Circumstantiality

Issues of Concern

Disorganized thinking, also known as a formal thought disorder, is typically inferred from an individual's speech. Circumstantiality, tangentiality, and flight of ideas can be symptoms of psychotic disorders, such as schizophrenia, or mood disorders with thought disturbances, such as mania with psychosis.[2] In contrast to tangentiality and flight of ideas, circumstantiality describes more coherent and connected thought associations. 

Tangentiality is a disturbance in the thought process that causes an individual to relate excessive or irrelevant detail that never reaches the essential point of a conversation or the answer to a question. These individuals completely change the course of a conversation or completely miss answering the question posed. In contrast to tangential speakers, who completely veer off from the original point of conversation or the question asked, circumstantial speakers eventually arrive back at the main point of speech or the answer to a question. Flight of ideas can be defined as the expression of rapidly shifting thoughts that are only loosely associated with one another. The listener may encounter the type of speech or communication characterized by flight of ideas, where the speaker rapidly shifts from one point or topic to another, making it difficult to follow. This speech may appear incoherent, nonsensical, or resemble a word salad. In contrast to speakers with flight of ideas, speakers who are circumstantial have more organized thoughts. 

For example, a healthcare professional may ask a question during an initial psychiatric assessment about the highest level of education that an individual has obtained. A circumstantial individual may start their answer by stating how much they loved high school, speaking about their favorite teachers, and recounting multiple lengthy tales of academic experiences during college before finally stating that they graduated with a bachelor's degree. When patients with bipolar I disorder experiencing a manic episode with a circumstantial thought process are asked about their known drug allergies, they may begin by listing some of their allergies. Then, the patients may narrate a detailed incident of how they went into anaphylactic shock after a bee sting at a childhood birthday party and discuss an interesting article they read in a magazine recently about the evolutionary origins of allergic reactions, before finally arriving at the answer to the initial question.

In contrast, when similar questions are posed to individuals with a tangential thought process, the conversation may begin with an over-inclusion of seemingly irrelevant details but eventually derail, leaving the initial question unanswered. In individuals with flight of ideas or loose associations, the answers provided are likely to be incoherent, difficult to follow, and irrelevant. The information provided by individuals with a circumstantial thought process or speech pattern can still be understandable, generally reliable, and clinically useful. 

Disorganized speech, for example, frequent derailment or incoherence, is a symptom of psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, and schizophrenia, and is part of the diagnostic criteria for these disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM–5-TR). Individuals with these diagnoses can present with circumstantiality, tangentiality, loose associations, thought blocking, or neologisms.[3] Circumstantiality is also observed in the pressured, grandiose, and disorganized speech patterns of individuals with mood disorders with thought disturbances, such as bipolar I disorder with psychotic features.[4]

A recent meta-analysis identified several neuroanatomical changes in individuals with schizophrenia with language-related impairments. In these individuals, functional neuroimaging showed hyperactivity in the left inferior frontal gyrus and middle frontal gyrus and hypoactivity in the right inferior frontal gyrus, the precentral gyrus, and the left caudate nucleus.[5] These findings suggest that neuroanatomical changes that correlate to disorganization in speech are found not only in the regions of the brain known to be related to language but also in areas associated with executive functioning, memory, and motor function.[5]

Obsessive-compulsive disorder is characterized by unwanted or intrusive thoughts and repetitive behaviors that cause functional impairment. Individuals with obsessive-compulsive disorder may demonstrate circumstantial speech that is compulsive or perseverative. These individuals may include details in their speech that they know to be irrelevant, trivial, or excessive, yet feel pressured to present them in sequential order due to their compulsive thought processes and behavior patterns, not as a manifestation of a psychotic thought process.[6][7]

Some individuals with personality disorders can also present with a circumstantial speech pattern or thought process. In particular, individuals with schizotypal personality disorder, characterized by the DSM–5-TR as a pervasive pattern of impairment in forming close relationships and eccentricities in thought and behavior, can present with odd thinking and over-inclusive, vague, or circumstantial speech. Individuals with narcissistic personality disorder, which is characterized by the DSM–5-TR as pervasive patterns of grandiosity, lack of empathy, and an excessive need for admiration, can also present with circumstantial speech. This speech pattern can reflect an inflated sense of self and be attention-seeking, stilted, grandiose, manipulative, or exploitative.

Children with developmental delays or adults with intellectual disabilities may also display signs of circumstantial thinking or speech that may present as the inclusion of irrelevant, concrete, or superfluous details. In these cases, clinicians must be careful not to misdiagnose these individuals with thought disorders or neurodegenerative processes. Instead, the speech patterns of these patients must be evaluated within the setting of their preexisting cognitive or functional baselines in the context of their developmental delay or intellectual disability.

Circumstantiality can also be observed as part of the behavioral changes associated with some epilepsy syndromes, particularly in individuals with temporal lobe lesions and in those with neurodegenerative diseases, such as amyotrophic lateral sclerosis or major neurocognitive disorders.[1][8] Some anecdotal studies have also documented circumstantial, rambling, and over-inclusive speech in a few patients with left-sided complex partial seizures.[9] The term Geschwind syndrome has been informally suggested to describe a personality syndrome present in some patients with temporal lobe epilepsy characterized by circumstantial speech and thinking, irritability, hypergraphia, hyperreligiosity, aggressive behavior, excessive verbosity, heightened emotional responses, and altered or heightened sexuality.[10][11] In temporal lobe epilepsy, these psychiatric symptoms can occur ictally, interictally, or postictally and are hypothesized to be caused by disruptions in social cognition or the pragmatic usage of language.[12][13] Although the underlying etiology is not clearly understood, Geschwind syndrome occurring in the context of temporal lobe epilepsy is treated by targeting the underlying seizure disorder.[12] There are also case reports of symptoms similar to Geschwind syndrome presenting in those with neurocognitive disorders, particularly the behavioral variant of frontotemporal dementia.[11] 

A speech pattern associated with tangentiality and circumstantiality can also be found in individuals with Ganser syndrome. This disorder is triggered by a stressor that can be a manifestation of a dissociative disorder, functional neurological symptom disorder, or factitious disorder/malingering. Although not universally defined, Ganser syndrome typically involves a symptomatic presentation consisting of approximate or near answers, a circumstantial or tangential speech pattern, visual or auditory hallucinations, functional neurological or conversion symptoms, disorganized behavior, or insensitivity to painful stimuli.[14][15]

Clinical Significance

Psychiatric disorders, neurological conditions, neurodegenerative processes, and personality disorders can all cause an individual to present with circumstantiality in their thinking as reflected by their speech. All healthcare providers should be familiar with the characteristics of circumstantial speech and be able to differentiate between circumstantial speech, tangential speech, loose associations, and flight of ideas.

When circumstantiality occurs in the context of a thought disorder, it can indicate the level of clinical severity. For example, an individual with hypomania may have circumstantial or over-inclusive speech. A more severely ill individual with mania or psychosis may present with loose associations, flight of ideas, or incoherence. Healthcare providers can also use the extent of disruptions in speech patterns as an indicator of clinical progress or treatment efficacy. As patients improve and their thought processes become more organized, their speech reflects this improvement. Individuals with narcissistic or schizotypal personality disorders who display circumstantiality should be assessed in the context of their personality and functional impairments. 

For neurological etiologies of disorganized speech, such as epilepsy or neurodegenerative processes, circumstantial speech must be recognized as indicative of an underlying disease process. In these cases, a complete diagnostic workup should be conducted, and the proper diagnosis should be made.

Generally, when patients present with circumstantiality or any other forms of disorganized speech, healthcare professionals must provide validation and redirection so that information-gathering is productive yet empathetic and patient-centered.

Nursing, Allied Health, and Interprofessional Team Interventions

When circumstantiality is a symptom of an underlying psychotic or neurological disorder, it can be best addressed by accurately identifying and treating the underlying cause. Some individuals may need medical treatment, and others may benefit from cognitive restructuring techniques used in cognitive behavioral therapy or with communication skills training, such as speech therapy or communication workshops. 

Providing patient-centered care for individuals with circumstantiality requires a collaborative effort among healthcare professionals, including clinicians, advanced practice practitioners, psychologists, social workers, pharmacists, and other healthcare providers. Healthcare professionals must possess the necessary clinical skills and expertise when diagnosing, evaluating, and treating this condition, including proficiency in recognizing disorganized speech patterns and assessing the underlying etiology. Consultation with psychiatry or neurology may be required. A strategic approach involving evidence-based guidelines and individualized care plans tailored to each patient's unique circumstances is vital.

Ethical considerations come into play when determining treatment options and respecting individual autonomy in decision-making. Responsibilities within the interprofessional team should be clearly defined, with each member contributing their specialized knowledge and skills to optimize patient care. Effective interprofessional communication fosters a collaborative environment where information is shared, questions are encouraged, and concerns are addressed promptly.

Care coordination is pivotal in ensuring seamless and efficient patient care. Clinicians, advanced practitioners, psychologists, social workers, pharmacists, and other healthcare providers must collaborate to streamline the patient's journey from diagnosis through treatment and follow-up. This coordination minimizes errors, reduces delays, and enhances patient safety, ultimately leading to improved outcomes and patient-centered care that prioritizes well-being and satisfaction.