Language Disorder In Schizophrenia Patient: A Case Study Of Five Schizophrenia Paranoid Patients In Simeulue District Hospital

8 CHAPTER II

REVIEW OF RELATED LITERATURE

2.1 Theoretical Background

2.1.1 Language and Brain

The ability of human to communicate with others through language cannot be separated from the role of the brain. As Steinberg (2001: 309-310) said that we have minds and in our minds we have the means for producing and comprehending speech.

Human brain is divided into two halves, a left hemisphere and a right hemisphere. Stainberg (2001: 309-310) stated that the general structure of the brain is that of a whole which is divided into vertical halves which seem to be a mirror images of one another. He also added that each half of the brain is called a hemisphere. There is a left hemisphere and a right hemisphere.

The brain controls the body by a division of labour, so to speak. The left hemisphere controls the right side of the body, including the right hand, the right arm, and the right side of the face, while the right hemisphere controls the left side of body (Steinberg, 2001: 313).

For most people, the language area is in the left hemisphere. However, recent evidence indicates that the right hemisphere too is involved in language processing. The right hemisphere has been found to be more adept at processing

9 single lexical items and the semantic relation between them, while it is the left hemisphere that combines syntactic, semantic, and pragmatic information into a conceptual representation of a sentence (Faust, 1998 cited in Steinberg, 2001: 324).

The complexity underlying speech first reveled itself in patient who were suffering various communication problems. The ancient Greeks noticed that the brain damage could cause loss of the ability to speak (a condition known as aphasia). In 1861, Pierre Paul Broca described a patient who could utter only single word – ‘tan’. When this patient died, Broca examined his brain and observed significant damage to the left frontal cortex, which has since become known anatomically as ‘Broca’s area’. The result of his finding is patients with damage to the Broca’s area can understand language, but they generally are unable to produce speech because words are not formed properly, this language disorder called Broca’s aphasia.

Other researcher who did research relates to language problems due to damage to the brain is Carl Wernicke. In 1876, he discovered that language problems also could result from damage to another section of the brain. This area, later termed as ‘wernicke’s area’, located in the posterior part of the temporal lobe. Damage to the Wernicke’s area can result in a loss of the ability to understand language or Wernicke’s aphasia. Thus, patient with damage in this area can continue to speak, but words are put together in such a way that they make no sense.

10 Peoples with Wernicke’s aphasia speech appear superficially similar to patient with schizophrenia. Kuperberg and Caplan (2003:446) said that the speech of some schizophrenic patients appears, at least superficially, similar to Wernicke’s aphasia. Lecours and Vanier Clement (1976) claim that Aphasia-like symptoms are “episodically observed in only a small portion of subjects considered to be schizophrenics”, whereas the aphasia produced by stroke or brain injury is in most cases constantly present. And patients with aphasia have normal thoughts and express them with difficulty; those with schizophrenia have unusual thoughts (or disorganized discourse plans) and express them with comparative ease (Covington et al., 2005: 87).

2.1.2 Psycholinguistics

The research on schizophrenia is traditionally seen as something belonging to psychology, while study of language belongs to linguistics. So, this study of language disorder in schizophrenia belongs to both psychology and linguistics or psycholinguistics.

Linguistics is the study of human language. The primary object is human language signifying that language is human specific and human species. It is only human that uses language as a means of communication. In its development, linguistics consists of two branches; micro linguistics and macro linguistics. The former, micro linguistics, focuses on the structure of language e.g., phonology, morphology, syntax, semantic, and pragmatic. The later, macro linguistics, focuses on the relation of language with other studies e.g., sociology, psychology,

11 neurology, etc. From this combination of studies some new inter-discipliners are appeared, such as sociolinguistics; studies the relation between language and society i.e. how social factors influence the structure and use of language, Neuroliguistics is the study of language processing and language representation in the brain, and psycholinguistics, or the psychology of language. It is a branch of linguistics which concerns with discovering the psychology process by which human acquire and use language.

Psycholinguists focus on three aspects of language competence; acquisition, comprehension, and production. Language acquisition is the process by which human acquire the capacity to perceive and comprehend language, as well as to produce and use words and sentences to communicate. The term language acquisition also refers to language learning, in the babyhood or later. Language comprehension is the ability to extract intended meanings from language. Language production is the ability to speak or write fluently.

Scovel (1998: 4) defined psycholinguistics as the study of the normal and abnormal use of language and speech to gain a better understanding of how human mind functions. In his book psycholinguistics (1998) he examined research questions on psycholinguistics in four sub-fields: (1) how are language and speech acquired? (2) How are language and speech produced? (3) How are language and speech comprehended? And finally, (4) how are language and speech lost?

Chaer (2009: 6) said that practically psycholinguistics tries to applied linguistics and psychology science into the problems such as language acquisition

12 and language learning, early reading and advance reading learning, bilingual and multilingual, language and speech disorder such as aphasia, stuttering, etc; as well as other social problems which related to language, such as language and education and developing nations.

From some definitions above, it can be concluded that psycholinguistics is a relatively new subject of linguistics due to the fact that it involves not only language study but pscychological aspects as well. Study of the mental processes involved in the comprehension, production, and acquisition of language. Traditional areas of research include language production, language comprehension, language acquisition, and language disorders.

2.2 Description and Classification of Language Disorders

Simanjuntak (2009: 248) stated that the term language disorder used as a large and common term to name certain abnormal verbal behavior, and other behavior deficits acquired by a child which is abnormal or different from another child in the same age with him/her. He then said that observed behaviors which is considered as abnormal behavior are various, including less speak or cannot speak at all, cannot understand the topic or given instruction, the use of vague words and phrases, grammatical errors which may interrupt the communication processes, queer pronunciation or voice, and etc. And at the end he also added that the term language disorder can be used to refer disruption in language acquisition and language use in mother tongue.

13 Paul, (2007: 8) said that a variety of names have been given to the problem relates to language abnormalities, including language impairment, language disability, language disorder, language delay, language deviance, and childhood or congenital aphasia or dysphasia. At certain points in the history of language pathology, some terms have predominated, whereas others were used less commonly. From this statement, it can be concluded that the term language disorder may refers to any language impairment in mother tongue.

2.2.1 Developmental and Acquired Language Disorder

Based on its origin, the language disorder can be classified into two groups; developmental and acquired language disorder. The former, Developmental language disorder is a disordered of language due to abnormalities acquired from the time of birth. Developmental language disorder currently has no known cause. It is first observed when a child is learning to talk and is much more common than the acquired form of the disorder. Children with this type of language disorder begin speaking late and progress more slowly than others normal children.

Second, acquired language disorder is a language disorder which occurs after a period of normal development as a result of a neurological or other general medical condition such as brain damage due to stroke, traumatic brain injury, and disease such as schizophrenia and dementia. Peach & Saphiro (2012: 203) said that acquired language disorder including; aphasia, dementia, and schizophrenic – a language disorder due to disorder of thought. Acquired language disorders refers

14 to language deficits that results from neural trauma (stroke, traumatic brain injury) or neurological disease (e.g., Alzheimer, Parkinson, schizophrenia), all of which result in some degree of language impairment.

2.2.2 Medical and Environmental language Disorder

According to Chaer (2009: 148) language disorder divided into two major divisions; (1) language disorder due to medical factor and (2) language disorder due to social factor. The language disorder results from medical factor including abnormalities in brain functions and speech organs. And the social factor including unnatural environment, such as separated or isolated from normal social life.

Language disorder due to medical factors differentiated into three groups. Sidharta (1984) in Chaer (2009: 148) said that medically, language disorder can be divided to three groups: Speech disorder, Language disorder, and Thought disorder.

2.2.2.1 Language Disorder

Human use language to communicate and interact with others. Language is human specific-species (Gleason & Ratner, 1998). It means that only human that has the ability to acquire and use complex system of communication.

In other view point, language can be defined as a symbolic, rule governed system used to convey a message. The symbols can be words, either spoken or written and gestures. In this viewpoint, the term language refers to speaking and

15 understanding language, it includes using words to built-up conversation and understanding and making sense of what people say. When this ability to speaking and understanding language is impaired due to several factors, such as damage to the portion of the brain which is responsible to language, in the left hemisphere of the brain for most right-handed people (Steinberg, 2001: 319), or due to disorganized thought in schizophrenia patients – since language and thought cannot be separated and thought reflects in language, this condition is called language disorder.

The American Speech-Language-Hearing Association (ASHA) has defined language disorder as an impairment in “comprehension and/or use of spoken, written, and/or other symbol system. The disorder may involve (1) the form of language (phonologic, morphologic, and syntactic system, (2) the content of language (semantic system), and/or (3) the function of language in communication (pragmatic system), in any combination” (American Speech-Language-Hearing Association, 1993: 40) (Paul, 2007: 3).

From the definitions above, it may be said that language disorder is a specific impairment in understanding and sharing thoughts and ideas, i.e., a disorder that involves the processing of linguistic information. Language disorder often use as general term refers to abnormalities in mother tongue or native language.

16 2.2.2.2 Speech Disorder

The term speech refers to three things; they are articulation/phonological skills, fluency, and voice quality. In other words, speech related to saying sounds accurately, speaking fluently without hesitating, or prolonging or repeating words or sounds, and speaking with expression and a clear voice, using pitch, volume and intonation to support meaning. It involves the physical motor ability to speak.

ASHA (American Speech-Language-Hearing Association) defined a speech disorder is an impairment of the articulation of speech sounds, fluency, and/or voice and in general, speech disorder include voice disorders, fluency disorders, and disorders of articulation and phonology.

Speech disorder is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced.

Language and speech disorders are similar in that they cause communication problems, but there is a distinction between the two conditions. The difference between language and speech disorders is that language deals with meaning and the speech deals with sounds. A person with a language disorder has trouble understanding what others say, or has trouble expressing himself. While

17 person with a speech disorder has trouble producing or pronouncing sounds in the correct or fluent manner. So, when a person is unable to produce speech sounds correctly or fluently, or has problems with his or her voice, then he or she has a speech disorder. Difficulties pronouncing sounds, or articulation disorders, and stuttering are examples of speech disorders

2.2.2.3 Thought Disorder

Thought disorders are conditions that affect the way a person thinks, creating disturbance in the way a person puts together a logical consequence of ideas. It is commonly recognized by incoherent or disorganized thinking. An individual suffering from a thought disorder may speak quickly and incessantly, skip from one idea to the next, suffer from paranoia, delusions or hallucinations (http://www.Mentalhealthcenter.org).

Maher (1972) proposed a model that attempted to demonstrate the link between thinking and the behaviour of speech in language. The model might be likened to a typist copying from a script before her. Her copy may appear to be distorted because the script is distorted although the communication channel of the typist’s eye and hand are functioning correctly. Alternatively, the original script may be perfect, but the typist may be unskilled, making typing errors in the copy and thus distorting it. Finally, it is possible for an inefficient typist to add errors to an already incoherent script. Unfortunately, the psychopathologist can observe only the copy (language utterances): he cannot examine the script (the thought). In general most theorists concerned with schizophrenic language have

18 accepted the first of the three alternatives, namely that a good typist is transcribing a deviant script. The patient is correctly reporting a set of disordered thoughts. As Critchley put it: ‘Any considerable aberration of thought or personality will be mirrored in the various levels of articulate speech – phonetic, phonemic, semantic, syntactic and pragmatic’. The language is a mirror of the thought (Oyebode, 2008: 175).

The script is likened to thought and the typist to language. Most clinicians have taken the view that language closely mirrors thought and see the primary abnormality as the thinking disorder (Beveridge, 1985). Disordered language is then seen as merely a reflection of this underlying disturbance, with diagnosis of thought disorder only possible on the basis of what the patient says.

Chaer (2009: 160) said that most of people represent their personality through the language they used. Verbal expression is a representation of thought. Therefore, language is a representation of one’s thought. And he concluded that impaired verbal expression as a result of an impaired thought. Language disorder due to thought disorder can be found in dementia, schizophrenia and depressive.

1) Dementia

Cummings (2014: 60) said that the dementias are a large and varied group of neuropathologies that lead eventually to the loss of cognitive and physical functions in affected individuals. People with dementia may experience mild cognitive impairment initially which develops over time into mutism, incontinence, immobility and dependence on others for all aspects of care.

19 Dementias can be caused by infections (e.g. HIV infection), excessive alcohol consumption over an extended period of time (e.g. Korsakoff’s syndrome), cerebrovascular disease (e.g. vascular dementia) and age-related degenerative changes in the brain (e.g. Alzheimer’s disease).

Kaplan & Sadock, (2007: 329) defined dementia as a progressive impairment of cognitive functions occurring in clear consciousness (i.e., in the absence of delirium). Dementia consists of a variety of symptoms that suggest chronic and widespread dysfunction. Global impairment of intellect is the essential feature, manifested as difficulty with memory, attention, thinking, and comprehension. Other mental functions can often be affected, including mood, personality, judgment, and social behavior. Although specific diagnostic criteria are found for various dementias, such as Alzheimer's disease or vascular dementia, all dementias have certain common elements that result in significant impairment in social or occupational functioning and cause a significant decline from a previous level of functioning.

Dr. Martina Wiwie S. Masun said that dementia is a deteriorating of degradation of memory function or ability to remember and other cognitive ability. This cognitive disturbance in dementia include impaired short-term memory, inability to recognized place, people, and time as well as impaired in language fluency (Chaer, 2009: 159).

Dementia can be occurs due to a great number of damage to the function of the brain, including degradation of chemical fluid in the brain. Language of

20 individual with dementia was characterized by inability to find appropriate words. They also often utter same sentence for several times. Conversation often disrupted because they forget the topic. It makes their speech incoherent (Chaer, 2009: 159).

From definition and explanation above it can be said that language disorder in dementia is an acquired language impairment due to degradation of cognitive and memory function because the factors of aging. The characteristic of language in dementia are influent speech, repetition, and incoherent topic.

2) Depressive

People with depression can be recognized through their language use. It is because a depressed people often project their depression through their language style and language content. They often speak with very slow sound and the fluency of their speech often disrupted for a long interval. However, their thoughts are not impaired. Their speech often disrupted when they take a breath. The characteristics of depressive speech are the topic often consist of sorrow, they often curse themselves, loss of interest in live and doing activities, unable to enjoy their life, and they tend to end their live by doing suicide (Chaer, 2009: 161).

3) Schizophrenia

Schizophrenia is one of the most serious and common psychotic disorders. Its name derives from the Greek meaning “split Mind” (William, 2014: 2). Kaplan and Sadock (2007: 467) said that schizophrenia is a clinical syndrome of variable,

21 but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior.

The cause of schizophrenia remains unknown (Kaplan & Sadock, 1998). It was suggested that several factors could play a role in the etiology of schizophrenia. Among these are genetic, biological, and environmental factors (Williams, 2006: 1).

The first signs of schizophrenia usually occur during adolescence and early adulthood. Often the effects of the disease are confusing and upsetting family and friends. People with schizophrenia have difficulty in articulating thoughts. This condition leads them to have hallucinations, delusions, disjointed thoughts and behaviors, and unusual speech (William, 2012: 2). Because of these symptoms, people suffering from this disease have serious difficulty interacting with others and tend to isolate themselves from the outside world.

In order to simplify diagnosis of schizophrenia, schizophrenia symptoms were classified into two categories, known as positive and negative symptoms. According to Kuperberg (2010: 577) positive symptoms of schizophrenia are characterized by an excess or distortion of normal function. They include hallucination (most often, verbal auditory hallucination), delusion (fixed false beliefs, out of keeping with cultural norms, and held against all evidence to the contrary), and positive thought disorder (disorganized language output). Negative symptoms describe the absence of characteristics that normally appear on healthy individuals. They include a lack of voluntary behavior, or lack of motivation,

22 apathy, flat or inappropriate affect, and negative thought disorder (poverty of speech and language).

Kuperberg (2010: 576) said that symptoms of schizophrenia reflect abnormalities in multiple aspects of human thought, language and communication. Delusion and hallucination in schizophrenia make people with schizophrenia may hear voices other people don’t hear, or see things that other don’t see. They also may believe other people ore reading their minds, controlling their thoughts, or plotting to harm them. People with schizophrenia may sit for hours without moving or talking.

Kuperberg and Caplan (2003: 444) stated that abnormalities in language are the central of psychosis, particularly the schizophrenic syndrome. Many, though not all, patients diagnosed with schizophrenia display abnormalities of language. These abnormalities are highly variable and often hard to characterize. It is often unclear whether they reflect deficits in language itself or in related cognitive processes such as planning, execution, and memory (Covington et al., 2005: 86). Chaer (2009: 160) called language disorder in schizophrenia as “sisofrenik”. He said that sisofrenik is language disorder due to thought disorder.

2.3 Schizophrenia Speech

Many of the general signs of psychiatric problems can be observed in speech. In fact, oral language is a particularly sensitive manifestation of thought processes and brain dysfunction. Andreasen (1979 : 1318- 1321) proposed 18 types of schizophrenic speech. Those 18 types of schizophrenic speech are:

23 poverty of speech, poverty of content of speech, pressure of speech, distractible speech, tangentiality, derailment, incoherence, illogicality, clanging, neologism, word approximations, circumstantiality, loss of goal, perseveration, echolalia, blocking, stilted speech, and self-reference.

1) Poverty of speech (poverty of thought, laconic speech)

Poverty of speech is a restriction in the amount of spontaneous speech, so that replies to questions tend to be brief, concrete and unelaborated. Unprompted additional information is rarely provided. Replies may be monosyllabic, and some questions may be left unanswered altogether. When confronted with this speech pattern, the interviewer may find him/herself frequently prompting the patient to encourage elaboration of replies.

Example from Andreasen (1979: 1318):

Interviewer: “ Do you think there’s a lot of corruption in government?” Patient: “Yeah, seem to be”.

Interviewer: Do you think Haldeman and Ehrlichman and Mitchell have been fairly treated?”

Patient: “I don’t know”.

Interviewer: “Were you working at all before you came to the hospital?” Patient: “No”.

Interviewer: “What kind of jobs have you had in the past? Patient: “Oh, some Janitor jobs, painting”.

Interviewer: “What kind of work do you do?”

Patient: “I don’t. I don’t like any kind of work. That’s silly.” Interviewer: “How far did you go in school?”

Patient: “I’m still in 11th grade.” Interviewer: How old are you? Patient: “Eighteen.”

24 2) Poverty of content of speech (poverty of thought, empty speech,

alogia, verbigeration)

In poverty of content of speech, although replies are long enough so that speech is adequate in amount, it conveys little information. Language tends to be vague, often over-abstract or over-concrete, repetitive and stereotyped. This interviewer may recognize this finding by observing that the patient has spoken at some length, but has not given adequate information to answer the question. Alternatively, the patient may provide enough information to answer the question, but require many words to do so, so that a lengthy reply can be summarized in a sentence or two. Sometime the interviewer may characterize the speech as ‘empty philosophizing’. Poverty of content of speech differs from circumstantiality in that the circumstantial patient tends to provide a wealth detail.

Example:

Example from Andreasen (1979: 1318):

Interviewer: “Tell me what you are like, what kind of person are you.” Patient : “Ah one hell of an odd thing to say perhaps in these particular circumstances, I happen to be quite pleased with who I am and many of problems that I have and have been working on I have are difficult for me to handle or to work on because I am not aware of them as problems which upset me personally. I have to get my feelers way out to see how it is and where that what I may be or seem to be is distressing, too painful or uncomfortable to people who make a difference to me emotionally and personally or possibly on an economic or professional level. And I am I think becoming more aware that perhaps on an analogy the matter of some who understand or enjoy loud rages of anger, the same thing can be true for other people, and I have to kind of try to learn to see when that’s true and what I can do about it.”

25 3) Pressure of speech

Pressure of speech is an increase in the amount of spontaneous speech as compared with what is considered ordinary or socially customary. The patient talks rapidly and is difficult to interrupt. Some sentences may be left uncompleted because of eagerness to get on to a new idea. Simple questions that could be answered in only a few words or sentences will be answered at great length, so that the answer takes minutes rather than seconds, and indeed may not stop at all if the speaker is not interrupted. Even when interrupted, the speaker often continues to talk. Speech tends to be loud and emphatic. Sometimes speaker with severe pressure will talk without any social stimulation, and talk even though no one is listening. If a quantitative measure is applied to the rate of speech, then a rate greater that 150 words per minute is usually considered rapid or pressured.

4) Distractible speech

In distractible speech, during the course of a discussion or interview, the patient repeatedly stops talking in the middle of a sentence or idea and changes the subject in response to a nearby stimulus, such as an object in a desk, the interviewer’s clothing or appearance, etc.

Example from Andreasen (1979: 1318):

Patient may say: “Then I left San Francisco and moved to… Where did you get that tie?” it looks like it’s left over from ‘50s. I like the warm weather in San Diego. Is that a conch shell on your desk? Have you ever gone scuba diving?”

26 5) Tangentiality

In tangentiality, patient replies a question in an oblique, tangential or even irrelevant manner. The reply may be related to the question in some distant way. Or the reply may be unrelated and seem totally irrelevant. In the past, tangentiality has been used as roughly equivalent to loose associations or derailment. The concept of tangentiality has been partially redefined so that it refers only to questions and not to transition in spontaneous speech.

Example from Andreasen (1979: 1319):

Interviewer: “What city are you from?”

Patient: “Well that’s a hard question to answer because my parents. . . I was born in Lowa, but I know that I’m white instead of black so apparently I came from North somewhere and I don’t know where, you know, I really don’t know where my ancestors came from. So I don’t know whether I’m Irish or French or Scandinavia or I don’t I don’t believe I’m Polish but I think I’m I think I might be German or Welsh. I’m not but that’s all speculation and that’s one thing that I would like to know and is my ancestors you know where where did I originate. But I just never took the time to find out the answer to that question.”

6) Derailment (loose association, flight of ideas)

Derailment is a pattern of spontaneous speech in which the ideas slip off the track on to another one that is clearly but obliquely related, or on to one that is completely unrelated. Things may by said in juxtaposition that lack a meaningful relationship, or the patient may shift idiosyncratically from one frame of reference to another. At times there may be a vague connection between the ideas; at others, none will be apparent. Perhaps, the commonest manifestation of this disorder is a slow, steady slippage, with no single derailment being particularly severe, so that the speaker gets farther and farther off the track with each derailment, without

27 showing any awareness that his reply no longer has any connection with the question that was asked.

Derailment differs from circumstantiality in that each new subject is only obliquely related or even unrelated to the previous one and is not a further illustration or amplification of the same idea or subject. It may lead to loss of goal, but the speaker may also realize that he has gotten off the track and return to his original subject, and this should also be considered derailment.

Example from Andreasen (1979: 1319):

Interviewer: What did you think of the whole Watergate affair?”

Patient: “You know I didn’t tune in on that, I felt so bad about it. I said, boy, I’m not going to know what’s going on in this. But it seemed to get so murky, and everybody’s reports were so negative. Huh, I thought, I don’t want any part of this, and I was I don’t care who was in on it, and all I could figure out was Artie had something to do with it. Artie was trying to flush the bathroom toilet of the White House or something. She was trying to do something fairly simple. The tour guests stuck or something. She got blamed because of the water overflowed, went down in the basement, down, to the kitchen. They had a, they were going to have to repaint and restore the White House room, the enormous living room. And then it was at this reunion they were having. And it’s just such a mess and I just thought, well, I’m just going to pretend like I don’t even know what’s going on. So I came downstairs and ‘cause I pretended like I didn’t know what was going on, I slipped on the floor of the kitchen, cracking my toe, when I was teaching some kids how to do some double dives.”

7) Incoherence (word salad, schizophasia, paragrammatism)

Incoherence or also called word salad, schizophasia, and paragrammatism are a pattern of speech that is essentially incomprehensible at times. The incoherence is due to several different mechanisms, which may sometimes all occur simultaneously. Sometimes the rule of grammar and syntax are ignored, and a series of words or phrases seem to be joined together arbitrarily and at random.

28 Sometimes portions of coherent sentences may be observed in the midst of a sentence that is incoherent as a whole. Sometimes the disturbance appears to be at semantic level, so that words are substituted in a phrase on sentence so that the meaning seems to be distorted or destroyed. Sometimes “cementing words” (conjunctions such as ‘and’ and ‘although’ and adjectival pronouns such as ‘the’, ‘a’ and ‘an’) are deleted (in English grammar).

This type of language disorder is relatively rare. When it occurs, it tends to be severe or extreme, and mild forms are quite uncommon. It may sound quite similar to a Wernicke’s aphasia or jargon aphasia; in these cases, the disorder should only be called incoherence (thereby implying a psychiatric disorder as opposed to a neurological disorder) when history and laboratory data exclude the possibility of a known organic etiology and formal testing for aphasia gives negative results.

Incoherence often is accompanied by derailment. It differs from derailment in that the abnormality occurs at the level of sentence, within which words or phrases are joined incoherently. The abnormality in derailment involves unclear or confusing connections between larger units, such as sentence or ideas.

Example fron Andreasen (1979: 1319):

Interviewer: Why do you think people believe in God?

Patient: “Um, because making a do in life. Isn’t none of that stuff about evolution guiding isn’t true anymore now. It all happened a long time ago. It happened in eons and stuff they wouldn’t believe in him. The time that Jesus Christ people believe in their thing people believed in, Jehovah God that they didn’t believe in Jesus Christ that much.”

29 Interviewer: “What do you think about current political issues like the energy crisis?”

Patient: “They’re destroying too many cattle and oil just to make soap. If we need soap when you can jump into a pool of water, and then when you go to buy your gasoline, my folks always thought they should get pop, but the best thing to get is motor oil, and money. May may as well go there and trade in some pop caps and, uh, tires, and tractors to car garages, so they can pull cars away from wrecks, is what I believed in”.

8) Illogicality

Illogicality is a pattern of speech in which conclusions are reached that do not follow logically. This may take the form of non sequiturs (i.e., it does not follow), in which the patient makes a logical inference between two clauses that is unwarranted or illogical. It may take the form of faulty inductive inferences. It may also take the form or reaching conclusions based on faulty premises without any actual delusional thinking. Illogicality may either lead to or result from delusional beliefs.

Example from Andrease (1979: 1320):

Patient may say: “parents are the people that raise you. Any thing that raises you can be a parent. Parents can be anything, material, vegetable, or mineral, that has taught you something. 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 be a parent.”

9) Clanging

Clanging is a pattern of speech in which sounds rather that meaningful relationships appear to govern word choice, so that the intelligibility of the speech is impaired and redundant words are introduced. In addition to rhyming relationships, this pattern of speech may also include punning associations, so that a word similar in sound brings in a new thought. For example, patient may say:

30 “I’m not trying to make noise. I’m trying to make sense. If you can make sense out of nonsense, well, have fun. I’m trying to make sense out of sense. I’m not making sense (cents) anymore. I have to make dollars.”

10) Neologisms

Neologisms are new word formations. A neologism is defined here as a completely new word or phrase whose derivation cannot be understood. Sometimes the term ‘neologism’ has also been used to mean a word that has been incorrectly built up but with origins that are understandable as due to a misuse of the accepted methods of word formation. For purposes of clarity, these should he referred to as word approximations.

Example from Andreasen (1979: 1320):

Patient may say: “I got so angry I picked up a dish and threw it at the gashinker”. “So I sort of bawked the whole thing up”.

11) Word approximations (paraphasia, metonyms)

Word approximations are old words that are used in a new and unconventional way, or new words that are developed by conventional rules of word formation. Often the meaning will be evident even though the usage seems peculiar or bizarre (i.e., gloves referred to as ‘handshoes’, a ballpoint pen referred to a ‘paperskate’, etc). Sometimes the word approximation may be based on the use of stock words, so that the patient uses one or several words repeatedly in ways that give them a new meaning (i.e., a watch may be called a ‘time vessel’, the stomach a ;food vessel’, a television set a ‘news vessel’, etc).

31 Example from Andreasen (1979: 1320):

Patient may say: “Southeast Asia, well, that’s like Middle Asia now”. “His boss was a seeover”.

12) Circumstantiality

Circumstantiality is a pattern of speech that is very indirect and delayed in reaching its goal idea. In the process of explaining something, the speaker brings in many tedious details and sometimes makes parenthetical remarks. Circumstantial replies or statements may last for many minutes if the speaker is not interrupted and urged to get to the point. Interviewers will often recognize circumstantiality on the basis of needing to interrupt the speaker to complete the process of history taking within an allotted time.

Although it may coexist with instances of poverty of content of speech or loss of goal, it differs from poverty of content of speech in containing excessive amplifying or illustrative detail and from loss of goal in that the goal is eventually reached if the person is allowed to talk long enough. It differs from derailment in that the details presented are closely related to some particular idea or goal and in that the particular goal or idea must by definition eventually be reached.

An example of circumstantiality is that when patient asked about the age of his mother at death, the speaker responds by talking at length about accidents and how too many people die in accidents, then eventually says how the mother’s age was at death.

32 13) Loss of goal

Loss of goal refers to failure to follow a chain of thought through to its natural conclusion. This is usually manifested in speech that is begins with a particular subject wanders away from the subject and never returns to it. The patient may or may not be aware that he has lost his goal. This often occurs in association with derailment.

14) Perseveration

Perseveration refers to persistent repetition of words, ideas or subjects, so that once a patient begins a particular subject or uses a particular word, he continually returns to it in the process of speaking (McKenna, 2005: 24). This may also involve repeatedly giving the same answer to different questions.

Example from Andreasen (1979: 1320):

Interviewer: “Tell me what you are like, what kind of person you are.” Patient: “I’m from Marshalltown, lowa. That’s 60 miles northwest, northeast of Des Moines, lowa. And I’m married at the present time. I’m 36 years old. My wife is 35. She lives in Garwin, lowa. That’s 15 miles southeast of Marshalltown, lowa. I’m getting a divorce at the present time. And I am at presently in a mental institution in lowa City, lowa, which is a hundred miles southeast of Marshalltown, lowa”.

15) Echolalia

Echolalia is a pattern of speech in which the patient echoes words or phrases of the interviewer. Typical echolalia tends to be repetitive and persistent. The echo is often uttered with a mocking, mumbling or staccato intonation. Echolalia is relatively uncommon in adults, but more frequent in children.

33 Example from Andreasen (1979: 1321):

Doctor say to the patient: “I’d like to talk with you for a few minutes”. The patient may responds with a staccato intonation: “Talk with you for a few minutes”.

16) Blocking

Blocking refers to interruption of a train of speech before a thought or idea has been completed. After a period of silence lasting from a few seconds to minutes, the person indicates that he cannot recall what he had been saying or meant to say. Blocking should only be judge to be present if a person voluntarily describes losing his thought or if on questioning by the interviewer he indicates that that was his reason for pausing.

17) Stilted speech

Stilted speech refers to speech that has an excessively formal quality. It may seem rather quaint or outdated, or may appear pompous, distant or over polite. The stilted quality is usually achieved through use of particular word choices (multisyllabic when monosyllabic alternatives are available and equally appropriate), extremely polite phraseology (‘Excuse me madam, may I request a conference in your office at your convenience’). Or stiff and formal syntax (‘whereas the attorney comported himself indecorously, the physician behaved as is customary for a born gentleman’).

Example from Andreasen (1979: 1321):

34 18) Self-reference

Self-reference refers to a disorder in which the patient repeatedly refers the subject under discussion back to himself when someone else is talking and also refers apparently neutral subjects himself when he himself is talking.

Example from Andreasen (1979: 1321):

Interviewer: “What’s the time?”

Patient: “It’s 7 o’clock. That’s my problem. I never know time it is. Maybe I should try to keep better track of the time”.

2.4 Related Researches

Some researchers also have been made some researches related to language disorder in schizophrenic patient. One of the research about language disorder in schizophrenic patient have been made by Ni Ketut Alit Ida Setianingsih, I Made Netra, I Gst. Ngurah Prathama (2009) from University of Udayana in their journal Kajian Psikolinguistik Bahasa Skizofrenik: Studi Kasus Pada Rumah Sakit Jiwa Bangli published in scientific journal of language and literature in University of North Sumatera.

Their research concerns on language production and comprehension in schizophrenia patient. To analyze language production and comprehension produced by the schizophrenic patient the writers used some psycholinguistic theories and applied direct observed conversation method. The samples of the research are three schizophrenia patients; an emergency patient, a semi-emergency patient, and a quite patient in Bangli mental hospital.

35 The result of the analysis showed that (1) a) such stages of language production as conceptualization, formulation, articulation, and self-monitoring were differently used by the patients. The emergency patient failed to use those stages of language production. The semi-emergency patients were able to make use of those stages of language production inconsistently. Meanwhile, the quite patient was able to use those stages of language production relatively consistently; b) the schizophrenic language was comprehended through phonetic and phonological, morphological, syntactic, and text units. The emergency patient failed in using those units of language comprehension. Therefore, the utterances produced were not properly structured and coherent. The semi-emergency patient used those units of language comprehension inconsistently through out the whole conversation. The quiet patient used those units of language comprehension relatively more consistently (2) generally, schizophrenic behavior included association obstacles resulting in sudden change and unclear concepts. Schizophrenic behavior was actually that of the self expression of which language was in a high linguistic level, semantics and pragmatics. Schizophrenic behavior was unique, eccentric, full of metaphor, and neologism.

Other research related to language disorder in schizophrenia patient is an analysis by Isra Az-Zahra, Gangguan Berbicara Pada Penderita Skizofrenia Pasien Rumah Sakit Jiwa Tampan Pekanbaru. This analysis focuses on language characteristic produced by paranoid schizophrenia patient. In doing this analysis, the researcher use theory of schizophrenia by Kaplan and applying a qualitative method.

36 As the result of the analysis, the writer found that pressure of speech, unintelligible speech, poverty of speech, voice disorder, disprosody, poverty of content of speech, stuttering and inability to answer spontaneously are common in patient with paranoid schizophrenia.

Other related research is a journal by Rizkhi Nurul Azizah, Kemampuan Verbal Penderita Skizofrenia: Sebuah Studi Kasus. This research uses cooperative pragmatic theory by Grice and focuses on pragmatic impairment in language used by schizophrenia patient. Based on this research, the researcher found that verbal expression of schizophrenia patient follows Grice’s maxims.

Other related research is A Psycholinguistic Study on Comprehension Disorder of the Main Character in A Beautiful Mind Movie (2010) written by Sumitro Agung Nugroho. This study focuses on analyzing comprehension disorder of the schizophrenic character in A Beautiful Mind movie. This study uses descriptive qualitative method and the data are utterances of John Nash, the main character of A beautiful mind movie.

The aim of the study is to get the understanding and detailed explanation about comprehension disorder found in the schizophrenic character of A Beautiful Mind movie. And the result of the study shows that the schizophrenic character of A Beautiful Mind movie, John Nash, has a comprehension disorder which occurred due to his delusion and hallucination. There are nine types of comprehension disorder found in the schizophrenic character of A beautiful Mind

37 movie, including derailment, flight of ideas, incoherence, irrelevant answer, blocking, retardation, perseveration, pressure of speech, and circumstantiality.

Other related research is a Thesis entitled Schizophrenic Language (a case study of Toni Blank) (2014) written by Wahyu Wiji Nugroho from Gadjah Mada University. It is a descriptive qualitative research which attempts to explain about language phenomenon occurred in schizophrenic or people with mental disorder, especially Toni blank. The aims of this study are (1) to describe the characteristics of language in schizophrenic, especially Toni Blank, (2) to describe about violation of cooperative principle and degree of relevance when Toni Blank speak to other (3) to describe cohesion and coherence of schizophrenic, especially Toni Blank.

The data of the research is taken from Toni Blank Shows and live interview between the researcher and Toni Blank. Toni Blank Shows is a video made by X-Code Yogyakarta Film, consists of dialogue between Toni Blank and the interviewer which is uploaded in youtube. And the data of this research are utterances and answers from Toni Blank.

The result of the study are (1) the characteristics of language of Toni Blank including: incoherence, Neologism, Blocking, repetition, code-mixing, dieksis, and pragmatic deficit, (2) Toni Blank tends to violate all of the cooperative principle and have a very low degree of relevance, (3) Toni Blank still have the ability to use cohesion tool effectively.

38 All of those related researches give a lot contribution to writer in understanding language disorder in schizophrenia as well as it helps writer in writing and organized this analysis. The method used in the journal Kajian Psikolinguistik Bahasa Skizofrenik: Studi Kasus Pada Rumah Sakit Jiwa Bangli written by Ni Ketut Alit Ida Setianingsih, I Made Netra, I Gst. Ngurah Prathama inspires the writer in collecting the data of A Psycholinguistic Analysis of Language Disorder in Schizophrenia: A Case Study in which the data will be collected by using direct observed conversation by doing involved interview with some schizophrenia patients.

There are some differences between this analysis and others related researches which only focus on language comprehension disorder in schizophrenia. This Analysis of Psycholinguistic analysis of language disorder in schizophrenia: a case study use Andreasen’s theory in analyze the subtypes of language disorder found in schizophrenia paranoid patients. And this analysis is a field research which will be done by using case study method, therefore, the result and finding in this analysis was expected deeper than the previous research.

33 Example from Andreasen (1979: 1321):

Doctor say to the patient: “I’d like to talk with you for a few minutes”. The patient may responds with a staccato intonation: “Talk with you for a few minutes”.

16) Blocking

Blocking refers to interruption of a train of speech before a thought or idea has been completed. After a period of silence lasting from a few seconds to minutes, the person indicates that he cannot recall what he had been saying or meant to say. Blocking should only be judge to be present if a person voluntarily describes losing his thought or if on questioning by the interviewer he indicates that that was his reason for pausing.

17) Stilted speech

Stilted speech refers to speech that has an excessively formal quality. It may seem rather quaint or outdated, or may appear pompous, distant or over polite. The stilted quality is usually achieved through use of particular word choices (multisyllabic when monosyllabic alternatives are available and equally appropriate), extremely polite phraseology (‘Excuse me madam, may I request a conference in your office at your convenience’). Or stiff and formal syntax (‘whereas the attorney comported himself indecorously, the physician behaved as is customary for a born gentleman’).

Example from Andreasen (1979: 1321):

34 18) Self-reference

Self-reference refers to a disorder in which the patient repeatedly refers the subject under discussion back to himself when someone else is talking and also refers apparently neutral subjects himself when he himself is talking.

Example from Andreasen (1979: 1321):

Interviewer: “What’s the time?”

Patient: “It’s 7 o’clock. That’s my problem. I never know time it is. Maybe I should try to keep better track of the time”.

2.4 Related Researches

Some researchers also have been made some researches related to language disorder in schizophrenic patient. One of the research about language disorder in schizophrenic patient have been made by Ni Ketut Alit Ida Setianingsih, I Made Netra, I Gst. Ngurah Prathama (2009) from University of Udayana in their journal Kajian Psikolinguistik Bahasa Skizofrenik: Studi Kasus Pada Rumah Sakit Jiwa Bangli published in scientific journal of language and literature in University of North Sumatera.

Their research concerns on language production and comprehension in schizophrenia patient. To analyze language production and comprehension produced by the schizophrenic patient the writers used some psycholinguistic theories and applied direct observed conversation method. The samples of the research are three schizophrenia patients; an emergency patient, a semi-emergency patient, and a quite patient in Bangli mental hospital.

35 The result of the analysis showed that (1) a) such stages of language production as conceptualization, formulation, articulation, and self-monitoring were differently used by the patients. The emergency patient failed to use those stages of language production. The semi-emergency patients were able to make use of those stages of language production inconsistently. Meanwhile, the quite patient was able to use those stages of language production relatively consistently; b) the schizophrenic language was comprehended through phonetic and phonological, morphological, syntactic, and text units. The emergency patient failed in using those units of language comprehension. Therefore, the utterances produced were not properly structured and coherent. The semi-emergency patient used those units of language comprehension inconsistently through out the whole conversation. The quiet patient used those units of language comprehension relatively more consistently (2) generally, schizophrenic behavior included association obstacles resulting in sudden change and unclear concepts. Schizophrenic behavior was actually that of the self expression of which language was in a high linguistic level, semantics and pragmatics. Schizophrenic behavior was unique, eccentric, full of metaphor, and neologism.

Other research related to language disorder in schizophrenia patient is an analysis by Isra Az-Zahra, Gangguan Berbicara Pada Penderita Skizofrenia Pasien Rumah Sakit Jiwa Tampan Pekanbaru. This analysis focuses on language characteristic produced by paranoid schizophrenia patient. In doing this analysis, the researcher use theory of schizophrenia by Kaplan and applying a qualitative method.

36 As the result of the analysis, the writer found that pressure of speech, unintelligible speech, poverty of speech, voice disorder, disprosody, poverty of content of speech, stuttering and inability to answer spontaneously are common in patient with paranoid schizophrenia.

Other related research is a journal by Rizkhi Nurul Azizah, Kemampuan Verbal Penderita Skizofrenia: Sebuah Studi Kasus. This research uses cooperative pragmatic theory by Grice and focuses on pragmatic impairment in language used by schizophrenia patient. Based on this research, the researcher found that verbal expression of schizophrenia patient follows Grice’s maxims.

Other related research is A Psycholinguistic Study on Comprehension Disorder of the Main Character in A Beautiful Mind Movie (2010) written by Sumitro Agung Nugroho. This study focuses on analyzing comprehension disorder of the schizophrenic character in A Beautiful Mind movie. This study uses descriptive qualitative method and the data are utterances of John Nash, the main character of A beautiful mind movie.

The aim of the study is to get the understanding and detailed explanation about comprehension disorder found in the schizophrenic character of A Beautiful Mind movie. And the result of the study shows that the schizophrenic character of A Beautiful Mind movie, John Nash, has a comprehension disorder which occurred due to his delusion and hallucination. There are nine types of comprehension disorder found in the schizophrenic character of A beautiful Mind

37 movie, including derailment, flight of ideas, incoherence, irrelevant answer, blocking, retardation, perseveration, pressure of speech, and circumstantiality.

Other related research is a Thesis entitled Schizophrenic Language (a case study of Toni Blank) (2014) written by Wahyu Wiji Nugroho from Gadjah Mada University. It is a descriptive qualitative research which attempts to explain about language phenomenon occurred in schizophrenic or people with mental disorder, especially Toni blank. The aims of this study are (1) to describe the characteristics of language in schizophrenic, especially Toni Blank, (2) to describe about violation of cooperative principle and degree of relevance when Toni Blank speak to other (3) to describe cohesion and coherence of schizophrenic, especially Toni Blank.

The data of the research is taken from Toni Blank Shows and live interview between the researcher and Toni Blank. Toni Blank Shows is a video made by X-Code Yogyakarta Film, consists of dialogue between Toni Blank and the interviewer which is uploaded in youtube. And the data of this research are utterances and answers from Toni Blank.

The result of the study are (1) the characteristics of language of Toni Blank including: incoherence, Neologism, Blocking, repetition, code-mixing, dieksis, and pragmatic deficit, (2) Toni Blank tends to violate all of the cooperative principle and have a very low degree of relevance, (3) Toni Blank still have the ability to use cohesion tool effectively.

38 All of those related researches give a lot contribution to writer in understanding language disorder in schizophrenia as well as it helps writer in writing and organized this analysis. The method used in the journal Kajian Psikolinguistik Bahasa Skizofrenik: Studi Kasus Pada Rumah Sakit Jiwa Bangli written by Ni Ketut Alit Ida Setianingsih, I Made Netra, I Gst. Ngurah Prathama inspires the writer in collecting the data of A Psycholinguistic Analysis of Language Disorder in Schizophrenia: A Case Study in which the data will be collected by using direct observed conversation by doing involved interview with some schizophrenia patients.

There are some differences between this analysis and others related researches which only focus on language comprehension disorder in schizophrenia. This Analysis of Psycholinguistic analysis of language disorder in schizophrenia: a case study use Andreasen’s theory in analyze the subtypes of language disorder found in schizophrenia paranoid patients. And this analysis is a field research which will be done by using case study method, therefore, the result and finding in this analysis was expected deeper than the previous research.