Conceptual thinking in psychiatric patients

[The understanding of metaphors in schizophrenia and depression. An experimental approach]

INTRODUCTION

Since the first clinical descriptions of schizophrenia, clinical practitioners have been interested in the difficulties experienced by patients with schizophrenia in interpreting the meaning of metaphors. A long tradition of proverb tests intended either for clinical or experimental use, has revealed that the difficulties in metaphor interpretation experienced by patients with schizophrenia refer to a large number of different types of interpretational errors (eg literality, concretism, or autistic, idiosyncratic and bizarre responses). A number of studies have adopted an experimental approach to investigating the dynamics of the cognitive processes that underlie the difficulties in accessing figurative meaning experienced by patients with schizophrenia. However, limited in the way they operationalise these phenomena and/or by their psycho-linguistic reference models, these studies have focused on only one aspect of metaphor: for example, multiple-choice tasks have tested the tendency of patients with schizophrenia to interpret metaphors literally ("literality bias"), whereas lexical decision tasks have investigated the importance that such patients attach to a single word in the expression ("concretism"). The first aim of our study was to investigate, in parallel and without confound, the respective contributions of the literality and concretism biases in the interpretation of metaphor in patients with schizophrenia. The second aim was to examine the question of the specificity of difficulties in accessing figurative meaning in patients with schizophrenia by comparing their performance profiles with those of patients with depression. The third aim was to examine the influence of the patients' clinical symptomatology on their result profiles.

METHOD

The participants consisted of 25 patients with schizophrenia (DSM IV, 1994), 18 patients with major depression (DSM IV) and 22 healthy controls. All the participants were matched on socio-demographic variables (age, vocabulary level and level of education). The participants had to complete a task consisting of 10 metaphorical sentences (eg "Ce milieu est un panier de crabes"=lit. "This place is a basket of crabs", fig. "What a bunch of sharks"). The participants had to choose only one word from a set of 4 responses: the figurative meaning (eg "magouille"=dishonest person), the literal meaning (eg "vivier"="pond"), the concrete meaning of the final word (eg "crustacé"="crustacean") and one unassociated word (eg "journal"=newspaper). The inter-group comparison and the symptomatic assessment of the patients (PANSS, Kay et al., 1987, TLC, Andreasen et al. 1979 for the schizo-phrenic and HAMD, Hamilton, 1960 and ERD, Widlöcher, 1983 for the depressive patients) made it possible to investigate the specificity of these difficulties in metaphor understanding amongst patients with schizophrenia, together with the effect of the severity of the symptomatology on the response profiles.

RESULTS

The results reveal that the literality bias and concreteness bias influenced the interpretation of metaphors in both groups of patients when compared with the control subjects. Furthermore, the results reveal a common bias towards literal responses (11%) and to concrete responses (4%) among both the patients with schizophrenia and those with depression. An important finding of our study is the heterogeneity of the performance observed in the schizo-phrenic and the depressive patients. Amongst the patients with schizophrenia, erroneous metaphor interpretation was influenced by the severity of the formal thought disorders (Andreasen et al., 1979), whereas in the patients with depression, it depended on the severity of the depressive symptomatology (Hamilton, 1960) and the psychomotor-retardation (Widlöcher, 1983).

DISCUSSION

This study represents a preliminary stage in studying metaphor understanding among patients with schizophrenia and major depression, and addresses new questions for further research, which may enhance exploration of the cognitive bases of these disorders.

Interpretation of ambiguous idiomatic statements in schizophrenic and depressive patients. Evidence for common and differential cognitive patterns

BACKGROUND

This study is concerned with the comprehension of ambiguous idiomatic statements in schizophrenic and depressive patients.

AIMS

Using a multiple-choice procedure, we simultaneously tested the presence of concrete and literal elements in the understanding of idiomatic statements.

METHOD

Fourteen schizophrenic and 10 patients undergoing a major depressive episode as well as 14 control subjects completed a questionnaire with 10 idiomatic expressions with two possible interpretations (figurative and literal) of equivalent prominence. The participants had to choose one word linked with the different interpretations of these idioms (figurative, literal, concrete or inappropriate meaning).

RESULTS

The main results show that, in all the subjects, the contextual characteristics of the task induced a bias in favor of figurative interpretations despite the equivalent prominence of the literal interpretations of the idioms. The selection of responses relating to the concrete meaning of a single word in the idiom constituted a response mode common to both the schizophrenic and depressed patients. Despite the contextual constraints of the task, the schizophrenics opted for the literal responses more often than the other participants. The descriptive analysis argues in favor of a cognitive and clinical heterogeneity of schizophrenic patients.

CONCLUSION

Results support the idea that literality and concreteness in idiomatic interpretation are possibly due to distinct cognitive impairments, though only some are specific to schizophrenic patients.

Psychotherapy of the affective psychoses

Too few research studies that identify effective therapeutic methods for treatment of psychotic depressions are available. A few studies indicate that cognitive therapy reduces symptoms and may provide prophylaxis in outpatients with moderately severe depressions. Cognitive theory provides a conceptual framework for developing techniques to treat more severely depressed patients. Specific obstacles in the psychotherapy of this group include negatively biased recall of current and past events; difficulties in forming a therapeutic alliance; memory and concentration deficits; hallucinations; delusions; and somatic complaints. This paper presents preliminary attempts to develop and apply cognitive change techniques to some of these difficulties. The role of medication in combination with psychotherapy, the identification of depressions requiring psychotheeapy, and the development of methods specific to psychotherapy with psychotic depressions and promising areas in need of further investigation.

Aetiological models of schizophrenia: relationships to diagnosis and treatment

In the current state of psychiatric knowledge, clinicians must synthesize their personal view of the nature and cause of schizophrenia from several competing, complementary, and sometimes contradictory perspectives. They are also faced with the necessity of making day-to-day decisions concerning the diagnosis and treatment of schizophrenic illness in their patients. The present study seeks to clarify the relationship between clinicians' opinions on the nature or cause of schizophrenia and the way they diagnose and treat this disorder, as reflected in their opinions on which are the most useful diagnostic signs and modes of treatment.

Cognitive functioning in acute and remitted psychiatric patients

Tests of vocabulary and abstraction administered to groups of schizophrenic and non-schizophrenic patients at time of hospital admission and at time of clinical remission and discharge home revealed some evidence of general cognitive impairment in both groups, with significant improvement by time of discharge, as well as evidence of continuing specific conceptual impairment among schizophrenics.