Introduction
The following exercise is a case study of a man of 26 years of age with schizophrenia who was studied by Hella et al. (Reference Hella, Niemi, Hintikka, Otsa, Tirkkonen and Koponen2013). Schizophrenia is a serious mental illness which has a lifetime prevalence of approximately 0.3% to 0.7% (American Psychiatric Association, 2013). It is diagnosed when two or more of the following symptoms are present: (1) delusions, (2) hallucinations, (3) disorganised speech, (4) grossly abnormal psychomotor behaviour (including catatonia) and (5) negative symptoms (e.g. diminished emotional expression or avolition) (American Psychiatric Association, 2013). The case study is presented in five sections: personal and medical history; clinical discourse analysis; focus on topic management; focus on reference; and discourse deficits in schizophrenia.
Personal and medical history
The client had a long-term doctor–patient relationship with the first author of the study, and was selected for investigation for this reason. His medication regime had previously included clozapine, which had been discontinued because of side effects. During the study, the client was taking a combination of olanzapine and perphenazine. The client had been hospitalised for treatment several times, most recently just one month prior to the interview that formed the basis of this study. He had previously lived in a rehabilitation unit, but a few months prior to interview had moved into his own apartment. He experienced problems with daily activities. The client's diagnosis was confirmed by the first author of the study following a SCID 1 interview (Structured Clinical Interview for DSM-IV Axis 1 Disorders; First et al., Reference First, Spitzer, Gibbon and Williams1995). This same transcribed interview was also used to undertake a PANSS assessment (Positive and Negative Syndrome Scale for Schizophrenics; Kay et al., Reference Kay, Opler and Lindenmayer1988). From the latter assessment, the following scores were obtained: positive symptoms: 25/49; negative symptoms: 26/49; general psychopathology: 46/112; total: 97/210. The client experienced a relapse of psychosis at the time of the study, and a decision on whether or not to send him to in-patient care was being considered.
Unit 47.1 Personal and medical history
(1) Clozapine is an atypical antipsychotic drug that is used when traditional antipsychotics fail to treat schizophrenia. The client in this case study was treated with clozapine but had to discontinue his use of the drug on account of side effects. Some of these side effects must be considered by the speech-language pathologist. State what these side effects are.
(2) The client exhibited positive symptoms during an assessment with PANSS. Which of the following symptoms in schizophrenia are positive symptoms?
(3) Which of the following symptoms in schizophrenia is associated with the contribution of unembellished turns in conversation? By what other term is this symptom known?
(4) Which of the following language impairments are typically associated with thought disorder in schizophrenia?
(5) Like many other individuals with schizophrenia, this client has had difficulties with functioning and independent living. It is increasingly recognised that speech-language pathology has an important role to play in improving the functioning and independence of adults with schizophrenia. Which of the following communication skills are targeted during a SLP intervention that is aimed at achieving these outcomes?
Clinical discourse analysis
The client's communication skills were assessed using a discourse analytic approach. Two conversation analytic concepts – turn and adjacency pair – were also used in the analysis. A rating scale was developed to detect sequences that were difficult for the addressee in the conversational exchange to follow. Called the Overall Comprehensibility of Turn (OCT), it takes into consideration the Gricean maxims of manner, quantity and relevance. Scoring was conducted by post-interview raters who assumed the viewpoint of the addressee. Scores of 0, 1, 2 and 3 represented transparent, slightly opaque, deviant and infelicitous turns, respectively. A slightly opaque turn was somewhat problematic to understand or contained unexpected elements to some extent. A deviant turn posed notable difficulties for comprehension on account of structural deficiencies, missing or vague propositional content, and unexpected associations of topics and/or referents. An infelicitous turn was completely obscure, contained elements which were totally unrelated or which violated the expectations of the interlocutor. Out of a total of 103 client turns which could be scored, 54 were transparent, 32 were slightly opaque, 9 were deviant and 8 were infelicitous. Three sequences with an accumulation of deviant and infelicitous turns will be examined in units 47.3 and 47.4.
Unit 47.2 Clinical discourse analysis
(1) Why is the use of a discourse analytic approach advisable when examining the language and communication skills of clients with schizophrenia?
(2) The authors of this study state that ‘[t]wo consecutive and semantically linked addressor-addressee turns make up an adjacency pair’ (Hella et al., Reference Hella, Niemi, Hintikka, Otsa, Tirkkonen and Koponen2013: 3). Is it the case that the two parts of an adjacency pair must be consecutive? Provide evidence to support your answer.
(3) Classify each of the following conversational behaviours as a violation of relevance, quantity and/or manner. Where the violation is one of quantity, further indicate if the behaviour in question is over-informative or under-informative:
An interlocutor talks at length about his holiday plans in response to a question about his job as a teacher.
A pedestrian fails to tell a motorist that the road ahead is closed when he is asked for directions to a church.
An interlocutor is relating a story to a friend but mixes up the order in which he describes the main events.
A guest at a dinner party talks incessantly about his new Porsche when the topic of conversation is the company's plans to expand into South America.
A patient does not tell an emergency doctor he is diabetic when he is asked if he has any health problems.
(4) Missing or vague propositional content is part of the definition of a deviant turn. Which of the following utterances contain such content? For the utterances that you select, justify your responses.
A speaker utters ‘I would’ in response to the question ‘Would you like turkey or chicken?’
Mary tries to dissuade Bill from going to the pub by saying ‘Big Jim will be there’.
Fran has been talking about her close friends Sue and June. Out of the blue she says ‘She has such a gorgeous house’.
When asked if she is going to the prom, Jackie says ‘I will be there’.
Sally asks her mother ‘Can I take the car to the shops?’.
Focus on topic management
Certain topics dominated the exchange between the client (C) and the first author (a doctor (D)) of the study. These topics were telepathy and harassment, thinking about words and particularly the names of people and places, and music and lyrics. These topics are evident in the two conversational extracts presented in this unit. In these extracts, irrelevant hesitation markers and signs of overlapped speech have been deleted. Authors’ clarifying comments are shown in brackets.
Extract 1
D: Your mother has told me that you feel that they [referring to client's paranoid experiences] don't leave you alone.
C: No, they don't. Well, as J. Karjalainen [a Finnish pop musician] sings in his song: ‘Do you remember when we played around with telepathy’. I don't know exactly what telepathy means. But maybe I believe in it a little. But, also my mother has to behave herself, but…she is sometimes discourteous in her words and she can be a bit rude. It may be the case that I'm the kind of person that speaks aloud a lot and thinks a lot what to say and so…
Extract 2
D: Has anybody else ever tried to harm you or tried to lead you to any kind of trouble?
C: Well, I have not thought about that…but not [they have not led me]…I have seen harm done and stuff, but people, those guys, let me be physically and mentally on my own…
D: Have you ever felt you would be especially important or that you would have abilities that no one else has?
C: Well, it's only that my name is John [altered], which happens to be the kind that others are laughing at. They are laughing right to my face, and then…
D: Why would they laugh at the name John?
C: Well, in some way that John that you har-har
D: What does John mean?
C: Well I don't know John [aborted utterance] probably…it refers to me and that a bit har-har and so on.
D: I can't quite understand. Can you tell what it is…
C: Then on the other hand…
D: Uh-huh.
C: …there are those X-ers [X-er refers to people from area X and is also client's family name] from Y [province capital] but yeah. As a joke, I kind of imagine that it is a kind of sacred relic that I should not be teased for that [laughs].
D: Do you mean that…
C: Yeah.
D: …that your name is a relic.
C: Or my family name X-er is one, since I am one [i.e. an inhabitant of province X bearing the province name].
D: Yeah, what does it mean…
C: Well…
D: …that it is a relic.
C: Well, it occurs to me all the time that X is the town [literally: municipality] [erroneous statement, confusion of province and hometown names]. It's definitely the town that is called X [erroneous statement repeated with emphasis] which is always seen on the [television] news…rolling [makes rolling gestures with arms]
D: Yeah.
C: X, yes. [Yawning] Well, I also do have other names.
D: What names?
C: I'd rather be some Marko, damn it, if I could myself decide upon taking a name.
D: Why would you change your name?
C: Well I don't know. It only occurred to me that it could be cool to be Marko, if not anything else, damn it.
Unit 47.3 Focus on topic management
(1) In extract 1, the client's turn received an OCT score of 2, i.e. it was judged to be deviant. Explain why this is the case.
(2) Although an unexpected topic intrudes into extract 1, the client also exhibits a number of discourse strengths in this extract. These include (a) the use of ellipsis, and (b) the use of anaphoric reference. Give one example of each of these discourse features in extract 1.
(3) How would you characterise the client's management of topic in extract 2?
(4) In extract 2, there are two utterances where the propositional content is particularly vague. Identify the utterances in question, and explain why their propositional content is vague.
Focus on reference
A number of referential anomalies (as well as strengths) were identified on the part of the client. Further referential anomalies are evident in extract 3 below.
Extract 3
C: I've been thinking about those that…going to work I'm always thinking about. Then some people, well they are stars and the like, they play soccer and we then watch, or they watch it and such like that.
D: Yes, who are watching?
C: Trades/professions I kind of think about.
D: Uh-huh.
C: They are a bit like a group of their own and such. They are jobless.
D: Uh-uh, who are you talking about now?
C: Well, I'm thinking about these kind of things. My father works at the city water works. Workers come to my mind sometimes.
D: Yeah.
C: That's it. Well, that I would want to be a bit better educated, but I am not. Then I am not extremely clever, perhaps. In a way that sometimes, well yes, I do watch something. A group of people can come up with wise things but…things are not like that now.
D: Yes. What…
C: [yawning] Well, I do have a trade school diploma.
Unit 47.4 Focus on reference
(1) This exchange with the client is difficult to follow on account of referential anomalies. Give three examples where the client uses terms which lack a clear referent.
(2) Referential anomalies are not the only reason why this exchange with the client is difficult to follow. There is also an abundance of vague and non-specific vocabulary in use. Give five examples of such vocabulary.
(3) Referential anomalies exist alongside a number of intact discourse skills. Such skills include: (a) topicalisation; (b) ellipsis; and (c) anaphoric reference. Give one example of each of these discourse skills in extract 3.
(4) Is the client aware that the doctor is having difficulty following him? What evidence are you basing your answer on?
Discourse deficits in schizophrenia
The investigators in this study made a number of important observations about the discourse behaviours of this client. The first observation is that this client exhibits language and discourse deficits that are typical of positive-state schizophrenia. A second, and probably more critical, observation is that what appears to be highly disordered discourse on the part of this client is more a reflection of limitations in the addressee's discourse model. Specifically, when an off-line analysis of the client's discourse is performed, it is not as disorganised as an on-line interpretation of his discourse suggests. In this way, although extract 1 contained what appeared to be an unexpected topic intrusion, ‘an analysis of background knowledge and contextual links revealed that the intrusive utterance was not as irrelevant as it seemed to be in the on-line situation’ (2013: 7). It was merely that these links were not active in the addressee's discourse model. Similarly, in extract 2, the gradual, radial extension of topics in this exchange may be seen to arise from an overreliance on semantic associations which are like those seen in normal language. It is simply that the client is developing lexical–conceptual links that are ‘too implicit, extensive or complicated from the viewpoint of a co-speaker’ (2013: 7). Finally, in extract 3, the abundance of instances of obscure reference is also explicable in terms of the addressee's discourse model. Quite simply, it would be possible to recover the referents of the expressions in this extract with the addition of further information and structure to the discourse. The point, Hella et al. (Reference Hella, Niemi, Hintikka, Otsa, Tirkkonen and Koponen2013: 8) argue, is the same throughout: ‘disorganized discourse is not merely a consequence of thought disorder of a schizophrenia patient. Rather, it should be regarded as a phenomenon of mutual interaction with possible divergent discourse models.’
Unit 47.5 Discourse deficits in schizophrenia
(1) The investigators concluded that this client exhibits discourse behaviours which are typical of positive-state schizophrenia. Identify these behaviours in the following list:
(2) In extract 1, the topic of music intrudes into the client's discourse after having been an earlier topic of conversation. Why might this occur?
(3) The investigators in this study believed that the client's overreliance on semantic associations was responsible for the gradual, radial extension of topics in extract 2. Which of the following terms describes the linguistic behaviour in schizophrenia where sound and/or meaning associations between words are developed?
(4) The presence of multiple instances of obscure reference in extract 3 might have a cognitive explanation in addition to the explanation advanced by the study's investigators. Which of the following cognitive factors might account for this linguistic behaviour?
(5) The conclusion of this study is that schizophrenic discourse would not appear so disorganised if there were greater alignment between the discourse models of the client and the doctor. This conclusion has an important implication for the management of clients with schizophrenia, including the SLP management of these clients. What do you think this implication is?
