Aphasia and Dysphasia

Aphasia and Dysphasia

Ideas and considerations for the NLP Practitioner.

“We are not judged by the words that we use, we are judged by the relationships that we form by them.” Austin

Asphasia: A disorder of language affecting the generation of speech and it’s understanding and not simply a disorder of articulation. It is caused by disease in the left half of the brain (the dominant hemisphere) It is commonly accompanied by difficulties in reading and writing.

Oxford Concise Medical Dictionary.

In the majority of people (95%) language is lateralised (focused) in the left hemisphere of the brain. For the other 5%, language is lateralised in the right hemisphere.

This appears to hold true for right-handed people, where the left hemisphere is considered to be “dominant”. However, in approximately 75% of left-handed people, some researchers suggest that language is also lateralised in the left hemisphere. In the other 25% of left-handed people language appears to show bilateral representation (occurring in both hemispheres). A review of the literature appears to show a lot of conflicting statistics, but as a generalisation, we can say that language occurs for most people in the left hemisphere.

The two primary language areas of the brain were named after the early neurologist, Paul Broca (1824 – 1880) and surgeon Carl Wernicke (1848 – 1904).

Broca’s Aphasia

Also called, “Ataxic”, “expressive”, “non-fluent” or “motor” aphasia.

Broca’s aphasia is most commonly seen following a cerebral vascular accident within the left hemisphere at the Broca’s area. Head injury, surgery and other pathology can also result in damage to this area. Although an equivalent area exists in the opposite hemisphere for our purposes here I refer to the left Broca’s area.

Broca’s aphasia ranges from a mild affect through to a total disruption of left hemispheric speech and language production.

In mild Broca’s aphasia (often referred to as “dysphasia”) the person may demonstrate two classic qualities in their speech:

Telegraphic Quality: The speech consists of primarily content orientated words and lacks functionality principals. So that words such as “and, “the”, “a”, “for” etc are missing.

Phonemic Paraphrasia: Classically, words are rearranged in a quality not dissimilar from “spoonerisms” so that “walking stick” becomes “stalking wick”.

The classic Broca’s aphasic will be rendered mono-syllabic with the left Broca’s area being unable to produce speech and language. The equivalent area of the right hemisphere – the area that can produce pressured speech – will still be operating unaffected. Thus we typically observe a patient that is only able to produce one syllable of an emotionally charged nature.

Whilst in rehabilitation, these patients will favour those staff that are able to decipher their intention. Quite often it is the frustration itself of their situation that will propel the right hemisphere into action to unleash a verbal torrent of, “SHIT shit shit shitshitshitshit!!!” with varying emphasis and tonality marking.

It is these variations that many nurses have learned to understand to mean, “I need a drink”, “I need the toilet” or simply “hello”.

With this kind of expressive dysphasia the listener can begin to discern differing qualities – auditory expressed submodalities if you like.

Listen for changes and variations in:

  • Tempo
  • Volume
  • Tone
  • Speed of repetition
  • Inflection

Although these can be taken to reflect “submodalities” – the parameters of variation are not sufficient for articulation to occur.

Arising from the right hemisphere, these variations reflect more of a sentiment or emotion – an analogue communication as opposed to a digital communication. Thus the attuned listener will discern the relationship (analogue) between the person and the event they are seeking to communicate about.

Where the Broca’s area is damaged in the left hemisphere, the person will commonly also lose the ability to write. In my own practice I have various reaction to attempts to test for agraphia (inability to write) ranging from the person just holding the pencil looking blankly (where there appears to be no recursion to this deficit – ie the person is totally unaware that they have even lost the ability because they have no access to the fact the ability even exists) through to a person throwing the pencil across the room with the frustrated tirade of “FUCK FUCK FUCK FUCK!!!!” (which his primary nurse translated for me as: “I think he wants you to leave him alone.”)

Because expressive aphasia results from damage in the forward regions of the Broca’s area next to the regions of the mouth and tongue on the motor cortex. It is not just the ability to articulate language that is affected, but the very ability to represent it physically that is also affected.

Thus we can see why some people will remain blissfully unaware of their speech and language deficits and others will experience immense frustration; where the damage occurs predominantly on the speech areas of the motor cortex, the person will be well aware of their deficits and inabilities and will experience their inability to speak effectively. In preverbal children, this might account for a degree of childhood “tantrums” where the child is able to represent speech before they are able to verbalise and express it.

Typically, young children are able to understand much more than they are able to say. Because of the different rates of development of the different language areas a complication is that they often do not hear their own verbalized communication. This is demonstrated in the classic example:

“What is your name?”
“No, Litha!”

One curious feature about language acquisition is the resistance a child gives to grammatical correction by a third party, also demonstrated by a classic example:

Child: “Want other one spoon, Daddy.”
Father: “You mean, you want the other spoon.”
Child: “Yes, I want other one spoon, please Daddy.”
Father: “Can you say, ‘the other spoon’?”
Child: “Other…one…spoon.”
Father: “Say ‘other.'”
Child: “Other”
Father: “Spoon.”
Child: “Spoon.”
Father: “Other spoon.”
Child: “Other…spoon. Now give me other one spoon.”

Typically Broca’s aphasic will also experience agraphia too.

To experience a little of what this is like try writing with the opposite hand to which you are accustomed. The ability to represent it is there (but it is in the other hemisphere) the writing will take on a distinct childlike quality – the pathways that translate the intention into motor coordination have not been developed, however with repetition this is rapidly achieved. Curiously, some people find using their unaccustomed hand to write can produce a mirror image text more easily, especially when a mirror is used as visual feedback.

Quick summary for the NLP Practitioner: The right hemisphere of the Broca’s aphasic is capable or producing “pressured speech” (this is why some people who get emotional/angry will suddenly litter their language with obscenity). Thus this speech is establishing an analogue relationship between the person and subject matter. This relationship is demonstrated by the “submodalities” of what little speech is produced. The damage to the left Broca’s area has destroyed the ability for the “content” (digital communication) of speech to be articulated – either by damage to the areas that engineer articulation or damage to the motor areas that produce it.

Wernicke’s Aphasia

(Also called, “Receptive”, “Sensory” or “Fluent” Aphasia, pronounced “VER-nick-keys”)

The Wernicke’s Area is the part of the brain that processes spoken and written language – broadly speaking where the Broca’s area is concerned with outgoing communication, the Wernicke’s area is concerned with incoming communication.

Also situated in the left hemisphere (generally) the Wernicke’s area is further back in the brain in the temporal lobe.

Damage to this area will classically produce the effect that a person will be able to speak, but will not be able to understand another person’s speech to varying degrees.

Also, the outgoing speech of this person may contain numerous errors owing to the fact that their own Wernicke’s areas cannot hear their own speech production.

Basically, their own feedback loop for monitoring their own speech is lost [to varying degrees]. Maybe from this effect, we can begin to re-examine why unaffected people frequently have conversations to/with themselves.

The Wernicke’s area [of the left hemisphere] appears to store memories of sequences of the sounds that occur in speech and when damage occurs to this area, the person will still hear the sounds when a person speaks but will fail to recognize them as speech.

Typically, whilst the receptive area of the left hemisphere (content, grammar, syntax) is damaged the equivalent area of the right hemisphere will operate as normal and recognize such things as tunes, rhythm and child/baby talk normally. It is this kind of feature that will be of interest to the NLP Practitioner especially when designing “double inductions” as part of NLP/Hypnosis practice.

One of the characteristics of Wernicke’s aphasia is the production of word “jargon”. On the surface, the Wernicke’s aphasic may appear to be talking normally with appropriate punctuation, rhythm and prose (sequenced by the right hemispheric equivalent) but may demonstrate serious deficits with the content.

The following classic example used by psycho-linguists reflects this type of structure:

“Colourless green ideas sleep furiously.”

With this sentence, the rules of grammar and rhythm are followed and the sentence “feels” right [hemisphere] whilst the left tells us the content and syntax just doesn’t work.

The Wernicke’s aphasic will take this one stage further:

“The stockety wance on my holiday, it ate up the laddersby until, you know, we fell it over and then he danced wither the meal.”

The Wernicke’s aphasic may produce the incorrect answer to a question but still may retain an understanding of the correct answer. In a characteristic that is termed “semantic paraphrasia” the answer produced may not be the correct answer but the answer will bear some relationship to the correct answer.

In the most extreme cases of Wernickes aphasia the person may be rendered completely ‘word deaf’ and will be blissfully unaware of the fact that they ever heard speech to begin with. Where a specific function of the brain has been totally destroyed there is a lack of recursion and thus the affected person is mostly unaware of the deficit that is painfully obvious to everyone else.

Where insight is retained, Luria (1973) recorded a case where the person with Wernicke’s aphasia had difficulty with the question, “Is an elephant bigger than a fly?” The patient understood the words “elephant” and “fly” but stated, “I just didn’t understand the words smaller or bigger. Somehow, I always think that the expression ‘a fly is smaller than an elephant’ means that they’re talking about a very small elephant and a big fly’.

Anomic Aphasia

Whilst many people are familiar with the two main speech and language areas of the brain, there is a function of the angular gyrus, an area that lies behind the Wernicke’s area in the parietal lobe that is responsible for naming things.

Thus damage to this area will affect the person’s ability to produce nouns in the correct fashion. Situated nearer the visual cortex, the left hemispheric angular gyrus plays an important role in the categorization of the world.

From “Programs of the Brain” by J.Z. Young:

“The person can’t give the right name. Shown scissors he says, ‘It’s a nail file.’ Told it should be “scissors” he repeats ‘Yes, that’s right. Of course, it’s not a nail file, it’s a nail file.’ For him, the wrong word had got the symbolic value of scissors.” P.189.

Circumlocution is the strategy employed to bypass this difficulty. This is where the person will describe what the object or thing does rather than give it’s name. For example, when asked to name an object (a hat) the person will say something like, “You put it on your head.”

Curiously, where a noun also acts to serve as a verb, the name can be given, but only in the context of the verb. For example, Penfield and Roberts (1959) describe a patient who couldn’t name a comb, but stated it as, “something I comb my hair with.”

As a point of curiosity, I wonder how much this area plays in the creation of nominalizations.

Other verb/noun items with which can be used to test (Thanks to Joe):

  • The stuff you WAX your car with.
  • Can you TAPE up the box?
  • Something I BRUSH my hair with.
  • Help me BANDAGE my wound.
  • Can you WATER the flowers?
  • I need to BOX up my albums.

Conduction Aphasia

This type of problem arises from damage to the nerve fibres connecting the Broca’s area with the Wernicke’s area (the arcuate fasciculus).

In this type of aphasia, the affected person will have difficulty repeating things that they have just heard. They will generally speak normally (assuming the other language areas are intact) and will understand speech normally. However, when asked to repeat a sentence exact replication is not possible and the person will produce their own version of what they heard. Typically, the overall meaning will be the same it is just that the words themselves may differ.

For example, if asked to repeat the word ‘president’, the aphasic may reply, “I know who that is – Kennedy”. Similarly, someone asked to repeat the sentence, ‘The auto’s leaking gas tank soiled the roadway’ may respond with, “The car tank’s leaked and made a mess on the street.”

Transcortical Aphasia

Typically, people with this type of aphasia will have both receptive and expressive difficulties. Meaning that they will understand little of what they hear and will have gross difficulty in producing speech [in varying degrees]. Although similar to someone with damage to both the Wernicke’s and Broca’s areas the damage lies beyond these two areas.

In one notable case, an unfortunate woman with severe brain damage following carbon monoxide poisoning demonstrated an unusual facet of speech. Without damage to the primary auditory cortex, Broca’s and Wernickes areas, large parts of the visual association areas were damaged and the speech mechanisms were isolated in function from other areas. During a protracted hospital stay lasting several years the only movements she made were with her eyes which would track movements in the room. She did attempt to volunteer any communication, did not obey commands and never showed any sign of comprehension to speech or other communication modes. She was described as being “not conscious of anything that was going on.”

What was curious, however, was her ability to complete lines from children’s poetry and to repeat back phrases said to her.

For example, if someone were to say, “Roses are red, violets are blue…” She would respond with, “Sugar is sweet and so are you”.

Another curiosity was that if she repeated a sentence spoken to her that contained a grammatical error, she would repeat the sentence without the grammatical error.

I have demonstrated this neurological effect when teaching language to NLP and hypnosis students. If a childlike poem is given, such as, “Mary had a little lamb it’s fleece was (long pause)……” The majority of people will automatically complete the sentence in their own heads. This effect can be utilized effectively when working with hypnosis when speaking to the right hemisphere (via the left ear). The important aspect for the NLP Practitioner to remember is the use of rhythm and tempo – qualities the right hemisphere excels at. Childlike singing, rhyming and speaking will assist producing trance as the brain tries to keep up whilst completing one sentence as another is delivered – meanwhile, the suggestion is delivered to the left hemisphere (via the right ear) to the equivalent structures that are better processing complex meaning and analysis.

Some Additional Aspects of Hearing

On a basic neurological a spoken word is little more than a complex wavelength of sound. And yet the brain can distinguish meaning and grammar, it can detect and locate accents, identify the speaker (even if the speaker tries unsuccessfully to disguise his voice), can tell the difference between “fa” and “la”, can identify tunes etc etc. The list is huge.

The frequency of sound that can be picked up by the cochlea of the ear is between 200hz and 20,000 hz. This compares to the dog which has a frequency range between 67hz and 45,000hz.

Species/Approximate Range (Hz)

  • human 64-23,000
  • dog 67-45,000
  • cat 45-64,000
  • cow 23-35,000
  • horse 55-33,500
  • sheep 100-30,000
  • rabbit 360-42,000
  • rat 200-76,000
  • mouse 1,000-91,000
  • Gerbil 100-60,000
  • guinea pig 54-50,000
  • bat 2,000-110,000
  • beluga whale 1,000-123,000
  • elephant 16-12,000
  • porpoise 75-150,000
  • goldfish 20-3,000
  • owl 200-12,000
  • chicken 125-2,000

This frequency number is the number of times the tympanic membranes vibrate per second in response to the sound that is channeled down the ear canal.

These vibrations are transferred to the cochlea where they are converted into nerve impulses that are transmitted down the cochlear nerve and are transferred to the opposite hemisphere to the primary auditory cortex for processing.

It is in this region that something pretty cool occurs.

The neurons of the auditory areas are “tonotopic” – this means that different frequencies of sound (which by this stage have been transferred to electro-chemical impulses) stimulate the neurons in different arrays. This means that basically, they respond to different sounds in different ways.

Depending on the frequencies and patterning of the sounds for example as in music, differing effects can be achieved. The factors involved here are huge – for example, playing Eminem to my elderly Grandmother is unlikely to induce a good feeling within her, and yet, to my younger brother, this is literally, “music to his ears.”

Sound has a powerful impact upon the neurology – for example, at Woodstock 1999, Limp Bizkit achieved a phenomenal crowd response along the lines of “lets go break stuff” – the crowd’s response being assisted by the tunes and rhythms of the music – in rapport with the band and each other – compare this to the original Woodstock, where the same rapport occurred, but with differing outcome.

Ohio psychologist, Jaak Panksepp, achieved a similar effect with his chickens, who appeared to rather enjoy “The Final Cut” by Pink Floyd. These chickens, having been played various tracks by Panksepp would tend to sway about, look pretty chilled and start passing around the joints.

Music can evoke wide ranges of emotion in the listener. Many people are familiar with the “they are playing our tune” effect, where the tune not only evokes a certain emotion but also acts as an anchor to a shared ‘moment’.

Music can be angry, sad, happy, exciting etc and can be all these things even without a lyrical content. Sometimes artists will use deliberate incongruencies with their music to evoke a deliberate effect. Some of the best examples can be seen with the punk band, The Sex Pistols, playing with the London Philharmonic Orchestra, or such songs where the lyrics tell a particularly tragic story that is masked by a really happy and upbeat tune (such as Springsteen’s “For You”). As RB warns – be careful what you sing to yourself inside your head – and be especially careful with country and western music.

As anyone who has suffered an evening in a Karaoke bar can testify – the quality of the voice will greatly affect the way the overall effect is experienced. I have heard many a good Springsteen tune be massacred by a cover artist, and yet my friends will suggest (somewhat blasphemesly) that it is Springsteen’s gravelly voice that is not in order.

As NLP Practitioners will be aware, a lot of emphasis is placed on the quality of the practitioners voice when communicating. For anyone seeking to improve their practice I would seriously recommend purchasing a decent sound recorder, so that they can tape record the client sessions they run – a lot can be learned here.

A common effect for people hearing their voice for the first time on tape is that it doesn’t sound like their voice and frequently they don’t like it much. Well, here is the bad news. This is exactly how you sound to other peoples neurology too. Given the way that the Broca’s (production of speech/language) area and the Wernicke’s (understanding received speech/language) area operates, your external dialogue is going to sound different to your internal dialogue and will affect your own neurology in the way it affects other peoples.

The use of a good tape recorder (it is worth spending the extra money) will enable you to recalibrate your voice against how you experience it from the inside.

Your tonality, the presentation of your communication will enormously affect the impact it has upon the neurology with which you interact – whether it is your own, your lovers or your clients. If, using your tone you can create the right internal environment within the recipient, the content of your communication will sit perfectly in the right parts of their neurology. It is not enough to just say the words and hope for the best – you will just be singing bad karaoke to your clients. Learn to calibrate your voice to your internal representation, learn to calibrate your voice to your client’s responses.

Think chickens, think Pink Floyds “The Final Cut”.

Practice different voices, learn to shout, learn to sing; learn to vary your states.

And most of all be nice to yourself. Frequently, when I elicit clients internal dialogue strategies where they verbally beat on themselves all day, I have a conversation that goes a bit like this:

“Would you talk to your child that way?”
“Would you encourage your child to talk to himself that way?”
“Would you talk to your wife that way?”
“Would you talk to your pet dog that way?”
“Would you talk to your plants that way?”
“So you are telling me that it’s ok to talk to yourself that way?”

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