Speech Stumbles

By Mary Carpenter

IN A DC-area creative writing workshop, a young woman reacted to another participant’s essay using what sounded like words but made no sense at all. At the break, after the teacher left the room with the woman, someone called the problem “word salad.”

Word salad most often refers to the nonsensical language that can result from aphasia—hence its clinical label “jargon aphasia” —which involves difficulties with expressive (producing) or receptive (understanding) language. Different forms of aphasia depend on which part of the brain is affected—most often due to stroke, as in the case of Pennsylvania U.S. Senate candidate John Fetterman. Aphasia can also result from physical damage, for example, the gunshot that tore into the brain of former Arizona congresswoman Gabrielle Giffords.

In news reports on the speech difficulties of Giffords and Fetterman, medical experts have struggled to convince audiences that aphasia does not indicate impairment of the neurological functions involved in cognition. Instead, aphasia usually results from damage limited to the two distinct language-producing regions of the brain, Wernicke’s and Broca’s areas. What can be confusing in discussions of aphasia, however, are different uses of the word cognitive. Cognitive functions —such as remembering and reasoning—play important roles in producing and understanding language and remain unaffected in most cases of aphasia.

Aphasia, however, has the label “cognitive disorder”; and severe aphasia can involve damage in the language regions, thus becoming one of the impairments of dementia. For actor Bruce Willis, reports of aphasia came years after co-workers noticed “loss of mental acuity,” according to the LA Times. Willis’s behavior had provoked questions about whether the actor was “fully aware of his surroundings on set.”

Most common, Wernicke’s aphasia can produce long, complete sentences that have no meaning and can include made-up words as in “word salad” —with the example, “You know that smoodle pinkered,” according to the National Institute on Deafness and Other Communication Disorders (NIDCD) . Wernicke’s is categorized as “fluent” aphasia, while the speech of nonfluent Broca’s aphasia can require great effort, emerge in short phrases and omit small words such as “and” and “the.”  “Walk dog,” for example, means “I will take the dog for a walk.” Sufferers of both kinds are often unaware that their speech is unusual.

John Fetterman’s use of closed captioning to improve his speech is an important clue that his cognitive abilities are unaffected.  As is common with Broca’s aphasia, Fetterman’s speech stumbles are often paraphasic errors, using an incorrect word that sounds like the intended word they are trying to say —such as “emphetic” instead of “empathetic.”

Damage from a stroke—which can be pinpointed using MRI or CT scans—is most often limited to the brain’s left hemisphere, the location of the two language centers. The most common kind of stroke, transient ischemia attack (TIA), can interrupt blood flow to the brain for as little as a few seconds, which affects language abilities for just a few hours or days.

“What” and “chicken” were the only two words that Gabrielle Giffords could say in the weeks after she was shot in Tucson, according to an editorial by Giffords in the Washington Post. Even when she practiced telling her husband “Happy Birthday,” she couldn’t “help adding ‘chicken,’” she wrote: “Happy Birthday—chicken!”

“Though my cognition— my understanding and intelligence—is unaffected by my aphasia, sometimes that is not clear to new acquaintances because of my speech,” Giffords writes. She explains learning about “functors”—the small words, including prepositions, conjunctions and articles— which her aphasia causes her to drop. In an effort to compensate, she communicates using as few words as possible and explains: “Words are precious to me.”

“Global” aphasia caused by severe injury or stroke, on the other hand, damages extensive portions of the brain, along with the language areas.  Severe damage can result in anomic aphasia, or anomia, with the speaker understanding words and sentences but struggling to come up with the names of objects.  What’s called primary progressive aphasia, on the other hand, involves deterioration in parts of the brain responsible for language —that can lead to further brain degeneration, including memory difficulties and the inability to manage daily activities, explained Giffords’s Tucson-based speech and language pathologist, Fabi Hirsch.

The struggles of aphasia sufferers like Giffords to make themselves understood can cause mounting frustration. When a member of my extended family, G.K., developed anomia, we explained that she was “losing her nouns,” and we became pretty good at figuring out what word she was searching for. But conversations became more difficult for her, and probably tiring; and she began speaking less often. G.K’s eventual diagnosis of dementia was an example of aphasia that eventually leads to cognitive impairment.

A specific frustration for those with jargon aphasia is the similarity of their garbled speech to that of schizophrenia patients—including poverty of content, perseverative speech and delays in responding, write Duke psychiatrist Zachary Paul Lane and colleagues. But among differences between the two, the psychiatrists explain, schizophrenia patients often speak with flat intonation and unusual voice quality. Compared with aphasia sufferers, schizophrenics generally “display a greater mastery of language, employing more complex word usage and better use of lexical rules for sentence structure;” also, their speech is “more circumstantial, more tangential and tends to have persistent themes, sometimes becoming bizarre or delusional.”

When I participated in the writing class with the word-salad woman, and later when I spent a lot of time with G.K., I had no understanding of their challenges. In both cases, despite wishing to be thoughtful about disabilities, I was impatient. Now that I know more— and have lost a few of my own nouns—I hope to show more kindness to anyone who struggles to speak.

—Mary Carpenter regularly reports on need-to-know topics in health and medicine.