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Formal Thought Disorder and Language Impairment in Schizophrenia Alteração Formal Do Pensamento E Prejuízo Da Linguagem Na Esquizofrenia Marcia Radanovic, Rafael T

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Formal Thought Disorder and Language Impairment in Schizophrenia Alteração Formal Do Pensamento E Prejuízo Da Linguagem Na Esquizofrenia Marcia Radanovic, Rafael T VIEWS AND REVIEWS Formal Thought Disorder and language impairment in schizophrenia Alteração formal do pensamento e prejuízo da linguagem na esquizofrenia Marcia Radanovic, Rafael T. de Sousa, Leandro L. Valiengo, Wagner Farid Gattaz, Orestes Vicente Forlenza ABSTRACT Schizophrenia is a psychiatric illness in which disorders of thought content are a prominent feature. The disruption of normal flow of thought, or “Formal Thought Disorder” (FTD), has been traditionally assessed through the content and form of patients’ speech, and speech abnor- malities in schizophrenia were considered as a by-product of the disruption in conceptual structures and associative processes related to psychosis. This view has been changed due to increasing evidence that language per se is impaired in schizophrenia, especially its semantic, discursive, and pragmatic aspects. Schizophrenia is currently considered by some authors as a “language related human specific disease” or “logopathy”, and the neuroanatomical and genetic correlates of the language impairment in these patients are under investigation. Such efforts may lead to a better understanding about the pathophysiology of this devastating mental disease. We present some current concepts related to FTD as opposed to primary neurolinguistic abnormalities in schizophrenia. Key words: schizophrenia, thought disorder, language disorders, thinking, linguistic, psychotic disorders. RESUMO A esquizofrenia é uma doença psiquiátrica na qual as alterações do conteúdo do pensamento são uma característica marcante. A ruptura do fluxo normal de pensamentos, ou “Alteração Formal do Pensamento” (AFP) é acessada através da forma e conteúdo da fala do paciente. Alterações de fala e linguagem em esquizofrênicos eram consideradas como consequentes à ruptura de seus sistemas conceituais e pro- cessos associativos relacionados à psicose. Esta visão alterou-se pelo aumento nas evidências de comprometimento primário da linguagem na esquizofrenia, especialmente em seus aspectos semânticos, discursivos e pragmáticos. A esquizofrenia é atualmente considerada por alguns autores como uma “doença humana específica relacionada à linguagem”, ou “logopatia”. Os correlatos neuroanatômicos e genéticos do prejuízo linguístico nestes pacientes estão sendo investigados. Estes esforços podem levar à maior compreensão da fisiopatologia desta grave doença mental. Nesta revisão, apresentamos conceitos atuais sobre AFP e sua diferenciação das anormalidades linguísticas primá- rias na esquizofrenia. Palavras-Chave: esquizofrenia, pensamento, transtornos da linguagem, pensamento, linguística, transtornos psicóticos. Formal thought disorder (FTD) is a syndrome with sever- disorder” to describe the symptom. She stated that only the al different symptoms, leading to thought, language and com- language is appreciable, not the thought. Likewise, Andreasen munication problems1, being a core feature in schizophrenia. argued that we can analyze only the speech, while thinking Eugen Bleuler, who named schizophrenia, regarded FTD remains always somehow inaccessible5. When approaching as central for the conceptualization of the disorder2. Today FTD, Andreasen used the expression thought, language and FTD remains as one of the diagnostic criteria for schizophre- communication (TLC), pointing to the construct complexity. nia according to the DSM-IV-TR3. Although FTD is listed as Ultimately, the basis for FTD analysis is the verbal behavior, one of the five characteristic symptoms of the disorder, it has the speech of the patient. not been operationalized in the manual. Empirically, thought and language are not perfectly relat- Since early FTD descriptions, there has been a debate on ed. For instance, people can use language to hide or distort ascribing the symptom to the field of language or thought. what they really think. Also, aphasic patients find it difficult Bleuler used the expression Beziehungslosigkeit (associative to express in words what they are able to think. loosening), attributing the symptom to thought. In a differ- In the last two decades the debate on the nature of ent approach, Chaika4 recurred to the expression “speech FTD led to an increasing interest in the relation between Laboratory of Neuroscience (LIM-27), Department and Institute of Psychiatry, Medical School, Universidade de São Paulo, São Paulo SP, Brazil. Correspondence: Marcia Radanovic; Laboratório de Neurociências – LIM 27 – Instituto de Psiquiatria do HCFMUSP; Rua Dr. Ovídio Pires de Campos 785 / 3º andar; 05403-903 São Paulo SP - Brasil; E-mail: [email protected] Conflict of interest: There is no conflict of interest to declare. Received 06 June 2012; Received in final form 06 July 2012; Accepted 13 July 2012 55 FTD and primary language disturbances found in schizo- bipolar mania and to present little improvement in schizo- phrenia. Crow6 postulated FTD could be derived from a phrenia/schizoaffective disorder1. lack of hemispheric asymmetry in language areas. This ar- In mania, FTD shows more combinations of confabula- ticle reviews studies on FTD and its association with neu- tory, incongruous, and mocking elements16. In turn, FTD in rolinguistic abnormalities. schizophrenia/schizoaffective disorder shows more disorga- nization, confusion and conceptual or ideational fluency, as well as the use of more peculiar words and phrases16,17. FORMAL THOUGHT DISORDER SYMPTOMS FTD can be divided into abnormalities of amount and FORMAL THOUGHT DISORDER – form of speech. Abnormalities concerning amount are pov- NEUROLINGUISTICS PERSPECTIVE erty of speech (laconic speech) and pressure of speech, while disconnection symptoms relate to the abnormalities in the Many studies focused on speech abnormalities in schizo- form1,7-9. Disconnection encompasses distractible speech, phrenia, and they often do not distinguish what is under- loss of goal, derailment (loose associations), illogicality (non stood as thought and/or language disorders and cognitive sequitur), and incoherence. function. In other words, there is not a clear distinction be- Besides this most usual description of FTD symptoms, tween the content of mental representations stored in the other authors analyzed FTD in the perspective of commu- brain, which are derived from innate programs and the pro- nication failure10,11. FTD symptoms described by Gordinier gressive experience of interaction with the environment, and and Docherty11 include inadequacy in language structure language itself, conceptualized as a symbol system that orga- leading to confusing references (a word or phrase that can nizes information mentally and also as a behavior that allows refer to at least two references), conceptual weakness as- interaction with other individuals. A major methodological sociated with the use of ambiguous word meanings and difficulty arises from the fact that “thought disorders” shall vague expressions, and missing information references be measured by the verbal output of the patient, making it (citing something not known by the listener and not previ- extremely difficult to differentiate between the former and a ously presented). primary language disorder. In fact, the terms “thought disor- der” and “speech disorder” are often used interchangeably in psychiatric literature. FORMAL THOUGHT DISORDER MIGHT BE The first studies on language disorders in schizophre- USEFUL IN THE DIFFERENTIAL DIAGNOSIS OF nia described the similarities between this disorder and SCHIZOPHRENIA aphasia, arguing that episodes of “intermittent aphasia” oc- curred in schizophrenia18. The speech of schizophrenics ap- Bleuler assigned FTD a prominent place in diagnosing parently shared some characteristics with fluent aphasia: schizophrenia, leading many American psychiatrists to re- increased fluency on spontaneous speech, paraphasias, im- gard thought disorder as a sine qua non finding for this di- poverishment of content, and idiosyncrasies in the use of agnosis5. Over time, however, FTD has been shown to be as- words. Comparative studies have also demonstrated similar sociated with many other psychiatric conditions, especially performance between schizophrenics with language disor- bipolar mania12,13. der and aphasia on tasks of language comprehension, nam- Although there are no FTD symptoms which are specific ing and repetition, with abundant semantic paraphasias for any disorders, their evaluation might be useful in the dif- present in both cases. However, this approach was not suf- ferential diagnosis of schizophrenia/schizoaffective disorder ficiently consistent across different studies19,20. and bipolar mania with psychosis (Table). Schizophrenia pa- The finding that schizophrenia patients have cognitive de- tients show a greater frequency of vague expressions in dis- cline in several areas obscured language impairment, which course than manic patients14, are more likely to construct came to be regarded as secondary to an overall cognitive def- ill-formed sentences12, and to present poverty of speech and icit, and not due to a primary problem in language process- its content13,15. In the follow-up, FTD tends to normalize in ing. However, the idea remained that in schizophrenia there Table. Formal thought disorder in schizophrenia and bipolar disorder. Disorder Most characteristic symptoms Follow-up Disorganization, confusion and conceptual or Schizophrenia/ ideational fluency, and the use of odd words and Persistence or little improvement Schizoaffective disorder phrases. Confabulatory, incongruous and mocking Mania Trend to
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