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Schizophrenia Research 105 (2008) 144 155

www.elsevier.com/locate/schres

The language of schizophrenia: An analysis of micro and macrolinguistic

abilities and their neuropsychological correlates
Andrea Marini a,b,, Ilaria Spoletini b , Ivo Alex Rubino c , Manuela Ciuffa b , Pietro Bria d ,
Giovanni Martinotti d , Giulia Banfi b , Rocco Boccascino e , Perla Strom e ,
Alberto Siracusano c , Carlo Caltagirone b,c , Gianfranco Spalletta b,c
a
University of Udine, Udine, Italy
IRCCS Santa Lucia Foundation, Rome, Italy
c
Department of Neuroscience, University of Rome Tor Vergata, Rome, Italy
d
Institute of Psychiatry, Catholic University of the Sacred Heart, Rome, Italy
e
Department of Mental Health, ASL RMF, Rome, Italy
b

Received 17 December 2007; received in revised form 11 July 2008; accepted 20 July 2008
Available online 2 September 2008

Abstract
Language disturbance is one of the main diagnostic features in schizophrenia and abnormalities of brain language areas have
been consistently found in schizophrenic patients. The main aim of this study was to describe the impairment of micro and
macrolinguistic abilities in a group of twenty-nine schizophrenic patients during the phase of illness stability compared to fortyeight healthy participants matched for age, gender and educational level. Microlinguistic abilities refer to lexical and morphosyntactic skills, whereas macrolinguistic abilities relate to pragmatic and discourse level processing. Secondary aims were to detect
the effect of macrolinguistic on microlinguistic ability, and the neuropsychological impairment associated with the linguistic
deficit. The linguistic assessment was performed on story-telling. Three narratives were elicited with the help of a single-picture
stimulus and two cartoon stories with six pictures each. A modified version of the Mental Deterioration Battery was used to assess
selective cognitive performances. A series of t-tests indicated that all the macrolinguistic variables were significantly impaired in
schizophrenic patients in at least one of the three story-tellings. Furthermore, the limited impairment found in microlinguistic
abilities was influenced by macrolinguistic performance. Multivariate stepwise regression analyses suggested that reduced attention
performances and deficit in executive functions were predictors of linguistic impairment. Language production in schizophrenia is
impaired mainly at the macrolinguistic level of processing. It is disordered and filled with irrelevant pieces of information and
derailments. Such erratic discourse may be linked to the inability to use pragmatic rules and to cognitive deficits involving factors
such as attention, action planning, ordering and sequencing.
2008 Elsevier B.V. All rights reserved.
Keywords: Schizophrenia; Schizophasia; Language; Discourse analysis

Corresponding author. Cattedra di Psicologia del Linguaggio,

Universit di Udine, Via T. Petracco, 8-33100 Udine, Italy. Tel.: +39
335 5393224.
E-mail address: andrea.marini@uniud.it (A. Marini).
0920-9964/$ - see front matter 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2008.07.011

1. Introduction
Language disturbance is one of the main clinical
features in schizophrenia (Andreasen and Grove, 1986;

A. Marini et al. / Schizophrenia Research 105 (2008) 144155

Covington et al., 2005). Abnormalities in language areas

have been consistently reported in schizophrenic
patients (Spalletta et al., 2003; Honea et al., 2005;
Koeda et al., 2006; Kuperberg et al., 2007). Language is
a complex dynamic cognitive system which entails
integration of multiple levels of linguistic and cognitive
processing (Kintsch and van Dijk, 1978; Caplan, 1992;
Marini, 2001). Two main dimensions exist for language:
1) a within-sentence or microlinguistic dimension, responsible for intra-phrasal functions, and 2) a betweensentence or macrolinguistic dimension, responsible for
inter-phrasal functions. Microlinguistic abilities involve
the organisation of phonological or graphemical patterns
into morphological strings and words (i.e. lexical
processing) and determine the syntactic context each
word requires for the generation of well-formed sentences
(i.e. syntactic processing). Macroelaborative abilities
determine the contextually appropriate meaning of a
word or a sentence (i.e. pragmatic processing) and allow
us to connect sentences or utterances by means of coherent
and cohesive devices in order to integrate both linguistic
and conceptual features of an uttered discourse or a written
text and understand its main theme or gist (i.e. discourse
processing) (Kintsch, 1994). Increasing evidence shows
that these levels can be analyzed separately (Davis et al.,
1997; Marini et al., 2005a,b).
At the level of lexical processing selective problems
have been reported in schizophrenic speech (Barr et al.,
1989; Allen et al., 1993; Spitzer, 1997; Marvel et al.,
2004). Although normal at the levels of segmental
phonology (Chaika, 1974) and morphological organization (Chaika, 1990), their speech is characterized by
flattened intonation (Cutting, 1985) and word-finding
difficulties (Andreasen, 1979; McKenna, 1994). These
data suggest preserved articulation skills and morphological competence, but defective abilities to entail their
utterances with the correct suprasegmental pragmaticprosodic contour. Furthermore, schizophrenic patients'
disturbances include verbosity and empty content with
verbal descriptions teaming with pronouns often without antecedents. Moreover, their productions often
include deictic terms with no clear referents and verbs
that make their discourse vague and ambiguous.
At the level of syntactic processing, schizophrenic
patients' speech is usually normal, with no relevant
aberrations (Andreasen, 1979; Covington et al., 2005).
However, their sentences may appear somehow simplified, characterized by reduced syntactic complexity
(Morice and McNicol, 1986; Fraser et al., 1986; Thomas
et al., 1990).
Schizophrenic patients usually have problems in the
pragmatic use of language. Indeed, difficulties in

145

dealing with non-literal expressions (i.e. sarcasms,

proverbs, metaphors, irony, idioms, indirect requests)
have been widely reported (Chapman, 1960; Gibbs and
Beitel, 1995; Mitchley et al., 1998; Sarfati and HardyBayl, 1999; Langdon et al., 2002a,b; Tny et al., 2002;
Corcoran and Frith, 2003; Lee et al., 2004). In some
cases, such deficits have been related to an inability to
generate a correct Theory Of Mind (TOM: Sperber
and Wilson, 2002), that is the ability to infer the mental
states of their interlocutors (i.e. their perspective and
their communicative intentions). In particular, TOM
performance predicted 39% of variance for proverb
comprehension in a group of schizophrenic patients
(Brune and Bodenstein, 2005). From a general point of
view, the pragmatic deficits showed by these patients
may be related to deficient TOM generation ability
which, in turn, may be the expression of a more
generalized cognitive impoverishment in schizophrenia
(Linscott, 2005).
The speech of schizophrenic patients is usually
reported as disordered, filled with irrelevant pieces of
information and derailments (Andreasen, 1979). Such
erratic discourse may be linked to the inability to use
pragmatic rules and/or by general cognitive deficits
involving factors such as attention (Neuchterlein et al.,
2002), and/or action planning, ordering and sequencing
(Woelwer and Gaebel, 2002; Docherty et al., 2006)
which are crucial for efficient discourse processing.
To sum up, schizophrenic patients show linguistic
deficits which are very selective and subtle at the
microlinguistic level. However, deficits become more
pervasive and severe at the macrolinguistic level when
patients need to organize what they want to communicate at the pragmatic-communicative level and generate appropriate mental models. Unfortunately,
patients' difficulties in these respects are not easy to
detect and quantify. Furthermore, studies in the field
have not used a standard or comparable set of research
methods. Finally, in order to adequately describe the
linguistic performance of a group of patients, it is
essential to extend the analysis to all of the abovementioned levels of complexity. Indeed, if a deficit at
the macrolinguistic level causes problems on the
microlinguistic level of text processing, the reverse
can also be true, with microlinguistic deficits reflecting on a more generalized difficulty in discourse
organization.
The main aim of the present study was to describe in
detail the micro- and macrolinguistic abilities in a group
of schizophrenic patients on a set of single-picture and
cartoon story description tasks. The narratives produced
by the group of schizophrenic patients were compared to

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A. Marini et al. / Schizophrenia Research 105 (2008) 144155

those provided by a comparison group of healthy

participants. The elicited narratives were analyzed using
techniques that allowed the evaluation of microlinguistic, macrolinguistic and informative aspects of discourse
processing. In order to better capture the exact nature of
their linguistic performance, additional analyses evaluated the effect of macrolinguistic variables on microlinguistic (i.e. lexical and sentence-level processing)
performance and the neuropsychological predictors of
schizophrenic patients' linguistic performance. In particular, it was hypothesized that selective problems in
microlinguistic processing may be related to a more
general problem in discourse planning and organization
which, in turn, may be the consequence of a deficit in
executive functions.
2. Methods
2.1. Participants and diagnostic assessment
Seventy-seven Italian-speaking participants were
included in the study. All participants gave written
informed consent to participate in the study after all
procedures had been fully explained. Approval for the
study had previously been obtained from the local ethics
committee.
The experimental group consisted of 29 schizophrenic patients diagnosed according with DSM-IV criteria
(American Psychiatric Association, 1994). For all
patients included in this study, clinicians who treated
the patients and knew their clinical history used DSMIV criteria to make a preliminary diagnosis of schizophrenia. All diagnoses were then confirmed by one
senior clinical psychiatrist (G.S.) using the structured
clinical interview for DSM-IV (SCID-P; First et al.,
1997a,b). Reproducibility of the preliminary and
confirmed clinical diagnoses showed substantial agreement with interrater reliability levels of k N 0.80.
All schizophrenic patients included in the study were
in the phase of clinical stability and had been receiving
stable oral doses of atypical antipsychotics for at least
one month.
Exclusion criteria included: substance abuse or
dependence during the foregoing year; a history of
traumatic brain injury or any other neurological illness;
any past or present major medical illness that may affect
brain structures such as diabetes, cerebrovascular
disease, etc; any brain pathology identified on T2- or
FLAIR-scans; and mental retardation.
The control group, 48 healthy participants, was
included in order to compare the narratives produced by
schizophrenic participants with those uttered by healthy

individuals. All comparison subjects were carefully

screened for a current or lifetime diagnosis of any axis I
or II disorder using SCID-I and SCID-II (First et al.,
1997a,b). Schizophrenia among first-degree relatives
was an exclusion criterion as well as the other exclusion criteria mentioned above for patients with
schizophrenia.
The two groups were matched for chronological age,
gender and level of formal education. The sociodemographic characteristics of patients with schizophrenia and healthy comparison subjects are described
in Table 1.
2.2. Neuropsychological assessment
Two trained neuropsychologists (I.S. and G.B.)
interviewed patients by administering the Mini Mental
State Examination (MMSE: Folstein et al., 1975) to
define the global cognitive impairment, and a modified
version of the Mental Deterioration Battery (MDB) to
assess selective cognitive performances. The MDB is a
standardized and validated neuropsychological instrument (Carlesimo et al., 1996). The tests were selected to
provide information about the functionality of different
areas of cognition: language (Phonological Verbal
Fluency; Categorical Verbal Fluency), verbal memory
(Rey's 15-word Immediate Recall and Delayed Recall),
visual memory (Immediate Visual Memory), and logical
reasoning (Raven's Progressive Matrices '47). Constructional praxis was assessed through the Copy of the
ReyOsterrieth Complex Figure Test (Osterrieth, 1944),
executive functioning by administering the Wisconsin
Card Sorting Test (WCST achieved categories, perseverative errors and non-perseverative errors) (Heaton
et al., 1993). Finally, information about psychomotor
speed, attention, and inhibitory processing was obtained
by using the Trail Making Test, Part A and Part B
(Reitan, 1992). Two of the 29 schizophrenic patients,
did not complete the neuropsychological examination
due to non-compliance. Neuropsychological scores are
shown in Table 2.
2.3. Assessment of narrative abilities
The narrative assessment was performed on the
story-tellings elicited with a picture-story description
task. Three narratives were elicited with the help of a
single-picture stimulus (picnic) and two cartoon
stories with six pictures each (flower pot and
quarrel). The single picture picnic, taken from the
Western Aphasia Battery (WAB; Kertesz, 1982),
describes the scene of a picnic on a lake. The two

A. Marini et al. / Schizophrenia Research 105 (2008) 144155

147

Table 1
Sociodemographic and clinical characteristics of 77 subjects with or without schizophrenia diagnosis
Characteristics

Schizophrenia patients

Comparison subjects

(n = 29)

(n = 48)

Mean SD

Mean SD

Age (year)
Educational level (year)
Age at the onset of the illness (year)
Duration of illness (year)
PANSS positive symptoms
PANSS negative symptoms
PANSS general psychopathology

43.4 13.3
11.8 3.7
27.0 7.3
16.5 11.3
28.9 5.1
22.9 6.6
52.3 10.9

43.4 16.8
12.4 2.1

0.003
0.940

0.998
0.350

N (%)

N (%)

Chi-square

Gender (male)
DSM-IV subtypes
Paranoid
Disorganized
Undifferentiated
Residual

21 (72.4)

35 (72.9)

0.002

0.962

17 (58)
4 (14)
6 (21)
2 (7)

SD: Standard Deviation; degrees of freedom (75 for t-tests and 1 for chi-square tests).

cartoon picture sequences were used by Huber and Gleber

(1982) and by Nicholas and Brookshire (1993) respectively, to analyze textual competence and discourse
information content. The former is about a man who is
walking with his dog and is hit on the head by a flower
pot. The latter story is about a quarrel between a husband
and wife. All three stories were very easy to describe and
the characters were clearly depicted. On average, it took
approximately 1 min to describe each story. Each
participant described all three stories. The order of
presentation was counterbalanced across subjects.
Since for this picture description task no normative
data are currently available, the narratives produced by
Table 2
Neuropsychological scores of 27 patients with schizophrenia
Neuropsychological test

Mean SD

MMSE
27.5 2.0
Phonological verbal fluency
26.6 9.1
Categorical verbal Fluency
15.0 4.6
Rey's 15-word immediate recall
29.7 8.9
Rey's 15-word delayed recall
6.1 2.3
Immediate visual memory
18.0 3.5
Raven's Progressive Matrices '47
25.1 6.4
Copy of the ReyOsterrieth Complex Figure Test
27.3 6.7
Wisconsin Card Sorting Test, achieved categories
5.2 1.2
Wisconsin Card Sorting Test,
4.6 6.3
perseverative errors
Wisconsin Card Sorting Test, non-perseverative errors
3.8 4.1
Trail Making Test, Part A (seconds)
102.0 63.4
Trail Making Test, Part B (seconds)
255.0 168.6
MMSE: Mini Mental State Examination; SD: Standard Deviation.

the group of 29 schizophrenic patients were compared to

those uttered by the group of 48 healthy comparison
subjects. In order to avoid poor performance due to
short-term memory limitations (Anderson et al., 1988;
Wicksell et al., 2004), the cartoon story remained visible
until the participant completed the description. Each
story-telling was tape-recorded and subsequently transcribed verbatim by one of the authors (A.M.) and by an
experienced speech therapist (M.C.) including phonological fillers, pauses, and false starts. The stories were
subjected to a quantitative textual analysis. The analysis
focused on four main aspects: verbal productivity,
lexical and morpho-syntactic organization, informativeness and textual organization (Marini and Carlomagno,
2004). The scoring procedure was performed independently by two raters and then compared. Acceptable
interrater reliability was defined as k 0.80, and the two
researchers, after an appropriate training, achieved this
level between them prior to the beginning of the study
and for all narrative values of the present study. The
residual differences were resolved through discussion.
2.3.1. Microlinguistic analysis
Verbal productivity was measured as the number of
units produced by each subject during the story-telling.
The unit count included all verbalizations, irrespective
of their linguistic or contextual correctness or appropriateness (Haravon et al., 1994; Marini et al., 2005b).
The total number of well-formed words, excluding
phonological fillers, phonemic paraphasias and phonetic
errors, was then computed (Words in Table 3).

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A. Marini et al. / Schizophrenia Research 105 (2008) 144155

Table 3
Levels of productivity and accuracy of microlinguistic processing of 29 schizophrenic patients and 48 comparison subjects, and comparisons between
groups for microlinguistic variables on the three story-telling tasks
Microlinguistic scores

Schizophrenic patients (Mean SD)

Comparison subjects (Mean SD)

t-value

p-value

Words (quarrel)
Words (picnic)
Words (flower pot)
% phonological selection (quarrel)
% Phonological selection (picnic)
% Phonological selection (flower pot)
% Semantic paraphasias (quarrel)
% Semantic paraphasias (picnic)
% Semantic paraphasias (flower pot)
% Paragrammatic errors (quarrel)
% Paragrammatic errors (picnic)
% Paragrammatic errors (flower pot)
Mean length of utterance (quarrel)
Mean length of utterance (picnic)
Mean length of utterance (flower pot)

86.4 57.1
81.0 41.8
99.3 48.9
98.5 2.1
98.1 2.0
98.9 1.1
0.8 1.1
1.2 1.6
1.5 1.8
1.3 1.6
1.3 1.9
1.5 1.3
6.2 1.4
6.4 2.1
7.0 1.6

81.3 28.2
79.2 41.9
87.4 22.1
98.5 2.5
98.5 2.5
98.6 3.0
0.1 0.4
0.2 0.6
0.3 0.5
0.1 0.3
0.3 0.7
0.5 1.2
7.2 1.9
8.8 4.5
8.5 2.3

0.518
8.570
1.458
0.052
0.681
0.544
3.906
4.152
4.551
4.931
3.497
3.698
2.638
3.497
3.225

0.606
0.850
0.149
0.958
0.498
0.588
0.0002
<0.0001
<0.0001
<0.0001
0.0008
0.0004
0.0101
0.0066
0.0019

SD: Standard Deviation; Significant after Bonferroni correction for multiple comparisons.

The lexical and syntactic organization was measured

in terms of lexical and morpho-syntactic processing.
Lexical processing was assessed in three ways. At the
first step, the analysis focused on the lexeme level of
word processing (Levelt et al., 1999) and a ratio of
phonological selection was computed. The ratio of
phonological selection (Marini et al., 2005a, 2007a,b)
was obtained by dividing the number of words by the
number of units. Units included all verbalizations,
irrespective of their linguistic or contextual correctness
or appropriateness. Word count included only wellformed words, i.e. excluding phonological fillers and
phonological errors. Thus, the ratio of phonological
selection allowed assessing the ability to retrieve
phonologically well-formed words (% Phonological
selection in Table 3).
The lemma level, i.e. the level at which semantic,
morpho-syntactic and morphological features of a word
become available, was assessed in terms of production of
semantic paraphasias and paragrammatic errors. The
ratio of semantic paraphasias was calculated by dividing
the number of semantic paraphasias by the number of
words (% Semantic paraphasias in Table 3) (Marini et al.,
2005b). These errors were scored when a target word
was substituted by a semantically related word (Haravon
et al., 1994). An example for a semantic paraphasia is the
word mother in the sentence here he's talking to his
mother, where the speaker implied wife.
For each story, the ratio of paragrammatic errors
included grammatical errors with bound morphemes
(for example, questo una coppia: this [masc in
Italian] is a couple [fem] in Italian questo should be
questa) and function words (for example, batte da una

porta he is knocking from a door in Italian da

instead of a). The ratio of paragrammatic errors was
calculated by dividing the number of paragrammatic
errors by the number of words (% Paragrammatic errors
in Table 3).
As a gross measure of syntactic organization the Mean
length of utterance was calculated (MLU, in Table 3). An
utterance is a unit of speech surrounded by silence. In the
transcription, utterance boundaries were determined by
intonation contours as well as by pause length. For each
story description, the total number of utterances was
assessed following the criteria established in the Shewan
Spontaneous Language Analysis System (Shewan, 1988).
The ratio measuring the MLU was calculated by dividing
the total number of words by the number of utterances.
2.3.2. Macrolinguistic analysis
The informative content of each narrative was
measured in order to obtain a numerical evaluation of
lexicalsemantic appropriateness in describing the gist
of the story. The lexicalsemantic appropriateness was
determined counting the Lexical Information Units
(LIUs), i.e. words that were not only phonologically
well-formed but also appropriate from a grammatical
and pragmatic point of view (Marini et al., 2005a,b).
Therefore, all those words that were classified as
semantic paraphasias, fillers, paragrammatisms or present in tangential utterances (i.e. utterances that were
somehow deviating from the gist of the story) were
excluded from the LIUs count. The ratio of lexical
informativeness was obtained dividing the amount of
LIUs by the amount of words (% Lexical informativeness in Table 4).

A. Marini et al. / Schizophrenia Research 105 (2008) 144155

149

Table 4
Levels of accuracy and informativeness of macrolinguistic processing of 29 schizophrenic patients and 48 comparison subjects, and comparisons
between groups for macrolinguistic variables on the three story-telling tasks
Macrolinguistic scores

Schizophrenic patients (Mean SD)

Comparison subjects (Mean SD)

t-value

p-value

% Cohesive errors (quarrel)

% Cohesive errors (picnic)
% Cohesive errors (flower pot)
% Local coherence errors (quarrel)
% Local coherence errors (picnic)
% Local coherence errors (flower pot)
% Global coherence errors (quarrel)
% Global coherence errors (picnic)
% Global coherence errors (flower pot)
% Lexical informativeness (quarrel)
% Lexical informativeness (picnic)
% Lexical informativeness (flower pot)
% Thematic informativeness(quarrel)
% Thematic informativeness (picnic)
% Thematic informativeness (flower pot)

1.1 1.6
1.3 1.9
1.7 1.4
16.7 23.6
10.3 11.2
28.3 23.9
11.8 12.1
16.0 14.4
13.2 14.4
70.5 15.6
69.0 14.3
68.1 17.8
53.8 13.6
44.1 20.5
52.0 13.3

0.4 0.6
0.5 0.9
0.5 0.9
1.4 3.9
1.8 5.0
3.5 8.3
0.5 2.0
0.7 3.0
0.4 1.6
94.2 5.9
90.7 7.9
94.0 5.5
70.2 14.9
64.1 23.4
68.4 9.5

2.691
2.364
4.594
4.421
4.552
6.594
6.348
7.150
6.130
9.451
8.570
9.377
4.804
3.816
6.305

0.0088
0.0207
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0003
<0.0001

SD: Standard Deviation; Significant after Bonferroni correction for multiple comparisons.

For each story the total number of possible thematic

units was identified (Marini et al., 2005a). Therefore, it
was possible to measure a ratio of thematic informativeness for each story dividing the number of thematic
units in the subjects' speech by the total amount of
thematic units that could be obtained by the story (%
Thematic informativeness in Table 4).
The macrolinguistic measure of discursive organization included ratios of cohesive errors as well as both
local and global coherence errors. Cohesive errors
measure the structural connectivity across utterances,
whereas local coherence errors are a measure of failure
to link utterances conceptually. A ratio of cohesive
errors was obtained by dividing the total amount of
cohesive errors by the number of utterances that formed
the description (% Cohesive errors in Table 4). A
cohesive error was scored each time cohesive function
words were used incorrectly or whenever utterances
were abruptly interrupted but at the condition that the
subsequent utterances were completing the idea previously introduced. The ratio of local coherence errors
was measured dividing the total number of local
coherence errors by the number of utterances produced
(% Local coherence errors in Table 4). Missing or
ambiguous referents and semantic shifts were counted
as local coherence errors. A semantic shift was scored
whenever there was an abrupt stop within an utterance,
after which the flow of thoughts was not continued in
the following utterance but, instead, a new concept
began. For instance, in he's trying to and here he is on
a landing the first utterance remained unfinished, the
second utterance introduced a new scene. Missing
referents were instances in which the referent of a

pronoun or the implicit subject of a verb (Italian is a prodrop language) were not unambiguously clear or were
incorrect. For example, consider the following sequence
of utterances: Qui stanno litigando furiosamente. Poi
dice: () (Here they are fighting furiously. Then
[implicit pronoun] says: ()). In the second utterance
there was a missing referent because it was not clear
whom the verb dice (says) referred to. A ratio of global
coherence errors was calculated dividing the total
number of tangential utterances by the amount of
utterances that formed each description (% Global
coherence errors in Table 4). An utterance where a
derailment in the flow of discourse was detected was
considered tangential. For instance, while describing the
picnic story, a schizophrenic participant said: It is a
picnic / I like picnics / I have had several picnics in my
life /. Obviously, with respect to the gist of the story,
utterances such as I like picnics and I have had several
picnics in my life are not relevant to telling the story per
se and were probably triggered by semanticconceptual
associations that can be considered as tangential.
2.4. Statistical analyses
Comparisons of sociodemographic variables were
made using chi-square test for gender and Student's ttest for continuous variables (i.e. age and educational
level).
A series of 10 t-tests was performed in order to
compare the two groups for all individual micro- and
macrolinguistic performance variables (i.e. Words,
% Phonological Selection, % Semantic paraphasias,
% Paragrammatic errors, Mean length of utterance,

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A. Marini et al. / Schizophrenia Research 105 (2008) 144155

% Cohesive errors, % Local coherence errors, % Global

coherence errors, % Lexical informativeness, % Thematic informativeness). These comparisons were
repeated separately for the three story-telling tasks. In
these analyses the level of statistical significance was
defined as p b 0.05 after Bonferroni correction for
multiple comparisons (alpha b 0.05/30alpha b 0.0016).
In order to control for the effect of macrolinguistic
variables involved in discourse processing often found
to be impaired in schizophrenia (i.e. % Local
coherence errors and % Global coherence errors) on
linguistic measures examining the microlinguistic level
of processing (namely % Semantic paraphasias, that is
errors at the lexico-semantic level, and % Paragrammatic errors, that is errors at the morpho-syntactic level),
we performed two univariate analyses of covariance
(ANCOVAs) with the two macrolinguistic variable
scores as covariates and the microlinguistic variable
scores as dependent variables. The cartoon story flower
pot was used as an index for linguistic performance in
these ANCOVAs. To determine the neuropsychological
variables which correlated with those linguistic variables that were impaired in schizophrenic patients on at
least two story-telling tasks, we performed a series of
stepwise multiple regression analyses, with those
individual linguistic variables which were impaired in
schizophrenic patients (i.e. % Semantic paraphasias,
% Paragrammatic errors, % Local coherence errors,
% Global coherence errors, % Lexical informativeness,
and % Thematic informativeness) as dependent variables, and the neuropsychological variable scores as
independent variables, using a forward procedure and an
F to enter of 4. This was done only in the schizophrenic
group. The linguistic scores obtained on the cartoon
story quarrel were used as an index for linguistic
performance in these multiple regression analyses. In
addition, pre-selection of neuropsychological variables
to include in the stepwise regression models was done by
using correlation analyses and Fisher's r to z transformation in order to determine the significance of correlations. In the stepwise multivariate models only variables
with p b 0.05 in the pre-selection univariate correlation
analyses were included.
3. Results
3.1. Assessment of narrative abilities
Tables 3 and 4 show the differences between groups
for all the micro- and macrolinguistic variables
separately for the three story-telling tasks. Apart from
Words, % Phonological Selection and Mean length

of utterance, which did not differ between schizophrenic and control participants, the remaining linguistic
variables did differ in at least one of the three storytelling tasks in the schizophrenic group compared to the
control subjects group. As shown in Tables 3 and 4, the
following six linguistic variables in at least two of the
story-telling tasks were significantly different between
groups: % Semantic paraphasias, % Paragrammatic
errors, % Local coherence errors, % Global coherence
errors, % Lexical informativeness, and % Thematic
informativeness.
3.2. Effect of macrolinguistic abilities on microlinguistic
performance
To further clarify the relationship between micro- and
macrolinguistic variable performances, we compared
% Semantic paraphasias and % Paragrammatic errors in
the flower pot story-telling of the patient and healthy
comparison groups. Two ANCOVAs were run with
% Local coherence errors and % Global coherence errors
as covariates in both analyses. Results revealed no
differences between the two groups on % Semantic
paraphasias (F = 0.104; df = 1,69; p = 0.748) and
% Paragrammatic errors (F = 2.025; df = 1,69; p = 0.159).
3.3. Neuropsychological predictors of linguistic performance in schizophrenia
As mentioned earlier, six out of the ten linguistic
variables were significantly different between the
schizophrenic and control subjects groups in at least
two story-telling tasks. The quarrel story-telling
scores of these six linguistic variables were used as an
index to analyze the relationship between linguistic
ability and cognition in schizophrenic patients only.
Cognitive variables which in the univariate correlation
analyses were related (p b 0.05) to the linguistic
variables (see Table 5) were selected as independent
variables in the further stepwise multiple regression
analyses.
None of the neuropsychological variables correlated
significantly with % Thematic informativeness or %
Local coherence errors in the univariate correlation
analyses. Thus, a series of four stepwise multiple
regression analyses was performed to identify the
neuropsychological predictors of % Semantic paraphasias, % Paragrammatic errors, % Global coherence errors,
and % Lexical informativeness scores as dependent
variables, because only these four linguistic variable
scores correlated with one or more cognitive variable
scores (as shown in bold in Table 5). Results indicated that

A. Marini et al. / Schizophrenia Research 105 (2008) 144155

151

Table 5
Relationships between % Semantic paraphasias, % Paragrammatic errors, % Global coherence errors, and % Lexical informativeness and cognitive
level in the schizophrenic group as emerged from the univariate correlation analysis
Semantic paraphasias

Paragrammatic errors

Global coherence errors

Lexical informativeness

Cognitive variables

Pearson's r (p-value)

Pearson's r (p-value)

Pearson's r (p-value)

Pearson's r (p-value)

MMSE
Phonological verbal fluency
Categorical verbal fluency
Rey's 15-word immediate recall
Rey's 15-word delayed recall
Immediate visual memory
Raven's Progressive Matrices '47
Copy of the ReyOsterrieth figure
WCST, achieved categories
WCST, perseverative errors
WCST, non-perseverative errors
TMA
TMB

0.401 (0.037)
0.047 (0.816)
0.153 (0.449)
0.280 (0.158)
0.303 (0.126)
0.202 (0.316)
0.361 (0.064)
0.401 (0.038)
0.097 (0.632)
0.315 (0.110)
0.039 (0.848)
0.116 (0.567)
0.260 (0.192)

0.064 (0.754)
0.026 (0.897)
0.129 (0.524)
0.311 (0.115)
0.104 (0.609)
0.115 (0.570)
0.291 (0.142)
0.427 (0.025)
0.418 (0.029)
0.191 (0.344)
0.619 (0.0004)
0.061 (0.765)
0.004 (0.984)

0.451 (0.0174)
0.476 (0.0113)
0.052 (0.800)
0.214 (0.288)
0.099 (0.627)
0.402 (0.037)
0.422 (0.028)
0.559 (0.002)
0.012 (0.951)
0.117 (0.565)
0.022 (0.915)
0.593 (0.0008)
0.692 (0.0001)

0.558 (0.0021)
0.356 (0.068)
0.047 (0.816)
0.255 (0.201)
0.053 (0.794)
0.297 (0.133)
0.517 (0.0051)
0.443 (0.020)
0.306 (0.122)
0.401 (0.038)
0.133 (0.513)
0.389 (0.044)
0.507 (0.006)

MMSE: Mini Mental State Examination; WCST: Wisconsin Card Sorting Test; TMA: Trail Making A; TMB: Trail Making B.

the MMSE score was the only predictor of % Semantic

paraphasias (F = 4.793; Standard coefficient = 0.401;
df = 1,25; r2 = 0.161; p = 0.0381). Secondly, number of
non-perseverative errors on the WCST was the only
predictor of % Paragrammatic errors (F = 15.546; Standard coefficient = 0.619; df = 1,25; r2 = 0.383; p = 0.0006).
Furthermore, Trail Making B score was the only predictor
of % Global coherence errors (F = 23.035; Standard
coefficient = 0.692; df = 1,25; r2 = 0.480; p b 0.0001).
Lastly, Raven's Progressive Matrices '47 score was the
only predictor of % Lexical informativeness (F = 9.104;
Standard coefficient = 0.517; df = 1,25; r 2 = 0.267;
p = 0.0051).
4. Discussion
The present work investigated linguistic abilities and
their neuropsychological correlates in a group of
schizophrenic patients. The main result indicates a
mild problem at the level of microlinguistic processing
and a severe deficit on the macrolinguistic dimension of
processing. Furthermore, three linguistic parameters
(i.e. Paragrammatic errors, Lexical informativeness, and
Global coherence errors) were explained by specific
neuropsychological domains whereas one additional
linguistic parameter (i.e. Semantic paraphasias) was
predicted by a measure of global cognitive level.
At the microlinguistic level, the speech of patients
with schizophrenia was quite variable, as there were
aspects of processing which did not statistically differ
from the comparison group (i.e. productivity) and
aspects of processing in which their performance was

not uniform. As for productivity (i.e. production of

words), despite the non significance, it is noteworthy
that schizophrenic participants were somehow more
verbose, producing on average more words than the
comparison subjects in all three stories. Lexical
processing analysis showed an absence of problems at
the phonetic or phonological level. Indeed, % Phonological Selection was similar in both groups. However,
schizophrenic participants produced more Semantic
paraphasias and Paragrammatic errors, suggesting the
presence of a selective problem in dealing with some
aspects of the lemma level of lexical processing.
Interestingly, the score of Paragrammatic errors was
explained by a measure of attention (specifically, setshifting ability), i.e. WCST non-perseverative errors.
This index likely reflects a failure in the use of
contextual information, which is necessary to set
shifting (Barcel and Knight, 2002). Such association
between Paragrammatic errors and WCST non-perseverative errors is consistent with models of lexical
processing (Indefrey and Levelt, 2004; Levelt et al.,
1999) where the role of contextual information in
speech production has been highlighted. Indeed, the
latter has been thought to involve a multi-step process:
a) a phase of pre-linguistic conceptual planning of the
intended message, in which the speaker retrieves all
available data from long-term declarative memory to
formulate a mental model coherent with the context;
b) a linguistic phase, in which the preverbal message
is converted into a speech plan by means of a preliminary stage of lexical selection followed by one of
lexical access; and c) an articulation phase in which

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A. Marini et al. / Schizophrenia Research 105 (2008) 144155

production actually takes place. The stage of lexical

selection allows speakers to select the lexical items
that correspond to the intended meaning through an
activation/inhibition mechanism (Green, 1986, 1998;
Paradis and Goldblum, 1989; Paradis, 1993). At the
end of the lexical selection process, the target word has
been activated and the linguistic system gains access to
its semantic, morpho-syntactic and morphological
features (lemma level of word representation) and
then to its phonological form (lexeme level of word
representation). In case of sentence production, the
morpho-syntactic structures requested by the selected
lemma (i.e. its argumental structure) guide the process
of sentence generation by means of thematic role
assignments and phrase generation, and the information
contained in the lemmas of the selected lexical items is
used to build up well-formed syntactic representations
(Chomsky, 1988, 1995; Caplan, 1992; Pinker, 1999).
Accordingly, the present results show that, although
schizophrenic speech is not impaired at the level of
lexeme processing, it seems to be characterized by
lemma-level deficits, that is in lexico-semantic and
morpho-syntactic aspects of lexical processing. Indeed,
abnormalities in associative connections between
words and concepts have long been considered a core
feature of schizophrenia (Manschreck et al., 1988;
Spitzer et al., 1993, 1994; Kuperberg et al., 2007) and,
in chronic schizophrenic patients, particularly those
with positive thought disorder, have been associated to
anomalous increases in activity within inferior prefrontal and temporal cortices (Kuperberg et al., 2007).
As for syntactic processing, the speech of patients with
schizophrenia was usually normal, with no relevant
aberrations (Andreasen, 1979; Covington et al., 2005)
even though the uttered sentences were somehow
simplified and characterized by reduced syntactic
complexity (see also Fraser et al., 1986; Morice and
McNicol, 1986; Thomas et al., 1990, DeLisi, 2001).
As to the macrolinguistic dimension of language
processing, the narratives of schizophrenic patients were
less informative and more tangential than those uttered
by the group of comparison participants. Indeed, the
story-descriptions provided by the schizophrenic
patients were barely informative and characterized by
empty speech, filled with semantic paraphasias and,
mostly, by local coherence errors such as the frequent
use of pronouns without antecedents, deictic terms with
no clear referents and frequent derailments that make
their discourse vague and ambiguous. Interestingly,
DeLisi (2001) reports reduced use of clausal embedding
and connectivity between sentences in the narrative
speech of chronic schizophrenic patients noting that the

number of conjoined and embedded clauses was

inversely correlated to poor content. However, in that
case it was not possible to discern whether the reduced
inter-sentential connectivity were linked to an aberrant
use of linguistic devices (which would cause cohesive
errors) or to the lack of conceptual connections between
continguous sentences (local coherence errors). In our
experiment, however, a strong group-related difference
was found in the production of local coherence errors
whereas only slight problems were due to cohesive
disturbances. This suggests that the reduced intersentential connectivity might have been determined by
difficulties in focusing on the connections between the
propositions conveyed by the sentences. Interestingly,
once measures of macrolinguistic discourse processing
(i.e. % Local coherence errors and % Global coherence
errors) have been included in the analysis as covariates,
no differences between schizophrenic and control
participants in the production of % Semantic paraphasias and % Paragrammatic errors were detectable.
This suggests that the lexico-semantic errors produced
by the schizophrenic patients included in the study are
related to more general difficulties in global reasoning
and sequencing as if a general problem in generating a
coherent mental model were responsible for their
semantic confusion. This is also consistent with our
finding of a correlation between Lexical informativeness and Raven's Progressive Matrices '47, which
measures logical reasoning, defined as the ability to
discriminate and perceive relations between any fundamentals, new or old (Cattell, 1943). In the conceptual
stage of message planning, declarative memory provides knowledge not only about what to say, but also
about what has previously been said (linguistic context)
and about the particular situation, place and time
in which the communicative exchange takes place
(Johnson-Laird, 1980; Levinson, 1983). It is assumed
that, during the phase of message planning, a supervisory attentional system (SAS: Green, 1998) is in
charge of controlling the speakers' communicative
intentions and modulating the amount of information
that the speaker intends to communicate as well as its
relevance with respect to what has previously been said
(Grice, 1975). Accordingly, our data show that variance
in Global coherence errors was explained by performance on the Trail Making B task, therefore confirming
our hypothesis that executive (specifically, inhibitory
processing) deficits may be related to difficulties in
conceptual message planning and, at the lexical level,
to selective problems in the process of lemma-level
semantic selection. This is also in accordance with
the dysexecutive model of formal thought disorder in

A. Marini et al. / Schizophrenia Research 105 (2008) 144155

schizophrenia (Barrera et al., 2005). Furthermore,

this finding supports previous reports where the schizophrenic speech disorder was attributed to deficient attention (Docherty et al., 2006). Overall, the present data
suggest that the problems observed at the microlinguistic
level of processing in the schizophrenic group may
reflect more general deficits at the macrolinguistic level,
such as the inability to take into account all available
contextual data and select an adequate mental model.
This latter finding is interesting in light of the hypothesis
that abnormalities within fronto-temporal systems play
an important role in the aetiology and expression of
schizophrenia-spectrum disorders (Woods et al., 2007).
Indeed, in previous studies deficits in context processing tasks have been associated with prefrontal
cortical dysfunction in both medicated and non medicated schizophrenic patients (Wood and Flowers, 1990;
Curtis et al., 2001; Barch et al., 2003; MacDonald et al.,
2005). In particular, on tasks requiring high context
processing demands, MacDonald et al. (2005) found
increased activity in the middle frontal gyrus (Brodmann's area 9) in a group of healthy participants and in a
group of patients with non-schizophrenia psychosis, but
not in the group of patients with schizophrenia.
Some issues have to be considered before the conclusion. Firstly, linguistic problems in schizophrenic
patients treated with psychotropic drugs may be secondary to the treatment. However, re-running each
analysis using antipsychotic drug dosages (in olanzapine
equivalents) as an additional independent variable did
not change the significance of results (data available
upon request). Secondly, because of the cross-sectional
design of the study and the chronic nature of the illness in
the majority of patients we cannot specifically attribute
these linguistic changes to psychosocial, neurodevelopmental or neurodegenerative factors. It must also be
considered that patients and comparison participants
were matched for educational level. Thus, one of the
possible social factors which can influence the linguistic
results was excluded.
In conclusion, the present data suggest that language
production in schizophrenia is impaired at both macro and
microlinguistic levels of processing, with the strongest
indicators being macrolinguistic. Patient's language is
disordered and filled with irrelevant pieces of information
and derailments (Andreasen, 1979). The pragmatic rules
governing local and global coherence structuring are
continuously violated leading to tangential, poor, sometimes even incoherent speech (see also Linscott, 2005).
Such erratic discourse may be linked to the inability to use
pragmatic rules and/or by cognitive deficits involving
factors such as attention (Neuchterlein et al., 2002), and/or

153

action planning, ordering and sequencing (Docherty et al.,

2006; Woelwer and Gaebel, 2002) which are crucial for
efficient discourse processing. Such an impairment likely
reflects prefrontal cortical dysfunction. Further research
is required in order to deepen the cognitive nature of
linguistic performance in schizophrenic patients and its
neuro-anatomical correlates.
Role of funding source
This research was supported by IRCCS Fondazione Santa Lucia.
IRCCS did not have any further role in the study design; in the analysis
and interpretation of the data; in the writing of the report, and in the
decision to submit the paper for publication.
Contributors
Gianfranco Spalletta and Andrea Marini designed the study.
Andrea Marini designed the linguistic protocol, supervised linguistic
assessment and coding, managed the literature search, and wrote
the final version of the manuscript. Gianfranco Spalletta and Carlo
Caltagirone designed the neuropsychological protocol and supervised neuropsychological assessment. Gianfranco Spalletta performed
the statistical analyses and contributed to the interpretation of the
data. Ilaria Spoletini and Giulia Banfi managed neuropsychological
data acquisition and processing. Manuela Ciuffa administered the
linguistic tests. Perla Strom, Ivo Alex Rubino, Pietro Bria, Giovanni
Martinotti, Rocco Boccascino, and Alberto Siracusano coordinated
patient recruitment.
Conflict of interest
No actual or potential conflict of interest including any financial,
personal or other relationships with other people or organizations
that could inappropriately bias their work, is reported by any of the authors.
Acknowledgements
This work was funded by IRCCS Fondazione Santa Lucia. The
authors would like to thank the two anonymous reviewers for their
insightful comments.

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