Perspectives on Agrammatism

Roelien Bastiaanse, Cynthia K. Thompson, Roelien Bastiaanse, Cynthia K. Thompson

• Publisher: Psychology Press
• Year: 2012
• Print ISBN: 9781848720558
• eBook ISBN: 9781136320811
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Agrammatic aphasia (agrammatism), resulting from brain damage to regions of the brain involved in language processing, affects grammatical aspects of language. Therefore, research examining language breakdown (and recovery) patterns in agrammatism is of great interest and importance to linguists, neurolinguists, neuropsychologists, neurologists, psycholinguists and speech and language pathologists from all over the world. Research in agrammatism, studied across languages and from different perspectives, provides information about the grammatical structures that are affected by brain damage, their nature, and how language (and the brain) recovers from brain damage.

The chapters in this book focus on the symptoms that arise in agrammatic aphasia at the lexical, morphological and sentence level and address these impairments from neurolinguistic, neuropsychological and neurological perspectives. Special attention is given to methods for assessment and treatment of agrammatism and to the neurobiological changes that can result from the treatments.

Perspectives on Agrammatism provides an up-to-date overview of research that has been done over the past two decades. With contributions from the most influential aphasiologists from Europe and the United States, it provides an indispensable reference for students and academics in the field of language disorders.

1 Introduction to agrammatism

Cynthia K. Thompson and Roelien Bastiaanse

The study of agrammatism has undergone a considerable transformation in the last two decades. We, therefore, offer Perspectives on Agrammatism, which consists of chapters reviewing contemporary issues, theories, and research on this intriguing disorder. The chapters are written from different perspectives by experts in the field, representing several disciplines within neurolinguistics and aphasiology, including communication sciences and disorders, linguistics, neurology, and psychology.

Definition of agrammatism

Agrammatism was initially characterized as affecting the linguistic structure of sentence production. For example, an aphasic person described by Deleuze in 1898 used only the infinitive form of verbs and no pronouns (cited in Pitres 1898). This idea prevailed in reports of agrammatism published up to the 1960s and early 1970s. Alajouanine (1968) suggested the following constellation of deficits: “reduction of the sentence to its skeleton, relative abundance of substantives, almost invariable use of verbs in the infinitive, with suppression of the small words (the function words of language) and loss of grammatical differentiation of tense, gender, number, as well as of subordination” (p. 84). In 1973 Tissot, Mouonin and Lhermitte described agrammatism as including the following:

(a) deletion of function words;

(b) production of a predominance of nouns, at the expense of verbs;

(c) loss of verb inflection, with substitution of the infinitive for finite verb forms;

(d) loss of agreement of person, number, and gender.

Salomon (1914) and other contemporaries, including Arnold Pick (1851–1924), favored the idea that these production patterns resulted from the effort required to produce speech, suggesting that deletion of semantically uninformative morphemes is an adaptation made for the sake of economy of effort. Pick (1913) suggested that the impoverished grammar of aphasic speakers was a regression from “conventional syntax” to the “syntax of thoughts” and the typical telegraphic speech was the consequence of an economy principle of the damaged cerebral organ, resulting in omission of redundant elements (i.e. free-standing and bound grammatical morphemes). Agrammatism, in Pick’s words, could be considered “Notsprache” (“emergency speech”), reflecting adaptation to the deficit. Pick’s ideas can be seen as the predecessor of the adaptation theory as formulated by Kolk (Kolk & Heeschen 1990; see later).

Jakobson (1896–1982), one of the first linguists to study aphasia, favored more linguistically based ideas. For example, Jakobson (1956b) argued that all forms of aphasia could be reduced to two basic types associated with paradigmatic (selection) and syntagmatic (combinatorial) poles of language. In the first case, the aphasic speaker cannot select correct items from a class of elements; whereas, in the second case he/she is unable to combine linguistic elements. The latter, a breakdown of the syntagmatic pole, was termed a “contiguity disorder,” expressed in agrammatism, where the linguistic elements that encode relationships between content words tend to disappear from speech.

In more recent literature, agrammatism is defined as a language disorder resulting from acquired brain damage, characterized by non-fluent speech with reduced speech rate and short, grammatically impoverished sentences in which syntactic and morphological devices are limited. Word order difficulty, omission or substitution of bound and/or free-standing grammatical morphemes, and omission or nominalization of main verbs are common (Goodglass & Menn 1985). Consider the following selected utterances produced by a 41-year-old gentleman with agrammatic aphasia, illustrating many of these characteristics. He is telling the story of Cinderella:

Cinderella uh scrubbing and uh hard worker. Step fa … mother uh go, but no. Scrubbing uh uh whatchacallit uh uh working. Stepmother … really ugly. Dress break, stepmother and … now what dress? Mother Teresa … not exactly, uh uh magic … godmother! Dress … beautiful and carriage where? I can uh pumpkin and uh servants and horse and beautiful carriage and so magic. But, better midnight … pumpkin carriage gone. Midnight uh clock uh Cinderella clock! Slipper fall. Prince can’t uh uh … stepmother fitting slipper? Cinderella where? Well locked. Sure enough fits … because Cinderella uh magic uh girl. And probably uh prince and Cinderella marrying and … happy. That’s it.

All utterances are short and simple in structure. Two wh-questions are produced (“carriage where?” and “Cinderella where?”) in which the wh-words have not been topicalized. There is only one embedding (“because Cinderella magic girl”) that lacks a verb. There is an overall reduction in production of verbs compared to nouns, with many utterances lacking a verb. In addition, when verbs are produced, they often are not inflected for tense and agreement (“pumpkin carriage gone”; “stepmother fitting slipper”). Also, most noun phrases lack articles (“pumpkin and servants and horse and beautiful carriage”). The style with predominantly content words and a lack of free and bound grammatical morphemes is often referred to as “telegraphic speech.”

Importantly, the symptoms of agrammatism vary somewhat depending on the language. For example, in languages that have no inflected verbs, such as Chinese and Indonesian, no tense and agreement omissions or substitutions are produced and case errors on determiners and nouns are only found in languages that have overt case inflections, such as German, Finnish, and Turkish.

It was Salomon (1914) who first proposed the existence of a disorder of syntactic comprehension in agrammatism. Although rejected by other contemporaries of the early 20th century, including Isserlin (1922) and Kleist (1916), experimental reports published in the 1970s confirmed that the agrammatism of Broca’s aphasia extends to comprehension (Parisi & Pizzamiglio 1970; Zurif & Caramazza 1976; Zurif, Caramazza, & Meyerson 1972). For example, Caramazza and Zurif (1976) showed that individuals with Broca’s aphasia had problems determining who did what to whom in semantically reversible sentences, such as the girl that the boy is pushing is blonde. Thus modern definitions of agrammatism include asyntactic comprehension as one of its characteristics, although the primacy of the production deficit as a defining characteristic of agrammatism remains today.

One important aspect of agrammatism is that not all agrammatic speakers present with all of the symptoms associated with the disorder. Further, in many agrammatic speakers dissociations exist between and among these characteristic symptoms. For example, some present with production, but not comprehension deficits; some present with word order, but not functional category deficits, etc. In addition, agrammatic individuals with word order deficits do not show impairments for all sentence types and those with functional category deficits may show difficulty with production of some grammatical morphemes in the face of a sparing of others. In one interesting study, Miceli et al. (1983) described two agrammatic Italian speakers. Both showed characteristics of agrammatism in spontaneous speech: omission of articles and prepositions and the use of infinitives for finite verb forms. However, the utterances of one agrammatic speaker were largely comprised of disjoint sequences of phrases, with the main verb omitted in 20% of sentences, whereas, the other agrammatic speaker rarely omitted verbs, but presented with two to three times more omissions of articles and prepositions than the first one. Miceli et al. (1983) concluded that the first case suffered from a moderate syntactic deficit and the second case from a morphological deficit, providing evidence that the two domains of language are dissociable. Because of such variability inherent across individuals with agrammatism, some modern experimental aphasiologists caution against studying groups of agrammatic speakers, suggesting that case studies are better suited for studying agrammatism, and hence revealing the nature of disorder (and other aphasic symptoms). Others, however, reject this position. In Chapter 3 (this volume), this issue is addressed by Caplan.

Kolk and Heeschen (1992) provide another explanation for the variable nature of agrammatic speech. According to their adaptation theory, aphasic speakers show various overt speech patterns based on how they adapt to the aphasia, rather than as a manifestation of an underlying syntactic or morphological impairment. In the face of inability to formulate sentences, some aphasic speakers adapt by using an alternative register: the register of ellipses, in which free and bound morphemes are kept to a minimum. Ellipses (for example “write letter” instead of “I am writing a letter”) require reduced processing costs. That is, working memory demands are minimized because fewer words and a reduced amount of syntactic information are involved in processing. This “preventive adaptation” results in a telegraphic speech pattern. Other aphasic speakers may use “corrective adaptation,” whereby sentences are started and restarted over and over, and others show vulnerability to free and bound grammatical morphemes, which are often substituted. This latter pattern is what Kolk and Heeschen (1992) call “paragrammatism.” Importantly, aphasic speakers may not necessarily be aware of the strategy they use and different strategies may be used on different occasions. Indeed, Bastiaanse (1995) described a single agrammatic speaker who, in one interview with an examiner, used two different registers: one characterized by use of relatively few verbs and a lack of free and bound grammatical morphemes, a preventive adaption per Kolk and Heeschen (1992) and similar to the syntactic impairment of Miceli and colleagues’ (1983) first case. The other agrammitic individuals speech was characterized by false starts, substitutions of free and bound grammatical morphemes and the use of verbs in almost every utterance (albeit not always with the correct inflection), a corrective adaptation on Kolk and Heeschen’s (1992) account and akin to the second case of Miceli et al. (1983). This discussion demonstrates that there is considerable variability in patterns of agrammatic speech. De Bleser et al. further address this issue in Chapter 8 (this volume). Also see Chapter 9 (Webster and Howard) for discussion of variability relevant to assessment of agrammatic language and (Faroqi-Shah & Thompson) relevant to treatment of agrammatism.

Agrammatism and Broca’s aphasia

Agrammatism is associated with Broca’s aphasia. Notably, as we discuss later, Broca did not describe the grammatical impairments that are today associated with Broca’s aphasia. Rather he focused on the “faculty of articulate language” and termed the deficit aphémie. On some accounts this deficit closely resembles apraxia of speech. The term aphasia was first used by Armand Trousseau (1801–1867) and the term Broca’s aphasia was probably introduced by Ogle (1867; see also Tesak & Code 2008). Since then, several terms have been used to refer to Broca’s aphasia, including acataphasia (Steinthal 1871), motor aphasia (introduced by Wernicke 1874, but used also by Goldstein 1933), verbal aphasia (Head 1926), expressive aphasia (Weisenburg and McBride, 1934), syntactic aphasia (Wepman & Jones, 1964) and efferent/kinetic motor aphasia (terms used by Luria 1970). The term agrammatism was introduced in 1877 by Adolf Kussmaul (1822–1902) and later used by Kleist (1916) and Pick (1913). For them, agrammatism was considered a single symptom within a larger syndrome of Broca’s aphasia. However, notably, Kussmaul (1877) identified two associated grammatical impairments: agrammatismus and akataphasie. Agrammatismus referred to the inability to inflect words, resulting in omissions and substitutions of (bound) grammatical morphemes, whereas akataphasie was associated with the inability to order words syntactically. In Chapter 8, De Bleser et al. discuss early German contributions to our understanding of the mechanisms underlying agrammatism.

Modern definitions of Broca’s aphasia are very similar to that of agrammatism discussed above (see Goodglass & Kaplan 1972, 1983). Individuals with Broca’s aphasia present with “awkward articulation, limited vocabulary, restricted grammar to the simplest and most overlearned forms, with deletion of obligatory grammatical words (…) and auditory comprehension is relatively preserved” (Goodglass, Kaplan & Barresi 2001: 61). This definition encompasses both grammatical and articulatory aspects of the disorder. Albert et al. (1981) expressed the relation between Broca’s aphasia and agrammatism as follows: “The speech patterns in Broca’s dysphasia (i.e., aphasia) vary from patient to patient along a continuum ranging from pure apraxia of speech with minimal agrammatism to relatively pure agrammatism” (p. 71). Indeed, agrammatism has evolved into a loosely defined syndrome in its own right and for some it is the central defining feature of a redefined syndrome of Broca’s aphasia (Berndt & Caramazza 1980). The present book, therefore, uses the term agrammatism throughout.

Broca’s aphasia and Broca’s area

Perspectives on Agrammatism appears 150 years after the death of Paul Broca’s first patient with speech disorders, Monsieur Leborgne (†1861). Leborgne and other individuals studied by Broca, a surgeon at the hospital Bicêtre in Paris, an anthropologist and secretary of the Association for Anthropology, are important to the field of aphasiology in general, and to the study of agrammatism, in particular, providing impetus for early theories and classifications of aphasia, which paved the way for modern studies of agrammatism. Monsieur Leborgne, a patient in the hospital Bicêtre for 21 years, came to Broca’s attention shortly before his death at age 57. Leborgne was originally hospitalized for mutism in 1840 at the age of 30, with ability to produce only the word “tan”, repeatedly (e.g., “tan, tan”) and occasionally the profanity “sacré nom de Dieu.” He was reported to understand everything that was said to him, respond appropriately, and communicate his needs and wants in spite of limited verbal ability. After approximately 10 years in the hospital, Leborgne experienced right upper extremity paresis and right facial weakness, and three years later, his right leg, in which he eventually developed gangrene, became paralyzed. Broca treated his leg, but was intrigued by Leborgne’s language deficit because of his interests in the then ongoing debate about the localization of language in the brain. Jean-Baptiste Bouillaud (1796–1881), for example, a follower of Franz-Joseph Gall’s phrenology theory, argued in 1830 and 1848, based on his own observations of neurologically impaired individuals, that language was located in the frontal lobes, in particular in the region above the eye sockets (supra-orbital area). Broca even invited a colleague, Ernest Aubertin (1825–1893), Bouillaud’s son-in-law and a proponent of his theory, to examine Leborgne and based on the results, Aubertin conjectured that Leborgne’s brain would be lesioned in the anterior lobes.

Following Leborgne’s death on April 17, 1861, Broca undertook an in-depth examination of his brain, which confirmed a lesion the size of a hen’s egg in the left frontal lobe. Using a probe, Broca first punctured a lateral cyst, located in the inferior frontal region and subsequently pierced adjacent tissue, checking for gray matter consistency. Results showed a lesion extending anterior, medial and posterior to the cyst (i.e., to the parietal operculum), which he divided into regions associated with the three stages of Leborgne’s illness. The first stage, lasting approximately 10 years and responsible for his compromised language was at the so-called “foot” of the third frontal gyrus and possibly extended to the second frontal convolution; the second stage of his illness, responsible for his right arm and facial paresis, was associated with “soft” tissue adjacent to the motor strip; and the third, responsible for the paralysis of his right leg, included posterior and more widespread involvement of the motor strip. One day later, on April 18, 1861, Broca presented Leborgne’s brain and the history of his illness to the Société d’Anthropologie and subsequently published his findings in August, 1861. In that paper he referred to Leborgne as having an isolated problem associated with the “faculty of articulate language.” The actual brain of Leborgne as displayed at the Musée Dupuytren in Paris (together with other brain specimens from patients studied by Broca) is shown in Figure 1.1.

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Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures and Tables
• List of contributors
• Series Preface
• 1. Introduction to agrammatism
• 2. Linguistic accounts of agrammatic aphasia
• 3. Resource reduction accounts of syntactically based comprehension disorders
• 4. Neurological accounts of agrammatism
• 5. Lexical impairment in agrammatism
• 6. Morphological aspects of agrammatic aphasia
• 7. Lexical, inflectional, and clitic morphology: Evidence from an agrammatic aphasic individual
• 8. Agrammatism at the sentence level: The role of morphology and prosody
• 9. Assessment of agrammatic language
• 10. Approaches to treatment of agrammatism
• References
• Author index
• Subject Index