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Schizophrenic Speech

Making Sense of Bathroots and

Ponds that Fall in Doorways

This book reviews our knowledge of the incoherent speech which is not uncommonly seen as a

symptom of schizophrenia, and is one of the most researched symptoms in the disorder. The

content covers clinical presentation, differential diagnosis and the theories proposed to account

for the symptom of thought disorder, ranging from the psychoanalytic to there being a formof aphasia involved. The book is unique in its ability to apply linguistic and neuropsychological

approaches, and is the first to cover comprehensively the range of clinical studies that followed

the introduction of Andreasens rating scale for thought, language and communication dis-

orders. This book is essential reading for all those working in the field of schizophrenia and also

for those interested in language and disorders of speech.

Peter McKennais a psychiatrist with a special interest in schizophrenia. He has written one

previous book on the subject and has carried out research, principally on the neuropsychology

of the disorder.

Tomasina Oh strayed into the area of schizophrenic thought disorder during her PhD.

A linguist by training, she is interested in language impairment, as well as the relationship

between language and cognition.

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Schizophrenic SpeechMaking Sense of Bathroots andPonds that Fall in Doorways

Peter J. McKennaConsultant Psychiatrist, Fulbourn Hospital, Cambridge and

Visiting Professor of Psychology, University of Hertfordshire

Tomasina M. OhAssistant Professor, Department of English Language and

Literature, National University of Singapore

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CAMBRIDGE UNIVERSITY PRESS

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, So Paulo

Cambridge University PressThe Edinburgh Building, Cambridge CB2 8RU, UK

First published in print format

ISBN-13 978-0-521-81075-3

ISBN-13 978-0-521-00905-8

ISBN-13 978-0-511-41020-8

Cambridge University Press 2005

The publisher has used its best endeavours to ensure that the URLs for external websitesreferred to in his book are correct and active at the time of going to press. However, the

publisher has no responsibility for the websites and can make no guarantee that a site willremain live or that the content is or will remain appropriate.

Every effort has been made in preparing this book to provide accurate and upto-dateinformation that is in accord with accepted standards and practice at the time ofpublication. Neverthless, the authors, editors and publisher can make no warranties thatthe information contained herein is totally free from error, not least because clinicalstandards are constantly changing through research and regulation. The authors, editorsand publisher therefore disclaim all liability for direct or consequential damages resultingfrom the use of material contained in this book. Readers are strongly advised to pay careful

attention to information provided by the manufacturer of any drugs or equipment thatthey plan to use.

2005

Information on this title: www.cambridge.org/9780521810753

This publication is in copyright. Subject to statutory exception and to the provision of

relevant collective licensing agreements, no reproduction of any part may take placewithout the written permission of Cambridge University Press.

Cambridge University Press has no responsibility for the persistence or accuracy of urlsfor external or third-party internet websites referred to in this publication, and does notguarantee that any content on such websites is, or will remain, accurate or appropriate.

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org

paperback

eBook (NetLibrary)

hardback
http://www.cambridge.org/9780521810753http://www.cambridge.org/http://www.cambridge.org/9780521810753http://www.cambridge.org/

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The authors are indebted to two psychologists,

Alan Baddeley and Rosaleen McCarthy, who

over a considerable period of time influenced

the writing of this book in many direct and

indirect ways.

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Contents

Preface page ix

1 Describing schizophrenic speech 1

2 Tho ught diso rder as a syndro me in schizophrenia 26

3 The differential diagno sis o f thought disorder 48

4 Tho ught diso rder as a form o f dysphasia 80

5 Tho ught diso rder and communicative competence 101

6 Tho ught diso rder as a dysexecutive phenomenon 123

7 The dyssemantic hypothesis of tho ught disorder 146

8 So me conclusions and a few speculations 172

References 186

Index 207

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Preface

I f e v e r t h e r e w e r e a p r e f a c e t h a t o u g h t t o s t a r t w i t h t h e w o r d s W h y a n o t h e r b o o k

on. . .

, t hi s i s p ro ba bl y i t. T ho ug ht d is or de r i s t he m os t s tu di ed s ym pt om o f a

m uc h- st ud ie d d is or de r, s ch iz op hr en ia , a nd t he re h as b ee n a l on g t ra di ti on o f

p u nc t ua t in g t h e s t ea d y s t re a m o f p ub l ic a ti o ns o n t h e s u bj e ct w i th b o ok s . T h er e

m ay b e s om e j us ti fi ca ti on f or c on ti nu in g t hi s t ra di ti on , i n t ha t t he l as t s in gl e-

a u t h o r b o o k o n t h e t o p i c w a s w r i t t e n i n 1 9 9 0 , a n d , w h i l e t h e r e h a v e b e e n o n e o r

t w o m u l t i - a u t h o r v o l u m e s s i n c e t h e n , i t i s f a i r t o s a y t h a t n e i t h e r o f t h e s e c a u g h t

t he t id e o f t wo m aj or d ev el op me nt s i n t he f ie ld . O ne o f t he se w as t he w av e o f

c l i n i c a l s t u d i e s t h a t f o l l o w e d t h e i n t r o d u c t i o n o f A n d r e a s e n s r a t i n g s c a l e f o r w h a t

s h e c a ll e d t h ou g ht , l a ng u ag e a n d c o mm un i ca t io n d i so rd e rs ; t h e s e co n d h a s b e ent h e r i s e o f t h e n e u r o p s y c h o l o g i c a l a p p r o a c h t o s c h i z o p h r e n i a .

N a t u r a l l y , n e i t h e r o f t h e s e d e v e l o p m e n t s w a s t h e r e a s o n f o r w r i t i n g t h i s p a r t i c -

u l a r b o o k , w h i c h h a d m o r e m a c u l a t e o r i g i n s . I t g r e w o u t o f o u r a t t e m p t s t o g e t a

p ap er b as ed o n t he r es ea rc h i n a P h. D. p ub li sh ed . A ft er e ng ag in g i n t he u su al

t it ani c st rug gle wi th t he r ev ie we rs, one of u s sa id t o t he ot he r in a fl ash of

e x a s p e r a t i o n t h a t t h e o n l y w a y w e w o u l d e v e r g e t t h e d a m n t h i n g i n t o p r i n t w a s

b y w ri ti ng a b oo k o n t ho ug ht d is or de r a nd p ut ti ng t he p ap er i n i t s om ew he re .

I mm ed ia te ly w e b ot h s aw t he p os si bi li ti es f or a b oo k, a nd w er e q ui ck ly a bl e t op er su ad e o ur se lv es t ha t t he re w as a p re ss in g n ee d f or o ne , a lo ng t he l in es l ai d o ut i n

t h e p r e c e d i n g p a r a g r a p h .

T he p he no me no n t ha t f or ms t he t op ic o f t hi s b oo k h as g on e b y m an y n am es

o ve r t he y ea rs . S om e o f t he se h av e b ee n p ic tu re sq ue a nd f an ci fu l, s uc h a s w or d

s al ad a nd k ni gh t s m ov e t hi nk in g. Q ui te a f ew h av e c om e w it h t he ir o wn t he or -

e t i c a l b a g g a g e , e i t h e r n e u r o l o g i c a l , f o r e x a m p l e s c h i z o p h a s i a , o r p s y c h o l o g i c a l , a s

i n t h e w i de l y u s ed A me r ic a n t e rm , l o os e ni n g o f a s so ci a ti o ns . E v en t ua l ly , p s yc h -

i a t r y s e t t l e d o n o n e o f t h e m o s t o p a q u e t e r m s e v e r u s e d , f o r m a l t h o u g h t d i s o r d e r t h e f o r m a l d e n o t i n g a d i s o r d e r i n t h eform o f t h e t h o u g h t p r o c e s s e s a s o p p o s e d t o

t he d is or de r o f content o f t ho ug ht e xh ib it ed b y p at ie nt s w it h d el us io ns . A s w e

w r o t e t h i s b o o k w e g r e w m o r e a n d m o r e i r r i t a t e d b y t h e c l u m s i n e s s o f t h i s t e r m ,

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a n d i t s u n i n t e n t i o n a l p r e t e n t i o u s n e s s , a n d s o w e h a v e s u b s t i t u t e d t h e s i m p l e r t e r m

t ho ug ht d is or de r t hr ou gh ou t. I t m ay b e m or e c on fu sa bl e w it h s ch iz op hr en ic

s ym pt om s o th er t ha n f or ma l t ho ug ht d is or de r, a nd p ur is ts m ay o bj ec t t ha t i t

e x cl u de s a b no rm a li t ie s o f l a ng u ag e ( a nd c o mm un i ca t io n ), b u t i t a t l e as t h a s t h ev i r t u e o f b e i n g l e s s o f a m o u t h f u l .

A n u m b e r o f p e o p l e h e l p e d i n t h e w r i t i n g o f t h i s b o o k i n a n u m b e r o f w a y s . I n

a d d i t i o n t o h e r g e n e r a l i n f l u e n c e o n o u r w a y o f t h i n k i n g , R o z M c C a r t h y s k n o w -

l e d g e o f n e u r o p s y c h o l o g y a n d a p h a s i a w a s i n v a l u a b l e . W e a l s o o w e h e r a d e b t o f

g r at i tu d e f o r p a ti e nt l y b u t d e te r mi n ed l y p e rs u ad i ng u s t h at e x ec u ti v e f u nc t io n

m ig ht b e r el ev an t t o s om e o f t he l in gu is ti c a bn or ma li ti es o f t ho ug ht d is or de r,

e s p ec i a ll y a s o n e o f u s f o u g h t l o n g a n d h a r d a g a i ns t a c c e p t i ng t h i s. G e r ma n B e r r i o s

i n fo rm e d t h e h i st o ri c al a s pe c ts o f t h is b o ok t h ro u gh h i s p u bl i sh e d w o rk , m a ny

c o n v e r s a t i o n s a n d o n e j o u r n a l i s t i c i n t e r v i e w ; b e y o n d t h i s h e a l s o p r o v i d e d a g r e a t

d ea l o f d ee p b ac kg ro un d. T he a ut ho rs k no w a l ot m or e a bo ut s pe ci fi c l an gu ag e

i m p a i r m e n t i n c h i l d r e n t h a n t h e y d i d b e f o r e , a f t e r o n e o f t h e m s p e n t a n a f t e r n o o n

w i th D o ro t hy B i sh op i n Ox fo rd . S t at i st i ca l ly , S t e v e Gr a h am a n d Ra y m on d S a lv a d or

g a v e u s a c r a s h c o u r s e i n f a c t o r a n a l y s i s , a n d K e i t h L a w s t a u g h t u s e v e r y t h i n g w e

k no w a bo ut m et a- an al ys is . P au la M cK ay a rr an ge d a t ri p t o I re la nd t o m ee t S en at or

D a v i d N o r r i s i n o r d e r t o t a p h i s e x t e n s i v e k n o w l e d g e a b o u t J a m e s J o y c e a n d h i s

d a u g h t e r , L u c i a , a n d w e w o u l d l i k e t o t h a n k b o t h o f t h e m f o r t h i s . W e a r e g r a t e f u l

t o C a m b r i d g e U n i v e r s i t y P r e s s a n d R i c h a r d Ma r l e y f o r o v e r l o o ki n g m a n y m i s s e dd e a d l i n e s . W e w o u l d a l s o l i k e t o t h a n k S h i r l e y E a s t o n f o r b a t t l i n g t o t r a n s c r i b e a

n u m b e r o f i n d i s t i n c t r e c o r d i n g s o f o f t e n n e a r l y u n i n t e l l i g i b l e s p e e c h . Ou r f a m i l i e s

w e re i n cr e di b ly t o le ra n t w i th u s , e s p e ci a ll y i n t h e l a st f e w w e ek s b e fo re c om p le t io n ;

w e h o p e t h e y k n o w t h a t t h e i r s u p p o r t w a s i n v a l u a b l e i n t h e w r i t i n g o f t h i s b o o k .

x Preface

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1

D es cr ib i ng s ch i zo p hr en ic s pe ec h

W h e n t r y i ng t o e x p la i n t h o ug h t di so r de r , or a n yt h i ng e l se f o r th a t ma t t e r, a g oo d

p la ce t o s ta rt is b y d es cri bi ng th e ph en ome non a ccu ra tel y. I n me di ci ne , t he

c us to ma ry w ay o f d oi ng t hi s i s b y o bs er vi ng a s ui ta bl y l ar ge n um be r o f p at ie nt s

w ho s how t he ph en ome non i n a ll i ts v ari ed f orms , a nd ex tr ac tin g t he c omm on

f ea tu re s s o a s t o a rr iv e a t s om e d is ti ll at io n o f t he e ss en ti al n at ur e o f t he s ym pt om

i ts el f. T hi s i s t he s o- ca ll ed c li ni ca l me th od , so me ti me s d ig ni fi ed a s d es cr ip ti ve

p sy ch op at ho lo gy i n p sy ch ia tr y, w he re t he s ym pt om s a re m uc h m or e i nd iv id ua ll y

v ar ia bl e t ha n i n t he r es t o f m ed ic in e, a nd o cc as io na ll y e le va te d t o t he s ta tu s o f i ts

o w n d i sc i pl i ne o f p he n om e no l og y .

Traditional and greatly respected in medicine, this approach to defining

t ho ug ht di so rd er wa s o bj ec te d t o b y t wo l in gu is t s, Ro ch es te r a nd M ar ti n (1979),

on the grounds that it was too dependent on inference. They levelled their

c r it i ci s ms p a rt i cu l ar l y a t B l e ul e r (1911) , w ho c oi ne d t he t er m s ch iz op hr en ia a nd

was responsible for giving what is still one of the mos t detailed accounts of

t ho ug ht di so rd er . I n t he f ir st p la ce , h e t oo k it a s a g iv en t ha t th e u nd er ly in g

a b n o r m a l i t y w a s o n e o f t h o u g h t r a t h e r t h a n o f sp e e c h , a n d a c c o r d i n g t o Ro c h e st e r

a nd M ar ti n t he u nc ri ti ca l a cc ep ta nc e o f t hi s v ie w b y t ho se w ho f ol lo we d h im

c a us e d m a ny p r ob l em s a n d o b sc u re d s o me i n te r es t in g i s su e s. S e co n dl y , B l eu l er

s p e c i f i e d t h e d i s o r d e r o f t h o u g h t a s o n e o f l o o s e n i n g o f a s s o c i a t i o n s o r a s s o c i a -

t i on d i st u rb a nc e , a s p ec u la t iv e c o ns t ru c t t o w h ic h h e a c co r de d g r ea t t h eo re t ic a lsi g n i f i c a n c e . B u t w h e n Ro c h e st e r a n d M a r t i n t u r n e d t o a c o n t e m p o r a r y t e x t b o o k

f o r a d e f i n i t i o n o f l o o se n i n g o f a sso c i a t i o n s t h e y w e r e c o n f r o n t e d w i t h st a t e m e n t s

l ik e, In t he l oo se ni ng o f a ss oc ia ti on t he f lo w o f t ho ug ht m ay s ee m h ap ha za rd ,

p u r p o se l e ss, i l l o g i c a l , c o n f u se d , a b r u p t a n d b i z a r r e w h i c h se e m e d m e r e l y t o l e a d

b a c k t o t h o u g h t d i so r d e r . C l i n i c a l a t t e m p t s t o d e f i n e t h e a b n o r m a l i t i e s c o n t r i b u -

t i n g t o t h o u g h t d i s o r d e r c o u l d , i t a p p e a r e d , a l l t o o e a s i l y d e s c e n d i n t o c i r c u l a r i t y .

I n f e r e n t i a l a n d c i r c u l a r o r n o t , o b s e r v a t i o n a l s t u d i e s h a v e o c c u p i e d a l a r g e p a r t

o f t he h is to ry o f a tt em pt s t o g et t o g ri ps w it h w ha t m ak es s ch iz op hr en ic s pe ec hd if fi cu lt t o f ol lo w. O ne c ou ld b eg in a n a cc ou nt o f t he se a tt em pt s w it h B le ul er ,

R o c h e s t e r a n d M a r t i n s v i l l a i n o f t h e p i e c e , w h o s e s w a y w a s s o g r e a t t h a t h i s t e r m

l oo se a ss oc ia ti on s b ec am e a nd r em ai ns a s yn on ym f or t ho ug ht d is or de r. B ut , i n

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f ai rn es s, t hi s o ug ht t o b e p re ce de d b y a d es cr ip ti on o f t he w or k o f B le ul er s

c o nt e mp o ra r y, K ra e pe l in , t h e o ri g in a to r o f t h e c o nc e pt o f s c hi z op hr e ni a a n d a

m a jo r i n fl u en c e o n h i s a n d e v er y on e e l se s v i ew s . K ra e pe l in s p ow e rs o f o b se r va -

t io n a re g en er al ly a cc ep te d a s h av in g b ee n a cu te , a nd h e h ad q ui te a l ot t o s ay a bo utt h ou g ht d i so rd e r, d e sc r ib i ng m a ny o f t h e p h e no m en a i n s o me o f t h e t e r m s t h a t f o r

b e t t e r o r w o r s e a r e s t i l l i n u s e t o d a y .

K r a e p e l i n a n d B l e u l e r : t h e c l a s s i c a l a c c o u n t s o f t h o u g h t d i s o r d e r

I n h is 1 91 3 t ex tb ook , in wh ich h e g av e h is mos t d et ai le d d es cri pt ion of t he

s ym pt om s o f s ch iz op hr en ia , K ra ep el in (1913a) s tat ed t ha t the pa tie nt s m en tal

a s so c ia t io n s o f te n h a ve t h at p e cu l ia r ly b e wi l de r in g i n co m pr e he n si b il i ty , w h ic h

d i s t i n g u i s h e s t h e m f r o m o t h e r f o r m s o f c o n f u s i o n [ a n d ] c o n s t i t u t e s t h e e s s e n t i a l

f o u nd a t i on o f i n c o h e r e n c e o f t h o u g h t ( i t a l i c s i n o r i g i n a l ) . I n l e s s s e v e r e c a s e s t h i s

sh o w e d i t se l f m e r e l y a s i n c r e a se d f a c i l i t y o f d i st r a c t i o n a n d i n c r e a se d d e su l t o r i -

n e ss , t h e p a ti e nt p as s in g w i th o ut a n y c o nn e ct i on f r om o ne s u bj e ct t o a n ot h er ,

with an interweaving of superfluous phrases and incidental thoughts. Sometimes,

h ow ev er , t he re c ou ld b e a n a lm os t c om pl et e l os s o f c on ne ct io n b et we en i de as .

A s a n e x a m p l e o f t h i s h e o f f e r e d t h e f o l l o w i n g p a t i e n t s r e p l y t o t h e q u e s t i o n , A r e

you ill?

Y o u s e e a s s o o n a s t h e s k u l l i s s m a s h e d a n d o n e s t i l l h a s f l o w e r s [ l a u g h s ] w i t h d i f f i c u l t y , s o i t w i l l

n o t l e a k o u t c o n s t a n t l y . I h a v e a s o r t o f s i l v e r b u l l e t w h i c h h e l d m e b y m y l e g , t h a t o n e c a n n o t

jump in, where one wants, and that ends beautifully like the stars. Former service, then she puts

i t o n h er h ea d a nd w il l s oo n b e r es pe ct ab le , I s ay , O G od , b ut o ne m us t h av e e ye s. S it s h im se lf a nd

e a t s i t . Q u i t e e x c i t e d , I w a s q u i t e b e s i d e m y s e l f a n d s a y t h a t t h e r e f o r e t h e r e s h o u l d b e m e a n n e s s

a nd t he re i s a m er ry g ro wt h o ve r. I t w as t he s ta rs . I , a nd t ha t i s a ls o s o c ur io us , t he n un

c o ns e qu e nt l y d i d n o t k n o w m e a n y m o r e , I s h ou l d c o m e f r om M . b e ca u se s o me t hi n g a l w a ys

h a p p e n s , a b r o k e n l e g o r s o m e t h i n g , t h e y v e h a d a q u a r r e l w i t h e a c h o t h e r , t h e c l e r g y m a n a n d

s h e ; a l e g h a s j u s t b e e n b r o k e n . I b e l i e v e t h a t i t i s c a u s e d b y t h i s t h a t s u c h a m i s f o r t u n e h a p p e n s ,s u c h a r e p a r a t i o n f o r d a m a g e s . I h a v e a l s o s a i d I s h a l l t h e n c o m e i n t h e e n d l a s t , w i t h t h e s u n a n d

t h e m o o n , a n d t o o m u c h e x c i t e m e n t , a n d a l l t h a t m a k e s s t i l l a g r e a t d e a l o f t r o u b l e . K i n g s d o n o t

c o l l e c t t h e m o n e y , i n t h i s w a y t h e l e t t e r s h a v e b e e n t a k e n a w a y f r o m m e , a s I t h a t a t l a s t o f t h o s e

t ha t p ar ti cu la rl y b el ie ve a s I a t l as t s pe ci al ly t hi nk , a nd a ll a re b ur ne d. Y ou c an i ma gi ne t ha t

c o m e s a l w a y s f r o m o n e t o t h e o t h e r .

D es pi te t he o n t he w ho le c om pl et el y a im le ss a nd f ra gm en ta ry n at ur e o f t he

p a t i e n t s u t t e r a n c e s , K r a e p e l i n o b s e r v e d t h a t i n a f e w p l a c e s a c e r t a i n c o n n e c t i o n

b e t w e e n t h e i d e a s c o u l d s t i l l b e m a d e o u t , f o r e x a m p l e : i l l s k u l l s m a s h e d ; h e l d b y m y l eg n ot j um p i n; m is fo rt un e r ep ar at io n f or d am ag es ; l et te rs t ak en a wa y

burned; and e x c i t e d q u i t e b e s i d e m y s e l f . T h i s , h e b e l i e v e d , p o i n t e d t o a n a b n o r m -

a li ty o f t ho ug ht ( i t c an s ca rc el y b e o nl y a q ue st io n o f d is or de rs o f l in gu is ti c

2 S c h i z op h r e n ic S p e e ch

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e xp re ss io n ). H e u se d t he t er m d er ai lm en t1 t o d es cr ib e t hi s a bn or ma li ty a

t end en cy f or t he l ine of t ho ug ht t o d ep ar t f rom t he g iv en i de a a nd mo ve i n

i nd is t in ct s ph er es o f i de as . I n s om e c as es , a lt ho ug h n ot i n t he a bo ve e xa mp le ,

t h e d e v i a t i o n f r o m o n e t r a i n o f t h o u g h t t o a n o t h e r c o u l d b e c l e a r l y i d e n t i f i e d . F o re xa mp le w he n a sk ed w ha t y ea r i t w as , a p at ie nt r ep li ed It m ay b e A us tr al ia ,

d e r a i l i n g f r o m t h e s e r i e s o f y e a r s t o t h e s e r i e s o f c o n t i n e n t s . T h e d e r a i l m e n t c o u l d

a ls o b e b as ed o n r hy me , a p he no me no n o th er wi se k no wn a s c la ng a ss oc ia ti on :

t hu s a p at ie nt r ep li ed t o a q ue st io n a bo ut w hi ch t ow n t he h os pi ta l w as i n b y s ay in g,

T h e h o u s e s t a n d s i n t h e g o s p e l o f L u k e o f t h e e i g h t h , a n d i f o n e h a s s w i n e , o n e c a n

sl a u gh t e r t h e m [ G e rm a n : d e s a c h t e n . . . schlachten ].

A t t he s am e t im e, a d is or de r o f l an gu ag e w as a ls o e vi de nt t o K ra ep el in . T he

a b ov e p a ti e nt s s y nt a x w a s c o nf u se d i n p l ac e s, f o r e x am p le i n f o r me r s e rv i ce a n d

t h e n s h e d o e s i t , a n d I , a n d t h a t i s a l s o s o c u r i o u s , t h e r e f o r e t h e n u n c o n s e q u e n t l y d i d

n o t k n o w m e a n y m o r e, a n d a s I t h a t a t l a s t o f t h o s e t h a t p a r t i c u l a r l y b e l i e v e . O t h e r

p a t i e n t s s h o w e d a m o r e s e v e r e d i s o r d e r o f g r a m m a r s o t h a t t h e i r s p e e c h b e c a m e

t e l e g r a m m a t i c , d o i n g w i t h o u t a l l su p e r f l u o u s p h r a se s. S t i l l o t h e r s e x h i b i t e d p a r a -

p h a s i a s a n d n e o l o g i s m s . T h e f o r m e r t o o k t h e f o r m o f a s i m p l e m u t i l a t i o n , c h a n g e

o r p a r t i a l f u s i o n o f c o m m o n l y u s e d w o r d s , o r t h e s u b s t i t u t i o n o f o n e w o r d w i t h

a no th er , u su al ly s im il ar i n s ou nd o r m ea ni ng , a s f or e xa mp le i n a p at ie nt w ho

c o mp l ai n ed t h at h i s s e ns e s w e re c he c ke d . N e ol og i sm s w er e n e w u n in t el l ig i bl e

w o r d s , w h i c h c o u l d b e c o m p o s e d e i t h e r o f s e n s i b l e c o m p o n e n t p a r t s o r s e n s e l e s sc ol le ct io ns o f s yl la bl es . T o a cc ou nt f or t he se a pp ar en t l in gu is ti c p he no me na

K r a e p e l i n e x t e n d e d t h e c o n c e p t o f d e r a i l m e n t t o i n c l u d e d e r a i l m e n t i n t h e p r o c e ss

o f f i n d i n g w o r d s .

B e t w e e n t h o u g h t a n d sp e e c h , K r a e p e l i n f e l t h e c o u l d i so l a t e y e t a n o t h e r f o r m o f

d er ai lm en t, t hi s t im e i n t he e xp re ss io n o f t ho ug ht i n s pe ec h ( fo r w hi ch h e i nt ro -

d uc ed h is o wn n eo lo gi sm , a ka t ap ha si a) . I n t hi s t yp e o f d er ai lm en t p a ti en ts u se d

p h r a se s o r se n t e n c e s w h e r e t h e w o r d s u se d o n l y a p p r o x i m a t e d t o t h e t h o u g h t t h a t

t h e y w i sh e d t o e x p r e ss. T h u s a p a t i e n t st a t e d t h a t h e l i v e d u n d e r p r o t e c t e d p o l i c e i n st e a d o f u n d e r t h e p r o t e c t i o n o f p o l i c e ; a n o t h e r sa i d h e h a d h i s f i a n c e e a l w a y s i n

sp e e c h i n st e a d o f h i s f i a n c ee st i l l c o n t i n u e d t o sp e a k t o h i m ( t h r o u g h v o i c e s) .

I f K r ae p el i n s o nl y f o ra y i n to i n fe r en c e a n d e x pl a na t io n w a s a s o me w ha t a w k-

w a rd a t te m pt t o s u bs u me s e ve r al d i ff e re n t e l em e nt s o f t h ou g ht d i so rd e r u n de r a

s in gl e h ea di ng o f d er ai lm en t, B le ul er (1911) strayed much further into this

t e r r i t o r y . I n f a c t , h i s b o o k o n s c h i z o p h r e n i a w a s a t o u r d e f o r c e o f t h e o r y , w h i c h

1 A c c or d i ng t o t h e h i st o ri a n o f p s yc h i at r y, B e r ri o s ( p e rs o na l c o mm u n ic a ti o n) , K r a ep e l in u s e d a v a ri e t y

o f G e rm a n w or d s i n t h is c on n ec t io n, n on e o f w hi c h w as n ec e ss ar il y a r ai l wa y m e ta p ho r. T h e E ng li sh

l a n g u a ge t e r m , w h i c h w e n t o n t o b e c o m e u n i v e r s a l , w a s a c t u a l l y i n t r o d u ce d b y h i s t r a n s l a t o rs , B a r c l a y a n d

Robertson.

3 De scribing schizophrenic speech

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b e g a n w i t h a s t a t e m e n t t h a t c e r t a i n s y m p t o m s w e r e c r u c i a l f o r u n d e r s t a n d i n g t h e

d i s o r d e r b y v i r t u e o f b e i n g p r e s e n t i n e v e r y c a s e a n d a t e v e r y p e r i o d o f t h e i l l n e s s

e v e n t h o u g h , a s w i t h a n y o t h e r d i s e a s e s y m p t o m , t h e y m u s t h a v e a t t a i n e d a c e r t a i n

d e g r e e o f i n t e n s i t y b e f o r e t h e y c a n b e r e c o g n i z e d w i t h c e r t a i n t y . F i r s t i n h i s l i s t o f t h e s e s o - c a l l e d f u n d a m e n t a l s y m p t o m s w a s a s s o c i a t i o n d i s t u r b a n c e . A s h e p u t i t :

I n t h is m a la d y t h e a s so c ia ti o ns l o se t h ei r c o nt i nu i ty . O f t h e t h ou s an d s o f a s so c ia t iv e t h re a ds

w h ic h g u id e o u r t h in k in g , t h is d i se a se s e em s t o i n te r ru p t, q u it e h a ph a za r dl y , s o me t im es s u ch

s i ng l e t h re a ds , s o me t im e s a w h ol e g r ou p , a n d s o me t im es e v en l a rg e s e gm e nt s o f t h em . I n t h is

w a y t h i n k i n g b e c o m e s i l l o g i ca l a n d e v e n b i z a rr e .

L oo se ni ng o f a ss oc ia ti on s l ed t hi nk in g t o o pe ra te w it h i de as a nd c on ce pt s

w hi ch h ad l it tl e o r n o c on ne ct io n w it h t he m ai n i de a, a nd c au se d p at ie nt s t o

l o se t h em s el v es i n i r re l ev a nt s i de a s s oc i at i on s . B u t a l on g si d e t h is B l eu l er c o ns i d-e re d t ha t t he re w as a no th er a bn or ma l p ro ce ss a t w or k, w hi ch w as e it he r c lo se ly

r el at ed t o t he a ss oc ia ti on d is t ur ba nc e o r p ar tl y o r w ho ll y r es po ns ib le f or i t ( he

n e ve r s p ec i fi e d w hi c h) . T h is w a s l o ss o f t h e n or m al g o a l -d i re c te d ne s s i n t h in k in g , a

l a ck o f t h e m o st i mp o rt a nt d e te r mi n an t o f a s so c ia t io n s t h at o f p ur p os e . I n h i s

w o rd s , t ho ug h ts a r e s u b o rd i na t ed t o s o me s o rt o f g e ne r al i d ea , b u t t h ey a r e n ot

r el at ed a nd d ir ec te d b y a ny u ni fy in g c on ce pt o f p ur po se o r g oa l. H e g av e e xa mp le s

o f p a ti e nt s w h o e i th e r w a nd e re d a w ay f r om t h ei r i n it i al t o pi c o f c o nv e rs a ti o n o r

a d h e r e d l o o s e l y t o i t b u t c o v e r e d a m u c h l a r g e r g r o u p o f i d e a s . P e r h a p s h i s m o s tg r a p h i c e x a m p l e w a s a l e t t e r f r o m a p a t i e n t t o h i s m o t h e r . A f t e r a n u n e x c e p t i o n a l

f i r s t p a r a g r a p h t h e p a t i e n t w e n t o n t o w r i t e :

I a m w r i t i n g o n p a p e r . T h e p e n w h i c h I a m u s i n g i s f r o m a f a c t o r y c a l l e d P e r r y & C o . T h i s

f ac to ry i s i n E ng la nd . I a ss um e t hi s. B eh in d t he n am e o f P er ry C o. t he c it y o f L on do n i s i ns cr ib ed ;

b ut n ot t he c it y. T he c it y o f L on do n i s i n E ng la nd . I k no w t hi s f ro m m y s ch oo ld ay s. T he n,

I a l w a y s l i k e d g e o g r a p h y . M y l a s t t e a c h e r i n t h a t s u b j e c t w a s P r o f e s s o r A u g u s t A . H e w a s a m a n

w it h b la ck e ye s. I a ls o l ik e b la ck e ye s. T he re a re a ls o b lu e a nd g ra y e ye s a nd o th er s or ts , t oo . I h av e

h ea rd i t s ai d t ha t s na ke s h av e g re en e ye s. A ll p eo pl e h av e e ye s. T he re a re s om e, t oo , w ho a re b li nd .T h e s e b l i n d p e o p l e a r e l e d a b o u t b y a b o y . I t m u s t b e v e r y t e r r i b l e n o t t o b e a b l e t o s e e . T h e r e a r e

p eo pl e w h o c an t s ee a n d, i n a dd it io n, c a n t h ea r. I k no w s om e w ho h e a r t oo m uc h. O ne c an h ea r

t o o m u c h . T h e r e a r e m a n y s i c k p e o p l e i n B u r g h o l z i ; t h e y a r e c a l l e d p a t i e n t s . O n e o f t h e m I l i k e a

g r e a t d e a l . H i s n a m e i s E . S c h . H e t a u g h t m e t h a t i n B u r g h o l z i t h e r e a r e m a n y k i n d s , p a t i e n t s ,

i n ma t es , a tt e nd a nt s . T h e n t h er e a r e s o m e w h o a r e n o t h e re a t a l l . T h ey a r e a l l p e cu l ia r p e op l e . . ..

T o B le ul er t he l et te r d em on st ra te d a c om pl et e a bs en ce o f p ur po se t o c on ve y

t o h is m ot he r h ow h e f el t, w ha t m ad e h im c om fo rt ab le o r u nc om fo rt ab le , o r

w h at m i gh t i n te r es t h e r. O t he r wi s e, t h e c h ai n o f a s so c ia t io n c ou l d b e c on s id e re dp e r f e c t l y v a l i d : L o n d o n g e o g r a p h y l e s s o n g e o g r a p h y t e a c h e r h i s b l a c k e y e s

g ra y e ye s g re en s na ke -e ye s h um an e ye s b li nd p eo pl e t he ir c om pa ni on s

h o r r i b l e f a t e , e t c . N e v e r t h e l e ss t h e l e t t e r w a s m e a n i n g l e ss.


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T h e c o m b i n e d i n f l u e n c e o f l o o se n i n g o f a sso c i a t i o n s a n d l o ss o f g o a l - d i r e c t n e ss

o f t h i n k i n g e n a b l e d B l e u le r t o p r o vi d e e x p l a n at i o ns f o r q u i t e a n u m be r o f d i f f er e n t

p h e no m e na se e n i n t h o ug h t - di so r de r e d sc h i zo p h re n i c sp e e ch . He n ce , t h e p a r ti a l

i n te r ru p ti o n o f n or m al l o gi c al a s so c ia t iv e p r oc e ss e s m e an t t h at i n di r ec t a s so c ia -t io ns a nd c la ng a ss oc ia ti on s c ou ld g ai n c on tr ol a nd d ir ec t t he t ra in o f t ho ug ht .

A ls o, t wo i de as w it ho ut a ny i nt ri ns ic r el at io n t o e ac h o th er c ou ld b ec om e

c o n n e c t e d f o r e x a m p l e a p a t i e n t c a l l e d a d r a w i n g o f a c o m b a w a s h - t u b b e c a u s e

a w a s h - t u b h a p p e n e d t o b e i n t h e d r a w i n g n e x t t o i t . F o r t h e s a m e r e a s o n i t w a s

q u i t e c o m m o n f o r a r e p l y t o h a v e n o t h i n g t o d o w i t h t h e q u e s t i o n p o s e d : a p a t i e n t

w as a sk ed w hy s he w as n ot d oi ng t he h ou se ho ld w or k s he w as s up po se d t o b e

e n g a g e d i n a n d r e p l i e d , B u t I d o n t u n d e r s t a n d a n y F r e n c h . I n s t e a d o f r e t u r n i n g

a g ree tin g a not he r s ai d, T hat is t he l it tl e J ew s c lo ck i n reg ard t o D ani el.

S om et im es a ll t he a ss oc ia ti ve t hr ea ds w er e b ro ke n, g iv in g r is e t o c om pl et e b lo ck in g

o f t h o u g h t , a f t e r w h i c h i d e a s c o u l d e m e r g e w h i c h h a d n o r e c o g n i sa b l e c o n n e c t i o n

w i t h p r e c e d i n g o n e s.

B le ul er re co gni sed muc h t he s am e r an ge of di sor de rs of w ord us ag e a s

K ra ep el in n eo lo gi sm s a nd u se o f w or ds a nd p hr as es i n a n i di os y nc ra ti c w ay .

H e a ls o a cc ep te d t ha t t he g ra mm at ic al c on st ru ct io n o f s en te nc es c ou ld b e d is -

t or te d. B es id es t he t el eg ra ph ic s ty le , h e d re w a tt en ti on t o a n i nc li na ti on t o u se

c on vo lu te d s en te nc e s tr uc tu re s a nd p re te nt io us a nd b om ba st ic s ty le s i n b ot h

s pe ec h a nd w ri ti ng ; f or e xa mp le a p at ie nt w ro te , Th e u nd er si gn ed w ri te r o f these lines takes the liberty of s ending you this by mail . . . . But, just as

R och es te r a nd M ar tin s tat ed, B leu le r s eeme d t o g o ou t of hi s w ay t o a voi d

i n t e r p r e t i n g t h e s e a s l i n g u i s t i c , i n v o k i n g e x p l a n a t i o n s i n t e r m s o f t h o u g h t w h e n -

e ve r h e c ou ld , a nd f al li ng b ac k o n m ec ha ni sm s i nv ol vi ng c at at on ia , d re am in g,

e t c . , w h e n h e c o u l d n o t .

C a m e r o n : t h e f i r s t e m p i r i c a l s t u d y o f t h o u g h t d i s o r d e r

C am er on w as a n A me ri ca n p sy ch ia tr is t w ho , w it h g ra nt s up po rt o f a d is ti nc tl y

u n us u al k i nd ,2 e mb ar ke d o n a s tu dy o f t hi nk in g i n s ch iz op hr en ia , w hi ch w as

p u bl i sh e d i n 1 9 3 8. H i s o r ig i na l a i m w a s t o i n ve s ti g at e p a ra l le l s t h at a u th or s l i ke

P ia ge t a nd V yg ot sk y h ad d ra wn b et we en t he r ea so ni ng o f c hi ld re n a nd s ch iz o-

p hr en ic p at ie nt s. H ow ev er , h is s tu dy s oo n m et am or ph os ed i nt o a d es cr ip ti ve

a cc ou nt o f t ho ug ht d is or de r, b ut o ne i n w hi ch t he o bs er va ti on s w er e c ol le ct ed

u n d e r c o n t r o l l e d c o n d i t i o n s a n d r e c o r d e d i n a sy st e m a t i c w a y . C a m e r o n s st u d y i s

a l l t h e m o r e i n t e r e s t i n g b e c a u s e h e m a d e i t c l e a r t h a t h e w a s a p p r o a c h i n g t h e f i e l d

2 T h e S u p r e m e C o u n c i l , 3 38 S c o t t i s h R i t e M a s o n s o f t h e N o r t h e r n J u r i s d i c t i o n , U S A .


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a f r e s h , a n d i n f a c t t h e c o n c l u s i o n s h e c a m e t o s h o w e d s c a n t r e g a r d f o r t h e v i e w s o f

K r a e p e l i n , B l e u l e r a n d o t h e r E u r o p e a n a u t h o r s.

T h e t we nt y -f i ve p at i en t s C am er on se le c te d f or e x am i na t io n w er e d i ag n ose d a s

q ui t e u nm i st a ke a bl y sc hi zo ph re n ic a n d t he y a l l sh ow e d sc a tt e ri ng a t t he t i me o f e x am i na t io n, t h e t e rm h e u sed t o d e sc ri b e t h ou g ht d iso rd er . S o me w er e a cu t el y i ll

p at ie nt s a t t he p re st ig iou s H en ry P hi pp s C li ni c o f t he J oh ns H op ki ns H os pi ta l,

whereas others were long-stay patients in the local asylum. To induce simple reason-

i n g , h e b o r r o w e d a t e c h n i q u e f r o m P i a g e t a n d g a v e t h e p a t i e n t s a se r i e s o f u n c o m -

pleted causal sentences, such as, Y o u r b o d y m a k e s a s h a d o w b e c a u s e . . . Replies were

f ol l ow e d u p b y d i re c t q u est io ns a nd r eq u ests f or e x pl a na t io n. T h e i n ve sti ga t or s

questions and the patients responses were recorded verbatim in shorthand.

F ro m a n a na ly si s o f t hi s m at er ia l C am er on p ic ke d o ut t hr ee f ac to rs t ha t h e

c o ns i de re d m a de t h e p a ti e nt s s p ee c h d i ff i cu l t t o f o ll o w a n d w hi c h w e re d i st i nc t

e n ou g h t o j u st i fy s e pa r at e d i sc u ss i on . T h es e w e re : a s y n d e t ic t h i n ki n g , metonymic

distortion, a nd i nt ro du ci ng p os si bl y t he m os t e lo qu en t t er m i n t he h is t or y o f

t h o u g h t d i so r d e r i n t e r pe n e tr a t io n o f t h e me s.

I n a sy nd et ic t hi nk in g, t he s ub s ti tu ti on o f l oo se c lu st er s o f t er ms f or w el l-

i n te g ra t ed c on c ep t s, t h e p a ti e nt w a s u na b le t o e x er c ise t h e f u nc t io n s o f se le c ti on ,

r es tr ic ti on a nd o rd er ly a rr an ge me nt n ec es sa ry f or t he p ro ce ss of l og ic al

t hi nk in g, r es ul ti ng i n a s t ri ki ng p au ci ty o f g en ui ne ly c au sa l l in ks i n s pe ec h.

F or e xa mp le , w he n a s ke d w ha t m ak es t he w in d b lo w, o ne p at ie nt r ep li ed :

B ec au s e i t s t i m e t o b l ow . [ Q ue s ti o n r ep e at ed ] T he a i r. [ T he a i r? ] T he s k y. [ H ow d o es t h e s k y

m a k e i t b l o w ] B e c a u s e i t s h i g h i n t h e a i r .

C a m e r o n a r g u e d t h a t t h i s r e s p o n s e c o n s i s t e d m e r e l y o f a l o o s e a g g l o m e r a t i o n o f

w or ds c on ne ct ed w it h w in d i n g en er al w in d, b lo w, a ir , s k y, h ig h ( th e i ni ti al

r e f e r e n c e t o t i m e w a s a p e r s e v e r a t i o n f r o m a p r e v i o u s a n s w e r ) . T h e p a t i e n t c l e a r l y

f e l t t h a t t h e e l e m e n t s b e l o n g e d t o g e t h e r , b u t a t t h e s a m e t i m e n o g e n u i n e l o g i c a l

c o n n e c t i o n w a s p r e s e n t , e v e n w h e n t h e t e r m b e c a u s e w a s u s e d .

T h is f a il ur e t o b i nd t og et h er w or ds a nd t e rm s i n to a n e xp l ic i t e x pl an at o ry c on -

st r u c t w a s e v e n m o r e a p p a r e n t i n a n o t h e r p a t i e n t s r e sp o n se t o t h e sa m e q u e st i o n :

[ Th e w in d b lo ws ] Du e t o v el oc it y . [ qu es ti on r ep ea te d] Du e t o l os s o f a ir , e va po ra ti on o f

w a t e r . [ W h a t g i v e s i t t h e v e l o c i t y ] T h e c o n t a c t o f t r e e s , o f a i r i n t h e t r e e s .

H e re , C a me r on p o in t ed o u t, t h e e l em e nt s o f t h e r e sp o ns e w e re n ot r a nd om , b u t

c o n si st e d o f p h e n o m e n a w h i c h a r e c o m m o n l y e x p e r i e n c e d d i r e c t l y o r i n d i r e c t l y i n

c o n n e c t i o n w i t h t h e w i n d b l o w i n g v e l o c i t y , l o ss o f a i r , e v a p o r a t i o n , c o n t a c t w i t h

t r e e s. S i m i l a r l y , a n o t h e r p a t i e n t a n sw e r e d t h e q u e st i o n :

[ T h e w i n d b l o w s ] B e c a u s e i t h o w l s . [ B u t w h y d o e s i t h o w l ? ] L a c k o f c o - o p e r a t i o n w i t h t h e r a i n

a n d t h e s u n .


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B o t h r e sp o n se s w e r e c o n n e c t e d w i t h t h e c o n c e p t o f w i n d , b u t o n l y l o o se l y : h o w l i n g

(physical feature) and rain and sun (other weather-related natural phenomena).

C a m e r o n c o n s i d e r e d t h a t a r e s t r i c t i o n o f t h e p a t i e n t s t h i n k i n g t o t h e m a t t e r i n

h an d a nd e ve n s om e d eg re e o f c la ri ty o f e xp re ss io n w as i mp os s ib le t o m is s, a ndt he re w as s ur pr is in gl y l it tl e r ea l i rr el ev an ce . B ut , a t t he s am e t im e, t he re w as a n

o b vi o us l a ck o f d i re c ti o n a n d n o e f fe c ti v e f i na l p u ll i ng t o ge t he r o f t h e e l em e nt s

i n t o a w e l l - f or m e d w h o le . T h e p a t i e nt s r e p l i es h o v e r e d a r o un d t h e p r o b l e m r a t h er

t ha n d is po si ng o f i t. T he m at er ia l t he y p ro du ce d w as d is ta nt , t oo l oo se a nd t oo

o v e r - i n c l u si v e , a c o l l e c t i o n o f f r a g m e n t s, a c o n g l o m e r a t e n o t a n i n t e g r a t e .

M et on ym ic d is to rt io n, o r t he u se o f w or d a pp ro xi ma ti on s, c on si st ed o f t he

s u b s t i t u t i o n o f a r e l a t e d t e r m o r p h r a s e f o r t h e m o r e p r e c i s e d e f i n i t i v e t e r m t h a t

n o r m a l i n d i v i d u a l s w o u l d b e e x p e c t e d t o e m p l o y . T h u s a p a t i e n t s a i d h e w a s a l i v e :

B e c a u s e y o u r e a l l y l i v e p h y s i c a l l y , b e c a u s e y o u h a v e m e n u t h r e e t i m e s a d a y ; t h a t s t h e p h y s i c a l .

[ W h a t e l s e i s t h e r e b e s i d e s t h e p h y s i c a l ? ] T h e n y o u a r e a l i v e m o s t l y t o s e r v e a w o r k f r o m t h e

s t a n dp o i n t o f m e t ho d i c al b u s i ne s s .

T h e m o st o b vi o us w o rd a p pr ox i ma t io n h e re w a s h a ve m en u i ns t ea d o f ea t o r

h av e m e al s . C a me r on a l so f e lt methodical business w as p r ob a bl y a d i st o rt i on o f

d a i l y r o u t i n e . I n a n o t h e r e x a m p l e a p a t i e n t e x p l a i n e d w h y t h e s u n c o m e s u p i n

t h e m o r n i n g i n t h e f o l l o w i n g w a y :

B e c a u s e i t i s t h e a c t u a l r o t a t i o n o f i t s a x i s b e t w e e n t h e a r c t i c a n d a n t a r c t i c z o n e s .

T h i s s u b s t i t u t e d w i d e g e o g r a p h i c a l a r e a s f o r t h e m o r e c o n v e n t i o n a l t e r m s , N o r t h

a n d S o u t h p o l e s .

A n o t h e r p a t i e n t c o n s i d e r e d t h a t h i s b o d y m a d e a s h a d o w :

B e c a u s e i t h i d e s t h e p a r t o f t h e l i g h t t h a t i s u s e d f o r f u l l r o o m c a p a c i t y o r a r e a c a p a c i t y w h i c h

you intervene.

Here intervene w a s a lm os t c or re ct , b ut i t s ho ul d h av e b ee n i nt er ce pt . F u ll r o omcapacity and a r e a c a pa c i ty b o th s ee me d t o r ef er t o t he i de a o f c om pl et e i ll um in -

a t i o n o f a r o o m a n d c o r r e c t l y i m p l i e d t h e a r e a f r o m w h i c h t h e l i g h t i s c u t o f f b y

o n e s b o d y , a l t h o u g h t h e p r e c i s e w o r d o r p h r a s e w a s u n c e r t a i n .

I n o t h e r i n s t a n c e s o n l y a g e n e r a l s e n s e o f w h a t t h e p a t i e n t w a s t r y i n g t o c o n v e y

c o u l d b e g u e s s e d a t . E x a m p l e s i n c l u d e d : A f i s h c a n l i v e i n w a t e r . . . B e c a u se i t s the

n a t u r a l r e s o u r c e o f l i f e . A b o y t h r e w a s t o n e a t m e . . . B e c a u se h e h a d m i sc h i e f a n d

a rm e xe rc is e t o e xe rc is e t he b od y . I am good . . . Be ca us e b ro ug ht u p r ig ht a nd

strictly confidential.C am er on f el t t ha t t he u se o f t he se w or d a pp ro xi ma ti on s l en t s ch iz op hr en ic

d i s c o u r s e a g r e a t d e a l o f i t s p e c u l i a r e l u s i v e n e s s . I t w a s a s t h o u g h t h e p a t i e n t w a s

u si ng a n i di om w hi ch c ou ld b e t ra ns la te d i nt o c on ve nt io na l u sa ge , b ut w hi ch


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r eq ui re d e ff or t t o d o s o. A s i n a sy nd et ic t hi nk in g, t he w or ds a nd p hr as es s t ru ck

s om ew he re o n t he p er ip he ry o f t he t ar ge t i ns te ad o f t he b ul ls ey e, a nd a f al se

e q u i v a l e n c e w a s a t t r i b u t e d t o se v e r a l t e r m s.

The material which became interwoven in interpenetration of the themes could beof fragments of different themes, or a theme and a counter-theme, but perhaps most

typically one theme which was concerned with the immediate problem and another

w hi ch r ef le ct ed w ha t C am er on c al le d pe rs is te nt p re oc cu pa ti on s o f a p er so na l

n at ur e w hi ch b y a nd l ar ge s ee me d t o b e d el us io ns . H e g av e p ri de o f p la ce t o t he

f ol lo wi ng e xa mp le o f a p at ie nt w ho h ad b el ie fs r ev ol vi ng a ro un d b od il y i nj ur y,

especially being bitten and having her back broken:

[ A f i s h c a n l i v e i n w a t e r b e c a u s e . . . ] B e c a u s e i t s l e a r n e d t o swim. [ W h a t i f i t c o u l d n t s w i m ? ]

N ot n a tu r al l y, h e c o ul d n t . W h y d o c e rt a in g o ds h a ve e f fe c ts o n seas l i k e t h a t ? W h a t d o e s t h eearth h av e s uc h a n e ff ec t t o b re ak t he ir b ac ks ? T he fishes n e ar h o me c o me t o t he s ur fa ce and

b r e a k . [ W h y ? ] I t h i n k i t i s d u e t o b o d i e s t h a t p e o p l e l o s e . A b o d y b e c o m e s a d a p t e d t o t h e a i r .

T h i n k t h o u g h t s a n d b r e a k t h e fishes.

T h e w o r d s a n d p h r a s e s i n i t a l i c s w e r e v a g u e l y r e l e v a n t t o t h e q u e s t i o n p u t t o t h e

p a ti e nt . O t he r wi s e, s p ri n kl e d t h ro u gh ou t h e r r e sp o ns e w e re r e fe r en c es t o g o ds ,

b od ie s, b ac k, e ff ec t, l os e, b re ak , e tc ., a ll o f w hi ch r ef le ct ed h er u su al d el us io na l

t he me s. B ot h l in es o f t ho ug ht w er e e qu al ly r ep re se nt ed , a nd w er e s om et im es

c o m b i n e d i n t o a s i n g l e p h r a s e , s u c h a s T he f is he s n ea r h om e c om e t o t he s ur fa cea n d b r e a k , a n d b r e a k t h e f i s h e s , a n d a b o d y b e c o m e s a d a p t e d t o t h e a i r .

I n a n o t h e r e x a m p l e , a p a t i e n t b e l i e v e d h e w a s G o d a n d i n a c o n s t a n t b a t t l e w i t h

t h e d e v i l ; h e a l s o c o n s t a n t l y r e f e r r e d t o t h e k e y t o t h e o u t s i d e :

[ I g e t w a r m w h e n I r u n b e c a u s e . . . ] B e c a u s e y o u p o s s e s s i n g a p o s i t i o n o f a d o c t o r h a v e t h e k e y .

T h e d e v i l s e e i n g y o u r u n, b e c o m e s i r e d . G o d d o e s n t g e t i r e d b e c a u s e i t d o e s n t h a v e a n y e f f e c t .

H e d o e s n t w a n t a railroad o r a n express company i n t h i s p l a c e .

T h e a n s w e r c e r t a i n l y i n c o r p o r a t e d e l e m e n t s o f t h e q u e s t i o n , a s w a s e v i d e n t i n t h e

i t a l i c i se d w o r d s, a l t h o u g h p h r a se s su c h a s r a i l r o a d a n d e x p r e ss c o m p a n y w e r e o n l y

d i s t a n t l y r e l a t e d t o t h e c o n c e p t o f r u n n i n g . H o w e v e r , t h e r e p l y w a s m o s t l y t a k e n

u p b y t h e b a t t l e b e t w e e n G o d a n d t h e d e v i l .

T he p re oc cu pa ti on s d id n ot h av e t o b e d el us io na l. C am er on g av e a f ur th er

e x a m p l e o f a p a t i e n t w h o h a d u n r e a l i s e d a m b i t i o n s t o b e a n e n g i n e e r .

[ M y h a i r i s b r o w n b e c a u s e . . . ] B e c a u s e i t i s a s o r t o f h y d r a u l i c e v e r i n g . [ W h a t d o e s t h a t m e a n ]

I t m e a n s t h a t i t g i v e s y o u s o m e s o r t o f a color-blindness b e c a u s e i t w o r k s t h r o u g h t h e r o o t s o f t h e

hair a n d h y d r a s e e t h a t i s a s t u d y o f t h e g r o w t h o f p l a n t s, a s o r t o f human barometer, hydraulic

hydroscenic method.

H ai r c ol ou r w as r el at ed c or re ct ly t o r oo ts o f t he h ai r a nd t o g ro wt h. B ut t he

c o n c e p t o f c o l o u r w a s e x t e n d e d t o c o l o u r - b l i n d n e s s , a n d g r o w t h t o t h e g r o w t h o f


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p l a n t s. I n human barometer , t h e t h e m e o f t h e q u e s t i o n a n d t h e t h e m e o f e n g i n e e r -

i n g a p p e a r e d t o b e f u s e d i n t o a s i n g l e i m p e n e t r a b l e p h r a s e .

C a me r on a r gu e d t h at i n te r pe n et r at i on o f t h em es c o ul d b e a n ot h er m a ni f es -

t at io n o f t he s am e d is or de r o f s el ec ti on , e li mi na ti on a nd f oc us in g o n t he t op icu nd er d is cu ss io n t ha t w as r es po ns ib le f or a sy nd et ic t hi nk in g a nd m et on ym ic

d i s t o r t i o n . I n t h i s c a s e t h e r e w a s a f a i l u r e o f t h e n o r m a l p r o c e s s o f s u b o r d i n a t i o n

o f o n e t h e m e t o a n o t h e r . I n s t e a d , e l e m e n t s o f b o t h p r o c e e d e d t o g e t h e r .

C a me r on m ad e s e ve r al m o re m in o r o b se r va t io ns . H e n o te d t h at t h e p a ti e nt s

w e r e i n v a r i a b l y f u l l y sa t i sf i e d w i t h w h a t w e r e u su a l l y t o t a l l y i n a d e q u a t e r e sp o n se s.

A ls o, o n t he o cc as io ns t he y d id g iv e a n i ni ti al ly f ai rl y s at is fa ct or y a ns we r, t he y o ft en

w en t o n t o a dd l es s r el ev an t m at er ia l; a n i n it ia l g o od p hr as e w ou ld b e f ol lo we d b y a

jumble of peripheral concepts. Finally, he made the point that the abnormalities he

f o un d w e re p o te n ti a ll y r e ve r si b le a n d c o ul d i m pr ov e m a rk ed l y w i th g e ne r al c l in i ca l

i mp ro ve me nt . H e i ll us tr at ed t hi s w it h t he p at ie nt s r ep li es s ho wn i n T ab le 1.1.

C a m e r o n s a n a l y si s w a s p e n e t r a t i n g : a g a i n a n d a g a i n h e m a n a g e d t o m a k e se n se

o f m a t e r i a l t h a t s u p e r f i c i a l l y c o u l d s c a r c e l y b e m o r e o p a q u e . S o m e o f t h e a b n o r -

m a l i t i e s h e i d e n t i f i e d h a d c o u n t e r p a r t s i n t h o se p r e v i o u sl y d e sc r i b e d b y K r a e p e l i n

a n d B l e u l e r . Hi s a sy n d e t i c t h i n k i n g e m b o d i e d m u c h o f w h a t t h e se a u t h o r s t r i e d t o

c a p t u r e w i t h t e r m s l i k e d e r a i l m e n t , l o s s o f t h e c e n t r a l d e t e r m i n i n g i d e a , a n d l o o s e

a ss oc ia ti on s. M et on ym ic d is to rt io n w as o bv io us ly s im il ar t o t he a bn or ma li ty

K r ae p el i n r e fe r re d t o a s a k at a ph a si a o r d e ra i lm e nt i n t h e e x pr e ss i on o f t h ou g hti n s p e e c h , a l t h o u g h t h e s p e c i f i c a t i o n w a s m u c h m o r e d e t a i l e d a n d p r o b a b l y m o r e

a c cu r at e . I n i n te r pe n et r at i on o f t h em e s, h o we v er , h e d e sc r ib e d a h i th e rt o u n re c -

o g n i s e d c l i n i c a l p h e n o m e n o n , o n e w h i c h , a s w i l l b e s e e n , w a s d e s t i n e d t o h a v e a

c h e q u e r e d f u t u r e c a r e e r .

T a b l e 1 . 1 P e r f o r m a n c e o f a t h o u g h t - d i s o r d e r e d p a t i e n t w h e n s e v e r e l y i l l a n d a f t e r p a r t i a l

r e c o v e r y

( F r o m C a m er o n , 19 38 )

During height of illnes s After partial recovery

My hair is fair because . . .

B ec a us e o f s o me t hi n g e l s e ; i t s o n m y

h e ad ; i t c o me s f r om m y m o th e r.

B ec a us e I i n he r it e d i t f r om m y p a re n ts .

A man fell down in the street because . . .

Of the World War. Because he slipped.

T he s un c om es u p i n t he m or ni ng . . .

Because its a gas . Because the earth goes around the sun.

T h e w i nd b l ow s b e ca u se . . .

Just cosmic dust. Because of atmospheric air-currents changing.


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Wing: poverty of content of speech

W hi le c ar ry in g o ut a s ur ve y o f m al e p at ie nt s w ho h ad r ec en tl y b ee n d is ch ar ge d

f r om l o ng s t ay c a re i n a m e nt a l h os p it a l, B r ow n et al. (1958) m ad e t he s ur pr is in gd is co ve ry t ha t t ho se w it h a d ia gn os is o f s ch iz op hr en ia w er e m or e l ik el y t o r el ap se i f

t h e y w e n t t o l i v e w i t h t h e i r p a r e n t s o r w i v e s t h a n i f t h e y w e n t t o l i v e w i t h b r o t h e r s

a n d s i s t e r s o r i n l o d g i n g s . T h i s w a s t h e s t a r t i n g p o i n t f o r a s e r i e s o f s t u d i e s w h i c h

e st ab li sh ed a m aj or a nd s ti ll f lo ur is hi ng a re a o f s ch iz op hr en ia r es ea rc h, t ha t o f

e xp re ss ed e mo ti on . I t w as a ls o t he p oi nt o f o ri gi n f or a n a bn or ma li ty t ha t w as t o

p l ay a n i m po r ta n t p a rt i n t h e d e ve l op m en t o f t h in k in g a b ou t t h ou g ht d i so rd e r,

p o v e r t y o f c o n t e n t o f s p e e c h .

Wing, who joined Brown to work on two replications and extensions of his

o r ig i na l s t ud y ( B ro w n et al ., 1962; Brown e t al., 1972) , h a d t h e t a sk of i n te r vi e wi n g

r ec en tl y d is ch ar ge d s ch iz op hr en ic p at ie nt s. F or t hi s p ur po se h e w as i n t he p ro ce ss

o f d e v e l o p i n g w h a t w o u l d e v e n t u a l l y b e c o m e a w i d e l y u se d st r u c t u r e d p sy c h i a t r i c

i n t e r v i e w , t h e P r e se n t S t a t e E x a m i n a t i o n ( W i n g et al., 1 9 7 4 ) . D u r i n g t h e c o u r se

o f t he s tu di es h e c am e a cr os s a n i nd iv id ua l w ho s ho we d a s tr ik in g d is or de r

o f s p e e c h t h a t h e h a d n o t e n c o u n t e r e d b e f o r e ( W i n g , p e r s o n a l c o m m u n i c a t i o n ) .

A s am pl e o f t hi s, w hi ch w as c ha ra ct er is t ic o f a ll o f t he p at ie nt s c on ve rs at io n,

w e n t l i k e t h i s :

Q . H ow d o yo u li ke i t i n ho sp it al ?

A. Well, er . . . n o t q u i t e t h e s a m e a s , e r . . . d o n t k n o w q u i t e h o w t o s a y i t . I t i s n t t h e s a m e ,

b e i n g i n h o s p i t a l a s , e r . . . w o r k i n g . E r . . . t h e j o b i s n t q u i t e t h e s a m e , e r . . . v e r y m u c h t h e

s a m e b u t , o f c o u r s e , i t i s n t e x a c t l y t h e s a m e .

Initially Wing was inclined to classify this a v ariant o f poverty of speech, a

s ym pt om w hi ch w as t yp ic al ly s ee n i n w it hd ra wn c hr on ic s ch iz op hr en ic p at ie nt s.

T hi s s ym pt om h ad b ee n p er ha ps m os t e lo qu en tl y d es cr ib ed b y K ra ep el in (1913a)

a s t h e c e s s a t i o n o f t h e n e e d t o e x p r e s s o n e s e l f :

T h e p a t i e n t s b e c o m e m o n o s y l l a b i c , s p a r i n g o f t h e i r w o r d s , s p e a k h e s i t a t i n g l y , s u d d e n l y b e c o m e

m u t e, n e v er r e l a te a n y th i n g o n t h e ir o w n i n i t i at i v e, a n d l e t a l l a n s we r s b e l a b or i o u sl y p r e s s e d o u t

o f t h em . T h ey e n te r i n to n o r e la t io n s w i th o t he r p e op l e, n e ve r b e gi n a c o nv e rs a ti o n w i t h a n yo n e,

a s k n o q u e s t i o n s , m a k e n o c o m p l a i n t s , g i v e t h e i r r e l a t i v e s n o n e w s .

Wing (1961) t he re fo re i nc or po ra te d t hi s n ew ly i de nt if ie d a bn or ma li ty i nt o t he

s c a l e f o r p o v e r t y o f s p e e c h . T h e m a x i m a l r a t i n g o f 5 w a s m a d e w h e n t h e p a t i e n t

w a s m u t e o r o n l y s p o k e t w o o r t h r e e w o r d s d u r i n g t h e i n t e r v i e w . A r a t i n g o f 4 w a sg i v e n w h e n t h e p a t i e n t s a n s w e r s w e r e m o n o s y l l a b i c , o f t e n w i t h l o n g p a u s e s o r a

f ai lu re t o a n s we r a t a ll . A r at in g o f 4 w as n ow a ls o g iv en w he n a lt ho ug h t he re w as a

r e a s o n a b l e a m o u n t o f s p e e c h , t h e a n s w e r s w e r e s o s l o w a n d h e s i t a n t , s o v a g u e a n d

10 S c h i z op h r e n i c S p e ec h

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l a ck i ng i n c o nt e nt , s o r e pe t it i ou s a n d w a nd e ri n g, t h at m e an i ng f ul c o nv e rs a ti o n

w a s a l m o st i m p o ssi b l e .

T h e f i rs t fu l l w or k in g dr a ft o f t h e P r es e nt S ta t e E x am i na t io n ( W in g et al ., 1967)

h a d a s e ct i on e n ti t le d P ov e rt y o f c o nt e nt , o r r e st r ic t io n o f q u an t it y , o f s p ee c h .T h is h a d su ch i t em s a s, P at i e nt i s a l mo st m ut e ; P at i e nt f r eq u en t ly f a il s t o a n sw e r ;

a nd An sw er s a re r es tr ic te d t o t he m in im um n ec es sa ry . T he re w er e a ls o t hr ee i te ms

r e l a t i n g t o p o v e r t y o f c o n t e n t o f sp e e c h . T h e f i r st w a s p o v e r t y o f c o n t e n t o f sp e e c h ,

d ef in ed a s: P at ie nt u se s q ui te a l ot o f w or ds b ut s ay s v er y l it tl e w it h t he m. N o

w an de ri ng f ro m p oi nt t o p oi nt . T he s ec on d w as va gu e w an de ri ng , w it h t he

d ef in it i on : P at ie nt t al ks a l ot b u t m ea nd er s f ro m o ne p oi nt t o a no t he r, o r c ir cl es

r ou nd o ne p oi nt t ry in g t o e xp re ss q ui te c om pl ic at ed i de as w it ho ut b ei ng a bl e t o

m a ke h i s m e an i ng c l ea r. B r ie f r e pl i es t o q u est io n s m a y b e q u i te n or m al . T h e se nt e nc e

st ru c tu re ( w it h in t h e l i mi t s o f c o nv e rsa t io n al st yl e ) i s n ot se ri o usl y d i st o rt e d, a n d

t he re i s a s eri ou s a tt em pt t o c on ve y me an in g. T he t hi rd i te m w as n ot g iv en a t it le , b ut

w a s d e fi n ed a s: L on g wi n de d , w o ol l y, p e d a nt i c m a nn e r o f sp ee c h w i th m a ny r e du nd -

a nt p hr as es , e .g . I b e li ev e w e l iv e i n a w or ld , i n a n a ge , w he re t he e le me nt s a re a f or ce

t h a t t h e e l d e r s o f p r o f e ssi o n a l i sm h o p e , n o t t o c o n q u e r , b u t t o c o n t r o l .

B y t h e f i na l , p u bl i sh e d 9 t h e d it i on o f t h e P r es e nt S t at e E x a mi n at i on ( Wi n g e t a l .,

1974 ) t hi s s ec ti on h ad b ee n r ed uc ed t o a s in gl e i te m, p ov er ty o f c on te nt o f s pe ec h.

Wing et al . d e fi ne d t hi s a s f ol lo ws :

T h e s u b j e c t t a l k s f r e e l y b u t s o v a g u e l y t h a t l i t t l e i n f o r m a t i o n i s p r o v i d e d i n s p i t e o f t h e n u m b e r

o f w o r d s u s e d .

T o w h i c h t h e y a d d e d , n o t w h o l l y t o n g u e - i n - c h e e k :

T h i s s y m p t o m m a y a p p e a r t o b e r e a d i l y r e c o g n i z a b l e i n s o m e o f o n e s c o l l e a g u e s , t h e r e f o r e o n l y

r a t e i t w h e n i t i s r e a l l y p a t h o l o g i c a l .

P o v e r t y o f c o n t e n t o f s p e e c h w a s n o w c l a s s i f i e d a s o n e o f t h r e e d i s o r d e r s o f s p e e c h ,

w ho se e ff ec t w as t o m ak e i t d if fi cu lt t o g ra sp w ha t t he p at ie nt m ea nt . T he o th er t woi te ms w er e i nc oh er en ce o f s pe ec h a nd a f or m o f t ho ug ht d is or de r c la ss ic al ly

a ss oc ia te d w it h m an ia r at he r t ha n s ch iz op hr en ia , f li gh t o f i de as . N eo lo gi sm s

w e re a l so i n cl u de d , b u t in a n ot h er s e ct i on .

W i ng g e nu i ne l y a p p ea r ed t o h a ve i d en t if i ed a n e w a b n or m al i ty o f t h o u gh t , w h ic h

h ad b ee n o ve rl oo ke d b y e ar li er a ut ho rs . If t he re w e

w er e o bs cu re . T he o nl y p os s ib le c an di da te i s K le is t s (1930) t e rm a l og i a. Ho w ev e r, a s

r e a n y p ri o r de sc ri p ti on s, t he se

described in Chapter 4, w h a t K l e i s t m e a n t b y t h i s t e r m i s f a r f r o m c l e a r . W i n g a l s o

l a i d t h e f o u n d a t i o n s o f a d e b a t e t h a t c o n t i n u e s t o t h e p r e se n t t i m e : o r i g i n a l l y f e e l i n gt ha t p ov er ty o f c on te nt o f s pe ec h w as m or e r el at ed t o p ov er ty o f s pe ec h, h e l at er

c ha ng ed h is m in d a nd d ec id ed t ha t i t b e lo ng ed m or e w it h o th er d is or de rs w hi ch

m a d e sp e e c h d i f f i c u l t t o f o l l o w .

11 De scribing schizophre nic spe ech

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H a r r o w : t h o u g h t d i s o r d e r a s b i z a r r e - i d i o s y n c r a t i c t h i n k i n g

Ar ou nd t he s ame t im e t ha t W in g a nd h is c o- wo rk ers w er e de ve lopi ng t he ir

s ta ndardised men ta l st at e a ss essment, which be ca me t he P re sent S tat eE xaminat ion, H arrow a nd c o- work ers ( se e H arrow an d Q ui nl an, 1985) were

c ar ry in g o ut a n a mb it io us p ro gr am me o f r es ea rc h d ev ot ed s ol el y t o t he s ym pt om

of t hou ght di sor de r. E arl y on i n t hi s t he y co nc en tra ted t hei r a tt ent ion on t he

f a sh i on a bl e e x pl a na t or y c on s tr u ct s o f t h e d a y, i n cl u di n g B l eu l er s l o os e a s so c ia -

t i on s ( e .g . R ei l ly et al ., 1975 ; Siegel et al ., 1976 ) , c o n cr e t e t h i nk i n g ( e .g . Ha r r ow

et al., 1974) , t h e p sy ch oa na ly ti c c on ce pt o f p ri mi ti ve d ri ve -d om in at ed t hi nk in g

(e.g. Harrow et al ., 1976), attentional disorder (e.g. Harrow et al., 1972a) and

a no th er c og ni ti ve d is or de r, o ve ri nc lu si ve t hi nk in g, d is cu ss ed i n C ha pt er 7

(Harrow et al ., 1972b) . Af te r a t ime , ho we ve r, t he y c am e t o t he c on cl us io n t ha t

a m or e d es cr ip ti ve a pp ro ac h m ig ht b e i n o rd er : lo ok in g a t d is or de re d t hi nk in g

i n t er ms o f m or e g en er al c on ce pt s, s uc h a s b iz ar re -i di os yn cr at ic t hi nk in g, i s a n

a l te rn a te w a y o f v i e wi n g i t t h at c a n b e q u it e p ro d uc t iv e .

H a rr ow a n d h i s c o -w o rk e rs t h er e fo re b e ga n t o e x pl or e b i za r re - id i os y nc r at i c

t h in k in g , a t e rm t h ey c h os e d e li b er a te l y i n o r de r t o r e fl e ct t h is n e w t h eo re t ic a ll y

n eu tr al a pp ro ac h t o t ho ug ht d is or de r. T o t hi s e nd t he y d ev el op ed a s ta nd ar di se d

i n te r vi e w i n w h ic h t h ou g ht d i so rd e r w a s e l ic i te d b y r e qu i ri n g p a ti e nt s t o i n te r-

p r et p ro v er bs l ik e St r ik e w hi le t h e i r on i s h ot a n d a n sw e r r ea so ni n g q u es t io nsf r o m t h e C o m p r e h e n si o n su b t e st o f t h e W e sc h l e r A d u l t I n t e l l i g e n c e S c a l e ( W A I S ) ,

s uc h a s , Wh y s h ou ld w e k ee p a wa y f ro m b a d c o mp an y ? . B iz a rr e- i di os y nc ra ti c

r es pon se s w er e s co re d o n a s ca le o f 0 t o 3 i n v ar io us n on -mu tua lly e xc lu siv e

c at eg or ie s, a s s how n i n B ox 1.1. A ll in te rv ie we rs w er e t ra in ed w it h t he a ss is ta nc e

o f a m a n u a l w h i c h d e f i n e d a n d g a v e e x a m p l e s o f t h e d i f f e r e n t a b n o r m a l i t i e s u n t i l

t h e y sh o we d a c ce p t ab l e i n t er - ra t er r e li a b il i t y.

B o x 1 . 1 Harrow et al . s a s s e s s m e n t o f b i z a r r e - i d i o s y n c r a t i c t h i n k i n g

( Fr om H ar ro w a nd Q ui nl an , 1985, re p ro d uc e d w i t h p e rm i s si o n)

R e s p o n s e s t o q u e s t i o n s a n d p r o v e r b s a r e s c o r e d 0 a b s e n t , . 5 m i n i m a l b i z a r r e

q u a l i t i e s , 1 A d e f i n i t e i d i o s y n c r a t i c o r b i z a r r e r e s p o n s e , 3 A v e r y s e v e r e b i z a r r e

response.

I Linguistic form and structure

A p ro bl em i n t hi s c at eg or y i m pl i es t h a t i t i s d if f ic ul t t o u nd er st an d w h at t he s u bj ec t

m e a n s o w i n g t o : ( a ) a l t e r a t i o n s i n l a n g u a g e , o r ( b ) g a p s i n v e r b a l c o m m u n i c a t i o n .


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P e c u l i a r w o r d f o r m o r u s e

D o n t s w ap h o rs e s w h en c r os s in g a s t re a m. T ha t s w i s h - be l l. D o u bl e v i si o n. I t s

l i k e w a l k i n g a c r o s s a p e r s o n s e y e a n d r e f l e c t i n g p e r s o n a l i t y . I t w o r k s o n y o u , l i k e

d y i n g a n d g o i n g t o t h e s p i r i t u a l w o r l d , b u t l a n d i n g i n t h e V e l l a w o r l d . [ C o m m e n t :N e o lo gis ms a r e p r e se n te d . ]

D o n t j u dg e a b o ok b y i t s c o ve r . A f a ca d e o f r e ga l c o mp l i an c e b i de s a n a e ti o l og y o f

i r e . [ C o m m e n t : V e r y p e d a n t i c t o o a b s t r a c t o u t o f p r o p o r t i o n w i t h t h e t a s k . ]

L a c k o f s h a r e d c o m m u n i c a t i o n

Th e us ed ke y i s a lw ays b ri gh t. Th e ri gh t pa th , yo u ll k now t he r ig ht p at h.

[ Co m me nt : T he r at er i s i m pr es se d w it h a l ar ge a mo un t o f m i ss i ng i nf o rm at i on .

V e r y d i f f i c u l t t o e m p a t h i z e w i t h l i t t l e i d e a o f w h e r e r e s p o n s e c o m e s f r o m . ]

II The content of the statement: the ideas expressed

T hi s c at eg or y p e rt a in s t o p ec ul i ar it i es w i th in a r es po ns e t h at r ef l ec t c o nf us i on i n

id e as , p e cu lia r o r id ios y nc r atic lo g ic , a n d a s oc ial a ttitu d es ( d e sc r iptio ns o f b e h av io ur

th a t mo s t p e o p le w o u ld r e c o g n iz e a s s tr a n g e , u n u s u a l o r ta b o o in o u r s o c ie ty ) .

C o h e r e n t b u t o d d i d e a s

W hy a re p eo pl e w ho a re b or n d ea f u su al ly u na bl e t o t al k? Be ca us e t he y h av e

n o t h i n g t o t a l k a b o u t e x c e p t t h a t t h e y a r e b o r e d .

D e v i a n t w i t h r e s p e c t t o s o c i a l c o n v e n t i o n

W h a t w o u l d y o u d o i f w h i l e i n t h e m o v i e s y o u w e r e t h e f i r s t t o s e e s m o k e a n d f i r e ?

I d w a l k a r o u n d i n c i r c l e s u n t i l I g o t d i z z y a n d f e l l d o w n a s l e e p a n d d r e a m a b o u t

a p a s s a g e w a y w o u l d n t y o u ?

P e c u l i a r r e a s o n i n g o r l o g i c

O n e s w a l l o w d o e s n t m a k e a s u m m e r . S u m m e r s a r e w a r m a n d i t t a k e s m o r e t h a n

o n e s u m m e r t o c o o l o f f . [ C o m m e n t : A n i l l o g i c a l r e s p o n s e . A l s o c o n t a i n s g a p s i n

communication.]

C o n f us e d i d e a s

W h y a r e p e o p l e w h o a r e b o r n d e a f u s u a l l y u n a b l e t o t a l k ? W h e n y o u s w a l l o w i n

your throat like a key it comes out, but not a scissors. A robin, too, it means spring.

[ Co mm en t: R at er i s i mp re ss ed b y l ac k o f o rg an iz at io n a nd c oh er en ce i n t he

r e s p o n s e . V e r b a liz a tio n s a r e g e n e r a lly c o n fu s e d a n d c o n tr a d ic to r y . ]

III Intermixing tendenciesT h i s c a t e g o r y a s s e s s e s t e n d e n c i e s t o m i x o r b l e n d m a t e r i a l i n t o t h e r e s p o n s e f r o m

t he s ub je ct s p as t o r c ur re n t e xp e ri en ce , o r t o e xt e nd o r e la bo ra te a s ee mi n gl y

n e u t r a l t h e m e o r i d e a , m a k i n g t h e r e s p o n s e s e e m s t r a n g e .


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B o x 1 . 1 (cont.)

T h e o v e r - e l a b o r a te d r e s p o n s e

A r ol l in g s to ne g at h er s n o m o ss . Th at w as a y es t er da y t h in g. I f y ou k e ep y ou rs el f

m ov in g t ow ar ds y ou r g oa l w ha tev er i t m ay b e a nd i f y ou k eep t he g oa l i n m in d w he n

you make decisions then you are most likely not to be led astray by feeling sorry for

yourself, or greed or that type of thing. And if you just forget about your goals and

v a l u e s a n d g i v e u p h o p e a n d s a y t h e h e l l w i t h e v e r y t h i n g , d e t e r i o r a t e , t h e n y o u c a n

g e t y o u r se l f i n t r ou b le . [ C om m e nt : H e re t h e a m o u nt o f e x tr a m a te r i al i s e x te n si v e.

A ls o s c o r ed fo r in te r min g lin g. ]

T h e i n te r m i n g l e d r e s p o n s e

A d r o w n i n g m a n w i l l c l u t c h a t a s t r a w . D u h . H e l p ! I s a n y o n e g o i n g t o s a v e h i m . Ic o u l d s a y I m a d r o w n i n g m a n r i g h t n o w . A n y o n e w h o a s k s f o r h e l p . A s k a n d y o u

s h a l l r e c e i v e . S e e k a n d y o u s h a l l f i n d i t . I t a l l h a s t o d o w i t h C h r i s t . [ C o m m e n t : T h e

a ns we r i s c le ar ly a f fe ct e d b y t he s ub je ct s c on ce rn o ve r h i s s ta t us a nd a sk i ng f o r h el p. ]

IV The relation between question and response

T h e e m p h a s i s i n t h i s c a t e g o r y i s o n d e t e r m i n i n g i f t h e s u b j e c t i s a b l e t o a d d r e s s t h e

t a s k o f i n t e r p r e t i n g t h e p r o v e r b o r r e s p o n d i n g t o a q u e s t i o n .

Attention to limited part of the stimulusD o n t s w a p h o r s e s w h e n c r o s s in g a s tr e a m. H o r s e s r u n c o u r s e s , th e r e a r e r a c e tr a c k s

a ll o v e r th e c o u n tr y .

T h e l a c k o f a r e l a t i o n b e t w e e n t h e s u b j e c t s s t a t e m e n t a n d t h e q u e s t i o n a s k e d .

W hy s ho ul d w e k ee p a wa y f ro m b ad c om pa ny ? S ay y ou r p ra ye rs . [ Co m me nt :

T h e r e i s l i t t l e t r a c e o f t h e o r i g i n a l q u e s t i o n ; t h e e x a m i n e r h a s o n l y a v a g u e h i n t o f

w h e r e t h e r e s p o n s e h a s c o m e f r o m . ]

W h y s h o u l d p e o p l e p a y t a x e s ? S h o w m e t h e t i m e t o r e a s o n . [ C o m m e n t : A g a i n i t

a l m o s t s e e m s a s i f a d i f f e r e n t p r o v e r b o r q u e s t i o n i s b e i n g a n s w e r e d . ]

V Behavior

T h is c a te g o r y a s s e s s e s b e h a v io r a s it r e la te s to c o n v e r s a tio n a l n o r ms fo r c o n d u c t in

a t es ti ng s it ua t io n. A s co re i n t hi s c at eg or y i s a t tr ib ut ed f or b eh av io r t ha t i s d ev i an t,

e i t h e r i n i t s e x t r e m e e x p r e s s i o n o r i n i t s i n c o n g r u i t y a n d i n a p p r o p r i a t e n e s s t o t h e

r e q u ir e me n ts o f th e s itu a tio n .

W h a t w o u l d y o u d o i f w h i l e i n t h e m o v i e s y o u w e r e t h e f i r s t t o s e e s m o k e a n d f i r e ?

R e p o r t t h e f i r e ( y e l l s ) F I R E ! F I R E ! ( r u n s a r o u n d r o o m w i l d l y ) .


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U si ng t hi s r at in g in st ru me nt , Ha rr ow s g ro up w er e a bl e t o d em on st ra te t ha t

b iz ar re -i di os yn cr at ic t hi nk in g w as c om mo nl y b ut no t u ni ve rs al ly p re se nt in

a cu te ly i ll s ch iz op hr en ic p at ie nt s, l es se ne d i n p re va le nc e a nd s ev er it y a s c li ni ca l

i mpr ov emen t t ook pl ace , a nd b ec ame s ome wh at mo re ma rk ed a gai n i n t hechronic phase of illness (see Harrow and Quinlan, 1985). Les s prosaically, their

a sse ssme nt m et ho d l ed t he m t o c on cl ud e t ha t, w hi le B le ul er s l oo se a sso ci at io ns o ft en

se em ed t o b e i nv ol ve d i n t he b iz ar re -i di osyn cr at ic t hi nk i ng o f sch iz op hr en ia , t hi s w as

n ot a lw ay s t he c as e, a nd i n m an y p at ie nt s b iz ar re v er ba li sa ti on s o cc ur re d w it ho ut a ny

noticeab le looseness . Sometimes it was odd meanings a nd outlooks which made

s peech se em unusual. For example, a patient explained the proverb, O ne s wa ll ow

d oe sn t m ak e a s um me r as:

J u st b e ca u se a b i rd s a ys i t s s u mm er an d a c ts l i ke i t s s u mm e r, m a yb e i t r e al l y i s n t . S o me t im es ab ir d c ou ld s ay i t s s um me r, a nd i t wo ul d r ea ll y b e w in te r.

A no th er f ac to r H ar ro w a nd c o- wo rk er s ( Ha rr ow a nd P ro se n, 1978, 1979) identi-

fied in schizophrenic patients bizarre-idiosyncratic speech was an intermingling

i n to t h ei r v e rb a li z at i on s ( an d p ossib ly i n to t he i r t hi n ki ng ) o f m at e ri al t ha t c om es

f r om t h ei r p ast o r c ur re nt e xp e ri e nc e . How f ar t he y m ad e t hi s o bse rv a ti on i nd ep e nd -

e nt ly o f C am er on s (1938) d e sc ri pt i on o f i n te rp en e tr at i on o f t h em es i s u n ce rt a in , b ut

i n a ny e v en t t he y d id n ot a c kn ow le dg e t he si mi l ar it y u n ti l se ve ra l y ea rs l a te r ( Ha rr ow

e t a l ., 1983), and then only rather grudgingly.

H a r r o w s g r o u p a p p e a r t o h a v e b e e n t h e f i r s t t o d r a w a t t e n t i o n t o t h e f a c t t h a t

t h e p e da n ti c o r s t il t ed s p ee c h i n s c hi z op h re n ia m e nt i on e d i n p a ss i ng b y B l eu l er

(1911) c ou ld m ak e s pe ec h d if fi cu lt t o u nd er st an d i n i ts o wn r ig ht ( Ha rr ow a nd

Quinlan, 1985) . O ne o f t he ir e xa mp le s w as :

Q . D i sc r et i on i s t h e b e tt e r p a rt o f v a lo u r.

A . P l ia n t r e c ti t ud e i s a t r ai t m o r e a p pr o pr i at e f o r s u cc e ss f ul l i vi n g t h an h o t- h ea d ed n es s w h ic h

i s e i t h e r s t u b b o r n o r c r u s a d y .

A f u r t h e r , l o n g e r a n d u n w i t t i n g l y p o i g n a n t e x a m p l e o f st i l t e d n e ss, t h i s t i m e i n a

p at ie nt s w ri ti ng , i s g iv en i n B ox 1.2.

B o x 1 . 2 S t i l t e d n e s s i n a s c h i z o p h r e n i c p a t i e n t

T he p at i en t s ub mi t te d t he f ol l ow i ng d oc um en t i n s up p or t o f h i s a pp ea l a ga in st

b e i n g d e t a i n e d i n h o s p i t a l :

R e p o r t r e H o s p i t a l M a n a g e r s H e a r i n g

I n a d d r e s s o f : T h e H o s p i t a l M a n a g e r s

F r o m : M r K J


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B o x 1 . 2 (cont.)

Introduction: M r J i s v eh em en t ly o bj ec ti ng o f s la nd er ou s r ep or ts b ea ra nt o f h is

n am e s ub mi t te d t o t he H os pi ta l M an ag er s a nd t o a ss oc ia ti ve m ea ns o f a pp ea l

a g a in s t le g a lly e n fo r c e d d e te n tio n a b le p s y c h ia tr ic tr e a tme n t o f h is p e r s o n .

Background: M r J i s a f or ty -f iv e y ea r o ld b ac he lo r w ho i s a l if e- de di ca te d yogi

w h i c h e n t a i l s a l i f e l o n g c o m m i t m e n t t o m a i n t a i n i n g t h e r e l i g i o u s o r d i n a t i o n a n d

s t i p u l a t e s w h e r e o f h i s l i f e i s s u r r e n d e r e d .

M r J i s a f or me r u nd er gr ad ua te o f U ni ve rs it y w he re of h e h as a n o pe n

i n v i t a t i o n t o r e t u r n t o s t u d y h a v i n g l e f t v o l i t i o n a l l y i n o r d e r t o p u r s u e a c a r e e r i n

m u s i c a l p e r f o r m i n g e n t e r t a i n m e n t a n d o f U n i v e r s i t y w h i c h d i s c h a r g e d M r J

f ro m a c our se of s tu dy i n F re nc h a nd It al ia n i n re sp ect o f a s ta te of h ea lt h

d e t e r m i n a n t l y u n s u i t a b l e f o r t h e r e s p e c t i v e c a m p u s o f t h e c o l l e g i a t e i n 1 9 7 9 .M r J a c t i v e l y a t t e m p t e d t o a c h i e v e a p e r s o n a l a m b i t i o n o f f u l l e m p l o y m e n t i n a

m u si c al p e rf o rm a nc a l e n te r ta i nm e n t u n ti l A p ri l 1 9 89 w h er e of a p r of e ss i on a l

c o n t r a c t w i t h V i r g i n R e c o r d s w a s p r o f f e r e d w h e n h e e n d e d a l l p e r s o n a l a s s o c i -

a tio n o f mu s ic ia n s h ip o w in g to ir r e c o n c ila b le p e r s o n a l d ete n te in p r o fe s s io n a l life ;

s in ce t hi s t im e Mr J w ho se m usi ca l co mp osi ti on s ar e k no wn o f t he R oy al

N o r t h e r n C o l l e g e o f M u s i c a n d w h o s e n a m e i s his registered copyright h a s m a i n -

t a i ne d a p e rs o na l p r ot e st a bl e d e no u nc e me n t o f i l l eg a l u t i li s at i o n o f h i s s o ng a n d

m u s i c a l w o r k a s s o c i a t e d w i t h a p r e v i o u s r e p e r t o i r e .M r J i s n o w a r e g i s t e r e d w r i t e r h a v i n g w r i t t e n a b o o k o f a p h o r i s t i c p o e t r y a n d

a n o r a t o r i a l ( i . e . p u b l i c l e c t u r i a l ) a c a d e m i c .

M r J i s c on si de re d b y h is f at he r, M r R J , t o b e s uf fe ra nt o f t he d ia gn os ab le

d i s e a s e o f t h e h u m a n b r a i n k n o w n i n t h e m e d i c a l t e r m s c h i z o p h r e n i c a n d h a s b e e n

r e c i p i e n t o f t h i s p a t e r n a l p a r t y s a d a m a n t s t r a t a g e m o f i m p l e m e n t i n g c o n t i n u o u s

p s y c h i a t r i c m e d i c a l t r e a t m e n t t h e r e o f s i n c e h e c o m m i t t e d h i m s e l f i n t o t h e s t a t e o f

i n s a n i t y a f t e r l e a v i n g t h e i n i t i a t e d l i f e o f d e v o u t r e l i g i o u s y o g a i n t h e I n d i a n D i v i n e

L ig h t M is s io n* e s t a b l i s h e d i n t h e U n i t e d K i n g d o m o f G r e a t B r i t a i n a n d N o r t h e r n

I r e l a n d i n 1 9 7 2 b e i n g a n a l t e r n a t i v e a c t t o p e r s o n a l s u i c i d e .

Social History: S i n c e a l o n g t o u r i n g h o l i d a y i n 1 9 9 3 M r J h a s l i v e d i n c o m m e r c i a l

b o a r d a n d l o d g i n g s i n N a n d s u r r o u n d i n g r e g i o n . H e h a s b e e n d e n i e d r e p e a t e d l y

t he m ea ns o f e st ab li sh in g h is o wn h om e a nd h as b ee n a bl e t o m ai nt ai n b as ic

e xi st en ce o nl y i n r es pe ct o f D ep ar tm en t o f S oc ia l S ec ur it y a nd p er so na l

a t t i t u d e s a n d p o l i c i e s t o w a r d s h i m s e l f .

Signed

K J

* n o w k n o w n b y t h e t i t l e E L A N V I T A L , R e g d C h a r i t y 2 4 8 6 4


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H a rr ow a n d c o -w or k er s d e co n st r uc t io n a n d r e co ns t ru c ti o n o f t h ou g ht d i s-

o rd er u lt im at el y t oo k t he m i n n ov el t he or et ic al d ir ec ti on s. T he y ( Ha rr ow a nd

Prosen, 1978, 1979; s e e a ls o H arro w a nd M ill er, 1980) s p ec u la t ed t h at i n te r mi n -

g li ng o r i nt er pe ne tr at io n o f t he me s, wh ic h i mp li ed a n i na bi li ty t o p re ve nt o ne so wn i nt er na l c on te xt f ro m i nt ru di ng i nt o s pe ec h, m ig ht b e d ue t o a f ai lu re t o

m o n i t o r a n d e d i t p e r s o n a l m a t e r i a l o u t o f s p e e c h , a n d t h a t t h i s i n t u r n p o i n t e d t o

f ai lu re i n sp ec if ic a sp ec ts o f t he e xe cu ti ve f un ct io n . . . i n vo l ve d i n c o nt r ol l in g a n d

g u id i ng l a ng u ag e a n d b e ha v io r . T h ey a l so r a is e d t h e p o ss i bi l it y t h at t h is a n d o t he r

f e at u re s o f t h ou g ht d i so r de r m ig h t i n vo l ve w h at t h ey t e rm e d i mp a ir e d p e rs p ec t iv e ,

a g e ne r al i m pa i rm en t o f s o ci a l k n ow l ed g e a n d u n de r st a nd i ng o f s o ci a l c o nv e nt i on s

r el at in g t o s pe ec h a nd d is co ur se . B ot h o f t he se i de as s ub s eq ue nt ly w en t o n t o

b e co me i mp o rt a nt t op i cs i n t h ou g ht d is o rd e r r e se a rc h a n d a r e d i sc u ss e d a t le n gt h

i n C ha pt er s 5 and 6.

A n d r e a s e n : t h e m o d e r n s y n t h e s i s

I n t he 1 97 0s A me ri ca n p sy ch iat ry w as i n c ri si s. T hi s w as t he f in al c ha pt er i n w ha t h ad

b e e n a n a l mo st c o mp l et e t a ke o ve r o f m a in st r ea m p syc hi a t ry b y p syc ho a na l ysi s i n

t hi s c ou nt ry . A s r ec ou nt ed b y S ho rt er (1997) in hi s hi st ory of 2 0t h century psy chi-

atry, in the heyday of this movement in the 1950s and 1960s virtually every

p re st ig io us c ha ir o f p sy ch ia try i n A me ri ca w as o ccu pi ed b y a p sy ch oa na ly st .A na ly st s a nd a na ly si s s y mp at hi se rs h ad t ak en o ve r m uc h o f t he a pp ar at us o f t he

A me r ic a n P syc h ia t ri c A ssoc i at i on . A n al y st s w r ot e t h e t e xt b oo k s, st af f ed t h e u n i-

v e r si t y d e p a r t m e n t s a n d sa t o n t h e e x a m i n a t i o n b o a r d s. A n a l y st s w e r e c o n su l t e d b y

g ov er nme nt a ge nc ie s a nd C on gr es s. P sy ch oa na ly si s w as t he b as ic s ci en ce o f

psychiatry.

C en tr al t o p sy ch oa na ly si s w

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