Phenom Cogn Sci DOI 10.

1007/s11097-013-9340-0

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 unusual ways in which language can be experienced by individuals with schizophrenia or severe mood disorders, specifically mania and melancholia (psychotic depression). Our discussion follows a tripartite/dialectical format: first we describe traditionally observed distinctions (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); then we consider some apparent similarities in the experience of language in these conditions (e.g., striking disorganization of manic as well as schizophrenic speech, interpersonal alienation in both schizophrenia and severe depression). Finally, we explore more subtle, qualitative differences. These involve: 1, interpersonal orientation (less concern with the needs of the listener in schizophrenia), 2, forms of attention and context-relevance (e.g., manic distractibility versus schizophrenic loss of orientation), 3, underlying mutations of experience (e.g., sadness/emptiness in melancholia versus disturbances of basic selfhood in schizophrenia), and 4, meta-attitudes toward language (i.e., greater alienation from language-as-such in schizophrenia). Such distinctions appear to reflect significant differences in underlying forms of subjectivity; they are broadly consistent with work in phenomenological psychopathology on other aspects of experience, including body, self, and social world. An understanding of such distinctions may assist with difficult cases of differential diagnosis, while also contributing to a better understanding of suffering persons 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 experience of language in three classic forms of mental disorder: schizophrenia, mania, and melancholia (the latter largely overlapping with the category of
L. Sass (*) : E. Pienkos Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, NJ 08854-8020, USA e-mail: lsass@rci.rutgers.edu

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psychotic depression).1 Linguistic anomalies are frequently mentioned in the psychiatric literature, and are often considered fundamental in schizophrenia (e.g., Crow 2000; Lacan 1981/1993; Schwartz 1982). Most studies of language have, however, adopted an external or structuralist perspective, with an emphasis on linguistic behavior, syntax, or the like. By contrast, the experience of language is a neglected topic, with relatively little discussion of this issue even in classic and contemporary phenomenological psychopathology. Here we hope to take some initial steps toward filling this lacuna. Our intention is to go beyond surface or structural characteristics of language: beyond words, as one might say, in the sense of focusing primarily (though not exclusively) on the subjective dimension, on what it is like for the patient to experience language, whether ones own or that of other people. Although our focus is on description, we also consider ways in which the experience of language may link with other themes central to schizophrenic psychopathology, including altered experiences of body, self, and social world. This article is theoretical, clinical, and qualitative in orientation: we offer a selective review of relevant writings in psychopathology, especially phenomenological psychopathology (both classic and recent), together with patient reports or other anecdotes that illustrate the phenomena at issue. Our approach is first and foremost a review of the available literature that is relevant, directly or indirectly, to the subjective experience of language and speech in the disorders discussed here (a literature that, if restricted to a phenomenological focus, is rather limited). Secondly, we offer some theoretical formulations that help to organize or otherwise make sense of the material. Our ultimate goal is to offer a preliminary guide that may sensitize both clinicians and researchers to the subjective side of the varied abnormalities found in these conditions. This is a study in phenomenological psychopathology; a comparative approach can sharpen theoretical understanding of the qualitative specificity of different forms of abnormal experience. As in several previous papers (2013a, b, under review), this article has a tripartite and dialectical structure: first we will describe certain differences in linguistic experience that have classically been recognized in schizophrenia and affective disorders (I: Differences), then some striking similarities, often found in typical cases of these apparently diverse disorders, that may suggest deeper affinities (II: Affinities). Finally we consider whether a still closer, phenomenological analysis might reveal some subtle yet profound ways in which these disorders may nevertheless differ from one another (III: Subtler Distinctions). These subtle differences are especially worthy of study because, when highlighted and clarified, they may contribute to more accurate differential diagnosis, richer theoretical understanding of these psychiatric conditions, and enhanced ability to empathize with such patients and thus achieve an effective therapeutic alliance. We hope to show, then, that superficial characterizations of difference can be challenged by some apparent commonalities, but also that the commonalities may themselves be somewhat superficialin the sense of masking different underlying experiential structures. A phenomenological approach is designed to go beyond mere behavioral description and superficial first-person accounts, allowing us to consider the underlying forms of subjectivity that may be involved. We note as well that phenomenology has an important role to play even in neurobiological and neurocognitive accounts, given that subjective experiences are among those factors that neurobiology and cognitive science must ultimately take
1

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

Beyond words: Language in melancholia, mania, and schizophrenia

into account. Conscious experience is, after all, an explanandum in its own right (Chalmers 1995, p. 209), as various philosophers have noted. And without some idea . . . of what the subjective character of experience is, we cannot know what is required 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 closely intertwined aspects of human existence. Indeed, when taken together, they play a dominant role in the constitution of inter-subjective reality and may even be said to define 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 of the social world, which it presupposes but also profoundly transforms. Many theorists have argued, in fact, that language could not even be referential were it not also shared. In this sense the very acceptance of language always returns the person, no matter how alienated, to the common world. The point is implicit in Ludwig Wittgensteins (1958) famous arguments against the very possibility of a private language (see also Laruelle 1978; Tatossian 1997) as well as in Lacans (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 of lived reality. One need not adopt an extreme linguistic determinism or post-structuralist position to recognize that we experience not only persons but virtually all objects and situations largely via schemata, scripts, and typifications of various sorts, and that these are, to a very large extent, verbally and socially mediated (see, e.g., Garnham and Oakhill 1994).3 It can be argued, as well, that it is in and through language that man constitutes himself 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 subjectivity is in the exercise of language (pp. 224, 226).4
For a parallel discussion, but more focused on the experience of other persons in melancholia, mania, and schizophrenia, see Sass and Pienkos (under review). For comparative discussions of self-experience and world-experience (time, space, atmosphere), see Sass and Pienkos (2013a, b). 3 This paragraph is nicely summed up in philosopher Merleau-Pontys (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 with the phenomenon of expressionviz, with the manifestation of thoughts and feelings and their communication to others, whether by word, facial expression, or bodily tension or movement. As Sartre, Levinas, and other philosophers have pointed out, expression implies something that is both immanent and transcendent, both present and beyond. Words, like faces, have a certain sensory presence, visual or auditory; but in both cases this presence directs our attention inward as well as outwardinward toward what is presumed to be a grounding awareness 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 normally experienced, can be considered an audible transcendence. In this sense both a word and a faceat least as normally experiencedshare a certain aura: that of a sensory presence whose immediacy always points beyond. Emmanuel Levinas (1969) argues that a face is authentically a face only if it is recognized as comprising an infinity and not a totality, which is to say, as something whose meanings are rich and ambiguous enough to transcend any single interpretation by the viewer. In the absence of the above-mentioned aura, one may feel oneself in the presence of something uncanny, e.g., of behavior that is somehow other than fully human, or a sound that functions as something far less, or far more, than a word.
2

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1.2 Schizophrenia and the affective psychoses The importance of the disorders to be considered here, and of the affinities and differences between them, hardly needs emphasis (for further discussion, however, see 2013a, b, under review). Indeed, the differentiation of schizophrenic from affective disorders has been described as the most crucial diagnostic differential in all of psychiatry (Tatossian 1997). It has been explored by virtually all the founders of modern psychiatry, including not only Kraepelin, Bleuler, and Jaspers, but also Kretschmer and Minkowski, among many others. While some, such as Kraepelin (at least until the end of his life (Kraepelin 1920/1974)), have conceived the endogenous psychoses as distinct disease entities, others have viewed them in less discrete and more continuous ways: thus for Kretschmer (quoted in Crow 2002, p. 336), endogenous psychoses are nothing more than marked accentuations of normal types of temperament, which he termed schizothymic and cycloidthe former prone to social withdrawal and disharmony with others, the latter more spontaneously engaged with the world (Sass 1992). The phenomenological psychiatrist, Eugene Minkowski (1927/2012) (who was influenced by Kretschmer) made a similar distinction between schizoid and syntonic orientations, describing the former as characterized by a distinctive form of autism involving loss of vital contact with the world. In recent years, however, a growing number of researchers have been questioning the validity and value of drawing a fundamental distinction between schizophrenia and affective disorderse.g., by proposing new categories such as salience dysregulation syndrome (van Os 2009) or new versions of the unitary psychosis hypothesis, or by suggesting that such disorders are best characterized on a continuum of psychotic and mood symptoms (Dutta et al. 2007; Hyman 2010; Rosenman et al. 2003). Some critics recommend that we focus not on diagnostic groupings but on domains of psychopathology (such as depression or reality distortion) or else on behavioral constructs with known neural bases (e.g., in the RDoC or Research Domain Criteria: negative and positive valence systems, cognitive and socialprocess systems, arousal/regulatory systems). Studies do show that many symptoms, or even groups of symptoms, can often be insufficient for distinguishing between these disorders (e.g., Taylor 1992; van Os 2009). It remains true, however, that Kraepelins basic distinctionwhether framed as a dichotomy or some form of continuum between schizophrenic and affective typescontinues to be the dominant view in contemporary psychiatry and psychology. It does seem obvious that many crucial psychological and physiological processes are shared across diagnostic entities (e.g., self-focused attention, experiential avoidance, or some forms of reality distortion; salience dysregulation), and that studying disturbances in these particular processes is worthwhile (Harvey et al. 2004; van Os 2012). Yet it seems equally obvious that particular symptoms or processes are likely to be of differential importance in distinct disorders, and likely as well that shared symptoms or processes will play out differently in distinct psychopathological settings, in accord with distinct experiential orientations or basic underlying disturbances (what Minkowski (1927/2012) called troubles genrateurs). It is wise to recall Karl Jaspers (1946/1963) opinion of the long-running debate regarding the schizophrenia/affective distinction. While recognizing the difficulties in defining the

Beyond words: Language in melancholia, mania, and schizophrenia

boundary, he believed that there must be some kernel of lasting truth in Kraepelins concept of the two great groups of diseases which has been actively applied since about 1892 (p. 567). Phenomenological research into the overlaps and disparities between these traditional distinctions is essential in order to inform these discussions and aid in developing an ever-more-accurate picture. This paper does not, however, attempt to engage the particulars of current debates on diagnosis and segmentation of psychotic disorders. Here we explore, in the realm of language, the traditional notion of an important distinction between schizophrenia and severe mood disorders. It should be noted that our focus on this distinction is consistent with various overall nosological visions, ranging from distinct disease entities to temperamental continua, and not precluding the possibility of mixed or intermediate 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 a qualitatively distinct kind of depression, one that is endogenous, particularly severe, associated with psychotic symptoms, or somehow odd (Akiskal 2009; Fink and Taylor 2007; Shorter 2013). DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision 2000) employs the specifier With Melancholic 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 experienced during bereavement or a non-melancholic depressive episode (p. 419). This melancholic form of depression is particularly relevant for the present study because of its severity and likelihood of generating experiential anomalies that may be more difficult to distinguish from schizophrenia. The term mania refers to particular experiences that can occur in someone diagnosed with Bipolar Disorder; here we are specifically interested in these manic experiences themselves, rather than in the range of 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 be distinguished in phenomenological terms. 5 We believe, however, that there is considerable valueat least at this stagein pursuing these comparisons on a more general plane. While we do not ignore all such nuances and qualifications, we do opt for a kind of Weberian ideal-type analysis in this paper. Such an approach is unapologetically perspectival (Weber 1904/1949, p. 90). It focuses on features that are typical of the phenomenon studied, but which may not apply equally well, or in just the same way, to all instances of the type (Wiggins and Schwartz 1991). We do not expect or propose that our characterizations of the disorders under consideration will apply universally. Rather, we pursue the more modest goal of highlighting and describing those features of melancholia, mania, and schizophrenia that may be highly 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 schizophrenia 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.

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relatively clear-cut examples of the various forms of psychosis: indeed we will be describing features found in prototypical instances of the different disorders or conditions at issue. It should be stressed, however, that the anomalous linguistic phenomena to be described below are not continuously present in either the experience or expression of any particular patient (Bleuler 1982); they are varying phenomena that tend to occur in certain kinds of patients. But as we shall argue, they do seem to represent important and often distinguishing features of the different conditions, features that express or otherwise indicate core features of the forms of psychopathology in question.6 Our claims in this paper, especially regarding subtler distinctions, are offered in tentative fashion. It is obvious that there is need for further exploration and, ultimately, for confirmation, disconfirmation, or refinement by controlled empirical studies.7 First-person testimony and anecdotal reports do of course pose methodological challenges. It can be difficult to interpret such reports, especially in the case of severe mental disorders; it would be nave to assume they involve purely unbiased description. First-person accounts are, for instance, influenced by the culture or era in which they are produced, as well as by the constraints of literary genre and autobiographical memory; this casts doubt on the assumption that such descriptions merely reflect what an experience is really like (Radden and Varga 2013; Woods 2011).8 Also, of course, it is often a matter of judgment to decide just how typical versus idiosyncratic a particular report can be considered to be. It is equally clear, however, that empirical research does require, as a preliminary step, work akin to the theoretical explorations offered below.9 Both descriptive work and theoretical speculation are indispensable for the generation of orienting hypotheses and the fashioning of operational descriptions. Experience without theory is blind, as Kant famously noted, just as theory without experience would be mere intellectual play.10

Such a comparison may also have relevance for psychotherapy or other psychological treatments. A better understanding of possible ways of experiencing language in psychopathology should help in developing empathy and improving ones therapeutic alliance with a patientas well as in accurately targeting specific areas of interpersonal experience for intervention. The relationship between therapist and patient, largely linguistic or linguistically mediated, is, of course, a primary tool for bringing about change in these domains. With greater understanding of the attitudes these patients may adopt and the challenges they may face in using and understanding language, one may be in a better position to develop sensitive and effective interventionsinterventions less likely to be undermined by failure to grasp some of the very issues they are intended to target and treat. 7 Together with colleagues (Borut Skodlar, Josef Parnas, Nev Jones), we are currently preparing a qualitative interview schedule, the Examination of Anomalous World Experience or EAWE, which is modeled on the well-known EASE: Examination of Anomalous Self Experience (Parnas et al. 2005). The EAWE will contain a major section focusing on the subjective experience of language, both productive and receptive; 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 ones scientific theory (Dennett 2003, p. 23). 10 Kants 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 in General Systems (General systems 1962).

Beyond words: Language in melancholia, mania, and schizophrenia

2 Differences Certain disturbances in the usage or experience of language have long been reported in schizophrenia, and have frequently been considered distinctive of the condition. Psychiatric theorists as disparate as Crow (2000) and Lacan (1981/1993) have seen either schizophrenia or psychosis more generally as fundamentally linked to disturbances in the use of, or abnormalities in the attitude toward, language. Crow, in particular, saw schizophrenia as resulting from a disturbance in the neural development of language modules, resulting in the inability to distinguish thought, speech output, and heard speech from others. Bleuler (1950) also viewed disturbed speech as evidence of the thought disorder or loosening of associations that he considered central to the schizophrenic condition. It is difficult to draw a clear line between what might be considered disorders of thought versus of language in schizophrenia; contemporary operational approaches focus on language production (Andreasen 1979). The varied anomalies that have been noted in schizophrenia include glossomania, echolalia, mutism or alogia (poverty of speech), poverty of content of speech, agrammatism, tangentiality, and clang associations (Andreasen 1986; Andreasen and Grove 1986; Andreasen 1979; Covington et al. 2005; Lecours and Vanier-Clement 1976; Sass 1992, ch 6; Schwartz 1982). Studies considering schizophrenic speech from a linguistic perspective have observed that disturbances tend to occur at the levels of phonology (e.g. flattened intonation and constricted timbre), pragmatics, and lexical access (seen in neologisms and stilted speech), though grammar and syntax tend to remain relatively unimpaired (Covington et al. 2005). Elvevg et al. (2002) suggest that although schizophrenia patients are able to access the same number of words and ideas as controls, they may use inefficient strategies to store and thus retrieve such information, disrupting verbal fluency. Similarly, a review article by Spitzer (1997) draws on cognitive neuroscience to conclude that the semantic associative networks of schizophrenia patients may be impaired, resulting in a low signal-to-noise ratio and creating such anomalies as loose associations and both overly concrete and overly abstract speech. Although such reports can be helpful in organizing the varieties of schizophrenic language disturbance, their approach tends to rely heavily on an external or behavioral standpoint. Such work also tends to favor a deficit perspective, emphasizing the problems and losses that occur in schizophrenia language. It is not necessary to assume, however, that differences in linguistic output always involve or are experienced as a loss; schizophrenia patients may, for example, experience an enriched sense of the potential ambiguities in language, or willfully adopt idiosyncratic manners 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 on subjective experience. For preliminary, illustrative purposes, we offer several statements from schizophrenia patients that convey some of the intensity these experiences can have. Describing his experience of others speech, one remitted patient stated, I used to get the sudden thing that I couldnt understand what people said. Like it was a foreign language. My mind went blank. Another patient notes that in his own attempts to speak, I thought my language was wrong. I believed that no one could understand what I said. I couldnt understand what I said. Just high-pitched noises came (Cutting 1985, p. 252). Still another person with schizophrenia

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(Sophie, quoted again below) spoke of words as social creatures that could breathe or blink, transforming the world and themselves. A final patient would use habitual words to express ideas quite differently from what they customarily expressedthey 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 a general, theoretical account of the subjective dimension of the anomalies of linguistic expression and understanding found in schizophrenia. In Chapter 6 of Madness and Modernism, Sass (1992) divides these anomalies into three general trends: 1, desocialization, the failure or refusal to incorporate the needs and rules necessitated by communication with another person, often associated with a preoccupation with private concerns; 2, autonomization, the tendency to adopt a passive attitude in which language loses its value as a communicative tool and emerges instead as the focus of attention or source of control over speech; 3, impoverishment: restriction of the amount of speech or diminishment of the apparent content or meaning of speech, which can be associated with a variety of different underlying experiences, including rejection of interpersonal contact and an overwhelming sense of the inadequacy of language in light of the ineffability of experience or the world. Sass argues that each of these trends is a language of inwardness, involving a distinctive departure from a standard social orientation. The first involves a move toward a kind of inner speech that is felt to be more authentic than conventional language; the second a new recognition of the independent nature of language, an acknowledgment of its existence as a system imbued with its own inherent mysteries and forms of production (what could be termed an apotheosis of the word); the third a new preoccupation with the uniqueness and particularity of unverbalized experience, or with hyper-abstract or ontological concernsand with the sense of ineffability this invariably evokes (Sass 1992). The language disturbances typical of melancholia and mania have generally been described rather differently: largely in terms of decrease or increase in amount or rate of speech, rather than as alteration of coherence, clarity, or interpersonal anchoring. This characterization echoes the general emphasis on increase or decrease in speed of thinking in affective disorders. Various studies have observed slower speech and increased 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 (Cutting 1997). William Styron, who suffered from severe depression, describes one dinner during which he had a virtually total failure of speech, when the ferocious inwardness of the pain produced an immense distraction that prevented my articulating words beyond a hoarse murmur; I sensed myself turning wall-eyed, monosyllabic My speech, he says regarding another occasion had slowed to the vocal equivalent of a shuffle (Styron 1990, pp. 20, 56). Pressure of speech, with increased rapidity of speech and ideational flow, is a common symptom of mania, second only to elevated mood (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).

Beyond words: Language in melancholia, mania, and schizophrenia

3 Affinities There are, however, also some studies that show little or no difference in the deviant verbalizations produced by persons with schizophrenia versus mania. Andreasen (1979), e.g., found a similar percentage of derailment, incoherence, and illogicality in manic as in schizophrenic speech, although there was greater incidence of clang associations in mania. A study analyzing the speech output of schizophrenic, bipolar, and depressed patients was unable to discriminate among groups on the basis of deviant linguistic variables (Lott et al. 2002). These behavioral findings might make one question the sharpness of underlying experiential differences as well. In one interesting clinical account, Lake (2008) describes blocking, loose associations, derailment, disorganization, and even apparent incoherence of thought and speechfeatures classically associated with schizophrenia, according to Bleuleras being common in many typical cases of mania as well. He recounts one manic patients own account of the uncontrolled drift of his loosely associated thoughts: a dropped key chain had caused him to think of the key of life, then of life beginning in Egypts Nile River valley, then of the pyramids, then of the desert, then of feeling hot and thirsty, then of desiring a glass of water. Clang associations have also been frequently observed in manic patients, and may well be more prevalent than in schizophrenia (Cutting 1997). Some examples are: Dr. Malmberg you are an ice woman an iceberg a lettuce; Mystery history; Ill never be sick like a tailor even though my dad was a tailor even though my dad was a sailor (p. 481). These manic patients appear to be paying excessive attention to sound qualities of the word rather than to its linguistic meaning, which is certainly reminiscent of the autonomization that can occur in schizophrenic language. Some first-person reports by severely depressed patients suggest that, like schizophrenia patients, persons with clear cases of depression will often experience a loss of either the ability or the desire to use language in standard and socially appropriate ways. I could not follow conversation, could not pretend any interest, said one depressed patient. There was no talking with anybody (Smith 1999, p. 12). At the extreme a melancholic patient can find himself utterly unable to care about expressing himself 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 inherent ineffability of melancholic experiences. I was not able to talk coherently for any length of time; I was too vague about the causes of my discomfort to make myself understood, said one depressed patient (Kaplan 1964, p. 164). Another such patient offers more detailed insight: I often found myself silent. When I spoke, it was with stumbles and stammers. Wordsunhappy, anxious, lonelyseemed plainly inadequate, as did modifiers: all the time, without relief. Ordinary phrases such as I feel bad or I am unhappy seemed pallid. Evocative metaphorsMy soul is like burned skin, aching at any touch; I have the emotional equivalent of a dislocated limbwere garish. Though this language hinted at how bad I felt, it could not express what it felt like to be me. (Shenk 2002, p. 248f)

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For other melancholic individuals, an overpowering sense of nothingness or indistinctness may create the feeling that there is, in fact, nothing to describe. As one depressed patient states, to be depressed is not to have words to describe it, is not to have words at all, but to live in the gray world of the inarticulate, where nothing takes shape, nothing has edges or clarity (Casey 2002). In initial psychiatric interviews, schizophrenic patients may also complain of the ineffability of their experiences (Mller and Husby 2000)which they too experience as somehow beyond wordsor make repeated use of vague or clichd pet phrases that convey little to the listener, demonstrating apparent poverty of content of speech. Some of these statements may sound similar to those of depressed or neurotic patients (Parnas et al. 2005), such as I feel down, I dont feel like myself, or I feel depressed. Henri Ey (1996) has also noted a strange taste for the abstract among schizophrenic patients, which can lead to overuse of vague words like thing or thingamabob, or of 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 between the 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 mutations of experience, and 4, Meta-attitudes toward language. 4.1 Interpersonal orientation In considering the similarities in manic and schizophrenic speech, one study indicated that, although frequency of language disorder may be similar in manic and schizophrenic patients, there were observable differences in severity of disturbance (Wykes and Leff 1982). In particular, manic patients provided the listener with more ties to relate 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 of the 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 the ability or will to convey intended meaning, or in the pragmatic function of language, indicating decreased concern for using language as a means of communicating and interacting with other people. This, of course, would be a linguistic manifestation of the turning-inward that is characteristic of schizophrenia, and that may, at the extreme, amount to a kind of solipsistic orientation (Sass 1992, 1994). Examples of such speech include such statements as We are already standing in the spiral under a hammer, and Death will be awakened by the golden dagger, which leave the interlocutor wondering what the speaker could possibly be referring to (Kraepelin 1919/1971, 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 Grices maxims, the mostly automatic rules people follow when they wish to communicate with others, such as give adequate information, but not too much, and be truthful (Covington et al. 2005, p. 16).

Beyond words: Language in melancholia, mania, and schizophrenia

Merely focusing on severity of disturbance in linguistic pragmatics fails, however, to take into consideration the various reasons for such disturbance. For some schizophrenia patients, lack of attention to the listener s needs may indeed indicate some form of interpersonal incompetence. It may, however, also reflect a specific attitude toward the interlocutor, an attitude less common or absent in mania and that may be bound up with the schizophrenia patients sense of radical uniqueness and willful eccentricity (with what Stanghellini and Ballerini (2007) term idionomia and antagonomia). There may be, for example, an element of indifference or even hostility toward the audience, resulting in a desire to obscure ones speech with the specific intention of making it more difficult to understand (Bleuler 1950, pp. 147, 150). One schizophrenia patient described intentionally speaking nonsense, into which he would occasionally insert meaningful statements about his mental and emotional 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, deliberately obscuring his intention when he was upset or angry with someone (Sass 1992). Similarly, Liddle and Barnes (1988) have observed that some patients may use poverty of speech and flattened affect as a sort of defense to protect them from intolerable intersubjective experiences. Other patients may experience a sense of superiority in being able to escape the bourgeois reliance on the conventionality of language (described in greater detail below) (Sass 1992). In these ways, rather than indicating mere lack or deficit, disturbance in the pragmatic dimension of linguistic communication may be manifestations of a language of inwardness (Sass 1992) that both serves the goals and reflects the subjective orientation of many patients with schizophrenia, 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 of linguistic context. Various authors have noted that, whereas the distractibility and disorganization of speech (and of thought) in mania suggests a fairly straightforward deterioration of selective attention, the situation in schizophrenia seems more complex (Cutting 1997; Holzman et al. 1986; Lake 2008; Sass 1992, chapters 4 & 5). A similar or even greater degree of disorganization or loosening may certainly occur in schizophrenia, and disturbed selective attention can play a significant role. However, some of the anomalies of speech or linguistic understanding seem to imply 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 (closely related) un-anchoring of thought or perception from the practical or conventional contexts 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 of signifier from signified, such that words can begin to appear absurd or meaninglessor perhaps meaningful in radically unconventional ways (see discussion of Autonomization in Sass 1992, pp. 178ff). This can involve a focus on the symbolic vehicle, as seen in clang associations or a focusing on the look of words, or of a single word, on a page. Here the expressive aspect of language disappears: the patients attention fixes so completely on the sound or look of a specific word that all sense of intended or potential meaning disappears.

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Such abnormalities of linguistic experience seem to reflect the isolating, sometimes rigidified forms of attention that can be characteristic of schizophrenia, giving rise, in the words of the German psychiatrist Paul Matussek (1987) (who combined phenomenology with Gestalt psychology), to a loosening of the natural perceptual context that allows individual perceptual components (p. 90) to float free of the usual anchoring in common-sense unities or scenes. Such forms of attention have both a passive and active/intentional aspect: the patient feels somehow held captive by [an] object, yet also shows himself capable, to a much greater degree [than normal persons], of fixing his attention on an isolated object, and even takes pleasure in doing so (p. 934, emphasis added; Sass and Pienkos 2013c). Analogous phenomena can occur with perception of a face (whether someone elses or ones own contemplated in a mirror)as when the (schizophrenia) patients attention fixes so intently on unrelated physical features (nose, eyeballs) that the face can 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 a word taken in isolation, divorced from expectations imposed by the semantic or practical context of the sentence and its function in verbal interaction (Kuperberg 2006). To the person with schizophrenia, sentences may then appear meaningless as overall units, yet somehow hyper-charged with meaning due to the unconstrained proliferation of semantic pathways now emerging from individual words or sounds; Lecours and Vanier Clement (1976) describe preoccupation with too many of the semantic features of a word in discourse (p. 561). As one schizophrenic patient stated, 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 such proliferating meanings, communicative aspects of speech naturally dwindle, resulting in diminished cues to orient the listener, such as cohesive ties between one sentence and the next. The prominence of clang associations in mania shows that they too may respond to alternative meanings, which, in turn, are likely to take one into a new context different from the original, intended meaning of a verbal communication. There seems a difference, however, between the manic persons rapid, often playful, yet always context-embedded shifting from context to context, as against the alienated and fragmenting orientation one more often finds in schizophrenia (Holzman et al. 1986). The schizophrenic person might better be described (at least in the most typical case) as experiencing words in the void, in a perplexing context of no context11thus manifesting a linguistic equivalent of the unworlding of the world that can characterize schizophrenic experiences of reality in general (Sass 1992). The semantic wandering prominent in schizophrenia seems, one might say, to be generated from within, resulting from the loosening of the thematic field that occurs with loss of any orienting perspective to anchor or fix the meanings of either words or things. Spitzer (1997) notes that in verbal association, schizophrenia patients have a lower signal-to-noise ratio, that is, both related (signal) and unrelated (noise) concepts may be equally accessible when target words are activated. This psychological 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.

Beyond words: Language in melancholia, mania, and schizophrenia

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 schema necessary to appropriately organize cognitive associations. By contrast, manic distractibility seems to occur more often in response to intruding mental contents or to stimuli 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 the patient or that she or he might wish to express. Melancholic patients often have difficulty finding the words to describe their despair. Language seems inadequate to capture their pain, sadness, or sense of profound emptiness. This is akin to the resistance to ready linguistic expression of bodily pain, which is often taken to epitomize the impossibility of communicating with others and the overwhelming fact of human isolation (Scarry 1985). In schizophrenia, by contrast, not just pain or suffering but all experience may come to seem ineffablewholly beyond words, as it were; and in a way that suggests a more basic sense of discontinuity between language and experience, with all its elusive particularity and complexity. One schizophrenic patient described this as so many echelons of realityso many innuendos to take into account (Sass 1992). Communication seemed impossible; language could never convey all the nuances and tonalities he wished to express. Research (Gross et al. 2008; Parnas et al. 2005) suggests that the vague complaints of unreality or dysphoria by early schizophrenia patients (as described above) may often mask subtle but profound anomalies in experience of basic or minimal selfhood, anomalies associated with the ipseity disturbance that may be a kind of trouble genrateur of schizophrenia (Parnas et al. 2005; Sass 2013; Sass and Parnas 2003). These disturbances would include the strange, ineffable, often uncanny experiencesbodily as well as cognitivethat can occur when internal sensations or thought processes that are normally mute or taken-for-granted (e.g., kinesthetic sensations, inner speech) come to the forefront of attention under conditions of hyperreflexive awareness, common in schizophrenia. This has important implications for the experience of language. Thus some patients express a desire to be completely true and faithful to the utter particularities 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 which normal individuals simply do not attend. But there is another sense in which the abnormal act of attention, a form of hyperreflexivity akin in some respects to intense introspection (Sass et al. 2013), actually transforms the experiences into something different and distinct from what others experiencee.g., into reified forms of what might be termed phantom concreteness (Sass 1992, 1994). Klaus Conrad (1958/1997, pp. 165168) spoke, in fact, of spasms of reflexion and of anastrophe, a term (Greek in origin) that he used to refer to a stepping-back from experience and a turning-inward toward the self characteristic of schizophrenia. There may also be forms of experience that most individuals have simply never approached. All this

L. Sass, E. Pienkos

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 directed toward experiences that other individuals have never had, or because it attempts to capture a degree of specificity or particularity incompatible with the generalizing nature of shared verbal categories. Schizophrenia patients may also become preoccupied with something too general or all-inclusive to be put into words, as for instance with the all-pervasive feeling of Being, of sheer existence itself, or with some general atmospheric quality or sense of ineffable meaningfulness or inevitability (Bleuler 1950, p. 67n; Bovet and Parnas 1993; Jaspers 1946/1963, p. 115; Sass 1992, chaps. 9, 10; 1994; Sass and Pienkos 2013c). Hence they may attempt to capture some mystical feeling or insight of an allencompassing nature that resists all normal or readily comprehensible forms of description, leading at times to a kind of hyper-abstract or hyper-philosophical style that may be, or may seem, but empty abstractions (Ey 1996, pp. 180, 185, citing various predecessors).12 Both trends are apparent when the writer Antonin Artaud, who suffered from schizophrenia, described feeling anguished by his sense that he was unable to capture in words the particularities of his inner feelings and sensations. I consider myself in my minutiae, he wrote. Yet it seems that not even the simple words it is cold felt adequate to him, capable of capturing his inner feeling on this slight and neutral point: What I lack is words to correspond to each minute of my state of mind (Sontag 1976, pp. 294295, 84). Artaud was also inclined to statements of what can seem the utmost abstraction: Like life, like nature, thought goes from the inside out before going from the outside in. I begin to think in the void and from the void I move toward the plenum; and when I have reached the plenum I can fall back into the void. I go from 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 is incomprehensible (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 says nothing and then one finds one has been talking about the whole of ones existence and one cant 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 a tendency to speak in cryptic or hyper-abstract terms) can, then, occur in both schizophrenia and melancholia. We suggest, however, that this typically occurs in melancholia because of a loss of energy or feelings of profound separation between oneself and other individuals, who seem to the patient to be operating at an entirely different pace and energy level, or because of a sense of the ineffability of ones 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; these include 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 possibility of this sort of all-encompassing statement as well.

Beyond words: Language in melancholia, mania, and schizophrenia

and hyperreflexity, of what may seem languages irredeemable incapacity to capture anything 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 merely inadequate in degree, but rather in kind. 4.4 Meta-attitudes toward language A final, closely related difference concerns a general sense of alienation from language-in-general that seems more common in schizophrenia than in mania and melancholia. When viewed in a certain alienated light, language may indeed appear absurd and arbitrary, and may well be experienced as an oppressive constraint or an intrusion into a purer or more authentic domain. (This is a factor emphasized in Lacans notion of the rejection of the symbolic order and nom du pre in psychosis. 13) An excellent example of this comes from reports of one young man, clearly suffering from schizophrenia, who was drawn to nihilistic views and inclined to find words meaningless or absurd, and semantic conventions arbitrary and thus pathetic and irredeemably conformist: Holding up a cup before his friends, he would ask contemptuously, Is this a cup? Or is it a pool? Is it a shark? Is it an airplane?14 In Lacans terms, the speech, or parole, of this patient demonstrates a rejection of the fundamental rules of language, or langue, which Lacan considers to be the central element of schizophrenia. Similarly, when asked to define the word parents, another schizophrenia patient replied, 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 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. (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 concern for 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 linguistic play described above, such as Dr. Malmberg you are an ice woman an iceberg a lettuce. In both schizophrenic and manic speech, then, there can be a shift from the normal constraints of language. However, there appears to be a more playful quality in the manic example, while the schizophrenia patients appear to draw attention to and intentionally refuse the conventions of language.

We would disagree with Lacans (1981/1993) claim that this rejection (of the symbolic order, or what he calls the nom du pre) is a factor for psychosis in general; rather it seems characteristic of schizophrenia in particular. 14 This is Jared Loughner, the young man who shot several people in Tucson in an attack on a local congresswoman, Gabrielle Giffords, on January 8, 2011. We are relying on a television report from 60 Minutes which included an interview with several of Loughners close friends who describe his behavior and attitudes from before the shooting (Descent into Madness 2011). Loughner was subsequently diagnosed as having schizophrenia and declared unfit to stand trial.

13

L. Sass, E. Pienkos

Given the alienation from conventional language, it is understandable that some schizophrenia patients, unlike those with either mania or melancholia, may create neologisms: If I could not immediately find an appropriate word to 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 on Sglas and active and passive mechanisms). They may even attempt to create a new or personal language (Wolfson 1970), whether to express exaggerated demands for autonomy and originality or in an attempt to capture, at least for themselves, all the nuances and innuendos that would otherwise be neglected. But it is also possible for words to be treated as omnipotent objects that can only be followed or revered. Henri Ey (1996) has described this duality: how, in schizophrenia, words can be treated as some plastic material on which one can exert the omnipotence of the ultimate subject, or alternatively as sacred objects, 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 the desert. 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 being manipulated to create entirely new realities. On the other hand, Sophie describes having the experience in which language comes to take on a life of its ownalmost an animation of words responsive, almost in possession of some sort of intrinsic agency or intentionality. Words breathe, they blink; they are capable of transforming the world and themselves. She goes so far as to describe words themselves as social creatures, divorced perhaps from interpersonal sociality, but not intertextual sociality. Schizophrenia, it seems, can be marked by certain paradoxes of omnipotence and powerlessness: with patients feeling, at times, able to assign idiosyncratic meanings to common words or even to create a private language, but at other times experiencing language as a rigid, recalcitrant, or controlling medium, or one possessed of magical powers of its own. Here again there are close parallels with schizophrenic experiences of other human beings: such patients may feel that other people and even the world itself is created or controlled by them, and yet, paradoxically enough, may also feel as if they themselves were puppets 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, language has a tendency to turn problematic, no longer to serve as the near-transparent medium of our social intercourse or practical engagement with others and the world. But it is in schizophrenia that language has the strongest tendency to emerge as a focal point or an end in itself, in a number of different waysdisorienting, oppressive, or grandiose, as the case may be. Words may emerge as brute sensory presences (mere sounds, mere marks on a page), as a prison-house of abstraction and clich, as spinning generators of uncontrolled meanings, or as a realm of autocratic, even solipsistic play.

Beyond words: Language in melancholia, mania, and schizophrenia

5 Conclusion In this paper, we have discussed unusual experiences of language that can occur in schizophrenia, melancholia, and mania. As we have seen, there are a number of anomalies common in these different disorders that can seem quite similar, at least on a superficial plane. Individuals with either schizophrenia or major affective disorder may, for instance, have extreme difficulty describing their experiences or otherwise expressing themselves, perhaps to the point of being unable to speak at all. In both mania and schizophrenia we sometimes find a tendency to focus on the intrinsic qualities of language and, often, to play on these qualities rather than using language as a more straightforward medium of communication. We have also suggested, however, that a nuanced understanding of underlying structural changes can help to differentiate the disorders at issue. A grasp of such potential distinctions is obviously relevant for psychopathological description and understanding. It might contribute as well to more accurate diagnosis and prognosisand also, perhaps, to a more focused exploration of differing pathogenetic pathways. In experience of language, these differences involve four sets of issues: concerning 1, social orientation, 2, forms of attention and context-awareness, 3, underlying kinds of anomalous experience, and, finally, 4, attitudes toward language as a system. Specifically, the disturbances in schizophrenia can often be traced either to an emphasis on ineffable global or personal experiences, a rejection of the constraints of language, an unworlding of normal contextual reality, or disturbance of an organizing form of ipseity or basic self-experience. Such experiences do not seem to be characteristic of either mania or melancholia, where difficulties with language are more likely to be related either to a kind of playfulness and distractibility, in the case of mania, or to the ineffability and numbness intrinsic to the severe depressive state. The linguistic anomalies typical of schizophrenia appear to reflect many of the underlying structural changes in modes of subjectivity and selfhood that have been discussed in works of phenomenological psychopathology. The alienation of the word is, e.g., highly reminiscent of the schizophrenic experience of alienation from the lived-body (Fuchs 2005), in which something that would normally be tacitly experienced (thus inhabited as the very medium of self-experience) comes instead to be experienced as a foreign object: strange and constraining, perhaps oddly concrete yet unreal at the same time (Sass 1992, chap. 7). Generally speaking, the experiences in question are bound up with a mode of subjective life in which inner and private concerns play a dominant and also destabilizing role. This can undermine the motivation and capacity for using or experiencing language in standard and conventional ways; it both reflects and induces the inwardness and peculiarity so characteristic of the schizophrenic condition. These linguistic anomalies of schizophrenia are highly consistent with classic descriptions of a characteristic schizophrenic autism (Parnas and Bovet 1991; Stanghellini and Ballerini 2004), 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 ipseitydisorder hypothesis of schizophrenia, which views the disorder as involving both hyperreflexivity (Sass 1992) and a diminished sense of self-presence (Sass 2013; Sass and Parnas 2003).

L. Sass, E. Pienkos

Although alterations of linguistic experience in mania and melancholia can certainly be severe, there appears to be something more fundamental about the disturbances that can occur in schizophrenia. In schizophrenia we often find a more complete alienation from common-sense reality and the meaning-making of normal conversation and social interaction, together with more severe alterations of the usual sense as being an autonomous yet social being who lives alongside other such individuals in a shared linguistic universe.

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