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Language and
Schizophrenia
Schizophrenia is one of the most enigmatic mental disorders, and language is one
of its most essential and distinctive traits. Language and Schizophrenia provides a
complete overview of schizophrenic language, utilising both psychological and
philosophical perspectives to explore the unique way language impacts on this
mental disorder.
Language and Schizophrenia investigates specific features of schizophrenic lan-
guage using cognitive psychology alongside the opposing field of phenomeno-
logical psychiatry, concluding that neither of these approaches fully succeeds in
explaining the linguistic features unique to schizophrenia. Cardella’s innovative
approach of combining psychological perspectives with philosophy offers a direct
alternative to traditional cognitive perspectives, emphasising the fundamental
role that language plays in the disorder.
This book provides a thorough analysis of the deep link between language
and schizophrenia and will be of great value to researchers and postgraduates
studying schizophrenia, phenomenology, neuropsychology and philosophy of
language.
Valentina Cardella
First published 2018
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2018 Valentina Cardella
The right of Valentina Cardella to be identified as author of this work
has been asserted by her in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other
means, now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested
Acknowledgments ix
Introduction 1
2 Language in schizophrenia 18
Grammar and syntax 18
Semantics 22
Speech disorganisation 26
Pragmatics 31
Non-literal use of language 34
References 89
Index 105
Acknowledgments
I would like to express my gratitude to the many colleagues and friends who have
helped me along.
Thanks to Antonino Pennisi, my mentor, who introduced me to the intrigu-
ing world of psychopathology of language. Special thanks to Alessandra Falzone,
Amelia Gangemi, and Francesco Paolo Tocco for their priceless support, and
most of all for their precious friendship. Thanks also to Franco Lo Piparo, with-
out whom I would never have developed a passion for the philosophy of lan-
guage. I am also grateful to all the colleagues of the Department of Cognitive
Sciences, who make my job at the University of Messina a very pleasant one.
Special thanks to Ceri McLardy for her interest in my book, and to Anna
Cuthbert, Hannah Kingerlee, and the crew at Routledge. Two anonymous ref-
erees made helpful comments on my proposal and have been supportive of the
project; I am grateful to them.
Last and most important: thanks to my husband, my parents, and my brother
for their constant support and encouragement in any aspect of my life.
Introduction
This book is an enquiry about language and schizophrenia and aims to show how
language contributes to the unique features of this mental disorder. In order to
investigate the specific features of schizophrenic language, I compare two differ-
ent approaches: cognitive psychology, on one hand, and phenomenological psy-
chiatry, on the other. My opinion is that, even if these theories can account for
some specific features of this kind of language, they are not able to identify single
impairments that can explain the entire schizophrenic language. Moreover, the
two approaches, admittedly very different, agree in considering schizophrenic
language as something that is not important per se, but as a simple reflection
of what happens to other levels (the broader cognitive one for the cognitive
approach, or the Lebensform for the philosophical one).
Yet, when we give voice to schizophrenic patients, they have a completely
d ifferent opinion of the role of language in their mental disorder. They seem to be
perfectly aware that language is a sort of natural fuel for their disease. Adam, for
example, is a paranoid schizophrenic who tells his story in the First Person section
of the American journal, Schizophrenia Bulletin. According to him, in order to un-
derstand what it is like to be a schizophrenic, the reference to W ittgenstein’s no-
tion of a linguistic game can be useful (Wittgenstein, 1953). This notion means
very different things: for example, telling a joke, asking, begging, promising,
and so on are different linguistic games because they are distinct ways to use a
proposition. Teaching the meaning of a term by the ostensive definition is a kind
of linguistic game too: while saying a word, I point at the c orresponding object,
so that the person listening to me can understand the reference of that term.
Wittgenstein remarks that linguistic games can only have sense in the context
of a common life form. In other words, to speak one language implies someone
to talk to (a social net) and also implies a background of shared actions, activ-
ities, and habits; this background is essential for every linguistic game and for
2 Introduction
Adam is like a child discovering language for the first time: a whole world of
potential meanings opens up, but since he is an adult already full of language,
this opening has dangerous effects, because everything can be seen as a coded
message once the conversations are examined in terms of linguistic games.
Moreover, in this case, language really hurts: it is through the conversations
that Adam’s persecution is committed. Language is what makes him feel alone,
derided, humiliated, and unhappy.
I want to report here another passage of Adam’s story that I think is particularly
important.
Thanks to his experience and to what he learned talking with other people
suffering from mental illness, Adam comes to the conclusion that being obsessed
with language is a common problem. People that are mentally ill are all lost in a
world of language games, as if they were locked up by language, together fasci-
nated and paralyzed by its infinite possibilities of signification (see the idea of the
limitless noetic field in Pennisi, 1998).
This book is in line with Adam’s thesis. The basic idea is that language plays a
fundamental role in the schizophrenic Lebensform. The analysis of schizophrenic
language cannot reduce to a simple description of how language changes in this
mental disorder, but implies questioning the deep link between language and
4 Introduction
existence, and the inseparable connection between language and human sociality.
The specific features of schizophrenic language have been highlighted for their
oddity since the first descriptions of schizophrenia as a separate syndrome, and
they keep on challenging psychiatrists and psychologists. Even if schizophrenic
speech is so peculiar that it can be considered the grounds for that early feeling
that allows also non-experts to perceive schizophrenia (Rümke, 1941), the actual
nature of the impairment underlying schizophrenic language has not been dis-
covered yet. The hypotheses, as we will see throughout the book, are varied and
single out very different capacities, like semantic memory, mentalising abilities,
and executive functions. But, the results of this kind of research appear to be
absolutely unsatisfactory; none of these theories seem able to identify the core
deficit that explains all the peculiarities of schizophrenic language.
Yet, language is one of the most important fields to understand s chizophrenia.
We cannot explain this complex and enigmatic mental disorder by putting
aside the peculiar way it affects and modifies language. People who, despite be-
ing schizophrenic, preserve the clarity of mind to analyse the disease from the
inside—people like Adam—testify to the linguistic nature of schizophrenia.
This is the reason why, even if the schizophrenic semantics and pragmatics’ core
is still unclear, it is still worth trying to explore this issue.
1
The enigma of schizophrenia
Schizophrenia in history
Is it possible to trace a history of schizophrenia? The answer to this question, as we
are going to see, depends on what we intend for both ‘history’ and ‘schizophrenia’.
Let us start by saying that if we want to know who was the first patient universally
recognised as schizophrenic, we have to look to Illustrations of Madness, by Haslam
(1810). Here we can find Patient Zero of modern psychiatry: James Tilly Matthews
(Jay, 2003). His case, described in detail by J. Haslam, the resident apothecary at
Bethlem (the London psychiatric hospital), can be considered the first genuine
example of schizophrenia in history.
In the year 1830, I was unfortunately deprived of the use of reason. This
calamity befell me about Christmas. I was then in Dublin. The Almighty
allowed my mind to become a ruin under sickness delusions of a religious
nature, and treatment contrary to nature. My soul survived that ruin.
(Perceval, 1840: 3)
In this case too, the self-description of the disease leaves no room for doubt. A
world dominated by voices and hallucinations, like that of Perceval, is undoubt-
edly a real portrait of schizophrenia.
Only a short time before I was confined to my bed I began to hear voices,
at first only close to my ear, afterwards in my head, or as if one was
whispering in my ear, or in various parts of the room. These voices I
obeyed or endeavoured to obey, and believed almost implicitly. [...] These
voices commanded me to do, and made me believe a number of false and
terrible things.
(Perceval, 1840: 265)
Yet, why do we begin a history of schizophrenia starting from such recent cases?
Must one infer that this mental disorder is a modern invention, a sort of by-
product of our society? Actually, we have no reason to cast doubt to the fact that
schizophrenia (a ubiquitous disease, present with the same prevalence all over the
world) always existed. However, writing a history of schizophrenia seems to be
really hard work for a number of reasons.
First of all, many attestations preceding those reported here are indirect,
and this makes the diagnosis much harder. On what grounds could we say
without a doubt that Joan of Arc or Henry VI were schizophrenic? Second,
schizophrenic symptoms are so different and sometimes so subtle that they are
much more d ifficult to find in the descriptions by ancient authors. The same is
not valid for depression or mania, for example: disorders characterised by symp-
toms that are homogeneous and clearly recognisable (Stone, 2006). Moreover,
as claimed by the same Stone, ‘observers in earlier times seldom paid attention
to characteristics that are now considered crucial to the diagnosis of schizophre-
nia, and they often paid close attention to details that we regard as irrelevant’
(Stone, 2006: 2). S chizophrenia is a very complex disorder that not only e xhibits
very d ifferent symptoms, but that also changed some of its expressions over
The enigma of schizophrenia 7
to be when we deal with schizophrenia, the symbol par excellence of mental illness,
which in addiction is difficult to define in an objective and unambiguous way?
By underlying these caveats, I do not mean to deny the existence of
schizophrenia. Though it seems a disease very hard to comprehend, it is a fact
that one per cent of the world’s population shows symptoms that appear the
same all over the world and that affect quality of life in a crucial way, even
with cultural differences taken into account. For this reason, it is now time to
take a closer look at this disease, beginning from its history (in the meaning
we specified at the beginning of this paragraph) and starting from nineteenth-
century psychopathology.
mood disorders; in this form, both delusions and hallucinations remain more
or less unchanged during the illness’s course, while in the other subgroups
they tend to disappear with time.
Beyond each subgroup’s specific features, the German psychiatrist sees
a basic unity grounded in the outcome that is, for all three forms, mental
deterioration. This unity of course and outcome brings Kraepelin to believe
that there is a unique underlying process of a cerebral kind (‘the disease appar-
ently develops on the basis of a severe disease process in the cerebral cortex’;
K raepelin, 1902: 219); thus, dementia praecox, as highlighted by Stone (2006),
is still considered a degenerative pathology, and the term used by Morel to
indicate an organic disease seems appropriated to identify it. The degenerative
outcome of dementia praecox also helps Kraepelin to separate this syndrome
from manic-depressive psychosis. Despite some overlap in symptoms between
the two psychoses, the outcome of manic-depressive psychosis is b elieved
favourable, while Kraepelin points out several times that schizophrenia is a
chronic illness. In 1902, Kraepelin says that ‘dementia praecox is the name
provisionally applied to a large group of cases which are characterised in com-
mon by a pronounced tendency to mental deterioration of varying grades’
(Kraepelin, 1902: 219). In 1905, he restates that ‘experience shows that an
incurable mental infirmity is by far the most frequent result of dementia
praecox’ (Kraepelin, 1905: 28). As noted by Woods (2011), the striking image
that Kraepelin uses when he talks about schizophrenia is that of a ‘mental
shipwreck’ (Kraepelin, 1902: 241, 275), some sort of catastrophe that tears
the subject down and inexorably obscures feelings, understanding, and acting.
There is no doubt that this catastrophist view of dementia praecox alimented
schizophrenia’s negative myth that under some respects endures to the present
day, because it characterised this disorder since its first identification in terms
of incurability and progressive and fatal deterioration.
In the successive editions of his Textbook of Psychiatry, Kraepelin often refers
to four groups of symptoms in order to identify schizophrenia. According to
the German author, these symptoms are delusions, hallucinations, disturbances
in thought, and disturbances in behaviour. Actually, in addition to the symp-
toms’ descriptions, Kraepelin also tries to distinguish between main symptoms
and secondary ones. As we will see later, subsequent psychiatrists will move
away from Kraepelin, not for the identification of schizophrenia’s characteristic
features, but for the importance given to some symptoms rather than others.
According to Kraepelin, the main symptoms of dementia praecox are emotional
deterioration, disorders of attention and will, and disturbed flow of thoughts.
The first symptom, which belongs to the disorders of behaviour, according to the
German psychiatrist, dominates schizophrenic emotional life and is the so-called
negativism, characterised by emotional indifference, detachment from relatives
and friends, loss of interest for activities once considered pleasant, and anhedonia.
In many cases, subjects considered friendly and sociable gradually become more
and more introverted, closed, and isolated:
12 The enigma of schizophrenia
Disturbed attention and will have the same importance for Kraepelin, because
they contribute to dramatically isolating the schizophrenic. In the most severe
cases, patients can be totally indifferent towards surroundings, and to draw their
attention can become an impossible task. Finally, Kraepelin focuses on the lin-
guistic features intimately related to schizophrenia, which will be one of the
most studied areas from this time on. The flow of thoughts in schizophrenia is
altered in many ways; this flow can be completely lost, stray towards unexpected
directions, be overwhelmed by accessory information, and turn around the same
topic. In every case, incoherent speech in its different forms is, according to
Kraepelin, one of the most important aspects of schizophrenia.
Kraepelin does not pay much attention to schizophrenia’s other typical
symptoms, like delusions and hallucinations. Or better, he investigates them from
a formal point of view and regards them as common symptoms of dementia prae-
cox, but considers them of secondary importance. As for the delusions, K raepelin
often states that this kind of false belief (like claiming to be persecuted or to have
special powers) naturally descends from a lack of judgement and therefore from
a weakness of intellect (Kraepelin, 1905, 1907). Regarding hallucinations, the
German psychiatrist underlines the frequency of auditory ones, observes that
many patients complain of hearing strange noises or voices, and notices that in
some cases visual hallucinations are also present. Yet, in his opinion, one does
not need to deeply investigate the meaning of this kind of symptom, because
their topics are absolutely irrelevant. It will be successive authors, like Bleuler
and Schneider, who will focus on schizophrenic delusions and hallucinations,
and restore the meaning that Kraepelin had taken away from these symptoms.
Bleuler is one of the first authors who rejects such a pessimistic view of schiz-
ophrenia. Being for many years the director of the mental asylum of Rheinau,
he has the chance to be in contact with the patients, talk with them, and observe
them, and he pays much attention to what they say and do (he always has a
notebook and a pen with him, as recalled by some of his contemporaries [see
Moskowitz and Heim, 2011]). Thanks to this, he can get an idea of the essence of
this mental disorder. First of all, he decides to abandon the expression dementia
praecox and rebaptises the disorder schizophrenia, using the term later adopted
all over the world. He prefers this term for a number of reasons; first of all, it
does not refer to dementia anymore, and for this reason it loses every allusion
to degeneration and chronicity; second, it can be used as an adjective (schizo-
phrenic); and finally, this term is particularly suitable for identifying the funda-
mental symptom—for Bleuler, that is Spaltung, a kind of split in psychic functions
(Bleuler, 1950). In detail, Bleuler divides primary symptoms (part of the basic
illness process, which he still considers of an organic nature) and secondary ones
(reactions of the subjects to the illness) from basic symptoms (which are the most
typical of a specific mental disorder) and accessory ones (shared with other dis-
orders). According to Bleuler, schizophrenia’s primary symptom is Spaltung, the
loosening of associative links in the different areas of affect, logic, and behaviour.
This impairment, besides being considered the primary symptom, is part of the
‘four A’s’, regarded by the Swiss psychiatrist as the fundamental symptoms: Autism
(detachment from reality and social isolation), Ambivalence (the simultaneous
presence of contradictory ideas and emotions), Affective disturbances, and im-
paired Associations. On the other hand, symptoms Kraepelin regarded as t ypical
of schizophrenia, like hallucinations and delusions, are c onsidered secondary by
Bleuler, that is, as something that does not stem from the disease process itself
but that only operates ‘when the sick psyche reacts to some internal or external
process’ (Bleuler, 1950: 348). Since secondary symptoms originate from the sick
psyche’s reactions, one has to focus on their meaning and trust the fact that they
can be understood; so, their contents have to be investigated rather than being
excluded by any attempt to interpret them.
As we are beginning to notice, and it will be clearer later in this paragraph,
the schizophrenic symptoms identified by Kraepelin will stay the same in the
successive classifications by other psychiatrists. Bleuler, though stressing the
importance of a symptom Kraepelin regarded as secondary (that is, the splitting),
stays nevertheless inside Kraepelin’s paradigm. We can say the same for another
German psychiatrist specifically interested in schizophrenia—Schneider. He also
refers to Kraepelin’s symptoms and moves from him only for the relevance given
to some symptoms as opposed to others. More precisely, Schneider pays close
attention to one specific symptom that is one of the most studied in the cognitive
and neuroscientific area today: auditory hallucinations.
The diagnostic criteria suggested by Schneider (1954) are grounded in
the d ichotomy between first-rank and second-rank symptoms. This dichot-
omy does not overlap with the other between fundamental and accessory;
14 The enigma of schizophrenia
Schneider considers some symptoms as first rank not because they are pathogno-
monic of schizophrenia (that is, for being particularly indicative of this disease),
but because they have a great diagnostic value. In other words, from clinical
psychiatry’s perspective, first-rank symptoms can be particularly useful in order
to suggest a diagnosis of schizophrenia (Cancro and Lehmann, 2000). Schneider
does not claim to get to the core of schizophrenia (the core that Bleuler searched
for), but tries to make the diagnosis easier and more consistent through the indi-
viduation of symptoms usually present in schizophrenia. Among those, Schneider
emphasises the role of auditory hallucinations, on one hand, and some kind of
delusions, on the other. Regarding the former, according to S chneider, voices
have to be considered symptoms of first rank, especially in some cases—for ex-
ample, when they argue or comment on what the patient does, or repeat the
patient’s thoughts. Among delusions, he calls attention to the bizarre ones, like
those of thought insertion (‘The thoughts I’m thinking are not mine’), broadcast-
ing (‘I can send my thoughts telepathically’), or withdrawal (‘They robbed me of
my thoughts’). More generally, the German psychiatrist stresses the importance
of the experience of passivity typical of schizophrenia, where what the schiz-
ophrenic says, thinks, does, feels, or wants is actually controlled or influenced
by external forces. We can find other symptoms in schizophrenia, like different
kinds of hallucinations (e.g., visual ones) or mood disturbances, but Schneider
does not regard them as having a high diagnostic value for schizophrenia and
judges them as second-rank symptoms.
The diagnostic criteria adopted by schizophrenia’s founding fathers give us
quite different pictures of this mental disorder. Which one is true? Is the schiz-
ophrenic a patient with different impairments fatally destined to a severe mental
deterioration, a subject with a split mind who is enclosed in an inner world, or
someone dominated by experiences of passivity and bizarre delusions? There is
no answer to this question yet, and the different versions of schizophrenia given
by the various authors must be viewed as the consequence of schizophrenia’s
mentioned resistance to any attempt to be fully understood. In other words,
none of these paradigms have been definitely validated. For example, there is
no symptom that we can find in all cases of schizophrenia and that could be
accounted for as its ultimate essence: neither Bleuler’s autism nor Kraepelin’s neg-
ative symptoms are restricted to schizophrenia (which shares them with autism
disorder and mood disorders like major depression), while Schneider’s first-rank
symptoms can be found in affective disorders. Finally, some schizophrenics do
not show splitting, regarded as a fundamental symptom by Bleuler, or intellectual
deterioration, that Kraepelin judged the fatal outcome of the disorder. This is the
reason why researchers recently have focused on a more reliable description of
schizophrenia rather than on the identification of some fundamental core symp-
tom of this mental disorder. The possibility to identify this schizophrenia’s es-
sential core will become a challenge accepted by another, and radically different,
perspective—that is, phenomenological psychiatry (which I will fully d iscuss
further in Chapter 4). Traditional psychiatry, on the contrary, will claim to be
The enigma of schizophrenia 15
account of seven factors. Regardless of the factor cluster included in the d ifferent
scales of evaluation, it is important to stress that in some cases a patient can be
schizophrenic without showing any positive or negative symptom, like in schiz-
ophrenia simplex (which we deal with later, in Chapter 4). This implies that the
positive-negative dichotomy, no matter how reliable from the diagnostic point of
view, does not catch every possible mode of being schizophrenic.
And so, we arrive at the most recent attempt to describe s chizophrenia, the
Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American
Psychiatric Association, 2013). This manual, which adopts a descriptive para-
digm, pretends to be free from theoretical assumptions and tries to delineate
those qualitative and quantitative criteria that make a diagnosis possible.
Regarding schizophrenia, the DSM-5 states that to be diagnosed as schizo-
phrenic, one has to show, for at least one month, two or more of the follow-
ing symptoms: hallucinations, delusions, disorganised thought, catatonic or
d isorganised behaviour, or negative symptoms; at least one of the symptoms
must be one of the first three. All symptoms perfectly overlap with those
identified by Kraepelin, even if symptom definitions are clearly changed.
For example, delusions are no more described as a defect of intellect, but as
‘fixed beliefs that are not amenable to change in light of conflicting evidence’
(American Psychiatric Association, 2013: 87). However, apart from these
changes linked to a different cultural paradigm, one can say that schizophre-
nia’s description we use today is definitely Kraepelinian.
It is worth noting that this newest edition of the DSM still attempts to identify,
among the different symptoms of schizophrenia, something that typifies it in a
more specific way. As we already noticed, it is specified that the patient has to
show one of three symptoms: delusions, hallucinations, or disorganised thought.
These symptoms would have a higher diagnostic value than others; that is to
say, they would be schizophrenia’s most typical aspects, but only with regard
to the diagnosis. Thus, we can say that in some sense, the DSM-5 surrendered
to schizophrenia, in that it quit the attempt to catch its essence, preferring to
adopt a completely descriptive point of view. After all, this text should only
be a practical instrument to diagnose mental disorders. However, I did not write
‘should’ accidentally, because the DSM-5 is actually far from being objective and
neutral; it is committed to that medical conception of mental disorder that is typ-
ical of modern Western countries. DSM-5’s different aspects have been criticised,
from the cut-off rigidity (i.e., the minimum number of symptoms, for example,
two symptoms are enough to diagnose schizophrenia, and there is no difference
between a person who presents two symptoms and another one who presents
six of them), to the huge discretionality left to the single psychiatrist (who, for
example, can judge the bizarreness of a delusion basing on his reference culture,
rather than on the patient’s one), to the tendency to consider abnormal some
behaviours that are only deviations from normality or ways to express suffering
(one can think of categories that are sometimes too abused, such as childhood
bipolar disorder or attention-deficit/hyperactivity d isorder). But, investigating
The enigma of schizophrenia 17
—Aa’s wai dá’ weertje nou d’r moar houê, riep ouë
Gerrit in ’t voorbij gaan tegen Dirk.
[Inhoud]
IV.
En die Piet! hep d’r nog acht sint moakt! Waa’s d’r
puur ’n meroakel! hoho! aa’s die noar stad gong.…
waa’s ’t alletait ’n kwart meer aa’s Dirk, die krek vaif
sint hoalt!
Ouë Gerrit wist zich niet goed meer te roeren. Dirk gaf
’m eerst na den grootsten worstel, de ontvangen
guldens uit den zak. De Ouë kromp van angst, als ie
’m dronken van den marktdag zag den dorsch
inschommelen, angst dat ie den heelen boel zou
verzopen hebben, of verspeeld. En als ie dan maar ’n
kik gaf, blafte Dirk hem nijdig tegen z’n hielen, dat ie
schrok, en afgebluft loenschte. Piet gaf alles dadelijk,
al gapte ie ’r later weer van weg voor de zuip, maar
Dirk hield de duiten in z’n ijzeren knuisten heet
gevangen.—Dan eindelijk, moest ie na z’n verbluffing
opspelen, schreeuwen, stompen en beuken in
bloedspuw van nijd, en traag ging de klepzak dan
eindelijk open, klefferden de morsige dubbeltjes,
kwartjes en centen naar buiten, naar hèm toe, onder
één grom en snauw. Ging hij natellen dan vloekte Dirk.
„Tel aa’s je je koarsies uitbloast”, hoonde die, en
sarrend liet ie ’m zien de notities, wel wetend, dat ouë
Gerrit toch niet lezen kon, ’n letter zoo groot als ’n
paardekop niet.—
—Gerrit goan d’r bai s’n bulle waif, sain bulle waif!
hoho!