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J. ~~e~~~~i~g~i~ric~, Volume 3, Number 2. pp. 185-232, 1988. 091 l-6044:88 $3.00 + ‘00
Printed in Great Britain 0 1988 Pergamon Press plc
Bilingual Aphasia in Iran: A Preliminary Report
Reza Nilipour
ABSTRACT
Fourteen Farsi speaking bilingual patients with symptoms of aphasia subsequent to either stroke, trauma, AVM or closed head injury, were administered relevant versions of the Bilingual Aphasia Test (Parades and Libben 1987) in order to assess their language deficits in each language and to determine the pattern of recovery of the patients’ respective languages.
The time of the evaluation of these patients ranges from less than two months (acute stage) to 8 years (chronic stage) post-onset. The patients’ages range from 22 to ‘79 years.
The languages involved are Farsi and one or more of the following: Armenian, Azari, English and German. The patterns of recovery and the aphasic symptoms of these patients are discussed in light of the variables associated with differences among bihnguals. etiology and site of lesion.
The pattern of recovery of one patient may change over time. It is suggested that individual variables of language acquisition may influence the pattern of recovery more during the acute stage of the aphasia than during the chronic stage, leading to a different pattern of recovery at each stage.
INTRODUCTION
Ever since Psradis’ (1977) comprehensive review of the literature on bilingual
and/ or polyglot aphasia, many new case studies have been published, with the aim
of improving on the previous methodological shortcomings and specifying the
effect of various relevant factors on the pattern of recovery(Albert and Obler 1978;
Paradis 1983; Vaid 1986). As a result, in the past decade or so, new insights have
been gained into the nature of bilingual aphasia with respect to language represen-
tation in the brain (Paradis 1984; Green 1986) and researchers have begun to
explore bilingual aphasia more systematically and comprehensively as it involves
different patterns of recovery. Yet our knowledge of the nature of the recovery
186 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
pattern, as it interacts with biological, neurological and environmental factors, is
still inadequate.
The insufficiency of our knowledge in the domain of bilingual aphasia and the
scarcity of evidence bearing on the effect of relevant factors on patterns of recovery
have been related to two main factors. namely: (1) the inadequacy of testing
materials; and (2) the lack of sufficient numbers of patients for whom the relevant
parameters are known (see Paradis and Libben 1987, for full discussion).
Yet another shortcoming of the recent literature may be related to the lack of
documented reports on a number of languages with substantial structural differ-
ences. For example, save for Nilipour and Ashayeri’s (1988) study, there is no
comprehensive documented report on Farsi-speaking bilingual aphasics.
The present study seeks to explore bilingual aphasia among a Farsi-speaking
bilingual population, using an equivalent measuring tool across languages, in the
hope that it will shed some light on the complex phenomenon of bilingual aphasia,
and on bilingualism per se.
Iran is a multilingual society where structurally different languages and regional
dialects are spoken. Farsi (or Persian), the official language of Iran, is spoken as a
native language in a large part of the country and as a second language, often the
language of education, by all minorities living within the borders of the Islamic
Republic. Farsi is the medium of instruction in schools and universities. National
mass media broadcast and publish mostly in Farsi. Besides Farsi, two foreign
languages. Arabic and English, are taught from junior high school through
university at the rate of 334 hours per week. German and French may be considered
as options for those who do not take English as a foreign language in high school.
A number of regional and ethnic languages are also spoken throughout the
country. Azari, Kurdish, Arabic, Armenian and Assyrian may be considered as the
languages most structurally distant from Farsi in Iran. They are spoken by a large
number of people.
Based on the recent official census, the population of Iran is about 50 million.
Unfortunately. no documented information is available with regard to the number
of people who are bilingual or multilingual in Farsi and one or two of the local or
ethnic languages. It can be conservatively estimated that close to 10 million
Iranians speak Azari and about 2 million speak Armenian. The large number of
people who have studied and worked in Germany, France, the United States and
England for a number of years and who are therefore fluent in a foreign language
must be added to the multilingual population of Iran.
With respect to writing, Farsi has adopted the Arabic alphabet with some
modifications, adding 4 new graphemes. Like Arabic, it is written from right to left.
Azari and Kurdish are mostly used in the spoken mode, but may be written with the
same alphabet as Farsi. if necessary. Armenian and Assyrian have their specific
Bilingual Aphasia in Iran 187
scripts and are written from left to right.
The subjects of this study comprised 14 adult bilingual or multilingual Farsi-
speaking patients with symptoms of aphasia as a result of cerebrovascular accident
(n=9), trauma (n=3), arteriovenous malformation (n=l) and closed head injury
(n=l). They were all considered fluent speakers of their various languages before
insult. They were referred to the clinic of the Department of Speech Therapy,
College of Rehabilitation Sciences in Tehran for speech therapy because of speech
disorders subsequent to brain damage.
All subjects spoke Farsi, with Azari, Armenian, English and/ or German as their
second or third language. The subjects were either native speakers of two lan-
guages, as in the case of Farsi and Armenian or Azari or they had at least 3 years of
residency and higher education in their second language environment, with the
exception of one subject (K.R.) who had more than 400 hours of instruction in his
second language but no foreign residency. By and large, the subjects had “practical
command of two languages” by Hackett’s (1958:8) criterion.
With respect to other variables associated with differences among bilinguals, no
restrictions were imposed; subjects simply had to be adult bilinguals with a
premorbid practical command of two languages. No restrictions were imposed with
respect to sex, etiology, handedness, post-onset time, site or size of lesion. The
sample represents unselected consecutive entries of bilingual aphasic patients at our
facility.
CASE 1 (T.B.)
T. B. was a 26-year-old right-handed male native speaker of Farsi with English as
his second language. His background in English represents 6 years in high school at
the rate of 3 hours per week and 4 years of college education in English in Canada.
Premorbidly, he was considered a fluent speaker of Farsi and English.
T. B. was a third year student of Journalism in Canada when he began to
experience severe headaches in 1982. He was diagnosed as having arteriovenous
malformation (AVM) and underwent an embolectomy. He was referred to our
clinic for speech therapy in 1984.
Clinical History
T. B. was hospitalized for craniotomy and embolisation in New York on 29
January 1982. He has since undergone 2 additional craniotomies and embolisations
(on 26 May 1982 and 2 February 1983). The craniotomy was performed with
resection of his AVM from the left temporo-parieto-occipital area in each case.
The patient became aphasic with no production in either Farsi or English after
the second operation. It was reported that he did not recognize people nor the
188 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
environment 2 months post-onset. He also presented with right hemiplegia and
hemianopsia.
The patient received physical therapy and speech therapy in English while he was
in the United States. His hemiplegia evolved into right hemiparesis but there was no
improvement in his linguistic abilities. His surgeon advised him to go back to Iran
for speech therapy in his mother tongue. The patient did so in May 1984.
A recent CT scan (15 June 1987) confirmed architectural damage and calcifi-
cation of the tissues of the left temporo-parieto-occipital cortex. There were also
signs of hypodensity of the right temporal lobe. There was slight dilatation of the
left ventricle. but no structural change in the ventricles was observed.
Skull radiography showed no fracture or abnormalities in the cranial vault. No
abnormal calcification or signs of increased intracranial pressure were observed.
Language Assessment (October 1984)
T. B. came to our clinic in Tehran when his linguistic abilities in both Farsi and
English were severely impaired subsequent to the AVM operations in the United
States. He was reported to suffer from a mild global aphasia and alexia, with signs
of apraxia and right hemianopsia. He had no gross motor deficit and was able to
ride his bicycle to the clinic. The patient was scheduled to undergo intensive speech
therapy in Farsi 3 times a week for 4 months.
Our evaluation of the patient’s aphasic deficits took place in October 1984 (2
years post-onset). He was given the experimental versions of the Bilingual Aphasia
Test (BAT) in Farsi (Paradis et al. 1987) and English (Paradis et al. 1987).
The Farsi version was administered on 31 October 1984 and the English version 2
weeks later. Both tests were administered by the present author. a native speaker of
Farsi who obtained his Ph.D. in Linguistics.
Figure 1 shows T.B.‘s performance in Farsi and Figure 2 in English. An overview
of the profiles of residual capacities in both languages indicates that Farsi was much
better recovered than English in all modalities. He was totally unable to perform 18
tasks in English and 11 in Farsi. In no task did he obtain a score higher in English
than in Farsi. We were not able to elicit spontaneous speech or writing in either
language. The picture-story description was elicited only in Farsi. As can be seen
(Figures I and 2), the pattern of recovery was differential 2 years post-onset, with
Farsi as the best recovered and English as the most impaired language. It must be
noted that he was in an English language environment before and after the
operation and that speech therapy was first provided in English.
The clinical picture of his aphasic symptoms may be described as reduced fluent
speech without articulatory difficulty, but with evidence of perseveration and of
word-finding difficulty. He had relatively good comprehension and repetition.
Bilingual Aphasia in Iran 189
Fluency (515. 541; 516. 517; 531, 557)
Accuracy (520, 521; 524-52R; 546, 547; 550-5541
Complexjty (516. 517: 542. 543: 529. 555; 530. 5561
Lerlcal Access (519, 545; 531. 557; 532. 558; 534, 5601
Polntlng l23-321
Simple Conaands 133-37)
SPnl-Complex Cornands (38-42)
Complex Commands 143-471
Vrrbal Auditory Olscrinination (46-65)
Syntactic Comprehension (66-152)
Scmantlc Categortes (153-157)
Synonynr (158-162)
Antonyms (163-1721
trarranaticallty Judgments (173-182)
Senantlc Acceptability (183-1921
Repetition (Words1 1193-2511
Lexical Oecislon (194-252)
Repetltlon (Sentences1 (253-259)
Series 1260-262)
Verbal Fluency (263-2671
Hamrng (269-288)
sentence Construction (269-3131
Semantic Opposites 1314-323)
Oerivational Horpholoqy (X4-333)
Morphological Opposites (334-343)
Mental Arithmetic (347-361)
Listening Comprehension (362-3661
Oral Reading (Words) (367-3761
Oral Reading (Sentences) (377-3861
Reading Comprehenston (Paragraph) (387-3323
Copying (393-397)
Ofctation (Words) (398-402)
01ctation (Sentences) (403-4071
Reading Comprehension Words1 (408-417)
Reading Comprehension (Sentences) (418-4271
spontaneous uriting (813-835)
1 Figure 1. T.B.‘s Farsi Profile on the BAT (November 1984).
190 Journal of Neurolinguistics. Volume 3, Number 2 (1988)
:lucncy (515, 541: 516. 517; 531, 5571
kcuracy i520, 521; 524-528: 546, 547; 550-5541
:omplexity (516, 517; 542. 543: 529. 555; 530, 5561
.exlcal Access (519. 545: 531, 557; 532. 558; 534. 5601
'olntfng f23-321
ilnple Commdndr (33-371
jcmi-Complex Comnnds (38-421
:omplcr Cornnandr (43-47)
/crbdl Auditory 01rCrlnination (48.65)
iyntdctlc Comprehension (66-1521
icmantic Categories (153-157)
jynonyns (158-162)
\ntonyms (163-1721
;ramrnatlcality Judgments (173-1821
jemantlc Acceptability (183-1921
&petitlan (words) (193-251)
.exical Declslon (194-2521
lepetitlon (Sentences1 (253-251)
jerles (260-2621
derbsl Fluency (263-2fi71
Vamlng (269-2881
Sentence Construction (289-313)
Semantic appasltes (314-321)
Derlvational Horphalaqy (324-3331
Yorpnolog~cal opposites (334-3431
Mental Arfthmetic (347-361)
Listening Comprehension (362-366)
Oral Reading (Words) (367-3761
Oral Reading (Sentences) (377-386)
Resdlng Comprehension (Paragraph) (387-392)
Copylllg (393-397)
almtlon (Words) (398-402)
Olctatlon (Sentences1 (403-407)
Reading Comprehension (Uordsl (408-417)
Reading CorQrehension (Sentences) (418-4271
Spontaneous Vriting (813-835)
12 3 4 5 6 7 B 9 I_
Figure 2. T.B.‘s English Profile on the BAT (November 1984).
I 0
Bilingual Aphasia in Iran 191
He was good at pointing (10 and 9/ 10 in Farsi and English, respectively), but had
difficulty with simple commands (4 and 3/ 5) and semi-complex commands (2 and
2/5). The latter shows the patient’s difficulty with locative prepositions (beside, in
front of, inside). Naming was also severely defective (6 and O/ 20) in both languages,
but more severely in English. Reading and writing tasks were very poor. Only
copying was performed without error in both languages. His reading compre-
hension for single words was relatively spared. Single word repetition was relatively
spared (20 and 22/ 30) but sentence repetition was severely defective (0 and O/ 7). His
description of the picture-story was typical of jargon aphasia. The patient can
therefore be diagnosed as having transcortical motor aphasia (see Paradis and
Libben 1987: Chapter 4, for full discussion).
CASE 2 (H.J.)
H.J. was a 63-year-old right-handed male bilingual speaker of Farsi and Azari.
Since his elementary school days, the patient’s dominant and practical language
had gradually become Farsi. He was well educated and had a Bachelor’s degree in
Law. He was married and had two grown children. His wife and children were
native speakers of Farsi. The patient and his family had lived in the United States
for 3 years. H.J. was referred to our clinic for his aphasic problems following a CVA
syndrome.
Clinical History
H.J.‘s clinical history started with an atria1 fibrillation in June 1983. The patient’s
heart problem led to an embolism which resulted in a coma. He was hospitalised
subsequent to the stroke. The diagnosis was confirmed by his neurologist as left
CVA originating from atria1 fibrillation. Following coma, the patient presented
with right hemiplegia, right hemianopsia, right hemianalgesia and right facial
weakness. He was also reported to have had global aphasia during this period. The
patient was not advised to undergo a head operation but was put under medication
and was prescribed physical therapy before he was released from the hospital (after
2 months). It was reported that he did not produce any speech either in Farsi or
Azari, although he had some comprehension.
Upon arriving home he visited his Azari-speaking brother. This occasion
triggered his use of Azari and he continued to speak Azari with some emotion.
Since then, Azari has become his dominant language. The patient’s home en-
vironment was unilingually Farsi and there was no appropriate occasion for him to
address anybody in Azari. It is reported by his sister that the patient was unable to
switch to Farsi when addressing a Farsi-speaking audience.
A CT scan was obtained while he was in the hospital. It showed extensive
192 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
hypodensity in the left temporo-parietal area with a slight similar change in the left
frontal lobe. There were also signs of slight hypodensity in the right occipito-
parietal area.
At the time of his language evaluation H.J. was able to walk but had a weak right
leg. He was well oriented in time and space and remembered events before and after
his neurological problems. No signs of hearing impairment were observed.
Language Assessment (28 September 1983)
H.J. was evaluated for his aphasic deficits with the experimental versions of the
BAT in Farsi and Azari (Paradis et al. 1987) 4 months post-onset. The patient’s oral
expression was believed to be dominantly in Azari at this point.
The patient’s evaluation took place in 3 different sessions. He was first addressed
in Farsi and was asked to talk (in Farsi) about his activities in the past. He spoke in
Azari with occasional phrases in Farsi. His spontaneous speech was fluent. He
complained about his speech problems and his inability to speak as he did before his
illness. When he was finished, he asked whether his speech in Farsi was good (when,
in fact, he was speaking Azari: with only occasional short phrases in Farsi and hence
seemed to be unaware of not speaking Farsi).
The second time we met him, he was again asked to speak in Farsi about his past
activities. He began in Azari again and continued with occasional Farsi phrases.
There were more paraphasic elements among Farsi words than Azari words. His
speech was assessed by M. R. Yaxchi, a native speaker of Azari. We concluded that
individual words and phrases were generally intelligible but that his speech as a
whole was not cohesive and did not appear pragmatically sound. His spontaneous
speech may be characterized as “word salad” in Azari. mixed with some Farsi
words.
The test results are represented in Figure 3. As can be seen. he totally failed I5 of
the tasks. He was unable to complete successfully any of the remaining tasks. Only
on 7 of them was the patient able to obtain a score over 50%. He scored below 50%
in 9 tasks (in addition to his 15 complete failures). This profile shows that the
patient’s residual capacities have been severely impaired across all modalities. Even
pointing, simple commands, single word repetition and automatic speech were
severely impaired.
His pattern of recovery is differential, with Azari being clearly dominant, mixed
with Farsi words and short phrases.
The clinical picture is typical of Wernicke’s aphasia. His language capacities are
characterized by empty speech, with severely impaired comprehension as well as
repetition and even series recitation. His writing was limited to copying.
Bilingual Aphasia in Iran 193
Fluency (515, 541; 516, 517; 531. 557)
Accuracy 1520, 521; 524-52R; 546, 547; 550-5541
Complexfty (516. 517: 542. 543: 529. 555; 530. 5561
Lexical Access (519, 545; 531. 557; 532, 558; 534, 5601
Pointing (23-323
Siwle Commdnds (33-371
Semi-Complex Cornands (38-421
Complex Cownandr (43-471
Verbal Audltory D~scrlninatlon (46-65)
Syntactic Comprchenrion (66-152)
Scmdntfc Categories 1153-1571
Synonyns 1158-162)
Antonyms (163-172)
Crdnxnatlcdlity Judgments I173-102)
Semantic Acceptabllity (183-192)
Repetitfon IUords) (193-2511
Lexical Oeclsfon (194-252)
Repetition ISentences) (253-2511
Series (260-262)
Verbal Fluency (263-267)
Naming (269-2881
sentence Construction 1289-3131
Semantic Opporltes (314-323)
Derivational Morphology (324-333)
Morphologfcal Opposftcs (334-343)
Mental Arithmetfc (347-361)
Listening Comprehension (362-366)
Oral Reading (Words) (367-376)
Oral Reading (Sentences) (377-386)
Reading Comprehension (Paragraph) (387-392)
copying (393-397)
Olctatlon (Words) f398-402)
Dictation (Sentences) (403-4071
Reading Comprehension (Uordsl (408-417)
Reading CornprehensIon (Sentences) (418-427)
spontaneous uriting (813-8353
Figure 3. H.J.‘s Farsi Profile on the BAT (September 1983).
194 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
CASE 3 (A.A.)
A.A. was a 46-year-old right-handed male bilingual speaker of Armenian and
Farsi, with 11 years of education. He was married and had two children. He was a
controller technician of electronic devices, The patient became aphasic subsequent
to a thrombo-embolic disease and was referred to our clinic for evaluation and
speech therapy.
Clinical History
In May of 1984, A.A. had a sudden abdominal pain which turned into paralysis
of both legs 3 days later. After 3 days he was able to walk again, but pain was still
present. A diagnosis of slipped disc was made and the patient underwent surgery
involving the fifth lumbar vertebra.
After the operation the pain in his legs was reduced, but both legs felt numb. A
week later, the pain returned but this time in the right leg only. Six weeks later, he
felt generally unwell and fell out of bed during the night. He was then found to be
paralysed on his right side and unable to speak, though he was able to understand.
Six months later, his legs improved so that he could walk with a stick, but the
condition of his right arm had not changed much. His speech improved to the
extent that he made indistinct sounds, but he could not produce words in either
Armenian or Farsi. It is reported that he had right homonymous hemianopsia
during the acute stage of his illness.
The final diagnosis, based on a comprehensive neurological examination per-
formed in England by a British neurologist, was that the stroke had been caused by
thrombo-embolic disease, originating either from the xenograft valves or from the
enlarged left atrium, in combination with atria1 fibrillation. The aortic bifurcation
is believed to have been occluded in May 1984 when his abdominal pain and the
numbness and weakness of the legs began.
Language Assessment (11 March 1985)
The patient’s aphasic deficits were evaluated 1 year post-onset with experimental
versions of the BAT in Farsi and Armenian (Paradis and Essegulian 1987). He was
well oriented in time and space and recognized the people around him. He suffered
from a severe right hemiplegia with a spastic right hand and a very weak right leg.
A.A. was unable to produce spontaneous speech or writing. His oral expression
was so severely impaired that he totally failed the word repetition task (O/30) in
both languages. He was not able to produce any distinct sound sequences. His
comprehension was preserved to some extent but limited to elementary tasks. He
failed semi-complex and complex commands. Pointing (6; 10) and simple com-
mands (3/5) were relatively preserved. His comprehension was better at the word
Bilingual Aphasia in Iran 195
level than at the sentence level. He obtained somewhat higher scores on auditory
discrimination (lo/ 18) and lexical decision (28/30) tasks, but even lower scores on
syntactic comprehension (28/87) and grammaticality judgment (5/ 10) tasks.
The patient’s overall residual capacities 1 year post-onset reveal a pattern of
parallel recovery of Armenian and Farsi, in the context of a clinical picture of
global aphasia.
CASE 4 (F.Z.)
F.Z. was a 5 1 -year-old right-handed male bilingual speaker of Azari and Farsi,
with 9 years of education. He had been bilingual from early childhood. His father
was also bilingual but his mother spoke only Azari. The patient’s neurological
problems originated in a CVA syndrome. He was referred to our clinic because of
his aphasic deficits.
Clinical History
F.Z. became aphasic subsequent to a CVA syndrome. The patient’s CVA was
diagnosed as the result of occlusion of the left middle cerebral artery. The diagnosis
was later confirmed by an electroencephalogram (EEG) and CT scan obtained on
30 September 1983. The EEG showed a focus with slow waves at the left temporal
lobe. The CT scan revealed a large infarction of the vascular territory of the middle
cerebral artery on the left side. There was no indication of damage to the right
hemisphere. The patient had been previously diagnosed as having global amnesia.
Language Assessment (June 1984)
F.Z. was administered the experimental versions of the BAT in Azari and
English. The Farsi version was administered by the author and the Azari version by
M. Dehghan, a speech therapy student and native speaker of Azari. Figure 4
represents the patient’s profile in Azari and Figure 5 in Farsi. Based on the results
on the BAT, the pattern of recovery appears to be parallel. Only his reading
comprehension was better in Azari than in Farsi (8 and O/ 10 for single words and 2
and O/ 10 for sentences).
The patient’s oral production was free of distorted pronunciation, but word-
finding difficulty was abundant. His automatic speech and word repetition skills
were spared. Naming was severely impaired in both languages (2 and 4/20). His
oral reading was relatively good, but reading comprehension and writing were
severly impaired. The most obvious symptom was anomia.
196 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
fluency (515, 541; 516. 517; 531, 557)
Accuracy 1520, 521; 524.52R: 546. 547; 5X1-554)
Complerlty (516. 517; 542. 543: 529, 555; 5.30. 5561 . . .._.
Lexical Access (519, 545; 531. 557; 532. 558; 534, 560)
Polntlng l23-321
S1o;ple Commands (11-17)
Scnl-Complex Cofnaandr (38-42)
:omplex Corrmands (43-471
Verbdl Auditory Olscrlnrndtlon (1,6_6Sj
Syntactic Comprehension (66-152)
Scmantlc Categories (151-157)
Synanynr (158-1621
jntonyms (163-1721
;ramnatlcality Judgments l173-1021
Semantic Acceptability (181-192)
kpetltlon (Words1 (193-2511
.exical Decision (194-252)
kpetit1on (Sentences) (ZSI-25?)
jerles 1260-2621
ierbdl Fluency (261-2671
iamlng I269-2881
ientence Construction (269-313)
Semantic Opposites (314-323)
krlvational Harpholoqy (324-333)
lorphologlcal Opposites (331-343)
lental Arithmetic (347-3611
.istening Comprehension (362-366)
lral Reading (Words1 (367-376)
lral Reading (Sentences) 1377-386)
leading Comprehension (Paragraph) (387-1923
:opying (393-397)
lictatlon (Words1 (398-402)
)1Ctdtion (Sentences1 (403-407)
leading Comprehension (Words1 (408-417)
Ieadlng Comprehension (Sentences) (418-4271
ipontaneous uriting (813-835) I I I I I I I I I
Figure 4. F.Z.‘s Farsi Profile on the BAT (June 1984).
Bilingual Aphasia in Iran 197
Fluency (515, 541: 516. 517; 531, 557)
Accuracy (520, 521; 524-52R: 546, 547; 550-554)
COmplexfly (516, 517: 542. 543: 529, 555; 530, 556)
Lerfcal Access 1519, 545; 531. 557; 532, 558; 534, 560)
Polntfng (23-321
Slmp1.e CoIlundnas (33-371
Scni-Complex Corndnds (38-421
Complex Corrmands (41.47)
Verbal Audltory Olscrinlnatlon (48-65)
Syntactic Comprehension (66-152)
Scmanclc Categories (153-1571
Synonyns (158-1621
Antonyms (163-1721
Grammaticality Judgments (173-102)
Semantic Acceptability (183-1921
Repetition (Words1 (193-251)
Lexical Decision (194-2521
Repetition ISentences) (253-259)
Series (260-262)
Verbal Fluency (263-2671
Naming (269-288)
sentence construction (289-313)
Semantic Opposites (314-323)
Oerlvational HorpholoqV (324-3331
HorphaloglCal Opposites (334-343)
Mental Arithmetic (347-361)
Llstenlng Comprehenston (362-366)
Oral Reading Mords) 1367-376)
Oral Reading (Sentencer1 (377-386)
Reading Comprehension (Paragraph) (387-392)
Copying (393-397)
lfctatlon (Words) (398-402)
lictatlon (Sentences1 (403-4071
leading Comprehension (Words) (408-4171
teadlng Comprehension (Sentences) (418-427)
jpontaneous Urlting (813-815) I
1 z 3 4 5 6 7 8 9 10
Figure 5. F.Z.3 Azari Profile on the BAT (June 1984).
NEL 3:2-P
198 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
CASE 5 (K.N.)
K.N. was a 79-year-old right-handed female speaker of Farsi with no history of
familial left-handedness. She was an illiterate housewife with 4 educated children.
Before her illness, she was staying with her 2 sons and was very active.
The patient was born in a unilingual Farsi family and lived in a bilingual
Farsi-Azari community until she was 15 years old (i.e. before her marrtage). Since
then she had been living in a Farsi-speaking environment and her family members
considered themselves to be unilingual Farsi speakers. The patient became aphasic
and spoke only some Azari subsequent to a CVA syndrome and was referred to the
clinic for evaluation and speech therapy.
Clinical History
K.N. suffered from a heart attack which led to a CVA syndrome on 1 September
1984. She lost consciousness and was hospitalized on the same day. It is reported
that she presented with right hemiplegia and agnosia for the first week and did not
move her right arm for 1 month. The diagnosis of a generalized CVA was later
confirmed by CT scan. Upon regaining consciousness. the patient is reported to
have spoken Azari. to the surprise of her family.
Language Assessment (5 November 1984)
K.N. was evaluated with the experimental version of the BAT in Farsi. She was
able to walk without a stick but had a weak right leg. She also presented with
brachio-facial weakness. She was well oriented in time and space and recognized
members of her family. We considered her a unilingual Farsi speaker and tried to
communicate with her in Farsi. Her answers were perseverative and mixed with
Azari as well as with paraphasic elements. Some of her answers were real Azari
short expressions. Our first attempts to start a conversation and to continue in
Farsi in order to elicit spontaneous speech were unsuccessful. Then we attempted to
give her the Farsi version of the BAT. We were not able to administer the standard
test items because of her impaired comprehension and lack of control over her oral
expression. Her speech was generally echolalic, perseverative and distorted. When
each instruction was read to her, she would listen attentively but she would not
follow the instructions. She was not able to provide any intelligible spontaneous
speech. Her automatic speech was also severely defective. She was not even able to
continue the task with the help of the test administrator.
The patient’s comprehension was severely impaired. She was totally unable to
perform the pointing task, as well as the semi-complex and auditory discrimination
tasks. She was not able to repeat single words nor to make lexical judgments about
them. She was able to repeat only 2 one-syllable words correctly. The remaining 28
Bilingual Aphasia in Iran 199
items were either repetitive neologisms or circumlocutions around the item. She
was not able to make a distinction between word and non-word items among the
stimuli. She was also unable to perform the naming task. Instead of naming the
objects she talked about them.
We tried to communicate with her in Azari via a native speaker of Azari. Her
mixed Azari-Farsi oral expression remained the same. An analysis of her speech
showed that it contained real Azari words and phrases, with some neologisms in
both languages and some real Farsi words and expressions.
The major features of the patient’s residual capacities may be summarized as
follows: mixed Azari-Farsi oral expression in the context of fluent paraphasic and
neologistic speech and severely impaired comprehension. Her automatic speech,
repetition and naming were also severely impaired. The patient’s clinical picture is
therefore consonant with typical mixed transcortical aphasia (Goldstein 1948;
Benson 1979). The bilingual recovery pattern is that of mixed Azari and Farsi.
CASE 6 (A.!%)
A.S. was a 49-year-old educated right-handed male with no history of familial
left-handedness. He was an experienced orthopaedic surgeon. He finished High
School in Iran and went to Germany for his university education at the age of 18.
He subsequently lived in Germany for 16 years and received his university degrees
from German universities in Hannover and Frankfurt. While he was in Europe, he
spent 1 year in England doing research at English medical institutions. He then
lived in Tehran and practiced in his field of speciality for the 16 years preceding the
onset of aphasia, but visited Germany for l-2 months every year.
The patient was a native speaker of Farsi. Besides Farsi, he knew both German
and English. He could read and write in all three languages, but Farsi and German
were his dominant languages. The medium of instruction was Farsi during his
elementary and High School years. He learned English as a foreign language in high
school at the rate of 3 hours per week for 6 years. Then he learned German in
Germany as a college student and continued his higher education in German for 16
years. During the 2 years prior to his accident, the patient had studied English and
had passed the Iran American Society English proficiency exams.
A.S. was an active surgeon with some talent in music and poetry, He was familiar
with Persian and Western classical music and played the violin and the piano. He
also wrote Persian poetry.
Clinical History
On 2 September 1985, the patient was the victim of an explosion, He was
hospitalized from 2-18 September in a hospital in Tehran in which the environment
200 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
was unilingual Farsi, but where the staff members were familiar with English. A left
fronto-temporal lesion as a consequence of the explosion was diagnosed. On the
same day, the patient underwent head surgery to remove skull fragments and other
debris from the lesion area. He was tracheotomized on the same day and remained
in this condition for 7 days. On 26 September 1985, he was able to remember recent
events, especially the events related to the moments before and after the explosion.
There were no symptoms of apraxia or agnosia. He had good right-left recogni-
tion and he was able to recognize parts of the body. photographs and colours. He
could also recognize doctors and friends. The patient’s short term memory span
was 5 digits in Farsi, but 4 digits in German and English.
The patient exhibited signs of sensory amnestic aphasia at different times in
Farsi, German and English. He suffered right hemiparesis with brachio-facial
emphasis and right homonymous hemianopsia. An EEG, performed on 12 January
1986, 41/, months after the accident, suggested an underlying dysfunction or an
underlying epileptiform process in the left temporal region. A CT scan confirmed a
left fronto-temporal lesion. There were no signs of skull bone defect after the
surgical removal of bone and shrapnel fragments. The size of the fronto-temporal
lesion was estimated at about 2 X 2cm. There were no signs of hematoma.
The patient was disoriented 1 day after the operation and to someextent until 11
September 1985. He was well oriented in time and space after that date.
Language Assessment (26 September 1985-16 January 1985)
The patient was tested in Farsi. German and English with equivalent experi-
mental versions of the BAT (Paradis and Libben 1987). The order of administering
the 3 versions of the BAT was Farsi, German and English. Because of the patient’s
fatigue and short-term memory span, we were forced to administer each version in
several sessions, but the general conditions of administering each version were kept
constant. He was tested regularly twice a week on Mondays and Wednesdays at
2p.m. from 26 September 1985 onwards.
Farsi and English versions were administered by the author. The German version
(Paradis ef af. 1987) was administered by Dr Ashayeri, a neurologist educated in
Germany. The results obtained on the 3 versions of the BAT are reported here (for a
more detailed description of this case, see Nilipour and Ashayeri 1988.)
Language Recovery Pattern
The patient’s linguistic behavior can be divided into two quite distinct stages. The
first stage or critical recovery period, was characterized by the alternating anta-
gonistic recovery of two languages (Farsi and German) with a temporary loss of the
third (English). It lasted from 2 September through to 11 October 1985. The period
of antagonistic recovery between Farsi and German in the absence of English can
Bilingual Aphasia in Iran 201
be divided into the following phases.
No
output
2-11
September
Farsi
output
12-17
September
German
output
18 September-
11 October
Farsi
output
11-15
October
Farsi
German
English
16 October
+
The patient was tracheotomized for the first 7 days and was in a critical
condition. His linguistic output was therefore nonexistent during the first 10 days.
He nevertheless remembered this period very well.
During the second phase, which lasted for 6 days, the patient spoke mainly Farsi
with occasional German phrases until he switched completely to German to the
surprise of everybody at home. This phase lasted for 24 days.
The period between 11 and 15 October is a period of transition between the
antagonistic recovery and the differential recovery of his languages. This period
started with his switch from German to Farsi upon the insistence of his sister-in-law
who did not know any German. He gradually regained control over the voluntary
choice of language over a period of 5 days. From 16 October onwards, he was able
to switch at will from Farsi to German or to English.
The juxtaposition of the scores obtained on the BAT in the 3 languages after 16
October gives us a clear picture of the patient’s relative capacities (Figure 6). The
profile shows that the residual capacities in the 3 languages were not exactly the
same. Based on the results shown in this profile, one may conclude that in the end
the 3 languages have been recovered differentially. The best recovered language is
Farsi, the least well recovered is English and German is in between.
The patient’s performance was characterized by fluent speech, poor compre-
hension, relatively good repetition and impaired writing. In accordance with the
symptomatic classifications suggested by Paradis (see Paradis and Libben 1987;
Chapter 4, for full discussion) and based on the elicited responses on the different
tasks of the BAT, our trilingual patient may be diagnosed as presenting with
transcortical sensory aphasia.
The patient exhibited an alternating antagonistic recovery. After a short initial
period of speaking Farsi, A.S. switched to German and could no longer speak Farsi
for 3 weeks, in spite of insistent requests from his relatives who spoke no German,
then he switched back to Farsi for 1 week, after which time he finally regained
control over his 3 languages.
202 Journal of Neurolin~uistics, Volume 3. Number 2 (1988)
Pointing (23-32)
Simple Commands (33-37)
Semi-Complex Commands (38-42)
Complex Commands (43-47)
Verbal Auditory Discrimination (48-65)
Syntactic Comprehension (66-152)
Sevantic Categories (153-157)
Synonyms (158-I&?]
Antonyms (163-172)
Grammaticality Judgments (173-182)
Semantic Acceptability (183-192)
Repetition (Words) (193-251)
Lexical Decision (194-252)
Repetition (Sentences) (253-259)
Series (260-262)
Verbal Fluency (263-267)
Naming (268-288)
Sentence Construction (289-313)
Semantic Opposites (314-323)
DerivatIonal Morphology (324-333)
Morphological Opposites (334-343)
Mental Arithmetic (347-361)
Listening Comprehension (362-366)
Oral Reading (Words) (367-376)
Oral Reading (Sentences) (377-386)
Reading Comprehension (Paragraph) (387-392)
copying (393-397)
Dictation (~0~s) (398-402)
Dictation (Sentences) (403-407)
Reading Comprehension (Words) (408-417)
Reading Comprehension (Sentences) (418-427)
'arsi
5
4
2
0
12
22
0
0
0
1
10
28
22
1
3
2
4
1
4
4
3
5
0
10
10
0
5
5
1
6
2
German
8
1
0
0
9
23
0
0
0
3
3
28
24
1
1
0
1
0
0
1
5
3
0
g
2
0
5
4
0
5
2
,gl
7
4
2
0
0
18
0
a
0
3
1
28
6
1
0
0
2
0
1
1
2
1
0
10
10
0
4
2
3
7
0
Figure 6. AS’s Comparrmtive Profiie in Far&, German and English on
the BAT (October 1985).
Bilingual Aphasia in Iran 203
CASE 7 (A.L.)
A.L. was a 54-year-old right-handed male who had a left-handed son. His mother
tongue was Armenian but he knew Farsi and Azari very well from childhood. He
had 5 years of elementary school education. His job was to fill up gas cylinders in a
gas company.
Clinical History
The patient lost consciousness on 10 September 1985 subsequent to the explo-
sion of a gas cylinder. While he was pumping in gas the top of the cylinder came off
forcefully, ricocheting off the ceiling onto the left side of his head, breaking the left
parietal bone.
A.L. went into a coma and was hospitalized on the same day. He underwent a
cranial operation which confirmed a lesion in the left parietal region. Upon
regaining consciousness after 3 days, he was aphasic and unable to communicate
verbally. It is reported that he suffered from right hemiplegia and right hemian-
opsia.
Two CT scans were performed. The first one, on 26 November 1985, showed
evidence of the craniotomy. The ventricles were normal, except for minimal
dilatation of the trigone of the left lateral ventricle. The posterior fossa was normal.
The second scan, on 4 February 1986, was performed with contrast injection. It too
showed evidence of the craniotomy. No shift of midline structures was seen. The
ventricles were mildly dilated. The posterior fossa was normal. A left parietal
traumatic lesion was thus confirmed.
Language Assessment (14 March 1985)
The patient’s aphasic deficits were assessed 6 months post-onset. He was
presenting with right hemiplegia and right hemianopsia. He had right facial weak-
ness but was able to whistle. There were no signs of lingual or palatal musculature
paralysis and the patient was able to move his speech organs on request. He was
well oriented in time and space.
A.L.‘s aphasic symptoms were typical of global aphasia. His speech output was
limited to the occasional utterance of “Amen” when he was addressed. We were not
able to elicit spontaneous speech nor a description of the picture story in any of the
3 languages he knew premorbidly. He was only able to hum the rhythm of religious
songs he used to sing at church. His comprehension was limited to simple elements.
He was able to perform simple commands, but not semi-complex commands. We
were not able to administer the other tasks of the BAT because of his limited
comprehension and lack of speech production.
204 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
The pattern of recovery was parallel, in the context of severe global aphasia 6
months post-onset.
CASE 8 (K.R.)
K.R. was a 22-year-old left-handed male native speaker of Farsi. He was the only
left-handed member of his family. He was an intelligent and successful student with
11 years of education. He had started to learn English when he was 5 years old. In
addition to his private lessons in English, he learned English in high school at the
rate of 3 hours per week for 5 years. During the same period he continued his
private lessons. K.R. was considered to have had practical command of English
premorbidly. He was interested in mountain-climbing, which, in fact, led to his
injury.
Clinical History
K.R. had a serious fall from the top of a mountain on 27 July 1982. He went into a
coma and remained unconscious for 50 days. He suffered right hemiplegia and
language loss following the fall. His right weakness gradually improved to normal
as a result of physical therapy, but he continued to have speech problems. After he
regained consciousness, his oral production was limited to “yes” and “no” for a
period of 2 months. At the time of testing he had received speech therapy for 1 year.
The diagnosis was severe cerebral contusion caused by a compound depressed
fracture in a vast area of the left temporo-parietal area. He underwent craniotomy
for the discharge of debris and excision of an epidural hematoma.
Subsequent to the operation, he is reported to have suffered from global aphasia
for a period of 2 months. The first language recovered was Farsi. He claimed that he
did not remember a word of English 1 year post-onset.
K.R. came to the clinic for language evaluation 4 years after his accident. His
main complaints were comprehension problems and difficulty with processing
verbal mental activities.
Language Assessment (23 September 1986)
The patient’s aphasic deficits were assessed with Farsi and English experimental
versions of the BAT. Both versions were administered by the author on successive
occasions (23 and 30 September, respectively). Figure 7 represents the patient’s
Farsi profile and Figure 8 his English profile.
We were able to elicit spontaneous speech in Farsi and, to a limited extent, in
English. His oral production was fluent, cohesive and without signs of paraphasia
or distortion. His writing was normal. As can be seen from the two profiles, the best
recovered language was Farsi. It was also the first to be recovered. Given the extent
Bilingual Aphasia in Iran 205
Fluency (515. 541; 516. 517; 511, 5571
Accuracy (520, 521; 524.5tA; 546, 547; 550-554)
Complexfty (516, 517; 542, 543: 529. 5S5; 530. 556)
Lexical Access (519, 545; 531. 557: 532. 558; 534, 560)
Po1ntfng f23-321
Sjmple Commands (33-37)
Semi-Complex Com;landr (38-42)
Complex Comndnds (43-47)
Vcrbdl Audltory Oiscrinindtion (!,6-65)
Syntactic Comprehension (66-152)
Scmantlc Categories 1153-157)
Synonyns (158-162)
Antonyms (163-172)
Grammaticality Judgments (173-1821
Semantic Acceptabilrty (183-192)
Repetition (words) (193-251)
Lexical Oeclrion (194-252)
Repetition LSentences) (253-251)
Series (260-262)
Verbal Fluency (263-267)
Naming (269-288)
Sentence Constructfon (289-313)
Semantic Opposites (314-323)
Oerivatlonal Horpholoqy (324-333)
Horpho)Ogical Opposites (334-343)
Mental Arithmetic (347-361)
Lirtenlng Comprehension (362-366)
Oral Reading (Words) (367-376)
Oral Reading (Sentences1 (377-3661
Reading Comprehension (Paragraph) (387-392)
copying (393-397)
Dlctrtfon (Words) 098-402)
lictaclon (Sentences) (403-407)
krding Comprehension (Words) (408-417)
7eadlng Coin?rehenrlon (Sentences) 1418-427)
jpontaneous Uriting (813-835)
12 3 4 5 6 7.3 9 10
Figure 7. K.R.‘s Farsi Profile on the BAT (September 1986).
206 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Flvcncy 1515, 54:; 516, 517; 531, 557)
Accuracy (520, 521: 524-528: 545, 547; 550-554)
Corplexity 1516, 517: 542, 543; 529. 555; 530, 556)
Lexical Access (519, 545; 511, 557: 532, 558; 534, 5601
Pointfng (23-321
Sinale Con'nands 133-37)
SC"I:-Complex Corrxalds (38-42)
:c"lp1ex cormdncs (43-471
Vcrbdl Aud!tary Olscrlnination (48.65)
Synt~ctlc Conprchentlon (66-152)
senantic catc~cries (153-15!i
jynalyx ll58-162)
4nwlysS iI63-:72)
;rd?ndt~cdl~ty Jud9mcnts (173-1821
jemaltic Accepcabllrty (183-192)
?epe:>t'zT (uctds) 1193-251)
"erlcal Oeclstor 1194-2521
?epecttion ISeltercesl 1253-25?1
jerles (250-262)
Jerbal Fluency (263-Zfi73
?aa~n~ [259-288)
Sentence Construction (289-3131
Sersntjc Oppsites (314-323)
k'rivatlonal HOrphoiP~ (324-333)
lorphaloglcal Opposites (331-343)
lental Arithrretic (347-3611
lstenfng Co~~tchcnsion (362-366)
rai Readtng (i(ords) 136?-376)
ral Reading (Senten:erl 1377-385)
eadlng Comprehension (Paragraph) (3R7-392)
0pylng (393-397)
ictatlon IYo-es) 1390-402~
tctatton iscltences) 14C3-4D7I
eading Cwprehensicn (Words) (408-4171
cad,ng Corprchenrion (SenCcflCeS) 1418-427)
pontaneoui ur1ting IkIll-8351
i2 3 4 5 6 7 8
Figure 8. K.R.‘s English Profiie on the BAT (September 1986).
Bilingual Aphasia in Iran 207
of his premorbid proficiency in English, the pattern of recovery may be considered
to be parallel at this point, that is, it reflects premorbid relative proficiencies.
K.R. obtained the maximum score on all tasks in Farsi except 3, on which he
scored above 80% and 1 on which he scored above 65%. He had few problems with
syntactic comprehension (79/ 87), semantic categories (4/ 5), repetition of sentences
(6/7) and mental arithmetic (lo/ 15). His overall performance represents an almost
normal score (see Table 4.2 in Paradis and Libben 1987, for the normal error
range).
CASE 9 (S.Y.)
S.Y. was a 42-year-old right-handed illiterate female bilingual speaker of Azari
and Farsi. She was married and had 3 children. Her mother tongue was Azari but
she was fluent in both languages.
Clinical History
On 13 February 1986, S.Y. was sitting with her family when her face suddenly
became red and she fell. She was no longer able to talk nor to move her right hand.
She was hospitalized on the same day. The diagnosis was a CVA syndrome in the
left cerebral cortex. It is reported that she suffered right hemiplegia and right facial
weakness. The diagnosis was later confirmed by a CT scan which revealed an
infarction the size of a quarter in the left fronto-temporal cortex.
The patient was put under medication and was released from the hospital after 7
days. She was advised to have physical therapy and speech therapy. While she was
in the hospital, her aphasic deficit was characterized as global aphasia.
Language Assessment (2 March 1986)
S.Y. was examined in order to evaluate her aphasic deficits 3 weeks post-onset.
She was able to walk but had weakness in her right leg as well as right brachio-facial
weakness. She was unable to whistle. She demonstrated good orientation in time
and space and remembered events before and after the CVA.
The patient was given the Azari and Farsi experimental versions of the BAT.
Spontaneous speech was almost nonexistent in both Azari and Farsi. She was not
able to produce any distinct sound sequences spontaneously. She even failed the
automatic speech task. She repeated words in neologistic forms: none of them were
correct (O/30) in either language.
Her ability to comprehend language was better than her oral expression, but was
limited to simple elements. She did well only on pointing (10 and 8/ 10) and simple
commands (5 and 515). She did poorly on verbal auditory discrimination (12 and
S/18) and syntactic comprehension (12 and 46/87). She scored somewhat better on
208 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Fluency (515, 541; 516. 517; 531, 557)
Accuracy 1520, 521; 524-52A: 546. 547; 550-5541
Camplexlty (516. 517; 542. 543: 529. 555; 530, 556)
Leafcal Access (519, 545; 531. 557: 532, 558; 534, 5601
Polntlng I&321
Slvle Commands (33-17)
Scnl-Complex Cornrnds (38-42)
Complex COrmands (43-47)
Verbal Audftory Olrcr(nfnatfon (46-65)
Syntactic Comprchenrlon (66-152)
Scmantlc Categories (153-157)
Synonynr 1158-162)
Antonyms (163-172)
trarunatlcallty Judgments l173-102)
Semantic Acceptability ll83-192)
Repetltlon (Uordr) (193-251)
Lexical Oeciston (194-2521
Repetition (Sentences) (253-259)
Series 1260-262)
Verbal Fluency (263-267)
Naming (269-288)
Sentence Construction (289-313)
Semantic Opposites (314-323)
Oerivational Horpholooy (324-333)
Morphologfcal OppOSfteS (334-343)
Mental Arithmetic (347-361)
Listening Comprehensfon (362-366)
Oral Reading (Uords) (367-3761
Oral Reading fSentencesl (377-3861
Reading Comprehension (Paragraph) (387-392)
Copyfng (393-397)
Olctation (Words) 098-402)
Dictaclon lkntencesl (403-407)
Reading Comprehension (Uordr) (408-417)
Readlng Comprehension (Sentencer1 (418-4271
,iZ 3 4 5 6 7 8 9 10
spontaneous urltlng (813-8351
Figure 9. S.Y.‘s Azari Profile on the BAT (March 1986).
Bilingual Aphasia in Iran 209
Fluency fSI5. 541; 516. 517; 531. 5571
Accuracy (520. 521; 52P-SZR: 546. 547; 550-5541
Complexity (516. 517; 542, 543; 529. 555; 530, 556)
lexical Access (519, 545; 531. 557; 532, 558; 534, 5601
PolnCln9 (23-321
Stmple Commands (33-37)
Semi-Conpler Coirnands (38-W)
Complex Colrmandr (43-47)
Vcrbsl Auditory D1scrinlnacion (48.65)
Syntactic Comprchenrion 166-152)
semantic categortes 053-1571
Synonyns (158-1621
Antonyms (163-172)
trammaclcality Judgments (173-1821
Semantic Acceptability (163-1921
Repecitlon (uords) (193-251)
Lexical Decision (194-252)
Repetition ISentences (253-2591
Series (260-2621
Verbal Fluency (263-267)
Naming (269-288)
Sentence Construction (289-313)
Semaotfc Opposites (3I4~323)
Oerivational Horphology (324-333)
Morphological Opposites (334-343)
Mental Arithmetic (347-361)
Listenin(l Comprehension (362-366)
Oral Reading (Uordst (367-3763
Oral Reading (Sentences1 (377-386)
Readtng Comprehension (Paragraph) (387-392)
Capylng (393-3971
Dfctation (Words) 6398-4023
Dictation (Sentencer) (403-407)
Reading Comprehension Words) (408-417)
Readfng Cowrehenrton (Sentences) (418-427)
Spontaneous uricing (813-835)
1 2 3 4 5 6 7 a 9 1c
Figure 10. SLY.% Farsi Profile on the BAT (March 1986).
210 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
semi-complex commands (3 and 415) and lexical decisions (17 and 20/30), but she
failed the naming task (0 and O/20) in both languages.
The patient’s residual capacities may thus be summarized as follows: no oral
production, severely impaired comprehension and poor repetition in both lan-
guages. This clinical picture is typical of global aphasia (see Paradis and Libben
1987:219).
The patient’s profiles in Azari (Figure 9) and Farsi (Figure IO) are indicative of a
parallel recovery 3 weeks post-onset. The only differential scores were better
auditory discrimination in Azari (12 and 5/ 18) and better syntactic comprehension
in Farsi (12 and 46/87). The rest of the scores were more or less the same (many of
them with a score of 0) in both languages.
CASE 10 (A.E.)
A.E. was a 48-year-old right-handed educated male speaker of Farsi who knew
English very well as a second language. His English background started with 6 years
of high school and 2 years of college instruction at the rate of 3 hours per week. He
obtained his B.A. in Iran and went to India for further education. He studied at
Indian universities for 10 years and received an M.Sc. and a Ph.D. in Management.
English was the language of instruction and of the textbooks and he wrote his theses
in English. At the time of the accident, he had been teaching at a university for 10
years, using English texts. He was a successful professor with publications in both
English and Farsi.
A.E. became aphasic as the result of closed head injury subsequent to a
motorcycle accident. He was referred to our clinic for evaluation and speech
therapy 3 months after his accident.
Clinical History
A.E. was hospitalized following a severe motorcycle accident on 13 October
1986. He lost consciousness and did not recognize people for 3 days. He was kept
under intensive care. The diagnosis was hemorrhage as a result of closed head
injury. There was no skull fracture or trauma. Two CT scans were obtained after
the accident to support the diagnosis. The first CT scan (4 January 1987) was
performed without contrast injection. The results showed contusion hemorrhage in
the left temporo-parietal area with surrounding infarction. The left lateral ventricle
was collapsed and there was a marked shift to the right. The right hemisphere was
normal. The cerebellum was normal. The second CT scan (24 January 1987) was
performed with contrast injection. The posterior fossa was normal. There was an
area of hypodensity in the left temporal region. The left lateral ventricle was
Bilingual Aphasia in Iran 211
Fluency (515, 541; 516. 517; 531, 557)
Accuracy (520. 521; 524-528; 546, 547; 550-5541
Complerlty (516. 517; 542, 543; 529. 555; 530. 556)
Lexical Access (519, 545; 531, 557; 532. 558; 534, 560)
Pointing (23-321
Sfmple Commands ~33-371
Scml-Complex Corrnands (38-42)
Complex Corrmandr (43-47)
Verbal Audltory Oiscrininatlon (46-65)
Syntactic Comprehension (66-152)
Scmantlc Categorfes IlSl-157)
Synanyns (158-1621
Antonyms (163-172)
Grammaticality Judgments ll73-1021
Semantic Acceptability Il81-192)
Repetition (Words) ll93-251)
Lexical Oeclslon (194-252)
Repetftian (Sentences) it53-2591
Series (260-262)
Verbal Fluency (263-2fi7)
Naming (269-2881
Sentence construction (289-3131
Semantic Opposites (314-3231
Oerlvatlonal Horpholqy (324-333)
Morphological Opposfter (334-3433
Mental Arithmetfc (347-361)
Listening Comprehension (362-366)
Oral Reading (Words1 067-376)
Oral Reading (Sentences) (377-306)
Reading Comprehension (Paragraph1 (387-392)
copying (393-3971
Otctatlon (Words1 (398-102)
Dictation (Sentencer) (403-4071
Reading Comprehensfon (Uordsl (408-417)
Reading Comprehension (Sentences) (418-427)
Spontaneous Writing (813-835)
12 3 4 5 6 7 0 9 10
Figure 11. A.E.‘s Farsi Profile on the BAT (January 1987).
212 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Fluency (515, 541; 516, 517; 531. 557)
Accuracy (520. 521; 52a-528; 546. 541; 550-554)
Complexity (516. 517; 542, 543; 529, 555; 530. 556)
Lerfcal Access (519, 545; 531. 557: 532. 558; 534. 5601
Pofntfn9 (23-32)
Slwle Commands (33-17)
Scml-Complex Cor;ndnds (38-42)
:omplcx Carmandr (43-471
/crbdl Auditory Oircrininatlon (1,6_65)
jyntactlc Comprchenrlan (66-152)
Scmantlc Categories (153-157)
Synonyms (158-162)
intonyms (163-172)
;rannatlcal~ty Judgmcntr 1171-102)
jemantlc Acceptability (183-192)
Iepetitlon (Words) l193-2511
.exlcal Oecfsion (194-252)
lepetftion (Sentences1 (253-2591
ierfes (260-262)
herbal Fluency (263-267)
iamlng (269-2881
ientence Construction (289-313)
jemantic Opposftes (314-323)
krivatlonal Horphology (324-333)
Krphologlcal oppostter (331-343)
lental Arithmetic (347-3611
.Istenlng Comprehension (362-366)
lral Reading (Words) (367-376)
lral Reading (Sentences) (377-3861
leading Comprehension (Paragraph) (387-3921
:opylng (393-397)
IIctatfan (Words1 (398-4021
)1ctatlon ISentences) (403-407)
kadlng Comprehension (Words) (408-417)
leading Comprehensfon (Sentences) (418-427)
ipontaneour Wrttlng (813-8351
12 3 4 5 6 7 8 9 10
Figure 12. A.E.‘s English Profile on the BAT (February 1987).
Bilingual Aphasia in Iran 213
normal. No mass effect or midline shift was noted. No abnormal enhancement was
seen after contrast injection.
The final diagnosis, based on the CT scans, was local atrophy in the left temporal
region as a result of closed head injury. The patient was discharged from the
hospital after 4 weeks. It is reported that his first speech production was in Farsi,
mixed with some Hindi and English neologisms and with distorted syntax.
Language Assessment (31 January 1987)
A.E. was examined on 31 January 1987. He was able to walk and did not have
any gross motor problems. He complained of a slight weakness in his right leg. He
was well oriented in time and space. He remembered events before and after the
accident. His short-term memory span was 5 digits.
The patient’s language capacities were assessed by administering the standard
short version of the BAT (Paradis and Libben 1987: 151) in Farsi and in English.
The Farsi version was given on 31 January 1987 and the English version on 22
February 1987 by the author. Figure 11 represents the results obtained for the Farsi
test and Figure 12 for the English test.
We were able to elicit spontaneous speech and the description of the picture-story
in Farsi only. His writing was very defective and limited in both languages. Three
months post-onset, the pattern of recovery was differential, with Farsi better
recovered than English. A.E. scored significantly better in Farsi than in English.
The patient’s oral expression was fluent but with clear evidence of word-finding
difficulty. His spontaneous writing was very limited and defective at both the
semantic and syntactic levels, in both languages. His oral expression was much
better preserved than his oral comprehension. Even pointing (6 and 4/ 10) and semi-
complex command (2, and O/ 5) tasks are impaired. Verbal auditory discrimination
(8 and 3/ 18) and syntactic comprehension are also impaired in both languages.
Repetition is defective at the sentence level (4 and 3/7) but word repetition (30
and 30/30), automatic speech (3 and 313) and copying (5 and 515) are preserved in
both languages. Reading and writing skills are defective. Reading aloud is relatively
well preserved but reading comprehension is defective.
The clinical picture can thus be summarized as fluent speech with severely
impaired comprehension and word-finding difficulty, but good repetition. The
patient can thus be said to have transcortical sensory aphasia, in accordance with
Paradis and Libben’s (1987) suggested classification.
CASE 11 (P.A.)
P.A. was a 48-year-old right-handed female Farsi speaker. She had a bilingual
high school background and a B.A. in English obtained in England. She had also
NEL 3:2-G
214 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
served as a bilingual secretary for 2 years. Premorbidly, the patient was considered
to be a bilingual speaker of Farsi and English. She lost consciousness as a result of a
CVA on 8 May 1983. She was hospitalized on the same day. The stroke was
diagnosed as the result of thrombosis of the left middle cerebral artery. On the
second day. the patient was described as conscious and as having global aphasia,
right hemiplegia and right central facial paresis. Evidence of agnosia was also
reported in her file.
Two weeks after she had regained consciousness at the hospital, the patient
began to receive physiotherapy. She was discharged from the hospital on 15 June
1983. She reported that she was unable to recognize people or to speak for the first
40 days. Since then, she had received 2 years of physiotherapy and 1 year of speech
therapy in Farsi.
Clinical History
On 9 May 1983 a neurological examination revealed a CVA syndrome in the left
fronto-temporal area. The diagnosis was confirmed by CT scan on the next day,
showing infarction of the left fronto-temporal area due to thrombosis of the left
middle cerebral artery. There was also extensive cerebral edema.
The patient was reported to have been taking cortisone since 2 weeks before onset
as treatment for her condition of total baldness. The EEG performed on 22 April
1983 indicated a general dysfunction of the brain. It showed dysrhythmia with slow
waves (5-6 PCS) around the left occipital area, indicative of CVA background.
On 2 March 1987, 4 years post-onset, a neuropsychological examination re-
vealed central right facial hemiparesis. The patient presented wtth right hemiplegia
but was able to walk without a cane. She was not able to write with her right hand,
but could with her left hand. No hearing impairment was observed. Her visual field
was normal. No symptoms of agnosia or apraxia were observed. She had good
recognition of colours and pictures. Her short-term memory span was 3 digits. The
patient was referred to our clinic for speech therapy. Her main complaint was about
reading and writing.
Language Assessment (2-10 March 1987)
The patient was given the Farsi version of the BAT on 2 March 1987 and the
English version on 10 March 1987. The short versions of both tests were adminis-
tered under the same general conditions by the author. Figure 13 represents P.A.‘s
performance in Farsi and Figure 14 in English. The patient’s performance was
approximately the same in both languages, indicating a pattern of parallel
recovery.
Comprehension was preserved in both languages, but relatively impaired at the
syntactic level. Her speech in Farsi was fluent and cohesive. without paraphasia or
Bilingual Aphasia in Iran 215
Fluency (515, 541; 516, 517; 531, 557)
Accuracy (520, 521; 524-528; 546, 547; 550-554)
Complerlty (516. 517; 542. 543: 529, 555; 530, 556)
Lexical Access (519, 545; 531. 557; 532, 556; 534. 5601
Pofnttng (23-32)
Simple Commands (33.37)
Semi-Complex Conwndr (38-421
Complex Comnandr (43-47)
Verbal Auditory ~~SCri~in~tiOn (48-65)
Syntactic Comptchenrioo (66-152)
Scmanttc Categories (153-157)
Synonyns (158-162)
Antonyms (163-172)
Gramnatfcality Judgments (173-182)
Semantic Acceptability (183-192)
Repetitfon (Uords) 1193-2511
Lexical Oecisfon (194-252)
Repetition (Sentences) (253-259)
Series (260-2621
Verbal Fluency (263-2671
Naming (269-288)
Sentence Construction (289-3131
Semantic Opporltes (314-3231
Oerivstional Horphology (324-333)
~O~phol~g~Cal OppOsfteS (334-3431
Mental Arfthmetfc (347-361)
Lfstenfng Comprehenrfon (362-366)
Oral Reading (Words1 (367-376)
Oral Reading (Sentences) (377-3861
Redding tomprehension (P~rdgraph) (387-392)
copying (393-3971
oictatfon (Words1 (398-402)
Dictation (SentencesI (403-407)
Reading Comprehenslon (Uordrl (408-4171
Reading Co~rehens{on ~Se~tences) (418-4271
spontaneous wting (Ei3-835) I 12 3 4 5 6 7 8 9 II
Figure 13. P.A.‘s Farsi Profile on the BAT (March 1987).
216 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Fluency (515. 541; 516. 517; 531. 557)
ACCUraCy 1520, 521; 524-528; 546. 547; 550-554)
Complexity (516. 517; 542. 543; 529, 555; 510, 556)
Lexical Access (519, 545; 531. 557; 532. 558; 534, 560)
Polntlng (23-321
S(mp1e Commands (31-371
Semi-Complex Corrnands (38-42)
:omplcx Corrmandr (43-47)
dcrbal Auditory Olscrlninatlon (46-65)
jyntactlc Comprchenslon (66-152)
jcmdntlc Categories (153.157)
jynonyns (158-162)
\ntanyms (163-172)
;rafrnatlcallty Judgments 1173-182)
iemantlc Acceptdbllity (183-192)
lepetltfon (Uords) (193-251)
.e*1cal Oecir~on (194-252)
lepetltlon (Sentences) (253-259)
ierfes (260-2621
'erbal Fluency (263-2671
lamlng 1269-288)
ientence Construction (289-313)
iemantic Opposites (314-323)
IerlvatIanal Morphology (324-333)
lorphologlcal Opposites (314-343)
lental Arithmetic (347-361)
.Istenfng Comprehensfon (362-366)
kal Reading (Uords) (367-376)
Iral Reading (Sentences) (377-3861
!eadlng Comprehension (Paragraph1 (387-3921
:apying (393-3971
Ilctatlan (Wards1 (398-4021
Iictatlon ISenterKes~ (403-407)
feading Comprehension (Words) (408-417)
.eadlng CornprehensIon (Sentences) (418-427)
,po"ta"ea"r !,rfttrTg (813-835)
12 14 5 6 7 8 9 10
Figure 14. P.A.‘s English Profile on the BAT (March 1987).
Bilingual Aphasia in Iran 217
neologisms. In English, her production was more limited, as was to be expected,
since she had not used English for the past 4 years. However, no dysfluency was
found in her English.
The patient failed the oral reading and dictation of sentences in both languages.
Poor performance on semantic tasks (synonyms, antonyms), poor sentence repe-
tition, poor sentence construction, poor dictation of words and poor reading
comprehension were also found across languages. The patient’s spontaneous
writing was abnormal in both languages and was limited to a few short phrases.
On the whole, the clinical picture that emerged was one of clearly impaired
repetition (at the sentence level) and fluent oral production in the context of
relatively well preserved comprehension. Her oral reading was abnormal, with
somewhat better reading comprehension. In accordance with the symptomatic
classifications suggested by Paradis and Libben (1987: Chapter 4, for a full
discussion), our patient may be said to present with conduction aphasia.
CASE 12 (P.O.)
P.O. was a 60-year-old male bilingual speaker of Azari and Farsi. with some
knowledge of French. He was right-handed with a familiar history of left-
handedness (his older sister). His parents were native speakers of Azari but knew
Farsi also. His wife and children were unilingual speakers of Farsi. The patient was
born in Iran and educated as a medical doctor there, with 2 years of education in
France.
Clinical History
P.O. became aphasic subsequent to a left CVA on 6 September 1986. He lost
consciousness for a few hours and was kept under intensive care for 5 days
following the CVA. Upon regaining consciousness, he presented with right hemi-
plegia and right facial weakness. It is reported that he could not speak and did not
recognize the people around him for 1 month. It is also reported that his first
attempts to speak were in Azari, 2 months post-onset. For the first 4 months, he
addressed the people around him predominantly in Azari, even his wife and the
other members of his family who were unilingual speakers of Farsi. During this
period the same phenomenon occurred twice with French, when addressing his wife
and the nurse at home. In neither case was he aware that he was addressing people
in an inappropriate language. From January 1987 onwards, his Farsi was stimu-
lated and reinforced by having Farsi classical prose and poetry read to him at home.
Language Assessment (18 April 1987)
P.O. was assessed 7 months post-onset with the short version of the BAT in Azari
2ts fournai of Neurolnguisties, Volume 3, Xumber 2 (1988)
Fluency (515, 541; 516. 517; 531, 557)
Accuracy 1520, 521: 524-52R; 546, 547; 550-5541
Compiexfty 1516, 517; 542, 543: 529, $55; 530. 5561
Lexical RCC&SI (519, 545; 531, 557; 532, 558; 534. f6Ol
Pointing [23-X)
Simple Commdnds (33.37)
Scml-Complex Comdndr 138-12)
Complex Cairmands 143-471
Ycrb31 kudftory Orzcrinfnatfon t&e-6*)
Syntactic tomprehension (S-152)
scrMntic Catcqoric~ 1153-1571
synonynr (158"1621
Antonyms (163-172)
Grdnzxstlcality Judgnentr L!73-1021
Swantic Accepcabilfty ~183-192)
Repetitton Words) l193-251)
Lexical 0ecfsfan (194-252)
Repetition (Sentences) (253-256)
Series 1260-262)
‘r'erbai Flwncy 1263-267)
Namrng (269-288)
Sentence Construction (289-313)
semantic 0pporftes (314-3231
Derivational Motphologj' f324-3331
MorshoToqfcal Opposites ;331-3431
Mental Arithmetic t347-3511
Listening Comprehekion (362-366)
Oral Reading (Words) (367-376)
Oral Reading iSentences 1377-386)
Reading foaprehensfon Waragrapht (387-3921
Copying 1393-397)
Dictation (wordr) (39a-4o2l
01ctatfon Isentences~ (403-401)
Reading CornprehensIon Wards) (408-417)
Rcadfng CoTrprehenafarr isentences (4le-42tt
Figure 15. P.O.% Farsi Profile on the BAT (April 1987).
Bilingual Aphasia in Iran 219
Fluency 1515, 541; 516. 517; 531. 557)
Accuracy (S20, 521; 524-SZA; 546, 547; 550-5541
Complexfty (516, 517: 542. 543: 529, 555; 530. 5561
Leafcal Access (519, 545; 531, 557; 532. 558; 534. 5601
Pointing (23-321
Slir?le Commdnds (33-37)
Semi-Complex Cor?nandr (38-42)
Complex Cormandr (43-471
Verbal Auditory Dlrcrinlnstlon (453-65)
Syntdctlc Comprchenrion (66-152)
Semantic Categories llS3-1571
Synonyns (158-1621
Antonyms (163-1721
Grarmatlcality Judgments 1173-182)
Semantic Acceptabllfty (183-1921
Rcpetl tlon LUardsl (193-2511
Lexical Oeclslon (194-252)
Repetition (Sentences) (253-259)
Series (260-2621
Verbal Fluency (263-2671
Naming (269-288)
Serltence Constructton (289-313)
Semantic Opposftes (314-323)
Derivational Horpholoqy (324-333)
MorpholOglCal OPpOSiteS (334-343)
Mental Arithmetic (347-3611
Listenfng Comprehension 062-366)
Oral Aeadlng (Words) (367-3761
Oral Reading ISentences) (377-386)
Reading Comprehension (Paragraph) (387-392)
Copyfng (393-3971
Ofctatlon (Words1 (398-402)
Dictation (Sentences) (403-4071
Reading Comprehension (Words1 (408-417)
Reading ComQrehenSlon (Sentences) (418-427)
I
12 3 4 5 6 7 8 9 lC
Spontdneous Writing (El)-83.5)
Figure 16. P.O.‘s Azari Profile on the BAT (May 1987).
220 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
and Farsi on two separate occasions. The Farsi version was administered by the
author on 18 April 1987 and the Azari version by M. Dehghan, a senior speech
therapy student and a native speaker of Azari, on 2 May 1987.
The patient was calm and somewhat depressed at this point. He had good
recognition of people and remembered events before and after the stroke. His
short-term memory span was 6 digits. He presented with right hemiplegia and right
facial weakness. He could walk with some difficulty. He could not write with his
right hand.
P.O.‘s performance in Farsi and Azari is represented in Figures 15 and 16.
respectively. The overall picture was almost the same in both languages. Seven
months post-onset, the patient’s spontaneous speech was very limited in both Azari
and Farsi. In Farsi, his description of the picture story was also limited to a total of
21 words in 6 short sentences. There was no evidence of paraphasia or agram-
matism in his speech in either language but he failed to perform the sentence
construction task in both.
It is apparent that the patient’s comprehension was more impaired than his
production. He totally failed listening comprehension and reading comprehension
tasks in both languages. His syntactic comprehension was also impaired (22 and
20/ 38). Thus, we have a picture of fluent speech with impaired comprehension but
relatively good repetition, reminiscent of Wernicke’s aphasia.
CASE 13 (KS.)
K.S. was a 36-year-old right-handed male native speaker of Farsi, with English as
a second language. He completed his high school education in Iran and obtained a
Bachelor’s degree in Engineering in the United States. He had lived and worked in
the United States for 5 years before and 3 years after his accident. He was married
and had two children.
K.S. became aphasic subsequent to a car accident on 5 October 1984. He lost
consciousness and remained unconscious for 25 days as a result of head trauma. It
is reported that he could not recognize anyone for 70 days. He presented with
quadriplegia and could not move for 4 months. The patient was hospitalized until
20 April 1987. He then moved back to Iran for therapy in his mother tongue.
The patient’s language recovery had been very slow over the past 3 years. It is
reported that he was not able to speak either English or Farsi while he was in the
United States. He was first able to communicate linguistically 6 months post-onset,
at which time he was able to write a few single words in English. His first oral
expressions are reported to have been in Farsi 3 years post-onset.
Bilingual Aphasia in Iran 221
Fluency (515. 541; 516, 517; 531. 557)
Accuracy (520. 521; 524-52R; 546, 547; 550-5541
Complexity (516. 517: 542. 543: 529. 555; 530. 556)
Lexical Access (519, 545; 531, 557; 532. 558; 534, 560)
Pointing (23-32)
Simple Colluxndr 03-371
Semi-Complex Comxnds 08-42)
:omplc& Corrmandr (43-47)
Vcrbdl Auditory Dlrcrinination (46.65)
Syntactic Comprehension (66-152)
Semantic Categories (153-157)
jynonyns ll5E-1621
jntonyms (163-172)
kdnwticality Judgments (173-182)
jemantic Acceptability (183-192)
kpetition (Words1 (193-251)
.exical Oecirion (194-252)
lepetition ~Sentencesl (253-259)
Series (260-262)
Yerbdl Fluency (263-267) i I
Namrng (269-288)
Sentence Construction (289-3131
Semantic Opposites (314-323)
Derivational Morphology (324-333)
Morphological Opposites (334-343)
Mental Arithmetic (347-361)
Listening Comprehension (362-366)
Oral Reading (Words) (367-376)
Oral Reading (Sentences) (377-386)
Reading Comprehension (Paragraph) (387-392)
copying (393-3971
Dictation (Words1 (398-402)
Dictation (Sentences) (403-407)
Reading Comprehension (Words) (408-4171
Reading Cavrehension (Sentencer1 (418-427)
Spontaneous Writing (813-835)
12 3 4 5 6 7 8 9 10
Figure 17. K.S.‘s Farsi Profile on the BAT (October 1987).
222 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Fluency (515, 541; 516. 517; 531. 557)
Accuracy (520, 521: 526-528: 546, 547; 550-554)
COmPlelfty (516. 517; 542. 541: 529. 555; 510. 556)
Leafcal Access (519, 545; 531. 557; 512. 558; 534, 560)
Pointfng l23-321
Sfn;ple Commands (13-371
Semi-Complex Canmandr (18-U)
Complcz Cormandr (11-471
Verbal Auditory Olscrfninatton (46-65)
Syntactic Comprchenrlon (66-152)
Semantic Categories (153-157)
Synonyns 1158-162)
Antonyms (163-172)
Granmatlcality Judgments (171-102)
Semdntlc Acceptability l181-192)
Repetition (Herds) (193-251)
Lexical oecision (194-252)
Repetftian (Sentences) (251-259)
Series (260-2621
Verbal Fluency (261-2671
Naming (269-288)
Sentence Construction /289-313)
Semantic Opposites ll14-1211
Oerlvational Horphology 024-1111
Morphological Opposites (314-141)
Mental Arlthmetlc (147-161)
Lfstenfng Comprehension (162-366)
Oral Reading (Words) (167-376)
Oral Reading (Sentences) (177-186)
Reading Comprehension (Paragraph) (387-1921
copying (393-197)
Ofctatfon (Words1 (398-4021
Oictation (Sentences1 (401-407)
Reading Comprehension (Uordsl (408-417)
Reading Con'qrehenrton ISentences) 1418-427)
1
5pontaneous Writing (813-835)
12 3 4 5 6 7 819&
Figure 18. KS.% English Profile on the BAT (October 1987).
Bilingual Aphasia in Iran 223
Language Assessment (19 October 1987)
K.S. was referred to our clinic for speech therapy after he was brought back to
Iran in April 1987. The patient was able to talk but with some difficulty. He suffered
from a deformed right hand, weak facial movements and weak right leg.
The patient was able to recognize the people around him. His short-term memory
span was 5 digits. He exhibited retrograde amnesia for the 8 years that preceded the
accident and did not remember his wife or children.
P.A. was tested by the author with the short versions of the BAT in Farsi and in
English. The Farsi version was administered on 19 October 1987 and the English
version on 21 October 1987 under the same general conditions. Figure 17 shows the
results on the Farsi version and Figure 18 on the English version. Overall, the
patient did better in Farsi than in English. In no task did he score significantly
better in English than in Farsi, but he scored significantly better in Farsi on many
tasks. Three years post-onset, the patient was thus exhibiting a differential pattern
of recovery. Even though he became aphasic in an English environment and
remained there for 3 years, Farsi was recovered better than English.
It was not possible to elicit spontaneous speech from the patient, nor to get him to
describe the picture-story in either language. Spontaneous writing could not be
elicited either. He totally failed the sentence construction task in both languages.
The patient’s linguistic profile may be summarized as nonfluent speech with
relatively good comprehension and repetition. These features suggest transcortical
motor aphasia (see Paradis and Libben 1987: Chapter 4, for full discussion).
CASE 14 (S.I.)
S.I. was a 51-year-old right-handed female native speaker of English with Farsi
as her second language. She was born in the United States and lived there until she
married a native speaker of Farsi. The patient and her family had lived in Iran for
the past 22 years. She had two grown-up bilingual children. It is reported that she
was fluent (though not literate) in Farsi before insult.
The patient received a B.A. in psychology from an American University. She had
taught psychology for a while but for the past 20 years she had been a housewife.
S.I. suffered from a CVA syndrome in July 1979 and was referred to our clinic for
speech therapy, eight and a half years later, in December 1987.
Clinical History
The patient had a history of high blood pressure. She was hospitalized in Tehran
consequent to a CVA syndrome in July 1979. She lost consciousness momentarily.
Subsequently, she suffered from hemiplegia. For the first 18 days, she was not able
224 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
to control her urine. During this period her speech was very limited and non-fluent
in both languages. She was put under medication and given physical therapy at the
hospital. Her right leg improved but her right hand did not improve much.
S.I. was discharged from the hospital after 30 days. She was then able to speak
both English and Farsi. During the second month after discharge, two episodes
took place. She had a fall which resulted in a fracture of the left occipital bone. Her
mother came to visit her from the United States. In the course of an argument, the
patient became very angry and is reported to have lost her speech in both languages
during this incident. She has not been able to speak either English or Farsi nor to
read or write English since August 1979.
The patient was diagnosed as having a left CVA syndrome caused by high blood
pressure. A recent CT scan (June 1987) with and without contrast injection showed
signs of cranial bone fracture in the left occipital area. There were signs of
hypodensity in the left hemisphere as a result of previous hemorrhage and atrophy.
A small calcified area in the left occipital area was also observed. The right
hemisphere was intact. At this point, the patient was alert, nervous and rather
aggressive. She was able to walk with a stick but could not use her right hand.
Language Assessment (December 1987)
S.1. was assessed by the author 8 years post-onset with the English and Farsi
versions of the BAT on 20 and 21 December 1987. She was unable to produce any
distinguishable sound in Farsi. Her English was limited to a few short fixed
expressions. such as “no, no . ” “come on” and “oh dear”. She was not able to write
spontaneously in English. She did not recite series in either language and was not
able to repeat even single words.
A general view of the patient’s residual capacities in English and Farsi is
presented in Figures 19 and 20, respectively. As the results indicate, the overall
performance was almost the same in both languages, thus suggesting a parallel
recovery.
The patient’s oral comprehension was preserved to a limited degree in both
languages. In English, she succeeded in pointing to all 10 objects but was not
completely successful in simple commands (4/5) and semi-complex commands
(3/5). She did very well in verbal auditory discrimination (16/ 18) thus indicating
excellent comprehension of single words, but she was not able to go beyond this
stage in comprehension. For example, she was not able to complete the syntactic
comprehension task. After listening to 3 items, she broke into tears and signalled
that she was not able to concentrate and recognize which picture would relate to
which sentence. The listening comprehension paragraph was read to her. She was
not able to give oral answers but acted as though she had understood the story when
questions were put to her in a multiple choice format. The items in the naming task
Bilingual Aphasia in Iran 225
Fluency (51s. 541; 516, 517; 531. 5571
Accuracy (520, 521; 525.52R; 546, 547: 550-554)
Complexity (516. 517: 562. 543: 529. 555; 530. 556)
Lexical Access (519, 545; 531, 557: 532, 558; 534, 5601
Pointlnp (23-321
Sinple Conaands (33-37)
Semi-Complex Ccinandr (38-42)
Complex Coirmands (43-47)
Verbal Auditory Oircrlninatlon (t&65)
Syntactic Comprchenslon (66-1521
Scmant(c Categories (153-157)
Synonyns fi58-162)
Antonyms (163-172)
Cramnatfcality Judgmcncr l173-102)
Semantic Acceptability 1183-1921
Repetition (Words) (193-251)
Lexical Decisfon (194-2521
Repetition [Sentences) (253-2591
Series (260-262)
Verbal Fluency 1263-2671
Naming (269-2881
Sentence constructton f289-313)
Semantic Opposites 1314-323)
Oerlvational tiorpholoqy (324-3331
Morphological Opposites (334-343)
Mental Arithmetic (347.361)
Listening Comprehension 062-3661
Oral Reading (Words) (367-376)
Oral Reading (Sentences) (377-386)
Reading Comprehenston (Paragraph1 (387-392)
Copying (393-397)
Oictatton Words) (398-402)
Dictation fkotences) f403-407)
Reading Comprehensfon (Uordsf (408-417)
Readlng Cor&w?henslon (Sentences) 1418-4271
Sponcsneous Uriting (813-835)
123456 7 8 9 IO
Figure 19. S.I.‘s English Profile on the BAT (December 1987).
226 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Fluency (515. 541; 516. 517; 531, 557)
Accuracy (520. 521; 524-528; 546, 547; 550-554)
Camplexlty 1516. 517; 542. 541: 529. 555; 510, 556)
Lexfcal Access (519, 545; 511, 557; 512. 558; 534. 560)
Polntlng 121-12)
Slvle Commands (11-17)
Scml-Complex Camandr (18-42)
Complex Commands (41-471
Verbal Auditory Olscrinination (1,6_6S)
Syntactic Comprchenrion 166-1521
Semantic Categories (151-157)
Synanynr 1158-162)
Antonyms (lhl-172)
Grdmmatfcallty Judgmcntr l171-102)
Semantic Acceptability (183-192)
Repetl tlon (h’ords) (191-251)
tealcal Decision (194-2521
Repetition (Sentences) (253-259)
Serler (260-2621
Verbdl Fluency (263-2671
Hamlng (269-288)
Sentence Constructfon (289-313)
Semantic Opposites 1314-321)
Derlvatlonal Horphology (124-3331
Horphological Opposites (314-141)
Mental Arithmetic (347-361)
Ljstening Comprehension (362-366)
Oral Reading (Uordsl (367-3761
Oral Reading (Sentences1 1377-386)
Readlng Comprehenslan (Paragraph) (187-1921
copying ll93-1971
Dictation (Words) (398-402)
Dictation (Sentences1 (401-407)
Reading Comprehension (Words1 (408-4171
Reddlng CamprehensIon lSentenCes) f418-4271
spontaneous Uriting (813-835)
I -I .l 2 14 5 6 7 a 9 10 I
Figure 20. S.I.‘s Farsi Profile on the BAT (December 1987).
Bilingual Aphasia in Iran 221
were presented to her one by one. She indicated that she had recognized all of them
but was unable to provide names.
In writing with her left hand, she was only able to copy single English words.
Beyond copying, her writing skills were limited to writing down numbers from 1 to
20 (in place of saying them orally during the series recitation task).
In Farsi, the patient was not even able to repeat single words. Her oral
comprehension was to some extent preserved, as it was in English. She did well in
pointing (9/ IO), simple commands (4/5) and semi-complex commands (3/5). Her
auditory comprehension at the single word level was relatively well preserved
(14/ 18). She also indicated that she understood the Farsi listening comprehension
paragraph. She was able to recognize all single words in the reading comprehension
task (lo/ 10).
In summary, the patient’s overall capacities were severely impaired in both
languages. She did not produce any speech in either. Her oral comprehension,
based on our assessment, was the same, albeit limited, in both languages. The
patient’s residual language capacities, as assessed with the BAT, support the
diagnosis of global aphasia in both Farsi and English.
DISCUSSION
Each patient’s language profile, as reported in the figures, was based on the
results of the 32 standard tasks of the BAT. With some patients, the short version
(22 tasks) was used. The BAT represents an objective method of assessment. All
measures on the BAT are quantitative. The qualitative clinical picture is obtained
by comparing the scores on the various tasks (e.g. comprehension relative to
production, repetition relative to comprehension and production, naming relative
to pointing, etc.).
Given the large number of possible variables (see Paradis and Libben 1987), one
should not expect definitive answers from such a small sample as the one presented
here. Bilinguals form a heterogeneous population with respect to context of
acquisition, context of use, degree of fluency in each of their languages and the
structural distance between them. Aphasic patients likewise form a heterogeneous
population, with respect to age at onset, months post-onset at time of language
assessment, etiology, site and size of lesion and major aphasic symptoms. It is
therefore not surprising that no correlation can be found between any of these
variables and type of recovery in the bilingual aphasic patients assessed so far in our
rehabilitation clinic.
Indeed, the 14 patients reported here differ from each other on a variety of
dimensions (Table 1). At the time of language assessment, their ages ranged from 22
to 79 years, the time post-onset from 2 to 100 months, their education from 0 to 26
228 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
Table 1
Selected Information on Cases Reported
Case Age Sex Hand Years of Occupation Etiology
Education
1. T.B.
2. H.J.
3. A.A.
4. F.Z.
5. K.N.
6. A.S.
7. A.L.
8. K.R.
9. S.Y.
10. A.E.
11. P.A.
12. P.O.
13. K.S.
14. S.I.
26
63
46
51
79
49
54
22
42
48
48
60
36
51
M
M
M
M
F
M
M
M
F
M
F
M
M
F
R
R
R
R
R
R
R
L
R
R
R
R
R
R
15
16 Retired
I1 Technician
9 Farmer
0 Housewife
25
5
Surgeon
Technician
11 Student
6
22
15
22
16
15
Housewife
Professor
Secretary
Physician
Engineer
Housewife
Student AVM
CVA
CVA
CVA
CVA
Trauma
Trauma
Trauma
CVA
Trauma
CVA
CVA
Trauma
CVA
Abbrevrations. Hand: handedness; L. left; R, right Languages: AR, Armenian; AZ, Azarl; EN. English; FA. Farsi; GE. German
Lesion site: B Frontotemp. bililateral fronto-temporal; L. Left; Mlddle C
Bilingual Aphasia in Iran 229
Table 1 - continued
Lesion
Site
Months Aphasia Languages Recovery Best
Post- Type Pattern Re-
onset covered
L Temporo-
Occipito-
Parietal
L Temporo-
Occipital
L Fronto-
Temporal
L Middle
C Artery
L Middle
C Artery
L Fronto-
Temporal
L Parietal
L Temporo-
Parietal
L Fronto-
Temporal
L Temporal
L Fronto-
Temporal
L Middle
C Artery B Frontotemp
R Occipital
22 Transcortical
8 R Temporal
FA and EN Differential Farsi
4
8
AZ and FA Mixed NA
11
Wernicke’s
R Occipto- parietal
Global AR and FA
22 Amnestic AZ and FA
3 Mixed
Transcortical
Transcortical
Motor
Global
FA and AZ
2
6
FA, GE
and EN
AR and FA
48
2
Mild
Wernicke’s
Global
AZ and EN
AZ and FA
3
46
Transcortical
Sensory
Conduction
FA and EN
FA and EN
8 Wernicke’s AZ and FA
36 Transcortical
Motor
Global
AZ and EN
L Middle
C Artery
100
Parallel NA
Parallel NA
Mixed NA
Antagonistic NA
Parallel NA
Parallel NA
Parallel NA
Differential Farsi
Parallel NA
Parallel NA
Differential Farsi
EN and FA Parallel NA
Artery, area subserved by the Middle Cerebral Artery
Months Post-Onset, number of months post-onset at time of assessment
NA: not applicable
NEL 3:2-A
230 Journal of Neurolinguistics, Volume 3, Number 2 (1988)
years. They also differ with respect to site of lesion, etiology and type and severity of
aphasic symptoms. In addition, four of the patients are global aphasics and their
aphasia is too severe to draw any conclusions from their (!ack of) performance. It is
almost inevitable that global aphasics should exhibit a parallel recovery. In fact, it
is not so much a parallel recovery as a total loss of language capacity. A floor effect
then prevents any diagnosis of differential recovery. Of the remaining 10 patients, 4
exhibited a parallel recovery (2 Wernicke’s, 1 amnestic and I conduction). 3 a
differential recovery (2 transcortical motor and 1 transcortical sensory). 2 a mixed
recovery (1 Wernicke’s and 1 mixed transcortical), and 1 an antagonistic recovery
(transcortical motor). It is important that all patients be assessed, irrespective of the
intrinsic interest of their particular case, so as to avoid a selection bias in the pool of
reported data. That is why even global aphasics, with very little or no expressive
language and with very limited comprehension, have been included in this pre-
liminary report.
Our patients also differed with respect to type and degree of bilingualism. Five
patients had acquired Farsi as a native language and had learned a second language
in high school or college and one had acquired English as a native language and
Farsi in her twenties. Eight patients were brought up bilingually from early
childhood with Armenian or Azari as their home language and Farsi as the
language of their environment and schooling. One of them spoke Armenian in the
home and both Azari and Farsi in the community. One patient was a native speaker
of Farsi who had spoken English as well since age 5. Not all patients used both
of their languages to the same extent. Some continued to have occasion to use both
every day, others had seldom used one of their languages, if at all, in the past several
years Patterns of recovery do not correlate with patients’ age. The age of patients
displaying a parallel recovery ranges from 22 to 60 years (mean age 46.7 years) and
of those displaying a non-parallel recovery, from 26 to 79 years (mean age 50. I
years). The sample is too small to further divide non-parallel patterns into specific
subtypes (3 differential, 2 mixed and 1 antagonistic). For example, the patients with
language mixing are the two oldest in the sample (63 and 79 years of age), but this is
not the trend in the reported literature (Paradis 1977, 1983). Patterns of recovery do
not correlate with patients’ degree of education either. The number of years ot
education range from 0 to 25 (mean 15.6 years) among patients exhibiting a non-
parallel recovery and from 5 to 22 (mean 11.7 years) among those exhibiting a
parallel recovery. Lesions in patients with both parallel and non parallel recovery
patterns are of various etiologies (parallel: 6 CVA and 2 trauma cases; non-parallel:
1 AVM, 2CVA and 3 trauma cases). All cases involve damage to the left hemis-
phere. three of them with some bilateral involvement. Both parallel and non-
parallel recovery patterns are found in patients with lesions injust about any area of
Bilingual Aphasia in Iran 231
the traditional language cortex and with a variety of aphasic symptoms (parallel: 4
global, 2 Wernicke, 1 amnestic and 1 conduction aphasia; non-parallel: 3 trans-
cortical motor, 1 transcortical sensory, one mixed transcortical and one Wernicke-
type aphasia).
In all three cases of differential aphasia, the best recovered language was the
language of the environment which was also the patient’s dominant language. The
two cases of language mixing were found in patients with posterior brain damage
(though in one case, not exclusively). The case of antagonistic recovery involved
languages that were equally fluent at the time of insult, a characteristic shared with
both cases reported by Paradis et al. (1982). A.S., like their first patient, had learned
his second language post-puberty and had used it extensively ever since. Our
patient’s third and less proficient language was eventually recovered to a lesser
degree than the other two, thus reflecting their premorbid order of relative fluency.
From the limited data at our disposal, it would therefore seem that degree of
mastery of each language at time of insult is more important than the context of
acquisition in determining the pattern of recovery. Moreover, pattern of recovery
in the same patient may change over time.
CONCLUSION
Fourteen bilingual or trilingual patients seen consecutively for assessment at the
Language Therapy Clinic of the College of Rehabilitation Sciences in Tehran have
been described. Even though all patients could be considered to have been fluent in
their 2 or 3 languages before insult, they nevertheless displayed 4 different patterns
of recovery. These patterns do not correlate with the patients’ age, degree of
education, lesion site, etiology or aphasia type.
Many more case reports are to be collected from many different research centers
around the world before correlation patterns can emerge. Provided that all patients
are assessed with an equivalent instrument in each of their languages, as is now
feasible with the BAT, it should soon be possible to have a large enough data base to
be able to ascertain what factor or combination of factors influence particular
patterns of recovery. While models of bilingual language processing based on
inhibition/disinhibition (Paradis 1977) and on control, activation and resource
(Green 1986) are beginning to account for the mechanisms underlying non-parallel
recoveries, the factors that determine the choice of the preferentially recovered
language remain problematic.
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