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Neuroscience and Biobehavioral Reviews 30 (2006) 11821205

Review
Neurocognitive mechanisms of gurative language
processingEvidence from clinical dysfunctions
Patrizia Thoma

, Irene Daum
Ruhr-University of Bochum, Institute of Cognitive Neuroscience, Department for Neuropsychology, Universita tsstraXe 150, Bochum 44780, Germany
Received 22 May 2006; received in revised form 25 August 2006; accepted 3 September 2006
Abstract
The interpretation of proverbs has a long tradition in the assessment of abstract thinking, particularly in schizophrenia. Although the
usefulness of proverb interpretation as a diagnostic tool has been questioned over the years, the comprehension of non-literal language
nevertheless plays an important role in social interactions. Thus, researchers remain interested in the neurocognitive mechanisms
mediating comprehension and use of gurative language.
The present paper summarizes and evaluates the evidence from behavioral, lesion and imaging studies including data for compromised
gurative language processing derived from clinical populations. One main focus is on studies of gurative language comprehension in
schizophrenia. Several theoretical explanations proposed to account for the difculties schizophrenia patients experience when
confronted with gurative language will be addressed. An integration of the evidence from different areas of research is attempted and
directions for future investigation are outlined.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Figurative language; Proverbs; Idioms; Schizophrenia; Right hemisphere
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183
1.1. Aims and scope of the article . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183
1.2. Denitions of relevant terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183
1.3. Main ideas about the mechanisms of gurative language comprehension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1184
1.4. The ontogeny of gurative language comprehension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
2. Neurocognitive mechanisms underlying the comprehension of gurative language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186
2.1. Lesion studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186
2.2. Neurophysiological studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1187
2.3. Semantic priming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1189
2.4. Metaphor processing in neurodevelopmental and neurodegenerative non-psychiatric disorders. . . . . . . . . . . . . . . . 1190
2.4.1. Agenesis of the corpus callosum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1190
2.4.2. Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1191
2.4.3. Neurodegenerative diseases involving subcortical structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1192
2.4.4. Alzheimers disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
2.5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
3. Figurative language processing in schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
3.1. Standardized assessment of proverb comprehension in schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1194
ARTICLE IN PRESS
www.elsevier.com/locate/neubiorev
0149-7634/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.neubiorev.2006.09.001

Corresponding author. Tel.: +49234 32 24631; fax: +49234 32 14622.


E-mail address: Patrizia.Thoma@ruhr-uni-bochum.de (P. Thoma).
3.2. Empirical evidence of impaired gurative language comprehension in schizophrenia . . . . . . . . . . . . . . . . . . . . . . . 1194
3.2.1. Figurative language impairment in schizophrenia: traditional views. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1194
3.2.2. Is the impairment of gurative language comprehension specic for schizophrenia? . . . . . . . . . . . . . . . . . . 1196
3.2.3. The processing of context information and the comprehension of non-literal language in schizophrenia . . . . 1197
3.2.4. The relationship between ToM abilities and gurative language processing in schizophrenia . . . . . . . . . . . . 1197
3.2.5. The role of psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1198
3.2.6. Impaired gurative language comprehension in schizophrenia: a state or a trait marker?. . . . . . . . . . . . . . . 1198
3.3. Conclusions and implications for further research in schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1199
4. General summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1200
1. Introduction
1.1. Aims and scope of the article
Non-literal expressions form an integral part of everyday
language, conveying features of the conventional wisdom,
social norms and rules characterizing a given society
(Gibbs and Beitel, 1995). A great deal of our everyday
communication is gurative rather than literal with gures
of speech occurring at an estimated rate of about 6 per
minute of speech (Pollio et al., 1977). Most people nd
non-literal language easy to understand presumably
because most of their thinking is conceptualized through
metaphor, proverbs, irony and other instances of non-
literal language (Lakoff and Johnson, 2004).
The ability to effectively use gurative communication
may promote personal and professional success. In healthy
adolescents, for instance, idiom comprehension has been
positively associated with academic achievement (Nippold
and Martin, 1989). On the other hand, the inability to
efciently cope with this form of communication may
substantially contribute to the poor social competence of
individuals suffering from disorders like schizophrenia
(Mitchell and Crow, 2005; Vallance and Wintre, 1997).
Acknowledging the relevance of non-literal language for
social interaction, an increasing amount of research has
addressed the neurocognitive mechanisms mediating the
processing of non-literal language. The present review
primarily aims to summarize and critically evaluate the
evidence derived from a range of cognitive neuroscience
methods. In the rst section, relevant terms and denitions
will be introduced, a brief outline of the available theories
about the cognitive and linguistic mechanisms underlying
gurative language comprehension will be given and the
development of non-literal language comprehension across
the lifespan will be briey described. In the second section,
evidence of impaired gurative language processing in
neurodevelopmental and neurodegenerative disorders will
be reviewed. The third section addresses impaired gura-
tive language comprehension in schizophrenia, the disorder
in which this topic has been comprehensively investigated.
A summary of the most relevant ndings and suggestions
for future investigations will be outlined in the concluding
section.
1.2. Denitions of relevant terms
It has proved surprisingly difcult to elaborate the
distinction between literal and non-literal language
(Glucksberg, 2001). Two major criteria have been estab-
lished. First, literal statements are supposed to express a
truth (e.g. Tim is in Canada.) while non-literal language
usually expresses a falsehood (e.g. Tim is on cloud nine),
although this distinction has not remained without contra-
diction (Gibbs and Beitel, 1995). Second, literal language
conrms to linguistic constraints while non-literal language
tends to violate them. For instance, in the sentence This
car is very thirsty. the linguistic constraint regarding the
use of the adjective thirsty is violated, because only
creatures can be thirsty (Fass, 1999).
Although the terms non-literal and gurative
language are sometimes used synonymously, the term
gurative language originally applies only to expressions
containing gures of speech or metaphors, which are
not necessarily involved in all non-literal statements (e.g.
Where theres a will theres a way) (Gibbs and Beitel,
1995). A metaphor can be constituted by a single word, a
phrase, a sentence or a whole text and makes an explicit
(My love is like a fever.) or implict (My life is a roller-
coaster ride) comparison between ideas from different
knowledge domains which are usually not associated
with one another (Gibbs, 1999; Glucksberg, 2003). To
put it more strongly, metaphors not only compare certain
unrelated categories with one another but also make
class inclusion assertions by attributing salient properties
of one category to another (Glucksberg and Keysar,
1990). Most neuroscience research focuses on gurative
language rather than on non-gurative, non-literal lan-
guage because it occurs more frequently in everyday
interactions and because its comprehension is supposed
to place higher demands on cognitive abilities (Lakoff and
Johnson, 2004).
This review will also focus predominantly on the
comprehension of metaphors in general and particularly
in association with proverbial and idiomatic expressions.
Research dealing with irony will be taken into account to a
lesser extent, because additional cognitive factors, like the
adequate perception of affective prosody, play a greater
role in the interpretation of irony (Wang et al., 2006).
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Sarcasm, humor and indirect requests will be not or only
marginally addressed.
Proverbs and idioms are among the most common
instances of everyday non-literal communications (Gibbs
and Beitel, 1995). Both do not represent a unitary class of
expressions. Proverbs may be broadly dened as familiar,
xed, sentential expressions that communicate well-known
truths, social norms, or moral concerns (Gibbs and Beitel,
1995). They are often characterized by certain lyrical
elements (e.g. rhyme, meter, alliteration, personication)
and specic syntactic structures (e.g. where theres X,
theres X or no X without X). The more of these typical
markers a proverb contains, the easier it is accepted as
such. For a comprehensive analysis of proverbs and their
characteristics see the article by Gibbs and Beitel (1995).
Due to the very heterogeneous nature of proverbial
statements and a lack of appropriate classication dimen-
sions, neurocognitive studies have mostly treated proverbs
as a unitary concept, at best distinguishing between
familiar and unfamiliar proverbs.
In the investigation of idiom comprehension, distinctions
between different classes of idioms have been taken into
account more often. Idioms are phrases whose gurative
meaning is not simply constituted by the literal meanings of
their individual words (Cacciari and Tabossi, 1988;
Cacciari and Glucksberg, 1991). For instance, the con-
stituents of the idiom Its raining cats and dogs! evoke
the association of a heavy rain shower only within this
special contextual conguration, while the words cats,
dogs and raining presented in isolation do not. Idioms
vary with respect to their literal plausibility, composition-
ality and transparency/opacity (Glucksberg, 2001). Am-
biguous idioms may be plausible both in a gurative and
in a literal sense, (e.g. to kick the bucket) while literally
implausible idioms (to be on cloud nine) make only sense
when interpreted guratively. Compositionality relates to
the extent to which the meanings of the words constituting
the idiom provide clues for its gurative meaning. While
the words forming the idiom to talk a mile a minute
easily connote speech rate, kick the bucket represents an
instance of a non-decomposable idiom (Gibbs et al., 1989).
The terms transparency/opacity are often used synony-
mously with compositionality: With transparent idioms, in
contrast to opaque idioms, speakers may easily recover the
motivation for the gures of speech used. These dimen-
sions, along with contextual bias, affect the ease of idiom
acquisition and comprehension: While decomposable
idioms are acquired in a rather context-independent way,
non-decomposable idioms rely more on contextual infor-
mation (Gibbs and Nayak, 1989).
In using irony, the speaker usually wants to convey the
opposite of what he says. The true speaker intention can be
often only identied with the help of specic context
information and often there is nothing inherently gurative
about the statement per se except that it is falsied by
context information (e.g. What lovely weather we have
when it is raining) (Gibbs, 1994).
As will be outlined in subsequent sections, partially
distinct neurocognitive mechanisms seem to mediate the
understanding of metaphors, idioms, proverbs and irony.
1.3. Main ideas about the mechanisms of gurative language
comprehension
A detailed account of theories dealing with gurative
language comprehension is far beyond the scope of this
article and only some of the main ideas will be introduced.
Interesting reviews have been for instance provided by Fass
(1999), Glucksberg (2001) and Lakoff and Johnson (2004).
Theories about the relative contributions of the two
hemispheres and those trying to explain gurative language
impairments of clinical populations will be addressed in the
corresponding sections in the text.
Specic theories have been put forward to explain the
processing of each subtype of gurative expressions.
However, most of these theories address the same hotly
debated issue applying to gurative language comprehen-
sion in general and relating to the question of the order in
which the literal and gurative meanings of a gurative
expression are accessed and whether both are always
accessed at all. Traditional views give priority to the literal
meaning suggesting that the search for a gurative meaning
begins only after the literal meaning has been rejected, e.g.
on the basis of context information (hierarchical hypoth-
esis) (Clark and Lucy, 1975). An example of this view is the
Idiom List Hypothesis (Bobrow and Bell, 1973) accord-
ing to which the meanings of idioms are stored in a kind of
list from which they are retrieved whenever the literal
meaning is judged to be inappropriate. The parallel
hypothesis states that both kinds of meanings are processed
at the same time (Glucksberg et al., 1982), illustrated e.g.
by the Lexical Representation Hypothesis (Swinney and
Cutler, 1979) according to which idioms are represented as
long complex words. The retrieval of their meaning is
supposed to take place at the same time as the lexical
processing of the expression. Similarly, according to the
Conguration Hypothesis (Cacciari and Tabossi, 1988),
the idiomatic meaning is activated as soon as active
analysis of the word conguration has prompted the
recognition of the idiomatic nature. By contrast, Gibbs
and Beitel (1995) propose that the literal meaning is
bypassed altogether and that the gurative meaning is
accessed immediately. They state that e.g. understanding
proverbs basically involves mapping of information from
familiar source concepts onto vaguer target domains/
concepts (Conceptual Metaphor Hypothesis). All these
hypotheses tacitly assume an intact lexico-semantic system
as basis for gurative language comprehension.
What is relevant for the direction of this review is the
question which other higher-order cognitive mechanisms
might be important for gurative language processing. The
concept of pragmatics, which is the study of how people
use and interpret linguistic utterances in conversations,
provides one answer. Grice (1957; 1975; 1978; 1989)
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proposed that human communication is always based on
the expression and mutual understanding of the inter-
locutors intentions and introduced the Cooperative
Principle. It states that speakers usually make their
conversational contribution such as is required, at the
stage at which it occurs, by the accepted purpose or
direction of the talk exchange (Grice, 1989, p. 26) in
which they are engaged. The Cooperative Principle
encompasses a number of maxims such as Avoid
obscurity, Do not say that for which you lack adequate
evidence, Make your contribution as informative as is
required and Be relevant. Grice (1975) assumed that
what is communicated or implied may deviate considerably
from what is literally said (conversational implicature)
which obviously particularly applies to metaphoric, idio-
matic, proverbial speech and other instances of non-literal
language. Sperber and Wilson (1995) developed Grices
ideas (1957; 1975; 1978; 1989) further introducing Re-
levance Theory. According to the Communicative
Principle of Relevance, a speaker communicates only
what he thinks will be worth to claim his interlocutors
attention. Sperber and Wilson (2002) emphasize that for
successful communication, people have to be able to go
beyond the sentence meaning and to infer what kind of
meaning their interlocutors intend to convey. The general
ability to form an adequate concept of other peoples
mental states (thoughts, feelings, wishes, beliefs and
intentions) in order to be able to understand their actions
has been called having a Theory of Mind (ToM)
(Premack and Woodruff, 1978), mentalizing (Frith et al.,
1991; Langdon and Coltheart, 1999) or mind-reading
(Baron-Cohen, 1995). The term ToM will be used in
this article. First-order ToM tasks assess the ability to infer
another persons thoughts or beliefs about the state of the
world. Second-order ToM tasks require the subject to infer
one persons thoughts (beliefs) about another persons
thoughts about the state of the world. First-order ToM
competence emerges around ages 34 while second-order
ToM competence does not develop until the age of 67
years (Baron-Cohen, 1995), depending on the social
environment (Carpendale and Lewis, 2004). However, as
the underlying neuronal correlates of ToM, mainly the
prefrontal cortex (PFC) and temporal lobe structures, are
not fully maturated until adolescence, ToM also undergoes
further development (see Singer, 2006). As outlined below,
there is considerable evidence conrming Sperbers and
Wilsons proposal that ToMor to be more specic: a
specialized submodule of ToMis critically involved in
inferring gurative meanings. The authors also proposed
that comprehending different types of gurative language
depends on distinct ToM processes. Understanding meta-
phors, basically a descriptive use of language, is supposed
to involve inferring how another person sees the world, i.e.
rst-order ToM. By contrast, comprehension of irony,
which represents an interpretative use of language, requires
the recognition that the interlocutor distances himself from
the way a third person sees the world (i.e. by saying Yeah,
what lovely weather for a picnic! after another person has
suggested a picnic although it is raining), which involves
second-order ToM (Sperber and Wilson, 2002). Some
authors argue (e.g. Brune and Bodenstein, 2005) that
although the majority of proverbs are metaphorical, they
also rather form an instance of interpretative language, as
most implicitly convey social norms, rules and behavioral
instructions.
Besides ToM, executive control function (ECF) might be
relevant for gurative language comprehension. Distinct
fronto-subcortical circuits seem to support ECF (Heyder et
al., 2004), which is thought to orchestrate and coordinate a
set of complex cognitive abilities, like inhibition, multi-
tasking, context processing, response selection and plan-
ning, in order to ensure exible and adaptive goal-directed
behavior (see Royall et al., 2002). Similarly to ToM,
executive abilities are not fully maturated until adolescence
(Paus, 2005). It is evident from this brief description of the
ECF concept that the ability to process multiple meanings
at the same time, to choose the appropriate one taking into
account context information as well to suppress inap-
propriate literal meaningsrelevant for gurative lan-
guage comprehensionmight be related to specic ECF
subcomponents. Corresponding evidence will be consid-
ered throughout the text.
1.4. The ontogeny of gurative language comprehension
Children develop the ability to understand gurative
language gradually during childhood, from the age of 34
years on, and adolescence (Nippold et al., 1988a), usually
making literal interpretation errors at rst (Lodge and
Leach, 1975).
Two of the hypotheses introduced earlier have been
predominantly put forward to explain the development of
gurative language competence: The Conguration Hy-
pothesis (Cacciari and Tabossi, 1988) predicts an earlier
understanding of gurative expressions that are easier to
decompose for active analysis. This has been demonstrated
for concrete relative to abstract proverbs (Nippold and
Haq, 1996) and for transparent relative to opaque idioms
(Nippold and Rudzinski, 1993; Nippold and Taylor, 1995,
2002). But there is also evidence for the view that idiom
meanings are acquired in the form of giant lexical units
(Swinney and Cutler, 1979) similarly to the meaning of
single lexical items: Relative to younger children, older
children and adults depend less on context information for
idiom comprehension and provide appropriate gurative
idiom interpretations even when the context strongly biases
their literal meaning (Ackermann, 1982). This indicates
that they have stored representations of their gurative
meanings, probably due to greater experience with non-
literal language.
According to the Language experience hypothesis
comprehension develops through exposure to non-literal
expressions in everyday discourse or during formal
training. It has even been suggested that people learn the
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meanings of proverbs, idioms and metaphors in a rote
manner (Lodge and Leach, 1975) establishing an associa-
tive link between a non-literal expression and its gurative
meaning. Evidence comes from a number of studies
demonstrating that familiar proverbs or idioms are easier
and earlier comprehended than unfamiliar gurative
expressions (Cunningham et al., 1987; Nippold and Haq,
1996; Nippold and Rudzinski, 1993; Nippold and Taylor,
2002; Penn et al., 1988).
The development of the ability to appraise the meaning
of non-literal statements appears to be associated with the
maturation of a number of related cognitive abilities. For
instance, the development of mental images evoked by
gurative phrases appears to support their comprehension.
Accordingly, school-age children report less sophisticated,
less comprehensive and more concretistic mental images of
idiom content than adults (Nippold and Duthie, 2003).
Context information (e.g. a background story) has been
found to facilitate the comprehension of the gurative
meaning of both proverbs (Nippold et al., 1988b) and
idioms (Cain et al., 2005; Nippold and Martin, 1989) in
school-age children and in adolescents. In younger children
(3.56.5 years) context does not aid idiom comprehension
(Abkarian et al., 1992) which might be partly due to the
fact that idiom-in-context comprehension seems to depend
on general reading comprehension skills (Levorato et al.,
2004), particularly for more difcult idioms. A study by
Cain et al. (2005) showed that 9-year-old children were able
to benet from context information for the interpretation
of transparent idioms regardless of their reading compre-
hension level. However, poor reading comprehenders were
impaired in their ability to use context for the interpreta-
tion of opaque idioms.
Most importantly, the development of gurative language
comprehension seems to be associated with the ontogeny of
ToM competence. This is e.g. illustrated by the fact that
metaphors are comprehended at an earlier age (ages 34)
than irony (ages 67) (Bara and Bucciarelli, 1998; Happe,
1993; Winner, 1988) which is in accordance with Sperbers
and Wilsons (2002) account of the differential involvement
of rst- and second-order ToM in the comprehension of
metaphor and irony. The developmental trajectories of rst-
and second-order ToM seem to parallel those of metaphor
and irony comprehension.
Only one study investigated proverb comprehension
across the whole lifespan (Nippold et al., 1997): The ability
to freely explain the meaning of proverbs (low-familiar,
within a story context) improved during adolescence and
early adulthood and reached a peak during the 20 s which
remained stable until the 50 s. A slight decline in
performance was observed during the 60 s which became
statistically signicant in the 70 s. Due to the cross-
sectional design of the study, a cohort effect, possibly
involving lower formal education for the older patients,
cannot be excluded. Education has repeatedly been shown
to be positively related to gurative language comprehen-
sion (Penn et al., 1988).
The detrimental impact language disorders can have on
overall life achievement is illustrated by a study investigat-
ing the longitudinal course of developmental language
disorder in a group of affected men from middle childhood
to mid adulthood (Clegg et al., 2005). In mid adulthood,
the language disordered group showed signicant impair-
ments of ToM, verbal short-term memory and phonologi-
cal processing, signicantly worse social adaptation (few
close friendships and love relationships as well as
prolonged unemployment) and a higher incidence of
mental illness relative to their siblings and a group of
typically developing subjects.
2. Neurocognitive mechanisms underlying the
comprehension of gurative language
Different methods have been used in order to gain
insight into the neural mechanisms supporting the proces-
sing of gurative language. The investigation of patients
suffering from selective brain lesions or specic neurologi-
cal and neuropsychiatric disorders, advanced imaging
techniques and behavioral studies involving divided visual
eld research contributed both in combination and
independently to the available knowledge base about the
neural correlates of gurative language comprehension. In
the following paragraphs the main ndings are summar-
ized.
2.1. Lesion studies
Traditionally, while the left hemisphere (LH) has been
viewed as dominant for most aspects of language proces-
sing, the understanding of gurative language has been
thought of as being lateralized to the right hemisphere
(RH) (see Bookheimer, 2002). This notion has been largely
based on a series of studies examining gurative language
processing in patients suffering from unilateral brain
damage (Burgess and Chiarello, 1996; Critchley, 1991;
Gagnon et al., 2003; Giora, 2003; Joanette et al., 1990;
Kemper, 1981; Van Lancker and Kempler, 1987; Weylman
et al., 1989).
One prototypical task involves the matching of orally
presented or written gurative expressions (e.g. His heart
fealt heavy) and their appropriate pictorial illustrations.
Patients with RH damage (RHD) have been reported to
choose the pictures depicting the literal (e.g. a man carrying
a giant heart) instead of the gurative meaning (e.g. picture
of a very sad man) of such expressions more often than
either LH damaged (LHD) patients or healthy individuals
(Hillekamp et al., 1996; MacKenzie et al., 2005; Schmitzer
et al., 1997; Winner and Gardner, 1977). It has been argued
that in sentence-to-picture matching tasks, the depicted
alternative meanings often do not show the same degree of
plausibility (Huber, 1990) and that visuo-spatial abilities,
which are more affected in RHD vs. LHD patients, ought
to be considered as a potential confounding variable. The
RH has been ascribed an important role in visuospatial
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P. Thoma, I. Daum / Neuroscience and Biobehavioral Reviews 30 (2006) 11821205 1186
analysis (Jordan and Hillis, 2005) and in the allocation of
cognitive resources (Monetta et al., 2006). Thus, damage of
this hemisphere might limit the cognitive capacities for the
analysis of alternative gurative meanings rendering
patients more prone to choosing the less demanding
and more obvious (literal) illustration of the gurative
utterance.
A major purely linguistic approach is the word triad
relatedness paradigm. In this task, subjects are presented
with sets of three words: an ambiguous word (e.g. the
adjective cold), its gurative equivalent (unfriendly)
and a foil representing its literal meaning (chilly).
Participants are then asked to group together the two
words that are closest in meaning. The result pattern
mostly resembled the one obtained in sentence-to-picture
matching tasks: RHD patients were more likely to select
the literal foils and less often chose the gurative
interpretations than both LHD patients and healthy
individuals (Brownell et al., 1984, 1990; Brownell, 1998).
The poor performance of RHD patients on gure
interpretation tasks has been related to the suppression
decit hypothesis (Tompkins and Lehman, 1998) accord-
ing to which RHD patients fail to suppress automatically
activated literal interpretations of ambiguous expressions
that eventually turn out to be irrelevant or incompatible
with the available contextual information. This is sup-
ported by impairments of RHD patients on resolving
lexical ambiguity, e.g. choosing between the gurative and
the literal meaning of ambiguous words/expressions, by
suppressing contextually inappropriate interpretations
(Grindrod and Baum, 2005; Klepousniotou and Baum,
2005; Tompkins et al., 2000).
However, not all studies support the notion that
gurative language processing decits are selectively
associated with RHD. LHD patients have been reported
to make more errors when requested to orally explain the
meaning of conventional metaphors (e.g. broken heart,
hard man) with a literally implausible meaning (Giora et
al., 2000). Also, LHD patients have been shown to be
impaired relative to healthy controls on a sentence-to-
picture matching task for idiomatic expressions without a
literal meaning (Papagno et al., 2004) and more frequently
than RHD patients chose the literal interpretation of
ambiguous targets in a word triad relatedness task (Giora,
2003). Performance on the latter task and lesion size were
negatively associated only in LHD patients (Zaidel et al.,
2002). It has been proposed that LHD patients, similarly to
RHD patients, might fail to suppress the literal interpreta-
tion of a gurative expression (Papagno et al., 2004).
Cacciari et al. (2006) used a sentence-to-word matching
task to assess the comprehension of ambiguous familiar
Italian idioms in aphasic LHD patients and healthy
controls. Each idiomatic expression was presented along
with four words and subjects were instructed to choose the
word corresponding to the idiomatic meaning of the
expression. One of the three foils was semantically
associated with the last constituent word of the idiom
string and the two remaining alternatives were unrelated
foils. Patients, especially those with frontal and/or tempor-
al lesions, were signicantly impaired on this task,
particularly showing a higher number of semantically
associate errors. According to the authors, this might
indicate an impairment of inhibition mechanisms and/or of
recognition/activation of the idiomatic meaning. The data,
however, did not allow for a distinction between these
alternatives. In other studies, both LHD and RHD patients
showed impairments (Chobor and Schweiger, 1998; Gag-
non et al., 2003; Tompkins, 1990; Tompkins et al., 1992).
Aphasia has been suggested as a potential factor con-
tributing to the unexpected decits of LHD patients either
by disrupting speech output on oral explanation tasks or
by impairing semantic comprehension as in Wernickes
aphasia (Gagnon et al., 2003). Thus, the type of the task
may have an impact. Papagno and Caporali (2006) found
that LHD patients performed relatively better on a
sentence-to-word matching task than on a sentence-to-
picture and an oral denition task for idioms.
Generally, the interpretation of ndings from brain-
lesioned patients is limited by the frequent co-occurrence of
various medical comorbidites, diverse cognitive impair-
ments and heterogeneous lesion etiologies.
Repetitive transcranial magnetic stimulation (rTMS)
offers the opportunity to temporally and reversibly disrupt
the activity of specic areas in the otherwise intact brain. In
an rTMS study by Oliveri et al. (2004), magnetic
stimulation was applied to frontal and temporal cortex
areas in the RH vs. LH while 15 young healthy subjects
were working on a sentence-to-picture matching task for
opaque idioms and literal expressions. Left temporal rTMS
disrupted both accuracy and response speed for both
idiomatic and literal expressions, whereas no such effect
was obtained after rTMS over the RH. The authors
conclude that the left temporal cortex contributes to the
understanding of both literal and idiomatic expressions.
Taken together, the evidence available from lesion
studies is inconsistent, suggesting that damage to both
hemispheres may affect the comprehension of gurative
language. However, it is unclear in how far differing testing
modalities might have inuenced the performance of RHD
and LHD patients. Also, various additional factors, which
seem not to have been taken into account in most lesion
studies, might have inuenced the result pattern. These
factors will be introduced in the subsequent paragraphs.
2.2. Neurophysiological studies
Functional neuromaging studies, using PET, fMRI or
EEG explicitly aim to identify networks of brain regions
involved in the processing of gurative language.
Bottini et al. (1994) carried out a PET study in which
they assessed brain activity while individuals judged the
plausibility of visually presented sentences with either a
metaphorical or literal meaning. Novel, unconventional
metaphors were used, such as The old man had a head full
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of dead leaves (plausible) in contrast to The old man had
a head full of barn doors (implausible). Judging the
plausibility of literal sentences (e.g. Tim used stones as
paperweights. vs. Tim used feathers as paperweights.)
as compared to deciding whether a non-word was present
in a string of words activated a number of regions in the
LH including the PFC and basal frontal cortex, the middle
and inferior temporal gyri and temporal pole, the parietal
cortex and the precuneus. Judging the plausibility of
metaphorical vs. literal sentences, in addition to activating
these LH regions, also recruited the equivalents of Brocas
and Wernickes in the RH. It has been pointed out that the
involvement of the RH might not be specic to the
processing of gurative language but might occur each time
complex syntactic and/or semantic linguistic structures are
processed (Bottini et al., 1994; Jung-Beeman, 2005; Lee and
Dapretto, 2005; Rapp et al., 2004; Stringaris et al., 2005),
including making references (Beeman, 1993; Mason and
Just, 2004) and structuring complex text information
(Marini et al., 2005). This would t in with Bottinis
(1994) report that her subjects found it more difcult to
judge the plausibility of metaphorical sentences as opposed
to literal sentences. Rapp et al. (2004) used novel
metaphorical and literal sentences strictly parallelized for
syntactic and semantic complexity. Metaphorical expres-
sions elicited the strongest activation in the left inferior
frontal and left temporal gyri. The authors conclude that
while the RH might contribute to the general appreciation
of complex semantic and syntactic structures, left frontal
and temporal areas might engage in the decoding of word
meaning in a metaphoric context.
Subsequent imaging studies conrmed the activation of
fronto-temporal networks during the processing of gura-
tive language. For instance, Lee and Daprato (2005)
presented auditory word triads to subjects who were
instructed to decide whether the last two words had a
similar meaning (either metaphoric or literal). Direct
comparison of the two conditions yielded signicant
activity only in left prefrontal and temporo-parietal areas.
In a study by Stringaris et al. (2005), subjects were
presented with either metaphoric, literal or non-meaningful
sentences. Left inferior frontal gyrus and BA47 were
activated while participants were reading both the meta-
phorical and the meaningless sentences, but not while they
were reading literal sentences. Additionally, activation of
the left thalamus was specically linked to the processing of
metaphorical sentences, which is not surprising, given the
close fronto-subcortical connectivity patterns (Alexander et
al., 1986).
Recent data indicate differential hemispheric activity for
different types of gurative language, such as methaphor
and irony (Eviatar and Just, 2006). Young healthy students
read short stories which ended with either a literal,
metaphoric or ironic statement, followed by simple yes/
no comprehension questions. Conventional and non-ironic
metaphoric expressions were used (e.g. the statement You
are like greased lightning by one story character after she
was left far behind by her friend in a race). The ironic
endings did not contain metaphors and always expressed
the opposite of what the story character really meant (e.g.
Thanks for keeping your promise when in reality the
promise has been broken). Processing of metaphors elicited
signicantly higher activation in the left inferior frontal
gyrus and in bilateral temporal cortex than ironic and
literal utterances. Irony activated the right superior and
middle temporal gyri more than literal statements did,
while metaphoric utterances elicited an intermediate level
of activation in these areas.
In event-related potential (ERP) studies of language
comprehension, a negative component peaking around
400 ms after stimulus onset (Tartter et al., 2002) has been
shown to vary according to the semantic content of the
information processed. The component is elicited by all
meaningful words and the amplitude of the N400 increases
if a word is unexpected in a given context (Kutas and
Hillyard, 1980).
Reading out sentences with a metaphoric ending has
been shown to evoke an increase in the N400 amplitude
relative to a condition which involved the processing of
literal sentence endings (Coulson and Van Petten, 2002).
Pynte et al. (1996) presented evidence supporting a context-
dependent account of metaphor comprehension. They
recorded ERPs while subjects were reading familiar (e.g.
Those ghters are lions) or literal control sentences
(Those animals are lions). The terminal word, which was
always identical under both conditions, elicited a larger
N400 amplitude when it was embedded in metaphoric as
compared to literal sentences, indicating that the literal
meaning of the metaphors was accessed, but obviously
judged to be incongruous in the metaphoric sentence
context. In subsequent experiments, unfamiliar metaphors
were introduced (Those apprentices are lions) and
sentences were preceded by an irrelevant (They are not
idiotic: Those ghters are lions) or a relevant (They are
not cowardly: Those ghters are lions) context or were
presented in isolation. The authors were able to demon-
strate an effect of context which became obvious as early as
300 ms following the onset of the nal word. More
precisely, the understanding of the metaphoric meaning
was facilitated in the relevant context condition which was
reected in a reduction of the N400 amplitude. This
supports the idea that only the metaphorical meaning is
accessed if primed by the context.
Although in the Pynte et al. (1996) study, the manipula-
tion of familiarity vs. unfamiliarity failed to elicit any clear
effects, more recent evidence suggests that familiar and
unfamiliar metaphorical expressions might indeed be
processed differently in the brain. In one study (Tartter et
al., 2002), 80 sentence frames that plausibly ended with
either a literal, a familiar metaphoric or a truly anomalous
(novel and unfamiliar) word were presented to 11 subjects.
A signicant N400 was elicited only for anomalous
endings. This effect has been investigated further by
Laurent et al. (2005). They recorded ERPs from 30 adults
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who performed a lexical decision task to a series of either
strongly or weakly salient (i.e. familiar and predictable)
idioms and to gurative or literal interpretations of these
idioms. The N400 amplitude following the last word of the
weakly salient idioms was larger than for the strongly
salient (familiar) idioms indicating that the terminal word
was less expected in the novel idiom context. Also, the
N400 amplitude in the condition involving targets related
to the salient meaning of a strongly salient idiom was
smaller than in the remaining combinations of salient/non-
salient meanings of strongly/weakly salient idioms and
subjects responded faster to salient interpretations. The
authors interpret their ndings in terms of an automatic
accessibility of salient meanings, independent of their
gurative or literal character. This indicates that salient
meanings are processed directly, based on entries in the
mental lexicon without the necessity to make inferences
based on linguistic or extra-linguistic context information.
Sotillo et al. (2005) carried out a source analysis of the
N400 associated with metaphor processing. In their task,
novel metaphoric expressions (e.g. green lung of the city)
were followed by words that were either metaphorically
(park) related or not related (semaphore) to the
expressions. The analyses yielded a larger N400, originat-
ing from the right but not the left superior/middle temporal
gyrus, for the metaphorically related words relative to the
non-related words.
These ndings are in line with the Graded Salience
Hypothesis of language comprehension, put forward by
Giora (2003). According to this theory, the more salient
meanings of linguistic utterances are processed before less
salient ones. The more conventional, frequent, prototypical
a meaning is, the more salient it is. Non-salient meanings
are supposed to be more dependent on context for their
derivation, processed predominantly in the RH. Evidence
for a differential processing of novel and familiar items in
terms of neuroanatomical localization came from two
fMRI studies by Mashal et al. (2005a, b). Healthy subjects
were presented with 96 word pairs and had to decide
whether the two words forming each pair were unrelated
(road-shift), literally related (water-drops) or meta-
phorically related. In the metaphorical condition, either
conventional metaphors (bright-student) or novel meta-
phors, mostly taken from poetry (pearl-tears) were used.
The data suggest that a specialized network comprising the
right homolog of Wernickes area, right and left premotor
areas, right and left insula and Brocas area, is recruited for
the analysis of novel but not of conventional metaphors.
Some of these brain areas have also been implicated in
verbal creativity (right homolog of Wernickes area: e.g.
Jung-Beeman et al., 2004) and in the retrieval of informa-
tion from long-term episodic memory (right precuneus: e.g.
Grasby et al., 1993; Shallice et al., 1994). These processes
are likely to be involved in inferring the meaning of novel,
unfamiliar connections of words, as found in novel
metaphors. Results consistent with those by Mashal et al.
(2005a, b) have also been reported for the processing of
metaphors in Mandarin Chinese (Ahrens et al., 2005). In
contrast to the processing of familiar metaphors, novel
metaphoric expressions yielded bilateral activation in the
middle frontal gyrus and the precentral gyrus, and RH
activation in the superior frontal gyrus. LH activation was
found in the inferior frontal gyrus and fusiform gyrus.
Taken together, the evidence yielded in imaging studies
suggests that the processing of gurative language con-
sistently activates fronto-temporal networks known to be
involved in language processing per se. As to the question
of lateralization, both hemispheres contribute to the
processing of gurative language, albeit in different ways.
The RH appears to be relatively more involved in
processing complex syntactic and semantic structures and
in accessing the meaning of novel or generally salient
metaphors, while the LH seems to contribute more to the
decoding of word meaning in a metaphoric context.
Some authors did not nd an RH advantage for novel
metaphors (Rapp et al., 2004, 2006). However, their stimuli
had not been previously rated for familiarity, so it cannot
be excluded that at least some might have been familiar to
subjects and were thus best processed by the LH. In the
work by Mashal and colleagues (2005a, b), both hemi-
spheres were involved in processing novel metaphors.
However, they used metaphorical word dyads, while
studies in which the processing of novel metaphors was
more clearly lateralized to the RH (Bottini et al., 1994;
Sotillo et al., 2005) used metaphors in a sentence context.
The latter is probably more ecologically valid and places
greater demands on the capacity of the RH to integrate
distant semantic meanings within a sentence context (Jung-
Beeman, 2005).
2.3. Semantic priming
A fairly large body of literature deals with the issue of
lateralized gurative language processing based on the
semantic priming approach in healthy subjects. For a more
detailed overview, the interested reader is referred to the
reviews by Neely (1991) and Hutchison (2003).
The common procedure entails the selective presentation
of prime-target pairs to the right visual eld/LH or to the
left visual eld/RH. In most cases, a lexical decision task
follows (Chiarello, 1991). Priming effects occur as the
faster recognition of a target word preceded by a
semantically related prime or the slowing of responses to
words following unrelated prime words.
Anaki et al. (1998) presented metaphorical or literal
associates to either visual eld as subjects performed a
lexical decision task (word/non-word judgments). The
priming stimuli consisted of ambiguous words with a
literal and a metaphoric meaning (e.g. the adjective
stinging). Target words were either related to the
metaphoric (stinging-insult) or to the literal (stinging-
mosquito) meaning of the prime or they were unrelated
(stinging-carpet). At shorter stimulus onset asynchronies
(SOA of 200 ms) priming effects were observed for
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metaphorically related targets for both visual elds/hemi-
spheres while literally related targets were primed in the
right visual eld/LH only. At longer stimulus onset
asynchronies (SOA of 800 ms) metaphorically related
targets were primed only in the left visual eld (i.e. the
RH) and literally related targets again only in the right
visual eld/LH. The implications of a slower decay of
gurative meanings in the RH are that this hemisphere
seems to be involved in the more advanced and more
elaborated stages of gurative language processing. Over-
all, the ndings suggest that metaphoric meanings decay
relatively fast in the LH while being maintained for longer
periods of time in the RH. Faust and Weisper (2000)
presented incomplete priming sentences (e.g. Some nights
are y) followed by literally true, false or metaphoric
target words to subjects who were instructed to decide
whether the sentences were literally true or false. In this
study, performance was slower and less accurate for
metaphorical target words than for literally false targets,
irrespective of the hemisphere to which the stimuli were
presented. The two studies differ in the mode of presenta-
tion of gurative material (in isolation vs. in sentence
context) and there is evidence that context may differen-
tially affect processing in the two hemispheres. Data by
Kacinik and Chiarello (2005) suggest that the way the LH
integrates both literal and gurative meanings is more
constrained by the sentence context, while the RH is more
independent of sentence context and also maintains the
activation of alternative interpretations.
The interpretations put forward by Anaki et al. (1998)
and by Kacinik and Chiarello (2005) largely correspond to
the coarse semantic coding hypothesis, rst proposed by
Beeman (1998). According to this account, the RH is
responsible for diffusely activating large semantic elds,
while the LH strongly activates selective semantic elds.
This is assumed to render the LH very efcient at selecting
the most common or contextually appropriate meanings,
particularly for single words, while the RH is more
sensitive to distant semantic overlap, particularly in the
case of multiple word meanings. Support for the coarse
semantic coding hypothesis comes from a number of
divided visual eld experiments in healthy populations
(Coney and Evans, 2000; Faust et al., 2002; Titone, 1998).
Another divided eld study (Schmidt et al., 2005) suggests
that the RH advantage for processing distant semantic
relationships is more a result of familiarity than of
metaphoricity per se. In this study, regardless of whether
the sentences used as stimuli were literal or metaphorical,
the unfamiliar sentences containing distant semantic
relationships (e.g. metaphorical: The close friends were
a bag of toffees. or literal: The interior designer used
cubes as a rain hat.) were preferentially processed in the
RH and familiar sentences involving close semantic
relationships (e.g. metaphorical: The mind is a sponge.
or literal: The childrens shoes were covered in dirt.) in
the LH. Finally, Klepousniotou and Baum (2005) at-
tempted to contrast the predictions of both the coarse
semantic coding and the suppression decit (described
earlier in this article) hypotheses by examining LHD and
RHD patients as well as healthy participants using a
semantic priming paradigm. The data did not provide
strong support for either theory, but the result pattern was
more consistent with the suppression decit hypothesis.
To summarize, the evidence yielded in semantic priming
experiments, similarly to that resulting from lesion and
neurophysiological studies, suggests that the RH seems to
be more engaged in activating distant semantic associa-
tions. Thus, the RH also activates more alternative
interpretations, particularly in the case of unfamiliar
gurative expressions and maintains their activation for
longer time periods.
2.4. Metaphor processing in neurodevelopmental and
neurodegenerative non-psychiatric disorders
Decits in interpreting gurative language have been
reported for a range of neurodevelopmental and neurode-
generative diseases. The evaluation of these ndings is
limited by certain factors. First and foremost, multiple
brain systems are affected in most of these conditions. In
neurodevelopmental disorders, the atypical development of
brain structures may entail some reorganization processes
which inuence the way language is processed. Notwith-
standing these limitations, the analysis of these cases can
provide important information about the neurocognitive
processing of gurative expressions in the intact brain.
2.4.1. Agenesis of the corpus callosum
Given that both hemispheres make specic contributions
to the processing of gurative language, it seems obvious
that interhemispheric information transfer might be a
critical mechanism for understanding non-literal language.
Accordingly, it has been reported that patients with
congenital or acquired agenesis of the corpus callosum
are impaired in providing appropriate verbal interpreta-
tions of proverbs and in recognizing the correct proverb
meaning in multiple choice tests. Comprehension of literal
language, on the other hand, appears to be preserved (Paul
et al., 2003). This might be due to partial information
transfer via subcortical pathways or non-callosal commi-
sures, which might partly compensate for callosal absence
for literal language processing, while it is insufcient for
the more complex integration processes involved in
gurative language comprehension (see Barr and Corballis,
2002). Reorganization processes might also play a role in
this respect (e.g. Sauerwein and Lassonde, 1994).
Figurative language comprehension does not seem to be
generally impaired; decits occur when more elaborate
context processing is required. Consistent with this view,
children and adolescents (age ranges 718 years) with either
complete agenesis or hypoplasia (i.e. partial or mild
agenesis) of the corpus callosum performed relatively well
with regard to the comprehension of decomposable idioms,
which are processed similarly as literal language, but failed
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to understand non-decomposable idioms, which require the
integration of contextual information (Huber-Okrainec et
al., 2005). In this study, familiar idioms varying on the
dimensions of compositionality (in how far the lexical items
of the idiom contribute to its overall gurative meaning)
and literality (how plausible an idiom is) were presented
verbally, either in an isolated sentence (Shelly hit the
sack) or preceded by a context sentence biasing the
gurative meaning of the idiom (Shelly had a long day.
Shelly hit the sack.). Subjects were asked to indicate
whether a picture illustrating either the gurative or the
literal meaning of the idiom, represented the idiom or not.
Children with callosal abnormities were particularly
impaired in terms of both speed and accuracy at accepting
the gurative meaning of non-decomposable idioms and in
rejecting their literal meaning. The impairment was most
pronounced in individuals with complete agenesis.
Adults with complete agenesis of the corpus callosum
have also been reported to perform more poorly than
controls on tests assessing the understanding of humorous
material. However, covarying comprehension of gurative
language abolished the group difference suggesting a
common mechanism probably involving the understanding
of second-order ToM (Brown et al., 2005).
Taken together, evidence suggests that the corpus
callosum mediates the understanding of second-order
meanings, probably via the integretation of relevant
context information. The fact that both children and
adults suffering from agenesis are similarly impaired with
regard to gurative language comprehension implies that
developmental reorganization processes cannot completely
compensate for the impaired interhemispheric connectivity
and its detrimental consequences for gurative language
processing.
2.4.2. Autism
It seems obvious that individuals suffering from general
communication disorders, like those from the autistic
spectrum, might have particular difculties with complex
linguistic demands including the comprehension of gura-
tive language.
Strandburg et al. (1993) observed an ERP correlate of
impaired idiom processing in adults with high-functioning
autism (IQ scores480). Subjects completed an idiom
recognition task involving literal, idiomatic and non-sense
phrases. Autistic subjects were impaired only with regard
to the identication of idiomatic statements and showed a
greatly reduced N400 amplitude to idioms. Dennis and
colleagues (2001) found subjects with a high-functioning
variant of autism to be impaired on the Figurative
Language subtest from the Test of Language Competence
(Wiig and Secord, 1989). In this task, subjects are rst
asked to explain a gurative remark preceded by some
context information, e.g. The situation is two boys talking
at a dog show. One of them said He is crazy about that
pet. What did the boy mean?. Subsequently, 4 written
sentences are presented and the subject has to point out the
one that could be used instead of He is crazy about the
pet. Autistic subjects more often failed to nd the correct
alternative expression. However, only 8 subjects were
examined in this study and within-group variation of
verbal IQ scores and language skills was rather high.
Several authors have attempted to elucidate the mechan-
isms which mediate decient gurative language compre-
hension in autistic spectrum disorders. The most
commonly suggested factors are impairments of ToM
and ECF, particularly context processing deciencies.
In an early study, Happe (1994) found that the ability to
provide adequate mental state attributions for the gura-
tive statements of story characters was comprised in high-
functioning autistic subjects, both relative to mentally
retarded subjects and healthy controls. The autistic
subjects comprehension of gurative utterances was
related to their performance on standard ToM tasks. But
even those subjects who performed well on the ToM tasks
had difculties with interpreting the more complex and
more naturalistic gurative story material. Data by Nor-
bury (2004) suggest that in children with communication
disorders, the question whether context information
improves idiom comprehension might be independent of
the presence of autistic features. Unfamiliar idioms were
presented, rst in isolation and, after a delay of 324 h,
embedded in a short-story context. Both children with
communication disorders and control participants per-
formed signicantly better in the idiom-in-context condi-
tion than in the idiom-only condition. However, clinical
subgroups exhibiting language impairment (with or with-
out autistic features) beneted signicantly less from
context than controls or a group of children showing
autistic features but no language impairment. Idioms-in-
context performance was predicted by age, memory for
story context and language abilities. ToM, despite being
impaired at least in subgroups of autistic children (Abdi
and Sharma, 2004), did not contribute signicantly to
idiom interpretation, once general language abilities were
controlled for. In another study, in which this factor has
not been covaried, ToM abilites proved critical for the
capacity of high-functioning autists to understand non-
literal language (Martin and McDonald, 2004). The
ndings by Norbury (2004) suggest that general language
impairment and not autistic features per se may be the
critical feature mediating the impairment of gurative
language comprehension in autism. Decient gurative
language comprehension in non-autistic children with
language impairment has been reported earlier (Lee and
Kamhi, 1990).
Landa and Goldberg (2005) were interested in the
relationship between gurative language comprehension
and ECF in autism. They assessed 19 children (ages 717)
diagnosed with idiopathic, high-functioning autism and a
matched control group of 19 children with inconspicuous
development. The gurative language subtest from the test
of language competence (Wiig and Secord, 1989) was
employed to assess comprehension and interpretation of
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metaphoric expressions and gures of speech. Also,
standardized measures of basic language abilities, as the
adequate use of semantics, grammar, morphology and
syntax, were administered. Three subtests from the Cam-
bridge Neuropsychological Test Automated Battery (Cam-
bridge Cognition, 1996) were selected in order to assess
planning, exibility and spatial working memory as ECF
measures. Overall, the performance of autistic participants
was heterogeneous, ranging from intact to impaired
language skills and ECF. As a group, autistic subjects
were impaired relative to the non-autistic children on
measures of expressive grammar, comprehension of g-
urative language, spatial working memory and planning.
The data suggest that both the inability to comprehend
gures of speech (as assessed by sentence-to-picture
matching tasks) and the inability to give a verbal
interpretation of non-literal language may independently
contribute to decient performance on tasks assessing
gurative language skills. As there were no correlations
between IQ, ECF and language abilities in the autistic
subgroup, the authors conclude that their data do not
support the idea of ECF as a core decit in autism which
might mediate the observed language impairments. This
conclusion has recently been questioned. In a study by
Rajendran et al. (2005) individuals diagnosed with
Asperger syndrome and healthy peers participated in a
computer-mediated dialog which was part of a scenario
involving gures of speech and sarcasm or inappropriate
requests. Here, verbal and executive abilities as well as
clinical diagnosis predicted comprehension of gures of
speech. The dialog task in this study was possibly more
demanding than the matching and interpretation tasks
used in the work by Landa and Goldberg (2005). In the
dialog situation, subjects might have had to rely more on
ECF in order to process different (context) information at
the same time and to self-structure and exibly respond to
changing demands.
Taken together, individuals suffering from communica-
tion disorders from the autistic spectrum appear to be
impaired in processing non-literal language, although,
within-group variation is rather high. It remains unclear
whether the decit is possibly mediated by an impairment
of general language abilities, verbal memory, ToM and/or
ECF, regardless of the presence of autistic features.
Inconsistent methodologies and heterogeneous patient
samples make it difcult to draw rm conclusions at this
point.
2.4.3. Neurodegenerative diseases involving subcortical
structures
The PFC, which has been implicated in gurative
language processing (see previous sections), is densely
interconnected with subcortical structures. Alexander et al.
(1986) described three main fronto-subcortical circuits
thought to subserve cognition: The rst circuit comprises
the interconnections between the dorsolateral PFC, the
dorsolateral caudate nucleus and the lateral globus
pallidus, which project back to the dorsolateral PFC via
the dorsomedial nucleus of the thalamus. The second loop
involves the orbitofrontal cortex, which is linked to the
ventromedial caudate nucleus and the medial globus
pallidus, as well as backprojections to the orbitofrontal
cortex via the dorsomedial thalamus. The third circuit
connects the anterior cingulate, the basal ganglia and
thalamic nuclei. Furthermore, in a frontocerebellar circuit,
the dorsolateral PFC and the lateral cerebellum are
interconnected via reciprocal pathways involving the
pontine nuclei, the dentate nucleus and the thalamus
(Daum and Ackermann, 1997; Schmahmann, 2004). These
fronto-subcortical connections have been shown to con-
tribute to cognitive functions, particularly to ECF (Heyder
et al., 2004). It is thus plausible to assume that subcortical
structures also might participate the processing of non-
literal language.
Support for an involvement of subcortical structures in
gurative language processing comes from a study showing
that patients suffering from olivo-ponto-cerebellar atrophy
were impaired relative to healthy controls in a proverb
interpretation task (Arroyo-Anllo and Botez-Marquard,
1998). Chenery et al. (2002) investigated basic and complex
language abilities in Huntingtons disease which involves
neurodegeneration of the head of the caudate nucleus and,
to a lesser extent, of the globus pallidus and putamen
(Zakzanis, 1998). The comprehension of non-literal lan-
guage was assessed by means of the ambiguous sentences
and gurative language subtests from the Test of
Language Competence (Wiig and Secord, 1989). Overall,
the performance pattern of the Huntington patients and a
group of patients with stroke-induced focal lesions of non-
thalamic subcortical structures was comparable, with basic
language abilities being relatively preserved in comparison
with a neurologically intact control group. However,
decits emerged on tasks assessing lexico-semantic abilities,
word uency and the interpretation of ambiguous and
gurative language. Both patient groups tended to provide
only one meaning of the ambiguous sentences and to stick
to the literal meaning of gurative utterances, regardless of
the context information provided. This is consistent with
earlier observations by Wallesch et al. (1983) that basal
ganglia patients are unable to provide adequate explana-
tions of idiom meanings.
Monetta and Pell (2006) reported impaired comprehen-
sion of gurative sentences in Parkinsons disease (PD), in
which neurodegeneration affects primarily dopaminergic
neurons in the substantia nigra (Fahn and Sulzer, 2004).
Primetarget sentence pairs were presented to subjects with
the prime sentences being either metaphorical (Those
babys cheeks are roses) or literal (Those owers are
roses.). Target sentences were either metaphor-relevant,
i.e. referred to a property relevant to the metaphorical
interpretation (That babys cheeks are roses./Roses are
often red.) or metaphor-irrelevant (Roses have
thorns.). PD patients were impaired in terms of both
accuracy and response speed in deciding whether the
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metaphorical sentences made sense or not, but only if they
also showed an impairment of verbal working memory
span. This indicates that in PD, the disruption of complex
language functions such as gurative language comprehen-
sion might be ascribed to limited working memory
capacity.
Altogether, the available evidence from populations with
neurodegenerative diseases affecting subcortical structures
suggests a potential participation of the basal ganglia and
the cerebellum in the comprehension of gurative lan-
guage. However, further support from patients with focal
subcortical lesions and from neuroimaging studies is
needed in order to elucidate which substructures are
precisely involved, the nature of their contribution and
the relationship of gurative language impairment to the
disruption of other higher-order cognitive functions.
2.4.4. Alzheimers disease
Conicting evidence has been reported for gurative
language comprehension in patients suffering from mild to
moderate Alzheimers disease (AD). While Kempler et al.
(1988) reported that from the early stages of the disease on,
AD patients have difculty in understanding abstract
meanings, Papagno and Vallar (2001) concluded that
decline of gurative language comprehension occurs at
later stages with idiom comprehension being preserved
longer than metaphor comprehension. In a subsequent
study (Papagno et al., 2003), patients with mild probable
AD were administered a sentence-to-picture matching task
for idiomatic and literal phrases. All patients had difculty
in choosing the correct picture illustrating the gurative
(instead of the literal) meaning of the idiomatic expres-
sions. Performance on this subtask correlated with that in a
paper-and-pencil dual task (Baddeley et al., 1997) em-
ployed as ECF measure. However, when, as an alternative
to the picture illustrating the gurative meaning of the
idiom, an unrelated situation was shown, performance
signicantly improved. AD patients also performed better
when asked to verbally explain idiomatic interpretations
than when they were administered the sentence-to-picture
matching task used in the rst experiment. This effect was
ascribed to the lack of an externally presented literal
interpretation in the oral task. In the few cases that literal
interpretations were provided in the oral task, they
represented plausible real-world situations. The authors
suggest that, although AD patients still retain knowledge
of the gurative meaning of the idiom, they are unable to
suppress its literal interpretation, which is concurrently
activated. These ndings also illustrate that performance
on gurative language tasks can vary as a function of the
testing modality.
In summary, it remains unclear, in which stage of AD,
an impairment of gurative language comprehension
begins to show. The knowledge about gurative meanings
appears to be preserved and a decit in suppressing
alternative literal interpretations of metaphoric expressions
might underlie the impairment. This is in line with the
suppression decit hypothesis proposed to explain the
poor gurative comprehension of RHD patients (see
Section 2). The fact that in AD, the RH seems to be
affected by neuropathological changes earlier and to a
greater extent than the LH, completes this picture
(Shinosaki et al., 2000).
2.5. Summary
Taken together, the available evidence suggests that
networks involving fronto-temporal cortical areas as well
as subcortical structures (left thalamus, caudate nucleus,
substantia nigra, cerebellum) in both hemispheres con-
tribute to the processing of gurative language. While the
RH seems to be more involved in processing the context in
which a gurative expression appears (Brownell et al.,
1986; Foldi et al., 1983; Tompkins et al., 2001), the LH is
responsible for processing propositional information (Long
and Baynes, 2002). Relative to the LH, the RH seems to
maintain more alternative interpretations of gurative
expressions and does so for longer time periods. Also, the
RH is more concerned with processing non-salient (i.e.
novel) metaphoric meanings. Both hemispheres support the
integration of the gurative expression within the overall
literal message, and interhemispheric communication
transfer via the corpus callosum seems to be critically
involved in this process.
An impairment of gurative language comprehension
has been observed across a range of neurodevelopmental
and neurodegenerative disorders like autism, Chorea
Huntington, Olivo-ponto-cerebellar atrophy, PD and
AD. However, for each of these disorders, even among
patients allegedly presenting with the same clinical status,
interindividual variability is high, ranging from preserved
to impaired gurative language comprehension. A more
specic characterization of these differentially affected
patient subgroups is clearly needed. It remains as yet
unclear to which degree the mechanisms proposed to
mediate the decit in gurative language processingsuch
as impaired general verbal abilities, ToM or compromised
ECFcontribute to the observed impairments. In parti-
cular, it is of interest which cognitive subcomponents
contribute to the understanding of gurative language and
in what way they are impaired in different populations.
3. Figurative language processing in schizophrenia
Disorders of thought and language are considered a core
symptom of schizophrenia. Since Finckh (1906) and
Benjamin (1944), researchers and clinicians have regarded
proverb interpretation as a potential tool assisting in the
diagnosis of disordered thinking in patients suffering
from this debilitating mental illness (see Reich, 1981).
Asked to explain the meaning of proverbs, schizophrenia
patients tend to stick to the literal meaning of the
expressions, a clinical phenomenon which since Bleuler
(1911, 1966) has been known as concretism. In clinical
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settings, assessments of proverb interpretation have rarely
been implemented in a systematic way, leading some
authors to question the reliability and validity of proverb
interpretation for diagnostic purposes (Andreasen, 1977;
Reed, 1968). However, systematic investigation of gura-
tive language comprehension in schizophrenia has the
potential to provide important insights into thought
patterns of schizophrenia patients. The review article by
Mitchell and Crow (2005) highlights the importance of
pragmatic abilities such as gurative language comprehen-
sion for general interpersonal skills of schizophrenia
patients.
As far as the neurocognitive underpinnings of gurative
language processing in schizophrenia are concerned, direct
evidence is scarce. Currently, ndings point towards
disrupted activity of cortico-subcortical circuitry (Buchs-
baum, 1990; Kubicki et al., 2003; Ragland et al., 2004;
Velakoulis and Pantelis, 1996) during the processing of
verbal material, reduced cerebral asymmetry (Sommer et
al., 2003) and impaired interhemispheric communication
transfer due to callosal abnormities (Innocenti et al., 2003)
in schizophrenia patients. As these networks have been
implicated in the processing of gurative language, it is
plausible to assume that patients affected by schizophrenia
have difculty in interpreting this form of communication.
3.1. Standardized assessment of proverb comprehension in
schizophrenia
In schizophrenia research, standardized proverb com-
prehension tests and standardized scoring criteria have
been applied more often than in studies involving other
patient groups or healthy individuals. Thus, a brief
description of these methods will be given at this point.
Until now, Gorhams pioneering proverbs test (Gorham,
1956a) has remained the best known standardized diag-
nostic tool for the assessment of proverb comprehension in
the English-speaking world. The test comprises a multiple-
choice part and three parallel forms of a free-answer
version. In the free-answer version, the subject is instructed
to explain the meaning of twelve proverbs. The multiple-
choice version consists of 40 proverbs with four possible
response alternatives representing various interpretations
of the proverb in question. As expected, it is more difcult
to give proverb interpretations in a free-answer format
compared to the multiple-choice version. In schizophrenia
patients, the free-answer version is also more likely to elicit
psychotic material (Gorham, 1956b).
A major problem with the free-answer format consists in
dening an appropriate scoring system. The most common
scoring indices which have been established over the years
distinguish between abstract and concrete (Gorham,
1956a, b), literal (Hertler et al., 1978) as well as bizarre-
idiosyncratic (Marengo et al., 1986) or autistic (Shimku-
nas et al., 1967) features of proverb interpretations. In
Gorhams terms (Gorham, 1956a, b), abstraction is
synonymous with accuracy, while a proverb interpretation
is to be scored as concrete if it fails to replace central
symbols by more abstract terms. Gorham adopted a three-
point scoring system (2: adequate response; 1: partially
correct; 0: complete failure). However, these criteria have
been repeatedly criticized as being too vague (Gibbs and
Beitel, 1995). For instance, not all parts of a proverb
necessarily have a metaphorical character. Therefore, these
words/phrases do not need to be rephrased in abstract
terms when an interpretation of the proverb is required.
Apart from that, evidence by Shimkunas et al. (1966)
indicates that abstractness and concreteness seem to
reect general intelligence rather than characteristic fea-
tures of schizophrenic psychopathology.
Hertler et al. (1978) view literalness as more specic
and more independent of overall intellectual ability than
concreteness. They broadly dene literalness as an
active attempt to interpret the words of the proverb as a
literal message rather than as symbols to be interpreted.
Finally, bizarre-idiosyncratic or autistic interpreta-
tions are obviously bizarre and unrelated to the proverb
(Shimkunas et al., 1967). On the basis of clinical ratings,
Shimkunas et al. (1967) developed a three-point scoring
manual comprising examples of autistic and non-autistic
proverb interpretations. In schizophrenia patients, bizarre
proverb interpretations are neither associated to concrete-
ness (Marengo et al., 1986; Shimkunas et al., 1967) nor to
general IQ (Shimkunas et al., 1966). In a sample of 80
schizophrenic patients, autistic scores were observed to
decrease over treatment, from admission to 26-week post-
admission (Shimkunas et al., 1967). Abstract and concrete
scores remained unchanged, except in schizophrenia
patients with a high general IQ (Shimkunas et al., 1966).
3.2. Empirical evidence of impaired gurative language
comprehension in schizophrenia
3.2.1. Figurative language impairment in schizophrenia:
traditional views
Goldstein (1944) and Benjamin (1944) were among the
rst authors to put forward the idea that the problems of
schizophrenia patients with proverb interpretation might
arise from the inability to assume an abstract attitude,
i.e. to transgress the immediately given specic aspect or
sense impression and to realize that a specic thing
represents an accidental sample or representative of a
category (Goldstein, 1944, p. 18). Benjamin (1944)
analyzed proverb interpretations given by schizophrenia
patients. For instance, as an explanation of the proverb
When the cats away, the mice will play a schizophrenia
patient suggested If there isnt any cat around, the mice
will monkey around, and maybe get into things.
(Benjamin, 1944, p. 73). This led Benjamin (1944) to
conclude that schizophrenia patients are unable to infer
the abstract meaning of the symbols used in proverbs
sticking to their literal meaning instead. Similarly, Goldstein
(1944) reported that the inability of schizophrenia patients
to abstract from a given example manifested itself not only
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in their language, but also on conceptual sorting tasks. For
example, on a color sorting task, schizophrenia patients
tended to form an extra category for each subshade of a
given color (e.g. bright green, emerald green) instead of
subsuming the different shades under one broader category.
The notion of decient abstract thinking in schizophrenia
has remained a matter of constant debate ever since
(Meadow et al., 1953). Following their observation that on
conceptual sorting tasks (e.g. grouping together words
belonging to different categories), schizophrenia patients
tended to include in a given category many incorrect
instances often belonging to a conceptually similar category,
Chapman and Taylor (1957) argued that schizophrenia
patients are prone to engage in overinclusive thinking.
Payne et al. (1964) related the presence of delusions to
overinclusiveness in proverb interpretation, as assessed by
the average number of words required to explain each
proverb. This could not be replicated by Goldstein and
Salzmann (1965), but it is doubtful whether the concept of
overinclusive thinking is adequately operationalized as the
number of words used in a proverb explanation.
Other authors suggested that at least in some cases,
personal associations evoked excessively by the words or
phrases constituting a proverb might prevent schizophrenia
patients from giving an abstract and impersonal inter-
pretation (Gjerde, 1983). These explanations (overinclusive
interpretation of gurative meanings, excessive personal
associations) of the decits schizophrenia patients experi-
ence in appreciating metaphoric language also lend
themselves to a more positive interpretation in terms of
increased creativity in psychotic individuals. In Eysencks
(1993, 1995) view, creativity is mainly characterized by
overinclusive thinking, i.e. by wider thought processes,
e.g. manifesting themselves by more unusual and uncon-
ventional responses on a word association task. Multi-
faceted processes underlie creative thinking with
conceptual expansion and creative imagery being
two of them. In a recent study (Abraham et al., 2005),
the degree of psychoticism, as assessed by the correspond-
ing scale of the Eysenck Personality Questionnaire in a
healthy population, was positively related to greater
degrees of conceptual expansion (e.g. drawing an animal
different from those living on our planet) and elevated
levels of originality in creative imagery (e.g. constructing a
practical and original object from a certain category using
three randomly assigned 3D gures). These ndings are
consistent with other evidence of enhanced creativity in
schizotypal individuals (Burch et al., 2006; see Nettle and
Clegg, 2006 for a review) or in relatives of psychotic
individuals (Karllsson, 1968; Karlsson, 2001). Note, how-
ever, that although schizotypy, which is the more recent
conception of psychoticism, may represent a potential
vulnerability marker for psychosis (Claridge and Beech,
1995) it is not per se considered pathological and is
probably not fully comparable to a clinically relevant
psychosis. Accordingly, a recent study has provided
evidence of enhanced verbal creativity in schizotypal
individuals both relative to schizophrenia patients and
healthy controls, but not in schizophrenia patients relative
to healthy controls (Folley and Park, 2005). Data relating
enhanced creativity to full-blown psychosis are scarce,
often based on case studies of mental illness among
individuals in creative professions (Andreasen, 1987;
Hasenfus and Magaro, 1976; Richards, 1981) and rare
group comparisons of psychotic patients and healthy
controls (Keefe and Magaro, 1980; Ryabova and Mendel-
vich, 2002). Overall, affective disorders appear to be more
strongly related to enhanced creativity than schizophreni-
form psychoses (Post, 1994). Overall, the available evidence
does not provide strong support for the assumption that
enhanced creativity might underlie the deviant interpreta-
tions of gurative expressions in schizophrenia.
The notion that gurative language comprehension is
compromised in schizophrenia due to an impairment of
abstract thinking also has been challenged. Goldstein
(1959) noted that schizophrenia patients were able to
abstract from a given exemplar to a superordinate category
when performing an object-sorting task. Blaufarb (1962)
suggested that schizophrenia patients are capable of giving
abstract proverb interpretations under certain conditions.
He stated that they suffer from an input decit due to a
loss of the capacity to use incoming information in an
effective manner. Schizophrenia patients and healthy
subjects were asked to interpret either single proverbs or
proverb sets. All proverbs contained metaphors involving
concrete objects. Each proverb set consisted of three
proverbial statements sharing the same abstract meaning.
Schizophrenia patients performed signicantly better on
the proverb sets than on single proverbs while there was no
such difference in the control group. Blaufarb (1962)
concluded that presenting proverb sets instead of isolated
proverbs constitutes an enrichment of stimulus conditions
which might eliminate the presumed input decit schizo-
phrenia patients suffer from. While a concrete interpreta-
tion might seem suitable for an isolated proverb at rst
glance, nding a single interpretation for three different
proverbs leaves no other possibility than abstracting the
common meaning from the set. Chapman and Chapman
(1973) stated that even healthy people show a tendency to
interpret single proverbs literally. In their view, schizo-
phrenia patients only exhibit a stronger form of this normal
response bias.
There is some evidence that the ability to comprehend
gurative language might depend on current illness
severity. Using the same experimental design as Blaufarb
(1962), Hamlin et al. (1965) showed that only schizo-
phrenia patients with a mild (former patients in remission)
and medium (open-ward) degree of illness severity bene-
ted from enriched input while closed-ward schizophrenia
patients and non-schizophrenic psychiatric patients per-
formed equally well on single proverbs and proverb sets.
The authors argued that patients in remission might either
have retained or regained the ability to effectively deal with
incoming information while in the most severely psychotic
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group, the input disruption might have already progressed
too far to be overcome by the enrichment procedure. On
the other hand, employing a slightly different approach, de
Bonis and colleagues (1997) did not nd any correlation
between the performance of schizophrenia patients in a
proverb interpretation task and global illness severity, as
indexed by the overall score on the Brief Psychiatric Rating
Scale (BPRS: Overall and Gorham, 1988).
The tendency of schizophrenia patients to be concretistic
in their interpretation of gurative language has been
demonstrated in further studies. Schizophrenia patients
were shown to provide literal rather than gurative
interpretations of metaphorical and ironic remarks (Cut-
ting and Murphy, 1990; Drury et al., 1998), to select literal
rather than gurative pictorial illustrations of metaphoric
utterances (Anand et al., 1994) and to show a lack of
semantic priming for metaphorically rather than literally
related prime target pairs (Spitzer, 1997).
Preliminary evidence suggests that an impairment of
gurative language competence might be a very early feature
of psychosis. To our knowledge, in the only study investigating
gurative language abilities in childhood onset schizophrenia
(Baltaxe and Simmons, 1995), pragmatic language competence
in general emerged as the most impaired linguistic domain. The
pragmatic difculties manifested themselves mainly as pro-
blems of referencing (failure to orient the listener by giving
relevant background information), topic selection and main-
tenance, appropriate sequencing of discourse and turn-taking.
About two-thirds of the sample also suffered from an
impairment in what the authors call abstract language,
assessed by three subtests (making inferences, sentence
ambiguities and gurative language) from the Test of
Language Competence (Wiig and Secord, 1989). However, it
does not become clear from the study description if
performance was equally impaired across all three subtests.
Also, of the 47 children participating in this study, 7 were
additionally diagnosed with mental retardation, 5 with a
seizure disorder and all 47 had been referred to a speech and
language service because of language problems. Thus, it
remains unresolved whether the language problems described
in this study are characteristic of childhood schizophrenia or
stem from a more general communication disorder.
Taken together, an impairment of abstract thinking has
long been held to be the primary reason for the concretistic
interpretations of gurative language (mainly proverbs in
the early studies) given by schizophrenia patients, particu-
larly in the acute phase of their illness. Given the empirical
evidence to date, it seems that this does not represent a
comprehensive account of the gurative language impair-
ment in schizophrenia, as, for instance, presenting sets of
semantically similar proverbs greatly reduces the literal
response bias.
3.2.2. Is the impairment of gurative language
comprehension specic for schizophrenia?
Only a few authors addressed the important question of
whether impaired proverb comprehension is specic for
schizophrenia or a more general feature of psychiatric
disorders. An early study by Harrow and Quinlan
(1977) showed that difculties in providing adequate
proverb interpretations are not selectively associated with
schizophrenic psychopathology. Relative to controls, the
depression subgroups in this study also showed impaired
proverb understanding. Irony comprehension has been
shown to be signicantly more compromised in schizo-
phrenia patients than in a group of patients with various
non-psychotic disorders like depression and anxiety
(Mitchley et al., 1998). Cutting and Murphy (1990)
assessed patients suffering from either schizophrenia,
mania or depression on a word triad relatedness paradigm.
Subjects could form either denotatively or connotatively
related word pairs. Denotatively related words were
either antonyms (warm-cold) or both belonged to the
domain human beings (foolish-loving), while conno-
tatively related words shared a metaphoric relationship
(cold-hateful) or both evoked either positive or negative
connotations (shallow-hateful). Schizophrenia patients
showed a greater bias towards grouping words together
according to the denotative relationship than according
to the connotative association. This bias was signicantly
enhanced relative to the mania subgroup and just failed to
reach signicance relative to the depressive subgroup.
These results are consistent with those obtained in an
Austrian study. Barth and Kufferle (2001) designed a
multiple-choice version of a test involving 15 Austrian
metaphorical proverbs. Subjects have to choose the
correct proverb interpretation among ve response alter-
natives: Type I answers are meaningful and abstract
( the only correct answer), Type II meaningful and
partially concretistic, Type III meaningful but highly
concretistic, Type IV meaningless and concretistic and
Type V answers are meaningless and abstract. Schizo-
phrenia patients chose signicantly more often meaningless
and concretistic proverb interpretations than depressive
patients. However, it is difcult to draw wider conclusions
from these two studies, as they did not involve a healthy
control group. In the study by De Bonis et al. (1997),
patients suffering from schizophrenia or depression as well
as non-psychiatric controls were presented with metaphoric
target proverbs. Subjects had to choose, among four
response alternatives, either a proverb that had a similar
or the opposite meaning. While depressive patients and
controls had more difculties in the contradiction than in
the similarity condition, schizophrenia patients were
equally impaired in both conditions and also in compar-
ison with depressive and control subjects. This indicates
that already the more basic ability of applying the
gurative meaning of one proverb to another seems to be
disturbed in schizophrenia.
Overall, although schizophrenia might not be the only
psychiatric disorder associated with difculties in ade-
quately processing gurative language, the impairment in
this patient group at least appears to be more pronounced
than in affective disorders.
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3.2.3. The processing of context information and the
comprehension of non-literal language in schizophrenia
The problems of schizophrenia patients with proverb
and metaphor interpretation also apply to the related eld
of idiomatic expressions. Titone et al. (2002) conducted a
semantic priming experiment which involved both literally
plausible (e.g. The man kicked the bucket.) and
implausible (e.g. Hillary was on cloud nine.) idioms.
Schizophrenia patients showed idiom priming only for
literally implausible idioms while control individuals
showed idiom priming for both literally plausible and
implausible idioms, indicating that schizophrenia patients
failed to activate the gurative meanings of idioms if a
literal interpretation was plausible. However, in the case of
implausible idioms, they were able to use idiom prime
context in order to facilitate the processing of idiomatic
target meanings in the same way as controls. Titone et al.
(2002) suggested that the difculties of schizophrenia
patients in adequately interpreting idiomatic speech stem
from a failure to inhibit literal interpretations of literally
plausible idioms rather than from an inability to process
context information. Note that this study involved a SOA
of 0 ms, i.e. targets were presented immediately after the
offset of the prime. As schizophrenia patients have been
shown to be impaired in semantic priming procedures
involving longer SOAs (Barch et al., 1996), the Titone et al.
(2002) study might have yielded a different result pattern
with schizophrenia patients potentially showing no priming
at allif a longer SOA would have been chosen.
Recent EEG ndings suggest that the schizophrenia
patients weakness in metaphor interpretation may result
from a general difculty in integrating the semantic context
of sentences, irrespective of whether the content is literal or
gurative. Strandburg et al. (1997) recorded ERPs from
schizophrenia patients while they completed an idiom
recognition task. Patients were generally impaired in their
ability to differentiate meaningful from not meaningful
sentences (higher error rates, longer response latencies).
Also, the N400 amplitude to idioms and literal sentences
was larger than normal in patients, with no difference in
N400 amplitude to nonsense phrases, indicating reduced
impact of linguistic context. In a study by Iakimova et al.
(2005), ERPs were recorded while schizophrenia patients
and healthy controls judged the meaningfulness of
metaphorical, literal and incongruous sentences. The
overall ERP pattern was similar across all subjects:
incongruous sentence endings elicited the largest N400
amplitudes while literal endings evoked more negative
N400 amplitudes than metaphorical ones. However,
schizophrenia patients showed a more negative N400
amplitude, a reduced late positive complex (or P600)
amplitude and latency delays in both components for all
sentences. Given that the size of the N400 amplitude has
been related to the ease of integration of information
within the semantic context (Kutas et al., 2000), these data
suggest that schizophrenia patients were less able to derive
specic expectations for the sentence ending from the
overall sentence context (Grillon et al., 1991). This was
interpreted as evidence of an impairment of context
processing (Tartter et al., 2002) and general processes of
decision making and successful comprehension (P600) in
schizophrenia patients.
Taken together, evidence suggest that the impairment of
schizophrenia patients in gurative language comprehen-
sion might be due to a combination of impaired context
processing for both gurative and literal language, and an
inability to suppress the literal meaning of a gurative
expression.
3.2.4. The relationship between ToM abilities and gurative
language processing in schizophrenia
As in autism and AD, impaired ToM has also been
proposed as a mechanism mediating impaired under-
standing of gurative language in schizophrenia. A series
of studies have demonstrated poor ToM performance in
schizophrenia patients (for a review see Brune, 2005).
Evidence by Langdon et al. (2002a) suggests a differential
contribution of poor ToM to the impairment of different
instances of gurative language in schizophrenia. A story
comprehension task was used involving stories ending with
either a literal, metaphoric or ironic remark. Schizophrenic
and healthy participants had to decide whether the remark
was appropriate within the story context or not. Impaired
ToM (as reected by an increased error rate in a false-belief
story sequencing task) was related to poor understanding
of irony, but not to poor understanding of metaphors.
Poor ToM and non-literal language comprehension
discriminated between patients and controls even when
ECF dysfunction (assessed by the performance on a Tower
of London task) was controlled for. This differential
impairment pattern is probably associated with increased
complexity of mental processes, namely second-order
ToM, involved in the interpretation of irony but not in
the comprehension of metaphors (Sperber and Wilson,
1995). In another study, the authors conrmed that the
understanding of metaphor and irony makes signicant
and independent contributions to the distinction of
patients from controls, suggesting the existence of two
qualitatively different underlying processes (Langdon et al.,
2002b). The impairment of irony comprehension also
seems to persist longer in the course of the illness: Remitted
schizophrenia patients have been shown to be able to
interpret the meaning of metaphoric remarks, embedded
within a story context, at a comparable level as healthy
controls but were impaired with regard to irony compre-
hension (Herold et al., 2002).
Two recent studies found correlations between ToM
decits and impaired proverb interpretation. Greig et al.
(2004) used Gorhams method for rating the bizarreness
of the answers in Gorhams Proverbs Test (Gorham,
1956a) as a measure of thought disorder in a sample of 128
schizophrenic subjects. The bizarreness scores were posi-
tively associated with poor performance in the Hinting
Task, a ToM measure by Corcoran et al. (1995). In this
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task, 10 brief scenarios describing an interaction between
two people are read aloud to the subject. At the end of each
scenario, one of the characters drops an obvious clue and
the participant has to take it up. Brune and Bodenstein
(2005) administered the German proverbs test by Barth
and Kufferle (2001) and a ToM task to a sample of 31
schizophrenic subjects. In this ToM task (Brune, 2003),
participants were instructed to sequence scenes belonging
to cartoon picture stories depicting the mutual cooperation
and deception of two characters while cheating a third
character. Additionally, a ToM questionnaire was admi-
nistered comprising 23 questions referring to the mental
states of the characters involved in the cartoon stories.
First-order questions addressed the intentions, wishes and
thoughts of some of the cartoon characters. Second-order
questions addressed the beliefs of some characters about
the intentions, wishes and thoughts of other characters in
the story. The authors found a strong correlation between
ToM story comprehension and the ability to adequately
interpret gurative proverbs. Again, ECF did not appear to
mediate this decit.
Taken together, several studies related impaired ToM to
a decit in comprehending metaphoric, proverbial and
ironic statements in schizophrenia. Irony and proverbs,
both instances of interpretative language use, seem to be
more impaired in schizophrenia than the understanding of
descriptive metaphors which is related to the differential
complexity of the required ToM processes.
3.2.5. The role of psychopathology
Analysis of syndrome-subtypes has frequently helped to
discriminate between different subgroups of schizophrenia
patients in terms of both cognitive performance and
outcome (Brekke et al., 1995; Goldstein et al., 2005; Rector
et al., 2005; Strauss, 1993; Thoma and Daum, 2005;
Villalta-Gil et al., 2006). In most studies, negative and
disorganized symptoms have been related to specic
cognitive decits while the cognitive performance of
patients predominantly affected by positive symptoms
appears to be in the normal range across most cognitive
domains (Shean et al., 2005; Zalewski et al., 1998).
Few authors have assessed the inuence of psycho-
pathology on gurative language comprehension in schizo-
phrenia, mostly using inconsistent diagnostic tools for this
purpose. De Bonis et al. (1997) subdivided their schizo-
phrenia sample into a paranoid and a non-paranoid
subgroup based on the presence or absence of derailment,
speech organization and incoherence (BPRS: Overall and
Gorham, 1988). The paranoid subgroup performed equally
well as depressive patients and non-psychiatric controls
and better than the non-paranoid group (see Section 3.2.1)
indicating intact ability to match similar and contradictory
gurative proverb meanings in paranoid schizophrenia.
The Langdon et al. (2002a) study (see Section 3.2.4)
suggests differential relationships between symptoms and
different types of gurative language. Positive formal
thought disorder, as assessed by the corresponding rating
on the Scales for the Assessment of Positive and Negative
Symptoms of Schizophrenia (Andreasen, 1982, 1984) was
associated with poor ToM abilities and poor appreciation
of irony. Negative formal thought disorder, represented by
the global ratings for alogia, was related to impaired
metaphor comprehension and executive dysfunction. These
ndings again suggest the existence of two qualitatively
distinct processes underlying the comprehension of irony
and metaphors. Using the free-answer format of Gorhams
test and applying the additional scoring indices presented
above, Sponheim et al. (2003) were the rst to relate both
psychopathology and cognitive abilities to several proverb
interpretation indices in 23 male schizophrenia patients. As
expected, the proverb interpretations of the schizophrenia
group were less abstract, but more concrete, literal and
bizarre-idiosyncratic than those given by control partici-
pants. Consistent with previous studies, the abstraction
score correlated positively with overall cognitive function-
ing and general intelligence, independent of the presence of
schizophrenia. Concrete proverb interpretations were
negatively associated with measures of set shifting,
problem solving and planning skills, i.e. ECF. As far as
symptomatology is concerned, only the correlation be-
tween positive formal thought disorder, as assessed by the
Comprehensive Assessment of Symptoms and History
interview (Andreasen et al., 1992), and the bizarre-
idiosyncratic response index reached signicance. How-
ever, 22 of the 23 patients were outpatients and
symptom severity presumably low. Associations between
symptom measures and distinct proverb interpretation
indices might be more prominent during an acute phase of
the illness.
Taken together, evidence suggests a relationship between
positive formal thought disorder and both irony compre-
hension decits and bizarre proverb interpretations.
Negative symptoms, in turn, seem to be associated with
an impairment of metaphor comprehension.
3.2.6. Impaired gurative language comprehension in
schizophrenia: a state or a trait marker?
Few studies attempted to elucidate the issue whether the
impairment of gurative language comprehension is a state
or a trait marker in schizophrenia, e.g. by assessing non-
clinical populations displaying schizotypal personality
characteristics.
Allen and Schuldberg (1989) investigated the interpreta-
tion of ten familiar and three unfamiliar proverbs in
subgroups scoring either high or low on the Chapman
Perceptual AberrationMagical Ideation Scales which
assess positive aspects of schizoptypy. Relative to low
schizotypal controls, high schizotypal individuals showed
higher scores for bizarre-idiosyncratic thinking according
to the Marengo et al. (1986) criteria (see 3.1), but only for
unfamiliar proverbs. Disordered thinking seems to emerge
only when subjects do not have the opportunity to learn
the proverb meaning by previous exposure but when they
have to newly engage in the analysis of gurative language.
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However, the low number of items in this study,
particularly for unfamiliar proverbs, makes it difcult to
draw any rm conclusions. Nunn and Peters (2001)
demonstrated that performance on a humor comprehen-
sion battery, Gorhams Proverb Test (Gorham, 1956a) and
a task requiring the ability to comprehend implicit
information by reordering a sentence predicted high scores
of positive schizotypal traits in otherwise healthy under-
graduate students.
There is also evidence that different types of gurative
language are differentially impaired in schizotypal indivi-
duals. In a study by Langdon and Coltheart (2004), young
healthy adults were subdivided into two subgroups
showing either a high or a low level of schizotypy, as
assessed by the Raine Schizotypal personality question-
naire. They were administered a story comprehension task
which assessed the ability to discriminate between incon-
gruous endings and the appropriate use of literal,
metaphorical and ironical expressions. Relative to low-
schizotypal subjects, individuals scoring high on
schizotypy were equally capable of identifying appropriate
metaphors but had problems to judge whether a literally
contradictory statement could be interpreted as irony or
not. This suggests continuity with schizophrenia with
regard to the impairment of irony comprehension but
discontinuity with regard to metaphor understanding (see
Section 3.2.4).
Overall, from the scarce evidence available so far, it
seems that schizotypy and positive schizotypal symptoms
in particular is associated with impaired comprehension of
proverbs and irony which parallels ndings in schizophre-
nia. Metaphor comprehension was found to be intact
which is consistent with ndings in remitted schizophrenia
patients.
3.3. Conclusions and implications for further research in
schizophrenia
Taken together, compromised gurative language com-
prehension in schizophrenia patients has been attributed to
a variety of factors including decreased ability to engage in
abstract thinking and to deal effectively with incoming
stimuli (input decit), distraction by excessive personal
associations evoked by the statements in question, en-
hanced creativity, a failure to inhibit literally plausible
interpretations of metaphoric expressions as well as
impairments of ToM, context processing and/or ECFs
(planning, set shifting and problem solving, in particular).
The available evidence highlights poor second-order ToM
as a prominent factor mediating impaired comprehension
of complex gurative language, particularly irony and
proverbs, in schizophrenia. A tentative association of
compromised gurative language and positive symptoms
has been established.
As pointed out above, familiarity with a gurative
expression increases the probability that it is interpreted
correctly (Cunningham et al., 1987; Penn et al., 1988) and
familiar and novel gurative expressions appear to be
processed differently in the brain (Laurent et al., 2005;
Mashal et al., 2005a, b; Tartter et al., 2002). Unfortunately,
familiarity with the gurative stimulus material has so far
not been controlled for in studies of gurative language
comprehension in schizophrenia. In fact, the poorer social
integration of schizophrenia patients (Mueser et al., 1990)
and their lower educational level render it plausible that
these subjects might have been less often exposed to
conventional gurative expressions during their lifetime
than healthy individuals. Future studies might include
gurative utterances which are unfamiliar to both schizo-
phrenia patients and healthy individuals (e.g. proverbs
adopted from foreign languages and cultural contexts) to
deal with the degree of familiarity as a potential
confounding variable.
Gibbs and Beitel (1995) pointed out that the ability of
schizophrenia patients to interpret metaphorical language
might be vastly underestimated by current assessment
procedures in which isolated gurative expressions are
employed. Healthy subjects, for instance, show superior
performance on proverb interpretation when the proverbs in
question are embedded within a contextual framework
(Kemper, 1981), like a story in which a character uses a
proverb to comment on a specic situation. It would be
interesting to know whether presenting gurative statements
within a story context has a similarly facilitating effect in
schizophrenia patients. In fact, it has been demonstrated
that these patients often fail to benet from context
information available in experimental tasks (Barch et al.,
2001, 2003) or during social interactions (Penn et al., 2002).
They also tend to misinterpret the meaning of ambiguous
words if the sentence context biases the infrequent word
meaning (Cohen et al., 1996, 1999; Cohen and Servan-
Schreiber, 1992) and are impaired in guessing the missing
word in a sentence, even if it is highly predictable from the
context (de Silva and Hemsley, 1977). Given these results,
one could speculate that individuals suffering from schizo-
phrenia might not benet from a contextual framework to
the same extent as normals do.
To our knowledge, only the receptive comprehension of
gurative language has so far been investigated in
schizophrenia patients. Future research might examine
their ability to use gurative language in active discourse,
e.g. by asking them to comment on a situation in a story
using a proverbial or idiomatic expression. As schizo-
phrenia patients affected by severe negative symptomatol-
ogy are held to suffer from a decit of willed action
(Frith, 1992), it is possible that this patient subgroup will
perform particularly poorly on such tasks.
Finally, the question of whether difculties in interpret-
ing gurative language is a state or trait marker of
schizophrenia merits further investigation in high-risk
populations like rst-degree relatives. Current ndings in
schizotypy suggest that the impairment of gurative
language comprehension might be a potential endopheno-
typic marker of schizophrenia.
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4. General summary and conclusions
The aim of the present article was to critically review
evidence of the neurocognitive mechanisms of the proces-
sing of non-literal languagemetaphors, proverbs and
idioms in particularwith an emphasis on pattern of
dysfunction in clinical groups.
Behavioral, lesion and imaging studies consistently
suggest differential contributions of fronto-temporal and
fronto-thallamo-striatal networks in both hemispheres to
gurative language processing. Relative to the LH, the RH
seems to be more involved in processing the broader context
of (unfamiliar) gurative expressions, activating a larger
number of alternative interpretations for extended periods
of time. Interhemispheric information transfer via the
corpus callosum contributes to the integration of the
gurative meaning within the overall literal message.
Compromised gurative language comprehensionwith
basic language abilities being widely intacthas been
documented in a range of neurodevelopmental, neurode-
generative and psychiatric disorders including autism,
Chorea Huntington, Olivo-ponto-cerebellar atrophy, PD
and AD and, most consistently, schizophrenia. Basic
assumptions about the neurocognitive mechanisms of
gurative language processing, such as differential complex-
ity of mental processes involved in different types of
gurative expressions (e.g. metaphor vs. irony), were
conrmed based on the ndings from diverse clinical groups.
Various problems limit the integration and interpreta-
tion of the inconsistent database available so far. With the
exception of schizophrenia, studies dealing with gurative
language comprehension in clinical populations are rela-
tively sparse and direct comparisons of different clinical
populations rare. Little is therefore known about the
specicity of the impairment patterns. Given that gurative
language comprehension is subject to developmental
change (see Section 1.3), the heterogeneous age structure
of diverse clinical groups (autistic children vs. elderly
patients with neurodegenerative diseases vs. mainly middle-
aged schizophrenia patients) also renders it difcult to
relate the different result patterns to one another.
Insufcient characterization of clinical groups and
diverse methodologies in terms of task design and type of
gurative material further complicate the comparison of
results across studies. The distinct neural networks which
appear to mediate the comprehension of different classes of
proverbs, idioms, ironic remarks and other instances of
non-literal language might be affected to varying degrees
across the investigated disorders. Given the almost
complete lack of functional neuroimaging investigations
in this area, the present database allows only for
speculations about the neural basis of the gurative
language impairment in these disorders.
The ndings suggesting a contribution of poor ToM and
compromised ECF to the difculties various clinical
populations experience in comprehending non-literal lan-
guage also needs further exploration. A more specic and
comprehensive assessment of the various subcomponents
of executive control (i.e. multitasking, set shifting, response
inhibition, context updating, planning and problem sol-
ving) and ToM abilities might help to further elucidate how
these domains might relate to the comprehension of
different types of gurative language. ECF enables the
individual to guide and coordinate behavior in complex
(social) situations, which usually involves the processing of
elaborate context information. By the same token, ToM-
based inference of the mental states of others usually
occurs within complex social interactions. Thus, it should
be considered that possibly both ECF and ToM abilities
might not come into play before gurative material is
presented in context. Moreover, taking into account
varying degrees of familiarity with gurative language
across clinical and healthy comparison groups and asses-
sing the ability to actively use and not only to comprehend
non-literal language remain topics to be explored in future
investigations.
Given the large interindividual variation of gurative
language competence across all clinical groups, the
identication of affected subgroups and of other markers
potentially characterizing these might be of high clinical
relevance, particularly when considering the importance of
gurative language comprehension for social interactions
(Vallance and Wintre, 1997). Incorporating the interpreta-
tion of common gurative expression into cognitive
training programs for affected patients might contribute
to helping them to deal with ambiguous social situations in
which the usage of non-literal language might play an
important role.
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ARTICLE IN PRESS
P. Thoma, I. Daum / Neuroscience and Biobehavioral Reviews 30 (2006) 11821205 1205

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