Circumstantiality

Issues of Concern

Along with tangentiality and flight of ideas, circumstantiality can often be a symptom of formal thought disorders such as schizophrenia or mood disorders with thought disturbances such as mania with psychosis.[1]

• Tangentiality: A disturbance in the thought process that causes the individual to relate excessive or irrelevant detail that never reaches the essential point of a conversation or the desired answer to a question
• Flight of ideas: The expression of rapidly shifting thoughts loosely associated with one another; the listener may find this type of speech in which the speaker jumps from one point to another, rendering their communication incoherent and nonsensical.
• Circumstantiality: Contains tighter and more coherent associations that may be easier to follow or understand (vs tangential speakers who eventually arrive back at the main point of speech or the answer to a question)

For example, a physician may inquire about the highest level of education that a patient has obtained. A circumstantial patient may start and say they loved high school, then recount multiple lengthy tales of interesting academic and travel experiences from college before stating that they graduated with a bachelor’s degree. Similarly, a nurse may ask a manic and expansive patient about allergies. The patient may begin by listing some of their allergies, then narrate a lengthy tale of how they went into anaphylactic shock after a bee sting in childhood, and discuss an interesting article they read recently in a magazine about the evolutionary origins of allergic reactions before finally arriving at the answer to the initial question.

Circumstantiality is commonly found in individuals with thought disorders, for example, brief psychotic disorder, schizoaffective disorder, or schizophrenia. It can also manifest in the pressured, grandiose, and disorganized speech of those with mood disorders with thought disturbances, such as bipolar I disorder with psychotic features.[2] It is also, more uncommonly, found in individuals with obsessive-compulsive disorder. In those diagnosed with psychotic disorders or thought disorders with psychosis, circumstantiality may be a direct and easily identified manifestation of the “disorganized speech” that is one of the five main diagnostic criteria for the disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). In those diagnosed with obsessive-compulsive disorder, the circumstantial nature of speech may be more compulsive in that individuals feel the need to include details in speech they consider to be relevant and feel compelled to present them in sequential order.[3]

According to an article by Levitas, children with an intellectual disability or developmental delay may also display signs of circumstantial thinking or speech that may present as the inclusion of irrelevant and concrete details. In these cases, clinicians must be careful not to misdiagnose these individuals with thought disorders. Instead, they must be evaluated 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. Some anecdotal studies have also documented circumstantial, rambling speech in a few patients with left complex partial seizures.[4] 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, excessive verbosity, heightened emotional responses, and altered sexuality.[5]

Clinical Significance

In the case of patients with thought disorders or mood disorders with thought disturbances, health professionals can use the extent of circumstantiality as an indicator of clinical progress or treatment efficacy. As patients improve, their speech will become more linear and less disorganized. In other etiologies of circumstantial or disorganized speech, such as epilepsy or intellectual disability, it is essential that the correct diagnosis is not missed or that an appropriate diagnostic workup is compromised.

However, when patients present with circumstantial or any other forms of disorganized speech, it is crucial that clinicians provide consistent validation and redirection so that information-gathering is efficient, empathetic, patient-centered, and productive.

Nursing, Allied Health, and Interprofessional Team Interventions

If clinicians encounter circumstantiality, they must be able to recognize it accurately and gently try to guide and redirect the patient back to the central point at hand. Therefore, it behooves anyone interacting with a patient on a clinical level to understand circumstantiality and note it as a finding in their examination or patient history.