Introduction

The following exercise is a case study of a girl (‘Mimi’) who was studied by Giddan et al. (Reference Giddan, Ross, Sechler and Becker1997). At 8 years of age, Mimi was referred to a school programme for the treatment of selective mutism. Selective mutism is a complex condition in which a child can be completely mute in one or more settings (typically, school), despite communicating effortlessly in other settings. The case study is presented in five sections: primer on selective mutism; client history; communication status; psychological intervention; and speech and language intervention.

Primer on selective mutism

Despite being known to the psychiatric community for over a century, selective mutism is still a poorly understood condition which has not been extensively investigated. The disorder is rare, with prevalence rates oscillating between 0.47% and 0.76% in research studies (Viana et al., Reference Viana, Beidel and Rabian2009). The disorder is more commonly found in females than in males, with the female:male sex ratio reported to be in the region of 1.6–3:1 (Busse and Downey, Reference Busse and Downey2011). The cause of the disorder is unknown. However, a number of factors appear to put children at increased risk of developing selective mutism. These factors include a background of migration, complications during pregnancy and delivery, delayed motor development and toilet training, premorbid speech and language disorders, behavioural abnormalities, comorbid diagnoses (such as enuresis and sleeping and eating disorders), a family history of selective mutism, and a pattern of interaction characterised by withdrawal, anxiety, depression and schizoid type behaviours (Unruh and Lowe, Reference Unruh, Lowe, Reynolds and Fletcher-Janzen2007). Reflecting a consistent finding of elevated anxiety in children with selective mutism, the Diagnostic and Statistical Manual of Mental Disorders classified selective mutism as an anxiety disorder for the first time in its fifth edition (DSM-5; American Psychiatric Association, 2013).

Although diagnostic criteria in DSM-5 state that selective mutism must not be better accounted for by a communication disorder, the presence of communication problems does not preclude a diagnosis of selective mutism in a particular case. Indeed, it is now widely acknowledged that children with the disorder exhibit a range of structural language deficits and pragmatic and discourse impairments. Cohan et al. (Reference Cohan, Chavira, Shipon-Blum, Hitchcock, Roesch and Stein2008) studied 130 children aged 5 to 12 years with selective mutism. The children in this study scored in the clinically significant range for syntax problems on the syntax subscale of the Children's Communication Checklist-2 (Bishop, Reference Bishop2003). Manassis et al. (Reference Manassis, Tannock, Garland, Minde, McInnes and Clark2007) examined the language skills of 6- to 11-year-old children with selective mutism. These children scored significantly lower on standardised language measures than children with anxiety and normal controls. Klein et al. (Reference Klein, Armstrong and Shipon-Blum2013) reported an expressive narrative language deficit in 42% of a sample of 33 children aged 5 to 12 years with selective mutism. McInnes et al. (Reference McInnes, Fung, Manassis, Fiksenbaum and Tannock2004) found that children with selective mutism used fewer story elements (i.e. settings, initiating events, internal responses) during their production of narratives than children with social phobia.

Client history

Mimi was 8 years old when she was referred to the school programme for the treatment of selective mutism. She was repeating her second grade and had displayed three years of silence in regular public school classes by that stage. Since the age of 3, she had not spoken to anyone outside her home. When communication became necessary, Mimi used handwritten notes in class and limited gestures. There was no spoken language used in school either during speech therapy or in individual sessions. However, Mimi did communicate without difficulty with certain family members at home.

Mimi's family situation and relationships were significant in several respects. Mimi's father, who spoke Spanish, left the family home when she was young. When she was 2 years old, Mimi fell and cut the inside of her mouth on the metal leg of a chair. This injury necessitated stitches. Mimi was hospitalised for over a week with a high fever when she was 3 years old. She had many needle sticks during her hospitalisation, and was frightened and did not speak. It was at this stage that Mimi stopped speaking entirely to people outside her immediate family. At 4 years of age, Mimi and her family moved to another state. Mimi's mother remarried. At the time of treatment, Mimi had four older siblings, but was the only child living at home. The relationship between Mimi and her mother was highly enmeshed. They participated jointly in most social activities. Outside the home, Mimi's mother often spoke for her and related her experiences to other people. Mimi's mother encouraged her dependence on her by continuing to bathe her and managing many aspects of her life. Mimi was not required to undertake any chores.

Communication status

At the point of entry to the school programme, Mimi would not talk in public places and on the telephone. She also would not talk to some relatives and even to her best friend, who would sometimes stay overnight at her home. Mimi's reason for not speaking was communicated in a written note: ‘When I was little my mother told me don't talk to strangers’. However, a home video-recording of Mimi which was made by her mother revealed that she would speak with animation in that setting.

Like other children with selective mutism, Mimi had speech and language problems. Her communication milestones were reportedly normal. A home video when Mimi was 9 years of age revealed that she had significant phonological and syntactic problems. Mimi distorted the /l/ and /r/ phonemes. She omitted /s/ in plurals, possessives and present tense verbs. Her utterances displayed immature syntax: ‘This a boy’; ‘This one name Andy’; ‘I'm gonna talk about what family do’. These problems had not been addressed in therapy because of her mutism. Mimi had significant pragmatic deficits. Other people had to assume the role of questioner, with Mimi providing only head nods and shakes for ‘yes’ and ‘no’, respectively. Mimi's language problems and lack of participation in school placed her at academic risk. At 9 years of age, Mimi should have been in the fourth grade. However, she was only in the third grade and even then was performing at second-grade level in reading, spelling and mathematics.

Psychological intervention

Mimi was initially seen by a child psychiatry fellow. A total of 10 therapy sessions resulted in improvements in her non-verbal communication skills. As a result of this therapy, Mimi was able to participate in pantomime activities in the classroom, attend with eye contact when spoken to, raise her hand more frequently in class and use more appropriate gesture. However, there was no improvement in vocalisation. Mimi's therapy was eventually taken over by a psychologist. Stimulus fading was used, with Mimi calling the therapist from home and reporting on voice mail. Early treatment sessions focused on establishing rapport and communication by means of written notes and writing on the chalk board. A response initiation approach was adopted within a month. In this approach, children with selective mutism receive the message that they are required to speak. The therapist then arranges a day when the child will spend the majority of it with the therapist. The child must say one word to the therapist before leaving his or her office. After the child speaks, he or she is reunited with his or her family. This session lasted four hours in Mimi's case. During that time, Mimi became very sad, sat curled up in a ball near the door, cried and hid under a chair. She attempted to bargain with her therapist through the use of written notes: ‘I promise I will talk Friday’. At nearly five o'clock, she whispered ‘I want to go home’. At that point, she was allowed to call her mother from the office phone and ask her to drive her home. Once whispering was established, Mimi's verbalisations were expanded by having her choose what to say. These messages were printed on cards. Mimi agreed to extend her whispering to her speech-language pathologist, her classroom teacher, an aide, and eventually others in the school environment. Other students also became involved in therapy, and Mimi whispered to them. Mimi along with her therapist wrote a puppet show which was performed to the class. Mimi's classroom participation increased – she took part in group discussions, for example – but this was still in a whispered voice.

After a few months, Mimi's therapy began to use shaping. Other vocalisations were encouraged – coughing, making sounds with a kazoo, producing animal sounds for the puppets. Rather than undertake another long day to elicit voice, Mimi agreed to use voice in speech therapy and the classroom to receive rewards. Although Mimi largely continued to whisper, she did begin to use voice on more occasions in response to a reward system. Each half hour, Mimi produced in a ‘normal’ voice a list of responses that had been compiled by her and her therapist. Some responses were short (e.g. ‘please’), while others involved the recitation of the spelling list. If Mimi did not use normal voice, she lost rewards. To generalise her use of full voice, homework assignments were employed. Further rewards were given if Mimi's mother reported that she had used full voice in community settings. Eventually, Mimi was encouraged to speak each day to one more person beyond school and home.

Speech and language intervention

Mimi was seen by the speech-language pathologist twice a week for individual treatment. At first, Mimi was encouraged to use gestures in therapy. Pantomime activities and guessing games on themes such as sports and emotions were used. Mimi readily participated in these activities and appeared to enjoy acting things out. She nodded for ‘yes’ and ‘no’. A game called ‘Guess Who?’ which involved other students was used. It served to initiate non-verbal communication, regulate other's attention and take turns. However, Mimi still did not attempt to initiate communication and used paper and pencil to communicate. The speech-language pathologist encouraged Mimi to record messages and read stories into a tape recorder. Mimi would only make these recordings when the therapist was outside the room. However, she and the therapist jointly listened to the recordings. At the point when Mimi started to use an audible whisper, her articulation, morphology and syntactic errors became the focus of therapy. A consistent reward system was used if Mimi participated by whispering. Along with another student, Mimi participated in question and answer games and activities that used a visual barrier to encourage verbal description. As whispering continued, Mimi became more animated in conversational exchanges and participated more in the classroom and other school settings. Mimi even went as far as whispering loudly into the intercom to announce the arrival of the school buses to the office. Mimi's daily speaking goals were consistently rewarded when they were achieved. Mimi assisted in setting up tasks to achieve the wider use of speech, greater volume, and more substantial verbal interactions. Full voice in school and in the community was achieved by the spring of Mimi's second school year. This was maintained throughout the summer months and when Mimi returned to her regular education setting in the autumn.

Introduction

The following exercise is a case study of two boys (‘Adam’ and ‘Abraham’) with attention deficit hyperactivity disorder who were studied by Peets (Reference Peets2009). The boys attended primary school special education classes in a large, urban, publicly funded school system in Toronto. These classes were designed to support children with language impairment. The case study is presented in five sections: primer on attention deficit hyperactivity disorder; language in attention deficit hyperactivity disorder; client language status; focus on narrative production – Adam; and focus on narrative production – Abraham.

Primer on attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has its onset in childhood and can persist into adulthood. The disorder is diagnosed on the basis of symptoms of inattention and hyperactivity and impulsivity which are described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Among the behaviours which are used to identify these symptoms are a failure to pay close attention to details, an inability to remain seated in appropriate situations, and difficulty organising tasks and activities. To receive a diagnosis of ADHD, children must have at least six symptoms from either (or both) the inattention criteria or the hyperactivity and impulsivity criteria in DSM-5. Older adolescents and adults must present with at least five symptoms for a diagnosis to be made. ADHD symptoms must not occur exclusively during the course of schizophrenia or another psychotic disorder, and must not be better explained by another mental disorder or by substance intoxication or withdrawal. Unlike earlier editions of DSM, DSM-5 does not contain exclusion criteria for individuals with autism spectrum disorder.

The prevalence of ADHD has been examined in several epidemiological studies. A recent study by Pastor et al. (Reference Pastor, Reuben, Duran and Hawkins2015) in the US estimated that in 2011 to 2013, 9.5% of children aged 4–17 years were diagnosed with ADHD. Within this figure, the prevalence of ADHD in children aged 4–5 years, 6–11 years and 12–17 years was 2.7%. 9.5% and 11.8%, respectively. Among all age groups, the prevalence of diagnosed ADHD was more than twice as high in boys as in girls. There is a complex interplay of genetic and non-genetic factors in the aetiology of ADHD. That there is a genetic susceptibility for ADHD is supported by findings of higher rates of ADHD in parents and siblings of affected probands compared to relatives of unaffected controls, and by higher concordance rates for ADHD in monozygotic than in dizygotic twin pairs (Thapar et al., Reference Thapar, Cooper, Jefferies and Stergiakouli2012). Lichtenstein et al. (Reference Lichtenstein, Carlström, Råstam, Gillberg and Anckarsäter2010) reported concordance rates for ADHD in monozygotic and dizygotic twin boys of 44% and 10%, respectively. Among environmental factors that have been associated with ADHD are maternally related prenatal risks (e.g. alcohol consumption, smoking and drug use in pregnancy), pregnancy and birth complications (e.g. prematurity and low birth weight) and external agents (e.g. infections, exposure to lead and other toxins) (Thapar et al., Reference Thapar, Cooper, Jefferies and Stergiakouli2012).

Comorbid conditions are commonly found in ADHD. These conditions can affect the assessment and treatment of ADHD. In the United States, Larson et al. (Reference Larson, Russ, Kahn and Halfon2011) examined the comorbidities of 5,028 children with ADHD aged 6–17 years. Learning disability was reported in 46% of these children. Other significant comorbidities were conduct disorder (27%), anxiety (18%), depression (14%) and speech problems (12%). Among these children, 33% had one comorbid disorder, while 16% had two comorbid disorders and 18% had three or more comorbid disorders. Giacobini et al. (Reference Giacobini, Medin, Ahnemark, Russo and Carlqvist2016) reported significant psychiatric comorbidity in Swedish children, adolescents and adults with ADHD. Autism spectrum disorders were the most common comorbidities for younger patients, while substance abuse, anxiety and personality disorder were the most common comorbidities in older patients. There are poor academic, vocational and psychosocial outcomes in children with ADHD. Sayal et al. (Reference Sayal, Washbrook and Propper2015) reported a 27- to 32-point reduction in GCSE scores in children with ADHD, while in boys with the disorder there was more than a twofold increased likelihood of not achieving five good GCSEs. Tervo et al. (Reference Tervo, Michelsson, Launes and Hokkanen2016) reported less education, more involuntary job dismissals and more alcohol abuse at 30 years of age in a group of 122 subjects with ADHD.

Language in attention deficit hyperactivity disorder

Children with ADHD often have receptive and expressive language impairments. DaParma et al. (Reference DaParma, Geffner and Martin2011) examined the scores of 100 children with ADHD aged 6–16 years on the Clinical Evaluation of Language Fundamentals – 4th edn (CELF-4; Semel et al., Reference Semel, Wiig and Secord2003). Compared to the typical population on whom the CELF-4 is standardised, a greater proportion of children with ADHD obtained scaled scores ≤ 4 (−2 SDs) on a number of receptive and expressive language measures. These children had problems understanding spoken language, following directions and understanding concepts, and understanding grammatical relationships. Children with ADHD also had trouble formulating sentences, recalling words rapidly and performing word association tasks. Reading and written expression are also impaired in ADHD. In a study of 179 children with ADHD aged 6 to 8 years, Sciberras et al. (Reference Sciberras, Mueller, Efron, Bisset, Anderson, Schilpzand, Jongeling and Nicholson2014) reported a higher prevalence of language problems than in controls after adjustment for sociodemographic factors and comorbidities. ADHD children with language problems had poorer word reading than children who had ADHD alone. Martinussen and Mackenzie (Reference Martinussen and Mackenzie2015) reported that young people with ADHD scored significantly lower than a comparison group on a standardised measure of reading comprehension. Poor comprehenders with ADHD exhibited weakness in expressive vocabulary and written expression relative to good comprehenders with ADHD.

Pragmatic and discourse skills are also impaired in children with ADHD. Bruce et al. (Reference Bruce, Thernlund and Nettelbladt2006) used a parental questionnaire to examine language and communication skills in 76 children with ADHD. The majority of these children had pragmatic problems. These problems were associated with some of the core aspects of ADHD symptoms, particularly inattention and impulsiveness. Redmond (Reference Redmond2004) examined the conversational profiles of children with ADHD and SLI. Children with ADHD were found to produce significantly more mazes and longer mazes than children with SLI or typically developing children. Mazes included false starts, fillers, revisions and repetitions. Discourse production and comprehension problems are also found in children with ADHD. Rumpf et al. (Reference Rumpf, Kamp-Becker, Becker and Kauschke2012) examined the organisation of narratives in children with ADHD. Only one of 9 children with ADHD (11%) was able to verbalise the core aspects of the story adequately. This contrasted with 27% of children with Asperger's syndrome and 82% of healthy controls. This difference in frequencies was significant and pointed to limited coherence in the narratives of children with ADHD (and Asperger's syndrome also). Berthiaume et al. (Reference Berthiaume, Lorch and Milich2010) found that boys with ADHD were less able than comparison peers to draw inferences, particularly explanatory inferences, which link events in a story. They were also less able than peers to monitor their ongoing comprehension of texts.

Client language status

The two children with ADHD in this study – Adam and Abraham – are both monolingual English speakers who live in English-speaking families. Both children met criteria for language impairment which were set by the school board. The parents of these children reported that they were late talkers. The listening comprehension and oral expression subtests of the Oral and Written Language Scale (OWLS; Carrow-Woolfolk, Reference Carrow-Woolfolk1995) were used to assess expressive and receptive language. Adam and Abraham scored more than 1.5 standard deviations below the mean on the composite language score of the OWLS and had percentile scores of 4 and 3, respectively. The expressive and receptive scores of these children did not differ significantly.

Focus on narrative production – Adam

Adam and Abraham were identified as having pragmatic difficulties. To examine these difficulties, Peets (Reference Peets2009) also analysed the narrative discourse skills of both children. In the extract below, Adam (A) is talking to his teacher (T) about snow tubing. This extract is part of a longer exchange in which Adam successfully engages the other children present, some of whom ask him questions. Adam is very popular among both teachers and his peer group on account of his vivacious and enthusiastic personality.

Focus on narrative production – Abraham

Abraham is an equally engaging story teller. In the extract below, he relates to his teacher in the presence of other students (S) an interaction he had with his baby brother.

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.

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.

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.

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.

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.’

Introduction

The following exercise is a case study of a woman (‘WM’) who was studied by Manning (Reference Manning1999). WM was diagnosed with DSM-IV bipolar disorder not otherwise specified. This diagnosis is used for individuals who experience hypomania without a history of major depressive disorder or a manic episode. WM's condition responded well to valproate therapy. The case study is presented in five sections: primer on bipolar disorder; communication and cognition in bipolar disorder; client history and family background; clinical presentation, diagnosis and treatment; focus on discourse in bipolar disorder.

Primer on bipolar disorder

Bipolar disorder (formerly known as ‘manic depression’) is a psychiatric disorder in which the patient's mood alters between manic episodes (characterised by euphoria, restlessness, poor judgement and risk-taking behaviour), depressive episodes (characterised by depression, anxiety and hopelessness) and episodes of normal mood (known as euthymia). The disorder is diagnosed on the basis of criteria contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is now in its fifth edition (American Psychiatric Association, 2013). When WM received her diagnosis, it was on the basis of criteria contained in the fourth edition of DSM. According to Angst (Reference Angst2013), one of the shortcomings of this edition was the large proportion of treated patients who had to be allocated to the vague ‘not otherwise specified’ group. WM is one such patient. In DSM-5, several new subthreshold groups of depression, bipolar disorders and mixed states are now operationally defined (Angst, Reference Angst2013).

The prevalence of bipolar disorder in the population varies between studies. In a New Zealand study, Wells et al. (Reference Wells, McGee, Scott and Oakley Browne2010) reported that the lifetime prevalence of bipolar disorder (types I + II) is 1.7%. Kozloff et al. (Reference Kozloff, Cheung, Schaffer, Cairney, Dewa, Veldhuizen, Kurdyak and Levitt2010) recorded a lifetime prevalence of 3.0% in 15–24-year-olds in a Canadian sample. A similar lifetime prevalence of 3.0% was reported by Calvó-Perxas et al. (Reference Calvó-Perxas, Garre-Olmo and Vilalta-Franch2015) in a population-based sample in Catalonia, Spain. Reviewing data from the Cross-National Collaboration on major depression and bipolar disorder, Grant and Weissman (Reference Grant, Weissman, Narrow, First, Sirovatka and Regier2007) found that there were no consistent sex differences in bipolar disorder. In a study of 1,665 subjects with type-I bipolar disorder, Baldessarini et al. (Reference Baldessarini, Tondo, Vazquez, Undurraga, Bolzani, Yildiz, Khalsa, Lai, Lepri, Lolich, Maffei, Salvatore, Faedda, Vieta and Mauricio2012) reported that the median age at onset was 23.0 years while the average age was 25.7 ± 11.3 years. Thesing et al. (Reference Thesing, Stek, van Grootheest, van de Ven, Beekman, Kupka, Comijs and Dols2015) found that increased family history of psychiatric disorders is associated with earlier age at onset, while negative stressors are associated with later age at onset of the first (hypo)manic episode.

Genetic and environmental risk factors for bipolar disorder have been identified. A history of bipolar affective disorder and other psychiatric disorders, including schizophrenia and schizoaffective disorder, in parents or siblings, is a risk factor for bipolar disorder. Päären et al. (Reference Päären, Bohman, von Knorring, Olsson, von Knorring and Jonsson2014) found that a family history of bipolar disorder was the strongest predictor of developing bipolar disorder in adulthood among adolescents with mood disorders. Mortensen et al. (Reference Mortensen, Pedersen, Melbye, Mors and Ewald2003) reported that people with a first-degree relative with bipolar affective disorder had a 13.63-fold increased risk of bipolar affective disorder. These investigators also found that children who experienced maternal loss before their fifth birthday had a 4.05 increased risk of bipolar affective disorder. Paksarian et al. (Reference Paksarian, Eaton, Mortensen, Merikangas and Pedersen2015) found that the number of years of paternal separation is positively associated with bipolar disorder. Comorbid conditions are common in bipolar disorder. Significant comorbid conditions in community studies are anxiety, substance use and conduct disorders, while eating disorders, ADHD, ASD and Tourette's disorder are comorbid conditions in clinical samples (McElroy, Reference Roy and Kent2004). Migraine, thyroid illness, obesity, diabetes and cardiovascular disease are the most common medical comorbidities (McElroy, Reference Roy and Kent2004).

Communication and cognition in bipolar disorder

Increasingly, studies are documenting a range of communication problems in clients with bipolar disorder. These problems include difficulties with the reception and expression of language. In a study of the prevalence of speech and language problems among patients receiving care from a mental health unit, Emerson and Enderby (Reference Emerson and Enderby1996) recorded language comprehension problems in 33% of their patients with bipolar disorder. Difficulties with spontaneous speech, picture description, naming and fluency were observed in 25%, 25%, 16% and 8% of bipolar patients, respectively. Radanovic et al. (Reference Radanovic, Villela Nunes, Farid Gattaz and Vicente Forlenza2008) examined the performance in language tests of 33 euthymic elderly patients with bipolar disorder but no dementia. When compared with healthy controls, these patients exhibited a mild but significant impairment in language-related ability scores. In a study that analysed the speech output of schizophrenic, bipolar and depressive patients, Lott et al. (Reference Lott, Guggenbühl, Schneeberger, Pulver and Stassen2002) found illogicality in 62.1% of bipolar patients, the highest figure of all three psychiatric diagnoses. Poverty of speech was present in 6.9% of bipolar patients. Poulin et al. (Reference Poulin, Macoir, Paquet, Fossard and Gagnon2007) reported the unusual case of a patient with bipolar disorder who presented with agrammatism and foreign accent syndrome.

Language impairments are not just a feature of adult-onset bipolar disorder but are also found in children. McClure et al. (Reference McClure, Treland, Snow, Schmajuk, Dickstein, Towbin, Charney, Pine and Leibenluft2005) found that paediatric outpatients with bipolar disorder performed more poorly than healthy comparison subjects on the pragmatic judgement subtest of the Comprehensive Assessment of Spoken Language. Sigurdsson et al. (Reference Sigurdsson, Fombonne, Sayal and Checkley1999) found that adolescents who developed early-onset bipolar disorder were significantly more likely to have experienced delayed language than a group of control subjects with depression but without psychotic features. As well as language problems, motor speech disorders such as dysarthria have also been documented in clients with bipolar disorder. In some cases at least, these disorders appear to be related to the client's drug regimen. Bond et al. (Reference Bond, Carvalho and Foulks1982) reported the case of a 19-year-old patient who developed persistent dysarthria with coexisting apraxia while taking high dose haloperidol and lithium carbonate. Swallowing disorders are also common in clients with bipolar disorder. Regan et al. (Reference Regan, Sowman and Walsh2006) reported that 27% of individuals with bipolar disorder in their study exhibited overt signs of oropharyngeal dysphagia.

There is growing evidence that clients with bipolar disorders exhibit certain cognitive deficits. Some of these deficits involve impairments of executive functions. Peters et al. (Reference Peters, Peckham, Stange, Sylvia, Hansen, Salcedo, Rauch, Nierenberg, Dougherty and Deckersbach2014) examined 68 subjects who met DSM-IV criteria for bipolar I disorder in a depressed or euthymic state. Significant impairment in every domain of executive functioning was found in these subjects. Peters et al. concluded that executive functioning problems are not entirely mood-state dependent. Other cognitive deficits take the form of theory of mind (ToM) impairments. Paediatric patients with type I bipolar disorder have been shown to exhibit deficits in the ability to understand another's mental state, with impaired ToM performance associated with poorer interpersonal functioning (Schenkel et al., Reference Schenkel, Chamberlain and Towne2014). Deficits in emotion recognition and theory of mind have been found in manic, depressed and euthymic bipolar subjects (Samamé, Reference Samamé2013). What relationship, if any, these cognitive deficits have to language impairments in bipolar disorder is uncertain at this time.

Client history and family background

WM is a 24-year-old woman. She has been married for one year to a law enforcement officer. The marriage is her first but her husband's third marriage. Her husband's second wife and child from that marriage live nearby. WM has a difficult relationship with her husband's ex-wife. WM and her husband have a 9-month-old child together. The pregnancy and delivery were uncomplicated. WM reported that her problems with mood began after the birth of her child. WM's general state of health is good. She takes birth control pills and has migraine headaches without aura. These have increased in frequency and duration since giving birth. WM is generally successful in treating her headaches with ibuprofen and rest. She smokes two or three packs of cigarettes per day but does not drink alcohol. She has never used marijuana, cocaine or other illicit substances. She drinks four caffeinated soft drinks per day.

Many of WM's relatives have experienced mood or anxiety problems. Her paternal grandfather was hospitalised on one occasion in a state mental health facility. He was diagnosed with manic depression. WM's father was an alcoholic. WM described him as being mercurial and impulsive, and prone to outbursts and violent behaviour even during extended periods of sobriety. Several other male relatives abused alcohol or cocaine.

Clinical presentation, diagnosis and treatment

WM presented with nervousness, headache and insomnia. She reported having difficulty dealing with stressful situations and controlling her temper. She also experienced periods of sadness which were often unexplained. These periods could last a week and could be intense, occurring all day every day. WM reported that she normally ‘bounced back’ from them. On occasion, her sadness was accompanied by a restless energy and irritability which could result in arguments with her husband's ex-wife. These periods of increased energy could rapidly switch back to an intense, depressed mood. When WM was depressed, she slept excessively and would overeat. She also isolated herself, was unable to get things done and would let the housework go. When depressed, WM was also excessively sensitive to feelings of rejection by others. However, her mood could be lifted temporarily if she engaged in activities she enjoyed. These periods of depressed mood had started since the birth of her child. WM reported that she was cheerful and outgoing prior to this time. There was no prior treatment for mood or anxiety problems.

At the initial interview, WM was dramatic and animated. She spoke for seven minutes uninterrupted in response to the question “What brings you here to see us today?”. Her speech was moderately pressured and she changed topics several times. WM was affectively labile and would alternately laugh and cry. There were elements of depression and hypomania in her mood. WM reported frenzied activity into the early hours of the morning. She would talk to friends on the phone and plan social outings. After a period of rest for three or four hours, she would wake up with a pressured desire to ‘get things done’. WM was often tearful and irritable during the day. Her judgement was not seriously impaired and she was not involved in self-damaging activities. Reality testing revealed no impairments.

WM was diagnosed with DSM-IV bipolar disorder not otherwise specified. She was prescribed divalproex sodium. After seven days, her headaches stopped and a normal sleep pattern was restored. WM reported greater emotional resilience and felt much less irritable. Over the next four weeks, improvement continued and her depressed moods disappeared. With stabilisation of her mood, WM was able to focus on her psychosocial difficulties with a clinical social worker. After two months of treatment, WM briefly discontinued valproate because of weight gain. Because her mood was normal, she felt that medication might no longer be necessary. The option of discontinuing medication altogether or changing to lithium or carbamazepine was considered. Rather than discontinue valproate therapy and risk a reoccurrence of symptoms with all their negative implications for her job and impending legal issues (WM had decided to get a divorce), WM decided to keep taking her medication and made lifestyle changes (diet and exercise) instead.

Focus on discourse in bipolar disorder

Like many other communication disorders, disordered language in clients with bipolar disorder is most usefully examined at the level of discourse. It is during conversation, narratives and other forms of discourse that features such as poverty of speech, pressured speech and referential anomalies are most evident. The following extracts are taken from an interview between a clinical psychology researcher (S) and a 33-year-old woman (B) with mania who was studied by Swartz and Swartz (Reference Swartz and Swartz1987). S is university educated, English-speaking and divorced. The interview was conducted three days after S's admission to a locked women's ward in a large psychiatric hospital. Although S was treated with phenothiazines and lithium, her state had not altered since her admission.