Introduction
The following exercise is a case study of a man (‘OP’) with right hemisphere damage (RHD) who was studied by Abusamra et al. (Reference Abusamra, Côté, Joanette and Ferreres2009). OP is 60 years old. Following a stroke three years earlier, OP displays many of the pragmatic and discourse deficits that are found in clients with right hemisphere language disorder. These deficits were revealed during assessment of his language skills using the MEC protocol (Joanette et al., Reference Joanette, Ska and Côté2004). The case study is presented in five sections: primer on right-hemisphere language disorder; right-hemisphere language assessment; client history and assessment; focus on metaphor; and focus on narrative discourse.
Primer on right-hemisphere language disorder
Historically, the right cerebral hemisphere has been somewhat neglected by investigators as a seat of significant language and communication disorder. This is on account of the fact that the right hemisphere is not typically associated with aphasic language disturbances. (Crossed aphasia – aphasia following a right-hemisphere lesion in right-handed individuals – is an obvious, but relatively uncommon exception.) Also, the pragmatic and discourse deficits that arise in RHD are not addressed by the types of language batteries that are used to assess aphasia, and have often evaded characterisation for this reason. Today, there is widespread acknowledgement among speech-language pathologists that clients who sustain RHD can experience significant communication problems. So-called right-hemisphere language disorder (RHLD) is a unique clinical syndrome which can be distinguished from the aphasias and from the types of language impairments that are associated with the dementias. However, like language in the dementias, RHLD is associated with cognitive deficits, earning it the name of a cognitive-communication disorder. The linguistic and cognitive features of RHLD are examined in this unit.
Focal damage to the right cerebral hemisphere can result in pragmatic and discourse deficits. In clients who sustain RHD, there may be an impairment of the comprehension of non-literal language including implicatures (Kasher et al., Reference Kasher, Batori, Soroker, Graves and Zaidel1999), metaphors (Rinaldi et al., Reference Rinaldi, Marangolo and Baldassarri2004), idioms (Papagno et al., Reference Papagno, Curti, Rizzo, Crippa and Colombo2006), sarcasm (Giora et al., Reference Giora, Zaidel, Soroker, Batori and Kasher2000; Shamay-Tsoory et al., Reference Shamay-Tsoory, Tomer and Aharon-Peretz2005) and indirect speech acts (Hatta et al., Reference Hatta, Hasegawa and Wanner2004). Although errors of interpretation vary, there is a general tendency towards literal interpretation of these utterances. Tompkins (Reference Tompkins2012) remarks how adults with RHD may comprehend expressions such as metaphors better when they are preceded by moderately to strongly biased linguistic context (e.g. the first two utterances in ‘The man is stubborn. He never quits. The man is a mule’). Problems with the interpretation of non-literal language have been attributed to theory of mind deficits (Winner et al., Reference Winner, Brownell, Happé, Blum and Pincus1998) and visuo-perceptual and visuo-spatial deficits (McDonald, Reference McDonald2000; Papagno et al., Reference Papagno, Curti, Rizzo, Crippa and Colombo2006). To the extent that affective prosody also plays a role in utterance interpretation, the well-recognised prosodic deficits of this population of clients may also compromise the understanding of figurative and other non-literal language (Yuvaraj et al., Reference Yuvaraj, Murugappan, Norlinah, Sundaraj and Khairiyah2013).
Discourse deficits have been extensively documented in clients with RHD. These deficits include the production of narratives which contain tangential errors and conceptually incongruent utterances (Marini, Reference Marini2012). The picture descriptions of clients with RHD have poor information content, cohesion and coherence (Marini et al., Reference Marini, Carlomagno, Caltagirone and Nocentini2005). Lehman Blake (Reference Lehman Blake2006) reported that discourse produced by adults with RHD during a thinking-out-loud task was rated as more tangential and egocentric than the discourse of healthy older adults. RHD discourse also contained extremes of quantity (i.e. extreme verbosity or paucity of speech). Alongside expressive discourse deficits, clients with RHD also have well-documented problems comprehending narrative discourse. Jerônimo et al. (Reference Jerônimo, Marrone and Scherer2011) examined narrative discourse comprehension in a 53-year-old man with RHD. This client was able to comprehend narratives at the micro-propositional level. However, he had significant difficulty in processing narrative macro-structure and situational model, especially in comprehending the main idea of narratives. Adults with RHD have been found to have difficulty drawing high-level inferences about the motives of characters in narratives (Tompkins et al., Reference Tompkins, Meigh, Scott and Lederer2009). The suppression of inappropriate inferences is a significant predictor of narrative discourse comprehension in adults with RHD (Tompkins et al., Reference Tompkins, Baumgaertner, Lehman and Fassbinder2000, Reference Tompkins, Lehman-Blake, Baumgaertner and Fassbinder2001).
Unit 28.1 Primer on right-hemisphere language disorder
(2) Why might a client with RHD have difficulty understanding the following utterances?
(3) An inability to decode prosody can compromise utterance interpretation in clients with RHD. However, these clients can also have difficulty with productive aspects of prosody. Describe one way in which this may compromise communication for clients with RHD.
(4) Clients with RHD display a number of linguistic strengths as well as weaknesses. Describe three aspects of language which are well preserved in RHD. The preservation of these aspects sets RHLD apart from another acquired language disorder. What is that disorder?
(5) Respond with true or false to each of the following statements about discourse in RHD:
Clients with RHD have difficulty observing maxims of relation and quantity during discourse production.
Clients with RHD struggle to comprehend the propositional content of narratives.
Clients with RHD can have difficulty establishing the gist of stories.
Clients with RHD produce many cohesive links between utterances.
Clients with RHD display discourse problems which are related to cognitive deficits.
Right-hemisphere language assessment
Speech-language pathologists have recognised for some time that RHD disrupts language in ways that are inadequately assessed by aphasia batteries. When Penelope Myers undertook the first formal study of communication impairments in adults with RHD, it was a discourse task – the cookie theft picture description from the Boston Diagnostic Aphasia Examination (Goodglass and Kaplan, Reference Goodglass and Kaplan1972b) – that was used to characterise these impairments. These adults, Myers remarked, produced ‘irrelevant and often excessive information’ and seemed ‘to miss the implication of [a] question and to respond in a most literal and concrete way’ (Myers, Reference Myers1979: 38). When attempting to respond to open-ended questions, these patients ‘wended their way through a maze of disassociated detail, seemingly incapable of filtering out unnecessary information’ (38). The components of a narrative, although available to these patients, could not be assembled into a narrative. There was difficulty ‘in extracting critical bits of information, in seeing the relationships among them, and in reaching conclusions or drawing inferences based on those relationships’ (39). Although the detail provided by these patients was related to the general topic, its appearance seemed irrelevant because it had not been ‘integrated into a whole’ (39).
It was nearly 10 years after Myers’ study that Bryan (Reference Bryan1988) confirmed what many clinicians had long suspected was the case: adults with RHD communicate inadequately even as they have no identifiable language disorder on aphasia batteries. Bryan devised a set of tests which included metaphorical comprehension and the understanding of inferred meaning and humour. Along with the Western Aphasia Battery (Kertesz, Reference Kertesz1982), these tests were administered to adults with left and right cerebral hemisphere damage and to normal control subjects. A discourse analysis was also undertaken. While the subjects with RHD were not significantly different from controls on the aphasia test, their performance was impaired compared to control subjects on the metaphor and other tests. Bryan (Reference Bryan1995) subsequently went on to develop the Right Hemisphere Language Battery. The seven tests in this battery include tests of spoken and written metaphor appreciation, verbal humour appreciation, comprehension of inference, production of emphatic stress and lexical semantic comprehension. There is also a comprehensive discourse analysis. The battery has been translated into other languages including Polish and Italian (Jodzio et al., Reference Jodzio, Łojek and Bryan2005; Zanini et al., Reference Zanini, Bryan, De Luca and Bava2005), and has been used in subjects with RHD caused by cerebrovascular accidents and brain tumours (Bryan and Hale, Reference Bryan and Hale2001; Thomson et al., Reference Thomson, Taylor, Fraser and Whittle1997).
The patient with RHD in this case study was assessed using the Protocole Montréal d’Évaluation de la Communication (MEC; Joanette et al., Reference Joanette, Ska and Côté2004). This standardised test was designed primarily for clients with RHD, although the authors also recommend its use in the assessment of clients with aphasia, traumatic brain injury and dementia. Verbal communication skills are assessed by means of 14 subtests. These tests examine conversational discourse, the comprehension and recall of narrative discourse, semantic judgement, repetition and understanding of emotional and linguistic prosody, and understanding of metaphors and indirect speech acts. The MEC is standardised on a sample of 180 non-brain-damaged control subjects who range in age from 30 to 85 years. Participants with RHD are also included in the psychometric data. Although the original MEC was in French, there are now versions available in Brazilian Portuguese and Spanish (Ferreres et al., Reference Ferreres, Abusamra, Cuitiño, Côté, Ska and Joanette2007; Fonseca et al., Reference Fonseca, Joanette, Côté, Ska, Giroux, Fachel, Damasceno Ferreira and Parente2008).
Unit 28.2 Right-hemisphere language assessment
(1) Myers’ description of the discourse problems of adults with RHD is particularly vivid and is as relevant today as it was in 1979. Which part of her description corresponds to the finding that adults with RHD have difficulty understanding indirect speech acts?
(2) Adults with RHD can display weak central coherence (Martin and McDonald, Reference Martin and McDonald2003). This is a type of processing in which there is a preference for parts over wholes. Which aspect of Myers’ description suggests a tendency on the part of her subjects for weak central coherence?
Client history and assessment
OP is a 60-year-old lawyer. He has 18 years of formal education. OP first attended the aphasiology service at the hospital, where the lead author of the study, Valeria Abusamra, works, when he was three years post-onset a cerebrovascular accident (personal communication, August 2015). At that time, he had a single, right-sided brain lesion. However, his neurological condition was subsequently complicated by the onset of epilepsy, and he exhibited bilateral brain lesions. At that point, it was decided that OP should be excluded from further investigation. The MEC protocol was used to assess OP. He performed very poorly in the tasks that assessed narrative, metaphors and speech acts. OP's responses on a task in which an examiner (EX) asked him to explain the meaning of indirect speech acts are shown below.
Indirect speech act 1
EX: Louise sees her dirty Ford parked on the street and asks her husband: “Don't you think it's a bit too dirty?” What do you think Louise means by that?
OP: That it would be convenient to wash the car. The Ford or any other car.
EX: Very good. Which of these options explains it best? Is she trying to tell her husband that the Ford is not clean, or does she want her husband to wash the Ford?
OP: No, I'd probably go with option A. I mean, because…if not, it's another…she's superimposing, imposing an assigned chore, regarding the husband [sic]. Because in theory, although the car can be washed in a car wash, the husband usually washes it, but the wife could just as easily wash it.
Indirect speech act 2
EX: Mr Martinez is busy in his living room when the phone starts ringing. He tells his spouse: “The phone is ringing”. What do you think Mr Martinez means by that?
OP: He's busy.
EX: (Rereads)
OP: That…well, it's assumed that he wants his wife – it isn't known what she's up to, it doesn't say that it isn't known if she's also busy or not. What is stated is that Mr Martinez is busy, but nothing is known about what the wife is doing, which could be in another task [sic] just as or more urgent or more of a different urgency [sic]. But with the information as stated here what's suggested is that she should answer the phone.
EX: And from the following options you have, is he trying to say that he hears the phone ring, or does he want his spouse to answer?
OP: Well, yes, he's says both things.
EX: Together.
OP: Right, because he hears the phone ring, yes. Which he's listening to, he's…now, in theory, along with that there's a request.
EX: Good.
OP: There should be a request.
EX: Right, in this given situation? When he says “the phone is ringing”?
OP: If he assumes…If he assumes that the wife, wife or spouse, already knows he's busy, then he's referring to the latter. But she does not know the former, you have to see whether the wife knows or not. Normally, in theory, living together makes…makes B work, but within a context, a specific context.
Indirect speech act 3
EX: Martin sits down in his living room to watch television. He tells his wife who's in the kitchen: “My glasses are on the table”. What do you think Martin means by that?
OP: Well, what he actually means – he's manifesting the difficulty he's having to watch television, which insofar that in theory, it's assumed that he needs glasses to watch television. He also could be requesting his partner, who's his actually his wife, partner, which is not legally correct…that he doesn't necessarily want them, well let's see…
EX: Let's see, from the following options, does he want to tell her where his glasses are, or does he want her to bring his glasses over to the living room?
OP: Well, he's obviously telling her where his glasses are, but in theory he's requesting that she bring him his glasses to the living room, where he's trying to watch television.
Indirect speech act 4
EX: Last one. The last one of this task. Peter works in an office and needs to print a document. Therefore, he tells his secretary: “There's no more paper”. What do you think Peter means by that?
OP: Well, here according to the guidelines that are followed within work relationships, in effect, insofar that she is his secretary [sic]. The word “his” is there, which is important to notice. He's requesting something, insofar that in theory she has a work obligation…of complying with her boss's requests.
EX: Very good. So what does it mean when he says there's no more paper, or does he want his secretary to put more paper in the printer?
OP: Well, it means both things. He explicitly says it, because you can't say there's no…
EX: But, in this case, which one do you think is best? If you had to choose one of the two for this situation.
OP: In theory, the second one, because let me say, the topic of…of the connection with “her” is important.
Unit 28.3 Client history and assessment
(1) OP first participated in Abusamra et al.'s study three years after suffering a stroke. However, he was later excluded from the study. Why do you think the decision was taken to exclude OP from further investigation?
(2) How would you characterise OP's understanding of indirect speech act 1?
(3) In indirect speech act 2, what evidence is there that more than one interpretation of the speech act is salient for OP?
(4) OP also entertains more than one interpretation of indirect speech act 3. But what other inference does he draw in this exchange? What is the significance of this inference for the speech act in the exchange?
(5) OP is eventually able to indicate to the examiner that indirect speech act 4 is a request for the secretary to put more paper in the printer. However, before he arrives at this interpretation of the speech act, OP appears to dwell on one aspect of the scenario that is presented to him. What is that aspect?
Focus on metaphor
In the following exchange, an examiner has asked OP to explain the meaning of one of the metaphors from the MEC protocol. The metaphor is ‘My friend's mother-in-law is a witch’:
EX: What does this phrase mean: My friend's mother-in-law is a witch?
OP: Let's change also one word: My son-in-law's mother-in-law is a witch?
EX: And so what does it mean?
OP: I know she is a person who hasn't had a pleasant life, throughout her marriage. That…that she's about to be separated from her husband; I'm referring to the mother-in-law of my son-in-law (ha, ha, ha)
EX: OK it's not important – it's the same.
OP: Certainly! The mother-in-law of my son-in-law. The mother-in-law of my son-in-law is a witch!
EX: What does being a witch mean?
OP: Because the woman is separated, because all her life she has criticized her husband for the way he is; only seen in his defects, who has kept his daughter all her life under a glass bell and she's now a poor lady because she can't find the fiancé her mother would like.
EX: So what does witch mean, then?
OP: What does it specifically mean? It means being tied down to religious sects, to religions, to umbanda…who knows, there are so many.
EX: So therefore, “The mother-in-law of my son-in-law is a witch”. Does it mean the mother-in-law of my friend practices black magic? And the mother-in-law of my friend has many brooms and she is also a bad person and rude?
OP: It's absolutely clear. My friend's mother-in-law has many brooms…no! My friend's mother-in-law practises black magic.
Unit 28.4 Focus on metaphor
(1) OP is clearly having difficulty explaining the meaning of this particular metaphor. How would you characterise his understanding?
(2) Is there awareness on OP's part that his interpretation of the metaphor may not be accurate?
(3) Egocentric discourse is a feature of right hemisphere language disorder. Is there any evidence that OP makes use of egocentric discourse in the above exchange?
Focus on narrative discourse
OP was also read a narrative text from the MEC Protocol and was asked to retell the story. The original narrative text and OP's retelling are shown below.
Original text
John is a farmer from the north. He has been busy for several days digging a well on his land. The work is almost over. This morning John has arrived to finish his work and sees that during the night the well has collapsed and half of it is filled with earth. He's very upset about this. He thinks for some minutes and says to himself, “I have an idea.” He leaves his shirt and cap on the edge of the well, hides the pick and pail, and climbs up a tree to hide himself. Later, a neighbour passes by and approaches John to talk to him a little. When he sees his shirt and cap he thinks John is working at the bottom of the well. The fellow passes nearby, bends down a little, and sees the well half-filled with dirt and starts to desperately cry out, “Help! Help! Friends! Come immediately! John is buried under the well!” The neighbours run towards the well and start digging to save poor John. When the neighbours stop taking away the earth, John comes down the tree, approaches them and says, “Thanks a lot, you've been a great help.”
OP's retelling
There was a farmer who was digging a hole uh uh uh uh well he was digging a hole until at a certain depth…uh uh uh uh…er. who was digging a well eh eh eh so he was digging with a shovel and a pick…uh uh uh…objects that don't look like what we call shovel and pick I mean they have really something to do with the ground…not only uh uh uh…generally a wine…the farmer moves the it it it more with shovel than pick or at least like a pick. And so he went down to a certain depth and he was, was tired, it was night and so and the next day…he sees the well has collapsed I mean collapsed from a part of of of of You don't remind me any more…
Unit 28.5 Focus on narrative discourse
(1) OP really only gets his narrative properly underway when he utters ‘And so he went down…’. How would you characterise OP's narrative prior to this point?
(3) Is there any evidence from OP's retelling of the story that he may be experiencing visuo-perceptual deficits?
(4) OP only introduces one character, the farmer, into his narrative. Is this introduction skilfully achieved?
(5) Respond with true or false to each of the following statements about OP's narrative:
