I. Definition
The term aphasia has been coined for more than 100 years and there are various definitions of aphasia, with scholars offering different definitions of aphasia from their own observations, studies and theories of aphasia. Benson is the name of a person from whom many aphasia ratings are derived. Aphasia is an acquired language disorder that manifests itself when the patient is conscious, has no mental impairment, no severe cognitive impairment, no sensory deficit (decline or loss of hearing or vision), no muscle paralysis of the articulatory organs such as the mouth, throat, or tongue, and no ataxia, but cannot understand the speech of others or himself, cannot say what he wants to say, and cannot understand or write the words and phrases he could read or write before the illness.
In the vast majority of people, the left hemisphere of the brain is the dominant hemisphere. Generally speaking, aphasia is caused by lesions in the dominant hemisphere, but not all patients with brain injury will have aphasia, and even damage to the dominant hemisphere will not necessarily cause aphasia.
They have language learning difficulties due to congenital or early childhood illnesses, and language functions are not acquired; they have language dysfunction but cannot be called aphasic. Disorders of consciousness such as coma and delirium, as well as psychiatric symptoms such as muteness and defiance, and language disorders due to ordinary mental retardation are not considered aphasia. Disorders of peripheral sensory and motor organs such as lesions of the visual and auditory organs that result in difficulty in hearing and reading should not be confused with disorders of spoken and written comprehension. Difficulties in writing due to physical motor disorders or phonological problems due to paralysis of the phonological organs such as the larynx, tongue, and lips are not part of aphasia, although they are both difficulties in language expression. Aphasia also generally does not include perceptual, learning and memory disorders unless they specifically infringe on speech symbols.
Etiology and speech symptoms
(A) Etiology
1. Cerebrovascular lesions (including cerebral thrombosis, cerebral embolism, cerebral hemorrhage, cerebral hemangioma, etc.)
Aphasia is a common cause of aphasia and may occur in more than 30% of stroke patients. The language area is the distribution of the middle and posterior cerebral arteries, so most aphasia is the result of hemorrhage, embolism or thrombosis in the middle or posterior cerebral artery branches. Most of them cause persistent aphasia, but it does not mean that the symptoms of aphasia are fixed.
2.Traumatic brain injury
Aphasia symptoms may vary depending on the location of the trauma. In temporal lobe trauma, Wernicke’s aphasia is more frequent, and ipsilateral hemianopia is seen in the lower quadrant of the visual field. In trauma to the supramarginal gyrus, aphasia is mild, with difficulties in both comprehension and expression, upper extremity monoplegia and upper extremity sensory symptoms, and aphasia. In angular gyrus trauma, there is a mild form of Wernicke’s aphasia, with reading difficulties more prominent and ipsilateral hemianopia as the main symptom. In the Chinese Rehabilitation Research Center where I studied, I could see a large number of young people with aphasia, mostly due to traumatic brain injury.
3.Brain Tumor
Most of the aphasia symptoms in the early stage of brain tumor patients are mostly temporary seizures, or accompanied with partial motor epilepsy, or constitute a precursor symptom of grand mal seizure. Brain tumor can show many types of aphasia, but naming disorder is the most common. Naming aphasia and motor aphasia are the most common persistent symptoms in brain tumor aphasia.
4.Inflammation of brain tissue
Transient aphasia is not rare in encephalitis and meningitis. Otogenic brain abscess often occurs in the temporal lobe, so persistent aphasia is also seen.
Pick’s disease or Alzheimer’s disease should be considered when there is progressive aphasia, no history of stroke, no concomitant hemiparesis, and progressive mental decline. In addition, temporary aphasic symptoms can also be seen in general infectious diseases, such as typhoid fever and pneumonia.
(B) Speech symptoms
1. Listening comprehension disorder
It refers to the reduction or loss of the patient’s ability to understand spoken language, mainly in the form of different degrees of comprehension of words, phrases, long sentences and articles. The hearing comprehension disorder is a common symptom in patients with aphasia, which can be divided into speech recognition disorder and semantic recognition disorder according to the characteristics and degree of hearing comprehension disorder.
(1) Speech recognition disorder manifests as the patient’s inability to correctly identify the speech heard in the case of normal hearing. It is rare and occasional in clinical practice. Patients can hear speech sounds, but they have problems in distinguishing the speech sounds, which is different from the natural sounds of our society.
For example, the patient may repeat “ni-hao” as “yi-yi” or other sounds. Patients may say they do not understand or keep asking each other to repeat, thus giving the impression that they cannot hear the speech. However, the patient’s hearing is normal or only diminished in high frequency hearing on a pure tone audiogram. The typical speech recognition disorder is called pure word deafness and is a rare clinical language comprehension disorder, accounting for approximately 1% of patients with aphasia. This patient has a single pattern of speech recognition impairment and generally has no problems with speaking, reading, or writing.
(2) Semantic comprehension disorder patients have difficulty or are completely unable to understand the meaning expressed by the speech they hear. Patients do not understand even simple words and do not even know the physician’s name when he calls them, probably because there is a problem with the brain’s decoding process for language. The patient is able to correctly identify the speech he hears and therefore can accurately repeat it, but in fact the patient does not understand the content of the repetition. For example, if the examiner asks the patient to perform the command “stick out your tongue,” the patient will repeat “stick out your tongue” but will not be able to perform the command because he or she does not understand the meaning of “stick out your tongue.
Semantic comprehension disorders are common in the following cases: in severe cases, the patient cannot understand the names of common objects in daily life or simple greetings; in moderate aphasia, the patient can understand common nouns, but has difficulty with infrequent words, or can understand nouns, but not verbs; in mild cases, the patient can understand simple sentences, but has difficulty understanding grammatical words, long sentences, and compound sentences. For example, if the examiner says “close your eyes”, the patient can execute the command, but if he says “raise your hands before closing your eyes”, the patient cannot execute the command.
2.Speech expression disorder
It refers to the difficulty in the process of language presentation, and the reduced or lost ability in the process of oral expression such as spontaneous conversation, repetition, naming, etc., which is manifested by the impairment in word finding, phonology, vocabulary, syntax and grammar.
(1) Word finding and naming difficulties
Word finding difficulty refers to the difficulty or inability to name the appropriate word (mostly nouns, verbs, adjectives) during conversation. As a result of word finding difficulties during conversation, patients often experience pauses or even silence, or exhibit repetition of ending words, prepositions, or other function words. All patients with aphasia have varying degrees of word finding difficulties. Naming disorder refers to the patient’s inability to name objects or pictures when confronted with them. Some patients are unable to find the right word and express themselves in a descriptive or illustrative way, a phenomenon known as meandering. For example, the patient cannot say the word “banana”, but can describe some characteristics of bananas to others, such as “edible…sweet…yellow skin…”.
(2) Stressful speech is characterized by intermittent and non-fluent speech, often accompanied by sighing, facial expressions and physical effort.
(3) Mispronunciation clinically aphasia mispronunciation commonly has three types: word-meaning mispronunciation; phonological mispronunciation; neologism.
(4) Miscellaneous language, also known as peculiar language, is manifested by the patient’s ability to speak long and fluent words, but the lack of substantive words, and interspersed with a large number of false words and misspoken words (word-meaning misspoken words and neologisms mainly), so that the words spoken are not understood by the other party.
(5) Stereotyped language is common in more severely ill patients and is manifested by repetitive, fixed, non-random use of specific language, either by stereotyped repetition of single syllables or multiple syllables, such as “um, um”, “mom, mom”, and “no”. Patients in this category answer any question with stereotyped language. Early and complete aphasia in Broca’s aphasia can be characterized by stereotyped language. This language disorder can also be seen in children with autism.
(6) Imitative language manifests itself as mechanical repetition of what the examiner says. For example, if the examiner asks the patient, “How are you today?” the patient will immediately answer “How are you today?”. . Most patients with imitative language also have the phenomenon of completion, that is, the phenomenon of completing the language, such as when the examiner counts “1, 2”, the patient will then count “3, 4 ……”, but in reality The patient does not necessarily understand the true meaning of the numbers.
(7) Repetition disorder is manifested by the patient’s inability to repeat the words, phrases and sentences spoken by the examiner with complete accuracy, and the existence of omission of words, change of sounds, and even change of meaning. Severe aphasic patients, such as those with complete aphasia, are almost completely unable to repeat themselves. The presence or absence of dysarthria in aphasic patients is also an important basis for the classification of aphasia. For example, patients with lateral perisylvian aphasia syndrome have dysarthria, whereas patients with watershed aphasia syndrome have a relatively preserved ability to retell.
(8) Perseverative disorder is characterized by the patient repeating the same syllable, phrase or sentence in oral expression. The patient still answered “elephant”.
(9) Grammatical disorder is the inability to express the meaning correctly and completely according to the rules of grammar, including dysgrammatism and grammatical disorder.
(i) dysgrammatism refers to the patient’s expression with a pile of nouns and verbs listed mostly, lacking grammatical structure, similar to the telegraphic style, called telegraphic speech.
(2) Grammatical disorder refers to the presence of real and imaginary words in sentences, but with wrong wording, resulting in disordered body structure and unclear hierarchy.
(10) Articulation disorders are manifested as vague speech, unclear spelling or difficulty in pronouncing monophthongs, and in severe cases, only vocalization is possible. In moderate disorders, there can be separation of casual speech and intentional expression, that is, deliberate expression is obviously less than casual speech, imitating language pronunciation is less than spontaneous language, with rhyme disorder and four-voice error. This kind of dysarthria is different from dysarthria, and the pronunciation errors are variable, mostly due to speech disuse.
3.Dyslexia
Also known as dyslexia, it is brain damage resulting in loss or impairment of the ability to read acquired words (written language), which may or may not be accompanied by dyslexia. Reading includes both reading aloud and comprehension of the text, and the two can appear separate. Reading comprehension disorder is also referred to as morphosyntactic dyslexia, and dyslexia is also referred to as morphosyntactic dyslexia. Dyslexia’s reading comprehension of text is also manifested in the hierarchy of utterances. Some patients can read words or phrases aloud correctly and word-image matching can be accomplished, but they cannot understand the meaning of the utterance.
(1) Patients with form, sound, and meaning dyslexia can neither read the words aloud correctly nor understand the meaning of the words. This is manifested by the incorrect matching of words and pictures, or the complete inability to match words with pictures or objects.
(2) Form and meaning dyslexia can read words aloud correctly, but cannot understand the meaning of the words.
(3) The misreading of form and meaning cannot be read aloud correctly, but the meaning of the words can be understood. This can be manifested as the phenomenon of mispronunciation, such as reading “apple” as “banana”, reading “hat” as “scarf “etc. Such patients can complete the matching of words with pictures or objects.
4.Writing Disorder
Writing is a form of language expression that is more complex than other language functions. In addition to language itself, writing also involves visual, auditory, kinesthetic, visuospatial, and motor involvement. A disorder in any of these areas can affect writing function. Dysgraphia can be distinguished as aphasic dysgraphia and non-aphasic dysgraphia. There are several common manifestations of dysgraphia in aphasia, as follows.
(1) Complete inability to write is the most serious writing problem, manifested by the patient’s inability to write only one or two simple strokes, irregular dots or scribbles, or to write any recognizable paraphernalia or Chinese characters, often seen in large areas of damage to the dominant hemisphere of the brain for language.
(2) Dysgraphia is the most common writing problem and is mainly manifested by various defects in the structure of the written characters. For example, additions or omissions of strokes, missing or substituted radicals, or even new characters that have no resemblance to the target character but conform to the rules of Chinese word formation but are not found in the Chinese character system.
(3) Mirror writing shows that although the strokes are correct, the left and right sides of the written character are reversed, like the character in a mirror. Two types of expressions can be seen.
(i) Partial mirroring, in which the positions of the left and right partials of the text are exchanged, but each partial is orthographically like the other.
② complete mirror image, for the entire text’s left and right side reversed. The mirror image writing is mostly seen in patients with right-sided hemiplegia who write with the left hand instead.
(4) Pictorial writing is characterized by drawing a picture instead of a word that cannot be written, such as drawing a circle instead of the word “circle” or drawing a curved moon instead of the word “moon”.
(5) Inert writing is manifested by the patient’s inability to make corresponding changes in writing with the change of writing instructions. The patient is often able to execute the first writing instruction as required, but keeps writing the same content repeatedly when executing subsequent instructions, similar to the persistent disorder in oral expression.
(6) Excessive writing is manifested as writing mixed with irrelevant words, phrases or constructed sentences.