Language and Schizophrenia

Perspectives from Psychology and Philosophy

Valentina Cardella

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138565906
• eBook ISBN: 9781351344630
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

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 language using cognitive psychology alongside the opposing field of phenomenological 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.

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.

Mr Matthews insists that in some apartment near London Wall there is a gang of villains profoundly skilled in Pneumatic Chemistry, who assail him by means of an Air Loom. [...] The effects which are produced on Mr. Matthews by the skilful manipulation of these ingredients are according to his relation dreadful in the extreme. [Among these we find] the cutting soul from senses, so that the sentiments of the heart can have no communication with the operations of the intellect; the fluid locking, a locking or constriction of the fibres of the root of the tongue, by which the readiness of speech is impeded; thought-making, where one of the gang will force into his mind a train of ideas very different from the real object of his thoughts. [The members of the gang] impart their voices to him by voice-sayings. This is an immediate conveyance of articulate sound to the auditory nerves, without producing the ordinary vibration of air; so that the communication is intelligibly lodged in the cavity of the ear, whilst the bystander is not sensible of any impression.

(Haslam, 1810: 19–40)

Matthew’s delusion presents many features now considered peculiar to schizophrenia. The references to voices, to different kinds of persecutors, to bizarre machines like the air loom, and to thought insertion make the diagnosis of paranoid schizophrenia very likely.

After a few decades, a new attestation of schizophrenia appears, but this time it is in first person: that of John Thomas Perceval. His story begins with these words:

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 undoubtedly 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 difficult to find in the descriptions by ancient authors. The same is not valid for depression or mania, for example: disorders characterised by symptoms 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 schizophrenia, and they often paid close attention to details that we regard as irrelevant’ (Stone, 2006: 2). Schizophrenia is a very complex disorder that not only exhibits very different symptoms, but that also changed some of its expressions over the years. As highlighted by Gilman (2008), some ‘versions’ of schizophrenia behaved like hysteria, which was well known to be extensively widespread in the Viennese society in the nineteenth century and has now become a clinical rarity. For example, waxy flexibility, regarded as one of the most common forms of schizophrenia in the 1800s, has now almost disappeared. Finally, as I already pointed out, symptoms of mood disorders (like wild motions or pressured speech in mania, or apathy and affective indifference in depression) are more noticeable, while the schizophrenic ones are not always that easy to identify. For example, what is the difference between a bizarre belief and a delusion? How can we discern, without a further analysis, between strong jealousy and delusional jealousy, or between inflated suspiciousness and persecutory delusion?

Actually, if we take a look at the psychiatric literature, we can find some attempts to retrace a history of schizophrenia. References to possible cases of schizophrenia in the Egyptian world, ancient Greece, the medieval era, the Renaissance, and the modern era are shown by those authors who were faced with the hard problem of tracing a history of psychiatry (see Hunter and Macalpine, 1963; Macdonald, 1981; Howells, 1993; Sedler, 1993; Berrios and Porter, 1995; Carlsson, 2003; Stone, 2006). However, for the reasons I mentioned before, such a history, when faced with schizophrenia, runs the risk to be only a projection on past of the actual diagnostic criteria.

Thus, the best way to proceed is probably by trying to retrace a history of the concept of schizophrenia, rather than a history of schizophrenia. This seems to be a much easier task, because there is no doubt that the concept of schizophrenia was born in the twentieth century, grounded in the psychopathological categories of the 1800s. In the next paragraphs, I will trace a brief history of ideas, underlining the role of those authors who tried to delimitate the notion of schizophrenia.

Yet, before doing this, I have to make a premise: when dealing with schizophrenia, it is important to separate myth from reality. There are a number of myths surrounding schizophrenia. As we will see, despite the huge amount of studies about its symptoms, diagnosis, and possible causes, this mental disorder is hard to catch in its essence. There are many ways to interpret this difficulty. According to some, the impossibility to grasp the essence of schizophrenia descends from the fact that this disorder would actually be a convenient cultural construct, because its symptoms are so different from case to case that claiming we have before us the same disease is a stretch (Szasz, 1961). How can we consider as affected by the same disorder a boy who accuses his parents of poisoning him, a woman who suffers from emotive indifference, and a girl dominated by a sense of unreality who feels that her body does not belong to her? Can we use the same term for such different manifestations? In his book, Shean claims that ‘we do not presently know what causes schizophrenia, nor do we know that the term refers to a single disorder. We continue to use the term for lack of a better or widely acceptable alternative’ (2004: 95). Additionally, some authors go beyond this, claiming that schizophrenia is a myth, in the sense that we talk of it as it actually exists, but this is not true (Hammersley and McLaughlin, 2010). According to this view, schizophrenia would be a sort of ‘sublime’ of the psychiatry, a complex object representing the limits of this discipline, used many times to characterise different aspects of contemporary society rather than a mental disorder—in other words, an ‘awash’ concept whose representation deeply depends on the cultural theory of reference (Woods, 2011).

On the other hand, the fact that schizophrenia affected ‘gifted’ people (like Hölderlin or John Nash, just to give two impressive examples) nurtures this myth. This is the reason why people can consider schizophrenia as a sort of price for genius, a disease the human species suffers from because it makes humans more creative (see, for example, Eysenck, 1995; Nettle and Clegg, 2006). This is the romantic view of schizophrenia, according to which madness and genius are intertwined. Yet, it is a state of fact that the schizophrenic subjects who reached unimaginable peaks of creativity are very few, compared to all those who have to fight every day against a devastating disease that affects many aspects of their social lives. Also, in many cases, creativity and genius survived in spite of the disease rather than thanks to it; one can think of the way schizophrenia leaked in Artaud’s poetry so that it completely destroyed its meaning (Pennisi, 1998). Thus, we must resist the temptation to make schizophrenia romantic without ceding to the opposite temptation, that of considering it something terrifying and beyond comprehension.

In fact, the label ‘schizophrenia’ seems to be weak from a diagnostic and scientific point of view, but very strong from a social and moral point of view. The label of ‘mentally ill’ (and, above all, that of schizophrenic) has the effect of taking away every meaning from the actions and the words of the labelled subject, and for this reason it becomes a sentence: the more implacable, the more schizophrenia is seen as something obscure, disturbing, and hard to define. In his classic experiment, David Rosenhan showed the effect of psychiatric labels and the way they affect the global perception of someone’s behaviour (Rosenhan, 1973). The aim of the experiment was to insert some pseudo-patients (normal people who never suffered from mental disorders) in different American hospital units, where they claimed to suffer from auditory hallucinations, and to verify when and how they would be recognised as normal subjects. What actually happened was that all the pseudo-patients (except one) were declared schizophrenic, and at the moment they left the hospital they were diagnosed as schizophrenics in remission (clearly because they did not show symptoms of any kind). This experiment showed the stability and endurance of schizophrenia’s label. As Rosenhan declares, ‘once being labelled as schizophrenic, there is nothing that the pseudo-patient can do to release from this label’ (Rosenhan, 1973: 253). Each behaviour, each word, and each emotion were considered a product of the disease: if a patient walked up and down the aisle, he was clearly nervous; if he lined up too early in the coffee bar, he showed the oral nature of his disorder; if he admitted that his relationship with his mother had highs and lows, he revealed the typical schizophrenic ambivalence. Given that it is in general hard to get rid of any kind of label shared by a social group, how careful should we have 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.

Patients with neither desires nor fear

During the nineteenth century, psychiatry found its place inside the medical discipline. The explosion of interest towards mental disorders concurs in fact with increasing studies on the human brain and on the way brain injuries affect how people think and behave. The idea that mental disorders were actually brain disorders begins to spread, and with it the belief that in the near future a clear aetiology of each mental illness will be founded. However, this increasing optimism about the possibility to identify the organic causes of mental disorders combines with a similar increasing discontent, which refers to questions that are still wide open: How many kinds of mental disorders can be identified? How can we classify them and on what basis?

Actually, in this period, there were essentially two positions on that matter. The first one is well documented by the following quotation, based on the Textbook of Psychiatry by Neumann: ‘there is only one type of mental disorder. We call it madness’ (Neumann, 1859: 67). Others, on the other hand, as shown by Jaspers, claim that psychiatry’s purpose must be to find some natural morbid entities with characteristic symptomatology, course, and somatics, and among which there are no passages (Jaspers, 1959). According to these authors, there are distinct nosological entities with different symptoms and that need to be investigated separately. Yet, this perspective raises a new question: how can we classify these morbid entities? In fact, an inaccurate analysis risks increasing the number of single mental disorders, producing chaos rather than order. Heinroth, for example, identifies an impressive 48 types of mental disorders, and he concludes that the criteria adopted so far in order to distinguish mental disorders are totally unreliable (see Kyziridis, 2005).

As it is well known, it is Kraepelin (1896) who organises the different types of mental disorders, grounding his classification in a series of elements that all need to be taken into account if one wants to avoid an excessive increasing of the different morbid entities. According to Kraepelin, in order to obtain an accurate classification, we must consider not only the symptoms (that constitute the psychological form of each disorder), but also the triad of onset-course-outcome. Mental disorders with similar symptoms but different outcomes must be considered as two different disorders (for example, schizophrenia and paranoia, which share many symptoms, are actually two different diseases for their different outcomes, because the former implies a progressive deterioration, while the latter does not), whereas disorders with different symptoms, when following the same course, have to be considered as different forms of the same disorder (as in the different subgroups of schizophrenia).

Kraepelin also has the merit to give a well-defined picture of schizophrenia. In order to clearly separate it from the other forms of mental disorder, he refers, on one hand, to the huge amount of clinical cases he had the chance to observe (some directly, but the majority through the analysis of medical records—the so-called Zählkarten) and, on the other, to previous studies by other researchers like Morel, Kahlbaum, and Hecker. Kraepelin adopts Morel’s name, dementia praecox, to identify schizophrenia. With this term, Morel referred to a specific mental disorder deriving from some hereditary defect that affected young patients and involved the loss of coherence and unity in different fields of intelligence, behaviour, and affect (Morel, 1860; Stone, 2006). Morel illustrated this expression’s meaning by referring to one of his patients:

This youth of 14 years of age progressively forgot all he had learned at school; his brilliant intellectual faculties underwent a very disquieting interruption. A kind of torpor close to hebetude took over from his earlier activities, and when I saw him again I felt that the fatal transition to the state of premature dementia was underway.

(Morel, 1860: 566)

At first, Kraepelin (1883) uses the expression dementia praecox to define a schizophrenic subtype, the one Hecker (1871) had called hebephrenia, with main features including a rapid form of cognitive degeneration and a final outcome characterised by extreme dementia and inappropriate thoughts and feelings. In this first classification, the other two schizophrenic subgroups, catatonia and paranoia, are still considered two independent entities. It is only in 1896 that Kraepelin groups the separate categories of hebephrenia, catatonia, and paranoia into one cluster, that of dementia praecox. The hebephrenic subgroup remains quite the same, and two additional forms of dementia praecox (the catatonic and the paranoid ones) are added to it. In detail, Kraepelin uses Kahlbaum’s term catatonia (Kahlbaum, 1874), which in the original meaning referred to a form of mental deterioration associated with muscular rigidity, stupor, peculiar postures and manners, and verbigeration. Kraepelin adds to these symptoms the so-called negativism, where voluntary impulses are repeatedly overcome by contrary impulses (for example, a patient can move his hand to grasp an object and stop himself in the middle of the action, putting his hand in the original position) or where there is an obstinate refusal of carrying out any action. Finally, according to Kraepelin, paranoid dementia’s features are delusional ideas associated with hallucinations and 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 apparently develops on the basis of a severe disease process in the cerebral cortex’; Kraepelin, 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 believed 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 common 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 symptoms’ 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:

As the disease progresses the absence of emotion becomes more mark...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgments
• Introduction
• 1 The enigma of schizophrenia
• 2 Language in schizophrenia
• 3 The cognitive perspective on schizophrenic language
• 4 The philosophical perspective on schizophrenic language
• 5 An alternative view: schizophrenia as a disease of language
• References
• Index