The role of the psycholinguistic characteristics

of words in the assessment of language

processing of patients with psychosis, ultra-
high risk of psychosis, or schizophrenia
Vlasta Erdeljac1 • Martina Sekulić Sović1 • Draženka Ostojić2,3 • Aleksandar Savić2,4
1
University of Zagreb, Faculty of Humanities and Social Sciences, Department of Linguistics,
2
University Psychiatric Hospital Vrapče, 3University of Zagreb, Faculty of Law, Social Work Study
Centre, 4University of Zagreb, School of Medicine, Chair of Psychiatry and Psychological Medicine

[Link]

1. Psychosis and schizophrenia-spectrum disorders

Psychosis is an umbrella term used to describe disorders in which one’s ability
to adequately test reality is compromised because of changes in perception and
thoughts as well as in affective responses, all of which leads to impaired func-
tioning on multiple levels. The most common features in all psychotic disorders
include delusions and hallucinations (often referred to as positive symptoms),
but clinical presentation can vary significantly among individuals diagnosed
with the same disorder, and even in the same individual over time, making the
process of differential diagnosis in certain cases extremely complex.
Delusions are fixed false beliefs that resist change even when the individual is
confronted with compelling contrary evidence; the most common are persecutory
delusions (the belief that someone wants to harm or hurt the person, or is plotting
against them) and referential delusions (the belief that random things/individuals
have special meaning for the affected person). Other types of delusions can also be
part of the clinical presentation (e.g. erotomanic, grandiose, somatic, and nihilistic
delusions), and these can further be divided into bizarre and non-bizarre delusions.
Hallucinations are changes in perception that take place in the absence of any
external stimulus and can affect any perceptual modality (visual, auditory, olfac-
tory, gustatory, and somatic). Not only are delusions and hallucinations linked to
psychosis, but other symptoms and symptom domains as well, such as disorga-
nized thinking and speech, changes in motor behavior, and negative symptoms
(e.g. flat affect, anhedonia, alogia, and amotivation). Certain symptom domains
are seen more often in specific psychotic disorders (e.g. negative symptoms in
schizophrenia), a fact that can be used in the process of reaching definitive diag-
nostic differentiation.
The disorder most commonly mentioned in the context of the psychosis
spectrum is schizophrenia, which is often seen as the paradigmatic psychotic
disorder. However, the spectrum also includes disorders such as schizoaffective
disorder, schizophreniform disorder, delusional disorder, schizotypal disorder,
and brief psychotic disorders. Psychosis symptoms can also be present in other
psychiatric disorders (e.g. bipolar affective disorder, depression, and personality
disorders) and can be induced by various psychoactive substances and medica-
tions or by various medical conditions (e.g. autoimmune, endocrine, and meta-
bolic disorders, tumors, etc.).
A diagnosis of a psychotic disorder is primarily based on a detailed patient
history and examination of mental status (whether by means of structured ques-
tionnaires or semi-structured and/or unstructured interviews). As of yet, there
are no widely accepted “objective” neuroimaging or laboratory tests used to di-
agnose schizophrenia or other psychotic disorders (although such tests are used
to diagnose medical conditions that potentially induce psychotic symptoms).

2. Schizophrenia
Schizophrenia (SCZ) is a psychotic disorder with a reported prevalence varying
between 0.4% and 1% and is among those mental disorders with the greatest im-
pact on the duration and quality of life as well as on the work and social function-
ing of those affected (Sadock, Sadock, & Ruiz, 2015, p. 301; Bhugra, 2005; Mcgrath,
Saha, Chant, & Welham, 2008; Desai, Lawson, Barner, & Rascati, 2013). The male
to female rate ratio of SCZ is reported to be 1.4:1 (Desai et al., 2013), while the
peak incidence in males is seen at an earlier age (15–25) than in females (25–35)
(Sadock et al. 2015, p. 301; Mcgovern & Cope, 1987). Women, however, show a bi-
modal distribution, and have a second peak of SCZ onset in middle age (Messias,
Chen, & Eaton, 2007). Men are reported to experience more negative symptoms,
and the outcome for women is considered to be generally more favorable.
Although we referred in the previous paragraph to SCZ as a psychotic disor-
der, today it is considered to be a group of related disorders with possibly vary-
ing clinical presentations, underlying pathological mechanisms, and outcomes.
One of the major, still unmet challenges in SCZ research today is therefore the
identification of valid sub-types (both clinically and in relation to a number of
different objective indicators).

2 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


2.1. Etiology
Even though the etiology of SCZ has been studied since its initial conceptualiza-
tion in the nineteenth century, no definitive model of its underlying pathology
has emerged, which might at least partially be the result of its above-mentioned
heterogeneity. We know from research carried out to date that there is a strong
genetic component of the disorder, informing us of the risk to relatives of those
affected, and recently, a number of additional candidate gene loci linked to SCZ
have been identified (Schizophrenia Working Group, 2014), driving forward re-
search on the genetics of the schizophrenia spectrum. The rate of concordance
in monozygotic twins is reported to be between 33% and 50%, and heritability
in SZC spectrum disorders is 73% (Sadock et al. 2015, p. 303; Hilker et al., 2018).
Even if we take the higher rate of concordance (50%) in monozygotic twins as
true, it still indicates that SCZ vulnerability depends on more than just genetic
loading.
The first studies on the neuropathology of SCZ failed to show clear signs of
brain changes, causing the disorder to be classified as functional, but subsequent
research indicated that there is a loss of brain volume, possibly stemming from
excessive synaptic pruning during adolescence. In addition to changes observed
in the prefrontal cortex, the limbic system, the thalamus, and some other specific
regions of the brain, reduced symmetry was also reported. This is believed to
originate during fetal life and to disrupt brain lateralization (Sadock et al. 2015,
p. 304).
Probably the most widely accepted theory is the dopamine theory of SCZ
(and psychosis in general), which argues that dysregulation of the dopamine
system causes most symptoms of the disorder (particularly its positive and neg-
ative symptoms). This has been supported by the effectiveness of dopamine an-
tagonists in the treatment of SCZ (for treating positive symptoms) and that of
all of the currently available antipsychotic medications that regulate dopamine
neurotransmission. Dopamine theory has survived many modifications, with
changes in focus among different elements (dopamine production, release, re-
ceptor changes), and even after it was challenged by other hypotheses explaining
the emergence of psychosis at different levels, it continues to be seen as the “final
common pathway” to psychosis (Howes & Kapur, 2009). The Glutamate and
GABA systems dysregulation hypotheses postulate changes in excitation/inhibi-
tion, which have been confirmed by a number of studies and computer models
of the disruptions seen in SCZ. Those changes have been linked to, among other
things, working memory problems observed in the SCZ population (Starc et al.,
2017). Neuroimaging studies of schizophrenia have also helped us to move from
focusing on a specific brain region(s) to seeing it characterized by changes in
widely distributed networks and functions (Yang et al., 2014).

The role of the psycholinguistic characteristics of words 3

 Many other theories on the etiology of SCZ and psychosis exist, possibly ex-
plaining other important elements of its underlying pathology (e.g. the infection
hypothesis, based on, among other facts, a high incidence of SCZ after prenatal
exposure to influenza), but listing all of them goes beyond the scope of this arti-
cle. It is important to note, however, that there are also a number of psycholog-
ical theories of SCZ (e.g. the double-bind concept) that have descriptive value
and can help us understand individual symbolic meaning behind some of the
symptoms, which helps in the treatment process when using psychological in-
terventions for SCZ patients.

2.2. Clinical presentation and diagnostic criteria

No symptom is considered to be pathognomonic for schizophrenia, as all symp-
toms and signs reported in SCZ can also be seen in other psychiatric disorders.
This, combined with the fact that we still do not have an objective diagnostic
instrument, illustrates the difficulty in making an early diagnosis of SCZ and
the importance of observations made over prolonged periods in order to cap-
ture all aspects of this psychopathology and its changes over time. Current con-
ceptualizations of the schizophrenia spectrum recognize the existence of sub-
tle, non-specific premorbid signs and symptoms progressing through the pro-
dromal stage into frank psychosis. Patients who go on to develop schizophre-
nia-spectrum disorder may have been more introverted and socially retracted,
and research has shown that cognitive changes may be among the first signs in
those who go on to be diagnosed with SCZ (Häfner et al., 1992). Even with clear
prodromal signs and symptoms predating the first episode of psychosis, we still
consider prodromes to be a retrospective concept, clearly defined as part of SCZ
only after the actual onset of the illness.
Keeping in mind that SCZ is a longitudinal concept without clear pathogno-
monic symptoms, we expect it to be present with a number of different signs and
symptoms, changing over time, which we usually divide into different symptom
domains. The clinical presentation of a patient with schizophrenia can range all
the way from a disorganized, agitated, and bizarre patient to one who is seem-
ingly inconspicuous, silent, and immobile. Two domains that have been part of
all previous and current conceptualizations of psychosis and SCZ are positive
and negative symptoms. Positive symptoms have occasionally additionally been
divided into “core” positive symptoms reflecting perceptual disturbances and
thought content (delusions and hallucinations), and formal thought disorder
that reflects changes not in the content but rather in the organization of thoughts
and speech. Disorders of the form of thought can be objectively assessed through
a patient’s speech and writing, and they include looseness of association, tangen-
tiality, echolalia, verbigeration, derailment, and incoherence (with word salad

4 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


being at its extreme point), as well as mutism. The thought process, on the oth-
er hand, can be inferred from a patient’s behavior as well as speech or writing,
and includes thought blocking and control, thought broadcasting, poverty of
thought content, changes in abstract thinking, idiosyncratic associations, and
perseveration.
Negative symptoms, which include flat affect, anhedonia, amotivation, and
poverty of speech (alogia), usually raise less flags than positive symptoms early
in the course of the disorder and are usually less prominent in other psychotic
disorders than in SCZ. On the other hand, compared to some other symptoms,
negative symptoms are linked to significant reductions in functioning and poor
prognosis. In addition to these two symptom domains, we also identify mood
changes, excitement, and the cognitive dimension. Symptoms in SCZ can be
evaluated using unstructured, semi-structured, or structured interviews, and
there are a number of questionnaires and scales which are used in research and
clinical practice. One of the most widely used scales to assess the severity of
symptoms is the Positive and Negative Syndrome Scale (PANSS), a 30-item scale
in which each item is rated from 1 to 7 based on the severity of a specific phe-
nomenon/symptom.
Changes in cognition in SCZ have been a particular focus of numerous stud-
ies and are now seen as central features of the disorder. Occasionally, cognition
changes are even considered as candidates for trait markers of SCZ. Cognitive
impairments precede the onset of psychosis and are relatively stable from the
first episode of psychosis throughout the course of the disorder; in addition, they
predict the level of social functioning (Häfner et al., 1992; Brewer et al., 2005).
A number of studies of SCZ patients have found changes in attention, work-
ing memory, executive functioning, speed of processing, verbal comprehension,
learning and memory, problem solving, and social cognition (Nuechterlein et
al., 2004), with overall intelligence, executive functioning, and verbal memory
being identified as especially influencing their social functioning (Green, Kern,
Braff, & Mintz, 2000; Leeson, Barnes, Hutton, Ron, & Joyce, 2009). A wide array
of cognitive impairments reflect the disruption of cortico-cerebellar-thalamic
circuits, leading to what was termed “cognitive dysmetria” (Andreasen, Paradi-
so, & Oleary, 1998).
Diagnosing SCZ is done according to accepted classification systems, two
of the most widely currently accepted and used being the 10th revision of the
International Statistical Classification of Diseases and Related Health Problems
(ICD-10) (World Health Organization, 1992) and the 5th edition of the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychi-
atric Association, 2013). In essence, a person can be diagnosed if he/she meets
a specified number of specific criteria with regard to symptoms, their duration,
and reduction in functioning. According to DSM-5, in order for a diagnosis to

The role of the psycholinguistic characteristics of words 5

be made, two symptoms from a list including delusions, hallucinations, disorga-
nized speech (e.g. incoherence), disorganized behavior, and negative symptoms
need to be present for most of the time during a one-month period (at least
one of these two symptoms needs to be delusions, hallucinations, or disorga-
nized speech). In addition to reduction of functioning, signs of the disturbance
must also persist for at least six months (including the above-mentioned one-
month period). ICD-10, on the other hand, places more emphasis on specific
symptoms, previously called first-rank symptoms. In order to be diagnosed with
SCZ according to ICD-10, a person should have for most of the time during a
one-month period one clear symptom from each of the following groups: (I)
thought broadcasting, thought echo, thought insertion; (II) delusions of con-
trol, influence, or passivity; (III) voices commenting on the person’s behavior
or discussing that person among themselves; (IV) persistent delusions that are
culturally inappropriate. The person can also be diagnosed if they have two less
clear symptoms from two different above-mentioned groups, or symptoms from
at least two other groups of symptoms (persistent hallucinations of any modality
followed by delusions without affective content, changes in the train of thought
resulting in incoherence or neologisms, catatonic behavior, negative symptoms,
and significant changes in behavior and social functioning).
It is clear that the differences between these classification systems, whether
we choose to see them as major or discreet, point to the problem of validity of
the diagnosis of schizophrenia, which has implications in research but also clin-
ical practice.

3. First-episode psychosis (FEP)

The past few decades have seen a rise in attempts at clarifying the complexity of
SCZ as a heterogeneous syndrome and at identifying markers of its subtypes and
predictors of different illness courses and outcomes. One of the most important
“helper” concepts on that road is that of clinical staging, acting as a more refined
way of diagnosing disorders across a timeline in hopes of allowing for early in-
tervention at earlier stages of a disorder (Mcgorry et al., 2006). Staging rests on
the idea of progressive reduction in functionality that comes with illness chro-
nicity and assumes that early interventions might prove to be more effective and
less harmful, and might be able to delay chronic phases. In order for staging to
be meaningful, it is important that we achieve a broader knowledge of the eti-
ology and course of a specific disorder, as well as of different risk and protective
factors, markers and predictors, as well as their relationships, all of which seems
to be mostly lacking in the case of schizophrenia and psychosis-spectrum disor-
ders. It is thought that clinical staging might help in mapping various biological,
cognitive, and other markers to a specific illness stage, thus also contributing

6 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


to the validation of illness subtypes and possibly even separate clinical entities
(Mcgorry, Killackey & Yung, 2008).
When trying to formalize the stages of SCZ and define the extremes on the
timeline, on one end of this line we usually position the chronic residual stage,
and on the other the ultra-high-risk states, a concept that proves more difficult
to define and operationalize. Authors have long talked about prepsychotic stages
that precede frank psychosis, and we have already briefly mentioned the concept
of prodromes earlier in this text. Prodromes include non-specific behavioral
symptoms that can progress into subthreshold positive symptoms, sometimes
years before actual symptoms of psychosis appear. Even with a number of initia-
tives trying to establish valid markers for states of clinical high risk for psycho-
sis and predictors of transitioning into psychosis, which would help in defining
certain symptoms as prodromal, we still talk about the prodromal phase as a
retrospective concept, only after the onset of actual psychosis.
It might seem that, compared to prodromes, first-episode psychosis (FEP)
must be something easier to define, as it rests on the appearance of the objecti-
fiable actual psychotic symptoms that we listed earlier in this text. However, the
clinical and research reality tends to deviate from that assumption. We can expect
FEP to be conceptualized in terms of (i) first contact with psychiatric services
and treatment (understandably an unreliable concept, given that symptoms can
be present for years before treatment starts), (ii) duration of use of antipsychot-
ics, and (iii) duration of psychosis (Breitborde, Srihari, & Woods, 2009). In order
to avoid pitfalls, the suggestion has been made that FEP should be re-conceptu-
alized as early-course psychosis or recent-onset psychosis in terms of duration
of psychosis, a definition that offers the promise of best construct validity. Given
that most functional deterioration takes place in the first five years, the five-year
point has often been used to mark the end of FEP or early-course psychosis,
although one has to be mindful of significant individual variation in the course
of the illness.
We are again using the umbrella term of psychosis, which reflects the fact
that FEP can have various trajectories and outcomes, from differentiation into
SCZ, affective psychosis, or other psychotic disorders, to full remission with-
out subsequent episodes. ICD-10 recognizes variations in the clinical presenta-
tion of acute psychotic disorder (F23), describing them as polymorphic without
SCZ symptoms (F23.0), polymorphic with SCZ symptoms (F23.1), schizophre-
nia-like (F23.2), predominantly delusional (F23.3), other specified (F23.8), or
unspecified brief (reactive) (F23.9). There is little predictive value in these diag-
noses, and so the diagnosis of schizophrenia-like acute FEP does not necessarily
mean the person diagnosed with it will progress to actual SCZ. The variation
of presentations, along with the fact that FEP can progress in the direction of
affective psychosis, also means that patients in an acute psychotic episode can be

The role of the psycholinguistic characteristics of words 7

treated with a number of other medication classes in addition to antipsychotics
(e.g. antidepressants, mood stabilizers). It is reported that from around 16% (up
to about one third) of those with FEP will not have another episode and might
show good long-term recovery. Around one third (up to 43%) will have repeated
episodes after FEP and an unremitted course of illness with increased impair-
ment, while the rest will have multiple episodes over their lifetimes with par-
tial or full remissions between episodes and varying patterns (Shepherd, Watt,
Falloon, & Smeeton, 1989; Messias, Chen, & Eaton, 2007). We currently have
no valid instrument to help us identify which FEP patient will fall into which
category, and as mentioned previously, even our diagnoses depend on long-term
observations of the clinical course.
Two points need to be emphasized and follow from what was presented about
FEP. First, because of the progressive and deteriorating nature of “chronic” psy-
chotic disorders (specifically those from the schizophrenia spectrum), it is vital
to promote the early detection of psychosis and implement early interventions,
and one of the ways to do that is to identify usable markers that might be shown
to even precede the onset of manifest psychotic symptoms. Secondly, given the
differences in the symptoms we see and the wide variety of possible outcomes
(in terms of remission and level of functioning, but also clinical presentation
changes), it is important to identify different predictors that might help us tai-
lor interventions and individualize our approach to individuals with FEP. Both
these markers and predictors could prove to be useful tools in our attempts to
finally elucidate processes that underlie heterogeneous disorders like SCZ, their
subtypes, and symptoms.

4. Lexical-semantic deficits in schizophrenia

As language disturbances are thought to be one of the most prominent char-
acteristics of psychosis, and hence schizophrenia, from the beginning of their
defining, they maintain the position of an important diagnostic criterion. Ab-
normalities of language production, such as derailment, tangentiality, poverty of
speech, illogicality or incoherence, are commonly understood in terms of formal
thought disorder (FTD) (Barrera et al., 2005, Kircher et al., 2018). FTD refers
to a clinical description of a range of language production deficits which can be
described as inadequacy of language production and alterations in the thought
process (Kircheret al., 2018). The symptoms of FTD are most often categorized
as being either positive or negative. Positive symptoms involve an increased
amount of produced speech, including the production of neologisms, idiosyn-
cratic associations, etc., while negative symptoms include deficits in speech and
thought production. FTD occurs in a range of neuropsychiatric disorders, but

8 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


chronic positive FTD is held as a diagnostic marker for schizophrenia and an
indicator for high-risk psychosis (Kircher et al., 2018).
FTD is observed through traditional clinical scales and encompasses a variety
of symptoms. Besides the aforementioned division into positive and negative
symptoms, other categorizations include subjective vs. objective and qualitative
vs. quantitative forms of the disorder. As these subdivisions present a hetero-
geneity of symptoms, different manifestations of the syndrome could represent
different aspects of cognitive dysfunctions (Cavelti et al., 2018), and overall FTD
diagnostics could obscure correlations between specific symptoms (Sumner et
al., 2018). Lewandowski et al. (2018) remark that there is cognitive heterogeneity
both within and between diagnostic categories, since patients across diagnoses
share similar cognitive deficits, and patients with shared clinical and diagnostic
features may exhibit different cognitive abnormalities. This heterogeneity pres-
ents problems for the study of cognitive dysfunctions in psychosis and should be
further distinguished, with novel strategies and different approaches. Further-
more, these differences accentuate the importance of studies of first-episode and
early-course psychosis along with longitudinal studies, as they could further en-
lighten the heterogeneity of symptoms accompanied with different cognitive or
language deficits. First-episode and early-onset diagnoses, along with language
and cognitive studies, could, if accompanied by longitudinal studies, distinguish
subgroups of this heterogenic diagnosis which could reveal underlying process-
es in schizophrenia, and psychosis in general, and could become a valuable tool
as a predictor for a particular course of the illness and its phases.
Brown and Kuperberg (2015) list four ways in which language disturbances
are important in schizophrenia: language abnormalities manifest in symptoms
of psychosis itself (particularly in positive FTD and auditory verbal hallucina-
tions); language dysfunction is a core consequence of schizophrenia and is more
strongly compromised in relation to other cognitive abilities; language produc-
tion deficits often extend to perceptual processing of speech, i.e. comprehension;
and language dysfunctions have been linked to functional and social impair-
ments. Cavelti et al. (2018, citing Kircher, 2008; Strik et al., 2008) conclude that
disturbances in the connectivity of the language network may be the underly-
ing neurobiological cause of FTD language deficits. Hence, language deficits in
schizophrenia may be tied exclusively to the semantic memory or may include
other mechanisms of language processing. They may be due to a combination of
deficits, the consequence of either a general deficit or a specific deficit.
The semantic memory is a long-term memory system containing organized
knowledge about words and their meanings, referents, and relations (Tulving,
1972). It is considered to be organized into a network of associated concepts rep-
resented by nodes of interconnected links which indicate semantic relationships
between them (Minzenberg, 2002, Collins and Loftus, 1975). Language process-

The role of the psycholinguistic characteristics of words 9

ing deficits in schizophrenia may be tied exclusively to the semantic memory, but
they also might include search and retrieval processes connected with executive
functions and working memory processes. Although it is yet unclear which do-
mains interact with which processes, both play a significant role in manipulating
semantic memory concepts in language processing, in goal-directed processing,
cognitive inhibition, flexibility, planning, etc. (Orellana and Slachevsky, 2013).
Studies have shown that, in schizophrenia, the semantic memory is pre-
served, meaning that the concepts and their features are not degraded as in cat-
egory-specific deficits, but that access to them is disrupted (Allen et al., 1993,
Elvevåg et al., 2002).
In 1938, Cameron (McKenna & Oh, 2005) described an overinclusion of objects
in categories by schizophrenia patients as compared to healthy controls. Lawrence
et al. (2007) presented similar results, concluding that overinclusion is the result
of an inability to preserve boundaries of categories, which leads to indistinct and
broadened category boundaries. Other studies have reached similar results (Chen
et al., 1994; Brébion et al., 2004; 2010; Kreher et al., 2008), while Elvevåg et al.
(2002) did not find qualitative differences between schizophrenia patients and a
healthy control group, but they did find slower reaction times in the patient group.
On account of hyperpriming results on priming tasks in schizophrenia pa-
tients, Spitzer (1993) concluded that patients have an increased amount of
spreading activation in the semantic memory. In explaining hyperpriming in
schizophrenia patients, Maher (1983) claimed that activating a concept activates
concepts associated with the first activated concept, which in its foundation con-
stitutes the theory of spreading activation. The increased spreading activation
theory was validated with other studies, in addition to priming tests, by analyz-
ing association production in schizophrenia patients’ discourse (Maher et al.,
2005), fluency tests (Johnson and Shean, 1993), categorization tests (Brébion et
al., 2010, Kreher et al., 2008), etc.
Maher (1983) proposed that, along with the increase in spreading activation,
inhibition processes in language processing are decreased in schizophrenia, re-
sulting in the intrusion of activated, and not inhibited, associations (Leeson et
al., 2005). In an ERP priming study, Kreher et al. (2008) also concluded that their
results of heightened activation in a shorter time frame in the semantic memory
of schizophrenia subjects, in comparison to healthy control subjects, could be
the result of increased automatic activation and/or a deficiency of inhibition.
Moritz et al. (2001), in a study on the processing of dominant and inferior mean-
ings of homographs, also conclude that there is a lack of inhibition in schizo-
phrenia patients compared to healthy control subjects.
Leeson et al. (2005) note that inhibition mechanisms play a significant role
in both the increased spreading activation and disorganization theories. While,
according to the spreading activation theory, inhibition seems to decrease in

10 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


schizophrenia, resulting in heightened activation of the semantic memory and
the activation of inappropriate concepts which would have been inhibited, the
disorganized semantic memory theory suggests that inhibition is heightened as
closely related activated concepts are inhibited and activation spreads to more
distantly related concepts. Furthermore, inhibition is not the only executive
function domain which seems to be affected in schizophrenia. Although abnor-
malities in both the semantic memory and the working memory or executive
function have shown to predict clinical language disturbances (Kuperberg 2010),
conclusions on their specific roles in language processing deficits in schizophre-
nia require further, more exhaustive studies.
On account of these theoretical approaches, Kuperberg et al. (2010) conclud-
ed that schizophrenia patients rely on semantic associations in language pro-
cessing, which leads to the disruption of the balance of necessary processes and
the generation of inappropriate meanings on a higher level. With further stud-
ies, Kuperberg et al. (2019) diverged research on schizophrenia language defi-
cits towards controlled and automatic processes and top-down and bottom-up
processing. Because patients with schizophrenia do not show heightened direct
priming results, and on account of neural studies and highly automatic priming
studies with 0 SOA, Kuperberg et al. (2019) concluded that increased automatic
(indirect) priming occurs because of noisier lexical representations, i.e. nodes
that describe the connections between the form and the meaning of words. While
automatic spreading activation theory does not account for why schizophrenia
patients mostly do not show heightened direct priming, Kuperberget al. (2019)
suggest that automatic activity can spread in a bottom-up direct pathway from
a prime word form representation to indirectly related representations, without
them being meditated by a directly related representation, because the lexical
representation encodes mappings between the word form and the semantic fea-
tures (which do not need to be pre-activated) and are connected to indirectly re-
lated representations, hence “noisier lexical representations.” These assumptions
are based on the fact that, under automatic conditions at 0 SOA, it is suspected
that there will not be enough time for pre-activation on the semantic level.
In a meta-analysis of studies concerning thought-disordered subjects, Sumner
et al. (2018) conclude that there are few studies which investigate correlations be-
tween behavioral and functional neuroimaging measures in thought disorder, al-
though there is behavioral evidence for executive dysfunctions in thought disorder.
Even though neuroimaging studies mostly concern the analysis of a general symp-
tom of attention and working memory, some neural correlates of thought disorder
can be interpreted as executive function deficits, such as attentional selection (Pes-
soa, 2009) or cognitive integration (Duff and Brown-Schmidt, 2012). Accordingly,
some cognitive evidence is indicative of combinatory semantic and executive dys-
functions in thought disorder (Leeson et al., 2005), as mentioned above.

The role of the psycholinguistic characteristics of words 11

5. The psycholinguistic characteristics of words in the assessment
of language processing
Any use of language (both in production and in perception), whether in healthy
individuals or in individuals with some form of linguistic difficulty, necessarily
involves access to information about the world that is stored in the form of lex-
ical concepts and categories in the human mind. People shape mental concepts
of categories of objects that enable them to respond appropriately to new objects
they encounter. Concepts, their categorical organization, levels of hierarchical
taxonomy, and ways of storing and retrieving information from lexical memo-
ry are the most commonly investigated psychological and neurolinguistic phe-
nomena, especially in linguistic pathology (Levelt, 1993; Murphy, 2002; Murphy,
2010; Levin & Pinker, 1992). The understanding and description of the mech-
anisms of language processing are primarily associated with semantic memory.
Semantic memory is the term for long-term memory in which conceptual infor-
mation (both semantic and lexical), as well as facts about the world, are present-
ed. It refers to the part of long-term memory that processes ideas and concepts
that do not derive from personal experience (as opposed to episodic memory)
but which includes generally known facts acquired during one’s life. This depos-
itory of signs, i.e. concepts or words and their characteristics, is thus found with-
in the long-term memory, specifically within the semantic part of the declarative
memory. Semantic memory derives from episodic memory inasmuch as new
facts or concepts are learned based on experiences, while episodic memory is
considered to intensify semantic memory. Semantic memory can also be defined
as “a mental thesaurus, organized knowledge a person possesses about words
and other verbal symbols, their meaning and referents, about relations among
them, and about rules, formulas, and algorithms for the manipulation of these
symbols, concepts, and relations” (Tulving, 1972, p. 386).
In order to understand the process of retrieving information from semantic
memory in the language processing of persons with psychosis, ultra-high risk of
psychosis (UHR), or schizophrenia, verbal fluency is used as a clinical test and
as a basic tool. Verbal fluency can be semantic (the meaning relations of words
within a category) and phonological (the connection between a word and its
initial phoneme). Semantic verbal fluency is identified as a possible predictor of
psychosis, neurocognitive deviations, and abnormalities and irregularities prev-
alent both in first-episode psychosis and in UHR patients. On the one hand, dif-
ficulties in semantic fluency may indicate problems in the very organization and
storage of semantic information in the mental lexicon (category organization,
levels of hierarchical taxonomy), but they may also indicate problems with the
retrieval of information from lexical memory. Studies of UHR patients indicate
impairment in selection, i.e. problems with selecting among alternatives during

12 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


language processing, but not problems with retrieval from semantic memory.
UHR patients have a lower mean value of total semantic fluency than help seek-
er controls. In young UHR patients, this effect is significant for each individual
semantic category (e.g. animals, fruit), but not for phonological fluency. In pa-
tients with schizophrenia, semantic verbal fluency is also more impaired than
phonological fluency. Difficult (poor) verbal fluency in schizophrenia may be an
expression two separate problems in semantic processing – either the semantic
memory has been damaged, or there is inefficient access to the semantic memo-
ry, which is actually normal.
The results of research on people at high risk of psychosis and non-psychotic
help-seeking young adults, which confirmed significant differences on seman-
tic fluency tests, suggest that semantic deficiencies occur during the prodromal
phase and precede clinical expression, i.e. the full onset of psychosis. The very
fact that verbal fluency (semantic categories) is impaired in patients at high risk
for psychosis can be used to improve the predictability of the illness’s develop-
ment in high-risk patients, or in the possible transition to psychosis.
Therefore, some cognitive impairment in schizophrenia can be detected be-
fore the onset of the illness itself and thus can help identify people with high risk
for psychosis. Recently great efforts have been invested in the development of
fine-grained procedures for evaluating the measurement of multiple cognitive
processes underlying performance. However, it is still unclear what independent
components are needed to describe in detail the linguistic processing involved
in a task of fluency.
Our goal in this book is to offer some of the possible linguistic elements (lex-
ical characteristics) that could serve to improve the diagnostic value of early
detection and illness monitoring tests in people with high risk for psychosis,
first-episode psychosis, and schizophrenia.
Lexical units may be tightly or loosely connected in the mental lexicon, but
their place in the semantic network is determined by the very fact that they
share some of the same characteristics with other lexical units or their represen-
tations. Numerous linguistic and extralinguistic factors affect the storage and
processing of language facts during spoken use. On the lexical level of language
use, three basic types of parameters are most commonly said to be responsible
for success in the use of words (Desrochers and Thompson, 2009; Desrochers
et al., 2010). The first group consists of intrinsic characteristics of words that
can be determined directly from their surface structure (e.g. the length of the
words expressed in the number of phonemes, phones, letters, or syllables; part of
speech; morphological characteristics, etc.). In the second group are parameters
that depend on the target word’s relationship to the wider corpus, i.e. contextu-
al characteristics (the size of the phonological neighbourhood of the word, the
word’s frequency of use in the text, etc.). The third group of variables that affect

The role of the psycholinguistic characteristics of words 13

the speed and accuracy of retrieving words from the mental lexicon during their
active and passive use is constituted by so-called psycholinguistic characteris-
tics, those which depend on the personal experience of the language user (e.g.,
the concreteness, subjective frequency, familiarity, and imageability of the word,
the user’s upon acquiring the word, etc.) and are calculated on the basis of the
subjective assessment of a speakers of some language. We believe that precisely
the psychological characteristics of the word could be a new element that would
enable us to improve the diagnostic value of early detection and illness moni-
toring tests in people with high risk for psychosis, first-episode psychosis, and
schizophrenia. Furthermore, we will address in particular those lexical charac-
teristics that have been examined in some of the experimental studies presented
in this book as well as characteristics that would be worth including in future
studies.

5.1. Imageability and concreteness

Imageability is a psychological variable that addresses the ease at which a re-
spondent creates a visual or auditory image of a reference that corresponds to
a word; in other words, it is a lexical parameter that indicates how well a word
leads to a mental image or sensory experience (Erdeljac, 2009; Erdeljac et al.,
2014). The value of this characteristic is determined along a scale, so that a high-
er or lower degree of conceivability is attributed to individual concepts, and it is
placed on the semantic level of language processing (Erdeljac et al., 2014). Im-
ageability is commonly used in evaluating the effect of meaning on memory and
word recognition. Imageability is often closely linked to concreteness, even to
the extent that some authors either do not distinguish between these two lexical
measures or they consciously equate them (Tyler and Moss, 1997; Paivio, 2010).
But although for many words these parameters are in high correlation, there
are data on subjective estimates that describe the same word as highly concrete
while having low imageability. There are numerous studies which, taking into
account this fact, prove that imageability is often a better predictor of the process
of language performance than concreteness.
The key differences between the lexical-semantic systems of abstractness and
concreteness consist in the fact that concrete words are adopted through sensory
experience with physical objects, while abstract concepts are adopted through
their use in sentences and in their mutual relations with other concepts within
the language (Noppeney & Price, 2004). With concrete concepts, the represen-
tational form varies depending on the modality in which it is represented (in
visual, auditory, tactile, or gustatory form), while abstract concepts are formed
u propozicijski. In addition, concrete concepts present a direct link with entities
in the physical world and have a fixed frame of meaning, while abstract concepts

14 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


are largely determined linguistic context. In accordance with these assumptions,
concreteness is associated with perceptual characteristics, and abstractness
with verbally learned information. People with deviations in language process-
ing perform linguistic tasks more successfully with words that refer to concrete
concepts than to those which refer to abstract concepts – they retrieve them
more quickly and accurately from lexical memory (the mental lexicon), associ-
ate them more easily with other similar words, more successfully detect different
types of semantic relations among them, and remember their meanings longer.
Both concrete and abstract words are represented in the verbal system, while
only concrete words are semantically coded in the non-verbal system (as they
correspond to easily imageable representations). Precisely because representa-
tions of concrete words are in both systems, such words are easier to retrieve
and are more accessible in the lexical memory (Erdeljac et al., 2014, pp. 41–42).
Thus, abstract and concrete words are encoded differently in our mind: concrete
words have both verbal and visual representations, while abstract words are only
verbal/linguistic. While functionally separate, there is also a certain level of in-
terconnectedness between the two systems, so that the activation of a represen-
tation in one system can activate the appropriate representation in the other.
Concrete/Imageable words are more accessible precisely because the systems are
connected, and both can be activated simultaneously (Tyler et al. 2002:476).

5.2 Subjective frequency, age of acquisition, and familiarity of words

Subjective frequency refers to how often, according to the subjective assessment
of native speakers of a given language, a word is used or heard in daily communi-
cation. The frequency of words can be evaluated in two ways: objectively or sub-
jectively. The objective frequency of a word refers to the sum of the occurrences of
a word in text corpora, while the subjective frequency of a word is the result of the
assessment of native speakers on a Likert scale (Desrochers & Thompson, 2009).
A comparison of objective and subjective frequency norms showed a high
correlation, so both modalities of assessment can be regarded as powerful predic-
tors of ease and speed of responses in different types of language tasks (Fernán-
dez-Fuertes & Thompson, 2010). In research on the processing of written (vi-
sual) and spoken (auditory) words, subjective frequency is a better predictor
than objective frequency (Balota et al., 2001). Furthermore, the influence of lex-
ical frequency on the speed of naming is confirmed, and words that are used or
heard more often are easier to retrieve from lexical memory than low-frequency
words. The frequency effect is undoubtedly situated at the level of phonological
coding because it influences the time it takes to activate and select the target lex-
eme; this effect can be explained by lowering the threshold for the activation of

The role of the psycholinguistic characteristics of words 15

the lexeme, which is low for frequent words and high for low-frequency words
(Jescheniak & Levelt, 1994).
Word frequency and age of acquisition are mutually very intertwined vari-
ables. The age of acquiring a word is defined as the period during which a person
was able to understand a particular word if someone used it, even if he or she did
not know how to use, read, or write that word at that time. It can be assumed that
words adopted at an earlier/younger age tend to be used more often in adult-
hood by that speaker, but also that precisely the high frequency words (those
used daily) are actually acquired earlier. These variables, it has been shown, are
so mutually dependent that it is not easy to separate their effects. Age of acquisi-
tion has long been a neglected variable in lexical processing research, and its in-
fluences have been attributed to the frequency of words, which is easier to prove
experimentally and to objectively observe (Barry et al., 2001).
Studies designed to observe the effects of word frequency and age of acquisi-
tion demonstrated the justification of the separation of these two characteristics
of words, as it was confirmed that these two factors have different effects on the
latency of response in different visual word processing tasks. It has been con-
firmed, for example, that age of acquisition affects naming latency, while word
frequency is not confirmed in such types of tasks (Cortese & Schock, 2012; Wil-
son, Cuetos, Davies, & Burani, 2013).
Therefore, the subjective word frequency, as well as age of acquisition, are im-
portant variables that influence the processing of words. The greater frequency
of a word and earlier acquisition of the word enable the speaker to retrieve and
produce them more quickly. The processing of high-frequency words in tasks
involving naming, as well as lexical and semantic decision-making, is faster than
the processing of low-frequency words. It has been shown that frequency also
plays a role in memorizing tasks such that low-frequency words are more dif-
ficult to invoke subsequently, but also that they lead to better results in tasks
involving subsequent recognition. Subjective word frequency is a variable that
correlates highly with many other characteristics – except with age of acquisi-
tion, it is also linked to word length, similarity to other words, etc.
The characteristics of word frequency and age of acquisition are also closely
linked to knowledge of the word (the characteristic of familiarity). Familiari-
ty refers to how often some object or concept is present in the experience of a
speaker of a language. The familiarity of a word, or rather, of a concept, has been
shown to have a significant impact on the speed of naming in healthy individu-
als as well as in those with some form of linguistic difficulty (aphasic patients).
Images representing familiar objects retrieve the appropriate words from lexical
memory more quickly than those representing unusual objects (Cuetos et al.,
1999). Although this effect has not been found consistently in all studies inves-
tigating the determinants of image naming, in the literature, naming latency is

16 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


considered an important possible linguistic processing predictor in pathology
and should therefore be taken into account when this type of research is con-
ducted (Alario et al., 2004; Barry et al., 1997).
It is assumed that familiarity affects the ease and speed of identifying objects
and that this variable has an effect at the level of the link between visual recog-
nition and the conceptual level (Cuetos et al., 1999). The effect of familiarity
has been discovered at different levels of semantic processing in patients suffer-
ing from the semantic variant of primary progressive aphasia (Hirsh & Funnell,
1995). The assumption is that the structural visual representations of very famil-
iar objects activate their corresponding semantic representations than is the case
with representations of objects that are not well known (Boukadi et al., 2016).

5.3. Associative norms

Associations are considered a reflection of semantic memorization because they
provide insight into the internal structure of concepts in language processing.
Within the framework of psychology and linguistics, studies of associations
were introduced as part of research on memory and language processing in
connection with various pathologies. Associations reflect the way in which hu-
man knowledge is structured, the semantic representations of words, and the
relationships among them (de Groot, 1989). Free-association tests (the listing
of associations with a stimulus without further limitation, except limiting the
quantity of data) are a means by which it is possible to construct maps of lexi-
cal knowledge of people who share linguistic and cultural background because
similar experiences create associative structures that include representations of
words and their connections, which are equated (Steyvers & Tenenbaum 2005).
Associations can be based either on the meaning or the form of the word,
but also on simultaneous similarity on both of these levels of representation (se-
mantic and phonological-acoustic). The characteristics of associative links can
be twofold, i.e. they can be unlimited in number and an unspecified in order,
so that a specific linguistic sign, word, or concept can activate an undetermined
number of associations in any order. On the one hand, one can talk about so-
called clang associations, which include an associative link between words on
an acoustic-phonological basis (rhyme, number of syllables, accents, etc.), and
on the other hand, these may be paradigmatic associations, which link words
of great semantic similarity. Semantic similarity may relate to the closeness or
overlap of certain characteristics, to the occurrence of another word, or inter-
changeability, while syntagmatic associations are those between words that are
often appear together.
In studies on the structure and organization of semantic memory, associations
provide information about the associative structures that reflect representations

The role of the psycholinguistic characteristics of words 17

of words, and the testing of associations has been carried out since the very be-
ginnings of interest in semantic memory (even Tulving concluded that tests of
the association provide wide insight into semantic memory, 1972, p. 402).
Associative norms provide insight into the relative accessibility of (associa-
tively) related words in the semantic memory and enable insight into the strength
of the connections between certain words in the semantic memory. Such norms
are useful in linguistic research: in the construction of a network of semantic
memory, they reveal the structure of freely remembering in learning and in lan-
guage processing; they reveal methods of searching within different semantic
domains; they serve as a standard for comparison in psychological studies of
healthy populations and those with linguistic pathologies; they can be used as a
base for creating language materials or a foundation for manipulation in tasks
with different variables of characteristics.
Memory search is considered an automated process based on the character-
istics of stimuli and is carried out according to the laws of association. There
are many different psycholinguistic models that attempt to describe semantic
processing. In connectivist models, the semantic memory is presented as a net-
work of connections that represent the characteristics of concepts, while con-
cepts are marked at the nodes of those connections, and activation spreads when
the searching towards these links reaches nodes that represent concepts. The
internal organization of the semantic storage is determined by the abstract links
between concepts and does not depend on the modality of the concepts or their
characteristics. Another applicable model for the description of semantic pro-
cessing is the dual code theory (Paivio, 1986), which envisages two repositories
of different modalities (verbal and visual storage) and a different activation that
depends on modality. In this model, information is activated from one or both
of the repositories. With respect to internal semantic organization, the models of
the organization are distinguished by domain-specific categorization, according
to which the concepts, depending on their category, are processed in different
regions partly according to their sensory modalities. Spreading activation theo-
ry, upon which most of the studies presented in this book are based, is unimodal:
it does not presuppose specific repositories for certain modalities and argues
that complex knowledge located in the semantic memory consists of nodes and
connections between nodes, and that the knowledge of one concept consists of a
whole network of nodes connecting the network via connections. In the spread-
ing of activation, or in semantic processing, inhibition plays a special role.

18 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić


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24 Vlasta Erdeljac • Martina Sekulić Sović • Draženka Ostojić • Aleksandar Savić