Biomarkers of "Linguistic Anxiety" in aphasia: a proof-of-concept case study

Spectrum of neuropsychiatric symptoms in chronic post-stroke aphasia

BACKGROUND

Neuropsychiatric symptoms (NPS) have been insufficiently examined in persons with aphasia (PWA) because most previous studies exclude participants with language and communication disorders.

AIM

To report a two-part study consisting of a literature review and an observational study on NPS in post-stroke aphasia.

METHODS

Study 1 reviewed articles obtained from PubMed, PsycINFO, Google Scholar and Cochrane databases after cross-referencing key words of post-stroke aphasia to NPS and disorders. Study 2 examined language deficits and activities of daily living in 20 PWA (median age: 58, range: 28-65 years; 13 men) with the Western Aphasia Battery-Revised and the Barthel Index, respectively. Informants of these 20 PWA were proxy-evaluated with the Neuropsychiatric Inventory and domain-specific scales, including the Stroke Aphasia Depression Questionnaire-10 item version and the Starkstein Apathy Scale. In addition, an adapted version of the Hospital Anxiety and Depression Scale was directly administered to the PWA themselves. This observational study is based on the baseline assessment of an intervention clinical trial (EudraCT: 2017-002858-36; ClinicalTrials.gov identifier: NCT04134416).

RESULTS

The literature review revealed a broad spectrum of NPS in PWA, including depression, anxiety, apathy, agitation/aggression, eating and sleep disorders, psychosis, and hypomania/mania. These findings alert to the need for improving assessment and treatment approaches of NPS taking into consideration their frequent occurrence in PWA. Study 2 showed that the 20 participants had mild- to-moderate aphasia severity and were functionally independent. A wide range of comorbid NPS was found in the post-stroke aphasic population (median number of NPS: 5, range: 1-8). The majority of PWA (75%) had depressive symptoms, followed by agitation/aggression (70%), irritability (70%), anxiety (65%) and appetite/eating symptoms (65%). Half of them also presented symptoms of apathy, whereas euphoria and psychotic symptoms were rare (5%). Domain-specific scales revealed that 45% of participants had apathy and 30% were diagnosed with depression and anxiety.

CONCLUSION

Concurrent NPS are frequent in the chronic period of post-stroke aphasia. Therefore, further research on reliable and valid assessment tools and treatment for this aphasic population is strongly warranted.

Effects of Positive and Negative Emotions on Picture Naming for People With Mild-to-Moderate Aphasia: A Preliminary Investigation

PURPOSE

The purpose of the study is to investigate how emotional arousal and valence affect confrontational naming accuracy and response time (RT) in people with mild-to-moderate aphasia compared with adults without aphasia. We hypothesized that negative and positive emotions would facilitate naming for people with aphasia (PWA) but lead to slower responses for adults with no aphasia.

METHOD

Eight participants with mild-to-moderate aphasia, 15 older adults (OAs), and 17 young adults (YAs) completed a confrontational naming task across three conditions (positive, negative, and neutral) in an ABA (where A = neutral and B = negative) case series design. Immediately following each naming condition, participants self-reported their perceived arousal and pleasure. Accuracy and RT were measured and compared.

RESULTS

As expected, PWA performed significantly less accurately and with longer RTs than both YA and OA groups across all conditions. However, opposite our hypothesis for the aphasia group, the negative condition resulted in decreased accuracy for the aphasia and the OA group and increased RT across all groups. No statistically significant differences were found between the positive and any other condition. Participants with aphasia who demonstrated an effect in the negative condition were observed to produce a larger proportion of semantically related errors than any other error types.

CONCLUSIONS

Findings suggest that strong negative emotions can interfere with semantic-lexical processing by diverting attentional resources to emotion regulation. Both clinicians and researchers should be aware of the potential influence of negative stimuli and negative emotional states on language performance for PWA, and these effects should be disentangled in future research. Further research should also be conducted with a larger number of participants with aphasia across a broader range of severity to replicate and extend findings.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19119356.

The Unfolding of Cognitive Effort During Sentence Processing: Pupillometric Evidence From People With and Without Aphasia

PURPOSE

Arousal and cognitive effort are relevant yet often overlooked components of attention during language processing. Pupillometry can be used to provide a psychophysiological index of arousal and cognitive effort. Given that much is unknown regarding the relationship between cognition and language deficits seen in people with aphasia (PWA), pupillometry may be uniquely suited to explore those relationships. The purpose of this study was to examine arousal and the time course of the allocation of cognitive effort related to sentence processing in people with and without aphasia.

METHOD

Nineteen PWA and age- and education-matched control participants listened to relatively easy (subject-relative) and relatively difficult (object-relative) sentences and were required to answer occasional comprehension questions. Tonic and phasic pupillary responses were used to index arousal and the unfolding of cognitive effort, respectively, while sentences were processed. Group differences in tonic and phasic responses were examined.

RESULTS

Group differences were observed for both tonic and phasic responses. PWA exhibited greater overall arousal throughout the task compared with controls, as evidenced by larger tonic pupil responses. Controls exhibited more effort (greater phasic responses) for difficult compared with easy sentences; PWA did not. Group differences in phasic responses were apparent during end-of-sentence and postsentence time windows.

CONCLUSIONS

Results indicate that the attentional state of PWA in this study was not consistently supportive of adequate task engagement. PWA in our sample may have relatively limited attentional capacity or may have challenges with allocating existing capacity in ways that support adequate task engagement and performance. This work adds to the body of evidence supporting the validity of pupillometric tasks for the study of aphasia and contributes to a better understanding of the nature of language deficits in aphasia. Supplemental Material https://doi.org/10.23641/asha.16959376.

What do people search for in stuttering therapy: Personal goal-setting as a gold standard?

PURPOSE

Stuttering affects people in individual ways, and there are multiple factors which may influence a person's goals when seeking therapy. Even though there is a common consensus that speech-language pathologists should discuss the individual's goals and expectations for stuttering therapy and outcomes, few studies have systematically investigated this issue. The aims of the present study were to investigate individual motivations and goal-setting related factors in stuttering therapy. The associations between self-reported impact of stuttering and the participants' perceptions of stuttering interference in communication, speaking abilities, and relationships with other people were also investigated.

METHOD

This study is part of a wider-ranging treatment study of individualized stuttering management tailored to the participants' personal goals and preferences. A mixed method, multiple single-case design was used to address the research questions. Twenty-one adults, age 21-61 years, took part in a pretherapy interview, which also included two quantitative measures: the Client Preferences for Stuttering Therapy-Extended version (CPST-E) and the Overall Assessment of Speakers' Experience of Stuttering-Adult version (OASES-A). Findings from the study sample was compared with a Norwegian reference group, in order to check for the representativeness of the study sample.

RESULTS

Quantitative data showed that most participants wanted to focus on both physical and psychological aspects of therapy, and that 95% considered 'to gain a sense of control over the stuttering' as important. Participants' perspectives on their speaking ability and stuttering interference in communication were identified as central factors, particularly in social and professional settings. These outcomes aligned well with the finding of avoidance behaviors, such as avoiding words and speaking situations. Qualitative data identified four main areas that the participants wanted to improve: speech fluency, emotional functioning, activity and participation, and understanding of their stuttering.

CONCLUSION

The study confirms that multiple and individual factors may influence the person's goals for therapy. Goals were mainly anchored in participants' wish of better coping in real world settings. A high degree of avoidance behavior was reported, suggesting that anxiety, and in particular linguistic-related anxiety needs to be taken into account when addressing social anxiety in fluency disorders.

How Responsiveness From a Communication Partner Affects Story Retell in Aphasia: Quantitative and Qualitative Findings

Purpose Because people with aphasia (PWA) frequently interact with partners who are unresponsive to their communicative attempts, we investigated how partner responsiveness affects quantitative measures of spoken language and subjective reactions during story retell. Method A quantitative study and a qualitative study were conducted. In Study 1, participants with aphasia and controls retold short stories to a communication partner who indicated interest through supportive backchannel responses (responsive) and another who indicated disinterest through unsupportive backchannel responses (unresponsive). Story retell accuracy, delivery speed, and ratings of psychological stress were measured and compared. In Study 2, participants completed semistructured interviews about their story retell experience, which were recorded, transcribed, and coded using qualitative analysis software. Results Quantitative results revealed increased psychological stress and decreased delivery speed across all participant groups during the unresponsive partner condition. Effects on delivery speed were more consistent for controls than participants with aphasia. Qualitative results revealed that participants with aphasia were more attuned to unresponsive partner behaviors than controls and reported stronger and more frequent emotional reactions. Partner responsiveness also affected how PWA perceived and coped with the communication experience. Conclusions Combined quantitative and qualitative findings suggest that, while unresponsive communication partners may not have robust effects on spoken language, they elicit strong emotional reactions from PWA and affect their communication experience. These findings support the need for communication partner training and suggest that training PWA on emotion regulation or relaxation techniques may help assuage their anxiety during socially challenging everyday communication and increase social participation. Supplemental Material https://doi.org/10.23641/asha.11368028.

Exploring Associations Between a Biological Marker of Chronic Stress and Reported Depression and Anxiety in People With Aphasia

Purpose Living with the communication impairment of aphasia can be stressful. Chronic stress, depression, and anxiety are intimately linked, may be more pervasive in people with poststroke aphasia than the general population, and may influence cognitive function and treatment outcomes. In this project, we explored the psychological constructs of depression and anxiety and their associations with a biomarker measure of chronic stress in people with aphasia. Method Fifty-seven participants with aphasia completed measures of depression and anxiety and provided a hair sample from which to extract the stress hormone cortisol. Pearson product-moment correlational analyses were used to identify associations between depression, anxiety, and long-term level of cortisol via hair sample. Results While cortisol level was not associated with depression and anxiety across this sample of people with aphasia, a post hoc analysis showed a significant, positive correlation between a subset of participants with moderate and higher levels of depression and elevated cortisol level. Conclusions Chronic stress, depression, and anxiety have been little explored in people with aphasia to date, yet they are associated with future health consequences and impaired cognitive function, motivating further research as well as consideration of these factors in aphasia rehabilitation.

Sleepiness, Exertion Fatigue, Arousal, and Vigilant Attention in Persons With Chronic Aphasia

Purpose Individuals in the acute and chronic stages of stroke recovery often report more daytime sleepiness (Sterr, Herron, Dijk, & Ellis, 2008) and fatigue that qualitatively differs from "normal" feelings of fatigue they experienced prestroke (De Doncker, Dantzer, Ormstad, & Kuppuswamy, 2018). Speech-language pathologists frequently observe signs of fatigue in their clients with aphasia and perceive that client fatigue impedes therapeutic interventions (Riley, 2017). The current study aimed to quantify daytime sleepiness, exertion fatigue, and physiologically measured arousal and vigilant attention in persons with aphasia. Method We measured sleepiness, exertion fatigue, arousal, and vigilant attention in 10 participants with aphasia and 10 neurologically healthy adults. Daytime sleepiness was measured using the Epworth Sleepiness Scale (Johns, 1991). Exertion fatigue was measured using the Visual Analog Fatigue Scale (B. Y. Tseng, Gajewski, & Kluding, 2010) before and after a 72-min computer-administered language task. Arousal was measured using heart rate and variability (Shaffer & Ginsberg, 2017). Vigilant attention was measured using electroencephalography and subsequently classified into 1 of 4 levels of vigilant attention using a classification algorithm (Berka et al., 2004). Results Persons with aphasia did not show significant differences from controls in reported amount of daytime sleepiness, exertion fatigue, or overall physiological arousal but demonstrated different patterns of electroencephalography-measured vigilant attention and error production as compared to controls. Conclusions Although overall sleepiness, exertion fatigue, and overall arousal did not differ between groups, physiological measures of vigilant attention may be more sensitive to differences and may explain feelings of fatigue that persons with chronic aphasia experience.

The Simple Aphasia Stress Scale

Purpose Clinically accessible and concise measures of acute stress in adults with aphasia are lacking. The current article evaluated some psychometric features of a single-item self-report measure of acute stress in adults with aphasia, the Simple Aphasia Stress Scale. Method Three archival data sets utilizing varying iterations of a stress scale developed for studies of stress in adults with aphasia were included in the present analysis. Results The single-item stress scale had good levels of absolute and relative stability. Scores were generally unaffected by aphasia severity, age, or sex. The scale was strongly correlated with emotional arousal. Conclusion The single-item scale performed reasonably well across different studies and psychometric indicators. A 7-point rather than a 5-point response version of the scale was recommended as a clinically accessible and concise measure of acute stress in adults with aphasia. Future research should examine whether the tendency for adults with aphasia to use a restricted range of lower stress responses was due to underreporting, not perceiving acute stress, or some other factor. The high correlation between stress and arousal in women suggests that there needs to be further investigation of discriminant validity. Future work should also expand the scope of variables to evaluate further evidence of convergent and criterion-related validity.

Dual-Task Effects on Story Retell for Participants With Moderate, Mild, or No Aphasia: Quantitative and Qualitative Findings

Purpose The aims of the study were to determine dual-task effects on content accuracy, delivery speed, and perceived effort during narrative discourse in people with moderate, mild, or no aphasia and to explore subjective reactions to retelling a story with a concurrent task. Method Two studies (1 quantitative and 1 qualitative) were conducted. In Study 1, participants with mild or moderate aphasia and neurotypical controls retold short stories in isolation and while simultaneously distinguishing between high and low tones. Story retell accuracy (speech productivity and efficiency), speed (speech rate, repetitions, and pauses), and perceived effort were measured and compared. In Study 2, participants completed semistructured interviews about their story retell experience. These interviews were recorded, transcribed orthographically, and coded qualitatively using thematic analysis. Results The dual task interfered more with spoken language of people with aphasia than controls, but different speed-accuracy trade-off patterns were noted. Participants in the moderate aphasia group reduced accuracy with little alteration to speed, whereas participants in the mild aphasia group maintained accuracy and reduced their speed. Participants in both groups also reported more negative emotional and behavioral reactions to the dual-task condition than their neurotypical peers. Intentional strategies for coping with the cognitive demands of the dual-task condition were only reported by participants with mild aphasia. Conclusion The findings suggest that, although communicating with a competing task is more difficult for people with aphasia than neurotypical controls, participants with mild aphasia may be better able to cope with cognitively demanding communication situations than participants with moderate aphasia. Supplemental Material https://doi.org/10.23641/asha.8233391.

Diurnal Cortisol Dynamics, Perceived Stress, and Language Production in Aphasia

Purpose The current study investigated diurnal cortisol dynamics in adults with and without aphasia, along with subjective reports of stress and measures of language production. Dysregulation of cortisol, a common biomarker of stress, is associated with cognitive dysfunction in different clinical populations. However, little is known about the consequences of stress-induced cortisol disturbances for stroke survivors, including those with aphasia. Method Nineteen participants with aphasia and 14 age-matched neurotypical adults were tested. Saliva samples were collected from participants to assess the cortisol awakening response, a marker of the integrity of the hypothalamic-pituitary-adrenal (HPA) axis. Participants also completed 2 subjective stress questionnaires. Language was evaluated using 3 short, picture description narratives, analyzed for discourse (dys)fluency and productivity markers. Results In contrast to neurotypical participants, adults with aphasia did not show the predictable cortisol awakening response. Participants with aphasia also showed an unusual heightened level of cortisol upon awakening. Additionally, neurotypical participants demonstrated an association between intact language performance and the cortisol awakening response, whereas the participants with aphasia did not, although they did perceive the language tasks as stressful. Conclusion This study indicates that the functionality of the HPA axis, as indexed by cortisol, contributes to optimal language performance in healthy adults. The absence of an awakening response among participants with aphasia suggests that stroke leads to dysregulation of the HPA axis, although the degree to which this impairment affects language deficits in this population requires further investigation.

Language as a Threat: Multimodal Evaluation and Interventions for Overwhelming Linguistic Anxiety in Severe Aphasia

Linguistic anxiety (LA) is an abnormal stress response induced by situations that require the use of verbal behavior, and it is accentuated during language testing in persons with aphasia (PWA). The presence of LA in PWA may jeopardize the interpretation of cognitive evaluations, leading to biased conclusions about the severity of the language alteration and the effectiveness of the treatments. In the present study, we report the case of a woman (Mrs. A) with severe chronic mixed transcortical aphasia due to left frontal and parietal hemorrhages that partially spared the perisylvian area. Mrs. A was treated with the dopamine agonist Rotigotine alone and combined with Intensive Language-Action Therapy (ILAT). Complementary evaluations included autonomic reactivity during the performance of different language tasks, resting state functional magnetic resonance imaging (rs-fMRI) and [18F]-fluorodeoxyglucose positron emission tomography (18F-FDG-PET). We found that formal language testing in a clinical setting triggered a dramatic increase of automatic echolalia, perseverations and frustration, making the task completion difficult. The treatment improved aphasia, but gains were more robust when evaluation was performed by Mrs. A's husband at home than by clinicians. Autonomic evaluation under Rotigotine revealed higher reactivity during tasks tapping an impaired function in comparison with a task evaluating a preserved function (verbal repetition). Baseline 18F-FDG-PET analysis showed decreased metabolic activity in left limbic-paralimbic areas, whereas rs-fMRI revealed compensatory activity in the right hemisphere. We also analyzed the different factors (e.g., premorbid personality traits, task difficulty) that may have contributed to LA in Mrs. A during language testing. Our findings emphasize the usefulness of implicating adequately trained laypersons in the evaluation and treatment of PWA showing LA. Further studies using multidimensional evaluations are needed to disentangle the interplay between anxiety and abnormal language as well as the neural mechanisms underpinning LA in PWA.

Language in individuals with left hemisphere tumors: Is spontaneous speech analysis comparable to formal testing?

BACKGROUND

The relationship between spontaneous speech and formal language testing in people with brain tumors (gliomas) has been rarely studied. In clinical practice, formal testing is typically used, while spontaneous speech is less often evaluated quantitatively. However, spontaneous speech is quicker to sample and may be less prone to test/retest effects, making it a potential candidate for assessing language impairments when there is restricted time or when the patient is unable to undertake prolonged testing.

AIM

To assess whether quantitative spontaneous speech analysis and formal testing detect comparable language impairments in people with gliomas. Specifically, we addressed (a) whether both measures detected comparable language impairments in our patient sample; and (b) which language levels, assessment times, and spontaneous speech variables were more often impaired in this subject group.

METHOD

Five people with left perisylvian gliomas performed a spontaneous speech task and a formal language assessment. Tests were administered before surgery, within a week after surgery, and seven months after surgery. Performance on spontaneous speech was compared with that of 15 healthy speakers.

RESULTS

Language impairments were detected more often with both measures than with either measure independently. Lexical-semantic impairments were more common than phonological and grammatical impairments, and performance was equally impaired across assessment time points. Incomplete sentences and phonological paraphasias were the most common error types.

CONCLUSIONS

In our sample both spontaneous speech analysis and formal testing detected comparable language impairments. Currently, we suggest that formal testing remains overall the better option, except for cases in which there are restrictions on testing time or the patient is too tired to undergo formal testing. In these cases, spontaneous speech may provide a viable alternative, particularly if automated analysis of spontaneous speech becomes more readily available in the future. These results await replication in a bigger sample and/or other populations.