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The linguistics of schizophrenia: thought disturbance as language pathology across positive symptoms

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We hypothesize that linguistic (dis-)organization in the schizophrenic brain plays a more central role in the pathogenesis of this disease than commonly supposed. Against the standard view, that schizophrenia is a disturbance of thought or selfhood, we argue that the origins of the relevant forms of thought and selfhood at least partially depend on language. The view that they do not is premised by a theoretical conception of language that we here identify as 'Cartesian' and contrast with a recent 'un-Cartesian' model. This linguistic model empirically argues for both (i) a one-to-one correlation between human-specific thought or meaning and forms of grammatical organization, and (ii) an integrative and co-dependent view of linguistic cognition and its sensory-motor dimensions. Core dimensions of meaning mediated by grammar on this model specifically concern forms of referential and propositional meaning. A breakdown of these is virtually definitional of core symptoms. Within this model the three main positive symptoms of schizophrenia fall into place as failures in language-mediated forms of meaning, manifest either as a disorder of speech perception (Auditory Verbal Hallucinations), abnormal speech production running without feedback control (Formal Thought Disorder), or production of abnormal linguistic content (Delusions). Our hypothesis makes testable predictions for the language profile of schizophrenia across symptoms; it simplifies the cognitive neuropsychology of schizophrenia while not being inconsistent with a pattern of neurocognitive deficits and their correlations with symptoms; and it predicts persistent findings on disturbances of language-related circuitry in the schizophrenic brain.
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HYPOTHESIS AND THEORY
published: 16 July 2015
doi: 10.3389/fpsyg.2015.00971
Edited by:
Andrea Moro,
Institute for Advanced Study IUSS
Pavia, Italy
Reviewed by:
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Pavia, Italy
Marta Bosia,
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*Correspondence:
Wolfram Hinzen,
Department of Linguistics, Grammar
& Cognition Lab, Universitat
de Barcelona, Gran Via de les Corts
Catalanes 585, 08007 Barcelona,
Spain;
Department of Philosophy,
University of Durham, Durham, UK
hinzen@ub.edu
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Frontiers in Psychology
Received: 17 November 2014
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Published: 16 July 2015
Citation:
Hinzen W and Rosselló J (2015)
The linguistics of schizophrenia:
thought disturbance as language
pathology across positive sym ptoms.
Front. Psychol. 6:971.
doi: 10.3389/fpsyg.2015.00971
The linguistics of schizophrenia:
thought disturbance as language
pathology across positive symptoms
Wolfram Hinzen1,2,3*and Joana Rosselló3
1Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain, 2Department of Philosophy, University of Durham,
Durham, UK, 3Department of Linguistics, Grammar & Cognition Lab, Universitat de Barcelona, Barcelona, Spain
We hypothesize that linguistic (dis-)organization in the schizophrenic brain plays a more
central role in the pathogenesis of this disease than commonly supposed. Against
the standard view, that schizophrenia is a disturbance of thought or selfhood, we
argue that the origins of the relevant forms of thought and selfhood at least partially
depend on language. The view that they do not is premised by a theoretical conception
of language that we here identify as ‘Cartesian’ and contrast with a recent ‘un-
Cartesian’ model. This linguistic model empirically argues for both (i) a one-to-one
correlation between human-specific thought or meaning and forms of grammatical
organization, and (ii) an integrative and co-dependent view of linguistic cognition and
its sensory-motor dimensions. Core dimensions of meaning mediated by grammar
on this model specifically concern forms of referential and propositional meaning. A
breakdown of these is virtually definitional of core symptoms. Within this model the
three main positive symptoms of schizophrenia fall into place as failures in language-
mediated forms of meaning, manifest either as a disorder of speech perception (Auditory
Verbal Hallucinations), abnormal speech production running without feedback control
(Formal Thought Disorder), or production of abnormal linguistic content (Delusions).
Our hypothesis makes testable predictions for the language profile of schizophrenia
across symptoms; it simplifies the cognitive neuropsychology of schizophrenia while
not being inconsistent with a pattern of neurocognitive deficits and their correlations
with symptoms; and it predicts persistent findings on disturbances of language-related
circuitry in the schizophrenic brain.
Keywords: schizophrenia, language, thought, formal thoughtdisorder, hallucinations, delusions, self-disturbance
A Novel Perspective on Language and Thought in
Schizophrenia
On a common view, language is a vehicle for communication, grounded in pre-existing thought,
which provides its content. On this view, delusional symptoms like a person’s belief that he is
Jesus Christ are typically classed as disturbances in ‘thought’ rather than language: language merely
‘reflects’ an underlying disturbance in the thought process, without being an aspect of its etiology1
.
1Cf. Frith (1992,p.97), who argues thatthereis a ‘fundamental dierence between languageandthought(...). Thinkingisa
private matter, whereas language is arguably the most important method we have for communicating with others.’
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Hinzen and Rosselló The linguistics of schizophrenia
If language is merely a tool, and this tool is detached or broken,
we would then expect that thought could stay the same, and vice
versa. Global aphasia, where core cognition can seem surprisingly
normal may illustrate precisely such a predicament (Varley, 2014;
but see Baldo et al., 2010). If aphasia is a language disturbance,
not a fundamental cognitive one, schizophrenia could then be
regarded as the reverse case, in line with the clinical impression
that aphasia-like language disturbances are not characteristic of
either schizophrenic speech or comprehension, and the empirical
finding that bad performance on aphasia-type test batteries is a
function of the general intellectual impairment seen in patients
with schizophrenia rather than a specific neuropsychological
deficit (Oh et al., 2002).
Bleuler (1911, p. 121) classically confirms this perspective
when he notes that the primary symptoms of schizophrenia
‘find their expression in language,’ but ‘here the abnormality
liesnotinlanguageitself,butinwhatithastosay.’Unlikein
aphasia, that is, where patients struggle to communicate normal
thoughts that others would articulate in normal sentences, in
schizophrenia the meaning itself is distorted. Yet it is clear
that we cannot separate ‘what language has to say’ (meaning)
from ‘language.’ More specifically, it is an inherent aspect of
language that it conveys content of a particular kind,which
carries information about the world and from which we can
learn. If language stops conveying such content, as in delusional
statements that cannot be true (‘I came to earth in a cosmic
bubble’), or disordered speech (‘A conclusion is my French
professor’), language loses its function of carrying and conveying
such content. If having and conveying such content is an inherent
aspect of language, such loss therefore is a disorder of language,
though crucially not an aphasic one. Bleuler (1911) himself didn’t
fail to document a fundamentally altered relationship that some
of his patients had with language, to the point of them developing
artificial languages (Kunstsprachen) used as if they were normal
ones. Moreover, his essential experimental methods were word
association experiments carried out with his assistant C. G. Jung,
who theorized that ‘words are really something like condensed
actions, situations, and things. [They are] linguistic substitutes
for reality’ (Jung, 1910, p. 223) – in short, the specific currency
of human thought.
Comparative studies of cognition and communication across
species confirm an explanatory gap between linguistic and
non-linguistic cognitive and communicative contents (Hauser,
1996;Penn et al., 2008;Tomasello, 2008). Some philosophers
(e.g., Davidson, 1982, 2004) deny the very applicability of the
term ‘thought’ to non-verbal species. Even if we don’t follow
them, language correlates with forms of thought, history, and
culture that are highly distinctive. It plays a crucial role in
cognitive development (Vouloumanos and Waxman, 2014).
Where language does not develop normally, thought is altered
as well, as in children on the autism spectrum (Eigsti et al.,
2011), or it radically impoverishes as in language-less adults
(Schaller, 1991) or deaf children deprived of a sign language
(Humphries et al., 2014). In the context of hominin evolution,
a radically different mind-set separates our own version of
Homo from all other species in this genus, in which language
is absent or uncertain (even if speech was present). According
to Tattersall (2008, 2014), language is the most likely cognitive
principle that transformed pre-sapiens cognitive phenotypes
into their modern human variety, re-configuring the hominin
mind rather than merely expressing one that pre-existed the
arrival of linguistic communication. Supporting this perspective,
Hinzen and Sheehan’s (2013) recent ‘Un-Cartesian’ linguistic
framework (Sheehan and Hinzen, 2011;Arsenijevic and Hinzen,
2012;Hinzen, 2014, 2015;Martin and Hinzen, 2014) provides
a language-based account of human-specific forms of thought,
reference, and selfhood centered on grammar. In the wake of
language, new diseases affecting this new mind could then have
arisen as well, with schizophrenia as a potential example: the
‘price we paid for language’ (Crow, 1997, 2007;seealsoKleist,
1914).
The un-Cartesian linguistic framework goes further than
recent foundational views that grant language a ‘supra-
communicative’ function, over and above its function as a tool
of interpersonal communication (Carruthers, 1996;Clark, 1998).
On Clark’s (1998) view, language functions as a technology
to ‘enhance’ cognition and facilitate thinking through verbal
assistance, aiding mental computation much like other external
artifacts such as sextants, compasses or maps do. Inventing
a compass or a map, however, is something that a creature
does that already has a modern human mindset. What is to be
explained is a difference in the fundamental cognitive type that
characterizes modern humans, putting a form of rational thought
in place that we do not see in non-human species, including
extinct human ones. The question that un-Cartesian linguistics
addresses is how we obtain this cognitive type, which uniquely
invented language and started communicating linguistically2
.Its
central claim, that the human-specific form of rational thought
and language arose together, makes the prediction that they
should also fall together. It follows that schizophrenia could be
re-conceptualized as manifesting a breakdown of the linguistic
frame of thought and hence that it can be illuminated in linguistic
terms.
The Hypothesis
The hypothesis of this article is that schizophrenia is a breakdown
of how language configures thought in the normal brain, viewed
against an un-Cartesian background theory of what language is.
Language circuitry in the brain is disturbed, resulting in forms
of thought that cannot be shared anymore and lose objectivity,
including thoughts about other minds, leading to a breakdown of
normal social cognition and communication that depend on the
linguistic frame of thought being intact.
Four Predictions
(1) Most fundamentally, language should illuminate cognitive
change seen in symptoms, which should not only have
linguistic interpretations, as already argued by Crow (1997),
but involve a malfunctioning in core linguistic variables that
are key to what ideas we can communicate in language.
2It builds on a long tradition in which language is regarded as primarily a tool
for thought rather than communication (von Humboldt, 1836;Mueller, 1887;
Chomsky, 2007).
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Hinzen and Rosselló The linguistics of schizophrenia
This malfunctioning should not be seen in superficially
similar conditions such as ‘fluent’ aphasia, when and as long
as cognition in these conditions is normal or changed in
different ways than it is in schizophrenia. In short, across
symptoms and conditions, linguistic and cognitive profiles
should match.
(2) Studies of the language of schizophrenia after Chaika (1974),
(Rochester and Martin, 1979;Morice and Ingram, 1982;
Wykes and Leff, 1982;Oh et al., 2002;Covington et al., 2005)
have tended to use linguistic theory as a way of formalizing
and identifying anomalies in schizophrenia speech rather
than as an explanatory framework. By contrast, the un-
Cartesian linguistic framework generates the prediction
that the linguistic anomalies we will find in such speech
specifically concern the ways in which, according to this
framework, grammar mediates referential, and propositional
forms of meaning. A very specific prediction is that the
more forms of reference are mediated grammatically, the
more they should manifest anomalies/impairment (e.g., the
use of deictic and definite noun phrases should be more
impaired/anomalous than the use of non-definites).
(3) The more language-dependent a neurocognitive variable is,
the more it should be affected (see Section “Language and the
Cognitive Neuropsychology of Schizophrenia”).
(4) The neural correlates of core symptoms – and even of
key cognitive variables including ‘theory of mind’ (ToM) –
should be part of the language network.
The Theory
Language is an integrative system: therein lies its special status
among all other neurocognitive variables. In any utterance we
ever make, all of the cognitive functions come together in
a coherent way: speech, thought, affect, perception, memory,
attention, planning, etc. If language falls apart, ‘loosening of
associations’ in Bleuler’s (1911) sense – i.e., the disintegration
of the ‘psychic functions’ – should therefore result. More
specifically, we can depict language as a triangle having three
essential corners: speech production, speech perception, and
content (we cannot but talk about the world). None of the corners
are independent of any of the others [hearing and speaking
go together as capacities (Menenti et al., 2011), and there is
meaning in both, inherently]. Moreover, in speech, the speech
agent identifies himself as the subject of the speech act in the
grammatical 1st person, and as talking to a speech-perceiving
agent identified in the grammatical 2nd person. In this sense, all
of our utterances are embedded under a silent ‘Ithink/say to you
that.’ Moreover, all such talk is about the world, the grammatical
3rd (or non-) Person (see Figure 1).
Depending, then, on which corner is disproportionally
affected by the disease process (perception, production, or
content), creating an imbalance in the normal language function,
we can give a linguistic characterization of the three core positive
symptoms according to current DSM-5 criteria in the following
way (Figure 2):
A disorder of speech perception leading to a conflation of
thought and speech, as in Auditory Vocal Hallucinations
(AVHs).
FIGURE 1 | The deictic frame of speech and thought. A grammatical 1st
Person, addressing a 2nd, talks about an object or event in the world (the ‘it’
or 3rd Person) expressing a thought.
FIGURE 2 | The three positive symptoms derived as a breakdown
of the linguistic frame of thought. Human language organizes speech
perception, production, and content as the co-dependent angles of a triangle.
Depending on which corner is affected most, symptoms result.
A disorder of speech production leading to disordered speech
without feedback control, as in varieties of Formal Thought
Disorder (FTD).
A disorder of content formation leading to distorted meanings
thatcannotbetrueasinDelusions.
The Evidence
We currently test predictions (1)–(2) above3. Current support
for the hypothesis and theory firstly comes from the independent
un-Cartesian linguistic theory (cf. Section “How can Language
Illuminate Psychosis?”), which argues empirically that a
propositional and referential capacity in humans is based on
language, depending on grammar (which crucially includes
a threefold Person distinction) as its essential principle of
organization. A breakdown of language thus viewed predicts
the loss of a propositional and referential capacity. This loss
is virtually descriptively equivalent to what we see in positive
symptoms as described in Section “Linguistic Dimensions
across Positive Symptoms.” These can thus not only be given
linguistic characterizations, in which core linguistic variables
identified in the linguistic theory figure, but these descriptions
provide a mechanism for symptom formation. The connection
3Project ‘Language and Mental Health,’ Arts and Humanities Research Council
grant AHL004070/1, 2014–2017.
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Hinzen and Rosselló The linguistics of schizophrenia
between the neurocognition of schizophrenia (i.e., language)
and symptoms now becomes immediate. In contrast, relating
general or specific neurocognitive deficits (say in memory or
executive function) to the ‘excesses’ of functions that the positive
symptoms represent (especially hallucinations and delusions)
has been a persistent problem (McKenna, 2007, Chap. 8–9). The
inherent involvement of language in human intelligence makes
our proposal nonetheless consistent with a pattern of general
intellectual impairment found in patients with schizophrenia,
which is less clear in Bipolar Disorder (Mann-Wrobel et al.,
2011;Bourne et al., 2013;Crow et al., 2013;Bora, 2015;butsee
Kuswanto et al., 2013), where language, though not perhaps in
all subgroups, may be affected less and differently (Morice and
Ingram, 1982;Andreasen and Grove, 1986). It is also consistent
with a pattern of specific impairments found in neurocognitive
variables such as declarative memory or ToM, neither of which
is arguably language-independent (see further Section Language
and the Cognitive Neuropsychology of Schizophrenia).
We review four decades of findings on the language of
schizophrenia in Section “The Language Profile of Schizophrenia
against our Predictions.” The pattern of these findings, we
suggest, is strongly consistent with our predictions. In Section
“Language in the Schizophrenic Brain,” we briefly review the
neural correlates of schizophrenia in the light of our hypothesis,
and again suggest that findings on disorders in speech perception
and comprehension areas as well asToM areas are consistent with
our account. Due to space limitations, we do not discuss negative
symptoms in this paper.
Linguistic Dimensions across Positive
Symptoms
According to current DSM-5 criteria, a diagnosis of
‘schizophrenia’ requires the presence of at least one of the
following three ‘positive’ symptoms (DSM-5 295.90, p. 99):
(1) Hallucinations
(2) Delusions
(3) Disorganized speech
A long-standing orthodoxy suggests that none of these syndromes
inherently relate to language4.
The Linguistic Profile of FTD
In FTD, a connection with language is obvious: DSM-5 refers
to it as ‘disorganized thinking,’ which is ‘typically inferred from
the individual’s speech’ (p. 88). Such speech can be productive
(no ‘poverty of speech’), and patients can be fully cooperative
communicators. Yet however much speech is produced, the
listener has difficulties identifying what is actually being ‘said’
(‘poverty of content’). In another classical profile, patients
4Cf. Titone et al. (2007, p. 93): ‘the thinking anomalies associated with psychotic
conditionsarenot,fundamentally,speechorlanguagedisorders(...).Rather, when
language is used in an idiosyncratic way, it represents the outcome of a deviant
thought process.’ This view has a long pedigree: ‘the causation of schizophrenic
speech defect lies in an underlying thought-disorder rather than in a linguistic
inaccessibility’ (Critchley, 1964, p. 359); also Maher (1972).
BOX 1 | Two examples of Formal Thought Disorder (from McKenna and
Oh, 2005, p. 10 and 43).
Q. How do you like it in hospital?
A. Well, er not quite the same as, er don’t know quite how to say it. It isn’t the
same, being in hospital as, er working. Er the job isn’t quite the same, er very
much the same but, of course, it isn’t exactly the same.
Q. How are you?
A. ’To relate to people about new-found talk about statistical ideology. Er, I find
that it’s like starting in respect of ideology, ideals change, and ideals present
ideology and new entertainments new, new attainments. And the more one
talks about like, ideal totalitananism, or hotelatarianism, it’s like you want new
ideas to be formulated, so that everyone can benefit in mankind, so we can all
live in our ideal heaven. Presumably that’s what we still want, and with these
ideas it can be brought about. I find the it’s like a rose garden.’
are clinically said to exhibit ‘loss of goal,’ ‘derailment,’ and
‘tangentiality’. One example of each, from McKenna and Oh,
2005, p. 34, are given in Box 1):
In poverty of content, phrasal and even sentential structure
can seem normal, but the thought carried by language is hard
to pin down. Thus in the second example, an initial topic is not
addressed, a new topic is vigorously set, but the speaker derails,
and the discourse is carried forth more on the basis of lexical
associations than propositional meaning. Overall, no point or
message emerges.
Chaika (1974) provided the first sustained linguistic analysis
of such speech after the onset of modern linguistics in the
1950s. According to her, the anomalies concern how words are
combined into meaningful sentences and discourses according
to linguistic rules, in particular the ability to organize discourse
according to sentence topics, hence grammatically, insofar as the
notion of topic correlates with that of the grammatical subject.
By consequence, words start appearing in strange grammatical
contexts with no stable sound-meaning associations, (e.g., the
clanging association in ‘I had a little goldfish too, like a
clown. ...Happy Halloween down’), which also leads to topic
losses and ‘derailment,’ and unresponsiveness to questions
(tangentiality). Chaika (1974) rejected the restriction of the single
sentence as a unit of linguistic analysis, taking the discourse to be
the relevant unit. Nonetheless, individual sentences themselves
can also become fragmented and ungrammatical (e.g., ‘I’m be
puped tall letter I’m write to you,’ from Chaika, 1982). Moreover,
sound combinations can be produced that cannot be identified
as words (e.g., ‘He still had fooch with teykrimez,’ from Chaika,
1974), have invented derivations (e.g., ‘plausity,’ ‘puterience,
‘amorition,’ from Chaika, 1982), appear in unusual compounds
(e.g., ‘night-illuminating object’ for ‘lamp’), or no static meaning
(McKenna and Oh, 2005,p.82).Typically,speakersofsuch
speech are not aware of such abnormal production, suggesting
impairment in meta-reflexive or self-monitoring capacities: a
feedback loop from production to thought is missing.
The intrusions of semantic (Pomarol-Clotet et al., 2008)
or phonological word-level associations inappropriate to the
context in which the words appear grammatically are nicely
demonstrated in the following example adapted from Chaika
(1974), where use of the sound /bill/ as appearing in its first
grammatical context requires processing it as a person-denoting
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Hinzen and Rosselló The linguistics of schizophrenia
proper name, after which the same sound is re-grammaticalized
as a verb denoting an action (as in ‘bill and coo,’ i.e., making love),
and further associated with a common noun denoting a bird’s
body part:
‘My mother’s name was Bill. [pause] [low pitch, as in an
aside, but with marked rising question intonation]...and coo?
St. Valentine’s Day is the official startin’ of the breedin’ season
of the birds. All buzzards can coo. I like to see it pronounced
buzzards rightly. They work hard.’
In a production like ‘A conclusion was a French professor,
uttered by one of the FTD patients in our study, the system of
grammatically categorizing ideas seems to have broken down
(a conclusion needs to be grammatically a sentence, not an
indefinite Noun Phrase like ‘a French professor’).
Over time, Chaika’s (1974) essential claim that there is a
‘linguistics of schizophrenia’ distinct from both aphasia and slips
of the tongue in normal speech, has held up (Oh et al., 2002;
Covington et al., 2005;McKenna and Oh, 2005), and all of the
essential characteristics of such speech that Chaika (1974)listed
have by now become reliably identifiable as part of standard
rating scales such as Chen et al.’s (1996) Clinical Language
Disorder Rating Scale (CLANG). Overall, there seems to be no
way to identify and characterize this syndrome independently
of the abnormal linguistic patterns in which it consists and as
which it is diagnosed. Specific linguistic processes and principles
of organization – e.g., derivational morphology, phrases vs.
sentences, referential phrases, proper names vs. common nouns,
etc. – are involved in it, which have to come together in the
right way to generate the clinical impressions of ‘emptiness’ and
‘disorganization’ that we see.
The Linguistic Profile of Hallucinations
Hallucinations are defined in DSM-5 as ‘perception-like
experiences that occur without an external stimulus’ (DSM-5,
p. 87). Auditory ones are identified as the most common.
These in turn prototypically take the form of voices, whether
familiar or unfamiliar. These do not prototypically grunt, bark or
whistle, but talk, using words and (usually short) sentences, and
hallucinations in this sense take an auditory verbal form (AVHs).
AVHs therefore are inherently a linguistic experience and hence
involve an anomaly of speech perception by definition. This
speech further has contents that ‘are perceived as distinct from
the individual’s own thoughts’ (ibid.), which is to say that they
are perceived as the thoughts of what is, from the viewpoint of
the voice hearer, a grammatical second (‘you’) or third (‘he’/’she’)
person, while the voice hearer in turn is a second or third
person from the viewpoint of the voices. This entails a loss of
first-person ownership of the patient’s self-generated thoughts,
which we earlier identified as the implicit subordination of
every thought or utterances under the phrase ‘I think that.’ To
illustrate, suppose an example of the thought in question is (1):
(1) I am weak.
Then there is a transition from this thought, to the thought
that would in mental health be expressed by another person’s
utterance of the form in (2), which is now what the voice is heard
to say (‘He thinks/says that’):
(2) He is weak.
We will call this a deictic shift, specifically from the 1st to the 3rd
(or else to the 2nd Person). While the words ‘I’ in (1) and the word
‘he’ in (2) refer to the exact same person, i.e., the voice hearer, the
thought as expressed in the two utterances has crucially become a
different one and the identification ‘he =I’ is not made by the
voice hearer, even though he is perceiving what are effectively
his own thoughts. In delusions the identification is made: ‘he’
becomes ‘I,’ leading, e.g., from ‘He is Jesus’ to ‘Iam Jesus’. This
seems to indicate a broader pattern of the loosening of deictic
anchoring to which we return.
Again these initial observations suggest that not only is
language a defining feature of AV Hs , but its linguistic profile
involves specific grammatical distinctions and pronominal
patterns, without which the phenomenon would not be what it
is. In line with this, language plays a crucial role in Bleuler’s
(1911, pp. 79–84) extensive discussion of hallucinations. He notes
that elementary auditory hallucinations (e.g., hearing shooting or
the wind blowing) were relatively rare, and if they occur they
are normally interpreted as involving reference to the patient
(e.g., the shooting occurs to rescue him), hence they really
represent what are now termed referential delusions. Crucially,
reference is nothing we can hear. As we argue in Section “How
can Language Illuminate Psychosis?,” it is a linguistic category
inherently. The most common auditory hallucinations, Bleuler
(1911) further notes, are those of language: ‘music is rarely
heard’5. For verbal hallucinations, moreover, audition is not
actually essential, as is now widely documented (McCarthy-Jones
et al., 2013): many so-called ‘voice hearers’ ‘cannot tell whether
they hear the voices or whether they only have to think them;
they are “lively thoughts,” which are nonetheless still called voices
by the patients themselves; then again they are “loud thoughts,”
“toneless voices” (...)’ (Bleuler, 1911,p.90).Whatpreciselycuts
across these phenomenological differences is that language is
perceived (whether or not sound is), in the sense that the thoughts
in question have a linguistic articulation,comewithacontent that
is given by this articulation, and that such thoughts/voices often
appear as acts of linguistic communication to the recipient (even
though the communicative situation is unusual).
Theseactsarenotdismissedbypatientsascuriousauditory
accidents, but, e.g., as meaningful commands (‘Go into the
water’), which are often followed by them, turning into the
thought‘Igointothewater,’justasforapersonwhogives
instructions to herself using self-talk (‘Climb this mountain!,
‘Give her a kiss now,’ etc.). In this regard the voice hearer is
confused as to whether the thought ‘he says I should do X’
5Consistent with this, Baethge et al.’s (2005) study of hallucinations among
4972 hospitalized persons confirms that the most frequent hallucinations were
auditory, followed by somatic and visual hallucinations. Hallucinations in the
schizophrenia group we re comparatively the most severe and least visual.Subtypes
of Auditory Verbal Hallucinations (AVHs) associated with the re-living of
traumatic experiences in post-traumatic stress disorder, too, are said to be ‘usually
visual, sometimes olfactory b ut rarely auditory verbal’ (McCarthy-Jones et al., 2014,
p. S277).
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Hinzen and Rosselló The linguistics of schizophrenia
really is the thought ‘I should do X.’ There is a Person confusion
in addition to a shift, which in and of itself would not entail
the phenomenology of AVHs. Perceiving speech of other people
normally simply means that we recognize them as individuals
like ourselves, who have their own bodies, 1st-personal narrative
histories and beliefs about the world, and whose commands for
actions are just that: things that someone else wants us to do.
But voices do characteristically not develop a personal narrative
or talk much about themselves in the 1st Person, nor about
the world, using the 2nd or 3rd Persons near exclusively (‘you’
or ‘she/he’/‘this loser,’ etc.). In commands like ‘wash your hair’
endlessly repeated, heard speech content cannot be rationalized
any more, as it normally can be, and voices cease to be rational
speech agents. Nor is such speech appraised as normal speech
would be. We may on occasion misattribute speech, but wewould
not hear the fridge or the bread talking to us. Nor would we
wonder why we can hear our relatives talking to us, while we have
to travel to them in order for them to do so (Bleuler, 1911, p. 94).
Many patients, Bleuler (1911) notes, do not look for explanations
for why the voices are there at all.
Lack of rationality transpires at the content level itself, where
such speech can appear like a tragic parody of normal language.
One voice commands that the patient goes into the water; at
the same time she mocks and chides him for doing so (Bleuler,
1911,p.80).MollyWatsonsvoice‘Takeiteasy,butremember,it
won’t be easy. Nothing will be easy.’ ‘We learn something and we
learn nothing’ (Watson, 2015, pp. 6–7). Some voices comment
passively and irrelevantly on what patients currently do. Some
patients perceive something, and the voice says aloud what it is (‘a
wedding’), reflecting an involuntary intrusion of speech into the
normal speechless perceptual process. Others say out loud what
the patient just thought, or repeat what he says the moment he
stops. According to Bleuler (1911), only rarely do voices say who
they are, and the patients are typically not interested in this, or
know it already; sometimes the patient’s confusion shows in many
voices talking at the same time, so that no thread can be followed.
Threats and abuses abound, as do commands, which correspond
grammatically to reduced clause types whose purpose is not to
share information about the world, make assertions, and express
thoughts, and develop narrative, but give directives for action.
Asking questions (interrogatives), too, is not a voice strength.
There is, then, a speech profile to voices6. A distortion of
normal propositional language and thought characterizes both
FTD and AVHs, though in different ways, with a disorder in
the interface between thought and speech as the distinguishing
feature of AVHs. AVHs not merely represent a (i) disturbance in
speech perception, (ii) deictic shifting and Person confusion, (iii)
content distortion, and (iv) grammatical narrowing, but also (v)
the erasure of a normal boundary between thought and speech,
providing another linguistic index for a disintegration of the
self, for whose integrity it is essential that one’s 1st Personal
6All four AV H s subtypes identified in McCarthy-Jones et al. (2012)areidentied
by linguistic distinctions: in the first (commanding and commenting), the voice
hearer is a 2nd- or 3rd-person addressee from the viewpoint of the voice
who predominantly uses imperatives; the second (replays of memorized speech
interactions) is no communicative e xperience as such; in the third, the voice speaks
in the voice hearer’s own 1st person: in the fourth, there is a semantic deficit.
thoughts are one’s own and private to oneself. It is a defining
phenomenological feature of normal 1st Person thoughts that
they are silent: we can voice them, if only by moving our lips, but
if we don’t, we don’t hear them. If we utter them and they become
overt, they become also different, being necessarily addressed to
a grammatical 2nd Person (not ‘I think...’but‘Isaytoyou...’).
In AVHs, thoughts become perceived as speech when they should
be silent7.
Delusions
Finally, delusions are defined in DSM-5 as beliefs rather than
perceptions, which is what hallucinations are. Qua perceptions,
the latter are not under voluntary control, while a belief, being
rational, is typically taken to be, like an assertion: we can decide
what we say or believe. The beliefs in question are further
described as ‘fixed,’ and as held with incontrovertible certainty.
These beliefs must be linguistically articulated internally, on the
assumption, to which we return, that a belief like ‘I came to
earth in a cosmic bubble’ cannot be formed without linguistic
articulation. This already entails an anomaly in language,
since delusions are beliefs that come with a quasi-perceptual
force, which propositions expressed as sentences in language
characteristically not only lack,butwhichtruthdoesnotrequire
(things can be true even if this truth is not evident or forceful).
In line with the anomaly of their incontrovertible certainty,
delusions are not contentful but contingently false, like a person’s
claim that coffee grows on trees. Instead, they are propositions
that are often bizarre and judged by others as being impossibly
true (‘Doctor, I wear my father’s hair’; ‘I am Jesus Christ,’ ‘The
Catholic Church is trying to kill me’). These, moreover, are
often generated without much consideration or reasoning – they
can simply ‘pop up’ and patients can typically not justify what
they believe. Apart from such delusions, there are referential
delusions such as the belief that gestures, utterances, and other
environmental cues refer to the patient. Also included among
delusions in DSM-5 are delusions expressing a loss of control over
one’s mind or body, e.g., thought withdrawal (one’s thoughts have
been removed by an outside force) and insertion (alien thoughts
are being put into one’s mind), i.e., Schneider’s (1957) first rank
symptoms.
We take the prevailing view to be that none of these delusions
are in some essential sense language-related. Yet as noted above,
it is part of the essence of language that it carries a content of
a particular kind: content, in particular, that can be true even if
false, and can, unlike a perception, be negated and reasoned with.
Language is not a system to which such content accrues somehow
accidentally: content is not something that it ‘also has,’ and could
also lack, while staying what it is. In virtue of having a certain
grammatical structure – with a predicate attributed to a subject –
asentenceipso facto has such content. The most immediate thing
to say, therefore, is that in the expression of a delusion such as
‘I am Jesus,’ a predicate (i.e., being Jesus) and a subject (‘I’) are
7Bell (2013) suggests that AVHs are hallucinated acts of communication, reflecting
a disturbance in ‘social cognition.’ A linguistic account of AVHs entails such a
disturbance. The communication in question is crucially linguistic, and in normal
conditions, perceiving speechis to p erceive both acts of communication and agents
behind them, while the reverse is not the case.
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Hinzen and Rosselló The linguistics of schizophrenia
combined in a way that a monstrous propositional content arises.
At the word level, ‘Jesus’ is presumably used correctly, but like
in FTD, the mistake lies at the grammatical level, i.e., how words
are related grammatically as subjects and predicates. In particular,
while the speaker still uses the proper name ‘Jesus’ correctly to
refer to Jesus (not Napoleon), he is not using ‘I’ properly to locate
himself in deictic space, as a bearer of the property of being Jesus.
Where ‘He is Jesus’ would be fine, a shift to the 1st Person has
taken place, and ‘I am Jesus’ results. Similarly, where ‘The Mafia
is trying to kill someone’ is surely true, and ‘the Mafia’ is used
correctly, a shift to the first Person takes place here too, resulting
in a falsehood ‘The Mafia is trying to kill me.
We do not think we learn anything about the world from
such delusional statements, which do not trigger any criminal
or religious investigation. Unlike all normal assertions, we take
them to inform us about the (pathological) thought of the
speaker only. The structure of meaning – the triangulation – has
thus fundamentally shifted8. A dysfunction of the propositional
function of language therefore is not restricted to FTD and AVHs
but concerns delusions as well, with one difference: in severe
thought disorder, the referential function of language is impaired
at all levels; in delusions, the propositional capacity is sufficiently
intact to nail down at least one referent – the Mafia, or Jesus – but
it then derails at the grammatical level, where no propositional
contents relating to the world are obtained. Bleuler’s (1911)
primary symptom called ‘ambivalence,’ too (patient utters ‘I am
a human being like you’ and ‘I am not a human being like you,’
now falls into place as an instance of the same problem with the
propositional function of language: in delusions, propositionality
is resolved in favor of perception, and a sense of truth is lost; in
ambivalence, the question which proposition is true cannot be
resolved.
Against this account, Frith (1992, p. 95) adopting the standard
view that delusions have nothing to do with language, asserts
that delusions are a ‘private’ matter that, unlike FTD, cannot be
studied objectively and ‘directly.’ But the disorder that delusions
represent is exactly as overt and objective as that of FTD:
delusions are linguistically articulated thoughts, even if not
pronounced, and pronounced they typically are. They are not
known (and could not be known) to be held in some ‘private’
mental space, while never appearing in overt language. The
essential difference between FTD and delusions is that in the
latter case, contents can still be identified but are judged to not
possibly be true, while in the former no contents may even be
discernible. Either way, the problems concern meaning generated
at a grammatical level.
Frith’s (1992) statement thus implies a Cartesian thought-
language distinction, where the normally inherent integration
of the two functions has become a contingent one. We could
insist for metaphysical reasons on a Cartesian distinction between
‘thought’ viewed as something non-linguistic, and ‘language’ as
merely an expressive tool. Yet in general, the exact identity of
a thought depends on the constituents and relations among the
8Critically, even an assertion like ‘I am sad’ is normally understood as telling us
about something more than the mental state of the speaker, implicating a fact about
the world – that the speaker is sad (lying is an exception and based on the fact here
noted).
partsthatitcontains,whichwesee in the sentences expressing
them. We would therefore have to stipulate the existence of
exact non-linguistic ‘mental’ equivalents of these constituents
and relations at the level of ‘non-linguistic thought’. But this
extra step seems to reap no explanatory benefits and the same
problem now arises: why are the mental equivalents of ‘I’ and
‘Jesus’ combined in such ‘non-linguistic thought’ as subject and
predicate in a fashion that a proposition arises that cannot be true,
yet is taken as true with quasi-perceptual force?
As in AVHs or FTD, the linguistic elements involved in
delusional statements are againspecific. Thus ‘Napoleon is Hitler
is not a likely delusional statement that a clinician would expect
to find; nor are ‘The Mafia is trying to kill Obama,’ ‘German
towns are beautiful,’ ‘I will be Jesus,’ or ‘I think I am Jesus.’ These
are grammatically of the wrong types9. Instead, typical examples
of delusions involve the grammatical 1st Person combined with
a 3rd person predicate, in a non-embedded sentence, often
copular, typically in the present tense or with an atemporal
meaning. If changing the grammar entails changing the status
of a sentence as a delusion, grammar is essential to its status of
a delusion, and propositional delusions have a linguistic identity
not contingently, but necessarily.
In the mouth of a normal speaker, moreover, the statement
‘I am Jesus’ means something different: it could be a joke
or metaphor, or it could mean that the speaker is the Jesus
figure in a play. The schizophrenia patient says none of these
things, but rather fixes his 1st Person identity via a 3rd Person
description, which is impossible in mental health, where no
such description ever accounts for our 1st Person identity as
selves:any descriptive properties we have (‘I am X’), we can
in principle also lose (‘I found out that I was switched as a
newborn and baptized a Y’). For the patient with schizophrenia,
not being Jesus would be for him not to exist. When ‘I am Jesus’
expresses a delusion, therefore, the sentence is not used with its
normal meaning: language changes.AgainthereisaPersonshift
involved.
Some of the same linguistic elements show up in the case of
referential delusions, where, e.g., utterances or other signs are
misinterpreted as being conspirationally directed at the patient,
who thereby mistakenly takes himself to be grammatically a
referent in the 2nd or 3rd Person, from the point of view of the
speaker: acts of reference and communication about the patient
are assumed to exist, where there are none. The communication
of such content is a linguistic matter, even if non-linguistic
elements (say, white T-shirts, which the patients takes to indicate
a conspiracy against him) can be used to code for it. As argued in
the un-Cartesian framework, reference is the prime function of
language. Even referential gestures such as declarative pointing
are closely correlated with language in human development
(Butterworth, 2003;Cartmill et al., 2014). In the case of referential
delusions, this referential arrow is fictitiously pointed from a 3rd
person to the patient’s 1st.
9The first two have two 3rd Person referential expressions, while core delusions
tend to involve the grammatical 1st Person. The third i s generic (and 3rd personal).
The fourth is finitely tensed. And as occurring embedded in a larger sentence like
‘I think I am Jesus,’ ‘I am Jesus’ expresses no delusion in the technical psychiatric
sense.
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Hinzen and Rosselló The linguistics of schizophrenia
Delusions of thought control, too, involve confusions in the
function of the system of grammatical Person. All thoughts
generated have to be deictically anchored in one of the three
grammatical persons: they are mine, yours, or a third party’s;
or else they are viewed simply as facts (nobody’s thoughts, but
an aspect of reality). When this species-specific deictic frame is
disturbed, we predict the Schneiderian first rank symptoms that
DSM-5 subsumes under delusions, in line with Crow (2010):
thoughts are generated, but the patient doesn’t know anymore
whose thoughts they are, which now float free of their deictic
anchors. There is direct connection here with AVHs: in delusions
of thought control, it is thoughts that lose their anchoring in
deictic space; in AVHs, it is utterances; and as noted the dividing
line between them is not sharp, as an acoustic element need not
be central.
How can Language Illuminate
Psychosis?
We have tried to lay bare the linguistic dimensions involved in
positive symptoms, addressing our first broad prediction and
suggesting in each case that these dimensions are inherent. Yet
even granting that language matters, why should it do? What
is it about language that makes it an essential neurocognitive
variable involved? Can linguistics illuminate psychopathology
apart from providing formal tools for analyzing anomalies in
language production and perception that we see? We answer that
a theory of psychosis qua ‘reality distortion’ requires specification
of a principle – some unified system – from which a sense of
‘reality’ in human cognition derives.Suchasense–thebasis
of science and rationality – is in part human-specific. It does
not come from perception, nor from logic alone, assuming that
the latter already presupposes possession of a notion of truth,
which in its human-specific form is arguably language-dependent
(Davidson, 1982, 2004;Hinzen and Sheehan, 2013, Chap. 9).
Within linguistically articulated thought, moreover, words in
isolation cannot be true or false; nor can phrases be when seen
in isolation, such as ‘the car,’ which taken as such is meaningless.
Only as part of a full sentence like ‘The car I saw was red,
uttered in context by an embodied being, it carries meaning
involving referential expressions picking out specific objects and
events. Language by its nature, moreover, is shared, crossing
between minds and integrating them with a reality independent of
thought. Not being an aspect of individual cognition confined to
a single person’s brain, language seems uniquely placed to explain
how, among speakers sharing a language, a sense of a shared,
objective reality can arise.
This also follows if we accept Bleuler’s (1911) conception of
schizophrenia as based on the ‘disorder of associations,’ which
is characterized as a disintegration of all the ‘psychic functions’
in their normal interconnections: thought, speech, memory,
perception, personhood, affect, etc. For it is precisely in every
single utterance we make, and only in language, that all of
these cognitive functions come together. Language unlike other
neurocognitive variables is an integrative system par excellence,
and therefore a prime candidate for the disintegration in question
(‘splitting,Spaltung). The unity of the person or self, moreover,
which Bleuler (1911) saw affected, is normally rooted in the
person’s 1st Person conscious self. ‘1st Person,’ however, is
agrammatical notion, defined through its contrast with the
grammatical 2nd and 3rd Person. Explications of what selfhood
or ‘first Person subjectivity’ are, standardly invoke reference to
oneself in the grammatical 1st Person, and we know of no
account of such self-reference that does not explicitly or implicitly
invoke the 1st Person pronoun, a crucial and universal element
of linguistic organization. Invocations in phenomenological
psychiatry of such terms as ‘Ichstörung’ (German for self-
disturbance, Spitzer, 1988;Mishara et al., 2014)or‘Me-ness’(Sass
and Parnas, 2003;Parnas et al., 2005;Sass, 2014)arecasesin
point10. It is plausible that our intuitive notion of self is layered
and not all forms of selfhood require language. Yet a full human
self, as the subject of creative thought in the 1st Person and with
a content of thought that is objective and shareable, depends on
language development. It is language that gives us a self-narrative,
a past and history, a shared culture, and imaginary worlds
to contrast the actual world with. A purely phenomenological
account of self-disturbance, which were to see human experience
as taking place in a completely pre-linguistic experiential space,
with language as only a secondary method of ‘translating’ its
contents for others, would be naïve11 .
Consider an example of a ‘self-disturbance’ reported as: ‘I often
feel that it is not I who is thinking.’ Could a structurally rich and
meticulously articulated thought such as this reflect ‘experiences’
that are as such non-linguistic and prior to language, yet
described correctly by this sentence? How could the ‘experiences’
be correctly described, if they did not exhibit the structural
distinctions the sentence encodes? Having the experiences in
question takes thought, it is not like seeing a flash of red.
A person of whom the above sentence is true is richly reflecting
on his or her experiences as and when these occur, activating
the conceptual network (Binder et al., 2009), and combining
its element into meaningful thoughts. The sentence in question
could not be true, in particular, without such a person at the
moment of such experiences having a notion of ‘thought’; or a
sense that a thought can be mine or yours; or that a thought is not
afact. A dysfunction in a system whose normal cognitive function
it is to enable such thinking predicts that uncertainties like the
above will arise12 .
10Cf. Newen and Vogeley (2003): ‘In language, the correct assignment and
involvement of 1PP [first person perspective] is reflected by the use of first-person
pronouns.’ Clearly, forms of self-reference in the 1st Person could be constitutively
involved in the formation of a ‘first person perspective.’ Its loss is reflected in
pronominal shifts that have been widelyattested in autism (Bartolucci and Albers,
1974;Lee et al., 1994;Hobson et al., 2010).
11Its shortcomings have been exposed by one of the fathers of phenomenology
himself, Merleau-Ponty (1964), who argued that language fundamentally changes
our relations to the world and ourselves.
12This linguistic derivation of self-disturbance accords with Mishara et al.’s
(2014) conception of patients with ‘Ichstörung,’ who ‘(1) struggle to identify
basic emotions in themselves, (2) grapple with distinguishing their own mental
operations from others, (3) have difficulty viewing events from multiple
perspectives, and (4) not make use of knowledge, in contrast to other groups, of
their own thinking when facing challenges’ (see also Lysaker et al., 2010;Nelson
et al., 2012). Patients facing such difficulties are linguistic agents, grappling with
linguistic distinctions and seeking to determine what is real.
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Hinzen and Rosselló The linguistics of schizophrenia
In the above instance such an uncertainty is articulated
correctly and grammatically: external language functions
sufficiently so as to capture a prior self-disturbance, which the
patient asserts and hence does take 1st Person ownership for. But
wearguethatthelanguagesystemdoesnotdosoatthemoment
when the experience occurs: here the deictic distinctions slip. In
FTD, language disintegrates further so as to lose the power even
of post hoc description; in delusions, the referential function of
language, which connects concepts to objects in the world, is
partially kept (the Mafia exists), yet the objects identified lack the
properties ascribed to them (the Mafia does not try to kill me).
These various distortions reveal health risks that uniquely arise
for a mind endowed with a language capacity. Thought carried
out in language is not stimulus-driven (Chomsky, 1959), being
based rather on internally stored concepts that can be activated
at will, as opposed to percepts, which depend on the presence of
a stimulus for their activation. Once creativity is there, the risk
is that it over-produces, creating delusions or confabulations,
which erase a boundary between personal and non-personal
truth that language normally maintains. The normal case, where
personal thoughts freely created out of concepts can be shared
in language and reflect an objective world, is thus a fragile
equilibrium. We see it shaken where reference only partially
functions, while predication is lost, or propositional content
becomes inaccessible to a mind altogether.
Understanding this fragility requires invoking the one system
we know where such contents exist. Concepts are most directly
associated with words: for every concept there is a word (though
maybe not in all languages), and with every word goes a concept.
Yet lexical concepts alone – HOUSE, MAN, GO, MOUSE,
DOWN – give us no content (or thought) in the above sense.
A principle of combination is needed. But there is no known
principle of combination of a kind that can productively generate
a potential infinity of thought with the relevant kind of contents,
than grammar. Grammar is the system that makes words become
nouns and verbs, gives them grammatical roles, turns them into
subjects and referential expressions, or else predicates exhibiting
generality. From the combination of subjects and predicates in
this sense, propositions arise, which are what can be true or
false. The function of grammar is thus not to add to our stock
of concepts but to make them referential, moving from MAN
to ‘the man,’ where the former cannot refer to an individual
man but the latter can. Referentiality comes in a number of
specific forms, thus we can refer generically or indefinitely to
the world (‘men are deceivers,’ ‘a man entered’), definitely (‘the
man entered’), rigidly (‘Tom’), deictically (‘this man,’ ‘he’), or
personally (‘you,’ ‘I’). Beyond the noun phrase, we obtain forms
of reference to states,thenevents, then propositions, then facts.It
is a crucial claim of un-Cartesian linguistics that all of these forms
of reference co-vary with specific grammatical configurations
(Sheehan and Hinzen, 2011;Hinzen and Sheehan, 2013,Chap.
4; Martin and Hinzen, 2014); that no further forms of reference,
in some non-linguistic world of thought, are known; and that in
animal cognition (‘non-linguistic thought’), none of these forms
of reference are seen (Hauser, 1996;Fitch, 2010). These findings
together suggest that our language capacity is what avails us
of these forms of reference; that when the limits of grammar
are reached, these limits are the limits of thought as well; and
that when grammar loses its grip on thought, thought must
disintegrate13.
In organizing the forms of reference to the world, language
negotiates both thought and reality while keeping them distinct.
Every utterance we make involves a thought, which is internal,
but it also has a ‘content’: it ipso facto says something about the
world,whichisindependent of my thinking. In talking, we always
both maintain and cross the divide between thought and the real.
If this capacity is lost, which is descriptively the phenomenon we
here seek to capture, the question why it is lost must lie in the
question what it is to understand when a sentence such as ‘I am
Jesus’istrue.Weanswerthatitisnotforittoseem to me that I am
Jesus, or that I want to be Jesus, or that I think IamJesus,orthatit
is evident for me that I am, or that he is Jesus. It is simply for me to
be Jesus. But how do I know that these and only these are the right
conditions for it to be true? From the grammar of the sentence,
which is a copular clause that does not embed the content that I
am Jesus under any such matrix verb as ‘seem,’ ‘want,’ or ‘think,
and involves 1st Person self-reference. In this sense it is the
grammar that tells me that I need to make a distinction between
thought and reality, between what seems to be the case and what
is. A loss of a grip on grammar in this way entails a loss of a
sense of truth, predicting quasi-perceptual certainties to arise in
language anomalously as well as ambivalence in Bleuler’s (1911)
sense and stimulus distractibility: language orders our experience,
and where this order fails, it makes sense that things will become
salient that in grammatical cognition would simply be regarded
as matters of ‘context’.
As noted, utterances not merely express thoughts but involve
an implicit reference to our own 1st Person. All referential
phrases within utterances require Person specifications that are
fixed relatively to this 1st Person. Thus ‘he’ in ‘He sleeps’ encodes
the 3rd Person Singular, in agreement with the inflection of the
verb; its meaning is that the relation of the person referenced,
who is the agent of the act of sleeping denoted, to the speech
act participants, as and when the act takes place, is non-identity.
Both the speech act and its 1st Person subject are thus implicitly
referenced in Person distinctions14 . And in thinking as such,
insofar as it involves reference as well, the situation cannot be very
different. As a result of the requirements of grammatical Person,
all reference to the world in language takes place in a ‘triangular’
deictic space spanned by a threefold person distinction: I,the
speaker and center of the deictic space, refer, in my speech act,
to a person, non-identical to both me and you,myhearer,andto
a fact about this person, which as such holds independently of us
all, being a fact about the world (‘it’; see Figure 1).
Specification of Person is a ‘syntactic’ constraint on
grammatical well formedness as well as propositionality in
language: there is no truth in language without such deictic
13This predicts that insofar as core cognition is unimpaired in severe and
global aphasia (Varley, 2014), the patients’ brain still somehow functions by the
grammatical code that it has used every minute of six or so decades prior, and the
difficulty lies in externalizing and perceiving this code in speech.
14The speech act is referenced a second time in the grammatical encoding of Tense,
which in this case encodes that the event denoted by the verb takes place as and
when the speech act does, and is ongoing.
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Hinzen and Rosselló The linguistics of schizophrenia
anchoring. Our proposal (Figure 2) is that all the positive
symptoms above can be characterized as disturbances in
this single grammatically determined deictic frame, which
predicts symptoms depending on which of its corners is
disproportionately affected. If it is not clear who speaks, speech
perception can more easily become abnormal as in AVHs. Where
the perceptual saliency of these deictically loosened thoughts
is not high, the loosening itself is enough to lead to confusing
experiences in which one doesn’t know whether the thoughts are
mine, yours, or simply truths. Some may appear up for public
viewing (thought broadcast), or taken out of the speaker’s mind
(thought withdrawal), who loses 1st Person control over them. In
yet other cases, this same 1st Person finds itself thinking thoughts
that are experienced as a 3rd Person’s (thought insertion). A ‘self-
disturbance’ must be the result: for to understand the notion of
self, we need all of the foregoing: concepts including a concept
of thought, a capacity for reference, where acts of reference take
place in a deictic frame marked by Person distinctions.
Phenomenological psychiatry set out to study a person’s
subjective experience as a premise for a search for neurocognitive
mechanisms giving rise to symptoms. Yet the distinctions that
are lost in symptoms are linguistic ones. There is no more to the
distinction between whether a given thought is my thought or
yours or a third party’s than this very distinction between 1st, 2nd,
and 3rd person. There is no more to the distinction between me
being Jesus and me thinking that I am, than this very grammatical
distinction between a clause that is embedded, functioning as
a syntactic argument, and one that is not. I think about the
person I am, my history, my body, my properties, or else just
me – the thoughts are different, and distinction is the linguistic
distinctions it is. ‘I’ cannot be equivalent to any of these other
ways of referring to me, because ‘I’ encodes no description, and
hence cannot be equivalent to one. If I start thinking of myself in
a ‘third person kind of way’ (Sass, 2014), this is to change amode
in which I normally use linguistic distinctions to refer to myself.
No known system other than language involves such distinctions,
encoding propositionality, Tense, and Person in every utterance
we make.
The Language Profile of Schizophrenia
Against our Predictions
We have now given a linguistic characterization of the positive
symptoms, and we have a linguistic model that derives a
propositional and referential capacity and new form of selfhood
from language, suggesting that grammar (which critically
includes Person) is the essential principle of organization of
human-specific thought. A breakdown of language viewed this
way predicts the loss of a propositional and referential capacity,
andthislossisvirtuallydescriptively equivalent to what we
see in positive symptoms. There is no gap here between
symptoms and the single essential explanatory variable invoked.
Linguistic dimensions in these symptoms moreover do not
involve elements peripheral to the organization of language or
irrelevant to its role in the organization of thought, but concern
its primary function as viewed in our linguistic framework,
namely to convert conceptual knowledge (the mental lexicon)
into referential expressions that have content on an occasion
of use. Based on this, highly specific testable predictions arise,
such as:
The more grammatically (and less lexically) mediated forms
of reference become in language, the more reference will
be impaired or anomalous. Splitting the forms of reference
mentioned above into two halves, with generic and indefinite
forms on one side, and definite, rigid, deictic, and personal
ones on the other, the latter should be disproportionately
affected. We do not know whether this is true, but note that:
(i) Delusional statements tend to be specific, involving the 1st
person pronoun, proper names such as Jesus, Superman,
or the Mafia; and by definition, they arise at the sentential
level, where alone truth values are encoded.
(ii) Lexical knowledge as such (as measured in confrontational
naming tasks), by contrast, should be least impaired of all,
which coheres with evidence (McKenna and Oh, 2005). As
noted, also neologisms and strange word uses arise within
occurrences of them in grammatical frames, where they
are referentially used.
(iii) Problems in encoding definite forms of reference are
virtually a re-description of the symptom of ‘poverty of
content,’ or ‘empty philosophizing’ used to characterize
some forms of thought-disordered speech (Andreasen,
1979).
(iv) It is often noted that patients with schizophrenia
‘frequently fail to use pronominal reference correctly’
(Frith, 1992, p. 99; see also Rochester and Martin, 1979;
Hoffman et al., 1985;McKenna and Oh, 2005, p. 112;
Watson et al., 2012): pronouns are often used without
their reference being clear to the listener, and they fail to
track referents across discourse. Pronouns are the most
grammaticalized form of reference that exist in language,
and pronouns paradigmatically, and almost exclusively
so in English, encode Person distinctions in grammar15 .
As Bleuler (1911, p. 118) reports, some patients speak of
themselves only in 3rd Person, preferring to use their own
name; one chronic patient only ever spoke in the 2nd.
(v) ‘Referential failures’ are highlighted in Ceccherini-Nelli
and Crow (2003) as having distinctive diagnostic value.
Vague references and missing information references are
reported to be over-represented in schizophrenic patients,
with referential disturbances transpiring as a trait-like
features of the illness independent of symptom (or FTD)
severity (Holzman et al., 1986;Docherty et al., 1988, 1996,
2003)16.
15Pronouns are highly grammaticalized (Martin and Hinzen, 2014) and in this
sense not a matter of ‘discourse-cohesion’ in some non-linguistic sense.
16Symptoms like peculiar use of language, disorganized and disconnected speech,
and verbal underproductivity, which are more state-dependent in mania and
frequently involve a return to normal levels during clinical remission (Andreasen
and Grove, 1986;Harrow and Marengo, 1986;Spohn et al., 1986), are found to
be present in schizophrenia in residual forms during both acute episodes and
remission (see also Harvey et al., 1984, 1990;Marengo and Harrow, 1997).
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Hinzen and Rosselló The linguistics of schizophrenia
Frith (1992, p. 98), by contrast, refers to the ‘general consensus
that only the highest levels of language processes are impaired
in schizophrenia,’ by which it is intended that lexical, ‘syntactic,
and phonological knowledge are relatively unimpaired,whereas
processes of ‘discourse planning’ are affected, as words and
sentences are combined with one another. However, there is no
‘discourse planning’ when there is no capacity to use language in
the normal, i.e., the propositional way, with sentences configured
that are true or false. A ‘pragmatic’ capacity to communicate
in language and to maintain a discourse plan presupposes a
grammatical ability to configure propositional information: by
definition, pragmatics begins where grammar leaves off. Is this
propositional capacity maintained in schizophrenia? Not in any
of the positive symptoms, by definition of these symptoms; nor
does the problem lie in communication, when the problem
instead is that thought is heard, or the content of thought is the
problem. If so, discourse is disordered because a propositional
capacity is lost, not vice versa. A patient who answers ‘Yes,
iron is heavy’ to ‘Are your thoughts wearing heavily on you?’
(McKenna and Oh, 2005, p. 104) fails at a discourse level. He
hasn’t understood that ‘heavy’ was predicated (metaphorically)
of thoughts – a sentence-level failure to integrate word meaning
with the grammatical frames in which they occur.
‘Syntax’ cannot be unimpaired (Marini et al., 2008)in
schizophrenia, if we view grammar as an inherent (rather
than contingent) aspect of what sentences mean. In speech,
grammatical complexity is never built without complexity in
forms of reference and propositional meaning arising alongside.
But these are impaired. Syntax moreover is empirically found to
be impaired. Morice and Ingram (1982) achieved a differential
diagnostic accuracy of 95% for schizophrenic vs. manic and
controls based on a linguistic profile involving in particular a
reduction in syntactic complexity, and syntactic and semantic
errors, without distinguishing between FTD and other symptoms
(see further Chaika and Alexander, 1986;Fraser et al., 1986;
Hoffman and Sledge, 1988;King et al., 1990;Thomas et al., 1990;
Oh et al., 2002;Walenski et al., 2009). Lower syntactic complexity
includes lack of clausal embedding – which ipso facto entails
that speech does not encode thinking about mental states or
ToM: changes in grammatical complexity and patterns are not
merely a ‘formal’ deficit, but have consequences for the meanings
we grasp and convey. If propositionality, reference, and Person
uniquely go with forms of grammatical organization, and to
mediate them is language’s cognitive role, thought disorder can
be investigated on a linguistic basis (Morice and McNicol, 1986,
p. 248).
A number of studies found defects identified under the
label ‘semantic,’ including semantic memory, i.e., abnormalities
revolving around words, general knowledge, and concepts
(Tamlyn et al., 1992;McKenna and Oh, 2005;Wang et al.,
2011), which are language-related. Oh et al. (2002)found
‘expressive semantic’ anomalies to be characteristic of FTD
independently of general intellectual impairment, yet crucially
not in naming but only at a grammatical level of speech
organization, where the referential function of language resides.
The finding is consistent with what Kleist (1960) referred to as
a ‘higher-level’ impairment, ‘responsible for word derivations,
word constructions, the formation of sentences, and for the
abstract meaning of speech conceptions – i.e., the thinking based
on speech’: in other words, language impairment is at a level
of language viewed as integrated with thought, or grammatical
meaning as it is viewed in the un-Cartesian framework.
Just as ‘discourse coherence’ is a putatively non-linguistic
variable that characterizes schizophrenic speech, the notion
of ‘context processing’ has been prominently invoked (see
McKenna and Oh, 2005, pp. 102–108). As with pragmatics,
however, the notion of ‘context’ analytically presupposes that
of ‘content.’ By defining propositional meaning, grammar on
the present model delineates content, and co-defines context,
while no other system is known to draw this distinction
(Hinzen, 2015). If I hear the sentence ‘Mary smiles’ uttered,
then it is a matter of context if she also wears red shoes,
or the speaker has a hoarse voice. This distinction disappears
(everything becomes context), if the sentence is not understood
as a proposition that as such defines a notion of context as what
is irrelevant to its content. A disturbance in a language-mediated
propositional competence therefore predicts a disturbance in the
understanding of context: while the patients generate speech
syntactically, their ‘ability to organize verbal messages into
meaningful grammatical units may be relatively fragile and
subject to disruption’ (Hoffman et al., 1985, p. 199). Tone of
voice or the sound form of a word then become significant
and relevant to content, rather than being demoted or inhibited
as part of the context, predicting distractibility and derailment.
This is in line with results documenting difficulties of integrating
word meaning with grammatical frames, as well as patients’
relative lack of sensitivity to grammatical constraints (Kuperberg
et al., 1998, 2006). Where the boundary between content and
context is shaken, speech will also fail to exhibit a literal-non-
literal distinction, predicting the ‘concretism’ of schizophrenic
speech.
Speech in FTD may appear to be grammatically normal
and to be organized according to topics/subjects and
comments/predicates. However, for there to be fluent speech at
all, there cannot but be use of grammatical frames – the same
ones that any patient with schizophrenia will have used for the
first two decades of his life virtually incessantly. But when we
investigate the linguistic profile of schizophrenia more closely,
we see that what appears to be demarcated grammatically as the
topic of conversation is not really treated as that: the patient
derails, and topics can shift according to any association made.
In a similar way, what appears to be a predicate applied to an
argument yielding an apparent assertion with a truth value,
e.g., the predicate ‘fell into the front doorway’ as applied to
the subject ‘the pond,’ cannot really be that, for that a pond
fell into a front doorway is nothing that anyone in his right
mind could possibly state as being true. What appears to
be a referential noun phrase such as ‘my spouse,’ as in ‘my
spouse left,’ turns out not to be understood as such when
we discover, a sentence later, that the patient refers to three
spouses she has at the same time, depriving the phrase ‘my
spouse’ in question of the required unique referent, and when
we discover, again a sentence later, that the patient also thinks
he has never been married, depriving the noun phrase of a
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Hinzen and Rosselló The linguistics of schizophrenia
referent altogether. Grammar is used, but it has lost its intrinsic
meaning17.
Language and the Cognitive
Neuropsychology of Schizophrenia
By the 1980s, neuropsychological deficits in the schizophrenia
population were well established, involving both general
intellectual impairment (Liddle and Crow, 1984;Buhrich et al.,
1988) and selective deficits, as in memory (especially verbal
memory: McKenna et al., 1990;Saykin et al., 1991) and executive
control, independently of general intellectual impairment
(Laws, 1999;Barrera et al., 2004;Henry and Crawford, 2005).
None of these cognitive functions, however, are in humans
completely independent of language, which integrates them
but also expands and transforms them, as compared with
their forms in other species and hominins (Coolidge and
Wynn, 2007). Nor is clear how neuropsychological deficits as
seen in neurological patients should give rise to the positive
symptoms, which as McKenna (2007) stresses are not properly
said to be ‘deficits18 .’ And while many correlations between
neuropsychological test performance (especially executive
dysfunction) and negative and disorganization symptoms
exist (Liddle, 1987), this does not seem to be true for positive
symptoms (Donohoe and Robertson, 2003;McKenna and Oh,
2005, Table 6.3; Dibben et al., 2008;Clark et al., 2010). In
Dibben et al.’s (2008) meta-analysis, pooled correlations between
executive impairment and negative/disorganization symptoms
were small to moderate, while positive (‘reality distortion’)
symptoms ‘close to zero.’ Berenbaum et al. (2008)foundthat
AVHs correlate with abnormalities in episodic memory, which
is consistent with our approach, while delusions were correlated
with no neuropsychological dimension. The latter finding we also
expect: delusions affect the content part (top vertex in Figure 2),
not processing aspects (production/comprehension) to which
standard neuropsychological tests may primarily be sensitive.
Frith (1992) broached new terrain by arguing that a number
of positive symptoms could be explained by a specialized form of
executive dysfunction implicated in the self-monitoring of willed
actions, including acts of thinking. This theory held considerable
promise in the domain of alien control symptoms and possibly
also AVHs, but its support from imaging studies is less clear
(McKenna, 2007, p. 254). In particular, in AVHs, contrary to
what is predicted by the executive dysfunction theory, there is no
de-activation of frontal areas (or other areas), but an increased
activity in the temporal lobe neocortex, often bilaterally. By
contrast, while listening to external speech, patients with AVHs
17This point arguably extends to the simplest forms of what is described in
the literature through the psychological term ‘conceptual combination.’ Titone
et al. (2007) show that patients with schizophrenia ‘combine concepts’ differently.
Hinzen and Sheehan (2013, Chap. 8) argue that the best predictor for their
performance is in fact a grammatical deficit. Moreover, ‘concepts’ of a non- or pre-
linguistic kind (e.g., Carey, 2009) are not known to productively combine in the
way of words.
18The explanatory problem is analogous to the one arising from positing deficits
in perception: how would these give rise to delusions, say, when misperceiving
typically does not have this effect?
show a decreased activation in the left superior temporal gyrus
(including Wernicke’s area), which is fundamental for speech
perception. This reversed pattern in comparison to controls
suggests, as Plaze et al. (2006) put it, that ‘auditory hallucinations
compete with normal speech for processing sites within the
temporal cortex in schizophrenia.’ In line with this, hallucinators
seem more prone to misattribute their own external recorded
(and manipulated) speech than patients without AVHs and
controls (Allen et al., 2007).
Generalized to include all ‘mentalizing’ (ToM), Frith’s (1992)
theory appeared promising at a theoretical level with regards
to persecutory and referential delusions as well, though it has
less scope in the case of delusions of the ‘I am Jesus/Superman’
type. A recent review (Garety and Freeman, 2013), surveying
199 studies, concludes that with respect to delusions generally,
‘the ToM account has not stood up to subsequent testing.’ A
further problem is whether ToM, like the psychological concept
of ‘meta-representation,’ can be a promising candidate for a
language-independent cognitive variable. As such Frith (1992)
invoked it to explain disturbances in productive speech in
FTD. The idea was that a defect in executive control would
prevent a thought-disordered speaker to structure their discourse
in accordance with a listener’s needs – a pragmatic’ deficit.
Hence there would be no language dysfunction per se in this
syndrome, a view he saw supported by the putative lack of a
comprehension deficit in language. However, a comprehension
deficit has by now often been reported (Kuperberg et al., 1998,
2006;Condray et al., 2002;Tavano et al., 2008;Thoma et al.,
2009). Nonetheless, ToM deficits in the wider schizophrenia
phenotype, irrespective of symptoms, are well established by now
(Frith and Corcoran, 1996;Bruene, 2005;Anselmetti et al., 2009;
Bora and Pantelis, 2013). However, we know independently, from
both normal and abnormally developing populations, that ToM
is highly correlated with language in development (Astington
and Jenkins, 1999;DeVilliers and Pyers, 2002;Hale and Tager-
Flusberg, 2003;deVilliers, 2007;Newton and deVilliers, 2007;
Paynter and Peterson, 2010). Whatever explanatory potential
the ToM notion contains, therefore, a linguistic perspective may
comprise it independently.
Hinzen and Sheehan (2013) argue that insofar as ToM denotes
a conceptual rather than perceptual ability, language makes
ToM redundant as a psychological construct, since it engenders
our cognitive mind-reading ability (‘reading’ being indeed
an appropriate metaphor). In particular, language competence
entails the formation of what Frith (1992) termed ‘first-order
representations, like ‘John is tall.’ The difference between this
and a representation with ToM content, i.e., a ‘second-order’ or
‘meta’-representation, is simply the application of a grammatical
operation: for the difference is not that between ‘John is tall’
and ‘John is sad,’ but like that between ‘John is tall’ and ‘Bill
believes John is tall.’ The former distinction is a lexical one, the
latter a grammatical one. If the latter was said to be as such a
mental or non-linguistic one, it would still have to mirror the
grammatical one exactly. The grammatical distinction is available
to a mind the moment that argument-taking is an option –
which is the moment that there is grammar. A grammar in which
there are arguments can make clauses arguments, too, which
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Hinzen and Rosselló The linguistics of schizophrenia
then are embedded in other clauses. If it does, ToM content
ipso facto arises, and no special capacity for representing mental
state contents has to be postulated beyond grammar itself, which
we need anyhow. A putative non-linguistic ToM module also
does not as such entail any propositional capacity, and it fails
to yield Person distinctions: ‘mentalizing’ is an unspecific term,
and if it is propositional, this does not follow from anything in
ToM. Crucially, second-order representations are propositions
too: it can clearly be false that Bill believes that John is tall. Such
representations are ipso facto part of language, which entails their
propositionality for free.
In sum, invoking impairments in neurocognitive variables
primarily known from neurological patients has met with
considerable obstacles in schizophrenia. Correlations of variables
with these symptoms have proven difficult; the mechanism of
symptom formation is unclear; and core variables like ToM
are not likely language-independent. This invites factoring
language into the cognitive neuropsychiatry of schizophrenia
and to develop more fine-grained clinical tests of grammar-
based meaning distinctions to re-assess the connection between
language and cognition.
Language in the Schizophrenic Brain
Our account makes us expect the finding that neuroimaging
the brain of persons with FTD in particular, have identified
anomalies in classical language-related areas and circuitry (Weiss
et al., 2005;DeLisi et al., 2006;Catani et al., 2011). Sans-Sansa
et al. (2013) found an association of FTD with gray matter
volume reductions in both Broca’s and superior temporal gyrus
(including Wernicke’s area) along with ventromedial prefrontal
cortex (vmPFC) and orbitofrontal cortices, the latter extended
dorsally to the insula (see also Horn et al., 2010). The vmPFC
is a classical ToM area (Saxe, 2006), and Ferstl et al. (2008)
present results that ‘strongly suggest an overlap between the
extended language network (ELN) and the regions implicated
for ToM processes19 .’ Further findings indicate a convergence
19 This suggests that relegating dimensions of language use to a ‘post-linguistic’
domain of ‘pragmatics’ may reflect classical conceptions of language driven by a
separation of language from its use, which we here do not adopt. Hagoort and
Levinson’s (2014) defense of the so-called ‘immediacy assumption’ may support
this claim.
between the ELN and the ‘language comprehension network’ of
Turken and Dronkers (2011), which in turn strongly overlaps
with the ‘(conceptual) semantic system’ of Binder et al. (2009),
who sees the latter as ‘strikingly similar’ to the ‘default state’ of
Binder et al. (1999)andRaichle et al. (2001), and further the
‘autobiographical memory retrieval system’ of Maguire (2001),
Svoboda et al. (2006). And Pomarol-Clotet et al. (2010), finally,
identify the mPFC ‘as a prominent site of abnormality in
schizophrenia,’ connected to the default state through failures
of deactivation, which the authors connect to conceptual over-
activations mediating a sense of ‘self.’
Many studies have reported aberrant patterns in fronto-
temporal networks across schizophrenia in response to a range
of tasks with linguistic demands (Ngan et al., 2003;Kircher
et al., 2005;Weinstein et al., 2006, 2007;Kuperberg et al., 2007,
2008;Dollfus et al., 2008;Borofsky et al., 2010). In addition,
while normal adults exhibit left-lateralization of neural activity
in fronto-temporal regions during language processing (Vigneau
et al., 2006), individuals across the schizophrenia spectrum
show more bilateral and right-lateralized activity during speech
processing, verbal fluency, and lexical discrimination tasks
(Weiss et al., 2005;Li et al., 2007;Diederen et al., 2010).
Angrilli et al. (2009) found, for a sample of patients with positive
and negative symptoms, and a high level of delusions – but
scarce AVHs – difficulties concurrent with a ‘hemispherical
indecision’ specific to phonological processing. This failure of
left hemispheric dominance of phonology appears then to extend
to schizophrenia in general, which suggests that linguistic sound
processing is to some extent impaired throughout the disease.
Conclusion
A linguistic model of positive symptoms may cast fresh light on
their pathogenesis and underlying neuropsychology. ‘Thought’
is not a standard neurocognitive variable. This makes it hard to
tackle delusional thought. If thought of the kind we see impaired
in positive symptoms is language-mediated inherently, and a
disintegration of basic functions of language in the configuration
of reference is seen empirically in symptoms, then language could
be a key neurocognitive variable to be targeted in understanding
symptom formation, therapeutic intervention, and cognitive
remediation.
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Frontiers in Psychology | www.frontiersin.org 17 July 2015 | Volume 6 | Article 971
... Previous studies in English 22 have used syntactic markers such as possessive and interrogative pronouns, reporting a decrease in possessive pronouns in SZ patients. Interestingly, we observed that indefinite pronouns were significantly different (P < 0.001), while personal and interrogative pronouns were close to significantly different between groups (P < 0.01), as well as indefinite and demonstrative determiners (P < 0.01), which may all be related to reduction 41,42 . Referential coherence accounts for the speech functional architecture of speech, and it is known to be altered in individuals with SZ schizophrenia; thus, syntactic markers are a direct and straightforward way to measure this coherence. ...
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Automated language analysis of speech has been shown to distinguish healthy control (HC) vs chronic schizophrenia (SZ) groups, yet the predictive power on first-episode psychosis patients (FEP) and the generalization to non-English speakers remain unclear. We performed a cross-sectional and longitudinal (18 months) automated language analysis in 133 Spanish-speaking subjects from three groups: healthy control or HC (n = 49), FEP (n = 40), and chronic SZ (n = 44). Interviews were manually transcribed, and the analysis included 30 language features (4 verbal fluency; 20 verbal productivity; 6 semantic coherence). Our cross-sectional analysis showed that using the top ten ranked and decorrelated language features, an automated HC vs SZ classification achieved 85.9% accuracy. In our longitudinal analysis, 28 FEP patients were diagnosed with SZ at the end of the study. Here, combining demographics, PANSS, and language information, the prediction accuracy reached 77.5% mainly driven by semantic coherence information. Overall, we showed that language features from Spanish-speaking clinical interviews can distinguish HC vs chronic SZ, and predict SZ diagnosis in FEP patients.
... As the disease progresses, nonspecific fluctuating persecutory ideas might remain but are secondary to the core residuum which impairs patients' understanding, leading to misinterpretations in close similarity with residual Wernicke's aphasias. 76 During episodes, patients exhibit a variety of affective and psychotic symptoms, that are frequently in the foreground. ...
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While the ICD-DSM paradigm has been a major advance in clinical psychiatry, its usefulness for biological psychiatry is debated. By defining consensus-based disorders rather than empirically driven phenotypes, consensus classifications were not an implementation of the biomedical paradigm. In the field of endogenous psychoses, the Wernicke-Kleist-Leonhard (WKL) pathway has optimized the descriptions of 35 major phenotypes using common medical heuristics on lifelong diachronic observations. Regarding their construct validity, WKL phenotypes have good reliability and predictive and face validity. WKL phenotypes come with remarkable evidence for differential validity on age of onset, familiality, pregnancy complications, precipitating factors, and treatment response. Most impressive is the replicated separation of high- and low-familiality phenotypes. Created in the purest tradition of