Thought & Speech › Thought Alienation

Thought Insertion

In thought insertion, the person is certain that thoughts are being placed into their mind by an outside force, and they recognise these thoughts as foreign, not originating from themselves, even though the thoughts appear inside their own head. This is distinct from an unwanted thought that is still felt to be one's own.

This has traditionally been treated as a 'pure' form of thought alienation because the foreign quality of the thought is total and explicit: the person does not merely dislike the thought, they attribute its authorship entirely to something outside themselves.

Recognition features

• A specific, confident conviction that particular thoughts have been placed into the person's mind by an outside agency
• The inserted thoughts are experienced as foreign in origin, not simply unwelcome
• The person can often identify the moment or manner in which a thought was inserted, or at least the fact that it clearly does not belong to them
• Commonly, though not exclusively, associated with schizophrenia

Eliciting it at interview

• Ask precisely: "Have you ever had the experience of a thought appearing in your mind that you knew wasn't your own — that had been put there by someone or something else?"
• Distinguish carefully from an obsession by clarifying ownership: an obsessional thought is unwanted but still felt to be the person's own, whereas an inserted thought is attributed to an outside source
• Ask the person to describe, in their own words, who or what they believe is responsible, and record this verbatim rather than summarising

Distinguishing features

• Differs from an obsession in the crucial matter of ownership: an obsession is unwanted but self-generated, while an inserted thought is attributed to an external source
• Differs from thought broadcasting, which concerns other people's access to the person's own thoughts, rather than an outside source contributing thoughts into the person's mind
• Though strongly linked historically to schizophrenia, related experiences of foreign-feeling thoughts have also been described in other conditions, so the symptom alone should not be treated as automatically diagnostic

Common misconceptions

• That thought insertion is the same as an intrusive or obsessional thought; the defining feature of thought insertion is the attribution of the thought's origin to an outside agency, not merely that the thought is unwelcome
• That the symptom is always described in dramatic, elaborate terms; some patients report it in a matter-of-fact way that can be easy to miss without directly asking about ownership of thoughts

Related phenomena

Thought Alienation · Thought Withdrawal · Thought Broadcasting · Passivity Phenomena

Diagnostically relevant to

Schizophrenia (links open the DSM-5 Learning Lab)

Practice this

A man tells you, with complete conviction, that when certain thoughts appear in his mind they are not his own — someone else has put them there. He can describe the exact sensation of a thought being placed into his head, and insists these thoughts feel foreign from the moment they arrive, not merely unwelcome. What is this? · A young woman says that intrusive violent thoughts sometimes enter her mind and that she finds them horrifying and wishes they would stop, but she is clear they are her own thoughts, arising from her own mind, however unwelcome. Before revealing the answer: is this thought insertion? · A patient describes an unwanted thought that keeps intruding into their mind. Before revealing the answer, decide what single question distinguishes an obsession from thought insertion. · A patient reports a disturbance affecting the privacy or ownership of his own thoughts. Before revealing the answer, decide what distinguishes thought broadcasting from thought insertion. · A patient describes an unsettling change in the privacy of his thoughts, but you are not yet sure whether this is thought insertion or thought broadcasting. Before revealing the answer, decide what single question separates the two. · A patient describes a disturbance affecting the contents of his own mind, attributed to an outside force. Before revealing the answer, decide what distinguishes thought withdrawal from thought insertion. · You suspect a patient may be experiencing thought insertion but they have not described it spontaneously. Before revealing the answer, decide how you would ask about this during the interview. · Explain why the question of ownership, rather than the unpleasantness of the thought's content, is what makes thought insertion clinically distinct from an obsession.

Illustration

A 31-year-old man states calmly that, three days ago, a thought about a stranger's name appeared in his mind that he knew immediately was not his own, and that it had been placed there by a neighbour who he believes has some means of putting thoughts into his head, an experience he describes as having happened "to" him rather than as anything he thought up himself.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 4, 'Disorders of Thought and Speech'.