be operating form clusters of questions and doubt.  That leads to more and more branch points or worry.  The manic person on the other hand especially if they have grandiose and expansive mania is not operating from excessive worry or doubt but declarative statements consistent with their confidence level.  As I thought about both people trying to sleep, the anxious person would be laying in bed the entire time, probably with their eyes closed going through these constellations of thought.  One of the commonest sleep complaints they describe is: "I can't shut my mind off - it is racing."  

The manic person for the same time frame would undoubtedly be up and engaged in some activity late into the night - if not for the entire night while experiencing a rapid progression of thoughts.  They will often describe their thoughts as going too fast to describe and certainly too fast to speak, even though many can speak at a very fast rate.  A secondary phenomenon that I typically ask about is excessive thoughts with no progression or what Sims calls "crowding of thought."  His specific description is that thoughts are being passively concentrated and compressed in the head: "the associations are experienced as being excessive in amount, too fast, inexplicable and outside of the person's control."  Sims sees this as occurring in schizophrenia, but I have definitely asked that question to manic patients and had them agree that was happening to them.  Jaspers also describes flight of ideas as a massive flow of content without an increase in the speed of thinking. 

The interesting aspect of focusing in only on the conscious experience of racing thoughts is that there is not necessarily an associated pressured speech.  Andreasen defined 18 different thought disorders in her early work and one of them was pressured speech.  She defined pressured speech as a rate of at least 150 words per minute. (3).

From a clinical standpoint a number of syndromes present with self descriptions of racing thoughts including anxious and agitated depressions, some forms of attention deficit~hyperactivity disorder, various intoxication states.  Racing thoughts is often the first phenomenon described by people who are under a lot acute stress and in some cases physical illness.  Many people become delirious for one reason or another and describe what amounts to a state very similar to pre-sleep reverie as racing thoughts.  The recent literature on racing thoughts supports the observations in this post and suggests that thought overactivation that includes both racing thoughts and overcrowding is a common phenomenon in mood disorders including unipolar states.  It also highlights an inherent limitation of the DSM - despite an abundance of descriptors it is inherently weak on phenomenology and this needs a lot of work with trainees who may be too focused on the DSM as a system for indexing rather than a comprehensive diagnostic system.  The criteria of racing thoughts certainly seems to lack specificity at several levels and clinicians encounter a broad spectrum of people who describe racing thoughts and do not have mania.  

Rather than a central feature of the diagnostic process, I would speculate that most experienced clinicians find that racing thoughts are an elaboration down the mental checklist after they have a detailed history of mood, activity level, and sleep changes.  At that level most of these clinicians are matching patterns of hundreds or thousands of people treated rather than specific written criteria.


George Dawson, MD, DFAPA



References:

1:  Andrew Sims. Symptoms in the Mind. Third Edition.   Elsevier Limited, Philadelphia, USA, 2003: p. 149-155.

2:  Karl Jaspers. General Psychopathology. Volume I.  John Hopkins University Press.  Baltimore, Maryland, 1997. p. 210-213.

3:  Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Arch Gen Psychiatry. 1979 Nov;36(12):1315-21. PubMed PMID: 496551.

Indexing Versus Diagnosis - A Non-trivial Difference?

There was an interesting article written by Kenneth S. Kendler, MD in this month's American Journal of Psychiatry.  It addresses a phrase that I have seen in typed evaluations that causes me to cringe: "The patient does/does not meet criteria for major depression."  I was asked why that phrase bothered me so much and I basically pointed out that I don't care whether a person "meets criteria" for a specific DSM criteria - the overall assessment was more important to me.  Kendler describes the difference in terms of phenomenology - are there other aspects of depression that merit further description than what is in the DSM?  That seems true to me as well as, the time domain of symptoms development and how some of the critical symptoms may have developed.  On a developmental basis - sleep, anxiety, and depression all may have different time frame and given the length of time that the DSM approach has been around - there has been very little discussion of some of the key convergences and divergences.  Is primary insomnia beginning in middle school associated with depression in the twenties - the same problem as no insomnia in childhood and depression in the twenties.

To study the issue Kendler looks at 19 textbooks and 18 symptoms domains described in each of those textbooks.  He has specific criteria for textbook selection that resulted in 19 texts from 5 countries published between 1899 to 1956.  He included full criteria published by Wendell Muncie in 1939 and Aubrey Lewis in 1934 as being particularly instructive.  He looks at the number of authors describing a particular symptoms and additional descriptors of the symptoms they found in depressive states.  Just looking at neurovegetative states, the results are interesting.  The atypical depressive symptoms of hypersomnia and increased appetite and weight gain were essentially absent. Fourteen authors described sleep problems as initial insomnia or non restorative sleep.  Three authors described early morning awakening.  Poor appetite was listed by 10 authors and weight loss by 9 authors.  Anhedonia was listed by seven authors.  Kendler provides a detailed analysis of the remaining symptoms and how many of the authors consider these symptoms to be representative of depression.

One of the most instructive aspects of the paper was a direct comparison with DSM5 criteria across 18 symptoms, whether they are covered in the DSM and to what extent.  The symptoms not covered included volition/motivation, speech, other physical symptoms, anxiety, and depersonalization/derealization.  Experienced clinicians commonly encounter depressed people with all of these symptoms in everyday practice.  As an example, some of the most severely depressed people that I have treated were somatically focused to one degree or another on a continuum to the point of somatic delusions.  Adhering to DSM5 criteria would leave out the most important feature of their illness.  A more complete description of these symptoms allows for a better demarcation of the line between depression and psychotic depression - a critical line for developing a treatment plan.  Another critical aspect is the relationship between anxiety and depression.  The DSM tends to sacrifice a broader phenomenological approach for narrow, easily determined diagnostic markers.  Instead of describing the anxiety associated with depression, depressed patients often end up with additional diagnoses of anxiety disorders and in the DSM field trials it appears that anxiety and depression morph into on another and the criteria appear to have low diagnostic reliability in that context.

The broader concept from Kendler's philosophical perspective is whether meeting criteria is that same thing as having the disorder.  From a phenomenological perspective it is certainly possible to produce detailed analysis of patients that do not resemble one another in many regards.  Considering the fact that depression is always mapped onto unique conscious states that should not be too surprising.  Kendler's idea is that the DSM5 criteria do a "reasonable but incomplete job of assessing the prominent symptoms and signs of depression in the western post Kraepelinian tradition  ".  The idea of indexing cases of depression from what is not depression is relevant here.  I think that he should have been a little more specific in his criticism.  I don't think they do a reasonable job when they are not part of a psychiatric assessment by a psychiatrist who has enough time to do a good job.  Taking the DSM5 criteria and converting them into a checklist and applying that to the masses comes to mind.  This is probably the most absurd conclusion to the indexing concept, surpassed only by telling those who are screened that "you meet criteria for depression and that meets our health plan criteria to start citalopram".

 Kendler points out the consequences of reifying diagnostic criteria to the point that they become distinct disorders in the absence of any quantitative markers.  Andreassen made similar arguments about DSM technology and the death of an interest in psychopathology in a previous paper (2).  Both authors seem to miss the mark in terms of what is really missed here.  The diagnostic nosology has shifted from a relative simple mind based paradigm to one that purports to pick up extreme conditions at the fringe of human behavior.  The accuracy of those diagnoses is less as the described disorders get more common.  Human consciousness appears to be the critical variable here and there remain very few commentators on this issue.  Psychiatric disorders become very complex once the psychiatrist goes far beyond symptom lists and even personality disorders and what is commonly considered personality traits to recognizing that the person in front of you is a truly unique conscious state associated with a unique neurobiological state.

              

George Dawson, MD DFAPA



References:

1: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PubMed PMID: 27138588.

2: Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull. 2007 Jan;33(1):108-12. Epub 2006 Dec 7. PubMed PMID: 17158191; PubMed Central PMCID: PMC2632284. (full text)


Attribution:

Quote at top is from reference 1 by Dr. Kendler.