Diagnostic dilemma, innit bruv

I’ve just been directed to a wonderful 2007 case study from the British Medical Journal that reports how middle aged doctors can mistake street slang for symptoms of schizophrenia.

Detailed and repeated assessment of [the patient’s] 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.

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.

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.

The article also contains a brief test where doctors can test themselves to see if they can distinguish between slang and thought disorder symptoms.

It’s probably worth noting that traditional British and, particularly London slang, could easily seem like thought disorder to the uninitiated as it is heavily based on word play and substitution.

For example, “I was having having a ruby when I caught Susan having a butchers at my missus’ new barnet” probably makes perfect sense to lots of British people, but if you’re not familiar with cockney rhyming slang, it could be mistaken for a language impairment.

I have noted that British sarcasm can cause similar difficulties during discussions with Americans.

Link to ‘Street slang and schizophrenia’ (via @Matthew Broome)

17 thoughts on “Diagnostic dilemma, innit bruv”

  1. Is it just me or do the phrases in the test that are examples of thought disorder sound exactly like management-speak/Americanisms?

    (“There’s been a residual reduction in intimacy”; “Non-lethargic. I don’t feel too lethargic. I don’t feel as if I’ll be reaching a state of lethargicness”; “I spend my time chronocolising”)

  2. The test samples “rated as evidence of thought disorder on the thought and language index” read to me as just a poor (but comprehensible) choice of words, and/or Buffy-speak.
    Terrible (but not shocking) that you can apparently get yourself institutionalised for the “thought disorder” of not having access to a good education or of allowing low-grade fandom to seep into your vocabulary.

  3. Diagnostic Penn and Teller? innit bruv a wonderful case study from the bleedin’ british medical journal that reports ‘a Hey Diddle Diddle aged trick cyclists can mistake field of wheat Matheson for symptoms of schizo. Cor blimey if the patient’s Radio Rental Two and Eight ain’t gone found a normal affect, nah delusions, ‘allucinations. ‘is speech peppered wif wot is (to ‘is Hey Diddle Diddle Bo-le and Glass and older trick cyclists) ter be an unusual use of dickie birds, although ‘e said they were field of wheat. whefer ‘e was displayin’ subtle signs of unusual dickie birds). we ought ter verify ‘is explanations usin’ an online Tom, Dick and Harry. many of the dickie birds ‘e used were listed. it’s prolly worf notin’ that traditional london Matheson, could easily seem loike thought disorder ter the uninitiated as it is ‘eavily based on Dicky Bird play and substitution. innit.

  4. “For example, “I was having having a ruby when I caught Susan having a butchers at my missus’ new barnet” probably makes perfect sense to lots of British people, but if you’re not familiar with cockney rhyming slang, it could be mistaken for a language impairment.”
    … so what DOES it mean?

  5. @Jen

    Cockney rhyming slang works by substituting a rhyming phrase for a term, frequently a two-word phrase. The second (and therefore rhyming word) is then usually dropped, making it totally opaque.

    I was having having a ruby when I caught Susan having a butchers at my missus’ new barnet

    ruby = Ruby Murray = curry
    butchers = butcher’s hook = look
    barnet = Barnet Fair = hair

    More seriously, @Ruth

    To describe these as ‘a poor choice of words’ exhibits the presumption that there is a ‘correct’ form of language, and that that form is as spoken by the educated elite. The point is that this is a perfectly reasonable choice of words for these individuals, for whom (and for whose peer group) it will make perfect sense. To decry these speakers as substandard is simply prejudice. This attitude is, of course, extremely widespread, and causes problems not just within medicine, but within law and other domains where working class or regionally variant language-speakers come into contact with the professions.

    1. You should hear my Catalan coleagues wrestling with their Catalan grammar: all absolutely convinced that the language they, their parents and grandparents use is not “correct”: plus they now need a certificate to change jobs, underline that Franco oppressed them etc etc etc – language is never just language, is it?

  6. Yeah, but this is a priori absurd.

    Word substitutions on their own are not enough to form a basis for a diagnosis of schizophrenia, even if the person uses neologisms (which are not even that common to begin with).

    They need to re-read their ICD-10 or DSM criteria.

  7. I’m a doctor and I find this language issue fascinating. Schizophrenia diagnosis and middle aged doctors appart, I think communication is essencial in a good medical appointment. Understanding exactly what your patient means with those exact words is fundamental for diagnosis. I have had difficulty with language when I moved to work in the countryside of Brazil. People spoke my language, but they used words and expressions I had never heard before, and it took me a while until I started to understand what they really meant. Also, people in different countries refer to the same symptoms with very different terms, so doctors studying in another country will probably face the same problem. I can say I requested many unnecessary exams and did a lot of uber thorough physical examination until I finally started to understand what my patients really meant. And that is an ongoing process. 🙂

  8. My mother was a psychiatric social-worker in a town in Lancashire. She told me of one psychiatrist (from overseas) who was concerned that a patient would often answer “champion” when asked how he was feeling. The doctor assumed this was some form of delusion rather than a (slightly archaic now) dialect term for feeling very well.

  9. I’d say the only thing better would be for cnpeaoims to try to loose money on the backs of real problems but then, there wouldn’t be any cnpeaoims, only problems.

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