A case-study of language-specific executive disorder
Charlotte Jacquemot, Anne-Catherine Bachoud-Lévi

To cite this version:
Charlotte Jacquemot, Anne-Catherine Bachoud-Lévi. A case-study of language-specific executive
disorder. Cognitive Neuropsychology, 2021, 38 (2), pp.125 - 137. �10.1080/02643294.2021.1941828�.
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Cognitive Neuropsychology

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A case-study of language-specific executive disorder
Journal: Cognitive Neuropsychology
Manuscript ID CN-SR 48.20.R2

Keywords:

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Manuscript Type: Short Report

Language processing, Executive functions, Domain-specific process,
Domain-general process, Performance dissociation, Aphasia

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A case-study of language-specific executive disorder

Charlotte Jacquemot 1-3*, Anne-Catherine Bachoud-Lévi 1-4

1

INSERM U955-E01, Neuropsychologie Interventionnelle, Institut Mondor de Recherche

Biomédicale, Créteil, France
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Département d'Etudes Cognitives, Ecole normale supérieure, PSL University, Paris, France

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Université Paris Sup, UPEC, Créteil, France

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AP-HP, Service de neurologie, Hôpital Henri Mondor-Albert Chenevier, Créteil, France

* Correspondence:
Charlotte Jacquemot
charlotte.jacquemot@ens.fr

ACKNOWLEDGMENTS AND FUNDINGS
This work was supported by the Fondation Maladies Rares [Programme Sciences Humaines et
Sociales & Maladies Rares to CJ], the Institut National de la Santé et de la Recherche Médicale
[contrat Interface to ACBL] and the Agence Nationale de la Recherche [ANR-17-EURE-0017].

Page 1 of 35

A case-study of language-specific executive disorder

Running title: Language-specific executive disorder

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Cognitive Neuropsychology

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Cognitive Neuropsychology

ABSTRACT
Executive control is recruited for language processing, particularly in complex linguistic
tasks. Although the issue of the existence of an executive control specific to language is
still an open issue, there is much evidence that executively-demanding language tasks rely
on domain-general rather than language-specific executive resources. Here, we addressed
this issue by assessing verbal and non-verbal executive capacities in LG, an aphasic
patient after a stroke. First, we showed that LG’s performance was spared in all non-

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verbal tasks regardless of the executive demands. Second, by contrasting conditions of

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high and low executive demand in verbal tasks, we showed that LG was only impaired in
verbal task with high executive demand. The performance dissociation between low and

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high executive demand conditions in the verbal domain, not observed in the non-verbal

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domain, shows that verbal executive control partly dissociates from non-verbal executive

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control. This language-specific executive disorder suggests that some executive processes
might be language-specific.

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Keywords: Language processing; Executive functions; Domain-specific process; Domaingeneral process; Performance dissociation; Aphasia

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INTRODUCTION
Executive control includes a wide range of mechanisms such as sustained attention, inhibition,
planning, flexibility, monitoring and initiation that provide resources for other cognitive
functions (Diamond, 2012). Executive control is essential for regulating processes and
resolving conflicts in order to orchestrate behavior according to our internal goals: It allows for
monitoring and updating working memory information, for inhibiting irrelevant stimulusdriven responses and suppressing task-irrelevant information, and for shifting between

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processes or stimuli (Miller, 2000).

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More specifically, in the language domain, executive control improves the efficiency and

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fluidity of language, enabling on-line processing of language components (phonology, lexicon,
syntax, semantic…) (Baddeley, 2003; Hoffman et al., 2009; Nozari et al., 2016). The impact of

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executive control in language is limited when comprehending canonical sentences such as

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active sentences when naming familiar pictures, when producing automatized sequences such
as the days of the week or even when producing lexically expected words in sentences; the

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latter being the basis of the Hayling sentence completion test (Burgess & Shallice, 1997) which
provides an excellent illustration of the potential contribution of the executive control in

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language. In this task, the participant listens to a sentence in which the last word is missing. In
section A, the patient has to simply complete the sentence such as "Before going to bed, we
switch off the [light]”. Whereas in section B, the patient is required to complete the sentence
with a nonsense ending word, thus imposing inhibition of the spontaneous meaningful word.
Executive control is higher in section B, where in addition to word production and initiation,
inhibition processes are required to perform the task. This supports the view that the executive
control of language is modulated by task complexity and that language may involve monitoring,
inhibition, switching or re-analysing of complex structures. Indeed, in speech comprehension,
whereas canonical sentences elicit an automatic response, non-canonical sentences conflict
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Cognitive Neuropsychology

with the automatic response and, hence, require a high-order executive control response (Kotz
et al., 2003; Mestres-Misse et al., 2012). Executive control also plays a substantial role in
disambiguation and reanalysis of semantic content or syntactic structure, when the
communicative context requires selecting an appropriate interpretation among multiple
alternatives (topic, speaker, etc) (Jacquemot et al., 2006; Kotz et al., 2003; Novick et al., 2005;
Ye & Zhou, 2009). In speech production, executive control allows for selecting the correct
lexical items from semantic memory according to both the communicative intention and the

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context, as well as to plan and monitor the speech output (Indefrey & Levelt, 2004; E Jefferies,

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2013; Shao et al., 2012).

An important issue is determining how language and executive control interact. Prior research

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has argued for a distinction between two separable systems: language and executive control,

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where domain-general executive resources apply in the language system similarly to other

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cognitive domains such as arithmetic, music, etc. According to this common view, even if
domain-general executive resources are engaged during language processing and impact

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language performance, they are independent from language: language and executive resources
can be selectively impaired and involved distinct networks. Indeed, there is much evidence

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from neuropsychological, brain imaging and behavioral studies indicating that even if executive
control and language system interact, the two domains dissociate (Ye & Zhou, 2009). In patients
with brain lesion, double dissociations between language and executive control demonstrate
that two systems may be independently impaired (Fedorenko & Varley, 2016). Some severe
aphasic patients perform flawlessly in executive tasks; conversely, patients without aphasia are
impaired in executive tasks (Reverberi et al., 2009; Varley & Siegal, 2000). Brain imaging
studies also show that executive control and language involve spatially and functionally
different brain networks (Fedorenko, 2014). Whereas left-lateralized brain areas in frontal,
temporal and parietal regions selectively and robustly respond to language processing, a

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bilateral fronto-parietal network responds to executively-demanding tasks regardless of the
cognitive domain (language, memory, arithmetic, etc.) (Duncan & Owen, 2000), suggesting
that domain-general executive control is modulated by task complexity regardless of the
domain. In addition, domain-general executive control ability predicts performance in complex
language tasks, suggesting that domain-general control processes support language tasks. Nonverbal executive control abilities such as was assessed with the go/no go task or the Wisconsin
Card-Sorting Test correlate with performance in complex language tasks such as producing

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words under conditions of high lexical competition or speeded action-naming tasks (Shao et

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al., 2012; Taler et al., 2010). Evidence also comes from multilingualism in which multilingual
individuals have to intensively control their speech input and output to select the target language

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(among the languages they master), while inhibiting the one(s) they are not using (Abutalebi et

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al., 2013; Hervais-Adelman et al., 2011). Bilingualism improves linguistic capacity – for
example, multilingual individuals outperformed monolinguals in comprehending non-

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canonical sentences in the presence of linguistic interference (Bialystok & Feng, 2009; Filippi

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et al., 2012, 2015). Interestingly, monolingual and multilingual individuals perform at the same
level with canonical sentences, suggesting that multilingual individuals show greater advantage
in complex linguistic tasks when the executive demand is high. In parallel, being multilingual

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is associated with higher capacity in non-verbal executive control tasks which require rapid
switching between rules, suppression of irrelevant information, monitoring and updating
changes (Bialystok, 2017; Bialystok et al., 2012; Pelham & Abrams, 2014). Although these
findings suggest that the enhanced executive control capacity observed in multilinguism is not
specific to language but spreads to other cognitive domains, this multilinguism advantage has
been recently questioned in a growing number of studies (Filippi et al., 2020; Lehtonen et al.,
2018; Paap et al., 2014; Paap & Greenberg, 2013). Finally, impaired performance in children
with specific language impairment (SLI), a developmental disorder affecting language

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Cognitive Neuropsychology

acquisition when processing complex sentences, (Im‐Bolter et al., 2006; van der Lely, 2005)
correlates with their deficit in inhibition and working memory; this therefore suggests a link
between general executive control ability and complex language tasks.
Altogether, this suggests that executive control in language is supported by domain-general
resources and modulated by the complexity of the linguistic task (January et al., 2008; Novick
et al., 2005). However, this hypothesis does not preclude that executive processes specifically

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dedicated to language may complement general executive functions (Hsu et al., 2017; Hamilton
& Martin, 2005).

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Here, by reporting the case of a patient with a dissociation between verbal and non-verbal

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executive tasks, we argue that there is a part of executive control specifically dedicated to

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language. This language-specific component of the executive network could be impaired
independently of its non-verbal component. In tasks with high executive demand, the patient

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showed impaired performance in the verbal domain but spared performance in non-verbal

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domain. This language-specific executive disorder undermines the notion of domain-generality
of executive control and suggests that some executive resources instead of being domaingeneral might be language-specific.

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MATERIAL AND METHODS
Case report

Patient LG, right-handed and 50-years old, was working as a computer programmer (14 years
of education) at the time of his stroke. He was admitted to the hospital for acute language
difficulties. A CT scan showed a stroke encompassing the left anterior cingulate cortex (ACC)
and the left caudate nucleus. LG was fluent but his spontaneous speech was sprinkled with

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semantic paraphasias and circumlocutions. The patient was tested from 3 to 9 months after the
stroke. Healthy participants were included in this study to provide controls for the novel tasks.
The study was carried out in accordance with the recommendations of the code of ethics in
French law for observational studies and of the Declaration of Helsinki. All participants
consented to this research.

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General neuropsychological assessment
Neuropsychological examination included verbal and non-verbal tests to assess global

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intellectual function, language, executive functions, working memory, visual processing, and

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attention. Whereas the assessment of LG’s intellectual functioning with the non-verbal test of

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the Wechsler Adult Intelligence Scale (WAIS III) (Wechsler, 1997) showed normal
performance, LG’s intellectual functioning assessed through verbal tests (WAIS III and Binois-

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Pichot Vocabulary Test) (Binois & Pichot, 1956) showed only low average performance (see

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Table 1). Intellectual assessment revealed a discrepancy between non-verbal and verbal
performance. Because intellectual functioning assessment is highly dependent on executive
functions and language, we further explored executive ability in non-verbal and verbal domains.

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In order to evaluate LG’s non-verbal executive ability, we assessed non-verbal tasks from
previous studies and contrasted tasks requiring low and high executive demand (Calabria et al.,
2014; Hoffman et al., 2009, 2011, 2012; Hoffman, Jefferies, et al., 2013; Jefferies et al., 2008;
Jefferies & Lambon Ralph, 2006; Thompson & Jefferies, 2013). The digit cancellation task
(Della Sala et al., 1992) is a three-step task which consists of cancelling a target digit, then two
targets, and finally three target digits in a panel of numbers. It allows for assessing attention
allocation. The Trail Making Test (TMT) consists of two parts (A and B) in which the
participant is instructed to connect a set of dots as accurately and quickly as possible

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Cognitive Neuropsychology

(Tombaugh, 2004). Part A (TMT A) consists of digits and assesses both attention and motor
speed while part B (TMT B), consisting of alternating digits and letters, assesses attention,
motor speed and flexibility, thus requiring executive resources. The Raven progressive matrices
task measures abstract reasoning (Raven, 1983). The participant is asked to identify the missing
pattern within a series of geometrical patterns. In the Wisconsin Card-Sorting Test, which
measures abstract reasoning, task switching and attention, the participant is asked to match
cards with figures differing with respect to color, quantity, and shape (Heaton, 1981). The Rey

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figure is a complex figure that the participant is asked to copy (Fastenau et al., 1999). In the

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Ratcliff test, the participant is asked to decide in which hand human figures from the front, from
the back or oriented upside down are holding a ball in order to assess spatial orientation

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(Ratcliff, 1979). The Protocole d'Evaluation des capacités Gnosiques Visuelles (PEGV)

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assesses visuospatial abilities, attention, working memory, planning, and monitoring to detect
eventual visual agnosia. It comprises of several tasks (embedded pictures to recognize, intruder

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detection, functional matching, and categorical matching) (Agniel et al., 1992). Patient LG

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performed within the normal range of all these non-verbal tests regardless of the executive
demand of the task.

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In contrast, LG displayed a dissociation in performance among verbal tasks, showing low
performance when the executive demand was high but spared when the executive demand was
low. More precisely, LG’s speech quality was normal in a free narrative and open-ended
conversation. He performed normally at picture-naming in both the DO80 (Oral Naming 80)
(Deloche & Hannequin, 1997) and the naming part of the French version of the Boston
Diagnostic Aphasia Examination (BDAE) (Goodglass et al., 2007). Conversely, LG’s
performance was below the normal range in the Commands part of the BDAE, in which he was
requested to carry out commands such as “place the watch on the other side of the pen and turn
the card over”, which imply subsequent embedded actions. He was also impaired in both

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categorical and letter fluency (Cardebat et al., 1990), tests where subjects are required to orally
elicit as many animal names (categorical) or words beginning with a specific letter (letter) in
two minutes. In contrast to picture naming, fluency tasks require higher executive resources for
monitoring and inhibiting the numerous competitors. Likewise, LG was impaired in the
similarities subtest of the WAIS, a verbal task in which the participant has to describe how two
auditory words or concepts are similar. This task assesses language conceptualization, verbal
abstraction, and analogical verbal reasoning. It examines the ability to think abstractly and to

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find similarities among words or ideas that may not appear to be similar on the surface. LG was

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also impaired in section B of the Hayling sentence completion test (Burgess & Shallice, 1997)
but not in section A. Consistently, LG was performed flawlessly in the forward digit span,

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which is mostly an attentional and immediate memory task, but was impaired in the backward

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span (Jacquemot et al., 2019; Wechsler, 1997) which involves the executive control component
of the verbal working memory (Baddeley, 2003b).

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In summary, the general assessment demonstrated impaired performance in verbal tasks with

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high executive demand, but spared performance in verbal tasks with low executive demand and
in all non-verbal tasks regardless of their executive demand. In order to directly assess the role

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of executive control in the patient’s verbal deficit, we assessed language tasks in which the
executive demand was modulated within-task.

Language assessment
Statistical methods

We performed case-control comparisons using the Crawford modified t-test (Crawford et al.,
2010) which calculates the probability that a single case comes from the distribution of a control
sample. In addition, to demonstrate the existence of a dissociation between performance across
two conditions, we compared the difference between LG’s scores with the analogous difference

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Cognitive Neuropsychology

in controls using the Revised Standardized Difference Test (RSDT, Crawford et al., 2010).
Two-tailed p values are reported. For each task, the percent of correct response and standard
deviation are reported. The correlation coefficient (r) among conditions in the control sample
is also reported.

Language comprehension
Word comprehension was evaluated with an auditory word-picture matching task (Jacquemot

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et al., 2007). A total of 64 pictures of common concrete nouns were selected and were visually

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presented with an auditory word. The word was either the correct name of the picture (e.g.,
“bureau” /byro/ desk for a picture of a desk), an unrelated distractor (e.g., “pomme” /pom/

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apple), a semantic distractor (e.g., “armoire” /armwar/ wardrobe), or a phonological distractor.

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There were two types of phonological distractors: words and pseudowords, which were
phonologically equidistant from the target word (e.g., the word /bylo/ whelk and the

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pseudoword /byfo/). Every picture was presented once with each auditory item (the identity and

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the four types of distractor) with a total of 320 trials. LG was asked to decide whether the
auditory word matched the picture. His performance was compared to that of matched controls

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(N=5; mean age: 52.2 2.16, p > 0.1; mean age of education: 14 3.9, p > 0.1).
Sentence comprehension was evaluated with a sentence-picture matching task. The patient was
asked to decide whether an auditory sentence matched a picture (Teichmann et al., 2005). We
contrasted two syntactic conditions: sentences followed either the French canonical syntactic
order (active and subject relative sentences, e.g. “The girl waters the flower that is white”,
N=16) or a non-canonical syntactic order (passive and object-relative sentences, e.g. “The
flower that is white is watered by the girl”, N=16) (Supplementary material, Table 1). The two
conditions were matched for sentence length and word frequency. LG’s performance was

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compared to that of matched controls (N=20; mean age: 46.1 6.6, p > 0.1; mean education
age: 13.2 4.3, p > 0.1).

Language production
Speech production was assessed through a word production task, using an oral definition
(Bachoud-Lévi & Dupoux, 2003). We contrasted two conditions: “concrete” and “abstract” in
which the expected responses were respectively, concrete and abstract words as rated by control

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participants from 1 to 5. Since the definition of abstract and concrete is debated, the scale was

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rated arbitrarily between two examples tomato (1) and freedom (5) (Bachoud-Lévi & Dupoux,
2003). The two conditions were matched for syllable length and word frequency. For each

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word, concrete (N=20) or abstract (N=20), a definition was constructed and presented orally to

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LG who was asked to produce the word corresponding to the definition (Supplementary

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material, Table 2). LG’s performance was compared to that of matched controls (N=17; mean
age: 56.8 3.6, p > 0.1; mean education age: 14.2 2.6, p > 0.1).

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We designed the CATEX® (CATegory / EXemplar) (Jacquemot & Bachoud-Lévi, 2019), a

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picture-naming task in which the executive demand is modulated independently of linguistic
factors. We contrasted two conditions: “exemplar” and “category”, in which the expected
responses were respectively, exemplar and category words. In this task, LG and matched
controls (N=37; mean age: 50.8 20.6, p > 0.1; mean education age: 11.4 4.95, p > 0.1) were
asked to produce a single word describing two pictures either of the same item (“exemplar”
condition, e.g. a banana and a peeled banana, with “banana” as the expected response) or of
two different items from the same category (“category” condition, e.g. a banana and an apple,
with “fruit” as the expected response). The production of category words is more demanding

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Cognitive Neuropsychology

of executive resources than the production of exemplar words, but conditions were equalised
for linguistic demand. We selected exemplar (N=31) and category (N=31) items with a mean
accuracy above 90% (data from a naming agreement pilot study with 40 participants), matched
for syllable length (mean syllable number of Exemplar: 1.87 0.72; Category: 1.87 0.56; p =
1), phonemes number (mean phoneme number of Exemplar: 4.6 1.12; Category: 4.44 1.32;
p = 0.6) and word frequency (mean word frequency1 of Exemplar: 65.2 112.1; Category: 52.2
54.2; p = 0.6) (Supplementary material, Table 3).

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Semantic cognition

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Lambon Ralph et al., (2017) refers to semantic cognition as the ability to use, manipulate

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and generalize knowledge acquired over a lifespan to support verbal and non-verbal
behaviours. It combines semantic memory, referring to acquired knowledge and its

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executive control component regulating and organising both retrieval and access to

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semantic memory. To assess semantic cognition, we constructed non-verbal picture tasks
such as anomalous picture detection, picture completion, categorical intruder detection

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and functional matching (N=140). In addition, we assessed LG’s capacity to retrieve
semantic information related to pictures of artefacts, animals, vegetables and tools
(N=66). LG had to answer yes/no questions with respect to pictures (e.g. “Is it edible?”,
“Does it fit in a shoe box?”, “Is it from inside or outside the house?”, N=308) (Jacquemot
et al., 2012). Finally, we assessed whether LG understood the concept of “category” by
asking him to produce a word from the same category of a given auditory word (N=28).

1 Lemma frequency from movies, www.lexique.org.

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For instance, on hearing the word “fork”, the patient was expected to reply “knife”,
“spoon”, etc.

RESULTS
Language comprehension

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Word comprehension

In word comprehension, LG performed as well as controls (percent of correct responses, LG:

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99.4%; controls: 99.80.3%; Z-score: -1.43; t = -1.4, df = 4, p = 0.16).
Sentence comprehension

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In sentence comprehension, LG comprehended canonical sentences as well as controls, but his

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comprehension of non-canonical sentences was poorer than controls (percent of correct
responses for canonical sentences, LG: 93,7%; controls: 999.6%; Z-score: -0.5; t = -0.52, df

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= 19, p > 0. 1; percent of correct responses for non-canonical sentences, LG: 81.3%; controls:
90.32.2%; Z-score: -3.8; t = -3.7, df = 19, p < 0.001; r = 0.59). The difference between LG’s

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performance on canonical and non-canonical sentences differs significantly from the
distribution of differences in controls (RSDT t = 3.3, p = 0.004, ES = 3.5) (Table 2).

Language production
Concrete and abstract word production
LG’s production was flawless for concrete words, but impaired for abstract words compared to
controls (correct responses for concrete words, LG: 95%; controls: 944%; Z-score: 0.22; t =
0.2, df = 16, p = 0.8; correct responses for abstract words, LG: 65%; controls: 90.65%; Z13

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Cognitive Neuropsychology

score: -5.17; t = -5.0, df = 16, p < 0.001; r = 0.21). The difference between LG’s performance
in concrete and abstract words differs significantly from the distribution of differences in
controls2 (RSDT t = 3.9, p = 0.001, ES = 4.3), (Table 2). The distribution of LG’s errors is
reported Table 3.
Exemplar and category word production (CATEX)
In the CATEX, LG performed similarly to controls for the exemplar condition (correct

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responses, LG: 90.3%; controls: 945%; Z-score: -0.76; t = -0.75, df = 36, p = 0.45) but lower
than controls for the category condition (correct responses, LG: 51.6%; controls: 89.18%; Z-

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score: -4.93; t = -4.9, df = 36, p < 0.001; r = 0.5). The difference between LG’s performance in

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exemplar and category conditions differs significantly from the distribution of differences in

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controls (RSDT t = 4.1, p < 0.001, ES = -4.2), (Table 2).

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Semantic cognition

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LG’s semantic cognition was intact. LG was unimpaired in non-verbal picture tasks:
anomalous picture detection, picture completion, categorical intruder detection and

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functional matching (97.1% of correct responses). LG’s capacity to retrieve semantic
information related to pictures of artefacts, animals, vegetables and tools was flawless
(100% of correct responses). LG performance in yes/no questions about semantic information
related to depicted items on picture was spared too (98.8% of correct responses). He performed
flawlessly in naming exemplars from the same category of pictures of items (96.4% of correct
responses), indicating a spared understanding of the concept of category.

2 Note that in controls, the absence of performance difference between concrete and abstract words,

and exemplar and category words is not due to a ceiling effect, since their performance with abstract
and category words are not at ceiling.

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DISCUSSION
LG displayed a language disorder with normal intellectual abilities following a left ACC and
left caudate nucleus lesion. He showed normal performance in executively-undemanding verbal
tasks (i.e. section A of the Hayling test, automatic speech, forward digit span, picture naming,
repetition, word comprehension) but impaired performance in executively-demanding verbal
tasks requiring executive control (i.e. section B of the Hayling test, verbal fluency, backward
digit span, similarities subtest of the WAIS, comprehension of commands and complex

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sentences). In contrast, his performance was unaffected in non-verbal tasks regardless of the

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executive demand: LG succeeded in both executively-undemanding tasks such as the TMT A
and the digit cancellation test, as well as in executively-demanding tasks such as the Raven

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progressive matrices, the Wisconsin card-sorting test, the TMT B and tasks assessing visual,

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spatial and mental rotation skills, i.e. the Ratcliff test, the Rey figure copying test and the PEGV
(Table 1). The results of the language assessment in which conditions of high and low executive

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demand were contrasted within each verbal task confirmed that LG was specifically impaired

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in conditions requiring high executive demand.

Unlike previous cases displaying a domain-general executive deficit affecting verbal and non-

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verbal tasks indiscriminately (Calabria et al., 2014; Hoffman et al., 2012; Thompson &
Jefferies, 2013; Vuong & Martin, 2015), LG displayed an impairment specific to verbal tasks
requiring executive control to be performed while sparing capacities in non-verbal tasks.
Acknowledging that comparison between tasks might mask uncontrolled biases, we further
assessed language through speech comprehension and production tasks in which we contrasted
two conditions within tasks: low executive control demand versus high executive control
demand while keeping constant linguistic parameters. Sentence length, syllable length and word
frequency were matched between conditions in the sentence picture matching task, in the
concrete/abstract word production task and in the CATEX® task, suggesting that LG’s lower
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Cognitive Neuropsychology

performance in high executive conditions was not due to linguistic parameters. In addition, we
ensured that LG had no semantic cognition impairment as demonstrated by LG’s excellent
performance in semantic cognition and category concept assessments.
One could argue that LG suffers from a disorder of semantic cognition in which semantic
control processes interact with semantic memory to ensure that the information accessed at any
given moment is appropriate for the current task and context (Jefferies & Lambon Ralph, 2006).
Indeed, two kinds of deficits affect semantic cognition: semantic dementia and semantic

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aphasia. Semantic dementia is characterized by an impairment of semantic memory affecting

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all tasks regardless of the modality (spoken and written words, pictures, environmental sounds,
object use…) and lower performance for specific concept and unique features (Patterson et al.,

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2007). For instance, patients with semantic dementia will forget the zebra stripes before

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forgetting a common feature in animals like its tail. Semantic dementia occurs after bilateral

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anterior temporal lobe damage. In contrast, semantic aphasia is due to an executive control
deficit of semantic memory and associated with prefrontal or temporo-parietal infarcts.

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Patients’ performance with semantic aphasia is consistent across the different modalities but
inconsistent across tasks since it depends of the executive control requirement of the tasks

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(Jefferies & Lambon Ralph, 2006; Noonan et al., 2010). Patients show deficits in executively
demanding semantic tasks in both verbal and non-verbal domains (Corbett et al., 2008, 2009;
Jefferies & Lambon Ralph, 2006; Thompson & Jefferies, 2013). In addition, their performance
in language tasks is highly influenced by the degree of competition between concepts and the
extent to which the task constrains semantic processing (Krieger-Redwood et al., 2015). We
can easily rule out semantic dementia in LG because the behavioural and anatomical data are
not consistent with the etiology of this neurodegenerative disease: LG's performance in
semantic cognition tasks is not impaired and the anterior parts of his temporal lobe are not
damaged. It is also unlikely that LG had semantic aphasia for several reasons. First, when

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assessing semantic cognition, LG showed no impairment even in tasks requiring the control of
semantic memory such as categorical intruder detection or functional matching. Second,
contrary to patients with semantic aphasia who perform poorly on a variety of executive
measures such as the WCST, the Raven matrices, the TMT B (Jefferies et al., 2008; Thompson
& Jefferies, 2013), LG was not impaired in non-verbal executive tasks. Third, in semantic
aphasia, we would expect some difficulties in the auditory word-picture matching task,
especially with semantic distractors and in the exemplar naming task, which was not the case

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with LG (Jefferies & Lambon Ralph, 2006).

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LG was impaired in speech production tasks in conditions that involve executive control
(abstract and category words) in comparison to exemplar and concrete words production. This

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dissociation between performance in abstract and category words compared to concrete and

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exemplar words deserves special interest. What factors make abstract and category words

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special compared to concrete and exemplar words? Concrete words are associated to richer
perceptual experiences and a higher number of active semantic features, than abstract words

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(Gao et al., 2019; Jones, 1985; Paivio, 1990). As the meaning of abstract words does not refer
to an object that may be perceived directly in the world (e.g. peace) and relates to intangible

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experiences or properties (Paivio, 1990), their context is highly variable (Hoffman, 2016). For
example, “peace” combines different contextual frameworks. It may refer to a state of mind or
to the status of two countries after a war. Similarly, a category refers to the relationships
between several exemplars that may differ considerably (e.g., cats and lions are very different,
but both are from the same category of felines). The meaning of abstract and category words is
heavily dependent on the context -the so-called semantic diversity- in which they are being used
(Hoffman et al., 2010, 2015; Hoffman, Jones, et al., 2013; Jefferies, 2013; Jefferies & Lambon
Ralph, 2006). In contrast to exemplar and concrete words, abstract and category words can
occur in many different contexts: they refer to many meanings, less tangible items with lower

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Cognitive Neuropsychology

sensory-perceptual content and lower number of active semantic features. Hence, processing
them requires greater demands on executive control of semantic knowledge to provide access
to competing aspects of semantic cognition not dependent on any particular perceptual
experience for retrieving the correct meaning in speech comprehension and selecting the correct
word in production. This suggests that LG’s verbal performance depends on the executive
demand of the task (Table 2). Consistently, LG was also impaired in the sentence
comprehension task, but only for non-canonical sentences, the condition that involves executive

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control in comparison to canonical sentences. LG’s verbal performance is modulated by

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executive demand whereas non-verbal performance is unaffected by executive demand (Table
1).

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This dissociation between verbal and non-verbal domains suggests that executively-demanding

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language tasks rely at least partly on mechanisms different from those used in the non-verbal

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domain. This effect might be the result of an impaired interaction between language processing
and a general executive system, where language modality would be specifically affected, or the

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result of an impaired language-specific executive component (Jacquemot & Bachoud-Lévi, in
revision). It has been recently proposed that executive control involved in language tasks,

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instead of being considered as a domain general “central controller” may be an emergent
property of distributed systems (Eisenreich et al., 2017). A similar proposal has been made in
the domain of short-term memory, where short-term memory capacity is an emergent property
of the language system relying on the links between the speech comprehension and speech
production modalities rather than a separate system (Jacquemot & Scott, 2006; Majerus, 2013).
Another view is that rather than being domain-general, some mechanisms can become
duplicated over evolution, with independent copies in different domains wrongly suggesting
there are domain-general mechanisms (Endress, 2019). Whereas our study does not specifically
address these hypotheses, LG’s dissociation between executive verbal and non-verbal tasks

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supports the view that verbal executively-demanding tasks rely on processes different from
those involved in non-verbal executively-demanding tasks which may specifically be impaired.
The location of LG lesions in the left ACC and caudate nucleus enhance their role in the
neuronal architecture underpinning executive functions dedicated to language. Previous
literature showed that executive control is associated with a fronto-parietal network including
the prefrontal cortex, the ACC, the temporo-parietal junction and basal ganglia (Duncan &
Owen, 2000; Friederici, 2006; Monchi et al., 2006; Noonan et al., 2013; Pini et al., 2020; Ye &

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Zhou, 2009). Within this network, a key role is attributed to the ACC when effortful control is

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required (Bush et al., 2000). Functional and structural imaging studies on language showed that
the caudate nucleus and putamen (dorsal striatum) played a critical role in language control and

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flexibility, notably in tasks involving selection among linguistic alternatives switching between

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languages (Abutalebi et al., 2013; Crinion et al., 2006; Giavazzi et al., 2018; Hervais-Adelman

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et al., 2015). Because they focused on the modulation of executive control in verbal tasks, these
studies did not indicate whether some parts of the network would be specific to executive

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control in language or rather be involved in domain-general executive control. In contrast, LG’s
case allowed us to dissociate language-specific executive processes from non-verbal executive

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processes. A potential candidate for the language-specific executive network may involve the
ACC and the caudate nucleus.

This patient case study shows that contrary to the traditional view, some executive processes
are language-specific and can be selectively impaired without affecting non-verbal executive
performance. We refer to executive control as a whole without distinguishing between different
executive processes (flexibility, monitoring, inhibition, etc.). A further step would be to
determine how domain-general and language-specific executive resources interact by focusing
on each type of executive process and assessing them separately. Finally, investigating their

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Cognitive Neuropsychology

neural correlates within the fronto-striatal network may help in comprehending the language
system.

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Disclosure of interest
The authors report no conflict of interest.

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Cognitive Neuropsychology

TABLES
Table 1
Test

Score

Z-score or cut- LG’s deficit2
off1

VERBAL TESTS
Intellectual function
13/44
IQ= 83

-1.33

Low
Average

Information

8/19

-0.67

Average

Hayling test

Section A

15/15

/

DO80

Picture naming

75/80

<73

Word discrimination

60/72

-1.80

Body-part identification

18/20

-0.64

Commands

10/15

-3.38

rR

Binois-Pichot Vocabulary Test3

Logical reasoning

8/12

-0.73

Articulatory agility

7/7

/

Phrase Length

7/7

/

Verbal production

12/14

-0.83

Automizeted sequences

9/9

/

Reciting

2/2

/

10/10

/

Concrete sentences

8/8

/

Abstract sentences

8/8

/

85/105

-1.30

6/19

-1.33

12

-2.86

Low
average
**

Letter P (2 min)

4

-2.58

**

Letter R (2 min)

0

-2.32

*

Letter V (2 min)

10

-1.32

Section B

6/15

-3.97

**

Digit span

7/19

-1.00

Forward digit span

6

-0.45

Low
average

Backward digit pan

3

-2.14

WAIS-III
Language

Fo

BDAE

Comprehension

Fluency

Confrontation naming

Executive functions
WAIS-III verbal tests

Similarities

Verbal fluency

Animal (2 min)

Hayling test

ly
On

Production

Words

iew

Repetition

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Automatic speech

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**

Working memory
WAIS III

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*

Page 29 of 35

Test

Score

Z-score or cut- LG’s deficit2
off1

NON-VERBAL TESTS
Intellectual function
WAIS-III
Executive functions

Raven progressive
matrices

54/60
IQ>135

+2.33

Series

24/25
(80 sec)
6/6

<21
(>151 sec)
/

Criteria

3/3

/

12/19

+0.67

14/16

-0.21

25/25
(27 sec)
10/10

<22
(>67 sec)
/

2 digits

20/20

/

3 digits

24/30

0.19

Identical figures

10/10

/

Entangled figures

10/10

/

Functional matching

10/10

/

Category matching

10/10

/

Trail Making Test B
Wisconsin card-sorting test
WAIS-III picture arrangement

Fo

Ratcliff Manikin test
Attention

Mental rotation

rP

Trail Making Test A

Digit cancellation test

PEGV

Rey figure

iew

ev

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Visual process

1 digit

ee

35/36

Very
superior

Average

0

Z-scores or published cut-offs are reported for LG’s scores that are not at ceiling. A

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negative Z-score value indicates that LG had a lower score than healthy participants. Cutoffs are indicated with superior or inferior signs. For score cut-offs, the value is the score
under which a score is considered as abnormal. For time cut-offs, the value is the time
above which a duration is considered as abnormal.
LG’s deficit with a Z-score below 1.96 (outside the 95% confidence interval) is indicated with
* and below 2.58 (outside the 99% confidence interval) with **, except for LG’s WAIS
normative scores for which the WAIS score interpretation is reported (Wechsler, 1997).

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Cognitive Neuropsychology

Table 2

Language
comprehension

Language
production

Low executive condition

High executive condition

Dissociation between low
and high executive load
compared to controls (RSDT)

Canonical sentences: 93.7%
Z-score: -0.5

Non-canonical sentences:
81.2%
Z-score: -3.8

p = 0.004
ES = 3.5, 95% CI = [2.2 to 5.1]

Concrete words: 95%
Z-score: 0.22

Abstract words: 65%
Z-score: -5.17

p = 0.001
ES = 4.3, 95% CI = [2.6 to 6.2]

Exemplar words: 90.3%
Z-score: -0.76

Category words: 51.6%
Z-score: -4.93

p < 0.001
ES = -4.2, 95% CI = [-5.5 to 2.9]

Fo

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Table 2: Dissociation of LG’s performance in language as a function of executive load.
Conditions of the language comprehension and production tasks are classified according

ee

to the executive resources they require to be performed (low or high executive load). We

rR

reported LG’s score, as well as a Z-score of LG’s performance in each condition and the
statistical difference (two tailed probability) between LG’s standardized scores for low

ev

and high executive language conditions compared to controls using the Revised

iew

Standardized Difference Test (RSDT, Crawford et al., 2010). Effect sizes (ES) for the
difference between LG and controls (Z-DCC) and 95% Bayesian Credible Interval (CI) are

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also reported. LG’s pattern of performance fulfils the criteria of dissociation between low
and high executive conditions for each of the language tasks.

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Page 31 of 35

Table 3
Picture Naming

CATEX

Word finding from
definition

DO80

BDAE

Superordinate
Semantic paraphasia

5

15

Category

Exemplar

5

1

3

2

Phonological paraphasia
Circumlocution
Single exemplar

Concrete

Abstract

6
1

5

Fo

1

5
2

rP

Table 3: Type of errors by LG in speech production tasks. The number of errors in each

ee

task is reported according to the error type. Superordinate error means that LG produced

rR

a word of a superordinate category instead of the correct word (i.e., animal instead of
feline). Circumlocution error means that LG produced a phrase that circles around the

ev

target item (i.e., an item that can be found in a room instead of furniture). Single exemplar

iew

is an error that can only be produced in the Category condition of the CATEX task and
where LG produced a word that corresponds to only one of the two exemplars he was

ly
On

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presented with.

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Cognitive Neuropsychology

Supplementary material
Table 1: Sentence comprehension task. Items of the Canonical and Non-canonical conditions.
Canonical sentences
la fille qui arrose la fleur est noire

the girl who waters the flower is black

le cheval qui attrape le garcon est noir

the horse that catches the boy is black

le garcon qui attrappe le cheval est noir

the boy who catches the horse is black
the fireman who has black boots water the

le pompier qui a des bottes noires arrose la valise

suitcase

la fleur qui arrose la fille est blanche

the flower that waters the girl is white

Fo

the postman with black shoes bites the dog

le facteur qui a des chaussures noires mord le
chien

le fleur qui arrose la fille est blanche

the flower that waters the girl is white

le cheval qui attrape le garcon est noir

the horse that catches the boy is black

le garcon qui attrape le cheval est noir

the boy who catches the horse is black

ee

rP

the fireman who has black boots water the
suitcase

le pompier qui a des bottes noires arrose la valise

rR

la fille qui arrose la fleur est blanche

the girl who waters the flower is white

le facteur qui a des chaussures noires mord le

the postman with black shoes bites the dog

chien

ev

the dog bites the postman who has black shoes

le chien mord le facteur qui a des chaussures
noires

iew

the suitcase waters the fireman who has black

la valise arrose le pompier qui a des bottes noires
le chien mord le facteur qui a des chaussures

boots

the dog bites the postman who has black shoes

noires

ly
On

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the suitcase waters the fireman who has black
la valise arrose le pompier qui a des bottes noires

boots

Non-canonical sentences
le garcon qu'attrape le cheval est blanc

the boy the horse catches is white

le cheval qu'attrape le garcon est noir

the horse the boy catches is black

le garcon qu'attrappe le cheval est noir

the boy caught by the horse is black

la fille qu'arrose la fleur est blanche

the girl who waters the flower is white

la fille qu'arrose la fleurs est blanche

the girl who waters the flowers is white

la fleur qu'arrose la fille est blanche

the flower the girl waters is white

le cheval qu'attrape le garcon est noir

the horse the boy catches is black

la fleur qu'arrose la fille est blanche

the flower the girl waters is white

la facteur qui a des chaussures noires est mordu

the postman who has black shoes is bitten by the

par le chien

dog

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Page 32 of 35

Page 33 of 35

la pompier qui a des bottes noires est arrosé par

the fireman who has black boots is hosed down

la valise

by the suitcase

le pompier qui a des bottes noires est arrosé par

the fireman who has black boots is hosed down

la valise

by the suitcase

le facteur qui a des chaussures noires est mordu

the postman who has black shoes is bitten by the

par le chien

dog

la valise est arrosé par le pompier qui a des

the suitcase is hosed down by the fireman who

bottes noires

has black boots

le chien est mordu par le facteur qui a de

the dog is bitten by the postman who has black

chaussures noires

shoes

le chien est mordu par le facteur qui a de

the dog is bitten by the postman who has black

chaussures noires

shoes

la valise est arrosé par le pompier qui a des

the suitcase is hosed down by the fireman who

bottes noires

has black boots

Fo

iew

ev

rR

ee

rP

ly
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Cognitive Neuropsychology

Table 2: Word finding from definitions. Items of the Abstract and Concrete conditions
Concrete

Abstract

lit

bed

paix

peace

chaise

chair

tante

aunt

chaine

chain

messe

mass

bague

Ring

paire

pair

beurre

Butter

dette

debt

delle

delle

panne

breakdown

hanche

hip

honte

shame

feuille

leaf

deuil

mourning

quille

keel

bail

lease

barbe

beard

perte

loss

forêt

forest

santé

rideau

curtain

salut

salvation

cheval

horse

rP

health

retard

delay

montagne

Mountain

semaine

week

journal

newspaper

vertige

vertigo

casquette

cap

discours

speech

serpent

snake

serment

oath

jardin

garden

respect

horloge

clock

organe

éponge

sponge

usure

ev

Fo

rR

ee

respect
organ
wear

iew
ly
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Page 35 of 35

Table 3: Picture naming task (CATEX). Items of the Exemplar and Category conditions.
Exemplar

Category

piano

piano

reptiles

reptiles

couteau

knife

vêtements

clothing

marteau

hammer

couverts

cutlery

table

table

outils

tools

artichaut

artichoke

meubles

furniture

banane

banana

animaux

animals

cerveau

brain

oiseaux

birds

fourmi

ant

fleurs

flowers

collier

necklace

arbres

trees

canon

cannon

légumes

vegetables

requin

shark

terre

Earth

cerises

cherries

voiture

Fo

fruits

végétaux

plants

organes

organs

car

insectes

insects

jambe

leg

bijoux

jewelry

un

one

armes

serpent

snake

nourriture

food

manteau

coat

félins

perroquet

parrot

jeux

aigle

eagle

poissons

rose

pink

rongeur

rodent

palmier

palm

pièces

rooms

cactus

cactus

bagages

luggage

cœur

heart

planètes

planets

gâteau

cake

desserts

desserts

castor

beaver

vivants

Living being

valise

suitcase

véhicules

vehicles

commode

dresser

singes

monkeys

chimpanzé

chimpanzee

membres

limb

trompette

trumpet

instruments

instruments

trois

three

chiffres

numbers

rR

ee

fruits

ev

rP

weapons
felines

games
fishes

iew

4

ly
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