Elsevier

Comprehensive Psychiatry

Volume 71, November 2016, Pages 106-120
Comprehensive Psychiatry

The communicative impairment as a core feature of schizophrenia: Frequency of pragmatic deficit, cognitive substrates, and relation with quality of life

https://doi.org/10.1016/j.comppsych.2016.08.012Get rights and content

Abstract

Background

Impairments in specific aspects of pragmatic competence, supporting the use of language in context, are largely documented in schizophrenia and might represent an indicator of poor outcome. Yet pragmatics is rarely included in clinical settings. This paper aims to promote a clinical consideration of pragmatics as a target of assessment and intervention. We investigated the frequency of the pragmatic deficit, its cognitive substrates, and the relation with quality of life.

Methods

Pragmatic abilities were compared in a sample of patients with schizophrenia and healthy controls based on a comprehensive pragmatic test (APACS). We assessed also for psychopathology, cognition, social cognition, and quality of life. We explored the co-occurrence of deficits in different domains, and we used multiple regressions to investigate the effect of cognition and social cognition on pragmatics, and of pragmatics on quality of life.

Results

Pragmatic abilities, especially comprehending discourse and non-literal meanings, were compromised in schizophrenia, with 77% of patients falling below cutoff. Pragmatic deficit co-occurred with cognitive or socio-cognitive deficits in approximately 30% of cases. Multiple regression analysis confirmed the interplay of cognition and social cognition in pragmatic behavior. Quality of life was predicted by symptoms and by pragmatic abilities.

Conclusions

The high frequency of impairment suggests that the pragmatic deficit is a core feature of schizophrenia, associated with quality of life. Cognitive and socio-cognitive abilities might represent necessary though not sufficient building blocks for the acquisition of pragmatic abilities throughout development. Therefore, a more precise incorporation of pragmatics in the description of the pathology is of high clinical and translational relevance.

Introduction

Alterations of communication are largely documented in schizophrenia since the first descriptions of the illness [1], [2]. In modern days, multidisciplinary approaches combining psychiatry, linguistics, and neuroscience of language have paved the way to a more principled characterization of linguistic disruption in schizophrenia [3]. In this perspective, the deficit seems to encompass both comprehension and production [4], [5], especially in the domains of syntax [6] and high-level semantics [7].

In this view, it has been claimed that the most obviously disordered language level in schizophrenia is pragmatics [3], [8], i.e. the ability of processing the relationship between language and context [9]. Beyond the grammatical aspects of language, patients with schizophrenia suffer from a failure in the use of language in social interaction, in producing contextually appropriate speech, and in inferring context-dependent meanings. Evidence supporting the claim of a diffuse pragmatic impairment is abundant yet sparse. Deficits in the comprehension of non-literal language, for instance, have been reported since at least 100 years, traditionally attributed to the inability of abstract thinking, clinically defined as “concretism”, i.e. adherence to the physical aspects of stimuli and words [10]. Recently, the interest on this topic has grown remarkably, with a plethora of studies reporting breakdowns in patients with schizophrenia across a range of specific tasks involving the comprehension of pragmatic aspects of language [11], [12], [13], [14], [15], [16], [17]. For instance, in a story comprehension task, when required to judge the appropriateness of a statement, patients make more errors than controls when the speech is metaphorical or ironic [11]. Similarly, patients are impaired in the comprehension of idiomatic expressions, as tested both in sentence-to-picture matching task [13] and in online sentence continuation verification task [15]. Several studies also deal with discourse production in schizophrenia [18], [19], [20], [21], reporting failures in maintaining thematic coherence and respecting the rules of conversation. For instance, Perlini et al. compared a sample of patients with schizophrenia with healthy controls and patients with bipolar disorder, evaluating several micro- and macro-linguistic aspects of discourse, including fine-grained analysis of pragmatic parameters such as informativeness and coherence [19]. Results showed diffuse deficits in the performance of patients with schizophrenia, compared to both the other groups. Linscott et al. showed that patients scored higher than controls in the Profile of Pragmatic Impairment in Communication (PPIC), being less compliant with Gricean conversational rules [18].

Globally, these findings strongly indicate a widespread pragmatic impairment in schizophrenia, yet this bulk of evidence is rarely described under the unifying umbrella of pragmatic competence. Only a few studies included a broad assessment of pragmatic abilities [22]. Among these, Colle et al. presented a preliminary assessment of verbal and non-verbal communicative abilities in patients with schizophrenia based on the Assessment Battery of Communication (ABaCo), with a special focus on the interplay between pragmatics and mindreading in understanding speech acts of different complexity. Results evidenced a wide dysfunction, with 80% of patients' scores below the 20th percentile of the normative data [22]. Apart from a few investigations, most studies focus on specific aspects of pragmatic capacity in schizophrenia, preventing from a comprehensive evaluation of the communicative disruption in this clinical population.

This “fragmentation” of the literature also hampers a clearer understanding of the relationship between pragmatics and both the cognitive and socio-cognitive abilities that are typically impaired in schizophrenia, as well as between pragmatics, psychopathology, and intellectual level. Indeed, performance in specific pragmatic tasks has been related either to executive functions or theory of mind (ToM) [11], [23], [24], [25]. For instance, cognitive abilities, especially executive functions and working memory, were found to predict the comprehension of idiomatic expressions [13] and proverbs [12]. Other authors, however, argued that the role of social cognition abilities is stronger than that of executive functions in comprehending proverbs [23] as well as indirect request [24]. Also, there is evidence that the role of ToM might vary across pragmatic tasks, being associated for instance with the understanding of irony, but unrelated to the understanding of metaphors [11]. Conflicting results are reported also for symptoms [15], [17], [18], [26]. Some studies found a relation between pragmatic performance and symptoms [14], [17], while others reported no association between though disorders and high-level language aspects such as idioms comprehension [13] or conversational abilities [18]. In sum, the relationship between the global domain of pragmatic abilities, cognition, and psychopathology appears still unclear.

Interestingly, several authors suggested that communicative and pragmatic impairment could impact on social interaction and daily living [27]. However, up to date, only a few studies explicitly explored the effect of communication abnormalities on functioning in schizophrenia [28], [29], [30]. According to these studies, disconnected speech and verbal underproductivity compromise the patients' social skills, including the ability to engage in social relationships [29], and the inability to comprehend sarcasm affects recreational functioning [30].

Further research shows that the pragmatic deficit is present in prodromal samples [31], [32] and in first-degree relatives [33], [34], and even that specific discourse coherence features in youths' speech might help predicting future development of psychosis [35], suggesting that communication [36] and more specifically pragmatic disruption may represent a biomarker of schizophrenia, fitting into the neurodevelopmental hypothesis [37], as rooted in early brain development.

In sum, so far pragmatics has been mainly confined to the research setting, and a complete and reliable assessment of pragmatic abilities is not included in the clinical practice. This undermines our comprehension of the frequency of the deficit, its possible role as a core feature of schizophrenia, its impact on daily living, and its cognitive substrates, as well as its possible consideration as a target of intervention.

In this study we sought to promote a clinical turn in the consideration of the pragmatic deficit in schizophrenia. Specifically, we aimed at: (i) providing a first estimation of the frequency of pragmatic impairment in schizophrenia; (ii) exploring the interplay of cognitive domains in determining the pragmatic deficit; and (iii) assessing the relation of pragmatics with quality of life. Our hypotheses were as follows: (i) we expected to observe a high frequency of pragmatic impairment, comparable to the frequency of core features of schizophrenia, such as the neurocognitive deficit [38]; (ii) the pragmatic deficit was expected to be intertwined with both cognition and social cognition; (iii) we predicted that pragmatic abilities would significantly contribute to quality of life, even when other variables are taken into account. To address these issues, we employed a comprehensive and reliable assessment tool for pragmatic abilities (the APACS test), recently validated and normed on the Italian population [39] and previously shown to be capable of detecting a pragmatic deficit in psychiatric illness [40]. Here the APACS test was administered to a wider sample of patients with schizophrenia and accompanied with a large-scale assessment of psychopathological, cognitive, socio-cognitive, intellectual, and daily living measures.

Section snippets

Participants

Forty-seven Italian native speakers outpatients, age 18–65 years, were recruited from the Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy. They all met DSM IV-R criteria for schizophrenia [41] and were clinically stabilized and treated with a stable dose of the same antipsychotic therapy for at least 6 months. Exclusion criteria were: substance dependence or abuse, co-morbid diagnosis on Axis I or II, major neurological illness, and perinatal trauma.

Demographic and clinical features

Demographic characteristics of all subjects and psychopathological, intellectual level, cognitive, socio-cognitive and quality of life measures for patients are reported in Table 1. The antipsychotic treatment was distributed as follows: 17 patients were treated with clozapine (mean daily dose 327.21 ± 130.98 mg), 10 with risperidone (mean daily dose 4.63 ± 2.94 mg), 6 with paliperidone (mean daily dose 7.50 ± 1.64 mg), 6 with haloperidol (mean daily dose 6.13 ± 4.91 mg), 4 with aripiprazole (mean daily

Discussion

This study aimed at shedding new light on the pragmatic deficit in schizophrenia as a possible target of clinical assessment and intervention. We investigated pragmatic abilities in patients with schizophrenia as compared to controls by means of the APACS test, a comprehensive and reliable test suitable to detect pragmatic breakdowns in mental illness. The relation between pragmatics and psychopathological, cognitive, socio-cognitive, and quality of life aspects was also explored in the

Conclusions

In this study we reported a diffuse pragmatic deficit in schizophrenia, connected with cognitive and socio-cognitive abilities, and associated with quality of life. Globally, this evidence could encourage to move beyond the sparse reports of impairment in specific communicative tasks and to promote a clinical perspective on the pragmatic deficit as a core feature of schizophrenia. When seen as a core feature, pragmatics would deserve a more serious consideration in the description of the

Authors contribution

Study design: Bambini, Arcara, Cavallaro, Bosia. Data collection: Bechi, Buonocore, Bosia. Data analysis: Arcara. Data interpretation and manuscript writing: Bambini, Arcara, Bosia. Clinical supervision: Cavallaro, Bosia. All authors provided feedback on the draft and approved the final version of the manuscript.

Declaration of interest

None.

References (73)

  • P Thoma et al.

    Proverb comprehension impairments in schizophrenia are related to executive dysfunction

    Psychiatry Res

    (2009)
  • JM Gavilán et al.

    Theory of mind and language comprehension in schizophrenia: poor mindreading affects figurative language comprehension beyond intelligence deficits

    J Neurolinguistics

    (2011)
  • M Joyal et al.

    Speech and language therapies to improve pragmatics and discourse skills in patients with schizophrenia

    Psychiatry Res

    (2016)
  • EJ Tan et al.

    Speech disturbances and quality of life in schizophrenia: differential impacts on functioning and life satisfaction

    Compr Psychiatry

    (2014)
  • CR Bowie et al.

    Communication abnormalities predict functional outcomes in chronic schizophrenia: differential associations with social and adaptive functions

    Schizophr Res

    (2008)
  • A Sparks et al.

    Social cognition, empathy and functional outcome in schizophrenia

    Schizophr Res

    (2010)
  • DJ Done et al.

    Pragmatic use of language by children who develop schizophrenia in adult life

    Schizophr Res

    (2013)
  • SA Sullivan et al.

    A longitudinal investigation of childhood communication ability and adolescent psychotic experiences in a community sample

    Schizophr Res

    (2016)
  • M Rosenstein et al.

    Language as a biomarker in those at high-risk for psychosis

    Schizophr Res

    (2015)
  • SR Kay et al.

    Reliability and validity of the positive and negative syndrome scale for schizophrenics

    Psychiatry Res

    (1988)
  • RSE Keefe et al.

    The brief assessment of cognition in schizophrenia: reliability, sensitivity, and comparison with a standard neurocognitive battery

    Schizophr Res

    (2004)
  • S Anselmetti et al.

    “Theory” of mind impairment in patients affected by schizophrenia and in their parents

    Schizophr Res

    (2009)
  • T Sela et al.

    A possible contributory mechanism for impaired idiom perception in schizophrenia

    Psychiatry Res

    (2015)
  • V Bambini et al.

    Communication and pragmatic breakdowns in amyotrophic lateral sclerosis patients

    Brain Lang

    (2016)
  • E Varga et al.

    Compensatory effect of general cognitive skills on non-literal language processing in schizophrenia: a preliminary study

    J Neurolinguistics

    (2014)
  • I Martin et al.

    Weak coherence, no theory of mind, or executive dysfunction? Solving the puzzle of pragmatic language disorders

    Brain Lang

    (2003)
  • M Catani et al.

    A model for social communication and language evolution and development (SCALED)

    Curr Opin Neurobiol

    (2014)
  • M Catani et al.

    Altered integrity of perisylvian language pathways in schizophrenia: relationship to auditory hallucinations

    Biol Psychiatry

    (2011)
  • TTJ Kircher et al.

    Neural correlates of metaphor processing in schizophrenia

    Neuroimage

    (2007)
  • B Elvevåg et al.

    An automated method to analyze language use in patients with schizophrenia and their first-degree relatives

    J Neurolinguistics

    (2010)
  • E Bleuler

    Dementia praecox: on the group of schizophrenias (J.Zimkin, trans.)

    (1950)
  • NC Andreasen

    Thought, language, and communication disorders

    Arch Gen Psychiatry

    (1979)
  • LE DeLisi

    Speech disorder in schizophrenia: review of the literature and exploration of its relation to the uniquely human capacity for language

    Schizophr Bull

    (2001)
  • GR Kuperberg

    Language in schizophrenia part 1: an introduction

    Lang Linguist Compass

    (2010)
  • A Barrera et al.

    Formal thought disorder in schizophrenia: an executive or a semantic deficit?

    Psychol Med

    (2005)
  • L Cummings

    Pragmatic disorders

    (2014)
  • Cited by (113)

    View all citing articles on Scopus
    1

    Joint co-senior authors.

    View full text