Aphasia (https://www.nhs.uk/conditions/aphasia/) is sometimes known as ‘dysphasia’. It is a language disorder that occurs when the brain is damaged. In most people, language is processed in the left side of the brain. Damage to this can affect a person’s ability to understand, talk, read or write or sign. The severity may be mild to profound. Understanding A person with aphasia cannot understand other people’s words, especially if they are complex, or lengthy utterances or spoken fast. Those with profound or severe aphasia may not consistently understand simple, single words such as ‘cup’, ‘pen’ or ‘bed’. Those with mild to moderate aphasia may struggle with sentences like, “The carpet the cat is on is red” or “The dog is chased by the cat”. “People with a cervix” is definitely much harder to understand than “women”. https://static.wixstatic.com/media/18f02a_2237bbadb66b449e99d811272f5735b4~mv2.webp It’s also more difficult to understand what people are saying in loud or busy environments even if the person can hear perfectly well. It can also be tricky to understand jokes. Talking When it comes to expressing language, many people with aphasia experience word-finding difficulties. This is a bit like the tip of the tongue phenomenon we all experience from time to time but turned up to the max. Many people will say they know the word in their head but cannot say it out loud, “We had a really lovely time, we went to… er, you know, … that place, so yeah, it was nice.” It is common for people to say the wrong word. Sometimes it shares a category or sometimes it sounds similar, and sometimes both. Or sometimes it’s completely unrelated. For example: Target word is “Dog”. A person with aphasia could say: • Cat • Og • Dat • D d d d d • Pet • Animal, four legs, barks • Fido • Bird • Cup • It was this, when I had it, so they went there and all…yes, it was, ah. This means that a person with aphasia could also mix up any word including those that require knowledge of biological sex, so “man” for “woman” and vice versa, when in fact he knows what sex the individual is but accidentally says the wrong word from the same category (nouns for the sexes). Sometimes parts of words and their sounds get switched around so instead of saying “postman” the person says, “mostpan”. Some words are completely unintentionally made-up such as “workle”, “daffgo”, or “sweetch”. It is usually easier to say single words or phrases that come easily rather than whole sentences. So she might be able to say, “tea”, “toilet”, “hairbrush” or count to ten or say the days of the week in order but cannot say, “There were two of us who went out to tea on Monday”. And sometimes made-up words are used with real words in a sentence but it doesn’t make sense, “I went to the fingle for the datter and it was all libbered”. People with hearing impairment who use sign language are also affected by aphasia. (1) Sign language is language and understanding or expression can be impaired. If it’s difficult to understand and/or express the spoken or signed word, then it is also difficult to read or write, use numbers, count/do maths or tell the time, either consistently or at all. Agrammatism There is also an aspect of aphasia called agrammatism. This means that the person with aphasia cannot understand or use certain aspects of grammar effectively, including pronouns. In one study (2), the difficulty understanding pronouns in discourse is stark. Around one-third fewer of people with aphasia compared to healthy subjects could not understood pronouns in discourse. PWA = Person With Aphasia CG = Control Group (healthy adult speakers) SG = Subject Group (PWA) F = Fluent Aphasia NF = non-fluent aphasia https://static.wixstatic.com/media/18f02a_31a92b2f7783455088ccfde883472cdf~mv2.webp When it comes to expression, there is a common resource for assessing aphasia that Speech and Language Therapists (or Speech-Language Pathologists) use called “The Cookie Theft picture”. (I rather enjoy how utterly stereotypical this. There have been attempts to update this picture but that’s a whole other blog). The Cookie Theft Picture https://static.wixstatic.com/media/18f02a_83de0f58e7ce49d585fb0e6dc1aedfba~mv2.webp Here’s an example of an agrammatic response (3) to looking at this picture: B.L.: Wife is dry dishes. Water down! Oh boy! Okay. Awright. Okay… Cookie is down ... fall, and girl, okay, girl ... boy ... um… Examiner: What is the boy doing? B.L.: Cookie is ... um ... catch Examiner: Who is getting the cookies? B.L.: Girl, girl! Examiner: Who is about to fall down? B.L.: Boy ... fall down! Not a pronoun in sight. When it comes to aphasia, there is a great deal of heterogeneity in pronoun processing. (4) This means that treatment or support for the problem is per individual. There is no one way to approach the difficulty. Demands to use preferred pronouns or gender-neutral language thus make it more difficult for the person with aphasia to communicate. Here are two examples of different types of aphasia. Non-fluent: https://youtu.be/JWC-cVQmEmY Fluent: https://youtu.be/3oef68YabD0 References: (1) Goldberg E,B., Hillis, A.E. 2022. Sign language aphasia. Handb Clin Neurol.;185:297-315. https://doi.org/10.1016/B978-0-12-823384-9.00019-0(https://doi.org/10.1016/B978-0-12-823384-9.00019-0) (2) Devers, C., Howard, D., Webster, J. 2016. Pronoun Processing in People with Aphasia. In: 2016 International Aphasia Rehabilitation Conference, 14 December 2016- 16 December 2016, London, UK. https://eprints.leedsbeckett.ac.uk/id/eprint/4217/(https://eprints.leedsbeckett.ac.uk/id/eprint/4217/) (3) Avrutin, S. 2001. Linguistics and agrammatism. GLOT International, 5 (3), 111. (4) Martínez-Ferreiro, S., Ishkhanyan, B., Rosell-Clarí, V., Boye, K. 2019. Prepositions and pronouns in connected discourse of individuals with aphasia. Clinical Linguistics & Phonetics. 33:6, 497-517, https://doi.org/10.1080/02699206.2018.1551935(https://doi.org/10.1080/02699206.2018.1551935)

These are different diagnoses arising from different causes but all result in difficulties with speech and how clearly the person comes across to the listener. Apraxia of speech(https://www.esht.nhs.uk/service/speech-and-language-therapy/patient-information-leaflets/information-about-acquired-speech-dyspraxia/) A person with apraxia of speech has usually had a stroke or brain injury. It is a motor-programming disorder. They will pronounce words in different ways on each time of trying. And that’s if they can get the word out at all. They may pronounce the target word “window” as: • W w w w w… • Dindow • Wintow • Derwin • Wodow • Wind • Ow • Glafit • Nerwit Etc. Imagine insisting someone with apraxia of speech consistently pronounces neopronouns. Here’s an example of apraxia of speech in an adult: https://youtu.be/1v14VErixcY Dysarthria(https://www.nhs.uk/conditions/dysarthria/) A person with dysarthria has a muscle weakness or reduced range of movement of the muscles for articulation or they just can’t get an accurate word sound out. There are lots of different types of dysarthria depending on the cause, which could be a stroke, brain injury or neuro-progressive disease or a developmental cause. So dysarthria presents in lots of different ways and each individual with dysarthria may be clearer at one time of day or another or easier to hear in a quiet room on 1:1 than in a busy, noisy environment. The ASHA website (https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/#collapse_2) details how many different speech characteristics can be involved. Imagine expecting someone with Huntington’s Disease to achieve clarity of speech when differentiating “he” or “she” or using a neopronoun when their speech may be significantly impaired. Dysarthria speech characteristics https://static.wixstatic.com/media/18f02a_8f6b13c560414d8db448ed36f1ace625~mv2.jpg Here’s an example of speech in an adult woman with dysarthria: https://youtu.be/R3VETCtPW9k Dysfluency(https://www.nhs.uk/conditions/stammering/) You may understand this best as ‘stammering’ or ‘stuttering’. Some adults have had this since childhood, others acquire it after a stroke, brain injury, neuroprogressive disease or mental health condition. Dysfluency comes with many outward and inward (https://michaelpalincentreforstammering.org/about-stammering/adults/what-is-stammering/)a(https://michaelpalincentreforstammering.org/about-stammering/adults/what-is-stammering/)spects.(https://michaelpalincentreforstammering.org/about-stammering/adults/what-is-stammering/) https://static.wixstatic.com/media/18f02a_e9f59b55e3084c6aaab3120ce49bec52~mv2.webp And by the way, there are sex differences (https://www.nhs.uk/conditions/stammering/#:~:text=sex%20differences%20and%20genes)in stammering.(https://www.nhs.uk/conditions/stammering/#:~:text=sex%20differences%20and%20genes) It’s more common in males. Quite how you would expect someone with any of these articulatory communication disabilities to consistently express any word is utterly unreasonable. Here is an example of a young man whose speech is dysfluent: https://youtu.be/3Rz18q3p-zY

A cognitive-communication disorder (CCD) can be the result of stroke, brain injury, neuroprogressive diseases, and mental health conditions. It can affect: • Attention (selective concentration) • Memory (recall of facts, procedures, and past & future events) • Perception (interpretation of sensory information) • Insight & judgment (understanding one’s own limitations & what they mean) • Organization (arranging ideas in a useful order) • Orientation (knowing where, when, & who you are, as well as why you’re there) • Language (words for communication) • Processing speed (quick thinking & understanding) • Problem-solving (finding solutions to obstacles) • Reasoning (logically thinking through situations) • Executive functioning (making a plan, acting it out, evaluating success, & adjusting) • Metacognition (thinking about how you think) Are you really expecting someone who has CCD to use preferred pronouns or know what this sign means? Ronnie Barker in the Ministry of Sex Equality sketch https://static.wixstatic.com/media/18f02a_77747e23db344e7a944b3c44a4b11069~mv2.webp Here’s a man explaining some of the problems he had at work arising from cognitive problems after a brain injury: https://youtu.be/V5c2K-bG6p4 and this is a good interview that summarises the problems: https://youtu.be/UQJ3VFvT7SA Dementia(https://www.nhs.uk/conditions/dementia/) One group of people who experience CCD are those with dementia. Language difficulties are recognised as a major problem for people with dementia (5). There are many different types of dementia and each individual has specific cognitive-communication difficulties. However, it is well recognised that people with Alzheimer’s disease dementia experience (6): • Impaired understanding of pronouns • Abnormal over-use of pronouns • Working memory impairment And that it is best that conversation partners avoid pronouns in favour of “concrete, specific and simple words”. (7) The ability to process pronouns, indeed any language elements, is diminished in all dementia types.(https://www.alzheimers.org.uk/about-dementia/types-dementia) • Alzheimer’s disease • Vascular dementia • Mixed dementia • Dementia with Lewy Bodies • Frontotemporal dementia • Young-onset dementia • Creutzfeldt-Jakob disease (CJD) • Alcohol-related dementia • HIV-associated neurocognitive disorder (HAND) • Mild cognitive impairment (MCI) • Learning disabilities and dementia • Rare dementias Again, is it reasonable to expect that someone with any of these difficulties could understand, process and/or use preferred pronouns or gender-neutral language consistently and effectively? Here’s a video that shows how difficult it is for a man with Alzheimer’s Disease dementia to process sounds and language: https://youtu.be/9dBcPL29XLU References: (5) Banovic S., Zunic, L.J., Sinanovic, O. 2018. Communication Difficulties as a Result of Dementia. Mater Sociomed. Oct;30(3):221-224. https://10.5455/msm.2018.30.221-224 (https://10.0.21.79/msm.2018.30.221-224) (6)Almor, A., Kempler, D., MacDonald, M. C., Andersen, E. S., & Tyler, L. K. 1999. Why Do Alzheimer Patients Have Difficulty with Pronouns? Working Memory, Semantics, and Reference in Comprehension and Production in Alzheimer's Disease. Brain and Language, 67(3), 202–227. https://doi.org/10.1006/BRLN.1999.2055(https://doi.org/10.1006/BRLN.1999.2055) (7) Rau, M. T. 1993. Coping with communication challenges in Alzheimer’s disease. San Diego, CA: Singular. pp77.

Psychosis is the word used to describe conditions that affect the mind. As the NIMH point out,(https://www.nimh.nih.gov/health/publications/understanding-psychosis) Psychosis may be a symptom of a mental illness, such as schizophrenia or bipolar disorder. However, a person may experience psychosis and never be diagnosed with schizophrenia or any other mental disorder. There are other causes, such as sleep deprivation, general medical conditions, certain prescription medications, and the misuse of alcohol or other drugs, such as marijuana. A mental illness, such as schizophrenia, is typically diagnosed by excluding all of these other causes of psychosis. Postnatal psychosis (https://www.nhs.uk/mental-health/conditions/psychosis/symptoms/)is a severe form of postnatal depression and women with schizophrenia or bipolar disorder are more likely to experience it. There are 3 main symptoms of psychosis: • hallucinations • delusions • disturbed, confused, and disrupted patterns of thought And within the latter, signs include: • rapid and constant speech • disturbed speech – switching from one topic to another mid-sentence • a sudden loss in train of thought, resulting in an abrupt pause in conversation or activity It can also be understood as 3 main types of disturbances: 1. disorganized speech - positive thought disorder 2. poverty of speech - negative thought disorder 3. flat affect The use of nonwords or word approximations are often present in psychotic disorders (8) See here (https://academic.oup.com/view-large/231915514)for a very comprehensive list of descriptions and examples of observed language production abnormalities in psychosis. Disorganized speech can be made up of neologisms, “word salad” and tangentiality. This short video explains it really well: https://youtu.be/1c1UV5oCBAE Imagine you’re an adult with a mental illness that results in language abnormality or disability. How would you get on at University? As a patient in the NHS? As a victim or accused in the justice system? How could you possibly understand or use preferred pronouns, or gender-neutral language? References: (8) Hitczenko, K., Mittal, V.A., Goldrick, M. 2021. Understanding Language Abnormalities and Associated Clinical Markers in Psychosis: The Promise of Computational Methods, Schizophrenia Bulletin, Volume 47, Issue 2, March, Pages 344–362, https://doi.org/10.1093/schbul/sbaa141(https://doi.org/10.1093/schbul/sbaa141)

As previously stated (above) for children, the same goes for adults. If an adult has hearing impairment (https://www.nhs.uk/conditions/hearing-loss/)a(https://www.nhs.uk/conditions/hearing-loss/)nd does not hear a word effectively, he may misunderstand its meaning or cannot also articulate that word clearly, especially if it is a neologism and even more so if it does not follow the phonotactic rules of English. Hearing loss in older people and its link with cognitive decline is complex (9). Accurate diagnoses and appropriate support is essential to help people communicate effectively who have hearing impairment and/or cognitive problems. As this NHS video about talking with d/Deaf patients states, even the best lip readers can only follow about 35% of what is being said: https://youtu.be/bVzA8j_NweA And here is the Deafblind manual explained in a video: https://youtu.be/cBChxknvCbA References: (9) Uchida, Y., Sugiura, S., Nishita, Y., Saji, N., Sone, M., Ueda, H. 2019. Age-related hearing loss and cognitive decline — The potential mechanisms linking the two, Auris Nasus Larynx, Volume 46, Issue 1, Pages 1-9, ISSN 0385-8146, https://doi.org/10.1016/j.anl.2018.08.010(https://doi.org/10.1016/j.anl.2018.08.010)