Scale for the Assessment of Thought, Language, and Communication (TLC)

VOL 12, NO. 3, 1986 Scale for the Assessment of Thought, Language, and Communication (TLC) by Nancy C. Andreasen The following set of definitions was or perceptual disorders) as manifesta- developed to improve the reliability tions of their schizophrenia. of assessments of "formal thought Because the term "formal thought disorder." In the past such assess- disorder" has been so misunderstood ments have been unreliable at least in and misused, it is recommended that part because clinicians and it no longer be used. The various researchers have not agreed upon the disorders which comprised the meaning of the terms which they concept of "formal thought disorder" have used. It is hoped that the can be better conceptualized as following definitions will provide a "disorders of thought, language, and common and reliable stock of terms communication." If viewed from an to describe the language and empirical perspective, most of them cognitive behaviors which can be are in fact disorders of commu- observed in psychiatric patients. nication, and the notion of thought This set of definitions began with a need only be invoked to explain a clinical recognition that the concept few of them. of "formal thought disorder" has That is, the following set of defini- often been misused and misunder- tions began with the idea that the stood. First, it has often been treated reliability of assessments could be as if it were unitary, but in fact it is improved if "thought disorder" were composed of a number of different defined in terms of language language behaviors which are behavior, and only behavior which conceptually divergent and not could be directly observed would be always correlated in the same evaluated. Most of the time, the patient, such as "poverty of thought" language behavior involves a dyadic and "loose associations." The recog- interaction between a speaker and a nition of the diversity of concepts listener, and the disorder occurs and terms has led to the specification because the speaker fails to follow a of 18 different types of "formal set of rules which are conventionally thought disorder." used to make it easier for listeners to Second, it has been assumed that understand. When the speaker fails "formal thought disorder," or at least to take the various needs of the "thought disorder," is patho- listener into account, the result is gnomonic of schizophrenia and usually a communication disorder. omnipresent within schizophrenic According to this definition, the patients. Clinical experience contra- following items from the scale are dicts both assumptions. Language "communication disorders": poverty behaviors such as associative of content of speech, pressure of loosening, clanging, blocking, over- speech, distractible speech, tangen- concrete or repetitive speech, and tiality, derailment, stilted speech, poverty of speech also occur in other echolalia, self-reference, circumstan- psychiatric disorders such as mania tiality, loss of goal, perseveration, or depression, and they also occur in and blocking. The concept of the speech of people who do not language disorder should be invoked meet the criteria for any psychiatric for those specific disorders in which diagnosis, particularly when they are fatigued or stressed. Furthermore, some schizophrenic patients seem to Reprint requests should be sent to speak and think normally, with only Dr. N.C. Andreasen, Department of Psychiatry, University of Iowa College of specific delusions or hallucinations Medicine, 500 Newton Road, Iowa City, (i.e., disorders of content of thought IA 52242. 474 SCHIZOPHRENIA BULLETIN the speaker violates the syntactical illogicality, and clanging. Since it is than test-retest reliability. The data and semantic conventions which probably impossible to achieve good in the appendix concerning reliability govern language usage: incoherence, reliability when clinicians must make are based on live interviews of 113 clanging, neologisms, and word judgments on how close relationships patients (32 manics, 36 depressives, approximations. The concept of are between various ideas, definitions 45 schizophrenics). thought disorder comprises only which must turn on this judgment those disorders in which thinking have generally been eliminated. alone seems aberrant: poverty of Therefore, for example, the term 1. Poverty of Speech (Laconic speech (aberrant because thought "flight of ideas" has been dropped Speech, Poverty of Thought) seems not to occur) and illogicality and is now subsumed under the (aberrant inferential processes). These concept of derailment. In order to Restriction in the amount of sponta- various disorders can be referred to permit an assessment of thought, neous speech, so that replies to collectively as thought-language- language, and communication in a questions tend to be brief, concrete, communication disorders, or TLC wide range of patients, the defini- and unelaborated. Unprompted disorders. tions have not been limited to additional information is rarely Experience in using this scale has disorders customarily considered to provided. For example, in answer to indicated that some TLC disorders be characteristic only of schizo- the question, "How many children do are more suggestive of severe psycho- phrenia. Definitions of two terms you have?", the patient replies, pathology than others. These have which are drawn from aphasiology, "Two. A girl and a boy. The girl is been grouped together at the semantic and phonemic paraphasia, 13 and the boy 10." 'Two" is all that beginning of the scale and consist of are also included so that they can be is required to answer the question, the first 11 items. The data collected distinguished from incoherence. and the rest of the reply is additional to date concerning the frequency of Most of the ratings can be made information. Replies may be these various TLC disorders in after a patient has been evaluated monosyllabic, and some questions mania, schizophrenia, and depression with an ordinary psychiatric inter- may be left unanswered altogether are summarized in the appendix. As view, since this is a good vehicle for When confronted with this speech those data indicate, some TLC eliciting typical patterns of speech pattern, the interviewer may find disorders considered to be very using relatively standardized himself frequently prompting the important in the past, such as questions. During some time the patient in order to encourage elabo- neologisms or blocking, are in fact so patient should be permitted to talk as ration of replies. To elicit this infrequent as to be of little use in long as possible to observe his speech finding, the examiner must allow the assessing most patients. during this condition. The patient patient adequate time to answer and to elaborate his answer. In choosing which disorders to should be interrupted at some time in cover in the scale and how to define order to see how he responds to this. them, decisions were sometimes Most of the ratings are described Example: Interviewer: "Do you made to redefine, combine, or delete quantitatively, i.e., how often they think there's a lot of corruption in older concepts in order to enhance occur during an interview. These government?" Patient: "Yeah, seem reliability. For example, the term ratings are based on the assumption to be." Interviewer: "Do you think "loose associations" has not been that most interviews take about 50 Haldeman and Erlichman and used because it is based on an minutes. For longer or shorter inter- Mitchell have been fairly treated?" outdated associationist psychology views, the values should be adjusted Patient: "I don't know." Inter- and because it has been used so accordingly. viewer: "Were you working at all loosely as to be nearly meaningless. The interrater reliability of these before you came to the hospital?" The term "derailment" has been definitions has been carefully Patient. "No." Interviewer: "What substituted because it carries a evaluated and found to be very kind of jobs have you had in the minimum of baggage and because it good. For a phenomenon such as past?" Patient: "Oh, some ]anitor is graphically descriptive. Four other TLC disorder, which depends on jobs, painting." Interviewer. "What terms which also may be at times subjective judgments about kind of work do you do?" Patient: "1 equivalent to the older concept of phenomena which may change don't. I don't like any kind of work. associative loosening are used in the dramatically over a few days, inter- That's silly." Interviewer: "How far scale: tangentiality, incoherence, rater reliability is more meaningful did you go in school?" Patient: "I'm VOL. 12, NO. 3, 1986 475 still in the 11th grade." Inter- Example. Interviewer: "Ok. Why, sentences may be left uncompleted viewer: "How old are you7" why is it do you think that, people because of eagerness to get on to a Patient: "Eighteen." believe in God7" Patient: "Well, first new idea. Simple questions which of all because, he uh ly, he are the could be answered in only a few 0 No poverty of speech. A substantial and appropriate person that, is their personal savior. words or sentences are answered at number of replies to questions He walks with me and talks with me. great length so that the answer takes include additional information. And, uh, the understanding that I minutes rather than seconds and 1 Slight poverty of speech. have, um, a lot of peoples, they indeed may not stop at all if the Occasional replies do not include don't really, uh, know they own speaker is not interrupted. Even elaborated information even personal self. Because, uh, they ain't, when interrupted, the speaker often though this is appropriate. they all, just don't know they own continues to talk. Speech tends to be 2 Moderate poverty of speech. personal self. They don't, know that loud and emphatic. Sometimes Some replies do not include appro- he, uh, seemed like to me, a lot of priately elaborated information, speakers with severe pressure will and many replies are monosyllabic 'em don't understand that he walks talk without any social stimulation or very brief ("Yes." "No." and talks with them.

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