Madness Explained

by Richard P. Bental

  Poverty of content of speech

  Speech that conveys little information. Language is vague and over-abstract.

  Pressure of speech

  An increase in the amount of spontaneous speech compared to what is considered customary.

  Distractible speech

  During mid speech, the subject is changed in response to a stimulus.

  ‘Then I left San Francisco and moved to… Where did you get that tie?’

  Tangentiality

  Replying to questions in an oblique, tangential or irrelevant manner.

  Q: ‘What city are you from?’ A: ‘Well, that’ a hard question. I’m from Iowa. I really don’t know where my relatives came from, so I don’t know if I’m Irish or French.’

  Derailment

  Ideas slip off the track on to another which is obliquely related or unrelated.

  ‘The next day when I’d be going out you know, I took control, like uh, I put bleach on my hair in California.’

  Incoherence (word salad)

  Speech that is incomprehensible at times

  Q: ‘Why do people believe in God?’ A: ‘Because making a do in life. Isn’t none of that stuff about evolution guiding isn’t true any more.’

  Illogicality

  Conclusions are reached that do not follow logically (non sequiturs or faulty inductive inferences).

  Clanging

  Sounds rather than meaningful relationships appear to groven words.

  ‘I’m not trying to make noise. I’m trying to make sense. If you can make sense out of nonsense, well, have fun.’

  Neologisms

  New word formations.

  ‘I got so angry I picked up a dish and threw it at the geshinker.’

  Word approximations

  Old words used in a new and unconventional way.

  ‘His boss was a see over.’ and unconventional way.

  Circumstantiality

  Speech that is very indirect and delayed at reaching its goal. Excessive long-windedness.

  Loss of goal

  Failure to follow chain of thought to a natural conclusion.

  Perseveration

  Persistent repetition of words of ideas.

  ‘I think I’ll put on my hat, my hat, my hat.’

  Echolalia

  Echoing of other’s speech.

  Q: ‘Can we talk for a few minutes?’ A: ‘Talk for a few minutes.’

  Blocking

  Interruption of a train of speech before completed.

  Stilted speech

  Speech excessively stilted and formal.

  ‘The attorney comported himself indecorously.’

  Self-reference

  Patient repeatedly and inapropriately refers back to self.

  Q: ‘What’s the time?’ A: ‘It’s 7 o’clock. That’s my problem.

  Phonemic paraphasia

  Mispronunciation; syllables out of sequence.

  ‘I slipped on the lice and broke my arm.’

  Semantic paraphasia

  Substitution of inappropriate word.

  ‘I slipped on the coat, on the ice I mean, and broke my book.’

  Meaning, Emotion and Disordered Speech

  One further assumption about thought disorder has taken a tumble in the last few decades. It will be recalled that Kraepelin regarded his patient’s disordered speech as merely ‘a series of disconnected sentences having no relation whatever to the general situation’. Rochester and Martin’s characterization of thought disorder as failed communication, in contrast, leaves open the possibility that the patient is attempting to communicate something of real importance to himself. This much was obvious to R. D. Laing, who found it is all too easy to comprehend the apparently bizarre utterances of Kraepelin’s patient:

  What does the patient appear to be doing? Surely he is carrying on a dialogue between his own parodied version of Kraepelin, and his own defiant rebelling self. ‘You want to know that too? I tell you who is being measured and is measured and shall be measured. I know all that, and I could tell you, but I do not want to.’ This seems to be plain enough talk. Presumably he deeply resents this form of interrogation, which is being carried out before a lecture room of students. He probably does not see what it has to do with the things that must be deeply distressing him. But these things would not be ‘useful information’ to Kraepelin except as further ‘signs’ of a ‘disease’.

  Kraepelin asks him his name. The patient replies by an exaggerated outburst in which he is now saying what he feels is the attitude implicit in Kraepelin’s approach to him: What is your name? What does he shut? He shuts his eyes… Why do you give me no answer? Are you getting impudent again? You don’t whore for me (i.e. he feels that Kraepelin is objecting because he is not prepared to prostitute himself before the whole classroom of students), and so on…

  Now it seems clear that this patient’s behaviour can be seen in at least two ways… One may see his behaviour as ‘signs’ of ‘disease’; one may see his behaviour as expressive of his existence… What is the patient’s experience of Kraepelin? He seems to be tormented and desperate. What is he ‘about’ in speaking and acting in this way? He is objecting to being measured and tested. He wants to be heard.16

  Laing was correct in supposing that psychotic speech can often be accurately decoded by an empathetic clinician. Psychologist Martin Harrow and his psychiatrist colleague Mel Prosen, working in Chicago in the late 1970s, took the unusual step of asking patients to account for their apparently bizarre verbalizations.17 Their patients were first asked to complete a few simple tests of verbal intelligence – for example, explaining the meaning of simple proverbs. Bizarre or idiosyncratic statements were then identified from the patients’ tape-recorded answers. A week later, each patient was sensitively interviewed by Prosen, who said that he was interested in learning what had been in the patient’s mind. Independent judges later evaluated each patient’s tape-recorded explanations. It would have surprised Kraepelin to learn that the patients were often able to give coherent explanations of their incoherent speech. Their idiosyncratic statements often reflected the intrusion of personally salient ideas, for example memories from early life, a phenomenon that Harrow and Prosen described as ‘intermingling’. Usually, the intermingled material centred around a variety of topics, rather than a single issue. It was as if the patient, when struggling to answer the intelligence questions, was constantly reminded of things that were more important to her, and was unable to stop herself from deviating from the task in hand.

  It should therefore be no surprise that the quality of speech of thought-disordered patients depends on what they are trying to discuss. Although unequivocal evidence that this is the case has only recently become available, this possibility was considered by earlier researchers. Unfortunately, although many studies carried out during the 1950s and afterwards attempted to assess the thought and language of patients when they were presented with emotionally laden and emotionally neutral stimuli, the results were inconclusive, almost certainly because the emotionally laden material was not personally signifi-cant.18 (For example, in a study carried out by Loren and Jean Chapman, patients were asked to solve analogy problems such as ‘Vagina is to lock as penis is to…?’).19 An exception was an experiment reported in 1972 by Algimantas Shimkunas, working at the University of Missouri, who interviewed patients in two conditions. In one, Shimkunas disclosed his own feelings about difficult interpersonal relationships and asked the patients to do the same; in the other, the same general themes were addressed but no pressure was put on the patients to talk about their feelings. Far more thought disorder was observed in the disclosure condition.20

  Recent studies have supported Shimkunas’ findings. In a small experiment conducted by Gill Haddock and myself, in which we used Andreasen’s TLC Scale, we compared thought-disordered patients’ speech when talking about emotionally neutral topics (for example, football) with their speech when talking about the circumstances leading to their admiss
ion to hospital. More thought disorder was evident in the second of these conditions.21 Similar findings were obtained by American psychologist Nancy Docherty and her colleagues at Kent State University in Ohio, in a much more impressive and extensive series of investigations. Docherty examined the speech of schizophrenia patients when asked to talk about ‘good memories of pleasant, nonstressful times’ and when asked to talk about ‘bad memories of stressful times’. In the different studies, communication disorder was measured in different ways, but a consistent pattern emerged – speech disturbance was markedly more evident when patients were asked to talk about negative topics.22

  This effect of emotional arousal does not seem to be restricted to schizophrenia patients. Sara Tai, a clinical psychologist based in my own department, has recently shown that bipolar patients who are currently manic are especially sensitive to the topic of conversation.23 Interestingly, she found that the speech of bipolar patients who are currently depressed is not affected in this way.

  Drawing this evidence together, it seems that vulnerable individuals are most likely to speak in an incoherent way when they are emotionally aroused, and they are most likely to be emotionally aroused when talking about personal issues. This conclusion will probably fail to amaze any reader who has attempted to explain something complex to a friend while feeling distressed; however, the effect seems to be much more marked in psychotic patients than in ordinary people.

  From Psychology to Language

  Given that thought disorder appears to be primarily a disorder of communication, it is obviously important to examine the linguistic skills of affected people. In this context it is useful to distinguish between language comprehension and language production. The account I have given so far suggests that psychotic patients experience specific difficulties when generating speech, while, not surprisingly, their ability to understand the speech of others seems relatively unimpaired. William Grove and Nancy Andreasen examined the ability of schizophrenic and manic patients to understand spoken language, using a variety of measures, and also included a test of digit span (the ability to recall short sequences of numbers) in order to check that poor performance on their linguistic tests could not be attributed to global handicaps, such as poor attention or a lack of motivation. Although they expected their patients to perform poorly on the linguistic tests and not on the digit span measure, the opposite turned out to be the case.24

  If thought-disordered patients can understand the speech of others, it might be expected that they would recognize when the speech of other patients is idiosyncratic. This prediction was supported by the results of a study carried out by Martin Harrow and Joan Miller. Patients were asked to explain the meaning of common proverbs and were then asked to judge their own answers and also the answers of other patients. Patients suffering from thought disorder failed to realize that their own incoherent answers were atypical. However, they accurately judged normal answers to be typical and the abnormal answers of other thought-disordered patients as idiosyncratic.25

  It will be recalled that Rochester and Martin argued that researchers should attempt to find out why ordinary people find psychotic speech so difficult to understand.26 In a nearly attempt to answer this question, Brendan Maher and his colleagues at Harvard University used a primitive computer program to analyse passages written* by schizophrenia patients.27 This system worked by using a dictionary to look up and assign words to various categories. Prior to the analysis, a panel of judges divided the passages into those that were thought-disordered and those that were not. The main finding was that writing tended be judged thought-disordered when there were more objects than subjects, which usually happened at the end of sentences (‘Doctor, I have pains in my chest and hope and wonder if my box is broken and heart is beaten for my soul and salvation and heaven, Amen’).28

  Rochester and Martin’s own research introduced the concept of cohesion analysis, which they took from the work of the linguists M. A. K. Halliday and R. Hasan. They studied three groups: thought-disordered schizophrenia patients, non-thought-disordered schizophrenia patients, and ordinary people. Speech was elicited from each of the participants using three procedures: an interview in which they were asked to speak about anything they found interesting, an experimental condition in which they were asked to talk about a series of cartoons, and a narrative task in which they had to listen to and repeat a short story.

  ‘Cohesion’, as defined by Halliday and Hasan, refers to the extent to which different parts of a spoken text are linked meaningfully together, so that they appear coherent to the listener. The links that achieve this effect are known as cohesive ties, and are categorized into five main types (see Table 15.2). For example, ‘reference’ refers to a link in which the interpretation of something said has to be sought elsewhere. An example is the use of pronomials, as in ‘John went down and later he returned home’ (the correct interpretation of ‘he’ is given by ‘John’ earlier in the sentence). Another type of cohesion is given by ellipsis, in which part of a sentence appears to have been deleted in order to avoid repetition, as in ‘He’s got energy too; he’s got a lot more than I do’ (‘energy’ is implicit but missing from the second part of the construction). Lexical cohesion involves parts of the text that are linked by meaning, as in ‘I got angry at my brother but I don’t often get mad’ (‘angry’ and ‘mad’ are synonyms in this example).

  As American psychologists Phil Harvey and John Neale later observed, perhaps one of the most important findings from this study was the unexpected competence of the non-thought-disordered patients.29 The speech of these patients appeared to be completely normal. By contrast, the thought-disordered patients produced fewer cohesive ties in the narrative condition and, during the interviews, they seemed to make excessive use of lexical cohesion. In a further analysis, Rochester and Martin classified the cohesive ties as endophoric and exophoric according to the location of the reference entailed. Endoph-oric ties refer to information that lies elsewhere in the text (as in, for example, ‘Penny is always late. I hope she gets here soon’). Exophoric reference involves information from the context or circumstances surrounding the speech (‘Here she comes!’). They found evidence that the thought-disordered patients made excessive use of exophoric references, and were more likely to provide unclear references than ordinary people.

  Table 15.2 Cohesive ties defined by Halliday and Hasan (adapted from S. Rochester and J. R. Martin (1979). Crazy Talk: A Study of the Discourse of Psychotic Speakers. New York: Plenum).

  Type of cohesion

  Example

  Reference

  Pronomial reference: ‘We met Joy Adamson and had dinner with her in Nairobi.’

  Substitution

  Verbal substitution: ‘Eastern people take it seriously, at least some of them do.’

  Ellipsis

  Nominal ellipsis: ‘He’s got energy too. He’s got a lot more [energy] than I do.’

  Conjunction

  Additive conjunction: ‘I read a book in the past few days and I liked it.’

  Lexical cohesion

  Synonym: ‘I got angry at M. but I don’t often get mad.’

  The publication of Rochester and Martin’s book was followed by a number of studies which mostly replicated their main findings for schizophrenia patients, although findings for manic patients were less consistent. In Britain, Til Wykes and Julian Leff conducted cohesion analyses of samples of speech from a small number of patients in both diagnostic groups. Like Rochester and Martin, they found a low number of cohesive ties in the speech of the schizophrenia patients, but more cohesive ties in the speech of the manic patients.30 (As there were no healthy controls, this finding should not be taken to imply that manic speech is normal.) In a more ambitious study, conducted in New York, Phil Harvey divided both schizophrenia and manic patients into subgroups according to whether they were thought-disordered or not, and compared them with ordinary people. There was no difference between the schizophrenia and many patients ove
rall, but there were clear differences between those patients who were thought-disordered and those who were not. The thought-disordered patients, regardless of their diagnosis, used fewer cohesive ties and more incompetent references.31

  Although some linguists have not been persuaded by Rochester and Martin’s approach,32 the evidence on the whole suggests that poor cohesion and abnormal references contribute to the listener’s bafflement when confronted with psychotic speech. Applying these ideas, Nancy Docherty has recently developed a measure of thought, language and communication disorder that focuses specifically on these kinds of peculiarities. The Communication Disturbance Index measures six types of linguistic abnormalities observed in schizophrenia and manic patients (see Table 15.3).33 Using this measure, Docherty was able to show that some kinds of speech disorder (over-inclusive or vague references, ambiguous word meanings and confused references) increase when patients are asked to speak about emotionally negative topics, whereas others (missing referents and structural unclarities) are unaffected.34

  And Back to Psychology

  So far I have emphasized the idea that thought disorder is best considered a disorder of communication. However, our ability to speak is presumably influenced by global cognitive processes. In order to explain psychotic speech, therefore, it will be necessary to ascertain how abnormal communication is connected, if at all, to the more general psychological deficits found in psychotic patients. (Of course, this approach does not necessarily imply a return to the old idea that thought disorder is literally disordered thought.)