Disorganized speech and psychiatric conditions
In past posts I focused on the psychiatric conditions Antagonism and Narcissistic Personality Disorder and Antisocial Personality Disorder, both of which are described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association.
In recent months, frequent episodes of disorganized and incoherent public speech have been reported. Some claim that it is just an idiosyncratic personal style, while others attribute it to the possibility of more serious issues. Looking back to the disorders mentioned above, it is worth considering what this disorganized and incoherent speech might indicate.
Disorganized speech is associated with the condition of schizophrenia. But such speech patterns may be indicative of something else.
Disorganized speech can occur in several other psychiatric and medical conditions beyond schizophrenia that may be worth considering.
Other Psychotic Disorders:
- Brief psychotic disorder
- Schizophreniform disorder
- Schizoaffective disorder
- Delusional disorder (less commonly)
- Substance/medication-induced psychotic disorder
- Psychotic disorder due to another medical condition
Mood Disorders:
- Bipolar disorder during manic or mixed episodes (flight of ideas, pressured speech)
- Major depressive disorder with psychotic features
- Severe depression (psychomotor retardation can affect speech organization)
Neurocognitive Disorders:
- Dementia (Alzheimer’s, vascular, Lewy body, frontotemporal)
- Delirium
- Traumatic brain injury
- Huntington’s disease
- Parkinson’s disease (advanced stages)
Developmental and Neurodevelopmental Conditions:
- Autism spectrum disorders (pragmatic language difficulties)
- Intellectual disability
- Specific language disorders
- ADHD (in some cases, rapid or tangential speech)
Substance-Related:
- Intoxication with stimulants, hallucinogens, or cannabis
- Withdrawal from alcohol or sedatives
- Chronic substance use effects
Medical Conditions:
- Seizure disorders (particularly temporal lobe epilepsy)
- Brain tumors
- Stroke affecting language areas
- Hyperthyroidism
- Severe metabolic disturbances
- Autoimmune encephalitis
Other Psychiatric Conditions:
- Dissociative disorders
- Severe anxiety disorders (circumstantial or tangential speech)
- Personality disorders with psychotic features
The relationship between disorganized speech and Narcissistic Personality Disorder (NPD) or antagonism is more complex and indirect.
Narcissistic Personality Disorder:
The DSM-5 doesn’t typically associate NPD with truly disorganized speech in the clinical sense. However, people with NPD may exhibit speech patterns that can appear disorganized or problematic:
- Circumstantial speech – taking lengthy, roundabout paths to make points, often to showcase knowledge or importance
- Tangential speech – going off on tangents, particularly when the topic shifts away from themselves
- Grandiose or inflated language – using exaggerated or pompous speech that may seem disconnected from reality
- Rapid topic changes when feeling criticized or when seeking to regain attention
- Incoherent explanations when confronted with evidence that contradicts their self-image
Antagonism (as a personality trait):
Antagonism itself doesn’t directly cause disorganized speech, but highly antagonistic individuals might display:
- Aggressive or hostile speech patterns that derail conversations
- Manipulative communication that can seem illogical to others
- Defensive rambling when challenged
Important Distinctions:
- These speech patterns in NPD are typically motivated and goal-directed (even if maladaptive), unlike the genuinely disorganized speech in psychotic disorders
- The person usually maintains logical connections in their thinking, even if their conclusions are distorted by narcissistic beliefs
- Speech organization typically improves when the person feels secure or admired
When It Might Overlap:
True disorganized speech might occur in someone with NPD if they also have:
- Comorbid psychotic features
- Severe personality decompensation under extreme stress
- Substance use
- Underlying neurocognitive issues
Antisocial Personality Disorder (ASPD) is not typically associated with disorganized speech in the clinical sense described in the DSM-5. However, there are some nuanced considerations:
Typical Speech Patterns in ASPD:
People with ASPD generally maintain organized, coherent speech and often exhibit:
- Superficial charm and articulate communication when it serves their purposes
- Manipulative rhetoric that is actually quite organized and goal-directed
- Smooth talking or “con artist” speech patterns
- Logical presentation of lies or deceptions
When Speech Might Appear Disorganized:
- Under interrogation or confrontation – may become evasive, contradictory, or rambling when caught in lies
- During aggressive outbursts – speech may become rapid, hostile, and less organized
- When intoxicated – substance use can affect speech organization
- Fabricating complex lies – may create inconsistent or convoluted narratives
Comorbid Conditions:
True disorganized speech in someone with ASPD would more likely result from:
- Comorbid substance use disorders (very common in ASPD)
- Traumatic brain injury (higher rates in antisocial populations)
- Comorbid psychotic disorders
- Severe personality decompensation under extreme stress
Key Distinction:
The manipulative, deceptive, or aggressive speech patterns in ASPD are typically purposeful and organized at a cognitive level, even if they appear chaotic or contradictory to observers. The person usually maintains logical thinking processes, unlike the genuine thought disorganization seen in psychotic conditions.
Bob Schwartz 