A Rare Disease?
Aphasia happens when a person has difficulty with their language or speech. It’s usually caused by damage to the left side of the brain (for example, after a stroke). Aphasia can also arise from brain tumours, brain infections, or a neurodegenerative disease, although the latter is far less prevalent.
At the end of March 2022, the world’s press announced that American actor Bruce Willis had decided to end his acting career of more than forty years after a recent aphasia diagnosis. The news was first reported in The New York Times. Willis’ ex-wife, actress Demi Moore, announced it on her Instagram page, the Times said. Although highlighting a somewhat rare disorder, it turns out not to be so rare after all. To be diagnosed with aphasia, a person’s speech or language must be significantly impaired in one (or more) of the four aspects of communication following acquired brain injury. In the case of progressive aphasia, it must have significantly declined over a short period of time. The four aspects of communication are auditory comprehension, verbal expression, reading and writing, and functional communication.
The difficulties of people with aphasia can range from occasional trouble in finding words to the loss of the ability to speak, read, or write. However, intelligence is unaffected. Expressive language and receptive language can both be affected as well. Aphasia also affects visual language, such as sign language. In contrast, the use of formulaic expressions in everyday communication is often preserved. For example, while a person with aphasia, particularly expressive aphasia (Broca’s aphasia), may be unable to ask a loved one when their birthday is, they may still be able to sing “Happy Birthday”. One prevalent deficit in aphasias is anomia, which may be explained as difficulty finding the correct word in communication.
With aphasia, one or more brain communication modes have been damaged and are functioning incorrectly. Aphasia is not caused by damage to the brain that results in motor or sensory deficits, which produces abnormal speech; that is, aphasia is not related to the mechanics of speech but rather the individual’s language cognition (although a person can have both problems, particularly if they suffered a hemorrhage that damaged a large area of the brain). An individual’s “language” is the socially shared set of rules, as well as the thought processes that go behind verbalised speech. It is not a result of a more peripheral motor or sensory difficulty, such as paralysis affecting the speech muscles or a general hearing impairment.
How widespread is Aphasia?
Aphasia affects about 2 million people in the USA and 250,000 people in Great Britain. Nearly 180,000 people acquire the disorder every year in the USA alone. Any person of any age can develop aphasia, given that it is often caused by a traumatic injury. However, people who are middle-aged and older are the most likely to acquire aphasia, as the other etiologies are more likely at older ages – for example, approximately 75% of all strokes occur in individuals over the age of 65. Strokes account for most documented cases of aphasia: 25% to 40% of people who survive a stroke develop aphasia as a result of damage to the language-processing regions of the brain.
Apart from the number of people affected by aphasia, statistics drawn from the latest survey summarised on The National Aphasia Association website show that:
- More people have aphasia than have many other common conditions, including cerebral palsy, multiple sclerosis, Parkinson’s disease, or muscular dystrophy.
- Stroke is a leading cause of long-term disability.
- After heart disease and cancer, stroke is the third leading cause of death in the USA and Great Britain.
- About 5,000,000 people survived strokes in the USA.
- About 750,000 strokes occur each year in the USA.
- About a third (225,000) of strokes cause aphasia in the USA each year.
The human brain has two halves. Language skills are in the left half of the brain in most people. Damage to that side of the brain may lead to language problems. Damage to the right side of your brain may cause other problems, such as poor attention or memory.
Aphasia may make it hard for people with the condition to understand, speak, read, or write. It does not make you less smart or cause problems with how they think. Brain damage can also cause other problems along with aphasia. There may be muscle weakness in the mouth, called dysarthria. There may be trouble getting the muscles in the mouth to move the right way to say words – a condition called apraxia. There can also be swallowing problems – called dysphagia.
Broca’s and Wernicke’s area of the Human Brain
Taken from NIH publication 97-4257, https://www.nidcd.nih.gov/health/aphasia (https://www.nidcd.nih.gov/sites/default/files/Documents/health/voice/Aphasia6-1-16.pdf)
Attribution: See page for author, Public domain, via Wikimedia Commons
File URL: [Recoloured] https://upload.wikimedia.org/wikipedia/commons/0/03/BrocasAreaSmall.png
Image URL: [Recoloured] https://commons.wikimedia.org/wiki/File:BrocasAreaSmall.png
Types of Aphasia
There are different types of aphasia. Each can cause impairment that varies from mild to serious. Common types of aphasia include the following:
- Expressive aphasia (non-fluent). With expressive aphasia, the person knows what they want to say, yet has a hard time communicating it to others. It doesn’t matter whether the person is trying to say or write what they are trying to communicate.
- Receptive aphasia (fluent). With receptive aphasia, the person can hear a voice or read the print but may not understand the meaning of the message. Often, someone with receptive aphasia takes language literally. Their own speech may be disturbed because they do not understand their own language.
- Anomic aphasia. With anomic aphasia, the person has a hard time finding words. This is called anomia. Because of the difficulties, the person struggles to find the right words for speaking and writing.
- Global aphasia. This is the most severe type of aphasia. It is often seen right after someone has a stroke. With global aphasia, the person has a hard time speaking and understanding words. In addition, the person can’t read or write. With a stroke, aphasia may improve with proper therapy.
- Primary progressive aphasia. Primary progressive aphasia is a rare disorder where people slowly lose their ability to talk, read, write, and comprehend what they hear in conversation over a period of time. There’s no treatment to reverse primary progressive aphasia. People with primary progressive aphasia can communicate in ways other than speech. For instance, they might use gestures. And many benefit from a combination of speech therapy and medications.
Wernicke’s aphasia is another name for receptive aphasia. It happens when the area of your brain that controls language called the Wernicke area is damaged. This condition is also called sensory aphasia or fluent aphasia. Broca aphasia is the term for expressive aphasia. People with Broca’s aphasia have trouble saying words but can understand language. They can form ideas and know what they want to say. Yet they can’t form sentences. Wernicke’s aphasia causes you to speak in a jumbled “word salad” that others can’t understand. Broca’s aphasia leaves you with limited language.
Aphasia and Dysphasia – what’s the difference?
- aphasia means a lack of language
- dysphasia means impaired language
There have been calls to use the term ‘aphasia’ regardless of severity. Reasons for doing so include dysphasia being easily confused with the swallowing disorder dysphagia, consumers and speech pathologists preferring the term aphasia, and many languages other than English using a word similar to aphasia. It would appear that the term “aphasia” is more commonly encountered in North America, while “dysphasia” is more frequently found in British literature.
Signs and Symptoms of Aphasia
People with aphasia often have trouble with the four main ways people understand and use language.
- typing or writing
Aphasia affects everyone differently, but most people will have difficulty expressing themselves or understanding things they hear or read.
Aphasia is often classified as “expressive” or “receptive”, depending on whether there are difficulties with understanding or expressing language or both. But most people with aphasia have some trouble with their speaking and will have a mixture of problems with writing, reading and perhaps listening.
Speaking problems are perhaps the most obvious, and people with aphasia may make mistakes with their words. Sometimes, it could be using the wrong sounds in a word, choosing the wrong word altogether, or putting words together incorrectly.
Although aphasia affects a person’s ability to communicate, it doesn’t affect their intelligence.
Aphasia can occur by itself or alongside other disorders, such as visual difficulties, mobility problems, limb weakness, and problems with memory or thinking skills.
People with aphasia may experience any of the following behaviours due to an acquired brain injury, although some of these symptoms may be due to related or concomitant problems, such as dysarthria or apraxia, and not primarily due to aphasia. Aphasia symptoms can vary based on the location of damage in the brain. Signs and symptoms may or may not be present in individuals with aphasia and may vary in severity and level of disruption to communication. Often those with aphasia will try to hide their inability to name objects by using words like thing.
So when asked to name a pencil they may say it is a thing used to write.
Common symptoms are:
- Inability to comprehend language
- Inability to pronounce, not due to muscle paralysis or weakness
- Inability to speak spontaneously
- Inability to form words
- Inability to name objects (anomia)
- Poor enunciation
- Excessive creation and use of personal neologisms
- Inability to repeat a phrase
- Persistent repetition of one syllable, word, or phrase (stereotypies, recurrent/recurring utterances/speech automatism)
- Paraphasia (substituting letters, syllables or words)
- Agrammatism (inability to speak in a grammatically correct fashion)
- Dysprosody (alterations in inflexion, stress, and rhythm)
- Incomplete sentences
- Inability to read
- Inability to write
- Limited verbal output
- Difficulty in naming
- Speech disorder
- Speaking gibberish
- Failure to follow or understand simple requests
The NHS say that people with expressive aphasia may have some of the following signs and symptoms:
- slow and halting speech – with difficulty constructing a sentence
- struggling to get certain words out – such as the names of objects, places or people
- only using basic nouns and verbs – for example, “want drink” or “go town today”
- spelling or grammatical errors
- using a wrong but related word – such as saying “chair” instead of “table”
- including nonsense words or their speech not making sense (speech-sound errors)
If aphasia has been caused by a sudden brain injury, such as a stroke or severe head injury, symptoms usually develop straight after the injury. In cases where there’s gradual damage to the brain due to a condition that gets worse over time, such as dementia or a brain tumour, the symptoms may develop gradually.
Someone with expressive aphasia experiences difficulty communicating their thoughts, ideas and messages to others. This may affect speech, writing, gestures or drawing and causes problems with everyday tasks like using the telephone, writing an email, or speaking to family and friends.
A person with receptive aphasia experiences difficulty understanding things they hear or read. They may also have difficulty interpreting gestures, drawings, numbers and pictures. This can affect everyday activities such as reading an email, managing finances, having conversations, listening to the radio, or following TV programmes. Also, someone with receptive aphasia may have some of the following signs and symptoms:
- difficulty understanding what people say
- difficulty understanding written words
- misinterpreting the meaning of words, gestures, pictures or drawings
- giving responses that may not make sense if they’ve misunderstood questions or comments
- not being aware of their difficulties with understanding, or their own speech errors
Aphasia symptoms associated with Dementia
People with the most common types of dementia, such as Alzheimer’s disease and vascular dementia, usually have a mild form of aphasia. This often involves problems finding words and can affect names, even of people they know well. It doesn’t mean they don’t recognise the person or don’t know who they are, they just can’t access the name or get mixed up.
Primary progressive aphasia (PPA)
This is a rare type of dementia where language is heavily affected. As it’s a primary progressive condition, the symptoms worsen over time. Usually, the first problem people with PPA notice is difficulty finding the right word or remembering somebody’s name. The problems gradually get worse and can include:
- speech becoming hesitant and difficult and making mistakes with the sounds of words or grammar
- forgetting the meaning of complicated words, and later also simple ones, making it more difficult for them to understand other people
- speech becoming more vague and the person having difficulty being specific or clarifying what they’re saying
- becoming less likely to join in with or start conversations
- speech becoming slow with short, simple sentences
A person with PPA may also experience other symptoms later in their illness, including:
- changes in their personality and behaviour
- difficulties with memory and thinking – similar to Alzheimer’s disease
- problems with movement – similar to Parkinson’s disease
Tips for Communicating with someone who has Aphasia
If you have aphasia, you may wish to give these tips to people who try to communicate with you.
Say to them:
To help me talk with you:
- Get my attention before you start speaking.
- Keep eye contact with me. Watch my body language and the gestures I use.
- Talk to me in a quiet place. Turn off the TV or radio.
- Keep your voice at a normal level. You do not need to talk louder unless I ask you to.
- Keep the words you use simple but adult. Don’t “talk down” to me.
- Use shorter sentences. Repeat keywords that you want me to understand.
- Slow down your speech.
- Give me time to speak. It may take me longer. Try not to finish my sentences for me.
- Try using drawings, gestures, writing, and facial expressions. I may understand those better than words sometimes.
- Ask me to draw, write, or point when I am having trouble talking.
- Ask me “yes” and “no” questions. Those are easier than questions that I have to answer in words or sentences.
- Let me make mistakes sometimes. I may not be able to say everything perfectly all the time.
- Let me try to do things for myself. I may need to try a few times. Help me when I ask for it.
Causes of Aphasia
Aphasia is caused by damage to parts of the brain responsible for understanding and producing language.
Common causes include:
- stroke – the most common cause of aphasia
- severe head injury
- a brain tumour
- progressive neurological conditions – conditions that cause the brain and nervous system to become damaged over time, such as dementia
Aphasia can affect people of all ages, but it’s most common in people aged over 65 – simply because strokes and progressive neurological conditions tend to affect older adults.
Aphasia is usually diagnosed after tests carried out by a clinician – either a speech and language therapist or a doctor. They can also help arrange treatment if necessary. These tests often involve simple exercises, such as asking a person to name objects in the room, repeat words and sentences, and read and write.
These tests aim to understand a person’s ability to:
- understand basic speech and grammar
- express words, phrases and sentences
- socially communicate – for example, hold a conversation or understand a joke
- read and write letters, words and sentences
You may receive speech and language therapy on an individual basis or in a group, depending on your needs and the service provided.
An increasing number of computer-based applications are available to support people with aphasia. But it’s important to start using these with the assistance of a speech and language therapist.
How successful treatment is, differs from person to person. Most people with aphasia make some degree of recovery, and some recover fully.
If the aphasia is caused by a one-off event, like a stroke, most patients recover to some degree with therapy. There’s no evidence to suggest that recovery stops at a specific time after a stroke. But the chance of recovery is poorer for people with aphasia resulting from a progressive neurological condition. Some people can still respond to therapy, but there are currently no effective ways of reversing the ongoing injury to the brain.
When aphasia is caused by a progressive condition, treatment focuses on making the most of what people can still do and developing other ways of communicating to prepare for a time when speaking will be more difficult.
How speech and language therapy can help
For people with aphasia, speech and language therapy aims to:
- help restore as much of your speech and language as possible (reduce impairment)
- help you communicate to the best of your ability (increase activity and participation)
- find alternative ways of communicating (use compensatory strategies or aids)
- provide information to patients and their relatives about aphasia
An intensive course of speech and language therapy may be recommended for some people. This involves several sessions given in a short period of time. But speech and language therapy can be exhausting, and an intensive course of treatment won’t be suitable for everyone.
For some people, shorter and less intensive sessions may be recommended. Therapy may be individual sessions, in groups, or using technology such as computer programmes or apps. For many people with aphasia caused by stroke, the most rapid changes are early on in the weeks and months after their stroke. But improvements can continue to be seen many years, and even decades, later.
Assessment before therapy
An assessment will be carried out before therapy begins so the therapist can identify which aspects of language with which you have the most difficulty. The treatment you receive will depend on your general health and the problems you have with your speech, language or social skills.
A therapist will talk to you and your family to try to determine whether your problems are related to understanding language or if you have problems expressing yourself. The assessment will then focus on the areas that need to be targeted in therapy. Other health problems that may impact the ability to communicate, such as hearing or sight problems, will also be considered.
Alternative methods of communication
An important part of speech therapy is finding different ways for you to communicate. The therapist will help you develop alternatives to talking, such as using gestures, writing, drawing or communication charts.
Communication charts are large grids containing letters, words or pictures. They allow someone with aphasia to communicate by pointing at the word or letter to indicate what they want to say.
For some people, specially designed electronic devices, such as voice output communication aids (VOCAs), may be useful. VOCAs use a computer-generated voice to play messages aloud. This can help when a person with aphasia has difficulty speaking but can write or type. There are also apps available for smartphones and computer tablets.
Communicating with a person with aphasia
If you live with or care for a person with aphasia, you may be unsure how best to communicate with them.
You may find the following advice helpful: when speaking to someone with aphasia:
- After speaking, allow the person plenty of time to respond. If a person with aphasia feels rushed or pressured to speak, they may become anxious, affecting their ability to communicate.
- Use short, uncomplicated sentences, and don’t change the topic of conversation too quickly.
- Avoid asking open-ended questions. Closed questions that have a yes or no answer can be better.
- Avoid finishing a person’s sentences or correcting any errors in their language. It may cause resentment and frustration for the person with aphasia.
- Keep distractions (such as background radio or TV noise) to a minimum.
- Use paper and a pen to write down keywords, or draw diagrams or pictures, to help reinforce your message and support their understanding.
- If you don’t understand something a person with aphasia is trying to communicate, don’t pretend you do understand. The person may find this patronising and upsetting.
- Use visual references, such as pointing, gesturing and objects, to support their understanding.
- If they’re having difficulty finding the right word, prompt them – by asking them to describe the word, think of a similar word, to try to visualise it, to think of the sound the word starts with, to try to write the word, use gestures, or point to an object.
Sources and Further Reading
Caution: No advice is implied or given in articles published by us. This guide is for general interest only. It should never be used as a substitute for obtaining advice from your Doctor or other qualified clinician/medical practitioner. The facts are believed to be correct as at the date of publication, but there may be certain errors and omissions for which we cannot be responsible. The hyperlinks were valid at the date of publication.
- Source: NHS at: https://www.nhs.uk/conditions/aphasia/ ↑
- At: https://www.nytimes.com/2022/03/30/movies/bruce-willis-aphasia.html ↑
- The text that follows on this page and the first two paragraphs on page 2, is largely derived from https://en.wikipedia.org/wiki/Aphasia ↑
- Source: https://www.asha.org/public/speech/disorders/Aphasia/ ↑
- Source: Damasio AR (February 1992). “Aphasia”. The New England Journal of Medicine. 326 (8): 531–9. doi:10.1056/NEJM199202203260806. PMID 1732792 ↑
- Source: Stahl B, Van Lancker Sidtis D (2015). “Tapping into neural resources of communication: formulaic language in aphasia therapy”. Frontiers in Psychology. (1526): 1526. doi:10.3389/fpsyg.2015.01526. PMC 4611089. PMID 26539131. ↑
- Source: Manasco MH (2014). Introduction to Neurogenic Communication Disorders. Burlington, MA: Jones & Bartlett Learning. ISBN 978-1-4496-5244-9. ↑
- Source: The National Aphasia Association, at: https://www.aphasia.org/aphasia-resources/aphasia-statistics/ ↑
- According to the National Aphasia Association at: https://www.aphasia.org/aphasia-resources/aphasia-factsheet/ ↑
- Source: https://my.clevelandclinic.org/health/diseases/5502-aphasia ↑
- See Aphasia FAQs at: https://www.aphasia.org/aphasia-faqs/ ↑
- Source https://www.webmd.com/brain/aphasia-causes-symptoms-types-treatments#1 ↑
- At: https://www.aphasia.org/aphasia-resources/aphasia-statistics/ ↑
- Source: https://www.asha.org/public/speech/disorders/Aphasia/ ↑
- Source: https://www.webmd.com/brain/aphasia-causes-symptoms-types-treatments#1 ↑
- See: https://www.webmd.com/brain/what-is-wernickes-aphasia ↑
- Ibid ↑
- Source: Worrall, Linda; Simmons-Mackie, Nina; Wallace, Sarah J; Rose, Tanya; Brady, Marian C; Kong, Anthony Pak Hin; Murray, Laura; Hallowell, Brooke (2016). “Let’s call it “aphasia”: Rationales for eliminating the term “dysphasia””. International Journal of Stroke. 11 (8): 848–851. doi:10.1177/1747493016654487. ISSN 1747-4930. PMID 27384070. S2CID 28020306. ↑
- Sources: “What’s the difference between aphasia, dysphasia and dysarthria?”. Touch Type Read & Spell. And “What is Dysphasia?”. Healthline. 14th December 2017. ↑
- Source: https://www.nhs.uk/conditions/aphasia/treatment/ © Crown Copyright duly acknowledged ↑
- Source: American Speech-Language-Hearing Association (1997-2014) ↑
- Source: Nolen-Hoeksema, S. (2014). Neurodevelopmental and Neurocognitive Disorders. In Abnormal Psychology (6th ed.). New York: McGraw-Hill. ↑
- Source: https://www.nhs.uk/conditions/aphasia/ © Crown Copyright duly acknowledged ↑
- Source: https://www.asha.org/public/speech/disorders/Aphasia/ ↑
- Source: https://www.nhs.uk/conditions/aphasia/treatment/ © Crown Copyright duly acknowledged ↑
- Ibid ↑