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Word retrieval in fluent and nonfluent dysphasia: Utilization of pictogram
J. COMMUN. 26 (1993).
DISORD. 113-128
WORD RETRIEVAL IN FLUENT AND NONFLUENT DYSPHASIA: UTILIZATION OF PICTOGRAM CONNIE B. BRACY and SAKINA S. DRUMMOND University
of Arkansas
at Little RocklUniversity
of Arkansus
for Medical
Sciences
Connected speech samples were elicited from 10 nonfluent and 10 fluent dysphasic subjects utilizing two contexts, picture and pictogram descriptions. Incidences of word retrieval problems were identified and assigned to nine word retrieval categories. Results revealed pictogram elicited a greater incidence of word retrieval problems, and therefore, proved as a more informative context for identifying word retrieval problems in mild dysphasia. Also, certain word retrieval categories were selectively used by specific dysphasic classification categories and severity levels.
INTRODUCTION Word retrieval in dysphasia has been investigated with a variety of tasks. These include confrontation naming, sentence completion, word fluency, and connected speech elicitations. Of the different contexts eliciting connected speech, picture description has been the most frequently used in routine clinical examinations (Goodglass and Kaplan, 1983; Kertesz, 1979). Picture descriptions necessitate descriptions of depicted referents. A variation of this context is pictogram description, which requires description of the same referent performing sequential events depjcted through multiple picture frames. Available data on pictogram description indicate that this context is preferable to picture description, because it can elicit a larger variety and number of word retrieval responses. These observations, however, remain limited to word retrieval data from nonfluent dysphasia (Cherepski and Drummond, 1987). Word retrieval responses have generally been analyzed through examination of hesitations, revisions, repetitions, circumlocutions, indefi-
Address correspondence to Sakina S. Drummond, Ph.D., Audiology ogy, UALJUUAMS, 2801 S. University, Little Rock, AR 72204. 01993 by Elsevier Science Publishing Co.. Inc. 655 Avenue of the Americas, New York, NY 10010
& Speech
Pathol-
113 002 I -9924/93/$6.00
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and DRUMMOND
nites/anaphors, and phonemic, semantic, and neologistic paraphasias (Cherepski and Drummond, 1987; Rinnert and Whitaker, 1975; Wilhams and Canter, 1982). Each of these response characteristics reflect the dysphasic subject’s word retrieval difficulties; however, they are not all representative of his/her “error” responses. For example, the dysphasic’s use of hesitations, revisions, and repetitions confirm the presence of word retrieval difficulties, but their use does not reflect word retrieval errors. The subject uses these overt behaviors to retrieve the target lexeme ultimately. Previous data also indicate that a difference exists between nonfluent and fluent dysphasic adults’ use of different word retrieval characteristics. Dunn, Russell, and Drummond (1989) and Williams and Canter (1987) have found that fluent dysphasic adults produced a greater frequency of semantic paraphasias and circumlocutions during confrontation naming tasks. The same finding was not observed, however, when dysphasic subjects were required to recall names of items during a word fluency task (Dunn, et al, 1989). This inconsistency in contemporary reports suggests two possibilities: 1. The dimension of verbal fluency in dysphasia interacts with the use of different word retrieval characteristics; or 2. The linguistic context interacts with the select use of some word retrieval characteristics among the two polar types of dysphasias. This investigation examined each of these possibilities by comparing the nature of word retrieval performance from both fluent and nonfluent dysphasic adults. Second, the investigation sought to determine if a distinction can be made between the occurrence of word retrieval behaviors (hesitations, revisions, and repetitions) and word retrieval errors (anaphors and circumlocutions, as well as phonemic, neologistic, and semantic paraphasias).
METHOD
Subjects Ten fluent and 10 nonfluent dysphasic adults, with single episode ischemic, left hemisphere cerebrovascular accidents (CVA), served as the experimental subjects. All of the selected subjects were righthanded native English speakers, and none of them had any visual field problems. Prior to subject-selection, medical records of potential subjects were reviewed for their neurological history, and the attending neurologist was consulted to clarify the obtained medical data and rule out possible evidence of visual field problems.
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All experimental subjects were administered the Boston Diagnostic Aphasia Examination (or BDAE; Goodglass and Kaplan, 1983) to assign them to the “fluent” versus “nonfluent” categories and, subsequently, to subclassify them according to the BDAE dysphasic type. The param-
eters of “melodic line,” “phrase length,” and “grammatical form” from the BDAE were used to identify fluent versus nonfluent linguistic characteristics. Subjects who received a rating of 4 or less on each of these parameters were assigned to the nonfluent dysphasic category, whereas those who received a rating of 5 or more were assigned to the fluent dysphasic category. The protocol and criteria for assignment of dysphasic classification and severity directly followed the guidelines of the BDAE manual. The mean age for all subjects was 59.6 years, and their mean duration of dysphasia was 2 years, 4 months. A total of five females and fifteen males served as experimental subjects. Table 1 presents the description Table 1. Background
Subject
Gender
Information
on the Experimental
Subjects BDAE
BDAE
Age in
Chronicity
Fluency
dysphasic
severity
years
in months
Assignment
classification
rating
1
nonfluent
transcortical
I
F
5.5
2
M
30
12
3
M
54
4
M
5
M
6
F
7
M
8
F
9
M
74
10
M -
11
M
62
2
12
M
67
18
fluent 0,
13
M
46
19
VI
14
M
62
3
,,
15
F
77
17
0,
16
M
46
65
I,
I,
17
M
65
1
I,
,I
18
F
80
4
,I
I,
19
M
55
1
I,
20
M -
54
motor ”
mean
16
0, ,I
Broca’s 0,
56
29
0,
V,
56
48
,I
0,
82
72
,I
0,
55
1
0,
0,
70
62
0,
,I
72
,I
,I
46
52
,,
I,
57.8
36.5
61.4
2 3 3 2 3 2 2 2.2
I, 13.1
3
-
anemic ,I ,I conduction I,
Wernicke’s I, -
4 4 4 4 4 3 3 2 2 2 3.2
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BRACY and DRUMMOND
of fluent and nonfluent dysphasic subjects by gender, chronological age, duration postonset, and dysphasic classification type and severity rating. It needs to be noted that in our strive for a larger sample size of nonfluent and fluent subjects we had to compromise the control over the variables of chronicity and severity of dysphasia. As a result, the selected nonfluent subjects were relatively more chronic and severe than the fluent subjects.
Stimuli Two different visual stimuli were used to elicit verbal output. One stimulus was presented in a pictogram format and consisted of seven picture frames. The “Tank McNamara” comic strip was selected as the pictogram stimulus since it has been reported to elicit a greater number and variety of verbalizations than the “Dennis the Menace” comic strip (Cherepski and Drummond, 1987). The rationale for selecting a comic strip to represent a pictogram related to the familiarity of its depiction to the average adult. The second stimulus was the “Cookie Theft” (CT) picture from the BDAE. This stimulus represented a stative context, and was selected because of frequent use in clinical practice.
Procedure Each subject was individually required to describe the pictogram and the “cookie theft” stimuli. The instructions for the pictogram were: “Describe everything you see in this comic strip.” The instructions for the CT picture were taken from the BDAE test manual, which reads: “Tell everything you see going on in this picture.” In order to control for the degree of familiarity with the stimuli, the selected subjects were required to describe the CT picture only once, therefore, they were not presented this portion of “section 1” during the comprehensive BDAE administration. The time taken to respond to each experimental stimulus was recorded for possible comparison between fluent and nonfluent productions. A two-minute interval period was given between the two stimuli administrations. A random order was used for the presentation of the two stimuli. All responses were audio tape-recorded for later analyses.
Data Organization All verbal responses were orthographically transcribed. Neologistic and phonemic paraphasias as well as sound and syllable interjections were phonetically transcribed using the International Phonetic Alpha-
WORD RETRIEVAL
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117
bet. Two judges identified the incidences of word retrieval problems, and they assigned each of them to one of nine possible categories. These nine categories were: hesitation, repetition, revision, anaphor, circumlocution, semantic paraphasia, phonemic paraphasia, neologistic paraphasia, and incomplete. Appendix A provides the operational definitions for each of these categories. Whenever any disagreements occurred between the two judges’ assignments, they were required to relisten to that particular utterance and reassign the word retrieval response until a consensus (or 100% agreement) was reached. RESULTS A total of 812 incidences of word retrieval behaviors were elicited. Analyses of variance (ANOVAs) and unpaired t-tests were used for data analyses. An alpha level of p < .05 was chosen to determine statistical significance between the examined variables. Type and Severity of Dysphasia Examination of the word-finding difficulties for the nonfluent and fluent dysphasic groups, irrespective of the experimental stimulus, revealed that the fluent group produced an average of 38.8 occurrences of wordfinding difficulties. In contrast, the nonfluent dysphasic group produced an average occurrence of 42.4 word-finding difficulties. This finding failed to yield a statistically significant difference (at the .05 level of confidence) for the occurrence of word-finding difficulties between the two subject groups. Table 2 lists the total output and incidences of word-finding difficulties for the nonfluent and fluent subjects for the two experimental stimuli. The incidence of word-finding difficulties for the four BDAE severity ratings and for the different classification categories were also examined (see Tables 3a and 3b). These mean data indicate that except for severity rating 4, the incidence of word retrieval difficulties progressively increased for those subjects assigned to severity ratings 1,2, and 3 (see Table 3a). The mean data for the five dysphasic classification categories failed to show any specific trend in the mean occurrence of word retrieval difficulties (see Table 3b). Effect of Stimulus Context The results of t-test revealed a significant difference existed between the two experimental stimuli for their elicitation of the total number of word retrieval difficulties for all dysphasic subjects (t = 4.44; p =
118
BRACY
and DRUMMOND
Table 2. Production of Total Words and lncidences of Word Retrieval Difficulties for the Nine Categories, Two Experimental Contexts, and Type of Dysphasia Word retrieval categories
Pictogram Nonfluent
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total Total words produced
168 27 23 IO 9 IS II 9 2 274 311
Cookie Fluent
theft
Nonfluent
80
16 30 37 20 II 14 8 0 216 797
Fluent
87 10
58 35
13 I2 4 8 5 II
20 22
Total 393 88 86 81 52 42 38 30 2 812 3124
I9 8 9 2 0 172 I450
0 150 566
.0003). This finding indicated that the pictogram (X = 22.15; total = 471) identified a significantly greater incidence of word retrieval difficulties than the “cookie theft” picture (% = 16.58; total = 337). Similar analysis, with separation of the nonfluent and fluent dysphasic performances, also revealed the pictogram stimulus to elicit a significantly greater incidence of word retrieval difficulties for both fluent (t
Table 3a. Mean Occurrences for the Nine Word Retrieval Four Severity Levels of Dysphasia Word
retrieval
categories
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total mean
Severity (n=2)
’ 1’
Severity (n=7)
‘2’
Categories
Severity
‘3’
for the
Severity
(n=6)
(n=S)
12.5
16.33
34.17
10.83
11.5
6.5
4.0
0.33
0
4.0
4.33
6.0
0
1.83
4.83
6.83
0
1.33
6.33
I .o
0.5
1.5
4.17
1.17
0
2.0
2.83
1.5
0
2.33
1.83
0.83
0
0.17
0.17
0
24.5
35.99
62.66
28.49
‘4’
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119
Table 3b. Mean Occurrences for the Nine Word Retrieval Dysphasic Classification Categories Word retrieval categories
Anemic (n=3)
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total mean
Conduction (n=S)
Wernicke’s (n=2)
Categories
for the Five
Broca’s (n=9)
Transcortical motor (n= I)
13.33 0.33 4.0 7.0 1.0 2.0 I.0 0.67
17.4 3.6 6.8 6.4 7.0 1.6 2.8 1.4
16.0 2.0 3.0 0.5 2.5 2.5 0.5
28.11 1.56 4.0 2.44 1.44 2.44 I .78 0.22
2.0 23.0 0 0 0 I.0 0 0
29.33
47.0
32.5
44.21
26.0
= 5.58; p = .003) and nonfluent
5.5
(t = 4.26; p = .0021) dysphasic
sub-
jects (see Table 2).
Word Retrieval Categories Table 2 provides the frequency of occurrences for the nine word retrieval categories for all subjects. Tables 3a and 3b also provide the mean occurrences for the nine word retrieval categories relative to the severity and type of dysphasia. Table 4 presents the p-levels from unpaired t-tests examining the nine word retrieval categories for the nonfluent and fluent dysphasic subjects for the two experimental stimuli. The results identified hesitations occurred significantly more often than the other eight word retrieval behaviors for both fluent and nonfluent subjects. The results also revealed fluent subjects used revisions and incompletes significantly more often. The findings for fment subjects were further explored by examining fluent subjects according to their BDAE classification assignments. Results from unpaired t-tests comparing the occurrences of the nine word retrieval categories for the anemic, conduction, and Wernicke’s dysphasic classifications are presented in Table 5. These results reveal that among the fluent subjects, those classified as anemic or conduction produced significantly more hesitations and revisions. In contrast, those subjects classified with Wernicke’s aphasia tended to produce neologistic paraphasias relatively more often (also see Table 3b). Analysis of the word retrieval behaviors according to the severity of
120
BRACY
Table 4. Significant Interactions for the Word Retrieval Experimental Stimuli, and for the Dysphasic Subjects
and DRUMMOND
Categories,
for the Two
All subjects Word retrieval
Pictogram
Cookie
theft
Cookie
categories
Nonfluent
Fluent
Nonfluent
Fluent
Pictogrdm
Hesitation by revision Hesitation by repetition Hesitation by incomplete
.0079
NS
.0349
.0109
.0084
.0218
.0069
.0009
.0239
.OOOl
.0047
.0109
.0099
.0404
.0316
.OllO
.0081
.0156
Hesitation by indefinite Hesitation by circumlocution Hesitation by phonemic paraphasia Hesitation by semantic paraphasia
.0127
.0012
.0370
.0005
.0068
.0140
.007 1
.OOlO
.0197
.0003
.0038
.0070
.0085
,003s
.0348
.0008
.0056
.0147
.0099
.0122
.0241
.OOOl
,006s
.0105
Hesitation by neologistic paraphasia
.0154
NS
NS
NS
NS
.0432
Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia
NS
NS
NS
NS
NS
.027 1
NS
NS
NS
NS
NS
NS
NS
.0269
NS
.0015
NS
NS
NS
.0125
.0317
.0009
.0137
.0002
NS
.0344
NS
.0165
NS
NS
NS
NS
NS
.0030
NS
.0038
NS
NS
NS
NS
NS
NS
theft
WORD
RETRIEVAL
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121
Table 4 (continued) All subjects Word retrieval categories
Repetition by incomplete Repetition by indefinite Repetition by circumlocution Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia
Pictogram
Cookie
theft
Cookie
Nonfluent
Fluent
Nontluent
Fluent
Pictogram
theft
NS
NS
NS
NS
.0135
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0145
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0166
NS
.0344
NS
NS
NS
.0029
.0383
.0182
.0007
.0049
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0359
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
(continud)
122
BRACY
and DRUMMOND
Table 4 (continued) All subjects Word
Pictogram
retrieval
categories
Indefinite by neologistic paraphasia Circumlocution phonemic paraphasia Circumlocution semantic paraphasia Circumlocution neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Nonfluent
Cookie
Fluent
Nonfluent
theft
Cookie
Fluent
Pictogram
theft
NS
NS
NS
NS
NS
NS
by
NS
.0264
NS
.0348
NS
.0200
by
NS
NS
NS
NS
NS
.Ol I I
by
NS
NS
NS
NS
NS
.0123
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0412
at .O.Slevel of confidence
Table 5. Significant Interactions for the Word Retrieval Categories Experimental Stimuli and for the Three Types of Fluent Dysphasic Pictogram Word retrieval categories
Anemic
Conduction
for the Two Subjects Cookie theft
Wernicke’s
Anemic
Conductron
Werenicke’s
Hesitation by revision
NS
NS
NS
.0404
NS
NS
Hesitation by repetition
NS
.04x0
.0147
.0246
.0084
NS
Hesitation by incomplete
NS
NS
NS
.OlY4
NS
NS
Hesitation by indefinite
NS
NS
NS
.016Y
.0260
NS
Hesitation by
NS
NS
.0147
.0246
.0204
NS
NS
NS
NS
,042 I
,006s
NS
.0340
NS
NS
NS
.OlOl
NS
NS
NS
NS
.0246
circumlocution Hesitation by semantic paraphasia Hesitation by phonemic paraphasia Hesitation by neologisric paraphasia
NS
NS
WORD RETRIEVAL
IN DYSPHASIA
123
Table 5 (continued) Pictogram Word retrieval
categories
Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia Repetition by incomplete Repetition by indefinite Repetition by circumlocution Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia Indefinite by neologistic paraphasia Circumlocution by phonemic paraphasia Circumlocution by semantic paraphasia Circumlocution by neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Anemic
Conduction
Cookie Wernicke’s
Anomic
NS NS NS NS
NS NS NS .0422
NS NS NS NS
NS NS JO83 NS
NS
.0176
NS
NS
Conduction NS NS .0373
theft Werenicke’s NS NS NS NS
.0224 NS .0240 NS
.0448
NS
NS
NS NS
NS
.0133
NS
NS
NS NS NS
NS NS NS
.0432 NS NS
.037l NS NS
NS
NS
NS
NS
.0145 NS NS NS
NS NS NS
NS NS NS NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS NS
NS .0432
NS .0371
NS
NS
NS
NS
.0434 NS NS
NS NS
NS St434 NS NS
NS
NS
NS
NS NS
NS
NS
NS
.0371
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
It434 NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
.0434 NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
.0434 NS
NS
NS
NS
NS
NS NS
NS
at .05 level of confidence
NS
NS
NS
NS NS
124
BRACY and DRUMMOND
dysphasia was also performed, and the significant p values for these unpaired t-tests are presented in Table 6. These results reveal that subjects assigned to the severity ratings of ‘3’ and ‘4’ used hesitations significantly more often. Subjects assigned to level ‘4’ also tended to produce revisions and incompletes more often than the remaining word retrieval categories (also see Table 3a). Table 6. Significant Interactions for the Word Retrieval Categories, for the Two Experimental Stimuli, and for the Three Levels of Dysphasic Severity Word retrieval categories Hesitation by revision Hesitation by repetition Hesitation by incomplete Hesitation by indefinite Hesitation by circumlocution Hesitation by phonemic paraphasia Hesitation by semantic paraphasia Hesitation by neologistic paraphasia Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia Repetition by incomplete Repetition by indefinite Repetition by circumlocution
Pictogram ‘2’
Cookie theft -
NS NS NS
.03 IO .029l .0240
.031 I NS
NS NS NS
.0283 .Ol64 .Ol92
.0180 .0004 NS
NS NS
.0213 .Ol75
.0206 .Ol64
NS NS
.0044 .oos I
.0003 .0004
NS
.0175
.0085
NS
.0070
.0009
NS
.034l
.0265
NS
.oos3
.0003
NS
.Ol97
.0171
NS
NS
.0008
NS NS NS NS
NS NS NS NS
NS NS NS NS
NS NS NS NS
NS NS NS .0348
.0018 NS .0027 .0018
NS
NS
.0420
NS
NS
.0062
NS
NS
NS
NS
NS
.0022
NS
NS
NS
MNS
NS
.0048
.0002
NS
NS
NS
NS
.0274
NS NS
NS NS
NS NS
NS NS
NS NS
NS NS
NS
WORD RETRIEVAL
IN DYSPHASIA
12s
Table 6 (continued)
Word retrieval categories Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia Indefinite by neologistic paraphasia Circumlocution by phonemic paraphasia Circumlocution by semantic paraphasia Circumlocution by neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Pictogram
Cookie theft
‘2’
‘3’
‘4’
‘2’
‘3’
‘4’
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0237
NS
.0449
NS
NS
.0274
.0260
NS
NS
NS
NS
.0480
NS
NS
.0364
NS
NS
NS
NS
NS
.049s
NS
NS
.0232
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
at .OS level of confidence
126
BRACY
and DRUMMOND
It should be noted that the use of multiple t-tests did not permit an overall analysis of error rate relative to the type and severity of dysphasia. This statistical analysis procedure was selected to obtain some pilot data regarding the possibility that some of the examined variables would indeed show significance. Also, the utilization of multiple t-tests contributed toward minimizing the possibility of a type-two error in accepting the null hypothesis (or failure to find any significance between the examined variables). DISCUSSION The present results indicate that there is no significant quantitative difference between the examined nonfluent and fluent dysphasic adults in their word retrieval problems. This finding from connected speech elicitations does not agree with previous results from other linguistic contexts. Dunn, et al (1989) found a significant difference between nonUuent and fluent dysphasic adults during confrontation naming and word fluency performances. In addition to the differences in the linguistic contexts used, the present and previous investigations also differed from each other in the subjects’ severity of dysphasia. The mean severity of dysphasia for the nonfluent and fluent subjects in the present investigation was 2.2 and 3.2, respectively, and those reported by Dunn, et al (1989) had mean severity assignments of 2.1 and 3.6, respectively. These differences in mean values indicate that the nonfluent and fluent subjects in Dunn, et al’s (1989) investigation represented a wider range in their overall severity of dysphasia, while the subjects in the present investigation did not. Based on this observation, one may assert that the variable of severity of dysphasia is perhaps more important than “verbal fluency” for quantification of word retrieval performantes. The results on elicitation of the nine word retrieval categories indicate that hesitations occurred significantly more often than the other categories irrespective of the stimulus context or type of verbal fluency. This finding for the use of hesitations is consistent with those reported in earlier investigations (Cherepski and Drummond, 1987; Williams and Canter, 1982). However, this finding was not confirmed when the data were examined relative to the different classification categories and severity levels of dysphasia (see Tables 5 and 6). The present results revealed that subjects classified to the Wernicke’s category, and those assigned to severity level ‘2,’ did not produce hesitations significantly more often than the other eight word retrieval categories. Therefore, these results suggest that subjects with impaired auditory comprehension, and those with relatively limited verbal output, do not show a
WORD RETRIEVAL
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127
selective bias toward the use of hesitations whenever they encounter word retrieval .problems. Interestingly, specific word retrieval behaviors tended to be associated with certain severity and types of dysphasia. For example, subjects at severity level ‘4’ produced more revisions and incompletes in addition to hesitations, and these subjects were also classified to anemic and conduction categories. Similarly, the more severely impaired, and Wernicke’s subjects, tended to produce a significantly greater number of neologistic paraphasias. The present results for the two experimental stimuli revealed that the pictogram context served as a relatively superior context for yielding quantitative data regarding word retrieval performances in dysphasia. A possible reason for the pictogram eliciting a significantly greater degree of word retrieval difficulties may be due to its use of multiple picture frames. Perhaps this mode of presentation increased the demands for lexical retrieval and consequently resulted in eliciting a relatively greater occurrence of word retrieval difficulties. This characteristic of the pictogram may not be clinically important when assessing word retrieval performances in nonfluent and/or severe dysphasias. However, it does have implications for identifying word retrieval problems in relatively less severe forms of dysphasia. For example, the “cookie theft” picture elicited a mean incidence of 10.17 word retrieval difficulties for subjects assigned to severity level ‘4’, whereas the pictogram context revealed a mean incidence of 18.33 for the same subjects. This difference between the two contexts suggests that the “pictogram” context, which elicits a greater quantity of verbal output, is perhaps more sensitive for identifying the exclusive symptom of word retrieval problems in mild dysphasia.
REFERENCES Cherepski, M., and Drummond, S. (1987). Linguistic description in nonfluent dysphasia: Utilization of pictograms. Brain and Language 30:285-304. Dunn, N., Russell, S., and Drummond, S. (1989). Effect of stimulus context and response coding variables on word retrieval performances in dysphasia. Journal of Communication Disorders 22: 209-223. Goodglass, H., and Kaplan, E. (1983). The Boston Diagnostic Aphasia Examination. Philadelphia: Lea and Febiger.
BRACY
128
Kertez, A. (1979). Western sity of Western Ontario. Rinnert, R., and Whitaker, patients, Cortex 9.5641.
Aphasia
Battery.
London,
H. (1973). Semantic
and DRUMMOND
Ontario:
confusion
Univer-
by aphasic
Williams, W. E., and Canter, G. J. (1982). The influence of situational context on naming performance in aphasic syndromes, Brain and Lunguuge 17:92- 106. This investigation was partially of Graduate Student Research Medical Sciences.
funded Funds,
by the Committee on Allocation the University of Arkansas for
APPENDIX A: OPERATIONAL DEFINITIONS WORD RETRIEVAL CATAGORIES Hesitation:
Repetition:
Revision:
Anaphor:
Circumlocution:
Semantic Paraphasia:
Phonemic Paraphasia: Neologistic Paraphasia: Incomplete:
FOR THE
Obvious hesitation or abnormal pausing (greater than 2 sec.) followed by eventual target word retrieval. For example, “uh-cookie.” Multiple whole word or part-word (initial syllable) repetitions of the target word. For example, “boy boy yes boy” or “co-co-co-cookie jar.” Inaccurate word production followed by target word production. or self-correction. For example, “boy no girl.” Use of indefinite pronouns such as “it,” “thing,” “that thing,” “some thing,” in place of the target word. Talking around the target word, such as giving description or sound effect, without actually producing “that’s a big mess” for puddle of it. For example, water. Substitution of a semantically associated or unassociated word for the target word. For example, “boy” for “girl.” Alteration of a phoneme or syllable within the target word. For example, “histle” for “whistle.” Production of a non-English, or nonsense, word for the target word. For example, /somp/ for “boy.” Absence of the target word in an utterance. For example. “this is a . . .”
DISORD. 113-128
WORD RETRIEVAL IN FLUENT AND NONFLUENT DYSPHASIA: UTILIZATION OF PICTOGRAM CONNIE B. BRACY and SAKINA S. DRUMMOND University
of Arkansas
at Little RocklUniversity
of Arkansus
for Medical
Sciences
Connected speech samples were elicited from 10 nonfluent and 10 fluent dysphasic subjects utilizing two contexts, picture and pictogram descriptions. Incidences of word retrieval problems were identified and assigned to nine word retrieval categories. Results revealed pictogram elicited a greater incidence of word retrieval problems, and therefore, proved as a more informative context for identifying word retrieval problems in mild dysphasia. Also, certain word retrieval categories were selectively used by specific dysphasic classification categories and severity levels.
INTRODUCTION Word retrieval in dysphasia has been investigated with a variety of tasks. These include confrontation naming, sentence completion, word fluency, and connected speech elicitations. Of the different contexts eliciting connected speech, picture description has been the most frequently used in routine clinical examinations (Goodglass and Kaplan, 1983; Kertesz, 1979). Picture descriptions necessitate descriptions of depicted referents. A variation of this context is pictogram description, which requires description of the same referent performing sequential events depjcted through multiple picture frames. Available data on pictogram description indicate that this context is preferable to picture description, because it can elicit a larger variety and number of word retrieval responses. These observations, however, remain limited to word retrieval data from nonfluent dysphasia (Cherepski and Drummond, 1987). Word retrieval responses have generally been analyzed through examination of hesitations, revisions, repetitions, circumlocutions, indefi-
Address correspondence to Sakina S. Drummond, Ph.D., Audiology ogy, UALJUUAMS, 2801 S. University, Little Rock, AR 72204. 01993 by Elsevier Science Publishing Co.. Inc. 655 Avenue of the Americas, New York, NY 10010
& Speech
Pathol-
113 002 I -9924/93/$6.00
114
BRACY
and DRUMMOND
nites/anaphors, and phonemic, semantic, and neologistic paraphasias (Cherepski and Drummond, 1987; Rinnert and Whitaker, 1975; Wilhams and Canter, 1982). Each of these response characteristics reflect the dysphasic subject’s word retrieval difficulties; however, they are not all representative of his/her “error” responses. For example, the dysphasic’s use of hesitations, revisions, and repetitions confirm the presence of word retrieval difficulties, but their use does not reflect word retrieval errors. The subject uses these overt behaviors to retrieve the target lexeme ultimately. Previous data also indicate that a difference exists between nonfluent and fluent dysphasic adults’ use of different word retrieval characteristics. Dunn, Russell, and Drummond (1989) and Williams and Canter (1987) have found that fluent dysphasic adults produced a greater frequency of semantic paraphasias and circumlocutions during confrontation naming tasks. The same finding was not observed, however, when dysphasic subjects were required to recall names of items during a word fluency task (Dunn, et al, 1989). This inconsistency in contemporary reports suggests two possibilities: 1. The dimension of verbal fluency in dysphasia interacts with the use of different word retrieval characteristics; or 2. The linguistic context interacts with the select use of some word retrieval characteristics among the two polar types of dysphasias. This investigation examined each of these possibilities by comparing the nature of word retrieval performance from both fluent and nonfluent dysphasic adults. Second, the investigation sought to determine if a distinction can be made between the occurrence of word retrieval behaviors (hesitations, revisions, and repetitions) and word retrieval errors (anaphors and circumlocutions, as well as phonemic, neologistic, and semantic paraphasias).
METHOD
Subjects Ten fluent and 10 nonfluent dysphasic adults, with single episode ischemic, left hemisphere cerebrovascular accidents (CVA), served as the experimental subjects. All of the selected subjects were righthanded native English speakers, and none of them had any visual field problems. Prior to subject-selection, medical records of potential subjects were reviewed for their neurological history, and the attending neurologist was consulted to clarify the obtained medical data and rule out possible evidence of visual field problems.
WORD RETRIEVAL
IN DYSPHASIA
115
All experimental subjects were administered the Boston Diagnostic Aphasia Examination (or BDAE; Goodglass and Kaplan, 1983) to assign them to the “fluent” versus “nonfluent” categories and, subsequently, to subclassify them according to the BDAE dysphasic type. The param-
eters of “melodic line,” “phrase length,” and “grammatical form” from the BDAE were used to identify fluent versus nonfluent linguistic characteristics. Subjects who received a rating of 4 or less on each of these parameters were assigned to the nonfluent dysphasic category, whereas those who received a rating of 5 or more were assigned to the fluent dysphasic category. The protocol and criteria for assignment of dysphasic classification and severity directly followed the guidelines of the BDAE manual. The mean age for all subjects was 59.6 years, and their mean duration of dysphasia was 2 years, 4 months. A total of five females and fifteen males served as experimental subjects. Table 1 presents the description Table 1. Background
Subject
Gender
Information
on the Experimental
Subjects BDAE
BDAE
Age in
Chronicity
Fluency
dysphasic
severity
years
in months
Assignment
classification
rating
1
nonfluent
transcortical
I
F
5.5
2
M
30
12
3
M
54
4
M
5
M
6
F
7
M
8
F
9
M
74
10
M -
11
M
62
2
12
M
67
18
fluent 0,
13
M
46
19
VI
14
M
62
3
,,
15
F
77
17
0,
16
M
46
65
I,
I,
17
M
65
1
I,
,I
18
F
80
4
,I
I,
19
M
55
1
I,
20
M -
54
motor ”
mean
16
0, ,I
Broca’s 0,
56
29
0,
V,
56
48
,I
0,
82
72
,I
0,
55
1
0,
0,
70
62
0,
,I
72
,I
,I
46
52
,,
I,
57.8
36.5
61.4
2 3 3 2 3 2 2 2.2
I, 13.1
3
-
anemic ,I ,I conduction I,
Wernicke’s I, -
4 4 4 4 4 3 3 2 2 2 3.2
116
BRACY and DRUMMOND
of fluent and nonfluent dysphasic subjects by gender, chronological age, duration postonset, and dysphasic classification type and severity rating. It needs to be noted that in our strive for a larger sample size of nonfluent and fluent subjects we had to compromise the control over the variables of chronicity and severity of dysphasia. As a result, the selected nonfluent subjects were relatively more chronic and severe than the fluent subjects.
Stimuli Two different visual stimuli were used to elicit verbal output. One stimulus was presented in a pictogram format and consisted of seven picture frames. The “Tank McNamara” comic strip was selected as the pictogram stimulus since it has been reported to elicit a greater number and variety of verbalizations than the “Dennis the Menace” comic strip (Cherepski and Drummond, 1987). The rationale for selecting a comic strip to represent a pictogram related to the familiarity of its depiction to the average adult. The second stimulus was the “Cookie Theft” (CT) picture from the BDAE. This stimulus represented a stative context, and was selected because of frequent use in clinical practice.
Procedure Each subject was individually required to describe the pictogram and the “cookie theft” stimuli. The instructions for the pictogram were: “Describe everything you see in this comic strip.” The instructions for the CT picture were taken from the BDAE test manual, which reads: “Tell everything you see going on in this picture.” In order to control for the degree of familiarity with the stimuli, the selected subjects were required to describe the CT picture only once, therefore, they were not presented this portion of “section 1” during the comprehensive BDAE administration. The time taken to respond to each experimental stimulus was recorded for possible comparison between fluent and nonfluent productions. A two-minute interval period was given between the two stimuli administrations. A random order was used for the presentation of the two stimuli. All responses were audio tape-recorded for later analyses.
Data Organization All verbal responses were orthographically transcribed. Neologistic and phonemic paraphasias as well as sound and syllable interjections were phonetically transcribed using the International Phonetic Alpha-
WORD RETRIEVAL
IN DYSPHASIA
117
bet. Two judges identified the incidences of word retrieval problems, and they assigned each of them to one of nine possible categories. These nine categories were: hesitation, repetition, revision, anaphor, circumlocution, semantic paraphasia, phonemic paraphasia, neologistic paraphasia, and incomplete. Appendix A provides the operational definitions for each of these categories. Whenever any disagreements occurred between the two judges’ assignments, they were required to relisten to that particular utterance and reassign the word retrieval response until a consensus (or 100% agreement) was reached. RESULTS A total of 812 incidences of word retrieval behaviors were elicited. Analyses of variance (ANOVAs) and unpaired t-tests were used for data analyses. An alpha level of p < .05 was chosen to determine statistical significance between the examined variables. Type and Severity of Dysphasia Examination of the word-finding difficulties for the nonfluent and fluent dysphasic groups, irrespective of the experimental stimulus, revealed that the fluent group produced an average of 38.8 occurrences of wordfinding difficulties. In contrast, the nonfluent dysphasic group produced an average occurrence of 42.4 word-finding difficulties. This finding failed to yield a statistically significant difference (at the .05 level of confidence) for the occurrence of word-finding difficulties between the two subject groups. Table 2 lists the total output and incidences of word-finding difficulties for the nonfluent and fluent subjects for the two experimental stimuli. The incidence of word-finding difficulties for the four BDAE severity ratings and for the different classification categories were also examined (see Tables 3a and 3b). These mean data indicate that except for severity rating 4, the incidence of word retrieval difficulties progressively increased for those subjects assigned to severity ratings 1,2, and 3 (see Table 3a). The mean data for the five dysphasic classification categories failed to show any specific trend in the mean occurrence of word retrieval difficulties (see Table 3b). Effect of Stimulus Context The results of t-test revealed a significant difference existed between the two experimental stimuli for their elicitation of the total number of word retrieval difficulties for all dysphasic subjects (t = 4.44; p =
118
BRACY
and DRUMMOND
Table 2. Production of Total Words and lncidences of Word Retrieval Difficulties for the Nine Categories, Two Experimental Contexts, and Type of Dysphasia Word retrieval categories
Pictogram Nonfluent
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total Total words produced
168 27 23 IO 9 IS II 9 2 274 311
Cookie Fluent
theft
Nonfluent
80
16 30 37 20 II 14 8 0 216 797
Fluent
87 10
58 35
13 I2 4 8 5 II
20 22
Total 393 88 86 81 52 42 38 30 2 812 3124
I9 8 9 2 0 172 I450
0 150 566
.0003). This finding indicated that the pictogram (X = 22.15; total = 471) identified a significantly greater incidence of word retrieval difficulties than the “cookie theft” picture (% = 16.58; total = 337). Similar analysis, with separation of the nonfluent and fluent dysphasic performances, also revealed the pictogram stimulus to elicit a significantly greater incidence of word retrieval difficulties for both fluent (t
Table 3a. Mean Occurrences for the Nine Word Retrieval Four Severity Levels of Dysphasia Word
retrieval
categories
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total mean
Severity (n=2)
’ 1’
Severity (n=7)
‘2’
Categories
Severity
‘3’
for the
Severity
(n=6)
(n=S)
12.5
16.33
34.17
10.83
11.5
6.5
4.0
0.33
0
4.0
4.33
6.0
0
1.83
4.83
6.83
0
1.33
6.33
I .o
0.5
1.5
4.17
1.17
0
2.0
2.83
1.5
0
2.33
1.83
0.83
0
0.17
0.17
0
24.5
35.99
62.66
28.49
‘4’
WORD
RETRIEVAL
IN DYSPHASIA
119
Table 3b. Mean Occurrences for the Nine Word Retrieval Dysphasic Classification Categories Word retrieval categories
Anemic (n=3)
Hesitation Neologistic paraphasia Incomplete Revision Repetition Phonemic paraphasia Semantic paraphasia Indefinite Circumlocution Total mean
Conduction (n=S)
Wernicke’s (n=2)
Categories
for the Five
Broca’s (n=9)
Transcortical motor (n= I)
13.33 0.33 4.0 7.0 1.0 2.0 I.0 0.67
17.4 3.6 6.8 6.4 7.0 1.6 2.8 1.4
16.0 2.0 3.0 0.5 2.5 2.5 0.5
28.11 1.56 4.0 2.44 1.44 2.44 I .78 0.22
2.0 23.0 0 0 0 I.0 0 0
29.33
47.0
32.5
44.21
26.0
= 5.58; p = .003) and nonfluent
5.5
(t = 4.26; p = .0021) dysphasic
sub-
jects (see Table 2).
Word Retrieval Categories Table 2 provides the frequency of occurrences for the nine word retrieval categories for all subjects. Tables 3a and 3b also provide the mean occurrences for the nine word retrieval categories relative to the severity and type of dysphasia. Table 4 presents the p-levels from unpaired t-tests examining the nine word retrieval categories for the nonfluent and fluent dysphasic subjects for the two experimental stimuli. The results identified hesitations occurred significantly more often than the other eight word retrieval behaviors for both fluent and nonfluent subjects. The results also revealed fluent subjects used revisions and incompletes significantly more often. The findings for fment subjects were further explored by examining fluent subjects according to their BDAE classification assignments. Results from unpaired t-tests comparing the occurrences of the nine word retrieval categories for the anemic, conduction, and Wernicke’s dysphasic classifications are presented in Table 5. These results reveal that among the fluent subjects, those classified as anemic or conduction produced significantly more hesitations and revisions. In contrast, those subjects classified with Wernicke’s aphasia tended to produce neologistic paraphasias relatively more often (also see Table 3b). Analysis of the word retrieval behaviors according to the severity of
120
BRACY
Table 4. Significant Interactions for the Word Retrieval Experimental Stimuli, and for the Dysphasic Subjects
and DRUMMOND
Categories,
for the Two
All subjects Word retrieval
Pictogram
Cookie
theft
Cookie
categories
Nonfluent
Fluent
Nonfluent
Fluent
Pictogrdm
Hesitation by revision Hesitation by repetition Hesitation by incomplete
.0079
NS
.0349
.0109
.0084
.0218
.0069
.0009
.0239
.OOOl
.0047
.0109
.0099
.0404
.0316
.OllO
.0081
.0156
Hesitation by indefinite Hesitation by circumlocution Hesitation by phonemic paraphasia Hesitation by semantic paraphasia
.0127
.0012
.0370
.0005
.0068
.0140
.007 1
.OOlO
.0197
.0003
.0038
.0070
.0085
,003s
.0348
.0008
.0056
.0147
.0099
.0122
.0241
.OOOl
,006s
.0105
Hesitation by neologistic paraphasia
.0154
NS
NS
NS
NS
.0432
Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia
NS
NS
NS
NS
NS
.027 1
NS
NS
NS
NS
NS
NS
NS
.0269
NS
.0015
NS
NS
NS
.0125
.0317
.0009
.0137
.0002
NS
.0344
NS
.0165
NS
NS
NS
NS
NS
.0030
NS
.0038
NS
NS
NS
NS
NS
NS
theft
WORD
RETRIEVAL
IN DYSPHASIA
121
Table 4 (continued) All subjects Word retrieval categories
Repetition by incomplete Repetition by indefinite Repetition by circumlocution Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia
Pictogram
Cookie
theft
Cookie
Nonfluent
Fluent
Nontluent
Fluent
Pictogram
theft
NS
NS
NS
NS
.0135
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0145
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0166
NS
.0344
NS
NS
NS
.0029
.0383
.0182
.0007
.0049
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0359
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
(continud)
122
BRACY
and DRUMMOND
Table 4 (continued) All subjects Word
Pictogram
retrieval
categories
Indefinite by neologistic paraphasia Circumlocution phonemic paraphasia Circumlocution semantic paraphasia Circumlocution neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Nonfluent
Cookie
Fluent
Nonfluent
theft
Cookie
Fluent
Pictogram
theft
NS
NS
NS
NS
NS
NS
by
NS
.0264
NS
.0348
NS
.0200
by
NS
NS
NS
NS
NS
.Ol I I
by
NS
NS
NS
NS
NS
.0123
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0412
at .O.Slevel of confidence
Table 5. Significant Interactions for the Word Retrieval Categories Experimental Stimuli and for the Three Types of Fluent Dysphasic Pictogram Word retrieval categories
Anemic
Conduction
for the Two Subjects Cookie theft
Wernicke’s
Anemic
Conductron
Werenicke’s
Hesitation by revision
NS
NS
NS
.0404
NS
NS
Hesitation by repetition
NS
.04x0
.0147
.0246
.0084
NS
Hesitation by incomplete
NS
NS
NS
.OlY4
NS
NS
Hesitation by indefinite
NS
NS
NS
.016Y
.0260
NS
Hesitation by
NS
NS
.0147
.0246
.0204
NS
NS
NS
NS
,042 I
,006s
NS
.0340
NS
NS
NS
.OlOl
NS
NS
NS
NS
.0246
circumlocution Hesitation by semantic paraphasia Hesitation by phonemic paraphasia Hesitation by neologisric paraphasia
NS
NS
WORD RETRIEVAL
IN DYSPHASIA
123
Table 5 (continued) Pictogram Word retrieval
categories
Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia Repetition by incomplete Repetition by indefinite Repetition by circumlocution Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia Indefinite by neologistic paraphasia Circumlocution by phonemic paraphasia Circumlocution by semantic paraphasia Circumlocution by neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Anemic
Conduction
Cookie Wernicke’s
Anomic
NS NS NS NS
NS NS NS .0422
NS NS NS NS
NS NS JO83 NS
NS
.0176
NS
NS
Conduction NS NS .0373
theft Werenicke’s NS NS NS NS
.0224 NS .0240 NS
.0448
NS
NS
NS NS
NS
.0133
NS
NS
NS NS NS
NS NS NS
.0432 NS NS
.037l NS NS
NS
NS
NS
NS
.0145 NS NS NS
NS NS NS
NS NS NS NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS NS
NS .0432
NS .0371
NS
NS
NS
NS
.0434 NS NS
NS NS
NS St434 NS NS
NS
NS
NS
NS NS
NS
NS
NS
.0371
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
It434 NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
.0434 NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
NS NS
NS
NS
NS
NS
.0434 NS
NS
NS
NS
NS
NS NS
NS
at .05 level of confidence
NS
NS
NS
NS NS
124
BRACY and DRUMMOND
dysphasia was also performed, and the significant p values for these unpaired t-tests are presented in Table 6. These results reveal that subjects assigned to the severity ratings of ‘3’ and ‘4’ used hesitations significantly more often. Subjects assigned to level ‘4’ also tended to produce revisions and incompletes more often than the remaining word retrieval categories (also see Table 3a). Table 6. Significant Interactions for the Word Retrieval Categories, for the Two Experimental Stimuli, and for the Three Levels of Dysphasic Severity Word retrieval categories Hesitation by revision Hesitation by repetition Hesitation by incomplete Hesitation by indefinite Hesitation by circumlocution Hesitation by phonemic paraphasia Hesitation by semantic paraphasia Hesitation by neologistic paraphasia Revision by repetition Revision by incomplete Revision by indefinite Revision by circumlocution Revision by phonemic paraphasia Revision by semantic paraphasia Revision by neologistic paraphasia Repetition by incomplete Repetition by indefinite Repetition by circumlocution
Pictogram ‘2’
Cookie theft -
NS NS NS
.03 IO .029l .0240
.031 I NS
NS NS NS
.0283 .Ol64 .Ol92
.0180 .0004 NS
NS NS
.0213 .Ol75
.0206 .Ol64
NS NS
.0044 .oos I
.0003 .0004
NS
.0175
.0085
NS
.0070
.0009
NS
.034l
.0265
NS
.oos3
.0003
NS
.Ol97
.0171
NS
NS
.0008
NS NS NS NS
NS NS NS NS
NS NS NS NS
NS NS NS NS
NS NS NS .0348
.0018 NS .0027 .0018
NS
NS
.0420
NS
NS
.0062
NS
NS
NS
NS
NS
.0022
NS
NS
NS
MNS
NS
.0048
.0002
NS
NS
NS
NS
.0274
NS NS
NS NS
NS NS
NS NS
NS NS
NS NS
NS
WORD RETRIEVAL
IN DYSPHASIA
12s
Table 6 (continued)
Word retrieval categories Repetition by phonemic paraphasia Repetition by semantic paraphasia Repetition by neologistic paraphasia Incomplete by indefinite Incomplete by circumlocution Incomplete by phonemic paraphasia Incomplete by semantic paraphasia Incomplete by neologistic paraphasia Indefinite by circumlocution Indefinite by phonemic paraphasia Indefinite by semantic paraphasia Indefinite by neologistic paraphasia Circumlocution by phonemic paraphasia Circumlocution by semantic paraphasia Circumlocution by neologistic paraphasia Phonemic by semantic paraphasia Phonemic by neologistic paraphasia Semantic by neologistic paraphasia NS = nonsignificant
Pictogram
Cookie theft
‘2’
‘3’
‘4’
‘2’
‘3’
‘4’
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
.0237
NS
.0449
NS
NS
.0274
.0260
NS
NS
NS
NS
.0480
NS
NS
.0364
NS
NS
NS
NS
NS
.049s
NS
NS
.0232
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
at .OS level of confidence
126
BRACY
and DRUMMOND
It should be noted that the use of multiple t-tests did not permit an overall analysis of error rate relative to the type and severity of dysphasia. This statistical analysis procedure was selected to obtain some pilot data regarding the possibility that some of the examined variables would indeed show significance. Also, the utilization of multiple t-tests contributed toward minimizing the possibility of a type-two error in accepting the null hypothesis (or failure to find any significance between the examined variables). DISCUSSION The present results indicate that there is no significant quantitative difference between the examined nonfluent and fluent dysphasic adults in their word retrieval problems. This finding from connected speech elicitations does not agree with previous results from other linguistic contexts. Dunn, et al (1989) found a significant difference between nonUuent and fluent dysphasic adults during confrontation naming and word fluency performances. In addition to the differences in the linguistic contexts used, the present and previous investigations also differed from each other in the subjects’ severity of dysphasia. The mean severity of dysphasia for the nonfluent and fluent subjects in the present investigation was 2.2 and 3.2, respectively, and those reported by Dunn, et al (1989) had mean severity assignments of 2.1 and 3.6, respectively. These differences in mean values indicate that the nonfluent and fluent subjects in Dunn, et al’s (1989) investigation represented a wider range in their overall severity of dysphasia, while the subjects in the present investigation did not. Based on this observation, one may assert that the variable of severity of dysphasia is perhaps more important than “verbal fluency” for quantification of word retrieval performantes. The results on elicitation of the nine word retrieval categories indicate that hesitations occurred significantly more often than the other categories irrespective of the stimulus context or type of verbal fluency. This finding for the use of hesitations is consistent with those reported in earlier investigations (Cherepski and Drummond, 1987; Williams and Canter, 1982). However, this finding was not confirmed when the data were examined relative to the different classification categories and severity levels of dysphasia (see Tables 5 and 6). The present results revealed that subjects classified to the Wernicke’s category, and those assigned to severity level ‘2,’ did not produce hesitations significantly more often than the other eight word retrieval categories. Therefore, these results suggest that subjects with impaired auditory comprehension, and those with relatively limited verbal output, do not show a
WORD RETRIEVAL
IN DYSPHASIA
127
selective bias toward the use of hesitations whenever they encounter word retrieval .problems. Interestingly, specific word retrieval behaviors tended to be associated with certain severity and types of dysphasia. For example, subjects at severity level ‘4’ produced more revisions and incompletes in addition to hesitations, and these subjects were also classified to anemic and conduction categories. Similarly, the more severely impaired, and Wernicke’s subjects, tended to produce a significantly greater number of neologistic paraphasias. The present results for the two experimental stimuli revealed that the pictogram context served as a relatively superior context for yielding quantitative data regarding word retrieval performances in dysphasia. A possible reason for the pictogram eliciting a significantly greater degree of word retrieval difficulties may be due to its use of multiple picture frames. Perhaps this mode of presentation increased the demands for lexical retrieval and consequently resulted in eliciting a relatively greater occurrence of word retrieval difficulties. This characteristic of the pictogram may not be clinically important when assessing word retrieval performances in nonfluent and/or severe dysphasias. However, it does have implications for identifying word retrieval problems in relatively less severe forms of dysphasia. For example, the “cookie theft” picture elicited a mean incidence of 10.17 word retrieval difficulties for subjects assigned to severity level ‘4’, whereas the pictogram context revealed a mean incidence of 18.33 for the same subjects. This difference between the two contexts suggests that the “pictogram” context, which elicits a greater quantity of verbal output, is perhaps more sensitive for identifying the exclusive symptom of word retrieval problems in mild dysphasia.
REFERENCES Cherepski, M., and Drummond, S. (1987). Linguistic description in nonfluent dysphasia: Utilization of pictograms. Brain and Language 30:285-304. Dunn, N., Russell, S., and Drummond, S. (1989). Effect of stimulus context and response coding variables on word retrieval performances in dysphasia. Journal of Communication Disorders 22: 209-223. Goodglass, H., and Kaplan, E. (1983). The Boston Diagnostic Aphasia Examination. Philadelphia: Lea and Febiger.
BRACY
128
Kertez, A. (1979). Western sity of Western Ontario. Rinnert, R., and Whitaker, patients, Cortex 9.5641.
Aphasia
Battery.
London,
H. (1973). Semantic
and DRUMMOND
Ontario:
confusion
Univer-
by aphasic
Williams, W. E., and Canter, G. J. (1982). The influence of situational context on naming performance in aphasic syndromes, Brain and Lunguuge 17:92- 106. This investigation was partially of Graduate Student Research Medical Sciences.
funded Funds,
by the Committee on Allocation the University of Arkansas for
APPENDIX A: OPERATIONAL DEFINITIONS WORD RETRIEVAL CATAGORIES Hesitation:
Repetition:
Revision:
Anaphor:
Circumlocution:
Semantic Paraphasia:
Phonemic Paraphasia: Neologistic Paraphasia: Incomplete:
FOR THE
Obvious hesitation or abnormal pausing (greater than 2 sec.) followed by eventual target word retrieval. For example, “uh-cookie.” Multiple whole word or part-word (initial syllable) repetitions of the target word. For example, “boy boy yes boy” or “co-co-co-cookie jar.” Inaccurate word production followed by target word production. or self-correction. For example, “boy no girl.” Use of indefinite pronouns such as “it,” “thing,” “that thing,” “some thing,” in place of the target word. Talking around the target word, such as giving description or sound effect, without actually producing “that’s a big mess” for puddle of it. For example, water. Substitution of a semantically associated or unassociated word for the target word. For example, “boy” for “girl.” Alteration of a phoneme or syllable within the target word. For example, “histle” for “whistle.” Production of a non-English, or nonsense, word for the target word. For example, /somp/ for “boy.” Absence of the target word in an utterance. For example. “this is a . . .”