WERNICKE'S APHASIA: SYMPTOMS, TYPES, CAUSES AND TREATMENT - NEUROPSYCHOLOGY - 2024

The Wernicke 's aphasia, sensory aphasia or receptive aphasia speech disorder in which the individual will have trouble understanding the language heard or repeating words or phrases that others have said; while the pronunciation will be correct.

Therefore, Wernicke's aphasia is the inability to understand words or speak while producing a coherent meaning, while maintaining the articulation of speech sounds. In this way, there is a mutual lack of understanding between the patient and his interlocutor; having this to make a great effort to understand the affected.

Wernicke's area, one of the affected areas in this type of aphasia

When a patient with this problem arrives for consultation, his rapid and uncut speech is striking, which requires the other person to intervene to stop. In fact, the affected person does not usually realize that what he says does not make sense and they do not feel that there are problems in the dialogue (or attempted dialogue).

characteristics

According to Luria, this disorder has three characteristics:

The patient does not distinguish the different phonemes (the sounds of the tongue)

In other words, in order to properly listen and emit the sounds of speech, you must first know how to recognize the sounds in your own language. People with this problem are not able to isolate the characteristic sounds of their language and classify them as known phonemic systems.

Speech defect

He has no problems articulating speech, however, by confusing phonetic characteristics he produces “word salad” (emitting words without connection to each other, giving rise to an incoherent speech, but without losing fluency).

Writing problems

As a consequence of the problem of poor recognition of phonemes, you will not be able to evoke graphemes (graphic representations of phonemes, like a written letter).

Causes

It can be acute (due to head trauma, stroke, neoplasms, etc.) or chronic (concomitant with Alzheimer's).

In Wernicke's aphasia, the affected areas are found in the parietal and temporal lobes of the dominant hemisphere (usually the left), the severity of the deficit depending on the magnitude of the injury.

At first it was thought to be due to damage or malfunction in the Wernicke area, where its name comes from. An area of ​​the brain responsible for language comprehension processes, located in the posterior part of the temporal lobe of the dominant hemisphere (usually the left).

However, it appears that the key deficits in this type of aphasia are not only due to damage to that area; rather, it is somewhat more complex since:

• Most brain structures participate in some way in language, that is, this function is not limited to a single place in the brain.
• It seems that the majority of patients with disorders of this type had had a stroke or obstruction in the middle cerebral artery, which supplies various areas of the brain such as the basal ganglia, which can also influence language.
• Wernicke's aphasia seems to give rise to a number of different symptoms, each probably having a different neurological basis.
• In addition, there are researchers who have affirmed that lesions in this area are not directly connected with fluent aphasia, but that it seems to affect the storage of sentences in memory from when they are heard until they have to be repeated, also affecting the rhyme of words (memory for sounds affected).

Medial temporal lobe and white matter damage

It has then been suggested that the main difficulties in this disorder stem from damage to the medial temporal lobe and the underlying white matter. This area is adjacent to the auditory cortex.

Superior gyrus of the temporal lobe

Its appearance has also been seen by alterations in a certain part of the superior gyrus of the temporal lobe, affecting the connections with other nuclei in charge of language located in occipital, temporal and parietal regions.

On the other hand, if Wernicke's area is damaged, but in the non-dominant hemisphere (usually the right), aprosodia or dysprosodia will appear. This means that there are difficulties in grasping the tones, rhythm, and emotional content of language expressions.

This happens because the right hemisphere is generally in charge of regulating the understanding and production of speech, affecting the interpretation and emission of intonation and rhythm.

Stroke

Wernicke's aphasia is usually due to a stroke, although it can also occur from blunt trauma due to an accident.

In conclusion, it is better to consider Wernicke's area as a very important area in this type of aphasia, forming part of a much broader process that includes more structures and their connections.

Symptoms

This type of aphasia can present in different ways and at different levels of severity. Some affected may not understand any spoken or written speech, while others may carry on a conversation.

The disease usually appears suddenly, while the symptoms appear little by little. The main symptoms of a person with Wernicke's aphasia are:

Inability to understand spoken and written language

Problems understanding language, even single words or simple phrases. They may not even understand the sentences they say themselves. However, understanding can deteriorate in very different degrees and the patient will have to use extralinguistic cues (tone of voice, facial expression, gestures…) to try to understand the other.

Fatigue effect

The affected person can understand several words or that a topic is being discussed, but only for a very short period of time. If you talk more than necessary, the patient cannot understand you; the problem increasing when there are other distractions such as noise or other conversations.

Nonsense speech and phrases

The stark contrast between fluid speech and the meaninglessness of the message is striking. They also emit phrases or sentences that are incoherent because they add non-existent or irrelevant words.

The level of errors they make in the expression of the speech of these patients can be variable, some may only have 10% errors while others 80%.

Phonemic paraphasias

These are difficulties in choosing and organizing the letters or syllables of a word, or verbal paraphasias, in which a real word is replaced by another that is not part of the semantic field.

Difficulty interpreting the meaning

A common symptom is misinterpretation of the meaning of words, pictures, or gestures. In fact, colloquial expressions such as: "it is raining heavily" or "see all the color of rose" can be taken literally.

Anosognosia

That is, they do not realize that they are using words that do not exist or that are not correct in that context. They don't know that what they are saying may not make sense to the recipient.

Preservation of words with emotional meaning

Interestingly, the words of affective type or associated with emotions are preserved. Therefore, it seems that the words that are forgotten or replaced are those that do not have emotional content for the person, without depending so much on the meaning of the word itself.

Difficulty repeating

Difficulties in repetition, reflecting their comprehension problems. Sometimes they add more words or phrases (this is called enlargement) or introduce made-up words or paraphasic distortions.

Neurological signs

In some cases, mild neurological signs such as paresis on the face may appear, which are usually temporary. They may present with cortical sensory problems, such as deficits in the recognition of objects by touch.

These symptoms, among others, are associated with the acute phase of the disease and resolve over time in parallel with recovery from brain injuries.

Others

- Sometimes they string together a series of words that sound like a sentence, but together they don't make sense.

- Neologisms or invention of words.

- Anomia: difficulties finding words.

- Change verb tenses, forget to say the keywords.

- In some cases, lack of pragmatic skills. They may not respect the turns of a conversation.

- Pressure of speech or verbiage: excessive increase in spontaneous language, that is, the person does not realize that he is talking too much.

- Jergafasia: incomprehensible oral expression, due to the large number of parafasias they present.

- They have deficits in the naming of objects, animals or people; although they can do it with the help of the examiner (if he tells you, for example, the first syllable of the word).

- Problems in reading and writing. When he writes, there are substitutions, rotations and omissions of letters.

- Problems can be observed to perform simple gestures such as saying goodbye, asking for silence, throwing a kiss, combing hair… which is a symptom of ideomotor apraxia.

- Copy of drawings with lack of details or totally unstructured.

- Rhythm and normal prosody, maintaining adequate intonation.

- They do not present any motor deficit, because as we said the articulation of speech is preserved.

- Intellectual abilities that are not related to language are completely preserved.

Here you can see what language is like in a patient with Wernicke's aphasia:

Types

According to Rabadán Pardo, Sánchez López and Román Lapuente (2012) the types of Wernicke's aphasia depend on the extent of the lesion in the brain.

There are patients with small damage to the superior gyrus of the temporal lobe and others, on the other hand, have lesions also in nearby structures such as the subcortical white matter and the angular and supramarginal gyri. The latter will have the language much more damaged.

In this way, there are two types:

Pure deafness for words

There is only damage in the Wernicke area. Many authors think that this is not a type of aphasia, since it only affects the reception of oral language and they classify it as a type of agnosia. These patients tend to understand written language better than oral.

Wernicke's aphasia

Lesions in Wernicke's area and other adjacent areas. Not only are there difficulties in recognizing sounds, but there are also deficits in oral, gestural and written expression and comprehension.

Differential diagnosis

Not surprisingly, Wernicke's aphasia is misdiagnosed as it is easy to confuse with other disorders. A differential diagnosis must first be made with a thorough neurological examination.

This is important because a bad diagnosis will have as a consequence that the real problem is treated late or not treated and thus the patient cannot improve.

Therefore, Wernicke's aphasia cannot be confused with psychotic disorder, since the way of expressing and behaving can be similar, such as incoherence of language or the appearance of disorganized thinking.

Treatment

As each person presents the disorder differently, the treatment will depend on the affectation and severity that occurs. In addition, the existing treatments are varied.

The first 6 months are essential to improve language skills, so it is important to detect aphasia and intervene early. It is important because the cognitive alterations would stabilize in a year and after that time, it is difficult for the patient to improve significantly.

There is no definitive method that is always effective for Wernicke's aphasia. Rather, experts have focused on compensating for impaired functions.

Many times patients with aphasia do not demand treatment for themselves, because they are not aware that they have problems. In order to intervene, it would be very useful to first motivate the person by making him understand his deficits and inviting him to treatment. Thus, cooperation with therapy is facilitated and the results are better.

These are the areas / aspects that are treated in Wernicke's aphasia:

Communication

First of all, we will try to improve patient communication. To do this, as soon as possible, they will be taught to communicate by means of signs, gestures, drawings or even using new technologies (as long as their damages are milder).

Therapies through conversation

Promoting strategies and skills for effective communication. They are framed in real contexts to facilitate understanding: such as ordering food in a restaurant, getting money at the cashier, going to the supermarket…

The interlocutor should provide the patient with contextual clues, speak more slowly and in short sentences (and gradually increase the difficulty) and be redundant so that the patient understands better.

Situational therapy

It is intervened outside the consultation, in a real environment. This encourages the patient to use the knowledge they had before the brain injury and use it to express themselves and understand others.

Above all, training the conserved capacities linked to the right cerebral hemisphere: understanding facial expressions, tone of voice, prosody, gestures, postures… Semantic memory is also enhanced, which refers to concepts and definitions.

Short-term and working memory intervention

Intervention to improve short-term memory and working memory has been found to be effective in Wernicke's aphasia. This is based on the fact that repeating words increases their memorization, which helps to link them with their meaning, improving the understanding of sentences and making the person include them in their vocabulary.

Those who received this treatment increased the number of words remembered and even began to include verbs that they had not been taught in the treatment.

Comprehension training

The goal is to improve your attention to the auditory messages that come to you from others and from your own voice. It is very effective in treating verbiage as it teaches patients to listen carefully rather than speak.

The specialist will give the patient certain instructions, using discriminative stimuli that he has to learn to identify (such as gestures or certain facial expressions). The affected person will end up associating these stimuli with stopping talking and starting to listen.

It is important that the affected person learns to slow down his own speech and to supervise it.

Schuell stimulation

Some authors consider it to be an effective treatment that works by increasing the activity of neurons in the affected areas. They defend that, in this way, brain reorganization is facilitated and; therefore, the recovery of language. It consists of subjecting the patient to strong, controlled, and intensive auditory stimulation.

Drugs

In a study by Yoon, Kim, Kim & An (2015) a case is presented of a 53-year-old patient who received treatment with donepezil for 12 weeks, finding a significant improvement in language coupled with a better brain recovery.

Family help

The help of the family is essential, introducing it in the treatment programs so that progress is better and faster. Thus, the specialists will educate the family so that they understand the disorder and stimulate the patient when and as necessary. Mainly they will be taught to adjust speech patterns to increase communication with the affected family member.

Forecast

The prognosis of this disorder depends on the severity of the symptoms and the degree of impairment of listening comprehension; since the more affected it is, the more difficult it will be to recover normal language.

References

1. Brown, Jason (1972). Aphasia, Apraxia, and Agnosia Clinical and Theoretical Aspects. Springfield, Illinois: Charles C Thomas Publisher. pp. 56–71.
2. Francis, Dawn; Clark, Nina; Humphreys, Glyn (2003). "The treatment of an auditory working memory deficit and the implications for sentence comprehension abilities in mild" receptive "aphasia". Aphasiology 17 (8): 723–50.
3. Höeg Dembrower, K., von Heijne, A., Laurencikas, E., & Laska, A. (2016). Patients with aphasia and an infarct in Wernicke's area benefit from early intensive speech and language therapy. Aphasiology, 1-7.
4. Jay, Timothy (2003). The Psychology of Language. New Jersey: Prentice Hall. p. 35.
5. Rabadán Pardo, MJ, Sánchez López, MP and Lapuente Román F. (2012). Wernicke's aphasia. In Neuropsychology through clinical cases (pp 127-137) Madrid, Spain: Editorial Médico panamericana.
6. Types of Aphasia. (March 6, 2015). Obtained from Stroke Association.
7. Wernicke's Aphasia. (sf). Retrieved on June 17, 2016, from the National Aphasia Association.
8. Whishaw, IQ & Kolb, B. (2009). The origins of language. In Human Neuropsychology (pp. 502-506). Madrid, Spain: Editorial Médica Panamericana.
9. Yoon, S., Kim, J., Kim, Y. & An, Y. (2015). Effect of Donepezil on Wernicke Aphasia after Bilateral Middle Cerebral Artery Infarction: Subtraction Analysis of Brain F-18 Fluorodeoxyglucose Positron Emission Tomographic Images. Clinical Neuropharmacology, 38 (4), 147-150.