BMJ  2007;335:1294 (22 December), doi:10.1136/bmj.39419.647118.25

Mixed messages

Street slang and schizophrenia

¹ Institute of Psychiatry, London SE5 8AF

Young people often use language in an unconventional way. This may create communication difficulties for older doctors, particularly in the identification of disorganised speech, say Oliver D Howes and colleagues

We report the case of a 26 year old streetwise young postman who presented with a six month history of reduced occupational and social function, low mood, and lack of motivation. He complained of feeling less sociable and less interested in his friends and of being clumsy and finding it harder to think. He was otherwise fit and healthy, with no physical abnormalities, neurological signs, or objective cognitive impairments. There was no history of a recent stressor that might have precipitated his symptoms. He was referred to a specialist service for patients in the prodromal phase of psychotic illness for further assessment after he had seen his general practitioner and the local community mental health team. The differential diagnosis at this stage was depression, the prodrome of schizophrenia, or no formal clinical disorder.

His premorbid occupational and social function had been good. There was no history of abnormal . social, language, and motor development and he left school with two A levels. After three years of service at the post office he had been promoted to a supervisory role. He had a good relationship with his family and had six or so good friends. There has been a number of previous heterosexual relationships, although none in the past year. Aside from smoking cannabis on two occasions when he was 19, there was no history of illicit substance use.

Detailed and repeated assessment of his mental state found a normal affect, no delusions, hallucinations, or catatonia, and no cognitive dysfunction. His speech, however, was peppered with what seemed (to his middle class and older psychiatrist) to be an unusual use of words, although he said they were street slang (table). It was thus unclear whether he was displaying subtle signs of formal thought disorder (manifest as disorganised speech, including the use of unusual words or phrases, and neologisms) or using a "street" argot. This was a crucial diagnostic distinction as thought disorder is a feature of psychotic illnesses and can indicate a diagnosis of schizophrenia.

View this table: [in this window] [in a new window]   Test your ability to differentiate between street slang and thought disorder (answers below*)

 
We sought to verify his explanations using an online dictionary of slang (urbandictionary.com). To our surprise, many of the words he used were listed and the definitions accorded with those he gave (see table). We further investigated whether his speech showed evidence of thought disorder by examining recordings of his speech as he described a series of ambiguous pictures from the thematic apperception test, a procedure that elicits thought disordered speech. His speech was transcribed and rated with the thought and language index, a standardised scale for assessing thought disorder.¹ Slang used in a linguistically appropriate way is not scored as abnormal on this scale. His score was 5.25, primarily reflecting a mild loosening of associations. For example, he described a picture of a boat on a lake thus: "There’s a boat and a tree. There seems to be a reflection. There are no beds, and I wonder why there are no beds. There’s a breeze going through the branches of the tree."

His score was outside the normal range (mean for normal controls 0.88, SD 1.15) and indicates subtle thought disorder, equivalent to that evident in remitted patients with schizophrenia (mean in remitted patients 3.89, SD 2.56) but lower than that in patients with formal thought disorder (mean 27.4, SD 8.3).²

Over the following year his social and occupational functioning deteriorated further, and he developed frank formal thought disorder as well as grandiose and persecutory delusions to the extent that he met DSM-IV criteria for schizophrenia. His speech was assessed as before, and the thought and language index score had increased to 11.75. This mainly reflected abnormalities on items comprising "positive" thought disorder, particularly the use of neologisms such as "chronocolising" and non-sequiturs.

To our knowledge this is the first case report to describe difficulties in distinguishing "street" argots from formal thought disorder. It is perhaps not surprising that slang can complicate the assessment of disorganised speech as psychotic illnesses usually develop in young adults, whereas the assessing clinician is often from an older generation (and different sociocultural background) less familiar with contemporary urban slang. Online resources offer a means of distinguishing street argot from neologisms or a peculiar use of words, and linguistic rating scales may be a useful adjunct to clinical assessment when thought disorder is subtle. Differentiating thought disorder from slang can be especially difficult in the context of "prodromal" signs of psychosis, when speech abnormalities, if present, are usually subtle.³ Nevertheless, accurate speech assessment is important as subtle thought disorder can, as in this case, predate the subsequent onset of schizophrenia,³ and early detection and treatment of psychosis might be associated with a better long term clinical outcome.⁴

Summary points Street slang can sometimes resemble disorganised speech Disorganised speech is a feature of schizophrenia and subtly disorganised speech might be evident in the prodromal phase of the disorder Assessment of speech using standardised linguistic instruments can help to differentiate subtly disorganised speech from street slang Young patients are increasingly rinsing the slang, which can confuse pixelated clinicians. Online resources cam help them Heinz with the latest "street speak" and avoid looking like an omni (see table for definitions of words in italics).

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Contributors and sources: The authors work at OASIS, a clinical service for people with prodromal symptoms of psychosis in South London and have expertise in the neurocognitive basis of disorganised speech in schizophrenia. The article developed from a clinical case presentation and discussions among the authors about the difficulties in assessing this case and others. ODH is guarantor.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Liddle PF, Ngan ET, Caissie SL, Anderson CM, Bates AT, Quested DJ, et al. Thought and language index: an instrument for assessing thought and language in schizophrenia. Br J Psychiatry 2002;181:326-30.[Abstract/Free Full Text]
2. Kuperberg GR, McGuire PK, David AS. Sensitivity to linguistic anomalies in spoken sentences: a case study approach to understanding thought disorder in schizophrenia. Psychol Med 2000;30:345-57.[CrossRef][Web of Science][Medline]
3. Haroun N, Dunn L, Haroun A, Cadenhead KS. Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research. Schizophr Bull 2006;32:166-78.[Abstract/Free Full Text]
4. Perkins DO, Gu H, Boteva K, Lieberman JA. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 2005;62:1785-804.

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