THERAPY FOR WORD FINDING IN APHASIA Effects on picture naming and conversation Ruth Elizabeth Herbert University College London Thesis submitted in fulfilment of the degree of PhD UMI Number: U6026B6 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U602636 Published by ProQuest LLC 2014. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 2 ABSTRACT Therapy for word finding deficits in aphasia have taken two forms: semantic and phonological, with relatively more examples of the former in the literature. Criticisms levelled against such therapies focus on the fact that in most reported cases treatment effects are limited to treated items, and there is very little evidence of real functional change in terms of improvement in everyday speech for the person with aphasia. Behaviour in conversation can vary and for this reason it is important to establish reliability and stability of the aspects of conversation under scrutiny. This was carried out in the work reported here in order to identify aspects of conversation which might be used as outcome measures for therapy. The analysis of inter and intra-rater reliability and of test retest stability produced a measure which was used to identify the effects of two forms of therapy. The two forms of therapy were presented consecutively to three people with aphasia. In the first phase phonological and orthographic cues were used. In the second phase participants were encouraged to use the set of treatment words in speech situations, ranging from naming to definition to use in conversation. The effect of each form of therapy on picture naming and on conversation was measured. The results showed a positive effect of the phonological and orthographic cues for two of the participants in terms of gains in picture naming. For the third participant this therapy was ineffective. The second phase of therapy was effective for all three in terms of gains in items only treated in that phase of therapy. The analysis of the conversation data showed unstable baselines for a number of aspects for all three participants. Nevertheless there were some aspects which were stable for a given individual and some evidence of positive changes after therapy. 3 ACKNOWLEDGEMENTS I would like to thank most particularly the three people with aphasia, and their significant others, who took part in the study with enthusiasm and interest. It was a real pleasure to work with them and to discuss aphasia and therapy with those who know most about it. In completing the thesis the advice, support, and wisdom of my two supervisors, Wendy Best and Shula Chiat, have been invaluable. Both Wendy and Shula read with enthusiasm the miles of script that came their way. The meetings we had throughout this time were always interesting and stimulating. I regret not insisting on more meals out but there is always tomorrow... While collecting the data for the study I was employed on a grant from the Tavistock Trust for Aphasia. During the data collection period I worked closely with the ideas of Felicity Osborne, and with the physical reality of Wendy Best and Julie Hickin. Those were very fruitful times which I look back on with fondness. Thanks to all three for those happy times. David Howard provided many of the test materials used here, computer programmes to ensure easy data management, and invaluable statistical advice throughout. Thank you. I would like to thank also staff at University College London for help and support. Jane Maxim, for enthusiastically embracing anything new and challenging, Chris Donlan for humour and advice on statistics, Katie Kay and Caroline Newton for being sane and friendly and keeping things in perspective. At Sheffield Martin Szcerbinski offered calm advice that was easy to follow. To all other friends and colleagues who have offered help when needed: Julie (always on the end of the phone when needed), Caroline, Jo, Sarah, Gill, Stephanie for being understanding about the time it has taken and for ongoing friendship. Finally I wish to thank the whole of my extensive and colourful family for being so encouraging throughout, in particular my mum and dad who are very special. 5 LIST OF CONTENTS CHAPTER ONE: SPOKEN WORD PRODUCTION IN APHASIA 21 1.0 Introduction 21 1.0.1 Aims and hypotheses of the research 21 1.0.1.1 Conversation and therapy 21 1.0.1.2 Therapy for word finding deficits 21 1.0.1.3 Relating deficit to therapy outcome 22 1.0.2 Overview of Chapter One 23 1.1 Anomia 23 1.1.1 Word finding in aphasia 23 1.1.2 Aphasia syndromes and anomia 23 1.1.3 Anomia: a cognitive approach to assessment 25 1.2 Methodological issues in aphasia research 26 1.2.1 Assessment methods 26 1.2.2 Issues of validity in testing word finding through picture naming 27 1.2.3 Reliability of methods and analyses in aphasia research 28 1.2.3.1 Age related controls 28 1.2.3.2 Error types and error classification 29 1.2.3.2.1 Whole word errors: semantic relationships 29 1.2.3.2.2 Whole word errors: syntactic relationships 29 1.2.3.2.3 Whole word errors: perseverations 30 1.2.3.2.4 Morphological errors 31 1.2.3.2.5 Formal or phonological errors 31 1.2.3.2.6 Mixed errors 32 1.2.3.2.7 Connected speech: circumlocutions 33 1.2.3.2.8 Summary 33 1.2.3.3 Reporting data 35 1.3 Anomia subtypes 37 1.3.1 Semantic deficits and semantic errors 37 1.3.1.1 Background 37 1.3.1.2 Semantic output errors in aphasia 39 1.3.1.3 Relationship between input and output semantic errors 39 1.3.1.4 Single cases with a lexical semantic deficit 40 1.3.1.5 Semantic errors without a lexical semantic deficit 42 1.3.1.6 Variables and semantic errors 42 1.3.1.7 Comparing targets and semantic errors 43 1.3.1.8 Summary 44 1.3.2 Pure anomia 45 1.3.2.1 Classical anomic aphasia 45 1.3.2.2 Pure anomia: a breakdown between semantics and 45 phonology 1.3.2.3 Tip of the tongue states in aphasia 46 1.3.3 Phonological deficits 47 1.3.3.1 Classical accounts of phonological impairment 47 1.3.3.2 Single case studies 47 1.3.4 Summary 49 1.4 Variables influencing naming success 50 1.4.1 Semantic variables 50 1.4.1.1 Imageability/Concreteness 50 1.4.1.3 Operativity 51 6 1.4.2 Lexical variables 52 1.4.2.1 Frequency 52 1.4.2.2 Age of acquisition 53 1.4.2.3 Familiarity 54 1.4.3 Variables acting upon phonological encoding 54 1.4.3.1 Syllable and phoneme length 54 1.4.3.2 Group studies and single case studies 55 1.4.4 Summary 56 1.5 Summary of the Chapter 56 CHAPTER TWO: MODELS OF SPOKEN WORD PRODUCTION 57 2.0 Introduction 57 2.1 Methodology 57 2.1.1 Speech errors 57 2.1.2 Reaction time experiments 58 2.1.3 Cognitive neuropsychology 58 2.1.4 Connectionism 58 2.2 Theories of spoken word production 59 2.2.1 Architecture: Boxes, arrows, units and interconnections 59 2.2.2 Architecture: Semantic and phonological levels 59 2.2.3 Evidence for independent levels: semantics and phonology 60 2.2.3.1 Speech errors in normal speakers 60 2.2.3.2 Tip of the tongue states 62 2.2.3.3 Reaction time experiments 62 2.2.3.4 Evidence from aphasia 63 2.2.4 One-step models 64 2.2.5 Two-step models 64 2.2.5.1 Lemma, or word level 64 2.2.5.2 The independence of syntax (lemma) and phonology: 65 tip of the tongue studies 2.2.5.3 The independence of syntax (lemma) and phonology: 66 Evidence from neuropsychological studies 2.2.5.4 The organisation of syntactic and phonological 67 knowledge 2.2.6 Activation within one and two step models 67 2.2.7 Four models of spoken word production 68 2.2.7.1 WEAVER ++ (Levelt, Roelofs and Meyer, 1999) 68 22.12 Dell, Schwartz et al (1997): Interactive two-step model 70 2.2.7.3 Rapp and Goldrick’s Restricted interactive activation 72 (RIA) model 2.2.7.4 Caramazza’s (1997) Independent Network model 73 2.3 Levels of representation 75 2.3.1 Semantics 75 2.3.1.1 Two systems or one? 75 2.3.1.2 Semantic representations 76 2.3.2 The lemma or word level 76 2.3.3 Morphological representations 77 2.4 Phonological encoding 77 2.4.1 Slot and filler model 77 2.4.2 Serial ordering in phonological encoding 78 2.4.3 Temporal aspects of phonological encoding 78 2.5 Models of spoken word production and aphasic naming errors 79 2.5.1 Background 79 2.5.2 Non-implemented explanations 79 2.5.2.1 Semantic errors in input and output 79 2.5.2.2 Output semantic errors without input semantic errors 80 2.5.2.3 Evidence for lemma level deficit 81 2.5.2.4 Form related errors 81 2.5.3 Computerised simulations of aphasicnaming 82 2.5.3.1 Dell et al (1997) 82 2.5.3.1.1 Problems with this simulation 84 2.5.3.2 Foygel & Dell’s (2000) semantic phonological model 86 2.6 Summary 87 CHAPTER THREE: SPOKEN WORD PRODUCTION 88 IN CONVERSATION 3.0 Introduction 88 3.1 Background 88 3.2 Conversation analysis 89 3.2.1 Sequentiality 90 3.2.2 Turn taking 91 3.2.2.1 Turn construction units and transition relevance points 91 3.2.2.2 Types of turns 93 3.2.3 Repair 94 33 Conversation analysis and aphasia 96 3.3.1 Turn taking in aphasia 96 3.3.2 Aphasia and repair 98 3.3.2.1 Causes of breakdown in aphasic conversation 100 3.3.2.2 The nature of repair in aphasic conversation 101 3.3.2.3 Influence of partner 102