Thought disorder in attention-deficit hyperactivity disorder

Structure in the stream of consciousness: Evidence from a verbalized thought protocol and automated text analytic methods

A key question about the spontaneous stream of thought (SST), often called the stream of consciousness, concerns its serial structure: How are thoughts in an extended sequence related to each other? In this study, we used a verbalized thought protocol to investigate "clump-and-jump" structure in SST-clusters of related thoughts about a topic followed by a jump to a new topic, in a repeating pattern. Several lines of evidence convergently supported the presence of clump-and-jump structure: high interrater agreement in identifying jumps, corroboration of rater-assigned jumps by automated text analytic methods, identification of clumps and jumps by a data-driven algorithm, and the inferred presence of clumps and jumps in unverbalized SST. We also found evidence that jumps involve a discontinuous shift in which a new clump is only modestly related to the previous one. These results illuminate serial structure in SST and invite research into the processes that generate the clump-and-jump pattern.

Stability of Thought Disorder Index among high-risk and low-risk adoptees in the Finnish adoptive family study of schizophrenia

The aim of the study was to evaluate whether thought disorders are stable, trait-like features specific to subjects who have a genetic liability to schizophrenia or a psychiatric disorder. The thought disorders of adoptees genetically at high risk (HR) or low risk (LR) for schizophrenia from the Finnish adoptive family study of schizophrenia were evaluated twice at a mean interval of 11 years, using the sum of the Thought Disorder Index (TDI) scores on the Rorschach (TDR). At the initial assessment, the mean TDR scores of women were significantly higher than those of men, while no association between genetic risk and psychiatric status or their interactions with the TDR scores at baseline were found. The main finding was that the initial TDR scores statistically significantly predicted the TDR scores at follow-up, thus indicating the stability of thought disorder over time. However, neither genetic or psychiatric status nor gender or any interaction between these variables associated with TDR at follow-up.

Formal Thought Disorder and Executive Functioning in Children and Adolescents with Autism Spectrum Disorder: Old Leads and New Avenues

Formal thought disorder (FTD) is a disruption in the flow of thought and a common feature in psychotic disorders and autism spectrum disorder (ASD). Executive dysfunction has often been associated with FTD, yet for ASD convincing evidence is lacking. This study investigated FTD and three core executive functions in 50 young children and adolescents with high-functioning ASD and 56 matched controls. Higher overall levels of FTD marked ASD compared to controls. Furthermore, in ASD decreased performance on verbal working memory was correlated with increased FTD ratings and explained a significant amount of variance of objective and subjective FTD. Verbal working memory is currently the most promising target executive function for understanding the development of idiosyncratic thought disorders in ASD.

Thought Disorder in Preschool Children with Attention Deficit/Hyperactivity Disorder (ADHD)

Preschool identification of and intervention for psychiatric symptoms has the potential for lifelong benefits. However, preschool identification of thought disorder, a symptom associated with long term risk for social and cognitive dysfunction, has received little attention with previous work limited to examining preschoolers with severe emotional and behavioral dysregulation. Using story-stem methodology, 12 children with ADHD and 12 children without ADHD, ages 4.0-6.0 years were evaluated for thought disorder. Thought disorder was reliably assessed (Cronbach's alpha = .958). Children with ADHD were significantly more likely than children without ADHD to exhibit thought disorder (75 vs 25 %; Fischer's Exact Test = .0391). Thought disorder can be reliably assessed in preschool children and is present in preschool children with psychiatric illness including preschool children with ADHD. Thought disorder may be identifiable in preschool years across a broad range of psychiatric illnesses and thus may be an appropriate target of intervention.

Formal thought disorder in autism spectrum disorder predicts future symptom severity, but not psychosis prodrome

Formal thought disorder (FTD) is a disruption in the flow of thought, which is inferred from disorganisation of spoken language. FTD in autism spectrum disorders (ASD) might be a precursor of psychotic disorders or a manifestation of ASD symptom severity. The current longitudinal study is a seven-year follow-up of 91 individuals aged 5-12 years with ASD. We tested (1) whether childhood FTD predicted prodromal symptoms of psychosis in adolescence and (2) whether childhood FTD was associated with greater ASD symptom severity in adolescence. ASD symptom severity was assessed in childhood (T1) and 7 years later (T2), using the autism diagnostic observation schedule (ADOS). At T1, the Kiddie-Formal Thought Disorder Rating Scale (KFTDS) was used to measure symptoms of FTD. At T2, the prodromal questionnaire (PQ) was used to assess prodromal symptoms of psychosis. FTD at T1 did not predict prodromal symptoms of psychosis at T2 in children with ASD. FTD symptoms at T1, namely illogical thinking, predicted ASD symptom severity at T2 and this effect remained significant after controlling for T1 ASD symptom severity. In children with ASD, illogical thinking predicts severity of ASD symptoms in adolescence, but FTD does not predict prodromal symptoms of psychosis.

Thought and language disorder among sexually abused children in a psychiatric hospital

The empirical literature offers evidence that childhood sexual abuse is a predictor of psychopathology in adults. However, the literature examining the relations between thought disorder and psychotic symptoms in children is sparse. Children with a history of childhood sexual abuse are expected to demonstrate more disturbances in thought relative to their peers with no childhood sexual abuse. Using the Thought and Language Index, Thematic Apperception Test (TAT) narratives for four commonly used TAT cards obtained from 39 closed charts of hospitalized children were analyzed. Narratives were assessed on seven dimensions including weakening of goals, perseveration, looseness, peculiar word usage, peculiar sentence construction, non-logical reasoning, and distractibility. Good inter-rater reliability was obtained. Sexually abused childrenhad higher aberrant scores on card number four compared to non-abused children. Sexual abuse history was a predictive factor for non-logical reasoning, with small effect size. Implications and suggestions for future research are discussed.

Child psychiatry

This paper first summarizes the main findings of clinical studies conducted over the past two and a half decades on psychopathology (i.e., psychiatric diagnoses, behavior and emotional problems) in children with new onset and chronic epilepsy both with and without intellectual disability who are treated medically and surgically. Although impaired social relationships are core features of the psychiatric disorders found in pediatric epilepsy, few studies have examined social competence (i.e., social behavior, social adjustment, and social cognition) in these children. There also is a dearth of treatment studies on the frequent psychiatric comorbidities of pediatric epilepsy, attention deficit hyperactivity disorder, anxiety disorders, and depression. Drs. Hamiwka and Jones then describe their current and planned studies on social competence and cognitive behavioral treatment of anxiety disorders, respectively, in these children and how they might mitigate the poor long-term psychiatric and social outcome of pediatric epilepsy.

Thought disorder and communication deviance as predictors of outcome in youth at clinical high risk for psychosis

OBJECTIVE

Given the fundamental role of thought disorder in schizophrenia, subtle communication disturbance may be a valuable predictor of subsequent development of psychosis. Here we examined the contribution of thought and communication disturbance to the prediction of outcome in adolescents identified as putatively prodromal for psychosis.

METHOD

Transcribed speech samples were elicited from 105 adolescents (54 identified as being at clinical high risk for a first episode of psychosis [CHR], and 51 demographically comparable comparison subjects) and coded for formal thought disorder (FTD) and linguistic cohesion. We then examined the association of baseline FTD/cohesion with conversion to psychosis and social and role outcome at follow-up, approximately 1 year later.

RESULTS

At baseline, CHR patients who subsequently converted to psychosis (CHR+) showed an elevated rate of illogical thinking and poverty of content (POC) in their speech, relative to both typically developing controls and CHR patients who did not convert to psychosis (CHR-). CHR+ youth also used significantly less referential cohesion at baseline, indicating that they provide fewer references to persons, objects, or events mentioned in preceding utterances. Multiple regression models indicated that, among measures of FTD/cohesion, illogical thinking was uniquely predictive of subsequent conversion to psychosis, whereas POC and referential cohesion were significant predictors of social and role functioning, respectively.

CONCLUSIONS

Despite the absence of fully psychotic symptoms, putatively prodromal individuals evidence signs of communication disturbance that are qualitatively similar to those seen in schizophrenia and are predictive of both conversion to psychosis and psychosocial outcome. These findings suggest that FTD measures have prognostic significance for at-risk youth.

Shared and nonshared symptoms in youth-onset psychosis and ADHD

OBJECTIVE

We compared ratings of behavior and attention problems between youth-onset psychosis and ADHD, two disorders in which attentional impairments play a key role, and examined the effect of psychostimulant use on age of onset in psychosis.

METHOD

Parent and teacher ratings of behavioral problems and ADHD symptoms were collected using the Achenbach CBCL, TRF, and SNAP-IV Teacher Rating Scales on 42 participants with psychosis, 36 with ADHD and 57 controls (ages 8-19).

RESULTS AND CONCLUSIONS

Results suggested that academic, externalizing, and attention problems reflect symptoms shared between the disorders, whereas internalizing, social and thought problems reflect factors that differ between disorders. Furthermore, participants with psychosis who had been prescribed psychostimulants had a younger age of onset of psychotic symptoms than those who had not. This difference could reflect dissimilarities in symptom severity symptom between subgroups or potentially harmful effects of psychostimulants in individuals predisposed to develop psychosis.

Psychiatric disorders and intellectual functioning throughout development in velocardiofacial (22q11.2 deletion) syndrome

OBJECTIVE

Velocardiofacial syndrome (VCFS) is associated with cognitive deficits and high rates of schizophrenia and other neuropsychiatric disorders. We report the data from two large cohorts of individuals with VCFS from Israel and Western Europe to characterize the neuropsychiatric phenotype from childhood to adulthood in a large sample.

METHOD

Individuals with VCFS (n = 172) aged 5 to 54 years were evaluated with structured clinical interviews for psychiatric disorders and age-appropriate versions of the Wechsler intelligence tests.

RESULTS

The frequency of psychiatric disorders was high and remarkably similar between samples. Psychotic disorders and depression were uncommon during childhood but increased in rates during adulthood (depressive disorders: 40.7% in young adults [aged 18-24 years]; psychotic disorders: 32.1% in adults [age >24 years]). Cognitive scores were inversely associated with age in subjects with VCFS, including patients without psychosis. Specifically, Verbal IQ (VIQ) scores negatively correlated with age, and the subjects with VCFS and psychotic disorders had significantly lower VIQ scores than nonpsychotic VCFS subjects.

CONCLUSIONS

Neuropsychiatric deficits in individuals with VCFS seem to follow a developmental pattern. The VIQ scores are negatively associated with age and rates of mood, and psychotic disorders increase dramatically during young adulthood. The data presented here support careful monitoring of psychiatric symptoms during adolescence and young adulthood in VCFS. Prospective longitudinal studies are needed to examine the nature of age-related cognitive changes and their association with psychiatric morbidity in VCFS.

Incidental and intentional sequence learning in youth-onset psychosis and Attention-Deficit/Hyperactivity Disorder (ADHD)

The goal was to compare incidental and intentional spatial sequence learning in youth-onset psychosis and ADHD. The authors tested 8- to 19-year-olds with psychosis or ADHD and healthy controls on a serial reaction time (RT) task and used manual and oculomotor measures to examine learning. Participants were also administered a block in which they were explicitly instructed to learn a sequence. As in our previous studies with healthy adults and children, oculomotor anticipations and RTs showed learning effects similar to those in the manual modality. Results showed intact sequence-specific learning but fewer oculomotor anticipations in both clinical groups during incidental learning. In intentional learning, only the psychosis group showed impairments compared to controls. There were no interactions between age and diagnosis. Thus, the psychosis group showed relatively preserved incidental learning despite impairments in intentional learning. Additionally, both clinical groups showed impairments in the ability to search for, extract, and anticipate regularities (whether the regularities were there or not), but not in the ability to respond to these regularities when they were there.

Thought disorder and frontotemporal volumes in pediatric epilepsy

The aim of this study was to determine if volumes of frontotemporal regions associated with language were related to thought disorder in 42 children, aged 5-16 years, with cryptogenic epilepsy, all of whom had complex partial seizures (CPS). The children with CPS and 41 age- and gender-matched healthy children underwent brain MRI scans at 1.5 T. Tissue was segmented, and total brain, frontal lobe, and temporal lobe volumes were computed. Thought disorder measures, IQ, and seizure information were collected for each patient. The subjects with CPS had more thought disorder, smaller total gray matter and orbital frontal gray matter volumes, as well as larger temporal lobe white matter volumes than the control group. In the CPS group, thought disorder was significantly related to smaller orbital frontal and inferior frontal gray matter volumes, increased Heschl's gyrus gray matter volumes, and smaller superior temporal gyrus white matter volumes. However, significantly larger orbital frontal gyrus, superior temporal gyrus, and temporal lobe gray matter volumes and decreased Heschl's gyrus white matter volumes were associated with thought disorder in the control group. These findings suggest that thought disorder might represent a developmental disability involving frontotemporal regions associated with language in pediatric CPS.

Psychopathology among offspring of parents with schizophrenia: relationship to premorbid impairments

INTRODUCTION

A broad range of psychopathology, including externalizing disorders is seen in offspring at genetic risk for schizophrenia. However, it is unclear whether such psychopathology may underlie a higher predisposition to the premorbid antecedents of schizophrenia. We examined the prevalence and correlates of psychopathology in an ongoing study of offspring genetically at risk for schizophrenia.

METHODS

Seventy five consenting high risk offspring (HR: offspring, age 15.68+/-3.27 years; male/female 34/41) and 82 matched comparison subjects (40 males and 42 females; age 15.92+/-3.0 years) participated in this study. Diagnoses were ascertained using structured psychiatric interviews and consensus meetings, including all available clinical information.

RESULTS

Sixty (60%) of the HR offspring had one or more lifetime diagnosis of axis I psychiatric disorder. HR subjects with axis I psychopathology had significantly more soft neurological signs, poorer premorbid adjustment, and higher schizotypy scores as measured by Chapman psychosis proneness scales. Among those with psychopathology, HR subjects with externalizing disorders showed the most abnormal scores in schizotypy.

DISCUSSION

A substantial proportion of HR offspring of parents with schizophrenia manifest a broad range of childhood psychiatric disorders. Psychopathology, especially externalizing disorders such as attention deficit hyperactivity disorder (ADHD) may represent a subgroup with an increased risk for schizophrenia spectrum disorders. This possibility needs to be examined by prospective follow-up studies, and would be of considerable importance to early diagnosis and intervention efforts in schizophrenia.

Formal thought disorder and the autism spectrum: relationship with symptoms, executive control, and anxiety

This study investigated whether children with autism spectrum disorders (ASDs) exhibit formal thought disorder (FTD), and whether this is related to ASD symptoms, executive control, and anxiety. Participants aged 8-17 with ASDs exhibited significantly more illogical thinking and loose associations than matched typically developing control subjects. In participants with ASDs, illogical thinking was related to aspects of cognitive functioning and to executive control. Loose associations were related to autism communication symptoms and to parent reports of stress and anxiety. When FTD is present in ASDs, it generally is not a co-morbid schizophrenia symptom, but is related to pragmatic language abnormalities found in ASDs. The clinical and neurobiological significance of this work is discussed.

Assessment of formal thought disorder: The relation between the Kiddie Formal Thought Disorder Rating Scale and clinical judgment

The presence of formal thought disorder (FTD) in childhood is sometimes viewed as a possible precursor of psychotic symptoms or adult schizophrenia. It is possible to assess FTD in childhood in a valid and reliable manner, by using the Kiddie Formal Thought Disorder Rating Scale (K-FTDS). However, training and rating procedures are very time consuming, and may be particularly difficult during clinical assessment. The aim of this study was therefore to compare the clinician's rapid judgment of FTD to the detailed ratings of the K-FTDS. The K-FTDS was administered to 172 consecutively referred children, aged 6 to 12 years and subsequently rated by two blind raters. The same criteria, as used in the K-FTDS (illogical thinking, loose associations, incoherence, and poverty of content of speech), were rated by nine clinicians. The overall agreement between K-FTDS scores and FTD scores as rated by the clinician was low. The clinician's judgment of FTD did not correspond very highly with ratings on the K-FTDS. Thus, although detecting FTD has important clinical value, the assessment of its presence or absence seemed to depend highly on which measure was used.

Thought disorder: A developmental disability in pediatric epilepsy

This study compared thought disorder (i.e., impaired use of language to formulate and organize thoughts) in 93 children with complex partial seizures (CPSs) and 56 children with primary generalized epilepsy with absence (PGE) and its relationship to age, seizure, cognitive, and linguistic variables. By the use of psychopathology, social competence, academic achievement, and school problem measures, the functional implications of thought disorder in these two groups were compared. When demographic variables were controlled for, there were no significant differences in thought disorder scores between the CPS and PGE groups. However, the profile of age, gender, seizure, and cognitive variables related to thought disorder differed in the CPS and PGE groups. Within each group, different aspects of thought disorder were associated with different seizure variables. Thought disorder was related to psychopathology, school problems, decreased academic achievement, and poor peer interaction in the CPS group, but with school problems in the PGE group. These findings suggest that CPS and PGE affect the normal maturation of children's discourse skills, albeit through different mechanisms. The relationship of thought disorder to behavioral, academic, and social problems implies that these discourse deficits are one component of the developmental disabilities or comorbidities associated with pediatric CPS and PGE.

Thought Disorder Index: a longitudinal study of severity levels and schizophrenia factors

BACKGROUND

Thought disturbances are commonly associated with psychiatric disorders, especially schizophrenia. Our aim was to clarify whether thought disorders are only stable at certain severity levels and in the presence of certain schizophrenia factors of the Thought Disorder Index (TDI) scale. Furthermore, we also examined the significance of genetic status and the psychiatric disorder for the persistence of TDI severity levels and factors.

METHODS

The thought disorders of 158 adoptees genetically at high-risk or low-risk for schizophrenia participating the Finnish Adoptive Family Study of Schizophrenia were evaluated twice at a mean interval of 11 years. Thought Disorder Index (TDI) was used to assess the severity levels and schizophrenia factors. TDI identifies 23 different items of thinking disturbances, which are weighted along a continuum of severity.

RESULTS

Thought disorders at the 0.50 and 0.75 severity levels and idiosyncratic verbalization indicative of the schizophrenia factors turned out to be stable phenomena throughout the follow-up period. The adoptees' genetic or psychiatric status was not associated with the results.

CONCLUSIONS

The study shows that the stability of TDI seems to be related to the most severe categories of thought disorders. However, of the specific schizophrenia factors, idiosyncratic verbalization, but not confusion and fluid thinking, showed stability over time. Although idiosyncratic verbalization does not necessarily represent the most severe type of thought disturbance, it turned out relatively stable and we can speculate that idiosyncratic verbalization have some predictive value, too.

ADHD and schizophrenia phenomenology: visual scanpaths to emotional faces as a potential psychophysiological marker?

Commonalities in the clinical phenomenology and psychopharmacology of ADHD and schizophrenia are reviewed. The potential of psychostimulants to produce psychotic symptoms emphasizes the need for objective psychophysiological distinctions between these disorders. Impaired emotion perception in both disorders is discussed. It is proposed that visual scanpaths to facial expressions of emotion might prove a potentially useful psychophysiological distinction between ADHD and schizophrenia. There is consistent evidence that both facial affect recognition and scanpaths to facial expressions are impaired in schizophrenia, with emerging empirical evidence showing that facial affect recognition is impaired in ADHD also. Brain imaging studies show reduced activity in the medial prefrontal and limbic (amygdala) brain regions required to process emotional faces in schizophrenia, but suggest more localized loss of activity in these regions in ADHD. As amygdala activity in particular has been linked to effective visual scanning of face stimuli, it is postulated that condition-specific breakdowns in these brain regions that subserve emotional behavior might manifest as distinct scanpath aberrations to facial expressions of emotion in schizophrenia and ADHD.

A controlled study of formal thought disorder in children with autism and multiple complex developmental disorders

Along with well-defined categories in classification systems (e.g., autistic disorders and attention-deficit/hyperactivity disorder (ADHD)), practitioners are confronted with many children showing mixed forms of developmental psychopathology. These clusters of symptoms are on the borderlines of more defined categories. The late Donald Cohen proposed heuristic criteria to study a group defined by impaired social sensitivity, impaired regulation of affect, and thinking disorders under the name multiple complex developmental disorders (MCDD). Although these children meet criteria for pervasive developmental disorder--not otherwise specified (PDD-NOS), they have additional important clinical features, such as thought disorder. After highlighting similarities and differences between MCDD and comparable groups (e.g., multidimensionally impaired children), this paper presents the findings of a study comparing formal thought disorder scores in children with MCDD to children with autism spectrum diagnoses, such as autistic disorder (AD), and to children with nonspectrum diagnoses, such as ADHD and anxiety disorders.

METHODS

Videotaped speech samples of four groups of high-functioning, latency-aged children with MCDD, AD, ADHD, and anxiety disorders were compared to a control group of normal children using the Kiddie Formal Thought Disorder Rating Scale (K-FTDS).

RESULTS

High formal thought disorder scores were found both in the AD and MCDD groups, low rates in the ADHD groups, and no thought disorder in the anxiety disorder and normal control groups. The severity of formal thought disorder was related to verbal IQ scores within the AD and MCDD groups.

CONCLUSION

High formal thought scores in children with complex developmental disorders, such as AD and MCDD, appear to reflect impaired communication skills rather than early signs of psychosis.

Psychopathology and Pediatric Complex Partial Seizures: Seizure-related, Cognitive, and Linguistic Variables

PURPOSE

This study examined the role of cognition, language, seizure-related, and demographic variables in the psychopathology of children with complex partial seizure disorder (CPS) of average intelligence.

METHODS

One-hundred one CPS and 102 normal children, aged 5.1 to 16.9 years, had a structured psychiatric interview and cognitive and language testing. Parents provided demographic, perinatal, and seizure-related information, as well as behavioral information through the Child Behavior Checklist (CBCL) and a structured psychiatric interview about the child.

RESULTS

Significantly more CPS patients had psychopathology, cognitive deficits, and linguistic deficits than did those in the normal group. Among the patients, Verbal IQ predicted the presence of a psychiatric diagnosis, as well as CBCL scores in the borderline/clinical range. Seizure, linguistic, and demographic variables were unrelated to psychopathology. The cognitive and linguistic deficits of the CPS group, however, were predicted by seizure factors (e.g., prolonged seizures/febrile convulsions; seizure frequency/number of antiepileptic drugs) and demographic factors (e.g., minority status).

CONCLUSIONS

Because subtle verbal cognitive deficits predict behavioral disturbances in pediatric CPSs, the study's findings highlight the importance of assessing behavior, cognition, and language in these children. They also underscore the negative impact of prolonged seizures, febrile convulsions, seizure frequency, and antiepileptic drug polytherapy on cognition and language in pediatric CPSs.

Early presence of thought disorder as a prospective sign of mental disorder

The purpose of this study was to assess whether premorbid signs, such as thought disorder, could predict the subsequent manifestation of psychiatric disorders. A group of 75 adoptees at high genetic risk for schizophrenia and 96 low-risk adoptees without any psychiatric disorder at the initial assessment were assessed blindly with the Thought Disorder Index (TDI). Their psychiatric status was re-assessed according to DSM-III-R criteria in a re-interview 11 years later and based on available registers 16 years later. High scores on several TDI variables at the initial assessment predicted a psychiatric disorder of all adoptees at follow-up. Prediction was statistically unsuccessful among the high-risk adoptees because of the small number of cases, but high scores at the 0.50 severity level did predict mental disorders among the low-risk adoptees.

Thought disorder and nucleus accumbens in childhood: a structural MRI study

Thought disorder has been described as a hallmark feature in both adult and childhood-onset schizophrenia. The nucleus accumbens (NAc) has been repeatedly proposed as a critical station for modulating gating of information flow and processing of information within the thalamocortical circuitry. The aim of the present study was to investigate the relationship of thought disorder measures, which were administered to 12 children with schizophrenia and 15 healthy age-matched controls, and NAc volumes obtained from high-resolution volumetric magnetic resonance imaging analyses. The propensity for specific thought disorder features was significantly related to NAc volumes, despite no statistically significant differences in the NAc volumes of children with schizophrenia and normal children. Smaller left NAc volumes were significantly related to poor on-line revision of linguistic errors in word choice, syntax and reference. On the other hand, underuse of on-line repair of errors in planning and organizing thinking was significantly associated with decreased right NAc volumes. The results of this pilot study suggest that the NAc is implicated in specific thought patterns of childhood. They also suggest that subcortical function in the NAc might reflect hemispheric specialization patterns with left lateralization for revision of linguistic errors and right lateralization for repair strategies involved in the organization of thinking.

Neural correlates of thought suppression

The present report used functional magnetic resonance imaging (fMRI) to examine the neural correlates of thought suppression. Subjects were imaged while alternately (i) attempting to suppress a particular thought, (ii) attempting to suppress all thoughts, or (iii) thinking freely about any thought. Suppression of a particular thought, when compared to the free-thought control condition, revealed greater activation in the anterior cingulate. When the task of suppressing all conscious thoughts was compared to free-thought, a more distributed network of brain regions, including the anterior cingulate and the insula, was activated. These findings are consistent with previous research on cognitive control and may provide potential insights into psychological disorders involving recurring, intrusive thoughts.