Language-Related Symptoms in Persons with Schizophrenia and How Deaf PersonsMay Manifest These Symptoms

Susan L. Trumbetta, John D. Bonvillian, Theodore Siedlecki, Barbara G. Haskins

Sign Language Studies, Volume 1, Number 3, Spring 2001, pp. 228-253 (Article)

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https://doi.org/10.1353/sls.2001.0012

https://muse.jhu.edu/article/31770

S U S A N L . T R U M B E T T A

J O H N D . B O N V I L L I A N

T H E O D O R E S I E D L E C K I J R .

B A R B A R A G . H A S K I N S

Language-Related Symptomsin Persons with Schizophreniaand How Deaf Persons MayManifest These Symptoms

D requiring social services have historically beenserved primarily by educational institutions or departments of reha-bilitation. Only in the last several decades have mental health serviceproviders begun to respond to the Deaf community’s requests forappropriate care and treatment. Largely because of this historical lackof input from mental health specialists, many of the individuals whotreated or served Deaf persons were knowledgeable about Deaf cul-tural issues but were unfamiliar with clinical features of certain severeillnesses, such as schizophrenia. Concomitantly, psychiatric cliniciansproviding mental health services to Deaf persons have often lacked a

Susan Trumbetta is Assistant Professor of Psychology at Vassar College. JohnBonvillian is Associate Professor of Psychology and Director of the Interdepartmen-tal Program in Linguistics at the University of Virginia. Ted Siedlecki is in privatepractice in clinical psychology in Charlottesville, Va., where he also serves as anadjunct faculty member at the University of Virginia. Barbara Haskins is AssociateProfessor of Clinical Psychiatry at the University of Virginia and Attending Psychia-trist for the Commonwealth of Virginia’s Mental Health Center for the Deaf atWestern State Hospital.

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strong background in the cultural and linguistic issues related to deaf-ness. In particular, very few clinicians and research investigators havebeen knowledgeable signers. This lack of facility in sign language canbe a serious obstacle to the accurate diagnosis and successful treat-ment of disorders in which language plays an important role.

Among the principal diagnostic criteria for schizophrenia, at leasttwo—disorganized speech and hallucinations (when auditory–linguistic)—are related to language processing and production(American Psychiatric Association ). In the past, nearly all theobservations about schizophrenic language have come from studiesof hearing individuals and their production and comprehension ofspeech. In recent years, however, this situation has begun to change.Accounts of signing in schizophrenic patients who are deaf are start-ing to appear (Thacker ).

Deaf persons who communicate primarily through signs are rep-resented in the approximately one percent of the total populationthat is identified as schizophrenic. Indeed, there is some evidence ofa slightly higher incidence of schizophrenia among deaf persons thanin the hearing population (Altshuler and Sarlin ; Remvig ).This estimate, however, may simply reflect the longer psychiatrichospitalizations that Deaf patients typically experience (Altshuler andAbdullah ) rather than an actual difference in the prevalence ofschizophrenia between deaf and hearing populations. A major factorcontributing to longer hospital stays for Deaf patients has been atherapist–patient communication barrier that made evaluation andtreatment extremely difficult (Altshuler and Abdullah ). Com-munication barriers may also result in longer hospital stays for manyDeaf patients with schizophrenia because they may preclude the es-tablishment of a close and effective social support network (Scho-nauer et al. ). Prevalence rates of schizophrenia among Deafpersons may also be inflated by misdiagnoses based, in part, on lan-guage symptoms whose etiology is not related to schizophrenic proc-esses but instead to the effects of delayed or deprived languageacquisition (Kitson and Fry ). Without an increased understand-ing of how schizophrenic language symptoms are manifested by Deafpersons, it is unlikely that the problems of diagnosis, treatment, andlengthy hospital stays will be resolved soon.

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The purpose of this article is to review some of the core featuresof the disorganized speech seen in schizophrenia and to illustrate howDeaf persons with schizophrenia may display such language anoma-lies. We begin the article with a brief discussion of the difficultiesinvolved in studying schizophrenic language in general and ofschizophrenic signing in particular. We then examine many of thespecific language-related symptoms of schizophrenia. In the courseof this examination, we supplement previous findings based on anal-yses of spoken language with observations of how schizophrenia-related language disorders may be expressed in Deaf persons’ signing.Although it is not yet possible to claim that the patterns of schizo-phrenic language disorders are equivalent across language modalities,there are many similarities or parallels in the speech and signing defi-cits observed in persons with schizophrenia. We conclude the articlewith recommendations for future clinical research.

Difficulties in Studying Schizophrenic Language

A principal difficulty in studying schizophrenic language processes isthe wide variety of language-related symptoms both across individu-als and within individuals across time (Andreasen b). Within thecurrent diagnostic criteria for schizophrenia, there is great heteroge-neity in language presentation. For example, the symptom of disor-ganized speech, characteristic of other forms of schizophrenia, is notas prominent in the paranoid type (American Psychiatric Association). Furthermore, because the illness of chronic schizophrenia isoften marked by a sequence of acute phases and remissions, any indi-vidual’s symptoms, including those of language, can change overtime. As a consequence, many individuals with schizophrenia maybe entirely lucid some of the time but not at other times. This lackof consistency in the display of language atypicalities complicates anydepiction of ‘‘schizophrenic language.’’

Not only may language-related symptoms vary among personswith schizophrenia, but those language patterns most frequently asso-ciated with schizophrenia can also be observed in other psychoticprocesses, such as mania (American Psychiatric Association ).With few exceptions, the presence of language abnormalities alonedoes not discriminate schizophrenia from other psychotic disorders

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(Andreasen a, b). Language symptoms characteristic of bothschizophrenia and other psychiatric disorders may reflect cognitiveprocesses common to those disorders (Oltmanns et al. ).

In their duration, however, schizophrenic language symptomsgenerally differ from those of other groups of psychiatric patients. Incontrast to manic patients, whose language improves with their re-covery from psychosis, most patients with schizophrenia retain someresidual language deficits even during their remission from psychoticepisodes (Andreasen a, b, ). There is also evidence thatschizophrenic language symptoms differ in their severity from thoseof other psychiatric disorders. During psychotic episodes, schizo-phrenic language production often becomes more disordered thanmanic speech, and the speech of persons with schizophrenia typicallycontains fewer structural links to facilitate communication of mean-ing (Wykes and Leff ).

Diagnostic difficulties arise not only from the heterogeneity ofschizophrenic language and its similarities to the language of otherpsychotic patients but also from the context in which language sam-ples are obtained for evaluation. The social context in which lan-guage occurs can affect its semantic, syntactic, and phonologicalcontent. Although most language is in the form of dialogue ratherthan monologue and thus reflects an interaction between speakers,the majority of studies of schizophrenic language have confinedthemselves to evaluations of schizophrenic monologue. Little consid-eration has been given to the role of others in conversations withpatients with schizophrenia, except in observations of how personswith schizophrenia respond to specific stimuli, such as direct ques-tions (Andreasen a, b) or word-association tasks (Allen). This monological bias may be a serious limitation when con-sidering pragmatic aspects of schizophrenic language. Of course, inlight of the relatively small proportion of schizophrenic patients whoare deaf and the small number of clinical staff members with signingskills, there may not be many opportunities to obtain samples ofschizophrenic signing in dialogue form.

A final issue in the study of schizophrenic language processing isthe nearly universal presence of antipsychotic medications in the his-tory and current functioning of patients with schizophrenia. Given

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the apparent superiority of antipsychotic medications over othertherapies in treating schizophrenic symptoms, most patients withschizophrenia have been exposed to antipsychotic medications atsome time during their disease and are likely continuing a regimenof such medications during their participation in scientific studies.Therefore, it is difficult to separate completely the effects of schizo-phrenia from those of the medications and/or of the interaction ofthe disease with the medications on language processing.

Difficulties Associated with Studying Language Processing in Deaf Persons

Before discussing the characteristics of schizophrenic language inmore detail, it is important to acknowledge that Deaf persons maymanifest communication deficits or atypicalities for reasons otherthan mental illness. One source of difficulty is that a number of deafchildren experience considerable language deprivation during child-hood, a period crucially important for normal language development.More than percent of deaf children have hearing parents (Scheinand Delk ), and many of these parents historically have electedoral-only early education programs for their deaf children (Meadow). These children frequently fail to acquire facility in speech and,probably because of their late introduction to signing, may notachieve fluency in a recognized sign language (Mayberry ). Inturn, this lack of fluency in any language mode may convey the im-pression of language use indicative of mental illness when the realproblem is inadequate language-learning opportunities.

Another potential source of diagnostic difficulty is that certainprenatal or perinatal insults to the brain that cause deafness may, insome cases, also damage other parts of the brain. Such damage to thebrain may create language deficits or disorders that resemble thoseseen in persons with schizophrenia when schizophrenia is not at allinvolved.

Finally, an additional source of difficulty in diagnosing schizo-phrenia in Deaf persons is that there are few resources to guide thepsychiatric clinician unfamiliar with the unique characteristics of theDeaf population. At present, research on signers with schizophreniais scant; only a single rather preliminary investigatory report that fo-cuses primarily on the sign language of prelingually deaf persons with

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schizophrenia exists (Thacker ). Because very few clinicians andresearchers are knowledgeable signers, they frequently must rely ei-ther on their own impressionistic accounts or the assessments ofknowledgeable signers who may lack clinical training. Fortunately, assign language training has become more widespread, this situationappears to be improving.

Expressive Language Symptoms of Schizophrenia

Studies of the speech of patients with schizophrenia have shown thatthe speech-related symptoms vary considerably in frequency. Derail-ment, loss of goal, poverty of content, and tangentiality are the mostfrequently identified symptoms. These are followed by poverty ofspeech and, finally, by pressured speech and perseveration. Some ofthese characteristics or symptoms, however, occur frequently in othergroups of patients. Only poverty of content and tangentiality reliablydifferentiated schizophrenic from nonschizophrenic patients (An-dreasen a, b).

Poverty of speech refers to restricted or limited amounts of spon-taneous speech. Patients with schizophrenia typically produce shorterand fewer utterances and hence fewer words than do comparisongroups consisting of manic–depressive patients and normal controls(Sanders et al. ). Moreover, this relative dearth in language pro-duction is amplified in patients with chronic schizophrenia (Ragin,Pogue-Geile, and Oltmanns ). Reduced overall verbosity thusappears to be a primary disturbance in schizophrenic language.

Poverty of content of speech refers to restricted or limited speechcontent when the amount of speech is adequate. Poverty of contentis usually identified in discourse that is either vague and overabstractor else is repetitive, overconcrete, and stereotyped (Andreasena). These characteristics may also be evident in Deaf patients.One hospitalized schizophrenic Deaf woman we observed typicallyexpressed herself in a very limited, repetitive fashion. She frequentlysigned ‘‘. . . .’’ In her signing, she never dem-onstrated complex communication skills as she failed to sign morethan three or four signs at a time. Her form of communication,moreover, differed from that of cognitively and linguistically limited,but not mentally ill, deaf persons in the stereotyped manner in which

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she signed. For example, she always signed the first ‘‘’’ with herright hand, then the second ‘‘’’ with her left hand, and then‘‘’’ with both hands. In addition, this level of functioning rep-resented a marked decline from her premorbid condition.

Although certain Deaf patients evidence poverty of thought con-tent in their signing, therapists need to exercise caution in makingsuch an evaluation. If the therapist is not a proficient signer but reliesheavily on an interpreter, then the translation into spoken Englishmay give the impression of disjointed language. This impression, inturn, may lead the therapist to make an erroneous characterization of‘‘poverty of thought content’’ (Misiaszek et al. ). Correspond-ingly, there may be a similar problem when a Deaf client has severelylimited signing skills (Cook, Graham, and Razzano ). Therefore,in such situations, corroborating nonlanguage information should becollected on a Deaf client’s behavior before making a diagnosis.

Even though the productive or expressive language deficits char-acteristic of schizophrenia are many and varied, a number of effortshave been made to organize the different language deficits into dis-tinct groupings or categories. The principal approach this articleadopts is based on the work of Barch and Berenbaum (). UsingLevelt’s () model of the cognitive processes involved in languageproduction, Barch and Berenbaum constructed four general catego-ries of schizophrenic language. Moreover, they were able to showthat three of their four categories were empirically related to differentcategories of thought disorder.

Barch and Berenbaum’s first type of productive language deficit,which includes neologisms and word approximations, was associatedwith grammatical–phonological encoding deficits. The second typeof language deficit they identified consists of derailment and non se-quitur responses; this type of language deficit was associated withworse speech monitoring. Incompetent references, their third cate-gory of language deficits, were associated with disruptions in discourseplanning. Their fourth and final category of productive language deficitscommon to schizophrenia consists of tangential responses. Unlike theother categories, tangential responses showed no significant associa-tion to any particular type of thought disorder.

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Neologisms and Word Approximations

Although neologisms and word approximations do not constitutespecific diagnostic symptoms of schizophrenia, they have often beennoted in the clinical literature (Andreasen a, b). They are,however, far less common than other markers of schizophrenic dis-course. In some instances, the derivation of these new or novel wordsor phrases is unclear, as in this example from one hearing patient: ‘‘Igot so angry I picked up a dish and threw it at the geshinker’’ (An-dreasen a, ).

The generation of neologisms is not restricted to hearing patients,as we have observed Deaf patients using signs of unknown derivationand meaning. Interestingly, these neologistic signs typically are well-formed ASL signs. That is, these neologistic signs use acceptable ASLmovements, handshapes, and locations but combine them in uniqueways so as to create signs unknown to other signers. Neologisms aresometimes difficult to detect in Deaf patients because of the relativelylarge number of sign variants (or dialects) used by native signers in theUnited States. Differences in signs are found not only from region toregion but also within cities if there has been more than one schoolfor deaf students in that locality. Therefore, when a patient uses aneologistic sign for a concept, it may be accepted too easily as aregional variant. This possibility can be ruled out by checking thesign with native signers from the same locale.

Word approximations are related to neologisms, but have clearerderivations. Word approximations occur when existing words areused in new or unconventional ways or when new words are gener-ated using conventional rules of word formation. For example, ahearing patient was reported to call gloves ‘‘handshoes’’ (althoughpossibly from the German word for glove, ‘‘Handschuh’’), and in an-other instance, a ballpoint pen was referred to as a ‘‘paper-skate’’(Andreasen a). We have also observed Deaf schizophrenic pa-tients produce novel combinations of signs to create new signs andmeanings. In light of the widely varying language background ofmany Deaf persons, apparent instances of word approximationshould be identified with caution and be considered only a possible

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indicator of language disorder. Regardless, neologisms and word ap-proximations can contribute to the incoherence of schizophreniclanguage.

Derailment and Non Sequitur Responses

In derailment, spontaneous speech ‘‘derails’’ from one track ofthought to another or from one frame of reference to another. De-railment is distinguished from the phenomenon of tangential speechin that tangentiality describes responses to queries, whereas derail-ment indicates changes of topic within spontaneous speech. Whenderailment is subtle, and discourse slowly drifts off topic without thespeaker’s awareness, the phenomenon is known as loss of goal (An-dreasen a).

The deterioration of schizophrenic speech in a relatively substan-tial discourse, such as observed by Salzinger, Portnoy, and Feldman(), may reflect an underlying process of increasing attentionalor discourse planning difficulties. Unlike normal discourse, whichbecomes more predictable and less repetitive as it progresses, schizo-phrenic discourse tends to become less predictable and more repeti-tive. One reason for the lack of cohesion in the speech of patientswith schizophrenia is that short discourses on topics unrelated to themain discourse topic are often interspersed throughout a speech sam-ple (Noel-Jorand et al. ). Repetition is a form of derailment inwhich discourse loses its initial focus and returns perseveratively tothe same word or phrase. A simple example from a hearing patientis: ‘‘I think I’ll put on my hat, my hat, my hat, my hat’’ (Andreasena, ).

Another form of repetition that has often been found in schizo-phrenic speech is echolalia. Echolalia occurs when an individual re-peats the words or phrases of a person who has spoken to him or her.If an interviewer says ‘‘I’d like to talk with you for a few minutes,’’ theecholalic speaker may say ‘‘Talk with you for a few minutes’’ (An-dreasen a, ). This phenomenon is not limited to the audi-tory–vocal modality. For example, Thacker () found that someprelingually deaf patients with schizophrenia slavishly imitated theirinterviewer’s British Sign Language (BSL) signs, a phenomenon shenamed echopraxia.

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Echolalia in hearing populations is more common among youngthan adult individuals with schizophrenia. Because echolalia is alsocommon among children with autistic disorder, some of the instancesof echolalia found among young individuals with schizophrenia mayrepresent language processes similar to those present in autism orsome diagnostic confounding of autistic disorder and schizophrenia(especially given autism’s previous label of ‘‘childhood schizophre-nia’’). Instances of repetition or echolalia in schizophrenic speech,however, are neither related to intellectual limitations nor are theythe consequence of restricted vocabulary, as the words and phrasesrepeated by individuals with schizophrenia are generally less com-mon, although not necessarily bizarre or unusual (Manschreck et al.).

Analysis of the speech of hearing patients with schizophrenia hasresulted in the identification of another form of repetitive speech,object chaining. Object chaining refers to a tendency to chain a seriesof object nouns together at the ends of sentences; this results in ahigh object-noun-to-subject-noun ratio (Maher, McKean, andMcLaughlin ). An example of this phenomenon would be: ‘‘Idon’t think they were over comparing God, Abraham, Mongoloid,somebody . . .’’ (Manschreck et al. , ). Object chaining mayrepresent another form of loosening of associations or derailment.Among Deaf patients such inappropriate chaining of object nounsmust be distinguished from the appropriate use of the ASL (AmericanSign Language) linguistic device of chaining several exemplar objectsto indicate a more general category (e.g., signing , , etc.to convey the concept of furniture).

‘‘Clanging,’’ perhaps a more severe form of derailment, occurswhen phonemic sounds, rather than meaning, determine the pro-gression of the discourse. Clanging often takes the form of rhyming,and such rhymes can eventually overwhelm the semantic relation-ships between words, resulting in nonsense rhymes. In milder formsof clanging, puns, rather than rhyming, may occur:

I’m not trying to make noise. I’m trying to make sense. If you canmake sense out of nonsense, well have fun. I’m trying to make senseout of sense. I’m not making sense (cents) anymore. I have to makedollars. (Andreasen a, )

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Deaf patients with schizophrenia have demonstrated various er-rors in signing that resemble clanging among hearing patients withschizophrenia. The first involves cross-linguistic contamination.Thacker (, ) observed errors that involved linking a BSL signto its English homophone:

Interviewer: ? , ?

Schizophrenic patient: (conventional sign) (pointing tobottom of foot) .

We have also observed another approximation to clanging in Deafpatients with schizophrenia in which a formational aspect of a sign(the location, handshape, or movement), rather than the phonemesof speech, determines the progression of discourse. For example, adeaf patient might continue a sentence using a sign with a handshapesimilar to that of a previous sign rather than relating to the meaningof the sign.

Incompetent Reference

One of the most systematically examined aspects of the speech ofpatients with schizophrenia is the apparent lack of cohesion in theirdiscourse that results from their use of unclear and ambiguous refer-ents (Rochester and Martin ; Sanders et al. ). The apparentincoherence of schizophrenic language may, at times, represent faultyassumptions about the listener’s frame of reference rather than beingevidence of other cognitive or linguistic disturbances. For example,patients with schizophrenia, particularly those with positive symp-toms, often use pronominal forms without clear referents (Allen andAllen ; Caplan, Guthrie, and Foy ; Harvey ; Harveyand Brault ). Similarly, patients with schizophrenia frequentlyseem to speak in non sequiturs as they fail to make clear associationsbetween statements (Berenbaum, Oltmanns, and Gottesman ).However, as clinicians have worked with the same patients over timeand become much better acquainted with the patients’ frames of ref-erence, previously unclear referents have often become more com-prehensible (Bleuler ). This finding suggests that, at least in some

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cases, schizophrenic language may be somewhat like children’s ego-centric speech, in which young children assume their listeners sharetheir own frame of reference.

The difficulty involved in understanding schizophrenics’ framesof reference and associations between statements is illustrated in ourobservations of a psychotic Deaf woman. As she approached the hos-pital staff, she signed ‘‘.’’ She had not yelled. After several repeti-tive exchanges of ‘‘Who yelled?’’ ‘‘’’ and ‘‘Do you hear a yell?’’‘‘,’’ she led the staff to a male patient and signed ‘‘ .’’ Inanother instance, this same woman approached the staff and signed‘‘ .’’ It took multiple attempts at clarification before sherevealed that her thought was ‘‘In the future, I will meet J ’’ (theboy who yelled).

In studies of schizophrenic speech, the frequency of incompetentreferents has been found to be closely associated with the severity ofthought disorder (Harvey and Brault ) and to be predicted bydistractibility and deficient reality monitoring (Harvey and Serper). Any relationship between the severity of thought disorder,distractibility, or deficient reality monitoring and developmental de-lays in referential understanding among patients with schizophreniaremains to be thoroughly investigated.

This issue is even more complicated in Deaf persons. Nonnativesigners (clinicians or interpreters) can sometimes miss or misunder-stand referents that are often expressed in ASL by subtle facial expres-sions or shifts in body posture. In addition, when deafness occurs inthe context of a prenatal or perinatal insult, there is increased likeli-hood of damage to other brain areas as well. Sign language research-ers have found that certain left hemisphere lesions can manifestthemselves in the absence of index pronouns or lack of pronominalindices (Poizner, Klima, and Bellugi ). Furthermore, a numberof deaf persons, because of their limited and late exposure to fluentsigning, do not acquire the full range of ASL (or other sign languagesused by deaf persons) grammatical rules (Mayberry ). (These in-dividuals are sometimes referred to as visual–gestural Deaf persons oras having minimal language skills.) It may well require great familiaritywith both the communication style of such visual–gestural Deaf per-sons and the language style of schizophrenics to differentiate between

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the impoverishment or fragmentation of communication resultingfrom signing skill deficits and those resulting from schizophrenicprocesses.

Tangential Responses

In tangential speech, responses to questions may be oblique, tangen-tial, or irrelevant. Tangential speech is similar to derailment exceptthat it refers to a loosening of associations in response to specificquestions rather than to those that occur in spontaneous speech. Ingeneral, the loosening of associations in schizophrenia presents iden-tically in deaf persons and hearing persons except for the use of asigned language as opposed to spoken language.

As we have noted before, most service workers assisting Deaf per-sons are hearing and are not fluent signers. These workers often tendto blame their lack of comprehension on their own lack of signingskills rather than to recognize when a client may be having difficultyparticipating in a logical conversation. Working through an inter-preter presents other problems in that a service worker may attributeillogical answers to difficulties in interpretation and not to the client’sillogical thought process. Possible solutions to this dilemma may beto ask for the impressions of a fluent or native signer or to comparenotes with other workers to determine whether they are also havingdifficulty ‘‘following’’ a particular client’s train of thought.

Speaking and Signing Behavior

In addition to the categories of expressive language deficits delineatedby Barch and Berenbaum (), the language of patients withschizophrenia differs from that of normal individuals in other impor-tant ways. One particularly noticeable difference is prosody. Prosodicaspects of language, such as intonation, stress, and rhythm, are alsofrequently disordered or unusual in patients with schizophrenia. Evi-dence of disorder of prosody as well as facial affect recognition isapparent in patients with chronic schizophrenia. In their studies ofhearing patients with schizophrenia, Fricchione, Sedler, and Shukla() found that prosodic deficits in spontaneous speech produc-tion, repetition, and auditory comprehension accounted for the ma-jority of the language difficulties that the patients experienced.Furthermore, when in an acute state, patients with schizophrenia

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tend to make longer pauses in their utterances, to speak more monot-onously and in a low voice, and to shift their vocal pitch towardhigher frequencies (Puschel et al. ). In contrast to these changesin speaking behavior, the comprehension of emotional gesturing wasfound to remain relatively intact in patients with schizophrenia (Has-kins, Shutty, and Kellogg ). Our observations of Deaf patientswith schizophrenia have revealed atypicalities in signing similar tothose reported for the prosodic aspects of speech. Some Deaf patientssigned overly fast, others much too slow. Still others would place toomuch emphasis on particular sign movements. The facial affect of theschizophrenic Deaf patients, moreover, was often not in accord withtheir sign communication and inappropriate for the situation.

Anomalies Unique to Signed Discourse

In addition to the disordered signing that resembles the disorderedspeech of hearing persons with schizophrenia, Thacker () hasidentified various anomalies of schizophrenic discourse unique tosigned languages. She identified phonemic (or cheremic in Stokoe, ,terminology) paraphasias in the signing of prelingually deaf patientswith schizophrenia. These included reversals of signs (some patientsmade the movements of signs backward), fingerspelling backward,and making signs in the wrong locations. Thacker () also ob-served one patient who associated the right side of her body withherself, and her left side with her brother. Her signing sometimesinvolved a dialogue between herself and her brother. Signs thatwould normally occupy a bilateral space were restricted to whicheverside of her body was associated with her intended character.

Another way in which the communication of Deaf persons withschizophrenia may become uniquely impaired is through the limita-tions of expression that are symptomatic of schizophrenia. For exam-ple, among the negative symptoms of schizophrenia is blunted affect,a condition in which affective expression is considerably diminished.Given the extensive use of facial expression in signed languages, par-ticularly to communicate varying meanings and intensities of mean-ing, it is possible that blunted affect may reduce the clarity of eitherthe denotative or connotative meanings a Deaf patient with schizo-phrenia intends to convey through signs that normally require moreprecise expression of affect.

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Receptive Language Deficits in Schizophrenia

In addition to abnormalities in language production, impaired lan-guage comprehension has often been observed in individuals withschizophrenia (Chapman ; Condray, Steinhauer, and Goldstein; Cutting and Dunne ; Cutting and Murphy ; Faberand Reichstein ; Laws, Kondel, and McKenna ; Morice andMcNicol ). Indeed, these patients themselves frequently noticea change in how they experience their own or others’ speech; thisoccurs both on a semantic and a perceptual level. The following twoexamples underline this point:

I thought my language was wrong; I believed that no one couldunderstand what I said; I couldn’t understand what I said; just high-pitched noises came out; it lost its meaning; I could understand whatothers said. (Cutting and Dunne , )

and

When people talk to me now it’s like a different kind of language.It’s too much to hold at once. My head is overloaded and I can’tunderstand what they say. It makes you forget what you’ve just heardbecause you can’t get hearing it long enough. It’s all in different bitswhich you have to put together again in your head—just words inthe air unless you can figure it out from their faces. (McGhie andChapman , in Rochester and Martin , )

Such subjective accounts suggest both an excess of perceptual infor-mation beyond what can be processed systematically and a generaltenor of disorganization and unreality in language perception. Thisdeterioration of receptive language processing in schizophrenia maybe considered from the perspective of both syntax and semantics.

Syntactical Understanding in Schizophrenia

A number of early studies of language processing in patients withschizophrenia examined whether syntactic relationships were under-stood by the patients. For many of the patients, syntactic relationsremained relatively intact. In an investigatory approach involvingclicking sounds embedded in discourse (see Fodor and Bever ),both the normal participants and those with schizophrenia wereasked to repeat sentences with the clicks properly placed. Both

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groups of participants showed a bias for placing clicks between mean-ingful phrases and clauses (Rochester ; Rochester, Harris, andSeeman ). This finding was interpreted as indicating that normaland schizophrenic participants alike utilize the syntactic organizationof surface structure in decoding or processing sentences. Further-more, both normal and schizophrenic individuals apparently utilizedsyntactic and semantic cues in remembering sentences and followedsyntactic and semantic rules in grouping words (Grove and An-dreasen ; Rochester and Martin ). Even in disorderedspeech, the units of speech tended to be preserved (Leff ).

Although patients with schizophrenia often maintain appropriatesyntactic relations in their production of sentences that are semanti-cally nonsensical (Andreasen a, b), they frequently have dif-ficulty in comprehending complex grammatical structures (Condrayet al. ; Thomas and Huff ). Patients with schizophrenia (andtheir siblings) also show poorer performance than normal individualson tasks requiring auditory comprehension of complex grammaticalstructures (Condray et al. ), perhaps indicating some deficits inthe sequential processing necessary for linguistic competence. Con-sistent with these findings, patients with early onset of schizophrenia,which is generally associated with greater severity of symptoms,showed reduced syntactic complexity in their speech production(Morice and Ingram ). At present, studies of syntactic processingin patients with schizophrenia have focused only on hearing individ-uals and their spoken language processing. Similar investigations havenot yet been conducted with Deaf patients with schizophrenia.

Deficits in Schizophrenic Patients’ Semantic Comprehension

There is some evidence that patients with schizophrenia have im-paired access to word meanings (Laws et al. ), that they oftenprefer denotative to connotative meanings of words, and that theyshow less inclination to select metaphorical interpretations of ambig-uous adjectives, even when such interpretations are appropriate. Anexample of preference of literal over figurative meanings is seen inthe sentence, ‘‘David turned yellow when he faced the enemy,’’ forwhich individuals with schizophrenia more frequently chose skin dis-coloration than cowardice in assessing the meaning of yellow (Chap-man ). From this failure to apprehend metaphor, it has been

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inferred by certain investigators that patients with schizophrenia mayrely more on their left hemisphere lexicon in performing semantictasks (Cutting and Murphy ) than do normal individuals. Indeed,damage to the right hemisphere has been shown to impair the com-prehension of metaphorical statements such as ‘‘the man had a heavyheart’’ (Winner and Gardner , cited in Cutting and Murphy). Whether this difficulty in understanding metaphor is indica-tive of right hemisphere damage in persons with schizophrenia, prob-lems in bilateral processing, or simply lower levels of cognitivefunctioning is not clear.

As the severity of their symptoms increases, patients with schizo-phrenia typically deteriorate in their ability to discern context-depen-dent meanings. When presented with a word-association task,schizophrenic patients with the most severe symptoms were quitelikely to respond with words that were contextually inappropriate(Allen ). Patients with schizophrenia also showed diminished per-formance on cloze tasks (filling in the missing word) when given in-creasing amounts of contextual material (deSilva and Hemsley ). Itis not clear from these studies, however, whether the schizophrenicpatients’ frequent failure to benefit from context is the product of at-tention difficulties, atypical association strategies, or both. Regardless,similar studies might be conducted with Deaf schizophrenic patients todetermine whether the same patterns occur in both populations andacross language modalities. This deficit may be a particular problem forDeaf persons with schizophrenia as ASL makes considerable use ofcontext to clarify the precise meaning of a particular sign.

Auditory and Verbal Hallucinations

Other language-related symptoms of schizophrenia include promi-nent hallucinations (American Psychiatric Association ), mostfrequently auditory hallucinations, and often specifically verbal hallu-cinations (Romme and Escher ; Rund ). Although the ex-perience of ‘‘hearing voices’’ is not necessarily related to languagedeficits, verbal hallucinations may in some cases either exacerbate orbe exacerbated by language-processing deficits.

There have been occasional reports over the past century ofprelingually deaf patients experiencing auditory hallucinations

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(Critchley et al. ; du Feu and McKenna ; Remvig ;Schonauer et al. ; Stearns ). Remvig () provides severalsuch accounts from deaf patients with schizophrenia.

During admission his behavior was indicative of his being halluci-nated, i.e. his attention was intensely fixed, he seemed to be listen-ing, and, at the same time, he would be moving his hands withextreme rapidity, as if in sign language. Following such an episode Ihad a conversation with him. This was for the most part carried onin writing, executed rapidly, legibly and apparently without miscon-ceptions. He stated that he heard voices. These struck both his earsand it felt as if they were being breathed upon. The voices ordered himabout. He was not able to say to whom they belonged. (,–)

In another case, a nonspeaking deaf patient with schizophreniareported that he experienced sensations that were ‘‘interpreted as vi-brations that partly ‘hit’ his ears, partly the soles of his feet, the hol-lows of his knees and his body’’ (Remvig , ); he interpretedthese vibrations as indicating that his neighbors were pestering himthrough sounds and noises. Another deaf patient claimed that ‘‘shefelt herself to be under the influence of sound waves that she couldfeel against her cheek’’ (Remvig , ). Furthermore, thesesound waves ‘‘spoke’’ to her by hitting her cheek with such force asalmost to knock her over (, ). Remvig continued his descrip-tion of the patient:

These sensations are experienced by her as very vivid speech andthey are at the same time, ‘‘memorized’’ by clearly expressed fingerlanguage. These movements appear to be ‘‘accompanying move-ments’’ akin to the mouth and throat movements seen in normallyhearing persons during auditory hallucinations. (, )

These reports that deaf patients experience auditory hallucinationsare striking in that they suggest that extensive use of speech andspeech input is not necessary for such events to occur. Moreover, thedeaf patients examined by Remvig () reported that their tactilesensations were focused around the areas of their ears and cheeks andthat they associated these sensations with communication, voices,and commands. It should be noted, however, that what these deafpatients are describing as auditory hallucinations or voices consists

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primarily of feelings of vibrations or air currents. For these individu-als, such experiences may have been associated with their efforts tolearn a spoken language.

The findings of two recent studies (du Feu and McKenna ;Schonauer et al. ) of auditory hallucinations in prelingually pro-foundly deaf patients with schizophrenia, however, suggest that theauditory hallucinations reported by some deaf patients may actuallyclosely resemble those reported by schizophrenic patients with hear-ing levels in the normal range. Ten of the patients examined bydu Feu and McKenna reported that they had experienced verbal au-ditory hallucinations and provided descriptions of the content ofthese episodes. Many of the patients were quite emphatic that theyhad heard voices and that they were not receiving information insome other way. In the Schonauer et al. () study, of the participants recalled that they had heard human voices in auditoryhallucinations. Moreover, some of the patients insisted ‘‘that theirhallucinatory ‘perceptions’ conveyed to them the ‘true’ impressionof hearing in a way which they never experienced outside theirschizophrenic episodes’’ (, –). If additional research con-firms that some prelingually profoundly deaf patients with schizo-phrenia are indeed hearing voices, it is not at all clear what mightaccount for such a phenomenon. Perhaps some deaf persons rely ona form of inner speech, and the reports of auditory hallucinationsreflect a misattribution of the source of this ‘‘speech.’’

Although on the surface the experience of ‘‘auditory’’ hallucina-tions among deaf persons seems like a paradox, it may be that Deafpatients are particularly vulnerable to auditory hallucinations. Indeed,studies of the antecedents to hallucinations have shown that auditoryhallucinations are more likely to occur in conditions of low auditoryinput (sensory restriction and white noise) than normal or high input(Gallagher, Dinan, and Baker ). Because many Deaf personshave some residual hearing, their experience may be more similar tothat of the low-input condition than that of persons with normalhearing levels.

Among hearing persons with schizophrenia, humming a singlenote softly was found to reduce self-reports of hallucinations by percent (Green and Kinsbourne ). This finding suggests that

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humming provides either some auditory distraction from the percep-tion of auditory hallucinations or cognitive processes to competewith those that are responsible for auditory hallucinations. Clinicalobservations, moreover, have been interpreted as indicating that anyoral activity, including drinking, can cause auditory hallucinations todiminish or abate (Forrer ). The exploration of how auditorypathways in the brain respond in the absence of sensory input, partic-ularly in Deaf persons, may further illuminate our understanding of‘‘auditory’’ hallucinations among schizophrenic patients who aredeaf. Investigation into behaviors that cause hallucinations to abatemay enhance our understanding of more general processes that gov-ern auditory hallucinations.

In addition to the auditory and/or vibrational hallucinations justdescribed, Deaf patients may experience visual hallucinations. Theincidence of visual hallucinations in Deaf patients with schizophre-nia, moreover, appears to be considerably higher than that reportedfor hearing patients with schizophrenia (du Feu and McKenna ;Schonauer ). One possible explanation for this difference in inci-dence level is that visual processing typically plays a much more im-portant role in the communicative and cognitive functioning of deafpersons, especially among those individuals who have been deaf frombirth or early childhood. Although some of the visual hallucinationsconsisted of such images as flashing lights or faces on the wall (du Feuand McKenna ), other reports of visual hallucinations includedaccounts of individuals signing or fingerspelling (Schonauer et al.). Of the seven patients who told Schonauer et al. that theyexperienced such visual communication hallucinations, six werecongenitally deaf, and the other patient’s onset of deafness could notbe dated precisely. This tendency for hallucinatory visual communi-cation to be largely confined to congenitally deaf individuals mayindicate that early sensory experience plays a role in the nature ofhallucinations. (It should also be noted that Remvig () reportedthat some of the deaf patients he studied, who had been designated asexperiencing hallucinations, talked with themselves manually duringsuch episodes. Unfortunately, he did not pursue this topic in depth.)In the future, it might be important to compare the incidence andcontent of sign language hallucinations in congenitally deaf patients

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with schizophrenia with that of hallucinatory spoken language inhearing patients with schizophrenia. In such analyses, it might beworthwhile to try to differentiate between those hallucinations thatare primarily verbal in nature (sign or speech) and those auditory andvisual hallucinations that are not language based. Finally, the inci-dence and type of verbal hallucinations experienced by deaf patientswith schizophrenia might be found to vary depending on age at onsetand degree of hearing loss, further identifying those characteristicscritical for verbal hallucinations (Evans and Elliott ).

Concluding Remarks

Although the heterogeneity of schizophrenic symptoms creates somediagnostic problems in the study of schizophrenic language process-ing, investigations of thought-disordered patients with schizophreniagenerally show consistent patterns of speech anomalies and compre-hension deficits. Preliminary observations indicate the presence ofmany similar patterns of language atypicalities in the signing of Deafindividuals with schizophrenia. These similarities across languagemodalities, if confirmed, should not be viewed as surprising for tworeasons. One is that cognitive processes appear to govern many as-pects of language production and understanding; language andthought are intricately interrelated for both Deaf and hearing persons.The second reason is that numerous parallels or similarities acrossmodalities have been identified for signed and spoken languages;there is no reason to expect that additional similarities will not beuncovered in the language use of persons with schizophrenia. Itshould be recognized, however, that the evidence for essentiallyequivalent schizophrenic language processes in sign and speech is notyet firmly established. Much more detailed and systematic researchneeds to be conducted by investigators knowledgeable in ASL andother sign languages before we can draw strong conclusions.

To accomplish such research, individuals with strong backgroundsin sign language linguistics need to collaborate closely with mentalhealth professionals in both clinical and research settings. Fluent sign-ers with expertise in sign language linguistics are probably needed todetermine patterns of sign-formational atypicality, grammatical aber-ration, generation of neologisms, and discourse violation. Once these

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and other types of linguistic dysfunction associated with schizophre-nia are carefully documented, it should be possible to prepare video-tapes of instances of such linguistic disorder to assist clinicians in theirdiagnoses in the future. Videotape records of schizophrenic patients’signing over time should also be made in order to help in the evalua-tion of the success of their therapy. In addition, universities withsign language programs might well be encouraged to expand theirprograms to include training on sign language disorders and deficits.

Research with Deaf clients with schizophrenia also promises toilluminate aspects of language processing implicated with schizophre-nia. The sign production of Deaf persons with schizophrenia shouldalso provide a new vantage point from which to examine deficienciesin sequential processing and discourse planning, attention deficits,and perhaps even atypical hemispheric processing patterns. Overall,the inclusion of schizophrenics who are deaf and the analysis of signlanguage atypicalities in studies of schizophrenic language should addimportant new information to our knowledge of schizophrenic lan-guage more generally. In turn, clinicians serving Deaf patients maybecome better at making accurate diagnoses and initiating successfultreatment programs. Finally, researchers interested in the linguisticstructure of ASL may find it fruitful to study how ASL breaks downin Deaf persons with severe mental illnesses.

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