bilingual aphasia in iran: a preliminary reportzabanazma.ir/uploads/docs/bilingual...

J. ~~e~~~~i~g~i~ric~, Volume 3, Number 2. pp. 185-232, 1988. 091 l-6044:88 $3.00 + ‘00

Printed in Great Britain 0 1988 Pergamon Press plc

Bilingual Aphasia in Iran: A Preliminary Report

Reza Nilipour

ABSTRACT

Fourteen Farsi speaking bilingual patients with symptoms of aphasia subsequent to either stroke, trauma, AVM or closed head injury, were administered relevant versions of the Bilingual Aphasia Test (Parades and Libben 1987) in order to assess their language deficits in each language and to determine the pattern of recovery of the patients’ respective languages.

The time of the evaluation of these patients ranges from less than two months (acute stage) to 8 years (chronic stage) post-onset. The patients’ages range from 22 to ‘79 years.

The languages involved are Farsi and one or more of the following: Armenian, Azari, English and German. The patterns of recovery and the aphasic symptoms of these patients are discussed in light of the variables associated with differences among bihnguals. etiology and site of lesion.

The pattern of recovery of one patient may change over time. It is suggested that individual variables of language acquisition may influence the pattern of recovery more during the acute stage of the aphasia than during the chronic stage, leading to a different pattern of recovery at each stage.

INTRODUCTION

Ever since Psradis’ (1977) comprehensive review of the literature on bilingual

and/ or polyglot aphasia, many new case studies have been published, with the aim

of improving on the previous methodological shortcomings and specifying the

effect of various relevant factors on the pattern of recovery(Albert and Obler 1978;

Paradis 1983; Vaid 1986). As a result, in the past decade or so, new insights have

been gained into the nature of bilingual aphasia with respect to language represen-

tation in the brain (Paradis 1984; Green 1986) and researchers have begun to

explore bilingual aphasia more systematically and comprehensively as it involves

different patterns of recovery. Yet our knowledge of the nature of the recovery

186 Journal of Neurolinguistics, Volume 3, Number 2 (1988)

pattern, as it interacts with biological, neurological and environmental factors, is

still inadequate.

The insufficiency of our knowledge in the domain of bilingual aphasia and the

scarcity of evidence bearing on the effect of relevant factors on patterns of recovery

have been related to two main factors. namely: (1) the inadequacy of testing

materials; and (2) the lack of sufficient numbers of patients for whom the relevant

parameters are known (see Paradis and Libben 1987, for full discussion).

Yet another shortcoming of the recent literature may be related to the lack of

documented reports on a number of languages with substantial structural differ-

ences. For example, save for Nilipour and Ashayeri’s (1988) study, there is no

comprehensive documented report on Farsi-speaking bilingual aphasics.

The present study seeks to explore bilingual aphasia among a Farsi-speaking

bilingual population, using an equivalent measuring tool across languages, in the

hope that it will shed some light on the complex phenomenon of bilingual aphasia,

and on bilingualism per se.

Iran is a multilingual society where structurally different languages and regional

dialects are spoken. Farsi (or Persian), the official language of Iran, is spoken as a

native language in a large part of the country and as a second language, often the

language of education, by all minorities living within the borders of the Islamic

Republic. Farsi is the medium of instruction in schools and universities. National

mass media broadcast and publish mostly in Farsi. Besides Farsi, two foreign

languages. Arabic and English, are taught from junior high school through

university at the rate of 334 hours per week. German and French may be considered

as options for those who do not take English as a foreign language in high school.

A number of regional and ethnic languages are also spoken throughout the

country. Azari, Kurdish, Arabic, Armenian and Assyrian may be considered as the

languages most structurally distant from Farsi in Iran. They are spoken by a large

number of people.

Based on the recent official census, the population of Iran is about 50 million.

Unfortunately. no documented information is available with regard to the number

of people who are bilingual or multilingual in Farsi and one or two of the local or

ethnic languages. It can be conservatively estimated that close to 10 million

Iranians speak Azari and about 2 million speak Armenian. The large number of

people who have studied and worked in Germany, France, the United States and

England for a number of years and who are therefore fluent in a foreign language

must be added to the multilingual population of Iran.

With respect to writing, Farsi has adopted the Arabic alphabet with some

modifications, adding 4 new graphemes. Like Arabic, it is written from right to left.

Azari and Kurdish are mostly used in the spoken mode, but may be written with the

same alphabet as Farsi. if necessary. Armenian and Assyrian have their specific

Bilingual Aphasia in Iran 187

scripts and are written from left to right.

The subjects of this study comprised 14 adult bilingual or multilingual Farsi-

speaking patients with symptoms of aphasia as a result of cerebrovascular accident

(n=9), trauma (n=3), arteriovenous malformation (n=l) and closed head injury

(n=l). They were all considered fluent speakers of their various languages before

insult. They were referred to the clinic of the Department of Speech Therapy,

College of Rehabilitation Sciences in Tehran for speech therapy because of speech

disorders subsequent to brain damage.

All subjects spoke Farsi, with Azari, Armenian, English and/ or German as their

second or third language. The subjects were either native speakers of two lan-

guages, as in the case of Farsi and Armenian or Azari or they had at least 3 years of

residency and higher education in their second language environment, with the

exception of one subject (K.R.) who had more than 400 hours of instruction in his

second language but no foreign residency. By and large, the subjects had “practical

command of two languages” by Hackett’s (1958:8) criterion.

With respect to other variables associated with differences among bilinguals, no

restrictions were imposed; subjects simply had to be adult bilinguals with a

premorbid practical command of two languages. No restrictions were imposed with

respect to sex, etiology, handedness, post-onset time, site or size of lesion. The

sample represents unselected consecutive entries of bilingual aphasic patients at our

facility.

CASE 1 (T.B.)

T. B. was a 26-year-old right-handed male native speaker of Farsi with English as

his second language. His background in English represents 6 years in high school at

the rate of 3 hours per week and 4 years of college education in English in Canada.

Premorbidly, he was considered a fluent speaker of Farsi and English.

T. B. was a third year student of Journalism in Canada when he began to

experience severe headaches in 1982. He was diagnosed as having arteriovenous

malformation (AVM) and underwent an embolectomy. He was referred to our

clinic for speech therapy in 1984.

Clinical History

T. B. was hospitalized for craniotomy and embolisation in New York on 29

January 1982. He has since undergone 2 additional craniotomies and embolisations

(on 26 May 1982 and 2 February 1983). The craniotomy was performed with

resection of his AVM from the left temporo-parieto-occipital area in each case.

The patient became aphasic with no production in either Farsi or English after

the second operation. It was reported that he did not recognize people nor the


environment 2 months post-onset. He also presented with right hemiplegia and

hemianopsia.

The patient received physical therapy and speech therapy in English while he was

in the United States. His hemiplegia evolved into right hemiparesis but there was no

improvement in his linguistic abilities. His surgeon advised him to go back to Iran

for speech therapy in his mother tongue. The patient did so in May 1984.

A recent CT scan (15 June 1987) confirmed architectural damage and calcifi-

cation of the tissues of the left temporo-parieto-occipital cortex. There were also

signs of hypodensity of the right temporal lobe. There was slight dilatation of the

left ventricle. but no structural change in the ventricles was observed.

Skull radiography showed no fracture or abnormalities in the cranial vault. No

abnormal calcification or signs of increased intracranial pressure were observed.

Language Assessment (October 1984)

T. B. came to our clinic in Tehran when his linguistic abilities in both Farsi and

English were severely impaired subsequent to the AVM operations in the United

States. He was reported to suffer from a mild global aphasia and alexia, with signs

of apraxia and right hemianopsia. He had no gross motor deficit and was able to

ride his bicycle to the clinic. The patient was scheduled to undergo intensive speech

therapy in Farsi 3 times a week for 4 months.

Our evaluation of the patient’s aphasic deficits took place in October 1984 (2

years post-onset). He was given the experimental versions of the Bilingual Aphasia

Test (BAT) in Farsi (Paradis et al. 1987) and English (Paradis et al. 1987).

The Farsi version was administered on 31 October 1984 and the English version 2

weeks later. Both tests were administered by the present author. a native speaker of

Farsi who obtained his Ph.D. in Linguistics.

Figure 1 shows T.B.‘s performance in Farsi and Figure 2 in English. An overview

of the profiles of residual capacities in both languages indicates that Farsi was much

better recovered than English in all modalities. He was totally unable to perform 18

tasks in English and 11 in Farsi. In no task did he obtain a score higher in English

than in Farsi. We were not able to elicit spontaneous speech or writing in either

language. The picture-story description was elicited only in Farsi. As can be seen

(Figures I and 2), the pattern of recovery was differential 2 years post-onset, with

Farsi as the best recovered and English as the most impaired language. It must be

noted that he was in an English language environment before and after the

operation and that speech therapy was first provided in English.

The clinical picture of his aphasic symptoms may be described as reduced fluent

speech without articulatory difficulty, but with evidence of perseveration and of

word-finding difficulty. He had relatively good comprehension and repetition.


Fluency (515. 541; 516. 517; 531, 557)

Accuracy (520, 521; 524-52R; 546, 547; 550-5541

Complexjty (516. 517: 542. 543: 529. 555; 530. 5561

Lerlcal Access (519, 545; 531. 557; 532. 558; 534, 5601

Polntlng l23-321

Simple Conaands 133-37)

SPnl-Complex Cornands (38-42)

Complex Commands 143-471

Vrrbal Auditory Olscrinination (46-65)

Syntactic Comprehension (66-152)

Scmantlc Categortes (153-157)

Synonynr (158-162)

Antonyms (163-1721

trarranaticallty Judgments (173-182)

Senantlc Acceptability (183-1921

Repetition (Words1 1193-2511

Lexical Oecislon (194-252)

Repetltlon (Sentences1 (253-259)

Series 1260-262)

Verbal Fluency (263-2671

Hamrng (269-288)

sentence Construction (269-3131

Semantic Opposites 1314-323)

Oerivational Horpholoqy (X4-333)

Morphological Opposites (334-343)

Mental Arithmetic (347-361)

Listening Comprehension (362-3661

Oral Reading (Words) (367-3761

Oral Reading (Sentences) (377-3861

Reading Comprehenston (Paragraph) (387-3323

Copying (393-397)

Ofctation (Words) (398-402)

01ctation (Sentences) (403-4071

Reading Comprehension Words1 (408-417)

Reading Comprehension (Sentences) (418-4271

spontaneous uriting (813-835)

1 Figure 1. T.B.‘s Farsi Profile on the BAT (November 1984).

190 Journal of Neurolinguistics. Volume 3, Number 2 (1988)

:lucncy (515, 541: 516. 517; 531, 5571

kcuracy i520, 521; 524-528: 546, 547; 550-5541

:omplexity (516, 517; 542. 543: 529. 555; 530, 5561

.exlcal Access (519. 545: 531, 557; 532. 558; 534. 5601

'olntfng f23-321

ilnple Commdndr (33-371

jcmi-Complex Comnnds (38-421

:omplcr Cornnandr (43-47)

/crbdl Auditory 01rCrlnination (48.65)

iyntdctlc Comprehension (66-1521

icmantic Categories (153-157)

jynonyns (158-162)

\ntonyms (163-1721

;ramrnatlcality Judgments (173-1821

jemantlc Acceptability (183-1921

&petitlan (words) (193-251)

.exical Declslon (194-2521

lepetitlon (Sentences1 (253-251)

jerles (260-2621

derbsl Fluency (263-2fi71

Vamlng (269-2881

Sentence Construction (289-313)

Semantic appasltes (314-321)

Derlvational Horphalaqy (324-3331

Yorpnolog~cal opposites (334-3431

Mental Arfthmetic (347-361)

Listening Comprehension (362-366)

Oral Reading (Words) (367-3761

Oral Reading (Sentences) (377-386)

Resdlng Comprehension (Paragraph) (387-392)

Copylllg (393-397)

almtlon (Words) (398-402)

Olctatlon (Sentences1 (403-407)

Reading Comprehension (Uordsl (408-417)

Reading CorQrehension (Sentences) (418-4271

Spontaneous Vriting (813-835)

12 3 4 5 6 7 B 9 I_

Figure 2. T.B.‘s English Profile on the BAT (November 1984).

I 0


He was good at pointing (10 and 9/ 10 in Farsi and English, respectively), but had

difficulty with simple commands (4 and 3/ 5) and semi-complex commands (2 and

2/5). The latter shows the patient’s difficulty with locative prepositions (beside, in

front of, inside). Naming was also severely defective (6 and O/ 20) in both languages,

but more severely in English. Reading and writing tasks were very poor. Only

copying was performed without error in both languages. His reading compre-

hension for single words was relatively spared. Single word repetition was relatively

spared (20 and 22/ 30) but sentence repetition was severely defective (0 and O/ 7). His

description of the picture-story was typical of jargon aphasia. The patient can

therefore be diagnosed as having transcortical motor aphasia (see Paradis and

Libben 1987: Chapter 4, for full discussion).

CASE 2 (H.J.)

H.J. was a 63-year-old right-handed male bilingual speaker of Farsi and Azari.

Since his elementary school days, the patient’s dominant and practical language

had gradually become Farsi. He was well educated and had a Bachelor’s degree in

Law. He was married and had two grown children. His wife and children were

native speakers of Farsi. The patient and his family had lived in the United States

for 3 years. H.J. was referred to our clinic for his aphasic problems following a CVA

syndrome.

Clinical History

H.J.‘s clinical history started with an atria1 fibrillation in June 1983. The patient’s

heart problem led to an embolism which resulted in a coma. He was hospitalised

subsequent to the stroke. The diagnosis was confirmed by his neurologist as left

CVA originating from atria1 fibrillation. Following coma, the patient presented

with right hemiplegia, right hemianopsia, right hemianalgesia and right facial

weakness. He was also reported to have had global aphasia during this period. The

patient was not advised to undergo a head operation but was put under medication

and was prescribed physical therapy before he was released from the hospital (after

2 months). It was reported that he did not produce any speech either in Farsi or

Azari, although he had some comprehension.

Upon arriving home he visited his Azari-speaking brother. This occasion

triggered his use of Azari and he continued to speak Azari with some emotion.

Since then, Azari has become his dominant language. The patient’s home en-

vironment was unilingually Farsi and there was no appropriate occasion for him to

address anybody in Azari. It is reported by his sister that the patient was unable to

switch to Farsi when addressing a Farsi-speaking audience.

A CT scan was obtained while he was in the hospital. It showed extensive


hypodensity in the left temporo-parietal area with a slight similar change in the left

frontal lobe. There were also signs of slight hypodensity in the right occipito-

parietal area.

At the time of his language evaluation H.J. was able to walk but had a weak right

leg. He was well oriented in time and space and remembered events before and after

his neurological problems. No signs of hearing impairment were observed.

Language Assessment (28 September 1983)

H.J. was evaluated for his aphasic deficits with the experimental versions of the

BAT in Farsi and Azari (Paradis et al. 1987) 4 months post-onset. The patient’s oral

expression was believed to be dominantly in Azari at this point.

The patient’s evaluation took place in 3 different sessions. He was first addressed

in Farsi and was asked to talk (in Farsi) about his activities in the past. He spoke in

Azari with occasional phrases in Farsi. His spontaneous speech was fluent. He

complained about his speech problems and his inability to speak as he did before his

illness. When he was finished, he asked whether his speech in Farsi was good (when,

in fact, he was speaking Azari: with only occasional short phrases in Farsi and hence

seemed to be unaware of not speaking Farsi).

The second time we met him, he was again asked to speak in Farsi about his past

activities. He began in Azari again and continued with occasional Farsi phrases.

There were more paraphasic elements among Farsi words than Azari words. His

speech was assessed by M. R. Yaxchi, a native speaker of Azari. We concluded that

individual words and phrases were generally intelligible but that his speech as a

whole was not cohesive and did not appear pragmatically sound. His spontaneous

speech may be characterized as “word salad” in Azari. mixed with some Farsi

words.

The test results are represented in Figure 3. As can be seen. he totally failed I5 of

the tasks. He was unable to complete successfully any of the remaining tasks. Only

on 7 of them was the patient able to obtain a score over 50%. He scored below 50%

in 9 tasks (in addition to his 15 complete failures). This profile shows that the

patient’s residual capacities have been severely impaired across all modalities. Even

pointing, simple commands, single word repetition and automatic speech were

severely impaired.

His pattern of recovery is differential, with Azari being clearly dominant, mixed

with Farsi words and short phrases.

The clinical picture is typical of Wernicke’s aphasia. His language capacities are

characterized by empty speech, with severely impaired comprehension as well as

repetition and even series recitation. His writing was limited to copying.


Fluency (515, 541; 516, 517; 531. 557)

Accuracy 1520, 521; 524-52R; 546, 547; 550-5541

Complexfty (516. 517: 542. 543: 529. 555; 530. 5561

Lexical Access (519, 545; 531. 557; 532, 558; 534, 5601

Pointing (23-323

Siwle Commdnds (33-371

Semi-Complex Cornands (38-421

Complex Cownandr (43-471

Verbal Audltory D~scrlninatlon (46-65)

Syntactic Comprchenrion (66-152)

Scmdntfc Categories 1153-1571

Synonyns 1158-162)

Antonyms (163-172)

Crdnxnatlcdlity Judgments I173-102)

Semantic Acceptabllity (183-192)

Repetitfon IUords) (193-2511

Lexical Oeclsfon (194-252)

Repetition ISentences) (253-2511

Series (260-262)

Verbal Fluency (263-267)

Naming (269-2881

sentence Construction 1289-3131

Semantic Opporltes (314-323)

Derivational Morphology (324-333)

Morphologfcal Opposftcs (334-343)

Mental Arithmetfc (347-361)


Oral Reading (Words) (367-376)


Reading Comprehension (Paragraph) (387-392)

copying (393-397)

Olctatlon (Words) f398-402)

Dictation (Sentences) (403-4071


Reading CornprehensIon (Sentences) (418-427)

spontaneous uriting (813-8353

Figure 3. H.J.‘s Farsi Profile on the BAT (September 1983).


CASE 3 (A.A.)

A.A. was a 46-year-old right-handed male bilingual speaker of Armenian and

Farsi, with 11 years of education. He was married and had two children. He was a

controller technician of electronic devices, The patient became aphasic subsequent

to a thrombo-embolic disease and was referred to our clinic for evaluation and

speech therapy.

Clinical History

In May of 1984, A.A. had a sudden abdominal pain which turned into paralysis

of both legs 3 days later. After 3 days he was able to walk again, but pain was still

present. A diagnosis of slipped disc was made and the patient underwent surgery

involving the fifth lumbar vertebra.

After the operation the pain in his legs was reduced, but both legs felt numb. A

week later, the pain returned but this time in the right leg only. Six weeks later, he

felt generally unwell and fell out of bed during the night. He was then found to be

paralysed on his right side and unable to speak, though he was able to understand.

Six months later, his legs improved so that he could walk with a stick, but the

condition of his right arm had not changed much. His speech improved to the

extent that he made indistinct sounds, but he could not produce words in either

Armenian or Farsi. It is reported that he had right homonymous hemianopsia

during the acute stage of his illness.

The final diagnosis, based on a comprehensive neurological examination per-

formed in England by a British neurologist, was that the stroke had been caused by

thrombo-embolic disease, originating either from the xenograft valves or from the

enlarged left atrium, in combination with atria1 fibrillation. The aortic bifurcation

is believed to have been occluded in May 1984 when his abdominal pain and the

numbness and weakness of the legs began.

Language Assessment (11 March 1985)

The patient’s aphasic deficits were evaluated 1 year post-onset with experimental

versions of the BAT in Farsi and Armenian (Paradis and Essegulian 1987). He was

well oriented in time and space and recognized the people around him. He suffered

from a severe right hemiplegia with a spastic right hand and a very weak right leg.

A.A. was unable to produce spontaneous speech or writing. His oral expression

was so severely impaired that he totally failed the word repetition task (O/30) in

both languages. He was not able to produce any distinct sound sequences. His

comprehension was preserved to some extent but limited to elementary tasks. He

failed semi-complex and complex commands. Pointing (6; 10) and simple com-

mands (3/5) were relatively preserved. His comprehension was better at the word


level than at the sentence level. He obtained somewhat higher scores on auditory

discrimination (lo/ 18) and lexical decision (28/30) tasks, but even lower scores on

syntactic comprehension (28/87) and grammaticality judgment (5/ 10) tasks.

The patient’s overall residual capacities 1 year post-onset reveal a pattern of

parallel recovery of Armenian and Farsi, in the context of a clinical picture of

global aphasia.

CASE 4 (F.Z.)

F.Z. was a 5 1 -year-old right-handed male bilingual speaker of Azari and Farsi,

with 9 years of education. He had been bilingual from early childhood. His father

was also bilingual but his mother spoke only Azari. The patient’s neurological

problems originated in a CVA syndrome. He was referred to our clinic because of

his aphasic deficits.

Clinical History

F.Z. became aphasic subsequent to a CVA syndrome. The patient’s CVA was

diagnosed as the result of occlusion of the left middle cerebral artery. The diagnosis

was later confirmed by an electroencephalogram (EEG) and CT scan obtained on

30 September 1983. The EEG showed a focus with slow waves at the left temporal

lobe. The CT scan revealed a large infarction of the vascular territory of the middle

cerebral artery on the left side. There was no indication of damage to the right

hemisphere. The patient had been previously diagnosed as having global amnesia.

Language Assessment (June 1984)

F.Z. was administered the experimental versions of the BAT in Azari and

English. The Farsi version was administered by the author and the Azari version by

M. Dehghan, a speech therapy student and native speaker of Azari. Figure 4

represents the patient’s profile in Azari and Figure 5 in Farsi. Based on the results

on the BAT, the pattern of recovery appears to be parallel. Only his reading

comprehension was better in Azari than in Farsi (8 and O/ 10 for single words and 2

and O/ 10 for sentences).

The patient’s oral production was free of distorted pronunciation, but word-

finding difficulty was abundant. His automatic speech and word repetition skills

were spared. Naming was severely impaired in both languages (2 and 4/20). His

oral reading was relatively good, but reading comprehension and writing were

severly impaired. The most obvious symptom was anomia.


fluency (515, 541; 516. 517; 531, 557)

Accuracy 1520, 521; 524.52R: 546. 547; 5X1-554)

Complerlty (516. 517; 542. 543: 529, 555; 5.30. 5561 . . .._.

Lexical Access (519, 545; 531. 557; 532. 558; 534, 560)

Polntlng l23-321

S1o;ple Commands (11-17)

Scnl-Complex Cofnaandr (38-42)

:omplex Corrmands (43-471

Verbdl Auditory Olscrlnrndtlon (1,6_6Sj


Scmantlc Categories (151-157)

Synanynr (158-1621

jntonyms (163-1721

;ramnatlcality Judgments l173-1021

Semantic Acceptability (181-192)

kpetltlon (Words1 (193-2511

.exical Decision (194-252)

kpetit1on (Sentences) (ZSI-25?)

jerles 1260-2621

ierbdl Fluency (261-2671

iamlng I269-2881

ientence Construction (269-313)

Semantic Opposites (314-323)

krlvational Harpholoqy (324-333)

lorphologlcal Opposites (331-343)

lental Arithmetic (347-3611

.istening Comprehension (362-366)

lral Reading (Words1 (367-376)

lral Reading (Sentences) 1377-386)

leading Comprehension (Paragraph) (387-1923

:opying (393-397)

lictatlon (Words1 (398-402)

)1Ctdtion (Sentences1 (403-407)

leading Comprehension (Words1 (408-417)

Ieadlng Comprehension (Sentences) (418-4271

ipontaneous uriting (813-835) I I I I I I I I I

Figure 4. F.Z.‘s Farsi Profile on the BAT (June 1984).


Fluency (515, 541: 516. 517; 531, 557)

Accuracy (520, 521; 524-52R: 546, 547; 550-554)

COmplexfly (516, 517: 542. 543: 529, 555; 530, 556)

Lerfcal Access 1519, 545; 531. 557; 532, 558; 534, 560)

Polntfng (23-321

Slmp1.e CoIlundnas (33-371

Scni-Complex Corndnds (38-421

Complex Corrmands (41.47)

Verbal Audltory Olscrinlnatlon (48-65)


Scmanclc Categories (153-1571

Synonyns (158-1621

Antonyms (163-1721

Grammaticality Judgments (173-102)

Semantic Acceptability (183-1921

Repetition (Words1 (193-251)

Lexical Decision (194-2521

Repetition ISentences) (253-259)

Series (260-262)


Naming (269-288)

sentence construction (289-313)


Oerlvational HorpholoqV (324-3331

HorphaloglCal Opposites (334-343)


Llstenlng Comprehenston (362-366)

Oral Reading Mords) 1367-376)

Oral Reading (Sentencer1 (377-386)


Copying (393-397)

lfctatlon (Words) (398-402)

lictatlon (Sentences1 (403-4071

leading Comprehension (Words) (408-4171

teadlng Comprehension (Sentences) (418-427)

jpontaneous Urlting (813-815) I

1 z 3 4 5 6 7 8 9 10

Figure 5. F.Z.3 Azari Profile on the BAT (June 1984).

NEL 3:2-P


CASE 5 (K.N.)

K.N. was a 79-year-old right-handed female speaker of Farsi with no history of

familial left-handedness. She was an illiterate housewife with 4 educated children.

Before her illness, she was staying with her 2 sons and was very active.

The patient was born in a unilingual Farsi family and lived in a bilingual

Farsi-Azari community until she was 15 years old (i.e. before her marrtage). Since

then she had been living in a Farsi-speaking environment and her family members

considered themselves to be unilingual Farsi speakers. The patient became aphasic

and spoke only some Azari subsequent to a CVA syndrome and was referred to the

clinic for evaluation and speech therapy.

Clinical History

K.N. suffered from a heart attack which led to a CVA syndrome on 1 September

1984. She lost consciousness and was hospitalized on the same day. It is reported

that she presented with right hemiplegia and agnosia for the first week and did not

move her right arm for 1 month. The diagnosis of a generalized CVA was later

confirmed by CT scan. Upon regaining consciousness. the patient is reported to

have spoken Azari. to the surprise of her family.

Language Assessment (5 November 1984)

K.N. was evaluated with the experimental version of the BAT in Farsi. She was

able to walk without a stick but had a weak right leg. She also presented with

brachio-facial weakness. She was well oriented in time and space and recognized

members of her family. We considered her a unilingual Farsi speaker and tried to

communicate with her in Farsi. Her answers were perseverative and mixed with

Azari as well as with paraphasic elements. Some of her answers were real Azari

short expressions. Our first attempts to start a conversation and to continue in

Farsi in order to elicit spontaneous speech were unsuccessful. Then we attempted to

give her the Farsi version of the BAT. We were not able to administer the standard

test items because of her impaired comprehension and lack of control over her oral

expression. Her speech was generally echolalic, perseverative and distorted. When

each instruction was read to her, she would listen attentively but she would not

follow the instructions. She was not able to provide any intelligible spontaneous

speech. Her automatic speech was also severely defective. She was not even able to

continue the task with the help of the test administrator.

The patient’s comprehension was severely impaired. She was totally unable to

perform the pointing task, as well as the semi-complex and auditory discrimination

tasks. She was not able to repeat single words nor to make lexical judgments about

them. She was able to repeat only 2 one-syllable words correctly. The remaining 28


items were either repetitive neologisms or circumlocutions around the item. She

was not able to make a distinction between word and non-word items among the

stimuli. She was also unable to perform the naming task. Instead of naming the

objects she talked about them.

We tried to communicate with her in Azari via a native speaker of Azari. Her

mixed Azari-Farsi oral expression remained the same. An analysis of her speech

showed that it contained real Azari words and phrases, with some neologisms in

both languages and some real Farsi words and expressions.

The major features of the patient’s residual capacities may be summarized as

follows: mixed Azari-Farsi oral expression in the context of fluent paraphasic and

neologistic speech and severely impaired comprehension. Her automatic speech,

repetition and naming were also severely impaired. The patient’s clinical picture is

therefore consonant with typical mixed transcortical aphasia (Goldstein 1948;

Benson 1979). The bilingual recovery pattern is that of mixed Azari and Farsi.

CASE 6 (A.!%)

A.S. was a 49-year-old educated right-handed male with no history of familial

left-handedness. He was an experienced orthopaedic surgeon. He finished High

School in Iran and went to Germany for his university education at the age of 18.

He subsequently lived in Germany for 16 years and received his university degrees

from German universities in Hannover and Frankfurt. While he was in Europe, he

spent 1 year in England doing research at English medical institutions. He then

lived in Tehran and practiced in his field of speciality for the 16 years preceding the

onset of aphasia, but visited Germany for l-2 months every year.

The patient was a native speaker of Farsi. Besides Farsi, he knew both German

and English. He could read and write in all three languages, but Farsi and German

were his dominant languages. The medium of instruction was Farsi during his

elementary and High School years. He learned English as a foreign language in high

school at the rate of 3 hours per week for 6 years. Then he learned German in

Germany as a college student and continued his higher education in German for 16

years. During the 2 years prior to his accident, the patient had studied English and

had passed the Iran American Society English proficiency exams.

A.S. was an active surgeon with some talent in music and poetry, He was familiar

with Persian and Western classical music and played the violin and the piano. He

also wrote Persian poetry.

Clinical History

On 2 September 1985, the patient was the victim of an explosion, He was

hospitalized from 2-18 September in a hospital in Tehran in which the environment


was unilingual Farsi, but where the staff members were familiar with English. A left

fronto-temporal lesion as a consequence of the explosion was diagnosed. On the

same day, the patient underwent head surgery to remove skull fragments and other

debris from the lesion area. He was tracheotomized on the same day and remained

in this condition for 7 days. On 26 September 1985, he was able to remember recent

events, especially the events related to the moments before and after the explosion.

There were no symptoms of apraxia or agnosia. He had good right-left recogni-

tion and he was able to recognize parts of the body. photographs and colours. He

could also recognize doctors and friends. The patient’s short term memory span

was 5 digits in Farsi, but 4 digits in German and English.

The patient exhibited signs of sensory amnestic aphasia at different times in

Farsi, German and English. He suffered right hemiparesis with brachio-facial

emphasis and right homonymous hemianopsia. An EEG, performed on 12 January

1986, 41/, months after the accident, suggested an underlying dysfunction or an

underlying epileptiform process in the left temporal region. A CT scan confirmed a

left fronto-temporal lesion. There were no signs of skull bone defect after the

surgical removal of bone and shrapnel fragments. The size of the fronto-temporal

lesion was estimated at about 2 X 2cm. There were no signs of hematoma.

The patient was disoriented 1 day after the operation and to someextent until 11

September 1985. He was well oriented in time and space after that date.

Language Assessment (26 September 1985-16 January 1985)

The patient was tested in Farsi. German and English with equivalent experi-

mental versions of the BAT (Paradis and Libben 1987). The order of administering

the 3 versions of the BAT was Farsi, German and English. Because of the patient’s

fatigue and short-term memory span, we were forced to administer each version in

several sessions, but the general conditions of administering each version were kept

constant. He was tested regularly twice a week on Mondays and Wednesdays at

2p.m. from 26 September 1985 onwards.

Farsi and English versions were administered by the author. The German version

(Paradis ef af. 1987) was administered by Dr Ashayeri, a neurologist educated in

Germany. The results obtained on the 3 versions of the BAT are reported here (for a

more detailed description of this case, see Nilipour and Ashayeri 1988.)

Language Recovery Pattern

The patient’s linguistic behavior can be divided into two quite distinct stages. The

first stage or critical recovery period, was characterized by the alternating anta-

gonistic recovery of two languages (Farsi and German) with a temporary loss of the

third (English). It lasted from 2 September through to 11 October 1985. The period

of antagonistic recovery between Farsi and German in the absence of English can


be divided into the following phases.

No

output

2-11

September

Farsi

output

12-17

September

German

output

18 September-

11 October

Farsi

output

11-15

October

Farsi

German

English

16 October

+

The patient was tracheotomized for the first 7 days and was in a critical

condition. His linguistic output was therefore nonexistent during the first 10 days.

He nevertheless remembered this period very well.

During the second phase, which lasted for 6 days, the patient spoke mainly Farsi

with occasional German phrases until he switched completely to German to the

surprise of everybody at home. This phase lasted for 24 days.

The period between 11 and 15 October is a period of transition between the

antagonistic recovery and the differential recovery of his languages. This period

started with his switch from German to Farsi upon the insistence of his sister-in-law

who did not know any German. He gradually regained control over the voluntary

choice of language over a period of 5 days. From 16 October onwards, he was able

to switch at will from Farsi to German or to English.

The juxtaposition of the scores obtained on the BAT in the 3 languages after 16

October gives us a clear picture of the patient’s relative capacities (Figure 6). The

profile shows that the residual capacities in the 3 languages were not exactly the

same. Based on the results shown in this profile, one may conclude that in the end

the 3 languages have been recovered differentially. The best recovered language is

Farsi, the least well recovered is English and German is in between.

The patient’s performance was characterized by fluent speech, poor compre-

hension, relatively good repetition and impaired writing. In accordance with the

symptomatic classifications suggested by Paradis (see Paradis and Libben 1987;

Chapter 4, for full discussion) and based on the elicited responses on the different

tasks of the BAT, our trilingual patient may be diagnosed as presenting with

transcortical sensory aphasia.

The patient exhibited an alternating antagonistic recovery. After a short initial

period of speaking Farsi, A.S. switched to German and could no longer speak Farsi

for 3 weeks, in spite of insistent requests from his relatives who spoke no German,

then he switched back to Farsi for 1 week, after which time he finally regained

control over his 3 languages.

202 Journal of Neurolin~uistics, Volume 3. Number 2 (1988)

Pointing (23-32)

Simple Commands (33-37)

Semi-Complex Commands (38-42)

Complex Commands (43-47)

Verbal Auditory Discrimination (48-65)


Sevantic Categories (153-157)

Synonyms (158-I&?]

Antonyms (163-172)

Grammaticality Judgments (173-182)


Repetition (Words) (193-251)

Lexical Decision (194-252)

Repetition (Sentences) (253-259)

Series (260-262)


Naming (268-288)



DerivatIonal Morphology (324-333)







copying (393-397)

Dictation (~0~s) (398-402)

Dictation (Sentences) (403-407)

Reading Comprehension (Words) (408-417)

Reading Comprehension (Sentences) (418-427)

'arsi

5

4

2

0

12

22

0

0

0

1

10

28

22

1

3

2

4

1

4

4

3

5

0

10

10

0

5

5

1

6

2

German

8

1

0

0

9

23

0

0

0

3

3

28

24

1

1

0

1

0

0

1

5

3

0

g

2

0

5

4

0

5

2

,gl

7

4

2

0

0

18

0

a

0

3

1

28

6

1

0

0

2

0

1

1

2

1

0

10

10

0

4

2

3

7

0

Figure 6. AS’s Comparrmtive Profiie in Far&, German and English on

the BAT (October 1985).


CASE 7 (A.L.)

A.L. was a 54-year-old right-handed male who had a left-handed son. His mother

tongue was Armenian but he knew Farsi and Azari very well from childhood. He

had 5 years of elementary school education. His job was to fill up gas cylinders in a

gas company.

Clinical History

The patient lost consciousness on 10 September 1985 subsequent to the explo-

sion of a gas cylinder. While he was pumping in gas the top of the cylinder came off

forcefully, ricocheting off the ceiling onto the left side of his head, breaking the left

parietal bone.

A.L. went into a coma and was hospitalized on the same day. He underwent a

cranial operation which confirmed a lesion in the left parietal region. Upon

regaining consciousness after 3 days, he was aphasic and unable to communicate

verbally. It is reported that he suffered from right hemiplegia and right hemian-

opsia.

Two CT scans were performed. The first one, on 26 November 1985, showed

evidence of the craniotomy. The ventricles were normal, except for minimal

dilatation of the trigone of the left lateral ventricle. The posterior fossa was normal.

The second scan, on 4 February 1986, was performed with contrast injection. It too

showed evidence of the craniotomy. No shift of midline structures was seen. The

ventricles were mildly dilated. The posterior fossa was normal. A left parietal

traumatic lesion was thus confirmed.


The patient’s aphasic deficits were assessed 6 months post-onset. He was

presenting with right hemiplegia and right hemianopsia. He had right facial weak-

ness but was able to whistle. There were no signs of lingual or palatal musculature

paralysis and the patient was able to move his speech organs on request. He was

well oriented in time and space.

A.L.‘s aphasic symptoms were typical of global aphasia. His speech output was

limited to the occasional utterance of “Amen” when he was addressed. We were not

able to elicit spontaneous speech nor a description of the picture story in any of the

3 languages he knew premorbidly. He was only able to hum the rhythm of religious

songs he used to sing at church. His comprehension was limited to simple elements.

He was able to perform simple commands, but not semi-complex commands. We

were not able to administer the other tasks of the BAT because of his limited

comprehension and lack of speech production.


The pattern of recovery was parallel, in the context of severe global aphasia 6

months post-onset.

CASE 8 (K.R.)

K.R. was a 22-year-old left-handed male native speaker of Farsi. He was the only

left-handed member of his family. He was an intelligent and successful student with

11 years of education. He had started to learn English when he was 5 years old. In

addition to his private lessons in English, he learned English in high school at the

rate of 3 hours per week for 5 years. During the same period he continued his

private lessons. K.R. was considered to have had practical command of English

premorbidly. He was interested in mountain-climbing, which, in fact, led to his

injury.

Clinical History

K.R. had a serious fall from the top of a mountain on 27 July 1982. He went into a

coma and remained unconscious for 50 days. He suffered right hemiplegia and

language loss following the fall. His right weakness gradually improved to normal

as a result of physical therapy, but he continued to have speech problems. After he

regained consciousness, his oral production was limited to “yes” and “no” for a

period of 2 months. At the time of testing he had received speech therapy for 1 year.

The diagnosis was severe cerebral contusion caused by a compound depressed

fracture in a vast area of the left temporo-parietal area. He underwent craniotomy

for the discharge of debris and excision of an epidural hematoma.

Subsequent to the operation, he is reported to have suffered from global aphasia

for a period of 2 months. The first language recovered was Farsi. He claimed that he

did not remember a word of English 1 year post-onset.

K.R. came to the clinic for language evaluation 4 years after his accident. His

main complaints were comprehension problems and difficulty with processing

verbal mental activities.

Language Assessment (23 September 1986)

The patient’s aphasic deficits were assessed with Farsi and English experimental

versions of the BAT. Both versions were administered by the author on successive

occasions (23 and 30 September, respectively). Figure 7 represents the patient’s

Farsi profile and Figure 8 his English profile.

We were able to elicit spontaneous speech in Farsi and, to a limited extent, in

English. His oral production was fluent, cohesive and without signs of paraphasia

or distortion. His writing was normal. As can be seen from the two profiles, the best

recovered language was Farsi. It was also the first to be recovered. Given the extent


Fluency (515. 541; 516. 517; 511, 5571

Accuracy (520, 521; 524.5tA; 546, 547; 550-554)

Complexfty (516, 517; 542, 543: 529. 5S5; 530. 556)

Lexical Access (519, 545; 531. 557: 532. 558; 534, 560)

Po1ntfng f23-321

Sjmple Commands (33-37)

Semi-Complex Com;landr (38-42)

Complex Comndnds (43-47)

Vcrbdl Audltory Oiscrinindtion (!,6-65)


Scmantlc Categories 1153-157)

Synonyns (158-162)

Antonyms (163-172)

Grammaticality Judgments (173-1821

Semantic Acceptabilrty (183-192)

Repetition (words) (193-251)

Lexical Oeclrion (194-252)

Repetition LSentences) (253-251)

Series (260-262)


Naming (269-288)

Sentence Constructfon (289-313)


Oerivatlonal Horpholoqy (324-333)

Horpho)Ogical Opposites (334-343)


Lirtenlng Comprehension (362-366)


Oral Reading (Sentences1 (377-3661


copying (393-397)

Dlctrtfon (Words) 098-402)

lictaclon (Sentences) (403-407)

krding Comprehension (Words) (408-417)

7eadlng Coin?rehenrlon (Sentences) 1418-427)

jpontaneous Uriting (813-835)

12 3 4 5 6 7.3 9 10

Figure 7. K.R.‘s Farsi Profile on the BAT (September 1986).


Flvcncy 1515, 54:; 516, 517; 531, 557)

Accuracy (520, 521: 524-528: 545, 547; 550-554)

Corplexity 1516, 517: 542, 543; 529. 555; 530, 556)

Lexical Access (519, 545; 511, 557: 532, 558; 534, 5601

Pointfng (23-321

Sinale Con'nands 133-37)

SC"I:-Complex Corrxalds (38-42)

:c"lp1ex cormdncs (43-471

Vcrbdl Aud!tary Olscrlnination (48.65)

Synt~ctlc Conprchentlon (66-152)

senantic catc~cries (153-15!i

jynalyx ll58-162)

4nwlysS iI63-:72)

;rd?ndt~cdl~ty Jud9mcnts (173-1821

jemaltic Accepcabllrty (183-192)

?epe:>t'zT (uctds) 1193-251)

"erlcal Oeclstor 1194-2521

?epecttion ISeltercesl 1253-25?1

jerles (250-262)

Jerbal Fluency (263-Zfi73

?aa~n~ [259-288)

Sentence Construction (289-3131

Sersntjc Oppsites (314-323)

k'rivatlonal HOrphoiP~ (324-333)

lorphaloglcal Opposites (331-343)

lental Arithrretic (347-3611

lstenfng Co~~tchcnsion (362-366)

rai Readtng (i(ords) 136?-376)

ral Reading (Senten:erl 1377-385)

eadlng Comprehension (Paragraph) (3R7-392)

0pylng (393-397)

ictatlon IYo-es) 1390-402~

tctatton iscltences) 14C3-4D7I

eading Cwprehensicn (Words) (408-4171

cad,ng Corprchenrion (SenCcflCeS) 1418-427)

pontaneoui ur1ting IkIll-8351

i2 3 4 5 6 7 8

Figure 8. K.R.‘s English Profiie on the BAT (September 1986).


of his premorbid proficiency in English, the pattern of recovery may be considered

to be parallel at this point, that is, it reflects premorbid relative proficiencies.

K.R. obtained the maximum score on all tasks in Farsi except 3, on which he

scored above 80% and 1 on which he scored above 65%. He had few problems with

syntactic comprehension (79/ 87), semantic categories (4/ 5), repetition of sentences

(6/7) and mental arithmetic (lo/ 15). His overall performance represents an almost

normal score (see Table 4.2 in Paradis and Libben 1987, for the normal error

range).

CASE 9 (S.Y.)

S.Y. was a 42-year-old right-handed illiterate female bilingual speaker of Azari

and Farsi. She was married and had 3 children. Her mother tongue was Azari but

she was fluent in both languages.

Clinical History

On 13 February 1986, S.Y. was sitting with her family when her face suddenly

became red and she fell. She was no longer able to talk nor to move her right hand.

She was hospitalized on the same day. The diagnosis was a CVA syndrome in the

left cerebral cortex. It is reported that she suffered right hemiplegia and right facial

weakness. The diagnosis was later confirmed by a CT scan which revealed an

infarction the size of a quarter in the left fronto-temporal cortex.

The patient was put under medication and was released from the hospital after 7

days. She was advised to have physical therapy and speech therapy. While she was

in the hospital, her aphasic deficit was characterized as global aphasia.


S.Y. was examined in order to evaluate her aphasic deficits 3 weeks post-onset.

She was able to walk but had weakness in her right leg as well as right brachio-facial

weakness. She was unable to whistle. She demonstrated good orientation in time

and space and remembered events before and after the CVA.

The patient was given the Azari and Farsi experimental versions of the BAT.

Spontaneous speech was almost nonexistent in both Azari and Farsi. She was not

able to produce any distinct sound sequences spontaneously. She even failed the

automatic speech task. She repeated words in neologistic forms: none of them were

correct (O/30) in either language.

Her ability to comprehend language was better than her oral expression, but was

limited to simple elements. She did well only on pointing (10 and 8/ 10) and simple

commands (5 and 515). She did poorly on verbal auditory discrimination (12 and

S/18) and syntactic comprehension (12 and 46/87). She scored somewhat better on


Fluency (515, 541; 516. 517; 531, 557)

Accuracy 1520, 521; 524-52A: 546. 547; 550-5541

Camplexlty (516. 517; 542. 543: 529. 555; 530, 556)

Leafcal Access (519, 545; 531. 557: 532, 558; 534, 5601

Polntlng I&321

Slvle Commands (33-17)

Scnl-Complex Cornrnds (38-42)

Complex COrmands (43-47)

Verbal Audftory Olrcr(nfnatfon (46-65)

Syntactic Comprchenrlon (66-152)


Synonynr 1158-162)

Antonyms (163-172)

trarunatlcallty Judgments l173-102)

Semantic Acceptability ll83-192)

Repetltlon (Uordr) (193-251)

Lexical Oeciston (194-2521


Series 1260-262)


Naming (269-288)



Oerivational Horpholooy (324-333)

Morphologfcal OppOSfteS (334-343)


Listening Comprehensfon (362-366)

Oral Reading (Uords) (367-3761

Oral Reading fSentencesl (377-3861


Copyfng (393-397)

Olctation (Words) 098-402)

Dictaclon lkntencesl (403-407)

Reading Comprehension (Uordr) (408-417)

Readlng Comprehension (Sentencer1 (418-4271

,iZ 3 4 5 6 7 8 9 10

spontaneous urltlng (813-8351

Figure 9. S.Y.‘s Azari Profile on the BAT (March 1986).


Fluency fSI5. 541; 516. 517; 531. 5571

Accuracy (520. 521; 52P-SZR: 546. 547; 550-5541

Complexity (516. 517; 542, 543; 529. 555; 530, 556)

lexical Access (519, 545; 531. 557; 532, 558; 534, 5601

PolnCln9 (23-321

Stmple Commands (33-37)

Semi-Conpler Coirnands (38-W)

Complex Colrmandr (43-47)

Vcrbsl Auditory D1scrinlnacion (48.65)

Syntactic Comprchenrion 166-152)

semantic categortes 053-1571

Synonyns (158-1621

Antonyms (163-172)

trammaclcality Judgments (173-1821

Semantic Acceptability (163-1921

Repecitlon (uords) (193-251)

Lexical Decision (194-252)

Repetition ISentences (253-2591

Series (260-2621


Naming (269-288)


Semaotfc Opposites (3I4~323)

Oerivational Horphology (324-333)



Listenin(l Comprehension (362-366)

Oral Reading (Uordst (367-3763

Oral Reading (Sentences1 (377-386)

Readtng Comprehension (Paragraph) (387-392)

Capylng (393-3971

Dfctation (Words) 6398-4023

Dictation (Sentencer) (403-407)

Reading Comprehension Words) (408-417)

Readfng Cowrehenrton (Sentences) (418-427)

Spontaneous uricing (813-835)

1 2 3 4 5 6 7 a 9 1c

Figure 10. SLY.% Farsi Profile on the BAT (March 1986).


semi-complex commands (3 and 415) and lexical decisions (17 and 20/30), but she

failed the naming task (0 and O/20) in both languages.

The patient’s residual capacities may thus be summarized as follows: no oral

production, severely impaired comprehension and poor repetition in both lan-

guages. This clinical picture is typical of global aphasia (see Paradis and Libben

1987:219).

The patient’s profiles in Azari (Figure 9) and Farsi (Figure IO) are indicative of a

parallel recovery 3 weeks post-onset. The only differential scores were better

auditory discrimination in Azari (12 and 5/ 18) and better syntactic comprehension

in Farsi (12 and 46/87). The rest of the scores were more or less the same (many of

them with a score of 0) in both languages.

CASE 10 (A.E.)

A.E. was a 48-year-old right-handed educated male speaker of Farsi who knew

English very well as a second language. His English background started with 6 years

of high school and 2 years of college instruction at the rate of 3 hours per week. He

obtained his B.A. in Iran and went to India for further education. He studied at

Indian universities for 10 years and received an M.Sc. and a Ph.D. in Management.

English was the language of instruction and of the textbooks and he wrote his theses

in English. At the time of the accident, he had been teaching at a university for 10

years, using English texts. He was a successful professor with publications in both

English and Farsi.

A.E. became aphasic as the result of closed head injury subsequent to a

motorcycle accident. He was referred to our clinic for evaluation and speech

therapy 3 months after his accident.

Clinical History

A.E. was hospitalized following a severe motorcycle accident on 13 October

1986. He lost consciousness and did not recognize people for 3 days. He was kept

under intensive care. The diagnosis was hemorrhage as a result of closed head

injury. There was no skull fracture or trauma. Two CT scans were obtained after

the accident to support the diagnosis. The first CT scan (4 January 1987) was

performed without contrast injection. The results showed contusion hemorrhage in

the left temporo-parietal area with surrounding infarction. The left lateral ventricle

was collapsed and there was a marked shift to the right. The right hemisphere was

normal. The cerebellum was normal. The second CT scan (24 January 1987) was

performed with contrast injection. The posterior fossa was normal. There was an

area of hypodensity in the left temporal region. The left lateral ventricle was


Fluency (515, 541; 516. 517; 531, 557)

Accuracy (520. 521; 524-528; 546, 547; 550-5541

Complerlty (516. 517; 542, 543; 529. 555; 530. 556)

Lexical Access (519, 545; 531, 557; 532. 558; 534, 560)

Pointing (23-321

Sfmple Commands ~33-371

Scml-Complex Corrnands (38-42)

Complex Corrmandr (43-47)

Verbal Audltory Oiscrininatlon (46-65)


Scmantlc Categorfes IlSl-157)

Synanyns (158-1621

Antonyms (163-172)

Grammaticality Judgments ll73-1021

Semantic Acceptability Il81-192)

Repetition (Words) ll93-251)

Lexical Oeclslon (194-252)

Repetftian (Sentences) it53-2591

Series (260-262)

Verbal Fluency (263-2fi7)

Naming (269-2881

Sentence construction (289-3131

Semantic Opposites (314-3231

Oerlvatlonal Horpholqy (324-333)

Morphological Opposfter (334-3433

Mental Arithmetfc (347-361)


Oral Reading (Words1 067-376)


Reading Comprehension (Paragraph1 (387-392)

copying (393-3971

Otctatlon (Words1 (398-102)

Dictation (Sentencer) (403-4071

Reading Comprehensfon (Uordsl (408-417)

Reading Comprehension (Sentences) (418-427)

Spontaneous Writing (813-835)

12 3 4 5 6 7 0 9 10

Figure 11. A.E.‘s Farsi Profile on the BAT (January 1987).


Fluency (515, 541; 516, 517; 531. 557)

Accuracy (520. 521; 52a-528; 546. 541; 550-554)

Complexity (516. 517; 542, 543; 529, 555; 530. 556)

Lerfcal Access (519, 545; 531. 557: 532. 558; 534. 5601

Pofntfn9 (23-32)

Slwle Commands (33-17)

Scml-Complex Cor;ndnds (38-42)

:omplcx Carmandr (43-471

/crbdl Auditory Oircrininatlon (1,6_65)

jyntactlc Comprchenrlan (66-152)


Synonyms (158-162)

intonyms (163-172)

;rannatlcal~ty Judgmcntr 1171-102)

jemantlc Acceptability (183-192)

Iepetitlon (Words) l193-2511

.exlcal Oecfsion (194-252)

lepetftion (Sentences1 (253-2591

ierfes (260-262)

herbal Fluency (263-267)

iamlng (269-2881


jemantic Opposftes (314-323)

krivatlonal Horphology (324-333)

Krphologlcal oppostter (331-343)

lental Arithmetic (347-3611

.Istenlng Comprehension (362-366)

lral Reading (Words) (367-376)

lral Reading (Sentences) (377-3861

leading Comprehension (Paragraph) (387-3921

:opylng (393-397)

IIctatfan (Words1 (398-4021

)1ctatlon ISentences) (403-407)

kadlng Comprehension (Words) (408-417)

leading Comprehensfon (Sentences) (418-427)

ipontaneour Wrttlng (813-8351

12 3 4 5 6 7 8 9 10

Figure 12. A.E.‘s English Profile on the BAT (February 1987).


normal. No mass effect or midline shift was noted. No abnormal enhancement was

seen after contrast injection.

The final diagnosis, based on the CT scans, was local atrophy in the left temporal

region as a result of closed head injury. The patient was discharged from the

hospital after 4 weeks. It is reported that his first speech production was in Farsi,

mixed with some Hindi and English neologisms and with distorted syntax.

Language Assessment (31 January 1987)

A.E. was examined on 31 January 1987. He was able to walk and did not have

any gross motor problems. He complained of a slight weakness in his right leg. He

was well oriented in time and space. He remembered events before and after the

accident. His short-term memory span was 5 digits.

The patient’s language capacities were assessed by administering the standard

short version of the BAT (Paradis and Libben 1987: 151) in Farsi and in English.

The Farsi version was given on 31 January 1987 and the English version on 22

February 1987 by the author. Figure 11 represents the results obtained for the Farsi

test and Figure 12 for the English test.

We were able to elicit spontaneous speech and the description of the picture-story

in Farsi only. His writing was very defective and limited in both languages. Three

months post-onset, the pattern of recovery was differential, with Farsi better

recovered than English. A.E. scored significantly better in Farsi than in English.

The patient’s oral expression was fluent but with clear evidence of word-finding

difficulty. His spontaneous writing was very limited and defective at both the

semantic and syntactic levels, in both languages. His oral expression was much

better preserved than his oral comprehension. Even pointing (6 and 4/ 10) and semi-

complex command (2, and O/ 5) tasks are impaired. Verbal auditory discrimination

(8 and 3/ 18) and syntactic comprehension are also impaired in both languages.

Repetition is defective at the sentence level (4 and 3/7) but word repetition (30

and 30/30), automatic speech (3 and 313) and copying (5 and 515) are preserved in

both languages. Reading and writing skills are defective. Reading aloud is relatively

well preserved but reading comprehension is defective.

The clinical picture can thus be summarized as fluent speech with severely

impaired comprehension and word-finding difficulty, but good repetition. The

patient can thus be said to have transcortical sensory aphasia, in accordance with

Paradis and Libben’s (1987) suggested classification.

CASE 11 (P.A.)

P.A. was a 48-year-old right-handed female Farsi speaker. She had a bilingual

high school background and a B.A. in English obtained in England. She had also

NEL 3:2-G


served as a bilingual secretary for 2 years. Premorbidly, the patient was considered

to be a bilingual speaker of Farsi and English. She lost consciousness as a result of a

CVA on 8 May 1983. She was hospitalized on the same day. The stroke was

diagnosed as the result of thrombosis of the left middle cerebral artery. On the

second day. the patient was described as conscious and as having global aphasia,

right hemiplegia and right central facial paresis. Evidence of agnosia was also

reported in her file.

Two weeks after she had regained consciousness at the hospital, the patient

began to receive physiotherapy. She was discharged from the hospital on 15 June

1983. She reported that she was unable to recognize people or to speak for the first

40 days. Since then, she had received 2 years of physiotherapy and 1 year of speech

therapy in Farsi.

Clinical History

On 9 May 1983 a neurological examination revealed a CVA syndrome in the left

fronto-temporal area. The diagnosis was confirmed by CT scan on the next day,

showing infarction of the left fronto-temporal area due to thrombosis of the left

middle cerebral artery. There was also extensive cerebral edema.

The patient was reported to have been taking cortisone since 2 weeks before onset

as treatment for her condition of total baldness. The EEG performed on 22 April

1983 indicated a general dysfunction of the brain. It showed dysrhythmia with slow

waves (5-6 PCS) around the left occipital area, indicative of CVA background.

On 2 March 1987, 4 years post-onset, a neuropsychological examination re-

vealed central right facial hemiparesis. The patient presented wtth right hemiplegia

but was able to walk without a cane. She was not able to write with her right hand,

but could with her left hand. No hearing impairment was observed. Her visual field

was normal. No symptoms of agnosia or apraxia were observed. She had good

recognition of colours and pictures. Her short-term memory span was 3 digits. The

patient was referred to our clinic for speech therapy. Her main complaint was about

reading and writing.

Language Assessment (2-10 March 1987)

The patient was given the Farsi version of the BAT on 2 March 1987 and the

English version on 10 March 1987. The short versions of both tests were adminis-

tered under the same general conditions by the author. Figure 13 represents P.A.‘s

performance in Farsi and Figure 14 in English. The patient’s performance was

approximately the same in both languages, indicating a pattern of parallel

recovery.

Comprehension was preserved in both languages, but relatively impaired at the

syntactic level. Her speech in Farsi was fluent and cohesive. without paraphasia or


Fluency (515, 541; 516, 517; 531, 557)

Accuracy (520, 521; 524-528; 546, 547; 550-554)

Complerlty (516. 517; 542. 543: 529, 555; 530, 556)

Lexical Access (519, 545; 531. 557; 532, 556; 534. 5601

Pofnttng (23-32)

Simple Commands (33.37)

Semi-Complex Conwndr (38-421

Complex Comnandr (43-47)

Verbal Auditory ~~SCri~in~tiOn (48-65)

Syntactic Comptchenrioo (66-152)

Scmanttc Categories (153-157)

Synonyns (158-162)

Antonyms (163-172)

Gramnatfcality Judgments (173-182)


Repetitfon (Uords) 1193-2511

Lexical Oecisfon (194-252)


Series (260-2621


Naming (269-288)


Semantic Opporltes (314-3231

Oerivstional Horphology (324-333)

~O~phol~g~Cal OppOsfteS (334-3431

Mental Arfthmetfc (347-361)

Lfstenfng Comprehenrfon (362-366)

Oral Reading (Words1 (367-376)

Oral Reading (Sentences) (377-3861

Redding tomprehension (P~rdgraph) (387-392)

copying (393-3971

oictatfon (Words1 (398-402)

Dictation (SentencesI (403-407)

Reading Comprehenslon (Uordrl (408-4171

Reading Co~rehens{on ~Se~tences) (418-4271

spontaneous wting (Ei3-835) I 12 3 4 5 6 7 8 9 II

Figure 13. P.A.‘s Farsi Profile on the BAT (March 1987).


Fluency (515. 541; 516. 517; 531. 557)

ACCUraCy 1520, 521; 524-528; 546. 547; 550-554)

Complexity (516. 517; 542. 543; 529, 555; 510, 556)

Lexical Access (519, 545; 531. 557; 532. 558; 534, 560)

Polntlng (23-321

S(mp1e Commands (31-371

Semi-Complex Corrnands (38-42)

:omplcx Corrmandr (43-47)

dcrbal Auditory Olscrlninatlon (46-65)

jyntactlc Comprchenslon (66-152)

jcmdntlc Categories (153.157)

jynonyns (158-162)

\ntanyms (163-172)

;rafrnatlcallty Judgments 1173-182)

iemantlc Acceptdbllity (183-192)

lepetltfon (Uords) (193-251)

.e*1cal Oecir~on (194-252)

lepetltlon (Sentences) (253-259)

ierfes (260-2621

'erbal Fluency (263-2671

lamlng 1269-288)


iemantic Opposites (314-323)

IerlvatIanal Morphology (324-333)

lorphologlcal Opposites (314-343)

lental Arithmetic (347-361)

.Istenfng Comprehensfon (362-366)

kal Reading (Uords) (367-376)

Iral Reading (Sentences) (377-3861

!eadlng Comprehension (Paragraph1 (387-3921

:apying (393-3971

Ilctatlan (Wards1 (398-4021

Iictatlon ISenterKes~ (403-407)

feading Comprehension (Words) (408-417)

.eadlng CornprehensIon (Sentences) (418-427)

,po"ta"ea"r !,rfttrTg (813-835)

12 14 5 6 7 8 9 10

Figure 14. P.A.‘s English Profile on the BAT (March 1987).


neologisms. In English, her production was more limited, as was to be expected,

since she had not used English for the past 4 years. However, no dysfluency was

found in her English.

The patient failed the oral reading and dictation of sentences in both languages.

Poor performance on semantic tasks (synonyms, antonyms), poor sentence repe-

tition, poor sentence construction, poor dictation of words and poor reading

comprehension were also found across languages. The patient’s spontaneous

writing was abnormal in both languages and was limited to a few short phrases.

On the whole, the clinical picture that emerged was one of clearly impaired

repetition (at the sentence level) and fluent oral production in the context of

relatively well preserved comprehension. Her oral reading was abnormal, with

somewhat better reading comprehension. In accordance with the symptomatic

classifications suggested by Paradis and Libben (1987: Chapter 4, for a full

discussion), our patient may be said to present with conduction aphasia.

CASE 12 (P.O.)

P.O. was a 60-year-old male bilingual speaker of Azari and Farsi. with some

knowledge of French. He was right-handed with a familiar history of left-

handedness (his older sister). His parents were native speakers of Azari but knew

Farsi also. His wife and children were unilingual speakers of Farsi. The patient was

born in Iran and educated as a medical doctor there, with 2 years of education in

France.

Clinical History

P.O. became aphasic subsequent to a left CVA on 6 September 1986. He lost

consciousness for a few hours and was kept under intensive care for 5 days

following the CVA. Upon regaining consciousness, he presented with right hemi-

plegia and right facial weakness. It is reported that he could not speak and did not

recognize the people around him for 1 month. It is also reported that his first

attempts to speak were in Azari, 2 months post-onset. For the first 4 months, he

addressed the people around him predominantly in Azari, even his wife and the

other members of his family who were unilingual speakers of Farsi. During this

period the same phenomenon occurred twice with French, when addressing his wife

and the nurse at home. In neither case was he aware that he was addressing people

in an inappropriate language. From January 1987 onwards, his Farsi was stimu-

lated and reinforced by having Farsi classical prose and poetry read to him at home.

Language Assessment (18 April 1987)

P.O. was assessed 7 months post-onset with the short version of the BAT in Azari

2ts fournai of Neurolnguisties, Volume 3, Xumber 2 (1988)

Fluency (515, 541; 516. 517; 531, 557)

Accuracy 1520, 521: 524-52R; 546, 547; 550-5541

Compiexfty 1516, 517; 542, 543: 529, $55; 530. 5561

Lexical RCC&SI (519, 545; 531, 557; 532, 558; 534. f6Ol

Pointing [23-X)

Simple Commdnds (33.37)

Scml-Complex Comdndr 138-12)

Complex Cairmands 143-471

Ycrb31 kudftory Orzcrinfnatfon t&e-6*)

Syntactic tomprehension (S-152)

scrMntic Catcqoric~ 1153-1571

synonynr (158"1621

Antonyms (163-172)

Grdnzxstlcality Judgnentr L!73-1021

Swantic Accepcabilfty ~183-192)

Repetitton Words) l193-251)

Lexical 0ecfsfan (194-252)


Series 1260-262)

‘r'erbai Flwncy 1263-267)

Namrng (269-288)


semantic 0pporftes (314-3231

Derivational Motphologj' f324-3331

MorshoToqfcal Opposites ;331-3431

Mental Arithmetic t347-3511

Listening Comprehekion (362-366)


Oral Reading iSentences 1377-386)

Reading foaprehensfon Waragrapht (387-3921

Copying 1393-397)

Dictation (wordr) (39a-4o2l

01ctatfon Isentences~ (403-401)

Reading CornprehensIon Wards) (408-417)

Rcadfng CoTrprehenafarr isentences (4le-42tt

Figure 15. P.O.% Farsi Profile on the BAT (April 1987).


Fluency 1515, 541; 516. 517; 531. 557)

Accuracy (S20, 521; 524-SZA; 546, 547; 550-5541

Complexfty (516, 517: 542. 543: 529, 555; 530. 5561

Leafcal Access (519, 545; 531, 557; 532. 558; 534. 5601

Pointing (23-321

Slir?le Commdnds (33-37)

Semi-Complex Cor?nandr (38-42)

Complex Cormandr (43-471

Verbal Auditory Dlrcrinlnstlon (453-65)

Syntdctlc Comprchenrion (66-152)

Semantic Categories llS3-1571

Synonyns (158-1621

Antonyms (163-1721

Grarmatlcality Judgments 1173-182)

Semantic Acceptabllfty (183-1921

Rcpetl tlon LUardsl (193-2511

Lexical Oeclslon (194-252)


Series (260-2621


Naming (269-288)

Serltence Constructton (289-313)

Semantic Opposftes (314-323)

Derivational Horpholoqy (324-333)

MorpholOglCal OPpOSiteS (334-343)

Mental Arithmetic (347-3611

Listenfng Comprehension 062-366)

Oral Aeadlng (Words) (367-3761

Oral Reading ISentences) (377-386)


Copyfng (393-3971

Ofctatlon (Words1 (398-402)

Dictation (Sentences) (403-4071

Reading Comprehension (Words1 (408-417)

Reading ComQrehenSlon (Sentences) (418-427)

I

12 3 4 5 6 7 8 9 lC

Spontdneous Writing (El)-83.5)

Figure 16. P.O.‘s Azari Profile on the BAT (May 1987).


and Farsi on two separate occasions. The Farsi version was administered by the

author on 18 April 1987 and the Azari version by M. Dehghan, a senior speech

therapy student and a native speaker of Azari, on 2 May 1987.

The patient was calm and somewhat depressed at this point. He had good

recognition of people and remembered events before and after the stroke. His

short-term memory span was 6 digits. He presented with right hemiplegia and right

facial weakness. He could walk with some difficulty. He could not write with his

right hand.

P.O.‘s performance in Farsi and Azari is represented in Figures 15 and 16.

respectively. The overall picture was almost the same in both languages. Seven

months post-onset, the patient’s spontaneous speech was very limited in both Azari

and Farsi. In Farsi, his description of the picture story was also limited to a total of

21 words in 6 short sentences. There was no evidence of paraphasia or agram-

matism in his speech in either language but he failed to perform the sentence

construction task in both.

It is apparent that the patient’s comprehension was more impaired than his

production. He totally failed listening comprehension and reading comprehension

tasks in both languages. His syntactic comprehension was also impaired (22 and

20/ 38). Thus, we have a picture of fluent speech with impaired comprehension but

relatively good repetition, reminiscent of Wernicke’s aphasia.

CASE 13 (KS.)

K.S. was a 36-year-old right-handed male native speaker of Farsi, with English as

a second language. He completed his high school education in Iran and obtained a

Bachelor’s degree in Engineering in the United States. He had lived and worked in

the United States for 5 years before and 3 years after his accident. He was married

and had two children.

K.S. became aphasic subsequent to a car accident on 5 October 1984. He lost

consciousness and remained unconscious for 25 days as a result of head trauma. It

is reported that he could not recognize anyone for 70 days. He presented with

quadriplegia and could not move for 4 months. The patient was hospitalized until

20 April 1987. He then moved back to Iran for therapy in his mother tongue.

The patient’s language recovery had been very slow over the past 3 years. It is

reported that he was not able to speak either English or Farsi while he was in the

United States. He was first able to communicate linguistically 6 months post-onset,

at which time he was able to write a few single words in English. His first oral

expressions are reported to have been in Farsi 3 years post-onset.


Fluency (515. 541; 516, 517; 531. 557)

Accuracy (520. 521; 524-52R; 546, 547; 550-5541

Complexity (516. 517: 542. 543: 529. 555; 530. 556)

Lexical Access (519, 545; 531, 557; 532. 558; 534, 560)

Pointing (23-32)

Simple Colluxndr 03-371

Semi-Complex Comxnds 08-42)

:omplc& Corrmandr (43-47)

Vcrbdl Auditory Dlrcrinination (46.65)


Semantic Categories (153-157)

jynonyns ll5E-1621

jntonyms (163-172)

kdnwticality Judgments (173-182)

jemantic Acceptability (183-192)

kpetition (Words1 (193-251)

.exical Oecirion (194-252)

lepetition ~Sentencesl (253-259)

Series (260-262)

Yerbdl Fluency (263-267) i I

Namrng (269-288)



Derivational Morphology (324-333)







copying (393-3971

Dictation (Words1 (398-402)

Dictation (Sentences) (403-407)

Reading Comprehension (Words) (408-4171

Reading Cavrehension (Sentencer1 (418-427)

Spontaneous Writing (813-835)

12 3 4 5 6 7 8 9 10

Figure 17. K.S.‘s Farsi Profile on the BAT (October 1987).


Fluency (515, 541; 516. 517; 531. 557)

Accuracy (520, 521: 526-528: 546, 547; 550-554)

COmPlelfty (516. 517; 542. 541: 529. 555; 510. 556)

Leafcal Access (519, 545; 531. 557; 512. 558; 534, 560)

Pointfng l23-321

Sfn;ple Commands (13-371

Semi-Complex Canmandr (18-U)

Complcz Cormandr (11-471

Verbal Auditory Olscrfninatton (46-65)

Syntactic Comprchenrlon (66-152)


Synonyns 1158-162)

Antonyms (163-172)

Granmatlcality Judgments (171-102)

Semdntlc Acceptability l181-192)

Repetition (Herds) (193-251)

Lexical oecision (194-252)

Repetftian (Sentences) (251-259)

Series (260-2621


Naming (269-288)

Sentence Construction /289-313)

Semantic Opposites ll14-1211

Oerlvational Horphology 024-1111


Mental Arlthmetlc (147-161)

Lfstenfng Comprehension (162-366)



Reading Comprehension (Paragraph) (387-1921

copying (393-197)

Ofctatfon (Words1 (398-4021

Oictation (Sentences1 (401-407)


Reading Con'qrehenrton ISentences) 1418-427)

1

5pontaneous Writing (813-835)

12 3 4 5 6 7 819&

Figure 18. KS.% English Profile on the BAT (October 1987).


Language Assessment (19 October 1987)

K.S. was referred to our clinic for speech therapy after he was brought back to

Iran in April 1987. The patient was able to talk but with some difficulty. He suffered

from a deformed right hand, weak facial movements and weak right leg.

The patient was able to recognize the people around him. His short-term memory

span was 5 digits. He exhibited retrograde amnesia for the 8 years that preceded the

accident and did not remember his wife or children.

P.A. was tested by the author with the short versions of the BAT in Farsi and in

English. The Farsi version was administered on 19 October 1987 and the English

version on 21 October 1987 under the same general conditions. Figure 17 shows the

results on the Farsi version and Figure 18 on the English version. Overall, the

patient did better in Farsi than in English. In no task did he score significantly

better in English than in Farsi, but he scored significantly better in Farsi on many

tasks. Three years post-onset, the patient was thus exhibiting a differential pattern

of recovery. Even though he became aphasic in an English environment and

remained there for 3 years, Farsi was recovered better than English.

It was not possible to elicit spontaneous speech from the patient, nor to get him to

describe the picture-story in either language. Spontaneous writing could not be

elicited either. He totally failed the sentence construction task in both languages.

The patient’s linguistic profile may be summarized as nonfluent speech with

relatively good comprehension and repetition. These features suggest transcortical

motor aphasia (see Paradis and Libben 1987: Chapter 4, for full discussion).

CASE 14 (S.I.)

S.I. was a 51-year-old right-handed female native speaker of English with Farsi

as her second language. She was born in the United States and lived there until she

married a native speaker of Farsi. The patient and her family had lived in Iran for

the past 22 years. She had two grown-up bilingual children. It is reported that she

was fluent (though not literate) in Farsi before insult.

The patient received a B.A. in psychology from an American University. She had

taught psychology for a while but for the past 20 years she had been a housewife.

S.I. suffered from a CVA syndrome in July 1979 and was referred to our clinic for

speech therapy, eight and a half years later, in December 1987.

Clinical History

The patient had a history of high blood pressure. She was hospitalized in Tehran

consequent to a CVA syndrome in July 1979. She lost consciousness momentarily.

Subsequently, she suffered from hemiplegia. For the first 18 days, she was not able


to control her urine. During this period her speech was very limited and non-fluent

in both languages. She was put under medication and given physical therapy at the

hospital. Her right leg improved but her right hand did not improve much.

S.I. was discharged from the hospital after 30 days. She was then able to speak

both English and Farsi. During the second month after discharge, two episodes

took place. She had a fall which resulted in a fracture of the left occipital bone. Her

mother came to visit her from the United States. In the course of an argument, the

patient became very angry and is reported to have lost her speech in both languages

during this incident. She has not been able to speak either English or Farsi nor to

read or write English since August 1979.

The patient was diagnosed as having a left CVA syndrome caused by high blood

pressure. A recent CT scan (June 1987) with and without contrast injection showed

signs of cranial bone fracture in the left occipital area. There were signs of

hypodensity in the left hemisphere as a result of previous hemorrhage and atrophy.

A small calcified area in the left occipital area was also observed. The right

hemisphere was intact. At this point, the patient was alert, nervous and rather

aggressive. She was able to walk with a stick but could not use her right hand.

Language Assessment (December 1987)

S.1. was assessed by the author 8 years post-onset with the English and Farsi

versions of the BAT on 20 and 21 December 1987. She was unable to produce any

distinguishable sound in Farsi. Her English was limited to a few short fixed

expressions. such as “no, no . ” “come on” and “oh dear”. She was not able to write

spontaneously in English. She did not recite series in either language and was not

able to repeat even single words.

A general view of the patient’s residual capacities in English and Farsi is

presented in Figures 19 and 20, respectively. As the results indicate, the overall

performance was almost the same in both languages, thus suggesting a parallel

recovery.

The patient’s oral comprehension was preserved to a limited degree in both

languages. In English, she succeeded in pointing to all 10 objects but was not

completely successful in simple commands (4/5) and semi-complex commands

(3/5). She did very well in verbal auditory discrimination (16/ 18) thus indicating

excellent comprehension of single words, but she was not able to go beyond this

stage in comprehension. For example, she was not able to complete the syntactic

comprehension task. After listening to 3 items, she broke into tears and signalled

that she was not able to concentrate and recognize which picture would relate to

which sentence. The listening comprehension paragraph was read to her. She was

not able to give oral answers but acted as though she had understood the story when

questions were put to her in a multiple choice format. The items in the naming task


Fluency (51s. 541; 516, 517; 531. 5571

Accuracy (520, 521; 525.52R; 546, 547: 550-554)

Complexity (516. 517: 562. 543: 529. 555; 530. 556)

Lexical Access (519, 545; 531, 557: 532, 558; 534, 5601

Pointlnp (23-321

Sinple Conaands (33-37)

Semi-Complex Ccinandr (38-42)

Complex Coirmands (43-47)

Verbal Auditory Oircrlninatlon (t&65)

Syntactic Comprchenslon (66-1521

Scmant(c Categories (153-157)

Synonyns fi58-162)

Antonyms (163-172)

Cramnatfcality Judgmcncr l173-102)

Semantic Acceptability 1183-1921

Repetition (Words) (193-251)

Lexical Decisfon (194-2521

Repetition [Sentences) (253-2591

Series (260-262)

Verbal Fluency 1263-2671

Naming (269-2881

Sentence constructton f289-313)


Oerlvational tiorpholoqy (324-3331


Mental Arithmetic (347.361)

Listening Comprehension 062-3661



Reading Comprehenston (Paragraph1 (387-392)

Copying (393-397)

Oictatton Words) (398-402)

Dictation fkotences) f403-407)

Reading Comprehensfon (Uordsf (408-417)

Readlng Cor&w?henslon (Sentences) 1418-4271

Sponcsneous Uriting (813-835)

123456 7 8 9 IO

Figure 19. S.I.‘s English Profile on the BAT (December 1987).


Fluency (515. 541; 516. 517; 531, 557)

Accuracy (520. 521; 524-528; 546, 547; 550-554)

Camplexlty 1516. 517; 542. 541: 529. 555; 510, 556)

Lexfcal Access (519, 545; 511, 557; 512. 558; 534. 560)

Polntlng 121-12)

Slvle Commands (11-17)

Scml-Complex Camandr (18-42)

Complex Commands (41-471

Verbal Auditory Olscrinination (1,6_6S)

Syntactic Comprchenrion 166-1521


Synanynr 1158-162)

Antonyms (lhl-172)

Grdmmatfcallty Judgmcntr l171-102)


Repetl tlon (h’ords) (191-251)

tealcal Decision (194-2521


Serler (260-2621

Verbdl Fluency (263-2671

Hamlng (269-288)

Sentence Constructfon (289-313)


Derlvatlonal Horphology (124-3331

Horphological Opposites (314-141)


Ljstening Comprehension (362-366)

Oral Reading (Uordsl (367-3761

Oral Reading (Sentences1 1377-386)

Readlng Comprehenslan (Paragraph) (187-1921

copying ll93-1971

Dictation (Words) (398-402)

Dictation (Sentences1 (401-407)

Reading Comprehension (Words1 (408-4171

Reddlng CamprehensIon lSentenCes) f418-4271

spontaneous Uriting (813-835)

I -I .l 2 14 5 6 7 a 9 10 I

Figure 20. S.I.‘s Farsi Profile on the BAT (December 1987).


were presented to her one by one. She indicated that she had recognized all of them

but was unable to provide names.

In writing with her left hand, she was only able to copy single English words.

Beyond copying, her writing skills were limited to writing down numbers from 1 to

20 (in place of saying them orally during the series recitation task).

In Farsi, the patient was not even able to repeat single words. Her oral

comprehension was to some extent preserved, as it was in English. She did well in

pointing (9/ IO), simple commands (4/5) and semi-complex commands (3/5). Her

auditory comprehension at the single word level was relatively well preserved

(14/ 18). She also indicated that she understood the Farsi listening comprehension

paragraph. She was able to recognize all single words in the reading comprehension

task (lo/ 10).

In summary, the patient’s overall capacities were severely impaired in both

languages. She did not produce any speech in either. Her oral comprehension,

based on our assessment, was the same, albeit limited, in both languages. The

patient’s residual language capacities, as assessed with the BAT, support the

diagnosis of global aphasia in both Farsi and English.

DISCUSSION

Each patient’s language profile, as reported in the figures, was based on the

results of the 32 standard tasks of the BAT. With some patients, the short version

(22 tasks) was used. The BAT represents an objective method of assessment. All

measures on the BAT are quantitative. The qualitative clinical picture is obtained

by comparing the scores on the various tasks (e.g. comprehension relative to

production, repetition relative to comprehension and production, naming relative

to pointing, etc.).

Given the large number of possible variables (see Paradis and Libben 1987), one

should not expect definitive answers from such a small sample as the one presented

here. Bilinguals form a heterogeneous population with respect to context of

acquisition, context of use, degree of fluency in each of their languages and the

structural distance between them. Aphasic patients likewise form a heterogeneous

population, with respect to age at onset, months post-onset at time of language

assessment, etiology, site and size of lesion and major aphasic symptoms. It is

therefore not surprising that no correlation can be found between any of these

variables and type of recovery in the bilingual aphasic patients assessed so far in our

rehabilitation clinic.

Indeed, the 14 patients reported here differ from each other on a variety of

dimensions (Table 1). At the time of language assessment, their ages ranged from 22

to 79 years, the time post-onset from 2 to 100 months, their education from 0 to 26


Table 1

Selected Information on Cases Reported

Case Age Sex Hand Years of Occupation Etiology

Education

1. T.B.

2. H.J.

3. A.A.

4. F.Z.

5. K.N.

6. A.S.

7. A.L.

8. K.R.

9. S.Y.

10. A.E.

11. P.A.

12. P.O.

13. K.S.

14. S.I.

26

63

46

51

79

49

54

22

42

48

48

60

36

51

M

M

M

M

F

M

M

M

F

M

F

M

M

F

R

R

R

R

R

R

R

L

R

R

R

R

R

R

15

16 Retired

I1 Technician

9 Farmer

0 Housewife

25

5

Surgeon

Technician

11 Student

6

22

15

22

16

15

Housewife

Professor

Secretary

Physician

Engineer

Housewife

Student AVM

CVA

CVA

CVA

CVA

Trauma

Trauma

Trauma

CVA

Trauma

CVA

CVA

Trauma

CVA

Abbrevrations. Hand: handedness; L. left; R, right Languages: AR, Armenian; AZ, Azarl; EN. English; FA. Farsi; GE. German

Lesion site: B Frontotemp. bililateral fronto-temporal; L. Left; Mlddle C


Table 1 - continued

Lesion

Site

Months Aphasia Languages Recovery Best

Post- Type Pattern Re-

onset covered

L Temporo-

Occipito-

Parietal

L Temporo-

Occipital

L Fronto-

Temporal

L Middle

C Artery

L Middle

C Artery

L Fronto-

Temporal

L Parietal

L Temporo-

Parietal

L Fronto-

Temporal

L Temporal

L Fronto-

Temporal

L Middle

C Artery B Frontotemp

R Occipital

22 Transcortical

8 R Temporal

FA and EN Differential Farsi

4

8

AZ and FA Mixed NA

11

Wernicke’s

R Occipto- parietal

Global AR and FA

22 Amnestic AZ and FA

3 Mixed

Transcortical

Transcortical

Motor

Global

FA and AZ

2

6

FA, GE

and EN

AR and FA

48

2

Mild

Wernicke’s

Global

AZ and EN

AZ and FA

3

46

Transcortical

Sensory

Conduction

FA and EN

FA and EN

8 Wernicke’s AZ and FA

36 Transcortical

Motor

Global

AZ and EN

L Middle

C Artery

100

Parallel NA

Parallel NA

Mixed NA

Antagonistic NA

Parallel NA

Parallel NA

Parallel NA

Differential Farsi

Parallel NA

Parallel NA

Differential Farsi

EN and FA Parallel NA

Artery, area subserved by the Middle Cerebral Artery

Months Post-Onset, number of months post-onset at time of assessment

NA: not applicable

NEL 3:2-A


years. They also differ with respect to site of lesion, etiology and type and severity of

aphasic symptoms. In addition, four of the patients are global aphasics and their

aphasia is too severe to draw any conclusions from their (!ack of) performance. It is

almost inevitable that global aphasics should exhibit a parallel recovery. In fact, it

is not so much a parallel recovery as a total loss of language capacity. A floor effect

then prevents any diagnosis of differential recovery. Of the remaining 10 patients, 4

exhibited a parallel recovery (2 Wernicke’s, 1 amnestic and I conduction). 3 a

differential recovery (2 transcortical motor and 1 transcortical sensory). 2 a mixed

recovery (1 Wernicke’s and 1 mixed transcortical), and 1 an antagonistic recovery

(transcortical motor). It is important that all patients be assessed, irrespective of the

intrinsic interest of their particular case, so as to avoid a selection bias in the pool of

reported data. That is why even global aphasics, with very little or no expressive

language and with very limited comprehension, have been included in this pre-

liminary report.

Our patients also differed with respect to type and degree of bilingualism. Five

patients had acquired Farsi as a native language and had learned a second language

in high school or college and one had acquired English as a native language and

Farsi in her twenties. Eight patients were brought up bilingually from early

childhood with Armenian or Azari as their home language and Farsi as the

language of their environment and schooling. One of them spoke Armenian in the

home and both Azari and Farsi in the community. One patient was a native speaker

of Farsi who had spoken English as well since age 5. Not all patients used both

of their languages to the same extent. Some continued to have occasion to use both

every day, others had seldom used one of their languages, if at all, in the past several

years Patterns of recovery do not correlate with patients’ age. The age of patients

displaying a parallel recovery ranges from 22 to 60 years (mean age 46.7 years) and

of those displaying a non-parallel recovery, from 26 to 79 years (mean age 50. I

years). The sample is too small to further divide non-parallel patterns into specific

subtypes (3 differential, 2 mixed and 1 antagonistic). For example, the patients with

language mixing are the two oldest in the sample (63 and 79 years of age), but this is

not the trend in the reported literature (Paradis 1977, 1983). Patterns of recovery do

not correlate with patients’ degree of education either. The number of years ot

education range from 0 to 25 (mean 15.6 years) among patients exhibiting a non-

parallel recovery and from 5 to 22 (mean 11.7 years) among those exhibiting a

parallel recovery. Lesions in patients with both parallel and non parallel recovery

patterns are of various etiologies (parallel: 6 CVA and 2 trauma cases; non-parallel:

1 AVM, 2CVA and 3 trauma cases). All cases involve damage to the left hemis-

phere. three of them with some bilateral involvement. Both parallel and non-

parallel recovery patterns are found in patients with lesions injust about any area of


the traditional language cortex and with a variety of aphasic symptoms (parallel: 4

global, 2 Wernicke, 1 amnestic and 1 conduction aphasia; non-parallel: 3 trans-

cortical motor, 1 transcortical sensory, one mixed transcortical and one Wernicke-

type aphasia).

In all three cases of differential aphasia, the best recovered language was the

language of the environment which was also the patient’s dominant language. The

two cases of language mixing were found in patients with posterior brain damage

(though in one case, not exclusively). The case of antagonistic recovery involved

languages that were equally fluent at the time of insult, a characteristic shared with

both cases reported by Paradis et al. (1982). A.S., like their first patient, had learned

his second language post-puberty and had used it extensively ever since. Our

patient’s third and less proficient language was eventually recovered to a lesser

degree than the other two, thus reflecting their premorbid order of relative fluency.

From the limited data at our disposal, it would therefore seem that degree of

mastery of each language at time of insult is more important than the context of

acquisition in determining the pattern of recovery. Moreover, pattern of recovery

in the same patient may change over time.

CONCLUSION

Fourteen bilingual or trilingual patients seen consecutively for assessment at the

Language Therapy Clinic of the College of Rehabilitation Sciences in Tehran have

been described. Even though all patients could be considered to have been fluent in

their 2 or 3 languages before insult, they nevertheless displayed 4 different patterns

of recovery. These patterns do not correlate with the patients’ age, degree of

education, lesion site, etiology or aphasia type.

Many more case reports are to be collected from many different research centers

around the world before correlation patterns can emerge. Provided that all patients

are assessed with an equivalent instrument in each of their languages, as is now

feasible with the BAT, it should soon be possible to have a large enough data base to

be able to ascertain what factor or combination of factors influence particular

patterns of recovery. While models of bilingual language processing based on

inhibition/disinhibition (Paradis 1977) and on control, activation and resource

(Green 1986) are beginning to account for the mechanisms underlying non-parallel

recoveries, the factors that determine the choice of the preferentially recovered

language remain problematic.

REFERENCES

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