Language Disorder of People with Schizophrenia and its Relationship with Severity and Functionality.

ABSTRACT

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Objective: To study language characteristics in patients who suffer scyzophrenia or other psychotic disorders.
Method: 55 patients diagnosed with scyzophrenia (50) and schizoaffective disorder (5). The Andreasen TLC Scale, the EEAG Scale for Functionality, and the CGI Scale for severity were applied. Sociodemographic data were retrieved.

Results: The medians are: age: 61.47 years old, admission: 19.47 years old, CGI: 5. 8, EEAG: 32.5. TLC Disconnection Subscale scores a median of: 8.43 and verbal sub production: 1.2. The disconnection is negatively correlated with EEAG, and positively correlated with CGI. Verbal sub production is correlated with CGI.

Conclusions: The participants have a high degree of severity and a low degree of functionality. Patients have language disorders, especially poverty of speech, but also verbal disconnection. Scores range from mild to moderate. Both subscales are correlated with severity. Furthermore, the disconnection is higher in patients with worse functionality.
Language disturbances in scyzophrenia are related with severity and functionality, which leads to significant consequences in the life of the people who suffer this disease.

INTRODUCTION

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Scyzophrenia is a severe mental disorder affecting more than 21 million people all over the world⁽¹⁾. Usually it starts during adolescence and lasts the whole life of a person, but with temporary variations. Its clinical picture is varied and complex, with symptoms encompassing most psychopathologies. Usually its progression is deteriorating and frequently some other diseases are added. Despite therapeutical progress, its forecast is gloomy. Language disturbances are one of the main symptoms of the disease. Both in CIE-10⁽²⁾: “incoherent or irrelevant discourse”, as in DSM-5⁽³⁾: “disordered discourse”, is recognized as one of the symptoms present for diagnosis. Disordered discourse/language in scyzophrenia is fundamental and has been described in the history of Psychiatry. As Berrios ⁽⁴) states: “we can assert that thought disorders were fully described as a symptom before Kraepelin´s or of Bleuler´s works”. He states that some years before, in 1892, Séglas (1856-1939) published the monograph “Des Troubles du Langage chez les Aliénées”. In 1902 Renée Masselon published his “Psychologie des Dements Précoces”, including a chapter on thought disorders regarding these patients. Colodrón ⁽⁵), states that the first references are found in Snell, who, in 1852, when Morel described some patients as precocious demented, he wrote an article about “changes in the way how to speak and the creation of new words and expressions in people with mental illnesses”. According to Kraepelin ⁽⁶), many of the symptoms in dementia praecox were thought disorders manifestations. In this way, it included judgment disorders, incoherence in the course of thought, neologisms, stereotypies, poor construction of sentences, etc. For Bleuler ⁽⁶⁾, who created the term scyzophrenia, thought disorders were the main symptom. According to Bleuler, associations lose their continuity, and thought becomes illogical and usually extravagant. Otto Dörr⁽⁷⁾ thinks scyzophrenia is a logopathy (alteration of understanding or comprehension) before thymopathies (affective regulation) which are mood diseases. Regarding language evaluation tests for scyzophrenia a recent work by Natalia Jimeno⁽⁸⁾ reviews this topic. She finally, recommends using Andreasen´s TLC Scale. In 1979, Nancy Andreasen designed a scale aimed to objectively summarize and define language disturbances in scyzophrenia^{(9, 10)}. These definitions derive from clinical experience, using an empiric approach and avoid making inferences on thought underlying processes. It indicates that some types of thought disorders deemed as important in scyzophrenia are rare and have a low diagnosis value, such as neologisms or blocking. In another article⁽¹¹⁾, she proves that loose associations or derailment, frequently happen both in manias as well as in scyzophrenia, and cannot be deemed as pathognomonic of scyzophrenia. Relaxation of associations, rhyme, blocking, the repetitive/hyper-concrete speech and poverty of speech, can also occur in other disorders, such as manias or depression; and they even can occur in people who do not suffer any mental disorder, but it happens when they are tired or stressed. The influence of this author and the use of her Scale (TLC) was quite impressive in DSM III, III-R and IV. Similarly, some other evaluation scales appeared including items on language⁽¹²⁾. The SAPS (Scale for the Assessment of Positive Symptoms) (Andreasen, 1982), the SANS (Scale for the Assessment of Negative Symptoms) (Andreasen, 1982) and the PANSS (Positive and Negative Syndrome Scale) (Kay, 1987). According to Cuesta & Peralta^{(13, 14)}, formal language disorders have an advantage before other more subjective symptoms which are easily objectivable; therefore these are more reliable among observers. Proof has been given that these do not specifically appear in schizophrenic disorders, but they also occur in patients with affective disorders. Not a specific symptom has been found that clearly separates schizophrenic population from the group with psychotic disorders, but a differentiated profile has been found: higher intensity in poverty of language, language content poverty, illogicality, tangentiality and perseverations. While some patients suffering manic bipolar disorder and other schizoaffective patients have severe disturbances in pressure of speech and loss of objectives.

METHOD

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METHOD
A descriptive/correlational/explanatory design has been carried out, with a purposive sample of 55 adults suffering scyzophrenia or psychotic disorders, using a quantitative approach⁽¹⁵⁾. The Thought, Language, and Communication (TLC) Scale, (Andreasen, 1979); the Clinical Global Impression Scale, (CGI), (Guy, 1976); and the Global Assessment of Functioning, (GAF) Scale, (American Psychiatric Association, 1987) have been applied.
 
Objectives and Hypothesis of the Study
The objectives of this general-purpose research are: (a) analyze language psychopathological symptoms described in institutionalized patients suffering scyzophrenia. (b) determine the correlation among psychopathological symptoms of thought and language, age, functionality and severity of patients.

Population & Sample
A descriptive/correlational/explanatory design has been carried out with a purposive sample of 55 adults suffering scyzophrenia and using a quantitative approach. The population is intentional, made up of 55 adults suffering scyzophrenia (90.9%) and schizoaffective disorder (9.1%). 43.6% of them are men, and 56.4% are women. Schooling level is low. 29.1 % with no formal studies or incomplete primary schooling. Only 20% of them were college students. In order to make up this sample, patients admitted in the Centro Sociosanitario Hermanas Hospitalarias of Palencia (Spain), in Rehabilitation or Residential Units were analyzed. A whole population of 67 adults was obtained. From the whole population a sample of adults meeting the inclusion criteria were selected, and a total sample of 55 participants was obtained.
The age of the 55 participants ranges between 38 years old and 78 years old, with an median of 61,47 years old (?=8,00). Medium stay at the Center was between 4 and 56 years old, with a median of 19.47 years (?=10.29). All patients are under psychopharmacological treatment with antipsychotics, as well as other types of psychosocial therapies: groups, psychotherapy, labor therapy, etc.
Criteria used for selecting the sample are:

1. Patients with a long term stay at the Center.
2. Patients diagnosed with scyzophrenia or psychotic disorders.
3. Patients who do not have a significant cognitive impairment, that prevent them from participating in the Andersen´s TLC Test.

All those who participated in the study have voluntarily accepted and have signed an Informed Consent. In case they are not capable, their relevant tutors signed for them.

Techniques and Instruments
Elementary sociodemographic data are retrieved from the patient´s clinical record, such as diagnosis, treatment and other variables described in the Tables. The foregoing measurement instruments have been used.
The TLC Scale^{(9, 10)} was translated and adapted into Spanish by Obiols. This scale has 20 items with scores ranging between 0 to 4 (Zero corresponds to non-appearance of the item and four corresponds to the extreme mode thereof), describing language characteristics of a patient suffering scyzophrenia. For study purposes, we will take only the most used in scyzophrenia and two dimensions of the disorder, which have been, previously used⁽¹⁶⁾: disconnected speech or disorganization & verbal under productivity syndrome. Disconnected speech was defined as the median of six items: language content poverty, derailment, tangentiality, loss of objectives, circumstantiality and incoherence; while verbal hypo productivity was defined by poverty of speech. 
 In order to apply it, the PRESEEA⁽¹⁷⁾ interview was made with the patient and each item of the TLC Scale is proved to be present; a score is given, depending on the degree of intensity it has. After that, a total score is obtained, so that the higher the score, the higher the alteration in thought, language and communication is.
The CGI⁽¹⁸⁾ has a unique item aimed to value severity, by using a Likert-type Scale of 8 values ranging from 0 (non-evaluated) to 7 (among the most extremely sick patients). In the heteroapplied version, clinicians, based on their experience, score the patient´s severity.
The EEAG⁽¹⁹⁾ is an instrument aimed to evaluate general functioning of psychiatric patients, along a continuum of health-disease. It has one single item, related with the global activity of the patient, and is scored by means of a scale ranging between 100 (satisfactory activity in a wide range of activities, autonomy, social relationships, work, activities, etc.) and 1 (evident death expectations). The higher the score, the better the level of activity. It is heteroapplied.

Procedure and Data Retrieval Process
All procedures necessary for the study respected the ethical rules meeting the Declaration of Helsinki (1975), updated in 2008, and were approved by the Committee of Ethics of the Institution where it was made. The data retrieval process is carried out by a Speech Therapist and a psychiatrist who work in various disciplines. The evaluation of the participants is made individually, and it takes 45 minutes. First, the TLC Scale was applied, using the interview as a procedure for retrieving data. Later, the script of the Preseea interview was applied by using the EEAG & CGI Scales.
Later, a further statistical analysis of the results is made. In order to do so, we use SPSS 24.0 software for Windows, which will allow us to obtain a direct score of all the tests. The Kolmogorov-Smirnova Test for Normality tells us when the sample does not have a normal distribution, as the significance level of all the variables in this test and in all those we will perform is lower than 0.05. That is why we have decided to perform parametric statistical tests as the Spearman's Rho Test.

RESULTS

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RESULTS
Figure 1 describes the percentage of participants, who suffer language pathologies (in black) compared against those who do not have it (in gray). Ranged from the most difficult to   the least difficult, we can find that 98.2% from all patients who have difficulties in poverty of speech and in loss of objectives; 89.3% in circumstantiality; 80.4% in content, 66.1% in tangentiality, 60.7% in derailment, 53.6% in lack of logics and 46.4% in incoherence. 100% of them had difficulties in, at least, one of the items.
Table 1 describes the correlation of EEAG and CGI with the rest of the variables.
 EEAG correlates -in a moderate and negative manner- with tangentiality (-0.409), derailment (-0.341), incoherence (-0.477), neologisms (-0.410) and perseverance (-0.380). This indicates that when the EEAG increases, the rest of the quoted variables decreases. The opposite is true when EEAG decreases.
The EEAG correlates –in a strong and negative manner– with CGI (-0.786), lack of logics (-0.505), loss of objectives (-0.590) and with the dimension of disconnection (-0.554); which indicates when EEAG decreases the rest of the variables increases; the opposite is true when the EEAG increases.
CGI correlates –in a weak and positive manner– with derailment (0.268), with poverty of speech (0.287) and with the productivity dimension (0.287). This means when the CGI increases, the other variables increase as well. The opposite is true when the CGI decreases.
The CGI correlates –in a positive and moderate manner– with incoherence (0.478), with lack of logics (0.478), with neologism (0.392), with perseverance (0.438). This means when the CGI increases the other variables increase and vice versa.
The CGI is correlated –in a strong and positive manner– with the EEAG (0.786), tangentiality (0.534), loss of objectives (0,658) and the dimension of disconnection (0.617). This means when CGI increases so do these variables. Contrariwise when it decreases.

DISCUSSION

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Patients included in our work are medium elderly people (61.47 years old), with a low schooling degree, with many years of evolution of the disease, with a high median of admission (19.47 years old). With a very high severity score (CGI: 5.8) and a very low degree of functionality (EEAG: 32.5). Such a long stay is necessary, in order to guarantee proper assistance and treatment to people with these disease characteristics. In fact –after using out all family resources– a significant amount of patients have endured alternatives or various resources, such as protected floors or assisted residences. All of them are under psychopharmacological treatment with antipsychotics and psychotherapy in their various individual and group forms. For some authors, this type of patients with severe scyzophrenia who require hospital admission, have a poor evolution and do not respond to medications, and could represent a subgroup named as Kraepelins(20, 21). In their evolution, these patients continue with psychotic symptomatology, with more negative symptoms and higher deterioration(22). Regarding severity (measured by CGI), language disorders and communication are some of the most disabling symptoms of scyzophrenia. Severe impairments in communication typify severe schizophrenic patients who are not capable to take care of themselves and with long periods of admission to receive care. Two communication dimensions are quite important: decrease of verbal production (poverty of speech or alogia) and connection impairment or speech disconnection(23). These seem to be stable features during part of scyzophrenia progression. A work with 180 psychiatric patients. They were prospectively diagnosed –at an early stage of the disease– had a follow-up program and their thought disorders were evaluated at 2, 4,5 and 7.5 years after hospitalization(24). When aging an increasing poverty of speech(25) seems to appear. It is correlated with cognitive impairment. In other longitudinal work(26), language poverty worsening is confirmed in time in elderly patients. Decrease of verbal productivity in time complements previous studies confirming an impairment of cognitive and functional skills in this time of life. The importance of communication disturbances and their functional/labor implications in patients with scyzophrenia (measured by us with the EEAG) have been more documented during the last few years. Harrow(27) found that formal/more severe/persistent thought disorders (i.e. disconnected speech) was correlated with a poorer/pre-morbid labor adjustment, rehospitalization and global deficits in adaptive functions, such as work. In this way, it predicts 12% of variance in labor functioning after 7.5 years of follow-up. In other work(28) patients with thought disorders were found to have higher rates of unemployment and rehospitalization. In a full-scale study, Keefe(29) found that total scores –in a measure of formal disorder of thought– were one of the main discriminators between patients with scyzophrenia who were fully and persistently disabled for 5 years or more and those who were not. Racenstein et al.(30) found that a severe/persistent formal disorder of thought was correlated with a poorer labor adjustment, in three follow-up cases made during 8 years. Suggesting that techniques minimizing thought disorders may have an application aimed to improve labor functioning in people suffering chronic schizophrenic disorders. Bowie et al(31) performed a study in 317 patients with chronically institutionalized scyzophrenia. They found that disconnected speech was significantly correlated with rude social behavior; while low verbal productivity was correlated with lack of social contact and fewer friends. Verbal under productivity predicted follow-up social skills, social commitment and friendship. In a study with 90 people suffering scyzophrenia –who lived in a community– Bowie et al(32) concluded that communication disturbances (disconnected speech and verbal under productivity) predict social functioning better than cognitive deficits in scyzophrenia. Communication disturbances are correlated with skills and specific social conducts and may be under treatment. In this way: social conduct qualified by the observer was predicted by verbal under productivity, while socially acceptable conduct was predicted by neurocognition and disconnected speech. Verbal under productivity and neurocognition predicted a higher impairment in self-informed quality of life. Other authors(33) found that verbal under productivity seem to affect daily functioning and relationships with others, while disconnected speech predicts life satisfaction. Muralidharan et al.(34) found that disconnected speech predicted occupational functioning, while verbal under productivity predicted the skill to properly communicate in social scenarios, as well as community functioning, by means of interpersonal/occupational/daily life domains. In another recent meta-analysis(35), thought disorders and social functioning disturbances are the main symptoms of scyzophrenia, but the strength of this correlation is still unclear. 13 studies, with 1,478 participants were reviewed. A small-median inverse correlation between language disorders and social functioning was observed. It seems evident that language/communication disturbances in schizophrenic patients are correlated with labor/social functioning, which is quite important for daily life of these people. A poor/incoherent speech hinders social/professional relationships, as well as work opportunities, or participation in community life.

CONCLUSIONS

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Elderly patients suffering scyzophrenia, who have a long-term admission, have a very high degree of severity and a very low degree of functionality, with language disturbances, especially poverty of speech, but also verbal disconnection.  Their scores range from mild to moderate.
Both TLC subscales are correlated with severity of the disease. The Disconnection Scale is higher in patients with worse functionality.
Language disturbances in scyzophrenia are correlated with severity and functionality, which has significant consequences in the lives of people who suffer this disease.

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