Speech-language intervention in schizophrenia: an integrative review

ABSTRACT

Objective:

to perform an integrative review to identify speech and language pathology intervention for schizophrenia.

Methods:

the review covered SCIELO, PUBMED, OXFORD JOURNALS and SCIENCEDIRECT databases for speech and language pathology intervention studies for schizophrenia. A narrative synthesis was adopted considering the level of clinical and methodological heterogeneity amid studies.

Results:

the results demonstrated an increase in publications since 2012 with 11 articles meeting the criteria. Language and discourse assessment were the speech and language pathology privileged procedures.

Conclusion:

the review indicates that the most eligible intervention was assessment, that studies’ methodology were heterogeneous and that the communication disorders identified were related to discursive, pragmatic and syntactic disorders, which evidences the importance of more systematized intervention procedures and research on schizophrenic patients.

Keywords:
Language; Schizophrenia; Speech; Mental Health; Communication; Speech, Language and Hearing Sciences

RESUMEN

Objetivo:

el objetivo de este estudio fue identificar la evidencia científica sobre la intervención fonoaudiológica en esquizofrenia.

Métodos:

se realizó una revisión integrativa de la literatura científica sobre intervenciones fonoaudiológicas en pacientes con esquizofrenia, en SCIELO, PUBMED, OXFORD JOURNALS y SCIENCEDIRECT, desde el año 2000 hasta marzo de 2017 y en los idiomas inglés, español y portugués. Se adoptó una síntesis narrativa en vista del nivel de heterogeneidad clínica y metodológica entre los estudios.

Resultados:

los resultados demostraron un aumento de publicaciones a partir del año 2012 y que en los 11 artículos que cumplirán con los criterios del estudio el procedimiento privilegiado fue la evaluación del lenguaje y del discurso.

Conclusión:

la revisión indica que la intervención privilegiada fue la evaluación, que los estudios presentaron heterogeneidad en la metodología y resultados relacionados con los problemas discursivos, pragmáticos y trastornos sintácticos, que evidencian la importancia de buscar más sistematicidad en la intervención fonoaudiológica del paciente con esquizofrenia.

Descriptores:
Lenguaje; Esquizofrenia; Habla; Salud Mental; Comunicación; Fonoaudiología

Introduction

Speech and Language Pathology (SLP) studies the prevention, assessment and treatment of human communication disorders (oral and written language, voice, hearing and oral motor skills) ¹. The role played by the speech and language pathologist in Mental Health is based on performing specific procedures for evaluation, intervention, counseling and follow-up on the SLP disordered processes, creating strategies to promote and maintain patient’s functional communication, a fundamental component of social interaction ².

Schizophrenia is a chronic mental disorder that has a multifactor etiology. Its global prevalence is 0.3% to 0.7% ³ and the incidence is higher in men though the definitions that include more mood symptoms and brief clinical events show an equivalent risk for both sexes ^3-5. The early symptoms occur usually between 15 and 45 years, often emerging at the beginning of youth (15-25 years) ³.

The schizophrenic signs fall into two categories: positive and negative. Positive symptoms include disorders of perception (hallucinations), language, behavioural organization (severely disorganized or catatonic) and of thinking (delusional ideas) ^4-7. Positive symptoms include two dimensions that may be related to underlying neural mechanisms and different clinical correlations: the psychotic dimension, which comprehends delusions and hallucinations, and the disorganization dimension that compromises behavior and language. Negative symptoms are characterized by disorders of perception, inferential thinking, language and communication, behavior organization, affectivity, speech, hedonic capacity, will, motivation, attention and a decrease or loss of emotions. They also include restrictions on the intensity of emotional expression (affective flattening), on the fluency and productivity of thought and language (alogia) and on the initiation of goal-directed behavior (apathy) ^5-8. Negative symptoms are correlated to language poverty and worse social and occupational function⁹.

The cognitive disorders in schizophrenia do not seem to be a consequence of the disorder itself, since there is no strong corresponding evidence between hallucinations or delusions severity with cognitive deficits severity. Attention and working memory problems are evident early and they do not recede even though the psychotic process is resolved, suggesting that there is no dependence on positive symptoms⁹. It has been established that attention deficits, which affect communication and language use, are observed before, during and after psychotic episodes and persist despite the attenuation effect of antipsychotic medication.

Communication disorders have been consistently considered as symptoms in the context of schizophrenia¹⁰, which implies a deficit of language comprehension and production (oral and written), pragmatic-discursive components and syntactic and semantic domains¹¹. Patients with schizophrenia present semantic memory problems, that are evident in semantic priming and verbal fluency tests, deficits in word association, in the use of language, in the production of contextualized speech, in inferring context-dependent meanings and in social interaction ^9,11-13. The discourse level attests to a lack of turn taking, discursive connectors and prosody alteration ^10,13. Authors consider that the formal disorder of thought can include the decrease in the content of discourse, perseveration, echolalia, empty discourse and speech blockade because it implies a disconnection or detachment of communicative competence, failures in understanding the communicative context, failures in the use of grammatical links that allow a correct cohesion, an irregular speech and more difficulties in metaphor interpretation ^14,15.

Considering that SLP is a professional whose specialty is the study of normal and pathological processes of human communication¹ then its practice collaborates to lead to the improvement of patient's quality of life since communication is essential for personal and social skills development and work integration.

It is relevant to analyze the scientific evidence on SLP praxis in schizophrenia for both clinical and research purposes, so the aim of this study was to synthesize the available evidence, which emphasizes SLP assessment and the therapeutic approach.

Methods

This study was carried out with an integrative review to a qualitative approach of descriptive scope. The search for articles used the following databases: SCIELO, PubMed, OXFORD JOURNALS and SCIENCEDIRECT, It was conducted between September 2016 and April 2017, comprising of articles published from January 2000 to March 2017. The selection considered the following inclusion criteria: studies with topics covering one or more Speech and Language interventions, complete free access studies with sample of schizophrenic patients with ages in the range of 18 - 75 years, articles with abstract, quantitative or qualitative methodology or both and with description of SLP disorders. The exclusion criteria comprehended systematic reviews, samples of subjects with another psychiatric pathology associated, samples of subjects younger than 18 years and older than 75 years.

The search was performed in Spanish, English and Portuguese languages; the key words, obtained from the PubMed, used the following combinations: ((Speech & Language Pathology AND Schizophrenia)) OR ((((Pragmatic AND Schizophrenia AND Speech & Language Pathology))) OR (((Mental Health AND Schizophrenia AND Communication))) OR (( (Speech Language Treatment AND Schizophrenia))); ((Fonoaudiología AND Esquizofrenia)) OR (((Pragmatica AND Esquizofrenia AND Fonoaudiología))) OR (((Salud Mental AND Esquizofrenia AND Comunicación ))) OR ((Lenguaje AND Terapia AND Esquizofrenia)); (((Fonoaudiologia AND Esquizofrenia))) OR (((Pragmática AND Esquizofrenia AND Fonoaudiologia))) OR (((Saúde Mental AND Esquizofrenia AND Comunicação))) OR (((Linguagem AND Terapia AND Esquizofrenia))).

After applying the inclusion and exclusion criteria, articles were analyzed according to author, year of publication, type of SLP procedure, number of subjects in the sample, sex and results.

Results

The initial search, with the keywords in English, Spanish and Portuguese, resulted first in 13,162 articles and in 8,648 after deleting the copies. Then, the process continued with refinement of the number of articles according to their title and relationship with the objective of the study, resulting in 1,198 articles. After the application of exclusion criteria, the sample dropped to 69 articles and with the application of inclusion criteria, to the final 11 articles. In a systematic review, authors found 18 articles but in their methodology there were different inclusion and exclusion criteria, a superior range of years and the incorporation of paid articles10. Figure 1 indicates the articles according to the language in which they were published and the country of origin of the study.

Figure 1:
Classification by language of publication and country of origin

According to the language in which the articles were written the results indicated 9 in English ^16-24 and 2 in Spanish ^25,26. In relation to the country of origin it was verified articles from United States of America ^16-18,20-22, Brazil ^19).(23, Italy ²⁴, Spain ²⁶ and Chile ²⁵. The investigations varied between individual case studies ^18-20,25,26 and sample studies ^16,17,21-24. Although the incidence of schizophrenia is greater in men ^17,27, in this review it was observed that only five articles specified the sex of participants ^{16,17,23,24,26}. The analyses of the articles characteristics are presented in Figure 2.

Figure 2:
Characteristics of selected studies

Discussion

The main objective of this integrative review was to identify scientific evidence on the SLP intervention in schizophrenia and in the reviewed literature it was observed that the 11 selected studies favor the SLP evaluation over other interventions. They also indicate an increase in publications since 2012, with a greater number of research studies carried out in the United States. A variety of topics was observed such as those that discuss the effects of social cognition damage in language disorders ²⁰, the components of cognitive control and speech symptoms in people with schizophrenia ²¹, the identification of the underlying processes of the disorder of schizophrenic speech ²², the communicative behavior of subjects diagnosed with schizophrenia ²³ and the communicative-pragmatic treatment in schizophrenia ²⁴.

The methodology of the evaluations showed heterogeneity of designs. The most used tests were semantic and phonological fluency ^{17,19), (24), (25} and the Trail Making Test part A and part B ^16,19,24,25.

The procedure to evaluate language and communication in subjects with formal thought disorder was the Thought Disorders, Language and Communication Scale, which serves to identify speech and speech content poverty, distracted speech, tangentially, incoherence, neologisms and echolalia among others ^17,18,22,26. The Index of Communication Disturbances (IDC), which measures and identifies the words or phrases with a confusing meaning and recognizes six types of errors (vague references, confusing references, lack of references in the information, ambiguous meanings of the word, incorrect use of the word and lack of structural clarity) was applied for the evaluation of the disorganized discourse ^16,21,20 .

Consonant to the results, the importance of speech and language pathology treatment in subjects with schizophrenia is confirmed by the alterations detected in the evaluations. The most obvious symptoms were related to the semantic-pragmatic area, speech coherence, verbal fluency, prosody, attention, planning, sequencing and facial expression ^16-22,25.

The reviewed studies suggest that cognitive deficits are associated with language poverty, alteration of speech and a worse social and occupational function ^9,15 and also that the presence of cognitive dysfunction and executive functions directly or indirectly affect language and communication ^{16,19,24,25).}

The pathological processes predisposing to schizophrenia are present early in life and the signs of social and language impairment are some of their nuclear characteristics ¹³, a fact that indicates the importance of a prompt and, when possible, longitudinal Speech and Language Pathology intervention.

Conclusion

In accordance to the evidence given here, the present review demonstrates that there is a lack of research in SLP therapy in schizophrenia, given that no article covering treatment was found in this review. The study also identified a wide range of communication disorders, in various degrees, especially the areas related to incoherent language and grammatical alterations and evaluation as the most frequent procedure. The data indicates the need for further investigation of therapeutic practices in order to build a scientific evidence foundation for the benefit of the patient’s quality of life. The information obtained serves as an argument for improvements in methodological homogeneity.

References

• ¹
  Romero L. Displacements with respect to disciplinary knowledge of Speech, Language and Voice Therapist. Revista Chilena de Fonoaudiología. 2012;11:99-106.
• ²
  Ramírez SA, Colina Matiz S. Papel del fonoaudiólogo en el área de salud mental: una experiencia profesional en el hospital militar central. Revista Med. 2009;17(1):26-33.
• ³
  Herráez D, Palacios J. Recordatorio de semiología. Semiología de la esquizofrenia. Servicio de Psiquiatría. Hospital Infanta Sofía. San Sebastián de los Reyes. Madrid: No.1755, 2009.
• ⁴
  American Psychiatric Association: Diagnostic and Statistical: Manual of Mental Disorders, Fifth Edition. Arlington: American Psychiatric Association, 2013.
• ⁵
  Holder SD, Wayhs A. Schizophrenia. American Family Physician. 2014;90(11):775-82.
• ⁶
  Musiol M, Rebuschi M. Rationality of inconsistency in schizophrenic conversation (Conversational pragmatical and formal semantic analysis). Psychologie Française. 2007;52(2):137-69.
• ⁷
  Abdollhian E, Ghravi MM, Soltanifar A, Mokhber N. Relationship between positive and negative symptoms of schizophrenia and psychotic depression with risk of suicide. Iranian Journal of Psychiatry and Behavioral Sciences. 2009;3(1):27-32.
• ⁸
  Almeida BPB, Cunha MC. Alterações da comunicação em pacientes institucionalizados portadores de esquizofrenia crônica. Rev. Soc. Bras. Fonoaudiol. 2011;16(1):117-8.
• ⁹
  Barrera A. Cognitive deficits in schizophrenia. Revista Chilena de Neuro-Psiquiatría. 2006;44(3):215-21.
• ¹⁰
  Joyal M, Bonneau A, Fecteau S. Speech and language therapies to improve pragmatics and discourse skills in patients with schizophrenia. Psychiatry Research. 2016;240:88-95.
• ¹¹
  Bordas C, Puyuelo M. Aspectos semánticos y pragmáticos en personas con esquizofrenia. Revista de Logopedia, Foniatría y Audiología. 2010;30(2):84-93.
• ¹²
  Figueroa A. Análisis pragmalingüístico de los marcadores de coherencia en el discurso de sujetos con esquizofrenia crónica y de primer episodio [Tesis doctoral]. Valadolid (ES): Universidad de Valadolid, 2015. Disponible en: https://uvadoc. uva.es/ bitstream /10324/16539/1/Tesis910-160314.pdf
• ¹³
  Bambini V, Arcara G, Bechi M, Buono-core M, Cavallaro R, Bosia M. The communicative impairment as a core feature of schizophrenia: frequency of pragmatic deficit, cognitive substrates, and relation with quality of live. Compr Psychiatry. 2016;71:106-20.
• ¹⁴
  McKenna P, Oh T. El lenguaje de los esquizofrénicos. Revista GU. 2005;1(3):229-32.
• ¹⁵
  Steinau S, Stegmayera K, Langb FU, Jagerb M, Strika W, Walthera S. Comparison of psychopathological dimensions between major depressive disorder and schizophrenia spectrum disorders focusing on language, affectivity and motor behavior. Psychiatry Research. 2017;250:169-76.
• ¹⁶
  Docherty NM, Hall MJ, Gordinier S W, Cutting LP. Conceptual sequencing and disordered speech in schizophrenia. Schizophrenia Bulletin. 2000;26(3):723-35.
• ¹⁷
  Bowie CR, Harvey PD, Moriarty PJ, Parrella M, White L, Davis KL. A comprehensive analysis of verbal fluency deficit in geriatric schizophrenia. Archives of Clinical Neuropsychology. 2004;19(2):289-303.
• ¹⁸
  Elvevág B, Foltz PW, Weinberger DR, Goldberg TE. Quantifying incoherence in speech: An automated methodology and novel application to schizophrenia. Schizophrenia research. 2007;93(1):304-16.
• ¹⁹
  Berberian AA, Trevisan BT, Moriyama T S, Montiel JM, Oliveira JAC, Seabra AG. Working memory assessment in schizophrenia and its correlation with executive functions ability. Revista Brasileira de Psiquiatria. 2009;31(3):219-26.
• ²⁰
  Docherty N, McCleery A, Divilbiss M, Schumann EB, Moe A, Shakeel MK. Effects of social cognitive impairment on speech disorder in schizophrenia. Schizophrenia Bulletin. 2013;39(3):608-16.
• ²¹
  Becker TM, Cicero DC, Cowan N, Kerns JG. Cognitive control components and speech symptoms in people with schizophrenia. Psychiatry Research. 2012;196(1):20-6.
• ²²
  Docherty NM. On identifying the processes underlying schizophrenic speech disorder. Schizophrenia Bulletin. 2012;38(6):1327-35.
• ²³
  Santos AED, Pedrão LJ, Zamberlan-Amorim NE, Carvalho AMP, Bárbaro AM. Communicative behavior of individuals with a diagnosis of schizophrenia. Rev. CEFAC. 2014;16(4):1283-93.
• ²⁴
  Bosco FM, Gabbatore I, Gastaldo L, Sacco K. Communicative-pragmatic treatment in schizophrenia: a pilot study. Front Psychol. 2016;7:166. doi:10.3389/fpsyg.2016.00166.
  » https://doi.org/10.3389/fpsyg.2016.00166
• ²⁵
  Servat P, Lehmann S, Harari A, Gajardo I, Eva C. Evaluación neuropsicológica en esquizofrenia. Revista Chilena de Neuro-Psiquiatria. 2005;43(3):210-6.
• ²⁶
  Insúa P, Grijalvo J, Huici P. Alteraciones del lenguaje en la esquizofrenia: Síntomas clínicos y medidas psicolingüísticas. Revista de la Asociación Española de Neuropsiquiatría. 2001;(78):27-50.
• ²⁷
  McGrath J, Saha S, Welham J, El Saadi O, MacCauley C, Chant D. A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Medicine. 2004;2(1):1-22.

Publication Dates

• Publication in this collection
  Mar-Apr 2018

History

• Received
  11 Dec 2017
• Accepted
  21 Feb 2018