RESUMEN
The present study is the first to investigate, using conversation analysis, the effects of a family member's participation in conversation regarding the assessment of need for treatment. We aim at describing the course of a treatment negotiation, focusing on interactional dynamics and on disclosure of paranoid symptoms in a clinically challenging situation characterized by an acutely psychotic patient with (1) disorganized discourse, (2) poor insight, (3) aspiration to avoid hospital treatment, and (4) a relative who was supporting in-patient care. In the triadic conversation, in which the patient, his relative, and the psychiatrist participated, different consecutive phases were distinguished. The Relative Prominent Information Phase (RIP) was characterized by the relative's statements on the patient's problematic behavior, and conflicting views between the patient and his relative led to denial of symptoms by the patient. When the patient was prominent in the latter Patient Prominent Information Phase (PIP), the display of several different social actions and corresponding linguistic devices were linked with more overt talk about paranoid experiences by the patient, albeit in a disorganized manner. RIP and PIP were followed by an Evaluation and Decision Phase (EDP).
Asunto(s)
Actitud Frente a la Salud , Familia/psicología , Trastornos Paranoides/psicología , Revelación de la Verdad , Comunicación , Emociones , Femenino , Humanos , Control Interno-Externo , MasculinoRESUMEN
BACKGROUND: Disorganized speech, manifested as derailment, tangentiality, incoherence and loss of goal, occurs commonly in schizophrenia. Studies of language processing have demonstrated that semantic activation in schizophrenia is often disordered and, moreover, the ability to use contextual cues is impaired. AIMS: To reconstruct the origins and most plausible intended meanings of disorganized discourse sequences in a clinical interview with a patient with thought-disordered schizophrenia. METHODS & PROCEDURES: We assessed the so-called pragmatic felicity of every turn using a novel tool called the Overall Comprehensibility of Turn (OCT) Scale. In addition to felicity analysis, all topics and referents of turns were registered. Three most disorganized discourse sequences from the transcribed interview were chosen for the thematic and semantic analysis, in which we attempted to reconstruct the structure and meaning of those sequences utilizing (1) the notion of discourse model extending up to contextual background knowledge, (2) the (re)occurrence of topical items, together with (3) the knowledge from findings of disordered semantic activation in schizophrenia. OUTCOMES & RESULTS: The linguistic analyses showed that the disrupted sequences were characterized by (1) unexpected, seemingly irrelevant topic intrusion, (2) pragmatically inappropriate chain of topic extensions, and (3) fuzzy reference together with disturbed ordering of propositions. The underlying causes seemed to be, respectively, (1) long-term semantic activation of topics, which popped out sporadically along the conversation, (2) overreliance on lexical-semantic associations, and (3) the inability to sequence the utterances and link them together using explicit or implicit bridging assumptions necessary to a coherent and cohesive message. All scrutinized passages violated the expectations of the addressee in on-line conversation. However, the post-hoc analysis showed that they contained items which were relevant to the global topic. CONCLUSIONS & IMPLICATIONS: Latent sources, motivations and even meanings, at least to some extent, of seemingly disorganized utterances can become analysable through linguistic analyses. The results suggest that continuity in the treatment is essential, because a practitioner who shares background knowledge with the patient has better opportunities to capture the relevance of the superficially disorganized utterances. Moreover, especially the most disorganized sequences should warrant thorough attention because they can convey, beneath their unexpected or obscure surface structure, items which are psychologically important to the patient. The results of this study should be taken into account in the training of interactional skills of professionals who work with schizophrenia patients.