Psychopathology of Speech and Communication in Non-Psychiatric Patients
Ramon A. Boza MD
Associate Professor University of Miami, Department of Psychiatry. Voluntary Faculty. Psychiatrist, Miami Veterans Administration Outpatient Clinic, Clinical Associate Faculty School of Pharmacy, Florida AM University
S. George Hanna MD
Associate Professor University of Miami, Department of Psychiatry. Voluntary Faculty. Manager, Psychiatric Services Miami Veterans Administration Medical Center
Jack Reich MSW
Social Worker, Miami VA Mental Hygiene Clinic (MHC)
The whole world spoke the same language,
using the same words - Genesis 11:1
Speech symptomatology has been reported since the original clinical descriptions of the founders of Modern Psychiatry, such as Pinel, Kraepelin, Kahlbaum, and others. In fact, the first organised description of the Mental Status, done by Adolph Meyer, made special emphasis on the pathological characteristic of speech, its delivery, content, feeling tone, and became a fundamental part of the diagnostic process. Neurolingustics has focused on issues related to speech and its relationship with personality development, normal and pathological, and has found in N. Chomsky, from MIT, one of its most prominent proponents. He holds that there is a "universal grammar" genetically pre-wired into the brain, regardless of the language a child might be brought up using.
In this review, we will limit ourselves to some unusual, specific, somewhat rare cases of speech pathology, seen during the last 30 years in our Academic practice at the Universities of Miami and Maryland, Departments of Psychiatry, and the Miami Veterans Administration Hospital, as well as a review, through MEDLINE, of relevant literature up to May 1999. We also touch upon the history, and development of spoken and written language. Therefore we will not deal with the most frequent forms of expressive and receptive aphasias, dysarthrias, and other clear cut neurological or psychiatric entities.
It is believed that the original roots of many of our European languages come from a Proto-Indo-European language developed about 5 millennia ago (9) which eventually branched into 10-12 linguistic limbs. Proximity within some of its particular
branches, Germanic, Italic and the like, could account for some of the easily found -
sliding - from language to language in todays multicultural world . One of the earliest reported phenomena found among stroke patients, was the so described Pitres rule (11) in which patients who had the use of more than one language, shortly after a cerebro-vascular accident, reverted to their mothers tongue, even though they may ultimately return to the most recently acquired languages. .
The first attempts in written language probably had to do with accountability of goods, such as sheep, oil, and wine. They were kept as tokens within stamped and sealed cylinders. In the third millennium BC Sumerian-Akadian, written language began to develop using clay tablets and cuneiform characters. Certain grammatical elements such as prefixes, suffixes, conjunctions, and adverbs needed for precise understanding were still absent. (27) Alphabets seemingly arose only once among the Semitic tongues during the second millennium BC. These proved to be quite superior to hieroglyphic or iconic based languages.
In our contemporary age, we see how languages enrich each other, by acquiring and modifying some of our contemporary languages. So, we may have anglicized French, and English or Spanish with gallicisms, all in spite of the efforts of Language Academies, and even legal sanctions for the misuse of such terms in advertisement, publications, official documents, etc. We also witness the multiplication of patois, pidgin , papiamento and dialects, in some instances reminding us of a sophisticated "child talk" and still connected with their tree predecessor. Also, new kinds of literacies have emerged and are related to the creation of codes of intelligenc agencies, artificial world languages such as Esperanto, Interlingua, Interglossa, new binary and computer languages, and finally non-articulated languages such as Silbo (whistle-talk), drum-talk, smoke signals and American Sign Language (Ameslan or ASL). There are also self-developed signs and symbols transmitted through elementary gestures, winks, "private languages", and other body-languages, etc.
3. PSYCHOPATHOLOGY IN EARLY LANGUAGE DEVELOPMENT
The acquisition of language is dependent on the plasticity of the brain of the child up to the age of 10 to 12. Among the children of Cuban-American exiled families, the ones who came before that critical age, speak English fluently, as learned from school and schoolmates (many of their parents speak mostly Spanish). It easy to notice that many of the children who came as teenagers speak a grammatically perfect English, but with a mellower recognisable accent. It seems as if linguistic mechanisms, emerge bilaterally early in the development of the child, though in time they consolidate in the left hemisphere, approximately in 95 % of right handed persons, and between 30 to 50 % of the left-handed and ambidextrous populations. The left-handed people are most likely to have it on the right-brain, or show more diffuse bilateral cortical representation. This
suggests a possible post-stroke advantage for a more complete language recovery in ambidextrous and left-handed patients.
a) Head Injury in Bilingual Patients:
As it pertains to our clinical interests, this group of Cuban-American may be roughly divided among those younger or older than 40 years of age. In instances of head trauma, the oldest group,in its recovery, retained the Spanish grammar, words, and everyday expressions. The younger group, even though their "mother tongue" was Spanish, were brought up in the US, and in their period of recovery, barely use Spanish except for some endearing, religious expressions, name of ethnic foods, child-like terminology, or expletives.
Ojeman and Whitaker (19) went further in their research with polyglot aphasics. They used the technique of mapping with electrical stimulation of the dominant hemisphere speech centres in polyglot aphasics. One subject was proficient in Dutch and English, the other in Spanish and English. They found that both languages were involved at the Center of the Brocas area; however, peripheral areas in the dominant frontal and parietal lobes were involved in only one of their languages. This could account for the observation that patients may recover one language, then regress to another that perhaps was seldom used.
4. SPEECH PSYCHOPATHOLOGY IN BRAIN DAMAGED ADULTS
a) Left Brain damaged Patients and Musicality :
In cases of expressive aphasias, verbal language is quite impoverished and may be limited to names, verbs, occasional adjectives, and expletives, repetitiously. However, we have often observed seriously speech impaired stroke patients, who nevertheless are able to sing the National anthem , Christmas carols or religious songs, while keeping the exact rhythm and wording ! This may be associated to redundant right brain areas imbued with functions of tonal and musical qualities consistent with J.H. Jacksons classic views of unequal but bilateral cerebral representation.
b) Hemispherectomy Patients:
Since Dandy did the first hemispherectomy on a glioma patient there has been continuous research in this radical intervention and its speech after-effects. Smith (23) reported on a 47 sear old patient with a left hemispherectomy done in a right-handed individual. Eventually at seven months post-surgery, he was able to retrieve some of his "automatic speech", expletives, and old familiar songs, though his "expressive speech" remained impaired. He concluded that the minor hemisphere has considerable capacity, even in the adult, to organise speech and other non-language mechanisms. Sperry (24) in his studies of split-brain patients conceptualised that the left-brain is analytical, verbal, able to abstract, logical, mathematical , digital, and thoughts managed in a linear sequence. The right-hemisphere instead is visuo-spatial, intuitive, musical , simultaneous, analogic, keen in facial recognition and self-dressing.
In Baltimore we had the opportunity of seeing a patient, in his middle twenties, several months after a left hemispherectomy, secondary to intractable seizures. His expressive speech was limited similar to a stroke patient; but he was able to respond to simply worded questions, and was fully attuned to his environment and immediate needs. He was able to sing religious songs of his childhood. On the other hand, there are several reports of patients who had in their childhood commissurotomies, or hemispherectomies, for the treatment of refractory seizures, who developed successfully with excellent life outcomes and a full range of professional and business activities
c) Pathology in the Writing of Japanese Stroke Patients
Geschwind (6) reports the interesting differences among Japanese patients that are used to writing either in Kana (a syllabic writing) or Kanji (ideographic). The Kanji characters stands for both a sound and a meaning very much like Egyptian hieroglyphics did . A patient of Dr. Imura quoted by Geshwind experienced a left brain (Broca) stroke and was able to write a dictated word or phrase in Kanji but not in Kana. Another patient with Wernickes aphasia wrote in Kanji effortlessly, but just generated meaningless disconnected words, very much as any other western patient would. Chinese use only ideograms and their stroke patients will show the same pattern as the Kanji patients.
5. PSYCHOPATHOLOGY OF ACQUIRED NON-VERBAL SPEECH
a) Paralanguage and Prosody:
Paralanguage was a term coined by Henry Rosin, while explaining the complexity of verbal communications. By this he understood, gestures, stressing a syllable or particle of speech, snarls, shrugs, yawns, and body-language that gave specific meaning and context to a phrase or a sentence.
An unsung and by now anonymous, Chief Resident at the August Medical College, made a summary for the first year residents back in the early 60s. He included a paragraph quoted from Elise McCormick (15). that is worth transcribing in its entirety:
- The statement "I think she is very nice" may have a dozen different meanings For instance
1) If said brightly and with a ring of sincerity it probably means that she is indeed very nice.
2) a faintly belligerent attitude with emphasis on the first word., lets us knowthat the lady is so unpopular that only a very courageous person would say anything in herfavour.
3) a flat, expressionless tone conveys the idea that she is quite a bore 4) a slight insidious drawling of "very nice" announces that the speaker could say a great deal more about her, and probably will when she gets a better chance Needless to say all of the above is gender neutral and would apply to any man as well, -
b) Right Hemisphere Functions and Non-Verbal Auditory Cues:
Bear (1) has described the exquisite sensitivity to auditory signals related to emotions in the right hemisphere . Therefore, there are systems related to surveillance, attendance, rapid eye and body orientation, and peripheral scanning to an affectively meaningful target. When lesions are found, they may manifest themselves in neglect, abulia, and apathy. In serious instances these lesions, may also result in anosognosia (2), denial of injury or illnesses, that even may extend to non-physical issues such as personal difficulties, financial worries, and sundry situations.
Kimura, (12) in her studies of dichotic listening, found that the right brain is honed in decoding the emotional tone of non-speech sounds, such as coughing, laughing, crying, and hummed melodies. On the other hand, deaf-mutes trained in ASL , who suffered from left brain strokes, displayed disturbance of their speech-related hand movements very similar to the experienced by normal speakers who sustain such a damage. They still can point, shrug, shake their heads and make sundry gestures, but they have lost their ability to sign. The same deaf-mutes suffering instead from right brain damage were able to sign but appeared to have lost their sense for topographic spaces and are as well unable to perceive things to their left (27)
Weintraub et al (28) believe that prosody is the third element of language (besides grammar and semantics). It entails melodic components of speech that imparts subtle nuances of meaning, and as we saw before, it may impact the connotation of a phrase in a major way .On the other hand, Ross et al (21) advanced the proposition that lesions in the right brain of the language areas, symmetrical to the left side, may produce the so called "aprosodies" . They submits the existence of six different types and they reported one case of "motor aprosodia" in a 47 year old dexterous patient with a left hemiplegia whose voice was characterized by monotonous speech, and inability to repeat sentences with prosodic-affective content, though able to understand it. Their hypothesis was that the left brain is dominant for the propositional components of language, while the right is predominantly involved in modulating its affective components.
Schmitt JJ et al (25) also tested 27 patients with right hemisphere lesions, 25 with left lesions, and 26 normal controls, for unimodal and multimodal recognition of emotional attitude. They found that the right hemisphere is superior for recognition of emotions conveyed by facial and prosodic information as well as recognition of fear. There is also one instance of a teacher who after a transient vascular phenomena in her right brain, found herself unable to convey to her students her affect or interests, either annoyance or enthusiasm, regarding a particular subject . She spoke in a monotone and her only way to make them pay appropriate attention, was either to speak louder, or to lower her pitch. This symptomatology disappeared a few months later.
c) Blindness and Right-Sided Lesions:
Perrier, Belin et al (20) reported a blind woman, fluent in Braille reading who, after suffering from a parieto-occipital lesion in her right brain, was suddenly deprived of her ability to read Braille. Nevertheless she kept her verbal language intact. The authors though that the defect was mainly related to the loss of her haptic and sensorial capabilities residing in her right brain
5. PSYCHOPATHOLOGY OF SPEECH IN NON-PSYCHIATRIC PATIENTS
a) American Sign Language (ASL) and Other languages
Signs and gestures were probably the initial form of communication among primitive men during hunting and dangerous situations, as well as in creative manifestations as found in the Lascaux and Altamira caves. In regard to deaf people the first one that attempted a systematisation was Abbé lEppé, a French priest who created a "methodological signing" on behalf of the French deaf-mute. In the early 19 century Rev. TH. Gallaudet brought the system in the United States that initially was not wholeheartedly welcome since the emphasis was on "oralism". Eventually ASL took hold, inasmuch children below the age of 6 have to learn a language, any language before their linguistic capabilities becomes rigid and ASL seems to be ideally suited . Activists in the deaf community (5) believe English should be a "second language". Linguists has found the ASL is a real living language that has evolved and is able to all kind of literary creativity, puns, poems, grammar except it lacks a written form. ASL is more than a pantomime, there are very subtle forms of communication only understood by another deaf person or a truly skilled hearing individual. Its syntax is spatial, and consists in signs and gestures in front of the "speaker", also facial expressions, eye brow movement, lips pursing, and the like. Bellugi (27) believes this translates to an "unprecedent opportunity to observe how the brain is organised to generate and understand language. Signed language is not related to sounds but to highly visible movements of arms, face and hands.
Furthermore deaf children from deaf parents starts to sign in a "baby babble " about the same time that hearing children start to use non-sense syllables. The deaf think and dream in signs. They believe English is linear, while ASL lets you see everything at the same time. ASL has the same grammatical principles than any other country deafs signing language but gestures are different and they dont understand each other. Bellugi remarks that a deaf Chinese proficient with Chinese sign language, who later on comes to the USA and learns ASL, is able to do it but, carries an accent in his signing (22).
Neville,HJ, Cofery SA, Lawson DL (17) et al. found that early acquisition of ASL include an increase role of the right hemisphere and for the parietal cortex, and this occurs in both hearing and deaf native signers. An increase role of the posterior temporal and occipital area occurs in the deaf native signers and thus me be attributable to auditory deprivation.. The same authors (18) using functional magnetic resonance imaging (fMRI) at 4T observed all groups fearing and deaf processing their native language, English or ASL, displayed strong and repeated activation within classical areas of the left hemisphere. Deaf subjects reading English did not display activation in these regions. Therefore early acquisition of a natural language is important in the expression of a strong bias for these areas to mediate language, regardless of the form of language. Furthermore native signers hearing or deaf showed extensive activation of homologous areas within the right hemisphere, indicating that specific processing requirements of the language in part determine the organisation of the language systems of the brain.
b) Silbo (Whistle- Speech and Drum-Talk:
Critchley Mac Donald (15) has speculated about the nature of other non-verbal languages such as Silbo found mainly in the Island of Gomera in the Canary Island, where the islander of Guanche origin can communicate with each other with an elaborate aural system with a range of up to 5 miles. El "silbador" is able to forward the melodic components of the spoke Spanish in a whistle form. Eventually it has become a "second language" in which some people have a remarkable fluidity, are able to recognise friends and even to crack jokes. A recent TV program brought two distant persons asking help from the other, explaining what happened, and what measures they would take. (13). He also hypothesises that the tonal component of the Drum-Talk, as it has been used by some African tribes with specific bitonal languages, allows them to use drums with high and low pitch. They confront the risk of ambiguity, and for that reason the signaller resorts to various qualifying and explanatory phrases. Some of the terms are rather archaic i.e. in the Kele drum-language. However neither when MacDonald wrote his article, nor in our recent review in the MEDLINE, we were able to find documentation on impairment of the communication capabilities of silbo or drum-talk performes with lateralized brain damage.
c) Ushers Syndrome
Has been defined as a congenital nerve deafness that later on developed blindness secondary to retinitis pigments (autosomal recessive inheritance). A recent article by Konradsson et al. (14) reports that children with profound hearing deficit, and absent vestibular function, have an incidence of about 6 % retinitis pigmentosa with concomitant progressive loss of vision. Patients with the variety of Ushers type 1 (USH-1) are in risk to loose their learned ability to use sign language. They believe that early examinations of vestibular function in infants are essential to use cochlear implant allowing for aural reception at an early age, therefore avoiding the "ultimate double handicap" of deafness and blindness.
However the most sensitive presentation of their predicament was the one presented in a TV series by Oliver Sacks (26). He follows the vicissitudes of a large community of about 800 Acadian deaf-mutes of French-Canadian origin with a great deal of family inbreeding. Because all were born deaf they are very proficient in ASL and have successfully adapted to their hearing deficit. Gradually, many of them start to develop a retinitis with progressive vision deficit. It is characterized by inability to stand glare, tunnel vision that simultaneously restricts their "syntactic space" from expressive hands gesture to a few inches in size. Initially they start to develop a touch sign language, by following the movements of the wrists of the other signer, eventually holding hands and transmitting information in a new kind of code. When asked if they wish to recuperate hearing, they all strongly dismiss it "We were born deaf, ASL is our tongue" but, all would wish to recuperate sight.
d) Paralysis, Mutism with Exceptional Forms of Communication:
Two cases are impressive for what has been called, by one of the Time magazine literary critics as a "Triumph of the Spirit" (4) (3), Jean-Dominique Bauby at age 43 was the chief editor of the French Magazine Elle, when he experienced a devastating unusual stroke of the brain stem, and as a consequence a "locked-in syndrome" . It rendered him totally unable to move to speak, and he had no other means of communication except blinking his left eye to a friends secretary. They developed a special alphabet based in the most frequently found letters in French. He describes, in exquisite and poignant detail the daily inconveniences he had to cope with, such as having the TV too loud, or a fly walking in his nose. .. and not to be able to do anything about it. Also delves with his "diving bell" meaning his corporeal trap. The butterfly is his very much alive imagination and memories. "You can wander in space and time, set out for Tierra del Fuego, or King Midass court. Relates vivid fantasies of cooking or going to best restaurants, including smells. He was able to keep an intense though silent relationship with his children, friends and people who wrote him, until he died two days after his book was published.
Another similar case in highly creative people, is described by Gironella (7) in his visit to the family of the Italian writer Giovanni Papini. In his last years he became progressively weaker, almost blind, and could barely express himself except with some guttural sounds. His granddaughter Anna, was able to translate them and write down essays, letters and the like. She was able to decipher his grunts and noises and made of it an understandable sequence of beautiful phrases. A somewhat similar relationship did develop between Stephen Hawking and one of his disciples in Cambridge, who was able to translate his unintelligible sounds into written formulas, witticisms and the like. Recently Professor Hawking using a computer, has been able to articulate his thoughts in an understandable way. Papini, however eventually did not have the strength to emit his growls, so, with his granddaughter, was able to develop a signal, a change in the rhythm of his breath, to point out a letter pronounced in alphabetic order. The day before his death he was able to compose meaningful prose for his last book "El Juicio Universal".
6. NON-CLINICAL USES OF LANGUAGE
a) Codes and Ciphers
All languages are essentially codes held by people of similar ethnicity, history, etc. However, now we will divert from our theme to discuss different ways to avoid giving understandable information. Instead, hiding, disguising, confusing facts with the purpose to keep some data as a highly classified secret documents. Most frequent perpetrators, may be governments agencies or business firms dedicated to manufacture methods or systems., to keep the adversary, or rival, unaware of the content of a given message. The ingenuity, effort to create "unbreakable codes" are only matched by the similar struggle, the decoders go though to "break it".
Codes consists on tables of equivalency of known words disguised as symbols, letters, digits and the like. They are consistent and predictable systems that are easier to crack. The ciphers have a changing "key" that is essential to open a given message. Historically there has been very ingenious systems, but perhaps the greatest achievement were the ones obtained during W.W.II by the Allies intelligence services. The Germans developed a machine called Enigma that would change daily the key of the cipher. The British developed a formidable team of mathematicians, philologist, scholars from Cambridge, that banded with Alan Taurig , one of the fathers of the modern computer. They developed the "bombe", a sort of device that could quickly calculate the probabilities of a messages key could be found. Some accidents, mistakes and casual events help to find the keys, including the fact that some of the German field officers did not change the key from day to day, or they began to use obscenities, or well known names such as Hollywood actors !! etc. Finally a captured U-boat provided the Enigma machine remarkably similar to the one developed by the British intelligence. During all W.W.II they were able to decipher the messages from the German Navy and the German High Command with decisive results in the Atlantic war. (10)
The Japanese had another machine and system called Purple and their American counterparts were able to figure it out and decode messages from the Japanese Foreign Service, and Department of the Navy. They were able to predict the eventual attack on Pearl Harbour (the date, not the place) and were essential during important operations such as the Midway Naval Battle. No complete Purple machine was ever found except a damaged one in the Japanese Embassy in Berlin after the end of the war.
The American intelligence was able to create a similar one, based in educated guesses, intuition, and a great deal of time, sweat and work.
b) Infrequent Languages used in Intelligence (Navajo)
A group of American soldiers of the Navajo Nation were selected to develop a language that could not be broken by the Japanese. They develop within the Navajo language paraphrases and metaphors such as "hawk diving" for bombers , "eggs" for bombs, and "potatoes" for hand grenades. An American POW officer of Navajo origin was taken to Tokyo, and did recognise the language but not the meaning of the "code within the code". This intelligence success did account for a significant advantage for the American within the Pacific Theatre war.
6. SUMMARY AND CONCLUSIONS:
Some genetic, neurological conditions may bring up amazing compensatory mechanism. This brief review attempts to bring out some of the most conspicuous instances with ethnic, historic and sociological connotations. In the history of the development of languages, and through the efforts of philologists, linguists, epigraphists, cryptoanalyst, they have been able to decipher some time-lost languages, such as the Sumerian, the hieroglyphics through Champollion use of the Rosetta stone, the Maya language, following clues from the contemporary Mayan languages. However, the Mohenjo-Daro script from the Indus civilisation still remain an incognito, though perhaps is an precursor of the present day southern Indias Dravidian tongue.. Neither Etruscan inscriptions, nor the Elamite from Irak has been broken as yet and remains "unknown codes". Nevertheless it remains a hopeful adage the saying "If a man can made a code, another one would eventually be able to break it" . It up to us clinicians, to understand and translate our patient efforts in communication, and to make our contact with them a meaningful one. It also may open the door to discern their inner mechanisms of its pathology, and their attempts to compensate their deficits.
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