Am

J Psychiatry

136:3,

March

Schizophrenic

1979

Thought

Disorders:

Bizarre

Associations

and

Intermingling BY

MARTIN

HARROW,

PH.D.,

AND

MEL

PROSEN,

M.D.

or current experience (8). We believe intermingling and other types of disordered language are influenced by a difficulty of the schizophrenic in maintaining perspective about, and monitoring, his own language and behavior such that he does not fully recognize when he is inappropriate (1 1). In recent research we found positive evidence about the presence of intermingling as a factor in disordered language (8, 9). However, this research was based on a small sample and lacked a control group of nonschizophrenics. The present research had several goals. The first was to investigate intermingling in a larger sample and to compare findings with those from a control sample of nonschizophrenics. Second, we wished to use our technique to explore other factors that might influence intermingling or disordered thinking. The specific questions on which we will focus in the present report are as follows: I Do nonschizophrenics’ strange verbalizations reflect intermingling, as we found to be the case for many schizophrenics? 2. Does each schizophrenic’s intermingling involve material from one central area of concern, or emotional “complex,” or does it represent overinvolvement in a variety of different topics? 3. Does the schizophrenic’s intermingling represent a tendency toward overelaborate verbalizations or overinvolved thinking? 4. Does the schizophrenic’s intermingling represent interference with language by strong emotional reactions or emotional overresponsivity to the material with which he or she is dealing? 5. Does the intermingling reflect delusional or paranoid material that influences thinking?

The authors assessed bizarre verbalizations elicited from 37 schizophrenic and 16 nonschizophrenic patients. Interviews with subjects indicated that much bizarre schizophrenic language resultsfrom patients intermingling materialfrom past and current experiences into their verbalizations. This intermingled material comesfrom many different problem areas rather than one central emotional complex. Ii does not arisefrom emotional overresponsi%’eness o verin volved thinking or delusional ideation. Twofactors hypothesized as responsiblefor bizarre schizophrenic language are the schizophrenic ‘s monitoring problems and difficulty maintaining perspective about his own behavior. ,

,

BIZARRE AND DISORDERED THINKING are considered central features in schizophrenia (1-7). At present, their cause is unknown. New techniques are needed to study more directly what factors influence or lead to disordered thinking. We have developed one such technique and have obtained results about intermingling, a factor that may play a role in determining disordered language in schizophrenia. In recent research, we have explored a formulation about the importance of intermingling in disordered language (8, 9). This formulation was based in part on previous findings of a strong relationship between overpersonalized responses and bizarre verbalizations (10). According to our hypothesis, one overt factor that leads to schizophrenic patients’ disordered verbalizations is an intermingling into their language (and possibly into their thinking) of material from their past

.

Presented at the 130th annual meeting of the American Psychiatric Association, Toronto, Ont., Canada, May 2-6, 1977; received May 18, 1977; revised Sept. 25, 1978; accepted Oct. 18, 1978. Dr. Harrow is Director of Psychology, Medical Center, 29th Street and Ellis and Associate Professor, Department

research

Mental the

National

The

authors

Brennan, analysis

was

Health

supported

Administration Institute wish

of to thank

and

Joanne

of the

data.

Mental Joab

Buckley,

Sample

Michael Reese Hospital and Avenue, Chicago, Ill. 60616, of Psychiatry, University of

Chicago. Dr. Prosen is Associate Professor tor of Psychiatric Education, Department byterian-St. Luke’s Medical Center. This

METHOD

of Psychiatry of Psychiatry,

in part

by

grants

MH-2634I

Alcohol,

Drug

The subjects were 53 psychiatric inpatients (37 relatively young schizophrenics and 16 nonschizophrenics) from a multidisciplinary research project on schizophrenia (8, 12-14). The schizophrenic sample included 10 paranoid schizophrenics and 27 schizophrenics whose most prominent symptoms were not primarily paranoid. These patients also met the criteria for a schizophrenic diagnosis on the New Haven Schizophrenia Index (15). The nonschizophrenic

and DirecRush-Pres-

Abuse,

and MH-30938

and

from

Health. Oberlander,

who

assisted

Ilene

Lanin,

Francine

in the collection

0002-953X/79/03/0293/04/$00.45

and

©

1979

American

Psychiatric

Association

293

SCHIZOPHRENIC

THOUGHT

An

DISORDERS

sample

these

(5 depressed

consisted of 7 patients with affective disorders and 2 manic) and 9 patients with severe personality disorders. Only 3 of the 16 nonschizophrenic patients (the 2 manic patients and I depressive) showed strong evidence of psychotic think-

sponse.

ing. The

mean

age of 32 males

and

21 females

was

22.9

years. Almost all of the schizophrenics (91%) were taking phenothiazines or phenothiazine-tike medications (e.g., haloperidol) at the time ofassessment. The mean educational level of the sample was 12.4 years. The mean raw score on the WAIS Information Scale was 16.2, which falls within the average range of intelligence (16). There were no significant differences between the schizophrenic and nonschizophrenic samples on age, education, or intelligence. Data

Collection

and

Ratings

oJ’Intermingling

The overall research plan, which has been described more fully in previous reports (8, 9), involved three stages: 1) eliciting bizarre responses from each patient, 2) interviewing each patient about the reasons bizarre responses, and 3) rating the reasons

for his for each

patient’s bizarre responses. For the first stage, each patient was given the Proverbs Test (17) and the Social Comprehension Test (16) during an acute stage of his or her disorder. The patient’s responses were later scored for idiosyncratic, bizarre verbalizations on a standardized scoring system

reported

previously

(18, 19). Three

accurate

or

near accurate responses and five idiosyncratic or unusual responses of each patient were selected for subsequent inquiry to him. In the next phase, which occurred the following week, a senior psychiatrist conducted a standardized taped interview to explore the patient’s reasons for and thinking involved in giving each of the eight responses chosen for analysis. The psychiatrist prefaced the interview by saying he was interested in greater detail about the patient’s responses and in learning what the patient had in mind when he gave them and what types of things had led him to give these responses. This was followed by a series of structured questions for each response, such as Do you remember what you were thinking of when you gave that answer?’ ‘What led you to make that response?” Third, the taped interviews were rated along stan‘ ‘

‘

‘

dardized dimensions hypothesized to be underlying reasons for disordered thinking in schizophrenia. Thus, patients were rated according to whether their own specific bizarre responses were influenced by I) faulty logic, 2) an intermingling of material based on their past or present experiences, 3) concrete thinking, 4) emotional overreactions to the questions, 5) delusional or paranoid ideation, etc. Intermingling was considered present when there was overt evidence in the original response or the taped interview of the patient’s blending material from his own experience into his response, or when the patient’s answer was obviously guided or influenced by

294

experiences

The

from

interviews

sible

J Psychiatry

the

and

presence

136:3,

very

ratings

of a number

March

beginning

also

of the

explored

of factors

1979

that

the might

repos-

be re-

lated to or influence intermingling or bizarre language, and these are reported in the current paper. Satisfactory interrater reliability was achieved for the ratings.

RESULTS

AND

DISCUSSION

Is intermingling As noted

when

an above,

Bizarre

intermingling

the patient

response

on

lFlflUeilce

blends

is guided

is considered

into

by,

Lan guage? present

his response,

material

from

or when

his neatly

the

past or curand makes

rent experiences that does not fit’ the response seem at least somewhat strange. Half (51%) ofthe schizophrenics showed strong evidence of overt intermingling and 27% showed milder evidence of intermingling. Overall, in a larger sample than we ‘ ‘

‘

used in our previous research, the mingling in schizophrenic bizarre

gested.

Strong

38%

of the

evidence

difference

the

data

suggest

ogy.

statistically

significant.

the

frequent,

The data teriat from

involved

but

Thus,

in inter-

They

tend to but also

nonschizophrenics. research

we found also

although less

evidence

patients

with show

in nonmanic

flagrant,

and

that schizo-

thought

pathol-

evidence less

that

might

underlie

of

patients severe

many

regardless of diagnosis. whatever mechanisms are for

in

dis-

this

(6,

1 1).

raise the possibility that intermingling maone’s own tife is one of several general

characteristics

syncratic factors occasions tions.

processes

unique to schizophrenia. common in schizophrenics

language,

batizations, whether

shown

of the schizophrenics in intermingling,

Nonschizophrenics

less

was

more engaged

are not the only

ordered is

not

that

in many

In previous

phrenics

that

was

mingling are not be slightly more

occur

of intermingling

of interwas sug-

nonschizophrenics.

The data indicate than nonschizophrenics this

importance tanguage

bizarre

ver-

The issue involved

here is in idio-

language in schizophrenia are also prominent nonschizophrenics on those less frequent when they do give idiosyncratic verbaliza-

is Schizophrenic ii’ith One Central

in termingling Prohlen Area

Due to Preoccupation or Emotional

Complex?

The results theories that

in this area schizophrenic

have some patients

bearing on older have one central that preoccupation

“complex” or problem area and with this area dominates their lives, leading tional disturbance and possibly to interference

to emoand dis-

ruption of behavior. The data indicate a clear trend for each schizophrenic’s intermingling to be centered around a variety of topics or areas from his experience (three or more areas), rather than only one central problem area. This tendency occurred for 18 of the 25 schizophrenics who

Au: J Psychiatry

showed

136:3,

evidence

(4%)

showed

March

/979

of intermingling intermingling

(72%).

in only

were similar for nonschizophrenics. Our results in this area were question:

the

is there

patient

does a almost language? in the pearance from a

MARTIN

one

responds

one

geared

dominating

when

Only

1 of 25

area.

Results

to answer problem

he becomes

Oil

psychotic,

.

in select

patients

cians. Overelaborate schizophrenics

It did appear, analysis

have

thinking (only 30%

dramatically,

indicated

noted

with

by many

was not common showed any signs

in select

a tendency

ing to be associated noid schizophrenics.

been

patients.

PROSEN

TABLE

1 with Disordered Language Influenced by Overelaborate Verbalizations, Strong Emotional Responsivity, and Delusional or Paranoid Ideation

Patients

Nonschizophrenics

Schizophrenics

or

Os’erelahora.’e verbalizations and thinking The resuIts in table 1 reflect patients’ tendency to give extensive and overelaborate verbalizations, which suggests elaborate sets of thoughts and possible overinvolved thinking about a topic. Dramatic examples of this fea-

ture

MEL

which

or Disordered

Intermingling

AND

a key

to

vulnerable patient tend to respond strangely to any topic of concern that leads to idiosyncratic Our data suggest that one important factor schizophrenic’s strange and idiosyncratic apis a tendency to intermingle overtly material variety of conflicts and concerns.

Possible influences Lan gua,te

HARROW

clini-

in the thereof).

Influences Disordered

(N =37)

on Thinking

Overelaborate verbalizations overinvolved thinking Very clear evidence Minor evidence No evidence Strong emotional responsivity Very clear evidence Minor evidence No evidence Unavailable for rating Delusional ideation Very clear evidence Minor evidence No evidence Unavailable for rating Paranoid ideation Very clear evidence Minor evidence No evidence

(N=I6)

N

%

N

%

5 6 26

14 16 70

3 0 13

19 0 81

4 4 18 11

15 15 70

4 3 5 4

33 25 42

5 3 19 10

19 II 70

0 0 100

-

0 0 12 4

7 10 20

19 27 54

2 I 13

13 6 81

or

-

-

-

Detailed

for

overinvolved

think-

a smaller

subgroup

of para-

These results indicate that overelaborate ruminative thinking is not characteristic of most early schizophrenics and is not an important mechanism in their intermingling or their bizarre behavior. However, a subgroup of early paranoid schizophrenics showed

overelaborate verbalizations and thinking. Further exploration to determine whether overelaboration plays an important role for some paranoid schizophrenics might be profitable. Strong emotional responsivity Table I reports the results on strong emotional responsivity to the relatively neutral proverbs as an influence on patients’ bizarre verbalizations. These data do not bear on whether or not the stimuli or emotional environment were emotionally laden. Strong emotional responsivity as

greater

for

paranoid

schizophrenics

than

for

non-

paranoid schizophrenics. It must be remembered, however, that many nonparanoid schizophrenics also show some degree of paranoid ideation, although it is less

frequent

and

less sustained. all of the schizophrenics had deluor paranoid ideas, and some paranoid material into the bizarre verbalizations of 46% of the During the early stage, however, delusional or

Overall, sional entered sample.

paranoid the

almost

ideas

were

schizophrenics’

not

the

major

factors

bizarre

idiosyncratic

Disordered

Language

in shaping responses.

.

an influence cur

slightly

on disordered more

verbalizations

frequently

than schizophrenics (58% ference was not significant.

among

versus Thus,

tended

to oc-

nonschizophrenics

30%), strong

but this emotional

difre-

sponsivity showed some influence on the nonschizophrenic patients’ idiosyncratic language-although it usually was not the only or major influence-

and

relatively

Paranoid

little and

influence

delusional

on the material.

schizophrenics. Delusions

of

dramatic cases, on the patients’ however, were

paranoid

material

delusions were the major influbizarre verbalizations. These rare. Surprisingly, the influence

on

bizarre

responses

was

Intermingling

The

not

and

previous

re-

search indicating that one immediate mechanism sponsible for many young schizophrenics’ bizarre batizations is a tendency to intermingle into their guage or allow it to be guided by material from personal experiences. At times the intermingling

revertantheir can

often

current

investigation

be found

supports

our

in nonschizophrenics

who

give

strange

verbalizations.

The were

very frequent among these young schizophrenics and may be an important influence on their overall behavior, but delusions usually were not the major determinant of their bizarre language (see table I). In select, very ence cases,

COMMENT

tions

results and

are not at variance

research

demonstrating

with that

clinical

observa-

schizophrenics’

language contains features which can be viewed as bizarre, idiosyncratic, autistic, or disordered (1,3,7, 10, 19). However, the present data and our previous results (8) suggest that these strange verbatizations are based on rationales which make some sense in terms of patients’ own experiences when looked at from their points of view. Since nonschizophrenics typically show less 295

SCHIZOPHRENIC

THOUGHT

Am

DISORDERS

thought pathology, we would propose that personal experiences dominate their verbalizations less, and when they do appear they blend into or guide their responses in a more socially acceptable and better disguised fashion. For the nonschizophrenic, the compromise between adhering to the topic and expressing part ofone’s personal concerns is an imperfect one but is more

closely

tion and cussion. Aspects

the

attuned

to the

consensually

listener’s

probable

correct

ofintermingling

and

subject

reac-

of

dis-

Its Determinants

Other information emerged about intermingling and the type of material involved. Delusional and paranoid ideation usually were not the major determinants of the schizophrenics’ bizarre language. The material that intermingled into the patients’ verbalizations and made them appear bizarre was not typically a result of overelaborate thinking or ofoverinvolvement with one central conflict. The intermingled material usually came from several different personal experiences or conflicts for each schizophrenic. These concerns were not necessarily more serious than those experienced by nonschizophrenics. The major factor was the schizophrenic’s

tendency

balizations was poor. shifted the consensual listeners.

to blend

the

concerns

into

his or her

ver-

at times when their “fit” with the topics The intermingling of this material often schizophrenics’ comments away from the response, without any explanation to the

Perspective-Monitoring

Ability

and

Disordered

Language

What is the underlying factor that leads schizophrenics to intermingle material from their personal lives into their verbalizations? We would propose that one important influence involves executive processes, namely, the schizophrenic’s difficulty in maintaining perspective about whether his own behavior is socially appropriate and monitoring his own language (perspective-monitoring ability). The normal person is typicalty able to maintain perspective (about what is socially

appropriate)

and

to

monitor

his

language

such

that his preoccupations do not enter into his verbalizations in a gross, bizarre manner. At times, however, these concerns do appear in the normal person’s language in minor, partially disguised ways. As formulated here, a prominent factor in schizophrenia is a disorder of that aspect of executive functioning involved in maintaining perspective about the social appropriateness of one’s own behavior and monitoring itto conform to the social demands of the situation. At the time of his strange, idiosyncratic behavior the schizophrenic the ability 1) to maintain

296

may have perspective

temporarily about and

lost recog-

J Psychiatry

/36:3,

March

1979

nize what is idiosyncratic to him versus what is appropriate in a social setting, and 2) to monitor his routine, minute-by-minute behavior such that his everyday concerns and wishes do not intermingle inappropriately into it. According to this hypothesis one would expect the schizophrenic to have better perspective about the social appropriateness of other patients’ language than about his own, and we are currently undertaking research to assess this assumption. Nonschizophrenic patients and normals may also have some, but less, trouble in monitoring their verbalizations, leading to small amounts of cognitive slippage, especially during periods of stress or upset. REFERENCES I.

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Lehmann HE: Schizophrenia: clinical features, in Comprehensive Textbook of Psychiatry. Edited by Freeman AM, Kaplan HI. Baltimore, Williams & Wilkins Co, 1967 8. Harrow M, Prosen M: Intermingling and disordered logic as influences on schizophrenic ‘ ‘thought disorders. ‘ ‘ Arch Gen Psychiatry 35:1213-1218, 1978 9. Prosen M, Harrow M: Do associate intrusions cause schizophrenia? Presented at the 129th annual meeting of the American Psychiatric Association, Miami, Fla, May 10-14, 1976 10. Adler D, Harrow M: Idiosyncratic thinking and personally overinvolved thinking in schizophrenic patients during partial recovcry. Compr Psychiatry 15:57-67, 1974 I I. Harrow M, Quinlan D: Disordered Thinking and Studies in Schizophrenia. New York, Gardner Press (in press) 12. Grinker RR Sr, Holzman PS: Schizophrenic pathology of young adults: a clinical study. Arch Gen Psychiatry 28: 168-175, 1973 13. Harrow M, Grinker RR Sr. Holzman P. et al: Anhedonia and schizophrenia. Am J Psychiatry 134:794-797, 1977 14. Harrow M, Grinker RR Sr, Silverstein M, et al: Is modern-day schizophrenic outcome still negative? Am J Psychiatry 135:1156-1162, 1978 15. Astrachan BM, Harrow M, Adler D, et al: A checklist for the diagnosis of schizophrenia. Br J Psychiatry 121:529-539, 1972 16. Wechsler D: Weschsler Adult Intelligence Scale Manual. New York, Psychological Corporation, 1955 17. Gorham DR: Proverbs test for clinical and experimental use. Monograph Supplement 1. Psychological Reports, 1956 18. Adler D, Harrow M: Manual for Assessing Components of Idiosyncratic or Bizarre Responses ASIS/NAPS 02191. New York, Microfiche Publications, 1973 19. Harrow M, Tucker GJ, Adler D: Concrete and idiosyncratic thinking in acute schizophrenic patients. Arch Gen Psychiatry 26:433-439, 1972