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Neurocase: The Neural Basis of Cognition
Publication details, including instructions for authors and subscription information:
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A left basal ganglia case of dynamic aphasia
or impairment of extra-language cognitive
processes?
a

Cristiano Crescentini , Alberta Lunardelli
c

Zadini & Tim Shallice

a c

a

, Alessandro Mussoni , Antonietta

a b

a

International School for Advanced Studies SISSA-ISAS , Trieste, Italy

b

Institute of Cognitive Neuroscience, University College , London, UK

c

Ospedale Maggiore , Trieste, Italy
Published online: 19 Jun 2008.

To cite this article: Cristiano Crescentini , Alberta Lunardelli , Alessandro Mussoni , Antonietta Zadini & Tim Shallice
(2008) A left basal ganglia case of dynamic aphasia or impairment of extra-language cognitive processes?, Neurocase:
The Neural Basis of Cognition, 14:2, 184-203, DOI: 10.1080/13554790802108380
To link to this article: http://dx.doi.org/10.1080/13554790802108380

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NEUROCASE
2008, 14 (2), 184–203

NNCS

A left basal ganglia case of dynamic aphasia or
impairment of extra-language cognitive processes?

Dynamic Aphasia in Left Basal Ganglia Lesion

Cristiano Crescentini,1 Alberta Lunardelli,1,3 Alessandro Mussoni,1
Antonietta Zadini,3 and Tim Shallice1,2
1International School for Advanced Studies SISSA-ISAS, Trieste, Italy
2Institute of Cognitive Neuroscience, University College, London, UK

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3Ospedale Maggiore, Trieste, Italy

We report the case of OTM who presented with dynamic aphasia following a stroke that occurred in the left
basal ganglia. He showed drastically reduced spontaneous speech in the context of well preserved naming, repetition and comprehension skills. OTM was particularly impaired in generating words, sentences and phrases
when cued by a stimulus allowing many response options. By contrast, when a single response was strongly suggested by a stimulus, he could generate verbal responses adequately. OTM’s non-verbal response generation
abilities varied across tasks. He performed in the normal range in a motor movement generation test and he
produced as many figures as controls when tested on a figural fluency task. He showed, however, many perseverations on this test. Moreover in a random number generation task he produced more responses that were
part of ascending and descending series of numbers. The patient’s impairments are interpreted as a consequence of two deficits. The first of these consists of an inability to generate verbal responses particularly in situations of high competition and involves the function of left frontal regions. The second deficit is one of
impaired novel thought generation as evidenced by perseverations. This second deficit has been proposed to be
a function of basal ganglia damage.
Keywords: Dynamic aphasia; Failure of inhibition; Verbal alternatives; Basal ganglia; Cortical-subcortical loops.

INTRODUCTION
Dynamic aphasia consists of an impairment in propositional language production characterized by an
exceptionally reduced spontaneous speech in the context of well-preserved naming, articulation, prosody
and repetition skills. Patients with dynamic aphasia
have great difficulty in the initiation and elaboration
of self-generated utterances. Nevertheless they may be
able to describe pictures and to answer certain types
of direct questions (Luria, 1970). Dynamic aphasia
generally occurs after lesions confined to the left cerebral hemisphere specifically involving frontal regions

(see Robinson, Shallice, & Cipolotti, 2005, for a
review). Both neurodegenerative disorders and focal
lesions have been reported to cause this disorder.
Recently several theoretical accounts for
dynamic aphasia have been proposed; most of
these accounts interpret such a syndrome within
the domain of language while other explanations
extend beyond this domain. Among the accounts
that interpret dynamic aphasia within the domain
of language, some consider the disorder as due to
a specific impairment in creating preverbal messages, following the theoretical framework proposed by Levelt (1989, 1999). Preverbal messages

This research was partially supported by a grant from PRIN to Tim Shallice and Raffaella Rumiati.
Address correspondence to Cristiano Crescentini, Cognitive Neuroscience Sector, International School for Advanced Studies
(SISSA), Via Beirut 2–4, 34014 Trieste, Italy (E-mail: crescent@sissa.it and cristianocresce@hotmail.com).

© 2008 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/neurocase
DOI: 10.1080/13554790802108380

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DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

consist of conceptual structures expressed in term
of lexical concepts, which are in turn associated
with the corresponding words in the language.
For example, Warren, Warren, Fox, and Warrington (2003) described a patient (ADY) with a
frontal lobe dementia who was impaired when
asked to combine various lexical concepts in
order to create a new sentence or a phrase, and
particularly when required to retrieve lexical concepts from among others or when asked to link
them in new ways.
A similar interpretation has also been advocated
by Robinson et al. (2005) to account for the
language disturbances shown by patient CH who
presented with focal atrophy to the left frontal lobe.
CH showed a defective conceptual preparation of
language, which was particularly evident when lexical
concepts had to be generated under conditions of
high competition, that is, by choosing them from
among others equally plausible such as when a
subject has to complete a sentence that can be completed in many different ways. According to
Robinson et al. (2005) when stimuli activate many
verbal response options, selection between them
cannot be accomplished by a damaged system;
nevertheless, an appropriate response can be
produced when lexical concepts are strongly
suggested by the context, namely in conditions of
low competition. CH’s impairment was shown to
be specific to the language domain since an
accurate examination of his non-verbal generation
abilities showed that these were intact. Robinson,
Blair, and Cipolotti (1998) also reported the case of
the patient ANG who was seen to be impaired in
the selection of a verbal response when there were
many competing options.
As stated before, dynamic aphasia has also
been held to occur due to impairments extending
beyond the domain of language. For instance
Raymer, Rowland, Haley, and Crosson (2002)
suggested that the deficits observed in case of
dynamic aphasia may also involve the ability to
produce non-verbal responses. In a similar fashion Robinson, Shallice, and Cipolotti (2006)
reported the case of a patient with progressive
supranuclear palsy (PSP) who, despite his propositional language impairment, performed well on
word and sentence level generation tasks that
required a single response, but did not do so in
non-verbal generation tasks. Following a discourse level generation analysis, Robinson et al.
(2006) claimed that their patient (KAS) was
defective in the generation of a “fluent sequence

185

of novel thought” (Robinson et al., 2006, p.
1344). These authors drew a distinction between
two subtypes of dynamic aphasia. They argued
that patients that present with word and sentence
level generation deficits have language specific
impairment and generally left inferior frontal
gyrus lesions. By contrast, the second type of
dynamic aphasia could be associated with bilateral frontal and subcortical damage; the patients
affected by this second subtype should present
with verbal–non-verbal generation deficits as well
as with problems with discourse level generation
tests. The authors also claimed that such patients
are supposed to be unimpaired in the word and
sentence level generation tests.
In explaining the dynamic aphasia suffered by a
patient (CO) who had a bilateral striatocapsular infarction, Gold et al. (1997) stressed the importance of
the circuit from the dorsolateral prefrontal cortex to
the dorsolateral caudate (Alexander & Crutcher,
1990). The authors claimed that a damage to this
circuit caused decreased spontaneous speech in their
patient, difficulties in executive functions and, most
importantly, also an inability to adopt effective
strategies for the retrieval of information from the
semantic network. CO was a rare case of dynamic
aphasia following a subcortical lesion.
The fact that impairments in executive functioning can be found even in non-demented patients
suffering from subcortical lesions has also recently
been explained as due to disturbance of subcorticalfrontal circuits (Kramer, Reed, Mungas, Weiner, &
Chui, 2002). According to this view, subcortical
ischemic vascular lesions would cause the disruption
of dorsolateral prefrontal-subcortical circuits and
produce signs of dysexecutive syndrome.
However, the functional role of subcortical
structures in language and aphasia remains
unclear. Some authors (e.g., Alexander, Naeser, &
Palumbo, 1987) have suggested that the basal ganglia may not be involved in language at all, though
they do recognize a role for some pathways within
the white matter. In a related fashion, Nadeau and
Crosson (1997) discussed four possible accounts of
subcortical aphasia involving structures other than
the thalamus, namely those of (a) diaschisis, (b)
direct involvement of basal ganglia structures in
language processes, (c) disconnection of cortical
structures involved in language, and (d) deregulation of release of cortically formulated language
segments. They argued that these mechanisms do
not easily account for the high degree of heterogeneity in language impairment following subcortical

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CRESCENTINI ET AL.

lesions to structures other than the thalamus. They
proposed instead that cortical hypoperfusion,
which often follows striato-capsular infarction,
may be the crucial factor. Nadeau and Crosson
(1997) also argue that neither the caudate nor the
putamen play a critical role in language.
More recently, Hillis et al. (2002) have stressed
the importance of cortical hypoperfusion in the
explanation of the language deficits of patients
with subcortical stroke. These authors tested a
population of 115 patients within 24 h of onset or
progression of stroke symptoms for aphasia or
hemispatial neglect. Many of these patients (44)
only had subcortical infarcts. The authors used
some imaging techniques that allow the assessment
of the structural lesion and also an evaluation of the
functional lesion in early stroke. Such techniques
were diffusion-weighted imaging (DWI) and perfusionweighted imaging (PWI). Hillis et al. (2002) also
studied whether the restoration of perfusion to the
cortex was reflected in the resolution of aphasia.
The authors found that most of the patients who
had only left hemisphere subcortical lesions
suffered from aphasia and that all patients also had
cortical hypoperfusion; according to Hillis and
colleagues, this suggested that the language deficits
suffered by the patients with subcortical lesions could
be explained by cortical hypoperfusion. Finally, these
authors also showed that the small group of patients
which benefited from reversal of cortical hypoperfusion also showed resolution of aphasia.
The evidence reported above suggests that cortical hypoperfusion plays an important role in the
aphasic deficits of patients with subcortical lesions;
however, this evidence does not completely exclude
the possibility that subcortical lesions can more
directly cause language deficits. In fact, a more direct role of basal ganglia in language has been proposed by others. Grossman, Stern, Gollomp,
Vernon, and Hurtig (1994) reported a verb-learning
impairment in Parkinson’s disease (PD) patients.
In this study, some PD patients were administered
a verb-learning task in the context of a forcedchoice sentence picture-matching task. These
patients were seen to have a deficit in “appreciating
grammatical information represented in the new
verb” (Grosmann et al., 1994, p. 413). Ullman
et al. (1997) reported evidence for a role of basal
ganglia structures in grammatical processing. They
found a correlation between the right-sided hypokinesia of PD patients and their difficulties in the
production of regular English past tense. Ullman
et al. (1997) claimed that “one kind of basal gan-

glia lesion, which leads to the suppression of motor
activity (Parkinson’s disease), also led to the suppression of rule use” (Ullman et al., 1997, p. 274).
A specific role for the striatum in the application of
linguistic rules has recently been proposed by
Teichmann, Dupoux, Kouider, and Bachoud-Lévi
(2006) in a population of Huntington’s disease (HD)
patients. These patients were administered a task of
acceptability judgments of conjugated verbs and
nonword forms and a task of lexical decision, and
were found to be impaired in rule application while
presenting preserved lexical abilities.
An involvement of basal ganglia structures in
lexical-semantic processing has also been proposed
following studies on patients with subcortical
lesions. Copland, Chenery, and Murdoch (2000a;
see also Copland, Chenery, & Murdoch, 2000b)
tested a group of 14 patients with chronic nonthalamic subcortical (NS) lesions using both standard
aphasia batteries (The Western Aphasia Battery,
WAB; The Boston Naming Test, BNT) and tests
that tap more complex language functions (Test of
Language Competence-Expanded Edition, TLC-E;
Test of Word Knowledge, TOWK). These authors
found that their patients performed as well as normal controls on standard aphasia tests. The exception was given by word fluency in which most of
the patients were impaired. Eight patients also had
problems in the BNT test. However, when assessed
on more complex language functions (TLC-E and
TOWK) the NS patients showed impaired performance on all the subtests (the only exception
was the Making inferences subtest of the TLC-E
where only two patients were impaired). According
to Copland and colleagues, the tests on which the
NS patients had the greatest difficulties required
lexical-semantic manipulation, use of language
strategies, cognitive-linguistic flexibility as well as
the ability to select between alternative solutions for
the same linguistic input. The authors proposed that
NS lesions impair the operations of the lexicalsemantic system, in particular generative language
and the interpretation of meaning at sentence level
(Copland et al., 2000a, p. 6). Importantly, Copland
and colleagues argued that their findings were consistent with the proposal (see Wallesch & Papagno,
1988) according to which basal ganglia, and more
generally the fronto-striatal loops, have a role in
the process of selection of relevant lexical items
and in the inhibition of irrelevant ones.
Copland (2003) provided further evidence for a
related position, through a semantic priming study.
Patients with nonthalamic subcortical vascular

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DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

lesions (NS), Parkinson’s disease patients (PD),
patients with cortical lesions, and controls were
required to perform lexical decisions to targets,
which were either nonwords or words that were
related or not to the prime. They were administered auditory prime-target pairs of four different
types (subordinate unrelated, bat-river; dominant
unrelated, foot-money; subordinate related, bankriver and dominant related, bank-money). There
were two conditions of prime-target interstimulus
interval (ISI; short, 200 ms, and long, 1250 ms). In
neither NS nor PD patients was there a selective
semantic facilitation of the dominant meaning at
long ISI. The authors suggested that damage to
frontal-subcortical systems led to impaired
controlled lexical processing in these patients. In
particular, they claimed that dysfunction in the
basal ganglia produced impairments in the
selective engagement of the semantic network due
to damaged inhibitory mechanisms.
Further evidence for the involvement of basal
ganglia in lexical processes comes also from
neuroimaging studies. In an fMRI experiment,
Crosson et al. (2003) administered 4 tasks to 21
subjects: generation of nonsense syllables, generation of words given a rhyming word, generation of
words given a semantic category in two conditions:
at a slow rate and at a fast rate. They found an
involvement of the left pre-supplementary motor
area (pre-SMA), dorsal caudate nucleus and ventral anterior thalamic circuit in lexical retrieval,
since some of these brain areas were active while
subjects performed word generation from rhyming
words and from category but, on the other hand,
were silent during nonsense syllable generation.
According to Crosson et al. (2003), subcortical
structures have the function of maintaining a bias
towards a lexical alternative chosen from among
others in competition during controlled word selection. The role of basal ganglia structures in the
attention-controlled access to lexical-semantic
information has been proposed by Longworth,
Keenan, Barker, Marslen-Wilson, and Tyler (2005)
not to be specific to language. These authors
have argued that patients with lesions to the
basal ganglia might have separate but parallel
deficits in semantic and syntactic processes.
However, they proposed that such deficits may
reflect an impairment of a function involved in
language comprehension and production which
is not specific to language, namely that of inhibition of competing alternatives during later controlled processes.

187

Figure 1. OTM’s CT scan. Four images are presented in radiological convention (left hemisphere on the right; see text for
details on the lesion).

In this study we report the case of patient OTM
who was classified as a dynamic aphasic following
a vascular accident to his left basal ganglia (see
Figure 1). Together with his language output disorder OTM presented with many signs of executive
dysfunction. In this respect our case shows similarities with that reported by Gold et al. (1997). However, Gold et al.’s patient was not given tasks to
investigate the level of competition in the response
set of the type used by Robinson et al. (1998, 2005,
2006). In the present study, we present a patient
with subcortical damage defined with a series of
tasks commonly used with other dynamic aphasic
patients. In addition, we aim to account for
subcortical language functions in terms of contemporary language production models (for
instance Levelt, 1999). The case of OTM is also
particularly relevant to the status of dynamic aphasia as a language specific disorder and on whether
functionally distinct sub-varieties of this syndrome
exist, as has been suggested by Robinson et al.
(2005, 2006).
CASE REPORT
OTM is a 67-year-old man, right-handed, with
8 years of education, who had retired from work
as a solderer. In May 2005 he suffered from an
ischemic stroke. A CT scan revealed a lesion
involving the left basal ganglia, the corona radiata, and the surrounding white matter. Within the
basal ganglia the lesion involved the putamen and
extended to the capsule close to the dorsal caudate (see Figure 1). A few days after his admittance to the Department of Neurology of the
Ospedali Riuniti in Trieste he had a second
stroke, this time concerning the right parietal
lobe. When he was discharged he was referred for
a neuropsychological evaluation. The testing was
carried out at the Neuropsychology Laboratory
of the Ospedali Riuniti in Trieste over a series of
sessions that took place between September and
October 2005.

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Neuropsychological assessment
The patient was given a general neuropsychological assessment in September 2005 (see Table 1).
He obtained similar values on the WAIS-R
(Wechsler, 1981) Verbal and Performance IQs.
OTM’s Verbal IQ was in line with those
obtained by previous dynamic aphasic patients
(Costello & Warrington, 1989; Robinson et al.,
1998, 2005), while his Performance IQ was in
line with that of patient ANG (Robinson et al.,
1998) and close to another case (Costello & Warrington, 1989), but considerably lower than that
of CH (Robinson et al., 2005). One of the most
striking results on the WAIS-R, was OTM’s very
poor performance on the Picture Arrangement
task. That OTM’s anterograde memory may be
mildly impaired is suggested by his performance
on a short story recall (Novelli et al., 1986). As
far as attentional functions were concerned,
selective attention was severely impaired (Attentive
Matrices, Spinnler & Tognoni, 1987). Interestingly,
OTM made many perseverations in this test as
the targets for the first and second matrix were
frequently incorrectly selected in the third
matrix.
Frontal executive functions
The patient was administered a series of tests
sensitive to frontal executive dysfunction (see
Table 2) that revealed severe deficits on this cognitive domain. He was tested on the Modified
Card Sorting test (MCST, Caffarra, Vezzadini,
Dieci, Zonato, & Venneri, 2004) using the
administration procedure described by Nelson
(1976). The MCST is a shortened version of the
original Wisconsin Card Sorting Test (WCST),
in which only 48 items are employed, with
excluded ambiguous stimuli that can be classified according to more than one category. OTM
performed very poorly on this test completing
only two categories; he was also highly perseverative in this test (14 errors were perseveration).
OTM was also impaired on both phonemic
(Carlesimo, Caltagirone, & Gainotti, 1996) and
semantic verbal fluency tests (Spinnler &
Tognoni, 1987).
OTM was administered a card version of the
Stroop test (Barbarotto, Laiacona, Frosio,
Vecchio, & Farinato, 1998). This consisted of 3
cards, each with 100 stimuli, organized in 10

TABLE 1
Patient OTM’s results on the general neuropsychological
assessment

Tests

Raw
scores

Normative data
(Mean ± SD)

Cut
offs

WAIS-R:
Verbal IQ
83
Digit span*
7
Vocabulary*
6
Arithmetic*
8
Similarities*
9
Performance IQ
85
Picture completion*
9
Picture arrangement* 5
Block design*
8
Object assembly*
8
TIBa
QI=101
LANGUAGE:
Aachner Aphasiae Test (AAT)b
Token test
13/50
2.0 ± 2.3
Repetition
129/150
147 ± 3.2
Comprehension
103/120
110 ± 8.4
Reading/Writing
80/90
87.2 ± 4
Naming
108/120
114 ± 4.3
Non Literal Language Comprehensionc:
− Metaphoric Expression 24/40
− Idiomatic Expression
22/40
MEMORY
Spatial Span – Corsi testd
5
Short story recalle
7
Recognition memory test:
Short Recognition
24/25
Memory Test for
Facesf
41/50
Recognition Memory
Test for Wordsg
LOGICAL FUNCTIONS:
Coloured Progressive
25/36
Matrices – CPMh
ATTENTION:
Attentive Matricesi

24/60

VISUAL PROCESSING:
Screening test
19/20
(VOSP)l
Object Decision
17/20
(VOSP)

4.67 ± 0.95
12.41 ± 3.28

average*
average*
≤3.75
≤8

22.8 ± 1.9
40.9 ± 4.8

27.22 ± 5.59

≤18.96

48.36 ± 8.55

≤31

19.92 ± 0.33

≤15

17.7 ± 1.9

≤14

IDEOMOTOR APRAXIA (IMA):
AIM testm
64/72
No IMA > 62
Borderline
53–62

<53

The bold character indicates pathological scores. *Age-scaled
scores; aBrief Intelligence Test, Sartori et al. (1995); bLuzzatti et al.
(1996); cPapagno et al. (1995); dSpinnler and Tognoni (1987);
e
Novelli et al. (1986); fCamden Memory test, Warrington
(1996); gWarrington (1984); hCarlesimo et al. (1996); iSpinnler
and Tognoni (1987); lWarrington and James (1991); mDe Renzi
et al. (1980).

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TABLE 2
Patient OTM’s results on frontal executive tests

Tests

Raw scores

EXECUTIVE FUNCTIONS:
WCST– Nelson’s modified versiona
− n. of Categories
− n. of Perseverative Errors

2/6
14

Stroop Testb

Failed

Normative data
(Mean ± SD)

Normal range: 4 – 6
Normal range: 3 – 0

Cut offs

<3
≥6.40

Brixton Testc
− Standard (num of correct)

36/55 SS = 5

SS = 5 moderate aver.

Cognitive Estimatesd
− Absolute error score
− Total bizarreness

Pass
15
2

10.81± 3.71
1.42 ±1.31

18
4

Trail Making Teste:
− Trail A
− Trail B

Time = 45”
Time = 210”

67.26 ± 28.69
167.54 ± 97.41

≥94
≥283

10

30.77 ± 11.09

≤17.35

11
5
8
9
33/4 = 8.25

16.76 ± 4. 38

≤ 7.25

Verbal Fuency (FAS)f
Semantic Verbal Fluencyg
− Animals
− Fruits
− Colors
− Cities
Total score

The bold character indicates pathological scores. aCaffarra et al. (2004); bBarbarotto et al. (1998); cBurgess and
Shallice (1996); dDella Sala et al. (2003) (original version by Shallice & Evans, 1978); eGiovagnoli et al. (1996);
f
Carlesimo et al. (1996); gSpinnler and Tognoni (1987); a raw score of 8.25 indicates mild impairment in this test.

columns and 10 rows. The patient was requested
to scan each card from the left and having to
give the appropriate responses as quickly as possible. The first card contained 5 colour words
(red, blue, green, brown, and violet) and OTM
was asked to read all words aloud. The second
card consisted of squares and he was asked to
name the colours of the squares. Finally, the
third card displayed the names of the 5 colours
printed in a conflicting ink colour. OTM had to
name the ink colour of the printed words. The
patient promptly and correctly read the words of
the first card and reported the colours of the
squares of the second card. For the third card
the number of correct responses in the fixed time
of 30 s was recorded following Barbarotto
et al.’s procedure (1998). OTM performed very
poorly on this card being able to name correctly
only 2 words in the first 30 s.
In contrast to his poor performance on the
Stroop, MCST, and fluency tests, OTM performed
at average level in the standard version of the Brixton
test (Burgess & Shallice, 1996), and he passed both
the Cognitive Estimates Test and the Trail Making
Test (see Table 2).

Language baseline
OTM was assessed on a wide range of language tests
from the Italian version of the Aachener Aphasie
Test (AAT, Luzzatti, Willmes, & De Bleser, 1996; see
Table 1). He showed a mild deficit on the Token Test
and in repetition of sentences. For the Token Test,
OTM’s understanding of simple verbal commands
was intact. Errors (13/50) were made only in the
most difficult subtests of the test, when he was
required to retain two characteristics of the tokens at
a time (i.e., shape and colour, colour and size).
Errors (21/150) in repetition of sentences were characterized by omissions of 1 or 2 words when asked to
repeat long sentences. Repetition of words was
within normal limits. On the comprehension subtests
his performance was within the normal range. In
addition his reading, writing and naming skills were
normal, as well as comprehension of metaphors and
idioms (Papagno et al., 1995; see Table 1).
Speech production
OTM’s spontaneous speech was greatly reduced;
he could produce only short phrases of 3–4 words.

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Family members claimed he tended not to speak at
home, while before the stroke he had been very
loquacious. He showed mild disprosodia and mild
articulatory problems. When asked to speak, he was
very often unable to communicate what he appeared
to want to say, and he usually stopped in the middle
of a sentence. When asked to describe something
(i.e., what he remembered of his first stroke) his
answers were characterized by many repetitions,
interruptions and circumlocutions. For example,
when asked to describe how he felt after his stroke
he produced the following: meglio . . . ma più di
tanto non so come parlar . . . non so come parlar . . .
parlo un pò con mia moglie . . . ma più di tanto . . .
(50 s) (I feel better . . . but I do not know how to
speak . . . I do not know how to speak . . . I speak a
little with my wife . . . but not so much . . .).
OTM’s speech was also analysed using tasks
that elicited speech from pictorial stimuli. In order
to obtain a spontaneous speech sample we asked
OTM to generate a story from three simple
pictures taken from the BADA (Battery for
the Assessment of Aphasic Deficits, Miceli,
Laudanna, Burani, & Capasso, 1994). He was
given 1 min to produce a story for each picture.
OTM was also asked to talk about both his job
when he worked and the city where he lives. One
minute was again given for each topic. Five Italian
control subjects matched to OTM for age, education, and gender carried out the same tasks (see
Table 3 for their performance and for comparison
with OTM). The modified t-test of Crawford and
Garthwaite (2002) was used to contrast the performance of OTM with that of control subjects.
OTM produced significantly less words than controls when he was required to speak about his job
and his city, whereas there was only a trend
towards a difference between OTM and controls
on the story generation task. Globally OTM produced less words (word/minute ratio; see Table 3)
than normal subjects but he was close to the rate

of word production of other dynamic aphasic
patients. OTM always began the story generation
task providing good descriptions of the pictures he
saw. Only rarely did he attempt to construct a
story as required. By contrast, controls provided
less detailed descriptions but tried to produce a
story for each single picture. These behaviours
could be the reason why OTM did not differ from
controls in the story generation task while doing
so when asked to describe, for example, his city. In
this latter task, stimuli (i.e., describe your city)
provide less constrains for verbal production relative to pictures which act as cues for production in
the story generation task.

Summary
In sum, OTM showed impairments in intellectual,
language, and executive functions as well as having
problems in verbal memory and selective attention.
Within the language domain OTM had a dissociation between dramatically reduced spontaneous
propositional speech and either preserved or only
mild impaired use of language in comprehension
and naming skills. The diagnosis derived from the
AAT (Luzzatti et al., 1996) was that OTM was not
affected by aphasic disturbances. However, his dysphasic impairment falls within the classification of
pure dynamic aphasia (Luria, 1970, 1973; Robinson
et al., 2005, 2006).
The next experimental series of tests was designed
to investigate OTM’s language output disorder.

WORD AND SENTENCE LEVEL
GENERATION TASKS
The aim of this experimental series of tests was to
pinpoint the nature of OTM’s word and sentence
level generation impairment. Most of the tests

TABLE 3
Speech rate of patient OTM, five matched controls, and four other dynamic aphasic patients

Story generation (3 × 1min)#
Event description (2 × 1 min)#
Speech rate (words per min)

OTM

Controls

T(4)

ANGa

MPb

CHc

KASd

50
39
17.8

130.2 ± 45.15
169 ± 47.5
59.8 ± 17.63

−1.62
-2.5
−2.17

29.2

<20

12.0

23.0

The total number of words produced are reported in each cell. The standard deviation for controls is also reported.
#See text for details on these tests. The bold character indicates significant differences between controls and OTM.
a

Robinson et al. (1998); bRaymer et al. (2002); cRobinson et al. (2005); dRobinson et al. (2006).

DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

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were based on those used by Robinson et al.
(1998, 2005, 2006). In addition others based on
those of Costello and Warrington (1989) and
Warren et al. (2003) were used. For comparison
purposes OTM’s performance in each test was
contrasted with that obtained from another sample of five age-, gender-, and education-matched
controls. As reported above, the modified t-test of
Crawford and Garthwaite (2002) was used to
make comparisons where needed. Where necessary, reaction times were calculated from a tape
recording. Reaction times were defined as the
time between the end of the stimulus and the
onset of a response.

Generation of sentences from single
common words and single proper nouns
(Robinson et al., 1998)
Single common words and single proper nouns
were given one at time to OTM who was asked to
produce a whole sentence incorporating the target
word. Both the responses of patient OTM and
those of control subjects are reported in Table 4
(the performances of patients ANG, CH and KAS,

191

of Robinson et al., 1998, 2005, 2006, respectively,
are also included in the table).
Remarkably, OTM produced sentences with
the same structure for 7 of the 12 common words
and for 8 of the 12 proper nouns. Despite his
tendency to produce sentences with the same
structure, the sentences OTM generated were
always grammatical and meaningful. Hence, he
globally produced 8/12 and 10/12 correct
sentences from, respectively, common words and
proper nouns. Control subjects performed at
ceiling in this task. OTM’s performance did not
differ from that of controls on either kind of
stimuli (p > .09 for both comparisons – common
words, proper nouns). Moreover he did not
show any significant difference across the 2 task
conditions (OTM common words vs. OTM
proper nouns, χ2(1) = 0.22, p = .64).
With common words he provided an explanation of function (e.g., ‘Il tavolo serve per mangiare’
– ‘The table is needed for eating’ – for the word
‘Tavolo’ – ‘Table’). Two sentences of this group
were correct but OTM initiated them only after
very long pauses (>13 s), while he did not produce
anything at all when given 2 other words. With
proper nouns OTM used the expressions ‘bellissimo’

TABLE 4
Word and sentence generation tasks: summary of correct responses on each task of patients
OTM, ANG, CH, KAS and control subjects
Number correct

Generation of sentences from
a. Common words
b. Proper nouns
Generation of sentences from
a. Pairs with strong association
b. Pairs with weak association
Generation of single words to complete sentences
a. High predictability
b. Low predictability
Generation of phrases to complete sentences
a. High predictability
b. Low predictability
Elaboration of nuclear sentences
Sentence construction task
Generation of a sentence given a pictorial scene
Generation of a sentence from a single picture

OTM

ANGa

CHb

KASc

Controls

8/12
10/12

11/28
26/28

10/30
22/30

14/15
15/15

12/12
12/12

23/30*
13/30

22/30
4/30

NT
NT

15/15
15/15

30/30**
30/30**

19/20*
10/20

NT
NT

NT
NT

NT
NT

20/20
20/20**

17/20*
10/20
2/10
9/10
10/10
2/20

9/12
3/12
3/20
14/15
34/34
0/6

19/22
11/22
NT
9/10
20/20
NT

10/10
10/10
5/5
8/10
15/15
9/10

20/20
20/20**
10/10**
10/10
10/10
20/20**

*Indicates significant differences (p < .05) across the two conditions of the relative test for patient OTM.
**Indicates significant differences (p < .05) between OTM and control subjects in the test. NT=not tested.
An arbitrary cut-off of 10 s was adopted for all the tests reported in this section; responses generated after this time were excluded by
the analyses.
aRobinson et al. (1998); bRobinson et al. (2005); cRobinson et al. (2006).

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192

CRESCENTINI ET AL.

and ‘bravissimo’ (‘very beautiful and very good’)
(e.g., ‘Pippo Baudo’ prompted ‘Pippo Baudo e’ un
bravissimo conduttore’ –‘Pippo Baudo is a very
good showman’). For two of these stimuli he did
not make any attempt to produce a sentence.
Clearly, OTM did not have problems in generating a response in this task; however he appeared to
use a compensatory strategy in coping with task
demands (explain function for common words and
report a description for proper nouns). Thus, when
he was asked to vary the structure of the sentences
he was producing, he complained that the task
was too difficult and that he did not have any
other word in mind. Moreover, OTM may have
perseverated on this test, as have other patients with
subcortical lesions when tested on similar tasks
(Esmonde, Giles, Xuereb, & Hodges, 1996; see also
patient MP, Raymer et al., 2002, for strategy use).
OTM performed this task differently by ANG and
CH who had more difficulties in generating sentences from common words than from proper
nouns. As stated also in Robinson et al. (2006),
proper nouns are associated with a dominant
response or with few verbal response options, while
common nouns tend to elicit many response options.

1980; ‘Il ragazzo spedì la lettera senza’. . . ‘francobollo’, is the Italian version) and also 20 sentences
which had many response options (e.g., ‘The policeman had never seen a man so . . .’ with ‘drunk’ being
the most often selected response, 18% of the
subjects; ‘La polizia non aveva mai visto un uomo
così . . .’, is the Italian version). The sentences given
to the patient were an Italian translation of either
the corresponding sentences used in a previous
study with a dynamic aphasic patient (Robinson
et al., 1998) or of the sentences of Bloom and Fischler
(1980).
OTM produced appropriate responses (in less
than 2 s on average) for almost all the sentences
with high response predictability (with low
competition in the response set). By contrast his
performance was significantly impaired on the low
response predictability sentences (with high
competition in the response set) (χ2(1) = 8.02, p < .006,
see Table 4). Control subjects performed at ceiling
in this task.

Generation of a sentence from word pairs
with strong and weak associations
(Robinson et al., 1998)

This task consisted of sentence frames, based on
those of Robinson et al. (1998), to be completed by
the addition of a whole phrase. Twenty had few
plausible verbal response options for their completion (e.g., ‘The hairdresser moved next to the lady
with her scissors and . . .’; ‘La parruchiera ando’
verso la donna con le forbici e . . .’, is the Italian version) while 20 sentences had many plausible verbal
response options for their completion (e.g., ‘The
man sat in his chair and . . .’; ‘L’uomo si sedette
sulla sua poltrona e . . .’ is the Italian version). Each
sentence was read to the patient. As for patients
ANG and CH, OTM produced significantly more
phrases in completing sentences with a highly
predictable response (the mean voice onset time for
the correct responses was 2.8 s) than in case of sentences with low predictability of the response (mean
voice onset time 3.2 s; χ2(1) = 4.10, p < .05) (see
Table 4). Controls perform at ceiling on this task.

The stimuli used in this task were the same of those of
Robinson et al. (1998). They consisted of strongly
associated word pairs (e.g., ‘giraffa-collo’, ‘giraffeneck’) and weakly associated word pairs (e.g.,
‘bambino-dolce’, ‘baby-sweet’). OTM was asked to
produce a sentence incorporating both words of the
pair. As for patient ANG, OTM had more difficulties
in producing sentences from weakly associated word
pairs than from strongly associated ones (χ2(1) =
5.62, p < .02) (see Table 4). Control subjects had no
difficulty with this task.
Generation of single words to complete
sentences with high and low response
predictability (Robinson et al., 1998)
This task consisted of 20 sentence frames to be completed with a single word where there were few
response options (e.g., ‘The boy sent the letter
without the . . .’ with ‘stamp’ being the selected
response for 98% of the subjects; (Bloom & Fischler,

Generation of phrases to complete sentences
with high and low response predictability
(Robinson et al., 1998)

Elaboration of nuclear sentences
(Warren et al., 2003)
OTM was presented with 10 complete sentences
and asked to produce a second sentence developing

DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

the theme of the first. OTM did not provide any
answer for 3 out of 10 sentences. For five sentences
OTM provided only a completion without generating
a separate sentence (e.g., for the sentence: ‘La ragazza ascoltava la storia . . .’, ‘The lady was listening
to the story . . .’, after more than 15 s he said ‘del
suo ragazzo’, ‘of her boyfriend’). For the remaining
two sentences OTM produced a correct response.
Controls had no difficulty with this task.

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Sentence construction task
(Costello & Warrington, 1989)
Dynamic aphasia can also be present in the context of concomitant syntactical or verbal planning impairments. OTM was provided with 10
sentences of 4 to 8 words in length which had to
be rearranged. Single words were printed on separate pieces of paper and had to be reorganized
to construct a meaningful sentence. OTM performed well in this task (9/10). His only hesitation concerned one of the two 7-word sentences.
He rearranged the target sentence: ‘Ieri Luca ha
rotto la sua macchina nuova’ (‘Yesterday Luca
broke his new car’) as ‘Ieri Luca ha rotto sua la
macchina nuova’. Insofar as this task is one of
verbal planning (Costello & Warrington, 1989)
this ability was shown to be spared in OTM.
Controls also had no problem in this task (see
Table 4).
Generation of a sentence given a
pictorial scene (Robinson et al., 1998)
As shown in Table 4 previous studies with dynamic
aphasics had found that patients were able to provide simple descriptions of pictorial scenes. In this
test OTM was given a series of pictures taken from
the BADA (Miceli et al., 1994) and was told to create a sentence that described the content of the picture. The patient was able to do this for all the
pictures he saw (10/10). Controls also performed
errorless in this task.
Generation of a sentence from a
single picture (Robinson et al., 1998)
Patient ANG (Robinson et al., 1998) was impaired
when asked to produce whole sentences (i.e., more
than a simple description) that incorporated the
meaning of single pictures with which he was

193

presented. OTM was presented with 20 single pictures selected from the BADA battery (Miceli et
al., 1994) and required to produce a whole sentence
incorporating the meaning of the picture, but not
to simply describe it. Pictures were divided in two
groups: 10 were of objects whereas 10 were of either
persons or animals doing an action. The pictures from
the two groups were presented at two different
times. Like patient ANG, OTM’s performance was
seriously impaired in this test (only 2 out of 20 sentences were correct). In most cases, OTM merely
produced a description of the picture rather than
generating a whole sentence as required. Controls
performed at ceiling (see Table 4).

Summary and conclusions from
the word and sentence generation tasks
The word and sentence level generation tests
showed that OTM has difficulties in generating
words, sentences and phrases. However, in certain cases he was able to produce plausible
words and phrases. OTM was particularly
impaired when stimuli activated many response
options (phrases and words low in response predictability, word pairs weak in association). By
contrast he generally performed much better
with stimuli that strongly constrained a response
(phrases and words high in response predictability, word pairs strong in association). In these
respects OTM’s performance resembled those of
the dynamic aphasic patients ANG and CH
(Robinson et al., 1998, 2005). The results from
this series of tests showed that OTM had problems in generating verbal messages in condition
of high competition between multiple response
options. However, OTM behaved differently
from ANG or CH in some ways. Qualitatively he
performed just in the normal range in the generation of sentences from proper nouns and common words. Nevertheless, as reported above,
he appeared to use a compensatory strategy in
this task.
Gold et al. (1997) reported the case of patient
CO who also became dynamic aphasic following a
basal ganglia lesion, namely a bilateral striatocapsular infarction. CO also presented with signs of
executive dysfunction. CO performed poorly on a
semantic categorization task and on a procedural
discourse test. The authors argued that he suffered from an impairment of concept formation as
well as from defective semantic strategy formation.

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They held that the latter problem was confirmed
by the difficulty the patient had in sorting items
from very closely related categories by contrast
with his intact performance in sorting items from
more distantly related categories. Gold et al.
(1997) suggested that CO’s deficits might reflect a
more general impairment in the ability to organize
knowledge in a hierarchical fashion. The following
section aims to assess whether OTM’s problems in
producing verbal responses in situations of high
competition may be due to deficits in concept
generation and in semantic strategy formation.

ROUTINE ACTIVITIES DESCRIPTION
AND SEMANTIC STRATEGY FORMATION
Procedural discourse task
(Gold et al., 1997)
In Gold et al.’s (1997) version of the task the patient
had to describe the steps involved in carrying out a
series of common actions such as preparing a cup of
coffee. The patient performed the task in two conditions. First he described the steps involved in the
procedures without any prompting, whereas in the
second the experimenter provided the patient with
cues such as ‘the first step is . . .’ etc.
We administered a similar task to OTM but
changing some of the required actions to fit with
those used by Rumiati, Zanini, Vorano, and
Shallice (2001). These authors provided a list of
the verbal descriptions of the discrete steps
involved in a series of multi-objects-actions
(MOT) that they administered to their apraxic
patients. They distinguished a total of 47 steps
for 10 common tasks with 7 tasks being divisible
into 5 discrete steps and 3 tasks into 4 steps. The
procedures were: Preparing orange juice, Making
coffee using a coffee pot, Lighting a cigarette,
Preparing a letter for posting, Pouring water from
a bottle, Lighting an electric torch, Hanging a
small picture, Lighting a candle, Sharpen a pencil,
Peeling a potato.
OTM was asked to describe the steps he usually goes through in carrying out these actions.
He performed as well as normal subjects (n = 5)
in this task. OTM gave an average of 3.9 steps
for each action while controls gave descriptions
formed of 4.3 steps on average with the difference being not significant (t(4) = –0.97; modified
t-test, Crawford & Garthwaite, 2002). Given
OTM’s ability to perform the task he was not

administered the sequence cued condition used
by Gold et al. (1997).

Semantic categorization task
(Gold et al., 1997)
Before assessing OTM’s abilities in semantic strategy formation and semantic categorization, we evaluated his ability to access semantic representations.
OTM was tested using only the picture section of
The Pyramids and Palm Trees Test (Howard &
Patterson, 1992), a test specifically aimed to assess
the integrity of the semantic network. His performance was well within the normal range and almost at
ceiling (50/52) indicating that he could recognize the
items and retrieve conceptual and semantic information about them.
Given that OTM’s ability to access meaning from
pictures was intact we gave him a semantic categorization task. We used the procedure developed by
Robinson et al. (2005) and the categories these
authors employed. They had found that the dynamic
aphasic patient CH was unimpaired in this task.
OTM was required to sort items into two categories.
A set of 80 words and a set of 80 pictures were chosen. Each of the two groups of stimuli formed 16 categories, each consisting of five highly associated
items. Pairs of categories were used with their degree
of association being either distant or close. OTM was
given 10 cards at the same time and was required to
sort the pictures or the words into two groups of five
each. In one condition the names of the two categories were given in advance to the patient (cued condition) and in another the names of the categories were
not given (uncued condition).
OTM’s performance on this task is reported in
Table 5 together with CH’s performance (Robinson
et al., 2005) and that of four control subjects who
were administered the task. OTM’s performance
on the task was good and similar to that of CH
(Robinson et al., 2005) and of normal controls.
OTM was only somewhat slower than controls in
the uncued condition of the closely related word
pairs category (t(3) = 2.88, p < .05).

Summary and conclusions from the
procedural discourse and the semantic
categorization tasks
Given OTM’s intact performance on the procedural discourse task, an explanation of his deficits

DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

195

TABLE 5
Semantic categorization task
Pictures
Close
Condition

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Cued
OTM
CH a
Controls
Uncued
OTM
CH a
Controls

Words
Distant

Close

Distant

N. Correct

Mean RT

N. Correct

Mean RT

N. Correct

Mean RT

N. Correct

Mean RT

40/40
39/40
40/40

12
28.3
13 (2.2)

40/40
40/40
40/40

10
25.5
11.5 (1.9)

38/40
40/40
39/40

23
18.8
15 (3.9)

40/40
40/40
40/40

18
20
14.2 (4.3)

38/40
38/40
38.2/40

25
47
26.2 (7.1)

40/40
40/40
40/40

13
28.3
16 (7.7)

35/40
37/40
37/40

44
34.8
22.75 (6.6)

40/40
40/40
40/40

18
19.3
16.5 (3.8)

Response times are expressed in seconds. Standard deviations for controls are shown in parentheses.
Robinson et al. (2005).

a

in terms of impaired generation of concepts can be
ruled out. OTM was able to retrieve information in
order to generate phrases for describing well
learned actions. OTM performed very differently
from Gold et al.’s patient in this test. The results of
the semantic categorization task showed that OTM
did not have a semantic strategy formation deficit of
the kind proposed by Gold et al. (1997) to account
for the difficulty their patient showed on the task. In
this respect the findings on OTM are similar to
those on patient CH (Robinson et al., 2005).
RANDOM NUMBER GENERATION TASK
(ROBINSON ET AL., 2005)
In this task OTM’s ability to generate numbers was
investigated. As discussed in Robinson et al. (2005;
see also Cappelletti, Butterworth, & Kopelman,
2001), numbers are a special category which can dissociate from other linguistic categories. Dynamic
aphasic patient CH (Robinson et al., 2005) had performed in the normal range on this task. The task
that we used consisted of three conditions differing in
the size of the response set. In the first part of the task
OTM was asked to generate numbers within the set
1–9 in a random order. In order to illustrate the concept of randomness, both the control subjects and
patient OTM were given the analogy of picking a
number out of a hat, reading it aloud, putting it back,
and then picking another. The number set 1–9 was
followed by two conditions in which the response set
was more restricted, OTM having to generate numbers from the sets 1–4 and 1–2. Each condition
involved 100 numbers. OTM had to generate a

number in time with a tone occurring once every 3 s,
as used by Robinson et al. (2005). The percentages of
number repetitions (e.g., the series 2–2 was scored as
1), descending series (e.g., 4–3, scored as 1) and
ascending series (e.g., 3–4, scored as 1; or 3–4–5,
scored as 2) were calculated.
OTM’s performance is reported in Table 6 along
with that of control subjects. For comparison
purposes performance of patient CH is reported as
well. OTM performed significantly different from
control subjects in each kind of response for the
1–2 number set. In the number set 1–4 OTM
produced significantly more descending series than
did the controls. In the largest number set (1–9)
OTM produced more responses that were part of
ascending series than control subjects.
Summary from the random number
generation task
The random number generation task showed that
OTM differed from normal controls particularly
in the length of ascending and descending series
he generated. This behavior was not related to the
size of the response set since differences between
OTM and controls were present in all conditions
of the task. In the Discussion, it will be argued
that, in the SAS framework of Norman and Shallice (1986), OTM’s abnormal generation of
ascending and descending series of numbers may
reflect a failure of the SAS to inhibit strong routine schemata within the contention scheduling
(i.e., counting in ones) in favor of switching schemata
as is necessary to accomplish the random number

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TABLE 6
Random number generation task

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Number generation task
Number set (1–2)
Repeats
Ascending series
Descending series
Number set (1–4)
Repeats
Ascending series
Descending series
Number set (1–9)
Repeats
Ascending series
Descending series

Chance %
Responses

OTM %
Responses

Controls %
Responses

t (4)

CHa %
Responses

48
25
25

36.5
32
31.2

51 (4.33)
25 (2.77)
24 (1.2)

*-3.05
*2.31
*5.47

48
28
23

25
18.75
18.75

0
33.7
33.7

11.2 (7.72)
22.2 (5.54)
21 (4.63)

−1.32
1.89
*2.50

30
21
25

11.1
9.9
9.9

0
20.4
23.4

2 (1.9)
8 (4.78)
17 (5.16)

−0.96
*2.36
1.13

2.5
24
13.5

*Indicates significant t values (p < .05) for comparison between OTM and controls.
Responses are reported as percentage. Standard Deviations for controls are shown in parentheses.
a
Robinson et al. (2005).

generation task. Excessive use of ascending and
descending sequences of numbers have also been
reported in the context of TMS involving the left
dorsolateral prefrontal cortex (Jahanshahi et al.,
1998) and, as noted also by Robinson et al. (2005),
this may indicate an associated deficit for OTM.

NONVERBAL GENERATION TASKS
Robinson et al. (2005) described the dynamic
aphasic patient CH who was found to have largely
preserved abilities to give non-verbal responses,
performing as well as normal controls in some
non-verbal generation tasks. This was taken as
evidence that CH’s dynamic aphasia did not extend
beyond the domain of language. The next session
aims to asses whether OTM’s generation deficit too
did not extend to cognitive domains other than
language. Two of the tests used by Robinson et al.
(2005) were chosen: figural fluency (Five-Points
test), and motor movement generation.

Five-points test: A figural fluency
test (Lee, Strauss, Loring, McCloskey,
& Haworth, 1997)
The five points test is a measure of non-verbal
figural fluency. A subject is presented with a sheet
of paper that consists of 40 five-dot matrices
arranged in 8 rows and 5 columns. The subject is
required to connect the dots in as many different

ways as possible. Lee et al. (1997) found that
patients with frontal lobe dysfunction made many
more perseverative errors than nonfrontal
neurological and psychiatric patients. Frontal lobe
patients produced about 25 designs with 27%
perseverations on the 3-min version which we used.
By contrast, the dynamic aphasic patient CH
(Robinson et al., 2005) drew 20 different designs
without making any perseveration.
OTM did not significantly differ from control subjects in the total number of designs produced. OTM
produced 15 designs while control subjects drew a
mean of 16.6 designs on average (t(4) = −0.39; modified t-test, Crawford & Garthwaite, 2002). However,
considering only the number of novel designs produced, OTM performed clearly worse than normal
controls (6 vs. 13.8, respectively, t(4) = −6.5; p < .001).
In fact OTM made 9 (60%) perseverative errors while
controls made only 2.8 (16%) perseverations on average, the difference being highly significant (t(4) =
5.16; p < .005, modified t-test, Crawford &
Garthwaite, 2002). OTM’s performance on this test
was extremely poor showing a clear impairment of
perseveration in figural fluency.
Motor movement generation
(Robinson et al., 2005)
In this test OTM was provided with a joystick
which could be moved in four directions:
right, left, up and down. OTM was requested to
select a movement using the joystick whenever

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DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

he heard a sound that occurred once each 3 s.
He was told that the movements did not have
to reproduce a schema or a pattern. Owing to
his right hemiplegia OTM moved the joystick
with his left hand. The task was divided
into three conditions according to the number
of movement options he could select. In the
first two conditions OTM could select between
two movement options, either Left (L)
and Right (R), or Up (U) and Down (D); in
the third condition there were four movement
options: U, D, L, R. As in Robinson et al.’s
(2005) study, each condition lasted 4 min. OTM
was familiarized with the task by performing a
baseline condition of 2 min in which he had to
move the joystick in one direction (U) in time
with the sound (once each 3 s). The percentages
of repeated responses (e.g., L–L) and opposite
responses (e.g., L–R) were calculated in order to
have measures of fixed or random responses.
Table 7 reports OTM’s results together with those
of CH and control subjects. No t values (modified ttest, df=4; Crawford & Garthwaite, 2002) reached
significance when OTM’s performance was compared with that of control subjects.
Summary and conclusions from
the non-verbal generation tasks
OTM’s performance on the non-verbal generation
tasks varied across tasks. OTM has normal performance in the motor movement generation task

197

while he was impaired in the figural fluency test.
Although OTM did not differ from normal controls in the number of total responses generated in
this test, he produced a small number of novel
designs and he made many more perseverations
than controls.
GENERAL DISCUSSION
OTM presented with abnormally reduced propositional language following an ischemic stroke to the
left basal ganglia. OTM’s language production was
characterized by reduced fluency particularly in
situations requiring more than a simple description
of the stimulus. His reduced spoken language was
not connected to general deficits in reading, repetition, naming or comprehension, as these skills were
either preserved or only mildly impaired. OTM
could only produce short phrases of 3–4 words and
exhibited mild disprosodia and mild articulatory
problems as well. Globally, this pattern of deficits
is consistent with dynamic aphasia (Luria, 1970,
1973). Indeed, a quantitative evaluation of his
speech rate showed that this was similar to those of
other patients with dynamic aphasia. In addition to
his language output disorder OTM presented with
signs of executive dysfunction performing poorly in
the Modified Card Sorting Task, phonemic and
semantic verbal fluency and in the Stroop test.
A series of tasks was administered aimed at
investigating OTM’s language output disorder.
Results from the word and sentence level generation

TABLE 7
Motor movement generation task
Motor movement
Generation Task
Two options
Left-Right
Repeats
Opposites
Two options
Up-Down
Repeats
Opposites
Four options
Up-Down–Left-Right
Repeats
Opposites
Other

t(4)

CHa %
Responses

48.6 (6.54)
51.4 (6.54)

−1.19
1.19

42.9
57.1

51.3
48.7

52 (14)
48 (13.7)

−0.04
0.04

52
48

1.4
36.6
62

17 (8.45)
33 (4.06)
50 (11.55)

−1.68
0.80
0.94

38.8
23.8
37.4

Chance %
Responses

OTM %
Responses

50
50

40
60

50
50

25
25
50

Controls %
Responses

Responses are reported as percentage. Standard deviations for controls are shown in parentheses.
Robinson et al. (2005).

a

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tests showed that OTM had great difficulties when
required to produce phrases and words; his problems became evident when stimuli did not suggest a
dominant response. In a similar fashion to patient
ANG (Robinson et al., 1998), OTM had more difficulties in producing sentences from word pairs
with weak association between them than from a
strongly associated word pairs and had also many
more problems in completing low predictability
sentences, either with phrases or words, than high
predictability ones. In a similar fashion to ANG
(Robinson et al., 1998) and CH (Robinson et al.,
2005) but differently from ROH (Costello & Warrington, 1989), OTM did not show any problem in
the sentence construction task. Tests of speech elicitation from pictures (generation of a sentence
given a pictorial scene and from a single picture)
produced similar results to those obtained in other
dynamic aphasic patients (Robinson et al., 1998,
2005); indeed OTM was severely impaired in producing sentences from single pictures whereas he
could give a simple description of them.
We also assessed whether OTM suffered from
the same kind of deficits described by Gold et al.
(1997) in their dynamic aphasic patient CO, who
also had a basal ganglia infarction. These authors
proposed that their patient suffered from deficits in
semantic strategy formation and concept generation, being impaired in both tasks of semantic categorization and procedural discourse. OTM’s
performance in the latter task showed that he
could correctly describe routine activities, he could
generate concepts and combine them in sequences.
OTM also performed almost errorless in the
semantic categorization task as done by patient
CH (Robinson et al., 2005). As discussed by
Robinson et al. (2005), the fact that CH and OTM
performed normally in the semantic categorization
test indicates that they do not have a primary deficit in semantic strategy formation.
OTM’s ability to generate numbers was also investigated. In a random number generation task he
performed differently from control subjects producing
more ascending and descending series of numbers. We
interpret these findings as due to a failure of suppression of strong routine responses (i.e., counting in ones).
Non-verbal response generation skills were
found to be preserved in 1 task; OTM was within
the normal range in the motor movement generation task. His performance on figural fluency
was however impaired; the number of responses
was in the normal range but 9/15 of these were
perseverations.

Possible explanations of OTM’s
dynamic aphasia
As previously reported in the text, OTM also suffered
from a stroke involving the right parietal lobe.
Interestingly, there has been reported evidence
showing that language performance may be influenced by the side of space to which subjects are
paying attention. Thus spatial information may
influence language functions. For instance, Coslett
(1999) investigated the performance of several
groups of patients on both motor and language
tasks. He found that subjects with right parietal
lesions performed better when they directed attention to stimuli in the right hemispace. The aim of
our study was not to further assess whether spatial
factors influence OTM’s performance on language
tasks. Nonetheless, OTM did not show any sign of
neglect when, for instance, the tests which involve
visual material in space (e.g., Progressive matrices)
are considered. Moreover he did not have greater
difficulties on the left than the right in tests which
involve space such as Attentive Matrices. Accordingly, OTM’s problems in generating responses
when alternative options are available, and his
high number of perseverative responses are more
likely due to damage to fronto-striatal regions.
As briefly reported in the Introduction, a
number of explanations have been proposed for
forms of dynamic aphasia extending both within
the domain of language and beyond the latter. As
far as accounts of dynamic aphasia that consider
the disorder within the domain of language are
concerned, for reasons similar to those presented
by Robinson et al. (2005) we can rule out the possibility that OTM’s deficits lay in damage to a
mechanism forming the linear scheme of a sentence
(Luria, 1970, 1973). Similarly, the possibility of an
impairment in verbal planning which Costello and
Warrington (1989) considered for their patient
(ROH) can be rejected for OTM. Our patient
performed almost errorless in the sentence construction test on which ROH had great difficulties.
In addition to showing problems in both semantic categorization and procedural discourse tasks,
patient CO (Gold et al., 1997) had been impaired
in design fluency, category fluency tasks and also
in some tests of frontal system functions, such as
the Trail making B and Wisconsin Card Sort. Due
to this empirical evidence, Gold et al. concluded
that CO’s deficit in propositional language could
be attributed to associated deficits in executive
functions. As already described, OTM was

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DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

impaired in some tests of executive functions as
well. OTM also showed difficulties in the short story
recall (see Table 1), a task that might be strategy
dependent, and also in the picture arrangement
subtest of the WAIS (see Table 1).
As far as the word and sentence generation tasks
are concerned, we have shown that the number of
response options associated with a task (verbal
response alternative options) was an important
factor helping to give rise to OTM’s performance
in many of the tasks we used. In a similar fashion
to CH (Robinson et al, 2005), OTM was not
impaired when a stimulus strongly suggested a
response. By contrast, OTM had great difficulties
when stimuli activated many response alternatives.
As stated in Robinson et al. (2005), a deficit in the
selection of verbal responses in propositional
speech is likely to be due to defective mechanisms
of conceptual preparation (Levelt, 1989, 1999).
Lexical concepts have sometimes to be generated
in conditions of high competition, namely when
many of them are simultaneously activated. These
conditions are those that pose the greatest requirements to the conceptual preparation mechanisms,
particularly when the latter are defective. The
empirical evidence collected in this study suggests
that OTM, similarly to patients ANG and CH
(Robinson et al., 1998, 2005, respectively), suffers
from an impairment in verbal response generation
in situations of high competition.
However, differently from CH, OTM also had
problems in figural fluency and in the random
number generation task. OTM made many perseverations in the figural fluency test while he gave increased
ascending and descending series of numbers in the
random number generation task. As briefly
reported previously in the text, we suggest that a
deficit of inhibition can explain OTM’s problems
with numbers. Among other processes assumed to
be involved in reasonable performance of the
random number generation task, one consists of
inhibiting the most familiar strategy of counting
upwards or downwards in ones which, in the terminology of the SAS model, is the strongest schema in
the contention scheduling. Thus it is possible that
OTM’s pattern of performance in this task reflects a
failure of the SAS to inhibit strong routine schemata
(i.e., counting in ones) in favor of less common
actions (i.e., counting in twos). An account based on
failure of suppression may also explain OTM’s
perseverative responses in the figural fluency task.
Nevertheless, an alternative possibility exists
for explaining perseverations on figural fluency.

199

Perseverations may reflect a deficit to generate
novel content. We have shown that OTM was able
to produce only 6 different figures relative to controls which generated almost 14 new designs in the
figural fluency test. OTM’s inability to generate
novel content may also be seen to fit with his difficulty in some language tasks. For instance, OTM
did not have any problem in producing a response
when given common words or proper nouns; however, he appeared to perseverate or to use a compensatory strategy in this task (see also his
problems in sentence generation from single pictures or elaboration of nuclear sentences in which
novel material has to been generated).
In summary, we propose that two deficits contribute to the overall pattern of performance of
patient OTM. An impairment of verbal response
generation in conditions of high competition is
present along with one of novel thought generation
evidenced by perseveration and due to either
failure of inhibition or inability to generate novel
content. These two deficits may be related to damage of different regions within the fronto-striatal
circuits, namely, left frontal regions and basal
ganglia, as is argued in the next section.
As reported in the Introduction, Robinson et al.
(2006) proposed a distinction between two subtypes
of dynamic aphasia. Since discourse generation has
not been specifically tested in OTM, it is difficult to
say to which subtype his dynamic aphasia relates.
We suggest that OTM has a similar impairment to
the first subtype of dynamic aphasia in which a verbal generation impairment is present along with
associated left frontal lesions. However, a profile
related to the second subtype of Robinson et al.
(2006) cannot be ruled out given that problems in
response generation may be also present in domains
other than language (figural fluency) in OTM.

Anatomical implications
The case of OTM, in a similar fashion to those of
the dynamic aphasic patients CO and KAS (Gold
et al., 1997; Robinson et al., 2006, respectively; see
also Raymer et al., 2002), suggests that subcortical
lesions which give rise to dynamic aphasia also
lead to deficits in non-verbal domains. OTM’s pattern of performance on both verbal and non-verbal
tasks suggests that he suffered from two different
deficits: impaired verbal response generation in
situations of high competition and impaired novel
thought generation as evidenced by perseveration.

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With regard to the first deficit, there is a considerable body of neuropsychological and neuroimaging
evidence supporting the role of the left inferior
frontal gyrus (LIFG) in the process of conflict resolution, which is made by selecting information
from among competing alternatives (Barch, Braver,
Sabb, & Noll, 2000; Persson et al., 2004; ThompsonSchill & Botvinick, 2006; Thompson-Schill,
D’Esposito, Aguirre, & Farah, 1997; ThompsonSchill et al., 1998; Zhang, Feng, Fox, Gao, & Tan,
2004). Recently, Badre, Poldrack, Paré-Blagoev,
Insler, and Wagner (2005) have provided fMRI
evidence supporting the fact that selection could be
subserved by the left mid-ventro lateral prefrontal
cortex (VLPFC) while controlled retrieval processes
could be subserved by the left anterior VLPFC.
Referring back to dynamic aphasia, the literature suggests the involvement of the LIFG in this
syndrome. As reported in the Introduction, both
neurodegenerative and focal lesions have been seen
to lead to dynamic aphasia. A review of these cases
supports the role of the LIFG in the emergence of
the reduced verbal output, which is generally
observed in dynamic aphasic patients (Costello &
Warrington, 1989; Esmonde et al., 1996; Raymer
et al., 2002; Robinson et al., 1998, 2005; Snowden,
Griffiths, & Neary, 1996; Warren et al., 2003).
According to this evidence, the findings on OTM
suggest that his verbal response generation impairment may be due to a frontostriatal damage
disrupting the left frontal region function of selection
in situations of high competition. Admittedly, a
word of caution is necessary with regard to the CT
scan: in fact this is not 100% sensitive for ischemic
damage, so that the precise extent of the frontal
lesion in OTM cannot be exactly defined.
As reported in the Introduction, there is evidence
suggesting the involvement of basal ganglia in
controlled cognitive processes (Copland, 2003;
Copland et al., 2000a, 2000b; Crosson et al., 2003;
Redgrave, Prescott, & Gurney, 1999). In particular,
recent studies assign the basal ganglia a non-language
specific role in the inhibition of competing
alternatives (Castner et al., 2007, in press; Crescentini,
Mondolo, Biasutti, & Shallice, 2008; Longworth
et al., 2005). Different studies have proposed that
deficits in the SAS may also reflect in poor
performance on tasks requiring inhibition of
prepotent or irrelevant responses. Lesions or malfunction of basal ganglia seem to be particularly
important in causing failure of inhibition. As an
example, Dujardin, Degreef, Rogelet, Defebvre,
and Destee (1999) (see also Bouquet, Bonnaud, &

Gil, 2003; Castner et al., 2007, in press; Crescentini
et al., 2008 for similar findings) have shown that
PD patients had problems in inhibiting task irrelevant information in a modified version of the
Stroop test and of the Brown–Peterson paradigm.
Moreover, in an fMRI study, Rossel, Bullmore,
Williams, and David (2001) studied the brain
correlates of automatic and controlled processing
in a semantic priming environment. Automatic and
controlled processing were investigated using,
respectively, short and long prime-target delays.
The authors found that the putamen was preferentially activated at long intervals and this led them
to suggest a role for this structure in controlled
semantic processes. The authors suggested that the
putamen may be involved in the processes of
response selection and inhibition. Even more
recently, McNab and Klingberg (2008) have proposed that the basal ganglia operate to allow only
task-relevant information into the working memory
(see also Frank, Loughry, & O’Reilly, 2001). This
would be possible through the selective filtering of
this information.
The role of basal ganglia in the suppression of
competing alternatives in the motor realm is well
known (see Mink, 1996). Nevertheless, the studies
briefly reported above suggest that Mink’s framework
can also be applied to domains other than motor
behavior (i.e., semantic priming, word selection,
cognitive inhibition, see also Crosson, Benjamin, &
Levy, 2007).
Accordingly, we suggest that a failure of inhibition
could explain the problems that OTM had in the random number generation task. Moreover, it is also a
possible explanation for his perseverative responses.
From another perspective, it is now usually
assumed that different areas of the frontal lobes
project to separate areas of the striatum so that parallel frontal-subcortical circuits are formed (Alexander
& Crutcher, 1990; Zgaljardic et al., 2006). Among
these, the dorsolateral prefrontal circuit involves:
Brodmann’s areas 9- and 10-dorsolateral caudatepallidum, the substantia nigra-ventral anterior, the
dorsomedial nuclei of the thalamus and the dorsolateral prefrontal cortex. The relevance of this circuit
has been stressed by Gold et al. (1997) in order to
account for several of the signs of frontal dysfunction
shown by their patient. OTM also showed impairments which correspond to malfunctions of the dorsolateral prefrontal cortex. Moreover, the
components of this circuit have been seen to be critically implicated in response suppression during the
random number generation task (Brown, Soliveri, &

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DYNAMIC APHASIA IN LEFT BASAL GANGLIA LESION

Jahanshahi, 1998, Jahanshahi et al., 1998) and also
during other tasks requiring challenging response
inhibition such as the Stroop task (Alexander, Stuss,
Picton, Shallice, & Gillingham, 2007). Furthermore,
recent evidence shows that the basal ganglia may be
implicated in each part of the two-process model
(selection and controlled retrieval) of control of
semantic memory proposed by Badre et al. (2005; see
Longworth et al., 2005). Finally, that this could be
the case has been confirmed more recently by further
evidence collected on Parkinson’s disease patients
(Crescentini et al., 2008).
In sum we propose that an impairment to the
basal ganglia, and the consequent abnormal functioning of subcortical-frontal circuits, are important factors in helping to give rise to the deficit of
novel thought generation found in OTM and,
more generally, to his pure dynamic aphasia.

Conclusions
We report the case of OTM who presented with
dynamic aphasia following a lesion to the left basal
ganglia. We interpreted the pattern of performance
of OTM as due to two deficits. The first concerns
the ability to generate verbal responses and is particularly present when stimuli activate many competing response options. The second deficit
consists of defective generation of novel thoughts
as evidenced by perseveration. We hold the first
deficit to arise from a frontostriatal damage disrupting the left frontal region functions, and the
second from a damage to the basal ganglia.
Original manuscript received 16 October 2007
Revised manuscript accepted 27 March 2008
First published online 4 June 2008

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