Paraphasia

Many speech and neurological pathologies are accompanied by such a disorder as paraphasia. It is a peculiar replacement of necessary syllables, letter or sound elements, words with other elements that are inappropriate for the situation or norm. Paraphasia is characteristic of people suffering from brain lesions (strokes, trauma, tumor or inflammatory processes), lack of speech or its underdevelopment, dementia of various etiologies. In all situations, paraphasia is not an independent pathology, but a symptom, so the degree and quality of correction depends on the treatment of the underlying disease.

Epidemiology

Over the last decade, there has been a marked increase in the frequency of speech pathologies, as well as an increase in the prevalence of complicated cases. Thus, there are often combined disorders, which are not limited to paraphasia alone.

Speech and mental defects are especially common among children of early and preschool age: the average age for pediatric paraphasias is 3-7 years. The period of the start of the pathology depends on the time when the etiological factor that provoked the lesion of certain areas of the cerebral cortex occurred. Often such etiological factors are tumor processes, aneurysms, hematomas, brain abscesses, encephalitis.

According to some data, paraphasias are more often diagnosed in male representatives (about 60% of cases). It has been proven that the left and right hemispheres differ depending on gender. The left hemisphere dominates the realization of speech function, while the right hemisphere is responsible for visual-spatial perception. Girls have better compensation for brain damage and early formation of interhemispheric interaction.

Poststroke paraphasias are diagnosed in more than 30% of stroke patients, which is associated with damage to speech areas of the cerebral cortex. [1]

Causes of the paraphasias

Paraphasia in speech therapy, in neuropsychology can appear as a result of negative factors or circumstances that can affect both externally and internally, or combine with each other. Specialists point to the prevalence of such pathological causes:

• Intrauterine disorders that cause abnormal fetal development. The future child is most vulnerable in the first third of pregnancy. When exposed to harmful factors during this period, the risk of abnormal formation or damage to the central nervous system of the fetus, and in particular to the speech areas of the cerebral cortex, increases.
• Genetic predisposition, hereditary anomalies. The peculiarities of the speech mechanism can be passed on from generation to generation. For example, there may be a predisposition to improper development of speech areas of the brain. In a family where there have already been cases of paraphasia, such a problem may occur in subsequent generations.
• Disturbances and exposure to harmful factors during the birthing period.
• Pathologies (diseases or injuries) that the baby suffered during early development.
• Various functional disorders. Emotional communication with relatives, interaction with the environment, satisfaction of cognitive processes are extremely important for an infant.
• Vascular disease, cerebral vascular disease, ischemia, aneurysms, hypoxia conditions and circulatory disorders.

In adult patients, paraphasias are capable of developing for these reasons:

• trauma;
• circulatory disorders in the brain;
• infectious processes affecting the brain;
• thromboembolism;
• aneurysms;
• brain tumors and cysts.

Immediate risk factors play a special role and should be addressed. [2]

Risk factors

Immediate triggering factors may include:

• intrauterine oxygen deprivation - in particular, against the background of toxemia in any half of pregnancy, high blood pressure, somatic pathologies of the future mother (diabetes, cardiovascular disorders, etc.);
• bacterial and viral infections a woman has had during pregnancy (influenza, coronavirus, rubella or measles, tuberculosis, scarlet fever, toxoplasmosis or hepatitis, syphilis, herpesvirus or HIV);
• Traumatic injuries (trauma to the abdomen during pregnancy can provoke placental abruption and premature labor);
• Rhesus conflict;
• prematurity or prematurity of the baby;
• use of alcoholic beverages and drugs, smoking;
• Taking certain medicines that are not allowed for pregnant women;
• environmental problems, pronounced iodine deficiency in the body;
• stressful conditions;
• birth traumatization, craniocerebral injuries, intracranial hemorrhages affecting the speech areas of the brain;
• inadequate oxygen supply to the brain;
• ischemic stroke;
• low birth weight, need for intensive resuscitation (e.g. Prolonged ventilation);
• infectious diseases, neuroinfections (meningitis, meningoencephalitis) that can damage the central nervous system;
• trauma and contusions to the brain and facial skeleton;
• prolonged colds, inflammatory processes in the middle and inner ear;
• negative social and living conditions, staying in dysfunctional families, psychological traumas, scares, stress.

Pathogenesis

Paraphasias can be formed as a result of the influence of all sorts of unfavorable circumstances on the baby's brain, and at all further stages of its development. The structure of such disorders is different, which depends on the period of exposure to a harmful factor, and the location of the affected area.

When it comes to immature brain damage, there is no complete correlation between the location, the extent of the lesion and the likelihood of adverse effects in terms of the development of paraphasia. Experts have confirmed that congenital or early acquired left hemisphere pathology in childhood does not lead to paraphasia as often as similar lesions in adulthood. Brain adaptation is largely determined by the immaturity of its structures.

In adults, paraphasias appear predominantly when the dominant left hemisphere is affected. In children, their appearance is characteristic of biphemispheric lesions: in addition, even with damage to the right hemisphere, it is possible to develop pronounced speech problems.

Therefore, when evaluating the influence of exogenous-organic causes on the appearance of paraphasia in children, it is necessary to take into account the time, nature and location of the lesion, the type of adaptation of the nervous system, as well as the degree of formation of speech functions at the time of exposure to the provoking factor.

Transient paraphasia is often observed in transient ischemic attacks, migraines, and epilepsy. The appearance of paraphasia on the background of a transient ischemic attack is considered to be one of the unfavorable factors indicating the probability of rapid stroke development in adults.

Gradually increasing paraphasia can be a sign of neurodegenerative pathology - in particular, frontal temporal degeneration, Alzheimer's disease and so on. [3]

Symptoms of the paraphasias

The basic symptoms of paraphasia are considered to be:

• loss of speech meaning;
• disturbed, garbled speech;
• inappropriate, incorrect use of certain sounds, words;
• inappropriate pace of utterances;
• haste in statements, a large number of mistakes, substitution of words.

The first signs of paraphasia are manifested by replacing necessary speech sounds or words with not quite appropriate analogs, incorrect use of sounds and words. The patient may replace the necessary words with words close in meaning. Specialists note that paraphasia is characterized by a large number of violations, including complete distortion and use of words that do not exist in the language, as well as the use of combinations that due to distortion acquire another, not quite appropriate meaning.

• It is possible to replace the required word with another one, without reference to the meaning or form of the required statement.
• There is often no connection between the required word and the spoken word.
• The required word may be replaced by a phrase or a whole phrase that has no semantic or audible connection to the required item.

The presence or absence of articulatory difficulties is not specific. There is often a combination of symptoms: for example, when it is impossible to distinguish sounds by ear, there are numerous paraphasias and perseverations, echolalia, and contamination. Articulation becomes approximate and speech meaning is lost.

Stages

Mental development is the basis for normal speech function. Various disorders, inhibition and failures of formation of mental processes in most cases lead to certain speech disorders, including the appearance of paraphasia. Usually talk about such degrees of this disorder:

• Mild paraphasia, often combined with retarded motor and mental development;
• rough paraphasia, accompanied by profound disorders of all speech sides and may be combined with a pronounced disorder of mental development;
• sharp paraphasia, associated mainly with organic lesions of the central nervous system.

Forms

The name paraphasia is made up of Greek words such as "para" (near) and "phasis" (speech). Therefore, literally, the term can be translated as "inaccurate expression". The essence of the pathology is a partial or complete replacement of a verbal element with another, unsuitable for the structure and meaning of the statement. At the same time, substitutions can occur both during conversation and when writing or reading: such disorders are called, respectively, paragraphia and paralexia.

In modern speech therapy practice, specialists use several types of paraphasia: literal (aka phonemic), verbal, mirror and semantic.

• Verbal paraphasias are characterized by the use of an incorrect word that does not correspond to the cue, but is not far removed in meaning and type (for example, "air" instead of "wind", etc.). This type of paraphasia is related to semantic and mnestic pathology and often develops against the background of a disorder in the temporoparietal region.
• Litteral or phonemic paraphasias are "errors" in separate sound, letter or complex elements within a single word (e.g., "lawn" instead of "vase", etc.). Such literal paraphasias are explained by a disorder of motor or sensory speech monitoring, which occurs in frontal areas.
• Semantic paraphasias occur in lesions of the parieto-occipital zone of the dominant-speech hemisphere. The disorder is accompanied by the appearance of difficulties in selecting the necessary word or arbitrary naming of things. Patients, instead of a clear verbal definition, call a description of the object.
• Mirror paraphasias are characterized by the division of a word into several parts, with one of the parts being pronounced backwards (for example, "canardash" instead of "pencil"). It is noteworthy that the suggestion to read "mirror" written phrases and words does not cause difficulties in such patients.

It should be noted that paraphasia is rarely found in only one variant. More often there is a combination of two or three types of pathology, with different intensity of manifestation. Thus, the patient's speech may have a different pace, with letter or word omissions, repetitions and substitutions, diction disorders. When it is necessary to say a deliberately complex phrase, patients resort to its shortening and simplification. [4]

Complications and consequences

Complications of paraphasia are primarily relevant for pediatric patients, as the speech disorder leads to problems in learning and socialization:

• reading and writing are impaired;
• Difficulties with schooling appear as a result of incorrect sound perception;
• There are difficulties in the sphere of communication, both with peers and adults;
• there are psychological problems.

Mental retardation and lowering of intellectual abilities are not uncommon consequences. With the beginning of the educational school process increases the likelihood of the development of deficiencies similar in mechanism of formation: we are talking about dysgraphia, dyslexia, dyscalculia. As a result, children have a higher risk of forming an inferiority complex.

Post-stroke and other paraphasias can lead to withdrawal, depression, and neuroses.

Diagnostics of the paraphasias

During the initial neurological consultation, the doctor interviews and examines the patient, collects information about the medical history, determines the neurological status of the patient. It is important to assess the presence of damage to the nervous system: abnormalities in the functionality of cranial nerves, extrapyramidal disorders, disorders of motor coordination and sensitivity, dysfunction of the autonomic nervous system.

Consultation with a geneticist may be relevant, particularly in the case of insufficient psycho-verbal or motor development of the child, disorders in the emotional, volitional and cognitive spectrum. It is necessary to clarify the causes of developmental defects, both single and multiple. If metabolic pathologies provoked by gene mutations are detected, the treatment will be fundamentally different.

To find out the causes of paraphasia sometimes requires non-specific laboratory tests, such as general blood and urine tests, hormonal status, etc.

Instrumental diagnostics is most often represented by electroencephalography - the main and highly informative diagnostic method. Based on the study of biometric brain activity, it is possible to confirm or exclude some pathologies with a hidden course - in particular, symptomatic epilepsy. Electroencephalography is prescribed by a neurologist in the presence of appropriate indications.

Almost all cases of paraphasia require consultation with a speech pathologist-defectologist, who assesses the degree of speech development, identifies individual characteristics of the patient, determines the communicative abilities and the breadth of the cognitive and emotional-volitional spectrum.

The clinical and therapeutic outcome of the diagnosis is formed by a neurologist. If necessary, the doctor prescribes drug treatment and gives personal recommendations for correction of the identified disorders.

If it is not possible to find out a clear root cause of paraphasia, then a complex diagnosis is prescribed, the purpose of which is to clarify and recheck the identified violations, followed by the appointment of effective treatment.

Differential diagnosis

When conducting basic diagnostic measures, it is important to pay attention to the presence of intellectual, speech, motor or sensory deficits, to assess the probability of one or another cause or mechanism of developmental disorders, to determine the educational and social prognosis, as well as possible directions and methods of correction of paraphasia.

Studies should exclude the presence of:

• of irreversible mental retardation;
• mental retardation (fully or partially reversible);
• damaged mental development (dementia, provided previously normal mental development);
• deficit development (visual or auditory impairment, somatic diseases);
• distorted mental development (infantile autism);
• mental disharmony (psychopathy).

Paraphasias must be distinguished from general developmental disorders such as autism, oligophrenia, elective mutism, and general and systemic speech impairment.

Treatment of the paraphasias

Treatment for paraphasia is aimed at correcting the underlying pathology, and also includes neurorehabilitation measures aimed at restoring and adapting the functionality of the psyche and speech development. In general, the following methods are indicated:

• physical therapy;
• drug therapy;
• psychotherapy;
• occupational therapy;
• speech therapy sessions;
• psychological and social compensation measures.

Treatment is started only after the area has been identified and the degree of damage has been assessed. Specialists such as a speech therapist, neuropsychologist and aphasiologist are involved in the direct restoration of speech activity. Among the most common medications indicated for paraphasia are nootropic drugs: Piracetam, Nootropil, Deanol, Meclofenoxate, etc., which can be used in the treatment of paraphasia.

Let's break down each of the treatment methods in more detail.

• Drug therapy, in addition to nootropic drugs, may include taking antihypoxants and antioxidants - medications that optimize the body's absorption of oxygen and improve tissue resistance to hypoxia. Among the most well-known drugs of this group are: Carnitine, Glutathione, Actovegin, Levocarnitine. When indicated, anticonvulsants and vasoactive agents are prescribed.
• Physiotherapy is used at the stage of active recovery. Physical therapy is recommended, and among physiotherapeutic methods, darsonvalization, mechanotherapy, transcranial micropolarization and electrostimulation are the leading ones.
• Neuropsychological support consists in the elimination of speech negativisms, stimulation of interhemispheric links, adjustment of higher mental functions, inhibition of the growth of cognitive insufficiency. In this therapeutic aspect, children are provided with game therapy. Patients regardless of age are shown neurodynamic gymnastic training, autotraining, psychotherapeutic sessions. Psychological support is provided not only to the patient, but also to his family and close people.
• Speech therapy is required to correct speech disorders. It includes the restoration of motor and sensory components of speech, depending on the structural features of the pathology. When the motor component fails, articulation gymnastic exercises, speech therapy massages, muscle electrical stimulation are practiced. Many patients are shown stimulation and disinhibition of speech, expansion and strengthening of the vocabulary. In sensitive speech disorders, they try to activate auditory cognition, develop differentiated perception of speech sounds, form an understanding of speech by ear, and train auditory, speech and visual memory.

Depending on the detected disorders, the doctor draws up an individual program of speech restoration. It should be taken into account that in paraphasia the patient should not have any speech restrictions, so relatives and family members of the patient should become an integral part of the recovery process. Their task is to support the patient's speech activity, help in consolidating the skills he receives during counseling and classes. Speech therapy exercises must necessarily be supplemented with physiotherapeutic procedures, physical therapy, massage, psychotherapy, and, if necessary, medication support.

Prevention

Specialists suggest the following measures to reduce the incidence of paraphasia:

1. Educate expectant parents about leading a healthy lifestyle to have healthy children and all patients about the dangers of smoking, drugs and alcohol.
2. Timely register pregnant women to monitor the course of pregnancy, correction of concomitant disorders.
3. Organize psychological support for expectant mothers and their preparation for childbirth.
4. Avoid professional referrals known to be harmful to the health of pregnant women and future children.
5. For infants and preschool children, consult a pediatric neurologist to monitor development.
6. To promote the proper development of children in the family, to create a trusting, developing environment.
7. If necessary, to connect speech therapy in a timely manner, to create all necessary conditions for speech correction.
8. Limit your toddler's time in front of the computer, TV, smartphone.
9. Avoid stressful situations, keep a good-natured atmosphere in the family.
10. Popularize active and healthy lifestyle, strengthen adaptive abilities.

Forecast

Treatment of paraphasia is usually long, lasting several months or even years. In many cases, the patient's speech is not completely restored, but the final result depends on the cause of the disorder, the timeliness of medical intervention, and the extent to which the original cause can be eliminated. The presence of paraphasia significantly reduces the quality of life of both patients and their immediate environment. In addition, patients with post-stroke paraphasias have a higher risk of death compared to patients with strokes but without speech disorders, and have a longer hospital stay.

The likelihood of recovery of speech function depends on the location and extent of brain damage. Younger patients with a normal level of speech and intellectual development have a more optimistic prognosis. If we compare post-stroke patients, paraphasia is easier to eliminate after hemorrhagic stroke.