Descriptive Psychopathology: The Signs and Symptoms of ...

239 Chapter 9: Disturbances in speech and language“Well, I tried to progress. A progress can vary. Your progress is different from mine. I’m notprogressed, but I tried it.”Kleist’s separation of thinking problems from speech and language problemshas been adopted by many others. 38 Structural and functional brain imagingstudies also find abnormalities in traditionally recognized language-related brainstructures in patients with FTD defined from this perspective. 39FTD as a form of aphasiaThe lack of a clear association between the language and cognitive problemsof psychotic patients is an important distinction, and is analogous to what isobserved in patients with aphasia. Aphasic patients have speech and languageproblems, but these difficulties result from disruption in the neurologic systemssubserving language. Thinking difficulties also occur in aphasic patients andcontribute to their overall decline in function and to some of their languagedeficits, but do not cause the bulk of their language problems. 40 The speechabnormalities of patients with schizophrenia are, however, associated with loss ofemotional expression and avolition (i.e. negative symptoms), but not with thepresence of hallucinations or delusions (i.e. positive symptoms). 41 FTD is alsoassociated with impaired executive function. 42 The combination of emotionalblunting, avolition, and impaired executive functioning as associated findings inpatients with FTD is consistent with the prevailing view that schizophrenia is acondition that involves frontal circuitry problems. These problems are bilateraland are also consistent with the neuropsychological findings in patients withschizophrenia. 43 The relationship between FTD and frontal circuitry also suggestsa neurologic model for understanding FTD.Although the speech of schizophrenic patients contains many elements ofaphasic speech, it can be distinguished from the speech of aphasic patients withcortical lesions. 44 The speech of schizophrenic patients with FTD, however, issimilar to that of patients with left-sided basal ganglia or thalamic strokes, andsubcortical aphasia is a model for the “formal thought disorder” of psychiatricpatients (Tables 9.3 and 9.4). 45 Similar to patients with FTD, patients withsubcortical aphasia have associated apathy and avolition, indifference to theirsituation, personality change, attentional deficits, poor word generation, andexecutive function impairment, particularly with working memory, planningand self-monitoring. 46The construct of FTD as a form of subcortical aphasia is consistent with presentunderstanding of the neurology of speech. Schizophrenics and psychotic patientswith brain dysfunction from illicit drug use exhibit FTD, often associated withmotor dysregulation and cerebellar motor signs. Patients with manic-depressive