Australian and New Zealand Journal of Psychiatry (1982) 1 6 1 1-21

LANGUAGE ANALYSIS IN SCHIZOPHRENIA: DIAGNOSTIC IMPLICATIONS

RODNEY D. MORICE and JOHN C. L. INGRAM
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Language profiles were developed for schizophrenic, manic and nonpsychotic control subjects from the analysis of free speech samples. The profiles comprised syntactic variables reflecting the complexity, integrity and fluency of spoken language. Linguistic differences between the 3 diagnostic groups enabled accurate (95%) classification by discriminant function analysis. The results suggest an important role for language analysis in psychiatric diagnosis.

Disorders of thought and speech are usually regarded as central to the concept and symptomatology of schizophrenia. The two sets of disorders are frequently confused, and the confusion is compounded by a widely variable terminology. To some, thought disorder refers to subjective changes experienced and reported by the patient, while observed alterations to spoken or written language are referred to as speech or language disorders. Others use these latter changes as evidence for the presence of formal thought disorder. Apart from terminological confusion, there is argument as to the primacy of thought or language in the undisputed relationship between the two cognitive phenomena. Until recently most authors have ascribed thought primacy over language, with the result that descriptions of thought disorders have, with few exceptions, paid scant attention to the possible role of primary language breakdown in their genesis. Kraepelin ( 197 1 ) described disorders of both thought and speech, assuming the latter to be largely due to derailments and incoherence of the train of thought. His ukatuphusiu was defined as . . . derailments in the expression o f thought in speech e.70). He did, however, refer to disorders of the syntax of speech, which in the more severe cases presented as telegraphic speech. Paraphasias and neologisms, which could be subsumed as word level errors, were also described and defined. Bleuleis (1950) ranking of thought and speech disorders was even further separated. Disorders of association of thoughts were ranked as the first of

the altered simple functions of his fundamental symptoms, while disorders of speech and writing ranked fifth in his list of accessory symptoms. While he reluctantly admitted that most disorders of thought could only be deduced from the speech of patiezts, he added that the abnormality does not lie m the language itself, but rather in its content @. 147). Despite this, he described every imaginable abnormality of linguistic expression, including misuse of auxiliary verbs, and other grammatical errors. Kurt Schneider (1959) regarded disorders of association of thoughts, as expressed in speech, as being of limited value in the diagnosis of schizophrenia, but apparently on grounds of reliability: Abnormalities of expression must take second place, since they are so largely a function of the interviewers impression and provide an easy source of subjective error (p.132). As Bleuler and Schneider have been, until reahtly, the predominant influences on diagnostic practices with reference to schizophrenia, it is not surprising that few attempts have been made to characterize schizophrenic speech from a linguistic or psycholinguistic point of view. Pavy, in a review of verbal behaviour in schizophrenia written in 1968, was mostly able only to review word association, cloze technique ( the effect of regular word deletion on the comprehensibility of a text), and type-token ratio (the ratio between the number of different word types and the total number of words) research. He noted the lack of detailed linguistic studies,

12

LANGUAGE ANALYSIS I N SCHIZOPHRENIA

especially those which might address the issue of the linguistic competence, or the intrinsic knowledge of the rules of language, of the schizophrenic speaker. Maher (1972) reviewing the language of schizophrenia four years later, covered virtually the same ground. In offering an interpretation for language disorders, he imputed an attentional deficit. While he acknowledged the occasional occurrence of disturbances of syntax, he concluded that many, perhaps most of the disturbances of language found amongst schizophrenic patients do not involve syntactic errors (p.13). At the same time, he reported the absence of any data from the sophisticated analysis of syntactically disturbed utterances @. 13). Linguists and psycholinguists have only recently begun to examine schizophrenic language. Chaika ( 1974) articulated six characteristics from the language analysis of one schizophrenic patient. Fromkin (1975) claimed in response that all but disruption in the ability to apply rules of syntax and discourse were prevalent in normal speech as speech errors and slips of the tongue. Rules of discourse have been examined by Rochester et al. (1977) employing a cohesion analysis, after the method of Halliday and Hasan (1976). Schizophrenic speakers used less cohesion, or linking devices, in their discourse than normal speakers. On finer analysis, thought-disordered schizophrenics used less conjunction cohesion (ties employing grammatical conjunctions - and, or, but) and more lexical cohesion (ties at the word level, eg. car-vehicle) than non-thought-disordered schizophrenics and normal speakers. The results were interpreted as evidence of an interpersonal failure. Using similar methods, Wykes and Leff (1981) contrasted schizophrenic and manic subjects who had been rated for incoherent speech on the Present State Examination. Total cohesive ties separated the two groups (p = 0.0002), with manics demonstrating the greater number. Durbin and Martin (1977) studied six manic subjects, reporting a disruption of certain cohesion strategies (such as ellipsis, the strategy of deleting redundant words) with the preservation of basic linguistic competence. In fact, while cohesion in discourse employs linguistic devices, it could be argued that it is predominantly a communication strategy, so that reduced cohesion might indicate an impairment of communicative competence rather than more specific linguistic competence. In one of the few studies that could be said to address linguistic competence, Fylyshyn ( 1970) reported that syntax scores, scores derived from verb phrase analysis, were more successful than stylistic markers (such as the total number of

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words, the number of questions etc.) in discriminating diagnostic groups. His study is also of interest in that it employed a limited automated parsing program in the analysis. Using a clinical approach, Andreasen ( 1979a, 1979b,) recently attempted to formalize the characteristics of formal thought disorder as represented in the speech of psychiatric subjects. She defined 20 such characteristics, and of the 18 for which she reported inter-rater reliability figures, 12 carried excellent to acceptable reliability. Using 10 variables (poverty of speech, poverty of content of speech, pressure of speech, distractible speech, tangentiality, derailment, incoherence, illogicality, loss of goal, perseveration), discriminant analysis was able to identify correctly 95.2% of schimphrenics (n 45) and 68.8% of manics (n 32). Impressive as these results are within a research context, any attempt to use the criteria on a broad clincial basis would almost certainly reduce interrater reliability. Judgements as to what constitutes derailment or poverty of content of speech, while probably reliably consistent in extreme cases, may become more idiosyncratic as the speech more closely approximates normal speech. In such latter cases, assessments may prove to be as unreliable as those for loosening of association have been. Few attempts, then, have been made to provide descriptively-adequateaccounts of the syntax of the spoken language of schizophrenic or manic subjects. In this paper, an empirical, rule-governed approach will be used to describe the speech of schizophrenic, manic and normal subjects. The extent to which particular features characterize the diagnostic groups will be explored.
Method

Clinical subjects were selected from consecutive inpatient admissions to Glenside Psychiatric Hospital and Flinders Medical Centre, Adelaide, South Australia, who had received an admission diagnosis of schizophrenia or mania, and who consented to participation in the study. Control subjects were selected from paid volunteers from Flinders Medical Centre staff (nurses, orderlies, bank clerks, laboratory technicians, medical students), and were matched to fall between the two patient groups on sex, age, education standard reached, and social class (occupation of father). All subjects, including controls, were Australian-born, with English as their first language, and each had at least completed primary school education. No subject showed any evidence of mental retardation, brain damage, or alcohol or drug abuse. The Present State Examination of Wing et al. (1974) was administered to all subjects, and only

RODNEYD. MORIC'E A N D JOHN C. L. INGRAM

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those who received a CATEGO diagnosis of schizophrenia (ICD-8, 295.0 - 295.3) or mania (ICD-8,296.1, 296.3), or, in the case of the controls, of no psychiatric disordez were included in the study. Seven patients and 5 controls were excluded through f a i h g to receive a CATEGO diagnosis (3 patients), receiving a different diagnosis (4 patients) 06 in the case of the controls, through receiving a psychiatric diagnosis. Thirty-four schizophrenics, 1 I manics and 18 controls remained in the study. Of the 34 CATEGO-schizophrenics, 4 (12%) had been given an admission (clinical) diagnosis of mania, and of the 1 1 CATEGO-manics, 6 (55%) received an admission diagnosis of schizophrenia (5) or schizoaffective disorder (1). Demographic characteristics of the final study population are listed in Table 1. Age and sex differences between the schizophrenic and manic groups were to be expected on clinical grounds. Approximately one-fifth of the schizophrenics and controls (21% and 22% respectively), and nearly half of the manic group (45%) had undertaken some tertiary education. The remainder had completed various levels of secondary education, except for two schizophrenics (6%) who had not proceeded beyond the completion of primary education. Social class assignment was based on the occupation of the subject's father. No significant differences existed between the groups on the demographic variables, except for the age difference between the schizophrenics and the manics.
TABLE 1 Demographic characteristics of study population

TABLE 2 Previous psychiatric admission and duration of illness data for patient population Schizophrenics (n34) Previous psychiatric admissions (%)* Manics

0 . 1-4 '5

10 (29) 15 (44) 8 (24)

1 (9) 9 (82) I (9)

Duration of illness (%): (from onset)

1-6 months 6 months2 years 2- 10 years >I0 years

9 (27) 10 (29) 7 (21) 8 (23) 22.3 (4.5) 13-35

0 (0)
3 (27) 6 (55) 2 (18) 30.2 (9.5) 18-46

Age of onset:+ Mean (S.D.) Range

*Data missing for 1 schizophrenic subject +t = 3.77, df = 43, p <.001 (2-tailed t-test)

,Previous psychiatric admission and duration of illness data are presented in Table 2. More schizophrenics than manics were either experiencing their first psychiatric admission or had been admitted previously on multiple occasions, but these differences did not reach statistical significance (x2 = 4.28, df = 2, p<.l). Nine schizophrenics (26%) had a duration of illness of less than 6 months. While DSM-I11 would have

Schizophrenics (n 34) Sex (76): Age: * Education standard reached (70): male female mean (S.D.) range 24 (71) 10 (29) 26.7 (6.3) 15 -,41

Manics (n 11)

36.5 (9.6) 20 - 5 1

31.6 (12.3) 20 - 65

primary secondary matriculation or post-secondary (eg. nursing) tertiary

1. professional 2. managerial 3. clerical/ commercial 4. skilled trade 5 . unskilled

2 (6) 19 (56) 6 (17)

7 (21)

0 (0) 4 (36) 2 (18)

5 (46)

0 (0) 7 (39) 7 (39) 4 (22) 2 (11) 2 (11) 9 (50) 4 (22)

1 (6)

Social class' (%):

3 (9) 4 (12) 7 (22) 12 (38) 6 (19)

3 (30) 3 (30)
1 (10) 2 (20) 1 (10)

'Age: Schizophrenics/manics, t = 3.92, df = 43, p <.001 (2-tailed t-test). No other significant differences. +Social class based on father's occupation. Information missing for 2 schizophrenics and 1 manic.

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L A N C ~ C I AANALYSIS GI: IN

SCtlIZOPHRtNIA

classified them as schizophreniform disorder; they were included in the study as the CATEGO program does not take duration of illness into account in formulating a diagnosis. No manic subject had a duration of less than 6 months. Differences in age of onset between the schizophrenic and manic groups were highly significant @<.OO 1 .) Sixteen schizophrenics (47%) and 3 manics (27%) had experienced the onset of their illness by the age of 21 years. The Present State Examination and its attendant CATEGO diagnostic program place main emphasis on the presence or absence of Schneiderian firstrank symptoms. Not surprisingly therefore, no manic subject received a rating for thought insertion, broadcast, echo or block, nor for nonaffective auditory hallucinations. Thirteen schizophrenics (38%) and 2 manics (18%) were rated for incoherence of speech and/or flight of ideas (as defined by the PSE). Ratings for incoherent speech are not used by the CATEGO program in the diagnostic process. At the time of PSE administration and of speech sample collection all patients were receiving antipsychotic medication in widely ranging doses, except for 3 schizophrenics who had not received any medication, and a fourth schizophrenic who had only received a single 10 mg dose of haloperidol. As a group, the manics appeared clinically to be less sick than the schizophrenics, presumably responding more rapidly to antipsychotic medication. This is perhaps best reflected in the so-called PSE scores, weighted ratings for recorded symptoms. The mean for the schizophrenics was 27.4 (S.D. 11.1) and for the manics 16.8 (S.D. 6.2) @<O.Ol, 2-tailed t-test). Free speech samples of 1000 words were taperecorded for all subjects, who were asked to talk about anything they wished. Standard prompts, such as Perhaps you could talk about your family or Perhaps you could talk about a holiday, were used only if necessary. In general, prompts were needed only rarely, and most subjects discussed their life-history in a narrative style. Samples were transcribed from tape by the collector as soon after the collection as possible, so that relevant contextual remarks could be appended as necessary. Each transcription was checked for accuracy by an independent rater blind to the diagnosis and to patient/control status. Sentence boundaries were created in the continuous-flowing transcription according to pre-established linguistic rules, using syntax, intonation and meaning, in that ordeq and these boundaries were checked by the projects linguist (J.I.). Each major sentence consisted of one main (or independent) clause,

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together with its coordinated and/or subordinated (dependent) clauses, if present. A manual grammatical analysis was performed on each analysable sentence, using a series of scans, or passes, through each speech sample. The first scan globally allocated sentences to a wellformed or deviant status, and the second tagged word-level errors, such as neologisms, and speech dysfluencies, such as pause fillers and false starts. The third scan comprised the construction of a syntax tree diagram for each sentence, a procedure which captured both clause- and phrase-level structures. All grammatical errors were tagged and classified in a fourth scan. The entire grammatical analysis was checked by the projects linguist. All linguistic data, including the syntax trees, were placed on floppy disks, and a linguistic profile of 98 variables was generated for each subject using an Apple 11 Microcomputer and PSYCHLAN, (Heatley, 1982) a program package written for this project. The variables represent measures of complexity, variety, integrity and fluency of spoken language. Complexity refers to the basic structure of each sentence, with particular emphasis being placed on the amount, depth and site of embedding of dependent clauses, and on the use of coordination. The range and sequence of dependent clause types provides the main index of variety. The recording of errors and their classification and locus reflect the integrity of speech. Fluency of speech is represented by a dysfluency index which incorporates counts of pause fillers, repeated words and retraced false starts. The accuracy of the PSYCHLAN programs was checked by both the projects computer scientist and linguist. The independence of the complexity, integrity and fluency dimensions has been validated by a principal components analysis (Ingram and Morice, 1982). Data were analysed using programs from the Statistical Package for the Social Sciences (Nie et al., 1975).
Results

The 98 linguistic variables from each subjects profile are listed in the Appendix. They were subjected to a stepwise discriminant function analysis, after setting F to enter and to remove at 2.0. Seventeen variables were selected, and these allocated subjects to their PSE/CATEGO diagnostic groups with 95% accuracy (Table 3). Two functions were formed, which accounted for 82% and 18% of the variance respectively. In order to facilitate interpretation of the functions, varimax rotation was performed. The percentage of variance attributed to each function was changed to 56% and 44% respectively.

RODNEY D. MORICEA N D

JOHN

c. L. I N G R A M

15

TABLE 3 Classification results of discriminant function analysis using 17 variables, selected in stepwise procedure Actual group No. of casks Predicted group membership
1

Figure I Discriminant function analysis plot of function 1 scores (horizontal)by function, 2 scores (vertical) for 63 subjects. S = schizophrenic, M = manic, C = control. * indicates group centroid.

2 3 8.8% I1 1 o o . w o 0 0.0%

3 0 0.0% 0
0.0%

34 Group 1 Schizophrenics Group 2 11 Manics 18 Group 3 Controls

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31 91.2% 0 0.0% 0 0.0%

18 100.0%

ss

Percent of 'grouped' cases correctly classified: 95.24%

:
0
-2.

ss

S SM s MU S

The rotated standardized discriminant function coefficients are listed in Table 4. Table 5 lists the intergroup differences for each variable. The 'distance' between diagnostic groups, as represented by centroid values and by subject scores, is depicted in Figure 1. Each subject's position was determined by plotting scores on the two canonical variates after rotation. Discriminant function analysis selects a minimally redundant set of variables, so that many variables which accounted for significant differences between the groups were not selected in this analysis. Accordingly, the functions do not provide the clearest picture of the actual language characteristics of each group. Rather, the variables employed were selected to provide maximal separation between the groups. Function 1 separated schizophrenics from the rest (manics and controls). The asterisked variables of function 1 in Table 4 are those which provided the greatest power for this separation. In general, schizophrenics scored higher on the variables with
TABLE4 Rotated standardized discriminant function coefficients. Variable PWFM ERR PDC 20 MEMB PV3FM TRUSEN PSYNSEM PWHQ PROAG 1 PLOC 3 PEXC MCSA PSEMB POM PPF GRAMINS PVING Function I 2.36. 2.16. -1.09' 0.96* -0.89. 0.72' -0.67* -0.65* -0.64' 0.64.
-0.59* 0.58*

s s
S

5 s

ss
S

M M

SM
C

cc
C

C C 4

-c,

cc c cc cc
C

-4

-2

Function 2 -0.33 0.03 0.73 0.04 0.30 0.12 0.59 0.03 0.4I -0.07 0.53 -0.54
-1.18. -0.83* -0.53. 0.52' 0.50'

0.42 0.46 0.07 0.2 I -0.18

negative coefficients, and lower on those with positive coefficients. Schizophrenics as a group received low scores on several variables which represent the complexity of speech, such as the mean number of embedded clauses per complex sentence. The result was less complex speech. The other main linguistic dimension which discriminated the schizophrenics in this analysis related to the integrity of speech. The group receives a low score on the percentage of well-formed major sentence types, and, relative to the manics, a low score on total number of errors. However, on certain errors, arguably of a more serious nature, such as the percentage of sentences containing both semantic and syntactic errors, they received higher scores. Function 2 separated the controls from the rest (schizophrenics and manics). The asterisked variables of function 2 in Table 4 indicate those with greatest power in effecting this separation. As a group, the controls obtained high scores on the percentage of sentences containing embedded clauses, indicating a wider distribution of complex sentences within their speech. While they made fewer errors overall than manics or schizophrenics, when they did occur, controls made relatively more errors of omission than either sentence-level errors or errors of commission. The speech of controls was less fluent, as indicated by a high score on the percentage of pause fillers in the samples, although

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LANGUAGE ANALYSIS IN SCHIZOPHRENIA

TABLE 5. Means, standard deviations and t-test results for variables selected in the discriminant function analysis Variable Mean (SD) PWFM ERR PDC 20 MEMB PV3FM TRUSEN PSYNSEM PWHQ PROAG 1 PLOC 3 PEXC MCSA PSEMB POM PPF GRAMINS PVlNG Schizophrenics Manics
(n = 11)
75.80 (10.09) 27.55 (15.38) 4.72 (2.64) 1.83 (0.46) 2.18 (1.59) 4.09 (3.15) 0.20 (0.45) 6.36 (15.67) 0.18 (0.41) 51.38 (9.81) 0 (0) 0.29 (0.14) 47.47 34.74 2.28 1.18 4.86 (11.29) (17.90) (1.77) (1.25) (2.42)

(n = 34)
77.5 (12.07) 21.68 (11.37) 5.31 (3.70) 1.61 (0.33) 3.52 (1.93) 3.56 (2.76) 0.62 (0.97) 22.45 (34.19) 0.12 (0.33) 40.08 (12.97) 2.94 (17.15) 0.29 (0.12) 45.38 40.14 4.49 0.56 4.04 (10.54) (21.99) (3.19) (0.71) (2.15)

Controls (n = 18)
85.21 (5.37) 13.11 (4.51) 2.77 (2.30) 1.94 (0.28) 3.04 (1.49) 1.67 (1.25)

S/M
n.s.

M/C Significance
0.013 0.01 1 0.046 ns.

S/C
0.003 O.OO0

ns. n.s. n.s. 0.044 n.s.

0.057 0.039

ns.
0.012 0.07 1

0 (0)
19.44 (38.88) 0.06 (0.24) 45.92 ( I 1.22)

0.004 0.00 I n.s. 0.000 0.009

ns.
0.011

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0 (0) 0.39 (0.1 I)

54.42 53.22 5.48 0.78 5.21
(10.01) (18.15) (2.45) (0.81) (2.42)

ns.
n.s.

n.s. ns. n.s. n.s.

0.03 1 0.095 0.013 0.001

ns. ns. ns.

n.s.
0.005

ns. n.s.
0.035

0.004
0.036 n.s.

ns. n.s.

n.s. n.s.

ns.
0.08 1

this measure separated them more from the manic group, which was very fluent, than from the schizophrenic group. It should be noted in Table 5 that several variables were either of a very low frequency or failed to differentiate significantly between groups. These variables, such as errors of pronoun agreement, type I (PROAG I,) percentage of marked sentences of an exclamatory type (PEXC) and errors composed of non-functional grammatical insertions (GRAMINS), had obviously been selected by the analysis to discriminate only a few (or even single) subjects. Their utility with a different group of subjects may be limited. Discriminant function scores for the 63 subjects from which the 2 functions were derived were used to classify the subjects back into their diagnostic groups. This constituted a measure of the validity of the discriminant analysis. Three subjects were changed from their PSE/ CATEGO diagnosis of schizophrenia by this classification phase of the analysis. The first was a 27 year old single male in his first psychiatric admission. Symptoms had been present for less than a week, and comprised restlessness, subjective ideomotor pressure, delusions of misinterpretation, grandiose delusions, agitation, hypomanic affect, lability of mood, pressure of speech and incoherence of speech. CATEGO would have diagnosed mania had it not been for a positive rating on delusions of control, a Schneiderian first-rank symptom. The discriminant analysis, using his linguistic profile only, allocated him to the manic group. His admission (clinical) diagnosis was mania. The second subject reallocated was a 37 year old divorced female, with a two year history and one

previous admission for schizophrenia. Her clinical diagnosis on this second admission coincided with her PSE/CATEGO diagnosis. She was rated for thought insertion, broadcast and withdrawal, delusional mood and delusions of misinterpretation and of altered bodily appearance. The discriminant analysis allocated her to the manic group. The late age of onset of her psychotic illness (35 years) would lend support to the linguistic diagnosis. The third subject was a 29 year old married female with an 11 year history of schizophrenia, although over recent years a more obvious affective component had been reported. This was reflected in her PSE, in which she was rated for both depressed mood and expansive mood, and for grandiose delusions, on the basis of her symptoms over the preceding month. Howevel; she was also rated on non-verbal auditory hallucinations, delusions of misinterpretation, and on thought insertion and echo. These latter ratings assured her CATEGO diagnosis of schizophrenia. Her linguistic profile reallocated her to the manic group. No manic or control subjects were reallocated to different diagnostic groups following discriminant analysis of their linguistic profiles. As the discriminant functions were formed from the subjects whom they subsequently classified diagnostically, the allocation results were probably spuriously high. In the absence of a group of subjects for an immediate replication study, the original subjects were partitioned into two unequal groups, the larger (n 50) being used to generate two discriminant functions from the same 17 variables. The discriminant analysis on these 50 subjects achieved a 96% correct diagnostic allocation, reallocating the 37 year old female to the manic

RODNEYD.

M O R l C t A N D JOHN

c. L. I N G R A M

17

group, and the 29 year old female to the control group. When the remaining 13 subjects were submitted to the functions derived from the 50 subjects, 11 (85%) were correctly allocated. Two were reallocated the 27 year old male described above, and a 36 year old single male with a 15 year history of manic depressive psychosis, resulting in four previous inpatient admissions. He had been given a CATEGO diagnosis of schizophrenia on the basis of a rating for audible thoughts, but his other symptoms included expansive mood, subjective ideomotor pressure, grandiose delusions, hypomanic affect, incoherence of speech, changed perception of time, and delusions of reference and misinterpretation. The discriminant analysis using the partitioned groups reallocated him to the manic group, similar to his admission diagnosis. Attempting a partitioning closer to a 'splithalves', functions were derived from 37 subjects, and the remaining 26 assessed by them. Of the original 37, 35 (95%) were allocated correctly, with the same two women described above being reallocated. Only 18 of the remaining 26 (69%) were correctly allocated, suggesting that a data base of 37 subjects was not large enough to form robust discriminant functions. While only age among the demographic variables reached statistical significance between the diagnostic groups (Table l), the presence of some nonsignificant differences with respect to sex, education and social class indicated the need for closer scrutiny of any effects they might have had on the discriminant analysis. One-way analyses of variance were performed on the two discriminant function scores by the four demographic variables. The results are presented in Table 6. The significance of sex on Function 1 at the 5% level and on Function 2 at less than 10% reflects the different sex ratios in the diagnostic groups. This could have contributed a little to the discriminating power of the functions, and indicates the desirability of a more stringent controlling for sex in a replication study. The significant effect of education standard reached on Function 2 at the 1% level is more
TABLE 6 . ANOVA results from discriminant function scores by

apparent than real. Function 2 separates controls from schizophrenics and manics. The only significant difference in Function 2 scores occurred between the matriculation/post-secondary group and the tertiary group. The former group contained an over-representationof control subjects, by virtue of their selection from a hospital-complex staff (see Table I). Therefore, the effect on Function 2 is probably one of diagnostic group rather than education per se.
Comment

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demographic variables

F ratio
Function I
Age Sex Education Social class

Function 2
0.197 3.622b 3.904' 1.760

1.812 3.82@ 0.964 I .27 1

Linguistic differences of a predominantly syntactic nature exist between schizophrenic, manic and non-psychiatric control subjects. The results of discriminant function analysis suggest that these differences could be used diagnostically. However, until a blind replication study can be conducted, using the discriminant functions formed on these 63 subjects to allocate the new subjects to diagnostic groups, circumspection must be exercised. Results from a limited partitioning of the original subjects support the likely stability of the variables used to discriminate the groups, but satisfactory results on replication will be necessary to justify fully the use of a relatively large number of variables, and to prove their reliability. For the demonstrated linguistic differences to be of consistent empirical value in diagnosis, the nature and causes of the differences should be due to disease-specific factors, and not to coincidental ones. Potentially, differences in speech performance may be due to many factors, including social class (Bernstein, 1958) and education. Matching of subjects attempted to minimize any such effects, but perfect matching could not be achieved because of the different epidemiological features of schizophrenia and mania, and because of limited availability of subjects. Analyses of variance, howevet demonstrated that the variables used to form the discriminant functions were not significantly affected by social class differences between the three groups. Apparent effects due to education differences were probably artefactual. Content of speech may influence its structure, as may context. For example, a prepared lecture on an esoteric subject is likely to be more grammatically complex than an informal chat over a drink. For all subjects the context was identical, although the evaluation of the context may have differed between patients and controls, as it may have done between patients. Most subjects talked about their past or present life, using a predominantly narrative style. Differences in content which did occur are unlikely to have substantially altered the structural measures employed, as they are relatively independent of meaning. Howevet future studies

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LANGUAGE

ANALYSIS IN

SCHlZOPHRENlA

should include the use of standardized stimuli for speech sample collection in order to confirm this assumption. Anxiety, either disorder-related or situational, might potentially produce less complex speech with higher error rates and greater dysfluency. Six schizophrenics (18% were rated positively on the PSE for subjective anxiety, and two (6%) for observed anxiety. For the 17 variables used in the discriminant analysis, no significant differences separated the anxiety-rated schizophrenicsfrom the remaining schizophrenics. Only one control (6%) and no manics were rated positively for anxiety. Anxiety did not appear to affect the linguistic variables used in this analysis. All patients except for three schizophrenics were receiving antipsychotic medication. At an observational level, articulation of speech did not appear to be affected apart from occasional slurring, which was not rated. Significantly, the manics were receiving equivalent doses of antipsychotics to the schizophrenics, so that the differences on fluency measures noted between schizophrenics and manics cannot be explained by medication effects. In fact, Hymowitz and Spohn (1980) have reported an increase in the complexity and coherence . . . and a decrease in pathological utterances in the speech of schizophrenics receiving medication as compared with a group during a drug-free period. It seems reasonable, then, to attribute the observed linguistic differences to specific effects of schizophrenia and mania, although whether these are specific language effects or more general cognitive or information processing effects could not be addressed by this study. Easiest differentiation was achieved between the schizophrenic and control groups. Multiple measures of complexity and integrity separated the groups at the 1% level or better, indicating that the speech of schizophrenics when compared to non-patients was either less complex in structure, or contained more errors, or both. It was more difficult to separate the schizophrenic and manic subjects using linguistic variables, although the discriminant analysis did achieve this. Fewer variables differentiated the two groups at the 1% level or better, and only one of these (the locus of maximum depth of embedding under the clausal object) was actually selected in the discriminant analysis. Manics, as a group, when using multiple levels of embedding of dependent clauses, sited the most deeply embedded clause under the top-level clausal object, while schizophrenics, as a group, sited their deepest dependent clause under the top-level clausal subject or pre-verbial adverbial clause. Embedding

under these latter two positions makes comprehension for the listener more difficult. Additionally, the speech of schizophrenics was less fluent, and contained significantly more semantic errors. There were also differences in complexity, with schizophrenic speech the less complex, but these differences only constituted a statistical trend @O. 1) Two factors may have induced an apparently greater similarity between schizophrenic And manic linguistic profiles than actually exists. First, the CATEGO program, by placing prime emphasis on the presence of Schneiderian first-rank symptoms, appeared to over-diagnose schizophrenia at the expense of mania. The use of more restricted diagnostic criteria in future studies may resolve this problem. Second, the small size of the manic group (1 1) could have limited inter-group differences, given the extent of the standard deviations of some of the variables. The potential value of language analysis as a diagnostic instrument will lie in its reliability and validity in discriminating schizophrenia from mania, more than in discriminating both from other psychiatric disorders and from no psychiatric disorder, although these latter discriminations would be of some clinical value. 'Tho further studies aimed at confirming this potential value are indicated. The first, mentioned above, is a blind replication study. Discriminant functions generated from the 63 subjects in this study should be used to allocate subjects from the replication study to diagnostic groups. Successful allocation would confirm the reliability of the language analysis, and would also demonstrate it to have equivalent validity to the PSE/CATEGO system, or to other diagnostic criteria if used. Furthez acceptable results on replication would enable a new set of discriminant functions to be formed from the larger, combined data-base of subjects from both studies. The larger the data-base, the more stable the discriminant functions should be. These could form the basis of a diagnostic package. The second study indicated is an examination of linguistic profiles over time and during treatment. Only from such a prospective study could changes due to an acute psychosis be separated from more stable process disorders specific to the underlying disease, if such differences exist. In the present study, speech samples were obtained at different times after onset of acute symptoms, and at different stages of severity. To maximize diagnostic differentiation, it may be important to collect samples at more uniform times. If the diagnostic efficacy of language analysis is proven by subsequent studies, in its current form it would hardly constitute a usable or practical

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RODNEY D. MORICE A N D JOHN C. L. INGRAM

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instrument. The main impediment lies in the expertise needed for, and time involved in, the manual stage of the grammatical analysis. Cert a d y PSYCHLAN, the computer program written to analyse the syntax tree diagrams, has been a significant advance in the general field of applied computer-assisted language analysis, but the construction of the syntax trees remains a non-trivial and time-consuming task. In parallel with replication and prospective studies, work should proceed on the development of an automated parsing program, which aims to reduce the manual component as much as possible. It is unlikely that completely automated parsing of sentences from natural languages will be accomplished, but the development of an interactive program using a human coder with only limited grammatical training should enable the development of language analysis into a practical, laboratory-type diagnostic test.

Acknowledgements

This work was supported by a grant from the National Health and Medical Research Council of Australia, by the Department of Psychiatry, Flinders University of South Australia (Prof R. Kalucy), and by the Mental Health Services Commission of Tasmania (Dr P. Eisen). We acknowledge the substantial contribution of our research assistants, especially Megan Smith (speech sample collection), Margaret Chandler (grammatical coding) and David Heatley (computer programs). Magie Brady and Dr Mike Georgeff participated in the planning stages of the study. Dr David Ratkowsky provided statistics advice. Professors R. Kendell, D. Kay and G. Andrews and Drs P. Eisen and M. Neilson gave constructive advice on earlier drafts of this paper.

Appendix
Variables in each linguistic profile (Variables selected in the discriminant analysis in italics) Variable No.
1 2

Variable Code PNOU PNOD PNOAS MLUA MLEXA LEXDEN

Description
% unintelligible words 9 % dysfluencies (PF, RW, RWW, FSR) % aha1 sable sentences Mean Lngth of analpable sentences Mean number of mqor lexical items r sentence Mean lexical density (MLEXA + M E . 4 ) % well-formed major sentences % sentences both synlacticaZly and semantically deviant % syntactical1 deviant sentences % semanticalry deviant sentences Number of neologisms Number of errors of derivational morphology Number of errors of inflectional morphology Number of phonological errors Number of word level errors (NEO + DER + INFL + PHO) % word level errors corrected %pausefillers (per total number oftokens) % false starts retraced % re at words (RW) and multiple word repeats (RWW) DysEency index %sentences with embeddin Mean number of embeddeiclauses per complex sentence Mean number coordinated top-level clauses Mean number coordinated non-to level clauses Mean maximum depth of embed$; % sentences with maximum depth ofembedding under subject % sentences with maximum depth of embedding under preverbal adverbial % sentences with maximum de th of embedding under object % sentences with maximum d p t h of embedding under complement % sentences with maximum depth of embedding under post-verbal adverbial % dependent clause, infinitival complement s u b p t raised % dependent clause, participle complement subject raised % dependent clause, infinitival complement subject deleted % dependent clause, articiple complement subject deleted % dependent clause, Enite complement full % dependent clause, finite complement reduced % dependent clause, wh-clause

3
4 5 6

7
8

PWFU
PSWSEM PSYN PSEM NEO DER INFL PHO WLE PCOR PPF PFSR PRW DYSIN PSEMB MEMB MCOT MCON MDEMB PLOC 1 PLOC 2 PLOC 3 PLOC 4 PLOC 5 PDC 11 PDC 12 PDC 13 PDC 14 PDC 15 PDC 16 PDC 20

9
1 0 11 12

13
14 16 17 18 19 20 21 22

1s

23
24 25 26 21 28 29

30 31
32

33
34 35 36

37

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LANGUAGE ANALYSIS IN

SCHIZOPHRENIA

38 39

40
41 42
43

44
45

46 47 48 49 50
51

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52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 61 68 69 70 71 72 73
74

PDC 31 PDC 32 PDC 33 PDC 40 PDC 5 1 PDC 59 PDC 60 MCSA MCSO MCCA MCCO MCPA MCPO PMST WNQ

75 76 71 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98

clause, full relative clause, reduced relative clause, sentential relative clause, adverbial 9 % dependent clause, direct speech % dependent clause, indirect speech % dependent clause, other Mean number andsentential coordinators Mean number of other sentential coordinators Mean number of and clausal coordinators Mean number of other clausal coordinators Mean number of and phrasal coordinators Mean number of other phrasal coordinators % non-declarative sentences % es no questions % questions % tag questions % imperatives PIMP % exclamatory sentences PEXC % sentences with negation PNEG % verbal negations PVNEG % nominal negations PNNEG PVNNEG % nominal and verbal negation Number of missing verb phrases VMIS % verbs in infinitival form PVINF % -in nominalized verbs PVINC % 6-ed; participle verbs PVED % verbs marked for past tense PVPST % verbs marked for perfective aspect PVPER % verbs marked for passive PVPAS % verbs marked for progressive aspect PVCON % modal verbs PVMOD % syntactically unmarked verb phrases PVUNM % verb phrases marked for 2 features PV2FM % verb phrases marked or 3 eatures PV3Fu % verb phrases marke for or more features PV4FM Total error count ERR Number of sentences with indeterminate clause structure NOICS Number of truncated sentences TRUSEN Number of telescoped sentences TELSEN PSENERR % sentence level errors Number of errors of clausal omission CLOM Number of errors of phrasal omission PHROM % errors of omission POM Number of errors of subject verb agreement SVAG Number of errors of number agreement BEAGN Number of errors of person agreement ANAG Number of errors of ronoun agreement type 1 PROAGI Number of errors o4ronoun agreement type 2 PROAG2 Number of errors of tense or aspect marking TENASP Number of errors of time reference TlREF Number of paradigmatic substitutions PARAS Number of errors of word transposition TRAREP Number of antonym substitutions ANTSUB SYNSUB Number of synon m substitutions LEXSUB Number of lexicalsubstitutions GRAMSUB Number of grammatical (function word) substitutions WORD Number of errors of word order GRA MINS Number of nonfunctional grammatical insertions UNELL Errors of under ellipsis in complex sentences % errors of commission PCOMIS

% dependent % dependent % dependent % dependent

FEZ

hi

d d

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