second language acquisition and schizophrenia

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Second language acquisition and schizophrenia

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Second language acquisition and schizophrenia

James E DuganNorthern Arizona University, USA

AbstractSchizophrenia is a complex mental disorder that results in language-related symptoms at various discourse levels, ranging from semantics (e.g. inventing words and producing nonsensical strands of similar-sounding words) to pragmatics and higher-level functioning (e.g. too little or too much information given to interlocutors, and tangential discourse). Most of the literature concerning people with schizophrenia who acquire a second or foreign language suggests that these linguistic deficits are not as prominent (in some instances, altogether absent) when patients use their non-dominant language, a phenomenon that has been used to support different claims posited by psychologists and linguists about schizophrenia and second language learning alike. This review explores the relationship between second language acquisition and schizophrenia, and discusses how empirical findings regarding multilingual individuals with a diagnosis of schizophrenia inform current notions regarding second language acquisition.

Keywordsdifferential symptoms, schizophrenia, second language acquisition, thought disorder

I Introduction

Schizophrenia has yet to be definitively traced to any specific neurological or genetic source, which might permit creation of conclusive tests for the disorder. Language, there-fore, is currently the sole vehicle for its diagnosis. Apart from assessing aberrant or unusual behavior (often related to language use) in patients, mental health providers rely almost exclusively on patient self-reports in order to ascertain symptom severity and recommend treatment options. The clinician’s job is to match interpretations of what patients say (and conversely, what they choose not to say) and how they act with the criteria for schizophrenia outlined in resources such as the Diagnostic and Statistical

Corresponding author:James E Dugan, Department of English, Northern Arizona University, 700 S Humphreys Cdr (Bldg 18), Flagstaff, AZ 86011, USA. Email: [email protected]

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308 Second Language Research 30(3)

Manual of Mental Disorders, or DSM-5 (American Psychological Association, 2013). A diagnosis of schizophrenia comes after ruling out other similar psychotic disorders that may produce nearly identical symptoms, such as schizotypal, schizoaffective, and bipo-lar disorders (for a complete list, see the DSM-5, 2013). In sum, detecting schizophrenia requires copious language data from patients and a mental health expert possessing a keen sense of reconciling this data with appropriate information in a reference manual, an indication that linguistics and psychology are, to an extent, bound up in each other and in the process of determining an appropriate diagnosis.

The complexity surrounding language and schizophrenia does not end at diagnosis. A wide variety of symptoms are directly related to patients’ ability to communicate. Indeed, in extreme cases, people with schizophrenia have so much difficulty expressing thoughts verbally that their speech is labeled ‘word salad’. This obviously makes depending on patient statements to identify severity of psychosis exceedingly difficult. Schizophrenia often leads to social isolation, which likely stems from delusional or paranoid thinking and auditory hallucinations. Thus, even when capacity for communication is left rela-tively intact, patients may engage in conversational exchanges with great reluctance and prove to be unsuccessful interlocutors.

Given the highly communicative nature of many of the disorder’s symptoms, it may seem unlikely for patients to successfully communicate in a second language (L2). If first language (L1) use for individuals with schizophrenia includes frequently incoher-ent, easily-derailed speech, how might people living with schizophrenia fare in an L2? Interestingly, research on individuals with psychosis who speak more than one language has commonly found uneven expression of symptoms across languages, leading some patients to appear healthier in one language than another (e.g. Del Castillo, 1970; De Zulueta et al., 2001; Matulis, 1977). In order to gain a sense of issues surrounding L2 acquisition in light of schizophrenia, this literature review will begin with an overview of symptoms related to L1 use seen in schizophrenia. I will then discuss a variety of stud-ies concerning individuals with schizophrenia who speak more than a single language. I will then conclude with factors making synthesizing this body of research problematic and possible areas of future empirical investigation.

When reading this synthesis it is crucial to keep a few key points in mind. First, lan-guage is both highly personal and variable, and making inferences about language char-acteristics of whole populations is challenging to do with any degree of certainty. This variability, compounded with the complex and heterogeneous nature of the symptoms seen in schizophrenia, makes generalizing research results exponentially more difficult. A second factor making results difficult to apply broadly is the small sample size of many linguistic studies of people with schizophrenia. The DSM-5 estimates that schizophrenia affects between 0.3% and 0.7% of the world’s population (American Psychological Association, 2013: 102), so most researchers, even those who are themselves mental health practitioners, may have access to relatively few patients; this number is sharply reduced when the subjects are people who use more than one language. The studies included in this review have sample sizes ranging from a single participant (Southwood et al., 2009) to 30 participants (Hemphill, 1971; Matulis, 1977). Third, it should be noted that a large number of the studies in the review use the term ‘bilingual’ in a manner more closely aligned with psycholinguistics, denoting some knowledge of an L2 (see Gass



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et al., 2013), than other L2 researchers. Bilingual patients profiled here have disparate proficiency levels (participants’ L1 and L2 proficiencies are sometimes not even indi-cated in the literature) and opportunities for use of their languages. Some would argue that true bilingualism necessitates acquiring an L2 before the onset of puberty and the hypothesized critical period (e.g. De Houwer, 1995; Deuchar and Quay, 2000), but many research participants in these studies learned second languages during their teenage and early adult years. The psycholinguistic notion of bilingualism is intended for the pur-poses of this review. Finally, it is important to be aware of the fact that mental health issues are greatly influenced by culture. One example of this is a phenomenon reported by some researchers (e.g. Frances, 2013; Gelfand and Kline, 1978; Kendell et al., 1971) which suggests that doctors in the USA diagnose schizophrenia more frequently than those in Great Britain. Language is not an issue in this case: Patients in these countries use the same language to describe comparable symptoms, but American therapists are more likely to interpret them as schizophrenia while their British counterparts interpret them as bipolar disorder. One theory to explain this diagnostic variance is the difference in psychiatric cultures of the two countries. When reading this review, which comprises several cultural groups, it is crucial to remember that mental health diagnosis and treat-ment is susceptible to cultural sway.

II Schizophrenia and language-related symptoms

Considering the fact that no definitive psychometric test exists to diagnose schizophre-nia, and that mental health professionals identify clusters of symptoms and check them against criteria outlined in psychiatric manuals, it is understandable that a clear and con-cise working definition of the disorder is difficult to procure. Schizophrenia is a brain-based condition considered by many to be manifested in a single umbrella symptom, ‘thought disorder’, in which patient’s thoughts may be affected by positive symptoms (most commonly in the form of auditory hallucinations in which patients perceive voices that others cannot hear, as well as delusional thinking), negative symptoms (e.g. flattened affect and decreased motivation), and cognitive symptoms (e.g. executive functioning difficulty, weak memory, and poor attention span) (Covington et al., 2005; Kay et al., 1994; Paradis, 2008). Until the publication of the most recent edition of the DSM (American Psychological Association, 2013), mental health providers additionally diag-nosed some patients with specific subtypes of schizophrenia, such as paranoid schizo-phrenia, if they displayed certain symptoms (e.g. an erroneous belief in being monitored by the FBI). However, the DSM-5 abandons these subtypes of schizophrenia, claiming limited usefulness in terms of practical diagnosis of the disorder. This change is a perfect example of how our current understanding and treatment of schizophrenia is continually evolving and subject to revision.

Thought disorder in schizophrenia is seen in a variety of language deficits. Covington et al. (2005) view the array of abnormalities in schizophrenic language as too diverse to stem from thought disorder alone, leading them to classify those that resemble other neurological diseases (e.g. Alzheimer’s disease) as stemming from a separate primary symptom, schizophasia. The exact nature of schizophrenic speech, and in particular how it deviates from normal speech, is currently under debate, but most scholars agree on




basic language-related symptoms: use of neologisms and word-approximations (made-up words that may relate somehow to their actual counterparts, such as ‘hand-sock’ for ‘glove’); incoherent or disorganized speech, such as ‘in myself I have been okay what with the prices in the shops being what they are and my flat is just round the corner’ (Kuperberg, 2010: 578); poverty of speech (patient supplying too little) or poverty of content (patient not adequately addressing the question); strings of phonologically-similar or rhyming words used inappropriately; and a host of pragmatic and paralinguistic issues (e.g. staying on topic during conversation, maintaining proper eye contact with interlocutors, excessive self-referencing during conversation, etc.) that disrupt commu-nication (for an in-depth description of these symptoms, see Paradis, 2008).

Individuals with schizophrenia have demonstrated linguistic processing and produc-tion deficits at nearly all levels of discourse. Stephane et al. (2007) found that patients were unable to discern incorrect linguistic stimuli (e.g. made-up words) from correct stimuli from lexical to discourse levels in L1 processing tasks. In a series of single-word production tests probing participants to list as many items as possible in different catego-ries (e.g. action words), Badcock et al. (2011) found that patients performed significantly worse than healthy counterparts, indicating a potential difficulty in the ability to search the mental lexicon in schizophrenia. In their literature review examining schizophrenic speech from all levels of discourse, Covington et al. (2005) found that speakers exhibited largely normal phonological capacity, morphology, and syntactic structure, with most noticeable difficulty emerging at the pragmatic level. The authors also observed mental lexicon retrieval difficulty, similar to the findings of Badcock et al. (2011), which some-times initiated use of neologisms. More recently, attention has been placed on break-downs between clauses in the speech of patients (Ditman and Kuperberg, 2010), ability to interpret lexical ambiguity within given contexts (e.g. Andreou et al., 2009; Titone et al., 2000) and pragmatic failure in speech acts (e.g. Colle et al., 2013).

Other scholars recognize global language deficits seen in schizophrenia as amalgams of smaller, less noticeable problems, or as more closely related to general cognitive issues. Titone (2010) interprets the individual symptoms in schizophrenia as slight (albeit significant) disturbances of lower-level abilities whose combination creates obstacles for patients involved in higher-level (discourse) functioning. Chaika (in France and Muir, 1997) abandons strictly linguistic terms in her overview of schizophrenia, emphasizing instead the cognitive symptoms of executive functioning and inattention during conver-sation. She argues that major language-related deficits of schizophrenia such as incorrect word use and inappropriate utterances are due to patients’ lack of maintained focus on a given topic.

It might be easy to assume that for people with schizophrenia who use more than one language, the linguistic problems seen in the L1 might be equally or more pervasive in the L2. For example, someone who invents words for items he cannot retrieve from his L1 mental lexicon might be prone to do so even more frequently when tapping into his smaller L2 lexicon. The literature concerning multilingual individuals with psychosis, however, has at times demonstrated the opposite: for some, symptoms are less severe during L2 use.

Observations of abnormalities in patients’ L1s have been used to inform many studies regarding multilingual patients (i.e. major problem areas in the L1 are regularly



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investigated in the L2). Researchers commonly analyse L2 speech samples provided by a participant in order to compare them either with the same participant’s L1 samples (e.g. Southwood et al., 2009; Theron et al., 2011), or control L2 samples (e.g. Bersudsky et al., 2005; Smit et al., 2011). In either event, these studies typically incorporate findings from L1 schizophrenia research in their analysis of L2 data.

III Second language acquisition (SLA) and schizophrenia

Case studies of multilingual individuals with psychosis date to the turn of the 20th cen-tury, with Bruce’s (1895) three-month case study of a middle-aged Welsh patient (L2 English) with a 15-year history of institutionalization for psychosis. This chronicle is surprisingly sophisticated given its age. The author makes note of daily changes in the patient’s physical coordination, in particular remarking his ambidexterity performing certain tasks (e.g. holding a teacup); the complex relationships between language, hand-edness, and physical coordination are currently gaining momentum in schizophrenia research (see, for example, Rushe et al., 2007). Additionally, Bruce (1895) intuits that the patient’s illness is somehow related to atypical activity of the left and right hemispheres of the brain, an idea that would remain dominant for the next several decades and contin-ues to be considered to an extent in more recent studies (e.g. De Zulueta et al., 2001). Most importantly, perhaps, in charting the patient’s language use and psychotic symptom severity the author discovered uneven expression of symptoms between languages, a trend seen in later studies as well (e.g. Del Castillo, 1970; De Zulueta, 1984; De Zulueta et al., 2001; Hemphill, 1971; Matulis, 1977). The patient exhibited what would come to be known as typical linguistic symptoms of schizophrenia, such as producing regularly incoherent speech and being overly talkative at times. He was equally capable in his L1 and L2, presumably, but would for much of the study choose to communicate exclusively in one or the other, leading the author to label Welsh and English ‘stages’, that could last for days at a time. These stages were by no means steadfast, however, and occasionally he would engage in light code-switching (described as one or two words of the other language). Curiously, the patient’s moods and symptoms of psychosis seemed contingent with this strong preference for one of his languages: The author notes several instances in which the otherwise calm and lucid patient would verbally or physically lash out when someone would attempt to engage him in the ‘wrong’ language.

Subsequent research on bilingual patients with psychosis did not emerge for several decades. Del Castillo (1970) provided a unique glimpse of the mental illness by profiling five bilinguals with schizophrenia and criminal backgrounds. Four participants were charged with murder and the last with aggravated assault and battery. The criminal status of participants adds a special (and potentially controversial) dimension to the discussion, but the author chooses not to highlight that factor. Instead, Del Castillo employs his own English–Spanish bilingualism to personally assess psychotic symptom severity in his participants (except an Italian woman, for whom he employed the assistance of an Italian nurse). Without indicating L2 proficiency, the author noted that the patients, who were often noticeably peculiar in their L1s, appeared entirely normal conversing in English (their L2), exhibiting none of the linguistic symptoms of schizophrenia in their non-dominant language. One patient profiled who presented as clearly psychotic in Spanish




was deemed sane enough to stand trial because of the responses he produced in English. The author postulated that this pattern arose because psychosis slowly distorts thoughts and dreams, and in turn the entire language becomes tainted. The second languages, he argued, are spared because of the mental effort required to produce thoughts in them. Language automaticity and facility might then impact the extent to which a patient exhibits symptoms: The amount of explicit concentration required for producing an utterance in the L2, not needed to produce the same message in the L1, may diminish the full spectrum of a patient’s thoughts, emotions, and language-related symptoms of psychosis.

Examining 30 multilingual patients with schizophrenia, Hemphill (1971) found that all experienced auditory hallucinations, especially the hearing of unreal voices, in only the language in which they naturally produced thoughts (L1). When probed in their L2, most of the individuals interviewed could not recall details of the voices (some even reporting not remembering having ever heard them). Nevertheless, the specifics of the hallucinations could be adequately described in patients’ L1s. The author concluded from these findings that being in L1 environments could exacerbate symptoms and nega-tively impact the mental health of patients, while conversing with them in their other language – and thus forcing them to activate a more explicitly-accessed linguistic system – could be psychologically beneficial.

In a landmark study, Matulis (1977) took these ideas further, testing the hypothesis that foreign language learning could actually mitigate the symptoms of schizophrenia. In an attempt to build ‘a new bridge to reality’ (Matulis, 1977: 462), the researcher acted as German-language instructor for 18 male patients in a schizophrenia ward at Michigan hospital for nearly a year (with regular weekly class sessions), documenting their lan-guage progress in tandem with changes in their symptoms. In this instance, L2 instruc-tion was meant not merely to establish an additional linguistic system in these individuals, but was intended to treat behavioral problems witnessed in the patients’ L1. The researcher made the choice of addressing participant outbursts related to hostility or auditory hallucinations with ‘an intrusion of and the involvement of the patient with the new-foreign language’ (Matulis, 1977: 465), as opposed to having patients removed from the German classes. Without being able to quantify his claims (as he explicitly reveals his choice not to use statistical analysis on his data), the experimenter observed that the patients’ overall well-being improved as a result of German instruction. The entire ward appeared calmer, patients were more coherent and used markedly less pro-fanity, and some members of the original class were released from the hospital prema-turely before the language instruction ended, a fact Matulis attributed to their exposure to German. It is difficult to ascertain precisely the extent to which L2 instruction enhanced the mental health of these individuals, as the author’s observations are the only source of data used in the study. However, the unanticipated early-discharge of some participants is an encouraging indicator of the experiment’s success. More research (especially quan-titative) needs to be performed to determine the exact effect of the language learning process on symptoms of schizophrenia.

This evidence of symptom variability across different languages in bilingual individu-als with schizophrenia, or ‘differential symptomatology’ as it came to be known, has intrigued linguists and psychologists alike. Scholars in these fields were, before the



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advent of sophisticated technology permitting the first glimpses into the mechanics of the brain, trying to understand the neurological basis of schizophrenia and language sep-arately and, as Paradis (2008) points out, differential symptomatology in schizophrenia supported now-outmoded ideas in both fields about activity in the brain. Because most patients seemed more normal in their L2, it was inferred that L2 use must occur in the right hemisphere of the brain, while the symptoms of schizophrenia target the left hemi-sphere. Support for this brain-hemisphere proposition is demonstrated by comparing the discussions in De Zulueta (1984) and De Zulueta et al. (2001), the latter benefiting from the emergence of neuroimaging technology (e.g. functional magnetic resonance imagery, or fMRI). De Zulueta (1984) describes in depth the process of lateralization and asserts that before the age of 10, the human brain is fully split and that most linguistic function-ing takes place in the left hemisphere. The author makes a distinction between balanced and dominant bilingualism and focuses on individuals whose L2 acquisition occurred after brain lateralization to highlight differential symptomatology. This lateralization position is revised somewhat in De Zulueta et al. (2001), with the claim that unilingual auditory hallucinations in multilingual patients result from the activation of ‘spatially distinct parts of Broca’s area’ (2001: 280). This shift from a strong-version of the laterali-zation claim allows the authors to delve more into patients’ affective concerns that could influence symptom severity (e.g. personal attitudes toward their languages).

As the view of hemispheric asymmetry causing differential symptomatology in schiz-ophrenia lost acceptance, scholars began turning toward other models to account for the patterns observed. Paradis (2004) explained schizophrenic speech using the L2 declara-tive-procedural knowledge framework, contending that bilinguals communicating in their L2 may rely more heavily on declarative knowledge and thus explicitly bring their attention to producing utterances. The automaticity of L1 use (i.e. the fact that language can be produced without conscious planning) may make it more conducive to hallucina-tory and delusional thinking, as procedural knowledge does not ordinarily require as much mental energy.

In addition to using newer models of language and cognition to account for differ-ential symptomatology in schizophrenia, researchers have begun to rely more heavily on statistical analysis in their research on language learners with schizophrenia. Unlike much of the purely qualitative, case-study research reviewed here, an interesting triad of studies from South Africa used transcribed speech samples from individuals with schizophrenia to quantitatively assess its divergence from that of other multilingual speakers. Southwood et al. (2009) coded oral interviews of a single male patient who was more comfortable speaking, and displayed fewer psychotic symptoms in his L2, English. According to the patient’s self-report, his English was better than his Afrikaans, but a linguistic analysis demonstrated the reverse. The patient’s L2 sample contained neologisms and other non-standard features, was riddled with uncomfortable pauses, fillers, and false starts not seen in the L1 sample, and had a larger proportion of unin-telligible sections. The pragmatic deficits typically seen in (L1) speech of patients, such as inability to stay on topic and maintain appropriate eye contact, were only wit-nessed in the English sample. The researchers concluded that most of the errors con-tained in the patient’s L2 sample were typical of learner language, except for his pragmatic difficulties. This study suggests that applying a strong version of either the




procedural-declarative knowledge framework or the hemispheric lateralization argu-ment to schizophrenia and L2 acquisition is probably inappropriate, because in this case linguistic symptoms of schizophrenia were witnessed in both of his languages. Using an L2, in other words, did not affect language abnormalities in this patient’s speech, as had been previously postulated. The research design employed in this study effectively allows for a comparison of this single patient’s L1 and L2, but it might have been more revelatory to match his use of the two languages with that of a healthy coun-terpart, as it could have provided a better sense of the his L1 irregularities, as well as the status of his L2 development.

Theron et al. (2011) used a similar methodology, collecting, transcribing, and coding spontaneous L1 and L2 speech samples from four late-bilingual patients with schizo-phrenia to assess differences in pragmatics along 30 separate parameters. The findings indicated that of the parameters measured only quantity of speech (conciseness) was deemed to be inappropriate in all four participants’ samples in both languages, as they would alternately provide too little or too much information to questions. While the researchers did find evidence for uneven symptoms between the sample’s languages in terms of pragmatic deficits, no specific linguistic features could be pinpointed to account for the variability they found among participants. Additionally, despite the fact that the two interviews were recorded with only a 60-minute lapse, participants sometimes pro-vided significantly differing accounts in their L1 and L2 interviews. The variability seen in participants’ responses, and the fact that their analysis was not designed to reveal if participants were telling the truth, led the researchers to posit that no single measure can capture differential symptomatology. Both Theron et al. (2011) and Southwood et al. (2009) emphasize that because the phenomenon arises in some patients, conducting clin-ical examinations in all of a patient’s languages is crucial in order to flesh out a more accurate and descriptive psychiatric profile.

Smit et al. (2011) re-analysed the L2 speech samples generated for Theron et al. (2011) and performed a series of matched tests (using controls with comparable gender, age, education, and age of L2 acquisition onset) analysing the grammatical interlanguage of individuals with schizophrenia. Of the errors captured in the samples, all were normal language-learning errors except for some semantic peculiarities (e.g. ‘I’m starting to develop myself into the church’; Smit et al., 2011: 509), which resulted in nonsensical utterances. This study suggests that in spite of any language abnormalities witnessed in patients’ L1s and L2s, interlingual development occurring before the onset of schizo-phrenia may follow a similar trajectory to that of healthy individuals.

The notion that psychotic individuals may acquire an L2 in a manner comparable to their non-psychotic counterparts was investigated by Bersudsky et al. (2005). Russian immigrants to Israel (n = 8) who received a diagnosis of schizophrenia prior to immigra-tion and exposure to the Hebrew language were matched with healthy immigrants and tested on L2 proficiency in syntactic ability, lexical knowledge, and pragmatics using extended sociolinguistic interviews conducted in Hebrew. Unlike L2 studies with research designs framed around known problem areas of patients’ L1s, Bersudsky et al. (2005) provide a unique glimpse into the effects of psychosis on interlanguage by sin-gling out linguistic structures (most notably the obligatory instances of definite articles) that are commonly problematic for all Russian learners of Hebrew. Contrary to the



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researchers’ hypothesis that patients would perform worse than controls, statistically-significant differences emerged in only two areas, number of pauses and ‘blocking’ (or inability to complete a thought verbally), and some patients actually outperformed their healthy equivalents. This lack of evidence in support of their hypothesis leads the authors to postulate that schizophrenia may factor into L2 acquisition like any other individual difference in learners, and that the illness’ effect on acquisition would be ‘difficult if not impossible to distinguish from motivation, daily exposure time to second language, and concentration’ (Bersudsky et al., 2005: 540). The findings suggest near-identical interlin-gual development between healthy learners and those with schizophrenia, and the author’s entirely novel conclusion that a major mental illness such as schizophrenia might play a relatively minor a role in L2 acquisition warrants further investigation.

A final emerging trend regarding research on bilingual speakers with schizophrenia concerns the context of immigration; participants in Bersudsky et al. (2005) were immi-grants but there is no discussion of that variable’s influence. Second languages learned in adulthood are not always the outcome of volition; immigrants and refugees may acquire host languages out of necessity, so the stakes are higher in terms of acquisition success. Furthermore, a substantial body of SLA literature, and meta-analyses in particular, has described the influence of context, generally identifying significant differences between second and foreign language learning processes and outcomes (e.g. Li, 2010; Plonsky, 2011). Perez Foster (2001) highlights several risk factors associated with immigration that could lead to post-traumatic stress and compromise the mental health of individuals suffering from conditions like schizophrenia. She concludes that trauma caused by immi-gration and refugee stressors must be treated by therapists that are sympathetic to their needs and who can relate to them in all the languages they speak. Other experts (e.g. Paradis, 2008; Smit, 2011; Southwood et al., 2009) have been major proponents of bilin-gual mental health providers in order to better diagnose symptoms that might go unde-tected if polyglot patients are assessed in only a single language. Perez Foster (2001) supports this notion and pushes for an increase in bilingual therapists in order to provide more effective treatment of all patients while meeting the demands of rising global immigration.

IV Limitations in synthesizing the literature

While each of these studies provides an interesting and informative glimpse into the relationship between second languages and schizophrenia, taken collectively they form a body of research with some gaps. First, while this research centers on the state of sec-ond language use as a result of psychosis, existing models of SLA are underrepresented in most of the articles so, from a linguistic standpoint, it is rather difficult to determine authors’ stances on SLA. Second, participants in these studies present with wide-ranging symptoms of schizophrenia and have diverse relationships with their L2s, making gener-alizing findings to larger populations quite difficult. Third, the researchers do not always identify the instruments used to assess patients’ symptom severity, and they use a variety of L2 data collection tools.

Although knowledge of an L2 is an indispensable component of the studies reported here, none has appeared in an SLA journal, and the connections the authors draw to




commonly-accepted models of SLA are at times fairly loose. This is interesting, consid-ering that the primary research questions posed in these studies center on differences between multilingual individuals with schizophrenia and those not affected by the disor-der, or on differences between native and L2 use in patients. It could be argued that most of these studies (Bersudsky et al., 2005; De Zulueta, 1984; De Zulueta et al., 2001; Matulis, 1977; Southwood et al., 2009) adopt a neurolinguistic position, as they either rely on evidence that the L1 and L2 activate different areas of the human brain or turn to hemispheric lateralization. Smit et al. (2011) appears to support an interlingual model of SLA, making a distinction between mistakes and errors (the former being more like slips of the tongue, which occur regardless of language proficiency), and referencing some seminal pieces in the field of SLA (e.g. Corder, 1967; Gass and Selinker, 2001). The con-nections made by other authors, however, are not always so overtly explicit, and it would be virtually impossible to couch all these studies within a single SLA model without losing some of their complexity. Paradis (2004) has successfully unified the disciplines of SLA and neuropsychology by focusing on the level of automaticity associated with language processing and production in L1 and L2 communication and turning to the procedural-declarative framework (Ellis, 2005; Gass et al., 2013). This model assumes that the amount of explicit mental effort required to understand and successfully produce utterances in a language is contingent with one’s familiarity with the language. As lan-guage learners become more acquainted with an L2, they are able to engage in conversa-tion with less (declarative) cognitive effort, and in the case of schizophrenia patients, this heightened familiarity with a language may introduce the opportunity for unusual lin-guistic behavior to appear. It would be advisable for researchers to support future studies with strong SLA underpinnings in a manner similar to this.

The participants in these studies present with wide-ranging symptoms, as can be seen in Table 1. Although the DSM-5 (American Psychological Association, 2013) has elimi-nated schizophrenia subtype designations, it is certainly worth noting that those studies that did report participant subtypes usually included participants from different subtypes. Hemphill (1971) studied individuals with paranoid and catatonic schizophrenia, as well as people with hebephrenia (also known as disorganized type). De Zulueta et al. (2001) included patients with schizoaffective disorder, a closely-related but distinct condition, in addition to paranoid schizophrenia. This sample heterogeneity is liable to continue in future studies informed by the DSM-5, as the subtype labels are no longer valid.

Not all of the studies indicate the measurement of schizophrenia symptoms used, which is especially problematic given the heterogeneity of participant samples. The four studies that do indicate their means of assessing the mental health of participants used the Kay et al. (1994) Structured Clinical Interview for the Positive and Negative Syndrome Scale, or SCI-PANSS, which creates an symptomatic inventory of patients. Having a consistent means of assessing specific symptoms of participants in studies like these is crucial in providing a general baseline of their mental health. In addition to merely nam-ing the tools employed in the assessment of participants, the results of these assessments should be provided in future studies as well, so the reader has a clearer idea of the indi-viduals in question.

The relationship between onset of schizophrenia and exposure to an L2 is the charac-teristic of this body of research which most hinders its synthesis (see Table 1). Of the



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studies, three (Smit et al., 2011; Southwood et al., 2009; Theron et al., 2009) have partici-pants with L2 exposure prior to the onset of schizophrenia, which means that they are not inquiries into SLA but L2 use (the participants all having acquired their additional lan-guages before onset of schizophrenia). These participants are referred to as ‘late’ or ‘unbalanced bilinguals’; however, without specific data comparing L1 and L2 profi-ciency, it is difficult for the reader to ascertain the exact degree of L2 knowledge involved. The participants in two studies (Bersudsky et al., 2005; Matulis, 1977) were exposed to an L2 following diagnosis, making them the only studies investigating the actual pro-cesses of L2 acquisition. The other studies either do not indicate the relationship between L2 exposure and onset of schizophrenia, or feature mixed samples (participants with L2 exposure before schizophrenia onset and after).

The researchers’ means of L2 data collection is another interesting factor to consider in this review. Only a single study (Southwood et al., 2009) incorporated linguistic-spe-cific tasks (vocabulary and verbal fluency tasks used to see if the patient was more pro-ficient in his L2, as he self-reported), with nearly all the rest relying on extended

Table 1. Participant and methodological characteristics of the studies.

Study (by author name and date)

Illnesses/subtype(s) of schizophrenia examined

Test of schizophrenia symptoms used

Relationship between onset of schizophrenia and L2 exposure

L2 data collection instrument(s)

Bersudsky et al., 2005

not specified not specified L2 exposure after onset

extended interview

Castillo, 1970 not specified not specified not specified not specifiedDe Zulueta, 1984

not specified not specified L2 exposure both before and after onset

not specified

De Zulueta et al., 2001

paranoid; schizoaffective disorder

SCI-PANSS L2 exposure both before and after onset

extended interview

Hemphill, 1971 paranoid; catatonic; hebephrenia

not specified not specified not specified

Matulis, 1977 chronic undifferentiated; paranoid

not specified L2 exposure after onset

L2 instruction

Smit et al., 2011 not specified SCI-PANSS L2 exposure before onset

extended interview

Southwood et al., 2009

not specified SCI-PANSS L2 exposure before onset

extended interview; linguistic task

Theron et al., 2009

not specified SCI-PANSS L2 exposure before onset

extended interview

Note. SCI-PANSS = Structured Clinical Interview for the Positive and Negative Syndrome Scale Source. Kay et al., 1994.




interviews eliciting certain linguistic features. Matulis (1977) used L2 instruction as a putative therapy for his patients, but does not indicate how he gauged their L2 develop-ment. It would be immensely useful to see how people living with schizophrenia perform in contexts other than the traditional clinical structured interview.

V Suggestions for future research

The literature cited in this review has examined: the ways in which a previously-learned L2 is affected by subsequent onset of schizophrenia; differences in L2 learning between individuals with and without the disorder; and differences in symptoms of psychosis across patients’ languages. These intriguing research threads need more attention in the future, as well as more direct influence from the field of SLA, in order to provide a clearer sense of the nature of L2 acquisition and use in patients with schizophrenia. A number of additional questions arise in light of this literature which may also be worth exploring in the future.

One principal question emerging from this literature, especially in light of Bersudsky et al. (2005), who suggest that schizophrenia may simply constitute an individual differ-ence, is: Are there linguistic areas in which people living with schizophrenia could potentially outperform other L2 learners and users? Coining and incorporating neolo-gisms or word-approximations into first-language conversation with other native speak-ers, for example, could lead to communicative breakdowns, as listeners are liable to expect speakers to share a certain L1 lexical base. However, it is probable that native speakers interacting with non-native speakers do not have the same conversational expectations. In such cases, the use of neologisms might be interpreted not as conversa-tional derailment but as a strategy on the part of the language learners for referring to things in the L2 for which they do not know the actual terms. The ability to think crea-tively about words and conceive alternative expressions conveying the same meaning on the part of language learners with schizophrenia might actually be found to prevent com-munication breakdowns resulting from lack of L2 vocabulary.

Similarly, how do auditory hallucinations, believed by most experts to interfere with L1 communication, function during L2 learning? Morley (2001) identifies auto-direc-tional listening, or monitoring the internal self-dialogue in which the thinker is both ‘speaker’ and ‘listener’, as one of three primary communicative listening modes useful for language learning. She suggests that actively tuning in to the language contained in one’s thoughts can be a skill used to complement other kinds of listening (in which oral input comes from external sources) in language learning, presumably by activating inter-nal dialogue conducted (at least partially) in the L2. Future studies could investigate whether attempts to explicitly activate auto-directional listening of language learners with schizophrenia help facilitate L2 acquisition.

All of the studies outlined here assessed L2 speaking in individuals diagnosed with schizophrenia, but no research has investigated L2 listening, reading, or writing in this population. Whitford et al. (2013) recently used eye tracking and phonological process-ing tests to pinpoint specific areas of difficulty (e.g. the amount of time spent gazing at individual words on a page) that people with schizophrenia may have in L1 reading;



Dugan 319

perhaps a similar methodology could be adapted for future investigations into patients’ L2 reading proficiency.

One moderating variable that is not controlled for in these studies, but that undoubt-edly has a significant effect, is the use of medication. A wide variety of antipsychotic medications are available today, and many have been demonstrated to be particularly effective at relieving symptoms of thought disorder (e.g. muting the voices tied to audi-tory hallucinations), which could heighten communicative success of patients in one or both of their languages. Future longitudinal studies should track long-term effects of antipsychotic medication in people with schizophrenia who speak more than one language.

Finally, new lines of research should explore the language produced outside the con-fines of question-and-answer interviews (generally conducted in a mental health care facility, institution, or laboratory) to understand the nature of more informal, conversa-tional speech in people with schizophrenia. L1 and L2 conversation analysis may reveal features, such as reporting conflicting accounts, which elude other kinds of analyses (e.g. pragmatic analysis). In all of the studies reviewed, participants interacted only with the researchers and, regardless of how naturalistic the interviews may have been, the partici-pants undoubtedly knew that the researchers’ only purpose in initiating conversation was to make observations about them. It would be highly beneficial to see how patients inter-act with known interlocutors in more casual settings where they are not being scrutinized by a stranger. Patients may be more coherent and better able to focus their attention on conversation (in any of their languages) when they are not ‘patients’ at all, but rather in familiar environments, speaking with people they know and with the agency to choose topics themselves.

Acknowledgements

As an advanced language learner living with the disorder outlined here, this article has been revela-tory to me both academically and personally. In addition to the reviewers for their insightful com-ments, I would like to thank Dr. Michel Paradis for his feedback and for providing one of the studies reviewed in this article. Special thanks to Dr. Luke Plonsky for his guidance and support at every step of this process.

Declaration of conflicting interest

The author declares that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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