Question
Should SLPs address schizophrenia using pragmatic skills?
Answer
Yes, pragmatic language is an area which needs to be addressed in order to improve language performance of individuals with schizophrenia. Language difficulties are a significant clinical marker in the identification of schizophrenia. Unfortunately language remains one of the least understood aspects of the disorder. Although impairments in language form and content have long been thought to accompany schizophrenia, more recently researchers have looked at pragmatic language skills mediated by the right hemisphere as being the primary language deficit seen in schizophrenia. Researchers have likened these pragmatic language difficulties to those observed in right-hemisphere disorder (RHD), traumatic brain injury (TBI), and autism.
Although it is clear that language skills mediated by the left hemisphere, such as syntax and semantics, are observed as deficits in schizophrenia, more right-hemispheric language skills, such as discourse formation, comprehension of figurative language and indirect requests, and use and perception of affective prosody, have recently been identified as specific areas of weakness for individuals with schizophrenia. These particular skills are thought to underlie higher-order language functions, such as the ability to infer communicative intent of others. The left-hemisphere is engaged in processing the phonology, syntax, and semantics of a spoken message; however, much of what is communicated goes beyond the form and content of language and requires the active engagement of the right-hemisphere to determine "how" the words are being used in order to gain the richness of meaning and full understanding of the intended message. Understanding the intentions of others is such a vital skill that individuals who show deficits in this ability are unable to integrate successfully in society.
There are several cognitive theories associated with underperformance in the pragmatic language arena: poor theory of mind, executive dysfunction, and weak central coherence. Theory of mind refers to the ability to infer the mental states of others and is vital in determining communicative intend. Executive function not only allows individuals to adapt to novel and complex tasks but allows for flexibility in thought. Central coherence refers to the ability to process information in a holistic manner rather than a "piecemeal" fashion, processing information in a gestalt rather than homing in on "the details." Central coherence is essential in deriving meaning from contextual cues.
These theories provide a framework for determining areas of weakness for each individual with a pragmatic language disorder and can serve as a starting point in determining the most appropriate course of treatment. While it is unclear whether one of these cognitive processes dominates or all three could be operating and interplaying at the same time, it is clear, based on current research, that individuals with schizophrenia display pragmatic language deficits and could benefit from a therapy approach which emphasizes social cognition.
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Kimberly Frazier Baker is an assistant professor at the University of Arkansas. She has 20 years of clinical experience working with children and adolescents with autism spectrum disorders.