People with aphasia have lost part of their ability to speak, perhaps due to a stroke. They have to painstakingly relearn even the simplest things. Their fate demonstrates how difficult everyday life becomes without language.

Der Schlaganfall erwischte Annette Schultz drei Tage nach der Geburt ihrer Tochter. Intensivstation, Koma, ihr Mann wusste nicht, ob sie das überleben würde.
Ihre rechte Körperhälfte war gelähmt. Und ihre Sprache weg. „Ich habe nur ‚jeb jeb jeb’ sagen können, mehr nicht“, erinnert sich Annette Schultz an die Zeit kurz nach ihrem Schlaganfall. Ein Jahr ist das nun her. „Damals war ich super nörgelig mit meinem Mann, weil ich so frustriert war, dass er nicht wusste, was ich meinte.“

But Annette Schultz was lucky: Her speech slowly returned. "My husband is Australian, and the first words that came back were in English." At first, even the simplest communication didn't work: "I confused yes and no," says Schultz. Today, the young woman can speak passably again. She stumbles occasionally, often unable to remember the words immediately, but then she smiles briefly during the pauses. With a little time, she can express almost everything she wants to say.

Doctors refer to language impairments as aphasia. For most people, language is processed predominantly in the left hemisphere of the brain, which is dominant in these individuals. Two areas are important there, among others: the Broca's area and the Wernicke's area. Aphasia usually occurs when one of these brain regions is damaged. Strokes are the most common cause. However, aphasia can also be triggered by accidents, tumors, brain inflammation, poisoning, or dementia (see info box).

The medical textbook distinguishes between Broca's aphasia, Wernicke's aphasia, and global aphasia, depending on the language problems that occur. Then there is amnesic aphasia, in which people have trouble accessing certain words they want to speak or write (word-finding difficulties). However, they usually manage to replace the word they are looking for with circumlocutions. "They used to call me 'Broca'"

"I used to be called 'Broca' in a support group," says André Laqua, who also suffered a stroke (video: Stroke — Werner Hacke). "Broca because I always spoke in extremely short sentences." This is a typical symptom attributed to people with Broca's aphasia: They are unable to use complex and correct grammar or to conjugate verbs. This is called agrammatism. Furthermore, they are often only able to use content words like "car" or "cake," while omitting function words like "if—then" or "although." Therefore, when they speak, they usually speak in a telegram style, such as: "Go to the cinema, film. Good." From such characteristic speech deficits, the physician Pierre Paul Broca concluded more than 150 years ago that the brain area later named after him could be essential for sentence formation and the application of grammar. Understanding language, on the other hand, is not such a big problem in classic Broca's aphasia. However, recent studies show that some patients have difficulty understanding grammatically complex sentences.

„In meiner Selbsthilfegruppe haben wir auch einen Wernicke“, sagt André Laqua. „Der redet und redet, in langen Schachtelsätzen – aber meist verstehen wir nicht, was er sagen will.“ Menschen mit Wernicke-​Aphasie sprechen oft in sehr komplexen Satzkonstruktionen, die inhaltlich allerdings keinen Sinn ergeben, weil Buchstabenfolgen, Semantik und Syntax durcheinander geworfen werden. Typisch ist zudem, dass Personen mit Wernicke-​Aphasie große Schwierigkeiten haben, das Gesagte des Gegenübers zu verstehen. Wegen solcher Symptome von Personen mit Hirnschädigungen folgerte der Neuroanatom Carl Wernicke, der Namensgeber besagten Areals, bereits im Jahr 1874, dass in dieser Hirngegend eine Art inneres Lexikon sitzt: Dort ordnet das Hirn den Worten eine Bedeutung zu.

"This classic classification into Wernicke's and Broca's aphasia plays no role for us in therapy," says Georg Greitemann. The linguist from the Lengg Clinic in Zurich has been working with people with aphasia for thirty years and is deputy chairman of the Society for Aphasia Research and Treatment. "There are patients who fit the prototypical pattern," he says. "However, many symptoms occur in both Broca's and Wernicke's aphasia." Speech therapists today therefore test all language abilities in each patient and thus set the individual focus for therapy. Recent findings on language

In the second half of the 19th century, the neuroanatomists Broca and Carl Wernicke deduced how the brain processes language from their observations of people with aphasia. This shaped research on the topic for a long time. However, since magnetic resonance imaging has made it possible to observe the brain at work, this knowledge has been greatly expanded (The Network of Language). We now know that there are networks distributed throughout the brain that are important for various language functions. The two classic language centers, Broca and Wernicke, are important parts of these networks, but there are many other areas in the brain that are active when we speak or understand language.

Zudem wird immer deutlicher, dass nicht nur die aktiven Hirnareale von Bedeutung für die Sprache sind, sondern auch die Nervenbahnen, die diese verbinden. So sind zum Beispiel auch das Broca– und das Wernicke-​Areal verknüpft, mit zwei ausgeprägten Nervenschleifen (dual loop). Da erscheint es plausibel, dass eine Schädigung in dem einen Sprachzentrum auch das andere beeinträchtigen kann – so wie es die Sprachtherapeuten seit langem beobachten. Tatsächlich gibt es auch Aphasien, bei denen Broca– und Wernicke-​Areal normal funktionieren, aber eine der beiden Leitungen zwischen ihnen geschädigt ist. Der Mediziner spricht dann von einer Leitungsaphasie. Sowohl Sprachverständnis als auch Sprachproduktion funktionieren bei solchen Patienten normal. Auffällig wird ihr Problem vor allem, wenn sie etwas nachsprechen sollen: Das gelingt ihnen fast gar nicht.

Tedious therapy

"That's the slice of bread..." Annette Schultz breaks off, leans forward, and looks intently at the photo on the table in front of her. She is in a speech therapy session. The photo shows a woman cutting bread. Now she whispers, lost in thought: "That's the slice of bread... that's the slice of bread..." She hesitates and carefully says: "the?" "No, not 'the'," speech therapist Anke Nicklas kindly corrects, offering a helpful suggestion: "How do you rephrase it? The woman is cutting..." "Ah, then it's: That's the slice of bread..." Annette Schultz pauses only briefly, "...that the woman is cutting." For a moment, she looks at the therapist with relief, then puts the photo aside and looks at the next photo in the stack. Anyone who wants to regain their speech must be very patient and diligent.

„Frau Schultz macht sehr schnelle Fortschritte“, sagt Anke Nicklas. „Und wir haben Hoffnung, dass es so weitergeht. Aber eine Garantie gibt es nicht, bei einigen Patienten verringert sich irgendwann die Geschwindigkeit der Genesung deutlich.“ Früher ging man davon aus, dass eine Aphasie spätestens nach zwei Jahren chronisch ist. Doch inzwischen weiß man: Auch noch Jahre später können starke Verbesserungen eintreten.

"I practice every day and still have therapy three times a week," says André Laqua. Today, eleven years after his stroke, he speaks with a similar halting slur to Annette Schultz; some words elude him, others he simply can't pronounce. "Kooapa... Kooapa... I always stumble over the word cooperation," he meant. He never got well enough to return to his job as a vending machine technician. Today, he volunteers, helping a woman in a nursing home—and as chairman of the Berlin Association of Aphasics. His goal: "People should learn about the problems of people with aphasia; they should know that we don't have a mental disability, we simply can't speak well."

Hardly any social contacts

Not everyone deals with their condition as openly as André Laqua. "We conducted a survey among people with aphasia, and many no longer have any social contacts outside of their families," says linguist Georg Greitemann. Some become depressed. "On the other hand, I know people with severe aphasia who live alone and yet can manage their daily lives—and enjoy life." People with aphasia always have to overcome major hurdles, such as when they're asked a question at the checkout and can't answer. Or when they can't name the product they want.

Auch Annette Schultz ist noch weit davon entfernt, wieder zu arbeiten. Sie ist selbstständige Versicherungskauffrau. Das normale Gespräch geht schon wieder halbwegs gut, aber das Telefonieren und das Schreiben fällt ihr schwer. Sie mag ihren Job, und sie ist zuversichtlich, dass sie ihn eines Tages wieder machen kann. Kurz nach ihrem Schlaganfall kam ihr Vater, er ist Arzt, und hat ihr erklärt, was mit ihr los ist. Das war in der Zeit, als sie noch ausschließlich „jeb jeb jeb“ sagen konnte. Sie hat schon damals alles verstanden, Sprache Verstehen war nie ein Problem für sie. Und dann sagte der Vater die entscheidenden Worte: „Das kriegen wir wieder hin.“ Das gab ihr den Optimismus, der sie seitdem durch die vielen Therapien und Reha-​Maßnahmen begleitet hat. Den Optimismus, den sie auch heute ausstrahlt.

zum Weiterlesen:

• Saur D et al, Ventral and dorsal pathways for language, PNAS, September 2008, Vol. 105 (46); 18035 – 18040,
• Psycholinguistik, hg. von Barbara Höhle, Berlin (2012)
• Bundesverband für die Rehabilitation von Aphasikern e.V. www​.aphasiker​.de

Aphasien bei Demenz

Dementia can also lead to aphasia. It usually begins with word-finding difficulties, then the patient forgets individual words, later loses entire sentences, and finally, speech disappears completely. The cause is the increasing deterioration of the brain's neurological functions, which can also affect the language centers. In fact, progressive language disorders are an important symptom for diagnosing dementias such as Alzheimer's. In primary progressive aphasia and semantic dementia, language disorders are even the predominant symptom in the early stages: In primary progressive aphasia, the nerve cells of the left frontal lobe are primarily destroyed. The result is aphasia of both spoken language and language comprehension, reading, and writing. What is striking about patients with semantic dementia is that although they can still pronounce words, they have forgotten their meaning—i.e., their semantics. The patient's memory and behavior are not impaired—at least in the initial stages of the disease.