Let’s Talk About Aphasias

Preston: [00:00:00] They might be like, oh, the wet is overflowing. I mean, the, the water's overflowing. The moist is overflowing. Or, or, or the, or the moist is too much. 

Margaret: They get close. 

Preston: Yeah. Like they understand what's happening, but they're not like assigning the right words to the ideas that they're trying to convey. 

Margaret: Close, but no cigarette.

Preston: Yeah. Excellent. Thank you. Wow.

So welcome back to How To Be Patient, the podcast where we talk about patients and do a lot of talking, which is germane to our subject today, which is aphasia. Margaret, aren't you excited to talk about aphasia? Margaret's not excited to talk about aphasia. 

Margaret: That's not, I didn't say that. I'm excited to learn from you.

Listeners, we have Wade into the area that is far from my brain at this point, three years far of neurology, and 

Preston: we're gonna wait into to many different areas of your brain. [00:01:00] Actually, 

Margaret: I was just practicing. I was just, I was just thinking all the ways, like some way I could make some pun around Preston, you always make me speechless.

I do that. Yeah. The words right outta your mouth. I'm gonna be nice to you the entire episode and so you can keep up the usual banter with it. 

Preston: So, uh, listeners, um, before we could start this episode, Margaret couldn't get her microphone to work, which was extremely relevant. And so it's basically just a one-way conversation with us.

So, in a way, Margaret was getting us started on like one of the first aphasia that we'll talk about, which is broke as aphasia or the inability to produce motor speech. 

Margaret: You heard it here First. They wouldn't, Preston wouldn't let a woman talk,

Preston: I think. I think you just loved the content so much. You wanted to cosplay it. 

Margaret: Yeah, that I was trying to really get into understanding and build my empathy. 

Preston: Before we get into that, I, I was like, this is a pressing guided episode so that everyone knows, and, and I was like, ah, [00:02:00] dude, are we still doing icebreakers?

Like how do we wanna weigh that out? And then I decided, I still wanted to do one. And it's because when I was first introduced to like aphasias in these kind of areas, I was in Psych 1 0 1. Mm-hmm. In like high school. So my question to you, Margaret, is what was your first psychology class like and where were you?

Margaret: I don't think I took psychology till college and it was my freshman year at Notre Dame. And it was 

Preston: like freshman Psych 100. It was, yeah, 

Margaret: it was a 1 0 1 class. And I remember that the guy who taught it, I can't remember the professor's name at this point. It was like a hundred person class. Like I just remember at the end of our, like the first lecture and the last lecture, he was like.

Some of you guys are already drinking at the, the route, at the way that alcoholics do it. And it's not just gonna stop once you like leave college like you are building your character now, please stop drinking as if like, well, you'll just stop and become like a different sort of like [00:03:00] person. And I, he like went on a rant and he had really long gray hair and was like, would cuss and stuff during class.

He was great. He was very eclectic. So that's my first psychology lecture of course. What about you? 

Preston: Oh, mine was, mine was in high school, and I just remember my teacher, her, I mean, I think a lot of the psychology teachers are, are either eclectic or eccentric people. And she insists on making all these puns that were like based in characters to help us remember the different parts of the brain.

And so she'd be up on the board and be like, see this part right here? This is the cerebellum. Whenever I see you see this, I want you to picture a ballerina named Sarah. Well, her full name is Cerebellum, but she's really bad at being a ballerina. And then she would like dance around the classroom and like fall over and be like, see how bad her balance is.

That's cerebellum. The, 

Margaret: that's actually kind of awesome.

Preston: But, and like I say this as a joke, but here I am, like two years into psychiatry residency, probably gonna apply to neuropsych fellowship. And I'm like, yeah, [00:04:00] cerebellum. 

Margaret: You're like, I'm actually locked in on that. 

Preston: Yeah. I feel 

Margaret: like this is why, like, don't, like I wish I'd had a teacher like that at some point for neuroanatomy.

Even at the simplest level. 'cause I feel like one of the things that confuses me so much with like functional imaging and some of the neuro stuff is that like, it feels like it's in one ear and out the other in terms of like when people are like, this is what this part of the brain does, but not really.

'cause now we're moving to brain circuitry and I just like get confused. 

Preston: Yeah. Yeah, exactly. And, and that's actually what we're trying to do today is make it like a little bit less confusing. And it sucks because like, I feel like I had. I have like a weak grasp on it, but I'm still holding onto it and I, and I started to confuse myself a little bit as I was researching for this video, and I was like, oh no, this is gonna be like a blind lead, the blind kind of situation.

Margaret: But, so there was a con wait, there was a comment on one of our YouTube. Comments recently that was like, I love this podcast. Are they always right? [00:05:00] No, but they try really hard and they know they're not always right. Are they 

Preston: always right? 

Margaret: No. Like keep it up guys and comment are, I love that. And that's honest.

And we try to be right more often than we're not. 

Preston: But yeah, you know, I don't, I don't know what our batting average is. We're.

Or, or at least we're not like blatantly standing on misinformation. 

Margaret: Just apology now. Yeah. 

Preston: Harm mongering or whatever else we're doing. So, you know, like if we are wrong, it doesn't lead you to go, you know, overthrow the capital or something. 

Margaret: Let's just, we'll do an apology video at the end of every season from now on.

Last time we had to do it with the eagle sound this time, who knows? 

Preston: Yeah, very true. So, um, we'll take a quick break, but when we come back, we're gonna go over some of the models that we use to understand processing language and speech, the whole concept of, um, aphasia disorders and how we kind of think about that in, in the models we use to describe [00:06:00] brain function.

And we're also gonna dive a little bit into the history of, of the story of how those things came about. To, to the best of Preston's ability. And, and we might get some stuff wrong, but we're, we're trying, I swear we trying new listeners 

Margaret: like slow, they're like, ah, these, these people don't know. We do know that.

I'll be right back.

Preston: So one podcast that I think all medical providers should be aware of is the sepsis spectrum by sepsis alliance. It's run by this great critical care provider, Nicole kic. One thing Nicole does really well is she captures the human story within infection. Anytime a person's involved, there's gonna be a story involved, and she finds a way to bring sepsis outside of the hospital, and she helps experts tell the stories of patients who have sepsis in the community and teaches you how to recognize signs when there's problems to bring them into the hospital.

We know that 87% of sepsis starts in the community, so it's important to make the conversations there. 

Margaret: If we know [00:07:00] anything, it's that as many reps as possible. Hearing as many iterations of presentations is how we recognize it better and more quickly, and this podcast can help all of us with that. And you can listen to the sepsis spectrum wherever you get your podcast, or watch it on Sepsis Alliance's YouTube channel.

To learn how you can earn free nursing CE credits just by listening, visit sepsis podcast.org.

Preston: Before we get started, Margaret, I, I want you to reflect on this statement. The brain is modular. What does that mean to you when I say that 

Margaret: I'm reaping what I sewed right now in the psychodynamic episode? Um, I would say that it, I would interpret it as, as the. This idea of the brain having like separate parts that do separate things rather than like a circuitry model where like different circuits go through different parts, so like [00:08:00] mm-hmm.

That we used. I mean, maybe the idea that used to be like, this is where this happens in your brain, like this one particular area is what makes you be able to talk. 

Preston: Yeah, exactly. Is it right. So, no, you nailed it. So it's just, that's how I think about it. Like I think of modules like little Legos. So it's like your brain is made up of all these different modules and each module is responsible for a certain function.

This module in this part of your brain is speaking. This part is understanding, this part is emotions like that's kind of how we have ascribed these modules. So you even gotta this early and which is that this model of the brain being modular is imperfect and doesn't capture how our brain functions.

But it's also not, not helpful, if that makes sense. And, and there are times where, well, okay, you would say it's not module and Yes. But then when you knock out this specific part of the brain, it [00:09:00] eliminates a very specific function. Mm-hmm. And that's kind of how we actually have discovered how the brain works over the last, like several hundred years is like one lesion at a time.

We've learned like what's important and it's, it's harder for us to look at these more complex models because we can't just take it out one sliver at a time. Mm-hmm. 

Margaret: So when you say like, it's helpful, it's like there are parts that maybe definitely aren't indicated in certain functions, but maybe it's not a complete picture to say, like just that little one spot is the thing that caused it.

Preston: Yeah, exactly. So, so I guess the way I would think about, it's like an engine where you have all these different parts that work semi-independently, but they also are dependent on working together. So you have this like belt chain and, and as a part of your car engine and you remove one part of it, it affects how they all interact with each other.

But then mm-hmm. Sometimes it can still continue to function, but sometimes you remove that linchpin piece, right? [00:10:00] And the whole thing falls apart. Gotcha. So that's kind of how it's like modular and not modular at the same time. Mm-hmm. However, it can be really helpful when you're trying to create models to think about it in this modular way.

So. Um, a lot of what we're talking about today is actually, it's coming from this paper called Aphasia and the Diagram Makers Revisited it's, um, by Kenneth Heman in like early 2006. One of, one of my attendings shout out to Dr. Parker, she's a behavioral neurologist. She suggested I read this as a part of my training and this is kinda like.

The story of how we developed these language processing models today. 

Margaret: So you're saying story time? 

Preston: Yeah. It really is story time. So we're gonna kind of following along in the footsteps of, of our forefathers who, who came up with the ideas of where language came from and no better place to start than with Paul Broka.

What does that name mean to you? 

Margaret: Broca's region of the [00:11:00] brain. 

Preston: Hell yeah. Something 

Margaret: I can't, that's all I got. If you ask me more of exact function, I'm gonna be like, let me pull up my flashcard.

Preston: So, so he's, the, the great, his eponymous region is still known today and he, he did a lot of great to contribute to neuroscience and then he did a lot of not great in other regions. Oh no. Just like every other person. So, um, I don't know 

Margaret: any of this. Okay. 

Preston: Yeah. Well, we'll get into that in, in a minute, but I'm gonna take us back to, to 1870s.

Um, in France. So that's where Paul Broka was studying. He, he was, um, becoming interested in neuropathology and there was this lecture that he attended by this, um, person, Alberton. And he was a, a student of Gall who was kind of one of the first people to propose this idea of a [00:12:00] topographical map of the brain, kind of implying that each region of your brain.

Is responsible for a certain function. That kind of modular model we were talking about earlier. 

Margaret: Is that like phonology? 

Preston: Yeah. The problem with this is the extrapolated phonology from that. Yep. So it was like, okay, a certain region, your brain is responsible for something, but then I should be able to palpate part of your skull, and then that tells me how developed or underdeveloped that region of your brain is, which makes.

Which lets me make inferences about your intelligence and reinforces the idea that like white people are superior about eugenic. 

Margaret: Yeah. You can't throw a stone too far in medicine before 1950 and not hit eugenics. 

Preston: Yeah. You're just like, oh shit. So. While, like we know, phenology kind of was largely disproven as pseudoscience.

The whole kind of concept of a topographical map, um, was still persisting at this time. And this guy, uh, Alberton was stuck on the idea that speech was totally [00:13:00] confined in the frontal lobes. He was like, all speech comes from the frontal lobes. And he was like, I challenge anyone to find a patient who has like a speech production difficulty.

And they're like, autopsy. You don't see a lesion in the frontal lobe, basically. Hmm. So Paul Broka is one of his, the guys in this audience, and he is like, oh, that's pretty interesting. And sure enough, he, he goes, he like goes to the hospital, um, to visit a patient, um, with one of his colleagues, lab Borg, and the patient has a speech production difficulty.

And they're like, oh, well, very interesting. And it's of course the 1870s and he was admitted to the hospital for cellulitis speech production difficulty. Yeah. He died like five days later. 

Margaret: So they killed him. Yeah. 

Preston: And he died. They were like, what are the chances? Like I just saw this lecture on like speech production and this dude I run into has issues.

I seriously die. Dies. Dies. Yeah. And then sure enough, [00:14:00] on the left frontal lobe, Hmm. Which has broke his area. He had this, um. This deficit. So then Paul Broka started doing a lot of work. He, he was like enthralled by this. So he starts kind of proposing that there are certain regions of the brain that affect your ability to produce speech.

And he kind of mm-hmm. Basically took that idea that was in the frontal lobes and started to vocalize it a little bit more 

Margaret: when he was thinking of it. What did he mean by Purdue speech? Like was there any division at that time of like, or was just like, this is. Brain go talk and this is the part that makes talk.

Preston: Yeah. That, that was the whole scheme at the time was like, frontal lobe equals talkie. That's how we, that's how we do it. Great. And, and so that's kind of like where, where we are in the science now until we have our, our new friend Carl Vernick. Well that guy, so he's, he's not in France, he's over in Germany [00:15:00] and he's studying under mine art.

Which probably sounds really familiar. So like the basal nucleus of mine Art 

Margaret: Uhhuh. Yep. I was like, that sounds like something I had to memorize. It sounds funny. Yeah, mine art had a lot of stuff 

Preston: named after him. He was also a neuropathologist and he actually had this idea that psychiatric disorders can be influenced by disturbances in the brain and childhood.

And that like issues with the brain could lead to mood issues later, which is like. A revolutionary concept at the time when they're like, wait, psych disorders are just moral failures. Like these, this is an issue with the soul. What do you mean? Like if I mess up the brain, it could lead to psychosis. He's like, no, I swear.

Swear got, I think so. Guy saying 

Margaret: that we got Freud being like, maybe this is. A lot of abuse is happening and impacting people. Everyone's like, no, when are lying minor's? Like 

Preston: maybe the brain is related to the mind and everyone's like, shut up. But Minor did, did come up with some, with some cool stuff. He was able to figure out that, [00:16:00] um.

We have a motor cortex and a sensory cortex. Like the, the anterior portion is like more of the motor cortex and the posterior portion is for more like input, sensory input, so like mm-hmm. Afar and efer inputs. But he didn't localize anything with language vey, however, was able to find these patients that didn't have any problems producing speech, they.

They could fluently construct language, but it was just nonsensical. Mm-hmm. And interestingly, they weren't able to understand speech at all. And these were different than Broca's patients, which they couldn't produce speech, um, but they seemed to have some intact understanding of speech. Yeah. When people talk to them and were frustrated by their inability to produce speech, 

Margaret: is that different than to just compare like that versus like confabulation.

Preston: Yeah. So, um, they actually thought that at some [00:17:00] point a lot of these patients were confabulating or like psychotic or saying delusional, nonsensical things. But what happens is that these patients were like unable to communicate in. Like any sort of like grammatical syntax or coherency. So it's not that they were just like making things up, it was almost like they forgot what sounds go with what words.

Mm-hmm. And so they, they created a lot of new words when they were talking. They're called neologisms. And, and they would just speak, um, uninterrupted in this like ble um, prosody called like logia. That was actually what vey proposed, which was that we have memories somewhere and, and we, we remember how each word sounds mm-hmm.

When it's coming in. And we have to remember that when we're both hearing the word and when we're producing the word. And so somewhere those [00:18:00] memories get messed up and which is why we can't understand language or produce language. Mm-hmm. Just really interesting and kind of groundbreaking concept that expanded.

On this in initial all, all speaking and talking is in the frontal lobes. Mm-hmm. Because when he looked at these patients, they found it was in the temporal lobe. Hmm. Which is, uh, and if you're not familiar with, with brain anatomy, frontal lobe is like right behind your forehead. Temporal lobe is like closer to by your ear.

And there's, these are two separately formed lobes. So we're like, wait, we thought speech was in this whole lobe, but now it's actually in this, in this other lobe. Mm-hmm. People can still talk, but they can't understand speech. 

Margaret: And for both of these, like subtypes of patients, it, at the time they would've known that they were not like hard of hearing or deaf, like that was something that obviously with the, the, you know, science, whatever, they could rule that out then.

So it's like these people could hear, but then their like sound would get in. But then what would happen next would be different from normal or, and from Wernicke versus Broca [00:19:00] patients like aphasia. 

Preston: Um, what do you mean by different from vernae, bro? Facia? Well, like 

Margaret: the, the thing that would get in the way, like the part in the process of hearing, understanding, producing, and then out loud saying speech is different for Wernicke's aphasia versus bro aphasia, right?

Preston: Mm-hmm. 

Margaret: Yeah. 

Preston: Yeah. So it, it's what they propose is that they're along the same like. Timeline or the, on the, the same event. So now I kinda wanna take a moment for us to like really think about all the physics that has to happen for like our brains as computers to understand speech because it's, it's really kind of fascinating to think about.

So when I am like talking to you right now. Mm-hmm. Right. If we were to turn this into like a sonogram, it would just be a bunch of like sound frequencies going up and down. Mm-hmm. Right? So that, that goes into your ears, which have to interpret the vibrations. A certain point it has to go through your Audi, like um, your audiologic cortex [00:20:00] or form, perform some kind of auditory analysis on it to separate what.

Pieces of noise are relevant and irrelevant. 'cause you're probably also hearing like your air conditioning or maybe some like ambient noise in the background too. So like all these frequencies are going to your ear, but you have to find a way to isolate the sound that's coming from Preston. Mm-hmm. And then it has to go to some part of your brain that pulls out which part of those frequencies are associated with words and which part, which of those words have like certain meanings that are related to you.

And then you have to like code that meaning come up with a response and then assign, okay, my response is gonna have certain vibrations associated with it, and then I have to tell that to the motor part of my brain to produce that kind of speech and to come out the other side. Mm-hmm. Yeah. So what we found is that the part of your brain that is interpreting those vibrations, that assigns meaning to each of those, to those words.

That's the part in Vernick. He's aphasia That is totally messed up. [00:21:00] So it's why they can still, the brain can still tell the mouth to speak. Mm-hmm. But the part that's like, there's some part in your data bake in your brain that's like saying, okay, this sound like P or or, or ger. Mm-hmm. Gr. That is assigned to a, when combined with this other sound, p or something is assigned to a certain meaning.

Mm-hmm. And it's like matching them together before it's like shipping them out to be, to turn into a sentence that you speak. 

Margaret: Mm-hmm. 

Preston: That part is totally screwed up in Phasia. So can 

Margaret: Vern aphasia, can they understand what the other person is saying? 

Preston: No. Because even when it's coming into you, even when you're hearing it, you still don't know how to, how to, so don't know both ways.

Distract meaning from those ways. Yeah. Right. Got it. You like there is a total mismatch between meaning or semantics and mm-hmm. Um, the, the vibrations that we're hearing, so they called this the phonologic lexicon, which is basically your dictionary of what does each spoken word [00:22:00] sound mean to me? Gotcha.

Especially in combination. So going in it's meaningless, coming out, it's meaningless. Mm-hmm. Mm-hmm. Even if they have like some intent of like what they're trying to say. So, and, and what's interesting is like they, these, these patients, they don't try to correct themselves. They make these neologisms, but they're like not aware of them.

So, so this kind of like really changed the whole field, so to speak. Mm-hmm. 

Margaret: And then can you compare that to like broke as aphasia, just so that the two comparisons right next to each other 

Preston: for Yeah. So, so in bro is aphasia now. The primary problem on that, that model we just talked about is producing speech only.

So before when Broka was just, just, um, finding his patients, he thought that was like all of speech. Mm-hmm. But now it kind of looks like there's an input and output part, so mm-hmm. You understand what each word means. So like, when you're telling me all of these vibrations, I'm able to interpret them, assign proper [00:23:00] meaning to them, but then when I try to export it, mm-hmm.

Now there's a huge disconnect. So I can't, my mind can't take meaning and then tell my mouth the words to say I can't produce the speech anymore. So like in in, I wanna say like, all these are not like perfect on or off switches. They're like faucets. So there are like patients with bro aphasia that they'll only be able to say tan.

It was, was one of the examples that they gave. Um, or, or they, they can say like one word. They'll be like Mike, Mike, Mike. Mm-hmm. Mike. So they, they can't produce complex speech, but they can produce some speech. Mm-hmm. And or the same with like benicky patients. They may say like one sentence over and over again, but then they can't extrapolate or like, say more complex things, which is kind of important to think about that.

Like you have the deficits there, but it's not 100%, you know, they're not completely mute, I guess, so to speak. [00:24:00] And, and. This is actually where we can also reflect on how the brain is not totally modular, because they found that there were some broca aphasia patients where they only had transient amounts of aphasia.

Like they wouldn't be able to speak for a certain amount of time, but then they'd regain their ability to speak. Hmm. And those patients had lesions in Brocas area, but they were smaller. So when they had smaller lesions, the other parts of the brain were able to kind of reshuffle and compensate because the brain is plastic ultimately.

But the patients had larger deficits, kinda like that whole, like left-sided region of the frontal lobe. They wouldn't be able to, um, recover. So we, we kind of now have two types of aphasia that we're dealing with. And like any model mm-hmm. You start to find that there's exceptions to that. Mm-hmm. And then you have to go back to the drawing board because that's exactly what we did with brokers.

So. One thing that Vernay hypothesized was that there's a region of your brain that produces [00:25:00] speech, and then there's a region of your brain that interprets speech essentially. Mm-hmm. Assign meaning to things. And he said, I imagine those two regions are connected. So I wonder if that connection between those two regions was severed somehow.

Mm-hmm. That you could have someone who could interpret speech. And produce speech, but would have trouble connecting those two things. So they would have trouble repeating things. Exactly. Huh. Yeah. Yeah. And that was actually a really profound hypothesis that he formed based on this kind of like working model he made.

Mm-hmm. So we're gonna take a quick break and when we come back we'll see if he was right about that.

So we're back, but dooo to find out if Benicky was right. And you probably guessed he, he was right about that part. So the, the question being, if there's a part of my brain that [00:26:00] interprets and assigns meaning to speech, there's a part of my brain that produces speech. If we sever the connection between them, we'll have some sort of issue continuously repeating speech.

Mm-hmm. And that's exactly what we found is that there were some patients who. Could seem to understand speech, but then would make a lot of syntactical or semantic errors when trying to reproduce speech. They were still speaking fluently, but they kind of almost like kept messing up. 

Margaret: Yeah, 

Preston: short, like short circuiting, but then they would recorrect really fast.

Margaret: You give examples of like syntactical versus semantic. 

Preston: Yeah. So, um, a great example of this would be if I hold up this glass. To you. I'm holding up like a glass of water and I say repeat after me. The, the, the glass is full of water. You would say the earn is full of water. Um, the, the vase is full. The, the glass is full y You know what I mean?

Mm-hmm. Mm-hmm. So, so like, it's like they weirdly like replaced mm-hmm. Parts or like single nouns with like synonyms of them. Okay. [00:27:00] Yeah. And that's actually something that, um, I'll see in. Patients in the hospital or something. So I have this like stroke card that I use, and it's just like if you work in neurology at all, you've probably seen the stroke card.

Mm-hmm. Which it's, it's a picture with some kids that are reaching into a cookie jar and like the chair's about to fall over. And so I've had people call that the cookie urn. They're like, oh, it's cookie. I'm like, cookie jar. And they're like, yep.

I'm like, yeah, like, um, like another way that, that they might kind of make these substitutions would be in like describing water. So another part of this car is like, the sink is overflowing. They might be like, oh, the wet is overflowing. I mean, the, the water's overflowing. The moist is overflowing. Or, or, or the, or the moist is too much.

Margaret: Yeah. 

Preston: You see how like, so 

Margaret: they get close, but not, 

Preston: yeah. Like they, they understand what's happening, [00:28:00] but they're not like assigning the right. Words to the ideas that they're trying to convey. 

Margaret: Then close the no cigarette. 

Preston: Yeah. Excellent. Wow.

Yeah, so, so sometimes they would just have to turn the other head and, and walk away.

Margaret: The rest of the episode is just gonna be puns. 

Preston: Yeah. So, no, no, it's, it's exactly like that. So, and that is kind of. A severing of what we call the, the ar arcuate fasciculus, which connects mm-hmm Um, the temporal lobe and the frontal lobe. So Vern's area to bro's area. Interestingly though, like if you have someone that can understand but has trouble producing speech, there was actually the inverse of that, that they saw too.

So there were people that didn't really understand speech. They could, um, repeat [00:29:00] pretty easily if you told them to, like, just repeat after me. You know? Mm-hmm. But then you try to explain things to them, or you ask them to name things. They have, they have trouble like understanding how to name it. And that was the opposite.

It was, it was called transcortical mixed aphasia is what we call it now. And the reason why that those two are kind of interesting is because it suggests that. This phonological lexicon we had before actually has like two parts of it. Mm. There's one part that is just like the sounds we make, and there's one part that's like the ideas that are assigned to those sounds.

And so weirdly enough there were some patients that when you ask them to repeat a phrase that they understood, they would be able to. So if I say like the cat sat on the tree, they could say that, but then if you ask them to repeat a phrase in like French mm-hmm. Where they didn't have a meaning assigned to those words, they were unable to just like repeat the [00:30:00] sounds.

Hmm. Because, interesting. Yeah. They had deficits in like the phonologic part, the sound part, but not the semantic part. 

Margaret: Got it. 

Preston: So it's like they would almost use the ideas of the word to piggyback off of the sounds to make, to repeat things. Mm-hmm. Kind of in, in total summary. Now we have these audiologic inputs.

So our ears interpret the vibrations and then they get divided into sounds. So we have our full vocabulary of all the sounds that we can make and produce, and we have our full vocabulary of ideas and how those are assigned to, and those are in separate kind of regions in this model. And then they combine into our phonogram lexicon, so to speak, all the words that we can produce.

And that is where we produce speech 

Margaret: complicated. I mean, and I know that this is like a merely a skimming of the top of the ice cube, but sorry, 

Preston: that was another, another green [00:31:00] one stop. 

Margaret: Um, but complicated, which is why I could never remember it in medical school or now 

Preston: apparently it's, um, it's, it's not quite rocket surgery, but it's close.

And, and so it's funny, I, I think that's like a good place for us to kind of stop for now. But actually if you wanted to keep going, there's like several other layers to this model, um, including like people that. They maybe could understand speech and reproduce speech, but they wouldn't like initiate it on their own.

Mm-hmm. And it comes into this idea that there's like circuits involved in our motivation or, yeah. And not motivation, but ability to like initiate tasks that also affect speech and other things. Yeah. So, so we have people that like, have spontaneous speech deficits but are otherwise okay to, um, repeat and understand language Yeah.

And engage in written language. So 

Margaret: it's making me think of like. The connection between it and what we usually more think of in child psych is anxiety and like selective mutism where there like [00:32:00] isn't necessarily a, like a hardware problem like that every, everything is working correctly. But then the anxiety or a motive part and how that interacts with this system is another part of what you're saying of, of speech, I would presume.

Um. Of of how this, this kind of linked circuit interacts with all the other linked circuits in the brain. 

Preston: Yeah. And, and that's where like the modular part of the brain starts to kind of fall apart with that model because we then we start to see like, okay, well, like this whole circuit functioning is dependent on another circuit influencing it.

Mm-hmm. And that's, that's circuit to like decide to even want to do anything in the first place. And the other thing is like. This is a, uh, more of a conceptual model, but we, we aren't able to map all of these like lexicons or dictionaries onto, like, specific parts of the brain anymore, right? Like, we know if we like blow out someone's brokers area, they can't talk.

But outside of that, you, you know what I mean? It's like it's [00:33:00] hard to pin down the exact points of someone's like semantic lexicon, so to speak. 

Margaret: It makes me think of how there's also interact, like the interaction between. Well, I know I just said this offline, but like when we use the term a alexathymia, which is like a difficulty or being without word, being able to not put words to emotional experiences.

Again, they're not having like a stroke. They have not lost these regions, but just the socialization practice and inner looping of these circuits both needing to work well for a function that we kind of call one thing, but is actually very. 

Preston: Like all 

Margaret: things in the brain complicated in terms of the interactions, because like you could imagine if someone has difficulty with word finding in general, that's not going to be like, how do you do therapy with someone who has word finding difficulties in general, I don't know.

Preston: Yeah. Um, and. It's interesting that like, um, I was just in supervision the other day and one [00:34:00] of, one of the things my, my mentor was telling me that is, if you can just get someone talking in therapy Yeah. They're healing. And he was like, don't, you know, like, I think it's like, he's like, it's a great place to start if, if they're talking, they're getting better.

And sometimes it doesn't even matter what they're talking about. And I'm sitting here going like, yeah, well if the patient has aphasia, they, they literally cannot be talking. 

Margaret: And you're like, and that's why I started my podcast. 

Preston: But I think with like a lot of these patients, um, so I, I don't personally deal with a lot of, um, acute aphasia patients who have experienced like strokes or other things, but we see a lot of these, like very similar aphasia play out in different types of dementias.

Mm-hmm. So in frontal temporal dementia, parts of your frontal lobe can deteriorate that almost make start to mimic bro aphasia, but it's more of a progressive aphasian that people experience. So they can get what's called like a logopenic or semantic aphasia. That's, it's very similar to Vernick. He's aphasia, but it's like slowly getting worse over [00:35:00] time.

So what I, uh, what I found these patients is that even though the parts of them that produce and understand speech are deteriorating, the other parts of their brain that recognize and intuitively respond to human emotion and body language are still very much intact. Hmm. So a lot of, like the parts of of them that recognize that like there's a human and they're expressing a certain thing, they're very responsive to that.

So if, if I like, use more like open body language when I'm talking, I express that I'm smiling and I, and I show that I'm interested in welcoming to them, they'll still respond positively to that even though all these other parts of their, like language centers are being taken away from them, 

Margaret: that there is somewhat of the modular part of it where.

This part of the brain is sort of deteriorating and the other ways of communicating that on their surface include language are understood from this other [00:36:00] part of the communication that we think about a lot in psychiatry. Because that, that was the other thing I was gonna not ask but wondering about was like you say, like semantic meaning of words and the sound meaning, and that like language isn't there, but I think of.

How, how in speech then like when I understand something someone's saying to me, I'm not just like getting the dictionary definition of the word it, like I'm also reading it mm-hmm. Through the emotion and you know, body language, whatever things that are happening too. Mm-hmm. But you're saying in this example, it's like, because those things are still like, are in a different maybe part or like the circuit at least is in a different part.

It's able to still be known by a patient, even if they're semantic and kind of phonetic abilities of speech are diminished. 

Preston: Yeah, like, like the meaning of the words are, are lost in some way, but, but the intent and the emotion behind them sticks. 

Margaret: Yeah. [00:37:00] 

Preston: And it, it's really interesting and I think that you kinda have to remember that when you're talking to patients that have these aphasia disorders.

And, and I think it actually just goes for any, yeah. Any patient, any interaction. You, you say in the hospital that people aren't gonna remember what you say, but they're gonna remember how you said it. Mm-hmm. Patients with aphasia language difficulties, it's like that times a thousand, like they're only gonna remember how you say it because they won't, won't have any ability to interpret what you said unless they have a specific, you know.

Aphasia that with intact comprehension, obviously, but that you can almost like take this as a lesson and say like, okay, like even on my patients that don't have aphasia, like almost like the more important thing I'm gonna be doing is gonna be expressing with my emotions and my body language and other things, rather than focusing on like the exact, um, syntax of my words, which I think is where a lot of people get preoccupied.

Margaret: Yeah. I mean, I feel like that's part of the limit in some ways embedded in these models is. I can't really [00:38:00] even, like, I can understand the like reading and producing speech function, like sort of in a vacuum devoid of emotion and human interaction. Like you can think of reading a book, but like it's hard to even understand language, like as a concept.

Preston: Mm-hmm. 

Margaret: And try to totally divorce that from. The context, the other contextual parts of it, I guess outside of reading. 

Preston: Yeah. I, I think, I guess this is how I'd put it. It's like 

Margaret: I, I'm not like, like I'm just, I'm not asking, like I don't, I'm not asking that. I'm only saying Yeah, no, I know you're 

Preston: not asking. I I'm also reflecting on it.

I think I would say like language is one of the many ways we communicate, but is not like the only way. So it's like, even if someone's. Unable to articulate, understand, or like reproduce written or spoken [00:39:00] language, that does not mean that they're beyond being communicated with. Yeah. And, and we have many other tools.

So that, that's also like the part of like the modular brain that doesn't hold up, which is like, oh, this part is responsible for communication. Well, like communication is a really broad term. It's the ability to translate one idea from one human to another, and words are one way to do that. And words have a really complex system, but there are many other ways that you can translate ideas.

Margaret: Yeah. What do you make of like, like we talk about the musicality of people's speech or like the rhythm of it. How does that fit in in your mind? I'm sorry, I'm asking Preston to go off script right now, but like 

Preston: Oh, sure. Um, 

Margaret: I'm like thinking of this, of like thinking of patients with like pretty severe depression or like who are experiencing the flattening of like prodromal, like before their first break for like schizophrenia?

Preston: Yeah. Like the, the way their prosody starts to flatten out and we become more robotic 

Margaret: and we say that's indicative of like. [00:40:00] Emotion, but at its core, it's still a function of an ability to produce a type of speech. 

Preston: Mm-hmm. 

Margaret: So is that flattening indicated in this. Circuit, I'm asking you off. Yeah, so I'm sorry.

I don't know anything about 

Preston: how these circuits affect prosody. Yeah. Um, but I do, but this, I guess is a whole other like, topic for me. I do find prosody very interesting. So like if you, um, follow someone's intonation over the sort, the course of like a sentence, it, it obviously implies certain things about what, what you're saying, even if you're saying the same thing each time.

So like if you, I think we, we, most of us know this, but like if you raise your intonation or you raise the frequency of your voice towards the end of a sentence mm-hmm. You're implying a what? 

Margaret: Question? 

Preston: Yeah. Question. Right? So, so if I'm like, like this is a glass of water, 'cause I'm pulling a glass of water, I'd be like, this is a glass of water, 

Margaret: it's an urn.

Preston: This is, this is, this is a wet of urn. [00:41:00] But then if I drop my, if I drop my prosody. Intonation at the end. Mm-hmm. It's, IT clinic conveys more authority. This is a glass of water one. One person who does that really well is Michael Babar from the Daily Publicity to him, and I always think about how he applies his prody.

He's like, this is Michael Babar and we're with the Daily. He doesn't say, this is Michael with the daily. Interestingly, if you raise your frequency and then drop it, that's like a way to sell punchlines or jokes. 

Margaret: Really? 

Preston: Yeah. This is a glass of water. 

Margaret: I feel like I like never whatcha doing with your 

Preston: headphones?

Very. I feel like I 

Margaret: believe you. I believe you in theory.

So do you use this, do you think of this when you're [00:42:00] like talking in the podcast? 

Preston: I mean, I, I don't, I don't try to like sell it when I'm doing different jokes, but sometimes it works, if you know what I mean. Like, that would, that'd be an example of me like trying to apply it. I, I think it is just a way to set up like into the anatomy of a joke, which is like a lingering question or uncertainty, followed by a punchline.

So like the joke or the punchline should be able to live on its own, but the prosody is a way to reinforce that. 

Margaret: If that, I'm thinking of the norm McDonald, like the Moth. I mean, he did stay up here and then he, he goes down at the end. It's like the light was on

and it doesn't fall. I 

Preston: dunno. McDonald's, like the basic example of that, 

Margaret: I think Go watch, go watch him on Conan. It's 

Preston: okay with the moth joke. Yeah, 

Margaret: he, you're right. There's, there's ways. He's just such a 

Preston: maverick of comedy that I'm like wondering if he, he's like following the. Like the tried and true methods, but I'm sure he has a lot of classics like that.

I love 

Margaret: [00:43:00] Norm McDonald. May he rest in peace? 

Preston: Why'd you, why'd you go into the, the restaurant anyways? Well, the light was on. 

Margaret: No, it was on. That's what I'm saying. That's why I literally just 

Preston: Okay. Gotcha. 

Margaret: Kill you. Um, okay. I interrupted your train of thought entirely with my questions. So where were we going next?

Preston: Oh, um, as we kind of like wrap up and, and summarize. Have been like thinking about like the different ways that people interpret and produce speech. Um, I, I was thinking about like going through a game, but I, I don't know if this is like the best one to do a game with. 

Margaret: Are you gonna quiz me? 

Preston: No, I'm not.

I'm not. 

Margaret: It's not gonna go. 

Preston: So I, I guess, um, I don't have. Much else to say ironically in this, in this aphasia episode. I, I think that, like, I always, how 

Margaret: do you, why do you think about this as a psychiatrist? '

Preston: cause I, [00:44:00] um, I think personally I'm just always very fascinated by the like, interplay or the interlocking of like the brain and the mind.

And so I'm trying to remember that like. Everything that controls some kind of like expressive or verbalizing process that someone has, has the potential to be like disrupted in a, in a mechanical way. And the same applies when like you have emotional dysregulation after a stroke or, or something like that.

So I think that like when I'm trying to anchor on all these ways or, or understand all these ways that. Our lived experience can be disrupted as our brains change. It can be helpful to then develop empathy for people that are in these situations. So it's one thing to be like, oh, this person can't talk, so I'm gonna like address their caregiver.

I know I'm gonna like fundamentally [00:45:00] believe that all of like my words are, are gonna fall on deaf ears. Or it's kind of like pointless to put an effort. But you could say, if you start to understand more. How language is processed. Mm-hmm. And how people are attempting to interpret the words you're saying, and also produce speech themselves.

It lets you find ways that you can meet with them on, on their level and, and see them as a fellow human, I guess. So weirdly enough, like the more I learn about how the brain works, the better I get at coming closer or sitting with someone in their personhood. I guess is what I would say. So I know that Margaret um, loves to hate on neuro, but 

Margaret: I don't love to hate on neuro.

I just didn't choose hate off choose to be a neurologist. You were torn between psych and neuro. Yeah, 

Preston: very true. 

Margaret: I think most psychiatrist, I think it's good that you know this stuff and I think neuropsych is really important as we in general, but like as psychiatry hopefully continues to advance. So that's why it's good [00:46:00] for me to.

How you teach me these things on the podcast mm-hmm. And our audience. 

Preston: Yeah. Yeah. And I hope that you don't, um, come across a lot of this in your, uh, child and psych endeavors. 

Margaret: Well, when you were saying it, it made me think of, um, how you understand, like I was thinking about, I had like an orientation to the.

Pediatric emergency room and the like acute psych unit. And we were talking about everyone's roles and then they were talking about child life and then ot. And a lot of the things that OT does for psych and peds especially is figuring out different ways of communicating, more so with, with like kids with different developmental considerations.

But it made me think of like how OT would be useful in. Some of these patients, right. And are, are useful I'm sure. But um, like if there was the same level of OT availability at all, adult, like [00:47:00] neuropsych units, maybe the way we interact with those patients, like you're saying would be different. And if we had someone whose specialty is understanding different ways of navigating the day-to-day life environment and clinical environment, like how would they weigh in on.

Which we need to have an OT on the show, so. Mm-hmm. Um, but it, it just made me think of that, of like thinking about just like differently abled. How do we make people who are, have different abilities and different disabilities able to get care in the best way possible? It all comes from, like, from the 

Preston: village, I guess.

Mm-hmm. And, mm-hmm. I think that the more we can understand about like, the ways we can get every individual group involved, it's like. It's like how you improve someone's experience. Yeah. 

Margaret: All our, all our different lenses. 

Preston: Yeah. Well, um, that being said, I think this is a, a shorter episode, but it was fun to, to go through all the aphasia with you.[00:48:00] 

Margaret: I learned something and you have 

Preston: plenty to say. Yeah. And, and to, to you listeners, um, if you like. Kind of talking about these more like niche, like insulated topics. Uh, we're happy to keep doing them if you're a med student who is listening. Um, I know Brooke is aphasia, Vernick, aphasia, the arch of fasciculus, conduction aphasia, transcortical, mixed aphasia.

Those are all fair game, uh, as you're studying. So they're our 

Margaret: boards too. 

Preston: Yeah. Maybe you'll get some benefit from it. Like even like, uh, selfishly 

Margaret: I was like, yeah, I need to study this president. 

Preston: So, so you'll get some benefit from all that, at least. Um, if you wanna come chat with us, you can always reach out to us at, uh, human Content pods.

We're on Instagram and TikTok, if you wanna watch full videos of this, it's on my YouTube at its prerow. You can always see Margaret at badar every day on Instagram and TikTok. Shout out to everyone who's been leaving. Um, nice comments. I know people have been reaching out with lots of [00:49:00] questions, especially on YouTube.

I know. Um, we got a, a lot of questions about kind of. Forensic psychiatry after our last episode. Mm-hmm. That was on the psychiatric detainment process. So we, we hear you and we've seen a lot of those. I think we're gonna start looking at a forensic psych and our episode 

Margaret: is a forensic psychiatrist. 

Preston: Yeah.

So. 

Margaret: Coming. We have our first forensic psychiatrist coming on, but we will have others. I'm sure. 'cause there's so much to legal that I feel like is like the complex and controversial parts of psychiatry. 

Preston: Yeah, exactly. Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Dunkin, Margaret Duncan Duncan.

See now my like ability to produce speech is getting impaired. Will Flannery Kristin Flannery, Aaron Corny, Rob Goldman and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is Bio Ma Benz V. To learn more about our program, disclaimer and. Ethics policy submission verification in [00:50:00] licensing terms and or HIPAA release terms.

Go to how to be patient pod.com or reach out to us at how to be patient at human content with any questions or concerns. How to be patient is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [00:51:00] background.