Beyond words- linguistic experience in melancholia, mania, and schizophrenia.pdf

Beyond words: linguistic experience in melancholia,mania, and schizophrenia

Louis Sass & Elizabeth Pienkos

# Springer Science+Business Media Dordrecht 2013

Abstract In this paper, we use a phenomenological approach to compare the unusualways in which language can be experienced by individuals with schizophrenia or severemood disorders, specifically mania and melancholia (psychotic depression). Our discus-sion follows a tripartite/dialectical format: first we describe traditionally observed distinc-tions (i.e., decrease or increase in amount or rate of speech in the affective conditions,versus alterations of coherence, clarity, or interpersonal anchoring in schizophrenia); thenwe consider some apparent similarities in the experience of language in these conditions(e.g., striking disorganization of manic as well as schizophrenic speech, interpersonalalienation in both schizophrenia and severe depression). Finally, we explore more subtle,qualitative differences. These involve: 1, interpersonal orientation (less concern with theneeds of the listener in schizophrenia), 2, forms of attention and context-relevance (e.g.,manic distractibility versus schizophrenic loss of orientation), 3, underlying mutations ofexperience (e.g., sadness/emptiness in melancholia versus disturbances of basic selfhoodin schizophrenia), and 4, meta-attitudes toward language (i.e., greater alienation fromlanguage-as-such in schizophrenia). Such distinctions appear to reflect significant differ-ences in underlying forms of subjectivity; they are broadly consistent with work inphenomenological psychopathology on other aspects of experience, including body, self,and social world. An understanding of such distinctions may assist with difficult cases ofdifferential diagnosis, while also contributing to a better understanding of sufferingpersons and of psychological factors underlying their disorders.

Keywords Schizophrenia . Mood disorder . Language . Phenomenology . Mania .Melancholia

1 Introduction

The present paper offers a comparative-phenomenological analysis of the expe-rience of language in three classic forms of mental disorder: schizophrenia,mania, and melancholia (the latter largely overlapping with the category of

Phenom Cogn SciDOI 10.1007/s11097-013-9340-0

L. Sass (*) : E. PienkosDepartment of Clinical Psychology, Graduate School of Applied and Professional Psychology, RutgersUniversity, 152 Frelinghuysen Road, Piscataway, NJ 08854-8020, USAe-mail: [email protected]

“psychotic depression”).1 Linguistic anomalies are frequently mentioned in the psychi-atric literature, and are often considered fundamental in schizophrenia (e.g., Crow 2000;Lacan 1981/1993; Schwartz 1982). Most studies of language have, however, adopted anexternal or structuralist perspective, with an emphasis on linguistic behavior, syntax, orthe like. By contrast, the experience of language is a neglected topic, with relatively littlediscussion of this issue even in classic and contemporary phenomenological psychopa-thology. Here we hope to take some initial steps toward filling this lacuna. Our intentionis to go beyond surface or structural characteristics of language: “beyond words,” as onemight say, in the sense of focusing primarily (though not exclusively) on the subjectivedimension, on what it is like for the patient to experience language, whether one’s ownor that of other people. Although our focus is on description, we also consider ways inwhich the experience of language may link with other themes central to schizophrenicpsychopathology, including altered experiences of body, self, and social world.

This article is theoretical, clinical, and qualitative in orientation: we offer a selectivereview of relevant writings in psychopathology, especially phenomenological psycho-pathology (both classic and recent), together with patient reports or other anecdotes thatillustrate the phenomena at issue. Our approach is first and foremost a review of theavailable literature that is relevant, directly or indirectly, to the subjective experience oflanguage and speech in the disorders discussed here (a literature that, if restricted to aphenomenological focus, is rather limited). Secondly, we offer some theoretical formu-lations that help to organize or otherwise make sense of the material. Our ultimate goal isto offer a preliminary guide that may sensitize both clinicians and researchers to thesubjective side of the varied abnormalities found in these conditions. This is a study inphenomenological psychopathology; a comparative approach can sharpen theoreticalunderstanding of the qualitative specificity of different forms of abnormal experience.

As in several previous papers (2013a, b, under review), this article has a tripartite anddialectical structure: first we will describe certain differences in linguistic experience thathave classically been recognized in schizophrenia and affective disorders (I: Differences),then some striking similarities, often found in typical cases of these apparently diversedisorders, that may suggest deeper affinities (II: Affinities). Finally we consider whether astill closer, phenomenological analysis might reveal some subtle yet profound ways inwhich these disorders may nevertheless differ from one another (III: SubtlerDistinctions). These subtle differences are especially worthy of study because, whenhighlighted and clarified, they may contribute to more accurate differential diagnosis,richer theoretical understanding of these psychiatric conditions, and enhanced ability toempathize with such patients and thus achieve an effective therapeutic alliance.

We hope to show, then, that superficial characterizations of difference can bechallenged by some apparent commonalities, but also that the commonalities maythemselves be somewhat superficial—in the sense of masking different underlyingexperiential structures. A phenomenological approach is designed to go beyond merebehavioral description and superficial first-person accounts, allowing us to considerthe underlying forms of subjectivity that may be involved.

We note as well that phenomenology has an important role to play even inneurobiological and neurocognitive accounts, given that subjective experiences areamong those factors that neurobiology and cognitive science must ultimately take

1 We thank two anonymous reviewers for their astute suggestions on revising this paper.

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into account. Conscious experience is, after all, “an explanandum in its own right”(Chalmers 1995, p. 209), as various philosophers have noted. And “without someidea . . . of what the subjective character of experience is, we cannot know what isrequired of physicalistic theory” (Nagel 1979, p. 71).

1.1 Language and its importance

Language and the experience of other persons are crucial as well as closelyintertwined aspects of human existence. Indeed, when taken together, they play adominant role in the constitution of inter-subjective reality and may even be said todefine human nature itself.2

The importance of language for social and practical life can hardly be overstated.Language, after all, is rooted in dialogue, and as such is both a cause and an effect ofthe social world, which it presupposes but also profoundly transforms. Many theoristshave argued, in fact, that language could not even be referential were it not alsoshared. In this sense the very acceptance of language always returns the person, nomatter how alienated, to the common world. The point is implicit in LudwigWittgenstein’s (1958) famous arguments against the very possibility of a “privatelanguage” (see also Laruelle 1978; Tatossian 1997) as well as in Lacan’s (1981/1993)notion of the need to submit (on pain of turning “psychotic”) to the “symbolic order.”

Furthermore, language is crucial to the experience and constitution of the entirety oflived reality. One need not adopt an extreme linguistic determinism or post-structuralistposition to recognize that we experience not only persons but virtually all objects andsituations largely via schemata, scripts, and typifications of various sorts, and that theseare, to a very large extent, verbally and socially mediated (see, e.g., Garnham and Oakhill1994).3 It can be argued, as well, that it is “in and through language that man constituteshimself as a subject.” In the words of the linguist Benveniste (1958/1971), the very“foundation of ‘subjectivity’” … is determined by the linguistic status of ‘person’which,in turn, is established by contrast, in relationship to an addressee: “The basis of subjec-tivity is in the exercise of language” (pp. 224, 226).4

2 For a parallel discussion, but more focused on the experience of other persons in melancholia, mania, andschizophrenia, see Sass and Pienkos (under review). For comparative discussions of self-experience andworld-experience (time, space, atmosphere), see Sass and Pienkos (2013a, b).3 This paragraph is nicely summed up in philosopher Merleau-Ponty’s (1945/1962) lapidary statement:“The spoken word is a gesture, and its meaning a world.”4 A shared feature of our experience of both language and other persons is that both are intimately bound up withthe phenomenon of “expression”—viz, with the manifestation of thoughts and feelings and their communicationto others, whether by word, facial expression, or bodily tension or movement. As Sartre, Levinas, and otherphilosophers have pointed out, expression implies something that is both immanent and transcendent, bothpresent and beyond. Words, like faces, have a certain sensory presence, visual or auditory; but in both cases thispresence directs our attention inward as well as outward—inward toward what is presumed to be a groundingawareness or emanating consciousness, outward toward the meanings or worldly objects that are being indicated.Jean-Paul Sartre (1966) described the face as a “visible transcendence”; in similar fashion, a word, as normallyexperienced, can be considered an “audible transcendence.” In this sense both a word and a face—at least asnormally experienced—share a certain “aura”: that of a sensory presence whose immediacy always pointsbeyond. Emmanuel Levinas (1969) argues that a face is authentically a face only if it is recognized as comprisingan “infinity” and not a “totality,” which is to say, as something whose meanings are rich and ambiguous enoughto transcend any single interpretation by the viewer. In the absence of the above-mentioned aura, one may feeloneself in the presence of something uncanny, e.g., of behavior that is somehow other than fully human, or asound that functions as something far less, or far more, than a word.

Beyond words: Language in melancholia, mania, and schizophrenia

1.2 Schizophrenia and the affective psychoses

The importance of the disorders to be considered here, and of the affinities anddifferences between them, hardly needs emphasis (for further discussion, however,see 2013a, b, under review). Indeed, the differentiation of schizophrenic from affec-tive disorders has been described as the most crucial diagnostic differential in all ofpsychiatry (Tatossian 1997). It has been explored by virtually all the founders ofmodern psychiatry, including not only Kraepelin, Bleuler, and Jaspers, but alsoKretschmer and Minkowski, among many others. While some, such as Kraepelin(at least until the end of his life (Kraepelin 1920/1974)), have conceived the endog-enous psychoses as distinct disease entities, others have viewed them in less discreteand more continuous ways: thus for Kretschmer (quoted in Crow 2002, p. 336),“endogenous psychoses are nothing more than marked accentuations of normal typesof temperament,” which he termed “schizothymic” and “cycloid”—the former proneto social withdrawal and “disharmony” with others, the latter more spontaneouslyengaged with the world (Sass 1992). The phenomenological psychiatrist, EugeneMinkowski (1927/2012) (who was influenced by Kretschmer) made a similar dis-tinction between schizoid and syntonic orientations, describing the former as charac-terized by a distinctive form of “autism” involving “loss of vital contact with theworld.”

In recent years, however, a growing number of researchers have been questioningthe validity and value of drawing a fundamental distinction between schizophreniaand affective disorders—e.g., by proposing new categories such as salience dysreg-ulation syndrome (van Os 2009) or new versions of the unitary psychosis hypothesis,or by suggesting that such disorders are best characterized on a continuum ofpsychotic and mood symptoms (Dutta et al. 2007; Hyman 2010; Rosenman et al.2003). Some critics recommend that we focus not on diagnostic groupings but ondomains of psychopathology (such as depression or “reality distortion”) or else onbehavioral constructs with known neural bases (e.g., in the RDoC or ResearchDomain Criteria: negative and positive valence systems, cognitive and social-process systems, arousal/regulatory systems). Studies do show that many symptoms,or even groups of symptoms, can often be insufficient for distinguishing betweenthese disorders (e.g., Taylor 1992; van Os 2009). It remains true, however, thatKraepelin’s basic distinction—whether framed as a dichotomy or some form ofcontinuum between schizophrenic and affective types—continues to be the dominantview in contemporary psychiatry and psychology.

It does seem obvious that many crucial psychological and physiological processesare shared across diagnostic entities (e.g., self-focused attention, experiential avoid-ance, or some forms of reality distortion; salience dysregulation), and that studyingdisturbances in these particular processes is worthwhile (Harvey et al. 2004; van Os2012). Yet it seems equally obvious that particular symptoms or processes are likelyto be of differential importance in distinct disorders, and likely as well that sharedsymptoms or processes will play out differently in distinct psychopathological set-tings, in accord with distinct experiential orientations or basic underlying distur-bances (what Minkowski (1927/2012) called troubles genérateurs). It is wise torecall Karl Jaspers’ (1946/1963) opinion of the long-running debate regarding theschizophrenia/affective distinction. While recognizing the difficulties in defining the

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boundary, he believed that “there must be some kernel of lasting truth” in Kraepelin’s“concept of the two great groups of diseases… which has been actively applied sinceabout 1892” (p. 567). Phenomenological research into the overlaps and disparitiesbetween these traditional distinctions is essential in order to inform these discussionsand aid in developing an ever-more-accurate picture.

This paper does not, however, attempt to engage the particulars of current debateson diagnosis and segmentation of psychotic disorders. Here we explore, in the realmof language, the traditional notion of an important distinction between schizophreniaand severe mood disorders. It should be noted that our focus on this distinction isconsistent with various overall nosological visions, ranging from distinct diseaseentities to temperamental continua, and not precluding the possibility of mixed orintermediate cases.

In our study of affective disorders, we focus specifically on “melancholia” and“mania.” By using the term “melancholia,” we refer to its recent connotation as aqualitatively distinct kind of depression, one that is endogenous, particularly severe,associated with psychotic symptoms, or somehow odd (Akiskal 2009; Fink andTaylor 2007; Shorter 2013). DSM-IV-TR (Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, Text Revision 2000) employs the specifier “WithMelancholic Features” to describe a Major Depressive Episode distinguished by its“near-complete absence of the capacity for pleasure, not merely a diminution” and“distinct quality of mood… qualitatively different from the sadness experiencedduring bereavement or a non-melancholic depressive episode” (p. 419). This melan-cholic form of depression is particularly relevant for the present study because of itsseverity and likelihood of generating experiential anomalies that may be moredifficult to distinguish from schizophrenia. The term “mania” refers to particularexperiences that can occur in someone diagnosed with Bipolar Disorder; here we arespecifically interested in these manic experiences themselves, rather than in the rangeof symptoms and disturbances that can occur in the entire course of Bipolar Disorder.

1.3 Our approach: some qualifications, potential contributions

We do not argue that experiences in these different conditions can always bedistinguished in phenomenological terms.5 We believe, however, that there is con-siderable value—at least at this stage—in pursuing these comparisons on a moregeneral plane. While we do not ignore all such nuances and qualifications, we do optfor a kind of Weberian ideal-type analysis in this paper. Such an approach isunapologetically perspectival (Weber 1904/1949, p. 90). It focuses on features thatare “typical” of the phenomenon studied, but which may not apply equally well, or injust the same way, to all instances of the type (Wiggins and Schwartz 1991). We donot expect or propose that our characterizations of the disorders under considerationwill apply universally. Rather, we pursue the more modest goal of highlighting anddescribing those features of melancholia, mania, and schizophrenia that may behighly distinctive of the disorders in question. As such we have tried to focus on

5 As noted, one perennial issue is whether there is indeed a sharp diagnostic distinction between schizo-phrenia and affective psychosis, or whether these conditions exist more on a continuum (Dutta et al. 2007;Tsuang and Simpson 1984) or perhaps constitute a more heterogeneous assortment.


relatively clear-cut examples of the various forms of psychosis: indeed we will bedescribing features found in prototypical instances of the different disorders orconditions at issue. It should be stressed, however, that the anomalous linguisticphenomena to be described below are not continuously present in either the experi-ence or expression of any particular patient (Bleuler 1982); they are varying phe-nomena that tend to occur in certain kinds of patients. But as we shall argue, they doseem to represent important and often distinguishing features of the different condi-tions, features that express or otherwise indicate core features of the forms ofpsychopathology in question.6

Our claims in this paper, especially regarding “subtler distinctions,” are offered intentative fashion. It is obvious that there is need for further exploration and, ultimate-ly, for confirmation, disconfirmation, or refinement by controlled empirical studies.7

First-person testimony and anecdotal reports do of course pose methodologicalchallenges. It can be difficult to interpret such reports, especially in the case of severemental disorders; it would be naïve to assume they involve purely unbiased descrip-tion. First-person accounts are, for instance, influenced by the culture or era in whichthey are produced, as well as by the constraints of literary genre and autobiographicalmemory; this casts doubt on the assumption that such descriptions merely reflectwhat an experience is “really like” (Radden and Varga 2013; Woods 2011).8 Also, ofcourse, it is often a matter of judgment to decide just how typical versus idiosyncratica particular report can be considered to be.

It is equally clear, however, that empirical research does require, as a preliminarystep, work akin to the theoretical explorations offered below.9 Both descriptive workand theoretical speculation are indispensable for the generation of orienting hypoth-eses and the fashioning of operational descriptions. Experience without theory isblind, as Kant famously noted, just as theory without experience would be mereintellectual play.10

6 Such a comparison may also have relevance for psychotherapy or other psychological treatments. A betterunderstanding of possible ways of experiencing language in psychopathology should help in developingempathy and improving one’s therapeutic alliance with a patient—as well as in accurately targeting specificareas of interpersonal experience for intervention. The relationship between therapist and patient, largelylinguistic or linguistically mediated, is, of course, a primary tool for bringing about change in thesedomains. With greater understanding of the attitudes these patients may adopt and the challenges theymay face in using and understanding language, one may be in a better position to develop sensitive andeffective interventions—interventions less likely to be undermined by failure to grasp some of the veryissues they are intended to target and treat.7 Together with colleagues (Borut Skodlar, Josef Parnas, Nev Jones), we are currently preparing aqualitative interview schedule, the Examination of Anomalous World Experience or EAWE, which ismodeled on the well-known EASE: Examination of Anomalous Self Experience (Parnas et al. 2005). TheEAWE will contain a major section focusing on the subjective experience of language, both productive andreceptive; this should facilitate one form of empirical research on the topic.8 See Sass et al. (2011) re the rejection, in most contemporary phenomenology, of “foundationalist” claims.9 Even the philosopher Daniel Dennett, a neo-behaviorist, acknowledges in his discussion of (so-called)“heterophenomenology” that descriptions of experience, properly criticized, can “inspire, guide, motivate,illuminate one’s scientific theory” (Dennett 2003, p. 23).10 Kant’s famous line from the Critique of Pure Reason (1855), “Thoughts without content are empty,intuitions without concepts are blind” (A51, B75), has been glossed more or less as paraphrased above inGeneral Systems (General systems 1962).

L. Sass, E. Pienkos

2 Differences

Certain disturbances in the usage or experience of language have long been reportedin schizophrenia, and have frequently been considered distinctive of the condition.Psychiatric theorists as disparate as Crow (2000) and Lacan (1981/1993) have seeneither schizophrenia or psychosis more generally as fundamentally linked to distur-bances in the use of, or abnormalities in the attitude toward, language. Crow, inparticular, saw schizophrenia as resulting from a disturbance in the neural develop-ment of language modules, resulting in the inability to distinguish thought, speechoutput, and heard speech from others. Bleuler (1950) also viewed disturbed speech asevidence of the ‘thought disorder’ or ‘loosening of associations’ that he consideredcentral to the schizophrenic condition. It is difficult to draw a clear line between whatmight be considered disorders of thought versus of language in schizophrenia;contemporary operational approaches focus on language production (Andreasen1979). The varied anomalies that have been noted in schizophrenia includeglossomania, echolalia, mutism or alogia (poverty of speech), poverty of content ofspeech, agrammatism, tangentiality, and clang associations (Andreasen 1986;Andreasen and Grove 1986; Andreasen 1979; Covington et al. 2005; Lecours andVanier-Clement 1976; Sass 1992, ch 6; Schwartz 1982).

Studies considering schizophrenic speech from a linguistic perspective have ob-served that disturbances tend to occur at the levels of phonology (e.g. flattenedintonation and constricted timbre), pragmatics, and lexical access (seen in neologismsand stilted speech), though grammar and syntax tend to remain relatively unimpaired(Covington et al. 2005). Elvevåg et al. (2002) suggest that although schizophreniapatients are able to access the same number of words and ideas as controls, they mayuse inefficient strategies to store and thus retrieve such information, disrupting verbalfluency. Similarly, a review article by Spitzer (1997) draws on cognitive neuroscienceto conclude that the semantic associative networks of schizophrenia patients may beimpaired, resulting in a low signal-to-noise ratio and creating such anomalies as looseassociations and both overly concrete and overly abstract speech.

Although such reports can be helpful in organizing the varieties of schizophreniclanguage disturbance, their approach tends to rely heavily on an external or behav-ioral standpoint. Such work also tends to favor a deficit perspective, emphasizing theproblems and losses that occur in schizophrenia language. It is not necessary toassume, however, that differences in linguistic output always involve or are experi-enced as a loss; schizophrenia patients may, for example, experience an enrichedsense of the potential ambiguities in language, or willfully adopt idiosyncraticmanners of speaking (see, e.g., Lecours and Vanier-Clement 1976; Schwartz 1982).In order fully to explore language in mental disorder, it is important to focus onsubjective experience. For preliminary, illustrative purposes, we offer several state-ments from schizophrenia patients that convey some of the intensity these experi-ences can have. Describing his experience of others’ speech, one remitted patientstated, “I used to get the sudden thing that I couldn’t understand what people said.Like it was a foreign language. My mind went blank.” Another patient notes that inhis own attempts to speak, “I thought my language was wrong. I believed that no onecould understand what I said. I couldn’t understand what I said. Just high-pitchednoises came” (Cutting 1985, p. 252). Still another person with schizophrenia


(“Sophie,” quoted again below) spoke of words as “social creatures” that could“breathe” or “blink,” “transforming the world and themselves.” A final patient woulduse habitual words to “express ideas quite differently from what they customarilyexpressed—they had acquired a different meaning for me: for example, ‘scabby’,which I used quite comfortably for ‘brave and plucky’…” (Jaspers 1946/1963,p. 249).

Only one phenomenological study of which we are aware attempts to offer ageneral, theoretical account of the subjective dimension of the anomalies of linguisticexpression and understanding found in schizophrenia. In Chapter 6 of Madness andModernism, Sass (1992) divides these anomalies into three general trends: 1,desocialization, the failure or refusal to incorporate the needs and rules necessitatedby communication with another person, often associated with a preoccupation withprivate concerns; 2, autonomization, the tendency to adopt a passive attitude in whichlanguage loses its value as a communicative tool and emerges instead as the focus ofattention or source of control over speech; 3, impoverishment: restriction of theamount of speech or diminishment of the apparent content or meaning of speech,which can be associated with a variety of different underlying experiences, includingrejection of interpersonal contact and an overwhelming sense of the inadequacy oflanguage in light of the ineffability of experience or the world.

Sass argues that each of these trends is a “language of inwardness,” involving adistinctive departure from a standard social orientation. The first involves “a movetoward a kind of inner speech that is felt to be more authentic than conventionallanguage”; the second a “new recognition of the independent nature of language, anacknowledgment of its existence as a system imbued with its own inherent mysteriesand forms of production” (what could be termed an “apotheosis of the word”); thethird “a new preoccupation with the uniqueness and particularity of unverbalizedexperience,” or with hyper-abstract or “ontological” concerns—and with the sense ofineffability this invariably evokes (Sass 1992).

The language disturbances typical of melancholia and mania have generally beendescribed rather differently: largely in terms of decrease or increase in amount or rateof speech, rather than as alteration of coherence, clarity, or interpersonal anchoring.This characterization echoes the general emphasis on increase or decrease in speed ofthinking in affective disorders. Various studies have observed slower speech andincreased pause times in depression (Greden and Carroll 1980; Trichard et al. 1995),while others note that this can lead in severe depression to complete mutism (Cutting1997).

William Styron, who suffered from severe depression, describes one dinner duringwhich he had a “virtually total failure of speech,” when “the ferocious inwardness ofthe pain produced an immense distraction that prevented my articulating wordsbeyond a hoarse murmur; I sensed myself turning wall-eyed, monosyllabic …”“My speech,” he says regarding another occasion “had slowed to the vocal equivalentof a shuffle” (Styron 1990, pp. 20, 56). Pressure of speech, with increased rapidity ofspeech and ideational flow, is a common symptom of mania, second only to elevatedmood (Cutting 1997). In her autobiographical account of bipolar illness, Kay Jamison(1995) speaks of her sense, during one manic episode, of “talking to scads of people”and being “irresistibly charming,” while someone who observed her said she seemed“frenetic and far too talkative” (pp. 70f).

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3 Affinities

There are, however, also some studies that show little or no difference in the deviantverbalizations produced by persons with schizophrenia versus mania. Andreasen(1979), e.g., found a similar percentage of derailment, incoherence, and illogicalityin manic as in schizophrenic speech, although there was greater incidence of clangassociations in mania. A study analyzing the speech output of schizophrenic, bipolar,and depressed patients was unable to discriminate among groups on the basis ofdeviant linguistic variables (Lott et al. 2002). These behavioral findings might makeone question the sharpness of underlying experiential differences as well.

In one interesting clinical account, Lake (2008) describes blocking, loose associ-ations, derailment, disorganization, and even apparent incoherence of thought andspeech—features classically associated with schizophrenia, according to Bleuler—asbeing common in many typical cases of mania as well. He recounts one manicpatient’s own account of the uncontrolled drift of his loosely associated thoughts: adropped key chain had caused him to think of the “key of life,” then of life beginningin Egypt’s Nile River valley, then of the pyramids, then of the desert, then of feelinghot and thirsty, then of desiring a glass of water.

Clang associations have also been frequently observed in manic patients, and maywell be more prevalent than in schizophrenia (Cutting 1997). Some examples are:“Dr. Malmberg you are an ice woman an iceberg a lettuce;” “Mystery history;” “I’llnever be sick like a tailor even though my dad was a tailor even though my dad was asailor” (p. 481). These manic patients appear to be paying excessive attention tosound qualities of the word rather than to its linguistic meaning, which is certainlyreminiscent of the autonomization that can occur in schizophrenic language.

Some first-person reports by severely depressed patients suggest that, like schizo-phrenia patients, persons with clear cases of depression will often experience a loss ofeither the ability or the desire to use language in standard and socially appropriateways. “I could not follow conversation, could not pretend any interest,” said onedepressed patient. “There was no talking with anybody” (Smith 1999, p. 12). At theextreme a melancholic patient can find himself utterly unable to care about expressinghimself or listening to others; and this may result in a complete “poverty of speech”that is behaviorally indistinguishable from what occurs in schizophrenia (Lott et al.2002; Silber et al. 1980).

In some cases these impoverishments of expression seem related to the inherentineffability of melancholic experiences. “I was not able to talk coherently for anylength of time; I was too vague about the causes of my discomfort to make myselfunderstood,” said one depressed patient (Kaplan 1964, p. 164). Another such patientoffers more detailed insight:

I often found myself silent. When I spoke, it was with stumbles and stammers.Words—unhappy, anxious, lonely—seemed plainly inadequate, as did modi-fiers: all the time, without relief. Ordinary phrases such as I feel bad or I amunhappy seemed pallid. Evocative metaphors—My soul is like burned skin,aching at any touch; I have the emotional equivalent of a dislocatedlimb—were garish. Though this language hinted at how bad I felt, it couldnot express what it felt like to be me. (Shenk 2002, p. 248f)


For other melancholic individuals, an overpowering sense of nothingness orindistinctness may create the feeling that there is, in fact, nothing to describe. Asone depressed patient states, “to be depressed is not to have words to describe it, isnot to have words at all, but to live in the gray world of the inarticulate, where nothingtakes shape, nothing has edges or clarity” (Casey 2002). In initial psychiatric inter-views, schizophrenic patients may also complain of the ineffability of their experi-ences (Møller and Husby 2000)—which they too experience as somehow “beyondwords”—or make repeated use of vague or clichéd pet phrases that convey little to thelistener, demonstrating apparent “poverty of content of speech.” Some of thesestatements may sound similar to those of depressed or neurotic patients (Parnaset al. 2005), such as “I feel down,” “I don’t feel like myself,” or “I feel depressed.”Henri Ey (1996) has also noted a “strange taste for the abstract” among schizophrenicpatients, which can lead to overuse of vague words like “thing” or “thingamabob,” orof enigmatic phrases that can seem meaningless to the listener (p. 180).

4 Subtler distinctions

A closer look at these affinities reveals particularities that might discriminate betweenthe disorders, on behavioral/expressive as well as subjective levels. In the following,we consider four areas that may help clarify some underlying distinctions: 1,Interpersonal orientation, 2, Attention and context-relevance, 3, Underlying muta-tions of experience, and 4, Meta-attitudes toward language.

4.1 Interpersonal orientation

In considering the similarities in manic and schizophrenic speech, one study indicatedthat, although frequency of language disorder may be similar in manic and schizo-phrenic patients, there were observable differences in severity of disturbance (Wykesand Leff 1982). In particular, “manic patients provided the listener with more ties torelate his sentences together than the schizophrenics did” (p. 123). This suggests that,on the subjective plane, the manic patient is likely to experience greater awareness ofthe social aspects of speech and greater concern for the needs of the interlocutor.Cutting (1985) states that the biggest disturbance in schizophrenic language is in theability or will to convey intended meaning, or in the pragmatic function of language,indicating decreased concern for using language as a means of communicating andinteracting with other people. This, of course, would be a linguistic manifestation ofthe turning-inward that is characteristic of schizophrenia, and that may, at theextreme, amount to a kind of solipsistic orientation (Sass 1992, 1994). Examples ofsuch speech include such statements as “We are already standing in the spiral under ahammer,” and “Death will be awakened by the golden dagger,” which leave theinterlocutor wondering what the speaker could possibly be referring to (Kraepelin1919/1971, p. 56; Sass 1992, p. 177). Similarly, De Decker and Van de Craen (1987)noted that schizophrenia patients often fail to follow what are known as Grice’smaxims, the mostly automatic rules people follow when they wish to communicatewith others, such as “give adequate information, but not too much,” and “be truthful”(Covington et al. 2005, p. 16).

L. Sass, E. Pienkos

Merely focusing on severity of disturbance in linguistic pragmatics fails, however,to take into consideration the various reasons for such disturbance. For some schizo-phrenia patients, lack of attention to the listener’s needs may indeed indicate someform of interpersonal incompetence. It may, however, also reflect a specific attitudetoward the interlocutor, an attitude less common or absent in mania and that may bebound up with the schizophrenia patient’s sense of radical uniqueness and willfuleccentricity (with what Stanghellini and Ballerini (2007) term “idionomia” and“antagonomia”). There may be, for example, an element of indifference or evenhostility toward the audience, resulting in a desire to obscure one’s speech with thespecific intention of making it more difficult to understand (Bleuler 1950, pp. 147,150). One schizophrenia patient described intentionally speaking “nonsense,” intowhich he would occasionally insert meaningful statements about his mental andemotional state, simply to see if his doctors were “paying attention” (Laing 1965);another would “go into his ‘schizy’ mode of speaking” more or less at will, deliber-ately obscuring his intention when he was upset or angry with someone (Sass 1992).Similarly, Liddle and Barnes (1988) have observed that some patients may usepoverty of speech and flattened affect as a sort of defense to protect them fromintolerable intersubjective experiences. Other patients may experience a sense ofsuperiority in being able to escape the “bourgeois” reliance on the conventionalityof language (described in greater detail below) (Sass 1992). In these ways, rather thanindicating mere lack or deficit, disturbance in the pragmatic dimension of linguisticcommunication may be manifestations of a “language of inwardness” (Sass 1992)that both serves the goals and reflects the subjective orientation of many patients withschizophrenia, something that may not be present in patients with mania.

4.2 Attention and context-relevance

Another possible difference concerns issues of attentional focus and the role oflinguistic context. Various authors have noted that, whereas the distractibility anddisorganization of speech (and of thought) in mania suggests a fairly straightforwarddeterioration of selective attention, the situation in schizophrenia seems more com-plex (Cutting 1997; Holzman et al. 1986; Lake 2008; Sass 1992, chapters 4 & 5). Asimilar or even greater degree of disorganization or “loosening” may certainly occurin schizophrenia, and disturbed selective attention can play a significant role.

However, some of the anomalies of speech or linguistic understanding seem toimply forms of alienation that are more distinctive of the schizophrenic condition:namely, alienation from the speech act or from language-as-such, or else a (closelyrelated) un-anchoring of thought or perception from the practical or conventionalcontexts that normally hold it in place. Schizophrenia patients seem, for instance,more likely to experience a partial or complete divorce of meaning from word, or ofsignifier from signified, such that words can begin to appear absurd ormeaningless—or perhaps meaningful in radically unconventional ways (see discus-sion of “Autonomization” in Sass 1992, pp. 178ff). This can involve a focus on thesymbolic vehicle, as seen in clang associations or a focusing on the look of words, orof a single word, on a page. Here the expressive aspect of language disappears: thepatient’s attention fixes so completely on the sound or look of a specific word that allsense of intended or potential meaning disappears.


Such abnormalities of linguistic experience seem to reflect the isolating, some-times rigidified forms of attention that can be characteristic of schizophrenia, givingrise, in the words of the German psychiatrist Paul Matussek (1987) (who combinedphenomenology with Gestalt psychology), to a “loosening of the natural perceptualcontext” that allows “individual perceptual components” (p. 90) to float free of theusual anchoring in common-sense unities or scenes. Such forms of attention haveboth a passive and active/intentional aspect: the patient feels somehow “held captiveby [an] object,” yet also shows himself “capable, to a much greater degree [thannormal persons], of fixing his attention on an isolated object,” and even takes“pleasure” in doing so (p. 93–4, emphasis added; Sass and Pienkos 2013c).Analogous phenomena can occur with perception of a face (whether someone else’sor one’s own contemplated in a mirror)—as when the (schizophrenia) patient’sattention fixes so intently on unrelated physical features (nose, eyeballs) that the facecan lose all its usual holistic and expressive qualities (Sass and Pienkos under review)(also see Phillips and Silverstein 2003 re gestalt breakdown).

There can also be an awareness of many possible meanings and connotations of aword taken in isolation, divorced from expectations imposed by the semantic orpractical context of the sentence and its function in verbal interaction (Kuperberg2006). To the person with schizophrenia, sentences may then appear meaningless asoverall units, yet somehow hyper-charged with meaning due to the unconstrainedproliferation of semantic pathways now emerging from individual words or sounds;Lecours and Vanier Clement (1976) describe “preoccupation with too many of thesemantic features of a word in discourse” (p. 561). As one schizophrenic patientstated, “each bit I read starts me thinking in ten different directions at once”(Matussek 1987). When attention is drawn either to the sound-vehicle or suchproliferating meanings, communicative aspects of speech naturally dwindle, resultingin diminished cues to orient the listener, such as cohesive ties between one sentenceand the next.

The prominence of clang associations in mania shows that they too may respond toalternative meanings, which, in turn, are likely to take one into a new contextdifferent from the original, intended meaning of a verbal communication. Thereseems a difference, however, between the manic person’s rapid, often playful,yet always context-embedded shifting from context to context, as against the alien-ated and fragmenting orientation one more often finds in schizophrenia (Holzmanet al. 1986). The schizophrenic person might better be described (at least in the mosttypical case) as experiencing words in the void, in a perplexing “context of nocontext”11—thus manifesting a linguistic equivalent of the “unworlding of the world”that can characterize schizophrenic experiences of reality in general (Sass 1992). Thesemantic wandering prominent in schizophrenia seems, one might say, to be gener-ated from “within”, resulting from the “loosening of the thematic field” that occurswith loss of any orienting perspective to anchor or fix the meanings of either words orthings. Spitzer (1997) notes that in verbal association, schizophrenia patients have alower “signal-to-noise” ratio, that is, both related (signal) and unrelated (noise)concepts may be equally accessible when target words are activated. This psycho-logical alteration (an updated version of Bleuler’s famous notion of “loose

11 We borrow this phrase from Trow (1997), who used it in a rather different context.

L. Sass, E. Pienkos

associations”) is understandable in the context of a loss of an orienting perspective:without any definite project or goal for speech, word storage loses the schemanecessary to appropriately organize cognitive associations. By contrast, manic dis-tractibility seems to occur more often “in response to intruding mental contents or tostimuli beckoning from somewhere entirely outside the [current] field of concern”(Sass 2004).

4.3 Underlying abnormalities of experience

Other differences pertain to the underlying types of experience that preoccupy thepatient or that she or he might wish to express.

Melancholic patients often have difficulty finding the words to describe theirdespair. Language seems inadequate to capture their pain, sadness, or sense ofprofound emptiness. This is akin to the resistance to ready linguistic expression ofbodily pain, which is often taken to epitomize the impossibility of communicatingwith others and the overwhelming fact of human isolation (Scarry 1985). In schizo-phrenia, by contrast, not just pain or suffering but all experience may come to seemineffable—wholly beyond words, as it were; and in a way that suggests a more basicsense of discontinuity between language and experience, with all its elusive partic-ularity and complexity. One schizophrenic patient described this as “so many eche-lons of reality…so many innuendos to take into account” (Sass 1992).Communication seemed impossible; language could never convey all the nuancesand tonalities he wished to express.

Research (Gross et al. 2008; Parnas et al. 2005) suggests that the vague complaintsof unreality or dysphoria by early schizophrenia patients (as described above) mayoften mask subtle but profound anomalies in experience of basic or minimal selfhood,anomalies associated with the “ipseity disturbance” that may be a kind of “troublegenérateur” of schizophrenia (Parnas et al. 2005; Sass 2013; Sass and Parnas 2003).These disturbances would include the strange, ineffable, often uncannyexperiences—bodily as well as cognitive—that can occur when internal sensationsor thought processes that are normally mute or taken-for-granted (e.g., kinestheticsensations, inner speech) come to the forefront of attention under conditions of“hyperreflexive” awareness, common in schizophrenia. This has important implica-tions for the experience of language.

Thus some patients express a desire to be completely true and faithful to the utterparticularities of their own inner experience, to infinitesimal eddies of sensation,thought, or emotion that do not normally enter the focus of our attention (Sass 1992,1995, pp. 187f). There is a sense in which these are normal experiences to whichnormal individuals simply do not attend. But there is another sense in which theabnormal act of attention, a form of “hyperreflexivity” akin in some respects tointense introspection (Sass et al. 2013), actually transforms the experiences intosomething different and distinct from what others experience—e.g., into reified formsof what might be termed “phantom concreteness” (Sass 1992, 1994). Klaus Conrad(1958/1997, pp. 165–168) spoke, in fact, of “spasms of reflexion” and of “anastro-phe,” a term (Greek in origin) that he used to refer to a stepping-back from experienceand a turning-inward toward the self characteristic of schizophrenia. There may alsobe forms of experience that most individuals have simply never approached. All this


may, in turn, lead to a yearning for something akin to a kind of “private language”that is on principle impossible (Wittgenstein 1958)—either because it is directedtoward experiences that other individuals have never had, or because it attempts tocapture a degree of specificity or particularity incompatible with the generalizingnature of shared verbal categories.

Schizophrenia patients may also become preoccupied with something too generalor all-inclusive to be put into words, as for instance with the all-pervasive feeling ofBeing, of sheer existence itself, or with some general atmospheric quality or sense ofineffable meaningfulness or inevitability (Bleuler 1950, p. 67n; Bovet and Parnas1993; Jaspers 1946/1963, p. 115; Sass 1992, chaps. 9, 10; 1994; Sass and Pienkos2013c). Hence they may attempt to capture some mystical feeling or insight of an all-encompassing nature that resists all normal or readily comprehensible forms ofdescription, leading at times to a kind of hyper-abstract or hyper-philosophical stylethat may be, or may seem, but “empty abstractions” (Ey 1996, pp. 180, 185, citingvarious predecessors).12

Both trends are apparent when the writer Antonin Artaud, who suffered fromschizophrenia, described feeling anguished by his sense that he was unable to capturein words the particularities of his inner feelings and sensations. “I consider myself inmy minutiae,” he wrote. Yet it seems that not even the simple words “it is cold” feltadequate to him, capable of capturing his “inner feeling on this slight and neutralpoint”: “What I lack is words to correspond to each minute of my state of mind”(Sontag 1976, pp. 294–295, 84). Artaud was also inclined to statements of what canseem the utmost abstraction:

Like life, like nature, thought goes from the inside out before going from theoutside in. I begin to think in the void and from the void I move toward theplenum; and when I have reached the plenum I can fall back into the void. I gofrom the abstract to the concrete and not from the concrete toward the abstract.(p. 362)

Artaud went so far as to make the paradoxical claim, “All true language isincomprehensible” (p. 549) (see also Sass 1995).

Another person with schizophrenia spoke of feeling dead, of living in unreality,and of being unable to express himself clearly: “One talks and it seems one saysnothing and then one finds one has been talking about the whole of one’s existenceand one can’t remember what one said” (Rosser 1979, p. 186; Sass 1992, p. 192).

Poverty of speech or poverty of content of speech (i.e., a failure to speak, or atendency to speak in cryptic or hyper-abstract terms) can, then, occur in bothschizophrenia and melancholia. We suggest, however, that this typically occurs inmelancholia because of a loss of energy or feelings of profound separation betweenoneself and other individuals, who seem to the patient to be operating at an entirelydifferent pace and energy level, or because of a sense of the ineffability of one’s pain.Such factors can certainly play a role in schizophrenia as well. There do, however,seem to be additional factors that seem more distinctive of the latter condition; theseinclude a far more general sense, reflective of a characteristic schizophrenic “autism”

12 In his early work, the Tractatus Logico-Philosophicus, Wittgenstein (1922) argued against the possibilityof this sort of all-encompassing statement as well.

L. Sass, E. Pienkos

and hyperreflexity, of what may seem language’s irredeemable incapacity to captureanything that really matters. As our informant Sophie, a sufferer from schizophrenia,put it, in her “experience of mutism it is not at all that language simply seems merelyinadequate in degree, but rather in kind.”

4.4 Meta-attitudes toward language

A final, closely related difference concerns a general sense of alienation fromlanguage-in-general that seems more common in schizophrenia than in mania andmelancholia. When viewed in a certain alienated light, language may indeed appearabsurd and arbitrary, and may well be experienced as an oppressive constraint or anintrusion into a purer or more authentic domain. (This is a factor emphasized inLacan’s notion of the rejection of the “symbolic order” and “nom du père” inpsychosis.13) An excellent example of this comes from reports of one young man,clearly suffering from schizophrenia, who was drawn to nihilistic views and inclinedto find words meaningless or absurd, and semantic conventions arbitrary and thuspathetic and irredeemably conformist: Holding up a cup before his friends, he wouldask contemptuously, “Is this a cup? Or is it a pool? Is it a shark? Is it an airplane?”14

In Lacan’s terms, the speech, or parole, of this patient demonstrates a rejection of thefundamental rules of language, or langue, which Lacan considers to be the centralelement of schizophrenia.

Similarly, when asked to define the word parents, another schizophrenia patientreplied,

Parents are the people that raise you. Anything that raises you can be a parent.Parents can be anything, material, vegetable, or mineral, that has taught yousomething. Parents would be the world of things that are alive, that are there.Rocks, a person can look at a rock and learn something from it, so that would bea parent. (Andreasen 1986, p. 478)

In his response, this patient appears to reject the normal conventions of the word“parents,” engaging in a promiscuous use of metaphor that reflects a lack of concernfor the needs of the listener and seems to highlight the arbitrariness of language.

Both of these example may seem similar, in some ways, to the manic linguisticplay described above, such as “Dr. Malmberg you are an ice woman an iceberg alettuce.” In both schizophrenic and manic speech, then, there can be a shift from thenormal constraints of language. However, there appears to be a more playful qualityin the manic example, while the schizophrenia patients appear to draw attention toand intentionally refuse the conventions of language.

13 We would disagree with Lacan’s (1981/1993) claim that this rejection (of the symbolic order, or what hecalls the “nom du père”) is a factor for psychosis in general; rather it seems characteristic of schizophreniain particular.14 This is Jared Loughner, the young man who shot several people in Tucson in an attack on a localcongresswoman, Gabrielle Giffords, on January 8, 2011. We are relying on a television report from 60Minutes which included an interview with several of Loughner’s close friends who describe his behaviorand attitudes from before the shooting (Descent into Madness 2011). Loughner was subsequently diag-nosed as having schizophrenia and declared unfit to stand trial.


Given the alienation from conventional language, it is understandable thatsome schizophrenia patients, unlike those with either mania or melancholia,may create neologisms: “If I could not immediately find an appropriate wordto express the rapid flow of ideas, I would seek release in self-invented ones,as for example wuttas for doves” (Bleuler 1950, p. 150; Ey 1996, p. 179 onSéglas and active and passive mechanisms). They may even attempt to create anew or personal language (Wolfson 1970), whether to express exaggerateddemands for autonomy and originality or in an attempt to capture, at leastfor themselves, all the nuances and innuendos that would otherwise beneglected.

But it is also possible for words to be treated as omnipotent objects that canonly be followed or revered. Henri Ey (1996) has described this duality: how,in schizophrenia, words can be treated as “some plastic material on which onecan exert the omnipotence of the ultimate subject,” or alternatively as “sacredobjects, imbued with a magical power” (he speaks of a “cult of words” (p.180)). One schizophrenia patient stated, “This letter is filled with the fire of thedesert.” Another claimed, “There are eyes at the tips of your fingers” (p. 181).In these strangely poetic phrases, one has the sense that words are beingmanipulated to create entirely new realities. On the other hand, Sophie de-scribes having the experience “in which language comes to take on a life of itsown—almost an animation of words … responsive, almost in possession ofsome sort of intrinsic agency or intentionality. Words breathe, they blink; theyare capable of transforming the world and themselves.” She goes so far as todescribe words themselves as “social creatures,” divorced perhaps “from inter-personal sociality, but not intertextual sociality.”

Schizophrenia, it seems, can be marked by certain paradoxes of omnipotenceand powerlessness: with patients feeling, at times, able to assign idiosyncraticmeanings to common words or even to create a private language, but at othertimes experiencing language as a rigid, recalcitrant, or controlling medium, orone possessed of magical powers of its own. Here again there are closeparallels with schizophrenic experiences of other human beings: such patientsmay feel that other people and even the world itself is created or controlled bythem, and yet, paradoxically enough, may also feel as if they themselves werepuppets or automatons controlled by other individuals or some omnipotent force(Sass and Pienkos under review).

4.5 Summary of the subtler distinctions

We see, then, that, both in schizophrenia and in severe affective disorders, languagehas a tendency to turn problematic, no longer to serve as the near-transparent mediumof our social intercourse or practical engagement with others and the world. But it isin schizophrenia that language has the strongest tendency to emerge as a focal pointor an end in itself, in a number of different ways—disorienting, oppressive, orgrandiose, as the case may be. Words may emerge as brute sensory presences (meresounds, mere marks on a page), as a prison-house of abstraction and cliché, asspinning generators of uncontrolled meanings, or as a realm of autocratic, evensolipsistic play.

L. Sass, E. Pienkos

5 Conclusion

In this paper, we have discussed unusual experiences of language that can occur inschizophrenia, melancholia, and mania. As we have seen, there are a number ofanomalies common in these different disorders that can seem quite similar, at least ona superficial plane. Individuals with either schizophrenia or major affective disordermay, for instance, have extreme difficulty describing their experiences or otherwiseexpressing themselves, perhaps to the point of being unable to speak at all. In bothmania and schizophrenia we sometimes find a tendency to focus on the intrinsicqualities of language and, often, to play on these qualities rather than using languageas a more straightforward medium of communication.

We have also suggested, however, that a nuanced understanding of underlyingstructural changes can help to differentiate the disorders at issue. A grasp of suchpotential distinctions is obviously relevant for psychopathological description andunderstanding. It might contribute as well to more accurate diagnosis andprognosis—and also, perhaps, to a more focused exploration of differing pathoge-netic pathways. In experience of language, these differences involve four sets ofissues: concerning 1, social orientation, 2, forms of attention and context-awareness,3, underlying kinds of anomalous experience, and, finally, 4, attitudes toward lan-guage as a system. Specifically, the disturbances in schizophrenia can often be tracedeither to an emphasis on ineffable global or personal experiences, a rejection of theconstraints of language, an “unworlding” of normal contextual reality, or disturbanceof an organizing form of ipseity or basic self-experience. Such experiences do notseem to be characteristic of either mania or melancholia, where difficulties withlanguage are more likely to be related either to a kind of playfulness and distracti-bility, in the case of mania, or to the ineffability and numbness intrinsic to the severedepressive state.

The linguistic anomalies typical of schizophrenia appear to reflect many of theunderlying structural changes in modes of subjectivity and selfhood that have beendiscussed in works of phenomenological psychopathology. The alienation of theword is, e.g., highly reminiscent of the schizophrenic experience of alienation fromthe lived-body (Fuchs 2005), in which something that would normally be tacitlyexperienced (thus inhabited as the very medium of self-experience) comes instead tobe experienced as a foreign object: strange and constraining, perhaps oddly concreteyet unreal at the same time (Sass 1992, chap. 7). Generally speaking, the experiencesin question are bound up with a mode of subjective life in which inner and privateconcerns play a dominant and also destabilizing role. This can undermine themotivation and capacity for using or experiencing language in standard andconventional ways; it both reflects and induces the inwardness and peculiarityso characteristic of the schizophrenic condition. These linguistic anomalies ofschizophrenia are highly consistent with classic descriptions of a characteristicschizophrenic “autism” (Parnas and Bovet 1991; Stanghellini and Ballerini2004), which Minkowski (1927/2012) described as a “loss of vital contact”with others and the world. They are consistent as well with the self- or ipseity-disorder hypothesis of schizophrenia, which views the disorder as involvingboth hyperreflexivity (Sass 1992) and a diminished sense of self-presence (Sass2013; Sass and Parnas 2003).


Although alterations of linguistic experience in mania and melancholia can cer-tainly be severe, there appears to be something more fundamental about the distur-bances that can occur in schizophrenia. In schizophrenia we often find a morecomplete alienation from common-sense reality and the meaning-making of normalconversation and social interaction, together with more severe alterations of the usualsense as being an autonomous yet social being who lives alongside other suchindividuals in a shared linguistic universe.

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