Journal of Abnormal Psychology Copyright 1983 by the

1983, Vol. 92, No. 3, 368-377 American Psychological Association, Inc.

Speech Competence in Manic and Schizophrenic Psychoses:

The Association Between Clinically Rated Thought Disorder
and Cohesion and Reference Performance
Philip D. Harvey
State University of New York at Binghamton

Thought-disordered (TD) manics and schizophrenics were compared to manic

and schizophrenic patients without thought disorder (NTD) and to a normal
contrast group on the rating scales of cohesion and reference performance in
speech developed by Rochester and Martin (1979); each group contained 10
subjects. Thought-disordered manics and schizophrenics differed from NTD pa-
tients and the normal group in their more frequent use of unclear references as
well as in their less frequent use of effective cohesion and reference strategies.
Speech elements of the TD patients were classified into disordered and nondisor-
dered segments, and the same natural language analysis was completed for each
category of speech segments. Nondisordered speech segments of TD patients were
quite similar to the overall speech performance of NTD patients and the normal
group. There were no cohesion or reference performance differences between TD
manics and TD schizophrenics in their disordered speech segments. These find-
ings are interpreted as validation of the usefulness of the Rochester and Martin
(1979) rating system for identifying aspects of speech performance that are related
to clinically rated thought disorder. Additional research using this system is sug-
gested.

The problem of communication disorders contribute to speech failures. Natural lan-

in psychosis has prompted years of research
but has met with questionable success. A
prominent researcher has concluded that lit-
tle progress in understanding communication
disorders has taken place since the early days
of psychiatry (Maher, 1972). Over the years,
three methods of study have evolved: clinical,
laboratory, and natural language. Clinical
studies, in the tradition of Bleuler (1950) and
Kraepelin (1919), have examined speech
from clinical interactions and identified de-
viant communication units. Laboratory stud-
ies have investigated cognitive deficits such
as association problems (e.g., Kent & Rosan-
off, 1910), attention deficits (e.g., Neale &
Cromwell, 1970), and conceptual difficulties
(e.g., Goldstein, 1939) in the hope of discov-
ering the underlying cognitive processes that
This research was supported in part by National In-
stitute of Mental Health Grant MH21145.
I would like to thank members of my dissertation com-
mittee, in particular John M. Neale, for their helpful
suggestions and guidance in this project.
Requests for reprints should be sent to Philip D.
Harvey, Department of Psychology, State University of
New York, Binghamton, New York 13901.
368
guage studies examine speech, but not nec-
essarily from clinical interactions, to identify
the discourse processes that lead to the prob-
lems listeners have in understanding the
speech of psychotics (e.g., Rochester & Mar-
tin, 1979; Rochester, Martin, & Thurston,
1977).
In recent years natural language methods
have been developed to the point where lan-
guage samples are collected in a variety of
ways, including writing (e.g., Maher, Mc-
Kean, & McLaughlin, 1966), speech in the
presence of a nonreactive observer (Gotts-
chalk & Gleser, 1964), and verbatim repeti-
tion of a story read to the subject (e.g., Roch-
ester et al., 1977). Although early rating sys-
tems were often unreliable and were
developed only to maximally discriminate
normals and schizophrenics (e.g., Gottschalk
& Gleser, 1964), later rating systems were
developed to assess performance according
to predefined linguistic models of speech with
adequate reliability (e.g., Rochester & Mar-
tin, 1979).
Although some early natural language
studies simply counted parts of speech or
 COHESION AND REFERENCE IN PSYCHOSIS 369

developed type-token ratios (e.g., Maher et from a carefully diagnosed population of

al., 1966), the Rochester et al. studies eval- manic and schizophrenic patients and a nor-
uated the processes that linked clauses and mal contrast group. A clinical evaluation of
ideas to one another. Rochester et al. found global communication competence was com-
that schizophrenics who were clinically rated pleted with an accepted clinical rating scale,
as thought disordered (TD) produced fewer the Scale for Assessment of Thought, Lan-
competent links between clauses and also guage, and Communication (TLC; An-
produced more unclear references to previ- dreasen, 1979a, 1979b). Finally, to subdivide
ously presented ideas than did schizophrenics the speech sample into thought-disordered
without thought disorder (NTD) and the nor- and nondisordered segments, the speech ele-
mal group. Both TD and NTD schizophren- ments of the TD patients were classified as
ics produced significantly fewer sophisticated disordered or nondisordered, and natural
references than did the normal group. The language ratings were completed separately
strong points of the Rochester et al. studies on speech in each category. The design al-
were that (a) a highly reliable (average inter- lowed for determination of whether diagnos-
rater reliability over .85) coding system was tic differences in speech competence, as well
used, (b) clinical evaluations of the speech of as thought-disorder differences, existed be-
the schizophrenic subjects were performed, tween manics, schizophrenics, and the nor-
and (c) the coding system was based on an mal group.
established model of cohesion and reference
processes in normal speech (i.e., Halliday Method
& Hasan, 1976).
There were, however, some serious prob- Subjects
lems with the Rochester et al. studies. First, Subjects were selected from consecutive admissions
only schizophrenic subjects were evaluated. to an acute treatment unit at a state psychiatric center.
Therefore, any differences between the TD Every new admission was approached and asked to par-
and NTD subjects in the studies cannot be ticipate in a study involving brief interviewing and cog-
regarded as specific to schizophrenia. In ref- nitive testing. Patients with a hospital diagnosis of al-
coholism or a disorder of the central nervous system
erence to this point, Durbin and Marshall were not approached. A structured diagnostic interview,
(1977) reported that manic patients made the Schedule for Affective Disorders and Schizophrenia
speech errors similar to those made by the (SADS; Spitzer, Endicott, & Robins, 1978), was used to
TD schizophrenics in the Rochester et al. collect diagnostic information. Hospital records were
used in cases where the patients provided unclear or con-
studies. Second, the diagnostic criteria in tradictory information. All schizophrenics were receiv-
their reports (i.e., the New Haven Schizo- ing neuroleptics (either chlorpromazine or haloperidol),
phrenia Index; Astrachan et al., 1972) are and all manics were receiving either neuroleptics or lith-
quite liberal and have a broader conception ium carbonate. The SADS interviews were tape-recorded
of schizophrenia than current criteria in the for the purposes of evaluating diagnostic reliability and
rating thought disorder. Independent diagnoses, using
Diagnostic and Statistical Manual of Mental DSM-HI criteria, were made by two experienced diag-
Disorders (DSM-III; American Psychiatric nosticians who assigned a confidence rating of 1 to 4 for
Association, 1980). Finally, Rochester et al. the diagnoses. Subjects who had a confidence rating of
identified the most deviant segments in their less than 2 for either rater were excluded. Reliability
(Kappa; Cohen, 1960) of the independent diagnoses was
patients' speech and examined those sections. high: .90 for mania and .80 for schizophrenia. In the
As LeCours and Vanier-Clement (1976) noted, case of a disagreement in the independent diagnoses, a
speech disorders in schizophrenia are epi- consensus diagnosis was obtained. The TLC (Andreasen,
sodic phenomena, with some competent 1979a) was applied to each patient's recorded SADS in-
speech segments present in patients clinically terview by two raters who were experienced in the use
of the scale and blind to diagnostic status. They assigned
regarded as thought disordered. Rochester ratings on a 5-point (0-4) scale. Patients with a score of
and her associates did not attempt to see if 0 (no speech disorder) or 1 (mild speech disorder) were
the nondisordered sections of TD patients' considered to be without thought disorder, those whose
speech resembled the speech of NTD patients score was 2 (moderate speech disorder) or more were
considered thought disordered. Interrater reliability
and the normal group. (Kappa) for these present/absent ratings was .90. Pre-
In the present report, the Rochester et al. vious findings (e.g., Andreasen, 1979b) indicated that the
rating system was used on a sample of speech speech of 95% of all schizophrenics receives a rating of
370 PHILIP D. HARVEY

1 or more on the overall TLC score, so this criterion of
2 is not overly conservative.
A normal contrast group was recruited from the
maintenance, clerical, and student population at the
State University of New York at Stony Brook. Secretarial
and maintenance staff and older undergraduate research
assistants were approached and asked to volunteer for
a study of speech and cognitive processes. Subjects with
a previous history of psychiatric care or hospitalization
were not tested. See Table 1 for demographic informa-
tion on all subjects.
The only demographic difference between groups was
that schizophrenics were rated as more severely ill on
the basis of the Global Assessment Scale of the SADS.
Although 23 schizophrenics and 25 manics were inter-
viewed, less than 50% of the patients in both of these
groups were considered thought disordered. The first 10
NTD manics and schizophrenics that were interviewed
were included in the final groups of subjects, which
yielded the following groups of 10 subjects each: normal,
NTD manic, NTD schizophrenic, TD manic, and TD
schizophrenic.
Procedure
Within 3 days of their admission to an acute care unit
of a state psychiatric center, all new patients were intro-
duced to graduate student interviewers by the treatment-
team psychologist. The interviewer first engaged the sub-
ject in conversation about any topic of interest to the
subject for a 10- to 15-minute period. If the conversation
faltered, the interviewer asked an open-ended question
such as, "Tell me about some happy times you've had"
or "What kind of person are you?" The interviewer tried
to talk as little as possible while conducting this portion
of the interview. The diagnostic interview followed col-
lection of this speech sample. Both the speech sample
and diagnostic interview were tape-recorded.
Normal subjects were tested in a laboratory at the
State University of New York at Stony Brook. The same
interviewers collected speech samples in the same fashion
as they had with the psychiatric patient subjects. Mem-
bers of the normal group were not interviewed with the
SADS, but they were asked to report any psychiatric care
or hospitalization.
Coding and scoring. Transcripts of speech samples
from the open-topic interviews were made by under-
graduate research assistants who were blind to the di-
agnosis of the subjects and the hypotheses of the study.
Other undergraduates, already trained in a previous
study to a high level of competence and interrater reli-
ability, coded the speech samples with the Rochester and
Martin (1979) rating system. A coding manual was pro-
vided by associates of Rochester and Martin (1979) and
was the basis of the training. The coders' reliability was
initially checked, and they were aware that random re-
liability checks were made. Both raters coded all of each
transcript; their ratings of each of the cohesion and ref-
erence variables were averaged and used in later statistical
analyses. The various content areas of the coding system
are described in the following sections. Reliabilities, cal-
culated by directly comparing 20% of their coding and
stratified by diagnostic group, were computed with
Cohen's (1960) Kappa.
Verbal productivity. A clause was defined as "any unit
which can be generated from a noun phrase and a verb
phrase" (Rochester, Martin, & Thurston, 1977, p. 99).
The two raters counted the number of words and the
number of clauses. Reliability (Kappa) for the identifi-
cation of the number of clauses was .95; perfect reliability
was obtained for the number of words.
Cohesion. Cohesion is the process whereby clauses
are connected (Halliday & Hasan, 1976). Referential

Table 1
Demographic Information on All Subject Groups
Group

Manic Schizophrenic

NTD TD NTD TD Normal

Variable M SD M SD M SD M SD M SD
Age 30.8 7.3 29.5 10.0 31.7 7.0 33.5 9.5 30.9 1.5
% female 70.0 60.0 80.0 60.0 70.0
— — —
Severity8 36.7 6.1 35.1 9.8 32.0 8.6 25.5 10.9" —
—
Hospitalizations 4.6 3.9 7.6 7.8 5.7 3.3 6.5 4.7
Education0 3.3 1.3 3.6 1.4 3.4 1.0 3.7 1.2 —
3.6 —
.84
Occupational status11 4.2 1.8 3.9 1.6 4.3, 1.2 4.9 1.3 4.9 1.5
Note. NTD = without thought disorder; TD = thought disordered. For each group, n = 10.
' From the Global Assessment Scale of the Schedule for Affective Disorders and Schizophrenia (Spitzer et al. 1978).
Lower scores indicate more severe psychopathology.
"Schizophrenics < manics, F(l, 38) = 6.30, p < .05.
c
From Current and Past Psychopathology Scales (CAPPS; Spitzer & Endicott, 1968); 7 = 7 years of school; 1 = PhD,
MD, or JD.
d
From the CAPPS (Spitzer & Endicott, 1968); 7 = unskilled worker; 1 = major professional.
 COHESION AND REFERENCE IN PSYCHOSIS 371

cohesion is the process of relating information in one
clause to an earlier clause. A later clause is understand-
able because of information presented in an earlier
clause. An example of referential cohesion could be
(cohesive element underlined) "I've known Bill for years.
He is a great guy." Conjunction is the cohesive process
whereby contiguous clauses are linked together. An ex-
ample of conjunction could be (cohesive element un-
derlined) "First. I went to school and then I came back,"
Lexical cohesion is the repetition, in successive clauses,
of the same word, a synonym, a word from the same
root, or a general term that is related to the earlier clause.
Examples of lexical cohesion could be (same root) "My
sister is pretty dependent. Independence has always been
one of her problems" and (general term) "Bring home
some more of those pencils from work. Those things are
good to have around."
Previous reports (e.g., Rochester & Martin, 1979) have
indicated that TD schizophrenics use higher proportions
of lexical cohesion and lower proportions of conjunctions
in their speech than do NTD schizophrenics and normal
individuals. The reliability (Kappa) of identification of
cohesive ties was .79 for lexical cohesion, .87 for refer-
ential cohesion, and .94 for conjunction.
Reference patterns. Speech units that present new in-
formation to the listener do not require additional in-
formation to be understood. In this same class of easily
understood speech elements are references to general
knowledge, Other speech elements presume that infor-
mation crucial to their interpretation has been presented
previously. A basic unit of information is the noun
phrase, also known as the nominal group (Rochester
& Martin, 1979). Therefore, there are two types of nom-
inal groups; those that present information (requiring
no other information for understanding) and those that
presume information (i.e., require other information for
interpretation).
Information can be presumed from previously pre-
sented verbal information, the immediate environment,
or general knowledge. Variables from all three of these
areas were examined, (In the following examples, items
requiring additional information are underlined.) Ref-
erent location can be explicit, such as in the immediate
verbal context (e.g., "There goes Sam. He's all right")
or in the immediate nonverbal situation (e.g., "Open that
window"), or it can be implicit (e.g., "I went to school
and I talked to the teacher"). Reference location can also
be in general information (e.g., "I don't trust the police").
Some reference patterns pose problems for listeners
and lead them astray. These types either refer to an un-
clear referent or call for decisions among several ambig-
uous referents. An example of unclear reference could
be "The two girls went up the hill, then he turned around
and left" An ambiguous reference could be "The two
girls went up the hill, then she turned around and left."
Examples of all rated reference patterns are presented
in Table 2. Previous reports have indicated that TD
schizophrenics use more unclear references, ambiguous
references, and generic references than do NTD schizo-
phrenics and normal individuals. In addition, they use
significantly fewer implicit references and verbal refer-
ences than do normal individuals. All schizophrenics
have been reported to make more references to the im-
mediate nonverbal situation than do normal individuals,
(An extended discussion of these and other reference
patterns, along with some speculations about the causes
of these phenomena, is contained in Rochester & Martin,
1979.) Reliability (Kappa) of identification of all rated
reference patterns was high, ranging from a low of .78
(implicit reference) to a high of .87 (explicit verbal ref-
erence).
Clinical ratings. To identify disordered segments of
each TD subject's speech sample, two trained raters lis-
tened to a tape recording of each subject's open-topic
interview. On a transcript copy of each interview, they
identified the beginning, duration, and end point of each
speech •segment that met the criteria of the TLC for
membership in any clinical rating category. If the overall
severity of a clinical rating category was judged to be 2
or more, all speech meeting criteria for that category was
identified. All clauses occurring between the beginning
and end point of each disordered segment were consid-
ered disordered clauses; all clauses not occurring in a
disordered segment were considered nondisordered
clauses. Examples of all of the TLC's categories are con-
tained in Table 3.

Table 2
Categories of Reference Patterns and Examples"
Category Referent location Example

Explicit Explicit verbal context I met Bill at school and went to the store with him.
Situationai Explicit situational context Look aTfhat fire.
Implicit Implicit verbal context I went to the classroom and talked to the teacher.
Unclear Unclear The two boys went up the hill, then she turned around and left.

Ambiguous Unclear The two boys went up the hill, and then he turned around and left,

Generic Nonspecific You know how the Chinese are.

Note. From "Speech Competence of Children Vulnerable to Psychopathology" by P. D. Harvey, S. Weintrab, and
J. M. Neale, Journal of Abnormal Child Psychology, 1982,10, 373-388. Copyright 1982 by Plenum Publications.
Reprinted by permission.
" Referents are double underlined; groups requiring more information to be interpreted are underlined.
372 PHILIP D. HARVEY

Table 3
Definitions of Clinical Thought-Disorder Categories*
Category Definition

Poverty of speech Restriction in the amount of spontaneous speech

Poverty of content of Speech adequate in amount but low in information
speech
Pressure of speech Increase in the amount of spontaneous speech
Distractible speech Interruption of a train of discourse, with focus shifted to an external object
Tangentiality Replying to a question in a manner not related to the question
Derailment Ideas expressed in spontaneous speech are obliquely related to previous speech
Incoherence Speech that makes no sense and ignores grammatical and syntax rules
Illogicality Overtly expressed reasoning that breaks logical rules
Clanging Speech that creates links on the basis of phonological rather than semantic rules
Neologisms Uniquely created words with a special meaning
Word approximations Use of old words in a new and unconventional way
Circumstantiality Indirect and lengthy speech gets to a goal slowly, if at all
Loss of goal Speech that never reaches logical end points
Perseveration Repetition of words, ideas, or concepts to an extreme degree
Echolalia Patient repeats whole words or phrases of the examiner
Blocking Interruption of a train of speech, with comment from patient that thought is blocked
Stilted speech Excessively pompous or formal speech
Self-reference Repeated references toward self

Note. From "The Specificity of Thought Disorder to Schizophrenia: Research Methods in their Historical Per-
spective" by P. D. Harvey and J. M. Neale in B. A. Maher (Ed.), Progress in Experimental Personality Research,
in press. Copyright 1983 by Academic Press. Reprinted by permission.
"Adapted from Andreasen (1979a).

Some TLC categories presented in Table 3 (e.g., neo-
logisms, word approximations) identify deviant words.
These categories, therefore, identify units of length less
than a clause and were not used in our ratings of the
individual clauses, although their presence contributed
to global ratings of speech disorder. Other TLC categories
identify sections of speech that are deviant by virtue of
overly rapid speech (i.e., pressure of speech) or speech
that is low in information (i.e., poverty of content of
speech). All speech occurring in a segment of pressure
of speech or poverty of content of speech was considered
to be disordered. The TLC also identifies speech that is
deviant because of deviant transitions between clause
units (i.e., derailment). In the case of derailment, only
the deviant transition and the following speech, which
was difficult to understand because of the derailment,
was considered to be disordered. Finally, the TLC iden-
tifies lengthy segments (e.g., tangentiality, incoherence)
that are difficult to understand. For speech that met the
clinical criteria for these categories, the entire segment
was considered to be disordered.
As the goal of the clinical ratings was primarily to
identify speech that was disordered in general, agreement
was not tallied separately for the discrete rating cate-
gories. If the two raters identified the same speech seg-
ment as disordered, with identical beginning and end
points, but said that it met criteria for different cate-
gories, the segment was scored as a disordered unit and
an interrater agreement was tallied. If the two raters
identified a segment as disordered but disagreed about
the beginning or end points of the segment, the portion
of the segment about which they both agreed was scored
as a disordered unit but an interrater disagreement was
tallied. Finally, if one rater identified a segment as dis-
ordered, but the other did not, a disagreement was tallied
and I resolved the discrepancy. Earlier reports have in-
dicated that there is a good deal of variability in interrater
agreements (Kappa) across TLC rating categories, rang-
ing from .32 to .91 (Andreasen, 1979a). Agreement as
tallied in the present study (Kappa) was .82.
Results
The data analysis for all speech variables
used a 2 (manic, schizophrenic) X 2 (TD,
NTD) design, with follow-up planned con-
trasts with the normal group. For significant
diagnostic effects, the normal individuals
were compared with the less deviant patient
group; for significant TD effects, the normal
individuals were also compared with the less
deviant group. In the case of interactions, the
patient subgroup that was least deviant was
compared to the normal subgroup. Finally,
when no effects of diagnosis or TD were pres-
ent, all patients were compared with the nor-
mal individuals. This strategy was adopted
to examine the effect of diagnosis and TD
within the patient groups, whereas a com-
parison with the normal individuals can give
information about both of these factors.
During all parts of the data analysis for the
speech variables, the data were analyzed ac-
cording to the number of occurrences per
clause. This scoring method was adopted be-
 COHESION AND REFERENCE IN PSYCHOSIS 373

cause the length of each subject's interview
was different, and this variability was at least
partially due to the interviewer. The relevant
number of clauses is presented for compar-
ison purposes. In keeping with the data an-
alytic procedures of Rochester and Martin
(1979), univariate procedures were used, but
the conservative Bonferroni procedure was
used to reduce the probability of Type I er-
rors. The alpha level was set at .05/11 (with
the number of clauses not counted as a de-
pendent variable). The Bonferroni procedure
was also applied to comparisons with the
normal contrast group.
Cohesion and Verbal Productivity
Dependent variables in this set (all divided
by the number of clauses) were words, total
number of cohesive ties, number of attempts
at referential cohesion, number of lexical ties,
and the number of conjunctions. Means and
standard deviations for these variables are
presented in Table 4. Pearson product>mo-
ment correlations were computed between all
dependent variables and age, education, oc-
cupational status, and sex; all correlations
were nonsignificant.
A series of 2 (manic, schizophrenic) X 2
(TD, NTD) analyses of variance (ANOVAS)
found significant main effects of TD for two
of the three types of cohesion: referential
cohesion, F(l, 36) = 17.25, p < .001, and
conjunction, F(l, 36) =11.57, p < .005.
Thought-disordered patients produced fewer
examples of each type of cohesive tie than
did NTD patients. No effects of TD were
present for any of the other variables, and no
main effects of diagnosis or Diagnosis X
Thought Disorder interactions were present.
Planned contrasts of normal and NTD pa-
tients on conjunction and referential cohe-
sion indicated that NTD patients had fewer
attempts at referential cohesion than did the
normal group, *(28) = 4.29, p < .001, whereas
no differences were present between the
groups on conjunction, *(28) = 1.43 (ns). No
differences were present between normal and
all other patients on number of words, lexical
cohesion, and the number of cohesive ties per
clause.
Reference Patterns
The dependent variables in this set (all
divided by the number of clauses) were ex-
plicit verbal references, situational refer-
ences, implicit references, unclear references,
ambiguous references, and generic refer-
ences. Means and standard deviations for all

Table 4
Total Scores on Natural Language Variables for Thought-Disordered and Non-Thought-Disordered
Manics and Schizophrenic Plus Normal Individuals '
Group

Manic Schizophrenic
Normal
NTD TD NTD TD contrast
Variable" M SD M SD M SD M SD M SD
Number of clauses 95.50 33.61 85.20 34.05 75.80 27.26 82.50 30.80 64,70 18.65
Words 6.84 .67 6.33 .71 5.70 2.04 6.04 .71 6,22 .45
Total cohesion 1.70 .26 1.54 .48 1.59 .41 1.45 .55 2.08 .47
Referential cohesion .61 .18 .48 .11 .69 .22 .44 .12 .97 .20
Lexical cohesion .70 .19 .81 .25 .60 .37 .80 .19 .66 .17
Conjunction .39 .12 .25 .13 .30 .08 .21 .08 .45 .25
Explicit reference .61 .18 .40 .12 .58 .27 .59 .42 .92 .22
Situational reference .07 .04 .14 .11 .14 .12 .16 .15 .05 .03
Unclear reference .01 .02 .18 .15 .01 .01 .24 .18 .00 .00
Ambiguous reference .00 .01 .04 .04 .00 .02 .05 .04 .00 .02
Implicit reference .09 .05 .03 .02 .05 .05 .02 .02 .14 .08
Generics .05 .03 .15 .09 .03 .03 .12 .11 .04 .03

Note. NTD = without thought disorder; TD = thought disordered.

* Except for number of clauses, all variables are number of occurrences per clause.
374 PHILIP D. HARVEY

variables are presented in Table 4. Pearson Nondisordered Speech Segments

product-moment correlations were com- For these analyses, the total scores on the
puted between all variables and age, sex, oc- previously described verbal productivity, /
cupational status, and education; all corre- cohesion, and reference variables for NTD
lations were nonsignificant. and normal patients were compared to the
A series of 2 (manic, schizophrenic) X 2 frequency of the occurrence of these variables
(TD, NTD) ANOVAS found no significant ef- in the nondisordered segments of the TD
fects of diagnosis and no Diagnosis X Thought patients' speech. Means and standard devia-
Disorder interactions. Significant main ef- tions for these variables are presented in Ta-
fects of TD were found for implicit refer- ble 5. Pearson product-moment correlations
ences, F(l, 36) = 9.95, p < .005; unclear ref- were computed between all speech variables
erences, F(\, 36) = 27.69, p < .001; ambig- and age, sex, occupational status, and edu-
uous references, F(l, 36) = 21.62, p < .001; cation; all correlations were nonsignificant.
and generic references, F(l, 36)= 15.88, A series of 2 (manic, schizophrenic) X 2 (TD,
p < .001. Thought-disordered patients used NTD) ANOVAS found no significant effects of
significantly fewer implicit references and sig- diagnosis or TD and no interactions.
nificantly more unclear, ambiguous, and ge-
neric references than did NTD patients. Disordered Speech Segments
Planned contrasts between NTD and normal
patients on implicit references, unclear ref- To compare the diagnostic groups on
erences, ambiguous references, and generic speech performance during the disordered
references found no significant differences segments of TD patients' speech, a series of
between the groups. Planned contrasts of all one-way ANOVAS were computed for each
patients and normal individuals on situa- previously described speech variable, with
tional and explicit references indicated that diagnosis as the factor. As before, no rela-
all patients made fewer explicit references tionship between demographic variables and
than did normal individuals, f(48) = 3.75, speech performance was found. Means and
standard deviations for these variables are

Table 5
Summary of Natural Language Speech Variables Occurring in Non-Thought-Disordered Segments
of All Subjects'Speech

Group
Manic Schizophrenic
Normal
NTD TD NTD TD contrast
Variable M SD M SD M SD M SD M SD
Number of clauses 95.50 33.61 28.10 16.09 75.80 27.26 23.80 10.10 64.70 18.65
Words 6.84 .67 5.87 1.29 5.70 2.04 6.19 .56 6.22 .45
Total cohesion 1.70 .26 1.42 .41 1.59 .41 1.68 .39 2.08 .47
Referential cohesion .61 .18 .57 .27 .69 .22 .71 .24 .97 .20
Lexical cohesion .70 .19 .65 .26 .60 .37 .66 .37 .66 .17
Conjunction .39 .12 .32 .29 .30 .08 .31 .14 .45 .25
Explicit reference .61 .18 .65 .32 .58 .27 .65 .20 .92 .22
Situational reference .07 .04 .20 .13 .14 .12 .31 .39 .05 .03
Unclear reference .01 .02 .07 .15 .01 .01 .03 .09 .00 .00
Ambiguous reference .00 .01 .01 .02 .00 .02 .01 ,02 .00 .02
Implicit reference .09 .05' .04 .05 .05 .05 .04 ,03 .14 .08
Generics .05 .03 .14 .24 .03 .03 .10 .07 .04 .03
Note. NTD = without thought disorder; TD = thought disordered.
"Except for number of clauses, all variables are number of occurrences per clause.
 COHESION AND REFERENCE, IN PSYCHOSIS 375

Table 6 ence strategies less frequently than do all of

Natural Language Speech Variables Occurring the other subjects evaluated, whereas they
in Thought-Disordered Segments of Thought- rely on general information more than the
Disordered Patients' Speech other subjects do.
Group
Patients without thought disorder, on the
other hand, are relatively difficult to discrim-
Thought- Thought- inate from normal individuals. There is a ten-
disordered disordered dency on the part of the NTD patients to use
manics schizophrenics somewhat less referential cohesion than the
Variable" M SD M SD normal group, but their performance in the
reference domain is quite similar to that of
Thought-disordered the normal group.
clauses 57.10 19.08 58.70 28.47 Most of the findings presented here are
Words 6.61 1.11 6.00 .86
Total cohesion 1.51 .52 1.09 .52
similar to those of Rochester and Martin
Referential cohesion .32 .08 .33 .17 (1979). The main inconsistency is the failure
Lexical cohesion .97 .41 .59 .31 here to find an increase in lexical cohesion
Conjunction .22 .18 .18 .09 on the part of TD patients. There is a reason,
Explicit reference .35 .07 .33 .17 however, for this difference. The present
Situational reference .13 .13 .11 .12
Unclear reference .23 .22 .27 .16 study reported total scores, which were cor-
Ambiguous rected for the length of the interview, whereas
reference .05 .05 .07 .06 Rochester and Martin (1979) reported cohe-
Implicit reference .04 .04 .02 .02 sion variables as a proportion of the total
Generics .17 .11 .13 .15 number of cohesive ties. A similar, percent-
% of clauses rated age-based data analysis in the present study
as thought found results equivalent to Rochester and
disordered 69.20 29.00 77.30 22.60 Martin's. Another inconsistency between
1
Except for number .of clauses, all variables are number these data and Rochester and Martin's is our
of occurrences per clause. finding that the number of implicit references
did not differ between the normal group and
NTD psychotics. This difference is poten-
presented in Table 6. Np significant effects tially important because they stated that con-
of diagnosis were found for any speech vari- servatism in discourse, as marked by the low
ables. frequency of attempting complicated implicit
Discussion reference patterns, was partially responsible
for the adequate performance of NTD pa-
The most general statement to be made tients. A possible cause of the inconsistency
about the analyses of cohesion and reference with respect to normal individuals' and NTD
presented here is that there are many differ- psychotics' use of implicit references is sta-
ences in speech performance associated with tistical in nature. In the present report, I used
the presence of clinically rated speech dis- the Bonferroni procedure to reduce the prob-
order in manics and schizophrenics, but there ability of Type I errors. In the Rochester and
are no diagnostic differences. Thought-dis- Martin reports, that correction was not done.
ordered patients present a pattern of dis- If the present report had not used the cor-
course that is more poorly integrated than rection, NTD psychotics would have been
that of NTD patients and normals. These found to use significantly fewer implicit ref-
patients also use significantly fewer of the erences than the normal group.
most effective types of cohesive ties. As a con- The primary addition to the information
sequence, due to the ineffective cohesive provided by Rochester and Martin is related
strategies and their frequent use of incom- to the inclusion of the manic subject group
petent reference strategies, their speech is and to the attempt at validating Rochester
much more difficult to understand than that and Martin's (1979) rating system by ex-
of NTD patients and normals. Finally, the amining the differences between disordered
TD patients use highly sophisticated refer- and nondisordered speech segments of the
376 PHILIP D. HARVEY
TD patients. It appears that the rating system
is not capable of identifying performance
patterns that are specific to a certain diag-
nostic group, whereas the system appears
valid with respect to identifying the aspects
of performance in speech that are related to
clinically rated thought disorder.
The process of validation of the rating sys-
tem has once again confirmed that speech
disorder in psychosis is indeed an episodic
phenomenon, with some perfectly competent
stretches, as asserted by LeCours and Vanier-
Clement (1976). The nondisordered seg-
ments of TD patients' speech were similar in
cohesion and reference patterns to the speech
of the normal group and the NTD psychotics.
In addition, the disordered speech, in terms
of cohesion and reference performance as
well as the proportion of disordered clauses,
was similar for manic and schizophrenic pa-
tients. The actual number of disordered
clauses was high relative to earlier reports
(e.g., Rochester & Martin, 1979; LeCours
& Vanier-Clement, 1976), but this was be-
cause segments of pressured speech ,and
speech with poverty of content were consid-
ered disordered. The earlier investigators had
used more stringent criteria for considering
a clause to be disordered.
Rochester and Martin (1979) speculated
that conservatism in speech performance was
at the root of performance diiferences be-
tween NTD and TD patients. Their findings
with respect to conservatism were not di-
rectly confirmed. Another speculation of
theirs was that information-processing defi-
cits cause deviant speech performance. That
idea has potential merit and should be ex-
plicitly investigated by later researchers; cor-
relations between speech and cognitive vari-
ables should be computed.
A final issue to be examined in later in-
vestigations is the consistency of cohesion
and reference performance across phases of
psychotic disorders. Harvey, Weintraub, and
Neale (1982) reported that children vulner-
able to psychopathology have deficits in cohe-
sion and reference performance. Harrow,
Grossman, Silverstein, and Meltzer (1982)
reported that speech performance was de-
viant in schizophrenics after remission of the
disorder. Later studies might provide more
insight into the processes of disordered speech
in psychosis by examining the same patients
regularly throughout their hospital stay, with
a follow-up evaluation later. At that time,
even more information about the processes
of cohesion and reference difficulties in psy-
chotic speech would be available, which
would add to our understanding of the phe-
nomena of psychotic speech disorders.
References
American Psychiatric Association. Diagnostic and sta-
tistical manual of mental disorders (3rd ed.). Wash-
ington, D.C.: Author, 1980.
Andreasen, N. C. Thought, language, and communica-
tion disorders: I. Clinical assessment, definition of
terms, and evaluation of their reliability. Archives of
General Psychiatry, 1979, 36, 1315-1321. (a)
Andreasen, N. C. Thought, language, and communica-
tion disorders: II. Diagnostic significance. Archives of
General Psychiatry, 1979,36, 1321-1330. (b)
Astrachan, B. M., et al. A checklist for the diagnosis of
schizophrenia. British Journal of Psychiatry, 1972,
121, 529-539.
Bleuler, E. Dementia praecox; or the group of schizo-
phrenias. New York: International Universities Press,
1950.
Cohen, J. A. A coefficient of agreement for nominal
scales. Educational and Psychological Measurement,
1960, 20, 37-46.
Durbin, M., & Marshall, R. L. Speech in mania: Syn-
tactic aspects. Brain and Language, 1977, 4, 208-218.
Goldstein, K. The significance of special mental tests for
the diagnosis and prognosis of schizophrenia. Amer-
ican Journal of Psychiatry, 1939, 96, 575-587.
Gottschalk, L. A., & Gleser, G. C. Distinguishing char-
acteristics of the verbal communications of schizo-
phrenic patients. In D. McRioch & E. A. Weinstein
(Eds.), Disorders of communication, Baltimore, Md.:
Williams & Wilkins, 1964.
Halliday, M. A. K., & Hasan, R. Cohesion in English.
London: Longman, 1976.
Harrow, M., Grossman, L., Silverstein, M. L., & Meltzer,
H. Y. Thought pathology in manic and schizophrenic
patients: Its occurrence at hospital admission and
seven weeks later. Archives of General Psychiatry,
1982,59,665-671.
Harvey, P. D., Weintraub, S., & Neale, J. M. Speech
competence of children vulnerable to psychopathol-
ogy. Journal of Abnormal Child Psychology, 1982,10,
373-388.
Kent, H., & Rosanoff, A. J. A study of association in
insanity. Journal of Insanity, 1910, 67, 326-390.
Kraepelin, E. Dementia praecox and paraphrenia. Edin-
burgh, Scotland: Livingstone, 1919.
LeCours, A. R., & Vanier-Clement, M. Schizophasia and
jargonaphasia: A comparative description with com-
ments on Chaika's and Fromkin's looks at "schizo-
phrenic" language. Brain and Language, 1976, 3,
516-565.
 COHESION AND REFERENCE IN PSYCHOSIS
Maher, B. A. The language of schizophrenia: A review
and reinterpretation. British Journal of Psychiatry,
1972, 120, 3-17.
Maher, B. A., McKean, K. O., & McLaughlin, B. Studies
in psychotic language. In P. J. Stone, R. F. Bales, Z.
Namenworth, & D. M. Ogilivie (Eds.), The general
inquirer: A computer approach to content analysis.
Cambridge, Mass.: MIT Press, 1966.
Neale, J. M., & Cromwell, R. C. Attention and schizo-
phrenia. In B, A. Maher (Ed.), Progress in experi-
mental personality research (Vol. 5). New York: Aca-
demic Press, 1970.
Rochester, S. R., & Martin, J. R. Crazy talk: A study of
377
the discourse of schizophrenic speakers. New York:
Plenum Press, 1979.
Rochester, S, R., Martin, J. R., & Thurston, S. Thought
process disorder in schizophrenia: The listener's task.
Brain and Language, 1977, 4, 95-114.
Spitzer, R. L., & Endicott, J. Current and past psycho-
pathology scales. New York: Biometrics Research,
1968.
Spitzer, R. L., Endicott, J., & Robins, L. The schedule
for affective disorders and schizophrenia. New York,
Biometrics Research, 1978.
Received October 20, 1982
Revision received March 14, 1983 •