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

Abstract

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.

Spectrum of neuropsychiatric symptoms in chronic post-stroke aphasia

“…It is noteworthy that anxiety has received comparatively less attention in PWA than depression[ 94 , 101 ]. Impairments in the ability to communicate is one the most significant sources of stress for PWA[ 102 , 103 ]. To date, the prevalence of anxiety among PWA is estimated to be around 44%, in contrast to the 18%-25% of stroke survivors without language disorders[ 94 , 104 , 105 ].…”

“…Even in mild aphasia, language-based anxiety can interfere with task performance[ 108 ]. Indeed, stress reactivity is considerably higher during linguistic in comparison to non-linguistic tasks[ 55 , 94 , 103 ] and higher anxiety and stress responses are related to non-fluent aphasias[ 96 , 102 ]. PWA also show heightened physiological arousal and anxiety scores in general compared to stroke patients without aphasia[ 94 , 109 ].…”

“…The patient’s fixation on his/her impaired language performance reduces the ability to follow language assignments, which is signaled by heightened physiological stress responses such as heart rate and skin conductance[ 96 , 108 ]. Premorbid personality traits (self-demand attitude, perfectionism) may also favor the emergence of anxiety in PWA[ 103 ]. The pathophysiological mechanisms involved in post-stroke anxiety in PWA remain unknown as there are few studies that explore the physiological stress responses in PWA during language examination[ 96 ].…”

Marriage and Post-stroke Aphasia: The Long-Time Effects of Group Therapy of Fluent and Non-fluent Aphasic Patients and Their Spouses

“…Nevertheless, group therapy can lead to more realistic attitudes toward burdensome and severely straining situations and may help caregiving spouses with coping ( Johannsen-Horbach et al, 1999 ). Studies demonstrated that merely providing information and recommendations on cognitive impairment in reducing the stroke survivor’s family stress ( McKinney et al, 2002 ; Torres-Prioris et al, 2019 ). Pooled analysis of two individual psychoeducation programs provided by Cheng et al (2014) showed a small effect on improving family functioning.…”

Does COVID-19 Impact Less on Post-stroke Aphasia? This Is Not the Case

“…Indeed, the language changes experienced by PWA often have sudden and long-lasting negative impacts on friendships, social engagements, quality of life, and psychological wellbeing (Engelter et al, 2006;Spaccavento et al, 2014;Mattioli, 2019). Less curiosity and less emotional stability with anxiety and depression, distress, social exclusion, and loss of autonomy are frequently reported symptoms in aphasic people (Kouwenhoven et al, 2011;Ayerbe et al, 2014;Hackett and Pickles, 2014;Feigin et al, 2015;Robinson and Jorge, 2016;Mitchell et al, 2017;Kirkevold et al, 2018;Torres-Prioris et al, 2019). In particular, regardless of the degree of language impairment, the patient tends to isolate him/herself and to have less intrinsic motivation in taking part in language rehabilitation programs since he/she feels oppressed by negative feelings (Cott et al, 2007;Woodman et al, 2014;Foley et al, 2019;Hjelle et al, 2019).…”