INT J LANG COMMUN DISORD, MAY–JUNE 2013,

VOL. 48, NO. 3, 320–328

Research Report
Disordered semantic activation in disorganized discourse in schizophrenia:
a new pragma-linguistic tool for structure and meaning reconstruction
Pertti Hella†‡, Jussi Niemi‡, Jukka Hintikka§¶, Lidia Otsa‡, Jani-Matti Tirkkonen‡ and Hannu Koponen†∗
†Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland
‡Linguistics, University of Eastern Finland, Joensuu, Finland
§Department of Psychiatry, School of Medicine, University of Tampere, Tampere, Finland
¶Department of Psychiatry, Päijät-Häme Central Hospital, Lahti, Finland
∗Faculty of Health Sciences, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
(Received September 2012; accepted January 2013)

Abstract
Background: Disorganized speech, manifested as derailment, tangentiality, incoherence and loss of goal, occurs com-
monly in schizophrenia. Studies of language processing have demonstrated that semantic activation in schizophrenia
is often disordered and, moreover, the ability to use contextual cues is impaired.
Aims: To reconstruct the origins and most plausible intended meanings of disorganized discourse sequences in a
clinical interview with a patient with thought-disordered schizophrenia.
Methods & Procedures: We assessed the so-called pragmatic felicity of every turn using a novel tool called the
Overall Comprehensibility of Turn (OCT) Scale. In addition to felicity analysis, all topics and referents of turns
were registered. Three most disorganized discourse sequences from the transcribed interview were chosen for
the thematic and semantic analysis, in which we attempted to reconstruct the structure and meaning of those
sequences utilizing (1) the notion of discourse model extending up to contextual background knowledge, (2) the
(re)occurrence of topical items, together with (3) the knowledge from findings of disordered semantic activation
in schizophrenia.
Outcomes & Results: The linguistic analyses showed that the disrupted sequences were characterized by (1) un-
expected, seemingly irrelevant topic intrusion, (2) pragmatically inappropriate chain of topic extensions, and
(3) fuzzy reference together with disturbed ordering of propositions. The underlying causes seemed to be, re-
spectively, (1) long-term semantic activation of topics, which popped out sporadically along the conversation,
(2) overreliance on lexical–semantic associations, and (3) the inability to sequence the utterances and link them
together using explicit or implicit bridging assumptions necessary to a coherent and cohesive message. All scruti-
nized passages violated the expectations of the addressee in on-line conversation. However, the post-hoc analysis
showed that they contained items which were relevant to the global topic.
Conclusions & Implications: Latent sources, motivations and even meanings, at least to some extent, of seemingly
disorganized utterances can become analysable through linguistic analyses. The results suggest that continuity in
the treatment is essential, because a practitioner who shares background knowledge with the patient has better
opportunities to capture the relevance of the superficially disorganized utterances. Moreover, especially the most
disorganized sequences should warrant thorough attention because they can convey, beneath their unexpected
or obscure surface structure, items which are psychologically important to the patient. The results of this study
should be taken into account in the training of interactional skills of professionals who work with schizophrenia
patients.

Keywords: schizophrenia, clinical discourse, linguistic analysis, Overall Comprehensibility of Turn (OCT) scale,
Finnish.

Address correspondence to: Pertti Hella, Kuopio Psychiatric Center, Kuopio University Hospital, POB 1777, FI-70211 Kuopio, Finland;
e-mail: pertti.hella@kuh.fi
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12011
Reconstruction in disordered discourse in schizophrenia 321

What this paper adds

What is already known on the subject?
As regards to language performance in schizophrenia, descriptions of language production as well as empirical and
neurophysiological studies on language perception are widely available. Individuals with schizophrenia are less able
than normal speakers to inhibit unnecessary semantic activation of consecutively and partially overlapping discourse
topics.

What this paper adds

The present extensive and in-depth case study of conversational discourse with an individual with schizophrenia
shows that a linguistic analysis of uninterrupted long passages of discourse enables one in many instances to uncover
the causes of seemingly unmotivated topics. In other words, the discourse sequence of the patient may be more
relevant and make more sense than the on-site and on-line interpretation by the addressee could show.

Introduction individuals with thought-disordered schizophrenia typ-

Thought disorder is one of the most salient features
in severe forms of schizophrenia. It is characterized by
disorganized discourse (in the case of positive formal
thought disorder) containing more or less frequent in-
stances of derailment, tangentiality, incoherence, loss of
goal or even signs of poverty of speech, the latter be-
ing a typical marker of negative formal thought disorder
(Andreasen 1986). According to Andreasen’s Scale for
the Assessment of Thought, Language and Commu-
nication (TLC) derailment is defined as ‘a pattern of
spontaneous speech in which the ideas slip off the track
onto another one which is clearly but opaquely related
or to one which is completely unrelated’ (Andreasen
1986: 476), while tangentiality refers to verbal responses
which are either only obliquely related or totally unre-
lated to the preceding question. Following Andreasen’s
terminology, derailment and tangentiality are character-
ized by lack of lexical/referential or semantic coherence
between subsequent sentences, whereas incoherence oc-
curs within a sentence or clause. Incoherent speech can
be totally unintelligible due to lexical choices which can
seem totally random from the point of the addressee. In
an instance of losing the goal, the speaker is unable to
follow a chain of thought to its natural conclusion. Loss
of goal occurs often in association with derailment.
As regards the mechanisms underlying disorganized
discourse, deficient processing of context in schizophre-
nia has been demonstrated in several behavioural (Bazin
et al. 2000, Babin et al. 2007, Andreou et al. 2009) and
electrophysiological (ERP) studies (Kumar and De-
Bruille 2004, Ditman and Kuperberg 2007, Kuperberg
2010, Ditman et al. 2011). These and other studies
speak for overactive semantic priming, inability to sup-
press context-inappropriate meanings and overreliance
on semantic memory-based associations. Moreover,
fixation to local coherence or semantic associations of
single words can disrupt the ‘big picture’. In other words,
ically display difficulties in comprehending contextual
cues. In addition, when processing language input, they
may drift away from global meaning due to semantic
associations.
However, empirical studies focusing on language
processing of patients with schizophrenia are most of-
ten restricted to comprehension. Moreover, they take
into account only the immediate co-textual context, i.e.
the context that precedes the target word, phrase or
sentence. In practice, the co-text is restricted to a few
sentences at most. In actual conversations both com-
prehension and production of language are based on
a wider frame: the discourse knowledge is constructed
also on interpersonal background knowledge and gen-
eral background knowledge (van Dijk 1985, Cutting
2008: 3–7).
In discourse we co-construct discourse models which
are not totally compatible with each other as the knowl-
edge stores differ from person to person. In addition,
ambiguous or obscure expressions can lead to misun-
derstandings and thus to diverging models. In terms of
temporal dynamics of discourse, the notion of a dis-
course model refers to the mental representation of on-
going discourse (Giacalone Ramat and Andorno 2006)
where every turn potentially refreshes the context for the
subsequent turns (Drew and Heritage 1992: 18).
The aim is to examine language production of a
patient with schizophrenia in a clinical situation, from
a pragmatic, global perspective. We chose to study
clinical interaction because we wanted to link the
findings of experimental studies with observations from
actual clinical conversations. Moreover, mutual patient–
doctor understanding has seldom been examined, even
though it has a significant role in the assessment of
psychopathology and making decisions about treatment
alternatives. Data from routine outpatient psychiatric
consultations have shown that psychiatrists make more
322
effort to understand patients with schizophrenia when
they rate the patient–doctor relationship more positively
(Themistocleous et al. 2009). In addition, psychiatrists
make less effort to create mutual understanding when
patients experience more symptoms. Swartz and Swartz
(1987) suggest that clinicians should become more
aware of the role they play in eliciting coherent or
incoherent discourse from patients. On the ground of
their results, they argue that adequate contextualization
of discourse can render incoherent speech more
understandable.
The main focus of this study will be on the meaning-
related clashes between the discourse models of the pa-
tient and the doctor, i.e. we aim to unravel the on-line
failures of the doctor’s expectance and understanding,
many of which, however, are expected to be amenable
to a post-hoc linguistic analysis. We hypothesize that
(1) by analysing long stretches of discourse and focus-
ing especially on recurrence of topics and referents, and
(2) by taking into account the various knowledge stores
and discourse models, we can often reveal structure in
the allegedly disorganized speech in schizophrenia. We
base this hypothesis especially on findings that speak for
an abnormally long-term lexical–semantic activation in
schizophrenia (Ditman et al. 2011) and the relative in-
ability of individuals in schizophrenia to inhibit parallel
topics and thoughts (Kiang et al. 2007, Niznikiewicz
et al. 2010).
Methods
Subject description
The subject is a 26-year-old male with schizophrenia;
he was selected due to his long-term doctor–patient re-
lationship with the first author. This was expected to
help in disambiguating the apparently unclear discourse
contributions of the patient. He was previously on cloza-
pine, but this was discontinued because of side-effects.
During data collection, his medication was a combi-
nation of olanzapine and perphenazine. He had been
in hospital treatment several times, the last time over
1 month prior to the interview. He used to live in a
rehabilitation unit, but moved to his own apartment
a few months before the interview. He had had prob-
lems with daily activities. Diagnosis was confirmed with
SCID I interview (First et al. 1995) by the first author.
The transcribed interview also included an assessment
with PANSS (Kay et al. 1988) with the following scores:
positive symptoms, 25/49; negative, 26/49; and general
psychopathology, 46/112, for a total of 97/210. At the
time of the interview the patient suffered from a relapse
of psychosis, and it was considered whether or not he
should be sent to in-patient care.
Pertti Hella et al.
Data collection
The videotaped semi-structured conversation was tran-
scribed at the Department of Linguistics. The patient
gave informed consent; the study was approved by the
local Ethics Committee. The conversation lasted for
25 min and was composed of 122 turns of the patient.
Data analysis
A discourse analytic approach was used to examine the
discourse. Besides that, we applied two basic concepts
of Conversation Analysis: turn and adjacency pair. A
turn is defined as one speaker’s whole sequence not in-
terrupted by the interlocutor (excluding instances of
non-propositional dialogue particles such as ‘uh-huh’ or
minimum feedbacks such as ‘yeah’). In the simplest form
one turn could be one word, e.g. yes or no. Two consec-
utive and semantically linked addressor–addressee turns
(e.g. question–answer) make up an adjacency pair.
In a previous study of discourse in Asperger’s syn-
drome we have shown that analyses focusing on local
features of short passages of discourse cannot handle
phenomena typical in pathological populations (espe-
cially long-term topic resumption; Niemi et al. 2010).
Therefore, we chose to analyse systematically every sin-
gle turn and adjacency pair by paying special attention
to recurring topics and referents.
The starting point was to detect those sequences
that were difficult to comprehend by the addressee (first
author) in the on-line situation. For that purpose, we
developed a rating scale of Overall Comprehensibility of
Turn (OCT), which takes into consideration the three
maxims of the Co-Operation Principle (Grice 1975)
relevant to the analysis, namely the maxims of manner,
quantity and relevance. In other words, structural clarity
(manner) and the amount (quantity) and relevance of
semantic contents are assessed as a whole. The scoring
is based on the viewpoint of the addressee (here, doc-
tor). The post-interview raters are supposed to imagine
themselves in the position or role of the interlocutor
and ask themselves the following questions: Am I able
to understand what the patient is saying and why s/he
is saying what s/he is saying at that specific moment? Is
the content of the utterance in accord with my view of
what we are talking about?
For each turn, an OCT score ranging from 0 to 3
is attributed based on the following criteria: (1) 0 rep-
resents a transparent turn; and the error categories are:
(2) slightly opaque turns (score 1) are somewhat prob-
lematic to understand or they contain unexpected ele-
ment(s) to some degree; (3) deviant turns (score 2) cause
notable difficulties for comprehension due to struc-
tural deficiencies, missing or vague propositional con-
tent or due to unexpected associations of topics and/or
Reconstruction in disordered discourse in schizophrenia
referents; (4) infelicitous turns (score 3) are totally ob-
scure or contain elements which are totally unrelated or
which violate the expectations of the interlocutor (for
examples, see appendix A).
The first 42 turns were assessed by a panel consisting
of three of the authors (P. H., J.-M. T., L. O.), and the
last 80 of the sample turns were independently rated by
four of the authors (P. H., J. N., L. O. and J.-M. T.).
Pearson and Spearman correlation coefficients for the
four of the authors ranged between 0.56 and 0.87. All
the correlation coefficients were statistically significant.
In addition, pair-wise comparisons measured by Mann–
Whitney test did not reach statistical significance preset
at 0.05.
In the second phase we labelled each topic and ref-
erent of the patient’s speech also registering whether a
topic was introduced, reintroduced or maintained by the
patient. Special attention was paid to unexpected intro-
ductions or (re-)occurrences of topical and referential
items. Finally, we tried to grasp the intended meanings
or discourse models of the patient by utilizing the back-
ground knowledge which is shared by the patient and
the doctor.
Using the OCT ratings, we chose three long passages
with the most incomprehensible sequences in the data.
Not unexpectedly, these passages deal with features that
are typical of disorganized speech, namely intrusions of
unexpected topics, exceptional topic extensions, and in-
felicitous ordering of propositions and fuzzy reference.
However, as will be shown, the degree of disorganization
will diminish after linguistic analyses. In other words,
there is more relevant information in discourse produc-
tion in schizophrenia that first meets the eye (or rather,
the ear).
Results
Overall comprehensibility of all turns according to
OCT
The output of the patient consisted of 122 turns, out
of which 19 are not scored due to lack of propositional
content or due to a conversationally fatal interruption
by the co-speaker. In the OCT analysis only half (i.e. 54)
of the 103 turns analysed are transparent, i.e. the kind
one expects to hear one’s co-speaker to produce. Out
of the remaining 49 non-transparent turns of the pa-
tient, 32 are slightly opaque, nine are deviant and eight
are infelicitous. There are three sequences with accumu-
lation of deviant and infelicitous turns, namely turns
from 11 to 14, from 31 to 42, and from 116 to 121.
The focal topics of the first sequence are telepathy and
harassment; the second portion is about names (of peo-
ple and places); and the third about the patient’s future
plans. These three passages will become objects of closer
323
Table 1. Topics of music/lyrics and thinking of words,
telepathy and harassment as ventilated by the patient
Number Music/ Thinking Telepathy/
of turns lyrics about words harassment
5 ×
11 ×a ×(a ) ×
25 ×a ×
44 ×a ×a
46–52 × ×
68 ×(a ) ×
70 ×(a ) ×
Note: a Topic introduction/shift violates the doctor’s expectancy.
scrutiny in the following subsection. In that post-hoc
analysis we aim at capturing those contextual factors that
underlie the online comprehension difficulties. Follow-
ing our methodological principles we reconstructed the
most plausible discourse model underlying the patient’s
aberrant contribution using the prior co-texts, shared
patient–doctor and general background knowledge.
The three most disorganized sequences
Unexpected topic intrusions
Topics of telepathy/harassment, music/lyrics and think-
ing of words/speaking aloud co-occur in different com-
binations throughout most of the sample (table 1). The
contents give a definite impression that these topics are
essential elements of his psychotic experiences. Although
the lyrics in the song cited by the patient (Excerpt 1)
are associated with telepathy, the topics of music and ha-
rassment also intrude into the conversation. In addition,
the unexpected statements about thinking of what to say
and speaking aloud are also, to say the least, perplexing
from the point of the interlocutor. The topic of music,
introduced by the patient five turns earlier in turn 5, was
not any more active in the addressee’s discourse model.
Moreover, after turn 11, the patient reintroduces mu-
sic and lyrics several times unexpectedly. Music/lyrics
thus seems to be an intrusive or interpenetrating topic
(Noël-Jorand et al. 1997, McKenna and Oh 2005: 6).
The first disrupted passage culminates in turn 11
(OCT score = 2), where the patient unexpectedly re-
introduces music (Excerpt 1). The excerpts are here
given in their ‘fluent’ English equivalents with, for in-
stance, deletion of irrelevant hesitation markers and
signs of overlapped speech. Authors’ clarifying com-
ments are in brackets:
(1)
Doctor: Your mother has told me that you feel that they
[referring to patient’s paranoid experiences] don’t leave
you alone.
Patient: No, they don’t. Well, as J. Karjalainen [a
Finnish pop musician] sings in his song: ‘Do you
324
remember when we played around with telepathy.’ I
don’t know exactly what telepathy means. But maybe
I believe in it a little. But, also my mother has to be-
have herself, but . . . she is sometimes discourteous in
her words and she can be a bit rude. It may be the case
that I’m the kind of person that speaks aloud a lot and
thinks a lot what to say and so . . . .
The present findings yield two kinds of possible, non-
mutually exclusive, mechanisms underlying the disrup-
tion of discourse. (1) In his turn, the topic of music
has sustained its semantic activation in the patient’s
discourse model and intrudes into the conversation.
In the subsequent passages the topic of music con-
tinues to be active and pops sporadically into con-
versation causing tangential and derailing expressions.
(2) The present passage contains elements of the pa-
tient’s psychotic schemas, which are relevant to the
global topic, but which the patient expresses fragmentar-
ily without constructing a coherent narrative. Whatever
the cause, it remains that the patient fails in building
up the necessary narrative bridges between the topics
of telepathy/harassment, music/lyrics and thinking of
words/speaking aloud.
Exceptional topic extensions
The second disrupted passage (Excerpt 2) is character-
ized by gradual and radial topic extensions. The passage
is initiated by a tangential expression (turn 31, OCT
= 2): when asked about special gifts, the patient tells
the doctor how he is been laughed at and harassed be-
cause of his name. This could be caused by sustained
activation or impaired inhibition of the previous topic
relating to the patient’s experiences of being harmed by
others (30, OCT = 1). In addition, there are reference
inaccuracies here, e.g. it remains unclear whether the
‘sacred relic’ is his first name, family name or something
else. The gradual, radial extension of topics is the most
infelicitous feature in this sequence:
(2)
Doctor: Has anybody else ever tried to harm you or
tried to lead you to any kind of trouble?
Patient (30): Well, I have not thought about that . . . but
not [they have not led] me . . . . I have seen harm done
and stuff, but people, those guys, let me be physically
and mentally on my own . . .
Doctor: Have you ever felt you would be especially
important or that you would have abilities that no one
else has?
Patient (31): Well, it’s only that my name is John [al-
tered], which happens to be the kind that others are
laughing at. They are laughing right to my face, and
then . . .
Doctor: Why would they laugh at the name John?
Pertti Hella et al.
Patient (32): Well, in some way that John that you
har-har
Doctor: What does John mean?
Patient (33): Well I don’t know John [aborted sentence]
probably . . . it refers to me and that a bit har-har and
so on.
Doctor: I can’t quite understand. Can you tell what it
is . . .
Patient (34): Then on the other hand . . .
Doctor: Uh-huh.
Patient (35): [shifting abruptly to his family
name] . . . there are those X-ers [X-er referring to people
from area X, like New Yorker. X-er used here is also pa-
tient’s family name] from Y [province capital] but yeah.
As a joke, I kind of imagine that it [obscure, which
name/location?] is a kind of sacred relic that I should
not be teased for that [laughs].
Doctor: Do you mean that..
Patient (36): Yeah.
Doctor: . . . that your name is a relic.
Patient (37): Or my family name X-er is one, since I
am one [i.e. an inhabitant of province X bearing the
province name].
Doctor: Yeah, what does it mean . . .
Patient (38): Well . . .
Doctor: . . . that it is a relic.
Patient (39): Well, it occurs to me all the time that
X is the town [literally: municipality] [erroneous state-
ment, confusion of province and hometown names].
It’s definitely the town that is called X [erroneous state-
ment repeated with emphasis] which is always seen on
the [television] news . . . rolling [makes rolling gestures
with arms]
Doctor: Yeah.
Patient (40): X, yes. [Yawning] Well, I also do have
other names.
Doctor: What names?
Patient (41): I’d rather be some Marko, damn it, if I
could myself decide upon taking a name.
Doctor: Why would you change your name?
Patient (42): Well I don’t know. It only occurred to me
that it could be cool to be Marko, if not anything else,
damn it.
The topics in the long passage spanning turns 31–42
can be summarized as follows. The patient’s first name
gives rise to mentioning inhabitants of his hometown
province (35, OCT = 3). This shift is reinforced by
the patient’s family name being the adjectival form of
the province name, meaning ‘inhabitant of and/or orig-
inating from province X’. This state of affairs leads to
the province capital. At this juncture he makes an un-
expected move as he introduces sacred relics. However,
this apparent leap can be post hoc motivated by the fact
that both relics and he himself (his name) are some-
how protected or in need of protection. This step is
followed by another unexpected topic shift from the
relic to his family name (‘inhabitant of province X’) (37,
OCT = 2), from which we move into the sphere of
Reconstruction in disordered discourse in schizophrenia
town/municipality as seen on television (most probably
in weather forecasts) (39, OCT = 3). Finally, inspired
by the doctor, the area of first names, not merely that
of his own, becomes totally open for discussion, and
he does eventually mention Marko as his potential new
first name. The reason here could be that this new name
would most probably not become a target of ridicule
and harassment (31).
All the shifts of this passage (except ‘sacred relic’)
derive from lexical–semantic associations, but the as-
sociations are here pragmatically irrelevant, resembling
manifestations of stream of consciousness. As a whole,
the patient’s turns lack global coherence. The gradual
derailment shifts the focus from personally meaningful
items (being harassed because of the first name) to more
remote or general topics (weather forecast maps). How-
ever, the patient closes this passage by expressing his
thoughts about changing his name, and thus he returns
to the more personal level.
Disturbed linear order of propositions and fuzzy reference
The third disorganized passage is characterized by a
lack of linear organization of topics and by instances
of fuzzy reference (Excerpt 3). The latter is demon-
strated through instances of unexpected lexical choice
like some people/they (turn 118, OCT = 3), and they
(116, OCT = 3, and 118). It is thus no wonder that
the doctor specifically asks the patient to specify the
reference of ‘they’ after turns 116 and 118. Moreover,
the patient ignores the psychiatrist’s requests for more
specific information about whom he is talking, thus
eventually producing tangential responses. Due to this
impaired referential cohesion and missing links between
propositions, i.e. tangentiality, the addressee cannot in-
tegrate the contents of this discourse sequence into his
own discourse model. From the psychiatrist’s in situ
view the patient seems to lose his goal. This passage is
activated with the doctor’s question about the patient’s
future plans:
(3)
Patient (116): I’ve been thinking about those
that . . . going to work I’m always thinking about. Then
some people, well they are stars and the like, they play
soccer and we then watch, or they watch it and such
like that.
Doctor: Yes, who are watching?
Patient (117): Trades/professions I kind of think about.
Doctor: Uh-huh.
Patient (118): They are a bit like a group of their own
and such. They are jobless.
Doctor: Uh-uh, who are you talking about now?
Patient (119): Well, I’m thinking about these kind of
things. My father works at the city water works. Workers
come to my mind sometimes.
325
Doctor: Yeah.
Patient (120): That’s it. Well, that I would want to
be a bit better educated, but I am not. Then I am not
extremely clever, perhaps. In a way that sometimes, well
yes, I do watch something. A group of people can come
up with wise things but . . . things are not like that now.
Doctor: Yes. What . . .
Patient (121) [yawning] Well, I do have a trade school
diploma.
After discussing work (turn 116) the patient abruptly
introduces (social) stars and soccer players (turn 116).
The latter may have been activated by the fact that he
plays soccer with his father. Soccer, being a spectator
sport, introduces the topic of watching, which is unex-
pectedly dropped at the expense of trades/professions,
probably supported by the topic of future plans. As
top-level soccer players are professionals, they are in the
classical sense ‘jobless’ — a topic that is mentioned in
turn 118. The topic of work is another bridge to his
father and especially to his father’s work (119, OCT =
3). From father’s work we jump back to his future plans,
and there to his lack of education and intelligence (120,
OCT = 3). Before finishing he makes a strange, quick
and condensed recourse back to the notions of ‘watch-
ing something’ and collectives (perhaps soccer teams)
‘coming up with wise things’ (120). Finally, considering
his future, lost prospects and work, he finishes off by
mentioning his trade school diploma.
In sum, when reconstructing the prior co-text and
background knowledge, we find that the superficially
disorganized passage contains topical items that appear
relevant from the view of the patient’s concerns and
from the view of the main topic — his plans about the
future. The topics of working ability, membership in
social groups, comparison of his own achievements and
intellectual ability to those of others, and his relation-
ship to father, seem to be important to the patient and
appropriate issues per se.
Discussion
We examined a clinical conversation with a patient with
schizophrenia using a discourse analytic approach where
we chose a long passage of discourse and analysed it in
depth. Using a new rating tool for quantifying the prag-
matic felicity of each turn, we chose three qualitatively
different sequences that challenged the discourse model
of the addressee (i.e. that of the psychiatrist) the most.
These sequences contained language disruptions typical
of positive-state schizophrenia, namely, intrusions of un-
expected topics, exceptional topic extensions, and infe-
licitous proposition ordering and fuzzy reference. It is of
interest that these pragmatic failures were not evenly dis-
tributed throughout the patient–doctor conversation,
but appeared in more or less self-contained chunks.
326
Topics understandably important to the patient (here:
hobbies/music, harassment [through names], [lack of]
work) thus seem to trigger and over-activate distantly re-
lated topics thus resulting in failures in inter-subjective
understanding.
The sequence of seemingly unexpected topic intro-
duction (Passage 1) contained an intrusive expression
coupled with derailment and with only loose connec-
tions to the preceding and subsequent discourse. How-
ever, an analysis of background knowledge and co-
textual links revealed that the intrusive utterance was
not as irrelevant as it seemed to be in the on-line situa-
tion. In fact, it appears that the patient’s utterance rep-
resented a constantly active and sporadically activated
topical item (of music) and conceptual schemas that co-
occurred with it (Kiang et al. 2007, Niznikiewicz et al.
2010). The links of these items were not active in the
addressee’s discourse model.
The second highly unintelligible passage with its de-
railment (Passage 2) was shown to be due to overreliance
on semantic associations, which eventually blurred the
construction of a coherent global picture (‘gist’) of the
discourse (Ditman and Kuperberg 2010, 2011, Ku-
perberg et al. 2010). Here the concepts of the imme-
diate context activated semantically related concepts,
which caused, due to failures in inhibiting irrelevant
competing associations, thoughts and meanings, prag-
matically irrelevant associations, eventually verbalized
by the patient. Referring to (philosophical) semantics
one can say that speakers with schizophrenia are less
constrained than normals in using the Wittgensteinian
notion of family resemblance, in which the periph-
eral (non-prototypical) areas of the semantic fields of
closely semantic associates (concepts, words) overlap in
the conceptual/semantic space (Wittgenstein 1953: 66–
71). Related to this, cognitive semantics tells us of radial
extensions of categories in which chains of concepts
overlap and one can mentally move from one seman-
tic area to another using these radial linkages (Lakoff
1987). Thus, in broad terms, some of the unrelated as-
sociations encoded in language in schizophrenia may not
qualitatively be different from semantic associations of
normal language. It may just be the case that a speaker in
schizophrenia does not bridge the links in an expected
manner through language. In other words, his bridg-
ing assumptions are based on lexical–conceptual links
that are too implicit, extensive or complicated from the
viewpoint of a co-speaker.
The remaining seemingly unintelligible sequence
(Passage 3) carried instances of obscure reference. There
were several instances of fuzzy reference and infelicitous
proposition ordering. Lack of referential cohesion has
been a well-documented disturbance in schizophrenia
since the research of Rochester and Martin (1979) and
Cohen and Docherty (2004). It has been emphasized
Pertti Hella et al.
by, for example, Thomas (1995) that lack of hierarchical
organization is an underlying factor of deficient coher-
ence. However, as we have shown, an off-line analysis
may locate the states of affairs about which the patient
is speaking. Thus, in terms of semantics, we often deal
with instances of fuzzy reference only, i.e. with referential
expressions that would in principle be recoverable given
some added information and structure to the discourse.
The strength of this study is that it attempts to take
into account the mutual construction of discourse and
the entire context of clinical interaction. We chose to
use a tool (OCT) developed by us to measure the prag-
matic felicity of the patient’s utterances. The strength
and weakness of OCT is to be found in one and the
same aspect. It looks at discourse from the point of the
addressee: can s/he achieve the contents of the patient’s
utterances and can s/he find aspects of relevance from
the contents during the on-line interaction? Thus, OCT
can be argued to be subjective. To diminish the effects
of subjectivity, we used a panel of raters, one of them
being the psychiatrist in charge and the addressee in the
original conversation. In addition, the majority of the
patient’s turns were rated independently by the raters in
order to measure the inter-rater reliability. The results
showed that the psychiatrist’s assessments did not differ
from those of the other raters, who were professional lin-
guists. In other words, statistically speaking, the panel
was unanimous in its decision.
The study is based on a single case and thus the
results cannot be extrapolated as such. However, we
demonstrate that different instances of disorganized dis-
course may have different underlying mechanisms and
that they may convey meanings related to the patient’s
personal life. The least is that the results suggest that each
occurrence of disorganized discourse should be consid-
ered as a phenomenon of its own.
The results yield three major clinical implica-
tions. Firstly, thought disorder or disorganized discourse
should not be seen as a separate entity involving language
competence only. Above all, it is a matter of pragmatic
performance, including not merely language, but also
the extra-linguistic context and world–mind–language
interfaces. This means that contextual factors affect its
appearance; in certain circumstances the utterances are
clear and comprehensible, in some others they are not.
Thus, the results corroborate with the interpretation of
Swartz and Swartz (1987). In a clinical setting the goal
should thus be to co-create such a discourse that would
foster mutual understanding in spite of the patient’s de-
ficient competence.
Secondly, it could be claimed that it is often the
most peculiar utterances that ought to deserve the most
persistent attention, as they may contain psychologically
important and relevant items. It could thus be argued
that in order to understand the world of the patient
Reconstruction in disordered discourse in schizophrenia
the different types of disruptions are of different value.
It is probable that pure co-textual derailment, which
is based on overreliance on semantic associations, does
not include a great amount of important information.
Instead, an accumulation of several related items that
resonate with the inter-subjective background knowl-
edge warrants a thorough examination. It could be asked
whether additional conversations with structured ques-
tions could help patients to organize their propositions
in a coherent manner. Furthermore, it would be rel-
evant to see whether patients could clarify their links
of linguistic reference in such a setting? Finally, the se-
quences that draw upon themselves several recurrently
reintroduced topics, in spite of their unexpected formu-
lation, could well be the most amenable to elaboration,
because these persistently re-occurring topics most cer-
tainly convey meanings that are of high significance to
the patient.
Thirdly, the results emphasize the importance of
continuity in treatment. Mental health workers who
have shared background knowledge with their patients
have richer resources for (re)construction of meanings
from disorganized discourse.
As a conclusion, the present results indicate that
disorganized discourse is not merely a consequence of
thought disorder of a schizophrenia patient. Rather,
it should be regarded as a phenomenon of mutual
interaction with possible divergent discourse models.
A mental health professional should be especially alert
when s/he ‘does not get it’. The instances of apparent
misunderstanding can be the ones that necessitate
an investigation into their linguistic meaning and
communicative relevance.
Acknowledgements
This research was financially supported by the following sources, i.e.
grants awarded to the second author: by a grant from the Finnish
Cultural Foundation (2011), and by a grant from the Strategic,
Innovative Research Initiative Funding of the University of Eastern
Finland (2011). The authors would like to thank Amélie Achim
for her insightful comments on a pre-final version of the paper;
and Alexandre Nikolaev for his help with statistics. Declaration of
interest: The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the paper.
References
ANDREASEN, N. C., 1986, Scale for the Assessment of Thought, Lan-
guage and Communication (TLC). Schizophrenia Bulletin,
12, 473–482.
ANDREOU, C., TSAPKINI, K., BOZIKAS, V. P., GIANNAKOU, M.,
KARAVATOS, A. and NIMATOUDIS, I., 2009, Effects of sen-
tence context on lexical ambiguity resolution in patients with
schizophrenia. Neuropsychology, 47, 1079–1087.
327
BABIN, S. L., WASSEF, A. A. and SERENO, A. B., 2007, Schizophrenic
patients exhibit hyper-reflexity in a semantic categorial prim-
ing task. Journal of Neurolinguistics, 20, 197–220.
BAZIN, N., PERRUCHET, P., HARDY-BAYLE, M. C. and FELINE, A.,
2000, Context-dependent information processing in patients
with schizophrenia. Schizophrenia Research, 45, 93–101.
COHEN, A. S. and DOCHERTY, N. M., 2004, Affective reactivity of
speech and emotional experience in patients with schizophre-
nia. Schizophrenia Research, 69, 7–14.
CUTTING, J., 2008. Pragmatics and Discourse, 2nd edn (London:
Routledge).
DITMAN, T., GOFF, D. and KUPERBERG, G., 2011, Slow and steady:
sustained effects of lexico-semantic associations can mediate
referential impairments in schizophrenia. Cognitive, Affective,
and Behavioral Neuroscience, 11, 245–258.
DITMAN, T. and KUPERBERG, G. R., 2007, The time course of build-
ing discourse coherence in schizophrenia: an ERP investiga-
tion. Psychophysiology, 44, 991–1001.
DITMAN, T. and KUPERBERG, G. R., 2010, Building coherence: a
framework for exploring the breakdown of links across bound-
aries in schizophrenia. Journal of Neurolinguistics, 23, 254–
269.
DREW, P. and HERITAGE, J., 1992, Analyzing talk at work: an in-
troduction. In P. Drew and J. Heritage (eds), Talk at Work,
Interaction in Institutional Settings (Cambridge: Cambridge
University Press), pp. 3–65.
FIRST, M. B., SPITZER, R. L., GIBBON, M. and WILLIAMS, J. B. W.,
1995, Structured Clinical Interview for DSM-IV Axis I Disor-
ders (SCID) (Washington, DC: American Psychiatric Press).
GIACALONE RAMAT, A. and ANDORNO, C. M., 2006, Referential
relations in spoken discourse. In K. Brown (ed.-in-chief ),
Encyclopedia of Language & Linguistics, 2nd edn (Amsterdam:
Elsevier), pp. 450–457.
GRICE, H., 1975, Logic and conversation. In P. Cole and J. L. Morgan
(eds), Syntax and Semantics, Vol. 3: Speech Acts (New York,
NY: Academic Press), pp. 41–58.
KAY, S. R., OPLER, L. A. and LINDENMAYER, J.-P., 1988, Reliability
and validity of the positive and negative syndrome scale for
schizophrenics. Psychiatry Research, 23, 99–110.
KIANG, M., KUTAS, M., LIGHT, G. A. and BRAFF, D. L., 2007,
Electrophysiological insights into conceptual disorganization
in schizophrenia. Schizophrenia Research, 92, 225–236.
KUMAR, N. and DEBRUILLE, J. B., 2004, Semantics and N400: in-
sights for schizophrenia. Journal of Psychiatry and Neuroscience,
29, 89–97.
KUPERBERG, G. R., 2010, Language in schizophrenia. Part 2:
What can psycholinguistics bring to the study of schizophre-
nia . . . and vice versa? Language and Linguistics Compass, 4,
590–604.
KUPERBERG, G. R, KREHER, D. A. and DITMAN, T., 2010, What
can event-related potentials tell us about language. and per-
haps even thought, in schizophrenia? International Journal of
Psychophysiology, 75, 66–76.
LAKOFF, G., 1987, Women, Fire, and Dangerous Things: What Cat-
egories Reveal About the Mind (Chicago, IL: University of
Chicago Press).
MCKENNA, P. and OH, T., 2005. Schizophrenic Speech. Making Sense
of Bathroots and Ponds that Fall in Doorways (Cambridge:
Cambridge University Press).
NIEMI, J., OTSA, L., EVTYUKOVA, A., LEHTOARO, L. and NIEMI, J.,
2010, Linguistic reflections of social engagement in Asperger
discourse and narratives: a quantitative analysis of two cases.
Clinical Linguistics and Phonetics, 24, 928–940.
NIZNIKIEWICZ, M., SINGH, M., MITTAL, M., NESTOR, P. G. and
MCCARLEY, R. W., 2010, Abnormal inhibitory processes in
328
semantic networks in schizophrenia. International Journal of
Psychophysiology, 75, 133–140.
NOËL-JORAND, M. C., REINERT, M., GIUDICELLI, S. and DASSA,
D., 1997, A new approach to discourse analysis in psychia-
try, applied to a schizophrenic patient’s speech. Schizophrenia
Research, 25, 183–198.
ROCHESTER, S. and MARTIN, J. R., 1979, Crazy Talk: A Study
of the Discourse of Schizophrenic Speakers (New York, NY:
Plenum).
SWARTZ, S. and SWARTZ, L., 1987, Talk about talk: metacommentary
and context in the analysis of psychotic discourse. Culture,
Medicine and Psychiatry, 11, 395–416.
THEMISTOCLEOUS, M., MCCABE, R., REES, N., HASSAN, I., HEALEY,
P. G. and PRIEBE, S., 2009, Establishing mutual understand-
ing in interaction: an analysis of conversational repair in psy-
chiatric consultations. Communication and Medicine, 6, 165–
176.
THOMAS, P., 1995, Thought disorder or communication disorder.
Linguistic science provides a new approach. British Journal of
Psychiatry, 166, 287–290.
VAN DIJK, T. A., 1985, Semantic discourse analysis. In D. Schiffrin,
D. Tannen and H. E. Hamilton (eds), Handbook of Dis-
course Analysis, Vol. 2 (London: Academic Press), pp. 103–
136.
WITTGENSTEIN, L., 1953, Philosophical Investigations (New York,
NY: Macmillan).
Appendix A: Examples of error categories in
the OCT classification
(1) Slightly opaque turns (OCT score 1): in the follow-
ing the doctor is interviewing the patient about telepa-
thy. (All examples are translated into English deleting ir-
relevant repetitions, hesitation markers, lexical searches,
etc. of the original Finnish. Authors’ comments are given
in brackets.)
Pertti Hella et al.
Doctor: But what does it mean in practice? I mean,
do you receive some messages with your head, or what
is it?
Patient: Well, I don’t know, there’s just, there are no
thoughts, the kind that, it’s not.
In this excerpt the main problem is an obscure
propositional content. It remains uncertain whether the
patient had had experiences of telepathy.
(2) Deviant turns (OCT score 2): the doctor has
asked the patient about possible special gifts in order to
probe into grandiose thoughts according to the SCID I
interview:
Patient: Well, it’s only that the name is John [altered],
which happens to be the kind that others are laughing
at. They are laughing right to my face, and then . . . .
Here the most salient disruption relates to tangential
response. In other words, the topic introduced by the
patient seems not to relate at all to the expectations of
the psychiatrist.
(3) Infelicitous turns (OCT score 3): also in this
excerpt the disruption is preceded by a question con-
cerning special talents (or grandiose thoughts):
Patient: Well, I do not have them very
much . . . . Sometimes when I listen to something at
home . . . music, then I will go through in my mind
words and everything that . . . . These are kind of ter-
rifically good-hearted . . . lyrics/words of songs . . . . My
second cousin is a musician, with a kind of dreadlocks,
that . . . .
Here the propositional content is clearly conveyed
but it totally violates the expectations of the addressee.
It diverges from the above-mentioned excerpt in that
aspect that the patient continues on shifting the topic
even further.