syndromes of schizophrenia and language dysfunction

Syndromes of Schizophrenia and Language DysfunctionÄ

Glenn D. SheanCollege of William & Mary

This study investigated the relationship between performance on wordassociation and sentence construction tasks and the three-syndrome modelof schizophrenic symptoms. Participants were 70 inpatients with a pri-mary diagnosis of schizophrenia. Each participant was rated on positiveand negative symptom scales, and ratings were grouped into three syn-dromal patterns (Reality Distortion, Psychomotor Poverty, and Disorgani-zation). Among the syndromes, only symptoms of disorganization weresignificantly related to the ability to construct meaningful sentences usingword associations. Results suggest that symptoms of disorganization, lengthof hospitalization, and premorbid adjustment are dimensions that are relatedto language disturbance in patients with schizophrenia. © 1999 JohnWiley & Sons, Inc. J Clin Psychol 55: 233–240, 1999.

The importance of disturbances of the associational processes as a diagnostic sign ofschizophrenia was first emphasized by Eugen Bleuler (1911). TheDiagnostic and Sta-tistical Manual of Mental Disorders, Third Edition, Reviseddescribed schizophrenia as:“A disturbance in the form of thought. . . . Themost common example of this is looseningof associations, in which ideas shift from one subject to another, completely unrelated oronly obliquely related subject” (American Psychiatric Association, 1987, p. 188). Althoughthe clinical literature has emphasized the diagnostic importance of disturbed associationsas a sign of thought disturbance; research has provided limited support for the assump-tion of a central role for disturbed associations in the diagnosis of schizophrenia. Only asubgroup of poor, premorbid, chronic patients has been reliably demonstrated to givemore bizarre or idiosyncratic word associations than nonschizophrenic psychiatric patientcontrols (Schwartz, 1978).

Despite considerable effort researchers have not been able to define the nature ortype of associational or language disturbance that is characteristic of all or most patientswith schizophrenia. Much of the research on language disturbances in schizophrenia hasfocused on identifying the underlying information-processing deficits thought to be mark-ers of a stable vulnerability factor across clinical states (Docherty et al., 1996; Morice,

Pilot research for this project was conducted with the assistance of Diane Johnson, Ph.D.Correspondence concerning this article should be addressed to Glenn D. Shean, Ph.D., Psychology Depart-ment, College of William & Mary, Box 8795, Williamsburg, VA 23187-8795.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 55(2), 233–240 (1999)© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/020233-08

1986; Neuchterlein, Dawson, & Green, 1994). In contrast to the assumption of a stablevulnerability factor Barch and Berenbaum (1996) have concluded that schizophrenicthought disorder and language disturbance are multifaceted in nature and etiology.

Cohen and Servan-Schreiber (1992) maintained that the language abnormalitiesobserved in patients with schizophrenia result from impairment in the ability to constructand maintain representations of contextual information over time. As a consequence,higher-level contextual representations and the related ability to generate appropriateexpectancies from these representations are disturbed, allowing inappropriate associativeprocesses and content to intrude into thought and speech. From this perspective patientswith schizophrenia are unable to maintain responding to expectancies generated from thecurrent context, expectancies that focus on relevant semantic concepts, and to inhibit theintrusion of information that is not appropriate.

The perspective articulated by Cohen and Servan-Schreiber (1992) emphasizes theparticular context in which communications are expressed. Two issues appear to beunresolved in the literature reviewed earlier. First, the relationship between associationaland language disturbances and current symptom picture remains unclear. Second, it is notclear whether schizophrenic language disturbance, if present, may be due to underlyinginformation-processing deficits as opposed to contextual and emotional influences thatinterfere with maintenance of a discourse appropriate focus.

Gordon, Silverstein, and Harrow (1982) studied whether the disturbed associationsof patients with schizophrenia would become meaningful when placed in the context of asentence created to explain their associations. They reported that 70% of schizophreniapatients’ responses that were originally judged to be pathological became meaningfulwhen used in the context of a sentence that included the stimulus word. Good premorbidpatients evidenced the highest frequency of associations that included personal material;however, members of this group were also best able to clarify their thoughts in context. Incontrast, poor premorbid schizophrenia patients gave fewer associations that were per-sonalized and were also significantly less able to clarify their associations. The authorsconcluded that good premorbid schizophrenia patients in particular did not evidence adisturbance in the associative network of responses but rather a difficulty in editing outpersonalized, idiosyncratic verbalizations and responding to the current context.

Recent multivariate research has indicated that a 3-factor solution best fits positiveand negative symptom ratings of schizophrenia patients (Andreasen, Arndt, Alliger, Miller,& Flaum, 1995; Cuestra & Peralta, 1995; Liddle, 1987). Liddle (1987) labelled the threesymptom patterns as Psychomotor Poverty/Negative syndrome, Disorganization syn-drome, and Reality Disturbance syndrome. Neuropsychological testing suggests that theDisorganization syndrome in particular, is related to impairment in higher language func-tion (Liddle & Morris, 1991).

This research studied the relationship between premorbid adjustment, the symptompatterns identified by Liddle (1987) and others, and performance on word associationand sentence construction tasks. It was predicted that idiosyncratic word associationsand impairment in the ability to use word pairs in the context of a meaningful sentencewould be significantly correlated with poor premorbid adjustment and symptoms ofdisorganization.

METHOD

Participants

Seventy patients in a state mental hospital served as participants. Participants were recruitedfrom all psychiatric treatment areas of the hospital. Care was taken to ensure that all

234 Journal of Clinical Psychology, February 1999

participants met the following criteria: an Axis I primary diagnosis of schizophrenia, nochanges in medication in the last 2 weeks, no record of an acute psychotic episode withinthe previous 2 weeks, and no diagnostic record of organic brain disorder, substance abusewithin the past year, or mental retardation. Additional information taken from recordsincluded age, education, race, age at first hospital admission, number of hospitalizations,current medications, and length of current hospitalization.

Staff diagnoses were confirmed using the psychotic and mood disorders section ofthe Structured Clinical Interview for the DSM-III-R (SCID; Spitzer, Williams, Gibbons,& First, 1990). The interviews were completed by an interviewer who had extensiveexperience conducting structured clinical interviews.

The sample included 43 men and 27 women. Average age was 35.6 years (range: 20to 65 years); average years of education completed was 10.15, and average IQ estimatewas 81 (SD5 7.65), based on estimates derived from the formula provided by Hafner,Corotto, and Curnutt (1978). The majority of participants could be characterized as chronicpatients: average length of current hospitalization was 9.54 months, number of hospital-izations (M 5 8.1,SD5 4.8), and age at first hospital admission was 20.8 years. Neuro-leptic medication was converted to Thorazine equivalents using conversion tables(Schatzberg & Cole, 1986). Average neuroleptic medication dosage for all participantswas 1,138 mg (SD5 816 mg). Newer antipsychotic medications and other psychoactivemedications were not included in the conversions, as no acceptable conversion formulaswere available.

Measures

The Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) wasused to assess symptoms. Data from an interview, as well as information from the par-ticipant’s hospital records, were applied within 24 hours after the diagnostic interviewand test session to scoring of the PANSS. The PANSS has been shown to have a highlevel of concordance with the Andreasen positive and negative symptom rating scales(Kay et al., 1987), and has been widely studied psychometrically (Cuestra & Peralta,1995).

A second rater was present during the interviews and chart reviews of 40 partici-pants. Ratings were completed by both raters individually. Interrater reliability of overallPANSS ratings using intraclass correlations was acceptable (negative symptomsr 5 .81;positive symptomsr 5 .72).

The Ullman and Giovannoni (1964) premorbid psychosocial history questionnairewas modified from a self-report format and used as a checklist to be completed by theinterviewer based on information from the interviews and chart reviews. Intraclass cor-relations of total score ratings for 40 participants was acceptable (r 5 .68).

All words included in the word association task were derived from the Kent-Rosanoff (Kent & Rosanoff, 1910) word lists. Response words were rated on common-ality based on revalidated Kent-Rosanoff norms (Bettner, Blum, & Jarvik, 1982). Thestimulus words used were high-frequency words: boy, mountain, spider, lamp, sleep,beautiful, window, child, scissors, music, butterfly, earth, quiet. Each of the 13 associa-tions were written down and later classified as either “common” or “idiosyncratic” basedon the norms published by Bettner et al. (1982).

Procedure

All procedures to assure confidentiality and voluntary consent of participants were fol-lowed. Each participant was tested individually by the experimenter in a single interview

Schizophrenia and Language Dysfunction 235

and test session. Participants were first interviewed using the PANSS interview guide-lines. Next, the Block Design, Similarities, and Picture Arrangement subtests of the Wech-sler Adult Intelligence Scale-Revised (WAIS-R, 1981) were administered.

After completion of the PANSS interview and intelligence subscales, the Word Asso-ciation Test was administered. Participants were verbally presented with a stimulus wordand asked to respond verbally with the first word that came to mind.

After completion of the word association task participants were given a 5-minutebreak, then they were asked to use each word pair in a sentence and to explain how thewords went together. For example, participants might be reminded that their first asso-ciation to the word “boy” was “tooth.” Next, they would be asked to make up a sentencethat included the two words. Each of the 13 sentences given to the word association pairswere written down by the experimenter verbatim. Finally, participants were asked toexplain how the words went together in the sentence. These explanations were also writ-ten down by the experimenter.

Sentence Ratings.Sentence formulation protocols were scored on a scale designed tomeasure the degree of relatedness between stimulus-response word pair associations usedin a sentence and take into account whether the meaning of the association is clear, vague,or nonmeaningful. To simplify data analysis raters grouped the eight rated sentence typesof the cognitive dimensions scale developed by Gordon et al. (1982) into a simplifiedframework of three categories: (a) Associated (including category 1, Well Clarified;category 2, Mediated Response; and category 3, Personalized Responses from Gordonet al., 1982), (b) Marginal (category 4, phonetic responses from Gordon et al., 1982), and(c) Not Associated (including categories 5, Semantically Ambiguous; 6, Unexplained;7, Elaboration of Stimulus or Response Word Only; and 8, Spoiled Responses from Gor-don et al., 1982). Two trained raters, blind to diagnoses of the participants, independentlycompleted the scoring of responses to the sentence formulation test. The two raters achievedsatisfactory interrater reliability for sentence type (intraclass correlations: (a) Associatedr 5 .77, (b) Marginalr 5 .88, (c) Not associatedr 5 .83).

RESULTS

Syndrome scores were obtained by adding the scores of all PANSS items that loaded onthat factor syndrome as indicated by previous research (Cuestra & Peralta, 1995; Liddle,1987). Interitem correlations within syndromes indicated good consistency of ratings.The syndrome Reality Disturbance was scored as the sum of the PANSS items: delusions,suspiciousness, and hallucinatory behavior. Cronbach’s alpha (.78) for the reality distur-bance items indicated acceptable reliability within items. Psychomotor Poverty (PP) wasscored as the sum of ratings on emotional withdrawal, passive/apathetic social with-drawal, lack of spontaneity, and motor retardation. Cronbach’s alpha for the PP items was.81. The Disorganization syndrome was scored as the sum of item ratings for level ofconceptual disorganization, stereotyped thinking, disorientation, and difficulty in abstractthinking. Cronbach’s alpha for the disorganization items was .80.

Syndrome scores were significantly correlated with the following variables: (a) real-ity disturbance symptoms with current neuroleptic medication (r 5 .41, p , .01),(b) education with disorganization symptoms (r 5 2.30, p , .05) and, (c) disorganiza-tion symptoms with length of current hospitalization (r 5 .45, p , .01). There were nosignificant gender or racial differences observed on any syndrome scores or dependentmeasures.


Word association responses were removed from the individual protocols and scoredblindly after all data was collected. A “common” score was recorded if the response wordappeared in the listing for the appropriate stimulus word. An “idiosyncratic” responsewas recorded if a response word was not found among the common associations listing.The majority of word associations to the 13 stimulus words were rated as common responsesaccording to normative data (M 5 9.24,SD5 3.24) and idiosyncratic associations (M 53.76, SD 5 1.43). Common word associations were significantly correlated with poorpremorbid history (r 5 2.29,p , .05), and with symptoms of disorganization (r 5 2.31,p , .05).

Participants gave nearly equal numbers of meaningful (M 5 6.83,SD5 3.95), andnonmeaningful (M 5 6.17,SD5 3.92) sentences. Sentence ratings were not significantlycorrelated with either common or idiosyncratic word associations. It was predicted thatmost patients’ idiosyncratic associations would become less deviant when placed in thecontext of a sentence. This prediction was not borne out in the majority of cases. Forty-two participants constructed the same number or more sentences that were rated as notmeaningful than their number of idiosyncratic associations, and 28 constructed moremeaningful sentences than idiosyncratic associations. Thirty-one of the 42 participantswho constructed more nonmeaningful sentences scored above the median on symptomsof disorganization.

The ability to place word pairs in the context of a meaningful sentence correlatedsignificantly with disorganization symptoms (r 5 2.49,p , .01), premorbid adjustment(r 5 2.28,p , .05), and length of current hospitalization (r 5 2.38,p , .01). Pearsoncorrelations between word associations, sentence ratings, participant characteristics, andsyndrome scores are presented in Table 1.

Listwise multiple regression, with symptoms of disorganization, premorbid adjust-ment, and length of current hospitalization as predictor variables, indicated that thesevariables predicted the ability to place word pairs into a meaningful sentence (F 5 13.37,df [3, 66], p , .001, multipleR 5 .62; adjustedR2 5 .35). Each of the three predictorvariables was negatively associated with the ability to create meaningful sentences: symp-toms of disorganization (b 5 2.31, t 5 22.75,p . .01), premorbid adjustment (b 52.34, t 5 23.32,p , .01), and length of current hospitalization (b 5 2.34, t 5 22.88,p , .01).

Nonmeaningful sentence ratings were also significantly correlated with symptoms ofdisorganization (r 5 .43,p , .01), poor premorbid history (r 5 .28,p , .05), and lengthof current hospitalization (r 5 .32,p , .05). Recall that some sentences were rated in a

Table 1. Pearson Correlations of Syndromes and Word/Sentence Categories

Associations

Sentence RatingsCommon

Responses Positive Negative

Reality Disturbance −.08 −.25 .24Psychomotor Poverty −.17 .02 .03Disorganization −.31* −.49** .43**

Poor Premorbid −.29* −.28* .28*

Current Hospitalization −.24 −.38** .32*

IQ Estimate .17 .24 −.23Education .16 .24 −.25

*p < .05. **p < .01.


third marginal category. Multiple regression with disorganization, premorbid adjustment,and length of hospitalization used as predictor variables for nonmeaningful sentenceratings was significant (F 5 9.35,df [3, 66], p , .001, multipleR5 .55, adjustedR2 5.27). Results indicated that poor premorbid adjustment (b 5 .33, t 5 3.02, p , .01),symptoms of disorganization (b 5 .27, t 5 2.23,p , .05), and length of hospitalization(b 5 .29, t 5 2.32,p , .05) were predictive or nonmeaningful sentence constructions.

DISCUSSION

Previous research by Gordon et al., (1982) indicated that 70% of the idiosyncratic wordassociations of schizophrenia patients were rated as meaningful when placed within thecontext of a sentence. The authors concluded that most patients with schizophrenia showedlittle evidence of a deficit in language function when contextual information was takeninto consideration. Poor premorbid patients were reported to have the most difficultyclarifying their associative responses in the context of a sentence.

In this study positive and negative symptom ratings of patients using the PANSSwere grouped into three syndromes based on multivariate studies published by Arndt,Alliger, and Andreasen (1991); Cuestra and Peralta, (1995); Liddle (1987); and others, todetermine if symptom groupings were differentially related to associational disturbanceand impairment in the ability to use associations in the context of a meaningful sentence.Among the three syndromes (disorganization, psychomotor poverty, and reality distur-bance), only symptoms of disorganization were associated with the ability to create mean-ingful sentences from word association pairs. In addition to symptoms of disorganization,length of current hospitalization and premorbid psychosocial adjustment were also pre-dictive of the ability to create meaningful sentences using word association pairs. Resultsindicate that these patient characteristics together account for about 35% of the variancein participants’ ability to construct meaningful sentences.

Docherty et al. (1996) observed that the speech derailments of schizophrenia patientsare the result of associative distractors that divert the speaker from a focused discourseplan and result in loss of coherence. They maintain that the communication disturbancesobserved in patients with schizophrenia are related to deficiencies in cognitive processessuch as working memory and sustained attention. The results of this study suggest thatlanguage deficits are most likely to be observed in patients with poor premorbid psycho-social histories and symptoms of disorganization, who have been hospitalized continu-ously for relatively long intervals. It would follow that the underlying cognitive deficitspostulated by Docherty et al., would be most likely to occur in patients who are charac-terized by high scores on these dimensions.

About one-half of the sentences constructed by participants, whether to common oridiosyncratic associations, were rated as meaningful uses of the word pairs. Contrary topredictions, only 22 of the 70 participants in this study were able to create more mean-ingful sentences from their association pairs than their total number of idiosyncratic wordassociations. In addition, only 52% of the sentences constructed by all participants wererated as meaningful compared to 70% reported by Gordon et al. (1982). Several differ-ences in methodology and sample characteristics may account for these differences inresults between the two studies. First, the group of schizophrenia patients studied byGordon et al. was younger (mean age5 23.9 years versus 35.6 years), better educated(average educational level mean5 12.5 years versus 10.8 years), and higher in estimatedIQ (102 versus 81) than the patients who participated in this study. Second, there wereseveral methodological differences between the studies. Gordon et al. administered thesentence formulation test within 24 hours of the word association test, whereas in this


study the sentence formulation task was administered within 10 minutes of the wordassociation test. Gordon et al. used 20 stimulus words of high frequency occurrence fromthe Thorndike-Lorge G count, and recorded up to 10 discrete associations for each word.We selected 13 common words for which updated word association norms were avail-able. Raters, rather than normative frequency tables, were used by Gordon et al. to deter-mine the relatedness of each word association. Finally, Gordon et al. selected only six toeight stimulus-response pairs that received low ratings, indicative of idiosyncratic asso-ciative responses, to be included in the sentence formulation task. In this study all 13word association pairs, whether rated common or idiosyncratic, were included in thesentence formulation task. The fact that participants in the Gordon et al. study gave ahigher percentage of meaningful sentences than the population sample in this study, eventhough they constructed sentences only from idiosyncratic associations, is consistent withthe descriptive differences between the study populations. Unfortunately, Gordon et al.did not provide information on sample characteristics such as average premorbid adjust-ment score, and length of current hospitalization; it would appear, however, that partici-pants in this study were also more chronic than participants in the Gordon et al. study.

In conclusion, results suggest that the tendency toward speech derailments observedin many patients with schizophrenia is correlated with premorbid psychosocial adjust-ment, length of current hospitalization, and current symptoms of disorganization. Lan-guage disturbances that interfere with the ability to engage in focused discourse andresult in lost coherence do not appear to be characteristic of all patients with schizophre-nia, but of those who tend to be hospitalized for longer intervals, with poor premorbidhistories, and symptoms of disorganization. These characteristics may be of particularinterest in future studies of language and information-processing deficits in patients withschizophrenia. In addition, clinicians might consider identifying the syndrome scores ofindividual patients as a useful source of information for placement in intervention pro-grams such as skills training and psycho-educational and therapy groups because thesesyndromes are related to levels of cognitive function, abstract ability, and verbal coher-ence that impact on patients’ ability to benefit from different intervention programs.

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