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Re-examining thought insertion: Semi-structured literature review and conceptual analysis

  • Simon Mullins (a1) and Sean A. Spence (a1)



Thought insertion is commonly regarded as diagnostic of schizophrenia. Little is known of its aetiology or pathophysiology.


To examine the definition and application of thought insertion in psychiatric and allied literatures.


A semi-structured literature review and conceptual analysis.


When ‘narrowly’ defined, thought insertion is reliably identified but not specific to schizophrenia. There is a range of related phenomena (‘alienated’, ‘influenced’, ‘made’ and ‘passivity’ thinking), less consistently defined but also not specific to schizophrenia. Whether thought insertion is solely an abnormal belief (or may also be an experience) is open to question. Nevertheless, the symptom has been used to explain schizophrenia, predict dangerousness and advance theories of ‘normal’ agency. Most applications have been subject to critique.


Despite its widespread occurrence and diagnostic application, thought insertion is an ill-understood and under researched symptom of psychosis. Its pathophysiology remains obscure.

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Corresponding author

Dr Sean A. Spence, Reader in General Adult Psychiatry, Academic Department of Psychiatry, University of Sheffield, The Longley Centre, Norwood Grange Drive, Sheffield S57JT, UK. Tel: +44(0) 114 22 61519; fax: +44(0) 114 22 61522; e-mail:


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Re-examining thought insertion: Semi-structured literature review and conceptual analysis

  • Simon Mullins (a1) and Sean A. Spence (a1)
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Thought insertion ? - The Symptom of Schizophrenia

25 June 2003

Thought insertion? - The Symptom of Schizophrenia


Mullins & Spence (2003) in their review on thought insertion have brought out the narrow and broad definitions of the phenomena very clearly. This was an interesting article and I wish to make few comments.

While considering the cultural beliefs about thought insertion, the effect of black magic seems to be one of the commonly held beliefs in countries like India. Sathyaseelan et al. (2001) had looked at patient perspectives on mental illness and had shown that patients hold beliefs about black magic and evil spirits as the cause of their illness. Similar beliefs have also been reported in less severe illnesses like dissociativedisorders (Hillard & Rockwell, 1978).

The author also mentions about the centrality of first rank symptoms to the diagnosis of schizophrenia in standard diagnostic manuals like ICD-10. However ICD- 10 has clubbed thought insertion along with other thoughtphenomena and thought echo in the first group of symptoms in the diagnostic criteria for schizophrenia (WHO, 1992). The phenomena of thought insertion is given an equal status along with the other two thought phenomena and thought echo. The inter rater reliability of first rank symptoms is widely accepted, however, thought insertion per se does not occupy a higher position among them.

We also find in our clinical practice that out of three thought phenomena in first rank symptoms, thought insertion is less frequent compared to thought broadcast and thought withdrawal. This is also in keeping with the findings of the Study of Factors Associated with the Course and Outcome of Schizophrenia (ICMR 1988).

Hillard, J.R., Rockwell, W.J. (1978) Dysesthesia, Witchcraft and Conversion Reaction. A case successfully treated with Psychotherapy. JAMA,240 (16): 1742-1744.Indian Council of Medical Research Final Report (1988) Report on Multi centered collaborative Study of Factors Associated with Course and Outcomeof Schizophrenia. Vellore: ICMR.

Mullins, S., Spence, S. A. (2003) Re-examining thought insertion. Semi-structured literature review and conceptual analysis. British Journalof Psychiatry, 182:293-298.

Sathyaseelan, M., Seema, P., Maret J., et al (2001) Patient perspectives on Psychosis. Indian Journal of Psychiatry, 43 (S): 72.

World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical description and Diagnostic guidelines.Geneva: WHO.
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